>18mg/dl on POD 4 is the predictive factor for clinically relevant POPF after pancreaticoduod-enectomy when diagnose POPF by ISGPF criteria.

Mo1635

Recurrence and Long Term Results of Laparoscopic vs Open Ileo-ColonicResection in Crohn's Disease. A Prospetive Longitudinal StudyGiuseppe S. Sica, Edoardo Iaculli, Sara Di Carlo, Rosa Scaramuzzo, Livia Biancone, SaraOnali, Cristina Fiorani, Alessandro Sturiale, Achille Gaspari

Modifications in host immune response have been demonstrated in both the pathogenesisof Crohn's disease (CD) and after laparoscopic resections for cancer. Relationships betweensurgical approaches and the rates and severity of CD recurrence after ileo-colonic resection(IC) are unknown. Aim of this study was to compare 2 groups of CD patients undergoingeither laparoscopic or open IC to verify whether the surgical approach might influence therecurrence rate of the population of study. Patient's satisfaction with regard to the treatmentreceived was also analysed. 80 consecutive patients undergoing elective IC by either laparo-scopic approach (LAP=30; 38%) or conventional open surgery (OPEN=50; 62%) wereenrolled in a prospective longitudinal study. Study protocol includes 3-years follow up (FU).Recurrence was investigated by CD activity index and clinical examination every 6 monthsand colonoscopy at 12 and 36 months in all patients. At 12 and 36 months patients werealso asked to fill out a specific Treatment Satisfaction Questionnaire. We have alreadyreported short term results and results of the 1st year of FU in a previous comparative studythat included 28 patients from this series. In this study we have analysed the results fromthe 3rd year of FU. Fisher's exact test and t-test were used to statistically compare qualitativeand quantitative data respectively. 62 patients completed 3-years follow up (FU) (RANGE3-6 years) and of these, 60 (97%) underwent a colonoscopy with ileoscopy. For 18 patients(23%) the 3-years FU is still in progress. Clinical recurrence at 3 years was 2 (9%) in theLAP and 3 (8%) in the OPEN group. Endoscopic recurrence according to Ruttgers scorewas seen in 14(63%) patients in the LAP group and in 27(69%) in the OPEN group. Thefrequency, severity and pattern of recurrence did not differ between the 2 groups (p=0.6).Three patients (1 in the LAP group and 2 in the OPEN group; tot. 4%) underwent re-resection during the FU period and 1 patient in the OPEN group underwent incisionalhernia repair. No significant differences in terms of readmissions or need for medicationwere seen during the FU period. However patients' satisfaction was still significantly infavour of laparoscopy also in the long-term assessment. No differences were observed interms of frequency, time-of-onset and severity of recurrence in a 3-years follow up in thisconsecutive series of patients undergoing laparoscopic vs open IC. Hence long-term outcomefor laparoscopy are comparable to standard procedure. However treatment's satisfactionassessment showed a strongly significant preference of patients for the mini-invasive approachdue to better cosmetic results, hospital experience and surgical treatment acceptance. Laparo-scopic IC should be offered to CD patients referred for surgery even though doesn't seemsto influence disease recurrence

Mo1636

Late Accidental Dislodgement of the Percutaneous Endoscopic Gastrostomy:An Underestimated Burden on Patients and the Healthcare SystemLaura H. Rosenberger, Timothy Newhook, Robert G. Sawyer, Bruce D. Schirmer

INTRODUCTION Since its introduction in 1980, the Percutaneous Endoscopic Gastrostomy(PEG) has become an efficient means of providing long-term enteral access for nutrition.Conveniently, the soft inner bumper allows PEG removal with relatively minimal externaltraction. Consequently, a major complication is early accidental dislodgement, from whichsignificant morbidity may occur. We have perhaps underestimated and underappreciatedthe burden to the healthcare system due to this issue—- not only in the acute setting butover the lifetime of the PEG. METHODS A retrospective analysis of PEG placements wasconducted at our institution, identifying all PEG tubes placed between July 1, 2007 andJuly 1, 2010 by one faculty surgeon. Patient charts were reviewed for 30-day mortality,major and minor complications, including early dislodgement, and subsequent management.Patients were reviewed until intentional removal of the PEG, cessation of records, or patientmortality. RESULTS A total of 563 PEGs were placed during our defined time period. The30-day mortality rate was 7.8% (44/563), 7-day early accidental dislodgement was 4.1%(23/563), and the total lifetime accidental PEG dislodgement rate was 12.8% (72/563). Ofthose early dislodgements, 11 were replaced directly with a replacement gastrostomy tube,6 were replaced with a second endoscopic PEG following several days of gastric decompres-sion and antimicrobials, 5 by an open gastrostomy, and 1 was not replaced at all. Anadditional 49 PEGs dislodged following discharge while at rehabilitation facilities and nursinghomes. The vast majority required an emergency department visit, level 1 surgical consulta-tion, replacement gastrostomy tube, and radiographic confirmation of position, totaling anaverage of $3535 in hospital charges. CONCLUSION Many large PEG reviews report anearly accidental dislodgement rate between 0.6% and 4.0%. The most clinically significantaccidental removals occur in the first 7 days following placement, in which the stomachmay fall away from the abdominal wall and open gastrostomy may cause obvious morbidity.Our early dislodgement rate (4.1%) is consistent with current reports. However, if followedlongitudinally, a significantly higher rate of late dislodgement is seen (12.8%). Frequentlyplaced into neurologically impaired or elderly patients, the PEGs that dislodge months andyears later require expensive transportation, emergency room visits, surgical consultations,and fluoroscopic confirmation of replacement. The late removal complication, and its associ-ated costs, are overlooked and underestimated. These data also suggest a need for improve-ment in the design of the soft inner bumper or a novel mechanism to secure a PEG in lightof this significant burden to the healthcare system.

S-1041 SSAT Abstracts

Mo1637

Prevalence of Adverse Intraoperative Events During Obesity Surgery and TheirSequelaeAlexander J. Greenstein, Abdus S. Wahed, Abidemi Adeniji, Anita P. Courcoulas, GregoryDakin, David Flum, Vincent L. Harrison, James E. Mitchell, Robert W. O'Rourke, John R.Pender, Ramesh Ramanathan, Bruce M. Wolfe

Background: Adverse intraoperative events (AIEs) during surgery are a well known entity.A better understanding of AIEs and their relationship with outcomes is helpful for surgeonpreparation and preoperative patient counseling. The goals of this study are to test thehypotheses that the laparoscopic approach to bariatric surgery results in fewer AIEs thanthe open approach and that patients who suffer an AIE are at greater risk of 30 day post-operative complications. Methods: The study included 5882 patients from the LongitudinalAssessment of Bariatric Surgery (LABS) study undergoing one of three types of primarybariatric surgeries between March 2005 and April 2009 - laparoscopic adjusted gastricbanding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), or open Roux-en-Y gastricbypass (ORYGB). AIEs included organ injuries, anesthesia related events, anastomotic revi-sions and equipment failure. Rates of AIE were compared between LRYGB and ORYGBgroups using Fisher's exact test. The relationship between AIEs and a composite end pointof 30-day major adverse complications (death, venous thromboembolism, percutaneous,endoscopic, or operative reintervention and failure to be discharged from the hospital within30 days from surgery) was evaluated using a multivariable relative risk model adjusting forDVT/PE, obstructive sleep apnea, body mass index, procedure type, and inability to walk200ft, as well as for clustering due to surgeon and site. Results: There were 1608 LAGB(27%), 3770 LRYGB (64%), and 504 ORYGB (9%) surgeries. AIEs occurred in 5% of theoverall sample and were most frequent during ORYGB (7.3%), followed by LRYGB (5.5%)and LAGB (3%), with no significant difference between the ORYGB and LRYGB groups (p=0.13). The most common AIEs were organ injuries (1.0%), followed by anesthesia events(0.9%) and equipment failure (0.8%). The rate of composite endpoint was 8.8% in the AIEgroup compared to 3.9% among those without a AIE (p < 0.001). While incidence of death(0.3%) and DVT/PE (0.4%) were similar (p>0.05) across those with or without an AIE,abdominal re-operation (4.8% vs. 2.4%; p=0.01), percutaneous drain placement (1.0% vs.0.3%; p=0.02) and endoscopic intervention (2.4% vs. 1.1%; p=0.04) were more commonamong those with an AIE. Multivariable analysis revealed that patients with an AIE were at90% greater risk of composite complication than those without an event (RR = 1.90, 95%CI: 1.26-2.88; p=0.002). Conclusion: There is no significant difference in the rate of AIEsin patients undergoing ORYGB versus LRYGB. While associations between specific AIEs andpost-operative complications could not be assessed due to the rarity of both events, theoccurrence of an AIE is not insignificant. Patients with AIEs are at nearly double the riskof future complication and thus merit close follow-up.

Mo1638

Comorbidities Remission After Roux-en-Y Gastric Bypass for Morbid Obesityis Sustained in a Long-Term Follow-upRafael M. Laurino Neto, Fernando A. Herbella, Renato M. Tauil, Fabricio S. Silva, MarcoG. Patti

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) is considered an effective therapy forweight loss although weight regain may be observed in a long-term follow-up. Obesity-related comorbities are also well treated by RYGB due to weight loss and intestinal hormonechanges. Few studies reported long-term status of comorbities especially if weight regain ispresent. AIMS: This study aims to analyze: (1) the resolution of obesity-related comorbitiesafter RYGB in a long-term follow-up and (2) its relationship to weight regain. METHODS:143 patients (mean age 41, 18 male) were followed-up after RYGB for morbid obesity forat least 5 years (mean follow-up 90, range 60-155 months). Mean body mass index beforeoperation was 52 (range 39-82) Kg/m2. Diabetes, cardiopaty, arterial hypertension, dyslipide-mia, sleep apnea, arthropathy, and infertility were present in 26(18%), 13(9%), 89(62%),18(12,5%), 85(60%), 88(61,5%), 7(8%)patients, respectively. RESULTS: Mean body massindex at last follow-up was 33 (range 19-47) Kg/m2. Comorbidities status is depicted intable 1. Comorbidities resolution was not related to the % of weight loss for cardiopathy(p=0.7), hypertension (p=0.3), dyslipidemia (p=1), sleep apnea (p=0.1), and infertility (p=0.2) but it was related to arthropathy (p<0.001). CONCLUSION: Our results show thatcomorbidities remission after RYGB is sustained in the majority of patients in a long-termfollow-up. Weight regain is linked to worse results for arthropathy.

Mo1639

Esophagogastroduodenoscopy (EGD) Reporting for Preoperative Managementof Gastric Cancer - Evaluation of QualityNikila C. Ravindran, Alyson L. Mahar, Calvin H. Law, Natalie G. Coburn, Jill M.Tinmouth

AIM: To identify important features of the EGD report for preoperative management ofgastric cancer and to develop and validate a tool for the same. METHODS: There were 3parts to the study. Part 1:We conducted a systematic literature review of Medline, Embase andthe Cochrane Databases using the search terms “gastric”, “stomach” & “cancer”, “carcinoma”,“neoplasm” or “tumour”. 2 independent evaluators reviewed the abstracts; only those thataddressed: “What are the important features of an EGD for the preoperative management

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of gastric cancer?” were retained. Part 2: A convenience sample comprising 5 gastroenterolog-ists (GIs) and 5 general surgeons (GSxs) from 2 academic and 2 community hospitals wasidentified. Semi-structured interviews focused on important elements of an EGD reportpertaining to gastric cancer and graded these on a 4 point Likert scale. Part 3: Two abstractorsseparately examined 224 EGD reports at diagnosis from all patients diagnosed with gastricadenocarcinoma (2005-2008) at a community hospital, an academic hospital and a regionalCancer Centre for report elements based on Part 2 results. Kappa statistic was used tocompare interobserver reliability for each report element, overall report quality and adequacyfor surgical planning. RESULTS: Part 1: The literature review yielded 7117 abstracts, noneof which addressed quality of EGD in preoperative planning for gastric cancer. Part 2: Studysample consisted of 80% males who perform a median of 275 (80-1000) EGDs/year. Allrespondents agreed that size and distance of gastric neoplasm from GEJ should be includedin the EGD report. Additionally, 90% felt that appearance of mass, video and photos wereimportant. Tattooing of a neoplasm was important if it was small (30%) or to be treatedlaparoscopically (40%). All GSxs indicated they would repeat EGD themselves to confirmlocation of the tumour for surgical planning, regardless of quality and content of the EGDreport. Part 3: Interobserver agreement was excellent (K>0.7) in abstraction of tumourdistance from GEJ, Siewart Type, tattooing and description of tumour appearance. Thesewere documented in 31 vs 33% (K 0.8 [0.7-0.9]), 0% (K 1) and 3% (K 1) of reportsrespectively. Ulceration was used as a descriptor for tumour appearance in 56 vs 57% (K0.8 [0.7-0.9]). Agreement was fair in report adequacy for surgical planning (K 0.3 [0.2-0.4]) with 30 vs 33% of reports being inadequate. CONCLUSIONS: There is a paucity ofresearch on the quality of EGD reporting in preoperative management of gastric cancer.Experienced practitioners felt that the most important aspects of an EGD report for preoperat-ive management of gastric cancer were location, size and description of neoplasm. Evaluationof EGD reports by these criteria reveals need for standardization of EGD reporting to improvegastric cancer care.

Mo1640

The Weight Loss Response to Roux en Y Gastric Bypass is Host MediatedJoseph A. Caruana, Shah Faisal, Katherine L. Hess, Scott V. Monte, Mark Cavaretta, DangTuan Pham

Introduction: Following Roux-en-Y gastric bypass (RYGB) suboptimal weight loss (SOWL),defined as <40% excess weight loss (EWL) at 18 months, occurs in ~10% or >15,000patients yearly in the US alone. Re operative techniques to accelerate weight loss (WL) inthese “failures” have been disappointing. Methods: To learn more about the WL responsewe studied 2427 consecutive patients with open RYGB from 2000 to 2008. First, longitudinalpatterns of WL were plotted from %EWL measured at follow up office visits with determina-tion of the effects of gender, body mass index (BMI), and age. Secondly, 21 patients withSOWL were compared retrospectively with 84 matched case-controls having >40% EWLfor demographic, anthropometric, social, and operative factors as well as co-morbidities anddietary compliance (DC). Finally, a prospective group with SOWL underwent aggressivedietary and behavior counseling over a 3 month period. Quantile regression techniques,multivariate analysis, or paired t-test was used to analyze outcomes. Results: %EWL overtime was significantly less in males, patients with preoperative BMI >55, and those >42years. After controlling for those variables in patients with SOWL only medication usageand DC were different. In the prospective SOWL group, patients reported improved proteinintake, decreased hunger and stress, and better meal frequency yet had no significant WLafter the intervention. Conclusions: WL after RYGB is affected by gender, weight, and agesuggesting patient specific or ‘host’ related factors which are independent of behavior orDC. Further research to identify why some patients have poor WL after RYBG could shedlight on the causes of obesity itself.

Mo1641

Anastomotic Complications Following RYGB: Can Ulcers/Strictures BePredicted?Shushmita Ahmed, Alex Taylor, Chhavi Bajaj, Dylan Gwaltney, Kate Kiely, John M.Morton

Background. Two of the most common complications following Roux-en-Y gastric bypass(RYGB) are anastomotic strictures and marginal ulcers. Our study aims to find predictorsof stricture and marginal ulcer formation to better prevent these complications. Methods.At a single academic institution, between 2004 and 2010, we measured the preoperativeand 12 month weights, laboratory values, preoperative comorbidities and postoperativecomplications in 992 patients undergoing RYGB. Of these, 20 patients developed anastomoticstrictures and 17 patients developed marginal ulcers. Lab values included platelet counts,C-reactive protein levels, hemoglobin A1C levels, as well as lipid and complete metabolicpanels. Data were analyzed using Students' T tests and ANOVAs. Results. Among patientswithout strictures/ulcers (non s/u), patients with strictures (s), and patients with ulcers (u),there was no significant difference in: age at surgery (44.2 vs 44.0 vs 43.7, p=0.98);preoperative BMI (46.7 vs 47.0 vs 47.4, p=0.91); preoperative CRP levels (10.3 mg/dl vs13.2 mg/dl vs 8.8 mg/dl, p=0.49); preoperative hA1C levels (6.3% vs 6.1% vs 6.0%, p=0.42); percent of patients with a history of H. pylori (18.8 vs 14.0 vs 16.7; p=0.991);operative time (184.8 m vs 202.7 m vs 200.1 m; p=0.28); or LOS (3.3 d vs 2.7 d vs3.2 d; 0.81). There was a significant difference, however, in the number of preoperativecomorbidities with which the patients presented (non s/u- 3.96; s- 6.20; u- 5.47; p<0.01).There was a trending difference between the preoperative waist circumference of thosewithout strictures/ulcers and those with strictures (132.8 cm vs 150.1cm; p=0.097). Theaverage time of diagnosis after surgery was 2.86 months for strictures and 12.6 months forulcers (p<0.01). Post operatively, there was a significant difference in the percent of patientswho had at least one complication (excluding strictures and ulcers) among the three groups(non s/u-11%; s-10%; u-47%). There was a significant difference in the percent of patientswho were readmitted after surgery (non s/u-7.9%; s-60%; u-69%) and were reoperatedupon (non-s/u- 4.0%; s-22%; u-44%). Finally, there is a trending difference in 12 month% excess weight loss among the three groups (non s/u-83.9%; s-97.8%; u-97%; p=0.082).Conclusion. Patients with strictures and ulcers tend to have more preoperative comorbidities

S-1042SSAT Abstracts

than patients without strictures/ulcers. Patients with strictures or ulcers have a greaterlikelihood of readmittance and reoperation. Finally, patients with strictures or ulcers havea greater %EWL at 12 months than patients without these complications.

Mo1861

Sustained Anal Pressure Improvement After Anal Sphincter Injury and SerialIV Infusions Suggests Homing of Mesenchymal Stem CellsMassarat Zutshi, Levilester Salcedo, Margot S. Damaser, Marc Penn

We have previously shown that mesenchymal stem cells (MSC) improve anal sphincterpressures after injury. We aim to demonstrate MSC homing to the injured anal sphincterby comparing anal sphincter pressures following IM MSC injection and serial IV MSCinfusion in a rat model of acute anal sphincter injury. Method: 45 virgin rats were dividedinto injury (n=35) and no injury (NI, n=10) groups. The injury group was divided intosaline(PBS) or MSC treatment and a control group (n=5) which received no treatment. Eachtreatment group was further divided into IM and serial IV (n=5) group . The MSC IM andIV (n=5) and control groups were followed up for 5 weeks The injury was a partial analsphincter excision(PSE) of 25% of the anal sphincter. Anal pressures were recorded prior,10 days and 5 weeks after treatment with a balloon connected to a digital recorder. 24hours after injury, the animals received 5x106 labeled MSC or 0.2ml saline into the analsphincter for IM treatment , while IV treatment group received the same dose daily for 6consecutive days via the tail vein. Anal sphincters were harvested and submitted for Masson'sstaining. Results: 10 days after IM treatment, significant increase in resting (P<0.001) andpeak pressures (P<0.001) was seen after MSC treatment when compared with PBS afterinjury . (9.78±0.84, 13.13±1.2, respectively) vs. (6.23±0.48, 8.32±0.64, respectively).Whencompared with the NI group and MSC treatment, recovery of the anal pressures was notcomplete (resting (P=0.04) and peak pressures (P=0.02). The IV infusion group showedsignificantly increased resting (P<0.001) and peak pressures (P<0.001) in MSC treatedanimals compared with PBS (11.03±0.71, 16.68±1.33, respectively) vs. (6.94±0.28,8.56±0.34, respectively) after injury(Figure). However recovery was complete and no signific-ant difference was seen pressures when compared to NI group. At 5 weeks after IM treatmentsignificant peak pressures (P=<0.001) after MSC treatment were seen compared to NI group.However, after IV treatment significant resting (P=0.01) and peak pressures (P=<0.001) wereseen compared to NI group Marked decrease in fibrosis and scar tissue was seen in theMSC treated group (See Figure), Conclusion: Although IM MSC treatment after injury causesincrease in anal pressures it is not sustained at 5 weeks . MSC home after serial IV infusionto the injured anal sphincter causing increase in the anal sphincter pressures which arecomparable to sham treatment and increase till 5 weeks. Healing is by fibrosis in the controlanimals while the MSC treated group showed less scarring with IV infusion group showingthe least scarring.

Mo1862

Gene Chip Analysis for Detection of Potential Tumor Suppressor Genes inColorectal Cancer Cell LinesMichael C. Gock, Dirk Koczan, Ernst Klar, Michael Linnebacher

Background Anomalies within the chromosomal structure are fundamentally involved intumorigenesis of colorectal cancer (CRC). Actual generations of gene chips provide veryhigh resolution to study phenomena like loss of heterozygoty (LOH) or total losses that areknown to cause inactivation of tumor suppressor genes (TSG). In this study we use thelatest generation of gene chips to reveal recurrent LOH and total losses in coding regionsof CRC cell genome and thereby to reveal unknown TSGs. Methods The genome of 7established human CRC cell lines was analyzed using latest gene chip technology (1.800kGenome Wide SNP 6.0 chip by Affymetrix). Results were compared in selected cases withconventional cytogenetic (mFISH analysis). After selecting potential TSGs their expressionprofile on mRNA level was analyzed using end point and real time PCR. cDNA cloning withsubsequent sequencing was performed to reveal possible mutations as well as alternativesplice variants. Results Gene chip results were basically congruent to those of mFISH analysisbut provided a major improvement in terms of resolution. In this initial analysis we limitedus to examine a microsatellite unstable cell line. We found four genes as candidate TSGs,two of them turned out to be described as TSG for CRC (FHIT und WWOX). ConclusionWe discovered two genes as potential, so far unknown, TSGs for CRC. These genes needfurther investigation. Additionally gene chip analysis proved to be a simple and usefultechnique detection of possible TSGs in tumor cell lines.