689 Transduodenal Resection of a Ampullary Adenoma

of a single-institution database to compare outcomes after POEM and LHM. 11 patients underwent POEM from 8/2010-11/2011 under the following IRB-approved inclusion criteria: age 18-85, no prior treatment for achalasia, and non-sigmoid esophagus. 50 patients were identified who had undergone LHM from 3/2004-7/2011 and fit these same criteria. T-tests and Fisher exact tests were used to compare results. Results: There were 7 (64%) and 26 (52%) male patients in the POEM and LHM groups respectively (p=ns). POEM patients were younger (36 ±11 vs. 50 ±16 years; p<0.01). BMI and ASA classifications were similar. There was no difference in duration of symptoms prior to surgery (2 ±5 vs. 2 ±3 years). POEM and LHM had similar procedure times (121 ±42 vs. 126 ±29 min; p=ns). POEM had less EBL (≤10ml in all cases vs. 91 ±55ml; p<.001) but LHM had longer myotomy lengths (8.0 ±1.1 vs. 8.5 ±0.7cm; p=.04). Pain scores were similar on the day of surgery (3.3 ±3.1 vs. 2.1 ±2.3; p=ns) and on POD#1 (2.5 ±2.8 vs. 2.1 ±2.3; p=ns). Patients used similar amounts of narcotics on the day of surgery (4.8 ±5.2 vs. 2.8 ±4.3 mg morphine equivalents; p=ns) and POD#1 (6.9 ±7.7 vs. 4.6 ±5; p=ns) despite the fact that fewer POEM patients received ketorolac (18% vs. 78%; p<.001) due to concern for potential post-op bleeding in the sub-mucosal tunnel. Length of stay was similar (2.3 ±3.6 vs. 1.6 ±2.9 days; p=ns) and all POEM patients except for one were discharged by POD#2. No mortalities and 1 major complication occurred in each group: A POEM patient had a contained leak at the EGJ requiring laparoscopic drain placement and a LHM patient had a delayed esophageal leak requiring thoracotomy for drainage and repair. 3 (27%) minor complications occurred in POEM patients, compared with 7 (14%) in LHM patients (p=ns). Per-protocol post-op high-resolution manometry (HRM) and timed barium esophagram (TBE) at six weeks showed that POEM patients had decreased basal expiratory EGJ pressures (12 ±7 vs. 25 ±10 mmHg, p=.04) and relaxation pressures (15 ±3 vs. 29 ±17 mmHg, p<.05) and decreased contrast column heights at 1, 2 and 5-minutes (4, 2 and 2 vs. 17, 16 and 11cm), although only significantly at 1 and 2-minutes (p=.02 and .004). LHM patients did not routinely undergo repeat HRM or TBE. Conclusions: POEM is a feasible procedure for creating an endoscopic myotomy for the treatment of achalasia. POEM and LHM appear to have similar perioperative outcomes. Further data are needed to define and compare long-term functional outcomes after POEM.

685 Robotic Assisted Duval Procedure for Pancreas Divisum and Cystic Neoplasm John Rodriguez, Sricharan Chalikonda, Au Bui, Jessica Titus, Matthew Walsh We present the case of a 35 year old female that was referred for management of recurrent pancreatitis. On pre-operative evaluation she was found to have pancreas divisum with a long narrowed segment of the main pancreatic duct. On further review of MRCP images, a cystic lesion was found in the proximal duct. Our therapeutic goals consisted of resection of the cystic lesion and drainage of the proximal duct. She was taken to the operating room and a robotic assisted Duval procedure was successfully completed. We believe that this approach is safe and offers the benefits of minimally invasive surgery for this complex pathology. 686 A Year in the Life of a Tubulovillous Adenoma - Combined Endoscopic and Laparoscopic Management Niket Sonpal, Amit Jain, Patrick Saitta, Truptesh H. Kothari, Gregory B. Haber, Paresh C. Shah A 39-year-old male with a large symptomatic tubulovillous adenoma of the first and second portion of the duodenum was initially managed by endoscopic submucosal resection (EMR). The majority of the adenoma was excised by EMR in two stages. However, follow up endoscopy revealed persistent adenoma with regrowth to about 30% circumferential involvement of the duodenum and proximity to the ampulla. A laparoscopic trans-duodenal local resection was then performed with primary repair of the medial and lateral duodenum avoiding a pancreaticoduodenectomy with excellent oncologic and clinical results. 687

684

Laparoscopic Partial Hepatectomy With Hepatoduodenal Lymphadenectomy for Early Gallbladder Cancer Ziad Awad, Keyur A. Chavda

SSAT Abstracts

Anatomo-Physiology of the Pharyngo-Upper Esophageal Area in Volunteers at the Light of High Resolution Manometry: Defining Normal Values Luciana C. Silva, Fernando A. Herbella, Luciano R. Neves, Fernando P. Vicentine, Sebastião Pannocchia, Marco G. Patti

Our case is 61year old female with T1b adenocarcinoma of gallbladder found incidentally after laparoscopic cholecystectomy for chronic cholecystitis. CT scan showed no evidence of liver lesion. Two 12 mm and four 5 mm ports were used. First, laparoscopic hepatoduodenal lymphadenectomy was performed. Lymphadenectomy started at proper hepatic artery and continued towards celiac artery. Next, liver segment IVb and V were resected laparoscopically with a 2 cm margin. The patient was discharged home in 2 days. Pathology: no evidence of tumor in liver or lymph nodes.

Introduction: High resolution manometry (HRM) is a recent and valuable tool in the assessment of esophageal motility. The experience with this technology in the evaluation of pharyngeal and upper esophageal disorders is still incipient. This study aims to: (a) define normal values for pharyngo-upper esophageal motility, and (b) correlate HRM plots with pharyngeal anatomic landmarks. Methods: 29 healthy individuals (mean age 30 years, 62% males) underwent HRM with a solid-state catheter with 36 circumferential sensors spaced 1 cm apart positioned to record from the base of the tongue to the esophagus. Pharyngeal, upper esophageal sphincter and proximal esophagus parameters were recorded by giving 10 swallows of 5 mL of water at 30-second intervals. The analysis was performed with the commercial dedicated software. Fourteen individuals also underwent a concomitant transnasal pharyngoscopy. Results: Manometric parameters are depicted in table 1. The correlation between HRM plots and pharyngeal anatomic landmarks is shown in figure 1. Conclusion: Normal values for pharyngeal, upper esophageal sphincter and proximal esophagus parameters have been determined. These results may be applied in future studies. Manometric values

688 Laparo-Endoscopic Single Site (LESS) Distal Pancreatectomy and Splenectomy With Extraction Port Alexander S. Rosemurgy, Harold Paul, Krishen Patel, Edward Choung, Sharona B. Ross This is a video of a single incision distal pancreatectomy with splenectomy. A 12mm vertical incision was made at the umbilicus. A 5mm deflectable tip laparoscope was utilized. The stomach was mobilized and the gastrocolic omentum was divided. A retractor lifted the liver and the dissection was carried along the inferior border of the pancreas toward the caudal tip of the spleen. The pancreas was divided utilizing a reinforced laparoscopic linear stapler. The specimen was delivered via extraction bag using a 2.2cm lateral incision. The diaphragm was irrigated with bupivacaine solution. The umbilicus was closed in a figureof-eight fashion. There was no notable scar. 689 Transduodenal Resection of a Ampullary Adenoma Robert Grützmann, Marius Distler Ampullary tumors display a favorable prognosis compared with other periampullary tumors. This prognostic difference can be attributed to the early presentation and easy diagnosis by upper gastrointestinal endoscopy and simultaneous histological verification and to biological differences that may determine the prognostic superiority of these tumors. The therapy of choice is complete resection. In benign cases this can be achieved either by endoscopic resection or surgical transduodenal resection, whereas malignant tumors should be treated with a pancreatic head resection and lymphadenectomy. Here we describe the technique of transduodenal resection of a adenoma of the papilla of Vater.

Data presented as median (interquartile range) 727 Post Roux-en-Y Gastric Bypass Biliary Dilation: Natural Process or Significant Entity? Kevin M. El-Hayek, Poochong Timratana, Joseph Meranda, Hideharu Shimizu, Bipan Chand Background: Changes in the biliary system after gastric bypass are not well defined. Dilation may be normal or due to biliary tract pathology, that latter of which is problematic to manage because access to the biliary tree following gastric bypass often requires specialized care due to altered anatomy. The purpose of this study is to review patients who underwent imaging of their biliary system both before and after Roux-en Y gastric bypass in an effort to elucidate the effect this operation has on hepatic duct diameter. Methods: Using an IRB approved database, patients who underwent laparoscopic Roux-en Y gastric bypass from 6/ 1/2010 and 9/30/2011 were evaluated. Those with imaging both before and at least 3 months after gastric bypass were analyzed. Patients who underwent remote cholecystectomy prior

SSAT Abstracts

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