34. Esophagectomy totally laparoscopic after neoadjuvant chemoradiation

S78 3. Opening retroperitoneal spaces (pararectal and paravesical) on both sides 4. Identifying and ligation of both ovarian vessels above the pelvic rim 5. Complete mobilisation of both ureters 6. Retroperitoneal ligation of round ligaments and uterine arteries 7. Dissection and resection of mesorectum until 2e3 cm below the Douglas pouch 8. Opening the anterior and posterior vaginal wall 9. Closing the vaginal cuff 10. Dissection of the rectovaginal space 11. Division of the sigmoid colon above the tumor 12. Division of the rectum below the Douglas pouch 13. Bulky pelvic nodes removal 14. Rectosigmoid end-to-end anastomosis with circular stapler. 15. Anastomotic leakage test Results: No macroscopic residual disease in pelvis was achieved in 100% cases. The median duration of the whole surgical debulking procedure, including en block resection was 280 min and the median hospital stay was 12 days (range: 7e44 days). Complications included: postoperative ileus (n ¼ 4), wound infection (n ¼ 4), anastomosis dehiscence (n ¼ 2), reoperation (n ¼ 2), and death (n ¼ 1, pulmonary embolism). Six patients required total parenteral nutrition. The median follow-up time was 28 months (range: 8e31 months). No patient experienced a recurrence of pelvic disease. Conclusion: The procedure often block resection of pelvic peritoneum, uterus, adnexa and rectum form the retroperitoneal approach is effective in term of achieving R0 cytoreduction and has acceptable morbidity in patients with AOC. Conflict of interest: No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2016.06.037

32. Body gastric cancer: Laparoscopic total gastrectomy C. Vendrame, B. Bodanese Regional Hospital of the West, Oncology, Chapeco, Brazil Background: Gastric cancer is among the most prevalent malignant neoplasm in the world. The laparoscopic approach is becoming more and more popular in recent years. Materials and methods: Patient AC, female, 39-year-old, previously asymptomatic, with no family history of malignant neoplasia, conducted an upper gastrointestinal endoscopy which showed mild enanthematous gastritis associated with an injury of 2  1.5 cm in the gastric body near the greater curvature, the biopsy was of an adenocarcinoma with signet ring cells. Chest and full abdomen tomography was conducted, to determine the staging, and showed no lymphadenomegaly or metastases in distance. As for the positioning of the team, the surgeon was positioned to the patient’s right side, the cameraman between her legs, and the first assistant to the patient’s left. The monitor was also positioned to the patient’s left but in a superior position. In some situations the surgeon and the cameraman switched positions. For this procedure the team used 6 trocars, one of 11 mm, another of 12 mm, and four of 5 mm. The energy used was the monopolar Hulk type and bipolar sealer and divider (LigaSureÒ). Endoscopy was performed during surgery to locate the lesion. According to histology, patient age and lesion location, a total gastrectomy with D2 lymphadenectomy was chosen. The reconstruction was done with Roux-en-Y and esophagusjejunal anastomosis with circular stapler (No. 25) was performed. Results: Total surgery time was of 310 min; blood loss was estimated at 150 ml. The patient had a good recovery after surgery. Enteral nutrition was initiated on the first postoperative day via jejunostomy. The liquid diet was introduced on the fifth postoperative day. The patient was discharged on the seventh day of hospitalization with full liquid diet. The increase of

ABSTRACTS food intake was weekly and on the thirtieth postoperative day the jejunostomy tube was removed and the diet was progressed to free. The anatomical pathology was of a gastric adenocarcinoma with signet ring cells, free margins, without angiolymphatic invasion, 39 lymph nodes were resected, all cancer-free. In the two following years up to the present day no evidence of disease recurrence has been found. Conclusions: Laparoscopic total gastrectomy with D2 lymphadenectomy has been shown to be feasible and safe in selected cases. Conflict of interest: No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2016.06.038

33. GIST: Partial gastrectomy C. Vendrame, B. Bodanese Regional Hospital of the West, Oncology, Chapeco, Brazil Background: The gastrointestinal stromal tumor (GIST) is relatively rare, sometimes its location is in an inconvenient position for resection, which makes the surgery and reconstruction more difficult. Materials and methods: This video shows the resection technique of a GIST in a 48-year-old female patient complaining of abdominal pain. The patient underwent a endoscopy, showing a bulging of the gastric mucosa located in the posterior wall of the gastric body, near the lesser curvature, measuring about 5 cm in its largest diameter, in computed tomography of the abdomen its size is of 3.5 cm in its largest diameter, with progressive and persistent contrast-enhanced. The tumor had a slow growth compared to a prior exam made one and a half years before in another service, suggesting a leiomyoma or a low-grade GIST. As for the positioning of the team, the surgeon was positioned to the patient’s right, the cameraman was between patient’s legs, the first assistant to the patient’s left, and the monitor, also, to the patient’s left in a superior position. For the procedure the team used 5 trocars, two of 11 mm and three of 5 mm, the energy used was the monopolar Hulk type and bipolar sealer and divider (LigaSureÒ). For reconstruction was used PDS 30 for two-plane continues suture. Results: Total surgery time was of 75 min and blood loss was negligible. The patient had a good postoperative evolution, starting a liquid diet on the first postoperative day, being discharged five days after surgery with a thickened liquid diet. The anatomical pathology was of a GIST of low-grade, without mitosis, with 4.5 cm, free margins. The findings were confirmed by immunohistochemistry. Conclusions: The resection of GIST by laparoscopy is feasible even when the tumors are located in the proximal body and near the lesser curvature, provided that there is the possibility for a good exposure of the tumor and for adequate margins. Conflict of interest: No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2016.06.039

34. Esophagectomy totally laparoscopic after neoadjuvant chemoradiation C. Vendrame, B. Bodanese Regional Hospital of the West, Oncology, Chapeco, Brazil Background: Esophageal cancer presents itself as a localized disease in approximately 22 percent of all cases, regional disease accounts for another 30 percent of patients. The goal of surgical management is curative, and a surgical resection is the traditional mainstay of multidisciplinary therapy for patients with localized disease. Surgical management is independent neoadjuvant therapy. Materials and methods: A 48-year-old female patient (JS) with progressive dysphagia for solids for 45 days. The patient underwent endoscopy, which identified a vegetating lesion of 25 cm from the upper dental arch extending itself to the mark of 29 cm. The biopsy confirmed a well-differentiated squamous cell carcinoma. The cancer staging was

ABSTRACTS done with CT of the chest, which showed lesion in the transition from the mid-distal esophagus in contact with 35% of the circumference of the aorta, the abdominal CT showed no alteration. The patient presented a “performance status 1”, and had a significant weight loss, dysphagia went to solid and pasty in 15 days. The patient underwent nutritional assessment and nasoenteric tube was indicated, however the patient refused it and jejunostomy was used. The multimodal treatment plan includes neoadjuvant chemoradiation with the CROSS trial scheme, which is the protocol adopted in our service (Weekly paclitaxel plus carboplatin plus concurrent RT 41.4 Gy over 5 weeks), followed by surgery 4 weeks after radiotherapy. Before surgery a new CT was performed to re-stage the cancer, and it showed a decrease in the esophageal injury and the cleavage plane with the aorta. The patient tolerated all the proposed treatment. The surgery began from the chest with left lateral decubitus (LLD). LLD was opted due to the size of the lesion and the possibility for a switch to open surgery. After dissection of the esophagus and the mediastinal lymph nodes the patient adopted the supine position with the legs opened to the abdominal time, with dissection of the stomach and preparation of the gastric tube. Anastomosis was cervical on two levels with separate stitches. Results: Total surgery time was of 240 min, estimated blood loss was of 300 ml, the patient began her diet by jejunostomy on the first day, on the fifth day a test with blue dye was performed and an orally diet with clear liquids was started. The patient was discharged on the eighth day with full liquid diet. The diet progressed on an outpatient basis, on the tenth day soft and liquid diet, on the fifteenth day soft diet and on the forty-fifth day it evolved to free diet with the removal of the jejunostomy. The anatomical pathology had a complete pathologic response (pCR) having all the 25 lymph nodes identified as cancer-free. Conclusions: The laparoscopic esophagectomy is a safe surgery and as it is minimally invasive, it allows us to have an early hospital discharge, even in larger lesions. Conflict of interest: No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2016.06.040

35. Pancreaticoduodenectomy with partial resection of pancreatic body and tail for a multifocal neuroendocrine tumor A. Lukashenko, O. Kolesnik, V. Zvirich National Cancer Institute, Abdominal Oncology, Kiev, Ukraine Background: Pancreatic neuroendocrine tumours are considered a relatively unusual oncologic entity. Due to its relative good prognosis, surgery remains the goal standard therapy not only in localized disease but also in the setting of locally or metastatic disease. Material and methods: The following article demonstrates the technical aspects of pancreaticoduodenectomy with resection of pancreatic body and tail for a multifocal neuroendocrine tumor. The indication for intervention in the underlying case was a patient diagnosed with a multifocal neuroendocrine tumor infiltrating caput, body and tail of the pancreas. Results: The resection was carried out in open way, and the reconstruction, which included «duct-to-mucosa» pancreaticojejunostomy a biliodigestive anastomosis and a gastroenterostomy, was carried. The total operative time was 245 min. The blood loss accounted for 200 ml. The postoperative course was uneventful, and the patient was discharged on the eighth postoperative day. Conclusions: Pancreaticoduodenectomy with resection of pancreatic body and tail is a treatment option in carefully selected indications. The

S79 complexity of the operation demands a high level of expertise in the surgical team. Conflict of interest: No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2016.06.041 36. Transanal total mesorectal excision (TaTME) for rectal cancer M.C. Arroyave Isaza, J.T. Marta, J.S. Tre´panier, M. Fernandez-Hevia, B. De Lacy, A. Otero, A.M. Lacy Hospital Clinic, Gastrointestinal Surgery, Barcelona, Spain Background: The transanal total mesorectal excision (TaTME) is now available to the surgical community in order to solve several issues with previous surgical approaches. It can be performed by a single surgical team or through combined and simultaneous dissection by two surgical teams (the Cecil Approach). Materials and methods: We present a video of a Low Anterior Resection with TME transanally and transabdominally (Cecil approach). 83 year-old woman with high blood pressure, dyslipidemia and Barrett’s esophagus. Due to rectal bleeding, the patient was diagnosed with rectal cancer 7 cm from the anal verge. Baseline staging revealed a mriT3N1 lesion plus resectable lung metastases by CT-Scan. Patient received chemoradiotherapy with moderate response to a mriT2N0. Results: The patient was placed in a lithotomy position. Four trocars were used transabdominally, a 12 mm trocar was placed umbilically for the camera, and three 5 mm trocars were also placed, two in the right iliac fossa and one in the left hemiabdomen. A gel cap platform was used for the transanal approach. The mesosigmoid peritoneum is incised to define the correct posterior plane. The inferior mesenteric artery is individualized and proximally ligated. Simultaneously the transanal approach is performed. After visualizing the rectal tumor, a purse string suture is made to close the rectal lumen. The down to up dissection is begun in a circumferential manner. We usually begin on the anterior side, where you can see some fibrosis secondary to the preoperative treatment. We continue on the posterior side dissecting the mesorectum and on the lateral side connecting the anterior and posterior planes following the “holly plane”. At the same time, the abdominal dissection is continued into the pelvic space to perform a total mesorectal excision. The left lateral side is also incised taking care not to damage the vessel and nerves. The rendez-vous between both teams is achieved, thanks to the combined work. Once the correct plane is achieved, we can continue the abdominal dissection applying the right traction. A prolene purse string on the distal rectum is made to perform the mechanical anastomosis. The correct proximal colon position is checked. The colorrectal anastomosis is checked for leakage or bleeding. Diverting ileostomy was performed. Patient was discharged on the fifth postoperative day with no complications. The ileostomy was reverted after one month. Pathology results: Moderately differentiated adenocarcinoma with fibrosis. Proximal and distal margins tumor-free. No lymph node metastases. Complete mesorectum. pT2N0. Conclusions: TaTME is a feasible and safe technique that brings several advantages in rectal cancer surgery. Conflict of interest: No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2016.06.042