Laparoscopy in the staging of upper gastrointestinal malignancy

treated with the 15mm balloon responded and required no further dilation, 1 responded to a further 15ram balloon dilation, and the other 4 patients responded to subsequent 18mm balloon dilation. The 2 patients treated with initial 18ram dilation required no further dilations. The averagelength of follow-up after successful dilation was 18 months (range 7-30 months). There were no perforations with any of the 23 dilations performed, Conclusion Stenosis of the gastrojejunostomy after laparoscopic gastric bypass occurred in 3.1% of the patients in this series. It can be successfully and safely treated with endoscopic balloon dilation with good Iongterm follow-up. 2491 Feasibility Of Lapareacopic Wedge Resection For Gastric Stromal Tumors Yoshihide Otani, Toshiharu Furukawa, Tetsuro Kubnta, Koichiro Kumai, Masaki Kitajima, Keio Univ Sch of Medicine, Tokyo Japan

OVBG(14) and LVBG(16). Patients received a standard anesthetic technique and a fixed dose of pain medication after surgery. Extra doses of analgesics were adnministered as needed. Pain intensity was evaluated four times a day. Respiratory function tests and a previously validated questionnaire to assess physical activity were performed before surgery and daily during the three initial postoperative days. Both, patients and the observer were blind to the procedure during this time period. Early and late complications, 1-year weight loss, cosmetic results and patient satisfaction were also evaluated. Results were analized using the Fisher's exact test, the Wilcoxon rank-sum test and Pearson Chi square. Results: Both groups were highly comparable in terms of demographic characteristics and overweight before surgery. Statistically significant differences between groups are showed in the table. One-year median excess body weight loSSwas 55%(range 30-88)in the OVBG group and 47%(range 22-97)in the LVBG group. Conclusions: LVBG had advantages over the OVBG in terms of analgesic requirements, respiratory function, postoperative recovery and cosmetic results. One-year weight loss was similar in both groups. Results

Background: Fifty-six patients with gastric submucosal tumors were treated laparoscopically in Keio University Hospital since 1993. Among them thirty-seven lesions (66%) ware diagnosed as stromal tumor. Clinicopathological findings of these cases arc reviewed. Indication: Our indication of curative local resection for submucosal tumor is; 1)20 mm < T < 50 mm, 2)Rapid increase in size indicating malignant potential, 3)location of the tumor is not on the cardia or pylorus. For the precise preoperative evaluation, not only barium meal but also endoscopic ultrasonography were performed. Procedure: The entire surgical procedure was performed laparoscopically. Four or five trocars were inserted in the upper abdomen. When the tumor was located on the lesser or greater curvature, the gastric wall nearthe lesion was fully devascularized and exposed using laparoscopic coagulating shears. Pulling the tumor toward the abdominal wall, wedge resection of the gastric wall was performed using multifire endoscopic staplers, maintaining a safe margin from the tumor. To avoid the tumor cell dissemination, no-touch technique keeping the capsule of the tumor intact was carefully performed. Results: Thirty-seven stromal tumors were immunohistochamicatly sub-classified into 4 groups; gastrointestinal stromal tumor (GIST, 25 cases, 44.6%), Schwannoma (6 cases), myogenic tumor (5 cases), and mixed type (1 case). The mean tumor size was 35 mm. No major complication during postoperative course was experienced and the patients could discharge in 7-10 days uneventfully. All patients have survived without local recurrence or distant metastasis over the 8-year follow-up period. Laparoseopic wedge resection of the stomach for gastric stromal tumors can be regarded as a safe, curative and minimally invasive procedure when the patients are carefully selected. Reference:Otani Y, ef al, Surgical Laparoscopy, Endoscopy & PercutaneoosTechniques 10 (1): 19-23, 2000

Imenm O p ~ t l m m , h$ E.~d~radomeo#m ~ , 1st day Score of m o l d l t r ~ I actlv~es 2nd poaopday 3¢dpoMopday ~ force 3rd poaop day Sere'sc~'e0-2 PMhok~ scarAt

2 hour

2.5 hour

CL (mL/cm) PIP (mmHg) PaCOz (mmHg)

Lap Open Lap Open Lap Open

31.0-+8.8 34.6 -+7.6 29.8-+5,3 28.8 -+5.1 38.5 -+4.3 37.6 -+4.5

18.6-+4.8" 26.6 -+ 6.5 33.1+_5.0" 27.6 -+ 3.9 40.6 -+ 3.8* 36.1 -+ 2.7

17.5-+5.7' 26.5 -+ 7.1 33.9-+4.5* 26.8 -+ 3.1 41.4 -+4.7* 36.7 _+3.2

18.9+5.2" 25.2 -+7.1 33.8-+5.2* 28.2 :L 3.3 41.9 -+4.4* 36.9 -+ 3.4

23 65 1 5

25/ 30•25 0.003•0.005 0.005/0.11 60/ 0.04 •008 0.006 0.002

PorcineSide to Side Line~ StapledAnastrnosis

Suture/Staple Stapled

RespiratoryMechanicsduring Laparoscopicand Open GBP 1 hour

0.04

2)

The laparoscapic linear stapled anastomoszshas been criticized for its inability to determine the size of the opening for the gastrojejunostomy or the jejunojejunostomy. The circular stapled EEA has a reported 25% stricture occurrence in reported series. We examined various techniques for the gastmjejunal anastomoszsvarying from circular stapled, linear stapled with triangulation and linear stapled combined with band suturing while performing laparoscopic RYGB. Methods: 41 patients underwent laparoscopic RYGB with 5 trocars. Three patients underwent circular stapled anastomosis, seven patients underwent triangulated linear stapled anastomosis with an endoscopic 45 mm linear stapler and thirty-one patients underwent combined linear stapled with hand sawn closure of the remaining enterotomy. A porcine model of the RYGBwas performed and casts ware made from jejunojejunostomy to determine the size of the anastomotic opening. Results: The circular 21 mm EEA stapler requires trocar dilatation and closure. The triangulated stapled anastomosis had three obstructions (2 at the gastrojejunal site, 1 at the jejunojejunal site) requiring modification of the anastomosis. The combined linear stapled with hand-sewn closure of the remaining enterotomy did not have any complications of obstruction or leakage. Patients returned to work within 8-14 days and weight loss is comparable to the open RYGB. The porcine casts of the stapled anastomosis are described in the table below. Conclusion: Combined laparoscopic 45 mm linear stapled anastomosis with hand-sewing is the safest and quickest method of performing laparoscopic gastrointestinal anastomosis. The porcine casts reveal that a completely stapled anastomosis without suturing will decrease the opening of the anastomosis by 27%. The triangulated anastomosis is dependent on the thickness of the bowel. In morbidly obese patients, the jejunum is greatly thickened resulting in a smaller length in the linear stapled anastomosis. Laparoscopic RYGB is easily performed with linear stapling and suturing.

Background: Hypercarbla and raised intraabdominal pressure during pneumoperitoneum (PP) can adversely effect ventilatory function. We evaluated intraoperative respiratory mechanics in morbidly obese patients during laparoscopic and open gastric bypass (GBP). Methods: Fifty-eight patients with a body mass index (8MI) of 40-60 kg/m2 were randomnly allocated to laparoscopic (n=31) or open (n=27) GBP. Pulmonary compliance (Ct), end-tidal C02 (ETC02), arterial PCO~(PaC02), peak inspiratory pressure (PIP), C02 production (VC02), and standard bemodynamics were recorded at baselineand at 30-rain intervals. During laparosocic GBP, ventilatory settings were adjusted to maintain a higher respiratory rate than during open GBP to keep the ETC02levels within an acceptable range and to maintain a lower tidal volume due to higher PIP. Results: The two groups were similar in age, gender, and BMI. Compared to open GBP, laparoscopic GBP significantly increasedETC02,PaC02,PIP, VC02,and decreased CL (p
Baseline

p 0.002 1 (0-

The Combined Endo-61A Linear Stapled and Hand-Sewn Bowel Anastomosis Is More EfficteM and Safer for Laparassopi¢ Roux ea Y Gastric Bypass Carson D. Liu, David Kwan, UCLA Medical Ctr, Los Angeles, CA

Respiratory Mechanics During Lapareacopie and Open Gastric Bypass Ninh T. Nguyen, Univ of CA, Davis, Medical Ctr, Sacramento, CA; Neal Reining, Johnathan Yahr, John Anderson, Charles Goldman, Steven J. Lee, Carol J. Cole, Bruce M Wolfe, UC Davis Medical Ctr, Sacramento, CA

GBP

LVBG 2.1(1 5~)

2494

2492

Parameters

OVIBG 1 45(I 1-2 5) 2 {0-3/ 20 /18 20/ 21 5O /54 2 12

Radius

Area

1,77 cm 1.51 cm

980.6 mrnz 718.2 m~

2495 Laparascopy In The Staging Of Upper Gastrointestinal Malignancy Roderick T. Skelly, Mark A. Taylor, Barry W D Clements, Mark C. Regan, Dept of Surg, The Royal Victoria Hosp, Belfast United Kingdom BACKGROUND: Optimal management of cancer of the upper gastrointestinal tract requires accurate preoperative staging to facilitate multimodality therapy and to identify those who would benefit from potentially curative surgery. Studies have suggested staging laparoscopy as a useful adjunct, reducing unnecessary laparotomy in those with advanced disease. The aims of our study were: (1) to compare the accuracy of CT scanning with staging laparoscopy in patients with suspected upper gastrointestinal malignancy, (2) to evaluatethe extent of reassignment of pre-operative stage after laparoscopy and (3) to assess the utility of peritoneal washout cytology. METHODS:All patients undergoing pre-operative staging from 1998 were entered into a database. An analysis was carried over a 2-year period from 1998 to 2000. Patients who had a suspected upper gastrointestinal malignancy and who had both CT and staging laparoscow were included. From this, 50 pstJentswere identified. RESULTS: 68% of the study group had gastric cancer or junctional tumours of the cardia. 20% had pancreatic cancer and the remaining 12% had other diagnoses. CT scanning identified ascites in 4 patients, which was confirmed laparoscopically. Laparoscopy detected a further 7 patients with ascites not previously identified by CT. In the assessment of liver metastases, there was concordance between the CT findings and laparoscopy in 91% of cases. Laparoscopy detected a further 2 cases of liver metastases not previously noted on CT. Assessment of nodal

* p
2493 Open versus Laparoscopic Vertical Banded Gastraplasty. A randomized double blind controlled trial. Andrea O. Davila-Cervantes,Delia Borunda, Guillermo Dominguez, Rosa Gaming, Rorencia Vargas-Vorackova,Jorge Gonzalez-Barranco,Miguel F. Herrera, Inst Nacional de Ciencias Medicas y Nutricion SZ, Mexico City Mexico Background: Vertical Banded Gastroplasty can be performed open (OVBG) or laparoscopic (LVBG).The aim of the study was to compare the postoperative outcome and one year followup of 2 cohorts of patients who underwent either OVBG or LVBG in a 1-year period. Patients and Methods: A total of 30 patients with morbid obesity were randomized into two groups:

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a stricture. All strictures presentedwithin 8 weeks of surgery and were managedsuccessfully with endoscopic dilation (1-5 sessions). Conclusion: Circular stapled anastomosis during LRYGBP results in a high rate of anastomotic stricture, even greater than that reported after open RYGBPwith CBA. This experiencesuggests that laparoscopy may impart an increased risk of stricture relativeto comparableopentechnique.A hand-sewntechniqueavoidsthis complication.

status found that there was concordance in 69% of cases. Laparoscopyidentified significant lymphadenopathyin an additional 7 cases. In addition to improved accuracy in the detection of a mass lesion, laparoscopymade a further beneficial contribution to staging by identifying the presence of serosal invasion in 9 cases. This information alone led to an upgrading of the disease stage in 5 patients. Laparoscopyidentified an additional 5 cases with peritoneal seedlings not detected by CT. Peritoneal washings were positive in 6 out of 18 patients however in this group other features of advanced disease were present at laparoscopy. CONCLUSIONS: This study demonstrated laparoscopy to be an important adjunct in the staging of upper gastrointestinal malignancy as it identified advanceddiseasethat CT failed to demonstrate, hence altering stage assignment and subsequent management. Positive peritoneal washout cytology did not contribute significantly in the pre-operativestaging.

n Pro-upBMI Length of Stay (D) Complication(%) G,JStricture Follow-up(wks)

2496 Minimally Invasive Resection of Gastric Stremal Tumors Giselle G. Hamad, Sayeed Ikramuddin, Michael G. Posner, Kenneth K W Lee, Wnifgang H. Schraut, Philip R. Schauer, Univ of Pittsburgh, Pittsburgh, PA

CSA

HSA

14 46 (36-58) 3 (2-8) 5 (36%) 3 (21%) 34

18 52 (41-65) 5 (2-23) 4 (22%) 0 9.2

2934a European Multicentre Validation Trial of Two New Non-lnvasive Tests for Detection of Antibodyto H, pylp~ Urine-based ELISA and Rapid Urine Test Andreas Leodoiter, Univ of Magdeburg, Magdeburg Germany; Dine Vaira, F 6azzoli, Univ of Bologna, Bologna Italy; Alexander Hirschl, Univ of Vienna, Vienna Austria; Francis Megraud, Univ Victor Segalen, Bologna Italy; Peter Maifertheiner, Univ of Magdeburg, Magdeburg Germany Objective: Non-invasivetests for assessment of H. pylori status have become part of the management strategies of patients with dyspepsia.Aim of this study was to evaluate a new urine-based antibody ELISA (URINELISA") and a near patient rapid test (RAPIRUN®) for the diagnosis of H. pylori infection in comparison with other established tests. Methods: Urine samples were collected from 449 patients (240 females, 209 males, mean age 53.9 years) with dyspeptic symptoms and without previous H. pylori eradication therapy in 5 centers across 4 European countries. All patients underwent a gastrointestinal endoscopy. A patient was consideredto be H. pyloripositive if either culture and/or both histology and rapid urease test were positive. Furthermore a serum lug ELISA (Pyloriset EIA-GIII), a whole blood test (Pyloriset Screen) as well as a 13C-UBTwas performed. Urine and serum samples were analyzed in a central laboratory. Results: 422 of 449 (94%) patients fulfilled the predefined criteria and were included for evaluation. 216 were infected with H. pylori. Comparison of all test results are given in the table. Accuracy of urine and blood based tests varies between the different countries (range 64-96%) in a wider range compared to the results of the ~3CUBT (86-96%) Conclusion:The near patienttest RAPIRUNfor detectionof H. pyloriantibodies based on urine analysis is an accuratetest for diagnosis of H. pylodinfection and comparable to results obtained with serum ELISA and slightly superior to that of the whole blood test. 13C-UBTis confirmed to be the most accurate non-invasive test. The RAPIRUN is a valid option for non-invasivediagnosis of H. pyloriinfection, easy to handle, and rapid to perform. Considering the limitation of regional variations it appears valuableto implement this urinebased test in non-invasive managementstrategies.

Background: Gastrointestinal stromal tumors (GISTs) are neoplasms of mesenchymal origin which are most often found in the stomach. Minimally invasive excision of GISTs has been describedin small serieswith favorable results. Methods: We report the results of 16 consecutive patients, ranging in age from 38 to 86 years (mean 61.9) with gastric stromal tumors who underwent minimally invasive excision 1rum April, 1997 to November, 2000. Eleven patients were diagnosed by preoperative upper endoscopy. In three patients undergoing laparoscopic Roux-en-Y gastric bypass for morbid obesity and two patients undergoing laparoscopic Nissen fundoplication and Collis gastroplasty, gastric stromal tumors were detected incidentally. All patients underwent intraoperativeendoscopyfor localization of the lesion. Tumors were excised with negativemargins by laparoscopicgastric sleeve resection, laparoscopic wedge resection, or laparoscopic intragastric excision via anterior gastrotomy. Results: Ten (63%) patients presentedwith gastroesophagealreflux. Five (31%) patients had preoperativegastrointestinal bleeding. Abdominal pain was experiencedby 6 (38%) patients and 3 (19%) wereasymptomatic.Tumor size rangedfrom microscopicto 5 cm. Meanoperative time was 195.5 minutes. There were no conversions. The averagetime to resumption of oral intake was 1.4 days and mean length of hospital stay was 2.9 days. Two patients had respiratorycomplications.Therewere no mortalities. Conclusions:Minimally invasiveresection of GISTsof the stomach is safeand effectiveand is greatlyfacilitated by the use of intraoperative endoscopyand endoscopic staplers, Benefits include an early resumption of oral intake and short inpatient stay. 2497 Poor Outcome and Quality of Life in Female Patients Undergoing SecondarySurgery for Recurrent Peptic Ulcer Disease Gonzalo V. Gonzalez-Stawinski,Jason M. Rovak, Hillard F. Seigler, John P. Grant, Theodore N. Pappas, Duke Univ Medical Ctr, Durham, NC Background:Secondarypeptic ulcer surgery is uncommon given the successof a wide variety of medical therapies, plus the good outcome expected after primary peptic ulcer surgery. Early reports of secondary peptic ulcer surgery in the 1950's and 1960's suggested a good long-term outcome in a majority of patients. However, recent reviewers have suggested a worsening outcome in these patients. We have attemptedto quantity the poor outcome with these patients and measure the effect of gender, a previously unrecognized risk factor for poor outcome after secondary peptic ulcer surgery. Methods:We reviewedthe outcomes of 35 patients who underwent secondary peptic ulcer surgery for symptoms of persistent or recurrent peptic ulcer symptoms or complications of the condition. These patients were compared to a "control" group of patients on the following parameters:gender, immediate outcome (morbidity and mortality), long term quality of life as measured by the SF-36 and Visick scores (averagefollow-up 60 months). Visick and SF-36 scores answerswere obtained through telephone interviews. The two groups of patients were age-matchedto eliminate age as a variable in the SF-36 results. Results:Therewere more females than males in both the secondary and primary groups but the ratio of female/male was significantly higher in the group of patients undergoing secondary peptic ulcer surgery (4.5/1 secondary peptic ulcer surgery vs. 1.7/primary surgery), Although perioperativemortality was zero for both groups, secondary peptic ulcer surgery patients suffered more complications than primary surgery patients (57% vs. 31%, p = 0.06). Secondarypeptic ulcer surgery patients scored poorer in 7 of the eight subclasses of the SF-36 than age matched cohorts. In contrast, average Visick grades slightly improved in 3 out of 4 symptoms reported. Immediate postoperative complicationswere not relatedto long term quality of life issues.Conclusion:Secondarypeptic ulcer surgery is more prevalentin females than in males.While secondarypeptic ulcer surgery is partially effective in alleviating symptoms, quality of life is poor.

RAPIRUN URINELISA P3dodsetE IA Pylodset Screen 13C-UBT

SensiUvity

Specificity

PPV

NPV

Accuracy

82.4 89.4 96.3

83.3 69.0 71.8

84.0 74.5 77.9

81.7 85.9 94.8

82.9 78.9 84.5

71.0

83.3

81.7

73.3

77.0

93,0

93.1

93.4

92,6

93.0

2934b A Novel Near-Patient Test for the Direct Detection of H. pylori Antigens in Stool Meret Lakner, Sven Leier, Sonja Dehnert, Georg Schwartz, Gerhard Cullmann, Connex GmbH, Martinsried Germany Objective:The developmentof an immunochromatographicrapid test which reflectsthe actual infection status by directly detecting excreted H. pylorifrom stool. Unlike commonly used H. pyiori diagnosticsthis near patient test allows for non-invasivesampling and does not require any laboratory equipment. Methods: The immunochromatographictest is based on the sandwich immunoassayprinciple employing monoclonal antibodies and colloidal gold as a visible label. For performing the test a stool sample is diluted and applied to the base of the test strip. The result is read after 10 minutes. A red control line indicatesthe correct performance of the test. Two red lines indicate a H. pylori-positive test result. Results: For the evaluation of the diagnostic accuracy of the test 199 patient stool samples were analyzed.The H.pylori infection status of the patients was defined by ~3C-UreaBreath Test and/or histology. The rapid test correctly identified 95 of 100 H. py/ori positive stool samplesand 94 of 99 H. py/ori negative stool samples. Diagnostic specificity and sensitivity were 95%. Discussion: The immunochromatographic rapid test is currently incorporated in a device designatedMiniLab. This device integrates sampling, processing and analysis in one test unit allowing for simple and hygienic handling. With its sensitivity and specificity equal to the reference methods the rapid test is suitable for the use at the doctors office, in the hospital or even for home use.

2498 Gastrojejunal Stricture Following Laparoscopic Gastric Bypass More Likely With Circular Stapler Than Hand-sewn Anastomosis W. Alan Bradshaw, C. Daniel Smith, Emery Univ, Atlanta, GA Background: The creation of a gastrojejunostomy using a circular stapled anastomotic (CSA) technique greatly facilitates performanceof laparoscopicRoux-en-Ygastric bypass(LRYGBP), thereby obviating the need for laparoscopic hand-sewntechniques and skill. In open gastric bypass, anastomotic stricture is described to occur in 12% of patients. We reviewed our experience with CSA during LRYGBP and compared clinical outcomes to similar patients undergoing LRYGBPwith a hand-sewn anastomosis (HSA). Methods: Between 1/99 and 10/ go, 36 patients underwent LRYGBPfor operatively induced weight loss. Fourteen patients had a gastrojelunostomy using a 21ram CSA technique. These patients were compared with 18 patients whose gastrojejunostomywas completed using a two-layer HSA technique. Demographics and outcome were compared, in particular, anastomotic strictures and their management.Results:Seetable. No strictures occurred after HSAwhile 21% of CSAdeveloped

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