Surg Endosc https://doi.org/10.1007/s00464-018-6181-5

and Other Interventional Techniques

26th International Congress of the European Association for Endoscopic Surgery (EAES), London, United Kingdom, 30 May–1 June 2018: Poster Presentations

Ó Springer Science+Business Media, LLC, part of Springer Nature 2018

P001 - Abdominal Cavity and Abdominal Wall

P002 - Abdominal Cavity and Abdominal Wall

Laparoscopic Preperitoneal Hernia Repair for Treatment Ventral Hernia (the Rectus Abdominal Diastasis, Flank Hernia and Recurrent Incision Hernia)

Morgagni Hernia - Laparoscopic Approach

K.S. Leong General Surgery, Far Eastern Hospital, New Taipei City, Taiwan Aims: Rectus abdominal diastasis, flank hernia and recurrent incision hernia are kinds of ventral hernia. The totally extraperitoneal hernia repair for inguinal hernia had already performed for many years. It had benefits at post operation hospitalization, wound pain, cosmetics. We believe that we can use the same approach for treatment the ventral hernia. We want to share our early experiences with this approach. We also evaluate the feasibility and post operation results. Methods: We performed the preperitoneal hernia repair with mesh for treatment ventral hernia since 2011, had already performed 37 cases. In this case of rectus abdominal diastasis patients and right flank hernia patient and left lower abdomen recurrent incision hernia status post mesh hernia repair with right lower abdomen incision hernia were performed at 2017. The demographic information and defect size were measured. Results: This rectus abdominal diastasis female was 41 years old. The rectal muscle distance about 7 cm. The operation time was about 4 hours. The right flank incision hernia male was 69 years old. The fascia defect was about 10 9 8 cm. The operation time was about 2 hours. The left lower abdomen recurrent incision hernia status post mesh hernia repair with right lower abdomen incision hernia female was 60 years old. The left lower abdomen fascia defect about 7 9 5 cm and right lower abdomen fascia defect about 2 9 2 cm. The operation time was about 4.5 hours. The 3 cases blood lose were about 5 ml. The wound pain was VAS:4 * 5. They discharged from our hospital within the 24 hours postoperative period. The seroma was noted at right flank incision hernia patient. Conclusions: We shared our early experience with preperitoneal hernia repair with mesh. They showed benefits at post operation hospitalization, wound pain and cosmetic to compare with open approach.

A.M. Vasilescu, C. Bradea, V. Bejan, E. Tarcoveanu First Surgical Clinic, St Spiridon University Hospital, Gr.T.Popa, University of Medicine and Pharmacy, Iasi, Romania Morgagni hernia develops after a congenital retrosternal diaphragmatic defect, a rare form of diaphragmatic hernia (1–3% of cases). In general, this pathology is diagnosed in children, and in adults it is frequently discovered in emergency. Methods: We prospectively evaluated a series of 7 patients admitted to First Surgical Clinic, St. Spiridon Hospital, Iasi during 2011–2017. Results: Out of 7 patients, 6 were operated, one refusing surgery but being followed periodically. Symptomatology was nonspecific in 5 cases that were discovered in the exploration of an associated pathology, either with cardiopulmonary symptoms of dyspnea or palpitations. In 2 cases, the clinical aspect suggested an occlusive syndrome (the herniated organ is usually the transverse colon). The laparoscopic approach was used in all cases, recording one conversion, due to the tight intrascale adherence of the herniated viscera (gastric, colon, epiplon). In 4 cases the surgical cure of hernia was performed by suture and in 2 cases with prosthesis: dual mesh in one case and polypropylene mesh in another case. We not registred morbidity and mean postoperative stay was 3.5 days (range 2–6 days). Conclusions: Hernia Morgagni is a rare pathology. The most common is asymptomatic but in complicated cases it is a cause of acute surgical abdomen. Surgical treatment is indicated even for asymptomatic cases due to serious complications to which it may evolve. Laparoscopic approach is ideal, reduction of viscera in the abdomen is easy, herniar sac in general is not excised and the defect will be repaired depending on size by suturing or using a prosthesis.

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Surg Endosc

P003 - Abdominal Cavity and Abdominal Wall

P005 - Abdominal Cavity and Abdominal Wall

’SLIM-MESH’: A New Laparoscopic Technique for The Treatment Of Abdominal Wall Hernias. The First Mid-Term Results

Welding of Biological Tissues and Surgical Treatment of Oesophagus Metaplasia in COMBINATION to Gastroesophageal Hernia

S.A. Canton, C. Pasquali

V. Tiselskiy1, A. Kebkalo1, B. Bondarchuk1, S. Plemyanik2, V. Dadaian3

Department of Surgery, University of Padua, Padova, Italy Aims: We designed a new laparoscopic fixation technique (‘‘Slim-Mesh’’, SM) to treat abdominal wall hernias (AWH) without the use of transabdominal full-thickness stitches in order to reduce surgical time, acute and chronic pain, or other associated complications. Methods: Between 2009 and October 2017, 60 consecutive patients with abdominal wall hernias (AWH) were treated at Padua University Hospital with a new approach called the SM technique. Data on all patients were collected retrospectively (55%) or prospectively (45%). Results: This study comprised 50 percent males with patient age averaging 58 years old (range: 31–82 years old). Mean body mass index was 29 and AWH operative size was\ 10 cm=‘‘‘‘ small=‘‘‘‘ medium=‘‘‘‘ awh=‘‘‘‘10–20=‘‘‘‘cm=‘‘‘‘ giant=‘‘‘‘ and=‘‘‘‘ i=‘‘‘‘[C 20 cm (massive) in 43, 13 and 4 cases respectively. Mean operative time for the following AWH was 88 minutes for small/medium (range: 55–150 minutes); 116 minutes for giant (range: 70–155 minutes); and 185 minutes for massive (range: 125–240 minutes). In 23.3% of patients, AWH operative size was larger than preoperative size, and in 10% laparoscopy diagnosed other AWH previously undetected by physical examination, and US- and/or CTscan. A composite mesh (Proceed (85%) and Dual Mesh (5%)) up to 30 cm was used in 90% of patients while a non-composite mesh (BIBRAUN Omyra) was used for the remainder (10%). SecureStrap was the fixation device used in 75% of cases. In this series, we had one (1.6%) intraoperative complication with transient bradycardia. One case of early postoperative abdominal pain was detected. The patient underwent a second laparoscopy, but no related SM repair complications were found. Mean length of hospital stay was 3 days. Mean follow-up time was 32 months (range: 1–98 months). Late surgical complications included three cases (5%) of hernia recurrence and one case (1.6%) of a 10 mm trocar site hernia. All four patients underwent surgery. Conclusion: This new surgical technique for AWH repair simplifies intra-abdominal introduction, well as mesh handling and fixation because it does not require transfascial sutures or other expensive alternatives. The SM technique is, in our experience, simple, safe and fast.

P004 - Abdominal Cavity and Abdominal Wall Prevention of Peritoneal Catheter Dysfunction in Patients with Terminal Stage of Renal Failure V. Vasyl Surgery, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine Background: Peritoneal dialysis (PD) in recent years is widely used as a method of renal replacement therapy in patients with renal insufficiency at the terminal stage. One of the problems associated with the functioning of the peritoneal catheter is its mechanical dislocation from the pelvis and the wrapping of a large omentum with a strand. Aim: Reduce the number of peritoneal catheter dysfunctions by using laparoscopic fixation, partial omentectomy and infusion of hyaluronic acid solutions. Materials and Methods: The first group consisted of 18 patients, who underwent Laparoscopy with Tenkoff peritoneal drainage. The second group consisted of 16 patients who had a peritoneal catheter mounted in a small pelvis with fixation to the anterior abdominal wall, partial resection of a large omentum and the introduction of 250 ml of hyaluronic acid in the antisepsis solution of Defensal. Patients were observed for 5 years. Modes of peritoneal dialysis were the same. Patients are comparable in age, sex and disease etiology. Results: In the first group of patients: 9 cases dislocation occurred in the first year after catheter placement, in 3 in the second year, 2 in the third year and in 1–4 year. Among 14 patients with catheter dislocation, in 12 she was accompanied by wrapping of the omentum. 12 patients were done by laparoscopic correction, 2 switched to hemodialysis. In 4 out of 14 patients, laparoscopic correction was repeated twice. In the second group: in 2 cases the wrapping with a large omentum appeared in the first year after the catheter placement, 1 - in the second and 1 in the third year. All patients underwent laparoscopic correction. Thus, in patients of the first group, a complication in the form of peritoneal catheter dysfunction appeared in 77% of cases, and in half in the first year after staging. In the second group of patients complications in the form of enveloping the catheter arose in 25% of cases. Conclusions: The use of the proposed one-stage method of laparoscopic fixation of the peritoneal Tenkoff catheter with partial omentectomy and intraabdominal injection of hyaluronic acid leads to a 3.1 times decrease in drainage dysfunction.

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1 Department of Surgery and Proctology, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine; 2Endoscopy department, Kyiv Regional Clinical Hospital, Kyiv, Ukraine; 3 Department of Surgery, Kyiv Regional Clinical Hospital, Kyiv, Ukraine

Topicality: oesophagus metaplasia is diagnosed in addition to gastroesophageal reflux disease with gastroesophageal hernia for 10–15% of patients. Purpose: Increase efficiency of treatment of metaplasia of esophagus in combination to gastroesophageal hernia by rational use of biological tissues welding and minimally invasive methods. Materials and Methods: We formed out 2 groups of patients. The groups consisted of patients with short-segment C2-3M3-4 (circular segment up to 3 centimeters) Barrett’s esophagus and dysplasia type I-II. At the first stage for the first group of patients (12 patients) was carried out as treated with argon-plasma coagulation with a further proton pump inhibitors and prokinetics therapy. After some time was fulfilled laparoscopic crurorrhaphy and fundoplication. For the second group (11 patients) was used mucosa destruction with Patones welding of biological tissues (EK-300M1) with further medication therapy same as in group 1 and further similar surgical treatment. Results: After 75 (± 5) days for the first group (postponed because of esophagus wall edema (by endo-ultrasound imaging data) and high probability of cardio-esophageal junction stenosis development) fundoplication and cruroraphia were performed with further patient monitoring. For the second group cardio-esophageal correction was performed after 50 (± 4) days because inflammatory states appeared in a less distinct manner and their regeneration went faster because of: absence post-coagulative eschar, heat-affected area and depth were limited by electrode area; after couple of minutes directly near welding area tissues took primary color, blood flow, and other functions didn’t have permanent consequences; during coagulation cicatrization didn’t occur, because organ histological structure rehabilitates almost fully. Histological remission was achieved for the patients of the first group on the 115th (± 7) day; for the patients of the second group on the 73rd (± 4) day. Conclusions: in order to improve treatment of n/3 esophagus metaplasia in combination to gastroesophageal hernia it’s recommended to perform destruction with Paton welding of biological tissues with further laparoscopic Nissen fundoplication and crurorraphia. Using metioned type of therapy treatment time and oesophagus cicatrization probability decrease, and this approach is cost-efficient for a patient.

Surg Endosc

P006 - Abdominal Cavity and Abdominal Wall

P008 - Abdominal Cavity and Abdominal Wall

Robotic Inguinal Hernia Repair: Is it a New Era In The Surgical Management of Groin Hernia?

A Case of Superior Lumbar Hernia Treated by Laparoscopic Surgery

E.K. Kakaishvili1, E.B. Brauner2, Y.K. Kluger2

K.K. Kawasai

1

Surgery, Okayama Rosai Hospital, Okayama, Japan

General Surgery, Galilee Medical Center, Kiriat Mozkin, Israel; General Surgery, Rambam Medical Center, Haifa, Israel

2

Aim: robotic techniques relevance in inguinal hernia surgery is being examined. The study presents comparison of perioperative outcome between different surgical approaches for inguinal hernia. Methods: retrospective cohort of 137 patients that underwent inguinal hernia repair at Rambam Medical Center during 2014–2016. Patients data was collected based on demographic characteristics, BMI, operating room time (ORT), Visual Analog Scale for Pain (VAS), postoperative need of analgesic, length of hospitalization (LOH) and perioperative complications. Results: study population included 97 patients that underwent open inguinal hernia repair [12 bilateral (12.4%); 85 unilateral (87.6%)], 16 laparoscopic [8 bilateral (50%); 8 unilateral (50%)] and 24 robotic repair [17 bilateral (70.8%); 7 unilateral (29.2%)]. Postoperative VAS level was significantly higher in open technique than in laparoscopic or robotic technique [median: 5.0 vs 2.0 vs 0; p \ 0.001]. Need of analgesics (per day) after surgery was also higher in open technique than in laparoscopic or robotic technique [median: 3.0 vs 1.5 vs 1.0; p \ 0.001). Operative room time (ORT) was much longer in robotic technique than in laparoscopic and or open technique [median: 92.5 min vs 79.0 min vs 44 min; p \ 0.001). Length of hospitalization was similar in each group (median1.0 day). There was no different in terms of postoperative complications between three groups. Conclusions: robotic inguinal hernia repair is technically feasible and safe procedure. Operative room time for robotic cases is significantly longer than laparoscopic and open techniques and there is substantial additional supply cost. There is clear benefit of robotic and laparoscopic techniques, comparing to open approach, in terms of patients postoperative recovery. Technical advantages of robotic technique and short learning curve may cause the more wide popularization of minimal invasive approach of the surgical management inguinal hernia.

P007 - Abdominal Cavity and Abdominal Wall Broad Ligament Hernia: Report of Two Cases

Introduction: Superior lumbar hernia is rare hernia which occurs in the superior lumbar triangle. We report a case with superior lumbar hernia treated successfully with laparoscopic surgery. Patients: An 84 year-old-woman visited near clinic complaining with left lateral lumbar pain. As her digital exam revealed bloody stool and the blood exam showed anemia, she was referred to our hospital with suspicion of ischemic colitis. But the physical exam revealed the tumor about 4 cm in diameter palpable on her lateral abdomen. CT scan showed incarcerated superior lumbar hernia. Incarcerated hernia content was easily placed back and we decided her to operate by laparoscopic procedure. Operation: We used three ports, at navel, below left costal area, and left lateral lower abdomen. After mobilization of descending colon from the retroperitoneum, we could notice the depressed area at the lumbar triangle which is the hernia orifice composed with the 12th rib, internal abdominal oblique muscle, and lumbar quadrate muscle. We resected the hernia sac and placed Modified Kugel PatchÒ with absorbable tackers. And we cover the mesh with fatty tissue preventing intestinal adhesion. Postoperative course was quite smooth and she was discharged on the 11th day after operation. We found no recurrence two year after surgery. Conclusion: As superior lumbar hernia is a rare disease, it might be difficult to select how to approach for this disease. We think that laparoscopic procedure is quite reasonable and useful for this disease.

P009 - Abdominal Cavity and Abdominal Wall Laparoscopic Treatment of Postoperative Hernia

J.O. Kim, S.Y. Nam, Y.Y. Choi

M.A. Khamidov1, Z.S. Mekhtikhanov2, A.S. Murtuzalieva1

Department of Surgery, CHA University, Gumi CHA Hospital, Gumi, Republic of Korea

1

Introduction: Internal hernia is a rare cause of small bowel obstruction. Herniation through a defect of the broad ligament is extremely rare. We report two cases of closed loop obstruction through broad ligament herniation. Case 1: A 54 year old multiparous woman presented to the department of internal medicine with symptoms of left lower quadrant abdominal pain, nausea and vomiting. She had no previous abdominal surgery. Initial CBC, electrolyte tests and abdominal CT scan showed no abnormal findings. During conservative management, her symptoms had not improved. Four days after admission, rechecked abdominal CT scan revealed closed loop obstruction of small bowel in left pelvic cavity. The patient underwent laparoscopic surgery. Incarcerated but not stranulated small bowel was easily reduced and there was 5 9 3.5 cm sized oval defect at left broad ligament. We closed the defect with several simple sutures. Her hospital progress was not eventful. She was discharged 4 days after operation. Case: A 52 year old multiparous woman visited to our hospital with left lower quadrant pain for several hours. The patient stated no previous abdominal surgery. Vital signs were normal range but left lower abdomen was slightly tender. Abdominal CT scanning showed closed loop obstruction in left pelvic cavity. Emergent laparoscopic exploration was done. Incarcerated small bowel was released and there was no bowel ischemia. We found 4 9 3 cm sized defect at left broad ligament and closed the defect. Postoperative day 6, she was discharged without complication. Conclusion: Broad ligament herniation is very rare cause of small bowel obstruction. But we should consider the broad ligament hernia as a possible cause of intestinal obstruction in females. Laparoscopic approach is a good option fort this condition.

Endoscopic surgery, Dagestan State Medical University, Makhachkala, Russia; 2Miniinvazive Surgery and Gerniology, MultiProfile Private Clinic, Healthy Nation, Makhachkala, Russia Surgical treatment of postoperative abdominal hernias has been and remains one of the most difficult problems of abdominal surgery. Aim: The aim of the study was to analyze the results of the laparoscopic method of treatment of postoperative abdominal hernias. Material and Methods: A prospective study of the results of treatment of 72 patients (57 women and 15 men) operated by laparoscopic methods (‘‘IPOM’’, ‘‘IPOM-Plus’’). The average age of patients was 52.5 ± 2.8 years (from 31 to 78 years). In 38 patients with localization of hernias M2–M3 and L4, pre-suturing of hernial gates with their dimensions W1–W2 with percutaneous throughpass sutures with a supra-fascial setting of the node was performed, and the remaining 34 patients were fitted with a mesh-prosthesis on the posterior surface of the abdominal wall with the localization of hernias M3–M4, and L2–L3 over a defect of width W1–W2 with overlapping of its edges by 3 cm in all directions. The time frame for monitoring patients after discharge from the hospital was 4 months to 2 years. Results: The average duration of the operation was 62.3 ± 0.18 min (45 to 130 min). Serum was detected in 17 patients in the early postoperative period. All these cases were associated with the formation of a closed space between the hernial sac and the prosthesis with IPOM plastic. At the time of 7 months and a year and a half after laparoscopic IPOM-plastic recurrence of the hernia in 2 patients (M4W3 and L4W3) was noted. Conclusions: Laparoscopic prosthetic plastic is an effective method of treating postoperative small and medium-sized abdominal hernias (up to 10 cm wide) of any site. The choice of the method of plastics largely depends on the geometry of the hernial defect, with defects close to the circle; it is preferable to ‘‘IPOM’’ -plastic, and for defects close to the ellipse - ‘‘IPOM-Plus’’ -plastic.

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Surg Endosc

P010 - Abdominal Cavity and Abdominal Wall

P012 - Abdominal Cavity and Abdominal Wall

Indolent Peritoneal Mesothelioma as an Incidental Finding Within an Inguinal Hernia SAC: Presentation of a Rare Case with an 11-Year Follow-Up

Laparoscopic Repair Of Complex Groin Hernia - Early Results: And Experience

K. Gasteratos1, P. Katafygiotis2, P. Christou3, K. Christodoulou1 General Surgery, General Hospital of Corfu, Corfu, Greece; 21rst Laboratory of Pathology, University of Athens, Athens, Greece; 3 Anaesthesiology Department, General Hospital of Corfu, Corfu, Greece 1

Aims: Primary malignant peritoneal mesothelioma (MPM) is a rare entity, especially in men accounting for less than 10–20% of all mesotheliomas. Only a few cases of MPM arising from an inguinal hernia sac have been reported. We present a case of a 65-year-old man with a known occupational asbestos exposure, who underwent a repair of an uncomplicated groin hernia. During surgical exploration, a lesion with irregular borders was found in the medial aspect of the hernia sac. The mass was debulked and the hernia sac was resected. Methods: In hematoxylin and eosin staining, a well-differentiated papillary mesothelioma (WDPM) of the peritoneum with benign biological activity was found. Histology showed evidence that the well-formed papillary structures are lined by a single layer of uniform cuboidal cells with centrally placed nuclei and inconspicuous nucleoli. Results: The patient underwent multiple investigations with computerised tomography (CT), magnetic resonance imaging (MRI) scans of the chest, abdomen, and pelvis to stage the disease and a bone scan to search for evidence of metastatic disease. All investigations, including baseline laboratory blood tests, were normal. After a period of 4 years, an exploratory laparoscopy was undertaken with a standard open approach (Hasson technique). Laparoscopy revealed widespread peritoneal deposits and a gastrointestinal stromal tumor of the sigmoid colon. Pathology reports of multiple samples confirmed the presence of a WDPM of the peritoneum. The sigmoid tumor was laparoscopically resected, and an endto-end anastomosis was performed. Six years following the first laparoscopy, he is currently being investigated with a second-look laparoscopy and further scans to assess the latency of the disease. To date, the patient is alive and well 11 years from the diagnosis. Conclusions: Rare tumors may present as inguinal hernias or as an incidental finding within a hernia sac, in which case surgical debulking of the tumor may be effective and curative treatment. Interestingly, highly diagnostic modalities, such as CT and MRI scans may fail to show the presence of the WDPM in the abdominal cavity. Long-term surveillance with laparoscopy and full work-up of these patients are warranted to ensure the disease remains limited.

H. Salgaonkar, R. Maia, S. Wijerathne, L. Loo, A. Shabbir, D. Lomanto General Surgery, National University Hospital Singapore, Singapore, Singapore Background: Complex groin hernia is a surgical challenge. Laparoscopy for repair of groin hernias is gaining popularity due to lesser pain, faster recovery, better cosmesis and reduced morbidity. However, there is still debate on its use in complex scenarios. Recurrent hernias, history of lower abdominal surgery anticipating adhesions and large inguino-scrotal hernias with difficulty in dissecting extensive hernia sac present technical challenges. Aim of our study was to assess feasibility of laparoscopy for repair of complex groin hernia. Method: Retrospective analysis of prospectively collected data was done in patients undergoing laparoscopic repair of large inguino-scrotal, incarcerated groin hernia, recurrent cases after open or laparoscopic repair and patients with history of previous lower abdominal surgery. The present study includes period from January 2013 to October 2017, 192 patients with large inguino-scrotal hernias, recurrent hernia, history of lower abdominal surgery, incarcerated femoral hernia were included in the study. 192 patients divided into 112 unilateral and 80 bilateral hernias totalling 272 groin repairs were treated with laparoscopic groin hernia repair. Patient characteristics, operating time, surgical technique, conversion rate, complications and recurrence recorded. Results: 109 patients had large inguino-scrotal hernia, 58 recurrent hernia (40 previous open, 10 patients had previous laparoscopic repair, 4 previous laparoscopic as well as open repair and 4 patient multiple laparoscopic repairs.), 21 had history of lower abdominal surgery (4 LSCS, 6 Appendectomy, 2 prostatectomies, 2 midline laparotomy), 3 incarcerated femoral hernia, 1 meshoma removal. 163 patients underwent total extraperitoneal (TEP) repair, 29 transabdominal pre-peritoneal (TAPP), 1 needed conversion to open, 4 patients a hybrid procedure. Mean operation time was 73 min for unilateral and 119 min for bilateral hernia. Seroma formation seen in 29 patients, 4 minor peri-port wound infections treated conservatively. Conclusion: We conclude that the laparoscopic approach can be safely employed for the treatment of complex groin hernias despite the technical difficulties. Surgical experience in laparoscopic hernia repair is mandatory with tailored technique in order to minimize morbidity and achieve good clinical outcomes with acceptable recurrence rates.

P011 - Abdominal Cavity and Abdominal Wall

P013 - Abdominal Cavity and Abdominal Wall

Redo-Laparoscopic Inguinal Hernia Repair - a Surgical Challenge

Modern Aspects of Laparoscopic Hernioplasty IPOM in Cases of Ventral Hernias

H. Salgaonkar, R. Maia, S. Wijerathne, L. Loo, D. Lomanto

A.G. Khitaryan, S.A. Kovalev, V.N. Kislyakov, R.N. Zavgorodnyaya, K.S. Veliev

General Surgery, National University Hospital Singapore, Singapore, Singapore Background: Inguinal hernia repair is one of the most commonly performed operations in general surgery. The major concern after an inguinal hernia repair is recurrence. It is recommended to prefer anterior repair for managing a recurrent hernia after previous posterior repair to minimize risk of complications associated with the repeated posterior repair. However, re-laparoscopic treatment of inguinal hernia recurrences after previous posterior repair is a relatively new concept with favourable results. The Aim of this study was to examine a series of re-laparoscopic repair, its feasibility, technical challenges and the clinical outcomes in patient having recurrence post laparoscopic mesh repair. Methods: Retrospective analysis of prospectively collected data of 18 patients who underwent re-laparoscopic repair (TAPP or TEP) for a recurrence after previous laparoscopic repair between January 2013 and October 2017 performed. Patient characteristics, operating time, surgical technique, conversion rate, complications and recurrence recorded. Results: All the patients were male with a mean age of 52 years. Technical failures in the previous repairs were the main factors contributing to recurrences. 10 patients had previous laparoscopic repair, 4 previous laparoscopic as well as open repair and 4 patient multiple laparoscopic repairs. In most cases of recurrence post laparoscopy, the mesh had migrated into a large defect. While improper mesh position, mesh contraction accounted for other reasons. Effort was made to keep the old mesh on the peritoneal side during preperitoneal dissection to avoid tears in peritoneum and to facilitate surgical manipulation. The mean operative time was 72 min for unilateral and 116 for bilateral repair. There were no conversions, injury to inferior epigastric artery was seen in 1 patient, and no morbidity or rerecurrence during a mean follow-up period of 14 months (range 2–20 months). Conclusion: Redo-laparoscopic repair appears to be safe and effective in the treatment of recurrent inguinal hernia and affords the same benefits as an initial laparoscopic repair in experienced hands. Further randomized control trials with larger patient groups is needed to validate the results.

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Department of Surgical Diseases, Rostov State Medical University, Rostov-on-Don, Russia Traditional hernioplasty is the most common method of surgical treatment of ventral hernias. At the same time, laparoscopic technique of this surgery gives the best results of treatment, rehabilitation, including a much smaller percentage of complications and relapses. Objective: To evaluate the results of applying laparoscopic hernioplasty IPOM in cases of ventral hernias. Materials and Methods: We had 72 patients with ventral hernia who were operated from 2015 to 2017. The first one was operated by the sublay technique and another one group has a laparoscopic hernioplasty IPOM. All patients had a pre-surgery medical examination. The size of the hernial ring, of the patients ranged from 3 to 15 cm2. The operation involved laparoscopy, herniolysis, separation and suturing of the hernia defect with a small size. Then intraperitoneally set mesh endoprosthesis ‘‘Reference’’ (Russia). The fixation of the prosthesis to the abdominal wall was performed using transvascular seams intracorporate suture. Results: Intraoperative complications were not observed. Additional analgesic drugs are administered. After operation on 1st day patient had been allowed to get up, to move independently.

The severity of postoperative pain was assessed by visual analogue scale (VAS) and noted by the patients as ‘‘mild’’ and ‘‘moderate’’. Early postoperative complications have not been observed. All patients were in our clinic not more than 5 days. Longterm results were evaluated during the period from 6 to 15 months. Recurrence was observed in 2 patients with a hernia orifice size exceeding 100 cm2 Conclusions: Laparoscopic intraperitoneal onlay mesh (IPOM) hernioplasty has proved to be an effective surgical procedure for ventral hernia repair. It provides much benefits with low complications and conversion in experienced hands.

Surg Endosc

P014 - Abdominal Cavity and Abdominal Wall

P016 - Abdominal Cavity and Abdominal Wall

The Comparison of Diagnoses of Pre Intra and Postoperative Appendicitis

Giant Esophageal Hiatal Hernia with Upside-Down Stomach Treated by Laparoscopic Surgery

N. Ozlem

M. Ishizaki, F. Uno, K. Kawasaki, R. Yoshida, N. Waki, N. Iga, H. Kawai, H. Nishi, K. Yamashita

General Surgery, Ahievran University, Kirsehir, Turkey Acute appendicitis is more than 50% of acute abdominal disease. If the disease is diagnosed and treated early the mortality is under 1/1000. Delay in t he diagnosis and treatment of this disease results increasing mortality and morbidity. At Ahi Evran University education and research hospital general surgery department the records of 208 patients with an age range of 3–74 years, which were operated between 2015–2017 with a diagnosis of suspicious acute appendicitis, were reviewed and the pre, per, post operative diagnosis of these patients were evaluated. Acute appendicitis is prediagnosis in 208 patient. The diagnosis of 194 patients in pathologic examination are acute appendicitis, 14 of them is not acute appendicitis. PPV is 194/2018. Out of 171 patients who has an upper abdominal X-ray has locally ileus sign on right lower quadrant, 36/38 patients has acute appendicitis. Pathologic examination of speciemens of 14/208 patients do not show acute appendicitis but out of 194 show acute appendicitis. acute appendicitis, acute disease needing surgical intervention is still seen in the same frequency as the past. Since its diagnosis and treatment needs prompt action, action must be taken as quick as possible. Leucocyte counts more than 10000/mm3 are in indications to acute and perforated appendicitis. its been shown that usg and diagnostic laparoscopy can be used in the diagnosis and treatment for appendicitis but its use mostly advise in women of child bearing age to prevent the risk of infertility. The fact that the patient with perforated appendicitis comes to medical attention much more later than others must make us aware that to prevent the negative effects of perforation, the potential patients meaning all the citizens should be educated and informed, first step physicians who first examine the patient mostly should educated well and the general surgeons must be motivated to improve themselves both technically and in knowledge. Lastly, the family practitioners, the members of a specialty which is new in our country, who will examine the patient in the first step should have through knowledge and capability in dealing with such disease. This work is supported by Ahi Evran University scientific research commitee with the project nu is E2 001

Department of Surgery, Okayama Rosai Hospital, Okayama-City, Japan Introduction: Esophageal hiatal hernia with upside-down stomach is a rare condition, sometimes requiring emergency surgery. We treated giant esophageal hiatal hernia with laparoscopic surgery successfully and report this case here. Method and Patients: The patient was an 83-year old lady with dysphagia. She had suffered swallowing difficulties for some time, but as she complained severe vomiting and aspiration pneumonia, she was referred to our hospital for treatment. Chest x-ray showed a large gas shadow overlapping mediastinum. CT scan showed two thirds of the stomach had slipped into the mediastinum through the esophageal hiatus. The hernia orifice was about 8 cm in diameter on CT scan. Operation: The operation was performed from five entries. With confirming the hernia orifice, the dislocated stomach was reduced back in abdomen. Dissection of the lesser omentum using the harmonic scalpel followed. After isolation of the right and left crus of the diaphragm, the distal esophagus was mobilized approximately 6 cm above the cardia. The hiatal defect was closed with non-absorbable sutures. The defect closure was reinforced with U-shaped PCO mesh. In a final step, an about 270° Toupet fundoplication was accomplished. Results: Postoperative course was smooth and she was discharged on the 20th day. We have found no recurrence for 2 years. Conclusion: Surgical treatment is the only curative therapy in patients with upside-down stomach. Laparoscopic surgery should be considered in old patients with upside-down stomach with expected safety and favorable outcomes.

P015 - Abdominal Cavity and Abdominal Wall

P017 - Abdominal Cavity and Abdominal Wall

Transabdominal Preperitoneal (TAPP) Repair for Incarcerated Obturator Hernia

Laparoscopic Ventral Hernia Repair with Endoscopic Component Separation Method

T. Kaetsu, M. Mizutani, K. Hatta, K. Yokomizo, M. Nagaya, K. Shimizu, M. Kikuichi

T. Aoki, H. Imoto, A. Yamamura, H. Karasawa, T. Takadate, M. Ishida, N. Tanaka, K. Watanabe, S. Ohnuma, T. Morikawa, H. Musha, F. Motoi, T. Kamei, T. Naitoh, M. Unno

Digestive Center, Department of Surgery, Kikuna Memorial Hospital, Yokohama, Japan Aim: Traditional repair for Obturator hernia (OH) is still common, even though the laparoscopic approach is widely accepted for groin hernia. The aim of this study was to clarify the efficacy of transabdominal preperitoneal (TAPP) repair for OH compared with an exploratory laparotomy. Methods: From 2008 to 2016, we retrospectively analyzed patients who performed surgery for OH at our hospital. Thirteen patients were enrolled in this study. Hernia sac was removed and synthetic mesh was inserted obturator foramen under the peritoneum for both the TAPP repair group and the traditional laparotomy group, whereas simple peritoneal closure of hernia orifice was only available if a small bowel resection was necessary. The surgical outcomes of TAPP for OH were compared with those of open laparotomy. Results: Three patients with OH were treated by TAPP repair, sixteen patients who were treated with open surgery. All the patients were female in both groups. These two groups were similar with regard to age, ASA Physical Status classification and operating time. Small bowel resection was found in three patients undergoing open laparotomy, whereas none occurred in the TAPP group. The intraoperative complications were not found in either group, however one metachronous contralateral OH occurred in both groups. Recurrence occurred for two patients in the open surgery group. The postoperative hospital stay was shorter in the TAPP group (5.3 ± 1.5) than in the open surgery group (16.5 ± 19.1). There was no incidence of postoperative morbidity or mortality. Conclusions: TAPP repair was associated with a reduced duration of postoperative hospital stay and recurrence of OH. TAPP repair is available if small bowel resection is not necessary. TAPP is a feasible, minimally invasive approach for the repair of OH.

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan Background: Laparoscopic Ventral Hernia Repair (LVHR) is approved as an insurance adaptation technique from 2012 in Japan. In our department, conventional three port LVHR had been performed as a regular surgical option. Furthermore, we recently add the endoscopic component separation method (ECS) to LVHR, in the case of large midline hernia and infectious wound. Aim: We present a case of LVHR with ECS, and assessed the safety and efficacy of this technique compared with LVHR only. Patients and Method: Patients who underwent the LVHR in our institute during 2004 and 2017. 44 patients underwent LVHR, and three patients were added ECS. Case Presentation: 47 year-old female. Total hysterectomy was performed. After then, the ventral hernia (13 9 8 cm orifice) was created. We planed LVHR with ECS. A 12 mm balloon-tipped trocar was placed at the posterior space to the external oblique aponeurosis. A dissecting balloon was used to create that space head to tail. The external oblique aponeurosis was divided overall with hook type electrocautery. The contralateral side was divided in the same manner. A 12 mm trocar was inserted to the abdominal cavity. After creating pneumoperitoneum, a second 5 mm trocar and a third 5 mm trocar was inserted. At first hernia orifice was closured with non-absorbable surgical sutures. We choosed a mesh enough covering the hernia orifice, and put it into the abdominal cavity. The mesh was lifted the abdominal wall by two non-absorbable surgical sutures. After lifting the mesh, the mesh was fixed using the laparoscopic absorbable tacker. Results: LVHR only was performed in 41 cases, and LVHR with ECS was in three cases. Between two groups, there was significant differences in terms of operative time (LVHR:LVHR with ECS = 118:188 min), but not in blood loss and hospital stay. There were no postoperative complications in each group. One case of ECS was performed primary closure not to use the mesh, because the patient has a hope of pregnancy. Both cases also have not recurred until now. Conclusion: LVHR with ECS would be acceptable procedure for large midline ventral hernia repair.

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Surg Endosc

P018 - Abdominal Cavity and Abdominal Wall

P020 - Abdominal Cavity and Abdominal Wall

Laparoscopy Hernioplasty (TAPP) 25 Years Experience (1992–2016)

Laparoscopic Coverage of the Pelvis Using the Mobilized Cecum for Secondary Perineal Hernia

J. Navarro Sanahuja, M. Pierres Mir, C. Mun˜oz Tabernero, E. Calvet Medina, M. Cubel Brun, F.C. Agaton Bonilla, M. Rovira Arguellages, A. Puigdollers Perez, F. Perez Bote

S. Ishiguro1, S. Komatsu1, T. Arikawa2, T. Saito1, K. Komaya1, K. Kaneko1, T. Sano1

General Surgery, Hospital de Mollet, Mollet del Valles, Barcelona, Spain

2

Introduction: With the appearance of laparoscopic surgery different surgical techniques were subsequently converted to this path. In our center in 1992 we initiated laparoscopic hernioplasty TAPP (preperitoneal transabdominal) with the intention that the benefits of laparoscopy, less pain, less infection, better aesthetic results and a more early work regain, could be applied to Inguinal Hernia. We present our experience gathered in a computer log (ACCESS) consecutively. Material and Method: Since 1992 we have included 4307 patients with 4919 hernioplasty (612 bilateral) in our registry. 3148 (63.99%) were mediated laparoscopic, as well as 89.86% of bilateral (550/612). We value the evolution of the complications of the technique over time and the impact of the learning curve by dividing the procedures in two periods the initial (IP) of 10 years of consolidation of the technique and compare it with the last 15 years (FP), evaluating typical complications, reconversion and evolution in the acquisition of expertise by the staff. And on the other side we value one of the items that were criticized in the laparoscopic hernia the possibility of Day surgery. Results: The entire service performed TAPP without distinction with the distribution that is attached in the graph, in the 1992–2001 IP, 1823 hernioplasties/1037 laparoscopic (56.89%) and FP 3096/2111 lap (67, 05%). Recurrences were 2.26% in (IP) and 0.94% in (FP) respectively. Reconversion of the technique to open in 0.32% (IP) and 0.18% (FP). Complications: Seromes 48 (4.63%) (IP)/64 (3.03%) (FP); Orquitis (1.45%)/(0.28%); Wounded infection (6.65%)/(2.37%); Chronic pain (1.54%)/(0.28%); Intestinal occlusion (0.19%)/(0%); Visceral lesion (0%)/(0.05%). We have associated surgery to other procedures, cholecystectomy, Hiatal hernia, etc. in 218 patients. Day surgery (DH) we started in 2002 and made 2533 procedures (82%) of the total. Conclusions: TAPP is a safe, reproducible procedure with a tax of complications and recurrences and with the possibility of performing in Day Surgery comparable to other techniques and that associates the advantages of laparoscopy.

Case: Was an 81-year-old male who underwent laparoscopic APR for rectal cancer. He noticed perineal bulging and it gradually grew larger. MRI revealed that majority of the small bowel was located into the pelvis beyond the ordinary pelvic bottom with a thin perineal skin. Two years after surgery, he underwent surgery for perineal hernia. Via transperineal approach, the adhesion of the small bowel was dissected and the skin was closed temporally. After an establishment of pneumoperitoneum, the right-sided colon was mobilized completely followed by the cecum moving into the pelvis. With a special attention to not preventing the passage of the ileum, the cecum was fixed to the bladder and the pelvic rim with an interrupted suture laparoscopically. Perineal wound was managed with negative pressure wound therapy by a plastic surgeon. He remains free of hernia recurrence one year postoperatively. Case: Was a 79-year-old female with a history of hysterectomy for uterine myoma. She was diagnosed as having rectal cancer and underwent APR. Two years postoperatively, she presented with a symptomatic perineal hernia. As in case 1, the small bowel was taken up from the pelvis via laparoscopically transabdominal and transperineal approach. The cecum was introduced into the pelvis and was fixed to the pelvic rim. Because of absence of the uterine, a lot of interrupted sutures were necessary to fix the mobilized cecum to her wide pelvis. As of 6 months after surgery, radiological evaluation demonstrated no evidence of recurrence. Conclusion: Laparoscopic coverage of the pelvis using the mobilized cecum is safe and feasible approach for secondary perineal hernia as an alternative method of mesh surgery.

P019 - Abdominal Cavity and Abdominal Wall

P021 - Abdominal Cavity and Abdominal Wall

Fixation-Free Mesh Repair in Laparoscopic Trans-Abdominal Pre-Peritoneal Inguinal Hernia is Superior to Fixation of the Mesh on Long-Term Follow-Up

Traumatic Rupture of a Meckel’s Diverticulum Presenting as an Enterocutaneous Fistula

M. Mitchard, J. Andrews, J.B. Reed, A.M. Almoudaris Colorectal Surgery, Colchester University Hospital, Colchester, United Kingdom Aim: To evaluate long-term outcome data from a single surgeon series of elective laparoscopic inguinal hernia repair comparing patients in whom a standard lightweight mesh was fixated with a tacking device versus those without tack fixation. Methods: Patient identification was performed from a prospectively maintained operative log. The operation note, patient demographics and post-operative recovery details were compiled into a bespoke database. Attempts were made to contact all patients by telephone using a standardised questionnaire to evaluate long-term outcomes. All patients underwent a standardised re-usable instrument three port technique with placement of a 10 9 15 cm ParietexTM flat-sheet mesh using no fixation of the mesh. A comparative group underwent the same procedure plus the addition of mesh fixation using a ProtackTM tacking device. All patients had sutured repair of the peritoneal incision. Results: 140 patients were contactable from 344 identified. Two groups were analysed, those with No Mesh Fixation (NMF) versus plus Tack Mesh Fixation (TMF). 93/140 (66.4%) underwent NMF compared with 47/140 (33.6%) undergoing TMF. Mean follow-up was 1545 (4.2 years) and 1459 days in the NMF and TMF groups respectively (p = 0.519). There were no differences in age (p = 0.798) or sex (p = 0.062) of patients. More patients in the TMF had bilateral herniae repaired 16/47 (11.4%) versus the NMF group 6/93 (4.3%)(p = 0.001). Median LOS was no different in both groups of 0 days (day-case)(p = 0.075). Pain scores were not significantly different (p = 0.675). There were no differences between the groups in pre-existing prostate/bladder diagnoses/pathology (p = 0.286). Patients were more likely to need a post-operative urinary catheter in the TMF group 11/47 (7.9%) versus 8/93 (5.7%) in the NMF group (p = 0.018). Recurrence only occurred in the TMF group 3/47 (p = 0.036) with a cohort recurrence rate of 2.1%. There were no recurrences in the NMF group of 93 patients. Conclusion: In this single surgeon cohort the majority of patients had no fixation of the mesh and had no recurrences. Patients were more likely to need a post-operative urinary catheter and more likely to have a recurrence in the tack fixation group. These findings may better inform surgeons during obtaining informed consent but also have important cost implications and suggest that routine mesh fixation is not necessary in the majority of laparoscopic hernia repairs.

123

1

Surgery, Aichi Medical University, Nagakute, Japan; Gastrointestinal Surgery, Aichi Medical University Hospital, Nagakute, Japan

D. Lim, V. Meytes, K. Bain General Surgery, NYU Langone Health, Brooklyn, USA Aim: To report the first case of a ruptured Meckel’s diverticulum secondary to blunt trauma which presented as an enterocutaneous fistula. Case Report: Patient is a 25 year old male with no significant past medical or surgical history, who presented with complaints of persistent drainage from a periumbilical wound which he sustained after bumping into the corner of muffin machine at work 1 month ago. It started as an area of erythema and progressed to persistent drainage, not amendable to oral antibiotics. Patient only admitted to pain around the area and denied any fever/chills, abdominal pain, nausea, vomiting or diarrhea. Patient’s white blood cell count was 6.9 on presentation. Abdominal CT scan was performed which demonstrated a portion of thickened small bowel with suspicion of an enterocutaneous fistula. The fluid was sent for microbiology which grew Enterobacter. Intraoperatively, the segment of inflamed bowel was carefully dissected and identified as a Meckel’s diverticulum about 2 feet from the ileocecal junction. This area was noted to be necrotic which was resected and intestinal continuity reestablished. Patient’s hospital course was uncomplicated and he was discharged after return of bowel function, tolerating a regular diet and adequate pain control was maintained. Upon follow up, patient reported to be recovering well, with no new complaints. Discussion/Results: Meckel’s diverticulum is an outpouching of the small intestine that is a result from incomplete closure of the vitelline duct. It is most commonly located 40–60 cm from the ileocecal valve and occurs in 2–3% of the population. In most insistences Meckel’s diverticula are benign and patients are asymptomatic. Traumatic rupture of a Meckel’s diverticula is a rare occurrence and can result in severe abdominal pain, hemoperitoneum and peritonitis. Previously, cases have been reported of traumatic rupture of a Meckel’s diverticulum secondary to blunt traumas such as motor vehicle accidents and contact sports. Each patient presented with signs of peritonitis. Conclusion: This case report serves to demonstrate a unique presentation of a ruptured Meckel’s diverticulum. It emphasizes the importance of obtaining a thorough history and physical exam along with proper imaging to guide the formulation of an accurate diagnosis.

Surg Endosc

P022 - Abdominal Cavity and Abdominal Wall

P024 - Abdominal Cavity and Abdominal Wall

Concurrent Acute Appendicitis and Uncomplicated Acute Diverticulitis

The Original Method of Cruroraphy in Patients with Hiatal Hernia with Medium and Large Size with Cholecystectomy Performed Simultaneously

H.C. Bennett, S. Cremen, F. Kilby, R. Mitru, A. al Alami, M. Aremu General Surgery, James Connolly Memorial Hospital, Blanchardstown, Dublin, Ireland, Dublin 15, Ireland Individually, diverticulitis and appendicitis are two of the most common surgical presentations to emergency departments. Although of a similar pathology, (obstruction leading to oedema and inflammation) and with similar complications if left untreated (perforation, inflammatory mass, abscess), management of the two presentations differs. The gold standard treatment for appendicitis is still appendicectomy, though also managed in selective cases with antibiotics. The management of diverticulitis depends on severity and includes low residue diet and antibiotics for uncomplicated diverticulitis, and percutaneous drainage of abscesses, laparascopic lavage, bowel resection and stoma formation for more complicated presentations. We hereby report a rare case of concurrent acute appendicitis and diverticulitis in a 62 year old man who presented to our Emergency Department with a one day history of lower abdominal pain localising to the RIF, suprapubically and LIF. On exam his pulse was 102, BP 110/80 and temperature of 37.6 °C. There was marked tenderness and guarding in his right and left iliac fossae, but maximal in the right iliac fossa. His FBC was elevated WCC at 13.4 g/dl and his CRP was 11.7 mg/L. CT scan of the abdomen and pelvis revealed distended appendix with adjacent fat stranding and sigmoid diverticuli with mesenteric stranding. He was commenced on intravenous antibiotic – Tazocin 4.5 g 8 h. The patient became increasingly tender especially in the RIF, spiked a temperature of 38.3 °C and his CRP rose to 270 mg/L in spite of the IV antibiotics. He was taken to theatre for laparoscopy 48 h after admission as he was not improving clinically. At laparoscopy, he was found to have an appendicular mass comprising of thickened appendix wrapped by terminal ileum, caecum and omentum with the sigmoid colon adherent to the mass and a small amount of infected fluid in the pelvis. The pelvis was washed with normal saline and a Robinson drain inserted. Patient did well postoperatively and was discharged home after 10 days of intravenous antibiotics and scheduled for interval appendicectomy. This case highlights that surgeons should be more aware of the concurrent coexistence of these two common presentations of acute abdomen to emergency departments.

M. Halei1, I. Shavarov1, I. Dzyubanovski2 1

Laparoscopic Surgery, Volyn Regional Clinical Hospital, Lutsk, Ukraine; 2Surgery of the Training and Research Institute of Postgraduate Education, SHEI, I.Ya.Horbachevskyi Ternopil State Medical University, Ternopil, Ukraine Introduction: Very frequently patients with hiatal hernia (HH) are treated conservatively by gastroenterologists for many years, but HH, which was formed, has the ability with the physical activity of patient in routine life. Accordingly significant part of HH, that are diagnosed are medium- and large-sized and standard cruroraphy (CR) by separate sutures is not always reliable. Aim: To develop appropriate method of CR for medium- and large-sized HH with minimally recurrence rate. Materials and Methods: Between 2010 and 2016 420 procedures for HH was performed, 45 (10.7%) of them medium- and large sized were. These patients were divided on 2 groups. In first group - 17 (37.8%) patients, were by our original method, the imposition of mesh on the areas, that are situated inside sutures on the cruses and covers them (patent UA A61B 17/00). 5 patients of this group were with gallstone disease simultaneously operated. In second group – 28 (62.2%) patients, in which CR was only by separate sutures performed. For 2 groups of patients fundoplication by Toupet was performed. Results: In first group there was no recurrences observed. In second group in 2 (7.1%) patients recurrences were happened. There was no other postoperative complication observed. Conclusions: CR with use of imposition of mesh on the areas, that are situated inside sutures on the cruses and covers them, is not complex in performance and provides minimally recurrence and complication rate.

P023 - Abdominal Cavity and Abdominal Wall

P025 - Abdominal Cavity and Abdominal Wall

Effect of Direct Defect Closure on Post-Operative Seroma During Tep Inguinal Hernia Repair

Our Experience About Recurrence After Laparoscopic Ventral Hernia Repair

S.M.P. Pathirana

G. Celona, C. Bagnato, F. Filidei, D. Pietrasanta, S. Sergiampietri, A. Costa

General Surgery, Ministry Of Health, Ragama, Sri Lanka Introduction: Post-operative seroma after laparoscopic TEP repair of direct inguinal hernia is a well known surgical complication. Prevention of seroma still a challenge to the surgeons. We observed that suture closure of the direct defect helps prevent post-operative seroma in these patients. Method: Prospective study in a single institution conducted from September 2016 to September 2017. The defect was closed using a non-absorbable suture before placement and fixation of the mesh when defect is larger than 2 cm (larger than the grasper jaws). Patients were followed up post-operatively and observed for pain, seroma and hematoma. Results: Twenty-two direct defects repaired in 17 patients. Out of 17 patients 12 were unilateral and 5 were bilateral hernia. Eleven indirect defects noted but no femoral defects. Exact operative time was not measured. However, mean time was not longer than 60 minutes. No objective difference noticed in analgesia requirement. One patient noticed to have hematoma at discharge another two patients noticed to have seroma at first visit to out patient clinic (after 2 weeks). all complications resolved spontaneously on follow up. Conclusion: Suture closure of the direct defect during TEP inguinal hernia repair may help prevent post-operative seroma. More structured and randomized studies would be needed to assess the exact outcome of this technique.

Department of General Surgery, Health Unit North West Tuscany, Pontedera, Italy The meta-analysis on laparoscopic ventral hernia repair report a recurrence rate ranging from 5.3 to 8.7%. Technical pitfalls as small size, weak fixation and shrinkage of the mesh, inadequate overlap of the defect or unrecognized abdominal wall defects are the most frequent causes of recurrence. Surgical site infection, previous failed hernia repair, chronic cough and obesity are main patient-related risk factors. Here we report our opinion about this matter, according to the analysis of our series. From September 2012 to November 2017, 129 patients underwent laparoscopy in order to repair ventral hernia. Conversion rate to open was 11.6%(15 patients), mainly because of severe adhesions. Laparoscopic repair was performed in 90 (79%) patients for incisional hernia and in 24 (21%) for primary hernia. In the first 44 (59%) cases we used a flexible composite mesh (Physiomesh, Ethicon), then for the following 70 cases repair was accomplished with Parietex Composite mesh (Medtronic-Covidien).In all procedures mesh was placed overlapping the margins of the defect by at least 5 cm and it was fixed with a double crown of absorbable tacks alone in the first 44 cases, with a combination of permanent and adsorbable spiral tacks in the remaining 70 cases. Mean follow-up time was 31 months (range 2–60 months).Hernia recurrence was clinically evident in 10 (8.7%) patients. Among recurrences, 3 patients underwent laparoscopic hernia repair in our institution. All these recurrences appeared outside of the area of the previous defect, at the site of the apparent sufficient original incision scar and previous mesh repair has always proved technically correct. A new repair was accomplished successfully with a placement of a new larger mesh over or next to the past repair. Unfortunately, one of these patients, obese and with chronic cough, showed a new recurrence and finally required an open repair. Obesity was present in all patients with recurrence, while surgical site infection was observed in 2 patients. One case of recurrence occurred at port site. Our experience supports the concept that the optimal laparoscopic ventral hernia repair needs to include exposure of the entire old incision, using mesh with proper size and a prevalence of non-absorbable spiral tacks. Obesity and surgical site infection appear to be strong prognostic factors for recurrence.

123

Surg Endosc

P026 - Abdominal Cavity and Abdominal Wall

P028 - Abdominal Cavity and Abdominal Wall

Outcomes of Laparoscopic Incisional Hernia Repair with Ventralight ST Mesh with Echo PS Positioning System

Condition of Patients Introducing Inguinal Hernia from Our Practitioner

D. Nita, H. Narula

C. Tono1, H. Ishioka2, Y. Yaegashi2, M. Masanori2, Y. Yukihiro2, T. Yoshida2, A. Sasaki3

General Surgery, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, United Kingdom Purpose to evaluate the use of Ventralight ST Mesh with Echo PS Positioning System in laparoscopic repair of incisonal hernias and to compare results with the use of mesh without the positioning system. Material and Methods: retrospective study, 18 patients operated laparoscopically from 2014 to 2017, 12 using the PS Positioning system. The size of the mesh and the fixation method were based on mathematical considerations. A recurrence of hernia, postoperative complications, pain and surgeon’s ease of technique were the primary end points. Results: No recurrence. Low intensity of pain (VAS \ 2). One seroma, and one localised perforation related to adhesiolysis and managed conservatively. Compared to procedures without PS Positioning system no difference in postoperative complication, pain and recurrence rate but noted reduced time (35% time saving), ease of use and surgeon preference (100%). Conclusion: The Ventralight ST Mesh with Echo PS Positioning System fixed with a Sorbafix stapler is a valuable, safe, easier and more technically desirable option for a laparoscopic ventral hernia repair.

Surgery, Kuji Hosipital, Kuji, Japan; 2Surgery, Iwate Prefectural Kuji Hospital, Kuji, Japan; 3Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan 1

Our hospital is the only general hospital in the Kuji medical area with a target population of 60,000. The total number of beds is 289 beds. We examined the status of our hernia surgery and the medical condition of referral patients introduced from practitioners. In January 2016 to October 2017, there were 73 cases of enlarged hernia surgery, 9 females, 64 men. Among them, the introduction from the practitioner was 24% in 18 cases. The details of the whole are 47 cases on the right side, 24 cases on the left side, 2 cases on both sides. The surgical procedure is the groin incision method, 36 cases of the direct Kugel method, 11 cases of the mesh plug method and 26 cases by the TAPP method for the laparoscopic method. For the operation time, the groin incision method was from 32 minutes to 146 minutes, an average of 75 minutes. The laparoscopic method is an average of 101 minutes in 60 minutes to 231 minutes. Bleeding from 1 ml to 170 ml, average 8 ml. According to the operation type, the groin incision method is from 1 ml to 170 ml with an average of 9.9 ml. For laparoscopy, the average value is 5.6 ml from 1 ml to 36 ml. Postoperative hospital stay is 1 day to 22 days on average 4 days. The groin incision method is on average 4 days. Laparoscopy is 3 days on average. In consideration of 18 cases of referral patients from practitioners in the whole above, in 2016, 21% in 8 out of 37 cases. In 2017, 10 out of 46 cases were similar to 21%. Eighteen cases were performed with inguinal incision in 8 cases and laparoscopic examination in 10 cases. The total surgical time for 18 cases was 33 minutes to 134 minutes with an average of 79 minutes. The bleeding was from 1 ml to 36 ml, with an average of 9 ml. The hospital days after surgery were 1 to 4 days on average, 3 days on average.

P027 - Abdominal Cavity and Abdominal Wall

P029 - Abdominal Cavity and Abdominal Wall

Laparoscopic Intraperitoneal Onlay Mesh (IPOM) in Ventral Hernia Repair

Hybrid Repair for Boundary Hernias

A.N. Lytvynenko, I.I. Lukecha, L.R. Nazarko

Institute of Minimal Access and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Laparoscopic Surgery, O. Shalimov National Institute of Surgery and Transplantology, Kiev, Ukraine Aims: Annually there are about 20 million of hernia repair surgeries performed in the world, and up to 85–90 thousands in Ukraine. Relapse rate after hernia primary surgical treatment is about 10%, and with every next surgery it increases to 30% which significantly reduces the working capacity and does not facilitate rehabilitation of patients. The implementing of laparoscopic technologies increases the reliability of hernioplasty methods with simultaneous reduction of the traumatism, which contributes to the development of herniology during past years. To evaluate the results of surgical treatment of patients with ventral hernia which was performed by laparoscopic intraperitoneal onlay mesh (IPOM). Methods: An analysis of the treatment of 47 patients with ventral hernia who underwent laparoscopic IPOM in the period of 2015–2017 years has been performed. All patients are matched according to age and sex. An average age was 45 ± 3.4 years, an average body mass index (BMI) was - 28.1 ± 3.2 kg/m2. According to the Classification for Incisional Hernia, M1-4W3R0 were noted in 27 cases, M1-5W3R0 in 13 cases and M4-5W3R0 – in 7 cases. Operations has been performed using endo-video surgical equipment with a standard set of tools. Composite mesh implants were used to close defects in the anterior abdominal wall. Implant fixation was carried out by placing nonabsorbable transfascial sutures and endosteplers. Results: Laparoscopic hernioplasty was performed in 100% of cases. Mesh implants were located intraperitoneally only. The surgery duration was 84.3 ± 15.1 min. Postoperative pain was eliminated by nonsteroidal anti-inflammatory drugs. The hospital stay was 3.5 ± 0.5 days. No hernia relapse has been found during 3 year observation period. Two patients have had minor complications like hematoma. In one case the correction has been required in the way of puncture under the control of ultrasound. Conclusions: Laparoscopic ventral hernia repair is a safe procedure with benefits: it is a minimally invasive intervention, which can reduce the traumatism of the operation, the severity of postoperative pain, the amount of postoperative complications, reduce the hospital stay period and has an excellent cosmetic effect.

123

A. Goel, S. Kalhan, P. Bhatia

Background: Boundary hernias might be a challenging situation for many surgeons. Problems include poor mesh fixation, high recurrence rates, seroma formation and mesh migration. Challenges associated with pure laparoscopic repair or pure open repair may be overcome by hybrid repair. We present our series of 17 patients who were managed with hybrid repair for boundary hernias. Method: A retrospective study of patients presenting with boundary hernias was done from January 2013 to December 2016. All patients underwent pre-operative Computed Tomography (CT) scan for hernia assessment. The patients underwent (1) Diagnostic laparoscopy, Adhesiolysis and reduction of hernial contents (2) Limited exploration through previous scar, hernia sac removal and anatomical closure in layers with or without onlay mesh (3) Reinforcement intraperitoneally using a large composite mesh. The procedure was assessed for intra-operative challenges, post-operative pain, seroma formation, recurrence and pseudo-recurrence, patient satisfaction score and cosmesis. Result: Out of the 17 patients, who presented with boundary hernias, ten patients were post-abdominal hysterectomy, three were post-appendectomy, two were post-donor nephrectomy, one was post-ureterolithotomy and one was post-trauma. Average size of the hernia defect noted was 5.41 centimetre (Standard deviation = 1.37). Intraoperative challenges like lack of four point transfascial suture, inability to tack in triangle of pain region (during pure laparoscopic repair) and large skin flaps, drawback of anterior repair only (during pure open repair) were overcome by hybrid repair. No patient had seroma formation after the hybrid repair. None of the patient had recurrence or pseudo-recurrence after the hybrid repair with a mean follow up of 2.52 years (Standard deviation = 0.71). Patient satisfaction score was excellent. Out of the 17, three patients had short term cosmesis issue, resolved after delayed followup. Minimal post operative pain was noted after hybrid repair. Conclusion: A hybrid technique is a safe alternative method for peripheral abdominal hernias with a low recurrence rate, less seroma formation, minimal post operative pain, and equating the benefits of pure laparoscopic repair and pure open repair.

Surg Endosc

P030 - Abdominal Cavity and Abdominal Wall

P032 - Abdominal Cavity and Abdominal Wall

Laparoscopic Liver Resection with Radiofrequency Ablation in Multiple Hepatocellular Carcinoma

ON the Learning Curve of Laparoscopic Posterior Component Separation with Transversus Abdominis Muscle Release Transabdominal Approach

I.Y. Park Surgery, Bucheon St. Mary Hospital, Catholic University of Korea, Bucheon, Republic of Korea Hepatocellular carcinoma (HCC) is the fifth most common solid tumor in the world. A liver resection remains the ‘gold standard’ for curative treatment of HCC, but perioperative mortality rate of HCC following resection is up to 3%. In recent years, radiofrequency ablation (RFA) has been used to treat small HCC due to the improved overall and disease-free survival. For the treatment of early stage HCC (solitary small HCC of B 2 cm), RFA is equivalent to hepatic resection in terms of overall survival. Thus, we performed two cases of laparoscopic live resection (LLR) combined with RFA. A 76-year-old female patient was admitted due to bi-lobar liver mass. She was hepatitis B virus carrier. Liver MRI revealed two liver masses in the Segment III (2.3 cm in size) and segment VI (1.9 cm in size). We performed LLR and laparoscopic RFA ablation simultaneously. The other patient was a 66-year-old woman who was admitted due to two liver masses in the segment III (1.3 cm in size) and segment VI (1.0 cm in size). We performed percutaneous transhepatic RFA first and conducted laparoscopic left lateral sectionectomy on the next day. 19 months and 1 month after operation, respectively, the patients are now in good condition without recurrence. In multi-located hepatocellular carcinoma, LLR combined with RFA can be a favorable option for the patients as RFA and LLR can be performed concomitantly or consecutively.

G. Kotashev, D. Penchev, V. Mutafchiyski Endoscopic Surgery, Military Medical Academy Sofia, Sofia, Bulgaria Materials and Methods: We conducted a prospective observational study in Military medical academy Sofia in patients with large hernias more than 10 cm in diameter, treated with laparoscopic transabdominal posterior component separation with transversus abdominis muscle release and inlay mesh placement. For the period between 01.07.2017–01.12.2017 in the department of Endoscopic Endocrine surgery and coloproctology were performed 10 operations. All patients had a preoperative abdominal CT and were prepared according to the local protocols. We used six trocars technique, but in the first 2 cases we needed to put 1 more extra trocar for posterior fascia closure. Results: Mean operative time was 270 min with 10% conversion rate, due to severe postoperative adhesion. No postoperative morbidity and/or mortality ware observed in the study group. We put 2 active drains in every patient, which were removed on postoperative day 1 and 2. Mean length of stay in study was 5 days. Mean postoperative pain, according to video analogue scale are 4, 3 and 0 on postoperative day one two and three. Conclusion: Laparoscopic posterior component separation with transversus abdominis muscle release is feasible and safe procedure. Minimally invasive abdominal wall hernia repair without intraperitoneal mesh placement may evade mesh related adhesions and future complications, related to small bowel obstructions or difficulties with redo operations in those patients. Also repair of abdominal domain lead to better function of abdominal wall at all. Less surgical trauma reduces immune response and postoperative pain, which leads to faster recovery and maybe few postoperative complications, such as infections and nonsurgical-related morbidity.

P031 - Abdominal Cavity and Abdominal Wall

P033 - Abdominal Cavity and Abdominal Wall

Simultaneous Procedures in Patients with Gallstone Disease and Obstructive Jaundice Combined with Hital Hernia Performed by Original Method

Restoring the Midline in Laparoscopic Ventral Hernia Repair. Conventional Closure of the Defect or Lira Technique?

I. Shavarov1, M. Halei1, I. Dzyubanovsky2 1

Laparoscopic Surgery, Volyn Regional Clinical Hospital, Lutsk, Ukraine; 2Surgery of the Training and Research Institute of Postgraduate Education, SHEI, I.Ya.Horbachevskyi Ternopil State Medical University, Ternopil, Ukraine Aim: To carry out simultaneous procedure in GD with OJ, combined with HH by our own method management. Patients and Methods: 72 patients with GD combined with HH between 2015 and 2017 were operated, within in 54 (75%) our own HH-repair method, that consists in fundoplication, that is done by 4 sutures between fundus of stomach and right crus (Patent UA A61B 17/00), was used. Among these 54 persons, in 15 (21%) OJ, caused by choledocholithiasis (CL), was presented, respectively laparoscopic cholangiography and choledocholitotomy was simultaneously performed. The average age of patients was 52.67 years. These patients were divided into two groups: in first (18 patients - 25% respectively) HH were by Toupet operated, in the second (54 patients - 75%, respectively) were by our own method operated. Results: Despite the presence of CL with common bile duct stone removal, respectively, increase of procedure total volume in second group, internal pain in late postoperative period was absent. The patients from first group almost all in late postoperative period suffered from internal pain. There was no recurrence of hernia observed. Conclusions: HH repair by our own method minimizes postoperative pain. Simultaneous procedures of GD combined with CL and HH has no negative influence for patient‘s postoperative condition in comparison with isolate procedure, respectively minimizes the number of surgical interventions for patients with those diseases.

J. Go´mez Menchero1, A. Gila Boho´rquez1, J.M. Sua´rez Grau1, I. Alarco´n del Agua2, J.A. Bellido Luque3, J. Garcı´a Moreno1, J.F. Guadalajara Jurado1, S. Morales Conde2 1 Cirugı´a General, Hospital General Ba´sico de Riotinto, Minas de Riotinto, Spain; 2Cirugı´a General, Hospital Universitario Virgen del Rocio, Sevilla, Spain; 3Cirugı´a General, Hospital Universitario Virgen Macarena, Sevilla, Spain

Introduction: Closing the Defect (CD) during Laparoscopic Ventral Hernia Repair (LVHR) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional LVHR. But tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a Component Separation (CS) for restoring the midline in medium-large defects. We have developed a new technique for restoring the midline in medium ventral hernias (LIRA-Laparoscopic Intracorporeal Rectus Aponeuroplasty) and we analyzed our results in terms of pain and recurrence compared to our Conventional CD series (CCD). Methods: We conducted a prospective controlled study of LVHR with CCD from January 2014 to December 2016 and a prospective controlled study performing LIRA technique from January 2015 to January 2017. We analyzed and compared both techniques in medium size defects (4–8 cm) in terms of postoperative pain (1, 7 days, 1, 3 months and 1 year) using a Visual Analogue Scale (VAS), Bulging and recurrence (by physical examination and Tomography). Results: CCD was performed in 42 patients (mean age was 58.10 ± 13.15 years old and mean BMI was 33.11 ± 6.61 kg/m2) and LIRA technique in 12 patients (Mean age was 56.5 ± 10.5 years old and mean BMI was 30.12 ± 5.30 kg/m2). The mean average Follow-up in both series was 1 year. Mean average VAS in CCD was 5.35 ± 2.49 (1 day), 2.01 ± 2.13 (7 days) 0.62 ± 1.45 (1 month) 0.10 ± 0.43 (3 months) and 0 at 1 year. In LIRA series VAS was 3.9 ± 2.2 (24 h) 1.08 ± 1.78 (7 days), 0.08 ± 0.28 (1 month), 0 (3 months) and 0 (1 year). There are 6 cases of Bulging in CCD series and 1 recurrence. Bulging and recurrence were absent in LIRA series. Conclusions: LIRA technique might be a safe procedure in medium size defects for restoring the midline in LVHR, and could be related to a lower pain rate compared to CCD with no recurrence or bulging.

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Surg Endosc

P034 - Abdominal Cavity and Abdominal Wall

P036 - Abdominal Cavity and Abdominal Wall

Minimally-Invasive vs Conventional Hernia Repair

Minimally Invasive Morgagni Hernia Repair with Simultaneous Cholecystectomy

I. Avram, R. Metzger, F. Schu¨tze Klinik fu¨r Allgemein-, Viszeral-, Thorax- und Tumorchirurgie, CaritasKlinikum Saarbrucken, Saarbrucken, Germany

V.S. Kyosev, K.S. Vasilev, V.M. Mutafchiyski, P.G. Ivanov Surgery, Military Medical Academy, Sofia, Bulgaria

Background: 3D-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice laparoscopists due to better depth perception. However, the benefits for experienced laparoscopic surgeons are still discussed. Aim: The aim of this study is to compare the conventional (2D) TEP hernia repair with three-dimensional TEP repair in terms of duration and short-term results. Methods: From a total of 1099 hernia patients that were operated in our clinics we selected 50 patients operated with the TEP technique using 3D Einstein Vision by the same team. As control group we randomly selected 50 patients who underwent TEP by the same team using a conventional HD laparoscope. All patients were retrospectively analyzed in terms of OR time, duration of operation, intra- and postoperative complications, length of hospitalization, pain score and necessity of analgesics. Risk factors for complications and recurrence (BMI, smoker, diabetes, COPD, BPH) were also registered. Results: Mean operation time in the study group was 38.3 minutes in the study group, while mean OR time was 79.3 minutes. Mean operation time in the control group was 41.3 minutes, while mean OR time 71.4 minutes. One early recurrence was noted in the control group. Conclusions: There were no significant differences regarding the outcome of inguinal hernia repair; total OR time was significantly higher in the study group due to the time needed to set up the 3D-laparoscopy unit. Also, there was no difference in short-term complication rate.

Introduction: Diaphragmatic hernias through the foramen of Morgagni are a very rare form, and often the preoperative diagnosis is difficult. The standard surgical procedure has required a laparotomy or a thoracotomy for symptomatic patients. Thirty percent of the cases are generally asymptomatic. Therefore they are usually identified incidentally during the other disease investigations, and there is a relation between the size of the hernia and visceral involvement and symptomatology. Here, we describe a laparoscopic approach to the management of small Morgagni hernias achieving a primary tissue repair without mesh implantation in conjunction with cholecystectomy. Case Presentation: A 58 year old female patient was admitted to urgent unit in our hospital with a 3-day history of progressive epigastric and right subcostal pain and distension with associated episode of nausea and vomiting. USG abdomen showed acute cholecystitis. Chest radiographs demonstrated an abnormal shadow with a clear border present at the right cardiophrenic angle; the lateral projection determined an anterior location of the shadow. A cholecystitis with mediastinal lipoma was the suspected diagnosis at this time. Chest computed tomography showed an omental herniation through the foramen of Morgagni. We did simultaneous laparoscopic cholecystectomy and laparoscopic hernia repair without mesh implantation. She made an excellent recovery and was discharged a two days after the operation. There was no evidence of recurrence for 6 months following period. Conclusions: The laparoscopic repair was considered a suitable and safe procedure for the treatment of a Morgagni hernia. This technique allows for the general benefits of minimally invasive surgery, to accomplish a simultaneous operation in abdominal cavity with less postoperative pain, reduced wound complications, short hospital stay, as well as offering an alternative to mesh implantation and its associated potential complications. Keywords: Morgagni hernia, Minimally invasive hernia repair, Diaphragmatic hernia.

P035 - Abdominal Cavity and Abdominal Wall

P037 - Abdominal Cavity and Abdominal Wall

Adhesiolysis-Related Difficulties During Re-Laparoscopy After Prior Ventral Hernia Repair with Intraperitoneal Onlay Mesh

Influence of IL-6, TNF-A and HS-CRP on Insulin Sensitivity in Patients After Laparoscopic Cholecystectomy or Open Hernia Repair

F. Turcu1, V. Diaconu2, D. Ulmeanu3, C. Copaescu1 General Surgery, Ponderas Ah, Bucharest, Romania; 2General Surgery, Malaxa Hospital, Bucharest, Romania; 3General Surgery, Regina Maria Baneasa, Bucharest, Romania

D. Micic, S. Mijatovic, S. Kajis, V. Djukic

Aim: The increasing number of patients with intraperitoneal mesh, rise the chance for the surgeon to face with the need of re-laparoscopy for another pathology. The purpose of this study presentation is to evaluate the difficulties that we have encounter at re-laparoscopy with adhesiolysis to intraperitoneal meshes. Method: We have review all documents and video recordings of the patients with laparoscopic re-exploration after prior ventral or incisional hernia repair. Main objectives where: the conversion rate, surface of the mesh covered with adhesions, the adhesion tenacity using the Jenkins’s scale, operative incidents and perioperative complications. Results: Indications for the 35 laparoscopic re-exploration were: recurrent or other hernia (n = 14), acute or chronic sepsis related to the mesh (n = 6), occlusive syndrome (n = 6), bariatric surgery (n = 4), cholecystectomy (n = 3), other (n = 2). Adhesions were find at intraperitoneal mesh in every case except one. Omentum adhesions were find in 17 cases, intestinal adhesions in 15 cases and filmy adhesions in two cases. The mean percentage of the covered mesh surface was 70%. The mean of adhesion tenacity was 2.8 ± 0.9, ranking from 0 to 4. Conversion was needed in 3 (8.5%) cases, all recurrent hernias, do to difficult adhesiolysis. There were 4 (11.4%) small bowel lesions (one related with the peritoneal access) that implies 2 conversion, and 3 segmental resections. All interventions (other than relapsed hernia) where completed by laparoscopic approach with success. There were no major perioperative complication. If we compare septic cases with the non septic cases there is no statistical significant difference regarding the adhesion tenacity (2.7 ± 0.5 vs. 2.8 ± 1.0) but it was a difference as regarding the hospital stay (11.0 ± 2.7 vs. 5.1 ± 3.0). Over all the laparoscopic approach was very useful in these cases by reducing to a minimum the abdominal wall trauma. Conclusion: despite the difficult adhesiolysis to the intraperitoneal meshes, re-laparoscopic approach is a good option for the patient with recurrent hernia and probably the best option for current abdominal surgical pathology.

Background: The aim of this study was to investigate the influence of IL-6, TNF-a and hs-CRP on insulin sensitivity during postoperative follow- up in patients with laparoscopic cholecystectomy (LC) or open hernia repair (OHR). Methods: 65 patients were studied: after laparoscopic cholecystectomy (Group LC; n = 40) or open hernia repair (Group OHR; n = 25). Glucose, insulin, hs-CRP, IL-6 and TNF-a were determined at day 0 (before the operation) and at days 1, 3 and 7 (after the operation). Results: There were no difference between LC and OHR groups concerning age (p = 0.262), BMI (p = 0.912), glucose (p = 0.239), insulin (p = 0.751), hs-CRP (p = 0.082), IL-6 (p = 0.567) and TNF-a (p = 0.195) at day 0. hs- CRP increased at day 1, 3 and 7 vs. day 0 (p \ 0.0005), without difference between groups (p = 0.561). IL-6 increased at day 1 and day 3 vs. day 0 (p \ 0.005). IL-6 was higher at day 1 in OHR group in comparison with LC group (p = 0.044). There were no differences in TNF-a levels between LC and OHR groups (p = 0.056). There was increase of HOMA-IR at day 1, 3 and 7 vs. day 0 (p \ 0.0005) in both groups. Significantly higher increase of HOMA-IR was in OHR group compared with LC group at day 1 (p = 0.045). There was a positive correlation between hs-CRP and HOMA-IR (r = 0.46; p = 0.025) and between IL-6 and HOMA-IR at day 1 in OHR group (r = 0.44; p = 0.030). Conclusions: Significantly higher HOMA-IR was found in OHR group compared with LC. Positive correlation between hs-CRP and IL-6 with HOMA-IR in OHR group at day 1, indicate possible influence of this mediators on impairment of insulin sensitivity.

1

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Emergency surgery, Clinic for emergency surgery, Emergency centre, Clinical centre of Serbia, Belgrade, Serbia

Surg Endosc

P038 - Abdominal Cavity and Abdominal Wall

P040 - Abdominal Cavity and Abdominal Wall

Efficacies of Using 3 mm Laparoscopic Devices to TEP Procedure for Postoperative Pain Suppression, for Cosmetic Outcome and for Economical Outcome

Transabdominal Preperitoneal (TAPP) Versus Totally Extraperitoneal (TEP) Approach for Primary Unilateral Laparoscopic Inguinal Hernia Repair

H. Oishi1, T. Iino2

I. Triantafyllidis, A. Tzikas, A. Sovatzidis, C. Demertzidis

1

General Surgery, General Hospital of Veria, Veria, Greece

Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan; 2Sugery 2, Tokyo Women’s Medical University, Tokyo, Japan Aims: We describe efficacies of using 3 mm laparoscopic devices to TEP procedure for postoperative pain suppression, for cosmetic outcome and for economical outcome. In our old standard TEP procedure, we had usually performed it with 3 ports (12–5–5 mm). We used disposable 5 mm laparoscopic energy devices, and 5 and 12 mm trocars were used for single usage. We believe that TEP procedure is a very effective training system for beginner of laparoscopic surgery. So we usually added intraabdominal observation to TEP procedure before and after it, for the purpose of diagnosis confirmation and operative method choice and repair confirmation. However it needed incision of umbilical ring to place 5 or 12 mm trocar at their navel for intraabdominal observation. And then we had to suture for closing their incision of umbilical ring after surgery. Some cases had postoperative wound pain at their navel. We guessed that it was caused by suturing of incisional wound of umbilical ring after intraabdominal observation. For postoperative pain suppression, we tried to do no incision of umbilical ring for intraabdominal observation before and after TEP procedure. Methods: In intraabdominal observation before and after TEP procedure, we inserted an reusable 3 mm trocar into the abdominal cavity through umbilical ring without incision of umbilical ring, and we performed intraabdominal observation by 3 mm laparoscope before and after TEP procedure. In our modified TEP procedure, we performed it with 3 ports (5–3–3 mm) by 3 mm laparoscope and 3 mm laparoscopic devices. A disposable 5 mm optical trocar was placed at patient’s navel wound, and two reusable 3 mm trocars were placed vertically at lower abdominal central line. And we used reusable 3 mm monopolar laparoscopic scissors as a reusable energy device in this procedure. Results: There were no technical difficulty and no complication in this procedure. Patients had no complaint of wound pain after this procedure. Scar in this procedure were smaller and less visible than standard procedure. In this procedure, single use device was a disposable 5 mm optical trocar only. Conclusion: Minimally invasive TEP procedure by 3 mm laparoscope and 3 mm forceps was very effective method for postoperative pain suppression, for cosmetic outcome and for economical outcome.

Introduction: Various surgical techniques have been developed over the past years, and total extraperitoneal (TEP) and transabdominal preperitoneal inguinal hernia repair (TAPP) are the endoscopic techniques that are most commonly used. Materials and Methods: This retrospective study was conducted in a single surgical unit of a district hospital. During the period from January 2007 to December 2016 all patients older than 18 years requiring elective unilateral TEP or TAPP for an inguinal hernia were included. The primary aim of the study was to assess the recurrence rate of hernias, whereas the secondary endpoints of the study were the demographics of the patients, the duration of operation, postoperative pain scores, conversion to other procedure, short and long-term complications, hospital stay, time to return to usual activities and cost. Results: Data on 752 patients who underwent either TEP (n = 257) or TAPP (n = 495) were retrieved retrospectively. Both groups were comparable in terms of demographic profile and hernia characteristics. The average operative time was higher in the TEP group (p = ns). The pain scores at 1 h and 24 h after surgery and at 3-month follow-up were significantly higher in the TAPP group (p \ 0.05). Patients who underwent TEP had a significantly higher rate of intraoperative complications (TEP: 2.3% vs. TAPP: 1%, p \ 0.05) as well as postoperative complications (TEP: 2.7% vs. TAPP: 0.8%, p \ 0.05). The postoperative length of stay was longer for patients who underwent TAPP whereas the duration of the operation was longer for TEP, although the difference was not significant. However, the conversion rate was significantly higher in TEP procedure. There was no significant difference in terms of return to physical activity and cost between the 2 groups. No 30-day mortality was registered and there has been no recurrence in either group during a mean follow-up period of 41 months. Conclusions: Intraoperative and postoperative complications were significantly higher in patients undergoing TEP. TEP was also associated with longer operating times and higher conversion rates. However, TEP had a significant advantage over TAPP for significantly reduced postoperative pain up to 3 months. In terms of surgical outcome, efficacy and cost, both techniques were equivalent.

P039 - Abdominal Cavity and Abdominal Wall

P442 - Abdominal Cavity and Abdominal Wall

Our First Results: After 44 Colorectal Robotic Operations in Slovenia

Quick, Easy and Work so Efficiently: Who Doesn’t Love a Sandwich? Long-term Results: Of the Laparoscopic SandwichRepair of Parastomal Hernia

I. Cerni Abdominal surgery, General and teaching hospital Celje, Celje, Slovenia Aims: Since the introduction of robotics in minimally invasive surgery in the 1990s, many new devices and advances in technique have been developed. With currently more than 750.000 worldwide procedures in 2016, guidance for the year 2017 is 14–15% growth. In Slovenia more than 300 procedures have been done in 2016, more than 40 general surgery procedures have been performed. The aim of the study is to evaluate the results in the period of 2014–2017. Methods: Until now we performed 44 colorectal robotics operations; female 21 (48%), male 23 (52%), average age 63.6 years. ASA classification: ASA I 37%, ASA II 62%, ASA III 1%. 80% patients had adenocarcinoma, 4% adenoma, the others had diverticulosis and status post polypectomiam. 25% patients had carcinoma of rectum, rectosigma 41%, colon ascendens 14%, colon descendens 4%, sigmoideum 14%. Results: We performed: 6 hemicolectomy right, 2 hemicolectomy left, 6 sigmoidectomy, 25 resection recti anterior, 5 low anterior resection. TNM classification: T1 6%, T2 32%, T3 56%, T4 6%, N0 56%, N1 26%, N2 18%. 68% patients had grade II differentiation. PTNM stage: stage I 51%, stage II 15%, stage III 34%, stage IV 0%. intraoperative blood loss: 50–150 ml. Duration of operation on console: 186.6 min. Hospital stay: 7.5 days. Conversion: 2 (4.5%). Coplication: 4 (9%): emphfisema subcutaneum 1, haemathoma intraabdominale 1, anastomotic leak 2, wound infection 1. Average number of lymphonodes: 18.5. Conclusion: Robotic surgery allowed surgeon to perform complex surgical tasks through tiny incisions using robotic technology. Benefits for patients are: less postoperative pain, blood loss, shorter hospital stay, more and faster recovery, quicker return to normal daily activities and low risk of infections.

A. Fortunova1, D. Berger2 1

Klinik fu¨r Allgemein- und Viszeralchirurgie, Klinikum Mittelbaden Baden-Baden, Baden-Baden, Germany; 2Klinik fu¨r Allgemeinchirurgie, Privatklinik Lindberg, Winterthur, Switzerland Background: The parastomal hernia is a common complication after ostomy formation. It has been also shown that the patients are mainly disabled by a hernia because of decreased quality of life which could be reestablished by a sufficient and long-lasting hernia repair. Materials and Methods: Retrospective analysis of prospectively collected data of 114 patients with a parastomal hernia between February 2004 and March 2017 Results: 114 patients with median follow up of 33 months (range, 1–156 months) were analyzed. In 80 (78.4%) cases the parastomal hernia repair was combined with an incisional hernia repair. Five patients (4.3%) developed a recurrence. Three of them required reoperation. Major early complications were a stenosis at the level of the fascia in 3 patients (2.6%) needing reoperation. Eight patients (7%) developed a seroma or hematoma. There was no mortality related to the procedure or further mesh- or procedure-related complications in the long-term follow-up. Conclusions: The laparoscopic sandwich-technique proved to be a safe and effective technique with a low overall complication rate. The recurrence rate is very low and better than described for the laparoscopic Sugarbaker-technique. So the described technique seems to be a promising alternative suitable in most cases of parastomal hernias which easily allows the diagnosis and simultaneous repair of frequently accompanying incisional hernias.

123

Surg Endosc

P480 - Abdominal Cavity and Abdominal Wall

P042 - Basic and Technical Research

Laparoscopic Repair for the Morgagni’s Hernia

Precise Laparoscopic Extralumenal Detection of Colorectal Tumors Using Golden-Platinium Coated Tacks and Augmented Sensors of Proximity

K. Hashida, M. Yokota, Y. Nagahisa, M. Okabe, K. Kawamoto General Surgery, Kurashiki Central Hospital, Kurashiki City, Japan Aims: Morgagni hernias are rare diaphragmatic hernias that are generally asymptomatic and incidentally discovered. Once the diagnosis is made, operation is indicated to avoid the strangulation ileus or bowel perforation. A few Laparoscopic repairs are reported recently. We report our laparoscopic repair using full-thickness anterior abdominal wall repair and mesh repair. Methods: The patient was diagnosed with Morgagni hernia on the findings of chest X-ray and CT. She underwent laparoscopic repair. During the operation, we found the Morgagni’s foramen measuring 1 cm 9 2 cm. Then we closed the hernia defect by suturing the full thickness of anterior abdominal wall and posterior rim of the defect using the nonabsorbable sutures. Furthermore, we placed the mesh on the sutured defect and anchored it. Results: The operation time was 1 h and 6 minutes and the estimated blood loss was a little. The patient recovered uneventfully after short hospitalization. The patient has remained free of recurrence in the 5 months since surgery. Conclusion: This laparoscopic repair can be effective to cure a Morgagni’s hernia.

P041 - Basic and Technical Research Experimental Evaluation of Effectiveness of Endoscopic Reparatory-Hemostatic Therapy of Peptic Ulcer Complicated with Bleeding and Hemorrhagic Shock V.V. Petrushenko1, D.I. Grebeniuk1, I.V. Radoga1, V.S. Sobko1, Y.A. Myronyshen2, O.V. Levadnyi1 1

Department of Endoscopic and Cardiovascular Surgery, National Pirogov Memorial Medical University, Vinnytsya, Vinnytsya, Ukraine; 2Department of Surgery Nr.1, National Pirogov Memorial Medical University, Vinnytsya, Vinnytsya, Ukraine Aims: The aim of our study was to evaluate of effectiveness of endoscopic reparatory-hemostatic therapy of peptic ulcer complicated with bleeding and hemorrhagic shock. Methods: The study was performed on 60 Wistar rats according to local and international rules for working with experimental animals. The average weight of animals was 183 ± 16 grams. In all animals our modification of type 2 acetic acid ulcer (Susumu Okabe, 2005) was modeled. We randomly divide all animals in 3 groups. 20 rats with only modeled ulcer were included in group 1. 20 rats with modeled ulcer and hemorrhagic shock after 3–3.5 ml blood sampling were included in group 2. In group 3 we included 20 rats with modeled ulcer and hemorrhagic shock and performed reparatory-hemostatic therapy. Reparatory-hemostatic therapy was performed using local periulcelar injection of 0.1 ml of autologous platelet-rich plasma. On 1st, 7th and 14th day measurement of the ulcers square and morphological study were performed. Results: The data we have received demonstrate a tendency of decrease of ulcers’ square in all groups with time flow. We also compared sizes of ulcerative defects in all groups at every point of the study. On the 1st day of investigation there were no differences (p [ 0.05) between ulcers’ square in all groups. On the 7th day we found out more rapid decrease of size in group 3 (p [ 0.05). However, this tendency had no statistical significance. On the 14th day difference was larger and it was statistically significant this time (p \ 0.01). Also the better ability to stimulate the activity of fibroblasts and revascularization in the young connective tissue with improving oxygenation in the ulcers and enhancing of cell proliferation, differentiation and accelerating of maturation of connective tissue and healing of ulcers was demonstrated in group 3. Conclusion: Platelet rich plasma reduces inflammatory response and stimulates proliferation of gastric epithelial cells on 7th day with the restoration of secretory activity and epithelialization of ulcers in 71.4% of experimental animals on 14th day, the activation of the fibroblastic reaction during the all experiment and decreasing of ulcers’ square.

123

V. Bintintan1, A. Calborean2, S. Macavei2, B. Mocan3, M. Mocan4, C. Ciuce1, A. Cordos1, S. Brad3, A. Bintintan4, D. Timofte5, G. Dindelegan1 1

Cl. Chirurgie I, UMF Cluj Napoca, Cluj Napoca, Romania; Research, INCDTIM, Cluj Napoca, Romania; 3Robotics, UTCN Cluj Napoca, Cluj Napoca, Romania; 4Cl. Medicala I, UMF Cluj Napoca, Cluj Napoca, Romania; 5Cl. Chirurgie, UMF Iasi, Iasi, Romania

2

Introduction: Determining exact location of digestive tumors by palpation is crucial in oncologic surgery but lacks precision especially in laparoscopy and for smallsized tumors. Endoscopic tatooing of tumors and synchronous intraoperative endoscopy are the actual methods that pin-point the location of these tumors but both have their disadvantages. Aim: In the present study we aim to develop a new, innovative and highly efficient sensing laparoscopic instrument focused on precise non-invasive extralumenal intraoperative detection of small digestive tumors. Materials and Method: Proof of concept. A sensing instrument compatible with minimally-invasive surgery is currently being developed within our multidisciplinary research team. It is equipped with an induction proximity sensor able to detect customly-modified endoscopic clips available in the standard endoscopic instrumentation which are attached endoscopically to the bowel mucosa at the periphery of the tumor. To enhance detection by the probe and provide adequate biocompatibility, these clips are coated with noble materials (Platinum-Gold). Our goal is to develop a system that detects clips when scanned from the serosal surface of the bowel with a minimum through-tissue detection range of 2 cm. Validity and detection accuracy are evaluated in in-vitro laboratory experiments. Results: The probe was constructed by the engineer team and in tests, the preliminary results are encouraging. It managed to detect the modified clips from a mean distance of 24 mm without interposition of bowel tissue and at 16 mm when placed inside the bowel in ex-vivo tests. Through experiments in ex-vivo anatomical models and in-vivo animal experiments are scheduled within the next 3 months. Final results will be available at the time of the EAES Congress. Conclusion: Detection of small tumors, so difficult in certain situations in laparoscopic surgery can be made easier for the surgeons by a simple and efficient detection system independent of the skills and availability of endoscopists. This invention may enhance the quality of surgery and ultimately the long-term prognosis of our patients.

Surg Endosc

P043 - Basic and Technical Research

P444 - Basic and Technical Research

Use of Negative Pressure Therapy for Extreme Patients Refractory to Conventional Therapies and Surgical Procedures

Potential Biological Hazard in the Surgical Plume: It Contains DNA Fragments of Virus Derived from the Host

S. Giungato, A.S. Pepe

M. Hirota1, S. Higashi2, H. Takahashi3, Y. Miyazaki3, T. Takahashi3, Y. Kurokawa3, M. Yamasaki3, M. Mori3, Y. Doki3, K. Nakajima2

General And Endoscopic Surgery, Castellaneta Hospital, Castellaneta, Taranto, Italy Aims: Negative Pressure Therapy represents a new technique for treatment of laparotomy dehiscences, subcutaneous ulcers and for open abdomensurgery since some years. This technique is an extreme procedure for those patients to whom all surgical treatments are failed. We ha demonstrated the safety and feasibility of this technique and we studied a new application of intra-abdominal negative pressure therapy. Methods: From February 2017 to November 2017 we have treated patients who presented cutaneous ulcers refractory to advanced medications, laparotomy dehiscences and post incisional muscular wall defects with application of negative pressure therapy. Results: We treated 13 patients with negative pressure therapy: 1 lower right leg post-drainage ulcer, 3 extended pst-traumatic lower right limb ulcers, 8 patients with laparotomy dehiscences and 1 patient with intra-abdominal negative pressure therapy (Renasys-AB, Smith&Nephew) plus BioA Gore prosthesis. Patients with subcutaneous ulcers healed with mean of 8 weeks (6–12 weeks) with medications every 3–4 days, instead patient with intra-abdominal negative therapy and proshtesis healed after 4 months without bowel fistula formation with medication every 4 days. Conclusion: Negative pressure therapy is a new and feasibility therapy for treatment of extreme subcutaneous ulcers with total restoration of skin without patient discomfort. Application of Bio-A Prosthesis and intra-abdominal negative pressure therapy found an excellent application in extreme cases and it is feasibility and simple to apply but after a careful study of patient.

Surgery, Osaka University, Osaka, Japan; 2Next Generation Endoscopic Intervention, Osaka University, Osaka, Japan; 3 Gastroenterological Surgery, Osaka University, Osaka, Japan 1

Aims: There is a lack of evidence about biological hazard in the surgical plume. We examined whether surgical plume generated during the usage of energy devices contains virus-related substances derived from the host. Methods: Experiment 1; Study on vivo model: A tumor mass which contain HBs and AFP gene and antigen was created by transplanting a hepatocellular carcinoma line PLC/RPF/5 into a Nod/SCID mouse. Surgical plume was generated on the clean bench by activating energy device (ultrasonically activated scalpel: US or electrocautery: EC) on the mass for a given time (1, 3, 5 minutes) and it was bubbled and collected into nuclease-free water. PCR and CLEIA were conducted on the solutions to confirm existence of HBs gene, HBs or AFP antigen. Experiment 2; Study on clinical specimen: As the experiment 1, surgical plume was collected from clinically obtained liver specimens of six HBV associated hepatocellular carcinoma patients, those preoperative serum HBVDNA were positive in three cases and negative in three. Detection of HBs gene and antigen was attempted. Results: Experiment 1: HBs gene fragment was positive in 13 of the US solutions (86.7%) and in 12 of the EC solutions (80%). In the quantitative PCR analysis, the amount of collected DNA fragment reached plateau at 3 minutes in the US and increased with time, up to 5 minutes, in EC. In US solution, HBs antigen was positive in one and AFP in two. HBs antigen was also detected in one EC solution. Experiment 2: HBV-DNA was detected, regardless of the devices, in all three cases whose preoperative serum HBV-DNA was positive. In the other three serum negative cases, HBV-DNA was not detected in any solutions. As to the protein detection, preoperative serum HBs antigen was positive in 5 of 6 cases, although, HBs antigen was not detected in any of the solution. Conclusions: DNA fragments of virus or its host tissue were detected in the surgical plume. Proteins from the target tissue were also detected in our in-vivo model. The surgical plume might potentially have some biological hazard, therefore should be isolated and intentionally evacuated using a dedicated line.

P443 - Basic and Technical Research

P044 - Clinical Practice and Evaluation

A Novel Universal Sils & Notes Port (SNP) For Cholecystectomy and Fundoplication

USING GMC/RCS ENG Guidelines to Introduce and Develop a Effective Surgical Handover List

S. Haribhakti, A. Tiwari, H. Shah, A. Shah, H. Soni, K.S. Patel

L.K. Karim1, B. Adabavazeh2, V. Dorrell2

G I Surgery, Kaizen Hospital, Ahmedabad, India

1

Introduction: In present era of minimal access surgery, proponents of Single Incision Laparoscopic Surgery (SILS) for cholecystectomy & fundoplication have increased. However, certain drawbacks of SILS still remains e.g. learning curve, longer operating time & cost. Performing SILS with routine SILS port is challenging in obese patients. We have designed new SILS & NOTES Port (SNP) to test its feasibility for performing cholecystectomy and Fundoplication. Materials and Methods: SNP are rigid ports, made from biocompatible SS 316L, manufactured in multiple diameters e.g. 12 mm, 20 mm, 40 mm, 60 mm and in multiple lengths e.g. 5 cm, 10 cm, 15 cm etc. The port having diameter of 20 mm and 5 cm length is labelled as SNP 20.5. Similarly, SNP 20.10 refers to port having diameter of 20 mm and length of 10 cm. SNP port consist of a sheath, a diaphragm & a silicon washer. Silicon washer can be changed depending upon the number & size of instruments required. SNP is inserted by a small periumbilical incision. Silicon washer (5,5,5) - which admits three 5 mm instruments (one camera & two working instruments) is applied to SNP 20.5 for performing cholecystectomy & fundoplication. We used 45 degree telescope, fundal retracting suture & roticulating instruments for cholecystectomy. Additionally, Hammock liver retractor, which is placed through SNP port was used during fundoplication. Results: We have performed 15 cholecystectomies and 3 Nissen’s fundoplication with SNP. The average operating time was 85 minutes & 112 minutes for cholecystectomy and Nissen’s fundoplication, respectively. Blood loss, morbidity rate, pain score & length of stay – all were comparable to SILS procedures. Conclusion: Innovative SILS & NOTES ports are feasible for performing SILC (Single Incision Laparoscopic Cholecystectomy) and SILF (Single Incision Laparoscopic Fundoplication). Its applicability in obese patients & low cost are significant advantages over standard SILS port.

General Surgery, University Hospital Lewisham, London, United Kingdom 2

General Surgery, Lewisham Hospital, Lewisham, United Kingdom

Introduction: Currently at UHL, there is no formal handover list which is updated on a daily basis. As a result of this, ward rounds have been delayed and essential aspects of patient management have been missed ultimately comprimising their care. The impact on Doctors included being late for clinics/theatre sessions and therefore creating financial implications for the trust which need to be addressed. Standards The RCS and GMC have developed a set of guidelines for effective handover and have a set criteria of what must be included on a handover list. Demographics Date of Admission Location Consultant/Reg/SHO (name and bleep) Presenting complaint PMH/PSH Examination Management/plan Investigations Patient condition (critical/stable/unstable or NEWS score) Pending Ix/Mx Is list updated daily Paper/electronic DNAR Status We have set the standard at 90% compliance Method: Retrospective review of the current handover sheet for all the patients being admitted during a general surgical take over a 2 week period. Results: Conclusion: UHL was not meeting the guidance set by the RCS/GMC. As part of the recommendations, it was decided that the trust will design and develop a template containing all the standards set which can be updated daily. This will ensure that certain standards were not missed and the list was updated effectively on a daily basis. The re-audit showed compliance of[ 90% for all of the standards described, thus initiating service improvement.

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P045 - Clinical Practice and Evaluation

P047 - Clinical Practice and Evaluation

Factors Influencing Postoperative Length of Stay Within an Enhanced Recovery Programme in Colorectal Surgery

Acute Surgical Assessment Unit (ASAU) - Does it Improve the Emergency Surgical Decision Pathway?

G.D. Tebala, A. Gallucci, A.Q. Khan

M. Salama, S. Elmasry

Colorectal Unit, Noble’s Hospital, Douglas, Isle of Man

General Surgery, Our Lady of Lourdes Hospital, Drogheda, Ireland

Background: Enhanced Recovery (ER) programmes are meant to improve the experience of patients undergoing surgery and to reduce their postoperative stay (LOS). Aim of the present study was to investigate the prognostic factors associated with LOS in patients undergoing resectional colorectal surgery, in order to help identify those that more likely will be discharged early. Methods: An ER in Colorectal Surgery programme has been implemented at the Colorectal Unit of the Noble’s Hospital (Isle of Man) in 2013, as part of a complete reshaping of the colorectal surgery service. Clinical records of 198 patients undergoing colorectal resections 3/2013 to 4/2017 have been reviewed and analysed. Endpoints were LOS, rate of patients discharged within day 4 and readmission rate. Univariate and multivariate analysis were performed. Results: 62.6% of all resections and 74.7% of elective resections have been performed by laparoscopy. Median overall LOS was 6 days and 34.3% of patients have been discharged within day 4. Unplanned readmission was necessary in 7.1% of cases. LOS was shorter in elective patients (p \ 0.02), in those operated on by laparoscopy (p = 0.000), in cancer patients (p \ 0.01) and where the clinical course was uncomplicated (p = 0.000). Rate of early discharged patients grew progressively as we got used to the ER protocol (p = 0.018). Readmission rate was significantly related only to the year of operation (higher in 2013, p = 0.018). In elective noncomplicated patient, LOS showed a significant reduction with time (r2 = 0.84483). At multivariate analysis LOS was inversely associated with laparoscopic and elective resection and with year of the operation. Rate of patients discharged within day 4 was independently associated only to laparoscopic resection, whereas we have not been able to find any independent causative variable for readmission rate. Conclusions: The highest benefits of ER protocols can be obtained in elective cases operated on by laparoscopy. Those patients can be safely discharged early in their postoperative course - as the risk of readmission is not in any way related to early discharge – provided that the surgical team has gained sufficient experience with the ER principles to be able to set their own criteria for discharge.

Introduction: There has been a rise in the number of emergency surgical admissions and a decrease in the number of hospital beds over the last 20 years with greater demands for efficiency and effectiveness. The RCS of England recommends acute unselected general surgical patients to be assessed within 1 hour of presentation and to spend no more than 4 hours in the Accident & Emergency (A&E) department. This necessitates every hospital to have a reliable ASAU. Aims: To prospectively audit our ASAU work over a one year period to evaluate its effectiveness and efficiency in managing acute surgical patients and achieving its targets and objectives. Methods: All ASAU admissions from January-December 2016 were prospectively entered into a database. We audited the patients’ demographics, presenting complaints, referral date, time taken for the patients to be seen (investigations, discharge, theatre, etc.) and outcomes. ASAU provides rapid assessment and treatment for adults above 16 years of age triaged with emergency surgical and urological conditions. Unstable patients or trauma patients are not suitable for the ASAU in our hospital. Our unit operates from 08:00 AM to 18:00 PM on weekdays only and it has 4 bays. Results: Out of 2079 patients who attended our ASAU for assessment during the audit period, 971 were discharged after assessment (47%), 337 (16%) were admitted to the Clinical Decision Unit (CDU) and 771 (37%) were admitted. Of the admitted patients, 215 underwent emergency surgery (10%). The average age was 44 years. The average length of stay for admitted patients, CDU patients and discharged patients was 94 hours, 26 hours and 4.9 hours respectively. The highest attendance by month were in August and December (198), and the lowest was in February (113). All patients were seen within one hour of attendance. Conclusions: ASAU can divert a substantial number of patients away from our busy A&E department. It facilitates an efficient and high quality emergency assessment and admission process. It achieved a discharge rate of 63% for all patients attended. To increase its effectiveness, we propose the ASAU to be open 24 hours, 7 days a week.

P046 - Clinical Practice and Evaluation

048 - Clinical Practice and Evaluation

Combined Laparoscopic and Transanal Total Mesorectal Excision for Lower Rectal Cancer

The Effect of Common Comorbidities on Surgical Outcomes of Laparoscopic Total Gastrectomy for Gastric Carcinoma: a Multicenter Retrospective Study

R. Ohta, M. Goto, Y. Tachimori, K. Sekikawa Department of Surgery, Institute of Gastroenterology, Kawasaki Saiwai Hospital, Kawasaki, Japan Background: Transanal total mesorectal excision (TaTME) technique will potentially improve the surgical and oncological outcome in lower rectal cancer. However, this procedure has the disadvantages of technical difficulties associated with its limited maneuver and lack of anatomical landmarks. In order to ensure the safety of the surgical procedure, we introduced the combined laparoscopic and transanal total mesorectal excision for lower rectal cancer. This study investigated the clinical results and perioperative and pathological outcomes of our modified TaTME in comparison with conventional laparoscopic TME. Methods: Our operative procedure started with the laparoscopic transabdominal part of the dissection according to total mesorectal excision principles and high tie with central ligation of the inferior mesenteric artery. Then a multiport device was placed at the anal side. Transperineal dissection was achieved in the down-to-up direction under endoscopic visualization. A total of 21 patients with lower rectal cancer who underwent our modified TaTME or conventional laparoscopic TME with ISR or APR from January 2014 to October 2017 were retrospectively studied. Results: Ten patients underwent conventional laparoscopic TME (cTME group) and the other 11 patients underwent our modified TaTME (mTaTME group) were included in this study. There were no significant differences in baseline characteristics between both groups. The duration of operation, estimated blood loss, and postoperative complications. were also not different. Regarding pathological outcomes, no patients with positive circumferential margin were observed. Conclusion: This procedure provides not only better exposure of the extralevator surgical field, but also safe and complete circumferential resection margins equivalent to the conventional laparoscopic TME. Our experience showed safety and feasible option for rectal cancer.

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Y.K. Park, O. Jeong, S.Y. Ryu, M.R. Chung Surgery, Chonnam National University Hwasun Hospital, Jeonnam, Republic of Korea Aims: Laparoscopic total gastrectomy (LTG) is a demanding procedure with substantial operative risk, but only a few studies have investigated the risk factors for postoperative complications. With extended life expectancy, it is increasingly common to perform LTG for elderly patients with different types of comorbidities. However, the impact of comorbidity on surgical outcomes of LTG remains uncertain. Methods: We retrospectively reviewed data on 303 patients who underwent LTG for gastric carcinoma between 2005 and 2016. We analyzed the relationship of each type of comorbidities with postoperative complications after LTG. Results: Of patients, 189 (62.4%) patients had one or more comorbidities; common types of comorbidity were hypertension (37.0%), pulmonary disease (27.1%), diabetes mellitus (17.8%), ischemic heart disease (3.3%), chronic hepatitis (2.6%), liver cirrhosis (2.6%), and cerebrovascular disease (2.3%). Postoperative morbidity and mortality rate were 20.1% and 1.0%, respectively. The incidences of local complications (p = 0.021) and C grade 3 complications (p = 0.025) were significantly increased with comorbidities. Of common comorbidities, pulmonary disease was found to significantly increase postoperative complications compared to normal patients (32.9% vs. 14.9%, p = 0.003). In the univariate analysis, age, gender, operative bleeding, and pulmonary disease were associated with increased morbidity. Multivariate analysis of these factors revealed that pulmonary disease was as an independent risk factor for complications (OR = 2.14, 95% CI = 1.03–4.64) after LTG. Conclusion: Of common comorbidities, pulmonary disease significantly increases postoperative complication after LTG. Proper perioperative care will be required for patients with pulmonary disease to reduce complications of LTG.

Surg Endosc

P049 - Clinical Practice and Evaluation

P051 - Clinical Practice and Evaluation

Feasibility and Usefulness of a Joystick Guided Robotic Scope Holder (SOLOASSIST) in Laparoscopic Colorectal Resection

Morbidity and Mortality of Radiofrequency Ablation for Patient with Hepatocellular Carcinoma

Y. Ohmura1, M. Nakagawa2, A. Teramoto2

T. Kimura, I. Inoue, K. Koida, M. Matsuoka, K. Kawashima, A. Hattori, Y. Matsuda

1

Cancer Treatment Center, Okayama City Hospital, Okayama, Japan

2

Surgery, Okayama City Hospital, Okayama, Japan

Aims: The Soloassist system, a unique robotic scope holder, is a joystick guided endoscope remote control system with which the surgeon can control the field of view. In this study, we estimated feasibility and usefulness of Soloassist in laparoscopic colorectal resection. Materials and Methods: A total of 263 laparoscopic colorectal resection was performed between March 2012 and October 2017. Among them, 123 cases were operated with human scope assistant (HA group), whereas 140 cases with Soloassist (SA group). We investigated operative duration, amount of bleeding, setting time, length of hospital stay after surgery, and the number of participated surgeons before and after introducing Soloassist. Results: There was no conversion to human assistant. There is no significant difference in their background, such as age, sex, BMI, ASA score and tumor location. The number of surgeons participated in surgery was significantly less in SA group (2.35 ± 0.52) compared with human assistant (HA) group (3.2 ± 0.47) and postoperative hospital stay were shorter (9.6 ± 2.2 vs 12.5 ± 4.2: p \ 0.001). There was no difference between setting time, operative time and amount of intraoperative blood loss. Conclusion: Soloassist provided with not only stable operative field, but saving human resources. There was no need to replace a human assistant and were no adverse events. Soloassist was regarded as an effective scope holder for laparoscopic colorectal resection.

Liver Center, HPB Surgery, Yao Tokushukai General Hospital, Yao, Japan Aims: Radiofrequency ablation (RFA) has been accepted as a less invasive and effective modality in cases with hepatocellular carcinoma (HCC) complicated with cirrhosis. Here we report our morbidity and mortality outcome of RFA in cases with HCC. Material and Methods: Past 5 years, we performed RFA for 260 patients with HCC. Among them, 9 cases developed complication (3.4%) more than grade 3 of Clavien– Dindo classification. Six cases developed bleeding complications, and each one with cholangitis, biloma, and peritonitis due to late perforation of duodenum. Clinical course was analyzed in each cases. Results: Among 6 cases of bleeding complication, 3 cases were intrathoracic bleeding, and all cases developed shock status at ward, which required emergency operation for hemostasis. Rest of 3 cases developed intra-abdominal or liver capsule haemorrhage which successfully treated conservatively. One case with cholangitis successfully treated conservatively. One case with biloma, a dimeter of 5 cm, developed 3 months after RFA, which did not show any clinical problem. He was closely monitored once a month. One case with perforation of duodenum suddenly developed 5 days after RFA. She was successfully treated by laparoscopic omentopexy. None of them died of complication after RFA. Conclusion: Morbidity was developed in 3.4% in cases with HCC who underwent RFA therapy, which is comparable with previous report. None of them died of complication (mortality 0%). RFA in patient with HCC appears safe and feasible option in patient with decompensated liver cirrhosis.

P050 - Clinical Practice and Evaluation P052 - Clinical Practice and Evaluation Laparoscopic Complete Mesocolic Excison for the Treatment of Descending Colon Cancer M. Fukunaga1, K. Nagakari2, M. Ouchi2, S. Yoshikawa2, D. Azuma2, S. Kohama2, J. Nomoto2, I. Iida2 1

Digestive Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan; 2Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan Background: Laparoscopic accurate mobilization of the left colon and the splenic flexure with central vascular ligation adherent to complete mesocolic excison (CME) is technically difficult. We introduced laparoscopic CME since 1994. The aim of this study is to assess safety and feasibility and long term outcomes of this procedure for descending colon cancer. Operative Procedure: The CT angiography is useful for the precise understandings of branching pattern of central vessels. 5 ports are placed in each abdominal quadrant. 1st step: the pedicle of inferior mesenteric artery (IMA) is lifted up ventrally. The origin of IMA or the left colic artery is identified and divided, and central lymph node dissection is performed. 2nd step. Mobilization of the left colonic mesentery is continued medial to lateral. 3nd step. Left lateral attachment is incised as far as cephalad. 4rd step: The splenic flexure is taken down through the omental sac. 4th step: Specimen extraction and functional end to end anastomosis or double stapling anastomosis is performed. Result: Between March 1994 and December 2017, 91 consecutive patients for descending colon cancer were performed curative surgery with CME. 41 in Stage II and 50 in Stage III. The mean operative time was 205. The mean estimated blood loss was 47 ml. 1 (1.1%) patients was converted to open surgery. Ileus was observed in 3 patients (3.3%), anastomotic leakage in 1 (1.1%), anastomotic stenosis 1, omental necrosis 1, GI bleeding 1. The 5-year overall survival rates were 91.3% for stage II and 87.2% for stage III disease. Conclusion: Our findings suggested that laparoscopic CME for descending colon cancer is feasible and acceptable both short and long term outcomes. However, complications related to anastomosis should be noted.

Imaging for Quality Control: Systematic Video Recording in Colorectal Cancer Surgery F.W. van de Graaf1, M.M. Lange2, J. Spakman3, W.M.U. van Grevenstein4, D. Lips3, A.G. Menon5, J.F. Lange1 1 Surgery, Erasmus MC, Rotterdam, The Netherlands; 2Pathology, VU University Medical Center, Amsterdam, The Netherlands; 3Surgery, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands; 4Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; 5 Surgery, Havenziekenhuis, Rotterdam, The Netherlands

Aims: Despite ongoing advances in the field of colorectal surgery, the quality of surgical treatment is still highly variable. These variations are not only observed on the level of treatment facilities, but also among surgeons. At present, the only source of technical information regarding the surgical procedure is the narrative operative note, which is subjective by definition and often omits critical information. This study aimed to investigate the added value of systematically recorded operative video as an adjunct to the current narrative operative report with regard to the essential information in colorectal cancer surgery. Methods: Patients aged C 18 years undergoing elective laparoscopic surgery for colorectal malignancy were prospectively included in an multicenter, prospective trial. Previously defined key moments of the included procedures were intraoperatively recorded on video and analyzed for adequacy. Study cases were case matched and compared to cases from a historical cohort as to avoid bias. Adequacy of the reported information was defined as the amount of present and adequately reported steps. Adequacy of the intraoperative video recordings and the narrative operative note were compared between the study and control groups. Results: Between January 2016 and October 2017, a total of 113 patients were included in the study. In the control group, 52.5% of the key moments were adequately described in the narrative operative report. For the study group, the adequacy of both intraoperative video and a combination of intraoperative video with the narrative operative report were significantly superior to the narrative operative report alone (78.5%, p = \ 0.001 and 85.1%, p = \ 0.001, respectively) Conclusions: Systematic intraoperative video registration in colorectal cancer surgery as an adjunct to the narrative operative report proved superior in documenting intraoperative key moments compared to the traditional narrative operative report alone.

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P053 - Clinical Practice and Evaluation

P055 - Clinical Practice and Evaluation

Safety of Laparoscopic Emergency Surgery in the Elderly 1

1

2

3

4

P. Fransvea , G. Massa , B. Frezza , G. Costa , F. Agresta , E. Finotti5, F. Rondelli6, L. Cobuccio7, G. Balducci1, E. Eraso8 1 Chirurgia d’Urgenza, Az.Osp. S. Andrea, Facolta` di Medicina e Psicologia, Sapienza, Roma, Rome, Italy; 2Department of Surgery, Division of General Surgery, Facolta` di Medicina e Psicologia, Sapienza, Roma, Arezzo, Italy; 3Chirurgia d’Urgenza, Az.Osp. S. Andrear, Facolta` di Medicina e Psicologia, Sapienza, Roma, Rome, Italy; 4Department of General Surgery, ULSS19 del Veneto, Adria, Italy; 5Department of Surgery, Policlinico di Abano Terme, Abano Terme, Italy; 6Division of General Surgery, San Giovanni Battista Hospital, Foligno, Italy; 7Emergency Surgery Unit, Cisanello Hospital, University of Pisa, Pisa, Italy; 8Chirurgia d’Urgenza, Assessment and Surgical Outcome Collaborative Study Group, Rome, Italy

Introduction: life expectancies are increasing and consequently there is an increasing elderly population with more complex co-morbidity. Emergency surgery in the elderly is challenging in terms of decision making, managing co-morbidity and post-operative rehabilitation with high morbidity and mortality rate. New physiopathology acknowledgement, improved surgical and anesthetic skills allowed the surgeon to achieve better results in treating these high risk patients. The aim of the present study is to evaluate the feasibility and safety of laparoscopic approach in the elderly population needing emergency surgical procedure. Materials and Methods: preliminary data of the Italian nationwide, multicenter prospective FRAILESEL study were analyzed (ClinicalTrials.gov Identifier: NCT02825082). This analysis was performed with data collected by all members of the ERASO collaborative study group, from December 2016 to November 30, 2017. Variability considered for analysis were age, sex, pre-operative comorbidities and patient fragility, type of procedure performed, timing, morbidity and mortality rate. Results: a total of 1549 emergency procedure were included in the database during the study period. Of these, 497 were performed laparoscopically. The conversion rate was of 14.9%. The most common diagnosis was cholecystitis (52.8%) and colorectal diseases (23.6%). The overall morbidity rate was of 33.2% cases. Laparoscopy group morbidity rate was of 20.3% while for Lap-Converted and OpenPlanned was of 47.3% and 38.1% respectively (p = 0.118; ns). The overall mortality rate was of 10% cases. Laparoscopy group mortality rate was of 1.9%, while for the Lap-Converted and Open-Planned was of 17.6% and 12.7% (p = 0.235; ns). Conclusion: from a preliminary assessment of the data, it emerged that Laparoscopic approach even in geriatric patients decrease global complications and mortality rates, so it is feasible and safe and should be increased due to more improved outcomes.

Can a Surgeon Perform a Macroscopic Inspection of a Gallbladder? B.J.G.A. Corten1, S. Alexander1, P. van Zwam2, R.M.H. Roumen1, G.D. Slooter1 1

Surgery, Maxima Medical Centre, Veldhoven, The Netherlands; Pathology, Foundation PAMM laboratories for pathology and medical microbiology, Veldhoven, The Netherlands

2

Aims: Routine histopathologic gallbladder examination has been a point of discussion for several decades. Recent changes in national guidelines suggest a selective histopathologic examination after cholecystectomy of a macroscopic normal gallbladder. The aim of this study was to evaluate the macroscopic examination by the surgeon. Methods: A prospective study was conducted to investigate the practice of macroscopic examination of the gallbladder by the surgeon compared to the routinely histopathologic examination of the pathologist. All consecutive laparoscopic cholecystectomies were included between November 2009 and February 2011. Patient characteristics, operative procedure, conversions to laparotomy, macroscopic examination of the gallbladder mucosa, alleged necessity for microscopic analysis and final histopathology of the gallbladder were analyzed. Results: A total of 319 consecutive cholecystectomies were performed in a large top-clinical teaching hospital. Twenty-nine patients were treated for acute cholecystitis. Of all macroscopic examinations the surgeon identified 62 gallbladders postoperative with macroscopic abnormalities, ranging from polyps to wall thickening or ulcers. Including the acute cholecystitis a total of 55 (17.2%) had reasons for microscopic evaluation by the pathologist. Macroscopic examination agreement between surgeon and the pathologist was rated ‘‘strong agreement’’ (j = 0.822). The surgeon and the pathologist had disagreement over the macroscopic examination in a total of 18 gallbladders. In these gallbladders supplementary histopathologic investigations by the pathologist showed no relevant clinical outcome. Thus, the disagreement did not result in a relevant microscopic outcome. Conclusions: Our study is the first prospective study to compare macroscopic examination of the gallbladder performed by a surgeon and a pathologist. Our study shows that the surgeon is capable of macroscopic gallbladder examination postoperative, to this extend is a selective microscopic gallbladder examination tenable.

P054 - Clinical Practice and Evaluation

P056 - Clinical Practice and Evaluation

Is Single-Incision Laparoscopic Appendectomy Appropriate for Complicated Appendicitis?

Diverting Ileostomy may Compromise Eras Program in Patients Undergoing Anterior Resection for Rectal Cancer

Y.T. Liao

D. Cassini1, M. Grieco2, N. Depalma3, B. Sollazzo3, F. Manoochehri1, M. Gregori4, D. Angelieri3, M. Miccini3, G. Baldazzi1

Surgery, Yunlin Branch, National Taiwan University, Douliu, Taiwan Background: Despite emerging evidence of the feasibility and efficacy of single-incision laparoscopic appendectomy (SILA) for managing simple appendicitis, advancing its use to treat complicated appendicitis is still unwarranted. The aim of this study was to evaluate the safety and feasibility of SILA for managing complicated appendicitis by comparing it with standard multiport laparoscopic appendectomy (MPLA). Methods: Between July 2013 and September 2017, 40 patients who underwent SILA and 150 who underwent MPLA for treating complicated appendicitis were recruited in this study. Demographic characteristics, intraoperative parameters, and recovery parameters were retrospectively recorded. No routine drainage was placed in the SILA group. Results: SILA was smoothly performed in all patients with complicated appendicitis without requiring conversion to MPLA. No significant difference was observed between the two groups in demographic characteristics, preoperative severity, or appendicitis type. The operation duration in the SILA group was approximately 8 minutes shorter than that in the MPLA group, but no statistical difference was noted (60.03 ± 21.01 vs. 68.04 ± 32.03 minutes, p = 0.222). The recovery parameters, including soft diet intake and postoperative hospitalization, were more favorable in the SILA group (p \ 0.001). Despite no routine drainage in the SILA group, only one patient developed intraabdominal hematoma necessitating further computed tomography-guided drainage. Conclusions: This study adds to the growing body of evidence that SILA could be safe and feasible for managing simple as well as complicated appendicitis. In this study, SILA had superior results in terms of time to resume oral intake and postoperative hospital stay. Furthermore, this study challenges the concept of routine postoperative drainage for complicated appendicitis.

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1 General and Minimally Invasive Surgery, Policlinico Abano Terme, Abano Terme-Padova, Italy; 2General Surgery Department, Saint Eugenio Hospital, Rome, Italy; 3General Surgery First Department, Sapienza University, Rome, Italy; 4Colorectal Surgery, Worcestershire Acute Hospital NHS Trust, Worcester, United Kingdom

Background: From 2013 ERAS guidelines has been largely applied to rectal surgery also to improve perioperative outcomes. At the same time, diverting ileostomy is widely adopted, after low anterior resection, to prevent anastomotic leaks and their complications, expecially in high risk patients. The aim of this study is to analyse adhesions to ERAS items in two groups of patients (patients with ileostomy vs. patients without ileostomy) and to assess whether ileostomy compromises adherence of several items of the ERAS protocol. Methods: A retrospective analyses was performed, evaluating a group of patients who underwent rectal resection for cancer with and without ileostomy, between January 2009 and November 2017. All patients gave their consent to actively participate in the ERAS recovery program. Patient preoperative, intraoperative and postoperative data were collected including: age, gender, ASA score, CACI score, TNM stage, bowel preparation, type of surgery, blood loss, operative time, conversion, ICU stay, postoperative perfusions, oral intake, mobilization, length of hospital stay, morbidity, 30-day readmissions and mortality. Results: During the study period, 181 patients underwent minimally invasive resections for rectal cancer. 80 patients (group A) with diverting stoma and 101 (group B) patients without ileostomy. Ileostomy group (Group A) had worse postoperative outcomes, endovenous fluid infusion was found to be superior during the first (group A 1350 ml/24 h vs group B 680 ml/24, p 0.002) and the second postoperative day (group A 850 ml/24 h vs group B 380 ml/24, p 0.011), solid oral intake was postponed, mobilization started later (14 hours in group A vs. 9 hours in group B, p 0.02), overall morbidity rate was higher, length of stay was longer (group A median 4 days vs. group B median 6 days ) and readmission within 30 days was significantly longer (group A 26% vs group B 9%, p 0.001). Conclusions: A tailored approach may be desirable for patients with diverting stoma after rectal surgery. The standard ERAS protocol may be inadequate because of the poor adherence to several items in this condition. Further randomized controlled trials need to be done to evaluate the preliminary results of this study.

Surg Endosc

P057 - Clinical Practice and Evaluation

P059 - Clinical Practice and Evaluation

Survival Rates of Patients with Rectal Cancer in the University Clinical Center Maribor, Who Underwent Surgery Between 2004 and 2014

Treatment Outcome of Laparoscopic Surgery after Neoadjuvant Chemoradiotherapy for Lower Advanced Rectal Cancer

N. Arlsani1, T. Mikuljan2 1

Abdominal and General Surgery, University Clinical Center Maribor, Maribor, Slovenia; 2First Aid, General Hospital Celje, Celje, Slovenia Aims: From 2004 to 2014, we operated on 578 patients who had been admitted for rectal cancer. We analyzed a variety of data to provide a summary of their survival rates. Methods: For analysis we used data gathered from preoperative diagnostic tests, reports gathered during operation, reports from pathohistologic review, and reports on complications after surgery and follow up. Results: In the case of 573 (out of 578) patients (99.1%) we performed resection. R0 was achieved in 551 patients (96.1%). R1 was achieved in 8 patients (1.4%). R2 was achieved in 14 patients (2.4%). Postoperative mortality in the first month after the resection was performed was 2.9% (9). 5-year survival rate of all patients surgically treated for rectal cancer was 67.3% (231). From 578 patients who were operated on 29 (4.5%) had recurrences. Conclusions: With advances in surgical techniques, with multimodal-multidisciplinary approach and with the use of total mesorectal excision we experienced a significant improvement in 5-year survival rate of patients with rectal cancer. However there still remains the question for truly optimal care for each patient with rectal cancer and his quality of life after surgical treatment.

M. Shimazu, M. Miura, T. Tsutsui, Y. Yamanashi, S. Sato, N. Nakamura, M. Watanabe Surgery, Kitasato University, Sagamihara-Shi, Kanagawa, Japan Background: The recommendation for the treatment of laparoscopic surgery for lower advanced rectal cancer is 1B in Clinical guidelines for colorectal cancer in Japan. This is because anastomosis and intestinal resection with laparoscopic surgery is difficult. Moreover, there is a possibility that the surgical exfoliation surface positive rate may be high. Purpose: The purpose of this study was to investigate the utility of laparoscopic surgery for lower advanced rectal cancer after Neoadjuvant chemoradiotherapy (NCRT). Patients and Methods: We investigated 3-year disease-free survival rate and recurrence risk factor in 57 patients with lower rectal cancer (cT3/T4, N0-2) who underwent laparoscopic surgery after NCRT from 2010 to December 2014 in Kitasato University hospital. Results: Of 57 patients, 36 patients underwent low anterior resection (LAR), 2 patients underwent intersphincteric resection (ISR) and 19 abdominoperineal resection (APR), ypCR rate was 28%, but 10 (17.5%) had recurrenced (5 liver, 5 lung and 1 internal iliac lymph node; There is some overlapping). ypT4 is extracted as a recurrent risk factor. The 3-year relapse-free survival rate (RFS) was 84.1% and the 3-year overall survival rate (OS) was 91.4%. Compared with open surgery, DFS and OS were not significant. Conclusion: The 3-year RFS and the 3-year OS are relatively good results, although an observation. We will conduct further follow-up, and it is necessary to investigate a long term prognosis. Laparoscopic surgery for rectal cancer after NCRT is an effective operative method.

P058 - Clinical Practice and Evaluation

P060 - Clinical Practice and Evaluation

Is there a Difference in Deep Vein Thrombosis Profilaxys in Laparoscopic Surgery Compared to Open Surgery?

Semi-Rigid Single Hook Wire in Localizing Small Pulmonary Nodules: Re-Aerated Swine Lung Experimental and Clinical Results

M.F. Avram1, I.O. Avram2, D. Koukoulas3, F.L. Cadariu4, M. Mari5, S. Olariu1 1

1st Department of Surgery, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania; 2Surgery, CaritasKlinikum Saarbru¨cken, Saarbru¨cken, Germany; 3Internal Medicine, Municipal Hospital, Lugoj, Romania; 41st, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania; 5Physiopathology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania

Aim: To evaluate if there is a difference in the risk for deep vein thrombosis in laparoscopic surgery compared to traditional, open surgery. Material and Method: We analyze and discuss the benefit of DVT prophylaxis in laparoscopic procedures. We included in the study 648 patients that underwent laparoscopic surgery. DVT and PE prophylaxis was made according to the international guidelines for DVT prophylaxis in general surgery, although the guidelines do not take into consideration if the procedure is open or laparoscopic During the operation the position and the high intraabdominal pressure are additional risk factors for DVT, while the shorter interventional time, reduces muscle trauma and early postoperative mobilization are protective factors. We introduced postoperative anticoagulation to all cases that lasted more than 2 hours and had no important hemorrhagic risk. We clinically checked all the patients for signs of DVT, we performed vascular echo Doppler examination to all patients with surgery that lasted longer than 2 hours. Results: In 4 patients the diagnosis of DVT was confirmed by Doppler evaluation, although no clinical signs or symptoms were present. We also discuss the current DVT prophylaxis guidelines elaborated by the American College of Chest Physicians as well as the recommendations elaborated by The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) highlighting the aspects regarding endoscopic general surgery. Conclusions: The relative risk of DVT in laparoscopic surgery versus open procedures is not well defined. Laparoscopic intervention specific guidelines based on large, well conducted studies are needed.

G. Zhao, X.Y. Yu, J. Jiang Thoracic surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China Purpose: The aim of this study was to compare the effects of currently available preoperative localization methods, including semi-rigid single hook-wire, doublethorn hook-wire, and microcoil, in localizing the pulmonary nodules, thus to select the best technology to assist video-assisted thoracoscopic surgery (VATS) for small ground glass opacities (GGO). Methods: Preoperative CT-guided localizing techniques including semi-rigid single hook-wire, double-thorn hook-wire and microcoil were used in re-aerated fresh swine lung for location experiments. The advantages and drawbacks of the three positioning technologies were compared, and then the most optimal technique was used in patients with GGO. Technical success and post-operative complications were used as primary endpoints. Results: All three localizing techniques were successfully performed in the re-aerated fresh swine lung. The median tractive force of semi-rigid single hook wire, double-thorn hook wire and microcoil were 6.5 N, 4.85 N and 0.2 N, which measured by a spring dynamometer. The wound sizes in the superficial pleura, caused by unplugging the needles, were 2 millimeters in double-thorn hook wire, 1 millimeter in semi-rigid single hook and 1 millimeter in microcoil, respectively. In patients with GGOs, the semi-rigid hook wires localization were successfully performed, without any complication that need to be intervened. Dislodgement was reported in one patient before VATS. No major complications related to the preoperative hook wire localization and VATS were observed. Conclusions: We found from our localization experiments in the swine lung that, among the commonly used three localization methods, semi-rigid hook wire showed the best operability and practicability than double-thorn hook wire and microcoil. Preoperative localization of small pulmonary nodules with single semi-rigid hook wire system shows a high success rate, acceptable utility and especially low dislodgement in VATS.

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P061 - Clinical Practice and Evaluation

P063 - Clinical Practice and Evaluation

Assessing the Adoption of Index Cholecystectomy for the Management of Cholecystitis in the UK

Disparity in the Adoption of Index Laparoscopic Cholecystectomy for Acute Cholecystitis and Gallstone Pancreatitis in the UK

H. Malik, J. Clarke, J. Marti, A. Darzi, E. Mossialos

H. Malik, J. Clarke, J. Marti, A. Darzi, E. Mossialos

Surgery and Cancer, Imperial College, London, United Kingdom

Surgery and Cancer, Imperial College, London, United Kingdom

Background: The collection of high-level evidence in favour of acute cholecystectomy should result in increased de-adoption of interval cholecystectomy. Despite this many hospitals and surgeons have not altered practice in order to provide best evidence based management. This results in both inefficient and ineffective care.

Background: It is assumed that the wealth of evidence in favour of index cholecystectomy for both cholecystitis and gallstone pancreatitis (GSP) has increased the de-adoption of interval cholecystectomy. Despite this many providers have not adjusted to best evidence based practice and concerns over variation in adoption have arisen. This results in inequity and inefficient care with poor patient outcomes.

Methods: A Retrospective evaluation of English administrative data was performed. All patients who underwent cholecystectomy following an emergency admission for cholecystits between 2007 and 2015 were included. The proportion index cholecystectomies (that performed within 2 weeks of diagnosis) as opposed to interval (between 2 and 52 weeks) was calculated for each trust and year. Variation in the rate of adoption of the index procedure over time and between providers was then investigated. Different characteristics that are common to providers whom are adopters and non-adopters were then outlined. Results: The total number of cholecystectomies included in the study was n = 55 094. There is significant variation in the rate of uptake of index cholecystectomy between trusts. Compared to the period from 2007 to 2010, in the period from 2010 to 2015 provider adoption of index cholecystectomy ranged from - 37% and 37% (range [r] = 75, interquartile range [IQR] = 18, standard deviation [SD] = 13.2). There is interestingly significant evidence of de-adoption of index cholecystectomy with approximately half of all trusts de-adopting the practice of acute cholecystectomy. Conclusions: This notable disparity amongst providers within the UK displays difficulties in process adoption. Furthermore, a significant proportion of providers have regressed from best practice. Policy measures in the form of financial incentives, didactic leadership and communication amongst surgical networks are required to address this issue.

Methods: A retrospective analysis of English administrative hospital data was performed. All patients who had a cholecystectomy following an emergency admission for cholecystitis or GSP between 2007 and 2015 were included. The proportion of index (performed within 2 weeks of admission) as opposed to interval (between 2 and 52 weeks) cholecystectomy was calculated for each trust and year. Variation in the rate of adoption of the index procedure over time and between providers was then investigated. Different characteristics that are common to providers whom are adopters and non-adopters were then outlined. Results: The total number of cholecystectomies included in the study was n = 132 743 (n = 55 094 for acute cholecystitis and n = 77 649 for GSP). There is significant variation in rates of adoption of index cholecystectomy between trusts. Compared to the period from 2007 to 2010, in the period from 2010 to 2015 provider adoption of index cholecystectomy ranged from - 37% and 37% (range [r] = 75, interquartile range [IQR] = 18, standard deviation [SD] = 13.2) for cholecystitis and - 39 and 28% (R = 67, IQR = 11, SD = 9.4) and for GSP. Importantly, more than half of the providers showed trends of de-adoption of index operation, therefore, not adhering to latest evidence and guidance. Conclusions: Current UK practice is far from best practice with notable variation amongst providers, furthermore a significant proportion of providers have regressed from best practice. There has been an improved response for the treatment of GSP which may be a result of more instructive guidance. Policy measure in the form of financial incentives, didactic leadership and infrastructural support may address this imbalance.

P062 - Clinical Practice and Evaluation

P064 - Clinical Practice and Evaluation

Variation in the UK Approach to Gallstone Pancreatitis in the UK

Chronic Appendicitis. A Surgical Entity

H. Malik, J. Clarke, J. Marti, A. Darzi, E. Mossialos

M.A. Pedonomou1, G. Georgiou2, A. Hadjineoclis3, I. Zouvani2

Surgery and Cancer, Imperial College, London, United Kingdom Background: The collection of high-level evidence in favour of acute cholecystectomy in the management of gallstone pancreatitis should result in increased deadoption of interval cholecystectomy, particularly in the presence of the didactic guidance for an operation to be performed within 2 weeks of diagnosis. Despite this many providers have not altered practice in order to provide best evidence informed management. This results in suboptimal care. Methods: A Retrospective evaluation of English administrative data was performed. All patients who underwent cholecystectomy following an emergency admission for gallstone pancreatitis between 2007 and 2015 were included. The proportion of index cholecystectomies (that performed within 2 weeks of diagnosis) as opposed to interval (between 2 and 52 weeks) was calculated for each trust and year. Variation in the rate of adoption of the index procedure over time and between providers was then investigated. Different characteristics that are common to providers whom are adopters and non-adopters were then outlined. Results: The total number of cholecystectomies included in the study was n = 77 649. There is significant variation in the rate of uptake of index cholecystectomy between trusts. Compared to the period from 2007 to 2010, in the period from 2010 to 2015 provider adoption of index cholecystectomy ranged from –39 and 28% (R = 67, IQR = 11, SD = 9.4) and for Gallstone Pancreatitis. Conclusions: This failure of adoption of best practice within UK providers displays the difficulties in process adoption. Furthermore, a significant proportion of providers have regressed from best practice. Policy measures in the form of didactic leadership and infrastructure support amongst surgical networks are required to address this issue.

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1

Surgical, Aretaeio Private Hospital, Nicosia, Cyprus; Histopathology, Nicosia General Hospital, Nicosia, Cyprus; 3 Medical School, University Of NIcosia, Nicosia, Cyprus 2

Aims: The existence of chronic appendicitis (CA) appears to be controversial among many physicians. It is a rare clinical entity that poses a diagnostic and therapeutic dilemma since a majority of patients present with atypical symptoms. Acute appendicitis (AA) is a surgical emergency, and is regarded as the most common cause of acute abdomen. Approximately 6% of the population will have it in their lifetime. The accepted treatment is to remove the appendix with either an open or laparoscopic appendectomy, with the assumption that an inflamed appendix will progress to perforation, and therefore removal of the offending organ is necessary. There have been studies carried out to review the outcomes of non-operative management of uncomplicated appendicitis, and also to compare the efficacy of antibiotic therapy to surgical appendicectomy. In some studies, antibiotic failure was recorded in 11.8% of patients, and recurrence in up to 35% of patients treated with antibiotics. Complication rates ranged from 5.3 to 14%. On the other hand, a surgical approach brings with it operative complications. Furthermore, normal appendices are removed in up to 20%. The aim of this study is to prove the existence of CA, to evaluate the rate of CA verified by histology between the total numbers of appendectomies, and to correlate them with the signs and symptoms the patients present. Methods: This is a prospective study carried out between December 2017 and February 2018 with participation of Aretaeio Private Hospital Surgical Department, Histopathology Department of Nicosia General Hospital and the University of Nicosia Medical School. All appendectomies performed within this time frame will be included. Results: It is an ongoing study. The final results will be known after the evaluation of the data will be completed. Conclusion(s): Acute and chronic appendicitis can be legitimately presented as separate entities. Histological findings and data from biopsied appendices, especially from the large database provided by the Nicosia General Hospital Histopathology Department has offered a statistically relevant enough number of samples so that a meaningful differentiation could be made. These findings are strongly associated with the clinical manifestation of the diseases.

Surg Endosc

P065 - Clinical Practice and Evaluation

P067 - Clinical Practice and Evaluation

Stress & Laparoscopic Surgeon: Assessment of Laparoscopic Dexterity

3D-Laparoscopic Appendectomy vs Conventional Laparoscopic Appendectomy

A.A. Dhahri, A. Rao, N. Kirmani

I. Avram1, M. Avram2, D. Koukoulas3

Surgery, The Princess Alexandra Hospital Harlow, Harlow, United Kingdom

1 Klinik fu¨r Allgemein-, Viszeral-, Thorax- und Tumorchirurgie, CaritasKlinikum Saarbrucken, Saarbrucken, Germany; 2Clinica I Chirurgie, University of Medicine and Pharmacy, Victor Babes, Timisoara, Timisoara, Romania; 3Compartiment Gastroenterologie, Spitalul Municipal, Dr. Teodor Andrei, Lugoj, Lugoj, Romania

Aim: To assess the impact of stress on the laparoscopic technical performance of surgeon of different grades while using stress-coping questionnaire in simulation setting. Methods: Different grades of surgical doctors were involved in the study who are working in surgical department at The Princess Alexandra Hospital Harlow. All the participants carried out same laparoscopic technical task on simulator under different conditions of observation. Stress-coping questionnaire was used during the task and assessment was based on performance using different variables like time to complete task, blood pressure and heart rate measurements, amount of errors, perception of task difficulty and amount of control, amount of distractions, and anti-stress strategies. Results: Different stress reactions were observed to complete the task with or without stressful conditions. Variable results obtained depending upon the seniority of surgeons and amount of stressful scenario. Stress was found to be elevated during intrusive situations. Conclusions: Effective tactics to cope stress during laparoscopic surgery has direct correlation with the outcome. Stress coping training should be the principal and integral part of the laparoscopic training to improve patient safety and care.

Background: 3D-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice surgeons due to better depth perception. However, the benefits for experienced laparoscopic surgeons are still discussed. Aim: The aim of this study is to compare the conventional (2D) laparoscopic appendectomy with three-dimensional laparoscopic appendectomy in terms of duration and short-term results. Methods: From a total of 289 appendectomies performed in our clinics we selected 50 patients operated using the 3D Einstein Vision system by the same team. As control group we selected another 50 patients operated by the same team using a conventional HD laparoscope. All patients were retrospectively analyzed in terms of OR time, duration of operation, intra- and postoperative complications, length of hospitalization, pain score and necessity of analgesics. Risk factors for complications (BMI, smoker, diabetes, COPD, BPH) were also registered. Results: Mean operation time in the study group was 23.3 minutes in the study group, while mean OR time was 67.4 minutes. Mean operation time in the control group was 21.1 minutes, while mean OR time 51.4 minutes. One reintervention was noted in the control group, two conversions to open surgery in the study group. Conclusions: There were no significant differences regarding the outcome of appendectomy; total OR time was significantly higher in the study group due to the time needed to set up the 3D-laparoscopy unit. Also, there was no significant difference in complication rate.

P066 - Clinical Practice and Evaluation

P068 - Clinical Practice and Evaluation

THE Importance of Laparoscopy in the Management of Accidentally Diagnosed Intraabdominal Tumors

Appropriate Timing of the Temporary Stoma Closure with Rectal Cancer Based on the Using Dose of the Antidiarrheal Drugs

A. Ba´lint, B. Brenner, G.Y. Herczeg, M. Ma´te´

T. Obuchi, M. Konosu, T. Ando, H. Yonezawa, O. Funato, M. Kobayashi, A. Takagane

General Surgery, St Emeric Teaching Hospital, Budapest, Hungary Introduction: The more and more frequently performed non-invasive imaging exams like ultrasound, CT scan, MRI resulted the frequent recognition of clinically ‘‘silent’’ intraabdominal tumors. This pathologies can be benign incidentalomas, but sometimes malignant ones, too with poor prognosis. The tumors suitable for removal following an accurate topographic clarification should be removed. In case of irresecable or disseminated alterations percutaneous or laparoscopic exploration and sampling should be done in order to achieve an adequate staging. Material: The case histories of three patients with accidentally revealed intraabdominal tumors are presented. A 60 years old female patient with moderate, non-specific abdominal symptoms had a left lower quadrant mass with diameter of 4 9 3 cm. The tumor was removed following arterial embolisation, histologically it proved to be Castellman’s disease which is a rarely observed entity. A 39 years old male symptom free patient underwent a screening abdominal ultrasound examination which proved a tumor with diameter of 8 cm in the epigastric region. The tumor was removed laparoscopically and the specimen histologically proved to be CD34 positive solitaire fibrous neoplasia. A 39 years old male patient free of symptoms underwent screening exams including abdominal ultrasound. The latter and a consecutive CT scan verified an upper abdominal mass with diameter of 5 cm. During laparoscopy a tumor was found in the greater omentum which was in toto removed from its surroundings. The tumor histologically proved to be a neuroendocrine neoplasia. Summary: Due to the increasing number of sophisticated screening imaging examinations frequent recognition of clinically ‘‘silent’’ intraabdominal and retroperitoneal tumors can be expected. In these cases interdisciplinary collaboration of different specialist can improve the accuracy of the diagnosis and makes possible the determination of the appropriate therapeutic algorithm. During the management of these cases the possibility of laparoscopic exploration and occasionally the removal/sampling of the tumor highlights the importance of minimal invasive surgery.

Department of Surgery, Hakodate Goryokaku Hospital, HakodateCity, Japan Objective: The objective was to study morbidity and mortality associated with early closure (6 months) of a temporary stoma compared with standard procedure (closure after [ 6 months) after rectal resection for cancer. Background: A temporary ileostomy may reduce the risk of postoperative pelvic sepsis after anastomotic complications. However, the temporary ileostomy is afflicted with complications and requires a emergent surgical procedure with its own complications. Methods: 46 patients were included from January 2012 and with last follow-up of the last patient in November 2017. Early closure (6 months after stoma creation) of a temporary ileostomy was compared with late closure ([ 6 months) in our hospital including patients undergoing rectal resection for cancer. Patients with a temporary ileostomy without signs of postoperative complications were analysed. Clinical data were collected up to 22 months. Complications were registered according to the Clavien–Dindo Classification of Surgical Complications was calculated. Results: The 46 patients were available for analysis. Early closure group was 20 patients and late group was 26 patients. Three patient in the early group suffered from severe output failure because of severe stenosis. The ASA score was similar in both groups (p = 0.99). The rate of complications and after surgery was similar in both groups (p = 0.2). The dose of the antidiarrheal drugs after stoma closure was similar in both groups (p = 0.34). Especially, there were no severe complications, grade 3a, and above according to the Clavien–Dindo classification in early group. Conclusions: It is safe to close a temporary ileostomy 6 months after rectal resection and anastomosis for rectal cancer in selected patients without clinical or radiological signs of anastomotic leakage.

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Surg Endosc

P069 - Clinical Practice and Evaluation

P071 - Clinical Practice and Evaluation

AN Audit of Evening Handovers Among Surgical Junior Doctors in a District General Hospital in Outer London

Operating Room Communication; the Name of the Game?

K. Hodson, I. Ahmed, K. Hassan, V. Shatkar

A.S.H.M. van Dalen1, J.A. Swinkels2, M.P. Schijven1 1

Surgery, Academic Medical Center, Amsterdam, The Netherlands; Psychiatry, Academic Medical Center, Amsterdam, The Netherlands

General Surgery, BHRUT, London, United Kingdom

2

Aims: Evening handovers are a necessary and vital tool in ensuring continuity of, and a high standard of, care for patients between day, evening and night teams. We wanted to ascertain the methods of handover between doctors, the reliability of these handovers, and the preferred methods among doctors. Methods: We audited methods of handover between Foundation Year 1 and 2 doctors in our hospital, including written and electronic. We firstly monitored handovers over a two-week period, and surveyed doctors about their expectations of handover, including what kind of system they would prefer to use. We then implemented a standardised system, utilising the hospital’s existing software for creating patient lists, and introduced a mandatory daily handover meeting. We then monitored handovers over a second two-week period. Doctors were then surveyed for a second time, to elicit their thoughts about a standardised system. Handovers were reaudited for a third time six weeks later. Results: Doctors were unanimous in wanting a standardised, robust handover system. The majority felt that current handovers did not provide adequate information about the patient in terms of background, current issues, and management out-ofhours. We found different opinions regarding the modility of handovers, with no consensus over whether written or electronic handovers were the better option. Difficulties arose in implementing a daily handover meeting, with doctors citing time constraints and heavy workloads as an obstacle to attending this. Six weeks later, electronic handovers had fallen to lower levels than pre-audit. Conclusions: A standardised system should be in place to ensure robust handovers, and clear careplans. We found that this was lacking in our hospital. Further, doctors noted that handovers were often insufficient, leading to an ineffective handover. We want to introduce a standardised system among doctors that will ultimately lead to improved patient care and safety.

Introduction: Poor communication in the operating room (OR) is a known leading cause of error. Good communication has consequently been identified as one of the most important skills for safer surgery. Yet, communication has been measured as one of the most vulnerable constructs. Studies have demonstrated that to ensure clear communication, team members should be addressed directly by their names. Therefore the Surgical Safety Checklist, operationalized by instituting a Time Out at start of procedure, has been introduced to assure that the entire team is introduced properly. However, compliance to this particular checkpoint remains a debatable issue. The aim of this study was to investigate how well the OR team members know and remember each other’s names. Methods: This study was part of a pilot study concerning the implementation of an OR ‘‘Black Box’’ in an academic medical centre, in which 34 predefined procedures were recorded and debriefed in a structured team debriefing session. All team members filled out a questionnaire post-operatively in which they, amongst others, were asked whether or not all the team members were introduced pre-operatively. Before starting the debriefing, the attending team members were asked to write down the names of all the attending team members. Results: Overall, 86.8% of the team members stated that all the OR team members were officially introduced before start of the procedure, but not all team members were always present during the Time Out. However, the majority indicated to have worked with the same team members before. Nevertheless, 61.2% of the team members was not able to recall all the names of the team members afterwards correctly, attending the team debriefing session that took place about 2 weeks after the actual procedure. Conclusion: Although OR team members may formally be introduced during the Time Out, they are often not able to recall the names of whom they actually worked with. Simply introducing team members to each other by the pre-operative checklist appears to be inadequate. In order to avoid potential miscommunication in the OR, alternative strategies to facilitate the OR team in addressing each other by their names are needed.

P070 - Clinical Practice and Evaluation

P072 - Clinical Practice and Evaluation

Case Control Study of the Enhanced Recovery After Surgery (ERAS) Program in Patients Undergoing Gastrectomy for Gastric Cancer

Factors Related to Postoperative Complication of Laparoscopic Gastrectomy

M.R. Jung, O. Jeong, Y.K. Park, S.Y. Ryu Surgery, Chonnam National University Hwasun Hospital, HwasunGun Jeollanma-Do, Republic of Korea Aims: Despite the encouraging results and expanding of the enhanced recovery after surgery (ERAS) program, a few studies have been reported the application of ERAS in gastric surgery. The aim of this study was to evaluate the feasibility and safety of ERAS program that was administered to the patients undergoing gastric cancer surgery. Methods: Between August 2012 and December 2013, 168 patients undergoing gastrectomy for gastric cancer were prospectively enrolled to the ERAS study and perioperatively managed using ERAS protocol consisting of 18 main elements (ClinicalTrials.gov/NCT01653496). The patients in the ERAS study were individually matched to the patients who received conventional perioperative care during same period using propensity score matching method. Surgical outcomes, hospital stay and readmission rate were compared between two groups. Results: The ERAS group had earlier oral diet (Postoperative days (POD) 1.4 ± 1.3 vs. POD 2.3 ± 3.6 days, P = 0.002) and gas passage (POD 2.2 ± 0.8 vs. POD 2.7 ± 0.9, P \ 0.001) than the Conventional group. There was no difference in postoperative morbidity between two groups (9.5% vs. 13.7%, P = 0.233) and no hospital mortality occurred in either group. Mean hospital stay were slightly shorter in the ERAS group but not statistically significant (7.2 ± 3.2 days vs. 8.0 ± 4.5 days, P = 0.075). Readmission rate after hospital discharge was similar in both groups (3.0% vs. 3.6%, P = 0.759). Conclusions: Our study suggests that the ERAS program is safe and feasible for patients undergoing gastric cancer surgery with equivalent to better surgical outcomes compared to the conventional perioperative care strategies.

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R. Matsui, N. Inaki Gastroenterological Surgery, Ishikawa prefectural central hospital, Kanazawa, Japan Aim: Recent studies have indicated that muscle mass reduction is associated with morbidity in various cancer, and that visceral adiposity represents a significant risk factor for several cancers. The aim of this study is to investigate the factors related to postoperative complication of laparoscopic gastrectomy. Subjects and Methods: We retrospectively analyzed 158 patients who underwent laparoscopic gastrectomy for gastric cancer between September 2014 and March 2016. Skeletal muscle mass and visceral adipose tissue were evaluated by preoperative computed tomography. Visceral adipose tissue was divided by height and visceral adipose tissue index (VAI) was calculated. Patients were divided into two groups by postoperative complication. Logistic regression analysis were performed to investigate the independent risk factors of postoperative complications. Results: Among 158 cases, total gastrectomy was performed in 24 cases and distal gastrectomy was performed in 134 cases. Post-operative complications ( ] Clavien–Dindo Classification grade II) occurred in 28 out of 158 patients (17.7%). In the complication group, BMI was higher than in the no complication group. The cutoff value of VAI was calculated from the ROC curve (men: 59.1, women: 28.7). Multivariate analysis confirmed statistically significant correlations between complications and the operation time ] 310 minutes (OR: 10.6, 95%CI: 1.64–68.3, P = 0.013), and VAI (OR: 6.82, 95%CI: 1.56–29.8, P = 0.010). Conclusion: The preoperative VAI was considered to be important for prediction of postoperative complications of laparoscopic gastrectomy for gastric cancer.

Surg Endosc

073 - Clinical Practice and Evaluation

P445 - Clinical Practice and Evaluation

A Rare Case of Treatment of Echinococcosis of the Adrenal Gland

Self-Expandable Metallic Stent as a Bridge to Elective Surgery Versus Emergency Surgery for Acute Malignant Right-Sided Colorectal Obstruction

A.E. Neimark1, Z.H. Osmanov2, A.A. Kovaliev3, I.N. Danilov3 1 Department of Abdominal Surgery, Almazov National Medical Research Centre, Saint-Petersburg, Russia; 2General Surgery, First Pavlov Stat? Medical University, Saint-Petersburg, Russia; 3General Surgery, Almazov National Medical Research Centre, SaintPetersburg, Russia

Echinococcosis remains a common parasitic disease. The most frequent localization of echinococcal cysts (50–85%), lungs (5–30%), less than 10% of cases occurs in the spleen 0.5–8%, kidneys 2–4%, bones, brain 0.5%, heart, adrenal glands 0.5%, pancreas 0.14–2%, ovary and thyroid gland. Very rare localization of echinococcal cysts is the adrenal gland. There are no standard approaches to the treatment of the hydatid cyst of the adrenal gland. Adrenalectomy, in case of complete destruction of the adrenal gland, minimally invasive catheterization and aspiration with partial capsule resection. Also, resection of the adrenal gland can be considered, which will preserve the hormonal function of the preserved part of the organ, especially for young patients. Method: 27-year-old man of residence with chronic pain in the epigastric region, in the anamnesis visit to Turkey. According to the ultrasound of the abdominal cavity organs and retroperitoneal space, a cystic formation of the right adrenal gland was revealed. In the MSCT of the abdominal cavity: In the region of the right adrenal gland box there is a rounded formation with even, clear contours, a homogeneous structure measuring 4.2 9 3.1 9 3.9 cm, density + 13 HU in all scanning phases. Echinococcus Ig G before the initiation of specific therapy 5.13 (0.00–0.84 norm). Therapy with Albendazole 400 mg twice a day was carried out. Against the background of the started therapy, just before the operation, Echinococcus Ig G - 2.88. Laparoscopic intraoperative revision - cystic formation located along the lateral edge of the right adrenal gland. Laparoscopic resection was performed, with the preservation of the greater part of the adrenal gland and the main adrenal vein. Results: In the postoperative period, adrenal insufficiency is absent, discharged on the 4th day after the operation. After the operation, Echinococcus Ig G - 2.44. Conclusion: All the cystic formations of adrenal gland it is necessary to investigate for the presence of echinococcosis. With resectable neoplasms of the adrenal gland with suspected echinococcal cyst, the desired amount of surgery is the resection of the adrenal gland. This approach allows you to maintain the function of the adrenal gland, especially in young people.

S.L. Cai, Y.S. Zhong Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, China Aims: The efficacy and safety of self-expandable metallic stents (SEMSs) as a bridge for patients with acute malignant colorectal obstructions, especially right-sided colorectal obstructions (AMRCOs), are still controversial. We conducted this study to evaluate the outcomes of patients with AMRCOs treated by different strategies. Methods: From July 2008 to November 2016, a total of 91 patients with AMRCOs from Zhongshan Hospital were retrospectively enrolled in this study. Thirty five patients successfully received stent placement followed by open resection in the stent group (containing 7 stage IV patients), and 56 patients received emergency operations in the emergency group. The median following-up was 30 months (0.1–108 months). Results: The median time from stent placement to surgery was 10 days, there was one re-obstruction and no displacement happened. The number of Intensive Care Unit stay and postoperative hospital stay were significantly shorter in the stent group (4/35 vs. 16/56, P = 0.045; 8.06 ± 4.20 vs. 10.95 ± 5.97 days, P = 0.014). The stent group also had significantly reduced the incidence of postoperative complications compared with the emergency group (3/35 vs. 14/56, P = 0.043). There was no difference in Lymph node detected number and blood loss among two groups. Kaplan–Meier survival curves showed no significant difference in both OS and DFS among two groups (P = 0.578, P = 0.995). There was seven patients belong to Stage IV due to the live metastasis in stents group. The median OS of them was 12 months (1–42 months), after receiving right hemicolectomy and partial hepatectomy. Conclusions: Stent placement as a bridge to surgery is a safe and feasible procedure and provides significant advantages in terms of short-term outcomes and equivalent prognoses for patients with AMRCOs.

P074 - Clinical Practice and Evaluation

P446 - Clinical Practice and Evaluation

Identifying Factors Affecting Theatre Efficiency using a TeamBased Approach: a Qualitative Study

A Novel Anti-Reflux Reconstruction after Totally Laparoscopic Total Gastrectomy: Jejunal Pouch-Esophageal Anti-Reflux Anastomosis (JPEAA)

L. Swafe, E. Stewart-Parker, A. Uzkalnis General surgery, University Hospital Lewisham, London, United Kingdom With increasing pressure on surgical departments to reduce waiting lists and save costs, identifying factors affecting theatre efficiency can lead to great improvements in service provision. The aim of this study was to identify and gain insight into main factors affecting theatre efficiency. A prospective study was carried out collecting data between July and August 2017 including data from elective theatre lists in the Department of General Surgery. 33 theatre lists comprised of 134 patients were included in the study. To develop a questionnaire identifying common themes for impaired theatre efficiency, interviews with various staff members were held June 2017 involving nurses, surgeons, anaesthetists, operating department practitioners and support workers. The themes were categorised in order of the patient’s pathway; cancellation on day of surgery, preoperative theatre delays, delays caused in theatre and post-operative theatre delays. These were further broken down into various subcategories. Team members involved in the patients care filled in the questionnaire data which was kept with the patient throughout their patient journey on the day of their operation. The data from the questionnaires was analysed to quantify common factors influencing theatre efficiency. A detailed time analysis was also carried out collecting data from real time information entered into the hospital database, including when patient was sent for, time of arrival, anaesthetic start, knife to skin, end of operation and out of theatre. Most delays occurred pre-operatively (24%) and commonest causes included late arrival of patient (6%), delays in consenting (3%) and lack of rooms to see patients in pre-operatively. 18% of delays were caused intra-operatively and were mostly caused by staff issues (late arrival of surgeon, lack of theatre staff, change of staff during list). We found that the start of the first case was acceptable despite late briefing, however cumulative delays need to be taken into account to improve theatre efficiency. Our data emphasises the importance of using a team-based approach in order to identify causes leading to theatre efficiency and further quantifies the significance of these. Addressing these factors involving all team members, has the potential to greatly improve theatre efficiency.

S. Chen, J. Xiang, X.J. Chen, D.W. Chen, J.S. Peng Department of Gastrointestinal Surgery, The 6th Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China Digestive tract reconstruction after totally laparoscopic total gastrectomy has always been a challenge for surgeons. Roux-en-Y (R-Y) anastomosis has commonly been used more recently. However, postoperative reflux disease and anastomotic leakage are the main problems for patients after R-Y anastomosis. Although some new reconstruction techniques were developed to reduce the incidence of these postoperative complications, the results have not been satisfactory. Jejunal Pouch-Esophageal Anti-reflux Anastomosis (JPEAA) was developed to reduce the rates of reflux and anastomotic leakage after totally laparoscopic total gastrectomy. We performed this procedure in 7 patients with gastric cancer and after 6-months follow-up; there have been no instances of anastomotic leakage or postoperative reflux disease. This manuscript describes a novel technique for jejunal pouch creation during laparoscopic total gastrectomy, facilitating a laparoscopic esophagojejunal pouch anastomosis and creating an anti-reflux fix to reduce symptoms. Reconstruction procedures of JPEAA 1.Creation of a jejunal pouch We made an incision in the upper abdominal wall, placed the wound protector, and then removed the stomach. First, the small intestine is divided into two ‘‘limbs’’ approximately 20 cm distal to Treitz’s Ligament, the biliopancreatic limb and the Pouch limb. We transected the jejunum, which was approximately 20 cm length, folded onto itself for a length of approximately 10 cm. Then, we used a linear stapler to do a side-side anastomosis to make the jejunal pouch (Figs. 1, 2). 2. Anastomosis between the proximal and distal jejunum. Side-side anastomosis was made between the proximal and distal jejunum by a linear stapler. Then, we used the 3-0 suture to close the entry hole (Fig. 3). 3. Anastomosis between the jejunal pouch and esophagus A hole was made on the posterior wall of the esophagus, 2–3 cm above the ligature rope. Then, another hole was made at the anterior wall of the jejunal pouch. We used another linear stapler to make a side-to-side E-J, making an entry hole. Then, we used a linear stapler or knotless tissue control device to close the entry hole (Figs. 4, 5). 4. Anti-reflux fix. We used a 3-0 suture to attach the two sides of the jejunal-pouch together, as shown in Fig. 6.

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P447 - Clinical Practice and Evaluation

P448 - Clinical Practice and Evaluation

A Randomised Trial of 3D Laparoscopy in Expert Performed Total Mesorectal Excision

A Low-Cost Portable Laparoscopic Simulator Exhibiting Construct Validity

N.J. Curtis1, J.A. Conti2, I.C. Jourdan3, J. Torkington4, R. Dalton5, J.B. Ockrim5, A.S. Allison5, T.A. Rockall6, S.M. Phillips4, J. Allison7, G.B. Hanna8, N.K. Francis7

S.M. Mansoor1, C. Va˚penstad2, M. Bliksøen1, T. Glomsaker1, R. Ma˚rvik3

1

Clinical Research Unit, Yeovil District Hospital/Imperial College London, Yeovil, United Kingdom; 2Colorectal Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; 3Colorectal Surgery, Royal Surrey County Hospital, Guildford, United Kingdom; 4 Colorectal Surgery, University Hospital of Wales, Cardiff, United Kingdom; 5Surgery, Yeovil District Hospital, Yeovil, United Kingdom; 6Minimal Access Therapy Training Unit, University of Surrey, Guildford, United Kingdom; 7Clinical Research Unit, Yeovil District Hospital, Yeovil, United Kingdom; 8Surgery and Cancer, Imperial College London, London, United Kingdom Aims: The role of laparoscopy in rectal cancer has been questioned. 3D laparoscopic systems are suggested to improve complex task performance and may aid optimal surgical performance and safe delivery of short term patient benefits. The impact of these systems has not been evaluated in expert surgeons performing advanced procedures. We hypothesised that stereoscopic imaging improves the intraoperative performance of laparoscopic total mesorectal excision.

Methods: A pragmatic, multi-centre, EAES research committee funded, parallel arm randomised trial was designed (ISRCTN59485808, ethical approval SC/16/0118). All trial surgeons had performed a minimum of 200 independent rectal cancer cases and underwent stereoscopic testing. Patients requiring elective laparoscopic total mesorectal excision with curative intent were centrally randomised (1:1) to 2D or 3D modes using Karl Storz IMAGE1 S D3-LinkTM and 10 mm TIPCAMÒ1S 3D passive polarising laparoscopic systems. Primary outcome was the number of enacted adverse events as assessed by the observational clinical human reliability analysis technique applied to blinded review of unedited case videos. This trial is powered to detect a 30% reduction in adverse events (a0.05, b0.8). Secondary endpoints are intraoperative factors, surgeon reported case difficulty, 30 day patient outcomes, histopathological specimen assessment and NASA task load index. Results: Recruitment opened in May 2016. Presently 77 patients have been entered the study (38 2D, 39 3D). 9 patients were withdrawn (5 converted, open and close, unfit, change to abdominoperineal resection, randomisation not followed). 65 cases videos have been analysed to date containing 1168 defined adverse events. The trial and follow up will be completed in spring 2018. Conclusion: An EAES funded, multi-centre randomised trial assessing the impact of stereoscopic systems in complex procedures has been performed. The first results presentation will be delivered at the London congress.

1

Department of Gastrointestinal Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway; 2Department of Medical Technology, SINTEF Technology and Society, Trondheim, Norway; 3The Norwegian National Advisory Unit for Ultrasound and Image-Guided Therapy, Trondheim University Hospital, Trondheim, Norway

Aims: Minimally invasive surgery has become the foundation in general surgery, thus surgeons need to acquire specialized technical skills. Laparoscopic simulation is a patient-safe method to practice and test technical skills. Many simulators are expensive and non-portable. Low-cost simulators rarely allow objective assessment of technical skills. In this study, we aim to test the construct validity of the eoSim, a low-cost, take-home laparoscopic simulator. Methods: Twenty-two novice surgeons (B 99 laparoscopic procedures) and fourteen experienced surgeons (C 100 laparoscopic procedures) were included. All participants watched task specific introduction videos provided by SurgTrac software before performing four tasks on the eoSim (eosurgical LTD, Edinburg, UK): intracorporeal suture and tie, tube ligation, peg capping and precision cutting. Time (seconds), distance (meters), handedness (percentage left hand (LH) versus right hand (RH)), off screen (percentage), distance between instruments (centimeters), speed (mm/ s), acceleration (mm/s2) and motion smoothness (mm/s3) were recorded by the SurgTrac software. Results: Path length (p B 0.001) showed construct validity for all four tasks. The experienced group used significantly less time to complete tasks (p B 0.025) except when performing peg capping (p = 0.052). Significant difference in handedness was found for all four tasks (p B 0.025). The experienced group used both hands more equally, except when performing peg capping (median 84% LH versus median 16% RH), where the novice group showed ambidexterity (median 48% LH versus median 52% RH). Conclusion: The eoSim simulator can be used to test laparoscopic technical skills when using intracorporeal suture and tie, tube ligation and precision cutting. The accessibility of this simulator is high, thus providing an easy way for surgical departments to implement testing of surgeons’ laparoscopic skills.

P483 - Clinical Practice and Evaluation Eras-Apptimize: Improving Compliance to the ERAS Care Pathway Through Improving Patient Participation by Using eHealth M. Jansen1, A. Rauwerdink1, C.A.J.M. de Borgie2, C.J. Buskens1, W.A. Bemelman1, M.P. Schijven1 1

Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands; 2Clinical Epidemiology and Biostatistics, Academic Medical Center Amsterdam, Amsterdam, The Netherlands Background: Perioperative care within colorectal surgery is systematically defined in the ‘Enhanced Recovery After Surgery’ (ERAS) program. This program aims to improve perioperative care in a multimodal way to ensure early but safe release from the hospital. Studies investigating protocol compliance show that higher protocol adherence rates are significantly associated with improved clinical outcomes, such as shorter length of hospital stay, lower rate of postoperative complaints and postoperative complications, reduced 30-day morbidity and lower readmission rates. ERAS-elements where the healthcare professional is mostly responsible for adequate execution show higher compliance rates than elements where the patient is mostly responsible. Adequate compliance to the elements of the ERAS protocol is multifactorial, but optimization of protocol adherence resulting in better patient outcome is to be found by involving the patient. Objectives: The aim of this study is to investigate whether a mobile application can activate and stimulate a patient to participate actively in the perioperative care pathway. Active participation should result in improved compliance to the ERAS protocol and therefore better post-operative outcomes and improved patient satisfaction. Methods: This is a multicenter randomized controlled trial. Sample size calculation resulted in 227 patients. Inclusion criteria are: patients aged over 18 years, in the possession of a smartphone, scheduled to undergo colorectal surgery in either one of the two academic medical centers of Amsterdam (AMC and VUmc). Patients will be randomized to either an intervention- or control group. Patients assigned to the intervention-arm of this study are asked to install the application for smartphone at least 7 days prior to their surgery. The patient is encouraged to use the app during the full perioperative period, via push-notifications reminding and motivating them to participate in the ERAS care pathway. Patients in the control group will receive standard of care. Both groups will wear an activity tracker to monitor daily activity of the patients.

Results: Primary outcome of this study is compliance with the ERAS-protocol. Secondary outcomes are length of hospital stay, number of complications, readmission rates, but also quantification of the achievement of individual ERAS elements. Expected start of the trial is May 2018.

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P075 - Day Surgery

P077 - Day Surgery

Day Case Laparoscopic Cholecystectomy, Fiscal and Safety Appraisal: is it now the Time to Switch to Day Case Surgery for Laparoscopic Cholecystectomy?

Outcomes of 77 Consecutive Transanal Total Mesorectal Excisions for Low Rectal Cancer

A.K.M. Farid Uddin1, U. Nisar1, S.M. Nouman1, S.W. Ali2, I. Ahmed1

R. Troller Visceral Surgery, Cantonal Hospital of Winterthur, Zurich, Switzerland

1

Surgery, Our Lady’s Hospital, Navan, Navan, Meath, Ireland; Accident & Emergency, Our Lady’s Hospital, Navan, Navan, Ireland

2

Background: Although Laparoscopic Cholecystectomy (LC) has established itself as the Gold Standard for the treatment of symptomatic gall stone disease, many surgeons still have reservations in performing them as day cases. The objective of this study was to evaluate the results of our day case LC in terms of safety, the length of hospital stay, cost-effectiveness, complications and human factors. Methods: All patients requiring cholecystectomy for the 5 years period from January 2012 to December 2016 were admitted for Day Case Laparoscopic Cholecystectomy (DCLC). The surgery was performed in the morning list to allow time to recover and discharge in the evening. The limitation for doing cholecystectomy in our hospital includes age B 70 years, American society of Anaesthetist (ASA) class 1 & 2 and Body Mass Index (BMI) B 40. Patients not fulfilling the above criteria were referred to a nearby larger hospital. Data were collected prospectively on a data sheet, analysed using SPSS-18 and results compared with other published studies. Results: 376 patients fulfilled the above criteria for LC in our hospital and all were scheduled for Day Case surgery. We had 304 (80.9%) females and 72 (19.1%) male patients in our series. Mean operating time was 48.30 ± 18 minutes. A total of 308 (81.91%) patients were discharged home on the same evening having an average stay of 9.5 hours. The rest 68 (18.1%) patients had to be admitted into the inpatient wards for various reasons. Of these 68 patients, 39 were kept over-night for pain relief, nausea or vomiting, and all were discharged home in the following morning. Remaining 29 patients were discharged within 2–8 days. 30 patients had insertion of a drain, five patients were converted into open laparotomy (1.32%) for difficult pathology, two patients had severe haemorrhage and two had laparoscopic CBD exploration, all requiring admission. Nine patients (2.39%) had superficial port site wound infection. There was no mortality in this series. 7 (2.27%) patients of the 308 discharged as successful DCLC were readmitted with pain. Conclusion: With careful patient selection and in experienced hand, Day case LC can be safe and very cost effective.

P076 - Day Surgery

Methods: Consecutive patients treated at a single centre by taTME were included in a prospective cohort study. Perioperative and short-term oncologic outcomes were measured along regular clinic visits and the results were reported as median and interquartile range (IQR). Results: 77 patients with a low rectal cancer (median 7 cm to anal verge, IQR 6–8) underwent a taTME between Feb 2013 and November 2017. Age and body mass index were 66 years (IQR 57–76) and 26 kg/m 2 (IQR 22.3–29). 54 (70%) patients had neoadjuvant radiochemotherapy. Median surgery time was 353 minutes (IQR 308–420), including an ileostomy in all patients. Dissection of the mesorectum was good (93.5% Quirke 3) and all distal and circumferential margins were clear. Median T stage was 3 (IQR 2–3). 19 patients had lymphnode metastases for a median number of retrieved nodes of 26 (IQR 20–37). Cumulative 30-day morbidity amounted to 28.47% minor complications (Dindo–Clavien I–II) and 29.8% major complications (Dindo–Clavien III–V), including 9 anastomotic leaks (11.6%). The 30-day reoperation rate was 3.89%. Most of the leaks could be managed endoscopically and the ileostomy reversed at last. Median length of hospital stay was 11 days (IQR 9–14). Conclusion: Transanal total mesorectal excision allows good surgical and oncologic quality to the expenses of a reasonable surgery time and morbidity.

P078 - Day Surgery

Fast-Track for Acute Cholecystitis 1

Background: Transanal total mesorectal excision (taTME) is an alternative to conventional mesorectal excision owing to its reported superior ability to achieve clear distal and circumferential resection margins in low rectal cancers.

1

2

1

T.V. Nechay , A.V. Sazhin , S.M. Titkova , A.E. Tyagunov , M.V. Anurov2, A.A. Tyagunov1, K.Y. Melnikov-Makarchyk1, Y.S. Balakirev1, V.S. Nechay3 1

Faculty Surgery, Pirogov Russian National Research Medical University, Moscow, Russia; 2Experimental Surgery, Pirogov Russian National Research Medical University, Moscow, Russia; 3Thoracic and Abdominal Surgery, Tula Region Clinical Hospital, Tula, Russia Introduction: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures. While the elective cholecystectomy is often an ambulatory procedure, in case of emergency LC inhospital stay averages 4.5 days. The reason for this is persisting pain, dyspepsia and complications which level is about 6% and has no tendency to decrease. Fast-track (FT) reduce the perioperative stress response and postoperative complications in elective surgery. Few studies investigate the advantages and disadvantages of FT in the treatment of acute cholecystitis (AC) with controversial results. There are no randomized studies of FT in AC. Aim: to study the FT protocol in patients with AC. Materials and methods. A prospective randomized study include 102 patients (45 of main group (FT) and 57 of control). Patients did not differ by TG13 severity index. The studied protocol included information, antibiotic prophylaxis, restriction of drainage, intraperitoneal anesthesia with long-term anesthetics, low pressure pneumoperitoneum, antiemetics in the presence of risk factors, early activation and feeding of the patient. Pain was assessed by VAS immediately after surgery, and 2, 6 and 12–24 hours postoperatively.

Results: The surgery duration didn’t differ in groups. The need for anesthesia and pain level was significantly lower in the FT group. A total absence of pain (VAS 0–1) on the 1st postoperative day was noted in 8 (17.7%) of FT and 2 (3.5%) patients of the control group (p = 0.038). Shoulder pain developed in 4 (8.9%) of the main and 22 (38.6%) of the control group (p = 0.001). Postoperative nausea developed in 13% of the FT group vs 40.5% in control (p = 0.05). The in-hospital stay was 1.29 ± 0.7 days and 2.7 ± 1.6 (p \ 0.0001) respectively. The time of first stool was not different. Twenty four (53.5%) patients of FT and 8.9% of control group were discharged on 1st postoperative day. There were 2 (IIIA) complications in the main group and 3 in the control group (IIIA, IIIB and IV). There were no mortality and readmissions. Conclusions: The FT in AC reduce postoperative pain, dyspepsia, shoulder pain and inhospital stay with equal number of postoperative complications.

Telephone Follow Up of 100 Patients in a Day Case Laparoscopic Surgery-Clinical Outcomes, Safety and Cost Effectiveness A. Solodkyy, Q. Azeem, A. Fedotovs, F. Difranco, A. Harris General Surgery, North West Anglia Trust, Huntingdon, United Kingdom Introduction: Day surgery is well established as a safe treatment for appropriate operations e.g. cholecystectomy and hernia repair. Also nurse led follow up is widely used in many day surgery units. It is safe and cost beneficial to our services. Methods: Prospectively collected data of all elective Laparoscopic Hernia Repairs (LHR) performed in a district general hospital from 2010 until 2016 with telephone follow up by nurse practitioner or surgeon in clinic. Data include demographics, operative data, complications arising in post-operative periods, re-admissions, follow up difficulties and cost calculations. Results: During the study period 1000 patients underwent elective LHR, 85 patients (8.5%) were booked for overnight stay due to multifactorial reasons and 915 planned as day cases. 5 (0.5%) patients were converted to open surgery. 817 (81.7%) were successful telephone follow up at 6 weeks after operation and 183 patients have failed to be in telephone contact by surgical practitioner. Clinic follow up by surgeon was done in 106 (13%) cases after concerns raised at the telephone follow up by nurse practitioner. Therefore, 711 (87%) patient have had uncomplicated telephone follow up by nurse practitioner and have been discharge to the primary care successfully. This lead saving of £36, 000 being a difference between clinic and telephone follow up with nurse practitioner. Conclusions: Nurse practitioner follow up is a recognised and well-established practice in day surgery units. Our large study showed that it does not compromise patient safety and allows clinicians to assess patients with concerns raised at initial telephone consultation. This helps to free up clinic appointments and provides cost efficiency.

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P079 - Day Surgery

P081 - Different Endoscopic Approaches

Impact of Obesety on Day Case Laparoscopic Surgery

Clinical Values of Dental Floss Traction Assistance in EFTR for Submucosal Tumors Originating from the Muscularis Propria Layer in the Gastric Fundus

A. Solodkyy, A. Fedotovs, M. Feretis, S. Gergely, A. Harris General Surgery, North West Anglia Trust, Huntingdon, United Kingdom Introduction: Daycase surgery has traditionally been considered appropriate for laparoscopic procedures such as cholecystectomy (LC) and inguinal hernia repair (LIHR). Many units still exclude obese patients [Body Mass Index (BMI) [ 35] from laparoscopic daycase surgery due to perception of increased risk. However, as the prevalence of obesity rises in the western world, strategies may need to be reconsidered in order to protect the healthcare resources. We present our experience on the outcomes and immediate complications following LC or LIHR in obese patients. Methods: Data was collected prospectively on all patients scheduled to undergo elective LC or LIHR as day cases in a District General Hospital over a 7-year period. Data was collected on baseline patient demographics, BMI, intra-operative complications, length of stay and reasons for unexpected overnight admission. P values \ 0.05 was considered to be statistically significant. Results: During the study period 1858 patients (1068 males) with a mean age of 54.5 years (SD 15.86) underwent elective LC and LHR. 181/1858 procedures (9.7%) were pre-planned as overnight stay due to multifactorial reasons leaving 1677 planned day-cases (923 LIHR and 935 LC respectively). Of these, 1422 patients (84.8%) were successfully operated and discharged on the same day- ‘‘true day cases‘‘ (TDC), with 254 patients (15.2%) requiring an unexpected overnight stay (UOS). The mean BMI of the study’s cohort was 28.1 (SD 5.26). The total number of patients with BMI [ 35 was 228 (15.5%). The proportion of patients with BMI [ 35 was similar between the two groups TDC/UOS (11.4% versus 14.4% respectively, p = 0.2). Post-operative complications: wound infection 2.4%/2.3% (TDC/UOS respectively). There were no deaths associated with either procedure. Conclusion: We have high ‘true day-case’ rate of 84.8% of planned day case surgery patients. In a specialist unit with appropriate experience and equipment, daycase laparoscopic procedures on obese patients with no other co-morbidity is safe and feasible. Our data shows that patients with high BMI [ 35 have no increased risk of complications or reason for overnight stay in comparison to general population. Therefore, the high BMI index criteria alone should not exclude patients from daycase surgery which will be cost beneficial to our service provision.

Q. Shi, Y.S. Zhong, P.H. Zhou, L.Q. Yao Department of Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Background and Aims: With the development and maturation of endoscopic resection, endoscopic full-thickness resection (EFTR) derived from endoscopic submucosal dissection (ESD) is gradually accepted and promoted to treat submucosal tumors (SMTs) originating from muscularis propria (MP) lays. However, there are some difficulties when EFTR is applied in the treatment of muscularis propria lesions in gastric fundus. This study intends to explore whether EFTR can be more simple, safe and effective with the traction assistance of dental floss. Methods: From January to December in 2016, the clinical data of patients (trial group) with lesions from MP in gastric fundus undergoing EFTR with traction assistance of dental floss at Zhongshan Hospital, Fudan University were reviewed retrospectively. Control group was matched with trial group according to tumor size by one to one from January to December in 2015. The differences in tumor resection time, patient hospitalization time and complication rate were evaluated. Results: The statistic difference occurred when operative time was compared in two groups (10.8 + 2.8 min vs 19.0 ± 4.7 min, t = 7.298, P \ 0.05). There was no statistically significant difference in postoperative hospital stay time (3.2 + 0.5 d vs 3.2 + 0.5 d, t = 0.291, P = 0.772). In the trial group, there were 19 cases of gastrointestinal stromal tumors (both Group 1) and 5 cases of leiomyoma. The control group have the same result. Two groups of patients were all not happened to postoperative delayed bleeding or perforation and other complications. Conclusions: First, dental floss traction could help expose the tumor boundaries, so that the operation field was clearer to simplify the operation process and significantly reduce the procedure time. Second, in the course of surgery, EFTR-assisted dental floss traction could better reveal the blood vessels or find bleeding blood vessels for prevention and early treatment of bleeding. Third, When the tumor was completely resected, dental floss could also prevent the tumors from falling into the abdominal cavity and help to remove the excised tumors.

P080 - Different Endoscopic Approaches

P082 - Different Endoscopic Approaches

A Case of a Caniopharyngeal Canal (CPC)-Associated Meningoencephalocele, Successfully Treated by Endonasal Endoscopic Surgery

Novel use of a Balloon Catheter to Enable Mechanical Lithotripsy of Difficult Common Bile Duct Stones after Initial Failed Attempt: a Case Report

S. Mitani

W.L. Loh1, J.Y.M. Tung2, T.H.Y. Tan2, L.T. Tan2, S.S. Ngoi2

Otolaryngology, Head and Neck Surgery, Japan/Ehime University, Toon, Japan

General Surgery, Singhealth, Singapore, Singapore; 2General Surgery, Ngoi Surgery, Singapore, Singapore

Carniopharyngeal canal (CPC) is a congenital defect of the skull base, which is a well-corticated duct from the sellar floor to the anterosuperior nasopharyngeal roof. It is a rare congenital abnormality, 0.42% in asymptomatic population. CPC is generally used to describe a small defect measuring \ 1.5 mm in diameter, so that this disorder developes no complications in most cases. However larger CPC can lead to transsphenoidal meningoencephalocele; then complications requiring surgical treatment, such as cerebrospinal rhinorrhea, recurrent meningitis, and upper airway obstruction, may develop. In previous studies, surgeries for meningoencephalocele associated with larger CPC have been performed primarily using transpalatal or transcranial methods, but these methods are highly invasive and are associated with many complications. We will present a case of endoscopic endonasal surgery with a good result in this report. A 31 year-old woman with no congenital craniofacial anomalities had been hospitalized for recurrent meningitis several times a year since she was 10 years old. In this admission, endonasal fiberscopy was performed for a purpose of thorough examination, which revealed a soft mass at each nasopharyngeal meatus. Computed tomography (CT) and magnetic Resonance (MR) imaging showed that these masses communicate to cranial cavity through a CPC. Thus, this recurrent meningitis was apparently caused by a CPC-associated meningoencephalocele. Endoscopic endonasal surgery was carried out for both the resection of meningoencephalocele and reconstruction of skull base defect with a pedicled septal flap. After 1.5 year, she is doing well with no complications such as meningitis and cerebrospinal rhinorrhea.

Introduction: Difficult and large common bile duct stones can be crushed and removed using a mechanical lithotripter. Very often the lack of working space within the common bile duct causing the failure of mechanical lithotripsy would inevitably mean repeat or further invasive procedures. Presentation of case: A patient with large and multiple common bile duct stones underwent ERCP, and initial deployment of a mechanical lithotripter failed due to the lack of working space within the common bile duct. A through-the-scope (TTS) dilator was utilized to increase the working space before successful deployment of the mechanical lithotripter, and subsequent clearance of all stones within the same setting. Discussion: We herein describe a novel and ingenious technique of utilizing a through-the-scope (TTS) dilator in helping to expand the space within the common bile duct to allow for full deployment of a mechanical lithotripter and successful clearance of common bile duct stones. This ingenious method can be easily applied by advanced endoscopists and is expected to lead to increased success rates of clearance of difficult common bile duct stones. Conclusion: Use of TTS dilators to increase working space within the common bile duct can be useful in increasing the success rates of mechanical lithotripsy in the setting of large and multiple common bile duct stones.

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P083 - Different Endoscopic Approaches

P085 - Different Endoscopic Approaches

Single Port Needlescopic Appendectomy in Children Using Mediflex Instrument: a New Simplified Technique

Transillumination and Indentation as Factors for Successful Peg Tube Placement

M. Ismail Lotfalla1, M. Ismail1, R. Shalaby1, A. Shams2, A.H. Fawzy3

A.K. Alexiou1, T.M. Terzopoulou1, M.D. Mpethani1, I.E. Ierapetritakis1, T.M. Tsivou1, S.G. Spithakis2, E.N. Economou1, K.P. Karantanos2

1 Pediatric Surgery, Al Azhar University, Giza, Egypt; 2Pediatric Surgery, Al Azhar University, Cairo, Egypt; 3Pediatric Surgery, Beni Sueif University, Beni Sueif, Egypt

1

1st Surgical Dpt, Sismanoglion Hospital, Marousi, Greece; Gastroenterology, Sismanoglion Hospital, Marousi, Greece

2

Background: Appendectomy is one of the most common operations. Needlescopic appendectomy (NA) is acceptable, safe technique and has many advantages such as better cosmoses and less hospital stay but the published techniques used two mm instruments which we consider it a multi-port surgery in children. Here in, we present an innovative Needlescopic technique for appendectomy using Mediflex facial closure needle and vascular access canula (VAC) to perform actual needle scopic appendectomy, where we ligate the base of appendix in addition to either ligation or cauterization of mesoappendix. The technique will be discussed in details. Material and Methods: twenty-eight children with acute non-complicated appendicitis were the material of this work, their age ranged from 4 to 16 years old. They were eight males and twenty females. All children were counselled and prepared for surgery by Clinical examination, routine laboratory investigations, abdominal ultrasonography and CT scan. All children with complicated appendicitis were excluded. Results: the mean operative time was 20 minutes on average ranging from 15 to 30 minutes. The post-operative hospitalization was 1.2 days on average ranging from 8 hours to 2 days. No single case of conversion to either open surgery or multiport laparoscopic surgery. No intra or postoperative bleeding. Excellent cosmetic results were gained (scar less surgery). Conclusion: This technique is safe, effective, reproducible and easy approach for appendectomy. The procedure showed significant reduction of both operative time and hospital stay in comparison to reported one without single case of conversion to open or multi-port surgery.

Introduction: We studied the impact of technical factors during PEG tube placement on the development of subsequent complications. Method: All patients undergoing PEG tube placement during a five-year period were included. Patients’ demographics and nutritional status were collected for the analysis. 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 into continuous numeric scores 1/2. Technical difficulties of the procedure were quantified as None/Some/Severe (1/2/3). Results: Over 5 years 214 patients underwent PEG tube placement. The Pull Technique was used in all cases under sedation, with antibiotic prophylaxis. Average time required was 16 minutes. Indications were stroke (86 patients), dementia (39 patients), Parkinson’s disease (39 patients), brain tumours (17 patients), head and neck cancers (16 patients), multiple sclerosis (11 patients), oesophageal cancer (6 patients), neonatal encephalopathy (3 patient). The mean age of the patients was 70 years. 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 and indentation score was poor in all 3 patients (100%) of the peritonitis group whereas these factors were graded as poor in only 8 patients of the non-peritonitis group (3.7%). There was no significant difference in the overall technical difficulty score between the two groups. Minor complications such us tube blockage, wound infection and inadverdent tube removal were present in 19 patients. Conclusion: There seems to be an association between technical factors during PEG and the development of peritonitis. Trans-illumination and indentation appear to be of great importance since, in our study, there was a peritonitis incidence of 27% in the group of patients where a satisfactory trans-illumination and indentation point could not be achieved.

P084 - Different Endoscopic Approaches

P086 - Different Endoscopic Approaches

Single Port Needlescopic Assisted Inguinal Hernia Repair in Children Using Extracorporeal Locking Sliding Knot

Hybrid Laparoendoscopic Approaches to Endoscopically Unresectable Colon Polyps

M. Ismail Lotfalla1, R.A. Shalaby1, M. Maged1, A.H. Fawzy2

S. Morales Conde, V. Pino Diaz, F. Lopez Bernal, M. Socas Macias, A. Barranco Moreno, I. Alarco´n del Agua

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2

Pediatric Surgery, Al azhar University, Giza, Egypt; Pediatric Surgery, Beni Sueif, Beni Sueif, Egypt Background: Needlescopic inguinal hernia repair (IHR) has many advantages over traditional multi-port hernial repair, because of its better cosmoses, early recovery, and lower rate of recurrence. The disadvantage of many Needlescopic repairs as patkowski technique is the application of the knot in the subcutaneous area with consequent formation of stitch sinus. In addition to the high rate of recurrence because of the Seton effect on the entrapped muscles. Here in, we introduce a simplified laparoscopic-assisted Needlescopic technique to encircle the deep ring, where we apply the knot by sliding locking extracorporeal knot through venous access canula (VAC) gauge 14.The technique will be presented in full detail. Material and Method: One hundred and twenty inguinal hernia repairs in children were the material of this study. Their age ranged from 10 month to 6 years. The hernia were bilateral in 35 children. Twenty-two were females and 63 were males. All children were counselled and prepared for surgery where preoperative routine investigation, clinical examination, and inguinal ultrasound were done. At the end of the operation we raised the intraabdominal pressure to double its level for 30 s as an air tight test. Results: The operative time was 8 (+-4) minutes in unilateral cases and 15 (+-6) minutes in bilateral cases. No single case needed conversion to either multiport or open technique. No single case of recurrence. Excellent cosmetic results were gained. No single case of air leakage with application of the air tight test proving that the knot is excellent securing tight knot. Conclusion: The technique proved to be simple, reproducible, and rapid, with a completely tight and secured extracorporeal knot with avoiding of stitch sinus and entrapment of abdominal wall muscles (pitfalls of patkowski technique and modified ponsky technique).

General Surgery, Hospital Universitario Virgen Del Rocio, Seville, Spain Secondary prevention of colorectal cancer relies on effective screening through colonoscopy and polypectomy. Resection of some polyps can present technical challenges particularly when polyps are large, flat, or behind colonic folds. Endoscopy as an adjunct to laparoscopy can aid in removing difficult colonic polyps without subjecting patients to radical segmental colectomy. Hybrid laparoendoscopic techniques are increasingly reported in literature as alternatives to segmental colectomy for the treatment of polyps that have a high likelihood of being benign. Laparoscopic-assisted colonoscopic polypectomy is the most frequently utilized technique; it harnesses the power of laparoscopy to aid endoscopic polypectomy by flattening folds, mobilizing flexures, and providing retraction. Colonoscopy-assisted laparoscopic wedge and transluminal resection are often reported in older studies and use the visualization provided by intraoperative colonoscopy to guide colonic resection that is limited to the area of the polyp. Materials and Methods: From 2013 to 2017, 15 patients who underwent laparoscopic treatment for ‘‘difficult’’ polyps that could not be treated by endoscopy were included. The demographic data, the type of surgery, length of post-operative stay, complications, and final pathology were reviewed prospectively. Results: The mean patient was 67,3 10,3 years of age. Laparoscopic mobilization of the colonic segment and colotomy with removal of the polyp was performed in 8 patients, laparoscopic segmental cecum resection in 7 cases. All of them underwent endoscopic assisted. The mean post-operative hospital stay was 1.9 days. All patients recovered after conservative treatment. The mean polyp size was 1.9 ± 1.03 cm. Final histopathology revealed tubular adenoma (n = 3), villous adenoma (n = 6), tubulovillous adenoma (n = 3), carcinoma in situ (n = 1), invasive cancer (n = 1) and lipoma (n = 1). We have not recurrences. Conclusions: The combined use of laparoscopy and endoscopy can expand the endoscopist’s armamentarium when dealing with the most challenging polyps, while serving the patients’ best interest by limiting the extent of colon resection. Minimally invasive segmental colectomy based on oncologic principles should be utilized when none of the previous techniques are suitable or when malignancy is strongly suspected.

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Surg Endosc

P087 - Different Endoscopic Approaches

P088 - Different Endoscopic Approaches

Novel use of Intraoperative Endoscopic Haemostatic Agents to Treat Anastomotic Line Bleed in Colorectal Anastomosis

Development of Laparoscopic Intraoperative Real-Time Diagnosis of Peritoneal Metastasis Using Endocytoscopy

Y.Q. Tan, W.K. Cheah, C.C.L. Lau

S. Shoji, S. Kudo, Y. Ishiyama, K. Kenta, C. Maeda, M. Misawa, Y. Mori, K. Wakamura, Y. Enami, N. Sawada, E. Hidaka, F. Ishida

Department of General Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore Aim: Anastomotic line haemorrhage after colorectal resection occurs in the early postoperative period and can be associated with serious morbidity, reportedly occuring in up to 9.6% of cases. Perioperative endoscopy is used to treat anastomotic bleeding, using endoscopic clipping, adrenaline injection or electrocoagulation for staple line haemostasis, all of which can compromise the newly created anastomotic line. We report our initial experience in using a new endoscopic therapy for anastomotic line bleed using topical haemostatic agents. Methods: Between October 2016 to October 2017, 90 patients with colorectal cancer underwent elective anterior resections. The colorectal anastomoses fashioned with DST EEA staplers (Medtronic). After creation of the stapled anastomosis, all patients had routine intraoperative endoscopy to assess the integrity of the anastomosis. Brisk active or spurting staple line bleed was found on endoscopy in 5 patients (5.6%). Either EndoclotÒ or SurgicelÒ were applied to the anastomotic line. Patients were followed-up 30 days post-surgery. Primary outcome studied was the rate of clinically significant anastomotic bleeding, defined as fresh bleeding perrectum, haemorrhagic shock, or need for urgent endoscopy or transfusion. Secondary outcomes studied were anastomotic leak rates and time to first flatus and bowel movement. Results: The patients’ mean age was 67.8 ± 6.05 years, 60% were female, and all were ASA 2 patients. All patients had normal pre-operative coagulation profiles and albumin levels. One patient was on long-term Aspirin, which was stopped 7 days pre-operatively. Mean tumour size was 26 ± 15.2 mm. 80% were in the sigmoid colon, with 20% in the upper rectum. 80% of cases were performed laparoscopically. All patients had successful haemostasis with single application of endoscopic haemostatic agents. Three patients received EndoclotÒ and two patients received SurgicelÒ. During a 30-day follow-up, there was no recurrence of anastomotic line bleeding. Average time to first flatus and bowel movement were 2.2 ± 0.45 days and 3.0 ± 0.71 days postoperatively respectively. No major procedure related complications were reported. Conclusion: Endoscopic topical haemostatic agents is safe and simple to use in anastomotic line bleed. We propose that this method is potentially a better option than more invasive techniques such as clipping.

123

Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan Introduction: Staging laparoscopy (SL) is often used to diagnose peritoneal metastasis (PM) in patients with advanced gastric cancer, but accurate detection of PM can be difficult. Furthermore, there is no instrument available to perform realtime in-situ histopathological diagnoses of PM. Thus, we investigated the feasibility of using endocytoscopy (EC, CF-Y0020, Olympus) to perform a real-time optical diagnosis of PM. EC is an ultra-high magnification technique that enables surface morphology to be assessed in real time, with magnifications in excess of 4509. By observing the nucleus of the living tumor cell and the vascular morphology of the tumor, it is possible to predict the real time pathological diagnosis of the lesion. By applying this EC to staging laparoscopy, we considered that it is possible to perform real-time diagnosis during surgery of peritoneal dissemination of cancer. In consideration of safety, we first started research from observation using resected specimens. Case Presentation: A 88-year-old women presented our hospital with anemia. Gastrointestinal endoscopic fiberscopy (GIF) was carried out and huge Borrmann Type2 advanced gastric carcinoma was found on lesser curvature of stomach. Computed tomography (CT) was carried out and regional lymph node metastases was suspected. But peritoneal dissemination was not detected. Staging laparoscopy (SL) was performed and peritoneal dissemination nodules were revealed. So, peritoneal dissemination nodules were taken out laparoscopically and observed with EC. The EC appearance of peritoneal dissemination nodules were shown below. (i) The cells are irregular. (ii) Larger amount of nuclear material. (iii) A higher nucleus-to-cytoplasm ratio. The EC with narrow-band imaging appearance of peritoneal dissemination nodules were shown below. (i) Caliber change of microvascular. (ii) Caliber irregularities of a single vessel. Pathological examination of the dissemination nodules led to the diagnosis of moderately-poorly differentiated tubular adenocarcinoma and EC appeared to correlate with the pathological examination. Discussion: Due to the spread of laparoscopic surgery, the safety of gastric cancer surgery has improved due to its ‘‘magnifying effect’’. In the future ‘‘ultra-high magnifying effect’’ that the applicant has developed in the EC. It would be possible to real-time diagnosis of cancer progress. Conclusion: Laparoscopic intraoperative real-time diagnosis of peritoneal metastasis could be performed using endocytoscopy.

Surg Endosc

P089 - Different Endoscopic Approaches

P091 - Different Endoscopic Approaches

Single Center Initial Experience in Robotic Whipple Procedure 1

2

2

3

P.P. Kim , M.G. Efanov , R.B. Alikhanov , V.V. Tsvirkun , I.V. Ivan Kazakov2, O.V. Melekhina4, N.I. Elizarova2, A.N. Vankovich2, D.G. Ahaladze2, K.D. Grendal2 1

Liver and Pancreas Surgery, Moscow Clinical Scientific Centre, Moscow, Russia; 2HPB, MCSC, Moscow, Russia; 3General Surgery, MCSC, Moscow, Russia; 4Intervention Radiology, MCSC, Moscow, Russia Background: Minimally invasive approach for pancreatoduodenectomy (PD) still remain the rare option worldwide. Majority of centers in USA have annual experience less than 10 procedures. Robotic approach is less applied than laparoscopic PD despite the well-known advantages of robotic complex.

The aim of the study was the estimation of intra- and early postoperative events in robotic PD in a single center initial experience. Material and Methods: The clinical data of 12 patients who underwent robotic Whipple procedure using the da Vinci Surgical System from May to September 2017 were retrospectively analyzed. All procedures were performed by single surgeon without previous experience of lap PD. There were six males and seven females with mean age of 63 ± 7 and ASA 2–3. Eleven patients had malignancy: pancreatic ductal adenocarcinoma (9), distal common bile duct cholangiocarcinoma (1), carcinoma of the major duodenal papilla (1), and one patient with pancreatic head benign cystic tumor. The mean BMI was 27 ± 7. Pancreatic main duct dilatation was present in 9 patients. The mean main pancreatic duct diameter was 5.1 ± 3 mm. Results: Mean operation time was 745 ± 113 (650–845) min. There was one conversion for right hepatic artery resection, involved in tumor. Blood loss was 281 ± 172 (15–700) ml without blood transfusion. The mean hospital stay was 18 ± 6 (8–28) days. There was no intra hospital mortality. 90-day mortality – 1 patient (death due to pulmonary embolism 2 months after PD). Major complications (IIIa,b) were in four cases: infected peritoneal fluid collection (1), anastomotic bile leakage (1), pancreatic fistula grade B (1), pulmonary embolism (1). Intra-abdominal complications were treated by percutaneously under US navigation. Delay gastric empty took place in 3 patients. Negative surgical margin (R0) was obtained in 11 patients. Average number of lymph node harvested was 10. Two cases (18%) were verified metastatic lesions to lymph nodes (N1). Conclusions: Robotic PD seems to be safe and feasible in selected patients. Relatively small morbidity and lack of surgical mortality in initial experience advocate applying of robotic approach as one of the options for starting with the program of minimally invasive PD.

Combined Endoscopic and Surgical Treatment of a Case of a Extended Small Bowel Blue Rubber Bleb Nevus Syndrome A. Pisani Ceretti, M. Giovenzana, N. Maroni, M. Longhi, G. Scifo, E. Opocher UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, ASST Santi Paolo e Carlo, Milano, Italy Background: Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular disorder with multifocal venous malformations (VM) that may involve skin, gastrointestinal (GI) tract and, rarely, other organs. GI lesions of BRBNS can cause acute or chronic bleeding. Vascular malformations may be treated either conservatively, with iron supplementation and/or blood transfusions, or may require endoscopic or surgical approach. Case report: We report the case of a 55-year-old woman hospitalised in our department with severe anaemia and melena. The patient underwent upper endoscopy, with band ligation of a gastric, non-bleeding angioma and colonoscopy that showed a single, non-bleeding angioma of 4 mm Ø, 25 cm from the anal verge. The patient came back after a few weeks complaining about relapse of asthenia and melena. Blood tests showed anaemia that required blood transfusions. Therefore, the patient underwent double-balloon enteroscopy that showed multiple vascular malformations involving a long tract of jejunum. To study the whole GI tract a capsule endoscopy was performed, that revealed multiple non-bleeding malformations located in jejunum and ileus. Since endoscopic treatment was not suitable because of the extent of the vascular lesions, we decided to treat BRBNS in a combined way: we performed a periumbilical mini laparotomy. The entire small bowel was explored and we identified the tract with highest number of malformations where we proceeded with an enterotomy. The combined approach consisted of an intra-operative enteroscopy (IOE), with band ligation of 24 venous lesions and a segmental resection of the ileal tract with the highest number of lesions. The histological examination confirmed the presence of vascular malformations typical for BRBNS. The postoperative course was uneventful. After a year follow up no more episodes of anemia or melena were detected. Conclusions: Many different therapies have been proposed to manage GI bleedings in BRBNS: anti-angiogenic agents, endoscopic band ligation or sclerosing treatment and surgical resection. In case of a disease extended to entire small bowel, as in our case, a combined approach with intraoperative enteroscopy and surgical resection provided an effective treatment of the vascular lesions, allowing a good control of the GI bleeding.

P090 - Different Endoscopic Approaches

P092 - Different Endoscopic Approaches

DO we have Another Option to treat bleeding haemorrhoids? The emborrhoid technique: our Experience and preliminary Results: In 8 patients

CAN Needlescopy Cholecystectomy Become the New Standard Elective Technique for Fit Female Patients?

E. Moggia1, M. Barattini2, G. Salsano2, A. Bianco1, S. Berti1, T. Stefanini2, G. Talamo1 1

General Surgery, Sant’Andrea Hospital, La Spezia, Italy; Interventional Radiology, Sant’Andrea Hospital, La Spezia, Italy

2

The aim of this study is to assess the preliminary results of the ‘‘Emborrhoid’’ technique as a new tool for the proctologist to treat severe bleeding haemorrhoids in patient not eligible for conventional surgery. We describe our technique in 8 patients with severe rectorrhagia due to haemorrhoids. From May 2017 to September 2017 a total of 8 patients with chronic rectal bleeding underwent super selective embolization of the superior rectal arteries at S. Andrea Hospital, La Spezia, Italy. Median Age was 62 years, 7 males (87.5%) and 1 female. The stage of the haemorrhoidal disease was II (2 patients) and III (6 patients, 75%). All patients were referred for embolization by a proctologist after discussion with a multidisciplinary team. Contraindication to conventional surgical therapies was the main inclusion criteria. All embolisations were performed under local anesthesia using a right femoral route after inserting a 4 or 5 Fr introducer sheath. The inferior mesenteric artery was catheterised; the superior rectal arteries were detected and catheterized with a rapid transit micro-catheter. Pushable fibered 2–3 mm/0.018 coils were used to obtain the occlusion of the distal branches of the superior rectal artery. The mean procedure time was 54.6 min. No post procedural and short-term complications were observed. Length of stay was 3.1 days (2–8 days). Median follow up was 2 months. Follow-up evaluation included clinical examination, blood tests, proctoscopy, analysis of the quality of life and patient satisfaction. A patient required a second embolization for recurrence of rectal bleeding. The reduction of the rectal bleeding with improvement of the quality of life was obtained immediately in 7 cases (87.5%). A single patient during the follow up complained further episodes of rectal bleeding. Therefore, the patient agreed to undergo another successful embolisation. Our study, although small in number, demonstrates that embolisation of superior rectal arteries is safe and effective and does not lead to immediate and short-term complications. This technique which could be offered in many general surgery departments with a vascular interventional radiology center, might become a new option to treat selected patients. Additional studies and randomised controlled trials are needed to evaluate the safety and feasibility.

E. Moggia, G. Talamo, C. Eretta, L. Dova, M. Imperatore, E. Francone, F. Sucameli, S. Berti General Surgery, Sant’Andrea Hospital, La Spezia, Italy Aim: Needlescopy consists in reducing the calibre of trocars in an otherwise standard 4 ports laparoscopic cholecystectomy and it seems to join the pursuit of ‘‘scarless’’ surgery without lowering the level of safety in many series of selected patients so as fit females without major episodes of biliary colic. Method: Between May 2012 and November 2017, 29 patients underwent elective needlescopy technique at the Department of General Surgery in La Spezia, Italy. All patients were females. Median age was 31.9 years (range 19–56 years) with median BMI 21.68 (range 19–28). Inclusion Criteria were a good performance status, no comorbidieties, ASA 1, absence of previous biliary colic episodes, BMI less than 30. Supine position with legs adducted was adjusted for all patients. 21 patients underwent standard 4-ports technique with needlescopy instruments. In 8 patients a slightly different variation was used: 3 mm ports were replaced with 2 mm angiocath and compatible instruments. Critical View of Safety was achieved in all procedures. An intra operative colangiography was performed in 12 patients with a suspicious of coledhocolytiasis. In one case a microlitiasis of the main biliary tract was detected; an intraoperative exploration of the main biliary duct was unsuccessful. A postoperative MRCP ruled out the need of further treatment. A drain in the upper right quadrant was placed in one patient. The endobag was necessary for specimen extraction in 6 cases. Result: Median procedure time was 66.79 minutes (range 25–120 minutes). Median hospital stay 1.48 days (1–7 days). Postoperative mortality was 0. A postoperative complication (Clavien – Dindo III b) occurred in one patient who underwent a further explorative laparoscopy for bile peritonitis due to Strasberg type A lesion. All patients were employed and 5 of them performed an heavy work activity. Median return to work activity without pain was 6.76 days (3–15 days). Median return to previous sport activity was 9.17 days. Conclusion: Any effort to reduce invasiveness and improve cosmesis must conjungate with safety. Our case series demonstrates that needlescopy can be safely associated with intraoperative cholangiography to recognize common bile duct stones. The technique offers the advantage of minor postoperative pain, better cosmesis results and early return to routinary life activities.

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Surg Endosc

P093 - Education

P095 – Education

‘MEAV ANATOMIE 3D’ Helps a Novice Surgeon Acquire the Practical Anatomical Knowledge and Shorten the Learning Curve for Laparoscopic Surgery

Comparative Analysis of the Medical Training Initiative Sponsorship Scheme and Various European Fellowships in the Field of Colorectal Surgery

Y. Kondo, T. Fujiwara

Y. Tryliskyy, G. Colucci

Gastroenterological surgery, Okayama University, Okayama, Japan

General Surgery, Worthing Hospital, Western Sussex NHS FT, Worthing, United Kingdom

The feature of a laparoscopic surgery is magnified vision which realizes a fine manipulation. On the other hand, it is difficult for novice surgeons to obtain a overview of the organ through a limited picture of laparoscope. It takes long learning curves for novices to obtain the same view point of experts. In order to cover this disadvantage of laparoscopic surgery, we develop the anatomical simulator ‘MeAV ANATOMIE 3D’, which was the application of reconstructed three-dimensional photographs of cadavers, dissected by clinical surgeons. We study the educational effect of this anatomical simulator in laparoscopic surgery retrospectively. Because proficiency of scope operator influences operative time, we compare the operative time of complete novice scope operators (Group N (n = 17)) with that of surgical senior residents (Group R (n = 12)). In group N, the scope operators must learn the anatomy by MeAV ANATOMIE 3D at least for 2 hours before the surgery. The period of the study was from August 1st in 2014 to January 31th in 2017. There were no significant differences in patients’ numbers, backgrounds, and operative procedures. There were no significant differences in the operative times between both groups. The education by the application of anatomical simulation can made the novice acquire the anatomical knowledge for the laparoscopic surgery efficiently.

Introduction: Laparoscopic approach has become preferred in the surgical management of many colorectal diseases. Nevertheless, the accessibility of laparoscopic techniques in colorectal surgery is not evenly distributed across the World. One of the contributing factors to that is lack of the structured national training programmes for surgeons. Several middle and long term fellowships have been organised in the EU to provide the possibility of visiting a specialist centres for colorectal surgeons from developing countries, helping them to learn the laparoscopic techniques. This study was set up to summarize information about fellowships in colorectal surgery advertised by the various European medical institutions for the doctors from the non-EU member states and to provide a comparative qualitative analysis of the UK’s Medical Training Initiative Sponsorship Scheme (MTI fellowship) as an alternative opportunity for the long term training in laparoscopic colorectal surgery. Methods: All colorectal fellowships and observerships advertised by the EU’s institutions, active on the day of search (14/12/2017), for the citizens of the non-EU member states were identified using internet search. The data on entry requirements, financial support (if any), conditions and duration of training was collected and tabulated. Additionally, similar parameters were analysed for the MTI Fellowship posts administered throughout the UK specifically in the area of colorectal surgery. Comparative table was presented. Results: The data which included fellowships administered by the ESO (European School of Oncology), ESSO (European Society of Surgical Oncology) ESCP (European Society of Coloproctology), AAF (American Austrian foundation), UEG (United European Gastroenterology) and AoRMC (Academy of Royal Medical Colleges) was summarized in Table 1.

Table 1 Conclusions: This study shows that standard UK’s MTI fellowship in colorectal surgery outperforms all other available European fellowships for non-EU’s surgeons by the number of case exposure, duration of training and financial support.

P094 - Education

P096 - Education

1996–2016: 20 Years of Robotic Surgery in Mexico. The Experience of an Educational Program in Robotic Surgery at Our Hospital by Competency

Planning and Simulation Software for Laparoscopic Surgery

H.S. Miller Fogel1, J.M. Sackier2, H. Orduna Castrezana3 1

Surgery, Hgr 20 Instituto Mexicano Del Seguro Social, Bonita, USA; 2 Surgery, Private Practice, Virginia, USA; 3Surgery, Uabc Imss, Tijuana, Mexico Introduction: En1993 in San Diego, California, at the University Hospital Dr. Sackier uset the first robotic system to hold the laparoscope called AESOP for its acronym in English Automated Endoscopic System for Optimal Positioning. On June 26, 1996 at H.G.R. N. 20 in Tijuana the first cases of cholecystectomies, robotically assisted with AESOP 1000 System. The first courses of robotic surgery as well as the arrival of the Zeus system of telesurgery at the Hospital in 1999. Since 1999, 09 robotic surgery courses, endorsed by AMCE, AMCG, ALACE, and SAGES. Material and Methods: there have been 182 laparoscopic procedures with system AESOP, first 20 cases with the system 1000, and 6 degrees of freedom. With AESOP 3000 7 degrees of freedom and voice recognition, 162 laparoscopic procedures have been made. During the 9 two weeks mini-fellows, they have trained 49 surgeons from different specialties and 16 surgical nurses, all surgeons and nurses proved to be competent. two of the nine mini-fellows included the Zeus System of Telepresence, All patients had informed consent by surgical team. Results: In 1996, 20 cases were performed with AESOP 1000, 14 cholecystectomies, 03 TEP hernia repairs, 01 gynecological, 02 of Nissen repair. 1999 to 2015 a total of 162 cases performed, during the 09 mini.fellos of the 2 weeks with AESOP 3000 voice activated, the 4th and 5th Fellow included the Zeus sytem: 01 liver biopsy, 01TAPP hernia repair, 12 Nissen, 01 diagnostic laparoscopy, 01 gastroplicature, 01 gastric sleeve and 136 laparoscopic cholecystectomies. Conclusions: Using a robotic arm with voice recognition and voice commands facilitates the performance of several basic laparoscopic procedures, and even some with technical difficulty like intracorporeal knots, dissections. In all minifellos the best area for training remains the cholecystectomy. The system out of the market, is still ideal for training and developing skills. Not mentioned in this summary Mexico is participating with Da´Vinci and new robust systems.

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L.G. Gruionu1, A. Udristoiu2, G. Gruionu3, A. Soimu2, V. Surlin4, S. Patrascu4, C. Tiu5 1

Faculty of Mechanics, University of Craiova, Craiova, Romania; Faculty of Automation, Mechatronics and Computer Science, University of Craiova, Craiova, Romania; 3Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA, Boston, United States of America; 4Department of Surgery, University of Medicine and Pharmacy of Craiova, Craiova, Romania; 5Surgery, MEDIS Foundation, Campina, Romania

2

The laparoscopic surgery is a minimally invasive technique in which the surgeon guides the instruments through patient ports based only on intuition and external landmarks. The selection of the appropriate ports could fail if the external landmarks does not correspond to the internal anatomy of the patient. In these situations, the surgeon has to select other incisions for more ports or abandoning the laparoscopic approach. To address this issue, we proposed a new approach based on computer software planning and simulation of the laparoscopic surgery. This planning is preoperatively realized by the surgeon and starts from the computer tomography scan of the patient. Based on this scan, a three dimensional reconstruction of the patient scanned volume is realized and rendered in a virtual scene. Further, in this virtual scene the surgeon can choose the position and orientation of the laparoscopic instruments, can realize measurements and visualize the incision points. This planning can be saved and used during the real intervention, also if optical tracking is used and optical markers are placed on the surgical instruments, the software application could ‘‘guide’’ the surgeon to place the real instruments close to the planned positions. Acknowledgments: The research leading to these results has received funding from Competitiveness Operational Program 2014–2020 under the project P_37_357 ‘‘Improving the research and development capacity for imaging and advanced technology for minimal invasive medical procedures (iMTECH)’’ Grant, Contract No. 65/08.09.2016, SMIS-Code: 103633.

Surg Endosc

P097 - Education

P099 - Emergency Surgery

IS Time for a Common European Strategy in the Field of Ultrasound Training for Surgeons

Impact of Introducing Northumbria Specialized Emergency Care Hospital (NSECH) on Our Emergency Laparoscopic Common Bile Duct Exploration (ELCBDE)

C. Tiu1, A. Melzer2, A. Keidar3, S. Antoniou4, A. Bolocan5, V. Surlin6, E. Yiannakopoulou7, C. Duta8 1

2

Research, Medis Foundation, Campina, Romania; Research, Innovation Center Computer Assisted Surgery, Leipzig, Germany, Leipzig, Germany; 3Research, Beilinson Hospital, Israel, Tel Aviv, Israel; 4Research, First Department of Surgery 401 General Military Hospital, Athens, Greece, Athena, Greece; 5Surgery, University Hospital Bucharest, Romania, Bucharest, Romania; 6Surgery, University of Medicine Craiova, Romania, Craiova, Romania; 7 Research, Highest Technological Educational Institute of Athens, Greece, Athena, Greece; 8Surgery, University of Medicine Timisoara, Romania, Timisoara, Romania Surgeon’s training in ultrasound is viewed and understood differently in different parts of the world. If in United States the need for surgeons’ training was accepted and taken over by the American College of Surgeons, in Europe the practice is completely different from one country to another, from one city to another, from one department to another within the same premises hospital. In some European countries, surgeons currently use ultrasound for diagnosis - especially in urgency, for follow-up, intraoperative, or as guidance for many surgical gestures. In other countries radiologists are expected even for intraoperative interventions. During this time, access to ultrasound of other surgical specialties - gynecology, urology, ophthalmology - is considered natural all over the world. Recently, the EAES Technology Commission had the initiative to introduce a Basic Ultrasound for Surgeons course in the pre-congress course program. A team of ultrasound surgeons leads this course. An electronic platform has been created to support those who require more information. The course designed in the Hands on manner was appreciated by 35 surgeons who graduated it so far. For the future, the course team aims to develop a multi-modular type curriculum. At the same time, it is desired to involve as many surgical centers as experienced in ultrasonography in a project that will outline the first guideline of practice in this area for the community space.

Y.M. Aawsaj1, M.J. Jones2, S.W. Woodcock2, K.S. Seymour2, J.B. Brown2 1

General Surgery, Northumbria Healthcare NHS Foundation Trust, North Sheilds, United Kingdom; 2Surgery, North Tyneside General Hospital, North Shields, United Kingdom Aim: Laparoscopic common bile duct exploration (LCBDE) is generally only undertaken by upper GI surgeons. Following amalgamation of two non-specialized on calls at the new Northumbria Specialized Emergency Hospital (NSECH), an upper GI surgeon was available daily. This study evaluates this change on the management of emergency choledocholiathiasis via LCBDE. Method: Cases of emergency LCBDE were identified via SIRIS. Activity and outomes were compared for 2 year’s pre-NSECH (from June 2013 to June 2015) and 2 years postNSECH (from June 2015 to June 2017). Results: There was an increase in the overall LCBDE number by 68% (19 pre-NSECH and 32 post-NSECH). There was reduction in time to surgery from admission, post-operative stay and overall hospital stay between pre-NSECH group and post-NSECH groups (3.11 days versus 1.03 days P 0.002, 5.33 days versus 3.67 days P 0.04, 8.45 days versus 5.13 days P 0.014 respectively). Conversion rate was significantly higher in pre-NSECH group (3/19) in comparison to post-NSECH group (0/32) P 0.04. There is no significant difference in terms of post-operative duct clearance, post-operative bile leak and T-tube usage between pre-NSECH and post-NSECH groups (16/19 versus 29/32 P 0.45, 5/19 versus 6/32 P 0.21 and 3/19 versus 3/32 P 0.4). No significant differences in terms of operative time between the two groups (pre-NSECH 130 versus post-NSECH 134 P 0.75). Conclusion: Having a dedicated emergency hospital and on call upper gastrointestinal surgeon has increased the overall activity, decreased time to surgery and reduced length of stay. There was no significant difference in terms of complications and duct clearance.

P098 - Emergency Surgery

P100 - Emergency Surgery

Emergency Laparoscopic Common Bile Duct Exploration using Disposable Bronchoscope (Ambu Scope)

Amyand’s Hernia: a Rare Entity

Y.M. Aawsaj1, J.B. Brown2, L.F. Horgan2 1

General Surgery, Northumbria Healthcare NHS Foundation Trust, North Sheilds, United Kingdom; 2General Surgery, Northumbria NHS Foundation Trust, North Sheilds, United Kingdom Aim: Single procedure of Laparoscopic cholecystectomy and common bile duct (LCBDE) exploration has been equally effective to endoscopic duct clearance for management of choledocholiathiasis. Furthermore, reducing the number of intervention can reduce the hospital stay and overall cost especially in emergency setting. This study is to show our experience of emergency laparoscopic CBD exploration using disposable bronchoscope. Methods: Retrospective data collection for all laparoscopic CBD exploration at Northumbria Specialized Emergency Care Hospital (NSECH) for the period from September 2015 to October 2017. Results: Thirty two patients in total had emergency LCBDE. There was 20 female and 12 male patients and their mean was 58 years. Emergency LCBDE was indicated in three acute pancreatitis, nine acute cholecystitis, ten acute cholangitis and ten colicky obstructive jaundice. The average time from admission to surgery was 1.1 day, the mean overall hospital stay for these patients was 5.8 days while the mean for post-operative stay was 3.8 days. Twenty nine (90%) patients had their common bile duct cleared with emergency LCBDE, three patients needed post-operative ERCP for retained stones. In five patients, LCBDE followed unsuccessful Endoscopic retrograde cholangio-pancreaticography (ERCP), in all cases CBD was cleared. Five patients had successful trans-cystic approach and twenty seven patients required choledochotomy. T-tube was placed in three patients. There was no conversion to open procedure in all cases, the mean operative time was 128 minutes. Post-operative bile leak occurred in six patients (18%), four patients required to go back to theatre for laparoscopic wash out. Conclusion: Disposable bronchoscope is safe and feasible alternative to re-usable choledochoscope for emergency LCBDE. Easy access to disposable bronchoscope to be used for LCBDE in emergency setting can overcome many logistic obstacles.

S. Krivan, A. Giorga, Z. Nash, O. al-Taan General Surgery, Luton and Dunstable Hospital, Luton, United Kingdom Aim: Claudius Amyand was the first to describe an inguinal hernia containing a perforated appendix and the first to perform a successful appendectomy (1735). Overall, it remains an unusual condition in which the hernia itself contains the appendix, inflamed or not. We report a case of acute appendicitis after its incarceration in the inguinal hernia and another case of Amyand’s hernia containing a healthy, non-inflamed appendix. Methods: A 58 year old female was admitted with severe abdominal pain and a palpable, tender non-reducible right inguinal hernia (RIH) with signs of inflammation. Medical history included hypertension and asthma. Her vital signs were BP 143/105 mmHg, HR 110 bpm and temperature 36.2. Blood results showed WBC 11.3 and CRP 192.2. A decision was made to perform surgical exploration. A laparoscopy was performed, which revealed an incarcerated RIH containing an inflamed appendix and an incarcerated loop of small bowel (SB) causing obstruction and ischaemia. The patient underwent an appendectomy, SB resection and anastomosis as well as TAP repair of the RIH with a mesh. Histology report showed necrotic and inflamed small bowel and appendix. Postoperative course was unremarkable. An 86 year old male was admitted with severe right inguinal pain and a long standing RIH. His vital signs were stable. Medical history included hypertension, rheumatoid arthritis but no surgical history. A partially-reducible right groin mass with tenderness on palpation was noted on physical examination. The abdominal x-ray revealed dilated SB loops. A CT scan with oral contrast showed a RIH with an incarcerated, not inflamed appendix. A preoperative diagnosis of an Amyand hernia was made and the patient underwent an open RIH repair with mesh under general anaesthesia with no resection of appendix necessary. Postoperative course was unremarkable. Results:/Conclusion: Amyand hernia is a rare entity with various presentation, from a reducible inguinal hernia containing a normal appendix to acute abdomen due to perforation of acute appendicitis secondary to incarceration. Only imaging can verify the contents of an incarcerated inguinal hernia and the approach varies upon those findings. It is generally accepted that surgical treatment includes both hernia repair and/or appendectomy.

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Surg Endosc

P101 - Emergency Surgery

P103 - Emergency Surgery

Our Management Approach for Bowel Obstruction Secondary To Migration Of Intra-Gastric Balloon: Case Report and Literature Review

Co-Existence of Acute Appendicitis and Meckel’s Diverticulitis Case Report

M. Salama, I. Ahmed General surgery, Our Lady of Lourdes hospital, Drogheda, Ireland Introduction: Obesity is a major health problem with growing concern worldwide. It has been challenging modern medicine with different treatment modalities. Intragastric balloons have been gaining popularity since the 1980s. It is generally considered safe and effective, but complications such as spontaneous deflation and migration with small bowel obstruction has been rarely reported previously. Case Report: We report a case of migration of a spontaneous partially deflated bioenteric intra-gastric balloon causing small bowel obstruction. The intra-gastric balloon was implanted in India one year previously and the patient denied any follow-up since. Clinical examination, PFA and CT scan confirmed the diagnosis. Conservative treatment was unsuccessful and oesophagogastroduodenoscopy failed to locate the balloon. Percutaneous deflation under radiological guidance was subsequently performed and the patient passed the intra-gastric balloon spontaneously per rectum 3 days later. Discussion: Bowel obstruction caused by migration of gastric balloons is rare and may constitute a diagnostic and therapeutic challenge to surgeons. To the best of our knowledge, this is the first reported instance of radiologically guided percutaneous deflation of an intra-gastric balloon. Conclusion: We report a case of successful percutaneous drainage of migrated gastric balloon. Most intra-gastric balloons should be removed after 6 months to prevent complications. Failure to follow up and remove intra-gastric balloons in time may lead to complications such as bowel obstruction.

M. Salama, A. Nasr General Surgery, Our Lady of Lourdes Hospital, Drogheda, Ireland Introduction: The occurrence of acute appendicitis and Meckel’s diverticulitis (MD) simultaneously is extremely rare. There have only been three reports of this phenomenon in the literature. We report a case that was clinically and radiologically diagnosed as acute appendicitis which turned out to be simultaneous appendicitis and MD. The diagnostic and therapeutic dilemma of this case gives us an opportunity to report it as a case of interest. Case report: A 12 year old girl presented with a two day history of lower abdominal pain associated with nausea and vomiting. She was tender in the right iliac fossa with rebound tenderness. Her inflammatory markers showed raised white blood cells (12.9) and C-reactive protein (92.8). Ultrasound abdomen and pelvis reported acute appendicitis. She underwent diagnostic laparoscopy where, in addition to acute appendicitis, MD was found. Laparoscopic appendicectomy and resection of the diverticulum were performed. Post-operatively she made a good recovery and the histology reported acute suppurative appendicitis and MD probably secondary to her appendicitis. Discussion: The literature suggests that a MD should be considered if the appendix is normal. If the appendix is overtly inflamed, a search for MD is controversial. Some authors have suggested that a search for MD should be routine since the two conditions may exist simultaneously. There exist only three case reports of acute appendicitis presenting concurrently with MD in the literature. In both cases, appendicitis was secondary to MD. In our case appendicitis is the primary pathology and diverticulitis is secondary to the appendicitis as was confirmed histologically. Conclusion: Co-existence of acute appendicitis and MD is extremely rare. We recommend a search for MD be performed routinely, even if acute appendicitis has been diagnosed. Laparoscopy allows for identification of other potential intra-abdominal pathology, when performing laparoscopic appendicectomy.

P102 - Emergency Surgery

P104 - Emergency Surgery

Incidence and Management of Low Grade Appendiceal Mucus Neoplasm (LAMN) in our Institution

Laparoscopic Surgery for Intestinal Perforation by Foreign Bodies

M. Salama

V.A. Bombizo, P.N. Buldakov, D.N. Ustinov

General Surgery, Our Lady of Lourdes Hospital, Drogheda, Ireland

Surgical Department, Regional Clinical Hospital of Emergency Medical Care, Barnaul, Russia

Introduction: Low grade appendiceal mucinous neoplasms (LAMN) of uncertain malignant potential are a rare and poorly understood entity. Despite the use of ultrasound (US), Computed Tomography (CT) and colonoscopy, preoperative diagnosis remains challenging. Currently there is no consensus regarding the appropriate management, extent and optimal type of surgery (open versus laparoscopy). In this study we retrospectively analysed cases of LAMN diagnosed in the past 10 years in OLOLH. Aim: To evaluate our experience of management of LAMN. To determine the incidence and prevalence of mucinous neoplasm in appendectomy specimens. To determine the impact of laparoscopy and recent technology as CT and US in the management of LAMN. Method: A retrospective study of all cases of LAMN treated in our institution between January 2007 and January 2017 was carried out. Data of all patients with histopathologically confirmed LAMN were reviewed and analysed retrospectively. Results: Total number of cases diagnosed with LAMN is 26 (11 Males, 15 Females, Age: 22–93 years). Of the 22 who had Preoperative CT, 16 were confirmed with LAMN. 4 cases had no preoperative CT. These 26 cases of LAMN presented as follows (12 cases as acute appendicitis, 4 as change in bowel habits, 2 as left iliac fossa pain and 7 diagnosed incidentally). The other pathologies associated with LAMN in our series include (Stercoral perforation with ischaemic colitis 1, Tubulo-ovarian abscess 1, Colonic tumour 5). In our LAMN series, 11 had laparoscopic appendicectomy, 4 had laparoscopic appendectomy with excision of caecal cuff, 7 had right hemicolectomy and there were 2 total colectomies and one Hartman’s procedure. 1 patient had a tubuloovarian abscess drained radiologically followed by laparotomy and appendectomy. Conclusions: The optimal surgical approach for treating LAMN remains controversial. There is debate concerning the use of laparoscopic versus open surgery. Laparoscopy may be considered a safe and effective approach but care should be taken to avoid iatrogenic rupture. The choice approach depends on surgeon experience. Simple appendicectomy is sufficient management for LAMN that is confined to the appendix.

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Introduction: Perforation of intestinal wall by foreign bodies is a rare pathology in the urgent surgery lacking a typical clinical picture and leading to the development of peritonitis. The optimal diagnostic and treatment method is considered laparoscopic surgery. Aim: To determine the possibility of implementation and the efficiency of laparoscopic surgery forintestinal perforation by foreign bodies. Materials and Methods:For the 5-year period (2012–2016) in the surgical departments of the Hospital of Emergency Medical Care, there have been treated 21 patients with intestinal perforation by foreign bodies. Among the causes of perforation were: in 15 patients – fish-bone, in 4 patients – sharp metal object (needle, pin), in 2 patients – toothpick. Results: In 3 patients, intestinal perforation by foreign bodies was detected by laparotomy; After the diagnostic laparoscopy, 4 patients underwent laparotomy; Laparoscopy was the final method of treatment in 14 patients; Foreign bodies, which had caused the perforation, were removed from all patients. In the majority of cases, there was performed the suture of the intestinal wall perforation defect; In all cases, there was performed abdominal drainage. Conclusion: In general, laparoscopic surgery presents an effective method of diagnostics and treatment of patients with intestinal perforation by foreign bodies. In 67% of cases, laparoscopy was the final method of treatment.

Surg Endosc

P105 - Emergency Surgery

P107 - Emergency Surgery

Acute Care Surgery: A New Model of Care for The Emergency General Surgery Patients, Experience Of An Academic Tertiary Care Center

Foreign Body in Gastrointestinal System; Case Series

M.Y. Kayyal, M. Corrigan, H.P. Redmond, A. Zaheer Surgery, HSE CUH, Cork, Ireland Introduction: Acute care surgery is defined as the urgent assessment and treatment of general surgical emergencies. acute surgical emergencies often represent the most common reason for hospital admissions. These conditions include, but are not limited to, acute appendicitis, cholecystitis, diverticulitis, pancreatitis, intestinal obstruction, intestinal ischemia, intra-abdominal sepsis, incarcerated hernias and perforated viscous. As a result of these challenges, numerous subspecialty trained surgeons have recently stated their aversion to on-call work because many emergent conditions now lie outside their comfort zone of clinical practice. In response to these limitations, the concept of acute care surgery has recently evolved worldwide. Objectives: To assess the benefits of providing acute care surgical model and the effects it has on improving patient care and efficiency, as well as streamline the path for this cohort of patients with faster access to senior assessment and management, diagnostics and definitive treatment. Methods: A retrospective analysis was performed of all emergency surgery admissions/procedures performed at an academic tertiary referral community hospital. Data were collected from the implementation of an acute care surgical (ACS) service, over a 6 month period 1st May to 1st December 2017, 2 dedicated consultant surgeons were providing the service with their junior staff. Results: There were overall shorter length of stay LOS (6.5 days to 4.6 days), Re-admission rate within 28 days improved from 7.2 to 4.97%, utilization of the emergency theatre was improved from (52–73%), average monthly procedures were increased from 135 procedure/month before ACS to 180 procedure/month after ACS, avarage starting time in theatre improved from an avarage of 10.04 am to 08.30 am after ACS. Conclusions: An acute care surgery service can be successfully implemented. The improvements seen in outcomes and efficiency are sustainable over time, it also has a positive impact on elective capacity for the sub-speciality services where they can focus more on their field, and increase their efficiency being out of the on call rota and the hassle of managing emergency surgical patients. This sort of coordinated, consistent care is successful and allows alignment of the goals of surgeons, hospitals, and patients.

N. Ozlem General Surgery, Ahievran University, Kirsehir, Turkey To swallow a foreign body, occured frequently in our country. Swallowed foreign body pass the gastrointestinal system mostly so it is rarely require surgical therapy. Number of foreign body swallowed, diameter and shape of foreign body, and time of swallowed make decision for treatment. Follow up of the patient with swallowed history discuss. Material method seven patients who present with history of swallowed a foreign body in last year evaluate retrospectivelly. Findings: our patients are a 6 year old child who swallowed coin, 3 patients who swallowed pin, a patient swallowed small nail, a patient who swallowed multiple stapler, a patient who swallowed a wrist watch 3 months ago. The child who swallowed coin could not pass the pylorus in 12 hours then a pediatric gastroenterologist removed the object with upper gastrointestinal endoscopy. The patients who have pin nail stapler swallowed history have a spontaneous passage for 72 hours follow up. The patient who give history of swallowed wrist watch has a bipolar disorder. The foreign body arrested in gastric lumen could not extracted cricopharengeal area with an upper gastrointestinal endoscopy. The patient needs a laparatomy and gastrotomy for extraction of watch, leave the hospital without any event in postoperative day 5. Discussion and results much more than 90% of foreign body swallowed leave gastrointestinal system spontaneously. 10% of those need an endoscopic extraction only 1% of them has to take out surgically. To extract those does not pass the pylorus and [ 6 cm in diameter with endoscopy should be first choice. ˙If an endoscopy is failure or there is a foreign body made hemorrhage obstruction then bring to mind surgery. this work is supported by ahi evran university scientific and research comittee with project number E2.001

P106 - Emergency Surgery

P108 - Emergency Surgery

Surgical Management of Acute Lower Abdominal Pain - The Role of Laparoscopy

An Unusual Case of Perforated Meckel’s Diverticulum with Small Bowel Obstruction and Appendiceal Mucinous Neoplasm

G. Dedemadi, C.H. Tzamourani, A. Kasouli, A. Papadopoulou, F. Kambosou, I. Kalaitzopoulos

A. Shamsiddinova1, A. Ahmad2, B. Aravind1, A. Shrestha1

Amalia Fleming Surgical Department, Sismanogleio - Amalia Fleming Hospital, Athens, Greece Aim: Acute lower abdominal pain is experienced commonly, leading patients to attend the emergency department. The aim is to present the management of acute lower abdominal pain and to consider the role of laparoscopy. Methods: An 8- year retrospective study was conducted from January 2010 to November 2017. Patients admitted to the surgical department suffering from acute lower abdominal pain were included. Results: A total of 1258 patients were included, 602 male and 656 female. Diagnosis was acute diverticulitis in 170 patients, right lower quadrant pain due to acute appendicitis, irritable bowel syndrome, infection/stones in the urinary tract in 976 patients, and different gynecological problems in 112 female patients (dysmenorrhea, endometriosis, ovarian cyst rupture and hemoperitoneum, ovarian torsion and pelvic inflammatory disease). 581 patients were operated on an emergency basis while 677 patients were treated conservatively. 41 patients underwent surgery for acute diverticulitis; a Hartmann procedure was performed in 30 patients, the remaining 11 patients underwent colectomy with primary anastomosis (one laparoscopically). 472 patients underwent appendectomy, 423 appendectomies with the standard technique, 42 laparoscopically, and 7 conversions to open procedure. Four patients underwent right colectomy (three due to plastron of the appendix and one cecum diverticulitis). Two patients with Meckel’s diverticulum underwent resection of the diverticulum, one laparoscopically. 62 female patients underwent various gynecological procedures (21 with ovarian cyst rupture and hemoperitoneum, 6 with ovarian torsion and 35 with pelvic inflammatory disease). 35.48% gynecological procedures were performed with the open technique, 59.67% laparoscopically and 4.83% conversions to open procedure. Concomitant appendectomy was performed in 18 patients. Diagnostic laparoscopy was undertaken in 69 female patients with unclear diagnosis of lower abdominal pain. Accurate diagnosis was made in all patients and revealed 37 with diverse gynecological problems and 32 with acute appendicitis. Overall 30.5% of these procedures were carried out laparoscopically, with the rate rising over the last 2 years to 39.58%. Conclusions: In female patients with unclear diagnosis despite imaging, laparoscopy is useful offering the advantage of accurate diagnosis with concomitant possibility of safe management. Laparoscopy is the preferred method of treatment of acute lower abdominal pain especially in women.

1 General Surgery, East Kent Hospitals University NHS Foundation Trust, Ashford, United Kingdom; 2General Surgery, EKHUFT, Ashford, United Kingdom

Meckel’s diverticulum is an uncommon entity, affecting 2% of the population. It usually presents due to a complication, more commonly in males, and is often misdiagnosed as appendicitis preoperatively. Low grade appendiceal mucinous neoplasm (LAMN) is an incidental finding in 0.7–1.4% of appendicectomies, and can progress to pseudomyxoma peritoneii. Here we present a rare case of a 19-year old man with a dual surgical pathology who presented as an emergency with small bowel obstruction initially thought to be due to Crohn’s stricture on radiological imaging. However, diagnostic laparoscopy revealed small bowel obstruction due to Meckel’s diverticulum and a finding of mildly inflamed distended tip of appendix. Hence, Laparoscopic appendicectomy and Laparoscopic-assisted small bowel resection was performed. Histopathological examination confirmed it to be a perforated Meckel’s diverticulum with ectopic gastric mucosa, and subacutely inflamed low grade appendiceal mucinous neoplasm (LAMN).

This case presents a rare constellation of pathologies, but also highlights the need to keep an open mind while undertaking diagnostic laparoscopies. It raises the question of whether if one pathology is already found during diagnostic laparoscopy, such as an inflamed Meckel’s, do we also perform appendicectomy.

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Surg Endosc

P109 - Emergency Surgery

P111 - Emergency Surgery

Thoracoscopic Esophagectomy for Aortoesophageal Fistula

Surgical Fear or Severity of the Peritonitis Affects on Conversion Rate for Appendicular Peritonitis?

Y. Ebihara, K. Tanaka, Y. Nakanishi, T. Asano, T. Noji, Y. Kurashima, S. Murakami, T. Nakamura, T. Tsuchikawa, K. Okamura, T. Shichinohe, S. Hirano Department of Gastroenterological Surgery II, Hokkaido University, Sapporo, Japan Background: Aortoesophageal fistula (AEF) is an uncommon but highly fatal conditions. There are surgical, endoscopic and interventional radiological treatment options, however, definitive treatment is surgical intervention. Video-assisted thoracoscopic surgery (VATS) is accepted as a substitution for thoracotomy to achieve a less invasive surgical intervention. We aimed to evaluate the VATS-esophagectomy (VATS-E) for AEF in this study. Material and Methods: Between 2009 and 2017, we retrospectively reviewed clinical charts of six patients requiring surgical treatment (VATS-E) for AEF. Results: The median thoracoscopic time was 146 min (range, 114–178 min). None of the patients were converted to open surgery. Thoracic endovascular aortic repair (TEVAR) was performed five patients (83.3%). Three patients underwent aortic replacement with artificial graft. Esophageal reconstruction was possible in three patients. Conclusion: Operative procedure for AEF is improving thanks to the introduction of TEVAR and thoracoscopic esophagectomy. Further accumulation of cases is necessary to establish safe and secure surgical strategy for AEF.

A. Sazhin, G. Ivakhov, A. Mirzoyan Faculty Surgery #1, Pirogov Russian National Research Medical University, Moscow, Russia Aim: Laparoscopic surgery for appendicular peritonitis remains still as ‘‘operation with unproven efficacy’’. The lack of evidence, the complexity of the randomization of patients with peritonitis significantly makes it difficult the recognition of laparoscopic surgery for appendicular peritonitis as a safe and effective procedure. In our routinely clinical practice we used laparoscopy for all cases of appendicular peritonitis regardless of severity of peritonitis. Open operation is performed only in case of absolute contraindications for pneumoperitoneum. Methods: During 2011–2016 years we perform more than 900 laparoscopic appendectomies for local and diffuse appendicular peritonitis. Local peritonitis was confirmed in 715 patients, diffuse – in 242 patients. 55% patients with diffuse peritonitis was admitted later 24 hours after onset of the disease, 13% - after 48 hours. Mean MPI and WSES Severity Sepsis Score for all patients with diffuse peritonitis was 20.6 (16–33) and 4.91 respectively. Results: Conversion rate was 2.2% and 14.8% for local and diffuse peritonitis respectively. So, 50 patients with conversion was analyzed, 36 of them was with diffuse peritonitis. Severe complication (Clavien-Dindo grade III-IV) was noted in 47.2% patients after conversion because of diffuse peritonitis, i.e. in 7.5 times higher than in the group of laparoscopic operations. Such a high prevalence of complications in the group of conversions is clear, if you believe that in the conversion group patients were with more severe peritonitis than in laparoscopic group. However, this is not quite true. Comparison of patients with diffuse peritonitis in conversion and laparoscopic group did not show a statistically significant difference – MPI: 24.8 ± 5.05 vs 23.2 ± 4.2 (NS) and WSES Severity Sepsis Score: 4.79 ± 1.86 vs. 4.45 ± 1.86 (NS). Futhermore, for 77% of patients in conversion group MPI was less than for laparoscopic group (20.46 ± 4.17). Conclusion: A retrospective analysis showed that more than 70% of conversions for diffuse peritonitis can be avoided. Improvement of manual skills and objective assessment of the severity of peritonitis are two main ways for increasing rate of laparoscopic surgery for patients with appendicular peritonitis.

P110 - Emergency Surgery

P112 - Emergency Surgery

Torsion of the Gallbladder Treated with Single-Port Laparoscopic Cholecystectomy

Pathology of the Gall Bladder can be a Problem in Differential Diagnosis of Right Iliac Fossa Pain. Presentation of a Rare Case

Y. Sakano, K. Furukawa, M. Mikamori, T. Saito, M. Ohtsuka, Y. Suzuki, M. Tei, K. Kishi, M. Tanemura, H. Akamatsu

G. Velimez, A. Ioannidis, A. Skarpas, I.M. Christodoulou, I. Rodolakis, N. Nikitakis, E. Papachristou

Gastroenterological Surgery, Osaka Police Hospital, Osaka, Japan

2nd Surgical Department, Sismanoglio General Hospital, Athens, Greece

Aims: We herein report the use of single-port laparoscopic cholecystectomy (SILC) for treatment of gallbladder torsion in an elderly woman. Patient and Method: A 90-year-old woman presented to our hospital because of epigastralgia. She showed an inflammatory reaction and increases in hepatobiliary enzymes on blood examinations. Abdominal computed tomography showed a distended gallbladder and remarkable edema at submucosal structure of the body of the gallbladder, as well as a feature in which tissues appeared to focus on the neck. Magnetic resonance imaging showed that this acute inflammation of the gallbladder was due to torsion of the cystic duct. Emergency laparoscopic cholecystectomy was performed under a diagnosis of gallbladder torsion. Results and Discussion: The gallbladder was a Gross type I floating gallbladder and was twisted counterclockwise 360 degrees. We proceeded with SILC because we observed neither signs of inflammation at the neck or Calot’s triangle nor perforation of the gallbladder. The operating time was 140 minutes with almost no blood loss, and no intraoperative complications occurred. Although discharge from our hospital was delayed due to urinary infection and pseudomembranous colitis, no surgeryrelated postoperative complications occurred. Several reports have stated that torsion of the gallbladder caused by a floating gallbladder is a good indication for laparoscopic cholecystectomy. However, only one study has shown that the anatomical characteristics of gallbladder torsion make SILS particularly effective for this condition. In the present case, SILS was a good treatment option for a case of early-stage gallbladder torsion after disease onset. Conclusions: Although gallbladder torsion is rare and difficult to cure, SILC is thought to be safe and effective for this condition based on adequate single-port laparoscopic surgery techniques.

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Aim of the Study: The presentation of a very rare case, that should be acknowledged in right iliac fossa pain. Methods: A 64 years old female patient, weighing 48 kg, was admitted in ER department, complaining of right iliac fossa tenderness. Radiological tests (U/S, CT & MRI), revealed an enlarged mass in the right lower quadrant, that its origin could not be evaluated initially. After discussing thoroughly with the radiologists and evaluating the patient, it was suspected a very enlarged gall bladder. Laparoscopy was performed, and a gigantic gall bladder reaching the right iliac fossa was found, which was full of pus. Laparoscopic cholecystectomy was performed. Patient postoperative course was uneventful. Results and Discussion: During differential diagnosis of right iliac fossa pain, except the usual pathology, we should always have in our mind, rare pathologies, like a very enlarged gall bladder, specially in a small patient.

Surg Endosc

P113 - Emergency Surgery

P115 - Emergency Surgery

Laparoscopic Repair of Sciatic Hernias

Minimally Invasive Surgery in the Treatment of Acute Colon Obstruction. Colostomy

Y. Mikane, K. Shigemitsu Surgery, Tsuyama Chuo Hospital, Tsuyama City, Okayama, Japan Sciatic hernias are one of the rarest types of hernia that arise from the greater or lesser sciatic foramen, with very limited published reports worldwide. Here, we report a case of laparoscopic repair of sciatic hernia with ileus release, wherein we obtained a good postoperative course. A 95-year-old female with abdominal pain and vomiting was presented to our hospital. At arrival blood pressure 122/66 mmHg, pulse 100 bpm, SpO2 98% (room air), body temperature 37.5 ° C. Abdominal findings are flat soft, no spontaneous pain, no tenderness. Her medical history had no laparotomy. Computed tomography revealed ileus caused by right sciatic hernia. An emergency surgery using the laparoscopic approach was performed. As observed by the laparoscopic view, necrotised small intestine was incarcerated in the right sciatic foramen. We carefully pulled the intestinal tract back into the peritoneal cavity and excised approximately 12 cm of the tract. Because the intestinal tract was necrotised, we did not use artificial mesh. After ligating the hernia sac, we sutured the right ovary and closed the hernia gate. Her postoperative course was uneventful, and at her 4-month follow-up, no relapse or symptoms occurred. Organ, which is incarcerated in the sciatic foramen, is ureter in many cases, but small intestine was incarcerated in our case. We experienced a very rare case. We were worried about her ability of surviving laparotomy operation. We selected laparoscopic repair of sciatic hernias, because quick recovery can be expected. In practice we obtained a good postoperative course. Sciatic hernia is a rare pelvic floor hernia that occurs through the greater or lesser sciatic foramen. Laparoscopic repair of a sciatic hernia appears to be a feasible and safe surgical option having all the advantages of a minimally invasive technique. Here we reported the surgical technique performed.

A. Bimurzayeva General Surgery, Astana City Hospital No2, Astana, Kazakhstan Aim: Acute colon obstruction is a very life-threatening disease and 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. The optimal choice of surgical treatment for acute colon obstruction, achievement of favorable outcomes, reduction in the number of days of patient stay in the clinic, a reduction in the consumption of medicines, a patient’s earlier return to work. Methods: CT, MRI, X-ray, ‘‘Karl Stors’’ endoscopic stand. Morphological, microbiological research methods, clinical and laboratory studies. Results: During the period from 2016 to 2017 in the General Surgery and Coloproctology Department at the City hospital No. 2, 18 operations were conducted for patients with severe colon obstruction: 16 (88.8%) left-sided laparoscopic hemicolectomy, 2 (11.1%) sigmoid resection. The operations were completed by the colostomy 16 patients (88.8%) had the operation on the colon tumors, 2 patients (11.1%) had megacolon, sigmoid turn diagnosis. Among them, there were 12 (66.6%) males and 6 (33.3%) females aged 30 to 82. At the preoperative stage all patients were prepared in accordance with the clinical protocol and guideline of patient treatment with colon diseases. Patients in an extremely serious condition, with the presence of concomitant pathology, a violation of the function of internal organs were conducted an open surgery. All patients are under the doctors’ supervision. Patients with tumor of colon were controlled by CT examination; no signs of metastasis were detected. Conclusions: Average patient stay in the hospital is 7–8 days, the activization of the patients was carried out on the 2nd day after operation. After 6 months, the patients underwent reconstructive surgery, in which minimal adhesions were found The prospective plan of our department includes 100% of surgical interventions by laparoscopic method.

P114 - Emergency Surgery

P116 - Emergency Surgery

Comparative Study of Inguinal Incision and Laparoscopic Surgery for an Emergency Inguinal Hernia Operation

Laparoscopic Surgery for Perforated Peptic Ulcer: Can We Predict Conversion?

Y. Kurumiya, E. Sekoguchi, G. Sugawara, K. Kawai, M. Kiriyama

A. Sazhin, G. Ivakhov, E. Stradymov

Department of Surgery, Toyota Kosei Hospital, Toyota, Japan

Faculty Surgery #1, Pirogov Russian National Research Medical University, Moscow, Russia

Background: Laparoscopic surgery for inguinal hernia is spreading rapidly in Japan, but it is not known which of inguinal incision or laparoscopic surgery is better for emergency cases. We examined retrospectively the patient outcome of the inguinal incision and laparoscopic surgery. Patients and Methods: 56 cases of emergency surgery with a strangulated inguinal hernia at our hospital from January 2013 to December 2017. Laparoscopic surgery was performed with TAPP in all cases. As a result of emergency surgery, the choice of an operation method of inguinal incision (Open) or laparoscopic surgery (TAPP) is selected by a doctor who can deal with it as a surgical technique of TAPP, surgical port was 12 mm, 5 mm 9 2 port. The hernia gate was incised under laparoscopic observation and the strangled intestinal tract returned gently. It was confirmed the viability of the intestinal tract and the perforation of intestinal tract. If there is no contamination of the surgical field it was repaired with mesh. If it is necessary to resect the intestinal tract, we extended the midline incision and excised the necrotized intestinal tract. Results: There were 42 cases in the Open group and 14 cases in the TAPP group. The mean age (y) was 73.6 vs. 75.7. The operation time (min) was 73.9 vs. 129.5 (2 cases on both sides) and it was long in the TAPP group. The intraoperative bleeding (g) was 15.2 vs. 2.0, which was small in the TAPP group. There was no difference in 5 cases (12.5%) vs.2 cases (16.6%) in the intestinal resection, the postoperative complications were Open group 9 cases (mesh infection 2, pneumonia 2, ileus 1, cerebral infarction 1, hematoma 1, sepsis 1, bladder injury 1) (22.5%), TAPP group 1 case (bladder injury 1) (8.3%). SSI did not occur in the TAPP group. The postoperative hospital stay (day) was 11.8 vs.9.0, which was short in the TAPP group. Conclusion: TAPP is also considered to be a useful technique in emergency surgery.

Aims: Laparoscopy surgery for perforated peptic ulcer (PPU) becomes the procedure of choice for cases of local peritonitis and non-comorbidities patients. Some centers routinely used laparoscopic suturing of PPU for patients with diffuse peritonitis with promising results. However, despite evidence supporting the use of laparoscopic repair, deciding to convert to open surgery is still a matter of debate. The aim of this study was to define simple predictive factors for conversion. Methods: a total of 172 patients were underwent emergency repair for PPU in Pirogov Russian National Research Medical University’s surgical clinics (Moscow City Hospitals #’- 1, #’- 4, #’- 29) during 2014–2016 years. Emergency operations were started from laparoscopy in 150 (87.2%) patients. Results: Conversion rate - 14.5% (25 patients). All patients in conversion group had diffuse peritonitis with mean Mannheim peritonitis index – 21.9 (range, 10–33) and 16.7 (range, 4–33) in laparoscopic group (LG) (p \ 0.05). The mean patient age was 56.8 (range, 32–86) years and 44.1 (range, 17–89). Conversion rate for patients with Boey 0 was performed in 7.7% (9 patients), with Boey 1 – in 25.6% (10 patients), Boey 2–37.5%(6 patients). Among all patients who underwent conversion 67% had Boey score 2. The average perforation size in conversion group of patients was 12 mm (ranged from 4 to 40 mm) compared to laparoscopic group where this parameter was 4.7 mm. Conversion analysis showed that the most frequent reasons for conversion to laparotomy are the size of perforation ([ 10 mm), severity of diffuse peritonitis MPI [ 20, unstable hemodynamic, friable edges of perforation that lead to suture eruption and adhesions. Early complications occurred in 6 (24%) patients of conversion group. Clavien-Dindo grade 3a (16.7%), grade 3b (50%) and grade 4 (33.3% ). Mortality rate – 8% (all of them had Boey 2) and mortality rate in primary open group (20 patients) was 10%. Thus, conversion was not associated with elevated mortality compared with the open approach. Mortality rate was 3.1% in laparoscopic group. Conclusion: we suggest that a preoperative significant predictor for conversion is Boey score 1, intraoperative conversion factors are MPI and size of perforation.

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Surg Endosc

P117 - Emergency Surgery

P119 - Emergency Surgery

Case Report: Pheochromocytoma Presented by Bowel Perforation

Laparoscopic Repair of Closed Loop Small Bowel Obstruction, Caused by Broad Ligament Hernia

H. Fahmy, M. Abdelwahab, B. Alsubhi, O. Alamodi

D.I. Kyriakidis1, J.G. Hardman2

Surgery, Royal Commission Medical Center, Yanbu Industrial, Saudi Arabia

1 General Surgery, Mid Chesshire Hospitals NHS Foundation Trust, Leighton Hospital, Crewe, United Kingdom; 2General Surgery, Colorectal team, Mid Cheshire Hospitals NHS Foundation Trust, Leighton Hospital, Crewe, United Kingdom

Pheochromocytomas are rare tumors were first identified by Frankel in 1885, but were not named as such until 1912 by Pick, who noted the characteristic chromaffin reaction of the tumor cells. They can occur at any age, with a peak incidence in the fourth and fifth decades of life, and have no gender predilection. high index of suspicion is necessary. Extensive diagnostic evaluations should be reserved for those who’s clinical or laboratory findings are more suggestive. Headache, palpitations, and diaphoresis constitute the ‘‘classic triad’’ of pheochromocytomas. New hypertension, or hypertension associated with unexplained orthostatic hypotension, are suggestive of an underlying pheochromocytoma. 24 h urine studies are consistently abnormal in patients with a pheochromocytoma. Values greater than 1.5–2-fold above the upper limit of normal are very suggestive, and warrant a more intensive subsequent evaluation. This combination of clinical screening, 24-hour urinary testing, and imaging studies is a useful and reliable approach to patients suspected of harboring a pheochromocytoma. We report a rare case of 57 years old Saudi lady presented to emergency department with severe watery diarrhea, abdominal distention and hypertension. The patient was found to have hypokalemia, severe dehydration and acute renal failure, patient was resuscitated, and admitted to the intensive care unit for observation, her clinical condition was improving but was not optimum, her CT scan and MRI showed right suprarenal mass suggestive of pheochromocytoma, VMA & Cortisol levels were both high, the patient was started on alpha and beta blockers to control her blood pressure with aggressive fluid replacement, then patient developed intestinal perforation which required emergency laparotomy with resection and anastomosis of affected parts, after which patient remained in the intensive care for optimization of her blood pressure and a second exploration was planed for removal of the pheochromocytoma. Patient post operatively was showing significant improvement, clinically and laboratory wise and was discharged in stable condition afterwards. Diagnosis of such complicated pheochromocytoma with intestinal manifestations, prompt great challenge for any surgeon, high suspicion and careful plan of management with multidisciplinary approach should be taken in consideration, few cases were reporting such manifestation and should be studied thoroughly.

Internal hernia as a cause for small bowel obstruction has an incidence of 0.2 to 0.9%. Broad ligament defect (congenital or acquired) causing herniation and small bowel obstruction is one of the rare types with an incidence of less than 7% of all internal hernias. Here, we present the case of a 36 year old female patient, who presented as an emergency with abdominal pain, distension and vomiting. She had previous normal vaginal deliveries and has not had any abdominal operations. CT of the abdomen and pelvis showed closed loop small bowel obstruction with transition point in left iliac fossa, and there was a suggestion that the most likely cause was a band adhesion. Eventually, she underwent a diagnostic laparoscopy. During the procedure, a 20 cm loop of mid ileum was found to be herniated through a defect in the left broad ligament. The loop of bowel was carefully released, and, as it was viable, no resection was needed. On close inspection there was similar defect in the right broad ligament, as well. The defect was closed with laparoscopic sutures to prevent further herniation. She recovered well postoperatively and she was discharged 2 days later. Defects in broad ligament can be congenital or acquired and can be a rare cause for internal hernias. High degree of suspicion may be necessary when a female without any surgical history presents with mechanical ileus. Accurate pre-operative diagnosis may be difficult even with CT scan. Diagnostic laparoscopy is a safe approach, in selected patients, and can lead to decreased length of stay in hospital, as well as less post-operative complications.

P118 - Emergency Surgery

P120 - Emergency Surgery

Complicated Diaphragmatic Hernia

A Comperative Analysis of the Patients who Operated Laparoscopic or Open Method for Acute Appendicitis

R. Galleano, O. Ghazouani, A. Badran, M. Ciciliot, P. Aonzo General Surgery, Santa Corona Hospital, Pietra Ligure, Italy Non hiatal diaphragmatic hernia constitutes an infrequent but potentially serious presentation of bowel obstruction in the adult patient. Herein, we present two cases who came to our observation with different manifestation. The first case is a 74-years-old male patient who came to emergency department for acute thoracic and abdominal pain, fever, severe dyspnea and PNX. A thoracic drain was placed and demonstrated fecal output. Thoracic and abdominal CT Scan with intravenous contrast medium reported a complete migration of the hepatic flexure in a diaphragmatic hernia complicated with strangulation of colon and perforation. This patient was approached with emergency laparotomic exploration; he presented a 10 9 5 cm right diaphragmatic hernia with the hepatic flexure completely herniated in thorax, perforated. After liberation of the cecum, of the first part of the ascending colon and of the second part of transverse colon, an accurated peritoneal and thoracic lavage and toilette was achieved. Then, a single layer suture in prolene 0 was performed to close the defect and a right hemicolectomy with a terminal ileostomy was done. A right thoracotomy was needed to complete a correct thoracic toilette and a thoracic drain was placed. Ileostomy was closed 6 month later. Also for the second case, thoracic and abdominal CT Scan with intravenous contrast medium reported migration of the hepatic flexure in a diaphragmatic hernia complicated with acute intestinal occlusion. The patient underwent delayed urgence laparoscopy that demonstrated a 8 9 5 cm right diaphragmatic hernia without hernial sac. After reduction of the herniated intestine and the omentum in abdomen, a thoracic tube was introduced from a thoracic trocar in the 5th intercostal space to reduce postoperatory pnx; to close hernial defect was performed a single layer suture with v-loc 3/0 and then a 11 9 11 cm shaped polypropylene prothesis was fixed with two single sutures in prolene 2/0 and ProTack. Both patients underwent surgical repair of diaphragmatic hernia by a single surgeon with laparoscopic, upper and lower-GI experience. Diaphragmatic hernias are rare with differents presentations; it is safer to proceed with the closure of the hernial defect before consequences such as those described occur.

123

N. Ozlem General Surgery, Ahievran University, Kirsehir, Turkey Introduction: Laparoscopic appendectomy is an operation that is done in increasing rate, between all other operations made for acute appendicitis. aim is to make a comperative analysis in laparoscopic and open appendectomy was done in our clinic material methods between April 2015 and November2017 in our clinic the files of the patients who have laparoscopic and open appendectomy retrospectively was review; the demographics and operative time and length of hospital stay was recorded and compared. Statistical data analysed with spss. Results: the patients were divided to the patients had laparoscopic appendectomy and the patients had open appendectomy. There are 63 (67.8%) male and 30 (32.2%) female and 93 (M + F) in total patients in laparoscopic appendectomy group. Open appendectomy group have 60 (41.7%) female and 84 (58.3%) male, 144 (F + M) in total patients. Laparoscopic appendectomy group consist more female patients than male ones this difference is statistically significant (p \ 0.001). the mean age in laparoscopic appendectomy group patients is 35.8 ± 14.8 (17–71) the mean age of open appendectomy group of patients is 33.8 ± 16.1 (15–84). There is no significant difference between the two group of patients age statistically (p = 0.327). the mean operative time in lap appendectomy group of patients is 78.01 ± 37 (29–240) min. I˙n open appendectomy group of patients this time is 51.6 ± 17.6 (24–110) min. Operative time is statistically significant longer in laparoscopic appendectomy group of patients.(p \ 0.001). length of hospital stay of laparoscopic appendectomy group of patients 2.39 ± 1.68 (1–9) day. Lohs of open appendectomy group of patients is 2.02 ± 1.73 (1–11) day. But there is not statistically significant differences between the groups of patients lohs. (p = 0.107). Conclusion: laparoscopic appendectomy is prefered to aid the diagnosis in female patients group. But laparoscopic appendectomy cause a longer operative time significantly, but it does not have a shorter length of hospital stay.

Surg Endosc

P121 - Emergency Surgery

P449 - Emergency Surgery

2 Cases of Laparoscopic Surgery for Stump Appendicitis 1

2

2

2

2

H. Murase , H. Iseki , A. Ogawa , M. Hayashi , S. Paku , T. Yoshida3, R. Oono3 Surgery, Tokyo Shinagawa Hospital, Tokyo, Japan; 2Surgery, Toshiba Hospital, Tokyo, Japan; 3Surgery, Nitobe Memorial Nakano General Hospital, Tokyo, Japan

The Abdominal Combat Trauma and Laparoscopic Technique V. Yarynych, M. Syroid Surgery, Military Hospital, Lviv, Ukraine

1

Case 1: A 56-year-old female was referred to our hospital with right lower quadrant abdominal pain for 3 days. She had undergone laparoscopic appendectomy 7 months ago in a different hospital. Her fever was 37.5 °C. Her white blood cell (WBC) count was 9,500/ll, and C-reactive protein (CRP) level was 12.3 mg/dl. Computed tomography (CT) revealed a residual appendiceal stump with staple. We diagnosed this case as stump appendicitis and emergency surgery was performed. An inflamed 10 mm appendiceal stump was found. Laparoscopic cecal partial resection with 3 ports was performed. A histological examination showed phlegmonous appendicitis. The patient was discharged 7 days after the operation. Case 2: A 81-year-old female was referred to our hospital with right lower quadrant abdominal pain for 2 days. She had undergone laparoscopic appendectomy 5 years ago in a different hospital. Her fever was 38.8 °C. Her WBC count was 12,570/ll, and CRP level was 17.3 mg/dl. CT revealed a residual appendiceal stump and a few free air. We diagnosed this case as stump appendicitis and emergency surgery was performed. An inflamed 12 mm appendiceal stump was found. Laparoscopic ileocecal resection with 4 ports was performed. A histological examination showed gangrenous appendicitis with perforation. The patient was discharged 8 days after the operation. We tend to rule out the possibility of acute appendicitis from the diagnosis when we examine a patient whose appendix has been resected. However, we have to consider the possibility of stump appendicitis and it is important to make diagnosis as early as possible. To prevent stump appendicitis, resection of the base of the appendix under clear visualization is most important during primary open appendectomy or laparoscopic appendectomy.

P449 - Emergency Surgery

Aim of this study was to study the results of the use of the laparoscopic technique in patients with combat trauma (CT) of abdomen cavity. Methods: 56 patients aged 20 to 45, with abdominal CT underwent laparoscopic procedures. Gunshot wounds in 48 (85.7%) cases were diagnosed: shrapnel wounds – in 31 (55.4%) and bullet wounds – in 17 (30.3%) patients. 40 (71.4%) patients had multiple wounds. The blunt abdominal trauma was revealed in 8 (14.3%) cases. Results: Damage to internal organs requiring a conversion to an open operation was detected in 47 (83.9%) of the 56 patients who underwent laparoscopy. Instead, in 9 (16.1%) cases, laparoscopy was the single diagnostic and therapeutic measure. Isolated shrapnel injury of liver, accompanied by mild bleeding, was detected in 3 (5.4%) patients. The bleeding was stopped by wound suturing and electrocautery. Shrapnel wound of the right diaphragm dome (without damage of the parietal pleura) was diagnosed in 1 (1.8%) case. The diaphragm wound was sewn by interrupted sutures. The defect of the abdominal wall in the right subcostal region with violation of peritoneum and mild bleeding from the muscles in 1 (1.8%) patient was revealed and primary debridement of the wound was performed. During laparoscopic exploration of the abdominal cavity and parietal peritoneum in 4 (7.1%) patients, no damage was found. Laparoscopic operations were completed by drainage of the abdominal cavity. Conclusions: The use of laparoscopic technique improved treatment outcomes for patients with CT. From 56 patients with abdominal CT in which laparoscopic procedures were performed, in 9 (16.1%) cases laparotomy was avoided.

P476 - Emergency Surgery

V. Yarynych, M. Syroid

Laparoscopic Management of Delayed Onset Diaphragmatic Hernia with Strangulated Small Bowel Obstruction Following RFA for Hepatocellular Carcinoma

Surgery, Military Hospital, Lviv, Ukraine

D.B. Kang1, M.K. Kim1, J.S. Kim1, S.Y. Lee1, J.T. Oh2

The Abdominal Combat Trauma and Laparoscopic Technique

Aim of this study was to study the results of the use of the laparoscopic technique in patients with combat trauma (CT) of abdomen cavity. Methods: 56 patients aged 20 to 45, with abdominal CT underwent laparoscopic procedures. Gunshot wounds in 48 (85.7%) cases were diagnosed: shrapnel wounds – in 31 (55.4%) and bullet wounds – in 17 (30.3%) patients. 40 (71.4%) patients had multiple wounds. The blunt abdominal trauma was revealed in 8 (14.3%) cases. Results: Damage to internal organs requiring a conversion to an open operation was detected in 47 (83.9%) of the 56 patients who underwent laparoscopy. Instead, in 9 (16.1%) cases, laparoscopy was the single diagnostic and therapeutic measure. Isolated shrapnel injury of liver, accompanied by mild bleeding, was detected in 3 (5.4%) patients. The bleeding was stopped by wound suturing and electrocautery. Shrapnel wound of the right diaphragm dome (without damage of the parietal pleura) was diagnosed in 1 (1.8%) case. The diaphragm wound was sewn by interrupted sutures. The defect of the abdominal wall in the right subcostal region with violation of peritoneum and mild bleeding from the muscles in 1 (1.8%) patient was revealed and primary debridement of the wound was performed. During laparoscopic exploration of the abdominal cavity and parietal peritoneum in 4 (7.1%) patients, no damage was found. Laparoscopic operations were completed by drainage of the abdominal cavity. Conclusions: The use of laparoscopic technique improved treatment outcomes for patients with CT. From 56 patients with abdominal CT in which laparoscopic procedures were performed, in 9 (16.1%) cases laparotomy was avoided.

1

Surgery, Wonkwang University School of Medicine, Iksan, Republic of Korea; 2Surgery, Gunsan Medical Center, Gunsan, Republic of Korea Introduction: Due to its effectiveness and safety compared to surgery, radiofrequency ablation (RFA) has recently been widely used to treat hepatocellular carcinoma (HCC). Rarely, diaphragmatic hernia can occur as a result of delayed complication of RFA for treatment of HCC. Therefore, we report the experience of the laparoscopic repair of diaphragmatic hernia with strangulated small bowel obstruction (SBO) induced by RFA for HCC. Method: 75-year-old male patient with a past medical history of cirrhosis and HCC (segment VIII) presented delayed right diaphragmatic hernia with strangulated SBO 8 years after his original RFA procedure. Successful laparoscopic hernia reduction and repair of diaphragmatic hernia was performed. We describe the surgical treatment of the laparoscopic repair of diaphragmatic hernia with strangulated SBO induced by RFA for HCC. Results: The patient was tolerated after surgery and recovered well without complications. Conclusion: Laparoscopic approach for diaphragmatic hernia with strangulated SBO is safe, feasible, and minimally invasive treatment. Awareness of this complication with rapid diagnosis and management is quite importance when patients, who previously underwent RFA, present with acute abdominal pain.

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Surg Endosc

P484 - Emergency Surgery

P123 - Endocrine Surgery

Emergency Periodic Laparoscopic Cholecystitis for Emphysematous Cholecystitis

Minimally Invasive Video-Assisted Management of Large Retrosternal Goitre to Avoid Sternotomy: Case Report and Technique Description

K. Shigemitsu, H. Mikane, S. Shinoura, K. Aoyama, M. Watanabe, Y. Nonaka Surgery, Tsuyama Chuo Hospital, Tsuyama City, Okayama, Japan Aims: Emphysematous cholecystitis is relatively rare. Due to the high rate of potentially fatal necrosis and perforation, early diagnosis and appropriate treatment are important in patients with acute emphysematous cholecystitis. Recently, the use of laparoscopic cholecystectomy for emphysematous cholecystitis after endoscopic retrograde gallbladder drainage (ERGBD) or percutaneous transhepatic gallbladder drainage (PTGDB) was reported. However, this approach requires a prolonged stay in the hospital. We report here the use of emergency periodic laparoscopic cholecystectomy for emphysematous cholecystitis. Methods: We report here the surgical findings of laparoscopic cholecystectomy for emphysematous cholecystitis. We carried out urgent and periodic cholecystectomies for 9 patients with emphysematous cholecystitis between January 2015 and May 2017. We compared the outcomes of six patients underwent laparoscopic surgery (EC-LC group) and three patients who underwent open surgery (EC-OC group). In addition, we compared these with 75 cases of acute cholecystitis treated with laparoscopic cholecystectomy (AC-LC group) in the same period. Result: The average bleeding, in EC-LC group, EC-OC group and AC-LC group were 41 mL, 292 mL and 90 mL, respectively. The average operation time was, 1 hour and 40 minutes, 2 hours and 27 minutes, 2 hours and 33 minutes for EC-LC group, EC-OC group and AC-LC group, respectively. The average duration of hospital stay after surgery was 10, 14.5, 8.9 days for EC-LC group, EC-OC group and AC-LC group, respectively. Considerations: Emphysematous cholecystitis is unlikely to be associated with gallstones, and the main pathology is the impairment of blood flow in the wall of the gallbladder. Therefore, it is relatively easy to identify the exfoliation layer by penetrating into the intra-mural vacuolar layer, and intraoperative bleeding is limited due to necrosis of the gallbladder wall. Therefore, this surgery is possibly safer than surgery for general acute cholecystitis accompanied with fibrosis due to chronic inflammation. Emergency periodic laparoscopic cholecystectomy is beneficial for patients with emphysematous cholecystitis.

S. Lanitis1, V. Ganis1, G. Sourtse1, P. Chortis1, S. Peristeraki1, E. Katsanou1, K. Daskalakis1, A. Vryonidou2, P. Brotzakis1 1 2nd Surgical Department and Unit of Surgical Oncology, Korgialeneio-Benakeio, Athens General Hospital-Greece, Athens, Greece; 2Department of Endocrinology, Korgialeneio-Benakeio, Athens General Hospital-Greece, Athens, Greece

Aim: Retrosternal goitre consists a challenge for the surgeon and requires experience and expertise. Although usually the operation is completed through a transcervical approach, occasionally there is a potential requirement for sternotomy. Studies have shown that goitre chronicity, thyroid gland density on CT and thyroid extension in the posterior mediastinum are important factors for sternotomy consideration. In all cases, optimal pre-operative assessment is of vital importance. Endoscopically-assisted thyroidectomy is known to consist an alternative approach for selected cases that undergo thyroidectomy. Nevertheless, this technique has not been widely tested for treatment of large retrosternal goitres. Our aim was to assess the potential management of such patients by minimally invasive endoscopically-assisted thyroidectomy in order to minimize the need for sternotomy. Method: A 60-year old patient was planned to be operated for a large retrosternal goitre. Preoperative assessment of this patient with a CT scan had demonstrated a large, right lobe goitre, with extension in the posterior mediastinum down to the tracheal bifurcation. Based on the literature there was a high probability to need a sternotomy for the completion of the operation and the theatre was prepared for this. Through a 4-cm cervical Kocher incision, typical access for total thyroidectomy was achieved, followed by ligation of the superior pole vessels and the middle thyroid vein, recognition of the recurrent laryngeal nerves as well as the superior parathyroid glands, and mobilisation of the entire gland. After a failure to lift the gland manually, a 5 mm, 30-degree camera was employed, by means of which the retrosternal part of the thyroid gland was mobilised and dissected, free of the surrounding tissues reaching back to the prevertebral fascia. The retrosternal part was fully mobilised under direct vision and the whole gland was removed transcervically. Finally, inspection of the mediastinum was performed, followed by drain placement and standard tissue closure. Results: The patient had an uncomplicated and rapid post-operative recovery and was discharged on the second post-operative day. The late cosmetic result was excellent. Conclusions: Minimally invasive endoscopically-assisted thyroidectomy may consist an alternative approach for patients with retrosternal goitres, and minimize the need for sternotomy.

P122 - Endocrine Surgery

P124 - Endocrine Surgery

New Approach in Single Incision Endoscopic Parathyroidectomy Using Lifting Method by Original Retractor via Chest

Minimally Invasive Adrenalectomy for Pheochromocytomas. Does Size Really Matters?

K. Kayano, O. Ohsawa, Y. Yaginuma, K. Kohmoto, S. Suzuka, K. Kojo, N. Nishioka

G. Giraudo1, S. Arolfo2, L. Rapetti2, M. Morino2

Surgery, 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. Recently, we have applied this method to parathyroid surgery. In this study, we present our method and results in parathyroid surgery with regard to surgical outcome and patients’complaints. Method: Endoscopic parathyroidectomy of C-SIET was performed in 5 patients with hyperparathyroidism in new approach (mean age 67, Male 1 Female 4). Single parathyroid adenoma was diagnosed using ultrasonic device, preoperatively. The patient is placed in a supine position with the neck extended. 30 mm vertical incision is made in anterior chest. Flexible scope (Olympus Co. Japan) is used through 5 mm trocar detached the retractor. In new approach, the parathyroid and thyroid are exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle. Both of the skin and sternal head are lifted up by our original retractor (Takasago Medical Co. Japan). Parathyroid adenoma behind the thyroid is resected using an ultrasonic scalpel. I would like to show our C-SIET procedure. Results: No scars in the neck were left in all cases. Benign and hemi lateral parathyroid adenoma sized from 8 mm to 25 mm (mean:17.8 mm) were operated. Mean operation time is 122 min. in new approach. There was no complication. Parathyroid hormone levels decreased in all patients, postoperatively. Conclusion: It is required to be careful of recurrent nerve palsy in this approach. New approach is useful to operate and make the working space wider without stress to find out of parathyroid. Our original retractor can be introduced easily in most hospital, because it is not so expensive. Most of women satisfied cosmetic results because of hidden scars.

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1

Department of Surgical Sciences, University of Torino, Torino, Italy; Surgical Sciences, University of Torino, Torino, Italy

2

Background: Minimally Invasive Adrenalectomy (MIA) has become the standard of care in adrenal surgery since the early nineties. The advantages on post operative outcomes of both transperitoneal laparoscopic and retroperitoneoscopic procedures compared to open surgery are unequivocal and nowadays almost all the procedures are performed in a minimally invasive way. Nevertheless Pheochromocytoma (PCC) is still considered by some guidelines not suitable of MIA if larger than 6 cm, because of the risk of tumour rupture and the technical challenge of early adrenal vein clipping. Aim: To evaluate intraoperative and post operative outcomes of MIA for PCC, focusing on tumour size. Methods: A retrospective analysis of a prospectively collected database was performed including all consecutive MIAs for PCC. Intraoperative and post operative outcomes were analyzed comparing lesions C 6 cm with lesions \ 6 cm. All results for continuous variables are expressed as the mean ± standard deviation. All reported p-values were two-sided, at the conventional 5% significance level. Results: Between January 1996 and December 2016 113 laparoscopic transperitoneal adrenalectomies for PCC were performed at our Institution. Mean size of lesions was 4.5 ± 2.85 cm. 82 lesions were smaller than 6 cm (group 1), while 31 C 6 cm (group 2). Mean Operative time was significantly longer in group 2 (89 ± 45 min in group 1 vs 116 ± 62 min in group 2; p = 0.03). No significant differences were found between groups in terms of conversion rate (1.2% in group 1 vs 6.5% in group 2; p = 0.14), intraoperative complications (3.7% in group 1 vs 6.5% in group 2; p = 0.54) and post operative complications rate (13.4% in group 1 vs 12.9% in group 2; p = 0.95). Pathological evaluation showed the adequacy of resection with clear surgical margins in all cases. Conclusion: In high volume centers with high expertise in laparoscopic surgery, MIA for PCC shows safe and effective even in adrenal masses C 6 cm. Conversion rate is very low and complication rate is comparable to masses \ 6 cm. The dogma that an adrenal PCC C 6 represents an hypothetical contraindication to MIA should be questioned.

Surg Endosc

P125 - Endocrine Surgery

P127 - Endocrine Surgery

Hand-Assisted Laparoscopic Surgery for Large Adrenal Tumors

Near Infrared Fluorescence Imaging with Indocyanine Green for Identification of Parathyroid Glands During Thyroid Surgery

C. Aggeli, A.M. Nixon, C. Parianos, G. Ntokos, G.N. Zografos Third Department of Surgery, General Hospital of Athens, Athens, Greece Aim: To evaluate the hand assisted technique in laparoscopic surgery of large or/and potentially malignant adrenal tumors. Method: We describe the use of hand-assisted laparoscopic adrenalectomy as an alternative minimal invasive surgical approach. Hand-assisted laparoscopic adrenalectomy was performed in 9 patients of a series of 476 patients who underwent laparoscopic adrenalectomy for adrenal masses. Of these 476 laparoscopic adrenalectomies, 97 (20.4%) were performed for tumors larger than 8 cm. The handassisted technique was used for large adrenal masses of the right adrenal gland. There were 7 men and 2 women aged 58–67 years. We used 2 ports of 11 mm, 1 port of 12 mm and 1 port of 5 mm. A small incision of 6 cm, including the incision for the 5 mm port was done in order to introduce the hand assisted device. The specimen was extracted from the hand assisted device. Results: In 8 patients the operation was completed laparoscopically and only in one case conversion to open surgery was necessitated. All tumors were larger than 10 cm (10–15 cm) in diameter. The use of this technique offered the advantage of a safer manipulation of the tumor as well as a more effective hemostasis. The pathology report revealed 5 adenomas, 1 paraganglioma, 2 myelolipomas and 1 necrotic neoplasm. All patients had uneventful postoperative course, similar to laparoscopic surgery. Conclusion: Hand- assisted laparoscopic adrenalectomy is an easily performed technique. It is associated with less operative time, avoiding fragmentation of large tumors whereas maintain the beneficial results of laparoscopic surgery.

J. van den Bos1, L. van Kooten2, N.D. Bouvy1, L.P.S. Stassen1 1 Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; 2Surgery, Maastricht University, Maastricht, The Netherlands

Aims: Iatrogenic injury of the parathyroid glands is the most common complication during thyroid surgery. Near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) is an evolving modality for intraoperative identification of the parathyroid glands and can thereby prevent their inadvertent surgical damage. This study assessed the feasibility, including the practical applicability and safety, of the use of NIRF imaging with ICG to identify the parathyroid glands intraoperatively. Methods: Patients undergoing elective hemi-, complementing or total thyroidectomy were enrolled in this prospective feasibility study. To visualize the parathyroid glands, a laparoscopic fluorescence imaging system was used. A bolus of 7.5 mg ICG was administered intravenously twice. The first bolus to identify the parathyroid glands before (partial) resection of the thyroid; the second to assess the vascularization of the parathyroid glands after resection. Intraoperative identification of the parathyroid glands was registered, as well as the subjective fluorescence intensity (grading scale 1 to 3) and opinion of the surgeon about the usefulness of the technique. Results: a total of 30 operations in 26 patients were included. In sixteen surgeries (53%), fluorescence imaging was rated as useful by the performing surgeon. Mean subjective fluorescence intensity of the parathyroid before was 2.6 and after thyroid resection, this score was 2.4. The measured mean TBR was 4.5 before and 2.5 after thyroid resection. 3 up to 9 minutes of the total surgical time were spent for the use of the fluorescence technique. No intra- or postoperative complications occurred because of the use of ICG. Conclusions: The use of near-infrared fluorescence imaging with the use of ICG can be useful for identification of the parathyroid glands during thyroid surgery. The technique seems especially helpful to confirm a suspicion on the presence of a parathyroid glans and to assess its vascularization after thyroid resection.

P126 - Endocrine Surgery

P128 - Endocrine Surgery

Surgical Treatment of Bilateral Adrenal Tumors

Laparoscopic Ventral Hernia Repair in Asian Obese Patients

C. Aggeli, A.M. Nixon, C. Parianos, C. Tserkezis, G.N. Zografos

R. Maia, H. Salgaonkar, S. Wijerathne, L. Loo, D. Lomanto

Third Department of Surgery, General Hospital of Athens, Athens, Greece

Surgery, National University Hospital, Singapore, Singapore

Introduction: Bilateral adrenalectomy is rarely indicated in patients with adrenal tumors. It serves as a treatment of choice in selected patients with persistent Cushing disease after an ineffective pituitary surgery or in patients with ectopic ACTH production. Other indications include bilateral pheochromocytoma in patients with hereditary paraganglioma -pheochromocytoma syndromes, congenital adrenal hyperplasia, bilateral adrenocortical adenomas and bilateral metastatic adrenal neoplasms. Over the past decades, a minimally invasive approach has gained universal acceptance as the standard of bilateral adrenalectomy. Aim: The aim of our study was to determine the indications of bilateral adrenalectomy in our series and show the results of this treatment. Methods: Between 1997 and 2017 593 patients underwent surgery for adrenal tumors. Of these 24 patients underwent bilateral adrenalectomy. Patients data, comorbidities, surgical approach, operative outcome were prospectively recorded. Two patients had synchronous and 22 metachronous bilateral adrenalectomy with an interval of 3 to 12 months. Two stage approach was selected in patients with comorbidities or in patients with bilateral benign tumors under surveillance, following unilateral adrenalectomy. A lateral transabdominal approach was performed in all patients and there were 2 conversions to open surgery. Results: Patients’ diagnoses included Cushing’s disease (n:11), subclinical Cushing syndrome (n:1), Carney Syndrome (n:1), MEN II syndrome (n:3), adrenal metastases (3), cortical adenoma and carcinoma (n:1), bilateral non secreting adenomas (n:2) bilateral cortical carcinoma (n:2). Hospital stay for laparoscopic adrenalectomy was 2 days compared to 5 days for the open cases. There was no 30-day hospital mortality or major morbidity in this series. Conclusion: Minimally invasive surgery is feasible in patients undergoing bilateral adrenalectomy and the choice of a single stage or staged approach is based on the disease and the presence of comorbidities.

Background: Morbidly obese patients (MOPs) are predisposed to develop abdominal wall hernias with the potential complication of small bowel obstruction and other morbidity. Many authors have suggested that a weight loss may help to improve the technical circumstances of the operation and help to reduce the potential recurrence rate, though it may not change the risk of perioperative complications in ventral hernia repair (VHR). We report our experience in treating, pre operatively, morbidly obese patients with a very low calorie diet to promote weight lost before surgery. Methods: We compare outcomes from 42 consecutive patients with BMI [ 27.5 kg/ m2 and 14 patients with BMI \ 27.5 treated between 2015 and 2017 with either laparoscopic (n = 47) or robotic ventral hernia (n = 9). In 4 patients, a concurrent laparoscopic sleeve gastrectomy was performed. Patient demographics, body mass index, defect size, mesh types, operative details, length of hospitalization, complications, early hernia recurrences and readmission rates were evaluated and compared on both groups. Results: The mean age was 59.2 years (range 34–82 years) with a mean BMI of 25.5 kg/m2 (range 18.8–34.8 kg/m2) for overweight group and 31 for the morbid obese group. The fascial defect sizes (in largest dimension) ranged from 2 to 10 cm with a mean defect size of 4.2 cm. Post-operatively 5 patients developed seroma, all managed conservatively. The mean length of stay was 2.2 days (range 1–4 days). Median follow-up was at 18 months (range 6–24 months) and there was no recurrence reported. In eight patients, a very low calorie diet (VLCD) was performed to achieve a 10% EWL. In our experience, laparoscopic hernia repair is a safe and feasible procedure for overweight as well as obese patients. The use of Da Vinci Robot may offer advantages in selective cases. In experienced hands, LVHR may be the approach of choice for obese patients.

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Surg Endosc

P129 - Endocrine Surgery

P131 - Endocrine Surgery

Can We Help patients with Type 1 Diabetes Mellitus by Surgery? Review of Our 6 Year Experience.

Postoperative Haemodynamic Instability After Laparoscopic Adrenalectomy for Phaeochromocytoma: Is Routine Intensive Care Admission Necessary?

I. Havrysh, V. Lukavecki, Y. Havrysh Surgery, Lviv Medical University, Lviv, Ukraine In 2011, we began to study influence of sleeve gastrectomy (SG) and gastric plication (GP) on carbohydrate metabolism in patients with type I diabetes mellitus (DM1). We divided study into 2 parts: I part – experimental. In 250 white laboratory rats we inducted diabetes with streptozotocine (STZ). After 1 month, we perform GP in those rats. 60 days after GP we completed the experiment. We take pancreatic tissue for morphology, morphometry, histochemistry examination. We saw decreasing of Langerhans islets in rats after induction of diabetes by streptozotocin. After GP we noted return to normal glucose level in 30% of animals, a reduction of hyperglycemia in 45% of animals, and absence of response to surgery in 25% of rats. During histological examination, we noted increase of Langerhans islets in 35% of rats after GP. In other animals, morphological changes were less pronounced, and in 20% of animals - no noticeable changes. In the second part of the study, we performed 27 operations in patients with type 1 diabetes mellitus. Age of patients 18–57 years, the average BMI-25 (18–31). In all patients, we performed GP. The criterion for choosing this surgery was the poor percentage of mortality and complications after GP compared to SG and RYGB. In 3 patients, we noted fully remission of DM with normoglycemia and normalization of HbA1c without the induction of insulin. First patient get 90 IU of insulin per day before surgery and had remission duration for 6 years. Second patient get 60 IU of insulin per day before surgery and had remission duration for 4 years. Third patient get 30 IU of insulin per day before surgery and had remission duration for 1 year. In 7 patients, the daily insulin intake was reduced by more than 50% from the preoperative level, in 8 patients – less than 50% and in 9 patients - no changes occurred. Conclusion: Our studies show a positive effect of GP on the course of DM1 in 66% of patients. In 80% of operated rats with STZ inducted diabetes GP leads to positive morphological changes in the pancreas.

R.P. Sutcliffe1, J. Thompson2, D. Bennett1, J. Ayuk3, M. O’Reilly3, W. Arlt3, N. Karavitaki3 1 Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom; 2Medical School, University of Birmingham, Birmingham, United Kingdom; 3Department of Endocrinology, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom

Background: Due to the potential for haemodynamic instability, patients undergoing adrenalectomy for phaeochromocytoma are typically monitored in an intensive care unit (ICU). However, ICU is a limited and expensive resource. The aim of this study was to determine the incidence and risk factors for postoperative haemodynamic instability in patients undergoing adrenalectomy for phaeochromocytoma. Patients and methods: Retrospective analysis of patients undergoing adrenalectomy for phaeochromocytoma during an 8-year period in a tertiary UK centre. Patient demographics, intra/postoperative haemodynamic data and perioperative outcomes were collected. Postoperative haemodynamic instability (HDI) was defined as (1) need for postoperative vasopressors, (2) systolic blood pressure \ 90 mmHg or (3) heart rate [ 120 or \ 50 bpm within the first 24 hours after surgery. Results: Data was available for 39 patients (open 20, laparoscopic 19). Median tumour size was 4.5 cm (range 1.3–13). A preoperative diagnosis was available in 35 patients (90%), all of whom were alpha-blocked, and 17 (49%) were beta-blocked. 18 patients (46%) had postoperative HDI, including 10 patients (26%) who needed vasopressor support. HDI was significantly more likely in patients with tumours [ 4 cm (63% vs. 22%; p = 0.02), open compared to laparoscopic surgery (70% vs. 17%; p = 0.001) and epidural use (90% vs. 29%; p \ 0.001). Conclusions: Patients undergoing laparoscopic adrenalectomy for tumours less than 4 cm are at low risk of postoperative haemodynamic instability. Such patients may be safely monitored on an acute surgical ward, potentially reducing the demand on intensive care units.

P130 - Endocrine Surgery

P132 - Endocrine Surgery

Laparoscopic Organ-Sparing Adrenalectomies in Patients with Unilateral and Bilateral Adrenal Tumors

Single-Stage Laparoscopic Adrenalectomy and Pancreatic Net Enucleation

J. Filipovic-Cugura1, Z. Misir2, D. Herman-Mahecic3, B. Misir2, N. Filipovic2

J. Filipovic-Cugura1, Z. Misir1, D. Herman-Mahecic2, B. Misir1, N. Filipovic1

1

Department for Upper Gastrointestinal Surgery, University Hospital Center, Sestre Milosrdnice, Zagreb, Croatia; 2Department for Upper Gastrointestinal Surgery, University Hospital Center, Sestre Milosrdnice, Zagreb, Croatia; 3Department of Endocrinology, Diabetes and Metabolic Diseases, Mladen Sekso, University Hospital Center, Sestre Milosrdnice, Zagreb, Croatia

Aims: The vast majority of partial adrenalectomies are now being performed laparoscopically. We present our experience with this type of surgery to evaluate its feasibility and safety. Methods: We retrospectively reviewed patients who underwent a partial adrenalectomy in our department over a 3-year period. The pathology reports included: aldosterone-producing adenomas, myelolipomas, ganglioneuromas, cortisol-producing adenomas, aldosterone-producing adenomas, and non-functional solitary lesion [ 4 cm in diameter. Laparoscopic transperitoneal approach was used in all cases with patients in a lateral decubital position. Tumors were resected with safety margins by endoshears or stapler, and hemostasis was achieved by bipolar coagulation. Results: All procedures were done laparoscopically, and no conversion was necessary. No perioperative morbidity or mortality occurred. Patient treated for cortisolsecreting adenomas are on cortisol substitution therapy postoperatively. Conclusions: Laparoscopic partial adrenalectomy is a technically challenging but feasible tissue-sparing operation in both unilateral and bilateral tumors. We recommend laparoscopic partial adrenalectomy for patients with small tumors of the adrenal gland, even with a healthy contralateral adrenal gland.

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1

1Department for Upper Gastrointestinal Surgery, University Hospital Center, Sestre Milosrdnice, Zagreb, Croatia; 2Department of Endocrinology, Diabetes and Metabolic Diseases, Mladen Sekso, University Hospital Center, Sestre Milosrdnice, Zagreb, Croatia

Aims: We present two cases of patients with unilateral adrenal pathology who underwent laparoscopic adrenalectomy. During the same procedure, pancreas NET enucleation was performed. Methods: The laparoscopic transperitoneal approach was used with patients in a lateral decubital position. NETs were enucleated using bipolar coagulation. Total operative time was 120 minutes. There were no operative or postoperative complications. Results: All procedures were done laparoscopically, and no conversion was necessary. No perioperative morbidity or mortality occurred. Conclusions: Laparoscopy allows surgical approach of patients with simultaneous lesions in several abdominal viscera. To our knowledge, this is the first report of onestage laparoscopic adrenalectomy and pancreatic NET enucleation.

Surg Endosc

P133 - Endocrine Surgery

P489 - Endocrine Surgery

Sequential Bilateral Adrenal Adenoma Laparoscopic Resection for Cushing Syndrome

Transoral Endoscopic Thyroid Surgery: New Introduction Device for Producing Operative Field: First Clinical Series

A. Miron, M. Nadragea, E.A. Toma, O. Enciu

R. Zorron, J. Raakow, V.A. Mu¨ller, A. Brandl, P. Seika, J. Pratschke, M. Mogl

Surgery, Elias University Emergency Hospital, Bucharest, Romania Laparoscopic adrenalectomy became the gold standard for adrenal disease, from incidentaloma to cancer. The technical difficulties as well as hemorrhagic risks associated with adrenalectomy are well known. In selected cases of benign secreting adrenal tumors, adrenalectomy may be inadequate, partial resections being perfectly justified. We present a particular case of Cushing Syndrome due bilateral adrenal adenomas proven to secrete cortisole by selective adrenal vein sampling. The patient was scheduled for sequential bilateral adrenal adenoma resection. The first intervention was performed on the right side and within a month the left adrenal adenoma was successfully resected. This allowed for optimal endocrine management of hormone imbalance. The patient was symptom free at 6 months followup after the second resection and did not need further endocrine treatment. The key points of adrenal adenoma resection reside in adenoma identification and careful dissection in the plane between the adenoma and the normal parenchyma. Preservation of the blood supply of the remaining parenchyma is also very important. Resection accuracy is audited by inspection of the tumoral capsule that should be intact. Laparoscopic adrenal adenoma resection is feasible for small benign tumors but has an increased level of technical difficulty. In the presented case, we feel it was the optimal course of treatment.

Department of Surgery, Campus Charite´ Mitte CCM, Campus Virchow Klinik CVK, Universita¨tsmedizin Charite´ Berlin, Berlin, Germany Objectives: Today, minimally invasive thyroid and parathyroid resections for both benign and malignant tumors are rarely performed. Recently, promising new endoscopic transoral approaches to the anterior neck (Transoral endoscopic thyroidectomy vestibular approach; TOETVA) have been described with good results and few complications. A new device is proposed to allow the safe entrance of trocars in the subplatysmal space. This study evaluates the blunt dissection device in performing TOETVA in a cadaver model. Methods: The technique was performed for 4 unilateral thyroidectomies in female cadavers with no preexisting neck operations, and clinical series for unilateral thyroidectomy in 14 patients. The technical steps consisted of a 10 mm incision made at the center of the oral vestibule, followed by subplatysmal hydrodissection. Then the blunt dissector stick was inserted creating a space below the platysma to the anterior neck and the strap muscles. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field. Three trocars were inserted in the vestibular area. For better exposure, strap muscles were retracted laterally by external sutures. The isthmus was dissected and transected. Anatomical structures as the superior thyroid artery, parathyroid glands and the recurrent laryngeal nerve could be easily identified with magnified vision. Results: Preliminary clinical experience with clinical peroral endoscopic thyroidectomy (POET) after cadaver study showed optimal operative field due to subplatysmal dissection by the device allowed for exposition of thyroid and parathyroid glands in all cases. Unilateral thyroidectomy was performed in a mean of 108 min. The device allowed for good exposure in the clinical and experience. No complications were recorded, no RLN or mental nerve lesion, no postoperative infection. Mean postoperative stay was 4 days. The cosmetic results were excellent. Conclusions: POET is a promising feature to allow feasibility of natural orifice thyroid and parathyroid surgery through the vestibular approach in early clinical series. Further studies in clinical series are needed to evaluate the broad application of this technique.

P134 - Endocrine Surgery

P135 - Flexible Surgery

The Role of Cortical Sparing Adrenalectomy in the Treatment of Pheochromocytoma in the Minimally Invasive Era: Systematic Review

Results: Of the Use of Double Covered and Double Uncovered Stents for the Treatment of Malignant Colorectal Obstruction: Comparative Randomized Study

E. Yiannakopoulou

A. Vodoleev1, V. Duvanskiy2, A. Kaprin3, A. Kostin4, Z. Margeani4

Department of Medical Laboratories, Highest Technological Educational Institute of Athens, Athens, Greece

2

Traditionally total adrenalectomy has been the standard procedure for the treatment of adrenal tumors irrespective of size and location. However, recently, there is growing interest on the performance of partial adrenalectomy in order to avoid the side effects associated with the need for lifelong exogenous steroid replacement. Aims: This systematic review aimed to investigate the role of cortical sparing adrenalectomy in the treatment of pheochromocytoma. Methods: Electronic databases were searched with the appropriate search terms for the time period up to and including December 2017. Full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria. Results: Seventy five possibly relevant studies were identified. Abstracts were reviewed and finally fourty one studies were retrieved in full text and included in the systematic review. The majority of the data came from retrospective studies, small case series and case reports. In fact, critical review of literature data generates more questions, than providing answers. Cortical sparing adrenalectomy has been described in both hereditary and sporadic pheochromocytoma. The use of cortical sparing adrenalectomy is highly debated in the case of unilateral pheochromocytoma due to the difficulty in excluding malignancy. The majority of literature data focus on hereditary pheochromocytoma patients with RET or VHL mutations. The low risk of malignancy and high risk of bilateral tumors are obvious in the above genetic syndromes especially in MEN2. Recurrence rate is estimated at about 10% for pheochromocytoma. Overall steroid dependence rate is estimated at 90%. Long term follow up of the patients has not been standardized. The surgical technique has not been standardized and open questions remain regarding the tumor margin, the adrenal vein preservation, the means of hemostasis. Conclusion: Cortical sparing adrenalectomy is an option especially for patients with bilateral pheochromocytomas. However, open questions remain regarding the indications in the case of unilateral pheochromocytoma. In addition standardization of the technique is needed.

1

GI Endoscopy, Eramishanzev Clinical Hospital, Moscow, Russia; Endoscopy, endoscopical and laser surgery, RUDN University, Moscow, Russia; 3Principal, FSBI NMRRC of the Ministry of Health of the Russian Federation, Moscow, Russia; 4Vice-principal, FSBI NMRRC of The Ministry of Health of the Russian Federation, Moscow, Russia

Endoscopic stenting for malignant colonic obstruction has advantages and disadvantages. One of the actual problems associated with colorectal stenting is the recurrence of symptoms of obstruction. The most common cause is migration of covered stents and ingrown of uncovered stents. The aim of our study was to compare the results of the use of stents of a new design, the development of which was aimed at preventing these complications. Design. Prospective, pandomized, single centre trial. Between December 2012 and September 2017, 100 patients with colonic malignant obstruction were implanted 101 stents (52 bare, 49 covered EGIS Colorectal stent, S&G Biotech Inc., South Korea).Groups of patients using coated and uncovered stents were comparable in terms of sex, age, duration of symptoms of obstruction, and stenosis localization. In 67%patients was palliative care,33% - bridge to surgery. Results: Clinical success was achieved in 97% patients. In two cases, when using covered stents, the symptoms of obstruction could not be regressed, the patients were operated. In one case, 3 hours after stenting with an uncovered stent, was diagnosed complication, that required surgical treatment. The average stay in hospital after the intervention was 3 days; the difference between the groups was statistically insignificant. 30 day mortality was 6%, the difference was statistically insignificant. Complications were detected in 5 patients in the group of bare stents and in 1 patient in the group of covered stents, the difference was statistically insignificant. In three cases perforation was diagnosed: after 3, 18, 77 hours after stenting (all bare stents). In 3% patients were identified the occlusion of the stents after 34, 83, 165 days after stenting. The causes of occlusion were tumor ingrown, fecal mass and fiber occlusion (uncovered stents) and stent overgrown (covered stent). The difference in cumulative stent patency and overall survival between groups is not statistically significant. Double bare and double covered colorectal stents were feasibility and efficacy for relieving malignant colorectal obstruction. Reobstruction was rare complication and not different in both groups stent groups. Necessary to continue to research for the accumulation of material from other centers.

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Surg Endosc

P136 - Flexible Surgery

P138 - Gastroduodenal Diseases

Umbilical Stoma (USTOMA) in Trans Anal Total Mesorectal Excision (Ta-TME) - A Preliminary Experience

Is 8th TNM Classification Better Than the 7th? A Long-Term Conditional Survival Analysis for Gastric Cancer

A. D’Alessandro, B. Vinson-Bonnet, N. El Kary, E. Chahine, E. Chouillard

C.M. Huang1, Q.Y. Chen2, C.H. Zheng1, P. Li1, J.W. Xie1, J.B. Wang1

Laparoscopic Surgery, CHI Poissy - Saint Germain en Laye, Poissy, France

1

Aims: The umbilicus, an embryological natural orifice, is nowadays increasingly used as the only access rout during single incision laparoscopic surgery (SILS), including for colorectal diseases. As a part of some of theses procedures, the temporary, diverting oostomy could be exteriorized through the umbilicus itself. Theoretical advantages include better preservation of the abdominal wall and potentially superior cosmetic results. Methods: We started performing colorectal SILS in 2010. Indications included patients with benign or malignant diseases, operated either electively or on an urgent basis. Between January 2010 and December 2017, we realized 294 colorectal SILS procedures. In 94 patients (31.9%), an ileostomy (56 patients) or a colostomy (38 patients) was performed. Of theses, 30 (40% of all oostomies) were umbilical stomas (ustomas). Results: Fifteen men and 15 women had either a loop ileostomy (24 patients) or an end (4 patients) or a loop (2 patients) colostomy. Mean age was 52 years (range, 29–81). There was no mortality. Operative stoma related morbidity occurred in only 3.3% of patients (1 ileal torsion volvulus). The accommodation to the stoma and the quality of life were satisfactory as estimated by both the patient and the stoma therapist. All stomas were reversed. Conclusion(s): This preliminary experience shows that Ustoma is a feasible and safe alternative to more conventional oostomy after SILS.

Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; 2General Surgery, Fujian Medical University Union Hospital, Fuzhou, China Aims: To compare the power to predict the 5-year conditional disease-specific survival (CS5) between the 7th and 8th editions of the TNM for gastric cancer (GC) patients. Method: This retrospective study recruited 20,548 patients who underwent GC surgery from the databases of the Surveillance, Epidemiology, End results and a center in Asia. The CS5 was evaluated with the 7th and 8th TNM classification. Results: A two-step model showed that at the 3–5th postoperative years, the 8th staging remained an independent risk factor, whereas there was no significant difference for 7th -edition staging. Further analysis of the ability to predict CS5 indicated that there were significant differences in the CS5 of 7th -edition stages IIb and IIIa at baseline and at the postoperative 1–4th years (all p \ 0.05, Cohen’s d [ 0.5). However, the CS5 of the fifth year was similar between them (p = 0.307, Cohen’s d = 0.35; Table 5). Meanwhile, the results indicated that the 8th -edition staging could effectively determine the CS5 among stages Ia, Ib, IIa, IIb, IIIa, and IIIb at baseline and at the postoperative 1–5th years (all p \ 0.05). However, neither the 7th - nor the 8th -edition staging could predict the CS5 for stages IIIb and IIIc from the postoperative third to fifth years (all p [ 0.05). Conclusion: For patients with stages II and III GC, the 8th TNM has a higher discriminatory value than the 7th edition for CS5 after the postoperative fourth year. However, a more detailed classification system is still needed to predict conditional survival for GC.

P137 - Gastroduodenal Diseases

P139 - Gastroduodenal Diseases

The Operative Results: Of One Hundred Cases of Dual-Port Gastrectomy for Gastric cancer

Development of a Nomogram for Predicting the Benefit of Adjuvant Chemotherapy After Resection in Patients with Linitis Plastica

H. Kawamura, Y. Ohno, N. Ichikawa, T. Yoshida, S. Homma, A. Taketomi Gastroenterological Surgery I, Hokkaido University, Sapporo, Japan Background: Recently, reduced-port surgery (RPS) is widespread in various surgery, however, there are few reports of small number of RPS in gastrectomy. We started reduced-port laparoscopic gastrectomy (RPG) through an umbilical multichannel port and an additional one port [dual-port laparoscopic gastrectomy (DPLG)] for gastric cancer in December 2009, and accumulate 100 cases until October 2015. At this time, the safety and feasibility of 100 cases of DP-LG was retrospectively examined by comparing with conventional 5-ports laparoscopic gastrectomy (5P-LG). Methods: Perioperative results of 100 DP-LG cases ware retrospectively compared with those of 5P-LG separately on distal gastrectomy and total gastrectomy. In the 100 patients of DP-LG, 79 patients underwent DP-laparoscopic distal gastrectomy (DP-LDG) and 21 patients underwent DP-laparoscopic total gastrectomy (DP-LTG). 133 cases of 5P-LG were performed during the same period. In the 133 patients of 5P-LG, 97 patients underwent 5P-laparoscopic distal gastrectomy (5P-LDG) and 36 patients underwent 5P-laparoscopic total gastrectomy (5P-LTG). Results: The mean age of DP-LDG group (63.4 ± 13.3) was significantly lower than that of 5P-LDG group (68.2 ± 9.6) (p = 0.006), however, there was no significant difference between DG-LTG group and 5P-LTG group. There was no significant difference in sex, body mass index, American society of anesthesiology classification, clinical stage, operation time, amount of blood loss, the rate of requiring additional port (s), conversion to open surgery, intraoperative complication, degree of lymph node dissection, the number of harvested lymph nodes, postoperative morbidity rate, and times of analgesic requirement both DG-LDG group and 5PLDG group and DG-LTG group and 5P-LTG group respectively. Conclusions: RPG was performed safely with high accomplishment both on distal gastrectomy and total gastrectomy. RPG is highly expected as an advance of laparoscopic gastrectomy for next generation.

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C.M. Huang, J. Lu, P. Li, J.W. Xie, J.B. Wang, C.H. Zheng Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China Aims: This study sought to explore prognostic factors for patients with linitis plastica and to establish a predictive model for the survival benefit of postoperative adjuvant chemotherapy in such patients. Methods: We studied 268 patients with linitis plastica who were diagnosed from 2006 to 2014 at Union Hospital of Fujian Medical University. Cox regression analyses were performed to identify prognostic factors that formed the basis for a nomogram and risk groups and to assess whether these risk groups could effectively identify patients with linitis plastica who would benefit from adjuvant chemotherapy. Results: Multivariate analysis showed that BMI, tumour differentiation, T stage, N stage, and ASA score were independent prognostic factors. A nomogram was established based on these independent risk factors, and nomogram scores were used to divide all patients into a high-risk group (score [ 16), an intermediate-risk group (8 \ score B 16) and a low-risk group (score B 8). Further stratified analysis based on AJCC stage showed that the 3-year survival rate was higher in the adjuvant chemotherapy group than in the surgery group for low- and intermediate-risk patients in each AJCC stage, while high-risk patients in stage III and stage IV did not significantly differ. Conclusion: The nomogram that we established can effectively be used to identify patients with linitis plastica who would benefit from postoperative adjuvant chemotherapy. In our model, adjuvant chemotherapy can significantly improve survival in low- and intermediate-risk patients.

Surg Endosc

P140 - Gastroduodenal Diseases

P142 - Gastroduodenal Diseases

Nomograms for Pre- and Postoperative Prediction of Long-Term Survival for Proximal Gastric Cancer Patients

Preoperative Lymph Node Size is Helpful to Predict the Prognosis of Patients with Stage III Gastric Cancer After Radical Resection

C.M. Huang1, Q.Y. Chen2, Z.L. Hong1, P. Li1, J.W. Xie1, C.H. Zheng1

C.M. Huang1, Q.Y. Chen2, X.C. Shang-Guan1, P. Li1, J.W. Xie1, C.H. Zheng1

1

Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; 2General Surgery, Fujian Medical University Union Hospital, Fuzhou, China

1

Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China; 2General Surgery, Fujian Medical University Union Hospital, Fuzhou, China

Aims: To develop nomograms for predicting long-term survival for proximal gastric cancer (GC) patients. Methods: Between January 2007 and June 2013, we prospectively collected and retrospectively analyzed the medical records of 746 patients with proximal GC. The data were split 75/25, with one group used for model development and the other group used for validation testing. A Cox regression analysis was used to identify the preoperative and postoperative risk factors for overall survival (OS). Result: Among the 746 patients examined, the 3- and 5-year OS rates were 66.1% and 58.4%, respectively. For the training set, the preoperative T stage (cT), N stage (cN), CA19-9, tumor size, ASA core, and 3–6-month weight loss were incorporated into the preoperative nomogram for predicting OS. In addition to these variables, LVI and the postoperative tumor size, T stage, N stage, blood transfusions and complications were incorporated into the postoperative nomogram. All the calibration curves for OS probability fitted well. In the training cohort, the preoperative nomogram achieved a C-index of 0.751 [95% confidence interval (CI): 0.732–0.770] in predicting OS and accurately stratified patients into 4 prognostic subgroups (5year OS rates: 86.8%, 73.0%, 43.72% and 20.9%, P \ 0.001). The postoperative nomogram had a C-index of 0.758 in predicting OS and accurately stratified patients into 4 prognostic subgroups (5-year OS rates: 82.6%, 74.3%, 45.9% and 18.9%, P \ 0.001). Conclusions: The nomograms accurately predicted the pre- and postoperative longterm survival of proximal GC patients.

Aims: To investigate the association between preoperative lymph node size (Ns) and prognosis of radical gastrectomy for gastric cancer. Methods: The clinical and pathological data of 970 patients undergoing radical gastrectomy for gastric cancer were retrospectively analyzed. The correlation between Ns and the identified variables for the prediction of overall survival (OS) and disease-free survival (DFS) was examined. Results: Three hundred and thirty-one (34.1%) of 970 patients developed recurrence, which was most commonly in local lymph nodes. The average Ns was 1.52 cm in patients with recurrence, which was significantly higher than the 1.14 cm observed in patients without recurrence (p \ 0.001). Patients were categorized into three groups as follows (Ns category): Ns0:0.00–1.10 cm, Ns1:1.20–1.70 cm, and Ns2: [1.70 cm, determined using the X-tile program. In univariate and multivariate analyses, Ns category, age, tumor size, lymphadenectomy, adjuvant chemotherapy and TNM stage were independent prognostic factors for DFS. Stratified analysis only in stage III was there a significant difference in the Ns category based on TNM stage. Furthermore, in the stage III subgroup, univariate and multivariate analyses revealed that Ns category, lymphadenectomy, and TNM stage was independent prognostic factors for DFS. A nomogram were developed to predict the 3-year DFS rate. Conclusions: Preoperative Ns is an independent prognostic factor for DFS of patients after radical surgery for gastric cancer. The proposed nomogram combined with Ns could be a simple and effective approach to predict the 3-year DFS of stage III patients.

P141 - Gastroduodenal Diseases

P143 - Gastroduodenal Diseases

Impact of Body Mass Index on Quality of Life After Distal Gastrectomy for Gastric Cancer

Comprehensive Complication Index (CCI) Predicts CancerSpecific Survival of Patients with Complications After Curative Resection of Gastric Cancer

K.B. Park Gastric Cancer Center, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea Objective: To evaluate the impact of postoperative shifting of body mass index (BMI) on quality of life (QoL) after distal gastrectomy in patients with gastric cancer. Summary Background Data: Few studies have evaluated QoL changes with respect to BMI changes after gastrectomy. Methods: QoL data from the European Organization for the Research and Treatment of Cancer (EORTC) gathered via the QLQ-C30 and QLQ-STO22 questionnaires were obtained from 1,036 patients preoperatively and at 1 year postoperatively. The patients were divided into two groups: Group 1, patients with decreased BMI postoperatively; Group 2, patients with unchanged or increased BMI postoperatively. Results: There were 577 patients in Group 1 and 459 in Group 2. According to global health status and functional scales, emotional functioning (P = 0.035) was significantly worse QoL in Group 1 than in Group 2 at 1 year postoperatively. One year postoperatively, there were significant decreases in QoL in symptom scales such as fatigue (P = 0.016), nausea and vomiting (P = 0.002), and appetite loss (P = 0.001) in Group 1 compared to Group 2. Regarding QLQ-STO22, reflux symptoms (P = 0.020), anxiety (P = 0.003), and body image (P = 0.003) were significantly worse in Group 1 than in Group 2 at 1 year after surgery. Conclusions: BMI shifting after distal gastrectomy influences QoL. Focusing on the control of gastrointestinal symptoms and psychological support is essential in patients with decreased BMI after surgery. Careful follow-up to maintain BMI such as by correcting dietary behavior and intensive nutritional support should be performed to prevent QoL deterioration after distal gastrectomy.

C.M. Huang, R.H. Tu, J.X. Lin, P. Li, J.W. Xie, C.H. Zheng Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China Aims: To investigate prognostic impact of postoperative complications for patients with gastric cancer. Methods: Postoperative complications of patients undergoing radical gastrectomy for gastric cancer were reviewed. The severity of complications was graded by the CCI and C-D classification. Results: A total of 5327 patients were included in the study. Complications were observed in 767 patients. When the C-D classification system was applied, for patients with grade I-II complications, the length of stay (LOS) of those with high CCI (CCI C 26.2) was significantly longer than that of patients with low CCI (CCI \ 26.2) (p \ 0.001). The 5-year cancer-specific survival rate of the patients with complications (52%) was lower than that of patients without complications (61%) (p \ 0.001). Analysis of the factors associated with prognosis in patients with gastric cancer revealed that complications were independent risk factors for specific survival. When CCI was used to classify complication severity, the 5-year cancerspecific survival rate of the high CCI group was 46.3%, which was lower than that of the low CCI group (54.9%, p = 0.009). Conclusion: Complication after radical gastrectomy is an independent prognostic factor, and the complication severity as graded by CCI reflects the difference of cancer-specific survival in gastric cancer patients with postoperative complications.

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Surg Endosc

P144 - Gastroduodenal Diseases

P146 - Gastroduodenal Diseases

Is the Eighth Edition of the AJCC TNM Staging System Sufficiently Reasonable for all Patients with Noncardia Gastric Cancer?

A Single Institution Experience of Laparoscopic Gastrectomy in Advanced Gastric Cancer

C.M. Huang, J. Lu, Z.F. Zheng, P. Li, J.W. Xie, C.H. Zheng Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China Aims: To compare the prognostic ability between the 7th and 8th editions of the AJCC TNM classification for gastric cancer (GC). Methods: 10,194 noncardia GC patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2008. Concordance index (C-index), bayesian information criterion (BIC) and time-dependent receiver operating characteristics (t-ROC) analyses were used. External validation was performed using a dataset (n = 2355) derived from Fujian Medical University Union Hospital (FMUUH). Results: Overall survival for all 5 AJCC N categories significantly differed when the patients were subgrouped into B 15 versus[ 15 examined lymph nodes (eLNs). The prognostic ability of the 8th edition (C-index: 0.716) was not improved over the 7th edition (C-index: 0.716). Subgroup analysis showed superior performance of the 8th edition over the 7th edition in patients with eLNs [ 15 (C-index 0.742 vs. 0.735); however, the two editions had similar performance for patients with eLNs B 15 (Cindex 0.713 vs. 0.713). The BIC and t-ROC analyses were consistent. To better predict the prognosis of patients with eLNs B 15, we established a novel prognostic model based on independent prognostic factors (C-index 0.735). The BIC analysis showed that this new model was better than the 7th and 8th editions. Similar results were obtained from the FMUUH datasets. Conclusion: The 8th edition of the AJCC TNM classification provides a better prognosis than the 7th edition in noncardia GC patients with eLNs [ 15, but no improvement was found in patients with eLNs B 15 ; therefore, a novel prognostic model is proposed.

Y. Lee, S.H. Min, H.H. Kim Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea Purpose: This study summarizes the single institution experience of laparoscopic gastrectomy in advanced gastric cancer and evaluates the postoperative morbidities and long-term oncologic outcomes. Methods: A total of 1,597 laparoscopic gastrectomy for advanced gastric cancer were performed at Seoul National University Bundang Hospital between May 2003 and May 2017. The characteristics of patients, surgical techniques, postoperative morbidities, and long-term oncologic outcomes were retrospectively reviewed using electronic medical records. Results: 109 patients required conversion to open surgery. The reasons of conversion to open surgery were advanced stage (n = 59), intraoperative bleeding (n = 19), adhesion due to previous abdominal operation (n = 10), small abdominal cavity (n = 4), associated disease (n = 4), and intraoperative pleural injury (n = 2). The mean hospital stay was 7.0 days for distal gastrectomy, 9.6 days for total gastrectomy, 8.3 days for proximal gastrectomy, and 6.5 days for pylorus preserving gastrectomy. The mean number of collected lymph nodes was 58.7 for distal gastrectomy, 70.1 for total gastrectomy, 43.0 for proximal gastrectomy, and 46.5 for pylorus preserving gastrectomy. The rates of postoperative complications of grade II or more were 9.4%. There was one case of postoperative mortality due to delayed bleeding after discharge. Old age was the only independent predictor of surgical morbidities. The 5-year overall survival rates were 90.8% in stage IB, 89.7% in stage IIA, 83.1% in stage IIB, 81.1% in stage IIIA, 67.1% in stage IIIB, 57.9% in stage IIIC, and 35.8% in stage IV. The 3-year disease free survival rates were 97.2% in stage IB, 94.1% in stage IIA, 87.2% in stage IIB, 77.5% in stage IIIA, 74.6% in stage IIIB, and 47.8% in stage IIIC. Histologic type, vascular invasion, tumor size, and TNM stage were factors associated with disease free survival rates in the multivariate analysis. Conclusion: Laparoscopic gastrectomy was safe and technically feasible for the treatment of advanced gastric cancer, with acceptable rate of morbidity and mortality.

P145 - Gastroduodenal Diseases

P147 - Gastroduodenal Diseases

A Propensity Score-Matched Comparison of Robotic Versus Laparoscopic Gastrectomy for Gastric Cancer: Short-Term Outcomes and Cost Analysis

Beyond Belsey: Complex Laparoscopic Hiatus and Diaphragmatic Hernia Repair

C.M. Huang, J. Lu, H.L. Zheng, C.H. Zheng, P. Li, J.W. Xie Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China Aims: Robotic-assisted gastrectomy (RAG) has been rapidly adopted for gastric cancer (GC) treatment. In the value (outcomes/costs)-based medicine era, costs must be considered along with outcomes. The aim of this study was to investigate whether RAG provides any significant outcome/cost advantages over laparoscopy-assisted gastrectomy (LAG) for the experienced laparoscopist. Methods: A retrospective review of a prospectively collected database identified 768 consecutive patients who underwent either RAG (n = 103) or LAG (n = 667) for GC between July 2016 and June 2017 at a large academic medical center. A 1:3 matched propensity score analysis was performed based on demographics, tumor stage, and type of surgery. We compared the short-term outcomes and hospital costs between the two groups. Results: A well-balanced cohort of 404 patients was analyzed (RAG:LAG = 1:3 match). All operations were performed successfully, and no conversions were required in either group. The mean operation times were 226.6 ± 36.2 min for the RAG group and 181.8 ± 49.8 min for the LAG group (P \ 0.001). The total numbers of retrieved lymph nodes were similar in the RAG and LAG groups (means 38 and 40, respectively, p = 0.115). The overall and major complication rates (RAG, 13.9% vs. LAG, 12.5%, p = 0.732 and RAG, 3.0% vs. LAG, 1.3%, p = 0.373, respectively) were similar. RAG was much more costly than LAG (1.3 times, p \ 0.001) mainly due to the amortization and consumables of the robotic system. Conclusions: RAG compared well with LAG despite the surgeon’s familiarity with LAG and lack of RAG experience; thus, RAG is a feasible and safe surgical procedure for GC. However, further studies are warranted to evaluate the long-term oncological outcomes and to elucidate whether RAG is cost-effective when compared to LAG.

123

D. Zanotti1, A. Botha2 1 Oesophago-Gastric Surgery, Churchill Hospital, Oxford, United Kingdom; 2Oesophago-Gastric Surgery, Guy and ST Thomas’ Hospital, London, United Kingdom

Aims: Diaphragmatic and hiatus hernias can cause mild chronic symptoms, or have an acute presentation with gastric volvulus and obstruction. Elective or emergency surgery is indicated in symptomatic patients, and nowadays is generally performed laparoscopically. Methods: We report 4 different types of hernias: a giant hiatus hernia following a gastric pull-up for recurrent congenital diaphragmatic hernia; a Bochdalek hernia in a pregnant young woman; concomitant hiatus and Morgagni hernias; a giant hiatus hernia occupying the right chest. All were approached laparoscopically, either electively on as emergency. Results: Surgery led to a resolution of symptoms in all the cases. We didn’t have any intra-operative complications. Two patients developed minor post-operative complications (chest infection). No recurrences were found during a mean follow-up of 12 months. Conclusions: Trans-abdominal laparoscopic approach is a safe and feasible approach to all cases of symptomatic hiatus and diaphragmatic hernia.

Surg Endosc

P148 - Gastroduodenal Diseases

P150 - Gastroduodenal Diseases

Technique of Esophagojejunostomy Using OrVil After Laparoscopy Assisted Total Gastrectomy for Gastric Cancer

Single Incision Laparoscopic Intra-gastric Resection for Proximal Gastric Gastrointestinal Stromal Tumor is Feasible

S. Sakuramoto, K. Aratani, M. Chuman, M. Kasuya, H. Sugita, Y. Miyawaki, H. Sato, K. Okamoto, S. Yamaguchi, I. Koyama

W.C. Fan

Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Japan Introduction: During esophagojejunostomy using a circular stapler after laparoscopy assisted total gastrectomy (LATG), placement of the anvil head via the transabdominal approach proved difficult. The authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head (OrVil) via the transoral approach. Methods and Procedures: Between January 2013 and November 2017, esophagojejunostomy was performed using OrVil in 97 patients after LATG. The anesthesiologist introduced the anvil while observing its passage through the pharynx. During the anastomosis, we kept the jejunum fixed in position with a silicone band Lig-A-Loops, thereby preventing the intestine from slipping off the shaft of the stapler. Results: Esophagojejunostomy using the OrVil was achieved successfully in all patients. No other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. The postoperative complications of anastomosis were leakage in two patients and stenosis in 4 patients, in whom mild relief was achieved using a bougie. Conclusion: Esophagojejunostomy using the OrVil is a simple and safe technique.

Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan Aims: Single incision laparoscopic intra-gastric resection is a new developed minimally invasive technique for local excision of proximal gastric tumors. The aim of this study is to determine whether SILS is a feasible treatment for gastric GIST. Materials and Methods: During April 2009 to August 2017, 31 patients with proximal gastric GIST received SILS in our community hospital were reviewed. Preand post-operative variables were analyzed and collected. Results: The tumor were located at esophageal-cardiac junction (n = 7), fundus (n = 12), and high body GIST (n = 12). All the tumors were successfully excised by single incision laparoscopic intra-gastric resection with home-made glove port. Intraoperative hemorrhage is minimal. The hospitalization period (mean 4.6 days) is short. All of cut margin were free of tumor. During a follow-up length of 48.5 months, no patient developed a recurrence. Conclusions: Single incision laparoscopic intra-gastric resection is a safe procedure and can achieve good results in terms of local tumor resection, with lower recurrences rates, lower complication rates for proximal gastric GIST.

P149 - Gastroduodenal Diseases

P152 - Gastroduodenal Diseases

How to Apply Three-Dimensional Computed Tomography Simulation for Laparoscopic Lymphadenectomy Around the Splenic Hilum for Gastric Cancer

Laparoscopic Versus Open Radical Gastrectomy for Clinical T4b Gastric Cancer: A Retrospective Cohort Study

H. Sunagawa, M. Tokunagawa, A. Kaito, T. Kinoshita Gastric Surgery Division, National Cancer Center Hospital East, Kashiwa, Japan Introduction: Lymphadenectomy alongside the splenic artery and splenic hilum is one of the most difficult procedures in D2 lymphadenectomy for gastric cancer, and the wide spectrum of anatomical deviation in this area is the reason for the difficulty. VINCENTTM, an integrated software to construct three-dimensional (3D) images, enables surgeons to recognize anatomical variations prior to surgery. The aim of this study was to demonstrate the usefulness of VINCENTTM in identifying anatomical landmark structures around the splenic hilum. Material and Methods: This single-institutional retrospective study included 35 patients with upper third gastric cancer who underwent laparoscopic gastrectomy with splenic hilar lymphadenectomy between April 2012 and March 2017. 3D images of the splenic artery and vein, pancreas, and spleen were reconstructed with VINCENTTM prior to surgeries. Surgeons referred to 3D images of anatomical landmarks for lymphadenectomy alongside splenic artery before and during surgeries, and the consistency of intraoperative surgical findings with 3D images was evaluated. Short-term surgical outcomes of these patients were also reviewed. Results: Total gastrectomy (88.9%) was the most commonly performed procedure, followed by proximal gastrectomy. The median duration of operation was 316 minutes (range 246–438 minutes) and the median intraoperative blood loss was 22 g (range 0–347 g). Intraoperative findings of anatomical landmark, such as meandering pattern of the splenic artery or the positional relationship between the splenic artery and vein, was completely matched with 3D image in all patients. There were no intraoperative major vessel or organ injuries. The incidence of postoperative Clavien-Dindo grade IIIa or more morbidities and mortalities were, 8.6% and 0%, respectively. Conclusion: Surgical landmarks for lymphadenectomy alongside the splenic artery were accurately simulated using VINCENTTM. 3D images could help surgeons to perform lymphadenectomy around the splenic hilum with reduced difficulty, leading to less intraoperative organ injury.

J.A. Bueno1, Y.S. Park2, D.J. Park2, S.H. Ahn2, S.H. Min2, K.B. Park2, Y.T. Lee2, H.H. Kim2 1

Surgery, University of Santo Tomas Hospital, Manila, Philippines; General Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea

2

Background: The use of laparoscopic gastrectomy for advanced gastric cancer is still controversial because of technical difficulties, complications, and uncertainty in oncologic outcomes. This is a preliminary study that aims to compare results of laparoscopic radical gastrectomy versus open radical gastrectomy for clinical T4b gastric cancer (direct invasion of the tumor to other organ/s). Methods: Patients diagnosed with clinical T4b gastric cancer who underwent radical gastrectomy with curative intent at Seoul National University Bundang Hospital in 2014 were followed-up until 2017. Demographic data and short & long-term outcomes were taken from the hospital database and were analyzed. Results: A total of 20 patients was evaluated. Eight patients (40%) underwent open radical gastrectomy and 12 patients (60%) had laparoscopic radical gastrectomy (with 3 open conversions due to far advanced disease). All patients (100%) underwent D2 or more lymph node dissection. Ten patients (50%) had splenectomy and/or combined resection of organ/s directly invaded by tumor. Eighteen patients (90%) underwent chemotherapy post-operatively. The mean hospital stay, operative time, blood loss, number of lymph nodes obtained, time to start of diet, and time to first flatus were not significantly different between the two groups (p = 0.36, 0.35, 0.92, 0.23, 0.93, and 0.55 respectively). There were no mortalities within the perioperative period. The rates of the early (p = 0.30) and late complications (p = 0.33) ClavienDindo grade 2 or greater in the laparoscopic group were comparable to the open group. The 3-year disease free survival (p = 0.19) and overall survival (p = 0.59) were similar in both groups. There were no differences in the patterns of recurrence between the two groups. Conclusion: Based on this preliminary study, laparoscopic radical gastrectomy is comparable to open radical gastrectomy for the treatment of clinical T4b gastric cancer in terms of short & long-term outcomes, recurrence, and survival. Laparoscopic radical gastrectomy may be done as an alternative treatment for advanced gastric cancers.

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Surg Endosc

P153 - Gastroduodenal Diseases

P155 - Gastroduodenal Diseases

Our Connection Procedure for an EEATMXL Stapler and Anvil Head Using EEATM OrVilTM for Laparoscopic Total or Proximal Gastrectomy

Minimal Invasive Surgery for Advanced Gastric Cancer: 7 Years Experience of National Cancer Institute Thailand

Y. Maezawa1, Y. Rino1, N. Yukawa2, K. Kano1, T. Sato1, T. Yamada3, T. Aoyama1, T. Oshima1, M. Shiozawa3, S. Morinaga3, H. Cho4, T. Yoshikawa3, M. Masuda1

Surgical Oncology, National Cancer Institute of Thailand, Bangkok, Thailand

1

Department of Surgery, Yokohama City University, Yokohama, Japan; 2Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan; 3 Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan; 4Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan Introduction: We describe an easier technique for connecting the anvil and center rod of the EEATM OrVilTM. Surgical Technique: The bulb tip of EEATM OrVilTM was orally inserted slowly until the valve tip reached the esophageal stump. Surgeon inserted forceps grasping the anvil from the right abdomen trocar. The EEATMXL stapler (circular stapler) was inserted via the cut-off stump of the lifted jejunum or remnant stomach through the intraumbilical incision. Then, the circular stapler was held with the shaft convex. When the automated stapler and center rod were confirmed to be completely aligned, the anvil and the main unit were connected, and firing was done. Discussion: Although we did only the reversed direction of the shaft of the circular stapler in our method, this method was able to facilitate operation more.

S. Khunpugdee, H. Moungthard, C. Sirisai

Introduction: Minimally invasive surgery for gastric cancer in increasingly being performed in tertiary centers. Two main approaches utilized are laparoscopic assisted gastrectomy and totally laparoscopic gastrectomy (TLG). According to cancer site, two main approaches utilized are laparoscopic total gastrectomy (LTG) and laparoscopic distal gastrectomy (LDG). We review our 7 year experience with totally laparoscopic gastrectomy with D2 lymph node dissection as perioperative outcomes and long term therapeutic outcomes. Methods and Procedures: At our institution, MIS gastrectomy was introduced in October 2010. We routinely performed totally laparoscopic gastrectomy with D2 dissection after the first case in our experience which performed Laparoscopic assisted fashion. We retrospective reviewed our gastric cancer patients treated with MIS gastrectomy in term of perioperative outcome and long term outcomes. We excluded gastric NHL and gastric GIST. Results: From 10/2010 to 09/2017; 7 years, 31 patients underwent MIS gastrectomy for gastric tumors. No conversion to open gastrectomy and no early re-operation. We had no leakage or postoperative hemorrhage. Of these, 28 patients underwent Laparoscopic Gastrectomy with D2 lymph node dissection for adenocarcinoma. 14 patients were males and 14 patients were females. 14 patients are alive, 7 males and 7 females. 3 of these 14 patients got 5 years disease free survival. Details are shown in table. Conclusions: inimally invasive surgery for gastric cancer is feasible and safe with adequate oncological control even in local advanced gastric cancer.

P154 - Gastroduodenal Diseases

P156 - Gastroduodenal Diseases

Comparison of Different Surgical Approaches in the Treatment of Adenocarcinoma of Esophagogastric Junction

Short Term and Surgical Outcomes of Laparoscopic Endoscopic Cooperative Surgery for Gastric Submucosal Tumors

X.Z. Wangpu

T. Yazawa1, R. Sato2, T. Abe1, A. Oyama1, T. Okada1, T. Kakita1, M. Oikawa1, T. Tsuchiya2

General Surgery, Ruijin hospital, Shanghai, China Aims: To investigate different surgical approaches in the surgical treatment of adenocarcinoma of esophagogastric junction (AEG). Methods: A total of 305 patients (159 male and 146 female) diagnosed with AEG and underwent different surgical treatment were collected. Clinical data (including general condition, tumor diameter, average number of lymph node dissection, postoperative complications and average length of stay after operation, etc.) were retrospectively collected and statistically analyzed. Results: Among these patients, 43 cases were treated with single left thoracal incision, 135 cases were treated with thoracoabdominal combined approach, and 127 cases underwent transabdominal laparoscopic surgery. The average diameter of cardiac carcinomas was 3.11 ± 1.12 cm. There was no significant difference (P [ 0.05) in margin-positive rate among three groups. The average number of lymph node dissection in these three groups were 18.9 ± 5.2, 22.1 ± 6.7, and 23.5 ± 4.1, respectively (P [ 0.05). For the postoperative complications, there was no significant difference in anastomotic leakage or bleeding among three groups (P [ 0.05), while the cardiopulmonary complications in transthoracic surgery were significantly (P \ 0.05) more than that in transabdominal laparoscopic approach. Also, the mean postoperative hospital stay and total cost in the two transthoracic operation group were significantly greater (P \ 0.05) than transabdominal laparoscopic group (7.4 ± 2.1 d; 43576 ± 3465 RMB ). While there was no significant difference (P [ 0.05) in 5-year life span among three groups. Conclusions: Compared with transthoracic operation, laparoscopic approach was demonstrated to be an effective way for the surgical treatment of II and III AEG with satisfied therapeutic outcome, owing to its unique clinical advantages. However, the choice of appropriate surgical approach should be based on tumor location and general condition of patients.

123

1

Gastrointestinal surgery, Sendai city medical center, Sendai open hospital, Sendai-City, Japan; 2Gastrointestinal surgery, Sendai city medical center, Sendai City, Japan

Aim: Laparoscopic endoscopic cooperative surgery (LECS) can identify tumor location accurately and resect tumor with minimum margin. In our hospital, we introduced LECS for submucosal tumors (SMTs) with intraluminal growth type at 2013. We examined the outcome and feasibility retroscpectively. Material and Method: We underwent 27 laparoscopic partial resection for SMTs from Jun 2013 to Mar 2017. We examined 11 cases of the LECS and 16 cases of the conventional wedge resection of the stomach. Our procedures of LECS are as follows. Both mucosal and submucosal layers around the tumor are circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, seromuscular layer is perforated and dissected along the incision line by endoscopy under the laparoscopic assist. The extent of dissection is about a half of the marked area. The seromuscular layer of the remaining area is laparoscopically dissected along the incision line using an ultrasonic device. The stomach wall defect is sutured by laparoscopically to minimize gastric deformities. The procedure is terminated following endscopic confirmination of the absence of bleeding stenosis and leakage. Result: LECS needs longer operative time than conventional procedure. (LECS vs. Conventional = 240 :112 min, p = 0.0001) But amount of bleeding, postoperative stay in hospital and incidence of postoperative complecation are not significantly different between LECS and conventional procedure. Conclusion: LECS is feasible for gastric SMTs.

Surg Endosc

P157 - Gastroduodenal Diseases

P159 - Gastroduodenal Diseases

Laparoscopic Operation in the Patients with GIST

Technical Evolution and Short Term Outcomes of Laparoscopic ? Radical? Gastrectomy for Early Gastric Cancer

Y.U.V. Grubnik, O.M. Yuzvak, V.A. Fomenko Surgery Department #3, Odessa National Medical University, Odessa, Ukraine The aim of this work was to decrease the morbidity in the patient with GIST. Methods and material: For 5 years we observed 9 cases with GIST, of stomach and duodenum. Seven patients were brought to clinic with the bleeding. Two patients were brought to clinic with vomiting and compensate stenosis. In all cases we done the CT, MRT and endoscopic examinations of stomach and duodenum with biopsy. In two cases we performed endoscopic operation. In one case we successfully take off the GIST from the duodenum endoscopically. During the operation we use the endoscopic instruments. In another case, after endoscopic excision the tumor appear the bleeding which was stopped by endoscopic local heamostasis, by putting clipps on the vessels. In 7 cases the tumors were in stomach. In 4 cases we performed laparoscopic wedge resection the tumors by staplers. In 2 cases when the tumor was very big and situated in the fundus of stomach, we performed laparoscopic resection of the fundal part of stomach by using laparoscopic staplers and ‘‘Liga Sure’’ sealing. In 1 case we took off the tumor by putting laparoscopic trocars inside the stomach for instruments and for visualization tumor. After excision the tumor and took it of the stomach we sutured the holes in the stomach. Results: We have no mortality after laparoscopic operation. There were no malignisation in all 9 cases. We have 2 cases morbidity. In 1 case the bleeding from the stomach that was stopped endoscopically. In 1 case there was wound infection. Conclusion: Laparoscopic and endoscopic operations are successful methods for the curing the GIST.

I.R. Lai1, H.H. Yen2, C.C. Yeh3 1 Graduate Institute of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei, Taiwan; 2Department of Surgery, National Taiwan University hospital, Taipei, Taiwan; 3 Department of Medical Education and Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan

Background: While gaining more acceptance, the reports of using laparoscopic gastrectomy to treat gastric cancer were still limited in Taiwan. This study aims to review our experience about the technique evolution and oncological outcome of using laparoscopic distal gastrectomy in treating the patients with clinical stage I gastric cancers. Methods: A retrospective review of the patients undergoing laparoscopic distal gastrectomy for clinical stage I gastric cancers by a surgical team at a tertiary medical center of Taiwan was performed. The demographics, peri-operative parameters, surgical methods, morbidities and oncological outcomes were analyzed and compared. Results: A total of 100 patients with clinical stage I gastric cancers between October 2005 and September 2016 were enrolled. Laparoscopy- assisted distal gastrectomy (LADG) was performed in the initial 69 cases. Total laparoscopic distal gastrectomy (TLDG) was done in the following 31 cases. There was no conversion of procedures, nor surgical mortality. The surgical morbidity rate was 13%, including 3 major complications. The ratio of using Billroth I reconstruction (83.9% versus 43.5%, p \ 0.01) and the mean number of harvested lymph nodes (38.6 ± 14.8 versus 31.2 ± 15.2, p = 0.02) were both higher in the TLDG group than that of the LADG group. Two patients had recurrence of diseases (liver, local). The 3-year recurrence-free survival for all patients was 93.3%. Conclusion: These results suggested that laparoscopic gastrectomy could be performed safely and feasibly for selected patients with early stage gastric cancers. Laparoscopy-assisted distal gastrectomy is recommended as the initiated procedure to establish the demanding technique.

P158 - Gastroduodenal Diseases

P160 - Gastroduodenal Diseases

The Clinical Outcomes of Laparoscopic Distal Gastrectomy for Gastric Cancer in Elderly Patients

Accuracy and Pitfalls of Preoperative Staging Laparoscopy for Advanced Gastric Cancer

C. Kameda, R. Kawabata, T. Matsumura, C. Koga, M. Murakami, S. Noura, J. Shimizu, J. Hasegawa

T. Yamada, Y. Kawashima, K. Ehara, S. Arai, Y. Ishikawa, Y. Itoh, H. Sakamoto

Surgery, Osaka Rosai Hospital, Sakai-City, Osaka, Japan

Division of Gastroenterological Surgery, Saitama Cancer Center, Saitama, Japan

Aim: The use of laparoscopic gastrectomy in the treatment of early gastric cancer has increased markedly following the demonstration of the safety and validity in many studies. However, the surgical indications for elderly (C 75 years of age) gastric cancer patients is difficult because the curability of the cancer and the tolerability of the surgery must be considered. This study aimed to assess the safety and efficacy of laparoscopic distal gastrectomy (LDG) for elderly patients. Method: From April 2008 to September 2017, a total of 322 cases of curative LDG were performed for gastric cancer patients with clinical T1 stage in our department (TNM-UICC). Of these, we retrospectively analyzed the surgical outcomes of 77 cases involving patients who were C 75 years of age (the elderly group) and 215 cases involving patients who were \ 75 years of age (non-elderly group). Results: Comorbidities were observed in 55 cases (71.4%) in the elderly group, and were more common in the elderly group than that in non-elderly group (p \ 0.0001). The mean operation time (245 min), mean blood loss (80 mL) and the average number of retrieved lymph nodes (31.9 nodes) in the elderly group were not significantly different from those in the non-elderly group. Postoperative complications were noted in 10.3% of the patients in the elderly group. The postoperative complications and postoperative hospital stay duration did not differ between the two groups to a statistically significant extent. There was no perioperative mortality in the elderly group. The median follow-up period of these 77 patients in the elderly group was 1096 days, 3 patients died of recurrent gastric cancer and 6 patients died from other illness. A multivariate analysis to detect predictive factors for postoperative morbidity using the following 9 clinicopathological determinants: age, gender, comorbid disease, operating time, blood loss, degree of lymph node dissection, preoperative albumin and preoperative hemoglobin revealed that no factor was significantly associated with postoperative morbidity. Conclusion: LDG was safely performed for the elderly patients in our department. Our data suggested that LDG was useful for treating elderly patients even when they had comorbidities.

Background and Aim: We performed staging laparoscopy (SL) in patients with advanced gastric cancer who are at high risk for peritoneal dissemination to avoid unnecessary exploratory laparotomy. However, we are sometimes unable to detect peritoneal dissemination during SL but regrettably find it during laparotomy. We evaluated the accuracy of SL and analyzed its pitfalls. Methods: In total 257 patients who underwent SL for advanced gastric cancer at our division between April 2001 and December 2016 were enrolled in this study. Results: Among the 215 patients who did not undergo serial open surgery on the same day, the operative time was 62.2 ± 21.3 minutes (mean ± SD, the same hereinafter). Assumed blood loss was 3.08 ± 10.1 g. A severe intraoperative adverse event (Clavien-Dindo, CGrade 3) occurred in one patient (conversion to open surgery because of bleeding). Average hospital stay after SL was 3.24 ± 2.80 days. Among the 144 patients who underwent open surgery after SL without neoadjuvant chemotherapy, the status of peritoneal dissemination was rediagnosed during open surgery, and we found peritoneal dissemination negative (P0) in 110 (84.6%) and peritoneal dissemination positive (P1) in 20 (15.4%) cases. Sensitivity, specificity, and positive and negative predictive values for P1 factor were 41.1%, 100%, 100%, and 84.6%, respectively. Among the 130 patients diagnosed with P0 during SL who did not undergo neoadjuvant chemotherapy, 110 (84.6%) had P0 and 20 (15.4%) had P1 disease during open surgery. Among these 20 patients, we found peritoneal disseminations in the omentum in 8 (40.0%), around the transverse colon in 6 (30%), in the bursa omentalis in 5 (25%), and at other locations in 5 (25%) cases. The reasons for this discrepancy were believed to be derived from insufficient procedures in 9 (45%), false-negative frozen section in 6 (30%), and a region impossible to observe (in bursa omentalis) in 5 (25%) cases. Conclusion: The accuracy of SL is satisfactory. However, close attention must be paid to identify peritoneal disseminations around the omentum and transverse colon for more accurate diagnosis. Exploring the bursa-omentalis during SL is probably invasive, and its efficacy should be evaluated in the future.

123

Surg Endosc

P161 - Gastroduodenal Diseases

P162 - Gastroduodenal Diseases

The Smart Approach to Surgical Treatment for Gastric and Duodenal GISTs Based on Preoperative EUS-Typing

Laparoscopic Correction of Perforated Peptic Ulcer: Retrospective Analysis in 103 Consecutive Patients

S.V. Dzhantukhanova, Y.G. Starkov, M.I. Vyborniy

B.M. Kang1, S.H. Lee2

Endoscopic Surgery, Vishnevsky Institute of Surgery, Moscow, Russia

1 Surgery, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea; 2Surgery, Gangdong Kyung Hee University Hospital, Seoul, Republic of Korea

Background: Surgical treatment is the treatment of choice for the resectable GISTs with objective of surgery being complete R0 resection. No need for extended resections and lymphadenectomy makes minimaly–invasive techniques the treatment of choice. Objective: To develop and demonstrate different surgical techniques of laparoscopic or endoscopic resection for GISTs based on classification of EUS-typing for optimal choice of treatment. By the ‘‘smart’’ approach we imply the approach which allows us to make a surgery less invasive and more accurate, including more functional results with no increase of complications. Material and Methods: The EUS-classification of GISTs was created based on the analysis of treatment of 80 patients with gastric and duodenal GISTs. The principles of classification included the following criteria. Location of tumor base in relation to GI layer Size of the tumor base (‘‘growing point’’) Type of growth in relation to GI lumen The EUS-typing includes Type I, Type II, Type III (a, b, c, d) tumors Optimal approach for type I Endoscopic removal of tumor by means of: Endoscopic submucosal dissection (large size) Endoscopic mucosal resection (small size) Type II Endoscopic enucleation of tumor after resection of covering mucosa Endoscopic tunneling dissection Type IIIa Endoscopic tunnneling dissection Type IIIb Laparoscopic atypical resection after gastrotomy (duodenotomy) Endoscopic tunneling dissection (advanced endoscopic surgeon and small tumor size) Laparo-endoscopic hybrid procedures Type IIIc Laparoscopic atypical (wedge) resection Type IIId Laparoscopic enucleation of tumor Laparoscopic atypical stapler resection Results: Patients with gastric and duodenal GISTs underwent laparoscopic resection – 62, endoscopic intraluminal resections – 18 patients (tunneling resection – 7, endoscopic submucosal dissection or endoscopic enucleation of tumor after resection of covering mucosa – 11) Median operation time was 150 min. Recovery was uneventful and median post-op hospital stay was 5 ± 2.4 (2–8) days. The pathology showed R0 resection in all cases. Histology and immunohistochemistry confirmed GIST. Four patients received adjuvant target therapy and were prescribed Gleevec for 1–2 years. The mean follow-up period was 42 months (range 3–74 months) with no local or distant recurrence or stenosis at the site of surgery. Conclusion: The classification of GISTs based on EUS-typing allows to select the optimal approach individually for each patient to perform surgery more accurate and less invasive.

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Aim: Perforated peptic ulcer was one of the frequently encountered, emergent situations requiring surgical intervention. Traditionally, open pyloplasty and vagotomy was recommended. Recently, laparoscopic primary closure was widely adopted. But, there were only a few studies to verify the safety and efficacy of laparoscopic surgery in perforated peptic ulcer. The aim of this study was to identify the appropriacy of laparoscopic repair for perforated peptic ulcer. Methods: From June 2006 to December 2012, total 137 consecutive patients with perforated peptic ulcer were referred to Gangdong Kyung Hee University Hospital. Among these patients, laparoscopic surgery was attempted in 103 patients. The study group was composed of 96 men and 7 women with a mean age of 49.9 years. The data of these patients were collected through review of hospital chart and analyzed retrospectively. Results: Among 103 patients, only fourteen patients were previously diagnosed with peptic ulcer through the endoscopy. Diagnostic modalities for hollow viscus perforation were CT scan in 98 patients and plain chest radiography in 5 patients. Conversion to open surgery occurred in eighteen (17.5%) patients. Operative procedures were primary closure in 96 cases, omental patch in 4 cases and others in 3 cases. Mean operation time was 88.8 minutes (SD ± 41.7 minutes). Intraoperative complication was developed in 1 patient with iatrogenic injury of gall bladder which was treated by laparoscopic cholecystectomy. Rate of postoperative complication was 12.6%. There was no mortality case. Median postoperative length of hospital stay was 7 days. Conclusion: Laparoscopic correction seems to be safe and effective in perforated peptic ulcer. To clarify these assumption, prospective comparative trial with greater number of patient was warranted.

P163 - Gastroduodenal Diseases Cholecysto-Gastric Fistulae: Is it Feasible the Laparoscopic Management? I. Karanikas, P. Siaperas, A. Ioannidis, F. Menoikou, A. Zoikas, M. Fakalou, G. Velimezis 2nd Surgical Department, Sismanoglio General Hospital, Athens, Greece Introduction: Cholecystogastric fistulae is a rare, life-threatening complication of cholelithiasis that presents a difficult challenge to the surgeon for laparoscopic management. Our purpose is to present a case that was treated in our unit laparoscopically. Methods: Four patients were admitted to our Unit for an elective laparoscopic cholecystectomy. All the patients had a history of repeated episodes of acute cholecystitis. Results: During laparoscopic procedure a cholecystogastric fistula was recognised in these 4 patients while part of the stomach was attached to the gallbladder. Following dissection the fistulae was possible to be excised in only one patient. The stomach was closed with Endo-Gia. The laparoscopic cholecystectomy was then carried on. In the other 3 patients the laparoscopic procedure was converted to open surgery due to difficulties in mobilization between the stomach and the gallbladder. All the patients had a satisfactory recovery and were discharged between the 6th and the 8th postoperative day. Discussion: Biliary fistulas occur in 3–5% of patients with gallstones, with the duodenum being the most common site of fistulation followed by the stomach. The laparoscopic correction of these fistulas is difficult depending on the local conditions, and is possible in few cases.

Surg Endosc

P164 - Gastroduodenal Diseases

P166 - Gastroduodenal Diseases

Gastrointestina Stromal Tumors (GIST) of the Stomach: Laparoscopic Approach

The Association of Postoperative Complications with Prognosis After Laparoscopic Gastric Cancer Surgery

J.S. Malo Corral, J. Hernandez Gutierrez, A. Aranzana Gomez, B. Mun˜oz Jime´nez, R. Lopez Pardo, A. Trinidad Borra´s, C. Alvaro Ruiz, P. Toral Guinea, G. Krazniqui, M.A. Morlan

T. Saito, K. Kishi, M. Mikamori, K. Furukawa, M. Ohtsuka, Y. Suzuki, M. Tei, M. Tanemura, H. Akamatsu

Cirugia General Y Del Aparato Digestivo, Complejo Hospitalario De Toledo, Toledo, Spain GIST tumors with Gastric location are an infrequent entity. Their surgical approach depends on the size, location, degree of malignancy and especially on their location, being the locations close to the cardia and the pylorus the most difficult due to the possible stenosis that may occur after resection. Proposed algorythm for resection includes: Symptomatic patients (i.e bleeding),[ 2 cm size, suspicious Endoscopic Ultrasound (EUS) Features. Aims: Demonstrate the safety and efficacy of the laparoscopic approach in this pathology. Methods: Patient is a 45 y/o male, admitted to the Gastroenterology department for upper gastrointestinal bleeding (Forrest I C) that required emergent endoscopic treatment. Further imaging studies showed a 3 cm tumor, located at the anterior wall at the level of the incisura angularis, highly suggestive of a GIST. Surgical treatment was opted due to high risk of bleeding during biopsy. Results: Complete laparoscopic approach, 5 trocars, plus 5 centimeter tumor affecting the serosa with a macroscopic appearance compatibly with a gist located from the small curvature towards the medial portion of the gastric body. Gastroesophageal junction and pylorus free of tumor. Gastrotomy was performed, individualazing the tumor with broad margins. Resection was made with utilizing Endo GIA-45 (purple load), tutorized with nasogastric Fouche´ tube #36. Insuflation and methilene blue injection were performed to insure no presence of leak. Suture line was reinforced using Vycril 3-0 sutures and omental patch. Good post-operative course, intake at the 2nd day after EGD with gastrografin, hospital discharge at POD 3. Definitive pathology report: low grade GIST tumors, CKIT +, CD34 +. Conclusions: Surgical management of gastric GIST tumors remains the initial therapy for symptomatic patients. The laparoscopic approach is a valid and safe alternative in gastric GISTs.

P165 - Gastroduodenal Diseases One Year Survival and Surgical Outcomes in Patients with Intestinal Perforation due to Lymphoma M.A. Gomez Ibarra, C.A. Thiels, P.E. Skaran, J. Bingener General Surgery, Mayo Clinic, Rochester, United States of America Aims: Recent U.S. data suggests morbidity and mortality in immune suppressed cancer patients with bowel perforation is high. Operative management can be challenging with limited success, thus some recommend non-operative treatment. Our aim is to review the 30-day post-operative outcomes and 1 year survival associated with intestinal perforation secondary to lymphoma at our institution. Methods: Electronic medical records from a single institution were retrospectively reviewed. Two search engines utilizing ICD9/10 codes for atraumatic perforation of intestines requiring urgent surgery were used to identify patient inclusion. Emergent bowel perforation was confirmed in the operative reports. Demographics, operating room (OR) time, estimated blood loss (EBL), length of hospital stay (LOHS), ASA score, use of chemotherapy and steroids, site of perforation, 30-day post-operative complications categorized by the Clavien-Dindo (CD), and dates of surgery, last follow up and death was abstracted from the identified records. Results: Between January 2006 to August 2017, 19 patients with non-Hodgkin lymphomas and perforations were identified. The most common; B-cell 14 (74%) and T-cell 2 (11%); 10 (53%) men, 9 (47%) women, mean age 65 ± 16 years, 4 (21%) started laparoscopic but converted to an open procedure, mean OR time 161 ± 87 minutes, mean EBL 372 mL ± 476 mL, mean LOHS 15 days ± 10 days, and mean ASA score 3 ± 0.73. Fifteen patients (79%) had small bowel perforations and 4 (21%) had large bowel perforations. Most common perforation sites were; 6 (32%) within the jejunum and 6 (32%) in the ileum. Eight (42%) patients were undergoing chemotherapy at the time of perforation: 4 (50%) received R-CHOP, 4 (50%) received other regimens. Five (26%) patients were on steroid therapy, 7 (37%) had a new diagnosis of lymphoma. Eight patients (42%) experienced serious complications, grade III/IV, most frequently infectious and cardiovascular complications. Four patients died (21%) as a result of sepsis, multiorgan failure, or refractory lymphoma. One year survival was 51% after perforation. Conclusion: Small bowel perforation in immune suppressed patients with lymphoma perforation carries a 21% 30-day mortality and 51% one year survival. Additional risk stratification may identify which patients benefit from surgical treatment.

Gastrointestinal Surgery, Osaka Police Hospital, Osaka, Japan Aims: The impact of postoperative complications on long-term outcome has been reported in several types of malignancies, including gastric cancer. However, it is unclear whether this concept can be applied for laparoscopic gastrectomy. This study focused on the relationship between postoperative complications and long-term outcome in gastric cancer patients with laparoscopic gastrectomy. Methods: This study included 679 consecutive patients who underwent curative laparoscopic surgery for pStage I-III gastric cancer. Patients were divided into two groups based on the occurrence of postoperative complications evaluated by Clavien-Dindo classification. Overall survival (OS) and recurrence-free survival (RFS) were compared, and a multivariate analysis was conducted to identify independent prognostic factors. Results: Postoperative complications (Grade II or higher) occurred in 82 of 679 patients (12%). The occurrence of complications was significantly associated with OS (p = 0.001) and RFS (p = 0.012) in the univariate analysis. Subgroup analysis showed that OS of patients with complications was significantly shorter in pStageI or III (p = 0.042, p = 0.003) and RFS in pStageIII (p = 0.022). Multivariate analysis identified the occurrence of postoperative complications as an independent prognostic factor for OS and RFS. Conclusions: Postoperative complications is the significant prognostic marker of recurrence and survival after laparoscopic gastric cancer surgery. Surgeons should minimize the postoperative complications to improve both short-term and long-term outcomes.

P167 - Gastroduodenal Diseases Duodenal Ulcer Induced by Hem-o-Lok Clip After Laparoscopic Cholecystectomy, a Rare and Challenging Entity M. Giovenzana, M. Barabino, E. Andreatta, R. Santambrogio, A. Pisani Ceretti, E. Opocher UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, ASST Santi Paolo e Carlo, Milan, Italy Background: Post-cholecystectomy hem-o-lokÒ clip migration (PCCM) is a rare late complication. A part from migration into the biliary tree, PCCM leads to other complications such as duodenal ulcer or clip embolism. Including our case report, we found other 12 descriptions of incorporation of surgical clips into a duodenal ulcer, two of them related to hem-o-lokÒ migration. Case report: A 77-year-old man was admitted in emergency room with a three days history of epigastric pain and vomiting. His medical history included hypertension and a laparoscopic elective cholecystectomy performed for chronic cholecystitis 3 months earlier. On physical examination, there was epigastric tenderness; just a mild leucocytosis and hypokalemia were detected at blood tests. A naso-gastric tube (NGT) was placed with drainage of 750 ml of gastric fluid. The patient was thus hospitalized and subjected to an uppergastrointestinal X-Ray study showing a threadlike appearance of the second portion of the duodenum. A CT scan demonstrated a thickening of the antrum-pyloric wall conditioning gastrectasia and a diverticulum of the second duodenal portion adjacent a surgical clip; furthermore, mild intra-abdominal free fluid and small air bubbles in right iliac fossa were described. In front of a suspect of a covered perforation of peptic ulcer we performed a conservative strategy. After one week, by enduring occlusive status, patient underwent to esophagogastroduodenoscopy (EGD) that showed a hem-o-lokÒ clip appearance at the anterior wall of the first part of the. Chronic inflammatory status conditioned an insuperable duodenal stenosis. Since conservative strategy was ineffective, an open Roux-en-Y gastrojejunal anastomosis (GJA) had been performed. Hospital stay was uneventful with discharge in 4^ post-operative day. Follow up at 18 months was regular. Conclusions: Etiology of this exceptional late event after cholecystectomy is mainly based on the anatomic proximity of the cystic duct stump to the duodenum, an inflammatory process (that represents ‘‘pabulum’’ for clip migration and duodenal erosion), and a preexisting ulcer. Conservative treatment (PPI and/or endoscopic removal) is effective in 80% of cases, while surgery is rarely performed. The use of hem-o-lokÒ in laparoscopic cholecystectomy is justified in selected cases because of their efficacy despite the rarity of their migration.

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Surg Endosc

P168 - Gastroduodenal Diseases

P170 - Gastroduodenal Diseases

Effect of Surgical Resection on Prognosis in Gastric Neuroendocrine Tumors

Risk Stratification According to the Total Number of Factors that Meet the Indication Criteria for Radical Surgery in Patients with Gastric Cancer

¨ . Firat, K. Erozkan, T.O ¨ . Sezer, S. Ersin B. Demir, O General Surgery, Ege University, Izmir, Turkey

K. Shoda1, T. Kubota1, J. Hamada2, T. Kosuga2, H. Konishi2, A. Shiozaki2, H. Fujiwara2, K. Okamoto2, E. Otsuji1

Carcinoid tumors are known to cause several pathological pictures by various peptides they produce, providing the continuity of disease. Initially these tumors have been considered as biologically and clinically more positively progressing tumors unlike adenocarcinomas. However, upon biological and clinical differences from pulmonary and intestinal carcinoids have been identified, these tumors have begun to be evaluated as a special type of a very different tumor family. The objective of this study is to perform a survival analysis in line with the WHO 2010 staging system in patients undergone surgical resection in our clinic with the diagnosis of Gastric NET and to investigate pathological factors affecting prognosis. Data of 27 patients who underwent surgical resection in our clinic due to the diagnosis of gastric NET between 2001 and 2015 were reached from information system of the hospital and screening of the file archives. According to the type of operation; 11 patients (40.7%) had undergone total gastrectomy, 9 (33.3%) subtotal gastrectomy (SG) and 7 (25.9%) Wedge resection (WR). Gastric NETs are rare tumors which typically show an inactive and slow growing course. However, all of them are potentially malignant and can metastasize to liver independently from lymph node metastasis status. Five-year survival is 93% in Type-1 NETs, while this rate is reported as 50% for Type-3. Prognosis may considerably vary in gastric NET patients. There are dramatic differences in prognosis between low-stage malignancies or those giving no symptom and NEC or high-stage malignancies. Good prognostic indicators include being confined to mucosa and submıcosa, absence of vascular invasion, a tumor diameter \ 1 cm, absence of endocrine syndrome and being associated with CAG or MEN1-ZES. Keyword: Gastric Neuroendocrine Tumors, Gastric Resection, Prognosis

Background: Extended indications for endoscopic resec- tion for early gastric cancer (EGC) have been widely accepted. However, according to current guidelines, additional gastrectomy with lymph node dissection (LND) is recommended for patients proven to have potential risks of lymph node metastasis (LNM) on histopathological findings. The aim of this study was to elucidate the risk stratification of outcome and LNM according to the number of factors that meet the inclusion criteria for radical LND for possible LNM (LNM risk factors) in patients with negative endoscopic resection margin. Methods: We enrolled 511 EGC patients whose tumors did not meet the absolute or extended indications for endoscopic resection, and investigated the risk stratification of prognosis and LNM according to the total number of LNM risk factors. Results: Recurrence-free and overall survival rates were significantly higher in patients with fewer LNM risk factors for surgical indication (p = 0.0274 and 0.0002, respectively; log-rank test), and the total number of LNM risk factors and frequency of LNM were significantly correlated (p \ 0.0001; Kruskal–Wallis test). When only one LNM risk factor was satisfied, the LNM ratio was 0.58% (1/173, 95% confidence interval 0.01–3.18). Conclusion: The present study suggested the possibility of using further minimally invasive treatment strategies based on the total number of LNM risk factors.

P169 - Gastroduodenal Diseases

P171 - Gastroduodenal Diseases

The Advantage over Traditional Laparoscopic Nissen-Rozet Fundoplication on for Treating Hiatic Hernias on the Results: Of Our Clinical Experience

Adult GIST with Intussusception: Laparoscopic Assisted Management

V. Tedoradze, D. Menabde, A. Baziak, K. Kashibadze

1

Department of Surgery, Republican Clinical Hospital of Batumi, Batumi, Georgia Recently there has been a significant increase in patients with reflux esophagitis and hiatic hernias around the world. However, the postoperative quality of the method of treatment of this pathology is not always satisfactory. The aim of the study is a comparison of the treatment results of laparoscopic and open fundoplication on Nissen-Rozet for treating hiatic hernias on the basis of surgical materials department Batumi Republican Clinical Hospital and City Hospital of Bila Tserkva. Work is based on a retrospective analysis of treatment of 60 patients diagnosed with hiatic hernias, which operated as laparoscopic and traditional method fundoplication on Nissen-Rozet from 2008 to 2016. Patients were divided us by 2 group.1 group of 30 patients with traditional, 2-group of 30 patients with laparoscopic access method, The operative time group 1 when there was more than 2. Group 1 was from 120 to 190 min., duration of operation group 2 on average 90–160 min. intraoperative complications and lethal outcomes were not in one of the groups of patients. Out of postoperative complication of suppuration wounds, observed 1 group of cases - 3 and 2 Group 1 cases, adhesive intestinal obstruction after a 1 months 1cases- group 1, group 2 complications are not observed and after a 6 months 1 cases- group 1, disfagia-1 group of cases - 3, group 2 complications-1cases. After operation the patients discharged from hospital for Groups 1 on day 5–6, as for group 2- on 3–4 day. The total size of surgical approaches in group 1 was 200–250 mm; In group 2 was 50–60 mm; It should be noted, that after operating interactions on the upper floor, We had laparoscopic fundoplication Nissen-Rozet with 4 thorker. As a result, the authors on the basis of above stated it conclude that laparoscopic approach showed the best clinical outcome of operations than open fundoplication Nissen-Rozet.

123

1 Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan; 2Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan

J.S. Deed1, S. Rathanaswamy2, E. Ahmad3, P. Sahadevan4 Department of Surgery, Zulekha hospital, Sharjah, United Arab Emirates; 2Department of Oncology Surgery, Zuleka hospital, Sharjah, United Arab Emirates; 3Department of Histopathology, Zuleka hospital, Sharjah, United Arab Emirates; 4Department of Radiology, Zuleka hospital, Sharjah, United Arab Emirates Introduction: Intussusception is uncommon in adult population. GIST (Gastrointestinal stromal tumor) forms only 0.04% of malignant small bowel tumors. Objective: Share uncommon occurrence of ileal intussusception with GIST in an adultLaparoscopic management of such unique condition method 28 year male presented with abdominal pain, nausea and loose stools on and off since a month. Abdominal examination was essentially normal except mild distension with exaggerated bowel sounds. Diagnosis of intussusception was clinched by contrast enhanced CT scan. Laparoscopy assisted resection of affected bowel with anastomosis was performed. Histopathology revealed low risk GIST of 3cms diameter. Regular follow-up was planned in multi-disciplinary board meeting. Results: Uneventful recovery with discharge on third postoperative day. 14 months follow-up is free of recurrence Conclusion: Intussusception though uncommon in adult may harbor GIST as lead point. Laparoscopic technique offers not only better visualization and maximal access but also planning of smaller incision for open surgical management with quick recovery

Surg Endosc

P172 - Gastroduodenal Diseases

P173 - Gynaecology

A Comparative Study of Intracorporeal Versus Extracorporeal Anastomosis During the Laparoscopic Distal Gastrectomy in Gastric Cancer Patients

Laparoscopic Simultaneous Rectopexy Conjoint with Posterior Colporrhaphy by Our Modified Ripstein Method for the Rectocele Caused by Rectal Drooping

W.H. Han1, B.Y. Amir2, B.W. Eom1, H.M. Yoon1, Y.W. Kim1, K.W. Ryu1

T. Nishida, H. Ikuta, T. Kudo, K. Yokoyama Surgery, Kasai City Hospital, Kasai City, Japan

1

Surgery, National Cancer Center, Korea, Goyang, Republic of Korea; 2Surgery, Asaf Harofe Medical Center, Tel-Aviv, Israel Purpose: Laparoscopic gastrectomy has been established as a standard treatment for early gastric cancer and is increasing recently. In totally laparoscopic distal gastrectomy (TLDG), reconstruction is performed intracorporeally, which can reduce the additional incision for anastomosis comparing to the conventional laparoscopyassisted distal gastrectomy (LADG). It has cosmetic effects as well as pain reduction to help early recovery. However, due to technical difficulties of intracorporeal anastomosis, there are few studies about postoperative outcome in TLDG. This study compared short term postoperative outcomes of TLDG versus LADG in gastric cancer. Method: A retrospective case control study was conducted on 1322 patients who underwent laparoscopic distal gastrectomy from January 2012 to June 2017 at the National Cancer Center. Postoperative shortterm outcomes were compared the differences in terms of complication and clinical course between the two groups. Pain score was measured by questioning the intensity of pain from 0 to 10 points on postoperative day 1 (POD #1) and POD #3 Result: 667 patients underwent LADG and 655 patients underwent TLDG. The postoperative pain scores were significantly lower in the TLDG comparing LADG on POD #1 (4.72 ± 1.5 vs. 5.43 ± 2.02 p = 0.002) and POD #33. (4.28 ± 1.77 vs. 5.67 ± 1.85 p \ 0.001) Estimated blood loss during operation was also significantly lower in TLDG. (60.8 ± 51.9 vs. 112.7 ± 60.7 mL p \ 0.001) There were no differences of postoperative complications between the two groups. Conclusion: Based on short term postoperative outcome in this study, TLDG is safe and feasible as well as LADG. Moreover TLDG can reduce postoperative pain and blood loss in gastric cancer surgery rather than LADG.

Aims: Trans-vaginal posterior colporrhaphy or trans-anal anterior levatoplasty had been operated for the rectocele conventionally. Trans-vaginal anterior levatorplasty, tension-free vaginal mesh, trans-vaginal mesh repair, stapled trans-anal rectal resection, trans-anal Delorme and trans-anal anterior Delorme were reported in recent years. However, the operative procedure should be changed according to the cause of rectocele. We experienced two cases of rectocele caused by rectal drooping, and operated by our modified Ripstein method. Methods: Case1 was 76-year-old female, who got rectocele 3 cm in diameter just after the trans-vaginal hysterectomy at 51-year-old, and which became 6 cm in diameter for 25 years. Case2 was 88-year-old female, who took the trans-abdominal hysterectomy at 45-year-old, got rectocele 7 cm in diameter from 75-year-old and complete rectal prolapse 3 cm in length from one month ago. Defecography showed the rectal drooping at strain in both cases, which was the main cause of rectocele. We simultaneously operated laparoscopic rectopexy conjoint with posterior colporrhaphy by our modified Ripstein method using T-shaped BARDTM mesh. In each case, mesh was sized in horizontal side 12 cm (almost 1.2 times longer than circumference of rectum to avoid rectal stenosis), short side 5 cm and vertical side 8.5 or 10 cm (to cover the rectovaginal septum as colporrhaphy). Mesh was fixed to rectum with Endo UniversalTM stapler and to sacrum with AbsorbaTackTM + Endo UniversalTM stapler. Results: In each case, operative time was 259 and 233 min., blood loss was 50 and 50 grams and postoperative stay was 13 and 9 days, respectively. There was no morbidity. Rectocele and the symptom of severe constipation were completely disappeared after the operation. Conclusions: Laparoscopic simultaneous rectopexy conjoint with posterior colporrhaphy by our modified Ripstein method was effective for the rectocele caused by rectal drooping. We show the video of the procedure.

P450 - Gastroduodenal Diseases

P174 - Gynaecology

A Novel Technique for the Splenic Ventral Lymph Node Dissection in Laparoscopic Total Gastrectomy for Upper Advanced Gastric Cancer

Preliminary Results: Of Robotic Gynecologic Surgery in Military Hospital in Bucharest, Romania

N. Ebata, Y. Ebihara, Y. Nakanishi, T. Asano, Y. Kurashima, T. Noji, S. Murakami, T. Nakamura, T. Tsuchikawa, K. Okamura, T. Shichinohe, S. Hirano

General Surgery II, Central Military Emergency University Hospital, Bucharest, Romania

Gastroenterological Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan Introduction: Splenectomy for upper advanced gastric cancer without major curvature invasion at JCOG 0110 was more invasive than survival of the spleen and the survival time was not improved. The purpose of this study was to present a novel technique for the splenic ventral lymph node dissection in laparoscopic total gastrectomy (LTG) under the concept of outside bursa omentalis approach (OBOA) for upper advanced gastric cancer. Method: The 5 patients who underwent LTG with OBOA for gastric cancer from January 2011 to August 2017 in Hokkaido University Hospital were retrospectively reviewed. Their clinicopathological characteristics and surgical and postoperative outcomes were collected and analyzed. Surgical procedures; Opening of the omental bursa, the lymph node dissection along the splenic vessels (No.11p, 11d) is advanced toward the splenic hiatus. Next, the dissection of the splenic ventral lymph node dissection (No.10) with OBOA. Results: The median duration of operation was 425 (range 296–455) min. No patients required blood transfusions. The number of dissected lymph nodes was 100 (range 20–30). There were no intraoperative complications, and no cases were converted to open surgery. Conclusions: In LTG, our novel OBOA in splenic ventral dissection (No.10) is feasible for upper advanced gastric cancer. Evaluation of a larger number of cases and longer follow-up are needed to assess the long-term outcomes of this technique.

F. Savulescu, C. Cirlan, C. Blajut, I. Budrugeac, R. Marin

Goal: Gynecologic surgery has been revolutionized in the past 30 years, especially because of laparoscopic surgery and, more recently, with the advent of robotic assisted surgery. This study describes the safety and feasibility of robotic platform as it is incorporated into a surgeon’s practice with extensive open and laparoscopic gynecologic surgical experience, but with emerging robotic experience, in a military hospital from Romania. Methods: We reviewed 21 women undergoing robotic gynecologic surgery by a single surgeon from December 2014 October 2017. Operative times (total operative time, console time, docking time) were collected prospectively. Clinical parameters, including age, estimated blood loss, body mass index (BMI), prior abdominal surgeries, procedure type, length of hospital stay, and complications, were retrospectively collected from medical charts. Findings and Results: All procedures were carried out by robotic approach. Nine procedures were performed for cancer (endometrial 5, cervical 4) and twelve procedures for benign condition (8 total hysterectomies, 3 myomectomies and one adnexectomy). All cancer patients underwent lymph node biopsy or pelvic lymphadenectomy. The median total operative time for benign hysterectomies was 98 minutes (range 63–145 minutes) and 124 minutes for malignant hysterectomies (range 98–160 minutes). We calculated the mean docking time at 18 minutes. Docking time decreased from a mean of 23 minutes for the first 10 cases at a mean of 15 minutes for the rest of 11 cases. Surgical times were longer with larger BMIs, but the console time decreased with experience regardless of BMI. Mean hospital stay was 2 days for benign cases and 4 days for malignant cases. No perioperative complications were recorded. Conclusion: The feasibility and safety of robot-assisted laparoscopy can be affirmed thanks to the numerous studies reported and this applies to most interventions in gynecology, and this is also true for our patients. With regard to the learning curve, it does not seem particularly steep for a surgeon who already has extensive experience with open or laparoscopic gynecologic procedure. We hope to continue our experience in order to provide our patients the best surgical treatment available.

123

Surg Endosc

P175 - Intestinal, Colorectal and Anal Disorders

P177 - Intestinal, Colorectal and Anal Disorders

Solitative Ulcer of Strain Treated with Sacropromontofixation

Laparoscopic Extraperitoneal Approach for Drainage of Retroperitoneal Abscess Complicating Anorectal Suppuration

N. Barros Pinheiro, A. Machado Bernard Ziegler, G. Cutait de Castro Cotti, R. de Castro Santana Arouca, J. Santos Valenciano

A.A.A.A.M Arafa

Department of Surgery, Hospital Sirio Libanes, Sa˜o Paulo, Brazil

General Surgery, AinShams University, Cairo, Egypt

The solitary rectal ulcer syndrome (SUSR) is characterized as a rare disease whose pathophysiology remains uncertain. It was first described in 1829 by Cruveilhier and his clinicopathological feature was reported in 1969 by Mandigan and Morson, where he is associated with defective disorders, internal rectal prolapse, and psychological changes. According to works about 26% of the patients are asymptomatic. When symptomatic the diagnosis can be made through physical examination, clinical history and, often, confirmed by endoscopy with biopsies. Treatment depends on the severity of the symptoms and the existence of associated rectal prolapse. According to the literature, conventional surgical options include local excision, rectal mucosectomy, retopexy, and segmental colonic resection. Currently none of the conventional surgical treatments seems satisfactory, due to recurrence rates. A 28-year-old male patient, complaining of anal bleeding at bowel movements 10 years ago. He has performed topical treatment for anal fissure countless times, but without improvement. He sought proctological care and underwent colonoscopy, in which he showed an ulcerated lesion on the anterior wall of the distal rectum. The pathology examination was compatible with solitary rectum ulcer of the rectum. Initially, it was chosen by conservative treatment with increased fiber intake, sucralfate suppositories and mesalazine, maintaining partial improvement of symptoms. Subsequent to cauterization sessions of the argon plasma ulcer, presenting clinical and endoscopic improvement for a short period. Because he did not adhere to the continuous clinical treatment, he evolved with recurrence of bleeding and mucorrhea. Further investigation with videodefecogram followed, and colorectal intussusception was diagnosed with associated mucosal prolapse. Based on this diagnosis, we chose to undergo sacro-bromontofixation. Therefore, the solitary ulcer of the rectum is a rare and difficult to treat pathology, it is important to individuate the treatment.

Aim of the study: Introducing a new approach for drainage of extensive anorectal suppuration. Methods: A 60 years old male patient with no comorbid conditions presented with persistant discharging sinus in the left ischiorectal fossa.(History of ischiorectal abscess drainage one month ago, initially drained with no clinical improvement and then patient developed septic shock so Magnitic resonance imaging of abdomen and pelvis done showed big ischiorectal collection with extension to the pelvis. So Patient was reoperated through perineal approach with wide deep incision and insertion of big tube drain at site of incision with frequent irrigation through it. Septic shock resolved and general condition improved, but tube drainage continued for one month with persistence of greenish pus with amount ranging from 70 ml to 100 ml/day. Follow up pelviabdominal computed tomograghy done showed collection retroand preperitoneal space in the right side with extension to right subphrenic area and down to the anterior aspect of right thigh. No improvement of amount of discharge in spite of systemic antibiotic according to culture and antibiotic sensitivity. Percutaneous ultrasound guided drainage failed due to thick content. Operative drainage for retro and preperitoneal collection done extraperitoneally through laparoscopic approach with complete necrosectomy and drainage of all collections. Wide tube drain left in the space and perianal drain removed. Results: remarkable improvement of pus discharge with gradual closure of perianal wound. Two weeks postoperative follow up computed tomography done and tube drain removed and perianal wound was nearly closed with no discharge. Conclusion: Anorectal suppuration can be a serious life threatening condition in case of inadequate drainage of its extension to various anatomical planes which is overlooked or unsuspected by the attending surgeon. Adequate drainage is mandatory for completed resolution of sepsis, percutaneous drainage is not effective to remove all necrotic tissues in this spaces and surgical drainage is mandatory. All previous reported cases used the open approach. Extraperitoneal drainage of retro peritoneal space using laparoscopic approach proved to be effective and superseded the open surgical approach and patient avoids the big incision needed, long hospital stay and the potential risk of wound infection which may develop.

P176 - Intestinal, Colorectal and Anal Disorders

P178 - Intestinal, Colorectal and Anal Disorders

Complications of Open and Laparoscopic Surgery for Rectal Cancer: Experience of the Kaohsiung Medical University Hospital in Taiwan

Laparoscopic Suture Versus Mesh Rectopexy for the Treatment of Complete Rectal Prolapse in Children; A Comparative Study

P.F. Yang Division of General and Digestive Surgery, Department of Surgery, Kaohsiung medical university hospital, Kaohsiung, Taiwan Aim: Surgical resection is the standard treatment for rectal cancer patients. Treatment options consist of open or laparoscopic surgery. The laparoscopic surgery have advantage over less post-operavtive wound pain, shorter hospital stay, less intra-operative blood loss, and fewer adhesions, compared with open surgery. The aim of this study is to compare post-operative complications of these two surgical choice, open or laparoscopic surgery. This study investigated the demographic and clinicopathological features of each patient. Methods: From January 2011 to June 2014, a retrospective analysis of 188 patients with rectal cancer undergoing laparoscopic or open surgery at Kaohsiung Medical University Hospital in Taiwan was investigated. The population of 188 patients was divided into 2 groups based on the surgical treatment, open (n = 153) or laparoscopic (n = 35) surgery. Results: Frequencies of complications due to postoperative infection in open and laparoscopic surgery are Anastomotic leakage (18/153, 11.8% vs 4/35, 11.5%), Wound infection (2/153, 1.3% vs 1/35, 2.8%), ureter injury (1/153, 0.7% vs zero ), acute urinary retention (1/ 153, 0.7% vs zero), fistula (1/153, 0.7% vs 1/35, 2.8%), post-operative ileus (2/153, 1.3% vs 2/35, 5.7%), respectively. There is no significant differences in anastomotic leakage, wound infection, ureter injury, acute urinary retention, fistula, post-operative ileus. Conclusion: Our study showed that no significant differences in post-operative complications between open surgery group and laparoscopic surgery for rectal cancer. We can perform laparoscopic surgery safely in patients with rectal cancer.

123

A. Yehya Mahmoud Pediatric Surgery, Alazhar University Hospitals, Cairo, Egypt Background: Rectal prolapse is a relatively common disease in children. The majority of cases are idiopathic. Surgery is indicated for persistent complete rectal prolapse. The aim of this study is to compare Laparoscopic mesh rectopexy with laparoscopic suture rectopexy as regard the technical details, the side-effects of mesh insertion behind the rectum, and to discuss early and late post-operative outcomes for both techniques. Patients and Methods: One-hundred and sixty children with persistent complete rectal prolapse were subjected to Laparoscopic rectopexy at Al-Azhahr-University hospitals during the period from October 2010 to June 2016. Patients were randomized into two equal groups for either laparoscopic mesh rectopexy or laoparoscopic suture rectopexy. The operative time, recurrence rate, post-operative constipation, and effect on fecal continence, were reported and evaluated for each group. Results: One hundred and sixty children with persistent complete rectal prolapse were the material of this study. They were 102 males and 58 females. Mean age at operation was 6.22 years. All cases were completed laparoscopically. Mean operative time in laparoscopic suture rectopexy was shorter than laparoscopic mesh rectopexy group. No early postoperative complications were encountered. Recurrence rate was one case (1.25%) in suture rectopexy group while in mesh rectopexy group it was one case (1.25%). Post-operative constipation occurred in two cases (2.5%) in suture rectopexy group and occurred in three cases (3.75%) in mesh rectopexy group. Fecal incontinence improved in 72 cases (90%) in suture rectopexy group while in mesh rectopexy group it was improved in 74 cases (92.5%) of cases. Conclusion: Although rectal prolapse may be a spot diagnosis in the first instance, more insight depth of thinking is needed because it may signify more serious underlying pathology. Both Laparoscopic mesh rectopexy and suture rectopexy are reliable methods for the treatment of complete rectal prolapse. Keywords: Laparoscopy, Rectal prolapse, Rectosigmoid redundancy, Suture rectopexy, Mesh rectopexy

Surg Endosc

P179 - Intestinal, Colorectal and Anal Disorders

P181 - Intestinal, Colorectal and Anal Disorders

The Oncologic Outcomes of IMA-Preserving Laparoscopic Lymph Node Dissection Using 3D-CT Angiography for Retal or Left-Sided Colon Cancer

Feasibility and Safety of Laparoscopic Appendectomy Performed by Resident

Y. Maeda, T. Shinohara, T. Hamada, M. Sunahara, N. Minagawa Surgery, Hokkaido Cancer Center, Sapporo, Japan

R. Yamamoto, Y. Mokuno, H. Matsubara, H. Kaneko, S. Iyomasa Surgery, Yachiyo Hospital, Anjo, Japan

Aims: The standard procedure of lymph node (LN) dissection for rectal or left-sided colon cancer remains controversial. Many laparoscopic surgeons cut the IMA (inferior mesenteric artery) at the root; however, this may cause bowel ischemia around the site of anastomosis. A technique for performing laparoscopic lymph node dissection with the preservation of the LCA or the SRA has been reported, however, the oncologic outcomes of these procedures have not been elucidated. The present retrospective analysis was conducted to evaluate the oncologic and long-term outcomes after IMA-preserving laparoscopic lymph node dissection using 3D-CT angiography. Methods: IMA preserving lymph node dissection using preoperative 3D-CT angiography was performed in 153 consecutive patients with rectal or left-sided colon cancer. The number of LNs dissected and the rates of overall and recurrence free survival were retrospectively analyzed to evaluate oncologic outcomes. Results: Laparoscopic D3 (n = 108) or D2 (n = 45) LN dissection were performed with the preservation of the LCA (left colic artery) and/or SRA (superior rectal artery). The mean number of LNs dissected in the D3 group (19.5) was significantly higher than that in the D2 group (14.6) (P = 0.0048). The median operative time was 240 minutes, and the median volume of blood loss was 16 ml. There were no treatment-related mortalities and the postoperative morbidity rate was 19%. The estimated 5-year recurrence-free survival rates of the Stage I, Stage II and Stage III patients were 100, 91 and 90%, respectively. No patients developed local or LN recurrence. Conclusions: Laparoscopic IMA-preserving LN dissection using 3D-CT angiography is an acceptable treatment strategy in patients with rectal or left-sided colon cancer.

Aims: Open appendectomy for acute appendicitis was commonly a training model for surgical residents to begin their surgical residency. Recently, laparoscopic appendectomy (LA) has been successfully adopted for appendicitis, and an opportunity of performing open appendectomy (OA) has been decreasing for residents. Surgical residents have been becoming to perform LA as their first abdominal surgery without experience of open OA. Feasibility and safety of LA without prior experience of laparotomy is controversial. We investigated surgical outcomes in LA performed by surgical residents without experience of OA. Methods: We retrospectively reviewed the records of LA for acute appendicitis from September 2009 to March 2017 in our hospital. We assigned LA to two groups according to the operator type: performed by surgical residents who had no experience of OA and surgical fellows who had 5–8 years of clinical experience with enough experience of OA but no experience of LA. We compared surgical outcomes of LA between the two groups. Results: During the study period, 130 patients underwent LA for acute appendicitis: 104 cases were operated by 5 surgical residents and 26 cases were operated by 3 surgical fellows. There were no statistical differences in age, sex, preoperative white blood cell, and complicated appendicitis rates. The median operative times (77 minutes vs. 66.5 minutes, p = 0.771), median blood loss (5 mL vs. 5 mL, p = 0.572), conversion to OA rates (1/104 vs. 1/26, p = 0.361), morbidity rates (14/104 vs. 5/26, p = 0.535), and mean length of hospital stay (5 days vs. 5.5 days, p = 0.430) were not different between the two groups. Conclusion: Laparoscopic appendectomy for acute appendicitis can be feasible and safe as first abdominal surgery of surgical residents who have no experience of laparotomy. The surgical outcomes between the two groups were not different.

P180 - Intestinal, Colorectal and Anal Disorders

P182 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Surgery for Rectal Cancer: A Single Center Retrospective Study from Prospective Collected Data. Outcomes in 474 Patients

Functional Outcome of Laparoscopic Low Anterior Resection Evaluated by Anorectal Manometry

E. Koutroumanos1, Y.V. van Molhem2 1

1st Department of General Surgery, General Hospital of Piraeus, Tzaneio, Piraeus, Greece; 2Department of General Surgery, OLV Hospital, Aalst, Aalst, Belgium Background: The aim of the present study was to estimate the effectiveness, feasibility, safety and oncologic adequacy of laparoscopic resection for rectal cancer in a single center, with an emphasis on perioperative variables and long-term oncological outcomes. Methods: From May 1995 to March 2009, 474 patients underwent non-consecutive laparoscopic surgical resection for rectal cancer. All of them had histologically proven adenocarcinoma of the proximal, mid and distal rectum. The clinical data of these patients was retrospectively reviewed from a prospectively collected computerized database at the Department of General Surgery, Onze-Lieve-Vrouwziekenhuis Hospital (OLV), campus Aalst, Belgium. All patients were followed up prospectively to evaluate complications and late outcomes. Patients with a lesion above 12 cm from the anal verge were excluded from the study. Patients are grouped by distance to the anal verge into three groups: B4 cm (200), 4–8 cm (122) and 8–12 cm (152). Results: 71.1% (337 pts) underwent a sphincter-preserving surgery and the remaining 28.9% (137 pts) had an abdominoperineal resection. LAR PME was performed in 108 pts (22.8%) and LAR TME in 229 pts (48.3%). Female: 36% (171), Male: 64% (303). 30-day mortality occurred in only one patient (0.2%). 30-day morbidity: 26.5% (126 pts). Intraoperative blood transfusion: 0.42% (2 pts). Postoperative blood transfusion: 0.84% (4pts). Mean follow-up time: 52.4 months. Lymph nodes harvested: Mean 10.1 Median 9 (1–44). pCRM positive (\ 1 mm): 6.7% (32pts). Distal margin (cm): Mean: 2.88 – Median: 2.5 (0.01–8) 63.9% received neoadjuvant radiotherapy. Anastomotic leak: 6.52% (22pts). Conversion rate: 2.1% (10 pts). Local recurrence: 4.64% (22 pts), 5-year overall survival: 67.2%, 5-year disease-specific survival: 74.4%, 5-year disease (recurrence)-free survival: 76.7% Conclusion: Our outcomes were comparable to internationally published data concerning local recurrence rate, conversion rate, perioperative complications and overall survival. Our results, clearly demonstrate that laparoscopic resection for rectal cancer is a feasible method at specialized high-volume centers. Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages.

P. Ihna´t, P. Va´vra, I. Slı´vova´, P. Ostruszka, I. Penka Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic Background: Majority of patients after low anterior rectal resection experience symptoms of bowel dysfunction, which are termed Low Anterior Resection Syndrome (LARS). These symptoms have been shown to severely impact on a patients’ quality of life. The aim of our study was to assess anorectal function after laparoscopic LAR by means of LARS score and anorectal manometry. Methods: Prospective cohort study was conducted in University Hospital Ostrava, Czech Republic. All patients undergoing laparoscopic LAR with TME within a 3-year study period (2012–2015) were assessed for study eligibility. Bowel dysfunction was assessed by LARS score and by anorectal manometry one year after the surgery. Results: In total, 65 patients were enrolled into the study and underwent analysis. Laparoscopic LAR with total mesorectal excision and end-to-end colorectal anastomosis was performed in all study patients; mean tumour height was 9.4 cm. One year after LAR/ ileostomy reversal, mean LARS score was 23.8 ± 10.8 points. Minor LARS (LARS score 21–29 points) was detected in 33.9% of patients and major LAR (LARS score C 30 points) in 36.9% of patients one year after the surgery. Anorectal manometry revealed reduced resting pressure in 50.7% of patients; squeeze pressure was within normal range in all study patients. Rectal sensitivity was significantly altered in majority of our patients – first sensation volume was reduced in 33.8% of patients, urge to defecate volume was reduced in 70.8% of patients and discomfort volume was reduced in all study patients. Rectal compliance was significantly decreased in all study patients. Conclusions: Bowel function/dysfunction presents a very important aspect of sphincterpreserving rectal resection techniques. Two thirds of patients after laparoscopic LAR experience symptoms of moderate or severe LARS. Anorectal manometry detected decreased resting pressure, decreased rectal volume tolerability and rectal compliance in patients suffering from LARS.

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Surg Endosc

P183 - Intestinal, Colorectal and Anal Disorders

P185 - Intestinal, Colorectal and Anal Disorders

Fast Recovery Program in the Laparoscopic Colorectal Surgery 1

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S. Maslyankov , V. Pavlov , M. Sokolov , K. Angelov , G. Todorov , A. Vlahova2, D. Tsoneva3 1

Second Surgery Clinic, Medical University of Sofia, Sofia, Bulgaria; Pathology Department, Medical University of Sofia, Sofia, Bulgaria; 3 Intensive Care Department, Medical University of Sofia, Sofia, Bulgaria 2

Feasibility of Wedge Resection of the Colonic Wall by Using Laparoscopic Endoscopic Co-operative Surgery to Colorectal Benign Tumor or TIS Cancer Y. Fukunaga1, Y. Tamegai2, S. Saito2, A. Chino2, S. Suzuki1, T. Nagasaki1, T. Akiyoshi1, T. Konishi1, M. Ueno1 1 Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan; 2Gastroenterology, Cancer Institute Hospital, Tokyo, Japan

Aim: The aim of this study is to compare the short term surgical outcomes of laparoscopic approach in colorectal cancer patients. Method: We evaluated the medical history records of 427 patients treated in Second Surgery of Aleksandrovska University Hospital between 2013–2016. Since the introduction of laparoscopic techniques in the department, miniinvasive approach was applied in 65 (15.2%) patients. The nasogastric tube and urine catheter usage, the day of passage restoration and the full patient mobilization were assessed. Results: 25 anterior resections, 5 intersphincteric resections, 9 abdominoperineal excisions, 11 right hemicolectomies, 9 left colectomies and 6 sigma resections were performed. The average postoperative stay detected was 5.3 and 7.6 days, respectively (P = 0.033). Nasogastric tube was left for one day in 24 (37%) cases after the operation. More than half of the patients - 39 (59%) had restored intestinal passage on the first postoperative day and 25 patients (39.5%) had flatulence on the second day. We registered full movement’s recovery between day one and four. Conclusions: We initiate high-quality surgery that result in very good short-term results. Quick recovery program added the necessary advantages to our laparoscopy colorectal patients.

Background and Aim: Some colorectal lateral spread tumors and submucosal tumors had been considered difficult resect completely and safely by endoscopic technique because of various factors. For these lesions, a newly established safe wedge resection technique approached by both laparoscopic and endoscopic procedure (Laparoscopy endoscopy co-operative colorectal surgery; LECS-CR) was previously reported. In this paper, feasibility of this technique was investigated comparing to conventional laparoscopic colectomy. Patients: Fifteen patients of difficulty of endoscopic resection, lateral spread tumor and submucosal tumor, were performed wedge resection by using laparoscopy and endoscopy since 2014 introducing the LECS-CR technique. Eighty five patients of the similar disease at the same period who underwent conventional laparoscopic colectomy were compared in terms of short-term outcomes. 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 by laparoscopic linear staplers. Results: One open conversion happened in the conventional lap colectomy group whereas no in the LECS-CR group. The mean operating time and blood loss were similar in both groups. In terms of inflammation, the max value of WBC and CRP is higher trend in the conventional lap colectomy group than the LECS-CR group. Post-operative complication over grade III according to ClavienDindo classification were recognized 2 in conventional lap-colectomy group whereas no case in the LECS-CR group, but the differences between the two groups was similar. Post-operative hospital stays of the LECS-CR group was 7 days in mean and this was significantly earlier than that of the conventional lap-colectomy group (p \ 0.049). Conclusion: LECS-CR in order to achieve one-piece resection with appropriate margin for some colonic lateral spread tumors and submucosal tumor expected for difficulty of the endoscopic resection may be feasible and less invasiveness than conventional laparoscopic colectomy.

P184 - Intestinal, Colorectal and Anal Disorders

P186 - Intestinal, Colorectal and Anal Disorders

Multidisciplinary Team for Rectal Cancer in a District Hospital: an Improvement of Outcome

A Relationship Between the Neutrophil-Lymphocyte Ratio in Acute Diverticulitis: An Added Value in the Preoperative Setting

A. Maurizi1, S. Mazzocato2, R. Campagnacci1 1

General Surgery, ASUR Regione Marche, Carlo Urbani, Hospital, Jesi, Italy; 2General Surgery, Universita` Politecnica delle Marche, Ancona, Italy Aims: In this paper the outcomes of rectal cancer patients before and after the era of multidisciplinary team was analyzed and compared. The purpose of the present study is to evaluate the value of discussing rectal cancer patients in a multi-disciplinary team. Methods: In our health institute, weekly multi-disciplinary team conferences were initiated in January 2015. Meetings were attended by surgeons, radiologists, radiation and medical oncologists and key nursing personnel. All rectal cancer patients diagnosed and treated in 2014–2015 in the General Surgery Division of the ‘‘Carlo Urbani’’ hospital in Jesi (AN, Italy) were included. Then, the data from rectal cancer patients in 2014 were evaluated, before the adoption of multi-disciplinary team and in year 2015 after the adoption of meetings. A database was created to include each patient’s workup, treatments to date and recommendations by each specialty. Analyzed variables included ‘‘Demographic variables’’, baseline carcinoembryonic antigen (CEA), the type of imaging, use of neoadjuvant chemo-radiation, restaging following neoadjuvant therapy, distance from the anal verge, operation type and use of adjuvant chemo-radiation. ‘‘Outcome variables’’ consisted in a comparison for each group between clinical and pathological stage. Results: Sixty-five patients were included in this study: thirty patients in 2014 (pre-MDT) and thirty-five patients in 2015. Demographic variables did not differ significantly between groups. Thanks to the multi-disciplinary team and the increased use of the neoadjuvant therapy, a statistically significant difference in reduction of the stage between the clinical and pathological stage in the patients of the MDT group was verified. Conclusions: The vast majority of rectal MDT decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account prior to the adoption of multi-disciplinary team. Analysis of the implementation of team decisions is an informative process in order to monitor the quality of MDT decision-making.

123

A.G. Garza Maldonado1, L.S. Salgado Cruz2, L.R. Romero Jua´rez3, S.E. Estevez Cerda1 1 General Surgery, Instituto Tecnolo´gico de Monterrey, Monterrey, Mexico; 2Colorectal Surgery, Instituto Tecnolo´gico de Monterrey, Monterrey, Mexico; 3General Medicine, Instituto Tecnolo´gico de Monterrey, Monterrey, Mexico

The aim of this study was to determine the prevalence of an elevated NLR in patients admitted with acute diverticulitis and to establish the relationship between an elevated NLR and the severity of the disease using the Modified Hinchey Classification system. This was a retrospective, observational study. The population included patients who were admitted to the emergency department in four hospitals with a diagnosis of acute diverticulitis from january 2003 to august 2017. Patients were divided into five groups according to the Modified Hinchey Classification system. NLR values were recorded upon admission and mean values were determined using the ANOVA T-Fisher, with an NLR \ 5 considered a normal value. Cut off values were determined for each Hinchey group using the ROC curve. P \ 0.05 was considered statistically significant. A total of 159 patients were included in the study, 62% were men (n = 99). Mean NLR values were 2.42 for Hinchey 0 (n = 12), 5.58 for Hinchey 1 (n = 71), 8.28 for Hinchey 2 (n = 46), 17.55 for Hinchey 3 (n = 25), and 18.43 for Hinchey 4 (n = 5). ROC curves determined the cut-off value of [ 6.9 for the Hinchey 3 group with a calculated sensibility of 92%, and[ 12.3 for Hinchey 4 with a sensibility of 80%. The overall complication rate for the surgical group was 29.5% with a mean NLR of 11.51 (p \ 0.05), with a global re-intervention rate of 16.35%, mean NLR 14.37 (p \ 0.02) and a cut-off value of [ 5.35. In conclusion, an elevated NLR (C 5) was observed in 60.8% of the target population with a mean NLR of 8.41. There was a clear association with statistical significance between an elevated NLR and acute diverticulitis that paralleled the severity of the episode. In addition, the NLR was significantly elevated in patients who developed postoperative complications, with specific relationship to the global re-intervention rate. This study raised the possibility that NLR may be of added value in the preoperative setting and may be particularly useful for in-patient monitoring when other biomarkers are costly and unavailable.

Surg Endosc

P187 - Intestinal, Colorectal and Anal Disorders

P188 - Intestinal, Colorectal and Anal Disorders

Splenic Flexure Cancer: Totally Laparoscopic or Laparoscopic Assisted, Which is the Best Approach? A Multicentre Retrospective Study

Criteria for Diverting Stoma Creation in Laparoscopic Low Anterior Resection for Rectal Cancer

U. Bracale1, G. Merola2, A. Sciuto3, F. Pirozzi3, J. Andreuccetti2, F. Pacelli1, G. Pignata2, F. Corcione4 1 Department of Surgical Specialities and Nephrology, AUOP Federico II Napoli, Napoli, Italy; 2General and Mininvasive Surgery, San Camillo Hospital, Trento, Italy; 3Department of Abdominal Surgery, Casa Sollievo della Sofferenza Research Hospital, San Giovanni Rotondo, Italy; 4Department of General, Laparoscopic and Robotic Surgery, Azienda Ospedaliera Specialistica dei Colli Monaldi Hospital, Napoli, Italy

Aim: Treatment of splenic flexure cancer represents a controversial topic; nowadays most authors seem to leave the wide resection in favour of splenic flexure resection. Two main mininvasive approach has been reported: Totally laparoscopic and Laparoscopic Assisted Resection. The aim of our study was to determine if there were advantages in short and long terms outcome for the two approach.

Methods: Using a prospective collected database, all consecutive patients, from January 2005 to April 2017, who underwent laparoscopic resection of splenic flexure for cancer were identified and included in a multi institutional analysis. The first 34 patients were treated with a laparoscopic assisted approach (Group LA) and the following 28 patients were treated with a totally laparoscopic approach (Group TL). Biometric features, intra and post-operative data were collected. Statistical analysis was performed using IBM SPSS Statistics 23. Biometric features, intraoperative and post-operative data were collected and analysed. To compare continuous variables, an independent sample T-test was performed. The Chisquare test was employed to analyse categorical data. All the results are presented as 2-tailed values with statistical significance if p values \ 0.05. Logistic regression was used to assess if comorbidities were related to post-operative complications. Kaplan Meier with Log-Rank test was used to compare the survival curves. Odds Ratio was used to estimate the risk of incisional hernia in the two groups. Results: No statistical differences about biometric features where found between. A Statistically significative difference were found in mean operative time (146.23 ± 55.63 min Group LA VS 189 ± 44.88 min Group TL, p \ 0.0001) and distal margin from the tumour (10.35 ± 2.88 cm Group LA VS 17.15 ± 8.57 cm Group TL, p \ 0.05). At mean followup of 56.12 ± 37.17 four incisional hernias were found, three of them in Group LA and one in Group TL (p = 0.402). Odds Ratio for incisional hernia was 2.41 in disagreement of Group LA. Kaplan Meier with Log-Rank analysis shows no differences in terms of survival rate. Conclusion: There are no differences between the two approach except for operative time and distal margin from the tumour. Laparoscopic assisted procedure seems to have a major risk of incisional hernia as reported by odds ratio.

A. Sadatomo, K. Koinuma, H. Horie, Y. Inoue, Y. Kono, H. Ito, K. Mori, M. Tahara, D. Naoi, Y. Sakuma, Y. Hosoya, J. Kitayama, A. K.Lefor, N. Sata Surgery, Jichi Medical University, Tochigi, Japan Aims: Diverting stoma (DS) is created to reduce morbidity and mortality associated with anastomotic leakage (AL) in patients undergoing laparoscopic low anterior resection (LapLAR) for rectal cancer. There are no evidence-based guidelines for the creation of DS in Lap-LAR. The aim of this study is to evaluate our original criteria for DS construction in Lap-LAR. Methods: One hundred nineteen patients who underwent Lap-LAR with total mesorectal excision from January 2013 to October 2017 were enrolled in a retrospective cohort study at Jichi Medical University hospital. DS was constructed based on local criteria. Absolute criteria for DS creation include: preoperative chemo-radiotherapy or chemotherapy, anastomosis within the anal canal, multiple-stage stapled rectal resection, incomplete anastomosis ring and positive air leak test (intra-operative colonoscopy). Relative criteria include male gender with large tumor, comorbid renal failure undergoing renal replacement therapy and prolonged use of corticosteroids. Postoperative rectal contrast study for clinically stable patients was not routinely performed. Results: Forty-six patients (39%) underwent DS creation in Lap-LAR. The overall symptomatic AL rate was 6.5% (3/46) in patients with DS (DS + group) and 4.1% (3/73) in patients without DS (DS- group) (p [ .05). All patients with AL in the DS- group required therapeutic interventions or re-laparotomy. Patients with AL in the DS + group did not undergo reoperation. One patient in the DS + group underwent CT-guided drainage for AL. Conclusions: The AL rates of the DS + were relatively higher compared to the DS- groups, although it did not reach statistical significant. Several patients of asymptomatic AL may be included in the DS + group. Our original criteria for DS creation are useful to select the patients with higher risk for AL. This study also indicated that the criteria for DS creation may reduce the impact of therapeutic interventions in patients with AL. Additional studies are needed to refine the criteria for DS creation.

P189 - Intestinal, Colorectal and Anal Disorders Applications of Indocyanine Green Enhanced Fluorescence in Laparoscopic Colorectal Resections C.S. Santi1, L.C. Casali2, C.F. Franzini2, A.R. Rollo2, V.V. Violi1 1 Surgery, Ospedale di Fidenza, Universita` di Parma, Fidenza (PR), Italy 2

Surgery, Ospedale di Fidenza, Via Don Enrico Tincati, Italy

Recently, Indocyanine Green (ICG) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information. The aim of our study is the application of ICG imaging during laparoscopic colorectal resections: to identify the sentinel lymph node (SLN) for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear; to assess anastomotic perfusion to reduce the risk of anastomotic leak and to identify the ureter to prevent iatrogenic injury. After tumor identification 5 ml of ICG solution (0.3 mg/Kg) is subserosal peritumoral injected. A Full HD IMAGE1 S camera, switching to NIR mode, in about 5 minutes displays fluorescence: the SLN is identified and the SLN biopsy (SLNB) is performed. When tumor is in difficult site, as hepatic or splenic flexure, 5 ml of ICG solution is intravenous injected: in 30–50 s a real-time angiography of tumor area is obtained; on this guide vascular dissection and pedicle ligation is performed. When tumor is tightly attached to the ureter, 5 ml of ICG solution is injected through the catheter allowing ureter identification. After anastomosis, another 5 ml of ICG solution is injected to confirm anastomotic perfusion. If there is an ischemic area, a new anastomosis is performed. From November 2016, 30 patients were enrolled: 8 left colectomy, 17 right colectomy, 2 transverse resections, and 3 resections of splenic flexure. In four cases, intraoperative angiography led to the identification of vascular anatomy. In one case surgical strategy was changed. In one right colectomy, ureter identification was useful to prevent injury during the dissection. In all cases the anastomotic perfusion was good. Three postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. From November 2017, 4 right colectomies were enrolled to perform, successfully, the SLNB. ICG-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. It’s recommended to facilitate the assessment of vascularization in order to perform oncological resections, to reduce the incidence of anastomotic leak, to identify the ureter and to perform the SLNB to study its clinical role on nodal status.

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Surg Endosc

P190 - Intestinal, Colorectal and Anal Disorders

P192 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Surgery for Locally Advanced Right-Sided pT4a Colon Cancer: Clinical Outcomes and Prognostic Factors

Laparoscopic Low Anterior Resection with Two Planned Stapler Fires Method for Rectal Cancer

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

K. Otsuka, T. Kimura, T. Matsuo, K. Sato, T. Hatanaka, S. Kondo, M. Yaegashi, H. Fujii, K. Takashimizu, A. Sasaki

Surgery, Kitasato University Scool of Medicine, Sagamihara, Japan

Surgery, Iwate Medical University, Morioka Iwate, Japan

Aims: The laparoscopic surgery for advanced colorectal cancer has become widely spread with demonstrated short-term benefits and long-term oncological outcomes as compared with the open surgery. There has been increasing interest in distinguishing between rightsided and left-sided colon cancer. For locally advanced right-sided pT4a tumor, however, the safety and feasibility of laparoscopic procedures remain controversial. Therefore, this study aimed to assess retrospectively short- and long-term outcomes and prognostic factors of laparoscopic surgery for right-sided pT4a colon cancer. Methods: This study group comprised 54 patients who underwent laparoscopic resection for right-sided pT4a colon cancer, excluding ones with distant metastasis from January 2004 through December 2012. The clinicopathological findings, short- and long-term outcomes, and prognostic factors in right-sided pT4a colon cancers were analyzed. Results: The median operative time was 190 minutes (105–303) with a median blood loss was 10 ml (5–180). Conversion rate was 3.7% (2/54). The median postoperative hospital stay was 7 days (5–35). 5 patients (9.3%) had postoperative complications. 35 patients (64.8%) had lymph nodes metastases. The mean harvested lymph node was 21.0. The R0 resection rate was 100% (54/54). The median follow-up time was 61 months (12–147). The 5-year OS and RFS were 63.6 and 64.5%, respectively. 19 patients (35.2%) had recurrence, and initial recurrence occurred in the liver (n = 10), peritoneum (n = 5), lung (n = 3), paraaortic region (n = 2) and locoregional region (n = 1). The multivariate analyses revealed that male (HR 3.92, 95%CI 1.39–12.02, p = 0.010), tumor diameter \ 38 mm (HR 7.37, 95%CI 2.16–28.24, p = 0.001), and vascular invasion positive (HR 6.68, 95%CI 2.09–23.70, p = 0.001) were significantly poor prognostic factors for OS. Conclusions: These results suggest that the laparoscopic surgery for right-sided pT4a colon cancer is safe and feasible, and the oncological outcomes are acceptable. Based on these presented findings and provided expertise, the patients with locally advanced right-sided pT4a colon cancer should not be excluded from a laparoscopic surgery.

Background: Anastomotic leakage during laparoscopic low anterior resection for rectal cancer is the biggest challenge for colorectal surgeons. Reports indicate that firing linear staplers several times is a risk factor of anastomotic leakage. Therefore, we usually plan to use a two-fire method followed by anastomosis with double stapling for rectal transection at our institute. Methods: Between November 2009 and September 2016, 272 consecutive patients underwent laparoscopic low anterior resection (LAP-LAR) with double stapling anastomosis for rectal cancer. We inserted a linear 45-mm stapler cartridge from the lower right quadrant port. The first transection was up to three-quarters of the rectum, and the remaining rectum was completely resected using a second cartridge. During this procedure, the intersection of the two staplers, which might otherwise be the cause of anastomotic leakage, was located in the center of the stump of the distal rectum, so it is easy to remove the intersection of rectal stump by circular stapler. Results: None of our patients were converted to open surgery. Among the 272 LAP-LAR that proceeded under a plan to use two stapler fires, three fires occurred in error only once (0.4%). Rectovaginal fistula and anastomotic leakage occurred in 1 (0.4%) and 9 (3.3%) patients, respectively, and 49 (18.0%) patients required a diverting ileostomy. Bleeding in the anastomotic region requiring hemostatic treatment did not arise. Conclusions: Rectal transection with two planned stapler fires appears safe, practical and straightforward with respect to standardization, and reduces the need for multiple linear fires and the incidence of anastomotic leakage.

P191 - Intestinal, Colorectal and Anal Disorders

P193 - Intestinal, Colorectal and Anal Disorders

Role of Laparoscopy in Redo Surgery for Fibrostenotic Crohn’s Disease

Fluorescence Guided Anastomotic Leakage Risk Reduction in Laparoscopic Left Colon and Rectum Surgery

V. Celentano, K. Flashman, F. Sagias, J. Conti, J. Khan

M.B. Sokolov1, P. Gribnev1, S. Maslyankov1, K. Angelov1, S.V. Toshev1, M. Vasileva1, M.P. Atanasova2, D. Tzoneva2, G. Todorov1

Colorectal Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom

1

Background: Over 80% of patients diagnosed with ileocolic Crohn’s disease (CD) have a surgical resection within 10 years of their diagnosis. 30 to 50% of these can have symptomatic recurrence during the first 5 years and 50 to 80% by 10 years after surgery. Up to 50% of patients undergoing surgery for CD are likely to need further operations within 10 to 15 years. These patients are typically young adults and might particularly benefit from a minimally invasive approach. However, widespread use of laparoscopy in inflammatory bowel disease has been more limited due to technical constraints: the inflammation encountered in CD is often multifocal and makes a minimally invasive approach challenging due to a thickened mesentery, as well as the potential for fistulas, abscesses, and large phlegmons. We assessed the feasibility of laparoscopic redo surgery for Crohn’s disease. Methods: Short term outcomes of patients undergoing laparoscopic surgery for recurrent anastomotic CD were prospectively evaluated. All patients undergoing open, single incision, robotic or hand assisted surgery were excluded. Primary outcomes were conversion to open surgery and overall 30-day morbidity. The indication for surgery was discussed at a dedicated IBD multidisciplinary team meeting, and preoperative assessment included colonoscopy, MRI enterography and intestinal ultrasound. Results: 41 patients were included. Median age was 45 and no mortality was recorded. There was 1 conversion to open surgery (2.4%). 30-day morbidity was 21.3%. 6 patients required readmission (14.6%), while one patient required reoperation (2.4%). There was 1 anastomotic leak (2.4%), while 3 patients had a temporary loop ileostomy at the index operation. Conclusions: Laparoscopic surgery for recurrent ileocolic CD is feasible and safe in dedicated centers.

123

Surgery, Medical University of Sofia, Sofia, Bulgaria

2

Anesthesiology and intensive care, Medical University of Sofia, Sofia, Bulgaria

Introduction: Anastomotic leakage is one of the most terrible postoperative complications, which directly contributes to increased incidence of secondary surgical morbidity and mortality rate and in cancer cases it also increases the frequency of the recurrent disease. One of the most important risk factors for leakage is the perfusion adequacy of the proximal and distal bowel segment. Materials and Methods: Prospective study of 28 patient underwent laparoscopic left colon and rectal anterior resection during January 2016 - April 2017. Use of Endoscopic Fluorescence Imaging Systems for assessing intestinal perfusion (three modalities; used contrast ICG) first- in planning the level of the proximal transection - laparoscopy and after the completion of the anastomosis. Comparative analysis of: demographic; risk profile of the anastomosis; changes of plan for the level of proximal transection; anastomotic leakage and other complications and mortality rate. Results: 23 patients (81%) were operated due to cancer and 19% (5) on the occasion of diverticular disease. The level of the anastomosis was on average 10 ± 5 cm from the line of Hilton (anal verge). Left flexure mobilisation is performed in 85% of cases. ‘‘High tie’’ ligation of IMA has been implicated in 35% of patients. The fluorescence perfusion assessment has changed surgical behavior in 5 cases - in three has adjusted the level of proximal transsection, and at 2 it is corrected a decision about protective stoma creation. There was no case of reshaping of an already completed anastomosis. It was registered one postoperative anastomotic leakage (3.8%). Relaparoscopy has been carried out by diverting ileostomy. Is was no early postoperative mortality. Discussion: Despite limited number of patients studied, the results of the application of fluorescence assessment of perfusion of the bowel segments and shaped anastomosis are comparable and support the results of PILLAR II study on the feasibility of the method and definitive clinical benefits of drastically reducing the incidence of anastomotic leakage in laparoscopic colorectal surgery. Cost savings for management of this serious complication are the economic rationale for introducing the methodology in Bulgaria also as is the a practice in developed Western European countries and the USA.

Surg Endosc

P194 - Intestinal, Colorectal and Anal Disorders

P196 - Intestinal, Colorectal and Anal Disorders

CT4B Rectal Tumors are not a Contraindication to Transanal Total Mesorectal Excision (TATME)

Does Robotic Proctectomy for Rectal Cancer Increase the Width of the Circumferential Resection Margin? A Case-Matched Comparison by the Same Surgeon

A. Torroella-Vallejo, V. Turrado-Rodrı´guez, F. de Lacy-Oliver, A. Otero-Pin˜eiro, B. Martı´n-Pe´rez, R. Bravo, D. Mombla´n, A. Ibarzabal, A. Lacy

C. Foppa, F. Coratti, P. Montanelli, T. Nelli, F. Staderini, B. Badii, I. Skalamera, G. Perigli, F. Cianchi

Gastrointestinal Surgery, Hospital Clı´nic de Barcelona, Barcelona, Spain

Department of Surgery and Translational Medicine, Florence University Hospital - AOUC, Florence, Italy

Aim: Historically, patients with cT4b rectal tumors were not candidates to minimal invasive surgery due to the technical difficulties to obtain both longitudinal but especially circumferential free margins, particularly in obese patients with big tumours or narrow pelvis. However, the advent of transanal total mesorectal excision (TaTME) has proved that oncologically safe resections may be possible using the transanal approach. We aim to evaluate patient’s outcomes by reporting three cases of locally advanced rectal cancer using a hybrid technique with Transanal Minimally Invasive Surgery (TAMIS) with Total Mesorectal Excision (TAMIS-TME), combined with a laparoscopic approach. Methods: As previously described by our group, a transanal-transabdominal approach with two simultaneous teams was performed in every case (Cecil approach). In one case, we opted for robotic assistance during the abdominal phase. Case 1: A 84 year-old man diagnosed of cT3N0 low rectal cancer in close contact with posterior prostate, who underwent neoadjuvant radio-chemotherapy with moderate tumoral response. Case 2: A 74 year-old woman diagnosed of cT4bN0 upper rectal cancer. Radiological images suggested invasion and perforation into the posterior wall of the uterus. Case 3: A 67 years old man diagnosed of locally advanced low rectal cancer T4bN2 affecting pelvic muscles, mesorectal fascia and prostate. Neoadjuvant therapy with moderate tumoral response. Results: Case 1: A TaTME with laparoscopic assistance was performed, with resection of the right seminal vesicle and terminal colostomy due to previous fecal incontinence. No intraoperative incidences. Case 2: TaTME with robotic assistance during the abdominal phase, hysterectomy with double ooforectomy was performed. No intraoperative incidences. Case 3: A transanal Miles procedure with total prostatectomy was performed. Complete section of the left ureter that required reimplantation and bladder perforation with primary repair were intraoperative complications. Conclusion: Short and mid-term results of patients with rectal cancer treated by TaTME are comparable to laparoscopy and open surgery. Pathologic outcomes have been described as better than those of laparoscopy. Laparoscopic approach of cT4b rectal cancer is controversial due to higher rates of circumferential resection margins. In our experience TaTME seems feasible and safe in cT4b tumours even though intraoperative complications may be present.

Aims: The literature has shown that robotic proctectomy for rectal cancer may result in wider circumferential resection margins (CRM) when compared to its open and laparoscopic counterpart. The aim of the study was to compare the impact of robotic proctectomy for rectal cancer on the width of the CRM with that of matched open and laparoscopic cases performed by the same surgeon. Methods: The first 40 unselected consecutive patients with rectal cancer undergoing robotic proctectomy by one surgeon were prospectively collected during 3 years. Patients undergoing open or laparoscopic proctectomy were matched for gender, body mass index (BMI), and tumor distance from the anal verge. Rectal cancer was defined as adenocarcinoma within 12 cm from the anal verge on rigid proctoscopy. CRM in mm and the quality of total mesorectal excision were assessed by pathologists blinded to surgical access. Results: Age (p = 0.60), gender (p = 0.5), BMI (p = 0.40) ASA class (p = 0.33), POSSUM Score (p = 0.68), comorbidities (p = 0.42), previous abdominal surgery (p = 0.95), tumor height (p = 0.10), neoadjuvant chemoradiation (p = 0.75), ileostomy (p = 0.78), resection type (0.78), diet (0.47), 1st bowel movement (p = 0.50), length of hospital stay (p = 0.42), complications (p = 0.36), reoperations (p = 0.80), reinterventions (p = 0.52), readmissions (p = 0.34), distal margins (p = 0.09), TME quality (p = 0.15) and pathology stage (p = 0.33) did not differ among the 3 groups. OR time was longer in the robotic group (p \ 0.0001) with a trend to be shorter during the surgeon’s learning curve. The number of harvested nodes and the lymph node ratio were significantly better with the minimally invasive (robotic or laparoscopic) approach (p = 0.001). The CRMs were significantly wider in robotic patients (p = 0.026). Conclusion: A surgeon’s learning curve in robotic proctectomy for rectal cancer in unselected patients resulted in wider CRMs as compared to matched open and laparoscopic cases performed by the same surgeon. This result can impact on patients overall survival and disease free survival since according to our still unpublished data the CRM width is an independent prognostic factor for overall survival and disease free survival at 5 years follow-up.

P195 - Intestinal, Colorectal and Anal Disorders Transanal Total Mesorectal Excision in Lower Rectal Cancer: Comparison of Short-Term Outcomes with Conventional Laparoscopic Total Mesorectal Excision Y.W. Chen1, T.C. Chang1, Y.T. Chen1, K.T. Kiu2 1

General surgery, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; 2Coloractal Surgery, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan Background: Transanal total mesorectal excision (TaTME) is a innovative surgical technique to treat rectal cancer and to get good-quality specimens. This study was aimed to investigate the clinical results and perioperative and pathological outcomes of TaTME in lower rectal cancer treatment in comparison with laparoscopic total mesorectal excision (LaTME). Methods: During January 2014 to May 2017, all consecutive patients with lower rectal cancer who underwent TaTME were identified. This cohort study was matched for age, gender, American Society of Anesthesiology (ASA) score, and clinical staging with a cohort of patients who underwent conventional LaTME. Results: The total of 46 patients was analyzed in both groups. There were no significant differences in baseline characteristics between the groups. The estimated blood loss, duration of operation, and postoperative complications were also not different between both groups. As regards pathological outcomes, no patients with circumferential margin (CRM) \ 1 mm were observed in the TaTME group compared to 4 patients with CRM \ 1 mm in the LaTME group (P = .037). Conclusion: TaTME is a safe and feasible procedure in this matched case–control study. TaTME had better pathological outcomes with CRM uninvolvement compared with laparoscopic surgery.

P197 - Intestinal, Colorectal and Anal Disorders Laparoscopic Splenic Flexure Mobilization in Sigmoid and Rectal Resection: A Systematic Review and Meta-Analysis of Observational Studies HJ Lee, D.E. Popa, A. Fingerhut, S. Uranues, L. Boni, M. Gachabayov, R. Bergamaschi Division of Colorectal Surgery, Westchester Medical Center, Valhalla, United States of America Background: There is no consensus in the literature whether splenic flexure mobilization (SFM) should be performed selectively or routinely for sigmoid and rectal resections. Objective: The aim of this study was to evaluate the impact of splenic flexure mobilization on anastomotic leak and surgical site infection rates in sigmoid and rectal resection. Data Sources: Scopus, MEDLINE and Pubmed databases. Study Selection and Interventions: Anastomotic leak and surgical site infection were the primary endpoints. Inclusion criteria were clinical studies comparing laparoscopic SFM to non-SFM during sigmoid and rectal resections. Non-comparative studies and studies comparing open or robotic SFM, and non-clinical studies were not included. Main Outcome Measures: Statistical heterogeneity and between-study variance were assessed using I2 and Tau2 statistics, respectively. A random-effects model was used for variables with heterogeneity exceeding 50%. Results: Six studies with 12,790 patients were analyzed including 5,089 SFM and 7,701 non-SFM. The overall bias risk was found to be high. No significant difference was found in anastomotic leak rates when SFM patients were compared to their non-SFM counterparts [OR(95%CI) = 0.96 (0.50–1.82); p = 0.903; number needed to treat (NNT) = 98]. SFM patients had longer operating time [OR(95%CI) = 4.84 (1.39–16.80); p = 0.013] and increased SSI rates when compared to their non-SFM counterparts [OR(95%CI) = 1.21 (1.09–1.35); p \ 0.001; NNT = 29]. Superficial incisional SSI rates were significantly higher in SFM patients [OR (95%CI) = 1.29 (1.14–1.47); p \ 0.001; NNT = 53], whereas there was no significant difference found in organ/space SSI rates. Limitations: Lack of standardized definition for splenic flexure mobilization, low quality and high risk of bias of included observational studies. Conclusion: This systematic review found that laparoscopic SFM was not associated with significantly decreased anastomotic leak rates. SSI rates were significantly increased in patients undergoing laparoscopic SFM. This favors individualized decisions rather than routine implementation.

123

Surg Endosc

P198 - Intestinal, Colorectal and Anal Disorders

P200 - Intestinal, Colorectal and Anal Disorders

Impact of Robotic Learning Curve on Circumferential Margin and Quality of Total Mesorectal Excision in Rectal Cancer

The Role of Sentinel Lymph Node in Colon Cancer Evolution. Maintenance of the Results: After More Than 5 Years of Follow Up

A. Chudner, C. Tarta, M. Gachabayov, R. Bergamaschi Division of Colorectal Surgery, Westchester Medical Center, Valhalla, United States of America

I. Go´mez1, L.L. Pallare´s1, C. Balague´1, N. Dominguez-Agustı´n2, C. Martinez1, J. Bollo1, P. Herna´ndez1, E.M. Targarona1 1 General and Digestive Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; 2Pathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Purpose/Background: A beneficial impact of robotic proctectomy on the depth of the circumferential resection margin (CRM) is expected due to the robot’s articulating instruments in the pelvis. There are however concerns about a detrimental impact of robotic proctectomy on the quality of total mesorectal excision (TME) due to the lack of tactile feedback. The aim of this study was to assess how CRM and TME quality are affected by the surgeons’ learning curve. Methods/Interventions: Individual patient data of robotic proctectomies for resectable rectal cancer performed by 5 internationally recognized expert surgeons were pooled. Learning curve was defined as the number of cases needed before reaching competency and included learning phase (LP) and plateau phase (PP). CRM was histologically measured by pathologists in mm. TME quality was macroscopically assessed by pathologists and classified as complete, nearly complete or incomplete. Statistical analysis was carried out using SPSS software (version 18: SPSS Inc., Chicago, IL, US). T-test and Chisquared tests were used to compare continuous and categorical variables, respectively. P-value less than 0.05 was considered significant. Results/Outcome(s): Data on 235 patients were available. 83 LP patients were comparable to 152 PP patients for age (p = 0.2), gender (67.5% vs. 65.1% males; p = 0.72), BMI (p = 0.82), ASA score (p = 0.86), previous abdominal surgery (p = 0.923), stage (p = 0.17), neoadjuvant chemoradition (p = 0.13), distance of tumor from anal verge (5.8 ± 4.4 vs. 5.5 ± 3.3; p = 0.56). TME quality was significantly improved in PP patients as compared to LP patients (73.5%:10.8%:4.8% vs. 92.1%:5.2%:2.6%; p \ 0.001) (Fig. 1A). CRM did not differ (7.7 ± 11.4 mm vs. 8.4 ± 10.3 mm; p = 0.62) (Fig. 1B). Conclusions/Discussion: While the circumferential resection margin was not affected by the surgeons’ learning curve, the quality of total mesorectal excision significantly improved during the surgeons’ plateau phase. This study confirms that lack of tactile feedback in robotic surgery entails a learning curve.

Objective: Between 2008 and 2011, 101 patients underwent laparoscopic surgery of colon cancer, with conventional lymph node study (CD) and use of the sentinel lymph node technique, and the correlation between the presence of micro metastasis and the recurrence of their disease were studied. Initially, data were obtained after a mean follow-up of 38 months, obtaining a recurrence rate of N0 patients by conventional study with GC- of 7% vs. 22% in the GC + group. The objective was to determine if the results obtained are maintained in the long term. Methods: Follow-up of patients with laparoscopic colon surgery who underwent sentinel lymph node detection was performed for an average of 70 months (minimum 60 months).Recurrence cases were identified by differentiating the group that presented micro metastases detected by the sentinel lymph node technique from those that were negative and a new calculation was made of the recurrence rate in both groups. Results: The overall recurrence rate in the group of patients evaluated was 17.39% (16 patients). In the case of patients with conventional negative study and GC- was 10.7% (7 patients). In the case of patients with conventional negative study but with GC + it was 33.3% (3 patients). In the case of patients with both positive results (EC + GC), the recurrence rate was 33.3% (5 patients) and recurrence was observed in a patient with CD + and CG-. Conclusions: The results in the long-term follow-up of patients N0 by conventional lymph node study with GC + seem to maintain the tendency to present a higher percentage of recurrences, arriving at being equated with patients with both positive results, which could lead to changes in the indications of adjuvant treatment in colon cancer.

P199 - Intestinal, Colorectal and Anal Disorders

P201 - Intestinal, Colorectal and Anal Disorders

Health Economic Evaluation of Laparoscopic Versus Open Surgery as Treatment for Colorectal Cancer

Laparoscopic Right Colectomy - Complete Mesocolic Excision, D3 Lymphadenectomy, Intraoperative Fluorescence to Assess Anastomosis Perfusion

J. Gehrman1, E. Angenete1, I. Bjo¨rholt2, E. Lese´n2, E. Haglind1 1

Dept. of Surgery, Inst. of Clinical Sciences, SSORG, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; 2Health Economics, Nordic Health Economics AB, Gothenburg, Sweden Aim: Laparoscopic surgery for colorectal cancer has been shown in clinical trials to be effective regarding short-term outcomes and oncologically safe. The aim of the study was to compare cost and clinical effectiveness between laparoscopic- and open surgery for colorectal cancer in a Swedish patient cohort operated on during 2013–2014. Methods: The cohort was retrieved from the Swedish ColoRectal Cancer Registry. Clinical effectiveness and resource use and unit costs were derived from this and other sources with nationwide coverage. The study period was 2013 and 2014 with one year follow-up after index surgery. Exclusion criterion comprised cT4-tumours. Clinical effectiveness was estimated in a composite endpoint of all-cause reoperations, readmissions and deaths up to 3 months. For the remaining 9 months of follow-up, only reoperations, readmissions and deaths predefined as related to the primary surgery were included. Costs included reoperations, readmissions and sick leave and were estimated for both the health-care and societal settings. Multivariable regression analyses were used to adjust for differences in baseline age, sex, tumour-stage (cTNM), tumour location and ASA-grade, between groups. Results: The cohort included 7797 patients who underwent colorectal cancer surgery: 6060 patients in the open surgery group and 1647 patients in the laparoscopic group. Adjusted mean difference in clinical effectiveness was 0.22 events (95% confidence interval: 0.12 to 0.33) in favour of laparoscopic surgery. Adjusted mean difference in cost was €4995 (95% confidence interval: 2166 to 5336) from the societal perspective and €3549 (95% confidence interval: 2183 to 4915) from the health care sector, both in favour of laparoscopic surgery. The main cost driving factor was reoperations. Conclusion: Laparoscopic surgery for colorectal cancer surgery was more effective and less costly than open surgery in a Swedish national cohort of patients.

123

J. Moravı´k, J. Rejholec Surgical Department, Krajska´ zdravotnı´ a.s. - Nemocnice Decı´n o.z., Decı´n, Czech Republic Introduction: Sharp dissection with the principles of total mesorectal excision described by Heald is already widely accepted. The right colectomy has the same principle – total mesocolic excision, described by Hohenberger with D3 lymphadenectomy. The good perfusion of anastomosis is one of the most important factors in the healing of anastomosis. Methods: To improve oncological results, it is important to standardize lymphadenectomy with CME. CME presents a sharp dissection in the embryological layers, preserving the visceral fascia of the mesocolon. D3 lymphadenectomy in the right colectomy present lymph nodes along the VMS, AMS, pancreas head and Henle´s gastrocolic truncus. This more radical operation can bring more complications, higher morbidity. Indocyanine green enhanced fluorescence can assess bowel perfusion during laparoscopic colectomy and this perfusion control can prevent anastomosis insufficiency. Results: We present a right colectomy done laparoscopically adherent to the principles of CME and D3 lymphadenectomy. Medio-lateral preparation, principles of CME, preserving the visceral fascia of the mesocolon, as well as parietal fascia of the retroperitoneum. Lymph node harvest – D3 lymphadenectomy. At the end laparoscopic intracorporeal anastomosis and intraoperative perfusion assessment of anastomosis using indocyanine green enhanced fluorescence. Conclusion: Metastasis to the central lymph nodes is described in 8% of patients with T3– T4 tumors. This is associated with a shorter rate of survival. Removing this lymph nodes can improve the rate of survival, like liver and lung metastasectomy. Laparoscopic D3 lymphadenectomy with CME is a safe method that produces good results. Intraoperative indocyanine green enhanced fluorescence can assess bowel perfusion and this control can prevent anastomosis insufficiency due to poor perfusion.

Surg Endosc

P202 - Intestinal, Colorectal and Anal Disorders

P204 - Intestinal, Colorectal and Anal Disorders

Diagnostic and Therapeutic Management of Chronic Small Bowel Obstruction. Laparoscopic Resection of Small Bowel Carcinoid

Clinical Prospect for Laparoscopic Closure of A Temporary Loop Ileostomy

K. Ali, K. Shalli

Y. Kita, S. Mori, K. Tanabe, Y. Uchikado, T. Arigami, M. Sakoda, A. Nakajo, K. Maemura, S. Natsugoe

General Surgery, Wishaw General Hospital, Lanarkshire, United Kingdom Aim: Neuroendocrine tumors (NETs) of gastrointestinal tract are rare and slow growing tumors but annual incidence has increased to 40 to 50 cases per million due to better diagnostic tools. NETs of small bowel are usually diagnosed in sixth decade of life.20% have liver metastasis and present with carcinoid syndrome. We present an interesting case of chronic small bowel obstruction admitted as an emergency. Methods: A 62 years old female was referred with 6 weeks history of worsening abdominal pain and distension along with a weight loss of 2 stones. Full routine investigations and CT scan was done followed by a diagnostic laparoscopy and small bowel resection. Results: CT scan confirmed dilated small bowel loops with a transition zone in left half of the abdomen and enalrged nodules in that area. Diagnostic laparoscopy showed a 7 cm stricture in the small bowel and a large mass in the mesentery of the small bowel. Resection and anastomosis was performed and patient made a good post op recovery. Histopathology of the specimen showed a completely excised 3 cm Grade 1 well differentiated low grade neuroendocrine carcinoma with a metastatic deposit in the mesentery and 6 out of 36 lymph nodes (pT4N1). Perineural and lymphovascular invasion was identified. Biochemistry reported patient having raised urinary 5HIAA. MRI liver and octreotide scan done later picked up a liver deposit. Conclusion: Small bowel tumors correspond to 1–2% of all gastrointestinal malignancies of which jejunal and ileal NETs are upto 0.7%. There is no gender preference in such tumors. Most are [ 2 cm at the time of diagnosis and are non functioning but 1 in 5 have liver metastasis and carcinoid syndrome due to its hormonal manifestations. Characteristically midgut tumors secrete serotonin and have elevated urinary 5HIAA. Patients often describe flushing of face and trunk lasting only a few minutes but occur several times a day. They also have explosive watery diarrhea. 5 year survival is predicted to be between 36 to 65% depending upon metastasis. Our case was interesting as symptoms were vague. CT was suspicious but not diagnostic. Laparoscopy, on the other hand, was not only diagnostic but therapeutic at the same time.

Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University, Kagoshima, Japan Aims: In closure of stoma, small working space and adhesion disturbed precise surgical procedure. We formulated and introduce new technique, laparoscopic closure of a temporary ileostomy. Moreover, we evaluated it comparing with conventional method. Methods: 6 patients with informed consent underwent this new procedure for closure of a temporary loop ileostomy at the present, and compared with conventional method with 9 cases from 2015 and 2017. The short-term outcomes were evaluated retrospectively. After Institutional Review Board permitted, this surgical procedure was performed. After a 12-mm trocar for 5-mm flexible scope was inserted avoiding scar which used previous laparoscopic surgery and pneumoperitoneum, two 5-mm trocars ware placed which worked by operator mainly. It is the priority work to dissect adhesion around arising ileum and then, a liner staler was inserted both orifices of loop stoma precisely and applied 2 times. Eventually, both oral and anal side of loop ileum was cut by liner staler where just under the abdominal wall. It is necessary to avoid the triple overlap of staple line and residual mesenterium was treated by some proper surgical device. Eventually, the arising stoma was removed by both intra-abdominal cavity and cutaneus approach. Results: This new technique was evaluated regarding as the clinical parameter and shortterm outcomes consist of bleeding volume, operation time, postoperative complication and hospital stay comparing with past method. There is no difference significantly abut each factor. Conclusion: Laparoscopic closure of a temporary loop ileostomy may have potential as new and substitute surgical procedure.

P203 - Intestinal, Colorectal and Anal Disorders

P205 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Complete Mesocolic Excision for Middle Transverse Colon Cancer by Infra-Colic Central Approach

Minimally Invasive Surgery In Rectal Cancer Treated with ShortCourse Radiotherapy Combined with Neoadjuvant Chemotherapy and Delay Surgery

Y. Xiao, J.Y. Lu Colorectal Surgery, Peking Union Medical College Hospital, Beijing, China Background: Laparoscopic techniques have been fully developed in surgeries for colorectal cancers. However, laparoscopic surgeries for transverse colon cancer have been rarely reported, which is most likely due to the low incidence and the diversities of the laparoscopic approaches. Objective: To evaluate the feasibility of laparoscopic middle colic vessel-priority dissection by central approach at the inferior border of pancreas for middle sited transverse colon cancer. Methods: A single-center retrospective study was conducted in a colorectal surgery division at a tertiary hospital in Beijing. The data from 20 patients with middle sited transverse colon cancers from 2012 to 2016 were selected. The feasibility and safety were measured by the terms of intraoperative and postoperative outcomes, postoperative complications, etc. Results: The average age of the 20 patients was 56.5 ± 13.1 years, and average BMI was 24.3 ± 2.9. All patients underwent laparoscopic procedure without conversion to open surgery. The patients were staged as pT3-4N0-2. Dissection of infra-pyloric vessels and detachment of vascular arcade from the greater curvature of stomach were depend on preoperative CT staging and intraoperative finding. The centrally approached procedure had an average operation time of 181.1 ± 51.1 min, and an average intraoperative bleeding of 55 ± 41.5 ml. There was no death within 30 days after surgery. Postoperative complications, as grade II by Clavien–Dindo classification, occurred in 2 patients (10%). The 3-year disease-free survival rate and overall survival rate were 65.7% (95% CI: 40.2%-91.2%) and 78.4% (95% CI: 55.7%-100%), respectively. Conclusion: The central infra-colic approach in laparoscopic complete mesocolic excision of middle sited transverse colon cancer is feasible and safe. Keywords: Laparoscopy; Complete mesocolic excision; Transverse colon cancer.

Y.L. Lai Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan Introduction: Radiotherapy has been proved to reduce the risk of local recurrence in rectal cancer. Pathological complete remission rate usually indicates better oncological outcome. The optimal combination with radiotherapy fractionation, period between radiotherapy and use of neoadjuant chemotherapy options all were widely discussed to increase complete remission rate. We aimed to study the effect of short course radiotherapy combined with neoadjuvant chemotherapy followed by delayed surgery. Method: This is a single institute, prospective, observational phase II study. All patients with biopsy proven adenocarcinoma of rectum were offered treatment protocol includes short course radiotherapy (5*5 Gy radiation dose) with surgery delayed after 10–12 weeks, interwined with neoadjuvant chemotherapy (mFOLFOX-6 or oral Xeloda) during waiting period. All types of surgery method were provided to patients including open, minimally invasive surgery, MIS, (laparoscopic or robotic surgery). Here we discuss surgical parameters, complications as well as pathological outcomes. Results: Between Jan. 2016 and Nov. 2017, 39 patients of locally advanced rectal cancer received this treatment plan. There are 20 male and 19 female patients with mean age at 54.56 years-old (36–78 years-old). The distance of tumor from anal verge was distributed in to three groups 0–5 cm, 5–10 cm and 11–15 cm (23:16:0). The average waiting time after radiotherapy to surgery is 74 days (48–142 days). All patients in this study underwent minimally invasive surgery (either laparoscopic or robotic surgery) and the conversion rate is 5.1% (2/39, all in laparoscopic surgery). All patients received radical surgery with curative intent except one. The mean operative time is 191 minutes (120–300 minutes). The mean hospital stay is 9.48 days (4–22 days) and re-operation rate is 2.56% due to internal bleeding. The pathological complete remission rate is 12.8% (5/39) and the circumferential resection margin positive rate is 15.4% (6/39). Conclusion: Short-course radiotherapy combined with neoadjuvant chemotherapy and delay surgery for locally advanced rectal cancer could be performed by MIS and the pathological complete remission rate is comparable to those with current standard treatment. However, long-term oncological outcome is still warranted.

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Surg Endosc

P206 - Intestinal, Colorectal and Anal Disorders

P208 - Intestinal, Colorectal and Anal Disorders

Transanal Total Mesorectal Excision: Single-Institution Experience After First Year of Implementation

Transanal Hybrid Total Colectomy for FAP

J.M. Romero-Marcos, C. Cuenca-Go´mez, L. Sobrerroca-Porras, J.C. Baanante-Cerden˜a, C. Maristany-Bienert, J.A. Pando-Lo´pez, A. Mun˜oz-Duyos, S. Delgado-Rivilla Surgery Department - Coloproctology Division, Hospital Universitari Mu´tua de Terrassa, Terrassa, Spain Aim: Transanal total mesorectal excision (taTME) has emerged as a new surgical technique intended to overcome the difficulties of both open and laparoscopic procedures of the rectum. Its feasibility and safety have already been assessed. We report our initial experience with taTME after 1 year of implementation in our institution. Methods: All patients in our institution requiring proctectomy and operated using a transanal approach were included in a prospective database, recording patient characteristics, disease features, intraoperative variables, postoperative results, anatomopathological features and follow-up data. Data were also included in the Pelican Cancer Foundation International taTMERegistry. Results: The first patient was operated in February 2017, and until December 2017, 22 patients have undergone TaTME. Median age of the patients was 61 years, of whom 9 were women. 2 patients were operated on for ulcerative colitis and the rest for cancer. Regarding the latter, the median distance of the tumours to the anal verge was 6 cm, and the circumferential margin was at risk in 7 patients. 17 received preoperative radiotherapy or both chemotherapy and radiotherapy. All the procedures were performed simultaneously by two surgical teams (abdominal and perineal), with a median duration of 175 minutes. Transanal specimen extraction was performed in 11 cases, and 7 anastomoses were hand-sewn. Median postoperative stay was 6 days. One patient had a grade IIIb complication and another a IVa, according to Clavien-Dindo classification. Regarding the anatomopathological results, excluding the two benign cases, the mesorectal excision was complete in all specimens and the distal margin was free. In one case, the circumferential margin was only at 0.16 mm from the surgical margin, therefore the composite endpoint of complete mesorectum and free margins was achieved in 95% of the neoplastic patients. Median number of lymph nodes harvested was 13. No recurrence was found after a median follow-up of 4.4 months. Conclusions: TaTME procedure is still evolving. Reporting initial and short-term results may help to identify potential advantages. Our short-term results are comparable to those published for both open and laparoscopic approaches, although longer follow-up time is needed to evaluate the oncologic results.

F. Graur1, M. Dragota2, L. Breaban2, R. Elisei2, N. al Hajjar1 1

Surgery, University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj-Napoca, Cluj-Napoca, Romania; 2Surgery, Regional Institute of Gastroenterology and Hepatology, O. Fodor, Cluj-Napoca, Romania Aim: Minimally invasive surgery has proven its efficacy in both benign and malignant colorectal surgery; we describe the surgical technique in a 28-year-old female patient with familial adenomatous poliposis. Methods: A step-by-step approach of the procedure is described. Using a transanal port aided by two 5 mm and 10 mm trocars on the abdominal midline, we performed a transanal hybrid total colectomy with transanal extraction of the specimen. Results: No intraoperative or postoperative incidents were reported. Patient was discharged on the 5th postoperative day with mild diarrhoea; Loperamide was administered in the two weeks following the procedure with good clinical response. Conclusion: Transanal hybrid total colectomy is a feasible option in patients with benign colorectal conditions in which total colectomy must be performed.

P207 - Intestinal, Colorectal and Anal Disorders

P209 - Intestinal, Colorectal and Anal Disorders

The Efficacy of Intraoperative Transanal Vacuum Prolapse Test During Laparoscopic Rectopexy for Rectal Prolapse

Lymphatic Flow and Spread Diagnosis Using Indocyanine Green (ICG) Fluorescence-Guided Laparoscopic Right Hemicolectomy

Y. Souma, T. Yumiba, J. Yasuda, T. Ono, T. Noyama, T. Saito, T. Kobayashi, S. Ohashi

K. Ueda, J. Kawamura, H. Ushijima, K. Daito, T. Tokoro, Y. Yoshioka, J. Hida, K. Okuno

Department of Surgery, Osaka Central Hospital, Osaka, Japan

Surgery, Kindai University Faculty of Medicine, Osaka Sayama, Osaka, Japan

Introduction: Laparoscopic ventral rectopexy (LVR) has been increasingly applied for rectal prolapse (RP) since it avoids a circumferential mobilization of rectum and subsequent rectal denervation. However, it has not been fully evaluated whether LVR can provide a sufficient upward fixation of prolapsed rectum. We have employed intraoperative transanal vacuum prolapse test (ITAVPT) to confirm sufficient upward fixation of prolapsed rectum and evaluate the need of circumferential mobilization of the rectum and posteriorly fixation (i.e. laparoscopic posterior rectopexy: LPR). The aim of this study was to evaluate the efficacy of ITAVPT for the selection of optimal procedure of laparoscopic rectopexy (LR). Methods: We have conducted retrospective chart review on 65 consecutive patients who underwent LR for RP. The following data were compared between the patients with ITAVPT for the selection of surgical procedure of LR (ITAVPT group; n = 41) and the patients without ITAVPT (non-ITAVPT group; n = 24): 1) patient’s demographics; age, gender, length of prolapsed rectum, etc. 2) operative findings; surgical procedure, operating time, blood loss etc. 3) post-operative outcomes; complications, rectal function, recurrence rate, etc. ITAVPT was performed by using vacuum cup with manual hand-pump after the anterior wall of lowest point of prolapsed rectum was dissected. Transanal vacuum suction was created by manual hand-pump under the upward traction on the anterior wall of lowest rectum by using gripping forceps from abdominal cavity. LVR was selected in the cases with no residual rectal prolapse by ITAVPT, and LPR following circumferential mobilization was selected in the cases with residual prolapsed rectum. Results: 1) No significant differences were observed between two groups in the patients’ demographics. 2) In ITAVPT group, LVR and LPR was performed in 25 and 16 cases based on the result of ITAVPT, respectively, while all cases of non-ITAVPT group were treated with LVR. Other operative findings were similar in both groups. 3) Postoperative outcomes were comparable between two groups, but the incidence of recurrence in ITAVPT group (n = 0, 0%) was significantly lower than that of non-ITAVPT group (n = 3, 12%) (p = 0.04). Conclusions: ITAVPT was considered to be a useful tool for the selection of optimal procedure of LR.

123

Aims: The concept of radical surgery for colon cancer is to extract in one package the tumor with free margin and mesocolon including the lymphatic spread along the supplying arteries at its origin. The aim of this study was to demonstrate lymphatic flow and spread diagnosis using indocyanine green (ICG) during laparoscopic right hemicolectomy. Methods: A 0.3 ml of ICG (2.5 mg/ml) was injected to the submucosal layer around the cancer using colonoscopy prior to the surgery (one or two days before). The lymphatic flow in the mesocolon was visualized using PINPOINT laparoscopic fluorescence imaging system (NOVADAQ technologies Inc., Canada). The laparoscopic right hemicolectomy was performed as a conventional fashion (radical surgery). After retrieved specimen, we harvested all lymph nodes (LN(s)) and scanned ICG uptake LN or not (ICG ± LN) by PINPOINT system. All harvested LNs were assessed pathological analysis. Results: Between November, 2016 and July, 2017, 21 patients were enrolled this study under the informed consent. All patients were administrated the ICG injection without any adverse events. Laparoscopic right hemicolectomy with curative resection was successfully performed in all patients. At the initiation of laparoscopic exploration, the ICG did not detect in 4 patients (ICG failure rate, 19%) by PINPOINT system (ICG detection rate, 81%). There were three pT3 or pT4a cancers in ICG failure patients. Another one was thought to be technical failure. In total, 661 LNs were examined for 21 patients. The median LNs yield was 30 nodes (IQR: 22–47). Among these LNs, median ICG + LNs were 3 nodes (IQR: 2–5). Of 17 patients with ICG + LN detected, two patients had positive LNs containing malignancy, however, the other two patients had metastatic LNs in ICG- LN. Both ICG ± LN were including ICG flow and spread area. No metastasis was observed in any LNs other than the ICG lymphatic flow and spread area. Conclusions: The ICG lymphatic flow and spread diagnosis is not the modality of metastatic LN exploration. However, the ICG injection around the cancer can detect the prediction of LN metastasis for radical surgery by PINPOINT system.

Surg Endosc

P210 - Intestinal, Colorectal and Anal Disorders

P212 - Intestinal, Colorectal and Anal Disorders

Feasibility and Safety of Laparoscopic Surgery Following SelfExpanding Metallic Stent for Obstructive Colon Cancer

Oncologic Safety of Low Ligation of The Inferior Mesenteric Artery with Additional Lymph Node Retrieval

K. Ietsugu, K. Yoshida, J. Okamoto, N. Ohta, S. Tabata, K. Kiyohara

S. Kim, J.H. Kim

Surgery, Tomani General Hospital, Tonami City, Japan

Department of Surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea

Background: In the past, obstructive colorectal cancer was difficult to secure visual field, and it was considered not to be applicable for laparoscopic surgery. However, the laparoscopic surgery becomes possible with the advent of self-expanding metallic stent (SEMS) for obstructive colon cancer. Aim: Based on the surgical treatment experience at our hospital, we will assess the feasibility and safety of laparoscopic surgery for obstructive colon cancer. Methods: We had investigated laparoscopic assisted surgery (Lap) and open surgery (OS) for obstructive colon cancer between November 2014 and November 2017 in our hospital. Results: 4 cases in laparoscopic surgery and 5 cases in open surgery was performed after inserting SEMS for obstructive colon cancer. The median interval from SEMS insertion to Lap vs. OS were 15days (range, 11–24 days) vs. 22 days (range, 15–30 days). There were no cases of conversion to open surgery. The median operation time on Lap vs. OS was 212 minutes (range,180–231 minutes) vs. 235 minutes (range,150–308 minutes), and the median bleeding volume of Lap vs. OS was 7 g (5–30 g) vs. 450 g (range,150–1410 g). Median length of hospital stay for Lap group vs. OS group was 12.5 days (range,11–16 days) vs. 22 days (range,15–30 days). Two complications during hospitalization were seen in OS group. Conclusions: The present study shows that laparoscopic surgery for obstructive colon cancer is a safe and feasible method if the SEMS is inserted and obstruction is released.

Aim: The aim of this study was to assess the oncologic safety of low ligation of the inferior mesenteric artery (IMA) with additional lymph node (LN) retrieval of IMA origin. Methods: From September 2004 to November 2014, a total of 170 patients underwent curative resection for sigmoid colon and rectal cancer. Finally, 170 patients who underwent LN retrieval of IMA origin were enrolled in this study. All patients diagnosed stage III colorectal cancer. LN retrieval of IMA origin was performed along the origin of IMA to the origin of the left colic artery. High group (n = 66) underwent high ligation of IMA after LN retrieval of IMA origin. Low group (n = 104) underwent low ligation of IMA after LN retrieval of IMA origin. Oncologic outcomes were analyzed. Results: There were no significant differences in gender, age, operation type, and tumor location between two groups. There were no significant differences in a lymphatic invasion, vascular invasion, neural invasion, T stage and adjuvant chemotherapy between two groups. The high group showed more frequent poorly differentiated cell type compared to low group (p = 0.014). The low group showed more advanced N stage compared to high group (p = 0.039). Metastases were presented in 20 patients (30.3%) in high group and 32 patients (30.8%) in low group (p = 0.949). There were no significant differences in disease-free survival and overall survival between two groups (p = 0.729, 0.724). Conclusions: Low ligation of the IMA with LN retrieval of IMA origin might allow curative resection and oncologic safety compared to high ligation of IMA in stage III patients.

P211 - Intestinal, Colorectal and Anal Disorders

P213 - Intestinal, Colorectal and Anal Disorders

Single-Incision Laparoscopic Appendectomy for Acute Appendictis with Adult Malrotation -A Case Report-

Preliminary Results: Of Robotic Colorectal Surgery in Military Hospital in Bucharest, Romania

Y. Iwaki, T. Watanabe, K. Koyama, K. Sadamura, M. Tochimoto, H. Kato, M. Kawaguchi

F. Savulescu, C. Cirlan, C. Blajut, I. Budrugeac, R. Marin

Surgery, Yokohama Sakae Kyousai Hospital, Yokohama, Japan Aim: Adult malrotation is a congenital rare disease entity. Laparoscopic appendectomy has been increasingly applied for appendectomy. Single incision laparoscopic appendectomy is a very effective surgical procedure to resect the appendix with adult malrotation. Case: A 30-year male was admitted to our hospital because of mid-lower abdominal pain. A blood sample revealed high levels of inflammatory response (WBC 19000/ lL, CRP 0.1 mg/dL). Contrast-enhanced abdominal CT showed a SMV rotation sign. In addition, the small intestine was deviated to the right side of the abdominal cavity, while the ascending colon and another colon were deviated to the left side. CT demonstrated fecalith formation in the enlarged appendix that was located in the mid-lower abdominal cavity. We diagnosed this case as acute appendicitis with adult malrotation and performed single-incision laparoscopic appendectomy. A 30-mm incision was made in the umbilicus. LAP PROTECTOR and EZ Access were placed through an open approach, and a 5-mm laparoscope and two 5-mm ports were inserted through the EZ Access. The stump of appendix was located in the mid-lower abdominal of cavity. Although there was no evidence of abscess formation around appendix. The ileocecal region was no fixed to retroperitoneum that enabled us to remove the appendix out side the body from umbilicus. The appendicular stump was buried by purse-string suture. We did not place no drainage tube. He did not show any complications after surgery. He was placed on a regular diet on postoperative day 1 and discharged 4th later. Conclusion: Taking it into consideration that single-incision laparoscopic appendectomy (SILA) for appendicitis with adult malrotation can be performed safely, we came to the conclusion that SILA is excellent procedure to be adopted for the dissection of appendix with adult malrotation.

General Surgery II, Central Military Emergency University Hospital, Bucharest, Romania Goal: The available literature on minimally invasive colorectal cancer surgery demonstrates that this approach is feasible and associated with better short term outcomes than open surgery while maintaining equivalent oncologic safety. Roboticassisted surgery has been evolving now for over two decades and has finally matured into a technology that has caused a monumental shift in the way colorectal surgeries are performed. Methods: Between December 2014 and October 2017, 66 patients underwent colorectal robot-assisted laparoscopic surgery in Central Military Emergency University Hospital, in Bucharest, Romania. All procedures were performed by the same team. Operative times (total operative time, console time, docking time) were collected prospectively. Clinical parameters, including age, estimated blood loss, body mass index (BMI), prior abdominal surgeries, procedure type, length of hospital stay, and complications, were retrospectively collected from medical charts. Findings and Results: All 66 patients were included in our analyses, with a median age of 61.3 (range 29–81), and a medium BMI of 28 (range 21–35). We performed 43 cases of low rectal resections with colo-anal anastomosis, 4 abdominoperineal resections, 9 recto-sigmoidian resections, 7 left colectomies and 3 segmental sigmoid colectomies. Our mean operative time was 210 minutes; median hospital stay was 6 days. We had no mortalities in the postoperative period. The conversion to open surgery was done in only one patient, who had a low rectal tumor, and the reason for converting was bleeding from the iliac vein. A total mesorectal excision with negative circumferential margin was accomplished in all patients with low rectal resection and abdominoperineal resections. No positive distal margin was seen on the pathological examination. Mean number of lymph nodes removed was 23. Median follow-up was 19.8 months (range 3–35.6 months). Conclusion: Our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles. The introduction of da Vinci robot changed the approach to colorectal cancer surgery revealing the patient-specific advantage of minimally invasive surgery, but also advantages for the surgeon.

123

Surg Endosc

P214 - Intestinal, Colorectal and Anal Disorders

P216 - Intestinal, Colorectal and Anal Disorders

Preoperative Bowel Preparation for Laparoscopic Colorectal Resection: Utility of Preoperative Bowel Preparation with Tokaku-Joki-To

Redo Management After Ileocoecal Resection in Crohn’s Disease

T. Kimura, K. Otsuka, T. Matuo, K. Sato, M. Yaegashi, T. Hatanaka, S. Konndou, T. Takahara, Y. Akiyama, T. Iwaya, H. Nitta, K. Koeda, M. Mizuno, A. Sasaki Surgery, Iwate Medical University School of Medicine, Morioka, Japan Background: Preoperative mechanical bowel preparation in laparoscopic colorectal resection is able to make surgical operation easier and may improve the operative field. However, some reports have stated that mechanical bowel preparation does not contribute to reducing complications such as surgical site infection and anastomotic leakage, and reports focusing on enhanced recovery after surgery have indicated delayed postoperative recovery. Therefore, since 2013, we switched from using bowel preparation with polyethylene glycol, which requires fasting, to using a Chinese herbal medicine called Tokaku-joki-to for bowel preparation. This has led to extremely favorable results. Materials and methods: A retrospective medical record review of all patients who underwent LCR was performed. We split the patients among two groups, those who had preoperative MBP (Group A) or those who had preoperative bowel preparation (BP) using Tokaku-joki-to (Group B).All relevant perioperative data were reviewed and compared. Results: A total of 114 patients had preoperative MBP (Group A) and 162 patients had preoperative BP using TJT (Group B). The mean time until resumption of oral intake was significantly faster in Group B than Group A.Hospital stay was significantly shorter in Group B than Group A (p = 0.002). The 2 groups had a similar course of change in CRP value; there was no statistically significant difference. However the reduction in CRP level of Day3 From Day5 was significantly higher in Group B than Group A (p = 0.031).Morbility rate was 25.4% among Group A patients and 9.3% among Group B patients (p = 0.0003). Experience diarrhea (p = 0.003) and SSI (p = 0.034) were significantly higher in Group A than Group B. Conclusions: Bowel preparation performed with Tokaku-joki-to while patients continue to eat meals may be a highly effective bowel preparation method for laparoscopic colorectal resection from the perspective.

´ braha´m1, Z.S. Simonka1, A. Paszt1, L. Szabo´1, L. Andra´si1, S.Z. A Z.Z. Szepes2, T. Molna´r2, G.Y. La´za´r1 1

Department of Surgery, University of Szeged, Szeged, Hungary; Department of 1st Internal Medicine, University of Szeged, Szeged, Hungary

2

Aims: In this study, we present our experience with redo surgery for recurrent Crohn’s disease with small bowel involvement. Short- and long-term results of surgical and gastroenterological therapy were analysed, especially regarding prognostic factors of possible recurrence. Methods: Between 1st January 2005 and 31th December 2015, twenty patients (ten males and ten females) were examined at our Department with recurrent Crohn’s disease. The mean age was 34 years (21–64) at the time of second surgical intervention. Patients underwent complex gastroenterological check-up examinations in a regional IBD centre. The localization of the disease was the following: jejunum 5% (1/20), terminal ileum 70% (14/20), terminal ileum and colon 25% (5/20). Disease behaviour were rather stenotising (65%, 13/20) than fistulising (35%, 7/20). In 14 cases colonoscopy was performed prior second surgery with the result of inflammation in 8 cases and chronic stenosis in 6 cases. Redo surgical managements were carried out in 20 cases. Results from surgical, gastroenterological treatments, histopathology reports, the timing of recurrent complaints, the interval between the surgeries and the factors regarding recurrence and the chance of redo surgery were evaluated. Results: Patients were presented after wide deviation of months with complaints following the first surgery. The average interval between the surgeries was 68.4 months (5–126). In 9 cases, small bowel resection, in 1 case ileocoecum resection, in 3 cases completion right hemicolectomy, in one case colon resection, in 5 cases multiple resection (small bowel and colon) and in one case stricturoplasty were performed. 10% of the patients underwent laparoscopic surgery, conversion rate was 60%. Hand-sewn anastomosis was preferred in 70% of the cases. We observed interintestinal abscess formation in 5 cases. No intraoperative complication was detected without mortality. Conclusion: The long-term, complex treatment of patients with Crohn’s disease requires much experience and its management in IBD centres. The rate of open surgeries is high with the same conversion rate. Abdominal procedures – despite its complexity - are effective interventions with low morbidity and mortality.

P215 - Intestinal, Colorectal and Anal Disorders

P217 - Intestinal, Colorectal and Anal Disorders

Comparison of Robotic Rectal Resection for Cancer Between the da Vinci Si and Xi: A Cusum and Costs Analysis

Evaluation of Laparoscopic Low Anterior Resection for Low Rectal Tumor: A Single-Center Safety and Feasibility Study

G. Di Franco1, M. Palmeri1, N. Furbetta1, M. Bianchini1, S. Guadagni1, D. Gianardi1, G. Caprili1, C. d’Isidoro1, V. Lorenzoni2, F. Mosca3, G. di Candio1, G. Turchetti2, L. Morelli1

N. Matsuhashi, T. Takahashi, J.Y.U. Tajima, T. Tajirika, C. Takao, Y. Murase, T. Tanahashi, S. Matsui, H. Imai, Y. Tanaka, K. Yamaguchi, K. Yoshida

Department of Surgery, University of Pisa, Pisa, Italy; 2Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy; 3EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy

Surgical Oncology, Gifu University, Gifu, Japan

1

Aim: No studies have analyzed the possible difference of learning curve and costs between da Vinci Si and the new da Vinci Xi. The aim of this study is to compare surgical parameters and costs of robotic surgery in rectal cancer with the use of these two different da Vinci surgical systems. Methods: From April 2010 to April 2017, 90 robotic rectal resections were performed at our Institution with the da Vinci Si (Si-RobTME), until December 2015, or with the da Vinci Xi (XiRobTME), since January 2016. Based on CUSUM analysis, two comparable groups of 40 consecutive Si-RobTME and 40 consecutive Xi-RobTME were identified. Data of the prospectively collected database were retrospectively compared. Costs of the two procedures were analyzed according to the robotic learning curve. Results: The CUSUM learning curves of the two groups identified two similar phases in both groups: Si1 and Xi1: cases 1–19; Si2 and Xi2: cases 20–40. No differences in the preoperative data, surgical procedure and pathological data were documented. A hybrid laparoscopic/robotic approach was used in 17 cases (42.5%) in the Si-RobTME group, in contrast to no cases in the XiRobTME group (p \ 0.001). A statistically significant reduction in OT by phase of robotic experience was detected (p \ 0.001), and resulted lower in the phase Xi2 than phase Si2 (265 vs 290 min, p = 0.052) with a reduction of personnel costs (1151.6 vs 1260.2, p = 0.052). Statistically significant reductions in overall variable costs (OVC) and consumable costs (CC) were found between robotic phases (p \ 0.001), and resulted lower in the Xi2 phase respect than Si2 phase (OVC: 7983 vs 10231.9, p = 0.009, CC: 3464.4 vs 3869.7, p \ 0.001). Conclusion: The similar learning curve for both groups were likely due to a ‘proficiency-gain effect’ related mainly to the use of a new robotic technology and not to the surgical operation itself. We reported a significant optimization of costs with the surgeon’s experience and the new technology. This result is mainly due to the shorter OT and a reduction of personnel and consumable costs because of the higher percentage of a full robotic approach performed with the da Vinci Xi.

123

Background: Laparoscopic colectomy by pioneering laparoscopic surgeons has been gradually accepted on the basis of its technical advantages, safety and feasibility in numerous studies. However, laparoscopic surgery for rectal cancer is still more complicated than laparoscopic colectomy. In addtion, Laparoscopic rectal surgery involving rectal transection and anastomosis with stapling devices is technically difficult. Anastomotic leakage (AL) is one of the major complications of rectal surgery, especially in patients with rectal tumor (Ra/b). The present study aimed to evaluate both technical feasibility and safety of laparoscopic low anterior resection (LapLAR) after lower rectal tumor. Study Design: Between July 2008 and November 2017, 1390 patients with primary colorectal tumor underwent surgery,893 patients with colorectal tumor underwent laparoscopic surgery at Gifu University School of Medicine. 202 patients with lower rectal tumor underwent Lap-LAR. The present study aimed to evaluate both the technical feasibility and safety of Lap-LAR with rectal tumor. Results: Average values of total blood loss and operation time were 20.0 ml and 294 min, There was no perioperative mortality, and the morbidity rate was 17.8% (36/202). Postoperative complications detected included AL in 18 (8.9%) patient, ileus in 6 (3.0%) patients and pelvic cavity abscess in 3 (1.5%) patients of Lap-LAR The rate of severe complications of grade ] 3a was 14.4% (29/202) and that of grade ] 3b was 2.5% (5/202) (Clavien-Dindo classification). Conclusions: The present study showed laparoscopic LAR to have a safe postoperative course and to benefit short term outcomes. Further studies including a large multi-institutional randomized controlled study are required to identify risk factors of AL and to develop the approaches to reduce this risk for patients with rectal tumors who undergo Lap-LAR.

Surg Endosc

P218 - Intestinal, Colorectal and Anal Disorders

P220 - Intestinal, Colorectal and Anal Disorders

Single Incision Laparoscopic Surgery used to Transanal Endoscopic Microsurgery

Late Complications and Quality of Life in Ulcerative Colitis After Laparoscopic Surgery

S. Hayashi1, M. Ikarashi1, K. Hagiwara1, T. Miyakuni1, Y. Matsuno1, T. Takayama1, T. Suzuki2

´ braha´m1, G.Y. La´za´r1, J. Tajti Jr.1, Z.S. Simonka1, A. Paszt1, S.Z. A 2 2 ´ K. Farkas , T. Molnar

1

Department of Digestive Surgery, Nihon University, School of Medicine, Tokyo, Japan, 2Department of Surgery, Toride-kitasouma Medical Association Hospital, Ibaraki, Japan Aims: We have reported Single Incision Laparoscopic Surgery used to Transanal Endoscopic Microsurgery (SILSTEM) from March 2013. We introduce this technique and the usefulness of SILSTEM for rectal tumor using four types of anal platform. Materials and Methods: Nineteen consecutive patients underwent SILSTEM under IRB approval. We examined any cases that have been diagnosed with adenoma, early cancer or NET preoperatively. The median age of the patients was 63 (range 46–83) years. The diameters of a tumor were 1.7 (range 0.6–6) cm and the distance from an anal verge was 7 (5–9.5) cm before operation. In surgical technique, the surgical position was determined according to the tumor position and the platform was gently introduced into the anal canal. The bowel was insufflated with carbon dioxide. The resection was performed using mainly ultrasonic surgical scissors. All defects created by resection were irrigated with saline solution to prevent local recurrence. The defect was closed with running sutures using a laparoscopic suturing device. Postoperative follow-up was performed periodically with colonoscopy, chest and abdominal enhanced CT, pelvic MRI. Results: The median operation time was 115 (range 69–313) min and the median blood loss was 3 (range 1–71) ml. The patients were discharged a median of 8 (range 5–14) days after the operation. Pathology reports confirmed the diagnosis of adenocarcinoma in ten, adenoma in three and NET G1 in six patients. None of the patients experienced fecal incontinence or soiling after the surgery. There was one case of rectal stenosis caused. After dilation, the patient experienced good defecation. One patient underwent laparoscopic intersphincteric resection (ISR) 3 months after this procedure, because of both lymphatic and venous invasion. None of all patients had recurrence of their adenoma, adenocarcinoma or NET during maximum 84 months follow-up. Conclusion: Although it is necessary to accumulate the number of cases in the future, this procedure is guaranteed postoperative anal function, safety, tumor control and is useful for diagnosis and treatment of rectal tumor.

1

Department of Surgery, University of Szeged, Szeged, Hungary; First Department of Internal Medicine, University of Szeged, Szeged, Hungary

2

Aim: For the surgical treatment of ulcerative colitis (UC), laparoscopy is used more widely, but less data are available on postoperative quality of life and late complications. The objective of our study is to compare the mean 5-year follow-up results of patients treated with conventional and minimally invasive surgical methods. Methods: Between 1 January 2005 and 31 March 2017 a total of 83 patients (42 women, 41 men) had undergone surgery for UC, out of which 29 (34.9%) were emergency (total colectomy with mucous fistula) and 54 (65.1%) were elective cases (proctocolectomy and ileal pouch-anal anastomosis). Laparoscopy was used in 57 (68.7%) and conventional method in 26 (31.3%) cases. Quality of life was examined with questionnaires. Functional Scoring System, Gastrointestinal Quality of Life Index and Short Inflammatory Bowel Disease Questionnaire were used for testing gastroenterological conditions; Spielberger’s State-Trait Anxiety Questionnaire, Beck Depression Inventory and Brief Illness Perception Questionnaire were performed to consider psychological status. Results: During the follow-up, significantly fewer complications were in the laparoscopy group such as septic condition (5.3% vs. 42.3%), intestinal obstruction (21% vs. 57.7%) and ‘‘other’’ complications (7% vs. 53.8%) such as hernia formation, anastomotic stenosis, per anum bleeding, and pouch-vaginal fistula. Trait anxiety and the incidence of abdominal pain were significantly lower in patients having undergone laparoscopic surgery. A significant correlation was found between the results of the psychological and gastrointestinal questionnaires. Conclusion: Minimally invasive technique provides a better long-term outcome for patients with UC, fewer late complications and a more balanced emotional condition.

P219 - Intestinal, Colorectal and Anal Disorders

P221 - Intestinal, Colorectal and Anal Disorders

Surgical Treatment of Ulcerative Colitis Associated Colorectal Tumors

Early Experience in Transanal Total Mesorectal Excision in Bulgaria

´ braha´m1, Z.S. Simonka1, J. Tajti Jr.1, M. Rutka2, K. Farkas2, S.Z. A A. Paszt1, T. Molna´r2, G.Y. La´za´r1

D. Penchev, P. Ivanov, V. Mutafchiyski

1

Department of Surgery, University of Szeged, Szeged, Hungary; First Department of Internal Medicine, University of Szeged, Szeged, Hungary

2

Aims: Ulcerative colitis (UC) associated colon tumor is a rare entity. It forms only 2% of the colorectal cancers, however it is the cause of death in 15% of the patients with UC. The objective of the study is to investigate the appearance of UC associated colorectal cancer in our UC population. Methods: Between 1 January 2003 and 31 December 2016, surgery was performed for UC associated colorectal carcinoma in 10 patients (2 women, 8 men) out of 90 patients, who had undergone surgery for UC. The mean age of the patients was 54.6 years. There was an average 24 years from diagnosing the disease to surgery. The average duration of the follow-up was 50.5 months. Results: Preoperative colonoscopy showed inflammation in 2 cases, while UC associated carcinoma was described in 6 patients in the rectum and sigmoid colon, in 1 patient in the coecum, and in 1 patient in the splenic flexure. Seven cases were elective interventions, while 3 were emergency surgeries. Palliative stomas were performed in the 3 emergency cases with open method. Total proctocolectomy with the creation of a J-pouch (4 cases) and colectomy with rectum exstirpation (1 case) were carried out laparoscopically. Conversion from laparoscopy to open surgery was required in one case because of the big size of the tumor. Total colectomy was carried out with the open technique in 2 cases. There were no postoperative mortality. Postoperative histology revealed high tumor stages (T2-T4) in 9 cases. In 5 patients there were positive locoregional lymph nodes and distant metastasis (liver, lung, urinary bladder, peritoneum). Conclusion: Considerable proportion of cases with UC associated colorectal carcinoma had undergone surgery in advanced tumor stages. The mean age of these patients were lower than in patients with sporadic colon carcinoma. Minimally invasive procedures can be used safely for the surgical treatment of UC associated colon tumors. UC population needs regular gastroenterological surveillance.

Endoscopic Surgery, Military Medical Academy Sofia, Sofia, Bulgaria Introduction: The aim of surgery is to reduce the impact of surgical trauma. In oncological point of view, laparoscopic surgery didn’t show any advantages about long term results over conventional open surgery. Rectal cancer, located in distal third still remains a technical challenge for surgeons. Transanal total mesorectal excision with laparoscopic assistance is a quite new surgical approach for rectal cancer treatment, which seems to solve some of those technical issues and maybe improve long term results. Materials and Methods: After local ethic committee approval, we conducted a prospective nonrandomized comparative trail. For the period between 27.02.2017 and 01.12.2017y. in the department of Endoscopic endocrine surgery and coloproctolgy at Military Medical Academy – Sofia were performed twelve laparoscopic assisted transanal total mesorectal excisions and 10 laparoscopic anterior rectal resections with total mesorectal excision procedures. Most of the cases are part of the international TaTME register. We used standard local protocols for every step in diagnostics, treatment and postoperative recovery, which are based on evidence in the literature. Laparoscopic visualization and assistance was provided through four trocars. For transanal access we used SILS Covidien port with three trocars. Results: There was no conversion in each group and operative time was significantly longer in transanal group in the first cases. Quality of mesorectal excision was satisfactory in all specimens, according to the Quirke classification. Distal and proximal surgical resection margins ware free of tumor invasion in every patient. In one patient the circumferential resection margin was positive. Two patients in each arm experienced postoperative complication, classified as C&D I, II and III grade. Mean length of postoperative stay was 5 days. There was no postoperative mortality in presented study. Conclusion: Transanal total mesorectal excision with laparoscopic assistance is a quite new minimally invasive surgical approach for rectal cancer treatment. The method is feasible and safe when is performed by surgeons with lots of experience on transanal and laparoscopic rectal surgery. To avoid the procedure-related complications during the learning curve, it is essential to carefully select every patient. Multicenter randomized control trial is needed to answer the many question which raised.

123

Surg Endosc

P222 - Intestinal, Colorectal and Anal Disorders

P224 - Intestinal, Colorectal and Anal Disorders

Robotic Elective Sigmoidectomy for Diverticular Disease

Laparoscopic Peritoneal Lavage in Treatment of Purulent and Fecal Peritonitis as Complications of the Colonic Diverticular Disease

G. Giuliani, G. Formisano, S. Esposito, P. Misitano, L. Salvischiani, P.P. Bianchi General and Minimally-invasive Surgery, Misericordia Hospital, Grosseto, Italy

V.Y.U. Shapovalov1, M.A. Kashtalyan1, K.L. Masunov2, D.Y.U. Artemchuck1 1

Aims: Elective laparoscopic sigmoidectomy for diverticular disease is a challenging procedure affected by high intraoperative complications and conversion rates. The robotic platform, with its intrinsic advantages, could potentially overcome the limitations of conventional laparoscopy. The current study aims to evaluate intra- and short-term postoperative results of a consecutive series of patients submitted to elective robotic sigmoidectomy for diverticular disease. Methods: A retrospective analysis of a prospectively collected database of all robotic resections for recurrent and/or complicated diverticulitis performed in our centre was carried out. From December 2014 to December 2017, 37 patients underwent elective robotic sigmoidectomy for diverticular disease. Mean age was 67 ± 12.08 years (range, 40–87), whereas the mean body mass index (BMI) was 25 ± 3 kg/m2 (range, 18–29). American Society of Anaesthesiologist classification of patients was II and III in 30 and 7 patients respectively. Recurrent diverticulitis, classified as Hinchey I, was the indication for surgery in 12 patients (35%). In 15 patients (40%) the indication for surgery was a recurrent diverticulitis classified as Hinchey II. In 6 (16%) patients, resection was undertaken for a diverticular stricture, whereas a colo-vescical and colo-vaginal fistula was the indications for surgery in respectively 3 and 1 patients. Results: Mean operative time was 241 ± 48 minutes (range, 190–345). No intraoperative complications were registered. The conversion rate was 2.7% (1/37 patients). The mean time of first flatus was observed at 2.1 ± 0.9 days (range, 1–6). Mean postoperative stay was 6 ± 5 days (range, 4–12). The overall 30-day complication rate was 18.9% (7/37 patients). Five patients had minor complications (13.5%, Clavien Dindo Grade I-II); anastomotic leak was recorded in 2 patients (5.4%, Clavien-Dindo III). Conclusions: In our experience, robotic resection for diverticular disease has proved to be feasible and safe, with no intraoperative complications and low conversion rates. More studies are needed to investigate the role of robotic surgery in the treatment of this common benign disease.

General and military surgery, Odessa national medical university, Odessa, Ukraine; 2Colorectal surgery, Military-medical clinical center, Odessa, Ukraine

Aims: To improve the results of complicated colonic diverticular disease treatment (Hinchey I-IV) using the videolaparoscopic equipment. Methods: The article presents examination and treatment of 178 patients who underwent surgery for complicated forms of colonic diverticular disease. In urgent order were performed 142 (74.4%) operations, 59 of them (41.4%) were performed by using videoendoscopic equipment, 83 (58.6%) operations were performed by using the traditional open method. 17 (28.8%) patients with Hinchey I undervent diagnostic laparoscopy, 15 (25.4%) patients with Hinchey II-III were performed laparoscopic peritoneal lavage and drainage (LLD) (without stoma). Peretonial lavage with laparoscopic sigmostomy for perforated diverticulitis was used in 21 (35.6%) cases with Hinchey III-IV. Laparoscopicassisted leftside hemicolectomy for bleeding as a complication of colonic diverticular disease was performed to 2 (3.4%) patients, for perforated diverticulitis - 4 (6.8%) patients. Results: LLD shows a smaller hospital stay of - 7 ± 1.9 days (Hartmann’s procedure – 12 ± 2.1 day; in the formation of primary anastomosis - 13 ± 3.1). The videolaparoscopic group revealed a low number of complications - 4 (17.4%), (Hartmann’s procedure - 10 (31.3%), primary anastomoses - 4 (25.0%)) There was the lack of mortality in LLD group (a mortality after Hartmann’s procedure - 5 patients (15.6%), after primary anastomoses with stoma or without it - 1 (6.25%)). Conclusions: The study found that the surgical treatment of the patients with complicated colonic diverticular disease in the stage of Hinchey II-IV is better to carry out using the method of LLD.

P223 - Intestinal, Colorectal and Anal Disorders

P225 - Intestinal, Colorectal and Anal Disorders

Robotic Total Mesorectal Excision for Extraperitoneal Rectal Cancer: 5-Year Oncological Outcomes

Retromesenteric Course of the Middle Colic Artery. Challenges and Pitfalls In D3 Right Colectomy for Cancer

G. Formisano, S. Esposito, G. Giuliani, P. Misitano, A. Salaj, P.P. Bianchi

J.A. Luzon1, B.V. Stimec2, B.T. Andersen3, S.R. Benz4, J.H.D. Fasel2, K.M. Augestad1, A.M. Kazaryan1, D. Ignjatovic1

General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy

1

Aims: Two recent randomized controlled clinical trials questioned the oncological safety of laparoscopic treatment for rectal cancer. Moreover, laparoscopic rectal resection with total mesorectal excision (TME) remains a demanding procedure with a steep learning curve and high conversion rates. Robotic surgery could overcome the technical limitations of conventional laparoscopy, increasing the diffusion of minimally-invasive TME and improving short term results with favorable long term oncologic outcomes. The current study aims to evaluate postoperative results and long-term survival rates of patients undergoing robotic TME for low and ultralow rectal cancer. Methods: From July 2009 to December 2016, 156 patients underwent robotic rectal resection for rectal cancer: among these, 118 patients were submitted to robotic TME (84 Low Anterior Resection and 34 Abdomino-perineal resection). Mean age was 65 years and the mean distance of the tumor from the anal verge was 6.8 cm. 67 patients underwent preoperative chemoradiotherapy (56.8%). A diverting ileostomy was carried out in 59 (70%) of 84 Low Anterior Resections. All patients were assessed at a median follow-up of 54 months and long-term oncological outcomes (disease free survival and overall survival) were assessed using Kaplan-Meier curves. Results: Mean total operative time was 265 minutes and the conversion rate was 2.5%. The mean length of hospital stay was 6.9 days. According to Clavien-Dindo classification, 30days minor postoperative complications (grade I and II) and 30-days major postoperative complications (grade III and IV) were 16.1% and 8.4% respectively. Anastomotic leakage rate was 5.9% and reintervention was needed in 8.4% of the cases. Mean number of nodes retrieved was 20, the mean distal resection margin was 2.8 cm and 2.5% of patients had an involvement of circumferential resection margin. 5-years disease free survival was 75.3%, whereas overall survival was 85.6%. Local recurrence rate was 1.7%. Conclusions: Robotic-assisted TME provided high-quality surgery with favourable longterm oncological results and low local recurrence rates.

123

Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway; 2Division of Anatomy, Geneva University Medical Centre, Geneva, Switzerland; 3Department of Gastrointestinal Surgery, The Vestfold Hospital Trust, Tønsberg, Norway; 4Klinik fu¨r Allgemeine-Viszeral Und Kinderchirurgie, Kliniken Bo¨blingen, Bo¨blingen, Germany Aims: The middle colic artery (MCA) is of crucial importance in right and transverse colectomies performed either laparoscopically or at open surgery. With this background, a high number of reports concerning anatomical variations of the MCA have been published intended to contribute to the improvement of operative techniques for the treatment of colon cancer. Despite this extensive literature, a course of the MCA posterior to the superior mesenteric vein, called a retromesenteric trajectory, has only been referred once, to the best of our knowledge. Methods: A total series of 507 patients included in two prospective trials concerning laparoscopic or open right colectomy for cancer between 2011 and 2017 are reported. The investigation included pre- or postoperative multidetector computed tomography angiography. Results: We found 4 (0.79%) cases of retromesenteric MCA. They all underwent meticulous image analysis with mesenteric vessels’ road mapping, detailed morphometry and surgical validation which revealed that, apart from their course, those cases did not differ significantly from the rest of the studied series. Conclusion: This paper thus documents the value of preoperative awareness of patient individual anatomy. A possible misinterpretation by the operating surgeon, unaware of the MCA abnormality, can have a concrete impact on patient-tailored surgical practice, in particular for laparoscopic D3 colectomy (including the ‘‘uncinated process first’’ approach).

Surg Endosc

P226 - Intestinal, Colorectal and Anal Disorders

P228 - Intestinal, Colorectal and Anal Disorders

Investigation of Laparoscopic Surgery for Colorectal Cancer in Patients of Elderly Over 85

The Gastrografin Enema Study Through Transanal Tube can Diagnose Anastomotic Leakage in a Grade A Condition After Laparoscopic Low Anterior Resection

N. Akazawa Gastrointestinal Surgery, Sendai City Medical Center, Miyagi, Japan Background: With the aging society, cases of colorectal cancer in the elderly are increasing. Laparoscopic surgery for colorectal cancer is standard surgical operation, and laparoscopic surgery for elderly people is also increasing. Purpose: We compare the clinicopathologic features of elderly laparoscopic colon resection with two groups of late-stage elderly group (75–84 years old) and super elderly group (over 85 years old) in our hospital. Target: 153 cases of laparoscopic colorectal surgery in patients of elderly over 75 years old who took operation from January 2008 to June 2015. Results: 133 cases of late-stage elderly people. Average age 78.5 years (75–84 years old). Male/female ratio 70: 63. ASA 1 to 2: 3 = 111: 22. The proportion with comorbidity disease was 66.9%. The median operation time was 250 minutes and the median bleeding volume was 20 ml. Stage 0: I: II: III: IV = 11: 58: 28: 33: 3. Degree of dissection D1: D2: D3 = 1: 68: 64. Clavien-Dindo complications classified as III or higher are 8 cases (6%), and the average length of hospital stay (LOHS) after operation were 17 (9–65 days). Super elderly group 29 cases. Average age 88.3 years (85–97 years old). Male/ female ratio 9: 11. ASA 1 to 2: 3 = 13: 7. All cases had comorbidities. The median surgical time was 236 minutes and the median bleeding volume was 27.5 ml. Stage 0: I: II: III: IV = 2: 6: 7: 4: 1. Degree of dissection D1: D2: D3 = 0: 16: 4. ClavienDindo complications classified as III or higher are 2 cases (10%). The average LOHS after operation were 26 days (15–103 days). Conclusion: Laparoscopic surgery for elderly people over 85 years who have comorbid conditions can be safely enforced although the length of hospital stay will be long.

M. Hamada1, T. Kawaguchi1, T. Yoshida1, K. Miki1, H. Mukaide1, T. Kobayashi1, T. Michiura1, K. Inoue1, M. Oishi2 Gastrointestinal Surgery, Kansai Medical University, Hirakata, Japan Purpose: The purpose of this study was to reveal the effectiveness of the routine use of a postoperative Gastrografin enema study through a transanal tube to diagnose postoperative anastomotic leakage in a Grade A condition after laparoscopic low anterior resection. Patients and Methods: A total of 46 consecutive rectal cancer patients whose tumors were located within 15 cm from the anal verge who underwent laparoscopic low anterior resection without diverting stoma at our institution between May 12, 2015 and March 31, 2017 were included. The tip of the transanal tube was placed about 5 cm above the anastomotic line. All patients received a postoperative Gastrografin enema study through a transanal tube between the 3rd and 10th postoperative day. Results: No case experienced symptomatic anastomotic leakage before removal of the transanal tube. In 33 cases, the Gastrografin enema study revealed no suspicion of radiological leakage. During a median follow-up period of 452 days (39–723) there were no clinical symptoms after removal of the transanal tube. We noted 13 cases of radiologic leakage by the Gastrografin enema study. Ten of those patients required a 2nd operation and diverting stoma construction and the other 3 cases were treated conservatively. Conclusions: Anastomotic leakage after laparoscopic low anterior resection with the double stapling technique can be predicted in a Grade A condition using a postoperative Gastrografin enema study through a transanal tube, which can suppress the symptomatic leakage until its removal.

P227 - Intestinal, Colorectal and Anal Disorders

P229 - Intestinal, Colorectal and Anal Disorders

Serum Amyloid A and C-Reactive Protein as Early Markers of Infectious Complications After Laparoscopic Colorectal Cancer Surgery with Eras Protocol

Effectiveness of Laparoscopic Surgery for Obstructive RightSided Colon Cancer After Tube Decompression

M. Wierdak1, M. Pedziwiatr1, M. Pisarska1, J. Dworak1, P. Malczak1, P. Major1, B. Kusnierz-Cabala2, A. Budzynski1 1

2 Department of Surgery, Jagiellonian University Medical College, Krakow, Poland; 2Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland The aim of the study was to assess the usefulness of preoperative plasma Serum Amyloid A (SAA) and C-reactive protein (CRP) concentration and their changes in postoperative period as indicator of infectious complications in patients undergoing colorectal cancer surgery with perioperative care according to enhanced recovery after surgery protocol (ERAS). Prospective analysis included 81 consecutive patients who underwent laparoscopic colorectal cancer resection between 08.2015 and 09.2017. Patients with IBD, distant metastases, undergoing emergency or multivisceral resection were excluded from the analysis. In all patients, blood samples were collected preoperatively and on postoperative day (POD) 1, 2 and 3. Plasma SAA and CRP concentration was measured. Subsequently, patients were divided into two groups depending on the presence of infectious complications. We analyzed the differences in levels of proteins and the dynamics of changes of their concentration in those two groups. Group 1(A) comprised 61 not complicated patients and group 2(B) 20 patients with at least one infectious complication. Preoperatively, there were no significant differences in levels of serum SAA and CRP between those groups [ SAA: (58.8 ± 155.7 (ng/mL), B-75.9 ± 148.7 p = 0.87); CRP: (13.6 ± 34.8 (ng/mL), B-3.3 ± 21.7 p = 0.34)]. In postoperative period increase in SAA and CRP concentrations were observed in both groups in all postoperative days [POD - 3 - SAA: (A-561.0 ± 456.1, B-1256.6 ± 551.0 p = 0.01); CRP:(A-96.2 ± 75.7, B-272.8 ± 108.0 p = 0.01)]. This increase was significantly bigger in group B. ROC curve analysis didn’t reveal differences in AUC value between SAA and CRP concentration in any POD. Our study show that perioperative analysis of SAA plasma concentration may be as useful as CRP in the early detection of infectious complications. It could be important tool in decision making, about safely patients discharge from the hospital especially nowadays when the hospital stay is very short.&&&

M. Ohtsuka, M. Tei, M. Mikamori, T. Saito, K. Furukawa, Y. Suzuki, K. Kishi, M. Tanemura, H. Akamatsu Department of Gastroenterological Surgery, Osaka Police Hospital, Osaka, Japan Introduction: Approximately 10% of patients with colorectal cancer (CRC) have obstructive symptoms at the time of diagnosis. However, determination of the optimal strategy for obstructive CRC (OCRC) remains challenging. In our department, one-stage surgeries have been performed for patients with OCRC after tube decompression. Furthermore, we have adapted laparoscopic surgery (Lap) for these patients since 2007. Objective: We assessed the treatment outcomes for patients with right-sided OCRC (rt-OCRC) after tube decompression and evaluated the feasibility and safety of Lap for these patients. Materials and Methods: In total, 35 patients with rt-OCRC were included in this study. Patients who underwent Lap were compared with those who underwent open surgery (OS). Results: A total of 32 patients with rt-OCRC successfully achieved tube decompression using an ileus tube (n = 29) or self-expanded metallic stent (n = 3). Twenty-two patients underwent Lap and 10 underwent OS. No differences in patient backgrounds were observed between the two groups. The operative time was significantly longer in the Lap than OS group (195 vs. 139 min), but the postoperative hospital stay was significantly shorter in the Lap than OS group (11 vs. 20 days). Fewer complications occurred in the Lap than OS group (7 vs. 8 cases). In particular, ileus was more common in patients in the OS than Lap group (3 vs. 0 cases). Moreover, there was no difference in the 5-year overall survival or disease-free survival between the Lap and OS groups. Conclusions: Lap appears to be as safe and feasible as OS for patients with rt-OCRC as demonstrated by successful tube decompression and adequate oncological outcomes.

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Surg Endosc

P230 - Intestinal, Colorectal and Anal Disorders

P232 - Intestinal, Colorectal and Anal Disorders

Our Procedure of Lateral Lymph Node Dissection for Low Rectal Cancer After Chemoradiotherapy Using 3D Laparoscopic System

Postoperative Complication of Laparoscopic Surgery for Colorectal Cancer

Y. Nakamoto

T. Kajiwara, S. Ottomo, T. Miyachi, T. Hukutomi, A. Sato, M. Ohara, K. Hatsugai, H. Ichikawa, I. Kaneda

Surgery, Meiwa Hospital, Nishinomiya, Japan Background: By the effect of stereoscopic viewing by 3D, we are trying to simplify the surgical technique, aiming at shortening the operation time and more sophisticated surgery. Moreover, it is possible to grasp exact surgical anatomy, and it is considered that the safety of surgery and the educational effect for young surgeons are also present. Especially in the lateral lymph node dissection (LLND) of rectal cancer, the depth feeling in a narrow space by 3D image is considered to be advantageous in 2D. Methods: Our indication of LLND is detection of LN with a minor axis of 5 mm or more by MRI. Since chemoradiotherapy (CRT) is used for low rectal cancer with T3 or more or N1 or more in our hospital, preoperative CRT is performed in all cases of LLND. The procedure is proceeded from No.283 LND to No.263 LND. The ureter is dissected to the vicinity of the bladder. External iliac vein is exposed, then to the large psoas muscles on its back, reaching internal obturator muscle. Since there are small blood vessels, it is necessary to stop bleeding frequently. Obturator nerve is identified medially and obturator vessels are divided around the obturator foramen. Obturator LN chain is clipped to prevent lymphorrhea. Medial side of No.283 LND should be done by consideration of vesicohypogastric fascia. The proximal LN chain is divided at the bifurcation of internal and external iliac vessel, and the proximal side of obturator vessels is divided. No.283 LND is performed with preservation of obturator nerve. Pelvic nerve plexus is confirmed and medially dissected, and lateral side of No.283 LN is dissected upon medial side of vesicohypogastric fascia (umbilical artery). No.283 LND is performed with or without superior and inferior bladder arteries preservation according to extent of LND. Results: In 5 cases we experienced LLND using the 3D laparoscopic system (3 cases: LAR, 2 cases: ISR with TaTME, 4 cases: unilateral dissection, one case bilateral dissection). We dissected 8 lymph nodes on average for one side. Conclusions: LLND for low rectal cancer after CRT using 3D laparoscopic system is promising procedure.

P231 - Intestinal, Colorectal and Anal Disorders Transanal Endoscopic Operation (TEO) for Multiple Recurrent Adenomas Close to the Dentate A. Tanase, S. Hossaini, R. Alexander Department of Coloproctology and General Surgery, Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom Aims: minimally invasive techniques such as Transanal Endoscopic Operations (TEO) and other transanal platforms are commonly used in the management of benign lesions and selected low-risk carcinomas of the lower rectum, including recurrent adenomas. Whilst a globally-accepted definition of a technically difficult polyp excision is lacking, it is generally accepted that factors such as polyp morphology, polyp location and the presence of recurrent or multiple polyps can make mucosectomy more difficult. Polyps that are close or adjacent to the dentate line can be technically challenging. We aimed to demonstrate the safety and feasibility of TEO for multiple recurrent adenomatous lesions close to and at the dentate line. Methods: high definition video-demonstration of TEO in an elderly male patient with multiple recurrent adenomatous lesions at the dentate line, excised using mucosectomy technique. Retrospective review of histology and postoperative follow up. Results: a total of five recurrent adenomatous polyps in a carpet-like configuration about the dentate line were excised. Histological evaluation demonstrated varying degrees of dysplasia with no focus of invasion. No postoperative complications or functional disturbance with regards to continence or defacatory disturbance were detected at 28-day follow up. Conclusions: minimally invasive transanal endoscopic techniques such as TEO, appears to be feasible and safe for very low rectal polyps at the dentate line, with good functional outcomes.

123

Surgery, Japanese Red Cross Ishinomaki Hospital, Ishinomaki-Shi, Miyagi-Ken, Japan Aims: Laparoscopic surgery is often performed for colorectal cancer, and is generally minimally invasive. However, postoperative complications do not decrease with laparoscopic surgery compared with open surgery. This study analyzed postoperative complications of laparoscopic colorectal surgery. Methods: A total of 179 patients underwent laparoscopic surgery for primary colorectal cancer between January 2012 and October 2017 at the Japanese Red Cross Ishinomaki Hospital. We divided into two groups according to whether postoperative complications over grade 2 in the Clavien-Dindo category developed. The complications group (CO group) included 19 patients and the non-complications group (NC group) included 160 patients. We compared characteristics of patients between the two groups. Results: The CO group included significantly more males than the NC group (male:female = 18:1 vs. 86:74, p \ 0.01). The mean age, mean body mass index, and mean American Society of Anesthesiologists scores were not significantly different between the two groups (70.7 ± 9.0 vs. 69.5 ± 10.8 years, 24.6 ± 3.8 vs. 23.9 ± 3.8 kg/m2, 2.05 ± 0.51 vs. 1.89 ± 0.57, respectively). The CO group included significantly more cases of rectal cancer than the NC group (colon cancer:rectal cancer = 8:11 vs. 117:43, p \ 0.01). The pathological T stage and lymph node metastasis-positive rate were similar between the two groups (T1/2:T3/4 = 14:5 vs. 108:52 and 15.8% vs. 24.4%, respectively). The CO group had a significantly longer mean operative time and more mean blood loss than the NC group (340 ± 74 vs. 263 ± 67 min and 88.7 ± 59.5 vs. 49.1 ± 69.1 ml, respectively, p \ 0.01). Multivariate analysis identified male sex and longer operative time as independent risk factors for postoperative complications. Conclusion: Male sex and prolonged operative time were risk factors for postoperative complications in laparoscopic colorectal surgery.

P233 - Intestinal, Colorectal and Anal Disorders Prognostic Factors for Return to Work and Work Disability Among Colorectal Cancer Survivors: A Systematic Review C.M. den Bakker1, J.R. Anema2, A.C.G.N.M Zaman3, H.C.W. de Vet4, L. Sharp5, E. Angenete6, M.E. Allaix7, J.A.F. Huirne8, H.J. Bonjer9, A.G.E.M. de Boer3, F.G. Schaafsma2 1 Surgery & Occupational and Public Health, VU University Medical Center, Amsterdam, The Netherlands; 2Occupational and Public Health, VU University medical center, Amsterdam, The Netherlands; 3 Coronel Institute of Occupational Health, Academic Medical Center, Amsterdam, The Netherlands; 4Epidemiology and Biostatistics, VU University medical center, Amsterdam, Nepal; 5Health & Society, Newcastle University, Newcastle, United Kingdom; 6Surgery, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden; 7 Surgical sciences, University of Torino, Torino, Italy; 8Gynecology, VU University medical center, Amsterdam, The Netherlands; 9Surgery, VU University medical center, Amsterdam, The Netherlands

Aims: Colorectal cancer is diagnosed progressively in employed patients due to screening programs and increasing retirement age. The objective of this study was to identify prognostic factors for return to work and work disability in patients with colorectal cancer. Methods: The research protocol was published at PROSPERO with registration number CRD42017049757. A systematic review of cohort and case-control studies in colorectal cancer patients above 18 years, who were employed when diagnosed, and who had a surgical resection with curative intent were included. The primary outcome was return to work or work disability. Potentially prognostic factors were included in the analysis if they were measured in at least three studies. Risk of bias was assessed according to the QUality In Prognosis Studies (QUIPS) tool. A qualitative synthesis analysis was performed due to heterogeneity between studies. Quality of evidence was evaluated according to Grading of Recommendation Assessment, Development and Evaluation. Results: Eight studies were included with a follow-up period of 26 up to 520 weeks. (Neo) adjuvant therapy, higher age, and more comorbidities had a significant negative influence on return to work. A previous period of unemployment, extensive surgical resection and postoperative complications significantly increased the risk of work disability. The quality of evidence for these prognostic factors was considered very low to moderate. Conclusion: Health care professionals need to be aware of these prognostic factors to select patients eligible for timely intensified rehabilitation in order to optimize the return to work process and prevent work disability.

Surg Endosc

P234 - Intestinal, Colorectal and Anal Disorders

P236 - Intestinal, Colorectal and Anal Disorders

The Development, Implementation and Evaluation of a New Smartphone Application for Optimal Discharge After Colorectal Surgery

Survival and Recurrence Outcomes Following Transanal Total Mesorectal Excision for Rectal Cancer

1

2

3

2

C.M. den Bakker , J.B. Tuynman , J.R. Anema , H.J. Bonjer , J.A.F. Huirne4 1

Surgery & Occupational and Public Health, VU University Medical Center, Amsterdam, The Netherlands; 2Surgery, VU University medical center, Amsterdam, The Netherlands; 3Occupational and Public Health, VU University medical center, Amsterdam, The Netherlands; 4Gynecology, VU University medical center, Amsterdam, The Netherlands Aims: In-hospital stay after colorectal surgery has decreased as a result of innovations in surgical techniques and the introduction of Enhanced Recovery After Surgery programs. However, there is no consensus about the optimal duration of in-hospital stay after colorectal surgery. Additional mHealth tools could be very helpful in improving communication and enable patients to easily access health information. By empowering patients they will achieve an active role in managing their own care and it provides opportunities for self-management. The aim of this study is to develop, implement and evaluate a smartphone application to achieve a shortened in-hospital stay with consistent or improved patient satisfaction regarding the quality of care. Methods: This smartphone application provides tailor-made advice on the expected timing of discharge after colorectal surgical procedures. is currently under development and this consists of three proposed phases. Phase 1 (the development phase): By using the Dutch Colorectal Audit register the median in-hospital stay per colorectal surgical procedure will be calculated according to the situation in the Netherlands. A prediction model will be made with person-, disease- and treatment-related factors that may affect the in-hospital stay duration. Phase 2 (the validation phase): A delphi procedure among surgeons will be performed to reach consensus on most ideal in-hospital stay duration and the affecting predictive factors based on the results of the development phase. Phase 3 (the implementation and testing phase): The results of the development and validation phase will be implemented in the smartphone application. Furthermore, the application will be evaluated among patients who will get a colon- or rectal resection. Conclusion: In this study a new smartphone application concerning optimal discharge for patients after colorectal surgical procedures will be developed, implemented and evaluated.

F.B. de Lacy1, J. van Laarhoven2, R. Pena1, A. Otero1, R. Bravo1, D. Mombla´n1, A.M. Lacy1 1

Gastrointestinal Surgery, Hospital Clinic of Barcelona, Barcelona, Spain; 2General Surgery, Jeroen Bosch Ziekenhuis, ’s Hertogenbosch, The Netherlands Aims: The transanal total mesorectal excision (TaTME) has recently gained popularity as an alternative for the treatment of rectal cancer. Reports published to date demonstrate that it is a safe and feasible technique. However, there have been no studies presenting survival and recurrence data from large sample sizes. This study aimed to report the oncological outcomes of the largest single-institution series of patients treated with TaTME. Methods: All patients with rectal cancer treated at our hospital by TaTME between November 2011 and March 2017 were prospectively included in a standardized database. Patients with tumors within 12 cm of the anal verge and clinical stage II or III were included in this analysis. The primary endpoint of the study was disease-free survival. Secondary endpoints included overall survival, locoregional and distant recurrence. Results: A total of 161 patients were included. Preoperative staging revealed cT2 in 5.6% (n = 9) and cT3 in 94.4% (n = 152). Positive lymph nodes were preoperatively diagnosed in 56.5% (n = 91) cases. The majority of patients had clinical stage III (57.2%, n = 91). Of all patients, 66.0% (n = 105) received preoperative chemoradiotherapy, 3.1% (n = 5) only radiotherapy and 0.6% (n = 1) only chemotherapy. The mesorectal specimen was complete or nearly complete in 98.7% (n = 153). The rates of circumferential and distal resection margins involvement were 9.7% (n = 15) and 4.0% (n = 6), respectively. The median follow-up was 23.3 months (IQR 12.1–41.6). The disease-free survival rate was 80.0%. The overall survival rate was 91.9%. The locoregional recurrence rate was 4.7%, with a median time to recurrence of 12.7 months (IQR 9.3–26.9). The overall distant recurrence rate was 11.3%, with a median time to recurrence of 12.0 months (IQR 7.0–16.4). Conclusion: Good disease-free and overall survival, together with low locoregional recurrence rates, can be achieved after TaTME for rectal cancer.

P235 - Intestinal, Colorectal and Anal Disorders

P237 - Intestinal, Colorectal and Anal Disorders

Laparoscopic Multivisceral Resection for CT4B Colon Cancer

Repeat Laparoscopic Colectomy: Perioperative Outcomes of The Second Resection

M. Ouchi, M. Fukunaga, K. Nagakari, S. Yoshikawa, K. Takehara, D. Azuma, S. Kohama, J. Nomoto Surgery, Juntendo University Urayasu Hospital, Chiba, Japan Aim: The aim of this study was to investigate safety and efficacy of laparoscopic multivisceral resection for cT4b colorectal cancer. Subjects: Out of 2239 patients who were treated with laparoscopic surgery for colon cancer between March 1994 and November 2017, 150 patients received multivisceral resection with a diagnosis of cT4b (SI/AI). Of these, 118 patients except for those with stage IV were included in this study. Results: The mean age of the patients was 64.1 years. The subjects included 71 males and 47 females. The mean BMI was 22.1. The lesion was located in the colon in 81 patients (68.6%) and in the rectum in 37 patients (31.4%). For pStage, 4 patients (3.3%) were in pStage I, 52 (44%) in pStage II, and 61 (51.7%) in pStage III. For depth of invasion, 2 patients were in pT2 (MP), 43 in pT3 (SS/A), 16 in pT4a (SE), and 55 in pT4b (SI/AI). The histological concordance rate (pT4b/cT4b) was 46.6%. The combined organ resection was performed for the abdominal wall in 24 patients, bladder in 19, pelvic hypogastric nerve in 14, uterus/vagina in 14, gonadal vessel in 11, prostate gland/vas deferens/seminal vesicle in 10, small intestine in 9, retroperitoneum in 7, duodenum in 6, colon/rectum in 6, ovary in 5, and any other organs in 9. The median for the operative time was 273.5 minutes and that for the amount of bleeding was 218 ml. For postoperative complications, ileus occurred in 5 patients, anastomotic leak in 3, and pelvic abscess in 1. The median for the postoperative observational period was 63 months, and local recurrence occurred in 8 patients (7.3%). Conclusion: Laparoscopic multivisceral resection for cT4b colon cancer can be considered safe and effective.

C. Ferretti1, A. Zarzavadjian Le Bian2, C. Denet1, A. Laforest1, B. Gayet1, T. Perniceni1, D. Fuks1 1

Department of Digestive disease, Institut Mutualiste Montsouris, Paris, France; 2Department of Digestive Surgery and Surgical Oncology, Avicenne Hospital, Assistance Publique, Bobigny, France Aims: Short-term outcomes of repeat laparoscopic colectomy are still unclear. Methods: Using a prospectively completed database in a tertiary academic centre from 2000 to 2017, all consecutive patients who had undergone repeat laparoscopic colectomies were retrieved and perioperative outcomes of the second procedure were scrutinized. Results: Among 1300 patients who underwent laparoscopic colorectal resection 23 were retrieved. The first procedure was a left-sided colectomy, a right-sided colectomy, a proctectomy and a sub-total colectomy in sixteen (70%), four (17%), two (9%) and one (4%) patient, respectively. Indications for surgery were colorectal cancer (CRC), polyposis, Crohn’s disease and symptomatic diverticulosis in fourteen (61%), four (17%), three (13%) and two (9%) patients, respectively. The second procedure was a right-sided colectomy, a left-sided colectomy and a rectal resection in ten (43%), ten (43%) and three (13%) patients, respectively. Indications for surgery were the same than for the first procedure except in five (22%) patients with anastomotic stricture (after CRC, Diverticulosis and Crohn’s disease in three, one and one patient, respectively). Thirteen (56%) conversions were performed during left-sided colectomy, right-sided colectomy and rectal resection in seven (64%), five (50%) and one (33%) patient, respectively, including all patients with anastomotic stricture. One (4%) patient was reoperated for an anastomotic leakage (drainage and diverting stoma) and another suffered from gastrointestinal bleeding treated with transfusion. No other major morbidity was observed. Median hospital stay reached 8.7 days. Conclusion: In spite of high conversion rate, a repeat laparoscopic colectomy is feasible and safe, without obvious difference in terms of morbi-mortality and length of hospital stay.

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P238 - Intestinal, Colorectal and Anal Disorders

P240 - Intestinal, Colorectal and Anal Disorders

The Clinical Significance in the Conventionalization and Standardization of Reduced Port Surgery in Laparoscopic Right Colectomy

Non Operative Management of Acute Diverticulitis with Extraluminal Air in 21 Patients Followed by Delayed Laparoscopic Sigmoidectomy

H. Toma

A. Costanzi, G. Mari, J. Crippa, R. Pellegrino, A. Miranda, V. Berardi, M. Gerosa, D. Maggioni

Surgery, Harasanshin hospital, Fukuoka, Japan Aims: The bulky tumors frequently occur in right-sided colon and its manipulation remains technically demanding and the elongation of wound for the retrieval of the specimen inevitably impairs the appearance of the abdomen in the procedure for laparoscopic right colectomy. We introduced Reduced Port Surgery (RPS) in laparoscopic right colectomy and are dedicated to overcome these problems through the conventionalization and standardization of the procedure. The present study aimed to investigate the operative outcomes for RPS in laparoscopic right colectomy as well as clarify its clinical significance. Methods: Out of 51 cases with right-sided colonic cancer from April in 2012 to December in 2017 in our hospital, the operative outcomes of RPS in laparoscopic right colectomy was retrospectively reviewed and the comparison was made between the former (2012–2014) and latter (2015–2017) time period. The procedure for RPS: The zigzag incision at the umbilicus was made and subsequently GelPOINT was applied in the wound and total 3 ports were inserted for the manipulation. The further two ports were inserted at both sides of the abdomen, respectively. In the peritoneal cavity, the mobilization of the right-sided colon from the retroperitoneum was preceded followed by the ligation of the feeding vessels as well as regional lymphadenectomy and the resection and reconstruction (functional end to end anastomosis) was performed extracorporeally. The 3D laparoscopic system was introduced since April 2015. Results: total 51 cases at the median 69 years old. pStage0/1/2/3a = 7/18/14/12, operative time: median 220 min, blood loss: median 40 ml, open conversion:1 (former) vs o (latter) case, additional port: 1 (former) vs 0 (latter), postoperative complications (CD classification [ III): 2 (former) vs 1 (latter) cases, SSI: 6 (former) vs 3 cases (latter). maximal tumor size:6.5 cm in diameter, the elongation of the wound: 0 Conclusion: The clinical outcomes of RPS in laparoscopic right colectomy showed the time-dependent improvement. RPS in laparoscopic right colectomy was suggested the promising procedure of choice with regard to the contribution to the improvement in the operative manipulation and security in addition to the cosmetic advantage.

P239 - Intestinal, Colorectal and Anal Disorders Use of the Free AccessTM in Single-Incision Laparoscopic Right Hemicolectomy S. Kitashiro, S. Okushiba, Y. Kawarada, Y. Suzuki Surgery, Tonan Hospital, Sapporo, Japan Background: The single port right hemicolectomy was first used in 2008 by Bucher. Single-incision laparoscopy has gained significance recently. The umbilicus has been the preferred access site for Single-incision laparoscopy by Free accessTM Method: Between June 2013 and September 2017, 113 patients presenting with malignant disease underwent single-incision laparoscopy for right hemicolectomy. The median age was 73 years. Seven percent had undergone previous abdominal surgery, and the median body mass index was 22 (range, 18–34). Free accessTM with three trocar was used. The access site was used for extracorporeal linear stapled anastomosis and specimen extraction. Result: The average surgical time was about 170 minutes. In almost all operations, we successfully managed to get an adequate operative field. There were no additional trocar. Only 1 patients were postoperative complication above Clevian Dindou Grade III. Median blood loss was 5 mL. Median lymph node number was 18 (range, 11–42). The median hospital stay was 16 days. There was one mortality in this series. Morbidity, including wound infection, was 3%. Conclusions: This represents the largest experience with single-port laparoscopic right hemicolectomy to date. This technique was used with acceptable morbidity and mortality and without compromise of conventional oncologic parameters by colorectal surgeons experienced in minimally invasive technique. These findings support the use of Free accessTM in a single-port approach for patients requiring right hemicolectomy.

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Surgery, ASST Monza - Desio Hospital, Desio, Italy Established treatment for acute diverticulitis with extraluminal air has been sigmoid resection. However, emergency sigmoid resections are associated with high mortality and morbidity. Laparoscopic lavage has not yet been validated as an alternative in prospective, randomized controlled trials. Few recent studies have reported encouraging results of nonoperative treatment of acute diverticulitis with extraluminal air. Patients and Methods: Between 2013 and 2017 within the Unit of General Surgery of Desio Hospital (ASST Monza) a series of 21 consecutive patients was admitted with perforated tamponated acute diverticulitis, M:F = 15:6, average age 52 years (range 22–72), whose CT scan showed extraluminal intrabdominal air, in 20 case intraperitoneal, in 1 case retroperitoneal showing pneumomediastinum. 6 patients showed a temperature [ 38°C, WBC was above range in 19 patients, average value 16132 U/mmc (range 7000–24000), CRP was above range in all patients, average value 220 mg/L (range 8.99–432), Procalcitonin resulted above range in 8 patients, average value 4.62 ng/ml (range 0.05- 29). 7 patients required the placement of a percutaneous abdominal drain. All patients underwent wide spectrum antibiotic therapy and parenteral nutrition. Average duration of admission was 7 days (range 3–21). Results: All patients were followed up and after full recovery underwent a colonoscopy and a barium enema at least 30 days after the acute episode. Indication to laparoscopic left sigmoidectomy was given to all patients. Average interval between the acute episode and the readmission for elective surgery was 96 days (range 25–200). Laparoscopic sigmoidectomy was successful in all patients, average operative time was 175 minutes (range 105–270), conversion were nil, Clavien Dindo grade 1 complications were 2, and grade 2 were 1, none above grade 2. No patients required the placement of a drain tube. Discharge occurred in average 5th post operative day (range 3–9). All patients were followed up without incidence of further complications. Conclusion: Initial experience in non operative management of perforated acute diverticulitis with extra-luminal air seems to be encouraging and may be followed by safe laparoscopic sigmoidectomy. Results need to be validated by trials.

Surg Endosc

P241 - Intestinal, Colorectal and Anal Disorders

P242 - Intestinal, Colorectal and Anal Disorders

Short-Term Oncological Outcomes of Laparoscopic and Open Surgical Approach in Rectal Cancer Patients. Single Institution Experience

Laparoscopic Versus Open Surgery in Rectal Cancer Experience of a Single Tertiar Center

1

T. Mersich , Z. Dubo´czki2, P. Me´sza´ros3, T. Sztipits2, T. Strausz4, E. Pap5, T. Nagy6, E. Jedera´n7, M. Lipta´k2 1 Center of Oncosurgery, Dept. of Visceral Surgery, National Institute of Oncology, Budapest, Hungary; 2Center of Oncosurgery, National Institute of Oncology, Budapest, Hungary; 3Center of Oncosurgery, Dept of Visceral Surgery, National Institute of Oncology, Budapest, Hungary; 4Center of Oncopathology, National Institute of Oncology, Budapest, Hungary; 5Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; 6Department of Medical Oncology, National Institute of Oncology, Budapest, Hungary; 7Center of Oncoradiology, National Institute of Oncology, Budapest, Hungary

Introduction: Despite of the promising results of COLOR II study in rectal cancer patients across Europe, the ASCOZOG Z6051 and the AlaCaRT study has failed to demonstrate the non-inferiority of laparoscopic technique in rectal cancer patients. Main criticism of these studies are the relatively long observational period, the involvement of multiple centers and low number of elected patients per institutes. Our study was designed to collect single-center experiences retrospectively and provide data to verify the safety and efficacy of laparoscopic rectal surgery compared to open procedure in our Institute. Patients and Methods: 394 consecutive patient’s data were analyzed retrospectively between the period of Jan 2013 and Dec 2016. All patients were included for comparison with rectal adenocarcinoma, who were operated with curative intent. 171 Laparoscopic operation (LP) were compared to 223 open procedures (OP) with rectal cancer lower than 15 cm distance from the anal verge. Besides basic demographic patient characteristics, we investigated stage, grade, presence of preoperative chemoirradiation. Short-term onco-surgical quality measures such as circumferential resection margin (CRM), distal resection margin (DRM), number of harvested lymph nodes (LN), and quality of total mesorectal excisio (TME) were compared. Results: There were no significant differences between the two groups in terms of age, sex, tumor stage, grade and the two groups were comparable in terms of the proportion preoperative irradiation. LP procedures were associated with a longer operation time (150 vs 120; p \ 0.0001) and shorter hospital stay however the latter was non significant (7 days vs. 9 days; p \ 0.062). There were no significant differences between harvested lymph nodes (15 vs. 14), completeness of TME (78% vs 83%; p \ 0.57) CRM positivness (4% vs. 7%; p \ 0.19) and negative DRM (0% vs 0.5%). There were no differences in the rate of Clavien-Dindo GrIII complications in the first 30 days (7.5% vs. 8.3%) and the rate of anastomotic leaks (6% vs 8.8%). Conclusion: Our data suggests, that laparoscopic technique provides equal oncological safety and radicality in rectal cancer patients with shorter hospital stay and longer operative time. Long-term oncological results as local recurrence, disease free and overall survival rate are planned to be verified.

F. Zaharie1, G. Ciorogar2, C. Zdrehus3, N. Nadim1, C. Iancu1 1 Surgical Clinic no 3, IRGH, O. Fodor, UMF, I. Hatieganu, ClujNapoca, Romania; 2Surgical Clinic no 3, IRGH, O. Fodor, ClujNapoca, Romania; 3Department of ATU, IRGH, O. Fodor, UMF, I. Hatieganu, Cluj-Napoca, Romania

Aim: This study presents analysis reports of a single center comparing laparoscopic versus open rectal resection for rectal cancer. Material and methods: A total number of 639 patients diagnosed with rectal cancer and admitted at the Surgery Clinic, ‘‘Octavian Fodor’’ Regional Institute of Gastroenterology and Hepatology, Romania, between 2012 and 2017. The inclusion criteria were anterior rectal resections and abdominoperineal rectal resection with curative visa for rectal cancer. A number of 294 patients were operated with abdominoperineal rectal resection and 345 patients with anterior rectal resection. From the total number of 625 patients we had 186 cases with laparoscopic approach. Results: There were no statistically significant differences gender, age, body mass index (BMI), tumor site, TNM stage, operative time. Comparing with the conventional group, the laparoscopic group presented advantages regarding antibiotic and analgesic therapy, early mobilization, hospital stay, intraoperative blood loss, resuming oral nutrition, bowel transit resumption, postoperative complications and wound complications. Conclusions: The evolution of laparoscopic surgery in rectal surgery is exciting. Patients should have the opportunity to choose this type of approach in surgical centers. Along with other studies from literature laparoscopic surgery in rectal cancer brings advantages for the patients and for the hospital costs. Introducing laparoscopic approach in rectal surgical treatment is an important driver of growth in health care. Keywords: rectal cancer, radical anterior resection, laparoscopic rectal

P243 - Intestinal, Colorectal and Anal Disorders Laparoscopic Approach in Complex Entero-Visceral Fistulas: A Comparative Study D. Hazzan1, G. Pascal2, L. Segev3, E. Eden2, M. Venturero3, R. Shapiro3 1

Minimally Invasive Surgery, Sheba Medical Center, Ramat Gan, Israel; 2Surgery B, Carmel Medical Center, Haifa, Israell; 3Surgery C, Sheba Medical Center, Ramat Gan, Israel Background: In primary Crohn’s disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex entero-visceral fistulas. The aim of this study was to assess the feasibility and safety of laparoscopic surgery for complex enterovisceral fistulas and compared it with CD patients who underwent primary laparoscopic ileo-colic resection. Patients and Methods: All patients who underwent laparoscopic primary ileocolic resection (LICR) for complex entero-visceral fistulas between 07/2006 and 07/2017 were included. They were compared with all consecutive patients who underwent LICR for non-fistulizing CD in the same period of time. Patients with previous bowel resections or recurrent disease, were exluded. Results: Nineteen patients with twenty entero-visceral fistulas (group I), were compared to sixty-one patients who underwent LICR for non-fistulizing disease (group II). There were no differences between groups according age, sex, preoperative BMI, nutritional status and ASA score. There was no conversion to open surgery in both groups. There were no significant differences between groups in terms of operative time 120 (range 65–232) vs 117 (range 62–217) minutes), p = 0.7), hospital stay (6 (5–8) vs 7 (5–65) days, p = 0.56), overall morbidity 26.3% vs 16.4% (P = 0.33), major morbidity (Clavien-Dindo [ 3) 15.7% vs 10%, (p = 0.66) and reoperation rates 5.3% vs 4.9%, (P = 0.9). There was no mortality in both groups. Conclusions: Even though strong evidence is lacking and more contributions with larger size are needed, our modest experience confirm that the laparoscopic approach for complex entero-visceral fistulas in CD patients is both feasible and safe in the hands of experienced IBD surgeons with extensive expertise in laparoscopic surgery.

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P244 - Intestinal, Colorectal and Anal Disorders

P246 - Intestinal, Colorectal and Anal Disorders

Impact of Age in Patients Undergoing Laparoscopic Colorectal Surgery with an Enhanced Recovery Program: Results: Of A Monocentric Study ON 839 Patients

Rare Location of the Appendix as a Potential Threat For Bowel Obstruction. A Case Report

A. Vignali, M. Lemma, G. Guarneri, U. Elmore, R. Rosati

A. Ioannidis, A. Skarpas2 I.M. Christodoulou, E. Papachristou, G. Velimezis

Gastrointestinal Surgery, San Raffaele Scientific Institute -University Vita Salute, Milan, Italy

2nd Surgical Department, Sismanoglio General Hospital, Athens, Greece

Aims: to assess if elderly patients undergoing elective laparoscopic colorectal surgery could benefit of ERAS pathway at the same extent as younger patients in term of adherence and postoperative outcomes. Methods: Between April 2014 and November 2017, a total of 839 patients undergoing elective laparoscopic colorectal surgery with an ERAS pathway were identified from a prospective database relating to patient demographic, co-morbidity on admission, ASA score, BMI, neoadjuvant chemotherapy, operative and postoperative variables including compliance with ERAS items. Patients were considered ‘‘fit for discharge’’ when objective discharge criteria were fulfilled. Postoperative 30-day morbidity according to Clavien-Dindo classification as well as readmission to hospital were also recorded. Results: patients were divided in three groups according to age: group 1:\70 years (n = 510), group 2: 70–75 years (n = 112), group 3: [ 75 years (n = 217). Overall adherence to the ERAS items was 75.9%. Patients [ 75 years old showed a trend toward lower adherence to ERAS items when compared to the other two groups (74.1% in group 3 vs 76.4% and 77.4% in groups 1 and 2, respectively; p = 0.06). A significantly higher ASA score (p = 0.001) and lower preoperative haemoglobin level (p = 0.001) was observed in patients [ 75 years old. Overall morbidity and mortality rate were 30.8% and 0.7% respectively. Overall complication rate did not significantly differ between the 3 groups (p = 0.72). Mayor complications (Clavien-Dindo III-IV) occurred in 11.3% in group 1, in 7.1% in group 2 and in 11.5% in group 3 (p = 0.42). A similar re-operation and re-admission rate was observed in the three groups. Median time to fit for discharge was significantly higher in patients [ 75 years old, when compared to other two groups (6 days in group 3 vs 5 days in group 1–2 ; p = 0.03) as well as length of hospital stay (7 days in group 3 vs 6 days in group 1–2; p = 0.002). Conclusions: Our results show the safety of the ERAS program in elderly patients who are able to adapt to the ERAS pathway with similar complications rates and hospital stay only 1 day longer when compared to younger patients.

Aim: To present a rare case where a dislocated appendix was found and removed during an elective laparoscopic cholecystectomy. Methods and Results: A 35 year old male patient, with no previous history of abdominal operations, underwent a scheduled laparoscopic cholecystectomy due to symptomatic cholelithiasis. During laparoscopy, an unusual appendix was found dislocated, long and adherent to the umbilicus, creating a dense adhesion that could potentially cause differential diagnostic dilemmas in the future. It was decided to proceed with an appendectomy as well. The patient was discharged the next day. Conclusions: It is well known that the appendix can be found in various locations around the cecum which sometimes can make it difficult to locate and remove it. In our case it was found in an extremely rare location, that could cause various abdominal diseases and serious diagnostic dilemmas in the future, thus we always have to be aware that in such occasions, incidental appendectomy is acceptable and perhaps necessary.

P245 - Intestinal, Colorectal and Anal Disorders Conservative Management of Duodenal Perforation During Laparoscopic Cholecystectomy. Is It Feasible? P. Siaperas, I. Karanikas, A. Ioannidis, A. Tellos, G. Velimezis 2nd Surgical Department, Sismanoglio General Hospital, Athens, Greece Aim of the study: Duodenal injury is a rare but extremely serious complication, during Laparoscopic cholecystectomy, variating from 0.05% to 0.14%. Usually this happens from thermal injury, or false trocar insertion and rarely during the process of adhesiolysis. Most of these injuries, are managed surgically, open or laparoscopic. We present a case of conservative management of a duodenal injury. Methods: An 83 old man, was admitted in the Surgical ward due to Acute Cholecystitis. Initially he was treated conservatively because of antiplatelet therapy he was receiving, and later on with percutaneous cholecystostomy. Three months later he had a scheduled operation for removal of his gall bladder. The procedure was performed laparoscopically, though it was very challenging. Two days later there was a minimal duodenal leak, verified by CT and biochemical test from the drain, while patient was in a stable good condition. He was treated conservatively with parenteral nutrition for few days, and finally the leak sealed, and patient was discharged on day 14th. Discussion: It is of common knowledge that duodenal injuries in laparoscopic surgery, are the result either of thermal injury, trocar injury or adhesiolysis in difficult cholecystectomies, and unfortunately most of them are not recognized during the procedure. They occur from the 1st till the 16th day postoperative and have high morbidity and mortality rate. It seems that injuries in the 1st part have a better prognosis, comparing to 2nd and 3rd part. With careful evaluation of the patient, some of them may be treated conservatively. Conclusion: Duodenal injuries are luckily very rare in laparoscopic cholecystectomy, however they have high mortality rate, and usually they require surgical intervention. In the literature there are rare occasions of injury in the 1st part of duodenum, which have been treated successfully conservatively.

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P247 - Intestinal, Colorectal and Anal Disorders Is Locally Advanced Colon Cancer a Contraindication To Laparoscopic Resection? L. Esposito, M.E. Allaix, F. Rebecchi, G. Giraudo, M. Morino Department of Surgical Sciences, University Of Torino, Torino, Italy Aims: The role of elective laparoscopic resection (LR) for the treatment of locally advanced colon cancer is unclear. Most studies have retrospectively investigated the outcomes of LR for pT4 cancers, while clinical T4 (cT4) cancers are excluded in the large randomized controlled trials comparing LR and open resection (OR). The aim of this study was to investigate the outcomes in patients undergoing elective LR for locally advanced colon cancer. Methods: A prospective single-institution database including consecutive patients undergoing elective LR for clinical locally advanced colon cancer (preoperative diameter C 6 cm, N+) between March 1997 and March 2017 was retrospectively reviewed. A multivariate analysis considering gender, ASA score, body mass index (BMI), tumor location, tumor diameter assessed by computed tomography (CT) scan, previous surgery, intraoperative complications and intraoperative evidence of T4 cancer was performed to identify predictors of conversion to OR. Results: A total of 298 patients undergoing LR for locally advanced colon cancer were included in the study. There were 170 (57%) males; mean age and mean BMI were 68.2 ± 11.3 years and 25.1 ± 4.6 kg/m2, respectively. The tumor was in the right-sided colon in 139 (46.6%) cases, in the left-sided colon in 151 (50.7%) cases and in the transverse colon in 8 (2.7%) cases. A total of 61 (20.5%) LRs were converted to OR. A multi-visceral resection was needed in 12 (4%) of patients (3 completed laparoscopically and 9 converted to OR): 6 ileal resections, 4 partial cystectomies and 2 distal splenopancreatectomies. R0 resection was achieved in 99.7% of patients. On multivariate analysis, intraoperative evidence of cT4b cancer was the only independent risk factor for conversion (P = 0.044). Blood transfusions were needed in 31 (10.4%) of patients. Postoperative Clavien-Dindo type 3–4 complication rate was 4.4%; there was no 30-day mortality. Conclusions: Clinical locally advanced colon cancer should not be considered a contraindication to LR. Conversion to OR is recommended if laparoscopic en bloc multivisceral resection cannot be performed adequately.

Surg Endosc

P248 - Intestinal, Colorectal and Anal Disorders

P250 - Intestinal, Colorectal and Anal Disorders

Caecal Tuberculosis, A Rare Cause of Intestinal Obstruction Case Report

Gallstone Ileus. A Retrospective Analysis of a Rare Cause of Bowel Obstruction Based on Over 20 Years of Digitally Documented History

R.A. Omar, L.M. Ndao Surgery, Coast Provincial General Hospital -Mombasa/Kenya, Mombasa, Kenya Background: Tuberculosis (TB) is a life threatening disease which can virtually affect any organ system with an estimated global burden of 12 million. Primary intestinal tuberculosis is an uncommon manifestation of the disease and usually poses a diagnostic challenge as it mimics other abdominal pathologies like colonic malignancies and Crohns disease. High index of suspicion, colonoscopy and biopsy are key in making timely diagnosis. Objective: To highlight a case report of caecal Tuberculosis in an immunocompetent young patient as a rare cause of bowel obstruction. Methods: We present a case of a 44 year old female who presented with vague abdominal pains, episodes of blood streaked stools, intermittent features of intestinal obstruction and weight loss. Abdominal examination revealed a soft abdomen with minimal tenderness elicited on deep palpation of right lower quadrant but no obvious palpable masses or organomegally. Abdominal Imaging confirmed a colonic mass and an impression of a possible colonic malignancy entertained. Colonoscopy visualised an intraluminal caecal mass and biopsy histology showed a mass of tuberculous origin. A definitive diagnosis of caecal tuberculosis was made and patient started on appropriate pharmacotherapy with subsequent colonoscopy follow up. Conclusion: Primary intestinal tuberculosis although a not so common variant of TB when compared to pulmonary TB should be considered as part of the differential profile for a patient who presents with a colonic mass. High index of suspicion, colonoscopy with biopsies for histology are key in making the diagnosis.

J. Viktorin General Surgery, Nemocnice Jablonec nad Nisou p.o., Jablonec nad Nisou, Czech Republic Aims: The aim of this paper is to look into the documented history of this disease in our hospital and compare our results with reported findings and recommended treatments. Background: Gallstone ileus is an uncommon cause of bowel obstruction. Incidence reported in the USA in 1985 came to 30–35/1,000,000 admissions. Almost one quarter of non-strangulated small bowel obstructions in elderly patients is caused by gallstones. Experience with such uncommon conditions is usually scarce, especially in smaller hospitals. Over a relatively long period of digitalization in our hospital (since 1996), 14 cases were documented. Methods: We used SQL queries to extract information from the database of an already unused information system, along with a statistical feature of the current system, both based on the ICD code of gallstone ileus K563. From the available documentation, processable data were collected manually. Radiography findings were assessed by a second inspection of recent plain radiographs and radiologist findings of older radiographs. Results: The average age of documented patients was 79 years, with the median of 80.5 years. Women were more affected than men in the ratio 4:3. 5 patients underwent laparoscopic assisted surgery. The first laparoscopic surgery for gallstone ileus at our department was performed in 1996, 3 years after the first report of such a laparoscopic procedure by Montgomery. None of the patients underwent a single-stage procedure with cholecystectomy, or cholecystoduodenal fistula repair. There was no cholecystectomy performed on these patients even later in the postoperative history. There were no instances of direct perioperative mortality, postoperative mortality was high. Trigler’s Triad was not observed in any of our patients. Conclusions: Our findings are consistent with the reports. Instances of this condition are scarce, therefore surgeons rarely encounter it. Nevertheless, laparoscopic-assisted management of gallstone ileus is not technically challenging, and has become the preferred procedure at our department in recent years. Repair of the fistula and cholecystectomy is not considered necessary on asymptomatic patients.

P249 - Intestinal, Colorectal and Anal Disorders

P251 - Intestinal, Colorectal and Anal Disorders

A Comparison of Two Transanal Surgical Devices for the Treatment of Rectal Tumors

Intracorporeal Versus Extracorporeal Anastomosis in laparoscopic right hemicolectomy: A Systematic Review and Meta-Analysis

G. Russo, A. Burza, M. Picchio, F. Stipa General and Oncological Surgery, San Camillo De Lellis, Rieti, Rieti, Italy Aims: Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. Originally described in 2010 by Atallah TAMIS was designed as a practical alternative to TEM to be available in most hospitals. Methods: From February 2015 to March 2017 we analyzed patients with rectal lesions who were candidates for transanal resection. We devided the population in two groups: group A: 25 patients who underwent TEM: 12 male, 13 female, and group B: 25 patients who underwent TAMIS: 14 male and 11 female. The indications were: rectal adenocarcinoma in 21 patients (84%) in A and 18 patients (72%) in B; rectal adenoma in 3 patients (12%) in A and 2 patients (8%) in B; rectal carcinoid in 1 patient (4%) in A and 1 patient (4%) in B; rectal solitary ulcer in 3 patients (12%) in B and rectal GIST in 1 patient (4%) in B. We analyzed the groups in terms of: mean tumor size, mean operating time, mean postoperative stay, number of R0 resections, postoperative complications ed relapse in the first year. Results: The mean distance of neoplasm from anal verge was 6 cm in A and 4 cm in B. 5 patients in A (20%) and 2 patients of B (8%) had undergone neoadiuvant therapy. The mean tumor size was 3 cm in both groups. We had R1 resection in 6 patients (24%) in A and in 2 patients (8%) in B. All of this patients underwent another transnal resection to reach R0. Mean operating time was 150 min in A and 110 min in B. Mean postoperative stay was 5 days in A and 4 days in B. Postoperative complication occured in 5 patients (20%) in A and 4 patients (16%) in B. There were no recurrences in the first year after surgery. Conclusions: TAMIS is a feasible option to treat middle rectal neoplasm and it is superior to TEM in terms of cost, learning curve, set up and possible robotic application. It is equivalent to TEM in terms of mean operating time, R0 resections, mean postoperative stay and complications.

S.E. van Oostendorp1, W.A.A. Borstlap2, C. Sietses3, J.B. Tuynman1 1

Colorectal surgery, VU Medical Center, Amsterdam, The Netherlands; 2Surgery, AMC, Amsterdam, The Netherlands; 3 Surgery, Ziekenhuis Gelderse vallei, Ede, The Netherlands Background: Laparoscopic right hemicolectomy for colon cancer is associated with substantial morbidity despite the introduction of enhanced recovery protocols and laparoscopic surgery. Laparoscopic right hemicolectomy with an intracorporeal anastomosis (IA) is less invasive than laparoscopic assisted hemicolectomy, possibly leading to further decrease in post-operative morbidity and faster recovery. The current standard technique includes an extracorporeal anastomosis with mobilization of the colon, mesenteric traction and a extraction wound located in the mid/upper abdomen with relative more post-operative morbidity compared to extraction wounds located in the lower abdomen. Methods: A systematic review of PubMed and Embase databases was performed on studies comparing the intracorporeal versus the extracorporeal performed anastomosis in laparoscopic right hemicolectomy. Primary outcomes were mortality, short-term morbidity and length of stay. For quality assessment, the MINORS checklist was used. Meta-analysis was performed using a random-effects model, and a subgroup analysis was performed for data regarding short-term morbidity and length of stay in studies published in 2012C. Results: A total of 2692 papers were identified, 12 non-randomized comparative studies were included in the analysis with a total number of 1492 patients. No significant change in mortality was found (OR 0.36, 95% CI 0.09–1.46; I 2 = 0%). Short-term morbidity decreased significantly in favour of IA (OR 0.68, 95% CI 0.49–0.93; I 2 = 20%). Length of stay was decreased, but with serious risk of heterogeneity (MD -0.77 days, 95% CI - 1.46 to - 0.07; I 2 = 81%). Subgroup analysis for papers published in 2012 C resulted in an even larger decrease in short-term morbidity (OR 0.65, 95% CI 0.50–0.85; I 2 = 0%) and a significant decrease in length of stay with low risk of heterogeneity (MD -0.77 days, 95% CI - 1.17 to - 0.37; I 2 = 4%). Conclusion: Intracorporeal anastomosis in laparoscopic right hemicolectomy is associated with reduced short-term morbidity and decreased length of hospital stay suggesting faster recovery as shown in this meta-analysis.

https://doi.org/10.1007/s00464-016-4982-y

123

Surg Endosc

P252 - Intestinal, Colorectal and Anal Disorders

P254 - Intestinal, Colorectal and Anal Disorders

Short- and Long-Term Outcomes in Laparoscopic Rectal Cancer Resections in High-Risk vs Low-Risk Patients, a Comparative Study of Over 300 Resections

Experience of Single Incision Laparoscopic Colectomies in a United Kingdom District General Hospital

1

2

3

2

S. Panteleimonitis , M. Aradaib , O. Pickering , N. Kandala , N. Figueiredo4, A.C. Parvaiz4 1 Colorectal surgery, University of Portsmouth, Eastleigh, United Kingdom; 2SHSSW, University of Portsmouth, Portsmouth, United Kingdom; 3Colorectal surgery, Poole Hospital NHS Trust, Poole, United Kingdom; 4Colorectal surgery, Champalimaud foundation, Lisbon, Portugal

Aim: Previous abdominal surgery, neoadjuvant chemoradiotherapy, obesity and low-lying tumours have been considered to increase the intra-operative difficulty of laparoscopic rectal cancer resections. However, whether patients with these ‘‘high-risk’’ characteristics suffer from worse short- and long-term outcomes is largely debated. The aim of this study is to examine the short- and long-term outcomes of high-risk vs low-risk patients receiving laparoscopic rectal cancer resections. Methods: Prospectively collected data for consecutive patients receiving laparoscopic rectal cancer resections between 2006 and 2016 from two centres, one in the UK and one in Portugal, were analysed. High-risk patients were defined as patients with either one of the following characteristics: BMI of C 30, neoadjuvant chemoradiotherapy, tumour \ 8 cm from the anal verge and previous abdominal surgery. High-risk patients were compared with low-risk patients, which were defined as patients with none of the above characteristics. Results: A total of 313 patients were identified (227 high-risk, 86 low-risk). The two groups differed in terms of the ‘‘high-risk’’ factors, procedures performed and p T stage. Regarding shortterm outcomes blood loss and length of stay were higher in the high-risk group (10 vs 2.5 ml, p = 0.045; 7 vs 5 days, p = 0.001). Multivariate logistic regression analysis showed that gender (p = 0.022) and low-lying tumours (p = 0.007) were risk factors for morbidity and mortality (defined as the presence of any one of: anastomotic leak, 30-day mortality, reoperation or readmission). 5-year overall survival (OS) and disease-free survival (DFS) were similar between the 2 groups (high-risk vs low-risk: OS 78.8% vs 79.7%; p = 0.757; DFS 78.2% vs 84.8% p = 0.148). This was still the case when OS and DFS were stratified for stage. Cox regression analysis revealed that only stage affected DFS while age, neoadjuvant chemoradiotherapy and stage affected OS. Conclusion: Short-term outcomes such as length of stay may be worse in patients with high-risk factors, with gender and low-lying tumours identified as factors affecting morbidity and mortality. However, long-term outcomes are similar between high-risk and low-risk groups patients. Further, larger scale observational data is required to validate these results.

P253 - Intestinal, Colorectal and Anal Disorders Adult- Onset Acute Appendicitis As A Manifestation Of Colorectal Cancer: A 10- Year Multi-Centre Study Q Ul Ain1,2, Y Bashir1, E Eguare2; O Al Sahaf2, Prof. P Ridgway1, Prof. K C Conlon1 1 Professorial surgical unit, Department of Surgery, University of Dublin Trinity College, Tallaght Hospital, Dublin; 2Department of surgery, Naas General Hospital, Naas

Introduction: Appendicitis is one of the most common surgical causes of acute abdomen with an estimated lifetime risk of 8.6% and 7.6% in male and female respectively. The risk tends to decline above the age of 40, making appendicitis a rare entity and its presence creating a suspicion for tumour. However, association of acute appendicitis and colon cancer hasn’t been fully investigated and this study is designed to ascertain if patients with appendicitis are being investigated for colorectal cancer. Aim: To assess the linkage of acute appendicitis to colorectal cancer and adherence of guidelines for endoscopy post-operatively. Method: This is a retrospective observational study conducted on all patients that presented with adult-onset ([ 40 years of age) acute appendicitis in Tallaght and Naas general hospital from January 2007 to December 2016. All patients were assessed for demographic factors, length of stay and post-operative complications and post-operative colonoscopy. The timing and positive findings were assessed for each colonoscopy. All the data was recorded in Microsoft Excel and all data was analysed with SPSS v. 24. Results: Out of the 541 patients who underwent appendectomy for acute appendicitis, 43.4% male and 56.6% females. The average age was 51.2 years (40–86 years). The average length of stay was 12.1 (1–127) days. There were 91 (16.8%) patients who underwent post-operative follow-up colonoscopy. Out of the 91 patients, 18 (3.33%) patients had colonoscopy between 6weeks6 months post-operatively whereas 10 (1.85%) patients had colonoscopy between 6–12 months post-operatively. Conclusion: This study establishes that very few patients undergo colonoscopy after appendectomy. With colorectal cancer on rise, it is mandatory every elderly patient should have colonoscopy post-operatively. There is no conflict of interest and no disclosures to be made.

123

D. Zosimas1, A. Mansuri1, P.M. Lykoudis2, J. Huang1 1

General Surgery, Queen’s Hospital, Romford, United Kingdom; HPB Surgery & Liver Transplantation, Royal Free London, London, United Kingdom

2

Aims: Colorectal single incision laparoscopic surgery (SILS) is currently expanding with intention to enhance the advantages of multi-port laparoscopy. Limited literature exists regarding its application and real benefit specifically for inflammatory bowel disease (IBD).Aim of the study is to present our experience with colonic SILS for IBD and add evidence on whether it can be considered valid alternative for this disease. Methods: All patients who underwent colonic SILS for IBD from 2013 to 2017 were reviewed retrospectively. Parameters studied were demographics, BMI, duration of diagnosis, previous surgeries, preoperative treatment, indication, timing, intra-operative transfusion, operative time, length of stay, post-operative pain, mortality, complications and histology. Median length of follow-up was 26 months (3–57). Results: Fourteen patients underwent SILS subtotal or total colectomy with end-ileostomy (50% males).Median age at time of surgery was 30.5 years (17–82).Median disease duration was 40.5 months (9–180) except 2 patients (6 + years).Mean BMI was 23.7 (18.1–35).Two patients had previous abdominal surgeries. Eleven patients had steroids (84.6%) and 4 patients immuno-suppressants (28.6%) pre-operatively. Indication for surgery included incontrollable symptoms in 12 and steroid dependency in 2 patients. Surgery was performed electively in 6, semi-electively in 5 and urgently in 3 cases. Average operating time was 216.25 minutes (120–360).No intra-operative blood transfusion was needed. Two cases were converted to open (14.2%).Mean length of stay (LoS) was 5.1 days. Mean maximum pain score on inpatient pain scale was 5. Histology revealed ulcerative colitis in 12 cases (6 severe,1 moderate,1 mild) and 2 cases of Crohn’s colitis (one with a background of colonic cancer). Three patients presented complications. No reoperations were required and no mortality has been recorded. Three patients developed parastomal hernias (21.4%). Five out of 12 patients with UC declined further surgery, 3 are awaiting laparoscopic/SILS pouch formation,1 underwent SILS pouch formation, 1 SILS ileo-rectal anastomosis,1 patient had SILS completion proctectomy and 1 patient was lost in F/U. Conclusions: Although limited data and great variability across studies exist regarding SILS for IBD, these results are generally comparable with the current literature. Our initial experience demonstrates SILS in selected cases for IBD to be feasible and safe, enhancing the advantages of laparoscopy (pain, wound complications, LoS, cosmesis, recovery) and offering if indicated the option for subsequent SILS completion/restorative procedures. Informal feedback on cosmesis, patient satisfaction and quality of life are reported but further evidence is required. Training curves and the issue of parastomal hernias needs to be studied further.

Surg Endosc

P255 - Intestinal, Colorectal and Anal Disorders

P257 - Intestinal, Colorectal and Anal Disorders

Simultaneous Colectomy and Nephrectomy in Synchronic Tumors

The Safety and Efficacy of Laparoscopic Ventral Mesh Rectopexy - Can Excellent Outcomes be Achieved in a District General Hospital Setting?

A. Rabal Fueyo1, I. Go´mez Torres1, M.C. Martı´nez Sa´nchez1, J. Bollo Rodrı´guez1, M. Solans Solerdelcoll1, M.P. Herna´ndez Casanovas1, A. Sa´nchez Puy2, I. Giron Nanne2, E.M. Targarona Soler1 1

General Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; 2Urology, Fundacio´n Puigvert, Barcelona, Spain Introduction: The simultaneous presentation of renal cell carcinoma (RCC) and colorectal cancer (CRC) has a prevalence that ranges between 0.03% and 4.85%. The systematic use of noninvasive imaging tests like computed tomography (CT) has increased the diagnosis of asymptomatic renal tumors. Currently, the laparoscopic approach of CRC and RCC is well established. Simultaneous colectomy and partial nephrectomy have been achieved anecdotally. Aims: To present our experience in simultaneous colectomy and nephrectomy performed by laparoscopy. Methods: We present 8 patients with synchronic RCC and CRC treated simultaneously by laparoscopy. In our series, both the ipsilateral and contralateral approaches were used. The latter posed greater technical difficulties, including the change in the position of the trocars and the patient. Results: Simultaneous surgery was performed in 8 patients, 1 woman and 7 men, with a mean age of 71 years old, all patients were performed laparoscopically. 5 patients presented colonic tumor in sigmoid, 1 in right colon, 1 in transverse colon and 1 in rectum (9 cm from anal verge). 5 patients presented left kidney tumor, 2 presented right kidney tumor and 1 case was bilateral. Mean operative time was 320 minutes and mean intraoperative bleeding was 420 cc. We observed complications in 2 cases: one patient with an intraabdominal abscess and other with a urinary fistula after a partial nephrectomy (requiring total nephrectomy). Mean hospital stay was 13 days (Range: 6–30). Conclusions: Simultaneous laparoscopic treatment of renal and colon cancer is feasible and reproducible. The greatest advantage of this technical option is that it allows for both lesions to be treated at the same time, thereby eliminating the delay of treating the lesions in sequential surgeries. This also avoids a second anesthetic procedure and reduces discomfort for both patients and family members. And, as a second hospitalization is avoided, it is also a more cost-effective option.

N.A. Yassin, G. Orfanos, A.L. Farquharson, J.C.H. Lacy-Colson Colorectal Surgery, Royal Shrewsbury Hospitals, Shrewsbury, United Kingdom Introduction: Laparoscopic ventral mesh rectopexy (VMR) is a popular treatment for symptoms of obstructive defecation in patients suffering with rectal prolapse and rectorectal intussusception. The procedure is technically challenging and may result in serious complications, such as mesh erosions. This study examines the clinical and functional outcomes of patients undergoing VMR in a district general hospital. Methods: A retrospective analysis was made of a prospectively maintained database of all laparoscopic VMR procedures. All cases performed by 2 surgeons between February 2012 and June 2016 were included. Length of stay, post-operative complications and functional outcomes were assessed. Results: One hundred patients underwent a laparoscopic VMR procedure during the study period. The mean age was 59.7 years. Nineteen of the patients had external prolapse and 81 had functional bowel symptoms with internal prolapse (rectocele and/or intussusception) as demonstrated on proctography. Pre-operative investigations and pelvic floor multi-disciplinary team (MDT) discussions were performed in all cases. Forty percent of patients had previous pelvic surgery. In the external prolapse group there were 2/19 recurrences (10%). Functional improvement was reported in 96% of the patients. There was only 1 mesh complication (1%). Conclusion: Laparoscopic VMR is an effective and safe procedure for the treatment of symptoms of obstructive defecation. This procedure can be safely performed in the district general hospital setting with excellent clinical and functional outcomes. Thorough preoperative investigations, MDT discussions and standardisation of the surgical technique lead to excellent outcomes.

P256 - Intestinal, Colorectal and Anal Disorders

P258 - Intestinal, Colorectal and Anal Disorders

Does Intracorporeal Anastomosis Have an Advantage in Laparoscopic Right Colectomy?

Adopting Robotic Surgery in Rectal Cancer - Which are Our Short-Term Results: ?

P. Guarner, R. Bravo, V. Turrado, A. Otero, B. Martin, R. Almenara, D. Momblan, A. Ibarzabal, J.J. Espert, A.M. Lacy

P.J. Guarda Filipe Vieira, H. Domingos, J.F. Cunha, N. Figueiredo, A. Parvaiz

Gastrointestinal Surgery, Hospital Clinic Barcelona, Barcelona, Spain

Digestive Surgery, Champalimaud Foundation, Lisbon, Portugal

Aims: Laparoscopic right colectomy with an intracorporeal anastomosis (IA) is less invasive than extracorporeal anastomosis (EA), possibly leading to further decrease in postoperative morbidity and faster recovery. This study compares the short-term outcomes of both approaches in our centre. Methods: We describe a consecutive prospective series of 118 patients (95 EA versus 23 IA) who underwent right colectomy at our hospital since May 2015 to November 2017 reviewed retrospectively. Variables included are demographic, operative data and shortterm outcomes. Statistical analysis was performed with SPSS II program (SPSS, Inc., Chicago, IL). Results: The two groups were comparable regarding demographic data (age, sex, body mass index, ASA score and pathology). Surgical data: No differences were found in operative time (116 min EA vs 131 min IA). Differences were found in twisted anastomosis (2.2 vs 0%), blood transfusion (3.2 vs 0%) and location of assistance incision (right flank in 94.7% of EC vs Pfannenstiel in 73.9% of IC, which leads to lower incision complications as reported in literature). Postoperative outcomes: favorable results for intraoperative approach as bowel function measured by flatulences (1 vs 0.29 days) or transit (1.02 vs 0.35 days) and oral intake start (1.23 vs 0.71 days). Short-term outcomes (\ 30 days): similar hospital stay (4.1 vs 3.9 days) and morbidity (48% vs 43.5%, approximately 30% of which are Clavien-Dindo I). Complications: postoperative ileus (16.8 vs 13%), hematoma (2.1 vs 0%), infection (6.3 vs 4.3%), leakage (1.1 vs 0%) and incisional hernia (1.1% vs 0%). After discharge, 11.6 vs 8.7% of patients were readmitted to the emergency room and finally admitted to hospitalization in 6.3% vs 0% of cases, with a mean hospital stay of 4.83 days for EA group. No mortality was reported. Conclusions: These results demonstrate that IA with transabdominal extraction has better outcomes compared with EA for laparoscopic right colectomies. However, most of the variables are not statistically different, probably due to the small size of the sample. Nevertheless, there is a favorable tendency for intracorporeal anastomosis that may lead to better results, which improve patients’ quality of life and reduce sanitary costs.

Introduction: A precise, consistent and reproducible total mesorectal excision (TME) is the most important factor to achieve good postoperative results, regardless being open, laparoscopic or robotic. Purpose: Compare the short-term results in rectal cancer patients who underwent robotic and laparoscopic TME. Methodology: Prospective trial of the first 25 consecutive patients who underwent robotic TME since May 2016. Comparing (1:2) with the last 50 consecutive patients who underwent laparoscopic TME. Statistical analysis of demographic and clinical features and shortterm results, using GraphPad PRISM ver6.0. X2 or Fisher tests for categorical variables and U Mann-Whitney’s test for continuous variables. P \ 0.05 for statistically significance. Results: Demographic characteristics, stage and neoadjuvancy were identical in both groups. Robotic TME took longer operative time (260 vs. 215 min; p = 0.001), had more excised lymph nodes (26 vs. 18; p = 0.0032) and had shorter hospital stay (5 days vs. 7 days; p = 0.0072). There was no difference in perioperative morbidity (Clavien-Dindo [ 2 2 vs. 7; p = 0.65), anastomotic leak/dehiscence (0 vs 2; p = 0.148), reintervention (2 vs. 4; p = 0.3916) nor TME quality (complete 22 vs. 46; p = 0.7914). Discussion/Conclusion: Robotic TME allows faster recovery, shorter hospital stay and identical morbidity. Long-term oncologic results need to be ascertained.

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Surg Endosc

P259 - Intestinal, Colorectal and Anal Disorders

P261 - Intestinal, Colorectal and Anal Disorders

Combined Abdominal and Intersphincteric Transanal Endoscopic Ultralow Resection of the Rectum For Distal Rectal Tumors

Trans-Perineal Closure of Recurrent Rectovaginal Fistula with Mesh: An Innovative Approach

V. Bintintan1, R. Chira2, A. Cordos1, A. Bintintan2, D. Timofte3, C. Ciuce1, G. Dindelegan1 1

Cl. Chirurgie I, UMF Cluj Napoca, Cluj Napoca, Romania; Cl. Medicala I, UMF Cluj Napoca, Cluj Napoca, Romania; 3 Cl. Chirurgie, UMF Iasi, Iasi, Romania 2

Introduction: Patients with distal rectal tumors which do not invade the intersphincteric plane may still benefit from a surgical technique that preserves the anal sphincter. While the abdominal part of the operation is quite standardized, the perineal stage of the procedure is more cumbersome. Nevertheless, the latter is of utmost importance as it determines the R status of the resection and may also profoundly damage the anal sphincter due to excessive manipulation and trauma. Material and Method: Patients with indication of ultralow intersphincteric dissection operated by our team were registered in a prospective database. The surgical technique consisted of an abdominal phase, performed through an open or laparoscopic approach, followed by a transanal endoscopic phase using the TEO proctoscope (Karl StorzTM). The transanal part of the operation had the aim to offer adequate distal resection margin and to complete the distal total mesorectal excision as dissection progressed upwards along the endoplevic fascia until it joined the abdominal dissection. The coloanal anastomosis was performed in a standard fashion through a perineal approach and protected by a loop ileostomy. Results: Seven patients were operated by our team with this approach, 4 having adenocarcinomas, 2 patients with villous adenomas and 1 patient with fibrotic stenosis of the rectum. Tumor size varied from 2.5 to 9 cm while distance of the tumor from the dentate line varied within 5 mm to 45 mm. An R0 resection was obtained in all patients, the distal resection margin varying from 2 to 20 mm. Five patients developed an anastomotic fistula postoperatively that was treated with anal vacuum therapy and secondary surgical closure. On the long term, the function of the anal sphincter was evaluated as fair in 3 cases, good in 2 and excellent in further two cases. Conclusions: TEO offers a stable camera platform in the lower rectum and distal pelvis that enable distal transaction of the rectum and completion of total mesorectal excision while at the same time reducing trauma on the anal sphincter. The proposed technique offers an oncologically adequate sphincter saving approach for selected patients with distal rectal tumors.

D. Martinez, D. Aguirre Surgery, Tecnologico de Monterrey, Monterrey, Mexico The aim of this presentation is to explain a new technique to close recurrent rectovaginal fistulas using a less invasive approach and a mesh to achieve adequate epithelization and isolate the rectum from the vagina. Methods: A 62 year old female with a rectovaginal fistula secondary to a transvaginal histerectomy was intervened in two times to repair the fistula, using a vaginal and a rectal approach with no success. Patient continues with symptoms and a colonoscopy corroborated a 2 cm fistula at 6 cm from the anal margin. So a trans perineal approach was used, the fistula tract was identified, isolated and resected. Then a biological mesh was implanted between the vaginal and rectal wall to allow for faster and adequate epithelization. The patient has 6 months of follow-up asymptomatic with no reccurence. Results: During the follow-up, the patient remained asymptomatic, and there were no signs or symptoms of recurrence. There was no rectal incontinence, bleeding or pain. Conclusion: We present a case of successful treatment of a complex, recurrent rectovaginal fistula with a perineal approach to identify correctly the fistulous tract and then use a mesh to isolate both cavities. This technique is useful in when previous mucous flaps have failed.

P260 - Intestinal, Colorectal and Anal Disorders

P451 - Intestinal, Colorectal and Anal Disorders

Increased Lymph Node Yield using Fluorescence-Imaging Technique During Robotic Lateral Pelvic Lymph Node Dissection

Single Incision Laparoscopic Surgery for Small Bowel Diseases

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

1 Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan; 2Kagoshima University Graduate School of Medical and Dental Sciences, Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima, Japan

Colorectal Cancer Center, Kyungpook National University Hospital, Daegu, Republic of Korea Purpose/Background: Lateral pelvic lymph node dissection (LPND) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (CRT). However, technical difficulties make it possible that lateral pelvic lymph nodes (LPNs) are not dissected completely and, thus, remained in the pelvis. Near-infrared fluorescence imaging (FI)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. This study aimed to evaluate the efficacy of FI using indocyamine green (ICG) to identify LPNs during robotic LPND. Methods/Interventions: 48 rectal cancer patients who were suspected LPN metastasis and had received preoperative CRT were prospectively enrolled. ICG in a dose of 2.5 mg was injected around tumor preoperatively. All procedures were performed with a totally robotic approach. After completing LPND, FI was checked again for identifying remained LPNs and resecting them completely. Results/Outcome(s): The LPNs were successfully detected in 42 (87.5%) of the 48 patients. However, after accounting for eight cases, having finished adjusting ICG injection, the LPNs were successfully detected in 39 (97.5%) of 40 patients. The FI-guided LPND group (N = 42) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic LPND (N = 62). However, the mean number of unilateral harvested LPNs was 11.0 in the FIguided LPND group, which was greater than the mean of 6.5 in the conventional group. LPN metastasis was identified in 40.5% of the FI-guided LPND group, which was higher than that of the conventional group, 31.7%. Conclusions/Discussion: FI-guided LPND identifies lymph nodes in pelvic side-wall with great reliability. This contributes to increased LPNs yield compared to conventional robotic LPND. This technique should be considered to dissect them completely by preventing subsequent missing of nonvisible LPNs.

123

Y. Nagamine1, S. Mori2, Y. Kita2

Objective: Single-incision laparoscopic surgery (SILS) has become an evolving trend over the past few years. In this study, we aimed to describe a novel technique and our experience with 7 patients who underwent SILS for small bowel disease. Methods: This study was designed as a retrospective case series. Between July 2011 and June 2017, 10 consecutive patients who received SILS were included (4 male and 6 female, age: 45.7 ± 24.1 years old). We performed operations using access port methods through an umbilical skin incision. The outcomes were evaluated in terms of operation time, intraoperative blood loss, length of hospital stay after operation, and surgical complications. Results: Five patients who had Meckel’s diverticulum, one patient who had intussusception due to lipoma and one patient who had polyp with Peutz-Jeghers symdrome were performed SILS. Median surgery time was 90 minutes, and median intraoperative blood loss was 5 mL. Median length of post operative hospitalization was 7 days. There were no complications and mortality in relation to the operation. Conclusion: Our experience indicates that single-incision laparoscopic surgery is a safe and feasible procedure for patients with small bowel disease.

Surg Endosc

P452 - Intestinal, Colorectal and Anal Disorders

P454 - Intestinal, Colorectal and Anal Disorders

Partial Mesorectal Excision for High Rectal Cancer. Does it Play a Role?

Quality of Mesorectal Excision After Open, Laparoscopic, Robotic and Transanal TME

R. Pena1, F.B. de Lacy1, J.J.E.M. van Laarhoven2, V. Turrado1, B. Martin-Perez1, A. Otero1, R. Almenara1, A.M. Lacy1

M.M. Lirici1, S.M. Tierno1, V. Romeo1, M. Giordano2, C.E. Vitelli3

1

Gastrointestinal Surgery, Hospital Clı´nic of Barcelona, Barcelona, Spain; 2Gastrointestinal Surgery, Jeroen Bosch Ziekenhuis, ’sHertogenbosch, The Netherlands Aims: The transanal approach represents a minimally invasive alternative offering good results for total mesorectal excision (TaTME) for mid and low rectal cancer. Nevertheless, the evidence of safety and efficacy of partial excision (TaPME) for proximal tumors is scarce. This study aimed to report our short-term outcomes with TaPME for high rectal cancer in an attempt to determine if this technique plays a role in these cases. Methods: All patients with rectal cancer treated at our hospital by TaTME and TaPME between October 2011 and July 2017 were prospectively included in a standardized database. Patients with high rectal cancer (tumors located 10–15cm from anal verge) were analyzed. Demographic data, clinical staging, postoperative complications, pathology reports and oncological outcome were registered. Results: A total of 84 patients were analyzed. Mean age was 68.07 years (SD 12.92) with 57.1% male (n = 48) patients. T staging included T1 through T4 tumors. Mean operative time was 142.8 min (SD 53.93) with no conversion to open surgery. Mechanical anastomosis was performed in 98.8% (n = 83) and a diverting ileostomy in 40.5% (n = 34) of the cases. The distal resection margin was free in all cases with a mean of 4.12 cm (SD 1.69). The mean number of yielded lymph nodes was 18.46 per specimen (SD 7.69). In the 30-day postoperative period, complications were reported in 41.0% (n = 34), with a rate of major complications of 22.7% (n = 19). Anastomotic leakage rate was 13.1% (n = 11) including 91% (n = 10) of cases in which ICG was not yet employed (p = 0.166). There was no report of mortality. The median follow-up time was 20.7 months (IQR 13.2) with overall and disease-free survival rates of 98.6% and 80.3%. Local and systemic recurrence were diagnosed in 4% (n = 3) and 17.3% (n = 13) of the cases. Conclusion: TaPME seems to be safe and feasible in the treatment of high rectal cancer, with good specimen quality and short-term outcomes. Further evaluation is needed to achieve validation and possibly expand indications for the transanal approach beyond mid and low rectal cancer.

P453 - Intestinal, Colorectal and Anal Disorders ICG Lymphatic Visualization During Laparoscopic Right Hemicolectomy Could Achieve More Radical D3 Lymphadenectomy of Advanced Right-Sided Colon Cancer S.Y. Park1, J.S. Park1, H.J. Kim2, G.S. Choi1, I.T. Woo2 1 Department of Surgery, Kyungpook National University, Daegu, Republic of Korea; 2Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea

Background: The concept of complete mesocolic excision with central vascular ligation emphasizes dissection of all drainage lymph nodes, including lymph nodes along the superior mesenteric artery/superior mesenteric vein (SMA/SMV), like Japanese D3 lymph node dissection. This study is aimed to investigate the pathologic radicality of indocyanine green (ICG)-guided D3 lymph node dissection for advanced right-sided colon cancer. Methods: We performed ICG-guided laparoscopic right hemicolectomy with D3 lymph node dissection for 27 patients with clinical T3/4 tumor after completing the informed consent form between June 2016 and October 2017. The dissected lymph nodes were classified as n1 (pericolic), n2 (intermediate), or n3 (main) lymph nodes. The clinicopathological outcomes of patients in the ICG group were compared with the 79 patients of the conventional group (white light only). Results: The fluorescing lymph nodes along the SMA and SMV were identified in 23 patients (85%) of the ICG group. In two patients (14.3% of patients hepatic flexure or transverse colon cancer), fluorescing lymph flow and lymph nodes were found along the right gastroepiploic vessels and en bloc resection was performed. There were no significant differences between the ICG and conventional groups regarding age, sex, body mass index, tumor location, colon length, and pathologic tumor depth. The number of all harvested lymph nodes in the ICG group was significantly larger than that of the conventional group (41 vs 33; p = 0.011). The numbers of the harvested n1 and n2 lymph nodes were not different between the two groups. The number of the harvested n3 lymph nodes was significantly higher in the ICG group than that of the control group (16 vs 9; p \ 0.01). In patients with metastatic lymph nodes, the numbers of n2 and n3 lymph nodes were significantly higher in the ICG group than those of the conventional group (11 vs 6, p = 0.003 and 13 vs 7, p = 0.039). Conclusions: ICG-guided laparoscopic surgery facilitated to remove more lymph nodes that may harbor occult metastatic cancer cells during right hemicolectomy with D3 lymphadenectomy. The pathological radicality could be confirmed from the increased number of harvested lymph nodes.

1 Surgery, AO San Giovanni Addolorata, Rome, Italy; 2Anatomia Patologica, AO San Giovanni Addolorata, Roma, Italy; 3Chirurgia 1, AO San Giovanni Addolorata, Roma, Italy

Colorectal cancer is third most common cancer in the World. Removing all of the mesorectum containing lymphnodes and tumour is paramount for a good outcome and minimal recurrence within the pelvis. Involvement of the circumferential resection margin (CRM) and the quality of total mesorectal excision (TME) are related to local recurrence and long-term survival. The aim of the present prospective study is to evaluate safety and efficacy of laparoscopic resection vs open vs robotic versus transanal TME. A successful resection was defined when meeting all the following criteria:complete total resection margin, clear CRM ([ 1 mm) and clear distal resection margin ([ 1 mm). Specimen from a series of 116 patients undergoing TME for histological proven rectal cancer from July2015 to November2017, were collected and pathology exam data recorded prospectically. Patients were divided according to surgical technique in four groups:open (OP), laparoscopic (VLS), robotic (ROB) and TaTME (Ta).Localization of tumour was categorized as:upper rectum (10–15cm from anal verge), middle rectum (5–10 cm), low rectum (\ 5 cm).Demographic data and histopathologic characteristics of the tumour such as lesion size, distance from anal verge, regression grade after neoadjuvant reatment according to Mandard scale and number of lymph nodes retrieved were analysed. CRM was defined involved when tumor cells were present within 1 mm from lateral surface of mesorectum. Completeness of mesorectal excision was defined according to Quirke classification as complete, nearly complete or incomplete. Thirthy-one (26.7%) patients underwent open rectal resection, 43 (37.1%) laparoscopic rectal resection, 24 (20.7%) robotic rectal resection and 18 (15.5%) were treated by transanalTME. Six patients (5.2%) were converted from mini-invasive to open rectal resection. 39 patients (33.6%)with cancer in the upper part of rectum underwent partial mesorectal excision (PME);36 patients (31.9%) with cancer in the middle rectum and 41 patients (35.3%) with cancer in the lower rectum underwent TME (67.2%). There were no statistically significant differences between group with respect to sex, age, body mass index, ASA grading, tumour stage and tumour location CRM resulted positive in 7 patients (6%),4 in the VSL group,2 in the ROB group and 1 in the TaTME group. Overall, mesorectal excision resulted complete in78 patients (68.1%), nearly complete in17 patients (14.7%) and incomplete in 20patients (17.2%). There were no statistically significant differences between groups (p = 0.3).In the sub-group analysis, considering patients with middle and low rectal cancer who underwent TME (77 patients) a completeTME was found in 76.5%patients in OPg.,63.6%in VSL g.,77.8.% in TaTME g. and 50% in ROB group. Nearly complete ME was found in 11.8% in the OP g.,4.5% in the VSL g.,16.7% in theTaTME g. and 25% in the ROB group. IncompleteTME was found in 11.8% in the OP g,31.8% in the VSL g.,25% in the ROB g. and 5.6% in the TaTME group (p = 0.04). Multivariate regression analysis showed that surgical technique was associated with the completeness of mesorectal excision (p = 0.02). No differences were found in term of lymph-nodes retrieval (p = 0.8) and distal resection margin (p = 0.2). This prospective single center study investigates hysto-pathologic assessment of the resected protectomy specimen focusing on clear distal and radial margins and completeness of TME, the combination of which defines optimal surgery, and has been shown in other trials to be associated with better long term oncologic outcomes. We demonstrates that TaTME is not only a feasible and safe technique but improves oncological resection principles in middle and low rectal cancer resulting in better mesorectal excision. Further prospective comparative study are needed to clarify which is the gold standard technique for middle and low rectal cancer.

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Surg Endosc

P455 - Intestinal, Colorectal and Anal Disorders

P457 - Intestinal, Colorectal and Anal Disorders

Three-Dimensional vs Two-Dimensional Minimally Invasive Surgery a Comparison of the Visual Work Load and Surgical Outcomes

Diverticular Disease: A Nigerian Cohort Study

M. Inama General and Mininvasive Surgery, Hospital Pederzoli, Peschiera del Garda, Italy Context: Three-dimensional imaging has been introduced to enhance depth perception and facilitate operations. The clear benefit of the 3D laparoscopy has never been tested. Some concerns emerged regarding the possible negative effects over the visual system in those surgeons who performed 3D surgery every day.

Aim: To evaluate the visual work load in surgeons performing 3D laparoscopic operations and to confirm the advantages of 3D technology in surgical operations. Material and Methods: We performed a observational clinical trial in which all patients older than 18 years and affected by neoplastic or inflammatory colo-rectal disease were enrolled. All the patients were randomized into 2 groups: 3D laparoscopy or 2D laparoscopy. Concerning the evaluation of the visual stress we used 2 subjective tests: NASA task load index and the Simulator Sickness Questionnaire. Results: From January 2015 to September 2017 a total of 313 patients were enrolled in the study: 231 in the 3D group and 82 in the 2D group. Preoperative, intraoperative and postoperative data were collected. There were 181 males (57.83%) and 132 females (42.17%). The median age of the entire population is 68.5 years (IQR 58–82). Over 313 operations, only 1 case belonging to the 3D group was converted in laparotomy due to fibrosis secondary to neo-adjuvant radiotherapy for T4 rectal cancer. The median operative time shows no difference between the 3D and the 2D (p 0.611). Less drains were positioned at the end of the 3D operations comparing with 2D procedures (0.013). The stapled anastomosis was the most frequent. The other intra-operative findings showed no significant difference between the two study groups. Conclusions: 3D HD camera system introduced the depth perception in laparoscopic mininvasive surgery. Recent technological improvements have made the 3D vision similar to real vision and the sickness felt by surgeons performing the 3D procedures is not superior to that felt in 2D laparoscopy. Although few optical problems remain, the SSQ questionnaire reveals that 3D vision is still perceived stressful by the surgical equipe. 3D operations are as safe and effective as the 2D.

E. Ray-Offor, P.O. Igwe Dept of surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria Introduction: Diverticular disease is uncommon among Africans with traditional high fibre diet. A westernization of diet, increasing aged population and access to colonoscopy in a metropolitan population is likely to affect the prevalence pattern. This study aims to study the prevalence of diverticular disease in a Nigerian metropolis of Sub-Saharan Africa. Patients and Method: This is a cohort study of all consecutive patients presenting for colonoscopy to a referral ambulatory care endoscopy facility in Port Harcourt metropolis, Niger Delta region of Nigeria from March 2014-September 2017. The variables studied included: demographics; clinical and endoscopic findings; treatment. Statistical analysis was done using SPSS (Chicago lL, USA) version 20. Results: A total of 213 colonoscopies were performed with 29 (13.6%) cases of diverticular disease. The age range of patients was from 27 to 80 years (mean 62.76 ± 12.77yrs). There were 22 males and 7 females; a male to female ratio of 3:1. Bleeding per rectum was the most common presentation. Seven (24.1%) and 6 (20.7%) cases showed evidence of inflammation and bleeding respectively;[5 diverticula were seen per patient in 18 cases. The left colon was affected in 23 (79.3%), especially the sigmoid colon in 15 (51.7%) cases. Colectomy was performed for 3 patients. Conclusion: Diverticular disease is not uncommon. A left-sided colon and male sex predominance are noted.

P456 - Intestinal, Colorectal and Anal Disorders

P458 - Intestinal, Colorectal and Anal Disorders

Endo-Rectal Foreign Body: a Treatment Strategy

Laparoscopic Cytoreduction Could Achieve Similar Completeness as Open Surgery in Patients with Limited Peritoneal Metastasis of Colorectal Cancer

V. Lazzari, S. Celotti, E. Asti, L. Bonavina General Surgery, Irccs Policlinico San Donato, San Donato Milanese, Italy Background: There are descriptions of retained rectal foreign bodies since the 16th century and their incidence is increasing. In most cases it is due to an intentional insertion for sexual stimulation, but there are often evidence of insertion for self-treatment of anorectal disorders or criminal intent. Often the hospital presentation is delayed due to embarrassment and shame, and patients do several attempts to self-retrieve the object. The management of these patients requires diagnostic examinations to find out a possible bowel perforation or bleeding. Size, shape, material and precise position of the foreign body may influence the therapeutic choice. Patient: A 48-years-old man presented to the Emergency Room with a retained showerhead in the rectum. The patient was haemodynamically stable and the abdomen was soft, painful. At rectal exploration, the object was palpable and there was no bleeding. Abdomen X-ray and CT scan showed no signs of perforation. Due to the impossibility of proceeding with manual extraction in the Emergency Room due to the size (10 cm 9 8 cm) and the position of the object, we attempt to extract it transanally in the operating room and under general anesthesia, unsuccessfully. A laparotomy was then performed. Even through this access it was impossible to transpose the foreign body manually towards the rectum because it was fitted in the pelvis between the pubic symphysis and the sacrum. We then proceeded to a colotomy from which the object was extracted. Due to the length of the colotomy it was considered appropriate to pack a protective colostomy, which was closed 3 weeks after the procedure. Discussion: Accurate medical history, physical examination and radiological diagnostics are essential to identify in the most precise way shape, size and location of the foreign body in order to better plan the extraction mode. In case of voluminous foreign bodies it is preferable carring out the extraction in the operating room, in narcosis, to limit the patient’s discomfort and avoid the proximal migration of the foreign body. A psychiatric consultation is always advisable to treat any obsessive-compulsive disorder that could be the basis of the repetition of abnormal behavior.

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S.Y. Park1, J.S. Park1, H.J. Kim1, I.T. Woo2, G.S. Choi1 1

Department of Surgery, Kyungpook National University, Daegu, Republic of Korea; 2Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea Background: Laparoscopic approach has been rarely reported for colorectal cancer patients with peritoneal metastasis. The purpose of this study was to investigate the safety and completeness of laparoscopic cytoreductive surgery for colorectal cancer patients with limited peritoneal metastasis, in comparison with open surgery. Methods: In our institution, laparoscopic surgery performed for colorectal cancer patients with peritoneal metastasis since December 2004. Data for colorectal cancer patients with peritoneal cancer index (PCI) B 10 were identified from the institutional database. Twenty-five patients underwent open surgery and 46 patients underwent laparoscopic surgery between December 2004 and December 2017. We compared the clinicopathological outcomes of laparoscopic surgery with those of open surgery. The primary outcome of this study was the completeness of cytoreduction (CC). The secondary outcomes were perioperative outcomes, pathologic outcomes, and survival outcomes. Results: The patient characteristics were not significantly different between the two groups. Fifteen patients (60%) in the open group and 33 patients (71.2%) in the laparoscopic group had PCI B 5 (p = 0.313). Five patients (10.8%) in the laparoscopic group were converted to open surgery. During the cytoreductive surgery, CC-0 was confirmed in 46 patients (100%) of the laparoscopic group and 23 patients (92%) of the open group (p = 0.249). Operation time and postoperative complication rate were similar between the two groups. However, the hospital stay of the laparoscopic group was significantly shorter than that of the open group (13.7 ± 6.9 vs. 20.5 ± 11.2; p = 0.003). Postoperative morbidity occurred in 4 patients (8.7%) in the open group, and 4 patients (8.7%) in the laparoscopic group (p = 0.320). Operative mortality occurred in one patient in each group. The 3-year overall survival rate was 75.4% in the open group, and 69.0% in the laparoscopic group (p = 0.623). The 3-year disease-free survival rate was 28.5% in the open group, and 29.2% in the laparoscopic group (p = 0.383). Conclusions: Laparoscopic surgery was technically feasible and did not impair the surgical completeness of cytoreduction and survival outcomes of colorectal cancer patients with limited peritoneal metastasis.

Surg Endosc

P459 - Intestinal, Colorectal and Anal Disorders

P477 - Intestinal, Colorectal and Anal Disorders

Long-Term Oncologic Outcomes After Neoadjuvant Chemoradiation Followed by Intersphincteric Resection for Locally Advanced Low Rectal Cancer

The Laparoscopic Management of Acute Appendicitis in the Third Trimester of Twin Pregnancy-Technical Details

J.S. Park Colorectal cancer center, Kyungpook National University Hospital, DAEGU, Republic of Korea Purpose/Background: With the frequent use of neoadjuvant chemoradiotherapy (PCRT), the indication of intersphincteric dissection with coloanal anastomosis (ISR) has been expanded to locally advanced low rectal cancer despite risk of inadequate resection margin. However, the oncologic safety of ISR in such advanced tumor has not been defined. The purpose of this study was to determine the oncologic outcomes and clinical factors affecting survival in patients who underwent PCRT following ISR for locally advanced rectal cancer located 3 cm below the anal verge. Methods/Interventions: From January 2009 to September 2015, 147 patients with low rectal cancer undergoing ISR with coloanal anastomosis with PCRT were included. 3-year disease-free survival (DFS) and local recurrence (LR) rates were calculated using KaplanMeier methods. Results/Outcome(s): After a median follow-up of 32 months (range 8–94 months), estimated overall 3-year DFS, and LR rates were 69.9% and 11.7%, respectively. Complete resection with negative histologic margins was achieved in 83% (n = 122). Pathologic T stage (yp T stage) and circumferential resection margins (CRM) status were important postsurgical predictors of outcomes. The 3-year DFS was 47.4% for patients with ypT3 compared with 82.0% for ypT0-2 patients (P = .001). The 3-year DFS for involved pCRM was 36.5% versus 69.7% (P = .003). Multivariate Cox regression analysis revealed that ypT stage, ypN stage and pathological CRM status were the independent factors affecting survival rates. Clinical T-stage and pathological distal margin status were not related to an increased risk of recurrence. Conclusions/Discussion: After a median follow-up of 32 months (range 8–94 months), estimated overall 3-year DFS, and LR rates were 69.9% and 11.7%, respectively. Complete resection with negative histologic margins was achieved in 83% (n = 122). Pathologic T stage (yp T stage) and circumferential resection margins (CRM) status were important postsurgical predictors of outcomes. The 3-year DFS was 47.4% for patients with ypT3 compared with 82.0% for ypT0-2 patients (P = .001). The 3-year DFS for involved pCRM was 36.5% versus 69.7% (P = .003). Multivariate Cox regression analysis revealed that ypT stage, ypN stage and pathological CRM status were the independent factors affecting survival rates.

K. Gu¨ndogdu1, F. Altintoprak2, E. Dikicier2, M.Y. Uzunoglu3, Y. Akdeniz4 1

Genel Cerrahi, C¸erkezko¨y State Hospital, Tekirdag, Turkey; General Surgery, Istinye University Medical Faculty, Kocaeli, Turkey; 3General Surgery, Siirt State Hospital, Siirt, Turkey; 4General Surgery, Sakarya University Medical Faculty, Sakarya, Turkey

2

Aim: Acute appendicitis is a challenging problem in pregnancy. By improvement of radiological imaging opportunities and laparoscopic experience, definitive minimal invasive surgery is getting feasible. The aim of this video presentation is to share technical details of minimal invazive appendectomy in third trimester pregnant case. Case Presentation and Surgical Technique: A 27-year-old woman, has twin pregnancy in 36th week, consulted with abdominal pain complaint at the right lower quadrant. Physical examination was compatible with acute appendicitis. She had no history of operation or disease. Laboratory examinations indicated 21.000/mm3 leucocytosis. Upon ultrasonographic inadequate imaging due fetal transposition, applied abdominal magnetic resonance imaging defined inflamed and perforated appendicitis and right hydroureteronephrosis with 2 cm diameter. A 10 mm port was initially inserted in the supraumblical region under direct vision. Additional 5 mm working ports were inserted in the left flank. Perforated appendicitis was detected in operation, appendectomy was performed with Ligasure and appendectomy material was taken out with endobag. She was uneventfully discharged on the second postoperative day. Discussion: Acute appendicitis is the most common cause of acute abdomen during pregnancy. Due to most of the signs of appendicitis are also found physiological during normal pregnancy period, diagnosis of acute appendicitis during pregnancy still remains challenging. Some authors encourage laparoscopic approach, whereas some have found open appendectomy to be safer. In a hospital-based retrospective review of 65 pregnant women with appendicitis, laparoscopic appendectomy was found to be a safe and feasible approach. There are also some limitations of laparoscopic appendectomy such as instance of diffuse peritonitis, advanced pregnancy with enlarged uterus, or lack of experience of the surgeon. In addition to shorter hospital stay and reduced risk of thromboembolic events, authors state that even in perforated cases, laparoscopy appears safe in pregnant patients also in last trimester. Conclusion: By the expanding horizon of minimal invasive surgery, laparoscopic treatment of acute appendicitis in pregnancy is quite feasible in convenient cases, even in third trimester.

P460 - Intestinal, Colorectal and Anal Disorders

P478 - Intestinal, Colorectal and Anal Disorders

An Experience of a Laparoscopic Low Anterior Resection by The TA-TME/ISR Combined with Pull-Through Technique

Long-Term Outcome of Laparoscopic Colon Cancer Resection. Review of 602 Cases

T. Mukogawa, S. Miyao, A. Nishioka, H. Ishikawa, S. Ko, A. Watanabe

C.P. Pe´rez San Jose´1, M. Aguinagalde1, A. Bilbao2, B. Uriarte1, A. Loizate1

Surgery, Nara prefectual medical center, Nara, Japan Background: Although laparoscopic surgery for rectal cancer has become wide -spread in Japan, it has the technical difficulties in patients with obesity, a narrow pelvis, or a bulky tumor. Recently, trans-anal total mesorectal excision (Ta-TME) has been introduced to overcome the difficulties. The procedure has potential advantages which include the facilitation of the dissection of the anorectum, regardless of the patient body habitus. On the other hand, intersphincteric dissection (ISR) procedure with the diverting ileostomy is performed for a very low rectal cancer in Japan. Lately, we performed a laparoscopic low anterior resection by the Ta-TME/ISR combined with pull-through technique without the diverting ileostomy for the obese woman who was diagnosed a very low rectal cancer and refused stoma strongly. Case Presentation: A 57-year-old woman was referred to our hospital for the treatment of a T3 very low rectal cancer. Because she was an obese patient (BMI 33.08 kg/m), we performed neoadjuvant chemotherapy (XELOX regimen, 3 cycles) for tumor reduction and weight loss. The tumor reduced remarkably and completely response was obtained endoscopically. She hoped a stomaless surgery strongly. So, we performed a laparoscopic low anterior resection by the Ta-TME/ISR combined with pull-through technique without the diverting ileostomy. Operative time was 454 minutes and blood loss was 50 mL. 10 days later, we performed the second operation, the colo-anal anastomosis. Operative time was 52 minutes and blood loss was only a little. Histological examination showed a pathological complete response in the specimen and no lymph node metastasis. The post-operative clinical course was good with no major complication. Conclusion: A laparoscopic low anterior resection by the Ta-TME/ISR combined with pull-through technique was safe and useful for the obese patient. It was because surgeon’s stress was reduced by the omission of the colo-anal anastomosis and the diverting colostomy in the first operation, and patient’s stress was reduced by the stomaless surgery.

Surgery, Basurto University Hospital, Bilbao, Spain; 2Research unit, Basurto University Hospital, Bilbao, Spain

1

Introduction: The laparoscopic approach on colon cancer is used in the surgical services for 2 decades. We show our results. Material and Methods: A total of 602 patients with colon cancer were operated on by laparoscopy for colon cancer between 1998–2017. 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. 452 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 72 ± 11 years. The location of the tumours was: right colon 37%, transverse 8%, descending 13%, sigmoid 40% and synchronous carcinomas in 2%. The surgical techniques used were: right hemicolectomy 43%, left hemicolectomy 13%, subtotal colectomy 2%, sigmoidectomy 34%, LAR 4%, segmental resection 3 9 6% and Hartmann operation 0.4%. It was converted to open surgery in 2 cases (0.23%). The operative time was 165 ± 25 minutes. The mean hospital stay was 7.5 ± 6.2 days. The rate of complications was 9.6% and of reoperation in 4.1%. The operative mortality was 0.99% (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 88%, stage I 95%, stage II 90%, stage III 79%, stage IV 13%. Kaplan-Meier survival curves for time to cancer death showed significant differences between all stages (p \ 0.05), except stages I and II (p = 0.21). The global rate of recurrence was 10.53% (3.57%, 9.14% and 19.64% in stages I, II and III, respectively). Kaplan-Meier survival curves for time to recurrence showed significant differences between stages I and II vs. III. Conclusions: Laparoscopic colectomy is a safe procedure with low morbidity and mortality and good oncological results.

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Surg Endosc

P481 - Intestinal, Colorectal and Anal Disorders

P488 - Intestinal, Colorectal and Anal Disorders

Does Laparoscopic Colorectal Surgery Result in Short and Long Term Post-Operative Cognitive Decline (POCD)?

Our Experiences with Trans Anal Endoscopic Operations at a District General Hospital

P. Vitish-Sharma1, R. van Oss2, B. Guo3, C. Maxwell-Armstrong2, A.G. Acheson2

P.V. Thambi1, D. Garg2, S. Rajeev1, Y.K.S. Vishwanath3, A. Agarwal1, D. Kumar1, D. Harji1, T. Gill4

1

1

Colorectal Surgery, Oxford University Hospitals, Maidenhead, United Kingdom; 2Division of Surgery, Nottingham University NHS Trust, Nottingham, United Kingdom; 3Medical Statistics, University of Nottingham, Nottingham, United Kingdom Postoperative cognitive dysfunction (POCD) is defined as a new cognitive impairment arising after surgical intervention. Cognitive function can be assessed using validated cognitive function tests including: N Back, Stroop; and Lexical Decision Making Task. There is some concern that prolonged head-down positioning during laparoscopic colorectal surgery may cause POCD. Patients with POCD may experience prolonged hospitalisation and longer recovery returning to their normal level of functioning. Aim: To assess percentage of short or long-term POCD following laparoscopic colorectal surgery. Methods: Patients undergoing laparoscopic colorectal surgery were recruited. Cognitive tests including: N-back, lexical decision making and stroop task were carried out preoperatively and repeated Day 1, and minimum 3 months post-operatively. For Day 1 the baseline was subtracted from Day 1 results for each test. This result was the divided by the standard deviation of the control group to give a Z score. A large positive Z score ([ 1.96) showed a deterioration in cognitive function from baseline for accuracy, and a large negative Z score ([ -1.96) for response time. (Abildstrom et al., 2000) An individual Z score of 1.96 or more was defined as cognitive dysfunction. Results: Forty-six patients were recruited (26 males, 24 female), mean age 66 years (SD ± 5.18). Of which 55.4% had POCD on Day 1; and 37 patients completed longterm follow up of which 31.6% had POCD. Conclusion: Our study does show a significant number of patients develop both long and short term POCD following laparoscopic colorectal surgery.

General surgery, University Hospital of North Tees, Stockton on Tees, United Kingdom; 2Colorectal surgery, James Cook University Hospital, Middlesborough, United Kingdom; 3General Surgery, James Cook University Hospital, Middlesborough, United Kingdom; 4 Colorectal surgery, University Hospital of North Tees, Stockton on Tees, United Kingdom Aim: Local excision of early rectal cancer clearly offers many advantages over radical surgery. It undertakes the principle of organ sparing resection preserves normal bowel function and eliminates the need for a stoma. It is a less invasive procedure, less postoperative pain and a shorter hospital stay. Methods: A retrospective analysis of a prospectively maintained database of a colorectal surgery unit, at a district general hospital was analyzed. All patients who underwent an elective Trans anal endoscopic operation (TEO) from July 2008 to July 2017 were included. Results: A total of 187 patients underwent TEO procedure. 73 patients underwent TEO for eventually benign rectal lesions. 114 patients had cancer on final histopathology. 60 patients were staged as T1, 39 patients as T2 and 15 patients as T3. Out of the 114 cancer patients, 82 patients did not have any further surgical treatment. A total of 99 patients belonged to the T1 and T2 subgroup and 73 of these patients were free of recurrence on follow up. Conclusion: Early rectal cancers can be effectively treated in selected patients with trans anal endoscopic operation only. TEO has been proven to have good success rate with fewer complications and preserved anorectal and sexual functions.

P487 - Intestinal, Colorectal and Anal Disorders

P490 - Intestinal, Colorectal and Anal Disorders

Single Incision Laparoscopic Reversal of Hartmanns Procedure; Largest Case Series of Unselected, Consecutive Patients

Prevention of Anastomotic Leak with Indocyanine Green Fluorescence Angiography Following Transanal Total Mesorectal Excision for Rectal Cancer

P.V. Thambi1, J. Hornsby1, S. Rajeev1, Y.K.S. Vishwanath2, A. Agarwal1, D. Garg3, D. Kumar1, T. Gill1 1

General surgery, University Hospital of North Tees, Stockton on Tees, United Kingdom; 2General Surgery, James Cook University Hospital, Middlesborough, United Kingdom; 3Colorectal surgery, James Cook University Hospital, Middlesborough, United Kingdom Aim: Restoring intestinal continuity following Hartmann’s has been associated with a serious risk of complications. Boyden initially described reversal of Hartmann’s procedure in 1950. Restoration of bowel continuity following Hartmann’s procedure is considered technically challenging and is major undertaking with associated mortality and significant morbidity rates ranging from 10 to 50%. Methods: A retrospective analysis of a prospective database of a colorectal surgery unit, compromising of 5 colorectal surgeons, at a district general hospital were analyzed. All patients who underwent an elective reversal of Hartmann’s procedure from February 2007 o Dec 2017 were included. Results: A total of 117 patients underwent reversal of Hartmann’s procedure, of which 61 patients had a single incision laparoscopic reversal. No complications were noted in 40 patients and 10 patients had Clavien Dindo I surgical complication. The median hospital stay was 4 days (2–128 days), with median return to bowel function was 3 days (1–13 days) Conclusion: In our service evaluation we noted that single incision laparoscopic reversal of Hartmann’s procedure is a safe and a feasible therapeutic modality with an acceptable morbidity and mortality rate. By accessing the stoma site for placement of the single port device, the trauma and complications associated with conventional multiport laparoscopic surgery is minimized. In our institute, single incision laparoscopic reversal of Hartmann’s procedure is recommended over open/multi port access. However this warrants further training, along with prospective and randomized controlled trials, before we can establish this as the treatment of choice for restoring bowel continuity.

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A.M. Otero1, B. de Lacy1, J. van Laarhoven2, B. Martin1, V. Turrado1, R. Bravo1, A.M. Lacy1 1 Gastrointestinal Surgery, Hospital Clinic, Barcelona, Spain; 2General Surgery, Jeroen Bosch Ziekenhuis, Hertogenbosch, The Netherlands

Aims: Anastomotic leak (AL) is the most feared complication in colorectal surgery. Indocyanine Green (ICG) fluorescence angiography (FA) allows for a real-time intraoperative evaluation of bowel perfusion and is considered as a promising tool to reduce AL. This study aimed to assess the impact of ICG on perioperative outcomes in patients treated with transanal total mesorectal excision (TaTME) for rectal cancer. Methods: All patients with rectal cancer treated at our hospital by TaTME between November 2011 and January 2017 were prospectively included in a standardized database. Our experience with FA started in March 2016, assessing bowel perfusion before proximal colonic transection and after the performance of the anastomosis. Hence, outcomes of the ICG group were compared with the historical cohort of nonICG assessed patients. The primary endpoint was AL. Results: A total of 254 patients were included in the analysis, 50 (19.7%) in the ICG group and 204 (80.3%) in the non-ICG group. Both groups did not differ in male-female ratio, median age, obesity, nor smoking rate. The majority of the patients were classified as ASA II. 137 patients (50.2% vs. 46.0%; p = 0.760) underwent neoadjuvant chemoradiotherapy. Mean anastomotic height was 4.85 cm vs. 4.68 cm (p = 0.985), splenic flexure mobilization was performed in 91 patients (34.3% vs. 42.0%; p = 0.327), while a diverting stoma was constructed in 186 patients (72.1% vs. 78.0%; p = 0.477). FA led to a change in the resection margin in 16 patients (32.0%) and to mobilization of the splenic flexure after anastomosis construction in 1 (2.0%) patient. AL was diagnosed in 1 patient (2.0%) in the ICG group and in 23 patients (11.3%) in the non-ICG group (p = 0.056). Postoperative intraabdominal collection was diagnosed in 17 patients (7.4% vs. 6.0%; p = 0.692), and reintervention was needed in 24 patients (10.8% vs. 4.0%; p = 0.182). The median length of hospital stay was 5.8 days (6.0 vs. 5.0; p = 0.037). Conclusion: FA improved anastomotic leak rate and presents a tendency to less reintervention probably due to a change in surgical plans of more than one third of the patients. ICG should be considered as a routine assessment for high-risk colorectal anastomosis.

Surg Endosc

P262 - Liver and Biliary Tract Surgery

P264 - Liver and Biliary Tract Surgery

Long-Term Outcomes of Laparoscopic and Robot-Assisted Liver Resections for Cholangiocarcinoma

Minimally Invasive Versus Open Hepatectomy for Colorectal Cancer Liver Metastases: Comparative Study with Propensity Score Matching

D. Akhaladze, R. Alikhanov, N. Elizarova, I. Kazakov, S. Iskhagi, P. Kim, A. Vankovich, K. Grendal, E. Zamanov, N. Kulikova, E. Zagaynov, M. Efanov

I.V. Kazakov, R.B. Alikhanov, I.V. Kazakov, V.V. Tsvirkun, P.P. Kim, D.G. Akhaladze, A.N. Vankovich, K.D. Grendal

Hepato Pancreato Biliary Surgery, Moscow Clinical Scientific Center n.a. A.S. Loginov, Moscow, Russia

Hepatopancreatobiliary surgery, Moscow Clinical Scientific Center, Moscow, Russia

Background: Long-term outcomes of minimally invasive liver resections for different types of cholangiocarcinoma are still not enough evaluated. Aim: To evaluate the survival after minimally invasive resections for intrahepatic cholangiocarcinoma (ICC), hilar cholangiocarcinoma (hCCA) and gallbladder cancer (GBC). Methods: Between March 2013 and October 2017, 16 consecutive patients undergone laparoscopic or robot-assisted liver resections for hCCA (n = 5), ICC (n = 5), GBC (n = 6). Among them bile duct resection was performed in 5 patients. The median age was 64 years (range, 48–79) and 63% of patients were female. Results: Curative resection was achieved in 15 patients. At a mean follow-up of 12 months, 6 (37.5%) patients were disease free. Three-year overall survival was 40%. Conclusion: Liver resection for cholangiocarcinoma provides favorable long-term cancer-specific survival benefit. Further studies are still needed to confirm the benefit of this approach.

Background: The objective of this study was to compare the long-term results of laparoscopic hepatectomy with those of open hepatectomy for colorectal cancer liver metastases (CCLM) using a propensity score matching (PSM) in our hospital settings. Methods: Patients in the laparoscopic approach (LA) surgery group were randomly matched with patients in the open approach (OA) group using a 1:1 allocated ratio with the nearest estimated propensity score. Matching criteria included age, gender, American society anesthesiologists score, N-status of primary tumor, perioperative chemotherapy, difficulty index of laparoscopic liver resection. Survival was compared in both groups. Results: From January 2010 to March 2017, a total of 215 hepatectomies were consecutively performed, of which 100 for CCLM, namely 40 in the OA group (40%) and 60 in the LA group (60%). Seventy-seven patients (77%) were followed up. There were no differences in survival before and after PSM. Four years survival for minimally invasive and open liver resections was 70%/68% respectively before PSM and 72%/70% respectively after PSM. Conclusions: Laparoscopic liver resections for CCLM seem to yield long-term results, which are similar to open hepatectomies, and could be considered as an alternative to open surgery in selected patients.

P263 - Liver and Biliary Tract Surgery

P265 - Liver and Biliary Tract Surgery Laparoscopic Hepatectomy for Giant Hepatocellular Carcinoma

Robotic liver resection. Evaluation of Short-Term Results 1

1

1

1

I.V. Kazakov , M.G. Efanov , R.B. Alikhanov , V.V. Tsvirkun , M.Y. Prostov1, D.G. Ahaladze1, O.M. Melekhina1, A.N. Vankovich1, K.D. Grendal1, S.V. Berelavichus2 1 Hepatopancreatobiliary surgery, Moscow Clinical Scientific Center, Moscow, Russia; 2Surgery, A.V. Vishnevsky Institute of surgery, Moscow, Russia

Cumulative summation test (CUSUM) is widely used for learning curve estimation in the last decade. No paper on CUSUM assessment of robotic liver resections are available. We aimed to assess by CUSUM the gaining of experience in robot-assisted liver resection al. Material and Methods: The results of 46 robot-assisted liver resections were analyzed retrospectively. Results: According to significant changes in difficulty index, three periods in the development of technology were identified. The 1st period of training procedures with the lowest index of difficulty (n = 16), 2nd period of expansion of the indications difficult resections (n = 18) and 3rd period of stabilization (n = 12). The dynamics of difficulty index, intraoperative blood loss, duration of procedure and morbidity (grade II-V according to the Clavien-Dindo) were evaluated. Five liver resection were needed to decrease blood loss and duration of liver resection. Expansion of indications is feasible after 16 procedures. Stable results obtained after 34 liver resections. Conclusion: CUSUM technology seems an effective method of assessing the learning curve in robot-assisted liver resections.

P. Wu1, W. Su2 1

Surgery, Kaohsiung medical university chung-ho memorial hospital, Kaohsiung, Taiwan; 2Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan According to the recommendations for laparoscopic liver resection from the second international consensus conference in Morioka in 2014, a minor resection is one in which 2 or fewer Couinaud segments are removed. A major resection is one in which 3 or more segments are removed. In actuality, most laparoscopic minor resections reported in the literature are left lateral section ectomies or resections of segments 2, 3, 4b, 5, and 6, that is, mainly the anterior and inferior segments. Experts rate the complexity of various open 2-segment resections, that is, left lateral sectionectomy, right posterior sectionectomy, and right anterior sectionectomy very differently. Generally speaking, resectability is often in patients with tumor size smaller than 5 cm, tumors at peripheral location, and without previous open abdominal surgery. We briefly report our case with a huge hepacellular carcinoma at right lobe. A 57-year- old man without hepatitis B or C had complained RUQ and RLQ pain for half year. Progressive orthopnea was noted recently. Physical examination showed hepatomegaly with RLQ tenderness. Abdominal CT showed a huge liver tumor, sized 22*14*10 cm, protruding from S6 to the lower abdomen and bilateral adrenal tumors. TACE was not considered due to impossibility for complete embolization of the tumor. Laparoscopic liver resection was performed. Three trocars with Pfannenstiel incison were used for right hepatectomy and retrieval of the specimen. The specimen was weighed 2191 g and sized 29*15*9 cm. The patient discharged at post-operative day 9 uneventfully.

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Surg Endosc

P266 - Liver and Biliary Tract Surgery

P268 - Liver and Biliary Tract Surgery

Spontaneous Cholecystocutaneous Fistula: Managed by Laparoscopy: A Case Report

Interval Laparoscopic Cholecystectomy after Endoscopic Retrograde Cholangiopancreatography

M. Pol, V. Singla

Y. Rathore, L. Aggarwal

Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Introduction: Anomalous communication of gall bladder to skin are uncommon and most of them develop following cholecystectomy. Spontaneous chole-cystocutaneous fistula represents an exceptional event - less than 30 cases have been reported. All of them except one were managed by open cholecystectomy. We present a case of laparoscopic management of spontaneous cholecytocutaneous fistula. Case outline: A70 year old lady presented with chief complaints of pain in right upper quadrant of abdomen since 2 years and swelling with discharging sinus in right upper abdomen since 2 years. Wedge biopsy from external opening was taken which showed granulomatous inflammation. Patient was given anti tubercular therapy for 1 year but had no relief in symptoms. Ultrasonography of abdomen showed a linear tract extending from gall bladder to skin 2 cm solitary calculus in gall bladder. Computerised Tomography scan of abdomen showed a tract of abnormal density that appeared to extend from the biliary tree or second part of duodenum to the anterior abdomen wall. A diagnosis of cholecystocutaneousistula was made and laparoscopic cholecystectomy with excision of fistulous segment was done. The fistulous tract healed completely in 21 days. Histopathology showed features of chronic cholecystitis. Discussion: Obstruction in the bile outflow during an attack of acute cholecystitis results in rise in pressure in the gall bladder and reduced blood supply resulting in ischemia and perforation into either the peritoneal cavity, adjacent viscera or overlying skin resulting in formation of fistula. The cases which have been reported have been managed by open cholecystectomy in view of altered anaomy and frozen calots triangle. Malik etal reported one such case in which laparoscopic management was done. To the best of our knowledge this a second case report of management of cholecystocutaneous fistula using laparoscopy.

Introduction: Laparoscopic cholecystectomy after successful endoscopic retrograde cholangiopancreatography with sphincterotomy is standard management for choledocholithiasis. Interval laparoscopic cholecystectomy in this group of patients can be performed without higher complications and conversion rate. Methods: A total data of 350 patients post ERCP with sphincterotomy was analyzed from Jan 2010 to Dec 2016. Patients characteristics, pain after ERCP, no. Of ERCP attempts, intraoperative findings, complications, and conversion to open were analyzed. All patients underwent standard four-port laparoscopic cholecystectomy after six weeks of post ERCP by experienced laparoscopic surgeons. Results: Of the total 350 patients, male to female ratio was 41.7–58.3%. 84.28% of the study population was less than 50 years of age. More than 50 years of age comprised the remaining population. 7.1% patients had mild pain abdomen post ERCP. 1.1% patients had moderate to severe pain requiring repeat ERCP for common bile duct clearance. 8.6% patients required more than 2 attempts of ERCP for bile duct clearance. 61 patients (17.4%) had intraoperative complications. 5 patients (1.4%) required subtotal cholecystectomy.6 patients (1.7%) required laparoscopic partial cholecystectomy. 32 patients (9.14%) required conversion to open cholecystectomy. 23 patients (6.6%) developed postoperative complications. Conclusion: Interval laparoscopic cholecystectomy after 6 weeks of post ERCP can be performed without higher complications and conversion rate when performed by experienced laparoscopic surgeons.

P267 - Liver and Biliary Tract Surgery

P269 - Liver and Biliary Tract Surgery

Treatment of Iatrogenic Injuries of the Extrahepatic Bile Duct After Laparoscopic Cholecystectomy Without Transhepatic Stent and Witzel Drainage

Laparoscopic Remnant Cholecystectomy: A Case Series with Technical Tips and Reveiw of Literature

Z.R. Rifatbegovic, M.K. Kovacevic, M.A. Agic, M.M. Mesˇic Department of surgery, University Clinical Center Tuzla, Tuzla, Bosnia-Herzegovina Iatrogenic bile duct injuries (BDI) are most frequently caused by laparoscopic cholecystectomy (LC). The incidence is about 0.6% than in laparotomy method where the incidence is about 0.1%. In most cases, treatment of iatrogenic BDI is based on primary repair of the duct, ductal repair with a stent, or creating duct-enteric anastomosis, often used and drainage by Witzel (Witzelenterostomy).Reconstructive hepaticojejunostomy is often recommended for major iatrogenic BDI during cholecystectomy. The goal of our research is to show that hepaticojejunal anastomosis without the use of biliary stent and Witzelenterostomy are functional and without stenosis after of surgical repair of iatrogenic lesion extrahepatic bile ducts. Some anastomoses are created immediately after the lesions were recognized, and some were created in a period of up to 1 month, as soon as the lesions were recognized. We have eleven hospitals and Clinical centers in Bosnia and Herzegovina who performing laparoscopic cholecystectomy. At the level of all the mentioned healthcare institutions, a monthly average is about 1000 LC’s. The reference center for HBP Surgery in BIH is the University Clinical Center of Tuzla, which covers about 5 million people. In our research we had a 42 patients with iatrogenic lesions of extrahepatic bile ducts, were we have performed a surgical treatment with creating hepatico-jejuno anastomosis, hepaticojejuno duplex ananstomoses, choledocho-jejuno anastomoses sec Roux without transhepatic biliary stent or Witzelenterostomy in every case. We used Strasberg’s classification of injuries extrahepatic bile ducts. Most of injuries were D and E type. The follow up period was 6 years, from 2011 to 2017. In that period, we had only one complication that resulted in a deadly outcome. We had 42% patients who had biliar fistula but nobody was reoperated because of that. All the patients with biliary fistula positively responded to conservative treatment. The Sandostatyn has been given to all patients in postoperative period. The time of the postoperative recovery was from 7 to 30 days. At the patients with early recognised bile duct injuries (first 48 hours after the lesion) after the revision operative procedure, were much less biliar fistulas than the patients with late recognised injuries (after 7–15 days) thay had a greater number of biliar fistulas and other complications. The most common surgical complications beside the biliar fistula were intaabdominals abscess most common position in subphrenical area and pleural effusion.

123

S. Safari1, M. Alemrajabi1, F. Zamani2, J. Vahedian1, M. Baghai Wadji1, B. Darabi1, N. Rashidian1 1

General Surgery, Iran University of Medical Sciences, Tehran, Iran; Gastroenterology, Iran University of Medical Sciences, Tehran, Iran

2

Aims: Remnant gall bladder (GB) or cystic duct (CD) is being more recognized as a cause of morbidity after laparoscopic and open cholecystectomy. In this study, we reviewed the data of 10 patients with remnant GB or remnant CD. Finally some technical tips are proposed to prevent this condition. Methods: From January 2014 to October 2017, 10 patients with remnant GB/CD have been operated at Firouzgar general hospital. All patients presented with symptoms similar to and even more severe and frequent than the primary biliary colics. Seven patients were referred from other centers and 3 others were local. Results: Seven patients (70%) were female. The mean age was 49.1 (31–68) years. The mean size of the remaining CD/GB was 2.6*3.5 cm (1*1 cm to 6*7 cm). The location of the remnant was proximal biliary tree in 2 cases (20%) and distal part in 8 (80%). Half of the primary surgeries were open cholecystectomy and the other half were laparoscopic cholecystectomy. The primary operation was performed from 2 weeks to 20 years before this admission. Endoscopic ultrasound (EUS) was the best modality for diagnose especially for small remnants, although MRCP and abdominal ultrasound were found helpful. Among the primary surgeries, only 2 cases were emergent cholecystectomy in acute setting and the remaining 8 were elective cases (80%). In 8 out of 10 patients, the surgeons were sure about doing a complete cholecystectomy which indicate the importance of CD (instead of GB) remnant. Laparoscopic exploration was the most common surgical technique for resection of the remnant GB/CD (8 cases, 80%). Conclusion: GB/CD remnant is an uncommon but morbid situation. Most cases can be diagnosed with detailed history taking and using EUS. Laparoscopic resection is usually feasible. CD remnants may be more important and missable than GB remnants because even in elective settings, we don’t pay enough attention to the long, wide and spiral CDs.

Surg Endosc

P270 - Liver and Biliary Tract Surgery

P272 - Liver and Biliary Tract Surgery

Hybrid Transvaginal Cholecystectomy in Asian Perspective: OneYear Clinical Outcomes

A Single Institution Experience of Colorectal Liver Metastasis Treatment with the da Vinci Robotic System

P. Jitpratoom, W. Wandee, A. Deeprasertvit, A. Anuwong

S. Guadagni1, N. Furbetta1, G. di Franco1, D. Gianardi1, M. Bianchini1, M. Guadagnucci1, M. Palmeri1, L. Rossi1, G. Caprili1, C. d’Isidoro1, F. Mosca2, G. di Candio1, L. Morelli3

Surgery, Police General Hospital, Bangkok, Thailand Aims: Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been developed as an alternative approach of minimally invasive surgery. Transvaginal NOTES procedures are becoming increasingly popular and gaining acceptance. Hybrid transvaginal cholecystectomy (TVC) also becomes an alternative procedure for conventional laparoscopic cholecystectomy. This study reported the clinical outcomes in the patients who underwent TVC with one-year follow up. Methods: Selected female patients with symptomatic gallstone disease who underwent TVC since February 2016 were enrolled in a retrospective database. The operative records was analysed. Patients were accessed for their post operative pain, progression to activity, gynecology-related problem and cosmetic satisfaction through questionnaires. Results: Five out of fifteen patients who were offered TVC returned for one-year period follow up. There was no major intraoperative complication including severe bleeding or biliary tract injury and 0% conversion rate. Mean operative time was 44 minutes (50, 45, 40, 40, 45) and mean hospital stay was 2.2 days (3, 2, 2, 2, 2). Mean postoperative visual analogue score was 0.2 on PO day1 (0, 1, 0, 0, 1). None of the patents observed postoperative abnormal vaginal discharge or dyspareunia. The results for cosmesis and body image after the transvaginal approach were excellent. Conclusions: TVC is a safe and feasible procedure when performed on selected patients. The transvaginal route seems to result in excellent surgical and cosmetic outcomes without gynecologic complications after 1-year follow up.

1 Department of surgery, University of Pisa, Pisa, Italy; 2EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy; 3Department of syrgery, University of Pisa, Pisa, Italy

Aim: In the treatment of colorectal metastasis (CRLM), minimally invasive surgery (MIS) has gained increasing importance. However the widespread of standard laparoscopy for this indication is still limited, due to the drawbacks of the ultrasound (US) laparoscopic probe in performing a complete study of the liver (frequent multiple localizations), the synchronous presence of primary tumor to be resected or presence of previous surgery. The role of robotassisted surgery (RAS) in this setting has not been evaluated in literature yet. The aim of this study, is to report our experience with RAS for treatment of CRLM. Methods: We retrospectively analyzed surgical and oncological data of all the robotassisted liver resections for CRLM performed at our center from a prospectively-collected Institutional database. All the resections were performed with the da Vinci platform (Si since 2012, and Xi since 2015 for multiple organs resections). Intra-operative US scan was obtained with a dedicated robotic probe using the TileProTM function. Result: Sixteen patients underwent robot-assisted resection of CRLM, between May 2012 and July 2017. Four patients (25%) had multiple synchronous CRLM resections (median = 2; range 2–3). The tumor size averaged 3.1 ± 1.6 cm. All the lesions were removed following a parenchymal sparing approach, with R0 resection margins. In two cases, with the aid of da Vinci Xi, a synchronous colon resection was performed, whereas in the remaining cases the primary cancer had already been removed (8/14, 57%, with MIS and 6/14, 43%, with traditional approach). Mean hospital stay was 4.5 ± 1.4 days. The mean follow up was 27.3 ± 19 months and there were no local recurrences; while 7 patients (43%) developed new systemic metastasis. All patients are still alive with a 1 and 3 years disease-free survival of 77.5% and 36.3% respectively. Conclusions: In our experience, RAS for the surgical treatment of CRLM surgical treatment was feasible, and seemed to be oncologically safe as no patients experienced local relapse in the treated area. In this setting a dedicated US robotic probe and the availbility of Da Vinci Xi could improve the MIS approach especially in multiple localization and previous or synchronous surgery.

P271 - Liver and Biliary Tract Surgery P273 - Liver and Biliary Tract Surgery Is Intraoperative Blood Loss Underestimated in Patients Undergoing Laparoscopic Hepatectomy? Y. Tomimaru, K. Noguchi, H. Nagase, A. Hamabe, M. Hirota, K. Oshima, T. Tanida, S. Morita, H. Imamura, T. Iwazawa, K. Akagi, K. Dono Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan Aim: Less intraoperative blood loss in laparoscopic hepatectomy (LH) than open hepatectomy (OH) is frequently reported as one of the common advantages of LH. On the other hand, working space in laparoscopic surgery is generally smaller than open surgery, which potentially leads to the situation where suction of blood accumulated in abdominal cavity may be insufficient, suggesting a possibility of underestimation of intraoperative blood loss in laparoscopic surgery. In order to precisely quantify intraoperative blood loss in LH, the possibility should be evaluated. The aim of this study is to evaluate the possibility based on comparison of estimated blood loss (E-BL) calculated with blood parameters and intraoperatively-counted blood loss (IC-BL) in patients undergoing LH. Methods: This study included consecutive 110 patients undergoing partial hepatectomy for solitary liver tumor; OH in 59 patients and LH in 51 patients. In the patients, IC-BL and E-BL were examined and the difference of them was calculated focusing on the surgical approach. Furthermore, factors affecting the difference were investigated. IC-BL was quantified by measuring suction fluid and weighing surgical gauzes used for blood and fluid collection, and E-BL was calculated with total blood volume and change of hematocrit. Results: IC-BL was significantly less in the LH group than the OH group (128 ± 177 versus 292 ± 198 mL, p \ 0.0001), while no significant difference was found in E-BL between the two groups (273 ± 166 versus 259 ± 167 mL, p = 0.6642). Although there were no significant differences between IC-BL and E-BL in the patients of the OH group (292 ± 198 versus 259 ± 167 mL, p = 0.1239), E-BL was significantly more than IC-BL in patients of the LH group (273 ± 166 versus 128 ± 177 mL, p \ 0.0001). Percentage of patients with E-BL [ IC-BL in the LH group was significantly higher than the OH group (86.3% versus 42.4%, p \ 0.0001). The surgical approach (OH/LH) was the only significant independent factor determining the E-BL [ IC-BL status. Conclusion: E-BL was significantly more than IC-BL only in patients with LH, and the approach (OH/LH) was the only factor affecting the E-BL [ IC-BL status. These results suggested the possibility of underestimation of intraoperative blood loss at LH.

Early vs Late Laparoscopic Cholecystectomy in the Treatment of Acute Cholecystitis K. Koutsouvas, T. Drakos-Galanis, N. Siasos, V. Kalliakmanis Department of Surgery, General Hospital of Agrinion, Agrinion, Greece Introduction: Laparoscopic Cholecystectomy (LC) is the gold standard in the treatment of symptomatic gallstone disease. However, the clinical approach of acute cholecystitis remains controversial. With the increase of laparoscopic experience, early LC tends to replace the more traditional approach of late LC after 4–6 weeks of onset of symptoms, following the initial conservative treatment. Methods: The patients with acute cholecystitis treated in our hospital the last ten years (January 2008 to December 2017) were divided in 2 groups. Group A consisting of 236 patients received early LC (within 72 hours of onset of symptoms), while group B consisting of 185 patients received late LC after hospitalization and administration of conservative therapy. The groups were made up of patients with similar clinical and demographic characteristics. We compared the two groups towards duration of surgery, duration of post-surgery hospitalization, conversion rates, intraoperative and postoperative complications and mortality. Results: Mean duration of surgery for group A was 1 hour, while for group B was 40 minutes. There were no statistically significant differences between the duration of postoperative hospitalization for both groups. Intraoperative complications - conversion rates were 7.2% for group A and 6% for group B. There were no deaths in both groups. Additionally, 16 patients, initially placed in group B, required urgent surgical treatment for complications of acute cholecystitis (such as gangrenous gallbladder) after the third day of conservative therapy. In this sub-group 2 patients died. Conclusion: Early LC is a safe treatment for acute cholecystitis. The traditional approach of late LC has increased risk of complication leading to surgery before completion of the conservative therapy.

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Surg Endosc

P274 - Liver and Biliary Tract Surgery

P276 - Liver and Biliary Tract Surgery

Safe Laparoscopic Cholecystectomy: A Systematic Review of Bile Duct Injury Prevention

Efficacy of Laparoscopic Liver Resection For Patients with Intestinal Stoma

F.W. van de Graaf1, I. Zaı¨mi1, L.P.S. Stassen2, J.F. Lange1

M. Aikawa, K. Takase, Y. Ueno, K. Okada, Y. Yukihiro, K. Okamoto, H. Sato, S. Sakuramoto, S. Yamaguchi, I. Koyama

1

2

Surgery, Erasmus MC, Rotterdam, The Netherlands; Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands Aims: Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. The aim of this systematic review was to delineate the different modalities that can be used to aid in the safe performance of LC and the prevention of BDI. Methods: A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 29 march 2017. Results: 89 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation. Conclusion: This systematic review was the largest to date within this topic. However, given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of bail-out techniques is critical to complete surgery with minimal risk of injury to the patient.

GI Surgery, Saitama Medical University, International Medical Center, Hidaka Saitama, Japan Background: Laparoscopic liver resection (LLR) is increasingly performed and its feasibility has been established in a variety of situations. However, LLR for patients with a history of abdominal surgery is often avoided because of difficulty placing trocars. The aim of this study was to assess the feasibility and safety of laparoscopic liver resection for patients with intestinal stoma in comparison with an open approach for patients with intestinal stoma. Method: Between April 2008 and September 2017, 8 patients who underwent LLR (LLR group) were compared with 10 patients who underwent open liver resection (OLR group). Patient background, characteristics, and perioperative outcomes were compared. The LLR group was included 4 patients who underwent concurrent liver resection and stoma closure. The OLR group was included 3 patients who underwent concurrent liver resection and stoma closure. Results: All patients in the LLR group were completely treated using the laparoscopic approach. There were no other significant differences in patient background and characteristics. Operative duration was similar for these groups. Blood loss, complication rate, and hospital stay in the LLR group were significantly decreased compared with the OLR group. Conclusion: In laparoscopic liver resection for patients with intestinal stoma, the open approach may require multiple large incisions, but the laparoscopic approach can complete procedures with a stoma wound and a few port wounds. Laparoscopic liver resection for patients with intestinal stoma may reduce infectious complications and hospital stay.

P275 - Liver and Biliary Tract Surgery

P277 - Liver and Biliary Tract Surgery

Standardized Use of Devices May Improve Cost-Effectiveness in Laparoscopic Liver Resection

Identification and Management of Aberrant Right Hepatic Duct Injury During Laparoscopic Cholecystectomy

M. Aikawa, K. Takase, Y. Ueno, K. Okada, Y. Yukihiro, K. Okamoto, H. Sato, S. Sakuramoto, S. Yamaguchi, I. Koyama

G. Dedemadi, C.H. Tzamourani, P.L. Chalkias, A. Zahariadou, A. Drakou, I. Kalaitzopoulos

GI Surgery, Saitama Medical University, International Medical Center, Hidaka Saitama, Japan

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

Background: Laparoscopic liver resection (LLR) is becoming widespread. However, the use of devices in LLR has not yet been Standardized for various facilities and operators. This study investigated whether Standardized use of devices in LLR improves perioperative outcome. Methods: Between 2008 and 2017, of 260 patients who underwent LLR for whole hepatoma in our facility, 176 underwent LLR for a solitary hepatoma and were divided into ‘‘before standardization’’ (BS; n = 147) and ‘‘after standardization’’ (AS) groups (n = 29). Patient background, characteristics, and perioperative outcomes were compared between these groups. Procedure: We chose the devices according to phases of liver transection. A softcoagulation monopolar device was used for marking surface. An ultrasonically activated device was used for transection of the liver surface within a 2-cm depth. Crash and sealing with BiClamp were indicated for deep-phase transection. The Cavitron Ultrasonic Surgical Aspirator was used if the lesion was close to the major Glisson’s sheath or the major hepatic vein. Results: No significant differences in the patients’ background were found between the two groups. The operative durations were 128 min (60–312 min) and 203 min (50–470 min) in the AS and BS groups, respectively, with a significant difference (p \ 0.001). The blood loss volumes were 5 cc (0–150 cc) and 30 cc (0–850 cc), respectively (p = 0.0548). The lengths of hospital stay after LLR were 5 days (range, 3–7 days) and 6 days (2–21 days), respectively, with a significant difference (p = 0.0012). A postoperative complication higher than grade III of the ClavienDindo classification occurred in none of the patients in the AS group and in 8 patients in the BS group (p = 0.365). Device cost were 52.1USD (14.4–15.8) vs 59.3USD (19.8–38.4) with significant difference (p = 0.003). Conclusion: LLR requires the use of various energy devices. However, standardization of the use of energy devices may improve cost-effectiveness and perioperative outcomes such as operative duration, blood loss, complications, and hospital stay associated with LLR.

Aim: Anatomic variations of the biliary tract are common rising to 37.4%, while anatomic abnormalities of right hepatic sectoral ducts come to 7.4%. These abnormalities seem to be major risk factors for iatrogenic bile ducts injuries during cholecystectomy. The aim is the presentation of a case, where a conversion from laparoscopic cholecystectomy to an open procedure was performed, due to the presence of intraoperative cholorrhea. The incident occurred as a result of an iatrogenic injury of an aberrant right hepatic duct. Methods: A 44-year-old female patient with a history of cholelithiasis presented to the emergency department complaining of right upper quadrant pain, nausea and vomiting during the last 24 hours. Ultrasonography revealed multiple microlithiasis of the gallbladder. Results: The patient underwent laparoscopic cholecystectomy, where extensive fibrosis around Calot’s triangle was present. The presence of an aberrant right hepatic duct was identified. The aberrant right hepatic duct drained into the cystic duct. An injury of the aberrant hepatic duct took place posteriorly during dissection of the cystic duct with the consequence occurrence of cholorrhea; subsequently the laparoscopic procedure was converted to an open cholecystectomy. Closure of the laceration of the aberrant hepatic duct was followed by the placement of a T-tube. Intraoperative cholangiography via the T-tube was performed, which revealed the anatomy of the hepatic biliary tract with no evidence of leakage. The postoperative course was uneventful. The patient was discharged on the 10th postoperative day with the T-tube left in place. No biliary obstruction or bile leakage was demonstrated in the postoperative T-tube cholangiography on the 22nd postoperative day. Therefore the T-tube was removed without any side effects. Conclusions: Iatrogenic injuries of the bile ducts are considered to be 80% of the entire biliary injuries and occur mainly during cholecystectomy. Proper diagnosis and management remains difficult with only 25% of these injuries diagnosed intraoperatively. Early identification and treatment of the injury is crucial to avoid biliary stricture which also depends on the extent and the type of injury. The awareness of biliary anatomy and its anatomical variants, as well as the presence of an experienced surgeon are of paramount importance.

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Surg Endosc

P278 - Liver and Biliary Tract Surgery

P280 - Liver and Biliary Tract Surgery

Laparoscopic versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Single Institutional Propensity Score Matching Comparison

Can Complications be Minimised by Sub-Specialisation in Benign Biliary Surgery?

W. Dumronggittigule1, H.S. Han2, Y.S. Yoon2, J.Y. Cho2, Y.R. Choi2, S.H. Kim2 1

Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; 2 Surgery, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea Background/Aims: The incidence of hepatocellular carcinoma (HCC) in elderly patients is now increasing worldwide. Although open hepatectomy (OH) has shown similar survival between elderly and young patients, longer recovery time with higher morbidity are concerning issues among elderly patients. A few compared studies shown benefits in improving short-term outcomes of laparoscopic hepatectomy (LH) in elderly patients. However, evidence regarding long term survival of LH in elderly HCC patients is scarce. This study aimed to compare both short-term and survival outcomes between LH and OH. Methods: All HCC patients who underwent LH or OH between 2003 to 2015 with age 65 years or older were included. The cohort divided into two groups, LH and OH. To overcome selection bias between two surgical techniques, propensity score matching was used. The outcomes were compared by standard statistics between groups. Results: Of total 1622 hepatectomies during study period, there were 496 hepatectomies for HCC. A total 148 elderly patients (LH 84 and OH 64) were included. After matching, there were 35 patients each group with similar demographics, tumor characteristics, extent and difficulty of resection. LH group had shorter hospital stay (7.5 vs. 10 days, p = 0.046) and trend toward decreasing complication (17.1% vs. 28.6%, p = 0.152). The completeness of resection and margin width were similar between groups. The 1-yr, 3-yr, 5-yr recurrencefree survival were 70.3%, 47.3%, 47.3% for LH group and 74.9%, 59.8%, 50.6% for OH group (p = 0.744). The 1-yr, 3-yr, 5-yr overall survival were 100%, 81.6%, 81.6% for LH group and 85.5%, 82.3%, 65.9% for OH group (p = 0.182). Conclusion: Our study demonstrated the benefit of laparoscopic hepatectomy over open hepatectomy for HCC in elderly patients in enhancing postoperative recovery. The oncologic safety were confirmed with similar pathological margin and comparable long-term survival between groups.

H.Z. Yong, H.J. Ng, S. Khan, H. Nassar General Surgery, Nhs Lanarkshire, Airdrie, United Kingdom Aim: With a healthcare training model that is leaning towards specialised training and early sub-specialisation, our aim was to determine if surgical complication rates could be reduced by sub-specialisation in benign biliary surgery on a unit dedicated to single-stage management of biliary emergencies. Method: A prospective database of laparoscopic cholecystectomies (LC) ± CBD explorations (CBDE) performed by a benign biliary surgeon between 1992 to 2017 was analysed. Demographics, ASA grade, difficulty grade and peri-operative complications were evaluated. Results: 5136 patients underwent LC of which 1143 (22.3%) had concurrent CBDE. 3838 (74.7%) were female and the mean age was 50.9 years (8–91 years). 2187 (42.6%) were emergency cases. ASA grade was as follows; ASA-I 1832 (35.7%), ASA-II 2038 (39.7%), ASA-III 644 (12.5%), ASA-IV 16 (0.3%) and 606 (11.8%) were not recorded. Difficulty grading was as follows; grade-I 1705 (33.2%), grade-II 1583 (30.8%), grade-III 1029 (20.0%), grade-IV 726 (14.1%) and grade-V 89 (1.7%). Mean operative time was 72.1 minutes (15–570 minutes). Overall peri-operative complications occurred in 364 (7.1%) cases. These included 125 (2.4%) stones spilt from iatrogenic perforation of gallbladder, 35 (0.7%) bile leaks including controlled leaks with no consequences, 46 (0.9%) surgical site infection, 19 (0.4%) post-operative pancreatitis, 34 (0.7%) chest infections, 13 (0.3%) returned to theatre, 3 (0.06%) iatrogenic bowel injuries, 2 (0.04%) bile duct injuries (one minor requiring stenting for 6 weeks) and 4 (0.07%) post-operative collections. 28 (0.5%) LCs were converted to open. 122 (2.2%) patients were readmitted. Conclusion: The surgical complication rate of patients undergoing LC by a specialist surgeon in this study were significantly lower at 7.1% compared to 10.8% in recent literature. The rates of most complications were also lower, stones spilt 2.4% vs. to 9.5%, bile leak 0.7% vs. 1.4%, surgical site infection 0.9% vs. 2.2%, chest infection 0.7% vs. 1.4%, return to theatre 0.3% vs. 0.7%, bowel injury 0.06% vs. 8.5%, bile duct injury 0.04% vs 0.3% and post-operative collections 0.07% vs. 2.1%. The rate of post-operative pancreatitis was the same at 0.4%. Readmission rate was 2.2% compared to 7.1%. Our study suggests that complications can be minimised by sub-specialisation.

P279 - Liver and Biliary Tract Surgery

P281 - Liver and Biliary Tract Surgery

Causes and Management of Biliary Re-Interventions in 5136 Cholecystectomies

The Utilisation of Choledochoscopy in Laparoscopic Bile Duct Exploration

H.J. Ng, K.H.Z. Yong, K.S. Khan, A.H. Nassar

H.Z. Yong, S. Khan, H.J. Ng, H. Nassar

General Surgery, NHS Scotland, Glasgow, United Kingdom

General Surgery, NHS Lanarkshire, Airdrie, United Kingdom

Aims: To evaluate the causes for re-intervention post laparoscopic cholecystectomy (LC) ± common bile duct exploration (CBDE) performed by a single surgeon providing an acute biliary service based on index admission. Methods: Prospectively maintained database of LC ± CBDE conducted by a single surgeon was analysed. Intra-operative cholangiography (IOC) was routinely performed followed by CBDE if CBD stones were suspected or identified. Patient demographic, difficulty grade, perioperative complications requiring re-intervention and readmissions were examined. Results: There were 5136 LC ± CBDE in the database of which 80 (1.6%) required reintervention. The mean age of the re-intervention group was 63.6 years (21–88 years) and male to female ratio was 1:1.5. The difficulty grading was; grade-I 10 (12.5%), grade-II 19 (23.8%), grade-III 13 (16.3%), grade-IV 31 (38.8%) and grade-V 7 (8.8%). 22 (0.4%) required further surgical intervention; 7 required re-laparoscopy for T- tube complications, and 4 underwent Whipple’s procedure for peri-ampullary lesions found during LC ± CBDE. There were two re-interventions for each of the following causes; biliary reconstruction by the liver unit on the following day due to sustained CBD injuries, biliary bypass secondary to Mirizzi syndrome type 3 and 4, bile leaks and re-laparoscopy for haemostasis. Other causes included mesenteric ischaemia, perforated duodenal ulcer and perforated undiagnosed bowel cancer, each with an incidence of one. 5 cases required suturing of port sites under local anaesthesia for haemostasis. 45 (0.9%) required endoscopic retrograde cholangiopancreatography (ERCP); 22 for retained CBD stone, 8 underwent stent insertion for pancreatic lesion, 8 for bile leaks, 3 for benign biliary strictures and 2 for removal of blocked stent. Other causes included deranged liver function test and T-tube complication. 8 (0.2%) required percutaneous drainage for collections. There were 127 (2.5%) readmissions within one year post-operatively. Conclusion: Re-intervention rates following LC ± CBDE are low. The most common form of re-intervention is ERCP for retained CBD stones. This series does not support the widely held view that emergency biliary surgery, including one session bile duct exploration, has high rates of complications and re-intervention.

Aim: Our aim was to assess the safety and efficacy of choledoscopy as a form of bile duct exploration in a unit dedicated to single session management of bile duct stones and its incidence of retained stones. Method: A database of patients undergoing laparoscopic biliary surgery was collected prospectively over a period of 26 years by a single surgeon. We analysed the data of all the patients who underwent a laparoscopic common bile duct exploration (CBDE) and analysed cases where a choledochoscope was employed. Results: 1143 patients in the database had CBDE. 678 (59.3%) of these had a choledochoscopy. Of those 678 cases, 267 (39.3%) were transcystic explorations and 411 (60.6%) were choledochotomies. Of all the choledochoscopies performed, 445 (65.6%) were female and 514 (75.8%) were emergency cases. 580 (85.5%) were identified as having risk factors for a ductal stone preoperatively. Intraoperatively, 625 (92.2%) patients were found to have a CBD stone. In the 678 patients who had a choledochoscopy, 659 (97.2%) patients had intraoperative cholangiogram and 23 (3.5%) were normal. Due to their high risk factors for ductal stones however, a choledochoscopy was also performed and 6 of those cases revealed a stone. 55 (8.1%) patients had post-operative complications; 11 (1.6%) controlled bile leaks, 8 (1.2%) post-operative pancreatitis, 6 (0.9%) retained stones, 3 (0.4%) chest infections, 3 (0.4%) urinary retention, 3 (0.4%) cholangitis and 2 (0.3%) had post-operative bleeding. Other complications included acute mesenteric ischaemia, CVA, jaundice, pain, pneumothorax and surgical emphysema of which incidence was 1 patient each. 7 (1.0%) patients required reoperation; 1 to stent CBD and 6 were all related to biliary drainage complications. Conclusion: The utilisation of choledochoscopy is a safe and effective way of exploring the bile duct. It allows direct visualisation of the duct and in 6 of the cases, detect stones that would otherwise have been missed based on cholangiogram alone. It holds a low postoperative complication rate and with a surgeon with the appropriate experience and expertise, is a safe way of CBDE and can reduce the incidence of retained stones.

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Surg Endosc

P282 - Liver and Biliary Tract Surgery

P284 - Liver and Biliary Tract Surgery

Minimization of Number of Trocars in Laparoscopic Fenestration of Solitary Liver Cysts

Long-Term Follow Up of Gallbladder and Bile Duct Stones Laparoscopic One-Stage Treatment

A.V. Malynovskyi, M.M. Mayorenko, D.V. Kudinov

O. Ghazouani1, R. Galleano1, A. Badran1, M. Malerba1, A. Francesch2

Department of robotic and endoscopic surgery, Odessa national medical university, Odessa, Ukraine

1

General Surgery, Santa Corona Hospital, Pietra Ligure, Italy; General Surgery, San Paolo Hospital, Savona, Italy

2

Aims: Laparoscopic fenestration of solitary liver cysts is relatively simple procedure performed for large superficially located lesions. It can be performed using two trocars only, but sometimes it requires placement of additional trocar, to retract liver or to grasp cyst wall. The aim of our study was to assess the feasibility of single-port solutions for performance of this step. Methods: A 39 y.o. woman, with solitary cyst located at the border of 3 and 4b liver segments, under the teres ligament, was operated. A 5 mm trocar was inserted through the umbilicus and used for laparoscope, another 5 mm trocar was placed in right subcostal region. During the procedure the need for retracting the ligament and grasping the cyst wall arised. To minimise the number of ports second 5 mm trocar was inserted through the umbilicus, and used for the Maryland clamp. Thus, the fenestration was completed by the hook and suction tube placed from subcostal trocar. No drain was used. The skin wounds were closed by intracutaneous absorbable sutures. Results: The fenestration was performed completely using this technique. The duration of the procedure was 40 minutes. There were no postoperative complications. The patient was discharged on the postoperative day 2. The patient had almost no postoperative pain. The patient has complete cosmetic satisfaction by the procedure. Conclusions: 1. Minimization of number of ports in laparoscopic fenestration of solitary liver cyst is feasible by application of some single-port solutions. 2. In selected cases, this procedure could probably be performed using single-port technique.

Background: The aim of this retrospective study was to evaluate the results of single stage laparoscopic treatment of colecystocholedochal lithiasis. Methods: From January 1998 to October 2012, 2360 patients underwent laparoscopic cholecystectomy for treatment of biliary lithiasis. Intraoperative cholangiography was routinely performed in every patient undergoing laparoscopic cholecystectomy. Associated common bile duct (CBD) stones were found in 155 patients after intraoperative cholangiography. 6 cases were false positive. Combined laparoscopic clearance of CBD was attempted by transcystic way (TCDE) in 113 patients (76%), by choledochotomy (TCE) in 39 patients, 34 of them as first attempt (23%) and 5 after TCDE, and 2 ‘‘rendez-vu’’ tecnique. Results: Trancystic duct extraction (TCDE) was successful in 92 patients of 113 (81%). Five patients underwent secondary choledochotomy. In all 82% of patients had complete clearance by laparoscopic approach. Failures were managed by laparotomic conversion (15 patients) and postoperative endoscopic retrograde cholangiopanreatography (ERCP) (11 patients). Biliary drainage was placed in 65% of patients (63 transcystic and 32 transcholedochal). Mean hospital stay was 6 days (1–22). Morbidity rate was 10% and there was no mortality. Relaparoscopy was required in 3 patients, 2 for bile leakage from Luska duct and one for transcystic biliary drainage dislodgement. One biloma developed after transcystic drain removal and was drained percutaneously. At 5 years follow-up, 120 patients (82%) had no recourrence or other problems related to the previous operation; 27 patients were lost at follow-up or died for other reasons. Conclusions: Intraoperative cholangioscopy as a routinary part of laparoscopic cholecystectomy is an efficient tool for detection of associated choledochal lithiasis either unsuspected either known in order to define the best way of treatment. One stage laparoscopic management of CBD stones was effective in 82% of cases with acceptable morbidity rate and it is particularly advantageous in tertiary center where ERCP is not available.

P283 - Liver and Biliary Tract Surgery

P285 - Liver and Biliary Tract Surgery

Miniinvasive Procedures in the Patients with Liver Cirrosis Complicated by Variceal Bleeding

Is Critical View of Safety Technique Adopted During Laparoscopic Cholecystectomy Training of Surgical Residents in the Middle East?

Y.U.V. Grubnik, O.M. Yuzvak, V.A. Fomenko Surgery department #3, Odessa National Medical University, Odessa, Ukraine The mortality in the patient with liver cirrhosis is very high. The aim of this work was to decrease mortality and morbidity by using endoscopic local heamostasis and laparoscopic operations, in the patients with bleeding from cirrhosis by variceal bleeding. Methods and Material: We observed 652 patients with cirrhosis complicated by variceal bleeding during 11 years. There were 248 patients with Child Phue A, 261 ones with Child Phue B, 143 ones with Child Phue C. All the patients were performed prolonged endoscopic heamostasis with conservative therapy. The main methods that we used were the ligation in 306 cases, sealing in 50 cases, sclerotherapy in 158 cases. In 18 cases we couldn’t stop the bleeding with band ligation method and introduce the Danis stents into esophagus and stopped the bleeding successfully. To prevent the re-bleeding we performed the laparoscopic dissection the abdominal part of esophagus with suturing the venous vessels, coagulations and dissection of short gastric vessels between stomach and spleen, clipping the left gastric artery and vein in the 61 patients. In 27 patients we performed laparoscopical suturing the variceal veins by introducing the laparoscopic trocars into the stomach. In 31 cases with varices vien of stomach, with non-effective local endoscopic heamostasis we performed laparoscopic resection the fundal part of stomach. Results: Endoscopic local heamostasis were successful (in 87%) in 567 cases. The relapse of bleeding were in 85 patients. 25 patients died. There was no mortality after laparoscopic operations. There were 7 cases for trocar wounds infection, 2 cases of subphrenic abscess. Conclusion: Endoscopic band ligation and placement of Danis stents are the most effective methods of local heamostasis. Laparoscopic operation is an effective method to prevent the re-bleeding from varices veins in the patients with cirrhosis.

123

S. Alshamsi, A. Albhair, M. Tohary, A. Bunaian, M. Maamoun, E. Zakarneh, A. Abouleid General Surgery, King Fahd Military Medical Complex, Dhahran, Saudi Arabia Introduction: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed worldwide. Bile duct injury (BDI) during LC is reported to be 0.16–1.5%. Recent guidelines suggest that adopting critical view of safety (CVS) technique reduces the rate of BDI. Aim: The aim of this study is to evaluate and assess the outcome of all cases of LC done by surgical residents and supervised by senior surgeons at a teaching hospital in the Middle East between January 2016 and December 2017. Methods: Retrospective analysis of prospectively maintained data of all patients, who had LC completely or partially by surgical residents supervised by senior surgeons, at a teaching hospital in the Middle East between January 2016 to December 2017. Data was retrieved via case note review and electronic maintained data. Results: Total number of 391 laparoscopic cholecystectomies were done during this period. Surgical residents had been supervised in 85 LC (22%). CVS technique had been followed in 69 cases (81.2%) while the infundibular technique (IT) in 16 cases (18.8%). In the CVS technique group the Mean age was 38.5 year (84% females and 16% males). 64/69 cases of the CVS technique group had the initial diagnosis of biliary colic (92.8%), 4/69 acute cholecystitis (5.8%) and 1/69 biliary pancreatitis (1.4%). The Mean operative time was 110.8 min with no conversion (0%) and one case of intraoperative liver tear 1/69 (1.4%). The Mean hospital stay was 3.7 days with no hospital re-admission (0%) and one case of postoperative wound haematoma (1.4%). In the IT group the Mean age was 37.9 (94% females and 6% males). All cases had the initial diagnosis of biliary colic (100%). The Mean operative time was 99.3 min with neither conversion or intraoperative complications. The Mean hospital stay was 2.5 days with one case of hospital re-admission due to retained bile duct stone (6.2%) which is cleared endoscopically. Conclusion: CVS technique is adopted in most of the cases during LC training of surgical residents in a teaching hospital in the Middle East with reasonable outcomes. More efforts are needed to adopt the technique during the training of surgical residents.

Surg Endosc

P286 - Liver and Biliary Tract Surgery

P288 - Liver and Biliary Tract Surgery

Laparoscopic Cholecystectomy in Cirrhotic Patients - A County Hospital Experience

Single-Incision Laparoscopic Cholecystectomy is Very Safe for Noncomplicated Cholecystolithiasis by Experienced Surgeon; One Surgeon’s Experience

A. Cotirlet1, L. Gavril2, E. Popa3, R. Anghel4 1 Surgery, University, Vasile Alecsandri, Iasi/Emercency Moinesti Hospital, Moinesti, Romania; 2Intensive Care, University of Medicine and Farmacy, Gr. T. Popa, Iasi/IRO Iasi, Moinesti, Romania; 3 Surgery, Emergency Moinesti Hospital, Moinesti, Romania; 4 Surgery, University of Medicine and Farmacy, Gr. T. Popa, iasi, Comanesti, Romania

Background: Gallstones are twice as common in cirrhotic patients as in the general population. Due to the concern of risk of intra and postoperative complications and associated morbidity, cirrhosis of the liver is often considered a contraindication for laparoscopic cholecystectomy. However, many authors have reported on the safety of laparoscopic cholecystectomy in cirrhotic patients. This article intends to underline the various approaches to dealing with this technically challenging procedure. Methods: From January 2014 to December 2017 we performed 2623 laparoscopic cholecystectomies in our hospital. We conducted a retrospective study from wich all the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing laparoscopic cholecystectomy were included in our analysis. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study. Results: Laparoscopic cholecystectomy for 173 cirrhotic patients with a mean age of 67 years, out of whom 52 (30.05%) were males and 121 (69.94%) were females. Comorbid conditions were identified in 53.17% (n = 92) patients). There were 67 (38.72%) emergency laparoscopic cholecystectomies and 106 (61.28%) patients were operated electively, mean operative time being 72 minutes. Fourteen (8.09%) patients required conversion, 23 (13.29%) patients developed postoperative complications, the mean hospital stay was 7.30 days. Conclusion: Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.

J.D. Kim, D.L. Choi Department of surgery, Catholic University of Daegu College of Medicine, Daegu, Republic of Korea Single incision laparoscopic cholecystectomy (SILC) has been increasingly performed for benign gallbladder disease with comparable results with conventional laparoscopic cholecystectomy (CLC). And so, it is predicted that this technique may become a standard approach to cholecystectomy but still demand more technical challenge. The aim of this study was to investigate the safety of SILC for noncomplicated cholecystolithiasis by comparing the surgical outcomes with those of CLC in focus of one experienced single surgeon’s experience. We retrospectively analyzed the clinical data of patients who underwent laparoscopic cholecystectomy for uncomplicated cholecystolithiasis by single experienced surgeon for cholecystectomy between January 2005 and October 2017. During the study period, 265 patients underwent laparoscopic cholecystectomy due to cholecystolithiasis. Of these patients, 39 underwent SILC and 226 underwent CLC. The operation time for SILC was not significantly longer than that for CLC (38.3 ± 8.0 min vs 35.9 ± 7.6 min, P = 0.067). Neither of additional ports nor conversion to laparotomy occurred in SILC group. The mean postoperative hospital stay in SILC group was 2.5 ± 0.7 days and that is comparable to that in conventional group. The overall complication rate was 5.1% and is similar between two groups. The only two patients developed wound seroma and there were no cases of bile leakage or bile duct injury. In conclusion, SILC did not increase the operation time and complication rate. SILC performed by experienced surgeon is at least as a very safe and feasible technique for noncomplicated cholecystolithiasis.

P287 - Liver and Biliary Tract Surgery

P289 - Liver and Biliary Tract Surgery

Organ-Saving Laparo-Endoscopic Operations on the Gallbladder

Clinical Value of Fluorescent Cholangiography for the Patients with Infrapotal Type of the Right Posterior Bile Duct

A. Babii, B. Shevchenko Department of surgery, SU, Institute of Gastroenterology of NAMS of Ukraine, Dnepr, Ukraine Aim: to study the effectiveness of organ-saving laparo-endoscopic operations on the gallbladder (GB). Materials and Methods: There was performed the analysis of the results of surgical treatment of 96 patients with GB pathology, including, gallstone disease in 88 cases, and the combination of gallstone disease with polyps of GB in 8 cases. The selection criterion included patients with uncomplicated symptomatic and asymptomatic cholecystolithiasis. The incision of GB wall during the laparoscopy was carried out in the area of the bottom. At the same time the bile was taken and the lavage of the GB cavity was performed. For the revision of GB cavity, a flexible endoscope with a diameter of 5 mm was used. The extraction of stone was performed using the Dormia basket. For polypectomy there were used snare, hot biopsy forceps, coagulation electrode. The integrity of the GB wall was restored by a continuous of absorbable suture. Post-operativelly, a rehabilitation program was used to prevent recurrence of cholecystolithiasis. Results: To all patients there was performed an organ-saving operation on the GB laparoscopic endoscopically assisted cholecystolithotomy and cholecystopolypectomy. The method of setting three trocars. The number of removed gallstone ranged from 1 to 5. Their size ranged from 9 to 33 (18.7 ± 3.5) mm in diameter. In 16 cases, after lithextraction, at the endoscopic examination of GB cavity, there were diagnosed small gallstones and mucus in the folds of the mucosa, which were removed by additional rinsing. In 8 cases, besides of lithextraction, the polyps of mucosa have been removed, with the size of 3–6 mm. The surgical intervention lasted 55–120 (85.36 ± 20.03) min. The recurrence of cholecystolithiasis from 8 months to 6.5 years was diagnosed in 5 (6.3%) out of 79 examined patients. Conclusions: 1. Organ-saving laparo-endoscopic surgery is the optimal method for treatment of GB pathology. 2. Endoscopic examination of GB cavity allows to remove gallstones not diagnosed according to the sonography, as well as to perform cholecystopjlypectomy.

T. Igami Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan Background: Reports about clinical value of fluorescent cholangiography using indocyanine green (ICG) during single-incision laparoscopic cholecystectomy (SILC) were increasing. We report clinical value and pitfalls of fluorescent cholangiography during SILC for the patients with the infraportal type of the right posterior bile duct. Methods: Our SILC procedure utilized the SILS-Port with an additional 5-mm forceps through the umbilical incision. Before SILC, 1 mL of ICG (2.5 mg) was administrated by intravenous injection. For fluorescent cholangiography, ICG fluorescent laparoscope system was used. Results: We performed fluorescent cholangiography during SILC in 13 patients with the infraportal type of the right posterior bile duct. All procedures were completed successfully. The interval from the injection of ICG to the first obtained fluorescent cholangiography before the dissection of Calot’s triangle ranged from 40 to 60 minutes. Detectability of infraportal type of the right posterior bile duct before dissection in Claot’s triangle was 23.1% (n = 3) and that during dissection in Calot’s triangle was 53.8% (n = 7). The infraportal type of the right posterior bile duct could be identified under fluorescent cholangiography only when it joined into the common hepatic duct. Conclusions: Utilization of fluorescent cholangiography can lead SILC to safe even for the patients with the infraportal type of the right posterior bile duct. Its benefit is emphasized when the infraportal type of the right posterior bile duct joins into the common hepatic duct.

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Surg Endosc

P290 - Liver and Biliary Tract Surgery

P292 - Liver and Biliary Tract Surgery

Laparoscopic Biliary Reconstruction 1

1

2

1

H. Okamoto , K. Takahashi , S. Maruyama , K. Kawashima , T. Fukasawa1, D. Ichikawa2, H. Fujii2

Advantages and Limitations About Early Laparoscopic Cholecystectomy: Experience in a District Hospital S. Mazzocato1, A. Maurizi2, R. Campagnacci2

1

1

2

2

Surgery, Tsuru-municipal Hospital, Tsuru-City, Yamanashi, Japan; Gastrointestinal, Breast&Endocrine Surgery, University of Yamanashi, Chuo-City, Yamanashi, Japan

Background: Choledocho-duodenostomy (CDD) and choledocho- or hepatico-jejunostomy (CDJ) were well known as an open surgical method of the biliary reconstruction. Aim: We have practically applied this technique to laparoscopic approach. To clarify the feasibility and safety of the laparoscopic biliary reconstruction, we evaluated our surgical outcomes of this techniques. Patients and Methods: We performed laparoscopic biliary reconstruction like laparoscopicCDD (10 cases) and CDJ (2 cases) in total 12 patients between June, 2014 and December, 2017. Diseases include a primary common bile duct (CBD) stone with choledochal dilatation and endoscopic management difficult or failed CBD stone. A biliary-enteric anastomosis was created intra-corporeally using water-tight running absorbable suture by handmade 4-0 monofilament with double side needles, starting from the right side of choledochus, and continued along posterior wall until the left side of the choledochus followed by anterior-wall anastomosis as the same manner. Results: Twelve patients were treated successfully by these laparoscopic procedures (10 CDD and 2 CDJ cases). All patients remained well without bile leakage and reflux cholangitis for the short-term follow-up. The median intracorporeally anastomosis time were 33 (30–38) min. Median blood loss was 35 (little-95) ml, median hospital stay was 7 (5–14) days, and median follow-up time was 32 months. Conclusion: Laparoscopic biliary reconstruction was feasible and safe as well as open procedure. Although this series was relatively small, further accumulated study including randomized series were needed to evaluate the accurate result.

General Surgery, Universita` Politecnica delle Marche, Ancona, Italy; General Surgery, Carlo Urbani Hospital, Jesi, Italy

Introduction: The standard treatment for lithiasic acute cholecystitis remains the laparoscopic cholecystectomy despite the timing of surgery is still controversial. The aim of this prospective study is to evaluate the advantages and limitations of early laparoscopic cholecystectomy in a district hospital. Methods and procedure: All patients undergoing laparoscopic cholecystectomy at the Surgical Department of ‘‘Carlo Urbani’’ Hospital in Jesi (Italy) from May to September 2017 were consecutively enrolled. Clinical data such as gender, age, BMI, comorbidity, previous abdominal surgery, previous acute cholecystitis were collected. Subsequently, the patients were arranged in two groups according to the timing of intervention (early versus elective surgery). For each group, we compared data concerning surgery, such as operative time, complications, length of hospital stay and cost analysis. Results: This study is a part of an ongoing research. So far, we collected 67 laparoscopic cholecystectomies. Ten (15%) of them were admitted with acute cholecystitis and were operated during the hospital stay (group A). Group B included patients scheduled for elective surgery (n = 57; 85%). The two groups were comparable with respect to clinical data. Conversion to open approach was performed in 3 cases, all of them in group B. Mean surgical time was comparable in the two groups (p = 0.494). No significant differences in intraoperative and post operative complications rates were seen in the two groups. Mean overall length of hospitalization was 6.4 ± 3.89 days in group A and 2 ± 1.63 days in group B (p = 0.001), whereas the difference in length of postoperative hospitalization was not statistically significant. Due to the extended hospitalization for group A, the cost increase as compared to group B was statistically significant, too. Conclusions: Early laparoscopy is comparable to delayed laparoscopy in terms of postoperative hospitalization and complications in the management of acute cholecystitis. A longer hospital stay among patients scheduled for immediate surgery may be associated with a more time-consuming diagnostic work-up before surgery. However, in future research we expect to enhance our cost analysis with more data regarding the costs incurred in the first hospitalization reserved to non-operative treatment of group B inpatients with acute cholecystitis.

P291 - Liver and Biliary Tract Surgery

P293 - Liver and Biliary Tract Surgery

An Early Assessment for the Use of Hololens During Laparoscopic Liver Resections

Transvaginal Notes Cholecystectomy Combined with Single Port Platform: Taiwan Experience

˚ . Fretland2, R. Palomar1, J.B. Alcoriza1, E. Pelanis1, R. Kumar1, A O.J. Elle1, B. Edwin1

C.M. Peng

1

The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway; 2Department of HPB surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway Aims: The goal of this work was to improve visualization and interaction during surgery by presenting the patient specific anatomy in mixed reality. Also assess the use of this work under sterile conditions. Methods: Here, we make use of existing volumetric data, such as CT and MR images, to create the patient specific 3D models. This is performed by initially segmenting the volumetric image data and creating 3D surface models, which can then be visualized and interacted with by using our internally developed mixed reality platform for the Microsoft HoloLens. The model includes the parenchyma, tumor, and hepatic and portal vessels. The HoloLens maps the user’s real environment to place the holograms in relation to the reality, through a transparent display. Our program allows users to, a) Import patient specific 3D models and CT/MR images, b) Interact with models through moving, scaling and rotating, solely using gestures, c) Create and adjust a resection plane, d) Share the models between users. Results: Surgeons planned surgery with our HoloLens application preoperatively. During the laparoscopic liver resection, surgeons placed and interacted with models, which contains the resection plane and CT/MR images. Multiple surgeons shared and interacted with the models using gestures, under sterile conditions. This technology was qualitatively evaluated during 3 procedures, where 6 surgeons in total responded to our questionnaire (one participated twice). Three of the questions were given on a six-point Likert scale and results were averaged from 7 collected questionnaires. Question1: Rate the field of view of the HoloLens (average score of 4.7 points, with 1 = narrow and 6 = wide); Question2: Rate the comfort lever while wearing the HoloLens (average score of 3.9 points, with 1 = uncomfortable and 6 = comfortable); Question3: Would you recommend HoloLens to other surgeons for use during surgery? (average score of 5.6 points, with 1 = disagree and, 6 = agree). Conclusion: We created and presented the patient specific liver models in our application, which is shown to be highly recommendable and relatively comfortable for use during surgery.

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Division of General Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan Purpose: Natural orifice transluminal endoscopic surgery (NOTES) has gained considerable momentum in today’s surgical operative techniques. The innovative idea of accessing the abdominal cavity via natural orifices such as the stomach, rectum, or vagina has the potential to initiate fundamental changes comparable with those brought on by the development of minimally invasive surgery (MIS) 20 years ago. After the first transgastric NOTES procedure was performed in a pig model by Kalloo et al1 in 2004, many groups started to develop novel NOTES approaches for clinical application. Initial reports confirm the safety and feasibility of natural orifice transluminal endoscopic surgery (NOTES) transvaginal cholecystectomy (TC). Benefits of TC include no visible scars, less pain, and shorter recovery. Materials and Methods: From July 2015 to September 2017, 14 patients performed NOTES cholecystectomy. We use single port platform such as Glove port, Lagis port and GelPoint. The port was introduced through the posterior vagina into the cul-de-sac. The gallbladder was visualized using an endoscope introduced through the vaginal port. Without extracorporeal stay sutures for retraction. The cystic duct and artery were dissected free, clipped, and divided by instruments. The gallbladder was then removed through the vaginal port. Results: 14 patients underwent a successful NOTES cholecystectomy. The average age was 34.9 years (27–65 years), average body mass index was 27.6 kg/m2 (17.2–35.1 kg/m2), and the mean operative time was 70.4 minutes (48–118 minutes)

Conclusion: NOTES cholecystectomy is a safe, feasible in well selected patients.

Surg Endosc

P294 - Liver and Biliary Tract Surgery

P295 - Liver and Biliary Tract Surgery

Safety and Efficacy of Percutaneous Gallbladder Stone Extraction in High Risk Surgical Patients: A Retrospective Cohort Study

The Incidence and Management of Suspected Bile Duct Stones in a Specialised Biliary Unit

P. Stirrat1, E. Shlomovitz2, S. Frosi Stella3, C.S. Ho4

K. Khan, H. Ng, K. Yong, A. Nassar

1

2

General Surgery, University of Toronto, Toronto, Canada; General Surgery and Interventional Radiology, University of Toronto, Toronto General Hospital, Toronto, Canada; 3Interventional Radiology, University of Toronto, Toronto, Canada; 4Interventional Radiology, University of Toronto, Toronto General Hospital, Toronto, Canada Aims: Acute cholecystitis in non-surgical candidates is often managed with cholecystostomy tube drainage. Once acute symptom resolution is achieved, there is a clinical dilemma regarding definitive management. Options range from cholecystectomy in a high risk surgical candidate, long term tube drainage or tube removal and observation, all of which represent trade-offs between complications and recurrence rates. Percutaneous gallbladder stone extraction (PGSE) may offer an attractive balance of risks and benefits for those patients. Methods: A retrospective chart review of PGSE performed at our institution between December 2000 and September 2017 was performed. Demographic information, diagnoses, risk factors, procedure details, gallstone-related complications, technical complications, readmissions, and mortality rates were reviewed. Results: Seventy-six consecutive patients were included with mean age of 75.8 ± 13.8 years and slightly predominance of males (52.6%). Mean follow-up was 2.8 ± 3.7 years. Cholecystectomy was declined in 61 patients (80.2%) due to medical comorbidities. Eleven patients (14.5%) had prior aborted cholecystectomy, and 4 patients had extensive adhesions precluding surgery. Complete PGSE was successful in 65 of 76 patients (85.5%), requiring 83 procedures. Success rate of PGSE for patients with aborted cholecystectomy was 100%. Reasons for failure included gallstone impaction (5.2%), immature tract (2.6%), lost access to gallbladder during procedure (3.9%), and no working domain within gallbladder (2.6%). During the follow-up period three deaths occurred, all unrelated to the procedure or biliary disease, and the readmission rate for technical complication or biliary disease was 21% (n = 16). Three (3.9%) patients went on to cholecystectomy (laparoscopic n = 1, open n = 1, failed n = 1). Intra-procedural complications were experienced by 3 (3.9%) patients, and included bleeding requiring takeback to interventional suite (2.6%), and gallbladder perforation (1.3%). Post-procedural abscess occurred in 2 (2.6%) patients, and delayed tract closure in 2 (2.6%). Gallstone related complications (21.8%) including recurrent cholecystitis (5.1%), choledocholithiasis (11.5%), cholangitis (1.3%), and pancreatitis (3.8%) occurred during the follow-up period. Conclusion: PGSE is a safe and viable option for management of symptomatic gallbladder stones in high risk surgical patients. There is a high rate of technical success, even in patients with prior failed cholecystectomy. Most patients avoided gallstone related complications following the procedure.

General Surgery, NHS Lanarkshire, Airdrie, United Kingdom Aims: Biliary disease is common in acute surgical admission. Patients with risk factors for bile duct stones are traditionally investigated with radiological imaging and/or endoscopic retrograde cholangioancreatography (ERCP) before proceeding with laparoscopic cholecystectomy (LC) ± common bile duct exploration (CBDE). Our aim was to evaluate the incidence and subsequent management of suspected bile duct stones. Methods: Prospective database of benign biliary cases operated over 26 years was analysed. Patients with risk factors for CBD stones such as previous or current jaundice, pancreatitis, cholangitis, dilated CBD ± filling defect on radiological imaging were identified. Demographics, ASA grade, pre-operative imaging/intervention, intra-operative findings and post-operative management were analysed. Results: 1776 (34.6%) patients in database of 5136 were identified as having risk factors for bile duct stones. 1208 (68.0%) were female, mean age was 54.6 years (8–91 years) and 1418 (79.8%) were emergency cases. ASA grades were; ASA-I 511 (28.8%), ASA-II 791 (44.5%), ASA-III 323 (18.2%), ASA-IV 13 (0.7%) and not recorded in 138 (7.8%). Pre-operatively; only 158 (8.9%) had MRCP and 133 (7.5%) had ERCP, mostly before referral to the biliary unit. 69 (3.9%) had CT scan, 2 had (0.1%) IVC and 1 (0.1%) had PTC. 1460 (82.2%) had ultrasound proven gallstones and 738 (41.6%) had ultrasound proven bile duct dilatation. 868 (48.9%) had LC and 908 (51.1%) had CBDE. 1737 (97.8%) had intraoperative cholangiogram. Operative difficulty grades were; grade-I 404 (22.7%), grade-II 508 (28.6%), grade-III 417 (23.5%), grade-IV 386 (21.7%) and grade-V 61 (3.5%). 19 (1.0%) required conversion to open. Of the 908 CBDEs; 378 (41.6%) were cholechodotomies and 530 (58.4%) were transcystic explorations. 837 (92.2%) had confirmed bile duct stones with clearance rate of 99.8%. 192 (22.8%) had t-tube insertion, 250 (29.7%) required cystic duct drain and 12 (1.4%) had biliary stenting. 181 patients had post-operative cholangiography, the mean time of which occurred at 5.4 days (1–28 days). 144 were normal, 21 showed filling defects and 16 had a displaced transcystic tube. Conclusion(s): In most cases with suspected bile duct stones, following an ultrasound scan, patients can undergo definitive procedure without the need for prior MRCP or ERCP reducing treatment costs.

P296 - Liver and Biliary Tract Surgery Single-Incision Laparoscopic Hepatectomy: An Analysis of Consecutive 16 Procedures S.H. Chuang, D.A. Chou Division of General Surgery, Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan Aims: Single-incision laparoscopic hepatectomy (SILH) has been showed feasible and safe in experienced hands for selected patients with benign or malignant liver diseases. There were only small series reported and most of the procedures were minor liver resections. We herein present our experience of SILH during a period of 16 months. Methods: Consecutive 16 SILHs were performed by two experienced laparoscopic surgeons with straight instruments. Patient characteristics and surgical outcomes were analyzed by reviewing the medical charts. Results: The patient age was 64.8 ± 10.2 (47–80) years with male predominance (9 patients, 60%). Eight patients (53.3%) had liver cirrhosis proved by pathologic examinations. Twelve procedures (75%) were indicated for malignancy. Four major hepatectomies (over two segments) and 12 minor ones were performed including eight anatomical resections. The abdominal incisions were para- or trans-umbilical except one which was along the old operative scar at lower midline, while most of them (n = 14, 87.5%) was within 5 cm in length. Inflow control was carried out by individual hilar dissection, extraglissonian approach, or Pringle maneuver. The operations were all accomplished successfully without additional ports or open conversion. The operative time was 440.6 ± 164.8 (163–673) min and the estimated blood loss was 444.1 ± 375.5 (75–1400) mL. Seven (43.8%) procedures encountered postoperative complications and five of them were classified as Clavien-Dindo grade I. The postoperative length of hospital stay was 6.3 ± 2.6 (3–12) days. There was no mortality. Conclusions: SILH can be performed safely and efficaciously for selected patients with benign and malignant liver diseases including cirrhosis. Not only minor but also major liver resections are feasible. This innovative procedure provides low postoperative pain and fast recovery. Before adopting this demanding technique, surgeons should be familiar with both single-incision laparoscopic surgery and laparoscopic hepatectomy. Better outcomes after the learning curve could be anticipated.

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Surg Endosc

P297 - Liver and Biliary Tract Surgery

P299 - Liver and Biliary Tract Surgery

Gallbladder Agenesis - Intraoperative Atonishment

Comparative Study of Choledochotomy Closure Techniques Following Lcbde- in Search Of Safety Guideline

1

2

D. Bandea , C.I. Avasiloaie , N. Bandea

3

1

General Surgery, Onesti City Hospital, Onesti, Romania; 2 Radiology, Onesti City Hospital, Onesti, Romania; 3Medical Analysis Laboratory, Onesti City Hospital, Onesti, Romania

M. Choudhury1, K. Baruah2 1 Laparoscopic Surgery, G I Surgery And Endo Laparoscopy Center, Guwahati, India; 2Surgery, Excelcare Hospital, Guwahati, India

Aims: Gallbladder agenesis (GA) without associating biliary tract atresia is a rare condition. GA exist alone or in association with other systemic anomalies involving the gastrointestinal, genitourinary, cardiovascular and skeletal systems. Methods: GA is usually asymptomatic, but it may manifest itself as a biliary colic or cholecystitis. Females are three times more affected. The rarity of this anatomical situation associated with its clinical and imagistic features often lead to an incorrect preoperative diagnosis and many patients undergo unnecessary surgical intervention. Results: We present the case of a 49-year-old female consulted in the hospital ambulatory with a recurrent right upper-quadrant pain, nausea, bloating and a recent abdominal ultrasonography showing gallbladder lithiasis. In the medical history she reported an appendectomy and smoke cessation for almost 10 years. I decide to go for a laparoscopic cholecystectomy. The intraoperative astonishment was that the gallbladder fossa was empty and we started to individualize the main structure from the hepatic pedicle. After the surgical recovery computer tomography with intravenous contrast administration revealed the absence of biliary bladder and a retroaortic left renal vein. The symptoms disappeared in the postoperative follow-up. Conclusions: It has been proven to be very difficult to make a correct preoperative diagnosis for agenesis of the biliary bladder in symptomatic patients, so many cases are still diagnosed intraoperatively. If intraoperative exploration cannot identify the biliary vesicle, a diagnostic procedure should be adopted to exclude an ectopic gallbladder (intrahepatic, left-sided, in the lesser omentum, retro-peritoneal, retropancreatic, retro-duodenal, retro-hepatic, in the falciform ligament): CT scanner with intravenous contrast and magnetic resonance cholangio-pancreatography (MRCP). MRCP allow to make the correct preoperative diagnosis by a non-invasive examination, avoiding unnecessary surgical intervention and minimizing the risk of complications. Keywords: Gallbladder agenesis, Retroaortic left renal vein, Magnetic resonance cholangiopancreatography.

Introduction: Laparoscopic common bile duct exploration has now been routinely performed in specialized centres. Choledochotomy closure with traditional T-tube drainage is associated with tube related morbidities. Primary closure is associated with risk of biliary leakage. Aim: Stents have been used with primary closure in the present study to evaluate the indications and compare the safety and effectiveness with T-tube drainage and primary closure in search of a safe Choledochotomy closure. Material and Method: 286 laparoscopic choledocholithotomy was performed at our centre during the period from October,2008 to November,2017. Lap supraduodenal Choledochotomy was performed. Calculus/calculi were extracted by flushing with normal saline as well as with the help of forceps or busket under direct vision of choledochoscope. Intra operative cholangiogram was done to re-confirm the clearance. CBD closure was done with T-tube drainage in 197, closure with stenting in 32 and primary closure in 57 cases. Selection of technique was determined by diameter, thickness of CBD, size and number of calculi. 3-0 vicryl was used to close the choledochotomy. Sub hepatic drainage was applied after completion of the procdure. T-tube or stent were removed after three weeks. Results: of closure techniques were analyzed in respect of indications (CBD, diameter, size and number of calculi) and compared in respect of duration of operation, complications and hospital stay. There were no significant difference in duration of operation and hospital stay. Significant Post operative complications were biliary leakage found transiently in 29.82% primary closure group and 6.09% following T-tube drainage. Signs of mild to moderate peritonitis in 15.7% after T-tube removal and 3.5% in primary closure post operatively (Chi square-20.06, p-0.00004 = p \ 0.05 at 5 level of significance but responded to conservative treatment these complications were negligible in closure with stent converted 9 cases 5 failure to identify CBD 4 failure to clear the CBD calculi p[ Conclusion: Study showed that the primary closure with stenting found to be the effective and better alternative than T-tube drainage and primay closure alone.

P298 - Liver and Biliary Tract Surgery

P300 - Liver and Biliary Tract Surgery

Laparoscopic Management of Type II Mirizzi Syndrome L. Navaratne, J. al-Musawi, A. Harris, K. Qurashi, A. Isla

Utility of Intraoperative ICG Fluorescence for Laparoscopic Liver RESECTION

Upper GI Surgery, Northwick Park & St Marks Hospitals, London, United Kingdom

K. Tsuboi, Y. Matsuo, G. Ueda, Y. Hayashi, H. Imafuji, K. Saito, T. Shamoto, M. Morimoto, H. Takahashi, H. Ishiguro, S. Takiguchi

Aims: Laparoscopic surgery can be hazardous in patients with Mirizzi syndrome as safe dissection of Calot’s triangle is difficult due to severe local inflammation and adhesions. Many authors recommend open cholecystectomy for Mirizzi syndrome and others advocate a laparoscopic approach for type I Mirizzi syndrome only. We describe our experience of type II Mirizzi syndrome using the laparoscopic approach. Methods: We retrospectively reviewed our prospectively kept database of laparoscopic common bile duct exploration (LCBDE) and included all patients with type II Mirizzi syndrome. Outcome measures included mortality, conversion to open surgery, treatment failure, major and minor complications and length of hospital stay. As a benchmark, we compared the type II Mirizzi syndrome group with the remainder of the LCBDE database. Results: 350 patients underwent LCBDE during the study period. Of these, 11 (3.1%) patients were identified as having type II Mirizzi syndrome. Nine (81.8%) patients underwent choledochotomy whereas two (18.2%) patients underwent transcystic choledochoscopy. Closure of choledochotomy were as follows: 3 T-tube, 5 antegrade stent and 1 primary closure. We compared outcome measures from the T2MS group to the remaining LCBDE patients from the database. Mortality (0% vs 0.9%, p [ 0.9999), conversion to open surgery (0% vs 1.2%, p [ 0.9999), failure (9.1% vs 3.8%, p = 0.3660), major complications (0% vs 7.7%, p [ 0.9999) and minor complications (18.2% vs 7.1%, p = 0.1930) were similar between the two groups. Length of hospital stay was higher in the type II Mirizzi syndrome group (median 5 vs 3 days, p = 0.0167). Conclusion: From our small series of type II Mirizzi syndrome, the laparoscopic approach appears to be effective and safe with similar outcomes to patients undergoing LCBDE for choledocholithiasis.

Gastroenterological Surgery, Nagoya City University, Nagoya, Japan

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Background: In liver resection, tumor mass is identified by visual examination, palpation, and intraoperative echo. It is difficult to identify a minute tumor. It is impossible to palpate especially with laparoscopic hepatectomy. Intraoperative echo is difficult to manipulate and identify lesions close to the probe. ICG fluorescence method can identify liver mass easily. In hepatocellular carcinoma, the tumor itself fluoresces. In other masses, the tumor does not fluoresce, and the marginal liver fluoresces. We examined whether ICG fluorescence method is useful for liver resection. Method: 33 patients underwent liver resection from January 1 to November 30 in 2017, of which 26 were laparoscopic surgery. ICG examination was performed, in principle, one week before surgery. ICG fluorescence method was used intraoperatively in 14 cases, and with resection specimen in 18 cases. We evaluated findings of vision, palpation, intraoperative echo and ICG fluorescence method in the operation and postoperative specimen. Result: Only one case failed to identify tumor mass by ICG fluorescence method. The case was colon cancer liver metastasis of 10 mm and underwent ICG examination 15 days before the operation. 2 cases could not be identified by visual examination nor echo, but could be identified by only ICG fluorescence method. These cases were hepatocellular carcinoma of 10 mm and esophageal cancer liver metastasis of 3 mm, and were able to be performed partial liver resection safely. Conclusion: The ICG fluorescence method has high detection rate and can be identified even with a minute liver mass unknown even by visual examination and intraoperative echo. Since laparoscopic surgery can not use palpation especially, it was suggested that intraoperative ICG fluorescence is particularly useful for small liver masses.

Surg Endosc

P301 - Liver and Biliary Tract Surgery

P303 - Liver and Biliary Tract Surgery

Clinical Aspects of Bile Culture in Patients Undergoing Laparoscopic Cholecystectomy

Opportunities of Laparoscopy in Clean Echinococcosis of the Liver

S.P. Yun, H.I. Seo

M.A. Khamidov, A.S. Murtuzalieva

Department of Surgery, Pusan National University Hospital, Busan, Republic of Korea

Endoscopic surgery, Dagestan State Medical University, Makhachkala, Russia

Aim: We identify the incidence of biliary microflora, most common biliary microflora and resistance of antibiotics. Methods: Bile samples were taken for culture according to a standard routine during all cholecystectomies performed from January 2015 to December 2015 in the department of surgery, Pusan National University Hospital. 366 laparoscopic cholecystectomy were performed during the study period. In 215 patients, the bile culture was performed and the culture positive was found in 54 cases. Prophylactic antibiotics were administered 30 minutes before incision. PO antibiotics were not used. Results: The mean age of the 54 patients was 65 years, male and female ratio was 26:28, and mean BMI was 24. ERCP was performed in 26 cases and PTGBD in 11 cases before operation. 30 of 54 patients were visited to ER. 85 bacteria were identified in 54 patients. Single bacteria positive culture was identified in 26 patients, and multiple were in 28 patients. In 20 patients with ERCP, 16 multiple strains were cultured, and in 5 out of 7 PTGBD patients, multiple strains were cultured. The culture positive group is older. (p = 0.000) The portion of patients with performance of ERCP, performance of PTGBD, presence of symptoms, presence of operative complication and hospital day is significantly higher in the culture positive group. In the mutivariate analysis of factors associated with positive culture, age, ERCP, and symptom were independent factor on positive bile culture. Conclusion: Patients who visited ER were more likely to have bacterial growth in the bile, and when ERCP was performed, multiple bacteria culture positive was more likely to be found. Although bile culture may be important for the selection of prophylactic antibiotics, more research is needed to determine the significance of bacterial growth in bile.

The urgency of the problem of treatment of liver echinococcosis is dictated by the high prevalence of this disease in endemic areas, the prevalence among patients of the most ablebodied age, the high percentage of complications after open interventions and the long rehabilitation period. Purpose: Improve the results of laparoscopic treatment of cystic liver echinococcosis. Material and Methods: The main principles of echinococcosis surgery are: aparasiticity and antiparasiticity, elimination of the residual cavity of the liver, detection and elimination of cystobiliary fistulas, and anti-relapse chemotherapy. We generalized and analyzed the experience of treatment of 94 patients with liver echinococcosis aged 14–56 years, between 1996 and 2014. Our studies showed that the process predominantly localized in the right lobe of the liver (V, VI, VII, VIII segments), the size of the cysts varied from 4 to 14.2 cm. Standard laparoscopic equipment was used, access was provided, as a rule, by 4 trocars. For the aparasitic puncture of the cysts, patented devices of intrinsic design were used; antiparasitic treatment was performed with a 25% solution of sodium chloride. Results: The average duration of the operative intervention was 48 minutes; the average bed-day was 6.5 days. In one case, there was a conversion to traditional access in connection with subdiaphragmatic cyst localization. Among all our patients, only one case had a relapse of the disease (0.9%). The method of selecting the elimination of the residual cavity of the liver is the method of abdomination (79 patients) using ultrasound dissection (48 patients), provided thorough endovideoscopy of the residual cavity of the liver. Conclusions: Laparoscopic technology is an effective method for the treatment of cystic liver echinococcosis, taking into account contraindications and strict implementation of all the technical principles of this operation, and abdominization is the preferred way to eliminate the residual cavity of the liver.

P302 - Liver and Biliary Tract Surgery

P304 - Liver and Biliary Tract Surgery

Feasibility of Laparoscopic Cholecystectomy in Patients with a History of Upper Abdominal Surgery

Dissection Technique of the Hepatic Hilar Area Focused On Laennec’s Capsule for Laparoscopic Systematic Hepatectomy using Cadaver Simulation

T. Yoshihara, Y. Tomimaru, Y. Yokota, K. Noguchi, H. Nagase, A. Hamabe, M. Hirota, K. Oshima, T. Tanida, S. Morita, H. Imamura, T. Iwazawa, K. Akagi, K. Dono Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan Aim: Laparoscopic cholecystectomy (LC) has gained widespread clinical acceptance as a safe and effective technique for the treatment of benign gallbladder diseases. With growth in experience, indication criteria for selecting patients for LC have expanded. Cases with a history of upper abdominal surgery was previously recognized as a relative contraindication to LC, but with the expansion, the recognition has gradually changed. This study aimed to investigate feasibility of LC in patients with a history of upper abdominal surgery. Methods: Among 2740 patients who underwent LC for benign gallbladder diseases in our institution between January 2005 and November 2017, 47 patients had a history of upper abdominal surgery. The 47 patients were included in this study, and their clinical outcomes of LC were assessed. The LC procedure was as follows; two 12-mm trocars and two 5-mm trocars were inserted. The first port was typically inserted via the open method at a periumbilical or umbilical site. Carbon dioxide was used for peritoneal insufflation, and pneumoperitoneum was maintained at 8 mmHg. We routinely freed the cystic artery and cystic duct, achieving a critical view of safety, and then dissected the gallbladder. The cystic artery was sealed and dissected with laparoscopic coagulation shears, and the cystic duct was intra-abdominally ligated. Results: he gallbladder diseases were symptomatic gallstones in 6 cases, gallbladder polyp in 1, and acute cholecystitis in 1. The previous upper abdominal surgery was as follows; gastrectomy in 32 cases, colectomy in 3 cases, hepatectomy in 3 cases, and other procedures in 9 cases. Operation time and intraoperative blood loss in the cases were 109 ± 50 min and 41 ± 109 ml, respectively. Among the cases, 8 cases (17.0%) needed conversion to open surgery because of severe adhesion. There were no cases with operative mortality. Postoperative complications determined by grade greater than II of Clavien-Dindo classification was observed in 2 cases (4.3%). The duration of postoperative hospital stay was 6 ± 5 days. Conclusions: The clinical outcomes were favorable. This would suggest feasibility of LC in patients with the history of upper abdominal surgery.

M. Morimoto, Y. Matsuo, G. Ueda, Y. Hayashi, H. Imafuji, K. Saito, T. Shamoto, K. Tsuboi, H. Takahashi, H. Ishiguro, S. Takiguchi Gastroenterological Surgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan Objective: Although laparoscopic systematic hepatectomy is a highly difficult operation, patients can benefit greatly from the low invasiveness. In order to safely perform this procedure, it is important to be familiar with the detailed layer structure around the Glisson’s sheath. The Laennec’s capsule is present around the Glisson’s sheath of the hepatic hilar area, we think that recognizing the layer structure of Laennec’s capsule is important for safe and highly accurate surgery. Methods: Cadaver training was conducted before introduction of laparoscopic systematic hepatectomy. In order to verify an appropriate peeling layer, a pathological search was performed on the peeled Glisson’s sheath cut stump. Fifteen laparoscopic systematic hepatectomy performed at our hospital from January 2015 to August 2017 (lobectomy: 6 cases, segmentectomy: 5 cases, subsegmentectomy: 4 cases ) were targeted. Operative time, bleeding volume, postoperative hospital stay, postoperative complications (Clavien - Dindo classification Grade 3 and above) were examined. Result: Since the cadaver used in our hospital is fixed by the Thiel method, it is very useful as a surgical training in the gastrointestinal surgery, because the layer structure is maintained like a living body. Pathological search was conducted on specimens taken from the cadaver and the living body. As a result, the Laennec’s capsule was retained on the hepatic parenchyma around the Glisson’s sheath cut stump. The operative time was 412 ± 83 minutes, the bleeding volume was 183 ± 103 g, the postoperative period of hospitalization was 9.8 ± 3.5 days, no complications of CD classification Grade 3 or higher was observed. We did not admit any cases of death in the hospital. Conclusion: We thought that by placing emphasis on the Laennec’s capsule of the hepatic hilar area, it is possible to safely treat the Glisson’s sheath. And, we could train a laparoscopic systematic hepatectomy focused on layer structure using cadaver, and the operation with high difficulty can be performed safely. Cadaver training is useful as a preoperative training for laparoscopic systematic hepatectomy.

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Surg Endosc

P305 - Liver and Biliary Tract Surgery

P307 - Liver and Biliary Tract Surgery

A Double Cystic Duct (DCD) Detected in Surgical Specimen After Completing Laparoscopic Cholecystectomy (LC): A Case Report

Laparoscopic Approach for Incidental Gallbladder Cancer

N. Ozlem General Surgery, Ahievran University, Kirsehir, Turkey

G. Rustamov, E. Rustamov General Surgery, Central Hospital Caspian Shipping Company, Baku, Azerbaijan

DCD is an extremely rare anomaly of EHBS (extrahepaticbiliarysystem).In English literature there are only14 DCD cases. Any anomalies of EHBS are undetectable in the preoperative examinations. Routine preoperative or intraoperative cholangiography (IOC) or preoperative and intraoperative ERCP are recommended to avoid complications. Actually it is very difficult to diagnose a DCD preoperatively. Here, a case of DCD diagnosed by macroscopic examination (ME) of the extracted gallbladder (GB), performing IOC during the operation. 60Y woman presented for 4 years epigastric pain had normal physical examination. USG revealed a thick wall GB with multiple calculi. LC completted on a partially gangrenous GB.A MEof the GB showed a DCD. Another 0.6 cm in diameter tubular structure was identified as arising from operation site, coursing toward the hilum. An IOC was performed under fluoroscopic guidance through the ductal structure opening into the bifurcation of EHBS. This accessory channel was ligated. the patient was discharged on POD5. DCD is a very rare anomaly of the extrahepatic biliary system (EHBS). To our knowledge our case is fifteenth case reported in English literature. DCD draining a single GB has been documented in isolated case reports in English, EU literature, accounting for fewer than 20%published cases. Twelwe of15 cases were diagnosed by operative 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 2DCD found inLC cases, authors recommended routine preoperative or IOC. Unfortunely we cannot perform preoperative cholangiography and/or ERCP in our clinic. The injury of the EHBS occurred in 2of5 cases that had undergone LC. A LC was unsuccessful;an open cholecystectomy (OC) was performed in the most recent DCD case. Nine of these fifteen cases had OCwithout complications. Eight of 15 DCD cases in the literature was diagnosed by operative finding. We couldnot identified appropriately another arising tubular structure from the GB and coursing toward the hilum. The GB was not meticulously dissected from GB bed, If ıt would be adequately this aberrant biliary duct could be identified and could be preserved. Momiyama et al thought that the second duct was dissected during the operation, the patient suffered from postoperative bile leakage. It is important to clarify the anatomy of the BT by preoperative, intraoperative examination, to carefully dissect the CD close the neck of the GB during cholecystectomy.

Gallbladder cancer is the most common malignancy of the biliary tract, representing 80–95% of biliary tract cancers worldwide. The incidence of gallbladder cancer in a population with gallstones varies from 0.3 to 3%. Aim: To evaluate the technical feasibility and safety of laparoscopic radical cholecystectomy for incidental early gallbladder cancer treatment. Methods: Articles reporting Laparoscopic Cholecystectomy for gallbladder cancer were reviewed from the first case reported in 2001 to 2016 (23 patients). All patients were incidental cases discovered during a laparoscopic cholecystectomy. Results: The majority of patients who underwent Laparoscopic Cholecystectomy were pT2. Parenchyma-sparing operation with wedge resection of the gallbladder bed or resection of segments IV-V were performed principally. Laparoscopic lymphadenectomy was carried out according to the reported depth of neoplasm invasion. No postoperative mortality was documented. Discharge mean day was 3.0 ± 1.4. Two patients had post operative morbidities. 5 years-survival rate ranged from 23.16 to 81.8 months. Conclusion: Laparoscopy can not be considered as a contraindication to gallbladder cancer but a primary approach for early case treatment.

P306 - Liver and Biliary Tract Surgery

P308 - Liver and Biliary Tract Surgery

Laparoscopic Parenchyma-Sparing Liver Resection for Colorectal Metastases

Robotic Left-Side Hepatectomy: Initial Experience of 11 Cases

˚ . Fretland2, A. Kazaryan3, M. Sahakyan1, D. Aghayan1, E. Pelanis1, A R. Røsok2, L. Barkhatov1, B. Bjørnbeth2, O. Elle1, B. Edwin1

S.J. Lee, J.H. Lee Department of Surgery, Asan medical center, Seoul, Republic of Korea

1

The Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway; 2Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; 3Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway Background: Laparoscopic liver resection (LLR) of colorectal liver metastases (CLM) is increasingly performed in specialized centers. While there is a trend towards a parenchymasparing strategy in multimodal treatment for CLM, its role is yet unclear. In this study we present short- and long-term outcomes of laparoscopic parenchyma-sparing liver resection (LPSLR) at a single center. Patients and Methods: LLR were performed in 951 procedures between August 1998 and March 2017 at Oslo University Hospital, Oslo, Norway. Patients who primarily underwent LPSLR for CLM were included in the study. LPSLR was defined as non-anatomic hence the patients who underwent hemihepatectomy and sectionectomy were excluded. Perioperative and oncologic outcomes were analyzed. The Accordion classification was used to grade postoperative complications. The median follow-up was 40 months. Results: 296 patients underwent primary LPSLR for CLM. A single specimen was resected in 204 cases, multiple resections were performed in 92 cases. 5 laparoscopic operations were converted to open. The median operative time was 134 minutes, blood loss was 200 ml and hospital stay was 3 days. There was no 90-day mortality in this study. The postoperative complication rate was 14.5%. 189 patients developed disease recurrence. Recurrence in the liver occurred in 146 patients (49%), of whom 85 patients underwent repeated surgical treatment (liver resection [n = 69], ablation [n = 14] and liver transplantation [n = 2]). Fiveyear overall survival was 48%, median overall survival was 56 months. Conclusions: LPSLR of CLM can be performed safely with the good surgical and oncological results. The technique facilitates repeated surgical treatment, which may improve survival for patients with CLM.

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Aims: Robotic hepatectomy has been suggested as a safe and effective management of liver disease including malignancy. In current study, we report our initial experience with robotic left side hepatectomy. Methods: A retrospective review of a prospective database of 24 consecutive patients who underwent robotic hepatectomy at a single institution by single surgeon was conducted. Eleven consecutive patients who underwent robotic left-side hepatectomy from June 2016 to December 2017, were identified and we analyzed their perioperative outcomes. Results: The disease included 4 hepatocellular carcinoma (HCC), 4 metastatic cancer to liver, 1 combined HCC and cholangiocarcinoma (CCC), 1 intrahepatic CCC and 1 intraductal papillary neoplasm of the bile duct (IPNB). The procedure included 6 left hemihepatectomies and 5 left lateral sectionectomies (two including single site incision). The median tumor size was 30 (range, 12–81) millimeters except 1 IPNB case and all patients had tumor free resection margin. The median totally operative time (skin to skin) of all patients was 195 (range, 105–295) minutes and each median totally operative time of left hemi-hepatectomy and left lateral sectionectomy was 269 and 165 minutes, respectively. The median postoperative hospital stay was 6 (range, 5–10) days. None of patients had transfusion. There is no open conversion and also no any postoperative in hospital complications and mortalities. Conclusion: Our initial experience confirms the feasibility and safety of robotic left side hepatectomy.

Surg Endosc

P309 - Liver and Biliary Tract Surgery

P462 - Liver and Biliary Tract Surgery

Management of Acute Cholecystitis During the Index AdmissionThe Service Model and Benefits

Robot-Assisted One-Stage Resection of Gastrointestinal And Colorectal Cancer and Syncronous Liver Metastases: Our Experience and Literature Review

H.J. Ng, K.S. Khan, K.H.Z. Yong, A.H. Nassar General Surgery, NHS Scotland, Glasgow, United Kingdom Aims: Laparoscopic cholecystectomy (LC) should be performed within one week of diagnosis of acute cholecystitis (AC) or after more than 4 weeks according to National Institute for Health and Care Excellence guideline. Despite this recommendation, practice remains divisive. The aim was to evaluate the complications associated with LC ± common bile duct exploration (CBDE) on AC during index admission. Methods: Patients admitted with calcular AC are routinely referred to the biliary team where LC ± CBDE is performed during the index admission. Prospective database of such patients, performed by a single surgeon from 1992 to 2017 was analysed. Patients with clinically suspected AC, pathologically confirmed AC and empyema were included. Data on patient demographic, difficulty grade, total length of hospital stay, peri-operative complications, operating time and conversion to open were analysed. Results: 5136 patients underwent LC ± CBDE of which 436 (8.5%) had clinically suspected AC. Out of these, 355 (81.4%) had confirmed diagnosis of AC or empyema of the gallbladder; 180 were confirmed on pathology and 175 had empyema. A further 275 patients with a diagnosis of AC were identified who did not present with symptoms of AC; 141 had AC on pathology and 134 had empyema. Male to female ratio was 1:1.6 and mean age was 55 years (16–91 years). Median length of total hospital stay was 6 days (1–58 days). A total of 630 patients had confirmed diagnosis of AC. Difficulty grading was as follows; grade-I 4 (0.6%), grade-II 28 (4.4%), grade-III 205 (32.5%), grade-IV 361 (57.3%) and grade-V 32 (5.1%). Mean operating time was 94.3 minutes (30–350 minutes) and re-admission rate was 3%. There were 7 (1.1%) conversions to open, 25 (4%) peri-operative complications and 2 (0.3%) mortalities from mesenteric ischemia and liver failure. Conclusions: Patients with clinically suspected AC do not necessarily have histologically confirmed AC or empyema. LC performed during index admission for patients with AC is highly recommended as it can be performed safely with low conversion rates and peri-operative complications. It can also avoid re-admissions from complications secondary to gallstones and provide financial benefit to the health service.

G. Ceccarelli1, L. Marano2, A. Rocca3, A. Fontani3, F. Ermili4, M. de Rosa1, E. Andolfi3 1 General and Minimally Invasive Surgery, San Giovanni Battista Hospital, Foligno, Italy; 2General and Minimally Invasive Surgery, ASL 2 Umbria, Spoleto, Italy; 3General and Minimally Invasive Surgery, Arezzo Hopsital, Arezzo, Italy; 4General and Minimally Invasive Surgery, San Giovanni Battista Hospital ASL 2 Umbria, Foligno, Italy

Background/Aims: Robotic surgery has been introduced to overcome the limitations of conventional laparoscopic approach. The robotic technology is increasingly used in selected patients with either gastrointestinal, colorectal or liver disease. The aim of this study was to evaluate the safety and feasibility of robotic-assisted one-stage resection of gastrointestinal and colorectal cancer combined with liver resection. Methods: From October 2012 through December 2016, 70 robotic-assisted liver resection were performed in our surgical unit. Final histology revealed: liver metastases (N = 32), HCC (N = 11), benign disease (N = 21), cystic echinococcosis (N = 2), one case of cholangiocarcinoma and one of galldbladder cancer while in two cases the diagnosis was not evaluable. Out of 70 robotic-assisted procedures performed, we have enrolled 20 consecutive patients affected by colorectal (N = 15) and gastric (N = 5) cancer with synchronous liver metastases who underwent one-stage robotic assisted resection. Results: The patients’ median age was 65 (range 31–85) years and the median body mass index was 23.7 Kg/m. The primary sites of colorectal cancer were: right colon (N = 6), left colon (N = 3) and rectum (N = 6). The gastric procedures were: total gastrectomy (N = 3), total gastrectomy with splenectomy en bloc (N = 1) and gastric resection (N = 1). Liver procedures included wedge resections (N = 16) and partial resections (N = 9). Three patients was converted to open approach. The median surgical time for patients with colorectal cancer was 337 (range 180–540) min and 372 (range 255–465) min for those with gastric cancer. Postoperative mortality did not occur. The median hospital stay was 11 (range 6–34) days. Conclusion: This study seem to show that the robotic-assisted one-stage resection of gastrointestinal and colorectal cancer with synchronous liver metastases is tecnically feasible and safe in selected patients. Robot assistence may facilitate liver resections expecially for patients with posterior segments metastases.

P461 - Liver and Biliary Tract Surgery

P463 - Liver and Biliary Tract Surgery

Single-Incision Laparoscopic Transfistulous Bile Duct Exploration After Failed Endoscopic Sphincterotomy and Lithotripsy for Mirizzi Syndrome Type III

Endovideosurgical Treatment of Acute Cholecystitis and its Complications in Municipal Hospital

S.H. Chuang, H.H. Huang

A. Ukhanov, D. Zakharov, S. Zhilin, S. Bolshakov, A. Leonov, V. Ambartzumjan

Division of General Surgery, Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan

Surgical, Central municipal clinical hospital, Velikiy Novgorod, Russia

Background: We have presented laparoscopic transfistulous bile duct exploration (LTBDE) for Mirizzi syndrome (MS) McSherry type II (Csendes type II-IV). As the impacted stone(s) at the cystocholedochal fistula is (are) usually big and hard in this scenario, it is still a big challenge to deal with it by endoscopic sphincterotomy (EST) and lithotripsy. Case Report: A 33 y/o male patient was admitted to our gastrointestinal ward with a chief complaint of (right) upper abdominal pain for one week. He had a history of cholelithiasis and choledocholithiasis s/p endoscopic retrograde cholangiopancreatography (ERCP) and EST for two times. Laboratory tests, abdominal echography and magnetic resonance cholangiopancreatography (MRCP) led to the diagnosis of small gallbladder stones with chronic cholecystitis and middle bile duct stone (1.3 cm) with obstructive jaundice. ERCP revealed a suspected choledochoduodenal fistula and a big stone impacted at cystocholedochal junction that indicated MS Csendes type III. The papilla was cannulated and an endoscopic sphincterotomy was performed to the fistula. The hard impacted stone was crushed by mechanical lithotripsy but only a few fragments could be extracted with a basket. We performed single-incision laparoscopic transfistulous bile duct exploration and partial cholecystectomy with conventional instruments. Early intraoperative findings included gallbladder shrinkage and dense adhesions at Calot’s triangle. The gallbladder was opened on the infundibulum and the diagnostic cholangiography showed residual stone fragments impacted at the cystocholedochal junction and the thin distal bile duct with proximal biliary dilatation. After all of the retained stones were removed by choledochoscopic basketing, stone clearance was confirmed by the completion cholangiography. Then the gallbladder remnant was closed by means of intracorporeal suturing. Finally, the gallbladder (fundus and body) was dissected from the liver bed and the subhepatic space was drained. The total operative time was 276 min and the blood loss was minimal. The subhepatic drain was removed and the patient was discharged on the 4th postoperative day uneventfully. There was no complication during a followup of 9 months. Conclusion: SILTBDE can be performed as an effective salvage procedure after failed endoscopic treatment for MS Csendes type III. Long-term follow-up is mandatory.

Aim: Improve the results of the treatment of patients with acute cholecystitis and its complications. Materials and Methods: 2006 patients with acute cholecystitis aged from 18 to 100 years were operated on in the period from 2007 till and 2017 in municipal hospital. Among the operated patients 977 (48.7%) were older 60 years. Destructive forms of gall-bladder inflammation (phlegmonous, gangrenous cholecystitis, empyema of the gall bladder, paravesical infiltration or abscess) were detected during surgery in 1340 patients (66.8%). Laparoscopic cholecystectomy (LCE) was performed in 1672 (83.3%) and in 27 patients LCE was combined with choledocholithotomy and choledochoscopy due to concomitant choledocholithiasis and cholangitis. 334 patients (16.7%) patients were operated on by laparotomy. Results: Among the patients who were operated on laparoscopically the conversion to open access was carried out in 52 (3.1%), herewith in 6 (22.2%) patients during laparoscopic interventions on the common bile duct. Postoperative intraabdominal complications were occured in 56 patients (3.3%), including bleeding in 4 (0.2%), peritonitis in 1 (0.06%), intra-abdominal abscesses in 19 (1.1%), acute intestinal obstruction in 1 (0.06%), bile leakage in 18 (1.1%), duodenal fistula in 1 (0.06%), suppuration of trocar wounds in 12 (0.7%) patients. Postoperative mortality was 0.7% (12 patients). All deceased patients were elderly and causes of death were extraabdominal complications of the cardiovascular and respiratory systems. A comparative analysis of the results of the operation with open surgery (334 patients) showed that the use of laparoscopic method in the treatment of patients with acute cholecystitis allows five times to reduce postoperative mortality and three times diminish postoperative morbidity. Conclusions: Laparoscopic surgery in the treatment of acute cholecystitis and its complications is a priority method and this trend should be continued in the treatment of concomitant choledocholithiasis.

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Surg Endosc

P464 - Liver and Biliary Tract Surgery

P310 - Morbid Obesity

Laparoendoscopic Interventions on Common Bile Duct in the Patients with Cholecystitis and Concomitant Bile Duct Stones

Two Years Performing One Anastomosis Gastric Bypasses A Single Center Experience

A. Ukhanov, D. Zakharov, S. Zhilin, S. Bolshakov Surgical, Central municipal clinical hospital, Velikiy Novgorod, Russia

J. Hilbert, R. Archid, D. Wulff, A. Ko¨nigsrainer, J. Lange Allgemeine, Viszeral- und Transplantationschirurgie, Universita¨tsklinikum Tu¨bingen, Tu¨bingen, Germany

Aim: To study the feasibility and effectivity of laparoendoscopic interventions in cholecystocholedocholithiasis. Materials and Methods: 2175 patients with acute cholecystitis, aged from 18 years to 100 years, were operated on for the period from 2007 to 2017. Among them laparoscopic cholecystectomy was performed in 1875 (86.2%). The combination of acute cholecystitis with suspected stones or presence of stones in the extrahepatic bile ducts were detected in 224 (10, 3%) of patients. During last 3 years the laparoscopic method of surgery in the presence of common bile duct stones was carried out. After performance of intraoperative cholangiography and visualization of stones in the common bile duct laparoscopic, choledochotomy and bile duct stones extraction was undertaken in 56 patients, using flexible choledochoscopy control. In all patients with gallbladder stones was then performed laparoscopic cholecystectomy. Results: Laparoendoscopic intervention on common bile duct was successfully performed in 48 patients (85.7%) and the operation was completed by common bile duct drainage by Kehr. In 8 patients due to technical difficulties conversion to open surgery was carried out. Postoperative morbidity in the form of bile leakage were diagnosed in 9 patients (16.1%). In three cases they stopped spontaneously in 5–6 days after the operation. 6 patients were operated on repeatedly and additional suturing on choledocholithiasis was carried out. Postoperative mortality was 2.4%. The death of the patient of 92 years was caused by acute cardiovascular failure. Conclusion: Our moderate experience of laparoendoscopic interventions on the common bile duct in patients with cholecystitis and choledocholithiasis shows good feasibility of this miniinvasive interventions. Further accumulation of experience with the development of indications and contraindications and the improvement of surgical technique is necessary for a comprehensive assessment.

Background: The one anastomosis gastric bypass (OAGB) was introduced in 2001 by Rutledge (Rutledge 2001). Since then the number of patients receiving this procedure increased (Deitel 2015). Within the last years multiple papers showed good results in weight loss and improvement of comorbidities (Musella et al 2017). In our university bariatric center we started to perform the OAGB in 2015. Aim: Studying short-term-results for our first OAGBs. Methods: A retrospective analysis was performed on all patients receiving an OAGB since 2015. We measured BMI and weight loss, the impact on Type 2 Diabetes and early and late complications. Results: Between May 2015 and July 2016 17 patients received an OAGB. 9 of them were female. The OAGB as a Redo-surgery was performed in 4 of these patients. Mean BMI was 50 ± 5.72 kg/m2 preoperatively. 1 year postoperative mean BMI was 33.6 ± 8.18 kg/m2, mean EWL was 63.9 ± 25.9%. Diabetes mellitus Type 2 was prevalent in 10 patients (58.8%) preoperatively, all of them had a complete remission within one year postoperative. There were no early (within the first 30 days) complications in any of these cases. Two years later 2 patients needed re-operation because of gastrooesophageal reflux. Another 2 patients suffered of severe malabsorption and needed medical treatment. There were no surgical complications at all. Conclusion: As reported in literature our data shows that OAGB is an effective treatment of morbid obesity with a positive influence on Diabetes mellitus Type II. The operation itself is safe without any major complications reported. Nevertheless there are existing mid-term problems like reflux and malabsorption with the eventual need of re-operation in the course.

P465 - Liver and Biliary Tract Surgery

P311 - Morbid Obesity

Laparoscopic Anatomical S7 and S8 Segmentectomy

Safe Access to Peritoneal Cavity in Laparoscopy for Obese Patients

K.H. Chen, T.F. Siow, U.C. Chio, Y.D. Chen Surgery, Far-Eastern Memorial Hospital, New Taipei, City, Taiwan Aims: to evaluate the feasibility and short-term results of laparoscopic anatomical resection of S7 or S8 Methods: Perioperative results of patients receiving laparoscopic isolated anatomical resection of S7 or S8 had been collected after reviewing the institutional database of 835 laparoscopic liver procedures. Anatomical S7 or S8 segmentectomy by exposing major hepatic veins were enrolled in this retrospective review. Surgical Procedure: The patient was placed in reverse Trendelenburg position. Extrahepatic Glissonean pedicle dissection has been done for inflow control. Liver parenchymal dissection was performed along the demarcation line. To complete anatomical segmentectomy, hepatic vein in the dissection plane was exposed to define the extent of resection. Intrahepatic Glissonean pedicle to the individual segment was identified and divided. Harmonic scalpel and monopolar cautery had been used as the primary tools for parenchymal dissection. Results: From Oct 2015 to Dec 2017, total 10 patients had been enrolled, including 9 patients with hepatocellular carcinoma and one patient with metastatic tumor of colorectal cancer. Perioperative results including mean operation time 255 min (195 * 375), estimated blood loss 267 g (50 * 550), tumor size 2.9 cm (1.7 * 4.6), postoperative hospital stay: 4.8 days (3 * 7). No patient needed perioperative blood transfusion. Margin free resection had been achieved in all patients. Perioperative complication including right pleural effusion in 2 patients. There were no perioperative morality. Conclusion(s): Laparoscopic isolated anatomical segmentectomy of S7 or S8 is reproducibly feasible with acceptable perioperative outcome. Detailed peroperative image evaluation and simulation is crucial. Inflow control during parenchymal dissection and flexible endoscopic image system allowed clear surgical view. Dissecting major hepatic veins from the root side avoided large branch tearing. However, long-term follow-up of larger series is necessary to evaluate the efficacy and oncological outcomes.

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S.M.P. Pathirana General Surgery, Ministry Of Health, Ragama, Sri Lanka Background: Safe Access to peritoneal cavity in laparoscopy is one of the key issues in obese patients. Especially in obesity safe open technique (Hassan’s) is not a feasible option as these patients have a thick fatty abdominal wall the incision may be few inches in length. Many centers use optical trocar entry, while others use veress needle to gain access to peritoneal cavity. Each of the techniques have its own constrains with reasonable amount of safety threat. We use a combination of veress with optical trocar entry while minimizing the threat of visceral injury. Aim of the study: To describe the technical steps of the procedure. Methodology: External anatomy of the anterior abdominal wall is marked. Identify the place where first port to be inserted. Usually this is at the right upper quadrant few centimeters above and lateral to the umbilicus. Adequate length incision is made through the skin and blunt dissection made through fat with an artery forceps until the fascia reached. Then toothed artery forceps (crocodile type) uses to pinch up the fascia and veress needle passes through the fascia into the peritoneal cavity while high flow gas insufflation on. Once needle enter into the peritoneal cavity (as felt by the surgeon and confirmed by smooth insufflation of carbon dioxide) smooth influx of CO2 confirmed the correct location. Once desired CO2 pressure achieved veress will be removed and same incision uses to enter with optical trocar with a zero degree camera. Results: Since October 2016 until 31st October 2017 access has been obtained in 15 obese patients (6 for bariatrics and 9 others) with mostly first pass entry and no visceral injury. Conclusion: This technique is simple and effective safe solution for peritoneal cavity access in obese patients.

Surg Endosc

P312 - Morbid Obesity

P314 - Morbid Obesity

Outcomes in Super Obese Patients Undergoing Mini Gastric Bypass and Laparoscopic Sleeve Gastrectomy

Utility of Epworth Sleepiness Scale to Predict Obstructive Sleep Apnea in Morbidly Obese Patients and Prediction of a Better Score

V. Singla, S. Aggarwal, H. Garg Surgical Disciplines, All India Institute Of Medical Sciences, New Delhi, India Introduction: The data on role of MGB in super obese patients and its direct comparison with LSG in super obese patients is scarce. Methods: Data of 48 matched patients with BMI [ 50, who underwent either laparoscopic sleeve gastrectomy (LSG) or mini gastric bypass (MGB) and analysed retrospectively on a prospectively collected data base. Percentage excess weight loss %EWL was calculated as per Dietal et al. Results: Both the groups were comparable for age, sex, BMI and presence or absence of comorbidities. mean EWL% ±2SD at 1y was 61.9% ± 39.4 in patients undergoing LSG, while it was 73.0% ± 28.6 in patients undergoing MGB (p = 0.051). 83.3% of patients in LSG group had remission of diabetes mellitus while 85.7% in the MGB group had remission. 66.67% of patients in LSG group. had remission of hypertension while 100% patients in MGB group had remission. Patients in the MGB group had a mean preoperative AHI of 44.35 which decreased to 5.99 at 1 year of follow up.100% of patients with OSA in LSG group had resolution of their symptoms at 1 year. All patients in MGB group had remission in their hypothyroid status while 67% of patients in LSG had improvement in their hypothyroid status. Conclusion: Weight loss following both MGB and LSG in super obese was found to be comparable in ur study, with slightly better resolution of comorbidities following MGB.

S. Aggarwal, V. Singla, G. Tharun Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India Introduction: Some studies have shown that Epworth sleeping scale (ESS) is not a good tool to predict obstructive sleep apnea (OSA), however data regarding accuracy of ESS in morbidly obese patients is lacking. Methods: 232 patients underwent polysomnography and also undertook the ESS questionnaire preoperatively. An ESS score [ 10 was taken as indicator of presence of excessive daytime reference sleepiness and OSA. A new score was derived using age, sex, BMI, ESS as the variables to predict OSA. Results: The mean age was 40.5 ± 11.8 years, the mean weight was 123.2 ± 23.8 kg and mean body mass index (BMI) was 47.6 ± 7.3 kg/m2. 70 patients (30.1%) had symptoms of excessive daytime sleepiness (ESS score [ 10). On polysomnography, 199 (85.7) patients had OSA and 152 patients (65.6%) had moderate or severe OSA. Among the 162 patients who had an ESS less than 10, a significant majority (93 patients, 57.4%) also had moderate to severe OSA (AHI [ 15). The sensitivity of ESS to predict moderate to severe OSA was found to be 38.8% and positive predictive value was 84.2% (Positive likelihood ratio 2.82, 95% CI: 1.57–5.06). A predictive score was identified as 0.031Age (years) + 0.039BMI (kg/m2) + 0.038ESS + Sex (1 for male, 0 for female). The score had a sensitivity of 80% and a specificity of 62.3% at a cut off of 3.3. Conclusion: The utility of ESS in predicting OSA is limited and requires development of better scores, especially in morbidly obese patients.

P313 - Morbid Obesity

P315 - Morbid Obesity

Acute Appendicitis and Peritonitis After Sleeve Gastrectomy for morbid obesity. A case report and Review of the Literature

Long Term Results: of the Sleeve Gastrectomy

D.V. Dardamanis, H.A.H. Hassan, D. Fortunati General Surgery, CH Jolimont-Lobbes, site Lobbes, Lobbes, Belgium Sleeve gastrectomy for morbid obesity is a very commonly practised surgical operation. Even as a stand alone procedure, it has very encouraging results in terms of weight loss and co-morbid conditions. Post-operative complications such as staple line leaking have been thoroughtly studied. Complex endoscopic procedures and re-operations are not rare in complicated patients. We present the only case of acute peritionitis caused by perforated appendicitis in the immediate post operative course in an adult patient. Literature review of acute appendicitis after bariatric procedures, laboratory examinations, radiologic images and perioperative findings are presented.

F. Martinez-Ubieto, A. Bueno-Delgado, I. Barranco-Dominguez, A. Pascual-Bellosta, J. Martinez-Ubieto Unit of Obesity Surgery, Hospital Viamed Montecanal, Zaragoza, Spain We present our firs 100 cases with laparoscopic sleeve gastrectomy. Since the beginning we have changed several aspects of the technique as the size of the bougie (currently 42F) and the position of the endostapler mainly with the first and the second fires in order to avoid the strictures of the sleeve.

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Surg Endosc

P316 - Morbid Obesity

P318 - Morbid Obesity

Treatment Strategies for Staple Line Leak After Laparoscopic Sleeve Gastrectomy; A Single Center Five-Year Experience

Predictors of Successful Weight Loss After Sleeve Gastrectomy: Sex Matters

P. Arnos1, R. Elazary2 1

F. Alsaleh1, S. al-Sabah1, A. Alserri2, S. Alqinai1, E. al-Hadad3, S. Almazeedi1

2

1

General Surgery, Hadassah Medical Centre, Jerusalem, Israel; Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

Aims: Laparoscopic Sleeve Gastrectomy (LSG) gained popularity as a low risk profile operation. However, like all stapled bariatric procedures, leakage remains the most fearful complication. The tendency towards non-surgical approaches led to multiple endoscopic modalities including Over-the-Scope Clips (OTSC) and SelfExpanding Metal Stents (SEMS) which emerged with encouraging results during the last years. The purpose of this study is to evaluate the efficacy of these approaches as treatment for leaks after LSG. Methods: We retrospectively collected data on patients who suffered from staple line leak after LSG and were treated in our department using endoscopic modalities during the last 5 years (2012–2017). Patients’ demographic and anthropometric parameters, medical history and surgical background, timing of diagnosis and location of the leak, overall treatment (endoscopic or surgical) with relevant morbidity, total duration and the final results were collected. Results: Data of 16 patients was reviewed. 11 females (68.7%), with a mean age of 37.8 years (SD + 14.1) and mean preoperative Body Mass Index (BMI) of 42 kg/m2 (SD + 3.62). Median period of time for diagnosis of the leak from the staple line was 12 days (range 1–670). Surgery as initial treatment was performed in 6 patients (37.5%). 13 patients (81%) were treated with a median of 1 OTSC (range 1–3) with no complications and 12 patients (75%) were treated with a median of 1 SEMS (range 1–3), of which 9 patients (75%) suffered from minor complications such as intolerance, pain, reflux and vomiting. 6 patients (37.5%) who failed endoscopic treatment underwent total gastrectomy as definitive surgery. The mean duration of treatment was 7.75 months (SD + 8.47). Conclusions: Our success rate was lower than expected regarding the nonoperative treatment of leaks after LSG. The sooner we treated a leak with a SEMS, the lower the chance of need for definitive surgery. The treatment strategy should be tailored to each patient but there has to exist a general consensus regarding the optimal techniques used.

P317 - Morbid Obesity Socioeconomic Aspects in the Implementation of New Laparoscopic Procedures with Emphasis on Bariatric Surgery A. Schoucair1, B. Kraemer1, M. Ried1, M. Langhans2, J. van Essen3 1

Hospital-team Frankfurt, MDK Hessen, Frankfurt, Germany; Hospital division, MDK Hessen, Oberursel, Germany; 3Medical director, MDK Hessen, Oberursel, Germany

2

The implementation of new laparoscopic procedures can pose a considerable challenge to the health system because they are often applied without adequate validation and comparison to established procedures. This can have far reaching consequences to the socioeconomic frame they are embedded in. In Germany the medical service of the sickness funds provides the sickness funds with the necessary medical and surgical information. Ideally the professional associations such as the German society of surgery (DGCH) with its specialized working groups (e.g. the Surgical working group for minimal-invasive surgery (CAMIC) and the Surgical working group obesity and metabolic surgery (CAADIP)) formulate standards and guidelines in which setting and under which circumstances new procedures can be applied. These guidelines are of utmost importance for the implementation. The development of 4 laparoscopic bariatric procedures (Mini-Gastric Bypass (MGB), One Anastomosis Gastric Bypass (OAGB), Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy (SADI-S) and Stomach Intestinal Pylorus Sparing surgery (SIPS)) in the last 21 years serve as examples. The importance of implementing such new procedures under study conditions preferably in reference centers is underlined.

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General Surgery, Al-Amiri Hospital, Ministry of Health, Kuwait, Kuwait City, Kuwait; 2Department of Clinical Genetics, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait; 3Pediatric Cardiothoracic Surgery, Colombia University, New York, United States of America Objectives: To investigate if there is a correlation between BMI, age and gender before undergoing a laparoscopic sleeve gastrectomy and the weight outcomes after. Design: A retrospective study was conducted. Absolute and percent excess weight loss were measured and compared across gender, age and pre-operative BMI at one and three years follow up. Setting: Amiri Hospital, Kuwait Subjects: Patients who underwent LSG from October 2011 to December 2014 Interventions: Laparoscopic Sleeve Gastrectomy Main Outcome Measures: %Excess weight loss post-op as compared to gender, age and BMI Results: A total of 597 patients were included, of which 139 (23.2%) had reached the three-year follow-up. The mean age was 35.5 ± 10.3 years and 75.2% of patients were female. Mean %EWL was 60.4% at one year and 64.8% at three years. Analysis showed significantly better outcomes in the male population in terms of successful %EWL at both one-year post-operatively (p = 0.014) and at three years (p = \ 0.005). Both younger age and lower pre-operative BMI were positive predictors of %EWL (p = \ 0.005 and p = \ 0.005 respectively) during the first year, with pre-operative BMI remaining a significant factor at the three-year follow-up (p = \ 0.005). Conclusion: There is a clear advantage in our population of successful %EWL after LSG for males, patients with lower pre-operative BMI, and younger patients at the time of surgery. The better outcome in males is still not fully understood, and more long terms studies are needed to compare the other possible predictors. Keywords: Bariatric Surgery; Sleeve Gastrectomy; Metabolic Surgery

Surg Endosc

P319 - Morbid Obesity

P321 - Morbid Obesity

Efficacy of Preoperative Intensive Diet Therapy in MultiOccupational Collaboration for Super Obese Patients Undergoing Sleeve Gastrectomy

3D Vision Reduces Operative Time in Laparoscopic Gastric Bypass with Hand Sewn Anastomoses: A Retrospective Single Operator Study

T. Naitoh, N. Tanaka, H. Imoto, H. Musha, S. Ohnuma, F. Motoi, T. Kamei, T. Ishida, M. Unno

M. di Giuseppe, M. di Giuseppe, M. Fitzgerald, A. Guerra, D. la Regina, M. Marengo

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan

General Surgery, San Giovanni Hospital, Bellinzona, Switzerland

In laparoscopic sleeve gastrectomy (LSG), complete resection of gastric fundus affects the operative result. However, excessive visceral fat, and hepatomegaly due to NAFLD may cause difficulties in securing the operative field and may lead to failure in appropriate resection. Although preoperative intensive diet therapy (PIDT) is considered as useful for the reduction of surgical complications, unregulated diet therapy may cause adverse events such as a decrease in skeletal muscle volume. PIDT is performed in cooperation with rehabilitation department, clinical dietician, and diabetology department. In the case of super obese patients with BMI C 60 kg/m2, patients are hospitalized to reduce weight until BMI \ 60 kg/m2 to reduce operative difficulty and complications. Here, we show the method of PIDT, and results of LSG for super obese patients. Of patients who underwent bariatric surgery, 39 cases underwent LSG. For patients with BMI \ 60 kg/m2 at first visit (BMI \ 60 group), PIDT was conducted for 4 weeks replacing one meal to formula diet (173 kcal, Carbs: 17 g, Protein: 21 g). In the case of super obese patients with BMI C 60 kg/m2 (BMI C 60 group), we use a low calorie diet and exercise therapy in hospital management and reduce weight until BMI becomes less than 60. Surgical procedure is performed laparoscopically. Briefly, after mobilizing the greater curvature of the stomach, stapling was started from 4 cm proximal to pylorus towards the angle of His, under the guidance of 36 fr. bougie. The staple line was secured with 2-0 non-absorbable suture. The mean age of overall patients was 42.7 years, and the average BMI was 49.2 kg/m2. Seven cases were categorized in the BMI C 60 group. The period required for PIDT was 7.1 months, and the reduction weight was 42.5 kg on average in BMI C 60 group. The operation time was 163.5 min in BMI \ 60 and 148.0 min in BMI C 60 group. The estimated blood loss was 12.6 ml in BMI \ 60, 7.4 ml in BMI C 60 group, respectively. Postoperative C-D C grade III complications were found in one case of BMI \ 60 group, postoperative hemorrhage requiring hemostasis. No leakage was found. We believe that PIDT in multi-occupational collaboration is essential for the safety of weight loss surgery.

Introduction: Laparoscopic roux-en-y gastric bypass (RYGB) for morbid obesity is one of the most frequently performed surgical interventions in bariatric surgery worldwide. The literature supports the hypothesis that hand-sewn anastomoses have lower rates of postoperative complications notwithstanding the technical challenge. With recent developments in 3D stereoscopic vision, surgeons are offered an improved depth of field and hand-eye coordination. The advantages are particularly valuable for activities such as suturing and knot tying. Thus, the value of this technological improvement is even more significant in technically challenging surgical interventions, such as RYGB. Materials and Methods: We retrospectively analysed prospectively collected database on patients who underwent a RYGB for morbid obesity from January 2014 to June 2017 at San Giovanni Hospital, Bellinzona, Switzerland. All patients were operated on by the same, experienced surgeon, who had surpassed the operative learning curve. We collected detailed data on every patient and operative time. Results: 48 patients were considered eligible for the study. In this series we operated on 30 patients with 2D vision and 18 patients with 3D vision. The operative time was 216 ± 33 min for the 2D vision and 164 ± 16 min for the 3D vision (p \ .000001). Conclusions: 3D vision does not alter the surgical technique and significantly reduces the operative time in RYGB for morbid obesity. The benefit is notable in expert surgeons who have already surpassed the learning curve with 2D vision. Larger series and randomized trials would better assess the surgical benefit of our findings.

P320 - Morbid Obesity

P322 - Morbid Obesity

Ipom-Plus for Incisional and Ventral Hernias in Morbidly Obese Patients

Gastric Emptying and Metabolic Response After a Laparoscopic Sleeve Gastrectomy and its Relationship with Gastric Antrum

A. Dixit1, K.M. Mannur2

M. Vives1, F. Sabench1, A. Molina1, M. Danu´s2, M. Parı´s1, E. Rebenaque3, E. Raga1, B. Homs1, E. Bartra1, P. Martı´nez1, A. Sa´nchez1, D. del Castillo1

1

Upper GI and Laparoscopic Surgery, Worthing Hospital, London, United Kingdom; 2Bariatric surgery, Homerton Hospital, London, United Kingdom Aims: Recurrent incisional hernias develop in the repairs of the large ventral hernias in almost 50% of obese patients and recurrence in the repair of the incisional hernias in almost 80% in this group of patients. We looked at the results of our method of repair, which is a combination of open and laparoscopic repair (IPOM - plus). Methods: All the obese patients who had the incisional hernia or large ventral hernia operated by IPOM- Plus over 7 years were looked at for their recurrence and morbidities retrospectively. The patients had either massive ventral hernia or incisional hernia with more 3 cm defect. Technique: Laparoscopy is first performed to remove all the adhesions and if possible to reduce all the contents of the hernia into the abdominal cavity. Then the fascia is approximated either by open or laparoscopic sutures depending on the size of defect and ease of approximation. Many interrupted far and near sutures applied and the edges are brought together with a continuous number ‘1’PDS suture and the interrupted sutures are tied. An appropriate size composite mesh is inserted into abdomen laparoscopically and fixed to the anterior abdominal wall with ‘Protack’ (Covidien) and or ‘Securestrap’ (Ethicon) stapler and sometimes 2/0 sutures. The skin wounds are closed with clips or sutures as required. A pressure dressing was applied. Results: 30 morbidly obese patients underwent this procedure (BMI range 35–130 kg/m2). The seroma development was minimal in 5 patients and there was no recurrence of hernias up to now. Conclusions: We strongly feel that abdominal wall hernias in obese patients should be repaired by combined Laparoscopic and open/percutaneous means, giving the advantage of tissue approximation and underlay placement of the mesh at the same time. We have also used this technique for non-obese patients, with no recurrence but we have to look at the morbidity.

1 Surgery, University Hospital of Sant Joan. Rovira I Virgili University, Reus, Spain; 2Nuclear Medicine service, University Hospital of Sant Joan. Rovira I Virgili University, Reus, Spain; 3RX, University Hospital of Sant Joan. Rovira I Virgili University, Reus, Spain

Aim: Laparoscopic sleeve gastrectomy (LSG) is a bariatric and restrictive surgical technique but with important metabolic implications that can be mediated through modifications in gastric physiology such as gastric emptying. In this sense, gastric antrum is a factor to be taken into account. Our goal is to determine the variations in the gastric volume, gastric emptying and metabolic response after a LSG in relation to two distances from pylorus. Also, to analyze the differences observed between diabetic and non-diabetic patients. Methods: Randomized prospective study with two intervention groups on 60 morbid obese patients. Group 1:30 patients, GVL with antral preservation (3 cm). Group 2: 30 patients, LSG without antral preservation (8 cm). We calculate preoperatively, at 6 and 12 months the gastric volume through CTscan, the speed of emptying through Scintigraphy (T1/2 min) and the metabolic response through blood tests (glucose, glycosylated hemoglobin, insulin, HOMA-IR, GLP-1, GIP and Peptide C). Results: At 12 months of surgery, the gastric volume increases significantly in both groups and any differences between them disappear. The gastric emptying speed increases significantly in both groups, at 6 months and a year of surgery, being higher in the 3 cm group (p \ 0.05). The distance of 3 cm improves the hyperinsulinemia significantly compared to the 8 cm group, but only in diabetic patients; this is maintained at 12 months. We found no difference between groups compared to the incretins analyzed. Conclusions: Diabetic patients of the 3 cm group have a higher gastric emptying rate and one improvement of insulin levels without differences in the incretins analyzed; this is a fact that opens a door to the role of other hormones that regulate the metabolic response beyond GLP-1.

123

Surg Endosc

P323 - Morbid Obesity

P325 - Morbid Obesity

Late Onset Gastric Volvulus After Laparoscopic Sleeve Gastrectomy

Endoscopic Closure of Gastro-Gastric Fistula After Roux-En-Y Gastric Bypass

P. Martı´nez, B. Homs, E. Bartra, C. Morales, M. Parı´s, M. Vives, F. Sabench, E. Raga, A. Molina, A. Sa´nchez, D. del Castillo

C. Tsai, J. Zehetner, R. Steffen, U. Kessler, H. Merki

Surgery, University Hospital of Sant Joan. Rovira I Virgili University, Reus, Spain Aim: Laparoscopic Sleeve gastrectomy, as a surgical treatment of morbid obesity, has become the most frequent bariatric surgical technique performed in the world. Despite this, it’s not exempt of complications that includes the appearance of leakage, bleeding, stenosis and other less frequent such as angulation/volvulation on its greatest degree. Methods: We present a case report of a patient # of 55 years old, with a BMI of 37 kg/m2, Diabetic and with a chronic liver disease. Initially proposed to perform a Roux-en-Y gastric Bypass, a LSG was finally performed due to giant hepatomegaly. The intervention did not present any notable incidence and was discharged at 72 hours. 3 months after surgery the patient presents a 2-day evolution of vomiting, both to liquids and solids; endoscopically diagnosed of a possible substenosis, an endoscopic dilatation was performed; due to the symptomatic resolution of the clinical symptoms, his ambulatory control was decided. 2 months later he came with the same clinical symptomatology; after unsuccessful endoscopy, it was decided to proceed with its surgical revision. During the intervention, an adherence syndrome at the body and gastric antrum is evident, and it conditions an axial angulation of the sleeve. Laparoscopic adhesiolysis is performed with deangulation and checking of the stapling line by intraoperative fibrogastroscopy. Results: The patient starts oral intake 24 hours after surgery, with a good tolerance, and being discharged at 72 hours. He follows periodic controls, being at the moment asymptomatic (6 months of the second intervention). Conclusions: The angulation/volvulation of LSG is an infrequent complication but it is necessary to take this into account in the face of obstructive clinical pattern after LSG; it may involve a surgical review or even a conversion to Gastric Bypass if it is not resolved spontaneusly.

Visceral Surgery, Clinic Beau Site, Bern, Switzerland Background: Gastro-gastric fistulas are reported to be as high as 12% after Roux-en-Y gastric bypass for treatment of morbid obesity. While different endoscopic methods are described, the management traditionally consists of surgical revision with high morbidity. The aim of the study was to assess feasibility of endoscopic closure using an endoscopic suturing device. Methods: From January 2016 to November 2017 we reviewed the electronic records of all patients undergoing endoscopic closure of a gastro-gastric fistula after gastric bypass with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA). Demographic details, procedure details and outcome variables were recorded. Results: A total of 6 patients (M:F = 5:1) underwent endoscopic gastro-gastric fistula closure. Five patients (83.3%) had a prior banded gastric bypass (with subsequent band removal). The median number of prior abdominal surgeries was 3, the mean time from gastric bypass to endoscopic fistula closure was 5 years. While immediate complete endoscopic fistula closure was possible in 11 of 12 attempts in these 6 patients (92%), all patients had recurrent or persistent fistulas at follow-up. After a mean follow-up time of 12 months, 4 patients (66.7%) had further open (n = 2) or laparoscopic (n = 2) revision with complete fistula closure. One patient is scheduled for laparoscopic revision, and one patient is refusing further intervention. Conclusion: Endoscopic fistula closure with an endoscopic suturing device is feasible but unlikely to be successful.

P324 - Morbid Obesity

P326 - Morbid Obesity

Hematologic Disorders and Their Association with Portomesenteric Vein Thrombosis After Routine Laparoscopic Sleeve Gastrectomy

Low Risk Technique for Specimen Extraction in Laparoscopic Sleeve Gastrectomy

K. Bain, V. Kassapidis, V. Meytes, G. Ferzli

G. Layton1, M. Naqvi2, I. Stoddart1, A. Russell1, J. Morton1, A. Khan1, S. Mirza1 1

Surgery, NYU Langone Hospital - Brooklyn, Brooklyn, United States of America Introduction: Portomesenteric vein thrombosis (PMVT) is a rare but serious postoperative complication following bariatric surgery, with an incidence rate ranging from 0.3 to 1%. Due to the nonspecific symptoms, a high index of suspicion is needed to make the diagnosis. If left untreated, PMVT can progress to intestinal ischemia, perforation and peritonitis. Case Presentation: A 51-year-old female presented to the Emergency Department five days after laparoscopic sleeve gastrectomy (LSG) complaining of worsening abdominal pain and low grade fevers. A CT scan and upper GI series were performed with no evidence of leak or abscess, and the patient was admitted for observation. On hospital day two, the patient had worsening abdominal pain, and an episode of emesis. An ultrasound revealed a new moderate amount of intraperitoneal free fluid. A CT scan was repeated which revealed a thrombus in the splenic and superior mesenteric veins. Upon further discussion, the patient admitted to a previous diagnosis of antithrombin III deficiency and non compliance with anticoagulation. The patient was subsequently started on therapeutic anticoagulation with resolution of her abdominal pain. The remainder of the hospitalization was uncomplicated and she was discharged home on oral anticoagulation. Discussion: It has been well established that morbid obesity is a significant prothrombotic factor for patients undergoing bariatric procedures. There has been increasing interest in identifying other factors which may contribute to hypercoagulability during these procedures. Possible etiologies for PMVT following LSG include thrombophilia, venous stasis from increased intra-abdominal pressure or patient positioning, and intraoperative manipulation of vasculature. Increasing interest has turned toward identifying patients who may be predisposed to PMVT following LSG. In a recent multicenter review of 40 patients who developed PMVT after LSG, 92% had a hematologic abnormality. The most common abnormality identified was elevation of Factor VIII (76%). Other significant abnormalities included deficiencies in antithrombin III, factor V leiden, and protein C/S. Conclusions: Patients undergoing LSG have an increased risk of developing PMVT. A high index of suspicion is important for prompt diagnosis and expeditious treatment. Up to 90% of PMVT after LSG can be successfully treated with therapeutic anticoagulation alone.

123

Bariatric Unit, Walsall Healthcare NHS Trust, Birmingham, United Kingdom; 2Bariaric Unit, Walsall Healthcare NHS Trust, Birmingham, United Kingdom Introduction: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity to become the most frequently performed bariatric surgical procedure worldwide[1,2]. The resected portion of the stomach is usually extracted through a 15 mm trocar site in a retrieval bag (Endo CatchTM II 15 mm Specimen Pouch - Covidien). We have adopted nonutilisation of the retrieval bag since October 2014 and have instead extracted the specimen using a Rampley forceps and judicious manual traction. Aim: To assess post-operative morbidity (extraction port site hernia and wound infection) with and without the use of a retrieval bag during LSG. Method: Retrospective data collection in a level 4 bariatric unit from July 2012 to June 2017. Results: 344 patients (249 female (72.4%), 95 male (27.6%)) with a median age of 50.2 years (range 22.7–73.0) were included, of which 30 patients (8.7%) with incomplete data were excluded. 111 (35.4%) were diabetic. Median pre-operative BMI was 49.8 (range 34 to 78) and median post-operative follow up was 33.4 months (range 5.7–65). A retrieval bag was used in 124 patients (39.5%), of which 69.4% were female (n = 86) and 30.6% were male (n = 38). 43 patients (34.7%) had diabetes and the group had a median BMI of 52.1 (range 38.3–78). The median follow up time was 53.8 months (range 38.5–65). 190 patients (60.5%) underwent extraction of the stomach specimen without a retrieval bag. 73.7% were female (n = 140) and 26.3% were male (n = 50). 67 patients (35.3%) had diabetes and the group had a median BMI of 47 (range 34–78). The median follow up time was 22.2 months (range 5.7–38). There were no extraction port-site wound infections or hernias in either group. There were no cases of spillage of gastric contents with an intact specimen in all cases. Conclusions: Our technique describes a reliable and reproducible method of intact specimen retrieval with no increase in wound infection or port-site hernia. Furthermore, in a financially challenged climate, this technique is cost effective resulting in a cost saving of £24,028 (£129.88 per Endo CatchTM pouch).

Surg Endosc

P327 - Morbid Obesity

P329 - Morbid Obesity

Endoscopic Gastrojejunal Revisions Following Roux-En-Y Gastric Bypass: Lessons Learned in More Than 100 Consecutive Procedures

Possible Role of Omentopexy in Minimizing Post Sleeve Gastrectomy Complications

C. Tsai, J. Zehetner, R. Steffen, U. Kessler, H. Merki Visceral Surgery, Clinic Beau Site, Bern, Switzerland Background: Weight-regain is one of the long-term challenges after Roux-en-Y gastric bypass in morbidly obese patients. Dilation of the gastrojejunal anastomosis is a factor leading to loss of restriction with resultant weight regain as well as dumping syndrome. The aim of this study was to analyze the feasibility, outcome, and learning curve of endoscopic gastrojejunal revision after its introduction in a bariatric center. Methods: The electronic records of patients (January 2016 to November 2017) undergoing endoluminal gastrojejunostomy revision with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA) were reviewed. Demographic details, procedure details, and outcome variables were recorded. For patients undergoing endoscopic anastomotic revision for weight-regain, the patients were dichotomized into the first half (Group A) and second half (Group B) of patients treated, and analyzed for weight, re-operation rate, and duration of surgery to assess trends in the learning curve. Results: There were 83 patients (M:F = 21:62) treated with endoluminal revision for weight-regain (n = 62), dumping syndrome (n = 13), or dumping syndrome and weightregain (n = 8) with a total of 102 endoluminal revisions. The median procedure time was 16.5 minutes (R 5–33), with a median number of 1 suture (R 1–3). There were no complications recorded within 30 days (no bleeding, no re-intervention, no dilation, no infection). For the weight-regain only group, there were no differences in post-operative weight trends nor procedure duration between Group A and Group B, although 81.4% of patients had either maintained or lost weight at 6 months after endoluminal revision. The rate of patients requiring further laparoscopic pouch revision decreased from 22.6% in Group A to 3.2% in Group B (p \ 0.05). All patients with dumping had treatment response, with 66.6% having resolved and 33.3% having improved symptoms after 1 or 2 endoluminal revision procedures. Conclusion: Endoscopic revision of the Roux-en-Y gastrojejunostomy is feasible. It can successfully stop the progression slope of weight-regain or achieve additional weight loss. It can also improve symptoms in patients with dumping syndrome.

I.A.M. Hassan Bariatric Surgery, Alomooma Hospital, Kuwait, Kuwait Introduction: laparoscopic sleeve gastrectomy (lsg) has recently been recognized as a potential stand-alone operation for the treatment of obesity worldwide. However the incidence of postoperative nausea and vomiting is not uncommon in surgical practice. Other serious complications like leakage or bleeding may happen. Study: this is a retrospective study that was performed at Alomooma hospital in Kuwait. data was collected from November 2014 to November 2017.㏴ patients were selected for this study :150 patients had underwent lsg with omentopexy (advancement of stapler line with omental patch) while the remaining 150 patients had lsg without omentopexy. Result: the mean age of group a and b was 36 ± 14.35 ± 12 subsequently. The mean body mass index (BMI) for group a was 44 ± 6 and for group b 43 ± 3. The mean operation time was 45 ± 10 minutes in group a while 37 ± 10 minutes in group b. The mean hospital stay was 32 ± 9 hours for group as compared to 40 ± 8 hours for group b. No patients had leakage for group a while one patient in group b had leaked in postoperative day 1. 8 patients had postoperative vomiting in group a and one of them required hospital readmission for supportive treatment while 18 patients in group b had suffered from vomiting and 4 of them were hospitalized. Blood transfusion was required for 2 patients in group b. Conclusion: it was noticed that omentopexy with lsg is offering an extra guard against postoperative nausea vomiting leakage, and bleeding.

P328 - Morbid Obesity

P330 - Morbid Obesity

Long-Term Evaluation of Biliary Reflux After One-Anastomosis Gastric Bypass

Indications and Outcomes of Sleeve Gastrectomy Conversion To R-En-Y Gastric Bypass: Multi-Center Retrospective Study

A.G. Khitaryan, A.V. Mezhunts, R.N. Zavgorodnyaya, K.S. Veliev, O.A. Starzhinskaya, A.V. Sarkisyan

C.E. Boru1, F. Greco2, P. Giustacchini3, M. Raffaelli3, G. Silecchia1

Department of surgical diseases, Rostov state medical University, Rostov-on-Don, Russia Introduction: One-anastomosis gastric bypass is one of the most popular bariatric procedure in the world. Nevertheless, there is controversy remains regarding biliary reflux after mini-gastric bypass/one-anastomosis gastric bypass (MGB/OAGB). The aim of this study was to analyze biliary reflux and its potential long-term consequences on esofagogastric mucosae in OAGB operated patients. Methods: Immediate and long-term outcomes (up to 30 months, mean 12 month) in a cohort of 70 patients undergoing surgery between 2014 and 2017 were analyzed. Patients were divided into two clinical groups, depending on the technique of gastroenteroanastomosis. A standard five-port laparoscopic technique was used. The first group included 32 patients who underwent MGB in a modified way in our clinic with the making of handsewn gastroenteroanastomosis. 38 patients were used the traditional technique with the making of anastomosis with using a linear stapler with a 45 mm blue cartridge. Then, mean 12 months after MGB, all patients was filled out a reflux symptom questionnaire (GerdQ). A gastroscopy with biopsies was done for all patients with a bile-reflux positive symptoms. Results: The number of patients who underwent surgery were 70 (mean body mass index 46 kg/m2). Mean percent excess weight loss (%EWL) at 12 months was 74.3%. Comorbidity resolution, determined by medication use, showed a reduction in diabetes (71.8–15.6%), hypertension (37.2–21.4%) and hypercholesterolaemia (40.4–13.4%). The absence of enterogastric biliary reflux was observed in 81.2% of patients in the study group, the absence of an ulcer of the gastroenteroanastomosis was observed in 97% of the study group, respectively. There was one death unrelated to surgery. Conclusions: Modified MGBP appears to be a safe and effective operation for the morbidly obese. It is durable, with good weight loss at up to 12 months post-surgery. The proposed technique for the formation of hand-sewn gastroenteroanastomosis allows decreasing the postoperative bile reflux up to 8.8%.

1

UOC Chirurgia Generale & Bariatric Centre of Excellence-IFSO EC, University La Sapienza of Rome, Dep. Medico-Surgical Sciences & Biotechnologies, LATINA, Italy; 2UOC Chirurgia Generale, Ospedale Andosilla, ASL VT, Civita Castellana, Italy; 3UOC di Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli, Universita` Cattolica del Sacro, Rome, Italy Introduction: Long-term results after laparoscopic sleeve gastrectomy (LSG) are inconsistent. In addition, the percentage data of failed sleeves requiring conversion to laparoscopic R-en-Y gastric bypass (LRYGB) in case of insufficient weight loss (IWL), weight regain (WR), and/or severe gastro-esophageal reflux disease (GERD) are controversial. Aim: To evaluate incidence, indications, and outcomes of LSG conversion to LRYGB in 3 bariatric high volume centers. Methods: Patients operated between 2012 and 2016 with primary, non-complicated LSG, and re-operated for IWL, WR or GERD by LRYGB were retrospectively analyzed for demographics, operative details, complications, comorbidities evolution, and weight loss. These patients were prospectively analyzed for overall satisfaction after revision surgery. Results: Thirty patients (7M/23F, mean age 41 ± 10.1 years, initial mean BMI 46.9 ± 6.3 kg/m2) were converted after a mean period of 33 ± 27.8 months to LRYGB for GERD (15 patients, 50%), GERD and IWL/WR (3 patients, 10%), and IWL/WR (12 patients, 40%). Surgical complications occurred in 3 patients (10%). Mean BMI at revision time was 36 ± 9 kg/m2; and 30.8 ± 5.2 kg/m2, 28 ± 4.9 kg/m2, and 28 ± 4.3 kg/m2 after 6, 12, and 18 months, respectively. Resolution of GERD was achieved in 83% of cases, and improvement was seen in the rest of the cases. Overall, postoperative satisfaction was obtained in 96% of the cases after a mean follow-up of 22 ± 8.6 months. Conclusions: Conversion of LSG to LRYGB is effective in case of weight loss and GERD remission, with a higher rate of postoperative complications. Long-term follow-up is mandatory to confirm data on weight loss durability and co-morbidities control.

123

Surg Endosc

P331 - Morbid Obesity

P332 - Morbid Obesity

Do Laparoscopic Transversus Abdominis Plane and Rectus Sheath Blocks Improve Enhanced Recovery After Bariatric Surgery Outcomes?

Pushing the Limits in Bariatric Surgery: Sleeve Gastrectomy for Morbidly Obese Patients Over 65 Years Old

1

2

2

1

A. Jarrar , N. Eipe , A. Budiansky , C. Walsh , J. Mamazza

1

1

P. Lainas1, C. Dammaro1, M. Gaillard1, G. Donatelli2, H. Tranchart1, I. Dagher1 1

Department of Surgery, The Ottawa Hospital, Ottawa, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Canada

Department of Minimally Invasive Digestive Surgery, AntoineBeclere Hospital, AP-HP, Clamart, Paris, France; 2Department of Endoscopy, Peupliers Private Hospital, Paris, France

Aim: The aim of this study is to evaluate the efficacy of a laparoscopically-guided, surgeonperformed transversus abdominis plane (TAP) and rectus sheath (RS) block in reducing pain while improving functional outcomes in patients undergoing bariatric surgery. Methods: Based on our previous research in an identical population, 150 patients undergoing elective laparoscopic Roux-En-Y gastric bypass (LRYGB) will be recruited to this double-blinded, placebo controlled Randomized Control Trial from a provincial Bariatric Center of Excellence over a period of 6 months. All patients will undergo objective prehabilitation with 6-minute walk test (6MWT) and peak expiratory flow (PEF) that will be measured before and after surgery. Patients will be electronically randomized on a 1:1 basis to either an intervention or placebo group. At the end of the surgery, patients in the intervention arm will receive a total of 60 mL 0.25% ropivacaine, divided into four injections: two 20 mL each for TAP and two 10 mL each for RS block under laparoscopic visualization. The placebo arm will receive normal saline in the same manner. All patients, providers and research personnel will be blinded and standardized surgical and anesthetic protocol will be followed, with careful adherence to established Enhanced Recovery after Bariatric Surgery (ERABS) protocols. Results: Demographic information, relevant medical history, surgical and anesthetic data will be collected from patients enrolled in the study. Our primary efficacy endpoint is cumulative post-operative narcotic use. Secondary outcomes are post-operative pain scores, change in PEF and 6MWT with assessment for return to baseline after discharge. Quality of recovery will be also assessed using a validated questionnaire (QoR-40). Statistical analysis will be conducted to assess differences within and between the two groups. The repeated measures will be analyzed by a mixed model approach and final results will be presented. Conclusion: While this study evaluates the impact of TAP and RS blocks on postoperative pain control and analgesic consumption, it will further confirm the role of objective prehabilitation and protocol standardization in ERABS. If the results show improvement, this study will make significant contribution to the evidence for laparoscopically-guided pain control methods on patient-centric outcomes in ERABS.

Aims: The number of morbidly obese elderly patients is progressively increasing worldwide, triggering an important health and financial burden for society. Data on elderly patients undergoing LSG are scarce, with limited data reported on patients older than 65 years-old. We therefore aimed to demonstrate that LSG is safe and effective in morbidly obese patients over 65 years-old. Methods: Prospectively collected data from all consecutive patients undergoing singleincision LSG in our department until May 2016 were retrospectively analyzed. For weight loss and comorbidity evaluation, only patients with at least 1-year follow-up were included in our analysis. Quality of life (QoL) was evaluated using the French version of Short-Form 36 (SF-36) questionnaire. Results: Fifty-four patients over 65 years-old (range: 65–75 years) underwent single-incision LSG in our department. Median weight was 119 kg, median BMI 43 kg/m2. Median duration of surgery was 86.5 minutes. Two patients (3.7%) suffered a gastric staple-line leak; the first was successfully treated using a purely endoscopic approach; the second was treated by relaparoscopy and subsequent endoscopic internal drainage. Mortality was null. Median length of hospital stay was 5 days. Six, 12 and 24 months after LSG, median BMI had decreased significantly to 35, 32.9 and 30.7 kg/m2, respectively (p \ 0.0001), with a mean excess weight loss of 76.3% at 2 years. Type II diabetes, hypertension, dyslipidemia, sleep apnea and arthralgia showed statistically significant remission at one year. Six out of 8 SF-36 scale scores of QoL assessment improved significantly. Conclusions: Our results suggest that LSG is safe and effective for patients older than 65 years-old, resulting in significant weight loss, comorbidities remission and QoL improvement. Morbidly obese patients over 65 years-old should not automatically be denied LSG. A careful patient selection after an adequate risk versus benefit evaluation by an expert multidisciplinary team is essential.

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P333 - Morbid Obesity Management of Gastric Leaks After Sleeve Gastrectomy: A 9 Years Single Centre Experience L. Grasso, A. Genzone, M. Toppino, A. Caltagirone, S. Arolfo, M. Morino Surgical Sciences, University of Torino, Torino, Italy Aims: Laparoscopic sleeve gastrectomy (LSG) has a firm position as a stand-alone procedure to effectively treat morbid obesity. Low morbidity and mortality have been advocated as advantages over more complex procedures. One of the most feared complications is early postoperative leak, due to perforation along the staple line, usually at its upper end. The incidence of leaks after sleeve gastrectomy ranges between 1.1 and 5.3% in literature. Management of leaks can be really difficult. We present our experience in a highvolume surgical centre. Methods: A series of 1113 morbidly obese patients underwent LSG at our university hospital between October 2008 and July 2017. A retrospective observational study of fistulas was undertaken. Patient data collected prospectively included demographic variables (age, gender, BMI, previous bariatric surgery, obesity-related comorbidity), time of appearance of fistula, radiological examinations performed and treatment. Results: Leak of the stapled line occurred in 20 patients (1.79%), mean BMI 42.2 kg/m2, mean age 42.3 years. In all cases, the clinically suspected diagnosis was radiologically confirmed by watersoluble upper gastrointestinal series and double-contrast abdominopelvic CT scan. Management was established according to time of occurrence and septic appearance of the patient. Conservative management (administration of broad-spectrum antibiotics and total parenteral nutrition) was sufficient for 3 patients (15%) presenting a small leak with no collection. A surgical reintervention with abdominal washing, identification of the leak site and primary repair with simple suturing was performed in 12 patients (60%), using a laparoscopic approach in 6 of them. In 3 cases a stent was inserted. In 3 cases the fistula persistance after the first attempt lead to a total gastrectomy with a Rouxen-Y esophago-jejunostomy. In the remaining 5 patients (25%), presenting with a complex fistula, first-intention open total gastrectomy was performed. No mortality was seen in our series and none of our patients suffered long-term persistent sequelae. Conclusion: Management of postoperative leaks after LSG is very challenging. Conservative or surgical management has to be considered in order to propose the best medical or surgical treatment in these patients. A laparotomic total gastrectomy is a well-tolerated and reproducible salvage procedure when conservative procedures are not possible.

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P334 - Morbid Obesity

P335 - Morbid Obesity

Surgical Complications and Management After Laparoscopic Sleeve Gastrectomy. Conclusion: S After 257 Cases at a Single Institution

Laparoscopic Sleeve Gastrectomy for Morbidly Obese Patients Under 18 Years-Old

C. Tserkezis, A.M. Nixon, G. Vletsis, C. Aggeli, A. Thanassa, S. Roditis, I. Margaris Third Department of Surgery, Athens General Hospital, Georgios Gennimatas, Athens, Greece Introduction: Laparoscopic sleeve gastrectomy has become one of the most widely adopted bariatric procedures due its relatively safe postoperative outcomes and benefits due to loss of excess weight. Surgical complications are rare but when they occur can be challenging to manage. Here we present surgical complications after 257 consecutive cases at a single institution. Materials and Methods: From 2008 to 2017, 257 patients underwent laparoscopic sleeve gastrectomy due to morbid obesity (BMI [ 35 kg/m2). In all cases methylene blue dye was administered through a nasogastric tube intraoperatively to rule out possible gastric leaks. On the second postoperative day all patients underwent an upper GI series with contrast medium to evaluate GI continuity. Mean BMI was 48.2 kg/m2 and mean age was 38. Results: Three patients were readmitted after the first postoperative week due to acute abdominal pain and fever which were attributed to a gastric leak. Two of these patients underwent an exploratory laparotomy due to a deteriorating clinical status. A gastric leak was identified and primarily closed. One of the patients had a splenectomy performed due to a perisplenic abscess. Subsequently both patients developed a gastric fistula non amenable to conservative treatment. Endoscopic clips were used in one of the patients without success. Both patients were eventually treated with a Roux en Y gastroenteroanastomosis and were successfully discharged. The third patient developed an intrabdominal abscess and was successfully treated by CT-guided drainage and total parenteral nutrition. One patient experienced excessive bleeding from the suture line and had to be reoperated on. Furthermore, one patient incurred an injury to the transverse colon due to port placement. Conversion to open procedure was performed and primary closure of the defect. Finally conversion to open procedure was performed in another patient due to equipment malfunction (malfunction of the laparoscopic stapler). Conclusions: Laparoscopic sleeve gastrectomy is considered a safer alternative to gastric bypass or mini gastric bypass procedures due to the lack of an anastomosis. Surgical complications are rare but when they do occur can be troubling to manage. Gastric leaks are especially challenging and may require surgical intervention.

P. Lainas1, H. Tranchart1, G. de Filippo2, G. Chahine1, C. Dammaro1, P. Bougneres2, I. Dagher1 1

Department of Minimally Invasive Digestive Surgery, AntoineBeclere Hospital, AP-HP, Clamart, Paris, France; 2Department of Pediatric Endocrinology and Diabetology, Bicetre Hospital, AP-HP, Kremlin-Bicetre, Paris, France Aims: The prevalence of morbid obesity is reaching epidemic proportions worldwide, without sparing any age group. The number of morbidly obese pediatric and adolescent patients is progressively increasing. In the past two decades, bariatric surgery has become an increasingly popular form for the treatment of morbid obesity. However, data on adolescent patients undergoing laparoscopic sleeve gastrectomy (LSG) are scarce in the literature, focusing mainly on patients over 18 years-old. We therefore aimed to demonstrate the safety and effectiveness of LSG on weight loss and comorbidities resolution in morbidly obese patients strictly under 18 years-old. Methods: Prospectively collected data from 1474 consecutive patients undergoing singleincision LSG were retrospectively analyzed. Adolescent candidates for bariatric surgery were referred by a tertiary care center for pediatric obesity. For weight loss and comorbidity evaluation, only patients with at least 1-year follow-up were included in our analysis. Results: A total of 77 adolescent patients underwent single-incision LSG. Median age of the cohort was 17 years (range: 15–18 years). Median weight was 119.5 kg (range: 86–227 kg), with median BMI of 42.3 kg/m2 (range: 31.5–74.6 kg/m2). Median duration of surgery was 68.5 minutes. One major complication was recorded: a patient developed severe pneumonia that necessitated ventilatory support and intravenous antibiotics with a hospital stay of 12 days. Mortality was null. Median length of hospital stay was 4 days. Mean excess weight loss was 50.7%, 62.2%, 77.7% and 79% at 3, 6, 12 and 24 months after LSG, respectively. Improvement of type II diabetes, hypertension, dyslipidemia, sleep apnea and a statistically significant remission for arthralgia were noted 1 year after surgery. Conclusions: LSG can be safely performed in the under 18 years-old, with good results regarding weight loss and comorbidities remission. A careful patient selection by an expert multidisciplinary team is essential. To our knowledge, this is the largest report of patients strictly younger than 18 years-old undergoing LSG for the treatment of morbid obesity.

P336 - Morbid Obesity Marginal Ulcer After Gastric Bypass: An Underestimated Complication A. Reyhani Calvo, S. Rajagopal, S. Panagiotopoulos, F. Rubino Department of Bariatric and Metabolic Surgery, King’s College London and King’s College Hospital, London, United Kingdom Aim: Marginal ulcer (MU) is a common yet underestimated complication of Laparoscopic Roux-en-Y Gastric Bypass (LRYGB). Here we report two cases that provided a challenge for time-sensitive diagnosis. Methods: Case 1: A 48-y-o lady, smoker, underwent an uncomplicated LRYGB. After discharge, she discontinued proton pump inhibitors (PPI) despite medical advice. One month postoperatively she consulted her general practitioner (GP) with complaints of periumbilical pain and nausea. The patient was referred to the bariatric team with a suspicion of an internal hernia. On the basis of this history she underwent an abdominal CT-scan and blood tests, which were unremarkable. An endoscopy was performed only subsequently, revealing a large MU distal to gastro-jejunal anastomosis. Case 2: A 59-y-o lady who had undergone LRYGB one year earlier presented to the GP with a complaint of back pain and vague abdominal discomfort. She also had previous episodes of dark faeces. She was given analgesics (Ibuprofen) for one week. She later presented to the emergency department with severe epigastric pain and was found to have free air on the CT-scan. Her inflammatory markers were elevated and clinical picture suggestive of a perforation. Results: Case 1: Patient was managed conservatively with high-dose intravenous PPIs and fluids. She responded well and was discharged with oral PPIs. Case 2: Patient underwent an urgent laparoscopic exploration, washout and drain insertion. Her postoperative course was uneventful and an endoscopy at discharge showed a healing MU. Conclusion: Marginal ulcers may present with atypical symptoms. Given the prevalence and possibility of serious complications, MU should always be ruled out in LRYGB patients who present with abdominal or back pain, persistent nausea and dark faeces. Previous helicobacter pylori infection, smoking, and medications (steroid and Non-Steroidal Anti-Inflammatory Drugs (NSAID)) should be carefully assessed preoperatively as these increase risk of MU post LRYGB and may indicate alternative procedures. These risk factors should also lower the threshold for indication of upper endoscopy in LRYGB patients who complain of abdominal symptoms. Increasing awareness of this potential complication of LRYGB among GPs, A&E doctors, general surgeons and patients is crucial for timely diagnosis and prevention of further complications.

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P339 - Morbid Obesity

Use of The Overstitch (TM) Endoscopic Suturing System Post Roux-En-Y Gastric Bypass: Patient Selection, Technical Tips and First Year Results

Effect of Laparoscopic Sleeve Gastrectomy on Nonalcoholic Steatohepatitis in Japanese Patients with Severe Obesity

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2

2

3

C. Markakis , R. Aggarwal , K.T.D. Yeung , M. Mano Lopes , D. Bansi3, A. Ahmed2 1

Bariatric surgery, St Mary’s Hospital - Imperial College Healthcare NHS Trust, London, United Kingdom; 2Bariatric surgery, Imperial College Healthcare NHS Trust, London, United Kingdom; 3 Gastroenterology, Imperial College Healthcare NHS Trust, London, United Kingdom Aims: We present our experience in a group of patients presenting with weight regain post Roux-en-Y gastric bypass after endoscopic gastrojejunostomy revision. Our aim is to describe a process to successfully and safely introduce this procedure, discuss strategies for optimal patient selection, share technical tips and present our first year results. Methods: We introduced this technique using the OverStitchTM device in 2016. We maintained a prospective database of all patients and recorded videos of all procedures. We then routinely followed-up all patients in the bariatric outpatient clinic. Results: 13 patients were approved for the procedure from the multi-disciplinary team. We performed the procedure successfully in 11 patients and we abandoned a planned attempt in 2 patients. There were no major complications and one patient had minor bleeding which was self-limiting. Weight loss was 6 kg (range 0–12 kg) after a median follow up of 5 months (range 1–12 months). Most patients reported mild dysphagia, which resolved and all had adequate restriction in the first postoperative review. 3 out of 11 patients did not report any restriction on subsequent review and had no weight loss. There was no need for endoscopic dilatation for stricturing in any of the patients. Conclusion: The OverStitch endoscopic suturing system can be safely used for weight regain post Roux-en-Y gastric bypass. Patient selection is essential to achieve satisfactory results. Results can vary during the learning curve period, but the majority of patients report sustained medium term weight loss.

A. Sasaki1, H. Nitta2, K. Otsuka2, S. Baba1, T. Kimura1, T. Takahara2, Y. Akiyama2, K. Koeda2, M. Mizuno2 Surgery, Iwate Medical University, Morioka, Japan; 2Surgery, Iwate Medical University School of Medicine, Morioka, Japan

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Background: Severe obesity has become a worldwide epidemic, bringing with it a multitude of metabolic abnormalities including nonalcoholic fatty liver disease (NAFLD). We previously documented the early improvement of NAFLD induced by laparoscopic sleeve gastrectomy (LSG). However, treatment options of nonalcoholic steatohepatitis (NASH) are still under investigation. The aim of the present study was to evaluate the effect of LSG on NASH. Methods: A total of 65 Japanese patients with severe obesity underwent LSG and concomitant intraoperative liver biopsies from 2011 to 2017. The Brunt classification system was used to grade liver biopsies for the presence and severity of steatosis, lobular inflammation, ballooning, and fibrosis. The relationship between improvements in histological features and clinical characteristics was assessed using retrospectively collected data including demographics and weight loss. We considered each of the histological features as resolved if the post-bariatric biopsy grade score became zero or improved if the postbariatric biopsy score is less than the intraoperative score but greater than zero. Results: Forty-two patients fulfilled criteria for NASH and 13 patients underwent repeat percutaneous liver biopsy at 12 months after LSG. The mean excess body weight loss at time of repeat biopsy was 57%. Mean NAFLD activity score was decreased from 4.7 to 0.2 (p\0.001). At the second biopsy, steatosis resolved in 62% and improved in 23%, lobular inflammation resolved in 39% and improved in 23%, ballooning resolved in 69% and improved in 8%, and fibrosis resolved in 39% and improved in 31%. None of the repeat biopsies revealed progression of grade or stage of NASH. Significant differences were observed in the following variables pre- and post-LSG: HOMA-IR 10.1 vs 1.8, p = 0.003), liver volume (2,668 vs 1,519 ml, p = 0.041), and visceral adipose tissue (289 vs 154 cm2, p\0.001). Conclusions: Our data suggest that intraoperative liver biopsy should be considered for Japanese patients with severe obesity undergoing bariatric surgery. LSG is associated with a significant improvement in both histological and clinical characteristics of NASH. Surgeryinduced weight loss should be considered as a treatment of choice for NASH patients with severe obesity.

P338 - Morbid Obesity

P340 - Morbid Obesity

Outcomes of Benign Biliary Surgery in Morbidly Obese Patients

Rootic Sleeve Gastrectomy: Does it Make Life Easier

K. Khan, H. Ng, K. Yong, A. Nassar

M.M. Ozmen, C.E. Guldogan, E. Gundogdu

General Surgery, NHS Lanarkshire, Airdrie, United Kingdom

General Surgery, University of Istinye, Liv Hospital Ankara, Ankara, Turkey

Aims: Obesity is perceived as a challenge in laparoscopic cholecystectomy (LC). Obese patients may be denied surgery in order to avoid perceived intra-operative challenges and complications. Our aim was to assess if LC ± common bile duct exploration (CBDE) is a safe and feasible procedure in such patients. Methods: Prospectively maintained database of LCs performed by a single surgeon from August 2002 to November 2017 was analysed. No patients were denied surgery because of obesity. Morbid obesity was defined as BMI C 40 or BMI C 35 with associated complications. All morbidly obese patients who underwent LC ± CBDE were identified. Patient’s demographics, ASA grade, intra-operative findings and complications were analysed. Follow-up data was available for 317 (55.7%) patients, median follow-up was 18 months (1–75 months) and no other complications were otherwise reported. Results: 5136 patient had LC ± CBDE, of which 569 (11.1%) had a BMI C35. 86 (15.1%) also had CBDE. 491 (86.3%) were female and mean age was 44.9 years (13–80 years). 257 (45.2%) were emergency cases. ASA grades were; ASA-I 134 (23.6%), ASA-II 329 (57.8%), ASA-III 92 (16.2%), ASA-IV 3 (0.5%) and not recorded in 11 (1.9%) patients. Mean BMI was 40.0 (35–59). Mean hospital stay was 5.2 days (1–41 days). Operative difficulty grades were; grade-I 170 (29.9%), grade-II 175 (30.8%), grade-III 141 (24.8%), grade-IV 74 (13.0%) and grade-V 9 (1.5%). Mean operative time was 66 minutes (22–300 minutes). None of these patients required conversion to open surgery during their operation. There were 15 (2.6%) complications in total; 6 wound infections, 3 chest infections, one bile leak, one pancreatitis, one hyperamylasemia, one port site (umbilical) hernia, one bleeding from port site and one had a tear of liver at falciform ligament. Conclusion(s): This study illustrates that, contrary to the common belief, LC and CBDE conducted in morbidly obese patients do not result in an increase in peri-operative complications. In fact, they can have low post-operative complication rates. Surgeons should consider operating on these patients during the index admission to avoid multiple admissions and potential complications associated with biliary disease.

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Introduction: The sleeve gastrectomy (SG) is a restrictive procedure in which a partial left gastrectomy of the fundus and body of the stomach is performed in order to create a long tubular ‘‘sleeve’’ along the lesser curvature. SG is an acceptable primary bariatric procedure and as a first stage for a Roux-en-Y gastric bypass (RYGB), single anastomosis gastric bypass or a duodenal switch (DS) (1).Robotic SG stands out as a popular surgical option for the treatment of morbid obesity in Europe and North America (2).Advantages of the robotic approach include better view of the surgical field and more precision during surgery (3).As a less technically demanding procedure we used the sleeve gastrectomy to gain dissection and suturing experience using da Vinci system. The aim of the current study is to analyze our Robotic SG experience. Materials and Methods: Between May 2016 and December 2017, 40 patients have undergone robotic sleeve gastrectomy surgery. All patients were reviewed by the multidisciplinary team pre-surgery and were of body mass index (BMI)[40 kg/m2 or BMI[35 kg/m2 with obesity-related health conditions. Patients with severe clinical contraindication or multiple previous abdominal surgeries were excluded. Patients were explained about the known advantages of the robotic surgery, such as 3D vision, better view of the surgical field, and more precise dissection. All bariatric procedures were performed by a single primary surgeon, with the assistance of one of two additional attending surgeons. Results: Total operative time (OT), docking time (DT), the early and late complication rate, length of hospital stay, post operative drainage (ml) and excess weight loss rates were evaluated. There were no cases of conversion to an open or standard laparoscopic approach. 17 were males and 23 were females. Their mean age was 39.2 years. Mean BMI was 43.2 kg/m2. There were no perioperative complications, mortality, or conversions to a laparoscopic approach or open approach in any patient. There were not any leaks. Conclusion: Robotic SG is feasible and may be an initial procedure to undergo more complex procedures. For the experienced bariatric surgeons the learning curve is much lesser for this procedure. Cost issues and operative times will need to be more clearly estimated in the future.

Surg Endosc

P341 - Morbid Obesity

P343 - Morbid Obesity

Nonoperative Management of Leaks After Laparoscopic Sleeve Gastrectomy with Endoscopic Stents in a Tertiary Referral Center

Radiological Findings in Patients Operated Due to Gerd After Sleeve Gastrectomy

¨ . Firat, K. Erozkan, T.O ¨ . Sezer, S. Ersin B. Demir, O General Surgery, EGE University, Izmir, Turkey Background: Laparoscopic Sleeve Gastrectomy (LSG) is a frequently performed operation. Leaks are formidable complications; however, optimal management of the leaks is controversial. Methods: We retrospectively reviewed the medical records of 18 patients referred to our tertiary center between 2012 – 2016 with leaks after LSG. Results: In 15 patients with whom ongoing leaks were identified, stents were inserted with the intent of definitive therapy. Besides the attempts of source control, percutaneous drainages were carried out for intraabdominal collections in nine and for pleural effusions in four patients. Length of stay in the intensive care unit was significantly shorter in patients referred earlier or without any intervention. Conclusion: LSG leaks can nonoperatively be treated in well organized centers under meticulously designed protocols, depending on the clinicial condition of the patient. Keywords: Laparoscopic Sleeve Gastrectomy, Leak, Stent

S. Espinoza, A. Ibarzabal, V. Turrado, A. Holanda, D. Momblan, A.M. Lacy Gastrointestinal Surgery, Hospital Clinic of Barcelona, Barcelona, Spain Introduction: Nowadays, Sleeve Gastrectomy (SG) is the most common bariatric procedure worldwide. This can be explained because weight loss outcomes are better than those observed after other restrictive procedures. SG is perceived as a technical simple procedure with few side effects and low associated complications. In spite of this, after more than 10 years of SG implementation, it has been reported that SG is also associated with complications such as suboptimal weight loss and gastroesophageal reflux (GERD), being GERD one of the most frequent SG complications requiring revisional surgery. Objective: To analyze patients with GERD after SG that necessitated a second surgical intervention. Methods: Retrospective single-institution study. Results: Patients undergoing revisional surgery (n = 40) between 2007 and 2016 secondary to GERD after SG were analyzed. 16 patients of the study cohort presented GERD as the main symptom, whereas 23 also referred insufficient weight loss. Only one subject had a stenosis with associated food intolerance. Of the 40 patients, 30 showed pathologic radiological findings in the barium swallow test. Among these radiologic abnormalities; fundus enlargement, gastric sleeve torsion and stenosis were the commonest documented. Conclusion: ‘‘De novo GERD’’ after SG is a frequent complication that can lead to poor quality of life and even require a surgical intervention. Technical errors during the SG procedure and misdiagnosed GERD in the preoperative workup are the main contributors of GERD after SG.

P342 - Morbid Obesity

P344 - Morbid Obesity

Bariatric Surgery in Super Obese Patients

Experience in Cases With Lagb That Cause Complication and Have to Remove

M.M. Ozmen, C.E. Guldogan, E. Gundogdu General Surgery, University of Istinye, Liv Hospital Ankara, Ankara, Turkey Introduction: The globally growing incidence of obesity and its related comorbidities is one of the most challenging public health issues. Operations for weight loss include a combination of volume-restrictive and nutrient-malabsorptive procedures that affect satiety, absorption, and insulin sensitivity via hormonal or entericderived factors in conjunction with behavior modification to achieve and sustain weight loss. Bariatric procedures are the most challenging operations and the robotic surgery known advantages over the laparoscopic approach, such as 3D vision, better view of the surgical field, and more precise dissection. Methods: The total cohort was consisted of super obesity (a BMI of [50 kg/m2) patients. We performed bariatric surgery to 135 (n = 37, 27.4% robotic) super obese (BMI[50 kg/m2) patients. 10 out of these 135 patients received sleeve gastrectomy (SG). In remaining 125 patients performed minigastric by-pass (MGB n = 66) and single anastomosis duodenal switch proximal approach (SADS-p n = 59), who were included in the study for evaluation. The patients BMI, body weight, co-morbidities, EBWL (%) and metabolic parameters were analyzed. Results: The mean (range) age of the patients were 41 (21–59) years, BMI were 55.95(50–68.7) kg/m2. The mean operative time was 82 (50–110) minutes. 77 patients had T2DM. Hospital stay were 4.1 (3–5) days. There was no complications. The preoperative mean (range) weight was 154.7 (108–222) kg. In the SG group mean weight decreased to 119 (95–185) kg at 12th months and EBWL (%) was 76 (55–88)%. In the MGB group mean weight decreased to 110 (80–165) kg at 12th months and EBWL (%) was 81 (67–88)%. In the SADS group mean weight decreased to 89 (75–118) kg at 12th months and EBWL (%) was 79 (57–90)%. Conclusion: Although %EBWL was lower in the SG group, all groups were feasible and safe bariatric surgical procedures for the resolution of comorbidities in super obesity patients.

N. Ozlem General Surgery, Ahievran University, Kirsehir, Turkey Banded-gastric bypass (BGB) is a highly effective bariatric procedure, yet the possibility of band erosion (BE) remains a significant drawback. Surgical removal of eroded bands may be associated with significant morbidity. No consensus exists concerning the appropriate management of BE including intragastric migration. Aim is to mention our small experience.20Y, F, has been had laparoscopic adjustable gastric banding (LAGB).She has lived with eroding port of abdominal wall, without weigth loss for 2 years, undergone a LAGB in 2.time. The last operation was done in 4 years for not having weight loss, vomiting;gastric band was removed laparoscopically. There are dense adhession in abdominal cavity, but has not any complication. The band has not eroded the gastric wall, viewed in upper gastrointestinal endoscopy.19 Y female in 2004 has operated for LAGB, in 2010she has operated for eroding band viewing band gastric lumen. The endoscopist could not remove with upper gastrointestinal endoscopy, cause risky to remove for leak to peritoneum, cause CTshowed the band eroded liver. LAGBand removed with open surgery.46 y female has been operated for obesity in 2010 first time, The second gastric banding laparoscopically has been done in 2012. But she has not been manage to adjust the band balloon, she never loss adequate weight. In 2015 her gastrointestinal endoscopy showed partially visible band in her gastric lumen. Laparoscopically gastric band removal has not been achived cause having dens adhession, the band removal has been done by open technique. Postoperative course was uneventfull. Shehab H et al; endoscopic removal of eroded gastric bands in patients with BGB is effective and safe in the majority of patients. When bands are adherent to the gastric wall, removal of the intraluminal portion of the band may lead to full or partial improvement of symptoms. Endoscopic band removal can be attempted even when a small part of band circumference has eroded. Kim S Y et al; endoscopic procedures afforded acceptable treatment of band migration, gastric leaks after LAGB. Our small serie experience; the management of LAGB for the patients is not easy;They experience the band erode their gastric wall. The surgeon and the patient have to discuss to occur gastric BE, leak possibility and need to remove it. This work was supported by the Scientific Research Projects Commission of Ahi Evran University (Project No:TIP E2 001)

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P466 - Morbid Obesity

P468 - Morbid Obesity

CT Scan Measurement of Gastric Volumes Pre and Post Laparoscopic Sleeve Gastrectomy. Does the Resected Volume Correlates to Weight Loss Results: ?

Barbed vs Conventional Sutures in Bariatric Surgery: A Propensity Score Analysis From a High Volume Center

C. Rodriguez-Otero Luppi, C. Balague Ponz, B. Gonzalo Prats, M. Garay Sola, J.C. Pernas Canadell, E. Ballester Vazquez, S. Fernandez Ananin, E. Targarona Soler General and Digestive Surgery, Hospital Sant Pau, Barcelona, Spain Background and Aims: Laparoscopic sleeve gastrectomy (LSG) has enormously grown in popularity as a standalone procedure for the treatment of morbid obesity. The aim of this study was to assess if the resected and the remnant gastric volumes (measured by multidetector CT scans) were predictors for effectiveness of weight loss at 1 year after surgery. Material and Methods: Sixty-four patients with BMI [40 kg/m2 or [35 kg/m2 and medical comorbidities underwent LSG between January 2012 and October 2016 included into a RCT (NCT02144545) study comparing different bougie sizes (33 Fr vs 42 Fr). Multislice CT scans were performed preoperatively, 2 months, and 1 year after surgery in those patients, to evaluate the gastric volume with a dedicated examination protocol. Parameters were compared to percentage of excess weight loss (%EWL) at 1 year. Results: Females accounted for 68.7% of patients. Mean age was 50.2 years. Mean preoperative BMI was 44.5 kg/m2, and mean preoperative gastric volume measured by CT volumetry was 686.8 ml. %EWL at 1 year was 60.1 ± 19.3%. Mean remnant gastric volume was 103.5 ml at 2 months and 178.5 ml at 1 year, this increase was statistically significant (p\0.001). No differences were found between the gastric volume increase after surgery (1 year volume - 2 months volume) with weight loss results at 1 year (r = 0.016, p = 0.92). No significant differences were found in %EWL (61% vs 59%) with the different bougie sizes (p = 0.327). A significant correlation was found between the percentage of resected stomach (2 months volume/preoperative volume) and %EWL (r = 0.322, p = 0.043). We also found a correlation between the resected volume (preoperative volume - 2 months volume) with weight loss results at 1 year (r = 0.384, p = 0.014). Conclusion: LSG is an effective treatment for inducing weight loss, and it seems that the bougie size should be tailored in each patient to resect a suitable gastric volume. Gastric dilatation does not seem to have an impact in short-term results.

F. Pennestrı`, P. Gallucci, F. Prioli, P. Giustacchini, L. Ciccoritti, L. Sessa, R. Bellantone, M. Raffaelli Division of Endocrine and Metabolic Surgery, Policlinico Universitario A. Gemelli - Universita` Cattolica del Sacro Cuore, Rome, Italy Aims: Laparoscopic intracorporeal suturing and knot tying for anastomosis are considered the most difficult laparoscopic skill to master. The introduction of barbed sutures seems to facilitate the practice, with bariatric surgery being one of the specialties that can most benefit from them. The aim of this study was to establish the safety and efficacy of barbed suture to close the gastrojejunal anastomosis (GJA) in bariatric laparoscopic procedure procedures (Roux-en-Y gastric bypass – RYLGB, and One-Anastomosis gastric bypass – MiniGB) using propensity score matching (PSM) analysis. Methods: A retrospective analysis of patients who underwent primary bariatric procedures (RYLGB and MiniGB) between January 2012 and May 2017 was performed. The patients were divided in two different groups (RYLGB-G and MiniGB-G). PSM analysis was performed to overcome patient selection bias (age, gender, BMI, previously abdominal operations, comorbidities, smoking, simultaneous cholecystectomy) between the two types of sutures (barbed – BS, and conventional – CS) in each group. The primary outcome measure was operative time. The secondary outcomes were the incidence of leak, bleeding, stenosis and post-operative hospital stay. Results: A total of 808 patients were reviewed. After PSM, 488 (244 B vs 244 C) patients in RYLG-G and 48 (24 B vs 24 C) patients were apiece compared. Median operative time (OT) was significantly shorter (p \ 0.001) for BS in RYLGB-G. In MiniGB-G BS were associated with a tendency shorter operative time, although no significant difference was observed (p = 0.183). Post-operative hospital stay was significantly shorter for BS in each group (p \ 0.001). Post-operative 30th-days complications were comparable: no leakage and bleeding of GJA were observed in BS patients. Median follow-up was significantly shorter for BS in each group (p \ 0.001). At median follow up of 28.78 months no late complication was observed. Conclusions: Despite some of the results of the present study may be influenced by increasing surgical skill during the study period, barbed sutures appear to be effective and as safe as conventional suture to close GJA in gastric bypass surgeries. Further studies are necessary to draw definitive conclusions.

P467 - Morbid Obesity

P469 - Morbid Obesity

Single Anastomosis Duodeno-Ileal Bypass with/After Sleeve Gastrectomy: Initial Experience of a High-Volume Single Institution

Rare Interesting Bariatric Complications

L. Sessa, F. Pennestrı`, P. Gallucci, P. Giustacchini, L. Ciccoritti, R. Bellantone, M. Raffaelli Division of Endocrine and Metabolic Surgery, Policlinico Universitario A. Gemelli - Universita` Cattolica del Sacro Cuore, Rome, Italy Aims: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been proposed as an alternative to biliopancreatic diversion with duodenal switch (BPD-DS) in order to maintain the outcome of the original procedure simplifying the technical complexity and to avoid potential complications. Moreover, it potentially represents the more natural second step bariatric procedure after sleeve gastrectomy (SG). We aimed to report the initial experience with SADI-S of our high volume bariatric Center. Methods: A retrospective analysis of patients who underwent bariatric procedure between July 2016 and November 2017 was conducted. The primary aim was the evaluation of the safety of SADI-S, defined as the rate of postoperative complications. The secondary endpoint was the bariatric efficacy of the procedure, defined as percent excess weight loss (%EWL). Results: Among 445 patients who underwent bariatric procedures at our institution 13 patients were scheduled for SADI-S. All patients had multiple comorbidities. Initial indication for SADI-S was failed SG in 2 patients (pre-SG BMI 54.1 and 48.9 kg/m2; 23 and 35 months after initial operation respectively) and primary procedure in 11 patients (median pre-operative BMI 55.4 kg/m2). The surgical procedure was accomplished with roboticassisted approach in the first case (operative time 240 minutes) and with laparoscopic 4 trocars standard approach in the remaining 12 cases (median operative time 150 minutes). The duodeno–ileal anastomosis was fashioned using a double layer hand-sewn running sutures. No patients showed early post-operative complications, the median post-operative stay was 4 days. At a mean follow up of 5.3 months the median %EWL was 45.9. To date no patients experienced surgical and/or nutritional complications. Conclusions: At least in a high volume bariatric Center SADI-S, both as second step after SG and as primary surgical option, seems to be a safe and effective bariatric metabolic procedure based on solid physiopathologic principles. On the other hand, longer follow-up is necessary to support the use of this procedure as a better alternative to BPD-DS

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M.R. Elkeleny, A. Abokhozima General surgery department, GIT unit, Alexandria University, Faculty of medicine, Alexandria, Egypt The presentation contains 3 rare complications and how to manage Case 1: Female patient with BMI 35 managed by intragastric balloon, after 4 months the balloon ruptured and traveled to the small bowel leading to small bowel obstruction a`laparoscopic exploration was done and extraction of the balloon. Case 2: Male patient with BMI 40 and diabetes mellitus managed by sleeve gastrectomy On day 4 persistent vomiting due to port site hernia managed by laparosopic exploration and reduction and fascial closure Case 3: Female patient with weight regain after sleeve gastrectomy managed by re-sleeve gastrectomy After 2 weeks she complained of persistent vomiting due to stricture at OGJ a`managed by self-expandable metallic stent for 1 month.

Surg Endosc

P470 - Morbid Obesity

P482 - Morbid Obesity

Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Adjustable Band In Obese Patients with BMI Below 50 kg/m2

Comparison Between Laparoscopic Banded and Non-Banded Gastric Bypass: Short Term Quality of Life and Outcomes

M.R. Elkeleny, A.A. Sabery, A. Abokhozima, A. Abo Nasr

A. Peri, S. Carando, G. Giambartolomei, F.C. Bruno, N. Mineo, A. Pietrabissa

General surgery department, GIT unit, Alexandria University, Faculty of medicine, Alexandria, Egypt Background: Laparoscopic adjustable gastric banding (LAGB) was the most popular restrictive procedure for obesity in Europe, and now laparoscopic sleeve gastrectomy become the most popular bariatric procedure worldwide. Both procedures best to be applied for morbid obese patients with BMI below 50 kg/m2. Aim of the work is to compare between LSG and LAGB in the management of obese patients with BMI below 50 kg/m2. Methods: the study include 50 morbidly obese patients with BMI below 50 and were divided randomly in two equal groups. Result: there was significant shorter in operative time, hospital stay in LAGB, significant more weight loss, % EWL, %EBMI loss over 1 year in LSG group.

P471 - Morbid Obesity Laparoscopic Conversion of Failed Sleeve Gastrectomy to RouxEn-Y Gastric Bypass in Dubai Hospital Bariatric Center - Early Postoperative Outcome B. Bereczky Bariatric Unit, General Surgery Department, Dubai Hospital, Dubai, United Arab Emirates Aim: Insufficient weight loss or weight regain after laparoscopic sleeve gastrectomy (LSG) has been reported in increasing number of patients. The reason of complications is multifactorial. In our institute we prefer to offer conversion to laparoscopic Roux-en-Y gastric bypasss (RYGB). Methods: In a prospectively kept database we have retrospectively collected 37 patients in total who underwent conversion from LSG to RYGB between 2013–2017. The patients’ characteristics, indications for redo surgery, early postoperative outcome, evolution of BMI and improvement of comorbidities were analyzed. Results: 37 patients underwent the above mentioned procedure, female:male ratio 5:1, mean age 36.61 years (range: 19–61 years). Mean preoperative BMI was 44.3 (18.1–62.3 kg/m2), the average hospital stay: 3.05 nights. The reason of conversion in 90.1% of cases was weight regain or insufficient weight loss; 36.3% had reflux symptoms or persistent vomiting. Two patients (5.4%) suffered from severe malnutrition (after 14 months) or excessive weight loss/food intolerance 4 months after LSG. We had 0% mortality and no stapler line or anastomotic leakage. We had no in-hospital or short-term complications or readmissions within 30 days. The mean achieved lowest BMI was 35.34 (17.5–51 kg/m2) and most of the pre-existing comorbidities: reflux 100%, dyslipidaemia 100%, hypertension 81.4%, depression 100% has significantly improved. 94.6% of patients would do the procedure again. Conclusion: The fully standardized laparoscopic conversion of LSG to a RYGB is a safe procedure with zero % mortality and very low morbidity rates. The increasing number of patients will provide more experience in our high volume bariatric center.

Chirurgia Generale 2, Policlinico San Matteo, Pavia, Italy Aims: To compare quality of life and outcomes after laparoscopic banded gastric bypass (bLRYGB) and laparoscopic gastric bypass (LRYGB) Methods: We retrospectively identified all the patients who underwent b-LRYGB at our institution between April 2014 and May 2017. We then compared demographics, comorbidities, peri-operative and post-operative outcomes with a cohort of patients submitted to the classic procedure. In the b-LRYGB, the pouch was ’sleeved’ on a 38 Fr bougie, ring sizes were 6.5, 7 and 7.5 cm. Food intolerance was assessed with a vomiting frequency scale. Results: A number of 40 patients were identified, of which 20 underwent b-LRYGB (85% females) and 20 LRYGB (75% females). Preoperative BMI was 45.29±4.81 in the b-LRYGB group vs 44.67±3.92 in the LRYGB group (p = 0.661). Comorbidities such as diabetes, hypertension, dyslipidemia, OSAS and GERD were in 20% vs 25% (p = 0.705), 50% vs 50% (p = n/a), 20% vs 30% (p = 0.465), 25% vs 55% (p = 0.052), 45% vs 30% (p = 0.327) of the patients in the b-LRYGB and in the LRYGB respectively. Perioperative outcomes such as time of surgery and length of stay were 213.8 min vs 228 min (p = 0.394) and 5.05 days vs 6.4 days (p = 0.014) in the b-LRYGB and in the LRYGB, respectively. No intraoperative complications were reported, no conversions to open, no deaths occurred. EWL% after 3, 6, 12 months was 37.51±11.09 vs 39.86±12.39 (p = 0.550), 57.06±12.40 vs 60.57±16.41 (p = 0.516), 81.12±14.65 vs 77.65±22.12 (p = 0.685) in the b-LRYGB and in the LRYGB, respectively. Only 5% (n = 1) of the patients in the b-LRYGB referred a monthly vomiting rate between 3 and 6 episodes compared to 10% (n = 2) in the LRYGB. No correlation between ring size and symptoms was found, no erosion or migration occurred. Conclusion: We found no significant differences between the two procedures in short term quality of life and outcomes. We therefore suggest that b-LRYGB does not add significant short term adverse effects such as food intolerance or chronic vomiting, and potentially reveal better outcomes in long term weight loss maintenance. b-LRYGB might preserve the restrictive aspect of the procedure, avoiding the need of a challenging and sometimes ineffective revisional procedure.

P485 - Morbid Obesity Duodenal Neuroendocrine Tumor in Bariatric Surgery Patients; A Surgical Dilemma! Presenting an Approach Algorithm S. Wadhera1, A. Ali1, A. Saha1, R. Goel2, R. Dhingra2, R. Madan3, S. Dogra3 1 GI, Bariatric And Minimal Access Surgery, Venkateshwar Hospital, New Delhi, India; 2Gastroenterology, Venkateshwar Hospital, New Delhi, India; 3Pathology, Venkateshwar Hospital, New Delhi, India

Aim: To provide a possible algorithm for management of Duodenal Neuroendocrine tumor in a Bariatric surgery patient. Methods: A 50 year old, Indian male with Weight of 128kg, Height 183cm, BMI 38.3 kg/ m2. Patient was a pure vegetarian, non smoker, no history of alcohol usage, history of lumbar disc prolapse 4 years ago and subsequent weight gain around 30 KG. Patient was initially planned for Laparoscopic Sleeve Gastrectomy. Preoperative Ultrasound revealed Cholelithiasis and UPPER GASTROINTESTINAL ENDOSCOPY revealed a Duodenal Mass lesion in the Duodenal Bulb, just distal to the pylorus which was highly suspicious of Carcinoid tumor, Gastrointestinal Stromal tumor or Brunner’s Gland Hyperplasia. Multiple biopsies were taken which were reported as Non specific Duodenitis with a nest of Brunner glands. ENDOSCOPIC ULTRASOUND & FNAC showed a tumor of 15 9 8 mm sessile broad based growth seen arising from the 3 layers of duodenum which was not amenable for Endoscopic Sub mucosal Dissection. Multiple deep FNAC revealed small round blue cell neoplasm likely to be a neuroendocrine tumor. DOTA NOC SCAN showed only a solitary enhancing lesion of 18x 15mm in first part of duodenum with no evidence of any other lesion elsewhere. Serum Chromogranin- A was 18.2 mg/ml. Results: In view of the above findings and the lack of an option for Endoscopic removal, a definitive surgery addressing both the problems of Duodenal Neuroendocrine tumor and Bariatric surgery was customized (Laparoscopic Partial Gastrectomy with excision of first part of duodenum and the gastric remnant with Formation of long Gastric tube and an Omega Loop Gastrojejunostomy with Cholecystectomy was performed. Histopathology showed tumor to be deeper to the mucosa and Sub mucosa and was covered with a layer of hyperplastic Brunner’s Glands. Conclusion(s): Duodenal Neuroendocrine tumors are a very rare entity, but are being diagnosed with greater frequency due to increased upper gastrointestinal endoscopies being performed. The review of literature shows these tumors have never been reported in bariatric surgery patients. Patience and perseverance is of utmost importance to successfully management. An approach algorithm and a short video are presented to deal with this unique combination of two diseases.

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Surg Endosc

P345 - Oesophageal and Oesophagogastric Junction Disorder

P347 - Oesophageal and Oesophagogastric Junction Disorder

Laparoscopic Transhiatal Approach for Treatment of Esophagogastric Junction Cancer

An Assessment of Clinical Outcomes Following Stretta Therapy for the Treatment of Gastro-Oesophageal Reflux Disease From a UK Tertiary Centre

Y. Lee, S.H. Min, H.H. Kim Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea Purpose: Laparoscopic transhiatal approach (LA) for esophagogastric junction cancer has advantage in point of providing better view comparing with open approach (OA). In the present study, we focus on the surgical outcomes comparing LA with OA. Methods: A total of 108 patients with Esophagogastric junction cancer who underwent gastrectomy with curative intent at Seoul National University Bundang Hospital between 2003 and 2017 were analyzed. Surgical outcomes were reviewed using electronic medical records. Results: Thirty-seven patients underwent LA, and 71 underwent OA. Compared with OA, LA was associated with significantly less postoperative hospitalization duration (10.1 vs. 14.9 days, p = 0.019) and extended operation time (251.5 vs. 213.8 min, p = 0.032). There was no significant difference between LA and OA in intraoperative blood loss (150 vs. 170 ml, p = 0.631), proximal resection margin (0.8 vs. 0.9 cm, p = 0.555), or rate of surgical morbidity (Cgrade 2) for complications (8.1 vs 23.9 %, p = 0.080). There were 2 cases of anastomotic leakage in OA group and no anastomotic leakage in LA group. There was no difference between groups in total number of harvested lymph nodes (58.5 vs. 57.7, p = 0.889). The 5-year overall survival rate and 3-year disease free survival rate were 81.8% and 79.7% for LA, and 50.7% and 56.1% for OA (p = 0.024 & 0.046). In multivariate analysis, TNM stage was the only independent factor associate with survival. Conclusion: LA for esophagogastric junction cancer appears feasible and safe in short-term or long-term oncologic outcomes.

P346 - Oesophageal and Oesophagogastric Junction Disorder Minimally Invasive Approach to Distal Oesophageal Diverticula How We Do it D. Zanotti1, A. Botha2 1

Oesophago-Gastric Surgery, Churchill Hospital, Oxford, United Kingdom; 2Oesophago-Gastric Surgery, Guy and ST Thomas’ Hospital, London, United Kingdom Aims: Epiphrenic diverticula are rare and often asymptomatic. When symptoms are present, surgery is suggested. While there’s agreement on the pre-operative assessment, no consensus is found on the surgical technique. In this study we report our experience and show a standardised approach to this rare oesophageal disorder. Methods: We analysed data of patients who underwent lower oesophageal diverticula resection between 2016 and 2017 at St Thomas’ Hospital, with regard to preoperative assessment, surgical technique and post-operative follow-up data. Results: Four patients, aged 68, 71, 59 and 49years respectively, underwent laparoscopic diverticulectomy, anterior myotomy and fundoplication. Three of them followed a diet in preparation for surgery. Mean pre-operative Eckardt symptoms score was 4.5. Two patients had normal manometry. Mean diverticulum size was 38 9 30 9 20 mm. No intra-operative complications occurred. All patients reported a complete resolution of symptoms after surgery. Conclusions: Laparoscopic approach to distal oesophageal diverticula is safe and effective. A pre-operative diet is useful in order to find an empty pouch at time of surgery. A dismotility disorder is not always associated with diverticula development. Better understanding of its pathogenesis will lead to improvements in the future.

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N. Maguire1, B. Obuobi1, Y.K.S. Viswanath1, T. Gill2, V. Shanmugam2, A. Reddy3, G. Bussa4, A. Gilliam5 1 Upper GI, Laparoscopic and Endoscopic Unit, James Cook University Hospital, Wynyard, United Kingdom; 2General and Colorectal Surgery, North Tees University Hopsital, Stockton, United Kingdom; 3General and Colorectal Surgery, James Cook University Hospital, Middlesbrough, United Kingdom; 4General and Bariatric surgery, North Tees University Hopsital, Stockton, United Kingdom; 5 General and Bariatric surgery, Darlington Memorial Hospital, Darlington, United Kingdom

Introduction: StrettaÒ offers a therapeutic alternative for patients suffering from refractory gastro-oesophageal reflux disease (GORD). The device utilises radiofrequency energy delivered to several levels above and below the gastro-oesophageal junction. The aim of the treatment is to augment the lower oesophageal musculature in order to enhance the anti-reflux barrier function of the lower oesophageal sphincter. Current evidence suggests the treatment may improve symptoms of GORD and decrease requirement for proton pump inhibitor (PPI) therapy. Methods: Analysis of a prospectively kept database of patients undergoing treatment with StrettaÒ between October 2014 and February 2016, in a UK tertiary referral centre. Patients were assessed for suitability using endoscopy; contrast studies; and pH and manometry studies. Data was held in accordance with The Data Protection Act 1998. The Gastro-esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) was utilized to evaluate symptoms pre and post treatment. Patients were followed up by outpatient clinic appointment and telephone consultation. Results: Fifty consecutive patients were followed up for a median of 25.3 months [771 days (Range 499–1162)] following StrettaÒ. The mean age of the cohort was 52.3 years (SD 13.9) and the majority were female (70%). Seventy-two percent of patients were taking a proton pump inhibitor and 27.9% were using at least two antiacid medications at referral. StrettaÒ was carried out under conscious sedation in 69.4% and general anaesthetic in 30.6%. The mean total heartburn scores improved from 21.8 (SD 6.5) to 6.7 (SD 7.5) and regurgitation scores from 20.0 (SD 8.3) to 6.7 (SD 7.7) out of a possible 30 following StrettaÒ. The average GERD-HRQL score improved from 46.2/75 (SD 14.2) compared to 15.2/75 (SD 17.3) Dissatisfaction with GORD as measured in the GERD-HRQL decreased from 100% to 6.2% with 4 patients showing no improvement. No complications or readmissions occurred following the procedure. Conclusion: There are currently a few effective therapeutic endoscopic procedures to anti-reflux surgery for refractory GORD. This series corroborates the value & safety of StrettaÒ as a viable option for patients who are unwilling or unable to undergo surgery and in majority can be performed as an outpatient under sedation.

Surg Endosc

P348 - Oesophageal and Oesophagogastric Junction Disorder

P350 - Oesophageal and Oesophagogastric Junction Disorder

Laparoscopic Remedial Myotomy for Recurrent Esophageal Achalasia

Hybrid Technique of Oesophageal Portosystemic Anastomoses Separation

G. Capovilla, R. Salvador, A. Perazzolo, G. Voltarel, E. Pesenti, S. Merigliano, M. Costantini

A. Reiti1, A. Kebkalo2

Dept of Surgical, Oncological and Gastroenterological Sciences, Universita` & Azienda Ospedaliera di Padova, Padova, Italy Aim of this study was to evaluate the feasibility, complications and final outcome results of laparoscopic revisional myotomy (LRM) for recurrent esophageal achalasia. We reviewed the data of patients who underwent LRM at our Institution after failed myotomy and complementary Pneumatic Dilations (PD) between 2000 and 2017. The outcome was assessed by a detailed symptom questionnaire, endoscopy, barium swallow and pH-monitoring. Fourty-one patients underwent LRM: 7 from our series and 34 referrals. Primary treatments included laparoscopic (20 patients) or open (5) Heller-Dor; laparoscopic (6) or open (7) Heller-Nissen; other 3 patients had open myotomy only. Thirty-four patients (83%) underwent a median of 3 (1–6) PDs between primary operation and LRM. All the operations were performed laparoscopically. The median operating time was 180 mins. (65–260). One patient was converted to open due to a mucosal lesion. After dismounting the fundopliction, a new myotomy was performed in a healthy tissue on a quadrant different from that of the previous myotomy. The fundoplication was reconstructed in 29 patients (70.7%) following the Dor (24 pts) or the Toupet (5 pts) technique. Two patients needed laparoscopic revision on 2nd POD for radiological evidence of an obstructive fundoplication and one for a leakage, treated by suture and converting a Toupet to a Dor fundoplication. Median follow-up was 76 months (2 – 179). Twenty-seven patients had a complete resolution of their symptoms (66%), whereas other 6 (14.6%) needed further PD to achieve a satisfactory outcome. Four patients (9.8%) still need periodic complementary PD and 3 patients (7.3%) required esophageal resection. Endoscopic gastrostomy was necessary in one patient (2.4%) unsuitable for esophageal resection. Finally, reflux was detected in 11 patients (26.8%). In conclusion, LRM is feasible when primary surgery plus PD fail to cure the symptoms of achalasia. One-third of the patients still require further additional treatment, such as repeat dilations or even esophagectomy, especially when a megaesophagus is present. Albeit this is a more difficult operation compared to primary laparoscopic myotomy and carries significant morbidity, LRM may provide the resolution of symptoms to an overall 80% of this selected group of patients, highly refractory to standard treatments.

1 Surgery and proctology kathedra, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine; 2Surgery, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine

Aim: Maintain sufficient level of circulation in the liver parenchyma, which would prevent the hepatic coma, in patients with the portal hypertension after massive gastrointestinal bleeding. Offer a technically simple and fast laparoscopic technic for dissociation of gastrointestinal portosystemic anastomoses. Methods: An oesophagus obturator is inserted by gastroscope. Gastrostomy is formed laparoscopically and ports are installed through the anterior abdominal wall and stomach. The injection of the hyaluronic acid is performed in submucous plane of oesophagus in the vascular free zone. The pouch stich is placer in this area and sewing device is placed beyond it. The handle of the sewing device is introduced through the up to 4cm longitudinal gastrocentic incision. Mucosa and submucosa along with variceals are polled in to the device, tighten with a pouch and dissected. The suture line can be clipped additionally if needed. Stomach is closed by a linear sewing device. Result: This procedure allows fast (average duration 40 ± 7.2 min, p\0.05) and safe permanent separation of portosystemic anastomosis without disturbing the integrity of the oesophagus and increas liver circulation by 40%, p\0.05. Conclusion: GI bleeding related to the portal hypertension is one of the thorny issues in current surgical practice. It is not enough only to stop the bleeding on the background of portal hypertension as impaired circulation and hypoxia increases liver dysfunction. Therefore, restoration of the circulation integrity does not guarante successful recovery of the patient. In addition, during massive bleedings, blood actively bypasses liver through the developed portosystemic anastomosis to the SVC and IVC, which in turns worsens liver hypoxia. Finally, massive bleeding leads to the shedding of nitrogen-containing waste product into the bloodstream causing a ‘‘toxic shock’’ which along with hypoxia lead to the progression of the liver failure.

P349 - Oesophageal and Oesophagogastric Junction Disorder

P351 - Oesophageal and Oesophagogastric Junction Disorder

Comparison of Robot Assisted with Conventional HumanAssisted Laparoscopic Fundoplication

Our Reflux Test Deciding Surgical Indication and Results: Of Laparoscopic Nissen Fundoplication for Gerd Patients

A.M. Samar, A. Bond, C. Ranaboldo

T. Suwa, K. Kitamura, T. Matsumura, K. Karikomi, M. Koyama, E. Totsuka, K. Okada, H. Suzuki, S. Masamura

Department of Surgery (Upper GI), Salisbury NHS Foundation Trust, SALISBURY, United Kingdom Objective: To compare the robot-assisted (FreeHand) to manual camera control approach for Fundoplication performed in district general hospital. Patients and Methods: 44 patients underwent laparoscopic anti-reflux surgery between Jan 2014 to June 2016. 26 (59%) underwent conventional human assisted fundoplication while 18 out of 44 (41%) of patients had a Robot (FreeHandÒ Prosurgics Ltd) assisted procedure. There were no conversions to an open procedure or another technique. The data was analyzed retrospectively for patient demographics; operative time, length of stay, post-operative morbidity, symptoms at first follow up and total OPD visits before discharge. Results: The mean operative time for conventional Laparoscopic fundoplication was 165 minutes compared with 129 minutes in Robot assisted group, showing shorter operative time (t39.003 = 3.600, p\.001). Overall 30 out of 44 patients (69%) were discharged within 48 hours. 16 of 26 patients (62%) undergoing conventional fundoplication met the discharge standard while 14 out of 18 (78%) undergoing Robot-assisted fundoplication achieved it. The mean length of stay (days) was 1.5 days in the Robot-assisted group while 2 days in the conventional group. 3 out of 18 Robot-assisted patients experienced complications (16% - all Clavien-Dindo grade I). In the conventional group 8 out of 26 (30%) patients had complications,5 Clavien-Dindo grade II complication, the others had 1 Clavien-Dindo grade I, IIIa, IIIb and IV complications each. 2 (11%) patients required more than 1 post-operative clinic visit before discharge in the Robotassisted group as compared with 6 (25%) in the conventional group. Conclusions: Both methods can be offered to patients safely giving good post-operative outcome but robot-assisted fundoplication was found to have significant reduced operative time, and a trend to fewer adverse events, shorter length of stay and less post-operative clinic visits. The mean operative time for robot-assisted fundoplication was nearly 36 minutes less than mean operative time for conventional fundoplication.

Surgery, Kashiwa Kousei General Hospital, Kashiwa, Japan Introduction: The indication of laparoscopic anti-reflux surgery for GERD patients is important. We have established ‘‘Reflux Test’’ as the tool for the decision in the surgical indication for GERD patients. Surgical indication: Reflux Test At the standing position a patient swallows 300ml 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 every 10 seconds in the order. During this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. If the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. If the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. The anti-reflux surgery was considered in the moderate and severe categories. Results: We have performed laparoscopic Nissen procedure in 87 cases. The mean operation time was 115 min. The outcome was assessed by Reflux Test performed on 4–5 postoperative day, and the results showed the reflux was disappeared in every cases. Median follow-up period of this study was 38 months (7–95 months). In 13 cases (14.9%) PPI was restarted before 6 months after the anti-reflux surgery. In 25 cases (28.7%) PPI was restarted after the anti-reflux surgery during the whole follow-up period of this study. The BMI of the patients had no relationship to the needed restart of PPI. To evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed ‘‘the esophagitis score’’. In this scoring method, a number from 0–5 was assigned according to the degree of esophagitis along with the LA classification. The results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the PPI restarted group (p\0.001). Discussion: The anti-reflux surgery is most effective for the patients who really have the obvious reflux. The results of the laparoscopic Nissen fundoplication were good and satisfied by the patients mostly.

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Surg Endosc

P352 - Oesophageal and Oesophagogastric Junction Disorder

P354 - Oesophageal and Oesophagogastric Junction Disorder

Morbidity and Mortality in Complex Robot Assisted Hiatal Hernia Surgery

Therapy Resistant Gastro-Oesophageal Reflux Disease and Bile Reflux - Should We Redefine Our Treatment Strategies? The Gladstone Protocol

A.C. Mertens1, R.C. Tolboom1, H. Zavrtanik1, W.A. Draaisma2, I.A.M.J. Broeders1 1

Surgery, Meander Medical Center, Amersfoort, The Netherlands; 2 Surgery, Academic Medical Center, Amsterdam, The Netherlands Introduction: Robot-assisted surgery in diaphragmatic hiatal hernia repair is rapidly gaining popularity in complex cases and redo surgery. However, published data regarding this approach are mainly limited to small cohorts. This study aimed to provide information on the safety of robotassisted diaphragmatic hiatal hernia repair and anti-reflux surgery in a high-volume center. Materials and Methods: All patients that underwent robot-assisted diaphragmatic hiatal hernia repair between 2011–2017 at the Meander Medical Centre, Amersfoort, the Netherlands were evaluated. This included all redo procedures. Analysis was performed on intraoperative details, 30-day morbidity and mortality. Complications were classified according to the Clavien-Dindo classification. Major complications were defined as Clavien-Dindo C3b. Results: Primary surgery: 215 primary surgeries were performed by two surgeons in total. The median age was 67 (IQR 58–73) years. The majority of the patients had an American Society of Anaesthesiologists (ASA) score of 2 (ASA1 18.1%; ASA2 65.1%; ASA3 16.1%; ASA4 0.5%). 82.8% of patients had a type III or IV hernia (9.8% Type I; 1.4% Type II; 44.7% Type III; 38.1% Type IV). In 2.8% no herniation was seen perioperatively. In 3.7% of procedures conversion to open surgery was required. 16.7% of patients experienced complications of any severity. The incidence of major complications was 5.6%. Nine patients (4.2%) were readmitted within 30 days. Symptomatic early recurrence occurred in 0.9%. The 30-day mortality was 0.9%. Redo surgery: 151 redo procedures were performed by two surgeons in total. The median age was 60 (IQR 51–68) years. The majority of the patients had an ASA score of 2 (ASA1 22.5%; ASA2 70.9%; ASA3 6.6%). In 2.0% the procedure was converted to open surgery. The overall incidence of complications of any severity was 11.3%, while the incidence of major complications was 2.6%. Three patients (2.0%) were readmitted within 30 days. One patients (0.7%) experienced symptomatic early recurrence. No patients died in the 30-day postoperative period. Conclusions: This study showed that robot-assisted laparoscopic repair of a diaphragmatic hiatal hernia is a safe procedure when performed in an experienced high-volume center and can safely be applied in complex cases and redo surgery.

S.A.M. de Clercq General Surgery, Queensland Health, Gladstone, Australia The coexistence and possible association of bile reflux with Gastro-Oesophageal Reflux Disease (GORD) is an ongoing source of discussion, without a clear therapeutic guideline. In rural Central Queensland most patients used to be treated conservatively and the incidence of severe GORD complaints and Barrett’s oesophagus is high. Recent commotion around the safety of long term use of proton pump inhibitors has reopened the pathway to surgical treatment We redefined a treatment strategy, The Gladstone Protocol, where anti-reflux surgery has a prominent role in the treatment of severe GORD with or without associated bile reflux. A first cohort of 100 patients underwent a laparoscopic Toupet funduplication in a small rural hospital. We recorded two post-operative complications and no mortality. The median hospital stay was 24 hours and short term complaint resolution was over 90 %. We continue this study with more cohorts and long term follow-up. Conclusion: The Gladstone Protocol for surgical treatment of therapy resistant and bile reflux associated GORD treatment proves successful in short term follow-up and can be safely adopted in rural hospitals.

P353 - Oesophageal and Oesophagogastric Junction Disorder

P355 - Oesophageal and Oesophagogastric Junction Disorder

The Endoscopic Full Thickness Plication with the Gerdx - System - A Good Alternative in the Treatment of Reflux Disease?

Hinged Double Flap with No-Knife Stapler Reconstruction After Proximal Gastrectomy For Patients with Adenocarcinoma of the Esophagogastric Junction

T. Roskaric, C. Pizzera, G. Rosanelli General Surgery, Holy Elisabeth Hospital Graz, Graz, Austria Laparoscopic fundoplication is a successful technique for the treatment of reflux disease. However, it also has its risks and complications, and a reoperation rate of up to 10%. Recently alternative techniques have been developed, such as the plication, the StrettaSystem and others. At the Holy Elisabeth Hospital, Graz, the endoscopic GERDX plication has been performed since 2010 and 68 patients have been treated using this technique. In a retrospective analysis with a follow-up of 7 years, the results of this procedure are presented. It can be concluded that the GERDX-System is a good alternative for patients with reflux disease not presenting with hiatal hernia. In 70% of patients a satisfactory outcome is achieved, with very low risk.

K. Shibao, T. Tajima, Y. Nagao, N. Sato, K. Hirata Surgery I, University of Occupational and Environmental Health, Kitakyushu, Japan Proximal gastrectomy has potential advantages over total gastrectomy, such as preserving gastric capacity and entailing fewer hormonal and nutritional deficiencies for adenocarcinoma of the esophagogastric junction. Following proximal gastrectomy, various reconstruction methods are reported, but no general agreement exists regarding the optimal one. Furthermore, because of the technical difficulties related to lymph node dissection and reconstruction, laparoscopic proximal gastrectomy (LPG) with distal esopahgectomy has rarely been performed. This report describes the technical details and results of hinged double flap with No-knife stapler reconstruction after proximal gastrectomy for Siewert types II/III tumors. Methods: We performed LPG, sometimes with transhiatal or thoracoscopic distal esophagectomy. After proximal gastrectomy, reconstruction was performed by intracorporeal esophago-gastrostomy (hinged double flap with No-knife reconstruction), which minimizes the postoperative esophageal reflux by incorporating a backflow valve. We modified original hinged double flap technique by adding an esophagogastric fixation with a bladeless linear stapler prior to anastomosis. Moreover, hand-sewn anastomosis was made using barbed sutures to make anastomosis easier. Results: Twenty-one patients with Siewert type II/III tumors underwent this operation. They included nine patients with Siewert type II cancer, twelve with Siewert type III early-stage cancer. The mean operation time was 395 min. Two postoperative anastomotic leakages were treated conservatively, and no anastomotic stenosis was observed. Postoperative three month and 1-year follow-up endoscopy revealed one case of reflux esophagitis that were well controlled by medication. Conclusions: LPG with the hinged double flap with No-knife method was successfully applied for Siewert type II/III tumors. This method is technically feasible in terms of patient safety with good postoperative quality of life and thus could be one of the attractive surgical choices for Siewert type II/III tumor patients.

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P356 - Oesophageal and Oesophagogastric Junction Disorder

P357 - Oesophageal and Oesophagogastric Junction Disorder

Transoral and Transcervical Surgery for Zenker Diverticulum: Short-Term And Long-Term Results

Ten-Year Experience of Pneumatic Balloon Dilation of Esophagogastric Junction Under Fluoroscopic Guidance

´ braha´m1, A.L. Andra´si1, P.A. Paszt1, Z.S. Simonka1, S.Z. A 2 3 1 A. Roszto´czy , L. Rovo´ , G.Y. La´za´r

A.V. Malynovskyi1, V.V. Grubnik2, V.V. Gutsulyuk1, M.M. Mayorenko1, M.M. Chernov1, D.V. Kudinov1, M.M. Shigimaga1

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Department of Surgery, University of Szeged, Szeged, Hungary; Department of 1st Internal Medicine, University of Szeged, Szeged, Hungary; 3Department of Oto-Rhino- Laryngology and Head- Neck Surgery, University of Szeged, Szeged, Hungary

2

Aims: We present our experience with open and minimal invasive surgery for Zenker diverticulums. Short- and long-term results of the surgical therapies were analysed, especially regarding changes in quality of life (QOL) and the chance of redo intervention.

Methods: Between 1 January 2006 and 31 December 2016, 29 patients were examined with a symptom-causing Zenker diverticulum. Patients underwent complex gastroenterological examinations (swallowing x-ray, endoscopy, pH and manometry) before surgery. In 17 cases, transcervical diverticulectomy was performed with cricomyotomy (TCD), in 16 cases, transoral stapler diverticulostomy (TSD) were carried out. Results from surgical treatments and changes in preoperative and postoperative complaints from patients were evaluated. In our long-term study (average duration was 86 months), changes in QOL were analysed for symptoms related to the function of the oesophagus (dysphagia and reflux), patient satisfaction, the chance of recurrence and redo surgery. Results: Patients were operated on after an average of 31 months with complaints (TCD group: 45 months, TSD group: 18 months). Leading symptoms were the severe dysphagia (TCD group: 76%, TSD group: 81%) and the severe regurgitation (TCD group: 76%, TSD group: 69%). We observed a significant weight loss in the TSD group (25%). No intraoperative complication was detected, and no mortality occurred. 1 patient had to be reoperated on for bleeding (TSD group: 6%), while in one case, pneumonia developed postoperatively (TCD group: 5%). Check-up examinations confirmed adequate oesophageal function and symptom improvement in the TCD group, but 50% of the patients remained symptomatic in the TSD group. In 4 cases, TCD surgery was performed after unsuccessful TSD surgery due to permanent complaints. We found residual complaints in 2 patients (moderate dysphagia and regurgitation, TSD group: 6–6 %). Eating Assessment Tool – 10 (EAT-10) average scores were 1 (TCD group) and 5.5 (TSD group), Reflux Severity Index (RSI) average scores were 2.6 (TCD group) and 1.5 (TSD group). Conclusion: Transcervical diverticulectomy with cricomyotomy and transoral stapler diverticulostomy are effective interventions with low morbidity. After TCD, QOL in patients significantly improves in the long-term, but following TSD surgery, symptoms can recur and redo treatment is necessary in some patients.

Department of robotic and endoscopic surgery, Odessa national medical university, Odessa, Ukraine; 2Department of surgery # 1, Odessa national medical university, Odessa, Ukraine Aims: Pneumatic balloon dilation (PBD) is used for early stage esophageal achalasia (EA), recurrences after Heller-Dor procedure (RHDP), and temporary dysphagia and esophageal stenosis after laparoscopic repair of hiatal hernia and fundoplication (RHHF). The aim of study was to find optimal mode of stepwise fluoroscopically guided PBD of esophagogastric junction (EGJ) based on 10-year experience. Methods: From 2007 until 2017, 34 patients underwent PBD. They included 7 patients with early stage EA, 13 patients with RHDP, 14 patients after RHHF. From them, 27 patients (79.4 %) underwent 2 courses of PBD, 5 patients (14.7 %) - 1 course, and 2 patients (5.9 %) - 3 courses. Within each course, 20 patients (58.8 %) underwent 3 procedures, and 14 patients (40 %) - 2 procedures. There were 26 women and 8 men. Mean age was 42 years (22 - 79). Under lidocaine spray throat anaesthesia, a 35 mm achalasia balloon (Cook Medical, USA) was placed at EGJ under fluoroscopic guidance by guidewire inserted endoscopically. Middle part of balloon was positioned at place of maximal stenosis determined by its hourglass narrowing. Stenosis was located at level of diaphragm in 11 of 14 patients (78.6%) after RHHF, thus was caused by tight crural repair. Stenosis was located 2–3 cm above diaphragm in 9 of 13 patients (69.2 %) with RHDP, thus was caused by incomplete myotomy. Pressure increased graduately from 150 mmHg to 200 mmHg and was tailored to patients’ pain reaction. We tried to achieve complete expanding of balloon by end of course. Exposure was 45 seconds (range, 30–60 sec). The interval between the procedures was 2–3 days. Results: There were no cases of esophageal perforation and bleeding. Terms of recurrences depended on disorder. Complete remission was achieved in 11 of 13 patients with RHDP, 2 were reoperated. Mean period of remission of primary EA was 2 years (range, 6 months - 4 years). Complete remission was achieved in 9 of 14 patients after RHHF, 5 patients were reoperated. Conclusions: 1. Our technique of stepwise fluoroscopically guided PBD is safe and effective. 2. It helps to determine the reason of dysphagia.

P358 - Oesophageal and Oesophagogastric Junction Disorder Does Closure of The Diaphragmatic Crura During Heller Myotomy for Treatment of Achalasia Reduce the Risk of Gerd and PPI Intake H. Mcheimeche, L. Chalaby, R. Saheli, D. Lichaa, H. Bitar, S. Dbouk General Surgery, Al Zahraa University Hospital, Beirut, Lebanon Background: Achalasia is a rare primary esophageal motility disorder, characterized by failure of relaxation of the lower esophageal sphincter and aperistalsis of the distal esophagus. Clinical presentation features include progressive swallowing difficulty for liquids and solids, chest pain, and regurgitation. Medical, endoscopic and surgical treatment options exist for treatment of Achalasia, but Heller myotomy remains the gold standard procedure in the management of this disease, although it is not devoted of complications, and gastro-esophageal reflux is reported to occur in 8–10% of cases. Objective: Some modifications of Heller myotomy technique should take place, in aim to decrease the rate of GERD post-Heller myotomy. In this article, we demonstrate that closure of the diaphgramtic crura, could be the needed modification. Regularly at our institute, when performing Heller procedure, esophageal myotomy is followed by a cruroplasty and an anti-reflux procedure. Significantly lower rate of GERD post heller myotomy and recurrence were obtained. Methods and Results: Between 2006 and 2017, 36 patients, with a median age of 44 years, were diagnosed to have achalasia after undergoing gastroscopy and manometry. All patients were treated surgically, using the same technique. The myotomy is extended, at least 8–10 cm over the esophagus and 3–4 cm below the GEJ. It was followed by a cruroplasty consisting of 2 stitches between both crura and an anterior Dor fundoplication. All patients underwent an upper GI series on day 1 post-op, and were discharged on liquid diet for 14 days and PPI for 1 month. After a median follow up period of 40 months, all patients undergone upper endoscopy and were assessed for any complaints denoting evidence of achalasia recurrence or new onset of GERD. GERD was evident only in 1 case, which decreased the rate of GERD post Heller to 2.7%. Another patient complained of dysphagia, but he was successfully treated by endoscopic dilatation. No other complications were noted. Conclusion: Cruroplasty, when added to the esophageal myotomy during a Heller procedure reduces significantly the rate of GERD post Heller myotomy, and should be considered when performing Heller myotomy in aim to offer the best outcome for the patients.

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P359 - Oesophageal and Oesophagogastric Junction Disorder

P360 - Oesophageal and Oesophagogastric Junction Disorder

Percutaneous Laparoscopic Surgical Approach for Achalasia: Minimize Skin Trauma While Ensuring Ergonomics and Results

Miniinvasive Treatment of Patients with Esophageal Varices Bleeding

L. Barbieri, G. Saino, G. Micheletto, D. Bona

V.V. Petrushenko, D.I. Grebeniuk, I.V. Radoga, M.O. Melnychuk, S.V. Khytruk, S.A. Cheshenchuk, A.M. Pankiv

General Surgery, Istituto Clinico Sant’Ambrogio, Milano, Italy Aim: In recent times, many efforts has been made to minimize the abdominal wall trauma in order to reduce postoperative pain and obtain a prompt return to daily activities, as well as improve cosmetic results of surgery. The progressive development of novel surgical devices has allowed the introduction of new minimally invasive surgical techniques and instruments. Criticism of the single incision laparoscopic surgery include a modification of surgical technique, intraoperative conflict of instruments and increased incidence of woundrelated complications as infections and incisional hernia; on the other side, peroral endoscopic myotomy has shown higher post-procedure gastro-esophageal reflux rate. In this study we propose a novel mini-invasive approach to perform a standard laparoscopic Heller’s myotomy with Dor fundoplication in order to reduce the impact on the abdominal wall and reduce skin visible scars as well as maintain the correct surgical approach for achalasia. Methods: We present our experience using MiniLap Percutaneous Surgical SystemÒ (TeleflexÒ) to perform a two-trocar laparoscopic percutaneous assisted esophageal Heller’s myotomy with Dor fundoplication. Five patients suffering from Type II achalasia underwent surgery between November 2015 and June 2016. The proposed technique allows the replacement of three 5 mm trocars with three MiniLap percutaneous instruments of 2.3 mm diameter. These devices can be percutaneously inserted using an integrated needle tip, so no trocar is needed. After removing these instruments no stiches are required, but wound closure strips are used. Results: After a minimum fifteen-months follow up, there was no recurrence of dysphagia in any of the patient treated. Median Eckardt’s score was 1 (0–2), in range with ordinary performed laparoscopic Heller’s myotomy. Postoperative analgesia was managed with acetaminophen, if required. The esthetic result was optimal as the 2.3 mm scars were nearly undetectable. No surgical site infections were recorded. The surgeons found the instruments comfortable and ergonomic and there was no need to change the surgical approach. Conclusions: The use of percutaneous instruments was not inferior in terms of clinical outcomes as compared with standard technique, while improving cosmetic results and reducing trocar-related abdominal pain.

Department of Endoscopic and Cardiovascular Surgery, National Pirogov Memorial Medical University, Vinnytsya, Ukraine Aims: The aim of our study was to decrease of mortality rates and improve the outcome of treatment in patients with esophageal varices bleeding. Methods: The study is based on the prospective analysis of treatment results of 237 patients with esophageal varices bleeding, who were on inpatient treatment in the Vinnitsa regional center of the gastrointestinal bleeding in 2014–2017. Total number of men – 135 (56.96%), women – 102 (43.04%). The average age of patients was 57.0±3.4 years. The source of bleeding was established during endoscopy. All patients received drug therapy – hemostatic, antisecretory, infusion, symptomatic. In 2014–2016 patients (group 1, n = 195) received just drug therapy. From the second half of 2016 we began to perform minimally invasive endoscopic surgical interventions such as ligation of bleeding esophageal varices (group 2, n = 42). After endoscopic band ligation reliable hemostasis was achieved in all cases. According to protocol and in the absence of contraindications to decrease portal pressure all patients received non-selective beta-blockers. Subsequently, to reduce portal hypertension and on purpose to prevent new varices emergence the splenic artery embolization was performed. Results: In group 1 total number of men was 105 (53.8%), women – 90 (46.2%). The average age of patients was 56.0±4.2 years. Using just drug therapy we have stopped bleeding in 152 (77.95%) cases. In all cases at the end of treatment we received improvement of clinical and laboratory indices. 43 patients (22.05%) were died. Duration of treatment was 10.2±2.1 days. In group 2 total number of men was 30 (71.4%), women – 12 (28.6%). The average age of patients was 54.0±5.1 years. Performing of endoscopic band ligation and splenic artery embolization we have stopped bleeding in 36 (85.7%) cases. In all cases at the end of treatment we received improvement of clinical and laboratory indices. 6 patients (14.3%) were died. Duration of treatment was 6.2±2.5 days. Conclusion: Under the condition of esophageal varices bleeding treatment by performing of combination of endoscopic band ligation and splenic artery embolization in comparison with drug therapy we can see the improvement of patient’s condition, decreasing of mortality and duration of treatment.

P361 - Oesophageal and Oesophagogastric Junction Disorder Esophageal Leiomyoma: A Sixteen-Year Experience from A Single Tertiary Care Referral Center P. Milito, A. Aiolfi, S. Zanghi, S. Siboni, L. Bonavina General Surgery, Policlinico San Donato, San Donato Milanese, Italy Background: Esophageal leiomyoma, although infrequent, is the most common benign intramural tumor of the esophagus. In about 50% of the cases, leiomyoma is asymptomatic and discovered incidentally. Minimally invasive enucleation is the treatment of choice but the surgical approach depends on tumor location. Aim of the study was to review our surgical experience in order to verify the safety and efficacy of minimally invasive enucleation. Methods: A retrospective review over a 16-year period of patients who underwent surgical resection for esophageal leiomyoma was done. Demographic data, presenting symptoms, tumor location, tumor characteristics and histology, diagnostic procedures, and treatment modalities/outcomes were analyzed. Results: Twenty-five patients with esophageal leiomyomas underwent surgical enucleation: 12 (48%) patients via laparoscopy and in 3 patients a Nissen fundoplication was added, in 9 patients a Toupet fundoplication and in 1 patient a Dor fundoplication. A prone thoracoscopy was performed in 12 patients (48%) and a hybrid endo-laparoscopic trans-gastric approach was performed in 1 (4%) patient with a plongeant tumor of the esophagogastric junction. Intraoperative endoscopy was routinely performed in order to identify landmarks and verify mucosal integrity. All patients underwent en-bloc enucleation without esophageal resection. Mean operative time was 151 ± 66.3 min. Mean tumor diameter was 5.4 ± 3.2 cm. A benign leiomyoma was diagnosed in all cases. No mucosal perforation occurred. The overall morbidity rate was 16%: there were 2 cases of pneumothorax treated with thoracic drainage, 1 case of subcutaneous emphysema and 1 case of pneumonia treated with antibiotics. Mortality rate was 0%. Mean hospital stay was 4.0 ± 1.8 days. Conclusions: Minimally invasive enucleation is safe and effective for esophageal leiomyoma. En-bloc enucleation can be successfully achieved by a variety of surgical approaches. Routine intraoperative endoscopy may reduce the incidence of unrecognized mucosal injury.

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P362 - Oesophageal and Oesophagogastric Junction Disorder

P364 - Oesophageal and Oesophagogastric Junction Disorder

Minimally Invasive Surgery for the Treatment of a Rare Pathology -Mid Esophageal Diverticula

Quality of Life After Antireflux Surgery in Barrett’s Esophagus

S. Constantinoiu, P.A. Hoara, M. Gheorghe, A. Constantin, C. Gindea, A. Caragui, A. Alkadour General and Esophageal Surgery Clinic, Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania Introduction: Esophageal diverticula are a relatively rare pathology, in which Zenker and epiphrenic pseudo-diverticula are responsible for the majority of cases. Mid esophageal diverticula are less encountered and are usually true diverticula. Material and Method: We have analyzed the incidence of midesophageal diverticula diagnosed and treated in our clinic in the last 5 years, regarding approach, technique and outcome. Results: There were 10 patients with the diagnosis of mid esophageal diverticula. The diagnosis included barium esophagram, upper endoscopy and, in some cases, esophageal manometry. The indication for surgical treatment was dysphagia, regurgitations, episodes of aspiration and the dimensions of the pouch. There were 5 patients who received surgical treatment, 3 by minimally invasive approach and 2 by open thoracotomy. There was 1 postoperative leak (20%), with consecutive pleural empyema, which required surgical reintervention with lavage and drainage of the pleural cavity, with conservative closure of the leakage after 21 days. The postoperative length of stay and complications were less in thoracoscopy group. Conclusions: Minimally invasive surgical treatment of mid esophageal diverticula is safe and feasible, but not all the diverticula have surgical indication.

P363 - Oesophageal and Oesophagogastric Junction Disorder Surgical Treatment of Patients with Complicated Gerd F.P. Vetshev, S.V. Osminin, T.V. Khorobryh, A.F. Chernousov, T.G. Mugadzaveta Faculty surgery, I.M. Sechenov First Moscow Medical State University, Moscow, Russia Aim: Optimization of surgical treatment of complicated GERD by using original antireflux procedure. Methods: In surgical treatment of complicated GERD with hiatal hernia (HH), more than 40 years we use fundoplication in original technique. We mobilize small curvature of stomach with circular mobilization of 4–6 cm of esophagus, ligate short gastric vessels, and form full symmetrical 4 cm length wrap, with its fixation to esophagus. Always excise hernial sac with HH type III and IV. With the hiatus widening [5 cm perform posterior cruroplasty. Even hiatus widened to 8 cm, reliable suture cruroplasty is possible. Since 1973, we performed 1,235 procedures. Since 2006, 408 minimally invasive (384 laparoscopic and 24 robotic-assisted) interventions on complicated GERD were performed. Patients mean age was 54 ± 11.9 years, disease duration 7 ± 3.2 years. There were 237 (58%) patients with hiatal hernia type I, 118 (29%) type III and 53 (13%) type IV. Short esophagus diagnosed in 79 (19.3%) patients, Barrett’s esophagus (BE) - 59 (14.5%), esophageal short (\3 cm) peptic strictures - 34 (8.3%), peptic ulcer - 18 (4.4%) patients. Quality of life was investigated by conducting specific (GSRS) and general (SF-36) questionnaires. To evaluate risk of oncological progression in BE patients, we examined abnormal methylation of tumor-suppressor genes (MGMT, CDH1, p16/CDKN2A, DAPK, RAR-b, RUNX3). Results: Before surgery 34 (8.3%) patients with short peptic strictures underwent balloon dilatation. In early postoperative period, 17 (4.2%) patients had grade I complications (Clavien-Dindo) and 14 (3.4%) grade II. In long-term 403 (98.8%) patients had complete regression of GERD symptoms (p = 0.0255). In 85 (20.6%) patients’ wrap located at or above diaphragm level, without GERD symptoms recurrence. In 5 (1.2%) patients, recurrence, requiring operation, was detected. 324 (79.4%) patients, within 0.5–10 years, showed quality of life improvement in all scales of both questionnaires (p \0.001). Among BE patients, regression of dysplasia and metaplasia (p \0.0001) and decrease of abnormal methylation (p = 0.0024) were diagnosed. Conclusion: Our antireflux procedure effectively eliminates symptoms of complicated GERD, contributes inflammatory regression including BE, improves quality of life. Migrating or leaving wrap in mediastinum does not affect functional results.

Z.S. Simonka, A. Paszt, J. Tajti, G.Y. Lazar Department of Surgery, University of Szeged, Szeged, Hungary 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 hour 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 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 to the long term follow-up laparoscopic Nissen procedure can control reflux among patients with BE.

P365 - Oesophageal and Oesophagogastric Junction Disorder Standardized Method for Nissen Fundoplication: Reproducibility and Effect on Learning Curve P.S.S. Castelijns1, J.E.H. Ponten2, M.C.G. Vd Poll1, N.D. Bouvy1, J.F. Smulders2 Surgery, MUMC?, Maastricht, The Netherlands; 2Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands

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Aims: Laparoscopic anti-reflux surgery requires advanced laparoscopic skills and comes with a great learning curve. We have developed a modified technique to create a standardized floppy Nissen fundoplication without the use of a bougie. The aim of this study was to determine the reproducibility of this novel technique, secondary outcome is the learning curve and the comparison between an experienced surgeon and a resident in creating a floppy Nissen. Methods: For this study, we created an ex-vivo laparoscopic set-up box with pig stomachs to mimic the intra-abdominal situation. Both A 5th year surgical resident and a experienced anti-reflux surgeon created 5 Nissen fundoplications (NF) as they were used to. Next, they performed each 5 fundoplications according the modified technique (MNF). Measurements regarding the wrapsize, time of surgery and ease of procedure was scored. Results: Each surgeon performed a total of 10 Nissen fundoplications with a mean operating time of 6.3 (range 4.7–7.6) for conventional method compared with 14.4 (range 13.5–15.3) for the modified technique. (p\0.05) The spread in overall diameter of the NF was larger for the resident than for the surgeon. When MNF was applied, this difference disappeared. There was no difference in operating time between the resident and surgeon for NF, where the surgeon was significant faster in creating the MNF. The resident scored the modified technique as significantly easier to perform than the NF, where there was no difference for the experience surgeon. Conclusions: The modified is better reproducible than the standard Nissen fundoplication and a surgical resident is able to create a fundoplication that is comparable with the one from an experience anti-reflux surgeon, within a few attempts. This technique will help beginning surgeons in performing the right fundoplication and might reduce learning curve in anti-reflux surgery.

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P366 - Oesophageal and Oesophagogastric Junction Disorder

P368 - Oesophageal and Oesophagogastric Junction Disorder

Toupet versus Nissen Fundoplication and Gastric Plication for Treatment of Obese Patients with Gastro Esophageal Reflux Disease

Laparoscopic Repair of Large Paraoesophageal Hiatus Hernia Quality Outcome from a Single District General Hospital

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O.C. Borz , T.Jr. Bara , T. Bara , A. Torok , M. Denes , B. Borz , P. Borz2, D. Marian1 1

2nd Surgery Department, Emergency County Hospital, Tg.Mures, Tg.Mures, Romania; 2General medicine, UMF Tg.Mures, Tg.Mures, Romania

S. Rajeev1, P. Thambi1, B. Gopinath1, M. Rao1, M. Shanmugham1, A. Musbahi1, D. Kumar1, Y.K.S. Viswanath2 1

Surgery, North Tees and Hartlepool NHS foundation Trust, Stockton on Tees, United Kingdom; 2Surgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom

Gastroesophageal reflux disease (GERD) is often associated with obesity and is considered a related comorbidity. Surgical treatment for these patients rises debates. Because fundoplication alone has a high failure rate and does not adress obesity, Nissen fundoplication and plication of the rest of the stomach was described as a treatment for obese patients with GERD who refuse major bariatric surgery (gastric by-pass or sleeve gastrectomy). Methods: We randomized 50 obese patients with GERD in two groups: 25 patients underwent Toupet fundoplication and gastric plication and the other 25 were operated on with Nissen fundoplication and gastric plication of the rest of the stomach. The mean body mass index was 40. Results: The follow-up at one year showed that the reflux symptoms were solved in all patients. Endoscopic findings were significantly improved in 75% of the Toupet group and 73% in the Nissen group. The patient satisfaction score GERD-HRQOL was better in the Toupet group. The % of excess weight loss was 54.6% at 6 month and 67% at 1 year in the Toupet group and 45% respectively 51% in the Nissen group. Discussion. There was no significant difference between the 2 groups regarding the endoscopic findings but a much better satisfaction score in the Toupet group. Also the % of excess weight loss was significantly higher (67% at 1 year) in the Toupet group compared to the Nissen group (51%). Conclusion: The data from our study suggest that Toupet fundoplication with gastric plication is a better aproach than the Nissen fundoplication with gastric plication, in obese patients who refuse major bariatric procedures as gastric by-pass or sleeve gastrectomy.

Aim: Paraoesophgeal hernia is relatively uncommon and usually seen in elderly patients. With improved life expectancy this has become more common and has the potential for development of life threatening complications. Laparoscopic repair is a treatment option, usually performed at specialised centre. We aimed to review our outcomes. Methods: Prospective database of all large paraoesophageal hernia repair performed both emergency and elective were reviewed over 5 1/2-year period (Jan 2012 until July 2017). Asymptomatic patients were discharged in 6 months and long term results gained by telephone interview. Patient demography, symptoms, Investigative findings, operative details, in hospital mortality and long term outcome were analysed. Results: 55 patients (Males= 12, Females= 43) were included in this study. During this period 46 patient were operated as electively and 9 patients had surgery as emergency or semi electively. Symptoms included were regurgitation (67%), epigastric pain (60%), heartburn (58%), vomiting (47%), dysphagia (45%) and bloating (29%). Age range was 40–87 (mean 66.9, SD 11.7). Median hospital stay was 2 days. Median operating time was 167 seconds. One patient required conversion to open surgery. Morbidity occurred in 11 (20%) and 1 died following emergency surgery due to severe cardiac failure. After the surgery 49 patients (89%) were satisfied about the results. In which 33 patients were completely asymptomatic and 16 patients had minimal symptoms. 5 patients (9%) had persisting significant symptoms. Postoperatively 32 patients got repeat prescription of PPI, in which 15 (46%) were asymptomatic. Conclusion: Laparoscopic repair of large paraoesophageal hernia can be safely performed in experienced hands with accepted morbidity and mortality with good symptom relief. Close.

P367 - Oesophageal and Oesophagogastric Junction Disorder

P369 - Oesophageal and Oesophagogastric Junction Disorder

The Role of Postprandial Acid Pocket in the Progression of Gerd on Background of Acidic and Bile Reflux

Quality of Life of Patients with Esophageal and Extra-Esophageal Manifestations of Erosive Gerd

I. Komarchuk1, V. Komarchuk1, K. Koliushko2, N. Veligotsky1

I. Komarchuk1, V. Komarchuk1, K. Koliushko2, A. Lohosha3

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Toracoabdominal Surgery, Kharkiv Medical Academy of Postgraduate Education, Kharkov, Ukraine; 2Pediatrics, Kharkiv National Medical University, Kharkov, Ukraine Background: The aim of the research was to analyze the influence of topographic and anatomical features of the location of postprandial acid pocket (PAC) on the reflux characteristics in patients with combination of acidic and bile gastro-esophageal reflux (GER). Methods: The research is based on the analysis of graphics of daily monitoring of 85 patients with combination of hiatal hernia, failure of the lower esophageal sphincter, acidic and bile esophageal reflux. Gastro-esophageal-pH-impedance monitoring was used to find the localization of PAC and to confirm acidic or bile GER. Results: In patients with failure of the lower esophageal sphincter (36 patients) and I degree hiatal hernia (HH) (28 patients) the PAC was found on the level of diaphragm. Patients with HH II - III degree (21 patients) the PAC was fixed above the diaphragm and moves in the hernial sac with an increased intra-abdominal pressure. In 64 patients with diaphragm level of the PAC in the postprandial period the total time of reflux established within 31.16 ± 0.81 min, that was significantly (p \0.05) lower than above the diaphragm PAC (21 patients) that was 77 ± 1.1 min. The number of reflux episodes unreliable (p[0.05) more at the diaphragm level PAC (14.59 ± 0.49), than above the diaphragm PAC (10 ± 0.32). The alternation of acidic and bile reflux provides a combined effect of pepsin, pancreatic enzymes and bile acid on the esophagus mucosa against a background of slightly acidic or neutral pH. Reflux episodes in the postprandial period characterized by high, slightly or neutral acidity (2.1 – 6.8) and the mixed nature (liquid ? gas). Conclusions: 1. The localization of PAC above the diaphragm significantly (p \0.05) increases the contact time of the acid with esophagus mucosa that can aggravate the GERD. 2. Despite the slightly acid and slightly alkaline nature of GER, pronounced changes in the mucosa of the esophagus occur due to the presence of pancreatic enzymes and bile acids in the refluxate, which is more pronounced in patients with a PAC location above the diaphragm.

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Toracoabdominal Surgery, Kharkiv Medical Academy of Postgraduate Education, Kharkov, Ukraine; 2Pediatrics, Kharkiv National Medical University, Kharkov, Ukraine; 3General surgery, Hospital with polyclinic Mijava, Mijava, Slovak Republic Background: Assessment of the quality of life of patients with extra-esophageal manifestations of erosive GERD (EGERD) against duodeno-gastro-esophageal and gastroesophageal reflux. Methods: The study is based on an analysis of the treatment of 86 patients with erosive esophagitis (EE) against a background of combined reflux between 2006 and 2017. The control group consisted of 56 patients with esophageal manifestations of EGERD. The main group included 30 patients with extra-esophageal manifestations. Patients assessed their condition on the SF-36 questionnaire before treatment, 1 and 6 months after the therapy. Conservative therapy included PPI, UDCA, alginates. Results: Patients of working age were 92.9% and 93.3% in the primary and control groups, respectively. Before the start of treatment, there were no statistically significant differences between the quality of life indicators in the main and control groups. The physical component of health (FC) before treatment was 76±6.5, the psychological component of health (PC) - 54.2±6.1. One month after the treatment, FC in control group increased to 81.2±4.1 (80.1±3.6 in the main one), PC was 78.1±3.8, which is significantly more than in the main group (61.6±4.1). One month after the treatment, 84 (97.7%) patients had no esophageal complaints. In the main group, in 7 (23.3%) patients, non-esophageal symptoms of GERD were completely stopped, in 22 (73.3%) - partially stopped, in 1 (3.3%) case, the therapy was ineffective. The lack of clinical effect in 2 (2.3%) cases required additional examination. In main 1 (1.8%) case with EE (type D) progression of cicatricial stricture of the lower third of the esophagus with violation of patency was revealed, which entailed increased dysphagia. In the control group, 1 (3.3%) patient with a EE (type B) had refractory to the PPI, which required an increase in the dose. After 6 months, a second survey was performed, which showed a significant improvement in the quality of life in both groups. FC was 88.1±4.1 (control group) and 82.9±3.3 (main group). The PC was 80.6±5.1 (control group) and 79.6±4.8 (main group). Conclusion: Extra-esophageal manifestations of EGERD significantly (p\0.05) affect the effectiveness of the treatment and contribute to a slower recovery of quality of life indicators.

Surg Endosc

P472 - Oesophageal and Oesophagogastric Junction Disorder

P473 - Oesophageal and Oesophagogastric Junction Disorder

Transoral Cardiomyotomy for Achalasia Cardia with Rigid Ports - Is it Feasible?

Robotic Heller Myotomy

S. Haribhakti, H. Shah, A. Tiwari, A. Shah, H. Soni, K.S. Patel G I Surgery, Kaizen Hospital, Ahmedabad, India Introduction: Flexible endoscopic platform, which is currently used for per-oral endoscopic myotomy (POEM) for achalasia cardia, has few inherent limitations e.g. suturing of mucosal incision, single instrument channel in the endoscope etc. Postprocedure reflux esophagitis is also a major problem. To overcome such limitations, we have developed rigid platform to perform Transoral Endoscopic Myotomy (TOEM). Materials and Methods: Surgeon sits on the head end, facing the patient. Transoral port for esophagus (TOP-E, 30 cm long & 2 cm in diameter), a new innovative port, which is made up of a sheath, a diaphragm & a silicon washer, is inserted under vision with a blunt introducer in a flexed neck position. It can admit upto two rigid instrumentsat a time (5mm each) & one telescope (5mm). By changing the silicone washer over the diaphragm of the TOP, even wider instruments (upto 12mm diameter) can be inserted. One airport is provided for continuous CO2 insufflation and a suction port for evacuating smoke. In TOEM, a vertical mucosal incision is placed at 25–30 cm over posterior wall of esophagus after submucosal injection with Hybrid knifeTM. Submucosal tunnel is created with an innovative Tunnel Pusher Sheath. Myotomy is performed by dividing circular fibresfor 8–10 cm in lower esophagus with a hook & it is extended for 2-3 cm into the stomach. The mucosal defect is sutured with Vicryl 00 suture with 5/8th circle needle using a regular needle holder and extracorporeal knotting. Results: We have performed this procedures in 16 animal tissues, 4 dead animals (pigs, goats) and 2 cadaver humans. Mean operating time for TOEM was 110.2 minutes (Range 88–136). Main challenges relate to the small diameter of the port, small working channels - creating difficulties for instrumentation, instrument clashing, difficulty in insufflation of esophagus and smudging of scope due to smoke generation in small field. Conclusions: Transoral cardiomyotomy for achalasia cardia is feasible in preclinical setting with the newly developed rigid TOP which forms a stable surgical platform. Human trials are needed to test this operative platform. The mucosal incision can be sutured with this platform. We have also performed transoral anterior Dorr fundoplication with the same platform, which would prevent post-procedure GERD & reflux esophagitis.

E. Akin1, F. Altintoprak2, M.Y. Uzunoglu1, E. Dikicier1, K. Gundogdu1, K. Ozdemir2 1 General Surgery, Sakarya University Research and Educational Hospital, Sakarya, Turkey; 2General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey

Introduction: Achalasia is the most common esophageal motility disorder characterized by dysphagia. Since its first description in 1991, Heller myotomy by minimal invasive procedures has been associated with better short term outcomes and shorter recovery time, compared to open techniques and its now generally accepted as the procedure of choice for achalasia. Robotic technology has recently been introduced into laparoscopic clinical practice with the aim of improving surgical performance and excellent results have been described with robotically assisted Heller myotomy in patients with achalasia. The aim of this study is to demonstrate six patients results who underwent robotic Heller myotomy with Dor fundoplication and had unsuccessful baloon dilatation history. Methods: We were evaluated with complaint of dysphagia about six patients. There were four patients female and two patients were male with the mean age of 32 years. In all patients had a history of more than one endoscopic balloon dilatation. By using the Da Vinci S Surgical manufactured by ˙Intuitive Surgical (Sunnyvale, CA, USA) Heller myotomy and Dor fundoplication was performed. In one patient, we repaired intracorporeally with 3/0 Vicryl suture the mucosal perforation which occured during myotomy. There were no complication in six patients after the surgery. Results and Conclusion: Achalasia is a primary motility disorder of the esophagus that is treated succesfully with operative myotomy or endoscopic balloon dilatation. Esophageal perforation is the most common major complication for balloon dilatation or surgical myotomy with varying rates reported in the literature. Robotic surgery is gradually find more space between other myotomy methods due to the 3-D visualization, the very steady operative view, above all the articulated arms of the robotic system allow the surgeon to visualize and divide each individual muscular fiber easily and identifying the submucosal plane at the gastro-esophageal junction. Especially in our cases that may be encountered in patients with performed unsuccessful balloon dilatation, in the maintenance of the mucosal perforation provides huge advantages. In suggests that, in skilled hands, the robotic platform may be safer with improved quality of life outcomes.

P474 - Oesophageal and Oesophagogastric Junction Disorder Systematic Review and Meta-Analysis on the Effect of Obesity on Recurrence After Laparoscopic Anti-Reflux Surgery Y. Bashir Surgery, Trinity College Dublin, Naas, Ireland Background and Aims: Laparoscopic anti-reflux surgery (LARS) aims to provide relief from gastroesophageal reflux disease (GORD). With increase in the prevalence of obesity, there is a concurrent increase in obese patients requiring LARS. In addition to being a more technically difficult procedure, there is conflicting evidence regarding the effectiveness of LARS in obese patients. We performed a systematic review and meta-analysis to compare the outcomes of LARS in obese versus non-obese patients. Methods: Articles on the effects of obesity on LARS were identified from Ovid Medline, EMBASE and the Cochrane Library databases up to 30th of November 2016. Two independent searches were conducted. Data were extracted independently by two researchers. The primary outcome was recurrence, whilst the secondary outcome was operative time. Pooled data were statistically analysed using forest and funnel plots. Results: Twelve studies (3,346 patients) met the inclusion criteria, with 923 patients in the obese group and 2,423 patients in the non-obese group. Based on a random effects model, there was a risk ratio of 1.36 (95% CI 1.08–1.72, P = 0.009, if studies reporting recurrence objectively are analysed risk ratio of 1.77 (95% CI 1.16–2.73, p = 0.08) showing an increased risk of recurrence for obese patients. Using a random effects model, the difference in operative time was 13.94 minutes (95% confidence interval (CI) 9.33–18.55, P\0.0001), showing an increased operative time for obese patients. Conclusion: A meta-analysis of 12 studies showed that there was greater recurrence of GORD symptoms and longer operative time relating to LARS in obese patients compared to non-obese patients. Keywords: GORD, LARS, Meta-analysis, Obesity, Recurrence, Systematic review

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Surg Endosc

P486 - Oesophageal and Oesophagogastric Junction Disorder

P371 - Oesophageal Malignancies

What to do When Heller´S Myotomy Fails?: Experience in a Specialized Unit and Systematic Review of the Literature

Semi-Prone Thoracoscopic Esophagectomty for Esophageal Carcinoma with an Aberrant Right Subclavian Artery (ARSA) Case Report-

S. Ferna´ndez-Ananı´n1, I. Go´mez1, D. Sacoto1, C. Balague´1, C. Guarner2, M. Poca2, E.M. Targarona1

K. Koyama, T. Watanabe, Y. Iwaki, M. Tochimoto, K. Sadamura, H. Kato, M. Kawaguchi

1

Surgery, Yokohama Skae Kyousai hospital, Yokohama, Japan

General Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; 2Digestive Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Background: Surgical treatment of achalasia fails in 10–20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. Different therapeutic options can be considered. Methods: We analyzed our series of patients underwent laparoscopic Heller Myotomy after the diagnosis of Achalasia and analyzed their long-term outcomes. We also performed a systematic review of the literature based on the best choice of the therapeutic options when myotomy fails. Following the guidelines established by MOOSE statement. We searched several Electronic Databases (MEDLINE, PubMED, EMBASE, Cochrane) from January 1991 to March 2017, with the diferent keywords. Results: From 1998 to 2017, a total of 127 patients diagnosed of achalasia underwent laparoscopic Heller myotomy. The recurrence rate was 11.8% (n = 15). 9 patients improved with pneumatic dilatation, 5 with re-surgery and one with POEM after surgical myotomy. All showed good results in the short and long term. Conclusion: It is still controversial what is the best initial treatment for patients who have failed surgical treatment as a first line. Although the initial procedure chosen by the majority of the authors after the ineffectiveness of the surgical myotomy is pneumatic dilatation, redo laparoscopic Heller myotomy is safe and effective in expert hands. However, POEM shows promising reslts in this area.

P370 - Oesophageal Malignancies Clinical Analysis of ESD for the Synchronous Multiple Primary Early Cancers in Esophagus and Stomach Q. Shi, Y.S. Zhong, L.Q. Yao, P.H. Zhou Department of endoscopy center, Zhongshan hospital, Fudan University, Shanghai, China Objective: With the improvement of endoscopic diagnosis and treatment, the discovery rate of the synchronous multiple primary early cancers in esophagus and stomach is gradually increased, while the traditional surgery bringing serious damages. Endoscopic submucosa dissection (ESD) has become the first treatment option of early cancer or precancerous lesions in the digestive tract partly. This study intends to explore the feasibility, safety and effectiveness of ESD in the treatment of the synchronous multiple early gastric cancer or precancerous lesions in esophageal and stomach. Methods: From January 2008 to December 2016, data of 12 patients with early esophageal cancer and early gastric cancer treated by ESD were reviewed. We analyzed the patient’s history, the size of esophageal and gastric lesions, pathological results, the results of complete or curative resection and so on. Results: Among thev12 patients here described, mean size was (2.2 ± 1.1) cm in esophageal when 3 lesions located in the upper esophagus, 8 in the middle, and 1 in the lower. The gastric lesions was (2.1 ± 1.3) cm with 5 lesions in the antrum, 2 in the gastric angle and 5 in cardia. Lesions were removed in 10 cases at the same time and were removed by stage in 2 case. The complete resection rate was 100% (10/10). Postoperative pathological results showed that there were esophageal precancerous lesions with gastric precancerous lesions in 4 cases, esophageal precancerous lesions with gastric cancer in 2 cases, early esophageal cancer with gastric precancerous lesions in 3 cases and early esophageal cancer with early gastric cancer in 3 case. 12 patients with 24 lesions were consistent with endoscopic indications, when curative resection rate was 100% (10/10). Postoperative esophageal stricture occurred in 2 cases, which were improved after dilation. Median follow-up time was 30 (8–115) months. Conclusion: Simultaneous endoscopic treatment for esophageal and gastric lesions is rarely reported. There are still many issues that need to be discussed, howere, ESD is a minimally invasive endoscopic surgery, which can be used as a method of treating synchronous multiple primary early cancers in esophagus and stomach.

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Aim: An aberrant right subclavian artery (ARSA) is a very rare disease. Its malformation is often a problem during esophageal carcinoma surgery. We could safely performed semi-prone thoracoscopic esophagectomy (SPTE) for esophageal carcinoma with this malformation. Case: A 70-year-old male is a case. Endoscopic examination diagnosed type 0-IIc esophageal carcinoma at the Mt area. In the CT examination, it was diagnosed as stage 1 of T1N0M0. Preoperative CT examination revealed ARSA, and demonstrated that ARSA was arising from the aortic arch and ascending through the left side the esophagous. Operative procedure: A patient is laid fixedly in the left half lateral decubitus position with the right side of his body lifted up at the angle of about 30 ° from the prone position, the bed being rotated to the ventral side to perform the chest manipulation. The position of port placement was taken in the 3rd, 5th, 7th intercostal space on the posterior axillary line. After cutting the azygous vein arch and the right bronchial artery, the right subclavian artery was directly branched from the aorta and then confirmed to travel on the left back side of the esophagus. We taped the right vagus nerve for peeling from the esophagus. It was possible to confirm nerves that recurrent the subclabian artery. Although the esophagus was present between the trachea and the subclabian artery narrowly, but we were able to resect at a satisfactory place. The right recurrent nerve could be preserved. Thoracoscopic esophagectomy and mediastinal lymph node dissection were conducted. The body position was put in a supine position, and abdominal operation was carried out. The gastric tube conduit was pulled through the reterosternal space. End-to-end anastomosis was undergone by hand sewing in the neck field. Result: He did not show any complications after surgery. He discharged 22th later. Conclusions: Taking it into consideration that SPTE for dissection of the esophageal carcinoma can be performed in safety under the wide an operative field of upper mediastinum, we came to the conclusion that SPTE is an excellent procedure to be adopted for the dissection of esophageal carcinoma with ARSA.

P372 - Oesophageal Malignancies Thoracoscopic Upper Mediastinal Lymph Node Dissection Based on Microanatomy of Membrane and Layer Y. Shirakawa, T. Ogawa, N. Maeda, T. Ninomiya, S. Tanabe, K. Noma, M. Nishizaki, S. Kagawa, T. Fujiwara Department of Gastroenterological Surgery, Okayama University, Okayama, Japan Background: June 2011, we started thoracoscopic esophagectomy in the prone position (TEPP) and to date have experienced more than 400 cases of this surgery. The upper mediastinal lymph node dissection is thought to be the most important and most difficult procedure in this surgery. Therefore, using the benefit of thoracoscopic magnified view, we have recently standardized the upper mediastinal lymph node dissection based on the microanatomy of membrane and layer in bilateral side. The purpose of this study was to establish and evaluate our microanatomy based standardization for the upper mediastinal lymph node dissection in TEPP. Patients and Methods: Subjects comprised 400 patients (349 males and 51 females) who underwent TEPP between June 2011 and November 2017. Patients were divided into one of two groups: a pre-standardization group (n = 240) and a post-standardization group (n = 160). Patient characteristics, technical details, and outcomes were compared between the two groups. Microanatomy-Based Standardization: In the bilateral side, after the detatchment of the so-called visceral sheath containing the esophagus, trachea and the lymphatic chain around the recurrent laryngeal nerve (RLN) from the surrounding tissues, we detach the esophagus and the lymphatic chain from the trachea and aggregate it to the esophagus side to make the so-called mesoesophagus. We proceed with lymph node dissection along the nerve upward. Results: Before the standardization, an experienced surgeon did almost all of our thoracoscopic esophagectomies. But, after the standardization, younger surgeons have been able to do more and more. After the standardization, although our younger surgeons have been performing more operations, our thoracoscopic operative time has been shortened by almost one hour, and there is no significant difference in the pre- and post- standardization morbidity rate. We had expected a decrease in the recurrent laryngeal nerve palsy rate after the standardization, but unfortunately there has been no improvement. Summary: After the standardization based on the microanatomy, in spite of an increase in the number of surgeries performed by less experienced operators, our thoracoscopic operative time has been decreasing. However, the high rate of the recurrent laryngeal nerve palsy is still an issue.

Surg Endosc

P373 - Oesophageal Malignancies

P375 - Oesophageal Malignancies

Laparoscopic Transhiatal Approach for Siewert Type 2 AEG

Requirement for Feeding Jejunostomy is a Prognostic Indicator in Patients Undergoing Neoadjuvant Therapy Prior to Oesophagogastric Surgery

M. Tokunaga, H. Sunagawa, A. Kaito, T. Kinoshita Gastric Surgery Division, National Cancer Center Hospital East, Chiba, Japan Background: In Japan, the transhiatal approach became a standard treatment for Siewert type 2 adenocarcinoma of the esophagogastric junction (AEG) with 30 mm or less esophageal invasion after JCOG9502 failed to demonstrate the superiority of the left thoracoabdominal approach. Laparoscopic transhiatal approach would be a plausible treatment option because recent technical and instrumental advancements made more precise and finer lymphadenectomy possible. However, the feasibility of laparoscopic transhiatal approach has not yet been fully investigated. The aim of the present study was to clarify the feasibility of this procedure for Siewert type 2 AEG. Patients and Methods: A total of 45 consecutive patients who underwent laparoscopic gastrectomy with lower mediastital lymphadenectomy for Siewert type 2 AEG with 30 mm or less esophageal invasion between 2008 and 2016 were included in the present study. Short and long term surgical outcomes were retrospectively reviewed, and the feasibility of the procedure was assessed. Results: The male/female ratio was 3.1:1, and the median age (range) was 68 (37–81) years. Total gastrectomy and proximal gastrectomy were performed in 7 and 38 patients, respectively. All surgeries were performed by an experienced surgical team. Median operation time and intra-operative blood loss were 265 (200–370) minutes and 17 (5–55) mg, respectively. Pathological tumor depth was T1 in 25 patients (56%), and nodal status was negative in 40 patients (89%). Clavien-Dindo grade IIIa or higher complications were observed in six patients (13%), and the mortality rate was 0%. The 5-year overall survival rate of all patients was 97.4% with a median observational period of 31 months. Conclusion: Laparoscopic transhiatal approach with lower mediastinal lymphadenectomy seems to be a technically feasible procedure, provided an experienced surgical team performs the surgeries. However, oncological safely for advanced disease needs to be confirmed in the future, considering that most patients included in this study had early stage disease.

S.K. Allen, F. Huddy, J. Sultan, S.R. Preston General Surgery, The Royal Surrey County Hospital, Guildford, United Kingdom Background: As a result of disease biology or dysphagia, it is not uncommon for patients with oesophagogastric (OG) cancer to be malnourished at the time of presentation. Feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase. The literature is unable to inform us whether the requirement for a feeding jejunostomy or weight loss during neoadjuvant therapy (NATx) are clinical prognostic indicators in this group of patients. This retrospective study aimed to evaluate these variables. Methods: All patients between January 2008 and December 2016 who underwent NATx prior to scheduled OG cancer surgery were identified. Data was collated using the Somerset Cancer Register, Multidisciplinary Team Meeting records, a prospectively maintained dietetic database, and clinic letters. Outcome measures included weight change during enteral feeding, cancer resection rate, and lack of surgery secondary to progressive disease or reduction in physical fitness. Normally distributed continuous data were expressed as mean ± standard deviation and skewed data as median with their interquartile range (IQR). Categoric variables were analysed using Chi2. p\0.05 was deemed significant. Results: 71/311 (23%) of patients required a feeding jejunostomy prior to or during NATx. Progressive disease despite NATx was observed in 17 (24%) of patients who required jejunostomy and only in 24 (10%) in those who did not (p = 0.00228). Those deemed to have become too unfit to progress to surgical resection were 14 (20%) and 8 (3%) respectively (p\0.00001). 31 (44%) of patients continued to lose weight during NATx despite enteral feeding. 12 (43%) of patients with ongoing weight loss underwent resection compared with 21 (58%) of those with stable weight or weight gain (p = 0.23). Conclusion: This 9 year observational study has shown that patients in whom jejunostomy was deemed necessary were less likely to undergo their scheduled curative surgery (p\0.00001), more likely to have progressive disease despite neoadjuvant therapy (p = 0.00228), and were less likely to receive surgery due to deterioration in physical fitness (p\0.00001). Patients with ongoing weight loss, despite NATx and preoperative enteral feeding, had a 57% chance of having palliative disease.

P374 - Oesophageal Malignancies P376 - Oesophageal Malignancies Intraoperative Recurrent Laryngeal Nerve Monitoring in the Thoracoscopic Esophagectomy T. Nakano1, C. Shibata2, T. Kamei3 1 Division of Gastroenterologic and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan; 2 Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medi, Tohoku Medical and Pharmaceutical University, Sendai, Japan; 3Department of Surgery II, Tohoku University, Sendai, Japan

Background: Postoperative recurrent laryngeal nerve palsy affects postoperative course in esophageal cancer surgery. Vocal cord palsy causes hoarseness or aspiration pneumonia in some cases. In this study, we report the outcome of our contrivance of lymphadenectomy around the recurrent laryngeal nerve using the nerve function monitoring method. Patients and Methods: NIM response 3.0 and EMG endotracheal tube (Medtronics TM) as the neural stimulation monitoring device were used for 66 patients who underwent thoracoscopic esophagectomy from 2014 to 2017 in Tohoku Univrsity Hospital and Tohoku Medical and Pharmaceutical University Hospital. The presence or absence of vocal cord palsy was determined using laryngeal fibers on postoperative day 1. From April 2015, a dedicated extender of nerve stimulator for use in a thoracoscopic surgery was customized and introduced. Results: We could identify right and left recurrent laryngeal nerves by this neural electrical stimulation device. Adverse events due to the intraoperative nerve monitoring were not observed. The sensitivity of this monitoring method was 100% of right side, 85% of left side. The specificity of it was 56.3% of left side. The incidence of vocal cord paralysis was 44.2% before the introduction of this method. After introduction of this method, it is decreasing to 36% until 2017. Discussion: It was possible to evaluate the recurrent laryngeal nerve function by using intraoperative nerve monitoring method. It was thought that the device helps to identify recurrent laryngeal nerves as well as visual observation. The incidence of recurrent nerve palsy tends to be decreased after introduction of customized extender for thoracic surgery. The dedicated extension tool has improved the ergonomics of the nerve stimulator. It is possible to identify the damaged part of the nerve in some cases. Although the protective surgical procedure is also important for preservation of nerve function, it was thought that the intraoperative nerve monitoring method in the thoracoscopic esophagectomy improved the surgical technique and educational effect of the surgical procedure.

Preoperative Treatment Based on the DCF Chemotherapy and Supportive Therapy for Minimally Invasive Esophagectomy of Esophageal Cancer? S. Tanabe, Y. Shirakawa, N. Maeda, T. Ninomiya, K. Noma, T. Fujiwara Gastroenterological surgery, Okayama University, Okayama, Japan Introduction: The neoadjuvant chemotherapy using CDDP and 5-FU (CF) is the standard treatment for advanced esophageal cancer, defined as clinical stage II/III in Japan. However, more powerful chemotherapy has been required for the treatment of cases of cStageIII cases. In 2011, the combination treatment of CF and Docetaxel (DCF) was introduced for the treatment of those cases in our institute. DCF therapy increased chemotherapy remarkable cases. But, adverse events occur at high rates, including high myelosuppression. Therefore, it is necessary to ensure support by early intervention of supportive therapy so as not to exacerbate adverse events. We report about treatment outcome in preoperative DCF therapy cases. Patients and Methods: We treated 128 esophageal cancer patients who underwent surgery following preoperative DCF therapy between 2011 and July 2017, and preoperative DCF was administered to 128 patients 2 course completely. The neoadjuvant chemotherapy regimen using DCF is Docetaxel:70mg/m2 (day1) ? CDDP:70mg/m2 (day1) ? 5-FU:700mg/m2 (day1–5). Result: In the preoperative DCF group, overall response rate (over PR) was 51.5%. There were 37 cases in 128 cases of pathological tissue effect judgment for Grade 2 and 3. 14 cases of them (14cases/37cases:37.8%) had lymph node metastasis. Therefore it is necessary to control lymph node metastasis by surgery even in a remarkable group. Almost all patients experienced grade 4 adverse events, particularly neutropenia is a high frequency. From the start of chemotherapy, pretreatment of intraoral infection lesion and prevention and treatment of oral mucositis are performed. Considering the degree of myelosuppression during initial chemotherapy, in the second course, we actively administer G-CSF preparation. Conclusion: A good prognosis can be expected if preoperative DCF therapy is effective. It is necessary to perform intensive and safe preoperative chemotherapy with appropriate supportive therapy intervention.

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Surg Endosc

P377 - Oesophageal Malignancies

P379 - Oesophageal Malignancies

Bilateral Approach for Thoracoscopic Esophagectomy with Lymph Node Dissection in the Dorsal Thoracic Aorta in the Patients with Esophageal Cancer

Minimally Invasive Esophagectomy - Pros and Contras

Y. Onodera1, T. Nakano2, Y. Taniyama1, T. Sakurai1, T. Heishi1, C. Sato1, H. Okamoto1, S. Maruyama1, T. Kamei1 1 Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Division of Gastroenterologic and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan

Introduction: The incidence of lymph node metastasis in the dorsal area of the thoracic aorta (DTA) is relatively low in patients with esophageal cancer. It is difficult to approach the DTA using surgical procedures, such as an open thoracotomy and thoracoscopy in the left decubitus position. Case Presentation Case 1: A 70-year-old man with esophageal cancer underwent thoracoscopic esophagectomy with mediastinal lymph node dissection via a right thoracoscopic approach, followed by lymphadenectomy in the DTA via left thoracoscopy in the prone position. Microscopic findings revealed two metastatic lymph nodes in the DTA. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T2N3M0 (Union for International Cancer Control [UICC], 7th edition). The patient showed lung metastasis 8 months after the surgery. Case: A 72-year-old man with esophageal cancer underwent esophagectomy via a bilateral approach in the prone position, using a similar procedure as in case 1. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T3N2M0. The patient showed a metastatic mediastinal lymph node 4 months after the surgery. Conclusion: Bilateral thoracoscopic esophagectomy in the prone position can be safely performed, and it might be an alternative curative surgery for esophageal cancer. However, both our cases showed metastasis in the early postoperative period. The long-term outcome and significance of dissection of lymph nodes in the DTA in patients with esophageal cancer remains controversial. Further studies are required to establish the indications and efficacy of this therapeutic approach.

S. Constantinoiu, F. Achim, D. Predescu, R. Birla, A. Constantin, P.A. Hoara, M. Gheorghe, A. Caragui General and Esophageal Surgery Clinic, Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania Introduction: Esophagectomy is a major surgical procedure, with morbidity and mortality related to the patient, the disease and the surgical team. Minimally invasive esophagectomy is an approach that tries to lower the complications. Material and Method: We present the experience of the Center of Excellence in Esophageal Surgery, ‘‘St Mary’’ Clinical Hospital in modified McKeown triple approach, thoracoscopic, laparoscopic assisted and cervical. In the last 2 years we have performed this operation in 10 patients, with reduced pulmonary and parietal complications comparing with open approach, less ICU and hospital stay. One patient died, because of anunrecognizedthoracic duct injury, that was treated thoracoscopic but in the end conducted to MSOF and exitus. There was another thoracic duct lesion that was identified and managed intraoperative. We have had one patient with cervical anastomotic leakage that required the application of a fully covered stent, and was healed after 16 days. The mortality rate was comparable with open approach, but the pulmonary and parietal complications were less. Conclusions: Minimally invasive esophagectomy is safe and feasible, requiring both open and laparoscopic advanced skills in esophageal surgery and the capabilities to manage complications.

P378 - Oesophageal Malignancies

P380 - Oesophageal Malignancies

Totally Minimally Invasive Esophagectomy Versus Hybrid Minimally Invasive Esophagectomy: Systematic Review and Meta-Analysis

The Impact of Elderly on Surgical Outcomes After Ivor-Lewis Esophagectomy: Review of a Single Institution Experience

F. van Workum1, B.R. Klarenbeek1, M.M. Rovers2, C. Rosman1 1 Surgery, Radboudumc, Nijmegen, The Netherlands; 2Health evidence and operating rooms, Radboudumc, Nijmegen, The Netherlands

Background: It is unclear whether hybrid minimally invasive esophagectomy (HMIE) or totally minimally invasive esophagectomy (TMIE) should be preferred. Objective: To perform a systematic review and meta-analysis of studies comparing HMIE with TMIE. Methods: A systematic literature search was performed in Medline, Embase and the Cochrane library. The review protocol was registered in PROSPERO with number CRD 42016043291. Articles comparing HMIE and TMIE were included if they reported results of at least 10 patients per arm. The Newcastle-Ottawa rating scale was used for critical appraisal of the methodological quality of the studies. The primary outcome parameter was pneumonia. Subset analysis was performed for laparoscopic HMIE versus TMIE and thoracoscopic HMIE versus TMIE. Results: Eighteen studies with a total of 2342 patients were included. Studies had a low to moderate risk of bias. As compared to HMIE, TMIE was associated with a lower incidences of pneumonia (RR: 1.77, 95% CI: 1.02 – 3.06), shorter hospital length of stay (SMD: 0.16, 95% CI: 0.01 – 0.32) and less blood loss (SMD: 0.74, 95% CI: 0.12 – 1.36), but with a longer operative time (SMD:-0.30, 95% CI: -0.57 – -0.03). In subset analysis, TMIE was associated with a lower incidence of overall complications (RR: 1.16, 95% CI: 1.02 – 1.32) compared to thoracoscopically assisted HMIE. Discussion: TMIE was associated with a lower incidence of pneumonia, less overall complications and a shorter hospital length of stay, but with longer operative times. Data from this systematic review and meta-analysis can guide decision making for clinicians.

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A. Cossu, F. Puccetti, P. Parise, L. Garutti, C. Ferrari, U. Elmore, R. Rosati Gastrointestinal surgery, San Raffaele Hospital, Milano, Italy Background: Esophagectomy is a surgical procedure burdened by a high morbidity rate. The effect of minimally invasive (MI) approach on elderly patients is still not clear. Aim of this study was to analyze the impact of MI approach on post-operative course according to the patient age. Methods: A consecutive series of 692 patients underwent to elective oncological esophagectomy between 1997 and 2017. All data were entered into a prospective database. Patients submitted to 3-flield or trans-hiatal esophagectomy were excluded and only Ivor-Lewis open, hybrid or totally minimally invasive esophagectomy were evaluated. Patients were stratified according to age in 3 groups: Group A (B 50 years) 53 patients, Group B ([ 51 and \ 70 years) 269 and Group C (were C71 years) 126. Clinical and pathological factors influencing surgical outcome were evaluated. Complications were classified according to Clavien-Dindo (CD). Results: As expected outcomes worsened with patients age (CD C 3b: 7.5% group A, 13% group B and 21% group C. p = 0.001), mortality (0% group A, 3% group B and 5.5% group C. p = 0.035) and length of stay (10 days group A, 11 days group B and 13 days group C. p = 0.001). A statistically significant higher incidence of anastomostic leaks was observed among patients submitted to totally MI esophagectomy in group C vs A and B that were respectively 12.5%, 0% and 7%. Major respiratory complications were not statistically different among these 3 three sub-group. Conclusions: Old age has a significant impact on outcomes after esophagectomy. In this subset of patients a MI approach could also increase postoperative morbidity. Elderly patients should be carefully selected before to be submitted to MI esophagectomy.

Surg Endosc

P381 - Oesophageal Malignancies

P383 - Paediatric Surgery

Minimally Invasive Management of Thoracic Duct Injury and Its Complications. Two Cases Presentation

Laparoscopic Versus Open Appendicectomy in Paediatric Patients with Complicated Appendicitis: A Meta-Analysis of Randomized Controlled Trials

M. Gheorghe, A. Constantin, F. Achim, F. Chiru, P. Hoara, S. Constantinoiu General and Esophageal Surgery, Saint Mary Hospital, Bucarest, Romania Background: Thoracic duct lesion is a rare but potentially life-threatening complication of esophagectomy by consecutive chylothorax, with a reported incidence rate of 1–4%. Two cases of thoracic duct injuries are reported in patient with minimally invasive esophagectomy for esophageal scuamous cell carcinoma (ESSC), after neoadjuvant treatment. The first case with postoperative chylothorax was managed by two consecutives thoracoscopic approaches. The second case illustrates a thoracic duct injury succesfully identified and cliped during the primary thoracoscopic approach for esophagectomy. Methods: In case 1, a 47-year-old man with cachexia presenting with an ESCC of the mid esophagus underwent thoraco- laparoscopic modified McKeown esophagectomy after neoadjuvant radio-chemotherapy. The thoracic duct was not identified, and no obvious leaks were detected. On postoperative day 5 a chylothorax was identified and conservatory treated. Once the conservative treatment of 72 hours was unsuccesfull, the patient was scheduled for surgery. A thoracoscopic approach was used, the lymph injury was not identified and the thoracic duct was clipped in bloc above the diaphragm. A second thoracoscopic approach was necessary 4 days later for recurrent chylothorax. A second thoracic duct injury was identified cranialy, near superior thoracic aperture and clipped. Unfortunately the evolution was marked by pulmonary sepsis and death of patient. In case 2, a 61 year-old man with an SCC of the mid esophagus underwent thoraco- laparoscopic modified McKeown esophagectomy after neoadjuvant radio-chemotherapy. After azygos vein transection, a complete injury of the thoracic duct was identified, and clipped. The postoperative evolution was uneventfull. Results: Prolonged conservative treatment of thoracic duct injury is associated with a high mortality. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10–16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax. Conclusion: The thoracic duct injuries can be managed efficiently by a thoracoscopic approach. The thoracic duct should be ligated during esophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. Early thoracic duct ligation at 48 hours from diagnosis is recommended for duct injury, if aggressive conservative management fails.

Z.X. Low1, J.J. Ng2 1

Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; 2Department of Surgery, National University Hospital of Singapore, Singapore, Singapore Aims: Acute appendicitis is a common surgical condition in the paediatric population. For patients with uncomplicated appendicitis, laparoscopic appendicectomy (LA) is the treatment of choice as compared to open appendicectomy (OA). However, in patients with complicated appendicitis (CA), as defined by gangrenous or perforated appendicitis, or appendicitis associated with a peri-appendiceal abscess, the decision to perform OA or LA remains unclear. Methods: An electronic database search in the period of 1997 to 2017 was performed using the Cochrane, Medline, PubMed, Scopus, Ovid, Embase and Web of Knowledge databases. A hand search of abstracts from IPEG, EAES, SAGES and ACS was also performed. The PRISMA guidelines were adhered to and only randomized controlled trials (RCTs) comparing LA versus OA in paediatric patients with CA were included. Data analysis was performed using RevMan 5.3 from the Cochrane Collaboration. Assessment of the methodological and statistical heterogeneity, as well as the publication bias of the included studies, were conducted. Results: Six RCTs (296 LA vs 373 OA) were analyzed. LA had significantly lower incidence of surgical site infections (OR = 0.62, P = 0.03) and readmission rates (OR = 0.27, P = 0.05), whereas OA had a shorter operating time (WMD = 29.48, P \0.00001). Although LA was favoured for a lower incidence of post-operative intraabdominal abscess formation (OR = 0.82, P = 0.85), postoperative ileus or intestinal obstruction (OR = 0.52, P = 0.35), and the need for repeat surgery (OR = 0.19, P = 0.14), it did not reach statistical significance. Length of stay (WMD = 0.77, P = 0.14) was comparable between both groups. Conclusion: This meta-analysis demonstrates the benefits of LA over OA, and in paediatric patients presenting with CA, LA should be the procedure of choice.

P382 - Oesophageal Malignancies Preliminary Results: Of Hybrid Minimally Invasive Ivor Lewis Esophagectomy S.C. Schmidt1, F. Marusch1, D. Pappert2, E. Hantel1, M. Deponte1 1 General- and Visceral Surgery, Klinikum Ernst von Bergmann, Potsdam, Germany; 2Anesthesiology, Klinikum Ernst von Bergmann, Potsdam, Germany

Aims: Conventional open esophageal surgery for cancer is still associated with a significant morbidity and mortality. To overcome these limitations, various minimally invasive procedures have been introduced in recent years. In our institution, we introduced minimally invasive esophagetomy in april 2016. We choosed the hybrid minimally invasive Ivor Lewis esophagectomy (HIL) with the hypothesis to combine the advantages of both, the laparoscopic (gastrolysis, creation of gastric tube) and open approach (intrathoracic anastomosis). Aim of the study is to evaluate our preliminary results. Methods: Between April 2016 and December 2016 a total of 12 patients underwent HIL for cancer in our institution. A single surgeon performed all operations. Surgery started with laparoscopic gastric mobilization, D2-lymph node dissection and creation of a gastric tube. Via a muscle sparing posterolateral thoracotomy in the fourth intercostal space, esophagus mobilization, lymph node dissection and end-to-side esophago-gastrostomy was performed. Clinical data were analyzed prospectively. Results: There were 2 women and 10 men with a mean age of 62 years (range, 32–80 years). 10 of 12 patients received neoadjuvant treatment before surgery. Mean operation time was 291 min. (range, 261–393 min.). Mean lengths of stay on the intensive care unit was 5.4 days (range, 2–8-days) and mean hospital stay was 14.7 days (12–18 days). Overall postoperative morbidity was 75%. (Anastomotic insufficiency: n = 1, Anastomotic stenosis: n = 2, Chylothorax: n = 2, Entherothorax: n= 1, pyloric dysfuntion: n = 2, Multiorgan failure: n = 1). Conclusion: Laparoscopic thoracotomic hybrid esophagectomy may combine the advantages of both laparoscpic and open approache in esophageal surgery for cancer. Further studies are needed to compare the hybrid approach with total minimally invasive methods.

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Surg Endosc

P384 - Pancreas

P385 - Pancreas

Superior Mesenteric/Portal Vein Resection Without Vessel Reconstruction During Whipple in Patients with Locally Advanced Pancreatic Cancer

Endoscopic Ultrasonography-Guided Drainage for Treatment of Pancreatic Fluid Collections After Laparoscopic Distal Pancreatectomy

A. Usenko1, M. Nichitaylo1, A. Lytvin1, M. Zagriichuk1, Y. Romaniv2, V. Kondratiyk1, M. Riznuk1, D. Skrupka1

M. Inagaki, K. Kitada, N. Tokunaga, T. Kato, R. Hamano, Y. Tsunemitsu, S. Otsuka, K. Iwakawa, H. Iwagaki

1 Laparoscopyc surgery and cholelitiasis, Ukrainian National Institute of Surgery and Transplantology, Kiev, Ukraine; 2Anestesiology and intencive care unit, Ukrainian National Institute of Surgery and Transplantology, Kiev, Ukraine

Department of Surgery, National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan

Aim: Pancreatic cancer is one of the worst GI cancers. In borderline resectable or locally advanced cancer of the pancreatic head and the uncinate process, treatment strategies are still under discussion. Superior mesenteric/portal vein invasion of more than 180 degrees is a contraindication for radical surgery. However, radical pancreaticoduodenectomy is the only option to cure this disease and it is still possible if blood stream is absent due to thrombosis of the portal/superior mesenteric vein occur and collateral venous outcome already exist.

Methods: 4 patients with borderline resectable head pancreatic cancer, localized at the uncinate process, with portal vein thrombosis due to tumor invasion underwent radical pancreaticoduodenectomy. This followed two courses of neoadjuvant personalized intra-arterial chemotherapy. In all cases a portomesenterial vein anastomosis was technically impossible. After evaluation of collateral vein outflow distal end of the superior mesenteric vein was cut and sutured in the same manner as the proximal end of the portal vein. The splenic vein was cut and sutured near portosplenomesenterical confluence. A Whipple procedure was then performed without venous reconstruction. Results: Three patients were discharged at 20–22 days postoperative. One died on the 18th postoperative day due to bleeding from a gastroduodenal artery remnant, caused by a grade C pancreatic fistula. All developed different postoperative complications, such as delayed gastric empting in two patients, POPF (grade B) in two, wound infection in one case, but not clinically significant. Among three patients, two developed liver metastases at 21 and 26 months respectively. One was disease free at 26 months post-op. All had adjuvant chemotherapy. Thus, the final mortality rate was 25%. Conclusions: Venous reconstruction is a method of choice in portal vein invasion and thrombosis. If it is impossible, collateral venous outflow has to be carefully evaluated. All collateral vessels must to be preserved and proximal and distal portal/superior mesentery vein can be sutured without reconstruction. This method can be implemented in rare cases, but it is feasible and safe in carefully selected patients. Via this technique R0 Whipple can be performed in borderline resectable and locally advanced head and uncinate process pancreatic cancer.

Aims: The treatment of pancreatic fluid collections due to pancreatic fistula after distal pancreatectomy sometimes need surgical interventions. Recently Endoscopic ultrasonography-guided technique is established as the best option for drainage of pancreatic pseudocysts and wall-off necrosis. We induced endoscopic ultrasonography-guided techniques and drainages for treatment of pancreatic fluid collections after laparoscopic distal pancreatectomy. Herein we reviewed those cases. Methods: We started laparoscopic distal pancreatectomy from December, 2007 and reviewed. Results: We performed laparoscopic distal pancreatectomy in 10 cases and 2 cases needed endoscopic ultrasonography-guided transgastric drainages because of pancreatic fluid collections. Case 1: 66-year-old male. He was uneventful after surgery and we removed peritoneal drainage on postoperative day 5. He discharged on postoperative day 14. Followup CT revealed fluid collections at the stump of pancreas. Endoscopic ultrasonographyguided drainage was performed postoperative day 85. A double pigtail plastic stent (7 Fr diameter) and additional nasocystic drainage catheter (6 Fr diameter) were successfully inserted. A nasocystic drainage catheter was removed a week later and a double pigtail plastic stent was removed 3months later. He was uneventful through the drainage period. Case2: 69-year-old male. Follow-up CT on postoperative day 7 revealed fluid collections around a stump of pancreas. Endoscopic ultrasonography-guided drainage was performed postoperative day 11. Two double pigtail plastic stents (7 Fr diameter) and additional nasocystic drainage catheter (6 Fr diameter) were successfully inserted. A nasocystic drainage catheter was removed on 4 post-drainage day. He discharged on 18 post-drainage day. We are going to remove double pigtail plastic stents on 3 and 6 months after drainage. Conclusions: We could successfully perform endoscopic ultrasonography-guided drainage for treatment of early and late onset pancreatic fluid collections after laparoscopic distal pancreatectomy. Endoscopic ultrasonography-guided drainage appears to be minimally invasive and shorten the patient’s hospital stay. It becomes an option for treatment of early and late onset pancreatic fluid collections after laparoscopic distal pancreatectomy.

P386 - Pancreas Laparoscopic Lateral Pancreatojejunostomy for Chronic Pancreatitis. First Ukrainian Experience I.U. Mikheiev, V. Yareshko Surgery and minimally invasive technologies, State Institution, Zaporizhia Medical Academy of Post-Graduate Education Ministr, Zaporizhia, Ukraine Background: Despite the development of modern endoscopic transpapillary technologies, surgery is a more effective option for pain relief in chronic pancreatitis. And the performance of early operations for chronic pancreatitis is justified. It is in those patients without an increase in the head of the pancreas, and there is only dilatation of the main pancreatic duct, a good long-term results can give the performance of laparoscopic longitudinal pancreatojejunostomy. We present our own experience over the past year. Materials and Methods: Three attempts of laparoscopic lateral pancreatojejunostomy were made in patients with early chronic pancreatitis without an increase in the head of the pancreas. There were two females and one man and average age was 42.6. The indications for surgery in all patients was abdominal pain and dilatation main pancreatic duct (the average diameter was 12.8 mm). Surgical Details: We used four-port technique. After opening omental bursa, we found, punctured and opened the main pancreatic duct. Then, using a two linear staplers Endo-Gia 60 to handle the jejunum loops by Roux-en-Y. After removing the Roux-en-Y loop through the mesocolon, we performed single-row lateral pancreatojejunostomy with barbed-suture V-Loc. Results: We had one conversion to open surgery, because of theinability to find the main pancreatic duct and bleeding. The average operation time was 207 minutes. Post-operative stay was average 9 days and on median follow-up of 10 month. Post-operatively, there were no major morbidity and nil mortality. All patients had complete pain relief and significant weight gain. Conclusions: Laparoscopic lateral pancreaticojejunostomy is safe, effective and feasible, especially with ‘‘early chronic pancreatitis’’ without an increase in the head of the pancreas.

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Surg Endosc

P387 - Pancreas

P388 - Pancreas

Selective Personalized Intra-Arterial Endovascular Neoadjuvant Chemotherapy Prior to Radical Surgery in Adenocarcinoma of the Pancreatic Head

Laparoscopic Pancreatoduodenectomy with Modified Blumgart Pancreaticojejunostomy

1

1

1

1

2

A. Usenko , A. Usenko , M. Nichitaylo , A. Lytvin , Y. Romaniv , I. Tereshkevich3, V. Kondratiyk1, V. Kondratiyk4, M. Riznuk1, D. Skrupka1 1

Laparoscopyc surgery and cholelitiasis, Ukrainian National Institute of Surgery and Transplantology, Kiev, Ukraine; 2Anestesiology and intencive care unit, Ukrainian National Institute of Surgery and Transplantology, Kiev, Ukraine; 3Endoscopyc surgery, Ukrainian National Institute of Surgery and Transplantology, Kyiv, Ukraine; 4 Endovascular surgery, Ukrainian National Institute of Surgery and Transplantology, Kyiv, Ukraine Aim: Pancreatic cancer is one of the worst GI cancers with 5 year survival rate of approximately 10 – 15%. In borderline resectable or locally advanced cancer of the pancreatic head, treatment strategies are still under discussion. Our main goal is to achieve down-staging and perform R0 resection. Selective intra-arterial endovascular personalized neoadjuvant chemotherapy is a modern option with promising results. Methods: 17 patients with borderline resectable head pancreatic cancer underwent endoscopic ultrasound with tumor biopsy. If adenocarcinoma was proven on immediate histological examination, live biopsy material was taken for further investigation. On live tumor tissue, sensitivity to the gemcitabine, gemcitabin with 5–ftoruracil and FOLFIRINOX were researched. An intra-arterial endovascular stent was placed at the gastroduodenalis artery and personalized neoadjuvant chemotherapy was injected by pump according to personal tumor sensitivity. All patients received two courses of selective personalized intra-arterial neoadjuvant chemotherapy followed by evaluation with CT. No complications due to intra-arterial chemotherapy infusion were observed. The chemotherapy toxicity score was half that of standard intravenous systemic infusion. Results: 10 has gemcitabin with 5–ftoruracil (59%), 5 – FOLFIRINOX (29%) and 2 gemcitabyne monotherapy (12%) according to personal sensitivity investigation on live tumor tissue. 14 patients (82%) had tumor down staging with pancreatoduodenectomy (Whiple, R0). Postoperative complications were comparable to the control group, who had undergone pancreaticoduodenectomy, but without neoadjuvant chemotherapy. 3 patients (18%) underwent explorative laparotomy, radical procedure was impossible due to locally advanced pancreatic cancer. One died due to profuse bleeding from the portal vein. Mortality was 7%. Lymph nodes (8, 12, 13, 16, 17 groups) was tumor cell negative in all patients. 3 (21%) patients developed grade B postoperative pancreatic fistula, but these were not clinically significant. Conclusions: Selective personalized intra-arterial endovascular neoadjuvant chemotherapy is new promising tactic for patients with borderline resectable or locally advanced cancer of the pancreatic head. The local influence on the tumor by the chemotherapeutic agent and further systemic effect is a competitive advantage of this technique compare to traditional approaches. Further research is needed to investigate long term outcomes. The procedure is feasible and safe; while effectiveness of this chemotherapy scheme is rising significantly.

M. De Pastena1, J. van Hilst2, T. de Rooij2, O. Busch2, M. Gerhards3, S. Festen3, M. Besselink2 Department of Surgery, Aoui Verona, Verona, Italy; 2Department of Surgery, Amc, Amsterdam, The Netherlands; 3Department of Surgery, OLVG, Amsterdam, The Netherlands 1

Background: Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis. Methods: The study describes and demonstrates (video) all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contraindications are body mass index [35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers. Results: The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent. Two surgical drains are placed alongside the pancreaticojejunostomy. Conclusions: The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

P389 - Pancreas Laparoscopic Bypass for Unresectable Peryampullary Tumors V.G. Yareshko, K.N. Otarashvili Surgery and mini invasive technologies, Zaporizhzhia State Medical Academy of Post-Graduate Education Ministry of Health, Zaporizhzhia, Ukraine Preamble: Treatment of patients with pancreatic cancer is one of the major problems of modern pancreatic surgery. Tumors of the pancreas hold the third place in the structure of malignant tumors of the digestive tract. If surgical treatment of pancreatic cancer is required, surgeons are constantly confronted with an alternative to choosing the method and scope of surgery. Patients selection for surgical treatment for pancreatic cancer should be strict and depends on the location of tumor, the expected size of the tumor, degree of progression of the tumor process and the patient’s condition. Methods: Over the past 9 years 808 patients with pancreatic cancer were operated in our clinic. In 768 (95.0 %) patients, the disease was complicated by mechanical jaundice, in 53 (6.5%) patients the disease was complicated by duodenal obstruction. The main in the diagnosis and staging of the tumor was the determination of Ultrasound, CT scan, MRI. A preoperative immunohistochemical check of the diagnosis was performed by needle core biopsy with ultrasound control and endoscopy, the informativeness of which was 93.4% and 26.4%, respectively. An overwhelming number of patients (96.6%) were diagnosed with adenocarcinoma of various types and differentiations. Results: Of 808 operated patients, 128 (15.8%) performed pancreaticoduodenal resection, 680 (84.2%) - various types of drainage operations. Minimally invasive decompression was performed in 82 (12.1%) patients in the form of external drainage of the bile ducts under ultrasound control (67) and endoscopic stenting of hepaticocholedochus (35). Taking into account the severity of the patients’ condition, the impossibility of performing surgical treatment, the frequency of postoperative complications in laparotomic palliative interventions, in the clinic for the last 2 years, laparoscopic techniques used include biliodigestive anastomosis. Total performed 55 surgeries, 39-cholecystogastric anastomosis, 16- Choledochoduodenostomy. In three patients of this group, signs of bilious hypertension were combined with duodenal obstruction, and therefore biliodigestive anastomosis was supplemented with laparoscopic gastroentero anastomosis. Conclusions: Each of the known methods of surgical treatment of pancreatic cancer requires individual approaches with the use of modern minimally invasive technologies, both in the preope.

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Surg Endosc

P390 - Pancreas

P392 - Pancreas

Endoscopic Treatment for Chronic Pancreatitis

Transgastric Laparoscopic Necrosectomy in Severe Acute Pancreatitis: Our Experience in Gregorio Maran˜on Hospita

M. Nychytaylo, P. Ogorodnyk, O. Lytvynenko, A. Deinychenko, O. Lytvyn, N. Yermak Laparoscopic surgery, National Institute of Surgery and Transplantology named by A.A.Shalimov, Kyiv, Ukraine

A. Moreno1, M.A. Iparraguirre1, A. Colon1, J. Ferreiroa1, B. Dı´azZorita1, L. Rodriguez-Bachiller1, J.A. Lopez Baena1, M. OrueEchebarria2, E. Velasco1 1

Aims: Chronic pancreatitis is a disease frequently encountered by pancreaticobiliary surgeons. Along with surgical management, there are a variety of endoscopic techniques that have been used with variable success in the treatment of symptoms or complications associated with chronic pancreatitis. The primary aim of most of endoscopic and surgical techniques is to help alleviate the pain as the most common symptom of chronic pancreatitis. Method: This study included 42 patients (34 male, 8 female, median age 56 years) with obstructive chronic pancreatitis for 10 years period. All patients presented severe chronic pancreatitis (stage III) according to the Cambridge classification. Results: The majority of the patients suffered intermittent pain attacks. 14 patients had strictures of the pancreatic duct; 12 patients had strictures and stones; 16 patients – obstructive jaundice. Dilation of pancreatic strictures, removal of pancreatic duct stones, endopancreatic and endobiliary stenting were performed. Good results were achieved in 66 (75.8%) cases. Clinical follow-up was performed annually to document the course of pain and the management of relapse. In the long term group 59% patients had no pain, 23% - had mild or moderate episodes of pain, whereas 18% severe episodes of pain. Recurrence of calculi was seen in 23% patients. Conclusions: Therapeutic ERCP for chronic pancreatitis offers good results on intermediate and long –term follow up.

P391 - Pancreas Early Biliary Complications After Pancreaticoduodenectomy M. Nychytaylo, O. Usenko, P. Ogorodnyk, O. Lytvyn, A. Deinychenko, V. Shkarban Laparoscopic surgery, National Institute of Surgery and Transplantology named by A.A.Shalimov, Kyiv, Ukraine Aims: Early biliary complications (EBC) after pancreaticoduodenectomy (PD) are poorly known. This study aimed to assess predictive factors, and treatment of EBC including bilio-enteric stricture, transient jaundice, biliary leak, and cholangitis. Method: From January 2008 to November 2017, 340 patients underwent PD. Statistical analysis including logistic regression was performed to determine EBC predictive factors. Results: In 40 patients developed 48 EBC, including 5 bilio-enteric strictures, 15 transient jaundices, 6 biliary leaks, and 14 cholangitis with no mortality and a 18% reoperation rate. In multivariate analysis, male gender, benign disease, malignancy with preoperative chemoradiation, and common bile duct (CBD) diameter 5 mm were predictive of EBC. Of the 5 strictures, all were associated with CBD \5 mm and 3 (60%) required reoperation. Transient jaundice resolved spontaneously in all 15 cases. Biliary leak resolved spontaneously in 4; otherwise, it required reoperation or miniinvasive technology. Cholangitis recurred after antibiotics discontinuation in 4 (22%). Conclusions: EBC following PD do not increase mortality. EBC are more frequent in case of male gender, benign disease, malignancy with preoperative chemoradiation, and CBD \5 mm. Transient jaundice or cholangitis have a favorable outcome, whereas bilio-enteric stricture or biliary leak can require reintervention.

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General Surgery, Hospital General Universitario Gregorio Maran˜on, Madrid, Spain; 2General Surgery, Hospital General Universitario, Madrid, Spain

Objectives: Necrotizing pancreatitis is a severe complication of acute pancreatitis (AP) with high mortality rates up to 28.7%. Step-up aproaches involving endoscopic and transgastric laparoscopic drainage has improved the results comparing to open surgical debridement. We report a case of a transgastric laparoscopic necrosectomy and abscess drainage in severe acute pancreatitis. Methods: A 63-year-old male with a postERCP acute pancreatitis complicated with an extensive necrosis (50% in CT scan). After three weeks of antibiotic treatment, transgastric drainage and placement of Axios 10 9 15 prostheses by endoscopy was performed. Four more endoscopic necrosectomy procedures were done without clinical resolution and sepsis progression. Therefore a laparoscopic approach was proposed. Via an anterior gastrotomy, with the Axios prostheses as guide, we got through the posterior gastric wall to the cavity using an endostapler. The necrotic pancreatic tissue was removed and the cavity was irrigated with saline. Gastric anterior wall was then closed with a continous suture. The surgical time required was 55 min. After the surgery, the patient evolution was satisfactory. Enteral feeding and oral intake were re-established at the third postoperitive day. CT scan and a new endoscopic exploration showed resolution of the collection. Results: The step-up approach has supposed a change in the therapeutic strategy of the pancreatic necrosis. Recent studies show that aggressive conservative management has reduced the need for emergent surgery. Survival in conservative management was higher (76.9%) versus early surgery (46.9%). There are several published series that demonstrate that this approach is safe and with comparable results in terms of morbidity and mortality to other laparoscopic techniques, providing a more definitive treatment in these patients. Conclusion: The aim of intracavitary laparoscopic debridement is to obtain an adequate evacuation of the infection and the necrotic pancreatic tissue while preserving the body’s natural attempt to contain the process. If cavitary access is preserved, multiple endoscopic ‘‘clean out’’ procedures can be performed without new incisions and with minimal perturbation to adjacent structures.

Surg Endosc

P393 - Pancreas

P395 - Pancreas

Ligasure Dissection in Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: Effect on Pathologic Evaluation of the Uncinate Margin

Usefulness and Safety of Laparoscopic Spleen Preserving Distal Pancreatectomy

L. Pugliese1, A. Vanoli2, L. Cobianchi1, A. Peri1, A. Viglio2, F. Capuano2, F. Argenti1, V. Gallo1, M. Paulli2, A. Pietrabissa1 1

Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Diagnostic Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

2

Aims: to assess whether pathologic evaluation of pancreaticoduodenectomy (PD) specimen on the uncinate margin is impaired by thermal or mechanical tissue damage induced when using Ligasurea¨ for dissection at that level. The present study focuses on pancreatic ductal adenocarcinoma (PDAC) cases only for which optimal margin assessment have crucial implication on prognosis. No reliable data are currently available on this issue given that inherent limitations affect the value of previously published experience. Methods: From all PDs performed for PDAC at our institution between May 2013 and November 2017 thirty-eight cases were retrospectively screened on the base of dissection technique. The specimens of 27 patients operated on with Ligasurea¨ were re-examined and compared with 11 nonLigasurea¨ controls. An expert pathologist, unaware of the type of surgical instruments used intraoperatively, searched for the following surrogate markers of dissection-related tissue alterations on the posterior margin: tissue fragmentation, cell damage and hemorrhage. These items had been validated for the same purpose in a prior study. Lymph node damage was also assessed as additional investigation. A score was attributed for each of them according to a scale of increasing severity and extent of tissue alterations (0 = no alterations; 3 = severe and extensive alterations) as previously done. Results: The two groups were comparable in term of patient specific features such as sex distribution, age and BMI. The mean scores of each of the four investigated histological markers resulted low (range 1.09–1.81) in both groups and no significant difference was found when comparing Ligasurea¨ vs. non-Ligasurea¨ usage. This is in contrast with previously published data reporting less hemorrhage and a trend towards less tissue fragmentation and cell damage when Ligasurea¨ was employed. Even lymph nodes resulted equally damaged regardless of the dissection technique used. Conclusions: The extent of tissue damage induced by Ligasurea¨ is similar to the one determined with conventional dissection technique. Pathologist’s evaluation of specimen’s posterior margin after PD for PDAC including lymph nodes assessment is not compromised by the routine adoption of this surgical device.

T. Takadate, T. Morikawa, M. Ishida, T. Aoki, T. Hata, M. Iseki, K. Ariake, K. Masuda, K. Fukase, H. Ohtsuka, M. Mizuma, K. Nakagawa, H. Hayashi, F. Motoi, T. Naitoh, T. Kamei, M. Unno Department of surgery, Tohoku University Graduate School of Medicine, Sendai, Japan Background: Spleen preserving distal pancreatectomy (SPDP) is recommended for benign disease or low malignant tumor of the pancreatic body and tail. Recently, laparoscopic spleen preserving distal pancreatectomy (LSPDP) is performed frequently. Aim: To investigate usefulness and safety of LSPDP. Methods: Between 2007 and 2017, 22 cases who underwent SPDP or LSPDP in our institution were retrospectively analyzed about clinicopathological features, perioperative factors and postoperative factors. We performed SPDP or LSPDP with conservation of the splenic artery and vein. Results: SPDP was performed in 9 cases and LSPSP was in 13 cases. There was no significant difference between SPDP group and LSPDP group in age and gender. Their pathological diagnoses were pancreatic neuroendocrine neoplasm (PanNEN) (n = 12), chronic pancreatitis (n = 3), intraductal papillary mucinous neoplasm (IPMN) (n = 2) and others (n = 5). PanNEN was almost in LSPDP group, chronic pancreatitis and IPMN were all SPDP group. There was difference between 2 groups in disease. LSPDP group had less intraoperative blood loss (113ml vs 591ml p = 0.025) and longer operative time (464min vs 286min p = 0.006) rather than SPDP group. Pancreatectomy was performed by automatic suture instrument in all LSPDP cases, by fish mouth method in all SPDP cases. Two cases of pancreatic fistula occurred in LSPDP group only. Complications related to spleen preserving was splenic infarction (n = 2), stenosis of splenic vein (n = 2) and pseudoaneurysm (n = 2). There was no significant difference between 2 groups in complications. Results LSPDP can be performed as safely as SPDP.

P394 - Pancreas

P396 - Pancreas

Central Pancreatectomy with Pancreato-Gastric Anastomosis by Totally Laparoscopic Approach

Investigation of Splenic Function and Effect on Left Portal Vein System in Laparoscopic Spleen Preserving Distal Pancreatectomy

D. Bartos, R. Stoian, I. Iancu, C. Cioltean, C. Breazu, A. Bartos

N. Hosomura1, D. Ichikawa2, H. Kawaida2, S. Furuya2, M. Watanabe2, H. Akaike2, Y. Kawaguchi2, H. Amemiya2, M. Sudou2, H. Kono2, S. Inoue2

Surgery Department, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania

1

Objectives: Pancreatectomy performed exclusively laparoscopically is the most advanced technique in the therapeutic arsenal of pancreatic surgery. For tumors of the pancreatic tail, laparoscopic approach has gradually become a standard indication in specialized centers. In contrast, central pancreatectomy and duodenopancreatectomy, although feasible through a minimal invasive approach, are not routinely performed, most likely due to the technical complexity and risk of complications. Case report: We present a case of a 40 year old female patient, diagnosed with corporeal pancreatic neoplasm on which we performed a laparoscopic central pancreatectomy with pancreaticogastric anastomosis. The postoperative outcome has been marked by an episode of acute necrotic cephalic pancreatitis, the previous laparoscopic approach facilitating a minimally invasive approach for necrectomies and drainage. The patient was discharged 14 days postoperatively, with remission of the pancreatitis. The video shows the main operative steps, illustrating both the resection and the reconstruction aspects. Conclusions: We believe that the total laparoscopic approach is feasible for the radical surgery of corporeal pancreatic tumors, dissection and reconstruction time being facilitated by the magnification and good quality of laparoscopic imaging. Moreover, the occurrence of complications such acute pancreatitis can be managed with minimal invasiveness, with a positive impact on disease progression.

First Department of Surgery, Faculty of Medicine, University of Yamanashi, Chuo City, Japan

2

First Department of Surgery, University of Yamanashi, Chuo, Japan

Aims: Laparoscopic spleen preserving distal pancreatectomy (Lap-SPDP) is classified into laparoscopic splenic vessel preserving method (Lap-SVPM) and laparoscopic splenic vessel resecting method that is called Warshaw method (Lap-WM). Lap-WM is immunologically more desirable, but it has a problem of gastric varices. We investigated a difference between Lap-WM and Lap-SVPM. Methods: From December 2015 to July 2017, 15 patients underwent Lap-SPDP. Four cases of LapWM and four cases of Lap- SVPM within them are subjects of this study. A contrast enhanced computed tomography (CT) was taken at 3 months postoperatively. Upper gastrointestinal endoscopy was performed in half a year to a year after Lap-WM. We examined in terms of splenic function and influence on left portal vein system. Results: the incidence of gastric varices: Lap- SVPM 0%, Lap-WM 50%, the spleen growth rate at 3 months after surgery: Lap- SVPM 16% (-13 to 75%), Lap- WM 40% (29–52%), hemoglobin decrease rate at 3 months after surgery: Lap- SVPM 4.4% (-5.4 to 75%), Lap- WM 9% (0 to 23%), platelet count decrease rate at 3 months after surgery: Lap- SVPM 17% (4.6 to 31%), Lap- WM 13% (1.1 to 29%), perigastric vessel dilatation frequency: Lap- SVPM 32% (-100 to 84%), Lap WM 54% (7.6 to 76%), splenorenal shunt dilatation frequency: Lap- SVPM 0%, Lap - WM 25%. Conclusion: 50% of Lap-WM had gastric varices. The spleen of Lap-WM showed a tendency to increase more frequent than Lap- SVPM. In a case of gastric varices after Lap-WM, contrast enhanced CT confirmed the growth of blood vessels in the stomach wall, and Lap - WM may affect the hemodynamics in the stomach wall. The portal hypertension is considered to form splenorenal shunt. However, in a case with splenorenal shunt dilatation, it was present before surgery and the perigastric vessel dilatation rate was smaller (7.7%). If there is splenorenal shunt, Lap - WM seems to be unlikely to form gastric varices. I think that it is necessary to confirm Splenorenal shunt before Lap-SPDP.

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Surg Endosc

P475 - Pancreas

P398 - Radiology/Imaging

Video Assisted Retroperitoneal Pancreatic Necrosectomy with an Innovative ‘Vard Port’

Advanced Imaging in Hipec Patients with Peritoneal Metastases of Colorectal Cancer

S. Haribhakti, A. Tiwari, H. Shah, A. Shah, H. Soni, K.S. Patel

N.R. Sluiter1, S.L. Vlek1, H.T. Brandsma1, A.R. Wijsmuller1, H.C.W. de Vet2, N.C.T. van Grieken3, G. Kazemier1, J.B. Tuynman1

G I Surgery, Kaizen Hospital, Ahmedabad, India

1

Introduction: Pancreatic necrosectomy by Video Assisted Retroperitoneal Debridement (VARD) procedure requires access to the retroperitoneum by minimal invasive approach. Necrosectomy requires a specialised port which allows debridement, lavage and removal of necrosum along with providing clear visibility and adequate hemostasis. As per our knowledge, currently there isn’t any port specifically designed for the VARD procedure. The aim is to study the feasibility of innovative VARD port for performing retroperitoneal debridement of pancreatic necrosis. Materials and Methods: VARD port is a type of SNP (SILS & NOTES port) designed by us. These are rigid ports, made from biocompatible SS 316L, manufactured in multiple diameters e.g. 12 mm, 20 mm, 40 mm, 60 mm and in multiple lengths e.g. 5 cm, 10 cm, 15 cm etc. The port having diameter of 20 mm and 5 cm length is labelled as SNP-20.5. Similarly, SNP-20.10 refers to a port having diameter of 20 mm and length of 10 cm. SNP port consist of a sheath, a diaphragm & a silicon washer. Silicon washer can be changed depending upon the number & size of instruments required. A percutaneous drain is placed in necrosis cavity under CT guidance. After 1 week when the tract has matured patient is taken for surgery under general anaesthesia. The skin is incised near the PCD entry site and the SNP port is inserted by a blunt introducer under telescopic guidance. Silicon washer (5, 5, 5) - which admits three 5 mm instruments (one camera & two working instruments) is applied to SNP 20.10. Under vision debridement, lavage & hemostasis is performed. Results: VARD through the SNP was performed in 11 patients over 12-months period. Average operating time was 65 minutes. No case of post-operative bleeding was recorded. Post-operative morbidity was seen in 7 patients which included fever, wound infection, pneumonia & paralytic ileus. 1 patient died due to sepsis with multi-organ failure. Conclusion: VARD pancreatic necrosectomy is a technically feasible with newly designed VARD port. VARD port gives the advantage of access to the necrotic cavity and allows proper debridement of cavity under telescopic guidance for necrosis of body-tail region of pancreas.

Surgery, Vu University Medical Center, Amsterdam, The Netherlands; 2Epidemiology, Vu University Medical Center, Amsterdam, The Netherlands; 3Pathology, Vu University Medical Center, Amsterdam, The Netherlands Background: Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival of patients with peritoneal metastases (PM) of colorectal cancer (CRC). Complete cytoreduction is crucial, however, still depends on visual inspection and tumor palpation by the surgeon. Advanced imaging techniques might improve PM detection, leading to improved cytoreduction rates and better survival. The aim of this study was to evaluate four advanced imaging techniques for intraoperative PM detection: narrow band imaging (NBI), near-infrared indocyanin green fluorescent imaging (NIR-ICG) and spraydye chromoendoscopy (SDCE). Methods and Materials: Potential HIPEC patients with PM from CRC were included in this prospective feasibility study. All patients underwent exploratory laparoscopy or laparotomy prior to cytoreduction and HIPEC. All abdominal regions were inspected with (1) white light, (2) NBI, (3) NIR-ICG and (4) SDCE. Primary endpoints were sensitivity and specificity for detecting malignant lesions, using pathological examination as reference standard. NBI was initiated by using the NBI mode on the laparoscopic tower. For NIRICG, ICG was administrated intravenously three to twelve hours prior to surgery. For SDCE, indigo carmine blue was sprayed on the peritoneum using a dye-spray catheter. Results: Between May 2016 and October 2017, 22 patients were included from which a total of 136 biopsies was taken. Sensitivity for detection of malignant lesions was 78.4% with conventional white light imaging, which increased to 97.3% (p = 0.016) and 79.5% (p[0.5) with NBI and SDCE, respectively. No fluorescence was seen using NIR-ICG. Specificities of white light, SDCE and NBI were 78.8%, 85.7% and 70.7%, respectively (not significant). No adverse events related to one of the imaging techniques occurred in any of the patients. Discussion: NBI is a safe and feasible option for improving PM detection and optimizing cytoreduction, identifying lesions that would have been missed with conventional imaging. Further prospective studies should assess whether this technique influences oncologic outcomes.

P397 - Radiology/Imaging

P399 - Radiology/Imaging

Focused Assessment with Sonography in Trauma Diagnosing Bladder Rupture Following Blunt Pelvic Trauma

3D Pelvimetry May Impact Surgical Options in Colorectal Cancer Patients

K. Bain, V. Meytes, V. Kassapidis, G. Glinik

T.F. Tirelli1, L. Lorenzon1, S. Quinzi2, F. Landolfi3, F. Bini2, F. Marinozzi2, G. Balducci3, E. Iannicelli3, A. Biondi1, R. Persiani1, D. d’Ugo1

Surgery, NYU Langone Hospital - Brooklyn, Brooklyn, United States of America Introduction: The focused assessment with sonography in trauma (FAST) exam provides a rapid bedside screening tool for intraperitoneal free fluid and solid organ injuries. Blood clots within an injured organ may have similar echogenicity to that of the parenchyma. The sensitivity for detection of solid organ injury is therefore more limited and ranges from 41–44%. Case Presentation: A 52-year-old male presented as a Level 2 Trauma notification after plywood fell onto him from fifteen feet. Upon presentation he was evaluated according to ATLS protocol. Secondary survey was significant for suprapubic tenderness and abrasions to bilateral hips. A FAST exam was performed, showing echogenic fluid filling the bladder. A foley catheter was placed and gross hematuria was noted. Xray in the trauma bay showed fractures of the left superior and inferior pubic rami. Subsequently a CT cystogram was performed which showed large clot within the bladder with small extraperitoneal extravasation. The injury was managed with transurethral foley and gentle irrigation. Discussion: The bladder is well protected by the bony pelvis, making rupture relatively uncommon in blunt trauma. However, it remains an important injury to rule out because mortality rates can be be as high as 22%. Pelvic fracture with associated gross hematuria is an indication for immediate cystography. Blunt extraperitoneal bladder rupture should be treated conservatively, with nonoperative management having comparable outcomes to primary repair. Relative contraindications to conservative management of extraperitoneal bladder rupture include bone fragments protruding into the bladder, open pelvic fractures, and concomitant rectal injuries. The use of transurethral catheters are preferred over suprapubic catheters, resulting in fewer complications and fewer days of catheterization. Conclusions: FAST exam is less sensitive for diagnosing solid organ injury and ranges from 41–44%. Hematuria and pelvic fractures are seen together in 90% of bladder ruptures. When both are present in blunt trauma, cystography should be performed. Extraperitoneal bladder injuries should be managed non operatively with drainage transurethral catheter alone. Intraperitoneal bladder injuries should be managed by primary repair with transurethral catheter or suprapubic tube drainage.

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1 General Surgery 1, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy; 2Department of Mechanical and Aerospace Engineering, La Sapienza University, Rome, Italy; 3Surgical and Medical Department of Traslational Medicine, La Sapienza University, Rome, Italy

Background: A narrow pelvis may affect surgical procedures and outcomes. In this field, few studies documented some differences in the female and male pelvic parameters, but the vast majority were underpowered investigations conducted without modern radiological techniques. The aim of this research was to investigate the differences between males and females pelvis. Materials and Methods: A consecutive cohort of elective and emergency patients born in 1956 (60 years old) undergone abdominal CT scans from January to December 2016 were reviewed. Patients with incomplete scans along with those presenting pelvic/hip/femoral fractures or prosthesis were excluded. DICOM data were collected from selected patients and an automatic segmentation of the pelvic bones was obtained using 3D Slicers Software. Sixteen diameters and 5 angles were measured in each patient. Continuous measures were calculated using means and standard deviations and then compared in females vs males using the T Test. Results: We documented a dissimilarity in the 3D pelvic assessment of the males and females patients. All pelvic measures differed in the two groups and this difference was of statistical value. Overall female pelvis was documented wider and shorter comparing with males. Conclusions: 3D pelvis segmentation using CT scans is a reliable and effective tool that allows standard pelvimetry measurements. These measurements may impact surgical options in patients candidate to urologic, gynecologic and colonproctologic surgical procedures. Assessments could be particular important for evaluating narrow pelvis in males in order to determine the best surgical strategy and instrumentation.

Surg Endosc

P400 - Robotics, Telesurgery and Virtual Reality

P402 - Robotics, Telesurgery and Virtual Reality

Surgical Performance and Subjective Ratings in Simulations Comparing 3D Monitors With And Without 3D Glasses

Learning Curve for Robotic Pancreaticoduodenectomy with Blumgart Pancreaticojejunostomy

M.M. Kjelllman1, A. Svenner1, X. Fan2, G. Ahlberg1, S. Hallbeck3, M. Forsman2

S.E. Wang, Y.M. Shyr Surgery, Taipei Veterans General Hospital, Taipei, Taiwan

1

Dept. of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; 2Dept. of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; 3Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rocherster, United States of America Aims: To compare a standard surgical 3D ? (with glasses) monitor with a novel 3D – (without glasses) monitor system with the intention to be used in a new surgical robot-assisted system. Methods: The participants used 3D ? glasses and 3D– glasses, and performed basic laparoscopic tasks in a validated Sim ball box simulator. Nine persons were randomly selected to start with the ? glasses system, and to use the – glasses system last. The participants in each test arm performed 4 tasks on the viewing systems. Group 1 started with 3D? and group 2 with 3D- and each group then switched and used the other modality. During the box training authentic surgical instruments was inserted and fixed in the instrument holder. In the present study we used four defined tasks; basal suturing, peg picker, rope race and precision cutting, all described on (http://www.g-coder.com/videos ). Subjective questionnaire ratings were included with pre-experienced and post-experienced questions. The post-experience evaluation was performed in both a direct and non-direct comparison (the questions were asked separated for each 3D technique). Results: The subjects experienced significantly higher image quality and spatial orientation when the 3D- glasses monitor was used. Also, the overall impression among the participants was in favor of the 3D-glasses monitor, which was especially clear when the direct comparison questionnaire was analyzed. There were no significant differences between the systems in errors or in time consumption, nor in physical symptom ratings. Conclusion: Our evaluation indicates an improved experience of image quality and spatial orientation when using the 3D- glasses monitor. Also, the overall impression among the participants was in favor of the 3D- monitor. There were no signs of short comings of the 3D- system in the production measurements or in the ratings. The new 3D technique is optimal when only one person stands in front of the screen and therefore can be used by the consol surgeon in a robot-assisted surgical system.

Objective: Pancreaticoduodenectomy has been a technically demanding and challenging procedure carrying a high morbidity. This study was to identify the learning curve of console time (CT) for robotic pancreatectomy (RPD). Perioperative outcomes were compared between early group before the learning curve and late group after the learning curve. Methods: Data for RPD were prospectively collected for analysis. The learning curve was assessed by cumulative sum (CUSUM). Based on CUSUM analyses, patients were was divided into early group before learning curve and late group after learning curve. Results: There were 70 RDP and 100 RPD cases. It took 37 cases to overcome the learning curve for RDP and 20 cases for RPD. The median console time was also significantly shorter in the late group for both RDP (112 min. vs. 225 min., P \ 0.001) and RPD (360 min. vs. 520 min., P \ 0.001). The median blood loss was significantly less in the late group for both RDP (30 c.c. vs. 100 c.c., P = 0.003) and RPD (100 c.c. vs. 200 c.c., P\0.001). No surgical mortality in both groups. Clinical relevant pancreatic fistula was 22.9% for RDP (32.4% in early group vs. 12.1% in late group, P = 0.043), and 11.5% for RPD (0 in early group vs. 17.1% in late group, P = 0.084). Conclusions: Robotic surgery is feasible both RDP and RPD. Moreover, earlier experience in RDP might shorten the learning curve for RPD.

P401 - Robotics, Telesurgery and Virtual Reality

P403 - Robotics, Telesurgery and Virtual Reality

Robotic Distal Pancreatectomy: Comparison of SpleenPreservation by Warshaw Technique And Splenectomy

Robotic Gastrectomy for Gastric Cancer Could be Adapted Quickly for Experienced Laparoscopic Surgeons

Y.M. Shyr1, S.E. Wang2

C. Lin, T. Tsai, T. Cheng, H. Wei

1

General Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; Surgery, Veterans General Hospital, Taipei, Taiwan

Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan

Purposes: Warshaw technique has gained the favor of some surgeons due to its simplicity. Outcomes and surgical risks after robotic distal pancreatectomy with spleen preservation (RDP-SP) by Warshaw technique and with splenectomy (RDPS) were compared. Methods: All the data for patients undergoing robotic distal pancreatectomy (RDP) were prospectively collected. The incidence and clinical significance of spleen infarction and gastric varices after spleen preservation by robotic Warshaw technique were also evaluated. Results: A total of 66 patients were included, with 33 in each group. The console time was significantly shorter in RDP-SP group than that in RDP-S group (165 vs. 220 min.). The wound length was also shorter in RDP-SP group (2.3 vs. 4.0 cm). The median blood loss was 50 c.c. in RDP-SP group and 100 c.c. in RDP-S group. The surgical morbidity was significantly lower in RDP-SP group (18% vs. 58%). Grade B pancreatic leakage (no grade C) rate was 20% for overall patients, and significantly lower in RDP-SP group (12 % vs. 27%). No intraabdominal abscess occurred in RDP-SP group, vs. 15% in RDP-S group, P = 0.020. Spleen infarction (15%), gastric (6%) varices and perigastric (45%) varices after RDP-SP were not associated with any subsequent complication. Postoperative platelet count and white blood cell (WBC) count were significantly higher in RDP-S group. Conclusions: RPD-SP is not only feasible but also time-saving. Although gastric/ perigastric varices and spleen infarction are not uncommon after RPD-SP, they appear to be clinically irrelevant.

Introduction: Robotic surgery has been ultilized more frequently in gastric cancer. However, the learning curve of robotic gastrectomy and the transition from laparoscopic surgery have not been well evaluated. Methods: From January 2016 to December 2016, the surgical results of first 12 consecutive robotic gastrectomy (RG) for gastric cancer performed by a single surgeon using da Vinci Xi system were collected. These data were compared to those of 25 laparoscopic gastrectomy (LG) by the same surgeon during the same period of time (recent period). Furthermore, they were compared to the results of the intial 20 cases of laparoscopic gastrectomy (initial period). Results: For laparoscopic surgery, the case number of total gastrectomy was more in the recent period compared with initial period (10/25 v.s 0/20, p = 0.0013). As compared with RG, the number of total gasrectomy in recent peroid showed no difference (2/12, p = 0.1558). The operation time of recent LG was shorter than initial LG (277.0±64.7 v.s 316±74.6, p = 0.02) and when compared with RG (297.7±41.1), there is no statictial significance (p = 0.079). The incidence of perioperative blood loss more than 50 ml was higher in the initial LG (8/20 v.s 2/25, p = 0.0103) but is similar between RG and recent LG (3/12 v.s 2/25, p = 0.1907). In terms of retrived LN numbers, there was no difference between RG, recent LG and initial LG (39.2±19.2, 32.2±15.8, 35.9±15.4). The total cost of laparoscopic gastrectomy was significantly lower than robotic gastrectomy (23.9±4.0 v.s 31.6±3.7*10000 NTD, p\0.0001). Conclusions: The surgical results of LG revealed improvement compared with initial LG. This surgical resuts of initial RG is similar to recent LG, but better than initial LG. Hence, robotic gastrectomy for gastric cancer could be adapted quickly and smoothly for experienced laparoscopic surgeons. However, larger series with longer follow up are mandatory to draw further conclusion.

2

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Surg Endosc

P404 - Robotics, Telesurgery and Virtual Reality

P406 - Robotics, Telesurgery and Virtual Reality

Robot-Assisted Surgery in Colorectal Carcinoma: Is Innovation Safe?

The Importance Of ICG for Al Reduction after Robotic Rectal Resection of the Rectum for Cancer

K. Dogan, L. Willems, F. Polat

J. Rejholec, J. Moravı´k, R. Malecek, O. Johanides

Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands

´ stı´ nad Labem, Deptartment of General Surgery, Regional Health U Decı´n, Czech Republic

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) gains interest of colorectal surgeons. The aim of this present study was to evaluate the safety, feasibility and survival data of RACRS. Methods: Prospectively collected data of 208 consecutive patients who underwent surgery (from dec-2014 to Oct 2017) for colorectal cancer were analyzed. All procedures were performed with the Davinci Xi Robot. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Secondary outcomes were other oncologic outcomes (radical margins, lymph nodes), major complications, hospitalization and operation time. Results: In total 208 procedures were analyzed. There were 138 (66%) male patients and mean age was 68±10 years. There were 132 (64%) colon tumors and 76 (36%) rectal tumors. Type of operation was distributed as: 75 sigmoidal resections, 59 low-anterior resections, 23 abdomino-perineal resections, 44 right colon resections, and 7 left colon resections. Tumor staging for colon cancer was divided as: 39% stage I, 28% stage II and 33% stage III. Pre-operative staging for rectal cancer was 13%, 15% and 72%, respectively. Rectal cancer was treated with neoadjuvant therapy in 65%. Median follow-up was 15 months (3–33). OS for colon cancer after 12, 18 and 24 months was 99%, 97% and 95%, respectively. OS for rectal cancer after 12, 18 and 24 months was 98%, 93% and 93%, respectively. DFS for colon cancer after 12, 18 and 24 months was 95%, 87% and 85%, respectively. DFS for rectal cancer after 12, 18 and 24 months was 88%, 80% and 80%, respectively. Radical margins were achieved in 202 (96%) patients. The average harvested lymph nodes was 16±7. The re-operation rate was 10% and an anastomotic leakage rate of 4% (7/170). The median hospital stay was 5 [3–30] days. 30-day mortality rate was 0.5%. The average of total operating time was 179±46 minutes. The average incision time was 134±43 minutes. Conclusion: Robot-assisted colorectal surgery seems feasible and safe. The oncologic outcomes and complications are comparable with other conventional techniques.

Aims: However, despite technical progress, the incidence of anastomotic leakage can not be reduced. We carry out an air exam, we perform the anastomosis without voltage, we try not to interrupt AMI, decompress the anastomosis, all without a significant effect on the reduction of the occurrence of AL. In recent years, indocyanine green have been used to diagnose the quality of anastomosis as an indicator of proper blood flow to the intestinal anastomosis. Methods: By using Indocyanone Green in Firefly by Intuive, I have tried to prove the benefit of better blood flow control to reduce anastomotic leakage. We used ICG in a set of 20 robotic low resections for rectal cancer with complete resection of the mesorectum. The first part was given after the gut skeletal - either intraabdominal or extraabdominal. We prevented visually assessing and pre-determined the line, and then, after ICG application, we definitively identified the resection line. After the double-stapling anastomosis, we submitted the second part of the ICG dose and evaluated the blood flow of the anastomotic line. Results: The above procedure was used in 25 cases in patients after a robotic low anterior resection with complete mesorectal excision and subsequent mechanical colorectal or coloanal anastomosis end to end. In all cases, we performed the protective ileostomy. In four cases we changed the resection line between 1cm and 8cm. In the given set we have noticed anastomosis II leakage. grade and we solved peranal drainage using Endosponge with complete healing. These are 4% leakage, however, if we count 4 operations with the shift of the resection line, it could be 5 leakages, or 20%. Conclusion: Over the long term, we have 14.7% of symptomatic leakages in a set of 272 robotic low resections. In part of this group, we performed an early endoscopic check and resulted in 27% of anastomotic leakages I-III. degree. Incidence of anastomotic leakage was only 5% in the observed population and only II. degree. We are aware of the small numbers of the set, but it seems that the routine use of ICG could reduce the incidence of anastomotic leak, especially those of the III. degree.

P405 - Robotics, Telesurgery and Virtual Reality

P407 - Robotics, Telesurgery and Virtual Reality

Robot Resection of Choledochal Cyst with Hepaticojejunostomy in Adults: 20 Cases of Initial Experience with Comparison of Laparoscopic Approach

Novise - A Virtual Reality Simulator for Advanced Endoscopy Training

J.H. Han1, J.H. Lee2 1

General surgery, Asan medical center, Seoul, Republic of Korea; 2 Hepatobiliary surgery, Asan medical center, Seoul, Republic of Korea For choledochal cyst, complete excision of cyst with Roux-en-Y hepaticojejunostomy (HJ) is the treatment of choice. It has been performed by laparoscopy with the advancement. Nowadays as it extended along the area of robotic surgery, there is a trend to increase robotassisted resection of choledochal cyst with HJ. The aims of study are to compare the robotic surgery (Group1) and the laparoscopic surgery (Group2) performed in our hospital for the same period and to evaluate the stability and efficacy of robotic surgery. We report the single center experience of robotic surgery. Between Jan 2014 and Sep 2017, we performed 20 cases of Group1 and 32 cases of Group1 for adult choledochal cyst. In both groups, there were more women than men. The mean age and BMI were 32.8 years and 24.5 kg/m2 in Group1, and 37.3 years and 22.8 kg/m2 in Group2. According to the Todani classification, there were 8 type Ia, 6 type Ic, and 6 type IVa in Group1 and 8 type Ia, 1 type Ib, 12 type Ic, 10 type IVa, and 1 type IVb in Group2. We used da Vinci system with 5 ports, two 12mm ports and three 8mm ports including assist port. The mean operation time was 272.8 min (range, 168–391 min) in Group1 and 235.9 min (range 135–396 min) in Group2. Extracorporeal jejunojejunostomy anastomosis was performed in both groups except one case in laparoscopic surgery. The median length of hospital stay was 7 days in both group. In the robotic group, there were three postoperative complications, cholangitis, bile leakage and necrotizing pancreatitis. In the laparoscopic group, there were six postoperative complications, choledochojejunostomy site stricture & intrahepatic duct stone, choledochojejunostomy site stone due to suture materials, jejunal branch bleeding, portal vein thrombus, acute pancreatitis, adhesive ileus. However, there was no mortality case in both groups. Robot–assisted resection of choledochal cyst with Roux-en-y hepaticojejunostomy is safe and feasible and its short-term results are comparable to laparoscopic surgery. Compared to laparoscopic surgery, the robot-assisted technique has definite advantage in intracorporeal suture and good 3D visual field. So, it can be a good surgical alternative for choledochal cyst.

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P. Korzeniowski, A. Barrow, M. Sodergren, F. Bello Surgery and Cancer, Imperial College London, London, United Kingdom Aims: We present the second version of our Natural Orifice Virtual Surgery and Endoscopy simulator – NOViSE Mk II, a haptics (force-feedback) enabled system with a fully functional flexible endoscope and support for advanced endoscopic procedures such as Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD). These procedures present new challenges and are associated with a steep learning curve. Methods: NOViSE Mk II has a redesigned haptic device. The behaviour of the virtual flexible endoscope is based on an improved implementation of an established theoretical framework – the Cosserat Theory of Elastic Rods. Tissues are simulated using PositionBased Dynamics and support a wide range of interactions with the instruments, such as inflation via saline injection, aspiration using clear cap and resection via electrocautery. The virtual EMR procedure is carried out using a double-channel scope and ‘‘band and snare’’ technique. The first step is to locate the lesion in an upper digestive tract. Next, the concentrated saline is injected into the submucosal layer to elevate the area containing the lesion from the muscle layer. A clear cap is then placed on the lesion and the mucosa containing the lesion is drawn up inside the cap by aspiration. The mucosa is caught by the snare, strangulated and then resected by electrocautery. During the virtual ESD procedure, after locating the lesion and injecting the saline, a circumferential cutting of the surrounding mucosa of the lesion and subsequent dissection of the connective tissue of the submucosa beneath the lesion is performed. Results: We present the application of NOViSE Mk II to the simulation of Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD) procedures. Preliminary tests with endoscopists during the development phase indicate that the simulator provides the required level of realism for training of endoscopic manipulation skills specific to EMR/ESD. Conclusions: Virtual Reality simulation of advanced endoscopic procedures can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. It can also contribute to keeping practitioners up to date with novel surgical techniques such as EMR/ESD.

Surg Endosc

P408 - Robotics, Telesurgery and Virtual Reality

P410 - Robotics, Telesurgery and Virtual Reality

Virtual 3D Modeling in Laparoscopic Surgery: The Possibilities for Diagnosis, Planning and Surgical Tactics

Short-Term Outcomes of Single Docking Fully Robotic Rectal Cancer Surgery with the da Vinci Si and Xi Systems: Analsyis of over 200 Cases

D.N. Panchenkov1, A.V. Kolsanov2, Y.U.V. Ivanov3, S.S. Chaplygin2, S.E. Katorkin4, S.A. Bystrov4, P.M. Zelter4, I.S. Andreev4, E.V. Shestakov4, R.M. Nazarov4, A.I. Zlobin1 1 Minimally Invasive Surgery, A.I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia; 2Operative surgery and clinical anatomy, Samara State Medical University, Samara, Russia; 3Surgery, Federal Research Clinical Center of Specialized Medical Care and Medical Technol, Moscow, Russia; 4 Surgery, Samara State Medical University, Samara, Russia

The aim of the study was to show the possibilities of pre-operative 3D modeling and intraoperative navigation by usage of ‘‘Avtoplan’’ system in abdominal surgery. Materials and Methods: We have an experience of treatment of 65 patients who underwent MRSCT with following pre-operative 3D modeling of problem areas in abdominal cavity. We use the original system of computer modeling with ‘‘Avtoplan’’ system. The stages of 3D modeling were the following: introducing data in DICOM format in ‘‘Avtoplan’’ system; parenchymal organs segmentation; vessels segmentation; receiving volume polygonal 3D model and its analysis; introducing the model into navigation module. Results and Conclusion: The usage of 3D modeling permitted to increase surgical precision and radicalism; to reduce tissue damaging, blood loss and time of surgery; to have detailed plan of procedure with optimal approach and volume; to improve communication between physicians in multidiscipline cases; to have the possibility of pre-operative ‘‘simulated surgery’’.

P409 - Robotics, Telesurgery and Virtual Reality Construct Validity of the Robotix Virtual Reality Robot Assisted Surgery Simulator for Basic Robotic Skills E. Leijte, L. Claassen, E.A.A. Arts, I. de Blaauw, C. Rosman, S.M.B.I. Botden Surgery, RadboudUMC, Nijmegen, The Netherlands Aims: The RobotiX is a virtual reality (VR) system constructed to simulate robot assisted surgery for the training of novice surgeons outside the operating theatre. This study was set up to determine the construct validity of the RobotiX VR simulator. Methods: Participants were recruited and allotted to three groups based on their laparoscopic or robot assisted surgical experience: novice (no experience), laparoscopic experience ([10 laparoscopic and no robot assisted experience) and robot experience (at least one robot assisted procedure performed). All participants performed two basic tasks: Wristed manipulation (Task 1) and vessel energy dissection (Task 2). For each task the most clinical relevant outcomes parameters have been assessed; total time, instrument path length, time instrument out of view, accuracy and errors. Results: Fifty-four participants were recruited, of which 28 novices, 21 laparoscopic experienced and five robot experienced. The only significant difference was found in Task 1 regarding the number of times the instruments were out of view, between the novice and robot experience group (mean 0.79 versus 2.75, p = 0.026). The participants have the following scores for Task 1: total time (161.5, 152.8, 158.6 seconds, p = 0.90), instrument path length (2505, 2065, 3173 millimeter, p = 0.23), time instrument out of view (0.76, 1.15, 11.16 seconds p = 0.54), accurate targeting percentages (12.6, 11.2, 9.8, p = 0.78) and number of missed targets (0.54, 0.86, 1.25 p = 0.52) for novices, laparoscopic experience and robot experience respectively. For Task 2 the parameters are the following: total time (249, 233, 188 seconds, p = 0.34) instrument path length (2097, 2046, 1599 millimeters, p = 0.63), number of instrument collisions (14.7, 15.2, 5.33, p = 0.86), percentage of accurate energy use (26.4, 24.6, 29.8, p = 0.95) and number of errors (5.04, 6.16, 4.40, p = 0.71) for novices, laparoscopic experience and robot experience groups respectively. Conclusion: The RobotiX VR simulator appears no to be able to distinguish the difference between neither of the groups of participants. However, the additions of more robot experienced users could show a better construct validity between experienced and novice users of robot assisted surgery. Although the groups of novices and laparoscopic experienced participants were large enough, no significant differences were found between these groups.

S. Panteleimonitis1, O. Pickering2, M. Harper3, M. Aradaib3, T. Qureshi2, N. Figueiredo4, A.C. Parvaiz4 1 Colorectal surgery, University of Portsmouth, Eastleigh, United Kingdom; 2Colorectal surgery, Poole Hospital NHS Trust, Poole, United Kingdom; 3SHSSW, University of Portsmouth, Portsmouth, United Kingdom; 4Colorectal surgery, Champalimaud foundation, Lisbon, Portugal

Aim: The limitations of laparoscopic rectal surgery have been highlighted by the ACOSOG and ALaCaRT trials. Robotic systems are designed to address these limitations, leading to a growing interest in robotic rectal surgery. However, certain technical limitations associated with the previous systems (da Vinci Si) have limited its adoption. The latest robotic platform, the da Vinci Xi, addresses these limitations. The aim of this study is to examine the short-term surgical outcomes of over 200 single-docking fully-robotic rectal cancer resections and compare the outcomes of cases performed with the Xi vs Si systems. Methods: All consecutive patients receiving robotic rectal cancer resections from three centres, two from the UK and one from Portugal, between 2013 and 2017 were identified from prospectively collated databases. The baseline characteristics and short-term surgical outcomes are presented. In addition, patients operated with the Xi system were 1:1 propensity score matched for ASA grade and p T stage and compared with patients operated with the Si system. Results: 206 patients were identified (124 Si, 82 Xi), 52 (25.2%) received neoadjuvant radiotherapy, median operative time was 260 minutes and conversion and 30-day mortality rates were 0. Median length of stay was 6 days, there were four clinical anastomotic leaks (2.2%) and R0 clearance rate was 95.1%. Regarding the Xi vs Si analysis, operation time and estimated blood loss were higher in the Si group (300 vs 210 min, p = 0.000; 20 vs 10 ml, p = 0.000) but length of stay, lymph node yield and R0 clearance favoured the Xi group (5 vs 6.5 days, p = 0.000; 20.5 vs 17.5, p = 0.010; 98.8% vs 90.2%, p = 0.034). Logistic regression analysis of all 206 cases showed that robotic platform did not affect CRM clearance for the participants in this study (univariate p = 0.083, multivariate p = 0.054). Conclusion: Single-docking fully-robotic rectal cancer surgery is safe, effective and can lead to good short-term surgical outcomes, making it a good alternative to laparoscopic rectal cancer surgery. Furthermore, the Xi system might lead to improved short-term outcomes such as R0 clearance, but the evidence is weak and further larger scale observational studies are required before reaching this conclusion.

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Surg Endosc

P411 - Robotics, Telesurgery and Virtual Reality

P412 - Spleen

Construct Validity of The Robotix Virtual Reality Robot Assisted Surgery Simulator for Advanced Suturing Tasks

Hilar First Approach to Laparoscopic Splenectomy

E. Leijte, L. Claassen, E.A.A. Arts, I. de Blaauw, C. Rosman, S.M.B.I. Botden Surgery, RadboudUMC, Nijmegen, The Netherlands Aims: The RobotiX is a virtual reality (VR) system constructed to simulate robot assisted surgery for the training of novice surgeons outside the operating theatre. This study was set up to determine the construct validity of the RobotiX VR simulator. Methods: Participants were recruited and allotted to three groups based on their laparoscopic or robot assisted surgical experience: novice (no experience), laparoscopic experience ([10 laparoscopic and no robot assisted experience) and robot experience (at least robot assisted procedure performed). All participants performed three tasks: Railroad track (Task 1), Intracorporeal suturing (Task 2) and Vaginal cuff closure (Task 3). For each task the most clinical relevant outcomes parameters have been assessed; total time, time instrument out of view, accurate needle punctures and task errors. Results: Fifty-four participants were recruited, of which 28 novices, 21 laparoscopic experienced and five robot experienced. The participants have the following scores for Task 1: total time (548.5, 488.2, 430.8 seconds p = 0.52), time instrument out of view (0.91, 1.25, 1.45 seconds p = 0.77), accurate punctures (8.8, 8.2, 7.0 p = 0.48) and inaccurate punctures (12.7, 11.3, 8.7 p = 0.68) for novices, laparoscopic experience and robot experience respectively. Results show two significant results, both regarding Task two on total time (546.2, 290.8, 198.6 seconds p = 0.001) between novices versus laparoscopic/robot experienced groups and on unnecessary needle piercings (10.36, 6.9, 3.0 p = 0.046) between novices and robot experience group. Task 2 scores in time needle out of view (11.1, 19.2, 5.4 seconds p = 0.47), accurate needle passages (89.5, 81.4, 90.0 percentage p = 0.33) and dropped needles (10.8, 6.0, 3.8 p = 0.042) for novices, laparoscopic experience and robot experience groups respectively. Task 3 scores in total time (590.8, 563.3, 525.1 seconds p = 0.82), time instruments out of view (25.8, 15.9, 41.1 seconds p = 0.61), unnecessary needle piercings (10.5, 11.5, 6.0 p = 0.76) and accurate needle passages (28.8, 34.3, 37.5 percentage p = 1.0) for novices, laparoscopic experience and robot experience groups respectively. Conclusion: The RobotiX VR simulator appears not to be able to distinguish the difference between neither of the groups of participants for Task 1 and 3. Task 3 shows some construct for total time and unnecessary needle piercings.

123

Z.J. Lee, W.H. Chan, N.G. Tan, C.H. Lim, E.K.W. Lim, A.K.H. Eng, W.K. Wong, H.S. Ong, J.T.H. Tan Upper Gastrointestinal Surgery, Singhealth, Singapore, Singapore Introduction: Traditional laparoscopic splenectomy is described in a lateral first approach where dissection of the ligaments begins laterally with the mobilization of the splenic flexure. In splenic abscess, the feasibility of laparoscopic splenectomy is of concern due to considerations of inflammatory adhesions, risk of rupture of the abscess with disseminated sepsis, along with the risk of bleeding from splenic vessels and surrounding inflammatory tissue. We describe a case of an enlarged splenic abscess where we performed a hilar-first approach to laparoscopic splenectomy to secure vascular control whilst dissecting inflammatory tissue. Methodology: Our patient is a 56-year-old Chinese gentleman with a significant past medical history of type II diabetes mellitus, who presented with a 6-month history of left hypochondrium pain. He underwent a computed tomography scan of the abdomen with the findings of splenomegaly with a large irregular hypodensity consistent with a large abscess. He underwent laparoscopic splenectomy 2 weeks after completion of the triple vaccine. Findings: The patient was positioned in a 45 degree left lateral position. The working ports included 12mm and 15mm ports in the left subcostal region and two 5.5mm ports in the epigastrium, left flank. Intraoperative findings included a large splenic abscess of 12cm in size, with adhesions to the left diaphragmatic surface and the tail of the pancreas. We adopted a hilar first approach, where the splenogastric ligament is dissected first and the short gastric vessels taken with the Ligasure device. The pancreas is then slung up in an attempt to dissect the splenic vessels from the superior aspect of the pancreas. After vascular control is obtained, an inferior to superior approach is taken to dissect the splenocolic ligament, and splenophrenic ligaments. Introduction of an extraction bag is done through the 15mm port site to avoid rupture and spillage of the splenic abscess. The patient recovered well post operatively and was discharged on postoperative day 5. Conclusion: In splenic abscesses where the surrounding inflammatory field is prone to bleeding, a hilar-first approach may be useful to secure vascular control prior to dissection of attaching ligaments.

Surg Endosc

P413 - Spleen

P415 - Spleen

Splenic Fibrosis in Portal Hypertension and the Effect of Laparoscopic Splenectomy on Liver Fibrosis

Portal Vein Thrombosis as a Complication After Laparoscopic Splenectomy

Y. Iimuro1, T. Okada2, J. Fujimoto2

J.S. Malo Corral, J. Hernandez Gutierrez, B. Mun˜oz Jime´nez, A. Trinidad Borra´s, A. Aranzana Gomez, C. Alvaro Ruiz, R. Lopez Pardo, P. Toral Guinea, G. Krazniqui, M.A. Morlan

1

Surgery, Yamanashi Prefectural Central Hospital, Kofu, Japan; Surgery, Hyogo College of Medicine, Nishinomiya, Japan

2

Treatment of hepatitis viral infection has revealed that viral eradication can lead to attenuation of established liver fibrosis. Meanwhile, advanced portal hypertension (PH) often remains even after the viral eradication. As a treatment of gastroesophageal varices or pancytopenia due to PH, laparoscopic splenectomy is sometimes performed in Japan. We analyzed the histological changes in the resected spleen tissues, as well as observed the effect of splenectomy on the established hepatic fibrosis. Methods: Forty-one HCV-positive patients with PH underwent laparoscopic splenectomy and liver biopsy. Histological examination of liver and spleen were performed. Effect of splenectomy on the liver fibrosis was investigated using nontumorous liver tissues from patients who developed HCC and underwent liver resection after splenectomy. Results: After splenectomy, significant leukocytosis was observed in addition to thrombocytosis. Moreover, the improvement of S-Alb and prothrombin activity was detected. In the spleen with mild PH, dilated splenic sinus and narrowed splenic cord were detected in the red pulp. In the spleen with advanced PH, many aSMA-positive cells and significant amount of fibrillar collagen were observed in the splenic cord. The aSMA-positive area and the amount of fibrillar collagen were well correlated with the preoperative splenic volume and platelet counts, suggesting the gradual development of splenic fibrosis in PH patients. As a mechanism of splenic fibrosis, increased expression of oxidative stress markers such as 4-HNE, 8-OHdG, nitrotyrosine, was detected in the red pulp. Among the 41 patients, 9 patients developed HCC during follow-up period (265–2309 days) and underwent liver resection. Remarked attenuation of the established liver fibrosis was detected in 7 out of the 9 patients, even though viral eradication could not be established in these patients. Conclusion: Splenic congestion could be reversible after viral eradication or liver transplantation in PH, while advanced splenic fibrosis observed in this study seemed irreversible. In addition, attenuation of established liver fibrosis by splenectomy in PH patients was suggested independent from viral eradication. In patients with advanced splenic fibrosis, splenectomy may possibly be useful therapeutic modality.

P414 - Spleen

Cirugia General y Del Aparato Digestivo, Complejo Hospitalario De Toledo, Toledo, Spain Aims: Determine the incidence of portal vein thrombosis and its correlation with laboratory data and coexisting diseases in patients who underwent laparoscopic splenectomy. Methods: A restrospective, longitudinal and descriptive analysis was performed. Data from patients who underwent laparoscopic splenectomy at Hospital Virgen de la Salud (Toledo, Spain) between January 2012 and December 2016 was analyzed. The N total was of 16 patients. Both, B-mode and doppler abdominal ultrasound were performed within 2–3 weeks after the procedure. Patients diagnosed of portal thrombosis were prescribed anticoagulant therapy as well as Ultrasound follow up at day 20 and 50 after portal thrombosis diagnosis. Clinical features during immediate postoperative period, as well as preoperarive and postoperative laboratory data suggesting the presence of portal thrombosis were analized. Results: Median age was 47 with equal gender distribution. Fifty six percent (56%) of our population were diagnosed of Idiopathic Thrombocytopenic Purpura (ITP) and 18.75% of pancreatic tail neoplasm. In regards of laboratory data, 25 % of our sample presented transitory thrombocitosis during the postoperative period and 56.25% had altered liver function tests (LFTs). Within this last group, 66.6% had preoperative altered LFTs. A large proportion of patient were asimptomatic postoperatively (87.5%), while 12.5% had self limited episodes of fever. Three patients (18.75%) were diagnosed of Portal Vein thrombosis via ultrasound and 66% of these presented ITP as a coexisting disease. Postoperatively, 66.6% and 33.3% of patients with portal thrombosis showed altered LFTs and transitory thrombocitosis respectively. Only one out of the three patients with portal vein thrombosis showed a self limiting fever episode, while the rest remained asymptomatic. Ultrasound follow up showed resolution of portal vein thrombosis after anticoagulant therapy. One patient was diagnosed of chronic portal vein thrombosis. Conclusions: The incidence of portal vein thrombosis after laparoscopic splenectomy is of almost 20%. The majority of patients remain either asymptomatic or with undetermined clinical signs/symptoms. Postoperative transitory thrombocitosis is seen at around days 2 to 10 with normalizing levels 30 days after the surgical procedure. Liver function tests show a similar tendency, though, a large proportion are diagnosed preoperatively.

Perioperative Parameters as Long-Term Response-Predicting Factors for Splenectomy Performed for Immune Thrombocytopenia A. Nyilas, B. Borda, A. Paszt, Z.S. Simonka, S.Z. Abraham, G.Y. Lazar Department of Surgery, University of Szeged, Szeged, Hungary Aims and Background: Therapy-resistant immune thrombocytopenia (ITP) is the most frequent indication of laparoscopic splenectomy (LS), which ensures the best results for this disease compared with possible second-line pharmacological therapies. Therefore, learning about the safety of the surgical method and its long-term efficacy is definitely important, as is selecting patients who respond to surgical treatment. Our aim is to analyse the safety of LS and the short-and long-term prognostic significance of known perioperative parameters. Methods: We performed 40 LS for ITP between 1 January 2000 and 1 January 2015. We analysed the roles of the perioperative parameters using evidence-based guidelines. Results: Complete response (CR) occurred in 28 cases (70%) and partial response (R) in 5 cases (12.5%). Below the age of 50, 9% (2/22) of the patients developed no response (NR); this rate was 28% (5/18) for those over the age of 50 (p = 0.023). In the steroid-refractory group, 30% did not respond, whereas 100% of the steroiddependent patients developed CR (NR: 7/23 vs. 0/17; p = 0.027). The patients were followed up for 10.9 ± 6.9 years on average, and a permanent response (PR) was detected in 21 cases among the responders (33). 71% of the patients who originally developed CR also achieved PR, whereas this only occurred among 20% of the R patients. Conclusion: LS is safe and remains the most effective method in the second-line treatment of ITP. In our study, younger age and response to preoperative steroids were a predictive factor for the long-term success of splenectomy.

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Surg Endosc

P416 - Spleen

P418 - Technology

Wandering Spleen, an Intriguing Rare Condition for Surgeons

3D Laparoscopy is a Useful Adjunct in Treating Metastatic Melanoma

M. Giovenzana, M. Barabino, M. Polizzi, A. Pisani Ceretti, R. Santambrogio, E. Opocher

A. Botha1, C. Healy2, D. Sinitsky1, J. Geh2

UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, ASST Santi Paolo e Carlo, Milano, Italy

1

General Surgery, St Thomas’s Hospital, London, United Kingdom; Plastic Surgery, St Thomas’s Hospital, London, United Kingdom

2

Background: Wandering spleen is a rare condition (0.5%), resulting from abnormal ligamentous laxity failing to fixate the spleen in its normal location in the left upper quadrant. Ligamentous laxity can be acquired (80% of cases), but in almost one third of patients, it can be found in children as a congenital disease. Because of this laxity, there is an elongated vascular pedicle, which is prone to torsion and resultant splenic infarction. Patients generally present with different clinical conditions such as asymptomatic, a painless mass in the abdomen, intermittent abdominal pain or acute abdomen due to vascular pedicle torsion. Case Report: A 27-year-old female was admitted with complaining about worsening chronic and intermittent lower abdominal pain over the course of several months, associated to nycturia and dysmenorrhoea. An ultrasound showed a homogeneous hypoechoic mass of 10 9 5cm in the hypogastrium with a terminal inner vascularization on colour doppler imaging. A CT scan with 3D reconstructions, confirmed the wandering spleen in the pelvis conditioning compression on urinary bladder and uterus. Concern was raised for an ectopic spleen inducing pain and urinary symptoms, thus a scheduled 3D laparoscopic splenectomy was performed. The laparoscopy confirmed the ectopic position of the spleen and the length of splenic vessels. The pancreas tail was found in an ante-colic position stretch throw the pelvis by splenic vessels. Post-operative course was uneventful with discharge on third postoperative day. Conclusion: Nevertheless its rarity, WS yet induces high interest among surgeons and physicians due to young population involved and different therapeutic strategies related on specific clinical settings. There aren’t randomized studies in literature, mainly case reports. The few reviews and retrospective studies chiefly concern paediatric population. Therefore, the rarity of the WS does not allow an appropriate comparison between splenectomy and splenopexis, even if these procedures are both effective in adults.

Introduction: New chemotherapy options have resulted in improved outcome for patients with metastatic melanoma. Not infrequently a differentiated response to chemotherapy is seen between liver, lymphatic and intra-peritoneal metastases. We investigated whether 3D laparoscopy can add to the oncological armamentarium when dealing with metastatic melanoma. Methods: 4 consecutive patients with abdominal metastatic melanoma were investigated. All four patients previously had primary surgery for cutaneous melanoma of the lower limb, and were currently receiving chemotherapy for metastatic disease. In all four patients the liver metastases resolved as assessed by PET-CT scanning, but single abdominal metastases showed no response to chemotherapy. Two patients had an unresponsive external iliac lymph node metastasis, one patient a small bowel mesenteric metastasis, and one patient had a pelvic lymph node metastasis on the obturator nerve. All four patients were put forward for combined surgery by a 3D laparoscopic surgeon and a melanoma surgeon. Results: Two external iliac lymph nodes, a small bowel mesenteric metastasis and a pelvic lymph node metastasis were found operable and were completely excised by 3D laparoscopy. All patients had an uncomplicated hospital stay with three staying one night and one staying two nights. PET-CT scans at 6 weeks post-operatively showed no evidence of metastatic disease in three patients while the fourth patient is awaiting a PET-CT. We present a 5 minute video clip to demonstrate the precision of 3D dissection. Conclusion: 3D laparoscopy can be a useful adjunct for the melanoma team dealing with metastatic abdominal disease. Because of the short hospital stay and early postoperative resumption of chemotherapy, 3D laparoscopic resection is particularly useful for non-responsive metastases that are isolated and resectable.

P417 - Technology

P419 - Technology

3D-SILS Cholecystectomy with Situs Viscerus Inversus 1

2

3

3

A. Voynovsky , D. Procenko , A. Chernookov , T. Duzheva , M. Karapetyan1, V. Petrov1

Tumor Localization Using the Radio Frequency Identification Clip Marker: An Experimental Result in Ex Vivo Porcine Model

1

C.I. Choi1, K.H. Kim2, S.H. Lee2, S.H. Hwang2, D.H. Kim1, T.Y. Jeon1, D.H. Kim1

2

1

Aims: Demonstration of the first performed 3D-SILS cholecystectomy in a patient with a transposition of internal organs (situs inversus). Methods: We have experience of more than 100 operations with the use of 3-D visualization, such as cholecystectomy, TAPP, gastrectomy, Nissen fundoplication, left-sided and right-sided hemicolectomy, anterior resection of the rectum, kidney resection and others. We have to perform operations on the laparoscopic system EXERA III with 3D laparoscope with the deflected distal end ENDOEYE FLEX 3D. We have the initial experience of SILS surgery through the monoport - cholecystectomy, resection of the sigmoid colon. We performed laparoscopic cholecystectomy through SILS for chronic calculous cholecystitis in a patient with a reverse organ arrangement. Through transumbilikalny incision of 2 cm is set monoport (production South Korea). The operation was performed using monopolar coagulation. The peculiarity of the operation was an unusual reverse arrangement of the organs. There were no other features of the operation. The duration of the operation was 45 minutes. The gallbladder was removed through the monoport. Results: Post-operative period was uneventful. The patient was discharged two days after the operation. Conclusion(s)–The uniqueness of this case lies in the fact that for the first time in a patient with a transposition of internal organs (situs inversus) the use of 3D imaging and SILS, which allowed to perform laparoscopic cholecystectomy safely and with a good cosmetic result.

Purpose: As a widespread of minimal invasive surgery such as totally laparoscopic gastrectomy, tumor detection (especially early stage cancer or small benign tumors) is becoming more difficult. In this study, we present the experimental result of radio frequency identification (RFID) lesion detecting system in an ex-vivo porcine model. Methods: We developed a RFID lesion detection system consisting of a clip add-on RFID tag and detector. This system was applied to stomach and colon of 40kg weighted pig. The clip add-on RFID tag was attached to upper and lower gastric mucosal side. And two kind of colon that has thin and thick wall was used. Clipped sites were marked by the pin. Based on this pin, we measured the longest distance at which the RFID tag is recognized 25 times in each of the four directions (up, down, left, right). Results: Upper gastric wall thickness was 4.0mm and distance that RFID tag was detected was 4.5±0.9mm in the right, 5.6±0.7mm in the left, 12.5±0.7mm in the upper and 5.3±0.5mm in lower direction. Antrum wall thickness was 6.0mm and distance was 5.8±0.7mm in right, 6.9±0.5mm in left, 5.6±0.5mm in upper and 3.7±0.5mm in lower direction. Thin colon wall thickness was 3.0mm and distance was 6.3±0.5mm in right, 5.0±0.5mm in left, 9.7±0.7 in upper and 6.4±0.4mm in lower direction. Thick colon wall thickness was 8.0mm and distance was 3.5±0.8mm in right, 6.6±0.5mm in left, 8.4±0.6mm in upper and 9.8±0.5mm in lower direction. Conclusions: Distance at which RFID tag was detected was usually within 10mm. These results imply the clip add-on RFID has clinical feasibility and usefulness as a marker to identify the location of various gastrointestinal tumors. In-vivo test would be needed in near future to get more reliable evidences.

Abdominal, S.Yudina Moscow clinical hospital, Moscow, Russia; Administration, S.Yudina Moscow clinical hospital, Moscow, Russia; 3Abdominal, i.M. Sechenov First Moscow State Medical University, Moscow, Russia

123

Surgery, Pusan National University Hospital, Pusan, Republic of Korea; 2Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea

Surg Endosc

P420 - Technology

P422 - Technology

Development and Clinical Evaluation of a Semi-Cocoon-Shaped Ultra-Thin Retractor

Innovative Portable Insufflation Device to Stop Uncontrolled Abdominal Bleeding

S. Katsuyama1, K. Hirano2, T. Takahashi1, K. Tanaka1, Y. Miyazaki1, T. Makino1, Y. Kurokawa1, M. Yamasaki1, M. Mori1, Y. Doki1, K. Nakajima1

L.G. Gruionu1, M. Bogdan2, V. Surlin3, S. Patrascu3, G. Gruionu4

1

Gastroenterological Surgery, Osaka University, Suita, Japan; Development Department, Tokusen Kogyo Co., Ltd, Ono, Japan

2

Background: In single-port or reduced-port surgery settings, an efficient organ retraction is always challenging. An ultra-thin, therefore multi-punctureable, trocarless retracting device might be useful. However, it has been considered technologically difficult to develop such an instrument with sufficient retracting capability and robustness. In collaboration with a special metal wire manufacturer, we have successfully developed a semi-cocoon-shaped ultra-thin trocar-less retractor. The aims of this study are 1) to report its bench-top/preclinical developmental process, and 2) to evaluate its safety and potential usefulness in a series of patients. The prototype: The prototype device was designed to be directly punctured without using trocar. The tip, composed of 5 fine wires, forms ‘‘semi-cocoon’’ shape when deployed, to gently retract intra-abdominal organs as surgeon’s ‘‘top of hand.’’ Methods: Bench top and animal experiments were repeated to finalize the specification of the above prototype. The device with fixed specification was then evaluated on human subjects (n = 11), to validate its safety and potential usefulness. Results: (1) Developmental process: In order to obtain sufficient retracting capability, each wire needed to be specially manufactured with circular cross section. The final outer diameter was determined as 2.7 mm, with 45cm-long shaft. (2) Clinical evaluation: The deployment of the tip was smooth without any organ injuries at puncture. The device functioned well for retraction of the left hepatic lobe in esophageal and gastric procedures. No serious organ damage was noted except for capsule laceration in a case with fatty liver. The device was re-punctured in 4 cases due to necessity of alteration of retracting angles. The cosmetic results after these multiple punctures were still acceptable. Summary: With positive collaboration with the industry, we could succeeded in the development of novel ultra-thin retracting device. The device is safe and potentially useful in single-port or reduced-port surgery setting, where ‘‘one more instrument’’ significantly improves safety and efficiency of surgical procedures.

P421 - Technology Feasibility Study for Tumor Localization Using The Hyperbranched Polymers Labelled with Dye: An Ex-Vivo Test in a Porcine Model

1

Faculty of Mechanics, University of Craiova, Craiova, Romania; Department of Pharmacology, University of Medicine and Pharmacy of Craiova, Craiova, Romania; 3Department of Surgery, University of Medicine and Pharmacy of Craiova, Craiova, Romania; 4Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA, Boston, United States of America 2

Our goal is to develop a Portable Abdominal Insufflation Device (PAID) that will provide rapid and controlled abdominal insufflation to the abdominal cavity to stop or significantly decrease bleeding from abdominal injuries. Methods: PAID generates an intraabdominal pressure gradient that compresses blood vessels to the extra-luminal space thus decreasing bleeding rate. The device is equipped with a Veress needle, a CO2 cartridge, skin grippers, a Maxon motor and mechanisms to insert the needle, valve, pressure sensors and a Raspberry PI3 processing unit to automatically stop insertion when the abdominal cavity and required pressure are reached. The bench top testing models are abdominal cavities build from silicone of different thickness to simulate different abdominal wall thicknesses. We used a swine abdominal wall model for a closer resemblance of the skin and abdominal wall mechanical properties to the human tissue. Results: The prototype was built from commercially available and rapid prototyping components. The bench top testing was performed by lifting the silicone wall, inserting the Veress needle and insufflating the simulated abdominal cavity. The animal tissue was purchased fresh from a local butcher and placed over a box which simulates the abdominal cavity. The total box and tissue weight was matched to add up to the normal weight of a human abdominal wall. The prototype passed our acceptance criteria for clinical specifications: grip strength to hold a typical abdominal wall, gradual advancement of the needle throught the entire abdominal wall, needle block when it entered the abdominal cavity, insufflation to the target 200mmHg pressure, and maintain the pressure for 30min. Conclusion: We have passed the technology readiness levels (TRL) 4 by building the functional PAID prototype and successfully testing it in an artificial model and animal tissue for safety and effectiveness. The next steps are to optimize the device dimensions to make is as small as possible while maintaining function and testing it on an animal model of internal bleeding. Acknowledgements: The research leading to these results has received funding from UEFISCDI Romania, under the project ‘‘Innovative portable insufflation device to stop uncontrolled abdominal bleeding in military and civilian trauma’’, contract no. 244PED/2017, PN-III-P2-2.1-PED-2016-1587.

C.I. Choi1, K.H. Kim2, S.H. Lee2, S.H. Hwang2, D.H. Kim1, T.Y. Jeon1, D.H. Kim1 1 Surgery, Pusan National University Hospital, Pusan, Republic of Korea; 2Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea

Aim: To evaluate the efficacy and feasibility of the hyperbranched polymers (HBP) labelled with dye for gastrointestinal tumor localization. Methods: for this study, two HBP compounds labelled with Rhodamine-B and Rose Bengal dye was developed. Indigocarmin was used with a control as conventional dye for tumor location. We compared color pigmentation power and persistency between each dye-compound in the ex-vivo setting. They were injected in submucosal layer of 40kg porcine stomach and colon. We observed immediate finding on the intestinal serosa after injection, changes at 1 day and 5 days after injection. Results: Two HBP compounds (Rhodamine-B and Rose Bengal, experimental) and indigocarmin (control) have good pigmentation power. However there was a difference of color persistency between HBP compounds and indigocarmin. HBP compounds showed good color persistancy at 6 days after injection without spread of dye, while indigo carmin showed the early wash out at 1 day after injection. Pigmentation power was dominant in colon because colon wall is thin. However, serosal color change of the stomach was observed first at 6 days after injection. It suggested the possibility of clinical usage for new tumor location technique. Conclusion: Rhodamine-B and Rose Bengal dye compound with HBP can be useful candidate substance for identification of the tumor location. Additional in-vivo test and clinical trial are needed for validating its efficacy.

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P423 - Technology

P424 - Technology

Development of a Novel Skills Training Platform for Purse String Suturing in Tatme Training

Risk of Anastomotic Leak After Ivor-Lewis Esophagectomy: Indocyanine Green Near-Infrared Angiography for Gastric Conduit Blood Supply Evaluation

S.F. Hardon1, R. van Kasteren2, J.B. Tuynman1, T. Horeman2 1 Surgery, VU University Medical Center, Amsterdam, The Netherlands; 2Biomechanical Engineering, TU Delft University of Technology, Delft, The Netherlands

Background: New surgical techniques such as Transanal Total Mesorectal Excision (TaTME) were developed to improve oncological and functional outcomes of patients with rectal cancer. For this advance minimally invasive procedure, adequate training is mandatory. Preferably, the novice experiences most part of the learning curve for purse string suturing in a safe environment outside the operation room, to acquire technical skills and enhance self-confidence. We aimed to establish a box trainer model for training and objective skill assessment, based on tissue manipulation metrics. Methods: In addition to an intensive hands-on cadaver training, we implemented a pre-course box trainer trial for purse string suturing. Seven novices for TaTME procedure and four experts were included in a newly developed box trainer model for transanal purse string suturing. The box was equipped with state-of-the-art ForceSense system (Medishield B.V., Delft, the Netherlands) for objective force-based assessment. A purse string suture was performed on an artificial bowel in a newly developed measuring platform for forces on the anal canal. Forces representative in the transanal port and the suture site were captured. Exerted forces and time to complete procedure were captured. Performances were evaluated and compared with outcomes of experts in TaTME procedure. Results: We found significant differences in mean- and maximum exerted forces for purse string suturing between novices and experts (resp. p = 0.014, p = 0.048). We also found that time to complete the suture was significantly lower in the expert group (p = 0.040). Qualitative analysis of the data showed differences in behaviour between expert and novice teams, although not yet statistically proven. Conclusion(s): This study was designed to evaluate possibilities for future training and research. After statistical analysis we concluded that Forcesense outcomes differ between novices and expert. Therefore this system could be used for validation studies and eventually for objective assessment of skill, based on tissue manipulation forces. Our research group is working on implementation to gain insight into procedure specific learning curves and into the effect of real time intra-operative force feedback.

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P. Parise, L. Garutti, A. Cossu, F. Puccetti, C. Ferrari, U. Elmore, R. Rosati Gastrointestinal Surgery Unit, San Raffaele, Hospital, Milan, Italy Aim: Indocyanine Green - Angiography (ICG-A) has been recently introduced for visceral perfusion evaluation. Aim of this study is to assess whether intraoperative use of ICG-A can improve the evaluation of blood supply of the gastric conduit in Ivor-Lewis esophagectomy. Methods: This is an interim analysis of a prospective interventional study, ongoing at our Institution, on 160 Ivor-Lewis esophagectomy patients. After an intravenous bolus of ICG during the abdominal and thoracic stage, the gastric conduit perfusion was evaluated by means of a near infrared ICG-A and graded as ‘‘well’’, ‘‘hypoperfused’’ or ‘‘ischemic’’. If present, the ischemic or hypo-perfused area was resected. Demographic and clinical parameters and others, such as conduit perfusion speed, intra or post-operative hypotensive episodes have been analyzed. Results: Currently 26 patients have been enrolled. An anastomotic leak of any grade was identified in 7 patients. Patients were divided in Group A (7 patients) who developed a leak and Group B (19 patients) who do not. No statistically significant differences were evidenced about demographic and preoperative clinical features, except for higher cigarette smoking history incidence in Group A. Those who developed a leak had an ‘‘hypo-perfused’’ conduit at ICG-A in 71.4% and those who do not in only 15.8% (p 0.014). Median time from ICG injection to appearance of fluorescence at the basis of the gastric conduit was significantly longer in Group A than in Group B, 36 sec. (32–43.5) vs 28 sec. (20–39.8) (p 0.04) but median gastric conduit perfusion speed was similar. Patients in Group B had a higher median width of the conduit than Group A, 5cm (5.0 – 6.0.) vs 4cm (4.0 – 5.0) (p 0.032). Postoperative prolonged hypotensive episodes were seen more frequently in Group A than Group B (p 0.028). No differences were evidenced in terms of fluids infusions, blood loss, conduit length or intraoperative hypotensive episodes. Conclusions: Preliminary results seem to show the usefulness of ICG-A in identifying patients at risk of leakage. Nevertheless no reduction of leakage incidence was induced by surgical strategy modification, probably because post-operative events may affect clinical course too. Definitive data have to be awaited.

Surg Endosc

P425 - Technology

P427 - Thoracoscopic Surgery

Increasing The Success of Implementations of New Technological Devices in the OR: A Pilot Study on Integrating a New Camera Stabilizing Device

Modified Uniportal Video Assisted Thoracic Surgery: The First 30 Cases in Vietnam

N.R.R. Sewberath Misser1, B. van Zaane2, H. Gooszen3, J. Versendaal4

A.N. Nguyen, T.T. Hoang General Surgery Department, Oncology Hospital, Ho Chi Minh, Vietnam

1

Medical Technology, UMC Utrecht, Utrecht, The Netherlands; Anesthesiology, UMC Utrecht, Utrecht, The Netherlands; 3 Pulmonary Diseases, Radboud UMC, Nijmegen, The Netherlands; 4 Digital Smart Services, Open University & HU University of Applied Sciences Utrecht, Utrecht, The Netherlands 2

Successful implementations of new technological devices in Operating Rooms (OR) happen less frequent than expected, regardless of the efforts and resources invested in the development of these devices. The purpose of this study is to identify the impact of the integration of new and innovative technological devices on pre-, per and postoperative activities of involved stakeholders, to increase the rate of success of implementations of devices in the OR. Method: A single center pilot study in the University Medical Center Utrecht, involving the introduction of a new camera stabilizing device for laparoscopic surgeries named Mofixx. Preparatory activities and pre-, per and postoperative activities regarding this device were observed and recorded. To evaluate observed surgeries, surgeons and scrub nurses completed a questionnaire based on their role and performed activities. Results: Following the technical approval by the Technology department and the central sterilization department, the CE-approved technological device was ready for introduction. Parts of the device were recorded in IT-systems. Approval of the Medical Ethics Committee was exempted, due to the specific aim of this study. The manufacturer instructed surgeons and scrub nurses regarding setup, use and disassembly of this device. Seven laparoscopic cholecystectomies (general surgery), three laparoscopic Essure removals (gynaecology) and one partial nephrectomy (urology), were scheduled to be observed. One laparoscopic cholecystectomy was performed without the Mofixx, due to logistical issues in preoperative activities. Preoperative activities were adjusted for use of the device and in various cases technical assistance was provided for detailed instructions and guidance to surgeons, scrub nurses and circulating nurses. Functional elements rated by surgeons and scrub nurses regarded ‘increased stability of images’ and ‘ease of use’. Challenges regarded patients positioning, sterile drapes, ‘points of entry’, use of trocars and as well as some functional features of the device. Disassembly, sterilization and storage of the device required additional communication in the beginning of the study. Conclusion: Successful implementations of new technological devices in OR’s require meticulous preparation and optimization of success factors such as coordination, communication, training and management of stakeholders. IT-systems and protocols for surgical procedures need to be updated and tailored to involved stakeholders.

Background: The acceptance of uniportal video-assisted thoracic surgery (VATS) for minor and major thoracic procedures is accepted widespreadly over the world. This study presents the first experience with modified uniportal VATS (i-VATS) at HCMC oncology hospital in Viet Nam. Methods: In a retrospective study of prospectively collected data, 30 modified uniportal VATS (i-VATS) were analyzed from 12/2016 through 06/2017. The technique was used for diagnostic aims, tumorectomies, wedge resections, and anatomical lobectomies. All procedures were performed without rib spreading. Patients’s demographic data, preoperative and postoperative management as well as results were analyzed. Results: A total of 30 patients, among them 16 patients (53%) were males. The mean age was 52.3 ± 12.9 (25–70) years. The i-VATS procedures included wedge resections in 3 cases (10%), tumorectomies in 3 cases (10%), biopsies in 6 cases (20%) and other anatomical lobectomies in 18 cases (60%). The median operation time was 243, 105, 58, and 80 minutes for lobectomies, wedge resections, biopsies, tumorectomies, respectively. There was one conversion in case of middle lobectomie. The mean chest tube duration was 3 days. The mean hospital stay was 4–5 days for the whole group. Conclusions: Modified Uniportal VATS is a feasible and safe technique for various indications in thoracic surgery. The perioperative results are promising. It can be performed by thoracic surgeons experienced in the lateral thoracotomy approach.

P426 - Thoracoscopic Surgery Exploratory Video-Assisted Thoracoscopic Surgery for Thoracic Impalement Injury Y.W. Liu Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Aims: Video-assisted thoracoscopic surgery (VATS) is widely performed in acute management of hemodynamically stable patients with penetrating thoracic trauma for its established safety and efficacy. Nevertheless, the use in thoracic impalement injury was sparsely reported. In this article we demonstrate our preliminary experience with exploratory VATS in the surgical treatment of thoracic impalement injuries. Methods: There are four patients undergoing exploratory VATS either for diagnostic and/ or therapeutic purposes owing to thoracic impalement injury in single medical center (Level I trauma center) from November 2010 to July 2016. Patient demographics, characteristics of injury, preoperative investigation, and postoperative outcome were collected and compared with relevant cases in literature. Results: VATS was successfully performed in 4 consecutive hemodynamically normal patients without conversion to thoracotomy. Procedures performed consisted of detecting injuries, evacuation of blood clots, repair of diaphragmatic laceration, and safe extraction of impaled objects. Neither in-hospital morbidities nor mortalities were found. A summary of management for thoracic impalement injury is also proposed in an algorithm. Conclusion: With imaging-based preoperative planning and exhaustive vital surveillance in hemodynamically stable patients, exploratory VATS takes a preceding role for managing thoracic impalement injuries.

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P428 - Thoracoscopic Surgery

P429 - Thoracoscopic Surgery

Vats Thymectomy - Experience in 100 Cases Over 5 Years 1

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R. Parshad , S. Kapila , E. Verma , S. Gupta , V. Goyal , L. Kashyap4, R. Sharma5 1

Department of Surgical Disciplines, All India Institute of Medical Science, New Delhi, India; 3Department of Neurology, All India Institute of Medical Sciences, New Delhi, India; 4Anaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India; 5Radiology, All India Institute of Medical Science, New Delhi, India Objective: In recent years, VATS thymectomy has emerged as a minimally invasive alternative to the standard trans-sternal approach. We present herewith the surgical and functional outcomes of 100 patients who underwent VATS thymectomy. Methods: A retrospective analysis of patients who underwent thymectomy between April 2012 and November 2017 was carried out. Their clinical and radiological profile, operative details, post-operative outcome and final pathological diagnosis was assessed. Neurological and biochemical outcomes were recorded as relevant. Neurological outcomes were assessed based on Myasthenia Gravis Foundation of America Post Intervention Status (MGFA-PIS) classification. Data was recorded on an MS Excel Spreadsheet and expressed as mean, median, range and standard deviation. Results: 105 patients were referred for thymectomy during the study period. 100 patients (97 for Myasthenia gravis and 3 for ectopic parathyroid) underwent minimally invasive thymectomy (96 conventional VATS/4 robotic VATS). The right sided approach was used in 54 patients, left in 35 patients and bilateral in 6 patients. 5 were operated by the subxiphoid approach. Mean operative time was 147 minutes (90–285 min, SD = 38.78). Median intraoperative blood loss was 100 ml (25–700 ml). No major intraoperative complications occurred. 2 patients required ICU stay in the post-operative period with prolonged ventilatory support in one patient. Median ICD indwelling time was 2 days and median postoperative hospital stay was 3 days. There was no 30-day mortality. Histology revealed 13 cases as normal thymus, 45 as thymic hyperplasia, 36 as thymomas and 3 as thymolipomas. Ectopic parathyroid adenoma was seen in 3 patients. 70 patients of myasthenia gravis have completed one year of follow up at the time of analysis. The MGFA-PIS is: Complete stable remission (CSR) in 22.8%, pharmacological remission (PR) in 20%, minimal manifestations (MM) in 38.5%, unchanged status (U) in 1.4% and worse (W) in 11%. 4 patients died after 1–2 years of thymectomy in the follow up period due to myasthenic crisis, all of whom had thymomas. Conclusion: Video-assisted thymectomy is a safe procedure and can be performed with minimal morbidity. It results in significant improvement of symptoms and reduction in drug dosage post-operatively.

Reduced-Port Endoscopic Thoracic Sympathectomy in Primary Craniofacial-Palmar Hyperhidrosis: A Preliminary Study P. Jitpratoom, R. Charoenpongpoon, W. Wandee, A. Anuwong, S. Vijitpornkul, W. Wachirapunyanukul Surgery, Police General Hospital, Bangkok, Thailand Aims: Primary hyperhidrosis typically effects either the craniofacial or axillarypalmar region. However, some patients present with multifocal primary hyperhidrosis which mandates multilevel thoracic sympathectomy. Our purpose is to determine the safety and efficacy of reduced-port endoscopic thoracic sympathectomy (rETS) for treating primary craniofacial-palmar hyperhidrosis. Methods: From January 2015 to October 2017, a total of 11 patients with primary craniofacial-palmar hyperhidrosis were treated with rETS at our center. Every operation was performed via a 12-mm lateral chest wall incision with multichannel working thoracoscope and another 3-mm port for lung retractor. Data was collected retrospectively and statistically analysed. Results: All 11 patients who underwent T2 and T5 sympathectomy reported successful treatment and their craniofacial-palmar hyperhidrosis resolved clinically. There was compensatory sweating observed postoperatively in nine patients occurred on back, trunk and lower limbs. Postoperative questionnaires were returned by all treated patients with a mean time from operation to follow-up of 16.3 months. There were transient chest wall paresthesia in two cases and both cases improved spontaneously in 3 months. No mortality, diaphragmatic hernia, pneumothorax, hemothorax or Horner’s syndrome was observed. Conclusion: Reduced-port endoscopic thoracic sympathectomy (rETS) of T2 and T5 levels is a safe and feasible alternative to the conventional approach for primary craniofacial-palmar hyperhidrosis.

P430 - Thoracoscopic Surgery The Analysis of The Safety of a Modified Left Recurrent Laryngeal Lymph Nodes Dissection in Thoracoscopic Esophageal Carcinoma Surgery J. Jie1, Y. Xiuyi1, G. Guojun1, L. Hongming1, M. Yanjun2, W. Liangliang1, M. Jie1, Y. Pan1 1 Department of thorocicsurgery, The First Hospital Affiliated to Xiamen University, Xiamen, China; 2Department of Medical Oncology, The First Hospital Affiliated to Xiamen University, Xiamen, China

Objective: To explore the thoroughness and safety of a modified left recurrent laryngeal lymph nodes dissection in thoracoscopic esophageal carcinoma surgery. Method: Retrospectively analyzed the clinical data of 136 patients with the left recurrent laryngeal lymph nodes dissection from October 2015 to October 2017 in the First Hospital Affiliated to Xiamen University. 67 cases were divided to the traditional dissection group (double lumen endotracheal intubation, 90 ° lateral position) and 69 cases were classified to the modified dissection group (single cavity tracheal intubation, thoracic CO2 positive pressure ventilation, lateral prone position and esophageal suspension technology). Observed and compared the left laryngeal recurrent nerve lymph nodes cleaning and time, intraoperative complications including thoracic duct injury, tracheal injury, hoarseness and pneumonia. Results: The cleaning time of the modified dissection group (23 ? 8 min) was significantly less than that of the traditional cleaning group (32 plus or minus 5min) (P\0.01). 5 patients occurred left laryngeal nerve injury in the modified dissection group, with statistically significance (P\0.01), less than traditional dissection group of 12 patients. The modified dissection method improves the exposure of intraoperative field, the probability of thoracic duct and tracheal injury (1/69, 0/69) were lower than the traditional group (2/67, 1/67), but the difference was not statistically significant (P[0.05). Moreover, there was no significant difference in lymph nodes metastasis and complications incidence rate (P[0.05). Conclusion: The modified dissection method, including single cavity tracheal intubation, thoracic CO2 positive pressure ventilation, lateral prone position and using esophageal suspension technology, can achieve good operation field exposure, the left recurrent laryngeal lymph nodes ‘‘the whole block’’ cleaning, and the greatest degree protection of laryngeal recurrent nerve, thoracic duct, trachea and other organs damage. It is worthy of clinical popularization and application. Keywords: left recurrent laryngeal lymph nodes; esophageal carcinoma; esophageal suspension technology; thoracic CO2 positive pressure ventilation.

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P431 - Thoracoscopic Surgery

P432 - Thoracoscopic Surgery

Analysis of Thoracoscope, Laparoscopy Combined with Total Laryngectomy in Treatment of Cervical Esophageal Carcinoma Operation

Uniportal Video-Assisted Thoracoscopic Wedge Pulmonary Resection Through Conventional Endoscopic Instruments in Our Early Experience

J. Jie1, Y. Xiuyi1, G. Guojun1, L. Hongming1, M. Yanjun2, W. Liangliang1, M. Jie1, Y. Pan1

M. Naruke

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Department of thorocicsurgery, The First Hospital Affiliated to Xiamen University, Xiamen, China; 2Department of Medical Oncology, The First Hospital Affiliated to Xiamen University, Xiamen, China Objective: To investigate the feasibility and efficacy of cervical esophageal carcinoma operation through thoracoscope, laparoscopy combined with total laryngectomy. Methods: Retrospect and analyze the data of 53 patients with cervical esophageal carcinoma undergone surgical treatment in Department of Thoracic Surgery, First Hospital Affiliated to Xiamen University from May.2010 to May.2017. Operation procedure: separate esophagus under thoracoscope, rebuild gastric tube, resect full throat, perform tracheostoma permanently, apply gastric-pharyngeal anastomosis. Results: Thoracic operation time was 50 * 65 min, average 57 min; abdominal operation time was 46 * 62 min, average 54 min; neck surgery time was 117 * 137 min, average 125 min. The amount of intraoperative bleeding was 78* 260 ml, average 180 ml. The postoperative hospital stay was 7 * 15d, average 10d. All the cases were squamous cell carcinoma, 6 cases of high differentiated squamous cell carcinoma, 31 cases of squamous cell carcinoma, 10 cases of middle-low differentiated squamous cell carcinoma, 6 cases of low differentiated squamous cell carcinoma. All the resection edges had been proved no residual tumor left by pathological examination. In 53 cases, lymph node metastasis occurred in 48 cases, anastomotic fistula occurred in 1 cases, 2 cases of pulmonary infection, 1 cases of gastric emptying and 1 case anastomotic stenosis happed, and there is no death case. All the patients were followed up from 1 months to 5 years, the 1st, 3rd, 5th year survival rate was 83.8%, 51.2% and 23.1% respectively. Conclusion: Cervical esophageal carcinoma operation treatment should be taken actively, Gastric pharyngeal anastomosis is an effective mean to treat cervical esophageal carcinoma. Keywords: cervical esophageal carcinoma, total laryngectomy, thoracoscope, laparoscopy, gastric pharyngeal anastomosis.

General Thoracic Surgery, Ida Kawasaki municipal hospital, Kanagawa, Japan Aim: As the uniportal video-assisted thoracoscopic surgery (VATS) becomes more widespread, and the various newly designed devices and some special techniques are reported for this approach. However, simple technique utilizing conventional tools are helpful to start VATS for every surgeon. Also, we present our early experiences of successful uniportal VATS by conventional technique using conventional instruments. Methods: We report our experiences of ten cases that underwent uniportal VATS wedge resection on the use of endoscopic automatic stapling devices (Endo GIA) and conventional instruments in parenchymal closure by simple technique. Targets were for 7 patients of spontaneous pneumothorax (SP), 2 patients of pulmonary metastases, and primary lung cancer. In principal the target lesion was detected using cotton made-dissectors and grasped by thoracoscopic Maryland grasping forceps and stapled using Endo GIA under the 5-mm 30 degree rigid thoracoscope view, and every instrument managed through a single access port of 25mm that was fixed by the silicon wound retractor. Their surgical procedures were done by one-lung ventilation general anesthesia. In the case of dissecting adhesion, an energy device was used. Following bullectomy for SP, the stapling line was reinforced with an absorbable polyglycolic acid sheet. Results: The average of pulmonary resection parts was one location (1–3 parts) for one patient. The mean operative time was 65 min (49–102). Severe intrathoracic adhesion was not found during operation in all cases. There were no any postoperative complications. Wedge resection for the lesions in the apical segment of upper lobe or in the superior segment of lower lobe were accomplished easily through uniporal access on the 5th intercostal space on the anterior axially line. Wedge resection for the lesions in the apical segment of upper lobe, lingular segment of upper lobe or lateral segment of lower lobe was accomplished easily through uniporal access on the 8th intercostal space on the mid-axillary line. Conclusion: According to limited experience, uniportal wedge pulmonary resection was possible for various parenchymal location by the appropriate access-port site as early experience.

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P433 - Thoracoscopic Surgery

P434 - Thoracoscopic Surgery

Minimally Invasive Cardiac Sympathetic Denervation for the Prevention of Life-Threatening Ventricular Arrhythmias: The Largest European Experience

Thoracoscopic Endoscopic Cooperative Surgery for a Large Esophageal Submucosal Tumor

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L. Pugliese , G.M. de Ferrari , V. Dusi , F. Dagradi , S. Castelletti , L. Crotti3, N. Mineo1, P.J. Schwartz3, A. Pietrabissa1

S. Maruyama1, Y. Onodera1, T. Nakano2, H. Okamoto1, C. Sato1, T. Heishi1, T. Sakurai1, Y. Taniyama1, T. Kamei1 1

Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; 2 Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; 3 Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Milan, Italy

Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Miyagi, Japan; 2Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Miyagino-ku, Sendai, Miyagi, Japan

Aims: we report the preliminary outcomes of a single European center experience in minimally invasive cardiac sympathetic denervation (CSD) for the prevention of life-threatening ventricular arrhythmias due to different cardiac diseases. Methods: Since October 2014, 24 patients were operated at our center. Some of them were referred to us from healthcare institutions of foreign countries (Europe and Asia). Major arrhythmic episodes had occurred in 70% (17/24) of them. Primary prevention (PP) surgery was offered to 7 asymptomatic patients not manageable with medical therapy alone. Left cardiac sympathetic denervation (LCSD) was performed in 20 patients with genetic arrhythmias: Long-QT Syndrome (LQTS) in 80% (16/20); all PP cases belonged to this group. Bilateral sympathetic cardiac denervation (BCSD) was performed in 4 patients with severe structural heart disease (dilated cardiomyopathy) all of whom suffered repeated episodes of malignant arrhythmias and multiple ICD shocks prior to surgery. All patients underwent a minimally invasive sympathectomy, removing the lower half of the stellate ganglion ? T2-T4. Results: LCSD patients included 11 males and 9 females with a median age of 25 years (range 5–48). BCSD patients (3 males and 1 female) had a median age of 52 years (range 42–61). The thoracoscopic approach was used in all cases except for the last three consecutive patients who received robotic cardiac sympathectomy (2 LCSD and 1 BCSD). No conversion to open surgery nor intraoperative complications occurred. The postoperative course was uneventful for pneumothorax, Horner’s syndrome and other major adverse events. Transient (\3 months) thoracic neuropathic pain was observed in 6/24 (25%) patients. At a median follow-up of 18±11 months no further cardiac events were observed except for a single arrhythmic episode in a BCSD patient occurred during thyrotoxicosis (4%). Conclusions: LCSD and BCSD can be safely performed with thoracoscopic or robotic technique, resulting in a highly effective therapeutic option to prevent lifethreatening arrhythmias caused by different heart diseases.

A case is the 47-year-old woman with a large esophageal submucosal tumor (SMT). It was in the left wall of the esophagus that diagnosed as a benign schwannoma on biopsy. Computed tomography revealed the tumor of length 60mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. We planned the resection of the tumor by thoracoscopic endoscopic cooperative surgery. On endoscopy, a submucosal tunnel was created 40mm proximal to the cranial edge of the tumor, and its only oral end was dissected from the mucosal and muscular layers. Endoscopic dissection was limited to about 30mm of the tumor and could not proceed further owing to the limited mobility of the tumor within the submucosal tunnel. Thereafter, left thoracoscopic access was performed. The surface of the tumor was easily identified on incising the esophageal muscular layer and dissection was performed along the tumor surface to enable its enucleation. The resected tumor was delivered out thorough the operating port. No postoperative complication were observed. Esophageal schwannoma is a relatively rare esophageal submucosal tumor. Enucleation is one of the treatment and minimally invasive surgery using thoracoscopy has been the usual approach. The left thoracic approach, although considered better for tumors involving the left esophageal wall, is limited by the presence of the aortic arch and the trachea. Per-oral endoscopic tumorectomy (POET) is an endoscopic technique for submucosal tumor. This technique allows for a complete endoscopic tumor resection. On the other hand, it is only recommended for tumors up to 40mm in size owing to the limited submucosal space available. In this case, the aortic arch and the trachea restricted left-sided thoracoscopic access and POET alone was not applicable owing to the tumor size. We combined the two procedures to overcome their respective limitations. To avoid the aortic arch and the bronchus in the thoracospic approach, we attempted to remove the cranial side of the tumor to the maximum extent possible by endoscopic dissection. In conclusion, this method may be a possible minimally invasive treatment opition for a large esophageal SMT.

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P479 - Thoracoscopic Surgery

P436 - Training

Video-Assisted Thoracoscope 3D and 2D Mode Comparative Analysis for Esophageal Chest Surgery

Toward Standardization of Laparoscopic Resection for Colorectal Cancer In Rural Area Even in Developed Countries

J. Jie1, Y. Xiuyi1, G. Guojun1, L. Hongming1, M. Yanjun2, W. Liangliang1, M. Jie1, Y. Pan1 1

Department of thorocicsurgery, The First Hospital Affiliated to Xiamen University, Xiamen, China; 2Department of Medical Oncology, The First Hospital Affiliated to Xiamen University, Xiamen, China Objective: To study the advantages and disadvantages of 3D and 2D thoracoscope in the thoracic surgery of esophageal carcinoma. Methods: Retrospectively analyze esophageal cancer cases between July 2013 and July 2017 of the first affiliated hospital to Xiamen University, depending on the different mode of Video-Assisted Thoracoscopic, which can be divided into 3D-VATS group 353 cases (observation group) and 2D-VATS group 351 cases (control group). Comparing the difference in operation time, intraoperative bleeding, lymph node transmission, volume of the drain by the first 24 hours, total volume of the drain, chest tube time and postoperative complications. Results: All the 704 patients with esophageal cancer were performed under the videoassisted thoracoscope. In terms of surgery time, 3D-VATS group (51.4±13.3min) was shorter than 2D-VATS group (65.7±9.1min), with statistical significance (t=-9.751, P = 0.013); on blood loss, 3D-VATS group (34.1±10.5ml) was less than 2D-VATS group (50.2±9.4ml) with statistical significance (t=-9.274, P = 0.009 about lymph nodes transmission, 3D-VATS group (16.8±3.2) was more than 2D-VATS group (13.1±3.7), with statistical significance (t = 5.213, P = 0.007 in volume of the drain by the first 24 hours, 3DVATS group (171.2.15±20.2ml was less slightly than 2D-VATS group (180.3±35.2ml), no statistical difference (t=-1.347, P= 0.281about total volume of the drain, 3D-VATS group (530.2±53.4ml) was less slightly than 2D-VATS group (553.8±57.5ml), no statistical difference (t=-1.911, P = 0.093 on chest tube time, 3D-VATS group (4.2±0.7d was less slightly than 2D-VATS group (4.9±1.1d), no statistical difference (t=-1.806, P = 0.069 Postoperative complications in two groups including the incidence of arrhythmia, pulmonary infection, anastomotic leakage and recurrent laryngeal nerve injury has no obvious difference (P[ 0.05). Conclusions: Video-assisted thoracoscopic surgery of esophagectomy under 3D-mode has certain advantages in operation time, intraoperative bleeding and lymph nodes transmission over 2D-mode. While in the item of volume of the drain by 24 hours, total volume of the drain, chest tube time and postoperative complications, they have no obvious difference. Keywords: Esophageal Carcinoma; Video-assisted thoracoscopic surgery; 3D thoracoscope; 2D thoracoscope.

S. Furuya, Y. Akazawa, M. Sudo, D. Ichikawa First Department of Surgery, Yamanashi University, Chuo, Japan Background: Despite the proven benefits, laparoscopic colorectal surgery is still underutilized among surgeons especially in rural area. A steep learning is also one of the causes of its limited adoption. Objective: To explore the learning curve of single surgeon experience in laparoscopic colectomy, and to explore the feasibility of implementing a well standardized step by step operative technique to overcome the beginning technical obstacles. Patients and Methods: This prospective study included 69 patients with carcinoma of the left colon and rectum recruited from the First department of surgery, Faculty of medicine Yamanashi University in the period 2013–2017. Almost of procedures were performed through laparoscopic approach. Intra and post-operative data were recorded and analyzed. Moreover, we evaluated the learning curve of individual and operation team by operation time and blood loss about ileocecal resection, low anterior resection, and high anterior resection. Results: The mean age was 69.2±10.1years (range: 44–93years). They were 36 males and 33 females, and the BMI was 22.5±3.0 (range: 15.6–28.0). The mean operation time was 362min (range 177–631 min), and the mean blood loss was 201ml (7–4649 ml). Two patients (3%) were converted to a laparotomy. 10 patients (14%) had postoperative morbidity, major morbidity occurred in three patients. none of the patients showed local recurrence or recurrence of the trocar site in the observation period. We observed the well slope of learning curve of not only individual but also operation team in each operation type. Conclusion: Laparoscopic surgery for colorectal cancer is safe and oncologically sound, standardized and well-structured laparoscopic technique leads to the procedure even in early learning curve setting.

P435 - Training

P437 - Training

Future-Proofing The Surgeons of Tomorrow - Introducing Minimally Invasive Surgical Training at the Undergraduate Level

Innovative Self-Improving Laparoscopic Rectal Surgery Training Program with A 3D-Printed Pelvi-Trainer

A. Phaily1, H. Esmail2, K. Quinn3, G.Y.H.R. Evans3

R.C. Elisei1, F. Graur1, C. Popa1, E. Mois2, L. Furcea1, N. al Hajjar1

1

Upper GI Surgery, Bedford Hospital NHS Trust, Uxbridge, United Kingdom; 2Colorectal Surgery, Bedford Hospital NHS Trust, Bedford, United Kingdom; 3Breast Surgery, Bedford Hospital NHS Trust, Bedford, United Kingdom

1

General Surgery, Regional Institute of Gastroenterology and Hepathology, Prof. Dr. Octavian Fodor, Cluj-Napoca, Romania; 2 General Surgery, Negresti-Oas City Hospital, Negresti-Oas, Romania

Aim: The 21st century has seen the establishment of minimally invasive surgery (MIS) as a viable, and often, clinically more beneficial alternative to open surgery. Laparoscopic surgery is being used in more complex oncological resections, whilst robotic assisted surgery is now commonplace in certain surgical specialities. Training for these techniques begins at the speciality trainee level. As future trend extrapolations show the increasing use of MIS, we propose that training in such techniques begins at an earlier stage. Methods: A systematic review of the literature including PubMed and Google Scholar was conducted to identify studies related to MIS training and the development of required skills necessary to prepare future surgeons. The attributes of MIS training programmes were examined and key points applied to guide undergraduate training. Results: The development of the required psychomotor skills which differentiate expert from non-exert begin away from the operating room. Hand eye co-ordination, bimanual dexterity, spatial awareness and economy of movement have all been successfully taught in simulators. Early acquisition of the above skills results in shorter learning curves when translated to operative practice. Conclusion: The future of surgery will include further operations being carried out using MIS. The most challenging part of MIS for trainee surgeons is the acquisition of the required psychomotor skills. Earlier teaching and adoption of these skills by trainees and medical students is necessary in order to enable the surgeons of tomorrow to be better adapted to the technological advances in MIS.

Rectal laparoscopic surgery skills are advanced skills and difficult to acquire. The currently laparoscopic skills training programs moved the training for advanced laparoscopic surgery out of the operating room with the help of different types of simulators and need to be optimized. We hypothesized that a innovative self-improving training program for rectal surgery will shorten the learning curve of this advanced laparoscopic surgery and reduce resource requirements. We developed a 3d-printed pelvi-trainer after a real woman pelvis empty of pelvic organs in which we designed several classic exercises used for laparoscopic skills training but in a phantom pelvis. In this way we try to enhance the laparoscopic dexterity training for rectal laparoscopic surgery. With this design we want to set a dexterity coefficient which will be able to compare the dexterity level of a student, resident, specialist or senior surgeon in this particular type of laparoscopic surgery. In the same time we design a software to save all the data and times of every person that performed the exercises we proposed. With this software we will add to every category of participants every new times for every exercise and calculate the median time for every exercise and compare it with all others. Also we propose an algorithm to be able to compare the results of different types of participants that we named experience coefficient. We’ll attach to the training program an accurate assessment and evaluation algorithm. With all this data we want to be able to enhance and to be more efficient in laparoscopic skills training in rectal surgery and to be continuously self-improving training program which we want to be accessible to as many surgeons as possible and standardize the laparoscopic rectal surgery training first in Romania than in as many countries as possible.

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Surg Endosc

P438 - Urology

P440 - Vascular Surgery

Bladder Tumour: Negative CT Uorgam but Positive Flexible Cystoscopy - Our Experience

Arcuate Ligament Syndrome: Favorable Results: With Surgical Treatment And Conservative Treatment

N. Maudarbaccus, F. Mustafa Hamza, Z. Ashraf

A. Vilchez Rabelo1, L. Va´zquez Medina1, A.A. Molina Martı´n2, A. Bedmar Perez2, A. Vilchez Casares3

Urology, Our Lady of Lourdes Hospital, Drogheda, Ireland

1

Macroscopic haematuria is a frequent cause for patient presenting to the emergency room. Causes of such kind of haematuria have a high clinical suspicion of an underlying urological malignancy until proven otherwise. Workup regarding macroscopic haematuria is already established with CT Urogrpahy which helps in establishing early diagnosis and also a triage in establishing urgency list for flexible cystoscopy. In this review, we want to emphasize the synergistic importance of CT urography and flexible cystoscopy as both goes hand in hand for the complete investigation of macroscopic haematuria as some small superficial stubborn bladder tumours are missed on CT scan.

General and Digestive Surgery, Hospital San Agustı´n, Jae´n, Spain; Radiology, Hospital San Agustı´n, Jae´n, Spain; 3Profesor, Wellington International College, Shanghai, China 2

Aims: This syndrome is characterized by extrinsic compression of the celiac trunk by the fibers of the arcuate ligament that join in the aortic hiatus. Four cases are hereby presented, two of them treated by conservative treatment, both presenting good results. Methods: Four female patients were chosen, all of them aged between 16 and 32 years, with a low Body Mass Index, one of them a smoker, the rest without any relevant medical history. All of the patients presented the same symptoms; postprandial abdominal pain, nausea and weight loss. The diagnosis of the four patiens was performed through exclusion, diagnostic was confirmed through Computerized Tomography angiogram. In all cases, conservative treatment was chosen, by weight gain and change in eating habits by having around six meals a day and eating small amounts. Results: Two of the patients gained weight and the symptoms disappeared completely, followed by subsequents follow-ups in our clinics. Two of the patients did not improve with the conservative treatment and did not manage to gain weight; thus, laparoscopic surgery was necessary to free the celiac trunk. Currently these patients are in procedural check-ups and present no symptoms. Conclusions: We believe that for initial diagnosis, any chronic abdominal pain that sets without any apparent reason must be considered, being abdominal achography the first diagnostic procedure to consider, because of its efficiency and innocuity. Gold standard treatment for arcuate ligament syndrome is surgical, essentially laparoscopic surgery. Treatment by endoprothesis or celiac ganglion block have been described latterly. However, in the existing literature, there are few references to the conservative treatment, which, we deem would be very recommended to consider as the first choice of treatment.

P439 - Urology

P441 - Vascular Surgery

Laparoscopic Management of Retroperitoneal Mass. Surgical and Oncological Safety

Endoscopic Versus Open Vein Harvesting: Our Experience

D. Khunovich, T. Taha, O. Levi, B. Sionov, A.A. Sidi, A. Tsivian Urologic Surgery, E. Wolfson Medical Center, Holon, Israel Objective: With growing experience in retroperitoneal laparoscopic surgery, the application of this approach for the investigation of retroperitoneal mass of unknown origin may provide an alternative to classical open surgery with all the benefits of laparoscopy. Herein, we report on our experience in laparoscopic resection of retroperitoneal masses. Methods: We reviewed a prospectively collected database of retroperitoneal masses treated between 2005 and 2017. There were 13 patients who underwent laparoscopic procedure. Demographic, radiological (size and tumor location), surgical (duration of surgery, pathology, complications) data were tabulated, oncological results were gathered. Results: 13 patients underwent laparoscopic resection of retroperitoneal mass, 2 of them with concomitant surgery: one- laparoscopic cholecystectomy and another laparoscopic POVH repair and open partial nephrectomy on the opposite site. Mean age was 61 years (range 46–80), 61% were males. Mean tumor size was 6.4 cm (215). The mean duration of surgery was 152 min (range 50- 258). There was no conversions to open surgery. In one patient an intraoperative small bowel injury occurred and was successfully repaired laparoscopicaly another patient suffered from adrenal insufficiency in the postoperative period. Pathology revealed: local recurrence of RCC- 4, Liposarcoma- 2, Retroperitoneal Fibrosis1, Ganglioneuroma- 2, Shwanoma- 1, Extraorganic Retroperitoneal Cyst- 3. During mean 8 year (range 1–12) follow-up 3 patients passed away. Overall survival was 77%, with 84% cancer specific survival: only one died from metastatic RCC 7 years after surgery. Conclusion: While open surgery remains the standard treatment for all retroperitoneal tumors, laparoscopic approach to retropritoneal masses is technically feasible and oncologically safe.

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N. Kadric, M. Jahic, S. Rajkovic, E. Kabil Cardiovascular surgery, Center for the Heart BH, Tuzla, BosniaHerzegovina Most commonly used conduit for coronary artery bypass grafting (CABG) is great saphenous vein (GSV). After introduction, endoscopic vein harvesting (EVH) take important place in standard clinical care. In our Center in the past standard method of vein harvesting we used. With introduction EVH procedurae we have more less local complications. Recent publications have data about quality and durability of an endoscopically harvested vein. Aim of our studies is represent clinical outcome after EVH in compared with open vein harvesting.