568 Endoscopic Vacuum Therapy in Colorectal Surgery

All laparoscopic J tubes placed over a five year period in a general surgical practice that manages its own J tubes long-term were retrospectively reviewed. Clinical burden was measured by the number of clinical contact events (tube-related clinic visits, phone calls, ED visits) and morbidity (dislodgement, clogging, tube fracture, infection, "other"). Tube replacement was also recorded. RESULTS Our study had 151 patients. Fifty-nine percent had an associated malignancy and 80% were placed concomitantly with another procedure. Thirty-five percent were placed for nutritional prophylaxis. Mean J tube duration was 225 days (2-1458). J tubes were expected to be temporary in > 90% but only 50% had sufficient oral intake for tube removal (after an average 146 days, 22-782). Tubes were removed prematurely due to patient intolerance in 8%. There was no mortality directly related to the J tubes but 17% died of other causes with the tubes in situ. Morbidity occurred in 51% of J tubes and included clogging (12%), tube fracture (16%), dislodgement (25%), infection (17%) and "other" (leaking, erosion, etc) in 17%. The median number of adverse events per J tube was 2 (0-8). Each patient had a mean of 2.5 clinic phone calls (0-22), 0.5 ED visits (0-7), and 1.4 clinic visits (0-13), with 82% requiring additional postoperative attention to the feeding tube by a physician. Thirty-nine percent required unplanned replacements due to complications; most were changed in the office. Neither diagnosis (malignant vs benign, p=0.08) nor preoperative chemoradiation (p=0.6) significantly affected complication rates. CONCLUSION While laparoscopic feeding jejunostomy is necessary for some patients with orogastric failure, care of these tubes requires a substantial time commitment from both patients and providers. In this high risk population (as demonstrated by a nearly 20% unrelated mortality rate), the presence of feeding tubes leads to additional ER visits for 1/ 3 of patients. Furthermore, many anticipated temporary tubes ultimately become permanent. Surgeons who perform these operations should be aware of the associated high clinical burden in order to appropriately set expectations and provide necessary care.

(88.9%) patients unsure or incorrectly answering at least one question. Most patients (88.9%) discussed the decision with others; most frequently with spouses (61%), friends (61%), parents (50%), and siblings (44%). These discussions were "extremely" or "very" important to 53% of patients. Patients desired active participation in decision making, with 93.8% reporting a preference to make the final decision about procedure type "on my own" or "on my own after seriously considering my doctor's opinion". CONCLUSIONS: When faced with the decision between end ileostomy and IPAA, ulcerative colitis patients desire an active role in decision making. Patients frequently use multiple sources to learn about the options and discuss the decision with a variety of people in their lives. Current surgical decision support tools provided by physicians could be improved and should provide the educational information needed to support an active role in decision making. These tools should be presented in a format that can be used during discussions with others. 568 Endoscopic Vacuum Therapy in Colorectal Surgery Florian Kuehn, Florian Janisch, Frank Schwandner, Michael C. Gock, Ernst Klar Introduction: Since the first larger studies in the late 1990s, vacuum assisted closure therapy has become popular in nearly every field of surgery. Endoscopic vacuum therapy (EVT) has been established in Germany for the treatment of anastomotic leakage after rectal resection. The principles of VAC therapy remain the same no matter of localization: Continuous or intermittent suction and drainage via an open-pored polyurethane sponge decrease bacterial contamination, secretion, and local edema. At the same time perfusion and granulation is promoted. However, data for use and long term results of EVT in colorectal surgery are still scarce and consist of only a few small patients series with short-term follow-up. Objectives: Here, we aimed to analyze treatment spectrum and outcome of EVT for defects of the lower gastrointestinal tract. Methods: Retrospective single center analysis of EVT for various defects of the lower gastrointestinal tract over a time period of 8 years (2007-2014) with a mean follow-up of 36 months. Results: In total, 426 polyurethane sponges were placed in lower GI defects of 38 patients (29 male, 9 female) with a median age of 67 years (range, 29-91). Most frequent indication for EVT were anastomotic leakage after rectal resection (n=18), Hartmann's stump insufficiency (n=9) and rectal perforation (n=3). The median number of sponge insertions was six (range, 1-37) with a mean changing interval of three days (range, 1-5). Median time of therapy was 20 days. A successful vacuum therapy with local control of the septic focus was achieved in 17 of 18 patients (94.4%) with anastomotic leakage after rectal resection and in 8 of 9 patients with a Hartmann`s stump insufficiency. Conclusion: EVT has earned its indication in complication management after colorectal surgery and can achieve a successful control of a local septic focus in the majority of patients.

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SSAT Abstracts

Experience and Results for Laparoscopic Median Arcuate Ligament Release in Young Patients With Postural Orthostatic Tachycardia Syndrome Mikael Petrosyan, Ashanti Franklin, philip Guzzetta, Hassan Abdullah, Timothy D. Kane Introduction: The Median Arcuate Ligament Syndrome (MALS) is a rare syndrome resulting in a compression of celiac artery which is associated with severe post prandial abdominal pain, emesis, nausea, and weight loss which may subsequently lead to significant debilitation. We have observed a strong association of MALS in patients with Postural Orthostatic Tachycardia Syndrome (POTS). The aim of this study is to review a single institutional operative experience and outcomes for patients undergoing laparoscopic MAL release. Patients and Methods: Between February 2013 and November of 2014, a total of 41 patients underwent laparoscopic MAL release at our hospital. Our operative technique evolved over the series but included ablation of the celiac ganglion plexus during ligament release. Demographics, techniques, complications were collected and analyzed retrospectively. Results: Forty one patients ages 14-22 years, 6 males (15%) and 35 females (85%) were diagnosed with MALS. A diagnosis of MALS was based on clinical symptoms as well as Ultrasound (US) and/or CT angiography results. All patients carried the diagnosis of POTS and all were on various hypertensive medications. Peak systolic velocities on expiration in the celiac artery were elevated in all patients (range 200-572 cm/sec) prior to operation. Twenty three patients also had evidence of celiac artery origin compression on CT angiography. All patients underwent laparoscopic median arcuate ligament release with intraoperative US evaluation. Average operative time was 110 min. Average length of hospital stay was 2 days. One conversion (2.4%) was required for a bleeding celiac artery. Re-operative rate was 7%. Thirty four (83%) patients had partial or complete symptomatic improvement immediately post op (less than 30 days). Follow up ranged from 1-21 months. POTS symptoms were improved in 38% after MAL release. Conclusion In patients with chronic abdominal pain and POTS, the diagnosis of MALS should be considered. In this experience, laparoscopic median arcuate release has provided significant symptomatic improvement (primarily for gastrointestinal and abdominal pain) in these patients. It is possible that the hyper adrenergic state in patients with POTS and concomitant MALS maybe lead to irregular stimulation of the celiac plexus. Although complete elimination of POTS symptoms is not usually found, laparoscopic MAL release may represent a viable therapeutic intervention for this patient population.

569 Novel Approach to Complete Luminal Stenosis Secondary to Leak and Stricturing After Esophagectomy and Substernal Gastric Pull up Caleb G. Van Essen, Tommy H. Lee, sumeet K. mittal A complication of esophageal resection with gastric pull up is the development of anastomotic leaks with subsequent stricturing. This often requiring serial dilation and stent placement. We present a case in which a patient developed a complete luminal stenosis secondary to leak and stricturing after esophagectomy and substernal gastric pull up. After failed attempts to regain luminal patency using conventional techniques, a novel two-endoscope approach was used, via the esophagus and stomach, to traverse the impassable stricture. A second novel technique was used to secure a migrating stent by using an endoscopically guided transcutaneous U- stitch. 570 Laparoscopic Removal of LINX Anti-Reflux Device Jamil L. Stetler, Sujata Gill, Ankit Patel, S. Scott Davis, Edward Lin Laparoscopic placement of the LINX® Reflux Management System is growing in popularity as a treatment for medically refractory gastroesophageal reflux disease. The short term data published to date is promising and shows that this treatment method has a minimal side effect profile. We currently do not have 10-year data on this treatment method, and as more of these devices are placed in the future there will be instances where they will need to be removed. The objective of this video is to demonstrate that laparoscopic removal of this device from the gastroesophageal junction in some cases may be challenging.

567 Surgical Decision Making in Patients With Ulcerative Colitis: The Patient Perspective Jessica N. Cohan, Elissa M. Ozanne, Justin L. Sewell, Uma Mahadevan, Daniel Dohan, Madhulika Varma, Emily V. Finlayson PURPOSE: Facilitating the meaningful participation of ulcerative colitis patients in the decision between end ileostomy and ileal pouch-anal anastomosis (IPAA) is an ongoing clinical challenge. We sought to characterize: 1) patients' desire to participate in decision making and 2) the processes used to prepare for decision making to inform the development of a surgical decision support tool. METHODS: In this pilot study, we recruited adult patients with ulcerative colitis who were referred for surgical evaluation at three colorectal surgery clinics (tertiary referral center, HMO, and safety net hospital) who were candidates for IPAA and end ileostomy. We measured desire for participation in decision making using the control preferences scale, knowledge using a 13-item instrument (possible answers "true", "false", and "unsure"), and used closed- and open-ended questions to determine how patients prepared for decision making prior to meeting with the surgeon and which sources of information they considered most useful. RESULTS: We analyzed data from 18 patients with a median age of 49 years. Prior to surgical consultation, 12 patients favored IPAA, 1 favored ileostomy, and 5 were unsure. Those who were unsure reported that they had inadequate information to make a decision. The most commonly cited reasons for choosing IPAA over ileostomy were concerns about ileostomy maintenance and desire to avoid a "bag". The median time spent learning about surgery was 5.5 hours (range 0-15). The most frequently used sources were the internet and information provided by physicians. Although patients reported that information provided by physicians was the most believable, it was also the least helpful. The median knowledge score was 9/13 (range 1-13), with 16/18

SSAT Abstracts

571 Iatrogenic Surgical Achalasia: A Mesh Complication After Hiatal Hernia Repair Lester B. Katz The use of mesh during hiatal hernia repair is controversial . While the use of synthetic mesh for the repair is associated with a lower rate of recurrence if a complication of the mesh occurs it is frequently catastrophic and often requires an esophogastrectomy. We present a patient who underwent laparoscopic paraesophogeal hernia repair with postoperative dysphagia. He had a second procedure with attempted mesh removal that was aborted. When he presented to us he had solid food dysphagia and a sigmoid esophagus. We were able laparoscopically to remove the mesh and reduce and takedown the incarcerated wrap. At six months the esophagus has regained a more normal shape and function. The patient is asymptomatic

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