Surg Endosc DOI 10.1007/s00464-017-5565-2

and Other Interventional Techniques

24th International Congress of the European Association for Endoscopic Surgery (EAES) Amsterdam, The Netherlands, 15–18 June 2016 Poster Presentations

 Springer Science+Business Media New York 2017

P001 - Abdominal Cavity and Abdominal Wall

P002 - Abdominal Cavity and Abdominal Wall

Relaparoscopic Approach of Recurrence After Laparoscopic Incisional Hernia Repair

Prospective Study on QOL After Laparoscopic Inguinal Hernia Repair with ProgripTM Laparoscopic Self-fixating Mesh with the EuraHS-QOL Instrument

S. Capitano, G. Boccoli, A.C. Del Pozo, V. Bartolotta, M. de Fusco, L. Chiodi Italian National Institute of Research and Ageing, ANCONA, Italy Aim: To demonstrate the feasibility and benefits of the relaparoscopic approach of a recurrent incisional hernia originally treated by laparoscopy. Methods: A 65 year old male obese patient with history of multiple laparotomies, underwent laparoscopic repair of a paramedial hypogastric insicional hernia with primary closure of the wall defect before the placement of a dual mesh. After an 8-month follow-up period a periumbilical recurrence was diagnosed and the patient reoperated by laparoscopy. At the upper mesh edge, a 3 cm defect was seen and closed with non absorbable stitches between the mesh an the fascial margin. Afterwards, a new bigger intraperitoneal dual mesh prosthesis was placed to cover the whole compromised abdominal wall. Results: No early either late complications were diagnosed. After one year of follow-up the patient remains free of recurrence. Conclusion: The use of a second intraperitoneal bigger mesh during a laparoscopic approach of a recurrent incisional hernia, already treated by laparoscopy, appears to be safe and effective.

F.E. Muysoms1, A. Vanlander2, R. Ceulemans3, I. Kyle-Leinhase1, M. Michiels3, I. Jacobs3, P. Pletinckx1, F. Berrevoet2 1 Maria Middelares Ghent, GHENT, Belgium; 2University Hospital Ghent, GHENT, Belgium; 3Heilig Hart ZIekenhuis, MOL, Belgium

Background: There is an increasing interest for patient reported outcome measurement (PROM) to evaluate hernia surgery. Several hernia specific Quality of Life (QoL) scales have been proposed, but none are constructed for preoperative assessment. Methods: The European Registry for Abdominal Wall Hernias proposed the EuraHS-QoL score for assessment pre- and postoperatively. The EuraHS-QoL was evaluated in a prospective multicenter validation study alongside the Visual Analogue Score (VAS), Verbal Rating Scale (VRS) and Carolina Comfort ScaleTM (CCSTM) (ClinicalTrials.gov NCT01936584). Results: We included 101 patients undergoing unilateral laparoscopic inguinal hernia repair with ProGripTM laparoscopic self-fixating mesh. Clinical follow-up at 12 months was 87% complete. The EuraHS-QoL score shows good internal consistency (Cronbach’s a = .90), good test-retest reliability (Spearman correlation coefficient r = .72) and high correlation for pain with the VAS, the VRS, the CCSTM pain scale (r between .64 and .86) and for restriction of activity with the CCSTM movement scale (r between .65 and .79). Our results show significant QoL improvement at 3 weeks compared to preoperative and further significant improvement at 12 months (p \ .05). No late complications or recurrences were recorded. Surgery was performed in day surgery ([75%) or with a less than 24 h admission ([95%) in the majority of the patients. Conclusion: The EuraHS-QoL score seems a valid PROM for patients after groin hernia repair. Laparoscopic inguinal hernia repair with ProGripTM laparoscopic self-fixating mesh results in a very favorable outcome and significant improvement of QoL compared to the preoperative assessment.

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Surg Endosc

P003 - Abdominal Cavity and Abdominal Wall

P004 - Abdominal Cavity and Abdominal Wall

Post-Operative Complications as Independent Risk Factor for Recurrence After Laparoscopic Ventral Hernia Repair: A Prospective Study of 417 Patients

Diagnostic Laparoscopy During Laparoscopic Operations. Towards Standardization of Technique

H. Mercoli1, S. Tzedakis2, A. d’Urso2, M. Nedelcu2, M. Meyer2, M. Vix2, S. Perretta2, D. Mutter2 1

Strasbourg university hospital, IRCAD - IHU, STRASBOURG, France; 2Strasbourg university hospital, STRASBOURG, France Laparoscopic ventral hernia repair (LVHR) has become nowadays widely used. The aim of our study was to evaluate outcomes of laparoscopic ventral hernia repair, with particular reference to complications, seromas and long-term recurrence. Methods: A retrospective review of a prospective database of consecutive patients undergoing LVHR with intraperitoneal onlay mesh was conducted at single institution. Patient’s characteristics, surgical procedure and post-operative outcomes were analyzed and related to long-term recurrence. Results: From 2005 to 2014, 417 patients underwent LVHR for primary (40%) or incisional (60%) hernia. Mean age and body mass index (BMI) were 54 years and 31 kg/m2, respectively. Mesh fixation was carried out with transfascial sutures, completed with of absorbable tacks (72%), metallic tacks (24%), or intraperitoneal suture (4%). Intraoperative complications occurred in 3 patients, with 1 conversion to laparotomy. There was no mortality. Overall morbidity included 8.25% of minor complications and 2.5% of major complications, according to Dindo-Clavien scale. The overall recurrence rate was 9.8%, with a median time for recurrence of 15.3 months (3–72) and median follow-up of 31.6 months (8–119). In multivariate analysis, previous interventions (OR = 1.44; CI = 1.15–1.79); p = 0.01), postoperative complications (OR = 2.57 (CI = 1.09–6.03); p = 0.03) and Dindo-Clavien score with a threshold of 2 (OR = 1.43 (CI = 1.031–1.876); p = 0.02) appeared as independent prognostic factors of recurrence. Minor complications were associated with 14.7% of recurrence and major complications with 30% of recurrence. Emergency LVHR (6%) did not increased complication rate. Overall seroma rate was 18.7%, with 1.4% of persisting or complicated seroma. BMI (OR = 1.05 (CI = 1.01–1.08); p = 0.026) and vascular surgery history (OR = 5.74 (CI = 2.11–15.58); p \ 0.001) were independent predictive factors for seroma. Recurrence did not appeared to be related to seroma. Long-term follow-up showed 6% of patients presenting chronic discomfort or pain, without any predicting factor. Conclusion: LVHR combines the benefits of laparoscopy with those of mesh repair. Seroma formation should no longer be considered and is spontaneously regressive in most cases. Postoperative complications and their severity appear to be independent prognostic factors for recurrence, which can be limited with standardized preoperative evaluation and operative technique, which may finally make IPOM-LVHR a reference procedure.

123

D. Majewski Pomeranian Medical University, SZCZECIN, Poland Introduction: Current methods of modern diagnostics are able to discover almost every morphologic lesion in abdominal tissues. However such diagnostics is not undertaken in every patient for lack of indications, lack of possibilities, patient disagreement or for financial reasons. In a very high number of laparoscopic operations made worldwide it seems reasonable that operating surgeon initially inspects abdominal cavity organs which are accessible for investigation. To do it properly an algorithm of such procedure is important. Such algorithms are available and one of them was proposed and validated by author. The results of abdominal investigation according to algorithm enrich the knowledge about the patient and may enable use prophylactic measures to avoid serious medical problems in the future. Aims: Retrospective analysis of own material of laparoscopic operations where validated algorithm of diagnostic laparoscopy(DL) was applied at the beginning of every procedure. Material and Method: In years 2008–2015there were undertaken 64laparoscopic interventions in patients mean age 47.3 years, between 19 and 89 years SD ± 18.2 years, with algorithm of LD. There were 26cholecystectomies, 26appendectomies, 5gastrointestinal perforations, 1adhesion obstruction, 5 other. DL was done according previously described method of reversed left–right number 5 *, inspecting liver, stomach, cardia, spleen and descending colon, turning up through transverse colon, hepatic flexure, ascending colon, cecum with appendix, or female reproductive organs, sigmoid, and when getting up seeing small intestine. Results: For 64DL during laparoscopic interventions in 31cases there were no changes discovered, in 33(51.6%)changes were found: 14abdominal adhesions, 3pelvis adhesions, 5diffuse peritonitis, 2ovarian cysts,2hepatic cysts, 2abscess, infection, 2stab wound of the spleen, 3abdominal organ anomalies,2hiatal hernias,and 3 others(pancreatic cancer,liver cirrhosis,uterus round ligament tumor) Discussion and conclusions: The majority of surgeons make LD during laparoscopic operations more or less carefully but attempt to accuracy requires to see abdominal organs as good way as possible, hence application of an algorythm. The given algorithm proved its value now as it proved before. Therefore widespreading of algorythms of diagnostic laparoscopy during every laparoscopic operations seem rational. *Majewski WD et.al. Reversed 5 pattern of diagnostic laparoscopy during laparoscopic cholecystectomy and its standardization. Surg Laparosc Percutan Tech.2004Aug;14(4): 226–9.

Surg Endosc

P005 - Abdominal Cavity and Abdominal Wall

P007 - Abdominal Cavity and Abdominal Wall

Influence of Pneumoperitoneum (Intra-Abdominal Hypertension) On Morphological Status of Internal Organs

Laparoscopic Treatment of Retroperitoneal Benign Multicystic Mesothelioma: Two Cases Report

Y.M. Turgunov1, D.N. Matyushko1, M.M. Tussupbekova1, A. Zlotnik2, D.K. Kaliyeva1, M.M. Mugazov1, A.E. Alibekov1

N. Apentchenko Eriutina1, C.J. Castello´n Pavo´n2, S. Morales Artero3, E. Larraz Mora3, J.M. de Jaime Guijarro1, M. Calvo Serrano3

1

Karaganda State Medical University, KARAGANDA, Kazakhstan; Soroka University Medical Center, BEER SHEVA, Israel

2

Background: To create a space for any laparoscopic surgery we use a pneumoperitoneum (intra-abdominal pressure – 12–15 mm Hg), which is pathological condition - intra-abdominal hypertension. It is known that increase of inra-abdominal pressure has a negative effect on the function of the gastrointestinal tract, respiratory, cardiovascular and urinary systems. Objective: To evaluate the influence of pneumoperitoneum on morphological status of internal organs. Materials and methods: Objects of the study - 40 male laboratory rats with the same age, size and weight. The main group - 30 rats, which were created intraabdominal pressure 15 mm Hg by pneumoperitoneum (recommended level of intraabdominal pressure in laparoscopy – 12–15 mm Hg). Exposure of pneumoperitoneum - 2 h (the average duration of laparoscopic surgery – 1–3 h). The control group consisted of 10 intact rats. In both groups we made histological examination of tissue of kidneys, liver, intestines, myocardium and lung. Results: We got these results: myocardium - vacuole dystrophy of cardiomyocytes; intestine - no changes; lungs - focal hemorrhages; liver - plethora of portal and central veins; kidneys - plethora of capillaries. Conclusions: *Intra-abdominal pressure 15 mm Hg for 2 h (corresponds to the magnitude and duration of pneumoperitoneum during laparoscopic operations) causes minor and reversible changes of morphological status of internal organs, which proves the safety of usual 2 h pneumoperitoneum. *The increasing of duration of pneumoperitoneum more than 1–3 h causes other irreversible morphological changes of internal organs. The degree of these changes depends on time and level of intra-abdominal hypertension.

1

Hospital Universitario Infanta Elena, VALDEMORO, Spain; University Hospital Infanta Elena, VALDEMORO, Spain; 3 El Escorial Hospital, EL ESCORIAL, Spain 2

Background: Benign multicystic peritoneal mesothelioma (BMPM) is a rare benign neoplastic disease with high tendency to recur locally, but no tendency to malignancy. The diagnosis is usually made postoperatively. Aims: Two cases of BMPM localized in the retroperitoneum are reported and the anatomoclinical characteristics of this disease described in the literature are specified, discussing the management and emphasizing the importance of a laparoscopic approach. Results: We report two cases of patients with large retroperitoneal cystic masses, which were treated by minimally invasive laparoscopic approach and identified as benign multicystic mesotheliomas in the postoperative histologic study. In both cases an intraoperative percutaneous aspiration of the cysts was performed. The postoperative outcome was uneventful and the patients continued free of recurrences in the moment of this study. Conclusions: BMPM is an exceedingly rare lesion which present as large multicystic mass with thin-walled septations and on preoperative evaluation can mimic many different entities. The diagnosis is based on pathological analysis. The preferred treatment is complete resection at laparotomy or laparoscopy. However, the advancement of minimal-access surgery has allowed laparoscopic excision as a safe and advantageous approach with minimal morbidity and shorter hospital stay and recovery time for the patient. The controlled intraoperative aspiration of the cyst content facilitates its removal. Due to the high rate of recurrences a close follow up is mandatory.

P006 - Abdominal Cavity and Abdominal Wall

P008 - Abdominal Cavity and Abdominal Wall

Reduced Port Laparoscopic Surgery for Inguinal Hernia:Tep with Single Incision

Titanium Vs. Absorbable Spiral Tackers Fixation in Totally Extraperitoneal (tep) Inguinal Hernia Repair

T. Nagahama1, M. Kitamura2, M. Ando3, K. Ami3, H. Gannno3, H. Amagasa3, M. Kawaguchi3

S. Wijerathne, W.B. Tan, A. Shabbir, D. Lomanto

Kudanzaka Hospital, TOKYO, Japan; 2Kitamura Family Clinic, SAGAMIHARA, Japan; 3Toshima Hospital, TOKYO, Japan

National University Hospital, Singapore, SINGAPORE, Singapore

1

Introduction: Recently reduced port laparoscopic surgery got familiar in various fields. However single incision laparoscopic surgery for inguinal hernia is not so popular since TAPP procedures need suture and ligation that is technically difficult due to restriction of forceps handling. TEP may be suitable procedure for single incision hernia repair due to lack of those procedures. Purpose: We will evaluate and report our series of TEP with single incision. Methods: Procedure was carried out through 2 cm long skin incision made at umbilicus. Trocar was inserted into retro muscular space through silicon rubber lid (EZ access Hakko corporation Japan) fitted to wound retractor. Dissection of pre-peritoneal space was carried out by Laparoscopic coagulating scissors. After reduction of hernia and isolation of vas deference, polyester mesh and absorbable tacker were used to cover inguinal wall. Results: From March 2012, 215 patients received TEP with single incision. 87 patients had bilateral hernia (bilateral direct 28, bilateral indirect 24, direct and indirect 21, and other bilateral lesion 14) and rest 128 patients had unilateral hernia (direct 27, indirect 97, and femoral or obturator 4). Duration of procedures for unilateral lesion ranges from 21 min to 110 min (average 50 min). Those for bilateral lesion ranges from 25 min to 168 min. (average 77 min) 28 patients needed trans-peritoneal repair for peritoneal perforation. 4 patients needed conversion to open repair due to severe adhesion of preperitoneal space. All patients could discharge hospital within 2 days after surgery without any adverse event except 31cases of seroma. Average duration of initial 20 procedures was 55 min for unilateral lesion and 102 min for bilateral lesion. But for the most recent 20 procedures average duration was improved to 41 min for unilateral lesion and 60 min for bilateral lesion. Those results were similar to the result for open hernioplasty carried out during same period. (Unilateral 46 min bilateral 80 min) (Discussion) Our result of TEP with single incision demonstrated acceptable result. At the initial phase limitation of coaxial handling more affected treatment for indirect hernia. But it could be overcome as we have experienced procedures. Conclusion: Our result demonstrated that TEP hernia repair with single incision was feasible procedure.

Background/Aim: Laparoscopic repair of inguinal hernia is increasingly becoming the standard of care in many institutions. Our study aims to compare the outcomes of patients who underwent TEP inguinal hernia repair with mesh fixation with titanium tackers versus absorbable tackers. Methods: This is a retrospective study of a prospectively collected database of patients who underwent TEP inguinal hernia repair in a single institution from 2009–2013. 38 patients with titanium mesh fixation (Group A) were compared with 42 patients with absorbable mesh fixation (Group B). Data including demographics, presenting symptoms, intra-operative findings and post-operative complications were collected and analyzed using SPSS. Results: The mean age was 56 (range 26–86) in Group A and 49 (range 22–76) in Group B. 92.25% were males and the median ASA score was 2 in both groups. Most patients presented with groin pain (13% in A vs. 21% in B) and/or lump (58% in A vs. 60% in B). All procedures were performed as day surgeries, and all patients had a 10 9 15 cm large pore mesh inserted and fixed at Cooper’s ligament (n = 2–3 tacks) and lateral to the inferior epigastric vein (n = 1). The size of hernia defect was based on the European Hernia Society Groin Hernia Classification - the mean size being L3M1F1 in Group A vs. L2M2F1 in Group B. Post-operatively, no Group A patient, but 1 Group B patient, developed chronic pain. 3 patients in both groups developed seromas, which were treated conservatively. All patients were followed up for a mean period of 24 months (range: 1-48 months); there were no recurrences in Group B, while 1 Group A patient patient developed a direct and femoral hernia. Conclusion: Both titanium and absorbable tackers showed minimal post-operative complications and similar post-operative pain scores. As such, they both appear feasible for mesh fixation during inguinal hernia repair.

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Surg Endosc

P009 - Abdominal Cavity and Abdominal Wall

P011 - Abdominal Cavity and Abdominal Wall

Laparoscopic Repair of Paraduodenal Hernias: A Report of Three Cases

Laparoscopic Transabdominal Preperitoneal Ventral Hernia Repair with Self-Adhesive Mesh. Preliminary Results After First Year Follow-Up

Y. Suenaga Yokkaichi Municipal Hospital, YOKKAICHI, Japan Aims: Internal hernia is a rare cause of small bowel obstruction. Paraduodenal hernias (PDHs) are the most common form of internal hernias. Recently, laparoscopic surgery has increasingly been performed. However, there are few reports on the laparoscopic repair of PDH. We aimed to evaluate the feasibility and efficacy of laparoscopic repair in three patients with PDH. Methods: Three patients presented with symptoms of intestinal obstruction and were preoperatively diagnosed with left-sided PDH by computed tomography. An emergency laparoscopic surgery was performed in one patient, whereas elective procedures were performed in the other two patients. Results: The length of each surgery was 90-169 min. The hernia orifice was closed in one case and widely opened in two cases. There were no conversions. Postoperative length of hospital stay was 3–4 days. All of the patients uneventfully recovered. There were no recurrences. Conclusion: Three patients with PDH were successfully treated with laparoscopic surgery. This approach appears to be feasible and decreases the length of hospital stay. Therefore, when the diagnosis of PDH is preoperatively confirmed, laparoscopic repair should be considered because it is a feasible and effective method.

J. Bellido Luque1, J.M. Suarez Gra´u1, J. Gomez Menchero1, A. Bellido Luque2, J. Garcı´a Moreno1, A. Tejada Gomez3, J. Gualajara Jurado1 1

Riotinto Hospital, MINAS DE RIOTINTO, HUELVA, Spain; Quiro´n Sagrado Corazo´n Hospital, SEVILLE, Spain; 3Infanta Elena Hospital, HUELVA, Spain

2

Introduction: Laparoscopic ventral or incisional hernia repair requires intraperitoneal mesh placement. It‘s associated with an increase of adhesions, bowel obstruction and enterocutaneous fistula. Intraabdominal meshes are laparoscopically fixed using traumatic fixation as helicoidal or transfascial sutures that increase acute, chronic pain and adhesions to bowel loops. Aim: Prospectively check the safety and effectiveness of the laparoscopic approach in small and medium size ventral or incisional hernia, using a self-adhesive mesh in the preperitoneal space without traumatic fixation (tackers or transfascial sutures) and objectively assess its benefits and complications. Materials and methods: Patients aged between 18 and 67 years old with medial, lateral ventral and incisional hernias 3 and 8 cm size are included in this prospective Cohort study. 50 patients were included in the study, from January 2013 to March 2015. he average length of surgery was 55.6 ± 10,7 min (110–31 min range). The average hospital stay was 1.1 ± 0.4 days (1–2 days range). The average time for back to work was 9 ± 2.44 days (4–16 days range). The most common postoperative complication was seroma, in 13 patients (27,6%), all type 1 in the Morales et al. classification. Other complications were (Clavidien-Dindo grade 1): 1 Paralytic ileus and 1 Haematoma of the abdominal wall. The average follow-up was 13.68 ± 3.2 months (2210 months range). There were 3 lost during this period. There was no hernia recurrence during examination nor in CT scan, in the follow-up period. The average visual analogical scale before surgery was 4.12 ± 1.15 (2–6 range). After surgery were as follows: 3.03 ± 0.73 (2–4 range) on the first day after surgery, 0.8 ± 0.62(0–2 range) after the first week and 0 after the first month. No patient showed chronic pain. Conclusions: The use of self-adhesive meshes during laparoscopic transabdominal preperitoneal approach in small and medium size ventral or incisional hernias is safe and effective, with low postoperative pain and quick functional recovery after the surgery without increasing recurrences in short-term.

P010 - Abdominal Cavity and Abdominal Wall

P012 - Abdominal Cavity and Abdominal Wall

Single Incision Laparoscopic Trocar-in-Trocar Method Ventriculoperitoneal Shunt Placement in Adults

Laparoscopic Repair of Recurrent Inguinal Hernias After Preperitoneal Approach

J.Y. Lee, Y.F. Su, D.L. Tsai, Y.W. Liu, T.H. Tsai, J.S. Hsieh, Y.T. Chang, C.L. Lin

A. Umezawa

Kaohsiung Medical University Hospital, KAOHSIUNG, Taiwan Background: Ventriculoperitoneal (VP) shunt placement is the most common surgical treatment for hydrocephalus. Laparoscopic-assisted placement of vnetriculoperitoneal (VP) shunt has been introduced since early 1990s. According to a systematic review and metaanalysis from Clinical Neurology and Neurosurgery in 2016, laparoscopic approach is associated with improved distal complications (distal obstruction and distal shunt failure). Here, we present our experience by using a unique trocar-in-trocar method. Methods: From July 2012 through December 2015, total 110 adults with hydrocephalus were managed by single incision laparoscopic trocar-in-trocar method ventriculoperitoneal shunt placement. Ventricular catheter was inserted via Keen’s points. Hoffman shunt passer, made from stainless steel, with internal diameter 3.2 mm, outer diameter 4.2 mm and total length 61 cm was applied. The abdomen was accessed with a single 11-mm port via the umbilicus. A Y-shape laparoscope with working channel for grasper was inserted and used for both visualization and manipulation of the catheter. Under pneumoperitonium status, use the tip of the 11-mm trocar to apply the counterforce to help the Hoffman shunt passer’s tip pointed inward into the cannula of abdominal trocar (the trocar-in trocar method). Then the obturator was removed and the insufflation stopped to facilitate passing of the catheter. By means of this method, surgeons could easily check the function of catheter outside from the peritoneal cavity. It is also easily to eliminate the air in catheter by syringe. Restarted the insufflation when whole passer removed and the majority of the catheter left. The catheter was then modified the length and pulled into the peritoneal cavity by the grasper under laparsoscopic guide. Results: Excluding cases combined with other procedures, the average operative time was 50 min. Intraoperative complications, such as bleeding or visceral injury were not encountered. No perioperative infections were noted. There was no death related to this procedure. There was no case of conversion from laparoscopy to laparotomy. During follow up, only three cases need shunt revision for different reasons individually. Conclusion: Current technique is simple, quick, economical and effective as an alternative to the conventional laparoscopic assisted ventriculoperitoneal shunt placement which needed the other split abdominal trocar.

123

Yotsuya Medical Cube, TOKYO, Japan Back ground: The repair of the recurrent hernia especially after preperitoneal approach is considerable technique because of obscured anatomy and cicatrices. Some reported that laparoscopic approach for recurrent inguinal hernias has a low recurrence rate. The aim of this study was to evaluate the efficacy of laparoscopic repair of recurrent inguinal hernias after preperitoneal approach in our institution. Methods: 26 of 98 laparoscopic herniorrhaphies were recurrent hernia. There were 13 right, 10 left, and 3 bilateral hernias. Previous approaches were 9 of mesh plug repair (MPR), 7 of preperitoneal with mesh (PPM) and 12 of open anterior (OA). The mean interval time from previous operation to recurrence was 87 months (range 4–276 months), 18 mo. for MPR, 17 mo. for PPM and 21 mo. for OA. A total of 25 herniorrhaphies were performed using the transabdominal preperitoneal (TAPP) method. The mean operating time was 127 min (range 49–218 min), 132 min for MPR, 123 min for PPM and 126 min for OA. Results: There were no recurrences. There were neither complication nor mortarity. Mean postoperative stay was 1 day. It was felt by all of the patients that their symptoms were relieved. Conclusions: These preliminary data show that the laparoscopic repair of recurrent inguinal hernias after preperiotneal approach is effective in term of operative outcome. While laparoscopic hernia repair requires a learning curve, it shows advantages of early recovery with minimal hospital stay and low post operative complications.

Surg Endosc

P013 - Abdominal Cavity and Abdominal Wall

P015 - Abdominal Cavity and Abdominal Wall

The Role of Laparoscopic Approach in Bilaterality Assessment in Patients with Unilateral Inguinal Hernia

Bovine Pericardium Laparoscopic Hernioplasty in Both Indirect Inguinal and Femoral Hernia; Long-Term Outcomes

A. Marzouk, H. Omar

A. Dobradin1, K. Meiklejohn2, J.A. Manu2

Faculty of medicine, Cairo University, CAIRO, Egypt

1 Florida Hospital Medical Group, ORLANDO, United States of America; 2St Matthew’s University School of Medicine, ORLANDO, United States of America

Aim: Patients presented with unilateral inguinal hernia are at risk for the possibility of contra-lateral occult hernias; small early-developed hernias may be difficult to be elicited by clinical, imaging assessment and during open repair. This study to evaluate laparoscopic identification of contra. Methods: retrospective analysis of patients presented in the period of March to December 2015 with unilateral inguinal hernia for which medical and ultrasound imaging assessment were done. Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) approach was done with intraoperative evaluation of the presence of contra-lateral occult hernias. Results: During the study period (27) patients (25 Males and 2 females) presented with unilateral inguinal hernia were clinically evaluated, 18 (66.6%) patients had right sided hernia, 9 (33.33%) had left sided, In all the studied patients routine ultrasound assessment was done and no documented cases of presence of contra-lateral hernia, Intraoperative abdominal exploration successfully Identifies bilateral inguinal hernias in 7 cases (25.9%) with mean age (44.14 years, SD 10.99) compared to (34.97 years, SD 10.51) in the Unilateral group, 3 cases on the left side (16.6% of total right side patients) and 4 cases on the right side (44.4% of total left side patients). operative time for unilateral repair was (Mean 85.8 min, SD 18.8), and for discovered bilateral cases (Mean 145.9 min, SD 46.8). Conclusion: The presence of occult inguinal hernia is a frequent finding specially in older age group of patients, also in our study we found the percentage of occult hernias are more in patients presented with left side disease. Laparoscopic (TAPP) approach is a useful tool for assessment of the presence of such hernias, and gives the privilege of simultaneous repair in same operation with the advantage of avoiding the patient’s later surgery together with the laparoscopic surgery benefits of less pain, rapid recovery and shorter hospital stay.

Introduction: Groin hernia repair is a commonly performed procedure and many approaches can be employed in this repair. The need for minimal post-operative pain and faster recovery time favors the tension free laparoscopic repair technique in using an alloplastic implant. However, the rate of recurrence after a groin hernia repair still remains a challenge. In our study, we report the novel use of the bovine pericardium in both indirect inguinal and femoral hernia repair. The degree of post-operative pain, hernia recurrence rate, and overall patient satisfaction will also be reported. Methods: Implantation of bovine pericardium was used in 18 patients who underwent laparoscopic hernia repair (16 indirect inguinal and 2 femoral hernias). Four cases were performed emergently for incarcerated hernias, of whom 3 patients required small bowel resection. The patients were followed over an average period of 3 years 9 months. The group was comprised of 13 men and 5 women between the ages of 19 and 82 with 57.5 years as the mean age. The average duration of the hernia repair surgery was 54.8 min (between 25 and 86 min). Results: Only 44% of the patients required pain medication more than 24 h postoperatively. Majority of the patients returned to their preoperative physical activity level within the first week after surgery. There was only one reported hernia recurrence reported. Conclusion: Bovine pericardium graft can be used effectively in laparoscopic preperitoneal and transperitoneal repair of indirect inguinal and femoral hernias. The outcomes were excellent in both elective and emergency cases.

P014 - Abdominal Cavity and Abdominal Wall

P016 - Abdominal Cavity and Abdominal Wall

Psoas Abscess in a Pregnant Woman Secondary to Double Pathology - a Rare Occurrence

Laparoscopic Treatment of Giant Hiatal Hernias: Comparison of Two Types Approach in a Case Control Study

M. Aremu1, S.S. Ahmad2, M.A. Aremu2, K.H. Perthiani3

C. Bergamini, D. Bisogni, G. Alemanno, A. Sturiale, A. Bocchetti, G. Maltinti, E. Falsetti, A. Grapsi, P. Montanelli, A. Giordano

1

Letterkenny University Hospital, LETTERKENNY, CO. DONEGAL, Ireland; Letterkenny University Hospital, Letterkenny, Co. Donegal, Ireland, LETTERKENNY, Ireland; 3Our Lady of Lourdes Hospital, Drogheda, Co. Louth., DROGHEDA, Ireland Psoas abscess is a very rare complication in pregnancy. It creates difficulties in diagnosis and treatment. This condition can be primary or secondary resulting from the hematogenous process or extension from the nearby source to the psoas muscle. Due to the close proximity of the psoas muscles to the pelvic and abdominal organs and the rich vascular supply of the muscles, infections in these organs can contiguously spread to the psoas muscles. We report a case of a pregnant 34 years old woman in her third trimester who presented to the emergency department a week before her delivery with complaints of limping and lower abdominal discomfort. She was admitted by the obstetric and gynaecological team who managed her conservatively and was discharged home. Postpartum, she presented again with the same complaints and was assessed by the surgical team. She had CT abdomen which showed right psoas abscess. She had radiological percutaneous drainage of the abscess and was discharged home. She presented again four days postdischarge with spiking temperature and feeling unwell and a repeat abdominal CT showed recurrence of the right psoas abscess. A repeat percutaneous drainage was performed. However, she was not improving clinically and was taken to the theatre for a laparotomy which showed perforated appendix and thickened terminal ileum. Right hemicolectomy was performed. Histology revealed perforated acute appendicitis and complicated Crohn’s disease. Postoperative recovery was uneventful. 2

Careggi Teaching Hospital, FLORENCE, Italy A giant hiatal hernia (GHH) includes at least 30% of the stomach in the chest, although a uniform definition does not exist. The laparoscopic approach of GHH includes the possibility of a direct repair of the diaphragmatic defect or a prosthetic mesh patch application. In the last years the production of more suitable meshes may have made the mesh technique safer. Nevertheless, the best approach is still debated. Aim of our study is to present the results of a preliminary small-series case–control study on the outcome data from laparoscopically treated patients for GHH with or without the use of prosthetic mesh in a short term setting. Twelve patients (8 males and 4 females, aged 59,3 ± 11) laparoscopically operated on for GHH since the last five years were enrolled. In the first group of six patients, the diaphragmatic defect was repaired through two to ten direct prolene stitches (direct repair group). In the second group two kinds of meshe were used (PhasixTM Mesh and Double Mesh). The two groups were overlapping for the anagraphic and the main pathological data. The followed-up lasted up to 12 months. For the quality of time parameters (QoL), symptoms relapse or persistence were explored by the Visick and the GERD-HRQL. The operatory time was significantly longer in the mesh group (128 ± 12 vs 74 ± 21 min, p \ 0.01), whereas the blood loss and the recovery time were similar in the two groups. During the follow-up period, 3 patients of the mesh group presented adverse symptoms such as dysphagia (2 cases, 33.3%,), requiring endoscopic balloon dilatation in one case, and chest pain (1 case, 16.6%). One patient of the direct repair group had reflux recurrence (16.6%). Both Visick and GERD-HRQL were progressively increasing, but no significant difference was noticed among mesh and direct repair patients. In conclusion: this preliminary case–control study, with the only bias of the small number of patients and the use of two kinds of prosthesis, shows that the mesh repair of GHH seems to be a significantly more technically demanding procedure, without showing a better either post-operative either follow-up result.

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Surg Endosc

P017 - Abdominal Cavity and Abdominal Wall

P019 - Abdominal Cavity and Abdominal Wall

Port Site Umbilical Hernias: Are They Different?

Laparoscopic Management Of Mirizzi Syndrome

1

D. O’Dwyer , T. Smith-Walker

2

1

M. Ghazanfar, M. Habib

Royal Cornwall Hospital Truro, GLASGOW, United Kingdom; 2Royal Cornwall Hospital, TRURO, United Kingdom Aims: The incidence of trocar site hernia is around 1% following laparoscopic surgery with a significant number occurring at the umbilical region. The aim of this study is to evaluate the presentation and most common source of port site umbilical hernia. Methods: Data was retrospectively collected on females who underwent surgical management of an umbilical hernia in the 5 year period between 01/01/10 and 31/12/ 15. Only those with a diagnosis of umbilical hernia following laparoscopy were included in the study. Patient notes were reviewed to collect data on the initial laparoscopic procedure, the presentation and symptoms of umbilical hernia and details of the hernia repair. Results: Five-hundred and eight females had an umbilical hernia repair and 43 (8%) of these were associated with a previous laparoscopic procedure. Mean age at diagnosis was 50.5 years and the mean length of time between laparoscopy and umbilical hernia repair was 3.9 years (range 7 days–14.3 years). The most common laparoscopic procedure was cholecystectomy (58%). Sheath closure was described in only 65% of all patients. The most common presenting symptom was a painful mass (46.5%), painless mass (21%), acute presentation (12%) and incidental finding (21%). The most common method of repair was open repair (72%). Conclusion: Laparoscopy is associated with a significant number of port site umbilical hernias. These have a similar presentation to primary hernias at this site.

NHS, ABERDEEN, United Kingdom

P018 - Abdominal Cavity and Abdominal Wall

P020 - Abdominal Cavity and Abdominal Wall

Tapp Hernioplasty without Mesh Fixation

Factors Associated with Recurrence After Laparoscopic Incisional Hernia Repair

L. Marko, L. Kokorak Roosevelt Hospital, BANSKA BYSTRICA, Slovak Republic Aim: The most accepted technique for inguinal hernia repair is TAPP procedure.Very important for postoperative result are precise anatomic preparation, type of the mesh and mesh fixation. Method - we perform at our Department of minimally invasive surgery TAPP hernia repair more than 10 years. In the beginning we started with hevyweight mesh and 3-point fixation. Now we use every time lightweight mesh with big pores 10 9 15 cm. Most of the meshes are partially resorbable meshes. Preparation is now more extensive than before - till midline and rectovesical connection. In patients with indirect or small direct inguinal hernia we use mesh without fixation. We fixed mesh only in patients with big direct hernia near midline if mesh can’t oversize defect more than 3 cm in all directions. Result: In last 10 years we performed 800 TAPP procedures. 692 (87%) were primary hernias, 108 (13%) were recurrent hernias but only 7 (0,9%) after previous TAPP. But in the last 4 years we dont record any recurence. In 240 (30%) patients we used mesh with 3-point fixation using hernia stapler but in 560 (70%) we used mesh without any fixation. Median operative time was in 2006 - 64,7 min and in 2015 - 38 min. Hospital stay is 1–2 days, and all of the patients can be active from the the day of operation. Conclusion: the most easy and effective procedure for inguinal hernia repair is TAPP. It is very important create adequate space by precise preparation in inguinal region for 10 9 15 cm mesh. Widely is recommended using of the lightweit mesh, partially absorbable. In our experiences mesh fixation is not necessary by indirect and small direct primary hernias where mesh overlap hernia defect in all directions more than 3 cm. By big direct hernia defect and by recurrent hernia is fixation recommended.

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Aims: Mirizzi syndrome is a rare complication of gallstone disease. First described in 1948 the condition can present in 0.05% to 2.5% of patients with cholelithiasis. Two commonly described types are external compression on CBD (type I) and cholecysto-choledochal fistula (type II). Patients usually present with obstructive jaundice. Surgery is challenging due to high risk of bile duct injury. Open surgery is thought to be the recommended treatment. Recent literature shows some reports about laparoscopic management but mainly for type I mirizzi. We retrospectively reviewed our experience of laparoscopic management of patients with mirizzi syndrome in a prospectively collected database. Methods: Patients operated for mirizzi syndrome from jan 2015 to dec 2015 in HPB unit of a tertiary care University Hospital were identified. Their clinical presentation, surgical management and post-operative course was reviewed. Patients were followed up in clinic to assess the long term outcome. Results: Three patients (all female) with mean age of 54 yrs were presented with mirizzi syndrome (1 type I and 2 type II) out of 103 laparoscopic cholecystectomies over a period of one year, incidence 2.9%. Initial presentation was with obstructive jaundice. All patients had US and two had MRCP to confirm the diagnosis. All patients have had preoperative ERCP and stent insertion due to inability to remove the stones. One patient developed post ERCP pancreatitis. A laparoscopic choledochoplasty was successfully performed in all patients and no patient needed a T-tube. None of the patients have post operative bile leak and drain was removed on day 2 in all. Two patients were discharged on day 2 and 3rd had delayed discharge (day 7) due to seizure disorder (mean hospital stay 4 days). At a mean follow up of 2 months all patients were asymptomatic. Conclusion: Open bile duct exploration is current gold standard for management of mirizzi syndrome. Review of literature shows that laparoscopic approach is emerging for type I mirizzi but not for type II. In our experience laparoscopic management of Mirizzi syndrome (type I&II) can be safely performed with good clinical outcomes.

G. Celona, N. Romano, D. Pietrasanta, F. Filidei, C. Bagnato, S. Sergiampietri Health Unit 5 - Pisa, PISA, Italy Recent reviews have indicated that the recurrence rate after laparoscopic repair of incisional hernia is 3–4%. Many factors were considered associated with recurrence. Technical pitfalls as small size of the mesh with an inadequate overlap of the defect, weak fixation or unrecognized abdominal wall defects are the most frequent causes of early recurrence. Excluding technical errors, surgical site infection, previous hernia repair, operator learning curve, obesity are independent risk factors for recurrence. Here we report our opinion about this matter, emerged from the analysis of our series.From September 2012 to December 2015 we performed laparoscopic repair of incisional hernia in 51 patients. In all procedures a flexible composite mesh (Physiomesh, Ethicon), overlapping the margins of the defect by at least 5 cm, was fixed with a double ring of absorbable tacks alone. Mean follow-up time was 16 months (range 1–39 months). Hernia recurrence was clinically evident in 3 patients (5.8%), confirmed by CT scanning. All 3 patients underwent laparoscopic hernia repair in our institution. All recurrences appeared just outside of the area of the previous defect, at the site of the apparently sufficient original incision scar. Previous mesh repair has always proved technically correct. A new repair was always performed successfully with placement of a new larger mesh placed over or next to past repair.Our experience supports the concept that insufficient coverage of the incision scar by mesh is a risk factor for recurrence because the entire incision has a potential for hernia development.

Surg Endosc

P021 - Abdominal Cavity and Abdominal Wall

P023 - Abdominal Cavity and Abdominal Wall

Analysis of Transabdominal Prepertitoneal Repair for Recurrent Inguinal Hernia

Suturing Techniques for Closure of Fascial Defect During Laparoscopic Ventral Hernia Repairs : A Review of The Literature

H. Kajioka, M. Inagaki, K. Isoda, K. Iwakawa, H. Iwagaki National hospital organization fukuyama medical center, FUKUYAMA-SHI, Japan

A. Urakami Kawasaki Medical School, OKAYAMA, Japan

Indication: Transabdominal preperitoneal approach (TAPP) of operations for inguinal hernias tends to increase in Japan. We investigated whether TAPP for recurrent hernias could be comparable to primary hernias regarding as perioperative factors. Methods: We reviewed 108 patients who underwent TAPP for inguinal hernias. Of these, 97 patients had primary hernia (Group 1) and 11 had recurrent hernia (Group 2). We used Japanese Hernia Society (JHS) classification for diagnosing types of hernia site (type 1: external inguinal hernia, type 2: internal inguinal hernia) and Clavien-Dindo classification for postoperative complications. We evaluated operative factor, complications, postoperative hospital stay and total amounts of analgesics during hospital stay. Results: In Group 1, type? was observed a lot (74%). On the other hand, type? was accounted for 73% in Group 2, but they were not significant(p = 0.103). Although operative procedures for recurrent cases were more difficult than in primary cases due to adhesions of primary surgery, mean operative time was 115 and 119 min (p = 0.431) and mean blood loss 2 and 0.6 ml (p = 0.67) in Group 1 and 2, respectively, those operative factors were not significant. Mean postoperative hospital stay was 4.3 and 5 days (p = 0.096), and mean total amounts of analgesics 2 and 0.7 (p = 0.299) in Group 1 and 2, respectively. Hospital stay was a little longer in Group 2, but not significant. There was no significant difference in incidence of complications between 2 groups (Group 1: Grade ? in 10 cases, Grade ? in 2, Grade ? in 1, Group 2: Grade ? in 3 cases). Seroma was evoked in 9 cases (9%) and 1 case (9%) in each group (p = 0.984). No recurrence was seen in either group. Conclusions: TAPP for recurrent hernias was technically more difficult than for primary cases, but outcomes of perioperative factor were comparable to those of primary cases. Therefore, TAPP might become an effective option of procedures for recurrent hernias.

Background: The technique for laparoscopic ventral hernia repair (LVHR) is now well established, using standard laparoscopic intraperitoneal onlay mesh repair (IPOM). Laparoscopic fascial defect closure with IPOM reinforcement (IPOM-Plus) has been introduced in the past decade, and some studies have reported satisfactory outcomes. Although detailed techniques of fascial defect closure and handling of the mesh have been published, standardized techniques are yet to be established. AIM: This review evaluated the suturing techniques and outcomes of fascial defect closure during LVHR with mesh that have been reported in the literature. Methods: A literature search of PubMed database was conducted and identified 17 reports in which the suturing technique and recurrence rate were described. Results: The fascial defect closure techniques could be classified into extracorporeal or intracorporeal, and by the use of interrupted or continuous sutures. 8 reports described extracorporeal, 7 described intracorporeal, and 2 described both techniques. 5 reports described continuous and others described interrupted techniques. The most popular technique was the extracorporeal interrupted sutures using suture passer. The unique techniques, including ‘double-breasting sutures’, ‘far near far near vertical mattress sutures’, ‘shoelacing technique’, and ‘reverse U stitch’ were reported. 2 reports of robotic surgery described intracorporeal continuous suturing. The recurrence rate was reported to be quite variable, 0 to 7.6%, however 10 reports described 0%. Conclusion: Several comparison studies between IPOM and IPOM-Plus seem to suggest that IPOM-Plus is associated with lower recurrence rate, and more favorable surgical outcomes. Although the techniques for fascial defect closure varied, those techniques might be necessary to perform secure repair.

P022 - Abdominal Cavity and Abdominal Wall

P024 - Abdominal Cavity and Abdominal Wall

Laparoscopic Postoperative Ventral Hernia Repair with LowCost Polymeric Mesh: Clinical and Economic Results

Tapp Laparoscopic Repair for Inguinal Hernia Using Glue Fixation - Our Initial Experience

D.N. Panchenkov1, Y.U.V. Ivanov2, P.V. Kudryavtsev3, Y.U.A. Stepanova4, N.A. Soloviev2, A.V. Baranov5, A.I. Zlobin1, M.V. Zinovsky2, V.S. Chugunov1

V. Calu1, R. Parvuletu2, M. Oun2, A. Miron2

1 A.I.Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 2Federal Research Centre of Specialized Medical Care and Medical technologies FMB, MOSCOW, Russia; 3Reutov Central Clinical Hospital, REUTOV, Russia 4Vishnevsky Institute of Surgery, MOSCOW, Russia; 5State Research and Clinical Center of Laser Medicine FMBA, MOSCOW, Russia

The high price of surgical meshes for intraperitoneal laparoscopic postoperative ventral hernia repair limits of their usage in some clinics and even some countries. The search of an adequate low-cost alternative permits to remove this restriction. Aim: to estimate the clinical and economic effect of usage the low-cost polymeric mesh in patients undergone laparoscopic postoperative ventral hernia repair. Methods: we have the first experience of treatment of 24 patients with postoperative ventral hernias, who underwent intraperitoneal laparoscopic ventral hernia repair with new low-cost polymeric mesh with antiadhesive cover. All the patients had abdominal adhesions - consequently all the operations have started with adhesiolysis. The technique of mesh implantation and fixation was standard and had now difference with other meshes. Results: There were no complications in early postoperative period. The middle time of hospital stay was 5,5 days (3–8 days). All the patients receive antibacterial therapy with cephalosporins for 5 days. All the patients underwent US and CT investigation in 3–5 months after the procedure. There were no mesh migrations and recurrent hernias. According to CT scans the mesh integration with abdominal wall noticed in all cases. The quality of life estimated according questionnaire SF-36. The control group was 78 patients, who undergone the same procedure with well-known meshes. Conclusion: The results of the study shows the same clinical results in both groups with significantly better economic effect in main group.

Elias Hospital, BUCHAREST, Romania; 2Elias Emergency Hospital, BUCHAREST, Romania

1

Aims: TAPP laparoscopic repair is gaining wide acceptance in the last years. There are several concerns regarding this technique, such as dangerous anatomical areas, postoperative pain, and recurrence rate. To overcome those aspects we used glue fixation with a novel device (Fix 8). Methods: We performed a retrospective study of our initial experience of TAPP with glue fixation. A group of 13 patients were operated during 2015. All subjects were male, aged between 26 - 59 y.o. Most of them (12 pts.) had unilateral hernia. Results: A proper and safe fixation was obtained in all cases, with no recurrence encountered. There was no postoperative pain, patients were able to resume normal activity after 2 weeks. No allergic reactions, deep pelvic infections or other complications were observed. Conclusion: Glue fixation seems to offer a proper and safe mesh fixation during TAPP repair, without any concerns regarding dangerous areas and no postoperative pain. This allows a faster recovery and return to normal activity for the patients.

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Surg Endosc

P025 - Abdominal Cavity and Abdominal Wall

P027 - Abdominal Cavity and Abdominal Wall

Controversies in Laparoscopic Ventral Hernia Repair

Incidence of Obturator Hernias During Laparoscopic Inguinal Hernia Repair

1

2

N. van Veenendaal , M.M. Poelman , H.J. Bonjer

3

1

VU University Medical Center, AMSTERDAM, The Netherlands; 2 Sint Franciscus Gasthuis, ROTTERDAM, The Netherlands; 3 COLOR II Study Group, The Netherlands

I.O. Avram1, M.F. Avram2, D. Koukoulas3, S. Olariu2 1

CaritasKlinikum Saarbrucken, SAARBRUCKEN, Germany; University of Medicine and Pharmacy ,,Victor Babes,, Timisoara, TIMISOARA, Romania ; 3City Hospital Lugoj, LUGOJ, Romania

2

Aim: The introduction of laparoscopy as a surgical technique provided a method which allows for preventing major abdominal wall incisions and improving recovery of the patient after surgery. In abdominal wall surgery, laparoscopic ventral hernia repair has proven to be at least as safe as open repair. However, the technique of laparoscopic ventral hernia repair has not been standardized. Despite all the research that has been conducted and all the articles that have been published, there still seems to be a lack of consensus about the best method to repair a ventral hernia. Aim was to review knowledge on incisional hernias and discuss several controversies regarding the laparoscopic management of ventral hernias. Methods: A review of the literature was undertaken, and a search identified twenty records: six RCTs on incisional hernias, five RCTs on ventral hernias, and nine reviews or metaanalyses. Results: Interpretation: of the scientific data was difficult because the outcomes in literature were often based on pooled data of primary ventral hernias and incisional ventral hernias. Controversy remains regarding the optimal laparoscopic management of ventral hernias in terms of selection of patients for laparoscopic repair, optimal technique, outcomes and cost-efficacy. Conclusion: Lack of evidence allows persisting controversies in laparoscopic ventral hernia repair. RCTs and registries are necessary to document efficacy, morbidity, quality of life and costs during a sufficient period of time to provide clinicians with the evidence required to make the right choice for the best surgical technique.

Background: Obturator hernia is an extremely rare entity, with a incidence of up to 0.14% of all hernias. Its diagnosis is difficult, being often missed, resulting in high rates of complications. One advantage of laparoscopic inguinal hernia repair is the opportunity to identify occult hernias. Whereas femoral hernias are often described as an intraoperative finding especially in female patients, obturator hernias still remain a rarity and these patients often present with acute small-bowel obstruction Methods: We studied the case files of 221 patients who underwent an elective inguinal hernia repair in our two clinics, between 01.01.2010-31.12.2015 by the same two operating teams who routinely checked for occult obturator hernias. The patients’ demographic data, medical history, operative findings and outpatient follow-up were studied. Results: A total of 303 laparoscopic hernia repairs were performed in 221 patients. There were 245 male patients and 58 female patients with a mean age of 46 years. Of these we found a number of 6 obturator hernias containing fat. The majority of occult hernias were found during TEP repair (4 Pts, 1 bilateral) and only one was discovered during TAPP repair. Conclusion:The incidence of obturator hernias seems to be much higher than described in literature. In our study the incidence of occult hernia findings during TEP hernia repair was much higher than in TAPP repair, as TEP approach allows viewing of the entire myopectineal orifice.

P026 - Abdominal Cavity and Abdominal Wall

P028 - Abdominal Cavity and Abdominal Wall

Hybrid Technique for Management of Large Flank Hernias

Laparoscopic Parastomal Hernia Repair: Modified Sugarbaker with Defect Closure, Technique and Results

S. Kalhan, V. Bindal, M. Khetan SIR GANGA RAM HOSPITAL, NEW DELHI, India Aim: laparoscopic management of large flank hernias remains a big challenge for all surgeons because of the high recurrence rates associated with both open and laparoscopic approach. We aim to develop an innovative hybrid technique accumulating the benefits of both repairs. Method: 12 large flank hernias were managed using this hybrid technique at our center from May 2012 to June 2015. Six out of these 12 were secondary to donor nephrectomy scars, 4 were large lumbar incisional hernias and 2 were hernias from Kocher’s incision. The average size of the defect was over 10cms.in all these cases we combined 3 steps. Step one: diagnostic laparoscopy, adhesiolysis and reduction of contents. Step two: anatomical layered repair through the previous scar, followed by an onlay repair. Step three: laparoscopic intraperitoneal onlay repair. Result: this hybrid sandwich technique provided double strength to the much weakened muscles and also took care of the bulge which persists after laparoscopic IPOM repair. Conclusion: We have seen in our clinical practice a high incidence of recurrence of flank hernias after laparoscopic as well as open mesh repair. The combined hybrid technique of IPOM plus accrues the benefits of both techniques to give best long term results in terms of recurrence as well as patients satisfaction. Short video demonstrating our technique.

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S. Udomsawaengsup1, P. Vichajarn2, N. Boonyagard1, R. Tanomphetsanga1, K. Kitisin1, S. Pungpapong1, C. Tharavej3, P. Navicharern1 1

Chulalongkorn Minimally Invasive Surgery Center, BANGKOK, Thailand; 2Chonburi Hospital, CHONBURI, Thailand; 3 Chulalongkorn University, BANGKOK, Thailand Introduction: Parastomal hernia is a common complication after stoma formation and associated with high incidence of recurrence after treatment. We reviewed our techniques and results of laparoscopic parastomal hernia repair with and without defect closure. Methods: Patients who underwent parastomal hernia repair were reviewed. After diagnostic laparoscopy was complete, lysis of adhesion was done. Size of defect was measured, stoma was mobilized laterally to the defect. In defect closure group, the defect was closed with prolene no.1 in two fashions; 1. transfascial suture if there was no contamination in suturing placement area and 2. intracorporeal suture if contamination was expected. Suture was tied after relief of intra-abdominal pressure and re-insufflation was done again after knot tying. Physiomesh was introduced, placed and fixed to abdominal wall in Sugarbaker fashion. Patients with more than one year follow up were reviewed. Results: From January 2010 - December 2015. There were 31 parastomal hernia repairs in 29 patients. 27 were repaired laparoscopically. 25 were modified Sugarbaker techniques of these, 18 were defect closure. There were 19 Sugarbaker-patients who had more than 1 year of follow up. Average age was 71.4 and 62.6 in defect closure and non defect closure respectively. Hernia size was 5.34 cm. 89.5% was end colostomy and ileostomy. Mean time to hernia development was 22.5 months. Average post operative pain (closure/non closure) was significantly different (post op day 1st, 2nd and 3rd were 4.33/4.71, 2.88/3.16 and 1.88/ 2.80 respectively). There was one defect closure patient who developed surgical wound infection required drainage and successfully treated conservatively. One hernia recurrence was found in non defect closure group that required stomal relocation. There was no clinically recurrence in defect closure group. Conclusion: Laparoscopic Modified Sugarbaker is safe and effective for parastomal hernia repair. Defect closure seems to provide better result with no significant increasing postoperative pain and any additional complication. Recurrence and long-term outcomes need longer follow up.

Surg Endosc

P029 - Abdominal Cavity and Abdominal Wall

P031 - Abdominal Cavity and Abdominal Wall

Laparoscopic Spleen Preserving Distal Pancreatectomy for Intrapancreatic True Aneurysm, Case Report and Review of the Literature

Years Experiece at Tei Closing the Defect Before Mesh Placement in Laparoscopic Incisional, Ventral, Umbilical, and Spigelian Hernia Repair

H. Fahimi, N. Rashidian

M. Hernandez, M. jr Franklin, J. Glass

Iranmehr hospital, TEHRAN, Iran

Texas Endosurgery Institute, SAN ANTONIO, United States of America

True intrapancreatic aneurysm is an extremely rare entity and like other rare conditions its optimal treatment is still in doubt. There are few reports of laparoscopic resection of peripancreatic aneurysm along with splenectomy, but there is just one case report of intrapancreatic true aneurysm that has been treated by open distal pancreatectomy and concomitant splenectomy. Here we report a rare case of intrapancreatic true aneurysm in the pancreatic tail, which radiologically was not distinguishable from pancreas tumor. The patient underwent a successful laparoscopic spleen-preserving distal pancreatectomy. Laparoscopic resection is a safe and feasible option for treatment of intrapancreatic true aneurysm.

Introduction: The repair of incisional, umbilical, and primary ventral hernia remains a challenge, traditionally; laparoscopic ventral and incisional hernia repairs have been performed with mesh by forming a bridge between defect’s hernia edges. Some ones around the world started to close the defect before reinforcement mesh placement, lowering the complications and hernia recurrence. The aim of this is study is demonstrating our experience in the field of laparoscopic ventral and incisional hernia repair with defect closure before reinforcement mesh placement at Texas Endosurgery Institute. Materials and methods: We performed a prospective study at Texas Endosurgery Institute, from February 1991 to December 2015, all the patients that underwent laparoscopic ventral, incisional, and umbilical hernia repair with defect close and mesh placement were included in this study, and the information was analyzed. Results: A total of 1512 patients were included in the study, 680(44.9%) were male and 832 (55.1%) were female. 936(62%) were laparoscopic ventral and incisional hernia repair, 556 (37%) laparoscopic umbilical hernia repair, and 20 Spigelian hernia repair. All of them with defect closer before mesh placement. 249 (16.5%) had type 2 Diabetes, 40 (2.7%) had chronic obstruction pulmonary disease COPD, we found 38(2.53%) recurrences, 33 of them in incisional and ventral hernias repaired, and 5 of them in umbilical hernias repaired. 8 of the recurrences had COPD. Surgery length was 58 min (45 - 340), and surgery blood loss was 22 ml (10 - 250 ml). Conclusions: We have demonstrated that the hernia defect close before mesh placement in laparoscopic ventral, incisional, and umbilical hernia repairs is safe and feasible, and decreases seroma formation, infection, and recurrence hernia rates.

P030 - Abdominal Cavity and Abdominal Wall

P032 - Abdominal Cavity and Abdominal Wall

Radical Laparoscopic Operations in Oncology: Our 5-Year Experience

Prospective Randomized Trial of Mesh Fixation with Absorbable Versus Nonabsorbable Tacker in Laparoscopic Ventral Incisional Hernia Repair

S. Baydo, A.B. Vinnytska, A.V. Zhygulin, D.A. Golub, A.S. Oparin, S.I. Pryndyuk LISOD - Hospital of Israeli Oncology, KYIV, Ukraine Aim: The use of laparoscopic access in cancer surgery is constantly increasing. It became a standard for some procedures: laparoscopic hysterectomy, colon resection, laparoscopic gastrectomy for early cancer in Japan. We want to report our experience in performing radical oncologic operations laparoscopically. Methods: In this study we analysed 1745 consecutive laparoscopic operations performed in our oncologic clinic. There were 860 (49,3%) radical surgeries for various cancers among them: colorectal resection - 272, gastrectomy with D2- lymphadenectomy - 78, esophagectomy - 11; anatomical liver resection - 13, pancreatic resection - 10. For gynaecological malignancies - 345 operations, including 110 radical hysterectomy with pelvic and paraaortal lymphadenectomy. For urologic cancers - 120 interventions: radical nephrectomy - 71, partial nephrectomy - 41, prostatectomy - 7, cystectomy - 1. There were 11 pelvic exenterations with formation of uretero-ileoconduit for recurrent and complicated pelvic tumors. Simultaneous operations (cholecystectomy, hernioplasty) were in 115 patients (13.4%). Results: The number of removed lymph nodes, as an indicator of radicalism, was: after pelvic lymphadenectomy for gynecologic cancers - 19.4, after colorectal resections - 18.2, after gastrectomy - 17.9. The average duration of the operation was: simple hysterectomy with pelvic lymph node dissection - 92 min, radical hysterectomy (C1) for cervical cancer - 165.4, total gastrectomy - 235, anterior resection of rectum - 148.4. Complications after surgery occurred in 157 patients (18.2%). Severe complications (grade III-IV (Dindo, 2004)), i.e. lifethreatening (stroke, myocardial infarction) and requiring reoperation (anastomotic leakage, intestinal obstruction) were in 49 (5.7%). The complication rate depends on the complexity and duration of the intervention: the lowest rate - 8.8% was after gynecological operations, the highest - after exenteration and gastrectomy - 73 and 27.6%. Conversion rate - 0.6%. Postoperative mortality - 0.9% (8 patients died). Conclusions: With a number of advantages for both the patient (less abdominal wall trauma, pain, blood loss, early recovery) and surgeon (excellent visualization) laparoscopic oncosurgery improves postoperative results (complications, mortality, length of stay) without compromising oncological principles. The undoubted advantage of minimally invasive technologies is the ability to perform simultaneous operations in different parts of the abdominal cavity without increasing access trauma.

N. Ozlem1, C. Elif2, G.O. Kucuk2, G.O. Kucuk2, R. Aktimur2, H. Calis3 1

This work was supported by the AhiEevran University, KIRSEHIR, Turkey; 2Samsun education and research hospital, SAMSUN, Turkey; 3 AHIEVRAN UNIVERSITY research and education hospital, KIRSEHIR, Turkey The aim of this prospective randomized trial was to compare 2 main fixation devices in regard to pain andrecurrence in laparoscopic ventral incisional hernia repair (LVIHR). A total of 51 patients were evaluated in this study(n = 25, nonabsorbable tack (NAT) and n = 26, absorbable tack (AT) groups). A visual analogue scale (VAS) wasperformed on both groups preoperatively and on the postoperative (PO) first day, second week, and sixth month.All patients were followed for recurrence by clinical examination, ultrasonography, and/or abdominal computed tomography.The median follow-up time was 31 months (15–45). The mean age and the mean body mass index (BMI)of the patients were 53.1 ± 11 years and 34 ± 5 kg/m2, respectively. The median defect size was 60 cm2 (35–150)and median operation time was 110 min (40–360). In 2 patients from AT group and 2 from NAT group (7.8%),recurrence occurred. The 2 groups had similar features regarding demographics, operation time, postoperativehospital stay, morbidity, and VAS scores. The 2 fixation methods were found similar for PO pain and recurrence. Inour opinion, the choice of either of these fixation methods during surgery should not be based on the concerns ofpain or recurrence. AT may be the preferable option in LVIHR due to the lower cost.

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Surg Endosc

P033 - Basic and Technical Research

P035 - Clinical Practice and Evaluation

Comparison of Reduced Port Totally Laparoscopic Total Gastrectomy (Duet TLTG) and Conventional Laparoscopic Assisted Total Gastrectomy

Comparison of Clinical Outcome of Laparoscopic Versus Open Appendectomy for Complicated Appendicitis

H.B. Kim, J.H. Lee, S.M. Kim, M.H. Ha, J.E. Seo, J.E. Kim, M.G. Choi, T.S. Sohn, J.M. Bae, S. Kim

¨ BINGEN, Germany University Hospital Tu¨bingen, TU

Samsung medical center, SEOUL, Republic of Korea Background: Laparoscopic-assisted total gastrectomy (LATG) has advantages compared with open total gastrectomy such as shorter recovery time, lesser pain, and better cosmetic outcomes. However, cases of single or reduced port LATG have been rarely reported. The aim of this study was to compare surgical outcomes of patients with gastric cancer undergoing reduced port totally laparoscopic total gastrectomy (duet TLTG) with those of patients undergoing conventional LATG. Methods: Between January 2013 and January 2015, 30 patients with gastric cancer underwent duet TLTG at the Samsung Medical Center. These patients were compared with surgical outcome of 24 patients who underwent conventional LATG. Results: Operating time was similar for duet TLTG and conventional LATG (222 min [range 163–287] vs. 233 min [range 170–310], respectively; P = 0.807). Blood loss during surgery was also similar between duet TLTG and conventional LATG groups (100 mL [range 50–400] vs. 175 mL [range 50–400], respectively; P = 0.249). The quality of lymph node dissection, including the median number of nodes dissected (duet TLTG vs. conventional LATG, 47 [20-67] vs. 41 [22–70], P = 0.338), did not differ significantly between the groups. The median postoperative hospital stay was similar (duet TLTG vs. conventional LATG, 8 [7–34] vs. 7 [7–12], P = 0.333). Pain scores were 3.9, 3.3, and 2.9, and 3.9, 3.4, and 2.8, at postoperative days 1, 3, and 5, respectively, in the duet TLTG and conventional LATG groups (P = 0.857, 0.659, and 0.427). Complication rates in the duet TLTG and conventional LATG groups were not significantly different (36.7% vs. 16.7%, P = 0.103). Also for morbidities according to Clavien-Dindo classification, both groups had similar results (Grade 1 & 2, 27.3% vs. 66.7%, Grade 3 & 4, 72.7% vs. 33.3%, P = 0.207). Conclusions: Duet TLTG is an acceptable procedure with quality of lymph node dissection, including the number of dissected lymph nodes and morbidity, but requires a learning period for practitioners to become proficient and gain experience.

P. Horvath

Background: Laparoscopic appendectomy constitutes the treatment of choice in uncomplicated appendicitis. Till today its importance in the treatment of complicated appendicitis is not clearly defined. Methods: From January 2005 to June 2013 in total 1762 patients underwent appendectomy for the suspected diagnosis of appendicitis. 1516 patients suffered from complicated appendicitis and were enrolled. 926 (61%) underwent open appendectomy and 590 (49%) underwent laparoscopic appendectomy. The following factors were analyzed: age, sex, operating times, histology, length of hospital stay, 30-day morbidity focusing on occurrence of surgical site infections, intraabdominal abscess formations, postoperative ileus and appendiceal stump insufficiency, conversion rate, use of endoloops and endostapler and microbiological analysis. Results: There was a statistically significant difference in operating time between the laparoscopic and the open group (60 vs. 64,5 min; P = 0.0024). Median length of hospital stay was 4 days in the open 3 days in the laparoscopic group and was highly significant (P = 0,000000000000172). Surgical site infections exclusively occurred in the OA-group (38 vs. 0). Intraabdominal abscess formation occurred statistically significant more often in the LA-group (2 vs. 10; P = 0.002). There were no statistical significances concerning the occurrence of postoperative ileus (5 vs. 1; P = 0.26) and appendiceal stump insufficiencies (0 vs. 2; P = 0.076). Conclusions: The laparoscopic approach for complicated appendicitis is a safe and feasible procedure. Surgeons must be aware of a higher incidence of intraabdominal abscess formation following laparoscopic appendectomy. Use of endobags, inversion of the appendiceal stump und carefully conducted local irrigation of the abdomen in a supine position may reduce the incidence of abscess formation.

P034 - Basic and Technical Research

P036 - Clinical Practice and Evaluation

Continuous Dissection Using Ultrasonic Scissors with Short-Pitch Technique Results in Higher Blade Temperature Compared to Full-Pitch Technique

The Forgotten Biliary Stent: Should we Implement a Registry?

K. Shibao, F. Joden, Y. Adachi, Y. Kudo, Y. Kikuchi, N. Matayoshi, K. Takahashi, T. Shundo, R. Murayama, K. Hirata University of Occupational and Environmental Health, KITAKYUSHU, Japan Background: Ultrasonic technology uses high-frequency mechanical vibration to combine cutting and coagulating. It gives us the precise dissection with less bleeding in various surgical procedures including laparoscopic gastrectomy (LG). Meanwhile, thermal injury caused by ultrasonic scissors can lead to fatal complications in laparoscopic gastrectomy (LG). Thus, it’s important to manage blade temperature of ultrasonic scissors for safety. There are two kinds of handling technique for ultrasonic scissors. One is short-pitch technique, and the other is full-pitch technique. The short-pitch technique is the technique to fire the shears with blades closed when a small amount of tissue is present in a distal 1/4 of the blade. This technique is appropriate for precise dissection including lymph node dissection in LG. The full-pitch technique is dissecting the tissue using entire the blade of ultrasonic shears, which is applicable for fast and rough cutting. Many reports demonstrated the thermal profile using ultrasonic scissors. However, no report was focused on the thermal profile difference coming from device handling, which provide valuable information for actual clinical usage. In this study, we examined blade temperature with two different techniques and evaluated the safe usage of the ultrasonic sissors. Methods: In ex vivo benchtop, safety of short-pitch technique was evaluated with that of full-pitch technique with respect to blade temperature using an infrared camera. The cutting speed and the blade temperature were measured during and after continuous dissection of a defined length of muscle (10 cm of muscle) under an axial tension of 10 g on the muscle with maximum power mode (Sonicision, Medtronic). The time to decline to 60 C after activation was also recorded. Results: Ex vivo tests of short-pitch technique demonstrated significantly higher blade temperature and longer time for returning to baseline than full-pitch technique after the completion of cutting 10 cm (334 C and 183 C, respectively, P \ 0.001; 79 s and 33 s, P \ 0.001). Conclusion: Although the short-pitch technique enables us to ensure precise lymph node dissection in LG, continuous dissection using short-pitch technique may increase thermal injury during surgery. Maximum attention should be provided to prevent thermal injury of ultrasonic scissors during surgery.

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H.K. Sran, A. Phaily, R. Shah, N. Shah, N.N. Menezes Ashford & St. Peter’s Hospitals NHS Foundation Trust, CHERTSEY, SURREY, United Kingdom Aims: Temporary plastic biliary stents are placed for the management of malignant biliary obstruction, benign strictures, biliary leaks and bile duct stones. Associated complications include stent occlusion, cholangitis and distal migration (which may result in bowel obstruction, perforation or fistula formation). The incidence of adverse events increases with prolonged stent indwelling time. Currently, there are no guidelines for the maintenance of a biliary stent registry within UK endoscopy units. The British Association of Urological Surgeons recommends a registry for ureteric stents, which prospectively tracks all stents inserted, with automatic electronic reminders when exchange or removal is due. This ensures timely follow-up and reduces the risk of stent-related complications. This study aimed to investigate our unit’s follow-up policy for patients who had undergone temporary biliary stenting, and establish the complication rate, thus demonstrating the need for a biliary stent registry. Methods: Data from a 2-year period was collected retrospectively from the endoscopy unit. This included patient demographics, indications for stenting, stent types, follow-up and stent-related complications. Results: Of 478 ERCPs performed on 341 patients (125 M: 215 F, median age 76), 149 underwent biliary stenting. The indications were: malignant obstruction 48 (32.2%), benign stricture 15 (10.1%), stone disease 76 (51%) and biliary leak 10 (6.7%). The mean duration temporary stents were left in situ was 102 days (range 4–553 days). Complications included: stent-related sepsis 10.3% (n = 12), stent migration 3.4% (n = 4) and occlusion 2.6% (n = 3). In 3.4% (n = 4) of these, the complication occurred after the period specified for follow-up ERCP. 10 patients (8.5%) were lost to follow-up. Conclusions: Although the data demonstrates acceptable complication rates relating to temporary biliary stenting in our unit, the implementation of a registry may further improve outcomes. It will ensure timely follow-up, reduce the number of patients ‘slipping through the net’, and prompt clear short- and long-term plans post stenting. Re-audit post-implementation should be carried out to establish its impact.

Surg Endosc

P037 - Clinical Practice and Evaluation

P039 - Clinical Practice and Evaluation

Incidence of Venous Thromboembolism in Laparoscopic and Open Surgery for Colorectal Cancer

Prospective Study Comparing the Use of Intraoperative Cholangiography with Fluoroscopic Cholangiogram During Laparoscopic Cholecystectomy

T. Yazawa1, H. Ohishi1, N. Yazaki1, A. Oyama1, T. Okada1, T. Kakita1, M. Oikawa1, H. Honda1, T. Tsuchiya1, S. Takenoshita2

V. Eisner1, S. Schneider-Koriath2, R. Wiebner3, K. Ludwig2

1

Sendai city medical center, Sendai open hospital, SENDAI, MIYAGI, Japan; 2Fukushima medical univercity, 1HIKARIGAOKA, FUKUSHIMA CITY, Japan

Klinikum Suedstadt Rostock, ROSTOCK, Germany; 2Klinikum Su¨dstadt Rostock, ROSTOCK, Germany; 3Bodden-Kliniken, RIBNITZ, Germany

Purpose: To identify the incidence of venous thromboembolism(VTE) and assess risk factors of VTE in patients ungergoing laparoscopic surgery and open surgery for colorectal cancer. Methods: Between January, 2010 and December, 2012, 572 patients underwent colorectal surgery in our hospital. We analyzed 345 cases except the cases that did not prevent deep vein thrombosis(DVT) with the anticoagulant and the cases for an emergency surgery. We measured serum D-dimer level at the preoperative day and the postoperative days 1, 4, 7, 14 in our course, and we underwent the ultrasound sonography of lower limbs to detect DVT when postoperative D-dimer level is more than 10 lg/ml. We examined outbreak frequency of DVT outbreak and assessed the risk factor for perioperative DVT. Results: 131 patients underwent laparoscopic surgery (L group) and 214 patients underwent open surgery (O group). There were no significant differences in gender ratio, the site of disease, the type of anticoagulant, BMI between two groups. Average age was significantly lower, the rate of the patient Stage?was higher, Stage?was lower, CEA and CA19-9 levels were lower in L group. In addition, operation time was longer, amount of bleeding during surgery, postoperative D-dimer level, WBC counts, and CRP level were less in L group. There was no incidence of symptomatic, fatal VTE and fatal bleeding in this study. There were no significant differences in incidence of DVT (L group/O group: 10%/15% p = 0.16). To assess the risk factors of DVT, univariable and multivariable analysis was performed for DVT incidence and patient-related factors, surgery-related factors. We showed that type of anticoagulant, age, amount of bleeding during surgery and CRP level of postoperative day4 were independently associated with a significantly greater incidence of DVT. Conclusion: Anticoagulant prophylaxisis for patients undergoing colorectal surgery was effective and safe to prevent VTE. We supposed Laparoscopic surgery is minimally invasive and reduce the risk of DVT outbreak, but there was no significant differences in the DVT incidence, so anticoagulant prophylaxis is necessary as well as open surgery. Further study will prove how to select any appropriate anticoagulant agents and administration period.

Background: Laparoscopic cholecystectomy (LC) belongs to the most common surgical procedures with a high level of standardization. Bile duct injury as a serious complication (0.3%) often bases on intraoperative misidentification of the extrahepatic biliary anatomy. Due to added cost, radiation exposure and a lack of evidence the routine use of intraoperative cholangiography (IOC) is controversial. Whereas fluorescent cholangiography (FC) is reported as an economical, effective new method for non-invasive visualization of the biliary structures. Materials and methods: The objective of this study was to evaluate the feasibility and efficacy of FC in the identification of biliary structures during LC in comparison to IOC. Patients undergoing LC were examined intraoperative according to a standardized protocol. Afterwards the data were evaluated regarding the intraoperative time and exposure of predefined anatomical structures. Results: A total of 75 patients underwent a LC with simultaneous IOC and FC during the study period. 4 patients had to be excluded for technical dysfunction (n = 2) or infeasible intubation of the cystic duct (n = 2). Mean age and body mass index were 52,4 years (range 19–83) and 27,85 (range 14–45) kg/m2. Overall mean operative time was 65,93 min (range 35–155). FC was significantly faster than IOC (1,47 ± 0,966 vs. 8,33 ± 3,463 min; p \ 0,001). Before complete dissection, the rates of visualization of the cystic and common bile duct using FC were 60,6% and 59,2%, afterwards 95,8% and 69,0%. Identification rate of biliary structures using IOC amount to 98,6% for DC and 100% for DHC. Utilizing IOC asymptomatic intraductal concrements were detected in 3 patients (4,2%) compared to 1 patient (1,4%) for FC. On the other hand, bile leakage from the liver bed after cholecystectomy being non-delineable by IOC was found in 1 case (1,4%) using FC. Conclusion: FC during LC is a feasible and effective procedure for real-time visualization of cystic and common bile duct anatomy. It also enables the immediate care of bile leakage from the liver bed being non-delineable by IOC. Regarding to intrahepatic biliary structures as well as intraductal concrements the IOC seems to be more effective.

P038 - Clinical Practice and Evaluation

P040 - Clinical Practice and Evaluation

Safety of Our Clinical Pathway and Validity of Enhanced Recovery After Surgery Protocol for Laparoscopic Distal Gastrectomy

Laparoscopy Endoscopy Cooperative Surgery(Lecs) Procedure to Overcome The Limitation of ESD for Colorectal Tumors

T. Tanioka, K. Kojima, M. Inokuchi, S. Otsuki, H. Murase, C. Tomii, T. Aburatani, K. Gokita, K. Okuno, T. Kawano Tokyo Medical and Dental University, TOKYO, Japan Aims: Enhanced recovery after surgery(ERAS) is the concept of aiming at early recovery after surgery. It has been spread all over the world from early 2000’s. It was adapted for colon resection at first, but it has been studied in various surgical procedures. The aim of ERAS is such as the shortening of hospital stay and reducing the fasting days after surgery. Generally, there existed a thought the gastric surgery is a highly invasive surgery and the effect of oral intake on postoperative complication is also high. Since we avoided to start oral intake in early postoperative days, there are few reports about ERAS protocol about gastric surgery. We started laparoscopic distal gastrectomy (LDG) at January 1991, and made the clinical pathway (CP) for LDG in 2001. Our CP, modified in 2005, have been made early oral intake and shortening of hospital stay after surgery. We show the safety of our CP and verified the validity of the ERAS protocol for LDG. Methods: We studied 403 patients who underwent LDG from January 2005 to December 2014. In principle, the patients who preoperatively diagnosed cStage I underwent LDG with D1+ or D2 lymphadenectomy.We evaluated retrospectively the length of postoperative hospital stay, the variance and complications. Clinical pathway: Patients start drinking and walking at POD 1, take soft meals at POD 2, are removed the epidural catheter and the drainage tube at POD 3 and discharge at POD 5–7. Results: The median length of postoperative hospital stay was 7 days. We found the variance with 8%, drinking, meals with 20.6%, drainage tube with 19.1% and discharge with 23.6%. The number of patients who occurred complications more than grade III according to Clavien-Dindo classification were 14 (3.5%). Five patients (1.2%) readmitted within 30 days after discharge. The reasons for readmission were 3 (0.6%)cases of anastomosis stenosis, one (0.2%) case of anastomosis leakage and one (0.2%) case of intraabdominal abscess. Conclusion: Our results suggest that our clinical pathway is safe and valid for the ERAS protocol.

1

Y. Tamegai, Y. Fukunaga, T. Kishihara, A. Chino, S. Saitoh, M. Igarashi Cancer Institute Hospital, TOKYO, Japan Aims: We established the Laparoscopy Endoscopy Cooperative Surgery (LECS) procedure to overcome the limitation of colorectal ESD. In this report, we will clarify the usefulness of LECS procedure applied with ESD technique to complete a safe one-piece resection with adequate surgical margin. Methods: We performed ESD on 1,164 colorectal tumors in 1,137 patients (male: female = 671:463; mean age, 65.8 years). Among these, 266 cases were accompanied by fibrosis. These cases were divided into three groups; absence of fibrosis (Type A), fibrosis due to benign causes (recurrence after EMR, etc. Type B), and fibrosis due to cancer invasion in the SM layer (type C). The degree of fibrosis was classified into mild (grade 1), moderate (grade 2), and severe (grade 3) degree. In this study, we examined the limitation of ESD and established the indication of LECS procedure. Results: The one-piece resection rates were as follows: Type A; 873/898(97.1%), Type B-1; 80/83(96.4%), B-2:42/48(87.5%), B-3:25/43 (58.1%), type C-1:45/45(100%), C-2:18/ 19(94.7%), C-3:15/28(53.4%). We experienced f0ur cases (0.3%) of perforation in Type B. In cases with Type B-3, one-piece resection becomes more difficult due to the risk of perforation. The limitation of ESD is thought to be existed in these lesions from the viewpoint of safety and curability. From these results, we established the LECS procedure applied with ESD technique to overcome the limitation of ESD. Indications of the LECS procedure were thought to be as follows; Intra-mucosal carcinoma and adenoma accompanied by wide and severe degree fibrosis due to tumor recurrence after EMR and surgical resection, submucosal tumors, tumors involved appendix or diverticle. We performed onepiece resection for 10 cases using LECS procedure, 3 case of mucosal cancer accompanied by severe degree fibrosis, and 2 cases of adenoma involved diverticle, 2 cases of mucosal cancer involved appendix, 2case of submucoal tumor, and 1 case of poor endoscopic operability. We experienced no complications, and average hospital stay was 7.9 days. Conclusion: We developed a LECS procedure to overcome the limitation of ESD, and completed one-piece resection of the tumors considered as high risk of perforation.

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Surg Endosc

P041 - Clinical Practice and Evaluation

P043 - Clinical Practice and Evaluation

The No-Show (Non-Attendance) Rate In Our Endoscopy Unit

Three Cases of Laparoscopic Colorectal Resection for Colorectal Cancer in the Patients on Continuous Ambulatory Peritoneal Dialysis (Capd)

M. Salama, I.A. Ahmed, A.R. Nasr, S.A. Elmasry Our lady of Lourdes hospital, DROGHEDA, Ireland Introduction: Endoscopy is very important in the management of gastrointestinal diseases. Access to the endoscopy unit is limited and demand for these services is increasing. It is important to keep the no-show rate to a minimum to maintain optimal utilization of the endoscopy unit. To date, there is limited data focusing on no-show rates in endoscopic units. Aims: To estimate the no-show rate in our endoscopy unit. To study how to reduce this rate. Methods: A prospective study was performed in our endoscopy unit between 01/11/14 and 30/10/15. All the patients scheduled for elective endoscopy (OGD, Colonoscopy, and sigmoidoscopy) during this period were included. Non-attending patient data were recorded on the procedure day electronically (Endoraad). Data was collected at the end of this period and analyzed by month. No-show was defined as patients missing the scheduled procedure without calling. To improve attendance, we phoned all patients who were scheduled for endoscopy in November 2015 before their procedure to confirm attendance, and then reaudited our no-show rate. Results: Total patients included in our study: 4,276 No show: 778 (18.1%), M: 360 [46.5%], F: 418 [53.7%]) OGD: 274 (35.2%), Colonoscopy: 399 (51.3%), OGD + Colonoscopy: 105 (13.5%) The highest no-show rate was (August 23%). The lowest rate was (June 12%). The highest number of procedures was done in March. One out of the 276 patients involved in our screening programme did not show (0.3%). Out of the 228 patients called before their procedure in November 2015, 15 cancelled when phoned, 110 confirmed their attendance and 103 did not answer. A re-audit of the no-show rate in November 2015 showed, 43 did not show with a rate of 18.9% compared to 17% noshow rate in November 2014. Conclusion: The no-show rate in our endoscopy unit is high where both open access endoscopy scheduling and patient dislike of procedure contributed to the high absenteeism. Phoning the patients a few days before the procedure did not improve the patient attendance rate. We need to change our strategies to decrease the no-show rate.

Y. Yoshimoto, A.A. Tanaka, T. Fujikawa, H. Hayashi, Y. Kawamura, T. Noda, H. Kawamoto, C. Nakasuga, T. Yamamoto Kokura Memorial Hospital, FUKUOKA, Japan Laparoscopic colorectal resection is the established procedure for treatment of colorectal cancer. We review our experience with three recent cases of colorectal cancer in the patients on CAPD who underwent laparoscopic colorectal resection. (Case-1) A 73-year-old male was diagnosed as a rectal cancer and laparoscopic assisted low anterior resection was performed. The CAPD catheter was removed during surgery due to the complication by intermittent episodes of exit-site infection and peritonitis, and then underwent postoperative hemodialysis (HD). (Case-2) A 71-year-old male was diagnosed as an early Ascending colon cancer and underwent endoscopic mucosal resection. After the results of the pathological diagnosis, reduced port laparoscopic rt. hemicolectomy was performed according to the Japanese guidelines for the treatment of colorectal cancer. Washing through CAPD catheter and CAPD can be resumed soon after the surgical procedure, without undergoing HD. (Case-3) A 77-year-old female was diagnosed as an early Transverse and Descending colon cancer and laparoscopic partial Transverse colectomy and Lt. hemi-colectomy was performed. Having started the washing and reservoir through CAPD catheter, a dialysate leakage into the subcutaneous was found by CT scanning on 14POD. We instituted temporary cessation of CAPD for 10 days after the leakage, maintaining the patient on HD during this period. He resumed routine CAPD on 24POD. As laparoscopic surgery has been gaining in popularity, surgical procedures for the patients with complications have also been increasing. There is no consensus on its use in patients receiving CAPD, and there is no clear recommendation in the literature of how to manage perioperative dialysis. Further discussions will be required to resolve the problems about how to resume CAPD after surgical procedures for the gastrointestinal cancer patients with CAPD, because an anastomosis site exists. We experienced three cases of laparoscopic colorectal resection for CAPD patients. Special attention must be taken not to cause complications in case of resuming CAPD in the early period after surgery.

P042 - Clinical Practice and Evaluation

P044 - Clinical Practice and Evaluation

Oncologic Outcomes of Laparoscopic Intersphincteric Resection for Very Low Rectal Tumor: A Single-Center Safety and Feasibility Study

Three Cases of Laparoscopic Colorectal Resection for Colorectal Cancer in the Patients on Continuous Ambulatory Peritoneal Dialysis (Capd)

N. Matsuhashi, T. Takahashi, T. Tanahashi, S. Matsui, H. Imai, Y. Sasaki, Y. Tanaka, N. Okumura, K. Yamaguchi, S. Osada, K. Yoshida

Y. Hirasaki

Gifu university, GIFU, Japan Background: Radical surgical treatment for very low rectal tumor near the anus has generally performed abdominoperineal resection.Intersphincteric resection (ISR) has been reported as a promising sphincter-preserving operation in selected patients with very low rectal cancer.The present study aimed to evaluate both technical feasibility and safety of laparoscopic Intersphincteric resection and short-and long-term outcomes after lower rectal tumor. Study Design: Between July 2008 and December 2015, 1083 patients with primary colorectal tumor underwent surgery,662 patients with colorectal cancer underwent laparoscopic surgery at our single institution.In addition,192 patients with low rectal tumor underwent laparoscopic surgery.36 patients with lower rectal tumor underwent laparoscopic ISR, Technical feasibility and safety of ISR,short and long- term outcomes after laparoscopic ISR were evaluated. Results: There was no perioperative mortality, 6 complications occurred in 6 patients, and the morbidity rate was 16.7% (6/36). Postoperative complications detected included bleeding in 1 patient, pyelonephritis in 1 patient,vaginal fistula in 1 patient and ileus in 3 patients of the laparoscopic ISR group. The rate of severe complications of grade = 3a was 11.1% and that of grade = 3b was 2.8% (Clavien-Dindo classification). In the matched case–control study, blood loss was significantly lower (p \ 0.05) in the laparoscopic ISR group. Median postoperative hospital stay was 14.1 days in the laparoscopic ISR group.Cancer recurrence was detected in 1 (2.8%) patient in 1 inguinal lymph node. Conclusions: The present study showed laparoscopic Intersphincteric resection to have a safe postoperative course and to benefit oncologic outcomes.

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Japan/Juntendo University Urayasu Hospital, URAYASU, Japan Background: Laparoscopy assisted colectomy (LAC) is a minimally invasive surgical technique that is gaining wider acceptance for the treatment of colon cancer. But LAC for descending colon cancer is difficult in technic, so indication for this part is controversial. The aim of the present study is to investigate the short-term and oncologic long-term outcomes associated with laparoscopic surgery for descending colon cancer. Method: Between May 1993 and December 2015, we performed 1998 LAC for colorectal cancer. In these cases, we experienced 107 cases LAC for descending colon cancer. We excluded 15 cases of stoma creation, adjacent organ resection and Cur B,C. We examined the peri-operative results, complications, surgical outcomes and the results of the 5-year follow-up analysis. Operation technique: Left colic artery is Main feeder of descending colon cancer in almost all cases. Some of them, accessory middle colic artery exists from SMA. In these cases, we also ligate accessory MCA under line of pancreas. We perform functional end to end anastomosis for descending colon cancer. However, we use DST technique around SDJ tumor. Result: Lesion site is 7 cases around SDJ, 4 cases around splenic flexure, 81 cases around the descending colon. Anastomosis technique is as follow: 65cases of FEEA, 19cases of DST, 5cases of triangle anastomosis, 3cases are using BAR. The average operative time is 223.3 min. The average bleeding volume is 140 ml. We experience 4 cases of wound infection, 5 cases of ileus, 1 case of anastomosis leakage and 1 case of anastomosis bleeding. DFS is 100% in stage1, 87.9% in stage 2 and 73.2% in stage 3. This result is comparable result compared with Japanese colorectal cancer guidelines. Conclusion: Use of laparoscopic surgery resulted in acceptable short-term and oncologic outcomes in patients with descending colon cancer. Further investigations with large-scale prospective studies and long-term analysis are mandatory to establish the oncological safety of laparoscopic surgery for descending colon cancer.

Surg Endosc

P045 - Clinical Practice and Evaluation

P046 - Clinical Practice and Evaluation

Iatrogenic Perforation after Endoscopic Hemostasis with Argon Coagulator

Interim Results of Staple Line Reinforcement with Endo GiaTM Reinforced Reload During Abdominal and Thoracic Surgery Procedures

R.A. Fursov, A.B. Fursov, Y.N. Kuspaev, D.T. Saipiyeva Medical University of Astana, ASTANA, Kazakhstan Objective: To study the incidence and causes of iatrogenic endoscopic complications. European Society of Gastrointestinal Endoscopy (ESGE) recommends to consider several factors associated with the risk of colorectal perforation during endoscopy, i.e. difficult endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) and balloon dilatation. Methods: of study: endoscopic surgeries outcomes processed by statistical methods. Results: of the study fully agreed with ESGE recommendations. The higher risk of perforation was associated with age (above 65) and presence of the colon inflammatory disease. From 1990 to 2015, the outpatient departments performed an average of 27,000 to 39,600 endoscopies a year. In-patient departments performed an average of 48300 endoscopies annually. The ratio of colorectal examinations was 10%. Over the past 25 years there were 120,750 colonoscopies. Iatrogenic complications occurred in 62 cases. Of these - 53 perforations, which mainly happened during endoscopic polypectomy at the colon and sigmoid. Despite the increase in the number of endoscopic operations, the complication rate remained stable. However, in the last 5 years perforations linked to the use of argonplasma coagulation for colonic bleeding have been observed in 15 cases (0.012%). Conclusion: All perforations were caused by coagulation injuries to the gut wall. Neither automatic nor manual control of plasma impact brought any considerable improvement. All cases were diagnosed within 3 to 6 h with further admission. In 10 patients the perforated wall was sutured at laparotomy. In 5 patients the closure was performed with the combined use of laparoscopy and colonoscopy techniques using a part of omentum pulled through the defect. Biopsy forceps were introduced to the abdominal cavity via the colon lumen and the omentum was pulled inside the colon via the perforation hole. A clip was applied to fix the omentum inside transversely to avoid slipping it back into the abdominal cavity. The outcomes were successful, no complications recorded. There were some insignificant leakage of the colonic content into the abdominal cavity without any complications.

S. Morales-Conde1, A. Ahmed2, R. Stanbridge3, E. Lim4, M. Shackcloth5, M. Legrand6, J. Himpens7, J.M. Baste8 1 Universtiy Hospital Universitario Virgen del Rocio, SEVILLA, Spain; 2Imperial College Healthcare NHS Trust, St. Mary’s Hospital, LONDON, United Kingdom; 3Imperial College Healthcare NHS Trust, Hammersmith Hospital, LONDON, United Kingdom; 4The Royal Brompton Hospital, LONDON, United Kingdom; 5Liverpool Heart & Chest Hospital, LIVERPOOL, United Kingdom; 6CHR de Huy, HUY, Belgium; 7Edith Cavell Hospital, BRUXELLES, Belgium; 8Rouen University Hospital, ROUEN CEDEX, France

Aims: Staple line reinforcement during surgical procedures is a practice that may decrease morbidity and may reduce the risk of staple line leaks and bleeding. The Endo GIA TM Reinforced Reload with Tri-Staple TM Technology utilizes a pre-attached, porous, synthetic polymer buttress during stapling and resection, and is used in multiple therapeutic areas. Methods: This prospective, two-arm (abdominal and thoracic), multicenter, post-market study includes 12 European hospitals evaluating the use of Endo GIA TM Reinforced Reload with Tri-Staple TM Technology. The primary endpoint is the incidence of reported device-related adverse events at 30 days. This interim analysis was planned at 50 patients consisting of abdominal and thoracic procedures. Any required intervention to control staple line bleeding was recorded and intraoperative leak testing was conducted on each patient. Results: From May 2015 to August 2015, 51 patients were prospectively enrolled (mean age(±SD): 44 ± 13 years for group-A; 65 ± 9 years for group-T). For group-A (19 patients; 9 Laparoscopic Sleeve Gastrectomy, and 10 Laparoscopic Roux-en-Y Gastric Bypass), the median hospital stay was 2 [1–5] days. Of these patients, 6 minor bleedings (\50 CC) requiring clips and/or ligation were observed at the staple line with no observed intraoperative leaks. Patients in group-T (32 patients; 9 open and 23 VATS wedge and/or lobectomy) had a median hospital stay of 4 [1–23] days with 2 observed minor bleedings at the staple line (\50 CC), 1 which was treated by pressure, and 3 air leaks, which required no intervention. During post-operative follow-up, 3 different patients from group-T required 8, 15 and 23 days of drainage for prolonged air leaks that were not observed during surgery. In addition to the 7 serious adverse events (SAEs) reported as unrelated to the device, there was one SAE involving bleeding and removal of additional lung tissue, wherein the device was released late, and thus not used in accordance with manufacturer instructions. Conclusion: Interim results demonstrate that the use of Endo GIA TM Reinforced Reload with Tri-Staple TM Technology is safe for both abdominal and thoracic surgeries when observed 30-days post procedure. Once completed, a final assessment of the study will be reported and further studies conducted.

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Surg Endosc

P047 - Clinical Practice and Evaluation

P049 - Clinical Practice and Evaluation

Anxiety and Choice of Sedation and their Effect on Patient Relaxation in Patients Undergoing Upper Gastrointestinal System Endoscopy

Application of an Eras Standardized Pathway for Peri-Operative Management of Esophagectomy

C. Ercetin1, A.C. Dural2, H. Yigitbas1, E. Yavuz1, I. Borucu3, M. Tokocin1, S. Arici1, H. Ozkan4, A. Celik1, F. Celebi1, H. Alis2

A. Melis, P. Parise, N. Incarbone, A. Cossu, U. Elmore, M. Mazza, R. Rosati San Raffaele Hospital, MILANO, Italy

1

Bagcilar Training and Research Hospital, ISTANBUL, Turkey; 2 Bakirkoy Dr.Sadi Konuk Training and Research Hospital, ISTANBUL, Turkey; 3Meditime Surgical Medical Center, ISTANBUL, Turkey; 4Karabuk Yenice Public Hospital, KARABUK, Turkey Aims: Patients undergoing endoscopy have seldomly reported a higher degree of anxiety before and during the intervention and this effect is known to negatively affect the efficacy of the procedure irrespective of the technique or degree of expertise of the endoscopist. The aim of this study is to evaluate the effect of sedation type on patient comfort and anxiety before endoscopy. Methods: Between June 2014 and June 2015, 359 patients who underwent upper gastrointestinal endoscopy at four different endoscopy centers were asked to complete a multicenter prospective questionnaire on the type of sedation and its effect their relaxation before endoscopy. The patients were grouped into three according to the sedation type, Group I (local Lidocain pump sprey) (n = 115), Group II (local Lidocain pump sprey + Midazolam intravenously) (n = 137), Group III (lokal Lidocain pump sprey + Midazolam intravenously + Propofol intravenously) (n = 107). Complexity of the procedure and state of anxiety were assesed by using a graphic rating scale and the statetrait anxiety inventory (STAI) respectively. Results: Median (min–max) STAI scores for all three groups were; Group I: 47 (20–80), Group II: 46 (20–73) and Group III: 43 (25–56), p \ 0.003; Mean ± standard deviation pre-procedure complexity scores for groups I, II and III were 5.1 ± 0.2, 5.4 ± 0.2 and 4.3 ± 0.3, p \ .01 respectively. Post-procedure complexity scores were 4.2 ± 0.2, 3.7 ± 0.2, 0.5 ± 0.1, p \ .001; Endoscopist-reported complexity scores were 2.3 ± 0.2, 2.7 ± 0.2, 0.4 ± 0.1, p \ .001; Operative duration (seconds) was 209.1 ± 12.5 for Group I, 232.6 ± 6.9 for Group II and 140.1 ± 23.9 for Group III, p \ .001. Conclusion: The complexity of upper gastrointestinal endoscopic procedures can be affected by factors such as anxiety state of patients, endoscopist and sedation type. For patients who receive anesthesia, the procedure is perceived to be easier and relaxing for both the endoscopist and patient.

P048 - Clinical Practice and Evaluation

P050 - Clinical Practice and Evaluation

Accuracy of Ultrasound in the Diagnosis of Inguinal Hernia 1

2

3

I.O. Avram , M.F. Avram , D. Koukoulas , S. Olariu

2

1

CaritasKlinikum Saarbrucken, SAARBRUCKEN, Germany; University of Medicine and Pharmacy ,,Victor Babes,, Timisoara, TIMISOARA, Romania; 3City Hospital Lugoj, LUGOJ, Romania

2

Background: The diagnosis of inguinal hernia is classically based on the clinical exam. Groin pain from an occult hernia can be a difficult clinical diagnosis, so ultrasound is often used as a diagnostic tool, being fast and relatively inexpensive, but operator-dependent. Material: The study involved a retrospective analysis of 100 patients who underwent TEP hernia repair in our clinic; of these, 56 were bilateral inguinal hernias, 41 bilateral inguinal hernias and 3 femoral hernias. Patients were routinely examined by ultrasound, and the diameter of the hernia defect was measured by our radiologists. The preoperative radiological measurements of the hernia size were compared to the intraoperative findings. Results: Mean size of hernia defect determined by ultrasound was 1.9 ± 0.6 cm, whereas intraoperatively measurement was 1.4 ± 0.5. We also compared the accuracy of the ultrasound measurement for each type of inguinal hernia according to the EHS classification. Conclusions: Ultrasound has a tendency to overdiagnose the size inguinal hernias. The accuracy of ultrasound in the diagnosis of inguinal hernias is best in diagnosis of medium sized hernias (1,5–3 cm diameter); for small hernias ultrasound has the tendency to overestimate the size of the defect, occasionally a lipoma being interpreted as a hernia.

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Objectives: Esophageal surgery has high rate of peri-operative (PO) morbidity with the use of increased resources. The application of standardized clinical pathways proved useful to reduce PO morbidity and hospital stay in several fields of surgery. Purpose of this study is to verify the results of our PO management pathway of patients undergoing esophagectomy (E) with gastric pull-up in terms of PO morbidity and achievement of discharge criteria. Materials and Methods: between May 2012-November 2015, a consecutive series of 190 patients submitted to E and treated according to our standardized clinical pathway. This protocol was designed by our multidisciplinary team, provides specific items for PO care and allows to verify, early postoperatively, the discharge criteria. All data were entered into prospective database. Clinical and pathological data influencing surgical outcome were evaluated. Complication were classified according to Clavien-Dindo classification. Adherence to protocol was assessed. Results: 190 underwent E. Minimally invasive surgery was performed in 83% (57% hybrid E). Complication of grade = 3b were 11%. Mortality was 3%. The median postoperative stay was 10 days (6-110). 29%(group A) patients was discharged within the 8th p.o. day, 36% (group B) between the 9th and the 14th p.o. day 35% (group C) later on. We identified 8 items to which adherence was \100%. Only patients whith adherence to at least 5/8 items reached discharge within D8 and we state 5 items-reaching as goal to clinical pathway adhesion. In the group A adherence to the protocol was 100%, in the group B 92% and 86% in grup C (p = 0,008). Multivariate analysis identified epidural positiong as the best predictor to reach discharge criteria (p = 0,006); the second predictor was oral intake within D4 but it wasn’t statistically significant (p = 0,06). Conclusion: Two third of patients undergoing E and treated with our ERAS protocol reached the discharge criteria within two weeks from surgery and half of them after one week. 86% had uncomplicated course or minor complications. Strong adhesion to the protocol allows to achieve early discharge criteria without increas in morbility.

Does Fluorescence Improve The Safety of Colorectal Anastomoses? N. de Manzini, M. Giacca, B. Casagranda, D. Cosola, N. Moretto, A. Turoldo University of Trieste, TRIESTE, Italy Background: Colorectal anastomoses remain at risk of leakage, mostly depending on level of resection, previous RT-CT, BMI and diabetes. Indo Cyanine Grey with Near Infra Red fluorescence can be used to check the vascular supply to colon and rectum. The aim of this study was to verify the usefulness of such a method in helping to prevent anastomotic leakage. Methods: Patients undergoing a colorectal resection were tested with ICG-NIR fluorescence prior to proximal resection and after anastomosis, in case of a colorectal anastomosis, and after trans anal extraction in case of coloanal anastomosis. For colorectal anastomoses, a pneumatic test was performed as well. A loop ileostomy was realized at surgeon’s choice. Postoperatively a digital examination and a water soluble contrast enema were performed to check anastomosis integrity. Results: 32 consecutive patients were enrolled, and 24 were submitted to a colorectal stapled anastomosis, 6 to a handsewn coloanal one and 1 to a Hartmann procedure due to a preoperative incontinence. 7 ileostomy were performedFluorescence demonstrated in 4 cases a bad vascular supply at the established proximal resection level, leading to a further resection of 2 to 5 cm.All 24 colorectal anastomoses but 4 could be verified widely. Postoperatively 1 patient (3,2%) developed a minimal leakage after a colorectal anastomosis without stoma, treated medically. Conclusion: ICG-NIR fluorescence test seems to be useful in verifying the perfect vascular supply of transposed colon and of a colorectal anastomosis, leading in the future to a reduction of protective stomas. An RCT is now started to confirm this first experience.

Surg Endosc

P051 - Clinical Practice and Evaluation

P053 - Day Surgery

Against the Greek Debt Crisis: A 4-Year Audit of Reusable Laparoscopic Instruments

Laparoscopic Appendectomy - Statistical Survey Of 10 Year Period

D.K. Manatakis1, C. Barkolias2, C. Stoidis2, V. Kalles2, N. Stamos2, I. Terzis2, N. Ivros2, P. Vamvakas2, I.D. Kyriazanos2, N.L. Georgopoulos2

F. Galgo´czyova´, J. Moravı´k, J. Rejholec Nemocnice Decin o.z., KZ a.s., DECI´N, Czech Republic

Aims: Health care management has always tried to balance between excellence and high quality of services and cost-effectiveness. In the past five years, the greek financial crisis imposed dramatic expense cut-downs in the National Health System and military hospitals were not exempt. Our Department introduced reusable laparoscopic instruments (RLI) in December 2011, following a preliminary study that predicted significant annual cost containment. The aim of the present study was to assess potential cost reduction of laparoscopic operations between 2012-2015 in general surgery. Methods: Hospital records, invoice lists and operative notes between January 2012 and December 2015 were retrospectively reviewed and data were collected on type and number of laparoscopic operations, instrument failures and replacement needs. Each set consists of a dissector, two atraumatic grasp forceps, Metzenbaum scissors, a suction-irrigation device, a Veress needle, a Hasson cannula, two 12 mm and two 5 mm bladeless trocars. Maintenance was calculated as the sum of resterilization, repackaging, repair and replacement expenses. Total expenditure was the sum of initial acquisition plus maintenance cost, and was compared with retail prices of disposable laparoscopic instruments. Results: Initial acquisition cost of 5 basic RLI sets was €21,422. Over the following 4 years, they were used in 1292 laparoscopic procedures, with a total maintenance cost of €21,178. Based on an average retail price of 450 euros per set, estimated cost with disposable instruments would amount to €581,400 thus creating savings of €538,800 over the 4-year period under study. Conclusions: Despite the seemingly high purchase price, each RLI set quickly amortized its acquisition cost after only 9 procedures and instrumentation cost depreciated to €33 per case after 4 years. According to our results, disposable instruments cost 13 times more than reusable ones, and their high price would almost cover the total hospital reimbursement by social security funds for most common uncomplicated laparoscopic procedures.

Aims: Laparoscopic appendectomy is a common surgical procedure. It is already ascertained that surgical site infection is reduced with laparoscopy and according to recent studies intra-abdominal complications are equally frequent in both methods. The aim of this statistical survey is to follow a shift from open to laparoscopic surgery during the years and to evaluate per-operative and post-operative complications of the laparoscopic procedure. Methods: A retrospective chart review of patient who underwent appendectomy during a 10-year period was performed. Authors followed frequency of per-operative and postoperative complications and appraised them using Clavien-Dindo classification. Patients who underwent appendectomy as a part of another procedure were excluded. Results: There were 1057 appendectomies performed during a 10-year period from 1st January 2004. Almost 85% of patients, 894 in number, underwent laparoscopic appendectomy. 7,5% of procedures required conversion and 6,2% of patients underwent open procedure. There was no initially open procedure in the last 2 years and no conversion during the last year. Talking about the laparoscopic group, per-operative complication occurred in 34patients (3,8%). Mainly bleeding from released omental adhesions or apendicular artery or deserosalization of small bowel or caecum was ascertained. Only 3 cases required conversion. Post-operative complication occurred in 111patients (12,4%). Clavien-Dindo grade I was present in 62patients (6,9%) - 77% of it was surgical site infection, other complications were ileus of the small bowel, bronchitis etc. Grade II complication occurred in 32patients (3,6%), grade III in 13patients (1,2%). Intra-abdominal abscess was found in 24 cases, of which only 12 required percutaneous drainage or surgical revision. Other 12 cases were successfully treated with antibiotics, so abscess is questionable. Grade IV and V complications occurred both in 2 cases and had connection with patients’ co-morbidities and advanced state of appendicitis. Conclusion: Laparoscopic appendectomy is a safe procedure with all the advantages of minimally invasive surgery such as superior abdominal cavity visualization, lower rate of surgical site infection and it is not increasing number of Clavien-Dindo grade III complications. It is significantly taking over the open procedure. But it is needed to be aware that acute appendicitis can still be a fatal disease.

P052 - Day Surgery

P054 - Day Surgery

Assessment of Laparoscopic Cholecystectomy as Day Care Surgery, Reveiw of Outcomes

Re-Audit Of ‘True Day Case’ Laparoscopic Cholecystectomy in a High-Volume Specialist Unit in a District General HOSPITAL

1

Agios Savvas Anticancer Hospital, ATHENS, Greece; 2Athens Naval and Veterans Hospital, ATHENS, Greece

A. Marzouk Faculty of medicine, Cairo University, CAIRO, Egypt Aims: laparoscopic cholecystectomy has turned into the commonest treatment of gallbladder illness. Despite the rising demand of reduction of medical service cost by decreasing admission length of time, however patient safety is still the main concern. The aim of this study is to assess the laparoscopic cholecystectomy as day case procedure with review of the pre, intra and post-operative concerns to the patients’ safety and outcomes. Methods: A retrospective review from March to December 2015 of the patients with symptomatic gall bladder diseases. Patients’ selection was based on inclusion criteria for day case surgery. Analysis of operative time, total hospital stay, presence of comorbidities, post-operative discharge criteria (oral intake, proper control of pain and Urine pass) and Post discharge follow up. Results: Among 36 cases presented with gall bladder disease, 25 (73.5%) cases had laparoscopic cholecystectomy on day surgery basis according to the inclusion criteria, 13 (52%) males and 12 (48%) females, Age was (24–59, Mean 36.84 Years) years, BMI was (21.37–35.03, Mean 27.41). (68%) of the patients had no comorbidities, (16%) had controlled diabetes mellitus and hypertension, (12%) had associated para-umbilical hernia, and one case (4%) had history of acute pancreatitis. Hospital stay was (9–14, Mean 12 Hours), operative time was (34–140, Mean 72 min), post-operative start of oral intake was (230– 490, Mean 290 min) and post-operative urine voiding was (125–520, Mean 292 Minutes). Regarding the pain control all the patients were discharged with pain scale (0–1/5) as in 11 patients (44%) pre-operative NSAID injection and Intraoperative local anaesthesia infiltration were sufficient, while in 12 patients (48%) additional 3-4 hors post-operative Paracetamol infusion was needed, and in only 2 patients Addition of Opiates or tramadol injection were given. All the patients were discharged safely with was no reported case of conversion to open surgery, fever, vomiting or need for overnight stay. Conclusion: Laparoscopic cholecystectomy is a safe day care procedure based on good patients’ selection and adherence to proper perioperative surgical and anaesthetic management.

A. Solodkyy Hinchingbrooke, HUNTINGDON, United Kingdom Introduction: Laparoscopic cholecystectomy (LC) is the gold standard treatment for gallstones disease. We previously audited the true day case (TDC) rate and reasons for unexpected overnight stay (UOS) and performed a re-audit to assess our improvement. Methods: Prospectively collected data on 500 consecutive elective LCs performed in a specialist Upper Gastro-Intestinal unit during a 32-month period from 2012-2015, compared with previous study of the same number of cases from 2010-2012. Results: 500 patients underwent elective LC during the study period. 444 patients were planned day cases of which 84% were discharged on same day (TDC) and 16% had UOS. This equates to 8% improvement in TDC rate. Drain insertion, long operation and late Recovery departure were main reasons for UOS. There were no conversions; complications and re-admissions were similar to previous study. Conclusions: After changes suggested by our previous study, TDC rate improved from 76% to 84%. The majority of UOS are unavoidable but this can be reduced by a combination of patient selection, stringent preoperative assessment and optimised theatre scheduling.

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Surg Endosc

P055 - Day Surgery

P057 - Day Surgery

Laparoscopic Appendectomy in Everyday Clinical Practice

Laparoscopic Cholecystectomy. A Safe Day-Case Procedure

G. Bagias, E.P. Misiakos, P. Patapis, K. Petropoulos, G. Martikos, A. Machairas, N. Koliakos

C. Halkias1, S. Kaptanis2, A. Argiriou3, M. Chatzikonstantinou4

Attikon University Hospital, Athens University School of Medicine, CHAIDARI, ATHENS, Greece Aims: Acute appendicitis is a very common clinical entity, and appendectomy is the most common abdominal operation performed in emergency base. Lately, laparoscopic appendectomy is widely adopted worldwide, mainly because of its advantages over conventional appendectomy in terms of postoperative pain and hospital length of stay. The purpose of this study is to present the current trends in laparoscopic appendectomy and its clinical outcome. Methods: A retrospective study in a group of patients with acute appendicitis that were admitted in our Department from 2010 to 2015 was carried out, in which a laparoscopic appendectomy was performed. We analyzed the medical history, clinical and laboratory data on admission, and evaluated the surgical technique and the hospital length of stay. We also present the complications that were developed after a follow-up period of 6 months. Results: The mean age of the patients was 24. 68 years, (23 male and 30 female). The most common symptoms were lower right quadrant abdominal pain, fever and vomiting, whereas the most prominent clinical sign was the McBurney sign. The mean WBC count was 13. 68x103 (8x103-21.5x103). The ultrasound findings consisted of inflammation and dilatation of the appendix, but in 14 cases (26. 42%) there were no specific findings. During the operation, the appendix was found with moderate to acute inflammation in the majority of cases (94. 33%), whereas in 16 cases a phlegmon had been developed (30. 18%). Due to the presence of intra-abdominal abscess the operation was converted to open appendectomy in 2 cases (3.77%). The mean hospital length of stay was 4.63 days (3-10 days). Postoperatively, only 2 patients needed reoperation: one had intestinal obstruction due to adhesions, while the second patient had a carcinoid tumor and required a right colectomy. Conclusion: Acute appendicitis requires urgent surgical management, as the risk of perforation is considerably high. Laparoscopic appendectomy is an efficient surgical method offering early convalescence, and decreased hospital length of stay compared to open appendectomy.

1

KSS Deanery, TONBRIDGE, United Kingdom; 2Homerton University Hospital, LONDON, United Kingdom; 3York Teaching Hospital, YORK, United Kingdom; 4Darrent Valley Hospital, LONDON, United Kingdom Aims: To assess the causes of variation in practice and different outcomes of laparoscopic cholecystectomy. Methods: A prospective cohort study was conducted during a two-month period in two University Hospitals in London. All patients presenting for a cholecystectomy (acute, elective or delayed) were included and variations in practice and outcomes were assessed. Results: Sixty-seven patients from two teaching hospitals were included. Sixty elective cases, 4 acute and 3 delayed admissions, were assessed. Most common indication was biliary colic (68.6% of the patients) followed up by cholecystitis (22.4%). Thirteen of the patients were not discharged the same day (21.6%), three were converted to an open procedure and only 4 did not have any operative complications (30.7%). 53.8% of the patients who had a prolonged hospital stay had a BMI greater than 30. Most common operative complication for those patients was bile split (61.5%). 38.5% of them needed an abdominal drain. Upper GI surgeons had the lowest prolonged admission rate (15.1%). There was no association between the difficulty of the case and the admission length although all cases converted to open where of difficulty level 4, as well as the only case that needed re-admission. Level 4 was also associated with a 100% complication rate. There was a high complication rate within acute admissions (75%) and as expected these patients were not managed as a day case. Conclusion(s): Laparoscopic cholecystectomy can safely be performed as a day case procedure. A high complication rate was associated with acute admissions and difficult cases. As expected, high BMI is a risk factor for prolonged hospital admission. Subspecialty trained upper GI surgeons also had a low complication rate.

P056 - Day Surgery

P058 - Different Endoscopic Approaches

Potential Strategies to Increase Day Case Discharges After Laparoscopic Cholecystectomy and Laparoscopic Hernia Repair

Single Incision Laparoscopic Total Colectomy for Eight Synchronous Tumors of the Colon: A Case Report

D. Larkin, L. Karim, E. Badger, R. Peacock, U.A. Khan, K. Habeeb

S. Takanami, Y. Ishiyama, Y. Hiring, K.D. Louden, M. Hatter, Y. Hashizume

East Cheshire NHS Trust, MACCLESFIELD, United Kingdom Aims: We sought to identify our day case discharge rates for laparoscopic cholecystectomies and hernia repairs. We aimed to identify reasons for delayed discharges which could be targeted to improve clinical practice and efficiency. Methods: We retrospectively reviewed 5 months’ data for patients undergoing elective laparoscopic cholecystectomies and hernia repairs. All were intended day case procedures. From a review of the Hospital’s electronic records all delayed discharges were identified. The case notes were recalled for all of these patients. On reviewing the case notes reasons for delayed discharge were documented and potentially avoidable causes were identified from these. Two individual researchers analysed the data by reviewing the same case notes. Both researchers’ findings were inputted into electronic proformas. Inter-rater variability was accounted for by re-reviewing case notes for clarification of the discrepancy. Procedures were identified using the assistance of the Hospital’s coding department and spanned July to November, 2013. A theatre database was reviewed in conjunction to avoid missing procedures through potential coding errors. Results: Data for a total of 149 patients was reviewed. There were 60 elective laparoscopic cholecystectomies and 89 elective laparoscopic inguinal hernia repairs over the period. There were 59 patients with delayed discharge (20 laparoscopic cholecystectomies, 39 laparoscopic hernia repairs). Potentially avoidable causes were ‘no one at home’ (4), late return from theatre (6) and confusion with day case staff whether a pacemaker was reactivated postoperatively (1). There were 17 patients who experienced difficulty passing urine postoperatively; 6 required catheterisation. The overall day case rate was 68% (laparoscopic cholecystectomy 68%, laparoscopic hernia repair 68%). Conclusions: Careful pre-operative planning such as ensuring the patient has a relative/ friend at home after their surgery could reduce delays in discharge. Structuring theatre lists with laparoscopic cholecystectomies and hernia repairs scheduled for the morning session allows more time for recovery and potentially facilitates day case discharge further. With regards to postoperative urinary retention a failed trial without catheterisation (TWOC) on the morning following surgery should not delay discharge These patients can be managed with a catheter and outpatient TWOC ± Urology follow-up.

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Fukui prefectural hospital, FUKUI, Japan Synchronous colorectal tumors that require surgical treatment are rare. Our preliminary experience with single-incision laparoscopic total colectomy for eight synchronous tumors of the colon is reported. A 44-year-old man was admitted to our hospital because of anemia. Colonoscopy showed a polypoid lesion with an irregular surface and a Borrmann 2-like lesion in the rectal colon, two Borrmann 2-like and one Type I subpedunculated lesions in the sigmoid colon, and two Borrmann 2-like lesions and one early tumor in the descending colon. Single incision laparoscopic total colectomy was performed for these multiple colon tumors. The postoperative course was uneventful. The patient was discharged from hospital on postoperative day 19. Postoperative pathological examination confirmed that all eight lesions were malignant. Single incision laparoscopic total colectomy is a safe and feasible option for eight synchronous tumors of the colon.

Surg Endosc

P059 - Different Endoscopic Approaches

P061 - Different Endoscopic Approaches

Cholecystectomy laparoscopy in situs inversus: what technical approach?

The Role of Laparoscopy in Diagnosis of Ascites of Obscure Etiology

S. Zatir, A. Selmani, R. Koudjeti Militery hospital university oran, ORAN, Algeria The most common practice is comfortable in front of a cholecystectomy laparoscopy: the problem arises before a cholecystectomy laparoscopy on situs inversus? How operates the patient and how the trocars placed in front of this mirror effect organs it’s a video of five minutes of a patient operated for cholecystectomy laparoscopy on situs inversus

W.B. Mohamed, U. Arafa Sohag University, SOHAG, Egypt Background: The advent and major developments in noninvasive imaging modalities like ultrasonography, computed tomography and magnetic resonance imaging markedly reduced the use of diagnostic laparoscopy. However many reports suggest imaging such as computed topography, ultrasound has a limited role for diagnosis of exudative ascites, also few studies s have done in the last decade about the usefulness of diagnostic laparoscopy in diagnosis of ascites of unknown cause. The aim of this study was to answer the question is there still a place for laparoscopy in diagnosis of ascites of obscure etiology? Materials and Methods: We prospectively evaluated patients seen in the Gastroenterology unit and general surgery Department of sohag University, sohag Faculty of Medicine between 2013and 2015. Results: Between October 2013 and October 2015, 32 patients were included in our study .30(93.75%) were female and 2(6.25%) were male. Patient age between 16 years and 68 years.all the patient were referred for the surgery department due to ascites of unknowns cause.two patients had weight loss as a presenting symptom. No mortality or morbidity was registered in our study. The entire patient was discharged from in the hospital after 24 h after they completely recovered from anesthesia and returned to their home activity. The final histopathological diagnosis after examination of ascetic fluid and biopsies that was obtained by diagnostic laparoscopy was: carcinomatosis peritonei in 24 (75%) cases, tuberculous peritonitis in 6 (18.75%) cases and cirrhosis in 2 (6.25%) cases. Conclusion: Despite of great advance in noninvasive diagnostic modality.diagnostic laparoscopy remain a valuable treatment option for diagnosis of ascites of obscure etiology. Keywords: Diagnostic laparoscopy, gastroenterology, tuberculosis, exudative ascites, malignancy

P060 - Different Endoscopic Approaches

P062 - Different Endoscopic Approaches

Hybrid Minimally-Invasive Surgery: Integration with Flexible Endoscopy. Optimizing Your Approach

Hybrid Notes Transvaginal Cholecystectomy: A Two Instrument Technique - Our Experience

S. Dzhantukhanova, Y. Starkov, E. Solodinina, M. Vyborniy, L. Shumkina, K. Slepenkova

S. Heyman, J. Valk, F. Van Sprundel, B. Gypen, L. Hendrickx

A.V. Vishnevsky Institute of Surgery, MOSCOW, Russia Background: As a minimally invasive techniques continue to evolve, the use of flexible endoscopy became increasingly important in gastrointestinal (GI) surgery. Flexible endoscopic skills are not only being used to complement surgical practice in foregut and colorectal surgery, but have also become an integral part of many surgical procedures. Goal of the study: The main goal of our study was to demonstrate the combined application of rigid and flexible endoscopy in order to make a procedure more accurate and less invasive. Study: In our clinical practice we used intraluminal endoscopy during different procedures: thoracoscopic diverticulectomy, laparoscopic Heller cardiomyotomy, laparoscopic pyloroduodenoplasty, laparoscopic wedge gastric resection, and colon resection. In laparoscopic gastric surgery endoscopy was used simultaneously during laparoscopy to localize the tumor and to ensure negative margins of resection. Transillumination with the flexible endoscope, so called endoscopic navigation, allowed identification of the small lesions with mainly intraluminal growth intraoperatively and also control full-thickness stapler resection. Endoscopy also allows evaluation of suture line at the site of surgery. Similarly, during colon surgery we used colonoscopy for identification of the small tumors or the location of the polypectomy scar in the cases of adenocarcinoma in polyp histopathology. We used colonoscopy to evaluate colon lumen and anastomosis in terms of bleeding and competence by insufflation of air, which helps to avoid leaks and bleeding complications. During diverticulectomy esophagoscopy facilitate identification of the neck of large diverticulum and was used at the step of resection to control the lumen width and evaluation of suture line. During pyloroduodenoplasty in the cases of significant stenosis flexible endoscopy was used to evaluate the anatomy of pyloric canal and duodenum which was often altered due to adhesions, to identify the location of stenosis, to evaluate the lumen width and suture line after pyloroduodenoplasty. Our experience showed that the use of intraoperative endoscopy in GI surgical procedures to plan, direct or assess resection improves outcomes. Conclusion: The combination of rigid and flexible endoscopy allows to get a creative approach, which provide a number of advantages, including improved localization of lesions, elimination of complimantary procedures and prevention of postoperative complications.

Ziekenhuis Netwerk Antwerpen (ZNA), ANTWERP, Belgium Aims: We recently set-up a NOTES platform in our department with access to flexible and rigid endoscopy. Combining the NOTES concept without losing triangulation is, to our opinion, the key to success with NOTES.Combining small (3 or 2.2 mm percutaneous) transabdominal instruments with a natural orifice shows this feature.We would like to present 15 consecutive patients treated for symptomatic cholecystolithiasis with a hybrid NOTES transvaginal cholecystectomy technique.We focus on the technique using 2,2 mm percutaneous instruments and a natural orifice (vagina) as utility port.The technique we evolved to during the learning curve. Methods: In the year 2015 we adapted this technique and implemented it in daily surgical care.15 patients were consecutively treated for symptomatic cholecystolithiasis.Cases with previous episodes of cholecystitis or nulliparous patients were excluded.All patients had an extensive informed consent. The technique used was a 3 mm trocar at the umbilicus, 2,2 mm or 3 mm trocar right upper quadrant and 12 mm diameter/15 cm length transvaginal trocar. Then a state-of the art cholecystectomy was performed.Clipping and extraction was preferably performed transvaginal. Results: All patients from the start using this technique were included. This reflects the learning curve observed in this study. Three out of 15 patients stayed one night after surgery. This prolonged stay was due to higher age or late surgery (afternoon). All other patients were treated in daycare.This is a relative contraindication, although we did not experience any problem in the peri- or postoperative period. We did not observe any perior postoperative complications:no wound infection, no abscess nor trocar site hernias.The average VAS (visual analogue scale) score for pain was 2. Four out of 15 patients (initial 4 patients) had 2 9 3 mm and 1 9 5 mm abdominal incisions. The technique evolved to a 2 9 3–2,2 mm abdominal incision technique. Nine out of 15 patients were clipped transvaginal using a long clip applier.In the other patients this was not possible due to obesity.The average operating time was 45 min. Conclusion: Hybrid NOTES transvaginal cholecystectomy is a safe and equal alternative for a conventional laparoscopic cholecystectomy for symptomatic cholecystolithiasis without cholecystitis in female patients. We believe that combining the NOTES concept with conventional/mini laparoscopic surgery is of great added value in the future

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Surg Endosc

P063 - Different Endoscopic Approaches

P065 - Different Endoscopic Approaches

Impact of Changed Suture Material on the Postoperative Outcome of Patients Treated With A New Full Thickness Endoscopic Plication Device For Gerd: Interim Report Of A Prospective Trial

Extraction of Intragastric Foreign Body Through Laparoscopic Transgastric Surgery, Endoscopically Assisted

M. Weitzendorfer1, G. Spaun1, A. Tschoner1, S. Antoniou2, K. Emmanuel1, O.O. Koch1

Regional Institute of Gastroenterology and Hepatology, CLUJ-NAPOCA, Romania

1

Sisters of Charity Hospital, LINZ, Austria; 2Neuwerk Hospital, ¨ NCHENGLADBACH, Germany MO Aims: The aim of this prospective study is to evaluate safety and efficacy of a new endoscopic full thickness plication device as an alternative treatment for patients with chronic gastroesophageal reflux disease (GERD). Methods: As primary endpoint of the study changes in the Gastrointestinal Quality of Life Index (GQLI) after endoscopic fundoplication with the GERDxTM device were defined. Secondary endpoints are: improvement of symptom scores, surgical aspects, esophageal acid exposure characteristics and lower esophageal sphincter pressure. Forty patients with documented GERD and persistent symptoms despite medical treatment, with hiatal hernia \ 2 cm and endoscopic Hill grading Type II-III should be enrolled in the study and undergo endoscopic full-thickness-gastroplication with two or more implants using the GERDxTM device. Gastroscopy is routinely performed six weeks after the procedure. Evaluation of GIQLI, symptoms typically related to reflux, gas-bloat and bowel-dysfunction, esophageal manometry and impedance-pH-monitoring are performed at baseline and three months after the procedure. Results: Twenty-eight patients underwent the procedure so far. The first 15 patients which were enrolled in the study had no complications. Then the company changed suture material during the study due to supply difficulties and six patients were treated with the converted sutures. 50% of these patients had postoperative complications, such as pneumonia, pleural empyema and pleural effusion. Because of severe persisting GERD symptoms 2/6 patients (33.3%) underwent laparoscopic fundoplication during follow up. The next seven patients enrolled were treated with the original sutures material again and no postoperative complications occurred. Therefore we conducted an interim analysis. Until submission, 16/22 patients (72.7%) treated with original sutures completed the 3-months follow-up. Mean GIQLI score and general and reflux specific scores improved in these patients (p \ 0.01). Manometric data was virtually unchanged. Mean DeMeester scores decreased significantly (p \ 0.01). 4/22 patients (18.2%) showed persistent symptoms and were considered treatment failures. Those four were assigned to undergo laparoscopic fundoplication. Conclusion: Suture-Needle length and material of the suture have a major impact on the outcome of the patients. This issue has to be further evaluated and firm conclusions about the device will be possible after all forty patients are enrolled in the study.

D. Bartos, A. Bartos, A. Fetti, C. Pojoga, C. Breazu

Introduction: Ingestion of foreign bodies can occur by accident on healthy persons or voluntary on psychiatric patients. The aggregated formed by these foreign bodies at the level of the digestive tract, with the symptoms related to obstruction, might be the only factor that determinates the patient to go to the doctor. Aims: In this paper we present the cases of two patients with associated psychiatric pathology that have voluntarily ingested foreign bodies. The removal of it was done in our service through minimally invasive approach: endoscopic assisted, transgastric laparoscopic surgery. Methods: We present the cases of two patients who were admitted to our service for digestive symptoms, suggestive for delayed gastric emptiness after voluntary ingestion of foreign bodies: credit card and wires. We decided for the laparoscopic removal of the foreign bodies by the use of minimal gastrotomy under endoscopic assistance. Results: Length of surgery was 120 min and 240 min respectively, without any blood loss, the extraction being done through a 3 cm gastrotomy, in both cases. The second case was time-consuming because of ingested foreign body characteristics (multiple wire filaments). In both cases, the postoperative outcome was uneventful, discharge being made on postoperative day 4 and 3. Conclusions: Laparoscopy provides a quick recovery for patients who have ingested foreign bodies, patients already exhibiting behavioral disorders. Endoscopic approach allows the tracking and immobilization of foreign bodies, the complete gastric emptiness being possible trough a minimum gastrotomy.

P064 - Different Endoscopic Approaches

P066 - Different Endoscopic Approaches

Endoscopic Assisted, Single Transgastric Trocar, Laparoscopic Pseudo-Cysto-Gastro-Anastomosis Procedure

Laparoscopic Intra-Operative ERCP Through A Transgastric Approach After a Roux-En-Y Gasrtic Bypass

A. Bartos, D. Bartos, C. Pojoga, C. Caraiani, C. Breazu

A. Mahajna

Regional Institute of Gastroenterology and Hepatology, CLUJ-NAPOCA, Romania

Rambam Health Care Center, Haifa, Israel, HAIFA, Israel

Introduction: Pancreatic pseudocyst is a complication of acute and chronic pancreatitis, which requires treatment in correlation with it’s size, symptomatology and mass effect on adjacent structures. Currently, pseudocyst drainage can be done with the stomach or small intestine through endoscopic, laparoscopic or open surgery approach. Aims: In this paper we present the case of a patient with pancreatic pseudocyst that we have internally drained by endoscopic assisted laparoscopic approach. Methods: We present the case of a 61 year old patient, with repeated episodes of acute pancreatitis, which presented in our service accusing epigastric pain. Imaging examinations indicated the presence of a pancreatic pseudocyst with a maximum diameter of 18 cm. We decided to perform a mechanical pseudo-cysto-gastro-anastomosis done laparoscopicallytransgastric through a single trocar under endoscopic guidance. Results: The lenght of surgery was 90 min with no blood loss. The laparoscopic examination of the pseudocyst cavity revealed no necrotic areas requiring debridement. The patient had no postoperative complications and was discharged 4 days after surgery. Conclusions: Internal drainage of pancreatic pseudocyst inside the stomach, by the technique described above, is facile, giving the patient the advantages of endoscopy and minimally invasive surgery. In these circumstances, we consider it superior to endoscopic drainage, by providing a broad communication between the pseudocyst and stomach cavity, reducing the risk of relapse and abcess formation. Moreover, it offers the possibility of exploring the pseudocyst cavity and of removing any necrotic tissues. The endoscopic assistance makes possible the single transgastric trocar approach, limitting the injury of the gastric wall.

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Introduction: A rapid weight loss following bariatric surgery is associated with increased incidence of gallstones and related complications. ERCP represent a major challenge in patients after RYGB. Case presentation: we present two cases, the first is a 42 years old female with a surgical history of RYGB and several admissions to the emergency department few months afterwards due to complications of gallstone disease. The second is a 54 years old female who underwent a RYGB combined with cholecystectomy. Several months following surgery, the patient was diagnosed to have gallstones in the common bile duct (CBD). Both patients underwent laparoscopic intra-operative endoscopic retrograde cholangiopancreatography (ERCP) through a transgastric approach. Surgical Technique: Laparoscopic approach was used in both operations. A small gastrotomy with a purse-string suture was performed on the anterior wall of distal remnant of the stomach. A 15 mm trocar was introduced in the left quadrant and through the gastrotomy and was tightened up by the purse-string suture. Intrabdominal CO2 was deflated and a duodenoscope was introduced through the trocar. Endoscopic sphincterotomy and stone extraction were carried out. The trocar was removed from the distal stomach remnant and the gastrostomy was closed with Endo GIA. In the first case, the surgery proceeded with a formal uneventful cholecystectomy. Both patients were discharged on the fourth postoperative day Conclusion: Laparoscopic intraoperative, transgastric ERCP for gallstones extraction in patients after RYGB is a technically feasible procedure and impose a good solution in such cases.

Surg Endosc

P067 - Different Endoscopic Approaches

P069 - Different Endoscopic Approaches

Bleeding Pancreatic Pseudoaneurysms: Treatment by Angioembolization Combined with Therapeutic Endoscopy

Laparoscopic Pneumomediastinal Dissection Replaces Blind Dissection to Create Retrosternal Route For Gastric Tube in Minimally Invasive Esophagectomy

P. Nyka¨nen, M. Udd, E.K. Peltola, A. Leppa¨niemi, L. Kyla¨npa¨a¨ Helsinki University Hospital, HELSINKI, Finland Aims: Bleeding pancreatic pseudoaneurysms (PPAs) are a rare but lethal complication of pancreatitis. Acute bleeding should be managed with transcatheter arterial embolization (TAE), but the best treatment modality for the definitive treatment of the remaining pseudocysts (PCs) is not clear. The aim of this study was to examine the safety and efficacy of the non-surgical management of bleeding PPAs by combining TAE with therapeutic endoscopy. Methods: The study group comprised patients with acute or chronic pancreatitis treated for bleeding PPAs in Helsinki University Hospital during 2004-2014. Acute bleeding was controlled with TAE. Therapeutic endoscopy with transpapillary or transmural stenting performed on an outpatient visit enabled the definitive treatment of the PCs. Results: We performed TAE on 58 patients with an overall success rate of 96.6%. Rebleeding rate (\30 d) was 15.5%. Nine patients with a re-bleed received a re-embolization and one underwent surgery. Mortality rate (\30 d) was 3.4%. Of the 58 patients, 47 had follow-up for their PCs in our unit. Spontaneous resolution of the PC occured in 13 (27.1%). The remaining 34 had an endoscopic treatment attempt. Endoscopy was initially succesfull on 32, and the cannulation failed on two (5.9%). Persisting PCs necessitated an additional drainage procedure on five (15.6%) of the 32 with initially successful endoscopies. Overall success rate of non-surgical management was 91.5%. Mortality rate after endoscopy (\30 d) was 2.9%. Our follow-up lasted 15 (1–75) months. Five-year survival of our patients was 63% with alcohol liver disease being the most common cause of death. Conclusions: Combination of TAE and therapeutic endoscopy is safe and efficient in the treatment of bleeding PPAs, and has a potential to save patients from the risks of pancreatic surgery. Surgery should be reserved to occasions when TAE or endoscopic treatment fails or is not feasible. Further research is needed on the optimal timing of therapeutic endoscopy and on the role empirical embolizations.

P068 - Different Endoscopic Approaches The Development of Laparoscopic Surgery Using the Perineal Approach Through the Presacral Space T. Tanimizu, H. Hase, J. Yamamoto, M. Hoshikawa, T. Noro, S. Aosasa, M. Nishikawa

Y.W. Liu, J.Y. Lee, D.L. Tsai, F.W. Yan, L.C. Chen, J.S. Hsieh, Y.T. Chang, S.H. Chou Kaohsiung Medical University Chung-Ho Memorial Hospital, KAOHSIUNG CITY, Taiwan Aim: Most of esophageal cancer in Taiwan is squamous cell carcinoma and the predominant location of occurrence is middle third. For resectable cases, modified Mckeown technique is often adopted rather than Ivor-Lewis technique under this circumstance. Introduction of thoracoscopic and laparoscopic approach in esophagectomy with reconstruction has gained more popularity in recent decade. Retrosternal route is one of the utilized choices in esophageal reconstruction. This study aimed to demonstrate the feasibility and advantage of laparoscopic pneumomediastinal dissection to create retrosternal route for gastric tube Method: Between May 2014 and May 2015, four patients with upper or middle third esophageal cancer who was planned to use retrosternal route for gastric tube reconstruction were enrolled. All patients were managed by minimally invasive esophagectomy. In laparoscopy stage, gastric tube was formed if there was no evidence of distant metastasis in peritoneal cavity. Only four ports were utilized. The port made for liver retractor located in subxyphoid area which could be used for creating the retrosternal route later. We put the trocar in retrosternal area and use CO2 insufflated to 8 mm Hg for pneumomediastinum. Laparoscope was introduced for both visualization and dissection to make the retrosternal space. Sometimes, harmonic scalpel could also be utilized simultaneously by single-port technique. Then pull-up of gastric tube via retrosternal route was performed following cervical esophagogastric anastomosis by hand sewing. The patient was shifted Result: In all the four patients undergoing minimally invasive esophagectomy, no patient required conversion to laparotomy or thoracotomy, and no intraoperative complication occurred. During the entire procedure among the patients, values of mean blood loss, operative time were analyzed. Postoperatively, no patient required intensive care unit care, no major complication such as pneumonia or leaks occurred, and the mean length of hospital stay is 11 days. Conclusion: Current technique for creating the retrosternal route is simple, quick, economical and even batter then conventional method which usually necessitating a mini-laparotomy wound and blind blunt dissection. Under direct visualization of laparoscope, both pleural cavities remain intact when performing the retrosternal route.

National Defense Medical College, TOKOROZAWA, Japan Purpose: We reported the animal experiments on the title’ Endoscopic approach to the peritoneal cavity’ at the 19th EAES, and the usefulness of perineal port as drainage route at the time of intraperitoneal irrigation on the title ‘Peritonitis surgery utilizing the perineal port’ at the 23rd EAES. This time we want to verify the safety and easiness of the procedure in anticipation for the adaptation of the same procedure on humans. Materials and Methods: 1. Verification by Imaging: On the basis of the image data of the contrast CT for intrapelvic disease, searching the vascular system of the presacral space and observing the angle of sacrum and the form of coccyx, we verify the safety of trocar insertion. 2. Cadaver Surgery: Wecarried outtrocarinsertionfrom theperineum on two cadavers, havingobtained theconsentfrom each personinhis lifetime. The cadavers were applied a specificfix (details not yet published) so as to prevent them from gettingformalin-fixedhard and to keep thestateas close as possible to theliving body. 3. Histological Examination: We carried out trocar insertion surgery from the perineum on two piglets. After a 4 week-feeding experiment, the animal was sacrificed and its presacral space tissue was examined histologically. Results: 1.Verification by image: We investigated the images of the contrast CT of 26 cases. The visualization rate of the middle sacral artery was 90%. It was not visualized in young people. The average angle of the sacral promontory was 139 degrees. Women had a greater angle than men. The coccyges which bent inward were 7.7%. 2. Cadaver Surgery: Theinsertionfromthe perineumtothe peritoneal cavity waswithout problem.However the vessel could not be confirmed at the time of insertion because they were fixed in a chemical solution. 3. Historical Examination: Although we attempted experiments on two piglets, one died due to problems related to the anesthesia. We inserted the trocar from the perineum in the surviving piglet.Scarring of the trocar insertion path was very mild and nearly the same as in normal tissue. Conclusion: The perineal approach through the presacral space route is likely to be a new intraperitoneal access route creating an easy and safe procedure. After gaining ethics committee’s approval,it is planned to be introduced as a method for surgery on humans.

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P070 - Different Endoscopic Approaches

P072 - Different Endoscopic Approaches

Endoscopic Internal Drainage as First Line Treatment for Fistula Following Gastrointestinal Surgery: A Case Series

Percutaneus Endoscopic Gastrostomy (Peg)-Related Peritonitis A Retrospective Analysis

G.F. Donatelli, F. Cereatti, J.L. Dumont, T. Tuszynski, B.M. Vergeau, P. Dhumane, B. Meduri

K. Alexiou1, D. Bethani1, G.T. Gougoulas2, K.P. Karantanos2, N. Economou1 1

HOPITAL PRIVE DES PEUPLIERS, PARIS, France

Sismanoglion General Hospital, MAROUSI, Greece; SISMANOGLION GENERAL HOSPITAL, MAROUSI, Greece

2

Leaks following gastro-intestinal surgery is a dreadful complication burdened by high morbidity and not irrelevant mortality. Endoscopic Internal Drainage (EID), by double pigtail stent, has showed optimal results in the treatment of leaks following bariatric surgery. We report our experience of EID as first line treatment for fistulas following surgery along all gastrointestinal tract. Until November 2015, 11 patients have been addressed to our endoscopic tertiary center for fistula following GI surgery. Surgical procedures were as follow: 4 duodenal fistulas (biliopancreatic surgery), 2 colic fistulas (colo-rectal surgery) and 5 oeso-gastric-jejunal fistulas (foregut surgery). Delay between first surgery and EID was of an average of 14 days (3–60). 10 out 11 patients had a previously positioned surgical or radiologic drainage. Opacification of fistula was always performed during endoscopic examination in order to evaluate the fistula opening, the collection, its shape and size. Endoscopic evaluation was of paramount importance to correctly decide the appropriate type of pigtail stent (diameter and length) and its number. With a Tandem  catheter(Boston Scientific, Massachusetts, Boston, USA) the defect was cannulated and after guidewire insertion one or more double pigtail stents (Advanix  Boston Scientific, Massachusetts-Boston-USA or G-Flex, Nivelles-Belgium) were deployed. In 5 out of 11 patients a jejunal feeding tube was left in place. Meanwhile 6 patients were allowed oral diet the day after the procedure. Systematic control was performed at 4-6 weeks in order to evaluate the evolution of the collection and to modify stent size according to the reduction of the cavity. Technical success was achieved in all patients (100%). Clinical success was reached in 9/11 patients (82%) after an average of 44 days of treatment (28–90) and 2,3 endoscopic sessions (1–4). A mean of 1.8 pigtail stent per patient were deployed (1–4). At mean follow up of 291 days all patients are symptoms free and on oral diet. EID is a valuable and efficient technique not only for leak following bariatric surgery but even for leaks and fistulas following other type of upper and lower GI surgery. As long as EID gain access to the fluid collection internal drainage may be achieved along all the GI tract.

We retrospectively studied the impact of technical factors during PEG tube placement on the development of subsequent peritonitis. Method: All patients undergoing PEG tube placement during a two years period were included. Patients’ demographics and nutritional status (albumin and proalbumin) were collected and evaluated for the evaluation of peritonitis. Technical factors including abdominal wall trans-illumination and indentation of the anterior gastric wall were graded by the surgical endoscopist as Excellent/Poor. These grades were converted in continuous numeric scores 1/2. Technical difficulty of the procedure was quantified as None/Some/Severe (1/2/3). Results: Over 5 years 140 patients underwent PEG tube placement. The Pull Technique was performed in all cases under sedation, with antibiotic prophylaxis. Average time required was 16 min. Indications were stroke (63 patients), Parkinson’s decease (31 patients), brain tumours (13 patients), head and neck cancers (9 patients), multiple sclerosis (17 patients), oesophageal cancer (4 patients), neonatal encephalopathy (3 patient). The mean age was 70 years. Female patients were 79 while male 61 . Three patients developed peritonitis due to gastric content leak around the PEG tube, requiring laparotomy. No difference was found in the nutritional status of the peritonitis group and the non-peritonitis group. The trans-illumination score was poor in the 3 patients (100%) of the peritonitis group whereas only in 5 patients of the non-peritonitis group. There was no difference in the overall technical difficulty score between the two groups. Minor complications such us tube dysfunction and cellulitis around the tube were present in 4 and 9 patients respectively. Conclusion: There seems to be a relation between technical factors during PEG tube placement and development of peritonitis. Trans-illumination is the most important.

P071 - Different Endoscopic Approaches

P073 - Different Endoscopic Approaches

Endoscopy and Reconstruction: Novel Applications for Autologous Tissue Harvest and Transfer

Laparoscopic Transection of the Rectum Using the ContourÒ Stapler

A. Rebecca1, L. Bryant2, C. Velazco2, K. Connolly2, W.J. Casey2 1

2

Mayo Clinic, CAVE CREEK, United States of America; Mayo Clinic Hospital, PHOENIX, United States of America In the continuous effort to minimize morbitidity for patients, reconstructive surgeons utilize their training in endoscopy to best harvest and transfer autologous tissue. Endoscopic techniques are applied to all anatomic areas including: head and neck, chest and back, abdomen and extremities. We have utilized endoscopic techniques to treat facial nerve palsy, brochopleural fistulae reconstruction, breast reconstruction, chest wall and sarcoma reconstruction, and pelvic floor reconstruction. Application of techniques learned during general surgical training have been utilized and modified by reconstructive surgeons to perform (1) functional tendon transfers in facial reanimation, (2) free and pedicled muscle flaps such as latissimus, rectus abdominus, gracilis and gastrocnemius flaps (3) pedicled and free omental flaps for thoracic and wound coverage (4)arterial and venous anastomosis in areas of limited accessability. The application of endoscopic and robotic surgical techniques have allowed reconstructive surgeons to limit additional morbidity to patients undergoing traumatic, infectious and oncologic treatment. We demonstrate the use of these techniques in patients for which we have coordinated reconstruction with thoracic, colorectal, orthopedic and oncologic surgery in our institution.

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R.J. Renger, F. Logeman Beatrix Hospital, GORINCHEM, The Netherlands Introduction: Laparoscopic surgery is widespread accepted in colorectal surgery. The industry has helped us a lot by developing better materials and tools. However, we are still waiting for the right laparoscopic instrument for one of the most challenging and crucial steps in rectal surgery: the transection of the lower rectum. The available laparoscopic stapling devices are mostly introduced through the right iliac fossa trocart. This way the stapler reaches the transection line in an oblique direction leading to an oblique rectal stump. When introduced from a suprapubic trocart, you will achieve the same result: an oblique rectal stump with poor vascularization of the corners and a higher risk of anastomotic failure.Therefore a perpendicular transection line is impossible with the current laparoscopic staplers. A technical solution: The Contour stapler has been developed for open surgery. It has a curved design which facilitates introduction in the narrow pelvis. With this stapler it is possible to encircle the distal rectum and perform a single shot horizontal staple line. However, this stapler is not designed for laparoscopic surgery. With its square shaft and its metal bar it impossible to make it air tight and to maintain pneumoperitoneum. We invented a technique in which we use the Contour stapler in a laparoscopic low anterior resection procedure by using a gynaecological glove and an Alexis ring (Applied ). In this way low rectal perpendicular stapling under direct laparoscopic view is possible. With a few illustrative intraoperative pictures this technique is demonstrated.

Surg Endosc

P074 - Different Endoscopic Approaches

P076 - Different Endoscopic Approaches

Laparoscopic Gastropancreatoduadenal Resection in the Treatment of Tumors Biliopancreatoduodenal’s Area

Laparoscopic Excision of Giant Mesenteric Cystic Teratoma

S.G. Blyumina1, A.S. Pryadko1, N.A. Maystrenko1, P.N. Romashchenko1, R.R. Sedletskii2, G.V. Mihalchenko2, I.Y. Boyko2, D.I. Vasilevsky2, E.N. Kamalov2 1

Medical Academy, ST.-PETERSBURG, Russia; 2Leningrad Regional Clinical Hospital, ST.-PETERSBURG, Russia Examined the results of 153 GPDR (including pylorus-saved PDR), 11 of which are made endovideosurgical. Indications for the GPDR and pylorus-saved PDR (PSPDR) were ductal carcinoma of the head of the pancreas in 85% of patients with cancer of the major duodenal papilla (MDP) 10%, the head of the pancreas neuroendocrine cancer - 5%. Analysis of clinical-laboratory and instrumental data on patients with tumors BPDA, as well as the results of public GPDR, allowed us to determine the possibility of performing laparoscopic surgery in the localization of the tumor in the pancreatic head MDP either less than 3 cm in greatest dimension without signs of invasion of large vessels. Open GPDR was performed in 80% of patients, pylorus-saved PDR - at 20%. GPDR in its embodiment as a laparoscopic Whipple’s operation with reconstructive stage two loops of the intestine were performed in four patients at pylorus-saved embodiment with three operations on the anastomoses one loop was done in 3 patients. In other cases performed laparoscopic-assisted GPDR. The duration of laparoscopic surgery with full version of the GPDR and laparoscopicassisted was 535 ± 45 min and 390 ± 20 min, respectively. The volume of intraoperative blood loss was 200 ml to 1000 ml. All patients were extubated on the first day, the restoration of peristalsis - the first day, enteral feeding - with 2 days. Postoperative complications were observed in 6 patients: bleeding from the bed head of the pancreas that required reoperation in 1 patient; inconsistency of pan?reatojejunoanastomosis, healed by conservative measures - at 3; obstructive abscess - at 2, allowed puncture and drainage under ultrasound guidance. 30 and 60-day in-hospital mortality were observed. Thus, the analysis of the first experience performing GPDR using endovideosurgical technologies indicates the possibility to observe the necessary oncologic requirements for surgery on BPDA, reduce surgical trauma and the period of stay in the intensive care unit, to carry out an early activation of patients and reduce hospital stay.

A.L. Moreno1, P. Fabiano2 1

Hospital, HUERCAL-OVERA, ALMERIA, Spain; 2La Inmaculada Hospital, HUERCAL OVERA, Spain Cystic teratomas are rare tumors, it has an incidence of 1/100000 income. Its most common site is ovarian. Extragonadal teratomas, are extremely rare.We report an extremely rare case of a 55 year old male with a giant mesenteric cystic teratoma treated by laparoscopy. Examination revealed a painless mass occupying the entire abdominal cavity and causes a great strain thereof without signs of abdominal defense. CT scan where a mass of 255.9 9 177.8 9 328.7 mm, which moves intra-abdominal structures observed in senior management is performed. The study was completed with an MRI that confirmed a giant retroperitoneal cystic mass of 27 cm 9 21 cm 9 12 cm with solid pole calcified anterior area of ??56 mm, obstructive uropathy bilateral ureteral compression by mass. The patient underwent surgery laparoscopically. The dissection was very difficult due to the large size of the lesion, to mobilize spontaneous rupture occurred with liquid outlet to the cavity. It was completely evacuated and laparoscopic cystectomy was completed. Alexis used through a phanesteil for specimen removal. The patient improved and was discharged to 4 days postoperatively. The pathological study of the piece described a mature cystic teratoma with a giant cell granulomatous reaction intracystic. The fluid analysis was negative for malignant cells. The treatment is surgical mesenteric cyst. Choice of the approach will depend on the size, location of the lesion and the surgeon’s experience. Despite the widespread popularity that laparoscopy has gained in all fields, mesenteric teratoma tumors are so rare that there are only 21 cases reported in the literature, and there is only the one described by laparoscopy and a ‘hand-assisted’. The peculiarity of our case is that despite the large size of the moving mass produced surrounding structures and even obstructive uropathy, was well defined with good tissue planes without evidence of vascular invasion. Laparoscopic excision without intraoperative or immediate complications and early recovery of the patient was performed.Our approach is totally laparoscopic, as we believe that is technically feasible and results in a shorter hospital stay and faster postoperative recovery.

P075 - Different Endoscopic Approaches

P077 - Different Endoscopic Approaches

Efficacy and Safety of Single-Incision Laparoscopic Totally Extra-Peritoneal Inguinal Hernia Repair - A Single Center Experience

Transanal Hartmann Reversal: Outcomes of the First 10 Patients

T. Miura, H. Yamada, H. Doumen, K. Ichinokawa, M. Kanai

1 IMDiM, BARCELONA, Spain; 2Hospital Clinic Barcelona, BARCELONA, Spain

Nippon Telegraph and Telephone East Corporation Sapporo Hospital, SAPPORO, Japan Background: Laparoscopic inguinal hernia repair is currently one of the most commonly performed minimally invasive surgical procedures. In recent years, single-incision operations have been developed to further reduce the invasiveness of the surgery. In our center, in addition to performing transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair, we have also adapted a single-incision totally extra-peritoneal (STEP) approach to inguinal hernia in the pursuit of a less-invasive approach and improved cosmesis. The aim of this study was to assess the efficacy and safety of STEP. Methods: Between January 2011 and December 2015, a total of 89 consecutive patients underwent laparoscopic inguinal hernia repair for unilateral hernia. Since 2013, we have applied STEP using a 2-cm incision made within the umbilical folds and a small incision in the anterior layer of the rectus sheath to insert a LAP PROTECTOR into the preperitoneal cavity. An EZ access is used as the lid of the LAPPROTECTOR. Three 5-mm ports were inserted through the EZ access. A 5-mm flexible laparoscope was used. STEP was performed on 32 of the 89 patients, and TAPP with three ports (one 12-mm and two 5-mm ports) was performed on the remaining 57. STEP and TAPP were retrospectively compared by statistical evaluation of differences in age, sex, body mass index (BMI), operative time, complications, use of analgesics, postoperative hospital stay, and hernia recurrence. Results: All procedures were performed successfully with no conversions. The mean postoperative hospital stay for STEP patients was shorter than that for TAPP patients (p = 0.004). There were no other statistically significant differences between STEP and TAPP, including operative time (p = 0.198), complications (p = 0.233), use of analgesics (p = 0.775), and hernia recurrence (p = 0.4511). Conclusions: These findings suggest that STEP is comparable to TAPP in terms of both feasibility and safety. Additionally, STEP is not a difficult operative method. Outcomes, including postoperative quality of life and cosmesis, need to be evaluated further by examining more cases.

R. Bravo1, M. Jimenez-Toscano2, M. Ferna´ndez-Hevia2, J.S. Tre´panier2, M.C. Arroyave2, B. De Lacy2, S. Delgado2, A.M. Lacy2

Aims: Hartmann’s procedure is still commonly performed for left colonic pathology. Reversal of Hartmann’s colostomy is a major abdominal operation that is considered a high-risk procedure, technically demanding and associated with significant morbidity and mortality, mainly in the presence of a short rectal stump. Multiple authors have shown that it is a safe and feasible alternative to open Hartmann’s reversal as laparoscopic procedure and single-port approach through the stoma site. We report short-term results of transanal Hartmann reversal (TaHR) assisted by laparoscopy in the first ten cases performed at the Hospital Clinic of Barcelona. Methods: Consecutive patients with previous Hartmann resection done in different hospitals and referred to Hospital Clinic of Barcelona were included in a trial of TaHR conducted from October 2013 to November 2015. Ten patients were prospectively registered in the study. The TaHR is performed by both abdominal and transanal surgical teams working together. Endpoint was safety of the procedure, analyzing intra- and postoperative complications. Results: Ten patients (5 women and 5 men) underwent TaHR. The mean age was 74.4 ± 8.8 years (58-90) and body mass index was 26.5 ± 3.8 kg/m2. American Society of Anesthesiologists classification of patients was I (n = 1), II (n = 7) and III (n = 2). The reasons for the Hartmann procedure were leak after anterior resection (n = 4), acute complicated diverticulitis (n = 3) and no anastomosis in advanced colorectal cancer (n = 3). The mean length of the rectal stump was 10.4 ± 4.5 cm. The time between Hartmann’s colostomy creation and reversal was 23 ± 18 months. The overall operative time was 204 ± 65 min. The mean length of hospital stay was 7.2 ± 4.3 days and a median of 5.5 days. The return to bowel transit was observed after a mean of 2.1 ± 2.1 days. Number of days before diet resumption was 3.5 ± 3.5. We had 4 minor complications in 3 patients. No patient required reoperation. Conclusions: Definitive conclusions cannot be made, but the short-term results are promising and we consider this technique as an effective and safe procedure.

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Surg Endosc

P078 - Different Endoscopic Approaches

P080 - Education

Endoscopic Assisted Gastrocnemius Flap for Lower Extremity Reconstruction in Sarcoma Patients:A Case Study Of Limitations

The Pareto-Analysis For Establishing Content Criteria In Surgical Training

A. Rebecca1, L. Bryant2, C. Velazco2, K. Connolly2, S. Azouz2, W.J. Casey2

K.H. Kramp1, M.J. van Det2, N.J.G.M. Veeger1, J.P.E.N. Pierie1

Mayo Clinic, CAVE CREEK, United States of America; 2Mayo Clinic Hospital, PHOENIX, United States of America

2

1

Patients undergoing treatment for soft tissue sarcoma present challenging cases for reconstructive surgeons. Using minimally invasive techniques in the face of radiation optimizes the peri-operative outcome in many regards. By limiting the length of incisions, allowing for placement outside the zone of radiation injury, and assisting in visualization, endoscopy is an advatageous tool for these cases. The gastrocnemius flap is elevated using several different access incisions, including medial calf, lateral calf and the ‘silk-stocking’ incision. The length and placement is variable between surgeons, and can be an important aspect of wound healing in the face of radiation, venous and arterial disease, and patient specific characteristics. We present a 65 year old male with a posterior knee sarcoma resulting in an open wound over the popliteal fossa. Minimally invasive elevation of the gastrocnemius flap for preservation of posterior calf skin integrity, avoidance of radiation damaged skin and preservation of a large tattoo was attempted. Future endoscopic elevation of gastrocnemius flaps would be best performed in a pre-emptive fashion. Our incisions resulted in a distal horizontal access incision for preservation of his tattoo and elevation of the medial head of the gastrocnemius flap for excellent popliteal fossa coverage using endoscopic visualization. The patient went on to heal without event. Improvements in this procedure would allow for shorter incsions, ease of flap elevation, visualization of the neurovascular pedicle and allow for greater flap mobility.

1

Medical Center Leeuwarden, LEEUWARDEN, The Netherlands; Hospital Group Twente, ALMELO, The Netherlands

Introduction: Currently, there is no widely used method to calibrate in vitro surgical training to the in vivo challenges during surgery on patients. The Pareto-principle states that in any population that contributes to a common effect a relative few account for the bulk of the effect. This is the first study that evaluates the Pareto-principle for establishing content criteria for surgical training. Method: Verbal corrections of supervising surgeons during a laparoscopic cholecystectomy performed by trainees in the OR were documented and tallied. The corrections were rankordered and a cumulative distribution curve was used to calculate which corrections accounted for 80% of the total number of verbal corrections. Results: The behaviour of 9 surgeons supervising 62 laparoscopic cholecystectomies performed by 12 novice trainees were analyzed. In total, 235 different verbal corrections were used 1570 times and were categorized into 40 different clusters of aimed changes in novice behaviours. The 32 highest ranking verbal corrections (14%) and the 11 highest ranking clusters (28%) accounted for 80% of the total number of verbal corrections. Conclusions: The Pareto-principle is a highly potential tool for identifying the few types of novice behaviour that account for the majority of corrections given by supervisors during a laparoscopic cholecystectomy on humans. Replicating this study for other surgical procedures could be an opportunity for creating surgical training tools that are more effectively calibrated to on-the-job challenges.

P079 - Different Endoscopic Approaches

P081 - Education

Tipp: ‘A Single Centre Experience and the Learning Curve’

The Neccessity of a Laparoscopic Skills Training Programme for Junior Surgeons in the United Kingdom

P. Ellanti, A. Kharief, K. Shariq, O. al Sahaf Naas General Hospital, NAAS, CO. KILDARE, Ireland Purpose: The learning curve surrounding trans inguinal pre-peritoneal (TIPP) hernia repair has always been an interesting topic for debate. Studies claim that the learning curve for this procedure is fairly short. While numerical values have been suggested for laparoscopic TEP (totally extra peritoneal) hernia repair ranging from 30-60 cases on average, no such figures are mentioned for TIPP herniorrhaphy. At our centre we show that averages of 30 cases are sufficient for the surgeon to become proficient in this type of surgery. Methods: A total of 30 patients who underwent TIPP herniorrhaphy by a single surgeon between 2013 - 2015 were followed prospectively. Analysis included patient review, perioperative issues as well as post-operative complications. Results: On detailed review of data collected no serious complications for example such as testicular injury, mesh infection, visceral complications were noted. The overall outcome was satisfactory for both patient and surgeon thus becoming one of the primary surgeons’ preferred choices for herniorrhaphy, taking into account patient selection criteria. Conclusions: TIPP herniorrhaphy we know is a safe procedure with low complication rates. We estimate that the minimum number of cases to overcome the learning curve in this procedure is about 30 cases.

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A. Phaily1, J. Thomas2, A. Ali1, A. Robinson1 1 Ashford and St. Peter’s Hospital NHS Trust, CHERTSEY, United Kingdom; 2University Hospital of Wales, CARDIFF, United Kingdom

Aims: Surgery has been revolutionised by the introduction of minimally invasive procedures such as laparoscopy. The rapid spread and dissemination of these procedures has left many surgical education programmes struggling to catch up to the advances, especially in the face of nascent robotics technology. Currently, there is exists no generally accepted laparoscopy training programme for junior surgical trainees in the United Kingdom. This article assesses the feasibility of such a programme and highlights its benefits and drawbacks. Methods: A literature review and analysis of current international laparoscopic surgery curricula and their merits. A discussion of medical education theories, acquisition of practical skills and cost implications for healthcare trusts and Local Education and Training Boards (LETBs). Assessment of current and future models of technological innovation as applied to surgery. Results: Current programmes such as the Fundamentals of Laparoscopic Surgery (FLS) and the Danish model focus heavily on formative assessment and certification. An outline of a novel laparoscopic surgery training programme is proposed. By the end of the programme, improvements will be seen in the following domains: spatial awareness, hand to eye coordination, efficiency of movement and tissue handling. Initial cost implications will be offset by development of the minimally invasive simulation suite and training courses for external applicants as a source of funding. Conclusions: As advances in technology and its applications in surgery are accelerating, early formal training in new surgical techniques is not only recommended but necessary. Early training and adoption will enable surgeons to better adapt to future innovations in minimally invasive surgery.

Surg Endosc

P082 - Education

P084 - Education

Is There a Difference in Laparoscopic Cholecystectomy Preformed in a Teaching Hospital or a General Hospital in Dutch Clinics?

The Influence of the Experience of Surgeon Assistant on the Outcome of Laparoscopic Surgery During the Surgeon‘S Learning Curve

B.J.G.A. Corten1, J.W. Leijtens2, L. Janssen3, J.L.M. Konsten3

M.F. Avram1, I.O. Avram1, D. Koukoulas2, S. Olariu1

1

2

VieCuri Adress, VENLO, The Netherlands; Laurentius ziekenhuis, ROERMOND, The Netherlands; 3VieCuri Medisch Centrum, VENLO, The Netherlands Aim: Laparoscopic cholecystectomy (LC) may have a complicated course with severe complications such as bile duct injury. Foreign studies report ambivalent results regarding the influence of a residency program on safety, efficacy and financial consequences. All the more reasons to take a closer look at the Dutch situation. We conducted a prospective cohort study to examine the safety of laparoscopic cholecystectomies in a training hospital (STZ) with a residency program and a general hospital without surgical residents. Methods: All consecutive (laparoscopic) cholecystectomies in the two hospitals were included between September 2014 and March 2015. Patient characteristics, operative procedure, level of experience (primary surgeon), operation time, intra- and postoperative complications, mortality, length of hospital stay, re-admittance and conversions to laparotomy were analyzed. Results: A total of 294 consecutive (laparoscopic) cholecystectomies were performed in both clinics (training hospital = 50%, non-residency hospital = 50%). Showing an increase in operation time in the teaching hospital compared with the general hospital. Operations performed in the teaching hospital took an average of 25 min longer to complete the surgery compared with a non-residency setting (residency program 72 min compared with 47 min in non-residency program). The number of conversions did not increase significant (p = 0.283) and the number of re-admissions were comparable in both clinics (p = 0.375). The residency program showed more peroperative liver lesions (p \ 0.001) among with more postoperative complications (p = 0.042). Both the increase in operation time and the liver lesions were not associated with an increase in complication rate. (p = 0.103 and p = 0.373) Conclusions: Current practice where residents preform cholecystectomies either supervised by fellow senior residents or by an experienced surgeon should not be discouraged. We found that is safe and lead to an acceptable increase in operation time. To this extent we should consider additional teaching methods and training.

1

University of Medicine and Pharmacy V. Babes, TIMISOARA, Romania; 2City Hospital, LUGOJ, Romania Background: There are many studies regarding the learning curve for laparoscopic surgery, but the influence of the surgeon assistant experience during the learning curve is poorly studied. Material: We did a retrospective analysis of 100 patients’ data who underwent laparoscopic cholecystectomy in our clinic. The surgery was performed by 5 surgeons in training performing their first 20 laparoscopic interventions. We used the operating time (OT), conversion rate (CR), total rate of postoperative early complications (PC), postoperative late complications and hospital stay (HS) to evaluate the outcome. We took into consideration the laparoscopic experience of the surgeon assistant, dividing the patients into 3 groups based on the surgeons assistant laparoscopic experience: group 1(100–500 interventions), group2 ([500 laparoscopic cholecystectomies), group3 (surgeons performing advanced procedures). Results: In group 1:35 patients, OT- 63 min,CR- 8.5%, PC- 11.4%, HS- 4.2 days. In group2:43 patients, OT- 49 min, CR- 4.65%, PC- 6.97%, HS- 3.4 days. In group3: 22 patients, OT-62 min, CR- 9%, PC-9.1%, HS- 3.8 days. No late postoperative complications were recorded. Conclusions: Our study suggests that surgeons with experience of more than 500 laparoscopic cholecystectomies helping surgeons perform their first basic laparoscopic surgery provide best outcome.

P083 - Education

P085 - Education

The Effect of E-Learning Vs Didactic Lectures on Knowledge in Basic Laparoscopic Skills and Advanced Suturing in Developing Countries

Endoscopic Muscles Harvesting - Experimental Study for Free Flaps

S. Wijerathne1, D. Lomanto1, W.B. Tan1, A. Shabbir1, A.A. Buenafe2 1

National University Hospital, Singapore, SINGAPORE, Singapore; 2 Batangas Medical Centre, BATANGAS, Philippines Knowledge on basic laparoscopic skills and advanced suturing is an essential component of the residency training in general surgery. The advancement of science has given us multiple platforms to deliver and acquire knowledge. E-learning is increasingly gaining popularity among both residents and lecturers due to its easy accessibility and reproducibility. But residents in developing countries may have limitations with access to basic laparoscopic skills training either by simple lectures and/or e-learning. E-learning may be superior to conventional lectures because it’s accessible any time. The improvement of connectivity is helpful in providing more e-teaching to surgical residents in remote areas. We created an online e-learning platform at http://coursemed.com in which different modules focus on basic laparoscopic skills and advanced suturing. An assessment test was performed before and after completion of the course and/or lectures using 20 predefined multiple choice questions (MCQs). 84 surgical residents from Nepal, Myanmar, Cambodia, Sri Lanka, and India were enrolled for the e-learning exercise. 75(89.3%) took part in the pre-test and 71(84.5%) took part in the post-test while only 63(75%) of them completed both pre and post-tests. Out of the 63 residents who completed both tests, 12(19%) had no change in test scores, 11(17.5%) had poorer test scores and 40(63.5%) had improved scores. The mean pre-test and post-test scores were 67.1(± 11.97) and 77.1 (± 11.94) respectively and this was statistically significant (p \ 0.0001). During an era where access for electronic data is widely available, e-learning can be effectively incorporated into the residency curriculum, which could help improve knowledge of residents on selected core topics.

I. Blidisel1, M. Cretu2, M. Ionac3, L. Jiga3 1 UMF Timisoara, TIMISOARA, Romania; 2City Hospital, TIMISOARA, Romania; 3County Hospital, TIMISOARA, Romania

Aim: The rectus abdominis, gracilis an latissimus dorsi muscle are one of the most frequent used free flaps in reconstructive surgery. Endoscopic harvesting of free flaps is increasingly used in reconstructive surgery due to minimal donor site morbidity. The present study aims in establishing a comparison between the experimental model of the rectus abdominis, gracilis and latissimus dorsi muscles endoscopic harvesting technique and the open harvesting technique in pigs. Material and Method: The study was conducted on 30 pigs with an average weight of 25–30 kg. 5 muscle were harvested by endoscopic technique and 5 muscle through the open technique for each muscle. After orotracheal intubation and anesthesia, each muscle were harvested in two ways. Laparoscopic surgery instruments were used along with the Emory retractor The anterior and posterior side of the muscle is dissected using a forceps and a Hook. After the muscle is sectioned using the hook, the pedicle is isolated and clipped on the desired length. The work chamber is created using Emory retractors. Results: Operating time was around 100 to 130 min for the open technique and 150 to 170 min with the endoscopic technique. During the study, the rate of conversion, bleeding, surgery duration, flap viability, length and aspect of the pedicle and moment of mobilization were followed. One pedicle was damaged during endoscopic surgery with following seroma development. Morbidity was lesser in animals where endoscopic harvesting was performed. Conclusions: Endoscopic harvesting of the rectus abdominis muscle, gracilis and latissimus dorsi leads to minimal donor site complications. At the same time, this techniques represents an excellent training model for developing endoscopic and open flap harvesting skills.

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Surg Endosc

P086 - Emergency Surgery

P088 - Emergency Surgery

Efficiency Vats Treatment in the Elimination of Pneumothorax Bullous Lung Disease

Delayed Presentation of Post-Traumatic Diaphragmatic Hernia Presented by Acute Gastric Outlet Obstruction (Case Report)

K. Rustemova1, K. Dzharkeyev2

M. Fahmy, M. Daradka, A. Taha, M. Abdulwahab

1

2

Medical university Astana JSC, ASTANA, Kazakhstan; Medical university Astana JSC, ASTANA, Kazakhstan

Objective: Minimize the risk of therapeutic and diagnostic Bullous emphysema Methods: (thoracoscopic stand firm Karl Storz, Germany), CT, Radiographic(X-ray digital)The clinic from 2010 to October 2015 with complications bullous emphysema treated 437 (100%) patients. Of these, 377 (86.3%) patients were admitted on an emergency basis with the clinic pneumothorax, 60 (13.7%) patients received routinely. In 295 (67.5%) patients had right-sided bullous emphysema, in 125 (28.9%) left, 17 (3.8%) patients had bilateral lung damage. All patients underwent surgical treatment. Thoracoscopic closure of bulls manually produced 227 (52.0%) patients; thoracoscopic loop ligation Bull Raeder made 164 (37,5%) patients; endoscopic resection of bullae crosslinking - cutting apparatus 46 (10,5%) patients; In 17 (3,8%) cases had bilateral lung - made one at a one-stage bilateral thoracoscopic lung bullae suturing Results: In carrying out surgery for bullous emphysema, to prevent the recurrence of pneumothorax after thoracoscopic resection and suturing Bull 137 (31,6%) patients, in addition subtotal ectomy pleuro dome of the pleura and the top-rear inner surface of the chest wall. Conclusion: Minimal risks of treatment, early rehabilitation of the patient allowed the introduction endovideosurgical treatment of bullous emphysema

P087 - Emergency Surgery Laparascopic Procedures for Variceal Bleeding Y.U.V. Grubnik, O.M. Iuzvak, V.Y.U. Grubnik, V.A. Fomenko Odessa national medical university, ODESSA, Ukraine Introduction: Variceal bleeding produces high mortality and morbidity. It can be decreased by usage of minimally invasive procedures. The aim of this work was to analyze the results of minimally invasive surgery, endoscopic hemostasis and laparoscopic procedures, for liver cirrhosis complicated by variceal bleeding. Methods: From 2007 to 2014 there were 420 patients with variceal bleeding. Endoscopic hemostasis were performed for 296 patients: 158 patients - sclerotherapy, 98 patients ligation, 30 patients - sealing. In 10 cases for massive bleeding and failed endoscopic hemostasis, we performed placement of stents of Denish. From 48 patients with varices of the stomach, 21 patients undergone laparoscopic resection of the fundal part of the stomach because endoscopic hemostasis was not effective. LigaSure sealing were used for devascularization of the stomach, and a stapler was used for resection. Results: Endoscopic hemostasis was successful in 340 cases (81%). Band ligation and stenting were the most effective methods. There were no mortality after laparoscopic procedures. Among these patients there were 2 cases of trocar wound infection, 1 case of subphrenic abscess, and 1 case of bleeding recurrence requiring endoscopic hemostasis. Conclusions: Endoscopic band ligation and placement of Denish stents are the most effective methods of local hemostasis. Laparoscopic resection of fundal part of the stomach is effective procedure for gastric varices.

123

Rcmc, YANBU, Saudi Arabia Introduction: The exact incidence of post-traumatic diaphragmatic hernia is difficult to define. The reason is that a significant number of cases of traumatic diaphragmatic rupture is clinically and radiologically overlooked early after injury. Case report: We are presenting a case of a 35 years old lady with acute onset of chest pain, dyspnea, tachypnea, and desaturation during the last twentyfour hours. She had a past history of road-traffic accident 5 years ago, with no history of previous surgery. During the last 2 years, the patient used to complain of recurrent attacks of chest pain, and vomiting after meals. No significant weight loss was reported. Since 72 h, she started to vomit coffee ground vomitus associated with epigastric pain that gradually increased until she developed a picture of acute gastric outlet obstruction, left lung collapse, and shift of mediastinum to the right side. Upon arrival,the patient was dehydrated, acidotic, and had chest pain, desaturated, and tachypnic. She was admitted to theICU, where correction of her fluid and electrolytes started. Her x-ray chest showed collapse of left lung, and right-sided mediastinal shift due to total migration of the stomach intra-throacically. CT scan with IV contrast revealed migration of the stomach, spleen, omentum, and splenic flexure of the colon to the left hemi-thorax,left lung collapse, right-sided mediastinal shift, with complete gastric outlet obstruction. The patient was transferred to operation room where left sided thoracotomy done through sixth left inter-coastal space. The stomach was evacuated by a gastrotomy and two liters of bloody gastric contents aspirated. The gastrotomy was closed in two layers and all intra-thoracic migrated abdominal organs were repositioned back to the peritoneal cavity through a large diaphragmatic defect of about 10 cm in diameter. The defect was then closed by prolene zero continuous stitching, and a chest tube was left intrapleurally after complete expansion of the left lung. The patient did well post-operatively. Conclusion: Diagnosis of traumatic diaphragmatic rupture requires a high index of suspicion and good knowledge of the exact mechanism of trauma.Complications such as traumatic diaphragmatic hernia should be treated surgically once diagnosed to avoid possible life-threatening acute complications.

P089 - Emergency Surgery Surgical Outcome of Laparoscopic Repair for Gastroduodenal Perforations in Comparison with Conventional Laparotomy T. Kaetsu1, K. Hosokawa2, H. Miyaji2, Y. Satoh2, Y. Masuda2, N. Matsumura2 Kikuna Memorial Hospital, YOKOHAMA, Japan; 2Digestive Center, Department of Surgery, Kikuna Memorial Hospital, YOKOHAMA, Japan

1

Background: Laparoscopic repair (LR) of perforated gastroduodenal ulcers is a common treatment for emergency gastric surgery. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of LR of gastroduodenal perforations outweigh the disadvantages. The aim of this study is to evaluate the safe and non-inferiority of laparoscopic approach for gastroduodenal perforations by comparison with conventional approaches. Materials and Methods: From April 2008 to October 2015, 57 patients underwent emergency operation for gastroduodenal perforations. Firstly, we chose a laparoscopic approach and then applied for 12 patients. The exclusion criteria for a laparoscopic approach ruled out patients who had shock at admission, severe cardiorespiratory diseases, or a history of abdominal surgery. According to the exclusion criteria, 45 patients underwent conventional open surgery. Results: Conversion to laparotomy was not seen in the LR group. The mean operative duration of open surgery was significantly shorter than that of laparoscopic approach (75 vs 94 min, p = 0.04). The laparoscopic group however, showed significant differences in the start of meal intake (3.2 vs 3.9 days, p \ 0.01), and the period until nasogastric tube removal (2.3 vs 2.7 days, p \ 0.01). There was no statistically difference in postoperative hospital stay (10.7 vs 11.7 days, p = 0.60), or postoperative morbidity rate (8.3% vs 17.8%, p = 0.39). Conclusion: Even though the operative duration was slightly longer in the laparoscopic group, Laparoscopic repair for gastroduodenal perforations was more favorable than conventional surgery regarding the start of food intake and the period until nasogastric tube removal. The laparoscopic approach was a safe and feasible for postoperative complications.

Surg Endosc

P090 - Emergency Surgery

P092 - Emergency Surgery

Laparoscopic Approach to Non-Traumatic Enterocolic Emergencies: The Success Factors Analysis in A High Experienced Center

Laparascopic Operations in Patients with Polytrauma

M. Berselli1, J. Galvanin1, V. Quintodei1, L. Livraghi1, L. Latham1, L. Farassino1, M. Bonzini2, G. Borroni1, L. Ungari1, G. Carcano2, E. Cocozza1

Odessa national medical university, ODESSA, Ukraine

1

Ospedale di Circolo e Fondazione Macchi, VARESE, Italy; 2Insubria University, VARESE, Italy Aims: Laparoscopic surgery has become highly effective to treat a wide range of elective general surgical operations. Its role in emergency settings is gaining attention by surgical community. In fact laparoscopy could be useful to diagnose many intraabdominal disorders allowing treatment in the same surgical procedure with minimal trauma to the patient. This study aimed to investigate the therapeutic efficacy of emergency laparoscopic surgery for nontraumatic enterocolic diseases. Methods: A series of consecutive patients who underwent a laparoscopic surgical approach for non-traumatic enterocolic pathologies in emergency setting, between January 2012 and December 2014, were retrospectively analysed. Mortality, postoperative complications, conversion and reoperation rate were investigated. Postoperative complications were divide in early and late (cutoff 30 days). All surgical procedures were performed by a surgical team highly trained in laparoscopy colorectal elective surgery. Results: 93 patients were enrolled. Mortality rate was 1,1% (1/93). Early postoperative complications occurred in 15 patients (16,1%) with statically significance for laparotomic conversion (p = 0,002). Late postoperative complications occurred in 4 patients (4,3%). Complete laparoscopic treatment was performed in 52 patients (55,9%). The conversion rate was related to bowel dilatation (p = 0,025) and presence of endoabdominal free fluid collection (p = 0,021). Reoperation rate was 9,7% (9/93) with significant difference between total laparoscopic group and conversion to laparotomy group (p = 0,032). Conclusions: Our results suggest that laparoscopic approach in emergency non-traumatic enterocolic diseases is a feasible and effective technique in selected patients. In this paper some factors appear meaningful to be considered for the best tailored surgical approach. Laparoscopy should also be considered as a part of the surgical planning in order to offer a superior overview of the abdominal cavity and to permit focused laparotomy with minimal surgical trauma

Y.U.V. Grubnik, V.A. Fomenko, A. Plotnikov

Introduction: Lapaproscopic procedures can decrease mortality and morbidity in the patients with polytrauma. The aim of the study was to analyse laparoscopic and open procedures for abdominal trauma. Methods: From 2008 to 2015, 767 patients were brought to our clinic with polytrauma. CT scan and ultrasound examination were performed for every patient. Results: Laparotomy was performed in 286 patients for massive liver rupture, spleen rupture, massive trauma of bowels, pancreas and kidneys. In 206 cases CT scan showed no data for trauma of intra-abdominal organs or massive intra-abdominal bleeding. These patients were treated conservatively. In 275 cases, laparoscopy was performed following CT scan. Among them, conversion to laparotomy was made in 112 cases, due to massive injuries of intra-abdominal organs found at laparoscopy. Ligation of bleeding points, suturing of liver parenchyma and defects of hollow organs was made in this setting. Laparoscopic operations were made in 163 patients. In 102 cases electrocautery or argonplasma coagulation of liver lacerations, with packing of them by the patch of omentum in 61 cases. Postoperative morbidity was significantly lower following laparoscopic procedured compared to open procedures. Of 767 patients, there were 9 deads because of severe multiple organ polytrauma. Conclusion: Laparoscopic operations are feasible in patients with polytrauma and can decrease mortality and morbidity.

P091 - Emergency Surgery

P093 - Emergency Surgery

Laparoscopic Approach for Perforated Ulcer Disease A. Cotirlet1, L. Gavril2, E. Popa1, M. Nedelcu1

Preventive Endovascular Embolization Versus Standard Treatment After Endoscopic Haemostatis in Peptic Ulcer Patients with high Re-Bleeding Risk

Moinesti Emergency Hospital, MOINESTI, Romania; 2University of Medicine, IASI, Romania

M. Mukans

1

Introduction: Laparoscopic management of perforated ulcer disease has clearly potential advantages over classical laparotomy. The aims of this study were to analyze the reasons for, and outcome of, conversion from laparoscopic to open surgery and to identify factors that may predict the need for conversion. Methods: In total, 63 patients who underwent laparoscopic simple closure for perforated ulcer disease from January 2010 to December 2014 were retrospectively analyzed. Patients were divided into totally laparoscopic and conversion groups. The characteristics of patients, intraoperative findings, postoperative complications, conversion rates and suture leakage rates of each group were investigated. Results: 18 women and 45 men with a mean age 32.8 (range 22–46) were included in our study. A laparoscopic treatment was performed successfully (suture with epiplonoplasty) in 58 patients (92.06%). Five patients (46%) needed a conversion to laparotomy. All of them had an ulcer perforation size greater than 15 mm. The mean operative time was 57 min (range 37–84 min) There were 8 postoperative complications (9.65%). In 7 of them, the onset of symtoms of =12 h was identified. Mean hospital stay was 4.8 days (3–16). No malignant pathology was identified at the biopsy during the control upper endoscopy 6 weeks after. No postoperative mortality was recorded. Conclusions: Perforated ulcer can be treated safely by laparoscopy. Ulcer size of [15 mm is a significant risk factor for predicting conversion to open surgery.The risk of postoperative morbidity was associated with late onset of symptoms (= 12 h)

Riga Stradinsˇ university, RIGA, Latvia Aims: The primary aim was to compare re-bleeding and mortality rate among patients with high re-bleeding risk who underwent preventive embolization after endoscopic haemostasis and patients who received standard conservative therapy. Secondary aim was to compare transfusion rate, a need of surgical treatment, intensive care unit (ICU) and hospital stay between groups. Methods: Retrospective case–control study conducted from 2011 to 2015. Cohort consisted of 287 patients who underwent emergent endoscopic haemostasis due to bleeding peptic ulcer classified as Forest Ia-IIb with following conservative management. Preventive endovascular embolization was additionally performed in 21 patient (EMB group) and 42 (STAND group) were managed without preventive embolization and was selected for control. Age, gender, co-morbidities, haemoglobin level before endoscopy, ulcer type according to Forest classification, ulcer size and type of the endoscopic haemostasis were matched in groups. Results: Age of patients were similar in groups median of 64 years and most of them (71%) had co-morbidities with predominance in heart (62%), metabolic (18%), and kidney diseases (17%). Re-bleeding rate was higher in STAND group 43% vs. 5% in EMB group, p = 0,001. No significant difference was found in transfusion rate of packed red blood cells median of 3 units (IQR 8–3) in EMB group vs. 4 units (IQR 6–2) in STAND group, p = 0,241 and fresh frozen plasma 3 units (IQR 4–2) vs. 4 (IQR 5–2), p = 0,359, respectively. ICU stay was also similar 3 days (IQR 6–2) vs. 4 days (IQR 7–2) accordingly, p = 0,337. Surgical treatment for rebleeding was more frequent in STAND group 21% vs. 5% in EMB group, p = 0,144. Finally significantly longer hospital stay was associated with standard treatment 10 days (IQR 16-6) in STAND group vs. 7 days (IQR 18-6) in EMB group, p = 0,001. No complications were observed during endovascular embolization so far. Treatment resulted in mortality 19% in STAND group vs. 5% in EMB, p = 0,251. Conclusion: Preventive endovascular embolization seems to be rational adjunct to endoscopic haemostasis in patients with high re-bleeding risk. Prospective randomized trial is justified.

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Surg Endosc

P094 - Emergency Surgery

P096 - Emergency Surgery

Outcomes of Surgical Treatment and Influence of the Laparoscopic Approach in Acute Small Bowel Obstruction Due to Adhesions

Laparoscopic Interventions for Abdominal Cavity Fat Necrosis: A Singe-Center Experience

E. Sebastian-Valverde, I. Poves, E. Membrilla, M. Pons, F. Burdı´o, L. Grande

M.E. Timofeev1, S.G. Shapovalyants1, E.D. Fedorov1, V.G. Polushkin2 1

Russian National Research Medical University, MOSCOW, Russia; High School of Healthcare Administration, MOSCOW, Russia

Hospital del Mar, BARCELONA, Spain

2

Aims: Postoperative adhesions are the most common cause of acute small bowel obstruction accounting for 75% of the cases, and nearly half of them will require surgical release. Surgery entails an important morbidity and mortality reaches to 4%. The aim of the study is to analyze the overall results of our series of patients who undergone surgery for adhesive small bowel obstruction (ASBO), and to assess the influence of the laparoscopy on these results. Methods: Retrospective study of a cohort of 225 consecutive patients operated due to ASBO between January 2007 and December 2014. Both adherences and internal hernia were included in the study. Patients converted to open surgery were included in the laparoscopic group. Patients were classified in: simple (SA), complex adhesions (CA) and internal hernia (IH). Results: 65 patients in the laparoscopic group and 160 in the open group were analyzed. Conversion rate was 33,8%. Mean age was 66,1 years. Mean previous surgeries was 1,85 although 16% of the patients had no previous surgeries. 41,3% were SA, 50,7% CA and 8% IH. Overall morbidity and mortality for ASBO were 59,6% and 5,2%, respectively. Intestinal resection was required in 20,9% and in these cases mortality reached to 6,9%. Sex, ASA and type of adhesion had a statistical different distribution within both groups, so we specifically focused only on the patients with SA or IH not requiring intestinal resection. In these cases, no differences were found in age, sex, number of previous surgeries, ASA, surgical time, bowel injury and reoperation between open and laparoscopic approach. Laparoscopic approach was associated with less morbidity (26,2% vs 55,3%; p = 0,005), earlier oral intake (2,15 vs 4,9 days; p \ 0,001) and shorter hospital stay (5,8 vs 11,7 days; p \ 0,001). Conversion rate was lower in experts in advanced laparoscopic surgery (20,5% vs 53,8%; p = 0,005). Conclusions: Laparoscopy approach in ASBO is feasible, safe and effective. In those cases of SA and IH without intestinal resection, there are less morbidity, earlier oral intake and shorter hospital stay than in open approach. However, advanced experience in laparoscopic surgery is a key factor to achieve a low conversion rate.

Background: Intraperitoneal fat necrosis rate in population could hardly be estimated easily, however intraperitoneal findings suggest that it is not a rare situation. Most of such episodes go unnoticed, but in some they lead to a severe inflammatory response, intraabdominal infection and other pathologic conditions requiring emergency surgery. Materials and Methods: Between 1997 and 2015 laparoscopic interventions for peritoneal tissue necrosis were made in 92 patient: epiploic appendixes of large intestine - 67 (72,9%), parts of omentum majus - 21 (22,8%), preperitoneal lipoma - 4 (4,3%). Age ranged from 18 to 81 (mean 41,6 ± 15,6), male - 58 (63,0%), female - 34 (37,0%), time upon admission ranged from 2,5 to 168 h. Results: Diagnostic laparoscopy performed in all 92 patients, successful diagnosis in 90 (97,8%) patients. Conversion to lower midline laparotomy in 6 (6,5%) patients: diagnosis not established following laparoscopy - 2 (2,1%), close fixation of appendices epiploices to sigmoid bowel - 3 (3,2%) patients, immence omentum majus necrosis - 1 patient. In laparoscopic group fat tissue was removed by scissors and monocoagulation, 1 patient requires lipoma basis ligation. There were neither intraoperative, nor postoperative complications in laparoscopic group. One patient in laparotomy group developed early acute adhesive small bowel obstruction 4 days after surgery - successfully treated by reoperation. No mortality following 1 month follow-up. Conclusion: laparoscopic interventions for abdominal fat necrosis are associated with good clinical results: almost 0% complications and zero mortality. Conversion rate was 6,5%. One complication occurred in conversion group only. Moreover, no conversions due to intraabdominal complications were observed. Thus, in all suspected or confirmed cases of peritoneal fat necrosis diagnostic laparoscopy should be considered as a primary surgical intervention.

P095 - Emergency Surgery

P097 - Emergency Surgery

The Use of Repeated Laparoscopic Procedures in Urgent Surgery

Endoscopic Hemostasis in Upper Gastrointestinal Tract

A.Y. Berdinskikh, V.A. Bombizo, P.N. Buldakov

A.Y. Berdinskikh, V.A. Bombizo, B.A. Stas, O.G. Saybel

Regional Clinical Hospital of Emergency Medical Care, BARNAUL, Russia

Regional Clinical Hospital of Emergency Medical Care, BARNAUL, Russia

Introduction: The huge acquired experience of performing laparoscopic procedures in urgent abdominal surgery allows to use the laparoscopy effectively in cases of the early postoperative complications. Aims: Determination of the optimal ways of the use of laparoscopic procedures for the repeated surgeries. Materials and Methods: We analyzed the opportunities and results of the repeated surgeries using the laparoscopic techniques in departments of surgery in the hospital of emergency medical care. 7620 patients underwent surgeries in the Regional Clinical Hospital of Emergency Medical Care from 2013 to 2015. There were 9125 surgeries performed. 532 patients underwent repeated surgeries. The reasons of performing repeated surgeries were: diagnostic search; peritonitis (local or diffuse); postoperative bleeding; a biliary drainage dislocation; bowel perforation; adhesive bowel obstruction. Results: The repeated surgeries with the use of laparoscopic techniques were performed: After percutaneous procedures - 27 (5,08%); after laparoscopic surgeries - 416 (78,2%); after traditional (open surgery) techniques - 89 (16,72%); total - 532 (100%). The use of minimally invasive laparoscopic techniques allowed to exclude postoperative complications among 68 patients and avoid using traditional (open surgery) procedures among 214 patients. Conclusion: Relaparoscopy is the most informative method for solving the problem of postoperative complications existence. The diagnostic search and also any procedure can be performed using laparoscopic technique. Relaparoscopy makes a big difference to the patients with severe multiple trauma and among the group of patients with sepsis-related organ failure.

Introduction: Upper gastrointestinal bleeding is one of the most important problems in emergency surgery. The amount of cases of upper gastrointestinal bleeding is increasing permanently. Endoscopic hemostasis is the most effective method. Aims: Endoscopic hemostasis efficiency evaluation when it is performed in short terms using several methods. Materials and Methods: There were 290 patients with upper gastrointestinal bleeding in Regional Clinical Hospital of Emergency Medical Care from 2013 to 2015. The results of diagnostics and treatment: Patients’ age: from 17 to 86 years. There were 187 men (64,4%) and 103 women (35,6%). Peptic ulcers - 238 patients (82%). Mallory-Weiss syndrome - 46 patients (16%). Stomach cancer - 6 patients (2%). Hemostasis evaluation was set according to Forrest J.A. classification. The following methods of hemostasis were used: - injection therapy - 202 patients; - thermocoagulation - 30 patients; - hemoclips - 17 patients; - combined - 41 patients. 34 patients underwent repeated endoscopic hemostasis and 16 patients underwent surgeries using traditional (open surgery) techniques. Results: Upper gastrointestinal bleeding treatment using gastroscopy with endoscopic hemostasis was crucial to determine the source of bleeding. - The best results were marked using endoscopic hemostasis in short terms from the moment of admittance. - The use of the different hemostasis methods and their combinations were the most effective. - The obligatory condition in case of high risk bleeding is the repeated endoscopy (endoscopic observing). Conclusion: The early endoscopy performing with hemostasis using different techniques allows to avoid traditional surgeries and to decrease mortality rate in group of patients with acute upper gastrointestinal bleeding.

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P098 - Emergency Surgery

P100 - Emergency Surgery

Surgical Treatment of Low Abdominal Pain in Women. A Surgical Department’s Experience

Single-Incision Laparoscopic Surgery for the Abdominal Emergencies

C. Oikonomou, P. Daikou, G. Dedemadi, L. Dritsoulas, E. Anastasiou, A. Dounavis

S.J. Yang, S.H. Yun, W.Y. Lee, H.C. Kim, Y.B. Cho, J.W. Huh, Y.A. Park, S.H. Kim

Amalia Fleming Surgical Department, Sismanogleio - Amalia Fleming Hospital, ATHENS, Greece

Samsung Medical Center,Sungkyunkwan University School of Medicine, SEOUL, Republic of Korea

Aim: Young women usually attend the emergency department suffering from low abdominal pain (LAP). Some of them undergo operation. Our aim is to investigate the role of laparoscopy in a female population with LAP treated at a surgical department. Methods–Results: During a six years period a total of 207 female patients were operated on emergency basis suffering from LAP. The final diagnosis was acute appendicitis in 156 patients and different gynecological problems in 50 patients. 86% of the appendectomies were performed with the standard technique and the remaining 14% laparoscopically. The percentages for gynecological procedures were 51 and 49%, respectively. The conversion rate was 11%.When a female patient, especially young, comes to the emergency department the attending surgeon must differentiate between acute appendicitis and gynecological diseases that need either operation or medical treatment. Diagnostic laparoscopy is a very useful tool that many surgeons and gynecologists use in order to clarify the cause of pain. Furthermore, the operation can be accomplished laparoscopically quite often. As expertise is evolving throughout the years, the tendency among surgeons is to perform most of these operations laparoscopically. This tendency is also obvious in our department. Conclusion: Laparoscopy is becoming the favorite method of investigation and treatment of LAP in women, replacing gradually open approach.

Aims: Recently, single-incision laparoscopic surgery (SILS) is getting popular in the field of elective abdominal surgery. The laparoscopic approach in patients with abdominal emergencies to be feasible and safe in experienced hands. It provides diagnostic accuracy as well as therapeutic capabilities. The purpose of this study is to evaluate the feasibility and efficacy of SILS for management of the complications in emergency surgical abdomen. Methods: This is a retrospective review of prospectively collected data in Samsung Medical Center, Seoul, Korea between January 2011 and December 2015. A retrospective review of 38 patients who underwent SILS for complications of previous surgery or abdominal procedure was perfomed. Custom glove port was used for the main port either transumbilical or future stoma site. All the operations were performed with conventional laparoscopic instruments. Results: Among 38 patients, 26 were male and 12 were female. Mean age was 57.16 ± 15.50. The type of Primary surgery included 30 colorectal procedures (24 low anterior resections(LAR), 4 anterior resection (AR), 2 total proctocolectomy with ileal pouch anal anastomosis (TPC-IPAA)) and 8 others. The indications for emergent SILS were 19 anastomotic leakage, 9 intestinal obstruction, 6 intestinal perforation, 4 others. Emergent SILS procedure were 19 loop ileostomy formation with abdominal drainage,8 adhesiolysis, 3 sigmoid colostomy, 2 Hartmann’s operation, 6 others. We used a additional port on the RLQ area in 3 patients (7.9%) Intraoperative conversion rates was 5.3% (2 patients). The reason for conversion were severe adhesion and difficult exposure. Mean OP time, EBL and Hospital length of stay was 163.16 ± 62.14(min), 113.84 ± 91.08(ml), 20.89 ± 9.41(days), respectively. Complications that were mainly atelectasis and ileus requiring minor intervention (grades I and II) occurred in 3 patients. Additional surgery was necessary in 1 patient due to inadequate drainage of peritoneal fluid. There was no surgery related mortality. Conclusions: Single incision laparoscopic approach for the abdominal emergencies is as safe and effective in selected cases after both open and laparoscopic surgery without wound problems that is common in open abdominal emergent surgery.

P099 - Emergency Surgery Management of Hemorrhage Associated with Ovarian Cyst Rupture in a Surgical Department

P101 - Emergency Surgery Right-Sided Acute Diverticulitis: A Single Western Center Experience

G. Dedemadi1, M. Nikolopoulos2, A. Dounavis2, I. Konstantinidis2, S. Adamopoulos2, I. Kalaitzopoulos2

F. Monari, E. Picariello, S. Vaccari, L. Alberici, V. Tonini, M. Cervellera

1

S. Orsola Malpighi Hospital, BOLOGNA, Italy

2

Introduction: Diverticular disease of colon is common in Western countries with predominant localization in the left colon while right sided disease is common in Asian people. Methods: Patients admitted to the emergency surgery unit for colonic diverticulitis were registered in database from September 2011 to August 2015. We included in this study only the patients undergone surgery with right colon diverticulitis proven at histologic specimen examination in emergency setting.Pre-, intra- and postoperative data were collected in a dedicated database. Results: In 17 cases we performed a surgical exploration in emergency setting for a disease localized in the right side of the colon. The mean age of these patients was significantly lower respect to patients with left sided diverticulitis (50 ± 17 vs 67 ± 14 years; p \ 0.001) and 5 patients (29.4%) were less than 40 years old (fig. 1). The presence of inflammation or perforation of a solitary diverticulum was found. 3 patients were Asian (17.6%) in contrast with the prevalence in our historic cohort of left colon diverticular disease (1.3% of patients; p \ 0.001). In 8 cases a preoperative scan was performed, while 5 patients had ultrasonography. Only one patient underwent preoperative endoscopy due to rectal bleeding. Preoperative diagnosis was acute right colonic diverticulitis in 8 cases (47.1%), acute appendicitis in 8 cases (47.1%) ad colonic neoplasm in one case (5.9%). A colonic resection (right hemicolectomy or ileocecal resection) with primary anastomosis was performed in 12 patients (70.6%); in 5 cases the intervention consisted in a diverticulectomy. Laparoscopic approach was performed in 13 cases (76.5%) with a conversion rate of 38.5%. Postoperative events occurred in 3 patients (17.6%). No patient required reintervention and the readmission rate was 5.9% (1 patient) due to transient rectal bleeding that stopped spontaneously without need of any transfusion. Conclusions: Right sided colon diverticulitis is a rare but not irrelevant condition in Western countries and prevalence tends to be higher in Asian people. Surgery can be safely performed with low complication rate and with minimally invasive approach. Diverticulectomy can be a valid option to treat this condition providing better postoperative results.

Sismanogleio - Amalia Fleming Hospital, ATHENS, Greece; Amalia Fleming Surgical Department, Sismanogleio - Amalia Fleming Hospital, ATHENS, Greece

Aim: To present the experience of a surgical department in the management of hemorrhage associated with ovarian cyst rupture. Methods: Eighteen females attended the Emergency Department with acute pelvic pain due to ovarian cyst rupture and hemoperitoneum between 2010-2015. All patients underwent ultrasound evaluation. Results: In 14 patients the cyst involved the right ovary. The mean age was 28 years. Twelve patients were treated with exploratory laparotomy: in 8 hemostasis was achieved by placing sutures, in 2 cautery was used, 1 patient underwent wedge resection of the ovary and 1 salpingo-oophorectomy. The remaining 6 patients underwent exploratory laparoscopy: in 3 hemostasis was accomplished by suturing the cyst, in 2 cautery was used and 1 underwent wedge resection of the ovary. Concomitant appendectomy was performed in eight patients who underwent laparotomy and in one who underwent a laparoscopic procedure. Pathology revealed non- significant findings of inflammation in the removed appendices. Conclusions: Laparoscopy has known advantages over laparotomy and, has become the treatment of choice in the treatment of patients bleeding from ruptured ovarian cysts, when surgery is recommended. However, the final procedure depends on the patient’s general condition and the surgeon’s laparoscopic skills.

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Surg Endosc

P102 - Emergency Surgery

P104 - Emergency Surgery

Factors Predicting Morbidity and Mortality After Surgery for Complicated Acute Diverticulitis. A Single Centre Experience

Laparoscopic Treatment of Perforated Bleeding Gastric Ulcer

F. Monari, S. Vaccari, E. Picariello, V. Tonini, M. Cervellera, L. Alberici S. Orsola Malpighi Hospital, BOLOGNA, Italy Introduction: Complicated acute diverticulitis (CAD) occurs in 10 to 25 percent of patients affected by diverticular disease and surgical treatment is often necessary. Postoperative morbidity and mortality are still high. The purpose of this study is to identify prognostc factor for postoperative morbidity and mortality in patients requiring intervention for CAD. Patients and methods: From September 2011 to May 2015 119 patients required urgent surgery for complicated acute diverticulitis (CAD)in our unit. Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed for postoperative morbidity and mortality. Results: There were 56 males and 63 females with mean age of 68 ± 15 years. 100 patients (84.0%) were at first admission for diverticular disease and in 16 cases (13.4%) the disease was localized at right colon. A stomy was required in 84 patients (70.6%) and postoperative morbidity rate was 52,9% according Clavien-Dindo. Only 10.9% of patients were affected by grade III or IV complication with mortality rate of 16.8%. At multivariate analysis the presence of a postoperative medical complication was the only predictive factor for mortality (OR 10.3; 95%CI 2.1–51.3 p = 0.004) while presence of COPD and purulent or fecal peritonitis were not significant (OR 3.3; 95%CI 0.9–12.2 p = 0.073 and OR 3.1 95%CI 0.8–11.6 p = 0.099 respectively). For postoperative morbidity logistic regression showed that patients = 75 years and with ASA score [2 were associated with postoperative morbidity (OR 2.8; 95%CI 1.1–7.2 p = 0.028 and OR 5.3 95%CI 2.0–13.9 p = 0.001 respectively). The same factors were associated with medical complication with OR 3.0; 95%CI 1.1–7.8 p = 0.028 and OR 6.5 95%CI 2.0–21.3 p = 0.002 respectively. Multivariate analysis showed that age =75 was the only predictive factor for postoperative surgical morbidity (OR 3.1; 95%CI 1.1–8.8 P = 0.027). Conclusions: The majority of patients who require surgery for CAD are at the first episode of diverticulitis. Medical complication is the only factor associated with mortality while surgical complications do not seem to have the same weight. Age = 75 and ASA score [2 are independent predictive factors for postoperative medical complications while only age seems to have a significant effect on surgical morbidity.

A. Mun˜oz Garcia, F.J. Buils Vilalta, J.J. Sa´nchez Cano, J. Dome`nech, R. Prieto, M. Parı´s, E. Bartra, D. del Castillo Sant Joan Universitary Hospital, REUS, Spain Aims: In the last hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. Laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years. Treatment for perforated ulcer can be performed laparoscopically in 85% of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late eventration. Methods: A 77-year-old male presented to emergency room with a three-hour history of progressively worsening epigastric pain and nausea. Physical examination revealed rebound tenderness compatible with an acute abdomen. A CT scan showed: important pneumoperitoneum unable to define the drilling point; distended stomach with plenty of fluid inside and dense content fundus/body suggestive of active arterial bleeding . Results: The patient was emergently taken to the operating room for diagnostic laparoscopy. Perforation shown in greater gastric curvature associated blood remnants. Gastrotomy for clot removal is done without observing active bleeding. The gastrotomy was repaired using standard stitches. All exudate was aspirated and the peritoneal cavity was irrigated with warm saline solution The patient had an uncomplicated post-operative course. JP drain was removed and he was discharged one week after surgery. Conclusion: The role of laparoscopic surgery in emergencies is well documented. Laparoscopic approach is indicated in any case of suspected gastroduodenal perforation and seems to offer the same advantages as for the vast majority of laparoscopic procedures. Laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer.

P103 - Emergency Surgery

P105 - Emergency Surgery

Features in Young Patients Surgically Treated for Acute Diverticulitis

Acute Appendicitis Complicated by Diffuse Peritonitis: Is Laparoscopy the First Intention Approach?

F. Monari, E. Picariello, S. Vaccari, L. Alberici, V. Tonini, M. Cervellera

G. Ivakhov, A.V. Sazhin, A.E. Tyagunov, G.B. Ivakhov, A.T. Mirzoyan, I.V. Ermakov

S. Orsola Malpighi Hospital, BOLOGNA, Italy

Pirogov Russian National Research Medical University, MOSCOW, Russia

Background: There is lack of consensus whether to consider acute diverticulitis in younger patients a more aggressive disease. In this study we evaluate differences between patients \/= 45 years old and [ 45 who underwent surgery for acute diverticulitis. Methods: From September 2011 to May 2015 119 patients underwent surgery for acute diverticulitis in our unit. Pre-, intra- and postoperative findings were collected in a prospective database. 12 patients (Group A, 10,1%) were \/= 45 years old. We compared Group A patients and the remaining 145 (Group B). Results: Slight difference between Group A and B was found about presence of males (75.0% vs 43.9%; p = 0.065). Differences were found for patients with one ore more comorbidities (16.7% vs 86.9%; p \ 0.001), in particular for cardiovascular diseases (0% vs 67.3; p \ 0.001). ASA score was 1-2 in 91.7% of Group A patients versus 29.0% in group B (p \ 0.001). Higher incidence of right colonic side was found in 41.7% of Group A patients respect to 10.3% (p = 0.010). Group A patients were at first admission in 91.7% of cases respect to 83.2% without significancy (p = 0.688). In group A, laparoscopy was performed in 50% of patients while in group B in 20.6% (p = 0.033) with no difference in conversion rate. The majority of Group A patients did not required ostomy after surgery respect to Group B patients (33.3% vs 74.8% p = 0.006). No difference was found for incidence of purulent/fecal peritonitis (33.3% vs 57.9%; p = 0.131). Morbidity rate was lower in Group A patients (8.3% vs 57.9%; p = 0.001); incidence of medical complications favoured younger patients (8.3% vs 44.9%; p = 0.015). The groups did not differ for mortality (8.3% vs 17.8% p = 0.688). Length of postoperative stay was shorter in Group A patients (6.3 ± 2.0 vs 15.3 ± 14.6; p = 0.002). Multivariate analysis between Group A and B showed only higher incidence of ostomy group B (HR 4.0; 95%CI0.85-19.0) that did not reached significance (p = 0.08). Conclusions: Acute diverticulitis in young patients shows some peculiar issues, but does not seem to be more aggressive. For these reasons surgical intervention should be taken into account not considering age but the actual clinical, laboratoristic and instrumental findings.

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Background: laparoscopic appendectomy (LA) is considered as ‘operation of choice’ for acute appendicitis in case of uncomplicated intra-abdominal infection (IAI). Laparoscopic treatment for appendicular peritonitis, especially in cases of diffuse peritonitis is controversial. Aims: to evaluate safety and feasibility of laparoscopic approach for diffuse appendicular peritonitis. Methods: the laparoscopic approach is the first-line standardised procedure used by our clinic for the management of acute appendicitis with or without peritonitis. About 1139 patients underwent LA for acute appendicitis during 5 years (January 2011-December 2015). 401 patients had local or diffuse appendicular peritonitis. Results: local peritonitis was confirm in 293 (73,1%) cases with low rate of conversion (1,7%). Diffuse peritonitis was verified in 108 (26,8%) cases. Fourteen (13%) patients required a conversion to an open operation. The degree of destruction of appendix is correlated with severity of peritonitis. Diffuse peritonitis was recorded in 7%, 17,3% and 58,2% of phlegmon, gangrenous and perforated appendicitis respectively. Mortality rate for patients with diffuse peritonitis was 3,7% (4 patients died after converted to open operation with subsequent relaparotomy ‘on program’ because of severe peritonitis with long (34 days) pre-hospital duration of peritonitis, multiple organ failure). No rate of mortality was registered in all cases of laparoscopic operations for local and diffuse peritonitis. Conclusion: LA is safe and feasible for diffuse appendicular peritonitis. Based on our results we suggest that laparoscopy should be considered as the first-line procedure for appendicular peritonitis.

Surg Endosc

P106 - Emergency Surgery

P108 - Emergency Surgery

Bedside Diagnostic Laparoscopy (Bdl) in Intensive Care Setting Demage Control Toll

Laparoscopic Management of Acute Small Bowel Obstruction

M.A. Sajid1, Z. Hanif2, J. Darabnia2, K. Khan2, S. Mahmud2 Liverpool University, WREXHAM, United Kingdom; 2Hairmyres Hospital, GLASGOW, United Kingdom

T. Klimovska, M. Mukans, I. Ivanovs, G. Pupelis Riga East University Hospital Gailezers, RIGA, Latvia

1

Aims: Unexplained lactic acidosis in a critically ill patient, often prompts investigations to rule out any reversible intra-abdominal cause. Equivocal results can lead to an emergency exploratory laparotomy (EEL) with subsequent high morbidity and mortality rates. Our objective was to determine the clinical impact of bedside diagnostic laparoscopy for critically ill patients with lactic acidosis. Methods and Materials: We conducted a case series on 28 critically ill patients with lactic acidosis, who were referred to a single surgeon over an 8 year period. BDL was carried out on all patients; of which 20 were female and 8 were male (mean age of 66). 24 patients were referred from a critical care setting, 3 from an acute surgical unit and 1 from an acute medical unit. Results: All patients had an unexplained lactic acidosis greater than 5 mmol/l. 18 patients underwent bedside BDL in the critical care setting and 10 were taken to theatre. Of all the patients, 14 had normal diagnostic laparoscopy, (10 had lactic acidosis secondary to low cardiac output states). 7 patients had features of mesenteric ischaemia; of these, 3 of which were global. 3 patients were diagnosed with hepatic ischaemia. 1 patient had features of acute pancreatitis with a normal serum amylase. 3 patients respectively had gangrenous acalculous cholecystitis, visceral perforation, and gastric volvulus. There was no significant morbidity or mortality associated with BDL. 20 patients had no further surgical intervention. 2 patients underwent laparoscopic cholecystectomy and gastropexy; 5 patients underwent open procedures for mesenteric ischaemia and visceral perforation. Conclusion: BDL is a valid investigation for unexplained lactic acidosis in the critically ill. There was no demonstrable morbidity or mortality associated with BDL. EEL was avoided in 20 patients (71.4%). 18 (63%) unwell, unstable patients did not require transfer operation theatres for UDL. We would recommend the use of BDL as a safe, feasible investigation in selected patients with an unexplained lactic acidosis.

P109 - Emergency Surgery

P107 - Emergency Surgery Does Imaging Help in the Diagnosis of Acute Appendicitis? 1

1

1

A. Shaw , Z. Rokan , B. das , A. Wan

Aims: The primary aim was to compare overall complication rate, while secondary aim was comparison of operative time, postoperative gastrointestinal function recovery and hospital stay between laparoscopic and open surgery of acute small bowel obstruction (SBO). Methods: In retrospective study conducted in time period 2011-2015 were analyzed 136 patients with acute SBO: 90 patients (OPEN group) underwent open surgery, 46 patients initially were managed laparoscopically (LAP group). Cases of conversion to open surgery were analyzed within LAP group. Both groups were compared by age, etiology of bowel obstruction, operation length, complications and postoperative outcomes. Results: Significant difference in median age of patients was found between groups: 49 years in LAP group, 61 year in OPEN group (p = 0,003). Complete laparoscopic treatment was performed in 76% of patients. Laparoscopy diagnosed the site of obstruction in 85% of patients. Both groups were statistically comparable by etiology: internal incarceration 48% in LAP group vs 52% in OPEN group, multiple adhesions 39% (LAP) vs 34% (OPEN), other findings 13% (LAP) vs 13% (OPEN) (p [ 0,05). Conversion to laparotomy was performed in 24% of cases mostly due to limited visualization because of severely distended bowels (6 cases), in 4 cases there was need for intestinal resection and in 1 case due to iatrogenic bowel injury. The median operative time was similar between groups: 75 min in LAP group and 70 min in OPEN group (p = 0,816). There was only 1 (2%) postoperative complication case in LAP group (observed in ‘converted to open’ patient) and 9 cases (10%) in OPEN group (p [ 0,05). In LAP group 89% of patients tolerated early liquid oral intake (on 0-1 postoperative day), comparing with 60% in OPEN group (p = 0,001). Normal peristalsis and passage of flatus (on 0-1 postoperative day) appeared significantly quicker in LAP group - 71% of patients vs 45% in OPEN group (p = 0,005). Median postoperative hospital stay was 4 (5-3) and 7 (9-6) days respectively (p = 0,001). Conclusions: Laparoscopic management of acute SBO had tendency to reduce overall complication rate in comparison to open surgery and was associated with quicker gastrointestinal function recovery, shorter postoperative length of stay.

2

1

St. George’s University Hospital NHS Trust, LONDON, United Kingdom; 2St George’s University Hospitals, NHS Foundation Trust, LONDON, United Kingdom Aim: To assess whether ultrasound (US)/Computed Tomography (CT) assists with decision making for diagnostic laparoscopy (DL) in suspected acute appendicitis. Methods: This retrospective study reviewed all patients over the age of sixteen who underwent laparoscopic or laparoscopic-converted to open appendicectomies performed at a regional teaching hospital between June and December 2015. Any imaging performed prior to surgery was assessed. All patients were identified using an electronic theatre system and handover lists, and data was collected using Electronic Patient Records and patient notes. Factors evaluated included time from admission to operation, time from admission to time of imaging, and a diagnosis of appendicitis was confirmed with histology. All imaging diagnoses were correlated with histological findings to ascertain accuracy. Results: One hundred and eight patients underwent DL for suspected appendicitis. Of these, 15% (n = 16) had an US prior to surgery and in 14% (n = 15) a CT was performed. A normal appendix was reported on US in one case, but was histologically found to be appendicitis. Only 50% of those thought to have appendicitis on US (1/2) was proven histologically. In 81.3% (13/16) the appendix was not visualised. Of these, 38.5% (5/13) had appendicitis histologically. Hence, appendicitis was only correctly diagnosed at US in 6.3% (1/16). Patients who underwent imaging in the form of CT were diagnosed with acute appendicitis in 100% of cases, all of which were confirmed histologically. There was no statistical difference in time from admission to surgery in those who were either diagnosed clinically, or who underwent CT imaging. However, time until operation was significantly longer if US was performed (p \ 0.05). Negative appendicectomy rates were 16.9% when based on clinical diagnosis only, 62.5% when US was used and 0% with CT imaging. Conclusion: In patients admitted with a view to DL for a suspected diagnosis of acute appendicitis, US delays the time until operation and does not significantly alter management or outcome. These patients should be considered for an immediate CT or DL.

Laparoscopic Versus Open Appendectomy - 5 Years Experience C. Tarta, A. Dobrescu, C. Lazar, S. Pantea, A. Isaic, L. Lazar, C. Duta County Emergency Hospital Timisoara, TIMISOARA, Romania Aim: To present our large experience in laparoscopic appendectomy and to raise a few questions about the boundaries between minimal invasive appendectomy and the open counterpart. Methods: All the patients’ electronic charts were reviewed for the code of open or laparoscopic appendectomy between 2011-2015. The sex, age, comorbidities, body mass index (BMI), stage of the disease, complications during and after procedure were recorded. Results: There were 612 cases of appendectomy. Laparoscopic appendectomy (LA) was performed in 431 cases, open appendectomy (OA) in 181 cases. Females: males ratio was 1.25:1, main reason for this was that in many cases of diagnostic laparoscopy we have chosen to perform appendectomy even if the reason for admission was a gynecological condition. Comorbidities were presented more often in the OA 15% versus 7% in the LA group. BMI was higher in the LA 28.7 kg/m2 compared to OA 26.5 kg/m2. Stage of the disease was more advanced in the OA group with more localized and generalized peritonitis. Complications were encountered more often in the OA group.Discussion. There was still a high percentage of OA during the first years, but then this change dramatically in favor of LA, which raised concerns about the training of the residents. Obese and female patients are more prone to be operated by LA. The more difficult cases were operated by OA. Conclusion: Although LA had become the preferred method we still have to train in OA, which kept its place in the surgeon armentarium.

123

Surg Endosc

P110 - Emergency Surgery

P112 - Emergency Surgery

Does Vac Therapy After a Major Ileal or Ileocolic Resection for Intestinal Ischemia Ameliorate the Surgical Outcome?

Perineal Penetrating Stab Wounds Extending into Thoracic Cavity: A Very Rare Case

C. Bergamini, D. Bisogni, G. Alemanno

N. Ozlem1, C. Elif2, R. Aktimur2, G.O. Kucuk2, S. Kesmer3, H. Calis4

Careggi Teaching Hospital, FLORENCE, Italy

1 This work was supported by the AhiEevran University,, KIRSEHIR, Turkey; 2Samsun education and research hospital, SAMSUN, Turkey; 3 Ministry of health education and reseach hospital, BURDUR, Turkey; 4AHIEVRAN UNIVERSITY research and education hospital, KIRSEHIR, Turkey

The outcome of ileal or ileocolic resection for intestinal ischemia is particularly severe and the surgical operation might not be able to save patients. On the other hand intrabdominal hypertension related to this acute abdominal condition could be another factor affecting the poor prognosis of this dramatic disease. We aim to evaluate the importance of the latter possible patho-physiological mechanism, comparing the application of VAC therapy vs simple intestinal resection with primary abdominal wall closure in patients with ileal or ileo-colic ischemia. Twenty patients (aged between 23 and 93 y.o. in age 79 ± 6) with intestinal infarction were enrolled for our prospective study. In the first group after the surgical procedure patients underwent primary full thickness closure of the intestinal wall, living drenage inside. In the second group patients were operated on according to the damage control method, i.e. without performing the intestinal anastomosis. The abdominal was left opened with a VAC system, removing that after 25 to 48 h; at this time the intestinal anastomosis was done and the abdominal wall full thickness closed. Both groups of patients have been admitted in intensive care unit until clinical conditions were safe to move in the ordinary world. In both groups we enrolled two patients with total colic resection, two patients with ileo-right colic resection and six patients with more than 1 m of ileal resection. Among the first group the two patients with total colic resection died after 7 and 13 days respectively; the patients with ileo-right colic resection were dismissed after a mean recovery time of 29 days. Within the other ileal resections one patient died after 13 days and 5 patients were dismissed after a mean recovery time of 22 days. The mean intensive care unit (ICU) recovery time was 11 days. Among the second group all patients survived and were dismissed after a mean recovery time of 19 days; the mean time of ICU recovery was 16 days. In conclusion the survival rate in VAC treated patients was better even though the ICU recovery time was slightly longer and patients needed two surgical operations.

The diagnosis and treatment of perineal injuries have some difficulties. The trauma caused perineal injury also frequently may make the pelvic and rectal and genito urinary injury so rate of morbidity and mortality like these multisystem trauma also are high. 34 years old male had fall from about 7 m on a iron fence 1 h ago. The iron has penetrated his scrotal skin, right thoracal cavity and only abdominal wall but did not penetrate abdominal cavity. There was stabil vital sign and his pain on right abdominal upper quadrant and right upper thoracal wall region. He has had lacerated area in diameter 5*5 cm on scrotal skin, but external genitalia are intact. Thorax and abdomen ct show smooth tissue loss of integrity on right abdominal wall and fracture of right 6. Rib, right pnx. The Urolog debride and repair of the scrotal wound under general anesthesia, at the same time the general surgeon intented too to evaluate and to rull out any diapraghm rupture to diagnostic laparoscopy. DL showed no injury in abdomen. The iron has introduced his scrotum and to traves the abdominal wall and passed tangentially the abdomina wall but never penetrated the peritoneum and to penetrated the thoracal cavity on right rib 6 and injuried it. A right chest tube thoracostomy and closed drainage was done. the patient discharged post op day in 5 with an uncomplicated recovery. The perineal injury has a speciality that also caries the risk of other organ/s injury an another World an associated additional organ injury in theperineal injury is frequently situation. So the value of correct diagnosis of any additional organ injury in a short period is high. it is a very rare occurence that an iron penetrated the perineum and without doing penetration the abdomen and peritoneum and penetrate the thorax cavity and fracture the rib

P111 - Emergency Surgery

P113 - Endocrine Surgery

The ‘Weekend Effect’ on Patients with Acute Appendicitis: Comparing Emergency Laparoscopic Appendicectomy Outcomes in Three London Hospitals

Single incision Laparoscopic Adrenalectomy: Is it Worth Doing?

1

2

3

3

1

K.W.J. Mok , R. Law , T. Hayes , S. Epton , S. Qureshi , S. Vig

2

1

St Georges University Hospital NHS Foundation Trust, LONDON, United Kingdom; 2Croydon University Hospital, LONDON, United Kingdom; 3Kingston Hospital NHS Trust, LONDON, United Kingdom Background: Emergency admissions to acute hospitals in the weekend have been shown to have increased morbidity and mortality in medicine and surgery. Worse outcomes on weekends (the so- called ‘weekend effect’) are thought to be due to treatment delays from the onset of symptoms to hospital admission and finally to treatment. Delay in time to appendicectomy for patients with acute appendicitis has been shown to lead to worse outcomes and increased hospital stay. Our aim is to determine whether day of admission is associated with worse outcomes for patients diagnosed with acute appendicitis. Methods: This is a retrospective review of patients who were admitted with a diagnosis of acute appendicitis over a 3 month period. Patients were divided in two groups: weekend (WE) or weekday (WD) admission. Outcome measures include 30-day post op complications (re-operations, wound infections, abscess, fistulas), 30-day mortality, time to surgery, length of hospital stay. Results: There were 133 patients admitted with acute appendicitis during the study period. 35 patients with acute appendicitis requiring emergency appendicectomy were admitted over the weekend compared to 98 admitted on a weekday. 17.14% of patients in the WE group had post op complications compared to 9.18% in the WD group. Median length of stay was the same in both groups. Mean time to surgery was longer in weekday compared to weekend admissions (22.68 versus 18.84 h). Conclusions: Patients with acute appendicitis requiring appendicectomy who are treated over the weekend have more complications compared to weekday admissions. However we have not found any delay in time to surgery in the weekend compared to the weekday or difference in the length of stay. Further studies are needed to investigate the cause of higher morbidity in the weekend group.

123

R. Singaporewalla, S.N. Khanna, A. Majumder Khoo Teck Puat Hospital, SINGAPORE, Singapore Aim: The advent of Single Incision Laparoscopic Surgery (SILS) has led to interest in using this approach for adrenalectomy. The described advantages of SILS have to be balanced with the significant technical difficulty of this approach. We present a teaching video of SILS approach for partial adrenalectomy, for Conn’s Syndrome, that required conversion to laparoscopic approach and subsequently to emergency open conversion for bleeding due to absence of the adenoma in the initial partial adrenalectomy specimen. Methods: The patient was a 37-year old male with hypertension. Investigations confirmed Primary Hyperaldosteronism and CT-adrenals revealed a 1.2 cm left adrenal nodule compatible with adenoma. The right adrenal gland was normal. He was keen to undergo Laparoscopic partial adrenalectomy using the SILS approach. The video shows the initial SILS surgery being carried out through the multichannel single port with standard laparoscopic instruments. On-table examination of the specimen did not reveal any palpable adrenal nodule and Frozen section confirmed normal left adrenal tissue but no associated adenoma. The procedure was therefore converted to traditional laparoscopic adrenalectomy and the left kidney was further mobilized and retracted to reveal the adenoma lying at the tip of the lower pole of the adrenal supero-medial to the kidney. Attempt to dissect off the remnant adrenal led to significant bleeding from an aberrant left renal vein branch which could not be stopped laparoscopic ally as shown in the video. This necessitated emergency conversion to open surgery in the flank position. Results: The bleeding from the aberrant left renal vein branch was ligated and hemostasis achieved. The specimen was removed and confirmed to contain the adenoma. Histology confirmed benign adenoma with intact capsule. The patient made an uneventful recovery and was discharged after 4 days. At 6 weeks follow-up his hypokalemia and hypertension had resolved. Conclusion: SILS for adrenal lesions is technically challenging and can lead to complications which may sometimes be difficult to manage laparoscopically.

Surg Endosc

P114 - Endocrine Surgery

P116 - Endocrine Surgery

New Approach in Single Incision Endoscopic Thyroidectomy Using Lifting Method by Original Retractor Via Chest or Axillary Incision

Transoral Parathyroidectomy in Parathyroid Adenoma (Vestibular Approach)

K. Kayano, N. Nishie, H. Yaginuma, H. Mizutani, I. Suzuka, M. Kojo, S. Nishioka

T. Sasanakietkul, A. Anuwong

Ako central hospital, AKO, Japan We started endoscopic thyroidectomy using the lifting method in 2001 and have developed single incision endoscopic thyroidectomy (SIET) via chest (C-) or axillary incision (A-) by our original retractor since 2007. We created a new approach in 2010. In this study, we present our method and results with regard to surgical outcome and patients’ complaints. Method: Endoscopic thyroidectomy was performed in 88 patients (mean age 55, Male 16 Female 72). Our procedure of C-SIET and A-SIET was performed in 33 patients. 19 patients of 33 (C-SIET: 14, A-SIET: 5) were operated in new approach. The patient is placed in a supine position with the neck extended. The arm on the tumor side is raised over the forehead to expose the axilla in A-SIET. A 30 mm(C-) or a 40 mm (A-) vertical incision is made in chest or axilla. Flexible scope (Olympus Co. Japan) is used through 5 mm trocar detached the retractor. In new approach, the thyroid is exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle (SCM) and both of the skin and sternal head are lifted up by our original retractor (Takasago Medical Co. Japan). Partial or hemi thyroidectomy is performed using an ultrasonic scalpel. I would like to show our SIET procedure by movie. Results: No scars in the neck were left in all cases. Benign and hemi lateral tumors sized to less than 6 cm and micropapillary carcinoma sized to less than 1 cm were operated. Operation time is 166.6 ± 2.5 min. (C-), 226.8 ± 16 min. (A-) in new approach including many difficult cases, 152.3 ± 2.9 min. (C-), 191.7 ± 8.9. (A-) in previous method. There was one complication (temporary hoarseness) in previous method. Conclusion: It is required to be careful of recurrent nerve palsy in all approaches. New approach is useful to operate and make the working space wider without stress. Our original retractor can be introduced easily in most hospital, because it is not so expensive. Operation time in A-SIET is longer than in C-SIET. However, most of women satisfied cosmetic results, young ladies especially prefer to A-SIET because of completely hidden scars.

Police General Hospital, BANGKOK, Thailand Objective: To present the technic of scarless endoscopic parathyroidectomy via transoral vestibular approach. Participant: a 64 year old male who had hyperparathyroidism from single left lower parathyroid adenoma. He was preoperative diagnosed by high blood level of parathyroid hormone = 118.1 pg/ml (15–65), Corrected Calcium = 10.6 mg/dL (8.5–10.5) and Tc99 m MIBI/Tc-99m04 scan showed a 0.8x0.6 cm sestamibi avid soft tissue lesion at inferior to lower pole of left thyroid lobe. Study Design: Case study Methods: We used the 30 degree rigid endoscope camera via 10 mm port (Vestibular approach) and inserted bilateral 5 mm instrumental ports beside the 10 mm port, aware of mental nerve injury. The CO2 insufflation pressure was set at 6 mmHg. A subplatysmal plane was opened by hydrodissection (0.9%NSS 500 cc with 1 mg adrenaline) and dilator. Result: The operation time was 98 min with 20 cc blood loss. Length of hospital stay were 38 h. The final pathology report was parathyroid adenoma. Postoperative PTH at day 13 = 86.08 pg/ml (15–65) Corrected Calcium = 9.9 mg/dL (8.5–10.5), day 41 PTH = 86.08 pg/ml (15-65) Corrected Calcium = 10.2 mg/dL (8.5–10.5) and day 83 PTH = 63.71 pg/ml (15–65) Corrected Calcium = 10 mg/dL (8.5–10.5). We did not find any problem or complication (Infection, Mental nerve injury, Hoarseness, Hematoma, Seroma) in this patient. Conclusion: Our experience with this case reinforce us that we can do scarless transoral endoscopic parathyroidectomy vestibular approach without any complication.

P115 - Endocrine Surgery

P117 - Endocrine Surgery

When the Attempt to Cure Becomes the Way to Make Diagnosis: A Case of Primary Adrenal Lymphoma

Minimally Invasive Bilateral Adrenalectomy: A Single Centre Experience and Literature Review

M. Mazzola, M. Boniardi, C. Magistro, P. Carnevali, I. Pauna, S. Andreani, G. Ferrari

G. Simutis, V. Beisa, K. Strupas

Grande Ospedale Metropolitano Niguarda, MILANO, Italy Sometimes, in clinical practice, can be very hard to make a correct diagnosis: adrenal masses are an example of these conditions. Among differential diagnosis there is primary adrenal lymphoma, a rare condition with very poor prognosis. We report the case of a right adrenal mass of unkown origin treated with laparoscopic adrenalectomy. Pathological examination on the surgical specimen revealed a primary adrenal lymphoma. Surprisingly the patient, after chemotherapeutic treatment, had a complete response and he is nowadays disease-free, after a follow-up of nearly 10 years. Laparoscopic transperitoneal right adrenalectomy is a well standardized and safe technique; it gives to the patient all the advantages of laparoscopic technique. This approach could be particulary usefull in the treatment of adrenal masses of undeterminated origin, irrespective of the size, keep firmly in mind the principles of en-bloc resection of all epinephric fat, and no touch technique.

Center of Abdominal Surgery, Vilnius University Hospital Santariskiu klinikos, VILNIUS, Lithuania Introduction: The minimally invasive adrenalectomy currently represent the gold standard for surgery of benign adrenal tumors. However, the indications, optimal surgical approach and timing to minimally invasive bilateral adrenalectomy (BA) have not been clearly defined because it is relatively rarely applied as a therapeutic procedure. Aim: To present our experience with different minimally invasive surgical approaches to BA, analyzing its indications, feasibility, outcomes and compare our results to data published in the literature. Materials and methods: We analysed retrospectively our patients who underwent minimally invasive BA between 1999 and 2015 and reviewed the literature (PubMed and Cochrane 1992 current). The analysis covered patient features, tumor characteristics, reasons for qualification for each approach, operative details and postoperative outcomes. Results: 213 minimally invasive adrenalectomies were attempted in 207 patients during the study period. Of those, 6 patients underwent minimally invasive BA. Patients diagnoses were bilateral pheochromocytoma (n = 2), Cushing’s syndrome (n = 2), and adrenal metastasis (n = 2). The average patient age was 51.2 years (range 20–66 years), and the male-to-female ratio was 1:2. The mean tumor size was 5.0 cm (range 1,5–13 cm). A single-stage posterior retroperitoneal (PR) approach to BA was used in 4 patients, a two-stage PR approach to BA - in 1 patient and two-stage lateral transabdominal (LT) approach - in 1 patient. There were no conversions to laparotomy but in one patient with history of open nephrectomy PR approach due to unclear anatomy was converted to LT approach. No major operative complications were noted. Postoperative complications included a surgical site infection after single-stage PR BA in patient with Cushing’s syndrome who have type 2 diabetes mellitus. Conclusions: BA is a procedure of the first choice in bilateral pheochromocytomas, metastatic adrenal tumors and Cushing’s syndrome. The PR approach must be selected for tumors up to 6 cm in size. For tumors larger than 6 cm LT technique should be preferred. The two-stage surgery appears to be the best treatment option for the high risk patients with bilateral adrenal tumors because it achieves optimal treatment effectiveness with minimized sequelae.

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Surg Endosc

P118 - Endocrine Surgery

P120 - Endocrine Surgery

Laparoscopic Bilateral Transperitoneal Anterior Adrenalectomy: 21 Years’ Experience

Short and Long-Term Outcomes of Laparoscopic Transperitoneal Adrenalectomy in Patients with Conn’s Syndrome

A. Balla1, S. Quaresima1, M. Guerrieri2, M. Ortenzi2, G. Lezoche2, G. d’Ambrosio1, E.L. Lezoche1, A. Paganini1 Sapienza University, ROME, Italy; 2Universita` Politecnica delle Marche, ANCONA, Italy 1

M. Wierdak, M. Pedziwiatr, G. Sokolowski, K. Morawiec, M. Natkaniec, A. Mydlowska, P. Major, M. Matlok, A. Budzynski Jagiellonian University, KRAKOW, Poland

Aims: Aim of the present study is to report the results of a retrospective analysis of prospectively collected data on the authors’ experience with laparoscopic bilateral adrenalectomy (LBA) for management of adrenal gland lesions. Methods: From 1994 to 2015, 486 patients underwent adrenalectomy in authors’ center. Of these patients, 21 (9 females, 12 males, mean age 42.5 years, range 21 - 67 years) underwent LBA using a transperitoneal anterior approach on the right side and a submesocolic approach on the left, in two centers (Rome and Ancona, Italy) following the same treatment protocol. Indications to surgery were as follows: Conn’s syndrome (3), Cushing’s syndrome (11), pheochromocytoma (6), cysts (1). Results: Mean operative time was 195 min (range 55–360 min). Conversion to open surgery occurred in 1 (4.7%) case for bleeding. Three patients (14.2%) underwent concomitant surgical procedures without changing the patient position but simply tilting the operative table: 3 laparoscopic cholecystectomies (LC), one of which associated with laparoscopic common bile duct exploration (LCBDE), stones’ extraction and T-tube placement. Postoperative complications were observed in 4 cases (19%): pneumothorax (1), left adrenal space abscess (1), sub-occlusion (1), pleural effusion (1). Postoperative blood transfusions were required in one patient (4.7%). Mean hospital stay was 8.9 days (range 2-19) and mortality was nil. Conclusions: LBA with transperitoneal anterior and submesocolic approaches has proven to be safe and effective. Relevant technical features of this procedure are early division of the adrenal vein as first step of the procedure prior to any gland manipulation, which is important in every case but particularly so for secreting tumors, and the fact that on the left there is no need to mobilize the spleno-pancreatic complex. In fact, no intraoperative change in blood pressure was observed in any case, including pheocromocytomas. Moreover, the transperitoneal anterior approach with patient supine allows the surgeon to perform associated procedures without the need to change the patient’s position on the operative table.

Aims: The aim of the study was to analyze short- and long-term results of laparoscopic adrenalectomy performed in patients with Conn’s syndrome (CS). Methods: Prospective analysis included 44 (M/F - 30/14, mean age55,23 ± 12,45 years) consecutive patients who underwent laparoscopic adrenalectomy for aldosterone secreting adenoma between 2004 and 2014 We analyzed the short-term results of operations (operation time, complication rate and conversions, length of hospital stay). Additionally, all patients were followed-up 6 and 24 months after surgery to assess changes in the biochemical parameters (aldosterone, Plasma Renin Activity[PRA],electrolytes), and the clinical regression of arterial hypertension. We also evaluated the usefulness of Adenoma Resolution Score (ARS) in predicting the hypertension remission in patients undergoing surgery for CS. Results: All patients underwent laparoscopic operation. None conversion was necessary. The mean operation time was 83.2 min (SD ± 31.3 min). Mean intraoperative blood loss was 52.5 ml (SD ± 87.3 ml). Complications occured in 5 (11,4%) patients. The mean duration of hypertension prior surgery was 9.52 years (SD ± 7.8 years). Hypokalemia and hypernatraemia preoperatively were found at respectively 83.4% and 15.8%. Although, electrolyte disturbances 6 months after surgery resolved in all cases, hypertension subsided completely only in 11.3% of them. In the next 43.2% cases we observed the reduction of antyhypertensive drugs. 24 monthspost surgery the complete remission of hypertension was found in 13.6% patients and partial in 45.5% cases. Analyzing the results of ARS index, only 50% of patients which with 4 or 5 points preoperatively, experienced complete remission of hypertension 6 months after the operation. Conclusions:Laparoscopic adrenalectomy is a safe method of treatment CS.Althoughit effectively eliminates electrolyte imbalance, does not allow for the complete elimination of hypertension in majority of patients. For this reason it seems reasonable that all patients are followed-up regularly after the procedure.ARS is not effective tool in predicting postoperative resolution of hypertension, especially in the elderly patients with a long history of hypertension.

P119 - Endocrine Surgery

P121 - Endocrine Surgery

Laparoscopic Treatment of Adrenocortical Carcinoma: The ‘Post-Quam’ Lesson

Laparoscopic Removal of Bilateral Adrenal Gland Metastases After Left-Sided Pulmonectomy. Case Report

C. Bergamini, G. Alemanno, D. Bisogni, A. Sturiale, G. Maltinti, A. Bocchetti, E. Falsetti, A. Grapsi, A. Giordano, P. Montanelli, P. Prosperi, A. Bruscino

P. Me´sza´ros

Careggi Teaching Hospital, FLORENCE, Italy

Introduction: Metastasizing non-small cell lung carcinoma (NSCLC) is a disease of poor prognosis. According to studies performed among small number of patients, in case of solitary adrenal gland metastasis of NSCLC, significantly better survival rate can be expected when metastasectomy is performed after chemotherapy, compared to receiving only chemotherapy. Patient material: In a 58-year-old female patient on 21st July, 2013 left-sided pulmonectomy was performed for a pT2N1M0 adenocarcinoma. After the surgery she received Cysplatin-Vinoralbin chemotherapy. In June, 2014 cerebral and chest CT examination were performed, that proved no metastasis. Bone scintigraphy revealed the suspicion of metastases of the 10th-11th thoracic vertebrae. After this PET-CT examination was performed that showed no vertebral metastases, but in the right adrenal gland a 1.1-cm sized and in the left adrenal gland a 0.7-cm sized metastasis were detected. Onco-team recommended bilateral adrenalectomy with the patient being in good general condition. After careful perioperative work-up in November, 2014 bilateral laparoscopic adrenalectomy was performed from intraperitoneal approach, in one step. During the surgery neither anesthesiological nor surgical complications were observed. After the surgery the patient spent two days in the Intensive Care Unit, then she was discharged on the 5th postoperative day with hormone substitution therapy. In both adrenal glands histology revealed the adrenal gland metastasis of the previous lung tumour. Since the operation neither local recurrence nor distant metastasis was discovered during follow-up. Conclusion: The fact of pulmonectomy in the medical history by itself does not mean the contraindication of laparoscopic adrenalectomy. Laparoscopic adrenalectomy can be performed even after pulmonectomy by careful patient selection and perioperative care. Advantages of laparoscopy in the postoperative stage (less pain, less disturbance in wound healing, faster recovery, less respiratory complication) had exponential importance in this case.

The main clinical problem of the adrenal cortical carcinoma (ACC) is the difficulty to make a correct pre-operative diagnosis. Indeed very often the ACC is clinically silent (incidentaloma). Furthermore, in some cases neither the dimension[6 cm neither other TC features may help in making the right diagnosis, and the discover of an ACC is a post-operative surprise. These type of patients are generally laparoscopically treated due to the diagnostic mistake, even though this type of approach are not internationally suggested in case of malignancy. We therefore present our experience facing with these small ACC, wrongly considered benign before surgery. Out of the 23 with CCS diagnised in the last 5 five years, 9 (7 females and one male) were laparoscopically treated due to their small dimension (main dimension 5.2 cm, range 3.9–6.2). All patients were asymptomatic at the diagnosis; in three patients the surgical excision was decided for a sudden [1 cm increase of an already followed-up incidentaloma. The CT features were pre-operatively described as benign, but when postoperatively revised, after the histological diagnosis of malignancy (‘post-quam’), in six out of the 9 patients (66.6%) the presence of slight spiculatures in the tumor profile was identified in three cases (33.3%), two area of hypodensity (necrosis?) were noticed in three cases, and, finally, in 7 (77.7%) the cranio-caudal dimension was that prevalent. One case had a very slight calcification. The surgical outcome and post-operative course was identical to those with benign lesions in 7 cases (77.7%) (patients alive without residual disease at a mean follow-up of 23 months ± 7 months). One case (11.1%) had a metastasis in the opposite adrenal gland after 13 months; another patients died for peritoneal carcinosis after 5 months. To conclude, from this small series but significant experience, due to the rarity of the pathology, we suggest a very careful morphological evaluation of the CT scan in all patients with adrenal incidentaloma, possibly using a magnification system, to more likely establish the possible malignant nature of the adrenal tumor and consequently more wisely indicate the best kind of surgical view.

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National Institute of Oncology, BUDAPEST, Hungary

Surg Endosc

P122 - Endocrine Surgery

P124 - Endocrine Surgery

Three Years Follow-Up After Laparoscopic Gastric Plication in Obese Patients With Type 2 Diabetes Mellitus

Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors

R. Havrysh1, Y. Havrysh1, O. Lukavetskiy2

M. Natkaniec, J. Dworak, M. Pedziwiatr, M. Wierdak, P. Major, M. Matlok, A. Budzynski

1

2

Lviv Regional Hospital, LVIV, Ukraine; Lviv National Medical University, LVIV, Ukraine Aim:To analyze the long-term results (3 years follow-up) after laparoscopic gastric plication (LGP) in obese patients with type 2 diabetes mellitus (DM2). Methods: From November 2010 to January 2012, we performed 37 LGP in obese patients with type 2 diabetes mellitus. There were 23 male and 14 female and age of patients was from 20 to 68 years. Disease lasts from 2 to 7 years. Eleven patients followed the diet, sixteen patients received oral hypoglycemic agents, ten patients had insulin therapy.The average duration of surgery 72 min (55 to 90 min). We obtained data about duration of diabetes, previous hypoglycemic treatment, age, weight, height, BMI, fasting glucose (FG),HbA1c, levels of cholesterol and lipoproteins before operation and every 6 months after surgery. Observation ranged from 36 to 60 months, but we give 36 month follow-up data. Results: There were no mortality after surgery. In 29 (78%) patients, we observed nausea within 3-7 days after surgery. Mean EWL at 12 months - 48%; at 24 months - 60%, after 36 months 65%. Mean ± SD preoperative characteristics were: BMI 42 ± 1,75 kg/m2; FG 10,5 ± 0,2 mmol/ l and HbA1c 8.6 ± 0,2%. At 36-months follow-up, mean ± SD characteristics were: BMI IMT 32.8 ± 0,9 kg/m2; FG 5.9 ± 0,3 mmol/l and HbA1c 6,1 ± 0,2%. We define the remission of diabetes according to criteria : complete remission if HbA1c \6% and FG \5.6 mmol/l; partial remission if HbA1c \6.5% and FG 5.6–6.9 mmol/l, in both cases in the absence of pharmacologic therapy, for a duration of at least one year. According to these criteria, we observed complete remission in 18 patients (48%), partial remission in 12 patients (33%). Conclusions: In our study, we observed that after LGP complete remission of diabetes occurs in 48% and partial in 33% of obese patients.

´ W, Poland 2nd Department of General Surgery, KRAKO Aims: Laparoscopic adrenalectomy is the gold standard for treatment of benign adrenal lesions. Tumor size is a factor that might influence decision concerning use of laparoscopic approach. The aim of this study was to analyze the results of adrenalectomy for tumors = 6 cm in diameter. Methods: Two groups of patients were analyzed: first group comprised 441 patients with tumors \6 cm in diameter, second group consisted of 89 patients with tumors =6 cm. Both groups were compared with regard to the duration of surgery, intraoperative blood loss, conversion and complications rate. Results: Median duration of surgery in group 1 and 2 amounted to 86.6 and 111.9 min (p \ 0.0001). Median intraoperative blood loss in group 1 and 2 was 56.5 and 172.8 mL, (p \ 0.0001). There was a linear relationship between tumor size and the duration of surgery, and between tumor size and intraoperative blood loss (p \ 0.0001). There were 2 (0.5%) and 6 (6,7%) conversions in group 1 and 2. There were 41 (9,3%) and 14 (15,7%) complications in group 1 and 2 (p = 0.0692). Conclusions: Laparoscopic adrenalectomy of tumors = 6 cm is more difficult, but it can be regarded safe and beneficial for patients.

LGP leads to blood pressure normalization in 81% of patients and normalization of lipid metabolism in 65% of patients. Mechanism of LGP action needs further study.

P123 - Endocrine Surgery

P125 - Gastroduodenal Diseases

Laparoscopic and Open Surgery for Adrenal Tumors: Results From 450 Procedures Performed in A Single Institution

A Belly of Blood: Surgical Intervention of Gastric Intramural Haematoma Precipitated by Therapeutic Endoscopy in an AntiCoagulated Patient

C. Aggeli1, A.M. Nixon1, I. Perysinakis1, A. Diamantopoulos1, A. Koroneos1, I. Spyridakis2, G.N. Zografos1 1

Athens General Hospital ‘Georgios Gennimatas’, ATHENS, Greece 251 Air Force General Hospital, ATHENS, Greece

2

Aim: Laparoscopic surgery for the management of benign adrenal tumors has become the goldstandard approach whereas laparoscopic approach in adrenal malignancy remains an open theme. The purpose of this study was to evaluate the feasibility and oncological safety of laparoscopic resection in malignant or potentially malignant adrenal tumors. Methods: From January 1998 to December 2015, 439 patients were operated for adrenal tumors, with a total of 450 procedures. There were 158 men and 281 women with a mean age of 54 years. In 361 patients laparoscopic procedure was successfully accomplished in tumors with a maximum size of 14 cm. In 3 cases, a hand assisted right laparoscopic adrenalectomy was done. There were 36 conversions to open surgery for oncological safety or technical reasons especially during the learning curve. Fifty patients were treated with open approach from the beginning and in 11 cases we performed en-block resection with other organs. In 8 patients an normal tissue sparing adrenalectomy was performed. Results: There were 63 Cushing’s syndrome, 72 adenomas with autonomous cortisol secretion, 66 Conn’s syndrome, 64 non functioning adenomas, 8 patients with Cushing disease and 63 pheochromocytomas. Among the pheochromocytomas, 5 cases were finally classified as malignant, 23 as potentially malignant and 36 as benign. There were also 18 metastatic tumors, 21 primary adrenocortical carcinomas, and 5 potentially malignant adenomas. One patient had postoperative hemorrhage and died 2.5 months after the procedure in the intensive care unit. Two patients developed postoperative low-volume pancreatic fistula that resolved spontaneously. Mean postoperative hospital stay was 2.1 days for the laparoscopic and 5 days for the open approach. One patient with adrenocortical carcinoma presented at the follow-up period with local recurrence following laparoscopic resection and had a R0 open resection. Conclusions: Laparoscopic adrenalectomy should be the treatment of choice for all benign large adrenal tumors up to 14–15 cm. Potentially primary malignant tumors, and solitary metastatic adrenal tumors, should be assessed by laparoscopy cautiously, only in centres with experience in advanced laparoscopic surgery. Open surgery is recommended from the start for large malignant tumors and en-block organ resections.

H.J. Tan1, S. Ngaserin Ng2, C. Keh3 1 MOH Holdings, SINGAPORE, Singapore; 2National University Hospital, SINGAPORE, Singapore; 3Jurong General Hospital, SINGAPORE, Singapore

Aim: Gastric intramural hematoma is a rare condition which may be classified as a spectrum of acute gastric mucosal injury. While most resolved with conservative management, we describe a successfully managed case requiring surgical intervention. This is the second case documenting both endoscopy and surgery for uncontrolled haemorrhage. Methods: An elderly female was admitted for a fall. Her prior medical conditions include hypertension, hyperlipidaemia, and osteoporosis. She developed a left segmental pulmonary embolus and was started on subcutaneous low-molecular-weight heparin (enoxaparin) 1 mg/kg twice daily. Upon initiating treatment, she was found to have progressive iron deficiency anaemia hence an upper gastrointestinal (GI) endoscopy and CT colonography was arranged. Upper GI endoscopy revealed pangastric erosions and a 4 mm ulcer with visible vessel in the gastric antrum. The Forrest 2a ulcer was treated with adrenaline injection and heater probe. Small biopsies were also taken. An hour later, the patient developed tachycardia, haematamesis, and significant haemoglobin drop of 2 g/dL. Repeated endoscopy revealed large amount of blood clots in the gastric antrum which could not be completely removed by suctioning and source of bleeding unidentified. Second attempt at therapeutic intervention was unsuccessful. Hence, decision was made for immediate exploratory laparotomy. Laparotomy revealed a large haematoma that had occupied the anterior aspect of the stomach causing extensive serosal stretch from fundus to pylorus. The lesser sac was entered and a gastrostomy was performed. The tense intramural gastric haematoma was revealed within the stomach lumen. Haemostasis was achieved and abdomen was closed in the usual matter. Results: She recovered well post operatively and was re-commenced on prophylactic dose enoxaprin 48 h after surgery. Conclusion: Gastric submucosal haematoma is a rare disorder that should be recognised to avoid unnecessary surgical intervention and misadventure, as most cases may be managed conservatively.

123

Surg Endosc

P126 - Gastroduodenal Diseases

P128 - Gastroduodenal Diseases

Laparoscopic Versus Open Resection for Gastric Gastrointestinal Stromal Tumor On Short- And Long-Term Outcomes: A Propensity Score-Matching Analysis

Can Laparoscopic Surgery be Applied in Gastric Gastrointestinal Stromal Tumors Located in Unfavorable Sites?-A Study Based on the NCCN Guidelines

C.M. Huang, Q.F. Chen, J.X. Lin, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J. Lu, Q.Y. Chen, L.L. Cao, M. Lin, R.H. Tu

C.M. Huang, Q.F. Chen, J.X. Lin, M. Lin, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J. Lu, Q.Y. Chen, L.L. Cao, R.H. Tu

Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China

Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China

Aims: This study investigated the short- and long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumor (GIST) compared with open surgery. Methods: 214 patients who underwent laparoscopic resection (LAP, n = 133) or open resection (OPEN, n = 81) at our institution (January 2006 to December 2014) were identified from a prospectively collected database. Propensity-score matching (PSM) was used to analyze the short- and long-term outcomes between these groups. Results: There were statistical differences in tumor resection method and tumor size between LAP group and OPEN group. And after PSM, there were no differences (P [ 0.05) in tumor size, mitotic rate, Fletcher classification, tumor resection methods, imatinib treatment after surgery (IM) between this two group. LAP group had less operation time, less blood loss, shorter time to first flatus, shorter time to first fluid diet, shorter time to pull out gastric tube and postoperative stay before PSM. But after PSM, except the time to pull out gastric tube was similar in these two groups, other short-term outcomes were similar with the result before PSM. Postoperative complication in LAP group and OPEN group were 6.8% and 22.8% respectively before PSM (P = 0.001), and 5.6% versus 22.5% after PSM (P = 0.004). Multivariate analyses for complication showed tumor location of the middle stomach, operation method and proximal gastrectomy were independent risk factors both before and after PSM. 5 year cumulative survival rates in LAP group and OPEN group were 95.4% and 85.9% respectively (P = 0.07) before PSM, but 93.1% versus 91.9% (P = 0.69) after PSM, which had no significant difference. Conclusions: Gastric GISTs laparoscopic resection had better short-term outcomes and similar long-term outcomes compared with open surgery. Localized gastric GISTs can be treated with laparoscopic surgery.?>

Objective: This article investigated the feasibility of laparoscopic surgery in unfavorable site gastric gastrointestinal stromal tumors (GISTs). Methods: We identified 214 patients who underwent primary gastric GIST resection at our institution (January 2006 to December 2014). These patients were divided into a Favorable group (140 cases) and an Unfavorable group (74 cases) according to the 2014 version of the National Comprehensive Cancer Network Clinical Guidelines. Results: The wedge resection rate of the Favorable group was higher than that of the Unfavorable group, and most procedures were performed laparoscopically (P \ 0.05). In addition, there were no differences in the other clinicopathological features between these groups (P [ 0.05). The postoperative stay of the Unfavorable group was longer compared with Favorable group (P = 0.02). Laparoscopic surgery in both groups resulted in a shorter operative time, lower blood loss, faster time to first flatus, faster time to first fluid diet, and shorter postoperative stay than open surgery (P \ 0.05). Although the difference was not significant (P = 0.09), the postoperative complication incidence of the Favorable group was less compared with Unfavorable group (10% vs 17.6%). Furthermore, in the Unfavorable group, the incidence of postoperative complications from laparoscopic surgery was significantly lower than that of open surgery (P = 0.001). There were no differences in the 5-year overall survival (OS) and recurrence-free survival (RFS) of these groups (P [ 0.05). Furthermore, in the Unfavorable group, the 5-year OS and RFS were similar for both laparoscopic and open procedures. Multivariate COX regression analysis showed imatinib (IM) treatment was an independent risk factor for poor prognosis. Conclusions: Laparoscopic operation for gastric GISTs located in unfavorable sites can yield similar long-term outcomes compared with an open operation. However, laparoscopic surgery has the obvious advantage of being minimally invasive, and the incidence of postoperative complications was low. Laparoscopic surgery is thus an option for the treatment of localized gastric GISTs.

P127 - Gastroduodenal Diseases

P129 - Gastroduodenal Diseases

Totally Laparoscopic Versus Laparoscopy-Assisted Billroth-I Anastomosis for Gastric Cancer: A Case–Control And CaseMatched Study

Laparoscopic Gastrectomy for Siewert Type II/III Esophagogastric Junction Carcinoma

C.M. Huang, M. Lin, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J.X. Lin, J. Lu, Q.Y. Chen, L.L. Cao, R.H. Tu Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China Objective: To evaluate the safety and feasibility of modified delta-shaped gastroduodenostomy (MDSG) in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer (GC). Methods: We performed a case–control and case-matched study enrolling 642 patients with GC undergoing laparoscopic Billroth-I anastomosis from January 2011 to December 2014. TLDG with MDSG was performed in 158 patients (Group TL) and laparoscopy-assisted distal gastrectomy (LADG) with circular anastomosis was performed in 484 patients (Group LA). One-to-one propensity score matching (PSM) was performed to compare the clinicopathological characteristics between the 2 groups. Results: Patients with smaller tumor size or stage I cancer were more likely to receive TLDG (P \ 0.05). In the propensity matched analysis with 143 pairs, there were no differences in demographic and pathologic characteristics. (P \ 0.05). All patients were performed laparoscopic surgery successfully. Before PSM, Group TL had more dissected LNs and longer time to first fluid diet and postoperative length of stay than Group LA (P \ 0.05). After PSM, except more dissected LNs were achieved in Group LA (P \ 0.05), no difference was found in the intraoperative and postoperative outcomes between 2 groups (P [ 0.05). The postoperative complications were similar in 2 groups (P [ 0.05). Stratification analysis performed in the cases after PSM showed that in early GC, no difference was found in intraoperative and postoperative outcomes between 2 groups. However, in the advanced GC, Group TL had higher rate of postoperative complication (P \ 0.05). Univariate analysis carried out in locally advanced cases after PSM showed that BMI, the way of digestive tract reconstruction and Chalson’s score were significant factors that affected postoperative morbidity (P \ 0.05). Multivariate analysis found that BMI was the independent risk factor for the postoperative morbidity (P \ 0.05). Conclusions: The DSG in TLDG is safe and feasible for early GC, while in locally advanced GC, especially in patients with high BMI, it should be carefully chosen.

123

C.M. Huang, C.B. Lv, J.X. Lin, Q.Y. Chen, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J. Lu Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China Background: We clarified the oncologic efficacy of laparoscopic-assisted total gastrectomy (LATG) for Siewert type II and III adenocarcinoma of esophagogastric junction. Methods: 700 patients with Siewert type II and III AEG who underwent radical total gastrectomy between January 2007 and June 2014 were analyzed retrospectively. The short- and long-term outcomes were compared in the matched groups using propensityscore matching method. Results: After matching, clinicopathologic characteristics between the two groups were well balanced. Before and after matching, LATG compared with open total gastrectomy (OTG) was associated with shorter operative time, less blood loss, more lymph nodes (LNs) retrieved and decreased length of stay. Before matching, stratified analysis showed that the 3-year overall and disease-free survival rates of LATG were comparable with that of OTG. However, after matching, the LATG group demonstrated significantly higher 3-year overall survival rate (82.7% versus 61.8%; P = 0.018) and disease-free survival rate (81.2% versus 60.0%; P = 0.037) for Siewert type II AEG compared with the OTG group; however, in the Siewert type III AEG subgroup, survival rates were similar (P = 0.974 and P = 0.898, respectively). Conclusions: LATG is a safe and feasible procedure with better short-term outcomes for Siewert type II and III AEG. Particularly for Siewert type II AEG, LATG may yield more retrieved LNs and better long-term survival.

Surg Endosc

P130 - Gastroduodenal Diseases

P132 - Gastroduodenal Diseases

D2 Lymphadenectomy for Gastric Cancer

Laparoscopy Gastrectomy for Advanced Gastric Cancer

C.M. Huang, J. Lu, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J.X. Lin, Q.Y. Chen, L.L. Cao, M. Lin, R.H. Tu

C.M. Huang, J.X. Lin, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J. Lu, Q.Y. Chen, L.L. Cao, M. Lin

Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China

Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China

Background: The effect of minimum examined lymph nodes (LNs) number in different type of gastrectomy on survival remains unclear. This study first aimed to seek the ideal cut-off of LNs during radical distal and total gastrectomy with D2 lymphadenectomy based on the long-term survival outcomes. Methods: We retrospectively analyzed 2662 patients who underwent radical resection for gastric cancer between January 2000 and September 2010, and randomly divided into development (70%) and validation (30%) datasets. The most informative cut-off for the examined LNs during different type of gastrectomy was identified. A hypothetical stage classification (hTNM) was proposed based on the relation between prognosis and the number of examined LNs. Survival was compared for disease classified according to the hTNM and AJCC 7th editions. Results: Mean number of nodes removed during radical distal and total gastrectomy were 26 ± 9.6 and 29 ± 10.7, respectively (p \ 0.01). The optimal LNs count thresholds were designed as 16 and 21 for patients underwent curative diatal and total gastrectomy, respectively. The hTNM staging system had higher linear trend and likelihood ratioX2 scores and smaller AIC values compared with those for the seventh AJCC TNM classification, which exhibited the optimum prognostic stratification. Similar results were found in the validation set. Conclusion: To maximize the survival benefit after radical total gastrectomy for gastric cancer, a minimum of 21 lymph nodes should be removed. The proposed hTNM staging may predict survival more accurately and discriminatively.

Objective: The aim of this study was to evaluate the safety of this single center, phase III, prospective, randomized trial with respect to morbidity and mortality. Methods: Patient eligibility criteria were pathologically-proven adenocarcinoma, 18 to 75 years of age, no history of other cancer, chemotherapy, or radiotherapy, preoperative stage T2-4aN0-3M0 with R0 resection. The morbidity and mortality were compared to evaluate the safety of this trial. Results: A total of 192 patients were randomized (LADG group, 96 patients; ODG group, 96 patients) between July 1, 2011 and August 31, 2014. There were no significant differences between the two groups in the clinicopathological Characteristics. Median number of lymph nodes per patient was 36, and the mean number of retrieved lymph nodes in LADG group was more than that in ODG group. The number of transfused patients, time to resumption of activities, time to resumption of soft diet, and post-operative stay were similar in the two groups; while the operation time, blood loss, and times to first flatus were significantly lower in the LATG group. The post-operative complication rates of the LADG and ODG group were 19.8% and 16.7%, respectively (P = 0.575). The postoperative mortality was 0% and 1.0% in the LADG and ODG groups (P = 0.316), respectively. Conclusions: This study suggests that LADG provides better peri-operative outcomes with acceptable morbidity and mortality rates compared with ODG. Keywords: Gastric carcinoma; Laparoscopic-assisted distal gastrectomy; Morbidity; Mortality; This study is registered at Chictr.org.cn and carries the following ID number: ChiCTRTRC-11001340.

P131 - Gastroduodenal Diseases

P133 - Gastroduodenal Diseases

Tailored Laparoscopic Surgery for Gastric Submucosal Tumors

Laparoscopic Gastrectomy in Octogenarians

E. Kanehira, T. Tanida, A. Kamei, M. Nakagi

C.M. Huang, J. Lu, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J.X. Lin, Q.Y. Chen, L.L. Cao, M. Lin, R.H. Tu

Medical Topia Soka, SOKA, Japan Background: Tailored surgery should be considered for gastric submucosal tumors to preserve the stomach as much as possible. We have performed tailored laparoscopic resection in 220 patients with gastric submucosal tumor over the last 4 years. We report the outcomes from this experience. Patients and operations: In 220 cases 5 different types of laparoscopic operation were performed. Exm: extragastric approach with manual resection + manual suture, Exs: extragastric approach with stapling resection, Enm: endoluminal approach with mamual resection + manual suture, Ens: endoluminal approach with stapling resection, and Gas: total or distal gastrectomy. Lesions located at EG junction, antrum, or showing intraluminal growth except for fornix were treated by Enm. For tumors in the abdominal esophagus manual resection was performed with the mucosal layer remaining intact. When the defect of the muscle layer is large it was not reconstructed and fundoplication was added. In all cases intraoperative peroral endoscopy was performed. Results: Exm: 58(26%), Exs: 61(28%), Enm: 92(42%), Ens: 3(1.4%), Gas: 6(2.8%). There were no conversion to open surgery. Single incision surgery was performed in 173(78%).Operation time ranged 40 to 290 min (avr 130). Postop. complications were bleeding in 2(1%), localized peritonitis in 1(0.5%), stasis in 2(1%), stenosis in 1(0.5%). En bloc resection was achieved in 219(99.5%). Average size of the tumor was 36 mm (max 90 mm). Pathology revealed GIST in 99(45%), leiomyoma in 81(37%), schwannoma in 17(7.7%), etc. Surgical margin was negative in 219(99.5%). There was one recurrence in an adjacent lymphnode in a GIST high risk case, who underwent laparoscopic resection of the metastatic tumor. Conclusion: The organ preserving ratio in the current study was 97%. This was achieved by considering tailored laparoscopic surgery according to location, size, growth type and so on in each individual case. This type of organ preserving procedures can be also justified from an oncological point of view as its ratio of negative margin was 99.5%.

Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China Background: As life expectancy is increasing, the use of laparoscopic surgery in the elderly is gaining interest. The aim of this study was to describe the short- and long-term outcomes after laparoscopic gastrectomy (LG) for gastric cancer, by comparing the procedure to open surgery in octogenarians. Methods: e retrospectively analyzed data from 165 gastric cancer patients aged 80 years or older, who underwent gastrectomy by either laparoscopic or open surgery from 2007 to 2012. Patient characteristics, operative outcomes, pathologic results, morbidity, mortality, and survival were compared. Results: 119 patients underwent LG and 46 patients underwent open gastrectomy (OG). LG demonstrated significantly less blood loss and operation time, faster time to first flatus, and a shorter postoperative hospital stay. Postoperative morbidity was similar in LG and OG groups (40.3 vs. 34.8%; P = 0.594). Multivariate analysis revealed that the type of operation had no effect on the occurrence of complications. The 3-year overall (LG,44.5%;OG,34.8%), recurrence-free (LG,34.3%;OG,26.0%), and cancer-specific (LG,49.7%;OG,38.3%) survival rates did not show any significant difference between the two groups. Conclusions: LG for gastric cancer can be performed safely and maintains the advantages of minimal invasiveness, even in extremely old patients. Furthermore, there was no significant association between the surgical procedure and the long-term survival rates. Therefore, the authors recommend laparoscopic resection of gastric cancer as the treatment of choice for octogenarians patients.

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Surg Endosc

P134 - Gastroduodenal Diseases

P136 - Gastroduodenal Diseases

The Gastros Study: Standardising Outcome Reporting in Gastric Cancer Surgery

Tumor-Associated NLR in Gastric Neuroendocrine Neoplasms

B. Alkhaffaf1, I.A. Bruce2, A.M. Glenny2, J.M. Blazeby3, P.R. Williamson4 1

Central Manchester University Hospitals NHS foundation Trust, MANCHESTER, United Kingdom; 2University of Manchester, MANCHESTER, United Kingdom; 3University of Bristol, BRISTOL, United Kingdom; 4University of Liverpool, LIVERPOOL, United Kingdom Aims: Partial or total gastrectomy remains the mainstay of treatment with curative intent for gastric cancer. Surgery, however, is associated with complications and a significant impact on quality of life. Identifying the best surgical approaches for gastric cancer (for example when examining the benefit of minimally invasive over open surgery) includes comparing and synthesizing data from surgical studies in systematic reviews and metaanalyses. This is presently difficult as there is great heterogeneity in the reporting of outcomes in surgical trials. Many trials do not report ‘quality of life’ or ‘patient-reported outcomes’. GASTROS (GAstric cancer Surgery Trials Reported Outcome Standardisation) is an international study which aims to develop a core outcome set (COS) - a minimum standardised group of outcomes - which should be reported by all future gastric cancer surgery trials to enable more accurate comparison of different surgical approaches. GASTROS is fully funded by the National Institute for Health Research and supported by the Medical Research Council’s Hubs for Trials Methodology Research. Here we present our study protocol. Methods: The GASTROS study has 3 stages. Stage 1 involves undertaking a systematic review of randomised control trials and observational studies to identify all previously reported outcomes and establish a ‘long-list’ of possible outcomes to include in the COS. Qualitative interviews with gastric cancer patients will be undertaken to identify any further outcomes which patients deem important. Stage 2 involves 3 rounds of a Delphi survey of key stakeholders (surgeons, cancer nurse specialists and patients) followed by a ‘consensus meeting’ to determine which outcomes to include in the COS. Stage 3 of the study will will focus on identifying the most appropriate methods of measuring these core outcomes. Anticipated Benefits: This study will enable more reliable and accurate comparison of surgical interventions for gastric cancer. It will inform future gastric cancer surgical trials, clinical practice and surgical audits by identifying a standardised, well-defined group of outcomes which are important and relevant to both patients and clinicians.

C.M. Huang, L.L. Cao, J. Lu, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J.X. Lin, Q.Y. Chen, M. Lin, R.H. Tu Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China Objective: This study investigated the predictive value of Tumor-associated neutrophil to lymphocyte ratio (TA-NLR) on clinical outcomes for patients with gastric neuroendocrine neoplasms (g-NENs) after radical surgery. Methods: Data from 142 patients who were diagnosed with g-NENs and underwent radical gastrectomy at our department from March 2006 to March 2015 were prospectively collected and retrospectively analyzed. Results: The TA-NLR was not significantly associated with clinical characteristics (all P [ 0.05). The TA-NLR were significantly correlated with tumor recurrence, especially with liver and lymph node metastasis (both P \ 0.05). Multivariate Cox regression analysis identified the TA-NLR as an independent prognostic factor for RFS and OS (both P \ 0.05). The concordance index (C-index) of the nomograms including the TA-NLR, Ki67 index and lymph node ratio for RFS (OS) were 0.788(0.759), which were higher than the C-index of traditional TNM stage system [0.672(0.663)]. Conclusions: The TA-NLR was an independent prognostic factor of g-NENs for RFS and OS. Nomograms with the TA-NLR, Ki-67 index and lymph node ratio had more superior discrimination ability to predict clinical outcomes than traditional TNM stage system for postoperative g-NENs patients.

P135 - Gastroduodenal Diseases

P137 - Gastroduodenal Diseases

Frailty Predicts Postoperative Complications and Survival

Totally Laparoscopic Versus Laparoscopic-Assisted Circular Stapling Esophagojejunostomy After Total Gastrectomy: A Propensity Score-Matched Cohort

C.M. Huang, J. Lu, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J.X. Lin, Q.Y. Chen, L.L. Cao, M. Lin, R.H. Tu Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China Background: The proportion of elderly patients who undergo surgery has rapidly increased; however, clinical indicators predicting outcomes are limited. Frailty is thought to estimate physiologic reserves, although its use has not been evaluated in laparoscopic surgical patients. This study aimed to evaluate the significance of preoperative frailty (PF) in octogenarians undergoing laparoscopic gastrectomy. Methods: We reviewed the prospectively collected data from 119 gastric cancer (GC) patients aged 80 years or older, who underwent radical laparoscopic gastrectomy (RLG) between January 2007 and December 2012. Three baseline frailty traits were measured by routine preoperative laboratory data: albumin \3.4 g/dL, hematocrit \35%, and creatinine [2 mg/dL. Patients were categorized by the number of positive traits as follows: nonfrail: 0 to 2 traits, and frail: 3 traits. Patient characteristics, operative outcomes, pathologic results, morbidity, and survival were compared. Results: A total of 43 (36.1%) patients were considered as frail and 76 (63.9%) patients were considered as nonfrail. PF was associated with an increased risk for postoperative complications (frail: odds ratio, 2.506; 95%CI, 1.113–5.643, P = 0.027). With a median follow up of 35.0 mo (range: 1.0-67.8 mo), the 3-year overall survival (OS), recurrence-free survival (RFS) and cancer-specific survival (CSS) rates in the entire cohort were 47.9, 34.3 and 51.7%, respectively. There was a significant difference in OS (frail, 37.2%; nonfrail, 53.9%; P = 0.047) and RFS (frail, 23.3%; nonfrail, 40.5%; P = 0.020) between the groups, but no difference in CSS (frail, 43.5%; nonfrail, 56.4%; P = 0.114). Conclusions: Frailty based on an easily calculable preoperative measure may have utility in the prediction of postoperative complications, 3-year OS and DFS after RLG in octogenarians. Therefore, PF could be used as a low-cost simple screen for high-risk individuals who might suffer more than expected during the postoperative period after RLG.

123

W. Wang Guangdong Province Hospital of Chinese Medicine, the Second Affiliated Hospital, GUANGZHOU, China Objective: Anvil insertion is technically difficult in laparoscopic radical total gastrectomy. This study aimed to compare the short-term outcome between totally laparoscopic (TL) and laparoscopic-assisted (LA) circular stapling esophagojejunostomy following total gastrectomy. Methods: Between November 2010 and December 2015, a total of 356 patients with proximal gastric cancer underwent laparoscopic total gastrectomy among which 45 patients underwent TL suture-tied-anvil circular stapling esophagojejunostomy. Patients in TL group were matched 1:2 to LA group using the propensity score for age, gender, BMI, tumor location and reconstruction style. Results: Between two groups, the reconstruction-related complication was comparable (TL 2.2% vs LA 3.3%; p = 0.10). The operative time in LA group was 18.6 min shorter than TL group (p = 0.01) but the time of anvil insertion and esophagojejunostomy anastomosis were no significant difference. The estimated blood loss and the postoperative recovery were similar between two groups. In cosmetic evaluation, the body image score (TL 18.3 ± 5.4 vs LA 16.0 ± 5.2; p = 0.02) and cosmetic score (TL 20.9 ± 6.1 vs LA 18.1 ± 5.9; p = 0.01) were better in TL group than LA group. Conclusions: TL suture-tied-anvil circular stapling esophagojejunostomy after radical total gastrectomy is as technically feasible, safe and effective as LA total gastrectomy for patients with proximal gastric cancer. Moreover, TL group was associated with better cosmetic outcome.

Surg Endosc

P138 - Gastroduodenal Diseases

P140 - Gastroduodenal Diseases

Blood NLR in Gastric Neuroendocrine Neoplasms

Laparoscopic Gastrectomy for Elderly Patients with Gastric Cancer

C.M. Huang, L.L. Cao, J. Lu, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J.X. Lin, Q.Y. Chen, M. Lin, R.H. Tu Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China Objective: This study investigated the predictive value of preoperative blood neutrophil to lymphocyte ratio (NLR) on clinical outcomes for patients with gastric neuroendocrine neoplasms (g-NENs) after radical surgery. Methods: Data from 147 patients who were diagnosed with g-NENs and underwent radical gastrectomy at our department from March 2006 to March 2015 were analyzed. Results: The blood NLR was significantly higher in the patients with g-NENs than in matched normal volunteers (P \ 0.05). Multivariate analysis showed a higher blood NLR was not significantly associated with clinical characteristics (all P [ 0.05). Multivariate Cox regression analysis identified a blood NLR of more than 2.15 as an independent prognostic factor for RFS and OS. A nomogram including the blood NLR had superior discrimination ability to predict clinical outcomes for patients. There was a recurrence rate of 37% (55/147). The median time to recurrence was 9 months, with 48 (87%) patients recurring within the first 2 years. Both the blood NLR and the Ki-67 index were not only significantly correlated with liver metastases (both P \ 0.05), but also negatively correlated with recurrence time (both P \ 0.05). Conclusions: As an independent prognostic factor for g-NENs, the blood NLR could improve the ability of predicting patients RFS and OS. We recommend that g-NENs patients with high blood NLR or high Ki-67 index undergo surveillance at the first month and then every 3 months for 2 years after surgery.

C.M. Huang, H.A. Chen, J. Lu, C.H. Zheng, P. Li, J.W. Xie, J.B. Wang, J.X. Lin, Q.Y. Chen, L.L. Cao, M. Lin, R.H. Tu Fujian Medical University Union Hospital, FUZHOU, FUJIAN PROVINCE, China Background: Old age is regarded as the risk factor of major abdominal surgery due to common underlying comorbidities and low functional physiological reserves. This study aimed to systematically evaluate the feasibility and safety of laparoscopic gastrectomy (LG) in elderly patients with gastric cancer(GC) by comparing with non-elderly patients. Methods: A systematic search of PubMed, Cochrane, OVID, and Embase from January 1994 to November 2015 was conducted. All original studies comparing elderly with nondelderly patients with GC undergoing LG were included for critical appraisal. The following factors were checked: operating time, blood loss, harvested lymph nodes, flatus time, hospital stay, mortality and morbidity, overall 5-year survival rates. Data synthesis and statistical analysis were carried out using RevMan 5.3 software. Results: Six studies were selected in this analysis, which included a total of 1268 patients (347in elderly and 921 in non-elderly).Compared with non-elderly patients, elderly showed later passage of flatus(WMD = 0.42,95%CI(0.22,0.61),P \ 0.05),longer postoperative hospital stay(WMD = 1.94,95%CI(0.73,3.14),P \ 0.05),higher postoperative complications rate(OR = 1.48,95%CI(0.68,1.02),P \ 0.05),especially higher Pneumonia(OR = 8.13,95%CI(1.66,39.92),P \ 0.05).The operative time, intraoperative blood loss, conversion to open surgery, mortality, overall 5-year survival rates were similar. Conclusion: Although the postoperative complications in elderly patients undergoing LG were higher than non-elderly, mortality and overall 5-year survival rates were comparable for each other. LG for elderly gastric cancer is feasible and safe with acceptable oncologic outcomes. Old age should not be alone considered a contraindication of laparoscopic surgery.

P139 - Gastroduodenal Diseases

P141 - Gastroduodenal Diseases

A New Method of Laparoscopic Endscopic Cooperative Surgery for Gastric Submucosal Tumor

Esophagojejunal Reconstruction After Laparoscopy-Assisted Total Gastrectomy Using the Transorally Inserted Anvil with a Simple Suturing Technique

M. Mizumoto, N. Shimeno, Y. Kumata, S. Kitano, H. Masui, R. Kita, Y. Sakamoto, H. Kinoshita, S. Imamura, M. Kondo, H. Kobayashi, S. Kaihara, R. Hosotani Kobe city medical center general hospital, KOBE, Japan Aim: Laparoscopic wedge resection has been performed for gastric submcosal tumor (SMT), such as gastrointestinal stromal tumor (GIST). But intraluminal type SMT sometimes cannot be detected by laparoscopy. Laparoscopic endoscopic cooperative surgery (LECS, so called ‘Classical LECS’ at the moment) is useful for intraluminal type SMT, because it can detect the appropriate resection line using ESD technique (Hiki et al. Surg Endosc. 2008). On the other hand, Classical LECS involves full-thickness wall resection, so it might cause tumor dissemination into the intraperitoneal space if it is preformed for GIST with ulceration. Therefore, we have performed Transformed LECS (T-LECS) preventing from full-thickness wall resection for intraluminal type SMT with ulceration in our hospital since 2008. The Aim of this study is to show the T-LECS procedure, and to evaluate the usefulness of T-LECS. Method: T-LECS procedure: (1) Detection of tumor location by endoscope and injection of glycerin into the submcosal layer. (2) Seromuscular incision using laparoscopic tools. (3) Traction intraluminal type tumor wrapped in the submucosal layer, and changing it like extraluminal type. (4) Excision gastric wall using autosutures. Patients: The consecutive patients underwent Laparoscopic wedge resection, Classical LECS, or T-LECS for gastric SMT in our hospital from 2008 to 2014. Method Patients backgrounds, surgical outcome and postoperative outcome were analyzed retrospectively. Result: The number of patients underwent Laparoscopic wedge resection, Classical LECS and T-LECS was fifteen, sixteen and five patients respectively. Operation time of Classical LECS and T-LECS is significantly longer than Laparoscopic wedge resection, but there is no significant difference among the three groups in terms of blood loss or the numbers of autsutures used for gastric resection. There is no significant difference of the early postoperative outcomes. Only one patient who was underwent T-LECS occurred tumor recurrence, and the tumor showed 150 of mitosis per 50HPF and was classified high risk. Conclusion: T-LECS is safe and usefull for intraluminal SMT with ulceration.

T. Kubota1, D. Matsubara1, D. Ichikawa2, S. Komatsu2, T. Kosuga2, Y. Itokawa1, K. Shimomura1, J. Ikeda1, F. Taniguchi1, Y. Shioaki1, E. Otsuji2 1

Japanese Red Cross, Kyoto Daiichi Hospital, KYOTO, Japan; Kyoto Prefectural University of Medicine, KYOTO, Japan

2

Aims: Although laparoscopic gastrectomy is widely performed for a treatment of gastric cancer, laparoscopy-assisted total gastrectomy (LATG) is not common. The reconstruction method after LATG has not been standardized due to the difficulty associated with esophagojejunostomy. Circular-stapled esophagojejunostomy has recently been performed using the transoral anvil delivery system (OrVilTM); however, some studies reported that the double stapling technique (DST) after LATG might increase the development of anastomotic stenosis. To reduce the incidences of the anastomotic stenosis, we devised a method for esophagojejunostomy after LATG using OrVilTM with a simple suturing technique (the ‘non-DST method’). Methods: Between July 2008 and February 2014, 66 patients underwent LATG using DST. Among these patients, 10 who converted to open surgery were excluded from this study, and we defined the remaining 56 patients as the DST group. Between September 2013 and August 2015, 14 patients underwent LATG with our non-DST method (the non-DST group, n = 14). The characteristics of patients and their surgical outcomes were compared between these two groups. Results: There was no significant difference in the clinicopathological characteristics between the two groups. Operative time was significantly shorter in the non-DST group compared to the DST group. No significant difference was observed regarding operative blood loss and hospitalization between the two groups. The incidence of complications did not differ significantly between the two groups. Although two patients in the DST group developed anastomotic stenosis, none in the non-DST group did. Esophagojejunal leakage did not occur in either group. Conclusion: We consider this method safe and feasible, and believe it can reduce the development of anastomotic stenosis after LATG.

123

Surg Endosc

P142 - Gastroduodenal Diseases

P144 - Gastroduodenal Diseases

Reconstruction After Laparoscopic Total Gastrectomy or Laparoscopic Proximal Gastrectomy Using PSD

Roux Stasis Syndrome and Gastric Food Stasis After Laparoscopic Distal Gastrectomy: Prevention by Use of an Uncut Roux Limb

K. Kojima, M. Inokuchi, S. Otuki, T. Tanioka, T. Kawano Tokyo Medical and Dental Unicersity, TOKYO, Japan Safe esophagojejunostomy is really important for standardization of laparoscopic total gastrectomy (LTG). We have performed complete laparoscopic esophagojejunostomy by circular stapler (CS) using Purse-string Suturing Device (PSD) that we co-developed with Takasago company in Japan. The advantage of this device is to provide surgeons same procedure with open surgery, and it doesn’t depend on surgeon’s technical skills, because this device doesn’t need laparoscopic hand-sewn technique. And we also have adapted PSD for double tract reconstruction after laparoscopic proximal gastrectomy. Surgical Procedure: Esophagus is resected by Endoscopic linear stapler (ELS). Left inferior port site is extended to about 4 cm. PSD is initially made up. From extended site, anvil head and PSD is inserted into the abdominal cavity. Stump of esophagus is grasped with PSD, and purse-string suture is performed. PSD is dislodged, and anvil head is inserted to stump of esophagus. Jejunum about 20-30 cm from the ligament of Treitz is searched, marked and turned out through the incision. Jejunum is cut by ELS, and CS is inserted from this point. Jejunum is brought up with the ante-colic fashion, and esophagojejunostomy is performed by CS. Finally, we close stump of the jejunum by ELS, and staple line is reinforced by absorbable running-suture. From November 2009 to November 2015, we have performed esophagojejunostomy using PSD in 81 cases (LTG:52 cases, LPG:29 cases). Average time to fix anvil head is about 22 min, and average time of esophagojejunostomy is about 43 min. Complications regarding esophagojejunostomy are 2 cases (2.46%) of jejunum fistula by drain contact, 1 case (1.23%) of jejunum stump leakage, and 1 case (1.23%) of anastomotic stenosis. We will present our surgical procedure in detail and clinical outcome.

Y.S. Park, K.H. Kim, D.J. Park, S.H. Ahn, D.J. Park, H.H. Kim Seoul National University Bundang Hospital, SEONGNAM-SI, Republic of Korea Background: Roux stasis syndrome (RSS) defined as delayed passage of gastric contents into proximal jejunum occurs at frequency of 10-67% of patients who underwent Roux-en Y gastrojejunostomy (RYGJ) after distal gastrectomy. Uncut Roux-en Y gastrojejunostomy (uRYGJ) was developed in 1988 for preventing RSS. The aim of this study is to compare uRYGJ with RYGJ after laparoscopic distal gastrectomy in terms of incidence of RSS and gastric food stasis on postoperative endoscopic findings. Methods: Between January 2006 and June 2012, we performed 51 RYGJ and 268 uRYGJ procedures after laparoscopic distal gastrectomy. We defined RSS as follows: (1) the presence of symptoms such as nausea, vomiting, or abdominal fullness; and (2) refasting after starting semi-fluid or soft blended diet, or (3) readmission due to above symptoms within POD 15. The endoscopic findings at postoperative 1- and 3-years were reviewed by two experienced surgeons. Gastric residue, degree of gastritis, and bile reflux in the remnant stomach were evaluated according to ‘residue, gastritis, bile’ (RGB) classification. Results: The incidences of RSS were 5.9% in RYGJ group and 1.1% in uRYGJ group (P = 0.054). The only variable affecting the occurrence of RSS was the reconstruction type (OR 0.18, 95% CI 0.04 - 0.92, P = 0.040). According to the endoscopic findings at postoperative 1-year, severe food stasis (Grade 3 or more of residual food) was observed at a significantly higher rate in RYGJ group (44.4% vs. 10.3%, P \ 0.001), and the uRYGJ procedure was the independent negative predictive factor of severe food stasis at postoperative 1-year in the multivariable analysis (OR 0.2, 95% CI 0.09 - 0.44, P \ 0.001). At postoperative 3-years, the incidence of severe food stasis was higher in RYGJ group but not significantly (5/20 (25.0%) vs. 18/171 (10.5%), P = 0.079). Conclusions: Uncut RYGJ reconstruction was superior to RYGJ in terms of prevention of RSS and severe food stasis in the remnant stomach at postoperative 1-year. However, the difference of the Roux limb movement according to reconstruction types could decrease as time passed.

P143 - Gastroduodenal Diseases

P145 - Gastroduodenal Diseases

Feasibility of Laparoscopic Gastrectomy in Elderly Patient

Five Year Nutritional Outcomes of Patients with Gastric Cancer After Curative Gastrectomy

E. Tanaka, Y. Matsui, T. Okumoto, T. Murakami, A. Ikeda, S.Y. Yao, T. Harada Kobe City Medical Center West Hospital, KOBE CITY, Japan Back ground: With the progress in treatment of chronic diseases, the mean age of the Japanese population is rising, and there are more patients over 80 years old with gastric cancer who undergo surgery. In general, laparoscopic gastrectomy is widely performed due to better short-term outcome. Objective: In this study, we assess the feasibility of laparoscopic gastrectomy in elderly patient. Method: 17 patients over 80 years old with gastric cancer who underwent laparoscopic gastrectomy between January 2013 and July 2015 in our institution were analyzed retrospectively. Operation Method: All gastrectomy were performed with D1, D1 + , or D2 lymphadenectomy with partial omentectomy. Roux-enY reconstruction was the first-line option for distal gastrectomy until March 2015, whereas Bilroth 1 or Bilroth2 was the main method after April 2015. Roux-enY reconstruction was performed for all total gastrectomy, and double tract reconstruction was performed for proximal gastrectomy. Result: Of the 17 patients, 11 underwent Laparoscopic distal gastrectomy (LDG), 4 underwent total gastrectomy (LTG), and 2 underwent proximal gatrectomy (LPG). 15 patients (88%) had at least one serious systematic illness, and 11 patients (64%) had two or more. 5 patients (29%) have been treated for a different cancer in the past. Average operation time and blood loss was LDG:286 ± 42 min 120 ± 173 ml, LPG:324 min 151 ml?LTG:347 ± 119 min 75 ± 45 ml, respectively. 6 patients (35%) had complications grade 2 or worse of the Clavien-Dindo classification. Complications in 4 of those patients were Grade 3 or worse, including 2 cases of intra-abdominal abscess due to pancreatic fistula, and 2 cases of anastomotic leakage. Mortality was observed in 1 patient with a performance status of 4, who was admitted to the ER department for hemorrhage and poor nutrition. Discussion: Elderly patients inevitably have serious systematic illnesses, which requires surgeons to make careful decisions about the surgical strategy including the extent of lymphadenectomy. When a proper method is performed, laparoscopic gastrectomy can be effective in elderly patients.

123

K.H. Kim, D.J. Park, Y.S. Park, S.H. Ahn, D.J. Park, H.H. Kim, Y.T. Lee Seoul National University Bundang Hospital, SEONGNAM-SI, Republic of Korea Background: The long-term nutritional outcomes of patients with gastric cancer after curative gastrectomy are poorly understood. This retrospective cohort study examined the nutritional outcomes of these patients for 5 years after surgery. Methods: All consecutive patients who underwent radical gastrectomy with curative intent for gastric cancer in 2008–2009 and lacked recurrence were included. All were followed up for 5 years. Body weight, serum hemoglobin, . Results: The mean age of the 658 patients was 58.3 years. The male:female ratio was 1.8:1. Distal and total gastrectomy were performed in 569 (86.5%) and 89 (13.5%) patients, respectively, and 118 (17.9%) and 540 (82.1%) patients did and did not undergo adjuvant chemotherapy, respectively. Compared with the distal gastrectomy and no-chemotherapy groups, the total gastrectomy and chemotherapy groups had lower NRI values and malnutrition rates for 5 and 1 years after surgery (P0.05), respectively. They also had anemia significantly more frequently 5 and 1 years after surgery (P0.05), respectively. PNI did not associate with gastrectomy type or chemotherapy. Conclusions: Patients undergoing total gastrectomy or adjuvant chemotherapy after surgery should be closely monitored and appropriately treated for both malnutrition and anemia for 5 and 1 years after surgery, respectively.

Surg Endosc

P146 - Gastroduodenal Diseases

P148 - Gastroduodenal Diseases

Laparoscopic Assisted Gastrectomy in Elderly Versus NonElderly Patients with Gastric Cancer: a United Kingdom Center Experience

Laparoscopic Wedge Resection of Gastric Gastro Intestinal Stromal Tumor (Gist)

A. Tandon, I. Rajendran, M. Aziz, Q. Nunes, M. Shrotri

P. Gribnev, G. Velev, S.V. Shumarova, A. Koychev, K. Grozdev, K. Angelov, G. Todorov

Aintree University Hospital, LIVERPOOL, United Kingdom

University Hospital Aleksandrovska, SOFIA, Bulgaria

Aims: The elderly age group (EAG) accounts for more than 50% of gastric cancers (GC) in UK, however, evidence regarding surgical management of GC in this group is sparse. This study was designed to evaluate the outcomes following laparoscopic assisted gastric resections (LAGR) in the EAG. Methods: A retrospective review of the prospectively collected database from 2005 to 2015, including all curative LAGR. Age[70 were included in EAG. Length of stay (LOS), anastomotic leaks and in-hospital mortality were observed as primary outcomes. Continuous and categorical variables were analysed using Paired ‘t’ and Chi square test respectively. Long term outcomes were collected as recurrence and survival of patient. Results: A total of 60 patients were included, of which 39(65%) were included in EAG & 21(35%) in the control group (CG). The outcomes were comparable between the EAG & CG with no statistically significant difference in the median LOS (n = 16.6 vs. 16.3; p = 0.792), overall surgical complications (n = 8(20.5%) vs. 2(4.8%); p = 0.469), anastomotic leak (n = 5(12.8%) vs. 2(4.8%); p = 1.000), non-surgical complications (n = 4(10.2%) vs. 2(9.5%); p = 0.238) and in-hospital mortality (n = 3(7.7%) vs.0; p = 0.54) as well. There were 8 recurrences in CG and 2 in EAG (Mantel-Cox p = 0.002). There was no significant difference in survival between the two groups. (Mantel-Cox p = 0.619). Conclusions: This study emphasise the fact that, LAGR is safe to be offered to EAG as their outcomes are similar to the younger counterparts.

Aim: Laparoscopic resection of gastric gist is well established for the lesion, smaller than 2 cm./d. According to the National Comprehensive Cancer Network (NCCN) report from 2010, laparoscopic resection in gastric GIST, lesser than 5 cm./d is considered as therapeutic strategy. In our case the lesion was with diameter of 3,5 cm. and we present our result to discuss the efficiency and safety of the procedure. Case Presentation: A 69 years old female, admitted to the hospital with accidentally founded formation in the stomach during prophylactic sonography. On CT scan, the formation was with diameter of 3,5 cm./d., located in the greater curvature of the stomach, prepyloric area. Methods: 4 working trocars were used. One 10 cm. under umbilicus, one 12 mm. and two 5 mm. Intraoperative finding: the formation was visualized in the suspected area. Greater gastric curvature was mobilized. Wedge resection was performed, using two edno GIA staplers. Several sutures was placed for homeostasis.The tumor was placed in ednobag and was removed from umbilicus incision, enlarged by 2 cm. Results: Intraoperative blood loss was 50 ml. Operative time - 90 min. One drainage was pleased and removed on the next day. The patient was discharged on the 5th postoperative day.Pathological finding: macroscopically - tumor formation with diameter of 2,5 cm/d (after fixation). Microscopically: the tumor was located in the submucossa, without invasion in lamina muscularis and underlying structures. Clear resection margins (R0). GIST was identified by immunophenotypization: co - expression of CD 117 + low and membrane expression of CD34. Predominated spindle - sell histological type in 70% of the tumor tissue. Without vessel invasion and tumor necrosis. Mitosis n = 2/50 HPF, risk group by Miettinen - 0, WHO prognostic group 1. Conclusion: Laparoscopic resection in clear resection margins is an feasible and safety option for treatment of gastric GIST with low grade of malignancy. In such cases no lymph dissection is recommended. The advantages of the procedure are well known - fast recovery, early feeding and better cosmetic results.

P147 - Gastroduodenal Diseases

P149 - Gastroduodenal Diseases

Five Year Nutritional Outcomes of Patients with Gastric Cancer After Curative Gastrectomy

Meta-Analysis of Intra-Corporeal Or Extracorporeal Anastomosis After Laparoscopic Total Gastrectomy for Gastric Cancer; Which is Better?

H. Murase, M. Inokuchi, S. Otsuki, T. Tanioka, K. Okuno, K. Gokita, C.H. Tomii, T. Aburatani, T. Kawano, K. Kojima

A. Nguyen, Y.W. Kim

Tokyo Medical and Dental University, TOKYO, Japan

National Cancer Center, HO CHI MINH, Vietnam

Background: Laparoscopy-assisted gastrectomy (LG) has been established to be a minimally invasive treatment for early gastric cancer. However, few studies have shown the feasibility of LG in patients with risky comorbidities according to the American Society of Anesthesiologists physical status (ASA-PS) classification. We performed this retrospective cohort study to assess the feasibility of LG in patients with an ASA-PS class of 3 or higher. Methods: We retrospectively identified 214 patients with an ASA-PS class of 3 or 4 among 1,192 patients who underwent radical gastrectomy with lymph-node dissection between 1999 and 2014 in our hospital. Finally, 106 patients were generated by propensity-score matching between LG and open gastrectomy (OG). Postoperative complications were compared between LG and OG. Result: The overall incidence of complications was the same in LG (30%) and OG (30%). Surgical complications were similar in LG and OG (19% and 17%, p = 0.80). Medical complications also did not differ significantly between LG and OG (21% and 15%, p = 0.45). Conclusion: LG was a feasible procedure for patients with gastric cancer who had an ASAPS class of 3 or 4 and could undergo general anesthesia.

Background: Totally laparoscopic total gastrectomy (TLTG) is still uncommon because of the difficult of esophago-jejunostomy technique laparoscopically which almost depend on surgeon. Until now, the benefit as well as the reality of TLTG is under controversial. The aim of this study was to determine the useful extent of this procedure. Methods: The literature on comparative studies of TLTG versus LATG and TLTG versus OTG up to now were extensively retrieved from database PUBMED, Cochrane library, EMBASE. The operation times, blood loss, time to flatus, time to first oral intake, postoperative hospital stay, postoperative complications especially anastomosis leakage and anastomosis were analyzed. The statistical analysis was performed with STATAs 13.0 software Results: Fourteen studies met the inclusion criteria for meta-analysis. Five of them were comparison between TLTG and LATG, the remains of studies were comparison between TLTG and OTG. Odds ratios (ORs) and weighted mean differences (WMDs) were calculated with 95% confidence interval (CIs) to evaluate the effect of TLTG. Compare to two other treatments, TLTG experienced less blood loss [weighted mean difference (WMD) = 229.11 ml, 95% confidence interval (CI): -299.22,-158.99,P \ 0.01)], less time of postoperative hospital stay (WMD = -2.00,95% CI: -3.72,-0.28, P \ 0.01), less time to flatus (WMD = -0.75,95% CI: -1.3,-0.2, p \ 0.01), earlier beginning to take diet (WMD = 1.19,95% CI: -1.76,-0.61,P = 0.035), lower rates of postoperative overall complications (p \ 0.01). The operation time, the mean number of lymph nodes retrieved, anastomosisrelated morbidity were similar between two groups (P [ 0.05). Conclusion: Compared with LATG and OTG, TLTG can significantly reduce bleeding, time to first flatus, time to diet, postoperative hospital stay and rates of overall postoperative complications. Future studies should evaluate oncological outcomes with adequate longterm follow-up, preferably in randomized trials.

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Surg Endosc

P150 - Gastroduodenal Diseases

P152 - Gastroduodenal Diseases

Reduced Port Surgery Versus Conventional Laparoscopic Resection For Gastrointestinal Stromal Tumors of the Stomach: A Single Institute Experience

A Prospective Study Comparing Open Vs Laparoscopy-Assisted Distal Gastrectomy in Early Gastric Cancer And Recurrence Pattern of Early Gastric Cancer

T. Obuchi, K. Sato, R. Kawagishi, S. Kanno, H. Yonezawa, O.S. Funato, M. Ogawa, M. Kobayashi, A. Takagane

H.J. Choi1, S. Kim2, M. Ha2, J. Kim2, M. Choi2, J. Lee2, J. Bae3, S. Kim2, T. Sohn2

Hakodate Goryokaku Hospital, HOKKAIDO, HAKODATE-CITY, Japan

1

Aim: Although the feasibility of a laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been established, the literature comparing reduced port surgery (RPS), including single incision laparoscopic surgery (SILS), to conventional laparoscopic surgery (CLS) for the treatment of GISTs is limited. This study aimed to evaluate the feasibility and effectiveness of RPS compared to conventional laparoscopic resections for GIST. Methods: Between November 2010 and December 2015, 20 patients in our department underwent laparoscopic gastrectomy for GISTs. A retrospective study compared the benefits and outcomes of RPS and conventional laparoscopic partial gastrectomy for GISTs. Five experienced surgeons performed all of these operations. In the case of RPS (including the SILS technique), a multichannel port was inserted through a 2.5-cm umbilical incision, and the lesion was mobilized and staple-resected with endoscopic stapling devices. A 5-mm port in the left lower abdomen and/or epigastric lesion was also employed, as necessary. Results: Of the 20 patients, 14 were female (70%) and six were male (30%), and they had a mean age of 75.1 ± 7.6 years. RPS was performed on eight patients (including two SILS cases), whereas 12 patients had conventional laparoscopic resections. Compared with the CLS group, the median operative time for the RPS group was significantly longer (57.7 vs. 85.5 min, p = 0.002). No difference was seen in the median days to oral intake (2.0 vs 2.0 days, p = 0.999) and maximum tumor diameter (RPS group 30 mm vs. CLS group 32 mm, p = 0.395). However, the postoperative hospital stays for the RPS group were significantly shorter than for the CLS group (6.0 vs. 8.0 days, p = 0.01). No intraoperative or postoperative complications were recorded in either group. According to the mitotic index, one (5%) tumor was evaluated as very low risk, 12 (60%) tumors as low risk, and seven (35%) tumors as medium risk. At a mean follow-up at 25.4 months, all patients were on full regular diets without any gastrointestinal symptoms. All patients are alive without recurrence. Conclusion: Compared with the conventional laparoscopic procedure, RPS for GISTs is feasible and safe leads to shorter hospital stays, though it does result in a longer operative time.

Samsung medical center, SEOUL, Republic of Korea; 2Department of Surgery/Samsung Medical Center, SEOUL, Republic of Korea; 3 Samsung Medical Center, SEOUL, Republic of Korea Background: Early gastric cancer (EGC) has a good prognosis, but some patients experience disease recurrence after surgery. So this study was aimed at evaluating the recurrence rate, the recurrence patterns prognostic factors and open vs laparoscopic-assisted distal gastrectomy(LADG) of early gastric cancer patients. Methods: The clinical and pathological records of 8820 patients who underwent gastrectomy for solitary EGC between 1994 and 2014 at Samsung medical center, Seoul were examined. Results: 106 patients showed recurrences with 1.2% recurrence rate. 39 cases were locoregional recurrences, 19 were liver recurrences, 10 were lymph node recurrence, 25 were multiple recurrences. The recurrence of open gastrectomy vs LADG is 1.3% vs 0.5%. The recurrence of LADG is lower than open surgery but the difference was not statistically significant (p = 0.806). Age, sex, depth were related to the incidence of recurrence in Univariate analysis. Multivariate analysis which was performed with significant factors identified by univariate analysis demonstrated that old age (age [=65; RR:2.327, p \ 0.001) and sex (female; RR:0.33, P \ 0.001) were independent factor for recurrence. Conclusion: Although the recurrence of EGC is very rare in general, old age and male has a higher of EGC. Even after curative resection of EGC, old age and male patients should be closely followed. LADG for EGC is safe and not difference than recurrence of open surgery.

P151 - Gastroduodenal Diseases

P153 - Gastroduodenal Diseases

Intracorporeal Roux-En-Y Reconstruction After Laparoscopic Distal Gastrectomy

Outcomes of Laparoscopic Gastrectomies For Cancer in the Elderly

K. Kato, M. Nakagawa

J. Baanante1, D. Momblan1, M. Jimenez Toscano1, J. Ordon˜ez1, A. Ibarzabal1, R. Almenara1, S. Delgado1, A.M. Lacy2, B. De Lacy

Saitama Red Cross Hospital, SAITAMA, Japan In our department, we usually perform the Roux-en-Y reconstruction after laparoscopic distal gastrectomy under complete laparoscopic assistance. As the method of reconstruction, the ß reconstruction is performed in principle, and the overlap method is carried out depending on the situation. In this study, we report on the procedures and short-term results of the two reconstruction methods. Both reconstructions were performed through the antecolic route and in the isoperistaltic direction. In the ß reconstruction, a side-to-side anastomosis of the greater curvature of the remnant stomach and the jejunal loop is made with the linear stapler (LS). LS is inserted from the oral side toward the anal side of the remnant stomach and the jejunum. Then, closure of the open end and simultaneous division of the jejunum are made with another LS. The jejunojejunostomy is made intracorporeally or extracorporeally. In the overlap method, the jejunum is transected and the jejunojejunostomy is made extracorporeally by using the 4-cm umbilical incision. After reestablishing a pneumoperitoneum, gastrojejunostomy is made by LS inserted from the anal side toward the oral side. The entry hole of LS is closed with the barbed suture. From April 2014 to December 2015, 19 patients were performed the Roux-en-Y reconstruction after laparoscopic distal gastrectomy. The ß reconstruction was performed in 11 cases, and the overlap method was performed in 8 cases. Average reconstruction time was 39 min in the ß reconstruction, and 52 min in the overlap method. Postoperative complication occurred in 1 case, it was a delayed gastric emptying. No cases of anastomotic leakage and anastomotic stricture were noted in this study. The ß reconstruction and the overlap method are both useful as an intracorporeal reconstruction method after laparoscopic distal gastrectomy.

123

1

Hospital Clinic Barcelona, BARCELONA, Spain; 2COLOR II Study Group, Spain

Introduction: The longer life expectancy encourage us to perform demanding laparoscopic procedures in a fragile group of patient. The improvements of surgical approaches has improve our postoperative results. Nowadays the age is not anymore an exclusion criteria for oncological resection. We evaluate our results in the laparoscopic treatment of gastric cancer on elderly patients Materials and methods: This is a retrospective study of gastric cancer patients who undergone laparoscopic gastrectomy and lymphadenectomy at the Clinic Hospital In Barcelona. The postoperative outcome Complication, mortality, recurrences and survival- are evaluated. Possible risk factors for poor postoperative results or long term results are also evaluated. Results: We retrospectively analyze 67 patients over 75 years old (41, 10% of patients), of a total of 163 patients with laparoscopic gastric surgery from May 2006 to May 2015. The mean age was 80 years old (sd 4,01), with a male/female rate of 1, 48/1 and a Charlson Comorbidity Index of 6,9 (sd 1,4). Most of them were ASA II/III with a T3 gastric cancer. Half of them had a laparoscopic total gastrectomy. The procedure was achieved with curative intention in 68.7% of cases. In 43.3% (n: 34) cases a D1 lymphadenectomy were performed and in 50.7% (n: 34) a D2 lymphadenectomy. The mean operative time was 257, 9 min (mediana 270, RIQ 210-318) The median of hospital stay was 8,5 (RIQ 88, 7–16,5). The overall postoperative complications rate was 34,7%. In 20,9% (n:14) the complication was related with the surgical procedure. The mortality rate was 4,5%. The Charlson Index and ASA Score had significant relation with postoperative complications. The mean follow up was 32,6 months with a mean of survival of 21 month (1 month- 82 months). In the univariant and multivariant analisys we could not find any factor related with a worse survival in this group of patients except for the TNM stage, which was related, with a worse survival of our patients. Conclusions: The gastric cancer laparoscopic surgeries are feasible and safe in patients over 75 years old. The procedure could be successfully performed with an acceptable complication rate.

Surg Endosc

P154 - Gastroduodenal Diseases

P156 - Gastroduodenal Diseases

Totally Laparoscopic Gastrectomy for Gastric Cancer After Endoscopic Submucosal Dissection: A Propensity Score Matching Analysis

The Role of Laparoscopic Surgery in the Palliative Treatment of Gastric Cancer

Y. Ebihara1, S. Okushiba2, Y. Kurashima1, T. Noji1, S. Murakami1, T. Shichinohe1, S. Hirano1 1

Hokkaido University, SAPPORO, Japan; 2Tonan hospital, SAPPORO, Japan

Purpose: A recently developed endoscopic mucosal resection (EMR) procedure, endoscopic submucosal dissection (ESD), makes en-bloc resection possible for mucosal cancer regardless of lesion size. ESD involves deeper and wider dissection of the gastric wall, and may therefore increase the difficulty of subsequent totally laparoscopic gastrectomy (TLG) and the risk of complications. However, the influence of ESD on subsequent TLG has yet to be demonstrated. The purpose of the present study was to clarify the influence of ESD on subsequent TLG. Methods: Between March 2006 and December 2013, we retrospectively collected data of 38 patients undergoing TLG with ESD (ESD Group) and propensity score matched 38 patients undergone TLG without ESD (non-ESD Group) for treatment of gastric cancer at Tonan Hospital and Hokkaido University Hospital. The covariates for propensity score matching were: age, sex, American Society of Anesthesiologists score, body mass index, and type of surgery. Clinicopathologic characteristics and surgical outcomes were compared between the two groups. Results: Operative times for TLG in ESD group and non-ESD group were 228.2 ± 53.9 and 228.1 ± 52.7 min (P = 0.989), and blood loss was 45.7 ± 83.0, 71.3 ± 74.5 g, respectively (P = 0.161). There were no significant differences between the groups of ESD and non-ESD in postoperative recovery and postoperative complications. In totally laparoscopic distal gastrectomy (TLDG), the patients with ESD-resected specimens of more than 50 mm in diameter had significantly longer operative times (P = 0.009). Conclusions: In this study, TLG is feasible procedure treatment of gastric cancer regardless of ESD. However, TLDG is more difficult in cases where the ESD-resected specimen is more than 50 mm in diameter.

C.H. Kim, J.J. Kim Incheon St. Mary’s hospital, INCHEON, Republic of Korea Purpose: Recent improvement in the result of chemotherapy for stage IV gastric cancer patients prompt us to concern more about the quality of life of these patients. Many patients with stage IV gastric cancer suffer from symptoms of advanced disease like obstruction, bleeding and perforation. The goal of palliative treatment is effective alleviation of these symptom and improvement of quality of life of the patients with or without improvement in survival. The purpose of this study is to evaluate the usefulness of laparoscopic surgery in the palliative treatment for stage IV gastric cancer patients. Methods: Fifty patients of stage IV gastric cancer who underwent various types of laparoscopic surgery for symptoms of obstruction, bleeding between January 2010 and August 2014 at the Department of Surgery, The Catholic University of Korea were enrolled into this study. Demographics, surgical data, and follow up data were reviewed retrospectively. There were 36 men and 14 women and the mean age was 67.9 ± 12.7. Forty one patients underwent surgery for obstruction and 7 patients for bleeding and 2 patients for both. Results: There were 10 cases of palliative resection, 40 cases of bypass (39 gastrojejunal, 1 small bowel) and 1 case of feeding jejunostomy. The mean operation time was 84.3 ± 46.2 min (Palliative resection: 132.5 ± 55.7, bypass: 73.0 ± 35.1, jejunostomy:45). The mean time for oral intake was 3.06 ± 2.5 day and the mean postoperative hospital stay 12.5 ± 6.6 day. There were 9 cases (18%; resection 3 cases, bypass 6 cases) of postoperative complication, and there was no case of postoperative mortality. During the mean 21.4 ± 15.7 months of follow up, the patients could eat food until 8.3 ± 7.1 months and the mean survival time of the patients was 8.7 ± 7.2 months. Conclusions: Laparoscopic surgery can offer a good palliation of symptoms of obstruction and bleeding or both in stage IV gastric cancer patients. More study about the usefulness laparoscopic surgery in increasing the quality of life of these patients is warranted.

P155 - Gastroduodenal Diseases

P157 - Gastroduodenal Diseases

Safety and Feasibility of Intracorporeal Anastomosis Using Linear Staplers During Minimally Invasive Total Gastrectomy

Clinical Results of Endoscopic Submucosal Dissection Treatment for Stomach

K. Obama, K. Matsuo, T. Ito, K. Kubota, H. Inoue, T. Sato, K. Kami, N. Tamaki, N. Yoshimura, T. Shono, E. Yamamoto, T. Morimoto

T. Suwa, S. Inose, K. Kitamura, T. Matsumura, E. Totsuka, M. Koyama, K. Karikomi, K. Okada, N. Nakamura, S. Masamura, S. Akiyama, T. Tanihira, M. Takagi, M. Kawai, S. Kobayahi

Kyoto City Hospital, KYOTO, Japan Aims: Minimally invasive total gastrectomy (laparoscopic (LTG) and/or robotic (RTG)) for gastric cancer has been gradually spreading worldwide, especially in Eastern Asia and Europe. However, this procedure has yet to become commonly established because radical lymph node dissection and intracorporeal reconstruction are considered technically demanding. We adopted a simple and safe Roux-en Y reconstruction method using linear staplers (LS) after LTG and RTG. The aim of this study is to evaluate the safety and feasibility of this reconstruction procedure following minimally invasive TG. Methods: Roux-en Y reconstruction procedures: First, the esophagus is transected while being rotated 45counterclockwise. After creation of the Y-anastomosis intracorporeally, the jejunal limb is brought up via the antecolic route and the left dorsal side of the esophagus and the jejunal limb are anastomosed using LS (functional end-to-end anastomosis). After the entry hole is roughly closed by intracorporeal sutures, closure is completed by application of LS. We evaluated the short-term outcomes of these patients who were reconstructed with this procedure. Results: Since our introduction of minimally invasive TG in April 2013, we have applied this reconstruction procedure for 27 gastric cancer patients (LTG:20, RTG:7). Clinical stages of the patients were as follows: cStage I: 15, II: 3, III:8, IV:1. There were three (11%) postoperative complications (pneumonia, intraabdominal abscess, and jejunal limb obstruction due to bending). All 3 patients with postoperative complications were treated with conservative therapy and recovered well (Clavien-Dindo classification Grade 2). We have encountered 1 (3.7%) intraoperative complication: 7 cm incision was necessary to control intraoperative bleeding from splenic vein. There was no mortality. Conclusion: Our Roux-en Y reconstruction using LS is considered feasible and safe, even though the number of patients were limited in this study. Especially in RTG, by virtue of the stability of both the robotic instruments and powered linear staplers, it was possible to completely avoid involuntary tremors and make esophagojejunal anastomosis in RTG safer and more feasible. We herein report the details and ingenuity of our intracorporeal reconstruction procedures after minimally invasive TG using LS.

KASHIWA KOUSEI GENERAL HOSPITAL, KASHIWA, CHIBA, Japan Introduction: We hereby report our clinical results of ESD treatment including complication ratio and frequency in cancer recurrence in Kashiwa Kousei General Hospital. Our Clinical Indication for ESD ESD treatment was performed for gastric cancer if the lesion was within the absolute indication and parts of expanded indication in Japanese gastric cancer treatment guidelines 2010 (ver. 3). ESD treatment was also performed for gastric adenoma if patients desired. Examination Object One hundred and thirty-nine cases from April 2009 until December 2015 in Kashiwa Kousei General Hospital were treated by ESD. The average age was 72.0 and 95 cases were male and 44 cases were female. One hundred and nine cases were gastric cancer and 30 cases were gastric adenoma. Clinical Results: We had a case of re-bleeding and 3 cases of stomach perforation. No case needed emergency laparotomy. In 109 cases of gastric cancer, 105 cases were judged as curative resection and 4 cases were judged as non-curative resection. Three cases in 4 noncurative cases were by the pathological reason of ly (+) and radical laparoscopic gastrectomy with lymph-nodes dissection was performed in these 3 cases, it revealed no residual cancer in all cases. One non-curative case had pHM1 and severe surveillance was performed for 3 years and this case had no tumor recurrence until today. One curative case had tumor recurrence at the initial tumor site 29 months after ESD and radical laparoscopic gastrectomy with lymph-nodes dissection was performed. The pathological results in the case revealed the similar well differentiated adenocarcinoma with no lymph-nodes metastasis (pT1a, ly0, v0). All the other ESD cases had no tumor recurrence at the initial tumor site. In all the cases of gastric adenoma ESD was successfully performed with surgical margin negative for tumor, but 3 cases were finally diagnosed as gastric carcinoma (10%). Conclusion: ESD is a feasible treatment procedure for gastric cancer with no loss of stomach volume and QOL. The complication frequency is low enough. Overall results of ESD are good so far.

123

Surg Endosc

P158 - Gastroduodenal Diseases

P160 - Gastroduodenal Diseases

Short-Term outcomes of Esophagojejunostomy After Totally Laparoscopic Total Gastrectomy Using a Trans-Orally Inserted Anvil: A Matched-Cohort Study

Comparison of Totally Laparoscopic Distal Gastrectomy with Intracorporial Anastomosis and Conventional LaparoscopicAssisted Distal Gastrectomy

K. Jun

O. Uyanik, C. Balague Ponz, I. Gomez Torres, S. Fernandez Ananin, V. Turrado Rodriguez, M.C. Martinez Sanchez, M.P. Hernandez Casanovas, J. Bollo Rodriguez, E.M. Targarona Soler, M. Trias Folch

St. Vincent’s Hospital, The Catholic University of Korea, SUWON, Republic of Korea Esophagojejunostomy using circular stapler in laparoscopic total gastrectomy can be performed extracorporeally or intracorporeally. This study was designed to compare short-term intracorporeal esophagojejunostomy (IEJ) with extracorporeal esophagojejunostomy (EEJ) outcomes after laparoscopic total gastrectomy. In the present study, we examined 40 patients with gastric cancer who underwent esophagojejunostomy using a circular stapler after total gastrectomy. Data on the clinocopathological features, operative time, amount of intraoperative blood loss, and incidence of anastomosis-related complications among the surgical groups were obtained by reviewing the medical records, which were then analyzed. The two groups were comparable in clinical and pathological characteristics. Although the operation time was not shorter for IEJ, the time required for esophagojejunostomy was significantly shorter in IEJ than in EEJ (34 vs 14 min, P \ 0.05). Leakage following esophagojejunostomy was noted in 1 of 20 patients who underwent IEJ, and 0 of 20 patients who underwent EEJ. No significant difference was noted in the incidence of stenosis, as a complication of esophagojejunostomy between the two groups. This study suggests that esophagojejunostomy using a trans-orally inserted anvil after laparoscopic total gastrectomy for gastric cancer is a safe and useful surgical procedure.

Hospital de Santa Creu i Sant Pau, BARCELONA, Spain Aim: Compare the effects of totally laparoscopic distal gastrectomy with intracorporial anastomosis and conventional laparoscopic-assisted distal gastrectomy in gastric cancer. Methods: Retrospective analysis of prospectively registered data of 31 patients who underwent laparoscopic distal gastrectomy with intracorporial anastomosis (LDGIA) and 26 patients who underwent laparoscopic-assisted distal gastrectomy with conventional gastro-jejunal anastomosis (LADGC) for gastric cancer in a single institution between January 2010 and January 2014. The clinicopathologic characteristics, operative time, intraoperative blood loss, post-operative hospital stay, incidence of complications and survival were compared between the groups. Results: Compared with LADGC, LDGIA had less intra-operative blood loss (87.1 ± 104.8 ml vs 192.3 ± 207 ml, p \ 0.05), shorter post-operative hospital stay (10.2 ± 6.3 vs 16.6 ± 9.8 days, p \ 0.05) and less incidence of anastomosis leak (0% vs % 11.2, p \ 0.05). There was no significant difference with respect to operative time, surgical margin achieved, number of extracted lymph nodes, incidence of local and systemic relapse or post-operative survival time. Conclusions: Intracorporial anastomosis in spite of its higher learning curve seems to be safe and associated with less post-operative complications and faster recovery. According these results we can suggest that the use of fast-tract protocols may be more convenient with intracorporial anastomosis in laparoscopic distal gastrectomy.

P159 - Gastroduodenal Diseases

P161 - Gastroduodenal Diseases

Monocentric Experience of Robotic Resection of Large and Critically Located Gastric Gastrointestinal Stromal Tumours

Laparoscopic Gastrectomy for Gastric Cancer: A Single Institution Review Over 5 Years Period

F. Borghi, A. Marano, L. Pellegrino, P. Geretto, A. Ferrarese

M. Jimenez Toscano1, D. Momblan1, J. Baanante1, J. Ordon˜ez1, J.J. Espert1, S. Delgado1, B. De Lacy, A.M. Lacy2

ASO S. Croce e Carle, CUNEO, Italy Aims: Laparoscopy showed to be safe and feasible for the treatment of primary and localized gastric gastrointestinal stromal tumors (GISTs). However, large GISTs or GISTs located in difficult anatomical sites can be challenging to manipulate and to remove laparoscopically, especially when a resection, rather than a gastrectomy is planned. In order to overcome some limitation of the laparoscopic approach, the robotic technique has been introduced. The aim of this study is to present our experiences about the application of robotic platform for large and unfavorable gastric GISTs. Methods: Between October 2014 and January 2016, 9 consecutive patients with large or unfavorable located resectable gastric GISTs underwent full robotic resection. Clinicopathologic characteristics and surgical outcomes were prospectively collected and analysed. Results: Lesions were localized at the sub-cardial region (N = 5), gastric body (N = 3) and near the pre-pyloric area (N = 1), respectively. Full robotic gastric resection was carried out using monopolar energy and hand sewn suture. No conversion, tumor rupture or perioperative complications have been registered. Mean tumor size was 67.6 mm (range, 32–110). A complete R0 resection has been achieved, in each case and at a mean follow-up time of 9 months, disease-free survival rate is 100%. Conclusion: (s)Our experience confirms that robotic approach for gastric GISTs is oncologically safe and feasible, especially for large and unfavourable lesions and when a resection, rather than a gastrectomy is planned.

123

1 Hospital Clinic Barcelona, BARCELONA, Spain; 2COLOR II Study Group, Spain

Introduction: The laparoscopic gastrectomy for gastric cancer has became more popular in the last decade. Its safety and feasibility has been demonstrated in randomized trials with good outcomes when comparing with open approach. The aim of this study is to evaluate the outcomes of our center in five years period. Method: A single institution prospective study was conducted. Patinets with gastric cancer from 2010 to 2015 wer included in a prospective database and the epidemiological data, preoperative study, surgical technique, postoperative outcomes and short and mid term results were recorded and analyzed. Results: 85 consecutive patients were evaluated. 68,2% were males with a mean age of 70,17 years (30-95 sd 13,34), a mean BMI 25,6 (sd 4,69) and a mean Charlson index of 4,67 (sd 2,074). In the TNM score, 25,8% had a T2, 43,5% a T3 and 8,1%a T4 with a 38,2% of positive lymph nodes. In 73,4% of cases the procedure was curative, requiring a total gastrectomy in 71,3%. The resection was R0 in 92% of cases and the lymphadenectomy performed was a D2 in 66,7% and a D1 or D1 + in 26,9%. 15% of cases were converted to laparotomy, mainly secondary to technical difficulties. 5 cases requiered reintervention. On the postoperative periods the complications related with surgery were 8 patients with leakage (7,8% duodenal stump and 3,9% esophagojejunal anastomosis), 5 patients with intrabdominal collection and 1 patient with pancreatic fistula. There were 2 deaths postoperatively. The mean follow-up of these group of patients was 18,18 months (minime 1-maxime 66 months). The mean time of recurrence was 12 months (minim 2-maxime 30 months). The recurrence ocurred in twelve patients. 15 patients die during the follow up, four of them without non related with the oncological pathology. There were not any differency in any item in eldery patients over 75 years all. Conclusion: Gastric laparoscopy is feasable and safe from surgical and oncological point of view with an aceptable postoperative morbidity

Surg Endosc

P162 - Gastroduodenal Diseases

P164 - Gastroduodenal Diseases

Laparoscopic Excision of Benign Gastric and Duodenal Tumors 1

2

1

1

I. Ivanovs , D. Zabrodins , G. Pupelis , A. Rudzats , M. Mukans

1

1

Riga East Clinical University Hospital Gaileres, RIGA, Latvia; 2 Latvian University, RIGA, Latvia

Evolution of Surgical Management of Gastric Gastrointestinal Stromal Tumours - A 12 Year Experience W.D. Clements1, J.M. Clements1, C. Mcilmunn2, R.P.G. Kennedy2, J.A. Kennedy2, P.D. Carey2 1

Aim of the study was to evaluate the feasibility of laparoscopic excision of benign gastric and duodenal tumors in emergently admitted patients from the view of operative and longterm oncological outcomes. Methods: Retrospective assessment of the outcomes after laparoscopic resection of the gastric and duodenal tumors performed in the index hospitalization in patients who were admitted with upper gastrointestinal bleeding or tumor were diagnosed during the other acute laparoscopic intervention during the period form 2013 till 2015. Results: Totally were operated 8 patients (males n = 3; females n = 5) with a median age of 71 year (range 66–78). The tumors were located at the cardia (n = 1), corpus (n = 2), antral part (n = 2) of the stomach and in the duodenum (n = 2). Mean size of the tumor was 2 cm (IQR = 5,5–1,5). In 5 cases there was bleeding from the tumor, in 3 cases it was an incidental finding during the other laparoscopic operation. Intraoperative ultrasound was used to identify tumor localization in four patients, combined endoscopy and ultrasound was used in two cases, only laparoscopic identification was in two patients. Wedge resection of the wall with tumor was performed in six cases, Billroth I resection was used in two cases. All lesions had negative resection margins. There was no need in conversion. The mean operative time was 130 min (IQR = 157,5–117,5). The defect was closed by one layer sewing technique (n = 6), linear stapler (n = 1) and both methods (n = 1). There were no postoperative complications. Wounds healed primary. The mean length of hospitalization was 5 days (IQR = 6–3, 5). Histological findings were: GIST (n = 3), ectopic pancreatic tissue (n = 2), angioleiomioma (n = 1), hyperplastic polyp (n = 1), fibrous nodules with myxomatous stroma (n = 1). Phone follow-up was up to 2 years postoperatively. All patients were satisfied with operation outcomes and esthetical results, there was no recurrence. Conclusion: Laparoscopic resection and one layer sewing technique is a safe and effective method in treating benign gastric and duodenal tumors characterised by low complication rate and shorter hospital stay. It could be recommended as a treatment of choice for patients with small benign gastric and duodenal tumors.

P163 - Gastroduodenal Diseases Long-Term Results of Minimally Invasive Laparoscopic Surgery And Open Suturing of Perforated Duodenal Ulcers E.N. Shepetko1, Y.U.V. Grubnik2, D.A. Strumensky3 1

National Medical University O.O.Bohomolets, KIEV, Ukraine; Odessa National Medical University, ODESSA, Ukraine; 3 Bohomolets National Medical University, KIEV, Ukraine

BELFAST HEALTH & SOCIAL CARE TRUST, MOIRA, United Kingdom; 2UGI Unit Belfast, BELFAST, United Kingdom The term ‘GIST’ was first coined in 1983. Subsequently a considerable body of evidence has fuelled the development of structured surgical ‘GIST guidelines’. Complemented by the advent of Speciality multi-disciplinary team (MDT) meetings patients are now receiving individualised multimodal treatment strategies. Aim: We sought to identify surgical trends in the management of gastric GIST’s before and after the formation of a Regional Upper Gastrointestinal [UGI] Unit with Departmental MDT (2012). Method: A retrospective casenote review was carried out between 1st January 2004 and 31st December 2015 on all primary gastric GIST’s. Primary GIST’s arising in other anatomical sites, recurrent disease and small incidental GIST’s were excluded. The primary outcome measure was mode of surgical resection. Secondary outcomes included GIST dimensions, pathological demographic and oncological input. Results: 60 primary Gastric GISTs were identified and sub divided into 2 cohorts (Pre MDT [n = 33] and Post MDT 2012 [n = 27]). There was no sexual preponderance (M34:F26). The median age at presentation was 68 years (range 22-89 years). All surgical resections were R0 (Open - 29: Laparoscopic - 29: Laparoscopic converted to Open - 2). Pre MDT 33% [10] patients were treated laparoscopically as compared with 70% [19] post MDT. The MMD of those resected laparoscopically was significantly greater post MDT [53.4 vs 40.8 mm p \ 0.05 students t test]. There was no significant difference in the use of Imatinib - adjuvant [18% pre MDT 19% post MDT] or neo-adjuvant [9% pre MDT 4% post MDT]. Conclusion: These data demonstrate a change in the referral practice and surgical management of gastric GIST’s. Since the inauguration of the UGI Regional Unit with dedicated MDT there has been 60% increase in patients referred with a trend towards laparoscopic resection. 70% of this cohort of patients underwent a safe and complete oncological resection laparoscopically. MMD - Mean Maximal Diameter

P165 - Gastroduodenal Diseases Laparoscopic Gastrectomy for Advanced Gastric Cancer -Our Standardized Concept for LymphadenectomyN. Inaki, T. Tsuji, Y. Sakimura, H. Tawara, T. Okude, R. Matsui, D. Yamamoto, H. Kitamura, N. Ota, M. Kurokawa, H. Bando, T. Yamada

2

Aims: Current trends in the treatment of perforated duodenal ulcers accompanied characterized by extensive use of minimally invasive laparoscopic surgery. Methods: Results of surgical treatment of perforated duodenal ulcers 251 patients with open palliative operations (suturing, isolated duodeno- and pyloroplasty) and 20 cases of laparoscopic suturing perforations. 167 cases after palliative operations allocated to a group of 23 patients with open suturing perforated compared with 20 cases of laparoscopic suturing duodenal perforation. Results: Laparoscopic surgery provide the best long-term results compared with the operations of the ‘simple’ suturing of perforated ulcer: a group of minimally invasive techniques in the frequency Visick I-II compared to the ‘simple’ suturing increases from 26% to 60% (2,3 times, p = 0, 0518), and the frequency of recurrences of ulcers decreased from 60,9% to 10% (6 times, p = 0,0018). Minimally invasive intervention duration not worse to traditional methods, the duration of use of painkillers decrease in two times, hospital stay is reduced by 2,7 times, followed by a more rapid social rehabilitation of the patients and the best indicators of the physical and psychological health. Conclusion: The use of laparoscopic suturing perforated ulcers should be limited to strict conditions.

Ishikawa Prefectural Central Hospital, KANAZAWA, Japan Background: There are still important technical issues when dealing with advanced gastric cancer in laparoscopic procedure. Its technical knack was demonstrated and the clinical result was evaluated. Surgical technique: Our D2 lymph node dissection as a golden standard for gastric cancer treatment in LG is demonstrated focusing how to make an operating field against the bulky lymph node and the tumor. Gauze is frequently used to retract or lift up stomach, and to absorb bleeding or lymphatic fluid, respecting oncological treatment. This gauze retraction technique can make wide and dry field. Main energy dissector is ultrasonically activated device (USAD). Bipolar electric device (Bi-ClampTM) is also used not only for hemostasis but also vessel sealing, which contributes for dry field even for fatty patients. Using the gauze retraction technique and hemostatic device, we can realize sure lymphadenectomy along the hepatic and splenic artery as a D2 lymph node dissection. In principle, we dissect lymph node tissue just along the neural layer surrounding artery, which we call ‘out-most layer’. Traction by both forceps of assistant is very important to keep the out-most layer. The traction consists of the grasping of gastro-splenic mesentery by assistant’s right forceps and the rolling down of pancreatic body by assistant’s left forceps. Results: In total, 150 patients underwent laparoscopic gastrectomy with D2 lymphadenectomy. Regarding the complication, the rate of either anastomotic leakage or pancreatic fistula was 4% (6/150). The grade 3 or higher morbidity rate, including systemic and local complications, was 5.2%. The post-operative mortality rate was 0. Conclusion: An adequate use of energy devices and knowledge of anatomical out-most layer is important to achieve laparoscopic D2 lymph node dissection for advanced gastric cancer. Its clinical results were acceptable and valid long-term outcome can be expected.

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Surg Endosc

P166 - Gastroduodenal Diseases

P168 - Gastroduodenal Diseases

Learning curve For Pure Single Port Laparoscopic Distal Gastrectomy for Gastric Cancer

Divergence in the Management of Acute Diverticulitis

S.H. Ahn, B. Lee, D.J. Park, H.H. Kim Seoul National University Bundang Hospital, SEONGNAM, Republic of Korea Background: A recent study reveals that pure single port laparoscopic distal gastrectomy (SDG) is safe and feasibility comparing its short-term outcomes with those of conventional multiport totally laparoscopic distal gastrectomy (TLDG). However, there have been few reports on SGD because of its technical difficulty. The purpose of this study is to identify with learning curve of pure SDG. Methods: This is a single-center study using prospectively collected data from 55 consecutive cases who underwent SDG between October 2012 and December 2014. All operations were performed by as single surgeon who had performed more than 100 cases of laparoscopic distal gastrectomy(LDG) before starting single port surgery. The mean operating time, estimated blood loss, mean hospital stay, and retrieved number of pathologic LN compared with the phases of the learning curve. The learning curve was defined using the moving average method. Results: The mean operating time of the fist 2 group (20 cases (the learning period)) was 158.75 min. After 20 operations (the experience period), the mean operation time was 143.92 min, which remained steady in the next group. Mean EBL were 66.9 and 34.71 ml, respectively (P = 0.001). There were no differences in the other factors between two periods. Conclusion: The learning curve of SDG for a surgeon who exceeds the learning curve of conventional LDG seems to require approximately experience with 20 cases of SDG.

V. Shanmugam, B. Aygun Darlington Memorial Hospital, DARLINGTON, United Kingdom Background: Diverticulosis is considered to be the disease of the modern Western World and contributes significantly to emergency workload, yet, there is variability in management and there are few guidelines available. National Complicated Acute Diverticulitis Audit (CADS) was established to generate evidence to streamline the management and was established to recruit data for and according to standards of CADS applicable to our trust hospital. Methods: Prospective observational audit from November 2015 to January 2016. Patients with admission diagnosis of query acute diverticulitis or complications and relevant data within 30 day follow-up including details of complications, readmission and mortality rates. Results: Nineteen (42%) of the total 40 patients (mean age of 68, 27 female) recruited were diagnosed with acute diverticulitis/related complications. Not all had CT imaging and antibiotics choices were variable. There were 5 re-admissions; 2 due to missed diagnosis at previous admission, 1 after conservative management with radiological intervention, 1 recurrent attack and 1 post-operative complication. 30-day mortality was 2 (5%), one related to diverticulitis. Patients without history of diverticulosis were more likely to get imaging (n = 16, 40%). Discussion: Less than 50% admitted with clinical diagnosis of diverticular-related pathology had acute diverticulitis or related complications. Most patients (n = 31) had gold standard imaging (CT). Surgery was performed based on CT scan showing complications. Twelve (30%) were given empirical intravenous antibiotics without diverticulitis. These findings highlight the necessity for a common guideline to avoid inconsistency in the disease management.

P167 - Gastroduodenal Diseases

P169 - Gynaecology

Eptfe Serosal Patch to Close the Duodenal Ulcer Perforation

Laparoscopic Surgical Intervention During Pregnancy, is the Keyhole Approach Safe?

N. Ozlem1, H. Calis2 1

This work was supported by the AhiEevran University,, KIRSEHIR, Turkey; 2Ahievran University, KIRSEHIR, Turkey

The diameter of perforation in DU may vary, 0.2–0.3 cm to a 2–5 cm. However simple closure may be achieved with a few interrupted sutures and omental or round ligamant patch or by suture closure reinforced with omentum. Care must be taken to avoid obstruction of the duodenoum with suture. In certain instances more radical operation is necessary such cases are a giant perforation that can not be closed by sutured,a large posterior ulcer,a perforated ulcer on anterior wall or the perforation accompanied by profuse bleeding for patients with preoperative shock, perforation exceeding 48 h and coexistent medical problems. Unless operating conditions are optimal the surgeon must choose a simple closure of a perforation as a life saving method. In these challenge circumstances the hole of the perforation may be closed with a 1 mm thick eptfe serosal patch.We studied 235 consecutive patients who had undergone surgery at our hospital forDUulcer perforation for last five years. We selected randomly 14 of these patients who taken informed consent to suture their DU perforation holes over a patch, 1 mm thick eptfe serosal one (gore tex w.l. gore and assoc flagstaff arizona) with laparoscopy. the median/ mean age, perforation hole and serosal patch diameter, perforation location, suture line leak, peritonitis, LOS of both groups of the patient were assesed. These patients treated with serozal patch to close their perforation and undertook an upper endoscopic examination for evaluation of ulcer base regeneration every two weeks for six weeks if there is any difference of the patch or above parameters. this examination showed the covering of the ulcer base started from edges to central bare area and no luminal stenosis.Eptfe serosal patch may be used to close the DU perforation especially when ulcer diameter is in large, may be avoid the obstruction of the duodenoum with suture. This patch may be used for large posterior ulcer a perforated ulcer on anterior Wall or perforation accompanied by profuse bleeding or to treat the patients with preoparative shock or perforation excedding 48 h and significant coexistent medical problems.

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L. Swafe, A. El-Hadi, J. Barwell, S. Brown, S. Wilson, A. Sudlow Norfolk and Norwich University Hospital, NORWICH, United Kingdom Introduction: Performing a laparoscopic procedure during pregnancy remains debatable and surrounded by challenges. It is estimated that approximately 1 in 500–700 women will require non-obstetrical abdominal surgery during their pregnancies. Anatomicaland physiological changes in pregnancy make the diagnosis challenging and can often lead to delays in treatment. Laparoscopy used to be considered a contraindication during pregnancy in its early days and has now become a veryacceptable approach to most surgeons if not the preferred one. We aimed to evaluate the safety of laparoscopic procedures during pregnancy in our institute with an ultimate goal to identify areas for improvement. Methods: All pregnant patients undergoing a laparoscopic non-obstetric surgical procedure over the last 15 years in our institute were included. These patients were identified using the hospital coding system in addition to the operating theatre database. Data collected was collected from inpatient records, operation notes, Pathology results and obstetric records. The data was thenanalysed using Microsoft Excel. Results: 29 cases were included (Mean Age 27.8) who underwent a Laparoscopic appendicectomy (n-22), laparoscopic cholecystectomy (n = 5) and normal laparoscopy (n = 2). There was one case of miscarriage that happened 6 weeks after a laparoscopic appendicectomy. No patients underwent delivery in the month following surgery. One patient had a major complication (intra-abdominal abscess treated with a laparotomy). 6 patients (20%) delivered before term (\37 weeks). Mean Length of stay was 5.5 days. No complications such as uterine injury or maternal mortality were encountered in our study population. The mean operating time was 56 min and the average birth weight was 3.02 kg. 21 (68%) procedures were performed by trainees. Conclusion: Our study suggests that it is safe to perform laparoscopic procedures during all trimesters of pregnancy. It shows no foetal loss within the first 6 weeks following surgery. It also suggests that these procedures could be safely carried outby trainees.

Surg Endosc

P170 - Gynaecology

P172 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Burch Colposuspension

Robot-Assisted Sacrocolporectopexy for Multi-Compartment Prolapse; A Prospective Cohort Study Evaluating Functional and Sexual Outcome

D.E. Georgescu, E.L. Catrina, T. Patrascu Cantacuzino Clinical Hospital Bucuresti, BUCHAREST, Romania Background: Retropubic Burch colposuspension has been considered by many to be the ‘gold standard’ procedure for treatment of female stress urinary incontinence for almost 50 years. The firs reported retropubic surgery performed laparoscopically was described 1991. Laparoscopic Burch colposuspension is an effective treatment for stress urinary incontinence and is equivalent to open Burch colposuspension, randomized trials have not not being able to identify any significant difference between the two procedures with respect to subjective or objective cure rates. No difference in subjective cure rates has been identified in comparison with tension-free slings; however, objective cure rates favor tension-free slings. We herein present a series of cases of stress urinary incontinence managed by laparoscopic Burch colposuspension, the postoperative long term evolution being favourable in all cases. Laparocopy allowed not only an efficient therapeutic solution, but also an exploratory and diagnostic method in some cases. Conclusion: We believe that laparoscopic Burch colposuspension can be a procedure of choice, with good results, which can also avoid the potential complications of mesh. More research is though indicated. Keywords: Burch, incontinence, colposuspension, laparoscopy

J.J. van Iersel, C.J. de Witte, P.M. Verheijen, I.A.M.J. Broeders, E. Lenters, E.C.J. Consten, S.E. Schraffordt Koops Meander Medisch Centrum, AMERSFOORT, The Netherlands Background: Pelvic floor disorders are a major public health issue. For genital prolapse sacrocolpopexy is the golden standard. Laparoscopic ventral mesh rectopexy is a relatively new promising technique correcting rectal prolapse. There is no literature combining the two techniques robotically-assisted. This study aims to prospectively assess safety, quality of life, functional and sexual outcomes of robot-assisted sacrocolporectopexy (RSCR) for multi-compartment prolapse of the pelvic floor. Methods: All sexually active patients undergoing RSCR between 2012 and 2014 were prospectively enrolled. Pre- and postoperative (12 months) questionnaires using the Urinary Distress Inventory (UDI-6), Pescatori Incontinence Scale, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and Pelvic Floor Impact Questionnaire (PFIQ-7) were completed. In addition Wexner and Vaizey Incontinence scores and the Wexner Constipation score were recorded at one year follow-up. Results: 51 patients with a median follow-up of 12.5 months underwent RSCR. One (2%) patient developed a mesh related complication (erosion). The simplified Pelvic Organ Prolapse Quantification (POPQ) improved significantly (p \ 0.0005) for all four anatomic landmarks. Both median fecal (pre- and postoperative Pescatori 4 vs. 3, p = 0.002) and urinary incontinence (UDI score 28 vs. 22, p \ 0.0005) scores improved significantly at 12 months. In addition, acceptable median Wexner (3) and Vaizey incontinence (6) and Wexner Constipation (7) scores were noted postoperatively. A positive effect on sexual function (PISQ-12 score 32 vs. 37, p 0.002) and quality of life for each compartment (p \ 0.0005) was observed. There were no multi-compartment recurrences. Conclusions: RSCR is a safe and effective technique for multi-compartment prolapse in terms of functional outcome, quality of life and sexual function.

P171 - Intestinal, Colorectal and Anal Disorders

P173 - Intestinal, Colorectal and Anal Disorders

Single Port Surgery with Complete Mesocolic Excison for Colon Cancer

Prospective Comparison of Dynamic Mr Defecography with Rectal Evacuation and Conventional Defecography for Prolapse of the Posterior Compartment

M. Fukunaga Juntendo University Urayasu Hospital, URAYASU, Japan Background: Single port surgery has rapidly gained popularity recent years. The aim of this study is to evaluate our short and long time outcomes of single port surgery with complete mesocolic excison for colon cancer (SPS-CME). Methods: Between April 2009 and December 2015, 179 consecutive patients underwent SPS-CME. The multi-trocar platform were placed in the umbilical site. The origin of the main mesenteric vascular pedicles was initially dissected and complete mesocolic excison was resected completely. Anastomosis was performed using double stapling technique intracorporeally for sigmoid cancer. Meanwhile for other part of colon cancer, anastomosis was achieved a functional end to end anastomosis extracorporeally. Results: Tumor was located in cecum in 52, ascending colon in 34, transverse colon in 4, descending colon in 7, sigmoid colon in 82. TNM stage was 0-I in 55, IIA in 49, IIB in 3, IIC in 2, IIIA in 12, IIIB in 42, IIIC in 10 and IV in 6 patients. There were 89 men (49.7%) and 90 women (50.3%) in this study; the mean age was 65.7 years and the mean BMI was 22.7. The mean operating time was 149 ± 43 min. The mean bleeding volume was 22 ± 10 ml. One patient (0.56%) was converted to the multi-port method due to severe adhesion. +1 port technique was used in 3 severe adhesion cases (1.68%). There was no mortality and no major postoperative complications such as anastomotic leakage. Postoperative morbidity rates were 2.8%. The number of harvested lymph nodes was 25 ± 6. The mean tumor-free resection margin was 11.7 ± 4.4 cm. The mean follow-up periods were 40 ± 19 months. The 5-year overall survival rates in stage 0-III were 95.4%, 100% in Stage I, 100% in Stage II, 90% in Stage III, and the 5-year relapse-free survival rates in stage 0-III were 94.6%, 100% in Stage I, 100% in Stage II, 83.3% in Stage III, respectively. Conclusion: Our study indicates SPS-CME is feasible in both short and long term outcomes for selected patients with colon cancer.

J.J. van Iersel1, H.A. Formijne Jonkers1, P.M. Verheijen1, I.A.M.J. Broeders1, B.G.F. Heggelman1, J.J. Fu¨tterer2, I. Somers1, M. van der Leest2, E.C.J. Consten1 1

Meander Medisch Centrum, AMERSFOORT, The Netherlands; Radboud University Medical Centre, NIJMEGEN, The Netherlands

2

Aim: To compare the diagnostic capabilities of dynamic MR defecography (D-MRI) with conventional defecography (CD, reference standard) for patients with symptoms of prolapse of the posterior compartment of the pelvic floor. Methods: Forty-five consecutive patients with symptoms of prolapse of the posterior compartment requiring radiologic assessment underwent both CD and D-MRI. Outcome measures were presence/absence of rectocele, enterocele, intussusception, rectal prolapse and the length of the anorectal junction. Examinations without rectal evacuation of contrast were excluded. Cohen’s Kappa, sensitivity, specificity, positive (PPV) and negative predictive value (NPV), as well as the positive and negative likelihood ratio of D-MRI as compared to CD were assessed. To determine interobserver agreement of both procedures Cohen’s kappa and Pearson’s correlation were calculated and regression analyses were performed. Results: Forty-one patients were available for analysis. D-MRI underestimated the extent of rectoceles with a difference in prevalence (CD 77.8% vs. D-MRI 55.6%), mean protrusion (26.4 vs. 22.7 mm, p = 0.039) and 11 false negatives. This resulted in a low sensitivity (0.62) and NPV (0.31). For diagnosing enteroceles, D-MRI showed an inferior diagnostic capacity with 5 false negatives generating a sensitivity of 0.17. Specificity (1.0) and PPV (1.0) were, however, excellent. Nine false positive intussusceptions were seen on D-MRI; only 2 intussusceptions were missed. Conclusions: The diagnostic quality of D-MRI was limited compared to CD for diagnosing rectoceles and enteroceles. However, for identifying intussusceptions D-MRI seems superior. CD and D-MRI are complementary imaging techniques in the evaluation of patients with symptoms of prolapse of the posterior compartment.

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Surg Endosc

P174 - Intestinal, Colorectal and Anal Disorders

P176 - Intestinal, Colorectal and Anal Disorders

Single incision Laparoscopy as a Standard for Colorectal Resection for Cancer

Infraumbilical Midline Ports in Laparoscopic Appendicectomy Does it Provide Ergonomic and Cosmetic Advantages ?

E.K. Chouillard, F. Daher, A. d’Alessandro, E. Chahine, R.L. Vitte

J. Das

POISSY MEDICAL CENTER, POISSY, France

Nazareth Hospital, SHILLONG, India

The concept of Natural Orifice Translumenal Endoscopic Surgery (NOTES) contributed to the evolvement of single port laparoscopy. Accessing the abdominal cavity solely through the umbilicus shifted laparoscopy from a multiport to a single port procedure. Proponents of this approach to further reduce the invasiveness of laparoscopic surgery with fewer abdominal wall complications, less postoperative pain, faster return to activity, and better cosmesis. This study reports the mid-term results of single port colorectal resections for cancer (sCR) in our institution. Methods and Procedures: All patients who had single port laparoscopic procedures were prospectively included in a database created in 2009. A single 25 to 35-mm diameter, umbilical (or right or left lower quadrant) incision was used. Three 5-mm ports (or two 5-mm and one 12-mm) were inserted through a special platform device. Exclusion criteria comprised total mesorectal excision, ASA III status, organ insufficiency, and hemostasis disorders. Results: From January 2009 to December 2014, sCR was attempted in 278 patients (right, left, transverse, total). During the same study period 111 patients were operated either openly or using standard multiport laparoscopy. An analysis of the distribution of the procedures per year is performed. Regarding patients who had sCR, the success rate without conversion to laparotomy was 89.7%. Additional procedures included cholecystectomy (24), oophorectomy (10), intraperitoneal chemohyperthermia (8), duodenal resection (2), hysterectomy (7), and atypical liver resection (6). Mortality rate was nil. The overall morbidity rate (mainly minor complications) was 12.8%. Eleven patients had leaks (3.9%). Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with colorectal disease, either benign or malignant. Advantages regarding postoperative pain and length of hospital stay could be demonstrated. However, larger scale, studies are needed for further evidence-based analysis, especially regarding oncological outcome.

Aim: To show modified port placement in laparoscopic appendicectomy for better cosmesis and ergonomics. Methods: Laparoscopic appendicectomies with this modified port placement was successfully performed in 224 cases over 79 month period from June2009 to December2015. The first 10 mm port is placed on the lower margin of umbilicus with a semi lunar horizontal incision. Next 5 mm port is given in the midline below the pubic hairline. A third 5 mm port is given in the midline between the previous two ports. If the appendicectomy is expected to be an easy one, the third 5 mm port is replaced by a 2.5 mm alligator (instrument) port to hold and lift the appendix. Whenever necessary a 5 mm telescope was used from any of the 5 mm port. Results: A total of 155 chronic and 69 acute appendicitis including 17 cases of perforation with generallized peritonitis, were operated. Bowel walking was performed in all the chronic cases. Extensive adhesiolysis, ovarian & fimbrial cystectomies, salpingostomy and tubal abscess drainage, omental and mesenteric lymph node biopsy were also performed in few cases along with appendicectomy without any extra port. The surgeon did not find any visualization or ergonomic difficulty. Three chronic cases had postoperative fever, pain abdomen and RIF collections; all managed conservatively. Except one, who developed pseudomembranous colitis, none of the acute and perforated cases had any complications. All patients were very highly satisfied with their postoperative scar. Conclusion: Laparoscopic approach using three infraumbilical midline ports gives a very good visualization, easy instrumentation & yields a better cosmetic result. One can also deal with other pelvic pathology easily, without any extra port.

P175 - Intestinal, Colorectal and Anal Disorders

P177 - Intestinal, Colorectal and Anal Disorders

Our Initial Experience with Stapled Hemorrhoidectomy (SH)

Colorectal Cancer Surgery - Postoperative Immune Changes

M. Salama, W.S. Shabo, S.A. Elmasry

V.S. Kyosev1, D. Popova1, E. Vikentieva1, R. Vladimirova1, V. Mutafchiyski1, K. Vasilev1, P. Ivanov1, G. Grigorov1, G. Kotashev1, E. Naseva2, V. Hristova1, H. Petrov1

Our lady of Lourdes hospital, DROGHEDA, Ireland Introduction: Haemorrhoids are one of the most common anorectal disorders with a reported prevalence of 4.4%–36.4% of the general population. None of the currently available surgical approach is ideal for treatment of hemorrhoids and Debate continues regarding the best surgical method. Stapled haemorrhoidectomy introduced by Longo in 1998 represented a radical change in the treatment of hemorrhoids. It is minimally invasive intervention which rapidly gained popularity. The available data comparing conventional hemorrhoidectomy with stapled hemorrhoidectomy are limited and conflicting. Controversy exist for the safety and acceptability of SH and some surgeon remained skeptical and concerned as reports of serious complications of SH emerged. Aims: To assess our initial experience with SH in our unit. To compare the outcome of our SH with previous reports in the literature. Methods: This is a prospective study. Patients who presented with hemorrhoids not suitable for endoscopic treatment (grade 3 & 4) were treated by SH using covidien EEA hemorrhoid and prolapse stapler device. All the procedures were performed by the same surgeon. Data collected included:-Addressograph, preoperative symptoms, surgery (operative procedure), operative time, length of the hospital stay, postoperative follow-up and complications. Results: The total number of patients who had stapled hemorrhoidectomy is 50 (M: 23, F: 27; age range 24-77). Additional intervention needed: Haemorrhoidal artery ligation (HAL) by sutures (not by us Doppler):3, excision skin tag: 12, extra hemostatic sutures: 10, external hemorrhoidectomy: 3, rubber band ligation: 1, diathermy excision of external piles: 1 Mean operative time: 20 min (15–40) Discharge: Same day: 10 vs Next day: 40 Re-intervention: 4 Repeat EUA & lateral sphincterotomy: 3, conventional hemorrhoidectomy: 1Complications: Follow-up period: 6–60 months Persistent pain: 2 cases (Settled with conservative treatment) Conclusion: While debate continues regarding the best treatment of hemorrhoids, SH is safe, effective and has a lower pain score if performed by an experienced surgeon. Additional interventions such as excision of skin tag & HAL, are added as needed.

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Military Medical Academy, SOFIA, Bulgaria; 2Faculty of Public Health, Medical University, SOFIA, Bulgaria

1

Aims: Curative treatment of colorectal cancer relies principally upon surgical resection, which evokes a variety of physiologic and immunologic alterations that should contribute to host defense. The objective of this study was to compare immune changes after minimally invasive and open colorectal cancer resections and defined which surgical approach is optimal for patients with colorectal cancer (CRC). Methods: Study included 29 patients with CRC who underwent minimally invasive colorectal surgery, with a mean age of 65.4 years (49–86) and 21 CRC patients who underwent conventional (open) colorectal surgery, with a mean age of 63.9 years (38–84). Blood tests were performed 24 h prior to surgery, 24 h and 7 days after surgery. Analysis included full blood count, total protein, albumin, markers of inflammation (CRP, ESR, fibrinogen) and YKL-40 serum levels. T- (CD3+), B- (CD19+) and NK-cell lymphocyte populations were studied by means of flow cytometry, as well as activation of leucocytes, according to the expression of HLA-DR, CD38, CD279, CD163. SPSS.v21. was used to manage patient data and to perform statistical analyses. Results: At first postoperative day there were significant decrease in lymphocyte percentages and increased leucocyte count, granulocyte percentages and CRP levels in conventional group. This ratio maintained at 7 days after surgery. Activated monocyte (CD 163+), total protein and albumin, eosinophiles, percentage of monocytes and lymphocytes were significant decrease in conventional group compared with minimally invasive group 24 h after surgery. NK cell activity decreased slightly on first postoperative day, and showed no significant difference between two groups. Reduced HLA-DR expression on monocytes were in two groups 24 h after surgery, but levels returned to normal only at minimally invasive patients on seventh postoperative day. Conclusions: Minimally invasive colorectal cancer surgery goes with lesser degrees of tissue injury, surgical metabolic stress, and immunosuppressive response to conventional (open) surgery. Minimally invasive approach is optimal surgical choice for patients with colorectal cancer.

Surg Endosc

P178 - Intestinal, Colorectal and Anal Disorders

P180 - Intestinal, Colorectal and Anal Disorders

Advanced Age and Co-Morbidities as a Predictor of Postoperative Complications in Laparoscopic Surgery for Colon Cancer

The Effect of Bupivacaine Infiltration After Single Incision Laparoscopic Appendectomy: A Double-Blinded Randomized Controlled Trial

L.A. Vega Rojas, X. Vin˜as, R. Claveria, P. Besora, J.M. Abad, R. Rodriguez, D. Salazar, J. Camps Consorci Sanitari de l’Anoia, IGUALADA, Spain Aims: To determine the impact of age over 70 years and co-morbidities in the development of medical and surgical complications and mortality assessed at 30 days in patients who underwent elective surgery for colon cancer. Methods: A retrospective cohort study of patients operated on electively with a total of 110 colon cancer patients in 2010-2015. We have divided for analysis to patients according to their age (\70 years and [70 years) and co-morbidities, categorizing them according to Charlson scale. To assess all the clinical impact of surgical complications observed we used the scale Clavien/Dindo. Results: Group I (low co-morbidity) 82 patients, Group II (intermediate morbidity) 15 patients, Group III (high co-morbidity) 13 patient. Also 48 patients were less than 70 years and 62 patients over 70 years. Association between the score on the Charlson index of 3 or more and the development of medical complications and mortality observed at 30 days after surgery (p \ 0.05) was observed. There was no difference in incidence of surgical complications (p = 0.4). The incidence of medical complications was 9.09% (10/110 patients), all occurring in the older group (p = 0.003). We objectify an incidence of surgical complications 14.58% (7/48) in the group of under 70 years and 12.9% (8/62) in those over 70 years (p = 0.79). Conclusions: The Charlson index allows us to categorize patients into three groups according to their baseline; generally it considered low comorbidity: 0-1 points, intermediate comorbidity high = 2 points and 3 points. In our series, we found a relationship between an index score greater than or equal to 3 Charlson, and age greater than 70 years in the development of postoperative medical complications and finding himself associated with postoperative mortality (p \ 0.05). The inherent morbidity to the surgical process has shown no statistically significant differences in relation to patient age (p = 0.71), or with co-morbidities (0.06).

H.K. Ha1, K.K. Choi2, W.S. Kim1, K.G. Lee1, H.J. Choi1, H.J. Shin1, J.H. Lee1, J.K. Park1 1 Myongji Hospital, Seonam University College of Medicine, GOYANG, Republic of Korea; 2Department of Trauma Surgery, Gachon University Gil Medical Center, INCHEON, Republic of Korea

Aim: Single incision laparoscopic appendectomy (SILA) is a feasible operative technique. Local anesthetics were used to decrease postoperative wound pain after open or laparoscopic appendectomy. This study is a double-blinded randomized controlled trial to verify the efficacy of local anesthesia for decreasing wound pain after SILA. Methods: Between March 2014 and October 2015, 68 patients with appendicitis were agreed to participate in this study. After anesthesia, patients were randomized to bupivacaine group and control group (normal saline), and the drugs were infiltrated into both subcutaneous fascia and deep to rectus fascia before incision by operating surgeons. Postoperative analgesics use and postoperative pain were recorded using visual analog scale (VAS) by investigators at 1, 8, 24 h and on 7 days. All of the surgeons, investigators and patients were blinded which group they were belong. Results: Thirty patients were allocated into control group and 37 patients were allocated into bupivacaine group. Among them, 10 were excluded and 23 in control and 34 in bupivacaine group completed study. Patients’ preoperative demographics and operative findings did not show differences. Control group needed more analgesics in post anesthetic recovery unit (PACU) (1.4 versus 1.1, p = 0.019). However, postoperative pain and overall analgesics use in ward were not significantly different. In subgroup analysis with longer operation time, over 40 min, control group (n = 12) needed more analgesics than bupivacaine group (n = 11) in PACU (1.6 versus 0.9, p = 0.011). The VAS score at 24 h was significantly lower in bupivacaine group (2.1) than in control group (3.7, p = 0.005). However, VAS scores at 1, 8 h and on 7 days were not significantly different. Conclusions: Bupivacaine group used less analgesics immediately after surgery than control group. With longer operations, bupivacaine group had less pain at 24 h after surgery.

P179 - Intestinal, Colorectal and Anal Disorders

P181 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Colorectal Surgery in Patiens with Inflamatory Bowel Disease

Laparoscopic Colectomy for Colon Cancer: Long-Term Complications

M. Kasalicky1, E. Koblihova1, P. Minarikova1, M. Bortlik2

J. Moravik, J. Rejholec, F. Galgoczyova, T. Tekula

1

2

Central Military Hospital, PRAGUE, Czech Republic; Iscare, PRAGUE, Czech Republic

Krajska´ zdravotnı´, a.s. - Nemocnice Decı´n, o.z., DECIN, Czech Republic

Aim: Laparoscopic colorectal surgery (LCS) in patients with inflammatory bowel disease (IBD) is becoming a standard and feasible surgical method worldwide. Over the last decade, there have been many studies documenting the safety and feasibility of the laparoscopic approach for IBD in well-selected patients. Methods: Patients without any previous gut resection with Crohn’s disease often with the tight iliac stenosis and prestenotic dilatation, various colon stenoses or with ulcerative proctocolitis were indicated for the LCS. From 2009 to 2015, 154 ileocolic resections, 41 hemicolectomies, 32 subtotal colectomies and 7 proctocolectomies with ileopouchanal anastomosis were performed either totally laparoscopically or laparoscopically assisted. Results: The average time of the procedure was 105 min (65–295 min), average blood loss 125 ml (0–350 ml) and the conversion to laparotomy was in 8.2%. Average return time of the bowel function was 3.5 days (2–8 days) and the average hospital stay was 7.1 days (6–11 days). 1 case of the early ileus due to adhesions, 5 cases incision hernia in minilaparotomy and 7 wound infections occurred. Conclusion: In well-selected patients with IBD, thanks to superior short- and long-term outcomes, the laparoscopic approach should be considered a safe and effective method when performed by experienced surgeons. Supported by MO1012.

Introduction: We focused on incidence of benign late complications such as colorectal anastomotic stricture and incisional hernia. Mentioned complications degrade patients’ quality of life after the surgery and can be a cause of reoperation. Methods: A retrospective analysis of 186 patients who underwent colon cancer resection from 1.1.2009 to 31.12.2013. We included elective and acute surgeries but excluded patients after rectal cancer resections and paliative operations. Results: A total of 141(75.81%) patients underwent laparoscopic resection. Acute operation was performed on 21(11.29%). Colorectal anastomotic stricture was discovered in 4 patients (2.15%), 3 of them were men and 1 a woman, all non-smokers and nobody went through a neoadjuvant chemoradiotherapy. In 2 of the cases sigmoid resection was performed, other 2 patients underwent rectosigmoid colon resection. The average distance of the anastomosis to the linea dentata was 12.6 cm. 3 patients were treated using endoscopic balloon dilatation. 1 patient required a reoperation. Incisional hernia was observed in 11 patients (5.91%), 8 men and 3 women. 7(4.24%) of them underwent elective operation, 4(19.05%) patients had an acute surgery. 6(4.25%) of hernias occurred after laparoscopic procedure, 4(8.89%) after an open one. 10 of these 11 patients had a surgical site infection, that is 90.91%. 7 patients underwent a hernia repair. Conclusion: Colorectal anastomotic stricture occured in our cohort only after sigmoid and rectosigmoid colon resection. Asymptomatic course of the mentioned complication requires a postoperative follow-up with possibility of endoscopic therapy. Incisional hernias were related with acute surgeries as well as with the development of surgical site infection. In the contrary the laparoscopic procedures had a lower incidence of hernias than the open ones.

123

Surg Endosc

P182 - Intestinal, Colorectal and Anal Disorders

P184 - Intestinal, Colorectal and Anal Disorders

The Usefulness of Palliative Prognostic Index for Preoperative Evaluation of the Laparoscopic Palliative Operation

Total Laparoscopic Right Hemicolectomy with Intracorporeal Anastomosis in a District Hospital

S. Yoshikawa1, M. Fukunaga1, T. Fukunaga2, K. Nagakari1, K. Yamasawa1, M. Suda1, Y. Iida1, S. Kanda1, G. Katsuno1, M. Ouchi1, Y. Hirasaki1, M. Ito1, Y. Yube1, D. Azuma1, S. Kohama1, J. Nomoto1, A. Mizushima2

A. Maurizi1, R. Campagnacci2 Universita` Politecnica delle Marche, ANCONA, Italy; 2General Surgery, ASUR Regione Marche, Carlo Urbani,, Hospital, JESI, Italy

1

Background: Palliative surgery for incurable malignancies is very useful in relieving symptoms. But, the condition of the patients who require palliative surgery is often poor, so operation must be minimally invasive. Therefore, It is considered that laparoscopic surgery is suitable for surgical palliation. In addition, we mast consider the limited prognosis of patients. Palliative Prognostic Index(PPI) is a short term prognostic indicator of terminal stage in malignancies. If the PPI is greater than 6, survival is less than three weeks. Aim: The aim of this study was to assess the usefulness of PPI as preoperative indicator of laparoscopic palliative operation. Method: A retrospective analysis was performed on 67 patients who underwent laparoscopic palliative operation between 2006 and 2015 in our institution. We compared 61 cases of High PPI group(6 or more) to the 6 cases of low PPI group(less than 6). Results: The patients in both group was comparable in age, sex, type of malignant disease, and surgical procedure. Overall survival of the low PPI group was significantly longer than the High PPI group. And the PPI of patients who were alive over 60 days was significantly smaller than the PPI of patients who were alive less than 60 days. Conclusions: High PPI group was significantly poor prognosis than the low PPI group. It suggest that post operative prognosis of the PPI 6 or more cases of the laparoscopic palliative operations is poor. PPI is considered useful in the decision of indication for laparoscopic palliative surgery.

Aims: Growing evidence suggests that the intracorporeal fashioning of an anastomosis after a laparoscopic right colectomy may offer several advantages and also improve cosmesis avoiding midline or paraumbilical incisions. Although it is considered as a feasible and effective surgery in terms of short- and long-term results and oncological radicality, due to the difficulty of the intracorporeal technique, laparoscopic extracorporeal confectioning of the anastomosis remains the most widely adopted technique and laparoscopic right colectomy is performed by a small number of surgeons. This study aims to compare the intraoperative and postoperative outcomes between intracorporeal and extracorporeal anastomosis after laparoscopic right colectomy. Methods: A retrospective review of 48 consecutive patients who underwent laparoscopic right hemicolectomy for colon cancer from January 2015 to December 2015 was performed. The patients were divided in two groups: a group of 16 who underwent laparoscopic right hemicolectomy with intracorporeal anastomosis (IA), and another group of 32 patients who underwent laparoscopic right hemicolectomy with extracorporeal anastomosis (EA). Results: Forty-eight patients (16 IA and 32 EA) met the criteria for inclusion in the study. The two groups were comparable in their demographic and baseline characteristics. Surgical post history, tumor localization, and stage of disease according to AJCC/UICC TNM were similar too. Although similar oncologic radicality in terms of number of lymph nodes harvested, as well as similar operative time, conversion to open rates, intraoperative blood loss, 30-day morbidity and mortality, have been registered, time to flatus was statistically lower after intracorporeal anastomosis. Performing the intracorporeal anastomosis offers significantly better perioperative recovery outcomes compared with the extracorporeal anastomosis, with a substantial reduction in the length of the hospital stay. Conclusions: Our results are encouraging to consider the intracorporeally approach as the better way to fashion the anastomosis after laparoscopic right colectomy, because it is a technically and oncologically safe procedure with acceptable operating time and low mortality.

P183 - Intestinal, Colorectal and Anal Disorders

P185 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Ventral Mesh Rectopexy for Rectal Prolapse Using Veritas Mesh - A Case Series

Heterotopic Ossification in Primary Colorectal Tumours - Case Report and Literature Review

V.L. Fretwell, K. Brannigan, C. Downes, R. Rajaganeshan, M. Chadwick

M. Abdeldayem, C. Jenkins, D. Cartwright, A. James, A. Joseph

1

Juntendo University Urayasu Hospital, URAYASU CITY, CHIBA, Japan; 2Juntendo University, TOKYO, Japan

Whiston Hospital, LIVERPOOL, United Kingdom Introduction: Rectal prolapse and obstructive defecation syndrome are life altering conditions, common across the age spectrum. When previously considered unfit for open abdominal surgery, elderly patients have tended to undergo perineal procedures, known to have higher failure rates. The laparoscopic ventral mesh rectopexy (Lap-VMR) allows all patients to benefit from the abdominal approach. Synthetic mesh erosion is the surgical complication of greatest concern and the use of biological meshes has gained increasing popularity because of this, although recent studies have shown equivalent safety and erosion rates. Traditional biological cross-linked collagen meshes are difficult to handle laparoscopically and do not allow for tissue integration. Veritas Collagen Matrix allows for neo-vascularisation of the implanted mesh and permits replacement of the mesh with host tissue (remodelling). We chose to use Veritas as it is much easier to handle laparoscopically and we are the only centre in the Merseyside region to use it for Lap-VMR. We present our initial results. Method: A retrospective analysis of prospectively collected data for sequential patients undergoing Lap-VMR in this unit Since October 2013 was undertaken Results: Eighteen patients (M:F 1:17, median age 60.7 years) underwent Lap-VMR between October 2013 and August 2015 after pelvic floor MDT discussion. The predominant symptoms were constipation, digitation to evacuate, and prolapse. 39% had concomitant urinary symptoms. Five patients had previous anorectal procedures (Delormes, banding, haemorrhoidectomy). Veritas mesh was used in all cases, mean operative time was 180 min with average length of stay was 3 days. There were no surgical post-op complications but there was one post-operative death secondary to CCF and Pneumonia. Median follow up was 6 months. One patient required treatment for prolapsing haemorrhoids 11 months post operatively but there were no genuine recurrences in this group and no mesh-related complications. 94% of patients reported improvement in symptoms postoperatively. Conclusion: Our series has shown the Veritas mesh to be safe and effective for the LapVMR and early follow up demonstrates low recurrence rates, high levels of patient satisfaction and low mesh-related complication rates.

123

CWM TAF University Healthboard, MERTHYR TYDFIL, United Kingdom Aims: Heterotopic bone formation has been reported in malignancies involving the kidneys, liver, breast, and skin. Ossification in the gastrointestinal tract is extremely rare; nevertheless, it has been reported in association with benign colonic polyps, carcinomas, carcinoid of the stomach and with mucocele of the appendix.In 1923, Hasegawa was the first to describe two cases of rectal carcinoma with bone formation in the stroma. In 1939, Dukes was the first investigator in the English literature to describe ossification of primary rectal carcinoma in two cases. Methods: We present a case of Heterotopic bone formation in caecal cancer in an 85 years old lady.Literature Search was performed via two search engines first is MEDLINE from the year 1946 to week 3 of September 2015 and second is EMBase from 1980 to week 39 of the year 2015. Search was narrowed to a relevant 50 papers, abstracts of the 50 papers read, 12 were excluded as it was not relevant, 11 excluded as they were about Heterotopic ossification in Colorectal Metastasis either liver or lung metastasis, 1 excluded as they were mainly about Heterotopic ossification as a postoperative complications after orthopedic surgery, 3 excluded as it was duplicated from the 2 search engines and the full text of the relevant 25 papers obtained, read and analyzed. Results: Overall 28 patients with heterotopic ossification were found in literature, 18 of which were rectal lesions ‘ 14 showed histopathology of adenocarcinoma, 3 inflammatory polyps and 1 as extra skeletal osteosarcoma’, 3 were caecal ‘including our case, 2 of which were adenocarcinoma and the third case was reported as granular cell tumour’, 2 were in the ascending colon ‘Both were adenocarcinoma’, 1 in the appendix ‘ Adenocarcinoma’, 1 in the left colon ‘ High grade dysplasia with foci of adenocarcinoma’ and 1 was in the sigmoid colon ‘ Tubular adenoma with mild dysplasia’. Conclusions: Heterotopic ossification in primary colorectal lesions is a rare lesion, can happen in association with different colorectal pathologies and need to be carefully diagnosed not to be mistaken with direct bone invasion .

Surg Endosc

P186 - Intestinal, Colorectal and Anal Disorders

P188 - Intestinal, Colorectal and Anal Disorders

Closure of Appendicular Stump Using Absorbable Polydioxnon Endoclips in Laproscopoic Appendictomy

Solutions Anastomotic Leak After Davinci Lar - Our Experience

W.B. Mohamed Sohag University, SOHAG, Egypt Introduction: Since 1983 when the 1st laparoscopic appendectomy was described by Semms, different methods for closure of the appendicular stump during laparoscopic appendectomy such as linear stapler (Endo GIA), endoloop ligature, intracorporeal suture and metal endoclips were used. The use of non-absorbable plastic clips was described in several studies which reported the low cost and easy application of these clips. Aim of the work: To evaluate the efficiency of closure of appendicular stump using large violet polydixanone endosclips [ABSOLOK AP 400TM,Johnson & Johnson, USA] techniques as regard the intraoperative and postoperative complications. Patients and Methods: This prospective study was conducted From June 2014 to October 2015 in General surgery department Sohag University Hospitals, Sohag,Egypt.40 patients undergoing laparoscopic appendectomy with closure of appendicular stump using large violet polydixanone endosclips [ABSOLOK AP 400TM,Johnson & Johnson, USA,USA} were included in this study. The study was approved by Ethic committee board in Sohag University Hospitals. All patients had informed written consent prior to surgery.Primary outcome measures: were feasibility of the clip, intra-abdominal surgical site (abscesses, stump leakages) and superficial wound infections. Results: The staples were applicable in nearly 80% of patients. Reasons for not applying the clip were mainly aninflamed caecum or a too large diameter of the appendix base. Superficial wound infections were found in two (5%), intra-abdominal abscesses in one (2.5%), no leak from appendicular stump was detected. Conclusions: The results suggest that the absorbable polydioxnon endo clip is a safe and effective option in securing the appendicular stump in laparoscopic appendectomy.Key words: Appendicitis, Laparoscopic appendectomy, Hem-o-lok clip, appendicular stump

J. Rejholec Regional Health a.s., DECIN, Czech Republic Aims: In this work we evaluate a group of patients operated in the center of robotic surgery for rectal cancer with anastomotic leak, operated on a da Vinci SHD and daVinci Xi. Anastomotic leak is essential complication at low resection for rectal cancer and is an important factor in the outcome of the operation. Early detection Leak reduce subsequent complications. Methods: Retrospective analysis resections for rectal cancer from 1.9.2009 to 11.26.2015 Total operated on 200 patients with rectal cancer, were excluded from the patients made palliative surgery. In this file is analyzed 25 leaks. The file is analyzed in terms of evaluation of the solutions in therapy Leake and evaluate various options. Also, we discuss the possible signs of the emergence and time speech leak. Results: Anastomotic leak is crucial complications of surgery for rectal cancer. In our sample of 200 robotically handled low anterior resection occurred in the number 25, i.e. 12.5%. The most common symptom was elevated CRP, subfebrile and secretions from the rectum, most frequent time of diagnosis leak in our group was four days after surgery. The most common solution to the pelvic lavage and drainage, sanitation was the second most frequent means of Endosponge. Conclusions: Solution Leaks after robotic resection for low cancer is no different from the solution after a leak in another way resections. The success solving this complication is meticulous monitorece clinical condition of the patient, particularly CRP, CT and flexible rectoscopy. Early intervention is a great opportunity to avert general and local complications.

P187 - Intestinal, Colorectal and Anal Disorders

P189 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Surgery for Rectal Cancer: A Standard Procedure or Just Attractive Method for (Over) Enthusiastic Surgeons

Long-Term Outcome of Laparoscopic Colon Cancer Resection. Review of 560 Cases

B. Krebs, M. Kozˇelj, A. Dzˇodan, S. Potrc

C. Pe´rez San Jose´1, M. Aguinagalde1, F. Ellacuria1, A. Bilbao2, S. Leturio1, B. Uriarte1

UCC Maribor, BRESTERNICA, Slovenia Introduction: It is now well established that concerning oncological outcomes laparoscopic surgery for colon cancer is equivalent to open surgery. Even better, laparoscopic operations result in a shorter hospital stay, less need for prescription pain medications, an earlier return to normal activities and less visible scarring. But is it the also true for rectal cancer? Methods: We searched available literature about recommendations for laparoscopic rectal operations and reviewed our own data on this issue. We performed retrospective evaluation of all patients operated on rectal cancer in our institution between 2010 and 2014 and compared short term outcomes between open and laparoscopic operations. Results: Several studies have evaluated the short term outcomes of laparoscopy surgery for rectal cancer and have shown superiority of the laparoscopic vs open approach. Studies also suggest that there is no difference between the laparoscopic and open approaches concerning the specimen’s quality, the intermediate and long term oncologic outcomes and survival but there are favorable short time results. In 5 year interval we operated radically on 320 patients with rectal cancer. 286 open and 35 laparoscopically. Mean postoperative time was 14,8 vs 12,67 days but the difference wasn’t statistically significant. Conclusion: Although there is not enough strong evidence yet, we may conclude that in the hands of well trained surgeon laparoscopic surgery is feasible and safe method for low stages rectal cancer.

Basurto University Hospital, BILBAO, Spain; 2Basurto University Hospital - REDISSEC, BILBAO, Spain 1

Introduction: The laparoscopic approach on colon cancer is used in the surgical services for 2 decades. We show our results. Material-Methods: Total of 560 patients with colon cancer were operated on by laparoscopy for colon cancer between 1998-2015. Tumours located in the rectum are not included in this series. The presence of distant metastasis, prior abdominal surgery or tumours with intraoperative evidence of invasion of adjacent structures were not motives for exclusion. 391 patients have been studied for a minimum of 5 years. The primary outcomes were time to cancer death and time to recurrence until 5 years. Kaplan–Meier survival curves were constructed for the primary outcomes for each stage and comparisons were performed with the log-rank test. Results: The mean age 70 ± 11 years. The location of the tumours was: right colon 37%, transverse 8%, descending 13%, sigmoid 41% and synchronous carcinomas in 2%. The surgical techniques used were: right hemicolectomy 42%, left hemicolectomy 12%, subtotal colectomy 3%, sigmoidectomy 35%, LAR 4%, segmental resection 3% and Hartmann operation 1%. It was converted to open surgery in 2 cases (0.35%). The operative time was 165 ± 25 min. The mean hospital stay was 7.5 ± 6.2 days. The rate of complications was 9.6% and of reoperation in 3.9%. The operative mortality was 1% (6 cases). TNM classification: stage I 26%, stage II 38%, stage III 25%, stage IV 11%. The number of lymph nodes was 13 ± 6. Port-site metastases 0.8% were detected. Disease-free survival at 5 years: stage I-III: 80%, stage I: 95%, stage II: 90%, stage III: 81%, stage IV: 11%. Cancer recurrence: Stage I 3.13%, Stage II 10.19%, Stage III 15.05%. Kaplan–Meier survival curves for time to cancer death showed significant differences between all stages (p \ 0.05), except stages I and II (p = 0.18). The global rate of recurrence was 9.5% (3.1, 10.2 and 15.1% in stages I, II and III, respectively). Kaplan– Meier survival curves for time to recurrence showed significant differences between stages I vs. II and III. Conclusions: Laparoscopic colectomy is a safe procedure with low morbility and mortadity and good oncological results.

123

Surg Endosc

P190 - Intestinal, Colorectal and Anal Disorders

P192 - Intestinal, Colorectal and Anal Disorders

Effect of Pre-incision Local Infiltration with 0.5% Bupivacaine in Single Incision Laparoscopic Surgery for Appendectomy

Short-Term Clinical and Oncological Outcomes After SingleIncision Plus One Port Laparoscopic Anterior Resection for Rectal Cancer

D.B. Kang1, J.T. Oh2 1 Department of Surgery, Wonkwang University Hospital, IKSAN, Republic of Korea; 2Department of Surgery,Gunsan Medical Center, GUNSAN, Republic of Korea

M. Hattori, Y. Hirano, M. Shimada, K. Douden, Y. Hashizume Fukui prefectural hospital, FUKUI, Japan

Purpose: As technology and innovation continue to advance the field of minimally invasive surgery, single incision laparoscopic surgery (SILS) is being applied to diverse surgeries as a new technique for minimal invasive surgery and cosmetic improvement. But some papers reported single incision laparoscopic surgery for appendectomy (SILS-A) had more postoperative pain complaint. Therefore, we investigated postoperative pain relief using wound infiltration with 0.5% bupivacaine in SILS-A, comparing it conventional SILS-A. Methods: Between July 2010 and September 2014, 100 patients who were performed SILS-A were enrolled in this study. The patients were randomly assigned to two groups: conventional SILS-A group(C-SILS-A) or wound infiltrated with 0.5% bupivacaine in SILS-A group (W-SILS-A). There were 60 patients in C-SILS-A and 40 patients W-SILSA. Patients with perforated appendicitis were excluded. The clinical outcomes were compared between the groups including VNRS(verbal numerical rating scale). Results: Clinical outcomes were similar in both study groups except pain score. W-SILS-A group showed significantly lower numbers of additional pain killer and lower scores of VNRS (1, 6, 12 h after operation) than C-SILS-A group. Pre-incisional local infiltration with 0.5% bupivacaine is an effective and simple method of reducing postoperative pain for patients undergoing SILS-A. Conclusion: W-SILS-A is technically simple and effective method of reducing an early postoperative pain, it could be applicable in SILS-A for pain control system.

Introduction: We have developed and previously reported single-incision plus one port laparoscopic anterior resection of the rectum in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection of the rectum. In the present study, our experiences with 141 consecutive patients with single-incision plus one port laparoscopic anterior resection of the rectum (SILS + 1-AR) for rectal cancer are reviewed, and its outcomes are evaluated. Methods: A Lap protector (LP) was inserted through a 2.5 cm transumbilical incision, and an EZ-access was mounted to LP and three 5-mm ports were placed. A 12 mm port was inserted in right lower quadrant. Almost all the operative procedures were much the same as in usual laparoscopic anterior resection of the rectum. Results: We underwent SILS + 1-AR in 141 patients with rectal cancer. Four patients were converted to laparotomy and one patient required an additional port insertion. The other 136 patients (96.5%) underwent an anterior resection of the rectum. Postoperative complications occurred in 12 patients. Six (5.6%) tumor recurrence or metastasis occurred in 107 patients with Stage I to Stage III disease with the median follow-up 30 months. The 2-year recurrence-free survival rates of patients with stage I, stage II and stage III were 88.0, 96.2 and 96.0%, respectively, and the 2-year overall survival rates of patients with stage I, stage II and stage III were 96.7, 96.2 and 96.0%, respectively. Conclusions: Short-term clinical and oncological safety of SILS + 1-AR for rectal cancer was established in this study. However, further studies are needed to prove the advantages of this procedure to conventional laparoscopic AR.

P191 - Intestinal, Colorectal and Anal Disorders

P193 - Intestinal, Colorectal and Anal Disorders

Single-Incision Laparoscopic Colectomy for Colon Cancer: Experiences with More Than 300 Consecutive Patients

Deviating Colostomy Versus Stent Placement as Bridge to Surgery for Malignant Left-Sided Colonic Obstruction

Y. Hirano, Y. Hattori, M. Shimada, K. Douden, Y. Hashizume

F.J. Amelung1, F.J. ter Borg2, E.C.J. Consten1, P.D. Siersema3, W.A. Draaisma1

Fukui prefectural hospital, FUKUI, Japan

1

Introduction: Our experiences with more than 300 consecutive patients with single-incision laparoscopic surgery (SILS) for colon cancer are reviewed, and its outcomes are evaluated. Methods: A single-surgeon’s experience of SILS for colon cancer are presented. 308 patients (148 women) with a median age of 71.0 years and a median body mass index of 22.9 kg/m2 were treated with the SILS procedure for colon cancer between December 2010 and March 2015. Almost all the procedures were performed with standard laparoscopic instruments, and the operative procedures were similar to those employed in the standard laparoscopic colectomy. Results: Of these 308 patients, 19 patients (6.2%) were converted to laparotomy including the extension of the skin incision over 3 cm. The mean skin incision length was 2.75 cm. The mean operative time and blood loss were 167.7 min and 74.0 mL, respectively. The mean number of harvested lymph nodes was 25.3. The pathological stages included stage 0 (n = 15), stage I (n = 58), stage II (n = 96), stage III (n = 84), and stage IV (n = 55). Intra-operative injury occurred in five patients. Post-operative complications were occurred in 19 patients (6.2%). Twenty (8.4%) tumor recurrence or metastasis occurred in 238 patients with Stage I to Stage III disease with the median follow-up 27 months. Converted patients experience a higher complication rate, longer operative time, more estimated blood loss and longer hospital stay compared with patients who had an operation completed laparoscopically. Conclusions: Our initial experiences suggested that SILC is feasible and safe for colon cancer patients. It seems to be an acceptable technical alternative to conventional multiport laparoscopic colectomy in suitable patients.

123

Meander Medical Center, AMERSFOORT, The Netherlands; Deventer Hospital, DEVENTER, The Netherlands; 3Academic Medical Center Utrecht, UTRECHT, The Netherlands

2

Aims: Recent data have shown that acute colonic decompression using a deviating colostomy (DC) or a self-expandable metal stent (SEMS) leads to fewer complications and permanent stomas in elderly frail patients with left-sided colonic obstructions (LSCO) compared to acute resection. However, no consensus exists on which of these two decompression methods is superior, especially in patients treated with curative intent. This study therefore aimed to compare both decompression methods in potentially curable LSCO patients. Methods: All patients presenting with malignant LSCO that were treated with curative intent between 2004-2013 in two teaching hospitals were retrospectively identified. In one institution, a DC was the standard of care, whereas in in the other all patients were treated with a SEMS. Results: In total, 88 eligible patients with malignant LSCO and curative treatment options were included; 51 patients had a SEMS placed and in 37 patients a DC was constructed. 235 patients were excluded due to benign or inoperable disease. Baseline characteristics were not significantly different between both treatment groups. In addition, no significant differences were found for the outcomes hospital stay, morbidity, overall and disease free survival and mortality. Major complications were seen in 13/51 (25.5%) patients in the SEMS group (stent dysfunction (n = 7), stent-related perforation (n = 1), anastomotic leakage (n = 1), wound dehiscence (n = 2) and surgical iatrogenic complications (n = 2)) and in 4/37 (10.8%) patients in the DC group (abdominal sepsis (n = 3) and wound dehiscence (n = 1)) (p = 0.10). Long-term complications were significantly more frequent in the DC group (29.7% vs. 9.8%, p = 0.01) and were mainly due to a high rate of incisional hernias. In addition, fewer patients had a temporary colostomy following elective resection after SEMS placement (62.2% vs. 17.6%, p \ 0.01). The permanent colostomy rate was similar between both groups. Conclusions: SEMS placement and DC construction are both effective decompression methods for acute LSCO in curable patients. SEMS placement seems to result in fewer long-term complications and surgical interventions (mainly due to stoma reversal and hernia corrections). It remains to be established whether SEMS placement is safe with regard to long-term oncologic outcomes as the number of SEMS patients in this study was limited.

Surg Endosc

P194 - Intestinal, Colorectal and Anal Disorders

P196 - Intestinal, Colorectal and Anal Disorders

A Case-Matched Comparative Study of Self-Expandable Metal Stent Placement and Emergency Resection in the Management of Proximal Colonic Obstructions

Trans-Anal Total Mesorectal Excision (TA-TME) Using a Novel Rigid Reusable Port: Initial Experience on 24 Cases

F.J. Amelung1, W.A. Draaisma1, E.C.J. Consten1, P.D. Siersema2, F.J. ter Borg3 1

Meander Medical Center, AMERSFOORT, The Netherlands; Academic Medical Center Utrecht, UTRECHT, The Netherlands; 3 Deventer Hospital, DEVENTER, The Netherlands 2

Aims: Traditionally, all patients with a malignant obstruction of the proximal colon (MOPC) are treated with emergency resection. However, recent data suggest that SelfExpanding Metallic Stent (SEMS) placement could lower mortality and morbidity rates. However, data regarding the safety of SEMS placement in the proximal colon is limited. This study therefore aimed to compare SEMS placement with emergency resection as treatment options for MOPC. Methods: All consecutive patients that underwent SEMS placement for MOPC between 2004-2015 at our institution were retrospectively reviewed. SEMS placement is the standard of care for colonic obstructions at our institution and emergency resection is only performed when colonic perforation is suspected. All included SEMS patients were matched(1:4) according to age, gender, ASA-score, tumor location, surgical approach and pTNM-stage with patients treated with emergency resection. Controls were selected from a national database that prospectively registers all patients undergoing surgery for colorectal cancer in the Netherlands. Results: In total, 41 patients received SEMS placement for MOPC. In 19 patients SEMS served as a definite palliative measure and in 22 patients as a bridge to surgery. Technical and clinical success rates of SEMS placement were 90.5% and 88.1%, respectively. No significant differences between the SEMS and emergency resection group were found regarding morbidity and mortality rates, the number of radical resections and the number of primary anastomoses. Patients treated with SEMS were, however, less likely to have a temporary stoma constructed (p = 0.04). No SEMS-related complications occurred in patients in whom SEMS was placed as bridge to surgery, whereas one stent-related perforation, three stent migrations and five stent re-obstructions were observed in the palliative group. Three re-obstructions could be treated with re-stenting, but all other SEMS-related complications required surgical intervention. Long-term SEMS success rate was therefore 52.6% Conclusions: SEMS placement for MOPC appears to be a relatively feasible and safe alternative for emergency resection in both the curative and palliative setting. SEMS provides rapid relief of obstruction and avoids stoma construction, which could positively influence quality of life. However, these benefits should be weighed against SEMS-related morbidity and mortality, and the uncertainty about long-term oncologic safety in curative patients.

L. Boni, E. Cassinotti, E.M. Colombo, I.G. Grosso, A. Marzorati University of Insubria, VARESE, Italy Introduction: Recently an alternative combined, abdominal and perineal endoscopic approach, for the complete excision of the mesorectum, known as Trans-Anal TME (TATME), has been recently proposed in order to overcome technical difficulties of laparoscopic TME such as very low tumor, obese and male patients, difficult localization of the distal tumor margin, the need for multiple staple firings for distal stump closure.Nevertheless, even TA-TME carries some specific challenges, mainly related to the limited ‘working space’ during the perineal part of the procedure that requires a very stable pneumo-rectum as well as a continuous aspiration of the surgical smoke. Furthermore, in order to perform a good excision of the upper part of the mesorectum, a long transanal port is required. So far, fairly expensive, single use plastic trans-anal port combined with disposable insufflation system have been used by most of the surgeons who are performing TA-TME. Aims: We present our experience of TA-TME using a novel, reusable rigid trans-anal port combined with a semi-disposable insufflation-aspiration system. Methods: Patients suffering from low-middle rectal cancer with or without neodjuvant therapy were scheduled for TA-TME using a rigid reusable trans-anal port equipped with high flow CO2 valve (B-PortTM, Karl Storz, Germany) and a semi-disposable, high flow insufflation-aspiration system (Endoflator 50TM and S-PilotTM, Karl Storz, Germany). Results: 24 suitable patients with middle and low rectal cancer undergone TATME with this device. The procedure was completed in all patients, with intact mesorectum in 23/24. Mean operative time was 292 min (range 180–510 min). The morbidity rate was 20%, including five radiologically detected anastomotic leakage (grade A) and two pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A mean of 14 nodes (range 5–24) were retrieved per specimen. Mean length of hospital stay was 8 days (range 6–22 days). We reported no complications related to the use of the port and the overall stability of the pneumo-rectum was judged as sactisfactomy Conclusion: TA-TME can be satisfactory performed also using reusable platform

P195 - Intestinal, Colorectal and Anal Disorders

P197 - Intestinal, Colorectal and Anal Disorders

Survival and Local Recurrence After Laparoscopic Lower Rectal Cancer Resection

Comparison of Outcomes After Sphincter-Saving Resection and Abdominoperineal Resection for Low Rectal Cancer

S. Yamaguchi, T. Ishii, J. Tashiro, H. Kondo, K. Hara, M. Ogura, M. Aikawa, S. Sakuramoto

D.W. Kang, H.D. Kwak, S.J. Baek, J.M. Kwak, J. Kim, S.H. Kim

Saitama Medical University International Medical Center, HIDAKA, Japan Purpose: Although controversial, laparoscopic resection for lower rectal cancer is increasing. Local recurrence is one of the biggest issue after rectal cancer resection. In this study, survival and local recurrence (LR) of laparoscopic lower rectal cancer resection were assessed retrospectively. Patients: Since 2007 to 2014, laparoscopic lower rectal cancer resection underwent for 216 patients, curatively. Mean age was 64.0 and 143 were male. Preoperative chemoradiation was performed for 5 patients. Procedures were; LAR 120, ISR 68, APR: 20, Others 8. Conversion to open surgery was 1.9%, mean operative time was 281 min and blood loss was 41 g. Anastomotic leak was observed in 6.8%. Pathological stage was; I 93, II 40, III 79. Mean observation was 1090 days. Results: Five-year overall survival and 3-year relapse free survival according to stage were; I: 94.1%, 91.1%, II: 94.1%, 73.4%, III: 87.5%, 77.4%, respectively. LR rates of each stage were; I: 3.2% (3/93), II: 12.5% (5/40), III: 3.8% (3/79). The sites of recurrence were lateral lymph node: 3, anastomosis: 3 (all of those were stage I or II), the levator muscle: 2, the piriformis:1 and presacrum: 1 (all of those were stage II, III). According to procedures, LR was 2.5% of LAR, 10.3% of ISR, and 5% of APR. According to attending surgeon, LR was; A: 1.5% (2/132), B: 11.6% (5/43), and C: 7.7% (2/26). Conclusion: Local recurrence after laparoscopic resection for lower rectal cancer was almost acceptable, however stage II and ISR were rather high recurrence rate, also surgeon looks like another factor.

Korea University Anam Hospital, SEOUL, Republic of Korea Aims: The aim of this study was to evaluate the outcomes following sphincter-saving resection (SSR) compared with abdominoperineal resection (APR) in low rectal cancer. Methods: All consecutive cases undergoing minimally invasive SSR and standard APR between September 2006 and December 2013 at Korea University Anam Hospital, was reviewed, with 127 cases in total (SSR, n = 92; APR, n = 35). All patients were treated by laparoscopic or robotic surgery. Perioperative clinicopathologic outcomes, oncologic outcomes, and prognostic factors affecting survival were evaluated. Results: The median follow-up period was 45.6 months. Perioperative clinicopathologic outcomes were not significantly different except tumor height from anal verge. The 5-year local recurrence rate was 8.5% in SSR group, and 12.8% in APR group (p = 0.354). The 5-year disease-free survival rate was 71.7% and 56.3% (p = 0.190), and the 5-year overall survival rate was 82.7% and 69.6% (p = 0.346), respectively. In multivariate analysis, age, yp/pTNM stage, and adjuvant chemotherapy were identified as prognostic factors for overall survival. Conclusions: This study shows that SSR may be comparable to APR in perioperative outcomes and also oncologic outcomes in patients with low rectal cancer.

123

Surg Endosc

P198 - Intestinal, Colorectal and Anal Disorders

P200 - Intestinal, Colorectal and Anal Disorders

Is the Benefit of Laparoscopy Maintained in Elderly Patients Undergoing Rectal Cancer Resection? An Analysis of 446 Consecutive Patients

Stump Appendicitis, an Unfinished Business!

` la Denise, G. Manceau, E. Hain, L. Maggiori, C. Mongin, J. Prost A Y. Panis Beaujon hospital, CLICHY, France Aims: Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age. Methods: From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age \ 45 (n = 44), 45–54 (n = 80), 55–64 (n = 166), 65–74 (n = 95) and = 75 years (n = 61). Results: Elderly patients presented significantly higher ASA score (p = 0.004), higher Charlson Comorbidity Index (p \ 0.0001), and more frequent cardiovascular, pulmonary (p \ 0.0001) and neurological (p = 0.03) comorbidities. Overall postoperative morbidity rate was similar between groups (34%-35%-37%-43%-43%, p = 0.70). Medical morbidity slightly increased with age (14%-9%-14%-19%-26%, p = 0.06) but there was no significant difference regarding clinical anastomotic leakage, surgical morbidity, major morbidity (Dindo = 3), cardiopulmonary complications and length of hospital stay. In multivariate analysis, age was not an independent factor for postoperative morbidity, unlike ASA score = 3 (p = 0.039), neoadjuvant radiotherapy/chemoradiotherapy (p = 0.034), and operative time = 240 min (p = 0.013). Conclusions: This study showed that laparoscopic rectal cancer resection might safely be performed irrespective of age. Elderly patients seem to benefit more from a laparoscopic approach than do younger patients.

M. Aremu, M.J. Naqeeb, S.S. Ahmad, K. Khalilullah, N. Couse, M. Sugrue, M.A. Aremu Letterkenny University Hospital, LETTERKENNY, CO. DONEGAL, Ireland Appendicectomy is the foremost procedure being taught to the surgical trainees. Stump appendicitis is an acute inflammation of the residual appendix, and is an under-reported complication that can occur after open or laparoscopic appendectomy. All operative notes and charts of patients who had laparoscopic and open appendicectomy in our institution between January 2012 and October 2015 were reviewed retrospectively. Three cases of stump appendicitis were identified; their chart notes, laboratory results, radiology reports and management were reviewed. One patient presented after two weeks, second patient after five months, and the third patient after two and half years of the appendectomy. All patients were diagnosed on the basis of clinical suspicions and CT evidence of stump appendicitis and were all treated conservatively with intravenous antibiotics. Stump appendicitis should be considered in the differential diagnosis for patients with right iliac fossa pain after previous appendectomy as misdiagnosis may cause a delay in the treatment and increase morbidity.

P199 - Intestinal, Colorectal and Anal Disorders

P201 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Rectovaginal Wall Mesh Reinforcement in Symptomatic Rectocele in Women

Laparoscopy Endoscopy Cooperative Surgery to Colorectal Tumor

J. Bellido Luque1, J. Gualajara Jurado1, J. Gomez Menchero1, J.M. Suarez Gra´u1, A. Bellido Luque2, A. Tejada Gomez3, J. Garcı´a Moreno1

Y. Fukunaga, Y. Tamegai, M. Ueno, S. Nagayama, A. Chino, Y. Fujimoto, T. Konishi, T. Akiyoshi, T. Nagasaki Cancer Institute Hospital, TOKYO, Japan

1

Riotinto Hospital, MINAS DE RIOTINTO, HUELVA, Spain; 2 Quiro´n Sagrado Corazo´n Hospital, SEVILLE, Spain; 3Infanta Elena Hospital, HUELVA, Spain Rectocele is one of the anatomical abnormalities in pelvic floor. Differents alterations in the defaecation mechanism can be present, such as pelvic floor dysynergia or anismus, intussusception, rectal inertia, perineum descent, etc., the clinical symptoms may overlap and several anatomical findings may co-exist simultaneously, often in association with psychological disturbances. Materials and methods: We present 19 pacients with symptomatic rectocele III-IV. All patients were fully investigated according to a standard protocol including a full history and examination by anoscopy. Colonoscopy or barium enema was also performed to exclude colorectal cancer or megarectum. Dinamic MRI is perfomed to show genital prolapse and rectocele. Inclusion criteria are symptomatic rectocele, genital exploration with grade III/IV rectocele. Exclusion criteria are contraindications to general anaestesia, previous pelvic surgery and recurrences. Surgical technnique includes laparoscopic dissections of rectovaginal wall and prosthetic reinforcement using a non-absorbable mesh attached to puborectalis muscles. Mesh is fixed to promontory. If there are pelvic organ prolapses associated, Colposacropexy with new mesh is performed. In order to assess the results of the surgical procedure, patients are asked to improve symptoms 1,6,12,24 months after surgery and dinamic pelvic MRI is performed annually Results: In 84%(16) of the patients, symptoms improve or disappear. In 16%(3) of the patients present perineal discomfort with the defecation or dyspareunia due to mesh related at 1 year after surgery. After two years follow-up no radiologic recurrences are shown. Only 1 patients complains of discomfort perineal. Conclusions: Laparoscopic prosthetic rectovaginal wall reinforcement provides good midterm results. Transabdominal minimal invasive surgery is an alternative to perineal surgery in symptomatic III/IV, and it could be considered in recurrences after perineal rectocele repair. If colpocele or cystocele are associated, colposacropexy should be added to the procedure.

123

Background and aim: Some colorectal lateral spread tumors are difficult to be resected completely, meaning one-piece, or safely by only endoscopic technique because of various factors. Upon recent drastic development of endoscopic and laparoscopic technique for colorectal lesion, a newly established safe resection procedure approached by both laparoscopic and endoscopic ways (Laparoscopy endoscopy co-operative colorectal surgery; LECS-CR) was previously reported. We collected 11 cases of LECS-CR and these cases were investigated this time. Patients: Eleven colorectal lateral spread tumor patients underwent LECS-CR. The factors affecting endoscopic submucosal dissection (ESD) were submucosal fibrosis because of previous ESD in 2, surrounding many diverticles in 2, location on the origin of the appendix in 4, difficulty of endoscopic technique in 1, and submucosal tumor in 2 cases. Techniques: Patient is placed under general anesthesia and 5 ports are put. Following confirmation of the tumor location by endoscopy and laparoscopy, the colon wall at the lesion is exposed. Firstly in endoscopically, mucosa to submucosa dissection is performed circumferential to the lesion with appropriate safety margin. Complete full thickness dissection is sequentially performed associated with laparoscopic excision by using an ultrasonic activating scissors. The specimen is withdrawn intraluminally. The opened colon is closed in latitude by laparoscopic linear staplers. Results: Location of the tumors were 9 cases at the colon and 1 at the rectum. The mean operating time and blood loss of this series was 205 min and 13 g respectively. There were no intraoperative and postoperative complications. All cases were discharged uneventfully within 6.5 days in median. Six cases had follow up endoscopy in one year later from the operation and no local recurrences or stenosis at the stapled caliber. Histological examination revealed 4 tubular adenomas with severe dysplasia with sufficient surgical margin, 4 mucosal cancers with adenoma, and 2 submucosal tumor (1 was schwannoma and another carcinoid). Conclusion: LECS-CR may be a feasible procedure for one-piece resection for some colonic lateral spread tumors and submucosal tumor expected for difficulty of the endoscopic resection with minimum removal of the colon.

Surg Endosc

P202 - Intestinal, Colorectal and Anal Disorders

P204 - Intestinal, Colorectal and Anal Disorders

Transanal Total Mesorectal Excision for Rectal Cancer: Preliminary Experience

Prevention of Symptomatic Anastomotic Leakage Without Divertinting Stoma Using Transanal Tube Enema (TATe) Procedure

U. Elmore, A. Vignali, A. Cossu, P. de Nardi, M. Lemma, P. Parise, R. Rosati San Raffaele Hospital and San Raffaele Vita-Salute University, MILAN, Italy

M. Hamada, T. Kobayashi, H. Miki, R. Inada, M. Oishi, T. Matsumoto Kansai Medical University Hirakata Hospital, HIRAKATA, Japan

Background: An oncologically effective total mesorectal excision (TME) still represents a technical challenge. Transanal Total Mesorectal Excision (taTME) and the ‘down-to-up’ mobilization concept might be possible alternatives to the standard TME especially in the presence of a low rectal cancer and anatomical restraints such as obesity or narrow pelvis . Aim: Of this preliminary experience was to test the feasibility and safety of transanal Total Mesorectal Excision and to evaluate its impact on short term functional outcome. Methods: Twelve consecutive patients with histologically proven low/middle rectal cancer were prospectively enrolled. All patients underwent laparoscopic anterior resection with transanal-TME using a 3D digital camera equipment (Olympus, Europe SE&CO.KG). Intraoperative complications, postoperative morbidity and oncologic adequacy of the surgical specimen were evaluated in all patients. A bowel function questionnaire using Information from Wexner’s score continence grading scale was administered to all patients one week before surgery and 6 months following operation. Results: Laparoscopically assisted transanal-TME was successful in all patients. Mean operative time was 227 min (range 200–270 min). There were no intraoperative complications. Anastomotic leak rate was 8.3%(1/12 pts). Clear distal and circumferential margins, and proper lymphadenectomy were obtained in all surgical specimens (mean nodes harvested, 32; range 19–68). Pelvic nerves were well visualized in all cases. A complete mesorectum specimen according to Quirke criteria was obtained in all patients. In no patients a major incontinence was observed according to Median (range) Wexner score at 6 months after surgery was 3 (1–8). Conclusions: Transanal Total Mesorectal Excision is safe and feasible. Preliminary outcomes meet oncologic criteria. Moreover, transanal approach does not have an adverse impact on functional outcome. Further long-term evaluation of results and clinical trials should be performed.

Purpose: The defunctioning stoma (DS) is now considered effective to prevent symptomatic anastomotic leakage after lapraroscopic low anterior resection (LAP LAR).However, defunctioning stomas are associated with various complications, dehydration, and need for a second operation. We present our novel technique for preventing symptomatic anastomotic leakage without DS using transanal tube enema (TATe) procedure. Method: Transanal tube (10 mm silicone gum tube) was inserted after completion of the Double Stapling Technique (DST) anastomosis which intraoperative air leak test was negative. DS was not constructed in the operation. Gastrographin enema examination through TAT tube is performed 3–7 postoperative days. If radiological anastomotic leakage was detected, second operation was performed immediately for abdominal irrigation and defunctioning stoma construction. If the leakage was not detected, TAT was removed and the patient was permitted to start diet. We examined the outcomes of TATe procedure and compared it to that of conventional DS procedure in which DS was constructed selectively for the high-risk patients of anastomotic leakage. Results: From January 2009 to May 2015, 123 patients of the rectal tumor underwent LAP LAR DST with conventional DS procedure (DS group). From May 2015 to January 2016, TATe procedure was adapted in every patient of rectal tumor without neoadjuvant therapy (TATe group, n = 24). There was no difference in age, gender, tumor size, tumor location from anal verge, TNM pT classification, TNM pStage between the groups. In the TATe groups no case encountered symptomatic AL, but 5 cases (20.8%) were revealed radiological AL after TAT enema examination without any symptoms of peritonitis. In the DS group, ten cases (8.1%) encountered symptomatic AL and required not only emergency operation for the acute panperitonitis but also intensive care (difference was not significant between the groups).In terms of stoma construction, 5 cases (20.8%) in TATe group, 56 cases (45.5%) of DS group finally required stoma construction, and the difference was significant (odds ratio 0.31, 011–0.90 p = 0.0194). Conclusion: Unnecessary DS can be avoided by TAT enema procedure after LAP LAR DST. This procedure may suppress the symptomatic AL after LAP LAR DST.

P203 - Intestinal, Colorectal and Anal Disorders

P205 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Surgery For Locally Advanced Colon And Rectosigmoid Cancer: Clinical Outcomes And Prognostic Factors

Laparoscopic vs. Open Resection of Colorectal Cancer - Is There a Difference in Postoperative Quality of Life?

T. Yamanashi, T. Nakamura, T. Sato, M. Naito, H. Miura, A. Tsutsui, M. Watanabe

1

Kitasato University School of Medicine, SAGAMIHARA, KANAGAWA, Japan Aims: In recent years, the laparoscopic surgery for locally advanced colorectal cancer spread rapidly owing to the clinical trials in the world. Meanwhile, the safety of laparoscopic surgery for T4 colon and rectosigmoid (RS) cancer is still not established. We validated the safety and the usefulness of laparoscopic surgery for T4 colon and RS cancer. Methods: The study group comprised 141 patients who underwent laparoscopic surgery for pT4 colon and RS cancer without transverse and descending colon cancer from 2004 through 2012, excluding ones with distant metastasis. There are 82 male patients (58.2%) and 59 female patients (41.8%). The mean age was 64 years old. pStages were II in 49 patients (34.8%), IIIB in 61 patients (43.3%) and IIIC in 31 patients (22.0%), respectively. Operative procedures were ileocecul resection in 19 patients (13.5%), right hemicolectomy in 33 patients (23.4%), sigmoidectomy in 61 patients (43.3%) and anterior resection in 28 patients (19.9%). The median follow-up was 61 months (11-135). We report clinical outcomes and prognostic factors. Results: The operation time was 210 min (130-460). The blood loss was 10 ml (5-655). The postoperative hospital stay was 8 days (4–278). The suture failure occurred in 3 patients (2.1%). The 5-year recurrence-free survival and overall survival rates were 61.3% and 74.1%, respectively. Fifty-four patients (38.3%) had recurrence, and initial recurrence occurred in the liver (n = 16), lung (n = 13), peritoneum (n = 11), para-aortic region (n = 9) and locoregional region (n = 6). The multivariate analysis identified male (RFS; HR 2.00, 95%CI 1.11–3.63, p = 0.02, OS; HR 2.62, 95%CI 1.35–5.10, p0.01), pN1/2 (RFS; HR 3.31, 95%CI 1.32–8.33, p = 0.01) and C/A colon cancer (OS; HR 2.14, 95%CI 1.17–3.94, p = 0.01) as independent prognostic factors. Conclusions: Laparoscopic surgery for T4 colon and rectosigmoid cancer provided good postoperative short-term outcomes. On the other hand, recurrence rates were slightly higher and there is still room for improvement in the long-term outcomes.

P. Ihna´t1, M. Peteja1, P. Gunkova´1, P. Va´vra2, P. Zonca2 University Hospital Ostrava, OSTRAVA, Czech Republic; 2Faculty of Medicine, University of Ostrava, OSTRAVA, Czech Republic

Aims: Quality of life (QOL) assessment plays increasingly important role in the evaluation of different therapeutic modalities nowadays. The aim of this study was to prospectively evaluate QOL outcomes of colorectal surgery (laparoscopic/open) for cancer at a single institution from a 6-month perspective. Methods: This was a cohort study based on prospectively collected data of patients who underwent elective colorectal resection (laparoscopic/open) in University Hospital Ostrava to assess postoperative QOL using a validated Medical Outcomes Survey Short Form 36 (SF-36v2TM)questionnaire at fixed intervals. Results: In total, 148 patients were enrolled into the study (laparoscopic resection was done in 83 patients, open colorectal resection in 65 patients). The two study groups were comparable with regard to demographics and clinical data. In laparoscopic group, operative time was significantly longer (161 vs. 133 min; P = 0.0073); hospital stay was significantly shorter (10.7 vs. 13.1 days; P = 0.0451). There was no difference in postoperative mortality. The difference in overall 30-day morbidity rates was not statistically significant (27.7% vs. 33.8%; P = 0.2116). QOL scores were comparable in both study groups before surgery (P \ 0.05). Statistical testing showed significantly lower QOL (in both - physical and mental components) two days and one week after open colorectal surgery in comparison with laparoscopic surgery. There were no statistically significant differences in QOL scores one month and six months after surgery between both groups. Conclusion: The present study shows that laparoscopic colorectal resection is associated with higher postoperative QOL within the first month after the surgery.

123

Surg Endosc

P206 - Intestinal, Colorectal and Anal Disorders

P208 - Intestinal, Colorectal and Anal Disorders

Analysis of Simultaneous Laparoscopic Hepatectomy and Colectomy for Synchronous Liver Metastases of Colorectal Cancer

Analysis of the Outcome of Routine Covering Ileostomy in Laparoscopic and Open Total Mesorectal Excision (TME)

M. Inagaki, N. Yasui, H. Kajioka, K. Kitada, N. Tokunaga, S. Otsuka, K. Iwakawa, H. Iwagaki National Hospital Organization Fukuyama Medical Center, FUKUYAMA, Japan Simultaneous or separated hepatectomy is recommended if liver metastases are resectable in synchronous liver metastases of colorectal cancer. When simultaneous resections are performed in open laparotomy method, skin incision is extremely wide from upper abdominal to lower abdominal area. So surgical stress becomes extremely invasive. Recently laparoscopic approach has become popular for hepatic and colorectal malignancy. Hereien we analysed the degree of invasiveness in simultaneous laparoscopic hepatectomy and colectomy in synchronous liver metastases of colorectal cancer. We performed simultaneous laparoscopic hepatectomy and colectomy in eight cases. Mean age was 66.5 years old. Seven patients were male and one female. Locations of colorectal cancer were cecal lesion in one case, ascending colon in 3 cases, sigmoid colon in one case and rectum in 3 cases. Operative methods for primary lesions were ileocecal resection in one case, right hemicolectomy in 3cases, sigmoidectomy in one and low anterior resection in 3 cases. Metastatic locations of liver were segment 2 in 3 lesions, segment 3 in one, segment 5 in 2, segment 6 in 2 and segment 8 in 2. Two lesions were detected in three cases. Mean tumor size of liver metastases was 1.6 cm (0.3*4.8 cm). Partial hepatectomy was performed in 7 cases and lateral sectionectomy in one. 2 lesions were resected in three cases. Mean blood loss during operation was 309 ml (50*700 ml). Mean operation time was 444 min (321*671 min). Mean operation time of hepatectomy was 146 min (105*185 min). Mean blood loss during hepatectomy was 64.2 ml (5*250 ml). Mean resected liver volume was 37.7 g (1*192 g). Mean postoperative hospital stay was 19.0 days (12*33 days) and 17.3 days (7*101 days) in laparoscopic colectomy group at the same periods (n = 68) with no significance (p = NS). Postoperative complication was observed in two cases (sepsis and ilesus). No complications concerning hepatectomy including bile leak was seen. Simultaneous laparoscopic hepatectomy and colectomy was feasible and less surgically invasive by reducing blood loss and cosmetically favourable. Mean postoperative hospital stay of simultaneous resection was comparable to laparoscopic colectomy alone and simultaneous laparoscopic hepatectomy and colectomy is a less invasive and beneficial for patients.

M. Matar, N. Naguib, K. Thippesway, L. Sparrow, H. Bakr, A.G. Masoud Prince Charles Hospital, LONDON, United Kingdom Aims: Low anterior resection is associated with relatively high anastomotic leak rate. To mitigate the effect of an anastomotic leak, a covering loop ileostomy is reconstructed on selective or routine basis. The aim of this study is to analyse the outcome of routine covering ileostomy in both laparoscopic and open TME. Methods: This is a retrospective analysis of prospectively collected database of consecutive open & laparoscopic TME performed by a single surgeon over a period of 13 years (2002–2015). Low anterior resection patients were identified. Patients’ demographics, postoperative recovery, hospital stay and complications were recorded. Water soluble enema reports and the reason of failure of reversal were documented. Statistical analysis was performed using ‘student’s t’ test. Results: 76 Patients were identified (35 open and 41 laparoscopic). M:F = 51:25. Median age = 66 (range 43–86). ASA = 3=27 (35.5%). Open resections were mainly performed in the first 5 years and laparoscopic resection were mainly performed in the last 5 years. The mean hospital stay was 6.8 (median = 5) and 12.1 (median = 11) days in the laparoscopic and open resections, respectively (p = 0.0096). 20 Patients (26.3%) received neo-adjuvant treatment.Septic complications occurred in 6/76 patients (7.9%), 3 in each of the laparoscopic and open resections. These included one anastomotic leak (laparoscopic group), 3 had air around the anastomosis treated by antibiotics and 2 collections treated by drainage (per-cutaneous/trans-anal). 6 patients were asymptomatic but had a radiological leak on a water soluble enema prior to the reversal of ileostomy (2 in the laparoscopic group). There were 4 mortalities (5.3%); 1 due to anastomotic leak and 3 due to myocardial infarction in the first year post-operative. 58 patients had their stoma reversed, one was complicated with anastomotic leak (open group). Two patients are currently awaiting reversal. 12/72 patients (16.7%) had no reversal; patient choice (4), co-morbidities (4), metastasis (3), surgical complication (1). Conclusions: Short hospital stay was the only advantage in laparoscopic TME. In 11/72 patients (15.3%), the stoma protected them from septic complication. One patient had anastomotic leak after reversal of ileostomy. 12/72 (16.7%) had the risk of primary anastomosis without the benefit of reversing their stoma.

P207 - Intestinal, Colorectal and Anal Disorders

P209 - Intestinal, Colorectal and Anal Disorders

Value of Laparoscopic Approach for Transvers Colon Cancer

Impact of Laparoscopic Surgery and Length of Stay on Long Term Survival Following Colorectal Cancer Resection

Y. Shingu, E. Sakamoto, S. Norimizu, K. Akahane, H. Watanabe, H. Nakamura, Y. Yonekawa, K. Nishimura, N. Ohara, Y. Akita, H. Kono

N.J. Curtis, E. Noble, E. Salib, M. Awad, R. Hipkiss, R. Dalton, A. Allison, J. Ockrim, K. Francis

Nagoya Daini Red Cross Hospital, NAGOYA, Japan

Yeovil District Hospital, YEOVIL, United Kingdom

Background: The value of laparoscopic surgery for colorectal cancer has been well known, however, laparoscopic approach of transvers colon cancer (TCC) was excluded from the most of previous studies. Therefore, the role of laparoscopic resection for advanced TCC is still under debate. The aim of this study was to evaluate the short and long term outcomes of laparoscopic resection for advanced TCC, in comparison with those of open surgery. Methods: Between January 2004 and March 2015, 268 patients underwent surgical resection for TCC. Of these patients, excluded from this study were 147 patients who had simultaneous multiple cancers, recurrence disease, and stage 0/I/IV disease determined by TMN classification (UICC 7th edition). Remaining 121 patients with stage II or III TCC who underwent potentially curative resection were enrolled. They were divided into two groups: 47 patients treated by open surgery (OS group) and 74 resected by laparoscopic approach (LS group). Their clinical records in our prospectively maintained database were collected, and were compared between two groups. Results: The two groups were homogeneous for clinical feature which includes surgical procedures and tumor stages. Patients in the LS group had significantly longer operative times and less estimated blood loss. Length of postoperative hospital stay were significantly shorter in LS group patients than in OS group. Morbidity rates in LS and OS group were 23.3% and 45.8%, respectively, indicating significantly lower rate in LS group. No surgicalrelated death occurred in both groups. Five-year overall survival rates in LS and OS group were 73.4% and 68.4%, respectively, showing no statistical significance. Conclusion: Although laparoscopic surgery for advanced TCC has a trend toward longer operative times, it made a great contribution to the short term outcomes. Concerning to the long term outcomes, laparoscopic resection was comparable to the open procedure. This study showed that the advantages and feasibility of laparoscopic colectomy is guaranteed in patients with TCC.

Purpose: The short term patient benefits of laparoscopic techniques for colorectal cancer surgery are well proven. This exploratory study aimed to investigate the impact of laparoscopic surgery and length of stay on long term survival following colorectal cancer resection. Method: A prospectively populated colorectal cancer surgery patient database at Yeovil District Hospital UK was reviewed. Data was captured on short term outcomes and Kaplan– Meier methods were used to calculate overall survival (OS) at 5 years. Cox regression model was used to evaluate the factors that predicted survival. Results: 854 colorectal cancer patients had elective surgery (43% female, median age 72 [25–96, IQR 15]) between 2002 and 2015. 481 patients (56.3%) underwent laparoscopic surgery with a 20% conversion rate. There was no difference in tumour stage between laparoscopic and open groups (p = 0.232). Median length of hospital stay was 7 days for laparoscopy [IQR 4 days] and 8 days for open ([IQR 6], p = 0.236). Twelve patients (1.4%) died within 30 days. 136 patients were readmitted within 30 days of discharge (laparoscopic 13.8% vs. 17.8% open/converted, p = 0.092). Five year OS for the cohort was 70%. Significant predictors of poor survival were age [70 (p \ 0.001), male sex (p = 0.01) and disease stage (p = 0.0003). Potentially modifiable poor prognostic factors included open surgery (p = 0.002) and length of stay [7 days (p = 0.003). Conclusion: Laparoscopic techniques and a shorter length of hospital stay are associated with better long term survival following elective colorectal cancer resection.

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Surg Endosc

P210 - Intestinal, Colorectal and Anal Disorders

P212 - Intestinal, Colorectal and Anal Disorders

Short and Long Term Impact of Laparoscopic Conversion in Colorectal Cancer Surgery

Impact of Conversion to Open Surgery on Early Postoperative Morbidity After Laparoscopic Resection For Rectal Adenocarcinoma: A Retrospective Study

N.J. Curtis, T. Dyke, E. Noble, F. Awad, E. Salib, R. Hipkiss, R. Dalton, A. Allison, J. Ockrim, K. Francis Yeovil District Hospital, YEOVIL, United Kingdom

A. Majbar1, M. Abid2, M. Alaoui1, F. Sabbah1, M. Raiss1, M. Ahallat1, A. Hrora1 1

Purpose: Laparoscopic techniques in colorectal cancer surgery have been widely accepted due to short term patient benefits. Patients in whom the operation is converted to a laparotomy may have a worse short term outcome than after a successfully completed laparoscopic procedure. The aim of this study was to investigate the impact of conversion following colorectal cancer resection. Method: A prospectively populated colorectal cancer patient database at Yeovil District Hospital UK was reviewed. Operations were performed or closely supervised by fully trained laparoscopic surgeons. Conversion was defined as the inability to complete the dissection laparoscopically (including the vascular ligation) and or requiring an incision larger than that required to remove the specimen. Overall survival (OS) was calculated by Kaplan–Meier at 5 years. Results: 1023 patients underwent colorectal cancer resection between 2002 and 2015 (median age 73 [25–96], 454 (44%) female), 423 (41%) were for rectal malignancies. Median follow up was 48 months (range 0–168). 854 (83.5%) were planned operations and 169 (16.5%) performed as emergencies. Patient demographics were equal between both laparoscopic and open, but the latter group contained higher stage cancers (p = 0.027). 513 patients (50%) underwent laparoscopic surgery with 108 requiring conversion (21% elective vs. 28% emergency, p = 0.311). Male gender (p = 0.006) and advanced tumour stage (p \ 0.001) were associated with higher conversion rate but age (p = 0.61) and tumour site (colon vs. rectum p = 0.33) were not. Length of stay was shorter in the laparoscopic group compared to converted and open cases (median 7 vs. 9, p = 0.001). Readmission rate was lower in completed laparoscopic cases (p = 0.005). Five year OS was superior in the laparoscopic group compared to converted and open cases (78% vs. 65% vs. 62% respectively, p \ 0.0001). Conclusion: A completed laparoscopic colorectal resection is associated with a shortened length of stay, less readmissions and a higher long term overall survival than those who are converted or undergo an open resection.

Ibn Sina University Hospital, RABAT, Morocco; 2Centre Anticancer, BATNA, Algeria

Background: the impact of conversion to open surgery after a laparoscopic resection for rectal adenocarcinoma on postoperative morbidity is still unclear. Most previous studies included colon and rectal carcinomas and produced conflicting results. The aim of this study was to investigate the impact of conversion to open surgery on early postoperative morbidity in patients who underwent a laparoscopic resection for rectal adenocarcinoma. Methods: this was a retrospective bi-centric study (Morocco and Algeria). It included all consecutive patients who underwent a laparoscopic resection for non-metastatic rectal adenocarcinoma between January 2005 and December 2013. The impact of conversion to open surgery on 30 days postoperative morbidity was analyzed by uni and multivariate analysis. Risk factors for conversion were also investigated by uni and multivariate analysis. Results: One hundred and thirty one patients were included. Conversion rate was 26.7%. The global 30 days morbidity rate was 31.3% (41 patients). Conversion to open surgery was associated to higher rates of postoperative complications, anastomotic leaks and re-operations. It was also an independent predictive factor to postoperative morbidity in multivariate analysis (p = 0.01; Odds ratio: 2.86; 95% CI: 1.23–6.63), in addiction to T4 tumors (p = 0.04; Odds ratio: 3.92; 95% CI: 1.05–14.61). Risk factors for conversion in multivariate analysis were T4 tumors (p = 0.006; Odds ratio 6.09; 95% CI: 1.66–22.32)and height of the tumor (p = 0.025; Odds ratio 2.7; 95% CI : 1.13–6.43). Conclusions: This study showed that conversion to open surgery after laparoscopic proctectomy for rectal adenocarcinoma was associated to higher rates of early postoperative complications. It also showed that T4 tumors and the height of the tumor were independent factor associated to the conversion to open surgery. Reducing postoperative morbidity could be achieved by a better patient selection and a policy of early conversion.

P211 - Intestinal, Colorectal and Anal Disorders

P213 - Intestinal, Colorectal and Anal Disorders

Anastomotic Leak After Anterior Resection for Cancer Reduces Long-Term Survival

Single Incision Laparoscopic Surgery for Multiple Colorectal Cancers

M.E. Allaix, F. Rebecchi, F. Famiglietti, G. Giraudo, A. Arezzo, S. Arolfo, M. Mistrangelo, M. Morino

S. Takanami, Y. Hirano, M. Shimada, K. Douden, M. Hattori, Y. Hashizume

UNIVERSITY OF TORINO, TORINO, Italy

Fukui prefectural hospital, FUKUI, Japan

Background: The impact of anastomotic leak (AL) after anterior resection (AR) for rectal cancer on oncologic outcomes is not clear. The aim of this study was to evaluate the relationship between AL and long-term survival in patients undergoing AR for nonmetastatic rectal cancer. Methods: It is a retrospective analysis of a prospectively collected database including all patients undergoing elective potentially curable AR for rectal cancer. AL was defined as a defect of the intestinal wall integrity at the colorectal or colo-anal anastomotic site leading to a communication between the rectal lumen and the abdominal cavity. Kaplan–Meier curves were compared to analyze overall survival (OS) and disease-free survival (DFS). A multivariable Cox regression analysis was performed to identify predictors of poor survival. Results: Between April 1994 and December 2010, a total of 452 AR for stage 1-3 rectal cancer were performed. AL rate was 7.5%. The 5-year OS rate was significantly lower in patients with AL than in those without AL (70.5% vs. 86.9%; P = 0.016). AL was also associated with poorer 5-year DFS (56% vs. 80.4%; P = 0.001). A local recurrence occurred in 11.7% of patients with AL and in 5.1% in those with no AL (P = 0.11). Distant metastases developed in 38.2% of patients with AL and in 13.9% of those without AL (P = 0.008). AL was an independent risk factor for poorer OS and DFS on multivariate analysis. Less stage 3 patients with AL received adjuvant chemotherapy than patients with no AL. Conclusion: AL is associated with poor survival and a higher rate of distant metastases after curative AR for rectal cancer.

Introduction: Synchronous colorectal neoplasms are defined as two or more primary tumors identified in the same patient at the same time. Synchronous colorectal cancers requiring simultaneous surgical treatment are extremely rare. The aim of this study was to evaluate short-term outcomes of single-incision surgery with two segmental colorectal resections and anastomoses for multiple synchronous colorectal cancers. Methods: This study represents a single-center, retrospective, observational case series analysis. Between August 2010 and May 2015, 550 patients with colorectal cancer underwent SILS at our institution. Ten patients with multiple colorectal cancers underwent two synchronous segmental colorectal resections and anastomoses. The methodology of the procedures, operative results, and postoperative outcomes were evaluated. Results: The median operative time was 270 min (range 146–427 min), and the median blood loss was 70 mL (range 10–260 mL). No conversions to open surgery or intraoperative complications occurred. Four cases needed additional ports, and one patient required diverting stoma construction. All procedures were completed laparoscopically without perioperative mortality. The mean length of the umbilical incision was 2.5 cm (range 2.5–3.0 cm). No cases were readmitted within 30 days. Regarding the oncologic outcome, one patient developed disease recurrence in an ovary. Conclusion: SILS with two segmental colorectal resections and anastomoses was safely performed in all cases without severe postoperative complications. This procedure seems to be a feasible option for resecting multiple synchronous colorectal cancers.

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Surg Endosc

P214 - Intestinal, Colorectal and Anal Disorders

P216 - Intestinal, Colorectal and Anal Disorders

Prospective Multicenter Study on the Need to Use Specimen Retrieval Bags in Minimally Invasive Colorectal Surgery to Prevent Infectious Complications

Cases of Minimally Invasive Right Colectomy with Complete Mesocolic Excision and Intracorporeal Anastomosis. Clinical and Oncologic Results

J.V. Valdes-Hernandez1, S. Morales-Conde2, C. Mittermeir3, L. Capitan-Morales1, I. Alarcon2, J. Cintas1, M. Socas-Macias2, H. Wiess3

W. Petz1, G. Formisano2, P. Misitano2, G. Giuliani2, P.P. Bianchi2 European Institute of Oncology, MILAN, Italy; 2Misericordia Hospital, GROSSETO, Italy 1

1

Virgen Macarena University Hospital, SEVILLE, Spain; 2Virgen Del Rocio University Hospital, SEVILLE, Spain; 3Saint John Of God Hospital, SALZBURG, Austria Aim: The impact of retieving the specimen through a reduced laparotomy during minimally invasive colrectal surgery may be understimated. We conducted a multicenter prospective study to analyze the possible relationship between these manouvers, and the eventual spillage of microorganisms and tumoral cells in the abdominal cavity, in order to determine wether traditional wound protectiona alone is enough, or additional use of retrieval bags for specimen should be advised in minimally invasive colorectal surgery. Methods: 88 consecutive patients form three different institutions were recorded and analyzed. Conventional or single port laparoscopic surgery for malignant and benign problems were included. In all cases, the specimen was brough out trough a previously protected minilaparotomy, but with the additional use of a plastic bag for specimen retrieval. Samples from the abdominal cavity, before and after colorectal manipulation and resection were taken and sent for culture and citology examination. These samples were compared to those taken from the bottom of the retrieval bag after specimen were removed. Statistical analysis of data was made (SSPS 22.0). Results: 49 single port and 39 laparoscopic procedures were included. 36 right colectomies, 36 left colectomies and 16 low anterior resections. Microbiology examination showed 10 positive cultures in the first sample (11,36%), 33 in the second (37,5%) and 59 in the sample taken from the bag(67%)(P \ 001). Citology examination showed only finding of atypical cells in one case out of 69 patients with oncologic procedures. Conclusions: Specimen retrieval through a reduced laparotomy is related to a higher risk of microorganisms spillage in minimally invasive colorectal surgery. The use of retrieval bags might, therefore, help to reduce this risk, and could help to dimisih the risk for surgical site infection and othe complications. Manipulation and dissection manouvers are related to a higher risk of spillage in minimally invasive colorectal surgery, specially in those cases with single port approach, malignant diagnosis, longer postoperative stay and intracorporeal anastomosis. The use of a specimen retrieval bag may be specially useful in these cases. The impact of these manouvers on the spillage of malignant cells remains unclear and further studies should be done.

Aims: Although technically challenging, intracorporeal anastomosis (IA) after minimally invasive right colectomy (MIRC) has shown some clinical advantages in comparison with extracorporeal anastomosis (EA). This study evaluates feasibility, clinical and oncologic results of a consecutive series of patients. Methods: From January 2009 to November 2015, 112 patients underwent MIRC (69 laparoscopic (LAP), 43 robotic (ROB)) with IA for adenocarcinoma. Preoperative assessment was performed with endoscopy and tumour biopsy and computed tomography scan of the thorax, abdomen and pelvis. A complete mesocolic excision (CME) was realized in all cases. Results: Patients median age was 69 years (range 24–90), median body mass index was 24 kg/m2 (range 18–39). Median surgical time was 193 min (178 in LAP group, 210 in ROB group). First bowel movements were observed in 2nd postoperative day, median hospital stay was 6 days. Major complications requiring reoperation occurred in 6 patients (5%); anastomotic complications occurred only in the laparoscopic group (7%); prolonged ileus was observed in one patient (0.8%). Incidence of extraction site infections and incisional hernias was 3% and 2% respectively. Mean number of harvested lymph nodes was 25. American Joint Committee on Cancer stage was 0 in 24 patients (21%), I in 16 (14%), II in 39 (35%), III in 22 (20%) and IV in 11 patients (10%). At a mean follow up of 29 months, overall survival rate is 92% and disease-free survival rate is 86%. Conclusions: In this series, MIRC with IA and CME was oncologically safe, as demonstrated by the high number of harvested lymph nodes and by survival rates; in the ROB group there were better clinical results with no anastomotic complications.

P215 - Intestinal, Colorectal and Anal Disorders

P217 - Intestinal, Colorectal and Anal Disorders

Selective Lateral Pelvic Lymph Node Dissection: A Comparative Study of the Robotic Versus Laparoscopic Approach

The Benefits of Laparoscopic Colectomy with Natural Orifice Specimen Extraction in the Elderly

H.J. Kim, G.S. Choi, J.S. Park, S.Y. Park, H.J. Lee

J.S. Hsieh1, C.J. Ma2, H.M. Chan2, C.J. Huang2

Kyungpook National University Medical Center, DAEGU, Republic of Korea

1 Kaohsiung Medical University, KAOHSIUNG, Taiwan; 2Kaohsiung Medical University Chung-Ho Memorial Hospital, KAOHSIUNG, Taiwan

Aim: Lateral pelvic lymph node dissection (LPND) is a challenging procedure due to its technical difficulty and higher incidence of surgical morbidity. We compared short-term outcomes between laparoscopic and robotic LPND in patients with rectal cancer. Methods: Between May 2006 and December 2014, prospectively collected data from consecutive patients undergoing robotic or laparoscopic total mesorectal excision (TME) with LPND were retrospectively compared. Patients’ demographics, perioperative outcomes, functional results, and initial oncologic outcomes were analyzed. Results: Fifty and 35 patients underwent robotic or laparoscopic TME with LPND, respectively. Bilateral LPND was performed in 10 patients (20%) in the robotic group and 6 (17.1%) in the laparoscopic group. For unilateral pelvic dissection, the mean operative time was not significantly different between groups (robotic vs. laparoscopic group, 41.0 ± 15.8 min vs. 35.3 ± 13.4 min; P = 0.146), but the estimated blood loss was significantly lower in the robotic group (34.6 ± 21.9 mL vs. 50.6 ± 23.8 mL; P = 0.002). Two patients (4.0%) in the robotic group and 7 (30.4%) in the laparoscopic group experienced Foley catheter reinsertion for urinary retention postoperatively (P = 0.029). The mean number of harvested lateral pelvic lymph nodes was 6.6 (range 0–25) in the robotic group and 6.4 (range 1–14) in the laparoscopic group. During the median follow-up of 26.3 months, 2 patients in the robotic group and 4 in the laparoscopic group had local recurrences. Conclusions: Robotic TME with LPND is safe and feasible with favorable short-term surgical outcomes.

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Aim: Laparoscopic natural orifice specimen extraction (NOSE) colectomy might decrease potential risks of wound complication and improve immediate postoperative outcomes. This study intends to examine if there is any clinical benefits of NOSE colectomy in elderly patients with colorectal diseases comparing with those without NOSE. Methods: Between January 2012and December 2015, forty five patients who had various colorectal diseases and were above 70 years old were divided into NOSE (n = 20) and conventional (n = 25) groups. The perioperative outcomes were evaluated between the two groups in terms of pain score, narcotic requirement, inflammatory response and wound complications. Results: Pain scores and the requirement of narcotic were significantly high in the conventional group. Inflammatory responses were greater in patients undergoing NOSE colectomy. However, complications and hospital stay were similar in these two groups. Conclusion: Laparoscopic NOSE colectomy was associated with less pain and lower narcotic requirements than the conventional laparoscopic surgery in the elderly with colorectal diseases.

Surg Endosc

P218 - Intestinal, Colorectal and Anal Disorders

P220 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Right Hemicolectomy with Transrectal Extraction Of Specimen

Early Versus Late Recurrence After Laparoscopic Surgery for Colorectal Cancer: A Cross-Sectional Study Suggesting Different Prognostic Factors

H.H. Tseng, H.M. Chan, C.J. Huang, J.S. Hsieh Kaohsiung Medical University Chung-Ho Memorial Hospital, KAOHSIUNG, Taiwan Aim: To assess the technical feasibility and immediate clinical results of laparoscopic right hemicolectomy with transrectal extraction of specimen. Methods: Following the right colon was completerly mobilized and vessels meticulously ligated. Right hemicolectomy and intracorporeal side-to-side ileo-transverse colostomy were performed with an endoscopical stapler. An incision was done at the anterior wall of the upper rectum for transrectal specimen extraction with the aid of a Transanal Endoscopic Operations (TEO, Karl Storz GMBH & Co.) rectoscope. Results: The operation was successfully performed in 10 male patients. The average operation time was 120 min and blood loss was 85 ml. These patients had an uneventful recovery with a mean hospital stay of 6 days. The median pain score was 2 (range 2–4). There were no any major complications during the perioperative period. Conclusions: Our technique eliminates the need for an additional abdominal incision in patients undergoing laparoscopic right hemicolectomy for specimen extraction and thus decreased the risks of wound morbidity and wound pain. Our results also demonstrate that it is safe and feasible with potential benefits of minimally invasive surgery in selected patients.

I.T. Son, S.I. Kang, H.K. Oh, D.W. Kim, S.B. Kang Seoul National University Bundang Hospital, SEONGNAM, Republic of Korea Aims: Prognostic factors for late recurrence after laparoscopic colorectal surgery remain unclear. We aimed to evaluate the prognostic factors for early and late recurrence in patients who had undergone laparoscopic surgery for colorectal cancer. Methods: Between January 2003 and December 2010, 963 patients who had undergone curative laparoscopic resection for stage 0-III colorectal cancer were enrolled and divided into early (\3 years) and late (=3 years) recurrence groups. We performed multivariate analyses using the Cox proportional hazards model for prognostic factors associated with early and late recurrence. Results: The early recurrence rate was 8.9% and the late recurrence rate was 2.3%. On multivariate analyses, independent factors associated with early recurrence were the TNM stage (hazard ratio [HR] of stage III vs. stage 0-II = 2.221, 95% confidence interval [CI], 1.27–3.87, p = 0.005), peri-neural invasion (HR = 1.920, 95% CI, 1.18–3.12, p = 0.009), and adjuvant chemotherapy (HR = 1.082, 95% CI, 1.08–3.79, p = 0.027). Tumor location was the only independent factor associated with late recurrence (HR of rectum vs. rightsided colon = 5.250, 95% CI, 1.19–23.10, p = 0.028), while the TNM stage was not associated. Conclusions: In this study, we observed that late recurrence after laparoscopic surgery might be more associated with rectal cancer surgery compared to colon cancer, different from the risk factor in the early recurrence.

P219 - Intestinal, Colorectal and Anal Disorders

P221 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Pull-Through Procedure with Side to End Anastomosis for Lower Rectal Cancer

Long-Term Oncologic Safety of Laparoscopic Surgery in T4 Colorectal Cancer: A Non-Randomized Single Center Study

C.L. Li, C.J. Ma, H.M. Chan, C.J. Huang, C.J. Huang, J.S. Hsieh

I.T. Son, S.I. Kang, H.K. Oh, S.B. Kang, D.W. Kim

Kaohsiung Medical University Chung-Ho Memorial Hospital, KAOHSIUNG, Taiwan

Seoul National University Bundang Hospital, SEONGNAM, Republic of Korea

Aim: Surgery for lower rectal malignancy continues a challenge via laparoscopic approach to preserve the anal sphincter function. The present study intends to evaluate the safety and feasibility of the pull-through procedure by laparoscopic approach for lower rectal cancer and reports the immediate postoperative outcomes Methods: The procedures of laparoscopic pull-through procedure included total mobilization for rectum in the fashion of total mesorectal excision, ligation of the inferior mesenteric vessels and transection of the distal sigmoid colon. The distal transected sigmoid colon was retrieved transannally and resected at least 2 cm distal to the tumor margin. The distal rectum was then returned to the pelvic cavity and an intracorporeal side to end anastomosis was performed by an endoscopic stapling device. The perioperative surgical outcomes were evaluated. Results: The operation was successfully performed in 6 patients. There were no any major complications during the perioperative period. The average operation time was 210 min and blood loss was 105 ml. These patients had an uneventful recovery with a mean hospital stay of 6 days. The median pain score was 2 (range 2–4). Conclusions: Our technique avoids the need of abdominal incision in patients undergoing laparoscopic lower anterior resection for specimen extraction and thus decreases the risks of wound pain and wound morbidity, and also adheres the concept of natural orifice specimen (NOSE). It is safe and feasible in

Aims: The long-term oncologic safety of laparoscopic surgery in patients with T4 colorectal cancer remains unclear. In this study, we aimed to evaluate the oncologic prognostic factors in patients with T4 colorectal cancer who had undergone laparoscopic and open surgery. Methods: This study included 225 patients with colorectal cancer of pathological stage T4 between January 2003 and Jun 2012. We reviewed a prospective database that included data on a major additional procedure, the pathological margins of the cancer, and the ClavienDindo classification (CDC) of the patients. Multivariate analysis for disease-free survival (DFS) of T4 colorectal cancer was conducted using the Cox proportional hazards model. Results: The open (n = 147) and laparoscopic group (n = 78) showed difference in the major additional procedure (37.4% vs. 6.4%, p = 0.001); however, no differences in the tumor location, differentiation type, positive pathological margin, and CDC were observed. The short-term outcomes including the operation time, estimated blood loss, and hospital stay in the laparoscopic group were better than in the open group. On a median follow-up of 60 months (range 2–146), the 3-year DFS rate in the laparoscopic group was similar to the open group (75.8% vs. 65.4%, p = 0.354). On multivariate analyses, the independent risk factors associated with DFS were the differentiation type (hazard ratio [HR] of the poor differentiated type vs. well or moderately differentiated type = 2.109, 95% confidence interval [CI], 1.05–4.20, p = 0.041; HR of the mucinous type vs. well or moderately differentiated type = 2.300, 95% CI, 1.08-4.88, p = 0.018) and a major additional procedure (HR = 1.842, 95% CI, 1.02-3.31, p = 0.041), but not for the positive resection margin (HR = 2.695, 95% CI, 0.81-8.86, p = 0.106) and, the positive nodal stage (HR = 1.809, 95% CI, 0.96-3.37, p = 0.063). Conclusions: We confirm that laparoscopic surgery had short-term benefits with long-term safety in patients with T4 colorectal cancer. In addition, this study showed that mucinous or poor differentiated carcinoma had a significant hazard for recurrence in patients with T4 colorectal cancer.

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P222 - Intestinal, Colorectal and Anal Disorders

P224 - Intestinal, Colorectal and Anal Disorders

A Rare Case of Colorectal Complete Anastomotic Stenosis Treated by TEM

Redo Single-Incision Laparoscopic Surgery in Primary Single Incisional Laparoscopic Surgery For Colorectal Surgery

D’Ambrosio, A. Picchetto, R. Palma, C. Panetta, A. Trecca, A. Lamazza, A. Seitaj, S. Campo, A.M. Paganini, E. Lezoche

S.W. Lee, S.H. Yun, S.H. Kim, W.Y. Lee, H.C. Kim, Y.B. Cho, J.W. Huh, Y.A. Park

University of Rome, Sapienza, ROME, Italy

Samsung Medical Center,Sungkyunkwan University School of Medicine, SEOUL, Republic of Korea

Aims: Since the introduction of Natural Orifice Transluminal Endoscopic Surgery (NOTES) in 2004, it has attracted a great deal of interest from surgeons. Transanal Endoscopic Microsurgery (TEM) is a type of NOTES, developed by Buess for rectal tumors, and utilized also to treat other rectal diseases. We achieved a wide experience utilizing TEM to treat rectal disorders such as recto-vaginal fistula, recto-vesical fistula, GIST, etc. We describe a rare postoperative complication solved by transanal approach by TEM. This is an original contribution because after a revision of the literature no other similar cases were described Methods: We present the case of a 36 year-old woman who presented with intermittent abdominal distention, pain and constipation. After Hirschprung Disease was diagnosed, the patient was submitted to a modified Duhamel operation and ileostomy. A postoperative barium enema control showed a complete stricture of the anastomosis. It was impossible to resolve the stricture by flexible endoscopic approach, because no orifice could be detected by the endoscopist. Then an intraoperative endoscopic approach to facilitate the localization of pre-anastomotic colon was performed by a small colotomy and the colonic recanalization was obtained by the creation of a neo-anastomosis by TEM. Results: The patient underwent a control barium enema on 30th POD, showing regular retrograde transit of contrast medium without evidence of stenosis. She underwent a surgical operation for the closure of the ileostomy with regular restoration of intestinal canalization. Conclusions: Transanal approach by TEM is safe and feasible and represents a model of NOTES which can be applied even to a wide range of applications.

Background: Single-incision laparoscopic surgery (SILS) for colorectal surgery is now widely accepted as an alternative to conventional laparoscopic surgery, but we don’t have reports on the clinical availability of redo-SILS in primary SILS for colorectal surgery. Method: This is a retrospective review of prospectively collected data in Samsung Medical Center, Seoul, Korea between April 2009 and December 2015. A retrospective review of 38 patients who underwent redo SILS in 2207 patients who underwent primary SILS for colorectal surgery was perfomed Result: The total 38 case of redo SILS were 24 primary SILS related complication(12 immediate complication, 12 delayed complication), 11 cancer related(5 metachronus, 6 recurrence), and other surgical indication(2 benign mass, 1 colostomy take down). Among 38 cases, 24 were elective operation and 14 were elective operation. Redo SILS route were 29 privious port site and 9 another site. Conversion case were 2 cases (1 case conversion to conventional laparoscopic surgery due to bowel dilatation, 1 case conversion to open surgery due to sever adhesion). Mean OP time and hospital length of stay were 138(min) and 10.1(days). Post operative complication were 7 cases of 38 redo SILS cases(5 minor complication, 2 major complication) Conclusions: In a highly selected patients, Redo SILS in primary SILS for colorectal surgery is feasible and safe by performed experienced single incision laparoscopic surgern

P223 - Intestinal, Colorectal and Anal Disorders

P225 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Complete Mesocolic Exicision for Left Colon Cancer

Technical Challenges of Laparoscopic Splenic Flexure Mobilisation in Difficult Patients

K.Y. Hahn

I. Diaconescu, I. Bratu, I. Beuran

Konkuk University Chungju Hospital, CHUNGJU, Republic of Korea

Emergency Clinical Hospital, BUCHAREST, Romania

The concept of complete mesocolic excision is surgical separation of visceral fascia layer from the parietal fascia resulting in complete mobilization of the entire mesocolon covered by an intact visceral fascial layer on both sides ensuring safe exposure and tie of the supplying arteries at their origin. The extent of the surgical procedures was determined by the location of the cancer and the pattern of potential lymphatic spread (W. Hohenberger et al.).The operative techniques of left colectomy in my experience are as follows, the inferior mesenteric vein is a good landmark for dissection in left colectomy because the left colic artery usually runs parallel to the inferior mesenteric vein. The dissection started from the right side of the inferior mesenteric vein with preservation of the inferior mesenteric artery. In addition, the lymph nodes along the trunk of the inferior mesenteric artery can be dissected, while preserving the hypogastric nerve plexus. The left colic artery is ligated just above its bifurcation. Dissection of the descending colon was carried out using the medial to lateral technique. The dissection is continued cephalad, and the pancreas is freed from the transverse colon mesentery. The inferior mesenteric vein is divided below the pancreas. Once the lesser sac was entered, the dissection moved laterally. Complete lateral mobilization of the left colon up to the splenic flexure is performed. The sigmoid colon and its mesentery are usually mobilized to ensure a tension free anastomosis. An extended wound is created at the paraumbilical area and anastomosis is performed using a linear stapler or hand-sewn method. To prevent postoperative complications, we should decide the extent of colonic resection, central ligation of vessels and range of lymph node dissection considering patients morbidities, condition and age.

Laparoscopic approach of colic tumors is frequently used all over the world with good results whether it is a left or right colic tumor. For left or transverse colic resections, when there should be no tension in anastomosis, splenic flexure mobilisation is a must. This is the most challenging part of the operation especially in obese patients with high visceral fat. The aim of this paper is to present tips and tricks of laparoscopic splenic flexure mobilisation. Anatomical landmarks of trocar insertion, first approach of mobilisation of the splenic flexure from transverse or from left colon, tips on tissue manipulation are described during the video presentation. Also, anatomical details of splenic flexure will be showed in the video. In 3 years we performed 70 laparoscopic colorectal resections of which 37 needed splenic flexure mobilisation. Five of these were transverse colon resections, 20 left colon resections and 12 rectal resections. We converted to open surgery 4 of these patients but only 1 was during splenic flexure mobilisation (splenic capsule effraction). As intraoperative incidents from 37 splenic flexure mobilisations we had 3 splenic bleedings, 1 colic lesion, 3 pancreatic lesions of which none developed acute pancreatitis. In conclusion, every colorectal surgeon must be familiarized with splenic flexure ligaments and intraoperative incidents that might appear.

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P226 - Intestinal, Colorectal and Anal Disorders

P228 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Anterior Resection Using Single Stapling Anastomosis with Natural Orifice Specimen ExtractionTechnique Feasibility and Surgical Outcome

Laparoscopic Versus Open Resection for Colon Cancer in a Low Volume Hospital

S.C. Chang, S. Bansal, W. Chen China Medical University Hospital, TAICHUNG, Taiwan Natural Orifice Specimen Extraction (NOSE) is considered a prequel of Natural Orifice Transluminal Endoscopic Surgery (NOTES) as it eliminates morbidity and post-operative pain related to extraction surgical wound. However, technique of bowel anastomosis relative to NOSE-LAR was high that we used single stapling technique (SST) to overcome it. SST was considered to avoid oblique stapler line, multiple staplers application, crossing of linear and circular staplers and ‘dog ear’ at the ends of stapler line. The goal of this study was to analyze the feasibility of laparoscopic LAR with SST anastomosis and NOSE, comparing their immediate postoperative outcomes with those undergoing conventional LAR with the DST anastomosis. Materials: Patients included in a prospectively maintained database with BMI \ 30 kg/m2 or ASA score I-III, undergoing elective laparoscopic AR for benign or malignant lesions between 10-30 cm from the anal verge, 5 cm or less in diameter on radiological examination, stage T1-T3, Nx, M0, at China Medical University Hospital between from January 2012 to April 2015 were retrospectively analyzed. Patients undergoing NOSE with laparoscopic SST were classified as SST-NOSE-LAR. Patients undergoing conventional laparoscopic AR with conventional abdominal specimen extraction and DST were classified as DST-LAR. Results: The mean age (64.7 vs. 63.3 years) (SD = 12.1) and BMI (24.4 vs. 24.4 kg/m2) (SD = 3.6) were quite similar between the two groups. There was no statistically significant difference in mean tumor diameter between both groups. Operative time was longer for SSTNOSE-LAR (227.9 + 55 min vs. 218.1 + 57) in DST-LAR (p = 0.304). All the patients were followed under Enhanced Recovery after Surgery (ERAS) protocol. Requirement of analgesia (p = 0.007), presence of first bowel movement (p = 0.001) and total hospital stay (p = 0.025) were significantly lower in SST-NOSE-LAR compared to DST-LAR. The overall readmission rate was 3.2% and did not differ between the two groups (4/106 (3.8%) vs 2/82 (2.4%). The overall morbidity was 11% with no significant difference in each group. Anastomotic leak rate and anastomotic bleeding were comparable in both the groups. Conclusion: Although SST-NOSE-LAR demand difficult technique and took longer time, it obtained better shout surgical outcomes and anastomotic successful rate was equal to conventional DST.

P227 - Intestinal, Colorectal and Anal Disorders Is Acetazolamide the Answer to the Intraocular Pressure Rise That Occurs During Laparoscopic Colorectal Surgery? P. Vitish-Sharma, A. Abbas, A. King, A.G. Acheson Nottingham University NHS Trust, NOTTINGHAM, United Kingdom Background: Laparoscopic bowel surgery often requires placing patients in very steeply angled positions for many hours. Perioperative vision loss has been reported but is rare in patients undergoing laparoscopic colorectal surgery. The cause of this is not fully understood, but rises in intraocular pressure (IOP) has been suggested as a possible factor. Recent evidence suggests that head-down positioning can produce a significant rise in the IOP. Acetazolamide decreases IOP by reducing the formation of aqueous humour. Aims: We aimed to investigate if acetazolamide reduces the IOP rise that can occur whilst in the Trendelenburg position. Methods: : The study was a randomised cross-over blinded pilot study. We recruited 9 healthy volunteers who were randomised to either start with the placebo or Acetazolamide with a minimum of 5 days’ washout period between the 2 days. The volunteers and Investigator measuring the IOP on the study days were blinded. Baseline IOP was measured on both the placebo and acetazolamide day. After 1.5 h of taking the medication, volunteers lay head down at 17 degrees’ for 4 h. IOP measurements were repeated in both eyes after the 4 h. This reading was subtracted from the baseline to give a ‘change in IOP’. A negative change in IOP shows an increase, and a positive change shows a decrease. Results: Of the 9 volunteers, 2 were male and 7 female with an average age of 54 years (range: 21–76). The change in IOP after 4 h lying head down placebo and acetazolamide were compared using a student T test. The mean change in IOP after the placebo was 2.15 mmHg (SD 3.34), whereas after Acetazolamide the mean change in IOP was much lower at 0.17 mmHg (SD 3.55). This was statistically significant with a T-value of -2.25 and P = 0.038. Conclusion: Our study shows that IOP does rise whilst in the Trendelenburg position. Acetazolamide can reduce the rise that occurs in IOP whilst in the Trendelenburg position.

R. Scicluna, P. Andrejevic, I. Blazic Mater Dei Hospital, GOZO, Malta Aims: Malta is a Southern European island-state with a population of around 400,000 served by a centralised national health service. Laparoscopic surgery is routinely performed in the treatment of colonic malignancies. Current guidelines recommend a minimum of 12 lymph nodes harvested as the standard of care. The aims of this study were to evaluate the feasibility of laparoscopic resection and to compare our findings with those available in literature. Methods: We performed a retrospective analysis of consecutive patients that underwent laparoscopic or open resection for histologically proven adenocarcinoma of the colon between January 2012 and September 2015. All procedures were performed by the same surgeon and both elective and emergency procedures were included in this study. Our primary aim was to compare lymph node harvesting in laparoscopic versus open resection and to compare our results with those available in literature. Results: A total of 63 patients were included in this study: 44 laparoscopic resections and 19 open resections. Our study included 31 males and 32 females with mean age of 53.2 years (range 34 -93). Median number of lymph nodes harvested in the laparoscopic approach was 15.5 (range 4 to 37). The median number of lymph nodes obtained in open resections was 15.0 with a (ranging 3 to 32). We also looked into the time taken for regaining bowel function, the length of hospital stay and the incidence and severity of 30-day postoperative complications and mortality rates. Conclusion: Laparoscopic resection for colon cancer is feasible and safe with similar short term outcomes when compared to open resections. Our results are also similar to those obtained from large centres and in accordance to international guidlines. These suggest that laparoscopic surgery is indeed a safe option even in low volume hospitals. Larger prospective comparative studies are needed to assess the equivalence of the two approaches.

P229 - Intestinal, Colorectal and Anal Disorders Laparoscopic Approach to Neoplastic Colonic Obstruction After Bridge to Surgery Placement of Self-Expandable Metal Stent M. Berselli1, G. Pagano1, G. Borroni1, L. Livraghi1, L. Latham1, L. Farassino1, V. Quintodei1, C. Cortelezzi1, J. Galvanin1, S. Segato1, G. Carcano2, E. Cocozza1 Ospedale di Circolo e Fondazione Macchi, VARESE, Italy; 2Insubria University, VARESE, Italy

1

Introduction: Colic obstruction is observed in 8-25% patients with colorectal cancer; this condition normally leads to surgical decompression. Endoscopic self-expandable metal stent (SEMS) placement as a bridge to surgery is an alternative to emergency surgery for the colorectal obstruction. There are some advantages in positioning SEMS, such as optimization of the clinical condition of the patient and reduction needing of definitive stoma. Few studies were published to evaluate the outcome of laparoscopic surgical approach after SEMS placement. Materials and methods: A series of patients with colorectal cancer leading acute colorectal obstruction from January 2007 to December 2014 were considered, and a linear regression was applied to analyze variables as patient age, time between the hospitalization and SEMS placement, and the time between SEMS placement and surgery. An analysis of complications related to stent placement, in the early perioperative period (within 30 days of surgery), and in the late postoperative period (over 30 days of surgery) was performed. Results: 33 patients were enrolled in the study. In the SEMS placement both the technical and the clinical success were 100% and the canalization was immediate in all cases after the procedure. Primary anastomosis in the context of a one-stage procedure was performed in 28/33 patients (84%). The rate of conversion to open surgery was 15,15%. An anastomotic fistula occurred in 2 patients (6,06%). Postoperative mortality rate was 6.06%. A trend for statistical significance (p = 0,0708) was observed in the relation between overall postoperative complications and surgical timing (= 7 days versus [ 7 days) after stent placement. Discussion: The use of SEMS as a bridge to surgery allows the surgeon to operate betterprepared patients. This approach can increase the feasibility of the packaging of primary anastomosis. The combination of decompression stenting and laparoscopic colectomy can be considered a valid and feasible treatment for the neoplastic colonic obstructions. A short period has to pass between stent placement and surgical resection. Larger studies can improve in the future this analysis and define the patient population most able to receive benefits from the use of SEMS as bridge for laparoscopic surgery.

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P230 - Intestinal, Colorectal and Anal Disorders

P232 - Intestinal, Colorectal and Anal Disorders

Robotic Rectal Surgery Produces Better Short Term Outcomes in High Risk Patients When Compared to Laparoscopic Surgery

Salvage Surgery After Local Excision of Rectal Cancer by Trans Anal Endoscopic Surgery can be Successfully Performed

J. Ahmed, S. Panteleimonitis, M. Farooq, J. Khan, A. Parvaiz

A.C. Engberts, P.A. Neijenhuis

Queen Alexandra Hospital, PORTSMOUTH, United Kingdom

Alrijne Ziekenhuis Leiderdorp, LEIDERDORP, The Netherlands

Introduction: Laparoscopic rectal surgery is associated with a steep learning curve and high conversion rate. Robotic systems can overcome some of these challenges due to better ergonomics and stable camera views in the pelvis. High-risk patients pose additional technical challenges during minimally invasive surgery. In this study we compared the perioperative outcomes of laparoscopic and robotic rectal cancer surgery in high-risk patients. Methods: Prospectively collected data for consecutive patients between May 2013 and November 2015 was analysed. High-risk patients were defined as patients with either one of the following characteristics: BMI of = 30, male gender, preoperative chemo-radiotherapy, tumour \ 8 cm from the anal verge and previous abdominal surgery. Chi Square and Mann–Whitney’s U-tests were used for categorical and continuous data respectively. Results: A total of 184 high risk patients were identified. Both the robotic (n = 99) and laparoscopic (n = 85) group had similar baseline characteristics. Robotic surgery was associated with a significantly better sphincter preservation rate (86% vs 74%, P = 0.045), hospital stay (7 vs. 9 days, p = 0.003), blood loss (10 vs. 100mls, p = 0.001), operative time (240 vs. 270 min, p = 0.046) and conversion rate to open surgery (0% vs. 5%, p = 0.043) when compared with laparoscopy. Re-operation, anastomotic leak rate, 30 day mortality and oncological outcomes were comparable in both groups. Conclusion: In this single center study, robotic surgery in high-risk patients is associated with higher sphincter preservation, reduced blood loss, better conversion rates, shorter operating time, and shorter length of stay. Further studies are required to validate these results.

Background: Benign lesions as well as early stage rectal cancer can be treated adequately by local excision like a transanal endoscopic microsurgery (TEM) procedure. If the lesion appears [ pT1 rectal cancer after resection with TEM, a complete total mesorectal excision (TME) is recommended, however, some patients are not willing to undergo further surgery if the lesion is radically removed and opt for an intensive follow-up instead. Aim:Aim of this study is to evaluate whether salvage surgery in case of unfavourable pathologic outcome or recurrence in follow-up can be safely performed. Methods: In a four-year period 28 patients underwent a local excision by TEM of a malignant rectal lesion. In nine the preoperative diagnosis was benign. All procedures were performed in one referral hospital for TEM. If a malignancy is preoperatively diagnosed further staging with MRI is done whereas in case of a benign lesions on pathology a direct excision by TEM is performed. Results: Of these 28 patients, three were in situ carcinomas which did not recur on followup. Ten were pT1 with 1 recurrence. Seven were pT2 of whom one went on for direct further surgery and six preferred not to undergo direct further surgery. Three of those had a recurrence which all three underwent salvage TME resection. Five were staged pT3, two of them underwent direct further surgery and the other three all had a recurrence of which one was treated by TME resection and the two others refused and opted for another TEM procedure.In the three patients with an undefined stage (no rest malignancy in TEM biopt), one showed a recurrence.In total three TME resections were done directly following the TEM procedure and seven later in the follow up period when a recurrence was diagnosed. In all ten post-TEM resections a R0 resection was achieved and to date no further recurrences were seen. Conclusion: After local excision of a malignant rectal lesion by TEM, further definitive surgery by TME resection can be safely done, either shortly after the TEM procedure in case of unfavourable pathologic outcome either in case of recurrence in follow-up.

P231 - Intestinal, Colorectal and Anal Disorders

P233 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Colectomy for Cancer - Does it Provide Oncologic Safety? A Case Match Comparison for Right, Left and Transverse Colon

Potential Factors Leading to Emergency Presentation in Colorectal Cancer Patients: A Literature Review

A.C. Miron, V. Calu, C. Giulea, M. Nadragea, S. Enciu Elias Hospital, BUCHAREST, Romania

Norfolk and Norwich University Hospital, NORWICH, United Kingdom

Aim: The role of laparoscopic surgery for colon cancer is still a matter of debate, especially for transverse colon cancer. The study aims to evaluate the oncologic safety of laparoscopic resections for right, left and transverse colon cancer. Methods: Thirty-six patients that underwent laparoscopic resections for colon cancer between January 2014 and October 2015 were compared to seventy-nine patients that underwent open resection in the same period. The cases were matched for age, tumor stage, tumor location (right, left, transverse colon) and BMI. The pathology reports for both open and laparoscopic resections were studied and compared for resection margins and lymph node number and involvement. Results: Sixteen patients underwent laparoscopic right hemicolectomy with extracorporeal anastomosis. The pathology reports noted three T4 tumors, the rest being T3. Lymph node ratio was 0.18 with a median of 20.25 nodes harvested. In 2 cases (12.5%) positive circumferential margins were obtained. Thirty five patients underwent the open procedure, with matching tumor characteristics. Positive circumferential margins were obtained in 4 cases (11.42%). Lymph node ratio was 0.21 with a median of 18.3 nodes harvested. Thirteen patients underwent laparoscopic left hemicolectomy. In 3 cases the tumors were staged as T3, the rest being T2 and T1 tumors. Positive microscopic axial margins were obtained in one case (7.7%). The median harvested lymph node number was 14.7 with a lymph node ratio of 0.27. In the 27 open procedures there were no positive margins and the lymph node ratio was 0.22 with a median of 16.2 nodes harvested. Seven patients underwent laparoscopic transverse colectomy. Negative margins were obtained in all cases with a median of 10.3 nodes harvested and a lymph node ratio of 0.31. In the 17 open procedure, negative margins were obtained in all cases as well, but the median harvested lymph node number was 26.7 with a significant lower lymph node ratio of 0.18. Conclusion: Laparoscopic resection for right and left colon cancer offers oncologic safety in terms of resection margins and lymph node harvest. Laparoscopic transverse colectomy does not allow a comparable lymph node harvest.

Background: There are several modes by which patients with CRC initially present, with the route to diagnosis producing a significant impact on eventual outcome. Emergency patients present with advanced disease, resulting in poor outcomes. This high rate of emergency presentation (EP) has been recognised by a number of patient and professional bodies as being unacceptably high. Aim: This systematic review aims to identify and evaluate the patient and general practitioner (GP) factors that contribute to EPs of CRC. Design and setting Systematic review Method: A search of the Medline and Cochrane databases was performed using relevant terms. All full papers published since 1995 commenting on EPs of CRC were included. Case reports and articles from developing countries were excluded. Data was extracted from the articles by two authors based on agreed themes; discrepancies were settled by the senior author. Results: Our systematic review of colorectal cancer emergency admissions identified 42 papers, which highlighted underlying themes contributing to and resulting from emergency admissions. Those patients presenting as an emergency were repeatedly identified as having poorer outcomes, with mortality rates approaching 30%, highlighting the importance of identifying causes for and preventing emergency admission. Conclusion: The National Awareness and Early Diagnosis Initiative (NAEDI) (4) has focussed on early diagnosis of cancer as a priority, and has identified primary care as a key to improving the rate of early cancer diagnosis. In order to obtain a comprehensive appreciation of the factors affecting the rate of EPs in CRC it is important to examine existing referral and diagnostic pathways along the patient journey, utilising data from General Practice, Hospitals and Patients in a co-ordinated and linked manner. Our review has highlighted important factors resulting in EPs and potential targets to address to reduce them.

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L. Swafe, J. Hernon, A. Esfandiari

Surg Endosc

P234 - Intestinal, Colorectal and Anal Disorders

P236 - Intestinal, Colorectal and Anal Disorders

Endoluminal Loco-Regional Resection by Transanal Endoscopic Microsurgery For T1 Rectal Cancer: A Valid Alternative to Total Mesorectal Excision

Short- and Long-Term Outcomes 3-Step Treatment with J-Pouch in Patients with Ulcerative Colitis

E. Lezoche1, S. Quaresima1, A. Balla1, M. Guerrieri2, G. Lezoche2, G. d’Ambrosio1, A. Paganini1 1 Sapienza University, ROME, Italy; 2Universita` Politecnica delle Marche, ANCONA, Italy

Aims: TEM is a suitable alternative to TME for the treatment of in situ and early rectal cancer, with low morb/mortality rates and no functional sequelae. The recurrence rate of T1 rectal cancer after TEM is 10-27%. Full-thickness excision en bloc with loco-regional mesorectal fat provided by ELRR has the potential to reduce the recurrence rate and to improve the local nodes’ status evaluation. Aim of the present paper is to report the long term results of this technique in two different centers following the same protocol. Methods: From 1992 to 2015, a total of 1414 patients with rectal cancer have been admitted in two centers (Rome and Ancona). After clinical and imaging evaluation, 120 patients (75 males, 45 females; mean age 67,3 ± 11,9 years, range 32-88) presenting with cT1 extraperitoneal rectal cancer underwent ELRR; 23 of them (19.1%) had a previous incomplete pT1 polypectomy. Results: Mean tumor distance from the anal verge was 5.2 ± 2.3 cm (range 3-12 cm) and mean tumor diameter was 3.3 ± 1.3 cm (range 1–5 cm). Mean operative time was 110 ± 73 min (range 35–300). No intraoperative complication or conversion were observed. Major complications were observed in 20 patients (16.6%): 14 bleeding (11.6%), 4 dehiscence (3.3%), 2 incontinence (1.6%), 1 stenosis (0.8%). Reoperation occurred in 1 case (0.8%) for dehiscence, treated with suture revision and ileostomy. Stenosis was managed by endoscopic dilatation. Final pathology confirmed pT1 rectal cancer in 41 patients. The other patients had: 27 benign lesions, 11 pTis, 16 pT2N0, 1 pT2 N+, 2 pT3N0, 1 pT3 N+, 1 neuroendocrine tumor, 1 GIST, 1 epidermoid cancer. Patients showing advanced cancer and/or high risk pathological features underwent TME (5) or radiochemotherapy (25). At mean follow-up of 122 ± 52 months (range 1-268), the recurrence rate for pT1 patients was 2,4% (1) and disease-related mortality was nil. Conclusion: On the basis of the observed low recurrence rate, ELRR by TEM may be considered a safe and effective treatment for T1 rectal cancer that does not preclude a more radical TME if risk factors or unfavorable features are found at final pathology.

A. Kravchenko First Moscow Medical University named I.M. Sechenov, MOSCOW, Russia Background: The aim of our study was analyse of short- and long-term outcomes 3- step treatment with J-pouch ulcerative colitis. Materials and methods: We evaluated the results 3-step surgical treatment of 22 patients. 20 patients was performed emergency surgery due to some complications of the UC. Average time of previous conventional treatment was 32,8 ± 4,5 months. For all patients first stage of surgical treatment was aimed to removing emergency conditions. Second stage - proctectomy with J-pouch and follow up, ileostomy closure as the third stage. Results: Surgical treatment in first stage in our department was much faster and lasted 4,7 ± 1,6 months compared to the other hospitals - 46,1 ± 39,8 months (p = 0,02). Average period of rehabilitation after the surgical treatment was 4 ± 2 month. Stool frequency was 6,1 ± 2,45 a day. Night stool has one in five patient. 19 of the 20 patients can trace out the character of excrements in J-pouch and control defecation. Pouchitis frequency was 21%. J-pouch leakage was 4%. Conclusions: 3-step surgical treatment of the UC is optimal strategy in case of complicate colitis. It provide to colproctectomy and J-pouch with minimal risk. Also this treatment provide to reach the social rehabilitation and avoid many postoperative complications.

P235 - Intestinal, Colorectal and Anal Disorders

P237 - Intestinal, Colorectal and Anal Disorders

Robotic Approach Improves the Quality of Total Mesorectal Excision for Complex Rectal Cancer: A Comparative Study of Robot Versus Laparoscopy

Laparoscopic Colorectal Surgery. Initial Experience with a Standardized Technique

H.J. Kim, G.S. Choi, J.S. Park, S.Y. Park, H.J. Lee

Regional Institute of Gastroenterology and Hepatology, CLUJ-NAPOCA, Romania

Kyungpook National University Medical Center, DAEGU, Republic of Korea Aim: Robotic surgery has many mechanical advantages over laparoscopic surgery. However, few studies have proven its clinical benefits in rectal cancer surgery. Therefore, we hypothesized that these advantages may help surgeons to facilitate rectal mobilization remarkably easier and more precise in complex rectal cancers. We aimed to identify clinical impact of surgical robot on time for rectal mobilization (Trm) and quality of total mesorectal excision (TME) in comparison to laparoscopy. Methods: Between 2011 and 2015, Trm was checked in 175 and 105 rectal cancer patients undergoing TME by laparoscopy and robot, respectively. In the laparoscopic group, multivariate analysis identified four risk factors for longer Trm: male sex (P \ 0.001), lower tumor location (\6 cm from anal verge, P \ 0.001), preoperative chemoradiation (P \ 0.001) and higher BMI ([25 kg/m2, P \ 0.001). According to the number of risk factors, we categorized all patients into three groups: easy (0–1 risk factor), moderate (2), and difficult (3-4). Results: Total operation time was significantly longer in the robotic group than the laparoscopy group (203.6 min vs. 155.3 min, P \ 0.001). In the easy and moderate groups, Trm was significantly longer in the robotic group (easy group: 30.6 vs. 40.8 min, P = 0.002; moderate group: 37.6 vs. 46.2 min, P \ 0.001). Interestingly, Trm in the difficult group was no longer different between the groups (laparoscopic vs. robotic group, 59.2 vs. 56.5 min, P = 0.483). Additionally, all three subgroups demonstrated significantly low volume of blood loss in the robotic group (easy group: 21.0 vs. 14.8 ml, P = 0.001; moderate group: 27.8 vs. 18.9 ml, P = 0.005, difficult groups; 44.2 vs. 19.3 ml, P \ 0.001). Lastly, quality of TME was similar between the groups for all patients (complete, laparoscopic vs. robotic group, 89.7% vs. 92.4%, P = 0.528), but in difficult group, it was significantly better in the robotic group (complete, laparoscopic vs. robotic group, 66.7% vs. 87.8%, P = 0.041). Conclusion: Despite nature of a surgical robot resulted in longer operation time, rectal mobilization in complex cases was easily completed with a significantly clearer surgical field. Subsequently, the quality of TME for rectal cancer was improved by the robotic approach in difficult cases. Our data enlightened potential of the robotic approach in selected patients with rectal cancer.

A. Bartos, D. Bartos, R. Stoian, C. Breazu

Aims: Even if the benefits of laparoscopic treatment of colorectal cancer are well known and have been proven, this approach is still not yet considered the gold standard. Some of the reasons are the lack of proper training and the long learning curve, the last being reached, according to the literature, at approximately 50 operated cases. In this study we wanted to prove that very good results can be reached in laparoscopic colo-rectal surgery even before finishing the learning curve, one of the main condition being the use of a standardized approach. Material and method: We present the initial experience of a single surgeon, currently situating itself in the middle of the learning curve indicated by the literature. The study includes the first 20 patients with colorectal tumors on which radical resections were performed by this surgeon. Pre and postoperative management and operative technique were standardized in all cases (patient position, trocar’s sites, the same camera assistant, the same technique of dissection, the same electrosurgical devices, etc.). Fast-track protocol was used in all patients. All surgeries respected the principle of complete mesocolic and mesorectal excision (TEM). We analyzed the rate of complications, postoperative deaths and recovery parameters. Results: There were 6 abdominoperineal resection, 6 low anterior resection, 8 segmentar sigmoid resection. Mean operative time was 235 min with a median blood loss of 100 ml. Mean time to flatus was 1.4 days and the mean length of hospital stay was 6 days. Overall morbidity was 15%, represented only by Clavien - Dindo I complications: 3 patients with wound infections at specimen extraction site. There was no anastomotic leak, no mortality and no 30 days readmission. Conclusions: We believe that in terms of standardized technique and when performed by the same surgical team, oncological laparoscopic colorectal surgery is safe, with excellent short-term outcomes, even when the learning curve indicated by the experts in the field is not entirety covered.

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P238 - Intestinal, Colorectal and Anal Disorders

P240 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Treatment of Synchronous and Metachronous Colorectal Tumours: A Single Centre Experience

Early Results of Laparoscopic Ventral Rectopexy (LVR) For Internal (IP) and External (EP) Rectal Prolapse In Korea

S. Panteleimonitis, J. Ahmed, M. Farooq, J. Khan, A. Parvaiz

D.S. Lee, D.S. Kim, D.H. Lee, E.G. Youk

Queen Alexandra Hospital, PORTSMOUTH, United Kingdom

Daehang hospital, SEOUL, Republic of Korea

Introduction: Synchronous and metachronous tumours are reported to account for 3% to 5% of all colorectal cancers. There is little evidence as to whether laparoscopic treatment of those tumours is a viable option. We present the outcomes of patients with metachronous and synchronous colorectal tumours receiving laparoscopic surgery in a single centre unit over the last 6 years. Methods: Patients with a metachronous or synchronous colorectal tumour treated with laparoscopic surgery were identified from a prospectively collected database. All patients were treated in a single centre institution form January 2009 to June 2015. We present their outcomes. Results: In total 1577 patients had colorectal resections during this period, with 77% (n = 1214) having laparoscopic and 23% (n = 363) open surgery. Thirty-five of those patients had synchronous and 8 metachronous tumours. Twenty (57.1%) patients with synchronous tumours were operated laparoscopically and seven (88%) of the patients with metachronous tumours received laparoscopic surgery during their second operation. 30 day re-admission rate was 14.3% in the synchronous group and 20% on the metachronous group. There were no anastomotic leaks or 30-day mortalities in either group. Median length of stay was 9 days in the synchronous group and 6 days in the metachronous group. Conclusion: Laparoscopy was successfully applied during the second operation of patients with metachronous colorectal tumours and in patients requiring surgery with synchronous tumours. Laparoscopic surgery is a viable option for the resectional treatment of synchronous or metachronous colorectal tumours.

Introduction: For the last decade, LVR has been the most popular treatment for an IP and EP in Europe. According to the literature, LVR for treatment of EP showed similar recurrent rates and better functional outcomes in comparison with traditional suture rectopexy. LVR is also effective in correcting IP such as rectocele, rectal intussusceptions and enterocele with obstructed defecation(OD) and fecal incontinence(FI). There has been little reports for early results of LVR yet in Asia. This study was designed to assess the early results of LVR in patients with IP and EP. Methods: From September 2013 to December 2015, 68 patients with IP (n = 32) and EP (n = 36) underwent LVR in single institute. EP was absolute indication for LVR. But, the patients with IP were strictly selected for the surgery after the conservative management for at least two months. Preoperatively all patients received colonoscopy, a colon transit time test, cinedefecography and anorectal function test. The constipation score and FI score were evaluated by using the Cleveland Clinic Florida (CCF) score preoperatively and at 6 month after the surgery. The questionnaire for the change of OD or FI symptom after the surgery was given to grade as cured, improved, unchanged and worsened. Results: The mean age of the patients was 59 ± 12.9 (19–84) years. 10 males who had EP were included. The mean operation time was 104 (85–195) minutes, and the mean hospital stay was 4.8 (3–14) days. The mean follow-up was 14.1 (1–32) months. There were no mesh related complications. Three patients among EP group needed additional resection through perineal approach after LVR. Both constipation and FI score were significantly improved after the surgery (p \ 0.001,respectively). 52 patients who had OD were graded as cured, improved, unchanged and poor in 14 cases (26.9%), 27 cases (51.9%), nine cases (17.3%) and two cases (3.8%), respectively, while 36 patients who suffered from FI were cured and improved in seven cases (19.4%) and 26 cases (72.2%), respectively. Conclusion: LVR is a reproducible and safe technique to treat EP and IP. LVR seems to improve both OD and FI in patients with EP and IP.

P239 - Intestinal, Colorectal and Anal Disorders

P241 - Intestinal, Colorectal and Anal Disorders

Colorectal Cancer Surgery in Elderly in Russia: Risk Factors and Results

CT Guided Drainage for Septic Intraabdominal/Thoracal Complications - A 3 Years Analysis

A. Kravchenko1, P. Tsarkov2, I. Tulina2, S.D. Markariyan2

A. Shamiyeh1, B. Klugsberger1, G. Klinmbacher1, H. Kratochwil2, P. Oppelt3

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2

First Moscow Medical University named I.M. Sechenov, MOSCOW, Russia; I.M. Sechenov First Moscow State Medical University, MOSCOW, Russia Introduction: surgical treatment of elderly patient is a real challenge, especially in oncology. Main risk factors for this age group is comorbidity. In elective colorectal cancer surgery decision-making process should be made by multidisciplinary team of experienced professionals.Purpose: review the outcome of elderly patients undergoing major colorectal surgery Materials and methods: A review of 122 patients who underwent colorectal cancer surgery. Before the surgery, all patient were evaluate by multidisciplinary team, including surgeon, anesthesiologist, intensive care specialist, cardiologist, neurologist, and other specialists if it was needed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores were also calculated. If there was decline in normal function of any system or organ, complex therapy was prescribed and after mean time of two weeks patients were reevaluate for surgery. Outcome measures were morbidity rates, 30-day mortality rates and overall survival. Results: the patients had a average age 79 (range 75–95 years). The index of comorbidity was 7.5 (4–11) and 82% of patients were classified ASA III and above. The predicted mortality rate based on CR-POSSUM was 13.2%. All patients were preoperatively treat during mean time of 12.7 days, 11 patients (9%) were implanted temporary pacemakers. All operations were elective and open. Curative resection with primary anastomosis was performed in 106 patients (87%), APR was made in 11 patients (9%) and 5 patient (4%) received Hartmann’s procedure. Postoperative complications were presented at 66 (54%) patients (anastomosis failure, gastroduodenal ulcerative lesion, festering of postoperative wound, arrhythmia etc.). The overall observed postoperative 30-day mortality was 4.9%, cumulative 5-year survival - 67.3 ± 5,6%, cancer specific survival - 77.1 ± 4,4%. Analised the rate of everyday dependence on one’s people we revealed at the most 27% our patients needed partial help and only 4% of patients who required permanent care. Conclusion: treatment decisions must be individualized based on each older person’s physical state (their function and degree of comorbidity) and not on chronological age. Involvement of multidisciplinary team in decision-making process lets surgeons achieve acceptable morbidity, mortality and survival rate in the most complex population of elderly patients with colorectal cancer.

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1 Kepler University Clinic, LINZ, Austria; 2Clinic for Radiology, Kepler University Clinic, LINZ, Austria; 4Clinic for Gyno¨kology, Kepler Univserity Clinic, LINZ, Australia

Background: Revisional Surgery is correlated with a higher morbidity. Radiological controlled interventional drainage are a reasonable alternative to surgery. We present the experience and analysis of 3 years at our clinic. Patients and Methods: From 1.1.2012 to 31.12.2014 CT guided drains or interventions have been performed by 61 patients (43 m, 18f; mean age 63,4 years, range 32–84) due to a septic intraabdominal or thoracic problem. Bacterial Culture has been gained in all cases. The drain management was done according to our clinic standard. The removal of the drain depended on the clinical progress of the patient. We analysed the patients with regard to indication, results, success and complications. Results: 9 patients had a primary problem, 52 had a previous surgical, urological or gynaecological operation (109 colorectal, 4 liver, 4 pancreas, 4 stomach, 2 esophageal, 5 gyn-uro, 4 multiviszeral, 4 biliary, 2 appendectomies and 10 others). In 6 patients a second drain had to be placed after removal. 5 times a consecutive surgery have been added due to disease progress. In 5 patients (82%) the drainage could solve the problem (including 9 patients with a primary problem). The time of drain in situ was median 21 days (range 0–90). 11 patients had oral anticoagulation during the intervention. There was no bleeding complication. There was no multi resistant bacteria in all cases. There was no drain related complication. 2 patients died in the follow up (1 duodenal perforation and 1 multi organ failure in a multi morbid patient). Conclusion: CT guided drainage for the management of septic complications is a safe technique with low morbidity and high effectiveness. It should be always considered before revisional surgery or primarily surgery in case of a septic complication.

Surg Endosc

P242 - Intestinal, Colorectal and Anal Disorders

P244 - Intestinal, Colorectal and Anal Disorders

Does Preventive Conversion Worsen Short and Long-Term Outcomes After Laparoscopic Colic Cancer Resection?

Laparoscopic Low Anterior Resection (Lar) with Totally Intracorporeal Anastomosis, and Anastomotic Leak Detection and Treatment Options

N. de Manzini, A. Turoldo, M. Casella, V. Barbieri, B. Casagranda, M. Giacca University of Trieste, TRIESTE, Italy Background: In colorectal resection for cancer the consequences of a conversion from laparoscopic to open surgery are still not well understood and there is no consensus on these questions. The problem is complicated by the absence of a uniform definition of conversion and by the observation that the results of conversion are reported independently of its cause. This study aims to evaluate the impact of the preventive conversion on postoperative outcomes and long term results among patients undergoing laparoscopic resection for nonmetastatic colon cancer. Methods: In this case–control study were included 257 patients who underwent laparoscopic resection for colonic cancer from January 2004 to November 2013 at the Department of Surgery of the University of Trieste. Patients whit a successful laparoscopic resection for cancer (VLS) were compared with those with preventive conversion (PC). Every unscheduled incision or any incision performed early during surgery was considered a conversion. Under unfavorable local conditions we preferred an early preventive conversion (PC) rather than a reactive conversion (RC) related to an intraoperative complication. The follow-up lasted up to 9 years. Long-term survivals were analyzed using Kaplan–Meier curves. Results: Overall conversion rate of PC was 20,3% (only 1 patient in our experience had a RC). The most common reasons for PC were adhesions (24.5%) and locally advanced cancer (19%). PC was associated with longer operative time but not with differences of oncological radicality, number of lymph nodes, postoperative mortality and morbidity, anastomotic leakage or hospital stay. No differences between the two groups in terms of 5-year overall survival (86.7 VLS group vs 89% CP group; p = 0.89 Log-Rank test) or 5-year disease free survival (84.6% VLS vs 85.9% PC; p = 0.91 Log-Rank test) were observed. Conclusion: Early Preventive Conversion per se is not associated with worse postoperative outcomes and does not affect long-term survival. PC, in case of locally advanced tumors, can be a surgical strategy able to avoid a dissection oncologically incorrect, with possible spread of the tumor. In addition, laparoscopy allows modulating the seat and the length of the laparotomy, with a favorable impact in terms of post-operative trauma, abdomen closure and winding infections.

M. Hernandez, M. jr Franklin, J. Glass Texas Endosurgery Institute, SAN ANTONIO, United States of America Background: It is thought that laparoscopic low anterior resection for lower rectal cancer improves quality of life of these patients. However, it is a highly demanding surgical procedure. Despite an increasing surgical experience and improvement in instrumentation in high volume hospitals, anastomotic leak still remains a challenge. Anastomosis leakage after laparoscopic LAR has been reported as high as 10% despite rapid advances and still remains a substantial problem. This study describes the treatment options when an anastomotic leak is detected or suspected at time of surgery. Materials and methods: Experience of Texas Endosurgery Institute between January 1991 and December 2015, 264 consecutive patients underwent Laparoscopic LAR with intracorporeal anastomosis for rectal cancer. We prospectively collected the leak rate and the treatment of those cases. We used the colonoscope as a tool to performed an anastomosis leak test, and ensure viability and equal coloration of the two segments of colon. Results: In 10 (3.7%) procedures the anastomotic leak test was positive by one or the other method. In 9 cases the anastomosis was repaired with sutures. In one case the anastomosis was redone without diversion. In all cases the anastomotic leak test after repair was negative, and good proximal and distal tissue coloration was present. Two patients demonstrated delayed leak at three weeks and three months post procedure. Conclusions: The Laparoscopic LAR with intracorporeal anastomosis is a difficult procedure, but it greatly improves the quality of life of patients compared with open surgery. LAR with intracorporeal anastomosis for rectal cancer is a safe procedure. It is vitally important to test the anastomosis with direct visualization and air test preferably with colonoscopy, in the case of leak or ischemia, immediate repair is indicated.

P243 - Intestinal, Colorectal and Anal Disorders

P245 - Intestinal, Colorectal and Anal Disorders

Lessons Learned from the First 132 Colorectal Resections within an Enhanced Recovery Programme

Cases in 10 Years of Experience Using Seamguardr (Stapler Line Reinforcement) in Laparoscopic Colorectal Surgery at Texas Endosurgery Institute

G.D. Tebala Noble’s Hospital, DOUGLAS, Isle of Man Aims: Enhanced Recovery Programmes (ERP) are policies and protocols to improve postoperative recovery after surgery. Hereby we report the results of the first audit on the outcome of ERP in colorectal surgery in a unique rural setting. Methods: Data regarding all patients undergoing colorectal resections were prospectively collected since the ERP was implemented at the Noble’s Hospital in the Isle of Man. Results: 132 patients underwent colorectal resection from 4/2013 to 12/2015. Elective cases were 114 and 81.6% of those had bowel cancer. 73.7% of elective patients have been operated on by laparoscopy, whereas none of the emergency patients had laparoscopic resection (p \ 0.0001). Conversion rate was 10.6%. Mean ± SD number of lymph nodes harvested was 15.2 ± 7.2 in elective patients and 15.4 ± 7.8 in elective laparoscopic resections (full ERP) vs 11.3 ± 3.3 in emergency patients (p = NS). Rate of R0 resections was 88.2% in elective patients and 90.4% in elective laparoscopic cases, but was 25% in emergency cases (p \ 0.0001). Total morbidity was higher in emergency patients (27.8% vs 16.7%, p = NS); 30 and 90-day mortality was statistically different between the two groups (0 vs 11.1%, p = 0.001, and 1.8% vs 11.1%, p = 0.046, respectively). Laparoscopic resections were associated with a lower morbidity rate than open resections (14.3% vs 23.3%, p = NS). Median postoperative stay was 5.5d in elective laparoscopic resections, 8d in elective open resections (p = 0.001) and 14d in emergency resections. Almost 40% of patients who had elective laparoscopic colorectal resections were discharged within day4, vs only 3.3% in the elective open resections group. Laparoscopy and younger age were independent predictors for early discharge. 90-day unplanned readmission rate was 8.3% in elective laparoscopic cases vs 13.3% in elective open cases. Conclusions: Results of this prospective audit demonstrate that the ERP actually improved outcome of colorectal resections. Prospective randomized comparison was not possible due to ethical reasons. Laparoscopic elective resections had the best oncologic outcome (highest rate of radical resections) and the best postoperative recovery (lowest morbidity, quicker discharge, lowest readmission rate). If possible, patients with colorectal cancer presenting as an emergency should not undergo emergency resection, but initial damage control surgery and delayed elective resection.

M. Hernandez, M. jr Franklin, J. Glass Texas Endosurgery Institute, SAN ANTONIO, United States of America Background: Anastomotic leak, bleeding, and stricture are recognized complications with increase morbidity and mortality. The frequency of anastomoses leakage rages from 1% to 24%. The leakage rate is generally higher for rectal anastomosis (12%–19%) than for colonic anastomoses (11%). During laparoscopic colorectal surgery, the anastomosis may be created intra or extracorporeally. The aim of this study is to describe our experience, quality of anastomosis, and the low rate of complications in laparoscopic colorectal anastomosis procedures with SeamguardR, and how it improves the outcomes. Methods: Retrospective study and collected data of 739 consecutive patients who underwent laparoscopic colorectal resection and primary anastomosis using SeamguardR since January 2006 to January 2016 were reviewed. Results: There were no differences in patients’ demographics, surgical procedure, and anesthesia used. Complete data was available for 739 patients; 371 (50.3%) female, 368 (49.7%) male. Procedures included were: 305(41%) right hemicolectomy, 222 (30%) sigmoidectomy, 144 (19.5%) low anterior resection, 29 (4%) subtotal colectomy, 28 (3.8%) left hemicolectomy, and 11 (1.5%) transverse solon resection. The diagnoses of the patients were: colorectal cancer 290 (39.5%), diverticulitis 168 (23%), polyps 128 (17.7%), Crohn’s disease 11 (1.5%), dysmotility 4 (0.5%), rectal prolapse 2 (0.3%), ulcerative colitis 12 (1.7%), fistula 22(3%), ischemic colitis 11 (1.5%), perforation 28 (3.8%), volvulus 14 (1.9%), and obstruction 49 (6.7%). Median follow-up was 7 months (range 1–13). Total intracorporeal anastomosis was done in 532 (72%), and hand assisted anastomosis in 207 (28%). There were 3 (0.4%) anastomotic leak detected and treated intraoperativelly. No strictures, and no bleeding in our early postoperative follow-up period. Conclusion: The use of SeamguardR at the anastomosis site is feasible and safe, and seems to show a low rate of stenosis, leaks, bleeding, and better quality of anastomosis.

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Surg Endosc

P246 - Intestinal, Colorectal and Anal Disorders

P248 - Intestinal, Colorectal and Anal Disorders

A Comparison of Nonabsorbable Polymeric Clips and Endoloop Ligatures for the Closure of the Appendicular Stump in Laparoscopic Appendectomy (PRT)

CT Guided Drainage for Septic Intraabdominal/Thoracal Complications - A 3 Years Analysis

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N. Ozlem , C. Elif , M. Kement , T. Mutlu , A. Gurer , H. Calis

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This work was supported by the AhiEevran University, KIRSEHIR, Turkey; 2Samsun education and research hospital, SAMSUN, Turkey; 3 Kartal education and research hospital, ISTANBUL, Turkey; 4 Ankara Ataturk education and research hospital, ANKARA, Turkey; 5 Ahievran University, KIRSEHIR, Turkey The aim of this prospective randomized trial was to evaluate the clinical outcomes of hem o lock ligation system in laparoscopic appendix stump closure by comparin the endoloop ligature. A total of 53 patients were evaluated in this study (n = 26 and 27 for hem o lock and endo loop groups respectively) the mean operation time were shorter in hem o lock group than endoloop group (64 ± 19.2 vs 75.4 ± 23, respectively) however the diferrence was not significant. Other surgical findings were similar there was no statistically significant difference in overall nonoperative hospitalisation time was also similar in both groups. Although it is not possible to make general conclusions on basis of such a limited study in our opinion closur of the appendix stump with polymeric nonabsorbable clips in laparoscopic appendectomy may be a cheaper and simpler alternative to other widely used methods.

P247 - Intestinal, Colorectal and Anal Disorders Which Patient Should Have an Abdominal Ultrasonography to Predict Acute Appendicitis (AA)? N. Ozlem1, H. Calis2 1

This work was supported by the AhiEevran University,, KIRSEHIR, Turkey; 2AHIEVRAN UNIVERSITY research and education hospital, KIRSEHIR, Turkey AA, the most frequent reason of the surgical acute abdomen(A).16(8-30) %of appendectomy(A)specimens are reported as normal A’dix vermiformis by pathologist before. The diagnosis (D)of AA is mainly made as clinical(C),to augment the C D’tic ultrasonography exam (UE) and CT of the A are also being used to help in D of the disease; which all carry some inherent limitations. Our aim is find out UE, labarotory examination(LE)make an advantage to predict AA, to reduce negativeA rate(NAR).582 patients, preoperative(PreOP) D is AA underwent laparoscopy.Of 401 have PreOP UE the remained 181 do not have. 355(88.5%)of401 patients have UE D’ed AA.170(93.9%) of 181 patient who do not have UE PreOp had AA. On the other hand, 46 of 410(11%) patients who have UE the laparoscopy of 11 o f 181 dont have UE PreOP patient show no pathology or any other reason for acute A in the abdominal cavity.This showed that UE has sensitivity of 54.08% specifity of 58.7% positive predictive value (PPV) of 90.99% and negative predictive value (NPV) of 14%. NAR rates between the patient who have UE, dont have statistically are not significant p [ .05. the sensitivity, specifity PPV and NPV of higher value of wbc are respectively 88.19%, 24%.56, 91.50% 18.42%.the predictive values (sensitivity, specifty, PPV, NPVs) of the physical examination(PE) are respectively 99.23%,5.26%, 90.6%, 42.85%. Hussain et reported that all UE has sensitivy of about 90 s PPV and NPV of 85–95, overall accuracy of 90%. Our UE results were poor ones in the recent literature.so they didnot aid to reduce our NAR, also make a pressure on the surgeon(S)decision to make a D’stic laparoscopy.As our results the values below 10000 K/mikrol that is upper limit for Wbc in our patients never must think the patients do not have AA. On the other hand if wbc value raise than upper limit (10.000 K/mikrol). It significantly support PreOp the D of AA. If the value than 20000 K/mikrol is almost always it means the patient has an acute abdominal condition, but it does not also mean he/she has a complicated A’dicitis. The S should principally make the D with PE, LA.PrOp UE help to support DofAA, to reveal any other pathologies that caused acute abdominal conditions.

123

H. Bolkenstein1, B.J.M. van de Wall2, W.A. Draaisma1, E.C.J. Consten1, I.A.M.J. Broeders1 1

Meander Medisch Centrum Amersfoort, AMSTERDAM, The Netherlands; 2Jeroen Bosch Ziekenhuis, DEN BOSCH, The Netherlands Introduction: Diverticulitis is a common disease which results from inflammation of diverticula, outpouchings at weak points in the colonic wall. Most patients (90%) have an uncomplicated diverticulitis, which can be safely treated in an outpatient setting. Complicated diverticulitis, such as perforation or abscess formation, has a high mortality and requires surgical intervention. To avoid unnecessary diagnostics, treatment and hospital admittance it is important to distinguish uncomplicated diverticulitis from complicated diverticulitis. The goal of this systematic review is to identify clinical characteristics and laboratory parameters which can predict complicated diverticulitis. Method: The databases Embase, MEDLINE and Cochrane were searched for studies reporting on risk factors for complicated diverticulitis. Meta-analyses were performed on outcomes when at least four studies reported on the outcome of interest. This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Results: A total of sixteen studies were included with a total of 5641 patients. Studies were heterogeneous in terms of definition of the outcome ‘complicated diverticulitis’. Most were of limited quality. Only the risk factors ‘age’ and ‘sex’ were eligible for meta-analysis, but none showed a significant effect on the risk for complicated diverticulitis. There was low quality of evidence suggesting that CRP, WBC count and clinical presentation are risk factors for complicated diverticulitis. Conclusion: Although high level evidence is lacking, this study demonstrated that certain parameters (CRP level, WBC count, clinical signs) could predict a complicated course of diverticulitis. In order to adequately select patients at risk for complicated diverticulitis a prospective study, aimed at identifying risk factors for complicated diverticulitis, should be performed.

P249 - Intestinal, Colorectal and Anal Disorders Close Rectal Versus Total Mesorectal Excision in Patients with Inflammatory Bowel Disease Undergoing Proctocolectomy or Completion Proctectomy E.J. de Groof1, O. van Ruler1, P.J. Tanis1, W.A. Bemelman2, C.J. Buskens1 AMC, AMSTERDAM, The Netherlands; 2COLOR II Study Group, The Netherlands

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Aim: Proctocolectomy or completion proctectomy in inflammatory bowel disease (IBD) is frequently complicated by disturbed perineal wound healing and presacral abscess formation. Close rectal dissection (CRD) could reduce this complication by leaving rectal mesentery in situ to minimize dead space cavity compared to total mesorectal excision (TME). However, in Crohn’s disease (CD), mesenteric adipose tissue has been associated to CD etiopathology with reduced migratory potential in wound healing fibroblast. Aim was to compare perineal wound healing in ulcerative colitis (UC) and CD patients undergoing TME or CRD. Methods: Patients undergoing proctocolectomy or completion proctectomy without reconstruction for UC or CD (2005–2015) were included. Endpoints were postoperative perineal complications, and healing at 6 and 12 months. Results: 56 patients (16 UC/40 CD) were included (44.6% male, mean age 44.0 years (± 14.0)). CRD was performed in 7 UC (43.8%) and 31 CD patients (77.5%). Laparoscopic approach in 20.8% of patients and laparoscopic handassisted in 13.2%. In UC, significantly less perineal complications (18.8% versus 47.5%, p = 0.05) and a higher healing rate at 6 months (87.5% versus 65%, p = 0.09) were seen compared to CD. There were no significant differences in outcomes between surgical techniques in UC. Perineal complications occurred less frequently in CD patients who underwent TME compared to CRD (22.2% versus 54.8%, p = 0.08), with higher healing rates at 6 months after TME (88.9% versus 58.1%, p = 0.09). Perineal healing rate at 12 months was 66.7% after CRD versus 87.5% after TME (p = 0.44). Healing rates after TME were comparable between UC and CD. Omental plasty was done in 66.6% of CD patients who underwent TME. Patients with omental plasty had perineal wound complications in 33.3% versus none without (p = 0.26). Healing rates were comparable at 6 and 12 months in both groups (83.3% and 80.0% with omental plasty versus 100% without (p = 0.45, p = 0.41)). Conclusion: In UC patients undergoing proctocolectomy or completion proctectomy, there were significantly less perineal complications compared to CD with higher healing rates. Over 50% of CD patients had perineal complications and impaired healing, which was seen more frequently after CRD compared to TME. Performing an omental plasty with TME did not improve outcome.

Surg Endosc

P250 - Intestinal, Colorectal and Anal Disorders

P252 - Intestinal, Colorectal and Anal Disorders

COLOR III Trial 1

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T.W.A. Koedam , C.L. Deijen , S. Velthuis , A. Tsai , S. Mavroveli , E.S.M. de Lange- de Klerk2, C. Sietses4, J.B. Tuynman2, A.M. Lacy5, G.B. Hanna3, H.J. Bonjer2 VUmc, AMSTERDAM, The Netherlands; 2VU University Medical Centre, AMSTERDAM, The Netherlands; 3Imperial College London, LONDON, United Kingdom; 4Gelderse Vallei, EDE, The Netherlands; 5Hospital Clı´nic de Barcelona, BARCELONA, Spain 1

Introduction: The transanal TME (TaTME) has been developed with use of laparoscopic single port platforms to improve the quality of the TME procedure in mid and low rectal cancer. In TaTME, the tumour is distally approached through the anus with laparoscopic instruments. This potentially facilitates a better quality dissection of the distal mesorectum with adequate visual determination of the distal resection margin and intact specimen. Potentially better specimen results in lower local recurrence rate. The new TaTME technique also facilitates difficult resections in the lower pelvis and has been shown to result in relative low morbidity. Study design: The COLOR III trial is an international multicentre randomised study comparing short- and long term outcomes of TaTME and laparoscopic TME for rectal cancer. The study will include a quality assessment phase to ensure required competency level and uniformity of the new TaTME technique and the laparoscopic TME. Patients with a histologically proved single mid or low rectum carcinoma (0-10 cm from anal verge) on MRI, eligible for TME surgery with a curative intent, are included. Main exclusion criteria are T4 tumours, T3 tumours with a suspected involved mesorectal fascia (MRF) after neoadjuvant therapy, patients with concomitant metastases or other malignancies, with malignancies in their medical history or with signs of acute mechanical obstruction by the tumour. The primary endpoint is involvement of CRM. Secondary endpoints include morbidity and mortality, residual mesorectum on postoperative MRI, local recurrence, disease-free and overall survival, percentage of sphincter saving procedures, functional outcome and quality of life. Statistics and randomisation A total of 1098 patients is needed, 732 patients in the TaTME arm and 366 patients in the laparoscopic TME arm. It will be stratified for T-stage, preoperative radiotherapy, height of the tumour, gender and BMI. All analyses will be performed on intention-to-treat basis. Hypothesis: The hypothesis is that TaTME will result in a lower rate of involved CRM and therefore lower rate of local recurrence. F, the TaTME procedure will potentially enable more sphincter saving procedures. These expected results will have positive effect on functional outcome and health related quality of life.

Educational Benefit of Intraoperative Indocyanine Green Angiography for Surgical Beginner During Laparoscopic Colorectal Surgery G.M. Son Pusan National University Yangsan Hospital, YANGSAN-SI, GYEONGSANGNAM-DO, Republic of Korea Aims: This study is to evaluate usability of intraoperative indocyanine green (ICG) angiography during laparoscopic colorectal surgery and whether fluorescence imaging could have educational benefit for surgical beginner to train surgical decision. Methods: Fluorescence imaging system, IMAGE1 SPIESTM (Karl Storz, Germany) was applied to colorectal cancer patients (n = 21) from July to October, 2015. Dosage of ICG for intravenous injection was 0.2 mg/kg. Times to enhance colonic artery and colonic wall were measured before colonic transection. Red color inversion (SPECTRA A mode) and Fluorescence image (ICG mode) were compared with laparoscopic standard image for decision of colonic perfusion and nerve identification. Surgical beginner group including medical students (n = 6) and surgical residents (n = 6) were asked five questions about colonic transection line, mesenteric vascular integrity and nerve identification to find the most preperred view for surgical decision. Results: Mean time to enhance marginal artery and colonic wall was 24.5 (range, 4–45) and 46.9 (range, 20–77) seconds, respectively. Side effect of ICG injection was not happened. Anastomotic leak (n = 1) was occurred on rectal cancer patient with sufficient colonic perfusion. Colonic necrosis (n = 1) was followed after delayed arterial enhance and venous malfunction on sigmoid colon cancer patient. On experienced surgeon and surgical beginner group, changing rates of colonic transection line was 9.5% and 54.2% (33.3–66.7%), respectively (p \ 0.01). Decisions of surgical beginners for transection line were dispersed with laparoscopic standard view, but it was converged to 83.3% with ICG mode. Surgical beginners preferred ICG image for mesenteric vascular integrity and red conversion image (SPECTRA A mode) for identification of hypogastric nerve. Conclusion: Fluorescence imaging with Intraoperative ICG angiography might be safe and useful to evaluate colonic perfusion for decision of colonic transection and could have educational benefit for surgical beginners to train surgical decision.

P251 - Intestinal, Colorectal and Anal Disorders

P253 - Liver and Biliary Tract Surgery

C-Reactive Protein and Procalcitonin as Predictors of Anastomotic Dehiscence in Colorectal Surgery. Preliminary Results

Total Laparoscopic Management of Parasitic and Non Parasitic Cystic Lesions Involving Liver Segments VII and VIII: 3 Port Technique

D. Sanchez Relinque, C. Lara Palmero, F. Grasa Gonzalez, L. Elmalaki Hossain, S. Gomez Modet, M. Rodriguez Ramos

A. Nagpal1, R. Solanki2

SAS Hospital Punta de Europa, ALGECIRAS, Spain

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Introduction: The AD continues to have a not insignificant impact, ranging between 1.8 to 15.9% for colorectal surgery, as well as an increase in morbidity and mortality rates of up to 12-27% according to literature. Objective: Evaluate the correlation between the values of procalcitonin (PCT) and C-reactive protein (CRP) as predictors of postoperative wound dehiscence in colorectal surgery. Materials and methods: Prospective observational study of patients operated for colorectal surgery with anastomosis between July 2014 and December 2015 in our department (both conventional and laparoscopic surgery).Systematic determination of PCT and CRP in the 1st, 3rd and 5th postoperative day. Results: 84 patients operated, 72 patients (40 men and 32 women) were collected, with an average age of 68.5 years. 12 patients were excluded by mistake in determining the values of PCT and/or CRP. 36 were operated for colon left, 23 right colon and Rectum 13. 42 (58,3%) laparoscopy (LS) and 30 (41,6%) conventional surgery (CS). 9 AD (12,5%), 4 by CS and 5 by CL detected. CRP in the third and fifth postoperative day without AD patients was 12.33 (27.45 to 3.9) and 7.54 (25.69 to 1.96) respectively, whereas in the case of AD was 15.39 (24.95 to 10.46) and 25.23 (41.32 to 8.07).). PCT in the third and fifth postoperative day in patients without AD was 0.75 (3.88 to 0) and 0.28 (1.12 to 0.05) respectively, AD was 6.6 (31, from 68 to 0.6) and 8.1 (38.38 to 0.6). Conclusion: Although the sample size is still not enough to provide statistically significant conclusions, the results obtained to date invite us to consider the values of procalcitonin and CRP as a predictor of postoperative anastomotic dehiscence in colorectal surgery, especially on the 5th postoperative day.

Introduction: The laparoscopic accessibility of liver cysts located in the anterosuperior (VIII) and posterosuperior (VII) segments is difficult. In support of the laparoscopic approach, we here describe our minimally invasive technique in 3 consecutive patients with symptomatic solitary cysts located in the liver segments VIII and VII. Method: All patients were placed in the supine position. Three trocars were used including the Palanivelu hydatid cyst trocar. One patient had Hydatid cyst, one had simple liver cyst and the last case was of Recurrent Chronic Liver Abscess. Results: The segment VIII cyst was easily reached via this anterior approach, while the segment VII cyst required some mobilization of the right liver lobe. In all cases a complete excision of the cystic roof was achieved using the harmonic scalpel without performing an omentoplasty. No spillage was seen in the case of Hydatid Cyst. No conversion to open technique was required. No recurrences were observed after one year follow up. Conclusion: Laparoscopic deroofing of the solitary parasitic cyst and non parasitic cysts located in segments VII and VIII of the liver of the liver is a safe and effective procedure. Cyst recurrences may best be prevented by a complete excision of the cystic roof with an adjacent rim of hepatic parenchyma.

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Dr. Jivraj Mehta Smarak Health Foundation, AHMEDABAD, India; Narayana Multispeciality Hospital, AHMEDABAD, India

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P254 - Liver and Biliary Tract Surgery

P256 - Liver and Biliary Tract Surgery

Single Incision Laparoscopic Cholecystectomy with Lagiport

A Cohort Study Evaluating Tertiary Referral of the Difficult Gallbladder: A Better Alternative Management Option

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W.L. Su , L.A. Chen , J.W. Huang , K.T. Lee

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Kaohsiung Municipal Ta-Tung Hospital, KAOHSIUNG CITY, Taiwan; 2Kaohsiung Medical University Hospital, KAOHSIUNG CITY, Taiwan

A.R. Jawad1, A. Fajardo2, A. Draz3, T. Pencavel3, N. Hakim3, L.R. Jiao3 Imperial College, London, LONDON, United Kingdom; 2Imperial College, LONDON, United Kingdom; 3Hammersmith Hospital, LONDON, United Kingdom

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Background: Laparoscopic cholecystectomy (LC) has been the golden standard procedure for the treatment of gallbladder diseases. It’s a safe and efficient surgery. However, as the improvement of the instruments and surgical technique, single incision laparoscopic cholecystectomy (SILC) becomes popular. Methods: During January 2014 to October 2015, 75 patients received SILC. Lagiport, a commercial kit made in Taiwan, was used on 66 patients (88%). The port was composed by three items. A transverse skin incision was made at subumbilical region, and then longitudinal fascial dissection was done to approach into the peritoneal cavity. The wound retractor was applied into the peritoneal cavity, and through the above dissection method, the wound defect will be in a circle fashion. A removable cap was then locked onto the wound retractor. Multiple ports of two 5 mm seal and two 12 mm seal enabled use of a wide range of instrumentation. Camera system with 5 mm elongate scope was introduced for vision of the peritoneal cavity. The manipulation of the cholecystectomy is via Endograb retraction system, 5 mm straight grasper and dissector. Results and Discussion: Male-to-female ratio was 2:3. Mean age was 51.47 ± 13.78 years, body mass index 24.58 ± 3.00 kg/m2, operation time was 72.71 ± 28.75 min, mean blood 21.09 ± 61.93 ml, mean VAS 1.49 ± 1.76 and mean length of stay 4.07 ± 0.92 days. Percentages of acute cholecystitis and intraoperative bile leakage were 29% and 2,67%, respectively. Two patients (2.67%) were converted to 2 ports. Two patients (2.94%) suffered from post operative bile leakage. The mean length of the wound was 1.5 cm. Comparison between the non-cholecystitis and acute cholecystitis groups showed significant differences in omental adhesion, bile spillage rate, operation time, blood loss, and pain scale. Conclusions: Single incision laparoscopic cholecystectomy with the assistance of Lagiport and Endograb retraction system is a safe and fast method for benign gallbladder disease.

Aims: While laparosopic cholecystectomy is considered a low risk procedure, complications such as intraooperative bleeding, bile duct injury and postoperative bile leak occur frequently in the ‘difficlut’ gallbladder with such cases being hard to predict preoperatively. We report a series of complex cases referred to a HPB unit to evaluate the outcome of surgery in a tertiary centre. Methods: A retrospective review of all patients referred to a senior hepatobiliary surgeon from other surgeons with a ‘difficult’ gallbladder between December 2013 and December 2015. Primary outcomes were rate of conversion to open procedure and 30-day postoperative complication rate. Results: A total of 177 patients underwent laparoscopic cholecystectomy during the study period whcih included 34 referred with difficult cholecystectomies. Of these 34 patients, 6 had undergone abandoned laparoscopic cholecystecomies prior to referral with extensive adhesions being cited as the most common reason for abandonment (66.7%). All cases underwent laparoscopy ± proceed to cholecystectomy. 31 cases had cholecystectomy completed laparoscopically (91.2%), total (n = 21) and subtotal (n = 10), 3 were converted to open (8.8%), total (n = 2) and subtotal (n = 2). The 30-day overall complication rate was 5/34 (14.7%). Conclusion: Abandonment or referral of the difficult gallbladder reduces the risk to that of conventional cholecystectomy and should be considered as a safe exit strategy by nonhepatobiliary surgeons.

P255 - Liver and Biliary Tract Surgery

P258 - Liver and Biliary Tract Surgery

Single - Incision Laparoscopic Cholecystectomy by an Abdominal Wall Lifting Method

Aggressive Hydration and Rectal Indomethacin Versus Rectal Indomethacin Only in Prevention of Post Ercp Pancreatitis: A Prospective Comparative Study

H. Ohara, Y. Masuda Heisei Memorial Hospital, FUJIEDA, Japan Background: Since 1994, We have performed 400 cases of laparoscopic cholecystectomy(LC)with good results by an abdominal wall lifting method using our original lifting bars. The bar consisted of a bent stainless steel rod 5 mm in diameter. Our lifting method is suitable for not only cardiopulmonary compromised patients but also the patients with severe inflammation. Single - incision laparoscopic cholecystectomy (SILS) has recently emerged as a less invasive alternative to standard multi -incision LC. We have tried to perform SILS by using our lifting method. This method, including the cost assessment of laparoscopic instrument, will be discussed. Method: Eleven patients underwent SILS between April 2013 and September 2015. One patient showed a negative cholecystogram in preoperative intravenous cholangiography. After placement of wound protector to umbilical incision, two lifting bars were inserted and drawn by winches into positions, that were to the bilateral side of the patient. A mini - loop retractor introduced subcostally was used to retract the GB and visualize Calot’s triangle. All these operations were performed with conventional straight laparoscopic instrument. Results: Only one cases was converted to three - port surgery in liver chirrosis case, but no cases were converted to conventional open surgery. The mean operation time was 96.2 min, and the estimated blood los was 17 ml. The postoperative course was uneventful in all cases. Conclusion: We didn’t have to use the specific multi - channel port and the disposable roticulater, which were expensive. Furthermore, we were able to perform SILS without sacrificing safety. Our lifting method is reasonable and reliable in SILS, too.

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M.A. Selimah, M.R. Abo Elsoud Medical Research Institute, ALEXANDRIA, Egypt Background and aims: Post ERCP pancreatitis remains by far the most common and serious complication encountered in all endoscopy units worldwide. We performed a prospective comparative study to determine whether adding aggressive periprocedural hydration with lactated Ringer’s solution to rectal indomethacin reduces the incidence of pancreatitis after ERCP compared to using indomethacin alone. Patients and Methods: The study was conducted on 200 patients admitted to the endoscopy unit of the medical research institute hospital in the period between November 2013 and November 2015 who had undergone ERCP for various reasons. Patients were randomly divided into equal groups which was stratified according to study center Group A included 100 patients which were assigned to receive aggressive hydration in the form of intravenous lactated Ringer’s solution at a rate of 20 mL/kg immediately after the procedure, plus 100 mg indomethacin suppositories before ERCP. Group B included 100 patients which were assigned to receive 100-mg indomethacin suppositories before ERCP as in group A Both groups primary end points was development of post-ERCP pancreatitis Results: None of the patients in group A developed pancreatitis compared to 4 patients in group B (4%), total length of hospital stay was less in group A compared to group B Conclusion: aggressive intravenous hydration with lactated Ringer’s solution in addition to rectal indomethacin appears to reduce the development of post-ERCP pancreatitis and is not associated with volume overload as compared to rectal indomethacin alone.

Surg Endosc

P259 - Liver and Biliary Tract Surgery

P261 - Liver and Biliary Tract Surgery

The Role of Laparoscopy in Cholecystectomy in Octogenarians

Laparoscopic Repeat Liver Resection for Recurrent HCC: Single Institution Experience with 8 Cases and Systematic Review of the Literature

T. Kakucs, L. Harsa´nyi, P. Kupcsulik, P. Lukovich Semmelweis University, BUDAPEST, Hungary Introduction and aim: The incidence of gallbladder stones increases with age, however there is still little data about the outcomes of cholecystectomy at octogenarians. Population ageing presents tremenduous challenges for surgeons. Our aim was to compare the emergency and elective cholecystectomies performed for octogenarians. Method: This retrospective study was based on the analysis of preoperative ASA score, operation type, conversion rate, complications, mortality, lenght of hospital stay of all patients over 80 who underwent cholecystectomy in the last 6 years at our department. Results: During this period a total of 994 operations were performed in patients over 80 years of age, of which 120 were because of gallbladder stones or it’s complications (69 elective, 51 emergency). In the emergency group pancreatitis in 9.8%, liver abscess in 14%, common bile duct stones in 27% were found at the time of admission. The mean preoperative ASA score was 2.87 for the elective and 3.41 for the acute group, where the difference was significant. Laparoscopic cholecystectomy could be performed at 84% of the elective, while only at 17.7% of the emergency group. 5.8% (4 patients) of the elective group were treated at the intensive care unit postoperatively for a mean of 1 day, conversely 61% of the emergency group needed critical caren for 9.1 days. The total lenght of hospital stay was 12/3.6 days for the elective and emergency group, respectively. At the emergency group mortality was 20%, reoperation 16%, nonsurgical complications 12%, while at the elective group none of these occured. The preoperative ASA score of the deceased patients was significantly bigger than those who survived (4.2 vs. 3.25, p \ 0,001). Conclusion: Laparoscopic cholecystectomy is a safe method for octogenarians’ elective operations. For this reason we recommend elective cholecystectomy in this age group, in this way avoiding the frequent and potencially fatal complications of an acute cholecystitis.

K.P. Goh, J.Y. Teo, C. Chan, S.Y. Lee, P.C. Cheow, A.Y. Chung Singapore General Hospital, SINGAPORE, Singapore Introduction: Repeat liver resection has been shown to be effective for treating recurrent hepatocellular carcinoma (rHCC). However, to date there are limited reports of laparoscopic repeat liver resection (LRLR) for rHCC. This study was performed to determine the safety, feasibility and oncologic integrity of LRLR for rHCC by analyzing our institution experience and performing a systematic review of the literature Methods: Between 2013 to 2015, 8 consecutive patients who underwent LRLR for rHCC were retrospectively reviewed. Additionally, we performed a systematic review of the English literature to identify all studies reporting on LRLR for rHCC Results: Six patients had previous open LR and 2 had LLR. LRLR was performed for rHCC in the ipsilateral lobe as the primary HCC in 4/8(50%) patients. Five of 8(62.5%) patients had rHCC in the difficult posterosuperior segments. There was 1(12.5%) open conversion for bleeding and 1(12.5%) postoperative morbidity. The median postoperative stay was 3.5(range, 3–8) days. At a median follow-up of 7.5(range, 3–24) months all 8 patients were disease-free. Systematic review identified 9 studies (including our present study) which reported 72 cases of LRLR for rHCC. Thirty-five to 100% of patients had cirrhosis. The index surgery was an open LR in 35/64(55%) patients. 17/72(24%) underwent LRLR of the difficult posterosuperior segments. LRLR was performed for rHCC in the contralateral liver lobe from the index surgery in 21/29(72%) patients. The median tumor size of rHCC ranged from 17-40 mm Median operative time ranged from 73 to 343 min. There were 2/72(2.8%) open conversions. Postoperative morbidity ranged from 5-33% and median postoperative stay ranged from 3.5 to 11 days. Conclusion: In highly-selected patients; LRLR for rHCC is feasible and safe. This can be performed even for patients with previous open liver resections, cirrhosis, lesions in the posterosuperior segments and prior LR of the ipsilateral liver lobe.

P260 - Liver and Biliary Tract Surgery

P262 - Liver and Biliary Tract Surgery

Introduction of Indocyanine Green Fluorescence Imaging in Laparoscopic Deroofing of Hepatic Cyst for Prevention of Bile Leakage

Evolution of Laparoscopic Liver Resection at a Single Institution: a Nine-Year Experience (2006-2014) with 195 Consecutive Resections

H. Kitamura, Y. Sakimura, H. Tawara, R. Sato, T. Okude, R. Matsui, T. Tsuji, D. Yamamoto, N. Ota, N. Inaki, M. Kurokawa, H. Bando

K.P. Goh, J.Y. Teo, C. Chan, S.Y. Lee, P.C. Cheow, P.K. Chow, O. London, A.Y. Chung

Ishikawa Prefectural Central Hospital, ISHIKAWA, Japan

Singapore General Hospital, SINGAPORE, Singapore

Aim: Laparoscopic deroofing (LD) has widely spread for treating hepatic cysts. However, bile leakage is still one of critical complications after LD. We have introduced indocyanine green fluorescence imaging (IGFI) for prevention of bile injury during LD. The aim of this study was to demonstrate our effective technique of LD using IGFI and evaluate its clinical results. Methods: Intravenous injection of 2.5 mg indocyanine green (ICG) was administered 2 h prior to the beginning of surgery. D-light P system (KARL STORZ, Germany) which integrated IGFI mode was prepared to recognize bile duct. At first, we confirmed that the hepatic cysts did not contain bile under the guidance of IGFI and the content was percutaneously aspirated. After that, we detected small biliary branches on the cyst wall and dotmarked along the cutting line of the cyst wall. Then the cyst wall was excised by ultrasonically activated device under the white-light guidance. In case of finding small branch of bile duct across the cutting line, it was clipped prior to dissection. Finally, we cauterized the bottom of cyst wall using high frequency electric node, and also avoiding the thermal injury of the bile duct. A drainage tube was placed at the deroofing area after final inspection under the IGFI guidance. Result: Six patients with symptomatic cysts underwent LD. The median size of dominant cysts was 15.6 cm. Branches of bile duct at the roof of cysts were detected in two cases and those at the bottom of cysts were detected in five cases under the IGFI guidance, although branches were not detected under the white-light guidance. The median operative time was 85 min, and the median blood loss was 1 ml. All patients were discharged uneventfully. The median postoperative stay was 6 days. Pathological findings in all cases were simple cysts. Postoperative (from 2 to 5 months) computed tomography revealed no relapse in every cases. Conclusion: IGFI was conveniently introduced for LD and useful for detecting bile duct of hepatic cyst wall. It can be expected that the use of IGFI during LD can reduce the risk of intraoperative bile duct injury.

Objectives: This study aims to study the changing trends, safety and outcomes associated with the adoption of laparoscopic liver resection (LLR) at a single center. Methods: Retrospective review of 195 consecutive patients who underwent LLR from 2006 to 2014 at a single institution. In order to study the evolution of LLR, the study was divided into 3 equal consecutive time periods (Period I: 2006–2008, Period II: 2009–2011 and Period III: 2012–2014) whereby 22 LLR were performed in period I, 19 in Period II and 154 in Period III. Results: 195 patients underwent LLR with 24(12.3%) requiring open conversions. 56(28.7%) patients had previous abdominal surgery and 50(25.6%) had pathologicallyproven liver cirrhosis. 154(79%) patients underwent surgery for a malignancy of which the most common cancer was hepatocellular carcinoma in 102 patients. 68(34.9%) patients had resection of tumors in the difficult posterosuperior segments and 12(6.2%) underwent major hepatectomies. The median operation time was 210 (range, 40–620) minutes and 32(16.4%) patients required intra-operative blood transfusions. The median postoperative stay was 4 (range 1–26 days). Major postoperative morbidity ([ grade 2) occurred in 11(5.6%) patients and there was 1(0.5%) 90-day postoperative/in-hospital mortality. Comparison of LLR during the study period demonstrated that there was an increasing number of LLR performed over time (22 vs 19 vs 154). Across the 3 time periods, there was a statistically significant increase in malignant neoplasms resected (54.5% vs 84.2% vs 81.8%, P = .011), increase in resection of difficult posterosuperior segments (13.6% vs 15.8% vs 40.3%, P = .009), longer median operation time (180 vs 200 vs 215, P = .027) min and decrease in open conversion rates (22.7% vs 26.3% vs 9.7%, P = .028). There was no difference in intra-operative blood loss, intra-operative blood transfusion rate, postoperative stay and postoperative morbidity. Conclusion: LLR is feasible and can be safely adopted. Over the study period, the case volume of LLR increased rapidly at our institution. Although, LLR was increasingly performed for malignant neoplasms and for lesions located in the difficult posterosuperior segments which resulted in longer operation times; open conversion rates decreased and there was no change in postoperative morbidity.

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Surg Endosc

P263 - Liver and Biliary Tract Surgery

P265 - Liver and Biliary Tract Surgery

Esophagogastroduodenoscopy (Ogd) Value Before Laparoscopic Cholecystectomy in Our Surgical Unit

Omalgia - A Common Problem Following Laparoscopic Surgery

M. Salama, R. Mitru, E.O. Ahmed, A.R. Nasr, S.A. Elmasry, I.A. Ahmed Our lady of Lourdes hospital, DROGHEDA, Ireland

K.N. Haxhirexha1, S. Heta2, N. Baftia2, F. Dika-Haxhirexha3 1

Clinical Hopsital - Tetove, DIBER, Macedonia; 2Clinical University Center Mother Teresa, TIRANA, Albania; 3Alba-Med, DIBER, Macedonia

Introduction: Gall bladder (GB) stones are very common. Laparoscopic cholecystectomy is the golden standard of treatment of symptomatic GB stones. GB stones and upper GI diseases may co-exist or may occur co-incidentally. In the available medical literature, there is a concern of unrecognized upper GI disease that may co-exist with GB stones or that occur incidentally. There are divergent opinions concerning the usefulness of OGD before the planned laparoscopic cholecystectomy. Aims: - To analyze the risk of co-existing upper GI disease and GB stones. - To analyze the usefulness of OGD before laparoscopic cholecystectomy Methods: This is a retrospective study. The collected data includes personal information, presenting symptoms and signs, investigations (bloods, US, and OGD), medications, surgical procedure (laparoscopic cholecystectomy), postoperative complications, and followup. Results: Out of a total 311 patients who had laparoscopic cholecystectomy performed in our unit between 01/01/2013 and 30/06/2015, only 55 (17.6%) patients had OGD before surgery. of them 30 patients had gastritis (54.5%), 7 patients had oesophagitis (12.7%) and 18 patients had normal OGD (32.7%). OGD did not change the plan of surgery in any patient in this study. Conclusion: OGD is important before laparoscopic cholecystectomy in selected patients but routine OGD is not useful or cost-effective.

Although shoulder pain is one of the common reported problem after laparoscopic surgery the nature and factors that may increase the risk of pain have not yet been explained. Aim of the study: objective of this study is to show our experience with omalgia respectively the incidence, preventive measures and management of this early post laparoscopic complaint. Materials and methods: The study was conducted at the Clinical Hospital of Tetove from January until December 2015. All the patients included in the study were randomly enrolled into one of the two groups. The group I totally 57 patients in which the residual CO2 was evacuated by abdominal oppression and the group II with 39 patients where the residual CO2 was evacuated by pumping warm saline into the abdomen until it spilled out of the open ports. Postoperatively, the presence and characteristics of shoulder pain were received from patients. Results: in the group of patients in which the residual CO2 was evacuated by abdominal oppression (57) nine patients reported pain after surgery predominantly in the right shoulder. During first days after surgery the pain was moderate to severe and most of the patients required analgesics. In 39 patients residual CO2 was evacuated by pumping warm saline solutions into the abdominal cavity until it is spilled out by the ports. In this group right shoulder pain is registered only in four patients marking the lower incidence of postoperative pain than in a previous group. Conclusion: Shoulder pain following laparoscopic surgery is relatively common complication. Filling the abdominal cavity with saline solutions at the end of surgery enables effective removal of residual CO2thus preventing post laparoscopic shoulder pain Keywords: omalgia, laparoscopy, saline solutions.

P264 - Liver and Biliary Tract Surgery

P266 - Liver and Biliary Tract Surgery

Transumbilical Single Incision Laparoscopic Hepatectomy

Surgical Outcomes After Laparoscopic Major Hepatectomy for Various Liver Diseases

M.T. Huang, S.A. Chen Shuang Ho Hospital-Taipei Medical University, NEW TAIPEI CITY, Taiwan Objective: To prove the feasibility and safety of single incisional laparoscopic hepatectomy (SILH) for peripheral segment of liver. Methods: Between October 2011 and Oct2015, a total of 40 patients with hepatic tumors underwent SILH at our hospital. Surgical techniques used the creation of a 2.5 cm wound on the umbilicus for port placement. The transection margin was decided by laparoscopic ultrasound. The liver parenchymal resection was performed using the Harmonic Scapel and endovascular staple for vascular pedicle in left lateral segmentectomy, with the specimens obtained then placed in a bag and removed directly via the umbilical port. Results: The 22 male and 18 female patients ranged in age from 24 to 86 years (mean 55.8). Preoperative diagnosis were 17 patients with HCC, 3 with cholangiocarcinoma, three with liver metastasis, 17with benign tumor or IHD stone. Surgical procedures included partial hepatectomies for 14 patients, anterior segmentectomy for 3 patients and left lateral segmentectomies for the other 23 patients, 39 patoents successfully completed using the SILH without conversion to open surgery. The mean duration of the operation was 93.8 ± 41.5 min (35 - 165). The blood loss during surgery was ranged from minimal to 300 ml with mean 102 ± 116 ml, without any requirement for intraoperative or postoperative transfusion. Mean hospital stay was 4.4 ± 1.3 days postsurgery. Conclusion: The results of this study suggest that SILH is feasible for selected patients with lesions in the peripheral segment of liver requiring limited resection. Individuals with small tumors may benefit; because multiple port wounds or extension umbilical wound is not required, the wound-related complication rate might be reduced.

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S.H. Kang1, K.H. Kim2 Dong-A university hospital, BUSAN, Republic of Korea; 2Asan Medical Center, University of Ulsan College of Medicine, SEOUL, Republic of Korea

1

Aim: Through the number of laparoscopic liver resection has been increased, expansion of laparoscopic major hepatic resection is still limited primarily due to the technical difficulties compared to open surgery. We described our experiences of laparoscopic major hepatectomy for various liver diseases. Methods: We retrospectively reviewed the medical records of 192 patients who underwent laparoscopic major hepatectomy between October 2007 and March 2015 at Asan medical center. Results: The mean age of the patients was 54 ± 11.6 years and mean BMI was 23.5. The most common preoperative diagonosis was Hepatocellular carcinoma (n = 82, 42.7%) and followed by intrahepatic duct stones (n = 51, 26.6%). We performed 108 cases of left hepatectomies, 55 of right hepatectomies, 18 of right posterior sectionectomies, 6 of right anterior sectionectomies, 2 of central bisectionectomies and 3 for donor right hepatectomies. Conversion rate was 2.1% (4 cases) because of bleeding, bile leakage and uncontrolled hypercapnea during operation. Mean operation time was 272 ± 80.2 min and mean estimated blood loss was 300.4 ± 252.2 mL. The mean postoperative hospital stay was 9.8 days. All of resection margins were tumor free in malignant tumors. Morbidity was 4.2% (8 cases) including portal vein thrombus and biliary stricture and there were no deaths. Conclusions: Laparoscopic major hepatectomy is safe and feasible option for various liver diseases including donor hepatectomy through selected criteria and abundant experience with surgical technique.

Surg Endosc

P267 - Liver and Biliary Tract Surgery

P269 - Liver and Biliary Tract Surgery

The Role of Percutaneous Cholecystostomy in the Age of Laparoscopic Cholecystectomy for Acute Cholecystitis

The Often Forgetten Wilkie Syndrome : Case Report and Litrature Reiview

A. Bove, R.M. di Renzo, S. Rossi, G. d’Urbano, M. Bellobono, V. d’Addetta, G. Bongarzoni

O. Elbernawi, H. Elgadi, W. Abubaker, S. Elfalah, T. Ginawi

University G.D’Annunzio, CHIETI, Italy Introduction: The gold standard for acute cholecystitis is laparoscopic cholecystectomy performed within the 24–48 h after the symptoms onset. If the general conditions of the patient are particularly compromised, surgery is contraindicated because of high mortality incidence. At least, acute sepsis status must be contained and, together with appropriate antibiotic therapy, a ultrasound-guided transhepatic cholecistostomy can be performed. This is a minimally invasive procedure that allows to solve the sepsis status. In our experience, we evaluated the incidence of this minimally invasive treatment and its short and long term results. Methods: We performed 1450 laparoscopic cholecystectomy from January 2005 to December 2014 with an acute cholecystitis incidence of 9% (141 patients). Surgery was contraindicated in 19 patients (ASA 4-5), so the minimally invasive treatment was performed. Age ranged from 77 to 88 y.o., 11 females and 8 males. Alithiasic cholecystitis was diagnosed in 5 patients, while the other 14 patients had biliary lithiasis. All procedures were performed under ultrasound guidance, using local anesthesia. Results: We did not observed perioperative mortality. We performed the treatment in 18 patients. Complications occurred in 4 cases (21%): 1 case of bleeding, 1 case of biliary peritonitis and 2 cases of catheter dislodgement. Recovery from sepsis occurred 24–28 h after treatment in all cases. Catheter for drainage was mantained for 11 days on average. During the follow-up period, 11 patients underwent laparoscopic cholecistectomy, and 1 patient underwent endoscopic papillotomy. Conclusions: Acute cholecystitis needs a sudden treatment in order to avoid complications as gangrene or even exitus. Also in the age of laparoscopic surgery, there are clinical conditions that contraindicate laparoscopic cholecistectomy, and ultrasound-guided transhepatic cholecistectomy is considered a valid alternative procedure to successfully face the acute condition.

Benghazi medical center, BENGHAZI, Libia Superior mesenteric syndrome SMS is a rare acquired form of gastrointestinal obstruction that can be life threatening. It is due to compression of the 3rd part of duodenum between the superior mesenteric artery and aorta. It often poses a diagnostic dilemma and it’s diagnosis is frequently done by exclusion. WE report a case of 19 years old female who presented with postprandial colicky epigastric abdominal pain associated with nausea, vomiting and significant weight loss. Barium sallow revealed delay gastric emptying and delay in visualization of the 3rd part of duodenum. Diagnosis was highly suggestive by CT scan which showed abrupt change in calibre of 3rd part of duodenum where it seems to be trapped between SMA and Aorta as the angle between the latest two was about 22. Laparoscopic gastrojejunostomy was done. After 3 months of follow up, patient is gaining weight and symptom free. In conclusion superior mesenteric artery syndrome is rare but serious condition presented with gastric outlet obstruction and surgery is the mainstay of treatment. Keywords: laparoscopy,superior mesentric artery,gastric outlet obstruction,and Wilkie’s syndrome

P268 - Liver and Biliary Tract Surgery

P270 - Liver and Biliary Tract Surgery

Long-Term Results of Laparoscopic Management of Hepatic Hydatid Disease

Single-Incision Robotic Cholecystectomy: A Special Emphasis on Utilization of Transparent Glove Ports to Overcome Limitations of Single Site Port?

V.V. Grubnik, V.V. Mishchenko, S.G. Chetverikov Odessa national medical university, ODESSA, UKRAINE, Ukraine Background: Incidence of hepatic hydatid disease is increasing in Ukraine. Surgery is the ‘gold standard’ treatment. Laparoscopic methods are new and promising for the treatment of this disease. Aim of the study was to assess long-term results of laparoscopic management of hepatic hydatid disease. Methods: From 2003 to 2013, 348 patients with liver hydatid disease underwent surgery in our department. Results of 283 patients were retrospectively studied. There were 129 males, and 154 females in the group. Mean age was 37,5 years (range 18–72). 42 patients had multiple cysts of both lobes. Results: 286 patients underwent laparoscopic procedures, 3 of them required conversion to open surgery. During laparoscopic procedures, conservative surgery (cystectomy) was made in 249 patients (88%), and radical surgery (resections of liver) was made in 34 patients (12%). 61 patients (21,6%) had a cyst-biliary communication revealed intra-operatively. Postoperative morbidity was seen in 48 patients (16,9%) which included deep cavity infection in 21 patients, and postopertive bile leak in 27 patients. Mean long-term follow-up was 42 months (range, 6 months - 7 years). Recurence was detected in 7 patients (2,5%). Conclusions: Our long-term results showed good outcomes with conservative surgery as the preffered approach of laparoscopic management, reserving radical approach for selected cases only.

H.E. Lee, Y. Jang Seoul National University Hospital, SEOUL, Republic of Korea Background: Robotic surgery is a rapidly developing field and has progressed as a new alternative surgical approach in single-incision surgeries. Current robotic platform overcomes some limitations of the single-incision laparoscopic cholecystectomy (SILC). Whether robotic surgery is a safe and feasible approach to gallbladder disease still remains to be investigated. Method: Patients referred for elective surgery willing to undergo single-incision robotic cholecystectomy (SIRC) at their own consent were enrolled. Patients enrolled underwent SIRC for gallbladder stones, polyposis and mild acute cholecystitis. Exclusion criteria includes: severe acute cholecystitis, combined common bile duct stone, suspicious or proven malignancy, bleeding disorder or coagulopathy or history of upper abdominal surgery. All procedures were performed by the same team using the da Vinci Si Surgical System and Glove PortTM was used in all patients. After discharge, patients visited the outpatient department at both postoperative two weeks and three months. Results: A total of 30 patients underwent SIRC since March 2015, including 12 males (40.0%) and 18 females (60.0%). The mean age was 43.73 ± 10.30 (range 18–56) and the mean BMI was 22.41 ± 2.97 kg/m2 (range 17.44–30.01). 17 patients (56.7%) were diagnosed with gallbladder stone. One patient (3.3%) was diagnosed with gallbladder adenomyomatosis while 11 patients (36.7%) underwent surgery for gallbladder polyps. One patient (3.3%) was diagnosed with acute cholecystitis. The mean overall operation time was 53.80 ± 15.20 min (range 32–80) and the mean console time was 16.67 ± 5.63 min (range 11–30). The mean hospital stay was 3.30 ± 0.54 days (range 3–5) and the mean postoperative stay was 1.30 ± 0.54 days (range 1–3). There was no perioperative major complications. Conclusion: SIRC learning curve can be rapidly achieved and be safely performed by overcoming the ergonomic difficulties encountered during SILC. SIRC can be an alternative treatment for several gallbladder diseases in selected patients with strong interest in cosmetic outcomes willing to pay at high costs.

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Surg Endosc

P271 - Liver and Biliary Tract Surgery

P273 - Liver and Biliary Tract Surgery

The Added Value of Fluorescence Imaging During Laparoscopic Resection of Liver Tumors

Reduced Port Surgery for Liver Cyst

L.S.F. Boogerd Leiden University Medical Center, LEIDEN, The Netherlands Aims: Recurrence-free survival after resection of primary and metastatic liver tumors is still rather short. Up to 69% of patients with colorectal liver metastases develops recurrent disease and the majority even within 1 year. These high numbers are not entirely explained by incomplete resections, but support the hypothesis that malignant lesions are missed during surgery. Current modalities, such as CT, MRI and laparoscopic ultrasonography (LUS) all have limitations. Fluorescence imaging using indocyanine green (ICG) is an innovative technique enabling real-time intraoperative identification of subcapsular liver tumors. The aim of the current study was to determine sensitivity of fluorescence imaging for detection of hepatic tumors and to show its added value during laparoscopic resection of liver tumors. Methods: Ten mg ICG was intravenously administered one day prior to surgery in patients undergoing resection of primary or metastastatic liver tumors. Fluorescence imaging was performed using the Karl Storz HD fluorescence laparoscope. Twenty-two patients were included, suffering from colorectal liver metastases (n = 12), hepatocellular carcinoma (n = 4), uveal melanoma liver metastases (n = 2), breast cancer liver metastases (n = 2) and cholangiocarcinoma (n = 2). Results: Two patients were excluded because their procedure was unexpectedly postponed several days, resulting in low fluorescence signals. A total of 46 lesions, including 27 malignant tumors, were resected in the remaining 20 patients. Of all lesions, sensitivity of the imaging methods was: 80% (CT), 85% (MRI), 63% (inspection), 89% (LUS), 93% (fluorescence imaging). Three additional malignancies (in 2 patients) were identified by fluorescence imaging only, sized 1-3 mm. All malignancies could be detected by combining LUS and fluorescence imaging. Conclusion: This study shows the added value of fluorescence imaging during laparoscopic resections of several types of liver tumors. Fluorescence imaging is an easy, effective and safe method. The only requirement is a fluorescence laparoscopic imaging system and ICG. Large series will have to determine if fluorescence imaging truly improves patient outcome, but based on our results we believe this technology should be part of laparoscopic resection of liver tumors.

H. Kashiwagi1, J. Kawachi1, N. Isogai1, R. Shimoyama1, K. Miyake1, R. Fukai1, H. Ogino1, Y. Terada2, K. Watanabe1 1 Shonan Kamakura Hospital, KAMAKURA, Japan; 2Shonai Amarume Hospital, AMARUME, Japan

Introduction: Most liver cysts are asymptomatic and tend to have a benign clinical course. However, symptomatic or complicated liver cysts sometimes require surgical intervention. The laparoscopic approach is crucial and provides definitive treatment for such cysts. Recently, a trend of laparoscopic procedure has been toward minimizing the number of incisions to achieve less invasiveness. We have reported surgical indicated cysts treated by reduced port surgery (RPS) or single incision laparoscopic surgery (SILS). Methods: Nine cases were nominated from Shonan Kamakura General Hospital and Shonai Amarume Hospital between 2010 and 2015. Mean age and Body Mass Index (BMI) were 73.9 and 21.0, respectively. All patients have had any complaint such as upper abdominal pain, dyspnea, and fever. 4 cases (44.4%) were prompted the aspiration drainage before operation. One life-threatening case had chronic heart failure with thrombosis in inferior vena cava (IVC) and this case was performed interventional mechanical stent insertion into IVC after SILS. For the specific surgical instpruments, a 5 mm flexible scope (Olympus, JAPAN), SILS-port (Covidien, JAPAN) and ENDO-Relief (Hope electronics, JAPAN) were used. Results: Mean of maximum cyst diameter measured by CT or sonography was 13.5 cm. One patient was converted to open procedure immediately because of severe adhesion of intra-abdominal cavity due to previous open surgery and infectious inflammatory condition. Mean operation time and blood loss of other eight cases were 120.1 ± 47.4 min. and 47.5 ± 64.3 ml, respectively. Mean length of total port sites incisions was 20.6 (7–27) mm. Additional cholecystectomy was performed for a case of chronic cholecystitis with gallbladder stones. Two cases of infectious liver cyst were required additional drainage for infectious control. Mean hospital stay after surgery of whole cases, non-infectious cases, infectious cases was 15.2, 4.9, 51.5 days, respectively. No recurrence of any symptom was shown in any cases in observation period (206-2176 days). Discussion: SILS or RPS is a useful treatment for symptomatic or complicated liver cyst. However, for the infectious cyst, infection control such as intensive drainage and/or administration of antibiotic before surgery may be needed to avoid additional treatment, leading to longer hospital stay.

P272 - Liver and Biliary Tract Surgery

P274 - Liver and Biliary Tract Surgery

Near Infrared Imaging with Indocyanine Green During Laparoscopic Cholecystectomy; An Overview and Meta-Analysis

Safety of Laparoscopic Left Lateral Sectionectomy in Patients with Histologically Confirmed Cirrhosis

S.L. Vlek1, D.A. van Dam2, S.M. Rubinstein3, L.J. Schoonmade3, E.S.M. de Lange-de Klerk1, J.B. Tuynman1, W.J.H.J. Meijerink1

J.Y. Cho, C. Im, H.S. Han, Y.S. Yoon, Y.R. Choi, Y. Jang, H. Choi, J.S. Jang, S.U. Kwon, H. Kim

VUmc, AMSTERDAM, The Netherlands; 2Rode Kruis Ziekenhuis, BEVERWIJK, The Netherlands; 3VU University, AMSTERDAM, The Netherlands

Seoul National University Bundang Hospital, SEONGNAM, Republic of Korea

1

Aims: Near infrared imaging (NIR) with Indocyanine Green (ICG) has been extensively investigated to identify biliary tract structures during laparoscopic cholecystectomy (LC). However methods and results vary between the studies. Aim of this review is to provide an overview of the current application in order to achieve consensus of the clinical application of NIR-ICG during LC. Methods: A systematic literary search of Pubmed, Embase, Web of Science and the Cochrane library was performed. Prospective trials were included describing the use of NIR-ICG during LC in humans. Outcomes were biliary tract identification, dosage and timing of ICG administration. Also a meta-analysis was performed comparing NIR-ICG to intra-operative cholangiography (IOC) in identifying biliary structures. Results: A total of 19 studies were included for quantitative synthesis. Most studies used a fixed dosage of 2.5 mg or 0.05 mg/kg. Cystic duct (CD), common bile duct (CBD) and common hepatic duct (CHD) visualization were respectively 81.3% [27.9], 61.0% [14.7] and 73.3% [33.1] before dissection and 96.7% [34.5], 84.2% [26.6%] and 87.3% [32.9] after dissection of Calot’s with a fixed dosage of 2.5 mg. CD, CHD and CBD visualization were respectively 84.1% [23.3], 79.6% [18.1] and 72.2% [13.3] before dissection and the CD and CBD were 98.9% [25.4] and 95.7% [27.6] after dissection with a dosage of 0.05 mg/kg. ICG was administered between 74 min before surgery until directly after anaesthesia. Meta-analysis comparing NIR-ICG to IOC revealed relative risks of 1.16 (p = 0.05), 1.00 (p = 0.92) and 0.76 (p = 0.06) for visualization of the CD, CBD and CHD respectively. Conclusions: This overview provides good results in biliary tract visualization for both dosage schemes and current peri-anaesthetic timing of administration. Despite these promising results future research is necessary for optimization and standardization of the technique so ICG-NIR can be used in all patients towards a save LC.

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Background: Laparoscopic Left lateral sectionectomy (LLS) is now considered as a standard practice. However, the safety of laparoscopic LLS in cirrhotic patients is unclear. This is the retrospective study of comparing the outcomes of laparoscopic LLS between cirrhotic and non-cirrhotic patients. Methods: We reviewed the clinical data for 107 patients who underwent laparoscopic LLS between July 2003 and July 2013. The patients were divided into cirrhotic group (n = 31) and non-cirrhotic group (n = 76) with histologically confirmed cirrhosis. Results: There were no differences between the two groups in terms of the operation time (P = 0.807), blood loss (P = 0.115), transfusion rate (P = 0.716), postoperative complication rate (P = 0.601) and duration of hospital stay (P = 0.261). Open conversion occurred in one non-cirrhotic patient (P = 1.000). The postoperative peak total bilirubin level was higher in cirrhotic patients than in non-cirrhotic patients (P \ 0.001). Among patients with hepatocellular carcinoma, the disease-free survival (P = 0.249) and overall survival (P = 0.768) rates were not significantly different between cirrhotic patients (n = 28) and non-cirrhotic patients (n = 12). There were no significant differences in the complication rate (P = 0.085), operation time (P = 0.159), blood loss (P = 0.306), transfusion rate (P = 1.00), and hospital day (P = 0.408) between laparoscopic LLS and cases of open LLS performed in the same study period (n = 10). Conclusions: Laparoscopic LLS is safe and reproducible, even in cirrhotic patients.

Surg Endosc

P275 - Liver and Biliary Tract Surgery

P277 - Liver and Biliary Tract Surgery

Safety of Two Ports Laparoscopic Cholecystectomy in Difficult Gall Stone Disease

Initial Experience of Single Incision Laparoscopic Liver Surgery

A.H. Abro, A.H. Pathan, A.A. Bhurgiri, Y. Jamal, A.A. Laghari Liaquat University of Medical & Health Sciences Jamshoro, HYDERABAD, Pakistan

A. Shabbir1, M. Malik2, I. Ahmed2, B. Alkari2 1

National Health Service Royal Bolton Hospital, WIRRAL, United Kingdom; 2Aberdeen Royal Infirmary, ABERDEEN, United Kingdom

Objective: To determine the safety profile of two ports laparoscopic cholecystectomies in gallstone diseases at Liaquat university hospital Hyderabad/Jamshoro. Patients and Methods: The descriptive case series study was conducted in Hepatopancreatobilliary and minimal access surgery at Liaquat University Hospital Hyderabad/ Jamshoro. All the patients with 35-70 years of age of either gender presented with gallstone disease were managed laparoscopically. The frequency and percentage was calculated for categorical variables and mean ± SD was calculated for numerical variables. As this was descriptive case series so there was no any statistical test of significance was applied. Results: During two year study period total 500 patients were presented with gallstone disease with means age 58.85 ± 5.93 (SD). Eighty five patients (400 females and 100 males) were underwent two port laparoscopic cholecystectomy procedure. The mean postoperative hospital stay after laparoscopy was 1.5 days while no any complication was observed in study participants. Conclusion: It has been concluded that two port laparoscopic cholecystectomies procedure is safe and has no complications in gall stone disease.

Aims: Since the first laparoscopic liver resection in 1992, minimally invasive techniques have been widely adopted by hepatic surgeons to reduce abdominal wall trauma and enhance recovery. With the recent interest in single incision laparoscopic surgery, it is being adapted by many specialties in current practice. We present our initial experience of this new technique in liver surgery. Methods: Data was collected from a prospectively kept database for single port surgery in a University Hospital setting. All the patients who had single incision liver surgery from September 2008 to September 2015 were included. Standard laparoscopic instruments were used4. Challenges in single incision liver resection involve crowding of instruments, restricted view and movement, requirement of 30 degree scope and extension of incision to extract specimen in malignant cases. Results: total of 11 patients (8 females) underwent single incision laparoscopic liver surgery. 7/11 patients had minor liver resections (2 x left lateral and 5 x non anatomical) and 4/11 patients had deroofing of liver cysts. There were no conversions to standard laparoscopic or open surgery. No intra operative or immediate post operative complication was recorded. All the patients were followed up according to existing hospital protocols. There were no reported late post operative complications in the follow up period. Conclusions: Single incision laparoscopic surgery is feasible and safe method of treating liver lesions. We found it technically easier to target benign lesions in which a wide resection marhgin is not essential, especially those located in segment II, III, V and VI.

P276 - Liver and Biliary Tract Surgery

P278 - Liver and Biliary Tract Surgery

Service Evaluation of Implementing a ‘Hot’ Gall Bladder List on Patient Outcomes

The Use of Laparoscopic Bile Duct Clearance Methods in a Rural Hospital

R.A. Dickson-Lowe, R. Lane, J. Faulkner, Y. Abdul-Aal, M.A. Enein

A. Mazor, G. Tolstov, I. Grevtsev

Tunbridge Wells Hospital, LONDON, United Kingdom

Yoseftal Hospital, EILAT, Israel

Introduction: Laparoscopic cholecystectomy is now performed frequently for gall bladder pathology during the acute, index admission. Delay in surgery may result in additional admissions due to biliary complications. Hypothesis: implementation of a dedicated list improves outcomes for patients with symptomatic biliary disease Methods: A single-centre prospective service evaluation of patients undergoing an acute laparoscopic cholecystectomy was performed pre and post-implementation of an emergency laparoscopic cholecystectomy list. The 30 day complications and readmission rates following surgery were collected. Results: Over the 6 month period 246 cholecystectomies occurred. All planned elective cases (n = 143) were excluded. Of the acute biliary admissions, 31 occurred pre acute list implementation, 33.4% were men. All-cause 30-day readmission rate was 6.5% pre- and 2.8% (2/71) post-implementation (p = 0.753) and 30 day complication rate was 12.9% pre and 8.5% post (p = 0.739). There was no significant difference in the length of hospital stay between the groups (p = 6.86). Conclusion: This data shows an improvement in 30-day readmission and complication rate post-implementation. Larger numbers are required to validate these findings.

Aims: Proven or suspected common bile duct (CBD) stones require CBD clearance. This can be done by magnetic resonance cholangiopancreatography (MRCP) or Endoscopic retrograde cholangiopancreatography (ERCP) followed by a laparoscopic cholecystectomy (LC), or by a single stage procedure: intraoperative cholangiography (IOC) and/or Laparoscopic CBD exploration (LCBDE) by a choledochoscopy, followed by LC. Yoseftal is a rural hospital lacking regular gastroenterology or magnetic resonance imaging units. Patients that needed CBD clearance measures were sent to a regional center, away from their supporting community. We introduced LCBDE capacities in order to treat CBD stones. In this paper we studied the impact of this new capability. Methods: Retrospective observational study comparing patients from the year 2013 to patients from 2014 and 2015, respectively before and after introduction of LCBDE. We enrolled patients that had gallstone and gallstone related pathology (pancreatitis and jaundice) ICD 9 codes. We excluded patients without proven gallstone disease and patient that refused surgery. We compered the management and outcome of the two groups. Results: 40 patients were identified in 2013, 60 in 2014 and 69 in 2015. Of the patients that needed CBD clearance 4/14 (28.5%) were operated in 2013, 24/27 (88.8%) in 2014 and 16/20 (80%) in 2015. CBD clearance meanings included, in 2013, 2014 and 2015 respectively: IOC in 2, 18 and 12 cases, IOC with pharmacological or manual manipulations in 2, 2 and 1 cases and LCBDE in 0, 4 and 3 cases. There were 2 conversions to open surgery: 1 in 2013 and 1 in 2014. In 1 case in 2013 we couldn’t manage the stone by meaning of IOC and manipulations and the patient was transferred for ERCP. Conclusions: LCBDE extends our capacities to treat patients who have CBD stones within their community without significant complications. It is a simple and cost saving method in a rural hospital that lacks costly gastroenterology or magnetic resonance imaging units.

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Surg Endosc

P279 - Liver and Biliary Tract Surgery

P281 - Liver and Biliary Tract Surgery

Combined Laparoscopic Colon Resection and Laparoscopic Ultrasound Guided Liver Ablation in Patients with Colon Cancer and Synchronous Liver Metastases

Incidence of Common Bile Duct Stones and Their Management in Patients Presenting with Jaundice and Acute Pancreatitis

1

2

P. Guldfeldt , T. Pless , M.B. Mortensen

2

Odense University Hospital, ODENSE, Denmark; 2HPB Section, Department of Surgery, Odense University Hospital, ODENSE, Denmark 1

Aims: To evaluate the feasibility of synchronous laparoscopic colon resection and laparoscopic ultrasound guided liver ablation in patients with colon cancer and synchronous liver metastases (CRC-LM) Methods: Retrospective, single-center experience. All patients having a combined laparoscopic resection and laparoscopic ultrasound guided liver ablation due to CRC-LM between 2006 and 2014 were included. Primary colon procedure, liver ablation technique, number of segments treated, hospitalization (days), postoperative morbidity (according to Clavien) and in-hospital mortality were registered. Results: Fourteen patients fulfilled the inclusion criteria, and the procedures were completed as planned using Radiofrequency Ablation (RFA) in seven patients or Microwave Ablation (MWA) in 6 patients. One patient had both a MWA and a RFA performed. Five patients had ablation in one liver segment, seven patients had ablation in two segments, and two patients in three segments or more. Three patients experienced complications. One patient developed pneumonia, one patient had a postoperative wound infection and one patient developed a leak of the colon anastomosis and an intraabdominal abscess. None of the complications could be related to the ablation procedure. The median hospitalization was five days (mean 7 days, range 1–27 days). Recurrent CRC-LM was seen in 7 out of the 14 patients. The average time to recurrence was 5 months (mean 6 months, range 1–17 months) during an average observation period of 14 months (1-32 months). Conclusion: Combined laparoscopic colon resection and laparoscopic ultrasound guided liver ablation is feasible in patients with colon cancer and synchronous liver metastases (CRC-LM).

P280 - Liver and Biliary Tract Surgery Bilateral Adrenal Hemorrhage After Laparoscopic Cholocystectomy A.M. Nixon1, I. Perysinakis1, S. Tsallas2, C. Aggeli1, I. Tsipras1 1

Athens General Hospital ,,Georgios Gennimatas,,, ATHENS, Greece; 2St Thomas Hospital, LONDON, United Kingdom Aims: Laparoscopic cholecystectomy is the mainstay of treatment for gallbladder disease. Serious and potentially life threatening complications rarely occur including hemorrhage, bile leak, bile duct injury, duodenal and large bowel perforation. Here we describe a case of bilateral adrenal hemorrhage after laparoscopic cholecystectomy in a patient who developed septic shock of unknown origin. Methods: A 62 year old female patient with symptomatic chololithiasis was admitted for elective surgery. She underwent a typical laparoscopic cholecystectomy. A silastic abdominal drain was placed in the subhepatic space. The patient was discharged on the first postoperative day. The patient returned the same day citing onset of acute abdominal pain. On the second postoperative day a computerized tomography (CT) scan did not reveal any significant pathology. On the fourth postoperative day the patient’s clinical status deteriorated. A new abdominal CT scan revealed bilateral adrenal enlargement and generalized oedema of the intestinal wall. The patient underwent emergency laparotomy where generalized purulent peritonitis was found with no identifiable cause and two abdominal drains were placed one in the subhepatic space and one in the lesser pelvis. Subsequent abdominal CT scans indicated adrenal hemorrhage as the cause of adrenal enlargement. The patient underwent 2 additional laparotomies where no abnormal findings were observed. Adrenocorticotropic stimulation tests verified acute adrenal insufficiency. The patient was placed on replacement corticosteroid therapy. Results: After the first laparotomy the patient was admitted into the intensive care unit (ICU). The additional explorative laparotomies failed to identify the cause of abdominal sepsis. Magnetic resonance cholangiopancreatography did not identify bile leak or injury. No duodenal or large bowel injury was observed either on CT scan or during explorative laparotomy. Initiation of glucorticoid therapy in the ICU resulted in significant clinical improvement. The patient spent 55 days in the ICU. She was discharged 4 months after the first procedure in good health with replacement corticosteroid therapy. Conclusions: Peritonitis is a rare occurrence after laparoscopic cholecystectomy. Initial strategies should try to exclude bile duct injury and duodenal/large bowel perforation. Acute adrenal insufficiency is extremely rare in these circumstances but should be excluded as a cause of persistent hemodynamic instability.

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A.K. Mirza1, T. Katbeh2, S. Zino2, M.K. Nassar2, S. Zidan2, H. Qandeel2, A.H.M. Nassar2 1

Monklands Hopistal, MANCHETSER, United Kingdom; Department of Laparoscopic and Biliary Surgery, Monklands Hospital, AIRDRIE, United Kingdom

2

Aims: Patients admitted with jaundice and pancreatitis have a higher incidence of common bile duct (CBD)stones. Most centres offer ERCP followed by laparoscopic cholecystectomy (LC). In our specialist biliary service, we offer single session management for suspected CBD stones to all patinets fit for anaesthesia. We do not rely on preoperative MRCP or ERCP. We perform intraoperative cholangiography (IOC) and laparoscopic bile duct exploration (LCBDE) when indicated. This study aims to investigate the incidence of bile duct stones in patients presenting with jaundice and acute pancreatitis and the predictive value of either presentation for choledocholithiasis. Methods: The biliary service received almost all patients suspected of harbouring ductal stones. The data was collected over 20 years comprising of n = 4088 patients who underwent laparoscopic cholecystectomy. All pre-operative, operative and post-operative data was analysed. Annual follow up of patients who underwent ductal exploration for research purposes. Results: From the total patient population of 4088, 1687 (41%) were emergencies. The vast majority of emergencies had cholecystectomy and IOC within a week of admission. 653 (female 415, male 237) presented with jaundice (Group A, ASA I: 195, II: 297, III: 133) and 286 (female 212, male 74) had pancreatitis (Group B, ASA I: 86, II: 126, III: 55). Bile duct stones were present in 62% of jaundiced patients (404/652, transcystic clearance: 181, Open: 2, CBDE 205, dormia Trawling: 16) compared to 32% in pancreatitis patients (92/ 286, CBDE: 19, tran-cystic clearance: 67, dormia trawling: 7) (p = 0.002). 130/939 of our patients had both jaundice and pancreatitis at presentation and 49 (38%) had CBD stones. Conclusions: CBD stones are more common in patients with jaundice than pancreatitis. However 60% of patients with jaundice had CBD stones which were successfully removed following laparoscopic bile duct exploration. Therapeutic ERCP for suspected bile duct stones is not routinely indicated. Our findings support a role for specialised units with a policy of single session routine IOC and laparoscopic duct exploration.

P282 - Liver and Biliary Tract Surgery Is Laparoscopic Cholecystectomy Safe and Effective in Gangrenous Cholecystitis? O. Tsimpoukidi, L. Gioxas, E. Kalogridaki, S. Papanikolaou, G. Dedemadi, A. Dounavis Amalia Fleming Surgical Department. Sismanogleio- Amalia Fleming Hospital, ATHENS, Greece Aim: To implicate that laparoscopic cholecystectomy (LC) is the procedure of choice even in gangrenous inflammation of the gallbladder. Methods -Results: Three very difficult cases of gangrenous cholecystitis (GC) are presented. All were accomplished laparoscopically and the patients had an uneventful recovery. All three were elderly patients with severe comorbidities. They were admitted at the emergency department, stabilized and operated soon after. During the last few years, many neglected cases present to the emergency department. These are usually elderly people suffering from many chronic diseases. Most of them also have social and economic problems. Suspected gangrenous inflammation of the gallbladder was considered a contraindication for LC in the past. However, nowadays many surgeons perform the operation successfully laparoscopically. In our department we have a big experience with such cases. These are difficult operations, which take longer than usual and have a high conversion rate. Among the most difficult cases three are presented. Conclusion: Although technically demanding, LC in GC can be performed safely, with great benefit for the suffering patients that are usually very ill. So, our suggestion is: try laparoscopically.

Surg Endosc

P283 - Liver and Biliary Tract Surgery

P285 - Liver and Biliary Tract Surgery

Empyema of the Gall Bladder… Does Early Index Admission Surgery Improve Outcomes?

Is the Laparoscopic Cholecystectomy Feasible in Patients with Post-Endoscopic Retrograde Cholangiographic Pancreatitis?

H. El Zanati, S. Zino, M.K. Nassar, T. Katbeh, A. Loh, A. Nassar

J.W. Hwang

Monklands Hospital, AIRDRIE, United Kingdom

Eulji University Hospital, DAEJUN-SI, Republic of Korea

Aims: Assessment of the outcomes of management of gall bladder empyema in a district general hospital with a dedicated biliary service. Methods: The biliary service received the majority of patients with biliary emnergencies. We do not rely on preoperative MRCP or ERCP. We perform intraoperative cholangiography (IOC) and laparoscopic bile duct exploration (LCBDE) when indicated.Prospective data was collected over 23 years comprising of 4206 patients who underwent cholecystectomy. All pre-operative, operative and post-operative data was analysed. The groups were compared as regards duration of surgery, complications, hospital stay and conversion rate. Results: There were 483 patients with confirmed acute cholecystitis intraoperatively. Of these 253 had empyemas of the gallbladder (52%). 151 were females and 102 males (a female:male ratio of 1.5:1). Ages ranged from 22-90 years with a mean age of 57 years. 24 patients were previously managed conservatively and 2 had previous percutaneous drainage procedures. 2 patients with incomplete records were excluded leaving 251 to be included in the data analysis (including patients undergoing concomitant laparoscopic bile duct exploration n = 78). The patients were divided into two groups. GI operated within 72 h of admission(n = 110) and GII after 72 h(n = 141).There was no statistically significant difference between both groups as regards mean operative time(GI = 103.35 min, GII = 98.56 min.p = 0.43),complications rate(GI:10%,GII:7.1% p = 0.41, conversion rate (GI = 1.82%, GII = 0.71% p = 0.42), while the hospital stay was significantly longer in GII(12.29 days vs 5.62 days in GI p = 0.000057) Conclusions: Surgical management of empyema should be performed as soon as possible as delaying it only results in a longer hospital stay subjecting patients to more pain with no improvement in outcomes.

Aims: Preoperative endoscopic retrograde cholangiopancreaticography (ERCP) followed by laparoscopic cholecystectomy (LC) have been generally accepted as treatment of choice for patients with combined choledocholithiasis and cholecystolithiasis. However, ERCP occasionally results in post-ERCP pancreatitis (PEP), which could defer and disturb laparoscopic approach in cholecystectomy (LC). The aim of this study was to evaluate the effect of the PEP on surgical outcome of LC. Methods: From January 2009 to December 2014, the patients who underwent ERCP followed by LC were retrospectively reviewed. Patients with biliary pancreatitis were excluded. The patients with PEP were classified as PEP group (n = 22), and those without PEP were classified as NPEP group (n = 46). Operative time, operative complications, conversion rate, and length of stay were compared in both groups. Student t test was used to compare continuous data and Fisher’s exact test was used for categorical data. Results: Groups were comparable in terms of age, sex, and American Society of Anesthesiologists classification. The operative time and length of stay were not significantly different in both groups (P = 0.420, P = 0.585). The morbidity occurred in 5 patients (22.6%) of PEP group and 3 patients (6.9%) of NPEP group (P = 0.105). Conversion to open cholecystectomy occurred in only NPEP group (n = 2). Conclusion: PEP does not have an adverse effect on the surgical outcome of LC in PEP groups compared to NPEP groups. Therefore, it is feasible and safe to perform LC in the patients with PEP.

P284 - Liver and Biliary Tract Surgery

P286 - Liver and Biliary Tract Surgery

A New Low Cost Endoscopic Device for the Surgical Treatment of Choledocolithiasis: A Preliminary Study

Laparoscopic Hepatectomy for the Patients with Liver Cirrhosis

A. Majbar, A. Kettani, M. Alaoui, F. Sabbah, A. Hrora, M. Raiss, M. Ahallat Ibn Sina University Hospital, RABAT, Morocco Introduction: In case of choledocolithiasis, the surgical exploration of the common bile duct (CBD) requires the use of a choledocoscope for both diagnosis and treatment. However, the high cost of the technology has limited its availability in developing countries. The aim of this study is to report the use of a new low cost endoscopic device as a choledoscope in the surgical treatment of choledocolithiasis. Methods: The new device is disposable and consist on a 60 cm flexible endoscope (5.5 mm and 3.2 mm in diameter) with an operating channel allowing the use of a Dormia probe with irrigation and suction. At the tip of the endoscope, there is a micro camera and two micro LED lights. The device connects to a small box for image processing. The box is powered via USB and can output a 250/250 pixels video image to any display via an RCA cable. We used this device for common bile exploration and stone extraction in four patients. Results: There were 3 female and one male patients. All of them had choledocolithiasis. One patient had history of cholecystectomy by laparotomy. Two patients were operated by laparoscopy. Exploration of the biliary tract was done using the endoscope in all patients. One patient had a stone extraction using a Dormia Probe. The Radiologic control two weeks after the surgery confirmed the absence of stones in the CBD in all patients. Conclusions: This preliminary study showed the feasibility and the efficacy of using this new low cost technology in the surgical treatment of choledocolithiasis.

K. Hashida, Y. Ome, M. Yokota, Y. Nagahisa, K. Yamaguchi, M. Okabe, S. Okamoto, K. Kawamoto, K. Sano, T. Park, I. Shiro, Y. Yasuo, T. Itoh, K. Ogasahara Kurashiki Central Hospital, KURASHIKI-SHI OKAYAMA-KEN, Japan Aims: Hepatectomy for the patients with liver cirrhosis should be taken much care of from the aspect of the function of residual liver, varix, easy bleeding and postoperative ascites or pleural effusion. We report our surgical method and short term outcome of laparoscopic hepatectomy for the patients with liver cirrhosis. Methods: Laparoscopic partial hepatectomy for 13 patients and laparoscopic left lateral segmentectomy for 3 patients were performed from June 2014 to December 2015. In this 17 patients, 3 patient’s Child-Pugh score was B, 4 patient’s Liver damage score was B, and 3 patients had been performed hepatectomy before. During the same period, Open partial hepatectomy for 8 patients and open left lateral hepatectomy were performed. Then we compared laparoscopic hepatectomy with open hepatectomy. The key points of operation method: Minimizing mobilization of liver and surgical interruption is achieved to control ascites. Sometimes we don’t use Pringle method or to cut round ligament of liver in case of well-developed varix. To cut liver parenchyma, Clamp crushing method is performed with BiClamp. This method is very useful for liver cirrhosis because liver parenchyma is crushed rapidly. Results: Between laparoscopic hepatectomy group (LH) and open hepatectomy group (OH), background factor were not significantly different. Laparoscopic hepatectomy group was not converted to laparotomy. Operation time (LH 204.1 min. vs. OH 187.4 min.) and postoperative length of stay (LH 7.7 days vs. OH 8.8 days) showed no significant difference. Breeding was significantly lower in LH (LH 73 ml vs. OH 509.6 ml, p = 0.0053). Postoperative maximum CRP is comparatively lower in LH (LH 4.84 mg/dl vs. OH 8.02 mg/dl, p = 0.0663). No serious complication occur in both groups. Conclusion: Laparoscopic hepatectomy is useful for the patients with liver cirrhosis.

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Surg Endosc

P287 - Liver and Biliary Tract Surgery

P289 - Liver and Biliary Tract Surgery

Mini-Invasive Treatment of Bile Leakage in Hepatobiliary and Pancreatic Surgery

Risk Factor of Positive Surgical Margin After Laparoscopic Hepatectomy for Liver Metastasis From Colorectal Cancer

O.Y. Usenko, P.V. Ogorodnik, M.Y.E. Nychytaylo, O.I. Lytvyn, A.G. Deynichenko

T. Igami, E. Ebata, Y. Yokoyama, G. Sugawara, T. Mizuno, J. Yamaguchi, M. Nagino

National Institute of Surgery and Transplantology named by A.A.Shalimov, KYIV, Ukraine

Nagoya University Graduate School of Medicine, NAGOYA, Japan

Introduction: Postoperative bile leakage (BL) is a well-known important complication after liver, biliary tract and pancreatic surgery and when not detected may increase the morbidity and mortality rates. Biliary endoscopic procedures and laparoscopic surgery have become the treatment of choice for management of biliary fistulae. The aim of this study is to evaluate the efficacy of the mini-invasive management of bile leakage after HPB operations. Materials and methods: A total of 270 patients with bile leakage after various hepatopancreatobilliary surgical operations between January 2000 and December 2015 were reviewed retrospectively at our hospital. BL was defined by the presence of bile in the abdominal drains, radiologically or surgically drained bilioma or biliary peritonitis. BL severity was established according to the Clavien-Dindo classification. 195 patients presented with bile leaks after cholecystectomy (open cholecystectomy in 45 patients, laparoscopic cholecystectomy in 100 patients and cholecystectomy with common bile duct exploration in 50 patients). There were 48 patients after liver resections and 27 patients after various types of reconstructive operations on bile ducts and pancreas. Results: Three main approaches of mini-invasive treatment of bile leakage was used: 1) percutaneous puncture with or without drain under CT-scan or ultrasound guidance in 110 patients; 2) endoscopic management in 137 patients (in 115 patients (83.9%) were managed with ERCP alone and nineteen (16.1%) were treated with a percutaneous intervention followed by ERCP. Endobiliary stent placement was performed after ES in 22 patients and without ES in twenty seven patients 3) relaparoscopy has been performed in 23 patients, in cases of biliary peritonitis. Conclusions: bile leakage remains a major concern after hepatobiliary and pancreatic operations. Clinicians should be alert in detecting bile leakage as early as possible. The endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage. Relaparoscopic method is effective in diagnostic and treatment of BL.

Background: We retrospectively investigated surgical margin status after laparoscopic hepatectomy for liver metastasis from colorectal cancer and clarified risk factor of positive surgical margin. Methods: Between 2011 and 2015, 35 patients underwent laparoscopic hepatectomy for liver metastasis from colorectal cancer. Of them, 11, 2, and 1 underwent 2, 3, and 4 laparoscopic hepatecomies at a time, respectively. A total of 53 laparoscopic hepatectomies were performed and their margin statuses were analyzed. Results: In the 35 study patients, there were 15 men and 20 women with a mean age of 66 ± 11 years. Of them, 16 underwent pure laparoscopic hepatetcomy and other 19 underwent laparoscopy-assisted hepatetcomy. Of 53 laparoscopic hepatectomies, 24 (46%) were performed for superoposterior segments (i.e. S4 superior, S7, and S8). Of 24 margin statuses after laparoscopic hepatetcomy for liver metastasis from colorectal cancer in superoposterior segments, 3 (13%) were positive surgical margins. These 3 positive margins were after partial resection of S7. The positive margin ratio after partial resection of S7 was 33% (3/8) and worse compared to other hepatecomies (p = 0.024). All 29 margin statuses after laparoscopic hepatecomy for liver metastasis from colorectal cancer in other segments were negative surgical margins. The positive margin ratio after laparoscopic hepatectomy for S7 lesion was 33% Conclusions: Laparoscopic hepatectomy for S7 lesion was the most important risk factor of positive margin status. When laparoscopic hepatectomy for liver metastasis from colorectal cancer in superoposterior segments was performed, more extended hepatectomy may be required for negative surgical margin.

P288 - Liver and Biliary Tract Surgery

P290 - Liver and Biliary Tract Surgery

Self-Expanding Metal Stents for Periampullary Malignancy

Needlescopic Grasper Assisted Single Incision Laparoscopic Approach for Mirizzi Syndrome

O.Y. Usenko, P.V. Ogorodnik, M.Y.E. Nychytaylo, A.G. Deynichenko, O.I. Lytvyn

K.H. Kim, S.H. Lee

National Institute of Surgery and Transplantology named by A.A.Shalimov, KYIV, Ukraine

Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, UIJEONGBU, Republic of Korea

Introduction: The treatment for malignant biliary obstruction includes performing surgery and interventional procedures such as insertion of biliary stent under endoscopic and fluoroscopic guidance. Plastic stents have a high tendency to become blocked in 3–4 months. The placement of metal self-expanding stent is an established method for the palliation of malignant obstructive jaundice in patients with unresectable pancreaticobiliary malignancies. The larger internal caliber of metal stents leads to a prolonged median stent patency of 9 - 11 months, as confirmed in several prospective series. Materials and methods: A total of 420 patients with metal stents were analyzed at our hospital between September 2010 and December 2015: 285 with covered and 135 with uncovered stents. 205 patients had pancreatic head carcinoma, 155 patients had ampullary cancer and 60 patients had distal common bile duct carcinoma. Results: In our study, 274 patients had biopsy-confirmed adenocarcinomas and 146 of patients lacked a confirming biopsy, but these patients had been diagnosed by the findings on abdominal spiral computed tomography, magnetic resonance cholangiography, endoultrasonography and endoscopic retrograde cholangiopancreatography. The stent patency rates were 92, 74 and 55% at 100, 200 and 400 days, respectively, for covered stents and 85, 70, and 41%, respectively, for uncovered stents. The incidence of mild pancreatitis was 2.1% for covered stents and 0.5% for uncovered stents. Cholecystitis occurred in 3 patients with covered stents vs none in the uncovered stent group. The retroduodenal perforation occurred in 1 case. There were three cases of proximal stent migration attributed to improper technique in stent deployment across the stricture and a lack of a suitable length stent. The distal migration of covered stent occurred in two cases. Late occlusions were managed by insertion of another covered metallic stent in 39, insertion of a plastic stent in 25 and mechanical cleaning in 52 patients. Conclusions: Endoscopic stent insertion is the modality of choice in the treatment of periampullary malignancy. The self-expandable metal stent is safe to use with acceptable complication rates.

Aim: Mirizzi syndrome (MS) is rare complication of cholelithiasis with an incidence of less than 1% a year. The aim of this study was to present our treatment methods focusing on needlescopic grasper assisted single incision laparoscopic approach. Methods: We retrospectively analyze 13 cases of MS which was done by laparoscopic approach between October 2012 and December 2014. We did needlescopic grasper assisted single incision laparoscopic cholecystectomy (nSILC) in 5 cases among 13 cases. A needlescopic grasper was used in nSILC, which was inserted through a direct puncture on right upper quadrant of abdomen. The scope and other instrument were inserted through umbilical port. Three trocars were used in CLC, 11 mm trocar for scope was inserted on umbilicus and two more 5 mm trocars were inserted on right middle quadrant and epigastric area Results: The incidence of MS was 1.4%, 13 of 897 cholecystectomized patients. There were 2 men and 11 women, with a mean age of 47.5 ± 21.9, and mean BMI was 26.8 ± 6.7. Nine patients had MS type I (69.2%). Seven patients underwent laparoscopic cholecystectomy, whereas 2 conversions were performed because of difficult dissection at calot’s triangle and common bile duct. Three patient had MS type II (23.1%), and all MS type II patient underwent laparoscopic cholecystectomy, and there was no conversion case. One patient had MS type III (7.7%), and underwent laparoscopic cholecystectomy and common bile duct repair. There was only one post-operative complication (7.7%) in MS type I, common bile duct was perforated because of common bile duct thermal injury. There was no postoperative mortality. Conclusion: It was not easy to apply the single incision laparoscopic approach for MS. However, the range of laparoscopic therapeutic application has spread because of development of laparoscopic instruments and skill. The laparoscopic surgery including the single incision laparoscopic approach for MS type I and II has been generalized already, the laparoscopic approach should be considered in highly selective cases of MS type III, IV, V.

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Surg Endosc

P291 - Liver and Biliary Tract Surgery

P293 - Liver and Biliary Tract Surgery

The Feasibility of Laparoscopic Resection in ‘Liver First’ Approach Among Advanced Colorectal Cancer Patients

Safety of Laparoscopic Cholecystectomy in Patients with Previous Abdominal Surgery

T. Mersich

Z.A. Katbeh, S. Zino, E. Donnelly, A.Y.H. Loh, A.H.M. Nassar

National Institute of Oncology, BUDAPEST, Hungary

Monklands Hospital, GLASGOW, United Kingdom

Introduction: ‘Liver first’ strategy is a relatively new approach in the therapy of liver limited advanced colorectal cancer. Due the complexity of these therapeutic strategy, only a few center are able to manage patients this way. There are quite a few data about the feasibility of laparoscopic resection either in liver part or the colonic part of surgery in these patients. Patients: Between 2012 and 2015 six patients were treated with ‘liver first’ approach out of 220 liver resected cases in our Institute. All patients had stage IV colorectal disease with liver only metastases. Oncotherapy of the patients began with chemotherapy after k-RAS examination. Liver first approach was indicated in patients with borderline resectable liver disease and having regressive or stable disease during chemotherapy. In cases of resectable liver mets we prefer traditional or simultaneous approach. However patients unsuitable for simultaneous resection may have benefit from liver first approach even those with locally advanced rectal cancer. 63y old female patients was treated initially with Folfox-bevacizumab therapy. In stable disease right trisegmentectomy was performed as a first step. After short course radio-kemotherapy (5x5 Gy) laparoscopic rectal resection was performed with ileostomy. (ypT3yN2a) After subsequent chemotherapy closure of loop ileostomy was performed with right adranelectomy. 78y old male patiens was treated with Folfiri-bevacizumab therapy. In regression simultaneous resection was planned, but the risk of potentially affected CRM in rectum was high, segmentectomy was performed by laparoscopy. After subsequent chemotherapy longcourse radiotherapy was carried out (25x2 Gy). 6 week after radiochemotherapy and 6 months after liver resection laparoscopic abdominoperineal resection was performed (ypT3N0). All two patients are tumor free and getting adjuvant chemotherapy Conclusion: Laparoscopic approach seems to be feasible alternative of open resection in both surgical part of ‘liver first’ approach in metastatic colorectal patients. The exact role, timing and quality of radiotherapy as well the limit of the procedures are to be addressed to investigate.

Aims: To analyse the effect of previous abdominal surgery on the outcomes of laparoscopic cholecystectomy (LC).To describe access and adhesiolysis strategies in performing LC safely in patients with previous abdominal surgery, identifying problems and potential solutions in this group. Methods: Analysis of prospectively collected data from 4088 consecutive patients undergoing LC from 1992-2014 by a single surgeon. Patients were classified into two groups: Group A: Patients without history of previous abdominal surgery (n = 2814); group B: Patients who had previous surgery (n = 1274).Our access strategy is based on avoiding abdominal scars and using distant sites for the first port inserted by modified open access. Adhesiolysis is limited to clearing sites of secondary ports, avoiding the umbilical site altogether in case of adjacent small bowel, and to dividing band adhesions with potential for future obstruction. Previous surgical site, altered access, operative time, difficulty grading, need for adhesiolysis, complications, conversion to open and mortality were analysed. Results: 1274 (31%) patients had previous abdominal surgeries. 933 had the procedure documented. 163 patients had 2 or more procedures. 123 upper and 928 lower operations had been performed. Modified access was used in 120 (9.4%) cases: Epigastric first in 48, supraumbilical in 34, through umbilical or incisional hernias in 36, and RUQ first in 2. Mean operative time, difficulty grading, perioperative complications, conversion to open and mortality rate were similar in both groups (p [ 0.05). Need for distant adhesiolysis was more common in group B 27.8% than group A 8% (p \ 0.05). Conclusion: Access modification strategies should be considered in patients with previous abdominal surgeries. These include: Epigastric first, Supraumbilical, Trans-umbilical/incisional hernia or RUQ first. This approach prevented access complications; while necessary adhesiolysis caused 3 (0.23%) cases of small bowel injury, managed by one minilaparotomy and two laparoscopic repairs. Previous surgery is not associated with increased operative time, difficulty grading, complications, conversion or mortality. LC could be safely performed by adopting modified access techniques depending on the site and nature of previous operations. Previous abdominal surgery is not considered a risk factor in laparoscopic cholecystectomy.

P292 - Liver and Biliary Tract Surgery

P294 - Liver and Biliary Tract Surgery

Evaluation of Parameters Increasing Difficulty of Laparoscopic Cholecystectomy

The Utility of Retrograde Hemi-Cholecystectomy in Difficult Laparoscopic Cholecystectomy

A. Solmaz1, O.B. Gu¨lc¸ic¸ek2, A. Biricik2, C. Erc¸etin2, H. Yigitbas2, E. Yavuz2, S. Arici2, A. C¸elik2, F. C¸elebi2

J. Su, J.K. Low

1

Background: Subtotal cholecystectomy has been traditionally advocated as an approach to avoid the need for conversion and bile duct injury in difficult laparoscopic cholecystectomy. Various operative techniques have been described for this procedure to allow for cholecystectomy in the difficult gallbladder. Methods: We review our series of 79 patients who underwent laparoscopic subtotal cholecystectomy from January 2011 to January 2015. Patients were identified using the hospital operating theatre listing system using keywords for ‘subtotal’ and ‘cholecystectomy’. All patients were operated by the same surgeon using the same operative technique. Patients with known malignancy were excluded from the study. In our study we routinely performed retrograde cholecystectomy with transection of the gallbladder at its mid-portion. Stone removal was then performed and the cystic duct or Hartmann’s pouch was then ligated using absorbable sutures. Results: A total of 318 patients underwent laparoscopic cholecystectomy of which 79 patients were recruited with a mean age of 62 years. Mean length of inpatient stay was 6 days. The majority of patients were male (54.4%). The most common complication was that of symptomatic retained gallstones in 10.1% of patients. Conversion rate to open cholecystectomy was 2.2%. There were no patients with bile duct injury or mortalities in our study. Discussion: Our technique of subtotal cholecystectomy is associated with a low rate of bile leakage and biliary injury. We recommend the use of this technique in the difficult gallbladder where Calot’s triangle cannot be clearly delineated.

Bagcilar Training and Research Hospital, ISTANBUL, Turkey; 2 General Surgery Clinic, Bagcilar Training and Research Hospital, ISTANBUL, Turkey Background: Laparoscopic cholecystectomy (LC) is a gold standard technique for cholecystectomy and one of the most common laparoscopic operation being performed all over the world. Aims: To evaluate the factors affecting the difficulty of the elective laparoscopic cholecystectomy Methods: In this prospective observational study 207 consecutive patients who undergone elective laparoscopic cholecystectomy in Bagcilar Training and Research Hospital General Surgery Clinic between June 2015 and December 2015 were included. Age, gender, body mass index, preoperative biliary symptoms, cholecystitis, pancreatitis, duration of the operation, scoring of the difficulty of the operation in 5 phases(entry to abdomen, degree of adhesions, dissection of Calot’s triangle, separation of gallbladder from liver, extraction of gallbladder from abdomen) discharge time from hospital were recorded. Results: We found that patients with the history of cholecystitis and endoscopic retrograde cholangiopancreatography (ERCP) have significantly higher scores compared to others (p \ 0.005). Male patients have significantly higher scores compared to females (p \ 0.005). History of pancreatitis and number of stones did not affect difficulty scores (p [ 0.005). Interestingly obese patients had lower difficulty scores in dissection of Calot’s triangle (p = 0.03) and separation of gallbladder from the liver (p = 0.022). Age of the patient affected significantly just degree of adhesion (p = 0.0001) other scoring parameters were not affected from the age. Conclusion (s): There are many factors affecting the difficulty of the laparoscopic cholecystectomy. LC after ERCP and cholecystitis are often a technical challenge. History of pancreatitis and number of Stone did not affect the difficulty of the operation. Obesity did not increase the difficulty; conversely it diminished the scores of dissection of Calot’s triangle and separation of gallbladder from the liver.

Tan Tock Seng Hospital, SINGAPORE, Singapore

123

Surg Endosc

P295 - Liver and Biliary Tract Surgery

P298 - Liver and Biliary Tract Surgery

Epigastric or Chest Pains as a Risk Factor of Common Bile Duct Stones

Technical Modalities to Seal the Biliary Communication of Hydatid Hepatic Cyst

Z.A. Katbeh, H. Qandeel, C. Ying Toh, E. Donnelly, A.H.M. Nassar

F. Graur1, E. Mois1, R. Elisei2, L. Furcea1, I. Catirau2, N. Al Hajjar1

Monklands Hospital, GLASGOW, United Kingdom

1 University of Medicine and Pharmacy ,,Iuliu Hatieganu,, ClujNapoca, CLUJ-NAPOCA, Romania; 2Regional Institute of Gastroenterology and Hepatology O. Fodor, CLUJ-NAPOCA, Romania

Background: Acute epigastric or chest pains may be presentations of choledocholithiasis, usually associated with deranged liver function tests. Such episodes can be short-lived in patients with no history of gallstones. Many of these are initially admitted to medical units where acute coronary events are excluded. Aims: To study the incidence of previous presentations with acute chest or epigastric pains in relation to ductal stones. Is such past history predictive of bile duct stones at operation? Methods: We have a policy of no preoperative ERCP in fit patients, with routine intraoperative cholangiography (IOC) for all-comers, followed by laparoscopic exploration when necessary. Hospital-wide protocols are in place to identify patients with risk factors and refer them to the specialist biliary firm. We analysed a prospective database of 4088 laparoscopic cholecystectomies. Preoperative ultrasound and operative findings were correlated to past history of previous admission with epigastric or chest pains associated with deranged liver function tests. Results: Of 4088 patients, 423 patients (10%) had a previous history of acute epigastric or chest pains (group A) and 3665 (group B) did not have such history. Group A were 73% female, with a mean age of 52.5 years. Patients referred with chest or epigastric pain were more likely to be referred to the service by physicians than those in Group B (p = 0.01). An ultrasound finding of CBD stones or dilatation were documented in 89 (21%) vs. 550 (15.0%) in groups A and B respectively (p = 0.001). Stones were present in the bile duct and required clearance at the time of cholecystectomy in 29% (124/423) of patients in group A and 18% (651/3665) of those in group B (p \ 0.0001). Conclusion: patients with gallstones may present with acute epigastric or chest pains and deranged liver function tests that rapidly resolve. A history of such episodes, leading to suspected myocardial ischemia is associated with a higher incidence of ductal stones at operation. Physicians and surgeons should recognise the need to exclude gallstones when dealing with these symptoms.

Background: The experience of laparoscopic treatment for complicated hydatid hepatic cyst is limited. The aim of this study is to analyze the technical modalities for sealing the cysto-biliary communication by laparoscopy. Methods: A systematic review of literature from 1990 to 2015 was performed in order to search for the methods of closing of the cysto-biliary communication. All articles concerning the treatment of liver hydatid cyst were searched for techniques used to seal cystobiliary fistula. All these techniques were analyzed regarding the number and percent of procedure and also the postoperative complications. Results: Complicated cysts are frequent and laparoscopic treatment is currently used for non-complicated disease. In the literature, the complications occur between 15-60% of hydatid hepatic cysts and the most frequent complication is biliary communication. However, more and more experienced surgeons try to treat the complications by laparoscopy. There are many therapeutic variants to treat the communication between biliary tract and hydatid cyst. The most used procedure is clipping the biliary canal. Conclusion: Laparoscopic treatment of complicated hydatid hepatic cyst has no standard protocols. There are many factors to be quantified in order to make a therapeutic decision. All procedures discussed vary as utility in concordance with surgeon’s experience, available devices, cyst’s localization and characteristics. However, more and more complicated hepatic echinococcosis are treated by laparoscopic means as the experience and technology evolve.

P296 - Liver and Biliary Tract Surgery

P299 - Liver and Biliary Tract Surgery

Total Laparoscopic Approach for One-Staged Liver Resection Combined with Resection of Colon, Pancreas and Gastric Cancers

Does the Use of an Endoscopic Retrieval Bag Reduce the Incidence of Post-Operative Wound Infections After Laparoscopic Cholecystectomy?

R. Alikhanov, R.E. Izrailov, M.A. Koshkin, P.S. Tyutyunik, B.A. Pomortsev, O.S. Vasnev, V.V. Tsvirkun, I.E. Khatkov

R. Tyler1, J. O’Brien2, A.M. Harris3

Moscow Clinical Scientific Center, MOSCOW, Russia Aim: To evaluate the feasibility and safety of total laparoscopic approach for radical treatment of patients with cancers of colon, pancreas and stomach with liver metastases or with cancer involvement of liver. Methods: Totally 8 cases of colon, pancreas and gastric cancers with liver metastases or direct liver invasion were evaluated in short term postoperative time. All of them underwent one-staged liver resection combined with resection of colon, pancreas and gastric cancers using total laparoscopic approach: 2 cases of combined right hemihepatectomy with hemicolectomy, 1 case of combined left hepatectomy with colectomy, 1 case of liver bisegmentectomy(2,3) combined with hemicolectomy, 1 case of liver segment 2 and 3 resection combined with Whipple procedure, 1 case of gastrectomy with resection of segment 4, 1 case of gastrectomy combined with resection of segment 3. Results: The median blood loss was 150 ml. There were no conversion.. Hepatic specific complications were not observed in all cases The postoperative course was uneventful. There was no mortality in 90-days of postoperative period. Conclusions: Total laparoscopic approach for one staged liver resection combined with resection of colon, pancreas and gastric cancers is feasible and safe which makes simultaneous surgery possible. The oncologic outcome of short-middle term is acceptable, and long-term survival is expected.

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1

Good Hope Hospital, SUTTON COLDFIELD, United Kingdom; Norwich and Norfolk Hospital, NORWICH, United Kingdom; 3 Hinchingbrooke Hospital, HUNTINGDON, United Kingdom 2

Aims: Post-operative wound infections can cause significant patient distress and a financial burden on the treating hospital. It has been hypothesised that using an endoscopic retrieval bag for removing the gallbladder can reduce the infection rate. However, it can be argued the use of a bag increases costs, may need a larger fascial incision thus increasing postoperative pain and should only be used in the case of intraoperative bile spillage. We aimed to compare wound infection rates between bagless extraction of a gallbladder and using a bag in operations where there was no bile spillage documented. Methods: A single centre, retrospective review of prospectively collected data from a series of laparoscopic cholecystectomies from January 2012- April 2014 was carried out. Wound infection was the primary outcome of interest. Wound infection was defined as those that had a confirmed microbiological diagnosis or treated empirically with post-operative antibiotics. Importantly, cases where there was documented evidence of bile spillage were not included in the analysis. We used logistic regression analysis to predict whether bagless extraction of a gallbladder had a statistically significant increase in the number of wound infections. Results: A total of 363 laparoscopic cholecystectomies were identified during a 27 month period (307 elective, 56 emergency.) 210 were carried out in women, 201 in men with an average age of 54. 229 procedures used an endoscopic bag, 134 did not. There were 19 wound infections (16 empirically treated and 3 microbiologically proven.) Of these 19 wound infections, 6 occurred without the use of an endoscopic bag (6/134,) whilst 13 occurred using an endoscopic bag (13/229.) This gave an odds ratio of 0.60 with a nonsignificant p-value (0.3746.) Conclusions: The bagless removal of a gallbladder in the context of an absence of bile spillage does not increase wound infection rates significantly and appears safe. By not using a bag regularly the financial burden and operating time could be reduced, whilst not increasing patient morbidity.

Surg Endosc

P300 - Liver and Biliary Tract Surgery

P302 - Liver and Biliary Tract Surgery

What the On-Table Cholangiogram Bring to the Table

Near-Infrared Fluorescence Cholangiography Assisted Laparoscopic Cholecystectomy Vs Conventional Laparoscopic Cholecystectomy (Falcon): Study Protocol

L. Swafe, A. El-Hadi, S. Wilson, S. Brown, J. Barwell, A. Sudlow Norfolk and Norwich University Hospital, NORWICH, United Kingdom Introduction: Performing routine on table cholangiogram (r-OTC) during laparoscopic. Cholecystectomy (LC) remains controversial. Advocates for r-OTC highlight the fact that it reduces the risk of Injury to the common bile duct (CBD) in addition to visualising the biliary tree and facilitating the management of ductal stones. Based in a University teaching hospital performing r-OTC in all LC we aimed to test the hypothesis that r-OTC reduces the risk of CBD injury and improves the overall management of gallstone disease. Methods: All Patients who underwent a Laparoscopic cholecystectomy and r-OTC from the 1st of October 2013 to the 30th of September 2015 were included. The data was collected using the hospital coding system in addition to the operating theatre database. Data collection included diagnosis, emergency vs elective surgery, pre-operative radiological findings, liver function tests, operative findings, post-operative complications and need for Endoscopic retrograde cholangiopancreatography following surgery (ERCP). The data was then analysed using Microsoft EXCEL. Results: A total of 1005 patients (75.1% female, mean age 51) were included. 836 (83.2%) LC were performed electively compared to 169 (16.8%). Emergency operations. There was no CBD injury in our study population. 4 (0.4%) cases were converted to open cholecystectomy. ROTC showed ductal stones in 101 patients (10.1%) of which 86 (85.2%) patients underwent a CBD exploration and stone extraction during the same operation, out of the remaining 15 patients with ductal stones 3 were managed by ERCP and 12 patients were successfully managed conservatively. In our study population there were only 3 (0.3%) readmissionsto the hospital with retained CBD stones. 6 patients (0.6%)returned to theatre for post-op complications (4 post-operative bleeding, 1 bile leak, 1 port site hernia). Conclusion: This study suggests that r-OTC reduces the risk of Common bile duct injury and could be performed safely in emergency as well as elective patients. It also suggests that r-OTC is very useful in ductal stone detection and hence reduces re-admission to hospital with retained stones. Further work is underway to elucidate the pre-operative predictors for ductal stones. Multi-centre randomised controlled trials are needed to validate this conclusion.

J. van den Bos, R.M. Schols, N.D. Bouvy, L.P.S. Stassen Maastricht University Medical Center, MAASTRICHT, The Netherlands Aims: The aim of this multicenter RCT is to assess the potential added value of the nearinfrared fluorescence (NIRF) imaging technique during laparoscopic cholecystectomy. The main objective is to evaluate whether earlier establishment of Critical View of Safety can be obtained using the NIRF imaging technique during laparoscopic cholecystectomy, by applying NIRF imaging as an adjunct to conventional laparoscopic imaging versus conventional laparoscopic imaging alone. Methods and Analysis: Starting January 2016, in total 308 patients scheduled for an elective laparoscopic cholecystectomy for gallstones will be included. The study will initially take place in 5 large teaching hospitals in the Netherlands. Subsequently, several international centers will be included. The participating patients are randomized into a NIRF imaging laparoscopic cholecystectomy (NIRF-LC) group or a conventional laparoscopic cholecystectomy (CLC) group. To obtain fluorescence imaging in the NIRF-LC group, 2,5 mg of Indocyanine green (ICG) will be given intravenously at least 30 min before surgery. The primary outcome is time to Critical View of Safety (CVS). Secondary endpoints are: time to identification of the cystic duct (CD) during dissection of CVS; time until identification of common bile duct; time until identification of the transition of CD in the gallbladder; time until identification of the transition of the cystic artery in the gallbladder; total surgical time; intraoperative bile leakage from the gallbladder or cystic duct; bile duct injury; postoperative length of hospital stay, complications due to the injected contrast agent; conversion to open cholecystectomy; postoperative complications (until 90 days after surgery) and cost-minimization. The endpoints will be measured during the operation, using an intra-operative Case Report Form. Additionally, postoperative video analysis by an expert panel will further objectify these findings. Furthermore, to determine the fluorescence intensity of the extra-hepatic vile ducts and cystic artery, the target to background ratio will be measured. A cost-minimization analysis will be performed. Results: As this is a presentation of a study protocol of a study only recently started, no results will be available yet during the EAES. Conclusion: As expected, this study will finally deliver solid evidence whether the use of NIRF imaging in laparoscopic cholecystectomy is of added value.

P301 - Liver and Biliary Tract Surgery

P303 - Liver and Biliary Tract Surgery

Laparoscopic Common Bile Duct Exploration After Upper Abdominal Operations

A Management of Pure Laparoscopic Heaptectomy in Our Institute

´ . Botos, E. Kiss J. Bezsilla, A. Berencsi, I. Karaffa, L. Sikorszki, A

M. Kido1, T. Fukumoto2, M. Tanaka2, H. Kinoshita2, K. Kuramitsu2, T. Ajiki2, H. Toyama2, S. Asari2, T. Goto2, Y. Ku2

B-A-Z County Hospital, MISKOLC, Hungary Previous abdominal surgery has been reported as a relative contraindication to laparoscopic operation because it is associated with an increased need for adheasiolysis, a higher open conversion rate, a prolonged operation time and a longer postoperative stay. With development of surgical skills and instruments recently, the laparoscopic procedures were performed as a common treatment in common bile duct (CBD) stones even in complicated cases. We aimed to evaluate the feasibility of laparoscopic common bile duct exploration (LCBDE) even in patients with previous upper abdominal operations.From January 2005 to December 2015, 114 patients with a diagnosis of CBD stone underwent LCBDE at the B-AZ County Hospital, Miskolc, Hungary. Among them, 20 patients had received various kind of upper abdominal operation before. This population comprised 15 females and 5 males with a mean age of 58,3 years (range, 42 to 78 years). There were 10 cases with previous open cholecystectomy, 2 cases with open common bile duct exploration, 6 cases with laparoscopic cholecystectomy and two cases with hepatic or gastric resection. The operation steps involved open insertion of trocar and creation of pneumoperitoneum, meticulous adhaesiolysis, direct choledochotomy followed by clearance of biliary stones using a flexible video-choledochoscope. After confirmed ductal clearance, the common bile duct was closed with t-tube diversion in 12 cases or directly in 8 cases - especially after a successful endoscopic sphincterotomy but failed stone retrieval. There were no intraoperative bowel lesions or other complications, conversions. The mean operative time was 108 min (range, 72 to 145 min). There weren’t any maior postoperative complications. The median hospital stay was 7 days (4–15 days).In summary LCBDE can be described as safe, minimally invasive procedures in the patient with previous abdominal operation as far as an experienced laparoscopic surgeon is available, and it can be the best alternative to failed ERCP for difficult cholelithiasis.

1 Kobe University Graduate School of Medicine, KOBE, Japan; 2Kobe university, KOBE, Japan Background: In the system of Japanese public health insurance, only two operative methods are allowed as laparoscopic hepatectomy. These are partial resection and lateral segmentectomy of the liver. It has been reported that there are almost no differences between laparoscopic hepatectomy and conventional hepatectomy in the point of complications and overall survival. But technical problems remain unsolved. Especially it is difficult to tract, grasp, and exclude the liver in pure laparoscopic hepatectomy. Therefore we developed KAIMENTM that is a kind of sponge. Using these devices can lead a beginner of pure laparoscopic hepatectomy to operate safely. Objective: The aim of study was to report how we have introduced pure laparoscopic hepatectomy in our institute. We examined differences between the rightsided group and the left-sided group, because anatomical location is one of the most important factor to complete pure laparoscopic heaptectomy. Patients & Method: Between February, 2011, and December, 2014, 31 patients were scheduled to perform the pure laparoscopic hepatectomy at Kobe University Hospital. We categorized tumor locations into two groups; right-sided group and left-sided group. And we make comparison and examination of two groups. Results: There are no significant differences in the two groups, because the number of patients is small. But, We had a tendency to perform left-sided hepatectomy more easily in operation time (426 ± 132 min. vs 340 ± 115 min., P = 0.0609), blood loss (250 ± 259 g vs 102 ± 174 g, P = 0.0694). Conclusion: We had a tendency to perform left-sided hepatectomy more easily in pure laparoscopic hepatectomy. So a beginner of pure laparoscopic hepatectomy had better perform left-sided hepatectomy in the first time.

123

Surg Endosc

P304 - Liver and Biliary Tract Surgery

P306 - Liver and Biliary Tract Surgery

Minimally Invasive Approach for Xanthogranulomatous Cholecystitis

A Pictorial Description of Difficulty Grading Scale for Laparoscopic Cholecystectomy, the Rationale and the Benefits

S.K. Lee

S. Zino, A. Mirza, T. Katbeh, K. Nassar, H. Qandeel, A. Nassar

Daejeon St.Mary’s Hospital, DAEJEON, Republic of Korea

Monkland Hospital, GLASGOW, United Kingdom

Purpose: Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder characterized by accumulation of lipid laden macrophages, fibrous tissue, and acute and chronic inflammatory cells. XGC often involves adjacent organs and mimicking a gallbladder cancer. The purpose of this study was to review the clinical and radiologic finding of XGC and to investigate an appropriate treatment plan for patients with XGC. Methods: We retrospectively analyzed the data regarding clinical demographics, operation records, and postoperative results of 20 patients with a pathologic diagnosis of XGC who underwent surgery between January 2010 and January 2015. Results: XGC was found in 2.0% (20/1006) of cholecystectomy patients in our hospital during 5 years. The most frequent clinical symptom was abdominal pain (14 patients, 70.0%). Preoperative radiologic studies revealed cholelithiasis in 9 patients (45.0%), thickening of gallbladder wall in 15 patients (75.0%), and suspicious cancer in 1 patient (5.0%); however, no gallbladder cancer was found in this series. Laparoscopic cholecystectomy was initially attempted in all patients, but converted to open cholecystectomy in 3 patients and T-tube choledocholithotomy was needed in one patient due to common bile duct (CBD) injury. Mean operation time was 183.2 min and estimated blood loss was 316.1 mL. There were 2 patients with complications greater than Clavien-Dindo Classification III. (CBD injury, pleural effusion). Conclusion: An initial minimally invasive approach was possible for XGC. However, it was difficult, challenging with significant higher conversion and complication rates compared to standard laparoscopic cholecystectomy.

Aims: This study describes a difficulty grading scale for laparoscopic cholecystectomy. Methods: Prospectively collected data for patients undergoing biliary surgery over 22 years (n = 4199) was analyzed. Laparoscopic cholecystectomies (LC) were classified prospectively into five difficulty grades based on intraoperative findings. Results: The criteria for difficulty grading scale were: GI: Floppy non-adherent gallbladder (GB), clear thin cystic pedicle (CP) or simple adhesion to GB neck and Hartmann’s pouch (HP). GII: Mucocele, GB packed with stones or deep fossa; Fat- Laden or anterior/accessory artery in CP; simple adhesions up to the body or omentum on liver preventing retraction. GIII acute Cholecystitis, contracted, fibrotic GB, HP adherent to CBD or stone impaction; short, dilated or obscured cystic duct (CD), impacted CD stones or abnormal duct anatomy; dense adhesions up to the fundus, involving hepatic flexure or duodenum or not on GB but hinder retraction or exposure of pedicle. GIV: completely obscured, empyema, gangrenous GB or abscess/mass; impossible to clarify the CP without fundusfirst dissection, Mirizzi I, cirrhosis, dilated veins; dense fibrous adhesions wrapping the GB, previous operation in the upper abdomen, or difficult to separate duodenum or hepatic flexure. GV: burnt out GB or Cholecysto-cutaneous abscess; Mirizzi II, Cholecysto-duodenal fistula or Choelcyto-colic fistula. Grading scale was recorded for 4146 LC: Grade I (32.9%), Grade II (31.3%), Grade III (20%), Grade IV (4.5%) and Grade V (1.1%). Mean age was 50 years, 75% female, and 41% of cases were emergencies. Difficult gallbladders were associated with male gender (42.5% in GIV), age above 50y (73% in GIV and 85% in GV), emergency admission (GIV 67% and 63%GV), acute cholecystitis (31% in GIV and 21%GV), previous cholecystitis (15.6% in GIV and 23% in GV. Fundus first dissection was required in GIV 11.7% and GV 43%. Conversion to open was significantly higher in GV 17.3% and in GIV 1.8%, when compared to overall rate of 0.7%. Conclusions: Our difficulty grading scale which has been already used in multiple studies allows the standardization of intraoperative findings, facilitate comparison between centers’ and help in planning operative strategies for difficult cholecytecomies, different access techniques and methods of skills assessment.

P305 - Liver and Biliary Tract Surgery

P307 - Liver and Biliary Tract Surgery

Single Stage Procedure for the Management of Cholelithiasis with Choledocholithiasis: A Safe and Effective Procedure

Laparoscopic Deroofing of Huge Symptomatic Liver Cysts with Greater Omentum Flap

C. Neophytou, E. Theophilidou, A.K. Awan

H. Kinoshita, T. Fukumoto, M. Kido, M. Tanaka, K. Kuramitsu, Y. Ku

Royal Derby Hospital, NOTTINGHAM, United Kingdom Aims: To review the outcomes and efficacy of primary common bile duct closure after laparoscopic common bile duct exploration (LCBDE) in a large series at a teaching hospital. Methods: All LCBDE cases from November 2009 to October 2015, under two hepatobiliary surgeons were examined. 9 patients who had a conversion to open procedure or T-tube insertion were excluded. The outcomes measured included early and late postoperative complications, length of stay, urgency and length of operation, approach to the CBD, readmissions and further interventions required. Results: 180 patients (128 female) underwent LCDBE. 58 cases (32%) were emergency procedures and 122 (78%) elective. 159 patients (88%) were discharged with no immediate complications. Early complications included infected haematoma (1 patient), high drain output ([250 ml/24 h) in 6 patients; out of which 3 required intervention (2 patients returned to theatre for suture reinforcement of closure; 1 patient required for ERCP and stenting), biloma secondary to blocked drain (2 patients) and respiratory infections (6 patients). Of the three cases requiring a second procedure for bile leak no patient had bile peritonitis, two were emergency cases and all three had a choledochotomy. There were no deaths in the series. Exploration was performed using a transcystic approach in 31 cases (17%) or via choledochotomy in 149 cases (83%). Median length of stay was 4 days (IQR 2-7). Mean operative duration was 147 min (range 75 - 361 min). Three patients were readmitted due to retained stones and underwent ERCP without further complications. Conclusions: Our series is one of the largest published to date. It confirms that cholecystectomy with primary closure after LCBDE is a safe single stage procedure with low morbidity. Most common complications encountered, include high drain output and respiratory infections but are usually managed conservatively. It can be performed in both the emergency and elective setting. A transcystic approach in selected cases (relatively short cystic duct and a small size and number of CBD stones) can be used to avoid bile leaks.

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Kobe University, KOBE, Japan Background: Surgical therapy of nonparasitic liver cysts is indicated in cases of clinical symptoms. Laparoscopic deroofing is the standard therapy for simple nonparasitic liver cysts. However, the usage of greater omentum flap sutured into the former cyst cavity is still under controversial. The aim of the study is to determine if a greater omentum flap has influence on the recurrence rate of nonparasitic liver cysts, and the recrudescence rate of symptoms during the follow-up period. Methods: From January 2011 to December 2015, 7 patients underwent laparoscopic deroofing for huge symptomatic liver cysts. All patients were symptomatic and all the liver cysts sizes were [ 15 cm. A greater omentum flap to fill the former cyst cavity was used in 5 patients (group 1), whereas in 2 patients operation was carried out without such an omentum flap (group 2). The patients were identified retrospectively and subjected to a follow-up examination. The 2 groups of patients were compared according to the recurrence of the liver cysts and the recrudescence of symptoms. Results: No patients had postoperative complications. There was an overall recurrence rate of 42.9% (3 of 7), with 3 cysts recurrence from group a (3 of 5). However, symptoms of all patients vanished, even after the recurrence of liver cysts. Conclusions: Laparoscopic deroofing is a safe and effective for huge symptomatic liver cysts. Although a greater omentum flap did not associate with symptoms, the recurrence rate of liver cysts increased by using a greater omentum flap. A greater omentum flap to prevent a local cyst recurrence after laparoscopic deroofing is dispensable.

Surg Endosc

P308 - Liver and Biliary Tract Surgery

P310 - Liver and Biliary Tract Surgery

Laparoscopic Exploration of Common Bile Duct, 21 Years of Experience in Texas Endosurgery Institute

Simultaneous Laparoscopic Resection of Colorectal Cancer and Synchronous Metastatic Liver Tumor: A Case Report

C. Jaurrieta Rico1, A. Ramos Mayo1, A. Garza Maldonado1, R. Alatorre Adame1, M. Hernandez2, J.L.G. Glass2, M. Franklin Jr2

K. Arai, M. Kido, H. Kinoshita, T. Fukumoto, M. Tanaka, K. Kuramitsu, T. Matsumoto, H. Toyama, S. Asari, T. Goto, T. Ajiki, Y. Ku

Hospital San Jose, MONTERREY, Mexico; 2Texas Endosurgery Institute, SAN ANTONIO, TEXAS, United States of America 1

Aims: Treatment of choledocholithiasis has evolved dramatically in the wake of the great success of minimally invasive and endoscopic procedures. Adoption of new techniques has allowed the laparoscopic common bile duct exploration (LCBDE) to gain acceptance. In our experience since the mid-1990s, we have avoided the definitive indications of ERCP to reduce complications and provide treatment in a single phase. This paper presents the experience of 21 years of LCBDE treatment. Methods: From 1994 to 2014, 401 patients diagnosed with cholecystolithiasis, choledocholithiasis and gallstone pancreatitis and treated with LCBDE, were reviewed retrospectively in Texas Endosurgery Institute. The vast majority of cases were performed by three surgeons in this time period with a standard technique. All patients were evaluated preoperatively with abdominal ultrasound and liver function tests, in selected cases by CT scan. All patients with were subjected to routine intraoperative cholangiography. Results: Of the sample of 401 patients: mean age was of 49.3 years, 72.8% were female with a male:female ratio of 1: 2.6, average BMI was 32.5 kg/m2. 60.6% were emergency surgeries. The operative time and blood loss was divided into 3 groups: choledochotomy, transcystic and failed transcystic turned into choledochotomy. The success rate was 97.7% for all groups, failure rate was 2.3%, with 9 unsuccessful cases, ERCP was performed postoperatively and none of the failed cases require reoperation. Transcystic approach was 23.6%, 76.4% with choledochotomy and 4.0% were started transcystically and turned into choledochotomy. Seven conversions (1.7%) were made due to extensive inflammatory reaction and impacted calculi. There were 13 intraoperative complications, 1 in the immediate postoperative period and 1 mortality. There was an average of five days of hospital stay. All patients were followed for 1 year operated without evidence of retained calculi. Conclusion: Increased experience and adoption of new techniques of laparoscopic reintroduced to the laparoscopic exploration of bile duct as a treatment for choledocholithiasis with a great success rate and lower level of retained calculi. Currently gastroenterologists refer difficult choledocholithiasis cases. The LCBDE is effective and safe for the treatment of choledocholithiasis and other diseases of the biliary tract

Graduate School of Medicine, Kobe University, KOBE-CITY, HYOGO,, Japan Introduction: Combined resection of colorectal cancer with surgery for synchronous liver metastases still remains controversial because of the possible higher morbidity rate, the necessity of an adequate abdominal approach for both resections and the impact on oncological results. Although simultaneous colorectal and hepatic resections has been attempted, laparoscopic simultaneous resection has been rarely reported. We report here a case of simultaneous laparoscopic resection of colorectal cancer and synchronous metastatic liver tumor Case presentation: A 85-year-old woman presented at our institute with dysphagia. Colonoscopy revealed an 6 x 5 cm-sized tumor on the ascending colon and Biopsy showed a moderately differentiated adenocarcinoma. Computed tomography showed a synchronous metastatic liver tumor measuring approximately 2 cm in diameter. She underwent simultaneous laparoscopic resection of colorectal cancer with D2 lymph node dissections and synchronous metastatic liver tumor. The total operation duration was 484 min, and blood loss was 570 mL. Negative surgical margins was achieved. She recovered uneventfully after surgery and postoperative hospital stay was 13 days. She has remained recurrence free 29 months after the surgery without any postoperative chemotherapy. Conclusion: Simultaneous laparoscopic resection of colorectal cancer and synchronous metastatic liver tumor may be useful for minimizing operative invasiveness while maintaining safety and curability.

P309 - Liver and Biliary Tract Surgery

P311 - Liver and Biliary Tract Surgery

Management of Iatrogenic Injuries Due to Endoscopic Sphincterotomy; Surgical or Conservative

Laparoscopy in Post Lap. Chole. Biliary Peritonitis

P. Yazici, O. Bostanci, M. Battal, U. Demir, C. Alkim

GNRC Hospitals Sixmile, GUWAHATI, ASSAM, India

Sisli etfal training and research hospital, ISTANBUL, Turkey

Aim: Exploratory laparotomy has been the standard of management of billiary peritonitis due to bile duct trauma following laparoscopic cholecystectomy. With the advances in technology and developing surgical skill, laparoscopic technique can be used to reduce the duration of hospital stay and period of recovery. We had undertaken laparoscopic approach for management billiary peritonitis to assess the advantage & feasibility. Method: Total 16 cases of biliary peritonitis out of 30 bile duct injuries were taken up for lap management during august, 2005 to august, 2015 august. Cases were clinically examined and investigated for the site and severity of injury, sepsis, fluid and electrolyte imbalance and organ dysfunction. CT scan and MRI were the mainstay of diagnosis. Patients were stabilized before taking up for surgical intervention Laparoscopic examination was carried out and contents were sucked out from all quadrants and irrigated with normal saline. Porta was gently approached from gall bladder fossa. Site of injury was dissected out carefully and 7/8 F feeding tube was pushed through the leakage site. Bile started coming through the tube. Tube was fixed to the duct with 4-0 PDS and tested for leakage. Operating field was irrigated. A sub hepatic drainage was applied. Ports were closed. Conversion was done if the leakage could not be identified. Results: we encountered 3 billiary peritonitis in our centre (7(0.1%) major bile duct injuries out of 5045 lap. chole. performed).In the referred group- 13 cases (23 bile duct injury) of billiary peritonitis was treated during the same period. 5 cases reported within 3-5 days, 3 reported in 5 -7 days, 5 cases reported after 7 days. 6(37.5%) of the 13 cases had to be converted to open procedure as the porta anatomy was found to be friable and site of injury could not be identified by laparoscopic approach. There was one post operative death. The patient presented three weeks after injury. Conclusion: Laparoscopy in billiary peritonitis is feasible and has the advantage over open procedure in selected cases. High conversion rate may be reduced by selecting. But feasibility may be decided by diagnostic laparoscopy to .

Aim: The best therapeutic approach for endoscopic retrograde cholangiopancreatography (ERCP) related perforations is still controversial; while some authors suggest routine conservative management, others advocate mandatory surgical exploration. We herein aimed to evaluate our clinical experience in perforations during endoscopic sphincterotomy. Material method: A retrospective chart review from January 2010 to October 2015 identified 17 instances of endoscopic retrograde cholangiopancreatography (ERCP) related perforation. Data collection included demographics, time to diagnosis, type of perforations, treatment strategy, surgical procedure, complications, course of hospital stay, and the outcome. All patients were classified into groups on the basis of radiological and operative findings. Results: Of 18 patients, only 5 patients (3 F and 2 M) with a mean age of 50 years underwent surgical treatment and remaining 13 were managed conservatively. Mean time to diagnosis was 8.4 h (range 1–36 h). Types of perforations included Type I and III in one patient each and type II injury in three patients. Surgical procedures included laparoscopic and open cholecystectomy plus t-tube drainage in 2 patients each and primary repair of duodenum injury plus hepaticojejunostomy in one patient. Conservatively managed patients had type II, type III and type IV injury in 6, 4 and 3 patients respectively. Of these 13 patients, 69% (n = 9) underwent percutaneous procedure. The mean length of hospital stay was similar for conservatively and surgically treated patients (13.2 days vs. 11 days, respectively, p = 0.590). One patient (5%) with Type I injury died of multiorgan deficiency. Discussion: With close clinical follow-up, medical treatment can be beneficial for the majority of patients and surgical procedure should be kept for patients with type 1(definite) and type2/3 of whose clinical parameters are likely to fail conservative management.

M. Choudhury, K. Baruah, K. Rajkhowa, B. Das

123

Surg Endosc

P312 - Liver and Biliary Tract Surgery

P314 - Liver and Biliary Tract Surgery

Mini-Single-Incision Versus Conventional Single-Incision Laparoscopic Cholecystectomy

Is a Drain Required After Laparoscopic Cholecystectomy?

S.H. Chuang MacKay Memorial Hospital, Hsin-Chu Branch, HSIN-CHU, Taiwan

N. Ozlem1, A. Gurer2, E.G. Dumlu2, E. Dikili2, G. Kiyak2, H. Calis3 1

This work was supported by the AhiEevran University, KIRSEHIR, Turkey; 2Ankara Ataturk education and research hospital, ANKARA, Turkey; 3Ahievran University, KIRSEHIR, Turkey

Aims: Mini-laparoscopic surgery and single-incision laparoscopic surgery are feasible and safe alternatives to conventional laparoscopic surgery. Less postoperative pain, fewer incisional complications, faster recovery, and better cosmesis are the potential benefits. We introduce mini-single-incision laparoscopic cholecystectomy (MSILC) as a novel technique to pursue a higher level of minimal invasiveness. Methods: In a period of 20 months, eighty-five consecutive single-incision laparoscopic cholecystectomies (SILC) including 51 conventional single-incision laparoscopic cholecystectomies (CSILC) and 34 MSILC were performed by a single surgeon for uncomplicated gallbladder diseases. We adopted single-incision multiple-port longitudinalarray (SIMPLY) and self-camera techniques for SILC. Mini-laparoscopic instruments were only used in MSILC. We defined that the 45 procedures before the first MSILC were in the CSILC period, while the others were in the MSILC period. Results: In the CSILC period, all the procedures were performed successfully except one (2.2%), which was converted to a three-incision laparoscopic cholecystectomy. In the MSILC period, six (15%) CSILC and 34 (85%) MSILC were scheduled. All of the former procedures were successful while three (8.8%) MSILC were converted to CSILC. The patients in the MSILC period had a significantly lower postoperative narcotic use compared with those in the CSILC period (0.595 ± 0.505 mg/kg vs 0.936 ± 0.912 mg/kg, p \ 0.05), while other parameters and operative results were similar. The complication rate was 2.2% (1/45) and 2.5% (1/40) in the CSILC and MSILC periods, respectively. Both of them were classified as Clavien-Dindo grade I. Conclusions: MSILC can be performed safely and efficaciously for most uncomplicated gallbladder diseases in experienced hands. The complication rate is low. Compared with CSILC, MSILC has an advantage of less postoperative pain but may potentially increase operative times.

Objective: Whether drains should be routinely used after laparoscopic cholecystectomy is still debated. We aimed to retrospectively evaluate the benefits of drain use after laparoscopic cholecystectomy for non-acute and non-inflamed gallbladders. Materials and Methods: Two hundred and fifty patients (mean age, 47 ± 13.8 years; 200 females and 50 males) who underwent laparoscopic cholecystectomy for cholestasis were included in the study. The medical files of the patients were examined retrospectively to obtain data on patient demographics, cholecystitis attacks, complications during the operation, whether a drain was placed in the biliary tract during the operation, etc. The volume of the fluid collection detected in the subhepatic area by ultrasonography on the first postoperative day was recorded. Results: Drains were placed in 51 patients (20.4%). The mean duration of drain placement was 3.1 ± 1.9 (range 1-16) days. Fluid collection was detected in the gallbladder area in 67 patients (26.8%). The mean volume of collected fluid was 8.8 ± 5.2 mL. There were no significant effects of age, gender, and previous cholecystitis attacks on the presence or volume of the fluid collection (P [ 0.05 for all). With regard to the relationship between fluid collection and drains, 52 of 199 (26.1%) patients without drains had postoperative fluid collection, compared to 15 of 51 (29.4%) patients with drains (P [ 0.05). Conclusion: In conclusion, there is no relationship between the presence of a drain after laparoscopic cholecystectomy and the presence of postoperative fluid collection. Thus, in patients without complications, it is not necessary to place a drain to prevent fluid collection. Keywords: Laparoscopic cholecystectomy; drains; ultrasonography

P313 - Liver and Biliary Tract Surgery

P315 - Liver and Biliary Tract Surgery

Laparoscopic D1+ Lymphadenectomy with Preservation of a Replacement Left Hepatic Artery During Distal Gastrectomy

A Vary Rare Biliary Tract Anomaly Double Cystic Duct

D. Gunji, T. Kitai, N. Sugimoto, R. Toda, I. Saito, H. Takagi, K. Yamanaka, M. Kogire

AhiEevran University Research and Education Hospital, KIRSEHIR, Turkey

Kishiwada City Hospital, KISHIWADA, Japan

Double cystic duct(DCD) is an extremely rare anomaly of bile duct.In English literature there are only 14 DCD cases.Any anomalies of the biliary tract (BT) are undetectable in the preoperative examinations(PE).Routine pre or intraoperative cholangiography(IOC) or preoperative ERCP and IOC are recommended to avoid complications.Actually it is very difficult to diagnose a DCD PODays.We report a case of duplication of the CD,which was diagnosed by macroscopic examination of extracted gallbladder(GB) and performing IC during the operation.The PEof 60 YOFemale with thick wall GB, multiple calculi, slightly high LDH,CK was normal,semigangrenous GB was found at laparoscopy,cholecystectomy(C)was undertaken.the GB has DCD, another 0.6 cmdiameter tubular structure was identified,arising from operation site and coursing toward the hilum.IOC was performed through the ductal structure opening into the bifurcation of the hepatic biliary ducts(BD).This accessory channel was ligated. PODs of the patient was uneventful, discharged onPOD5.DCD is a very rare anomaly of the extrahepatic BD. To our knowledge our case is 15th reported in literature. DCD draining a single GB has been documented in isolated case reports in literature, accounting for fewer than 20% published cases. 12 of 15 cases were diagnosed by intraoperative findings or IOC. Though the diagnosis of this anomaly is difficult, 3 cases have been diagnosed by ERCP but routine ERCP was unsuccessful in the first 2 DCD found in laparoscopic cholecystectomy (LC) cases and authors recommended routine preoperative or IOC cholangiography. Unfortunely we can not perform preoperative and/or IOC and/or ERCP in our clinic. The injury of the BD occurred in 2 of 5 cases that had undergone LC.LC was not unsuccessful, open cholecystectomy(OC) was performed in the most recent DCD case. 9 of 15 had OC complication free. 8 of 15 DCD cases in the literature was diagnosed by operative finding. We could not identified appropriately another arising tubular structure from the GB and coursing toward the hilum. The GB from it’s bed was not meticulously dissected, If it would be adequately this aberrant BD could be identified and could be preserved. Momiyama et’al thought that the second duct was dissected during the operation and the patient suffered from postoperative bile leakage. It is important to clarify the anatomy of the BD tract by pre, intraoperative examination, to carefully dissect the cystic duct close the neck of the GB during cholecystectomy

Aim: The incidence of the replacement left hepatic artery (rLHA) arising from the left gastric artery (LGA) was reported as 10%. Preoperative evaluation of vascular running pattern prior to laparoscopic gastrectomy for gastric cancer is important to prevent accidental injury of rLHA which may cause an ischemic necrosis of the liver. Contrastenhanced Computed Tomography (CT) is recommended for this aim, but the use is sometimes limited because of allergy to contrast medium. In this study, we present the proper and safe lymphadenectomy procedure in a case which preoperative evaluation by enhanced CT was not available. Case: We performed laparoscopic-assisted distal gastrectomy for an early gastric cancer of a 65 year-old female with vascular anomaly of type II in Michels classification, in which the right hepatic artery (RHA) arises from the celiac artery (CA), and the rLHA arises from the LGA. A typical D1+ laparoscopic lymphadenectomy was performed until the division of the left gastric vein and the indication of the LGA. The rLHA was identified at the time and resected the lymph nodes located anterior to the rLHA. The anterior side of the LGA was exposed towards its origin. The branch of the LGA towards the stomach was clipped and resected and the lymph nodes located posterior to the rLHA. Lymphadenectomy was then completed without injury to the rLHA during the dissection of the lymph node around the LGA. Histopathological examination revealed a T1b N0 M0 tumor with 19 lymph nodes resected. Conclusion: In our case, we could not use enhanced CT to diagnose vessels anomalies of rLHA preoperatively. By keeping consideration of the variation of celiac trunk, we performed laparoscopic-assisted distal gastrectomy with D1+ dissection safely and in proper qualities.

123

N. Ozlem, H . Calis

Surg Endosc

P316 - Morbid Obesity

P318 - Morbid Obesity

Antral Resection in Sleeve Gastrectomy: Long-Term Results of Prospective Randomized Trial

Using ‘Customized’ Care Pathways in a Multidisciplinary Bariatric Surgery Program to Improve Resource Use: Developing a Comprehensive Triaging Tool

V.V. Grubnik, M.S. Kresun, O.V. Medvedev Odessa national medical university, ODESSA, UKRAINE, Ukraine Introduction: Laparoscopic sleeve gastrectomy (LSG) is a popular surgical method for treatment of morbid obesity, but the technique of this procedure is not standartized. Aim of the study was to investigate the role of antral resection on weight loss. Methods: Forty five patients were randomized into two groups: group I (22 patients, gastric transection started 2 cm proximal to the pylorus), and group II (23 patients, gastric transection started 6 cm proximal to the pylorus). There were 38 females and 7 males. Mean preoperative weight was 138,9 ± 21 kg (range, 98 - 182), mean preoperative excess weight was 70,4 ± 18,2 kg (range, 36,5 - 110,8), mean preoperative body mass index (BMI) was 49,6 ± 6,8 kg/m2 (range, 38 - 65). Preoperative data were comparable in both groups regarding age, sex, BMI, and comorbidities. The primary outcome measure was the percent of exessive weight loss (%EWL), secondary outcomes included postoperative morbidity and improvement of comorbidities. Results: There were no serious postoperative complications in the both groups. Mean follow-up period was 22,3 ± 4,2 months (range, 17 - 28). Postoperatively, mean %EWL was 68,3 ± 11,1 in group I, and 61,4 ± 10,5 in group II (p [ 0,05). There was significant improvement in comorbidities in the both groups. Conclusion: There is tendency of better weight loss in the group with increased size of resected antrum in LSG.

P317 - Morbid Obesity Remission of Type 2 Diabetes After Mini Gastric Bypass for Morbid Obesity V.V. Grubnik, O.V. Medvedev, V.V. Grubnik Odessa national medical university, ODESSA, UKRAINE, Ukraine Background: Mini gastric bypass now is poular as simple bariatric procedure, but its effect on type 2 diabetes (T2D) is unclear. Methods: Laparoscopic mini gastric bypass was performed in 12 patients with T2D. There were 7 males and 5 females. Mean age was 48.0 ± 10.5 years, mean weight before surgery was 123.0 ± 10.5 kg, mean body mass index (BMI) was 45.1 ± 7.8 kg/m2. All patients received insulinotherapy. Mean preoperative level of glucated hemoglobin (HbA1c) was 8.2 ± 1.9 g/dL. Remission of T2D was defined if HbA1c level was \6% without concomitant therapy. Results: Over a mean follow-up period of 25.6 months (range 3–72), mean weight decreased to 90.6 ± 21.0 kg/m2 and mean BMI decreased to 35.8 ± 4.4 kg/m2. Eleven patients (91.6%) had complete remission of T2D, and only 1 patient was being treated with insulin. Mean HbA1c level after 2 years was 5.6 ± 0.5 g/dL. Conclusion: Mini gastric bypass is effective treatment for obesity in terms of weight loss and remission of T2D.

C. Lobo Prabhu1, M. Cleghorn2, A. Mirkolaei2, A. Diamant2, S. Robinson2, S. Sockalingam2, A. Okrainec2, T.D. Jackson2, F.A. Quereshy2 1

University of Toronto, TORONTO, Canada; 2Toronto Western Hospital, TORONTO, Canada

Aims: Most bariatric surgical programs use a linear care pathway for pre-operative evaluation which includes medical, social work, dietary and psychological assessments, and ultimately surgical consultation. However, the current model results in system inefficiencies as patients that are unlikely to reach surgery occupy limited resources. Our study aims to develop a predictive triaging tool used to create tailored care pathways for patients that better address their individual needs and that will in turn improve resource utilization and system performance. Methods: Analysis of retrospective data on 1664 patients was used to develop an intake questionnaire that could identify patients at risk of medical and/or psychosocial issues that would likely delay their progress through or hinder their success in the program. Focus groups conducted with medical staff and patients were used to validate the questionnaire. The questionnaire was distributed to patients after referral for scheduled orientation classes between March and October 2015. Assessment codes representing priority appointments were assigned to patients based on their responses and used in the scheduling process to alter care sequence accordingly. Results: 615 patient intake questionnaires were completed, representing a response rate of 62.8%. The mean age of patients surveyed was 46 years. 76.6% of patients were female. The majority of patients received a priority assessment code for nursing consultation (46.6%), followed by psychological or psychiatric (20.6%), social work (13.5%), surgical (2.9%) and dietary (1.9%) consultation. A total of 14.5% of patients did not receive an assessment code. 26.0% of the assigned codes indicated that patients referred were unsuitable for bariatric surgery. Conclusions: This study challenges the concept of a standardized linear care pathway used in bariatric surgery programs. In this study, we use an intake questionnaire to identify relevant information for developing customized care sequences that meet patients’ unique needs. There appears to be a significant opportunity for resource optimization by identifying patients who are ineligible for surgery early in the program in order to relieve system congestion. We are currently following this cohort prospectively to evaluate the impact of using this triaging tool on wait times and late attrition rates.

P319 - Morbid Obesity Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy: The First Report From Thailand S. Techapongsatorn, A. Tansawet, W. Kasetsermwiriya, P. Tiewprasert, T. Yongpradit, I. Loapiamthong Navamindrahiraj University, BANGKOK, Thailand Aims: To report the results of the first case of the single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) in our institute. Methods: A 46-year-old female patient underwent the SADI-S for her metabolic syndrome. All steps of the procedure was performed laparoscopically. Like a standard sleeve gastrectomy, we mobilized a gastric greater curvature to the angle of His, then a vertical gastric resection was performed with an intraluminal 36 Fr bougie inserted for calibration. The dissection was continued to free and transect the first part of duodenum. An ileum was measured 250 cm from an ileocaecal valve, then the duodenum was anastomosed with the ileum at this site by hand-sewn technique. Leak test was performed at the end of the procedure. Results: The SADI-S was successfully performed without complication. The patient’s preoperative body weight (BW) and body mass index (BMI) were 89 kg and 35.7 kg/m2 respectively. Her BW was 76 kg at the 2nd month follow-up and it was 34.2% in term of excess weight loss (EWL). Her co-morbidities - diabetes, hypertension, and dyslipidemia were also improved. A HbA1c level was changed from 10.2% pre-operatively to 6.6% in 2 months after the operation. Conclusions: Impressive results can be expected from the SADI-S, which is an easier variant of biliopancreatic diversion. Nevertheless, a well designed studies are still needed to assess the outcomes of this procedure.

123

Surg Endosc

P320 - Morbid Obesity

P322 - Morbid Obesity

Laparscopic Rouy-En-Y-Gastric Bypass Comparing Circular Stapled, Linear Stapled and Combined Linear Stapled with Hand-Sewn Gastrojejonostomie

Early Postoperative Progression to Solid Foods is Safe After Roux-En-Y Gastric Bypass

J. Lange1, M. Von Feilitzsch2, R. Bachmann2, A. Ko¨nigsrainer2, M. Zdichavsky2 ¨ BINGEN, Germany; University Hospital of Tu¨bingen, Germany, TU 2 ¨ BINGEN, Germany University Hospital of Tu¨bingen, TU

C.M.J. Theunissen, J. Maring, N. Raeijmaekers, I. Martijnse, B. Langenhoff Elisabeth-Tweesteden Ziekenhuis, TILBURG, The Netherlands

1

Background: Obesity has become one of the most important public health problems in many resource-rich countries worldwide. Bariatric surgery is currently the most efficacious and enduring treatment for clinically severe obesity. Therefore the number of bariatric surgery procedures performed has risen dramatically in recent years. For morbidly obese patients laparoscopic Roux-en-y-gastric bypass (LRYGB) remains the most commonly performed bariatric procedure. Global trends show an overall decline. LRYGB involves the creation of a small gastric pouch, thereby restricting food and limiting caloric absorption. Nevertheless no consensus exist which method is superior for the gastrojejunostomy. The anastomosis can be performed totally hand-sewn or circular stapled or linear stapled with additional closure of the stapler defect. The aim was to show the development by optimizing the gastrojejunostomy at our department. Methods: We included retrospective data from 58 LRYGB patients operated between december 2008 and october 2015. We included patients in consecutive way. After learning time, three different experienced surgeons performed all the surgeries following standard procedure. We studied operative time, length of hospital and intensive care unit stay and postoperative complications. Between 2008 and 2011 we performed circular stapling (CS), followed by linear stapling (LS) between 2011 and may 2014. From may 2014 till now we use linear stapling and close the stapler defect with stratafix absorbable bidirectional monofilament barbed suture (LSS). Results: Preoperatively the groups were comparable (BMI 44 kg/m2 years for CS, 47 kg/ m2 for LS and 46 kg/m2 for LS with stratafix; age 49,5 yeras, 44,8 years; 47,3 years). Changing the operation procedure from CS and LS to LSS operative time (353 min, 129 min and 90 min) and hospital stay reduced (from 10 days to 8 days and 5 days). The rate of reoperations was 5% in CS, 10% in LS and 3% in LSS. Conclusion: CS was found to be associated with longer operative time, hospital stay and postoperative complications compared with LSS.

Introduction: Even though admission-time is significantly reduced with the implementation of various enhanced recovery protocols, many clinics still instruct patients after weight loss surgery to maintain a fluid or minced-food diet for at least 2 weeks postoperatively. We reasoned that with adequate pre-operative instructions, including adequate chewing of all foods, early progression to solid foods would not increase the risk of (gastro-)enterostomy leakage. Methods: In December 2010 a new dietary protocol was implemented for all patients undergoing a Roux-en-Y gastric bypass, allowing progression to solid foods from 12 h post-procedure onwards. All patients received thorough preoperative eating instructions and eating-awareness counselling from a qualified dietician and psychologist. A retrospective study was performed of 936 patients who underwent a primary or redo laparoscopic Rouxen-Y gastric bypass between January 2011 and June 2014 in our hospital. All 30 day complications, readmissions and reoperations were noted. Results: No 30-day loss to follow-up occurred. Overall 30 day complication rate was 9.4%, with gastro-intestinal leakage occurring in only 0.6%. A low threshold for readmission was maintained due to the short mean admission time of 1.87 days. Readmission rate was 4.8% -mainly for observation of postoperative pain- and 1.8% of our patients required reoperation within 30 days. Mortality was 0.1%. Our results are comparable to results published by other Dutch centres advocating conventional diets, showing no increase in leakage or other complications. Conclusions: We conclude that early progression to solid foods after Roux-en-Y gastric bypass surgery is safe as no increase in complication rate is observed.

P321 - Morbid Obesity

P323 - Morbid Obesity

Changes of Hospital Anxiety and Depression Scores in Obese Patients After Laparoscopic Sleeve Gastrectomy

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

S. Arici, C. Ercetin, A. Solmaz, H. Yigitbas, E. Yavuz, O.B. Gulcicek, F. Celebi, R. Kutanis

C.M.J. Theunissen, N. Guelinckx, J. Maring, B. Langenhoff

Bagcilar Training and Research Hospital, ISTANBUL, Turkey

Background: The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure - signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations) - frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure. Methods: Data were collected from patients operated from 2012 through 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step versus two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons. Results: No difference in major complication rate was seen (2.8% vs. 2.3%, p = 0.73) between redo and primary LRYGB and overall complication severity for redo’s was low (mainly Clavien-Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redo’s were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5 min for the two-step (median, p \ 0.001), excluding the operating time of separate AGB removal (mean 61 min, range 36–110). Conclusion: Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1 year post redo LRYGB as after primary LRYGB procedures.

Objective: Altough several studies point to a correlation between morbid obesity and anxiety - depression symptoms in obese patients, impact of weight loss after sleeve gastrectomy is unknown. This study aims to investigate the association between weight loss and preoperative - postoperative depression/anxiety scores in patients undergoing laparoscopic sleeve gastrectomy (LSG), using ‘Hospital Anxiety and Depression (HAD) Scale’. Method: Fifty patients who underwent LSG for morbid obesity between October 2014 and April 2015 were selected for this study. The inclusion criteria for the study included body mass index (BMI) = 40.0 or 35.0-39.9 with the diagnosis of Metabolic Syndrome or with obesity related co-morbidities. Anxiety and depression scores were assesed by the HAD Scale pre-operatively and at 6th month post-operatively. Results: A total of 50 (Male/Female, 19/31) patients with a median (min.-max.) age of 37.5 (20-51) years were included. Median (min.-max.) BMI decreased from 42 (36–51) kg/m2 preoperatively to 33 (24–38) kg/m2 at 6 months postoperatively. Preoperative median (min.-max.) HAD-Anxiety score was 10.5 (5–17) decreasing to 3 (0–11) at 6 months postoperatively (P \ .005). Preoperative median (min.-max.) HAD-Depression score was 11 (3–17) decreasing to 3 (0-8) at 6 months postoperatively (P \ .005). Conclusion: Depression and anxiety are frequent among individuals selected to undergo bariatric surgery. HAD scale was found to perform well in evaluating the symptom severity and caseness of anxiety disorders and depression in patients and in the general population. This study shows that LSG is a safe and effective bariatric operation for inducing weight loss and significant improvements in HAD scale.

123

Elisabeth-Tweesteden Ziekenhuis, TILBURG, The Netherlands

Surg Endosc

P324 - Morbid Obesity

P326 - Morbid Obesity

Conversion of Adjustable Gastric Banding to Laparoscopic Gastric Bypass. A Comparison to Primary Bypass

Wall Thickness of Gastric Tissue as Measured During Sleeve Gastrectomy Excision

N. Beglaibter, A. Al Kurd, M. Ghanem, I. Mizrahi, A. Eid, R. Grinbaum

A. Raziel1, S. Susmallian2, D. Goitein1

Hadassah Mount Scopus University Hospital, JERUSALEM, Israel

2

Aims: Laparoscopic Adjustable Gastric Banding (LAGB) has a failure rate as high as 40-50% and the incidence of revisions us 20-40%. Laparoscopic Roux en Y Gastric Bypass is one of the rescue options. The aim of this study is to compare immediate and midterm outcomes Between LAGB converted to LRYGB and primary LRYGB. Methods: Retrospective analysis of prospectively collected data of all the patients converted from LAGB to LRYGB between the years 2007 and 2015. This group was compared to a cohort of patients, matched for age and gender who underwent primary LRYGB during the same period. Primary outcomes included early and late complications. Secondary outcomes included weight loss and resolution of comorbidities. Results: 106 patients underwent conversion from LAGB to LRYGB. These patients were compared to 106 primary LRYGB. Mean age (41.7Y), male to female ratio (1:2) and ASA score (2.4) were identical. Mean preop BMI for the conversions was 42.4 and for the primary LRYGB was 44.9. There was a higher prevalence of comorbidities in the primary bypass group. 76.7% of the patients underwent band removal and LRYGB in the same operation. Early overall complication rate in the conversions and the primary group were 6.8% and 10.7% respectively. Late complications were 18.9% and 25.5% respectively. After a mean followup of 25 months excess weightloss was 59.5% and 79.5% for the conversion and the primary groups respectively. Resolution of comorbidities were comparable. Resolution/improvement in Diabetes was 90.5% for the conversions vs 75.9% for the primary group. Hypertension resolution/improvement ?was 35% vs 57.4% and dyslipidemia 43.5% vs 75.9% respectively. Conclusions: Conversion of LAGB to LRYGB even as a one step procedure is safe without any additional risk for early or late complications when compared to primary RYGB. The weight loss tends to be less but the resolution/improvement of comorbidities is excellent.

Background: The most dreaded complication after sleeve gastrectomy is leakage from the stapler line, occurring in 2.4% of surgeries. Due to variability in stomach wall thickness in different zones, a possible cause for leakage is utilization of staplers with an inappropriate staple size. Objectives: The aim of this study was to measure stomach wall thickness in different zones and to find a correlation between this measurement and different variable Materials and Methods: 100 patients (52% females) were enrolled. Stomach wall thickness was measured immediately after surgery using a digital caliper at the antrum, body, and fundus. Results: were correlated to Body Mass Index (BMI), age, gender, and presurgical diagnosis of diabetes mellitus, hypertension, hyperlipidemia and fatty liver Results: Stomach thickness was found to be 5.1 mm ± 0.6 mm for the antrum, 4.1 mm ± 0.6 for the body, and 2.6 mm ± 0.5 for the fundus. No correlation was found between stomach wall thickness and BMI, gender, or comorbidities. Conclusion: Stomach wall thickness increases gradually from fundus to antrum. We found no preoperative predictor for the actual measurement and so the surgeon performing sleeve gastrectomy needs to assess the tissue properly before choosing the correct staple-height for resection. Our data is comparable to previously reported tissue thickness measured by ultrasound, computed tomography and cadaveric studies. Application of the correct stapleheight during sleeve gastrectomy is crucial to prevent leaks. Staples should be chosen according to the thickness of the tissue.

P325 - Morbid Obesity

P327 - Morbid Obesity

The Clinical Impact of Preoperative Upper Endoscopy in Bariatric Surgery, 498 Consecutive Cases

Unexplained Abdominal Pain After Bariatric Surgery

M. Tenhagen, B.M.M. Reiber, M.A.J.M. Hunfeld, A. Demirkiran, H.A. Cense

Onze Lieve Vrouwe Gasthuis (OLVG) locatie West, AMSTERDAM, The Netherlands

Rode Kruis Ziekenhuis Beverwijk, BEVERWIJK, The Netherlands

Aim: To inventory the percentage of patients who develop unexplained abdominal pain after bariatric surgery and to determine predictive factors for this outcome. Methods: A retrospective study was performed, using a consecutive database with all patients who underwent Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy. Both primary and revisional procedures were included. Baseline characteristics and the postoperative course were. Results: A total of 1788 patients underwent bariatric surgery between November 2007 and April 2015 of which 387(21.6%) patients suffered from postoperative abdominal pain and were therefore included. The study population consisted of 337 (87.1%) women and 50 (12.9%) men; the mean age was 43.3 (standard deviation 10.1) years and the median body mass index was 43.7 kg/m2. Abdominal pain was explained in 246 out of 387 patients (63.6%), whereas this remained unexplained within 133 patients (34.4%). Revisional surgery was a significant predictor for unexplained pain (p = 0.047). The majority of patients in the unexplained pain group had a mixed defecation pattern, in the explained pain group the majority of patients had discolored stool or obstipation. Type and place of pain, number of readmissions, diagnostics and emergency room presentations were not significantly different between patients with and without explained abdominal Conclusion: A total of 387 patients experienced abdominal pain (21.6%) after surgery. In nearly two-third of these patients, the pain was explained. However, in one-third (7.4% of the entire bariatric surgery population) no diagnosis was found as explanation. Current study results suggest that unexplained abdominal pain should be added to the complication list and that more research is needed regarding further management of this chronic, and patient burdensome complication.

Aims: Evaluate the clinical impact of preoperative esophagogastroduodenoscopy (EGD) in bariatric surgery. Methods: A retrospective analysis of 498 consecutive cases (2011-2013) scheduled for a Roux-en-Y gastric bypass (RYGB), Gastric Sleeve (GS) and band removal with conversion to RYGB or GS (redo). Anamnestic upper gastrointestinal symptoms and proton pump inhibitor (PPI) use were recorded. All findings at EGD were recorded, as well as the treatment and implications on scheduled surgery time or operation type. Results: A total of 498 patients were included of which 414 (83%) were female. Mean age was 45,3 years, body weight 125,8 kg and BMI 43,6 kg/m2. RYGB was performed in 74%, a redo procedure in 18% and GS in 7%. A total of 457 (92%) EGD’s were performed. No abnormalities were found in 164 (36%) cases. One abnormality in 179 (39%), two abnormalities in 100 (22%) and three abnormalities in 14 (3%) cases. Medical treatment was initiated in 81 (17.6%) cases. Surgery was postponed in 7 (1.5%) cases pending treatment and awaiting control endoscopy, 1 operation was cancelled due to adenocarcinoma found at the gastro-esophageal junction and in 2 cases RYGB was performed instead of GS. Abnormalities found were; gastritis 164 (36%), sliding hernia diafragmatica 129 (28%), esophagitis 90 (20%), ulceration 10 (2,2%), duodenitis 4 (0,9%), fundic polyps 13 (3%), varices 3 (0,7%), Shatzki ring (0,2%), adenocarcinoma 1 (0,2%). Helicobacter Pylori testing was performed in 456 (92%) cases and positive in 70 (15%). Age was the only variable identified as a risk factor for an abnormal finding at EGD (mean age 43.5 years for no abnormalities and 46,5 years for any abnormality, p = 0.006). Conclusion: Performing EGD prior to bariatric surgery reveals abnormalities in 64% of all screened patients. Surgery was rescheduled or cancelled in 8 patients (1,7%), and a change in type of procedure occurred in 2 (0,4%). In 17% of the cases the findings resulted in medical treatment, such as PPI, without impact on surgery date and type. Age was the only risk factor for finding abnormalities at EGD. The question remains whether these findings justify routine endoscopy in all bariatric surgical candidates.

1

Assia Medical Group, Assuta Medical Center, TEL AVIV, Israel; Assuta Medical Center, TEL AVIV, Israel

A.S. Pierik, U.K. Coblijn, C.A.L. de Raaff, B.A. van Wagensveld

123

Surg Endosc

P330 - Morbid Obesity

P332 - Morbid Obesity

Single Port Bariatric Surgery: Our 5 Years Experience

Long Term Results Following Laparoscopic Sleeve Gastrectomy

1

S. Morales-Conde , I. Alarco´n1, V. Duran1, E. Perea1, J. Gomez Menchero2, A. Barranco1, J.M. Suarez Grau2, M. Socas1 Hospital Universitario Virgen del Rocio, SEVILLE, Spain; 2Hospital Rio Tinto, HUELVA, Spain

A. Assalia, K. Hallon, M. Khorieh, Y. Kluger, A. Mahajna RAMBAM HEALTH CARE CAMPUS, HAIFA, Israel

1

Objective: Analysis of our results in bariatric surgery using single Incision Laparoscopic Surgery (SILS), as a minimally invasive surgical procedure. Selection of the patients, according to our inclusion criteria for SILS, were patients with a BMI under 50 and a xifoumbilical distance less than 25cms. Bariatric procedures was Roux-en-Y gastric bypass (RYGB) and the sleeve gastrectomy(GT). Methods: Retrospective analysis of a Prospective database. From January 2010 to December 2014, was performed at our center a total of 69 SILS bariatric surgeries (31 RYGB and 38 GY). All cases were performed by single port transumbilical access. Results: 69 patients were included; 31 were RYGB (average age 43.2 years; 30 female, 1 male) and 38 GT (average age 41.2 years; 36 women, 2 Men). The average preoperative BMI was 42.3 (42.1 in RYGB and 43.3 in GT) with a comparable ASA in both arms of the study (2,3 RYGB vs 2,1 SG). The device SILS (Covidien Ltd) was the most used (65 cases). The average operative time was 74 min in GT vs 112 min in RYGB. The average blood loss were 17,2 cc GT and 17,3 cc in RYGB. The average size incision in GT was 24,7 mm and 28,5 mm in RYGB. As early complications there was only one case of leak in RYGB that required emergency surgery, and 2 wound infections in GT. In long term, RYGB showed: 1 reoperation for 1 internal hernia, 3 anastomotic ulcers, one incisional hernia and 6 cases Vitamin/iron deficiency. In GT, 2 cases were convert to RYGB (1 fissure stenosis, 1 (ERGE) and 2 incisonal hernias. The percentage of Excess weight loss (% EWL) was 73.2% (71% in GT, 75% in the RYGB). Conclusions: Single-port bariatric surgery is a safe and effective alternative in selected patients. Early and late complications and effectiveness are comparable to the data showed conventional laparoscopic approach, as well as weight loss results at first postoperative year. New long-term and comparative analysis are needed to definitively confirm these preliminary results and to compare sigle-port technique to conventional multiaccess laparoscopy in the bariatric surgery. * Study partially funded by Instituto Carlos III

P331 - Morbid Obesity Two Years Folow Up After Laparoscopic Sleeve Gastrectomy S. El-Shakhs, A. Albtanony, A. Fayed, T. Saleh Menufia University Hospital, MENUFIA, Egypt Aim: the aim of this study is to evaluate the metabolic and biochemical outcomes after two years of laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients. Methods: This retrospective study included thirty five patients who underwent laparoscopic sleeve gastrectomy (LSG) at Menoufia University Hospital, in the period between January 2011 to February 2013 and aimed at evaluating the comorbidity changes (hypertension, type II diabetes mellitus T2DM, etc.) and other biochemical variables at 12 and 24 months follow up. Results: The mean age of the studied group was (30 ± 8.6) years (range 20-48 years). Twenty eight patients (80%) were females and seven were males (20%). Mean weight loss was 38.9, 60.0 and 71.5% at 6, 12, and 24 months respectively. Pre-existing co-morbidities (hypertension and T2DM) were markedly improved postoperatively (80% and 70% respectivly) after two years with gradual decrease of hypotensive and hypoglycemic drugs. There was no late postoperative complications. Conclusions: The LSG proved to be a safe and effective type of bariatric surgery, with reduction of body weight, improvement of related comorbidities and quality of life.

123

Background: Laproscopic Sleeve gastrectomy (LSG) has become the most prevalent bariatric procedure for morbid obesity. However, the long term results are not clear enough. We describe herein the results of long-term outcome with regards to weight loss, improvement of co-morbidities and the development of the late sequela of gastro-esophageal reflux disease (GERD). Methods: A retrospective analysis of 112 patients who completed at least 5 years of follow up was done We included patient who had prior failed laparoscopic gastric banding (n = 17). Outcomes included excess BMI loss (%EBMIL), modification of co-morbidities, and development of GERD. Surgical success was defined as %EBMIL [50%. Results: The mean age was 38.9 (range 18–63 years). Women comprised 80.4 percent of the patients (n = 90), median preoperative BMI was 43.1 kg/m2. Seventeen patients (15%) underwent previous band surgery. Ninety one patients completed 6 years of follow up, 28 had 7 years and 12 had 8 years. After 8 years the average %EBMIL was 62%. Four out of 12 patients (33%) had %EBMIL less than 50%. After 7 years the average %EBMIL was 58%. Twelve out of 28 (42%) had %EBMIL less than 50%. After 6 years the average %EBMIL was 60. In 44 patients (48%) the %EBMIL was less than 50%. Reoperation was necessary in 15.2% of the patients (n = 17). Ten out of 17 (58%) were operated due to weight regain or insufficient weight loss. Five out of 17 (29.4%) were operated due to severe Reflux and 2 were reoperated for both. By 6 years of follow up, co-morbidities improved noticeably, a remission of type 2 diabetes was 57.1%, Hypertension in 54.3% and Dyslipidemia in 67.6%. Gastroesophageal reflux (GERD) symptoms developed in 41.1% of the patients (significant in 26.8%) Conclusions: In spite of weight regain in significant portion of patients, eight years postoperatively LSG remained safe and effective procedure with a remarkable improvement of co-morbidities. Nevertheless, GERD is a common long-term complication.

P333 - Morbid Obesity Laparoscopic Adjustable Gastric Banding After Failed Roux-EnY Gastric Bypass M. Uittenbogaart, W.K.G. Leclercq, A.A.P.M. Luijten, F.M.H. van Dielen Ma´xima Medical Centre, VELDHOVEN, The Netherlands Background: Roux-en-Y gastric bypass (RYGB) is associated with approximately 25% weight loss failure, resulting in insufficient weight loss or weight regain. Strategies of revisional surgery focus on alteration of limb length, pouch or stoma size. Altering pouch size and outlet by adding an adjustable gastric band (LAGB) might initiate further weight loss. Objectives: Reviewing safety and efficacy of LAGB after failed RYGB in a retrospective cohort of patients in our institute. Methods: Patients with secondary LAGB (n = 44) were studied between May 2012 and January 2015. Demographics, effects on weight loss and complications were analysed. Results: Mean age and body mass index (BMI) at time of LAGB was 45.8 ± 8.2 years and 37.2 ± 5.4 kg/m2 respectively. Mean interval between RYGB and LAGB was 2.6 ± 1.3 y. Mean follow-up was 14 ± 7.9 months, with 25% loss to follow-up at 12 months. Due to LAGB, patients lost an additional 17.6% ± 28.3% excess weight (EWL). Patients with weight regain after initial weight loss success showed more EWL compared to patients whom never reached 50%EWL after RYGB. Overall complication and reoperation rates were 30% and 21% respectively, with 16% band removal. One fatality due to septic shock following band erosion was observed. Conclusion: In this, so far, largest cohort, secondary banding of RYGB after failure provides only limited additional weight loss. Furthermore, this technique is associated with high morbidity and reoperation rates. A significant difference in effect was found between patients with weight loss failure and weight regain. Larger prospective series are necessary to evaluate if the modest benefits are worth the risks of secondary gastric banding.

Surg Endosc

P334 - Morbid Obesity

P336 - Morbid Obesity

Usefulness of New Indicators of Weight Loss After Bariatric Surgery

Effects of Laparoscopic Sleeve Gastrectomy, with Or Without Antrum Preservation, on Quality of Life: A Randomized Study

F. Sabench, A. Molina, E. Raga, S. Blanco, M. Vives, A. Sa´nchez, J. Dome`nech, L. Pin˜ana, E. Homs, D. Del Castillo

F. Sabench, A. Molina, M. Vives, E. Raga, A. Sa´nchez, M. Parı´s, A. Mun˜oz Garcia, E. Homs, E. Bartra, D. Del Castillo

Hospital Universitari Sant Joan de Reus. Universitat Rovira i Virgili, REUS, Spain

Hospital Universitari Sant Joan de Reus. Universitat Rovira i Virgili, REUS, Spain

Aim: The variable percentage of excess of BMI lost (% EBMIL) not represent a really good indicator because it uses parameters based on an ideal weight of 25. Expected BMI (BMIe) represent a new indicator, adjusting the weight loss by surgical technique. We compare the actual BMI with expected BMI in our patients after surgery, according to the formulas of Baltasar et al. Methods: Retrospective analysis of 444 patients (n = 266 Sleeve Gastrectomy-SG/ n = 178 Roux-Y-Gastric Bypass-RYGB). The following indicators (12-24-36 months) are calculated: actual and expected weight, actual and expected BMI adjusted by technique, % EBMIL and % EBMIL adjusted by expected BMI. Results: The maximum weight loss occurs at the first year after surgery in BMI \ 45 kg/ m2, in both surgical groups. In BMI [ 55 kg/m2, the maximum weight loss occurs at three years for SG, but at 2 years for RYGB, regaining weight after the third year. The expected BMI is closer to actual BMI in RYGB group. In SG group with higher BMI there is no correlation with BMI expected. The % of adjusted EBMIL is significantly higher than standard values in both surgical groups. Conclusions: Expected BMI can be useful in clinical daily practice in order to provide more realistic patient expectations. This value seems to be more useful in subgroups with BMI \55 kg/m2 and in RYGB, considering that in our hospital SG technique is performed as a first step of Duodenal Switch (with BMI higher).

Aims: The exact consequences of antrum preservation in bariatric surgery is still unknown in many aspects. Regarding this, we compare the effects of antral preservation or not on Quality of life in patients undergoing Sleeve Gastrectomy. Methods: prospective study with two randomized groups according two distances at the initial section of LSG (3 cm and 8 cm from pylorus); 30 patients/group. Quality of life questionnaire (Moorehead-Ardelt Quality of Life Questionnaire II) was used. This questionnaire explores six areas: esteem, physical ability to develop activities, desire for social relationships, ability to do the job, sex and patient attitude with food. Each section provides a score of -0.5 to +0.5 points. Results: When comparing the scores obtained 3 months after surgery in both groups, they show a significant increase in all questions from baseline values. 6 months after (3 cm group), it significantly increased the score in four questions, while in 8 cm group only increases in one question (laboral activity). At 12 months, both groups significantly increase scores on all sections of the test. 3 cm group: from a score of -0.74 ± 1.33 points before surgery, classified as reasonable, to 2.04 ± 0.67 points at 12 months, classified as good. 8 cm group: from a score of 0.87 ± 1.30 points before surgery, classified as reasonable, to 1.94 ± 0.70 points at 12 months, classified as good. Before surgery (3 cm), 40.0% of patients had a poor or very poor quality of life, while at 12 months no patient was in those categories: 96.7% of patients had a good or very good quality of life. In contrast, in 8 cm group, a 43.4% of patients had a poor or very poor quality of life at the beginning, while at follow-up, no patient was in those categories, and also a 83.4% of patients had a good or very good quality of life. Conclusion: Quality of life increases significantly after Sleeve gastrectomy in both surgical groups. No differences between two groups were found, considering that this is a test that assesses only ‘external’ aspects. More physiological aspects, as the depositional behavior, are not taken into account.

P335 - Morbid Obesity Ghrelin Levels After Gastric Plication and Sleeve Gastrectomy in an Experimental Model of Obesity F. Sabench, A. Cabrera, M. Vives, S. Blanco, A. Mun˜oz Garcia, M. Herna´ndez, E. Raga, A. Molina, M. Parı´s, D. Del Castillo Hospital Universitari Sant Joan de Reus. Universitat Rovira i Virgili, REUS, Spain Aim: Gastric plication is a technique that trends to emulate the restrictive and metabolic effect of Sleeve gastrectomy. There is great controversy about the benefits, and comparative studies are needed. Our objective is to determine the weight and ghrelin changes in both techniques in an experimental model of obesity. Methods: Sprague–Dawley rats ? 7 weeks old (12 GP + 12 SG + 6 sham). High fat (Cafeteria) diet for 4 weeks. Prior to surgery: puncture and cannulation of the external jugular vein under microscopic control for the extraction of blood (2 cc). Daily monitoring of weight Surgery: Midline laparotomy (4 cm). Greater curvature dissection and ligation of vasa recta (silk 5/0). GP: invagination and longitudinal suture of the gastric greater curvature and the rumen by using tutor (pipette 1 cm-diameter) SG: linear longitudinal gastrectomy with partial resection of the rumen and double continuous suture (polypropylene 4/0) Tube of 8 Fr. 4 weeks after surgery, we proceed to sacrifice and another blood extraction Results: Sleeve gastrectomy causes a major weight loss at long term than Gastric Plication. Gastric plication group trends to have a similar weight than sham group after four weeks. A decrease in ghrelin levels is evidenced after Sleeve gastrectomy, but not in Gastric Plication group (1.14 ± 0.34 ng/ml to 2.29 ± 056 mg/ml after surgery (p = 0.002)) Conclusion: Gastric Plication may represent an alternative in bariatric surgery at short term, in terms of weight loss, but metabolic effects are not the same as Sleeve Gastrectomy. More studies in morbid obese population are needed in this direction.

P337 - Morbid Obesity Bleeding After Laparoscopic Sleeve Gastrectomy: Single Bariatric Center of Excellence Experience in Over 600 Patients A. Iossa, G. Guida, M. Abdelgawad, F.D. de Angelis, G. Silecchia University of Rome Sapienza-Bariatric Centre of Excellence, LATINA, Italy Introduction: Laparoscopic sleeve gastrectomy (LSG) is becoming the second most performed bariatric/metabolic procedure in the world. Major complications after LSG occur in 5% of patients, with a bleeding rate of 1-6%. The percentage of re-operation for complications ranged from 0% to 10%, with a mean of 1.6%. The aim of this retrospective study was to evaluate the efficiency of reinforcement in prevention of post LSG bleeding with standardization of the technique. Materials and methods: From January 2012 to December 2016, prospectively maintained database was investigated about the incidence of post-operative bleeding. A total of 671 LSG were performed and calibrated on 42 Fr bougie using Stapler 60 mm (Ethicon EchelonTM Stapler-Echelon FlexTM) with cartridges reinforced with absorbable synthetic buttress material (Gore Seamguard). During laparoscopic haemostasis revision, blood pressure was maintained higher than 100/70 and an intra-abdominal pressure lower than 15mmhg. Intra-abdominal drainage was routinely placed with strict monitoring of the parameters for the first 36 h. Results: Out of 671 LSG, ten patients (1.56%) had post-operative bleeding. Intraoperatively, the source of bleeding was; 5 cases from gastrolysis, 2 from staple line, 1 from spleen, 1 from liver, 1 from the 12 mm trocar. Six of these required laparoscopic reoperation for haemodynamic instability (5 pts) or large haematoma (1 pts), however, one case required open splenectomy, so, the conversion rate was 10%. The remnant 4 cases required non-operative management with blood transfusion in 3 of these and clinical management in the last one. Mortality rate was 0% with a mean hospital stay prolongation to 4.2 days. Conclusion: Our results confirm the effectiveness of buttress materials as reducingbleeding product, with an incidence rate similar to these reported in literature. Standardization of the surgical technique together with the use of buttress makes LSG, which is a procedure with high risk of bleeding from the long suture line, safer with less bleeding rates.

123

Surg Endosc

P338 - Morbid Obesity

P340 - Morbid Obesity

Laparoscopic Sleeve Gastrectomy. Technical Details and Initial Outcomes in 180 Patients at a Single Institution

Sleeve Gastrectomy - 3 Ports Technic

A.M. Nixon, C. Aggeli, C. Tserkezis, C. Parianos, I. Margaris Athens General Hospital, Georgios Gennimatas, ATHENS, Greece Aims: Laparoscopic sleeve gastrectomy (LSG) has been found to be effective as a single procedure for the treatment of morbid obesity. Here we present technical details and initial outcomes over a 5 year period at our institution. Methods: LSG was performed in 180 patients. Preoperatively patients underwent abdominal ultrasound, transthoracic echocardiogram, spirometry and gastroduodenoscopy for evaluation of comorbidities. The patient is placed in an antitrendelenburg position at 30o and 15o rotation to the right. The surgeon is placed between the legs. Five ports (211 mm, 2 9 5 mm, 1 9 12 mm) are placed in strategic anatomical points. Coagulation and hemostasis is achieved by a sealer (Ligasure or Thunderbeat). The use of staplers (EndoGIA or Echelon) with buttress material effectively prevents staple line leaks. Operation steps: 1: Dissection of the gastric greater curvature, 2–3 cm above the pylorus, toward the His angle by separating the gastrocolic ligament using a sealer. 2: Initial section of the pylorus (3 cm) with a stapler, guided by a 36 F bougie tube. 3: Gastric section is completed with GIA or Echelon. Only the two first staplers are used without buttress material. 4: Removal of the bougie 5: Instillation of methylene blue via the nasogastric tube to exclude leakage. 6: Insertion of a Penrose type drain. 6: Extrication of the gastric remnant from the 12 mm port. 7: Removal of the gastric tube before extubation. Results: 180 patients (48 males-132 females) underwent LSG. Mean age was 38 years (range 19–67). Mean operative time was 83 min (range 48–132 min). Mean body mass index was 43.8 kg/m2. There was no mortality. There was one conversion to open surgery because of technical problems with a stapler. Two leaks from the resection line, one reoperated and the other conservatively treated. One patient developed hemorrhage from the short gastric vessels necessitating reoperation and splenectomy. One pulmonary embolism from deep vein thrombosis conservatively treated. Three patients developed surgical site infection at the point of insertion of the 12 mm port. Excess weight loss was 54% at 12 months. Conclusions: Results from our series confirm previous studies suggesting that LSG is a safe bariatric procedure with minimal perioperative morbidity.

L. Marko, L. Kokorak Roosevelt Hospital, BANSKA BYSTRICA, Slovak Republic Aim: In the last years increase morbid obesity around the world. A lot of patients need surgical intervetion for morbid obesity and complications - metabolic surgery. In our department we started with sleeve gastretomy as a best procedure for most patients. Method: we started at our Department of minimally invasive surgery with sleeve gastrectomy since 2012. 5 years before we apply more than 100 gastric banding, but with no expected result. Sleeve gastrectomy is easy performed procedure with minimaly impact to metabolism, but with great impact to diabetes. Result: In last 4 years we performed 83 sleeve gastrectomies - 24 mens (29%) and 79 women (71%) with median age 46 years (20-61 years). Median body weight was 118,3 kg (90 - 230 kg) and median BMI before operation 43,6 (35 - 67). %WL was 31,4% (23,454%) and %EWL was 61,4% (42,9-103%). BMI in follow up is 32 (25-44). Median operative time was 78 min. (45 - 180 min). Hospital stay is 3-7 days - median time is now 3 days. We have leaks in 3 patients with 2 deaths. In all patients we used 60 mm endostapler - from 5 to 9 cartridges. Oral intake starts day after surgery after X-Ray. We started this procedure with 5 ports, than we go down to 3 or 4 ports - depend of size of the left liver lobe. Patients with diabetes mellitus type II.change your status in 91% and patients with hypertension change status in 81%. Conclusion: in our experiences is sleeve gastrectomy best choice for solving of morbid obesity with great result in EWL, resolution of diabetes mellitus and hypertension. In selected patients is possible peform this procedure with only 3 ports -with excellent cosmetic result.

P339 - Morbid Obesity

P341 - Morbid Obesity

Patients Adherence to Follow Up Appointments After Sleeve Gastrectomy. A 3 Years Cohort Study of 178 Patients

A 3 Years Cohort Study of Long Term Outcomes of 178 Patients Who Underwent Sleeve Gastrectomy

A. Goldenshluger1, L. Keinan Boker2, M. Cohen3, M. Goldenshluger4, T. Ben Porat5, B. Gerasi5, M. Amun5, A. Khalaileh5, R. Elazary5

A. Goldenshluger1, M. Cohen2, L. Keinan Boker3, B. Gerasi4, M. Goldenshluger5, M. Amun4, T. Ben Porat4, A. Khalaileh4, Y. Mintz4, R. Elazary4

Hadassah hospital, JERUSALEM, Israel; 2Israel Ministry of Health ICDC, RAMAT GAN, Israel; 3Center of Quality and Clinical Safety, Hadassah-Hebrew University Medical Center, JERUSALEM, Israel; 4 Chaim Sheba Medical Center, TEL HASHOMER, Israel; 5Hadassah Hebrew University Medical Center, Ein Kerem, JERUSALEM, Israel

1 Hadassah hospital, JERUSALEM, Israel; 2Center of Quality and Clinical Safety, Hadassah-Hebrew University Medical Center, JERUSALEM, Israel; 3Israel Ministry of Health ICDC, RAMAT GAN, Israel; 4Hadassah - Hebrew University Medical Center, Ein Kerem, JERUSALEM, Israel; 5Chaim Sheba Medical Center, TEL HASHOMER, Israel

Objective: To evaluate the scope of post operative adherence to recommended appointments to both surgeon and dietitian, and to identify predisposing factors for non adherence. Methods: A retrospective cohort study was conducted on 3 years follow up of 201 patients who underwent sleeve gastrectomy between March 2011 and August 2012. 3 years post surgery a telephonic detailed questionnaire regarding socio-demographic data, anthropometric parameters, medical evaluation and adherence characteristics was performed by skilled interviewers. A patient was defined as adherent if he had reached at least 5 annually appointments, which resembled 50% of the recommended follow up meetings in the first postoperative year according to our protocol. Results: 2% of the patients have not arrived to any postoperative appointment, 27.3% showed in 1-3 appointments, 38.3% came to 4-6 appointments and 32.4% arrived to 7-9 appointments.45.27% of patients were found to be adherent. 178 of the included patients completed the 3 years follow up questionnaire. We thoroughly examined separately the factors for non adherence to recommended appointments for the surgeon and the dietitian. The main reasons for non adherence were (presented as: surgeon, dietitian respectively): occupation related (20.8%, 43.3%), transportation issues (16.8%, 40.4%), difficulties in scheduling appointment or long waiting time at the clinic (18.5%,37.6%), lack of knowledge regarding the expected postoperative follow up regime (19.7%, 9%). No significant correlation was found between postoperative adherence to follow up and weight loss outcomes. Conclusion: Non adherence rate after bariatric surgery was found to be significant. This fact can seriously bias published effects of bariatric surgery due to exclusion of major percent of the operated patients. In our study, the main factor for non adherence was found to be occupation related. Unlike demonstrated in several publications, we have not found any significant correlation between adherence and weight loss outcome, however, we do believe that there is a crucial influence of adherence to follow up on other outcomes that should be studied further.

Objective: To evaluate long-term outcomes of Laparoscopic Sleeve Gastrectomy (LSG). Methods: A retrospective cohort was conducted on 3 years follow up of 201 patients who underwent LSG between March 2011 and August 2012. 3 years after surgery a telephonic detailed questionnaire regarding socio-demographic data, anthropometric parameters and medical evaluation was made by skilled interviewers and was compared to existing medical data including registered weight 6 month and 1 year after surgery. Results: 178 of the included patients completed the 3 year follow up. Mean excess body weight loss (%EBWL) was 65.14% ± 15.74 at 6 months, 78.53% ± 20.28 at 12 months, and 74.32% ± 23.92 after 3 years. The maximum %EBWL achieved post operatively was 88.61% ± 1.59. Remission of comorbidities was: Dyslipidemia in 83.5% patients (P \ 0.001), Hypertension in 65.79% (P \ 0.001), Diabetes in 62.06% (P \ 0.001) and Gastroesophageal reflux (GERD) in 60.7% (P \ 0.001). A significant reduction in medications quantity taken by patients was found (P \ 0.001). 90 days post operative re-admission rate was 5.6%. New onset GERD was found in 36.6% of the patients (P \ 0.001); 25.9% of patients reported to have emesis, 4.5% had diarrhea, 24.7% suffered from constipation, 22.5% reported some degree of food intolerance and 42.7% complained of alopecia. Conclusion: Our research suggests that LSG is a potential tool in achieving almost 75% of %EBWL with a significant remission rate of related comorbidities and a reduction in the quantity of medications needed. A significant presentation of GERD was shown as in other studies. The importance of our study lies on a long-term follow up also on the patients who had lack of adherence to their routine clinical appointments after surgery. So far, only few studies included non-adherent patients to follow up for their post-operative assessment analysis.

1

123

Surg Endosc

P342 - Morbid Obesity

P344 - Morbid Obesity

Laparoscopic Sleeve Gastrectomy Versus Gastric Bypass for Morbid Obesity: A Single-Institution Experience

The Impact of Radical Antral Resection in Outcomes Following Laparoscopic Sleeve Gastrectomy

C.H. Su, Y.C. Chen, C.C. Huang, J.Y. Lee, J.S. Hsieh

C. Markakis, A. Laliotis, J. Mok, A. Shaw, S. Lazaridis, A. Wan

Kaohsiung Medical University Hospital, Kaohsiung Medical University, KAOHSIUMG, Taiwan

St George’s University Hospitals, NHS Foundation Trust, LONDON, United Kingdom

Aims: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most popular bariatric procedures with the best long-term results. However, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure is gaining wide acceptance. The aim of this study is to compare the short term outcomes of LSG to LRYGB in a single institution. Methods: Between 2011 and 2015, 132 patients undergoing either LSG or LRYGB were included in this retrospective study. Of these, 65 patients underwent LSG and 67 patients underwent LRYGB. Demographics and clinical data were compared to identify differences in complication rates, length of hospital stay, extent of diabetic remission, and weight loss. Results: The mean operative time of LSG was 136 min while LRYGB was 215 min (p \ 0.05). Thirty-day complication and readmission rates for LSG and LRYGB were 0.4 and 0.3% vs 1.2 and 3.4%, respectively (p [ 0.05). The length of hospital stay was shorter in the LSG group (3.6 vs. 5.5 days); however, this result was not statistically significant (P [ 0.05). There were no significant differences in percentage of excess weight loss between the two groups in the first 12 months. However, 18 months after surgery, average excess weight loss was 75.4% in LRYGB and 55.6% in LSG (p \ 0.05). Both LSG and LRYGB provide good results in remission of diabetes at 18 months. Conclusions: LSG is safe with more favorable short-term outcomes in terms of shorter operative time and less complication rate. In our study, the extent of excess weight loss and resolution of diabetes confirmed the excellent effect of both procedures. However, randomized studies with a larger patient pool are needed to better elucidate our findings.

Aim: The extent of resection of the gastric antrum is one of the most controversial technical points of laparoscopic sleeve gastrectomy. Proponents of radical resection of the antrum argue that it would lead to better weight loss and prevent weight regain. However, there are surgeons who argue that it has the potential to increase complications and GORD. Our aim was to compare outcomes following antral resection versus antral preservation techniques in a group of patients undergoing sleeve gastrectomy. Methods: We prospectively collected data from November 2011 until February 2014 for 143 patients that underwent laparoscopic sleeve gastrectomy. Patients were allocated from a pooled list to individual surgeons’ preference for antral resection (AR) or antral preservation (AP). Excessive weight loss percentage (EWL%), decrease in BMI (body mass index), morbidity and mortality were measured at 6 and 18 months postoperatively. Results: In the AP group (n = 70) mean EWL% amounted to 41.1% at 6 months, and there was no significant difference compared to the AR group (n = 73) where EWL % amounted to 41.5%, (p = 0.43). At 18 months there was a significant difference between groups: EWL % was 47% for the AP and 59% for the AR group (p = 0.04). There were no deaths in our patient population. No patient exhibited staple line bleeding, while there were 2 cases of staple line leak, 1 in each group. One patient in the AP group had a stricture, while one in the AR group had a kink. There were no differences in GORD, which was reported by 7.7% of patients overall. Conclusions: Both variations of laparoscopic sleeve gastrectomy are quite effective in weight loss at six months, but there was higher EWL % and less weight regain in the AR group at 18 months, while there were no significant differences in complications between groups. Further study is required to confirm whether this difference persists in longer term follow-up.

P343 - Morbid Obesity

P345 - Morbid Obesity

The Effect of Sleeve Gastrectomy on Thyroid Hormone Levels

Laparoscopic Sleeve Gastrectomy for Morbid Obesity: 5-Year Results

I. Gomceli, U. Dogan, N. Bulbuller, M.T. Oruc, B. Mayir, M. Habibi, T. Cakir, O.Z. Oner, H.Y. Ellidag, N. Yilmaz Antalya Education and Research Hospital, ANTALYA, Turkey Aims: To evaluate thyroid hormone serum levels after sleeve gastrectomy in morbid obese patients. Methods: Laparoscopic sleeve gastrectomy surgery performed 30 morbidly obese and euthyroid patients were included in the study. Before laparoscopic sleeve gastrectomy surgery and postoperative 3 months and 6 months serum thyrotropin (TSH), free T4, free T3 were measured by chemiluminescence method. Preoperatively and 3, 6 months after surgery body mass indexes (BMI) were calculated. Kruskal–Wallis, One Way Anova, Bonferroni-Dunn tests were used for statistical analysis. Results: Mean age of 30 morbid obese patients in the study was 41.23 ± 10.37. Preoperatively, postoperatively 3. month and 6. month mean BMI were 49.30 ± 7.92, 39.48 ± 7.32 and 34.39 ± 7.56 respectively (p \ 0.001). Preoperatively, postoperatively 3. month and 6. month mean TSH levels (lIU/mL) were 2.22 ± 1.06, 1.58 ± 0.90 and 1.83 ± 1.71 respectively (p \ 0.001). Preoperatively, postoperatively 3. month and 6. month mean FT3 levels (pg/mL) were 3.25 ± 0.46, 3.02 ± 0.38 and 3.0 ± 0.30 respectively (p \ 0.05). Preoperatively, postoperatively 3. month and 6. month mean FT4 levels (pg/mL) were 0.88 ± 0.15, 0.99 ± 0.20 and 0.86 ± 0.12 respectively (p \ 0.05). Preoperatively BMI showed a statistically significant decrease in 3. and 6. months. Preoperatively serum TSH and FT3 levels showed a statistically significant decrease in 3 and 6. months but there was no difference between 3. and 6. months. Preoperatively serum FT4 levels increased in 3. month but regressed to preoperative levels in 6. month. Conclusion: BMI, TSH and FT3 serum levels were decreased after laparoscopic sleeve gastrectomy but serum FT4 levels were increased in early stages.

E. Mpaili, A. Alexandrou, S. Orfanos, M. Vailas, T. Diamantis, D. Sxizas, T. Liakakos Laikon University Hospital, National and Kapodistrian University of Athens, ATHENS, Greece Background: Data concerning the long-term efficacy of laparoscopic sleeve gastrectomy in the treatment of morbid obesity remain scarce. In this retrospective, the authors present 5-year followup of 30 patients having undergone laparoscopic sleeve gastrectomy. Methods: Since 2004, 30 patients underwent laparoscopic sleeve gastrectomy and completed 5 years of follow-up. Five patients were subsequently subjected to laparoscopic Roux-en-Y gastric bypass and were excluded from further analysis. The remaining 25 patients comprised the study population. Results: Mean excess weight loss was 65.2 6 6.1%, 64.7 6 5.6%, 62 6 4.9%, 58.2 6 5.5%, and 56.4 6 5.8% for the first 5 years, respectively. There were no deaths, nor any major morbidity. Remission of comorbidities was observed in 40% to 80.9% of cases. Conclusions: Laparoscopic sleeve gastrectomy is a safe and effective means of treatment of morbid obesity both in the short and in the long term. More research is needed to better predict which patient will benefit most from this operation.

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Surg Endosc

P346 - Morbid Obesity

P348 - Morbid Obesity

The Impact of Laparoscopic Sleeve Gastrectomy on Plasma Obestatin and Ghrelin Levels

Is Age Extremis a Risk Factor for the Surgical Outcomes of Laparoscopic Gastric Banding?

U. Dogan, H.Y. Ellidag, A. Aslaner, T. Cakir, M.T. Oruc, U. Koc, I. Gomceli, B. Mayir, N. Bulbuller

Z.H. Perry1, S. Atias1, M. Rivin1, M. Mizrahi1, G. Gibor1, Y. Glazer1, B. Kirshtein1, U. Netz1, T. Sela2, R. Shalev2, L. Lantsberg1, E. Avinoh1

Antalya Education and Research Hospital, ANTALYA, Turkey

1

Aim: To investigate the effect of laparoscopic sleeve gastrectomy (LSG) on the levels of obestatin and ghrelin hormones and body mass index (BMI) in morbidly obese patients. Methods: The study included 30 morbidly obese patients who had LSG. Five cc blood samples were taken from the patients preoperatively and at postoperative months 3 and 6. After serum extraction, the levels of obestatin and ghrelin hormones and the levels of fasting insulin and glucose were studied using the enzyme-linked immunosorbent assay (ELISA) method. The homeostatic model assessment of insulin resistance (HOMA-IR) score was calculated. Preoperative and postoperative 3- and 6-month BMI were calculated. Kruskal–Wallis Analysis of Variance, Bonferroni-Dunn Test, Spearman’s correlation test, and Pearson’s correlation test were used for statistical analysis. Results: BMI of the patients were statistically significantly reduced at postoperative months 3 and 6 compared to preoperative values, and at postoperative month 3 compared to month6 values (p \ 0.001). Ghrelin values were higher at postoperative month 6 compared to the preoperative and postoperative month3 values (p \ 0.001). Obestatin values of the patients were lower at postoperative month 6 compared to the preoperative and postoperative month3 values (p \ 0.001). Insulin and glucose values were statistically significantly lower at postoperative months 3 and 6 compared to preoperative values (p \ 0.001), whereas there was no difference between months 3 and 6. HOMA-IR score was significantly lower at postoperative month 3 compared to preoperative values (p \ 0.001). Conclusions: LSG enables effective weight loss and glucose regulation in obese patients. LSG has also effects on obestatin and ghrelin hormones, which are coded by the same gene and have opposing effects, and the associated mechanisms of which are still controversial. Obestatin produces a feeling of satiety, whereas ghrelin initiates eating by producing a feeling of hunger. The patients were observed to have increased ghrelin and reduced obestatin postoperatively due to a negative energy balance.

Soroka University Medical Center, BEER-SHEVA, Israel; 2BenGurion University Medical School, BEER-SHEVA, Israel

Introduction: The problem of obesity is rising in elderly and pediatric populations. The experience and research knowledge in regard to the safety and efficacy of LAGB in the age extremis population for the long term are lacking. Methods: In the current study we have tried to estimate the benefits against the risks of this procedure in the 65+ age group and in pediatric patients (i.e. age extremis), and by that to determine its’ worthwhileness. Results: In the current study we enlisted 287 patients, of them 87 (30.6%) were males. When grouping for age, 166 patients (58.7%) were 18–65 upon the operation, 58 (20.5%) were less than 18, and 59 (20.8%) were 65 or older. This meant that age extremis patients comprised 117 patients, or 41.3% of our study population. When comparing the post-op anthropomorphic results, between the age extremis (65+, or younger than 18) to the control group (18–64.99) we found no significant difference. When looking at the improvement in the medical condition, we have seen a significant advantage for the control group (18–64), both in DM and HTN. Comparing post-op complications (like removal, slippage, re-operation or the number of re-operations needed) we have found no significant difference between the groups. If we look at the BAROS score, there has been a significant difference between the 2 groups - 3 (± 2.41) in the age extremis, in comparison to 4.43 (± 2.45) in the control group, but the verbal coding of the BAROS showed similar medians (2-fair). Looking at the percentage of failure in each group, we saw a borderline significance (0.045) - 10% in the control group in comparison to 17% in the age extremis. Discussion: LAGB results in a substantial loss of weight for the long term among age extremis patients. Although the excess body weight loss percentage is lower in the age extremis, still the loss of weight results in markedly improvement in morbidity and quality of life in these patients, leading to a BAROS score of fair at least to most of the patients.

P347 - Morbid Obesity

P349 - Morbid Obesity

Are Minorities at Greater Risk for Bad Surgical Outcomes in Laparoscopic Gastric Banding?

Effects of Bariatric Surgery on Urinary Incontinence

Z.H. Perry1, S. Atias1, M. Rivin1, M. Mizrahi1, G. Gibor1, Y. Glazer1, B. Kirshtein1, S. Bar1, R. Averbauch2, L. Lantsberg1, E. Avinoh1 1

Soroka University Medical Center, BEER-SHEVA, Israel; Ben-Gurion University Medical School, BEER-SHEVA, Israel

2

Introduction: The prevalence of obesity is increasing, especially in different ethnic populations. Bariatric operations have proved as an effective measure for weight reduction and for long term maintaining of the lower weight that have been achieved. The experience and research knowledge in regard to the safety and efficacy of LAGB in minorities has long been debated upon, and evidence upon its for the long term are lacking. Methods: In the current study we have tried to estimate the benefits against the risks of this procedure in the different ethnic sub-groups, and by that to determine its’ worthwhileness. This was a retrospective cohort study that compared the safety and effectiveness of LAGB amongst different minority groups which was operated in comparison to a control group which was operated upon. Results: In the current study we enlisted 455 patients, of them 84 (18.5%) were males. When grouping for minorities and the control group, 194 patients (42.6%) were of the control group, and 261 (57.4%) were minorities - 127 were Arabs or Bedouins (27.9%) and 134 were former immigrants from the ussr (29.5%). When comparing the basic demographics we have seen no significant difference between the minority and the control group. We found no difference in hospitalization days or post-op days, but there was a small significant difference in the follow-up period. In post-op comparison weight loss, BMI or excess weight loss were significantly lower than in the general population. Medical condition improved more in the general population. Post-op complications (like removal, slippage, re-operation or the number of re-operations needed) showed no difference, as did the BAROS score. But, we did see a significant in the need for re-operation and in the general complication rate, which was lower in minority patients. Discussion: LAGB results in a substantial loss of weight for the long term among minority patients at large. Although the excess body weight loss percentage is lower in minorities, still the loss of weight results in markedly improvement in morbidity and quality of life in these patients, leading to a BAROS score that is equivalent to the general population.

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M. Habibi1, M. Yuksel2, O. Ozener2, N. Bulbuller3, M.T. Oruc2, M.A. Kazak2 1

Esenler Maternity and Child Health Hospital, ISTANBUL, Turkey; Antalya Training and Research Hospital, ANTALYA, Turkey; 3 Akdeniz University Faculty of Medicine, ANTALYA, Turkey 2

Background: Obesity is an important modifiable etiological factor for many systematic diseases. There is strong evidence that increased body mass index (BMI) is also correlated with urinary incontinence (UI). To investigate this correlation, we examined the effects of weight loss on UI in female patients who had undergone laparoscopic sleeve gastrectomy (LSG). Study design: We prospectively collected data preoperatively and 6-months postoperatively from 50 female patients who had undergone LSG at Antalya Training and Research Hospital between March 2015 and July 2015. To do so, we administered the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF), in which a decrease in score indicates an improvement in symptoms. Using the collected data, we determined the incidence of UI and examined the relationship between the preoperative and postoperative BMI and ICIQ-UI SF values. Results: The mean age of the patients was 38.5 (SD = 9.3) and the mean preoperative BMI was 46.3 (SD = 6.3). Of the 50 patients, 34 (68%) complained of UI preoperatively. Among these 34 patients, 12 (35.3%) described urge incontinence, 10 (29.4%) stress incontinence, and 12 (35.3%) mixed-type incontinence. At 6 months postoperatively, the percentage of excess weight loss was 66.7%. In patients with UI, the mean preoperative ICIQ-UI SF score of 6.5 significantly decreased to a mean 6-month postoperative score of 1.61 (P \ 0.005). Conclusion: LSG results in a clinically significant improvement in UI. This finding indicates that bariatric surgery should be recommended to morbidly obese patients with UI.

Surg Endosc

P350 - Morbid Obesity

P352 - Morbid Obesity

Is LGB an Appropriate Salvage Operation for Prior Bariatric Procedures?

Metabolic Profile in Obese Patients: The Bariatric Surgery Impact

Z.H. Perry1, S. Atias1, M. Mizrahi1, M. Rivin1, Y. Glazer1, G. Gibor1, B. Kirshtein1, L. Lantsberg1, U. Netz1, R. Shalev2, E. Avinoh1

D. Timofte, I. Hristov, V. Mocanu

Soroka University Medical Center, BEER-SHEVA, Israel; 2BenGurion University Medical School, BEER-SHEVA, Israel

University of Medicine and Pharmacy Gr.T.Popa Iasi, IASI, Romania

1

Introduction: The prevalence of obesity is increasing. Bariatric operations have proved as an effective measure for weight reduction and for long term maintaining of the lower weight that have been achieved, but some operations do fail after time. The experience and research knowledge in regard to the safety and efficacy of LAGB in patients who had prior bariatric operations has long been debated upon, and evidence upon it’s for the long term are lacking. Methods: In the current study we have tried to estimate the benefits against the risks of this procedure in the different patients after prior bariatric operations, like SRVG, sleeve and bypass and by that to determine its’ worthwhileness. This was a retrospective cohort study that compared the safety and effectiveness of LAGB amongst different minority groups which was operated in comparison to a control group which was operated upon. Results: In the current study we enlisted 189 patients, of them 119 (63%) were females. When grouping for prior operation and the control group, 71 (38%) had a prior operation 19 had a bypass (27%), 4 sleeve (6%) and 48 undergone a SRVG.VBG (67%). When comparing the demographics we have seen no significant difference. Weight loss and ? BMI were lower in the prior surgery group. Post-op complications (like removal, re-operation or the number of re-operations needed) showed no difference, except for the slippage rate which was higher in the control group. Prior operation patients showed a longer operation time, as expected. BAROS score did not differ between the groups. Discussion: LAGB results in a substantial loss of weight for the long term among patients with prior bariatric operation. Thus we conclude that LAGB is an efficient and safe surgery for treating obesity in the patients with prior bariatric operation, and its’ advantages overcome its’ risks, which are surly lower than other bariatric procedures.

P351 - Morbid Obesity

Introduction: Abdominal obesity is associated with an increased risk of coronary heart disease, in part due to a chain of systemic disorders starting with insulin resistance and including: atherogenic dyslipidemia (high triglycerides and low HDL cholesterol), raised blood pressure and raised fasting plasma glucose. Objectives: Our objective was to evaluate the metabolic syndrome parameters in obese patients before bariatric surgery and 6 months after the procedure. Materials and methods: Between July 2013 and December 2014, 60 patients (35 females and 25 males, mean age 39.1 ± 9.1 years) with mean BMI 43.5 kg/m2 ± 7.9 were enrolled. The metabolic syndrome parameters were evaluated in all patients before and 6 months after the metabolic surgery procedure. Weight loss was significant 6 months after surgery with average EWL of 31,2%. Results: Mean triglycerides value at baseline was = 136 mg/dl vs 113 mg/dl 6 months after bariatric surgery (reduction of 16,9%); high level of triglycerides [150 mg/dl at baseline were found in 46.2% of patients vs 26,3% 6 months after bariatric surgery; Low levels of HDL- cholesterol (\40 mg/dl in men) were identified in 75,86% at baseline vs 33,33% 6 months after bariatric surgery and (HDL \ 50 mg/dl in women) in 87,5% of the patients vs 60% 6 months after surgery. Fasting glucose levels [100 mg/dl was found in 51,4% of the patients. Diagnosis of T2DM was present in 41,1% of the patients. 6 months after surgery all the patients in our lot had fasting glucose levels 100. Conclusions: The high prevalence of the metabolic syndrome in obese patients offers an additional indication for bariatric surgery, as the metabolic profile for these patients is significantly improved after bariatric surgery. This study confirms the existing data on the benefits of the metabolic surgery procedures as the most effective therapy for T2DM and atherogenic dyslipidemia.

P353 - Morbid Obesity

It is Possible to By-Pass the Learning Curve in Bariatric Surgery?

Are We There Yet? - Nutritional Interventions’ Insights After Gastric Sleeve

D. Timofte1, M. Blaj1, D. Reurean-Pintilei2, E. Mitrofan3

D. Timofte1, E. Pintilei2, D. Reurean-Pintilei2

1

University of Medicine and Pharmacy Gr.T.Popa Iasi, IASI, Romania; 2Consultmed Hospital, IASI, Romania; 3Pneumology Hospital, IASI, Romania Objectives: The Learning Curve (LC) represents a concept which refers to the acquisition of a new technique in any domain supposing to guide training and implementation at institutions not currently using the new procedure, in bariatric surgery being a complex process starting with selection of cases, perioperatively management and treatment of complications. Materials and methods: There were included 120 patients operated in the 3rd Surgical Unit between June 2012 and December 2015 divided in 3 groups of 40 patients and the main parameters were analyzed. Results: Univariate analysis revealed a significant decrease of the operative time in the 3rd lot (70 ± 20 min) comparing with lot 1 (90 ± 15 min) and a significant decrease of incidents and complications following the learning curve: lot 1 - 13,33% (4/30), lot 2 3,33% (1/30) and lot 3 with 0 complications. Conclusions: The results can be biased by retrospective design of the study with the lack of follow up for all the patients. On our cohort (120) the estimation of the breaking point for fulfilling the LC is to be after 80 patients in accordance with literature data. One of the most important methods to shorten the LC is to initiate and maintain a mentored communication with an experienced bariatric surgeon from a specialized centre to proper recognize and manage the incidents and complications. The concept ‘once seen, once done, once teach’ is not available in surgery, the LC in bariatric surgery being reported to be 100 cases.

1

University of Medicine and Pharmacy Gr.T.Popa Iasi, IASI, Romania; 2Consultmed Hospital, IASI, Romania Background and aim: Bariatric procedures are curently regarded as the most effective treatment for severe obesity. However, after surgery, the overall longterm patients’ wellbeing depends on daily adequate macro- and micronutrient supply. Patients’ understanding and applying dietary recommendations has been shown to be challenging. Our papers’ aim is to discuss a series of particular cases regarding nutritional management after gastric sleeve. Material and method: we had chosen three particular types of patients who have undergone LSG. Patient 1: woman with ovo-lacto-vegetarian diet, having vitamin B12 and mild serum albumin deficiency. Patient 2: 18 year old young woman, having transient emotional outbursts, low self-esteem and mild difficulties in relating. Patient 3: 43 year old woman, experiencing significantly impaired joint mobility from gonarthrosis, with a firm weight loss indication before arthroplasty. Results: Patient 1: alternative protein sources and supplemented B12 vitamin had to be added to in patients’ diet, with respect to her personal choices; patient 2: in addition to regular nutritional advice, augmented attention regarding psychological approach has been offered; patient 3: considering limited physical activity, an adapted low calorie diet has been prescribed. Having performed these interventions a desired outcome was observed in all these three patients. Conclusions: Further efforts should focus on support tools enabling a unified, nevertheless tailored strategy for the bariatric patient. These cases confirm that collaborative approach is of paramount importance in obtaining the desired results along with maintaining maximal safety conditions.

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Surg Endosc

P354 - Morbid Obesity

P356 - Morbid Obesity

Laparoscopic Sleeve Gastrectomy as a Revisional Procedure for Adjustable Gastric Band Failure: A Retrospective Study

Management of Distal Gastric Leak After Laparoscopic Sleeve Gastrectomy by a Double Pigtail Catheter

A. Assalia, M. Speier, Y. Kluger, A. Mahajna

M. Habibi1, H. Seyit2, O. Kones2, C. Seyhun2, H. Alis2

RAMBAM HEALTH CARE CAMPUS, HAIFA, Israel

1 Esenler Maternity and Child Health Hospital, ISTANBUL, Turkey;2Bakirkoy Dr. Sadi Konuk Training and Research Hospital, ISTANBUL, Turkey

Background: Laparoscopic Sleeve Gastrectomy (LSG) is an acceptable option as a revisional surgery after failed Laparoscopic Adjustable Gastric Banding (LAGB). The objective of this study was to compare the outcomes of primary LSG as compared to revisional LSG after failed LAGB, in terms of weight loss and safety. Methods: Retrospective analysis of 967 patients who underwent LSG during the years 2008–2011 was done. We analyzed patient demographics, operative and postoperative parameters, with at least 3 years follow up of body mass index (BMI), and the occurrence of co-morbidity (hypertension, diabetes mellitus type II, obstructive sleep apnea and dyslipidemia). Results: The study group included 37 eligible patients who underwent revisional LSG after failure of LAGB (out of 79 patients) and a random control group of 68 patients that underwent primary LSG during the same period. Operative time was significantly longer in our study group (01:28 ± 00:35 vs. 00:51 ± 00:16 h; p \ 0.001). Furthermore, it was significantly longer in the subgroup that underwent a 1-step vs. 2-step procedure (01:58 ± 00:30 vs. 01:17 ± 00:29, respectively; p \ 0.001). Perioperative complication rate and re-admission rate showed no significant difference, also when comparing 1-step vs. 2-step procedures. Length of hospital stay was longer in the study group, compared to the control group (4.1 ± 1.5 vs. 3.3 ± 1.2 days, respectively. p = 0.044). An obvious trend towards higher BMI in the study group compared to primary LSG was seen, starting as soon as 3 months after surgery. This difference reached a statistical significance at 4 years of follow up (p = 0.009). No significant difference as to the occurrence of co-morbidities between the two groups was demonstrated. There was no mortality shown in this study. Conclusions: LSG is a feasible and safe surgery after LAGB failure compared to primary LSG irrespective of the fact if the band is removed before or during surgery. It has been shown to be as safe a primary LSG. A trend towards better weight loss was achieved in the primary LSG group as compared to the revisional LSG.

Background: Gastric leaks after laparoscopic sleeve gastrectomy (LSG) is the most feared complication due to the difficulty in its management. Management of these leaks frequently requires use of internal drainage catheters accompanied by self-expandable metal stents (SEMS). Recently, endoscopic internal drainage by double pigtails catheter (DPC) has been recommended after previous studies found it was better tolerated, required fewer procedures, and was associated with a shorter healing time compared to use of SEMs. In this report, we describe our treatment by DPC of a patient who had experienced distal gastric leak after undergoing LSG. Case Report: A 28-year-old female patient who had undergone LSG 40 days ago was referred to our clinic. She had experienced postoperative leaking that had been unsuccessfully managed by conservative treatment. Upper gastrointestinal (GI) examination and computed tomography (CT) scanning showed perigastric distal leak and abscess formation. Endoscopic examination revealed a 5 mm fistula orifice from the starting point of the staple line and the guide delivered across the orifice emerging from the skin from the drain side. After expanding the fistula orifice using endoscopic electrocautery, we placed a DPC. Soft food digestion which was initiated on postoperative day 1 is then followed by normal food digestion on postoperative day 3. The DPC was removed using endoscopic snare after complete closure of the orifice was observed at postoperative week 4. Conclusion: Use of DPC in the treatment of distal leaks provides complete drainage of perigastric collections and stimulates mucosal growth over the catheter, making it a safe and effective means of leak management.

P355 - Morbid Obesity

P357 - Morbid Obesity

All a Surgeon Should Know About OSA and Bariatric Surgery

Gastrobronchial Fistula as a Complication of Bariatric Surgery

D. Timofte1, E. Mitrofan2

P. Muriel, N. Mestres, M. Santamarı´a, J.A. Baena, V. Palacios, M. Gonzalez, E. Cuello, M. Merichal, A. Escartı´n, J.J. Olsina

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University of Medicine and Pharmacy Gr.T.Popa Iasi, IASI, Romania; 2Pneumology Hospital, IASI, Romania Objectives: Obstructive Sleep Apnea (OSA) is more prevalent in obese population. Bariatric surgery (BS) is an effective method to reduce and maintain weight loss, an important step in OSA therapy. The aim of this presentation is to assist practitioners to deliver effective and save medical care. Materials and methods: All the obese patients are investigated for OSA. BS is recommended for obese OSA with BMI [ 35 kg/m2, with pre-operatory treatment of 6–8 weeks with CPAP and follow up after BS. Post-surgical reevaluation should be at 1, 3, 6 months and 1 year. Results: In a recent meta-analysis of 13.900 patients who underwent BS, 79% of them had either resolution or improvement of OSA. In a prospective, multicentre observational study of patient undergoing BS, complications occurred in 4,1% this included 0,3%mortality. Patients more likely cured of OSA were less morbidly obese and younger. Patients should repeat polysomnograms after BS and those patients with residual OSA, must be treated with CPAP. The metabolic improvements that accompany weight loss (by BS and dietary means) may be maximized if OSA is also treated by CPAP. Conclusions: Ongoing diet and behavioral programmes are necessary to maintain initial dramatic weight loss achieved by BS. No clear guidelines exist upon which to base the recommendations for retesting for OSA following BS. Patients after BS with regain of weight, a history of previous OSA, must be retesting for OSA.

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Hospital Universitari Arnau de Vilanova de Lleida, LLLEIDA, Spain Introducion: Gastro-bronchial fistula (GBF) is a rare complication in gastroesophagueal procedures with significant morbidity and mortality. This is why diagnostic and treatment strategies are very important. Generally it is due to an hyperpressive mechanism because of distal stenosis of the sleeve gastrectomy which has a rate of leak of 2.4% approx. (89% at esophagogastric junction). Aimed: We aim to review the clinical aspects, diagnosis and treatment strategies of the GBF. Case: A 53- year- old -woman with 43.66 pre-operative BMI, HAT, SAOS with CPAP treatment and hipotiroidism was operated of gastric sleeve. She presented slow evolution because of a collection in left upper quadrant that was treated by antibiotic therapy, percutaneous drainage and prosthetic esophageal endoscopic management, being solved after 5 months. Afterwards, she was followed at outpatient until she referred clinical respiratory and fever at 1 year post-op. For this reason chest radiograph and esophago-gastro-duodenal transit were done and we realized a GBF and the fulfilling of contrast of the left lower lobe bronchus. As the patient was stable, we decided conservative handle with no diet and parenteral nutrition without success after 2 weeks. We decided to do a fistulectomy by laparotomy with bad result so it required a new endoscopic treatment without achieving a complete resolution. Finally we decided to do a Roux-limb placement at the fistulous orifice getting the final resolution. The patient follows controls without complications 9 month after the last intervention. Discusion: GBF is a rare complication that usually has a late diagnosis (average of 136 days). The therapeutic management in unstable patients is: clinical support and draining surgery. In stable patient the best option is conservative treatment based on parenteral nutrition, percutaneous drainage and endoscopic treatment (stenting) with a success rate of 80%, leaving surgery as a last option. In our case we chose an unsuccessful early intervention, requiring endoscopy and surgical reintervention. Conclusion: GBF is a diagnostic challenge to treat successfully this rare and severe complication. Endoscopic treatment should be the gold standard for stable patients leaving surgery for those extreme cases.

Surg Endosc

P358 - Morbid Obesity

P360 - Morbid Obesity

Rare Interesting Bariatric Complications and Management 1

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2

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A. Abokhozima , M. Gamal , M. Abbas , M. Mourad , M. Refae

1

C Reactive Protein, White Blood Cells and Neutrophils as Early Predictors of Complications in Patients Undergoing OneAnastomosis Gastric Bypass

1

Alexandria university, ALEXANDRIA, Egypt; 2Miami hospital, ALEXANDRIA, Egypt The presentation include 3 bariatric cases: 1. Female patient with intragastric balloon, minor leak from the balloon and its migration to the jejunum leading to small bowel obstruction emergency diagnostic laparoscopy was done, enterotomy and extraction of the balloon, direct repair of enterotomy and balloon extraction through 10 mm port site. 2. Male patient present after 5 days of LSG with small bowel obstruction due to entrapment of small bowel loop through one of the port sites emergency laparoscopy was done with reduction of the herniated segment and closure of the port site. 3. Female patient presented with stricture of the OGJ after re-sleeve gastrectomy managed by balloon dilatation which recur after 2 weeks the managed by expandable metallic stent for 6 weeks with good response and the stent is removed.With a short video for each case.

P359 - Morbid Obesity Laparoscopic Sleeve Gastrectomy: A Report of a 5-Year Experience in Weight Loss K. Albanopoulos, M. Natoudi, C. Bartsokas, E. Mantonakis, C. Savvidis, D. Keramidaris, G. Zografos, G. Zografos, E. Leandros University of Athens Medical School, Hippocratio Hospital, Laparoendoscopic Unit, 1st Propaedeutic Department of Surgery, ATHENS, Greece Aim: To present the 5-year follow up results in Laparoscopic Sleeve Gastrectomy (LSG) for morbid obesity. Methods: One hundred sixty three (163) patients (66 men, 97 women) underwent LSG in our specialized unit from January 2008 to December 2009. The mean age was 38.98 years old (range of 18-64) and the mean preoperative Body Mass Index (BMI) was 48.34 kg/m2 (range 35.0-78.6). From our 163 patients, 79 were lost during follow-up, resulting in 84 patients included in the long-term follow-up. Results: Mean BMI, weight loss and weight loss percentage during follow-up is shown in the following table. BMI values preoperatively and during the 1st, 3rd, 6th, 12th, 18th month, 2nd, 3rd, 4th, 5th year of follow-up were 48.34, 42.9, 38.28, 34.42, 31.04, 29.5, 29.24, 29.44, 30.25, 30.92 respectively. Weight loss values during the 1st, 3rd, 6th, 12th, 18th month, 2nd, 3rd, 4th, 5th year of follow-up were 15.73, 29.16, 40.32, 50.11, 54.65, 55.37, 55.03, 52.9, 50.52 respectively. Weight loss percentage during the 1st, 3rd, 6th, 12th, 18th month, 2nd, 3rd, 4th, 5th year of follow-up was 11.11, 20.74, 28.68, 35.6, 38.61, 39.09, 38.71, 37.27, 35.65 respectively. Seven patients (4.3%) presented with postoperative complications as follows: 2 (1.2%) staple line leaks, 3 (1.8%) haemorrhages and 2 (1.2%) intra-abdominal abscesses. Five patients (5.9%) were re-operated, while no peri-operative deaths were reported.During the 4th year of follow up, one patient regained weight, presented with aggravation of his type-II Diabetes Mellitus and underwent One-Anastomosis Gastric Bypass. One patient died from irrelevant to operation cause. Conclusion: LSG procedure seems to be an effective bariatric procedure in terms of weight loss after a 5-year follow-up.

M. Natoudi, K. Bananis, L. Alevizos, A. Loizos, G. Zografos, E. Leandros, K. Albanopoulos LaparoendoscopicUnit, 1st Propaedeutic Department of Surgery, Hippocratio Hospit, ATHENS, Greece Goal: This study aimed to evaluate C-reactive protein (CRP), white blood cell (WBC) count, and and neutrophil (NEU) count in relation to the early diagnosis of major surgical complications after OAGB. Methods: A prospective study of 91 patients who underwent OAGB, as primary procedure or redo operation, during 2012-2015 was performed (20 men and 71 women). Mean age was 41 years old and the mean preoperative BMI was 48.0 Kgr/m2. Measurements of WBC, NEU, and CRP were performed on postoperative days 0, 1, 3, 5, 7, 9, 11, 13 and 15. Results: Major complications were observed in 8 patients (8.8%): 3 patients had anastomosis leak, 1 patient had abscess and 3 patients had bleeding. Both WBC and NEU were correlated with leak or abscess on postoperative day 11. The increase of CRP was statistically significant on postoperative day 5, 7, and 11. Conclusion: CRP detected leak, abscess or bleeding with higher sensitivity and specificity than WBC and NEU in patients who underwent OAGB. However, this study is still in progress, as higher number of postoperative complications is needed, to be able to prove the value of CRP, WBC and NEU counts as accurate markers of the early detection of major complications.

P361 - Morbid Obesity Intrathoracic Migration After Laparoscopic Sleeve Gastrectomy Can it be Controlled? M. Priboi, S. Filip, C. Copaescu Ponderas Hospital, BUCURESTI, Romania Background: A migration of the proximal end of the suture above the level of the diaphragm could be observed in postoperative examinations, indicating a mediastinal herniation of the upper sleeve; this might be identified as a possible cause of specific postoperative symptoms like persistent regurgitation, heartburn or even total obstruction.AIM: To identify the strategy to prevent, diagnose and treat the intrathoracic migration after LSG. Methods: We have conducted a prospective study to identify the specific conditions that promote intrathoracic migration and the possibilities to prevent and treat it.The results of the routine intraoperative stomach fixation to pre-pancreatic fascia were analyzed in a cohort of five hundred consecutive obese patients who undergone laparoscopic sleeve gastrectomy (LSG) in 2015 and compared with the outcomes of a similar group of 500 LSG patients having no fixation of the gastric tube. Results: Extensive data on the exact geometrical behavior of sleeve stomachs and other parameters have hardly been investigated. The three-dimensional gastric shape and its possible changes after LSG represented a diagnostic challenge. Even in cases associated with specific symptoms, presence of sleeve migration was significantly underestimated by both conventional radiology and upper GI endoscopy, CT being more accurate for the detection of morphological alteration.Radiological signs of mediastinal migration of the upper sleeve were more often identified in the non-fixating group (48%) versus the fixating group (14%). Symptomatic migration was present in 16% of the non-fixating group while in the group of gastric tube fixation was only 4, 5%.Still, prevention is the key and besides diagnostic and repair of simultaneous hiatal hernia when identified, the stomach fixation strategy in LSG is easy to use, safe and can reduce complications arising from improper positioning and gastric tube alterations. Conclusion: An operative and post-operative protocol that allows new insights into the anatomical behavior of the stomach after LSG was proposed. Routine intraoperative stomach fixation to the pre-pancreatic fascia reduced the rate of postoperative mediastinal migration of the upper sleeve. Further studies are needed to assess the real mechanisms responsible for this complication and the effectiveness of this and other preventive measures.

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Surg Endosc

P362 - Morbid Obesity

P364 - Morbid Obesity

One-Anastomosis Gastric Bypass: Results of Two-Year FollowUp

Laparoscopic Gastric Plication for Morbid Obesity Treatment

M. Natoudi1, L. Alevizos1, E. Mantonakis2, J. Papailiou1, C. Loizou2, G. Zografos1, E. Leandros1, u. K. Albanopoulos1

I. Havrysh1, V. Lukavetskiy2, Y. Havrysh1 1

Lviv Regional Hospital, LVIV, Ukraine; 2Lviv National Medical University, LVIV, Ukraine

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LaparoendoscopicUnit, 1st Propaedeutic Department of Surgery, Hippocratio Hospit, ATHENS, Greece; 2University of Athens Medical School, Hippocratio Hospital, ATHENS, Greece Aim: To present the short term (2-year) follow-up results of One-Anastomosis Gastric Bypass (OAGB). Patients: Seventy two (72) patients underwent OAGB, as primary procedure or redo operation, in our Unit between January 2012 and June 2013. Mean age was 43.5 years (range 19 to 61) and mean preoperative Body Mass Index (BMI) 49.1 kg/m2 (range 35 to 77.8). Complete follow-up records were obtained for 44 patients (14 men, 30 women). Weight loss was assessed at the 1st, 3rd, 6th, 12th, 18th and 24th postoperative month. Results: BMI values (Kg/m2) preoperatively and during the 1st, 3rd, 6th, 12th, 18th month and 2nd year of follow-up were 49.1, 42.7, 37.9, 34.3, 29.9, 28.5, and 27.7 respectively. Weight loss values (Kg) during the 1st, 3rd, 6th, 12th, 18th month and 2nd year of followup were 16.3, 30.3, 42.7, 53.9, 59.2, and 59.9 respectively. Weight loss percentage during the 1st, 3rd, 6th, 12th, 18th month and 2nd year of follow-up was 12.1, 22.2, 30.4, 38.6, 41.8 and 42.9 respectively. All operations were completed laparoscopically. Two (2.7%) anastomotic leaks were recorded. One patient presented with anastomotic stricture and was treated with endoscopic dilatations. One patient presented with anastomotic ulcer and was conservatively treated. Eight patients (18.2%) regained weight (2-7 kg) over the follow-up period: 7 after the 18th month and 1 after the 12th month. Conclusions: OAGB seems to be a successful bariatric operation in terms of weight loss over the first two years. Longer follow-up studies with more patients are needed to further evaluate postoperative outcomes and the impact of OAGB on patients’ obesity-related comorbidities.

Aim: To study the influence of Laparoscopic Gastric Plication (LGP) for some metabolic parameters in patients with morbid obesity. Our experience. Methods: From 2010 to 2015 we performed 55 LGP in obesity patients with out diabetes mellitus. The patients age range from 21 to 65 years, there were 20 males and 35 females. BMI of patients ranged from 36 to 70 kg/m2. We obtained data about duration of obesity, previous treatment, age, weight, height, BMI, fasting glucose (FG), HbA1c, levels of cholesterol and lipoproteins, leptin level before operation and every 6 months after surgery. Before and every 12 months after surgery, patients filled out SF-36 Health Survey and our own questionnaire. Results: Duration of operation was from 63 to135 min. Mean hospitalization time - 4 days. There were no mortality after surgery. One patient had spleen injury during operation and one had pulmonary embolism, both successfully treated. After 1 year of follow-up, we found: normalization of leptin level in 26% of patients, normalization of lipids levels - 79% of patients, normalization of cholesterol - 60% of patients, mean EWL 32%. After 2 years mean EWL 48%. After 3 years of follow-up mean EWL 51% and after 5 years mean EWL 55%. Three years after surgery, we conducted a survey of life quality of through own questionnaire and SF-36. Fifteen patients (27%) noted depression before surgery and three(5.4%) one year after. Headaches in 17 (30%) patients before surgery and 2 (3,6%) after surgery. Dyspnoea at physical activity in 30 (54%) patients before surgery and in 12 (21.8%) after surgery. Conclusions: The results give reasonable grounds for assumptions about the positive impact of LGP on the morbid obesity course: improvement of carbohydrate and lipid metabolism.

P363 - Morbid Obesity

P365 - Morbid Obesity

Improvement of Nonalcoholic Fatty Liver Disaese After Bariatric Surgery Measured by Transient Elastography

Long and Narrow Gastric Pouch in Laparoscopic Proximal Gastric Bypass: Effect on Weight Loss and Dumping Syndrome

F. Nickel1, C. Tapking1, J. Sollors2, L. Kohlhas1, S. Mu¨ller2, A.T. Billeter1, J.D. Senft1, H.G. Kenngott1, G.R. Linke1, L. Fischer1, B.P. Mu¨ller-Stich1

A. El-Attar

1

University of Heidelberg, HEIDELBERG, Germany; 2Salem Medical Center, HEIDELBERG, Germany

Background: Bariatric surgery aims at reducing comorbidities associated with morbid obesity. This study aims at evaluating changes of Non-alcoholic fatty liver disease (NAFLD) and Non-alcoholic steatohepatitis (NASH) with transient elastography (TE) after bariatric surgery. Liver stiffness measured via TE is correlated with degree of liver fibrosis. Materials and methods: In 100 patients scheduled for bariatric surgery liver stiffness was evaluated via TE preoperatively and postoperatively after sleeve Gastrectomy or gastric bypass). Clinical data included body mass index (BMI), excess weight loss (EWL), age, sex, comorbidities, Edmonton Obesity Staging System (EOSS) and WHO-classification of obesity as well as liver fibrosis scores based on laboratory parameters. Results: BMI was reduced significantly after bariatric surgery (48.6 ± 7.4 kg/m2 vs. 36.8 ± 6.8 kg/m2 (6 months, p \ 0.001) vs. 34.1 ± 6.8 kg/m2 (12 months, p \ 0.001)).After a median follow-up of 10 months post bariatric surgery TE showed a significant improvement of liver stiffness values (13 ± 10.4 kPa vs. 7.7 ± 5.1 kPa, p = 0.007). Liver fibrosis scores improved as well postoperatively (AST/ALT-ratio: 0.8 ± 0.3 vs. 1 ± 0.3 (6 months, p \ 0.001) vs. 1.1 ± 0.4 (12 months, p \ 0.001); NAFLD-Fibrosis-Score: -1 ± 1.5 vs. -1.6 ± 1.3 (6 months, p = 0.03) vs -1.7 ± 1.3 (12 months, p = 0.04). Conclusions: Bariatric surgery had positive effects on NAFLD and NASH already shortly after surgery with BMI reduction in the usual range described in the literature. In the future prospective RCTs and longterm studies should follow to specify the influence of different types of operations on liver diseases after bariatric surgery.

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Tanta University, NEW CAIRO, Egypt Laparoscopic proximal gastric bypass has been regarded for a long time as the gold standard treatment for morbid obesity and its comorbidities. With the presence of the newer strong options, like the gastric sleeve and the mini gastric bypass, refinement of the technique are taking place to avoid its current problems. Early and delayed gastric dumping are known problems after proximal gastric bypass, an area where dietary adjustment was the commonly feasible solution. Modifications in the technique by providing the patient with a long narrow pouch might help the problem by slowing the gastric emptying time, should it keeps the weight loss in an acceptable range. Aim: The aim of this study is to evaluate whether constructing a long and narrow pouch can decrease the incidence of early and late dumping after laparoscopic proximal gastric bypass and to evaluate its impact on the weight loss rates. Patients and methods: In this prospective study, 42 morbidly obese patients with average BMI of 44 kg/m2 were recruited. All recieved standardized long narrow pouch of 8 cm length created over 36 Fr pougy. The 3, 6, 9 and 12 months follow up data regarding their % weight loss in addition to a questionnaire for early and delayed dumping symptoms existence and severity were collected. The data were compared to our records of a previous larger (112 patients) study on globular 35 ml pouches in which similar data were collected. Results: Percentage Weight loss after 3, 6, 9 and 12 months were 13, 24, 47 and 62% respectively. The weight loss data showed no statistically difference from the compared group. Early dumping symptoms were recorded in 12.6% of the studied group with 83.3% recorded the symptoms as mild. Late dumping symptoms were recorded in 8% of the studies group, all of them recorded mild symptoms. The dumping rates were significantly less on comparison for the early symptoms but not the delayed symptoms. Conclusion: Performing long and narrow pouches during laparoscopic proximal gastric bypass may help reducing the incidence of early dumping with acceptable weight loss rates.

Surg Endosc

P366 - Oesophageal and Oesophagogastric Junction Disorder

P368 - Oesophageal and Oesophagogastric Junction Disorder

Biological Mesh for Laparoscopic Hiatal Hernia Repair. Five Years Experience in Colombia

Mesh Repair for Prevention of Recurrence in Laparoscopic Redo Fundoplication

E. Dorado

V.V. Grubnik, A.V. Malynovskyi, V.V. Ilyashenko, S.A. Uzun

Fundacion Valle del Lili, CALI, Colombia

Odessa national medical university, ODESSA, UKRAINE, Ukraine

Introduction: Gastroesophageal reflux disease is associated with 20% hiatal hernia. The use of mesh in larger defects to 4 cm has been shown to reduce recurrence in [50%, but also known to defects [7 cm this percentage decreases. oesophagogram is useful to determine the size of the hernia and if necessary use mesh. Methods and Materials: Descriptive, retrospective. cohort of 28 patients diagnosed with GERD and hiatal hernia who required repair with mesh. the average age was 50 years, 80% female, average size of hernias 4 cm and two patients with 7 cm, were corrected with biological mesh preformed primary closure of the pillars, and subsequent placement fixed with 4 points Ethibond. Results: Descriptive retrospective. 70% were women, average age 50 years, the size of the hernia was 5 cm and only two patients showed 7 cm defects. Photo 2. Biological mesh was used, and fixed to the pillars with Ethibond stitch. Patients were evaluated with endoscopy at 6 months a year and two years of the procedure. none had dehiscence of fundoplication or reappearance of reflux symptons. Only two patients with defects [7 cm after an episode of vomiting and a cough showed migration of the fundoplication to the thorax. two patients did not have reflux and were taken to diagnostic laparoscopy without evidence mesh complications . Conclusions: Laparoscopic repair with biological mesh in hiatal hernia has proven effective, with few complications in patients with defects [ 4 cm. Also known to giant defects have increased risk of relapse in spite of the mesh. The advantages of biological implant is no penetration to other organs which is the major complication of other materials.

Background: Outcomes after redo fundoplication (RF) in recurrent GERD may have lower success rate with higher morbidity compared to primary fundoplication (PF). Aim of the study was to evaluate the role of mesh in RF. Methods: We prospectively followed 54 patients (34 women and 20 men, mean age 51,1 ± 3,4 years) with RF. Indications for RF were: disruption of fundoplication wrap and hiatoplasty with mediastinal migration (25 patients), paraesophageal recurrent herniations (18 patients), slipped wraps (5), isolated disruption of wrap (8). Mean time interval between PF and RF was 34,2 months (range, 2 months - 10 years). In 30 patients we used lightweight mesh for hiatal repair (group I), in 24 patients hiatal closure was performed by nonabsorbable sutures (group II). Results: All 54 RF were completed laparoscopically. Mean operative time was 79,1 ± 10,0 min. There were no perforations of either esophagus or stomach. Mean hospital stay was 3,6 ± 0,5 days in both groups. 52 patients were followed with a mean period of 25,7 ± 4,3 months. Mean De Meester score decreased from 92,5 ± 5,2 to 22,4 ± 4,9 (p \ 0,05). A significant decrease in symptom score from 31,0 ± 2,8 to 10,3 ± 2,4 (p \ 0,01) was detected. There were no recurrent hernias in group I. Recurrent hernias were detected in 2 patients (8,3%) in group II. Conclusions: Laparoscopic RF leads to acceptable objective outcome. The use of lightweight mesh may improve results of RF and decrease the rate of recurrences, compared to PF.

P367 - Oesophageal and Oesophagogastric Junction Disorder

P369 - Oesophageal and Oesophagogastric Junction Disorder

Minimally Invasive Three Fields Esophagectomy for Patients with Incomplete Myotomy and Severe Esophageal Dilatation. Experience in Colombia

Laparoscopic Repair of Giant Hiatal Hernias Using New Mesh: Long-Term Results with a Minimal Follow-Up Period of 3 Years

E. Dorado

Odessa national medical university, ODESSA, Ukraine

Fundacion Valle del Lili, CALI, Colombia

Background: Giant hiatal hernias [i.e. with hiatal surface area (HSA) exceeding 20 cm2] is still a challenge for laparoscopic surgery as recurrence rate following mesh repair is 20–40%. Thus, development of new method of prosthetic repair is necessary. This method must also prevent complications. Aim of the study was to assess long-term results of laparoscopic tension-free repair of giant hiatal hernias with a fundamentally new prosthesis. Methods: Forty four laparoscopic repairs of giant hiatal hernias were performed starting from 2010. From them, 40 patients were evaluated with a mean follow-up period of 47.0 ± 7.8 months (range 36–61). A half of these patients had follow-up period exceeding 48 months. Symptom questionnaires, barium studies, endoscopic examinations, and 24 h pH testing were used pre- and postoperatively. Mean HSA was 37,5 ± 15,6 cm2 (range 21,7–75,4). The posterior tension-free hiatal repair was performed with a new prosthesis Rebound HRD-Hiatus hernia (Minnesota Medical Development, USA) which was fixed to the crura with 3–5 separated sutures. This prosthesis is heart-shaped lightweight polytetrafluorethylene (PTFE) mesh with peripheral nitinol frame. Key advantages of this revolutionary technique are: 1. Peripheral nitinol frame (with shape memory) maintaines week tissues of the diaphragm, thus, prevening recurrence, 2. Easy fixation, 3. Small risk of oesophageal complications as prosthesis is made from new generation of lightweight PTFE (MotifMESH, Proxy Biomedical, USA), 4. Easy insertion through 10-mm trocar. Nissen fundoplication was performed for every patient. Results: All procedures in the cohort were successfully completed without any complications. Mean time of fixation of the prosthesis was 24,8 ± 5,6 min (range 15–35). Longterm follow-up showed absence of anatomical recurrences, and oesophageal complications (i.e., persisting dysphgia, strictures, and erosions). There were only 2 symptomatic (5%) and 1 asymptomatic (2,5%) reflux recurrences. Conclusions: New method of laparoscopic repair of giant hiatal hernias is highly effective as provides absence of anatomical recurrences and complications at a minmum 3 years long-term follow-up. It may be compared with other methods of repair in randomized controlled trials.

Introduction: Achalasia is an esophageal motor disorder that is diagnosed with manometry, endoscopy and barium swallom. In cases with mild to moderate esophageal dilation, Heller myotomy with partial fundoplication is an effective treatment. But in patients with severe dilatation despite performing myotomy, or incomplete myotomy, they will suffer disphagia or regurgitation and compromises their quality of life. Main: Describe three cases of patients with failed Laparoscopic Heller Myotimy Methods: Case 1 male patient with severe esophageal dilatation, he was operated one year ago of laparoscopic myotomy with Dor type fundplication without dysphagia but severe regurgitacion. Case 2 patient with incomplete myotomy with severe dysphagia postoperatively and six months later with aphagia, and grade 3 esophageal dilation, is scheduled for surgery. Case 3 A female patient was performed myotomy and toupet fundoplication, she had seven months asymptomatic but started with mild dysphagia to solids, surgeon order 3 dilations and she felt improvement of this condition, but two months later readmitted with severe dysphagia and grade 3 esophageal dilation. Result: All patients had enteral nutritional recovery, preoperative endoscopy and barium swallow. They were scheduale to Minimally invasive Three fields esophagectomy and gastric rise. First step back prone thoracoscopy, second laparoscopic release of adhesions, sleeve gastrectomy and third cervicotomy stomach and esophageal anastomosis laterolateral. Operating time 4 h. Drains: cervical and right thoracostomy, tube feeding for nutrition and the third day esophagogram. At this time removed chest tuve and started liquid per oral. 5 to 8 postoperative day is discharged with liquefied diet Per month it is advanced to soft. Results: No patient s with fistula, 8 days of hospital stay, transient hoarseness in 1 patient ans at second months tolerance normal diet. Conclusion: In patients with incomplete myotomy or severe esophageal dilatation and severe symptoms of reflux, the best option is video-assisted esophagectomy, this must be done by advanced laparoscopic to ensure good results and zero mortality.

A.V. Malynovskyi, V.V. Grubnik

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Surg Endosc

P370 - Oesophageal and Oesophagogastric Junction Disorder

P372 - Oesophageal and Oesophagogastric Junction Disorder

Antireflux Mucosectomy (Arms) in the Treatment of Patients with Gerd and Columnar-Cell Lined (barrett‘s) Esophagus. First Experiences

Per-Oral Endoscopic Myotomy Kickoff and the Results of the First Case of Vajira Hospital

D.I. Vasilevskiy1, S.F. Bagnenko1, A. Smirnov1, A.S. Lapshin1, S.U. Dvoretskiy2, A.S. Pryadko3

A. Tansawet, S. Techapongsatorn, W. Kasetsermwiriya, I. Laopiumtong, S. Srimontayamas, T. Yongpradit, P. Teawprasert Navamindradhiraj University, BANGKOK, Thailand

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First Saint Petersburg I.P. Pavlov State Medical University, SNT. PETERSBURG Russia; ST. PETERSBURG, Russia; 3Leningrad Regional Clinical Hospital, ST. PETERSBURG, Russia Background: New technology in the treatment of GERD - the Anti-reflux gastro-esophageal junction endoscopic mucosectomy (ARMS) was first described by H. Inoue in 2014. Preliminary results of this method were vastly encouraging. Materials: Six patients with typical symptoms of GERD and short segment of columnar-cell lining of esophagus were managed by ARMS technique. Hiatus hernia wasn’t observed in any of the patients included in the study group. Patients were previously treated with PPI for more than three years. In all the above cases endoscopic resection of columnar-cell mucosa along with 2/3rd of gastro-esophageal junction were performed, as in the treatment of Barrett‘s esophagus. The main idea of this procedure relies on the formation of the short controlled stricture, which plays a vital role as an anti-reflux valve. Decrease in the diameter of the gastro-esophageal junction leads to the decreased reflux and GERDassociated symptoms. In the ARMS technique a HD-videoscope 29-i10 Pentax with distal cap, knifeI-type (Finemedics), carbon-dioxideinsufflator (Medivators), ERBE-electrosurgical unit-300S were used. During the post-operative period all patients were treated with PPI for four weeks. Results: Good subjective results three months post-surgery (anti-reflux endoscopic gastro-esophageal junction mucosectomy) were observed in four out of six patients. In the remaining two persons postoperative symptoms of GERD were noted but with varying reduced intensity. During control endoscopic investigation reduced strictures of diameter = 9-10 mm were noted in all patients without any signs of dysphagia. Post-operative regeneration of squamous epithelium in the esophagus was also noted in all cases. Conclusion: Short-term results of ARMS technique in the treatment of patients with GERD and columnar-cell lined esophagus are satisfactory and enables to use this technique in day-to-day practice. Long-term effects of the ARMS technique are yet to be evaluated.

Aims: To report our techniques and the results of our first per-oral endoscopic myotomy (POEM) case. Methods: We performed POEM in the 48-year-old female achalasia patient, who was suffered from dysphagia symptom for 2 years. Under general anesthesia, an endoscopic examination was performed to assess the entire anatomy of esophagus and esophagogastric junction (EGJ). Our POEM techniques can be divided into 2 major steps- submucosal dissection and myotomy- all was performed with Triangle-tip knife (TT knife, Olympus, Japan). Esophageal mucosa was incised to gain access into submucosal space at 2 o’clock position and approximately 10 cm above the EGJ. A mixture of saline and indigo carmine was injected into submucosa space to separate the mucosa out of muscular layer. The submucosal space was dissected into gastric side for 2 cm beyond the EGJ. We started myotomy just distal to the entry incision, targeting the circular fiber of esophageal muscle. The myotomy was carried on to the end of submucosal tunnel. The procedure was finished by mucosal incision closing with multiple hemostatic clips. Results: The procedure was successfully performed without any complication and the patient recovered uneventfully. Her symptoms were significantly improved- the pre- and post-operative Eckardt score were 8 and 1 point respectively. At 3 months follow up, no change of the Eckardt score nor gastroesophageal reflux was detected. Conclusions: the POEM is a feasible procedure to be performed in the advance endoscopic unit. The results from our first case was very impressive, however, more POEM cases need to be collected for an accurate assessment of this procedure.

P371 - Oesophageal and Oesophagogastric Junction Disorder

P373 - Oesophageal and Oesophagogastric Junction Disorder

Value of Pepsin in Saliva and Oropharyngeal Ph -Metry to Predict the Outcome of Antireflux Surgery in Patients with Primary Extraesophageal Symptoms

Use of Self Expandable Plastic Stents in Management of Refractory Benign Oesophageal Strictures

O.O. Koch1, M. Weitzendorfer1, A. Tschoner,1, S. Antoniou2, K. Emmanuel1, P. Pointner3 Sisters of Charity Hospital, LINZ, Austria; 2Department of General ¨ NCHENGLADBACH, and Visceral Surgery/Neuwerk Hospital, MO Germany; 3Department of General Surgery/General Hospital Zell am See, ZELL AM SEE, Austria 1

Aims: The aim of this study was to evaluate the significance of pepsin in saliva and pharyngeal pHmonitoring as tests to predict surgical outcome of patients with GERD and primary extraesophageal symptoms. Methods: Ten consecutive patients with documented chronic GERD and primary extraesophageal symptoms despite treatment with a proton pump inhibitor received laparoscopic anti- reflux surgery (LARS). 24-hour esophageal impedance pH- monitoring (MII-pH) and high-resolution esophageal manometry (HRM) data were documented preoperatively and 3 months after surgery. In addition, pre- and postoperatively an ENT examination was performed, including assessment of Belafskys Reflux Finding Score (RFS). Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Evaluation of extra-esophageal symptoms was carried out, using the standardized Belafsky Reflux Symptom Index (RSI) questionnaire. Three times during the 24-hMII-pH monitoring, pepsin - determination in saliva (Peptest, RDBiomed TM) was accomplished. Simultaneous to the 24-h-MII-pH monitoring and collection of saliva samples, detection of oropharyngeal reflux events was performed using the Restech Dx-pH Measurement System TM (Dx-pH). The data before and after procedure were compared. Treatment failure was defined with postoperative pathologic RFS or RSI score and improvement of GIQLI of less than 10 points. Results: Before LARS all ten patients had a pathological ENT examination, RSI score and MII-pH data. After surgery all patients showed a normal distal acid exposure. Four patients were defined as treatment failure. In these patients, pepsin concentration in saliva reduced from a mean of 1486 ng/ml to 1058 ng/ ml, and mean oropharyngeal pH- monitoring data showed a lower acid exposure than preoperatively. In patients defined as treatment success, mean value of pepsin decreased from 1476 ng/ml to 324 ng/ml but mean oropharyngeal pH- monitoring data showed a higher acid exposure than preoperatively. Conclusion: Neither Pepsin in saliva nor oropharyngeal pH- monitoring seem to be able to predict the postoperative outcome of patients with GERD and primary extraesophageal symptoms. Nevertheless significant reduction of pepsin in saliva could be a marker for treatment success. However, adequately powered studies are required to reach firm conclusions.

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M.A. Selimah, M.R. Abo Elsoud Medical Research Institute, ALEXANDRIA, Egypt Benign oesophageal stricture is a common cause for dysphagia in adults.It can negatively influence the patient’s quality of life and may cause important complications such as malnutrition, weight loss, and aspiration. Benign oesophageal strictures are caused by various disorders and procedures such as gastroesophageal reflux disease, surgery (anastomotic stricture), radiotherapy, ablative therapy, caustic ingestion, and pill-induced injury. Aim of the work: The aim of the study is to assess the efficacy of self expandable plastic stents (SEPS) insertion in refractory benign oesophageal strictures in patients admitted to the endoscopy unit of the medical research institute hospital. Patients and methods: Nine patients with refractory benign oesophageal strictures were included in the study,7 patients with benign oesophageal stricture and 2 patients with oesophageal leaks. SEPS was inserted in all patients. Results: All patients were dysphagia free after insertion of SEPS and complications reported were one patient with slipping of the stent and 2 patients with ulceration. Conclusion: The use of SEPS in the management of benign refractory oesophageal strictures appears to be promising with high clinical success rate and few manageable complications.

Surg Endosc

P374 - Oesophageal and Oesophagogastric Junction Disorder

P376 - Oesophageal and Oesophagogastric Junction Disorder

Laparoscopic Paraesophageal Hernia Repair with Absorbable Polyglactin Mesh as a Technique to Improve Outcomes and Avoid Mesh-Related Complications

Mesh Application in Antireflux Surgery: A Six-Year Experience

H. Mercoli, S. Perretta, S. Tzedakis, A. d’Urso, D. Mutter, B. Dallemagne Strasbourg university hospital, IRCAD - IHU, STRASBOURG, France Background: Laparoscopic paraesophageal hernia repair (LPHR) has a recurrence rate up to 66%. Prosthetic mesh reinforcement is controversial since complications such as esophageal stricture, erosion, and perforation have been described. The aim of this study was to evaluate the mid-term outcomes of an absorbable polyglactine (PL) mesh for large hiatal hernias repair, with particular reference to recurrence and post-operative complications. Methods: Single institution retrospective review of a prospective database of consecutive patients undergoing LPHR with reinforced crural repair with an onlay PL mesh. Subjective outcomes were assessed using the Gastro-Esophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL). Objective follow-up was carried out by videoesophagogram between 6 to 12 months PO. Radiologic recurrence was defined by radiologic herniation greater than 2 cm. Results: From September 2009 to January 2015, LPHR with hiatal PL mesh reinforcement was performed in 49 patients (mean age 68 years ± 13,3; 19 men, 30 women). All but one procedure were completed laparoscopically. The crus was sutured and reinforced with an onlay PL mesh. A fundoplication was performed in 94% of patients: Nissen (25 patients, 51%), Toupet (11 patients, 23%), Collis-Nissen (7 patients, 14%), Collis-Toupet (3 patients, 4%), and Dor (1 patient, 2%). Overall PO complication rate was 16%. Minor complications (Clavien 1-3A) occured in 6 patients (12%), major complications (Clavien 3B-4) in 2 (4%). One patient died from respiratory failure. There were no mesh-related complications. Median follow up was 31 months (1-65) with 81% of subjective follow-up and 61% of both objective and subjective follow-up. Heartburn (p \ 0,001), chest pain (p \ 0,001), anemia (p \ 0,001), dyspnea (p \ 0,001) and PPI use (p \ 0,001) improved significantly. Mean GERD-HRQL score was 7,2/50, with 80% of patients being satisfied. Objective radiologic recurrence rate was 33%. All but one recurrence were \ 5 cm with no impact on quality of life. Conclusion: LPHR with PL mesh is safe and effective, combining the advantage of preventing early migration of the wrap, and avoiding long-term synthetic or biologic meshrelated complications. Longer follow-up and larger studies will define the role of this promising technique.

D.I. Vasilevskiy1, S.F. Bagnenko1, A. Smimov1, A.S. Lapshin1, S.U. Dvoretskiy2, A.S. Pryadko3, V. Kulagin4, C. Aruldas1 1 First Saint Petersburg I.P. Pavlov State Medical University, SNT. PETERSBURG, Russia; ST. PETERSBURG, Russia; 3Leningrad Regional Clinical Hospital, ST. PETERSBURG, Russia; 4Janelidze Research Institute of Emergency medicine, ST. PETERSBURG, Russia

Introduction: Hiatal closure is one of the most difficult problems of antireflux surgery. Materials: From 2010 to 2015 we performed laporoscopic surgery in 319 patients with GERD. In order to prevent the recurrence of GERD symptoms, mesh-prostheses were used in 173 cases (54.2%). In all patients, the ‘mesh-reinforced’ technique was applied. The indications for mesh hiatal closure were: (i) muscle atrophy, (ii) scarring of diaphragm crura, and (iii) hiatal diameter over 5 cm. In some 17 cases meshes of combined materials (‘Vipro’, ‘Ultrapro’) were used and in other 156 cases polypropylene meshes (‘Prolen’, ‘Esfil’) were employed. The prosthesis was fixed with a stapler behind or in front of the esophagus (without touching it). Circular prostheses have never been used before for the prevention of dysphagia or for the perforation of the esophagus. In the remaining 146 cases (45.8%) where none of these indications were met, the hiatal closure was performed by simple sutures. Results: Recurrence of GERD symptoms occurred in 7 cases (5.1%) after the ‘meshreinforced’ hiatoplasty (only after ‘Vipro’or ‘Ultrapro’ mesh use) and in 11 cases (7.5%) after a simple cruroraphy. The total number of relapses was 18 (5.6%) out of 319 patients. No complications from the usage of prostheses were noted. Conclusion: If hiatal crura malfunction exists and hiatal opening exceeds 5 cm, the ‘meshreinforced’ method of hiatal closure is safe and allows for decreasing the recurrence rate after the surgical treatment of GERD.

P375 - Oesophageal and Oesophagogastric Junction Disorder

P377 - Oesophageal and Oesophagogastric Junction Disorder

Our Surgical Indication and Results of Laparoscopic Anti-Reflux Surgery for Gerd Patient

Laparoscopic Repair of Large Paraesophageal Hernia

T. Suwa, S. Inose, K. Kitamura, T. Matsumura, E. Totsuka, M. Koyama, K. Karikomi, K. Okada, N. Nakamura, S. Masamura KASHIWA KOUSEI GENERAL HOSPITAL, KASHIWA, CHIBA, Japan Introduction: Laparoscopic anti-reflux surgery for GERD patients are still unusual among Japanese gastroenterologists. We have established the surgical indication for GERD patients using The Reflux Test. Surgical indication: The Reflux Test At the standing position a patient swallows 300 ml barium solution. After total solution goes into stomach, a patient lies down at the flat position. Then a patient changes the position to left lateral decubitus position, flat position, right lateral decubitus position and flat position again. During this procedure, gastro-esophageal reflux was evaluated and divided into severe, moderate and slight case. The anti-reflux surgery was recommended to the moderate and severe cases. The Characteristic Features of our Procedure: Floppy Nissen fundoplication, No use of bougie device or taping technique for esophagus, Rotation of scope site Results: We have performed this procedure in 74 cases. This procedure needs 2 surgeons (the operator and the assistant (scopist)). The mean operation time was 115 min. A favorable outcome was assessed by radiograms performed during hospital stay. Median follow-up period of this study was 37 months (1-73 months). In 4 cases (5.4%) PPI was restarted before 6 months after the anti-reflux surgery. In 16 cases (21.6%) PPI was restarted after the anti-reflux surgery during the whole follow-up period of this study. The reflux esophagitis was improved obviously (p = 0.02) after the anti-reflux surgery.

S. Wijerathne, A. Shabbir, J. So, D. Lomanto National University Hospital, Singapore, SINGAPORE, Singapore Introduction: Paraesophageal hernias (PEH) are relatively uncommon and account for 5 to 10% of all hiatus hernias. However, their frequency is presumed to be higher as diagnostic modalities become available. Risks of obstruction, incarceration and strangulation are clear indications for surgical repair. Conventional repair is usually accomplished through large incision over chest or abdomen with associated implications of a sizeable incision. Minimally invasive repair is becoming the preferred approach even though the use and the type of prosthesis is still debatable. We are reporting our experience on laparoscopic large paraesophageal hernia mesh repair. All patients recovered without any complications and remain symptom free. Materials and Methods: Data from 6 patients (2011–2013) were collected and analyzed. All patients were worked up pre-operatively with Computerized Tomography (CT) scan (Fig. 1) and OesophagoGastroscopy (OGD) (Fig. 2). All patients underwent 5 ports laparoscopic repair. The hernia sac was completely excised using a combination of HF energy and ultrasonic device (Thunderbeat, Olympus - Japan), the extra-abdominal content reduced inside the abdomen and the repair was carried out using interrupted non-absorbable suture (Ethibond, Ethicon, USA) to narrow the hiatus and synthetic mesh (n = 3; Parietex Composite Mesh, Covidien, USA) and Biological Mesh (n = 3; Permacol, Covidien USA) to buttress the repair. Mean operative time was 145 min (range 118–206). Results: 4 pts have Type II PEH, 1 each type II and IV. No Intraoperative and postoperative complicatiosn were reported and no recurrence at follow-up. Discussion: Advantages of minimally invasive repair remain undisputed. We propose based on our experience that laparoscopic repair should be more extensively used or repair of para-esophageal hernias. The operative times are comparable and cost effectiveness due to shorter hospital stays and faster return to daily activities are clear.

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P380 - Oesophageal and Oesophagogastric Junction Disorder

Surgical Treatment of Gastroesophageal Reflux Disease

Laparoscopic Hiatal Hernia Repair in the Elderly Patient

O. Usenko, O.S. Tyvonchuk, O.P. Dmiyrenko, V.V. Moskalenko

J.E. Oor1, J.H. Koetje2, D.J. Roks1, V.B. Nieuwenhuijs2, E.J. Hazebroek1

Shalimovs National Institute of Surgery and Transplantation, KYIV, Ukraine Abstract: Evaluate the results of surgical treatment of gastroesophageal reflux disease (GERD) in early and late period after laparoscopic fundoplication. Materials and methods: The study based on the results of examination and surgical treatment of 93 patients with GERD, which was performed laparoscopic fundoplication. The average disease duration was 45,4 ± 11,4 months. Women were 55 (59.1%), men were 38 (40.9%). The age of patients ranged from 20 to 73 years, the average age was 45,3 ± 6,8 years. Endoscopic negative GERD form registered in 50 (53.8%) patients. In 7 (7.5%) patients developed the same complications as ulceration and stricture of the esophagus, Barrett’s esophagus. In 89 (95.7%) patients with GERD was observed on the background of hiatal hernia. During manometry in 6 (6.5%) lower esophageal sphincter pressure (LES) was within the norm (15-20 mm), while others reduced, averaged 9,64 ± 0,97 mm. Hg Average length of LES in patients examined was 1,2 ± 0,6 cm. Laparoscopic Nissen fundoplication made for 82 (89.2%) patients, Toupet - 10 (10.8%). We perfomed posterior crurorraphy, in 7 (7.5%) we developed by application Teflon gasket, in 2 (2.2%) - with polypropylene mesh. Results: Duration of the surgical intervention 196,9 ± 30,3. Avereage DeMeester index was 10,53 ± 0,92, LES pressure 29,80 ± 6,80 mm. Dysphagia in the postoperative period were in 9 (9.7%) patients with uninterrupt passage radiograficly. Complaints were stopped on their own. Deaths, damage of the esophagus, and complications of septic character in any patient we have not seen. Intraoperative complications: bleeding from short gastric vessels in 1 (1.1%), traumatic liver damage 1 (1.1%), left-sided pneumothorax in 3 (3.2%), what was the cause of conversion in 2 patients. Relapse were registered in 4 (4.3%) patients, which was associated with the presence of the original hiatal hernia type III. Patients returned to the reception of drugs in smaller doses, the quality of life was higher than before surgery. Summary: Laparoscopic fundoplication is an effective treatment for patients with GERD, allowing normalize the index DeMeester, increase LES pressure and normalize the status of mucosal esophageal-gastric junction, provides good and satisfying results in 95.7%.

1 St. Antonius Hospital, NIEUWEGEIN, The Netherlands; 2Isala Clinics, ZWOLLE, The Netherlands

Aims: Hiatal hernias (HH) are more common among elderly patients, with an increase in incidence with advancing age. Elderly patients frequently suffer from comorbidity, causing them to have an increased risk of perioperative mortality and morbidity. The aim of this study was to assess the safety of laparoscopic HH repair within elderly patients in two specialised centres. Methods: We performed a retrospective analysis of all patients with a HH operated between July 2009 and May 2015 at two large teaching hospitals in the Netherlands specialised in antireflux surgery and HH repair. Mortality rates and short- and long term morbidity rates were compared between patients aged under 70 years and those aged over 70. Results: A total of 204 consecutive patients underwent laparoscopic HH repair at our institutions, of whom 121 were aged under 70 years and 83 were aged over 70. There was no mortality intraoperatively, nor during 30-days of follow-up. Intraoperative complications occurred in seven patients aged 70 years and over, with no significant differences compared to the patients aged under 70 (8% vs. 4%, p = 0.20). The 30-day morbidity rate did not significantly differ between the two age groups, with an overall postoperative complication rate of 9.3% (10% vs. 8%, p = 0.53). Only length of stay (LOS) was significantly longer in the elderly patients (p = 0.007). Using 75 years as a cut-off value for elderly patients did not change the previous mentioned relations. Performing univariate analysis, only the occurrence of intraoperative complications was associated with 30-day morbidity (p;0.001). Conclusions: In the present study, age was not associated with an increased risk of postoperative mortality and morbidity following laparoscopic HH repair. We can therefore conclude that in a carefully selected cohort of elderly patients, being operated in specialised centres, laparoscopic HH repair is as safe as HH repair in younger patients.

P379 - Oesophageal and Oesophagogastric Junction Disorder

P381 - Oesophageal and Oesophagogastric Junction Disorder

Nissen or Toupet Fundoplication? Five Year Experience

Laparoscopic Repair of Diaphragmatic Hernia with Propylene Pledgets and Toupet Fundoplication: Superior, Safe and Cheap

1

E. Koblihova , M. Kasalicky

2

Central Military Hospital, PRAGUE 6, Czech Republic; 2Faculty of Health Sciences and Social Work, TRNAVA, Slovak Republic

A. Mamound, C.H.M. Clemens, W.R. ten Hove, W.E. Hueting

Aim: Incidence of hiatal hernia (HH) ranges between 25-50% in Western Europe. Prevalence of gastroesofageal reflux (GER) is between 4-10%. Nissen’s 360 fundoplication (NFP) is currently the most common surgical method for GER and HH. Toupet’s 270 fundoplication (TFP) is not so common. The aim of surgery is restoration of the hiatus and mechanical gastroesofageal barrier against gastric reflux. Methods: 157 laparoscopic procedures for HH or for gastroesophageal reflux disease (GERD) were done at the Surgery Department of 2nd Faculty of Medicine of Charles University and Central Military Hospital from 2010 to 2015. The group of patients included 73 men and 84 women with the mean age 53.9 in the range from 20 to 88 years. 109 (69.4%) patients underwent NFP and 48 (30.6%) patients underwent TFP. Patients were followed after 3, 6, 12 and 24 month after the operation. Symptoms such as heartburn, dysphagia, belching, bloating or recurrence of HH or GERD were collected prospectively and analyzed retrospectively. Results: Similar rates of considerable improvement were observed after three months from the surgery. Disease recurrence was observed in 22 patients (14 after NFP, 8 after TFP) with satisfactory response to PPI medication. Laparoscopic rehiatoplasty and refundoplication according to Nissen were performed in 14 patients with HH recurrence with/without the reflux (8 after NFP, 6 after TFP). Conclusion: Laparoscopic antireflux surgery of GERD and HH is safe and associated with very low morbidity and minimal mortality. Both NFP and TFP have similar effect on restoration of mechanical gastroesofageal barrier against gastric reflux with significant effect on resolution of GERD and HH symptoms and improvement of patient’s life quality. Supported by MO 1012.

Aims: This study aimed to asses the results of laparoscopic repair of diaphragmatic hernia in two groups: group with propylene pledgets for the strengthening of the cruroraphy and group without propylene pledgets. Methods: A retrospective study was performed on all patients with diaphragmatic hernia repair, in our hospital between January 2011 and November 2015. Preoperative and operative variables, complications and anatomical recurrence were evaluated. Postoperative data were gathered using GERD-HRQL, dyspnea-index, Visick-score and subjective patient opinion. Results: Until November 2015, 176 patients; 125 females, median age 60 years (18-92) underwent repair of diaphragmatic hernia with complete hernia sac resection. 104 patients had a reinforcement of the cruroraphy with prolene pledgets, 46,2%, for a type I, 8,7% for a type II, 14,4% for a type III and 30,8% for a type IV hernia diaphragmatica. From the 72 patient in the group without prolene pledgets, 41,7% had a type I hernia diaphragmatica, 26,4% a type II, 11,1% a type III and 20,8% had a type IV. The total anatomical recurrence rate was 7/176 (3,98%), 2/104(1,9%) in group with propylene pledgets and 5/72(6,9%) in group without propylene pledgets. In these five years of follow-up (median 23 months) no cases of complications related to the propylene pledgets were observed. Mortality rate was zero. Conclusions: In our regional referral center a decrease of recurrence and postoperative symptoms was observed in patients after laparoscopic repair of hernia diaphragmatica with propylene pledgets compared to a group without propylene pledgets. An improved, safe and cheap method according to basic principles of hernia surgery.

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Alrijne Zorggroep, LEIDEN, The Netherlands

Surg Endosc

P382 - Oesophageal and Oesophagogastric Junction Disorder

P384 - Oesophageal and Oesophagogastric Junction Disorder

An Unusual Cause of Halitosis

Laparoscopic Repair of Large Hiatal Hernias with Autologous Fascia Lata Graft: Initial Experience with the Surgical Technique

G.J. Bathgate, M. Aboul Enein, R. Dixon-Loe, Y. Abdulaal, H. Ali Maidstone & Tunbridge Wells NHS Trust, MAIDSTONE, United Kingdom

¨ .P. Horva´th, A. Vereczkei A. Papp, O Medical Faculty of Pe´cs University, PE´CS, Hungary

Introduction: Prosthetic mesh is commonly used to reinforce closure of large hiatal defects in hiatus hernia repair in current surgical practice. This may be associated with reduced rates of hernia recurrence but stricture formation and erosion are uncommon complications. Case report: A case of mesh erosion is described occurring eight years after mesh-reinforced hiatus hernia repair. A female patient with a giant hiatus hernia underwent repair with simple cruroplasty and fundoplication in her early 30 s. Following recurrence four years later, a redo repair with PTFE mesh reinforcement was undertaken. After a further eight years, she presented with progressively worsening halitosis. Mesh erosion was identified at endoscopy. The mesh was found to have eroded through the full thickness of the oesophageal wall but due to complete external healing of the erosion tract, this presented insidiously without clinical evidence of free oesophageal perforation. Few case reports exist describing the same phenomenon. The patient was managed with elective endoscopic removal of the mesh, without the need for invasive intervention. Complete resolution of halitosis was reported following the procedure, with no symptoms to suggest significant recurrence of gastro-oesophageal reflux. Conclusion: This case is notable in chronicling the outcomes of serial surgical procedures to manage a giant hiatus hernia in a single patient. It prompts us to reflect on key considerations relevant to selecting the optimal approach to managing this condition in the individual patient. Finally, the symptom of halitosis which heralded the discovery of mesh erosion in this case should be considered as an unusual presenting feature of gastrointestinal disease.

Background: In order to reduce high recurrence rates observed after laparoscopic repair of large hiatal hernias, several techniques were developed. The most accepted method is the mesh hiatoplasty. Although series showed lower recurrence rates in favor of mesh hiatoplasty compared to primary repair, mesh related complications are also published. Patients and Methods: Two cases with symptomatic, large recurrent hiatal hernia were treated with reinforced suture repair of the pillars with autologous fascia lata patches. The hiatal closure was performed in the ordinary fashion, with was covered with a 5 9 7 cms large fascia lata patch, harvested from the right distal lateral thigh. The patch was fixed with the combination of sutures and hernia staples. Results: Operation times were 169 and 186 min. There were no procedure related complications or mortality. The postoperative length of stay was 4 days. Both patients completed the annual follow-up visits and so far no symptomatic or radiologic hernia recurrence or swallowing problems occurred. Conclusion: Laparoscopic reinforcement of the hiatal closure with the autologous fascia lata patch is a safe, technically feasible and cheap option in cases of large hiatal hernia. The most feared complication of mesh penetration can possibly be prevented with this method.

P383 - Oesophageal and Oesophagogastric Junction Disorder

P385 - Oesophageal and Oesophagogastric Junction Disorder

Cost-Effectiveness Comparison Between Laparoscopic Fundoplication and Endostim Electrostimulation for the Treatment of Gastroesophageal Reflux Disease

Modern Minimally-Invasive Management of Boerhaave’s Syndrome

F.A. Philipszoon, P.C. Philipszoon PhilMed, RIEL, The Netherlands Aims: Currently, laparoscopic fundoplication is the golden standard for the surgical treatment of gastroesophageal reflux disease (GERD). Nonetheless, the evidence of the less invasive EndoStim electrostimulation treatment is increasing. The cost-effectiveness of EndoStim versus laparoscopic fundoplication has not been studied yet. Therefore, the aim of this study was to compare cost-effectiveness study outcomes of EndoStim and laparoscopic fundoplication, in patients who were initially treated with proton pump inhibitor (PPI) medication therapy. Methods: Cost-effectiveness outcomes were derived from the Schulz (2015) EndoStim study with 68 patients, and the Epstein (2009) laparoscopic fundoplication study with 104 patients. Cost-effectiveness was presented in costs per quality-adjusted-life-years (QALY) gained per year, 10 years and 20 years. Difference in cost-effectiveness was calculated in difference in QALYs gained per 20 years, cost difference per 20 years and cost difference per QALY gained. All costs were transformed into 2015 EURO’s and converted to the Dutch situation according to the Dutch official cost-profiles. Costs were estimated from the Dutch health care systems’ perspective. Results: Laparoscopic fundoplication compared to PPI medication therapy was found to be cost-effective with an incremental benefit of 0.0305 QALYs gained per year and 0.61 QALYs gained per 20 years at an additional cost of €10,289; resulting in an incremental cost-effectiveness ratio (ICER) of €8,756 per QALY gained. EndoStim compared to PPI medication therapy was found to be cost-effective with an incremental benefit of 0.11 QALYs gained per year, 1.1 QALYs gained per 10 years and 2.2 QALYs gained per 20 years at an additional cost of €23,967; resulting in an ICER of €8,645 per QALY gained. Compared to laparoscopic fundoplication, the EndoStim treatment showed a difference of 1.56 more QALYs gained over 20 years, combined with a cost difference of €13,679 less per patient. Resulting in an €111 lower ICER per QALY gained, compared to laparoscopic fundoplication. Conclusion: Both treatments seem cost-effective in GERD patients when PPI medication therapy fails. The findings suggest that the EndoStim treatment is considered to be dominant over laparoscopic fundoplication and it shows benefits of the less invasive treatment character. Further research is required to estimate comparative long-term costeffectiveness.

A.J. Cockbain, D. Liu, S.P.L. Dexter, A.I. Sarela, H. Sue-Ling St James’s University Hospital, LEEDS, United Kingdom Aim: Boerhaave’s syndrome is a rare but dramatic surgical emergency, which has always excited surgeons, and trainees in particular. However, despite understanding the principles of early recognition and treatment, the practicalities of operative management and surgical techniques are often poorly understood. We aim to describe how modern minimally-invasive techniques can be used to treat Boerhaave’s syndrome. Method: We reviewed all cases of Boerhaave’s syndrome presenting to a tertiary referral oesophagogastric unit in the last two years. Of those requiring operative intervention, three cases were selected that highlight the range of minimally-invasive approaches available. A literature review was also performed to identify relevant literature comparing open and minimally-invasive management. Results: We present three cases to discuss the minimally-invasive management of Boerhaave’s syndrome. Two cases highlight the use of thoracoscopy and lavage and the principles of management of early and delayed presentations. The third case highlights thoracoscopic and transhiatal laparoscopic approaches to repair an oesophageal tear. A literature review yielded 15 articles with only two small studies comparing thoracoscopic and open approaches. Conclusions: Minimally invasive approaches can be used both for lavage and drainage of mediastinal contamination and for repair of the oesophageal tear in Boerhaave’s syndrome. Small comparison studies have demonstrated their non-inferiority to traditional approaches. The minimally invasive approaches we highlight should be considered for managing the Boerhaave’s patient where appropriate expertise is available.

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P386 - Oesophageal and Oesophagogastric Junction Disorder

P388 - Oesophageal and Oesophagogastric Junction Disorder

Laparoscopic Surgery for Gastroesophageal Reflux Disease: Analysis of Outcomes in a District Hospital

Quality OF Life After Antireflux Surgery in Barrett’s Esophagus

T. Santos, C. Freitas, C. Alvarez, M.J. Dantas, J. Carvalho, J. Pinto-de-Sousa Centro Hospitalar Taˆmega e Sousa, PENAFIEL, Portugal

Z. Simonka1, A. Paszt1, T. Geczi1, Sz. Abraham1, I. Toth1, Z. Horvath1, J. Pieler1, J. Tajti1, M. Lup1, L. Tiszlavicz2, A. Varga3, I. Nemeth3, T. Wittmann4, F. Izbeki4, A. Rosztoczy4, G. Lazar1 1

University of Szeged, Department of Surgery, SZEGED, Hungary; University of Szeged, Department of Pathology, SZEGED, Hungary; 3 University of Szeged, Department of Dermatology, SZEGED, Hungary; 4University of Szeged, 1st Department of Internal Medicine, SZEGED, Hungary 2

Aims: Gastroesophageal Reflux Disease (GERD) has long been recognized as a major health problem in developed countries. Along with medical therapy, surgical approach has proven to have good long term results in controlling the symptoms of GERD. Laparoscopic approach has showned its beneficts, being the gold standard in the surgical management of GERD. In our center (area of 550 000 inhabitants) during the last years, we have an increasing number of patients candidates to antireflux surgery. Our aim is to analyse and compare our results in what concerns antireflux laparoscopic surgery to those described in literature. Methods: We’ve analysed, using a prospective database, the demographic and surgical outcome data on all patients submitted to antireflux surgery in our center between January 2011 and December 2014. Results: During this period we’ve performed 114 antireflux laparoscopic surgeries. The mean age was 51,2 years, with equal sex distribution. 66,7% of our study population was either overweighted or grade I obese, no grade II or morbid obese were noted. Over 20% had antidepressants as usual medication. Laparoscopic Nissen procedure was performed in all but one of the cases, being 5 of them a reintervention after a failed previous surgery. No conversions to open surgery were recorded. In the group with no prior antireflux interventions, an associated hiatus hernia was found in 43% of the cases. There was one iatrogenic pneumothorax during surgery and two cases of intra-abdominal abcesses following surgery. This performs a surgical short term morbidity of 2,6%. Mean hospital stay was 1,95 days.In the long term follow-up, there was 1 (0,9%) esophageal stenosis requiring endoscopic dilatation, 4 (3,5%) gas bloat syndrome, 12 (10,5%) patients experienced transient dysphagia that recovered with time and 6 (5,3%) patients had recurrence of the symptoms. 80% went uneventfully. Conclusions:There has been an increasing recognition and referral of GERD patients to our center and we have now more than twice the patients undergoing surgery per year than in the past. Our results are similar to those described in the literature, showing that good outcomes can be achieved in small centers, providing that there are experienced foregut laparoscopic surgeons.

Introduction: Barrett’s esophagus (BE) is the only known precursor of adenocarcinoma occuring in the lower third of the esophagus. According to statistics, severity and elapsed time of gastroesophageal reflux disease (GERD) are major pathogenetic factors in the development of Barrett’s esophagus. Long term efficacy of antireflux surgery is controversial. Patients and methods: In a retrospective study between 2001 and 2008, we compared the pre- and postoperative results (signs and sympthoms, 24 h pH manometry, esophageal manometry, Bilitec) and long term (6–13.75 years) quality of life of BE patients, who have undergone laparoscopic Nissen procedure for reflux disease. Results: Patients were admitted for surgery after a median time of 1.5 years (19.20 months) of ineffective medical (proton pump inhibitors, PPI) treatment. Preoperative functional tests showed severe presence of acid and bile reflux (DeMeester score 41.9). Manometry was confirming lower esophageal sphincter (LES) damage (12.57 mmHg). We performed laparoscopic Nissen antireflux surgery in all the cases. We did not experience any mortality, though in one cases we had to convert during the operation due to injury to the spleen. 3 months after the procedure repeated functional examinations proved, that LES functions improved (18.70 mmHg), and the frequency and exposition of acid and bile reflux decreased (DeMeester score 12.72). Significant decrease, or lapse was experienced in reflux complaints (81% of patients) according to Visick score. 57 patients filled up the modified GERD HRQL questionnaire. The average follow-up time was 8.4 (6–13.75) years. According to questionnaire the GERD symptoms improved after the surgery in 87.3% of the patients. Unfortunately 56.4% of the patients need again medical (PPI) treatment. Heartburn occurred only in 8.8%, and dysphagia in 5.3% of the patients. Conclusion: The severity of abnormal acid and bile reflux occuring parallel with the incompetent function of the damaged LES triggers not only inflammation in the gastroesophageal junction, but also metaplastic process, and the development of Barrett’s esophagus. According ti the long term follow-up laparoscopic Nissen procedure can control reflux among patients with BE not responding to conservative therapy.

P387 - Oesophageal and Oesophagogastric Junction Disorder

P389 - Oesophageal and Oesophagogastric Junction Disorder

Quality of Life After Nissen Fundoplication in Patients with Gerd - Follow-Up of up to 14.5 Years

Is Transition to Day Case Laparoscopic ?Fundoplication Possible?

P.S.S. Castelijns1, J.E.H. Ponten2, M.C.G. Vd Poll2, N.D. Bouvy2, J.F. Smulders1

A. Hamouda, M. Aboul Enein, A. Nisar, A. Okaro, N. Boyle, H. Ali Maidstone Hospital, MAIDSTONE, United Kingdom

1

Catharina Hospital Eindhoven, EINDHOVEN, The Netherlands; 2 MUMC, MAASTRICHT, The Netherlands Background: Nissen fundoplication is the gold standard for treatment of gastroesophageal reflux disease (GERD). Many studies report excellent short-term results, however data regarding long term quality of life are lacking. The aim of this study was to study the longterm quality of life after Nissen fundoplication in patients with GERD. Methods: We retrospectively analyzed all patients who underwent laparoscopic Nissen fundoplication for GERD between January 2004 and August 2015. All patients received a validated GERD-HRQL questionnaire by mail to assess postoperative quality of life with a maximum score is 75. Secondary outcome measures are complications and recurrence rate. Results: Hundred seventy-two of the 219 operated patients returned the questionnaire. (78.5%) The median follow-up was 3.1 (0.1–14.5) years. Mean age was 49 years (range 47–51) and 103 patients were male. We report an excellent quality of life with a median total score of 70 (2–75). We found a reoperation rate of 14.2% (31/219) from which 15 were due to recurrent reflux, 16 due to persistent dysphagia. Mortality rate was zero. Conclusion: We report one of largest series on single center single surgeon laparoscopic Nissen fundoplication. Despite the reoperation rate of 14.1% we found excellent symptomatic outcome at a follow-up of up to 14.5 years.

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Aim: Many studies have confirmed the feasibility of performing laparoscopic anti-reflux surgery in the day case and ambulatory settings. Recently in the UK, guidelines have been set aiming for a 40% days case rate for all-comers for this type of surgery. The primary outcome was to audit the results of our high volume unit in relation to the target. Secondarily, we aimed to identify the parameters limiting the transition to a 40% day case rate. Methods: All patients who had laparoscopic fundoplication at a high volume centre in Kent for 12 months (2014) were identified from theatre log books and notes were reviewed retrospectively. The following data was collected; length of stay, analgesic and anti-emetic requirement during admission, post-operative oral intake and the estimated day of discharge from the surgeon’s operative note. Results: The total number of patients were 64, only 12 (19%) went home on the same day. Of the remaining 52 patients; 45 (70%) stayed for one night and 5 (8%) for two nights and 2 (3%) stayed longer. Fourty seven (73%) patients required analgesia and 28 (43.7%) were managed with simple analgesia with no need for opioids. Twenty three (36%) require antiemetics.Fifty two (81%) tolerated their oral feeding. Only 20 (31%) patients were discharged on the day indicated by the surgeon in their operative notes. One Patient (1.5%) was not discharged due to sliding scale insulin,one (1.5%) with left leg pain, two (3%) patients had low oxygen saturations, one (1.5%)with abdomen discomfort,one with abdomen/chest pain and shortness of breath and one (1.5%)with swelling over epigastrium and diarrhoea . Conclusion: 19% of patients were discharged as a day case, bowel dysfunction, pain and low oxygen saturation were some of the reasons patients had a prolonged stay. At least 50% of the patients who had a delayed discharge, had no clinical reason for their extended stay. Educating doctors and nurses regarding the feasibility for performing the procedure as a day case, prioritising surgery at the beginning of the list and managing patient expectations can increase the chances of doing the procedure as a day case.

Surg Endosc

P390 - Oesophageal Malignancies

P392 - Oesophageal Malignancies

The Effect Analysis of Oral Administration of Olive Oil to Prevent Chylothorax Caused by Esophageal Cancer Endoscopic Surgery

Thoracoscopic Salvage Esophagectomy for Remnant Cancer After Curative Chemoradiotherapy: Our Experience

J.J. Jiang

K. Tanaka, Y. Ebihara, S. Poudel, Y. Kurashima, S. Murakami, T. Shichinohe, S. Hirano

Department of thorocicsurgery,the First Hospital Affiliated to Xiamen University, XIAMEN, China

Hokkaido University Graduate School of Medicine, SAPPORO, Japan

Objective: Study the advantages of preoperative oral administration of olive oil and intraoperative exposure of thoracic duct during endoscopic esophagectomy for esophageal cancer. Methods: From June 2013 to June 2015, 136 patients were treated with 100 ml olive oil 12 h before surgery, and then the exposure of the thoracic duct was observed. Results: All patients were successfully operated, no transfer to open chest. In operation thoracic duct was plentiful, transparent, milky white and clearly exposed. 131 patients successfully retained the thoracic duct. 5 cases of thoracic duct injured when separating due to tumor invasion, and then clamped by titanium. All the patients were lien chest tube drainage postoperatively, extubated 3*5d later; postoperative 24 h drainage volume was 150 ± 35 ml, postoperative total drainage volume was 500 ± 130 ml; no postoperative chylothorax occurred; postoperative hospitalization time was 9 ± 2d. Conclusion: Preoperative oral administration of olive oil for esophageal cancer endoscopic surgery was simple, safe, effective and no injury. In operation the thoracic duct was clearly exposed, injury of the thoracic duct reduced, thoracic duct preserved intact, normal glucose and lipid metabolism retained, accordant with the physiological functions of the human body. It is a good choice of preparation before the operation of esophageal cancer and worth spreading.

Introduction: Thoracoscopic esphagectomy has been performed in our department since 1996. Since 1998, we also introduced this approach for salvage esophagectomy after chemoradiotherapy (CRT). Salvage esophagectomy was initially performed by using mediastinoscopic approach and was later changed to prone-position thoracoscopic approach. The purpose of this study is to evaluate the clinical outcome of salvage esophagectomy and to validate our operation policy of salvage esophagectomy. Methods: 111 patients underwent thoracoscopic esphagectomy between January 2007 and June 2015 in our department. This included 15 cases of salvage esophagectomy during the same period. The thoracoscopic esphagectomy after unsuccessful curative CRT was defined as salvage esophagectomy. In salvage esophagectomy, lymphadenectomy was performed selectively on the stations identified as metastatic lymph nodes on pre-CRT tests. Univariate Analysis between salvage esophagectomy and conventional thoracoscopic esphagectomy was applied to variables from clinical and pathological features, operative outcomes and nutrition scores. Survival data and recurrence pattern of salvage esophagectomy were assessed. Results: All nutrition scores and body-mass index were significantly lower in salvage esophagectomy (P \ 0.05). There was higher frequency of presternal route reconstruction and pR(+) in salvage esophagectomy (P \ 0.05). The clinical features of salvage esophagectomy showed 9 patients were diagnosed with cT3 before CRT and 3 were cT4. 9 patients underwent hand-assisted thoracoscopic and laparoscopic esophagectomy, 5 prone position thoracoscopic esophagectomy and total laparoscopic surgery, and 1 laparoscopic transhiatal esophagectomy. Severe postoperative complications ([Clavien Dindo IIIa) were observed in 5 cases including one postoperative in-hospital death. There were 5 cases with pR(+) and 7 cases with postoperative recurrence. Except for 1 case with pR1, most of the cases had distant metastatic recurrence. Median survival time after salvage esophagectomy was 17.7 months. Conclusions: Our policy of selective lymphadenectomy for salvage esophagectomy was validated by few local recurrences. However, patients with salvage esophagectomy had lower nutrition score and poor prognosis. They may benefit from nutritional intervention before CRT and additional therapy after salvage esophagectomy.

P391 - Oesophageal Malignancies

P393 - Oesophageal Malignancies

Waiting Time from Diagnosis to Treatment has no Impact on Survival in Patients with Esophageal Cancer

Laparoscopic Hand-Assisted Versus Complete Laparoscopic Gastric Tube Reconstruction Following Thoracoscopic Esophagectomy for Esophageal Cancer

E. Visser1, A.G. Leeftink1, P.S.N. van Rossum1, S. Siesling2, R. Van Hillegersberg1, J.P. Ruurda1 1

University Medical Center Utrecht, UTRECHT, The Netherlands; Netherlands Comprehensive Cancer Organization, TWENTE, The Netherlands

2

Background: Waiting time from diagnosis to treatment has emerged as important quality indicator in cancer care. This study aims to determine the impact of waiting time on longterm outcome of patients with esophageal cancer who are treated with neoadjuvant therapy followed by surgery or primary surgery. Methods: Patients who underwent esophagectomy for esophageal cancer at the University Medical Center Utrecht between 2003 and 2014 were included. Patients treated with neoadjuvant therapy followed by surgery and treated with primary surgery, were separately analyzed. The influence of waiting time on survival was analyzed using Cox proportional hazard analyses. Kaplan–Meier curves for short (\8 weeks) and long (=8 weeks) waiting times were constructed. Results: A total of 351 patients were included, 214 received neoadjuvant treatment, and 137 underwent primary surgery. In the neoadjuvant group, the waiting time had no impact on DFS (hazard ratio[HR]0.96, 95% confidence interval[CI]:0.88–1.04; p = 0.312) nor OS (HR0.96, 95%CI:0.88–1.05; p = 0.372). Accordingly, no differences were found between neoadjuvantly treated patients with waiting times of \8 and =8 weeks in terms of DFS (p = 0.506) and OS (p = 0.693). In the primary surgery group, the waiting time had no impact on DFS (HR1.03, 95%CI:0.95–1.12; p = 0.443) nor OS (HR1.06, 95% CI:0.99–1.13; p = 0.108). Waiting times of \8 weeks versus =8 weeks did not result in differences regarding DFS (p = 0.884) nor OS (p = 0.374). Conclusion: In esophageal cancer patients treated with curative intent by either neoadjuvant therapy followed by surgery or primary surgery, waiting time from diagnosis to treatment has no impact on long-term outcome.

T. Saito1, Y. Ebihara2, K. Yo2, K. Hiroshi2, T. Kimitaka2, M. Sochi2, S. Toshiaki2, H. Satoshi2 1

Hokkaido University, SAPPORO, HOKKAIDO, Japan; Gastroenterological Surgery? Hokkaido University, SAPPORO, HOKKAIDO, Japan

2

Background: Thoracolaparoscopic esophagectomy (TLE) is a type of minimally invasive esophagectomy for esophageal cancer. The aim of the present study was to evaluate the technical feasibility of alimentary tract reconstruction with laparoscopic gastric tube reconstruction (LGR) in comparison with laparoscopically hand-assisted gastric reconstruction (LHGR) following thoracoscopic esophagectomy. Methods: Consecutive 77 patients with esophageal cancer underwent TLE with 2 or 3-field lymphadenectomy January 2007 to June 2015 at Hokkaido University Hospital: for reconstruction after thoracoscopic esophagectomy, 38 patients underwent LGR, and 39 patients underwent LHGR. We compared surgical outcomes after reconstruction with LGR and that with LHGR. Results: The patients’ backgrounds were not significantly different. In operative findings, the mean amount of blood loss was significantly less with LGR than with LHGR (80 vs. 330 g, p \ 0.0001). Other perioperative findings (operation time, transfusion and the number of abdominal dissected lymph nodes) were not significantly different. In postoperative complications (operative mortality, Clavien Dindo grade and duration of postoperative hospital stay) were not significantly different. Conclusion: In this study, LGR is recommended as a surgical approach in comparison with LHGR in TLE. However, a randomized controlled trials to confirm the result should be performed.

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Surg Endosc

P394 - Oesophageal Malignancies

P396 - Oesophageal Malignancies

Internal and External Validation of a Multivariable Model to Define Hospital-Acquired Pneumonia After Esophagectomy

Anatomic/Histologic Patterns of Siewert Type II Adenocarcinoma of the Esophagus and Cardia Originating Gastric Greater Curvature Metastases

M.F.J. Seesing1, T. Weijss1, P.S.N. van Rossum1, M. Koeter2, P.C. van der Sluis1, M.D.P. Luyer2, J.P. Ruurda1, G.A.P. Nieuwenhuijzen2, R. van Hillegersberg1 1 UMC Utrecht, UTRECHT, The Netherlands; 2Catharina Ziekenhuis, EINDHOVEN, The Netherlands

Background: Although pneumonia incidence following esophagectomy decreased since the introduction of minimally invasive surgery, it remains an important complication following esophagectomy. However, a wide range of pneumonia incidence is reported. The lack of one generally accepted definition prevents valid inter-study comparisons. We aimed to simplify and validate an existing scoring model to define pneumonia following esophagectomy. Patients and methods: The Utrecht Pneumonia Score, comprising of pulmonary radiography findings, leucocyte count and temperature, was simplified and internally validated using bootstrapping in the dataset (n = 185) in which it was developed. Subsequently the intercept and (shrunk) coefficients of the developed multivariable logistic regression model were applied to an external dataset (n = 201). Results: In the revised Utrecht Pneumonia Score, the Uniform Pneumonia Score, points are assigned based on: the temperature, the leucocyte, and the findings of pulmonary radiography. The model discrimination was excellent in the internal validation set and in the external validation set (C-statistics 0.93 and 0.91, respectively), furthermore the model calibrated well in both cohorts. Conclusion: The Uniform Pneumonia Score can serve as a means to define postesophagectomy pneumonia. Utilization of a uniform definition for pneumonia will improve inter-study comparability and improve the evaluations of new therapeutic strategies to reduce the pneumonia incidence.

S. Mattioli, B. Mattioli, N. Daddi, A. Ruffato, M. Lugaresi, D. Malvi, A. d’Errico University of Bologna, BOLOGNA, Italy A 15/18% rate of gastric greater curvature metastases has been reported in authoritative articles on surgery for Siewert type II adenocarcinoma of the esophagus and cardia. This data raises discussion on surgical indications and techniques to adopt in these cases. Very scarce information is available on this topic. We reviewed a case series to provide further information. Materials and methods: In 142 Siewert type II adenocarcinomas we performed (no neoadjuvant therapy) total gastrectomy, esophageal resection at the azygos vein level, radical lymphadenectomy. Preoperatively CT, PET, CT-PET scan were performed, primary surgery (no neo-adjuvant therapy) was indicated up to T4a, N1, M0 in various clinical stage combinations. The final pathology report documented greater curvature lymphatic metastases in 30/142 cases (21%), forming the study group. We considered histology according to Lauren, Grading, T,N,M, Stage 7th AJCC ed., lymphatic, vascular, perineural invasion, Lymph -Nodes ratio, recurrence site, cancer specific survival. Results: 9 females, 21 males, median age 67,5(IQR 60.5–74.2); histology type %: intestinal 46.7, diffuse 53.3; G% I 6.7, II 23.3, III 70; T% –3.3, 3–50, 4-46.7; N% 1–26.7, 2-6.7, 3–66.7; M% 0–76.7, 1–23.3 (lymphnodes but 1 liver), Stage %: 2a–3.3, 3a–20, 3b–13.3, 3c–40, 4–23.3; vascular diffusion %: negative 13.3 positive 86.7; perineural diffusion %: negative 13.3 positive 86.7. Relationship between/among anatomic-histologic parameters and cancer specific survival: univariate analysis histology p = .002, T p = .01, N p = .009, pStage p = .011; Cox multivariate analysis, histology p = .032. In 26/30 patients (87%) cancer recurred in one site in 12 (liver 6, mediastinum 3, brain, lung lumbar-aortic nodes 1 each), in multiple sites in 8, with peritoneal or pleural carcinosis 3, not assessed 3. Kaplan–Meier survival, intestinal histology type versus diffuse type (p = 0.000). Comment: Gastric greater curvature metastases occur prevalently in aggressive diffuse type adenocarcinoma, which primary surgery must be questioned.

P395 - Oesophageal Malignancies

P397 - Oesophageal Malignancies

Techniques and Short-Term Outcomes for Minimally Invasive Ivor Lewis Esophageal Resection in Distal Esophageal and Gastro-Esophageal Junction Cancers

Surgery for Giant Fibrovascular Polyps of the Oesophagus

J. Straatman1, N. van der Wielen1, G.A.P. Nieuwenhuijzen2, C. Rosman3, J. Roig Garcia4, J.J.G. Scheepers5, M.A. Cuesta1, M.D.P. Luyer2, M.I. van Berge - Henegouwen6, F. van Workum3, S.S. Gisbertz6, D.L. van der Peet1

St James’s University Hospital, LEEDS, United Kingdom

1

VU University Medical Center, AMSTERDAM, The Netherlands; Catharina Ziekenhuis, EINDHOVEN, The Netherlands; 3Canisius Wilhelmina Ziekenhuis, NIJMEGEN, The Netherlands; 4Hospital Universitari Dr. Josep Trueta, GIRONA, Spain; 5Reinier de Graaf Ziekenhuis, DELFT, The Netherlands; 6Academisch Medisch Centrum, AMSTERDAM, The Netherlands

2

Introduction: Esophagectomy for cancer can be performed in a two-stage procedure with an intrathoracic anastomosis: the Ivor Lewis esophagectomy. A growing incidence of distal and gastro-esophageal junction adenocarcinomas and increasing use of minimally invasive techniques has prompted interest in this procedure. The aim of this study was to assess short-term results of minimally invasive Ivor Lewis esophagectomy (MIE-IL). Methods: A retrospective cohort study was performed from June 2007 until September 2014. Including patients that underwent MIE-IL for distal esophageal and gastro-esophageal junction cancer in six different hospitals in the Netherlands and Spain. Data was collected with regards to operative techniques, pathology and postoperative complications. Results: 282 patients underwent MIE-IL, of which 90,2% received neoadjuvant therapy. Anastomotic leakage was observed in 43 patients (15,2%), of whom 13 patients (4,6%) had empyema, necessitating thoracotomy for decortication. With an aggressive treatment of complications, the 30-day and in-hospital mortality rate was 2.1%. An R0-resection was obtained in 92,5% of the patients. 20,1% of patients had a complete response after neoadjuvant therapy. Conclusions: Minimally invasive Ivor Lewis esophagectomy for distal esophageal and gastro-esophageal junction adenocarcinomas is an upcoming approach for reducing morbidity caused by laparotomy and thoracotomy. Anastomotic leakage rate is still high probably due to learning curve, technical diversity of anastomotic techniques, and a high percentage of patients treated by neoadjuvant chemoradiotherapy. An aggressive approach to complications leads to a low mortality of 2.1%. Further improvement and standardization in the anastomotic technique is needed in order to perform a safe intrathoracic anastomosis.

123

A.J. Cockbain, S.P.L. Dexter, A.I. Sarela

Aims: Giant fibrovascular polyps of the oesophagus are very rare benign tumours, and can present a diagnostic challenge. Cross-sectional imaging, contrast swallow and endoscopy may struggle to either identify a stalk, or delineate the tumour as luminal or submucosal in origin. The differential diagnosis includes leiomyoma, sarcoma and inflammatory fibroid polyps. Excision is advised, although the diagnosis and therefore the optimal operative approach may not be apparent until the time of surgery. Methods: Between 2006-2015, four patients underwent surgery for fibrovascular polyps of the oesophagus. All presented with dysphagia. One patient also presented with otalgia, hoarse voice and a palpable neck swelling. All had pre-operative OGD and CT scan. Barium swallow was performed in three patients. All lesions were noted to arise in the cervical oesophagus and extend either to, or through, the gastroesophageal junction. A stalk was identified on imaging in two of the four lesions. Our favoured approach is to perform a cervical oesophagostomy to identify the base of the polyp. This can then be either suture ligated or divided with a vascular stapler. Once transected, the polyp can be retrieved either through the cervical oesophagotomy or through a laparoscopic gastrotomy. Results: All four patients made good post-operative recoveries. Two patients are disease free at 2 months and 4 years respectively. One patient developed recurrence in the upper oesophagus at 3 years which was excised with rigid oesophagoscopy. The fourth patient developed a 3 9 1.5 cm polyp recurrence in the pyriform fossa at three years which was excised at rigid oesophagoscopy. He was lost to follow-up and then presented with a supraglottic recurrence causing respiratory arrest at 5 years. Conclusions: Giant fibrovascualr polyps are rare. Patients should be counselled carefully pre-operatively when there is diagnostic uncertainty and the possibility of either thoracoscopic or open excision if the lesion is found to be submucosal, or oesophagectomy if local excision cannot technically be performed. We recommend annual endoscopic surveillance because of the risk of polyp recurrence.

Surg Endosc

P398 - Oesophageal Malignancies

P400 - Oesophageal Malignancies

The Clinical Impact of Greater Curvature Metastases in Siewert Type II Adenocarcinoma of the Esophagus and Cardia

Enhanced Recovery After Surgery for Minimally Invasive Esophagectomy: A Systemic Review

S. Mattioli, B. Mattioli, N. Daddi, A. Ruffato, M. Lugaresi

M.L. Kang, S.Y. Soon

University of Bologna, BOLOGNA, Italy

Ng Teng Fong General Hospital, SINGAPORE, Singapore

The current answer of proponents of the routine use of the gastric pull up after esophagectomy with minimally invasive techniques to the question regarding the fact that esophageal adenocarcinoma may colonize gastric greater curvature lymph nodes, is that these metastases occur in not curable patients. However, neither data support this empiric belief, nor a not radical esophagectomy is easily acceptable. We compared two groups of Siewert type II adenocarcinomas undergoing total gastrectomy, esophageal intrathoracic resection, radical lymphadenectomy, (1) without (2) with greater curvature metastases, to try to fill the information gap. Methods: Group 1, 112 cases, group 2, 30 cases; preoperatively CT, PET, CT-PET scan; primary surgery (no neo adjuvant therapy) was indicated up to T4a, N1, M0 in various clinical stage combinations. We considered histology according to Lauren, G, T, N, M, Stage 7th AJCC ed., cancer specific survival. Results: Cox multivariate analysis among anatomic, histology parameters and cancer specific survival: Group 1histology p = .007; group 2 histology p = .023.Cases clinically under staged (pathological staging 3b to 4): Group 1 44,7%, Group 2 76,6%; survival functions group1 versus 2 : intestinal type adenocarcinoma Log rank p = .003; diffuse type adenocarcinoma Log rank p = .121. Groups1-2 comparative analysis demonstrated significantly higher cancer aggressiveness in cases of group 2 for the following parameters: nodal metastases (p = .000), organ metastases (p = .004), Stage (p = .000), Cancer Specific Survival, total (p = .003),for intestinal histology type (p = .033), for diffuse histology type (n.s.). Comment: Gastric curvature metastases are present in end stage disease probably caused by delayed diagnosis (intestinal type) or disease aggressiveness (diffuse type). To reduce clinical under staging without excluding from cure potential candidates, we may empirically propose primary surgery up to clinical T3-N1 for intestinal type, not for diffuse type. Reliable preoperative biological indicators and further oncologic research are mandatory to avoid not targeted surgery. Proper indication to surgery will allegedly pair with the routine use of the gastric pull up.

Aims: The benefits of enhanced recovery after surgery (ERAS) programs have been well demonstrated in colonic surgery. Use of laparoscopic surgery has been identified as a contributing factor in these favourable outcomes. Preliminary evidence shows that this benefit extends to esophagectomy patients as well. There is a paucity of literature focusing on the use of ERAS in patients undergoing minimally invasive esophagectomy (MIE). The combination of MIE and ERAS may enhance patient outcomes. Methods: Studies describing protocolized care, enhanced recovery pathways or ERAS programs in conjunction with esophagectomy were analysed to focus on components central to ERAS programs. Studies comparing open to minimally invasive esophagectomy were reviewed to identify these key elements of ERAS in post-operative care. Results: The majority of studies pertain to open esophagectomy and show that ERAS is beneficial in decreasing length of stay, morbidities, and time to mobilization. Limited evidence is available for the use of ERAS for MIE specifically, but the combination may show benefits to length of stay and time to mobilization. Conclusion: The use of ERAS in MIE is an area with scanty evidence published as yet. Elements of protocolized care in MIE may have confounded trials comparing MIE to open esophagectomy. Increased adoption of ERAS and the shifting paradigm toward minimally invasive surgery may combine to improve patient outcomes.

P399 - Oesophageal Malignancies

P401 - Oesophageal Malignancies

Adenocarcinoma of the Esophagus and Cardia (Siewert Type I– II) Does Comprehend Three Different Biological Patterns

Our Experience of Minimally Invasive Esophagectomy for Thoracic Esophageal Cancer - Left Lateral Decubitus Position and Prone Position-

S. Mattioli, B. Mattioli, N. Daddi, A. Ruffato, M. Lugaresi, D. Malvi, A. d’Errico University of Bologna, BOLOGNA, Italy

M. Hiramatsu1, M. Kawai2, T. Kobayashi1, I. Tsunematsu1, M. Ishii1, Y. Takano1, S. Maezawa1 1

It has been shown that in Siewert type I- II adenocarcinomas three CK 7-20 patterns are present: Ck7+/20-, CK 7-/20+,Ck7+/20+ furtherly characterized by the absence or presence of intestinal metaplasia in the gastric corpus and antrum mucosa. Other studies have shown that in adenocarcinoma of the esophagus and cardia different nodal metastases and cancer specific survival patterns occur according to the presence/absence of Barret’s intestinal metaplasia in the esophagus and of intestinal metaplasia in the stomach. We investigated the relationship between the histology/CK 7-20 patterns and the presence/absence of Barret’s/gastric intestinal metaplasia. Methods: we assessed histology according to Lauren classification (intestinal and diffuse types) the positivity, negativity of CK 7–20 in groups : (1) Barret’s intestinal metaplasia +, gastric intestinal metaplasia-; (2) Barret’s intestinal metaplasia -, gastric intestinal metaplasia +, (3) Barret’s intestinal metaplasia - gastric intestinal metaplasia - . Results: group 1 (intestinal type 36,4%, diffuse type 63,6% CK7 +/CK20- 100%; group 2 (intestinal type 42,9%, diffuse type 52,7% CK7-/CK20 + 100%; group 3 (intestinal type 75%, diffuse type 25% CK7 +/CK20 + 100%; p = 0.037 Chi Square test among groups Comment: the histology and CK7-20 patterns distribute differently in groups characterized by the presence/absence of Barret’s and gastric intestinal metaplasia. This finding supports the existence of three different types of adenocarcinoma of the esophagus and cardia. As literature demonstrates that to different biology do correspond different metastases/cancer specific survival patterns, histology and CK7-20 assessment may help to tailor therapy.

Takatsuki Red Cross Hospital, TAKATSUKI, OSAKA, Japan; Osaka Medical College, TAKATSUKI, OSAKA, Japan

2

Background and Purpose: We started the minimally invasive esophagectomy (MIE) in the left lateral decubitus position (LLDP) for the patients with esophageal cancer in 2008. Then, we shifted to the MIE in the prone position (PP) in 2011. From our experience, we considered superiority of MIE, especially of in PP. Patients and Methods: Fifty nine patients were underwent MIE, 33 in LLDP and 26 in PP. The patients with bulky tumor (possible T4) and salvage surgery were excluded from the indication of MIE. Abdominal procedure was mainly performed by laparoscopic approach. Three field node dissection was performed for most of the patients. Reconstruction with gastric conduit via the posterior mediastinal route, and cervical anastomosis were selected as a first choice. Results: The rate of recurrent laryngeal nerve palsy (RLNP) in patients receiving LLDP was 18.2% and 15.3% in PP. Anastomotic leakage was observed 12.1% in LLDP and 15.4% in PP. Operative mortality was 1 case in LLDP. The risk of RLNP was higher than open esophagectomy, but most of the RLNP were temporarily. There was one patient in each group, who underwent open thoracotomy with conversion because of severe pleural adhesion. However, no patient was required emergency thoracotomy by massive bleeding etc. The advantage of PP was as follows; Better visualization, especially around left recurrent laryngeal nerve and in most upper mediastinal region; Less damage of lung due to spontaneous collapse by pneumothorax; Avoidance of blood stain from the operation field. In addition, one expert surgeon and immature resident can complete the procedures in PP with standard laparoscopic instruments, though the skillful first assistant is necessary for LLDP. Discussion: Several procedures of MIE have been reported recently, such as LLDP, PP, hybrid and mediastinoscopic approach. MIE is feasible and safe, but further multi-institutional joint study will be necessary to judge a survival benefit.

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Surg Endosc

P402 - Paediatric Surgery

P404 - Paediatric Surgery

Comparison of Results of Laparoscopy Versus Open Approach in Acute Appendicitis in Paediatric Patients (5–15 Years Old)

Our Peri- and Post- Operative Care for Laparoscopic Congenital Choledochal Cyst Resection and Hepatico-Jejunostomy in Pediatrics

L.A. Vega Rojas, J.M. Abad, P. Besora, R. Claveria, D. Salazar, R. Rodriguez, L. Blay, J. Camps Consorci Sanitari de l’Anoia, IGUALADA, Spain Aims: To describe our experience in the use of laparoscopic surgery for acute appendicitis in paediatric patients (5-15 years old). Methods: A series of cases treated in our department from January 2010 to December 2014. We collected variables inherent to the patient such as age, gender, ASA; Own the procedure: Type of anesthesia, surgical approach, surgical time and intraoperative complications and length of stay; 30-day morbidity has been categorized according to the scale of Clavien/Dindo us to measure the clinical impact of these. Results: We have intervened in this period 147 cases of acute appendicitis aged 5-15 years old; 72 by laparoscopic approach (Group I) and 75 by open surgery (Group II) (With incision Mc Burney). 100% were ASA I, and were operated under general anesthesia (13 catarrhal (8.84%), phlegmonous 112 (76.19%), 16 gangrenous (10.88%), 6 perforated (4.08%). The laparoscopic surgical time in cases was 46.36 min while operated in open surgery group was 42.14 min. The average stay in group I was 3.11 days and the group II of 3.65 days (p = 0.04). Morbidity at 30 days in the open surgery group operated was 6.66% (5 patients) vs. 2.77% (2 patients) (p = 0.26). In the laparoscopic group one patient present intrabadominal abscess (requiring ultrasound-guided drainage) and other a superficial wound infection (treated conservatively), while in the open surgery group three patients presented intrabadominal abscesses (2 required drainage and one antibiotic) treatment and two surgical wound infections (one requiring debridement). Conclusions: The use of laparoscopy in this age group remains controversial, in our experience we have found that it is an alternative, safe and fast; by joining shorter and lower incidences of complications.

R. Shirotsuki, H. Uchida, A. Tanano, T. Tainaka, C. Shirota, A. Hinoki, K. Yokota, N. Murase, K. Ohshima, K. Chiba Nagoya University Graduate School of Medicine, NAGOYA, Japan Introduction: Choledochal cyst (CC) should be performed extra biliary duct resection and hepatico-jejunostomy because of its potential of malignancy even in pediatrics. Although laparoscopy repair for CC seems to be difficult, better extended vision brings more precise resection of extra-biliary duct at the head of pancreas and hilar ductoplasty against abnormality like stenosis, which might reduce postoperative biliary stone formation. Here, we report peri- and post- operative performance with short-term and mid-term outcome. Method & Results: Clinical data were retrospectively collected. Our operation was consisted of (i) laparoscopic resect of dilated common bile duct, (ii) laparoscopic check of the pancreatic duct protein plug with fluorography, (iii.) check of intrahepatic duct stenosis by a rigid scope, and if the stenosis is found, hilar ductoplasty to enlarge the anastomotic diameter of hepatic duct, (iv) Roux-en-Y jejuno-jejunostomy with exteriorization of the umbilical Benz incision, and (v) laparoscopic anastomosis of hepatico-jejunostomy. We performed MRCP postoperatively, which might reveal residual bile ducts and intrahepatic biliary stones. Since 2013 September to 2015 December, 17 patients were performed as primary operation in laparoscopy. There was no conversion to laparotomy. Median operation time was 375 min (234–852), blood loss was 51 ml (5–1216), drain removal was post-operative day (POD) 6 (4–13), and hospital days was POD 10 (7–36). Short-term complications; biliary minor leakage (2 cases), subileus (1 case), wound infection (1 case) and chylous ascites (1 case) were observed. All the complications were treated successfully by conservative therapy. Long-term complication; biliary stone formation at intrahepatic duct in 1 case was observed by MRI at one postoperative year, and double-balloon assisted endoscopic cholecystolithotomy was performed. There were no residual bile ducts. Discussion: Laparoscopic congenital choledochal cyst resection and hepatico-jejunostomy in pediatrics were safely performed. Roux-en-Y jejuno-jejunostomy with exteriorization of the umbilical Benz incision was easily done. Although, hilar ductoplasty with stenosis or anatomical abnormality were slightly difficult, removal of stenotic biliary lesion and enlarging the hepatic duct might help to prevent postoperative biliary stone formation hepatico-jejunostomy.

P403 - Paediatric Surgery

P405 - Paediatric Surgery

The Umbilical Benz Incision Enables a Feasible Single-Site Laparoscopic Surgery in Children

Minilaparoscopic Approach for Single Port Laparoscopic Appendectomy for Acute Appendicitis in Children

C. Shirota

Y. Kawakami, H. Fujii, Y. Hirose

Nagoya graduate school of medicine, NAGOYA, Japan

Japanese Red Cross Fukui Hospital, FUKUI, Japan

Aims: Indications for single-site laparoscopic surgery have increased in paediatrics with a good aesthetic outcome. However, it requires a skilled surgical technique. Umbilical Benz incision (inverted Y-shaped incision with three triangular skin flaps) provides greater access into the peritoneal cavity. The larger umbilical orifice enables easy manipulation of forceps and exteriorization of target organs. The umbilicus can keep its natural form despite the large incision. We report the use of the Benz incision for single-site laparoscopic surgery. Patients and Methods: We studied 190 patients who underwent laparoscopic surgery at our department between August 2013 and December 2015, excluding those with appendectomy, herniorrhaphy and orchidopexy. During surgery, a multiport device was placed in the Benz incision. We retrospectively investigated all cases wherein the single-site laparoscopic surgery was completed. Results: The Benz incision was used in 103 patients; it was applied through a single-site incision in 35 patients (hypertrophic pyloric stenosis in 12, an ovarian cyst or teratoma in 9, intestinal obstruction in 6, liver dysfunction in 2, solid tumour in 2, cholecystolithiasis in 1, Hirschsprung’s disease in 1 and others disorders in 2). The other 68 patients underwent reduced port surgery with miniature or standard laparoscopic forceps. As the Benz incision was applied in many operations, multiport laparoscopy evolved to single-site or reduced port surgery. Initially, pyloromyotomy was performed via three ports in 5 cases and through a single-site incision in 12, pulling the hypertrophic pylorus out through the Benz incision. After introducing the incision, single-site laparoscopic surgery was aggressively performed for intestinal obstruction and other diseases, combined with exteriorization of the intestine or target organs through the incision. Because the Benz incision allows a wide abdominal opening, the manipulation angle could be secured, decreasing difficulties of complete single-site incision endoscopic surgery. Conclusion: Single-site laparoscopic surgery is feasible and acceptable by introducing the umbilical Benz incision in children. This may increase single-site surgery application in the future.

Aims: Recently, reduced port laparoscopic surgery using minilaparoscopic instruments has been widely adopted as innovative features in minimally invasive surgery. We attempted to apply modified technique using minilaparoscopic instruments to transumbilical single port access laparoscopic appendectomy (TUSPA-LA) in children. Methods: From April of 2009 to November of 2015, 130 consecutive patients with acute appendicitis were assigned to undergo modified TUSPA-LA. We conducted to study our technique using reusable metallic trocar (ENDOTIPTM, 3.3, 6 mm in diameter, KARL STORZ GmbH & Co. KG, Tuttlingen, Germany, BJ-NeedleTM trocar, 2.1 mm in diameter, NITI-ON Co., Chiba, Japan) as working port, XCELTM, 5 mm in diameter, ETHICON ENDO-SURGERY, INC., Pittsburgh, PA, USA, VERSAPORTTM, 5 mm in diameter, COVIDIEN, INC., Mansfield, MA, USA as camera port. Straight-type grasping forceps, dissecting forceps (2.1, 3.3 and 5 mm in diameter) were used both in the parallel setup at umbilical site, in the triangular co-axial setup with supra-pubic puncture. Results: Clinical records of 678 cases diagnosed as acute appendicitis (From April of 2009 to November of 2015) were analyzed retrospectively in background factors, operative time and length of hospital stay. Of them, we had 164 pediatric patients with acute appendicitis, 130 cases needed operative treatment and 34 cases were intended to treat by conservative therapy. In operation group, we had 75 modified TUSPA-LA (male 38, female 37, average age of 11.7, range 6–15) and 55 open cases (m 34, f 21, 11.3, 5–15) with the ratio of laparoscopic surgery to open surgery exceeded up to 57.7% in recent cases. The average operative time in the modified group was 77.7 min (32–178), as was 49.6 (22–100) in open group. The mean hospital stay in the modified group was 5.4 (2–11) days with 5.2 (3–22) in open cases. No major postoperative complications were observed. In conservative therapy group, we had 34 non-operative cases (male 13, female 21, average age of 10.7, range 5–15). The mean hospital stay in the non-operative group was 2.0 (1–5) days. Conclusions: We conclude that modified technique for TUSPA-LA could be useful for reducing invasiveness while keeping a safety and good cosmetic result as an attractive advantage in managing this condition.

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P406 - Paediatric Surgery

P408 - Pancreas

Long Term Outcome of Nonoperative Treatment Versus Appendectomy for Acute Uncomplicated Appendicitis in Children

Factors Associated with and Consequences of Open Conversion After Laparoscopic Distal Pancreatectomy: Initial Experience at A Single Institution

R.R. Gorter1, F.A.C.J. Heijsters2, H.A. Cense3, K.H. In ‘t Hof4, R. Bakx2, J.H. Van der Lee5, H.A. Heij2

K.P. Goh, C. Chan, S.Y. Lee, P.C. Cheow, W.H. Chan, P.K. Chow, O. London, A.Y. Chung

1

Singapore General Hospital, SINGAPORE, Singapore

VU Medical Centre, AMSTERDAM, The Netherlands; 2Paediatric Surgical Centre of Amsterdam, AMSTERDAM, The Netherlands; 3 Red Cross Hospital, BEVERWIJK, The Netherlands; 4 Flevoziekenhuis, ALMERE, The Netherlands; 5Paediatric clinical Research Office, Academic Medical Centre, AMSTERDAM, The Netherlands Aim of the study: To evaluate the outcome of initial non-operative treatment (NOT) versus appendectomy for uncomplicated appendicitis in children. Methods: Between September 2012 and June 2014 children aged 7-17 years with a radiologically confirmed uncomplicated appendicitis were invited for a multicentre prospective cohort study in which they were treated with an initial NOT strategy (consisting of clinical observation, antibiotic administration and pain medication). Non-participants underwent appendectomy. An interview by telephone and review of the medical charts of participants and non-participants was conducted in October 2015 in order to assess the outcome in terms of delayed appendectomy, recurrent appendicitis and complications. Main results: 44 children were treated for acute simple appendicitis, 25 with the initial NOT strategy and 19 with appendectomy. In the NOT group, six children underwent appendectomy between 7 days and 16 months after presentation: one because of faecolith that was missed on initial imaging; three had recurrent appendicitis (histologically confirmed); two had interval appendectomy without histological signs of inflammation. Nineteen (76%) of the 25 children did not undergo an appendectomy. Three complications were noted in the NOT group while two complications were seen in the OT group. (Table 1) None of the 6 patients experienced post-appendectomy complications after their delayed appendectomy. Two of the 19 patients in the OT group experienced a post-appendectomy complication. Conclusion: Our results show that appendectomy can be avoided in approximately 75% of the children treated with initial non-operative treatment strategy for uncomplicated appendicitis. Table 1. Complications after NOT or OT strategy for acute uncomplicated appendicitis. Data is displayed as number of patients (percentage) unless stated otherwise. *Data is displayed as median (range)

Background: Laparoscopic distal pancreatectomy (LDP) has been increasingly adopted world-wide as a result of rapid advancements in surgical techniques and equipment. This study aims to determine factors associated with and consequences of open conversion after LDP. Methods: This is a retrospective review of the first 40 consecutive LDP performed for pancreatic tumors from 2006 to 2015 at a single institution. Individual surgeon volume was stratified by =5 vs [5 cases and institution experience was stratified by 2 time periods 2006–2010 and 2011–2015. Results: The median age of patients was 57.6 (range 21–78) years. LDP was performed for malignancy in 4 (10%) patients. The median tumor size was 25, range (8–75) mm. Eight patients (20%) underwent subtotal pancreatectomies and 7 (17.5%) had concomitant surgeries. Eleven (27.5%) LDP were spleen-saving procedures. Ten (25%) procedures were converted to open. Twenty-nine (72.5%) patients experienced 90-day/in-hospital morbidity of which 8 (20%) were major ([grade II). There were 24 (60%) pancreatic fistulas of which 10 (25%) were grade B and 8 required percutaneous drainage. Univariate analyses demonstrated that splenectomy [10 (34.5%) vs 0, p = 0.025], individual surgeon volume (\5 cases) [8 (38.1%) vs 2 (10.15%), p = 0.044] and institution experience [5 (55.6%) vs 5 (16.1%), p = 0.016] were risk factors for open conversion after LDP. Open conversion was associated with a nonstatistically significant increased rate of intra-operative blood transfusion (P = 0.053). Conclusions: Splenectomy, institution experience and individual surgeon volume were important factors associated with open conversion after LDP.

P407 - Pancreas

P409 - Pancreas

Assignment for Prevalance and Standardization of Laparoscopic Pancreatic Resection: From the Standopoint of a Municipal Hospital

Short-Term Surgical Results of Standardized Laparoscopic Spleen-Preserving Distal Pancreatectomy

T. Komokata, M. Kaieda Kagoshima Medical Center, National Hospital Organization, KAGOSHIMA, Japan Background: Laparoscopic distal pancreatectomy (LDP) is spreading quickly and has been already covered by official medical insurance in Japan. In contrast to LDP, laparoscopic pancreaticoduodenectomy (LPD) still has been performed in few institutions because of its technical difficulties and complexity, even though it was first reported two decades ago. Our aim was to investigate the assignment for prevalence and standardization of laparoscopic pancreatic resection, presenting 10 initial cases of those procedures at our institution. Methods: From June 2013 to December 2014, we performed LDP for 6 pts, hybrid LPD for 1 and pure LPD for 2 pts, and laparoscopic spleen preserving distal pancreatectomy (LSPDP) for 1 pt with benign (n = 6) or node negative malignant (n = 4) lesions. Results: The operation time, estimated blood loss, and hospital stay ranged from 311 to 404 min, 50 to 700 ml, and 8 to 56 days in LDP, 672 to 699 min, 250 to 600 ml, and 30 to 135 days in LPD, respectively. Clinical relevant pancreatic fistula (ISGPF, grade B) was found in 2 pts of LDP and in 1 pt of LPD. One another pt in LPD developed to ClavienDindo IIIb complication. The pt underwent LSPDP was converted to open procedure following massive bleeding (estimated blood loss: 3200 ml) due to splenic vein injury with a vessel sealing device. A R0 resection was achieved in all four pts with malignant lesions. Conclusion: LDP will become a standard surgical therapy, secured by cosmetic benefit along with less invasion, establishing criteria, while still has problem in terms of preventing pancreatic fistula. LPD may extend the variation in laparoscopic gastroenterological surgery by completing this procedure. However, this procedure will not be prevalent in municipal hospital because it takes a very long time due to technical difficulties and complexity and cannot include predominance except for cosmetic benefit. LPD needs to be put together into high volume centers so as to establish as a highly developing pancreas surgery. LSPDP has a pitfall leading to massive bleeding by injury of the splenic vein with a vessel sealing device.

T. Noji, Y. Ebihara, T. Kimitaka, Y. Nakanishi, T. Asano, Y. Kurashima, T. Nakamura, E. Tamoto, S. Murakami, T. Takahiro, K. Okamura, T. Shichinohe, S. Hirano Hokkaido University Graduate school of Medicine, SAPPORO, Japan Background: In this report, we show our standardized procedures for laparoscopic splenic vessel-preserving distal pancreatectomy (SVP-LSPDP) and Warshaw’s operation, as well as our cases with intraoperative complications and how we solved these complications. Patients and methods: We focused on the courses of the splenic arteries and classified them into 2 major types: Type A, the splenic artery curved and ran superior to the pancreas; and Type B, the splenic artery passed relatively straight to the dorsal side of the pancreas. For Type A, the peritoneum was cut along the superior pancreatic border to expose and tape the splenic artery at the dividing line. For Type B, the artery was exposed and taped using the same procedure as that used for the vein. Surgical procedure: With the patient in the Trendelenburg position with the legs apart. Connecting tissue between the spleen and stomach was preserved in both procedures Results: For 4 years, there were 10 cases of SVP-LSPDP and 3 cases of L-Warshaw operation. Median operation time and operative bleeding were 364 (246–584) minutes and 63 (0–780) g, respectively. Five cases had postoperative complications (pancreatic fistula: 4, and abdominal abscess formation: (1). All patients had good patency of the splenic artery and vein. Case presentations: Case 1: A woman in her 60 s with pancreas neuroendocrine tumor (pNET). SVP-LSPDP was selected as treatment for her tumor. Major intra-operative bleeding from the splenic vein and artery was treated with a tissue sealing sheet after vascular clamping. Case 2: A woman in her 60 s with metastatic tumor from renal cancer in the pancreatic body. L-Warshaw operation was selected as treatment for her tumor, because the tumor was closely attached to the splenic vein. After pancreatectomy, large part of splenic ischemia was seen due to some splenic arterial branch injuries. A postoperative CT scan revealed a very small splenic infarction. Additional splenectomy was not required, because we preserved the whole collateral flow from surrounding tissue to the spleen. Conclusion: Standardization of the surgical procedure will lead to satisfactory results in LSPDP.

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P410 - Pancreas

P412 - Pancreas

Pancreatic Exocrine Secretion Modulates Copper Absorption in Man and is Therefore Important in Copper Homeostasis

Fluorescence Assissted Pancreatic Surgery on a Pancreatic Tumor Animal Model

P.R.S. Tasker, H. Sharma, M. Case, J.M. Braganza

F.M. Sa´nchez Margallo1, J.A. Sa´nchez Margallo2, T. Langø2

Manchester Royal Infirmary, MANCHESTER, United Kingdom

´ CERES, Spain; Minimally Invasive Surgery Centre Jesus Uson, CA SINTEF Technology and Society, TRONDHEIM, Norway

1 2

Aim: To determine the influence of pancreatic exocrine function in man. Method: 64Cu absorption was measured using computerised deconvolution of serum samples Results: Patients with clinical pancreatic insufficiency (CPI) have almost zero useful pancreatic function. In these patients 64Cu absorption is reduced on the water-based tests (32%). However, by adding supplements with the dose 64Cu absorption in two patients was normal (42%). With casein-based meal, the fall in absorption is double (15%), compared to two close-fitting controls (31%). The rate of 64Cu-caeruloplasmin synthesis in chronic pancreatitis, in the water-based test, was elevated compared to the control group; this was more significant (P2 P \ 0.001) throughout when expressing the results in terms of the percentage absorption. Thus in spite of lower absorption there was a greater metabolism of 64Cu in chronic pancreatitis. Lower absorption to 20% was seen in two patients with primary biliary cirrhosis (PBI). Here Cu status was elevated; cu absorption was limited by the rise in copper status. Experimental work in rats suggests that pancreatic exocrine insufficiency leads to increased Cu status; an effect reversed by giving pancreatic supplements. Experimental perfusions of gut at set pH showed greater acidity or reduced pH led to more 64Cu being absorbed. Due to the strong alkaline duodenal tide, instillation of strong acid or alkali had little effect on gut luminal pH. Thus, rat pancreatic juice instillations compared to saline instillations causing a lowering of 64Cu retention wasn’t due to pH but some component in pancreatic juice. This depression in absorption was more likely due to the protein content of the juice than elevation of Zn levels. Metallothionein reaches high levels in the stimulated secretion from the mouse pancreas. Conclusion: Pancreatic insufficiency in man causes abnormal accumulation of copper which leads to a reduced absorption of 64Cu on testing but a greater rate of synthesis of 64Cu-caeruloplasmin and, because recent metabolic studies in man show the influence of Cu status on Cu absorption, this can now be explained on the basis of increased Cu status rather than depletion.

Aims: The goal of this study is to prove the feasibility of developing a pancreatic tumor animal model and to determine the usefulness of near infrared (NIR) technology for image guidance in laparoscopic pancreaticoduodenectomy and single-site distal pancreatectomy. Methods: An experimental porcine model of an artificial pancreatic tumor was created on the head and tail of the pancreas in two and one animals, respectively. A mixture of saline and alginate was percutaneously injected to reproduce each tumor. Laparoscopic pancreaticoduodenectomy was performed for the tumors on the head of the pancreas and singlesite distal pancreatectomy for the tumor on the tail. For image guidance during surgery, Indocyanine green (ICG) was intravenously injected 30 min prior to the intervention. Doses of 5 mg and 10 mg (2.5 mg/ml) were used during the laparoscopic pancreaticoduodenectomies and 5 mg during the distal pancreatectomy. Image1 SPIESTM was used as imaging system. Patency of the hepaticojejunostomy was assessed by means of ICG and fluoroscopic imaging. For fluoroscopy assessment, contrast agent was injected through the common bile duct. Results: Artificial pancreatic tumors were successfully developed in the three animals and all procedures were completed without complications. Fluorescence visualization of the gallbladder and common bile duct was possible in all procedures, but this was clearer with the increase of ICG dose. Visualization of the gallbladder and common bile duct provided crucial information to find a suitable dissection point during laparoscopic pancreaticoduodenectomies. Fluorescence identification of the pancreatic artery improved with the dose of 10 mg ICG. Patency of the hepaticojejunostomy by means of biliary excretion of ICG was not clearly visualized in any of the two cases. However, patency test using fluorescence imaging was positive in one anastomosis. Conclusions: The creation of artificial pancreatic tumors on the head and tail of the pancreas was feasible. Dose of 10 mg of ICG improved the fluorescence visualization of both common bile duct and pancreatic artery during pancreatic surgery. Therefore, this imaging technique could be beneficial during pancreatic surgery in cases where the surgical anatomy is difficult to identify. Further studies should be done to optimize injection time and dose of ICG.

P411 - Pancreas

P414 - Pancreas

Irreversible Electroporation - New Minimally Invasive Method of Treatment of Locally Advanced Pancreatic Cancer

Laparoscopic Distal Pancreatectomy : Our Standardized Procedure

D.N. Panchenkov1, Y.U.V. Ivanov2, N.A. Soloviev2, A.I. Zlobin1, D.A. Astakhov1, A.A. Nechunaev1

T. Goto Kobe University, KOBE, Japan

1

A.I.Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 2Federal Research Centre of Specialized Medical Care and Medical technologies FMB, MOSCOW, Russia Introduction: The methods of local destruction now a day are not widely spread in treatment of pancreatic cancer because of characteristics of blood supply, anatomic and histologic structure of pancreas and high rate of complications and recurrence. The method if irreversible electroporation (IRE) is a new unique technology of non-thermal ablation directed to destruction of cancerous cells by subjecting them to a series of short electrical pulses using high-voltage direct current. This creates multiple holes in the cell membrane, irreversibly damaging the cell’s homeostasis mechanisms and leading to cell death. Aim of the study: To estimate the possibilities of IRE in treatment of locally advanced pancreatic cancer (LAPC). Method: 18 patients underwent IRE for unresectable LAPC with ‘Nanoknife’ surgical system. Our experience shows the following advantages of IRE: comparable technical simplicity, safety for vascular and duct structures, minimal impact on the pancreas. Results: The efficacy of IRE proved with ultrasound, CT and histologic (biopsy) investigation in postoperative period. The maximal period of supervision was 19 months. In one case acute pancreatitis noticed on the 8th day after the procedure with following successful conservative treatment. Conclusions: Though the definite indications to IRE in patients with LAPC are not established but the world results and our own first experience permit to acknowledge the efficacy of this technique in palliative surgical treatment of LAPC and its safety.

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Background: With the approval of the ethical committee of our hospital, we introduced laparoscopic pancreas surgery (LPS) in March 2007. Indications of LPS in our center are benign, borderline and low-grade malignant tumors. We gradually standardized our surgical procedure. Object: To report our experience with LPS to introduce a safe procedure and how to inherit and develop the surgical technique in LPS. Results: The number of subjects with IPMN, MCN, NET, SCN, and others were 31, 16, 9, 5 and 8, respectively. Median age was 60 and mean tumor size was 3.5 cm. We performed 1 laparoscopic-assisted distal pancreatectomy (extraperitoneal resection), 8 HALS-DP, 1 HALS-SPDP, 53 LAP-DP, and 6 LAP-SPDP. The median operative time was 339 min and hemorrhagic volume was 177 ml. In Lap-DP, points of surgical procedure are (1) to make effective visual development by using tapes tugging stomach and pancreas (2) to use clamping device for pre-compression before dissecting pancreas parenchyma. Postoperative pancreatic fistula (grade B of the ISGPF classification) occurred in 12 (17%) patients. The mean postoperative number of days taken to initiate oral food intake was 3.3, and the mean length of the hospital stay was 16.6 days. No recurrent tumor was observed. Conclusion: Making a standardized procedure is the key to an effective way of transmitting the surgical technique from generation to generation.

Surg Endosc

P415 - Pancreas

P417 - Pancreas

Novel Method Using Lapra-Ty Suture for Pancreaticogastrostomy Following Laparoscopic Central Pancreatectomy

The Role of Endoscopic Ultrasonography Tattooing in Laparoscopic Surgery of Pancreatic Insulinomas

C. Takishita, Y. Nagakawa, Y. Hosokawa, Y. Sahara, T. Nakajima, Y. Hijikata, K. Kasuya, A. Tsuchida

C. Aggeli1, A.M. Nixon1, I. Karoumpalis1, G. Kaltsas2, G.N. Zografos1 1

Athens General Hospital ‘Georgios Gennimatas’, ATHENS, Greece; National University of Athens, ,,Laiko,, Hospital, ATHENS, Greece

Tokyo Medical University Hospital, TOKYO, Japan

2

Background/Rationale: Although laparoscopic central pancreatectomy (Lap-CP) has been expected as minimally invasive surgery for patients with benign and borderline malignant pancreatic tumor, the reconstruction under laparoscopic procedure is still technically difficult. Herein, we developed novel procedure using LAPRA-TY Suture Clip for pancreaticogastrostomy(PG) with the safety and reliability. Method Surgical Technique: The patient was placed in supine position and five ports were placed. The round ligament of the liver and the posterior wall of the stomach were fixed to the abdominal wall to secure the surgical view. The pancreatic neck was transected using staple. The pancreatic body was isolated from the splenic artery and vein, an then pancreatic gland was transected at appropriate position using Harmoic. Laparoscopic PG (invagination method) was attempted for reconstruction. The anterior and posterior wall of the stomach were opened, then anastomosis was performed through an anterior gastrotomy under a coaxial setting position. An end-to-side pancreaticogastric anastomosis was performed using 4-0 absorbable monofilament thread. After sewing pancreatic parenchyma and gastric wall, assistant retracted the sewed threads to anterior side, and then each threads was knotted using Lapra-Ty clip. Each threads was knotted with optimal firmness. Finally, the pancreatic stump was embedded into the posterior wall of the stomach with 12 sutures, and then the anterior wall of the stomach was closed. Result: PG following Lap-CP was performed in 7 patients between September 2013 and February 2015. Mean operation time was 482 min and mean blood loss was 40 g.The incident rate of postoperative pancreatic fistula (GradeB/C was 14.3%) Conclusion: This method is a feasible and safe for PG following Lap-CP, which can be an alternative method for pancreatic reconstruction.

Aims: Insulinomas are typically small, solitary and benign and are predominantly located in the body and tail of the pancreas. Laparoscopic excision has emerged as the procedure of choice due to its safety and efficacy. Preoperative localization dictates the appropriate surgical approach. Biphasic thin section helical computerized tomography (CT) with endoscopic ultrasound (EUS) are associated with an almost 100% sensitivity in localizing insulinomas. In situations where laparoscopic ultrasound (US) is not available EUS-guided fine needle tattooing is an alternative method of localization. Methods: After abnormal serum insulin concentrations have established insulinoma diagnosis, dual-phase thin-section multidetector CT in tandem with EUS are performed in all patients. EUS permits fine-needle aspiration cytology of the lesion and reveals its proximity to the pancreatic duct. Once the tumor’s location and the relationship to the pancreatic duct have been determined, decision for laparoscopic enucleation or distal resection is made. A second EUS is performed one to two hours before the operation where trans-gastric injection of 1 cc methylene blue dye in the tumor is performed. During laparoscopy the pancreas is exposed after division of the gastrocolic ligament and cephalad retraction of the stomach. The anterior surface of the pancreas is exposed and usually a coloured area at the anterior surface of the pancreas is clearly visualized. Lesions at the anterior or inferior surface of the pancreas require minimal mobilization. Conversely, lesions at the posterior or superior surface demand adequate mobilization of the body and tail. The insulinoma is then enucleated or a distal resection is made and the tumor is submitted for frozen section and histology. Results: Tattooing was performed in 6 patients (2 males, 4 females). Five laparoscopic enucleations were done. There was no mortality. There was one conversion to open surgery due to difficulty of localizing the tumor laparoscopically which resulted in peripheral pancreatectomy. Two patients developed pancreatic fistula which resolved spontaneously after a period of 15 days. Conclusions: EUS-guided fine needle tattooing of insulinomas is a safe and effective method of preoperative localization of these small lesions and permits the performance of laparoscopic excision in centers without availability of laparoscopic ultrasound.

P416 - Pancreas

P418 - Pancreas

Robotic-Assisted Distal Pancreatectomy Compared to Laparoscopic and Open Approach

Laparoscopic Pancreatoduodenectomy for Elderly Patients with Cancer for elderly patients with cancer

H. Duran Gimenez-Rico, E. Vicente Lopez, Y. Quijano Collazo, E. Diaz Reques, I. Fabra Cabrera, B. Ielpo, R. Caruso, L. Malave, V. Ferri

P. Tyutyunnik, D. Rotin, S. Drapun

SANCHINARRO UNIVERSITY HOSPITAL, MADRID, Spain Objective: In the area related to pancreatic surgery, robotic procedures have not yet been evaluated against the high standards of open and laparoscopic approaches. The present study aims to compare the results between robotic distal pancreatectomy against laparoscopic and open surgery. Methods: A retrospective study of 57 patients who were subjected to distal pancreatectomy in our center between 2008 and 2015, with three different approaches: 19 robotic, 18 laparoscopic and 20 with open surgeries. Results: No significant differences exist between groups concerning preoperative data. Conversion rate was higher in the laparoscopic group, 20% versus 5% in robotics one.Significant differences exist in blood loss in the open group (mean: 375 ml) compared to robotics (mean 210 ml) (P \ 0.001) or laparoscopic (0 units) technique (P \ 0.01). The hospital stay was shorter in the robotic group (9.25 days) compared with laparoscopy (19.16 days) and the open group (17.36 days) (p \ 0.05). All surgical procedures resulted to be R0 with a higher mean number of resected lymphnodes in the open group (13.2), followed by robotic (12.5) and laparoscopic (5) group (p \ 0.05). Significant perioperative morbidity (Clavien III/IV) was lower in the robotic group (10%) when compared with laparoscopic (44%) and to open group (30%) (p \ 0.01). Conclusions: Our study suggests that robotic distal pancreatectomy is a safe and efficient procedure as the laparoscopic and open approach.

Moscow Clinical Scientific Center, MOSCOW, Russia Introduction: The length of life increase thuswise there are more senior patients with pancreatic and periampullary cancer. Laparoscopic pancreatoduodenectomy for elderly patients is not widely describe in the literature so far. Purpose: Evaluate using of laparoscopic pancreatoduodenectomy for patients older 75 years with pancreatic and periampullary cancer. Patients and Methods: From January 2007 to December 2014 sixteen patients older 75 years with pancreatic and periampullary cancer were underwent laparoscopic pancreatoduodenectomy. Median age was 76 (75–82) years. Fourteen laparoscopic Whipple procedure and two Longmare-Traverso procedure were done. Final histological examination were represented: duodenal cancer n4, distal biliary duct cancer n4, panceratic cancer n8. T2N0M0 - n4, T3N0M0 - n4, T2N1M0 - n1 and T3N1M0 - n7. All patients had ASA 3. The operation time, blood loss, complications rate and the length of stay were evaluated. Results: Median operation time for both laparoscopic pancreatoduodenectomy 385 (325–660) min. Median blood loss 150 (10–1000) ml. Postoperative complications (Clavien-Dindo-Strasberg): IIIa (n-2), IIIb (n-2), IV (n-0) ? V (n-0). Pancreatic fistula grade B (International Study Group of Pancreatic Surgery (ISGPS)) - n2, pancreatic fistula grade C (ISGPS) - n1. Median length of stay 13.5 (7–39) days. Conclusion: All benefits of laparoscopic surgery for patients older 75 years with pancreatic and periampullary cancer are achievable. Laparoscopic pancreatoduodenectomy for senior patients with pancreatic and periampullary cancer is feasible and safe.

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Surg Endosc

P419 - Radiology/Imaging

P421 - Robotics, Telesurgery and Virtual Reality

Resection of the Stomach with Intraoperative Fluoloscopy for Early Gastric Cancer

A Single Center Experience of Robotic Assisted Liver Resection. IMPROVEMENT Over the Course of Experience

J. Kawachi

V. Ferri, E. Vicente Lopez, Y. Quijano Collazo, H. Duran GimenezRico, E. Diaz Reques, I. Fabra Cabrera, B. Ielpo, R. Caruso, L. Malave

Shonan Kamakura General Hospital, KAMAKURA,KANAGAWA, Japan Introduction: In japan, laparoscopic distal gastrectomy in common for early gastric cancer.Formerly,we used to decide the proximal incisional line making sure the location of the marking clip with our hands,after taking out the stomack through the epigastric small incision. In 2015, we introduced ingraabdominal recontsruction (Billroth I or Roux-en-Y) and started to decide the incisional line using the intraperative fluoloscopy.We verify the efficacy and safety of this procedure. Method: Eight cases of this procedure have been implemented.The day before operation, we clip the several points along 2 cm proximal to the cancer edge endoscopically. After lymph node disscetion, we incise a stomach with the autosuturing device using ingraoperative fluoroscopy to locate clips All cases were reconstructed with Billroth I or Roux-enY procedure. We studied the proximal distance, operative time, and complication. Result: We had 7 cases which the average of proximnal distance was 30.6 mm. No additional incision was needed and the average of operative time is 4 h and 47 min. Also, no major complication was observed. Conclusion: the resection of the stomach with intraoperative fluocloscopy in considered to be safe and effective.

SANCHINARRO UNIVERSITY HOSPITAL, MADRID, Spain Objective: The use of robotic surgery in liver resection is still limited. Our aim is to present the early experience of robotic liver resection of a single surgical center. Methods: It is a retrospective review of Sanchinarro University hospital of Madrid experience of robotic liver resection performed from 2011 to 2014. Clinicopathological characteristics, perioperative and postoperative outcomes were recorded and analyzed. Results: Twenty-one procedures have been performed and 13 (65%) of them were for malignancy. There were 2 left hepatectomies, one right hepatectomy, one ALPPS procedure (both steps by robotic approach), one bisegmentectomy and 3 segmentectomies, 9 wedge resections and 3 pericystectomies. The mean operating time was 282 min (range 90–540 min). Overall conversion rate and postoperative complication rate were 4.7% and 19%, respectively. Regarding malignancy, observed at pathological exam, all specimen margins showed to be free of disease. The malignant tumor size ranged from 1 to 7 cm with a mean size of 4.3 cm. The mean length of hospital stay was 13.4 days (range 4–64 days). Conclusions: According to our early experience from a single surgical center, robotic liver resection is a safe and feasible procedure from the beginning of its use, even if major hepatectomies and a number of malignacies are included. We expect improvement over the course of experience.

P420 - Robotics, Telesurgery and Virtual Reality

P422 - Robotics, Telesurgery and Virtual Reality

Robotic Assisted Pancreatic Resection: Improvement Over the Course of Single Center Experience

Robot-Assisted Gastroduodenal Surgery: Five Years Single Center Experience

V. Ferri, Y. Quijano Collazo, E. Vicente Lopez, H. Duran GimenezRico, E. Diaz Reques, I. Fabra Cabrera, B. Ielpo, R. Caruso, L. Malave

R. Caruso, E. Vicente Lopez, Y. Quijano Collazo, H. Duran GimenezRico, E. Diaz Reques, I. Fabra Cabrera, B. Ielpo, L. Malave, V. Ferri

SANCHINARRO UNIVERSITY HOSPITAL, MADRID, Spain

Objective: Robot-assisted gastroduodenal surgery (RAS) provides a 3D-amplified view to the surgeons and an increased ability to control the operative field by manipulating optics, as well as enhanced mobility and precision of instruments. The aim of the present study is to evaluate the main outcome of a single center experience in gastroduodenal robotic surgery. Materials and Methods: We report a case series of patients who underwent robot-assisted gastroduodenal surgery at Sanchinarro University Hospital between January 2010 and March 2015. Main patient demographic characteristics, type of surgery, peri and postoperative data and follow-up were evaluated. Results: A total of 27 consecutive robotic gastroduodenal resections were analyzed, 14 women and 13 men, with a mean age of 62.4 years (22–80). According to the anesthetic classification, 5 patients were ASA I, 19 patients ASA II and only 3 patients ASA III. In 90% of patients the surgical indication was for malignant disease: 17 gastric adenocarcinomas, 6 GIST, 1 neuroendocrine tumor, 1 submucosal lipoma and 2 pancreatic heterotopia was. Were performed 16 total gastrectomy, 4 subtotal gastrectomy, 4 enucleations of duodenal tumors and 3 atypical partial resections of gastric wall. Intracorporeal esophagojejunostomy anastomosis was performed manually in 12 cases. Conversion to open procedure was required in 4 patients. The mean operative time was 360 min (range 210–720 min). The mean blood intraoperative transfusion was 0.4 (0–2 units). The mean stay in intensive care was 1,5 (0–11) days and the mean hospital length of stay was 12 days (3–26). Complications occurred in three patients, of which 1 case was due to an intraabdominal collection. Another complication was stenosis of jejuno-jejunal anastomosis caused by torsion with ischaemic damage which required surgical reinterventation. The last complication was due to acute pulmonary edema secondary to heart failure. There were no anastomotic leakages. No case of postoperative mortality was recorded. Conclusions: Robot-assisted gastroduodenal surgery is a safe and feasible technique in experienced centers with advanced robotic skills. In the literature, there are only few reports of robotic assisted gastroduodenal resection. Further studies are necessary to better confirme our results.

Objective: Robotic assisted minimally invasive surgery in pancreatic field has gained world-wide acceptance because it offers severals advantages compared to laparoscopic approach. However, in the literature only few reports are reported. The aim of the present study is to present the experience of robotic pancreatic resection and the improvement over the course of a single center. Methods: Perioperative outcomes of patients who underwent robotic pancreatic resection between October 2010 and May 2015 at our institution by a single surgical team were analyzed. Results: We performed 45 consecutive robotic pancreatic resections: 20 distal pancreatectomy, 13 pancreatic enucleation, 11 pancreaticoduodenectomy, 1 central pancreatectomy. All procedures were R0. Mortality was 2%. Rate of Clavien = IIIb was 13.6%. The International Study Group on Pancreatic Fistula grade A and B fistula rate was 4.5% and 4.5%, respectively. Biliary leak rate was 6.8%. Conversion to open procedure was required in 6 patients (13.6%) Mean hospital stay was 11.9 days. Continuous improvement in operative times, post operative morbidity as well as conversion to open approach was observed over the course of the experience. Conclusions: Our series of robot-assisted pancreatic resections adds further evidence that this technique is feasible and effective in centre with advanced robotic experience.

123

SANCHINARRO UNIVERSITY HOSPITAL, MADRID, Spain

Surg Endosc

P423 - Robotics, Telesurgery and Virtual Reality

P425 - Robotics, Telesurgery and Virtual Reality

Insight into the Da Vinci Xi - Technical Notes for Left-Sided Colorectal Procedures

The Mesorectal Fascia: Do you Mean What I Mean? Embryologic Planes Demonstrated with Robot Assisted Laparoscopy

J. Ngu, S. Sim, S. Yusof, C.Y. Ng, S.Y. Wong

R.M.P.H. Crolla

Changi General Hospital, SINGAPORE, Singapore

Amphia, BREDA, The Netherlands

Purpose: The adoption of robot-assisted laparoscopic colorectal surgery has been limited by issues with docking, operative duration, technical difficulties in multiquadrant access, and cost. The da Vinci Xi Surgical System has been designed to overcome some of these barriers. We describe our initial experience with the system and offer technical insights to its application. Methods: Various combinations of procedure settings and robot docking configurations were evaluated prior to implementation in live surgery. Technical issues encountered throughout our initial series were systematically recorded and critically analysed. Results: Between May 2015 and December 2015, 36 cases of robot-assisted laparoscopic colorectal procedures were successfully completed. The majority consisted of left-sided oncological resections. Port placement and robot docking were more straightforward compared to earlier versions of the da Vinci surgical system. Multiquadrant surgery involving dissection from the splenic flexure to the pelvis is now possible with a single docking of the da Vinci Xi. Conclusions: The da Vinci Xi manages to overcome several technical limitations faced by earlier adopters of robotic colorectal surgery.

Aims: The concept of operating in rectal cancer surgery along the ‘holy plane’ has been propagated by Bill Heald in order to remove the rectal cancer with clear surgical margins to decrease the risk of local recurrence. In the surgical and anatomical literature there is no consistent terminology to describe the planes around the rectum. Total mesorectal excision, extrafascial resection, fascia propria recti, Waldeyer’s fascia, mesorectal fascia, rectal adventitia, presacral fascia, rectosacral fascia, hypogastric nerve sheath, prehypogastric nerve fascia etc. are all terms that are used without consistency. So what exactly is the holy plane that doesn’t compromise the concept of removing the rectum within its embryologic entity and without damaging the structures like bloodvessels and hypogastric and splanchnic nerves that surround the rectal envelop. Method and results: In this video the ideal dissection line is demonstrated in three cases. It is shown that the fat forming the mesorectum is surrounded by a very thin visceral layer or fascia. This layer is consistent with the embryologic layers along which surgeons mobilize the colon. It’s origin may be mesothelial. It is not a strong thick layer of connective tissue as surgeons commonly characterize a fascia. Between the mesorectum and hypogastric nerves there is a layer of loose connective tissue. In this layer one can dissect at several levels and it is possible to create several fascia by condensing the connective tissue at several levels. Those fascia are not fascia that should be created. Conclusion: The ideal dissection line is along the innermost border of the connective tissue next to the very thin embryologic visceral border of the rectal compartment. This dissection line is shown in the video.

P424 - Robotics, Telesurgery and Virtual Reality

P426 - Robotics, Telesurgery and Virtual Reality

Robotic Colorectal Surgery. Experience of 160 Operations 1

2

M.E. Moiseev , D.V. Gladyshev, D.S. Shelegetov , S.A. Kovalenko

1

1

Cyti Hospital #40, SAINT-PETERSBURG, SESTRORECK, Russia; 2 Military-medical Academy, ST. PETERSBURG, Russia Endoscopic surgery for colon cancer is currently well recognized by most specialists worldwide. However, some specific limitations of traditional laparoscopic technique cause intraoperative difficulties. Using da Vinci robotic surgical system may overcome these limitations. From August 2013 to January 2016 160 robotic colorectal cancer cases were performed. Among them: right hemicolectomy - 25, left hemicolectomy - 5, sigmoid resection - 40, anterior resection of the rectum - 84 (35 with TME), abdominoperineal extirpation of rectum - 5, subtotal colectomy in one case. 59 patients were men, 101 - women. Age from 23 to 88 years. BMI between 18,5 and 38. Histologic type of tumor was adenocarcinoma. 13 patients with rectal cancer was treated with neoadjuvant chemoradiotherapy. Preferred operative technique involves medial–lateral mobilization of colon with high vessel ligation. In case of rectal caner we use a single docking technique. In patients with low anterior resection Tornbulls ileostomy was performed. Short-term results: length of the procedure was 152,6 ± 6,9 min (ascending and sigmoid colon) and 206,5 ± 4,7 min in rectal cancer cases. Intraoperative blood loss during colonic cancer cases was 69,4 ± 9,1 ml. and 102,2 ± 11,3 ml - in rectal cases. First bowel movement time was - 1,9 ± 0,1 days. Duration of hospital stay - 8,7 ± 0,4 days. Postoperative complications were observed in 15 cases (9.6%). In six cases - intestinal anastomosis leakage, in six cases - early postoperative intestinal obstruction, in one case postoperative bleeding, in one case - abdominal abscess and in one case - varicose esophageal bleeding. There were 4 conversions (2.5%). Conversions were predominately associated with the preoperatively undiagnosed involvement of adjacent structures to pathologic process. In-hospital mortality was 1,9% (3 patients). Oncological results: the average number of lymph nodes removed was 12,9 ± 0,3. In 2 TME cases (49 partial and 35 total) positive margin was recognized (patients after neoadjuvant chemoradiation). TME quality was rated as good (Grade-3) in 20 cases, satisfactory (Grade-2) and in 12 cases and as unsatisfactory (Grade-1) in 3 cases. Our first experience with this technique demonstrate potential advantages, especially for the surgeon.

Use of Bipolar Vessel Sealer Device in Abdominal Robotic Surgery M. Ortenzi1, R. Ghiselli1, P. Sperti2, G. Belfiori2, M. Guerrieri1 1

Universita` Politecnica delle Marche, ANCONA, Italy; 2Clinica chirurgica, ANCONA, Italy

Introduction: In the last ten years several robotic systems have begun to be broadly employed in general surgery. Vascular control during minimally invasive procedures is crucial. The newest robotic bipolar vessel sealing tools have been described as effective to seal vessels up to 7 mm in diameter, letting to perform the procedures with reduced blood loss and operative time. The aim of this retrospective study was to assess the efficacy and reliability of this device used in different robotic procedures investigating operating data and postoperative course. Patients and Methods: We restrospectively analyzed data collected from all robotic procedures performed in our centre.The EndoWrist One VesselSealer (Intuitive Surgical, Sunnyvale, California), a fully wristed bipolar device designed for the da Vinci Si surgical system (Intuitive Surgical, Sunnyvale, California), was used to coagulate and dissect tissues in all the interventions. Data including age, gender, body mass index (BMI) were collected. Robot docking time, overall operative time, intraoperative blood loss and robot malfunctioning wereanalyzed. Results: Between November 2013 and November 2015 Seventy-three robotic procedures were performed, consisting in 32 right colectomies, 18 Nissen funduplications, 10 ventral rectopexies, 7 left colectomies, 2 left adrenalectomies and 1 splenectomy.Mean operative time was 118.2 min (75–125 min) without robot docking or undocking time. Mean robot docking time was 43.2 min (20–60 min). Despite considering different procedures a significative correlation was found between number of intervention and the decreasing in robot docking according to Pearson test (r = -0.534), and between number of intervention and operative time for the three most performed procedures: right colectomy, funduplications and rectopexies (r = 0.85, r = 0.67, r = 0,48). Exstimated mean blood loss was 103 ml (10–250 ml). There were no intraoperative complications and two postoperative complications (2.74%). Conclusions: The bipolar vessel sealer device offers the advantages of bipolar diathermy fully wristed instrument. It is under the direct control of the first surgeon from the console and do not require instruments exchange for coagulation or involvement of the bedassisstant surgeon. This characteristics results in the reduction of blood loss, operative time and in a faster learning curve.

123

Surg Endosc

P427 - Robotics, Telesurgery and Virtual Reality

P429 - Robotics, Telesurgery and Virtual Reality

First Year Results of Robot-Assisted Colorectal Surgery: Single Center Experience of 80 Consecutive Patients

Robotic Approach for Colorectal Cancer in Slovenia-First 25 Cases

K. Dogan, D. Faraj, F. Polat

I. Cerni, O. Stefanovski, M. Podgorsˇek

Canisius Wilhelmina Ziekenhuis, NIJMEGEN, The Netherlands

General and teaching hospital Celje, CELJE, Slovenia

Aims: Minimally invasive surgery is an important modality in colorectal surgery. Robotassisted surgery made its appearance the last years. Although there is lacking of high evidence literature, robot-assisted colorectal surgery (RACRS) seems to be an auspicious technique and it gains interest of colorectal surgeons. The aim of this present study was to evaluate the feasibility and safety of RACRS. Methods: Prospectively collected peri-operative data of 80 consecutive patients who underwent surgery (between dec-2014 and dec-2015) for colorectal cancer or a benign pathology were analyzed. All procedures were performed with the Davinci Xi Robot. All procedures were performed by 2 dedicated GI surgeons who had extensive experiences in laparoscopic colorectal surgery. Primary outcomes were oncologic outcomes (radical margins, lymph nodes). Secondary outcomes were major complications (e.g. anastomotic leakage, re-operations, mortality), hospitalization and operation time. Results: In total 81 procedures were analyzed. One patient underwent a right colon resection and low-anterior resection in the same session because of double tumor. There were 53 male (66%) patients, mean BMI was 26.6 kg/m2 and mean age of 68 years. 14 patients were classified as ASA 1, 54 as ASA 2 and 12 as ASA 3. 14 patients had a benign pathology (adenoma/diverticulosis) and 66 malignant pathology (carcinoma). Type of operation was distributed as: 37 sigmoidal resections, 18 low-anterior resections, 3 abdomino-perineal resections, 12 right colon resections, and 2 left colon resections. 4 patients were managed with neoadjuvant chemotherapie. All malignant tumors were radically resected. The average harvested lymphe nodes in patients operated for a malignant tumor was 16.8. The average of total operating time was 190 min; the average incision time was 144 min. The conversion rate was 7.4% (6/81). The re-operation rate was 8.6% (7/81) and the anastomotic leakage rate was 3.7% (3/81). The median hospital stay was 5 days. There was no 30-day mortality. Conclusion: Robot-assisted colorectal surgery seems feasible and safe. The oncologic outcomes and complications are comparable with other conventional techniques. However larger studies should corroborate these findings.

Introduction: Laparoscopic sergurgy is the therapy of choice in the patients with benign and malignant lesions of the large bowel. Following the successful introduction of robotic surgery to the field of urology, its use more and more in the field of colorectal sergury. We present our initial observations and results of robotic operations of the large intestine with special regard to the patient undergoing robotic surgery for colon rectum cancer. Methods: The first robotic - assisted resection of rectum cancer with hybrid technique, we performed in our department 2010. In May 2014 we started again and the first total robotic assisted resection of colon rectum cancer were performed. Until December 2015, 25 patients were operated(female-14, male-11). The colorectal carcinoma were presented in 86% of patients, the others had diverticulosis and other benign disease. The average age was 64,5 years(female- 61,5;male 65,8). In five cases preoperative radiotherapy and chemotherapy was performed. ASA classification: ASA I (36%), ASA II (64%). Results: In all patients radical resection has been done. We performed 3 sigma resection, 4 rectosigma, 9 anterior rectum resections, 5 low anterior rectum resections, 3 right hemicolectomy, 1 left hemicolectomy. In 3 cases protective ileostomy has been done. The pathological stage was: Stage I (57%), stage II (8%), stage III (35%). The average lenght of stay in hospital was 6,5 days. The average number of lymph nodes was 17,5. Intraoperative blood loss has been minimal(0-150 ml). We had no conversion, in one case we had to perform reoperation, because of peritonitis. Conclusion: The robotic surgical system Da VinciS can help us to overcome step learning curves and give us more chances of minimally invasive surgery, especially for rectal cancer. There are this advantages and limitations of robotic colorectal surgery such as: high cost, limited range of motion that is not fit for multiquadrant surgery like rectal surgery, but robotic surgery is safe and feasible option in colorectal surgery and a promising field.

P428 - Robotics, Telesurgery and Virtual Reality

P430 - Robotics, Telesurgery and Virtual Reality

Indications of the Robotic Approach in a General Surgery Department: An Analysis of 1000 Cases Performed in a Single Center

The Implementation of Robotic Surgery in Colorectal Surgery: How we did it?

O.M. Stanciulea, M.A. Eftimie, I.B. Mosteanu, V.N. Tomulescu, C. Vasilescu, I. Popescu

Canisius-Wilhelmina Hospital, NIJMEGEN, The Netherlands

Fundeni Clinical Institute, BUCHAREST, Romania Aims: The robotic surgery has opened a new era in general surgery, but due to its high cost and in spite of its technical benefits, the adoption of the technique was slower, compared with the laparoscopy. The study aims to evaluate the results of an institutional experience with robotic procedures and, thus, to identify the procedures that would benefit the most from the advantages conferred by the robotic system. Methods: Between January 2008 and December 2015 a total number of 1000 patients underwent a robotic procedure in our Department. The data were retrospectively analyzed in terms of demographics, surgical techniques and postoperative outcomes. Results: The robotic approach was used for: procedures performed frequently using the laparoscopic approach (benign GE junction surgery, colonic resection, splenectomy, adrenalectomy, hysterectomy, minor liver resections), procedures performed using laparoscopic approach in a limited number of cases (distal pancreatectomies, resections for mid-rectal cancers, radical surgery for gynecological cancers) and procedures never performed using the laparoscopic approach (pancreatic resections requiring reconstructions, major liver resection,radical resections for gastric cancer,para-aortic lymph nodes dissection for endometrial cancer,redo surgery for achalasia). 56% of all the procedures were performed for malignat diseases. The conversion rate was 2.6%. The overall postoperative morbidity rate was 21%, with a 2.4% reoperation rate. The mean hospital lenght of stay was 8 days. Conclusions: The robotic approach in general surgery can be safely performed, with low morbidity and low conversion rates. The robotic system allowed us to extend the indications of minimally invasive surgery.Difficult laparoscopic procedures like pelvic cancers, redo surgery for GE benign pathology and hepatobiliopancreatic surgery benefits the most from the advantages of the robotic system.

123

D. Faraj, K. Dogan, F. Polat

Aims: Robot-assisted surgery is an upcoming modality in colorectal surgery and it is gaining ground in a breakneck speed. The objective of this article was to summarize the implementation process of robot-assisted colorectal surgery as a novel modality in a training hospital. Methods: The training module/certification process consisted of observation, online modules, hands-on-courses and supervised/proctored procedures facilitated by Intuitive. First, 2 dedicated laparoscopic gastro-intestinal surgeons followed case observations in a hospital were robotic surgery was a standard management strategy of patients with colorectal carcinoma. Second, they joined the online community and followed an E-learning module. This was followed by hands-on courses with the DaVinci on pigs. Thereafter, the 2 surgeons were certified to perform robot-assisted colorectal surgery under supervision of a proctor. To create dedicated teams, the OR-nurses followed similar courses. After a pilot of 20 patients, the department was visited by an advanced international proctor. Additionally, the surgical team is able to improve and maintain their skills through virtual reality training modules. Patients with colorectal carcinoma or benign pathology were considerable for robot-assisted surgery. Results: Interim-analysis after first 20 consecutive patients whom underwent a robotassisted colorectal resection, showed similar oncologic results and complication rate compared to laparoscopic procedures in our clinic. This was the starting point of introduction of robot-assisted surgery as a standard modality beside laparoscopic surgery in patients who undergo a colorectal-resection. Nowadays, the surgical team is expanded with a senior GI-differentiated surgical resident. After one year, 80 patients underwent a colorectal resection with the Robot. Conclusion: The certification/implementation of robotic surgery in our clinic was commemorated and streamlined. The introduction was successful, however, long-term results must emphasize the safety and feasibility of robot surgery in the future.

Surg Endosc

P431 - Robotics, Telesurgery and Virtual Reality

P433 - Robotics, Telesurgery and Virtual Reality

Da Vinci Xi Full Robotic Colorectal Resections with Other Major Oncological Surgical Procedures: Preliminary Experience

Role of Robot-Assisted Surgery: Lessons Learned From Initial 231 Consecutive Procedures of a Single Center Institute

G. Di Franco1, S. Guadagni1, M. Palmeri1, G. Caprili1, F. Loupakis1, A. Moglia1, V. Ferrari1, F. Melfi2, A. Falcone1, G. di Candio1, F. Mosca1, L. Morelli1

R. Caruso, Y. Quijano Collazo, E. Vicente Lopez, H. Duran GimenezRico, E. Diaz Reques, I. Fabra Cabrera, B. Ielpo, L. Malave, V. Ferri SANCHINARRO UNIVERSITY HOSPITAL, MADRID, Spain

1

University of Pisa, PISA, Italy; 2AziendaOspedalieroUniversitariaPisana, PISA, Italy

Aims: The new characteristics of da Vinci Xi could have an important role in robotic multiquadrant surgery, especially in colorectal surgery and particularly in attaining fully robotic colorectal resection combined with other major surgical procedures. Methods: We reviewed the charts of all patients undergoing fully robotic combination procedures involving colorectal resections using the da Vinci Xi, from January 2015 to October 2015. Variables examined include patient demographic characteristics, preoperative data and postoperative variables. Ten patients were included in the study, including 12 colorectal procedures: 5 right hemicolectomy and 5 anterior rectal resections with TME were performed in combination with sigmoidectomy (1), right nephrectomy (2), hysterectomy (1), hepatic resection (3), enucleation of pancreatic tail lesion (2) and ileocecal resection (1). Results: All the operations were completed by a fully robotic approach, without conversion to hand assisted laparoscopy or laparotomy, and without hybrid approaches or without the need to change the robotic cart position. Trocar positions respected the Universal Port Placement Guidelines provided by Intuitive Surgical for ‘left lower quadrant’. Simultaneous procedures in the same quadrant or left quadrant and pelvis, or left/right and upper, were performed with a single docking/single targeting approach; in cases of left/right quadrant or right quadrant/pelvis, we performed a dual-dock operation where we re-targeted using the camera to orient the system towards the new work space (an opposite facing quadrant) and redocked the remaining arms. No external collisions or problems related to trocar positions were noted. Mean overall procedural time was 360 min (±128 min). No patient experienced postoperative surgical complications and the mean hospital stay was 6 days (±3 days). Conclusions:The herein presented a high success rate of robotic colorectal resection combined with other surgical interventions for synchronous tumors, without conversion or excessive operating time, suggest the efficacy of the robotic platform, and in particular the new released product da Vinci Xi, in minimally invasive multiquadrant combined surgery. A further possible advantage may be provided by da Vinci Xi Integrated Table Motion feature (available only in the EU), that allows patients to be repositioned without undocking the robot and without removing instruments from inside the abdomen.

Objective: In the last decade the growing interest in robotic surgery is evident as shown by several published articles. There are still few centers with extensive experience in robotic surgery. The most important reason is the high cost to set up a robotic surgery program. The aim of the present study is to evaluate the main outcome of a single center experience in robotic surgery. Matherials and metods: We report a case series of patients who underwent robot-assisted surgery at Sanchinarro University Hospital since the beginning of the program (October 2010) until november 2015 Main patient demographic characteristics, type of surgery, peri and post-operative data and follow-up were evaluated. Results: A total of 231 robotic procedures were performed for a total of 230 patients. The prevalence of malignant disease was 86%. In 2010, the first year of the robotic program, eight procedures were performed, in 2011 increased to 30, in 2012 72 procedures have been performed. In 2013 were 67 and until november 2015, 54 robotic surgeries have been performed. A total of 22 liver resections (mean operating time: 190 min) were performed; 23 gastrectomy (mean operating time 310 min); 50 pancreatic surgery; 10 esophagectomy (mean operating time: 490 min); 109 colorectal resections (78 rectal resections, 17 sigmoidectomy 9 hemicolectomies right, 5 left colectomy (mean operating time: 220 min); 4 Nissen procedures (mean operating time: 130 min), 2 Achalasia (operating time: 90 min); 3 adrenalectomy (mean operating time: 240 min). Four partial resection of the duodenum, one mesenteric cyst and 3 retroperitoneal tumor have been performed. Conversion rate was 6%, total morbidity have been 17%. There has been no peri and postoperative mortality up to 30 days after surgery. The average hospital stay and intensive care were respectively16 days (range 6–45 days) and 1.9 days (range 0–12 days). Conclusion: Robot-assisted surgery is a safe and feasible technique in experienced centers with advanced robotic skills. Robotic learning curve is shorter compared with the laparoscopic approach. The highest cumulative experience has allowed to incorporate increasingly complex procedures as major hepatectomy, duodenopancreatectomy and esophageal hiatal dissection.

P432 - Robotics, Telesurgery and Virtual Reality

P434 - Robotics, Telesurgery and Virtual Reality

Totally Robotic Right Colectomy for Colon Cancer Via Suprapubic Approach Using Da Vinci Xi System: Initial Clinical Experience

Intracorporeal Rectal Traction with a Beaded Plastic Hanger of Urinary Foley Catheter Bag in Robotic Rectal Cancer Surgery

H.J. Lee, G.S. Choi, J.S. Park, S.Y. Park, H.J. Kim Kyungpook National University Medical Center, DAEGU, Republic of Korea Purpose: We described our technique of totally robotic right colectomy with D3 lymphadenectomy and intracorporeal anastomosis via suprapubic approach, with an assessment of short-term outcomes in a series of four patients. Methods: All robotic right colectomies via suprapubic approach were performed by using da Vinci Xi system. Four robot trocars were placed in the suprapubic area transversely. Totally robotic right colectomy was performed including colonic mobilization, D3 lymphadenectomy, and stapled functional anastomosis intracorporeally. Two suprapubic trocar incisions were then extended to retrieve the specimen. Results: The mean operation time was 191.3 min and the mean estimated blood loss was 28.8 ml. The time to clear liquid intake was three days in all patients, and the mean length of stay after surgery was 6.3 days. No patient required conversion to conventional laparoscopic surgery. There was no perioperative complication. In the pathology report, the mean number of harvested lymph nodes was 35.3. Three patients were stage III, and one patient was stage II. Conclusions: Totally robotic right colectomy via suprapubic approach could be performed successfully in selected patients. Further comparative studies should be required to verify the clinical advantages of our technique over conventional robotic surgery.

S.W. Lim, D.H. Kim, J.H. Park, J.I. Ju Hallym University Sacred Heart Hospital, ANYANG-SI, GYEONGGI-DO, Republic of Korea Aims: Various methods of rectal handling before rectal transection during laparoscopic rectal cancer surgery were introduced. We used a beaded plastic hanger of urinary foley catheter bag for rectal traction and dissection before transection during robotic rectal cancer surgery. Methods: Four-channeled Octo-port (Dalim Surginet) was applied to elliptical incision about 4 cm along periumbilical area and optic camera robotic arm was placed. Four-robotic arms and dual docking technique were performed for robotic rectal cancer surgery using davinci Xi (Intuitive Surgical). High ligation of inferior mesenteric vessels and mesocolic dissection of medial to lateral approach were done in abdominal phase, and pelvic dissection of total mesorectal excision was started by assistant surgeon’s traction or countertraction via umbilical port after intracorporeal ligation of the rectum with a beaded plastic hanger of foley catheter bag. The endoscopic linear stapler was introduced through the 12 mm port in the right lower area and rectum was transected. Extracorporeal specimen delivery was done transumbilically, and intracorporeal double stapling anastomosis was done after re-establishing pneumoperitoneum. Results: Twenty-seven patients were performed robotic rectal cancer surgery using this traction technique from March 2015 to January 2016. The mean operation time was 315 min (range 205–545 min). No intraoperative or postoperative mortality was noted. The average number of stapler cartilage for rectal transection was 1.7 for each patient. Conclusions: Intracorporeal ligation of the rectum with a beaded plastic hanger of foley catheter bag is a useful method for rectal handling and traction in robotic rectal cancer surgery.

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Surg Endosc

P435 - Robotics, Telesurgery and Virtual Reality

P437 - Spleen

Robot Assisted Minimally Invasive Esophagectomy (Ramie) Initial Experience

It is Advisable to Put Drainage After Laparoscopic Splenectomy?

R. Diaz del Gobbo, D. Momblan Garcia, R. Bravo Infante, M. Fernandez-Hevia, M. Jimenez Toscana, A. Otero Pin˜ero, A. Lacy Hospital clinc of barcelona, BARCELONA, Spain Aim: Esophageal surgery is technically complex because of the characteristics of this organ within a restricted working space inside the thoracic cavity. This study looks to asses the initial experience in our center after the first year working with the Da Vinci Xi system and analyze the initial results of the RAMIE approach in terms of quality of oncological resection and morbi-mortality. Methods: All cases of esophaguectomy by RAMIE approach were prospectively collected, Variables included: patients and tumor characteristics, type of surgical resection and anastomosis, intra and postoperative complications until discharge. Results: From November 2014 until May 2015, a total of 12 robot-assisted esophagectomies were performed. All were male patients with a median age of 64 years. Median BMI was 25 kg/m2 (20–29); ASA score classification was II (83%) and III (17%). The type of tumors were Adenocarcinoma 66,7% and Squamous cell carcinoma 33,3%, location of the lesion was Siewert I: 16.7%, Siewert II: 8,3%, medium-distal esophagus 75% cases, 75% of the patients had received neoadjuvant treatment. Robot assisted total Esophaguectomy (3field) was performed in 4 cases (33,3%) and Robot assisted Ivor Lewis in 8 (66,7%). Conversion to laparoscopy was mandatory in 1 case due to Pachypleuritis and there was no need to convert to open surgery, Median operating time was 320 min. (210–480 min). 1 case of intraoperative bleeding solved during surgery. Thoracic anastomoses were performed by robot end-to-end 8 cases (66,7%), and cervical anastomosis in 4 cases (33,3%). We diagnosed an anastomotic leak in two cases (17%). Type of resection was R0 in all cases, Median of retrieved lymphatic nodes were 18 (6–35), pT0 25%, pTis 8%,pT2 17%,pT3 25%,pT4 17%, Barretts 8%, Median ICU stay 6,5 Days (1–25), Median Hospital stay 13,9 Days (8-28), 30 days mortality 0%. Conclusion: RAMIE is proving to be a safe and feasible technique with an adequate oncologic resection. This approach can be considered a good alternative to esophageal pathology whit the benefits of a robotic platform.

F.J. Garcı´a Angarita, P. Priego Jime´nez, P. Luengo, A. Morante, P. Giordano, F. Garcı´a-Moreno, G. Rodrı´guez-Velasco, J. Galindo Hospital Universitario Ramo´n y Cajal, MADRID, Spain Aims: To evaluate wether the use of intra-abdominal drainage after laparoscopic splenectomy (LS) is a benefit or a detriment in the development of postoperative complications and to clarify if it is advisable or not to put it after LS. Methods: A retrospective research of all LS performed at the Hospital Universitario Ramon y Cajal from January 1999 to January 2015. A total of 62 patients were collected. The indication for using drainage or not was randomly based on surgeon preference. For further study we divided patients into 2 groups: Group A formed by patients in whom we left a suction drain after surgery and group B formed by patients without drainage. The criterion for removing the drain was a serohematic aspect with a debit lower than 50 ml/24 h. Results: Between the 62 cases studied, 62.9% were female and 37.1% were male with a median age of 50 years (range 16–84 years). The main indication for laparoscopic splenectomy was thrombocytopenia (37 cases) and within this indication idiopathic thrombocytopenic purpura (ITP) with 36 cases. In 8 cases the indication of the intervention was a malignant disease. 54 cases (87.1%) were performed in right lateral decubitus position and the rest (8 cases) in supine. In 40.3% of patients (25 cases, who form the Group A) we placed a low suction drain in the splenic fossa. No statistically significant differences were found between the two groups when compared to the diameter of the spleen, operative time, conversion rate and rate of intraoperative or postoperative complications. The length of hospital stay was significantly longer in group A than in group B (14 + 15 days, and 7 + 4 days, respectively p \ 0.05). Conclusions: The insertion of drainage in splenic fossa after LS not only prolongs hospital stay but also does not prevent the occurrence of intraabdomial abscesses. For that, its placement should not be recommended in a routine way.

P436 - Robotics, Telesurgery and Virtual Reality

P438 - Spleen

Robot-Assisted Sleeve Gastrectomy in Morbidly Obese Versus Super Obese Patients

Minimally Invasive Treatment of Splenic Cysts: The Role of Robotic Surgery in Partial Splenectomy

V.I. Bindal, P. Bhatia, S. Kalhan, M. Khetan, S. John

C. Vasilescu, S. Manciu, S. Tudor, M. Lacatus, D. Gavrila, L. Costin

Sir Ganga Ram Hospital, DELHI, India

Fundeni Clinical Institute, BUCHAREST, Romania

Background and Objectives: This study evaluates our technique for robot-assisted sleeve gastrectomy for morbidly obese and super obese patients and our outcomes. Methods: A retrospective analysis of patients who underwent robot-assisted sleeve gastrectomy at a single center was performed. The procedure was performed with the da Vinci Si HD Surgical System (Intuitive Surgical, Sunnyvale, California). The staple line was imbricated with No. 2-0 polydioxanone in all cases. The super obese (body mass index = 50 kg/m2) subset of patients was compared with the morbidly obese group in terms of demographic characteristics, comorbidities, operative times, perioperative complications, and excess body weight loss. Results: A total of 81 patients (32 female and 49 male patients) with a mean body mass index of 48.17 ± 11.7 kg/m2 underwent robot-assisted sleeve gastrectomy. Of these patients, 32 were super obese and 49 were morbidly obese. The mean operative time was 98.3 ± 24.7 min, and the mean docking time was 4.5 ± 5.4 min. Mean blood loss was 19.36 ± 4.62 mL, and there were no leaks, bleeding, conversions, or perioperative mortality. When compared with the morbidly obese patients, the super obese patients showed no significant difference in operative time, blood loss, and length of hospital stay. There was a steep decline in operating room times after 10 cases of robot-assisted sleeve gastrectomy. Conclusion: This study shows the feasibility and safety of robot-assisted sleeve gastrectomy. Robotic assistance might help overcome the operative difficulties encountered in super obese patients. It shows a rapid reduction in operative times with the growing experience of the entire operative team.

Aims: The treatment strategy of the splenic cyst is controversial and surgical approaches of splenic cysts have recurrence rates that vary according to the procedure. Minimally invasive partial cystectomy is a safe and feasible method, with minimal morbidity but with higher recurrence rates. Advances in medical technology have made minimally invasive partial splenectomy a preferred treatment for splenic cysts having the benefits of preserving the immune function of the spleen. Methods: Between 2002 and 2015, 74 cases of splenic cysts (39 non-parasitic and 35 hydatid cyst) were treated in the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute. Among these cases, 37 patients were approached classically (23 total splenectomies, 6 partial splenectomies and 8 partial cystectomies) and 37 patients were operated in a minimally invasive fashion (22 laparoscopic approaches: 7 total splenectomies, 4 partial splenectomies, 11 partial cystectomies and 15 robotic procedures: 2 total splenectomies and 13 partial splenectomies). Results: For the robotic approach all the procedures were completed using entirely the DaVinci robotic system with no conversion to laparoscopy or open approach and with minimal blood loss due to the transection of the splenic parenchyma with the stapler device. The mean operative time was 120 min (±37 min) with a console time of 95 min (±28 min); the mean hospital stay was 5 days (±2 days). No morbidity and no mortalities occurred. Conclusion: Robotic splenectomy will probably not replace the laparoscopic splenectomy for the most common indications like ITP, hemolytic anemia. It may be a very useful surgical tool in difficult splenectomy and allows resection of splenic cysts with a margin of healthy tissue without risk of bleeding or recurrence. Robotic surgery of splenic cysts seems to offer safety and all benefits of minimally invasive surgery, preserves the immune function of the spleen and allows the surgeon to conserve as much of splenic parenchyma as possible.

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Surg Endosc

P439 - Spleen

P441 - Spleen

Laparoscopic Splenectomy for Immune Thrombocytopenic Purpura: Analysis of the Result After 107 Operated Patients

A Comparision of the Complication Rates of Laparoscopic Splenectomy with Open Surgery

S. Matic1, N. Grubor1, D.J. Knezevic1, D. Antic2, S. Suvajdzic2, S. Knezevic1

M. Browning, N. Bullen, T. Nokes, M.G. Coleman Plymouth Hospitals NHS Trust, PLYMOUTH, United Kingdom

1

Clinical Centre of Serbia, First University Surgical Hospital, BELGRADE, Serbia; 2Clinical Centre of Serbia, Clinic for Hematology, BELGRADE, Serbia

Aim: Laparoscopic splenectomy (LS) is considered safe and effective procedure for a number of hematological diseases. In the case of immune thrombocytopenic purpura (ITP), LS represents first line of therapy after failed medical treatment. We wanted to evaluate safety and efficacy of LS in the treatment of ITP. Methods: During a nine-years period (2007–2015) we operated 107 patients with refractory chronic ITP by LS. All the patients were initially treated by the hematologist for 2–96 months, and presented for surgery in case of failed therapy or refractory disease. There were 85 female and 22 male patients with median 37.8 (16–75) years. Mean preoperative platelet count was 81 9 109/l, and mean BMI was 28.3 kg/m2. Patients were operated by the same operating team using hanging spleen technique and approach with 4 ports. Data were collected prospectively in all the patients. Results: LS was successfully performed in 103 patients with 3.7% conversion rate, all of which performed for bleeding in 4 patients. Mean spleen size was 116 mm and weight 248 g. We found a total of 26 accessory spleens (1–3) in 22 patients. Hilar blood vessels were secured with a stapling device in a majority of patients, and the spleen specimen was removed after morcelation in endo-bag. Mean operative time was 78.4 (45–135) min. Blood transfusion was necessary in 3 patients which required conversion into open procedure. We registered minor postoperative complications in 6 patients and none of the patients needed reoperation. One patient died of acute agranulocytosis and fulminant sepsis due to aggressive preoperative immunosuppressive therapy. Mean postoperative stay was 2.7 days. We registered positive platelet response in 86 patients in whom no further therapy was needed, with relapse of the disease in other 7 patients during the first 12 months after surgery, hence in 73.8% of patients LS was successive treatment. Conclusion: LS has become procedure of choice for patients with ITP who fail to respond to medical treatment. It can be performed safely and effectively, with low morbidity and mortality and high success rates. Accessory spleens can be successfully localized, therefore improving response and limiting recurrence of ITP.

Complication rates from splenectomy are high and infective complications such as pneumonia and intra-abdominal abscesses are more common than after other major abdominal surgery. We describe a case series of 58 elective splenectomys from 2001 to 2015 carried out in this tertiary referral centre by a single surgeon (MGC), who specialises in LS. We compare the rate and severity of complication between groups undergoing different techniques and with different pathology. We reviewed patients’ medical notes, discharge summaries and histology. Twenty-four out of 58 spleens (41%) were removed via OS and 32 (55%) via LS, two were removed with a planned laparoscopically assisted technique (LAS). The conversion rate was 4/32 (12.5%). The mean spleen weight after LS was 449 g and 1944 g in the OS group. 92% of spleens under 1000 g in weight were removed via OS but all spleens over 1500 g were resected by OS, either as planned or by conversion. Thirty-one complications (rate of 53%) developed in twenty four patients (41%), they were stratified according to the Clavian-Dindo classification which is a scale of severity from 1–5 with 3–5 being major. Complication rates were similar between groups (LS 49.5%, OS 50%) but major complications were much less common in the LS group (9.1% vs 22.6%) and there were no grade 4 or 5 (death) complications with LS. Major complications were not seen outside the setting of haematological malignancy, where 30% (10/33) had such a complication. Haemorrhage was more common with LS (12% vs 4.5%) but was much more minor (grade 1 vs grade 4). Pneumonia was much more common with the OS technique (13.6% vs 3%). Splenectomy has a high complication rate and more severe complications are seen after splenectomy for malignancy, perhaps reflecting the poor premorbid state of these patients and larger spleens. Fewer severe complications are seen with laparoscopic surgery and this should be the preferred technique for spleens likely to weigh less than 1.5 kg.

P440 - Spleen

P442 - Technology

Role of Laparoscopic Splenectomy in Patients with Immuno Thrombocytopenic Purpura with Extremely Low Platlet Count (\20,000/cumm)

Single-Incision and Natural Orifice Translumenal Endoscopic Surgery in Switzerland

V.I. Bindal, S. Kalhan, P. Bhatia, M. Khetan, S. John

D.C. Steinemann1, A. Zerz2, S.H. Lamm2 1

University Hospital Heidelberg, HEIDELBERG, Germany; Cantonal Hospital Baselland, BRUDERHOLZ, Switzerland

2

Sir Ganga Ram Hospital, DELHI, India Introduction: Laparoscopic Splenectomy (LS) is preferable as compared to open surgery for the treatment of Idiopathic Thrombocytopenic Purpura (ITP) because of known advantages of minimal access techniques. Objective: The aim of the study is to compare the feasibility and safety of LS in extremely low platelet count (\20,000/cumm) and low platelet count patients (\50,000/cumm). Methods: This is a retrospective analysis from Jun 2010 to Aug 2015 including patients of ITP with platelet counts below 50,000/cumm whounderwentLS. The parameters studied were age, gender, duration of ITP in years, preoperative platelet count, duration of surgery, blood loss, duration of drain tube, total drain tube drainage, requirement of perioperative blood product transfusion and length of hospital stay. Perioperative medical management has also been reviewed. Results: A total of 9 patientswere included out of which 4 were having extremely low platelet count (\20000/cumm) while 5 were having low platelet counts (\50,000/cumm). The mean operative time was 145.3 ± 34 min. There was no need for any Intraoperative blood transfusion (PRBC) in any patient, while platelet apheresis was used in both groups without any significant difference. All patients recovered well (nocomplications [ = Clavien-Dindo grade III). Conclusion: LS is a safe and feasible technique in treatment of ITP patients with extremely low platelet counts in experienced centres.

Aims: Single-incision laparoscopy (SIL) and natural orifice translumenal endoscopic surgery (NOTES) aim at reducing surgical access trauma. To monitor the introduction of emerging technologies, the Swiss Association for Laparo- and Thoracoscopic Surgeons launched a database in 2010. The current status of SIL and NOTES in Switzerland is reported and the techniques compared. Methods: The number and type of procedures, surgeon experience, their impressions of performance, and conversion and intra- and postoperative complication rates between 2010 and 2015 are described. A survey was used to acquire data of SIL and NOTES procedures not included in the registry. Results: Nine centers included 650 eligible procedures. Cholecystectomy (55%) and sigmoidectomy (26%) were most prevalent in both techniques. The frequencies of taught procedures were 4% and 43% for SIL and NOTES (P \ 0.001), and surgeon self-estimated impression of performance was perfect in 50% and 89%, respectively (P \ 0.0001). Conversions in total were 3.6% and 5.7%, respectively, and 1.1% to open for both techniques. Complication rates were 5% in SIL and 2.7% in NOTES, with 0.8% access-related complications in NOTES and none in SIL (P = 0.29). Survey results included 951 SIL and 898 NOTES procedures; 11.4% and 15.6% of cholecystectomy, sigmoidectomy, and right hemicolectomy cases were operated using SIL or NOTES, respectively (P \ 0.0001). Conclusion: In selected specialized centers, a considerable proportion of patients were operated with novel techniques and low overall and access-related complication rates. Most conversions involved an early change to conventional laparoscopy. Possibly because of a better impression of comfort during the procedures, NOTES surgeons were more willing to teach the procedure. The adoption of scarless surgery in specialized centers in a relevant proportion of patients is welcomed.

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Surg Endosc

P443 - Technology

P445 - Thoracoscopic Surgery

Development of an Autonomous Grasping Instrument for Prevention of Grasp-Induced Tissue Damage

Uniportal Video-Assisted Thoracoscopic Surgery Using Conventional Endoscopic Instruments for Spontaneous Pneumothorax

A.W. Brown, Z. Wang, D. Mclean, S. Brown, A. Cuschieri, S. Coleman

M. Naruke

University of Dundee, DUNDEE, United Kingdom

Kanagawa hospital, TOKYO, Japan

Aims: Trauma caused by grasping is well documented as a frequent occurrence during bowel resection operations performed by minimal access surgery (MAS). These injuries usually result from re-grasping actions and excessive forces due to diminished tactile feedback. A prototype autonomous grasping instrument equipped with vibration-detection sensors was developed to address this frequently encountered problem during MAS Methods: The autonomous grasping device consists of 10 mm parallel action grasping forceps actuated by a DC motor. A polyvinylidene fluoride (PVDF) sensing element to detect slip and incipient slip equipped with closed loop control software, developed in LabVIEW and comprising a state machine architecture using Boolean triggers. These triggers are based on the output of the PVDF sensor capable of detecting (i) no slip, (ii) incipient slip, and (iii) ongoing slip occurring with grasping failure. These events, controlled automatically through the closed loop, induced incremental increases/decreases of the grasping forces. Cyclic testing was carried out by tensiometer, retracting ex vivo porcine bowel tissue at various forces and rates from the jaws of the autonomous device. Each cyclic test was carried out 22 times with a duration of 25 min. Results: The data from the experiments confirmed that the Boolean triggers based upon 2nd derivative, peak voltage and peak detection are able to determine slip, incipient slip and grasping failure. Grasping for the duration of the cyclic test was successful 91% of the time. However the grasping force was found on average to be 71.81% (±24.4) greater than the pull force. Conclusions: The study confirmed that the autonomous grasping instrument successfully grasps tissue more often than standard forceps (91% vs 63%) and that the pressure it applied is lower than those exerted by standard grasping instruments. Further work is needed to measure more accurately the grasping force to address the discrepancies between the retraction force and grasping force observed in the present study.

Aim: Uniportal video-assisted thoracoscpic surgery (VATS) for spontaneous pneumothorax (SP) has been started to spread recently, and the various new designed devices includes Single-incision laparoscopic surgery (SILS) port and special techniques are reported. For the uniportal VATS bullectomy becomes widespread more, simple technique by conventional tools is helpful. And, we present our experiences of successful uniportal VATS by conventional technique using conventional instruments for SP. Method: We report here 3 cases who underwent uniportal VATS by conventional simple technique using conventional straight endoscopic instrument for SP. A single port of 25 mm on the 5th intercostal space at the anterior axially line was fixed by the silicon wound retractor. Their bullectomies were performed using the cotton-made dissectors, thoracoscopic Maryland grasping forceps, Endo GIA stapler, and 5-mm 30 degree rigid thoracoscope, In the case of dissecting adhesion, the energy device was used. Following bullectomy, the stapling line was reinforced with an absorbable polyglycolic acid (PGA) sheet. Result: The mean age of SP patients of this study was 46.0 ± 25.2 years (range, 18 to 79 years) and the mean operative time was 73.6 ± 21.8 min. They underwent bullectomy for the blebs located in the left upper lobe. The movement of instruments was limited due to the limited access port, however all procedures could be accomplished by an ingenious grasping at a camera of an assistant. Conclusion: According to limited experience, uniportal VATS bullectomy and reinforcing with an absorbable PGA sheet using conventional instruments for SP was possible. A various located and formed blebs and adhesions should be experienced future more for being standardized.

P444 - Technology

P446 - Thoracoscopic Surgery

Integrated Signal Transmission and Hydraulic Steering Using Hypertonic Saline Solution in MRI-Compatible Intravascular Catheters

Staging Implications of Intraoperative Ultrasound Guided Mediastinal Lymphadenectomy in Non-Small Cell Lung Cancer Vats Surgery

A. Caenazzo, H. Liu, K. Althoefer

D. Orsulic, N. Ilic

King’s College London, LONDON, United Kingdom

University Hospital Split, SPLIT, Croatia

Background: Use of ionising radiation in intravascular catheterisation increases risks of cancer and other side effects to both patients and medical staff. Widespread adoption of a safer and more effective imaging methodology, real-time MRI, is still difficult as current cardiac catheter technology is largely unsuitable from a safety and compatibility perspective. Transmission of sensor readings and electrophysiological signals is particularly challenging, as this is normally accomplished with long, low-impedance conductors (e.g. metal or carbon leads) that are prone to heating up dangerously and causing imaging artefacts in the MRI environment. Methods: We are proposing an alternative technique for signal transmission that drastically reduces the need for low-impedance materials in MRI-guided intravascular procedures. In our approach, a plastic lumen filled with hypertonic saline solution is used in lieu of a traditional metal lead. Such saline-filled lumen has electrical and magnetic properties not dissimilar to the surrounding anatomy, dramatically decreasing the likelihood of tissue heating and artefacts caused by the catheter. Concentration of the solution can be increased above physiological levels to improve signal transmission properties without detriment to safety in case of accidental leakage. Our approach also allows for integration between hydraulic steering mechanisms and sensing; this is achieved by using common structures and fluid for both signal transmission and actuation. While by no means a requirement for MRI safety and compatibility, such integration may bring advantages in terms of miniaturization, ease of manufacturing and cost-effectiveness in a future commercial implementation. Results: Effectiveness of signal transmission through saline solution was tested using a real-life-sized lumen. Hypertonic solutions that would be well tolerated by adult and paediatric patients showed favourable results. Tests of real-size catheter designs with integrated steering and sensing through hypertonic solutions are currently under way. Conclusions: The experimental results have confirmed the feasibility of using hypertonic saline solution as an alternative to traditional low-impedance conductor leads in MRI catheters, while integration of steering and sensing using common fluids is being tested. Stemming from our early positive results, we believe practical adoption of this technology may help the widespread adoption of MRI in intravascular procedures in the reasonably near future.

Objective: Extent of lymph node involvement in NSCLC is a key prognostic factor as it determines the stage of the disease and influences both modality of the treatment and the final outcome. Skip nodal metastases are determined as N2 disease, without evident N1 involvement, and are the theoretical principal for radical lymphadenectomy. The aim of this study is to determine the efficacy of ultrasound guided VATS dissection of mediastinal lymph nodes in patients with NSCLC. Methods: We conducted a prospective randomized trial from April 2015 till December 2015. Twenty six patients, enrolled into the study thus far, had undergone surgical staging after radical resection for NSCLC. Patients were divided into two groups according to the methods used for systemic nodal dissection: fifteen patients in whom ultrasound guided VATS mediastinal lymphadenectomy was performed and eleven patients in the standard nodal dissection group. Lymph nodes were mapped by their stations and are harvested for histopathological examination. Results: The number and stations of evaluated lymph nodes was significantly higher (p \ 0.001) in the US guided VATS lobectomy group. Skip nodal metastases occurred more often in ultrasound mediated VATS nodal dissection. In the same group 10% of patients were upstaged using US guided mediastinal lymphadenectomy and received adjuvant treatment that otherwise would have been omitted. Conclusions: Temporary results suggest that VATS lymphadenectomy guided by ultrasound is safe and allows for a more radical mediastinal lymphadenectomy. Furthermore, the interim results suggest that intraoperative US may have important staging implications. As this is still an ongoing study, we believe that further findings will be relevant to clinical practice once this study is finished.

123

Surg Endosc

P447 - Training

P449 - Training

The Formulation of a Simple Error Reduction Checklist to be Applied by Junior Trainees During Laparoscopic Tasks

Training In Laparoscopic Cholecystectomy a Ten Year StudY

M. El Boghdady1, B. Tang2, I.S. Tait2, A. Alijani2 1 Cuschieri Skills Centre, DUNDEE, United Kingdom; 2Cuschieri Skills Centre, Ninewells Hospital and Medical School, DUNDEE, United Kingdom

Aims: Surgical checklists are introduced by WHO for safer surgery. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. We aimed to formulate a simple performance based checklist to be applied by the junior trainees during laparoscopic procedures as a way of error reduction mechanism. Methods: A link for an online questionnaire on 6 predetermined technical factors influencing the laparoscopic task performance was sent via email to 8 laparoscopic consultants and 6 senior surgical trainees at a teaching hospital. Results: Six consultants and 5 registrars returned the completed questionnaire. ‘Exposure’ scored 4.9 (on a scale of 1-6), ‘bi-manual coordination’ scored 4.09, ‘degree of force’ and ‘direction of force’ were equally ranked with 3.18, ‘following the steps of the task’ scored 3.09, and ‘speed’ scored 2.55. Conclusion: A standardised content for a simple performance based intra-procedural checklist was formulated by consensus among the surgeons based on the technical factors influencing the laparoscopic performance.

K. Alexiou, D. Bethani, A. Tellos, E. Ierapetritakis, M. Terzopoulou, M. Emmanouilidis, N. Economou Sismanoglion General Hospital, MAROUSI, Greece Aims: To establish the feasibility and safety of laparoscopic cholecystectomy (LC) when performed by resident surgeons. Methods: In a period of ten years (2005–2015) 3497 LCs were carried out in our department. Seventy percent of those (2448) were scheduled. One thousand seven hundred and eighty eight (1788) procedures were performed by consultants and one thousand seven hundred and nine (1709) by residents. Results: Of the 3497 LCs initiated, 269 required open cholecystectomy (OC) for completion. Conversion to open cholecystectomy was needed in 142patients in the group operated by consultants and in 127 in the group operated by residents. There were no mortalities and no major complications in either group. Conclusion: When performed by residents, under the guidance of experienced surgeons, LC is a safe procedure for the patient and its results are similar to those of consultants. Therefore training in LC should be an integral part of surgical training in every teaching hospital.

P448 - Training

P450 - Training

A Method to Master Endoscopic Thyroid Surgery: Split Training (Wari-Geiko)

Current State of Training and Evaluation in Minimal Invasive Surgery

Y. Usui

S. Ganni1, C. Chmarra1, J.J. Jakimowicz1, D. Lomanto2

Okayama Medical Center, OKAYAMA, Japan

TU Delft, DELFT, The Netherlands; 2YLL School of Medicine, SINGAPORE, Singapore

Background and Object: We started gasless endoscopic thyroid surgery in 1999. To facilitate the surgical procedures, the U-retractor(2000), the U-trocar(2005), the U-Kelly forceps(2008), and the U-suction retractor(2013) were made and presented at previous congresses. Endoscopic thyroid surgery has slowly but gradually become more popular in Japan. Patients’ preference for this operation has been increasing. In order to master an operation, it might be more beneficial to split the operation into several parts. We devised a method to master endoscopic thyroid surgery. It is called ‘wari-geiko’ in Japanese and has been used in training Japanese tea ceremony. ‘Wari’ means ‘to split’ and ‘geiko’ means ‘ practice’. We split the operation into several parts and developed a scoring system according to the endoscopic surgical technique authorization system of the Japanese Society of Endoscopic Surgery. Result: Gasless endoscopic thyroid lobectomy consists of several important parts. They are subplatysmal dissection, space making, thyroid isthmus dissection, lower pole dissection, finding and preservation of the recurrent nerve, upper pole dissection, and the Berry ligament dissection. There are 9 scoring items for the endoscopic thyroid surgery, as follows. 1. Protection of the skin 2. Understanding the anatomy of the strap muscles and the right approach to the thyroid gland. 3. The trachea is identified and exposed. 4. The superior and inferior thyroid arteries are identified. 5. The lobe is freed. 6. The superior laryngeal nerve is preserved. 7. The recurrent laryngeal nerve is identified and preserved. 8. The parathyroid glands are identified, and preserved. 9. Capsule of the thyroid gland and the thyroid lobe itself are handled with care. Considering these items, trainees were evaluated and graded. The trainees could learn the gasless endoscopic thyroid surgery by ‘wari-geiko’ more easily and self evaluate their skill. Conclusion: It might be easier for young surgeons to master endoscopic thyroid surgery by split-training, ‘wari-geiko’. This new training programme is progressing satisfactorily.

1

Aim: The aim of this survey was to determine methods and perception of training and evaluation in minimal invasive surgery (MIS) globally. Methods: An open-ended questionnaire with information pertaining to demographics, education and training in MIS and certification of MIS was prepared and sent out to surgeons and surgical residents through European Association for Endoscopic Surgery (EAES), Endoscopic and Laparoscopic Surgeons of Asia (ELSA) and through private channels. The participants of the survey were informed on the anonymity clause related to individual identification except for demographic data. At the end of the questionnaire, the participants were asked whether they agree that there is a need for a global standard for training and evaluation in MIS. Results: A total of 663 participants responded to the survey from over 40 countries. 83% of the participants were surgeons and 17% were surgical residents. 73% of the participants’ countries do not require certification in MIS. 52% of the participants indicated that training is insufficient in their respective countries. However, more than 86% agreed that there is a need for global standard for MIS training and evaluation. Conclusion: Regardless of demographic and experience factors, there was a general consensus on the inadequacy of training in MIS. Subsequently the need for a global standard for training and evaluation in MIS was evident from the results of the questionnaire. Majority of the participants agreed that a curriculum based format is crucial for training and evaluation.

123

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P451 - Training

P453 - Training

Sleep Deprivation Among Residents: Does it Affect Performance While Practising a Surgical Technique?

The Needs of Change in Surgical Training

J.I. Martin Parra1, H. Real Noval1, A. del Castillo Criado1, J.C. Manuel Palazuelos1, A. Lopez Useros1, R. Fernandez Santiago1, M.E. Gonzalez Noriega1, J.L. Ruiz Gomez2, S. Regan˜o Diez3, M. Gomez Fleitas1 1

Hospital Marques de Valdecilla, SANTANDER, Spain; 2Hospital Sierrallana, TORRELAVEGA, Spain; 3Hospital de Laredo, LAREDO, Spain

Aim: To assess whether sleep deprivation affects work in the experimental laboratory. Methods: A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups have been established; the FATIGUE group (F): anastomosis performed by residents coming off shift and/or who have slept less than seven hours and the ‘OPTIMAL REST’ (R) group, being those who have slept at home for more than 7 h. The time taken, length of the anastomosis and quality of such are compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches. In addition, an analysis by subgroup has been conducted, between novice and advanced residents. Results: 219 anastomoses were studied (115 F group, 104 R group). The average time taken to perform the anastomosis in Group R was 46.3 min. and the average length of the anastomosis was 47.8 mm, conversely, the F group took 45.9 min. for an average length of 50.1 mm. There were no statistically significant differences. In the F group leaks were detected in 31.3% anastomoses, as opposed to 19.2% in the R group (p = 0.04). In the F Group 57.4% of the anastomoses were of high quality satisfying the 4 parameters compared with 61.5% in the R group (not statistically significant). The D group performs better in the evaluation of the suture tension, distance between stitches and opposition of the edges without statistical significance. Leak rate with the novice residents (F group was 36.7% versus 17.8% in the R, p = 0.04). With advanced residents the leak rate was 32.3% in the F group and 22.6% in the R group (p [ 0.05). There are no significant differences in the parameters of length, time and quality of anastomosis between the F and D groups in terms of level of training. Conclusions: Fatigue increases the risk of leakage. With novice residents, fatigue causes more anastomotic leaks. Fatigue does not appear to influence the time taken to perform the anastomosis.

C.I. Tiu1, A. Negoita Tiu1, W. Korb2, S. Kotzsch2, F.M.S. Margallo3, L.F.S. Peralta3, J. Sa´ndor4, G. We´ber4, E. Fenyo¨ha´zi2, L.E.B. Vera2, J.S. Fernandez3, B. Pagador3 Medis Foundation, CAMPINA, Romania;2University of Applied Sciences, LEIPZIG, Germany; 3Centro de Cirugı´a de Mı´nima Invasio´n Jesu´s Uso´n, CACERES, Spain; 4Semmelweis University, BUDAPEST, Hungary 1

Aim Background: of the SurgTTT Project is the need to improve specialty training in surgical specialties and a lacking standardization on the pan-European level. Thus, the main objective of the project is to define the professional profile of surgical trainers by designing and testing the most suitable curricula. Another objective is broadening the scope of application of this professional profile to a European level through the development of an open multilingual online learning platform for consultants. Materials and methods: The project started with a transnational survey of the national frameworks for specialty training and a needs assessment for designing a TTT program. On this basis the professional profile for a surgical trainer will be designed in order to afterwards develop a curriculum and teaching materials. The next step is the testing and validation of the curriculum in TTT courses with our target group. The revision of the program will close this process. Results: The change will work in two directions. On one hand (bottom-up approach) the consultants educated by all partners in or after the project will act as role-models, promote and create interest among colleagues, in the hospitals and medical associations (i.e. dissemination by participants). On the other hand (top-down approach) we will create interest and lobbyism through dissemination to people and organizations on the various levels of decision making. In addition, the online-learning platform will enable impact independent of personal contact and thus multiply effects Conclusion: This works puts forward the need for a European professional profile of the surgical trainer and defines a set of competences to be acquired by this health professionals devoted to training of surgical residents.

P452 - Training

P454 - Training

Effect of Simulator Training To Improve Reverse-Alignment Laparoscopic Skills

Laparoscopic Training Model Low Cost

H. Guzman del Castillo, A. Morandeira, C. Moreno Sanz, F. Sanchez de Pedro, C. Sedano, A. Lopez, V. Crespo, M. Lopez Saiz, J. Picazo

Complejo Hospitalario Universitario de Badajoz, BADAJOZ, Spain

Hospital Mancha Centro, ALCAZAR DE SAN JUAN, CIUDAD REAL, Spain Introduction: Nowadays the use of simulators is an important tool on the development of surgical skills. The aimof this study was to compare the effect of simulator training to improve reverse-alignment ‘mirror image’laparoscopic skills. Materials and Methods: Surgeons with different levels of laparoscopic experience participated in a training session using a ventral hernia repair laparoscopic physical simulator. Prior and post-training evaluation was conducted. The task used was to achieve a number of targets placed in the simulator wall, both in direct as in mirror view. In the analisis was included time spent in complete the task, loading and mental fatigue were analyzed by the NASA - TLX multidimensional tool. Results: 20 surgeons participated in the study (five with high experience, 10 with medium experience, and 5 with low experience). Surgeons with low experience in laparoscopic surgery took significantly longer time to complete both tasks in direct vision and mirror view vision compared with surgeons with high and medium experience (p \ 0.05). The load and mental fatigue evaluation scores were also worse in the low experience group, although no significant differences were found. Altogethera significant decrease in time and NASA-TLX score for both tasks, between pre and post-training was observed (p \ 0.05). Conclusion: Training with this simulator reduces time employed to complete the studied tasks under direct and reverse-alignment visionand the perception of mental fatigue by surgeons. The tasks evaluated in this study discriminate among surgeons with high or low experience in laparoscopic surgery.

123

E.J. Barzola Navarro

Introduction: In the current era of surgery there is no doubt that the laparoscopic approach is the present, so the laparoscopic skills should be part of education programs and daily activity of specialist training. There are models of training, but their high cost in some cases makes them difficult to access. We are presenting a new model of low-cost laparoscopic training. Materials and methods: Laparoscopic training model is based on the principle of triangulation of laparoscopic procedures (Figure 1). So a camera with USB port is made (regular use of a digital microscope is reversed lens to the author), which connected to a computer enables extended real-time and excellent quality image (Figure 2); malleable fiber cartons with a measure of 30 cm x 25 cm. This model allows portability due to its pyramidal shape (Figure 3). For the placement of ports geometric principles of a triangle 45 are followed, and the placement of a single port model silicone (Figure 4) and using a Smartphone model (Figure 5) The total cost of development it is 40 euros: USB camera 22 €, cartons 4 €, disposable materials € 10, silicone model folding funnel 4€. The device is complemented with disposable laparoscopic instruments. Discussion: The laparoscopic approach requires training based on many hours of practice to be able to reach certain psychomotor skills, so it is necessary to make a work of previous training outside the operating room environment. For this, they are indispensable models that reproduce viewing conditions, spatial orientation, coordination and handling of instruments that the surgeon will require in practice. There are some devices on the market for laparoscopic surgery training, which vary in complexity as well as size and cost. Conclusion: Based on ergonomic and geometric principles and laparoscopic surgery, we have developed a new model of low-cost training that improves the basic skills of laparoscopic surgery training specialist.

Surg Endosc

P455 - Training

P457 - Urology

Validation of Laparoscopic Cholecystectomy Training with Explanted Porcine Livers on the Pulsatile-Organ-Perfusion Trainer

Nonumbilical Single Port (Less) Laparoscopic Surgeries

M. Friedrich1, K.F. Kowalewski1, F. Rehberger1, J.D. Hendrie1, B.F.B. Mayer1, H.G. Kenngott1, V. Bintintan2, L. Fischer1, G.R. Linke1, B.P. Mu¨ller-Stich1, F. Nickel1

E.Wolfson M.C., HOLON, Israel

1

University of Heidelberg, HEIDELBERG, Germany; 2University of Medicine and Pharmacy, CLUJ NAPOCA, Romania Background: The Pulsatile-Organ-Perfusion (POP)-trainer provides training of laparoscopic procedural skills and full procedures with cadaveric organs. It also facilitates simulation of perfusion and allows for the use of instruments on real tissue. Although the POP-trainer is widely used in training, the face validity has not yet been evaluated.This study aimed to establish face validity of the POP-trainer for laparoscopic cholecystectomy (LC) and its usefulness compared to other training modalities. Materials and Methods: During laparoscopy courses at the Department of General, Visceral, and Transplantation Surgery at Heidelberg University, participants (n = 52) used the POP-trainer to perform LC. Face validity was assessed with questionnaires for realism and usefulness on a 5-point Likert scale. Participants were stratified into two groups: Experts (n = 15) who had performed over 50 laparoscopic procedures, and novices (n = 37) respectively. Secondary objectives included a ranking of training modalities, as well as depicting their particular advantages and disadvantages. Results: Having been positively rated by both groups, overall realism of LC on the POPtrainer was found to be high (3.8 ± 0.9), as well as its usefulness (4.6 ± 0.9). Items to which experts and novices differed regarding their opinion were ‘The training modality resembles reality’ (3.1 ± 0.8 vs. 3.8 ± 0.7; p = 0.010), ‘The OR simulation on the POPtrainer is realistic’ (3.4 ± 1.1 vs. 4.5 ± 0.8; p = 0.003), and ‘It would be desirable to have a POP-trainer at my own hospital’ (4.2 ± 1.1 vs. 4.8 ± 0.8; p = 0.040). When ranking the training modalities, animal training (1.1 ± 0.3) placed first, the POP-trainer (2.3 ± 0.9) second with VR- (2.8 ± 0.9) and Box-trainer (2.8 ± 1.1) having been placed third. The realistic simulation of animal training was most frequently referred to as an advantage, while the unrealistic simulation of the VR-trainer was the most often to be named a disadvantage of this modality. Conclusions: The POP-trainer was rated a highly realistic and useful training modality with face validity for LC. Differences between experts and novices existed concerning realism and desirability. Future studies should evaluate the POP-trainer for more advanced surgical procedures. It widens the spectrum of modalities for surgery training by providing a safe environment outside the operating room.

R. Bass, Y. Stanevsky, A. Sidi, A. Tsivian

Introduction: For the past five years our department implemented an innovative laparoscopic method, in which surgery is performed through a single port. Typically, due to aesthetic advantage, these surgeries are done through a umbilicus, but in some cases it is necessary to change approach. Here we present an analysis of cases in which the working channel was not inserted through the navel. Patient and methods: Prospectively accumulated database of patients undergoing LESS surgery was reviewed. Of 50 patients who underwent LESS 15 had intervention not through the umbilicus. Results: Patient age ranged between 7 and 81 years, duration of surgery (average) 106 min. The surgeries included: 4 Post-operative hernias (POVH and Parastomal); 4 Nephrectomies and Adrenalecomies; 3 - Urachal remnant removal; 3 - Renal cyst unroofing; 1 - Ureterolithotomy. The access was inserted at the retroperitoneum in 4 cases, at Pfannenstiel - 1, Left upper quadrant - 9, Right upper quadrant - 1. In all cases there were no complications or conversion to open surgery. Conclusions: Selecting a location for working port insertion depends not only on aesthetic considerations but also on comfort of access to the surgery area and previous surgeries.

P456 - Urology

P458 - Vascular Surgery

Laparoscopic Management of Urachal Remnants: Our Technique and Outcome

A Systematic Review of Operative Techniques for Kidney Transplant Recipients: Better Results for Minimally Invasive Surgery

K. Sakata, T. Shikano Yokkaichi Municipal Hospital, MIE-KEN, Japan Aim: The urachus is a remnant of the allantois, which usually becomes obliterated shortly after birth. Urachal remnants are relatively rare but may potentially cause symptom requiring intervention and an increased risk for developing adenocarcinoma. Although traditionally they are treated by open complete surgical excision of the urachal tract from the umbilicus to the bladder, recently there have been several reports of the laparoscopic excision of urachal remnants. Here we report our experience with the laparoscopic excision of urachal remnants as a less morbid, minimally invasive surgical alternative. Methods: Between December 2008 and December 2015, 18 patients with a mean age of 26.5 years old (range 14 to 55) who had a symptomatic urachal cyst underwent laparoscopic excision of the urachal remnant. Three ports were routinely used, one 12 mm camera port and two 5 mm additional working ports on the right abdomen. After the introduction of a 5 mm flexible scope, we performed this operation through three 5 mm port. The urachal remnant was dissected from the umbilicus to the bladder dome and then removed intact with the intra-abdominal ligation and suturing reconstruction of the peritoneum. We reviewed the perioperative records to assess morbidity, recovery and outcome Results: All operations were completed with no complications. Mean operative time was 90.3 min (range 53 to 144), mean blood loss was 1.7 ml, and average post-operative hospital stay was 2.2 days (range 1 to 3). Conclusions: The laparoscopic management of the urachal remnants appears to be a safe and effective alternative to open surgery for this condition. The minimized morbidity of this procedure and better cosmetic result would appear efficacious.

S. Wagenaar, J.H. Nederhoed, A.W.J. Hoksbergen, H.J. Bonjer, W. Wisselink, G.H. van Ramshorst VU medical centre, AMSTERDAM, The Netherlands Aims: Minimally invasive techniques have become increasingly popular for kidney transplantation surgery. Our aim was to systematically review available literature and to compare conventional and minimally invasive operative techniques for kidney transplant recipients. Methods: A systematic review was conducted in Pubmed-medline, EMBASE and Cochrane library. Articles were included and scored by two independent reviewers using Group Reading Assessment and Diagnostic Evaluation (GRADE) scale, Newcastle Ottawa quality assessment Scale (NOS) and Oxford Guidelines. Main outcomes were surgical site infection, incisional hernia, cosmetic result and graft survival. Results: In total, 16 out of 1823 identified publications were included and assessed. In general, quality of evidence was low (GRADE range 1–3; NOS range 0–4; Oxford level range 2–4). Within 15 different techniques, 4 subgroups were distinguished: conventional open techniques, minimally invasive open techniques, laparoscopic techniques and robotically assisted techniques. Minimally invasive operative recipient techniques showed lower surgical site infection (0–8%) and incisional hernia rates (0–6%) with improved cosmetic result (incision length: 0–13 cm) and post-operative recovery (hospitalization 8-21 days). Reported disadvantages included prolonged cold and warm ischemia time (0.5–14 h and 2–67 min, respectively) and operation time (118–257 min). No differences were found for graft or patient survival. Conclusion: Although the level of evidence was generally low, minimally invasive techniques showed promising results with regard to complications and recovery and should be considered to use. For open surgery, authors recommend using the smallest possible Gibson incision.

123

Surg Endosc

P459 - Vascular Surgery

P461 - Abdominal Cavity and Abdominal Wall

Three Cases of Laparoscopic Lumber Artery Ligation for Type II Endoleak Repair After Endovascular Aneurysm Repair (Evar)

Subcostal Port Reduces Port Site Hernia. Comparative Study

N. Kawai, Y. Ebihara, D. Miyazaki, Y. Kurashima, S. Murakami, T. Shichinohe, S. Hirano, Y. Matsui Hokkaido University Graduate School of Medicine, SAPPORO, Japan Introducion: Endovascular aneurysm repair (EVAR) has recently become popular as a less invasive operation for abdominal aortic aneurysm. It has been reported that blood flows back into the aneurysm from lumbar artery (type II endoleak) after EVAR in approximately 10% of the patients after acute phase. Transarterial embolization, translumber embolization, and ligation by laparotomy or laparoscopy are recognized as treatments for type II endoleak. We consider that laparoscopic technique is minimally invasive for type II endoleak repair and we have experienced three cases underwent with this technique. Case.1 79-year-old man who underwent EVAR three years ago and three months ago presented with an expansion of aneurysm by type ? endoleak caused by lumber arteries (L24). Case.2 79-year-old man who underwent TEVAR and EVAR four years ago and presented with a gradual expansion of aneurysm from post operation by type II endoleak caused by inferior mesenteric artery (IMA) and lumber arteries(L2-4). Case.3 87-year-old man who underwent EVAR three years ago and presented with a gradual expansion of aneurysm by type II endoleak caused by lumber arteries(L2-5). In all cases, we performed laparoscopic ligation of lumber arteries, and also IMA for case 2. Postoperative CT revealed disappearance of endoleak and they haven’t had recurrence type II endoleak caused by the ligated arteries. Conclusion: Laparoscopic lumbar artery ligation is a minimally invasive and feasible treatment for type II endoleak after EVAR.

A. Hussain1, S. El-Hasani2 1

DONCASTER ROYAL INFIRMARY, DONCASTER, United Kingdom; 2Kings College Hospital, LONDON, United Kingdom Background: port site incisional hernia is a complication of laparoscopic surgery and a potential risk for bowel strangulation and perforation which could results in resection with increased morbidity, cost and patient’s dissatisfaction. Methods: Since 2011,subcostal ports were used for all 6424 patients who underwent different laparoscopic operations. The subcostal ports of 10-15 mms were inserted immediately at the midclavicular line at either subcostal regions. The ports were closed at skin level only.The patients who had ports that were extended because of large specimen extraction and closed at the sheath level were included while converted operations were excluded. The patients were reviewed at 1,3,6 and 12 and 24 months for bariatric surgery. The other patients were reviewed 6 weeks after the operations. This cohort compared to 4774 patients operated on between 2000-2007 by non subcostal port technique. The correlation and p value were calculated. Results: 6424 laparoscopic procedures were performed using subcostal ports as additional ports. Four hematomas and 3 port infections were reported and no port site hernia. Of the other 4774 patients,8 port site hernia reported. There was no significant statistical difference in the number and type of operations in each arm, p value = 0.643.The correlation coefficient was 1 and there was significant difference in the incidence of PIH, p value was 0.021058547. Conclusions: subcostal port insertion is significantly reducing the port site hernia.

P460 - Technology

P462 - Abdominal Cavity and Abdominal Wall

Diagnosis with Image Enhancement and Autofluorescence System for Advanced Gastric Cancer

Adhesiolysis-Related Difficulties During Laparoscopic Re-Exploration After Prior Incisional Hernia Repair

R. Matsui, N. Inaki, R. Sato, T. Okude, D. Yamamoto, H. Kitamura, N. Ota, H. Bando

F. Turcu, S. Filip, B. Banescu, C. Copaescu

Ishikawa prefectural central hospital, KANAZAWA, Japan Background: Laparoscopic surgery for gastric cancer has been spread. The indication for advanced cases such as serosa-positive or peritoneal dissemination is still controversial. We report clinical experiences of laparoscopic diagnosis with image enhancement and autofluorescence system for laparoscopic gastric cancer surgery. Method: The image enhancement system; IMAGE 1 SPIESTM (Karl Storz, Germany) was introduced into our clinical cases of laparoscopic surgery for gastric cancer. The system integrates auto fluorescence system, which was combined for the diagnosis. Results: A series of 161 cases (male/female: 110/51) were investigated. Median age was 67 years old. Clinical stages were IA/IB/IIA/IIB/IIIA/IIIB/IIIC/IV = 105/14/8/6/2/6/10/10. In 10 cases of peritoneal dissemination, an autofluorescence was positive and macroscopic abnormal vascularlization was detected. The sensitivity, specificity, positive predictive value and negative predictive value of AF-positive and abnormal vascularlization for pathological peritoneal dissemination are 100, 99.4, 87.5 and 100%, respectively. In 37 cases of Serosa-positive, an autofluorescence was positive and macroscopic abnormal vascularlization was detected. The sensitivity, specificity, positive predictive value and negative predictive value of AF-positive and abnormal vascularlization for pathological serosal invasion or more are 75.7, 97.6, 90.3, and 93.1%, respectively. Conclusion: Our clinical results suggested the image enhancement system in combination with autofluorescence system was useful for laparoscopic intraoperative diagnosis of peritoneal dissemination and serosal invasion for gastric cancer.

123

Ponderas Hospital, BUCHAREST, Romania The purpose of this video presentation is to highlight the difficulties we have encountered at re-laparoscopy with adhesiolysis to intraperitoneal non-absorbable barrier-coated meshes. The indications for the 8 laparoscopic re-explorations were: infected seroma (n = 3), recurrent incisional hernia (n = 2), recurrent parastomal hernia (n = 1), subocclusive syndrome (n = 1), gynecologic pathology (n = 1). Adhesions were found at intraperitoneal mesh in every case. We have use Jenkins’s scale to characterize the adhesion tenacity and the mean was 2.8 ± 0.3. The majority of patients in each group had small bowel or colon adherent to the mesh. Our conclusion is that, despite the difficult adhesiolysis to the intraperitoneal mesh, relaparoscopy is the best option for the patient.

Surg Endosc

P463 - Abdominal Cavity and Abdominal Wall

P465 - Day Surgery

Laparoscopic Management of Vascular Injuries During Pelvic and Paraaortal Lymph Node Dissection

A Case of Laparoscopic Cholecystectomy After Coronary Artery Bypass Grafting Using The Right Gastroepiploic Artery

S. Baydo, A.B. Vinnytska, A.V. Zhygulin, A.S. Oparin, D.A. Golub

T. Yamamoto

LISOD - Hospital of Israeli Oncology, KYIV, Ukraine

Kokura Memorial Hospital, KITAKYUSYU,FUKUOKA, Japan

Aim: Injury of major vessels during laparoscopic surgery is a rare but very dramatic complication. Almost in all cases it required conversion to laparotomy for completion of hemostasis. This work represents our experience in performing laparoscopic hemostasis after major vascular injuries during pelvic (PLND) and paraaortal (PALND) lymph node dissection. Methods: In 2010-2015 we performed 214 PLND and 313 PALND (527 procedures in 492 patients). Among them there were 457 cases of single region dissection: 179 PLND and 278 PALND, while 35 patients underwent both of them. Lymphadenectomy was the part of radical procedure for: cervical cancer - 109 (20,7%), endometrial cancer - 91 (17,3%), ovarian cancer - 12 (2,3%), colorectal cancer - 270 (51%) and other malignancies (seminoma of testis, melanoma) - 10 (1,9%). Dissection was performed by harmonic scissors and bipolar. To achieve hemostasis after major vascular injury we used the next steps: (1) pressure of vascular wound; (2) round dissection of vessel and applying of vascular clamps for injuries longer than 2 mm; (3) suturing the vascular damage with prolene 5/0. Results: Performing lymphadenectomy we obtained 7 major vascular injuries (1,3%): 2 aorta, 2 - vena cava inferior, 2 - vena iliaca and 1 - arteria iliaca. In all cases we performed laparoscopic hemostasis by suturing the defect of vessel without conversion to laparotomy. All vascular injuries occurred in patients with history of chemoradiotherapy, and there weren’t any in case of primary treated patients. The size of vascular damage was up to 2 mm in 5 cases and more than 5 mm (5 mm and 8 mm) in 2 cases of vena cava injury. The average time from injury to completion of hemostasis - 17 min (11–34). The estimated blood loss - 150 ml (45–700). There was no need for transfusion in all cases. The median hospital stay in case of vascular injury was 4, 9 days and no significantly longer than in main group (4,5). No thrombotic complications and death occurred. Conclusions: Vascular injury of major vessels during lymphadenectomy is rare but very serious complication that can be successfully treated laparoscopically by experienced surgeon.

Background: Laparoscopic cholecystectomy (LC) has become the standard procedure for cholecystolithiasis. However, in case of performing cholecystectomy on a patient who had undergone upper abdominal surgery, open cholecystectomy (OC) is often performed as a first choice. Case Report: A 78-year-old female was diagnosed as a cholecystolithiasis, who had undergone coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) 15 years before. We used multidetector-row computed tomography (MDCT) for preoperative planning, and we regarded that LC is safer than OC for avoiding the risk of the RGEA graft injury. We performed LC with transumbilical multi-port device adding an assist port under the right costal arch, avoiding the adhesion of the epigastric scar. During the operation, no ST changes on the electrocardiogram were seen, and the postoperative course was uneventful. Discussion: In cases of performing cholecystectomy on a patient who undergone CABG using RGEA, there are some risks of the graft injury due to the adhesion and the disorientation. But recognizing the vascular anatomy of the RGEA graft preoperatively in detail, and contriving the arrangement of the ports, we think LC could be performed safely even in such cases. Conclusion: We could perform LC safely on the patient who had undergone CABG using the RGEA. It is important for surgeons to select the safer procedure according to an individual case to prevent complications.

P464 - Clinical Practice and Evaluation

P467 - Emergency Surgery

Laparoscopic Methods of Surgical Treatment of Colon Diseases

Laparoscopic Abdominal Exploration in the Non-Diagnosed Acute Abdomen

A. Bimurzayeva, K. Rustemova, A.B. Aitmoldin City hospital 2, ASTANA, Kazakhstan Aims: The optimal choice of surgical treatment for colon diseases, achievement of favorable outcomes. The colon pathology is one of the most pressing and socially significant problems of modern health care. Surgical diseases of the colon leads to reduction of the working population employed in manufacturing, in some cases to disability and reduced quality of life. Active development and introduction of endovideosurgery led to common use of minimally invasive surgery in the treatment of colon pathology. The new tools and techniques that will make these operations safer and easier to perform are constantly developed and introduced in clinical practice. Methods: CT, MRI, ‘Karl Stors’ endoscopic stand. Morphological, microbiological research methods, clinical and laboratory studies. Results: During the period from 2013 to 2015 in the Septic Surgery and Coloproctology Department at the City hospital 2, 35 operations were conducted: 16 (45,7%) left-sided laparoscopic hemicolectomy, 7 (20%) - right-sided laparoscopic hemicolectomy, sigmoid resection 12 (34,2%). 19 patients (54,2%) had the operation on the sigmoid colon tumors, 9 patients (25,7%) had dolichosigmoid diagnosis. For 7 patients (20%) the operation was conducted on tumors of the ascending part of colon. Among them, there were 20 (57.1%) males and 15 (42.9%) females aged 15 to 49. At the preoperative stage all patients were prepared in accordance with the clinical protocol and guideline of patient treatment with colon diseases. Average patient stay in the hospital is 7-8 days, the activization of the patients was carried out on the 2nd day after operation. All patients are under the doctors’ supervision. Long-term results: stool normalization up to 1 time per day (one month stool detention before surgery), improved overall health, memory and attention improvement, overall appearance improvement and life quality improvement. Patients with tumor of colon were controlled by CT examination; no signs of metastasis were detected. Perspective plan of our department includes the increasing of such operations up to 50–70 per year. Conclusions: Minimally invasive laparoscopic surgery in the treatment of benign and malignant diseases of the colon, as an alternative to open surgery, is widely recognized in the practice of surgical community.

E. Balen, M.M. Demiguel, I. Otegi, G. Gonzalez, M.A. Ciga COMPLEJO HOSPITALARIO DE NAVARRA, PAMPLONA, Spain Case Report: An 80-years old lady made a consultation in the Emergency Department suffering from vomiting, diarroea, abdominal pain and fever (38 C). She had a peptic ulcer years before, and her abdomen was distended and tender, especially in the left lower quadrant. Chest and abdominal X-Ray were normal, but she showed an increase in leucocyte count, C-Reactive Protein and Procalcitonin. Abdominal CT-scan demonstrated a small epigastric neumoperitoneum, uncomplicated sigmoid colon diverticula, a hiatal and umbilical hernia and a duodenal diverticulum, possibly perforated (nearby neumoperitoneum). An exploration laparoscopy was performed under general anaesthesia with a Hasson umbilical port: there was no subdiaphragmatic or paracolic fluid, but the pelvic ileum was slightly inflammed. By using 2 additional 5 mm ports (in the right and left flank) a more thorough look showed no signs of inflammation or perforation of the duodenum, stomach and colon: also colecystitis and appendicitis were ruled out, and an uncomplicated mesenteric diverticulum was found in a jejunal loop. The only remaining area to be more thoroughly explored was the pelvis, and genitourinary infections were also ruled out, but there was a small amount of pus in the Douglas pouch, and also around the sigmoid colon: several colon diverticula were identified with no perforations, but some fibrinous tissue over one of them. The laparoscopic diagnosis was a Hinchey III sigmoid diverticulitis without intestinal perforation, an ideal candidate for peritoneal lavage: a sample from the pelvis was obtained for culture, and the lavage was followed by leaving a pelvic drain in the pelvis and around the sigmoid colon. The patient was treated with a 7-day course of IV antibiotics and suffered no complications. A virtual CT-Colonoscopy ruled out any neoplastic suspicion 2 months later. Conclusion: a complete laparoscopic exploration of the abdomen is demonstrated.

123

Surg Endosc

P468 - Gastroduodenal Diseases

P470 - Gastroduodenal Diseases

Innovative Anastomosis for Reconstruction in Totally Laparoscopic Total Gastrectomy

Laparoscopic Resection of Giant Gastric Gist with Endoscopic Assistance

Y.I. Sakimura, N. Inaki, T. Tsuji, T. Okude, R. Matsui, D. Yamamoto, H. Kitamura, N. Ota, M. Kurokawa, H. Bando, T. Yamada

E. Delgado Oliver, A.M. de Lacy, R. Bravo, R. Corcelles

Ishikawa Prefectural Central Hospital, KANAZAWA, Japan

Fundacio´n clinic, BARCELONA, Spain

Background: Laparoscopic procedure for upper gastric cancer is not generally established due to complicated anastomotic technique under laparoscopic view. Our procedure for anastomosis in totally laparoscopic total gastrectomy (TLTG) followed by Roux-en-Y reconstruction(R-Y) is demonstrated and its clinical results are evaluated. Patients and Methods: We have introduced overlap technique (side-to side anastomoisis) using linear stapler for esophago-jejunosotomy since October 2008. Barbed suture has been used for closing the entry hole of the stapler since 2012. All consecutive patients from 2008 to 2015 are evaluated. Surgical Technique: Total procedure until gastrectomy with appropriate lymphadenectomy is performed by laparoscopic technique using 5 ports. Resected specimen is removed from an enlarged umbilical port site at most 3 cm. Insufflation is restarted using sealing retractor and R-Y is performed. A jejuno-jejunostomy and an esophagojejunostomy are carried out by liner stapler technique, what we call, overlap technique. The each entry hole of linear stapler is closed by intracorporal suturing technique, using barbed suture (3-0,V-LocTM). Results: Total of 117 cases were laparoscopically completed in safety. One staple failure is occurred (0.9%), but safely recovered without any complication. The median amount of blood loss was 20 ml, ranging from 5 to 620. There was three anastomotic leakage (2.6%), but there was no stenosis. Conclusions: Our procedure of TLTG followed by R-Y (Overlap method using linear stapler and barbed suture) is safe and feasible. Its clinical results are acceptable. This technique might become one of the gold standard methods in TLTG for upper gastric cancer.

Background: Gastrointestinal stromal tumors (GISTs) are uncommon tumors of the gastrointestinal (GI) tract. These neoplasms start in very early forms of special cells found in the wall of the GI tract, called the interstitial cells of Cajal. GISTs occur along the entire gastrointestinal tract but more than half start in the stomach. Surgery is the primary treatment of choice in localized or potentially resectable GIST and he same surgical principles as open surgery are applicable in laparoscopic surgery for GISTs. Case report: A 73-year-old female studied for 3 months asthenia was found to have severe anemia. Abdominal CT scan revealed a 12.3 cm voluminous mass tumor extending beyond the gastric wall, close the liver, diaphragm and spleen. No clear signs of tumor infiltration were reported at this level. Endoscopic ultrasound (EUS) revealed sub-mucosal lesion at the wall of the gastric fundus with histopathological result of low malignant potential GIST. The initial diagnostic was infiltrating neoplasia. She started treatment with chemotherapy (imatinib), noting a slight decrease regarding tumor size after 8 months of antitumoral treatment. Thereafter, the patient underwent surgical resection of the gastric tumor upon curative intent surgery. The procedure was performed by laparoscopic approach. Importantly, no tumor infiltration of the nearby structures was identified and the neoplasm was successfully en-bloc removed (R0 resection). Intraoperative esophagogastroduodenoscopy (EGD) confirmed free resection margins. Pathologic examination revealed spindle cell type GIST with low malignant potential; 10.2 cm of maximum diameter, T3 grade. Immunohistochemistry was positive for CD34 and CD117, but negative for desmin. Her postoperative period was uneventful and she was discharged home on the 4 th day. Conclusion: This case report suggests that large GISTs of the stomach can be safely removed by laparoscopy.

P469 - Gastroduodenal Diseases

P471 - Intestinal, Colorectal and Anal Disorders

Fesibility and Safety of Duet Totally Laparoscopic Distal Gastrectomy in Gastric Cancer

The Use of the EndograbTM Port-Free Endocavity Retractor i n Single-Incision Laparoscopic Right Hemicolectomy

J.Y. Jang1, J.H. Kim2, S.S. Park2, S.H. Park2, Y.J. Mok2

M. Shimada, Y. Hirano, M. Hattori, K. Douden, Y. Hashizume

1 KOREA UNIVERSITY, SEOUL, Republic of Korea; 2KOREA UNIVERSITY COLLEGE OF MEDICINE, SEOUL, Republic of Korea

Fukui prefectural hospital, FUKUI, Japan

Objectives: Laparoscopic-assisted distal gastrectomy (LADG) is a treatment method for patients with early gastric cancer. This study aimed to compare surgical outcomes of patients with gastric cancer undergoing 3port totally laparoscopic distal gastrectomy (duet TLDG) to those of patients undergoing conventional LADG. Methods: This retrospective study included 38 patients with early gastric cancer who underwent duet TLDG (21patients) or conventional LADG (17 patients) at Korea university Guro Hospital at 2015. Results: Operating time was similar for duet TLDG than for conventional LADG (135.38 ± 12.8 min vs. 137.18 ± 31.7 min, P = 0.898). There were no complication in both the duet TLDG and conventional LADG groups were similar (15.7% vs. 10.0%, P = 0.294). The number of dissected lymph node, the median postoperative hospital stay were similar both groups. Conclusions: Duet TLDG for early gastric cancer is feasible and safe procedure .

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Introduction: The EndoGrabTM Port-Free Endocavity Retractor is an internally anchored retracting device that enables surgeons to reduce not only the number of ports and incisions but also the number of assistant surgeons. To perform these procedures safely while maintaining the minimal invasiveness of SILC and the quality of the lymph node dissection, we use this retractor. We report on right hemicolectomy for colon cancer with the new EndoGrabTM Retractor. Methods: 49 patients underwent a single-incision laparoscopic right hemi-colectomy. First, a Lap protector was inserted through a 2.5 cm transumbilical incision to protect the wound. Next, an EZ-access was mounted onto the LP, and three 5 mm ports were placed in the EZaccess. Almost all procedures were performed with standard laparoscopic instruments and the operative procedures were similar to those employed in standard laparoscopic right hemicolectomy procedures. In this procedure, we use this retractor to the mesenteric tissue, including the ileocolic vessels and the mesentery of the transverse colon, and overcame the technical problems related to SILC. Results: The mean skin incision was 2.62 cm. The mean operative time and blood loss were 191.2 min and 59.6 ml, respectively. The mean number of harvested lymph nodes was 35.3. Postoperative complications occurred in two patients. The patients were discharged on 11.3 postoperative days. Conclusions: To perform SILC safely while maintaining the minimal invasiveness and the quality, the use of this retractor is essential, especially in difficult situations, such as an unfavorable visual field when performing a lymph node dissection around middle colic vessels in right hemicolectomy.

Surg Endosc

P472 - Intestinal, Colorectal and Anal Disorders

P474 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Surgery for Locally Recurrent Rectal Cancer

A New Laparoscopic Rectal Transection Method Via Umbilical Incision Using Endo GiaTM Radial Reload

M. Uemura, M. Ikeda, M. Miyake, M. Miyazaki, S. Maeda, K. Yamamoto, N. Hama, K. Nishikawa, A. Miyamoto, M. Hirao, S. Nakamori, M. Sekimoto National Hospital Organization, Osaka National Hospital, OSAKA, Japan Background: Local recurrence of rectal cancer (LRRC) is still a major problem after curative resection of primary rectal cancer. Extensive pelvic surgery can achieve complete resection of LRRC. Such surgery is often associated with extensive blood loss during surgery and severe postoperative complications. To improve surgical outcomes, minimally invasive procedures should be considered. Recently, several reports suggested that preferable outcome of laparoscopic surgeries for extended surgery of colorectal cancer. But for extremely invasive surgeries such as resection of LRRC, there are no reports discussing the feasibility of laparoscopic surgery. Feasibility of laparoscopic surgery for LRRC is discussed here. Method and Patients: From 2012 to 2014, 32 patients underwent curative intent resection for LRRC at our institution. Of these, 14 patients received laparoscopic surgery including 3 cased of total pelvic exenteration. Surgical outcomes were compared between laparoscopic surgery and open surgery. Results: There were no significant differences between the laparoscopic surgery and open surgery groups in terms of median operating time (557 (209–851) min vs. 577 (259–1098) min, respectively). Intraoperative blood loss was significantly fewer in laparoscopic surgery compared to open surgery (255 (0–1620) ml vs. 2380 (580–17930) ml, respectively, p \ 0.05). Surgical complications were assessed via the Clavien-Dindo Grade classification. Major complications (grades 3 and 4) occurred in 8 patients (44%) in open surgery group, though there were no major complications in laparoscopic surgery group. Conclusions: Laparoscopic surgery for LRRC is feasible. A large-scale prospective study should be considered to confirm the superiority of laparoscopic surgery for over open surgery for LRRC.

R. Shigemi, Y. Hirano, M. Hattori, M. Shimada, K. Douden, Y. Hashizume Fukui prefectural hospital, FUKUI, Japan Introduction: We developed a new rectal transaction method via umbilical incision using Endo GIATM Radial Reload with Tri-StapleTM Technology (RR) (Covidien, New Haven, CT) stapler. Methods: 8 patients (3 women) with a median age of 72.5 year were treated with a singleincision laparoscopic rectal transection with RR for colorectal cancer. First, a Lap-Protector was inserted through a 2.5-cm transumbilical incision, and an EZ-access was mounted to the LP and three 5-mm ports were placed in the EZ-access. In two cases performed low anterior resection, an additional port was inserted in the right lower quadrant which we could utilize for drainage after operation. Almost all the operative procedures were much the same as in a usual single-incision laparoscopic colorectal procedure. After rectal lavage, the RR was inserted directly into the abdominal cavity through the 12-mm port mounted on the EZ access. The curved head of the RR was rotated to the sagittal orientation at the anal side of the rectal clamp to insert the rectum between the jaws of the stapler. The stapler was closed and fired, and a rectal transection was thus performed. Result: In all eight cases, we successfully performed a rectal transection via umbilical incision using this stapler, and no postoperative complications including anastomotic leakage were occurred. Conclusion: The possibility of rectal transection via umbilical incision was demonstrated in our experiences, and this procedure may enable completion of single-incision laparoscopic colorectal surgery without any additional ports. However, further studies are needed to confirm the safety and feasibility of this procedure.

P473 - Intestinal, Colorectal and Anal Disorders

P475 - Intestinal, Colorectal and Anal Disorders

Robotic Total Mesorectal Excision for Low and Ultralow Rectal Cancer: 3-Year Oncological Outcomes

R0 Resection as Standard Procedure in Intussusceptions Caused by Intestinal Tumors in Adults

G. Formisano1, M. Misitano1, G. Calamati1, G. Giuliani1, S. Esposito1, W. Petz2, P.P. Bianchi1

B. Smeu, C. Copaescu

Misericordia Hospital, GROSSETO, Italy; 2European Institute of Oncology, MILAN, Italy

Ponderas Hospital, BUCURESTI, Romania

1

Aim: Robotic surgery is regarded as a new modality to surpass the technical limitations of conventional laparoscopic surgery in the treatment of rectal cancer, with a potential major benefit in low and ultralow anterior resection. To date, however, few reports about oncological outcomes have been published. Our aim is to evaluate short-term postoperative and 3-years oncological results of robotic total mesorectal excision (TME) for low and ultralow rectal cancer. Methods: From August 2008 to April 2015, 88 patients (49 Male) underwent robotic TME for rectal cancer (66 low anterior resections and 22 abdomino-perineal resections). Median age was 66 years. Mean distance from the anal verge was 7 cm. Median follow-up was 42 months (range 1-75). Splenic flexure takedown was performed laparoscopically in 46/66 patients (70%). In the remaining cases, a full-robotic single-docking technique was performed. A diverting loop ileostomy was carried out in 46/66 cases (69%). Results: Mean overall operative time was 295 min. Mean hospital stay was 6.9 days. Conversion rate to open surgery was 2.3%. Grade I-II and III-IV 30-day complication rates were 14.7% and 6.8%, respectively, according to Clavien-Dindo classification scale. Anastomotic leak rate and reoperation rate were 6% and 6.8%, respectively. Mean lymph node yield was 20. Mean distal resection margin was 2.92 cm and circumferential resection margin was involved in 2.3% cases. 3-year disease-free and overall survival were 74.4% and 93.3%, respectively. Three-year local recurrence rate was 2.2%. Conclusions: Robotic-assisted TME is a feasible and safe option for the surgical management of low and ultralow rectal cancer. The mid-term oncological safety justifies the practice of robotic rectal resection to further investigate its role on long-term outcomes.

Background: Intussusceptions was reported for the first time in 1674 by Barbette of Amsterdam. The occurrence of intussusceptions in adults is rare, accounting for less than 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction. In contrast to pediatric intussusceptions, which is idiopathic in 90% of cases, adult intussusceptions has an organic lesion in 70% to 90% of cases. In adults, intussusceptions is more likely to present insidiously with vague abdominal symptoms and rarely presents with the classic triad of vomiting, abdominal pain and passage of blood per rectum, making diagnosis difficult. Aim: to present the technique of laparoscopic segmental small bowel resection with lymphadenectomy and side to side intracorporeal isoperistaltic anastomosis in intussusceptions caused by intestinal tumors and the postoperative outcomes. Methods: The best resection must take into account all possible malignancy choosing to have always mesenteric lymph nodes dissection for best results knowing that there might always be malignancy and knowing that studies have shown a survival advantage to individuals capable of undergoing complete resection of all intraabdominal disease. Followup chest and abdominal CT scans were negative for recurrence or distant metastasis. Results: Between 2011 and 2015, we have operated 12 cases of intussusceptions due to small bowel tumors for which we have always choose an oncological segmental small bowel resection with regional lymphadenectomy in order to obtain an R0 resection. This video demonstrates our technique of laparoscopic segmental small bowel resection with lymphadenectomy and side to side intracorporeal isoperistaltic anastomosis.The oncological outcomes are presented. Conclusions: Segmental small bowel resection with lymphadenectomy should be the standard procedure in intussusceptions caused by intestinal tumors. The laparoscopic technique is challenging the surgical team.

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P476 - Liver and Biliary Tract Surgery Endoscopic Treatment of Cholecystoduodenal Fistula with Common Bile Duct Stone: Case Report K.S. Burmich, O.I. Dronov, I.O. Kovalska, I.L. Nastashenko, T.V. Lubenets, K.O. Zadorozhna

P478 - Oesophageal and Oesophagogastric Junction Disorder Laparoscopic Repair of Large Hiatal Hernias - Challenge for Surgeons A. Balint, R. Rozsa, B. Brenner, G. Herczeg, T. Regoczi

Bogomolets National Medical University, KYIV, Ukraine

St Emetic University Teaching Hospital, BUDAPEST, Hungary

Background: cholecystoduodenal fistula (CDF) with common bile duct stone (CBDS) simultaneously is rare and uncommon complication of gallstone disease which is often diagnosed during operation and has been one of the reasons for conversion from laparoscopic to open surgery. Here, we describe the case of CDF with CBDS which successfully managed by endoscopic approach. Materials and methods: a 66-years woman was admitted to our department for laparoscopic cholecystectomy (LC) with cholelithiasis. The patient has no clinical, laboratory and transabdominal ultrasound predictors of CBDS, therefore pre-operative endoscopic retrograde cholangio-pancreatograhy (ERCP) was not performed. CDF also was not suspected preoperatively and detected during laparoscopy. LC was attempted under general anesthesia with standard four-trocar technique. After dissection CDF was found and transected with ultrasound scissors. The duodenal defect was closed with absorbable interrupted sutures in a double layer after cholecystofistulectomy. CBD transcystic drainage and two suction subhepatic area drainages were placed. CBDS was detected on postoperative cholangiogram in the distal of CBD. Results: the operative time was 130 min and the estimated amount of blood loss was 50 ml. The patient had no postoperative complications, suction subhepatic area drainages were removed on postoperative day 5. Considering the duodenal sutures delayed ERCP with endoscopic papillotomy and clearance of CBD was performed after readmission on postoperative day 30, than CBD transcystic drainage was removed and patient was discharged. Conclusion: endoscopic treatment of CDF with CBDS is feasible and safe in spesializated medical center.

The tension free repairs of abdominal hernias meant a breakthrough in surgery. The recurrence rate of hernias considerable decreased (10-15% - [ 1-3%) following these kinds of repairs. The recurrence rate after hiatal hernia repair is much higher, it can be as much as 40% according to literature data. This was the reason why surgeons tried to decrease the high incidence of hernia recurrence. Reconstructions using different types of meshes and different anchoring methods showed quite good short term clinical results but during follow-up period seldom we could experience different mesh-related, sometimes severe complications causing occasionally even life-threatening condition for the patients e.g. scar formation around the mesh, stricture, abscess formation and penetration of the mesh into the esophagus. The decrease of recurrence rate following mesh repairs seems to be not so convincing like it proved to be in case of abdominal wall and inguinal hernia repairs. This may be the reason why the literature is controversial concerning the application of meshes during hiatal hernia repairs. Our team recently has changed the surgical strategy of hiatal hernia repairs due to rare but severe mesh related complications. During surgery we try to mobilize the esophagus as much as possible, to prepare the both crura and to perform the reconstruction of esophageal hiatus by means of direct sutures of the crura even in cases of hiatal hernias with diameter larger then 6 cm. The procedure is always supplemented with partial or total fundoplication. Between January 2013 and December 2014 we never used mesh implantation during surgery (22 and 15 patients in all 37 pts.) The laparoscopic management of 61 years old female patient’s incarcerated paraesophageal recurrent hiatal hernia is demonstrated. The poor results of hiatal hernia repairs can be explained by the presence of the so-called ‘short esophagus’, the quality of the crura, the postoperative vomitus, the weakness of connective tissue and the high BMI value.

P477 - Liver and Biliary Tract Surgery

P479 - Vascular Surgery

Laparoscopic Cholecystectomy in Situs Inversus Totalis

Robotic Aneurysmectomy with Vascular reconstruction for Hilar Splenic Artery Aneurysm

I. Sarici1, F. Kala2, Y. Sevim3, T. Sarigoz4 1

Kanuni Sultan Suleyman Training and Research Hospital, ISTANBUL, Turkey; 2Kadirli State Hospital, OSMANIYE, Turkey; 3 Ankara Training and Research Hospital, ANKARA, Turkey; 4 Kayseri Training and Research Hospital, KAYSERI, Turkey Aim: Situs inversus totalis is a rare anomaly characterized by transposition of organs to the opposite site of the body. Laparoscopic cholecystectomy is much more challenging in the presence of this disorder due to loss of usual orientation. Methods: We present a case of a 25-year-old woman who was diagnosed at our centre to have calculous cholecystitis in the presence of situs inversus totalis. Diagnosis of situs inversus totalis was confirmed with ultrasound, revealed a left-sided gallbladder with presence of multiple gall bladder stones with no intra or extrabiliary duct dilatation. The patient underwent laparoscopic cholecystectomy for cholelithiasis. Results: The patient tolerated the operation very well and was discharged home after 24 h. On follow-up visit the patient was doing very well and completely free of symptoms. Conclusion: Feasibility and technical difficulty in diagnosis and treatment of such case pose challenge problem due to the contra lateral disposition of the viscera. Difficulty is encountered in skelatonizing the structures in Calot’s triangle, which consume extra time than normally located gall bladder.

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A. Peri, A. Pietrabissa, L. Pugliese, E. Cavazzi, F.P. Tinozzi, F. Argenti, V. Gallo IRCCS Policlinico San Matteo, PAVIA, Italy This video shows the case of a female patient with a 2,5 cm splenic artery aneurysm located on the posterior aspect of the splenic hilum. Sharp dissection of the vascular anatomy of splenic artery was safely accomplished by the use of DaVinci surgical robot. Specifically, all the inward and outward arterial branches were isolated and clamped before complete excision of the aneurysm was performed. Vascular reconstruction was achieved by robotic T-T anastomosis with Prolene 7-0 sutures. No splenic ischemia was developed at the end of surgery nor at later follow-up. No other intra-operative complications occurred and blood loss was insignificant. Patient’s postoperative course was completely uneventful. Robotic technology allows a safe and effective minimally-invasive approach for the treatment of visceral artery aneurysms in selected cases.

Surg Endosc

P481 - Morbid Obesity

P483 - Abdominal Cavity and Abdominal Wall

Laparoscopic Gastric Plication: How We Do It?

Synchronous Digestive Tract Tumors with Plurifactorial Etiology. Multidisciplinary Treatment

A. Nagpal Dr. Jivraj Mehta Smarak Health Foundation, AHMEDABAD, India Introduction: Laparoscopic gastric plication, also known as laparoscopic greater curvature plication, has recently emerged as a new bariatric procedure. The rationale for this procedure addresses issues that may limit the acceptance of other bariatric procedures. Specifically, the gastric plication does not involve gastric resection, intestinal bypass, or placement of a foreign body, and this could potentially provide a lower risk alternative that will appeal to patients and referring physicians. The operation involves mobilizing the greater curvature of the stomach similar to the dissection for a sleeve gastrectomy and infolding or imbricating the stomach to achieve gastric restriction. Method and Result: Gastric plication was done after taking local ethics committee approval (Dr. Jivraj Mehta Smarak Hospital, Ahmedabad, India) and patient was explained in details about the procedure and also that it is still not a standard bariatric surgical procedure. Patient was a young male and had Body Mass Index of 39 and he had Hypertension. The gastric greater curvature was plicated using 2/0 polyester suture from fundus at the level of diaphragm preserving the His angle to just proximal to the pylorus. Two rows of sutures were placed. Inner row was taken interrupted and outer row was with continuous suturing. The post operative recovery was uneventful except that the patient had severe nausea for 3 days and required proton pump inhibitors and anti emetics for a prolonged period of 6 weeks. Post surgery 3 months patient has lost 15 kg and is asymptomatic. Conclusion: Laparoscopic gastric plication is effective restrictive method to lose weight. However, the data available at this time is insufficient to draw any definitive conclusions regarding the safety and efficacy of this procedure. It should be considered investigational procedure and patient explained properly with approval from local or regional ethics committee or Institutional board.

A.F. Savulescu, C. Cirlan Carol Davila Central Military Hospital, BUCHAREST, Romania Synchronous digestive tract tumors of different etiology represent a small percentage of the synchronous abdominal tumors. We present the case of a man of 53 years whose preoperative diagnosis was of tumor of the descending colon, intraoperative also adding the diagnosis of jejunal tumor which, after pathological examination, proved to be a type T non Hodkgin lymphoma. An important role in the treatment of patients with synchronous tumors of the digestive tube is the multidisciplinary collaboration between surgeon, pathologist, oncologist, radiation oncologist, radiologist.

P482 - Abdominal Cavity and Abdominal Wall

P484 - Abdominal Cavity and Abdominal Wall

Intraoperative Complications of Laparoscopic Hernioplasty

Laparoscopic Repair of Giant Hiatus Hernia

V.O. Tedoradze, O.O. Vorovskiy, D.M. Menabde, A.M. Bazyak

Y. Chen, Y. Soon

Republican Clinical Hospital of Batumi, BATUMI, Georgia

Ng Teng Fong General Hospital, SINGAPORE, Singapore

Materials and methods: We have taken and analyzed 728 cases of laparoscopic hernioplasty,Among them were recorded 488 (68.5%)inguinal-femoral hernias,126 (17.3%) umbilical location,104 (14.3%) hernias of the white abdominal linea,4 (0.5%) hernias of spiheliv’s line and 6 (0.8%) hernias of the right iliac region. Recurrent hernias were submitted in 108 (14.8%) patients, postoperative hernias were seen in 34 (4.7%) cases.Intraoperative complications occurred in 13 (1.8%) cases. While conducting this analysis were highlighted the following complications: bleeding from epigastric vessels (4 (0.5%) cases), a bowel injury (4 (0.5%)cases), subcutaneous emphysema (3 (0.4%)cases), a damage of the bladder (1 (0.1%)case), hematoma (1(0.1%)case). Results: and discussion: The damage of inferior epigastric vessels were made during the fixation of a polypropylenemesh using the herniostepler. At all cases hemostasis was achieved by clipping and bipolar coagulation. Coagulation intestinal damage (burn) appeared in 2 (0.3%) cases, when we have made the processing of bowel adhesions. Using noninvasive intestinal clamps, careful use of bipolar electrocoagulation were adequate prevention of these complications. Perforation of the dome cecum occurred in 2 (0.3%) patients. In these cases we began dissecting the peritoneum in the region of the medial folds without coagulation. Damage of the bladder emerged in those cases, whenthe urethral catheter wasabsent. Mandatory bladder catheterization allowed in the future avoiding this complication. Subcutaneous emphysema wasprevented usingcarboperitoneumat 12-8 mmHg. In 8 (1.1%) cases weused the laparolift with insufflation of CO2 to 3 mmHg. Hematoma occurred in the case of the laparoscopic hernioplasty on a large bilateral inguinal-scrotal hernia. So, hernia channel was drained through a separate incision in the scrotum. Conclusions: Established that increasing surgical experience and improve laparoscopic hernioplasty methods subsequently allowed to avoid intraoperative complications

Aim: Hiatus hernia (HH) is herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. Giant hiatus hernias are defined as more than 30% of the stomach in the chest on radiologic imaging or endoscopy. Giant hiatus represents from 0.3% to 15% of all HH. The potential risk of incarceration and strangulation is often quoted as an indication for surgery. Methods: We report an unusual case of 79 year old female with giant HH for operation video presentation. Result: The 79 year old female presented with epigastric and chest pain for one day, associated with regurgitation and vomiting. Chest XRay showed widened mediastina, and subsequent CT revealed a type III giant HH with herniation of the gastric fundus into the thoracic cavity. The hiatus measures 5 cm in diameter. She underwent laparoscopic repair of giant hiatus hernia, the combined sliding and paraesophageal hernia was reduced and repaired with primary closure. A 270 degree Toupet’s wrap was performed. After operation the patient recovered well and was discharged on post operative day 3. Chest XRay after operation showed the mediastinum has reduced to normal size. Conclusions: Type III giant hiatus hernia is rare, and surgery should be performed to repair the hernia.

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P485 - Abdominal Cavity and Abdominal Wall

P487 - Clinical Practice and Evaluation

Laparoscopic Repair of Diaphragmatic Hernia with Composite Mesh

Laparoscopic Resection of Retroperitoneal Tumor Complicated by a Bleeding From Left Renal Vein: Laparoscopic Management & Discussion

Y. Chen, Y. Soon Ng Teng Fong General Hospital, SINGAPORE, Singapore Aim: Diaphragmatic hernias (DH) are rarely found in adults. Left-side DH is more common than right side. They are mainly congenital or caused by trauma. Methods: : We report an unusual case of 67 year old male with diaphragmatic hernia underwent laparoscopic repair with video presentation. Result: The patient presented with chronic coughing and epigastric pain for 5 years, associated with constipation. No significant trauma history. Chest XRay showed left lower zone opacity 4x5 cm. CT revealed left anterior diaphragmatic hernia with herniation of splenic flexure. He underwent laparoscopic repair of left diaphragmatic hernia, the hernia was reduced and the sac was repaired with primary closure. A composite mesh was tagged to diaphragm over the defect. After operation the patient recovered well and was discharged on post operative day 1. Conclusions: Diaphragmatic hernia is rare in adults. Hernia repair should be performed for symptomatic DH.

I. Carmeli, A. Ben Yaacov, M. Ben David, H. Kashtan, A. Keidar Rabin Medical Center, EINAT, Israel Background and history of present illness: 55 years old patient was diagnosed with a retroperitoneal tumor, situated posterior to the head of the pancreas and duodenum, and pushing the aorta to the left and the IVC to the right, encroaching on the left renal vein (LRV) insertion into the IVC (see pictures). All investigations did not bring about the diagnosis (including two attempts of biopsy). The decision was made to proceed with a laparoscopic biopsy or resection. Methods & results: during the laparoscopic exploration the tumor was not seemed to be a lymphoma, and we proceeded with a laparoscopic resection. It was intimately associated with the aorta, LRV, and RRA, which were dissected free. During the dissection of the LRV major bleeding has started. The bleeding was finally controlled laparoscopically by hemoclips. Discussion: the possibilities of control of a severe bleeding from a major vessel are discussed. Specifically, for the LRV, stapler transaction is possible. Conclusion: Complications during advanced laparoscopic procedures are not rare. Laparoscopic management of a severe bleeding is feasible and efficient, but require advanced laparoscopic skills and preliminary preparation. Video displaying the surgical technique is presented.

P486 - Abdominal Cavity and Abdominal Wall

P488 - Different Endoscopic Approaches

Clinical Outcomes of Single-Port Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair Under Local Anesthesia with Conscious Sedation

Endoscopic Nasomediastinal Approach to Mediastinal Abscess Developing After Zenker Diverticulectomy

N. Wada, T. Furukawa, Y. Kitagawa Keio University School of Medicine, TOKYO, Japan Introduction: Laparoscopic hernia repair is considered to be a minimally invasive surgery for inguinal hernia. However pneumoperitoneum during laparoscopic surgery requires muscle relaxation and general anesthesia which needs preoperative preparation and postoperative recovery process. On the other hand, open surgery with anterior approaches, such as Lichtenstein repair, can be safely performed under local anesthesia and ensures early recovery and safety especially for patients with comorbidities. We developed a novel minimally invasive technique of single-port laparoscopic totally extraperitoneal (TEP) inguinal hernioplasty for bilateral inguinal hernia feasible even under local anesthesia. Methods: From January 2012 to July 2015, a consecutive group of 105 patients with bilateral inguinal hernia was included. Obese patients, patients with giant hernia or irreducible hernia were excluded. We used 0.5% lidocaine with epinephrine as local anesthesia. An incision of 30 mm in the lower abdomen was made and a wound protector with sealing silicon cap was placed. We used three 5-mm trocars and a 5-mm flexible laparoscope. A flat self-fixating mesh with resorbable microgrip was installed and spread over the myopectineal orifice. No tacking devices were used. Results: The mean ± SD age was 67 ± 10 and male sex was 85%. The mean operating time was 163 ± 39 min. The total dose of lidocaine was 129 ± 42 mg. Surgical complications were not observed except for 25 cases of minor seromas. Pneumoperitoneum due to peritoneal injury was occurred in 9 cases and managed by suturing the defect. During median follow-up of 27 months, we observed no complications other than seromas, but one case hernia recurrence (0.95%). Conclusions: The short- to mid-term outcomes were similar to those of conventional TEP or open hernia repair. Surgical invasiveness of this technique was minimal because the area of dissection in the preperitoneal space is smaller than that of umbilical TEP. Postoperative recovery was rapid and patients can walk and eat anything soon after surgery. This novel procedure may be a promising strategy to reduce the invasiveness of hernia repair.

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F. Altintoprak1, K. Gundogdu2, A.T. Eminler1, E. Parlak1, G. Cakmak2, M.Y. Uzunoglu2 1

Sakarya University Faculty of Medicine, SAKARYA, Turkey; Sakarya University Research and Educational Hospital, SAKARYA, Turkey

2

Zenker diverticulum is the most frequent diverticulum of oesophagus and treatment is surgery. We aim at presenting nasomediastinal drainage approach to madiastinal abscess developing in late post-operative period due to leak from staple line.A sixty-six years old male patient had diverticulectomy and cricopharyngeal myotomy with diagnosis of Zenker diverticulum and was discharged 7 days after operation uneventfully. He re-applied on 27.day with fever, dysphagia and inflammatory findings on cervical incision line. Abscess formation with 5x4 cm diameter under the incision was detected on cervical USG examination, and anastomotic leakage in oesophagus passage graphy. 53 9 36 mm diameter of abscess image were detected in left anterior mediastinum in thoracic CT examination. During antibiotherapy with parenteral hydration, cervical abscess was drained spontaneously. Endoscopic examination was planned, and 0.5 9 1 cm gap detected on diverticulectomy area. Because of localization, endoscopic clip application was not available. 7-Fr nasobiliary drainage catheter was placed in mediastinum through the gap with guide and localization is confirmed by CT after procedure. Daily drainage amount was about 50 cc for first four days, stopped on 11.day. No leakage and no mediastinal abscess were detected on repeated radiologic examination on 13.day. Nasomediastinal drain was removed on 15.day. After prospering oral intake, the patient was discharged on 17.day and 4 months follow-up period is uneventful. Zenker diverticulum, pseudodiverticulum of oesophagus, requires surgical treatment and classical approach is diverticulectomy and cricopharyngeal myotomy. Leakage, fistula, abscess, mucosal perforation, mediastinitis, hemorrhage, cervical hematoma and recurrent nerve injury are potential complications of this procedure. Secondary interventions may be needed for complications of post operative early period. In our case, fistula and abscess formation were observed in late period due to sutural leakage. Our patient had favorable outcome by endoscopic nasomediastinal abscess drainage with hydration and antibiotherapy support, alike late period oesophagus injury management.Late period leakage and abscess are very rare complications after Zenker diverticulectomy. Post-operative fever, cervical mass and abscess complaints should remind leakage possibility and the patient should be taken in close follow-up. Drainage with endoscopic nasomediastinal catheter may be an alternative procedure to surgical intervention.

Surg Endosc

P489 - Different Endoscopic Approaches

P491 - Emergency Surgery

Minimally-Invasive Endoscopic Techniques in Diagnosis and Treatment of Young Female with Large Pancreatic Cystic Lesion of Unknown Etiology

Laparoscopic Aproach in Perforated Peptic Ulcer - Case Matched Comparative Study

S. Dzhantukhanova, Y. Starkov, E. Solodinina, R. Zamolodchikov A.V. Vishnevsky Institute of Surgery, MOSCOW, Russia Background: The differential diagnosis of pancreatic cystic lesions can be a challenge on preoperative step despite of the modern imaging techniques, which frequently results in unjustified extended pancreatic surgery marked by up to 30% rate of complications. The definite diagnosis of pancreatic cystic lesions and its malignant potential allows apply minimally invasive surgical techniques. Objective: To demonstrate the efficacy and benefits of minimally invasive endoscopic techniques in diagnosis and treatment of patients with controversial diagnosis on preoperative imaging studies. Methods: A 29-year old female with no symptoms was admitted to the hospital regarding an incidental finding of large pancreatic cyst during routine health assessment. CT with contrast revealed a 7,5 cm cystic lesion in pancreatic body, the differential diagnosis between pseudocyst and cystic lymphangioma. Endoscopic ultrasound confirmed the cystic lesion in the body of the pancreas, most likely - cystic tumor, the differential diagnosis between serous cystadenoma (macrocystic type) and mucinous cystic tumor. Taking into account the uncertain diagnosis requiring various surgical treatment options the EUSguided FNA was performed as a first step. The cytology, biochemical and tumor markers testing of the cystic fluid excluded mucinous cystadenoma and IPMN (the absence of mucin and normal CEA level), pancreatic pseudocyst (normal amylase), cystic lymphangioma (no lymphocytes or other blood cells). In that respect the diagnosis of serous cystadenoma or congenital pancreatic cyst was made for which no extensive pancreatic surgery is needed. The cystic content was completely removed with FNA with no visible cyst on EUS. The CT 3 months later revealed a 2,5 cm cystic lesion in the pancreas. The small size of the lesion and no intimate contact with major pancreatic duct allows perform laparoscopic excision of cystic wall guided by laparoscopic ultrasound. Results: Operation time was 105 min. Recovery was uneventful and patient was discharged on the 5th postoperative day. The follow-up abdominal US and CT 5 month later showed no pathological changes. Histology confirmed congenital pancreatic cyst. Conclusion: This case of undetermined pancreatic cystic lesion in a young female demonstrates the benefits of the modern endoscopic techniques to confirm the diagnosis and to optimize the laparoscopic surgical approach.

M. Bica, D. Cartu, T. Bratiloveanu, S. Sandulescu, M. Lazar, F. Cioara, D. Marinescu, S. Ramboiu, I. Georgescu, V. Surlin University of Medicine and Pharmacy of Craiova, CRAIOVA, Romania Aim: the study of the laparoscopic approach in perforated ulcer with generalised peritonitis compared to open surgery. Material and method: prospective matched-case study of 2 groups of patients: group 1 48 patients with perforated peptic ulcer and generalised peritonitis (2008-20015) that underwent laparoscopic surgery; group 2 - 48 matched cases of perforated ulcer with open surgery. The inclusion criteria for group 1 patients were: onset of peritonitis under 24 h, the absence of any ulcer history, a good general status of the patient. Group 2 patients were matched from all patients with perforated ulcer admitted and treated in our practice between 2008 - 2015. The followed parameters were: length of intervention, duration of hospital stay and cost, postoperative morbidity and prognosis. Suture of perforation with omental patch was performed in all cases for both groups. Results: Medium length of intervention was 1 h and 15 min for group 1 and 1 h and 5 min for group 2. Median postoperative hospital stay was 5.1 days for group 1 and 8.4 days for group 2. Postoperative morbidity: group 1: subphrenic abscess - 1 case - laparoscopic reoperation, wound seroma - 4 cases, wound infection 1 case, prolonged postoperative ileus 3 cases, prolonged postoperative fever of undetected cause - 2 cases; group 2: postoperative bleeding - 1 case that required reintervention, wound seroma - 3 cases, wound infection - 3 cases, postoperative ileus - 5 cases. All patients received postoperative treatment with proton pump inhibitors as well as eradication of Helicobacter pylori infection. Control endoscopy was scheduled after 6–7 weeks from surgery. Conclusion: laparoscopic approach for perforated ulcer proved to be a viable alternative to open surgery with shorter hospital stay and cost without any influence in postoperative morbidity, with fair postoperative outcome, but still reserved for selected cases.

P490 - Emergency Surgery

P493 - Gastroduodenal Diseases

Acute Appendicitis in the Era of Laparoscopic Surgery

Worldwide Practice in Gastric Cancer Surgery

A. Maghiar, G. Dejeu

L. Haverkamp1, H.J.F. Brenkman2, J.P. Ruurda2, R. Van Hillegersberg2

Spitalul Pelican Oradea, ORADEA, Romania Appendectomy is, probably, the most common surgical intervention in hospitals worldwide. In the era of laparoscopic surgery there is still a large number of places that do not perform laparoscopic surgery for appendectomy, especially in the acute setting. We enrolled in an prospective surveillance of all patients with acute pain in the lower right qadrant in our hospital from 2008 onwards. Of the 1756 patients with pain in the lower right quadrant only 1512 were addmitted for extra testing, in 1237 accute appendicitis was diagnosed and all patients underwent surgery. Of the 1237 operated patients 1187 (96%) were operated laparoscopicaly. Most of them were under the age of 39 ([ 65%) and females (63,5%). Most were released from hospital within 72 h from addmission. Only a small number of cases (\2,5%) needed readmission or relaparoscopy, most because of intraperitoneal abcess (7 cases). Following the long follow up and large number of patients treated over more than 7 years we conclude that a laparoscopic approach to all emergency setting acute lower right quadrant pain patients can, and should be used.

VUmc, AMSTERDAM, The Netherlands; 2UMC Utrecht, UTRECHT, The Netherlands

1

Aim: To evaluate the current status of gastric cancer surgery worldwide. Methods: An international cross-sectional survey on gastric cancer surgery was performed amongst upper gastro-intestinal surgeons. Members of the International Gastric Cancer Association filled in a web-based questionnaire with regard to their surgical preferences. Questions asked included the use of neo-adjuvant treatment, preferred surgical approach, extent of the lymphadenectomy and preferred anastomotic technique. Results: The corresponding specific response rate was 227/615 (37%). The majority of respondents: originated from Asia (54%), performed [ 21 gastrectomies per year (79%) and used neo-adjuvant chemotherapy (73%). An open surgical procedure was performed by the majority of surgeons for distal gastrectomy for advanced cancer (91%) and total gastrectomy for both early and advanced cancer (52% and 94%). A minimally invasive procedure was preferred for distal gastrectomy for early cancer (65%). In Asia surgeons preferred a minimally invasive procedure for total gastrectomy for early cancer also (63%). A D1+ lymphadenectomy was preferred in early gastric cancer (52% for distal, 54% for total gastrectomy) and a D2 lymphadenectomy was preferred in advanced gastric cancer (93% for distal, 92% for total gastrectomy) Conclusion: Surgical preferences for gastric cancer surgery vary between surgeons worldwide. Although the majority of surgeons use neo-adjuvant chemotherapy, minimally invasive techniques are still not widely adapted.

123

Surg Endosc

P494 - Gastroduodenal Diseases

P496 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Surgery of Gastric Gists - Presentation of a Case and Review of the Literature

Ileal Malt Lymphoma and Laparoscopic Approach

S. Bordu1, T. Bratiloveanu2, E. Georgescu2, S.T. Patrascu2, A. Goganau2, D. Cartu2, I. Georgescu2, V. Surlin2 SCJUC Craiova, Romania, CRAIOVA, Romania; 21st Surgery Department, University of Medicine and Pharmacy of Craiova, CRAIOVA, Romania

1

Introduction: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract (80%) and represent 2% of the tumors of the human gastrointestinal tract. The most frequent location is gastric (60%). Laparoscopic approach has been extended lately for this pathology. Aims: We present the case of a 75 years old woman admitted at Emergency Department for severe anemia, hematemesis and melena. Laboratory data were within normal range. Upper digestive tract endoscopy discovered a submucosal gastric tumor 4/5 cm, with ulceration of the mucosa and adherent blood clot, on the posterior gastric wall. Distant metastasis were excluded by imagery. Methods: Surgical intervention was carried out after normalization of hemoglobin with blood transfusions, by laparoscopic approach. The tumor was approached by laparoscopy, excised from the posterior wall through an anterior longitudinal gastrotomy, with an endoscopic stapler. Another recharge was used to close the anterior gastrotomy. Results: The histopathologic examination and imunohistochemical analysis revealed a gastrointestinal stromal tumor with low potential for malignancy. Actually, at 7 months follow up, the patient is well, disease free and undergoing therapy with Gleevec. Conclusions: The diagnosis is difficult because they are asymptomatic for a long time or with unspecific symptoms. Surgery is the main curative treatment. Laparoscopic approach for gastric GISTs is feasible, safe for the patient in selected cases.

M.Y. Uzunoglu1, F. Altintoprak1, E. Dikicier2, K. Gu¨ndogdu1, I. Zengin2 1 SAKARYA UNIVERSITY MEDICAL SCHO0L, SAKARYA, Turkey; 2Sakarya University Research and Educational Hospital, SAKARYA, Turkey

Introduction: Extranodal marginal zone B-cell lymphoma (MALT lymphoma) constitutes 8% of all non-Hodgkin’s lymphomas. Whereas its usual localisation in the gastro-intestinal system is the stomach, ileal involvement is rarely reported. In this paper, we present a rarely-seen ileal MALT lymphoma case, who we treated with the laparoscopic approach. Case Report: The seventy-four years old male patient applied to our clinic with abdominal pain since four months, significant weight loss and a palpable abdominal mass. During the physical examination of the patient with no known chronic disease, we palpated a mobile,well-circumscribed mass of 12 9 10 cm in size in the abdomen near to umbilicus. Computerized tomography (CT) of the abdomen displayed a mass of 12.1 9 10 cm in size originating from jejunum segments and causing partial intestinal obstruction (Picture 1). In the laparoscopic exploration we observed that the omentum was full with small nodules with a carpet-like appearance (Picture 2), several lymph nodes in the mesoileum and a tumoral mass 12 cm away from the Treitz ligament, involving the antimesenteric wall and a 10-cm long segment of the jejunum (Picture 3). Although the suspected diagnose was lymphoma regarding the existing findings, we decided for a resection because of the presence of intestinal obstruction symptoms. We performed laparoscopic segmentary ileal resection and partial omentectomy and the patient was discharged in the 6th day of the operation without any complication. As the histopathological analysis showed extranodal marginal zone B-cell lymphoma (MALT lymphoma), the patient was evaluated in the haematology department Discussion/Conclusion: Although the etiology of the MALT lymphoma, whichis a type of non-Hodgkin’s lymphoma, not fully clarified, the chronic inflammation arousing as a consequence of pathogens and auto-antigens is the suspected cause. Whereas its usual localisation in the gastro-intestinal system is the stomach, ileal involvement is rarely reported. Clinical findings are uncommon in patients with ileal involvement. Radiotherapy, chemotherapy, surgical resection or their combinations are the choices for the therapy. Although the carcinomas are the most frequent ileal malignancies, even if they are relatively rare, MALT lymphomas should be kept in mind.

P495 - Gastroduodenal Diseases

P497 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Gastrectomy Following Preoperative Chemotherapy for Locally Advanced Gastric Cancer

Laparoscopic Techniques in Coloproctology

N. Musha, H. Ogawa, T. Tanabe, A. Kuwabara, T. Tsubono, Y. Sakai

Samara State Medical University, SAMARA, Russia

Saiseikai Niigata Daini Hospital, NIIGATA, Japan

The relevance of the study. Laparoscopic techniques are now widely used in colorectal surgery for various diseases of the colon. The advantage of laparoscopic procedures before operations with traditional laparotomy is not in doubt.Materials and methods. In the period from 2012 to 2015, was operated on 32 patients, including 22 women and 10 men. The average age of patients is 50.0 ± 12.3 years. Criteria for choosing laparoscopic version of the operation were: patients older than age 70 years, body mass index not more than 25, the absence of pronounced cardiovascular and respiratory failure.When performing operations used ultrasonic Harmonic scalpel, and EnSeal generator LugaSure. To cross the intestine in the abdominal cavity were used vehicles and Echelon EndoGIA. Circular suturing apparatus used for the formation of intracorporeal colorectal anastomosis. Laparoscopic surgery to patients suffering from chronic constipation in the stage of decompensation, and failure of conservative therapy - 8; benign neoplasms of the colon (tubulo-villous adenoma) - 8; diverticular disease of the colon - 4; colorectal cancer 12 patients.4 ileorectal colectomy with anastomosis, 10 left hemicolectomy with the formation of transverso-rectal anastomosis, 4 resection of the sigmoid colon, 10 anterior resection of the rectum, 4 mesorectumectomy with extirpation of the rectum.The average duration of operations with the use of the laparoscopic approach to 250 ± 43 min. Conversion was performed in 8 (25%) patients at risk of intraoperative complications. As they gain experience, we noted a decrease in the number of conversions, reducing the time of operations. Postoperative complications were detected in 2 (6%) patients were operated on in 2012. Wound of the left ureter was one female patient that was diagnosed at 8 days after surgery. Even in 1 patient has developed failure of colorectal anastomosis. There were no lethal outcomes. The average length of stay of the patient after laparoscopic resection of the colon had an average of 12.3 ± 6.1 days. Conclusions: Laparoscopic surgery is a complex surgery that requires systematic training of operating room staff and, at the stage of exploration, followed by high risk of complications in the postoperative period.

Background: Perioperative chemotherapy has been widely accepted for locally advanced gastric cancer. Considering the patient compliance with intensive chemotherapy, implementation of presurgical chemotherapy is a rational strategy. The effect of preoperative chemotherapy on a laparoscopic gastrectomy remains unclear. We report on the short-term consequences of laparoscopic gastrectomy following preoperative chemotherapy. Methods: From March 2011 to December 2015, 21 patients underwent preoperative chemotherapy followed by laparoscopic gastrectomy with lymph node dissection, and 46 patients without preoperative chemotherapy had laparoscopic gastrectomy for clinical T3-T4 advanced gastric cancer. We evaluated the short-term results and outcomes between two groups. Results: Patients with clinical T4, N2 and stage 3B-4 cancers were more likely to receive preoperative chemotherapy. The mean number of chemotherapy cycles was 4.3 (2-13). Thirteen (61.9%) of 21 patients had the DCS (Docetaxel + Cisplatin + S1) regimen, 3 (14.3%) had the XP (Capecitabine + Cisplatin) with Trastuzumab, 3 (14.3%) had SP (S1 + Cisplatin) with Trastuzumab, 1 (4.8%) had the XP, and 1 (4.8%) had the SP regimen. The preoperative chemotherapy group in comparison with the clinical T3-T4 group showed a higher indication rate of total gastrectomy (61.9% vs. 23.9%, p \ 0.01), longer operation time (392 min vs. 321 min, p \ 0.01). Laparoscopic procedure had to be converted to the open procedure in 3 patients (14.3%) due to tumor invasion of adjacent structures. There were no significant differences in number of lymph nodes retrieved (43 vs. 41), overall postoperative complication rate (28.6% vs. 30.4%) and median length of postoperative hospital stay (9 days vs. 9 days), respectively. In the preoperative chemotherapy group, down-staging was obtained in 15 cases (71.4%) in clinically. Sixteen (76.2%) patients with preoperative chemotherapy had pathologic primary tumor response (grade 1b-3). Five (23.8%) of the 21 patients experienced a pathological complete response (pCR) in their primary tumors. There were no significant difference in survival time, between the patients with pathological response to presurgical chemotherapy and the clinical T3-T4 patients without preoperative chemotherapy. Conclusion: Preoperative chemotherapy for patients with locally advanced gastric cancer resulted in significant clinical downstaging. Laparoscopic gastrectomy for downstaged patients following preoperative chemotherapy is acceptable strategy.

123

P.S. Andreev, S.E. Katorkin

Surg Endosc

P498 - Intestinal, Colorectal and Anal Disorders

P500 - Liver and Biliary Tract Surgery

Laparoscopic Colon Surgery was Feasible for Octogenarian at a New-Opened Community Hospital: A Prospective Analysis of 508 Consecutive Patients

A Totally Laparoscopic Alpps Assisted with Radiofrequency (Ralpp) for Staged Liver Resection

W.C. Fan, F.M. Chen

T. Gall, L.R. Jiao, D. Hakim, R. Fan, M.H. Sodergren, T. Pencavel, A. Fajardo

Kaohsiung Municipal Ta-Tung Hospital, KAOHSIUNG, Taiwan

Imperial College, LONDON, United Kingdom

Purpose: The feasible procedure of colon surgery for octogenarian has been presented in literature. There is few data from a community hospital. The purpose of this study was to evaluate whether the laparoscopic colon surgery could be safely performed for octogenarian in a new-opened community hospital Materials and Methods: During April 2009 to October 2015, we reported 508 consecutive case of laparoscopic colectomy, 109 of these were performed for patients 80 years of age or older. All operation were performed by two surgeons. Data were collected prospectively including patient demographic feature, co morbidity, peri-operative event, post-operative complications. The clinical data were compared. Results: The octogenarian group included 109, and the non-octogenarian group included 399 patients. No differences were found between the two groups with regard to gender, operative time, blood loss, and transfusion rate. The ASA score, comorbidity, length of hospital stay (9.78 vs. 6.9 days, p = 0.001) is significant higher in octogenarian group, and the bowel recovery is slower in octogenarian. (1st flatus passage 50.2 vs. 41.8 h, p = 0.007) The pain score, and dose of analgesic use were less in octogenarian group. The postoperative morbidity and mortality is higher in octogenarian group, but no significant. Conclusion: Laparoscopic colon surgery is safe procedure for benign and malignant colon disease for octogenarian in a new-opened community hospital.

In order to induce liver hypertrophy to enable liver resection in patients with a small future liver remnant, various methods have been proposed in addition to portal vein embolisation. Most recently, the ALPPS technique has gained significant international interest. This technique is limited by the high morbidity associated with an in situ liver splitting and the patient undergoing two open operations. We present the case of a variant ALPPS technique performed entirely laparoscopically with no major morbidity or mortality. An increased liver volume of 57.9% was seen after 14 days. This technique is feasible to perform and compares favourably to other ALPPS methods whilst gaining the advantages of laparoscopic surgery.

P499 - Intestinal, Colorectal and Anal Disorders

P501 - Liver and Biliary Tract Surgery

Laparoscopic Permanent End-Colostomy Creation Through the Extraperitoneal Route by Using Single-Port Technique

Cystic Duct Remnant Stump Stones and Post Cholecystectomy Syndrome After Laparoscopic Cholecystectomy

Y. Kagawa, T. Kato, A. Naito, Y. Katsura, Y. Ohmura, K. Murakami, A. Takeno, Y. Takeda, S. Tamura

C. Ivan1, V. Ivan2, S. Olariu1, P.L. Matusz1, A. Dema1, A.M. Ungureanu1

Kansai Rosai Hospital, AMAGASAKI, Japan

1

Background: The incidence of a paracolostomy hernia has been reported to be from 10% to 50%. Parastomal hernia causes not only impairment of quality of life, but sometimes serious life-threatening complications. Colostomy through the extraperitoneal route reported by Goligher. It has been reported that the rate of parastomal hernia is significantly lower in extraperitoneal route than in the intraperitoneal route. For this reason, we have been introduced colostomy through extraperitoneal route in laparoscopic abdominoperineal resection. In recent years, the tunnel of the extraperitoneal route was created under laparoscopic view by using single port technique. Objective: We examined the effects of the extrapeitonieal route for stoma creation to prevent parastomal hernia after laparoscopic abdominoperineal resection for rectal cancers. Patients and Methods: Data on a total 27 consecutive patients who underwent abdominoperineal resection from Janualy 2011 to December 2015 in Kansai Rosai Hospital were examined retrospectively. Group A included 15 patients whose stoma was created through the extraperitoneal route, and group B included 12 patients whose stoma was created through the transperitoneal route.The main outcome measures were the rate of parastomal hernia determined through CT and clinical examinations in the 2 groups. Results: Median duration of the follow-up period between the latest CT examination and the primary operation was 329 days(127–1637) in group A and 397 days (23–1054) in group B (p = 0.051). In group A, no case was diagnosed as having a parastomal hernia, whereas, in group B, 6 cases were diagnosed as having a parastomal hernia. The difference in incidence between the 2 groups was significant (p = 0.003). Conclusion: Group B developed parstomal hernia more frequently. Laparoscopic stoma creation through extraperitoneal rout can prevent the incidene of parastomal hernia after laparoscopic abdominoperineal resection.

Aims: In laparoscopic surgery era, post cholecystectomy syndrome meets more often, may be due to a long cystic duct remnant stump preferred by the surgeons. Methods: We present two female patients from our clinic (Surgery 1 Clinic, Emergency Clinic County Hospital Timisoara, Romania) that were admitted with hypocondrium and epigastric pain accompanied by nausea. Both patients have laparoscopic cholecystectomy in antecedents (2 years and 5 months and respectively 10 years ago) for acute lithiasic cholecystitis. Abdominal ultrasound and cholangio-IRM confirm the present of a long cystic duct remnant stump, globular dilated and the present of stones at this level. At both patients we tired an laparoscopic technique but we converted to open technique due to intensive adhesions process. Histopathological examinations revealed cystic duct and infudibulo-cystic structures. Results: Both patients have a favorable postsurgical evolution and at 7 days discharged. Conclusions: Laparoscopic cholecystectomy increase the risk of postcholecystectomy syndrome due to preferring leaving in place of a long cystic duct stump ([1,5 cm). Laparoscopic cholecystectomy in patients with acute lithiasic cholecystitis increases the risk of a remnant long cystic duct stump due to a difficult dissection and highlighting of common bile duct. Dilatation of cystic duct stump, lithogenesis at this level and postcholecystectomy syndrome is a reality what should be considered. Keywords: cystic duct stump, infudibulo-cystic, postcholecystectomy syndrome, stones.

University of Medicine and Pharmacy Victor Babes Timisoara, TIMISOARA, Romania; 2Emergency County Hospital ,,P. Brıˆnzeu,,, TIMISOARA, Romania

123

Surg Endosc

P503 - Liver and Biliary Tract Surgery

P505 - Morbid Obesity

Single-Stage Laparoscopic Treatment for Obstrustive Jaundice of Benign and Malignant Origin

Minimally Invasive Approach in Intraabdominal Upper Gastrointestinal Leakage: Is it Possible?

I. Shavarov1, M.M. Halei1, K.M. Halei2

A. Sanchez Ramos, G. Orlando, L. Arru, A. Legrand, V. Poulain, M. Goergen, J.S. Azagra

1

2

Volyn regional clinical hospital, LUTSK, Ukraine; SHEI I.Ya.Horbachevskyi Ternopil State Medical University, TERNOPIL, Ukraine

CENTRE HOSPITALIER LUXEMBOURG, LUXEMBOURG, Luxembourg

Background: Obstructive jaundice, caused by choledocholithiasis, pancreatic- and bile duct tumors, that in the part of cases combines with gallstone disease, is one of the most common pathology in minimally invasive surgery. Aim: To provide single-stage minimally invasive treatment of obstructive jaundice (OJ) for benign and malignant origin, respectively to minimize total procedure and anesthesia duration, postoperative and recovery period. Materials and methods: During the period between 2009 and 2015, 459 patients were operated on OJ for benign and malignant origin. Benign 361 (78.6%) was presented by choledocholithiasis (CL) combined with gallstone disease (GD). Malignant 98 (21.4%) was presented by: pancreatic head cancer (PHC) with no possibility of radical treatment 89 (91%), common bile duct cancer (CBDC) 11 (9%). Patients was divided on two groups. In first group 297 (82.3%) patients: with CL and GD 2-stage treatment - endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphyncterotomy and endoscopic common bile duct stone extraction, and laparoscopic cholecystectomy as second stage, with PHC - preoperative ERCP, then laparotomic cholecystectomy and choledochoduodenostomy, with CBDC - preoperative ERCP, then laparotomic cholecystectomy and Roux-en-Y hepaticojejunostomy. In second group 64 (17.7%) for all patients preoperative magnetic resonance cholangiopancreatography (MRCP) was performed, accordingly there was no need to conduct ERCP. In patients with CL and GD - laparoscopic cholecystectomy, common bile duct stone extraction using intraoperative cholangiography and cholangioscopy and biliary drainage, with PHC - laparoscopic cholecystectomy and choledochoduodenostomy, with CBDC - laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy. Results: Average total procedure duration in first group was 125 min. Average total procedure duration in second group was 85 min. The average duration of hospital stay after treatment in first group was 8-10 days. The time patients stay in the hospital after treatment in second group was 4–5 days. Conclusions: Single-stage minimally invasive surgical treatment of OJ reduces hospital stay, total procedure and anesthesia duration, minimize recovery period, respectively improves patient’s quality of life.

Aims: Anastomotic leak is the most devastating surgical complication in upper gastrointestinal procedures, increasing morbidity and mortality, affecting long-term survival rate and treatment’s cost. Incidence and risk factors are well described. Surprisingly, a definition or a management algorithm has not been characterized yet. Methods: Between 2003 and 2013, 1.856 patients underwent an UGI operation in our center: 121 gastrectomies; 1.654 gastric bypass; and 81 sleeve gastrectomies. 15 (0,08%) confirmed leaks were reported (10 acute; 5 chronic). Diagnosis methods, management and complications were analyzed. Leak was defined in our study as a disruption of esophago-jejunal, gastro-jejunal or jejunojejunal anastomosis, as well as on staple line and paraanastomotic abscesses. Results: CT scan with oral contrast showed leak in 13 patients. Endoscopy verified radiological findings and assessed severity in 9. In 5 cases it was performed before surgery. No differences in rates in reoperation, leakage and postsurgical complications were described. Imminent exploratory laparoscopy was performed in 2 unstable patients. Conservative management was carried out in 4, healing 3 of them. 11 submitted surgical treatment (8 by laparoscopic approach). Stent was deployed in 8 (sealing rate: 62,5%). Clavien-Dindo IV complications were more frequent in patients under surgical management. One (6,6%) patient died. Patients with conservative management had short intensive care course and hospital stay. Conclusions: Early diagnosis of IAAL is paramount. Endoscopic exploration should be performed when possible, allowing early diagnosis, providing information of anastomosis’ morphologic characteristics that will help accurate the best management. Eventually treatment can be done at the same time. Management by a multidisciplinary team, combining endoscopic, surgical and radiological techniques is the best strategy. Conservative management is effective in stable patients and can obviate a reintervention. Targets are: adequate drainage, covering leak with stent, enteral feeding. Surgical management is the definitive treatment in unstable patients. We perform laparoscopic approach when possible, allowing evaluation of anastomosis, consenting peritoneal lavage and positioning effective drains. Laparotomy remains anecdotal. We suggest applying our definition in forthcoming studies to homogenize reporting of outcomes thus facilitating comparison of the results from different studies. To conclude, a management algorithm is proposed.

P504 - Liver and Biliary Tract Surgery

P506 - Morbid Obesity

Minimally Invasive Approach of Spontaneous Cholecystocutaneous Fistula with Gallbladder and Secondary Bile Duct Lithiasis and Fibromatous Uterus

Laparoscopic Gastric Plication After Removal of Failed Band is a One Step Procedure

M.A. Eftimie, O.A. Stanciulea, L. David, I.B. Mosteanu, M.L. Tirca, I. Popescu Fundeni Clinical Institute, BUCHAREST, Romania Aims: Spontaneous cholecystocutaneous fistula is a rare complication of neglected calculous biliary disease that has become increasingly rare because of prompt diagnosis and expedient surgical intervention for gallstones. Minimally invasive treatment can solve this rare pathology. Methods: 62 YO female with no surgical history and no knowledge of pain in the right upper quadrant or right flank. For four months, prior to surgical consultation, the patient described the appearance of a skin lesion, with inflammatory signs, located in the rihgt flank (mid axillary line). After one week several calculus were exteriorized through a small hole in the middle of the skin lesion in the right flank. A CT exam revealed multiple gallbladder stones, with secondary common bile duct lithiasis and a cholecysto-cutaneous fistula. It also described a fibromatous uterus with enlarged cervical region. So a gynecological consult was performed and recommended total hysterectomy with bilateral adnexectomy. Two days previous to surgery an ERCP with papilla sphincterotomy and calculus extraction were performed Results: A laparoscopic one stage cholecystectomy with total hysterectomy and bilateral adnexectomy were performed Conclusions: minimally invasive approach of complex, rare, biliary surgical pathology is a feasible tool that can provide means of treatment with rapid recovery and reduced morbidity.

123

M. Hussein American University of Beirut Medical Center, BEIRUT, Lebanon Aims: Laparoscopic Gastric Plication as one step procedure Methods: Laparoscopic gastric band was the first common procedure in Europe for the treatment of Morbid Obesity but the failure of this procedure with its complication can reach up to 40%. Shifting to laparoscopic sleeve gastrectomy as one step procedure associated with increase in the leak rate up to 7.5%. Results: I report my experience failure of 47 band removal and gastric plication as a one step procedure to treat failure of band with no complication and excellent weight loss. Conclusion: Laparoscopic Gastric Plication is a safe procedure to treat failed gastric band as a one step procedure

Surg Endosc

P507 - Morbid Obesity

P509 - Morbid Obesity

Laparoscopic Treatment of Sleeve Leak with Roux-En-Y Gastric Bypass

Single Incision Laparoscopic Cholecystectomy in Obese Patients: A Case-Matched Comparative Analysis

M. Hussein

J. Raakow1, J. Schulte-Ma¨ter1, R. Raakow2, M. Biebl1, J. Pratschke1

American University of Beirut Medical Center, BEIRUT, Lebanon

1

Charite´ - Universitaetsmedizin Berlin, BERLIN, Germany; Vivantes Klinikum Am Urban, BERLIN, Germany

2

Aims: Leak is one of the common complications of Laparoscopic Sleeve Gastrectomy that entail prolongation of Hospital stay, morbidity and even mortality. Methods: We report the treatment of 13 cases of complicated leak post sleeve gastrectomy that failed all conservative measure to heal including stenting by Laparoscopic Roux En Y Gastric Bypass all were cured except one mortality due to sepsis. Results: The video will show the steps used to dissect the Gastroesophegeal are identifying the leak and Roux En Y Gastric Bypass. Conclusion: Sleeve Gastrectomy level can be handled by minimal invasive surgery in advanced centers in Bariatric surgery.

Aims: Single-incision laparoscopic surgery (SILS) is safe for elective and acute cholecystectomies and offers patient-related benefits over multiport laparoscopy. However, especially in the early days of SILS its use in obese patients was limited because of technical difficulty and the fear for higher complication and conversation rates. The aim of this study was therefore to investigate the impact of obesity on the outcome of SILS cholecystectomies. Methods: A prospectively maintained database was analyzed identifying patients undergoing SILS cholecystectomy between October 2008 and October 2014. Patients were categorized into obese (BMI = 30 kg/m2) and non-obese (\ 30 kg/m2) and matched in a 1:2 ratio in terms of age, gender, Diagnosis and operative procedure. Statistical evaluation included the description and comparison of demographic factors and perioperative outcome. Results: A total of 225 patients were grouped. 75 obese patient were well matched with 150 non-obese patients in demographics, diagnosis and undergoing procedure. The obese cohort had significantly higher BMI (p \ 0.001) and ASA score (p = 0.019) and longer operative time (63.3 ± 17.9 vs. 54.5 ± 22.7 min, p = 0.004). There were no significant differences in conversion rates (p = 0.097), length of hospital stay (p = 0.873) and postoperative complications (p = 0.763). There were no intraoperative complications and no reoperations. Conclusion: Single-incision laparoscopic cholecystectomy in obese patients with a BMI exceeding 30 kg/m2 had significantly longer operative time but comparable rates of conversion, length of hospital stay and overall morbidity. Therefore, obesity does not significantly reduce the feasibility, safety and outcome of cholecystectomies performed through a single incision. With additional operative time obese patients can benefit from the same patient-related advantages of minimal invasive surgery as the non-obese.

P508 - Morbid Obesity

P510 - Morbid Obesity

Stenosis After Sleeve Gastrectomy to Treat Morbid Obesity

Laparoscopic Biliopancreatic Diversion with Doudenal Switch: Comparison Between Primary Procedure and Conversion After Failed Sleeve Gastrectomy

F. Martinez-Ubieto, I. Barranco-Dominguez, C. Gracia-Roche, A. Bueno-Delgado, M. Gutierrez-Diez, M.J. Valenzuela-Martinez, M. Albiac-Andreu, J. Martinez-Ubieto

I. Carmeli, A. Ben Yaacov, M. Ben David, H. Kashtan, A. Keidar

VIAMED MONTECANAL HOSPITAL, ZARAGOZA, Spain

Rabin Medical Center, EINAT, Israel

Stenosis after sleeve gastrectomy to treat morbid obesity is a well known complication with a prevalence between 0 and 4%. These strictures use to be situated near to angularis incisura y the lenght is variable. The endoscopic treatment depends on the presentation time of the proccess. So, if the patient presents symptoms in the inmediate postoperative is better to place a fully covered removable stent and later to perform a balloon dilatation. If the symptoms are delayed is preferable to begin with balloon dilatations. In this complication a resourceful endoscopist in the bariatric team is essential. Some of these stenosis are short in the swallow studies but much longer in the endoscopy. So in the inmediate postoperatory is better to insert a covered stent in order to avoid the risks of an untimely dilatation with perforation of the sleeve. Later and in the not inmediate stenosis as well, the dilatation can be carried out. In some cases is mandatory to repeat the process to resolve the stenosis. In one of our cases a achalasia dilator was used to achieve more pneumatic pressure. We present three stenosis after 150 sleeve gastrectomies for the surgical treatment of morbid obesity. The three cases were successfully treated with total response of the patients.

Background: Sleeve Gastrectomy (SG) has gained popularity as a stand alone Bariatric procedure. Duodenal switch (DS) can be done in selected patients as Primary procedure or as a conversion after Failed SG, defined by inadequate weight loss or weight regain. Methods: All patients who underwent DS as Primary procedure (n = 21) or as a conversion after failed Sleeve Gastrectomy (n = 8) due to inadequate weight Loss or weight regain between January 2010 and December 2013 were enrolled. Results: The mean body mass index (BMI) reduction was 21 kg/m2 in the primary DS group compared to 14 kg/m2 in the conversion group. The total BMI reduction In the conversion group, including SG, was 18.7 kg/m2. The two groups had a similar pre operation BMI (45.3 vs 44 kg/m2) and average age (45.8 vs 45.5 years). Mean follow up time was 29 months in the primary DS group and 34 months in the conversion group. Four patients in the primary DS group were lost to follow-up and were not included in the analysis. Three patients after primary DS underwent a Laparoscopic common channel lengthening due to severe vitamin deficiency and malnutrition, while only one in the conversion group. Conclusion: DS is feasible as a primary procedure or conversion after failed SG but the weight lost results are inferior as a conversion Bariatric procedure after SG. Keywords: Laparoscopic sleeve gastrectomy failure; Conversional Bariatric surgery; Laparoscopic Biliopancreatic diversion with duodenal switch

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Surg Endosc

P511 - Morbid Obesity

P513 - Paediatric Surgery

Efficacy of Resection Point on Excess Weight Loss After Bariatric Surgery: How Far Should We Go?

Treatment Outcome of Infant Complete Thracoscopic Pneumectomy for Congenital Lung Diseases - A Comparison with Open Lobectomy

P. Yazici, M. Mihmanli, G. Isil, U. Demir, C. Kaya, O. Bostanci Sisli etfal training and research hospital, ISTANBUL, Turkey Aim: Primary end point was to investigate whether the resection point to the pylorus has any effect on postoperative complication. Secondary end point was to determine association between surgical technique and excess weight loss (EWL). Methods: Between January 2014 and December 2014, all morbidly obese patients who underwent laparoscopic sleeve gastrectomy were reviewed. Prospective data collection included demographic features, surgical data, postoperative morbidity and mortality and follow-up period (EWL). All patients were divided into two groups considering the length of resection point to the pylorus: Group 1, n = 64 (3 cm to the pylorus) and Group 2, n = 55 ([3 cm to the pylorus). Results: A total of 119 patients (83 female and 36 male) with a mean age of 37 ± 9 years were included into the study. Two groups were similar considering demographic parameters including BMI (47 ± 6 vs 50 ± 10, respectively, p = 0.064). During a mean follow-up time of 18.5 ± 3.9 months, EWL at 6th and 12th months were significantly higher in Group 1 (67 ± 7% vs 63 ± 5%, p \ 0.01 and 82 ± 4 vs 76 ± 5, p \ 0.01). Postoperative morbidity was similar between groups. Nause & vomiting was two-fold higher in Group 1 (15% vs 7.2%, p = 0.253) but statistically insignificant. Conclusions: Better EWL without similar morbidity can be achieved with a marginal resection point (=3 cm to the pylorus) during laparoscopic sleeve gastrectomy.

T. Tainaka Nagoya University Graduate School of Medicine, NAGOYA, Japan Background: Complete thoracoscopic pneumectomy for infants becomes a graduallyspreading surgical technique in recent years, but it also has technical difficulties in some cases such as cases of incomplete lobulation of lung, impaired visibility by a large occupied cystic lesion. We made a comparative study of the treatment outcomes for complete thoracoscopic pneumectomy. Patients and Methods: The study covered 36 cases of complete thoracoscopic lobectomy or segmentectomy (TL group) as study subjects and 14 cases of open lobectomy (OL group) as comparative subjects at our institution from October 2000 to October 2015. All patients were below the age of 1 year. We compared etiology of lung disease, surgical procedure, operation time, blood loss, postoperative complications, and postoperative thoracic deformity. Result: Age and body weight at the time of surgery for the TL and OL group were 111 ± 97 and 115 ± 143 days, and 5.5 ± 1.8 and 4.5 ± 2.0 kg, respectively. In addition, the number of prenatal diagnosis cases was 33/36 (TL group), and 7/14 (OL group), respectively. The etiology of operation indicated 31 CPAM cases, 3 intrapulmonary sequestration cases, 1 bronchial atresia case, and 1 middle lobe torsion case in the TL group, and 10 CPAM cases and 4 cases in the OL group. All thoracoscopic surgery completed without open conversion. The TL group included lobectomy for 34 cases and segmentectomy for 2 cases. The lobectomy was performed in the OL group. The operation time, and blood loss in the TL group and the OL group were 195 and 178 min, and 5 and 16 ml (P \ 0.01), respectively. Postoperative complications included 4 cases (11%) (atelectasis in 2 cases, pneumothorax, middle lobe torsion in 1 case) in the TL group, and 2 cases for pneumothrax (14%) in the OL group. The TL group and the OL group had 3 and 5 cases of postsurgical thoracic deformity, respectively (P \ 0.05). Conclusion: This study suggested that complete thoracoscopic resection of the lung can be a safe and feasible surgical procedure for infants, even compared to open lobectomy, and would also be superior in intraoperative blood loss and postsurgical cosmetic results.

P512 - Paediatric Surgery

P514 - Pancreas

Minimal Invasive Surgery for Solid Pseudopapillary Tumor in Children

The Hammersmith Laparoscopic Pancreaticogastrostomy (Hlpg): A Novel Laparoscopic Pancreatic Anastomosis During Central Pancreatectomy

J.M. Namgoong, D.Y. Kim Asan Medical Center, University of Ulsan College of Medicine, SEOUL, Republic of Korea Purpose: Solid pseudopapillary tumor (SPT) of the pancreas is rare primary neoplasm of the pancreas with low-grade malignancy. The aim of this study was to evaluate the outcome of minimal invasive surgery (MIS) for SPT in children. Methods: A retrospective review was conducted for patients under the age of 18 years old who had undergone laparoscopic pancreas surgery for pathologically confirmed SPT between January 2006 and December 2015. Results: 24 patients underwent MIS for SPT. The patient group comprised 20 females and 4 males, with a mean age of 14.7 ± 2.8 months. They underwent laparoscopic distal pancreatectomy [LDP (n = 16)], robotic distal pancreatectomy [RDP (n = 1)], laparoscopic pancreaticoduodenectomy [LPPPD (n = 2)], laparoscopic central pancreatectomy [LCP (n = 1)] and laparoscopic enucleation of pancreas [LEP (n = 4)]. 88.2% of the LDP performed were spleen-sparing LDP (SSLDP) included 4 cases of splenic vessel sacrificing SSLDP (Warshow technique) and Single port SSLDP. Mean duration of surgery was 229.8 ± 145.5 min and one patient was performed transfusion. Perioperative mortality was not developed, but 9 patients were involved postoperative complications included fluid collection (n = 1), splenic infarct (n = 3), pancreatic fistula (n = 4), and wound seroma (n = 1). Recurrence of tumor was shown in one patient who underwent LEP due to incomplete resection. Conclusion: Lately, MIS is being used more and more extensively in pediatric population, and its scope of usage has widened to include pancreas surgery. The prognosis of MIS for SPT was good in pediatric patients. SPT is the most common pancreas tumor in children and malignancy of pancreas is extremely rare in children, therefore pancreatic MIS would be a safe and feasible option for STP in children.

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T. Gall, M.H. Sodergren, R. Fan, L.R. Jiao, A. Fajardo Imperial College, LONDON, United Kingdom Introduction: Central pancreatectomy (CP) is preferred to distal pancreatectomy (DP) for the excision of benign tumours at the neck or body of the pancreas, in order to preserve pancreatic parenchyma and the spleen. However, the pancreaticoenterostomy is technically difficult to perform laparoscopically and the postoperative pancreatic fistula (POPF) rate is high. Thus there are few reported series of laparoscopic CP. We present the Hammersmith Laparoscopic Pancreaticogastrostomy (HLPG) technique, a novel method for reconstruction of the pancreatic stump during CP. This method is technically easier to perform than standard techniques. Methods: From March 2012 to July 2013, four patients underwent HLPG during a laparoscopic CP. This involves creating a sleeve gastric tube for an end-to-end anastamosis between the distal pancreatic stump and the stomach. Operative outcomes were reviewed prospectively. Results: Two males and two females with a median age of 49 years had a CP with HLPG. The total operative time was 437.4 ± 12 min (mean ± SD) and the time taken for reconstruction of HLPG anastomosis was 37.6 ± 7.6 min (mean ± SD). After a median follow-up of 27.5 months there was no mortality. One patient had a grade A postoperative pancreatic fistula (POPF) requiring no medical or surgical treatment. Conclusion: The HLPG is technically easy to construct laparoscopically. It is a feasible operation which may reduce operative time and POPF rate. A larger series in the future will fully evaluate the operative outcomes.

Surg Endosc

P515 - Pancreas

P517 - Spleen

Laparoscopic Enucleation of the Pancreatic Tumor Located Close to the Splenic Hilum: A Case Report

Coexisting Situs Inversus Totalis and Immune Thrombocytopenic Purpura

Y. Mochida, A. Nakajima, S. Okumura, A. Arimoto

K. Gundogu1, F. Altintoprak2, M.Y. Uzunoglu1, E. Dikicier1, I. Zengin1, O. Yagmurkaya1

Osaka Red Cross Hospital, OSAKA, Japan

1

We report a case of 24 year-old woman with a tumor of the pancreatic tail, which was found incidentally. The tumor was an about 5 cm cyst with solid lesion. It was located close to the splenic hilum and 5 mm ventral to the main pancreatic duct. The diagnosis was suspected of a mucinous cystic tumor, an epidermoid cystic tumor or a lymphoepithelial cyst. The resection of the tumor was planned to exclude malignancy. The operation was performed with 4 trocars. First we opened bursa omentalis and identified the tumor. The enucleation was performed by using Laparoscopic Coagulating Shears, cutting carefully between the normal parenchyma of the pancreas and the capsule of the tumor. We sutured to close the enucleated field of pancreas and applied fibrin material. The postoperative course was good and the patient discharged 10 days after the operation. The histopathological diagnosis was non-neoplastic pancreatic cyst and the solid lesion was revealed the protein coagulation. The benign tumor of the pancreatic tail is generally resected by standard distal pancreatectomy, but the enucleation of pancreatic tumor can preserve the spleen and pancreatic function compared with distal pancreatectomy. It is widely accepted that laparoscopic surgery has advantages related to minimal access surgery. In addition, laparoscopic enucleation of the pancreatic tumor on the ventral surface doesn’t require the mobilization of the spleen which is usually required for open enucleation of the pancreatic tumor located close to the splenic hilum. Laparoscopic enucleation of the pancreatic tumor is a safe and feasible technique and can be a good option for resection of the pancreatic benign tumor.

Republic of Turkey Ministry of Health, SAKARYA, Turkey; Sakarya University, Faculty of Medicine, SAKARYA, Turkey

2

Introduction: Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by an immune response to thrombocyte membrane antigens. ITP is generally treated with surgery and steroids (1). Situs inversus totalis is a rare congenital abnormality in which all of the mediastinal and abdominal organs are transposed to mirror symmetry of the normal anatomy. This paper reports the coexistence of these two rare conditions. Case Presentation: A 35-year-old woman was referred to our clinic with a diagnosis of ITP resistant to medical treatment in whom a splenectomy was indicated. Preoperatively, dextrocardia was detected on an electrocardiogram and thoracoabdominal computed tomography (CT) showed situs inversus totalis (figure 1). The pancreas had not crossed over to the right side of the superior mesenteric vascular axis and there was no pancreatic tissue near the splenic hilum (Figure 2). The patient underwent a laparoscopic splenectomy (Figure 3) with no complications or adverse events following surgery. She was discharged on the third postoperative day with thrombocyte count of 155,000/mm3. Discussion: Immune (idiopathic) thrombocytopenic purpura is an autoimmune disease characterized by the destruction of thrombocytes or suppression of their production as a result of an immune reaction with thrombocyte membrane autoantigens. Accessory spleens are found in 15% of the general population and should be detected in ITP patients when a splenectomy is planned to prevent incomplete removal of spleen tissue. In our case, an accessory spleen was detected on preoperative CT and excised. Situs inversus totalis is a rare condition with an incidence of 1/10,000 characterized by transposed organs and systems to mirror symmetry instead of the normal anatomy. Coexistence of SIT and various congenital abnormalities has been reported. The absence of a pancreatic tail in our case corresponded with the literature. The pancreatic abnormality in our case did not cause any problems because it was identified preoperatively. Furthermore, the absence of pancreatic tissue near the splenic hilum facilitated isolation of the splenic vessels, eliminated the risk of pancreatic injury, and facilitated perioperative movements, contributing to an uneventful operation.

P516 - Pancreas

P518 - Thoracoscopic Surgery

Laparoscopic Distal Splenopancreatectomy After Open Left Nephrectomy

Thoracoscopic Resection of the Giant Bullae of the Lung

M. Lavazza, E. Cassinotti, A. Marzorati, L. Boni University of Insubria, VARESE, Italy Aims: Laparoscopic distal pancreatectomy is associated with decreased postoperative pain, reduced need for analgesia and a lower the length of the hospital stay. Herein, we report a case of laparoscopic distal pancreatectomy. Methods: a 59-years-old woman with previous history of open left nephrectomy for clear cell renal cancer (pT2pNXG3). During the oncological follow-up abdominal ultrasound revealed 3x2 cm hypoechoic lesion in the body-tail of the pancreas. A CT scan demonstrated the presence of a hypervascular 22 9 18 mm diameter lesion; a further PET scan confirmed pancreatic involvement without other pathological localizations. Lab tests were normal, including the tumor markers CEA and CA 19-9. In the hypothesis of metastatic lesion from renal cell cancer or neuroendocrine tumor, the patient was scheduled for a laparoscopic splenopancreatectomy. The patient was placed in a semi-lateral right position; pneumoperitoneum was induced with Veress needle in left iliac fossa at 12 mmHg. Four trocars were placed: 10 and 12 mm respectively in left paraumbilical area and left flank, one 5 mm trocar in right hypocondrium. Because of previous laparotomic left nephrectomy, it was necessary to perform an extended adhesiolysis with full mobilization of the splenic flexure and the whole transverse colon, to expose pancreatic body and tail. The peritoneal lining along the inferior edge of the pancreas was dissected and the splenic vein and artery surrounded using a surgical sling. The pancreas was transected using articulated endoscopic stapler. Splenic artery and vein were divided with a vascular stapler. At this point the spleen was fully mobilized after ligation of short vessels at the upper pole and the specimen removed ‘en-bloc’ using an endobag through a sovra-pubic mini-laparotomy. A drain was placed in the lesser sac. Results: The postoperative course was uneventful. The patient was discharged on postoperative day 6. Pathological examination revealed a 23 mm clear cell renal cancer metastases in the pancreatic tissue; the surgical margins were clear. No metastatic lymphnodes were found in the peripancreatic harvested. At 12 months follow-up the patient had no later complications neither disease recurrence. Conclusions: Laparoscopic splenopancreatectomy can be safely performed even in case of previous open procedures on the left side of the abdomen.

S. Sugiyama1, S. Miyahara1, S. Wakimoto1, K. Sugiyama1, Y. Doki2, T. Hommma2, N. Ojima2 1 Tomei-Atsugi Hospital, ATSUGI-SHI, Japan; 2Toyama University, TOYAMA, Japan

Initial: Currently, thoracoscopic resection or plication of the small bulla of the lung for pneumothorax is commonly used in thoracic surgery. However, previously, giant bullae occupying about 50% of the ipsilateral lung were observed with prolonged air leakage following thoracoscopic surgery.Therefore, the revised automatic anastomotic device is reinforced for air leakage after lung resection. For five cases of giant bulla, we performed lung resection without reinforcing the resected line by hand anastomosis. Method: After identifying the bulla using the thoracoscope, and the apex of bulla revealed the bottom of the bulla which pass through the air from the parenchyma of the lung. After twisting the bulla wall using forceps, we resected using an automatic anastomotic device. After the water sealing test and insertion of the thoracic drain, operation was performed. Result: In the last five years, we have treated 8 cases of giant bullae. Thoracoscopic resection for giant bullae was the same as thoracotomy, except for the operative bleeding volume (55 ml in thoracoscopic resection cases vs. 267 ml in thoracotomy cases) and the operation time (72 min in thoracoscopic resection cases vs. 126 min in thoracotomy cases). Recovering rate of the postoperative respiratory function was similar in both, thoracoscopic and thoracotomy cases. Conclusion: Thoracoscopic resection is an alternative to thoracotomy for giant bullae

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Surg Endosc

P520 - Training

P522 - Abdominal Cavity and Abdominal Wall

Examination of Assistant Learning Curve of Laparoscopic Distal Gastrectomy (Delta-Shaped Anastomosis) in the Induction Phase

Self-fixating Mesh in Tapp Technique. Possibility of Reduction of the Chronic Pain and Recurrence Rate. Results of a Prospective, Single Centre Study

N. Akazawa, T. Kakita, T. Yazawa, H. Oishi, A. Oyama, T. Okada, M. Oikawa, H. Hohda, T. Tsuchiya Sendai city medical center Sendai Open hospital, MIYAGI, Japan Aim: In recent years, laparoscopic gastrectomy for early gastric cancer has spread in Japan, but it is difficult of reconstruction under laparoscopy in the introduction phase. There is no model has been established for assistant training.We try to set the number of cases that are required to the safety and proficiency of Laparoscopic gastrectomy. Methods: We were examined delta reconstruction method 37 cases of distal gastrectomy. The first assistant is the sixth year after graduation and a beginner of laparoscopic surgery. We were examined five items: surgery time, amount of bleeding, length of postoperative hospital stay, complications and the time required for delta-shaped reconstruction. Results: Surgery time and the time required for delta-shaped reconstruction are approximated to the median in about 20 cases. Conclusion: We regard necessary number of cases as about 20 in the stylized procedures learning. It’s made some help of making the hospital education program of laparoscopic surgery.

P. Klobusicky Helios St.Elisabeth Hospital Bad Kissingen, BAD KISSINGEN, Germany Introduction: Transabdominal laparoscopic (TAPP) approach in the therapy of inguinal hernia is a suitable alternative to classical open inguinal hernia repair mainly in the hands of an experienced surgeon. TAPP repair offers the possibility of gentle dissection with implantation of the mesh and possibility of non invasive fixation of implanted mesh. The fixation of mesh thru penetrating techniques using staples, clips or screws is associated with a significantly increased risk of developing a post-herniotomy pain syndrome (CPIP). In order to answer the question ‘fixation or no fixation of the mesh’ the use of self-adhesive mesh is an optimal compromise. Methods: Data analysis included all patients, who underwent inguinal hernia surgery at our Surgical Department within the period from 1.10.12 to 30.09.14, who fulfilled the inclusion criteria. Standard surgical technique was used. Data were entered and subsequently analyzed on Herniamed platform. Results: There were 218 patients enrolled to the group and there were totally 357 inguinal hernias repaired. The minimal follow up was at 12 months. At the assessment in one year was reported mild discomfort in the groin in 4 patients (1.12%) (1–3 VAS). There was no recurrence and no chronic postoperative pain reported. Conclusion: Our study demonstrates that laparoscopic inguinal hernia repair using TAPP technique with implantation of a self-gripping mesh seems to be fast, effective and an optimal compromise for TAPP hernioplasty, which according to our results reduces the occurrence of CPIP with simultanously low recurrence rate.

P521 - Abdominal Cavity and Abdominal Wall

P523 - Abdominal Cavity and Abdominal Wall

A Survey of Inguinal Hernia Repairs in Wales with Emphasis on Laparoscopic Repair

Laparoscopic Appendectomy in Patients with Chronic Residual Appendicitis Complicated by Appendicular Infiltration

E.A. Williams, I. Salih, A. Woodward

R.V. Bondarev, A.I. Sopko, R.M. Kozubovich, I.I. Zarya, I. o. i. Kundelskiy, S.S. Kramarenko

Royal Glamorgan Hospital, WALES, United Kingdom Aims: In 2013 a consensus document on inguinal hernia repair was produced by the ASGBI. In 2007 NICE published its guidance on the use of laparoscopic repair for inguinal hernias. A study conducted at the time showed the uptake of laparoscopic surgery for inguinal hernia repair was low in Wales. This study aimed to re-assess current practice for inguinal hernia repair against the evidence based NICE guidance and the ASGBI consensus document as well as comparing with the previous Welsh study. Method: An online questionnaire survey of 100 consultant surgeons in Wales was performed with a 42% response rate. Results: 40% of surgeons perform laparoscopic inguinal hernia repair in Wales compared to 15% previously; 64% of these performed TEPP, 24% TAPP and 11% performed both techniques. 85% of surgeons in Wales agreed with the NICE guidance compared to 10% in 2007. No surgeon currently is using a laparoscopic repair as the technique of choice for repair of primary inguinal hernias. 99% of surgeons perform hernia repair as day cases compared to 15% in 2007 however an average of 10% actually stayed overnight. The uptake of repairs under local anaesthesia has doubled from 15% to 30%; 41% of surgeons do not use any form of thromboprophylaxis for elective inguinal hernia repair (unchanged), while the use of routine antibiotic prophylaxis has increased from 78% to 89%. Postoperative advice regarding return to sedentary work and driving was highly variable. Conclusions: The uptake of laparoscopic surgery for inguinal hernia repair in Wales has more than doubled over the last 8 years. Almost all procedures were attempted as day cases. The percentage of procedures performed under local anaesthesia has improved but remains low. The use of thromboembolic prophylaxis is empirical and inconsistent although antibiotic prophylaxis has increased. Overall, current practice does not reflect the evidencebased guidance in many areas.

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O. O. Bogomolets National Medical University, KYIV, Ukraine Aims: To determine the timing of laparoscopic appendectomy in patients with chronic residual appendicitis complicated by appendicular infiltration. Methods: Analysis of the results of treatment of 39 patients who recieved laparoscopic appendectomy (LA) at different times after appendicular infiltration. Regression of appendicular infiltrate has been evaluated based on clinical and laboratory results and daily dynamic inspection using ultrasound (US) of the abdominal cavity. In 4 cases LA has been conducted after 3 months of appendicular infiltrate regression, at 12 patients accordingly 4 months, at 6 - 2, 7 - 1, and at 10 patients immediately after abdominal infiltrate had not been visualized on a ultrasound of the abdominal cavity. Results: Patients who had recieved LA in the first month after the regression of appendicular infiltrate, had been detected with deformation of the appendix at the expense of the adhesions in the dome’s area of the cecum and the right iliac area more often. 88.2% of patients had infiltration of the appendix’ wall, meso appendix also had been infiltrated. But this did not cause technical difficulties when LA was performed. There weren’t any complications during surgery and in the postoperative period. Conclusion(s): Performing of LA for chronic residual appendicitis is possible right after regression of appendicular infiltrate.

Surg Endosc

P524 - Abdominal Cavity and Abdominal Wall

P526 - Emergency Surgery

Our Experience of Laparoscopic Treatment of Acute Pancreatitis

Puncture Like a Treatment Option for Acute Obstructive Cholecystitis. How Can it be? Experimental Study

S.M. Vasyliuk, V.M. Klymyuk, V.V. Ivanyna Ivano-Frankivsk National Medical University, IVANO-FRANKIVSK, Ukraine Aims: to increase the efficacy of the laparoscopic treatment of acute pancreatitis. Methods: We have operated on 51 patients with severe acute alimentary (52.9%) and biliary (47.1%) pancreatitis. The volume of operation was in laparoscopic sanitation of abdominal cavity and establishment of four contact silicon drainages. Peritoneal omental sac drainage wasn’t set. In biliary pancreatitis laparoscopic cholecystectomy was simultaneously performed. Results: In 30 (58.8%) patients, in enzymatic peritonitis, symptoms of peritoneal irritation and muscular tension of anterior abdominal wall were not detected. Therefore, ultrasonographic signs were absolute indications for surgery: abdominal effusion and characteristic changes in the pancreas. Laparoscopic pancreatic necrosis signs were: the presence of hemorrhagic (78.4%) or sero-hemorrhagic (21.6%) effusion, stearic spots (25.5%), stomach bulging and omental bag tension (33.3%), swelling of the small omentum with the spread into the gallbladder (29.4%). Postoperative period was best in patients, whose operations were performed within 12-24 h of the onset of acute pancreatitis clinical signs. Ultrasonographic monitoring indicated that the volume of liquid in the omental bag has decreased during the first postoperative day, despite the lack of drainage. False cysts formation of the pancreas was in 7.8% of patients. Necrotic suppurative complications were not observed. One patient died (3.9%) of hepatorenal dysfunction. Conclusion(s): Abdominal cavity laparoscopic sanitation and drainage in patients with severe pancreatitis should be performed urgently. Drainage of omental bag is not mandatory stage of the surgical treatment. In biliary genesis of pancreatitis it is necessary to perform laparoscopic cholecystectomy simultaneously.

N. Glagolev, G. Ivakhov Pirogov Russian National Research Medical University, MOSCOW, Russia Introduction: Now we can see like US-guided and EndoUS-guided punctures of gallbladder can replace US-guided GB drainage in high-surgical risk patients with acute obstructive cholecystitis (AOC). But, if we will saying about pathogenetic substantiation of decompressive techniques of GB in cases of AOC, we still have many questions. The aim of our experimental study were to justify efficacy of decompressive GB-puncture in treatment of AOC. Materials: In our experiment were included 20 rabbits. Model of AOC: after laparotomy we have been made ligation of cystic duct, than introduce in gallbladder microbial culture of Esherichia coli 106. Animals were divided into two group. First group was without any treatment. At second group have been performed re-laparotomy on 3 day. At this procedure we made decompression by puncture of gallbladder and instillation of antiseptic solution. Then we have been evaluated indicators of SIRS, microbiological and histological analysis (on 7 and 14 days). Results: All animals died to 15 days in first group without treatment. On the autopsy on 14 day we were revealed that microbiological growth of Escherichia coli from abdominal cavity were 1011. Peritonitis with the necrosis of the GB-wall were found in died animals by histology. Decrease of SIRS-reaction were at group after decompressive puncture and instillation of antiseptic. Count of leucocytes and temperature were decreased to the 9,8 + 0,3*109/l and 38,3 + 0,4C. Decrease of total microbial count had to 14 day in gallbladder (from 106 till 103) and in abdominal cavity (without growth). At histology we found that the decompressive GB-puncture with intraluminal instillation of antiseptic have been promoted to decrease of neutrophilic infiltration with development of the chronic inflammation and fibrosis of the GB-wall. Conclusion: Decompressive gallbladder-puncture with intraluminal instillation of antiseptic solution in cases of acute obstructive cholecystitis promotes to decrease of microbial contamination of the gallbladder and abdominal cavity, manifestetions of SIRS and neutrophilic infiltration with development of the chronic inflammation and fibrosis of the gallbladder wall. Treatment by means of decompressive gallbladder puncture with instillation of antiseptic solution is warranted in the case of human AOC.

P525 - Education

P527 - Gastroduodenal Diseases

Residual Heat Characteristics of Advanced Energy Devices: A Bipolar Vessel Sealing Device and Ultrasonic Shears

‘Many Ways to Skin Gastric Cancer’ - Robotic Versus Laparoscopic Versus Open Gastrectomy

Y. Watanabe

E. Kakiashvili, E. Brauner, O. Ben Yshai, R. Almog, A. Beny, Y. Kluger

Hokkaido University Graduate School of Medicine, SAPPORO, Japan Aims: While bipolar vessel sealing devices and ultrasonic shears are ubiquitous for both sharp and blunt dissection in laparoscopic surgery, the residual heat of these instruments may cause serious injuries. There is limited information regarding the tip temperature of these latest energy devices during consecutive use. The purpose of this study was to analyze the residual heat of the bipolar vessel sealing device and ultrasonic shears throughout the course of activations. Methods: The mesenteries of the porcine small intestine were dissected by a polyphthalamide-covered bipolar vessel sealing device (LigaSureTM Maryland jaw) and ultrasonic dissection device (SonicisionTM). To simulate real usage in the operating room, each instrument was activated for 10 consecutive times with pauses between activations. The residual heat of energy devices was measured using a certified thermal imaging instrument (Fluke Ti9 Infrared Camera) throughout 10 activations. Data are expressed as median [25th percentile; 75th percentile]. Results: For each energy device, 5 small intestine mesenteries were dissected. The activation time was 3.8 [3.2; 4.0] seconds for the bipolar instrument and 3.2 [2.6; 4.2] seconds for the ultrasonic shears (p = 0.04), whereas the pause time was 1.3 [1.0; 2.5] seconds for the bipolar and 1.0 [0.8: 1.7] second for the ultrasonic shears, respectively (p = 0.26). The maximum temperature of instrument tip was 88.2 C for the bipolar device and 134.7 C for the ultrasonic shears. The temperature after the 1st, 2nd 5th, and final activation was 72.1 [50.8; 76.0], 72.5 [67.8; 75.7], 81.3 [79.5; 82.2], 82.8 [80.2; 85.1] for the bipolar device; and 84.9 [75.9; 95.6], 86.7 [79.8; 105.6], 92.9 [85.2; 107.2], and 109.7 [102; 124.4] for the ultrasonic shears, respectively (p = 0.04, p = 0.01, p = 0.01, and p = 0.01). Conclusions: The ultrasonic shears have greater tip temperature than the polyphthalamidecovered bipolar sealing device. The bipolar sealing instrument heated less than 100 C throughout 10 activations which may have a lower potential for causing residual heat related injuries. These practical findings help better understand these common energy devices and could alert the way surgeons use these devices for safer surgery.

RAMBAM MEDICAL CENTER, KIRIAT MOZKIN, Israel Background: robotic surgery has gained acceptance in oncological surgery. Its relevance in gastric cancer surgery is being examined. Aim: the study presents preliminary comparison of operative and postoperative outcome between robotic, laparoscopic and open gastrectomies for gastric adenocarcinoma. Methods: Retrospective cohort of 85 consecutive patients that underwent total or partial gastrectomy for gastric adenocarcinoma at Rambam Hospital during 2012-2015. For each patient data was collected on basic demographic characteristics, BMI, operating room time(ORT), number of dissected lymph nodes(LN), length of hospitalization(LOH), intra and postoperative complications. Non parametric statistical tests MW and Kruskal–Wallis were used for group comparisons. Results: Study population included 55 patients after total gastrectomies, 10 of them robotic and 30 partial gastrectomies, 12 of them robotic. Age, gender and BMI were similar between patients who underwent robotic, laparoscopic and open procedures. Median length of hospitalization (LOH) for robotic total gastrectomy was 4.5 days and it was significantly shorter than both laparoscopic total gastrectomy(LTG) 7.0 days (p = 0.003) and open total gastrectomy(OTG) 9.0 days (p \ 0.001). Similar significant differences in LOH between the 3 groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of LPG. Median ORT was significantly longer among robotic gastrectomies compared to open, the difference was 64 min in total gastrectomy group and 145 min in partial gastrectomy group (p \ 0.001 for both differences), but the difference in ORT between laparoscopic and robotic procedures were smaller and non-significant. The number of dissected LN was similar between the 3 procedures in total gasrectomies. In partial gastrectomies, the number of dissected LN was even higher among both laparoscopic and robotic gastrectomies compared to open (p \ 0.001). Conclusion: robotic total and partial gastrectomies for gastric adenocarcinoma are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer operating time.

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Surg Endosc

P528 - Gastroduodenal Diseases

P530 - Gastroduodenal Diseases

Functional End to End Anastomosis Method in Laparoscopic Total Gastrectomy

Intraoperative Complications and Recovery Methods for Laparoscopic Gastrectomy

S. Miura, S. Kanaya, H. Kawada, A. Arimoto

S. Otsuki

Osaka Red Cros Hospital, OSAKA, Japan

Tokyo medical and dental university, TOKYO, Japan

Purpose: Laparoscopic total gastrectomy (LTG) hasn’t become popular yet as a treatment for gastric cancer like laparoscopic distal gastrectomy (LDG), because reconstruction of LTG is technically difficult. We have performed reconstruction of LTG using liner stapler since April 2011. The head of the liner stapler is small, then we can get a larger surgical sight during making anastomosis and carry out the reconstruction easily and safely. And moreover, reconstruction of LTG by liner stapler has less stenotic issue. Methods: In LTG, functional end to end anastomosis (FEEA) is chosen as a first choice. FEEA is simple, easy and time-saving method. Overlap method is selected in case with esophageal invasion. It is a space saving method, but a little complicated, it needs hand sewing. FEEA was carry out as follows. The esophagus was divided with a liner stapler, preserving phrenoesophageal membrane. The jejunum (25 cm distal from the Treiz ligament) was divided with a liner stapler. The jejunum rim was lifted via the antecolic root, after jejunojejunostomy was performed. Left edge of the esophagus stump was cut off to make the entrance to the stapler. The jejunum was stapled to left side of the esophagus with a liner stapler. The entry hole was closed with a liner stapler. Finally, Petersen’s defect was closed by hand sewn and the duodenal stump was buried with reinforcement sutures. Results: From April 2011 to March 2014, 87 patients underwent LTG. The mean time of anastomosis was 13.5 min. Two postoperative anastomotic leakage were confirmed, which were treated conservatively, No anastomotic stenosis was observed. Conclusions: FEEA is a simple and safe procedure in laparoscopic total gastrectomy.

Laparoscopic gastrectomy has been gradually and widely spread and laparoscopic distal gastrectomy (LDG) with D1 + dissection in early gastric cancer becomes to be one of the standard treatment. In the future, depending on the results of JLSSG0901, LDG will be adapted for the advanced gastric cancer. However, not only radicality but safety is required as the same level as open surgery. However, intraoperative complications will happen with some constant possibility, even if it was performed very carefully. Proper treatment is important to avoid complication. In survey by JSES, 70% of intraoperative accidents was bleeding and the other half was organ injury. Therefore, we have to know and understand the points that is easily bled and injured. Venous bleeding is more often serious problem than arterial one. Point to venous bleeding is to control bleeding and detect accurately bleeding point. So, it is important to restrict the bleeding by compression and keep clear the operation field. Actual hemostasis way for small bleeding is cauterization using soft congelation devices together with hemostasis sheet. For bleeding to be hardly treated, hemostasis is carried out by transfixion suture. In organ injuries, most of them are mechanical damage by improper traction and handling of forceps or staplers. For damage to solid organ such as liver, spleen and pancreas, it is useful to cover with fibrin glue or omental patch after hemostasis. For damage of intestine tract, we have to restore and reinforce by transfixion suture at the intra or extra corporal field and confirm that intestinal tract is completely restored. In any recovery methods, knack is to keep enough operation field and to carry out perfect repair. So basic skills such as transfixion suture is essential for any intraoperative complications and it is necessary for us to train enough. Furthermore we have to understand the characteristics of these devices. The recovery method will be described with actual examples.

P529 - Gastroduodenal Diseases

P531 - Gastroduodenal Diseases

Laparoscopic Surgery of Gastric Cancer: Indications, Technique And Results After 100 Cases

A New ‘Outside-In’ Approach to Lymph Node Dissection in Laparoscopic Distal Gastrectomy

M. Uccelli, S. Olmi, G. Cesana, F. Ciccarese, G. Castello, V. Reggiani, R. Giorgi, G. Legnani

S. Kanda1, T. Fukunaga1, K. Yamasawa1, Y. Yube1, M. Fukunaga2, K. Nagakari2, Y. Ida2, S. Yoshikawa2, T. Suda2, G. Katsuno2, M. Ouchi2, Y. Hirasaki2, M. Ito2, D. Azuma2, S. Kohama2, J. Nomoto2

San Marco Hospital, ZINGONIA (BG), Italy Aims: Laparoscopic surgery of the stomach is extended to treat advanced gastric cancer with encouraging results similar to open surgery in terms of oncological results. The aim of this study is to evaluate efficacy, safety and results in terms of postoperative complications and follow-up in patients undergoing laparoscopic gastric resections for malignancy. Methods: From January 2008 to May 2015, after more than 120 surgical procedures for gastric cancer performed with minimally invasive approach, we performed 64 laparoscopic subtotal gastrectomy (LSG) and 28 total gastrectomy (LTG), both for EGC and for AGC. We always made a D2 lymphadenectomy or higher, and omentum-preserving. Results: The study population of 92 patients, operated from April 2007 to May 2015, was composed of 51 men and 41 women (age: 68.66 ± 10.66 years; BMI of 26.57 ± 2, 65 kg/ m2). We made 64/92 LSG (69,57%) and 28/92 LTG (30.43%). The average time of surgery was equal to 154 ± 37 min (range 75–280). The average number of lymph nodes removed was equal to 21.63 ± 7.79 (range 8–65). We proceeded to partial omentectomy (omentumpreserving) in 83/92 cases (90.22%). We recorded 8/92 conversions (8.70%). We have a rate of intraoperative complications and positive resection margins at 0%. The average postoperative hospital stay was equal to 12.90 ± 14.19 days (range 7–116). We recorded a regular postoperative course in 75/92 patients (81.25%). Postoperative surgical complications in 10/92 cases (10.87%). The mean follow-up time was 44.33 ± 28.54 months (range 1.41–95.67 months), and is still ongoing, so the data presented are preliminary. We recorded an average survival time equal to 40.80 ± 0.31 months. We recorded so far 22/81 deaths, with a survival rate at follow-up part amounts to 72,84%. Conclusions: Laparoscopic treatment of gastric cancer with D2 lymphadenectomy and omentum-preserving is safe and feasible, both for EGC and for AGC. Short and medium term follow-up show that there are no differences in survival and recurrence rate from previous reports. To establish this technique as a standard treatment for gastric cancer, randomized controlled trials are necessary to compare the short- and long-term outcomes.

123

Juntendo University, URAYASU, Japan; 2Juntendo Urayasu Hospital, URAYASU, Japan

1

Extended lymph node dissection is performed in patients undergoing distal gastrectomy for gastric cancer, and laparoscopy-assisted distal gastrectomy (LADG) has necessitated the development of specific techniques aimed toward precision and ease of laparoscopic dissection. We began LADG in 1994. Initially, we transected the duodenum and approached the suprapancreatic lymph nodes from the right side. In 2004, we developed a left-sided approach that does not require transection of the duodenum. With this method, we pull the stomach upward toward the abdominal wall and approach the left gastropancreatic fold from the back side. In 2010 we expanded the indications to stage T4a, N(+) gastric cancer. We decreased the number of pedicles needing to be stretched and introduced an approach by which we dissect the suprapancreatic nodes and station 6 nodes in the mesogastria from the outside to the inside. Suprapancreatic lymph node dissection can be done regardless of whether the duodenum has been transected. We first pull nodes 12a, 8a, and 9 (right side) from the left side of the portal vein toward the abdominal wall and detach the diaphragm on the cranial side, taking care to avoid the anterior hepatic plexus. Next, as with the left-sided approach, we pull the left gastropancreatic fold from the left back side and dissect station 11p to 9 (left side) nodes, taking care to avoid the pancreatic plexus. With such dissection in the surrounding area, the root of the left gastric artery is exposed, and we dissect it. Dissection of the station 6 nodes can be performed in a similar manner. The advantage of this surgery is that it follows the concept of laparotomy in avoiding excessive movement of the ligaments, a clearer view is provided because bleeding from the ligaments is minimized, the site is stabilized by lifting the vascular pedicles, and the surrounding tissue is repositioned after dissection. We report this dissection technique as an uncomplicated method that replicates the simple laparotomy method, and we consider this method to be useful for teaching both laparotomy and laparoscopic surgery and for understanding the concept of lymph node dissection.

Surg Endosc

P532 - Intestinal, Colorectal and Anal Disorders

P534 - Intestinal, Colorectal and Anal Disorders

Does the use of a Laparoscopic Approach in the Initial Surgery Has an Impact on the Postoperative Evolution of Loop Ileostomy Closure?

Significance of Sentinel Node Technique in Laparoscopic and Open Colorectal Surgery

V. Turrado-Rodriguez, N. Freixas Lo´pez, C. Rodriguez-Otero Luppi, J. Bollo Rodriguez, E. Targarona Soler Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain Aims: To analyze the difference in the postoperative evolution of patients who underwent a loop ileostomy closure according to the use of a laparoscopic approach in the initial surgery. Methods: We retrospectively analyzed 191 patients operated between 2000 and 2015 of an ileostomy reversal. We studied preoperative date, intraoperative variables, postoperative complications, lenght of stay, reinterventions and mortality. The Dindo-Clavien classification for postoperative complications was used. Patients were divided in two groups: laparoscopic approach used on the initial surgery and open approach used on the initial surgery. Results: We found that the use of a laparoscopic approach in the first surgery was associated with a faster return to normal bowel movement; dieta and a shorter hospital stay than the open approach. Conclusions: The use of a laparoscopic approach in those procedures that include a loop ileostomy should be encouraged because it has a positive impact on the postoperative evolution of the loop ileostomy closure, reducing the hospital stay; the return to normal bowel movement and diet.

´ . Botos, R. Temesi, A. Berencsi, J. Bezsilla L. Sikorszki, A B.A.Z.County Hospital, MISKOLC, Hungary Aim: Information about the significance of the sentinel lymph nodes in colorectal cancer is contradictory or missing. The sentinel node technique is regarded as a suitable method to investigate lymph-node involvement. Methods: Between October 2009 and June 2012, sentinel lymph node sampling was performed in 188 cases of colorectal resections randomized either for open or laparoscopic approach. Dyed lymph nodes were identified by a surgeon right after the operation and were fixed in formalin using specific markers. If the standard histology was negative, the detection of micro-metastases was also accomplished The pathologist considered the most intensively dyed lymph nodes, closest to the formalin fixed tumor to be the sentinel ones (pathologic sentinel), which ensured the dual marking technique in this seria. If the standard histology was negative, the detection of micro-metastases was also accomplished in thesentinel lymph nodes by pan CK immunohistochemistry The convergence of the lymph nodes in the vicinity of the tumor leads to the so called distal marker lymph node, while the nodes along the vessel shaft of the resected bowel to the proximal marker lymph nodes. Results: Laparoscopic surgery:n = 95. Open surgery:n = 93. In lymph node positive patients only 52,78% of sentinel nodes were positive. Neither the peritumoral nor the surgical or pathological sentinel marking have clinical significance. Among the 34 lymph node positive in 12 cases. The proximal markers signaling a higher level of involvement were positive just in 4 cases. Conclusion: Beyond the regular sentinel nodes, so called marker nodes were found to give additional information.In T1-T3 categories in lymph node negative cases, the micro metastasis in sentinel and marker lymph nodes can influence the postoperative treatment. In T1-T2 categories, the intraoperative examination of the sentinel lymph nodes can influence even the size of the resection, particularly in high-risk patients. Significantly higher numbers of lymph nodes were detected in cases with sentinel sampling, since the identification of the blue-coloured lymph nodes were easier. Regarding feasibility, there was no difference between the open and the laparoscopic approaches. Further research is planned to identify whether there is a possibility of intraoperative tumor cell scattering with the sentinel method.

P533 - Intestinal, Colorectal and Anal Disorders

P535 - Liver and Biliary Tract Surgery

Oncologic Outcomes of Laparoscopic Rectal Cancer Surgery J.K. Ju

Impact of the Laparoscopic Approach for Colorectal Liver Metastases on Short- and Long-Term Outcomes. A Propensity Score Analysis

Chonnam National University Hospital, GWANGJU, Republic of Korea

F. Cipriani1, M. Rawashdeh1, L. Stanton1, T. Armstrong1, A. Takhar1, N.W. Pearce1, J.N. Primrose1, M. Abu Hilal1, S. Barbaro2

Background: Recent studies demonstrated favorable short and mid-term results after laparoscopic surgery for rectal cancer. However, long-term results from large series are lacking. The present study analyses long-term results of laparoscopic rectal cancer surgery from a large-volume center. Methods: From January 2004 until March 2012, 1025 patients underwent laparoscopic rectal resection due to carcinoma. The data were analysed using oncological data (tumour recurrence) as well as overall survival. In addition, the effect of conversion to open resection on overall survival was analysed. Results: With a median of 51 months at follow-up, the overall and disease-free survival was 70.5 and 70.1%, respectively. Local recurrence of all patients was 5.8% and none of the converted patients was within this group. The median time interval for the development of local recurrence was 30 months. Patients with a conversion to open surgery had primarily a significantly worse outcome than patients resected completely laparoscopically (p = 0.03). However, this difference was no longer apparent using a multivariant analysis (hazard ratio 1.33; p = 0.689). Conclusions: Overall survival and local recurrence rate of patients undergoing laparoscopic resection of rectal cancer are comparable to open surgery. However, in our analysis, patients undergoing laparoscopic anterior resection had a higher survival rate compared with patients with abdominoperineal resection.

1 University Hospital Southampton, SOUTHAMPTON, United Kingdom; 2Southampton General Hospital, SOUTHAMPTON, United Kingdom

Aims: Higher levels of evidence on the efficacy of laparoscopic liver resections (LLR) have been recently advocated. Observational studies are influenced by patients’ characteristics when allocated to a treatment. Propensity Score (PS) matching has shown to be effective in minimizing treatment selection bias. Our aim was to compare the surgical and oncologic long-term outcomes of patients with colorectal liver metastases (CRLM) undergoing laparoscopic and open liver resections (OLR). Methods: A 1:1 PS matching was implemented. Covariates selected for matching included: number and size of lesions, extent and number of resections, phase of surgical activity, location and lymphnode status of the primary, perioperative chemotherapy, synchronous/ metachronous disease. Analyses on the pre-matching and balanced cohort were compared. Results: 119 patients from each group were matched. At pre-matching analysis, LLRs showed longer OS and higher R0 rate than OLRs, and lower blood losses. Analyses on the balanced cohort failed to confirm these results, showing similar OS and R0 rate between the two groups (61 vs. 44 months, p 0.09; 91.6% vs. 89.1%, p 0.662) and comparable blood losses (425 vs. 500 mL, p 0.056). The 5-year OS was 52% and 46% for laparoscopic and open group. However, longer operative times, shorter postoperative stay and lower morbidity for LLRs were confirmed on pre- and post- matching analysis. Conclusions: LLRs for CRLM provide R0 resection rate and long-term OS comparable to OLRs, with similar blood losses, shorter postoperative stay and lower morbidity. PS matching appears to offer clarity on the true impact of LLRs for these patients.

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Surg Endosc

P536 - Liver and Biliary Tract Surgery

P538 - Liver and Biliary Tract Surgery

Oncological and Surgical Results of Laparoscopic Liver Resection for HCC : A Single Center Experience

Laparoscopic Cholecystectomy Complicated by Acute Cholecystitis in Patients Older Than 60 Years with Concomitant Coronary Heart Disease

W.H. Kang, K.H. Kim, D.H. Jung, T.Y. Ha, S.H. Hwang, G.W. Song, C.S. Ahn, D.B. Moon, G.C. Park, W.J. Kim, S.G. Lee

V.G. Mishalov, R.V. Bondarev, V.M. Ivantsok, S.A. Kondratenko

Asan medical center, SEOUL, Republic of Korea

O. O. Bogomolets National Medical University, KYIV, Ukraine

Background: Liver resection is potentially curative therapy for Hepatocellular carcinoma(HCC). Laparoscopic liver resection(LLR) is developing and known as safe technique. It is associated with shorter hospital stay, less pain, cosmetic effect and same rates of complication as open surgery. But, limited data about long-term outcomes were published. This study aimed to evaluate the oncologic outcomes and effectiveness of patients underwent LLR. Methods: Among 249 patients performed Laparoscopic liver resection for hepatocellular carcinoma between July, 2007 and August, 2015 in Asan Medical Center. The all LLR was done by a single surgeon. The clinical data and follow-up results in these patients were retrospectively analyzed by SPSS21. Results: Mean age of the patients was 55.9 years (range: 31 - 81) and male were 176. The follow-up period was 33.7 ± 24.1 months (range 3-99). 240 patients(96.4%) performed LLR were on CTP grade A. The type of resection were as follows: Right lobectomy(38 patients), Left Lobectomy(36), non-anatomical partial hepatectomy(72), Left lat. segmentectomy(73), Right post. segmentectomy(15), Mono-segementectomy(7), Right ant. segmentectomy(6) and central bisegmentectomy(2). Obtained tumor free surgical resection margin was averagely 1.92 ± 1.71 cm. In 6 patients, tumors are on resection margin. The overall survival rates were 98.3% at 1 year, 84.8% at 3 years, and 78.4% at 5 years. The recurrence free survival rates were 75.7, 59.3 and 46.5%, each year. Conclusions: Laparoscopic Liver Resection for hepatocellular carcinoma is a safe, feasible and oncologically accepted treatment option with mini-invasive benefits. LLR is worth consideration of standard operative treatment for hepatocellular carcinoma due to remarkable surgical outcomes.

Aims: to compare the results of treatment patients with complicated acute cholecystitis (AC) over the age of 60 years, with concomitant coronary heart disease (CHD) by using the technique of traditional cholecystectomy (TCE) and laparoscopic cholecystectomy (LCE). Methods: The results of treatment had been analyzed in 392 patients aged 60 years and older with coronary artery disease who had been TCE (n = 178) and the LCE (n = 214) apropos AC with complications. Among the complications AC: perivesical infiltrate 96.9%, perivesical abscess - 5.4%, empyema ?? gallbladder - 35.7%, local peritonitis 52.8%, diffuse purulent peritonitis - 8.8%. In both groupshad been studied the character of postoperative complications and functional disorders of the myocardium according to the 24-hour monitoring of the electrocardiogram (ECG), by Holter. Results: After TCE emerged following common post-operative complications: pneumonia - 2 (1.1%), vein thrombophlebitis of the lower extremities - 2 (1.1%), intestinal paresis - 34 (19.1%) cases. After LCE only intestinal paresis had been observed accordingly in 18 (8.4%) cases. The frequency of appearing bile leakage, developing postoperative bile peritonitis, b?loma in groups had not differ much: TCE - 1.8% LCE - 2% of cases. Pyoinflammatory intraperitoneal complications in patients that had undergone TCA had been appeared in 6.7% of cases, the wound - in 24.7% and 2.8%accordingly LCE and 4.2%. Conclusion(s): LCA complicated by AC in old people with CHD allows to reduce the number of post-surgical intra-abdominal and wound inflammatory complications, to reduce the functional disorders of the myocardium, to reduce mortality.

P537 - Liver and Biliary Tract Surgery

P539 - Liver and Biliary Tract Surgery

Experience of Treatment of Patients with Complicated Gallstone Disease on the Background of Liver Cirrhosis

Minimally Invasive Treatment of Hepatic Hydatid Cysts: Long Term Results

F. Muraviov, N. Rudkovska

A. Uzunkoy

Zhytomyr Regional hospital, ZHYTOMYR, Ukraine

Harran University School of Medicine, SANLIURFA, Turkey

Topicality: The question of the treatment strategy of complicated gallstone disease in patients with liver cirrhosis still has not lost its relevance due to the fact that the prognosis and of postoperative period course. The aim: of this study was to improve the results and determine the most optimal method of treatment in patients with complicated gallstone disease on the background of verified liver cirrhosis. Materials and methods: The results of 107 of patients treatment with complicated gallstone disease on the background of verified liver cirrhosis in Zhitomyr Regional Center of Miniinvasive Surgical Techniques between 2009 and 2015 were analyzed. All of patients in addition to traditional methods of research during admission were underwent to endogenic ultrasonography, gastroscopy, abdominal MRI in cholangiography mode. For the liver cirrhosis verification elastography and liver biopsy, in some cases- splenoportography were performed. Patients were divided into three groups: Group I - 73 (68,2%) of patients with acute calculous cholecystitis (Child A-14, Child B - 59), group II - 32 (29,9%) of patients with cholelithiasis complicated by obstructive jaundice due to choledocholthiasis and Mirizzi- syndrome (Child A - 4, Child B - 28), and group III - 2 (1,87%) of patients with acute biliary pancreatitis (Child A - 1, Child B - 1). Results: 73 (100%) of patients from the I group were underwent laparoscopic cholecystectomy. In 19 (59,3%) of patients from the II group endoscopic papillosphincterotomy with lithoextraction was combined with simultaneous laparoscopic cholecystectomy; in 4 (12,5%) of patients laparoscopic cholecystectomy was supplemented by choledocholithoextraction. In 9 of patients from this group the Mirizzi’s syndrome was verified during surgical procedure. Laparoscopic cholecystectomy with precise suturing of the common bile duct defect was performed in 4 patients (type 2, Csendes), conversive cholecystectomy with choledocholithoextraction- in 3 of patients (type 3, Csendes), conversive cholecystectomy with biliodigestive anastamosis by Roux implementation - 1 of patients (type 4, Csendes). In patients with biliary pancreatitis the endoscopic papillosphincterotomy with lithoextraction were performed. 3 of patients died: one from a severe postoperative pancreatitis, 1 from progressive liver failure and 1 from recurrent abdominal variceal bleeding. The mortality rate was 2.8%.

Background and Aim: The hydatid disease is an important health problem. This disease can lead to severe complication and death. Hydatid cysts can be treated with medically, surgically or minimally invasive interventions. The effectiveness of medical treatment is limited. Surgery is still the most effective treatment method. Surgical interventions can be performed open or laparoscopic methods. Percutaneous interventions techniques for hepatic hydatid cysts may be selected. In this study, it was Patients and methods: Thirty-eight patients with hepatic hydatid cysts undergoing minimally invasive treatment (laparoscopic surgery or percutaneous treatment) were evaluated. The patients were evaluated with radiographic imaging methods (abdominal ultrasonography and computed tomography), biochemical parameters (SGOT, SGPT, ALP, bilirubin’s, etc.) and serological tests. Laparoscopic surgeries were performed with general anesthesia. Percutaneous interventions were performed under abdominal ultrasonography. All patients received medical treatment for two weeks prior to surgery or percutaneous intervention. Medical treatment was continued for 3 months after surgery or percutaneous intervention. Patients’ follow-up was made with abdominal ultrasonography and computed tomography. Diameter of cyst cavity was measured at 1st month, 6th month, 1st year 2nd year and 3rd year. Results: The average cyst diameter with abdominal ultrasonography and computed tomography was 8.1 ± 2.2 cm. Local recurrence or peritoneal spread of the disease was not seen. According to abdominal ultrasonography and computed tomography results after three years; mean residual cyst diameter was 2.6 ± 0.7 cm. The cysts in the liver were disappeared in the thirteen cases. All of the remaining cysts were considered inactive (12 cases had CE4 cyst and 13 cases had CE5 cyst). Conclusion: Minimally invasive treatments for hepatic hydatid cysts can be effectively and safely performed. There has no recurrence and important complication. Minimally invasive methods may be an alternative to open surgery for selected patients.

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Surg Endosc

P540 - Morbid Obesity

P542 - Vascular Surgery

EIGHT-Year Results of Laparoscopic Sleeve Gastrectomy 1

1

2

A Clinical Investigation of Subfascial Endoscopic Perforator Surgery for Management of Chronic Venous Insufficiency (Class 6)

2

N. Schoucair , J.M. Catheline , R. Dbouk , Y. Bendacha , C. Bonnel2, R. Romero2 1

Centre Hospitalier de Saint denis - Hopital Delafontaine, SAINT DENIS, France; 2Centre Hospitalier de Saint Denis, SAINT DENIS, France Aims: It is an evaluation of the efficacy and safety of Sleeve Gastrectomy (SG) at 8 years follow-up. Patients and methods: From May 2004 to November 2006, 64 patients underwent a SG. Percentage of EWL and EBL, as well as co-morbidities, gastroesophageal reflux disease (GERD), and complications were evaluated at 2 years after SG according to a retrospective study using our prospectively collected database. Results at 8 years were then evaluated according to a patient survey conducted between April 2013 and December 2014. Results: A complete record was obtained for 55 patients (85.9%) including 45 patients who only had a SG and 10 who had a second bariatric procedure (7 gastric bypasses, 3 revisional SG). The mean %EWL of 55 patients was 58.4 at 2 years and 52.1 at 8 years; the mean %EBL was 65.1 at 2 years and 57.2 at 8 years. Three patients (5.5%) had postoperative complications: 2 fistulas (3.7%), 1 hemorrhage (1.9%). The sub-group analysis of 45 patients who only had a SG presented a mean %EWL of 59.1 at 2 years and 50.3 at 8 years; the mean %EBL was 66.1 at 2 years and 54.2 at 8 years. For these 45 patients we found a favorable evolution of comorbidities at 8 years follow-up: diabetes decreased of 53.9%; hypertension decreased of 47.1%; dyslipidemia decreased of 50%; sleep apnea syndrome (SAS) decreased of 68%. But GERD increased of 200%. Conclusions: At 8 years post-SG, weight loss and reduction of comorbidities were satisfying. The rate of complications was low but the frequency of GERD was increased.

P541 - Oesophageal and Oesophagogastric Junction Disorder Proximal Gastrectomy with ‘Double-Shoulder’ anchoring of Remnant Stomach to Diaphragm as an Antireflux Procedure After Esophagogastrostomy A. Ben Yehuda1, Y. Kim2

L.B. Malynovska, V.G. Mishalov, V.M. Selyuk, A.V. Dinets O. O. Bogomolets National Medical University, KYIV, Ukraine Aim: to investigate and evaluate the efficacy of subfascial endoscopic perforator surgery (SEPS) for management of patients with chronic venous insufficiency (CVI) with legs ulceration (class 6). Materials and methods: There were identified 52 patients (19 males, 33 females) with CVI associated with legs ulceration (class 6) who underwent surgical or conservative treatment at the Department of Vascular Surgery at Olexandrivska Teaching Hospital (Kyiv, Ukraine). These individuals were diagnosed with class 6 leg ulceration associated with the dilation and malfunctioning valves of tibial perforator veins. The diagnosis was confirmed by duplex ultrasonography. Patients in the study group (n = 34) reported a history of phlebectomy 10-20 years ago, failed conservative therapy[6 months and underwent SEPS under the spinal anesthesia. Patients in the control group (n = 18) received only conservative therapy. Results: At follow up of 6 month the ulcer healing was observed in 32 (94%) patients after SEPS, which was more frequent as compared to 11 (61%) patients in control group (p = 0.012). Conclusion(s): SEPS is an effective tool for surgical treatment of patients with CVI associated with ulceration and with history of phlebectomy.

P543 - Abdominal Cavity and Abdominal Wall The Use of Antiadhesive Gel in Patients with Chronic Gallstone Disease and Hital Hernia M.M. Halei1, I. Shavarov1, K.M. Halei2, I.Y. Dzyubanovsky2, I.O. Babin1 1

N.C.C Ilsan, Republic of Korea, ILSAN, Republic of Korea; NCC Gastric Branch, ILSAN, Republic of Korea

Volyn Regional Clinical Hospital, LUTSK, Ukraine; 3SHEI I.Ya.Horbachevskyi Ternopil State Medical University, TERNOPIL, Ukraine

Background: The optimal reconstruction after proximal gastrectomy (PG) remains an elusive riddle. The main concern comes from the high rate of gastroesophageal (GE) reflux symptoms related to this reconstruction. Aim of this study is to report a new technique and the early outcome. Methods: We created a modification for the esophagogastrostomy(EG), that has been recently implemented, of anchoring the gastric walls to the diaphragm, and by that creating a neo-double His angle and fundus which looks like ‘double shoulder’ (DS). In this retrospective preliminary series of 11 patients undergoing this procedure between April 2012 and February 2015 we present the patients in-operative and clinical outcome with comparison to classic esophagogastrostomy reconstruction and the double tract(DT) reconstruction operated on the same study time scale in our institution. Results: 8/11 cases were operated by laparoscopic approach. Mean age was 68.64 ± 11.6 Operative time was 211 ± 60. EG anastomosis was done with the use of circular stapling technique. Postoperative complication were 2 cases of grade 2 Clavien Dindo (CD), and 2 cases of grade 3a CD. No grade 3b or higher complications were recorded. The mean length of stay was 11.3 ± 5.8 days. Seven patients (63.6%) had no reflux symptoms in the clinics follow up, while 4 had mild reflux symptoms without hampering normal life and only 1 patient necessitating pharmacologic treatment (9%). No postoperative esophagitis was noticed on esophagodeudenoscopy among the DS group. Conclusion: The ‘Double-Shoulder’ anchoring technique is a safe and simple technique without prolonging neither operative nor postoperative course and may prove to reduce reflux symptoms after PG. Further evaluation of DS-PG is warranted.

Introduction: Increasingly in postoperative period patients, who underwent to simultaneous surgery on the gallstone disease (GD) and hital hernia (HH), are worried about the pain that is caused by the formation of adhesive connections in the abdominal cavity. Postoperative patients take painkillers and antispasmodic remedy that bring temporary symptomatic effect. By clinical trial, it was found that this pain has adhesive connections’ origin. This prompted us to lead in antiadhesive gel into the abdominal cavity in the end of the procedure. Aim: To prevent the formation of adhesive connections in the abdominal cavity which causes postoperative pain. Patients and methods: 1758 patients with GD were operated between 2009 and 2015, within 52 (2.95%) had the combination of GD and HH. Among this 52 persons with combined GD and HH pathology: male - 9 (17.5%), female - 43 (82.5%). The average age of patients was 53.14 years. These patients were divided into two groups: the first (14 patients - 24.56%) had the antiadhesive gel put into the abdominal cavity, the second (38 patients - 75.44%) were operated without putting into the antiadhesive gel into the abdominal cavity. Results: The use of the antiadhesive gel Defensal (Yuria-Farm) in the first group of patients prevented the formation of adhesive connections in the abdominal cavity. As a result, there was no abdominal pain in the whole first group of patients. Conclusions: The use of antiadhesive gel can be the alternative way in healing and preventing the formation of adhesive connections in the abdominal cavity after the surgions, so that no pain syndrom will occur in postoperative period.

1

2

123

Surg Endosc

P544 - Abdominal Cavity and Abdominal Wall

P546 - Liver and Biliary Tract Surgery

The Effect of Number of Tack on Mesh Infection in Totally Extraperitoneal Inguinal Hernia Repair

Simultaneous Laparoscopic Procedures in Patients with Gallstone Disease and Inguinal Hernia

K.R. Kim, B.D. Chae, K.H. Park, K.M. Hong

M.M. Halei1, I.Y. Shavarov1, K.M. Halei2, I.Y. Dzyubanovsky2, I.O. Babin1

Daedong hospital, BUSAN, Republic of Korea

Volyn Regional Clinical Hospital, LUTSK, Ukraine; 2SHEI I.Ya.Horbachevskyi Ternopil State Medical University, TERNOPIL, Ukraine

1

Aims: Totally extraperitoneal (TEP) inguinal hernia repair is common surgical procedure in repairing inguinal hernia. It is known that serious complications from this technique are infrequent, especially mesh infection. The aim of the present study was to evaluate the correlation between the number of tacks used in fixation of mesh and mesh infection. Methods: From April 2010 to March 2013, 95 consecutive healthy patients (87 men and 8 women) underwent TEP procedure. All cases were performed by using standard TEP techniques. The preoperative data, including patient age, sex, body mass index (BMI), hernia characteristics, operation time, complication, length of hospital stay, time until return to full activity and pain score were prospectively collected. Results: A total of 47 TEP repair by using more than 3 tacks were performed in 35 patients and compared with 77 TEP repair by using 3 tacks or fewer in 60 patients. The mean pain score 24 h postoperatively in the more than 3 tacks group was significantly higher than the less tacks group. (3.6 ± 1.8 vs. 2.1 ± 1.7 p = 0.01) 2 cases of the mesh infection were only occurred in the more than 3 tacks group. (5.7% vs. 0%) Other perioperative parameters were comparable between two groups. Conclusion: By using less tacks on fixation of mesh on standard TEP repair, less traumatic procedure appears to cause the lower inflammatory response and to be the less traumatic approach to hernia repair comparing TEP procedure which had used more than 3 tacks.

Introduction: Gallstone disease (GD) is consequential pathology in surgery that lowers patients’ quality of life and decreases working capacity. Often this disease is combined with inguinal hernia (IH). Such patients, that have a combination of GD and IH, we mark out as a separate category. Aim: to carry out the one-stage surgical solution of GD and IH. Patients and methods: 1758 patients with GD were operated between 2009 and 2015, within 27 (1.53%) had the combination of GD and IH. Among this 27 persons with combined GD and IH pathology: male - 23 (85.18%), female - 4 (14.82%). The average age of patients was 53.14 years. These patients were divided into two groups: the first (5 patients - 18.51% respectively) earlier had diferrent surgery(ies) on the abdominal cavity, the second (22 patients - 81.49%, respectively) were operated for the first time. Results: Surgeon demands more time to operate the first group of patients while to do the same manipulations with in the second group patients occupies less time (95 min and 60 min, respectively). Although this division did not play a significant role in the scheme of arrangement of ports for input of working tools and the passage of postoperative period. Conclusions: Simultaneous surgery of combined pathology (GD and IH) significantly alleviates the number of surgical perturbations in patients of this category, which is reverberated in hastening the recovery of working capacity and providing the highest level of quality of life after surgery. This approach may be the method of choice for this combination of pathologies.

P545 - Intestinal, Colorectal and Anal Disorders

P548 - Morbid Obesity

Handmade Intraluminal Vacuum Therapy System Using for Anastomotic Leakage After Laparoscopic Low Anterior Resection

ACTIVE Search for Hiatal Hernia in Laparoscopic Sleeve Gastrectomy - A Surgical Protocol

M. Ozer, M. Ince, H. Sinan, S. Demirbas, O. Kozak

Ponderas Hospital, BUCURESTI, Romania

Gulhane Military Medical Academy, ANKARA, Turkey

Background: The prevalence of gastro-esophageal reflux disease (GERD) and hiatal hernia(HH) is significantly higher in morbidly obese patients. Up to 40% of morbidly obese patients have hiatal hernia. In the literature some studies demonstrated that after gastric sleeve alone, de novo GERD occurs in 22,9% of patients, but after gastric sleeve and hiatal hernia repair the postoperative GERD is significantly reduced. Moreover, despite a careful preoperative work-up, HH is still underdiagnosed in the obese patients proposed for a bariatric procedure. Aim: The aim of this study is to demonstrate the importance of intraoperative active dissection and identification of a potential undiagnosed hiatal hernia in the obese patients proposed for laparoscopic sleeve gastrectomy (LSG) . Method: From a prospectively maintained database of Ponderas Hospital - Center of excellence in Bariatric and metabolic surgery we studied 2247 patients who underwent laparoscopic sleeve gastrectomy in a period of 3 years, beginnig with January 2013 untill December 2015. We present the cases with patients who underwent laparoscopic gastric sleeve and concomitant hiatal hernia repair. From all patients, 696 (31%) were diagnosed preoperatively with hiatala hernia and 534 (24%) were diagnosed intraoperatively with hiatal hernia. A total of 1230 (54%) benefited of concomitant hiatal hernia repair. Results: Time of surgery is higher for laparoscopic sleeve gastrectomy (LSG) and simultaneous hiatal hernia (HH) repair comparing with simple laparoscopic sleeve gastrectomy. We did not have important intraoperative accidents. Follow-up of the patients was from 3 months to 36 months. After LSG with HH repair, 73 patients were diagnosed with gastroesophageal reflux disease (5,9%). Dysphagia for solids was present at 1 month in 85 patients (7%), but ameliorated at 3 months and resolution at 6 months except 4 patients. We had 9 recurrences (0,71%) and 4 cases of stenosis (0,32%). Conclusion: Hiatal hernia can be missed preoperative, therefore active identification of a potential hiatal hernia is appropriate, crural closure in addition to gastric sleeve in this obese patients provide good outcomes in terms of GERD symptoms control, weight loss and therefore should be included as a surgical protocol.

Anastomotic leakage is an important postoperative complication after laparoscopic rectal surgery with an incidence of 5–15% and increases morbidity and mortality. The intraluminal vacuum therapy system is used in order to drain sepsis, favor granulation and secondary closure of defects. It is indicated in anastomotic leaks in presence of an extraluminal cavity. Because of the system is expensive we use our handmade system. The aim of this study is evaluate the effect of our handmade system on the outcome of patients with anastomotic leakage after laparoscopic low anterior resection. We reviewed patients with anastomotic leakage and treated handmade intraluminal vacuum therapy system. Leaks diagnosed with direct endoscopic exploration and CT scan in all cases. We make our intraluminal vacuum system using Nelaton catheter and a piece of polyurethane sponge that taken from VACTM system. The sponge can be prepared appropriate size for the cavity. The sponge prepared is attached to tip of the Nelaton catheter by using a prolene suture. The system is connected to vacuum generator after sponge is placed in the cavity. Between 2013 and 2015, 6 patients with diverting stoma (5 males and 1 female; median age 62 years old) and leakage of a colorectal anastomosis were treated with mean 14 times intraluminal vacuum therapy. Healing was observed mean 59 days. Conventional operative management of a colorectal anastomotic leak includes explorative laparotomy, peritoneal lavage and diverting stoma, but surgical management leads to a relatively high mortality and morbidity rate. Handmade intraluminal vacuum therapy for anastomotic leaks can prefered as an alternative method to operative management in clinically stable and suitable patients.

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I.C. Hutopila, C. Copaescu, B. Smeu

Surg Endosc

P549 - Robotics, Telesurgery and Virtual Reality

P551 - Morbid Obesity

Robotic Assisted Versus Pure Laparoscopic Adrenalectomy: A Case-Matched Study

Laparoscopic Sleeve Gastrectomy as a Treatment of Morbidly Obese Patients Prior to Waitlisting for Kidney Transplantation

S. Guadagni1, D. Tartaglia1, A. Gennai1, J. Bronzoni1, G. di Franco1, M. Palmeri1, G. Caprili1, C. D’Isidoro1, A. Pietrabissa2, G. Di Candio1, F. Mosca1, L. Morelli1

¨ fner-Velano, K. Kienzl-Wagner, P. Gehwolf, A. Weissenbacher, D. O H. Wykypiel, S. Schneeberger Innsbruck Medical University, INNSBRUCK, Austria

1

University of Pisa, PISA, Italy; 2University-Hospital Polyclinic of San Matteo, PAVIA, Italy

Aim: The role of da Vinci System in adrenal gland surgery is not well-defined yet. This case–controlled study aims to compare robotic assisted surgery with pure laparoscopic surgery, in the authors’ mono-centric experience. Materials and Methods: 116 patients underwent minimally invasive adrenalectomies in our Department between June 1994 and December 2014: 75 with pure laparoscopic surgery (LS), whereas 41 with da Vinci robotic system (RS). This case-controlled study was performed comparing 19 patients operated with RS and 19 operated with LS according to BMI, age, laterality and neoplasia dimensions. The two groups were compared for clinical and surgical data. Patients of each group were divided in subgroups according to nodule dimensions (\3 cm, between 3 and 6 cm, = 6 cm). Statistical analysis was performed with Student’s t-test for independent samples. Value of p \ 0.01 was considered significant. Results: The laparoscopic group of this case-controlled study showed a significant increase of operative time in patients with malignancy, in those with BMI = 30 kg/m2 and with nodules [6 cm (p \ 0.01). This trend was not evidenced in the robotic group (p = NS). The direct comparison between RS and LS did not reveal differences in the operative time with nodules \3 cm or between 3 and 6 cm, whereas with nodules = 6 cm the robotic group operative time resulted significantly lower compared to the laparoscopic group (163.3 vs. 276.4 min; p \ 0.01). Conversions to open surgery were 2 for the laparoscopic group and 0 for the robotic group. Post-surgical complications were 2 and 0 respectively. No reoperations or deceased patients occurred. Conclusions: In our experience, robotic system in adrenal gland surgery shows potential benefits compared to classic laparoscopy in patients with malignancy, BMI = 30 kg/m2 and neoplasia [ 6 cm.

Aims: The prevalence of obesity and obesity related morbidity in end-stage renal disease patients is rising. While it is established that obesity does not negatively influence the benefit achieved through transplantation with respect to lower long-term mortality and cardiovascular risk, obesity is associated with increased graft failure, delayed graft function, surgical site infection, prolonged hospital stay and costs. Methods: We herein report a two step approach for morbidly obese renal transplant candidates. Patients with end-stage renal disease and a BMI of 35 kg/m2 or higher underwent laparoscopic sleeve gastrectomy. After sustained weight loss and a BMI of less than 35 kg/ m2, patients were waitlisted for kidney transplantation. Results: Laparoscopic sleeve gastrectomy was performed in 7 morbidly obese renal transplant candidates with a mean BMI of 38.6 kg/m2. BMI dropped below 35 kg/m2 within a median of 3 months. Excess body mass index loss (EBMIL) was 63.4% at 1 year after the bariatric procedure. Within a mean of 17 months from bariatric surgery 6 patients underwent successful kidney transplantation with good renal function and a serum creatinine of 2.0 ± 0.8 mg/dl at discharge. One patient is waitlisted for transplantation. Conclusion: Laparoscopic sleeve gastrectomy may be a safe and efficacious weight reduction strategy in morbidly obese renal transplant candidates. Rapid weight loss and subsequent waitlisting of kidney transplantation may reduce the overall and in particular the post-transplant patient morbidity.

P550 - Liver and Biliary Tract Surgery

P552 - Gastroduodenal Diseases

Single Center Experience with Ultrasound Guided Percutaneous Cholecystostomy for the Management of Acute Cholecystitis

The Reconstruction After Totally Laparoscopic Distal Gastrectomy by the Argmented Rectangle Technique

R. Mourelatou, I. Gomatos, A. Marinis, H. Moschouris, A. Apostolopoulos, M. Drakopoulou, I. Kougia, N. Paschalidis

K. Shigemitsu, A. Urakami, M.T. Takaoka, T. Yamatsuji, J.H. Hayashi, K.Y. Yoshida, N.I. Ishida, Y.N. Naomoto

Tzaneio General Hospital, PIRAEUS, Greece

Kawasaki medical school, OKAYAMA, Japan

Aims: To present a single center experience with ultrasound guided Percutaneous Cholecystomy (PC) for the management of acute cholocystitis (AC) in elderly patients, with elevated surgical risk. Methods: Treatment was according to the 2013 Tokyo guidelines. Patient characteristics, outcomes, procedure-specific complications, morbidity and mortality rates, were retrieved from patient records and retrospectively evaluated. Results: A total of 657 AC patients were admitted in our Surgical Department between 2009 and 2015. Thirty seven patients (6%) were allocated to PC (group A), 72 (11%) were submitted to emergency cholecystectomy (group B) and 548 (83%) recieved concervative treatment (group C). All group A patients were elderly ([80 yrs old) with severe anesthetic risk (ASA score = III), who failed to improve after 48 h of conservative treatment. In another 2 patients, where PC was not technically feasible, conservative treatment was initiated (patients allocated in group C). There were 8 deaths (21.6% mortality rate) in the PC group of patients, all of whom failed to improve despite successful PC. Procedurerelated bleeding was observed in 2 patients (5.4%), in 3 patients (8.1%) the percutaneous catheter was inadvertently dislocated, in 2 patients the catheter was obstructed (5.4%) in 1 patient (2.7%) pericholecystic fluid collection (8/37, 21,6%morbidity rate). Conclusion: Percutaneous Cholecystostomy is a useful damage control approach offering urgent decompression of the infected gallbladder, bailing out patients from the dreaded outcomes of severe sepsis. Severe comorbidity apologizes for the increased mortality and morbidity rate in this group of patients.

Recently, laparoscopic gastrectomy has become popular for the treatment of early gastric cancer. But reconstruction after laparoscopic gastrectomy is often performed extraabdominally or under small incision because intraabdominal anastomotic procedure is complex. At our institution, we introduced the laparoscopic surgery for early gastric cancer in 2012. Reconstruction after laparoscope-assisted distal gastrectomy had been carried out in Billroth? method using circular stapler with a small laparotomy. As we start totally laparoscopic distal gastrectomy in 2014 for less invasive surgery, we introduced argmented rectangle technique (ART), a intraabdominal Billroth anastomosis using endoscopic linear staplers. First, the the 45-mm endoscopic linear stapler is inserted with one jaw in each small incision created on the greater curvature side of the remnant stomach and duodenum. The posterior wall of the stomach and duodenum are put together and cut. A V-shaped anastomosis is made on the posterior wall. Consequently, the common stab incision is closed with two applications of the linear stapler. The duodenal separating line which is prone to ischemia is also resected at the same time as the third fire. The advantages of this procedure are wide anastomosis caliber due to rectangle shape and the normal duodenal passage of food. We performed this procedure for 11 cases, and found that pitfall of this method is stenosis caused by tearing the entry hole of duodenum. This surgical procedure is simple and safe by careful manipulations with caution on that point.

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P553 - Amazing Technologies

P555 - Amazing Technologies

Reinforced Reload Endogia with Tri-Staple. A Good Concept for Pancreatectomy Resection

Technical Aspects and Results of Robotic- Assisted Operations on the Pancreas

C. Lara Palmero, D. Sanchez Relinque, L. Elmalaki Hossain, S. Gomez Modet, L. Tejedor Cabrera

A. Kaldarov, A.G. Kriger, S.V. Berelavichus, D.S. Gorin, A.V. Smirnov

SAS, ALGECIRAS, Spain

A.V. Vishnevsky Institute of Surgery, MOSCOW, Russia

Introduction: The laparoscopic approach is a safe and effective technique in distal pancreatectomy (DP) for resection of benign and malignant lesions (borderline) tail of the pancreas. Complications include abscess, bleeding and fistula 8–27%. Different studies have concluded from 0 to 64% of pancreatic fistulas and a conversion of 12%. Clinical case: four cases laparoscopic surgical of tumor in the tail of pancreas are presented, using Endo GIA tri-staple for the pancreatic parenchyma section. Results: The surgery was completed without incident, with an average surgical time of 150 min. The postoperative was favorable in the four patients without pancreatic fistula or postoperative complications, with an average hospital stay of 5.5 days. Pathology reports were a serous cystadenoma, pseudopapillary tumor, neuroendocrine tumor, papillary tumor. Conclusions: The laparoscopic approach is a safe choice for DP. The use of Endo GIA Reinforced Reload with Tri-Staple delivers an added measure of confidence without any additional steps. The synthetic material is absorbent and soft, while the preloaded feature saves time and waste, it has been effective in terms of complications of pancreatic fistula or bleeding in our series. It is necessary a higher number of cases to be considered as statistically significant.

Aim of research: To improve results of pancreatic diseases treatment. Materials and methods: 70 patients with staging and survival data after robotic - assisted procedures on pancreas performed in A.V. Vishnevsky Institute of Surgery in the period from 2010 to 2015. Results: Mean operation pancreaticoduodenectomy time was 463.1 ± 111.1 min, distal pancreatectomy - 215.3 ± 67.1, central resection - 253.0 ± 37.7, enucleation 150.0 ± 49.0 min. Blood loss volume was 335.7 ± 128.2 ml in pancreaticoduodenectomy group, 274.2 ± 11.3 ml in distal pancreatectomy. Postoperative complications occurred in 26 (37.1%) patients, most of them were postoperative pancreatic fistula 21 patients, gastro stasis 3 and postpancreatecomy hemorrhage 2. There were two mortal cases due to acute severe pancreatitis in ARDS in one case and in the second case of postpancreatecomy hemorrhage. Conclusion: Although robotic assisted pancreatic surgery is a reasonable option for patients with malignant tumors T1–T2, neuroendocrine and benign tumors less than 5–6 cm it doesn’t prevent specific postoperative complications.

P554 - Amazing Technologies

P556 - Amazing Technologies

A New and Safe Open Access Technique for the First Trocar in Laparoscopic Surgery

Technical Aspects and Results of Robotic-Assisted Distal Pancreatectomy

O.V. Ozkan1, S. Uranues2, G. Tomasch2

A. Kaldarov, A.G. Kriger, S.V. Berelavichus, D.S. Gorin, A.V. Smirnov

1

Sakarya university, Faculty of Medicine, SAKARYA, Turkey; Medical University of Graz, GRAZ, Austria

2

Despite modern developments in techniques and surgical equipment, the search continues for an optimal method of placing the first trocar. This is because potentially preventable intra-abdominal injuries must be avoided. We enter the abdomen through a vertical incision, which is the most appropriate region. The first trocar will be placed after dissection of the abdominal wall layers between two Kocher clamps without any potential of injury. The fascia will be tightened with a tourniquet in order to prevent any gas leak. No damage to an intraabdominal organ caused by entry of the first trocar has been noted in any patient. The technique is easy to learn, and neither prolongs surgery nor increases the cost of surgery. The method is easily and rapidly applicable in even obese patients. It can facilitate introduction of materials into the abdominal cavity and removal of specimens without time loss. Gas leakage during surgery is easily and effectively prevented.

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A.V. Vishnevsky Institute of Surgery, MOSCOW, Russia Aim of research: To develop technique of distal pancreatectomy using robotic surgical complex and estimate its efficiency. Materials and methods: During the 6 years period 38 patients underwent robotic assisted distal pancreatectomies in A.V. Vishnevsky Institute of Surgery. Results: Spleen saving operations were performed in 24 cases. The indications were benign or low grade malignancy potential tumors. Procedures with splenectomy were performed in 14 cases with ductal adenocarcinoma or when there was no technical opportunity of spleen preserving. Operation time - 215.3 ± 67.1 ml; blood loss - 274.2 ± 11.3 ml, number of lymph node harvest – 15–21. Postoperative complications arose in 14 (36.8%) cases, there were 18 postoperative complications. There was one death because of severe pancreatitis. Conclusion: Indications for performing robotic assisted distal pancreatectomies are malignant tumors T1–T2, neuroendocrine and benign tumors with size not more than 5–6 cm. Use of robotic complex doesn’t prevent specific postoperative complications.

Surg Endosc

P557 - Amazing Technologies

P559 - Amazing Technologies

Consequences of Ergonomics in the Operation Room: An Online Survey Among Dutch Surgeons

Laparoscopic Surgery and the Surgeon is in Sitting Position is Better Than Robotic and Standard Laparoscopic Surgery

S Janki, E.E.A.P. Mulder, J.N.M. Ijzermans, T.C.K. Tran

M Hussein

Erasmus MC, ROTTERDAM, Nederland

American University of Beirut Medical Center, BEIRUT 1107 2020, Lebanon

Since the introduction of minimal invasive surgery, surgeons seem to suffer more frequently from occupational musculoskeletal injuries. The aim is to investigate frequency and effects of these injuries on work leave. A questionnaire was conducted among members of the Dutch Societies for Endoscopic Surgery, Gastrointestinal Surgery, and Surgical Oncology, and surgeons/gynecologists/ urologists of one Dutch general surgical training region. There were 127 respondents. Fifty-six surgeons currently suffer from musculoskeletal complaints and 30 have previously suffered with no current complaints. Frequent localizations were neck (39.5%), erector spinae muscle (34.9%), and right deltoid muscle (18.6%). Currently, 37.5% uses medication and/or therapy to reduce complaints. Of surgeons with past complaints, 26.7% required work leave, and 40.0% made intraoperative adjustments. More surgeons with a medical history of musculoskeletal complaints have current complaints (OR 6.1; 95%CI 1.9–19.6). There were no significant differences between surgeons of different operating techniques in localizations and frequency of complaints, or work leave.

Background: The advantages of Robotic surgery in comparison to standard laparoscopic surgery is the ability to do surgery in sitting position and 3D view and the ergonomic of movement and third hand assistance, disadvantages is one field surgery, extra expenses, the elongated time and absence of tactile sensation and the disadvantages of standard laparoscopic surgery is increased musculoskeletal complaint. Aim: Laparoscopic surgery is feasible in the sitting position and can maintain all the advantages of standard laparoscopies and avoid the disadvantages of Robotic surgery. Project Description: I report my experience in the field of Laparoscopic surgery at the American University of Beirut Medical Center and affiliated hospitals where I shifted all laparoscopic procedures including Bariatric procedures to sitting position with 100% completion of the procedures more than 900 cases. Preliminary Results: Laparoscopic sitting position will allow you to do long list surgery with decreased muscle fatigue, back and knee pain.

P558 - Amazing Technologies

P560 - Amazing Technologies

Cephalo-Medial to Lateral Laparoscopic Total Mesorectal Excision for Rectal Cancer

Hybrid Single-Incision Laparoscopic Appendectomy: Initial Experience OF 11 Patients

J.J. Ma, M.H. Zheng, J.Y. Lu, H.J. Hong, A.G. Lu, L. Zang, F. Dong, B. Feng, Y.P. Zong

A. Nagpal

Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, SHANGHAI, China. Background: There are a series of technical hurdles in the conventional medial-to-lateral approach total mesorectal excision for rectal cancer. Aim: was to develop a modified, cephalo-medial-to-lateral (CML) approach to facilitate the procedure in terms of surgical plane identification, vascular ligation and lymph nodes dissection. Project description: This was a retrospective study. 82 consecutive patients who underwent TME through either the conventional medial-to-lateral approach or the CML approach were included in this study. Results: All laparoscopic surgeries were completed successfully without conversion or intraoperative complications. The CML approach increased the yield of station 253 lymph nodes from an average of 1.9 ± 1.1 in each patient in the conventional group to 3.5 ± 2.4, although the total lymph nodes harvested were similar (17.0 ± 4.7 18.6 ± 7.7, respectively). In addition, metastatic 253 nodes were found in 1 case in the CML approach group. The CML also allowed individualized preservation of the left colic artery without comprising lymph nodes dissection.

Anya Gastro Surgicentre, AHMEDABAD, India Introduction: Single-incision laparoscopic surgery (SILS) is a well-described technique for many general surgical procedures. The data related to SILS related hernias are yet not available. This report describes a technique of hybrid single-incision laparoscopic appendectomy (Hybrid SILA) for acute appendicitis. Methods: Patients with non-complicated acute appendicitis underwent SILA. The procedure was performed using umbilical scar for two 5 mm ports and a single 5-mm-diameter suprapubic incision. Results: We performed SILA in 11 patients during June 2012 till August 2015. There were 8 women and 3 men with a mean age of 22.09 years. The mean operative time was 50 min. One patient developed minor wound infection and the median hospital stay was one day. Conclusion: The Hybrid SILA technique is safe and feasible for selected patients with non complicated acute appendicitis. Compared with other transumbilical techniques of SILS, Hybrid SILA has the advantages of feasibility and an acceptable operative time.

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Surg Endosc

P561 - Amazing Technologies

P563 - Amazing Technologies

Abdominal Complaints After Sigmoid Resection Underestimated: Multicenter Study on Quality of Life After Surgery for Carcinoma of Rectum and Sigmoid

OUR Experience with Mini Grip (Teleflex) Laparoscopic System

M. van Heinsbergen1, J.W. Leijtens2, G.D. Slooter3, M.L. Janssen-Heijnen4, J.L. Konsten4 1

Viecuri Medisch Centrum Venlo, VENLO, The Netherlands; Laurentius Ziekenhuis, ROERMOND, The Netherlands; 3Maxima Medisch Centrum, VELDHOVEN, The Netherlands; 4VieCuri Medisch Centrum, VENLO, The Netherlands

2

Background:Low Anterior Resection Syndrome(LARS) severely affects quality of life (QoL) after rectal cancer surgery. Data are lacking for sigmoid resection. Aim: Investigation of LARS and QoL after surgery in patients with sigmoid cancer versus rectal cancer. Project description: 501 patients after resection for rectal or sigmoid cancer between 2008 and 2013 who were at least one year colostomy-free were included. Bowel function was assessed using the LARS-Score, QoL by EORTC-QLQ-C30 and -CR29 questionnaires. Potential risk factors were tested in multivariable analysis. Preliminary results: Interim-analysis (n = 343) showed Major LARS decreasing significantly with increasing tumor height from 90% in low rectum carcinoma to one fifth in sigmoid carcinoma. Lower anastomotic height and temporary diverting colostomy were significant risk factors for major LARS. Those patients fared worse in many QoL domains. Conclusion: Functional abdominal complaints after sigmoid surgery are a major problem, with a potential effect on QoL that should be further investigated.

N. Kontoravdis, I. Papanikolaou, P. Tavlas, I. Makris, K. Dogramatzis, N. Salemis General Army Hospital of Athens, ATHENS, Greece Innovative laparoscopic surgical instruments were succesfully or not, used in the past in order to minimise trauma and immume response to surgical patients. The less invasive Mini Grip system was tried from our laparoscopic team during the last year, to find out pros and cons of its use. We used the system performing mainly laparoscopic cholecystectomies substituting the non dominant surgeon forceps with Mini Grip. In all instanses our effort was to complete the operation with three trocars (11-5-2,4 mm) without compromise safety. We did’t exclude distended gallbladers from our study to deliniate the efficacy of the system. In every case where safety was at risk we converted to formal laparoscopic instrumentation. Finally we performed 36 out of 48 gallblader removals, with variable degree of complexity using all forms of grasping tips available for the system. Our success rate, recommentations and review are available.

P562 - Amazing Technologies

P564 - Amazing Technologies

Medical Apps - How They Will Change Your Practice

Successful Treatment of Biliary Sump Sundrome with the Help of Robotic Technology

P.A. Wetter SLS, MIAMI, United States of America Advances in materials science and miniaturization along with over nine million app developers worldwide is about to change the practice of medicine in a big way. Many changes will come from outside traditional medicine that will disrupt medical practice as we know it in the same way Uber, Amazon and Apple have disrupted Taxis, Books and Music. My role as a developer of educational materials on the Apple format was unique until recently. Thousands of Medical Apps are being designed to work with every kind of scientific and medical sensor you can imagine. Medical Apps and the advanced computer chips in our cell phones represent a giant leap for mankind and it is very exciting to live and work at a time when this is happening with big implications for healthcare including surgery.

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V.A. Iyoob Ali Aster MEDCITY, KOCHI, India Sump syndrome following side to side bilioenteric bypass is well known. A 56 year-old lady with sump syndrome presented at our department after multiple failed ERC treatment. She underwent dismantling of choledochoduodenostomy, excision of lower CBD and creation of end to side Roux-En-Y hepaticojejunostomy with the help of daVinci Robot. This video demonstrate how to create hepaticojejunostomy- one of the most difficult anastomosis by minimally invasive technique, much easly by the help of a newer technology, i.e., da Vinci Robot. Robotic technology is highly useful for difficult anastomosis to be performed by minimally invasive technique.

Surg Endosc

P565 - Amazing Technologies

P567 - Amazing Technologies

Robotic Roux-En-Y End to Side Esophago-Jejunostomy Following D2 Gastrectomy for Carcinoma Stomach

Transanal Resection of a Neuroendocrine Rectal Tumor. A Safe Technique

V.A. Iyoob Ali

A. Forero Torres, B. Die´guez Ferna´ndez, M. Losada Ruiz, C. Gilsanz Martı´n, A. Alonso Poza

Aster MEDCITY, KOCHI, India Total gastrectomy with D2 lymph node dissection is one of the surgical treatments for carcinoma of the stomach. Creation of esophago-jejunal anastomosis is difficult when this procedure is performed by minimally invasive technique. Robotic technology helps in performing this anastomosis much easly just like hand sewn. This video demonstrate how a successful esophago-jejunal anastomosis can be done using daVinic Robot without staplers. Robotic technology enable us to perform difficult minimally invasive esophagojejunal anastomosis much simply like a conventional technique.

P566 - Amazing Technologies Robotic Versus Laparoscopic Right Hemicolectomy with Intracorporeal Anastomosis R. Bravo1, R. Corcelles2, D. Momblan2, M. Ferna´ndez2, M. Jimenez2, A. Otero2, G. Dı´az del Gobbo2, A. Hessheimer2, S. Delgado2, A.M. Lacy2, B. De Lacy Oliver2 1

IMDiM, BARCELONA, Spain; 2Hospital Clinic Barcelona, BARCELONA, Spain Laparoscopic procedures in general surgery have been performed successfully for more than 20 years. Technical advances have also allowed for more complicated procedures, such as colorectal resections, to be performed safely by laparoscopy. In light of these advances, and favorable results seen, it seems clear that laparoscopic colectomy should be considered the gold standard. The use of robotic technology in laparoscopic procedures has been shown to be a safe and effective alternative to standard laparoscopic surgery, particularly when dealing with complex pathology. The success of robotic surgery should be based on confirmation of equal oncological safety and superior perioperative outcomes. However, to date, few clinical trials in the surgical literature have evaluated robot-assisted surgery, especially in the context of colonic cancer. In this video, we present technical details and discuss potential advantages of robot-assisted right hemicolectomy comparing with laparoscopic right hemicolectomy both with intracorporeal anastomosis.

Hospital Universitario del Sureste, MADRID, Spain Neuroendocrine tumors (NETs) are a heterogeneous group of tumors that arise in various anatomical sites. Rectal NETs are the most common. A 38-year-old woman, presented with proctalgia and mild rectal bleeding. Colonoscopy revealing a whitish nodule, located at 7–8 cm from the anal margin. Histopathology showed features compatible with a neuroendocrine carcinoid tumor. Pelvic MRI showed no abnormal lymphadenopathies. Endoscopic mucosal resection and polypectomy was performed. Histopathology report confirmed the presence of a neuroendocrine tumor involving the deep resection margin. We perform an excision by transanal approach. The histology report showed no evidence of residual malignancy. The treatment of rectal NET is determined by the size of the primary lesion. For lesions 1–2 cm in size transanal endoscopic microsurgery may be considered. Transanal endoscopic microsurgery allows the removal of lesions up to 20 cm from the anal margin; is a safe technique that in selected cases prevents major surgery.

P568 - Amazing Technologies A Novel Approach for Parastomal Hernia Repair : A Technical Note and First Results J. De Gols1, J. Knol2, G. Vangertruyden2 1

SFZ Heusden-Zolder, HEUSDEN-ZOLDER, Belgium; 2Jessa Hospital, HASSELT, Belgium Background and Aims: Keyhole repair for parastomal hernias (PSH) has an unacceptable high recurrence rate. We modified the Keyhole-approach by reinforcing the centre of the mesh with a hand-made funnel, directed in-to-out. Methods: The central opening in a flat prosthesis for PSH-repair has a tendency to become bigger as a result of shrinkage, often leading to recurrence. With a tubular mesh, the risk of stenosis occurs. Therefore, in our model, we aim to create an adaptable inner diameter by cutting triangular shaped flaps in the central opening. These flaps are directed in-to-out, so according to the direction of bowel peristalsis. By attaching a resorbable tubular prosthesis on the inside of these flaps chance of mesh erosion is minimized, the position is maintained and scarring on the flaps is allowed while normal tissue bridges are created inbetween the flaps. Dilatation remains possible when needed.

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Surg Endosc

P569 - Amazing Technologies

P571 - Amazing Technologies

Laparoscopic Retrieval of Gastric Denture

Safety and Feasibility of Reduced-Port Robotic Distal Gastrectomy for Gastric Cancer Using Single-SiteÒ

I.M. Geogloman, K. Orzechowska, S. Downey, K. Aryal James Paget University Hospital, GR. YARMOUTH, NORFOLK, United Kingdom In emergency surgical practice, the ingestion of a foreign body is not an uncommon presentation. Most of them, however, pass spontaneously. An interesting case is presented of a swallowed denture in a 60 year-old fit man which caused abdominal pain after it failed to progress beyond the stomach at 18 days post-ingestion. It was assessed as unsuitable for endoscopic extraction and was retrieved by laparoscopic surgery. Patient remained well at 5 weeks clinic follow up.

H.I. Kim, S.H. Lee, J.K. Kim, S.Y. Yang, T. Son, Y.M. Kim, W.J. Hyung Yonsei University College of Medicine, SEOUL, Republic of Korea Background: reducing the number of port could be attractive options for minimally invasive surgery for gastric cancer. Reduced-port robotic gastrectomy allows the surgeon to perform distal gastrectomy without restriction in the movement of surgical instruments using 2–3 ports. Aim: to assess the safety and feasibility of reduced-port robotic distal gastrectomy for gastric cancer Project description: this prospective phase II study included patients with EGC located distal third of the stomach. The primary endpoint was evaluation of in-hospital or 30 days morbidity and mortality following RDDG graded by Clavien-Dindo Classification. The secondary endpoints were operation time, blood loss, bowel recovery, and the length of hospital stay. Preliminary results: operation time, bleeding, number of retrieved lymph nodes, day of gas passing, hospital stay were 179.3 min, 28.7 ml, 47.9, 2.7 days and 5.4 days, respectively. No major complications, readmissions or recurrences were observed during a median of 10 month’s follow-up.

P570 - Amazing Technologies

P572 - Amazing Technologies

Laparoscopic Distal Splenorenal Anastomosis in Treatment Portal Hypertension Syndrome

Human Extensions: Designing an Ergonomic Human Interface for a Motorized Flexible Endoscope

I. Dzidzava, I.E. Onnitsev, B.N. Kotiv, S.A. Soldatov, A.V. Slobodyanik, A.V. Smorodsky

A. Szold1, M. Sholev2

Military Medical Academy, SAINT-PETERSBURG, Russia Background: Bleeding from varices of the esophagus and stomach is a life-threatening complication of portal hypertension syndrome. Aim: To study the possibility of DSRA performed by laparoscopic method. Materials and methods: In 2015 5 cirrhotic patients with portal hypertension underwent laparoscopic DSRA. All patients had a history of 2 to 3 relapses of esophageal and gastric variceal hemorrhage in spite of repeated courses of endoscopic ligation. Results: Isolation of splenic and the left kidney veins was performed using an ultrasonic scalpel Harmonic. End-to-side vascular anastomosis was performed by intracorporal continuous suture. Laparoscopic DSRA was supplemented with gastric devascularization. The maximum extent of blood-loss was 100 ml. Intraoperative complications were not observed. Follow-up EGD showed VES regression up to 1–2 degrees. Episodes of thrombosis of vascular anastomosis, recurrent esophageal-gastric bleeding and ascites were not observed. Conclusions:The first experience of laparoscopic DSRA demonstrated the possibility of its minimally invasive performance. .

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1

Assia Medical Group, Assuta Medical Center, TEL AVIV, Israel; Human Extensions, NETANYA, Israel

2

Background: Interventional flexible endoscopy is emerging as a growing field in surgery, with procedures potentially replacing traditional surgical equivalents. One of the strong barriers to the acceptance of complex flexible endoscopic procedures is the traditional design of the flexible endoscope, originally designed for diagnostic purposes only. Project and results: Using Human Extensions platform technology we have prototyped a motorized user interface that replaces the traditional one and allows for an instinctive manipulation of the flexible endoscope. Future directions: We believe that when further developed, a robotized flexible endoscope will allow a short learning curve and the wide use of the endoscope for complex endoscopic tasks.

Surg Endosc

P574 - Amazing Technologies

P576 - Amazing Technologies

The Insertion of a Percuatenous Endoscopic Sigmoidostomy Tube

Endoscopic Double-Layer Suture for the Gastrointestinal Wall Defect After Full-Thickness Resection

V. van Cubas, O. Adedeji NHS, BIRMINGHAM, United Kingdom Background: Traditional treatment options for sigmoid volvulus and pseudo-obstruction comprise endoscopic decompression and/or open resection. However, these management options have varying success with endoscopic decompression having a recurrence rate of approximately 40% and open resection may be contraindicated for frail, elderly patients or the severely immunocompromised. Aims: We present a video demonstration of insertion of a percutaneous endoscopic sigmoidostomy tube and a brief overview of possible problems and after care. Project Description: The main indications are recurrent sigmoid volvulus and chronic pseudo-obstruction. It may also be used for chronic constipation to administer enemas. Preliminary Results: Percutaneous endoscopic sigmoidostomy offers an alternative treatment for patients who have tried conventional treatment options without success. It is a safe procedure with minimal morbidity for commonly encountered problems often necessitating repeat hospitalisation. Please see the video: http://db.tt/LRev54SD or the you tube link: https://youtu.be/wD1b o1-toLE

B.R. Liu, J.T. Song The second affiliated hospital of Harbin Medical University, HARBIN, China Background: Successful closure of gastrointestinal (GI) wall defects is the key procedure following endoscopic full-thickness resection (EFR). Aims: To describe a new endoscopic closure method for gastrointestinal wall defects after EFR procedure similar to hand-sewn double-layer suture technique-endoscopic doublelayer suture (EDS) and evaluated the safety and efficacy of this method. Methods: 15 patients with GI tumors (13 of gastric subepithelial tumors, 2 of colonic lateral spreading tumors) underwent EFR, with the resulting full-thickness wall defects being closed using EDS technique. Description: The seromuscular and mucosal layers of wall defects were sutured separately by using endoclips with or without endoloops assistance during EDS procedure. Preliminary results: Successful en bloc resection and closure of wall defects were achieved in 15 cases (100%). EDS is relatively safe and effective method for repairing GI wall defects resulting from EFR. The new closure method mimics hand-sewn double-layer suture technique during surgical procedure.

P575 - Amazing Technologies

P577 - Amazing Technologies

Conversion Factors During Laparoscopic Treatment of Acute Gallstone Cholecystitis

Treatment of Recurrent Anal Fistula with Video-Assisted Anal Fistula Treatment (VAAFT)

M.A. Bourguiba, F. Souai, A. Khemir, G. El kebir, A. Ben Taher, Y. Ben Safta, S. Sayari, M. Ben Moussa

G. Giarratano1, C. Toscana1, E. Toscana1, M. Shalaby2, N. Di Lorenzo2, P. Sileri2

Charles Nicolle Hospital, TUNIS, Tunesia Background:The acute cholecystitis is a common complication of the cholelithiasis.The laparoscopic surgical approach is the gold standard with a relatively high rate of conversion. Aim: identify the main factors of Coelio conversion in the acute gallstone cholecystitis. Project description: It is a retrospective study including 300 consecutive patients who have been operated, between 2006 and 2012 for an acute gallstone cholecystitis. Preliminary results: the average age of the population was 52,7 years. The gender ratio was 0, 56. The rate of coelio conversion was 24,6%. The main causes of conversion were: the difficulty of dissection in 22% of the cases. The risk factors of conversion in a univariate analysis were an age [50 years, ASA [ II, male gender, duration of symptoms [72 h, CRP, leucocytosis [18000 and GII of TGS . In a multivariate analysis a rate of CRP [ 13.5 was the only risk factor of conversion.

Casa di Cura Villa Tiberia, ROME, Italy; 2Policlinico Universitario Tor Vergata, ROME, Italy

1

Aim: We report data of a prospective study designed to evaluate short and long-term outcomes of VAAFT (Video-assisted anal fistula treatment) in the treatment of recurrent anal fistula. Methods: Between 2012-2015, 30 consecutive patients with recurrent anal fistula were treated. All patients underwent previous surgery. All patients were evaluated for continence with Cleveland Clinic Incontinence Score. Patients were treated by VAAFT. Postoperative evaluation was made at 15 days, 1, 3, 6 and 12, 24 and 36 months. Results: Median follow-up was 26 months. Fistulas were transphincteric (18 patients), extrasphincteric (8 patients), intersphincteric (4 patients). 5 patients experienced minor bleeding. Mean postoperative pain evaluated according to VAS was \7. Overall success rate 77%. No continence impairment. 7 patients had persistent symptoms and required further treatment. Discussion: Surgical treatment of recurrent and complex anal fistula still remains challenging and a sphincter-saving procedure is desirable. Our data suggest that VAAFT is safe and effective.

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Surg Endosc

P579 - Amazing Technologies

P581 - Amazing Technologies

Multidisciplinary Approach in the Treatment of Adrenal Diseases

Importance of Pivot and Mobility of the Fulcrum in Laparoscopic Surgery with Forceps

O. Gulko, O. Usenko, A. Skums, O. Simonov, V. Serdjuk, B. Tsubera, V. Ganzha

Y. Nishizawa, M. Ito, T. Sasaki, Y. Tsukada

National Institute of Surgery and Transplantology, KYIV, Ukraine

National Cancer Center Hospital East, KASHIWA-CITY, Japan

In this presentation, 11 cases are described in which adrenal arterial embolization and coagulation of central vein was performed as part of the treatment of primary tumors of the adrenal glands. We reviewed the records of the eleven patients referred for adrenal arterial embolization during a one-year period (2015–2016). Adrenal arterial embolization and coagulation of central vein was performed in 11 patients, 5 with adrenal cortical carcinoma and 6 with adrenal pheochromocytoma. Endovascular electrocoagulation of adrenals central vein was performed in 11 cases. All patients underwent laparoscopic adrenalectomy after embolization of the arteries of the adrenal gland and the adrenal central vein coagulation. No deaths resulted from embolization. The average blood loss was 100 mL. Adrenal arterial embolization and coagulation of central vein may play an effective role without serious side effects in reduction of hormone production in adrenal lesions.

Background: Laparoscopic surgeons commonly operate forceps through a trocar with a pivot in the center of the abdominal wall fulcrum. The abdominal wall under the pneumoperitoneum is moveable in laparoscopy due to the external force, and this mobility of the abdominal wall can lead to instability in operation of forceps. Method: During a random period of 30 s in laparoscopic colorectal surgery, movement of the abdominal wall fulcrum was measured 10 times at intervals of 3 s, using a fixed point camera. The baseline position for measurement of movement was defined as that before the procedure. Result: In seven procedures performed by an operator who was familiar with laparoscopic surgery, the average movement of the abdominal wall fulcrum was 0.58 mm/the diameter of the trocar (0.03–1.08). Conclusion: The abdominal wall fulcrum was moveable due to operation of forceps through a trocar, and this mobility could differ among operators.

P580 - Amazing Technologies

P582 - Amazing Technologies

Endoluminal Suturing: Novel Instruments and New Technique

Laparoscopic versus Open Distal Pancreatectomy for Left-Sided Pancreatic Cancer: A Propensity Score-Matched Comparison

M. Seleem Cairo university, SHEIKH ZAYED, Egypt Back ground and aim: To provide a less costly technique for endoluminal suturing-in the esophagus, stomach, colon and rectum Project description: Instruments A-The flexible needle holder B-Eyed needle holderfor taking interrupted sutures for small defects C-The conduit A-taking sutures with the flexible needle holder -The gastroscope will be introduced to the stomach -An over-tube (50 cm-length and 19 mm external diameter) will be introduced B-taking sutures with the eyed needle The fixed needle holder with the eyed needle is loaded in a retrograde manner in the conduit The conduit is introduced in the over tube-the same way like the flexible needle holder- the needle will pass through the 2 edges of the stomach/colon defect Conclusions: Future Directions More modifications are needed to allow precise direction of the needle holder The need for modifying a type of suture to allow taking sutures through the eyed needle without extracorporeal suturing

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G.D. Wu, M.H. Dai, T.P. Zhang, Q. Liao, Z.W. Liu, J,C, Guo, W.M. Wu, G. Chen, Y.P. Zhao Peking Union Medical College Hospital, BEIJING, China Background: Although laparoscopic distal pancreatectomy (LDP) is increasingly carried out with satisfactory results, it is applicable to resection of benign and borderline malignant lesions mostly. Aim: This study was to compare the clinical and oncologic outcomes between LDP and open distal pancreatectomy (ODP) for pancreatic cancer to learn about LDP. Project description: Data from 21 patients treated with LDP were collected.133 patients performed ODP for the pancreatic cancer at the same duration were as case-control. Preliminary result: In unmatched patients, there was a significant difference in the length of hospital stay(LOS),postoperative time to recovering diet and estimated blood loss(EBL).On survival analysis, differentiation, combined resection and resection margin status were independent factors of prognosis. 21 patients in LDP and 42 patients in ODP were selected by propensity score matching. In matched patient, LDP was associated significantly with a shorter LOS and postoperative time to recovering diet. The median survival was 30.23 months in LDP which was 31.16 months in CDP (p = 0.761).

Surg Endosc

P583 - Amazing Technologies

P585 - Amazing Technologies

Single-Incision Laparoscopic Appendectomy with a Low-Cost Technique and Surgical-Glove Port

Indocyanine Green Lymphograhy-Guided Thoracic Duct Ligation for Chilothorax After Oesophagectomy

A. Birindelli1, M. Mandrioli1, G. Tugnoli1, A. Piccinini1, L. Di Donato1, F. Nigro1, A. Biscardi1, F. Agresta2, D. Weber3, E. Jovine1, S. Di Saverio1

G. Guarneri, P. Parise, A. Cossu, A. Melis, M. Mazza, D. Poldi, U. Elmore, R. Rosati Istituto Scientifico San Raffaele, MILANO, Italy

1

Maggiore Hospital, BOLOGNA, Italy; 2Adria Hospital, ADRIA, Italy; 3Royal Perth Hospital, PERTH, Australia After the acceptance of laparoscopic appendectomy(LA) as the gold standard in young females with suspected appendicitis, in some centers it is increasingly spreading the use of single-incision laparoscopic appendectomy (SILA),that is an innovative but technically demanding technique, able to improve the impact of minimally invasive surgery on cosmesis, postoperative pain and return to daily activity. However, the high cost of SILS compared with the already costly LA is still a considerable disadvantage that limits the use of this technique. We developed a low-cost single-incision laparoscopic appendectomy technique (SGP-SILA) that allows to reach the same cosmetic and clinical results as the standard SILA, avoiding its high expenses. Our 45 cases of low-cost SGP-SILA compared to a series of conventional SILA, showed SGP-SILA not only to be feasible but also safe and effective. This new technique is expected to gain surgical interest worldwide, including in the developing countries or in rural hospital or setting without availability of SILA equipments or limited budgets.

Chilothorax is a complication of oesophageal surgery and is associated with significant morbidity and mortality. Chilotothorax management remains controversial and often requires redo surgery and ligation of the thoracic duct. However the intraoperative detection of the thoracic duct leakage can be extremely difficult. This video shows the application of an intra-operative Indocyanine green (ICG) limphography in order to detect the thoracic duct leakage and pathway and to perform a selective ligation. An intra-venous ICG bolus (0.3 mg/kg) was injected an hour before thoracoscopic reoperation for chilothorax in a patient who underwent oesophagectomy for cancer. Thoracoscopy was performed using a dedicated camera which allows near infra-red vision in order to achieve intra-operative limphography which allowed the selective duct ligation. Moreover ICG-lymphography confirmed the resolution of the lymph leakage. The postoperative course was uneventful without any evidence of chilotorax relapse and the patient was discharged seven days after re-operation

P584 - Amazing Technologies

P586 - Amazing Technologies

Hiatal Hernias After Esophagectomy: What About Type of Surgery, Tumour Status And Neoadjuvant Chemo- and/ or Radiotherapy?

Study of Gastroesophageal Reflux in Patients Submitted Laparoscopic Sleeve Gastrectomy: Correlation Between Symptoms and Nuclear Tests

L.M. Helsloot, P. Willemsen, D. De Roover

J.F. Ruiz-Rabelo, N. Diaz Jimenez, E. Navarro Rodriguez, A. Membrives Obrero, J. Briceno Delgado

ZNA Middelheim, WILRIJK, Belgium Background: Since the increased survival of esophageal cancer, the incidence of hiatal hernias after esophagectomy (HHAE) rises. Mounting evidence suggests hiatal hernias are more common following minimally invasive esophagectomy. Aim: The aims were to define the incidence and presentation of HHAE in our population and its correlation with type of esophagectomy, tumour status at diagnosis and pre-operative chemo- and/or radiotherapy. Project description: A retrospective monocentric cohort study was performed (11/ 2000–04/2015). All pre- and post-operative computed tomography images and radiology reports were reviewed, as well as type of surgery, tumour status and oncological treatment. Preliminary results: Six out of 73 patients (8.2%) developed HHAE. The mean time between esophagectomy and diagnosis was 9,2 months. All hernias occurred into the left chest after partial esophagectomy by laparoscopy and right thoracotomy. Five patient had pre-operative chemoradiotherapy, one only chemotherapy. Tumour stage was stage IIB or higher, pTNM from pTisN0 to pT3N1.

H.U. Reina Sofı´a, CORDOBA, Spain Background: Gastroesophageal reflux after sleeve gastrectomy is a controversial issue, the posibility to develop ‘the novo’ gastroesophageal reflux disease (GERD) due to the impact on esophagogastric union. The aim of this studio is to analyze the correlation betwee GERD symptoms and the study of gastroesophageal and bile reflux after sleeve gastrectomy. Patients and methods: 34 consecutive patients were submitted sleeve gastrectomy by the same surgery team. Six months after surgery patients filled in GERD-Q and Rome III. After that they were performed a gastroesophageal reflux scintigraphy and biliar-Tc99m-scintigraphy to evaluate both gastroesophageal and bile reflux. Results: A 11,8% of patients showed GER in scintigraphy, and 5,9% of them showed bile reflux at biliar Tc99m scintigraphy. Regarding ROME-III criteria, 6 patients had functional heartburn criteria and 5 had functional dispepsia criteria. Conclusions: Our study showed good correlation between GERD symptoms and scintigraphy. Biliary reflux is difficult to interpret.

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Surg Endosc

P587 - Amazing Technologies

P589 - Amazing Technologies

Rate of Skill Acquisition in the Use of a Robotic Laparoscope Holder (FreehandÒ): Fast development in Solo Surgery in an Era of Staff Shortages

Presentation of True 2-Port Laparoscopic cholecystectomy for an Uncomplicated Cholelithiasis

N. Warnaar, M. Sbaih, T. Arulampalam, R. Motson Colchester University Hospital, COLCHESTER, United Kingdom Background: Robotic equipment can greatly add to the ergonomics of surgical procedures and the efficiency of available staff. Freehand is a camera-holding device available to laparoscopic surgeons. It is controlled using head and foot movements, delivering precise control of position and view. Preoperative simulation provides training without risks for patients. Aim: The purpose was to assess the rate of skill acquisition in the use of the FreeHand robotic camera controller by laparoscopic surgeons by enrolling them into training modules at The ICENI Centre, Colchester University Hospital. Description: Twenty registrars performed a series of exercises controlling the FreeHand System. Subjective and objective assessments by an observer and by tracking analysis software were evaluated. Results: The FreeHand robotic laparoscope holder is a useful device, which is easy to operate and requires a very short course of training to achieve competence and confidence in its use.

A. Khawaja, I, Halim, S.I.H. Bukhari Peterborough City Hospital, PETERBOROUGH, United Kingdom Background:Laparoscopic cholecystectomy in the UK accounts for the single most common elective procedure in surgery for the management of cholelithiasis. Some surgeons advocate for a 3-port procedure to further minimise post-operative pain and quicker return to activities compared to the traditional 4-port technique. We demonstrate that a true 2-port technique can be used safely in selected cases of uncomplicated biliary colic. Aim:To demonstrate a novel approach to treating uncomplicated gallstone disease with a safe and ultra-minimally invasive technique. Project description:Demonstration of technique with pictures and video presentation. Preliminary results and conclusion: 2-port laparoscopic cholecystectomy can be performed safely in uncomplicated patients presenting with gallstone disease. The patient benefits from less post-operative pain, quicker healing and return to activities and better cosmesis. This procedure can also be used as a stepping stone in the learning curve for a hybrid NOTES cholecystectomy.

P588 - Amazing Technologies

P590 - Amazing Technologies

Copper Absorption in Chronic Pancreatitis

A Randomized Controlled Multicenter Study of an Incisionless Operating Platform for Primary Obesity (PoseTM) Vs. DietExercise: The Milepost Study

P.R.S. Tasker, H. Sharma, J.M. Braganza Manchester Royal Infirmary, SWANSEA, United Kingdom Background: 64Cu absorption increased in exocrine pancreatic insufficiency (EPI) in rats Aim: To determine the influence in man. Project Description: 64Cu absorption was measured by a computerised deconvolution program after separating 64Cu in serial blood samples from that bound to caeruloplasmin by elution through charcoal. Preliminary Results: 10h-64Cu absorption in healthy volunteers was 42.3 (±9.7) % (n = 9) [or 1.84 ± 0.43%/BMI]; 6 male, 3 female) on their habitual diet. In nine patients with chronic pancreatitis, 10-h absorption was 35.9 (±12.8) %[1.71 ± 0.52]; 6 male and three female. Clinical pancreatic insufficiency (CPI) patients had pancreatic steatorrhoea. Lower absorption 26.9 (±7.5) % (n = 5) [1.33 (±0.33)] associated more with CPI (t = 4.078, P2 P \ 0.01) than with vagal transection (VT+) (n = 3) (t = 3.588, P2 \ 0.01). Non-CPI patients absorbed 47.2 (±7.3) % (n = 4)[2.17 ± 0.18]. Without achlorhydria group CPI 10 h absorption was still low at 32.1 (±3.1) % (n = 3).

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J.W. Greve1, K. Miller2, R. Turro3, J. Espinos3 1

Atrium Medisch Centrum Parkstad, HEERLEN, The Netherlands; Diakonissen & Wehrle Private Clinic, SALZBURG, Austria; 3Centro Medico Teknon, BARCELONA, Spain

2

Background: The poseTM procedure is a minimally invasive technique which uses the g-CathTM EZ Suture Anchor, part of the Incisionless Operating PlatformTM (USGI Medical, San Clemente, CA, USA) to treat patients with Class I and II obesity. Aim: To measure the difference between the experimental and control groups in total body and excess weight loss (%TBWL, %EWL) at 12 months. Project Description: A prospective, multi site, open label, randomized controlled trial was conducted in 3 EU countries. Following Ethics approval, 44 patients with class I-II obesity were randomized in a 3: 1 ratio (pose with diet and exercise counseling: diet and exercise counseling only). Results: 12-month endpoint data showed that patients treated with pose experienced a 2.5 fold greater greater weight loss than patients who received diet and exercise guidance alone that was sustained beyond one year. In addition, pose procedure patients showed significant reduction in satiety parameters.

Surg Endosc

P591 - Amazing Technologies

P593 - Amazing Technologies

Laparoscopic Management of a Duplicated Gallbladder: A Case Report

Assessment of a Laparoscopic Robotized Needle Holder for Intracorporeal Suturing and Knot Tying

S.G. Kim, S. Lee

R. Mittal, R. Motson, T. Arulampalam

The Catholic University of Korea, SEOUL, Republic of Korea

Colchester General Hospital, COLCHESTER, United Kingdom

Gallbladder duplication is a rare congenital anomaly, usually asymptomatic. Recognition of this anomaly is important since it can complicate a cholecystectomy. We report a case of a 54 year old male who presented intermittent right upper quadrant abdominal pain for 1 week. His lab findings were normal including liver function tests. Computed tomography scan showed evidence of duplicated gall bladder or choledochal cyst. Pre-operative Magnetic resonance cholangiopancreatography (MRCP) revealed the duplicated gallbladder. He underwent laparoscopic cholecystectomy successfully. Laparoscopic cholecystectomy for duplicate gallbladder is a challenging operation and should be performed with meticulous dissection. Two gall bladders were all connected to common bile duct. Duplicated gall bladder were resected all. After 4 months follow up the patient remained asymptomatic and no sequelae. A literature review revealed an incidence of 1 in 4000 autopsies with a duplicated gallbladder.

Background: When compared to open or robotic surgery, laparoscopic instruments have limited degrees of freedom. The laparoscopic robotized needle holder adds two motorized degrees of freedom, rotation and bidirectional flexion. We compared this with a conventional needle holder, for intracorporeal suturing and knot tying. Methods: Six consultants and 6 trainees performed 2 predefined tasks (hexagonal suture, knot tying) with both instruments. A trained instructor assessed anonymised videos for quality and quantity using structured assessment forms. Results: There was no difference between the two for knot tying. Quantitative, but not qualitative scores for suturing were lower for the robotized needle holder (p \ 0.001), overall and among trainees and consultants. There were no differences in scores based on experience, laparoscopic case volume or grade. Conclusions: The robotized needle holder can be effectively used for suturing and knot tying. Further studies are necessary to assess learning curve and use in performing complex tasks.

P592 - Amazing Technologies

P594 - Amazing Technologies

A Hydro-Jet Propelled Colonoscope

Single-use Endoscope for Laparoscopic Choledocoscopy

S.A. Coleman1, S.C. Tapia-Siles2, A. Cuschieri1

I Pirlet, A. Lintis

1

University of Dundee, DUNDEE, United Kingdom; 2Universidad Privada Boliviana, COCHABAMBA, Bolivia Background: Colonoscopy is the gold standard for diagnosing colorectal cancer, but is often painful for the patient and requires a high degree of operator skill. Hydro-colonoscopy has been introduced and shown to reduce patient discomfort. Aims: Development of a novel hydro-jet propelled colonoscopic system, which aims to reduce patient discomfort by utilising a manoeuvrable, self-propelled device for hydrocolonoscopy. Operator skill required should also be reduced by offering simple controls. Project description: A hydro-jet propelled colonoscopic system is in development. Multiple small jets are utilised to propel a small ‘submarine’ device through a fluid-distended colon. The jets are controlled by on-board micro-valves in order to manoeuvre the device. Preliminary results: A preliminary prototype has been constructed and initial assessment in a test-bed demonstrates the feasibility of this approach. The safety of the jets has been assessed using ex vivo tissue, and has shown that atraumatic jet propulsion should be achievable.

Centre Hospitalier de Dunkerque, DUNKERQUE, France Choledocolithiasis is encountered in approximately 10 to 15% of patients with cholelithiasis. Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy has been proven to be a safe and effective single-stage procedure for the management of common bile duct stones, with excellent outcomes and equivalent success and complication rates compared to endoscopic retrograde cholangiopancreatography (ERCP).So far, this procedure requires a flexible choledoscope, together with a light source and a camera, combined to disposable instruments. The sophisticated equipment, its cost and its time consuming decontamination and installation processes somewhat limited its widespread application. We present several surgical procedures completed in our institution using a new disposable flexible choledoscope, provided with the same characteristics of a classical device and affording high quality and wide angled vision, with a plug and play interface connection. This new technology allows an immediate utilization, also overcoming the repair, maintenance and decontaminating issues.

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Surg Endosc

P595 - Amazing Technologies

P597 - Intestinal, Colorectal and Anal Disorders

Endoquick (EQS) Suture is Pre-made Knot can complete a Secure Ligation Intracorporeal with Just Twice the Pulling Manipulation

Arteriovenous Malformation of Jejunum as a Source of Obscure Bleeding in 57 Year Old Female. Case Report

T. Ikeda, R. Nakata, S. Obata, M. Hashizume

S. Stabina, I. Ivanovs, A. Kaminskis, G. Pupelis

Kyushu University, FUKUOKA, Japan

Riga East Clinical university hospital Gailezers, RIGA, Latvia

Back ground and purpose: In conventional surgical methods such as laparotomy, ligation is carried out by using the five fingers of both hands, whereas in endoscopic surgery, performing ligation inside a body cavity consists of ligating by tying knots by using two forceps and a needle holder passing through a port which penetrates through the body wall. Structure and function of EQS: The EQS are pre-made with a one-thread worth of margin, and the final tightness of the knot can be adjusted on the basis of the operator’s own judgment. In addition, because the suture ligature is entirely inside the body cavity, the operator has absolutely no need to divert their line of sight from the body cavity. Instead, ligation can be completed with the same needle holder and forceps as those used for suture. Conclusion: EQS could be reduce the stress of endoscopic surgeon and length of surgery.

Introduction: Approximately 5% of gastrointestinal bleeding occurs between the ligament of Treitz and the ileocecal valve and might be potentially life-threatening when source of bleeding cannot be identified Matherial and Methods: Case report Results: 57- year old female were delivered to emergency department in unstable condition with hypotension and melena which started 3 h ago. Patient underwent emergent upper and lower endoscopy however source of bleeding was not identified. CT angiography finding was in favour of probable arteriovenous malformation in the jejunum. Digital subtraction angiography (DSA) did not found the source of bleeding, however following conservative treatment was successful and bleeding stopped. Patient was discharged from hospital and 9 days later was second episode of bleeding. On second admission DSA and diagnostic laparotomy with intraoperative endoscopy did not found the bleeding source and bleeding stopped again. Repeated upper endoscopy revealed lesion resembling small diverticulum in duodenojejunal junction and selective endovascular embolisation of jejunal branches were done. After embolisation patient experienced attack of progressive severe abdominal pain leading to emergent laparotomy. Intraoperative finding was partial necrosis of the jejunal segment and small bowel resection with end to end anastomosis was performed. Histopathologic examination of the specimen has proved arteriovenous malformation of jejunum. Conclusion: Despite available endoscopic, invasive radiologic and surgical treatment modalities, small bowel bleeding is still a challenging emergent pathology

P596 - Liver and Biliary Tract Surgery

P598 - Liver and Biliary Tract Surgery

Laparoscopic Versus Open Surgery for Hydatid Disease of the Liver:A Single Center Experience

Gasless Portless Laparoscopic Cholecystectomy with Needle Forceps

P. Yazici, O. Bostanci, K. Kartal, M. Battal, U. Demir, M. Mihmanli

Y. Shindo

Sisli etfal training and research hospital, ISTANBUL, Turkey

Nakadori General Hospitak, AKITA, Japan

Background: Cystic Echinococcosis is a chronic parasitic infection, which is still an important problem in rural areas. Due to the development in technology, laparoscopic surgery has been introduced for the surgical treatment of hydatid disease of the liver (HDL). The present study aimed to evalaute the clinical outcomes of laparoscopic versus open surgery for HD-L in a comparative analysis. Methods: Between January 2010 and March 2015, medical records of 91 patients who underwent surgery for HD-L were retrospectively analyzed. Patients’ demographic data, cystic features, operative details and postoperative outcomes were reviewed from the database. All patients were divided in two groups regarding the surgical approach; Group A (open surgery, n = 72) and Group B (laparoscopic surgery, n = 19) Results: Both groups were similar regarding demographic variables and cystic features. In group B, mean operative time was significantly lower when compared to Group A (89 ± 28 min vs. 144 ± 19 min, respectively p \ 0,01). Hospital stay was also lower in laparoscopic group (3.38 ± 0.7 vs 8.81 ± 5.4 p \ 0,01). Overall postoperative complication was 19% and it was similar between groups. Incidence of biliary fistula was 14% (n = 13). Conclusion: Laparoscopic approach in the treatment of HD-L is safe and feasible. Additionally, it has some advantages including shorter operative time and hospital length of stay.

A single incisional laparoscopic cholecystectomy by the pneumoperitoneum method is a standard method recently. However, there is a burden to the heart and the lung, deep venous thurombosis by the air pressure of pneumoperitoneum. Furthermore, in order to control the cost concerning an operation, the following operation way types were considereded. It makes an incision in the abdomen by about 2?2.5-cm incision to the umbilical region. Then, an abdominal wall is lifted using retractor for an incision in the abdomen, and muscle hook, and an operation space is secured. And I inserted forceps of 2.4 mm diameter in left and right side of the abdomen directly and performed an operation. A method: It compared with the single incisional Gasless Portless laparoscopic cholecystectomy B method: & the conventional method (four ports under pneumoperitoneum: C method: about the validity and the safety of the A method so much. The target patient is 146 examples which enforced the laparoscopic cholecystectomy from April, 2010. The A method is 18 examples and the number of the B methods is 23 and the number of the C methods is 105. Average operation time of A:B :C method were 101.3 ± 41.1:109.9 ± 15.5:110.8 ± 56.0 min. The amounts of bleeding of A:B :C method were 33.3 :45.1:93.1 ml. The postoperative number of days in the hospital, postoperative complications wrer no differents. The A method is not inferior as compared with the B & C methods. An about 50,000 japanese yen cost cut was possible for the A & B method by no torocar, no pneumoperitoneum, no bag which collects specimens. The A method is considered to be a useful method.

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P599 - Urology

P601 - Emergency Surgery

Laparoscopic Left Varicocelectomy - Initial Experience

Emergency Laparoscopy in Diagnosis of Acute Pancreatitis

V. Jinescu, G. Chidiosan, G.H. Plugaru, G.H. Lica, G. Beuran

K.O. Zadorozhna, O.I. Dronov, I.O. Kovalska, K.S. Burmich, A.I. Gorlach, R.S. Tsimbaliuk

BUCHAREST CLINICAL EMERGENCY HOSPITAL, BUCHAREST, Romania

Bogomolets National Medical University, KIEV, Ukraine

Background: Abnormal dilation of the pampiniform plexus is an important factor of male infertility. Patients and Methods: We retrospectively analised the cases of varicocele admitted and operated on our ward between january 2010 and july 2014. The diagnosis was made based on clinical examination with Valsalva manoeuvre and doppler ultrasound. We performed laparoscopic left varicocelectomy in 43 patients with varicoceles and abnormal seminal findings. 63% of the patients were in their 3rd decade of life. Average operating time was less than 1 h in more than half of the cases. The spermatic artery was identified and preserved in all cases. Spermatic vein was disected and sectioned between titanium or plastic clips. Results: All the patients were able to walk within 24 h and most of them (91%) were discharged after 48 h from the laparoscopic intervention. No serious complications occured. The postoperative checkup at 6 month interval showed significant improvement of the spermogram. Conclusions: Laparoscopic varicocelectomy performed with standard laparoscopic equipment is safe, effective, with short hospital stay and excellent post-operative results.

Aims: To evaluate accuracy of laparoscopy in differential diagnosis of acute pancreatitis. Materials and methods: Total 126 diagnostic laparoscopies were performed during 2013-2015. Distribution according to nosology was following: acute appendicitis 35 (27,7%), acute pancreatitis 31 (24,6%), gynecological disorders 22 (17,4%), small bowel obstruction due to adhesions 15 (12%), acute cholecystitis 3 (2,4%), gastroduodenal ulcer perforation 10 (8%), mesenteric ischemia 8 (6,3%), other 2 (1,6%). Retrospective study of 31 patients with acute pancreatitis, who underwent diagnostic laparoscopy, was performed. Indications for laparoscopy were diagnostic uncertainty in cases with not specific clinical symptoms (atypical abdominal pain, normal serum amylase level, absence of typical signs on transabdominal ultrasound) and suspected peritonitis. There were 11 females (35,4%), and 20 males (64,6%) in mean age 52,7 ± 19,15, and disease duration 94,3 ± 34,5 h. Results: Generally definitive diagnosis was possible in 98,4% cases. Acute interstitial edematous pancreatitis was diagnosed in 12 (38,7%), acute necrotizing pancreatitis in 19 (61,3%) cases. Laparoscopic diagnosis of acute pancreatitis was based on the identification of significant and the likely signs. In cases of edematous acute pancreatitis only likely signs were revealed: the ousting of the stomach to the anterior abdominal wall (58,3%), bulging gastrocolic ligament (83,3%), congestion and oedema of the less omentum (91,6%), serous peritoneal effusion (41,6%). In cases of acute necrotizing pancreatitis spots of steatonecrosis on peritoneum and omentum appeared in (89,5%) cases, congestion and oedema of the less omentum and mesocolon (100%), hemorrhagic infiltration of omentum (47,3%), mesocolon (94,7%) and retroperitoneal fat (73,6%), hemorrhagic peritoneal effusion (89,5%). Mortality rate was 22,6%. All died patients had combination of following signs: dynamic ileus, hemorrhagic infiltration of mesocolon, small bowel mesentery, and retroperitoneal fat, more than 500 ml of hemorrhagic exudate in abdominal cavity with high amylase activity (mean 877,7 ± 371,3 U), persistent multiorgan failure [48 h, persistent systemic inflammatory response syndrome. Conclusions: Emergency diagnostic laparoscopy has high accuracy for acute pancreatitis differential diagnosis in cases of diagnostic uncertainty. Noninvasive diagnostic methods should be exhausted first.

P600 - Oesophageal and Oesophagogastric Junction Disorder

P602 - Gastroduodenal Diseases Heterotopic Pancreas Mimicking Gastric Stromal Tumour

Laparoscopic Nissen-Rosetti Fundoplication Performed with Standard Laparoscopic Equipment V. Jinescu, G. Chidiosan, R. Mehic, G.H. Lica, G. Beuran BUCHAREST CLINICAL EMERGENCY HOSPITAL, BUCHAREST, Romania Background: Laparoscopic Nissen-Rossetti fundoplication is effective to control gastrooesophageal reflux. Patients and Methods: Five patients suffering from gastroesophageal reflux were operated using this laparoscopic procedure, with standard laparoscopic equipment, dissection of the oesophageal hiatus and the retro-oesophageal window being realised using the hook electocautery. Pre-operatively all patients underwent oesophago-gastroscopy, X-ray barium swallow and oesophageal manometry. Results: Nissen-Rossetti fundoplication without division of the short gastric vessels and use of anterior fundus to create the wrap produces an effective barrier against reflux, thus significantly reducing possible bleeding from these vessels and from splenic lesions which may be difficult to control or may lead to splenectomy. The dissection was done in all cases using hook cautery. The hiatus is repaired after the completion of the wrap. There were no complications. All of the patients were satisfied with their decision to have the operation. Conclusions: This technique which avoids routine division of short gastric vessels is good for surgeons who wants to perform an antireflux procedure using a standard laparoscopic equipment with no advanced electrosurgery devices.

S. Mukherjee, D. Mukherjee Queens Hospital, Romford, LONDON, United Kingdom Aims: Pancreatic heterotopia is a rare finding where there is presence of pancreatic tissue outside the pancreas without any vascular or anatomic connection with the pancreas. Heterotopic pancreas may be present in all segments of the gastrointestinal tract. They are usually asymptomatic and often picked up incidentally, but occasionally present with symptoms. Our aim was to present 2 patients with submucosal tumours of the stomach (suspected gastrointestinal stromal tumour (GIST)) who were treated with a local gastric resection but the histology revealed them to be heterotopic pancreas. Methods: Patients with suspected GISTs were identified from a prospectively maintained Upper GI surgical database. The patients with heterotopic pancreas on histology were extracted and their clinical presentation, imaging, endoscopy and surgical findings were reviewed along with their clinical outcome. The current literature was also reviewed. Results: Two patients were investigated for symptoms of early satiety and occasional vomiting after meals. Gastroscopy revealed a moderate sized submucosal tumour in the antrum of the stomach in one and on the greater curvature in the body of the stomach in the other, and the suspicion of a GIST was entertained. Biopsies were unrepresentative. Computed Tomography (CT) of the abdomen revealed the lesions on the anterior wall of the stomach. Following discussion in the MDT, both were offered a laparoscopic surgical excision of the tumour. One patient underwent a laparoscopic converted to an open distal gastrectomy and the other patient underwent a laparoscopic local gastric resection. Both patients recovered well, with the patient who had a distal gastrectomy experiencing some delayed gastric emptying. The histology of both showed heterotopic pancreatic tissue. Conclusions: Even though pancreatic heterotopia is a rare entity, it should be considered in the differential diagnosis of extramucosal gastric tumours which we are picking up more and more due to advances in endoscopy and imaging. However, in spite of all the available diagnostic modalities, its pre-operative diagnosis remains elusive. Surgical excision provides symptomatic relief and is recommended especially if diagnostic uncertainty remains.

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P603 - Liver and Biliary Tract Surgery Robot-Assisted Treatment of Benign Diseases of Extrahepatic Bile Duct E.F. Kauffmann, N. Napoli, F. Menonna, S. Iacopi, F. Vistoli, U. Boggi Division of general and transplant surgery, PISA, Italy Introduction: Surgery for benign diseases of extra-hepatic bile duct (EBD) is required when endoscopic treatment is not feasible or indicated, laparoscopy could reduce operative trauma. However, some operations require complex dissections and/or fine sutures that may be better performed by robotic assistance. Methods: Two patients (8-year old female and 30-year old male) had Todani type 1 choledochal cysts; a 77-year old female had stricture of biliary anastomosis and stones after laparoscopic robotic-assisted pancreaticoduodenectomy; a 35-year old female had multiple, large, difficult biliary stones that could not be removed after repeated endoscopic attempts. Results: Choledocal cysts were removed and the biliary tract reconstructed using a Rouxen-Y jejunal loop. In the child resection reached the biliary bifurcation, making double biliary anastomosis necessary for reconstruction. In the patient with biliary anastomotic stricture, a brim of bile duct wall was resected. Stones were removed and the anastomosis easily reconstructed. In the last patient, after cholecystectomy, the EBD was open transversally and the stones were removed using a combination of wristed robotic instruments and Fogarty catheters. Clearance of the EBD was confirmed by choledoscopy and cholangiography. A biliary stent was placed in the EBD and the duct was closed in a double layer of polydioxanone sutures. Mean post-operative time was 227.5 min (range 120–280). The post-operative course was uneventful for all the patients. Mean length of hospital stay was 5.5 days (range 5–7). Conclusion: Enhanced dexterity offered by robotic assistance may be rewarding when dealing with complex biliary diseases requiring complex dissections and fine sutures.

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