2016 Scientific Session of the Society of American Gastrointestinaland Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA,16–19 March 2016

Poster Presentations

� Springer Science+Business Media New York 2016

P034

The Physiological Assessment to Burden on the Surgeonin Laparoscopic Surgery Using the 128 Channels EEG

Hisae Aoki, MD1, Toshiyuki Mori, MD, PhD2, Hiromasa Yamashita,

PhD3, Toshio Chiba, MD, PhD3, Akio Mori, PhD4, 1Department

of Surgery, Sanraku Hospital, 2Department of Surgery, Kyorin

University, 3University Research Center (URC), Nihon University,4College of Humanities and Sciences, Nihon University

Introduction: The laparoscopic surgery has been evolved by development of the variouslaparoscopic surgical systems, for example, the robotic surgical system or the 3-dimensionlaparoscopic surgery system. In addition, the laparoscopic instrument such as forceps andenergy devices has been progressing developed. As a result, the evaluation of their usabilityshould be required. In general 3D camera system has believed to be better than 2D camerasystem, however there is no report of proving advantage of the 3D camera by physiologicalassessment recoding during operating tasks. Multi-channel Electroencephalogram(EEG) isa well-known tool to assess the brain activity during tasks, and the beta band patternchanges in accordance to the brain activity We used the 128 channel EEG to evaluate thesurgeon’s brain activity in laparoscopic surgery.Method: The eight surgeons performed standardized skill tasks(‘‘Space pointing task(SPT)’’, ‘‘Move the ring’’ and ‘‘Ligation’’) in the training box. In our study, 128 channelelectroencephalograms were used. Continuous EEG was recorded with a 128 channel EGI(Electrical Geodesics Inc.). The electroencephalogram was measured continuously whileperforming the tasks. After recording, these data were passed through a digital low passfilter (30 Hz) and a digital high pass filter (3 Hz) to investigate alpha beta and theta bandpatterns during tasks. Each band pattern, alpha(8–13Hz), beta(13–25Hz) and theta(4–8Hz)were analyzed. The each band activity was expressed as a percentage of the total power ineach segment as 2D topography.Result: There was no significant difference of beta band patterns between using 2D cameraand 3D camera. In space pointing task, there was no significant difference of beta bandpatterns between novice group and expert group. However in performing the ‘‘Ligation’’and ‘‘Move the ring’’, significant differences of the beta band pattern between novice groupand expert group were noted.Conclusion: The 128 channels EEG can be the physiological evaluation to burden on thesurgeons. When the new device is used in laparoscopic surgery, it might be possible toprove usability with beta band patterns using the 128 channels EEG. And the assessment onlaparoscopic training progress might be possible.

P035

Biomechanical Comparison of the Immediate Fixation Strengthof Non-Traumatic Mesh Fixation Methods: LifemeshTM,TisseelTM, and ProgripTM

Charles P Shahan, MD1, Nathaniel Stoikes, MD1, Esra Roan, PhD2,

James Tatum, BS2, David Webb, MD1, Guy R Voeller, MD1,1University of Tennessee Health Science Center, 2University

of Memphis

Background: LifeMeshTM is a novel self-fixating mesh adhesive technology where large-pore, lightweight polypropylene mesh is embedded in a dry matrix of porcine gelatin andmicrobial transglutaminase enzyme. Non-traumatic mesh fixation is becoming more widelyaccepted, however little is known about the immediate fixation strength of these techniques.The purpose of this study was to compare the immediate strength of fixation for Life-MeshTM, ProGripTM, and TisseelTM.Methods: 7 Mongrel swine underwent implantation of two 4x7cm pieces of either Life-meshTM, ProGripTM, or polypropylene mesh fixated with 2mL of TisseelTM. 10 minutesafter application, the samples were excised with the abdominal wall and stored forimmediate biomechanical testing. The samples underwent lap shear testing to determine theimmediate fixation strength of these three technologies.Results: ProGripTM demonstrated mean fixation strength of 1.3 N/cm (± STE 0.2). Meanfixation for mesh fixated with TisseelTM was 2.6 N/cm (± STE 0.5). LifeMeshTM sampleshad mean fixation strength of 8.0 N/cm (± STE 2.1). Analysis of variance testing showedthat immediate fixation strength of LifeMeshTM was significantly greater than that of eitherProGripTM or TisseelTM (p=0.0004). ProGripTM and TisseelTM were not significantly dif-ferent from each other (p=0.06).Conclusions: Immediate strength of mesh fixation is an undescribed factor in hernia repair,but could have significant implications for early recurrence and mesh contraction. Whilefurther investigation is needed to define adequate interface strength, this comparison of non-traumatic mesh fixation methods shows that the novel LifeMeshTM technology exhibitsgreater strength than other non-traumatic fixation techniques.

123

Surg Endosc (2016) 30:S325–S500

DOI 10.1007/s00464-016-4771-7

and Other Interventional Techniques

P036

High Resolution Manometry - An Underappreciated Toolfor Examination of Dysphagia in a Surgical Setting

Jonas S Jensen, MD, Jan M Krzak, MD, Lars Stig Jorgensen, MD,

Lillebaelt Hospital, Kolding, Denmark

Introduction: Examination of dysphagia in Danish surgical departments, rely primarily on upper gastrointestinalendoscopy. When no visible or histological cause can be detected, esophageal motility disorders are important

differential diagnosis. In examining these disorders and in evaluating gastroesophageal reflux disorder (GERD), High

Resolution Esophageal Manometry (HRM), provide valuable insights.

The purpose of this study was to examine referrals and final diagnosis from HRM in a surgical center specializing in

esophageal disorders.

Methods and Procedures: All patients referred to HRM at our surgical center were included in the study and HRMwas performed from September 2013 to June 2015. All patients had previously undergone upper gastrointestinal

endoscopy at our center or the referring department. All procedures were performed using InSIGHTTM HRiM� andaccompanying software (Sandhill Scientific, Colorado, USA) and graded according to the Chicago-classification.

Referring department, referral-diagnosis, demographics and final HRM-diagnosis were prospectively collected and

analyzed.

Results: 438 patients were referred to HRM, primarily from our own department (N=350, 79,9%), other departmentsin our hospital (N=12 2,7%), private practice (N=20, 4,6%) and departments at other hospitals (N=56 12,8%).

Of the 390 procedures performed, the referral-diagnosis was motility disorder (n=161, 41,3%) and GERD (n=229,

58,7%). The mean age was 50,4±17,0 years (rage 16–86 years) with 58,5% female and 41,5% male. There were no

significant differences in age or sex when comparing the two groups.

Pathological findings were present in 197 cases. There was no difference in frequency of pathological findings

stratified for referral-diagnosis (p=0.11). Patients referred with suspicion of motility disorder had a significantly higher

frequency of abnormal bolus transit (p=0.02), achalasia (p\0.01) as well as EGJ-outlet obstruction and pseudoachalasia (p\0.01). Patients referred as part of investigation of GERD, had a significantly higher frequency of weak/ineffective motility (p=0.02). There was no difference in frequency of nutcracker/jackhammer esophagus between the

two groups (p=0.035)

At our surgical center, the rate of HRM per upper gastrointestinal endoscopy was 4,4% based on 8031 endoscopies. A

similar surgical centre in our area had, based on referral to our center, a HRM to endoscopy rate of 0.1% based on

10419 endoscopies.

Conclusion: HRM is an important diagnostic tool and supplements upper gastrointestinal endoscopy in examination ofdysphagia as well as GERD, with significant differences in patterns of motility disorders. Knowledge and availability

of HRM increases use at a surgical center, yielding better diagnostics of patients with suspected motility disorders.

P037

Compliance of the Abdominal Wall During LaparoscopicInsufflation

Chuck Becker, MEM1, Margaret Plymale, MSN, RN2, John

Wennergren, MD2, Crystal Totten2, Kyle Stigall1, J Scott Roth, MD2,1University of Kentucky College of Medicine, 2University

of Kentucky Department of Surgery

Introduction: To provide working space between the internal organs and abdominal wall, insufflation with carbondioxide is a common practice in laparoscopic surgeries. An insufflation pressure of 15mmHg is considered to be safe

in patients, but any amount of insufflation has peri-operative and post-operative cardiopulmonary and renal effects. As

a composition of viscoelastic materials, the abdominal wall should distend in a predictable manner given the pressure

of the pneumoperitoneum underneath during insufflation. The purpose of this study is to elucidate the relationship

between degree of abdominal distention and the insufflation pressure, with the goal of determining which patients’

abdomens may distend sufficiently without requiring 15mmHg pneumoperitoneum.

Methods: A prospective, IRB-approved study was conducted to video record the abdomens of patients undergoinginsufflation prior to a laparoscopic surgery. Photo samples were taken every 5 seconds, and the strain of the patient’s

abdomen in the sagittal plane could be determined, as well as the insufflator pressure (stress) at bedside. Patients were

insufflated to 15mmHg. The relationship between the stress and strain was determined in each sample, and a com-

pliance of the patient’s abdominal wall was calculated. In addition, patients enrolled had prior, previously indicated

abdominal CTs, which were used to calculate body parameters, such as abdominal fat thickness and rectus muscle

thickness. Correlations between abdominal wall compliances and adipose and muscle content were determined.

Results: Twelve patients studied were undergoing foregut laparoscopic procedures, whereas 9 were undergoingventral wall hernia repairs. Of patients studied without abdominal wall hernias (i.e., a structurally-intact abdominal

wall), the relative proportion of muscle in the abdominal wall had an inverse logarithmic relationship with abdominal

wall compliance (R2 = 0.66, p\0.05 given 3 degrees of freedom). Conversely, data is trending that an increasingproportion, as well as increasing absolute amounts of adipose tissue in the abdominal wall, produces a direct loga-

rithmic relationship with abdominal wall compliance (p=0.1). No change in compliance between patients with

abdominal wall hernias and without abdominal wall hernias was found.

Conclusion: The procedural standard for insufflation pressure during laparoscopic surgeries has been 15mmHg. As theabdominal walls of patients contain different amounts of adipose and muscle tissue, not all patients need the same

insufflation pressure to obtain the same degree of abdominal distention. Thus, it could be possible to tailor the

insufflation pressure used for patients with lower relative muscle mass, or who may be more susceptible to the side

effects of laparoscopic insufflation.

P038

Markedly Elevated Levels of Vegf, Ang-2, and MMP-2 in WoundFluid After Colorectal Resection Are Likely Responsiblefor Elevated Plasma Levels of These Proteins During the FirstPostoperative Month – Preliminary Results

Hmc Shantha Kumara, PhD1, Hiromichi Miyagaki, MdPhD2, Charles

Petrick, BS1, Xiaohong Yan, PhD1, Linda Njoh, PhD1, Vesna Cekic,

RN1, Nipa D Gandhi, MD1, Richard L Whelan, MD1, 1Department

of Surgery, Mount Sinai Roosvelt Hospital, New York, USA,2Department of Gastroenterological surgery,Osaka

University,Osaka,Japan

Introduction: Persistently elevated plasma levels of proangiogenic proteins including VEGF, Angiopoietin 2 (Ang2) andMatrix Metalloproteinase 2 (MMP2) have been noted for 3–5 weeks after colorectal cancer (CRC) resection. Whereas

increases early after surgery may be due to the brief acute inflammatory response, the origin of the week 2–5 elevations is

uncertain. We hypothesize that wounds are a major source since angiogenesis plays a critical role in wound healing. This

study’s purpose is to determine the levels of the above 3 proteins in fluid from intra-abdominal wounds taken during the 1st

month after CRC resection and compare them to previously determined postoperative plasma levels of the same proteins.

Method: The study population was CRC patients who agreed to enter an IRB approved wound fluid study. Woundfluid samples (WFS) collected via Jackson Pratt drains on postoperative day (POD) 1, 3, and a variety of later time

points were centrifuged and stored at -80�C. Late samples (POD 7–20) were bundled into 7 day blocks and consideredas single time points. VEGF, ANG2 and MMP2 levels were determined in duplicate via ELISA and reported as

mean± SD. The paired t-test was used for statistical analysis (significance p\0.05).Results: Nine cancer patients were studied (8 rectal, 1 colon; mean age 65.3± 2.3 years; surgical methods used:laparoscopic-assisted, 4; hand-assisted laparoscopic, 1; and lap. converted to open, 4 (mean incision length for lap &

hand, 6.4±4.3; for open 23±8.2). The mean length of stay was 7.8± 3.5 days. The cancer stage breakdown was; Stage

1, 25%, Stage 2, 38%, stage 3, 25% and stage 4, 12%. The range of wound levels noted after surgery were: VEGF,

1762–7586 pg/ml; ANG-2, 9082–17393 pg/ml; and MMP-2, 579–1216 ng/ml. Previously determined plasma levels in

similar CRC patients ranged from: VEGF, 164–371 pg/ml; ANG-2, 2671–4095 pg/ml; and MMP-2, 177–262 ng/ml.

Further, the POD 7–13 wound levels of VEGF, ANG-2 and MMP-2 were higher than the POD1 results.

Conclusions: When compared to previously determined postop plasma levels, wound levels of VEGF, ANG-2, andMMP-2 were 6 to 13 times higher. Also, wound levels continued to rise and peaked during the second (ANG-2) and

third weeks (VEGF, MMP-2) after surgery. These results suggest that the very high wound levels of these proan-

giogenic proteins contribute to the elevated plasma levels noted after surgery. The plasma changes may promote the

growth of residual tumor deposits after surgery.

P039

Gut Bacterial Translocation is Correlated with Stimulated Tlr4Signaling Pathways in a Rat Model of Abdominal CompartmentSyndrome

Adam Strier, MD3, Ibrahim Matter, MD3, Izhak Srugo, MD3, Nir

Bitterman, MD3, Gideon Sroka, MD3, Tatiana Dorfman, MD1, Yulia

Pollak, MD2, Igor Sukhotnik, MD3, 3Bnai Zion Medical Center,

Haifa, ISRAEL, 1Rambam Healthcare Campus, Haifa, ISRAEL,2Technion-Israel Institute of Technology, Haifa, Israel

Objective: Pneumoperitoneum is the basic step in every laparoscopic procedure, and has been established in previousstudies as a trigger for bacterial translocation. Toll-like receptor 4 (TLR-4) is responsible for the recognition of

bacterial endotoxin or lipopolysaccharide (LPS) and for initiation of gram-negative bacillary septic shock syndrome.

Our objective was to determine the effects of elevated intaabdominal pressure (IAP) on bacterial translocation and

TLR-4 signaling in a rat model of abdominal compartment syndrome (ACS).

Methods: Male Sprague-Dawley rats were randomly assigned to one of two experimental groups: control animals(CONTR) and ACS animals that were subjected to a 15 mmHg pressure pneumoperitoneum for 30 minutes. Rats were

sacrificed 24 hours later. Bacterial translocation (BT) to mesenteric lymph nodes, liver, portal blood and peripheral

blood were determined at sacrifice. TLR4-related gene and protein (TLR-4, myeloid differentiation factor 88 (Myd88)

and TNF-a receptor-associated factor 6 (TRAF6)) expression were determined using Real Time PCR, Westernblotting and immunohistochemistry.

Results: About 30 % of control rats exhibited BT toward the mesenteric the lymph nodes (level I), 20% toward theliver and portal blood (level II). ACS rats demonstrated a 80% BT to lymph nodes (Level I) and a 40% BT to liver

portal flow (Level II). Elevated BT was accompanied by a significant increase in TLR-4 staining in jejunum (51%) and

ileum (35.9%), as well as in a number of TRAF6 positive cells in jejunum (2.1%) and ileum (24%) compared to

control animals. ACS rats demonstrated a significant increase in TLR4 and MYD88 protein levels compared to control

animals.

Conclusions: 24 hours after induction of abdominal compartment in a rat model, elevated bacterial translocation rateswere accompanied by a stimulation of TLR4-signaling in intestinal mucosa.

123

S326 Surg Endosc (2016) 30:S325–S500

P040

The Validity for the Laparoscopic Colorectal Surgery Usingthe Absorbable Adhesion Barrier Made of Oxidized RegeneratedCellulose

Masanori Naito, MD, PhD, Masahiko Watanabe, MD, PhD, Ken

Kojo, MD, Takahiro Yamanashi, MD, PhD, Naoto Ogura, MD,

Hirohisa Miura, MD, Atsuko Tsutsui, MD, Takeo Sato, MD, PhD,

Takatoshi Nakamura, MD, PhD, Kitasato University, Department

of Surgery

Background: Clinical use of absorbable adhesion barrier made of oxidized regenerated cellulose(INTERCEED) is reported in the field of obstetrics and gynecology to prevent adhesion ileus. Meanwhile, in

the field of gastrointestinal surgery, sodium-hyaluronate / carboxymethylcellulose (Seprafilm) is reported to

be used as an absorbable adhesion barrier. However, Seprafilm is difficult to use with the trocars in

laparoscopic surgery.

Methods: We analyzed 50 patients who were performed laparoscopic colorectal surgery using INTER-CEED from 2013 to 2014 in Kitasato University. We investigated maneuverability of INTERCEED for

laparoscopic surgery. We used the VAS (Visual Analog Scale) for evaluation.

Results: We investigated the relationship between the length of the small incision and theease of trimming, the ease of intraabdominal delivery, the ease of extent in surgical site andthe stick to surgical site for the evaluation of maneuverability. Results showed that themean was 9 cm or greater by VAS for all investigation factors.Conclusion: We showed that INTERCEED has excellent maneuverability in laparoscopic surgery which theoperating space is narrow. INTERCEED is an extremely valuable medical resource, and we think that the

use of this material will be able to contribute extensively to the prevention of postoperative adhesions.

P041

Simultaneous Laparoscopic Surgery for Advanced Gastricand Colon Cancer

Hanae Matsumoto, Takashi Mitsui, Michiya Bando, Yoshinori

Oikawa, Noriyasu Tamura, Kawakita general hospital

Background: The safeness of simultaneous laparoscopic surgery for synchronous advanced cancer ofstomach and colon has not been fully verified. We’ll report our experience of simultaneous laparoscopic

surgery for total gastrectomy and left colorectal resection.

Case Presentation: A 71-year-old man was admitted to our hospital for his stomachache. On ComputedTomography (CT), we found that his colon and small bowel were filled with intestinal liquid due to

obstruction caused by descending colon cancer. We inserted a stent to alleviate the obstruction, which took

ten days. Before the operation for the colon, we did gastroscopy and found gastric cancer, 2 x 2 cm in size,

4cm from the esophagus-gastric junction. It was confirmed as poorly differentiated adenocarcinoma by

biopsy. No lymph node swelling or metastatic lesion was found on CT. Our diagnosis: gastric cancer

cStage1A (T1 N0 M0) and colon cancer cStage2 (T4a N0 M0).

Operation and Outcome: The trocar positions are shown in the following Fig. 1.Umbilical port (No.1)- we inserted a laparoscope from this port and performed extracorporeal anastomosis

on colorectal resection. We used 12mm trocars (Nos.2, 4, and 6) and 5mm trocars (Nos.3, 5, and 7). For

gastric cancer, we performed laparoscopic total gastrectomy with D1+ lymph node dissection and Roux-en-

Y reconstruction under Japanese guidelines. Simultaneously, for colon cancer, we performed laparoscopic

left colorectal resection with D3 lymph node dissection and functional end-to-end anastomosis. There were

no serious troubles during the operation: the operating time was 586 minutes and the estimated blood loss

200ml. On postoperative day (POD) 2, we performed upper gastrointestinal series, and found no leakage

from the esophageal gastrostomy and the small intestinal anastomosis. On the same day, the patient started

to drink water at lunch, and oral liquid diet at supper. He was discharged on POD7. Pathological exami-

nation of the stomach showed moderately differentiated adenocarcinoma invading the lamina propria and

that of the colon moderately differentiated adenocarcinoma invading the serosa. Under Japanese guidelines,

our final diagnosis was T1 N0 M0 fStage1A for the stomach cancer and T3 N0 M0 fStage2 for the colon

cancer. Recurrence has not been found for 8months since the operation.

Conclusion: We experienced simultaneous laparoscopic surgery for total gastrectomy and left colorectalresection with no complication. It will be safe and useful to perform simultaneous laparoscopic surgery for

advanced gastric and colorectal cancer for selective patients.

P042

Long Term Results of Laparoscopic Surgery Following LongCourse Chemoradiotherapy for Locally Advanced Rectal Cancer

Omer Jalil, Dr, Thanjakumar Arulampalam, Dr, Bruce Sizer, Dr,

Darren Boone, Dr, Roger Motson, Professor, ICENI Centre

Objectives: The treatment of locally advanced rectal cancer (LARC) has undergone significant change overthe last 20 years. Although surgical resection remains the mainstay of treatment, neoadjuvant radiotherapy

(CRT) may render LARC operable and enable sphincter preservation. In parallel, laparoscopic rectal cancer

surgery (LRS) has developed so that it is feasible to utilize this technique with its proven short term benefits

for pelvic dissection. This study assesses the outcome of patients who have undergone laparoscopic surgery

following CRT for LARC.

Methods: Between January 2004 and June 2012 consecutive patients undergoing LRS following CRT forLARC at our institution were entered into a prospective database. All surgery was performed in a specialist

laparoscopic surgical unit with surgery carried out by trained attending surgeons. Patients underwent

standard CRT if poor risk features were identified on MRI and the decision to treat was ratified by the

colorectal multidisciplinary team (MDT). All MRI protocols were standardized. CRT consisted of oral

Tegafur–uracil (UFT) and two-phase, conformal, external beam radiotherapy of 45–50.4 Gy in 25–28

fractions over 5 weeks. Clinical assessment was carried out twice weekly from 4 weeks post completion of

CRT and MRI was repeated at 6–7 weeks and 10 weeks with the median time to surgery being 12 weeks.

Patients underwent standard technique laparoscopic resection of the rectum. Data was collected on demo-

graphics, treatment regime, ASA grade, BMI, operative data, length of stay, complications defined by

Dindo, mortality and overall and disease free survival.

Results: 112 patients underwent CRT of whom 103 underwent surgical resection. Median follow up was 42months. Laparoscopic TME was carried in 89 (86.4%) patients with 11 (12.4%) conversions to open

surgery. 11 patients underwent open surgery and 3 patients underwent local resection. 30 day post operative

mortality occurred in 3 (2.9%) patients. Major complications occurred in 33% patients and minor com-

plications in 13% patients. Anastomotic leaks occurred in 14/59 (24%) patients of whom 7 patients required

surgical intervention. R0 resection was achieved in 92% of patients and complete pathological response was

seen in 21 (19%). The local recurrence rate was 11%. The overall, disease free and relapse free survival

were 57%, 49% and 67%.

Discussion: This study demonstrates the feasibility and safety of the laparoscopic approach for surgical resectionof rectal cancer following CRT in a specialist unit with structured training. Delaying surgery following CRT does

not seem to have an adverse oncological outcome.

P043

Comparison Between Laparoscopic Surgery and Open Surgeryfor Patients with Locally Advanced Colon Cancer by PropensityScore Matching

Shoichi Fujii, PhD1, Takahiro Yagi1, Mitsuo Tsukamoto1, Yoshihisa

Fukushima1, Takuya Akahane1, Ryu Shimada1, Keisuke Nakamura1,

Tamuro Hayama1, Takeshi Tsuchiya1, Keijiro Nozawa1, Keiji

Matsuda1, Hirokazu Suwa2, Atsushi Ishibe2, Jun Watanabe2,

Mitsuyoshi Ota2, Yojiro Hashiguchi, Prof1, 1Teikyo University,2Yokohama City University Medical Center

Background: Laparoscopic colectomy (LC) was not able to show non-inferiority in overall survival (OS)from results of JCOG0404 study that was RCT of LC versus open colectomy (OC) for the advanced colon

cancer. However, 5y-OS was 90% or higher in both arms, and the relapse-free survival (RFS) was also

equal. LC was favorable in the short-term results compared with OC. The transverse and descending colon

were excluded, and participated facilities were limited strictly in JCOG0404.

Purpose: To clarify whether LC is applicable as a standard surgery for patients with advanced colon cancerby analysis of treatment results

Patients & Methods: The short-term and long-term results were compared between 675 LC and 815 OC top-stageII/III of the colon and rectosigmoid cancers that were treated from 2000 to 2014. Because the

indication of LC changed over the years, the backgrounds were matched by propensity score matching. The

variables were as follows: gender, age ([70), ASA (2 or more), history of laparotomy, location (right orleft), pT4, diameter ([50mm), p-Stage, operator (certified surgeon by JSES), and observation time (3 years).Result: The conversion from LC to OC was 3.9% (26 patients). Each of the 379 patients was extracted bypropensity score matching. There was no difference in both groups’ backgrounds. In the short-term, the

results of LC were favorable in terms of blood loss (292ml:77), transfusion (9.0%:3.4), all early compli-

cations (35.9%:19.5), grade 2B (23.5:10.6), grade 3B (7.4:2.6) and postoperative stay (17days:14), however,

operative time (197min:214) was longer. In the pathologic findings, there were no differences in the number

of dissected lymph nodes (25.1:25.8), proximal margin (107mm:106), distal margin (108mm:101), and the

positive vertical margin (1.1%:1.3). In the long-term, the results of LC were excellent in 5y-OS

(79.4%:87.8). There was no difference in 5y-RFS between both arms (69.6%:74.9). LC was excellent in OS

(94.0%:92.8) of p-stageII in the analysis of each stage. There were no differences in the recurrence

(15.0%:18.7) and the first recurrent organs. Pathological T4 and p-stage III were risk factors in the analysis

of recurrence. The peritoneal recurrences of pT4 were higher in LC than OC (6.3%:16.1).

Conclusion: The short-term results of LC were excellent, and the long-term results were equal to OC. It wassuggested that LC was possible to be regarded as a standard surgery for most patients with advanced colon

cancer. However, it seemed that greater caution was necessary for T4 cases with respect to peritoneal

recurrence.

Fig. 1 .

123

Surg Endosc (2016) 30:S325–S500 S327

P044

Prophylactic Mesh for Prevention of Parastomal Hernia: A Meta-Analysis of Randomized Controlled Trials

Sunil V Patel, MD, Msc1, Sami A Chadi, MD, MSc2, Steve D

Wexner, MD2, 1Kingston General Hospital, 2Cleveland Clinic Florida

Introduction: The purpose of this meta-analysis is to determine if prophylactic placement of mesh in thoseundergoing stoma creation reduces the odds of developing a parastomal hernia.

Methods and Procedures: A meta-analysis was completed, after searching both EMBASE (1946 – 2015)and MEDLINE (1946 – 2015). Randomized controlled trials were included in our analysis if they assessed

the placement of prophylactic mesh vs. non placement in patients undergoing stoma formation. We included

both biologic and synthetic mesh, as well as any technique for mesh placement (preperitoneal, sublay). The

primary outcome was parastomal hernia formation at[1 year of follow up. Secondary outcomes includedparastomal hernia requiring surgical repair and perioperative complications. Subgroup analyses were

planned to assess the effect of biologic vs. synthetic mesh, mesh position (sublay vs. preperitoneal) and

method of diagnosis of parastomal hernia (clinical vs. imaging). Heterogeneity was explored using the I2

statistic. Risk of bias of included studies was assessed as per the Cochrane Handbook. The quality of

evidence was evaluated using the GRADE criteria.

Results: After title, abstract and full article screening, a total of 7 randomized controlled trials, with 395participants, fit the inclusion criteria. Included studies had similar patient characteristics between groups.

Four of 7 studies had a high risk of bias, while the other 3 had unclear risk of bias. Two studies used biologic

mesh. Three studies used a preperotineal placement of mesh, while 4 studies used a sublay mesh placement.

The pooled analysis showed a significant decrease in the odds of developing a parastomal hernia in the

prophylactic mesh group (OR 0.19, 95%CI 0.10 – 0.34, I2 = 47%). There was no evidence that placement of

mesh increased the odds of complications (OR 1.54, 95%CI 0.78 – 3.05, I2 = 53%) or the odds of patients

requiring surgical intervention (3 Studied, OR 0.76, 95%CI 0.27 – 2.14, I2 0%). The quality of evidence was

determined to be moderate.

Limitations: Moderate heterogeneity was seen in the assessed primary and secondary outcomes, whichcould not be explained through subgroup analysis.

Conclusions: There is moderate quality of evidence to suggest that prophylactic mesh reduces the odds ofparastomal hernia in those requiring a stoma. There is no evidence to suggest that placement of mesh

reduces the odds of surgical repair of parastoma hernia or increases odds of complications.

P045

Short Term Outcome of the Laparoscopic Colectomyfor Transverse Colon Cancer in a Single Institution

Ryuichi Sekine, Showa University Fujigaoka hospital

Background: The role of laparoscopic surgery in the treatment of transverse colon cancer remains con-troversial in Japan. The aim of the present study is to review the short term outcomes of the laparoscopic

surgery for transverse colon cancer.

Methods: Most cases were advanced cases. Our principle of the procedure is to perform D3 dissection andcomplete resection of mesocolon (CRM) for the advanced cases. Thirty-one patients underwent laparoscopic

surgery for transverse colon cancer in our hospital from February 2010 to November 2014. We conducted

partial resection of transverse colon, right hemicolectomy and left hemicolectomy depending on the location

and stage of the tumor. We reviewed short term outcomes including operative time, blood loss, postoper-

ative complication, conversion to open surgery, recurrence after resection.

Results: Patients with transverse colon cancer underwent 22 (70%) partial resection of transvers colon, 6(20%) right hemicolectomy and 3 (10%) left hemicolectomy. Median operative time was 240 min (125–555

min). Median blood loss was 100 mg (5–700 mg). Rate of postoperative complications was 12% (lymph

fistula: 10%, ileus: 3%). Conversion rate to open surgery was 3% because of the invasion to duodenum. So

far no recurrence case has been observed.

Conclusion: Laparoscopic resection of transverse colon cancer is technically feasible and not associatedwith a significantly higher rate of complications compered with laparoscopic resection for other colon

cancer.

P046

Laparoscopic Lateral Pelvic Lymph Node Dissection for LocallyAdvanced Rectal Cancer

Mitsuyoshi Ota, MD, PhD1, Jun Watanabe, MD, PhD2, Atsushi

Ishibe, MD, PhD3, Hirokazu Suwa, MD1, Masashi Momiyama, MD,

PhD3, Yasushi Ichikawa, MD, PhD4, Chikara Kunisaki, MD, PhD1,

Itaru Endo3, 1Gastroenterological Center, Yokohama City University

Medical Center, 2Surgery, Yokosuka Kyosai Hospital, 3Department

of Gastroenterological Surgery, Yokohama City University,4Department of Clinical Oncology, Yokohama City University

Purpose: Lateral pelvic node metastases occur in 10 to 20 % of locally advanced rectal cancer. Lessinvasive and effective lymph node dissection of lateral pelvic lesion is required when skipping routine

preoperative radiation therapy. We developed the technique for laparoscopic lateral pelvic node dissection

(LLPND) and assessed its feasibility.

Methods: Two areas of lateral pelvic region are dissected. One of which is the area alongthe obturator artery running in front of the internal obturator muscle. The other is the areaalong the internal iliac artery and its visceral branches which is enveloped in the endopelvicfascia with pelvic organs and its dominant nerves. To avoid nerve injury, the pelvic plexusshould be separated from the internal iliac artery and its branches.Results: From April 2012 to March 2015, 52 patients with clinical Stage II/III rectal cancerunderwent total mesorectal excision with LLPND. None of the patients received preoperativeradiation therapy. Forty two of the 52 patients received neoadjuvant chemotherapy. Sphincterpreserving operation was performed in 46 patients (79.3%). Average operation time and bloodloss were 411 minutes and 193ml respectively. Clavien-Dindo Grade 3 or worse morbidity ratewas 5.8% and none of the patients required urinary clean intermittent catheterization or fecalincontinence. Average number of harvested lymph nodes of lateral pelvic region was 11.6.Lateral pelvic node metastases existed in 8 (15.4%) patients; 5 in the internal iliac artery and itsvisceral brunch area, 1 in internal obturator area and 2 in both areas.Conclusion: Laparoscopic lateral pelvic node dissection can be performed safely. Togetherwith neoadjuvant chemotherapy, it may become an effective alternative for radiationtherapy in locally advanced rectal cancer.

P047

Minimally Invasive Colorectal Resection (MICR) Is Associatedwith Elevated Plasma Levels of Matrix Metalloproteinase 2(MMP2) During the First Month After Surgery Which MayPromote Tumor Growth and Metastasis

Hmc Shantha Kumara, PhD1, Hiromichi Miyagaki, MDPhD2, Charles

Petrick, BS1, Xiaohong Yan, MDPhD1, Linda Njoh, PhD1, Vesna

Cekic, RN1, Nipa D Gandhi, MD1, Richard L Whelan, MD1,1Department of Surgery, Mount Sinai Roosvelt Hospital, New York,

USA, 2Department of Gastroenterological surgery,Osaka

University,Osaka,Japan

Introduction: Matrix Metalloproteinase -2(MMP-2) degrades type IV collagen, a major component ofbasement membranes. MMP-2 plays important roles in tissue remodeling and wound healing but has also been

implicated in disease processes including cancer. Elevated MMP-2 activity has been linked to a poor prognosis

in lung, breast, prostate and colorectal cancer (CRC). MMP-2, by degrading basement membrane, facilitates

tumor cell invasion and metastasis formation. MMP-2 is also thought to promote tumor angiogenesis by

facilitating Endothelial Cell migration and VEGF release. The impact of minimally invasive colorectal

resection (MICR) for CRC on plasma MMP-2 levels is unknown. This study’s aim was to measure plasma

MMP-2 levels during the first postoperative (postop) month.

Method: CRC patients undergoing MICR who were enrolled in an IRB approved data/plasma bank forwhom adequate plasma samples were available were eligible. Prospectively gathered clinical, operative and

pathological data were utilized. Blood samples were collected Preop and at varying postop time points and

were stored at -80C. Only patients for whom Preop, Postop day (POD) 1, 3 and at least 1 late postop plasma

sample (POD 7–41) were available were included in the study. The late samples were bundled into 7 day

time blocks and considered as single time points. MMP-2 levels were analyzed in duplicate via ELISA and

the results reported as mean and ±SD .The paired t-test was used for analysis. (Significance, p\0.008 afterBonferroni’s correction).

Results: A total of 101 CRC (rectal, 27%; colon, 63%) patients that underwent MICR were studied (51 males /49 female, mean age 66.5± 12.8 years). The mean incision length was 8.2 ± 4.2cm and mean LOS 6.8± 4.1

days. The cancer stage breakdown was: Stage I, 34%; Stage II, 29%; stage III, 33%; and stage IV, 5%.The mean

PreOp MMP-2 level (ng/ml) was 176.8±40.6 (n=101). Significantly elevated mean plasma levels were noted

on POD1 (213.0±49.2, n=100,p=\0.0001), POD3 (256.3±65.9,n=90,p=\0.0001), POD7–13(227.5±60.2,n=75,p=\0.0001), POD 14–20 (236.0±45.9,n=29,p=0.003), POD 21–27 (231.0±64.2,n= 21,p=0.0003 and onPOD 28–41 time point (261.7±61.1,n=18,p=0.0005).

Conclusion: Plasma MMP-2 levels are significantly elevated from baseline for over 4 weeks after CRCMICR. The etiology of these changes in unclear, however, surgical trauma-associated inflammation may

account for the early increase whereas tissue remodeling associated with wound healing likely accounts for

the mid and late postop elevations. Increased MMP-2 levels may promote tumor growth in residual tumor

deposits and formation of metastases. Further study is warranted.

123

S328 Surg Endosc (2016) 30:S325–S500

P048

Usefulness of Needle-Guided Laparoscopic AbdominoperinealResection for Low Rectal Cancer

Takehito Yamamoto, Akiyoshi Kanazawa, Ryo Ohno, Hiroyuki

Matsubara, Toru Goto, Takuya Okamoto, Yoichiro Uchida, Shugo

Ueda, Akira Mori, Hiroaki Terajima, Kitano Hospital,The Tazuke

Kofukai Medical Research InstituteIntroduction: During laparoscopic abdominoperineal resection (APR) for low rectal cancer, prevention ofcircumferential resection margin (CRM) involvement is important. Laparoscopic APR is superior to open

APR because it allows for direct and precise visualization of the deep intrapelvic space. However, the local

recurrence and survival rates after APR are reportedly not lower than those associated with anterior

resection. One reason for this is the difficulty in properly resecting the levator muscles to prevent CRM

involvement. We implemented a method that allows for resection of the levator muscles without closely

approaching the rectal wall and that creates a cylindrical specimen.

Methods and Procedures: The mesorectum is dissected caudally to the level of the levator muscle, and theureter and pelvic autonomic nerves are carefully protected during dissection. The surgeon inserts the needle

through the perineum from the dorsal side of the anus to the internal aspect of the tip of the sacrum. The

levator muscles and fat tissue are resected laparoscopically following the needle, which emerges from the

levator muscles. The specimen is resected from the perineum following the needle, and the intra-abdominal

space is easily reached.

Results: Laparoscopic needle-guided resection of the levator muscles is safe and superior to the conven-tional procedure because it avoids the surgical waist caused by conventional APR and easily prevents CRM

involvement.

Conclusion: Needle-guided laparoscopic APR can be easily and safely performed to reduce CRMinvolvement. This technique contributes to the standardization of laparoscopic APR.

P049

Laparoscopic Sigmoidectomy for Complicated DiverticularDisease

Asem Ghasoup, MD, FACS1, Turki Al Qurashi, MD1, Mohammed

Widinly, MD1, Omar Sadieh, MD, FACS2, 1Security Forces Hospital

Makkah, 2Saad Specialty Hospital

Background: laparoscopic colo-rectal surgery has shown its advantages in terms of reduced post-operativepain, earlier recovery of intestinal peristalsis and shorter hospital stay.

Few studies reported results of laparoscopic surgery in complicated diverticulitis. The aimofThis study to analyze the results of laparoscopic sigmoidectomy in patients with fistulizedsigmoiditis.Methods: we reviewed 8 patients operated on for fistulized sigmoidectomy between January 2010 toDecember 2014, in a series of 60 laparoscopic colectomies. five patients presented with colo-vesical fistula,

two with colo-cutaneous fistula and one with complicatged colo-cutaneous and coli-vesical fistula and all

were caused by sigmoiditis. The procedure always consisted in laparoscopic sigmoidectomy with stapled

transanal suture and eventually closure of the cystic orifice.

Results: Mean age was 54 years (range: 39 to 70 years). Mean number of diverticulitis crises beforeoperation was 3 (range: 1 to 5). Mean time between the last crisis and operation was 32 weeks (range: 2 to

120 weeks).The mean operating time was 120 min (range: 90 to 180 min). Mean hospitalization stay was 5.7

days (3–12 days). Mortality rate was 0%. Postoperative morbidity (0%). Long-term follow-up demonstrated

no diverticultis recurrence.

Conclusion: laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized diverticularsigmoiditis if it is done by a trained surgeon.

123

Surg Endosc (2016) 30:S325–S500 S329

P050

Single Incision Plus One Port Laparoscopic Anterior Resectionfor Rectal Cancer

Yasuhiro Ishiyama, Yasumitu Hirano, Kenji Douden, Masakazu

Hattori, Yasuo Hashidume, Fukui Prefectural Hospital

Background: We have developed single-incision plus one port laparoscopic anterior resection of the rectum(SILS+1-AR) as a reduced port surgery in which we can utilize the incision for drainage as an additional

access route for laparoscopic procedures including the transection the lower rectum. In this retrospective

study, the perioperative and oncologic outcomes of SILS+1-AR were reported and showed surgical

procedure.

Methods: A Lap protector (LP) mini was inserted through a 2.5 cm transumbilical incision, and an EZ-access was mounted to LP and two 5-mm ports and one 12-mm port were placed in EZ-access. A 12 mm

port was inserted in right lower quadrant. Almost all the procedures were performed with usual laparoscopic

instruments, and the operative procedures were much the same as in usual laparoscopic low anterior

resection of the rectum using a flexible 5mm scope. The rectum was transected normally using only one

endoscopic linear stapler inserted from the right lower quadrant port.

Results: 124 consecutive patients underwent a single incision plus one port anterior resection for rectalcancer between August 2010 and March 2015. Mean operating time was 180 (range, 81–350) min, with an

estimated blood loss of 20 ml. No intraoperative complications or conversions to conventional laparoscopic

surgery. Four cases converted open surgery. Four patients required conversion due to the great size of the

tumor. 1 case necessitated additional ports. The median times to first postoperative liquid and solid intake

were 2 and 3 days, respectively. Most patients were discharged on postoperative day 10. Postoperative

complication occurred in the 124 of the 7 cases (5.9%) Complications included five anastomotic leakages

(4.0%), one intra-peritoneal abscess (0.8%), one small bowel obstruction (0.8%). The median follow up time

was 30 months. Six patients developed recurrence. One patient had died of local recurrence.

Conclusions: In our experience, a single incision plus one port laparoscopic anterior resection for rectalcancer has been shown to be safe and feasible, with operative and oncological outcomes comparable to

conventional laparoscopic surgery.

P051

Evaluation of the Lymphatic Flow at the Splenic Flexurein the Laparoscopic Colon Cancer Surgery

Jun Watanabe1, Mitsuyoshi Ota2, Yusuke Suwa1, Hirokazu Suwa2,

Masashi Momiyama3, Atsushi Ishibe3, Kazuteru Watanabe4,

HIdenobu Masui1, Kaoru Nagahori1, 1Department of Surgery,

Yokosuka Kyosai Hospital, 2Department of Surgery,

Gastroenterological Center, Yokohama City University, 3Department

of Gastroenterological Surgery, Yokohama City University Graduate

School of Medicine, 4Department of Surgery, NTT Medical Center

Background: Complete mesocolic excision (CME) and central vascular ligation (CVL) are nowadays stateof the art in the treatment of colon cancer that provides improved oncologic outcomes. However, the

treatment of colon cancer located in splenic flexure is not standardized because the lymphatic drainage at

this site is variable. It is considered that carcinoma at this site has dual lymphatic drainage of the Middle

colic artery (MCA) and left colic artery (LCA) areas and in addition, if it exists, accessory left colic artery

(aLCA) area. There is no systematic data in the literature on the frequency of lymphatic drainage root.

Purpose: The aim of this study is to evaluate the lymphatic flow at the splenic flexure.Methods: From July 2013 to June 2015, we enrolled consecutive patients of colon cancer located in splenicflexure with preoperative diagnosis of clinical N0. Primary outcome is frequency of the direction of lym-

phatic flow from splenic flexure. At first, we injected indocyanine green (2.5mg) to submucosal layer near

the tumor and observed lymphatic flow using the laparoscopic near-infrared camera system in 30 minutes

after injection.

Results: A total of 26 consecutive patients were enrolled in this study. These patients included 7 females,and had a mean age of 66.8 years, a mean body mass index of 23.3 kg/m2. A mean duration of operation was

220 minutes and a mean blood loss was 62 ml. The presence of aLCA rate was 38% (10 cases). The

prevalence of direction of lymph flow type was 7 cases (26.9%) for LCA area, 5 cases (19.2%) for LCA and

aLCA areas, 5 cases (19.2%) for MCA area, 3 cases (11.5%) for aLCA area, 2 case (7.7%) for MAC and

aMCA areas. Lymph flow not accompanying artery directed to the root of IMV was 4 cases (15.4%). 0 case

(0.0%) for LCA and MCA areas. There are 14 cases (53.8%) with lymph flow directed to the area of root of

IMV if aLCA exist or not. a number of retrieved lymph nodes (LNs) was 17.6 and fluorescence LNs was

10.7. LN metastases were 6 cases, but were all lymph flow areas domain by the fluorescence lymphatic flow

evaluation.

Conclusion: In CME and CVL for colon cancer located in splenic flexure, we should perform LN dissectionof the root of IMV area plus LCA area or MCA area by the fluorescence lymphatic flow evaluation, and LN

dissection of 3 areas is not necessary.

P052

Perioperative Outcomes in Laparoscopic Multivisceral Resectionof Primary Colorectal Cancer

Kazuhiro Sakamoto, Shunsuke Motegi, Yurika Makino, Shingo

Kawano, Kazuhiro Takehara, Shinya Munakata, Koichiro Niwa, Shun

Ishiyama, Kiichi Sugimoto, Hirohiko Kamiyama, Makoto Takahashi,

Hiromitsu Komiyama, Yutaka Kojima, Michitoshi Goto, Atsushi

Okuzawa, Yuichi Tomiki, Department of Coloproctological Surgery,

Juntendo University, Tokyo, Japan

Introductions: Laparoscopic surgery for colorectal cancer has been widely performed as a surgical treat-ment option. However, the use of laparoscopic surgery for locally advanced colorectal cancer invading or

adhering to adjacent organs or structures is controversial because of oncological and technical issues. The

aim of this study was to evaluate the feasibility of laparoscopic multivisceral resection of colorectal cancer.

Method: Between January 2010 and May 2015, 34 patients underwent multivisceral resection of primarycolorectal cancer invading or adhering to adjacent organs or structures. The tumors were located in the right

colon (n = 10), left colon (n = 18), and rectum (n = 6). Of the patients, 17 were male and 17 were female,

with a median age of 71 years (45–86 years).

Results: The distribution of the resected adjacent organs or structures was as follows: abdominal or pelviclateral wall, n = 7; small bowel or colon and rectum, n = 7; vagina or uterus, n = 7; peritoneum, n = 5;

bladder, n = 4; vessels, n = 3; and seminal vesicles and levator ani muscle, n = 1. One patient had two

resected organs (the bladder and small bowel). Conversion to open surgery occurred in 6 patients (17.6%).

Although intraoperative complications were observed in 3 patients, these complications were managed

laparoscopically. Postoperative complications occurred in 4 patients (11.8%), which were classified as grade

2 according to the Clavien-Dindo classification system. Reoperation was not required. The mean operation

time was 306 min (range, 252–556 min), and blood loss was 47 mL (10–450 ml). Pathological invasion to

other organs (pT4b) was confirmed in 17 patients (50%). Four patients had residual pathological tumors,

corresponding to an R0 resection rate of 88.2%. The pathological TNM classification was stage 2 in 14

patients, stage 3 in 11 patients, and stage 4 in 9 patients. The mean postoperative hospital stay was 11 days

(range, 8–22 days).

Conclusions: For primary colorectal cancers, the use of laparoscopic multivisceral resection is feasible forcarefully selecting patients and diagnosing the involvement of adjacent organs. Conversion to open surgery

before multivisceral resection is an important procedure to avoid dissemination of cancer cells and local

recurrence, if the tumor margin is unclear, or if massive adherence to adjacent organs or structures is

observed laparoscopically.

P053

Laparoscopic Colectomy with Intracorporeal Anastomosisfor Early-Staged Colon Cancer

Fumihiko Fujita, MD, Yusuke Inoue, MD, Masahiko Nakayama, MD,

Hiroko Kinoe, MD, Yuka Mine, MD, Shinichiro Kobayashi, MD,

Kengo Kanetaka, MD, Kosho Yamanouchi, MD, Kazuma Kobayashi,

MD, Tamotsu Kuroki, MD, Susumu Eguchi, MD, Nagasaki

University Graduate School of Biomedical Sciences

Introduction: Conventional laparoscopic assisted surgery for colon cancer requires small skin incision forthe extraction of the specimen and the ensuing anastomosis. For selected cases, we performed laparoscopic

colon resection with an intracorporeal anastomosis in order to reduce incision. We presented our surgical

technique and preliminary outcomes at SAGES meeting in 2012. At this time, we show our consecutive

surgical outcomes until now.

Methods and Procedures: We retrospectively collected the data, and analyzed the patients who underwentlaparoscopic colectomy from February 2011 to July 2015. The intracorporeal anastomotic method was

selectively performed only for early-stage colon cancer. The surgical technique was as follows. Four or five

trocars were used, and the surgeon uses a 3 or 5 mm in diameter grasper with the left hand. First, the lesion

lymph nodes are dissected. The lesion of the colon is transected using a linear stapler with adequate margins

on both the oral and anal cut ends. Both ends of the intestines were over lapped for 6cm in the opposite

direction. A laparoscopic linear cutting stapler is deployed through the bowel opening, to form a side-to-side

isoperistaltic anastomosis. The enterotomy is closed with full thickness 3–0 vicryl continuous suture, and a

seromuscular continuous suture is added. The resected specimen enclosed in a bag can be extracted through

one of the trocar sites without laparotomy. We compared the results of the intracorporeal anastomosis with

extracorporeal anastomosis, and analyzed the data for statistical significance.

Results: Laparoscopic intracorporeal anastomosis was successfully performed for 20 consecutive patients(10 male and 10 female). The average age was 66.3 years, and the locations of the tumors were 8 in the

sigmoid colon, 4 in the descending colon, 3 in the ascending colon, 3 in the cecum and 2 in the transverse

colon. The average length of the operation was 223.6 minutes, and the estimated blood loss was 19.2 ml.

There was no case that was converted to open surgery. Although one case was complicated by a wound

infection, there were no major complications, such as anastomotic leakage or stricture. Intracorporeal

anastomosis method was superior in estimated blood loss during the surgery to extracorporeal anastomosis

method, and there was no statistical difference in the operation time between two groups.

Conclusions: The laparoscopic intracorporeal anastomotic method can be performed safely, and has thebenefit of inducing minimal abdominal wounding and less blood loss in comparison to extracorporeal

anastomosis.

123

S330 Surg Endosc (2016) 30:S325–S500

P054

Alvimopan in the Setting of Colorectal Resection with an Ostomy:To Use or Not to Use?

Yuxiang Wen, BM, Murad A Jabir, MD, Michael Keating, BA,

Alison R Althans, BA, Justin T Brady, MD, Bradley J Champagne,

MD, Conor P Delaney, MD, MCh, PhD, Scott R Steele, MD,

University Hospitals Case Medical Center/Case Western Reserve

University

Introduction: Postoperative ileus (POI) is a major cause of morbidity, increasing length ofstay (LOS) and hospital costs after colorectal surgery. Many efforts have been made todecrease the rate of POI. Alvimopan is a mu opioid antagonist approved to accelerate upperand lower gastrointestinal function after bowel resection. We hypothesized that alvimopanwould reduce LOS in patients undergoing colorectal resection with stoma.Methods and Procedures: Over an 8 year period (2006–2014), 725 patients underwentcolorectal resection for both benign and malignant disease with stoma creation at a singleacademic medical center. The 58 patients who received alvimopan were matched to 116non-alvimopan patients based on age, diagnosis and procedure performed. We comparedoverall LOS, incidence of POI, and other postoperative complications.Results: There were 18 laparoscopic and 40 open resections in the alvimopan group and 23laparoscopic and 93 open resections in non-alvimopan group. 39 patients underwentresection for malignant disease and 19 patients underwent resection for benign disease inthe alvimopan group. Of the patients who did not receive alvimopan, 87 patients underwentresection for malignant disease and 29 patients underwent resection for benign disease.Mortality was similar at 0 vs. 1.7%. There was no significant difference in median LOS(alvimopan 5.89 vs. control 6.69 days, P=0.15). Reoperation rates (5.2% vs. 5.2%, p[0.05)and complication rates (43.1% vs. 52.6%, p=0.238) were comparable. Readmission ratewithin 30 days was similar between groups (alvimopan 22.4% vs. control 20.7%, P=0.793).Conclusions: The use of alvimopan in patients undergoing colorectal resection with stomais not associated with a shorter LOS, or decreased readmission or complication rates.Pending further larger clinical trials, alvimopan should be reserved for patients undergoingprimary anastomosis without diversion.

P055

Selective Lateral Pelvic Lymph Node Dissection: ComparativeStudy of Robot Versus Laparoscopic Approach

Hye Jin Kim, Gyu-Seog Choi, Jun Seok Park, Soo Yeun Park, Hee Jae

Lee, Kyungpook National University Medical Center, School

of Medicine, Kyungpook National University, Daegu, Korea

Background: Lateral pelvic lymph node dissection (LPND) is a challenging procedure dueto its technical difficulty and higher incidence of surgical morbidity. The present studycompared the short-term outcomes for laparoscopic versus robotic LPND in rectal cancerpatients.Methods: Between May 2006 and December 2014, prospectively collected data fromconsecutive patients who underwent robotic or laparoscopic total mesorectal excision(TME) with LPND were retrospectively compared. Data regarding patient demographics,perioperative outcomes, functional results, and initial oncologic outcomes were analyzed.Results: Fifty and 35 patients underwent robotic or laparoscopic TME with LPND,respectively. Bilateral LPND was performed in 10 patients (20%) in the robotic group and 6patients (17.1%) in the laparoscopic group. For unilateral pelvic dissection, the meanoperative time did not show significant difference between groups (robot vs. laparoscopicgroup, 41.0 ± 15.8 vs. 35.3 ± 13.4 min; P = 0.146), but the estimated blood loss wassignificantly lower in the robotic group (34.6 ± 21.9 vs. 50.6 ± 23.8 mL; P = 0.002). Twopatients (4.0%) in the robotic group and 7 patients (30.4%) in the laparoscopic groupexperienced Foley catheter reinsertion for their urinary retention, postoperatively (P =0.029). The impairment of urinary function, analyzed by total IPSS after surgery, was lowerin the robotic group. The mean number of harvested lateral pelvic lymph nodes was 6.6(range, 0–25) in the robotic group and 6.4 (range, 1–14) in the laparoscopic group. Duringmedian follow-up of 26.3 months, 2 patient in the robotic group and 4 patients in thelaparoscopic group experienced local recurrences.Conclusions: Robotic TME with LPND was safe and feasible with favorable short-termsurgical outcomes. Further large cohort studies and long-term follow-up are warranted.

P056

Comparison Between Younger, Middle and Elderly Patientsin Laparoscopic Surgery for Colon Cancer

Emiko Takeshita, MD, Yoshihisa Saida, MD, Toshiyuki Enomoto,

Kazuhiro Takabayashi, Sayaka Nagao, Yoichi Nakamura, MD,

Ryohei Watanabe, MD, Yasushi Nagaoka, MD, Natsuya Katada, MD,

Manabu Watanabe, MD, Koji Asai, MD, Shinya Kusachi, MD,

Department of Surgery, Toho University Ohashi Medical Center

Purpose: The aim of the present study was to assess the validity of laparoscopic surgery forcolon cancer in younger, middle and elderly patients.Patients and Methods: The subjects selected for this study were a total of 273 consecutivepatients who were diagnosed with primary colon cancer and those who underwentlaparoscopic surgery between January 2000 and December 2010 at our hospital. We ret-rospectively analyzed and compared the preoperative clinicopathological features of thethree different age groups: group A (32- 69years); group B (70- 79years)and group C (80-90years).Results: Therewere134 patients in group A, 98 patients in group B and 41 patients in groupC. The comorbidity of group A was 38%, group B was 53% and group C was 63%(P\0.01).The operation time of group A was 197.6±6.4 minutes, group B; 202.5±6.99 minutes andgroup C; 182.7±10.8 minutes (N.S.). The average blood loss of group A was 66.2ml, groupB; 53.5 ml and group C; 55.1 ml (N.S.). The average postoperative days for oral intake ingroup A was 3.2 days, group B; 3.1days and group C; 3.0 days. The rate of overallincidence of postoperative complication after laparoscopic surgery in group A was 17%,group B; 14% and group C; 17% (N.S.). The average hospital stay of group A was 11.6days, group B; 10.3 days and group C; 11.1 days (N.S.). Early postoperative mortality wasnull. Among the three age groups, there were no statistically significant findings in gender,Dukes stage and the grade lymph node dissection.Conclusions: These results suggest the efficacy of laparoscopic surgery for colon cancer inelderly patients in their 70s and 80s as well as in middle and younger patients.

P057

When You Gotta Go: A High Resolution Anal Manometry StudyEvaluating the Urge to Defecate in Patients with Mixed FecalIncontinence and Obstructed Defecation

Elyse LeeVan, MD1, Aaron Lewis, MD2, Alex Huang1, Gabriel

Akopian, MD1, Howard Kaufman, MD1, 1Huntington Hospital, 2City

of Hope

Objectives: In the past 5 years, three-dimensional high resolution anorectal manometry (3DHRAM) has replaced traditional perfusion catheters in the evaluation of defecatory disor-ders. Our objectives were to utilize 3D HRAM to identify physiologic differences betweengroups of female patients with fecal incontinence (FI), obstructed defecation, and mixeddisorders (both obstructive and incontinent symptoms), to evaluate these relationships inmale patients, and to determine the relationship between the rectal sensory threshold urge todefecate and sphincter function, specifically, mean resting sphincter tone, residual analpressure, and percent anal relaxation.Methods: A retrospective chart review of of 77 females and 27 males was performed usinganorectal physiology reports for patients undergoing 3D HRAM for evaluation of defeca-tory disorders between January 1, 2013 and April 1, 2015 at a single institution. Exclusioncriteria included patients with rectal cancer and ileal j-pouches. Remaining patients werecategorized into three groups: incontinent, obstructed, and mixed based on presentingsymptoms. Physiologic values including mean resting sphincter pressure, maximal squeezepressure, residual anal sphincter pressure, percent anal relaxation, and sensory threshold ofurge to defecate were recorded. Kruskal-Wallis tests were performed to assess differenceswith regards to physiologic variables between groups. Bivariate correlation tests wereperformed to assess the relationship between these variables within groups. SPSS wasutilized for statistical analysis.Results: Women with mixed defecatory disorders had mean resting pressures and maxi-mum squeeze pressures that were significantly different from patients with pure FI orobstruction. Men with mixed defecatory disorders had only mean resting pressures thatwere significantly different from patients with pure FI or obstruction. In females with mixeddefecatory disorders there was a positive correlation between the rectal sensory thresholdurge to defecate and the resting mean sphincter pressure, residual anal bear down pressure,and percent anal relaxation (p values 0.021, 0.036, 0.006 respectively). These relationshipswere not demonstrated in the incontinent or obstructed defecation groups.Conclusion: Females and males with mixed defecatory disorders demonstrate unique, butdistinct physiologic profiles that can be characterized using 3D HRAM. The female mixeddefecatory group demonstrates relationships between physiologic parameters that are notseen in the incontinent or obstructed groups. These relationships provide further insight intothe etiology of this poorly described disease process and may aid in developing treatmentregimens.

123

Surg Endosc (2016) 30:S325–S500 S331

P058

Extralevator Versus Standard Abdominoperineal Excision: DoesRadiotherapy Play A Part in Wound Breakdown?

A Musbahi, D Kamali, A Sharpe, Y Viswanath, A Reddy, James

Cook University Hospital, Middlesbrough UK

Introduction: Little data are available on post-operative outcomes of extralevator abdominoperinealexcision (ELAPE) such as wound complications, herniation and infections compared to standard

abdominoperineal excision (SAPE). ELAPE is purported to have a better oncological outcome than SAPE.

However, due to the larger perineal defect, it is postulated that there is a greater perineal wound breakdown

and herniation after ELAPE than SAPE. This study evaluated the association between wound breakdown

and the use of pre-op radiotherapy in either of ELAPE and SAPE.

Methods: Data were collected on all ELAPE and SAPE resections at a single major surgical unit for patientswith rectal cancer between January 2009 and December 2014. Information was collected on length of stay,

pre-op staging, histological grading, pre-op CEA measurement, pre-op CT and MRI results as well as post-

op complications including perineal wound breakdown, diabetes and immunosuppression status. Patient

notes and computer records were reviewed to obtain data on perineal wound complications, specifically

wound breakdown and symptomatic perineal herniation. Categorical data was analysed using Fisher exact

test where appropriate. A P value of\0.05 was considered as significant,Results: Data on 45 patients (35 male; mean age 67.4 years; 24 ELAPE and 21 SAPE) were recorded. 39/45(87%) patients had radiotherapy prior to surgery [20/24 ELAPE and 19/21 SAPE]. 10/24 ELAPE and 5/21

SAPE developed wound breakdown. 3/4 of patients with diabetes developed wound breakdown. Of the

ELAPE patients who had undergone prior radiotherapy, 7/20 had wound breakdown, one of whom was

diabetic. There was no significant difference in the number of patients with wound breakdown in the ELAPE

group with and without pre-op radiotherapy. 5/19 SAPE patients who had pre-op radiotherapy developed

wound breakdown. 2/5 were diabetics. The two remaining patients without adjuvant radiotherapy in the

SAPE group did not develop wound breakdown. Radiotherapy was not a significant factor in wound

breakdown in patients undergoing SAPE. There was no significant difference in wound breakdown in the

SAPE group between radiotherapy and wound healing. There was no perineal herniation in either group of

patients.

Conclusion: Radiotherapy is common in patients undergoing abdominoperineal resection of either type.Wound breakdown rates were high in both surgical group of patients, in particular those who underwent

ELAPE. However, radiotherapy was not a significant factor in wound breakdown between either group.

Furthermore, there was no significant difference in wound breakdown in diabetic patients in either group.

P059

A New Composite Program to Eliminate Anastomotic Leakagein Laparoscopic Colorectal Surgery

Hitoshi Idani, MD, FACS, Hiroyuki Araki, MD, Soichiro Miyake,

MD, Hisanobu Miyoshi, MD, Kazutaka Takahashi, MD, Toshihiko

Fujita, MD, Naoki Mimura, MD, Toshihiro Ogawa, MD, Yasuhiro

Komatsu, MD, Hiroaki Inoue, MD, Kenji Yamaguchi, MD, Hijiri

Matsumoto, MD, Yasuo Nagai, MD, Masao Harano, MD, Yasutomo

Ojima, MD, Noriaki Tokumoto, MD, Hiroyoshi Matsukawa, MD,

Takashi Kanazawa, MD, Yasuhiro Choda, MD, Daisuke Sato, MD,

Michihiro Ishida, MD, Shigehiro Shiozaki, MD, Masazumi Okajima,

MD, FACS, Motoki Ninomiya, MD, Department of Surgery

Hiroshima City Hospital

Background: Anastomotic leakage (AL) is still a crucial matter in colorectal surgery. We have introduced anew program to eliminate AL in laparoscopic colorectal surgery and evaluated the outcome.

Methods: Our program consisted of basic care and surgical protocol. The former included smoking ces-sation, control of blood sugar and nutrition, lactobacillus preparation, disuse of NSAIDS and continuous use

of aspirin. The latter included surgery with meticulous hemostasis, anastomosis by linear stapler in

colectomy and double stapling technique in anterior resection (AR) with reinforcement sutures at all staple

on staple site. Especially in AR, the left colic artery was reserved as long as possible, the rectum was

resected with one stapler or two (planned) in which staple on staple site was resected by circular stapler and

anastomosis was confirmed by intraoperative colonoscopy. Pelvic drain was used and trans-rectal decom-

pression tube was used if needed. From January 2014 to August 2015, 91 out of 226 patients who underwent

laparoscopic colorectal surgery were enrolled in this program. The occurrence of AL in every grade of

Clavien Dindo classification (CDC) was evaluated separately in colon surgery and in AR.

Results: There was no leakage in every grade of CDC in 61 colon surgery. Patients underwent AR consistedof 21 men and 10 women with a mean age of 64.3 years. Body mass index was 23.3. Location of the tumor

was Rs: 5/Ra: 14/Rb: 12. Comorbidities were as follows; diabetes mellitus: 4, aspirin use for coronary stent:

4, warfarin use: 2, chronic renal failure with hemodialysis: 1. High AR, low AR and super low AR were

performed on 5, 24 and 2 patients, respectively. Operation time and blood loss were 223 min and 32.8g,

respectively. The number of stapler used for rectal resection was one: 24, two: 6, three: 1. Bilateral

reinforcement sutures were achieved laparoscopically in 28 (90.3%) patients. Diverting ileostomy was

added on 4 patients. Pelvic drain was used in all patients, however, trans-anal tube was never used. The

distance from anal verge to the anastomosis was 5.9±1.8 cm. Mean postoperative stay was 10.4 days and

there was no leakage in every grade of CDC, whereas there were 6 leakages (grade 2/3: 4/2) in patients who

have not enrolled in this program.

Conclusion: Our new composite program can minimize the risk of anastomotic leakage in laparoscopiccolorectal surgery. Reinforcement sutures may play an important role to improve resistant pressure at the

anastomosis.

P060

Short & Middle Term Results of Lower Rectal Cancer Accordingto Procedure

Toshimasa Ishii, PhD, Shigeki Yamaguchi, Prof, Saitama medical

university international medical center

Purpose: Since April 2007 of hospital opening, we tried to perform intersphincteric resection (ISR) andlaparoscopic resection (Lap) for lower rectal cancer. This study was assessed short term results for recent 7

years.

Patients: One hundred fifty-four patients of curative advanced lower rectal cancer laparoscopic resection(Stage II, III) were included in this study. There are 107 males and 48 females. Each number of procedure

was; low anterior resection (LAR) 87, ISR 46, Abdomino-perineal resection (APR) 22. Thirty patients

received lateral lymphadenectomy. All cases of LAR and ISR had diverting stoma. The mean follow-up

length were 934.3 days.

Method: We analyzed retrospectively. Statistical analysis of short term results was performed using Stu-dent’s t-test and chisquare test method. 3-years disease free survival rate (middle term result) was calculated

using Logrank method.

Results: There in no motality and all patients returned to normal daily life after surgery. Mean operatingtime, mean blood loss count, and mean postoperative hospital stay (median) were LAR 259 min., 22 g, 10

days, ISR 332 min., 76 g, 9 days, APR 283 min., 94 g, 11 days, respectively. Regarding postoperative

complication rates, anastomotic leakage, intestinal obstruction, and wound infection were LAR 11.5 %, 13.8

%, 1.1 %, ISR 4.3 %, 8.7 %, 0%, APR -%, 0 %, 22.7 %. There were no difference of postoperative

complications between LAR and ISR and APR. But APR were difference of wound infection. There were no

difference of 3-years disease free survival rate (LAR 76.2 %, ISR 69.7 %, APR 81.9 %).

Conclusion: Short & middle term results of laparoscopic resection for lower rectal cancer in a single centerwere similar to that each procedure. Laparoscopic resection for lower rectal cancer was usually already

operations.

P061

Single Incision Laparoscopy as a Standard for ColorectalResections for Cancer

Elie K Chouillard, PARIS POISSY MEDICAL CENTER

Introduction: The concept of Natural Orifice Translumenal Endoscopic Surgery (NOTES) contributed tothe evolvement of single port laparoscopy. Accessing the abdominal cavity solely through the umbilicus

shifted laparoscopy from a multiport to a single port procedure. Proponents of this approach to further

reduce the invasiveness of laparoscopic surgery with fewer abdominal wall complications, less postoperative

pain, faster return to activity, and better cosmesis. This study reports the mid-term results of single port

colorectal resections for cancer (sCR) in our institution.

Methods and Procedures: All patients who had single port laparoscopic procedures were prospectivelyincluded in a database created in 2009. A single 25 to 35-mm diameter, umbilical (or right or left lower

quadrant) incision was used. Three 5-mm ports (or two 5-mm and one 12-mm) were inserted through a

special platform device. Exclusion criteria comprised total mesorectal excision, ASA III status, organ

insufficiency, and hemostasis disorders.

Results: From January 2009 to December 2014, sCR was attempted in 278 patients (right, left, transverse,total). During the same study period 111 patients were operated either openly or using standard multiport

laparoscopy. An analysis of the distribution of the procedures per year is performed.

Regarding patients who had sCR, the success rate without conversion to laparotomy was 89.7 %. Additional

procedures included cholecystectomy (24), oophorectomy (10), intraperitoneal chemohyperthermia (8),

duodenal resection (2), hysterectomy (7), and atypical liver resection (6). Mortality rate was nil. The overall

morbidity rate (mainly minor complications) was 12.8 %. Eleven patients had leaks (3.9 %).

Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with colorectal disease,either benign or malignant. Advantages regarding postoperative pain and length of hospital stay could be

demonstrated. However, larger scale, studies are needed for further evidence-based analysis, especially

regarding oncological outcome.

123

S332 Surg Endosc (2016) 30:S325–S500

P062

Outcomes of Surgery with Colonic Stents for Obstructive ColonCancer

Yu Sato, MD, PhD, Yoshimasa Gohda, MD, Tomoko Horie, MD,

Tsuyoshi Takaya, MD, Ryuichiro Suda, MD, Yasutaka Syuno, MD,

PhD, Hideaki Yano, MD, PhD, Department of Colorectal Surgery,

National Center for Global Health and Medicine

Objective: This study is aimed at evaluating the outcomes of colonic stents used as a bridge to surgery in themanagement of obstructive colorectal cancer.

Methods: We retrospectively identified nine consecutive patients who underwent colonicself-expanding metallic stents (SEMSs) as a bridge to surgery in the management ofmalignant colonic obstruction in our institution from July 2012 to December 2013. Themain outcome measures were the technical success rate, short-term results of surgery,recurrence and overall survival.Results: All patients had obstructive tumor in the left colon. Of these patients, 55.6% had localized coloncancer without metastasis. Procedural success was 77.8% (7/9). Clinical success was 66.7% (6/9). Elective

surgery was performed in 8 patients (7 laparoscopic, 1 open, 1 converted) and 1 emergency surgery in 1

patients for treatment of stent occlusion due to growth of tumor (1 stoma). Median time between stent

placement and surgery was 9 days (range 6–15). The postoperative complication rate was 22.2% (2/9). The

median postoperative hospital stay was 11 days (range 7–49). The recurrence rate was 50% and mean time

to recurrence was 13 months. Median survival was 27 months (range 13–37).

Conclusions: SEMSs provide an effective bridge to surgery treatment in patients with malignant colonicobstruction, allowing elective surgery with an acceptable complication rate. However, our results suggest

long-term outcomes of patients with a bridge to surgery might be worse.

P063

Propensity Score Analysis in Comparisons of Long-TermOutcomes for Locally Advanced Colon Cancer BetweenLaparoscopic Colectomy and Open Colectomy

Kiichi Sugimoto, Kazuhiro Sakamoto, Yuichi Tomiki, Michitoshi

Goto, Yutaka Kojima, Hiromitsu Komiyama, Makoto Takahashi,

Hirohiko Kamiyama, Shun Ishiyama, Koichiro Niwa, Shingo Ito,

Masaya Kawai, Shingo Kawano, Kazuhiro Takehara, Shinya

Munakata, Jun Aoki, Yu Okazawa, Rina Takahashi, Kousuke

Mizukoshi, Hisashi Ro, Ryosuke Ichikawa, Kazumasa Kure, Kumpei

Honjo, Ryoichi Tsukamoto, Department of Coloproctological

Surgery, Juntendo University Faculty of Medicine

Introduction: Laparoscopic colectomy (LAC) for colon cancer has been applied to locally advanced coloncancer. However, because there have been some biases in the indications between LAC and Open colectomy

(OC) for locally advanced colon cancer, we can’t simply compare the long-term outcomes between the two

procedure on non-randomized conditions. Here, we retrospectively compared the long-term outcomes

between LAC and OC using propensity score adjustment.

Methods: 226 patients who underwent colectomy (LAC: 98 patients, OC: 128 patients) for curative intent atour department between 2004 and 2010 were enrolled in the present study. Propensity score analysis was

used to adjust for differences in severity of clinicopathological factors between the patients who underwent

LAC and OC. The estimated probability that a patient underwent LAC was modeled for potential con-

founders: year of surgery (-2006 / 2007-), age, location (C, A / S, RS), invasion depth (T1–3 / T4), American

Society of Anesthesiologists (ASA) score (1, 2 / C 3) and the diameter of primary tumor (\50 / C 50mm).The discrimination of the propensity model was assessed with calculation of the c-statistic. The propensity

score was subsequently incorporated into a proportional hazards model as a covariate. The Cox propor-

tional-hazard model was used to determine Hazard ratios and 95% confidence intervals.

Results: There was a significant difference between the LAC group and the OC group in recurrence-freesurvivals (LAC; Hazard ratio= 0.59, 95% CI 0.35–0.98, P=0.04). On the other hand, there was no significant

difference in cancer-specific survivals between the two group (LAC; Hazard ratio= 0.63, 95% CI 0.27–1.37,

P=0.25). The median propensity score was 0.31 (0.09–0.93) in the LAC group, and 0.82 (0.08–0.99) in the

OC group (P\0.0001). The c-statistic was 0.85, indicating satisfactory discrimination. After propensityscore matching analysis, there were no significant differences between the LAC group and the OC group in

recurrence-free survivals (LAC; Hazard ratio= 0.91, 95% CI 0.41–2.01, P=0.82) and in cancer-specific

survivals (LAC; Hazard ratio= 1.38, 95% CI 0.41–4.82, P=0.59). Similarly, the analysis using the propensity

score inverse probability weighting (IPW) estimator showed that there were no significant differences in

both RFS and CSS.

Discussion: Propensity score analysis revealed that there was no difference in both recurrence-free survivalsand cancer-specific survivals between the LAC group and the OC group. Therefore, this results suggested

that LAC for locally advanced colon cancer would be equivalent to OC in long-term outcomes.

P064

Surgical Outcomes of Laparoscopic Right Colectomyin Octogenarians

Ron Shapiro, MD1, Uri Keler, MD1, Hatib Kamal, MD2, Guy Pascal,

MD2, Aviram Nissan, MD1, David Hazzan, MD2, 1Chaim Sheba

Medical Center, 2Carmel Medical Center

Introduction: Surgical morbidity rates are higher in the elderly when compared to younger age groups. Theaim of this study was to evaluate the impact of age on operative results of laparoscopic right hemicolectomy.

Methods: This is a comparative study, according to age groups, of patients who underwent laparoscopicright hemicolectomy for neoplasm of the right colon. Patients were divided into three groups: age\65 years(GroupA) age 65–79 (GroupB) and age[80 years (GroupC). Short and long-term outcomes were compared.T-Test was used for continuous variables and Chi Square was used for analysis of categorical variables.

Results: 207 consecutive patients were included in the study, 48 in group A, 105 in group B and 54 in groupC. There was no statistically significant difference in the groups in terms of BMI and gender. Octogenarians

(GroupC) included a higher proportion of patients with existing comorbidities (GroupC- 70.4%, GroupB-

54.3%, GroupA- 35.4%, p=0.002), higher proportion of patients with ASA 3 and above (GroupC- 70.4%,

GroupB- 52.4%, GroupA- 33.3%, p=0.001), and a higher proportion of patients operated on for colon cancer

as well as patients with existence of other active malignancy. There was no difference between the groups in

the extent of the operation performed (Right colectomy vs. extended right colectomy) and anastomosis

technique (intracorporeal vs. extracorporeal). The operative time was shorter in the Octogenarians group

(GroupC- 139 minutes, GroupB- 147 minutes, GroupA- 159 minutes, p=0.036). Octogenarians (GroupC)

needed more blood transfusions (GroupC- 9.3%, GroupB- 0%, GroupA- 2.1%, p=0.005). There was no

statistically significant difference between the groups in overall rate of postoperative morbidity and mor-

tality. Intra-abdominal infection (leak+abscess) rate was higher in the youngest age group (GroupA)

(GroupA- 8.3%, GroupB- 1%, GroupC- 1.9%, p=0.035). However, this did not result in differences between

the groups in terms of need for re-intervention and the Clavien-Dindo score. Length of stay was longer in

octogenarians (GroupC- 7 days, GroupB- 6.1 days, GroupA- 6 days, p=0.002). There was no statistically

significant difference in the occurrence of long-term complications, namely small bowel obstruction and

incisional hernia. Nevertheless, there was a trend towards a higher incisional hernia rate in octogenarian

(GroupC- 18.5%, GroupB- 7.6%, GroupA- 6.3%, p=0.061).

Conclusions: Laparoscopic right hemicolectomy does not result in increased morbidity and mortality inoctogenarians. Nevertheless, a longer recovery time should be expected when compared to younger age

groups.

P065

Safety & Efficacy of Synchronous Robotic Surgery for ColorectalCancer with Liver Metastases

Steven S Tsoraides, MD, Rozana H Asfour, MD, Matthew J Scheidt,

MD, J Stephen Marshall, MD, University of Illinois at Peoria

Introduction: Timing of resection & treatment of colorectal cancer (CRC) with liver metastases variesbased on patient characteristics & center protocols. Concerns of increased morbidity & mortality (M&M)

related to anesthetic time & blood loss have limited widespread adaptation of synchronous colorectal & liver

resections. Furthermore, technical challenges have made minimally invasive synchronous resections less

common. We present the first reported series of synchronous robotic surgery for CRC with liver metastases.

Methods & Procedures: Retrospective review of prospectively collected data of patients with stage IVCRC with liver metastases treated at a tertiary center from February 2013 to June 2014. Patients who

underwent synchronous robotic surgery for CRC with liver metastasis(es) were included & selected by a

multidisciplinary cancer committee. Data included patient demographics, disease stage, OR time, EBL, &

complications. All resections were performed robotically by the same well-experienced surgeons. A radi-

ologist was present for intraoperative ultrasound. Liver treatment was performed first in consideration of

intraoperative bleeding risk.

Results: Sixty-six patients with Stage IV CRC were seen at the tertiary center during the study period. Sixpatients met inclusion criteria (2 male, 4 female). Mean age was 59.3 years & mean BMI was 23.46. Mean

of 2 liver segments were involved. Four patients underwent metastatectomy; three with concurrent

microwave ablation. One patient had ablation without resection & another had no identifiable lesion on

ultrasound. The colonic resections included 3 low anterior resection, 2 abdominal perineal resections (APR),

& 1 right hemicolectomy. Mean operative time was 401 mins (349–506 mins) with mean EBL of 316 mL

(150–1000 mL). No conversions to an open approach occurred. Median length of stay (LOS) was 4.5 days

(3–10 days). Complications included delayed wound healing after an APR & a rectal anastomotic failure

after ileostomy reversal. There was no 30-day mortality. At a mean follow up of 19 months, one death

occurred at 26 months & the remaining patients had documented metastatic disease.

Conclusions: Synchronous resection for metastatic CRC carries risks. We report the first series of syn-chronous robotic surgery for CRC with liver metastases. The robotic approach contributed to low blood loss,

appropriate LOS, & no 30-day mortality. Morbidity experienced was consistent with the procedures & not

related to the robotic technique. This series supports the potential benefits of synchronous resection from a

technical standpoint. Further data is required to determine treatment & survival benefits. Limitations include

small number & retrospective review of data.

123

Surg Endosc (2016) 30:S325–S500 S333

P066

The Methodology to Stylize the Laparoscopic Surgery for ColonCancer for Education and Tradition

Hidekazu Takahashi, MD, Ichiro Takemasa, MD, Naotsugu

Haraguchi, MD, Junichi Nishimura, MD, Yasushi Hata, MD,

Hirofumi Yamamoto, MD, Tsunekazu Mizushima, MD, Yuichiro

Doki, MD, Masaki Mori, MD, Osaka University Graduate School

of Medicine, Gastroenterological Surgery

Recent laparoscopic surgery benefit surgeons due to the microscopic effect of the targetsand knowledge of micro-anatomy obtained through high quality visualizations under HDimage. Thus, by performing laparoscopic surgery with fine and accurate manipulation,surgeons could pursuit high quality and convincing procedures yield to the proceduresconducted by conventional operation through major laparotomy. However, acquisition ofappropriate technique for laparoscopic surgery is challenging and surgeons should at leastaware of laparoscopic-surgery specific weak point such as difficulty of acquisition of wideand bird visualizations to accomplish safe and adequate procedure. In this line, for edu-cation and tradition of laparoscopic surgery, adequate training and standardized techniquethought to be critical.Here, we present our original efforts to overcome these difficulties in laparoscopic surgeryfor colon caner. First, 3-dimentional (3D)-triple fusion virtual images, which were con-structed from multi-directional computed tomography (MDCT)/positron emissiontomography (PET) and air-colonography, were routinely obtained for decision of operativestrategy; e. g., dimension of lymph node dissection and location of ligation of the vessels,shared by all operative team members preoperatively. Second, perioperatively, surgeonsrefer obtained 3D-triple fusion virtual images for the navigation surgery on demand. Bydoing these, surgeons could perform dissection by carefully tracing the ‘‘embryologic tissueplane’’ to accomplish complete mesocolic excision (CME) and central vascular ligation(CVL) which thought to be indispensable for curative resection for colon cancer.From 2004 to 2011, 511 laparoscopic surgery for advanced colon cancer were performed inline with our original efforts described above. The mean operative time was 175mins andthe mean blood loss was 30g. Five-year disease free survival rate was 86.7% at stageII and76.1% at stageIII, respectively. Since 2009, we have been applied our method for singleincision laparoscopic surgery and performed 350 cases. In the presentation, we also showrepresentative movie of the case of single incision laparoscopic hemi-right colectomy.

P067

Robotic Surgery for Rectal Cancer in Our Center -First 50Resection

Chu Matsuda, Katsuki Danno, Susumu Miyazaki, Kazumasa Fujitani,

Masar