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Use of a Magnetically Coupled Camera and Novel Mini Laparoscopic Instruments to Perform Minimally Invasive Sigmoid Colon Resection
according to cell surface markers CD133 and CXCR4 and cultured in serum-free media. The stem cell spheroids were infected with NV1066, a third-generation herpesvirus, or NDV-F3aa-GFP, a Newcastle Disease virus mutant. Both viruses carried the marker gene green fluorescent protein (GFP), which allowed monitoring by fluorescent microscopy. Cell cycle analysis and cell migration assay were also performed. Results: Viral infection of cancer stem cells was rapid (GFP expression was seen by 24 hours). The viruses from both families each produced efficient infection and killing of cancer. At doses of multiplicity of infection (MOI, number of viruses per tumor cell) of 0.5 or 1, >95% of cells were dead by day 6. Infection with virus also produced decreased migratory capacity of the cancer stem cells and shifted the population to a higher fraction in S phase. Conclusion: Multiple types of oncolytic viruses effectively target the stem cell subpopulation of pancreatic cancer cells. Infection decreases metastatic potential and effects killing of such stem cells. These data support clinical studies of oncolytic viruses in the treatment of chemo- and radioresistant tumors.
800 A Standard “Oncologic” Segmental Colorectal Resection is Indicated for Dysplastic Adenomas That Come to Surgery; ESD and EMR Are Best Avoided in These Patients Joon H. Jang, Emre Balik, Michael J. Grieco, Tromp Wouter, Daniel D. Kirchoff, Anjali S. Kumar, Daniel L. Feingold, Richard L. Whelan Introduction: Endoscopic submucsal dissection (ESD) and endoscopic mucosal resection (EMR) methods are now being used for benign colorectal polyps judged not removable using standard colonoscopic methods. Also, laparoscopic partial circumference “wedge” resections of the colon wall (+ polyp) are being done in an effort to avoid a standard “Oncologic” Colorectal Resection (OCR) and its attendant morbidity. Unfortunately, a subset of these “benign” polyps contain invasive adenocarcinomas; in these patients (pts) an OCR is indicated. This retropsective review of benign polyp pts that underwent OCR's was undertaken with the hope of identifying polyp characteristics that would allow stratification of these lesions into low and high risk categories which might then guide treatment choices. Methods: All patients with the preoperative (preop) diagnosis of adenoma (+/- dysplasia) who underwent a standard colorectal resection over an 18 year period were included in the study. Hospital and office records, operative reports, colonoscopy and pathology reports were reviewed. The polyp size and location for each patient was noted; likewise the preop and final pathologic diagnoses were recorded and compared. The unpaired t-test and Fisher's Exact test were used to analyze the results and a p-value less than 0.05 considered significant. Results: A total of 386 benign adenoma pts underwent OCR during the period assessed. The distribution of large bowel polyps was: right, 263 (68.1%); transverse, 33 (8.6%); sigmoid, 38 (9.8%); rectum, 23 (6.0%), and multiple sites, 13 (3.4%). The preop pathologic diagnosis was adenoma alone for 288 (74.6%) and adenoma with dysplasia for 98 pts (25.4). Final post resection pathology revealed 62 invasive cancers (16.1% of total). Thirty five percent of pts (34/98) with a preop diagnosis of dysplasia had an invasive cancer whereas 9.7% (28/288) of the adenoma alone pts proved to have a malignancy (p<0.0001). The mean lymph node harvest for the entire group was 16.0±10.2; there was no difference in lymph node recovery for the cancer and benign adenoma groups. The cancer stage breakdown for the 62 pts with a malignant polyp was: Stage 1, 73%; Stage 2, 8.1%; Stage 3, 16%; Stage 4, 3.2%. The mean polyp size for benign lesions was 3.0±1.9cm whereas for cancers it was 3.9±2.4cm (p=0.0008). There was a higher incidence of Stage 3 cancers in pts with a preop diagnosis of dysplasia (p=0.008). Conclusion: Ten percent of pts with the preop diagnosis of adenoma alone and over 1/3 of pts with the preop diagnosis of dysplastic polyp had invasive cancers. Larger polyps were more likely to contain a cancer. A standard segmental colectomy is advisable for pts with dysplastic polyps because of the high likelihood of cancer. ESD, EMR, and wedge resection should be reserved for selected adenoma pts without dysplasia after thorough evaluation.
696 Minimizing MIS Using Magnetically Anchored and Percutaneous Needlescopic Instruments for Basic and Complex Procedures Nabeel Arain, Sara Best, Jeffrey A. Cadeddu, Deborah C. Hogg, Richard Bergs, Raul Fernandez, Lauren B. Mashaud, Daniel J. Scott This video shows techniques for minimizing MIS using magnetically anchored and percutaneous needlescopic instruments for both basic and complex procedures which included a laparoscopic cholecystectomy (porcine model) and a laparoscopic Roux-en-Y Gastric Bypass (human cadaver). We combined instrumentation including a magnetically anchored camera, 3mm percutaneous instruments, and a single 12mm working port. This combination afforded excellent triangulation and minimized the number and size of incisions. Furthermore, this strategy may offer comparable or even better cosmesis compared to single incision laparoscopic procedures without the associated technical difficulties. 697 Endoscopic Treatment of Weight Regain in the Post-Bypass Patient Rabindra R. Watson, David B. Lautz, Christopher C. Thompson Weight regain affects a significant proportion of post-bypass patients. Pouch and stoma dilation have been implicated as important factors in this process. The significant risk of morbidity with surgical revision makes endoscopic therapy an attractive treatment modality. This video reviews current endoscopic techniques including sclerotherapy, tissue anchor placement, and endoscopic suturing. Current evidence regarding these techniques is sparse, though compelling data are forthcoming. Given the growing bariatric population, endoscopic treatment of surgical failure will play an important role in the management of these patients.
801
Single port surgery of rectal tumours may be associated with shorter learning curve and fewer costs than transanal endoscopic microsurgery (TEM). A semicircumferent adenoma located 6-12cm from the anus was successfully resected using a single-site access system transanally. Endoluminal features were comparable to TEM. Full thickness, en bloc resection was possible. The defect was sutured transversally with continuous self-anchoring sutures. Operating time was 55 min. Blood loss was nil. The patient was hospitalized overnight. Histopathology showed tubulovillous adenoma with focal high grade dysplasia, radically resected. Single port transanal surgery may become an alternative to TEM.
Use of a Magnetically Coupled Camera and Novel Mini Laparoscopic Instruments to Perform Minimally Invasive Sigmoid Colon Resection Calvin D. Lyons, Rohan A. Joseph, Nilson Salas, Patrick R. Reardon, Barbara L. Bass, Brian J. Dunkin Natural orifice translumenal endoscopic surgery (NOTES) and single site laparoscopy (SSL) have led surgeons to seek less invasive methods of performing even standard operations by reducing port number and size. This video demonstrates how novel technology can be used to perform reduced port surgery, even during complex operations, without compromising visualization, triangulation, or instrument function. Use of MAGS in combination with percutaneous internally assembled instruments enables reduced port surgery while maintaining the visualization and function of 4 port laparoscopic surgery. The ergonomic benefit of this technology will aid in the performance both reduced port surgery and SSL.
802 Transesophageal Endoscopic Myotomy (TEEM) for the Treatment of Achalasia - The United States Human Experience Ozanan R. Meireles, Garth R. Jacobsen, Toshio Katagiri, Kari Thompson, Abraham Mathew, Noam Belkind, Michael Sedrak, Bryan J. Sandler, Takayuki Dotai, Thomas J. Savides, Saniea F. Majid, Sheetal Nijhawan, Mark A. Talamini, Santiago Horgan
699 Laparoscopic Rectosigmoid Resection With Transvaginal Rectopexy and Extraction for Rectal Prolapse Patricia Sylla, Samantha J. Pulliam, May Wakamatsu
From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic trans-esophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility and efficacy of TEEM in a series of patients with achalasia. Methods: Under IRB approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, age between 18 and 50 years old, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical co-morbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 O'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastro-esophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm bellow the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Results: Four patients underwent TEEM, with no peri-operative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first post-op day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach and absence of leaks. All patients were discharged on the second post-op
The patient is a 39 year-old G4P4 female with full-thickness rectal prolapse, constipation, symptomatic cystocele, rectocele, and stress urinary incontinence. Laparoscopic rectosigmoid mobilization was performed using 4 abdominal trocars and a 12mm port was inserted through a posterior colpotomy. The rectum was transected transvaginally with a stapler and suture rectopexy was performed through the vaginal trocar. The rectosigmoid was exteriorized transvaginally, the anvil was placed, and intracorporeal stapled anastomosis was completed. Anterior and posterior colporrhaphy with tension-free vaginal sling were performed perineally. The patient was discharged on postoperative day 4. 700 Notes Transoral Remnant Extraction (TORE) for Sleeve Gastrectomy Sheetal Nijhawan, Saniea F. Majid, Toshio Katagiri, Takayuki Dotai, Michael Sedrak, Bryan J. Sandler, Garth R. Jacobsen, Mark A. Talamini, Alan Wittgrove, Santiago Horgan Laparoscopic sleeve gastrectomy has rapidly become the procedure of choice for morbid obesity. We have utilized our considerable experience in natural orifice translumenal endoscopic surgery (NOTES) to develop techniques which will eliminate the potential complications of transabdominal organ extraction. Here we demonstrate the world's first case of the unisex approach to transoral remnant extraction or TORE.
S-1001
SSAT Abstracts
SSAT Abstracts
Single Port Transanal Surgery of a Giant Rectal Adenoma Renée M. Barendse, Pascal G. Doornebosch, Willem A. Bemelman, Evelien Dekker, Paul Fockens, Thomas M. Van Gulik, Eelco J. de Graaf
698
800 A Standard “Oncologic” Segmental Colorectal Resection is Indicated for Dysplastic Adenomas That Come to Surgery; ESD and EMR Are Best Avoided in These Patients Joon H. Jang, Emre Balik, Michael J. Grieco, Tromp Wouter, Daniel D. Kirchoff, Anjali S. Kumar, Daniel L. Feingold, Richard L. Whelan Introduction: Endoscopic submucsal dissection (ESD) and endoscopic mucosal resection (EMR) methods are now being used for benign colorectal polyps judged not removable using standard colonoscopic methods. Also, laparoscopic partial circumference “wedge” resections of the colon wall (+ polyp) are being done in an effort to avoid a standard “Oncologic” Colorectal Resection (OCR) and its attendant morbidity. Unfortunately, a subset of these “benign” polyps contain invasive adenocarcinomas; in these patients (pts) an OCR is indicated. This retropsective review of benign polyp pts that underwent OCR's was undertaken with the hope of identifying polyp characteristics that would allow stratification of these lesions into low and high risk categories which might then guide treatment choices. Methods: All patients with the preoperative (preop) diagnosis of adenoma (+/- dysplasia) who underwent a standard colorectal resection over an 18 year period were included in the study. Hospital and office records, operative reports, colonoscopy and pathology reports were reviewed. The polyp size and location for each patient was noted; likewise the preop and final pathologic diagnoses were recorded and compared. The unpaired t-test and Fisher's Exact test were used to analyze the results and a p-value less than 0.05 considered significant. Results: A total of 386 benign adenoma pts underwent OCR during the period assessed. The distribution of large bowel polyps was: right, 263 (68.1%); transverse, 33 (8.6%); sigmoid, 38 (9.8%); rectum, 23 (6.0%), and multiple sites, 13 (3.4%). The preop pathologic diagnosis was adenoma alone for 288 (74.6%) and adenoma with dysplasia for 98 pts (25.4). Final post resection pathology revealed 62 invasive cancers (16.1% of total). Thirty five percent of pts (34/98) with a preop diagnosis of dysplasia had an invasive cancer whereas 9.7% (28/288) of the adenoma alone pts proved to have a malignancy (p<0.0001). The mean lymph node harvest for the entire group was 16.0±10.2; there was no difference in lymph node recovery for the cancer and benign adenoma groups. The cancer stage breakdown for the 62 pts with a malignant polyp was: Stage 1, 73%; Stage 2, 8.1%; Stage 3, 16%; Stage 4, 3.2%. The mean polyp size for benign lesions was 3.0±1.9cm whereas for cancers it was 3.9±2.4cm (p=0.0008). There was a higher incidence of Stage 3 cancers in pts with a preop diagnosis of dysplasia (p=0.008). Conclusion: Ten percent of pts with the preop diagnosis of adenoma alone and over 1/3 of pts with the preop diagnosis of dysplastic polyp had invasive cancers. Larger polyps were more likely to contain a cancer. A standard segmental colectomy is advisable for pts with dysplastic polyps because of the high likelihood of cancer. ESD, EMR, and wedge resection should be reserved for selected adenoma pts without dysplasia after thorough evaluation.
696 Minimizing MIS Using Magnetically Anchored and Percutaneous Needlescopic Instruments for Basic and Complex Procedures Nabeel Arain, Sara Best, Jeffrey A. Cadeddu, Deborah C. Hogg, Richard Bergs, Raul Fernandez, Lauren B. Mashaud, Daniel J. Scott This video shows techniques for minimizing MIS using magnetically anchored and percutaneous needlescopic instruments for both basic and complex procedures which included a laparoscopic cholecystectomy (porcine model) and a laparoscopic Roux-en-Y Gastric Bypass (human cadaver). We combined instrumentation including a magnetically anchored camera, 3mm percutaneous instruments, and a single 12mm working port. This combination afforded excellent triangulation and minimized the number and size of incisions. Furthermore, this strategy may offer comparable or even better cosmesis compared to single incision laparoscopic procedures without the associated technical difficulties. 697 Endoscopic Treatment of Weight Regain in the Post-Bypass Patient Rabindra R. Watson, David B. Lautz, Christopher C. Thompson Weight regain affects a significant proportion of post-bypass patients. Pouch and stoma dilation have been implicated as important factors in this process. The significant risk of morbidity with surgical revision makes endoscopic therapy an attractive treatment modality. This video reviews current endoscopic techniques including sclerotherapy, tissue anchor placement, and endoscopic suturing. Current evidence regarding these techniques is sparse, though compelling data are forthcoming. Given the growing bariatric population, endoscopic treatment of surgical failure will play an important role in the management of these patients.
801
Single port surgery of rectal tumours may be associated with shorter learning curve and fewer costs than transanal endoscopic microsurgery (TEM). A semicircumferent adenoma located 6-12cm from the anus was successfully resected using a single-site access system transanally. Endoluminal features were comparable to TEM. Full thickness, en bloc resection was possible. The defect was sutured transversally with continuous self-anchoring sutures. Operating time was 55 min. Blood loss was nil. The patient was hospitalized overnight. Histopathology showed tubulovillous adenoma with focal high grade dysplasia, radically resected. Single port transanal surgery may become an alternative to TEM.
Use of a Magnetically Coupled Camera and Novel Mini Laparoscopic Instruments to Perform Minimally Invasive Sigmoid Colon Resection Calvin D. Lyons, Rohan A. Joseph, Nilson Salas, Patrick R. Reardon, Barbara L. Bass, Brian J. Dunkin Natural orifice translumenal endoscopic surgery (NOTES) and single site laparoscopy (SSL) have led surgeons to seek less invasive methods of performing even standard operations by reducing port number and size. This video demonstrates how novel technology can be used to perform reduced port surgery, even during complex operations, without compromising visualization, triangulation, or instrument function. Use of MAGS in combination with percutaneous internally assembled instruments enables reduced port surgery while maintaining the visualization and function of 4 port laparoscopic surgery. The ergonomic benefit of this technology will aid in the performance both reduced port surgery and SSL.
802 Transesophageal Endoscopic Myotomy (TEEM) for the Treatment of Achalasia - The United States Human Experience Ozanan R. Meireles, Garth R. Jacobsen, Toshio Katagiri, Kari Thompson, Abraham Mathew, Noam Belkind, Michael Sedrak, Bryan J. Sandler, Takayuki Dotai, Thomas J. Savides, Saniea F. Majid, Sheetal Nijhawan, Mark A. Talamini, Santiago Horgan
699 Laparoscopic Rectosigmoid Resection With Transvaginal Rectopexy and Extraction for Rectal Prolapse Patricia Sylla, Samantha J. Pulliam, May Wakamatsu
From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic trans-esophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility and efficacy of TEEM in a series of patients with achalasia. Methods: Under IRB approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, age between 18 and 50 years old, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical co-morbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 O'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastro-esophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm bellow the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Results: Four patients underwent TEEM, with no peri-operative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first post-op day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach and absence of leaks. All patients were discharged on the second post-op
The patient is a 39 year-old G4P4 female with full-thickness rectal prolapse, constipation, symptomatic cystocele, rectocele, and stress urinary incontinence. Laparoscopic rectosigmoid mobilization was performed using 4 abdominal trocars and a 12mm port was inserted through a posterior colpotomy. The rectum was transected transvaginally with a stapler and suture rectopexy was performed through the vaginal trocar. The rectosigmoid was exteriorized transvaginally, the anvil was placed, and intracorporeal stapled anastomosis was completed. Anterior and posterior colporrhaphy with tension-free vaginal sling were performed perineally. The patient was discharged on postoperative day 4. 700 Notes Transoral Remnant Extraction (TORE) for Sleeve Gastrectomy Sheetal Nijhawan, Saniea F. Majid, Toshio Katagiri, Takayuki Dotai, Michael Sedrak, Bryan J. Sandler, Garth R. Jacobsen, Mark A. Talamini, Alan Wittgrove, Santiago Horgan Laparoscopic sleeve gastrectomy has rapidly become the procedure of choice for morbid obesity. We have utilized our considerable experience in natural orifice translumenal endoscopic surgery (NOTES) to develop techniques which will eliminate the potential complications of transabdominal organ extraction. Here we demonstrate the world's first case of the unisex approach to transoral remnant extraction or TORE.
S-1001
SSAT Abstracts
SSAT Abstracts
Single Port Transanal Surgery of a Giant Rectal Adenoma Renée M. Barendse, Pascal G. Doornebosch, Willem A. Bemelman, Evelien Dekker, Paul Fockens, Thomas M. Van Gulik, Eelco J. de Graaf
698