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451 A Simplified Technique for Placement of Biologic Mesh in Paraesophageal Hernia Repair (PEH)
SMV/PV confluence. Splenic vessels were ligated at their origin. Oncologic vascular control was completed prior to pancreatic transection. Conclusion: Tumors of the pancreatic neck can be laparoscopically resected with no change in morbidity or mortality.
454 Standardization of Laparoscopic Distal Pancreatic Resection (LapDPR) with Regional Lymphadenectomy in Malignant Pancreatic Neoplasms (MPN) Laureano Fernández-Cruz
353
Some surgeons have suggested that MPN are contraindicated to LapDPR because of concerns for the radicality of resection and oncological outcomes. Herein, described the LapDPR with and without splenectomy in patients with suspected pancreatic malignancy. The LapDPR includes radical lymph node dissection of the peripancreatic, portal, hepatic and superior mesenteric areas; the Gerota fascia and fatty tissue on the adrenal gland are also removed. The LapDPR achieved 90%. Ro resection in 15 patients with ductal adenocarcinoma and 100% in 10 patients with neuroendocrine MPN.
Laparoscopic Approach in Patients with Gastrinoma Which Are the Limits? Laureano Fernández-Cruz To present the limits of the laparoscopic approach in patients with gastrinoma in 4 consecutive patients. The Laparoscopic Approach (Lap A) was successful in one patient after tumor excision (1 cm) localized between the duodenum and vena cava (primary lymph node gastrinoma) and in another MEN-1 patient after spleen-preserving distal pancreatectomy. Conversion in 2 patients, one localized in the posterior duodenal wall, and in another with lymph node metastasis. The Lap A was feasible and achieved cured in 50% of gastrinomas. The association of lymph node metastasis or the localization in difficult surgical areas, may limit its success.
455 Laparoscopic Sigmoid Resection for Complicated Diverticulitis (Colovaginal Fistula) Barry Salky
449
This video demonstrates the technical challanges that can occur in complicated diverticulitis. This case has the small intestine walling off an abscess from the sigmoid in conjunction with the sigmoid's attachment to the back wall of the bladder and the vagina. It demostrates a safe way to approach these structures, and it demostrates a good way to avoid ureteral injury. A tension free anastomosis to the upper rectum is shown, along with sigoidoscopy to check the anastomosis.
Combined Treatment of Esophageal Perforation: A New Approach Bryan J. Sandler, Michelle K. Savu, Garth R. Jacobsen, John Cullen, Thomas J. Savides, Mark A. Talamini, Santiago Horgan Esophageal perforation can be difficult to manage. This demonstrates a novel approach to this problem, using a combination of laparoscopic and endoscopic techniques to close and stent the perforation. The patient presented following dilatation of an esophageal stricture. His post-operative recovery was uneventful and he was discharged home without further intervention. This result is an example of the close collaboration between surgery and gastroenterology as both fields move forward, developing minimally invasive and endolumenal therapeutics.
456 Laparoscopic Celiac Artery Decompression Khashayar Vaziri, Edward Auyang, Nathaniel J. Soper, Eric S. Hungness Compression of the celiac artery by the diaphragmatic crura, the median arcuate ligament or fibrous periaortic ganglionic tissue results in a rare constellation of symptoms known as celiac artery compression syndrome (CACS). First described in 1963 by Harjola in a patient with symptoms of mesenteric ischemia, it remains an elusive diagnosis. External compression of the celiac artery leads to a wide variety of symptoms frequently resulting in multiple diagnostic tests. A firm diagnosis is difficult to establish, and treatment is equally challenging. We describe a laparoscopic approach to decompression of the celiac artery facilitated by intraoperative ultrasound.
450 Dual Incision Adjustable Gastric Band Placement Garth R. Jacobsen, Bryan J. Sandler, John Cullen, Mark A. Talamini, Adam Spivack, Santiago Horgan Laparoscopic operations require multiple incisions to achieve the angles necessary to perform the operation. Wristed instruments allow for completion from fewer access points. Two patients underwent AGB placement using a two incision technique, under an IRB approved protocol. All ports were placed through a 3 cm incision in the patient's abdomen. A liver retractor was placed in the epigastrium. Either a laparoscope or endoscope was used for visualization. The operation was successfully completed in both patients in under one hour. Flexible laparoscopic instruments can reduce the number of incisions needed to perform AGB placement.
457 Pneumatosis Coli: Resection of the Splenic Flexure with Intracorporeal Anastomosis Melina C. Vassiliou, Douglas S. Smink, Gina L. Adrales Pneumatosis coli is a clinical problem that infrequently requires surgical treatment. This video describes laparoscopic resection of the splenic flexure in a patient with symptomatic pneumatosis coli limited to this area. The decision to perform an intracorporeal anastomosis was based on body habitus and location of the diseased segment. Intracorporeal anastomosis requires less mobilization, limits the size of the extraction incision, and provides more flexibility when selecting the incision site. This video presentation briefly demonstrates mobilization of the left colon and splenic flexure and the creation of a side to side anastomosis entirely intracorporeally.
SSAT Abstracts
451 A Simplified Technique for Placement of Biologic Mesh in Paraesophageal Hernia Repair (PEH) Tayyab S. Diwan, Danny V. Martinec, Michael Ujiki, Christy M. Dunst, Lee L. Swanstrom The placement of mesh in the crural closure of PEH repairs has been shown to decrease hernia recurrence rates. Synthetic mesh is easy to use but has a high rate of esophageal erosion and therefore has been largely abandoned. Use of biologic mesh decreases the risk of erosion and recurrence rates, but there is currently no well described method for placement. We present a method which requires no additional sutures or staples and achieves excellent contact and reinforcement of the crural closure. Our method incorporates biological mesh into the standard closure using pledgeted polyester sutures placed in a horizontal mattress fashion. This technique has worked well in over 150 PEH operations.
557 Epigenetic Regulation of WNT Signaling Pathway Genes in Inflammatory Bowel Disease (IBD) Neoplasia Mashaal Dhir, Elizabeth A. Montgomery, Kornel Schuebel, Susan L. Gearhart, Nita Ahuja Background: DNA methylation of promoter CpG islands in the Wnt signaling pathway is an important event in the pathogenesis of Colorectal Cancer (CRC). We hypothesized that chronic inflammatory states, like IBD, may lead to increased aberrant methylation and inactivation of Wnt genes which in turn accelerate the development of cancer. This study examined the role of epigenetic silencing of Wnt genes in the pathogenesis of IBD Neoplasia (Dysplasia and Cancer). Methods: Paraffin embedded tissue samples were obtained from The Johns Hopkins Hospital Pathology archive with IRB approval. We analyzed 11 Wnt genes using methylation specific PCR including APC1A, APC2, dickkopf family genes (DKK1, DKK2), soluble frizzled related proteins (sFRP1, sFRP2, sFRP4, sFRP5), Wnt inhibitory factor-1 (WIF-1), Delta like3 (DLL3) and a serine threonine kinase, LKB1. Methylation analysis was performed in 41 IBD samples [6 IBD cancers, 2 High grade dysplasia (HGD), 8 Low grade dysplasias (LGD) and 25 IBD colitis] from 20 IBD patients (Median disease duration=12 years), 27 normal colons (NCs) and 24 sporadic CRCs (Stage 1-3). Results: There was no significant difference in the overall frequency of methylation of Wnt signaling pathway genes in sporadic CRC and IBD cancers (52% vs. 61%; p=0.42). However, a progressive increase in the percentage of methylated genes from NCs (3.7%) to IBD Colitis (39.7%) to IBD Neoplasia (63.39%) was seen (NC vs. IBD Colitis p<0.001, IBD Colitis vs. IBD associated Neoplasia p=0.016). More importantly, a distinct increase in methylation of APC1A and APC2 was seen during progression to IBD Neoplasia (Figure 1). Multivariate logistic regression analysis showed that methylation of APC1a and APC2 were predictive of IBD Neoplasia as compared to IBD colitis (OR APC1a:6.2, 95% CI: 1.1-36.3; OR APC2:8.5, 95% CI: 1.2-59.0). Conclusions: The frequency of methylation of the Wnt signaling pathway genes increases progressively during development of IBD Neoplasia. Moreover, the findings of early methylation of APC1A and APC2 in IBD associated dysplasia may provide a method for early detection of IBD associated carcinoma.
452 Human NOTES Hybrid Transgastric Cholecystectomy Edward Auyang, Khashayar Vaziri, John A. Martin, Eric S. Hungness, Nathaniel J. Soper Natural Orifice Translumenal Endoscopic Surgery (NOTES) is a rapidly developing area of minimally invasive surgery that has the potential to improve post-operative outcomes by eliminating abdominal incisions. Hybrid techniques using mostly endoscopic and minimal laparoscopic instruments are being performed in human patients. At Northwestern, we have successfully performed two human NOTES hybrid transgastric cholecystectomies and this video demonstrates the technique we have used to perform this procedure. 453 Video: Totally Laparoscopic Extended Right Hepatectomy Andrew A. Gumbs, Brice Gayet This video will demonstrate the relevant technical maneuvers necessary to perform a totally laparoscopic extended right hepatectomy. The five principal steps of this procedure include: mobilization of the liver, control of hepatic inflow, division of the hepatic parenchyma, control of the hepatic outflow and removal of the specimen. A total of 4 totally laparoscopic extended right hepatectomies have been successfully performed at our institution. Our short and long-term results have been similar to our open historical controls. No mortalities have been observed. The minimally invasive approach to hepatic resections is limited by the comfort level of the operator and not the technique.
SSAT Abstracts
A-848
454 Standardization of Laparoscopic Distal Pancreatic Resection (LapDPR) with Regional Lymphadenectomy in Malignant Pancreatic Neoplasms (MPN) Laureano Fernández-Cruz
353
Some surgeons have suggested that MPN are contraindicated to LapDPR because of concerns for the radicality of resection and oncological outcomes. Herein, described the LapDPR with and without splenectomy in patients with suspected pancreatic malignancy. The LapDPR includes radical lymph node dissection of the peripancreatic, portal, hepatic and superior mesenteric areas; the Gerota fascia and fatty tissue on the adrenal gland are also removed. The LapDPR achieved 90%. Ro resection in 15 patients with ductal adenocarcinoma and 100% in 10 patients with neuroendocrine MPN.
Laparoscopic Approach in Patients with Gastrinoma Which Are the Limits? Laureano Fernández-Cruz To present the limits of the laparoscopic approach in patients with gastrinoma in 4 consecutive patients. The Laparoscopic Approach (Lap A) was successful in one patient after tumor excision (1 cm) localized between the duodenum and vena cava (primary lymph node gastrinoma) and in another MEN-1 patient after spleen-preserving distal pancreatectomy. Conversion in 2 patients, one localized in the posterior duodenal wall, and in another with lymph node metastasis. The Lap A was feasible and achieved cured in 50% of gastrinomas. The association of lymph node metastasis or the localization in difficult surgical areas, may limit its success.
455 Laparoscopic Sigmoid Resection for Complicated Diverticulitis (Colovaginal Fistula) Barry Salky
449
This video demonstrates the technical challanges that can occur in complicated diverticulitis. This case has the small intestine walling off an abscess from the sigmoid in conjunction with the sigmoid's attachment to the back wall of the bladder and the vagina. It demostrates a safe way to approach these structures, and it demostrates a good way to avoid ureteral injury. A tension free anastomosis to the upper rectum is shown, along with sigoidoscopy to check the anastomosis.
Combined Treatment of Esophageal Perforation: A New Approach Bryan J. Sandler, Michelle K. Savu, Garth R. Jacobsen, John Cullen, Thomas J. Savides, Mark A. Talamini, Santiago Horgan Esophageal perforation can be difficult to manage. This demonstrates a novel approach to this problem, using a combination of laparoscopic and endoscopic techniques to close and stent the perforation. The patient presented following dilatation of an esophageal stricture. His post-operative recovery was uneventful and he was discharged home without further intervention. This result is an example of the close collaboration between surgery and gastroenterology as both fields move forward, developing minimally invasive and endolumenal therapeutics.
456 Laparoscopic Celiac Artery Decompression Khashayar Vaziri, Edward Auyang, Nathaniel J. Soper, Eric S. Hungness Compression of the celiac artery by the diaphragmatic crura, the median arcuate ligament or fibrous periaortic ganglionic tissue results in a rare constellation of symptoms known as celiac artery compression syndrome (CACS). First described in 1963 by Harjola in a patient with symptoms of mesenteric ischemia, it remains an elusive diagnosis. External compression of the celiac artery leads to a wide variety of symptoms frequently resulting in multiple diagnostic tests. A firm diagnosis is difficult to establish, and treatment is equally challenging. We describe a laparoscopic approach to decompression of the celiac artery facilitated by intraoperative ultrasound.
450 Dual Incision Adjustable Gastric Band Placement Garth R. Jacobsen, Bryan J. Sandler, John Cullen, Mark A. Talamini, Adam Spivack, Santiago Horgan Laparoscopic operations require multiple incisions to achieve the angles necessary to perform the operation. Wristed instruments allow for completion from fewer access points. Two patients underwent AGB placement using a two incision technique, under an IRB approved protocol. All ports were placed through a 3 cm incision in the patient's abdomen. A liver retractor was placed in the epigastrium. Either a laparoscope or endoscope was used for visualization. The operation was successfully completed in both patients in under one hour. Flexible laparoscopic instruments can reduce the number of incisions needed to perform AGB placement.
457 Pneumatosis Coli: Resection of the Splenic Flexure with Intracorporeal Anastomosis Melina C. Vassiliou, Douglas S. Smink, Gina L. Adrales Pneumatosis coli is a clinical problem that infrequently requires surgical treatment. This video describes laparoscopic resection of the splenic flexure in a patient with symptomatic pneumatosis coli limited to this area. The decision to perform an intracorporeal anastomosis was based on body habitus and location of the diseased segment. Intracorporeal anastomosis requires less mobilization, limits the size of the extraction incision, and provides more flexibility when selecting the incision site. This video presentation briefly demonstrates mobilization of the left colon and splenic flexure and the creation of a side to side anastomosis entirely intracorporeally.
SSAT Abstracts
451 A Simplified Technique for Placement of Biologic Mesh in Paraesophageal Hernia Repair (PEH) Tayyab S. Diwan, Danny V. Martinec, Michael Ujiki, Christy M. Dunst, Lee L. Swanstrom The placement of mesh in the crural closure of PEH repairs has been shown to decrease hernia recurrence rates. Synthetic mesh is easy to use but has a high rate of esophageal erosion and therefore has been largely abandoned. Use of biologic mesh decreases the risk of erosion and recurrence rates, but there is currently no well described method for placement. We present a method which requires no additional sutures or staples and achieves excellent contact and reinforcement of the crural closure. Our method incorporates biological mesh into the standard closure using pledgeted polyester sutures placed in a horizontal mattress fashion. This technique has worked well in over 150 PEH operations.
557 Epigenetic Regulation of WNT Signaling Pathway Genes in Inflammatory Bowel Disease (IBD) Neoplasia Mashaal Dhir, Elizabeth A. Montgomery, Kornel Schuebel, Susan L. Gearhart, Nita Ahuja Background: DNA methylation of promoter CpG islands in the Wnt signaling pathway is an important event in the pathogenesis of Colorectal Cancer (CRC). We hypothesized that chronic inflammatory states, like IBD, may lead to increased aberrant methylation and inactivation of Wnt genes which in turn accelerate the development of cancer. This study examined the role of epigenetic silencing of Wnt genes in the pathogenesis of IBD Neoplasia (Dysplasia and Cancer). Methods: Paraffin embedded tissue samples were obtained from The Johns Hopkins Hospital Pathology archive with IRB approval. We analyzed 11 Wnt genes using methylation specific PCR including APC1A, APC2, dickkopf family genes (DKK1, DKK2), soluble frizzled related proteins (sFRP1, sFRP2, sFRP4, sFRP5), Wnt inhibitory factor-1 (WIF-1), Delta like3 (DLL3) and a serine threonine kinase, LKB1. Methylation analysis was performed in 41 IBD samples [6 IBD cancers, 2 High grade dysplasia (HGD), 8 Low grade dysplasias (LGD) and 25 IBD colitis] from 20 IBD patients (Median disease duration=12 years), 27 normal colons (NCs) and 24 sporadic CRCs (Stage 1-3). Results: There was no significant difference in the overall frequency of methylation of Wnt signaling pathway genes in sporadic CRC and IBD cancers (52% vs. 61%; p=0.42). However, a progressive increase in the percentage of methylated genes from NCs (3.7%) to IBD Colitis (39.7%) to IBD Neoplasia (63.39%) was seen (NC vs. IBD Colitis p<0.001, IBD Colitis vs. IBD associated Neoplasia p=0.016). More importantly, a distinct increase in methylation of APC1A and APC2 was seen during progression to IBD Neoplasia (Figure 1). Multivariate logistic regression analysis showed that methylation of APC1a and APC2 were predictive of IBD Neoplasia as compared to IBD colitis (OR APC1a:6.2, 95% CI: 1.1-36.3; OR APC2:8.5, 95% CI: 1.2-59.0). Conclusions: The frequency of methylation of the Wnt signaling pathway genes increases progressively during development of IBD Neoplasia. Moreover, the findings of early methylation of APC1A and APC2 in IBD associated dysplasia may provide a method for early detection of IBD associated carcinoma.
452 Human NOTES Hybrid Transgastric Cholecystectomy Edward Auyang, Khashayar Vaziri, John A. Martin, Eric S. Hungness, Nathaniel J. Soper Natural Orifice Translumenal Endoscopic Surgery (NOTES) is a rapidly developing area of minimally invasive surgery that has the potential to improve post-operative outcomes by eliminating abdominal incisions. Hybrid techniques using mostly endoscopic and minimal laparoscopic instruments are being performed in human patients. At Northwestern, we have successfully performed two human NOTES hybrid transgastric cholecystectomies and this video demonstrates the technique we have used to perform this procedure. 453 Video: Totally Laparoscopic Extended Right Hepatectomy Andrew A. Gumbs, Brice Gayet This video will demonstrate the relevant technical maneuvers necessary to perform a totally laparoscopic extended right hepatectomy. The five principal steps of this procedure include: mobilization of the liver, control of hepatic inflow, division of the hepatic parenchyma, control of the hepatic outflow and removal of the specimen. A total of 4 totally laparoscopic extended right hepatectomies have been successfully performed at our institution. Our short and long-term results have been similar to our open historical controls. No mortalities have been observed. The minimally invasive approach to hepatic resections is limited by the comfort level of the operator and not the technique.
SSAT Abstracts
A-848