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669 Chronic use of PPI and H2 Antagonists Decreases the Risk of Pouchitis After IPAA for Ulcerative Colitis
intra-operative bleeding that may have led to the patient's eventual clinical failure. The patient underwent a laparoscopic Heller myotomy four months later which is shown in the second part. We see that the prior POEM had not created significant mediastinal or submucosal adhesions. This is the first evidence that patients who fail POEM can then undergo laparoscopic Heller myotomy without significant added operative difficulty.
obtained. Two-sided Fisher's exact test was used to compare groups. Results: 85 patients were identified that had complete PPI/H2 data available. The data is shown in the table. There was a statistically significant increase in the use of daily PPI/H2 in patients without pouchitis. There was also a statistically significant increase in the use of antacids more than one time per week in patients without pouchitis. There was no association between the use of PPI/H2 and the use of antacids. Occasional use of PPI/H2 did not alter the rate of pouchitis. None of the other variables were statistically significantly different between groups (see table). Conclusions: 1. Our data suggests that the daily use of PPI or H2 antagonists is associated with a decreased risk of pouchitis and may be protective against pouchitis in patients with IPAA for UC. 2. Occasional use of these agents did not seem to afford the same protection. 3. Regular antacid use provided similar protection as PPI and H2 antagonists. 4. This data suggests that altering the acid content/pH of the GI tract may influence the development of pouchitis, possibly by altering the bacterial flora. Further work to identify the changes in fecal flora is warranted.
585 Hiatal Mesh: When the Crura Cannot Be Closed Tatyan M. Clarke, Ross F. Goldberg, Armando Rosales-Velderrain, Steven P. Bowers The value of mesh-buttress over approximated crural musculature in hiatal hernia repair remains a topic of continued research and debate. However, there are situations in which mesh use is essential. When the crura are fibrotic, immobile, or damaged, and in the case of unusually large defects, crural re-approximation is not feasible and a mesh-bridge repair is indicated. Presented here are 3 cases where mesh is deemed necessary and appropriate. First, a case of fibrotic crura after hiatal hernia recurrence. The second case describes the technique of repair for a large para-hiatal hernia. The final case demonstrates repair of hiatal hernia occurring years after transhiatal esophagectomy. 586 Minimally-Invasive Robot-Assisted Modified Appleby Resection for Pancreatic Adenocarcinoma Joel Baumgartner, Mehmet F. Can, Herbert Zeh, A. James Moser Selected patients with pancreatic adenocarcinoma involving the celiac trunk may derive prolonged survival benefit from surgical resection. We report two patients who underwent robot-assisted modified Appleby resection after chemoradiation. Median age was 82. Median duration of surgery was 374 minutes, median EBL 225 and 11 day length of stay. Surgical margins were negative in both patients. The most severe morbidity was Clavien grade 3 gastric ischemia that resolved with bowel rest. The other patient had an ISGPF grade C pancreatic leak requiring endoscopic drainage. Robot-assisted minimally invasive modified Appleby resection can be completed safely with acceptable morbidity and mortality. 587 Laparo-Endoscopic Transgastric Resection of a Submucosal Mass at the Gastro-Esophageal Junction Neil Ghushe, Parambir S. Dulai, Thadeus Trus
670
The management of gastric submucosal masses adjacent to the gastro-esophageal junction presents an interesting therapeutic challenge. Wedge resection is not possible in this location without compromising the lower esophageal sphincter or esophagus. Endoscopic submucosal dissection provides an inadequate deep tissue margin. We present a combined laparoendoscopic approach for transgastric resection of this type of lesion.
The Prevention of Laparoscopic Bile Duct Injuries: Delineation of the Principal Active and Passive Mechanisms of Bile Duct Injury Lygia Stewart, John G. Hunter, Lawrence Way Introduction: The most common mechanism of major bile duct injury (BDI) involves misidentification of the CBD as the cystic duct, which is then deliberately transected. A common, but less frequent, mechanism occurs when the hepatic duct is injured during dissection in the triangle of Calot that is unknowingly too close to the common hepatic duct. Both mechanisms involve misperception, but one is active and the other passive. We analyzed the two to find clues that would help improve prevention. Methods: 433 lap cholecystectomies (125 uncomplicated, 308 BDI) were studied. BDI were categorized according to the type: active (deliberate transection of common bile duct mistaken for the cystic duct) and passive (lateral injuries during dissection too close to the common hepatic duct). Operative reports were examined for sensemaking cues and clinical factors. Results: Of the 308 BDI: 223 (72%) were active (ActBDI), 77 (25%) were passive (PassBDI), and 8 (3%) followed CBDE with T-tube. The level of biliary injury is shown in the second table; injury to proximal bile ducts was more common with ActBDI. Fewer PassBDI (16%) than ActBDI (34%) were recognized intra-op (P=0.006). Factors limiting visibility (inflammation, bleeding, etc) were more common in PassBDI (Table); while what were thought to be abnormal anatomic findings (additional ductal/tubular structures, arteries, vessels, abnormal biliary anatomy) were more common in ActBDI (Table). The surgeon's intra-operative sense-making also differed: A deliberate search for possible BDI was more common in ActBDI than in PassBDI (Table); cases were more commonly opened for compromised visibility with PassBDI (Table); and ActBDI were more commonly identified intra-op among all BDI cases as well among those converted to a laparotomy. Certain cues inhibited BDI detection. Detection of all BDI was less common in cases with bleeding (9% vs 36%, bleeding vs none, P<0.0001), and when multiple factors limited visibility (BDI detection: 35% no visibility issues, 28% one issue, but only 11% with two or more factors limiting visibility, P<0.0001). Conclusions: This study highlights differences in BDI mechanisms and possible means of prevention. Most surgeons are aware of the perceptual trap of misidentifying the CBD for the cystic duct, but passive injury has been less completely elucidated. These data show that PassBDI were less often detected, and identification of all BDI was hindered when visibility was impaired (mainly by bleeding or inflammation). Thus, when the surgeon's attention was occupied by inflammation or bleeding, consideration of an injury to the bile duct was inhibited. Increased emphasis on this risk factor should help prevent passive injury to the common hepatic duct. Active and Passive BDI Characteristics
SSAT Abstracts
668 Robotic-Assisted Rectal Dissection for Restorative Proctectomy for Ulcerative Colitis Brian Bello, Marie C. Ziesat, Konstantin Umanskiy, Alessandro Fichera Robotic-assisted rectal dissection for cancer has been well-described, but experience in patients with inflammatory bowel disease is lacking. The inflamed, friable tissue of the ulcerative colitis patient adds an element of complexity to the rectal dissection during a restorative proctectomy. Robotic assistance can aid in visualization and maneuvering within the limited space of a narrow pelvis. At our institution, we use the robot to safely perform the complete circumferential rectal dissection in patients with inflammatory bowel disease. We depict a robotic-assisted rectal dissection during a restorative proctectomy in a thirtyone year old female patient with ulcerative colitis. 669 Chronic use of PPI and H2 Antagonists Decreases the Risk of Pouchitis After IPAA for Ulcerative Colitis Lisa S. Poritz, Rishabh Sehgal, Arthur Berg, Lacee Laufenberg, Christine Choi, Emmanuelle Williams Introduction: Pouchitis is one of the most common long term complications after ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC). One common theory of pathogenesis is bacterial overgrowth in the pouch. Proton pump inhibitors (PPI) and H2 antagonists (H2) are commonly used in the general population for control of gastric acid. The change in pH of the stomach effluent caused by anti-acid therapies may lead to alteration of the enteric bacteria population in the gastrointestinal tract and is known to be associated with small bowel bacterial overgrowth. We hypothesize that chronic use of PPI or H2 antagonists will alter the incidence of pouchitis after IPAA for UC. Methods: Patients who had undergone IPAA for UC at least 2 years ago were identified from our familial inflammatory bowel disease registry. They were classified as having no history of pouchitis (no attacks of pouchitis since IPAA 2 or more years ago) or pouchitis (documented episodes of pouchitis in the medical record by biopsy and/or endoscopy and response to antibiotic therapy). Patients were then contacted and questioned about use of PPI, H2, and antacids. PPI and H2 were classified as never used, daily use, or occasional use (1/month-2/week). Antacid use was classified as less or more than once a week. Patients were also questioned about known risk factors for pouchitis including tobacco use, extraintestinal manifestations of IBD, primary sclerosing cholangitis (PSC) and the use of NSAIDS. Data on the use of fiber supplementation, antidiarrheal medications, probiotics, and immunosuppressive medications was also
SSAT Abstracts
S-1032
obtained. Two-sided Fisher's exact test was used to compare groups. Results: 85 patients were identified that had complete PPI/H2 data available. The data is shown in the table. There was a statistically significant increase in the use of daily PPI/H2 in patients without pouchitis. There was also a statistically significant increase in the use of antacids more than one time per week in patients without pouchitis. There was no association between the use of PPI/H2 and the use of antacids. Occasional use of PPI/H2 did not alter the rate of pouchitis. None of the other variables were statistically significantly different between groups (see table). Conclusions: 1. Our data suggests that the daily use of PPI or H2 antagonists is associated with a decreased risk of pouchitis and may be protective against pouchitis in patients with IPAA for UC. 2. Occasional use of these agents did not seem to afford the same protection. 3. Regular antacid use provided similar protection as PPI and H2 antagonists. 4. This data suggests that altering the acid content/pH of the GI tract may influence the development of pouchitis, possibly by altering the bacterial flora. Further work to identify the changes in fecal flora is warranted.
585 Hiatal Mesh: When the Crura Cannot Be Closed Tatyan M. Clarke, Ross F. Goldberg, Armando Rosales-Velderrain, Steven P. Bowers The value of mesh-buttress over approximated crural musculature in hiatal hernia repair remains a topic of continued research and debate. However, there are situations in which mesh use is essential. When the crura are fibrotic, immobile, or damaged, and in the case of unusually large defects, crural re-approximation is not feasible and a mesh-bridge repair is indicated. Presented here are 3 cases where mesh is deemed necessary and appropriate. First, a case of fibrotic crura after hiatal hernia recurrence. The second case describes the technique of repair for a large para-hiatal hernia. The final case demonstrates repair of hiatal hernia occurring years after transhiatal esophagectomy. 586 Minimally-Invasive Robot-Assisted Modified Appleby Resection for Pancreatic Adenocarcinoma Joel Baumgartner, Mehmet F. Can, Herbert Zeh, A. James Moser Selected patients with pancreatic adenocarcinoma involving the celiac trunk may derive prolonged survival benefit from surgical resection. We report two patients who underwent robot-assisted modified Appleby resection after chemoradiation. Median age was 82. Median duration of surgery was 374 minutes, median EBL 225 and 11 day length of stay. Surgical margins were negative in both patients. The most severe morbidity was Clavien grade 3 gastric ischemia that resolved with bowel rest. The other patient had an ISGPF grade C pancreatic leak requiring endoscopic drainage. Robot-assisted minimally invasive modified Appleby resection can be completed safely with acceptable morbidity and mortality. 587 Laparo-Endoscopic Transgastric Resection of a Submucosal Mass at the Gastro-Esophageal Junction Neil Ghushe, Parambir S. Dulai, Thadeus Trus
670
The management of gastric submucosal masses adjacent to the gastro-esophageal junction presents an interesting therapeutic challenge. Wedge resection is not possible in this location without compromising the lower esophageal sphincter or esophagus. Endoscopic submucosal dissection provides an inadequate deep tissue margin. We present a combined laparoendoscopic approach for transgastric resection of this type of lesion.
The Prevention of Laparoscopic Bile Duct Injuries: Delineation of the Principal Active and Passive Mechanisms of Bile Duct Injury Lygia Stewart, John G. Hunter, Lawrence Way Introduction: The most common mechanism of major bile duct injury (BDI) involves misidentification of the CBD as the cystic duct, which is then deliberately transected. A common, but less frequent, mechanism occurs when the hepatic duct is injured during dissection in the triangle of Calot that is unknowingly too close to the common hepatic duct. Both mechanisms involve misperception, but one is active and the other passive. We analyzed the two to find clues that would help improve prevention. Methods: 433 lap cholecystectomies (125 uncomplicated, 308 BDI) were studied. BDI were categorized according to the type: active (deliberate transection of common bile duct mistaken for the cystic duct) and passive (lateral injuries during dissection too close to the common hepatic duct). Operative reports were examined for sensemaking cues and clinical factors. Results: Of the 308 BDI: 223 (72%) were active (ActBDI), 77 (25%) were passive (PassBDI), and 8 (3%) followed CBDE with T-tube. The level of biliary injury is shown in the second table; injury to proximal bile ducts was more common with ActBDI. Fewer PassBDI (16%) than ActBDI (34%) were recognized intra-op (P=0.006). Factors limiting visibility (inflammation, bleeding, etc) were more common in PassBDI (Table); while what were thought to be abnormal anatomic findings (additional ductal/tubular structures, arteries, vessels, abnormal biliary anatomy) were more common in ActBDI (Table). The surgeon's intra-operative sense-making also differed: A deliberate search for possible BDI was more common in ActBDI than in PassBDI (Table); cases were more commonly opened for compromised visibility with PassBDI (Table); and ActBDI were more commonly identified intra-op among all BDI cases as well among those converted to a laparotomy. Certain cues inhibited BDI detection. Detection of all BDI was less common in cases with bleeding (9% vs 36%, bleeding vs none, P<0.0001), and when multiple factors limited visibility (BDI detection: 35% no visibility issues, 28% one issue, but only 11% with two or more factors limiting visibility, P<0.0001). Conclusions: This study highlights differences in BDI mechanisms and possible means of prevention. Most surgeons are aware of the perceptual trap of misidentifying the CBD for the cystic duct, but passive injury has been less completely elucidated. These data show that PassBDI were less often detected, and identification of all BDI was hindered when visibility was impaired (mainly by bleeding or inflammation). Thus, when the surgeon's attention was occupied by inflammation or bleeding, consideration of an injury to the bile duct was inhibited. Increased emphasis on this risk factor should help prevent passive injury to the common hepatic duct. Active and Passive BDI Characteristics
SSAT Abstracts
668 Robotic-Assisted Rectal Dissection for Restorative Proctectomy for Ulcerative Colitis Brian Bello, Marie C. Ziesat, Konstantin Umanskiy, Alessandro Fichera Robotic-assisted rectal dissection for cancer has been well-described, but experience in patients with inflammatory bowel disease is lacking. The inflamed, friable tissue of the ulcerative colitis patient adds an element of complexity to the rectal dissection during a restorative proctectomy. Robotic assistance can aid in visualization and maneuvering within the limited space of a narrow pelvis. At our institution, we use the robot to safely perform the complete circumferential rectal dissection in patients with inflammatory bowel disease. We depict a robotic-assisted rectal dissection during a restorative proctectomy in a thirtyone year old female patient with ulcerative colitis. 669 Chronic use of PPI and H2 Antagonists Decreases the Risk of Pouchitis After IPAA for Ulcerative Colitis Lisa S. Poritz, Rishabh Sehgal, Arthur Berg, Lacee Laufenberg, Christine Choi, Emmanuelle Williams Introduction: Pouchitis is one of the most common long term complications after ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC). One common theory of pathogenesis is bacterial overgrowth in the pouch. Proton pump inhibitors (PPI) and H2 antagonists (H2) are commonly used in the general population for control of gastric acid. The change in pH of the stomach effluent caused by anti-acid therapies may lead to alteration of the enteric bacteria population in the gastrointestinal tract and is known to be associated with small bowel bacterial overgrowth. We hypothesize that chronic use of PPI or H2 antagonists will alter the incidence of pouchitis after IPAA for UC. Methods: Patients who had undergone IPAA for UC at least 2 years ago were identified from our familial inflammatory bowel disease registry. They were classified as having no history of pouchitis (no attacks of pouchitis since IPAA 2 or more years ago) or pouchitis (documented episodes of pouchitis in the medical record by biopsy and/or endoscopy and response to antibiotic therapy). Patients were then contacted and questioned about use of PPI, H2, and antacids. PPI and H2 were classified as never used, daily use, or occasional use (1/month-2/week). Antacid use was classified as less or more than once a week. Patients were also questioned about known risk factors for pouchitis including tobacco use, extraintestinal manifestations of IBD, primary sclerosing cholangitis (PSC) and the use of NSAIDS. Data on the use of fiber supplementation, antidiarrheal medications, probiotics, and immunosuppressive medications was also
SSAT Abstracts
S-1032