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W1993 Single Incision Laparoscopic Cholecystectomy Using Flexible Endoscopy: Saline Infiltration Gallbladder Fossa Dissection Technique
LV vs. LA, significance was also achieved (p<0.0001). The time to peak temperature for each device (LV 2.63 seconds, 0.46 SD, LA 3.82, 0.93 SD, HS 6.83, 0.89 SD) was also significantly different (p<0.0001) as well as the average jaw temperatures of LV vs. LA (63.2°C, 5.14 SD vs. 68.3°C, 5.94 SD, p<0.02) when compared to HS (237.9°C, 9.37, p<0.001 and p<0.004). There was less thermal spread with the LV vs. LA (1.14mm, 0.53 SD vs. 1.25mm, 0.34 SD, p<0.0495) and significantly less thermal spread when both the LV and LA were compared to the HS (1.73mm, 0.50 SD, p<0.0001 and p<0.0001). Conclusions: The LV and LA had significantly less thermal spread and peak temperatures when compared to HS, thus minimizing the risk of thermal damage to adjacent tissues. The LV had less thermal spread, lower average jaw temperatures, and quicker time to peak temperatures than the LA. Further investigations including burst pressure testing and histological analysis of sealed vessels will help elucidate differences between these electrosurgical devices.
part of the pathogenesis of NAFLD. As a result of the rise of the prevalence of obesity, the number of bariatric surgery procedures performed across the United States has been increasing. This study investigates the hypothesis that steatosis and NASH improve after bariatric surgery. Methods: All patients who underwent bariatric surgery from 1997 to 2002 were retrospectively reviewed. Any patients who underwent another surgical procedure with a concomitant liver biopsy were included in this study. Fisher's exact test were utilized for statistical analysis. Results: There were 37 patients (34 females) with an average age of 39.3 years (range 23 to 57), average age was with paired biopsies identified. All liver biopsies were performed from an average of 21 months (range 8-58) after the procedure. All patients had evidence of NAFLD at the first operation, and of those, 31 showed improvement at the time of second surgery (p<0.001) Preoperatively 34 had steatosis, of these, 28 (82%) had improvement, 5 demonstrated no change and 1 showed progression to NASH. There were 3 patients who had NASH at the original surgery. All three improved post operatively. Conclusions: Bariatric surgery is an effective tool to help improve histology in those patients with NAFLD. Patients who are morbidly obese and have NAFLD should be considered for bariatric surgery.
W1845
SSAT Abstracts
Epithelial Cell Turnover Is Increased in the Excluded Stomach Mucosa After Vertical Banded Roux-en-Y Gastric Bypass for Morbid Obesity Adriana V. Safatle-Ribeiro, Pedro A. Petersen, Ulysses Ribeiro, Bruna S. Quevedo, Thaise Y. Tomokane, Rogério Kuga, Joel Faintuch, Paulo Sakai, Arthur B. Garrido, Carlos E. Corbett, Ivan Cecconello
W1995 Impact of Gastric Irrigation On NOTES Mesh Placement Lauren Buck, Joel E. Michalek, Samer Sbayi, Kent Van Sickle, Wayne H. Schwesinger, Juliane Bingener
Mucosal alterations after vertical banded Roux-en-Y gastric bypass for morbid obesity have not been clearly evaluated, since the excluded stomach is not easily reached by conventional endoscopy. Aim: to analyze the mucosal alterations (proliferative rate, Ki-67; apoptosis, caspase-3; hormonal function, gastrin; and inflammatory infiltrate (CD3 and CD4) in the excluded stomach and in the gastric stump (functional pouch) after gastric bypass. Methods: Double balloon endoscopy was performed in 35 patients who underwent vertical banded Roux-en-Y gastric bypass longer than 36 months. They underwent endoscopic examination with multiple biopsies of the gastric stump mucosa (four), of the excluded stomach mucosa (four at the body and four at the antrum) and duodenal biopsies (four). Gastric biopsies from 31 non-operated obese patients were utilized as controls. Endoscopic biopsies were cut from tissue blocks fixed in formalin and embedded in paraffin. Sections 4 µm thick were examined for expression of gastrin, Caspase-3, Ki-67, CD3 and CD4 using the streptavidin-biotin-peroxidase method. The grade of inflammation, atrophy and/or intestinal metaplasia, and the presence of Helicobacter pylori were recorded. Results: Thirty patients (85.7%) were female and the mean age was 43.4 years-old (22 - 61 years-old). The mean postoperative time was 77.6 months (range 36 - 110 months). All patients had chronic gastritis in the bypassed stomach, with pangastritis in 33/35 (94.3%). Five cases (5/35, 14.3%) presented atrophy and four of them also had intestinal metaplasia. H. pylori was detected in 7/35 (20%) of the excluded stomach, and was positive in the antrum in all of them, and also positive in the body in four patients. The mean number of positive gastrin cells was 51.2 (13.6%) in the control group and 32.5 (9.2%) in the cases, p = 0.02. Ki-67 proliferative index in cases (body = 25.4%, antrum = 25.6%), was significantly higher than that in controls (body = 14.8% and antrum = 20.2%), p = 0.02 and 0.03. Caspase-3 immunoexpression was higher in the excluded stomach compared to the controls (45% vs. 18%), p = 0.02. The CD3+ T cell population contained 54% CD4+ (range 10-70%). There was no difference in studied immunoexpressions between the functional pouch and the controls for Caspase-3, Ki-67 and inflammatory infiltrate. There was no association between the immunoexpressions and the presence of Helicobacter pylori or histological alterations. Conclusions: Cell proliferation and apoptosis are increased in the excluded stomach mucosa compared to the nonoperated obese controls. Alterations in cell turnover in these conditions may be of relevance in long term follow up.
To avoid intestinal contamination of the peritoneal cavity is a long held surgical principle that is not fully compatible with Natural Orifice Surgery. We investigated the impact of gastric saline irrigation on bacterial content in animals pretreated with Proton pump inhibitors and in animals undergoing transgastric intraperitoneal mesh placement. Methods: 24Yorkshire swine were randomized to NOTES transgastric mesh placement or proton pump inhibitor pretreatment for 14 days, upper endoscopy + laparoscopic mesh placement. A 12 swine control group received NOTES with diagnostic peritoneoscopy. All groups received prophylactic parenteral antibiotics and gastric lavage with 500 cc saline. Gastric aspirates were cultured on blood agar for 48 hrs. The laparoscopy group utilized a 3 trocar procedure with polypropylene mesh. In the NOTES mesh group a transport balloon was used to transfer the mesh into the peritoneal cavity under minimal contamination. In both groups the mesh was clipped to the periumbilical peritoneum. Total procedure time for all groups was preset at 90 minutes. The animals were survived for 14 days. At necropsy peritoneal and mesh infection was assessed. Results: Gastric irrigation reduced bacterial content in the gastric aspirate significantly in all groups (p< 0.001). There was no statistically significant difference in the mean bacterial count after irrigation at 24 or 48 hrs between the group that had undergone PPI treatment and the untreated groups. In the endoscopy + laparoscopic mesh placement group no clinically apparent mesh infection was encountered. In the transgastric mesh placement group 4 of 12 animals were found to have a grossly apparent mesh infection (p= 0.03). In the infected group mean count of colony forming units at 24 hrs was 6.3 + 7.2; the bacterial count in the uninfected group was 6.9 + 9.1 (p=0.81). No peritoneal infection was seen in the NOTES control group. Conclusion: Gastric irrigation with 500 cc saline significantly decreased the gastric bacterial count independently of pretreatment with proton pump inhibitors. Mesh infection was significantly more frequent in the transgastric route despite prophylactic antibiotics, gastric irrigation and a protective transport balloon. NOTES mesh infection appeared independent of the gastric bacterial count after irrigation in this study. Additional measures will have to be taken to enable translumenal mesh placement.
W1993 Single Incision Laparoscopic Cholecystectomy Using Flexible Endoscopy: Saline Infiltration Gallbladder Fossa Dissection Technique John N. Afthinos, Glenn Forrester, Steven Binenbaum, Eugenius J. Harvey, M. J. Latif, Scott J. Belsley, Ninan Koshy, James J. McGinty, Domingo C. Nunez, George J. Todd, Grace J. Kim, Julio Teixeira Background: The introduction of natural orifice translumenal endoscopic surgery (NOTES) has demanded the creation of new techniques to accomplish minimally invasive procedures using flexible endoscopic instruments. We evaluated a technique similar to that employed in endoscopic mucosal resection and applied it to the dissection of the gallbladder from the liver bed. Methods: Eight patients underwent an elective, transumbilical single incision cholecystectomy using a flexible endoscope in our institution from August to October of 2007. Approximately 15 mL of saline were strategically injected into the gallbladder fossa with an endoscopic injection needle. After infiltration of this potential space, dissection of the gallbladder and hilum was carried out with endoscopic instruments and the cystic duct and artery were clipped with standard instruments. Results: One of the eight patients had inadvertent perforation of the gallbladder during dissection. The technique of infiltrating the potential space between the gallbladder and the liver bed leads to a significantly improved visualization of the plane between the gallbladder and the liver bed. Conclusions: The technique of saline injection to develop surgical planes is an invaluable tool in performing a cholecystectomy using flexible endoscopic instrumentation. The enhancement of the potential space between the gallbladder and the liver bed improved visualization in all of our patients. This technique can prove valuable in dissections and requires further experimentation to evaluate its effectiveness in other applications. W1994 The Effect of Bariatric Surgery On Non-Alcoholic Fatty Liver Disease Mankanwal S. Sachdev, David S. Tichansky, Atul K. Madan Background: Non-alcoholic fatty liver disease (NAFLD) is becoming an epidemic in the United States. NAFLD is a spectrum of disease that includes steatosis and non-alcoholic steatohepatitis (NASH). This mirrors the obesity epidemic, which is thought to be an integral
SSAT Abstracts
A-914
part of the pathogenesis of NAFLD. As a result of the rise of the prevalence of obesity, the number of bariatric surgery procedures performed across the United States has been increasing. This study investigates the hypothesis that steatosis and NASH improve after bariatric surgery. Methods: All patients who underwent bariatric surgery from 1997 to 2002 were retrospectively reviewed. Any patients who underwent another surgical procedure with a concomitant liver biopsy were included in this study. Fisher's exact test were utilized for statistical analysis. Results: There were 37 patients (34 females) with an average age of 39.3 years (range 23 to 57), average age was with paired biopsies identified. All liver biopsies were performed from an average of 21 months (range 8-58) after the procedure. All patients had evidence of NAFLD at the first operation, and of those, 31 showed improvement at the time of second surgery (p<0.001) Preoperatively 34 had steatosis, of these, 28 (82%) had improvement, 5 demonstrated no change and 1 showed progression to NASH. There were 3 patients who had NASH at the original surgery. All three improved post operatively. Conclusions: Bariatric surgery is an effective tool to help improve histology in those patients with NAFLD. Patients who are morbidly obese and have NAFLD should be considered for bariatric surgery.
W1845
SSAT Abstracts
Epithelial Cell Turnover Is Increased in the Excluded Stomach Mucosa After Vertical Banded Roux-en-Y Gastric Bypass for Morbid Obesity Adriana V. Safatle-Ribeiro, Pedro A. Petersen, Ulysses Ribeiro, Bruna S. Quevedo, Thaise Y. Tomokane, Rogério Kuga, Joel Faintuch, Paulo Sakai, Arthur B. Garrido, Carlos E. Corbett, Ivan Cecconello
W1995 Impact of Gastric Irrigation On NOTES Mesh Placement Lauren Buck, Joel E. Michalek, Samer Sbayi, Kent Van Sickle, Wayne H. Schwesinger, Juliane Bingener
Mucosal alterations after vertical banded Roux-en-Y gastric bypass for morbid obesity have not been clearly evaluated, since the excluded stomach is not easily reached by conventional endoscopy. Aim: to analyze the mucosal alterations (proliferative rate, Ki-67; apoptosis, caspase-3; hormonal function, gastrin; and inflammatory infiltrate (CD3 and CD4) in the excluded stomach and in the gastric stump (functional pouch) after gastric bypass. Methods: Double balloon endoscopy was performed in 35 patients who underwent vertical banded Roux-en-Y gastric bypass longer than 36 months. They underwent endoscopic examination with multiple biopsies of the gastric stump mucosa (four), of the excluded stomach mucosa (four at the body and four at the antrum) and duodenal biopsies (four). Gastric biopsies from 31 non-operated obese patients were utilized as controls. Endoscopic biopsies were cut from tissue blocks fixed in formalin and embedded in paraffin. Sections 4 µm thick were examined for expression of gastrin, Caspase-3, Ki-67, CD3 and CD4 using the streptavidin-biotin-peroxidase method. The grade of inflammation, atrophy and/or intestinal metaplasia, and the presence of Helicobacter pylori were recorded. Results: Thirty patients (85.7%) were female and the mean age was 43.4 years-old (22 - 61 years-old). The mean postoperative time was 77.6 months (range 36 - 110 months). All patients had chronic gastritis in the bypassed stomach, with pangastritis in 33/35 (94.3%). Five cases (5/35, 14.3%) presented atrophy and four of them also had intestinal metaplasia. H. pylori was detected in 7/35 (20%) of the excluded stomach, and was positive in the antrum in all of them, and also positive in the body in four patients. The mean number of positive gastrin cells was 51.2 (13.6%) in the control group and 32.5 (9.2%) in the cases, p = 0.02. Ki-67 proliferative index in cases (body = 25.4%, antrum = 25.6%), was significantly higher than that in controls (body = 14.8% and antrum = 20.2%), p = 0.02 and 0.03. Caspase-3 immunoexpression was higher in the excluded stomach compared to the controls (45% vs. 18%), p = 0.02. The CD3+ T cell population contained 54% CD4+ (range 10-70%). There was no difference in studied immunoexpressions between the functional pouch and the controls for Caspase-3, Ki-67 and inflammatory infiltrate. There was no association between the immunoexpressions and the presence of Helicobacter pylori or histological alterations. Conclusions: Cell proliferation and apoptosis are increased in the excluded stomach mucosa compared to the nonoperated obese controls. Alterations in cell turnover in these conditions may be of relevance in long term follow up.
To avoid intestinal contamination of the peritoneal cavity is a long held surgical principle that is not fully compatible with Natural Orifice Surgery. We investigated the impact of gastric saline irrigation on bacterial content in animals pretreated with Proton pump inhibitors and in animals undergoing transgastric intraperitoneal mesh placement. Methods: 24Yorkshire swine were randomized to NOTES transgastric mesh placement or proton pump inhibitor pretreatment for 14 days, upper endoscopy + laparoscopic mesh placement. A 12 swine control group received NOTES with diagnostic peritoneoscopy. All groups received prophylactic parenteral antibiotics and gastric lavage with 500 cc saline. Gastric aspirates were cultured on blood agar for 48 hrs. The laparoscopy group utilized a 3 trocar procedure with polypropylene mesh. In the NOTES mesh group a transport balloon was used to transfer the mesh into the peritoneal cavity under minimal contamination. In both groups the mesh was clipped to the periumbilical peritoneum. Total procedure time for all groups was preset at 90 minutes. The animals were survived for 14 days. At necropsy peritoneal and mesh infection was assessed. Results: Gastric irrigation reduced bacterial content in the gastric aspirate significantly in all groups (p< 0.001). There was no statistically significant difference in the mean bacterial count after irrigation at 24 or 48 hrs between the group that had undergone PPI treatment and the untreated groups. In the endoscopy + laparoscopic mesh placement group no clinically apparent mesh infection was encountered. In the transgastric mesh placement group 4 of 12 animals were found to have a grossly apparent mesh infection (p= 0.03). In the infected group mean count of colony forming units at 24 hrs was 6.3 + 7.2; the bacterial count in the uninfected group was 6.9 + 9.1 (p=0.81). No peritoneal infection was seen in the NOTES control group. Conclusion: Gastric irrigation with 500 cc saline significantly decreased the gastric bacterial count independently of pretreatment with proton pump inhibitors. Mesh infection was significantly more frequent in the transgastric route despite prophylactic antibiotics, gastric irrigation and a protective transport balloon. NOTES mesh infection appeared independent of the gastric bacterial count after irrigation in this study. Additional measures will have to be taken to enable translumenal mesh placement.
W1993 Single Incision Laparoscopic Cholecystectomy Using Flexible Endoscopy: Saline Infiltration Gallbladder Fossa Dissection Technique John N. Afthinos, Glenn Forrester, Steven Binenbaum, Eugenius J. Harvey, M. J. Latif, Scott J. Belsley, Ninan Koshy, James J. McGinty, Domingo C. Nunez, George J. Todd, Grace J. Kim, Julio Teixeira Background: The introduction of natural orifice translumenal endoscopic surgery (NOTES) has demanded the creation of new techniques to accomplish minimally invasive procedures using flexible endoscopic instruments. We evaluated a technique similar to that employed in endoscopic mucosal resection and applied it to the dissection of the gallbladder from the liver bed. Methods: Eight patients underwent an elective, transumbilical single incision cholecystectomy using a flexible endoscope in our institution from August to October of 2007. Approximately 15 mL of saline were strategically injected into the gallbladder fossa with an endoscopic injection needle. After infiltration of this potential space, dissection of the gallbladder and hilum was carried out with endoscopic instruments and the cystic duct and artery were clipped with standard instruments. Results: One of the eight patients had inadvertent perforation of the gallbladder during dissection. The technique of infiltrating the potential space between the gallbladder and the liver bed leads to a significantly improved visualization of the plane between the gallbladder and the liver bed. Conclusions: The technique of saline injection to develop surgical planes is an invaluable tool in performing a cholecystectomy using flexible endoscopic instrumentation. The enhancement of the potential space between the gallbladder and the liver bed improved visualization in all of our patients. This technique can prove valuable in dissections and requires further experimentation to evaluate its effectiveness in other applications. W1994 The Effect of Bariatric Surgery On Non-Alcoholic Fatty Liver Disease Mankanwal S. Sachdev, David S. Tichansky, Atul K. Madan Background: Non-alcoholic fatty liver disease (NAFLD) is becoming an epidemic in the United States. NAFLD is a spectrum of disease that includes steatosis and non-alcoholic steatohepatitis (NASH). This mirrors the obesity epidemic, which is thought to be an integral
SSAT Abstracts
A-914