- Email: [email protected]
365 Extended Duration Thromboprophylaxis Cost-Effectiveness in Abdominal Surgery
free subjects, 13 having undergone PPPD, and in 13 after the Whipple procedure (Table1). Gastric emptying was measured by the paracetamol absorption method. Plasma concentrations of glucose, insulin, GLP-1, and paracetamol were measured at baseline, 10, 20, 30 60, 90, 120, 150, and 180 minutes. Homeostasis model assessment-estimated insulin resistance (HOMA-IR) and oral glucose insulin sensitivity were calculated from glucose and insulin concentrations. RESULTS. Patients with Whipple procedure as compared to PPPD had accelerated gastric emptying (p=0.01) which correlated with early (0-60 min.) integrated GLP-1 (AUC30; r2=0.61; p=0.02) and insulin sensitivity (r2=0.41; p=0.026), and inversely with HOMA insulin resistance (r2=0.17; p=0.033). 2 of 13 Whipple patients (15%) as compared to 7 of 13 after PPPD (54%) had postload glucose concentrations (i.e. 120 minutes postmeal) ≥200 mg/dl (p,0.05). None of 13 (0%) after Whipple procedure but 4 of 13 (31%) after PPPD had fasting glucose concentrations ≥126 mg/dl (p,0.05). CONCLUSIONS. Gastric emptying was accelerated after Whipple procedure as compared to patients who have undergone pylorus preserving PD, resulting in higher postprandial GLP-1 concentrations and insulin sensitivity and improved glycemic control.
365
Background: Post-discharge thromboprophylaxis is the practice of prescribing antithrombotic therapy for 21 days after discharge, commonly used in surgical patients who are at high risk for venothromboembolism (VTE). Multiple consensus guidelines recommend extended duration thromboprophylaxis (EDTPPX) after major abdominal oncologic resections based on randomized clinical trials demonstrating a significant reduction in VTE events after surgical discharge in these patients. While the National Comprehensive Cancer Network suggests all major abdominal oncologic resections receive EDTPPX, the American College of Chest Physicians suggests an individualized risk assessment, with only high risk patients undergoing oncologic resections suggested to receive EDTPPX, however, high risk is not currently defined. The threshold for high risk ought to be informed by when it is costeffective to provide EDTPPX, which has not previously been established. In order to further inform current guidelines this study sought to determine the VTE incidence threshold for the cost-effectiveness of low molecular weight heparin for 4 weeks after surgery as compared to inpatient prophylaxis only. Methods: A cost-effectiveness decision tree was created using TreeAge (Figure 1). Assigned probabilities were derived from published literature. The decision point compared extended duration thromboprophylaxis with low molecular weight heparin for 21 days after discharge to inpatient-prophylaxis alone, with base case assumptions (table 1) based on an abdominal oncologic resection without complications in a 45 yearold male. The end points were pulmonary embolism or deep vein thrombosis with attendant costs and assigned effectiveness evaluated by Quality Adjusted Life Years (QALY). Willingness to pay was set at $50,000/QALY. Sensitivity analyses were performed to assess uncertainty within the model, with particular interest in the threshold for cost-effectiveness based on VTE incidence. Results: Given base case assumptions with VTE probability of 4%, extended duration thromboprophylaxis had an incremental cost effectiveness ratio of $8123/QALY, which was considered cost-effective. The results were robust to sensitivity analysis with the highest uncertainty associated with VTE incidence and medication cost. The threshold for the relative cost-effectiveness was a VTE incidence exceeding 2.53%. Conclusions: Given the base case assumptions, extended prophylaxis is more cost effective than inpatient prophylaxis alone, and the threshold for its use should be cases where the estimated VTE risk exceeds 2.53%. These findings should inform future guidelines' definition of "high risk" and individualized risk scores should be developed to predict patient likelihood of post-discharge VTE. These results can lead to specific individualized EDTPPX application. Table 1:Baseline Model Assumptions and Sensitivity Analysis
363 Safety and Efficacy of Portal Vein Embolization Before Planned Major Hepatectomy: An Institutional Experience of 358 Patients Junichi Shindoh, Ching-Wei D. Tzeng, Thomas Aloia, Steven Curley, Giuseppe Zimmitti, Steven Y. Huang, Armeen Mahvash, Sanjay Gupta, Michael J. Wallace, Jean-Nicolas Vauthey Introduction: Portal vein embolization (PVE) induces hypertrophy of the future liver remnant (FLR) in patients with unfavorable tumor distribution and low calculated standardized FLR (sFLR). We sought to evaluate the safety and efficacy of PVE. Methods: We evaluated 358 consecutive patients who underwent PVE before intended major hepatectomy from 19952012. Diagnoses, morbidity, degree of hypertrophy (DH), and post-PVE resectability were evaluated in the whole study period and compared over time. Results: The diseases treated included colorectal liver metastases (CLM, 217, 61%), hepatocellular carcinoma (49, 14%), extrahepatic biliary cancers (31, 9%), neuroendocrine metastases (25, 7%), intrahepatic cholangiocarcinoma (13, 3%), and others (23, 6%). Right PVE alone was performed in 31% of cases; due to tumor distribution and to the necessity of resecting segment IV, right PVE with segment IV PVE was required in 66% of patients. The first-session PVE success rate was 98%. Post-PVE complications occurred in 12/358 patients (3%), with portal vein thrombosis occurring in 6 (2%) patients. Median pre-PVE standardized FLR (sFLR) was 19% (inter-quartile range, IQR, 15.0-25.9). Median post-PVE sFLR was 30% (IQR, 22.538.2). Of 358 patients who underwent PVE, 282 (79%) were taken to the operating room with 240/358 (67%) undergoing curative hepatectomy. Post-hepatectomy major complications occurred in 62/240 (26%) patients, with postoperative hepatic insufficiency (PHI) in 20/ 240 (8%) and a 90-day liver-related mortality rate of 9/240 (4%). Over the 18-year study period, the rate of PVE performed for CLM increased from 39% before 2005 to 78% in 201012. The use of preoperative chemotherapy and long-duration ( .12 weeks) chemotherapy increased from 26% to 86% and from 16% to 43%, respectively, in that time frame (all p,0.001). However, despite increased preoperative chemotherapy usage, PHI and 90-day liver-related mortality rates improved over the last decade (11% and 4%, respectively before 2010 vs. 3% and 3%, in 2010-12). Conclusions: PVE is safe and effective in inducing hypertrophy in patients with small FLR and allows 2/3 of patients with inadequate FLR the opportunity for curative resection. 364 Gastric Emptying, Ensuing GLP-1 Release and Insulin Sensitivity After Partial Pancreaticoduodenectomy: Improved Glycemic Control in Cases Without Pylorus Preservation (Whipple Procedure) Johannes Miholic, Marlene Wewalka, Stefan Harmuth, Jens J. Holst
VTE= Venothromboembolism, DVT=Deep Vein Thrombosis, PE= Pulmonary Embolism, LMWH= Low Molecular Weight Heparin
OBJECTIVE: Investigate the relationship between gastric emptying, postprandial GLP-1 and insulin sensitivity after pancreaticoduodenectomy (PD). BACKGROUND. Abnormal glucose regulation is highly prevalent in patients with pancreatic neoplasm, and resolves in some after PD, the cause of which is unclear. The procedure is carried out with pylorus preservation (PPPD) or with distal gastrectomy (Whipple procedure). Accelerated gastric emptying, and ensuing enhanced release of glucagon-like peptide-1 (GLP-1) conceivably play a role in glucose metabolism after PD. Any procedure associated with accelerated gastric emptying might improve glycemic control. It was the purpose of this study to shed light on the relationship between gastric emptying, GLP-1 and glycemic control after PPPD and the Whipple procedure. METHODS. A 75 g oral glucose tolerance test was carried out in tumor
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SSAT Abstracts
SSAT Abstracts
Extended Duration Thromboprophylaxis Cost-Effectiveness in Abdominal Surgery James C. Iannuzzi, Aaron S. Rickles, James G. Dolan, Fergal Fleming, John R. Monson, Katia Noyes
Fig 2 Microvessel density (MVD) in pediatric Crohn's disease ileum (inflamed and noninflamed) increased compared to control, detected by CD 31 quantitative immunohistochemical staining. Results expressed as mean ± SEM (*P = 0.008).
442 Difficult Diverticulits and Failed Anastomosis: Troubles and More Troubles Barry Salky This is a 68 year old female with mulitiple episodes of diverticulitis documented on CT scans. Dyspareunia is a recent symptom. This video demonstates several technical challenges assoiciated with chronic diverticulitis. After completion of the descending rectal anastomosis, a leak was detected and the video demostrates one technique of recovery in a difficult clinical situation. 443 Laparoscopic Repair of a Large Right Sided Morgagni's Hernia David Lawrence, Yuhsin V. Wu, Michael J. Rosen Morgagni's hernias are rare congenital anterior diaphragmatic hernias for which the optimal method of repair is unknown. This video presents a morbidly obese patient with oxygen dependent chronic obstructive pulmonary disease and a Morgagni's hernia that compresses her entire right lung. Omentum and colon are seen herniating through the 10x15cm defect. Through a laparoscopic approach the intra-abdominal contents were reduced, the defect primarily closed, and re-enforced with mesh. After the repair, the patient had significant improvements in pulmonary status. Laparoscopic repair with mesh re-enforcement is a viable and easily accomplished approach for Morgagni's hernia repair.
Figure 1: Decision Tree 437 Robotic Assisted Median Arcuate Ligament Release Martin J. Dib, Mark P. Callery, Marc Schermerhorn, A. James Moser 40-year-old female with chronic abdominal pain and preoperative aortography consistent with median arcuate ligament syndrome. Ports and a laparoscopic liver retractor are placed. After docking the robot, the left gastric vein is divided. The left gastric artery is encircled with a vessel loop to apply inferior traction and identify the common hepatic artery of the celiac trunk. The left lateral border of the celiac trunk is dissected. Hook cautery and LigaSure is used to divide the left crus of the diaphragm. Finally, circumferential skeletonization of the aorta at the entrance of the celiac trunk is achieved.
445 Modern Chemotherapy Mitigates Adverse Prognostic Effect of Regional Nodal Metastases in Stage IV Colorectal Cancer Yun Shin Chun, Steven Cohen, John H. Donohue, Barbara Burtness, Michael J. Hall, David M. Nagorney Background: In colorectal cancer, the involvement of regional lymph nodes with metastasis is an established prognostic factor. However, the impact of the number of positive regional nodes on patient outcome with stage IV disease is not well-defined. Methods: A retrospective review was performed of 869 patients at two tertiary referral centers with synchronous stage IV colorectal cancer who underwent resection of their primary tumors. Associations between number of positive regional lymph nodes stratified by the 7th edition AJCC staging system, lymph node ratio (LNR), and overall survival (OS) from date of diagnosis were analyzed. Median follow-up was 19 months (range, 1-211 months). Results: The number of positive regional nodes and LNR correlated with the presence of multiple sites of distant metastases (p,0.001). Survival was significantly associated with number of positive nodes and LNR, with median OS of 36 months with negative regional nodes, compared to 17 months with ./= 7 positive nodes (p ,0.001). Among 315 patients treated with modern oxaliplatinor irinotecan-based chemotherapy after colorectal resection, survival was not significantly associated with number of positive regional nodes (p=0.072) or LNR (p=0.34). The number of regional nodal metastases correlated with OS among 249 patients who underwent resection of liver metastases but lost prognostic significance in the subset of 105 patients who underwent hepatectomy with perioperative modern chemotherapy. Conclusions: In stage IV colorectal cancer, increasing number of positive regional lymph nodes and LNR correlate with multiple sites of distant metastases and poorer survival. The number of metastatic regional lymph nodes loses prognostic significance with modern chemotherapy, particularly in patients undergoing resection of liver metastases.
438 Enucleation of Hepatic Neuroendocrine Tumor Metastases Nicholas N. Nissen, Vijay G. Menon Neuroendocrine tumors (NET) represent a unique type of hepatic metastasis. These tumors tend to be well encapsulated and generally carry a favorable prognosis. Many of these patients will require repeated hepatic interventions over a period of several decades. Surgical enucleation of hepatic NETs is a technique that is not often employed but that holds great potential for preservation of maximal hepatic parenchyma, while carrying a low risk of injury to underlying vascular and biliary structures. This video describes the application of enucleation to patients with NET metastases and addresses patient selection, surgical techniques and management of complications.
SSAT Abstracts
439 Endoscopic Removal of a Laparoscopic Adjustable Gastric Band That Is Eroded Aurora D. Pryor, Dana A. Telem, Joshua Karas, Georgios Spentzouris, Eleanor Fallon, Jonathan Buscaglia This is a case of a 52-year-old male with history of morbid obesity status-post Laparoscopic Band at an outside hospital complicated by port infection and band erosion. Following port removal, the patient presented for removal of the laparoscopic band. Due to the extent of the intra-gastric band erosion, total endoscopic removal was attempted succesfully. This case highlights the mechanism of endoscopic removal of the band, challenges encountered, and techniques to navigate these obstacles. The patient tolerated removal of the band, was started on a liquid diet immediately, and was discharged on post-operative day one. 440 Totally Laparoscopic Left Colonic Resection With Intracorporeal Anastomosis Laura Doyon, Celia M. Divino, Scott Q. Nguyen, Edward Chin This video demonstrates two complementary laparoscopic cases, each focusing on techniques for intracorporeal anastomosis. The first is an elective sigmoid resection for history of uncomplicated diverticulitis. It uses an end-to-side intracorporeal anastomosis performed with a circular stapler. The second is a left hemicolectomy, performed for descending colon cancer. It employs a side-to-side intracorporeal anastomosis performed with a linear stapler and sewn common enterotomy. Totally laparoscopic colonic resection with intracorporeal anastomosis can facilitate resection in obese patients, as well as improve cosmesis and wound complications by reducing incision length for extraction.
446 Totally Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Mucinous Adneocarcinoma of the Appendix Cherif Boutros, Nader Hanna
441
Open cytoreductive Surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) has emerged as the procedure of choice for mucinous adenocarcinoma of the appendix (MAA), however is associated with substantial morbidity. We present a case of a totally laparoscopic R0- CRS-HIPEC for MAA. CRS included: right hemicolectomy, omentectomy, cholecystectomy, bilateral salpingo-oopherectomy, excision of the round and falciform ligaments and stripping of the peritoneum of the right diaphragm; followed by HIPEC through single inflow and outflow catheters. OR time was 380 mns and EBL was 100 mL. There was no postoperative morbidity. The patient was discharged home on postoperative day 8.
Laparoscopic Central Pancreatectomy and Pancreaticogastrostomy for the Management of a Proximally Migrated Pancreatic Stent Marc G. Mesleh, Frank Lukens, Michael B. Wallace, Horacio J. Asbun, John Stauffer A 43 year old female had a pancreatic stent placed during ERCP for elevated LFTs. The stent migrated proximally into the pancreas and was unable to be retrieved with multiple endoscopic attempts. After several episodes of pancreatitis, she was evaluated for surgical retrieval. A laparoscopic central pancreatectomy was performed to remove the stent, and a pancreaticogastrostomy was created for reconstruction.
SSAT Abstracts
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365
Background: Post-discharge thromboprophylaxis is the practice of prescribing antithrombotic therapy for 21 days after discharge, commonly used in surgical patients who are at high risk for venothromboembolism (VTE). Multiple consensus guidelines recommend extended duration thromboprophylaxis (EDTPPX) after major abdominal oncologic resections based on randomized clinical trials demonstrating a significant reduction in VTE events after surgical discharge in these patients. While the National Comprehensive Cancer Network suggests all major abdominal oncologic resections receive EDTPPX, the American College of Chest Physicians suggests an individualized risk assessment, with only high risk patients undergoing oncologic resections suggested to receive EDTPPX, however, high risk is not currently defined. The threshold for high risk ought to be informed by when it is costeffective to provide EDTPPX, which has not previously been established. In order to further inform current guidelines this study sought to determine the VTE incidence threshold for the cost-effectiveness of low molecular weight heparin for 4 weeks after surgery as compared to inpatient prophylaxis only. Methods: A cost-effectiveness decision tree was created using TreeAge (Figure 1). Assigned probabilities were derived from published literature. The decision point compared extended duration thromboprophylaxis with low molecular weight heparin for 21 days after discharge to inpatient-prophylaxis alone, with base case assumptions (table 1) based on an abdominal oncologic resection without complications in a 45 yearold male. The end points were pulmonary embolism or deep vein thrombosis with attendant costs and assigned effectiveness evaluated by Quality Adjusted Life Years (QALY). Willingness to pay was set at $50,000/QALY. Sensitivity analyses were performed to assess uncertainty within the model, with particular interest in the threshold for cost-effectiveness based on VTE incidence. Results: Given base case assumptions with VTE probability of 4%, extended duration thromboprophylaxis had an incremental cost effectiveness ratio of $8123/QALY, which was considered cost-effective. The results were robust to sensitivity analysis with the highest uncertainty associated with VTE incidence and medication cost. The threshold for the relative cost-effectiveness was a VTE incidence exceeding 2.53%. Conclusions: Given the base case assumptions, extended prophylaxis is more cost effective than inpatient prophylaxis alone, and the threshold for its use should be cases where the estimated VTE risk exceeds 2.53%. These findings should inform future guidelines' definition of "high risk" and individualized risk scores should be developed to predict patient likelihood of post-discharge VTE. These results can lead to specific individualized EDTPPX application. Table 1:Baseline Model Assumptions and Sensitivity Analysis
363 Safety and Efficacy of Portal Vein Embolization Before Planned Major Hepatectomy: An Institutional Experience of 358 Patients Junichi Shindoh, Ching-Wei D. Tzeng, Thomas Aloia, Steven Curley, Giuseppe Zimmitti, Steven Y. Huang, Armeen Mahvash, Sanjay Gupta, Michael J. Wallace, Jean-Nicolas Vauthey Introduction: Portal vein embolization (PVE) induces hypertrophy of the future liver remnant (FLR) in patients with unfavorable tumor distribution and low calculated standardized FLR (sFLR). We sought to evaluate the safety and efficacy of PVE. Methods: We evaluated 358 consecutive patients who underwent PVE before intended major hepatectomy from 19952012. Diagnoses, morbidity, degree of hypertrophy (DH), and post-PVE resectability were evaluated in the whole study period and compared over time. Results: The diseases treated included colorectal liver metastases (CLM, 217, 61%), hepatocellular carcinoma (49, 14%), extrahepatic biliary cancers (31, 9%), neuroendocrine metastases (25, 7%), intrahepatic cholangiocarcinoma (13, 3%), and others (23, 6%). Right PVE alone was performed in 31% of cases; due to tumor distribution and to the necessity of resecting segment IV, right PVE with segment IV PVE was required in 66% of patients. The first-session PVE success rate was 98%. Post-PVE complications occurred in 12/358 patients (3%), with portal vein thrombosis occurring in 6 (2%) patients. Median pre-PVE standardized FLR (sFLR) was 19% (inter-quartile range, IQR, 15.0-25.9). Median post-PVE sFLR was 30% (IQR, 22.538.2). Of 358 patients who underwent PVE, 282 (79%) were taken to the operating room with 240/358 (67%) undergoing curative hepatectomy. Post-hepatectomy major complications occurred in 62/240 (26%) patients, with postoperative hepatic insufficiency (PHI) in 20/ 240 (8%) and a 90-day liver-related mortality rate of 9/240 (4%). Over the 18-year study period, the rate of PVE performed for CLM increased from 39% before 2005 to 78% in 201012. The use of preoperative chemotherapy and long-duration ( .12 weeks) chemotherapy increased from 26% to 86% and from 16% to 43%, respectively, in that time frame (all p,0.001). However, despite increased preoperative chemotherapy usage, PHI and 90-day liver-related mortality rates improved over the last decade (11% and 4%, respectively before 2010 vs. 3% and 3%, in 2010-12). Conclusions: PVE is safe and effective in inducing hypertrophy in patients with small FLR and allows 2/3 of patients with inadequate FLR the opportunity for curative resection. 364 Gastric Emptying, Ensuing GLP-1 Release and Insulin Sensitivity After Partial Pancreaticoduodenectomy: Improved Glycemic Control in Cases Without Pylorus Preservation (Whipple Procedure) Johannes Miholic, Marlene Wewalka, Stefan Harmuth, Jens J. Holst
VTE= Venothromboembolism, DVT=Deep Vein Thrombosis, PE= Pulmonary Embolism, LMWH= Low Molecular Weight Heparin
OBJECTIVE: Investigate the relationship between gastric emptying, postprandial GLP-1 and insulin sensitivity after pancreaticoduodenectomy (PD). BACKGROUND. Abnormal glucose regulation is highly prevalent in patients with pancreatic neoplasm, and resolves in some after PD, the cause of which is unclear. The procedure is carried out with pylorus preservation (PPPD) or with distal gastrectomy (Whipple procedure). Accelerated gastric emptying, and ensuing enhanced release of glucagon-like peptide-1 (GLP-1) conceivably play a role in glucose metabolism after PD. Any procedure associated with accelerated gastric emptying might improve glycemic control. It was the purpose of this study to shed light on the relationship between gastric emptying, GLP-1 and glycemic control after PPPD and the Whipple procedure. METHODS. A 75 g oral glucose tolerance test was carried out in tumor
S-1047
SSAT Abstracts
SSAT Abstracts
Extended Duration Thromboprophylaxis Cost-Effectiveness in Abdominal Surgery James C. Iannuzzi, Aaron S. Rickles, James G. Dolan, Fergal Fleming, John R. Monson, Katia Noyes
Fig 2 Microvessel density (MVD) in pediatric Crohn's disease ileum (inflamed and noninflamed) increased compared to control, detected by CD 31 quantitative immunohistochemical staining. Results expressed as mean ± SEM (*P = 0.008).
442 Difficult Diverticulits and Failed Anastomosis: Troubles and More Troubles Barry Salky This is a 68 year old female with mulitiple episodes of diverticulitis documented on CT scans. Dyspareunia is a recent symptom. This video demonstates several technical challenges assoiciated with chronic diverticulitis. After completion of the descending rectal anastomosis, a leak was detected and the video demostrates one technique of recovery in a difficult clinical situation. 443 Laparoscopic Repair of a Large Right Sided Morgagni's Hernia David Lawrence, Yuhsin V. Wu, Michael J. Rosen Morgagni's hernias are rare congenital anterior diaphragmatic hernias for which the optimal method of repair is unknown. This video presents a morbidly obese patient with oxygen dependent chronic obstructive pulmonary disease and a Morgagni's hernia that compresses her entire right lung. Omentum and colon are seen herniating through the 10x15cm defect. Through a laparoscopic approach the intra-abdominal contents were reduced, the defect primarily closed, and re-enforced with mesh. After the repair, the patient had significant improvements in pulmonary status. Laparoscopic repair with mesh re-enforcement is a viable and easily accomplished approach for Morgagni's hernia repair.
Figure 1: Decision Tree 437 Robotic Assisted Median Arcuate Ligament Release Martin J. Dib, Mark P. Callery, Marc Schermerhorn, A. James Moser 40-year-old female with chronic abdominal pain and preoperative aortography consistent with median arcuate ligament syndrome. Ports and a laparoscopic liver retractor are placed. After docking the robot, the left gastric vein is divided. The left gastric artery is encircled with a vessel loop to apply inferior traction and identify the common hepatic artery of the celiac trunk. The left lateral border of the celiac trunk is dissected. Hook cautery and LigaSure is used to divide the left crus of the diaphragm. Finally, circumferential skeletonization of the aorta at the entrance of the celiac trunk is achieved.
445 Modern Chemotherapy Mitigates Adverse Prognostic Effect of Regional Nodal Metastases in Stage IV Colorectal Cancer Yun Shin Chun, Steven Cohen, John H. Donohue, Barbara Burtness, Michael J. Hall, David M. Nagorney Background: In colorectal cancer, the involvement of regional lymph nodes with metastasis is an established prognostic factor. However, the impact of the number of positive regional nodes on patient outcome with stage IV disease is not well-defined. Methods: A retrospective review was performed of 869 patients at two tertiary referral centers with synchronous stage IV colorectal cancer who underwent resection of their primary tumors. Associations between number of positive regional lymph nodes stratified by the 7th edition AJCC staging system, lymph node ratio (LNR), and overall survival (OS) from date of diagnosis were analyzed. Median follow-up was 19 months (range, 1-211 months). Results: The number of positive regional nodes and LNR correlated with the presence of multiple sites of distant metastases (p,0.001). Survival was significantly associated with number of positive nodes and LNR, with median OS of 36 months with negative regional nodes, compared to 17 months with ./= 7 positive nodes (p ,0.001). Among 315 patients treated with modern oxaliplatinor irinotecan-based chemotherapy after colorectal resection, survival was not significantly associated with number of positive regional nodes (p=0.072) or LNR (p=0.34). The number of regional nodal metastases correlated with OS among 249 patients who underwent resection of liver metastases but lost prognostic significance in the subset of 105 patients who underwent hepatectomy with perioperative modern chemotherapy. Conclusions: In stage IV colorectal cancer, increasing number of positive regional lymph nodes and LNR correlate with multiple sites of distant metastases and poorer survival. The number of metastatic regional lymph nodes loses prognostic significance with modern chemotherapy, particularly in patients undergoing resection of liver metastases.
438 Enucleation of Hepatic Neuroendocrine Tumor Metastases Nicholas N. Nissen, Vijay G. Menon Neuroendocrine tumors (NET) represent a unique type of hepatic metastasis. These tumors tend to be well encapsulated and generally carry a favorable prognosis. Many of these patients will require repeated hepatic interventions over a period of several decades. Surgical enucleation of hepatic NETs is a technique that is not often employed but that holds great potential for preservation of maximal hepatic parenchyma, while carrying a low risk of injury to underlying vascular and biliary structures. This video describes the application of enucleation to patients with NET metastases and addresses patient selection, surgical techniques and management of complications.
SSAT Abstracts
439 Endoscopic Removal of a Laparoscopic Adjustable Gastric Band That Is Eroded Aurora D. Pryor, Dana A. Telem, Joshua Karas, Georgios Spentzouris, Eleanor Fallon, Jonathan Buscaglia This is a case of a 52-year-old male with history of morbid obesity status-post Laparoscopic Band at an outside hospital complicated by port infection and band erosion. Following port removal, the patient presented for removal of the laparoscopic band. Due to the extent of the intra-gastric band erosion, total endoscopic removal was attempted succesfully. This case highlights the mechanism of endoscopic removal of the band, challenges encountered, and techniques to navigate these obstacles. The patient tolerated removal of the band, was started on a liquid diet immediately, and was discharged on post-operative day one. 440 Totally Laparoscopic Left Colonic Resection With Intracorporeal Anastomosis Laura Doyon, Celia M. Divino, Scott Q. Nguyen, Edward Chin This video demonstrates two complementary laparoscopic cases, each focusing on techniques for intracorporeal anastomosis. The first is an elective sigmoid resection for history of uncomplicated diverticulitis. It uses an end-to-side intracorporeal anastomosis performed with a circular stapler. The second is a left hemicolectomy, performed for descending colon cancer. It employs a side-to-side intracorporeal anastomosis performed with a linear stapler and sewn common enterotomy. Totally laparoscopic colonic resection with intracorporeal anastomosis can facilitate resection in obese patients, as well as improve cosmesis and wound complications by reducing incision length for extraction.
446 Totally Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Mucinous Adneocarcinoma of the Appendix Cherif Boutros, Nader Hanna
441
Open cytoreductive Surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) has emerged as the procedure of choice for mucinous adenocarcinoma of the appendix (MAA), however is associated with substantial morbidity. We present a case of a totally laparoscopic R0- CRS-HIPEC for MAA. CRS included: right hemicolectomy, omentectomy, cholecystectomy, bilateral salpingo-oopherectomy, excision of the round and falciform ligaments and stripping of the peritoneum of the right diaphragm; followed by HIPEC through single inflow and outflow catheters. OR time was 380 mns and EBL was 100 mL. There was no postoperative morbidity. The patient was discharged home on postoperative day 8.
Laparoscopic Central Pancreatectomy and Pancreaticogastrostomy for the Management of a Proximally Migrated Pancreatic Stent Marc G. Mesleh, Frank Lukens, Michael B. Wallace, Horacio J. Asbun, John Stauffer A 43 year old female had a pancreatic stent placed during ERCP for elevated LFTs. The stent migrated proximally into the pancreas and was unable to be retrieved with multiple endoscopic attempts. After several episodes of pancreatitis, she was evaluated for surgical retrieval. A laparoscopic central pancreatectomy was performed to remove the stent, and a pancreaticogastrostomy was created for reconstruction.
SSAT Abstracts
S-1048