key: cord-0022824-wo7f49cm
authors: nan
title: 2021 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Las Vegas, Nevada, 31 August–3 September 2021: Posters
date: 2021-11-03
journal: Surg Endosc
DOI: 10.1007/s00464-021-08748-9
sha: 92c7d4da259cbcfeea9b3a12a10e30f7af639cbe
doc_id: 22824
cord_uid: wo7f49cm

nan

Introduction: Mesenteric cysts are a rare benign disorder, thought to be caused by a disruption of the lymphatics in the mesentery either by traumatic disruption, mechanical obstruction, or congenital lymphatic malformations. This is a rare surgical finding with only 19 documented cases noted in review of the literature. Surgical excision remains the standard of care with complete enucleation due to risk of malignant degeneration and associated issues, including intestinal compromise. In our case, we discuss a unique case of incidentally noted chylous mesenteric cyst following abdominal trauma. Case presentation: This is a 78-year-old man with a past medical history of hypertension and hyperlipidemia who presented to the Mission Health emergency department following a motor vehicle accident. CT scan demonstrated multiple injuries including multiple spinal fractures, rib fractures, sternal fracture, and a lobulated foci measuring approximately 6 9 3.2 cm within the anterior upper mesentery. CT diagnosis was mesenteric hematoma. On exam, patient's abdomen was soft and non-tender. Given his recent trauma and concern for possible active mesenteric hemorrhage patient was taken to the operating room for diagnostic laparoscopy. Laparoscopy revealed a large soft cystic-appearing lesion in the mesentery which appeared to be fluid-filled. A 22-gauge spinal needle was used to aspirate approximately 3 cc of milky white fluid concerning for lymphocele. Fluid was sent for cytology. Following aspiration, there was noted leaking of chylous material from the aspiration site. The area of needle aspiration was covered with fibrin hemostatic sealant. Following two applications of the adhesive substance, no further leaking was noted. Patient was admitted to the ICU postoperatively for management of his multiple other injuries. CT scan was performed on postoperative day #2 which demonstrated no intraperitoneal fluid. Cytology demonstrated no evidence of malignancy with a scant amount of fibrinous debris. Final diagnosis was chylous mesenteric cyst. Postoperatively, patient ultimately did well and was discharged on POD#16. No acute problems have occurred since discharge. Conclusion: Chylous mesenteric cysts represent a small subset of mesenteric cysts and should be considered when a physician encounters an intra-abdominal mesenteric mass. Typical imaging does not always provide an accurate diagnosis and many are found intraoperatively. Cyst aspiration with sealant application using fibrin hemostatic sealant can be considered an alternative in patients not able to tolerate a larger operation for complete excision. Time to discharge,days 7.5 7.0 0.0(-6.2, 6.2) 6.0 9.0 3.0(-0.90, 6.9) Introduction: Life-saving procedures in cases like perforation peritonitis have to be performed even during the present COVID pandemic by adopting appropriate safety measures. Here, we report a rare case of laparoscopic closure of duodenal perforation in a Child A cirrhosis patient.

Case description: A 55-year-old male with a history of chronic alcoholism and smoking for the past 40 years presented with severe upper abdominal pain. He is a known case of Child A cirrhosis (Child score 6) with portal hypertension. On examination, tachycardia, and peritoneal signs were present. Encephalopathy and coagulopathy were absent. Pneumoperitoneum was diagnosed with X-ray imaging. There were no radiological features of COVID-19. The nasopharyngeal swab was sent for COVID testing but considering the patient's condition, after preoperative resuscitation, he was posted for emergency diagnostic laparoscopy. General anesthesia was administered as per the ISA (Indian Society of Anaesthesiologists) National Advisory and Position Statement regarding COVID-19. Diagnostic laparoscopy revealed an 8 mm perforation over the anterior duodenal wall: Two liters of contaminated fluid with pus flakes and associated nodular cirrhotic liver. Laparoscopic closure of the perforation was done using modified Graham's Patch repair and drain placed in subhepatic space. Pneumoperitoneum was then evacuated via HEPA filter into a sodium hypochlorite jar. The operating time was 110 min and estimated blood loss was 200 mL. On postoperative day 2, he had a deranged coagulation profile, and thrombocytopenia, which was managed conservatively. COVID reports turned out to be negative. He was started on full oral liquids from day 3 and full diet from day 4. The drain was removed on day 5, and the patient discharged on day 6. On subsequent visits, the patient was asymptomatic. Discussion: There are very few cases reports available in the literature regarding laparoscopic closure of peptic ulcer perforation in cirrhosis patients. Here, the authors would like to highlight that the laparoscopic approach is safe and feasible in carefully selected cirrhotic patients with duodenal perforation even during the current COVID pandemic when handled with appropriate safety precautions. Laparoscopic perforation closure is standard care of practice for perforated peptic ulcers with the benefits of minimal-access surgery. Laparoscopy with smoke evacuator systems and decent precautions also reduces the risk of COVID exposure. Acute abdominal surgery in cirrhotic patients during the present pandemic can present as a necessity. Intraoperative bleeding, postoperative sepsis with the potential of multiple organ failure are the main reasons for poor Results in such cases.

Gastric volvulus in a patient with limb-girdle muscular dystrophy 2A Malavika P Sengupta; Joon K Shim, MD; Yee M Wong, MD; Wright State University Boonshoft School of Medicine Introduction: Gastric volvulus is an abnormal rotation of the stomach. 80-90% of cases of gastric volvulus occur in adults above 50 years old and 20% occur in infants under 1, secondary to congenital diaphragmatic defects. Though gastric volvulus presents with nonspecific symptoms, it can lead to foregut obstruction and stomach strangulation with necrosis, perforation, and shock. Since the mortality of acute gastric volvulus is 30 to 50%, early identification is crucial Muscular dystrophies such as myotonic dystrophy, Duchenne muscular dystrophy, and spinal muscular atrophy have been associated with gastric volvulus, though never before with limbgirdle muscular dystrophy as with this patient. Case report: A 24-year-old woman with a history of limb girdle muscular dystrophy 2A and history of gastric volvulus presented to the hospital with abdominal pain, nausea, and emesis. She was ill appearing and diaphoretic, appearing septic. Her abdomen was distended and tender to palpation diffusely. Abdomen/pelvic CT demonstrated gastric distention with pneumatosis and large pneumoperitoneum, concerning for gastric volvulus. The patient underwent an exploratory laparotomy. The large distended stomach was rotated, confirming gastric volvulus. Necrosis and perforation along the greater curvature of the stomach were discovered. The necrotic areas were transected out and the perforation was repaired. Though the patient confirmed history of paraesophageal hernia repair, no evidence of this procedure was noted. A gastrojejunostomy tube was inserted, a gastropexy was performed, and the abdomen was closed. Postoperatively, she transitioned to eating and was subsequently discharged. Discussion: This patient is atypical of gastric volvulus. Firstly, she is between the peaks of age of incidence. A 17-year-old boy has previously been described with the condition, though he had a congenital defect of the diaphragm. This patient also had no immediate etiology of her condition. Though she claimed to have had a paraesophageal hernia, there was no evidence of the condition. Borchardt's triad (occurring in 70% of cases of gastric volvulus) is retching, epigastric pain, and inability to pass an NG tube. This patient was atypical as though she demonstrated first two signs of the triad, she was able to have an NG tube placed. This instance of gastric volvulus is unique due to her age of onset, lack of precipitating factors, and association with limb-girdle muscular dystrophy. Due to several instances of gastric volvulus appearing in patients with forms of muscular dystrophy, physicians should consider gastric volvulus higher on the differential for these patients.

Multidisciplinary management of bowel ischemia after cardiac surgery in a patient with a Roux-en-Y gastric bypass complicated by enterocutaneous fistula Karolin E Ginting, MD; Neilendu Kundu, MD; Yasir Khan, DO; Samuel R Vester, MD; Cory Barrat, MD; Michael Caparelli, MD; The Jewish Hospital A 59-year-old morbidly obese female with a history of Roux-en-Y gastric bypass presented with an acute abdomen eight days after elective coronary artery bypass grafting. A bariatric surgeon was consulted, and the patient taken for emergent exploration. A sigmoid colonperforation was noted requiring segmental resection. Additionally, there was full thickness necrosis at the midpoint of the Roux limb -necessitating resection as well. The patient was left in discontinuity with temporary abdominal closure (TAC) and taken to the intensive care unit for further resuscitation. During the takeback, the colon was not viable and an area of necrosis at the common channel was noted both requiring resection, subtotal colectomy, and another TAC. On subsequent re-exploration, the biliopancreatic limb was severely dilated with a small perforation on the remnant stomach fundus. This was repaired with an omental patch and a gastrostomy tube was placed. Two days later, she was taken to the OR with assistance from colorectal surgery for anastomosis of previous resections at the Roux limb and the common channel, ileostomy creation and abdominal wall excisional debridement. The abdomen was closed with biosynthetic mesh bridge. Her course was complicated with mesh breakdown. It was explanted and a Vicryl mesh was used as a new bridge for abdominal wall closure. She was discharged to a rehabilitation facility on day 14 from her last surgery. Three months later, she had split-thickness skin graft for abdominal wall wound closure with plastic surgery. She had excellent graft take. After completion of rehabilitation, medical and nutrition optimization, the patient underwent ileostomy reversal, gastrocutaneous fistula takedown and incisional hernia repair with bilateral component separation. Her post-operative course was complicated with small incisional wound dehiscence that is treated with negative pressure wound therapy.

Gastrointestinal perforation is a rare but severe complication of cardiovascular surgery with high mortality. Successful outcome required a multi-disciplinary approach including bariatric, colorectal and plastic surgery. The liver is the largest solid abdominal organ and is one of the most commonly injured organs in abdominal trauma. Patients with liver injuries have a high rate of mortality, between 40 to 80%. There are many Hemostatic techniques to treat these injuries, like packing, liver resection, hepatectomy, and liver transplantation. The usual method describes is gauze packing, but has complications like reoperations and bleeding when is removed. with this technique, a single surgery was needed in order to stop bleeding in liver injuries that produce hemodynamic instability

We develop a novel technique using a pneumatic balloon, as a packing compressive method, for patients with hemodynamic instability. The patients selected for this technique were unstable patients that need blood transfusion and Intensive Care Unit management. A midline incision made with abdominal exploration and liver mobilization was performed. Identification of the blunt trauma, we consider the use of the technique in liver injuries grade III to V. A Pringle maneuver, and liver mobilization is important, to have the lacerated area exposed. We use hem collagen as a film between the liver and the balloon, the balloon is insufflated until no bleeding is seen, and the Pringle maneuver is removed.

The patients are observed in the intensive care unit, the pneumatic balloon was controlled on a daily basis, and air from the balloon is removed after 72 h. The balloon stays in situ for at least one week. Then, if no blood from drainages appears and hemodynamic stability is achieved, the balloon is removed, without the need for another surgery for this reason. We consider this technique safe and suitable for unstable patients, but more cases are needed in order to establish this technique for high-grade liver injuries. No extra surgery was required using this technique in our experience.

USS in diagnosis of appendicitis; a confirmatory modality or unnecessary delay Amina A Bouhelal, Dr; Joseph Reynolds, Dr; Adeela Ashraf, Dr; Thomas Fowler, Dr; Lorik Begolli; Queens Hospital. London, UK Introduction: with development of the medical care and with the change of the demographics and the need to be certain as well as the pressure faced by the medical establishment to make the correct diagnosis swiftly and accurately, perhaps the clinical judgment is getting increasingly unacceptable as the sole indication to take a patient to theatre for an appendicectomy. More and more we are using other modalities to prove the diagnosis of appendicitis, arguably even when the clinical suspicion would have been enough USS being the most cost efficient and least harmful in term of radiation exposure and availability. On the other hand it is operator dependent, is it needed for all patients or does the gender and the age of the patient play a key role in the decision. how about the timing ? is our preference to have an additional modality delaying the decision to operate? In our study we aimed to evaluate our practice and factually reflect on the management of acute appendicitis whether or not a clinical judgment is sufficient and when an additional modality is essential is USS the answer Methodology: To answer this question, we carried a retrospective review of all patient who presented to our hospital with abdominal pain. We evaluated the impact on the management, the care and on the swiftness with which the decision to operate was made and whether or not there was any delays. we also studied the influence of the the seniority of the and the surgeon oncall, the radiographer oncall and the age and the gender of the patient P012 Robotic-assisted cholecystectomy in an acute care setting: a better operation? Jason Cundiff, MD; Blake Medical Center Background: Laparoscopic cholecystectomy (LC) has long been the standard of care for acute cholecystitis with well-established outcomes, but patients with higher acuity and surgical comorbidity remain challenging populations with potentially higher complication rates. The popularity of robotic-assisted cholecystectomy continues to grow. The enhanced optics and wristed instrumentation potentially provides improved technical capability and may result in lower intraoperative complication rates and conversion to open cholecystectomy in patients admitted with acute cholecystitis. Methods: From March 2012 to October 2020, a total of 586 patients with acute cholecystitis underwent robotic-assisted cholecystectomy by one surgeon at three institutions. All patients were identified as having acute cholecystitis based on clinical presentation, laboratory studies and imaging. A retrospective review was performed for these patients, noting the outcomes and complications of the procedure. Results: 586 patients had a mean age of 61.9 years (range, 19-98) . Mean preoperative body mass index (BMI) was 38.4 kg/m 2 (range, 24.8-80.4 ). 100% of patients were categorized as having acute cholecystitis. Sixteen (2.7%) patients were diagnosed with acute acalculous cholecystitis. 159 patients (30.%) were diagnosed as having gangrenous or ischemic cholecystitis. 178 patients (34.6%) had prior history of major abdominal surgery. The incidence of common bile injury was 0.0%. The incidence of bile leak was 0.0%. Eight patients (1.3%) required percutaneous drainage of an intraabdominal abscess within one month of surgery. No patients required conversion to open cholecystectomy (0.0%) Conclusion: Robotic-assisted cholecystectomy in patients with acute cholecystitis resulted in improved patient outcomes when compared to traditional complication rates for LC. Laparoscopic cholecystectomy is the most common abdominal surgical procedure in the U.S. with approximately 750,000 performed annually. Statistically, complication rates for bile leak, common bile duct injury and conversion to open cholecystectomy remain relatively low for patients with acute cholecystitis undergoing LC, but the overall volume still affects thousands of individual patients annually. The technical advantages conferred by the 3D Hi-definition visual system and endowrist instrumentation allows for a better visualized, more precise means of performing cholecystectomy in patients with difficult exposure and access due to acute inflammatory state and/or the presence of surgical comorbidity. Larger prospective studies are needed to further substantiate these findings.

Emergency surgery in the elderly: is the attitude changes cause laparoscopy? A 2 years prospective follow-up in 120 consecutive patients, compared with NELA Monica Zese, MD 1 ; Elena Finotti, MD 2 ; Giovanni Cestaro, MD 1 ; Fabio Cavallo, MD 1 ; Daniela Prando, MD 1 ; Tobia Gobbi, MD 1 ; Riccardo Zese, PhD, RN 3 ; Salomone Di Saverio, MD 4 ; Ferdinando Agresta, MD 1 ; 1 Santa Maria Regina degli Angeli Hospital-Adria (Ro); 2 Ospedale Civile Santi Giovanni and Paolo, Venezia (Ve); 3 Department of Engineering, University of Ferrara (Fe); 4 Cambridge University Hospitals, England-University of Insubria, Varese

Background: World population is becoming rapidly ageing in Western Countries. The term Frailty considers an age-related cumulative decline as a better predictor of mortality and morbidity than chronological age. The aim of this study is a 2-year follow-up evaluation in frailty and elderly patients treated with urgent surgical intervention in our Department, discussed to NELA. Methods: prospective single-centre study of 120 patients [ 65 yo, treated in our Department for surgical Abdominal emergencies and followed until 2 years. We considered co-morbidities (ASA Score), type of surgery (laparoscopic, laparotomic or converted) Frailty Score and mortality at recovery, at 30 days and at 2 years, and complications. Conclusions: 70 (58,4%) patients were treated with laparoscopic approach, 49 (40,8) with open approach, in 1 (0,8%) case surgery was converted from laparoscopic to open. At 2 years, 86 (71.6%) patients were alive and 34 (28,4%) were dead. The univariate analysis showed that laparoscopy associated to less mortality then laparotomy at 2 years (P 0.0004). It correlated with Frailty Scores Criteria with a lower worsening of frailty at 2 years (P 0,0005). Regression showed that mortality strictly depended on type of surgery (laparotomic VS laparoscopic), complications during recovery and even with Fried Frailty Score Criteria at recovery and after 2 years. The long-term follow-up can be a useful tool to highlight and identify a possible better surgical approach, as laparoscopic instead of laparotomy in frailty patients, especially in the elderly ones. We consider laparoscopic approach feasible in emergency, with similar or better outcomes than laparotomy.

An unusual case of recurrent post-surgical small bowel obstruction, leading to decompressive double-barrel ileostomy; possible adult Hirschprung's disease Christopher Gamez, MD; Sameh Shoukry, MSIV; Landry Umbu, MD; Penelope Mashburn, DO; Peter M DeVito, MD; Trumbull Regional Medical Center-WRHE Introduction: Acute Small Bowel Obstruction (SBO) is considered a surgical emergency that accounts for 20% of emergency surgical procedures for abdominal pain and places a significant financial burden on the healthcare system. Here we present a case of SBO secondary to a volvulus, which was surgically repaired, followed by another recurrence of unknown etiology. Presentation of case: A 41-year-old male with chronic constipation, prior history of an unknown volvulus resected in 2014, and a ventral hernia repair with mesh in 2017 complicated by post-operative SBO. He presented to the ED with acute, severe abdominal pain. CT imaging and clinical signs indicated likely SBO secondary to a volvulus. Decompression was achieved in the OR through a small enterotomy incision in an ischemic, 5 cm loop of small bowel, and 3000 cc of feculent material was evacuated. The loops were decompressed, volvulus released, and the abdomen closed with staples. On Post-Op Day (POD) 7, despite appearing to recover well, the patient's small bowel was noted to have eviscerated through the inferior aspect of his abdominal incision. He was taken back to the OR for repair and again, the small bowel was noted to be dilated. A double-barrel ileostomy was performed to mitigate the risk of another SBO until a definitive diagnosis is achieved for this patient. Discussion: The patient was recovering well but, was transferred to a larger academic facility for further management and investigation for an underlying cause of his recurrent SBO. He was ultimately discharged in stable condition on POD 13. A possible diagnosis explaining these events and history is Adult Hirschprung's Disease. This rare syndrome often masks itself in patients with chronic constipation who are already managing their condition with enemas or medication, such as in this patient. Conclusion: Awareness of this rare condition may lead to more prompt treatment with definitive surgery, such as a modified Duhamel-Martin procedure, and prevents the burden of recurrent surgery on both the patient and the healthcare system as a whole. Fig. 1 A. Coronal and B. Saggital views from the initial CT in the ED Introduction: Peritonitis is a surgical emergency that is traditionally approached through laparotomy. However, the laparoscopic approach has gained popularity over the last two decades as minimally invasive surgery evolves. This study aims to evaluate the 30-days outcomes of laparoscopic and open appendectomy in patients presented with acute appendicitis and generalized peritonitis (AAGP). Methods and procedures: Using the ACS-NSQIP database (2017), patients who presented with AAGP were identified and divided into two groups: laparoscopic (LA) and open appendectomy (OA). The outcomes examined included 30-day mortality, morbidity, overall, readmission rates, operative time, and total length of hospital stay (LOS). Pearson's chi-squared and Fisher's exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, with statistical significance set at a value of p \ 0.05. Results: Of a total of 41,368 patients with appendicitis, 4,296 (10.4%) had appendicitis and generalized peritonitis (AAGP). We divided the AAGP patients into two groups. Group A, laparoscopic appendectomy (LA), which included 3739 patients (87%) and

Group B, open appendectomy (OA), which included 557 (13%). Overall, both groups had similar demographic characteristics. However, patients in Group B were older and had higher BMI compared to Group A with a mean (SD) of 51.15 (± 17.7) years vs. 47.6 (± 17.55) years, p \ 0.001, and mean (SD) of 30 (± 8.2) vs. 29 (± 6.64), p = 003, respectively. Group B had more comorbidities, including HTN (30.5% vs. 24.9%, p = 0.004), bleeding disorders (5% vs. 2.9%, p = 0.006), and kidney disease or on dialysis (1.8% vs 0.4%, p = 001). Additionally, Group B presented more frequently with sepsis (50.8% vs. 39.7%, p \ 0.001). Group B had higher 30-day mortality (0.9% vs 0.1%, p \ 0.001), higher serious morbidity (37.5% vs. 23.3%, p \ 0.001), and overall morbidity (43.6% vs. 24.7%, p \ 0.001), respectively. Group B had increased mean (SD) hospital LOS, 6 (± 4.6) vs. 3.3 (± 3.7) days, p \ 0.001, and increased mean (SD) total operative time, 81(± 38) vs. 59 (± 28) minutes, p \ 0.001]. There were no differences between Group B and Group A in 30-day readmission rate (8.6% vs. 7.2%, p = 0.221). Conclusion: Patients presented with AAGP who underwent laparoscopic or open appendectomy shared mostly similar demographic characteristics. However, those who underwent an open approach tended to be older, overweight/obese, and have higher comorbidities. Additionally, they had worse 30-day outcomes, including higher mortality, serious morbidity, overall morbidity, increased LOS, and operative time. The laparoscopic approach should be considered in all patients presenting with AAGP.

A rare instance of tip appendicitis after appendectomy Kurt Piening, MD 1 ; Clayton Theleman, MD 2 ; Adam Awwad 1 ; 1 University of Illinois College of Medicine Peoria; 2 Liberty Hospital Introduction: Acute appendicitis is one of the most common surgical conditions accounting for approximately 300,000 annual hospital visits in the USA. As technologic advancements have been made, laparoscopic appendectomy has become the treatment of choice. While safer than the traditional open approach, post-operative complications include wound infection, adhesions, abscesses, and residual stump appendicitis. Presented here is an exceedingly rare case of residual tip appendicitis, diagnosed two months after appendectomy, and successfully treated with completion laparoscopic appendectomy. Case description: A 52-year-old female presented to the Emergency Department two months after a laparoscopic appendectomy with gnawing right upper quadrant, flank, and suprapubic pain beginning 8 h earlier. She reported having similar intermittent pain since the operation. She noted worsening nausea, but denied any vomiting, fevers, or chills. Physical exam revealed tenderness to palpation in the right mid-abdomen, lower quadrant, and suprapubic region. She had a leukocytosis of 15.8 with left shift. An abdominal CT demonstrated a 6 mm tubular structure in the right paracolic gutter, non-communicating to the cecum, with adjacent fat stranding. Cecum and mesoappendix staple lines were consistent with appendectomy. Upon surgeon review, a small segment of mesentery traveling from the ileocolic junction toward the tubular structure was visualized on arterial phase. A diagnosis of tip appendicitis was made, and the patient was taken to the OR for completion appendectomy. Laparoscopy revealed an inflamed appendiceal tip in the right paracolic gutter with an intact mesenteric blood supply, and completion appendectomy was performed without complication. The patient was discharged the next morning following resolution of pain and leukocytosis. Pathology of the specimen confirmed the diagnosis of acute appendicitis with transmural inflammation. Discussion: Acute and subacute appendicitis after incomplete appendectomy remains rare but is increasingly reported following appendectomy. Long appendiceal stump is typically the culprit, and has been noted surgical literature, but there have been few reported cases of appendicitis secondary to retained appendiceal tip. The time interval between operations can range between months to a decade. Diagnosis can happen via radiography, and the CT performed here demonstrated a vascular supply, decreasing time to surgery. Cases with similar features have been reported, including intact mesenteric vessels supplying the tip. We hope to contribute to this literature and to serve as a reminder that appendicitis following appendectomy should remain on the differential diagnosis in the appropriate clinical scenario.

Imaging and the diagnosis of appendicitis, when did your clinical judgement become insufficient Amina A Bouhelal, Dr; Adeela Ashraf, Dr; Shamira Hassan, Dr; Joseph Reynolds, Dr; Thomas Fowler, Dr; S Samlalsingh, Dr; Queens Hospital. London, UK Introduction: with development of the medical care and with the change of the demographics and the need to be certain as well as the pressure faced by the medical establishment to make the correct diagnosis swiftly and accurately, perhaps the clinical judgment is getting increasingly unacceptable as the sole indication to take a patient to theatre for an appendicectomy. more and more we are using other modalities to prove the diagnosis of appendicitis, arguably even when the clinical suspicion would have been enough. USS, CT and MRI are the modalities used.

Methodology: To answer this question, we carried a retrospective review of all patient who presented to our hospital with abdominal pain and were diagnosed with acute appendicitis. we investigated how many times was imaging used and what modality was used and the rational of escalation. We investigate all patient and the impact of the imaging modality on the management, and care and impact on the swiftness with which the decision to operate was made and whether or not there was any delays. we also studied the influence of the the seniority of the and the surgeon oncall, the age and the gender of the patient P019 Laparoscopic duodenal ulcer perforation closure in a COVID 19 positive patient with a large abdominal aortic aneurysm Kishore M Malireddy, MD; Minden Medical Center, Minden, LA Introduction: Laparoscopic repair of duodenal ulcer (DU) perforation has become the standard of care in acute care settings. However, Laparoscopic repair of acute DU perforation in patients with abdominal aortic aneurysm (AAA) is not much reported in the literature. There is one reported case of DU perforation closure in COVID 19 patient from China. During this pandemic, we report a case of laparoscopic closure of DU perforation in COVID 19 positive patient with AAA. Presentation of case: 81-year-old male with a history of COPD and hypertension admitted with COVID 19 positive pneumonia and upper abdominal pain. He was in mild distress with tachypnea and tachycardia. CT scan of the abdomen showed pneumoperitoneum with duodenal inflammation. Incidentally, he was noted to have 5.8 9 5.6 9 7.8 cm infrarenal AAA. He has consented for laparoscopic DU perforation closure.

Given his COVID 19 positive status, we followed strict contact precautions and scheduled surgery in negative pressure operating room. Diagnostic laparoscopy showed pulsating fullness in the central abdomen from the large AAA and 300 cc of bile tinged fluid in the abdomen and DU perforation of size about 1 cm identified. Laparoscopic closure of the perforation with silk and omental graham patch was performed. We performed gastrograffin study on postoperative day (POD) #2, which showed no evidence of a leak. Subsequently, he was started on clear liquids and diet advanced as tolerated. He was discharged to a long-term acute care facility on POD # 5. All the operating room staff who were involved in this case were on observation for COVID 19 symptoms for ten days and none of them had any symptoms.

Discussion: Peptic ulcer disease is common in patients with AAA. During laparoscopic surgery in patients with AAA, it is very important to keep a close watch on all the instruments going in and out of the trocars, especially the needles to avoid any catastrophic complications like major bleeding by inadvertently injuring the aneurysm. It is very easy to run into an aneurysm if proper care is not taken while placing trocars. Regarding COVID 19 status, contact precautions and operating in a negative pressure room, and minimizing the traffic operating room will prevent any risk of cross-contamination and spread of the virus. Conclusion: Laparoscopic DU perforation closure can safely be performed in COVID 19 positive patients with large AAA if proper contact precautions and basic laparoscopic surgical principles are followed. P020 ABC: air way, breathing, CT. Are we over using CTs in managing abdominal pain?

Amina A Bouhelal, Dr; Thomas Fowler, Dr; Joseph Reynolds, Dr; Adeela Ashraf, Dr; S Samlalsingh, Ms; Queens Hospital. London, UK Introduction: With the increase availability of CT many believe that we are over using CT as a diagnostic modality neglecting our clinical judgment and depriving the new generation of surgeons from ever obtaining the ability of making diagnosis without the help of CT. On the other hand, we practice in a different era why not use what is readily available to us. Methodology: To evaluate this repeated point of contention we carried out a retrospective analysis in which we looked at 100 consecutive patients over the period of three months who presented with abdominal pain looking at how many had a CT and how many resulted in positive findings and how many of those findings had an impact on the clinical management. We also looked at the years of experience of the surgeon oncall and the age, gender and background of the patient to sub analyse if that had any impact Results: (on going, will be emailed ASAP)

Gallstone ileus as a cause of intestinal obstruction Mauricio Pasten, MD; Bolivian Japanese Institute of Gastroenterology Gallstone ileus is an important, though infrequent, cause of mechanical bowel obstruction, affecting older adult patients who often have other significant medical conditions. It is caused by impaction of a gallstone in the ileum after being passed through a biliary-enteric fistula. The diagnosis is often delayed since symptoms may be intermittent and investigations fail to identify the cause of the obstruction. The mainstay of treatment is removal of the obstructing stone after resuscitating the patient. Gallstone ileus continues to be associated with relatively high rates of morbidity and mortality. We present a case of a 71 year old women with two weeks of abdominal pain, history of cholecystectomy 30 years ago, and choledocolitiasis 4 years before this consult. She presented with abdominal pain and jaundice, with remarkable abdominal distension. This atypical rare presentation, make us doubt about an obstruction of the bowel, but recurrent exams shows obstruction of the small bowel associated with nausea and vomiting. Since this patient present also jaundice and a previous history of choledocolitiasis, an ERCP was perform, confirming a cholecystenteric fistula and the previous installation of a biliary endoscopic drain. During the ERCP stones from the bile duct were removed. A final exam demonstrates an image atypical at the ileum, where the obstruction was produced compatible with a gallstone ileus. A surgery was perform with the removal of a big stone at the ileum, concluding with the suspicious images that were also rests of previous biliary plastic drains. This experience shows how atypical a condition like a gallstone ileus could be, and how difficult the diagnosis is, making this pathology, challenging and rare.

Biliary hyperkinesia: a potentially overlooked source of abdominal pain following bariatric surgery Gabrielle Falco 1 ; Freeman Condon, MD 2 ; Christopher Yheulon, MD, FACS 2 ; 1 USUHS; 2 Tripler AMC Abdominal pain following bariatric surgery may be the result of myriad heterogeneous etiologies ranging from benign constipation to life threatening internal small bowel herniation. We present a series of three post-bariatric surgery patients at our institution who suffered from persistent abdominal pain of elusive etiology. While biliary colic was considered early, the absence of gallstones seemed to reassure against this diagnosis. After cholesyntigraphy was performed and alternate diagnoses ruled out, a presumptive diagnosis of biliary hyperkinesia was made. Upon cholecystectomy, all three patients were found to have histologic chronic acalculus cholecystitis and clinically improved. We encourage consideration of this diagnosis and advocate for cholecystectomy in the setting of hyperkinesia regardless of the presence of cholelithiasis. Introduction: Current perioperative venous thromboembolism (VTE) prophylaxis administration practices vary widely among bariatric surgeons with historically poor compliance. While current institutional VTE rates are well below the national average, pulmonary embolism is the leading cause of death postoperatively among bariatric surgery patients. The primary aim of this study is to increase preoperative heparin administration from a baseline of less than 25% to 90% within a 12-month period without increasing bleeding rates. The secondary aim is to identify key barriers to postoperative VTE prophylaxis compliance and reduce these errors by 15% during the same time. Methods and procedures: This was a retrospective study performed at a single academic hospital for all patients undergoing primary or revisional bariatric surgery (9/2019-10/2020). A multidisciplinary group of bariatric clinicians and pharmacists reviewed the literature and created a standardized VTE protocol as follows: 1) 5000 units preoperative subcutaneous (SC) Heparin within 60 min of induction and 2) 5000 units postoperative SC Heparin every 8 h. Key stakeholders caring for bariatric patients were educated on the VTE protocol and a checklist was developed to assist with compliance. Monthly administration compliance rates were determined through chart review. We further identified underlying barriers contributing to non-compliance through surgeon and nursing interviews over a limited period (1/27/2020-10/ 31/2020) . Results: A total of 271 patients were identified. Preoperative heparin administration rates increased from 22 to 100% after 12 months. Pre-intervention, only 17% of preoperative heparin doses were given within 60 min of induction; this increased to 100% by October 2020. In September 2019, 67% of patients received the first VTE prophylaxis dose on post-op day (POD) 0, an average of 21.4 h after their pre-op dose which decreased to 10.6 h by the end of the study period. Since January 2020, over 80% of patients received VTE prophylaxis on POD 0, with 5 months achieving 100% compliance. VTE non-compliance rates at the patient-level decreased from 43 to 26% with an overall protocol error rate that decreased 50% February to October 2020. Key barriers to noncompliance included order timing error (n = 15), patient refusal (n = 10), and nursing error (n = 9). No VTE or significant bleeding events requiring transfusion were identified during the study period. Conclusions: VTE prophylaxis administration improved at all timeframes during a 12-month review after standardizing a dosing protocol, improving education, and creating a checklist. Next steps include improving patient education, standardized postoperative electronic order sets, and continued surveillance to identify barriers to non-compliance.

Fernando Munoz-Flores 1 ; Nicolas Fuentes 2 ; Gonzalo Wiedmaier 1 ; Andrew T Bates 2 ; John M Davis 2 ; Dominick Gadaleta 2 ; David M Pechman 2 ; 1 Clinica Alemana de Santiago; 2 Northwell Health-South Shore University Hospital Introduction: Bariatric surgery offers well reported benefits to patients with severe obesity. Obesity is a risk factor for gallstone formation and many bariatric patients suffer from symptomatic cholelithiasis. Patients with high BMI are at increased risk of surgery-related and anesthesia-related morbidity. This study assessed morbidity data for patients undergoing bariatric surgery with and without concomitant cholecystectomy. Methods: ACS-NSQIP database for years 2006-2016 was used. Patients were included if they underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (LRYGB). Patients who underwent cholecystectomy during the same procedure were assigned to the BOTH cohort. All other patients were assigned to the bariatric surgery only (BSO) cohort. Intraoperative factors, length of stay and 30-day morbidity were assessed. Results: 163,413 patients underwent non-revisional bariatric surgery. The BOTH group included 4,390 (2.7%) patients. In this group 1,306 (29.7%) underwent SG and 3084 (70.3%) underwent LRYGB, vs 91,104 (57.3%) SG and 67,919 (42.7%) LRYGB in the BSO group (p \ 0.001). The mean BMI was 46.66 ± 8.21 for the BOTH group and 45.98 ± 8.18 for the BSO group p \ 0.001. There were no differences in the presence of comorbidities prior of the surgery. Demographics were not statistically different The BOTH group was associated with increased operative time, 122.12 ± 52.21 vs 87.24 ± 42.70 min, p \ 0.001 in SG group and 166.33 ± 67.96 vs 133.26 ± 55.99 in the LRYGB group. There were no differences in clinical outcomes between groups in the patients who underwent a SG. However, there was a significant difference in complication rate between the groups who underwent a LRYGB (2.64% ± 2.71 vs 2.44% ± 4.55, p = 0.020) In the 30-day morbidity, there were differences in the presence of septic shock 0.5% vs 0.2% p = 0.006 in the group of patients who underwent a LRYGB. There were no differences in the 30 days mortality rate for both groups (p = 0.476). Conclusion: Patients undergoing bariatric surgery with concomitant cholecystectomy had an overall major morbidity compared to BSO patients. There is no difference in the 30 days mortality. Further study is warranted to help guide operative planning for patients with morbid obesity and symptomatic cholelithiasis.

Exploring factors that contribute to weight regain after bariatric surgery Introduction: Severe obesity is increasingly common in youth and young adults, but outcomes following bariatric surgery remain largely unknown. The purpose of this study was to examine the trends, clinical characteristics, and post-operative outcomes of youth who underwent bariatric surgery. Methods and procedures: This retrospective cohort study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018 inclusive. All youth and young adults aged 15-24 who underwent elective sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Bivariate analysis of trends, clinical characteristics, and postoperative outcomes was performed using Chi-squared tests for categorical variables and independent two sample t-test for continuous variables. Multivariable logistic regression modelling was used to determine patient and operative factors predictive of serious complications. Results: A total of 21,592 youth and young adults underwent bariatric surgery during the study time frame, representing 3.7% of total cases (n = 583,567) within the MBSAQIP. The cohort had a mean age of 21.5 ± 2.0 years, a mean BMI of 47.2 ± 8.0 kg/m 2 and were predominantly female (84%). A relatively constant number of youth and young adult cases per hospital was observed over time (7.4 cases/center in 2015 vs. 6.7 cases/center in 2018). Overall, \ 5% of cases required reoperation, reintervention, readmission, or led to serious complications within 30 days of surgery. Multivariable logistic regression analysis identified RYGB as the single greatest independent predictor of serious complications (OR 3.1; 95% CI 2.58-3.64; p \ 0.0001). Additional factors predictive of serious complications included female sex (OR 1.31; 95% CI 1.01-1.70; p = 0.04), sleep apnea (OR 1.27; 95% CI 1.02-1.58), and non-insulin dependent diabetes (OR 1.35; 95% CI 1.04-1.75; p = 0.025). Conclusion: Bariatric surgery in youth is safe but comprised only 3.7% of total MBSAQIP cases from 2015 to 2018. These data should serve as a call to government and healthcare agencies to develop policies and strategies that prioritize bariatric surgery for young people living with severe obesity.

Laparoscopic sleeve gastrectomy in patients with advanced heart failure: a retrospective review and systematic literature search with pooled analysis P033 Ehlers-Danlos syndrome should not be considered an absolute contraindication to bariatric surgery: a case report and review of the literature Stacey A Kubovec, MD; Matthew Davis, MD; University of Tennessee Health Science Center Ehlers-Danlos syndrome (EDS) is a heterogenous group of inherited connective tissue diseases caused by defects in collagen synthesis leading to a variety of clinical manifestations including skin hyperextensibility and fragility, joint hypermobility, atrophic scarring, poor wound healing and spontaneous bowel perforations and rupture of vessels and solid organs. Manifestations of EDS can increase peri-operative morbidity and many surgeons have been hesitant to perform elective procedures in these patients. That being said, there have been several reports of successful surgeries in patients with EDS. We present a 35 year old woman with EDS, subtype unknown, obstructive sleep apnea, polycystic ovarian syndrome, hypertension, and a body mass index of 67 who was referred for Bariatric surgery. With regard to her EDS, she has a chronically dislocated shoulder, subluxed ribs and hyperextensible joints, but no personal or family history of vascular abnormalities. After a standard pre-operative work-up, she successfully underwent a laparoscopic Roux-en-Y gastric bypass. She had a negative post-operative swallow study, had an uneventful post-op recovery, and she was discharged on post-operative day two. Bariatric surgery is a viable option in patients with obesity. However, the literature regarding surgery on patients with EDS is limited and predominantly focused on acute, non-elective surgery. Pre-operative evaluation should include a thorough discussion of the increased risk of complications including bleeding, anastomotic breakdown, hernia formation, and poor wound healing. Patients with the vascular subtype, which carries a significant increase in peri-operative complications, should generally avoid elective surgery. However, the terminal nature of untreated morbid obesity may make the need to perform metabolic surgery a more pressing issue. While patients with this uncommon disease should be considered higher risk surgical candidates, an individualized approach to pre-operative preparation should be undertaken to provide them the appropriate treatment to improve their overall health.

Association of patient self-efficacy and pursuit of bariatric surgery Sara M Jafri, BS 1 ; Grace F Chao, MD, MS 2 ; Nabeel R Obeid, MD 1 ; Oliver A Varban, MD 1 ; Dana A Telem, MD, MPH 1 ; 1 University of Michigan; 2 Veterans Affairs Ann Arbor Introduction: An estimated 60% of persons who initiate the process leading to bariatric surgery will ultimately not pursue the procedure. We hypothesized that patient self-efficacy, one's belief in one's ability to succeed in specific situations, may be one component contributing to the multifactorial underutilization of bariatric surgery. In this context, we sought to explore this association to leverage this information to design an effective intervention technique. Methods: A validated 8-question self-efficacy questionnaire utilizing a five-point Likert scoring scale was administered to 276 participants who attended bariatric surgery information sessions at a single institution from 2017-2018. Exclusion criteria included inaccessibility of health records and survey incompletion. Patients were prospectively followed over a 2-year timeframe, and progression to surgery was used as the primary outcome metric. Data relating to the patient's demographics and bariatric progress records were collected and analyzed using multivariable logistic regression to determine the significance of self-efficacy as a preoperative predictor. Results: Our analysis included 237 participants (86%). Mean overall self-efficacy score was 4.19, and there was no statistically significant difference in perception of self-efficacy between populations that underwent bariatric surgery (25%, n = 59) versus those that did not (75%, n = 178) ( Table 1) . However, commercial insurance (p = 0.018) was associated with pursuit of bariatric surgery. Conclusions: After controlling for patient demographic, insurance, and clinical factors, patient self-efficacy did not independently associate with completion of bariatric surgery. We will continue to longitudinally follow patients to ascertain whether patient self-efficacy is associated with surgical outcomes, like post-operative weight loss.

Feasibility of percutaneous-assisted surgery system for bariatric surgery: clinical outcomes and patient satisfaction Yen-Yi Juo; Chan Park; Jin Yoo; Daniel Guerron; Ranjan Sudan; Kelli Friedman; Dana Portenier; Keri A Seymour; Duke University Background: Percutaneous surgical systems are novel laparoscopic platforms that involve the use of 3 mm skin incisions and forego conventional trocars. These systems have the potential to provide superior cosmesis and reduce post-operative pain. Unlike single-incision surgery, percutaneous surgical systems allow triangulation, traditional surgical motion and robust retraction of tissues. As such, they eliminate the need to have instruments working in-line and provide better instrument mobility and better visualization. However, there is little understanding of the effectiveness of percutaneous instruments in morbidly obese patients. We report perioperative outcomes and perception of body image with use of percutaneous instruments after bariatric surgery. Methods: Laparoscopic bariatric procedures were performed on 30 adults at a single academic medical center from January to December 2017. Patients were randomized to conventional laparoscopy (LAP) or percutaneous-assisted (PERC) surgery (Percuvance System, Teleflex, Wayne PA). Data regarding clinical outcomes such such as mortality, anastomotic leak, and wound infection incidence were recorded. The Multidimensional Body-Self Relations Questionnaire (MBSRQ) and Patient Scar Assessment Questionnaire (PSAQ) were completed at 6 months and 1 year. Univariate analysis was performed on perioperative outcomes and survey scores. Results: Surgery was completed on (N = 13) with LAP compared to (N = 17) with PERC. The mean BMI was 41.4 kg/m 2 LAP and 41.1 kg/m 2 PERC. The most common procedure was Roux-en-Y Gastric Bypass, with 13 cases within the LAP group and 12 cases within the PERC group (P = 0.76). The operative time for all procedures was not significantly different between the LAP and the PERC group (209.5 ± 66.1 vs 181.9 ± 58.1 min, P = 0.48). There was no leak or mortality in either group within the 30-day follow-up period. Within MBSRQ, the patient's appearance self-evaluation score was similar between LAP and PERC. (2.5 ± 0.6 vs 2.4 ± 0.6, P = 0.61). Within PSAQ, the mean satisfaction score for incision appearance was also similar between LAP and PERC (16.1 ± 2.9 vs 15.4 ± 4.6, p = 0.85). Incision-related perceptions remained consistent at 6 months and 1 year after bariatric surgery. Conclusions: Percutaneous-assisted surgery is a safe and a viable alternative to conventional laparoscopic instruments during bariatric surgery. Perception of incision appearance and body image was similar between the two comparison groups. Future studies with percutaneous instruments should include patients with BMI [ 35 kg/m 2 and consider increasing sample size to detect potentially small difference in subjective perception of incision appearance.

Predictability of robotic sleeve gastrectomy operative times Jeffrey P Marcoe, MD; Wai Yip Chau, MD; Princeton Medical Center Introduction: Bariatric surgery has been performed almost exclusively by laparoscopy but now is beginning to see a transition towards robotic surgery. The Da Vinci Surgical System has been shown to reduce postoperative pain and length of stay in bariatric patients. Additionally, the robot offers improved ergonomics and better visualization for the surgeon. Due to the direct surgeon benefits, this study hypothesized that operative times would not vary with increased BMI as seen in laparoscopy. Methods: A retrospective review of our institution's MBSAQIP data was performed in order to correlate operative time to BMI. Patients who underwent robotic sleeve gastrectomy were included in this study. Patients were divided into groups based on BMI (\ 39.9, 40-49.9, 50-59.9, [ 60) at the time of surgery. BMI \ 39.9 was utilized as a baseline for comparison of operative times. Results: Data was collected from May 2018 to December 2019. During this interval a total of 71 consecutive robotic sleeve gastrectomy procedures were performed. All cases were performed by a single surgeon at a single institution. The average BMI in this study was 43.6. The average operative time for all robotic sleeve gastrectomy procedures was 170 min. The mean operative time was 167 for BMI \ 39.9; 167 for BMI 40-49.9 ; 183 for BMI 50-59.9; and 178 for BMI [ 60. There was no statistically significant difference among operative times with increased BMI (pvalue [ 0.05 in all comparisons). Conclusion: The direct surgeon benefits offered by the Da Vinci Surgical System allow surgeons to adapt to increased BMI without lengthening the operative time. This predictability allows the surgeon to more accurately plan the patient's perioperative needs such as patient and family expectations, re-dosing antibiotics, and operative room time allotment.

Bariatric surgery improves patient-reported musculoskeletal function Michelle Campbell, MD 1 ; Eliza Conaty, MA 2 ; Harry J Wong, MD 1 ; Hoover Wu, MD 1 ; Mikhail Attaar, MD 1 ; Kristine Kuchta, MS 1 ; Stephen P Haggerty, MD 1 ; Woody Denham, MD 1 ; John G Linn, MD 1 ; Zeeshan Butt, PhD 3 ; Michael Ujiki, MD 1 ; 1 NorthShore University Health System; 2 Loyola University Chicago Stritch School of Medicine; 3 

Introduction: This study aims to assess the effect of bariatric surgery on patientreported quality of life (QOL) metrics of musculoskeletal function. We hypothesized that bariatric surgery improves both upper and lower extremity musculoskeletal (MSK) function. Methods and procedures: A retrospective review was conducted of a prospectively maintained surgical quality database. We included patients who underwent primary bariatric surgery at a single institution between 2012 and 2020, excluding revisional procedures. Patient-reported outcomes were assessed using Surgical Outcomes Measurement System (SOMS) upper and lower extremity function questionnaires at time of pre-operative consult, and routine post-operative follow-up visits at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years. Data were analyzed using a statistical mixed effects model. Results: A total of 510 patients (81.4% female) were identified with completed SOMS questionnaire data on MSK function. Of these, 340 (66.7%) underwent gastric bypass, 164 (32.2%) underwent sleeve gastrectomy, and 6 (1.2%) underwent either gastric banding or duodenal switch. Patients reported significant improvement in both upper and lower extremity function scores at 6-week follow-up (both p B 0.001); this effect was sustained at 3-month, 6-month, and 1-year follow-up without change in statistical significance (Fig. 1) . On subgroup analysis, no difference was observed between sleeve and gastric bypass MSK outcomes. Multivariable analysis demonstrated both older age at time of surgery and higher BMI at all time points as inversely associated with lower (worse) scores of upper extremity function (age p = 0.012, BMI p = 0.006) and lower extremity function (age p = 0.001, BMI p = 0.003). By 1-year follow-up, patients reported a greater improvement in lower extremity function than upper extremity function. Conclusions: Bariatric surgery Results in significant improvement in patient-reported scores of upper and lower extremity musculoskeletal function beginning 6 weeks post-operatively which are sustained through 1-year follow-up. This has particular implication on overall patient QOL and physical activity levels which are likely to contribute to an increased ability to maintain weight loss.

How the COVID-19 coronavirus pandemic affected post-bariatric surgery weight loss Emily Ortega, MD; James Patrick Ryan, MD; Wellspan York Hospital Objective: For years it has been appreciated that psychosocial stress can influence the ability to lose weight. In the spring of 2020, much of the United States experienced stress by way of the COVID-19 Coronavirus pandemic. We suspected the combination of stress inherent to quarantining along with major disruptions in daily life would adversely affect successful weight loss. The goal of this study was to assess if the COVID-19 pandemic and resulting quarantine orders affected postbariatric surgery weight loss. Designs and methods: This was a retrospective study. Patients who had bariatric surgery between February 24, 2020 and March 20, 2020, the four-week period preceding the stay-at-home orders, were compared to patients who had surgery the year prior in a similar four-week period between February 25, 2019 and March 22, 2019. Patient data was organized according to the type of surgery, laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass (RNYGB) , and year performed. Percent weight loss at six weeks and four months following surgery were organized, and the mean percent weight loss was calculated. Four compare groups were defined and a Two-sided Two-Sample t-Test Assuming Equal Variances was performed. The alpha-level was set at 0.05. Results: The laparoscopic sleeve gastrectomy patients were found to have lost 13.08% of their body weight in 2019 and 12.42% in 2020 at the six-week postoperative appointment (p = 0.247) and 22.49% and 19.20% (p = 0.018) at the fourmonth appointment, respectively. The laparoscopic RNYGB patients were found to have lost 13.74% of their body weight in 2019 and 12.28% in 2020 at the six-week post-operative appointment (p = 0.134) and 27.87% and 21.40% (p = 0.002) at the four-month appointment, respectively. On average, both laparoscopic sleeve gastrectomy and laparoscopic RNYGB patients were found to have significantly decreased weight loss in 2020 compared to 2019 at the four-month post-operative appointment. Discussion: During this pandemic, there has been a statistically significant decrease in post-bariatric surgery weight loss. It is unlikely that the stay-at-home orders themselves are the cause of this decrease, but rather the stressors of quarantine which greatly impacted both physiologic and emotional health. Future studies will be aimed at assessing if this decreased weigh loss is sustained through the one-year postoperative period, in addition to assessing which factors contribute most to weight loss in the post-surgical period.

Hybrid laparoscopic and endoscopic management of gastric band erosion resulting in small bowel obstruction: a case report Katie Marrero; Michael Nolte; John Kim; Christian Perez; Carle Foundation Hospital While gastric bands are not popularly done for bariatric surgery, the management of bands and their complications remains an important part of the practice of bariatric surgeons.

In our case, a 48-year-old male initially presented with abdominal pain, and signs and symptoms consistent with a small bowel obstruction for approximately 24 h. The patient had a history of laparoscopic gastric band placement over 5 years previously and no fluid remained in his band. Based on imaging, there was concern for erosion and distal migration of the band causing obstruction in the proximal jejunum. On physical exam, the patient had no signs of infection at his port site and minimal abdominal tenderness. The decision was made to take the patient to the OR for further management.

Intraoperative, an upper endoscopy was first used to examine the prior band location and locate the band. Several laparoscopic ports were also placed to allow for visualization of the stomach and band tubing. The tubing was ligated close to the stomach and the port was removed without any signs of infection. The small bowel was run laparoscopically, and the port was located without the jejunum. Instead of making an enterotomy in the bowel for removal of the band, graspers were used to milk the port backwards from the jejunum to the proximal duodenum. Then, endoscopically, the port was located in the duodenum and removed transorally. The patient recovered uneventfully and was discharged expediently without any complications.

This case highlights a hybrid approach with laparoscopic manipulation and endoscopic retrieval of the band without enterotomy for band erosion and migration. While this technique is not well described in the literature, it avoids an enterotomy and the possible morbidity associated with it. Management of band erosion patients with hybrid laparoscopic and endoscopic retrieval can expedite recovery while minimizing morbidity. This case demonstrates the feasibility of minimally invasive approach in treating in lap band erosions and describes an uncommon case of band migration to the small bowel.

Gastric band erosion and migration resulting in small bowel obstruction is an uncommon complication. There are few reports of this complication in the literature. our case is a rare example of lap band bowel obstruction to be resolved utilizing a combination of laparoscopic and endoscopic techniques without need for enterotomy or gastronomy. This treatment is effective and should result in decreased morbidity than other approaches.

Smoking history as a predictor for 30-day morbidity following bariatric surgery Nicolas Fuentes, MD; Benjamin Souferi, MS; Andrew T Bates, MD; John M Davis, MD; Dominick Gadaleta; David M Pechman, MD; Northwell Health-South Shore Univeristy Hospital Introduction: Smoking and postoperative complications are well documented across surgical specialties. Preoperative smoking cessation is frequently recommended by surgeons. In this study, we assessed to what degree documented smoking history increased a patient's risk of postoperative complications. Methods: The MBSAQIP database for the years 2015-2018 was used. Patients were included if they underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (GB). Patients with a documented smoking history were assigned to the ''SH'' cohort and patients without smoking history were assigned to the ''NSH'' cohort. Patients without documentation regarding smoking history were excluded. 30-day morbidity and mortality data were assessed. The rate of these postoperative complications were compared between the ''SH'' and ''NSH'' cohort using the Chi-Square Test of Independence to assess for statistical significance. Results: After evaluation of 760,076 patients on the MBSAQIP database, 650,930 patients underwent non-revisional bariatric surgery, including 466,270 SG and 184,660 GB. Of the total patients included in the study, 53,697 patients were assigned to the SH cohort and 592,605 were assigned to the NSH cohort. 4,628 of patients did not have documented smoking status. SH patients had higher rates of readmission within 30 days (4.34% vs 3.89%, p \ .005), reoperation within 30 days (1.49% vs 1.29%, p \ 0.005), postoperative sepsis (0.15% vs 0.11%, p \ 0.05), unplanned intubation (0.18% vs. 0.14%, p \ 0.05), and unplanned ICU admission (0.84% vs 0.70%, p \ 0.005). Conclusion: SH patients undergoing bariatric surgery were at significantly increased risk of readmission and reoperation within 30 days of procedure. In addition, SH patients were more likely to have postoperative sepsis, unplanned intubation, and unplanned ICU admission. The current study supports preoperative smoking cessation in patients prior to primary bariatric surgery. Further study is warranted to compare short-term cessation vs. long-term cessation preoperatively, which was not assessed in our study.

Progressive paraplegia after bariatric surgery-micronutrient deficiency versus Background: The number of revisional bariatric procedures is growing. Minimally invasive revisional bariatric surgery (M-RBS) is more challenging than primary procedures. The aim of this study is to analyze the influence of the primary bariatric operation on M-RBS postoperative outcomes. Methods: A retrospective analysis was performed on a prospectively collected database of patients who underwent M-RBS between 2012-2019. Adjustable gastric banding (AGB) removal alone was excluded. Patients were divided into two groups according to their index procedure: conversions from a non-stapled procedure (AGB, G1) and conversions from a stapled procedure (G2). Stapled procedures included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and vertical banded gastroplasty. Demographics, operative and postoperative variables were compared between groups. Results: Two hundred seventeen patients underwent M-RBS; 135 (62.2%) were conversions to SG and 68 (31.3%) to RYGB. Operative approach was laparoscopic in 61.7% and robotic in 38.3% of cases. Insufficient weight loss (89.9%) and gastroesophageal reflux (5.1%) were the main indications for revision. The index operation was non-stapled (G1) in 169 (77.9%) and stapled (G2) in 48 (22.1%) patients. Age, sex, ASA class, obesity-related comorbidities rates, and BMI at revision (G1: 46.5 vs. G2: 42.6, p = 0.26) were comparable between groups. Intraoperative complication (G1: 0.6% vs. G2: 0%, p = 1) and conversion rates (G1:0.6% vs. G2: 2.1%, p = 0.34) were similar between groups. Operative time (G1: 139 vs. G2: 188 min, p \ 0.001) and length of hospital stay (G1: 1.7 vs. G2: 2.8 days, p = 0.03) were longer in patients undergoing conversion from a stapled index procedure. Overall morbidity (G1: 4.1% vs. G2: 16.7%, p = 0.003), major morbidity (G1:1.8% vs. 8.3%, p = 0.02), readmission (G1: 1.8% vs. 12.5%, p = 0.001), and urgent reoperation rates (G1: 1.8% vs. G2: 8.3%, p = 0.04) were also higher in patients with a stapled index procedure. Mortality rate (G1: 0.6% vs. 0%, p = 1) was similar between groups. Percentage of total weight loss (%TWL) at 3 (G1: 10.5% vs. G2: 8.3%, p = 0.06), 6 (G1: 15.9% vs. G2: 11.9%, p = 0.01), 12 (G1: 17.8% vs. 13.6%, p = 0.05), and 24 months (G1: 19.5% vs. G2: 18.7%, p = 0.83) was higher among patients undergoing conversion from AGB. Conclusion: M-RBS is safe and helps achieve additional weight loss. The nature of the primary bariatric procedure influences M-RBS postoperative outcomes. Operative time and LOS were longer, and morbidity, readmission, and reoperation rates were higher in conversions from a stapled index procedure. Further research on this topic is necessary.

Gastric bypass is superior tosleeve gastrectomy in long-term reduction of total cholestrol/HDL ratio (cardiac risk ratio): a 5year study with 100% follow up Background: Total Cholesterol/HDL ratio is a predictor of cardiovascular risk including acute myocardial infarction. Few studies have shown that bariatric surgery can reduce this ratio but are limited by their short term follow up of 1 year or significant loss of patients to follow up in longer studies. The aim of this study was to compare the long-term effect of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass on total cholesterol/HDL ratio and the prescription of statin therapy in this cohort. Methods: A training bariatric surgical unit went through phased introduction of procedures. This commenced with 70 laparoscopic sleeve gastrectomies followed by 70 bypasses. All patients received similar perioperative and postoperative care. Patients undergoing revisional procedures were excluded. This resulted in 58 patients and 61 patients who underwent sleeve gastrectomy and gastric bypass respectively. Cholesterol levels were monitored and managed by the patients' primary care physicians. Total Cholesterol/HDL ratio and the use of statins preoperatively and at 1 and 5 years post-surgery were studied and statistical analysis was carried out using SPSS. Results: The baseline characteristics for both groups were comparable as shown in Table 1 . There were no mortalities, and no patients were lost to follow up. At 1 year the cardiac risk ratio differed significantly between operation groups (Sleeve 3.40 vs Bypass 2.80 mmol/L, p \ 0/0001). In the sleeve group there was a plateau of reduction after 1 year compared with a continued reduction in the bypass group up to the study period of 5 years (3.40 vs 2.60 mmol/L, p \ 0.0001). (Fig. 1 ). Statin use was lower at 5 years compared to preoperative use in the bypass group. Statin use however was higher in the sleeve gastrectomy group at 5 years (Fig. 2) .

Conclusion: Laparoscopic Roux-en-Y gastric bypass Results in significant reduction of Total Cholesterol/HDL ratio (cardiac risk ratio) compared with laparoscopic sleeve gastrectomy at 5 years. This was achieved with a reduction in use of statins in the bypass group whereas the use of statins increased to more than preoperative levels in the sleeve gastrectomy group. Introduction: With the increasing trend in minimally invasive bariatric surgery, the incidence of GIST (Gastrointestinal Stromal Tumor) appears to be concomitantly increasing. Although previous studies have reported incidences to be about 0.5-0.8% in the bariatric surgery population, our institutional experience has found this to be much higher. While there is no established causal relationship between morbid obesity and GIST, recognition of an at-risk patient cohort can lead to increased awareness and surgical selection for management of the tumor. Methods and procedures: his was an IRB approved retrospective study of bariatric surgeries (gastric sleeves, conversion to sleeves, resection of gastric remnants) done at a single institution between 2010 and 2018. Case logs of bariatric surgeons were reviewed for pathology of GIST. Patient characteristics, operative and pathological variables, and treatment details were recorded. Results: There were 567 patients (including revisional procedures) that underwent a bariatric surgery procedure. There were 19 patients that were diagnosed with a GIST (3.4%) . Of the patients with GIST, mean age was 59 years (range 44-82) and most were female (n = 15, 79%). Mean BMI was 43.9 kg/m 2 . Most patients had preoperative endoscopy prior to planned bariatric surgery and 6 patients were diagnosed with GIST pre-operatively on endoscopy. Four patients were diagnosed intra-operatively and planned operation of gastric bypass was changed to gastric sleeve. There were 5 patients found to have GIST on final pathology. Sixteen patients had a known operative procedure-most were performed laparoscopically (n = 14), one was converted to open, and one was entirely an open resection. Average size of GIST was 1.5 cm (range 0. 3-5.1 cm) and most (n = 17) had low mitotic rate (\ /= 5 mitoses/ 50HPF) with two patients with unknown mitotic rate. Two patients had multifocal tumors. Most GISTs had spindle histology (n = 9), 3 had mixed, none had epithelioid, and 7 were unknown. Resection margin was known for 15 patients and were all negative. There are no known complications on follow up and no adjuvant treatment administered. Conclusions: Incidence of GIST in the setting of bariatric surgery is not uncommon and may be increasing. Resection of GIST during bariatric surgery can be safely performed with a minimally invasive procedure with oncological Results. Bariatric surgeons should be aware of the potential incidental finding of GIST during work up and management of morbid obesity.

Endoluminal transgastric stenting for internal drainage of an ''Orphaned'' stomach segment after revisional gastric bypass Manuel E Sanchez-Casalongue, MD, PhD; Todd H Baron, MD; Timothy M Farrell, MD; UNC Chapel Hill Introduction: Roux-en-Y gastric bypass has a number of well-defined possible complications, both in the early (infection, bleeding, leak) and late (marginal ulcer, dumping syndrome, weight regain, fistula creation) settings. Revisional bariatric procedures are sometimes applied for weight regain or anatomic derangements, and these procedures carry additional potential risks. We present here an uncommon complication after gastric bypass revision, namely the creation of an ''orphaned'' stomach segment inadvertently left in discontinuity, which led to recurrent intraabdominal abscesses and required a novel endoluminal treatment. Case presentation: A 43 year-old female presented with a history of Roux-en-Y gastric bypass in 2014 followed by revision in 2019 for inadequate weight loss. This revision included resection of the gastrojejunal anastomosis and part of the proximal gastric pouch, with redo gastrojejunostomy. The operative note also described wedge resection of the distal gastric remnant adhered to the posterior aspect of the gastrojejunostomy. The patient's recovery was complicated by left upper quadrant abscesses not amenable to percutaneous drainage, eventually requiring an exploratory laparotomy and abdominal washout. At that operation, the area of suspected fluid collection was determined to be the upper extent of the remnant stomach. Unfortunately, she continued with severe upper abdominal and left shoulder pain, and developed failure to thrive. Additional radiographic studies showed an expanding peri-splenic fluid collection.

At our institution, she underwent a diagnostic laparoscopy, adhesiolysis, drain placement, and remnant gastrostomy. Intraoperatively, there was suspicion of a chronic proximal gastric remnant leak feeding the recurrent abscess. In follow up, a sinogram documented a fistula between the surgical drain and what appeared to be an ''orphaned'' segment of the distal gastric remnant that was not in continuity with the antrum.

Once the remnant gastrostomy was sufficiently matured, retrograde endoscopy allowed ultrasound-and fluoroscopically-directed placement of a transgastric covered stent into this undrained segment of proximal remnant stomach. Her symptoms immediately improved. After 6 weeks, the covered stent was exchanged for two double-J stents to maintain the iatrogenic gastro-gastric fistula patent, and the gastrostomy was removed. The patient has remained symptom-free with no further evidence of abscesses and with moderate weight regain. We plan to remove the stents in one year. Discussion: Recurring abscesses after revisional gastric surgery should raise suspicion of a gastric fistula arising from an ''orphaned'' segment of stomach. Application of advanced endoscopic techniques may allow internal drainage without the need for major gastric resection.

Early 1-year outcomes following limb distalization to a common channel length of 500 cm for weight regain Russell D Dolan, MD 1 ; Kimberly Schuster 2 ; Kaitlin Schuster 2 ; Christopher C Thomas, MD, MHES 1 ; Laura M Doyon, MD 2 ; David B Lautz, MD 2 ; 1 Brigham and Women's Hospital; 2 

Background: Roux-en-Y gastric bypass distalization (D-RYGB) is a treatment for weight regain (WR), that avoids gastric pouch revision. The terminal Roux limb is transposed to a more distal location, shortening the common channel (CC). Although CC length of 200-300 cm can induce weight loss, intractable diarrhea and nutritional deficiencies may occur. We report our experience with weight loss, symptoms and nutritional deficiencies after shortening to a 500 cm CC. Methods: This is a retrospective review of patients that underwent 500 cm CC D-RYGB for WR, after previous RYGB, at a single tertiary care center in 2019. The follow up period was one year; postoperative weight loss, nutritional deficiencies and comorbidities were evaluated. Results: Ten patients (9 women) underwent D-RYGB for WR in 2019. Mean follow up was 11.1 months. Patients met NIH criteria for primary bariatric surgery. Mean age was 48.8 years prior to D-RYGB. Mean weight and body mass index (BMI) prior to RYGB were 339.5 lbs and 56.5 kg/m 2 , respectively. Median weight was 269 lbs and mean BMI 45.5 kg/m 2 prior to D-RYGB. Mean pre-D-RYGB CC, Roux limb and pancreaticobiliary limbs: 830 cm, 140 cm and 88 cm, respectively. Median weight was 226.9 lbs and mean BMI, total weight loss and excess body weight loss were 36.8 kg/m 2 , 47 lbs and 25.7% at 12 months, respectively (Figure) . Nutritional deficiencies are presented in the Table. Among 7 patients followed for 12 months, 28.6% (n = 2) had persistent daily diarrhea. Conclusion: D-RYGB to 500 cm may treat WR and lessen risk of diarrhea and vitamin deficiencies. Further data are needed on optimal CC length to maximize weight loss while minimizing complications. Background: Bleeding is one of the most common complications after bariatric surgery. Given the medical comorbidities of the bariatric population, management may be very challenging. Therefore, we established a quality improvement project to identify the reasons behind bleeding after bariatric surgery and implement a perioperative protocol to optimize outcomes. We aimed to share our initial experience with bleeding after bariatric surgery. Methods: Patients who underwent robotic (RSG) or laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (LRYGB) surgery over the last 3 years were identified from a prospectively collected retrospective institutional database. Bleeding was defined as extraluminal bleeding requiring blood transfusion within 30 days of surgery. Demographics, preoperative and operative factors were reviewed.

Results: A total of 789 patients were reviewed and 10 were included in the study. Eighty-one percent of the patients underwent sleeve gastrectomy (n = 641), and 10.7% of these patients underwent robotic approach. Incidence after RSG was highest (2.9%) which was followed by LRYGB (2%) and LSG (0.8%) (p = 0.5). Patient demographics, comorbidities, etiology of the bleeding and management are demonstrated in Table. Etiology was not identified in three patients. All patients were managed non-operatively, however an Esophagogastroduodenoscopy was done in four patients. Most common reason for bleeding was staple line bleeding (40%). All patients were given appropriate VTE prophylaxis preoperatively. Discussion: The incidence of postoperative bleeding was more common after Robotic Sleeve Gastrectomy. The differences in stapler height and reinforcement as well as trocar placement with robotic surgery might be related with the Results. Introduction: Bariatric surgery offers well-documented benefits to patients with severe obesity. Obesity is a risk factor for venous thromboembolism (VTE) and bariatric patients are at especially high risk in the perioperative period due to multiple risk factors. Because of this, perioperative thromboprophylaxis, including extended postoperative chemoprophylaxis is of benefit in many bariatric patients. Risks/benefits of chemoprophylaxis must be considered on a case-by-case basis. In this study, we assessed whether the documented use of a mobility device preoperatively significantly increased the patient's risk of postoperative VTE. Methods: The MBSAQIP database for the years 2015-2018 was used. Patients were included if they underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (GB). Patients with documented use of a mobility device preoperatively were assigned to the ''Mobility Device'' cohort (MD) . All other patients were assigned to the ''No Mobility Device'' cohort (NMD) . Intraoperative factors, length of stay, and 30-day morbidity were assessed. Primary endpoints were the rate of pulmonary embolism (PE) and death. The rate of postoperative PE and death was compared using the Chi-Square Test of Independence, to assess for statistical significance. Conclusion: MD patients undergoing bariatric surgery were at significantly increased risk of postoperative PE and associated death than NMD patients. The current study suggests that decreased mobility alone, identified as the use of a preoperative mobility device may be an independent risk factor and predictor for postoperative VTE and should be incorporated into the risks/benefits calculation to determine whether postoperative chemoprophylaxis is indicated or should be extended. Further study is warranted to further study the association between decreased mobility and postoperative DVT.

Complications associated with impaired mobility in patients undergoing weight loss surgery: an analysis of the metabolic and bariatric surgery accreditation improvement project (MBSAQIP) Zachary Wargel, BS; Timothy Ritchie, BS; Andrew A Wheeler, MD; University of Missouri-Columbia

Introduction: Obesity and its comorbid medical conditions can significantly impact a patient's mobility. This can further negatively impact their health due to limitations on exercise and the ability to adequately care for themselves. Weight loss surgery can dramatically help people who have impaired mobility but whether or not they are at increased risks for post-operative complications is not well-defined. We aim to characterize post-operative complications in patients with impaired mobility who are undergoing weight loss surgery. Methods: MBSAQIP patient use files, 2015-2018, were queried for all patients having undergone a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). Complications were compared based on presence of preoperative impaired mobility. Patient characteristics were analyzed using Chi-square test to look at categorical variables. Logistic regression modeling was used to control for confounding variables. Significance was considered at p \ 0.05. Results: 575,787 patients were identified who underwent primary LRYGB or LSG. After controlling for confounding variables, mobility impairment was associated with increased risks of post-operative complications including: acute renal failure, cardiac arrest, blood transfusion, unplanned intubation, unplanned admission to ICU, and 30-day rates for death, readmission and reoperation. Conclusion: Weight loss surgery is still safe for patients who have impaired mobility. However, they are at higher risk for multiple complications and this should be considered when assessing patient's preoperative risks as well as counseling patients considering weight loss surgery.

Timing and impact of bleeding after bariatric surgery Introduction: The timing of bleeding after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB), the managment, surgical (reoperation) or non-surgical (reintervention) and its implication on patient outcomes has not been thoroughly studied. We sought to describe the rates of reoperation or reintervention after bleeding following SG or RYGB and establish the difference between the two, as well as compare the need for subsequent management after the initial approach. Methods: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was queried between 2015 and 2018 for any bleeding after SG or RYGB and subsequent reoperation or reintervention. Multivariable Fine-Gray models were used to compare the hazard of reoperation/reintervention. Multivariable generalized linear regression models were used to compare the number of subsequent re-operations/re-interventions depending on the initial management. Univariate analysis was used to adjust for significant confounding risk factors and deaths as competing events.

Results: 6251 patients with early or late bleeding after SG or RYGB were identified. 1927 and 1057 patients had reoperation and reintervention, respectively. For patients who developed bleeding, SG was associated with significantly higher reoperation risk while RYGB was associated with significantly higher risk of reintervention.

Early bleeding was associated with significantly increased risk of reoperation and decreased risk of reintervention, regardless the initial procedure. The total number of subsequent reoperations/reinterventions did not differ significantly depending on whether the patients had reintervention or reoperation first (HR 1.01, 95% C.I (0.75,1.36), p-value 0.9418). Conclusion: Patients after SG who experience bleeding are more likely to undergo reoperation than RYGB patients. On the other hand, patients with bleeding after RYGB are more likely to undergo non-surgical reintervention compared to SG patients. Early bleeding is associated with higher risk of reoperation and lower risk of reintervention both after SG and RYGB. The initial approach did not play a role in the total number of subsequent reoperations/reinterventions.

Intussusception following Roux-en-Y gastric bypass Alexandra R Schmidt, DO; Luke Swaszek, MD; Elizabeth Renza-Stingone, MD; Temple University Hospital Introduction: As global and national rates of obesity continue to rise, the demand and need for more metabolic and bariatric surgery will also increase. Intussusception following RYGB (Roux-en-y gastric bypass) is one such post-operative scenario for which there is no agreed upon management strategy. Presentation of cases: We describe three cases of intussusception in patients who had previously undergone RYGB and analyze the management strategies employed. The patients in our case series were each managed differently. One was managed non-operatively, while the other two were managed surgically. Of these two, one initially underwent exploratory laparotomy and the intussusception was found to have already resolved so no further intervention was done at that time. The second patient underwent reduction and resection. Conclusion: There are a range of treatment options for managing intussusception following RYGB. Resection seems to be the most commonly performed procedure with the lowest risk of recurrence. One should seriously consider operative interventions such as resection or enteropexy, as the data seems to lean towards recurrence when intussusception is left untreated. Definitive research on the matter is lacking, but due to the rarity of the condition, it may not be possible to study the problem fully. More studies need to be done to better define the site and etiology of intussusception, and this may help in individualizing treatment for each patient.

Hiatal hernia repair after gastric bypass Background: Gastric bypasses are among the most common bariatric surgeries currently performed. Hiatal hernias may result after gastric bypass, however, symptomatic hiatal hernia (HH) with pouch migration is a lesser known complication that requires surgical repair. There are few published data on patient outcomes after surgical repair of these hernias. Objective: To present a case series of patients requiring surgical repair for isolated symptomatic hiatal hernias after gastric bypass. Methods: A retrospective chart review was performed at a single tertiary referral center to identify patients presenting with symptomatic HH after gastric bypass between July 2012 and October 2020. Patients who underwent hiatal hernia repair as a part of an additional revisional surgery were excluded from the case series. The review identified age, sex, body mass index, presenting symptoms, imaging studies, time from index surgery, operative details, postoperative imaging, and symptomatic outcomes. Results: Nine patients were included in the case series. The average time from index surgery was 65.3 months (range 24-215 months). The average body mass index at the time of hiatal hernia repair was 29.1 kg/m 2 . Two patients had a hiatal hernia repair at their initial surgery. The most common presenting symptom of recurrence was gastroesophageal reflux (GER). Patients were diagnosed with a preoperative upper gastrointestinal series or computed tomography. Pouch hiatal hernia repair was performed with nonabsorbable sutures in all patients with the addition of bioabsorbable mesh in three patients. All patients with long term follow up (7/9) reported resolution in pain, feelings of food sticking, and dysphagia, and 5/7 (56%) reported complete resolution of GERD. Overall, symptom improvement was reported in all patients after pouch hiatal hernia repair. Four patients had subsequent imaging with no recurrence on imaging. Conclusions: Although a rare complication, symptomatic pouch hiatal hernias after gastric bypass most frequently manifests with GER, pain, or oral intolerance and the majority of patients report resolution of these symptoms after surgical repair.

Remission rates and achieving control of type 2 diabetes mellitus (T2DM) following longitudinal sleeve gastrectomy (LSG) Introduction: The aim of our study was to determine the impact of LSG on remission of T2DM in the context of modern medical management. The prevalence of obesity and T2DM is increasing in the US. Bariatric surgery has ameliorative effects on T2DM and is an accepted intervention in obese diabetic patients. Advances in medical management of T2DM include Glp-1 analogs and SGLT2 inhibitors (SGLT2i), which allow for improved glycemic control and weight loss. Methods: Retrospective cohort study reviewing all LSG patients undergoing bariatric surgery at an academic medical center from October 1, 2017 to June 1st, 2020. The primary endpoint of this study was remission of T2DM at one year postoperatively, defined as Hgb-A1c \ 6.5% without use of diabetic medications. Statistical analysis was performed using SAS, continuous data was analyzed using Student T tests and discrete data using Fisher's Exact Test. Results: LSG patients with follow up data one year postoperatively were included in our analyses (N = 91); with a mean age of 49 ? 11 years, 24% male, BMI of 45 ? 8 and Hgb-A1c of 6.6 ? 0.7. At time of LSG, patients used 1.5 ? 0.8 diabetic medications, with 89% on metformin, 22% on Glp-1 analogs, 21% on insulin and 9% on SGLT2i. T2DM remission rate at one year following LSG was 65.9%. Remitters were significantly less likely to use insulin (6.6% vs 50%, p \ 0.0001) and SGLT2i (3.3% vs 20%, p = 0.0143). Additionally, they had a lower preoperative HgB-A1c (6.4 ? 0.7 vs 6.9 ? 0.5, p = 0.0007), used a lower number of diabetic medications (1.2 ? 0.6 vs 2.0 ? 0.9, p \ 0.0001), and had a lower DIAREM score (4.35 ? 3.7 vs 10.1 ? 5.6, p \ 0.0001). Non-remitters manifested significant reduction in number of diabetic medications (2.0 ? 0.9 vs 1.2 ? 0.7, p = 0.0005), use of insulin (50% vs 20%, p = 0.292), use of GLP-1 analogs (30% vs 3.3%, p = 0.0122) and Hgb-A1c (6.9 ? 0.5 vs 6.4 ? 0.7, p = 0.002337) at one year postoperatively compared to their preoperative levels. Preoperative weight loss and improvement in Hgb-A1c, and postoperative weight loss were not associated with remission. Conclusion: Use of insulin, SGLT2 inhibitors, number of diabetic medications, and preoperative Hgb-A1c, are associated with T2DM remission following LSG. We infer that factors predictive of remission have more to do with progression of the T2DM, and less with weight loss or lifestyle changes. The group of patients that did not achieve remission still manifested significant metabolic benefits. LSG has a role in T2DM management, and its optimal use in the context of current medical management is an avenue for further investigation.

Hypoalbuminemia is a risk factor for 30-day morbidity after laparoscopic Roux-en-Y gastric bypass Eric Introduction: Despite an excess in adiposity, patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) may in fact be protein-calorie malnourished preoperatively. Preoperative serum albumin levels represent a surrogate for nutritional status, and are frequently obtained prior to surgery. As is suggested by prior reports, the aim in this investigation is to use the 2017 ACS-MBSAQIP dataset to discern the role of hypoalbuminemia in 30-day outcomes after LRYGB. Methods: We reviewed 22,345 patients from the dataset who underwent LRYGB and met inclusion criteria. Our outcomes were 30-day reoperation, readmission, reintervention, mortality and a composite representing the occurrence at least one of these four events. Using bivariate regression analysis, patient and surgeon factors associated with the endpoints were identified, and nominal logistic multivariate analyses were performed to determine whether serum albumin constituted an independent predictor of any of the five outcomes. Results: Among 22,345 patients included, median preoperative serum albumin was 4.0 g/dL. Incidence of 30-day reoperation, readmission, reintervention, mortality and the composite endpoints were 2.1%, 5.4%, 2.1%, 0.2% and 7.3%, respectfully. Upon bivariate analysis and taken as a continuous variable, serum albumin was inversely correlated with 30-day readmissions (P = .005) and the composite endpoint (P = .01). After adjustment, serum albumin was significantly associated with both 30-day readmissions (n = 20,143, OR 0.85 [95% CI 0.72, 0.99; P = .04]) and the composite endpoint (n = 20,143, OR 0.87 [95% CI 0.76, 0.999; P = .05]). Conclusions: Analogous to other general surgical procedures, depressed preoperative serum albumin levels may confer increased risk of 30-day morbidity after elective LRYGB. Patients undergoing this procedure are best served being nutritionally replete prior to surgery and prospective studies are needed to assess impact on outcomes.

Outcomes of conversion of sleeve gastrectomy to single anastomosis duodenoileal bypass (SADI-S) to enhance weight loss Juan S Barajas-Gamboa, MD; Alia Alhareb, MD; Yaqeen Qudah, MD; Gabriel Diaz Del Gobbo, MD; Mohammed Abdallah, MD; Carlos Abril, MD, PhD; Javed Raza, MD; Matthew Kroh, MD; Ricard Corcelles, MD, PhD; Cleveland Clinic Abu Dhabi Introduction: Single anastomosis duodenoileal bypass (SADI-S) has being recently endorsed by the American Society for Metabolic and Bariatric Surgery (ASMBS). Outcomes available in current literature involve SADI-S as primary and revisional procedures. Data reported on conversion of sleeve gastrectomy (SG) to SADI-S to enhance weight loss is limited. The aim of this study was to evaluate short-term Results of SADI-S for suboptimal weight loss (SWL) and characterize perioperative outcomes in a cohort of patients at a single academic medical center. Methods and procedures: Patients who underwent revisional surgery to convert SG to SADI-S to enhance weight loss at our institution from December 2018 to August 2020 were retrospectively reviewed from a prospectively maintained registry. Mixed-effects and polynomial regression models were used to evaluate weight loss evolution and to compensate missing metrics during follow up. This study was approved by the Institutional Review Board (IRB). Results: Twenty-six patients were identified, 69.2% female with a mean age of thirty-nine years and mean body mass index (BMI) before SG of 51.1 kg/m 2 (SD ± 9.5). At the time of SADI-S, mean BMI was 44.2 kg/m 2 (SD ± 7.0), which corresponded to 13.6% total weight body loss (TBWL) and 22.9% excess weight loss (EWL) from the initial operation. Comorbidities included hypertension (23%), Gastroesophageal Reflux Disease (GERD) (19.2%), hyperlipidemia (15.3%), obstructive sleep apnea (11.5%) and type 2 diabetes (7.6%). The median ASA score was 3. Primary operations performed at outside facilities were 96.1%. Minimally invasive surgery (MIS) approach was successfully completed in all cases including fourteen laparoscopic (53.8%) and twelve robotic-assisted (46.2%) cases. The median operative time was 193 min. There were no intraoperative complications and the median hospital stay was two days. No postoperative complications and no reoperations occurred during the study period. Based on the mathematical model, at 6-months post-conversion, patients had a mean BMI of 38.2 kg/m 2 (SD ± 6.3) and 11.6%TBWL. At 9-months, patients had a mean BMI of 35.6 kg/m 2 (SD ± 5.9) and 17.5%TBWL. At 12-months, patients had a mean BMI of 33.1 kg/m 2 (SD ± 5.5) and 23.3%TBWL, with (4/5) patients completed follow up. There were no mortalities and the mean follow-up period was 6 months. Conclusions: Conversion of SG to SADI-S appears safe and effective when performed for SWL. Future studies with larger sample sizes are needed to explore the medium and long term outcomes, and compare with other procedures. Introduction: The implications of presurgical hypoalbuminemia have not yet been investigated in patients undergoing elective bariatric surgery and may represent an important modifiable factor in optimizing patient outcomes. The aim of this study was to characterize the prevalence and clinical characteristics of hypoalbuminemia in elective bariatric surgery patients and to further evaluate its impact on serious complications and 30-day mortality. Methods and procedures: Data was extracted from the MBSAQIP data registry from 2015 to 2018. All primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included while prior revisional surgeries and emergency surgeries were excluded. A presurgical serum albumin level of \ = 3.5 g/d was used to define our study population into hypoalbuminemic (HA) and non-albuminemic (NA) cohorts. Multivariable logistic regression analysis was used to determine the influence of hypoalbuminemia on post-operative complications and 30-day mortality. Results: Of 590 971 patients, 42 618 (7.2%) were identified as having presurgical serum albumin levels \ 3.5 g/dL. HA patients were younger (44.5 ± 12.0 years vs. 44.0 ± 11.9; p \ 0.0001), had increased BMI (48.5 ± 9.0 kg/m 2 vs. 45.1 ± 7.7 kg/ m 2 ; p\ 0.0001), were more likely to be of female sex ( 0.09%; p = 0.001) rates were also more prevalent among HA patients. Multivariable regression analysis revealed that after functional status, hypoalbuminemia was the strongest modifiable predictor of serious complications (OR 1.2; 95% CI 1.14 to 1.26; p = \ 0.0001) but was not found to be predictive of 30-day mortality. Conclusion: Hypoalbuminemia among elective bariatric surgery patients is prevalent and comprises over 7% of all elective MBSAQIP cases. Adoption of strategies to identify and improve preoperative malnutrition, specifically focused on improving serum albumin levels ([ 3.5 g/dL), may reduce overall serious complications among elective bariatric surgery patients.

Revisional bariatric surgery in the older: outcomes from three tertiary referral centers in the Middle East and North-America Juan S Barajas-Gamboa, MD 1 ; Christine Tat, MD 1 ; Ahmed Karmstaji, MD 1 ; Michael J Klingler, MD 2 ; Paola Barrios, MD 2 ; Gabriel Diaz Del Gobbo, MD 1 ; Mohammed Abdallah, MD 1 ; John Rodriguez, MD 2 ; Carlos Abril, MD, PhD 1 ; Javed Raza, MD 1 ; Ali Aminian, MD 2 ; Raul Rosenthal, MD 3 ; Ricard Corcelles, MD, PhD 1 ; Matthew Kroh, MD 1 ; 1 Cleveland Clinic Abu Dhabi; 2 Cleveland Clinic Foundation; 3 

Introduction: Bariatric surgery has been proven safe and effective but a subset of patients will need a revisional surgery secondary to inadequate weight loss, weight regain, lack of comorbidity resolution or postoperative surgical complications. Older patients are perceived to have higher complication risks and as such, may not be offered these procedures. However, data reported on outcomes is limited. The aim of this study was to analyze the safety and efficacy of revisional bariatric surgery in a cohort of older patients. Methods and procedures: All patients C 60 years old undergoing revisional bariatric surgery at Cleveland Clinic Abu Dhabi, Ohio and Florida from March 2013 through October 2020 were reviewed from a prospectively maintained registry with Institutional Review Board approval. Indications for surgery and perioperative outcomes were analyzed. Results: Twenty-four patients were identified. 70.8% were female with a mean age of 65 years and median body mass index (BMI) of 36 kg/m 2 . Comorbidities included hyperlipidemia (75.0%), hypertension (75.0%), type 2 diabetes (58.3%), and gastroesophageal reflux disease (GERD) (58.3%). The median ASA score was 3. The most common indications for revision were weight regain (37.5%), GERD (20.8%) and sleeve stricture (12.5%). Nineteen patients (79.1%) had previously undergone sleeve gastrectomy (SG), three patients (12.5%) Roux en-Y gastric bypass (RYGB), one patient (4.1%) one-anastomosis gastric bypass (OAGB), and one patient (4.1%) Primary Obesity Surgery Endolumenal (POSE) procedure. 58.3% of the primary operations were performed at our facilities. Nineteen patients (79.1%) underwent conversion to RYGB, two patients (8.3%) revision of gastro-jejunal anastomosis, one patient (4.1%) re-sleeve, one patient (4.1%) biliopancreatic diversion with duodenal switch (BPD-DS), and one patient (4.1%) distalization. 91.6% of cases were completed laparoscopically with a mean time of 326 min (SD ± 235). The mean hospital stay was nine days (SD ± 13.8). Three patients (12.5%) were readmitted to the hospital within 30 days of discharge. Major postoperative complications occurred in five patients, including three anastomotic leaks, one case of gastrointestinal bleeding, and one small bowel obstruction. At twelve months, the median BMI was 29.8 kg/ m 2 . Successful resolution of the primary indication that warranted revisions was 87.5%, the mean follow-up was 27.6 months, and one death occurred unrelated to the procedure after 2 months. Conclusions: This series, representing the only reported multi-center experience in older patients, suggests that revisional bariatric surgery is effective in the older. Postoperative complications occurred, and longer follow-up and larger trials are needed to validate this data.

Simultaneously laparoscopic ventral hernia repair and bariatric surgery. A case series report Enrique Arias Ramirez, MD, FACS; Gustavo A Portillo, MD; Francisco A Ruiz, MD; Mario N Urquiza, MD; Obesity El Salvador Introduction: Morbid obesity is an important risk factor for the development of primary and recurrent ventral hernias. Most surgeons consider that severe obese patients should undergo some weight loss before elective ventral hernia repair. We report our experience performing laparoscopic bariatric surgery (BS) with simultaneous ventral hernia repair (VHR) Methods: This is a retrospective observational study, of patients who underwent laparoscopic VHR and BS in Obesity El Salvador from 2011 to 2017. We studied demographic variables, hernia defect size, comorbidities, surgery time, type of bariatric procedure, hernia repair strategy, and postoperative complications Results: Between the years, 2011 and 2017, eight patients underwent laparoscopic BS with simultaneous VHR (Table 1 ) Two underwent sleeve gastrectomy, four Roux-en-Y Gastric Bypass, and two revisional bariatric procedures. 71.4% male and 28.6% female. The average age was 46 years (31-64) and the average BMI was 46.1 kg/m 2 (36.6-57.9). The defects size were from 3 9 4 cm to 5 9 10 cm, the mean operative time was 168 min (90-240 min). The hernia repair technique in all those cases was intraperitoneal onlay mesh (image 1) Conclusion: Actually we evidence showing safety performance of BS and VHR at the same time without an increase in the complications rate. The repair of ventral hernia with synthetic mesh concomitantly to bariatric surgery is feasible, and it offers safety in terms of infections. The risk of hernia incarceration and small bowel obstruction after leaving an unrepaired small hernia defect during a bariatric procedure is high and may be questionable P064 Effect of intravenous scopolamine before stapling on postoperative nausea and vomiting in sleeve gasectomy patients. A randomised controlled trial Qurrat Al Ain Atif 1 ; Omar Al Obaid 2 ; Ahmed Mujtaba Malik 3 ; 1 Dartford and Gravesham NHS Trust, UK; 2 Dr. Sulaiman Al Habib Medical Group, Saudi Arabia; 3 University Hospitals Sussex NHS Trust, UK Introduction: Postoperative nausea and vomiting (PONV) is a common complication of general anesthesia that is further potentiated in an obese patient undergoing a bariatric procedure. Literature shows trials of myriad of drugs used alone or in combination, as a prophylaxis for this cohort of patients with varied benefits. Objective: The objective of the study was to determine the effect of intravenous scopolamine prior to stapling in obese patients undergoing sleeve gastrectomy. Methodology: A prospective randomized controlled trial of consecutive patients with BMI [ 35 kg/m 2 , undergoing laparoscopic sleeve gastrectomy (LSG) was performed after approval of the hospital's ethical committee, explanation of trial to the patients and obtaining a consent. Patients were randomized into two groups; patients receiving intravenous scopolamine just before firing first stapler (Group 1) and patients receiving placebo (Group 2). Primary outcome parameter was PONV. The secondary outcome parameters were use of rescue antiemetic, time to oral intake and time to ambulation. Results: In our study, out of 100 cases of patients undergoing LSG, 50 received scopolamine before stapling and 50 were assigned to the control group. There was a significant difference between the 2 groups in terms of PONV, where mean PONV at 6 and 24 h postoperative were significantly higher in control group (16.96 ? -26.564 and 6.00 ? -13.887) then in the study group (1.16 ? -3.792 and 0.04 ? -0.283 Introduction: In evaluating Roux-en-Y gastric bypass (RYGB), Video Based Analysis (VBA) can be utilized to quantify surgeon operative technique and identify intra and inter surgeon variability. Previously, studies of technique variability were limited to surveys and subjective performance assessment. This study aims to leverage a classification system of the steps in RYGB with a cohort of surgeons to statistically quantify variability. Specifically, we aim to objectify individual surgeons' preferred step sequence and quantify the intra and inter surgeon procedure variability from this preferred sequence. Methods and procedures: Videos were de-identified to remove patient identifying information, then labeled by surgeon annotators leveraging internally developed definitions following previously published literature on the operative steps of RYGB.

Steps were categorized as Required, Quality, Optional, Complications or Complexity. All videos that did not contain the required steps of a RYGB were removed. Videos were segmented by the type of gastrojejunal (GJ) anastomosis technique.

Step time was calculated using time points labeled in the video. Preferred sequence and surgeon variability were determined based on Modified Levenshtein Distance (MLD), which measures differences between two strings of characters (in this case, steps). All possible combinations of procedure sequences were created for each surgeon and the sequence with minimum MLD is chosen as preferred sequence. Surgeon variability was then computed by comparing procedure sequence against preferred sequence.

Results: A total of 328 Roux-en-Y Gastric Bypass video recordings from nine different bariatric surgeons were collected. No surgeon's preferred sequence was the same as another surgeon, and sequence alone enabled identification of particular surgeons (Fig. 1) . Still, individual surgeons varied from procedure to procedure generally having between 2-4 deviations from their ''preferred'' step sequence in any given case. The presence of Complications or Complexity steps did not have a statistically significant effect on step sequence variability (pvalue = 0.4). We found inter and intra surgeon variability in step time among surgeons (Fig. 2 However, given the benefit and potential quality of life improvement associated with renal transplantation, the incidence of adverse events is not so high as to preclude surgery, and thus should continue to be offered to eligible patients.

Laparoscopic magnetic sphincter augmentation (MSA) system for the treatment of severe GERD post sleeve gastrectomy There were no major complications. Conclusions: The Linx MSA System has been shown to be a safe and effective treatment for GERD after sleeve up to 10 months FU. It seems to be a good alternative to gastric bypass, for patients with GERD after LSG with no weight regain.

Gastrotomy tube-induced pancreatitis: a rare case in a patient with Roux-en-Y reconstruction Jack Coorts, MD; Alice Lee, DO; Andrew A Wheeler, MD; University of Missouri Introduction: Gastrostomy tube (g-tube) placement, while crucial for providing enteral access, is not without complications which include wound infections, leakage, inadvertent tube dislodgement, and tube occlusion. In this case report, we present a case of pancreatitis caused by obstruction due to gastrostomy tube balloon in a patient with Roux-en-Y reconstruction. Case: A 49 year old female presented to the emergency department for acute epigastric pain with radiation to her mid-back. Patient had a history of a Roux-en-Y gastric bypass with prolonged complicated post-operative course due to unexplained chronic abdominal pain, dumping syndrome and malabsorption. Four months prior to her presentation, she underwent a diagnostic laparoscopy with placement of gastrostomy tube in her gastric remnant due to continued left upper quadrant abdominal pain and severe malabsorption requiring supplemental tube feeds. On the day of presentation, the patient experienced an acute pain more severe than her typical chronic symptoms. On exam she was hemodynamically appropriate and afebrile with moderate tenderness to palpation in the epigastric region. Laboratory testing was remarkable for elevated lipase to 1,457 units/L (reference range 60 units/L), and a very mild transaminitis AST/ALT of 187/109 (reference range 32/35). When interviewing the patient, she noted that her gastrostomy tube had advanced into her gastrostomy tract further than normal which correlated with onset of her acute abdominal pain. The patient denied alcohol use and had prior cholecystectomy. Abdominal CT found that the balloon of the gastrostomy tube was positioned within second part of the duodenum. Therefore, diagnosis of gastrostomy tube-induced pancreatitis was suspected. Her g-tube was exchanged and subsequent lipase on hospital day two was 19 units/L. Her abdominal pain resolved with conservative management treatment of IV fluids and pain medication. Tube feeds were restarted on hospital day four and she was discharged without complications. Discussion: Pancreatitis due to mechanical obstruction from enteral feeding access devices is a rare complication with only case reports and case series found in literature. Our case of gastrostomy tube related pancreatitis is a previous bariatric patient who underwent a Roux-en-Y gastric bypass who eventually required a gastrostomy tube in the gastric remnant for severe protein-calorie malnutrition. To our knowledge this is the first reported case of a gastrostomy-tube induced pancreatitis in a previous Roux-en-Y gastric bypass patient. Background: Many patients with obesity suffer from gastroesophageal reflux (GERD). The impact of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on GERD outcomes differs. The objective of this study was to compare GERD health-related quality of life (HRQL) and the need for antireflux medications (ARM) after LRYGB versus LSG. Methods: The medical records of patients who underwent LRYGB or LSG between August 2016-December 2019 with pre and postoperative GERD-HRQL scores [range 0 (no symptoms)-115 (severe GERD)] were reviewed. Statistical analysis included chi-square tests and t tests. Results: Overall, 170 patients were included (86 LRYGB; 84 LSG). The mean follow-up duration was 1.8 ± 0.9 years. Patients who underwent LRYGB had greater total body weight loss compared to those who underwent LSG. More patients undergoing LRYGB were taking ARMs preoperatively when compared to patients undergoing LSG. Of those patients taking ARMs preoperatively, 79% and 23% were able to discontinue these medications at 1 year after LRYGB and LSG, respectively (p \ 0.001). However, of those patients without ARM use preoperatively, 97% and 92% of patients remained off of ARMs at 1 year after LRYGB and LSG, respectively (p = 0.64). Regardless of ARM use, early postoperative GERD-HRQL scores were similar between groups. Conclusions: While LRYGB is likely to reduce GERD medication requirement when compared to LSG, patients who do not require ARMs preoperatively are not likely to require ARMs postoperatively after either surgery. In addition, postoperative GERD-HRQL scores are similar between LRYGB and LSG groups in the early postoperative period.

Bariatric surgery alleviates non-alcoholic fatty liver disease: a study conducted with transient elastography Sabri A Karatas, Dr, MD 1 ; Aylin Erdim, PhD 2 ; Ö mer Günal, Prof, Dr, MD 1 ; Yusuf Yilmaz, Prof, Dr, MD 3 ; 1 Marmara University, School of Medicine, Department of General Surgery; 2 Marmara University, Vocational School of Health Services; 3 Marmara University, School of Medicine, Department of Internal Medicine Introduction: Non-alcoholic fatty liver disease (NAFLD) has become the most common liver disease in the last decades. It has an increasing prevalence because of the strong relation with morbid obesity. Obesity surgery is a promising treatment for NAFLD in obese patients. In this study, it was aimed to investigate the possible positive changes in liver tissue, following bariatric surgery performed on morbid obese patients, by using Transient Elastography (TE). Additionally, it was aimed to examine if there is any alteration in TE measurements according to the selected surgical method in the treatment of morbid obesity Methods: 302 patients who had bariatric surgery due to morbid obesity between November 1st, 2016 and December 31st, 2019 in Marmara University Medical School Training and Research Hospital were examined. 112 patients, with preoperative and postoperative 12th month follow-up Fibroscan (F/S) examinations, were included in the study. Patients were divided into two groups: Sleeve Gastrectomy (SG) (n = 39) and RnY Gastric Bypass (RYGB) (n = 73). Liver tissue was evaluated by F/S. Weight loss was measured by %EWL. The evaluation of comorbidities was done clinically and biochemically. F/S measurements, Liver Stiffness Measurement (LSM) for fibrosis and Continued Attenuation Parameter (CAP) for steatosis, were used as the primary measurement value. Also, the fibrosis and steatosis status of patients, according to the determined threshold values in literature were used. All data were collected prospectively, analysed retrospectively. Results: Mean LSM value was decreased from 9,5 ± 6 to 5,7 ± 2,2 kPa (p \ 0,001). It was 10,2 ± 6,9 kPa vs. 5,5 ± 2,3 kPa (p \ 0,001) in SG group; 9,2 ± 5,5 kPa vs. 5,8 ± 2,2 kPa (p \ 0,001) in RYGB group. Mean CAP value was decreased from 350 ± 43 dB/m to 240 ± 42 dB/m (p \ 0,001). It was 345 ± 41 dB/m vs. 237 ± 43 dB/m (p \ 0,001) in SG group; 352 ± 45 kPa vs. 242 ± 42 dB/m (p \ 0,001) in RYGB group. When the mean values of preop and postop LSM and CAP were compared, a significant decrease was observed in both values in the postop 12th month. In the stages of fibrosis and steatosis, a significant regression was observed in the 12th postoperative month. There was no significant difference between the groups. Conclusion: Bariatric surgery improves NAFLD in morbidly obese patients. This improvement can be demonstrated reliably with the TE. SG and RYGB have also been shown by this method to be equally effective in improving NAFLD. Keywords: Bariatric Surgery, NAFLD, Transient Elastography Background: Over 100,000 laparoscopic sleeve gastrectomy procedures are performed annually in the United States. One of the rare, but most feared postoperative complications of sleeve gastrectomy is gastric staple line leak. When selecting staple cartridges intraoperatively, surgeons must account for the decrease in thickness of the stomach from the antrum to the fundus. This study focused on postoperative gastric leak by comparing different energy devices, staple types, staple heights, number of staples, staple reinforcement, and over-sewing of staple line. Methods: A retrospective cohort analysis of patients undergoing sleeve gastrectomy between 2005 and 2019 was performed. Patient demographics, comorbidities, procedure details including type of energy device, staple type (Ethicon, Covidien, da Vinci Sureform, GORE Seamguard), open staple height (range 2.5 mm to 4.8 mm), staple line suturing (none, complete, selective), and staple line clipping were compared for postoperative staple line leak. Postoperative leak was confirmed radiographically with extravasation of contrast. Differences across groups were determined by Fisher's exact test for categorical variables and multiple logistic regression analysis was performed to determine if any factors contributed to postoperative staple line leak. Results: There were 1213 patients who underwent sleeve gastrectomy. All patients had intraoperative bougie size of 36 French or larger (median 40 Fr). Of these 1213 patients, only two (0.2%) had postoperative staple line leak. In terms of patient demographics, there was no observed difference in staple line leak with respect to age, gender, height, weight, BMI, or comorbidities (Table 1 ). There was also no significant difference in gastric staple line leak between various energy devices (p = 0.72), staple type (p = 1.00), staple height (p = 0.82), number of staples (p = 0.07), staple suturing or clipping (p = 1.00). Conclusion: The long staple line, high intraluminal pressure, ischemia, hematoma formation, and staple misfiring places patients at risk of staple line leak. In this study there was no observed benefit in reducing gastric staple line leak by using larger staple height, staple reinforcement, or over-sewing the staple line. We also acknowledge that a larger study may be needed to find a statistical difference for a rare postoperative complication such as staple line leak.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypassdoes indication for conversion affect outcomes? Omobolanle Oyefule, MD; Timothy Do, MD; Omar Ghanem, MD; Enrique Elli, MD; James Madura, MD; Travis McKenzie, MD; Todd Kellogg, MD; Mayo Clinic.

Introduction: Although 10-15% of patients undergoing sleeve gastrectomy (SG) require conversion to a secondary bariatric procedure for various reasons, there is little known about the long-term effects of conversion on weight loss and incidence of post-operative complications. We designed a study aimed at investigating the amount of weight loss and peri-operative complications that patients experience after undergoing conversion from SG to Roux-en-Y gastric bypass (RYBG). Methods: We performed a retrospective review of patients at Mayo Clinic who underwent conversion from SG to RYGB from 2009-2019. In addition to demographics, we obtained information on timing and indication for conversion, presence of hiatal hernia and presence of key obesity related co-morbidities (GERD, hypertension, hyperlipidemia, type II diabetes, and obstructive sleep apnea). Postoperatively, we measured thirty day complications and percent total weight loss(%TWL) at 6 months, 12 months and 24 months post-op. Statistical analyses were performed using univariate analyses, Fisher's test and Wilcoxon Rank sum tests. Results: Of the 42 patients included, most underwent conversion due to GERD (57.1%) and inadequate weight loss/weight regain (35.7%). A small subset underwent conversion for anatomic complications including stenosis and stricture (7.1%). The mean time from SG to conversion was 52.9 months. Mean BMI prior to conversion was 31.1 kg/m 2 in the GERD subgroup and 42 kg/m 2 in the IWL/WR subgroup. 54% of patient in the GERD subgroup had evidence of hiatal hernia intraop compared to 20% in the IWL/WR group (p = 0.035). When comparing IWL/ WR vs. GERD subgroups, the percent total weight loss (%TWL) was 17.1% vs 11% at six months (p = 0.064), 20.7% vs 11.6% at one year (p = 0.044) and 18.8% vs 11.7% at two years (p = 0.291). Thirty-day major complication rate (Grade III-V) was 9.5%. Study follow-up rates were 92.9% at six months, 71.4% at one year and 40.5% at two years. Conclusion: Patients who undergo conversion from SG to RYGB tend to do so primarily because of symptomatic GERD, followed by weight related reasons. Patients with IWL/WR as primary indication for conversion achieved a greater %TWL than those whose primary conversion indication was GERD. There was a significantly higher incidence of hiatal hernia found during conversion in the GERD subgroup compared to the IWL/WR subgroup. The thirty day complication rate was as expected for revision bariatric surgery.

Patient perspectives on post-bariatric surgery nutritional supplementation Introduction: Bariatric procedures increase patient risk of long-term metabolic complications primarily due to nutrient deficiencies. The mainstay of prevention includes routine vitamin and mineral supplementation, however, barriers to patient compliance with therapy are poorly understood. Methods: Post-bariatric surgery patients electively participated in an 11-point outpatient survey at a single academic institution. Surgical procedures comprised of either laparoscopic sleeve gastrectomy (SG) or gastric bypass (GB). At the time of survey, patients ranged from 1-month to 15 years from surgery. Patients were encouraged to complete multiple surveys at different post-operative time periods. Survey items consisted of dichotomous (yes/no), multiple choice, and open-ended free response questions. Descriptive statistics were evaluated. Results: A total of 214 responses were collected, 116 (54%) underwent SG and 98 (46%) underwent GB. Post-operative timeline demonstrated 49% short-term followup visits (0-3 months post-op), 34% intermediate (4-12 months), and 17% longterm visits ([ 1 year). Vitamin cost ranged from $0-90, and 98% of patients reported that insurance did not cover their supplement cost. Many patients documented taking a bariatric specific vitamin brand (75%). Most patients reported current vitamin use (95%), with 87% of patients reporting daily compliance. Daily compliance was consistent throughout the post-operative timelines and surgical procedures. Of the SG patients, daily compliance was reported by 94% of short-term visits, 79% of intermediate, and 73% of long-term visits. For GB patients, daily compliance rates included 84% of short-term visits, 100% of intermediate, and 92% of long-term visits. Of those who were unable to take vitamins daily, non-compliance was attributed most commonly to forgetting (9%), and less often due to side effects (2%), or taste (2%). Strategies for remembering to take vitamins included tying into daily routine (55%), use of a pill box (7%), and alarm reminders (7%). Conclusions: Post-bariatric surgery nutritional supplementation remains an important lifelong goal for both patients and healthcare providers. Daily compliance does not appear to vary based on post-operative time period or surgical procedure. Although undesirable side-effects of these supplements have been reported, it does not appear to be a significant contributor to non-compliance. Incorporation of daily reminder strategies may lead to improved overall compliance.

The relationship between body mass index and risk of mortality in severely obese patients undergoing bariatric surgery Anastasios Mitsakos, MD; William Irish, PhD; Eric J DeMaria, MD, FACS; Anish Shah, MD; Walter J Pories, MD, FACS; Maria S Altieri, MD, MS, FACS; East Carolina University, Department of Surgery.

Introduction: Prior literature has demonstrated that bariatric surgery is a safe approach for patients who are severely obese. However, the relationship between body mass index (BMI) and risk of mortality in these patients has not been fully elucidated. Primary objective of this study was to evaluate the functional relationship between BMI and risk of mortality using data obtained from a national database. Methods and procedures: A retrospective cohort study of severely obese (BMI C 40 kg/m 2 ) patients who underwent first-time bariatric surgery between 2015-2018 was performed using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Primary outcome variable was intra-operative death or death within 30 days post-procedure as reported in the database. Generalized linear model with log-link was used to evaluate the association of BMI with risk of 30-day mortality. Functional form was evaluated by categorizing BMI into quartiles. Relative risk (RR) and 95% confidence interval (CI) are provided as measures of strength of association and precision, respectively. Results: There was a total of 463,436 patients included in the analysis (mean age [SD] = 43.5 [11.9] 2.5-4.3) . For patients with BMI C 70.0 kg/m 2 , the RR of 30-day mortality was even more pronounced (RR versus the lowest quartile = 8.6; 95% CI = 5.6-13.2).

[ Figure] When examining the subgroup of patients with BMI C 70.0 kg/m 2 , although sleeve gastrectomy (SG) was the most common procedure (65.4%), the risk of 30-day mortality was significantly higher in patients undergoing Roux-en-Y gastric bypass (RYGB) (RR versus SG = 2.1; 95% CI = 1.0-4.2; p = 0.044). Conclusions: BMI is significantly associated with increased risk of 30-day mortality, as the effect of BMI is more pronounced in super-obese patients (BMI C 70.0 kg/ m 2 ). These patients tend to undergo SG more often than RYGB; however, the risk of 30-day mortality is significantly higher in patients undergoing RYGB. Even though there is a higher risk, the risk of mortality is still relatively low (0.49%).

Demographics, weight/BMI and weight-related medical complications vary by health insurance in 146,159 surgical patients with obesity Danielle Tamburrini, DO; Gus L Slotman, MD; Inspira Health Network.

Introduction: The obesity epidemic now requires all surgeons, not just bariatric specialists, to operate upon and manage patients with severe obesity. In these medically complex and fragile patients, every clinical insight helps. Advanced knowledge of pre-operative clinical characteristics may help reduce complications. Whether or not clinical factors differ between health insurance carrier populations among patients with obesity is unknown. Objective: To identify clinical variation by health insurance status in pre-operative surgical patients with obesity. Methods: Data from 146,159 pre-operative Surgical Review Corporation BOLD patients undergoing LRYGB (n = 83,059), Open RYGB (n = 5,389), LAGB (n = 67,514), SLEEVE (n = 8,966), or BPD/DS (n = 1,673) was analyzed in four groups: Self-Pay (n = 7,085), Private (n = 117,612), Medicaid (n = 5,115) and Medicare (n = 16,347). Statistics: Chi-square and ANOVA. Results: Weight, BMI, age, race, sex, and 34 pre-operative clinical characteristics vary by health insurance carrier (Table 1) . Medicare/Medicaid/Private/Self-Pay %Female (74/87/78/77) , %African American (12/17/11/4), %Caucasian (78/61/76/ 83), %Hispanic (5/16/7/6) varied by insurance (p \ 0.0001). Medicare: oldest, highest hernia, angina, back pain, cholelithiasis, CHF, depression, DVT/PE, fibromyalgia, impaired functional status, GERD, diabetes, gout, hypertension, ischemic heart disease, dyslipidemia, lower extremity edema, irregular menses, musculoskeletal pain, obesity hypoventilation syndrome, obstructive sleep apnea, peripheral vascular disease, psychological impairment, pulmonary hypertension, stress urinary incontinence, unemployment (n = 27); lowest alcohol abuse, PCOS. Medicaid: youngest; highest weight, BMI, panniculitis, liver disease, asthma, mental health diagnosis, pseudotumor cerebri, substance/tobacco abuse (n = 9). Private: highest alcohol abuse, PCOS; lowest weight (tied with Self), substance/tobacco abuse and unemployment (n = 5). Self-pay: highest alcohol abuse (tied with Private); lowest in all others except alcohol, substance/tobacco abuse, PCOS and unemployment (n = 30). Conclusion: Pre-operative clinical characteristics of surgical patients with severe obesity vary by health insurance. Medicaid have highest weight/BMI, liver disease, and psychological/behavioral issues, but are youngest, with fewer other life-threatening co-morbidities. Highest liver disease in Medicaid may relate directly to excessive BMI. Private and Self-Pay have lowest weight/BMI, drink the most, but are lowest in most serious weight-related problems, including liver disease. Medicare are oldest and carry the highest rates of 27 obesity co-morbidities. Having this clinical knowledge in advance may raise surgeons' pre-operative index of suspicion, when confronted with severely obese patients, especially Medicare, to the relative risks of dangerous co-morbidities. As a result, targeted pre-operative cardiopulmonary, endocrine/metabolic, abdominal/hepatobiliary and psychological/behavioral evaluation, planning and management by all surgeons caring for patients with obesity could lead to minimized peri-operative morbidity and maximized salubrious outcomes.

Gastric bypass provides better co-morbidity resolution and weight loss than sleeve gastrectomy in patients with central obesity Shannon M Larabee; Nicole Shockcor, MD; Mark Kligman, MD; University of Maryland.

Body-fat distribution has been implicated in the severity of the metabolic effects of obesity. Specifically, compared to peripheral obesity, central obesity has a higher risk of metabolic syndrome and sleep apnea. Unfortunately, little data is available on how body-fat distribution impacts bariatric surgical outcomes. We investigated the effect of preoperative body-fat distribution on outcomes after Roux en Y gastric bypass and sleeve gastrectomy.

A 5-year retrospective review of consecutive patients undergoing primary bariatric surgery procedures at a single institution was undertaken. The proportion of patients achieving [ 50% excess weight loss (%EWL) and the frequency of obstructive sleep apnea, hypertension, GERD, hyperlipidemia, COPD, diabetes, and chronic insulin use. At 6 months follow up 413 patients were included in the analysis, 369 of whom are female. At one year follow up 246 patients were included, 220 of whom are female. Analysis was performed using SAS software. Weight loss analysis was performed with logistic regression and comorbidity statistical analysis was performed using Fischer's exact test.

At 1 year, the odds ratio of achieving at least 50%EWL was 3.19 (CI 1.42 -7.16) for gastric bypass compared to sleeve gastrectomy in patients with central obesity. No difference was seen in patients with peripheral obesity. No significance was seen at six months. When limited to female only patients, the majority of patients who underwent bariatric surgery, the odds ratio at six months was 1.76 ) and at one year was 3.52 (1.53-8.08 ). In peripheral and centrally obese female patients who had gastric bypass at six months there was a statically significant change in the percentage of diabetic patients (p = 0.0312), more specifically in insulin dependent diabetics (p = 0.0128), with trends towards changes in hypertension (p = 0.0738) and hyperlipidemia (p = 0.0635). Likely due to the smaller number of patients who complete one year follow up, in peripheral and centrally obese female patients who had gastric bypass there is only a statically significant change in the percentage of diabetic patients using insulin (p = 0.0226).

Overall, centrally obese patients benefit most from gastric bypass bariatric surgery to achieve greater than 50% estimated weight loss and reduction in comorbidities associated with obesity. Peripherally obese patients may not achieve the same weight loss but do benefit from a reduction in comorbidities with bariatric surgery.

Hill gastroplasty for gastroesophageal reflux disease after bariatric surgery Background: Gastroesophageal reflux disease (GERD) persists or develops in many patients following bariatric surgery. With altered gastric anatomy, fundoplication is not a therapeutic option and prosthetic sphincter augmentation has not been FDA approved. The Hill anti-reflux procedure is an alternate treatment approach that anchors the gastroesophageal junction (GEJ) to the preaortic fascia using a series of sutures. The aim of this study was to evaluate early outcomes using the Hill repair in post bariatric patients suffering from GERD. Methods: A retrospective review was performed on patients who underwent Hill repair for GERD after bariatric surgery from 2014-2020. GERD was defined as an abnormal pH test with a DeMeester score of [ 14.7, or endoscopic evidence of reflux disease (Barrett's esophagus or LA class C/D esophagitis). Data was collected from electronic medical records and included patient demographics, hospital records, and clinic visits. Patients were contacted by telephone interview clinical follow up and quality of life questionnaire. Results: Eighteen patients had a Hill repair during the study period; 17 females and one male. Previous bariatric surgery included: 12 roux-en-y gastric bypass, 4 sleeve gastrectomy, and 2 duodenal switch. At the time of Hill repair, 16 of 18 had a concurrent sliding or paraesophageal hernia repair. The average BMI was 33.5. All procedures were completed laparoscopically. There were no complications. Fifteen patients were available for follow-up. Post operatively, 4 patients reported dysphagia treated with balloon dilation.

Quality of life follow up was obtained from 15 of 18 at an average of 32 months after surgery (2-80 months) . The average HRQL score was 14.5. Nine were overall satisfied (HRQL 4-24) with their outcomes, three were neutral with their outcomes , and three were dissatisfied (HRQL 3-48) with their outcome due to persistent symptoms. Conclusions: Medically refractory gastroesophageal reflux after bariatric surgery remains a challenging problem. Repair of co-existent hiatal hernia and Hill repair provides improved quality of life in most patients. Future endeavors with objective pH testing will further elucidate physiologic improvements.

Portomesenteric thrombosis after robotic sleeve gastrectomy: a case report Nicole M Lopez Canizares, MD; Omkaar Jaikaran, DO; Derek Lim; Sharique Nazir; NYU Langone Health-Brooklyn.

Introduction: Bariatric surgery is an increasingly utilized and efficient treatment modality for our enlarging morbidly obese population. Despite the well-established safety profile of laparoscopic and robotic bariatric surgery, venous thromboembolism (VTE) remains a leading cause of morbidity and mortality. This may be due to the inherent risk factors as well as prothrombotic effects of minimally invasive abdominal surgery. Case report: Our patient is a 47-year-old female who underwent a robotic sleeve gastrectomy (RSG) with an immediate uneventful postoperative course. She was discharged home on POD#1. On postoperative day 12, she presented with abdominal pain and fever. She was subsequently diagnosed with main portal vein thrombosis, as well as complete right intrahepatic portal vein and splenic vein thrombosis. Hypercoagulable work-up ultimately demonstrated a compound mutation of the methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C alleles. Discussion/conclusion: Portomesenteric vein thrombosis (PMVT) is a rare but potentially lethal complication following bariatric surgery. It has been suggested that the incidence of PMVT may be directly related to the inherent risk of obesity as well as factors related to the local and systemic effects of laparoscopic surgery. Furthermore, robotic surgery may expose patients to additional risk factors for PMVT. One proposed mechanism is unintentional retraction of the pancreas and the retroperitoneum by robotic arms, resulting in splenic vein thrombosis. The diagnosis of postoperative PMVT can be challenging, as the presentation can be quite variable. A hypercoagulable work-up may identify one of several possible abnormalities in blood coagulation, such as the MTHFR mutation in our patient. Management of PMVT is dictated by the risk factors and the severity of the thrombosis. Our patient was prescribed apixaban for six months. She remains asymptomatic, has been compliant with nutrition follow up, and has been tolerating a regular diet well with an overall 25-pound weight loss at her six-month follow-up appointment.

Retrospective review of venous thromboembolism incidence and prophylaxis at the Ottawa Hospital bariatric center of excellence Introduction: Venous thromboembolism (VTE) is the most common cause of death after bariatric surgery. The American Society for Metabolic Bariatric Surgery recommends postoperative pharmacoprophylaxis for all bariatric surgery patients; however, this practice varies between institutions. In recent years, the trend has been towards providing select patients with extended VTE prophylaxis post discharge. Aim: To evaluate VTE prophylaxis practices at The Ottawa Hospital Bariatric Centre of Excellence (TOH BCoE) in patients undergoing elective bariatric surgery, specifically the dosing regimen and timing of perioperative VTE prophylaxis. The outcomes assessed included objectively confirmed VTE and major bleeding events at 90 days. Methods: We performed a chart review of all patients who underwent bariatric surgery at TOH BCoE from January 2014 to December 2018. We collected factors for increased VTE risk (BMI, smoking history, prior VTE, OR time, re-operation, LOS), dose/timing of VTE prophylaxis, incidence of post-operative thrombotic complications and major bleeding events (defined as bleeding requiring transfusion of 3 2 units pRBCs or re-operation). Results: Of the 2208 patients identified, 1919 (87%) had a Roux-en-Y Gastric Bypass and 13% had a Sleeve Gastrectomy. Baseline characteristics revealed 1807 (82%) were women with a mean age of 45. Intraoperative VTE risk factors included an average OR time of 90 min and mean BMI of 47.4 kg/m 2 . 87% of patients received intraoperative heparin (5000u IV); and those who did, received it on average 7 min prior to cut time. Nearly all patients (98%) were given in hospital post-operative VTE prophylaxis with enoxaparin. Eighteen patients (0.82%) were discharged home on extended VTE prophylaxis due to a history of prior VTEs. At 90 days 8/1891 patients (0.42%) had suffered a post-operative VTE (5 PEs and 3 portal/SMV thrombi). Two of these patients had not received preoperative heparin. All had LOS of 1 day and received post-operative in hospital enoxaparin. One received extended prophylaxis (2 weeks of BID enoxaparin 60 mg SC) due to a prior PE.

Major bleeding complications occurred in 30 (1.59%) patients. Conclusion: Our findings demonstrate a low rate of postoperative VTE events. The number of major bleeding events may outweigh the benefit of extended prophylaxis. Additional study is needed to balance the benefits and harms of extended prophylaxis before this practice is adopted locally.

Bariatric surgery as a bridge to kidney transplantation in endstage renal disease patients Background: End-stage renal disease (ESRD) is a condition with significant healthcare utilization, and the reason for kidney transplantation. Obesity predicts increased risks of mortality and peri-transplant complications. Bariatric surgery has been suggested as a bridge to kidney transplantation, but its impact is unclear. This study aimed to evaluate the incidence of kidney transplantation after bariatric surgery for obese ESRD patients. Methods: The New York Statewide Planning and Research Cooperative System database was used to identify patients diagnosed with obesity and ESRD between 2007 to 2016 and patients who underwent bariatric procedures. Subsequent kidney transplantation was captured up to 2018. Multivariable proportional sub-distribution hazard regression analysis was performed to compare the incidence of kidney transplantation after ESRD diagnosis among obese ESRD patients with and without bariatric surgery. Results: We identified 233 ESRD patients who underwent bariatric surgery and 24,490 obese ESRD patients without bariatric intervention. Among them, 22.8% of bariatric surgery patients and 4.8% of non-surgery patients underwent kidney transplantation by 2018. The cumulative incidence of post-surgery kidney transplantation for the bariatric surgery group was 1.8% (95% CI, 0.1%-3.5%) at 1 year, 24.3% (95% CI, 17.9%-30.7%) at 5 years and 36.8% (95% CI, 26.0%-47.7%) at 10 years after ESRD diagnosis. The cumulative incidence of kidney transplantation for the non-bariatric surgery group was 1.6% (95% CI, 1.4%-1.7%) at 1 year, 6.6% (95% CI, 6.2%-7.0%) at 5 years and 10.0% (95% CI, 9.2%-10.7%) at 10 years after ESRD diagnosis (Fig. 1 ). Bariatric surgery patients were more likely to undergo kidney transplantation than patients without bariatric surgery (HR 2.0; 95% CI, 1.5-2.7; p \ 0.0001). Conclusions: These findings suggest that bariatric intervention was associated with an increased rate of kidney transplantation in obese patients with pre-existing ESRD. This study supports the expansion of bariatric surgery to serve as a bridge to kidney transplantation in obese patients with ESRD.

Functional status is more strongly associated with complication rate after bariatric surgery than is age: a NSQIP analysis Introduction: Bariatric surgery Results in sustained weight loss with an attendant reduction in mortality and is being performed in increasingly older individuals. Current literature suggests an acceptable complication rate in those as old as 65. However, these data remain limited and additional interrogation is needed. Methods and procedures: 164,711 patients entered in the NSQIP database were selected who underwent bariatric surgery (based on CPT codes and postoperative diagnosis of morbid obesity) from 2005-2018. To investigate age based 30-day complication rate, we stratified patients into four cohorts: 18-50 years-old (N = 109,707), 51-60 (N = 38,782), 61-70 (N = 15,206) , and over 70 (N = 1,016). Complications included superficial and deep surgical site infection, organ space infection, wound dehiscence, sepsis, septic shock, UTI, pneumonia, failure to wean from ventilator for over 24 h, re-intubation, pulmonary embolism, DVT, CVA, MI, cardiac arrest, bleeding requiring transfusion, and acute renal failure. Aggregate complication rate was 4.57%. Results: One-way ANOVA with post-hoc tukey test revealed significant differences in overall complication rate between age groups [F (3, 164, 711 )] = 88.55, (p \ 0.000)] with an increased complication rate in all groups compared to the 18-51 group (p \ 0.000), and in patients in their 60 s vs 50 s (p \ 0.000). There was no difference observed between patients in their 50 s vs 70 s, or 60 s vs 70 s. Mortality was analysed in the same fashion with significant differences observed between groups [F (3, 164, 711 )] = 20.96, (p \ 0.000)]. There was significantly higher mortality in all groups compared to the 18-51 group (p \ 0.001) but not between any of the older age groups.

In order to further investigate the relative contributions of patient characteristics on complication rate, multivariate regression was performed. A significant regression equation was found X 2 (8) = 1437.27, (p \ 0.000). Dependent functional status, ASA grade, diabetes, smoking status, underlying cardiovascular conditions, BMI, and age were all significantly predictive of complication rate (p \ 0.000). Dependent functional status had the largest effect, with an odds ratio of 2.18. Age had a comparatively small, though significant, effect with an odds ratio of 1.014. Sex showed no effect on complication rate (p = 0.228). (Fig. 1) . Conclusions: Together these data suggest that underlying disease burden and dependent functional status are more strongly associated with higher complication rates following bariatric surgery than is age. Further data regarding long term outcomes are needed to better understand the risks for this patient group.

Rates of readmission and ER visits of publicly funded patients in an MBSAQIP accredited center Background: Patients with governmental insurances are known to utilize the ER at a higher rate than other patients. They also have a higher readmission rate. We used our MBSAQIP data to examine rates of readmission, reoperation, reintervention and ER visits in Medicaid and Medicare (publicly insured) patients vs commercially insured and self pay pati'ents at our center. Our hypothesis was that there would be an increased rate of ER visits and readmission in Medicaid and Medicare patients undergoing bariatric surgery within 30 days. Methods: We used the data submitted to the MBSAQIP Participant Use Data File for the years 2015-2018 and added insurance status. We then described quantitative variables using mean, and standard deviation (SD). We assessed the unadjusted and adjusted association. These were reported as regression coefficients (RC) and prevalence ratio (PR), along with their 95% confidence interval (CI). P values less than 5% were considered statistically significant. Results: There were 403 patients included. Seventy-one percent were commercially insured, self funded patients made up 8.7%, Medicaid 7.4% and Medicare 12.4%. Males were 26% of the population and Hispanics made up 69%. Medicaid and Medicare pateints had higher rates of hypertension, obstructive sleep apnea and GERD. Medicaid patients had longer operative times (p = 0.04) and were more likely to have an emergency department (ED) visit within 30 days/ Conclusions: Medicaid patients have a higher rate of ED visits and a longer LOS. There is no difference in complications or mortality.

Minimally invasive approach to management of a twisted sleeve causing a partial gastric outlet obstruction Lindsay Tse; Care New England Kent Hospital.

Laparoscopic sleeve gastrectomy has rapidly become the most frequently preformed bariatric surgery in the United States as it is an effective, safe, and reproducible operation with relatively low complication rates. The most common complications include bleeding, gastroesophageal reflux, leak, sleeve stenosis, and twisting/kinking of the sleeve. Many of these complications can be managed nonoperatively or endoscopically. However, a small subset of cases fail nonoperative or endoscopic management and therefore require operative intervention. Our patient is a 50 year old Female who underwent a laparoscopic sleeve gastrectomy for morbid obesity with no obesity related comorbidities in the Dominican Republic. Her initial post operative course was complicated by dysphagia and persistent acid reflux despite maximum medical therapy. 8 months later, she underwent a revisional sleeve operation at the same institution. Post operatively, she was hospitalized for one month, had multiple surgical drains and never recovered to her baseline. Over the next 3 years she lost over 100 pounds, with current BMI 23.9, and was only able to tolerate small amounts of liquids with excessive post prandial belching and nausea. UGI demonstrated a dilated fundus with distal narrowing and delayed emptying of contrast through the remainder of the sleeve. An EGD showed a large highly distensible fundus with the mid portion of the sleeve appearing to spiral down towards the incisura. Once the fundus was completely distended with CO2, then the scope was passed easily through the twisted portion of the sleeve. This abnormal sleeve anatomy created a partial gastric outlet obstruction that was not amenable to dilation or stent placement as there was not a true narrowing or stricture. The patient was then taken to the operating room and laparoscopy confirmed the pre-operative findings. The mid portion of the sleeve appeared twisted at the staple line, and a large fundus folded over the twisted portion and rested on the antrum, creating a functional obstruction. A laparoscopic partial gastrectomy with Roux en y gastric bypass was then performed by removing the effected segment of the stomach. Post operatively the patient remained hemodynamically stable, her diet was advanced to a stage II bariatric diet, and she was discharged home. UGI preformed two weeks later demonstrated expected Roux en y anatomy with no evidence of leak. This case report describes a rare technical error from a laparoscopic sleeve gastrectomy that was successfully corrected with a laparoscopic partial gastrectomy and conversion to a gastric bypass.

Eradication of Helicobacter pylori in patients underwent sleeve gastrectomy: should it be performed and by who?

Sultan M Almuallem, MD; James Ellsmere, MD, MSc, FRCSC, FACS; Dalhousie University.

Introduction: It is common to find H. Pylori infection on pathology reports in asymptomatic patients undergoing sleeve gastrectomy. It is not clear in the reviewing the literature whether treating this infection is necessary or advisable and whether it should be done in the bariatric clinic or in the primary care setting. Methods: We retrospectively reviewed our bariatric and drug information system from January 1, 2009 to December 31, 2018 to assess the effectiveness of prescribing asymptomatic patients post sleeve gastrectomy with eradication therapy in the bariatric clinic. Results: During the study period, 478 cases of sleeve gastrectomy were performed. Of those undergoing sleeve gastrectomy, 25 patients were found to have histologic diagnosis of H. Pylori infection (5.2%). The median age of those with patients with H. pylori infection was 50; 16 were female (64%). At the first postoperative follow up appointment, 80% of patients with H. pylori infection were prescribed PPI triple therapy [PPI ? Amoxicillin ? Clarithromycin] or [PPI ? Metronidazole ? Clarithromycin for 10-14 days. The most interesting finding was 44% of those patients did not fill their prescriptions. Only 32% of patients prescribed triple therapy completed the course. Of those, only 25% had confirmation testing performed. The other 20% of patients with H. pylori infection, were advised to follow up with their primary care practitioner regarding the result. Conclusions: The current guidelines are all patients treated for H. pylori should be confirmed for eradication because of increasing antibiotic resistance. Based on the variable rationales for eradication, differing response rates and need for continuity of care, we believe therapeutic decisions and assessing eradication of H. Pylori infection in asymptomatic patients is better managed in the primary care setting.

Laparoscopic three-port sleeve gastrectomy: feasility and short term outcomes Hossam Elbohoty, MD; Tanta Faculity of Medicine.

Background: Laparoscopic sleeve gastrectomy (LSG) has become increasingly popular as a primary procedure because of its simplicity, low morbidity and mortality, and effectiveness in achieving sustained weight loss over time. Up till now, there is no standardized technique for performing LSG. The aim of this study was to report our experience in LSG by means of three port technique. Materials and methods: This was a prospective study done from February 2016 to February 2018. Fifty morbidly obese patients (40 females and 10 males) were included. Mean age of (30.20 ± 10.61) years, median preoperative body mass index (BMI) of 46.55 kg/m 2 . This study discussed the demography of the patients, the technique of the procedure, postoperative convalescence, early and late complications. Follow up was done at 1, 3, 6, 12, 24 and 36 months. Results: All procedures were completed laparosopically. Mean operative time was 64.76 ± 24.29 min, mean hospital stay was 2.2 days. The %EWL during follow-up was 23. 42%, 40.47%, 58. 65%, 69.31%, 68.77%, 64.75% at 1,3, 6, 12, 24, 36, months, respectively . After LSG, 66% of patients with AHT presented resolution (no medication) or significant improvement (doses reduced) of the disease. As regards T2DM, 80% described resolution or significant improvement after surgery. Furthermore, all patients with preoperative OSAS reported resolution/improvement within a year from surgery. Conclusions: Three port LSG is safe, technically feasible, effective and offers better cosmetic Results, however additional port may be necessary in selected patients.

Safety and efficacy of laparoscopic sleeve gastrectomy in elderly morbid obese Egyptian patients Hossam Elbohoty, Dr; Tanta Faculity of Medicine.

Background: The incidence of obesity is increasing progressively worldwide even among geriatric populations. Controversy exists regarding the safety of Laparoscopic sleeve gastrectomy (LSG) in elderly patients. The aim of this study was to assess the safety and efficacy of LSG in elderly morbid obese Egyptian patients. Materials and methods: This was a prospective study conducted in the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospital from December 2018 to February 2020. Twenty six morbidly obese patients (17 females and 9 males) were included. Mean age of 62 years, median preoperative body mass index (BMI) of 43.2 kg/m 2 . This study discussed the demography of the patients, the technique of the procedure, early and late complications and excess weight loss Results. Follow up was done at 1, 3, 6, 12, and yearly thereafter. Technique: The patients were placed in the supine split-leg position (French position) and reverse Trendelenburg. The surgeon stands in-between the legs, the assistant stands on the patient's left while the camera man stands on the patient's right. Four to five trocars were used. Following complete greater curvature mobilization, A 38-Fr sized orogastric tube was passed down trans-orally up to the pylorus to calibrate the gastric sleeve which is then created by successive firings of articulating linear stapler (Echelon Flex TM Endopath, Ethicon Endo Surgery Inc., Johnson and Johnson, Cincinnati, OH, United States). Results: All procedures were done laparosopically with no conversion. We recorded one mortality 4 month post-operative with unrelated surgical cause. The total 30d postoperative complication rate was 7.7% (2/26 patients). Mean operative time was 68.43 min, mean hospital stay was 2.8 days The %EWL during follow-up was 19.9%, 31.37%, 43.35%, 56.63%, at 1,3, 6, 12 months, respectively. After LSG, 30% of patients with hypertension (AHT) presented significant improvement of the disease (doses reduced). As regards type 2 diabetes mellitus (T2DM), 60% described resolution or significant improvement after surgery, 41.1% of patients with chronic joint pain experienced improvement. As regard early complications, two patients (4%) had early major postoperative bleeding that required blood transfusion and re-exploration. Three patients experienced moderate to severe vomiting and intolerance to early oral intake. Those patients (11.5%) required intravenous fluid theapy and anti-emetic and all improved and discharged. As regard late complications, symptoms suggesting of gasto-esophageal reflux developed in four patients. Conclusions: LSG is safe, feasible and effective in elderly obese patients with low morbidity rate.

The effect of pregnancy on weight regain after bariatric surgery Edward Hernandez, MD; Dimitrios Athanasiadis, MD; Leah D Frischmann; Zachary Gunderson; Ambar Banerjee, MD; Dimitrios Stefanidis, MD; Indiana University.

Introduction: Weight regain (WR) after bariatric surgery is a common concern. Factors that contribute to WR must be explored and discussed preoperatively as they affect the patient's expectations of weight loss. The hormonal changes that occur during pregnancy may counter those after bariatric surgery and increase WR risk. The aim of our study was to assess the impact of pregnancy on WR after bariatric surgery. Methods: Patients who underwent bariatric surgery at our institution between 2010-2016, successfully carried a pregnancy to term, and had at least 4 years postop and 1 year post pregnancy follow up were identified. Patient characteristics such as age, type of surgery, preoperative weight, nadir weight, time from surgery to pregnancy and delivery, and subsequent weights after pregnancy were recorded. Female patients who underwent bariatric surgery during the same time period and had at least four years of continuous follow up were used as controls. For both groups' percent WR was calculated as 100 x (4th year post-operative weight -nadir weight)/nadir weight. In accordance with the literature, clinically significant WR was defined as [ 10%. A p-value of \ 0.05 was considered significant. Chi-Square analysis was performed using SPSS statistical software. Results: Eighteen post-bariatric patients (13 gastric bypass and 5 bands) had successfully carried a pregnancy to birth. The average time from surgery to conception was 18.5 months with 50% of the participants becoming pregnant within 18 months of their operation. The control group consisted of 174 patients (165 gastric bypass, and 9 bands). Clinically significant WR ([ 10%) four years after surgery was identified in 83.3% (15/18) patients who had become pregnant compared to 59.2% (103/174) in the control group (p = 0.045). The Pregnant group was younger than the control group (31.8 SD:6.0 vs 45.6 SD:12.1, respectively). Conclusion: Patients who became pregnant and gave birth after bariatric surgery had a higher rate of weight regain compared with nonpregnant controls. Although the miracle of birth is something to be celebrated, factors that affect weight regain must be discussed with patients preoperatively to set realistic expectations.

Trends in revisional bariatric surgery: comparing outcomes based on reported specialty of the primary surgeon using the MBSAQIP database Marc A Sarran, MD 1 ; Scott W Schimpke, MD 1 ; Ethan M Ritz, MS 2 ; Benjamin R Veenstra, MD 1 ; Alfonso Torquati, MD, MSCI 1 ; Philip Omotosho, MD 1 ; 1 Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Rush University Medical Center; 2 Bioinformatics and Biostatistics Core, Rush University.

Introduction: Previous investigations of revisional bariatric surgery have evaluated outcomes when procedures are assisted by residents and/or fellows but not based on the specialty of the primary surgeon. The objective of this study is to compare the outcomes of revisional bariatric surgery when performed by self-reported metabolic and bariatric surgeons (MBS) versus those performed by self-reported general surgeons (GS) utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Registry. Methods: The MBSAQIP registry was queried (2016-2018) for revisional procedures based on the self-reported specialty of the primary surgeon. Surgical complications, reoperations, reinterventions, operative time and approach were compared with univariate, multivariate, and propensity matching analyses. Results: 87,250 revisional procedures were performed by MBS (versus 2209 by GS). Of those performed by MBS, 89.3% were laparoscopic or robotic (versus 75% by GS), 3 .3% were open (versus 13.5% by GS), and 7.4% were other approaches (versus 11.5% by GS). The average operative time was 106 min for MBS (versus 109 for GS). When compared with MBS cases, those performed by GS were associated with an increased risk of deep incisional SSI (OR = 3.6, 95% CI 2.4-5.3, p \ 0.001), organ space SSI (OR = 2.2, 95% CI 1.7-2.8, p \ 0.001), sepsis (OR = 2.2, 95% CI 1.6-3.2, p \ 0.001), septic shock (OR = 2.4, 95% CI 1.6-3.8, p \ 0.001), ventilator use [ 48 h (OR = 2.5, 95% CI 1.5-4, p \ 0.001), transfusion (OR = 1.4, 95% CI 1.1-1.9, p \ 0.001), 30-day reoperation (OR = 1.6, 95% CI 1.3-1.9, p \ 0.001), and 30-day readmission (OR = 1.3, 95% CI 1.1-1.5, p = 0.002).

Conclusions: This study found significant differences in the immediate peri-operative and short-term outcomes of revisional bariatric surgery depending on the primary specialty of the surgeon as reported in the MBSAQIP registry. When performed by self-reported GS (compared to self-reported MBS) revisional bariatric procedures were more often open, and were associated with significantly more complications, reoperations, and readmissions. Factors underlying these significant outcome differences are unclear and should prompt further investigation.

Outcome of staple line reinforcement during laparoscopic sleeve gastrectomy with oversewing and fibrin sealant Warit Rungsrithananon, MD 1 ; Tichakorn Parnich, MD 2 ; Narong Boonyagard, MD 2 ; Setthasiri Pantanakul, MD 1 ; Panot Yimcharoen, MD 1 ; 1 Bhumibol Adulyadej Hospital, Royal Thai Air Force, Bangkok, Thailand; 2 Bangkok Metropolitan Administration General Hospital, Bangkok, Thailand.

Background: Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure over the past decade. Despite its proven safety and effectiveness, staple line leak and bleeding are one of the most worrisome complications. Several surgical materials and techniques for staple line reinforcement (SLR) have been proposed to reduce complications and improve outcomes. This study aimed to evaluate the impact of SLR with oversewing and fibrin sealant in LSG. Methods: A retrospective study was conducted on 132 patients who underwent standard LSG from January 2015 to August 2020. Patients were divided into 2 groups: Group 1 (n = 71) underwent LSG without SLR, and group 2 (n = 61) received SLR with oversewing (continuous seromuscular suture) and overlying fibrin sealant along the entire staple line. Preoperative patient characteristics, total operative time, intraoperative blood loss, postoperative complications (staple line leak, bleeding, stenosis), and length of hospital stay were collected from medical record review. All procedures were performed by experienced bariatric surgeons. Routine postoperative barium swallow study was done in all cases. Results: There was no significant difference in age, gender, ASA classification, and intraoperative blood loss between groups. Mean preoperative body mass index was higher in group 1 compared to group 2 (47.88 vs 40.25, p \ 0.01). Mean total operative time was significantly shorter in patients without SLR compared to those with SLR (115.13 vs 137.18, p = 0.03). No staple line leak was detected in this study. One patient from group 1 suffered from suspected intra-abdominal bleeding, without a statistical difference between groups (1.4% vs 0%, p = 0.538). The patient recovered without reoperation. Although no stenosis was found in both groups, 2 cases from SLR group experienced severe postoperative nausea and vomiting which were successfully treated conservatively (0% vs 3.3%, p = 0.212). No statistical difference in length of stay was observed between groups (4.45 vs 4.16, p = 0.136). Conclusion: Our study suggested that SLR during LSG with oversewn seromuscular suture and fibrin sealant had no significant effect on postoperative complications such as leakage, bleeding, or stenosis. While technically safe, SLR procedures significantly prolonged overall operative time. Our limitations included the retrospective nature of the study design and the inability to obtain actual SLR performance time. Larger-scale prospective randomized trials with more comprehensive study designs are essential to strategically evaluate the effectiveness of SLR in LSG.

Lesson learned from endoscopic management of a recurrent staple-line leak that progressed to gastro-pleural fistula, a rare but dreaded long-term complication of sleeve gastrectomy Katsiaryna Khatskevich; Joseph Sujka, MD; Ali Abbas, MD; Christopher G DuCoin; University of South Florida. This is a 51-year-old woman who underwent a lap band conversion to a sleeve gastrectomy. A few months following that she started experiencing proximal stapleline leakage that lead to multiple intra-abdominal collections. Over a span of year and a half, she underwent multiple interventions directed towards percutaneous drainage of the collections, endoscopic closure of the leak site, and nutritional support with TPN. These interventions were initially successful but complicated by recurrence of the leakage three times. She was referred to our center following the failure of the first endoscopic intervention.

The initial endoscopic intervention was pre-pyloric luminal stenting with covered stenting. After initial success, the leak recurred. Eventually the stent was removed, and the patient was left with only external drainage which eventually was effective in resolving the leak for several months, Fig. 1 . Unfortunately, several months later, the leak recurred at the same location but with a much smaller gastric site. This was successfully addressed with over-the-scope clipping and external drainage with post-operative Barium study showing lack of persistence of the leakage, Fig. 2 .

Following the second recurrence, the patient presented with severe dyspnea and large left sided effusion with imaging consistent with gastro-pleural fistula. Chest tube placement was performed for decompression followed by pulmonary decortication. Endoscopy showed recurrence of the proximal gastric leak and now leading to the gastro-pleural fistula. Intra-operative contrast instillation showed gastric outflow obstruction at two levels severe stenosis in the proximal sleeve just below the fistula site (likely related to the prior band fibrosis) and severe angulation and narrowing of the gastric sleeve at the level of the incisura. The fistula opening was small (around 5-6 mm) with contrast delineating its tract to be around 6 cm extending under the left hemidiaphragm. Ablation of the mucosal that covers the fistula tract, orifice and the upper part of the septum (that divide the fistula lumen from the gastric lumen) was done with high energy Argon Plasma Beam. Following that primary closure of the ablated area was endoscopic suturing. To address the outflow obstruction and correct the gastric sleeve angulation, two fully covered, transpyloric 15.5 cm esophageal stent was placed from the bulb to the GE junction and was anchored with endoscopic suturing. Follow up Barium study showed gradual improvement of the gastric sleeve angulation with prompt transpyloric drainage without evidence of leak, Fig. 3 , 4, 5.

Comparison of early post-operative complications in primary and conversion laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch: a 5-year MBSAQIP analysis William Background: While laparoscopic gastric bypass (GB) has been the ''gold standard'' bariatric surgery, sleeve gastrectomy (SG) has become the most commonly performed bariatric surgery. Duodenal switch (DS) is an increasingly popular conversion procedure for patients who has had treatment failure from SG. The purpose of this study was to compare the surgical outcomes of primary GB and DS to SG. In addition, we explored the early safety profile of SG, GB, and DS as a revision/conversion procedure. Methods: The MBSAQIP between 2015 and 2018 was queried for adult patients who had a SG, GB, or DS. Exclusion criteria included those who had open procedures or Natural Orifice Transluminal Endoscopic Surgery (n = 1,924), concurrent procedures (n = 7,035), BMIs \ 30 or [ 100 (n = 11,975) , and revision/conversion surgeries (n = 52,956). Our final sample size was 596,082. We used multivariable logistic regression to calculate crude and adjusted odds ratios for the following 30-day complications: any surgical site infection (SSI), readmission, and re-operation. Models were adjusted for age, BMI, cardiac history, preoperative hypertension, previous bariatric surgery, smoking status, pre-operative steroid use, diabetes, surgery conversion.

In a separate similar analysis, we compared the early post-operative outcomes of revision/conversion SG, GB, and DS. Results: Most procedures were SG (72.5%), followed by GB (26.7%), and DS (0.9%). Compared to primary SG, both primary GB and DS were associated with higher odds of readmission (OR 1.96 [1.90, 2. [1.26, 2.11]) , and re-admissions (OR 1.44 [1.20, 1.74] ) among revision/conversion procedures compared to primary procedures even after controlling for confounders.

Among GB procedures there was not a higher risk of re-operation (OR 1.06 [0.89, 1.25]) or readmission (OR 1.11 [0.99, 1.24 ]) among revision/conversion procedures than primary procedures. Conclusions: In primary procedures, GB and DS are comparable but higher than SG in early perioperative complications. As a conversion procedure, DS has a higher risk of reoperation and readmission while SG and GB were comparable to primary procedures.

Esophagojejunostomy or fistulojejunostomy are safe salvage operations for sleeve gastrectomy leaks Introduction: Sleeve gastrectomy is the most commonly performed bariatric surgery, and complications from staple line leak occur in 1-3% of patients. Endoscopic management can avoid additional surgery by successfully healing the leak; however, in some cases surgical intervention is required. Definitive surgical management is mainly accomplished with esophagojejunostomy or fistulojejunostomy. Proceeding with surgical management of these leaks is poorly understood given the rare need and high risk. We reviewed our outcomes of definitive surgical management for leaks following sleeve gastrectomy. Methods: An institution review board approved prospectively gathered database was used to identify patients undergoing definitive surgical management for sleeve gastrectomy leaks with either an esophagojejunostomy or fistulojejunostomy. Initial data that led to the leak, intraoperative factors, and postoperative outcomes were collected. Primary endpoints to the study were postoperative complications and successful resolution of the leak. Results: A total of 22 patients were eligible for this study. Twelve patients underwent esophagojejunostomy and 10 patients underwent fistulojejunostomy. There was mean of 90 days to leak recognition (range 7 -508 days, median = 51). Two patients went straight to surgery after the leak was found while 20 patients had received prior endoscopic management (i.e. endoluminal vacuum therapy, stent placement, internal drainage, etc.). There was a mean of 228 days from first endoscopic procedure to definitive surgery in the 20 patients undergoing initial endoscopic management (range 1 -2693, median = 39). The mean time from the sentinel sleeve gastrectomy to definitive surgery was 296 days (range 11 -2744 days, median = 134). There were 7 patients (31%) that had subsequent leaks after definitive surgery. Six of the leaks were from a sutured anastomosis and 1 was from a stapled anastomosis. All were healed with endoscopic therapy, and no further surgery was indicated. No deaths occurred. Conclusion: Sleeve gastrectomy leaks are difficult to manage. When endoscopic management fails, esophagojejunostomy and fistulojejunostomy are safe and feasible salvage options. Additional leaks following these salvage operations can occur in up to 30% of patients.

Quality of life and satisfaction after sleeve gastrectomy versus gastric bypass Jeffrey Lipman, MD; Lang Li; Randal Zhou, MD; Timothy Farrell, MD; University of North Carolina.

Background: Laparoscopic sleeve gastrectomy (SG) has overtaken laparoscopic gastric bypass (GB) as the most common primary bariatric surgery performed in the United States. Relative technical ease, decreased risk of micronutrient deficiency, and lack of anatomic complications such as internal hernia and marginal ulceration make SG an attractive surgical option for many patients compared to GB. However, worsening of pre-existing gastroesophageal reflux disease (GERD) or development of de novo GERD is significantly higher after SG than GB. Furthermore, the weight loss afforded by SG is more modest than GB. We hypothesize that postoperative patient satisfaction will be lower after SG compared to GB because of these differences in outcome.We hypothesize that both of these factors could be associated with decreased patient satisfaction after SG compared to GB. Methods: We distributed quality of life and symptom-based surveys to all patients who underwent bariatric surgery at our institution between 2000 and 2020. Mean follow up time was 2.3 years for GB patients and 3.4 for SG. Statistical analysis was conducted on the 323 survey responses received. Weight loss is defined as the difference between the pre-operative weight and the current weight. Preoperative and postoperative symptoms such as heartburn and regurgitation were compared and recoded into improved, neutral and worsened categories and treated as ordinal responses. To compare the treatment effect between the two operations, we used Welch's two-sample t-test for continuous responses such as weight loss, Cochran-Mantel-Haenszel test for ordinal responses, and chi-square test for categorical responses such as satisfaction. Results: Among the 323 patients, 126 underwent GB and 197 patients underwent SG. Patients who underwent GB were significantly more satisfied with their operation (92.6%) compared with patients who underwent SG (73.6%) (p \ 0.0001). GB patients reported significantly less reflux (p = 0.003) with decreased reported heartburn (p \ 0.0001) and regurgitation (p = 0.0003). We also found that patients who underwent GB had a larger reduction in BMI compared to SG (-17.1 GB, -14.7 SG, p = 0.023.) Conclusion: In a survey of patients having undergone SG or GB at our institution over a 20 year period, we found GB patients are significantly more satisfied with their operation. We suspect factors contributing to the difference in satisfaction include SG patients reporting more GERD symptoms and having less mean weight loss.

Constance L Joel, MD; Thomas A O'Hara, MD; Maeghan L Ciampa, MD; Byron J Faler, MD; Dwight D Eisenhower Army Medical Center.

Objectives: Evaluate a single institution's rate of hyperparathyroidism in bariatric surgery patients. Determine if bariatric surgery affects parathyroid hormone (PTH) and which patient related factors may contribute to this relationship. Methods: Retrospective chart review of 64 bariatric surgery patients who underwent routine preoperative and postoperative laboratory evaluations between 2018 and 2020. Patients were divided into normal vs. high PTH ([ 77.8 pg/mL), based on preoperative values. T-tests were used to compare the normal and high PTH cohorts. Paired t-tests were used to evaluate the effect of surgery on lab values and BMI. Results: Patients were evenly divided between sleeve gastrectomy and RYGB. Preoperative hyperparathyroidism (HPTH) was seen in 26 patients (40.625%, p \ 0.001), and was correlated with a higher average BMI compared with the normal preoperative PTH (NPTH) cohort (BMI 43.7 vs. 40.0, p 0.01). Patients achieved significant decreases in BMI over one year, with a decrease in the HPTH group from BMI 43.7 to 30.5 (p \ 0.001), and NPTH group from 40.0 to 28.3 (p \ 0.01). The HPTH group saw a decrease in PTH from 109.3 pg/mL preoperative to 82.9 pg/mL at 9 months (p 0.001), though still not within the normal PTH range. At 12 months, PTH levels returned roughly to preoperative values (106.3 pg/mL). In the NPTH group, on average, the PTH remained within the normal range, but a significant increase in PTH was seen when comparing preoperative values to 6 and 12 months (50.2 pg/mL, 60.2 pg/mL, 62.4 pg/mL; p 0.01, 0.03). The HPTH group was noted to have statistically lower levels of vitamin D (\ 30 ng/mL), an average of 25.88 ng/mL, when compared with the NPTH group, who had an average of 33.07 ng/mL (p 0.03). All patients, on average, had normal calcium levels (8.9 -10.3 mg/dL) throughout the study. Conclusion: Hyperparathyroidism is very common in the bariatric population, with nearly half of patients presenting preoperatively with elevated PTH. Additionally, patients with hyperparathyroidism were shown to have low vitamin D levels, without an associated hypocalcemia. Based on our study, patients generally continued to maintain their preoperative PTH level status following surgery (normal stayed normal and high stayed high). All bariatric patients should undergo preoperative lab screening, and those with HPTH and low vitamin D should be started on supplemental vitamin D and undergo routine postoperative screening.

The utilization of laparoscopic sleeve gastrectomy is rising in patients with preexisting GERD: an MBSAQIP analysis Andrew T Bates, MD, FACS; David Pechman, MD; John Davis, MD, FACS; Dominick Gadaleta, MD, FACS, FASMBS; Northwell Health. Background: Since its widespread adoption in 2011, laparoscopic sleeve gastrectomy (LSG) has quickly increased in popularity, becoming the most commonly performed bariatric procedure in 2013. However, the main drawback to LSG remains the higher incidence of postoperative de novo reflux, as well as the possible worsening of existing reflux, which often prompts surgeons to recommend roux-en-Y gastric bypass (RYGB). In this study, we aim to analyze the relative rates of these procedures over time in patients with and without preexisting GERD. Methods: The MBSAQIP public use file (PUF) was queried for years 2015 through 2018. Only primary bariatric surgeries were included in the analysis. Patients were separated into those with and without preoperative GERD, and relative proportions of LSG, RYGB, and other procedures were abstracted. Results: Total primary bariatric procedures rose from 144,516 to 172,745 (19.53% increase). The number of bariatric patients with preexisting GERD rose from 45,167 to 51,643 (14.34%) between 2015 and 2018. The proportion of LSG increased from 58.83% to 62.24%, while the proportion of RYGB decreased slightly from 33.98% to 32.06%. Among non-GERD patients, the proportion of LSG increased from 66.53% to 74.07%, while RYGB decreased from 25.96% to 20.96%. During the same time period, the proportion of non-LSG and non-RYGB primary bariatric procedures fell from 7.18% to 5.69%. Conclusion: In patients with preexisting GERD, the relative rate of laparoscopic sleeve gastrectomy is increasing over time. Further studies are needed to elucidate the causes of this trend but may include patient preference, increased surgeon comfort with LSG in patients with GERD, or decreased technical proficiency with RYGB.

Incidence and risk factors for early gastrojejunostomy anastomotic stricture requiring endoscopic intervention following laparoscopic Roux-En-Y gastric bypass: a MBSAQIP analysis Usah Khrucharoen, MD; Zachary N Weitzner, MD; Yijun Chen, MD; Erik P Dutson, MD, FACS; University of California, Los Angeles.

Background: Gastrojejunal (GJ) anastomotic stricture is one of the recognized complications following laparoscopic Roux-en-Y gastric bypass (LRYGB). The risk involving the formation of GJ stomal stenosis is unknown. The aims of this study are to evaluate the rate and risk factors for GJ anastomotic stricture and stomal obstruction requiring endoscopic intervention within 30 days after LRYGB. Study design: This is a retrospective study of patients who underwent LRYGB and required endoscopic intervention for stricture and stomal obstruction at the GJ. Data were retrieved from MBSAQIP database from 2015-2018. Descriptive, bivariate, multicollinearity, and binary logistic regression analyses were performed. Those who had reoperation, readmission, and endoscopic intervention for other indications rather than stricture and stomal obstruction were excluded from the risk factor analysis, as well as those who expired from other causes. Results: Of a total of 760,076 bariatric patients during the 4-year period, 184,660 (24.3%) underwent LRYGB. Overall incidence of early GJ stricture and stomal obstruction requiring intervention after LRYGB was 0.47%. The incidence decreased from 0.63% in 2015 to 0.35% in 2018, p \ 0.001. After removing the excluded cases, 875 were those having early stricture and stomal obstruction and 169,538 were those that did not require any readmission, intervention, or reoperation. Among 875 cases requiring endoscopic intervention due to stricture and stomal obstruction, 744 (85.0%) required therapeutic endoscopic intervention, 117 (13.4%) diagnostic endoscopy, and 14 (1.6%) other intervention. Of those requiring therapeutic endoscopic intervention, 722 (97.0%) had dilation without stent placement, 4 (0.5%) had stent placement, and 18 (2.4%) had other therapeutic intervention. 792 (90.5%) underwent one intervention and 83 (9.5%) required more than one intervention. 341 (40.0%) had readmission and 81 (9.3%) required reoperation within 30 days following LRYGB. From a logistic regression model, factors independently associated with increased risk for early stricture and stomal obstruction include concurrent hiatal hernia repair (Adjusted Odds Ratio-AOR 1.81, 95% CI 1.53-2.15), previous bariatric/foregut surgery (AOR 1.30, 95% CI 1.07-1.57), and gastroesophageal reflux disease (AOR 1.24, 95% CI 1.08-1.41). Conclusion: The incidence of early GJ stricture and stomal obstruction following LRYGB has been decreasing at MBSAQIP participating centers over the review period. The majority of these patients underwent therapeutic endoscopic dilation. Those having concurrent hiatal hernia repair, previous bariatric/foregut surgery, and gastroesophageal reflux disease were at risk of developing early stricture and GJ stomal obstruction after LRYGB. Introduction: Revision bariatric surgery accounts for nearly 14% of the total cases performed at bariatric centers of excellence in the US. Scarce data exists on the influence of index operation on long-term weight loss and resolution of obesity related comorbidities after revision. We designed a study aimed at investigating the effect that primary procedure has on the total weight loss and perioperative complications that patients experience after conversion to Roux-en-Y gastric bypass. Methods: We performed a retrospective review of patients at Mayo Clinic who underwent conversion from sleeve gastrectomy (SG) or adjustable gastric band (AGB) to Roux-en-Y gastric bypass (RYGB) between 2009 and 2019. In addition to demographic information, we obtained information on timing and indication for the conversion and the presence of major obesity related co-morbidities (GERD, hypertension, hyperlipidemia, type II diabetes, and obstructive sleep apnea). Post-operatively, we measured short and long term complications, and percent changes in total body weight at 6 months, 12 months and 24 months post-op. Statistical analyses were performed using univariate models, Fisher's test and Wilcoxon Rank sum tests. Results: 42 patients underwent SG to RYGB conversion and 116 patients underwent single stage AGB to RYGB conversion. The most common reason for SG conversion was GERD (57.1%), compared to weight regain (77.6%) for AGB conversion. Mean time to conversion was 52.9 vs. 94.7 months for SG vs. AGB. Mean pre-conversion BMI was 36.7 kg/m 2 vs 43.8 kg/m 2 for SG vs AGB. The rate of complications was 9.5% vs 6% in SG vs AGB at thirty days (p = 0.48). At two years, the total complication rate was 31% vs 14.5% in the SG vs AGB (p = 0.02). Overall mean %TWL was 13.2% vs 24.7% in the SG vs AGB at two years (p \ 0.0035). At one year, mean %TWL was 24.6% vs. 11.6% for AGB vs SG converted for GERD/dysphagia (p = 0.014) and 27.6% vs. 20.7% for AGB vs SG converted for weight related issues (p = 0.027). Conclusion: Our study demonstrates that patients undergoing AGB conversion to RYGB experience significantly greater weight loss initial and long term weight loss than those undergoing conversion from SG, even after accounting for indications for conversion. Patients undergoing conversion after AGB also experience less short and long-term complications when compared to SG patients.

Foregut surgeons trust manometry, but will patients follow through? Introduction: Technological advancements in the interpretation of manometric studies have dramatically changed the understanding of esophageal motility. However, patients remain apprehensive about the discomfort associated with manometric catheters. The objective of this study was to identify the rate at which patients complete manometric studies. Methods: We retrospectively reviewed all manometry orders placed in our healthsystem from May 2018 to May 2020 and to determine how often patients had completed their manometry study. The study was approved by our Institutional Review Board (IRB) for a retrospective chart review using the CPT code 91,010 for manometry. Continuous variables were assessed with Kruskal-Wallis test and categorical variables were assessed with Chi-square test. Results: A total of 443 patients had manometry ordered and 388 (87.6%) of those patients has a test scheduled. Of those with manometry scheduled, 325 (83.7%) patients completed the test successfully, 36 (9.27%) did not complete the study, and 27 (6.95%) had failed. Patients who competed the study had a high rate of gastroesophageal reflux disease (238 73.2%) and laryngopharyngeal reflux (223 68.6%). Of those who failed only 3 were referred for a repeat manometry study, while 5 went on to impedance testing. Of the 388 patients who had the manometry test scheduled, 120 patients went on to have surgery with 14 of them not having manometry Results. Of the 120 surgical patients, the most common complaint was gastroesophageal reflux disease 109 (90.8%) or laryngopharyngeal reflux 106 (88.3%). The most frequent surgery performed was a Nissen fundoplication (51 42.5%) followed by a Toupet or Dor fundoplication (28 23.3%). Conclusion: Foregut surgeons trust manometry tests to guide surgical decisions, however, patients may not always complete the study. The failure to complete manometry should not inhibit proceeding with surgical intervention, but rather tailor surgical approach to care for patients. In this study, manometry completion was 83.7%, reinforcing a promising outcome of successfully completing manometry despite the discomfort that comes with the test.

Bariatric surgery revisions versus emergencies at a high-volume referral center: experience and perspective from a rural community hospital Rodolfo J Oviedo, MD, FACS, FASMBS 1 ; Tapan Nayak, PhD 2 ; Jichong Chai, PhD 2 ; Zhouxin Long, BS 2 ; 1 Houston Methodist Hospital, Department of Surgery; 2 George Washington University, Department of Statistics.

Introduction: Bariatric surgery revisions and emergencies are associated with higher morbidity and mortality compared to primary bariatric surgery. However, outcomes are not frequently reported in the literature by rural community hospital accredited programs. Methods: A retrospective chart review with IRB approval was conducted on 53 bariatric surgery revisions at a rural community hospital accredited program and compared to 61 emergencies performed by a single fellowship-trained metabolic and bariatric surgeon from 2018 to 2020. Primary outcomes were 30-day morbidity and mortality. Secondary outcomes included intraoperative time, leaks, and intraabdominal abscess. A logistic logistic regression analysis was conducted. Results: There were similar demographic risk factors in both cohorts. Most revisions (83%) were done laparoscopically, with a minority done robotically (15%) and open (2%). In contrast, 92% of emergencies were laparoscopic while 8% were open (p = 0.0006). Most revisions were done for a prior Roux-en-Y gastric bypass (RYGB) (45%), sleeve gastrectomy (19%), or adjustable gastric band (17%). For emergencies, 87% of patients had undergone a prior RYGB. For revisions vs emergencies, the 30-day morbidity (35.8% vs 47.5%, p = 0.2073) and mortality (3.8% vs 1.6%, p = 0.5967) were not statistically significant. The mean follow-up was 5.1 and 6.2 months, respectively (p = 0.1925). Statistically significant secondary outcomes for revisions vs emergencies included intraoperative time (149.5 vs 89.4 min, p \ 0.0001), superficial surgical site infection (SSI) (5.7% vs 21.3%, p = 0.03), surgical site occurrence (SSO) (1.9% vs 29.5%, p \ 0.0001), and anastomotic stricture requiring endoscopic dilation (15.1% vs 0%, p \ 0.002). The most common type of revision was a reconstruction (41%) followed by a conversion (34%). The most common type of emergency was small bowel obstruction from internal hernia (46%) and adhesions (41%). There were no differences for revisions vs emergencies in the rate of anastomotic leak (1.9% vs 1.6%, p = 1) or intraabdominal abscess (17.0% vs 16.4%, p = 0.9331). Logistic regression analysis showed the following predictive factors of higher morbidity: pre-operative albumin \ 3.5 g/ dL (p = 0.0003), recent bariatric procedure within the last 30 days (p = 0.01), prior revisional bariatric surgery (p = 0.02), prior duodenal switch (p = 0.01), and preoperative COPD (p = 0.04). Conclusion: Bariatric surgery revisions and emergencies have similar morbidity and mortality in a high-volume rural community hospital. Revisions have a longer intraoperative time and higher anastomotic stricture incidence requiring endoscopic dilation, but lower incidence of SSI and SSO compared to emergencies. Factors associated with higher morbidity include prior revisional surgery, prior DS, pre-op COPD, abnormally low pre-op albumin, and recent bariatric procedure within the last 30 days.

Robotic platform advantages for reoperative bariatric surgery Kimberly C Jacinto, DO; Kenneth L Ford IV, MSIII; Gerald Ogola, PhD; Christine Sanchez, MPH, CCRC; Anthony Waddimba, PhD; Daniel Davis, DO; Baylor University Medical Center.

Background: Up to 20% of bariatric operations eventually need a revisional reoperation, presenting distinct technical challenges to surgeons. Revisional bariatric operations pose a greater risk of postoperative complications such as leaks, extended ICU stays, and lengthy hospitalizations. Traditionally, open surgery was required due to the dense adhesions and altered anatomy in affected patients. The advent of laparoscopy led to improved re-operative outcomes. However, the robotic platform with its improved dexterity and visualization is potentially superior in tackling the increased pathologic complexity. We investigated short-term outcomes of totally robotic re-operative bariatric surgeries performed at a high-volume academic medical center.

Methods: This was a single-surgeon, single-institution, retrospective, observational study of a prospective registry of obese adults who underwent bariatric reoperations during 1/2016-12/2019 following an earlier/index bariatric surgery. Data from a Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSA-QIP)-accredited center of excellence for weight loss surgery were analyzed. Rates of complications (leaks, abscesses, strictures, bleeds, etc.), 30-day readmissions/reoperations/interventions, and conversion to open laparotomy were recorded and compared with published rates. Results: Of the 901 total bariatric surgeries performed by the surgeon during the study timeframe, 90 were totally robotic re-operative bariatric procedures. Robotic re-operative bariatric surgery was a safe technical alternative to laparoscopy. Indications for reoperation included weight loss failure, reflux/dysphagia, hiatal hernia, anastomotic stricture, marginal ulcer, intussusception, and chronic fistula from gastric sleeve leak. 10.6% of patients suffered major complications within 30 days including leaks, obstruction, bleeds, DVT/PE, and CVA evaluation. No obstructions, significant bleeds, or DVT/PE adverse events were reported. There were no conversions to open laparotomy. 4/47 (8.5%) of patients were returned to the operating room, with leak as the only indication. 6.4% suffered minor complications (dehydration alone and no stenosis/stenting ulcers were reported). The average length of hospital stay was 4 days. 17% were readmitted within 30 days. Conclusion: As more index bariatric operations are performed each year, there is a rising need for improving the quality of revisional bariatric surgery skills and technologies. Newer robotic technologies need to be investigated as feasible options for re-operative bariatric surgery. Due to weight recidivism and technical challenges of re-operative foregut surgery, laparoscopy and open surgery exert a greater physical toll on the surgeon, compared to robotic surgery. Improved ergonomics of robotic platforms are advantageous to bariatric surgeons. We conclude that robotic platforms are a safe alternative to traditional laparoscopy with equivalent adverse events and outcomes for re-operative bariatric surgeries.

Canadian trends in bariatric surgery A Jarrar, MD; A Hardy-Henry, MD; N Kolozsvari, MD, MSc, FRCSC; University of Ottawa.

Introduction: This study describes the landscape of bariatric surgery in Canada, including procedural and technical variation. The Roux-en-Y gastric bypass (RYGB) is considered the gold-standard bariatric surgical intervention, but sleeve gastrectomy (SG) is rapidly increasing in prevalence, overtaking RYGB as the most common performed procedure worldwide. While in the USA bariatric procedures plateaued in 2009, Canada's bariatric surgeries are still on the rise. Methods and procedures: An online survey was included in the Canadian Association of General Surgeons (CAGS) newsletter. The survey topics included types surgical practice, fellowship training, bariatric surgical experience, types of procedures performed, preoperative workup and technical specifics for each procedure. Results: Twenty-three respondents indicated they performed bariatric surgery, representing approximately 30% of the estimated 78 surgeons with bariatric practices in Canada. Sixteen (69.6%) practiced in an academic setting, 6 (26.1%) practiced in the community and 1 (4.3%) in the private sector. The majority of bariatric surgeons were fellowship trained. Academic surgeons were more likely to have bariatric surgery as their main practice. Most surgeons performed more than the minimum 100 lifetime stapling procedures (91.3%) and minimum 25 yearly stapling procedures (87%) required for ASMBS bariatric certification. RYGB was the most commonly performed bariatric for 21 (91.3%) of the surgeons. SG was the next most common performed procedure. Only 3 surgeons (39.1%) performed duodenal switches. No one performed adjustable gastric banding. Perioperative work-up was similar across practice types. For RYGB, 78% of surgeons used a bougie to size the gastric pouch, with most using a 30-40Fr bougie (n = 16, 69.6%). A combined stapler and hand-sewn gastrojejunostomy was the most common anastomotic technique (n = 16, 69.6%). All but one surgeon routinely performed a leak test. Most surgeons did not use routine intraoperative gastroscopy (n = 17, 73.9%) and did not routinely leave a drain (n = 21, 91.3%). For SG, most surgeons used a bougie to size the sleeve (n = 22, 96%), with majority using a 30-40Fr bougie (n = 19, 82.6%). The majority did not routinely oversew the staple line (n = 22, 95.6%) and did not routinely perform intraoperative gastroscopy (n = 19, 82.6%). Approximately half routinely performed a leak test. Conclusions: While SG is now the most common bariatric surgery performed worldwide, the gold-standard RYGB remains the most common bariatric surgery performed in Canada. Surgeons performing bariatric surgery in Canada had similar training, experience and consistent practice patterns. Introduction: Sleeve gastrectomy (SG) is the most common bariatric surgical procedure. While the SG procedure derives its popularity from its safety, efficacy, and ease of operation; the onset of new or worsening gastroesophageal reflux disease (GERD) is a well-described complication. For patients with pre-operative GERD, clinical practice recommendations are to perform Roux-en-Y Gastric Bypass (RNY). However, there is a large group of patients who prefer an alternate surgery to RNY. A possible option would be to perform SG with concomitant Magnetic Sphincter Augmentation (MSA) for weight loss and GERD reduction in selected patients. An area of concern regarding MSA placement in this setting is translocation of bacteria at the staple line and subsequent infection of the MSA device. We hypothesize that the SG staple line is sterile and a safe operative field to place MSA devices. Methods and procedures: This study was performed from June 25, 2020 to November 8, 2020 and included all patients undergoing a sleeve gastrectomy. The study design was approved by the institutional IRB. The proximal staple line was cultured and sent for both gram stain and culture. Basic demographics such as BMI, gender and age were collected, and Results were analyzed. Results: There were 47 cultures collected over the study time period. All cultures collected returned with no growth at two days, with the exception of rare growth of Diphtheroid bacteria in one patient and rare growth of non-meningitidis, non-gonorrhoeae Neisseria and Streptococcus sanguinis in one patient, and rare growth of Staphylococcus cohnii in one patient. Two patients had rare growth of Citrobacter freundii complex with Rothia mucilaginosa. Gram stain was negative for all samples. Conclusions: Based upon our preliminary Results, the operative field does not harbor gastrointestinal bacteria. Thus, SG with concomitant MSA could be considered as a primary treatment option for GERD in the setting of morbid obesity. We feel it is feasible and safe to place MSA at the time of SG and recommend future investigations into the efficacy of combining these procedures.

Roux-en-Y gastric bypass reversal for postprandial hyperinsulinemia hypoglycemia is associated with modest weight regain and reduction in symptoms at 3 years Russell D Dolan, MD 1 ; Kimberly Schuster 2 ; Kaitlin Schuster 2 ; Christopher C Thomas, MD, MHES 1 ; Laura M Doyon, MD 2 ; David B Lautz, MD 2 ; Mary Elizabeth Patti, MD 3 ; 1 Brigham and Women's Hospital; 2 Emerson Hospital; 3 Joslin Diabetes Center.

Background: A rare late complication of Roux-en-Y Gastric Bypass (RYGB) is Postprandial Hyperinsulinemic Hypoglycemia (PHH), likely secondary to GLP-1 hypersecretion. A minority of these cases can become severe, medically intractable and require surgical revision. Reversal of the RYGB has replaced distal pancreatectomy as the preferred, however, little data are available on the efficacy of this approach. This descriptive retrospective series aimed to evaluate the efficacy of RYGB reversal with Roux limb resection (revRYGB) for intractable PHH. Methods: Retrospective review of outcomes in patients referred to a large regional diabetes treatment center who underwent revRYGB with primary indication of intractable symptomatic hypoglycemia, having failed maximum dietary and medical therapy. Perioperative weight change, hypoglycemic symptoms and comorbidities were evaluated. Results: Nine patients underwent revRYGB for PHH, with a mean follow-up of 2.9 years. Mean age at revRYGB was 48.5 years. The median weight prior to RYGB reversal was 142 lbs, representing a median loss of 104.4 lbs since RYGB, and mean body mass index (BMI) 26.9 kg/m 2 . Daily hypoglycemic episodes, serum glucose nadir, weight, weight gain and BMI prior to and after RYGB reversal are listed in the Table and Figure below. Prior to RYGB reversal, 22% (n = 2) and 89% (n = 8) of patients experienced seizures and syncope, respectively. The median time between RYGB and hypoglycemia symptom onset was 1.0 years. Conclusion: Intractable post-RYGB hypoglycemia is rare and may respond to roux limb resection based on these limited retrospective data. Further data on optimal surgical strategy for these rare cases with profound morbidity are needed. Introduction: Paraesophageal hernias (PEH) are often encountered in the bariatric patient population. Surgical repair is commonly performed with concomitant bariatric surgery, including laparoscopic roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG). Although the use of permanent mesh to enforce the repair is associated with higher complications and is rarely utilized, the use of non-permanent biosynthetic mesh is controversial. This study analyzes the outcomes of patients who underwent concomitant bariatric surgery and PEH repair, with and without biosynthetic mesh reinforcement.

Methods: This study is a retrospective review from February 2018 to December 2019. All patients who underwent PEH with concomitant laparoscopic RYGB or LSG were included. Perioperative thirty-day outcomes were reviewed as well as recurrence at 1 month, 6 months, 1 year, and 2 years. Recurrences were diagnosed based on the Results of post-operative upper gastrointestinal series (UGI), esophagogastroduodenoscopy (EGD), or computed tomography (CT) scan findings.

Results: A total of 214 patients met inclusion criteria and approximately half underwent PEH with mesh (45.8%) and half without mesh (54.2%). The mean ± SD age and median(IQR) BMI for patients who underwent repair with mesh versus no mesh were 52.7 ± 10.9 and 42.0(40.0-48.0) versus 48.9 ± 11.4 and 44.0(40.0-49.0), respectively. Repair with mesh was associated with a longer length of stay (LOS) with a median(IQR) LOS of 2(1-2) days versus 1(1-2) days (p = 0.021); however, perioperative outcomes were otherwise similar. There were no mortalities or re-operations and readmission rates were similar in both groups (6.1% vs 5.2%, mesh vs no mesh, p = 0.736). Repair with mesh was associated with lower recurrence rates both at 6 months (1.3% vs 5.2%, mesh vs no mesh, p = 0.137) and 2 years (7.1% vs 11.8%, mesh vs no mesh, p = 0.505). Conclusion: Paraesophageal hernias frequently require repair at the time of bariatric surgery. Repair can be performed with or without biosynthetic mesh reinforcement. In our study, repair with mesh was associated with lower recurrence rates and similar perioperative outcomes when compared to repair without mesh. Intraoperatively, the hiatus should be carefully inspected for evidence of a paraesophageal hernia; when identified, repair with biosynthetic mesh reinforcement should be considered.

Characterizing timing of postoperative complications following elective Roux-en-Y gastric bypass and sleeve gastrectomy Introduction: The timing of post-operative complications following bariatric surgery is currently poorly understood and has yet to be fully characterized. With the growing prevalence of bariatric procedures performed worldwide, it is important to understand the timing of these complications and the differences which may exist between procedures.

Methods: This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2017 to 2018. All patients with Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included, while patients with prior surgery, revision/conversion surgery, or emergency surgeries were excluded. Complications occurring within a mean of ten days were defined as early, while those occurring later than 10 days were termed late. The primary outcome was to characterize the timing of post-operative complications for RYGB and SG. Bivariate analysis was conducted using Chi-squared test or independent t-tests for parametric data, and Mann-Whitney U tests for non-parametric continuous data.

Results: A total of 316,314 patients were identified with 237,066 (74.9%) in the SG cohort and 79,248 (25.1%) in the RYGB cohort. Early complications included myocardial infarction (4.7 ± 6.4 days), cardiac arrest (6.4 ± 8.5 days), pneumonia (6.9 ± 6.9 days), progressive renal insufficiency (8.1 ± 8.1 days), and acute renal failure (8.2 ± 7.6 days). Late complications included C. difficile infection (11.3 ± 7.8 days), organ space infections (11.7 ± 7.9 days), incisional infections (12.4 ± 6.6 days), superficial incisional infections (13.2 ± 6.9 days), and urinary tract infections (14.0 ± 8.4 days). SG patients were more likely to be diagnosed later than RYGB patients with regards to superficial incisional infections (14.0 ± 7.4 days vs. 12.5 ± 6.3 days; p = 0.002), organ space infections (12.6 ± 7.8 days vs. 10.8 ± 7.9 days; p = 0.001), acute renal failure (9.3 ± 8.1 days vs. 6.8 ± 6.8 days; p = 0.03), and pulmonary embolism (13.7 ± 7.5 days vs. 11.3 ± 8.0 days; p = 0.003). No significant difference in timing was observed for any other complication by procedures.

Conclusion: This study provides the first characterization regarding the timing of postoperative complications following bariatric surgery. We demonstrate that significant differences in timing exist between complications and that these differences also vary by surgical procedure. Understanding the course of bariatric surgical complications will enable providers to optimize perioperative care by helping overcome delays in diagnosis and management.

Comparative study of the efficacy and safety of three primary bariatric operations performed in super obese patients-a decade of the Mayo Clinic experience Introduction: Bariatric surgery is the most efficacious method to durably decrease BMI and resolve obesity related comorbidities; however there is limited data directly comparing the three most common bariatric operations in the superobese population (BMI [ 50). We designed a study to compare efficacy and safety of biliopancreatic division with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB) and the sleeve gastrectomy (SG) in a superobese population at a bariatric center of excellence. Introduction: Idiopathic intracranial hypertension(IIH) has been shown to be associated with morbid obesity. Bariatric surgery, namely Roux-en-Y gastric bypass (RNYGB), has been shown to significantly improve the symptoms associated with idiopathic intracranial hypertension. Patients with IIH may be treated with a ventriculoperitoneal (VP) shunt. Once these patients undergo bariatric surgery, the surgeon is faced with a challenge in terms of perioperative management of the VP shunt. Previous case reports have suggested that ventriculoperitoneal shunts should be externalized at the time of surgery to preserve sterility, followed by a subsequent operation to re-internalize the shunt.

Objective: The purpose of this study was to review our institutional experience with intraabdominal (VP) shunts at the time of bariatric surgery.

Methods: This was a retrospective review of all patients undergoing bariatric surgery and with the diagnosis of idiopathic intracranial hypertension at a tertiary academic hospital from 1/1/2015 to 10/1/2020. These patients underwent a standard laparoscopic RNYGB. The shunts were managed by placement into the right upper quadrant, or into a specimen bag during the length of the operation, but otherwise not externalized.

Results: Of the patients that underwent bariatric surgery, 12 were found to have a diagnosis of intracranial hypertension, 5 had indwelling ventriculoperitoneal shunts at the time of surgery. All 5 patients with indwelling shunts underwent laparoscopic RNYGB. Two patients had hiatal hernias repaired at that time of surgery, one patient underwent cholecystectomy for chronic cholecystitis, and one patient was a revision from sleeve gastrectomy to RNYGB. The average BMI at the time of surgery was 38.2 kg/m 2 (31.0-42.1 kg/m 2 ), all patients were female, the average number of comorbidities was 3. Four patient's shunts were managed by temporary placement into the RUQ, followed by replacement into the pelvis at the Conclusion of the case. One patient had her shunt placed into a specimen bag for the duration of the procedure, which was removed at the Conclusion. There were no shunt related complications within the cohort. There was no evidence of contamination, migration, or dysfunction of any shunts, with the average follow up of 14 months (1-36mo). One patient did develop stricture of her jejunojejunostomy, which was revised with the indwelling catheter in place, with no additional complications. Conclusion: Avoiding externalization of VP shunts during bariatric surgery appears to be a safe and effective strategy and obviates the need for additional operations to re-internalize the shunt.

Efficacy of antral resection versus antral preservation in laparoscopic sleeve gastrectomy -a randomized comparative study Post-operatively there was significant increase in reflux esophagitis in AR group on UGIE, however no statistically significant increase on comparison of two groups (p value = 0.559).

On 24-h impedance pH manometry post-op Demeester score increased in both AR and AP groups, however there was no significant difference in between the groups (p value = 0.661. Conclusion: Although weight loss was significant in both AR and AP group postoperatively but there was no statistically significant difference in between the two groups. There was no statistically significant difference of GER/reflux esophagitis in between the two groups. Background: A minimally invasive approach to Heller myotomy is currently the standard surgical intervention for achalasia. Robotic Heller myotomies (HM), however, have gained considerable favor amongst surgeons under the assumptions that advantages over laparoscopy include better dexterity and improved visualization. Studies demonstrate no statistical difference between rates of perforation or disease recurrence. This review aims to compare the hospital costs and overall procedure-related charges between laparoscopic and robotic Heller myotomies. Methods: The 2015-2019 Florida Agency for Health Care Administration Inpatient data was queried for laparoscopic and robotic esophagomyotomy procedures. ICD10 procedure codes were used to capture the two procedure types. Data was further cleaned by including case with diagnostic codes K220, K225 and K224, referring to achalasia of cardia, diverticulum of esophagus, acquired and dyskinesia of esophagus, respectively. Patient demographics were evaluated using student's t-test and chi square test, p \ 0.05 considered significant. Propensity score matching (1:1) was used to perform a more comparative analysis between length of stay (LOS) and various types of charges associated with each procedure type. Procedures were matched on age, gender, race, ethnicity, Charlson comorbidity index, admission source and admission priority. Results: A total of 662 procedures were performed, 471 laparoscopic and 146 robotic, at 71 hospitals of which 37 had robotic capabilities and were done by 135 physicians. For each robotic procedure, a single closest match was compared for LOS and charges with a laparoscopic case. (146 vs 146). There was no significant difference between the LOS for the two procedure types (3.45 vs 3.92, raw data) and (3.02 vs 3.92, matched data). However, charges were statistically significantly lower for laparoscopic vs robotic HM in the raw and matched data. Total charges (79 k vs 109 k), OR (28 k vs 45 k) and Medical/Supply charges (8 k vs 14 k), whereas for matched data the comparisons were (77 k vs 19 k), (28 k vs 45 k) and (9 k vs 14 k), respectively. (all p-value \ 0.001). Conclusion: Robotic HM is associated with increased index hospital costs and overall procedure-related charges while there is no statistical significance in LOS. Laparoscopic HM is the more cost-effective approach to achalasia. Keywords: achalasia, Robotic-assisted surgery, laparoscopy, Heller Myotomy. Introduction: Surgeon technique and preferences vary dramatically in the performance of laparoscopic Roux-en-Y gastric bypass (RYGB) and these differences potentially lead to significant implications on weight loss, metabolic improvement, and complications. Understanding the landscape of current practice patterns will be an important step towards optimizing outcomes following RYGB. The objective of this study was to characterize techniques used during laparoscopic RYGB using a survey of practicing bariatric surgeons. Methods and procedures: A comprehensive and anonymous 44-question survey was distributed using REDCAP to all practicing bariatric surgeons of the American Society of Metabolic and Bariatric Surgeons, Society of Gastrointestinal and Endoscopic Surgeons and American College of Surgeons by email from April 1 to June 30, 2020. Questions were designed by expert consensus to evaluate surgeon demographics, experience, and variation of technical factors. Only surgeons who performed RYGB in the past year were included in the analysis. Primary outcomes included characterizing differences in techniques with respect to pouch size, limb length, gastrojejunostomy/jejunojejunostomy formation, and mesenteric defect closure. Results: In total, 534 of 2848 (18.8%) surgeons responded and the majority (n = 518, 97.0%) reported performing RYGB in the past year. Respondents were predominantly from the United States (77.8%) followed by Canada (4.1%) and Mexico (2.7%). Surgeons had a mean 14.7 ± 7.2 years of experience and performed a median of 40 procedures in the past year. Preoperatively, only 19.9% performed upper gastrointestinal series while the majority 60.2% performed esophagogastroduodenoscopy. Evaluation of limb length revealed mean biliopancreatic limb lengths of 67.4 ± 32.2 cm and mean Roux limb lengths of 124.1 ± 29.4 cm. Limb length was predominantly measured using the length of the grasper (78.4%). The gastrojejunostomy was most commonly formed using a linear stapler with handsewn closure of the common enterotomy (52.8%) followed by a circular stapler (22.2%), and total hand-sewn technique (20.9%). The most common jejunojejunostomy techniques were linear stapled anastomosis with handsewn closure of the common enterotomy (60.7%) and the triple-stapling technique (27.7%). The vast majority of surgeons closed the jejunojejunostomy mesenteric defect (90.9%) while 65.4% closed antecolic or retrocolic mesenteric defects. Intra-operative leak tests were performed in 95.9% of all cases. Only 22.0% of surgeons routinely performed postoperative upper gastrointestinal swallow studies. Conclusions: There are wide variations in pre-and intra-operative practice patterns for the performance of laparoscopic RYGB in North America. Further trials designed to evaluate the impact of these practice pattern differences on patient outcomes are warranted. Dysphasia lusoria is an impairment of swallowing due to esophageal compression from an aberrant right subclavian artery (ARSA). The majority of patients with ARSA are asymptomatic with incidental discovery on imaging or postmortem analysis. However, 20-40% of aberrant arteries lead to tracheal-esophageal symptoms such as dysphagia.

Currently, the best method for diagnosing dysphagia lusoria is a barium esophagram followed by either a CT or MRI scan. The severity of symptoms primarily dictates the management of patients with dysphagia lusoria. Often, changes in lifestyle and dietary modification are successful treatments for mild to moderate symptoms. However, surgical intervention is justified for patients that do not respond to conservative therapy.

We present a 49-year-old female who was diagnosed with dysphagia lusoria two months status post an uneventful laparoscopic Roux-en-Y divided gastric bypass with primary hiatal hernia repair. After diagnosis, the patient saw a vascular surgeon and underwent plug embolization of her aberrant right subclavian artery followed by right subclavian carotid transposition. Following this procedure, her dysphagia symptoms resolved, she continued to lose weight from her gastric bypass surgery, she was able to come off all diabetic and hypertensive medications, and her gastroesophageal reflux symptoms resolved.

We hypothesize that the patient's dysphagia lusoria may be related to her considerable weight loss following gastric bypass surgery and that the loss of the periesophageal fat pad may have aided in esophageal compression by the ARSA. Background: Considering the opioid epidemic, it is imperative to understand factors associated with high opioid use. The aim of this study is to understand whether intraoperative opioid use (IOU) is correlated with postoperative opioid use (POU) for patients undergoing bariatric surgery. Methods: In this single-center prospective study, data on perioperative opioid use was collected from 317 adults undergoing bariatric surgery between 06/2018 and 12/2019. IOU was measured as the number of oral morphine milligram equivalents (MME) provided by anesthesiology intraoperatively and in the post-anesthesia care unit (PACU). POU was measured as the number of MMEs given during a patient's inpatient postoperative stay. The correlation between IOU and POU was measured by calculating a Pearson's r. A multivariable linear regression model was used to adjust for preoperative opioid use, preoperative BMI, ASA classification, presence of obesity-related comorbidities, operative time, length of stay (LOS) and drain placement. Results: The median IOU was 75 MME (IQR 60-105 MME); the median POU was 186 MME (IQR 115-296 MME). 92 (29%) patients reported using opioids prior to surgery. The mean preoperative BMI was 51.9 ± 12.0 kg/m 2 . Mean operative time was 141.0 ± 72.5 min and mean LOS was 2.7 ± 2.0 days. IOU and POU were positively correlated (r = 0.137, p = 0.015). Using the forward selection method, a statistically significant linear regression model was found to predict POU (F = 18.1, p \ 0.001, R2 = 0.226). Independent variables included preoperative opioid use, ASA classification, presence of obesity-related comorbidities, drain placement, LOS, and IOU. IOU remained an independent predictor of POU in this multivariable model (b = 0.453, 95% CI [0.009, 0.897]). Conclusions: For patients undergoing bariatric surgery, POU can vary widely and is influenced by multiple factors, including IOU. Attempts to minimize IOU through a multimodal pain management approach should be considered as part of a global strategy to reduce postoperative opioid requirements.

First assistant level of training as a predictor of perioperative outcomes in primary bariatric surgery, a MBSAQIP survey Andrew Varone, MD; Andrew Luhrs, MD; Marcoandrea Giorgi; Brown University Department of Surgery.

Introduction: The purpose of this study was to investigate the impact of the first assistant level of training on perioperative outcomes in bariatric surgery. Surgical education and training future surgeons is essential to maintaining a sustainable and efficient healthcare system. An integral part of surgical education in both residency and fellowship is assisting and participating in surgery under the supervision of attending surgeons with graduated responsibility. There have been many studies in various surgical specialties that have demonstrated longer operative times, increased operative costs, and, in some studies, worse patient outcomes in patients undergoing interventions in teaching institutions when compared to a non-teaching facility. Many weight loss surgery programs exist in teaching hospitals and have surgeons-intraining available to assist; however, most rely on advance practice providers (APP) or surgical technicians (ST) as first assistants (FA). Methods: We utilized the MBSAQIP database to investigate if the level of FA training correlated to perioperative outcomes. Patients from 2015-2018, C 18 years old, who underwent primary bariatric surgery were included. The primary outcome was perioperative mortality. Secondary outcomes included post-operative surgical site infections (SSI), conversion to open surgery, cardiovascular (CV) event, readmissions, non-operative reintervention, and re-operation. Results: 760,076 bariatric operations were surveyed. 670,935 met criteria for analysis. As compared to no assist, using APP, residents and fellows as FA was not associated with higher odds of mortality. There were higher odds of SSI (OR 1.13, 1.26, and 1.81 respectively), cardiovascular events (OR 1.30, 1.81, and 1.75), readmission (OR 1.06, 1.25, and 1.32). While resident and fellow FAs were associated with higher odds of sepsis (OR 1.29 and 1.61 respectively), conversion to open surgery (OR 1.25 and 1.14), nonoperative reintervention (OR 1.21 and 1.29) and fellow acting as FA was associated with higher odds of reoperation (OR 1.19) . Conclusions: The impact of the FA in bariatric surgery is not well defined but there seems to be a correlation of FA with perioperative outcomes. Further study is needed to determine whether these training level of a FA has a direct impact on perioperative outcomes.

Incidence and prevalence of vitamin and micronutrient deficiencies in a predominantly Black population undergoing Bariatric Surgery Curtis J Frederick, MD; Edward Bauer; Olufajo Olubode, MD; Howard University Hospital.

Over the last decade Obesity and being overweight have continued to plague the American population and have long been considered risk factors to many comorbidities such as, Hypertension, Diabetes Mellitus and Heart disease. What was initially considered an issue only in high income communities is now becoming a predominant issue in urban settings. With failure to achieve weight loss through conservative management (exercise and diet), or with medical intervention, Bariatric Surgery has become the forefront treatment to achieve weight loss in patients suffering from morbid obesity. The most commonly performed Bariatric procedures are Roux-en-Y Gastric Bypass (RYGB) and Laparoscopic Sleeve Gastrectomy (LSG). Though both of these procedures have shown high efficacy in promoting weight loss, this loss does not come without the cost of potential complications, specifically malnutrition. Therefore, the aim of this study was to determine the incidence and prevalence of these nutritional deficiencies among a predominantly Black population undergoing bariatric surgeries. We concluded that there was a high incidence of nutritional deficiencies among the black population both pre-operatively and postoperatively, for which both Vitamin D and Pre-albumin were the most common denovo and persistent deficiencies. It is our hope that this study will allow for new strategies that guarantee the success of nutritional supplementation or new strategies that help prevent nutritional deficiencies.

Phytobezoar causing SBO after RYGB: Two cases managed with laparoscopic extraction A phytobezoar is an intraluminal collection of undigested plant matter. Due to the small aperature of the pylorus, bezoars most often occur in the stomach. After gastrojejunostomy the pylorus is bypassed, with increased risk of bezoar causing SBO. Plant matter becomes impacted when the bowel caliber narrows from jejunum to ileum.

A 49 y/o female, BMI 30 with LRYGB 9 years prior, presented with 2 days of N/V and abdominal pain, which began after a heavier meal. CT demonstrated gastric remnant dilatation and . Diagnostic laparoscopy was performed. The proximal Roux limb was identified and run distally past the jejunojejunostomy. A transition point was encountered in the mid-ileum of the common channel. Gentle laparoscopic palpation revealed an obstructing intraluminal mass. To minimize spillage, atraumatic graspers were used to occlude the dilated bowel proximal to the mass and the decompressed bowel distal. A longitudinal antimesenteric enterotomy was made over the mass, and an impacted bezoar was expelled into an endocatch bag (Fig. 4) . The bezoar consisted of short fibrous pieces of food matter, which looked like coconut. Remaining small bits were also retrieved. Stay stures were placed on each side of the enterotomy and at each vertex. Using suture retraction the enterotomy was closed transversely with a laparoscopic GIA stapler. The abdomen was then irrigated, the bag removed, and the fascial defect closed. Return of bowel function occurred on POD#3, and the patient subsequently tolerated bariatric full liquids. At follow-up she endorsed consuming coconut flakes while preparing the aforementioned meal.

A 53 y/o edentulous male, with history of LRYGB 2 years prior, BMI 51 (72), presented with 1 day of nausea and abdominal pain which began at 10 pm after dinner. CT demonstrated a fluid-filled gastric remnant, and distended biliopancreatic and distal Roux limbs (Fig. 5, 6 ). The proximal common channel was also dilated with transition point at a possible bezoar (Fig. 7, 8 ). On diagnostic laparoscopy, an intraluminal mass was palpable in the common channel. A phytobezoar was extracted and removed in an endocatch bag using similar technique. The bezoar consisted of poorly-chewed green beans (Fig. 9 ). In this case the enterotomy was closed with single-layer running 3-0 vicryl. Bowel function returned on POD#1, and liquid diet was then tolerated. Upon discharge dietary instructions were provided to minimize risk of recurrence.

Impact of pre-operative obstructive sleep apnea on outcomes after bariatric surgery Stephen Stopenski, MD; Sahil Gambhir, MD; Brian R Smith, MD; F Dehkordi-Vakil; Jeffry Nahmias; Ninh T Nguyen, MD; University of California, Irvine.

Objective: The prevalence of obesity and resultant obstructive sleep apnea (OSA) in the United States continues to rise. OSA is a known risk factor for increased peri-operative morbidity following elective surgeries. Bariatric surgery with either laparoscopic Rouxen-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) are effective modalities to treat obesity and OSA. This study aims to characterize the post-operative outcomes in patients with OSA that are undergoing elective bariatric surgery. Methods: The 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MSBAQIP) database was queried for patients undergoing either LRYGB or LSG. Outcomes of patients with pre-operative OSA were compared to those without OSA. Demographic and peri-operative data were collected and compared using bivariate analysis. A multivariate model adjusted for age, gender, race, ASA class, and comorbidities was used to calculate an adjusted odds ratio (OR) for mortality, 30-day readmission, reoperation, and overall morbidity. Results: A total of 142,835 LRYGB (43.8% with OSA) and 380,928 LSG (36.2% with OSA) were performed during the study period. Patients with pre-operative OSA were significantly older, had a higher rate of being male, and higher rate of medical comorbidities relative to patients without OSA. On multivariable analysis there was no associated risk of mortality for OSA patients compared to patients without OSA undergoing either LRYGB or LSG. However, OSA patients undergoing both procedures had an associated increased risk of overall morbidity (OR 1.19, CI 1.123-1.262, p \ 0.001 for LRYGB and OR 1.201, CI 1.139-1.267, p \ 0.001 for LSG). Patients with OSA undergoing a LRYGB also had an increased associated risk of 30-day readmission (OR 1.059, CI 1.01-1.112, p = 0.02) compared to patients without OSA. Conclusion: Patients with OSA undergoing bariatric surgery had an increased associated risk of overall morbidity -emphasizing the importance in pre-operative diagnosis and counseling for these patients.

Comparison of bioimpedance analysis and computed tomography for body composition changes in Asian obese patients after bariatric surgery Ja Kyung Lee, MD; Young Suk Park, MD; Tae Jung Oh, MD; Won Jang, MD; Seoul National University Bundang Hospital.

Introduction: Assessment of body composition change after bariatric surgery is necessary for evaluating cardiometabolic risks. Computed tomography (CT) provides quantified information on body composition, but the exposure to radiation and time-consuming analysis limit its routine usage. Whether bioimpedance analysis (BIA) in obese patients provides accurate information regarding body composition has been questioned due to their difference in water composition. This study aims to analyze body composition changes before and after bariatric surgery using both CT and BIA and to compare the Results of the two modalities. Methods and procedures: This retrospective study included Korean patients with BMI C 35 or C 30 with metabolic comorbidities. All subjects received bariatric surgery and had BIA and CT evaluation before (pre-op) and 6 months after the operation (post-op). The muscle mass, fat mass, and visceral fat from BIA were compared with the skeletal muscle index (SMI) and visceral fat index (VFI) calculated from the cross-sectional area of CT at the vertebral body of the L3 spine. Percent changes of visceral fat were significantly correlated (r = 0.73, p \ 0.0001), whereas muscle percent changes were not (r = 0.02, p = 0.88). In addition, patients with higher visceral fat before surgery had greater visceral fat loss (r = 0.54, p \ 0.0001) and less muscle loss (r = -0.4, p = 0.007). Conclusion: Although BIA and CT did not demonstrate a significant correlation in muscle percent change, other parameters including muscle, fat, and visceral fat before and after surgery showed significant correlations. The visceral fat percent change was also significantly correlated between BIA and CT, and both tests showed that fat and visceral fat losses were greater than muscle loss after bariatric surgery. Our Results suggest that BIA can be a reliable tool for measuring body composition, especially for visceral fat tissue and its change, after bariatric surgery.

Sleeve gastrectomy: will we ever find consensus on technique? Objective: Sleeve gastrectomy is the most common bariatric procedure in the United States and there is considerable variation with regards to surgical technique. In 2015, the first analysis of the MBSAQIP was utilized to identify technical parameters (distance from the pylorus, bougie size, and staple line reinforcement (SLR)) that impacted outcomes of sleeve gastrectomy. It was noted further distance from pylorus, no SLR and larger bougie size led to better outcomes. Our objective was to evaluate if there were any shifts or trends in these techniques and if uniformity was gained over time. Methods: Using the MBSAQIP data registry from 2015 to 2018, data analyzed year over year for distance from the pylorus (\ 5 cm, C 5 cm), bougie size (\ 38Fr, or C 38Fr), and SLR (SLR, oversew, both, or neither). We then used a chi-squared test of association to determine if over time there were significant differences in these parameters from 2015 to 2017. Results: From 2015 to 2017, 297,220 laparoscopic sleeve gastrectomies were performed. Sleeve staple lines starting \ 5 cm from the pylorus ( Objectives: Among bariatric surgery patients, body mass index (BMI) does not fully capture the severity of obesity and it may be complicated to stratify patients at higher risk of peri-operative complications. In our study, we surveyed the MBSAQIP database to determine whether bariatric patients with metabolic syndrome (MetS) are at higher risk for peri-operative complications. Methods: MBSAQIP database was used to investigate the correlation between MetS and perioperative outcomes. All patients between 2015 and 2018, C 18 years old, who underwent primary bariatric surgery were included. Patients were excluded if they underwent NOTES or had surgery performed by gastroenterologist or interventional radiologist. MetS was defined in our study as hypertension requiring medication, hyperlipidemia, diabetes, and a BMI greater than 30. The primary outcome was perioperative mortality. Secondary outcomes included post-operative surgical site infections (SSI), conversion to open surgery, cardiovascular (CV) event, re-admissions, non-operative reintervention, and re-operation. Introduction: The mechanism of the effect of the Roux en Y gastric bypass (RNYGB) procedure on weight loss is still a matter of debate. Importance of common limb length still remains unknown. This study aimed to investigate the effect of common limb length on weight loss after RNYGB operation. Methods: 52 consecutive patients who had by-pass procedure by single surgeon, due to morbid obesity, between February 1st, 2019 and December 31st, 2019 in Marmara University Medical School Training and Research Hospital were examined. Common limb lengths (CLL) have been counted intraoperatively. Ileal Bipartition (n = 12) and redo surgery (n = 1) patients were excluded. 39 patients had Laparoscopic RNYGB operation were included. They were followed up twelve months postoperatively. Weight loss was measured by %EWL. Correlation between the weight loss and common limb length has been investigated by statistical analysis. All data were collected prospectively and analysed retrospectively. Results: Mean CLL was 282 ± 70 cm, median CLL was 280 cm (range 140-450 cm) Bivariate correlation was analysed between CLL and %EWL on the postop 3rd, 6th, 9th and 12th months. There was no significant correlation (p [ 0.05). Conclusion: Common limb length seemed not to be related to the weight loss effect of the RNYGB operation. Keywords: Roux-en-Y gastric bypass, common limb, %EWL.

How can we predict diabetes resolution after metabolic surgery? Background: Bariatric surgery was proven to be the most efficient treatment of obesity and type 2 diabetes mellitus (T2DM). Despite detailed qualification, not every patient achieve desirable outcome of T2DM remission after intervention. Recently, new scores: Individualised Metabolic Surgery (IMS), DiaRem, Ad-Dia-Rem, DiaBetter and Robert's score have been developed to predict diabetes remission after bariatric surgery. Objectives: The aim of the study was to validate and compare the performance of different models as the predictors of diabetes remission 1 year after surgical treatment. Methods: The retrospective analysis included consecutive patients with T2DM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2009 and 2017 in a single tertiary referral center and completed 1-year follow-up. The scores of five different models were calculated for each patient. Each score relationship with diabetes remission was assessed using logistic regression. Discrimination was evaluated by area under the receiver operating characteristic (AUROC) whereas calibration by Hosmer-Lemeshow test. Results: Out of 252 patients enrolled in our study 150 (59.5%) were women whereas 102 (40.5%) were men with median age 48 years. 46.83% of patients underwent SG whereas 53.17% of them had RYGB. The T2DM remission rate reached 90.5%. Median of preoperative A1c was 6.75% and preoperative BMI was 45.39 kg/m 2 , both decreased to 5.8% and 33.09 kg/m 2 respectively after 1 year. %EWL after surgery amounted to 53.4%. All IMS, DiaRem, Ad-DiaRem, DiaBetter and Robert's scores were predictive of diabetes remission in a logistic regression analysis (OR 0.97, p \ 0.0001; OR 0.83; p \ 0.0001; OR 0.80, p = 0.0001; OR 0.51, p \ 0.0001; OR 1.93, p = 0.0031, respectively). The majority of models showed acceptable discrimination power. Robert's score had poor discrimination with AUROC = 0.67 (p \ 0.0001) whereas DiaBetter presented excellent discrimination with AUROC 0.81 (p \ 0.0001). Most of scores exept IMS did not lose their goodness of fit. Conclusion: All developed scores can be used in preoperative assessment of patients before bariatric surgery. Since DiaBetter score seems to be more accurate than other scores in predicting metabolic outcomes after bariatric surgery it is more likely to be implemented into day-to-day practice. Introduction: Conflicting data exist regarding the degree to which the direct costs of robotic bariatric approaches differ from that of current laparoscopic techniques. Variability, small samples sizes, and non-transferability of costs are barriers in determining the cost-effectiveness of robotic systems. The objective of this study was to evaluate the clinical outcomes and direct costs of robotic-assisted bariatric surgery versus conventional laparoscopy, specifically primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Methods and procedures: A literature search of the MEDLINE database was performed from January 2010 to August 2020 to obtain cost estimates of bariatric procedures. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, 30-day postoperative outcomes for records between January 2015 to December 2018 were examined. Separate SG and RYGB one-to-one propensity score matched cohorts were determined using 23 independent patient characteristics: robotic-SG (R-SG) vs. laparoscopic-SG (L-SG); and robotic-RYGB (R-RYGB) vs. laparoscopic-RYGB (L-RYGB). Univariate and multivariable regression analyses were performed to evaluate clinical outcomes. Direct costs, in US dollars, attributed to length of stay (LOS), operative time (OT), and surgical supplies, were estimated from published cost data of two US bariatric centers and the Vizient clinical administrative database. These were then extrapolated to the propensity matched MBSAQIP cohorts. Probabilistic sensitivity analyses (PSA) were performed to assess impact of parameter uncertainties. Results: A total of 33,488 patients were matched to the SG cohort while 12,092 patients were matched to the RYGB cohort. R-SG had lower rates of mortality (mean difference -0.048%, P = 0.039) but had longer OT (MD ? 27.74, P \ 0.001), increased LOS (MD ? 0.055, P \ 0.001), and more serious complications (? 0.31%, P = 0.012) than L-SG. In comparison to L-RYGB, R-RYGB patients had fewer bleeds (-0.46%, P = 0.003), yet longer OT (MD ? 39.05, P \ 0.001), and higher reoperation (? 0.53%, P = 0.005), readmission (? 0.91%, P = 0.003), and reintervention (? 0.42%, P = 0.03) rates. Direct costs for R-SG and R-RYGB were estimated to be on average $236.31 to $3411.34 and $120.22 to $3479.97 more per case, respectively. Substantial variability was observed in direct cost analysis due to inconsistency in reported LOS and surgical supply costs. Conclusions: Based on our findings, neither clinical nor economic arguments support adoption of robotic approaches in bariatrics at this time. While OT were substantially longer, which may be attributed to longer set up times and unfamiliarity with robotic systems, clinical outcomes were also inferior. Additional research is thus warranted to justify the ongoing use of the robotic approaches in bariatric surgery.

Small bowel ischemia secondry to gastric pacemaker wires in a patients with lupus Gastric stimulator is a known surgical option for patients with refractory gastroparesis who do not improve with dietary modification and medications. Complications from the procedure are not common but can be life threatening, we present a case report of small bowel ischemia due to strangulation by gastric stimulator electrode.

Preoperative endoscopy in bariatric surgery: evaluation of 1000 patients Amy E Somerset, MD 1 ; David A Edelman, MD 1 ; Michael H Wood, MD 2 ; 1 Wayne State University School of Medicine; 2 Detroit Medical Center.

Introduction: Some institutions practice routine preoperative upper endoscopy on all bariatric patients though there is no definitive consensus. The aim of this study was to evaluate pathologic findings of predominantly Black patients undergoing upper endoscopy prior to bariatric surgery. Methods: This is a retrospective analysis of 1000 patients undergoing bariatric surgery at a single institution. All patients underwent at least one upper endoscopy prior to surgery. Results: A total of 1000 patients were included, of which 88.4% were female and 79.7% were Black. The mean age was 52 years with a mean BMI of 49. Seven hundred sixty-two patients underwent sleeve gastrectomy, 198 Roux-en-Y gastric bypass, and 40 underwent a form of revisional bariatric surgery. All patients underwent preoperative endoscopy. The average time from preoperative endoscopy to surgery was 181.4 days (± 166.8 days) for all patients. Seventy-five patients required an additional preoperative endoscopy. For patients with more than one preoperative endoscopy, the average time was 334.8 days (± 348.2 days) compared to 169 days (± 135.4 days) for patients with only one scope (p \ 0.001). Sixty-three patients had symptoms to prompt endoscopy independently. Hiatal hernias were present in 534 patients, with 95.8% of those identified preoperatively. Gastritis was noted in 80.2% of patients and H. pylori in 137 (13.7%) patients. Esophagitis was identified in 36.4% of patients, of which 3 (0.3%) were considered erosive esophagitis and 1 (0.1%) was Barrett's esophagitis. Esophageal leiomyoma was found in 2 patients, esophageal rings in 3, esophageal varices in 1, and an esophageal polyp in 1. Fifty-eight patients (5.8%) had ulcers and included 46 gastric, 9 duodenal, and 3 esophageal ulcers. Twenty-eight cases involved operative resection of gastric masses, with 7 of these masses being identified endoscopically. These endoscopic findings identified five benign polyps and two ectopic pancreatic tissue specimens. Preoperative endoscopy resulted in two endoscopic polypectomies (one tubular adenoma and one benign polyp) and four intentional gastric mass resections (two benign polyps, two ectopic pancreatic tissue) surgically. Ten gastrointestinal stromal tumors were identified on surgical pathology, none of which were seen endoscopically. Three patients (0.3%) had an endoscopic finding that resulted in delay or change in the surgical plan (2 erosive esophagitis, 1 Barrett's esophagus), of which two were significantly symptomatic. Conclusion: Routine preoperative upper endoscopy is a useful adjunct in identifying multiple pathologies in bariatric patients. Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is one of the principal bariatric procedures performed around the world. It allows for the reduction of around 60-70% of excess weight loss at 2 years after the procedure. However, the reproducibility of these outcomes across age groups has been controversial, especially in the extremes of age, where the safety of the intervention comes in question with our most frail patients. This study assessed a one-year percentage of excess weight loss after LRYGB comparing the different age groups operated in our center. Methods: Montefiore-MBSAQIP database for years 2014-2017 was used. Patients were included if they underwent primary RYGB. The patients age underwent analysis of normality allowing for the division of our sample in four age quartiles. A one-way Welch ANOVA test was conducted to determine if the percentage of excess weight loss (%EWL) one year after surgery was different between the 4 groups. Data are presented as mean ± standard deviation. A p-value of \ . 0.05 was considered statistically significant. We also compared the complication rates and general patient characteristics.

Results: A total of 803 patients underwent non-revisional LRYGB in the analyzed period. Mean %EWL at one year was 59.2% in the whole sample. However, when compared between groups, there was a statistically significant difference in %EWL: 61.9 vs. 59.3 vs.60 vs. 56.1. (p = 0.003). The general characteristics of our patients were equivalent between age groups. The differences in complication rates between our groups did not reach statistical significance. Conclusions:There is a difference in the percentage of excess weight loss one year after LRYGB based on the age group in our patient population. The quartile of age presenting the less %EWL was the eldest. Factors associated with less %EBL in the elder population merit further analysis to better understood. However, the outcomes of LRYGB in our eldest group proved to be acceptable in terms of safety as complication rates were equivalent to other quartiles of age.

Exploring outcomes after bariatric surgery in patients with congestive heart failure Tiffany Sinclair, DO 1 ; Kandace Kichler, MD 1 ; Joshua Parreco, MD, MPH 2 ; 1 University of Miami; 2 Florida State University.

Patients who undergo bariatric surgery often have significant medical conditions associated with obesity, such as congestive heart failure (CHF), hypertension, diabetes, and more. These medical comorbidities can contribute to morbidity and mortality rates during the index admission and the risk of readmission within 30 days. Outcomes are important for evaluating patient safety and areas for quality improvement. As CHF is considered a severe medical comorbidity for perioperative morbidity and mortality, we sought to evaluate the correlation between CHF and mortality rate during index admission as well as the risk of readmission within 30 days in patients undergoing primary bariatric surgery.

The Nationwide Readmissions Database for 2010-2014 was queried for all patients undergoing bariatric laparoscopic sleeve gastrectomy or roux en Y gastric bypass. The primary outcome was mortality during the index admission. The secondary outcomes were readmission within 30 days and readmission to a different hospital. Univariable comparison was made using chi-squared tests and the statistically significant variables were then used with multivariable logistic regression for each outcome. Results were weighted for national estimates.

There were 915,792 patients undergoing bariatric surgery in the US during the study period. Of these patients, 15,011 had congestive heart failure (CHF) during the index admission. The overall mortality rate was 0.04% (n = 368) while the mortality rate for patients with CHF was 0.29% (n = 44, p \ 0.001). After controlling for confounding factors through multivariable logistic regression, the risk of mortality during the index admission for patients with CHF was not statistically significant (OR 1.16, 95% CI 0.80-1.69, p = 0.439). The overall 30-day readmission rate was 5.13% (n = 46,936) and for patients with CHF the rate was 10.66% (n = 1,596). The regression revealed an increased risk of readmission for these patients (OR 1.51, 95% CI 1.43-1.60, p \ 0.001), however, there was no difference in risk for readmission to a different hospital (OR 1.07, 95% CI 0.94-1.21, p = 0.335).

There is no increased risk of mortality during the index admission for patients undergoing bariatric surgery who have CHF. Although having CHF did not statistically affect the mortality of bariatric surgery patients during the index admission, the readmission rate was significantly higher when compared to patients without CHF. By exploring these outcomes, future quality improvement projects could address solutions to reduce readmission rates in this specific population. Future research should target preoperative medical optimization, slightly longer index admission stays, or closer follow up appointments, all in order to potentially reduce the risk of readmission.

Improving hemostasis in sleeve gastrectomy: a randomized clinical trial comparing staplers James G Redmann, MD 1 ; Thomas E Lavin, MD 1 ; Matthew S French, MD 1 ; Toby D Broussard, MD 2 ; Maxime Lapointe-Gagner, BSc 3 ; 1 Surgical Specialists of Louisiana; 2 Weight Wise Bariatric Program; 3 McGill University.

Background: Staple line bleeding can be a major intraoperative complication during laparoscopic sleeve gastrectomy, requiring reinforcing interventions that may diminish the integrity of the staple line and put patients at risk for post-operative hemorrhage or leak. The risk of bleeding is commonly mitigated using buttressing, oversewing or fibrin glue to reinforce the staple line, however, these bleeding control methods are costly, often redundant, and may result in further complications. For this reason, it is necessary to produce a drier staple line that leads to less staple line manipulation. Objective: The primary goal of this prospective study is to assess staple line bleeding of Stapler A against Stapler B for use in laparoscopic sleeve gastrectomy. Methods: Sixty consecutive randomized laparoscopic sleeve gastrectomy procedures were performed by three surgeons; 30 sleeves using Stapler A and 30 using Stapler B. Stapler performance was measured by the incidence and degree of staple line bleeding. Images of the first firing and fundus regions were taken with the laparoscope 10 s after the final firing. Images were evaluated by a third-party blinded surgeon and given a ''bleeding score,'' a qualitative measure of intra-operative staple-line bleeding (1 = no Introduction: There are known disparities in utilization of bariatric surgery among eligible individuals, with advantages for females versus males, Caucasians versus minorities, and privately insured. We aimed to evaluate recent trends in utilization of bariatric surgery among different demographic groups in the U.S. Methods and procedures: The study population consisted of all individuals C 20 years old (yo) who underwent bariatric surgery in 2008-2017, captured by National Inpatient Sample. Trends in bariatric procedures were calculated with breakdown by gender, age group, race, and income. Denominators accounted for annual subpopulation size according to the U.S. Census projectiles and for annual subpopulation-specific prevalence of morbid obesity (MO) obtained from National Health and Nutrition Examination Surveys, 2007-2016. Results: During the time period 2008-2017, the utilization of bariatric surgery among individuals with MO increased among the 20-39 yo (0.93% to 0.95%) and C 60 yo (0.69% to 0.72%) age groups, African-American males (0.23% to 0.33%) and females (0.64% to 0.75%), and Hispanic females (0.78% to 0.90%). It decreased in males (0.67% to 0.65%) and females overall (1.34% to 1.30%), in the 40-59 yo age group (1.49% to 1.37%), and in Caucasian males (0.63% to 0.51%) and females (1.26% to 0.89%). A steady increase in volume of bariatric procedures was also noted since 2011. Populations with the fastest absolute increase in bariatric procedures were females 40-59 yo, and African-Americans of lower income. Conclusion: The interracial gap in utilization of bariatric surgery in individuals with MO substantially decreased, mainly within females. However, gender disparity persists, with a fraction of males with MO undergoing bariatrics being twice as less than that of females. Our study poses compelling trends in data to prompt further investigation of factors influencing accessibility and utilization of bariatric surgery among different demographic groups.

The impact of patient reported outcomes on loss to follow-up care after bariatric surgery Alexandra Jacobs, MS; Paige Martinez; Ellen Morrow, MD; Anna Ibele, MD; University of Utah.

Background: High rates of attrition to post-bariatric surgical care continue to be common, despite recommendations for lifetime follow up. There is little available work focusing on the etiology of attrition to post-bariatric surgical follow up. Patient reported outcomes (PROs) are metrics of patients' perceptions of their own health and have been used for their predictive value in other specialties. The relationships between PROs and loss to follow up have not yet been explored. Methods: PRO data from patients who met the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) definition of loss to follow up at one year postoperatively were reviewed and compared to data from patients who were compliant with one year follow up. Patient reported outcomes measurement information system (PROMIS) measures are routinely collected preand post-operatively at our institution using a series of validated computer-adaptive tests that assess depression, satisfaction with social roles, pain interference, and physical function. A series of univariate logistic regressions tested whether baseline PROs or change in PROs from baseline to six-months postoperatively predicted loss to follow up at one year. Results: Neither baseline PROs nor change in depression, satisfaction with social roles, pain interference, or physical function were significant predictors of loss to follow up. Similarly, demographics, Charlson Comorbidity Index, BMI, and percent excess weight loss were not significant predictors of follow up attrition. Conclusion: The PROs in this study were not significant predictors of loss to follow up at one-year post operatively. As the rate of bariatric procedures continues to increase nationally, so does the potential for late post-surgical complications. Given the potential impact of loss to follow up on adverse late post-surgical outcomes, there is a need to facilitate long-term post-surgical follow-up and more investigation is needed to identify and intervene on underlying causes of bariatric patient follow up attrition.

Concomitant hiatal hernia repair during bariatric surgery does not require increased postoperative narcotic requirements in presence of liposomal bupivacaine Russell Dolan, MD 1 ; Kimberly Schuster 2 ; Kaitlin Schuster 2 ; Julie Cao, PharmD, RPh 2 ; Christopher C Thomas, MD, MHES 1 ; David B Lautz, MD 2 ; Laura M Doyon, MD 2 ; 1 Brigham and Women's Hospital; 2 Emerson Hospital.

Background: Evidence suggests liposomal bupivacaine (LB) reduces total inpatient narcotic requirements after bariatric surgery. However, there are no data evaluating whether concurrent hiatal hernia repair (HHR) reduces the efficacy of LB in this setting. The aim of this study was to determine whether there was a reduction in LB's efficacy in reducing narcotic requirements in postoperative bariatric surgery patients with concurrent HHR. Methods: Patients undergoing primary bariatric surgery were divided into two groups, those who had not received LB, and those who had as part of an Enhanced Recovery After Surgery (ERAS) protocol. Within each group, a comparison between patients without and with concomitant HHR was made. The morphine milligram equivalent (MME) usage of each group was calculated and compared. Results: Out of a total of 247 patients, 141 underwent laparoscopic sleeve gastrectomy (LSG) and 106 underwent Roux-en-Y Gastric Bypass (RYGB). Among LSG, 43 (19 without HHR and 24 with HHR) did not receive post-operative LB compared to 98 (48 without and 50 with HHR) who did receive LB. Among RYGB, 40 (19 without HHR and 11 with HHR) did not receive post-operative LB compared to 76 (49 without HHR and 27 with HHR) who did received LB. There were no significant differences in total morphine milligram equivalent (MME) requirements between LSG patients with and without concomitant HHR either with or without LB. Similarly, there were no significant differences in total MME requirements between RYGB with and without concomitant HHR either with or without LB (Table) . Conclusion: Among patients undergoing primary bariatric surgery, there were no significant differences in post-operative morphine milligram equivalent requirements between those with or without concomitant HHR in either the presence or absence of liposomal bupivacaine. For 21 patients, the mean percentage of excess weight loss and body mass index was 77.5 ± 6% and 29.7 ± 1 at 12 months.

The resolution of diabetes mellitus, hypertension, and Obstructive sleep apnea syndrome was 70%, 57%, 75%, and 100% respectively. Conclusion: Bariatric surgery in carefully screened patients ± 65 years can be performed safely and can achieve improvement in comorbidities.

Identifying patient factors asociated with bariatric surgery program drop-out A Hardy-Henry, MD; A Jarrar, MD; N Kolozsvari; University of Ottawa.

Introduction: This study aimed to identify patient characteristics associated with bariatric surgery program drop out. Bariatric surgery is the most effective long-term treatment for obesity, improving morbidity and mortality. Numerous studies in the United States identified a lack of health insurance and socioeconomic status as significant predictors of eligible patients not undergoing bariatric surgery. Despite good outcomes and a favourable risk profile in a system that provides universal health care, only a small portion of people eligible for bariatric surgery undergo surgery in Canada. Methods and procedures: Patients who attended The Ottawa Hospital Bariatric Centre of Excellence surgical open house between June and December 2018 were reviewed retrospectively. The surgical open house is the first step in our provincial bariatric surgery program. Patient characteristics were obtained from the patient health history questionnaire. We identified whether patients underwent surgery within 18 months of the open house. Logistic regression analysis was used to compare patient characteristics of both groups. Results: Of the 252 patients that attended the open house, 100 (39.7%) did not have bariatric surgery. Patients who did not undergo surgery were more likely to be older (48 vs. 43; p = 0.0013), male (33.0% vs. 19.1%; p = 0.013), and unemployed (39.0% vs 21.1%; p = 0.002). They made less behavioral changes for weight loss (3.5 vs 5.1; p \ 0.0001) and were more likely to have a history of smoking (50.0% vs 34.3%; p = 0.0061). They also were more likely to have diabetes (38.0% vs 23.0%; p = 0.011) and overall had more obesity-related comorbidities (2.4 vs 1.8; p = 0.0015). There was trend correlating not undergoing surgery with less education, but this was not statistically significant. There were no differences in BMI (46.6 vs 47.7; P = 0.2885), goal percent total body weight loss (38.8% vs 40%; p = 0.3) or psychiatric history (58.0% vs 63.8%; p = 0.35). Conclusions: Despite having the most health benefit from bariatric surgery, patients with more obesity related comorbidities were more likely to drop out of the program. Patients who did not undergo surgery were also more likely to be older, male, unemployed, and had made less changes for weight loss prior to enrolling into the bariatric surgery program. This study suggests that despite having a well-developed and accessible bariatric surgery program in the context of universal healthcare, there are disparities in undergoing bariatric surgery. Identifying patient characteristics most associated with dropping out of a bariatric surgery program may be a step towards improving access.

Pre-operative weight loss is associated with improved 30-day mortality following elective bariatric surgery: a retrospective analysis of 548,597 MBSAQIP patients Introduction: The effects of pre-operative weight loss on bariatric surgery outcomes are still unclear, despite the practice being adopted by bariatric centers worldwide. Ongoing studies are needed for routine adoption of this practice given the multiple issues patients face with following difficult pre-operative weight loss protocols. The aim of this study was to characterize the prevalence of preoperative weight loss and evaluate its impact on outcomes following elective bariatric surgery. Methods: This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018. All primary Roux-en-Y and sleeve gastrectomy procedures were included while prior revisional surgeries and emergency surgeries were excluded. Cases were then divided into preoperative weight loss (PWL) and control cohorts. Primary outcomes included evaluating leaks, bleeds, and serious complication rates. Secondary outcomes included identifying the impact of PWL on 30-day mortality. Multivariable logistic regression modelling evaluated the influence of PWL on outcomes after adjusting for comorbidities. Results: A total of 548,597 patients were identified with the majority achieving preoperative weight loss (n = 459,500; 83.8%). The PWL cohort was older (44.8 ± 12.0 years vs. 43.2 ± 11.9 years), had a reduced body mass index (45.0 ± 7.4 vs. 46.1 ± 7.6 kg/ m 2 ), and was more likely to be male (20.3% vs. 18.7%). Patients with preoperative weight loss were more likely to have metabolic comorbidities including medication and insulin dependent diabetes (27.0% vs. 23.2%), hypertension (48.9% vs. 44.7%), dyslipidemia (24.6% vs. 21.0%), and sleep apnea (39.6% vs. 32.3%). No clinically significant differences were observed for operative length between cohorts (85.3 ± 46.9 min PWL vs. 83.9 ± 46.2 min control). Multivariable logistic regression revealed that PWL was independently associated with improved leak rates (OR 0.81; 95% CI 0.72-0.90; p \ 0.001) and improved odds of 30-day mortality (OR 0.79; 95% CI 0.63-1.0; p = 0.048). In contrast, PWL was not found to be associated with bleeds or overall serious complications after adjusting for covariates. Bivariate analysis revealed that PWL was associated with decreased mortality (0.08% vs. 0.11%) but not with differences in rates of serious complications, reoperation, reintervention, or readmission. Conclusion: Pre-operative weight loss prior to bariatric surgery is common, occurring in over 80% of elective cases. Our findings suggest that pre-operative weight loss is associated with improved 30-day leak rate and mortality, advocating for routine adoption of this practice in addition to ongoing development of tolerable pre-operative weight-loss protocols.

Magnetic grasper technology for laparoscopic gastric sleeve surgery Marcos Berry; Lionel Urrutia; Fernando Chaparro, MD; Clinica Las Condes.

Background: The present study evaluates an innovative solution through the use of magnetic devices that are coupled and mobilized by external magnetic fields through the abdominal wall. To evaluate a new magnetic surgical system during reduced-port gastric sleeve surgery (GS). Methods: This magnetic surgical system is an innovative technological platform that utilizes magnetic retraction designed to grasp and retract tissue and organs. It is composed by a grasper device with a detachable tip and a magnetic controller. Results: We operated 46 patients, 33 women and 13 men. Average age of 36 years old. (17-62) The BMI range 30-38,3 with a media of 33,4 kg/m 2 . All of them had comorbidities including insulin resistance, dyslipidemia, arterial hypertension, hypotyroidism, arthralgia, non alcoholic fatty liver disease and/or obstructive sleep apnea. The mean OR time for the GS was 1:42 h. All of them were fully performed by a reduced port technique. Reduced port means that we used 3 ports, when we generally need 4 or 5. Magnetic grasper was used to retract the stomach and the liver. Average stay of 2 days and no intraoperative or postoperative complications. Conclusions: This novel technology is safe. It allows a greater exposure in reduced port laparoscopic surgery. It is very easy to manipulate because its shape and function are equal to a regular grasper, and it can be utilized with a minimal learning curve.

Retrograde intussusception in a patient with a gastric bypass involving both the roux and biliary limbs: a case report Jejunojejunal intussusception is a rare complication of gastric bypass surgery which can present in a delayed fashion.

Our patient is a 58-year-old female with a history of laparoscopic gastric bypass performed 16 years prior at our facility where we prefer to use a ''W'' configuration for the jejunojejunal anastomosis. She presented with acute onset of abdominal pain and findings on CT concerning for intussusception. She was taken to the OR for diagnostic laparoscopy where she was found to have a retrograde intussusception at the jejunojejunostomy site. The intussusceptum was found to have traveled in a retrograde fashion up the roux limb, doubled back on itself, and then continued through the biliary limb, totaling roughly 30 cm of involved small bowel. Manual reduction of the intussusception was attempted both laparoscopically and open but was unsuccessful. We ultimately resected all of the involved small bowel and revised the jejunojejunostomy. We opened the specimen on the back table and confirmed the entirety of the intussusceptum was edematous and necrotic, which had precluded us from reducing it manually. To the best of our knowledge, this is the first reported case of retrograde intussusception of both the Roux and biliary limbs.

Small bowel intussusception is a rare condition in the adult population, but it's incidence is increasing, likely secondary to the increasing number of patients undergoing gastric bypass surgery. In adults, intussusception is typically due to a pathological lead point. In bypass patients however, the cause is unknown but theorized to be secondary to motility disorders and usually occurs in a retrograde fashion. The majority of patients present with abdominal pain, nausea, and vomiting. Physical exam is often unrevealing with nonspecific tenderness. CT may aid in diagnosis. Treatment is surgical and may involve reduction or plication, though studies show lowest recurrence rates with resection and revision of the anastomosis. This complication is rare but likely underreported and due to its nonspecific nature requires a high index of suspicion in bypass patients presenting with recurrent abdominal pain.

Single anastomosis gastric plication ileal bypass (SAGPI) Alaa Eldin Badawy, MD; Alexandria University Hospital.

Background: Overweight (BMI \ 35) and some morbid obese patients still refuse that part of their body should be removed during surgery, others also fear sleeve gastrectomy complications, mainly leakage. In our region some patients seek relatively low coast operation as gastric plication which turned to be a weak modality. Objective: The idea is to combine the relatively low coast gastric plication with single loop antral anastomosis to the ileum (Bi-partition) then observe weight loss and co-morbodities. Methods: Overweight patients and others of BMI 35-40, who refused sleeve gastrectomy or SASI and prefer relatively lower coast operation were subjected to the study knowing that it is a new reversible modality they can try. As in single anastomosis sleeve ileal bypass surgery (SASI), greater gastric curve was dissected, instead of using staplers, interrupted ethibond 2/0 round needle was used in the inner row, prolene 2/0 round in continuous mode for the second row, leaving the antrum for the single loop anastomosis 3-4 cms wide (stapled or hand sewn) that was done with the ileum 250-300 cms proximal to the cecum. Results: In one year time only fifteen patients agreed to be subjected for this new operation. Hospital stay of one day. Excess weight loss quite comparable to sleeve gastrectomy 25.45 ? 3.6 k.gm after 3 months (excess weight loss 27%), 39.53 ? 4.1 k.gm in 6 months (excess weight loss 43%) and 48.82 ? 5.7 k.gm after one year (excess weight loss 56%). No major complications or mortality, no repeated vomiting or leakage, less anemia than sleeve mean hemoglobin 10.9 ? 1.8 after one year, relatively longer operation time 172 ± 23 min. More economic than sleeve, mini-gastric bypass (MGB), or single anastomosis sleeve ileal bypass (SASI). Conclusion: Single anastomosis gastric plication ileal bypass (SAGPI), is a new promising modality that can be done for patients seeking low coast, safe, reversible and effective bariatric surgery without gastric resection. Still longer time and more patients needed to fully assess the procedure. Background: Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are the two most common weight loss operations. There is a general acceptance that weight regain can occur in patients following bariatric surgery, but there is little consensus on when this occurs, contributing factors and how to address it. The aim of this study was to identify the time at which weight regain starts after surgery in patients undergoing laparoscopic bypass or sleeve. Methods: Consecutive patients undergoing bypass or sleeve were selected from a prospectively maintained database. All patients were monitored closely by the dietetic, psychological and surgical team both pre-and post-operatively. Patients who had gastric bands and revisional procedures were excluded. BMI and Percentage Excess Weight Loss (EWL) was analysed at 3, 6, 9, 12, 18, 24 and 60 months after surgery. Statistical analysis was carried out using SPSS. Results: 119 patients were included in the study and no patients were lost to follow up. Their median age was 47.2 years (range 21.3 to 65.4) and 26.9% were male. Median baseline BMI was 51.6 (range 35.7 to 72). Baseline median excess body weight was 74.9 kg (range 28.5 to 147.4). 61 patients underwent laparoscopic gastric bypass and 58 laparoscopic sleeve gastrectomy. The median percentage EWL was maximum at 18 months overall (66.8%) and also for sleeve (61.6%) but 12 months for bypass (69.6%), as shown in Fig. 1 and Fig. 2 . Despite the trend towards weight regain overall, 33 patients (27.7%) and 19 patients (16.0%) continued to loose weight at 24 months to 60 months respectively.

Conclusion: In this cohort, maximal weight loss occurs on average at 12-18 months after surgery and patients start to regain weight by 24 months. We suggest that 12 months is the time to refocus patients and the wider bariatric team into intensive dietetic intervention, intensive psychological intervention and even further surgical intervention (particularly where sleeve is used as the first stage of a two-stage operation). The characteristics of patients who maintain or continue to loose weight at 5 years must be compared with those who regain in further studies to enable further personalisation of long term management strategies.

Do bariatric patient's in rural areas achieve comparative weight loss as national average? Single center experience in appalachia West Virginia Jenalee A Corsello, MD, MPH; Ruth P Gerola, MD; Blaine Nease, MD; Semeret Munie, MD; Mercy Babatope; Joan C. Edwards School of Medicine, Marshall University General Surgery.

Introduction: Obesity is a leading public health concern with a 50-100% increased risk of premature death, resulting in around 300,000 deaths per year. Associated comorbidities greatly impact morbidity and mortality. The United States is the leading country for obesity with more than 33% of Americans being considered obese. West Virginia has the leading rate of obesity in the nation with limited knowledge in society about long lasting impact of morbid Obesity. There is also limited support within the society for post bariatric surgery patients due to the stigma associated with it. This study aimed to evaluate if the limited societal support as well as resources for bariatric patients has an impact of the amount of weight patients are able to lose. We looked at the weight loss outcomes of a single bariatric center of excellence in Cabell county, West Virginia. Methods: This is a retrospective review of patients who underwent bariatric surgery between the years of 2015 and 2018 at Center for Surgical Weight Control and Cabell Hospital in Huntington, West Virginia. Included subjects were [ 18 year old and underwent primary minimally invasive sleeve or gastric bypass operations. We reviewed demographic information as well as post-operative weight loss outcomes of all patients. Results: There were 95 patients that underwent bariatric surgery at Center for Surgical Weight control between 2015 and 2018.Fifty patients underwent minimally invasive Vertical Sleeve Gastrectomy (VSG) and 45 underwent minimally invasive Roux-en-Y gastric bypass (RYGB). Pre-operative average BMI was 47 (range of 37-64) for VSG and 45 (range 35-63) for RYGB. Pre-operative average weight was 290 lbs (range 206-409 lbs) for VSG and 281 pounds (range 198-384 pounds) for RYGB. Post-operative average weight loss at 6 months was 70 pounds (range 24-129 lbs) for VSG and 72 pounds (range of 36-120 lbs) for RYGB. Average weight loss at 1 year was 91 lbs (range 30-221 lbs) for VSG and 100 lbs (range 43-252 lbs) for RYGB. Average weight loss at 2 years was 85 lbs (range 20-130 lbs) for VSG and 106 lbs range (62-172 lbs) for RYGB. Conclusion: Despite the limited resources post bariatric patients have in rural areas compared to urban regions, we have found similar weight loss that was noted up to two years out from surgery similar to well-known national data. This shows them importance of making bariatric surgery more accessible in rural areas as it is in urban cities.

Video based analysis to evaluate step inclusion and step order in minimally invasive Roux-En-Y gastric bypass Introduction: Video Based Analysis (VBA) offers a tool to assess the inclusion and sequence of operative steps in evaluating surgical techniques. Previously, studies of surgeon technique specifically focused on the tools utilized to perform operative steps (i.e. hand sewn vs circular stapled anastomosis). However there is minimal literature on the effect of techniques, step order and optional step choices on step times. This study aims to evaluate how VBA can assess these effects in selected sequences of Roux-en-Y Gastric Bypass (RYGB) video recordings. Methods and procedures: Videos were labeled by surgeon annotators leveraging internally developed definitions following previously published literature on the operative steps of RYGB. All recordings that did not contain the required steps of a RYGB were removed.

Step time was calculated using time points labeled in the video. ANOVA was performed on gastric pouch creation (GPC) step times when performing perigastric vs pars flacida technique entrance to the lesser sac; GPC step time when choosing to dissect the angle of His prior to GPC; jejunal division (JD) and jejuno-jejunal anastomosis (JJ) step time when performing JJ prior or after JD; and phase timing when adhesiolysis is present. Results: A total of 441 de-identified video recordings from nine different bariatric surgeons were collected, with 328 being eligible for the final analysis. When comparing pars flacida vs perigastric dissection techniques for entering the lesser sac, there was no statistically significant difference between the two groups in both GJ (557 ns 472 s, p_value = 0.13) and GPC times (370 vs 374 s, p_value = 0.9). We found performing the dissection of the angle of His provided no statistically significant difference in GPC step time (583 vs 807 s, p_value = 0.5). There was no statistically significant difference in performing JD prior to JJ vs after JJ on JJ step time (779 vs 729 s, p value = 0.07). Phase timing for groups that have adhesiolysis during the procedure was found to be not statistically different from ones that do not (2316 vs 2082s, p value = 0.4).

This study demonstrates that certain variation on techniques, step order and optional step choices do not impact step times for gastric bypass. While this is preliminary data derived from a small subset of procedures, it illustrates how this type of objective analysis can provide a useful guidance in selecting techniques and potentially eliminate variability of procedures. Background: Over 100,000 sleeve gastrectomy procedures are performed annually in the United States to achieve meaningful weight loss in morbidly obese patients with related comorbidities. Despite technological advances, postoperative bleeding and gastric staple line leak are complications of this procedure. We analyzed patient specific and perioperative factors to determine their association with these complications. Methods: We performed a retrospective cohort analysis of patients who underwent sleeve gastrectomy between 2005 to 2019 at our institution. Patient demographics, comorbidities, and procedure details including type of energy device, staple type, staple height (range 2.5 mm to 4.8 mm), staple line suturing (none, complete, selective), and staple line clipping were compared using multiple logistic regression for combined postoperative complications (blood transfusion, bleeding, and staple line leak). Postoperative bleeding was defined by requiring blood transfusion and surgical hemostasis. Staple line leak was confirmed radiographically. Results: There were 1213 patients who underwent sleeve gastrectomy. Fifty-two high-risk patients were excluded due to cirrhosis, end stage renal disease, and anticoagulation use for left ventricular assist device. Of the remaining 1161 patients, twenty-five (2.2%) received postoperative blood transfusion, nine (0.8%) had postoperative bleeding, two (0.2%) had staple line leak, and twenty-eight patients (2.4%) had combined postoperative complications. The median age was significantly higher for patients with combined postoperative complications (43 vs 49; p = 0.02). There was no difference in postoperative blood transfusion, bleeding, staple line leak, or combined postoperative complication with different energy devices (p = 0.92), staple types (p = 0.21), staple heights (p = 0.50), or staple line suturing/clipping (p = 0.95). In addition, there was no difference in bleeding when comparing staple line sewing techniques (p = 0.44). Predictably, patients with combined postoperative complications had increased length of stay (1 day vs 3 days; p \ 0.001). Conclusion: Sleeve gastrectomy procedure has tremendous variability in technique and devices used. We observed no difference in combined postoperative complications with respect to different energy devices, staple height, or over-sewing the staple line. Patient selection is crucial, as patient age and coagulopathic comorbidities were found to lead to higher combined postoperative complications.

Postoperative scheduled antiemetic regimen on length of stay in sleeve gastrectomies Barbara Nguyen, MD 1 ; Anthony Tabatabai, DO 1 ; Kensey Gosch, MS 2 ; Michael Arroyo, MD 1 ; 1 Saint Luke's Surgical Specialists; 2 Saint Luke's Health Systems.

Background: Sleeve gastrectomies have emerged as the most popular approach in bariatric surgery. Of the few possible complications after surgery, postoperative nausea and vomiting (PONV) is the most common, which can result in prolonged stay. By initiating a scheduled antiemetic regimen, a prophylactic approach to expected PONV could lead to shorter hospital stay. Methods: In December of 2018, the protocol of postoperative sleeve management at one facility by one bariatric surgeon was changed to include a scheduled dose of intravenous dexamethasone 4 mg in the morning of postoperative (POD) one, as well as scheduled sublingual hyoscyamine 0.125 mg every six hours. A retrospective review was performed from September 2017 to October 2019 of patients receiving laparoscopic sleeve gastrectomy: patients prior to initiation of scheduled medications (PRN group) and patients after (scheduled group). Patient variables, including age, body mass index (BMI) at time of surgery, and gender were included in the review. Our focus was on length of stay. Continuous variables were compared using Student's T-test. Categorical variables were compared using chi-square or Fischer's exact test. Results: There were twenty two patients in each group. Patients were comparable in gender, average age, and average BMI. Average length of stay was significantly shorter in the scheduled group at 1.1 ± 0.4 days, versus 1.9 ± 0.7 days in the PRN group (P \ 0.001). The range for the scheduled group was 1 to 2 days, whereas patients in the PRN group stayed up to three days. One patient in each group returned to the emergency department within two weeks, both for dehydration. Conclusions: In our experience, the addition of one dose of steroid and scheduled sublingual hyoscyamine demonstrated a significant decrease in hospital stay due to better PONV control. This contributes to decreased hospital costs for both the hospital and the patient, as well as a better recovery for patients. Although the number of patients in this study is small, the Results still advocate for a prophylactic approach to PONV, and we encourage others to consider utilizing our regimen for their bariatric patients.

The triangle of calot: let's have a conversation Nathan I Ozobia, MD, FACS; Retired. WHO WAS CALOT?: Jean Calot was a French physician and anatomist. He trained at the University of Paris where he was also an anatomy prosector. His mentor was Mr. Terrier, one of the first surgeons that embraced cholecystectomy after Langenbuch first performed it in 1882. Mr Terrier encouraged Calot to study hepatobiliary anatomy. This led to Calot's publication of De la Cholecystectomie which he used for his doctoral thesis and presentation to the German Surgical Congress in 1891.

Dr Calot in his presentation, described an equilateral triangle as having the following boundaries:

SUPERIORLY: The cystic artery. INFERIORLY: The cystic duct. MEDIALLY: The common hepatic duct.

The following is Calot's description translated to English from Medieval French, with no known ''original '' English translation:

''We believe useful to describe the provisions of this delicate area. The bile duct from the right edge of the omentum and the cystic duct continues about its direction. Together, these two channels describe a concave curved line, to the right and forward. A union of the two channels is to connect the hepatic duct which thus forms with the artery and cystic duct an equilateral triangle'' I believe that it is from this description that an unknown physician came up with the moniker:

The Triangle of Calot. BUT. The upper boundary was changed from the cystic artery to the undersurface of the liver.

WHAT IS THE IMPORTANCE OF THE TRIANGLE OF CALOT ? Identifying the landmarks of the triangle is one of the Critical steps to a successful and uneventful cholecystectomy.

The undersurface of the liver is where the SOUL of the liver is. This area should always be interrogated with great caution as it harbors the vital structures to the liver and injury to any of the structures there has grave consequences. If the structures in Calot's triangle are identified, and the Critical View of Safety assured, safe cholecystectomies can always be assured without venturing to the undersurface of the liver. In complicated cholecystectomies, acute or chronic, further help should always be sought.

Prolonged post-operative stay following laparoscopic cholecystectomies and its contributing factors James Lucocq; Ganesh Radhakishnan; John Scollay; Pradeep Patil; NHS Tayside.

Introduction: Laparoscopic cholecystectomy (LC) is the treatment for symptomatic gallstone disease and LCs are commonly performed as a day case with low risk of complications. Patients who undergo LCs for gallstone disease are a heterogenous population with many variables involved in their management. Our aim was to identify the proportion of patients who stay 3 days or longer post-operatively and the variables that most contribute to prolonged patient stay following LC. Methods: We retrospectively collected data for all patients who underwent either an emergency or elective LC in a tertiary hospital from 2015 to 2020. Open cholecystectomies after conversion from laparoscopic cholecystectomy and unplanned bile duct explorations were included. Patients undergoing a planned open cholecystectomy, bile duct exploration or additional intervention during cholecystectomy (e.g. liver resection) were excluded. Variables associated with prolonged post-operative stay were identified using multivariate logistic regression models (variables included age, sex, emergency versus elective, complicated operative findings, intraoperative complications, post-operative complications requiring further imaging or intervention, subtotal cholecystectomy, drain insertion and significant post-operative pain). Results: A total of 2775 patients were included between 2015 and 2020 (median age, 53 years (range 13-92); M:F, 1:2.7). Two-hundred and ninety-nine (10.8%) patients stayed at least 3 days following LC. The rate of prolonged post-operative stay (C 3 days) in emergency group was 25.8% versus 7.7% in the elective group (p \ 0.0001). Of those with prolonged post-operative stay, 46.5% had an emergency LC (OR of prolonged stay 4.7, p \ 0.0001); 58.9% had complicated operative findings (OR 10.02, p \ 0.0001); 48.8% required intra-abdominal drains (OR 6.57, p \ 0.0001); 21.4% had post-operative complications requiring further investigations or intervention during index admission (OR 4.24, p \ 0.0001) and 41.8% had significant post-operative pain (OR 25.3, p \ 0.0001). Age (years) was also associated with prolonged admission (OR 1.02, p \ 0.0001). Conclusion: The rate of prolonged post-operative stay following laparoscopic cholecystectomy is significant at 10.8%. Post-operative pain was an important contributing factor in more than 40% of these patients. Although some of the inherent risks of a complicated cholecystectomy including subtotal cholecystectomies, drain insertion and reintervention cannot be eliminated, strategies should be implemented to minimise them. Most important is patient information regarding the possibility of prolonged postoperative stay and need for reinterventions. This should be followed by the clinical aim to optimise pain relief to reduce postoperative stay and make the stay tolerable for patients who have had complicated cholecystectomies. Introduction: Peritoneal tuberculosis (PTB) is a rare disease in developed countries. It can occur following reactivation of latent tuberculosis in the peritoneum via hematogenous spread from a primary lung focus, as well as hematogenous spread in the setting of active pulmonary TB or miliary TB. As the disease progresses, the peritoneum becomes studded with tubercles. Bowel obstruction is a potential complication of PTB secondary to progressive strictures or adhesions. Case description: This is a case of a 21-year-old male who presented with 10-day history of abdominal pain, diarrhea, nausea and emesis. Prior to presentation he was treated with oral antibiotics for possible bacterial gastroenteritis. He had no past medical or surgical history nor family history of cancer or IBD. He recently emigrated to the US from China 6 months prior to presentation. Patient was having normal bowel function on the day of the presentation. In the emergency room, he was tachycardic to 125 and febrile to 39.4. His white blood cell count was 11.7 K/ mL and lactate was 2.3. On exam, abdomen was slightly distended with some tenderness to palpation on left side, without rebound or guarding. A computed tomography of the abdomen and pelvis showed high grade small bowel obstruction with possible bowel ischemia, due to possible volvulus. Patient was taken to the operating room and exploratory laparotomy revealed dilated loops of small bowel with extensive studding suspicious for intestinal Tb. He was also found to have a closed loop obstruction secondary to adhesive band which was lysed, and bowel was viable. On further inspection, the liver, entire peritoneum and small bowel mesentery had studding (Fig. 1) . Biopsies of the small bowel mesenteric lymph nodes, omentum, and peritoneum showed diffuse necrotizing and non-necrotizing epithelioid granuloma and AFB and FITE stains were positive for acid fast microorganisms. Patient had uneventful recovery post-operatively. His sputum AFB was positive, and he was treated for active pulmonary TB and PTB. Discussion: In the United States in 2017, Centers for Disease Control and Prevention reported that 5.9 percent of all extrapulmonary TB cases were peritoneal. Diagnosing PTB can be challenging. Patients can present with ascites, abdominal pain, fever or SBO. In young patients without past surgical history, extrapulmonary TB should be kept in the differential diagnosis. Care should be taken to consider TB in the setting of the patient's symptoms, comorbidities, immune-suppressing medications, recent travel and exposure history. Background: Endoscopic retrograde cholangiopancreatography (ERCP) is known to be a technically complex procedure and adverse effects are more common than in other endoscopy procedures. Abdominal compartment syndrome (ACS) is an uncommon complication of ERCP. We report a case of fulminant fatal ACS after ERCP due to large-volume ascites in a critically ill patient. Case description: A 73-year-old woman of Greenlandic origin was referred to our hospital with a history of jaundice, significant weight loss, and non-specific abdominal symptoms. Computer tomography (CT) revealed a near-hilar stricture of the biliary tree with intrahepatic cholestasis (classified as Klatskin tumor type 3A) along with ascites, peritoneal carcinomatosis, and an ovarian mass suspicious for ovarian cancer. The patient underwent a technically challenging ERCP. Unfortunately, it was not possible to decompress the stricture of the biliary tree, despite multiple attempts including endoscopic dilation and use of both plastic and metal stents. Biliary brush cytology was collected and the procedure was concluded with a follow-up plan for percutaneous biliary drainage. The patient's condition deteriorated immediately post-operatively. Urgent CT while the patient remained intubated revealed massive ascites, dilated intestinal loops, and displaced endotracheal tube with resulting atelectasis of the left lung. There were no signs of complications directly related to endoscopy. Immediate surgical decompression and intestinal desufflation through enterotomy were performed. Nearly 5 L of ascites were drained and peritoneal specimens were obtained. The patient was transferred to ICU, where her condition remained stable. Due to disseminated neoplastic changes with very poor prognosis, no further active treatment was initiated. The patient passed away shortly after. Histopathology of peritoneal specimens confirmed the diagnosis of disseminated ovarian cancer. Biliary brush cytology was negative. Conclusion: ACS is a very rare complication of ERCP. To our knowledge, only 2 other cases of ACS after ERCP have been described, both related to bile duct perforation and retroperitoneal hemorrhage. In our case, ACS was secondary to a challenging and prolonged procedure combined with massive ascites and anesthetic complications. We suggest that paracentesis should be considered prior to ERCP in patients with massive ascites.

Our approach to make a difficult cholecystectomy safer Md Sana Ullah, Professor; Adnan Bacha, Assistant Professor; Mayin Uddin Mahmud, Resident Surgeon; Southern Medical College and Hospital. Laparoscopic cholecystectomy is one of the most common laparoscopical procedures done throughout the world. Post-operative complications are still higher for laparoscopic cholecystectomy compared to open cholecystectomy. Acute cholecystitis is the most common cause for a difficult gall bladder dissection and accounts for 10% of the cholecystectomies. The aim of the study is to demonstrate a safe method for dissection of a difficult cholecystectomy laparoscopically. We are working at CSCR (Centre for specialized care and research) Chittagong, Bangladesh and are following the development of different stages of safe laparoscopic cholecystectomy as TG13/ TG18 and safe cholecystectomy program of SAGES. From February'2017 to November 2020 we have performed 151 laparoscopic cholecystectomies (Male female ratio 1:4) out of which 33 were acute cholecystitis cases among which male female ratio was about 4:3. Our percentage of acute cholecystitis is almost double of the usual. Aspiration of the gall bladder was done whenever needed. Difficult dissection of hepatocystic triangle was done by pouring water first then adapting blunt dissection, what we named as hydro-dissection. If needed clipping of cystic artery or arteries before clipping cystic duct was preferred. Usually we clip vessels near the gall bladder ascertaining it ends in gall bladder surface in such acute cases. It helps us in anatomical variations though apparently differs with the CVS but actually not because these are anatomical variations. If we failed to do total cholecystectomy, subtotal cholecystectomy was considered in such cases, by not closing the stump, putting the drain for two weeks and follow up USG sometimes before removing the drain. We didn't do any cholecystostomy for Grade III cases as a bail out procedure. We didn't use intra operative cholangiogram. Last four years we had no conversion and no major complications other than one mortality after one month of operation related to patient's comorbidities. Diabetes and elevated creatinine were most common co-morbidities. So we consider hydro-dissection and handling of artery first, if possible and cystic duct last as a safe method of doing acute cholecystitis.

(Our view will be supported by 1 or 2 videos). Abbrevations: CVS: Critical View of Safety, USG: Ultrasonography.

Surgical characteristics and associated risk factors to a complex laparoscopic cholecystectomy using the Parkland grading scale in eight hospitals in Mexico City Introduction: The altered anatomy in patients following Roux-en-Y gastric bypass (RYGB) poses a challenge to performing traditional endoscopic retrograde cholangoipancreatography (ERCP). The best approach to the treatment of bile duct stones in this group of patients remains debatable. Options such as trans-gastric (TG) and double-balloon (DB) assisted ERCP are feasible but have a variable clearance rate between 60-100%, and a morbidity rate of 20-30%. One-stop laparoscopic cholecystectomy and bile duct exploration has shown effectiveness with a bile duct clearance rate of over 95% and low morbidity (5%). In this study, we aim to evaluate the latter in the setting of patients post-RYGB. Methods: Between 2005 to 2020, we retrospectively reviewed a single surgeon's experience of laparoscopic cholecystectomy (LC) in patients following RYGB. Data was collected with regards to patient demographics, clinical presentation, pre-operative investigations, operative details, postoperative complications and length of stay.

Results: This cohort consisted of forty-six patients, 12 (26%) males and 34 (74%) females, with a median age of 49 (18-69) years. All patients had imaging of the biliary system; either MRCP pre-operatively (52%), peri-operative cholangiogram (85%) or both (41%). Choledocholithiasis was present in 22 (48%) based on biliary imaging. Of these, 6 (27%) had spontaneous clearance and 16 (73%) underwent laparoscopic bile duct exploration; 8 (50%) via a trans-cystic approach, and 8 (50%) through primary choledochotomy. Ductal clearance was achieved in all patients.

Complications occurred in 2 (4%) patients, and 90-day mortality was 0%. The median postoperative hospital stay was 1 day.

Conclusions: Pre or perioperative imaging is essential to ensure bile duct clearance at the time of cholecystectomy in post-RYGB patients. This small series does suggest that laparoscopic clearance of the CBD can be achieved with low morbidity and mortality, especially when compared to the published Results for TG or DB assisted ERCP. The one-stop laparoscopic cholecystectomy and bile duct clearance may be a preferred approach in this cohort, due to the physical barrier to ERCP that the RYGB imposes.

Characterizing the risk factors for conversion to laparoscopic subtotal cholecystectomy on humanitarian assistance missions Introduction: Limy bile syndrome, a term describing a gallbladder filled with semisolid whitish material, composed mainly of calcium carbonate. The syndrome was initially reported by Churchman in 1911. The term used now a days was first described by Volkmann in 1929. The diagnosis of the condition is made by a finding of hyperintense material filling the gallbladder on plain abdominal X-ray, CT scan or an MRI. We presenting a case report of a 40-year-old female with a limy bile syndrome.

Case presentation: A 40-year-old lady, complaining of recurrent attacks of upper abdominal pain that radiate to the back for the past month. The pain is aggravated after having a fatty meal. Attacks are associated with nausea, no changes in bowel habits or recent weight loss reported. Physical examination and laboratory investigations including Bilirubin level were within normal. CT abdomen showed a hyperintense material filling the gallbladder and few gallstones, with no signs of cholecystitis. Patient underwent an uneventful laparoscopic cholecystectomy as a day procedure. Surgical pathology reported chronic cholecystitis with no malignancy.

Discussion: The pathophysiology behind the formation of limy bile is not fully understood. Being a female, older than 40 years and ICU admission considered as risk factors. The syndrome was also reported in pediatric age group. In theory, the formation of limy bile can be due to cystic duct obstruction, lower than normal bile PH, and abnormal calcium metabolism leading to concentration of calcium in the bile forming the thick whitish semisolid material. Few articles reported limy bile syndrome in patient with hyperparathyroidism. Limy bile syndrome can be associated with gallstones or not. The thick concentrate of calcium carbonate causes cystic duct obstruction which manifest with biliary colic symptoms. It can also lead to obstructive jaundice and pancreatitis due to common bile duct obstruction. Double localization refers to the filling of both the gallbladder and the biliary tree with the limy bile. Limy bile syndrome follows the same management principles of gallstones and its complications. spontaneous disappearance of limy bile had been also reported.

Conclusion: Limy bile syndrome, is a benign findings of thickened calcium carbonate concentrate in the gallbladder. Etiology of the disease is not fully understood. It can be diagnosed using CT scan, X-ray, MRI but not an US. It has a minor clinical significance when it comes to management of the affected gallbladder. Awareness of the condition suffice further unnecessary investigations and delay in management.

Laparoscopic cholecystectomy in patients older than 90 years in a private hospital in ecuador: a case series Introduction: The rate of biliary lithiasis and its complications are higher in the elderly. Some authors describe age as the main factor that significantly increases the morbidity and mortality of patients undergoing cholecystectomy. Therefore, we aim to describe the safety of laparoscopic cholecystectomy, focusing on complications and surgical conversion rate in patients older than 90 years, in a private hospital of a developing country. Methods and procedures: This case series enrolled patients older than 90 years diagnosed with acute cholecystitis by using the Tokyo 2013 criteria. All included patients underwent laparoscopic cholecystectomy between January 2010 to December 2016 at Vozandes Hospital Quito (Quito, Ecuador). Frequencies and percentages, and mean were reported for categorical and numerical variables, respectively. Results: We included 15 patients aged between 90 and 96 years. 53.3% of patients were male. After the diagnosis, 5 (33.3%) patients had a delayed surgery (surgery performed after 7 days) due to the need for hemodynamic stabilization. Preoperative evaluation determined that 9 (60.0%) patients had ASA III. Grade II cholecystitis was found in 8 (53.3%) patients and grade III cholecystitis was found in 4 (27.7%). Conversion was performed in 2 patients (13.3%) due to impossibility of visualizing the anatomical structures and obtaining an adequate critical view of safety due to gallbladder phlegmon. There were 3 postoperative complications, 2 cases of hypovolemic shock secondary to bleeding that stopped without reoperation (13.3%) and one case of delirium (6.7%). Finally, all patients were discharged after a mean hospital stay of 7 days. Conclusion: Laparoscopic cholecystectomy seems to be a safe approach with relatively low complications and conversion rates in patients older than 90 years.

Gastroscopic cholangioscopy through accidental choledochoduodenostomy after percutaneous transhepatic cholangiography in a patient with disseminated pancreatic cancer Michael Ørting, MD 1 ; Jan M Krzak, MD 2 ; 1 Aarhus University Hospital; 2 Aabenraa Hospital.

Introduction: I malignant obstructive jaundice the golden standard is Endoscopic Retrograde Cholangiopancreatography.

(ERCP) with high technical success and fewest adverse events. When the procedure is not possible on unsuccessful alternatives include percutaneous transhepatic cholangiography (PTC), surgical bypass or Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CD). In our center PTC is first choice after ERCP. PTC is associated with a higher degree of complications than both ERCP and EUS, including cholangitis, perforation, bleeding, pneumothorax and fistulation. In this case we rapport a rare case of accidental choledochoduodenostomy which benefited til patient. Case description: 62 year old female presents with 14 days of upper abdominalia and jaundice. Ultrasound reveal double duct sign and cholecystolithiasis. CT showed a 18 mm malignant tumor of caput pancreatis. Biopsy showed adenocarcinoma. Whipples procedure was planed but peroperative the patient was non-resectable because of involvement of the inferior vena cava. ERCP was planned but unsuccessful and PTC was performed with great difficulty due to several via falsa. Finally a fully covered 10 9 100 mm SEMS was placed and patient started chemotherapy. During the next few month there were progression of the disease with pulmonary metastasis and carcinomatosis. Due to stent occlusion, vomiting and obstruction in the second part of duodenum due to tumor on CT scan, a ERCP was performed. After removing the stent a choledochoduodenostomy was visualized in bulbus duodenum in tumorous tissue. The opening was 12 mm I diameter and direct cholangiography was performed with a gastroscope to the level of the bifurcation. Using af Fusion ballon catheter we could visualize intrahepatic dilation but no obstruction. The 7 cm tumor occlution in the duodenum were handled with a 22 9 120 mm uncovered SEMS allowing passage from the choledochoduodenostomy through the SEMS. Discussion: Fistula formation after PTC is well described as biliobronchial fistula, cutaneobiliary fistula or bile-blood fistula. Duodenobiliary fistulas is also describe as a complication to cholecystolithiasis, ulcer and tumor. Our patient presumably had a PTC guidewire penetrating the pancreatic tumor and exiting the duodenal bulb, and the SEMS thereby creating a choledochoduodenostomy. This complication for PTC greatly benifited the patient by allowing excellent drainage for the bile duct and easy acces to perform future ERCP. This case rapport describes a rare and interesting case of accidental choledochoduodenal fistula as a complication to PTC demonstrating high resolution pictures from direct cholangiography using gastroscope.

The challenges of sump syndrome. A case report and literature review Sump syndrome is a rare complication of a side to side choledochoduodenostomy (CDD). After the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in 1968, choledochoduodenostomy and its complications are seldom seen. The diagnosis of sump syndrome is further befogged by the lack of characteristic clinical or laboratory findings, the inability of the patient to provide medical records of their CDD and the fact that sump syndrome only presents decades after a CDD.

In this article, we will present a case of a 39 year old female patient who presented as a case of ascending cholangitis with an initially unknown past surgical history. A detailed medical history was thoroughly taken and her previous medical reports were presented after which an ERCP was done with extraction of debris was preformed.

In a time where choledochoduodenostomy is rarely being chosen as a choice of treatment and it's complications are infrequently encountered, this case serves as a reminder that even in the ERCP era, complications of choledochoduodenostomy should still be well understood. Introduction: In our community-based practice, we observed that a large proportion of patients with chronic symptoms of gallbladder pathology and a history of Lyme disease failed to show evidence of cholelithiasis, sludge or gallbladder wall thickening on ultrasound examination. In this retrospective analysis of our 5-year experience, we aimed to determine the value of performing a HIDA scan to reach an accurate diagnosis in this patient population and we report on symptom resolution following cholecystectomy. Methods: Between June 2014 and July 2019, 61 patients (87% females, mean age 32) with a history of Lyme disease and symptoms consistent with gallbladder disease underwent laparoscopic cholecystectomy. A retrospective chart review was undertaken, and descriptive statistics were reported for all available data. McNemar's test, Chi-square, and/or Fisher's exact test were used where appropriate for cohort comparison and symptom resolution analysis with P \ 0.05 considered statistically significant. Results: Preoperatively, 84% (51/61) had normal gallbladder findings on ultrasound, while 16% showed at least one pathologic finding such as cholelithiasis (5/61, 8%), sludge (1/61, 2%), gallbladder wall thickening (3/61, 5%) and hepatobiliary ductal dilatation (2/61, 3%). On HIDA scan, 21% (13/61) had biliary dyskinesia (EF \ 38%). Reproduction of symptoms occurred in 77% (44/57) of all patients receiving cholecystokinin (CCK), and 84% (37/44) of those with a normal EF ([ 38%). Microscopic histology demonstrated presence of chronic cholecystitis in 89% (54/ 61) of resected gallbladder specimens. With a median follow-up of 17.7 months (5.3-26.1), nausea resolved in 60% (34/57), abdominal pain in 72% (39/54), vomiting in 89% (25/28), bloating in 75% (21/28), and postprandial discomfort in 96% (22/23), all P \ 0.01. Conclusions: Our study demonstrates that abdominal ultrasound is an unreliable diagnostic modality in patients with a history of Lyme disease who present with biliary symptoms. In our series, 92% of patients had absent cholelithiasis and may have been misdiagnosed or suffered delay in treatment without further investigation. Performing a HIDA scan, with attention to the reproduction of symptoms with CCK provocation, is critical in selecting patients for cholecystectomy. By following this guideline, 89% of operated patients in our series had histologic evidence of chronic cholecystitis and a large majority enjoyed durable resolution of biliary symptoms.

Non-traumatic biliary perforation: lessons for diagnosing a rare but deadly condition Matthew S Lee; Kevin M Lowe, MD, PhD; Carle Illinois College of Medicine.

Introduction: Non-traumatic biliary perforation is exceedingly rare in adults; most cases are associated with biliary obstruction. Due to its rarity, this condition is difficult to recognize. However, mortality is high without timely diagnosis and treatment. Case description: A 78-year-old female with unremarkable medical history presented with nausea, vomiting, and abdominal pain. Physical exam showed ascites, and labs indicated gallstone pancreatitis. Abdominal ultrasound showed gallstones with a non-dilated common bile duct (CBD). Hemodynamic instability developed after admission, with CT showing pneumoperitoneum. Exploratory laparotomy revealed turbid peritoneal fluid, but found no bowel perforation or bile leak. Drains were placed in each paracolic gutter, and she was admitted to the ICU.

The patient worsened on post-op day (POD) 3; bilious output was noted from the right drain. ERCP on POD5 could not stent the CBD, and again identified no bile leak. Repeat laparotomy showed necrotic bowel, which was resected. Bile was seen in the RUQ, and a perforation was identified at the confluence of the CBD and common hepatic duct. Due to tissue necrosis and the size of the defect, hepaticojejunostomy was deferred, and a T-tube placed instead. The patient continued to deteriorate, expiring after life support was withdrawn. Discussion: Though only * 100 cases of non-traumatic biliary perforation are found in the literature, the mortality is as high as 20%. The pathogenesis is hypothesized to involve increased intraductal pressure from biliary obstruction, leading to ischemia and necrosis. Like ours, many cases are associated with gallstones. The goal of treatment is to stop bile leakage and decompress the biliary tree. In most cases, repair of the biliary lesion is unfeasible, and likely unnecessary, as they are often observed to close spontaneously. Interestingly, initial laparotomy revealed no biliary defects, suggesting that bile duct rupture developed during our patient's hospital stay. This may reveal clues for earlier diagnosis. While bilious drainage was not noticed until POD3, bilirubin was present in the drain output as early as POD1. Ascitic fluid bilirubin analysis could be an early diagnostic tool when suspecting biliary damage.

Moreover, ERCP failed to identify a bile leak, suggesting this modality may not be sufficiently sensitive. Some evidence suggests that percutaneous transhepatic cholangiography, MRCP, and hepatobiliary scintigraphy may be superior for identifying bile duct injury.

Non-traumatic biliary perforation is a rare but dangerous condition. We propose ascitic fluid analysis as an early diagnostic tool, and recommend other imaging modalities to complement ERCP for confirmation.

Simultaneous gallstone Ileus and Bouveret syndrome Omkaar Jaikaran, DO; Huriye Hande Aydinli, MD; Steven P Schulberg, DO; Onaona Gurney, MD, FACS; NYU Langone Brooklyn.

The majority of patients with gallstones are asymptomatic and only 15-25% will become symptomatic after 10-15 years of follow-up. The most common complications of cholelithiasis include biliary colic, acute cholecystitis, and choledocholithiasis. Other less common complications should be kept in mind while evaluating patients with abdominal pain. Bouveret syndrome is a gastric outlet obstruction secondary to the impaction of a large gallstone within the pyloric channel or duodenum. Gallstone ileus is a rare form of small bowel obstruction(SBO) caused by an impaction of a gallstone within the lumen of the small intestine. While these conditions are well-described in the literature, they are rarely reported to occur simultaneously. Here we present a case of simultaneous gallstone ileus and Bouveret syndrome. Case report: This is an 89-year-old female with a history of dementia and remote cholecystectomy presented to our institution with abdominal pain for approximately one week. Her history was significant for progressive nausea, vomiting, and anorexia over the week prior to presentation. Labs were significant for mild leukocytosis and computed tomography of the abdomen revealed a high-grade SBO with an intraluminal structure in the distal ileum along with a 3 cm air and fluid-containing structure in the right upper quadrant contiguous with gallbladder fossa and the stomach. She underwent exploratory laparotomy which revealed a clear transition point in the distal jejunum secondary to a large palpable stone with associated serosal erosion. Our patient also, simultaneously, underwent an esophagogastroduodenoscopy revealing a large gallstone impacted in the duodenal bulb with evidence of a cholecystoduodenal fistula. She underwent small bowel resection, removal of jejunal gallstone, and lithotripsy of the duodenal gallstone and was ultimately discharged to a subacute rehab center after an uneventful recovery. Discussion: Gallstone ileus and Bouveret syndrome are rare complications of biliary pathology. The diagnosis of gallstone ileus is often delayed due to a lack of specific symptoms. The mainstay of treatment is the removal of the obstructing stone with delayed cholecystectomy and takedown of the fistula when feasible. Bouveret syndrome is managed similarly with surgery to remove the impacted stone, repair of the fistula, and cholecystectomy. For patients who are unable or unwilling to undergo surgery, options include endoscopic removal of the obstructing stone and lithotripsy of obstructing stones. We demonstrated that when patients present with both pathologies simultaneously, a combined approach allows for successful management of both entities and highlights the efficacy of collaboration between gastroenterology and surgery.

Laparoscopic-assisted and trans-gastric rendexvous in a patient with altered intestinal anatomy by Roux-en-Y bypass: a case report of institutional experience Camilo Pachón, Surgeon, MD; Paola A Roa, Gastroenterologist, MD; Adriana Mora, Surgeon, MD; Sandra Pantoja, Surgeon, MD; Sergio A Prado B, MD, MScc; Clinica de Marly.

In recent years, the management of choledolithiasis in altered bowel anatomy's patients had led the development of different approaches for realize an endoscopicretrograde cholangiopancreatography (ERCP) with the use of laparoscopic, enteroscopic or interventionist radiologic pathways (1, 2) . Exists scarce data about the management of biliary complications in patients with previous gastric bypass with gallbladder treated in single operative time, we found a case report of a woman treated with an endoscopic trans-gastric ERCP approach with a cholecystectomy at the same time with good Results (3).

We perform a case of a 34 years-old woman with medical history of RYGBP two years earlier for obesity that presented with upper abdominal pain than worse in postprandial period and vomiting, abdominal examination revealed upper right quadrant pain and positive murphy's sign, laboratory test showed normal blood count, aspartate aminotransferase 1416U/L (normal 14-36U/L), alanine aminotransferase 900U/L (\ 35U/L), total bilirubin 1,79 mg/dL (0,2-1,4 mg/dL), direct bilirubin 1,21 mg/dL (0,0-0,3 mg/dL), indirect bilirubin 0,58 mg/dL (0,0-1,1 mg/ dL), alkaline phosphatase 371U/L (38-126U/L); abdominal ultrasonography suggestive signs of cholelithiasis and cholecystitis with increased bile duct diameter (8 mm) and the magnetic nuclear cholangio-resonance showed a 6.6 mm calculi in bile duct, a laparoscopic cholecystectomy was performed, next a cholangiography was realized with a catheter through the cystic duct with detection of two calculi in common bile duct, the excluded stomach was fixed with a suture purse and an incision was made in anterior wall, a 15 mm trocar was introduced through gastrostomy and next a duodenoscopy across the trocar until reaching the papilla, the common biliary duct was selectively cannulated by a sphincterotome. The fluoroscope revealed two filling defects, the calculi were extracted with a balloon catheter, the gastrostomy was closed with mechanical suture. At the next day bilirubins descends, two days later the patient was discharged. Background: Prolonged preoperative fasting in the presence of surgical stress increases perioperative insulin resistance and can lead to considerable discomfort before surgery. Administration of oral carbohydrate beverage before surgery has been supported by growing evidence to have a beneficial effect in enhancing patient's well-being and recovery times. However, few studies have examined its role in intermediate outpatient surgical procedures. This randomized controlled study aimed to investigate the effect of preoperative carbohydrate oral (CHO) hydration on hospital length of stay (hLOS) and perioperative complications and recovery in laparoscopic cholecystectomy (LC) compared with the conventional fasting protocol.

Methods: A single-center randomized controlled study of 76 patients undergoing elective LC was conducted. The intervention group (CHO; n = 36) received 355 mL of a carbohydrate-rich beverage at least 2 h before surgery. The control group (NPO; n = 40) was fasted from midnight until surgery. Patients' hLOS was measured, and perioperative outcomes including intraoperative hypotension, preoperative and postoperative plasma glucose levels, postoperative nausea and vomiting (PONV), and postoperative pain were evaluated. The quality of postoperative recovery was assessed using the QoR-40 questionnaire within 24 h postoperatively. Results: The mean hLOS was not significantly different between the NPO group (3.7 days) and the CHO group (3.3 days; P = 0.54). With respect to perioperative outcomes between the NPO and CHO group, no significant difference was observed in the incidence of intraoperative hypotension (67.5% vs. 75%; P = 0.61), PONV (100% vs 97.2%; P = 0.47), postoperative pain rating (4.7 ± 2.75 vs. 5.4 ± 1.90; P = 0.19), and postoperative pain requiring medications (62.5% vs. 66.7%; P = 0.81) requiring medication control. Similarly, the mean score for preoperative plasma glucose (96 mg/dL vs. 104 mg/dL; P = 0.43) and postoperative plasma glucose (120 mg/dL vs. 112 mg/dL; P = 0.26) were comparable in both groups. However, preoperative CHO loading significantly reduced plasma glucose fluctuation before and after LC compared to NPO (23.5 mg/dL vs. 4 mg/dL; P = 0.01). There were no significant differences among the NPO group (172.8 ± 13.38) and the CHO group (173 ± 11.53) in terms of global QoR-40 scores (P = 94). Conclusion: Compared to conventional overnight fasting, preoperative oral administration of CHO drinks in patients undergoing outpatient elective LC did not significantly reduce hLOS nor enhance perioperative outcomes and quality of recovery.

Jeziel Karina Ordonez Juarez, MD; Victor Manuel Pinto Angulo, MD; Jose Luis Gomez Goytortua, MD; Alfredo Olvera Lujan, MD; Raul Gomez Cruz, MD; Hugo Enrique Estrada Gonzalez, MD; Hospital Juárez de México.

Background: Bile duct injury is defined as any change secondary to surgery that conditions bile leakage from the biliary tract before the duodenal papilla and Results in difficult or impossible passage of bile to the duodenum or a combination of these. 1 The incidence of the bile duct injury after cholecystectomy occurs around 0.6%, and it involves a drastic change in the lives of patients that can trigger legal implications. 2 The objective of this study is to demonstrate our experience as a third level hospital in laparoscopic approach of bile duct injury repair. Material and methods: This is a retrospective, descriptive and observational study that was developed between August 2014 and September 2019. Twenty-one patients with bile duct disruption after cholecystectomy were include.

The injuries were staged using the Strasberg classification and we recorded videos of laparoscopic Roux-and Y hepaticojejunostomy.

A side-to-side anastomosis between the left hepatic duct and a jejunal Roux loop was always used for the bile duct reconstruction.

Surgical time, hemorrhage, hospital stay, complications, mortality, oral intake, evolution and a 4-years follow up were registered. Results: Twenty-one patients were operated, the most frequent lesion that was registered was Strasberg E3 type (57.1%). The median operative time was 180 min (range 150-300 min) and bleeding 150 ml (range 50 -400 ml), the most common complication was biliary fistula in 3 patients (14%), oral intake was started in the first 72 h, one patient required reintervention (4.5%) while other patient developed stenosis (4.5%) resolved by endoscopic approach, the maximum follow-up was for four years and no mortality was recorded. Conclusions: The benefits of minimally invasive approach seems to be safe and it is important to consider that is a complex procedure that represents a great challenge for the surgical team and reflects low mortality and morbidity and impacts in a good quality of life for each patient after surgery.

Laparoscopic cholecystectomy with and without indocyanine green fluroscopy: a prospective randomised comparative study Unmed Chandak, MS; Arti S Mitra, MS; Prasad Y Bansod, MS; Government Medical college Nagpur.

Introduction: Laparoscopic Cholecystectomy is one of the most common surgical procedures carried out for the treatment of Cholelithiasis. Injury of the biliary tract, especially the common bile duct is one the feared complications that occurs intraoperatively. Indocyanine Green dye, a fluorescent dye injected intravenously is excreted in the biliary tree. Real time imaging using infra-red light enables clear visualization of the biliary tract. The outcomes of Laparoscopic Cholecystectomy with and without the use of ICG were compared. Methods: Outcomes of Laparoscopic Cholecystectomy with and without ICG were compared in a prospective comparative study. Multiple parameters, chief among them being the time taken to reach the Critical View of Safety and the rate of bile duct injury were analysed. The intraoperative and postoperative complications, rate of conversion to open surgery and overall outcomes were seen. Inclusion Criteria:

• Cases of Cholelithiasis with/without Cholecystitis (acute or chronic) • Cases of Biliary Pancreatitis • Post ERCP cases of Cholecystectomy Exclusion Criteria:

• Cases with end stage liver disease • Portal Hypertension • COPD • Cases unfit for General Anaesthesia

Results: A total of 76 patients underwent Laparoscopic Cholecystectomy, 38 with and 38 without the use of Indocyanine Green Fluoroscopy. The median time taken to reach the Critical View of Safety (CVS) was 20 min with and 28 min without ICG. The rate of bile duct injury, and therefore conversion to Open Surgery, was 2.63% in the group without ICG and none in the group with ICG. Introduction: Gallstone ileus is seen in 0.3% of cholelithiasis and less than 0.1% of Intestinal obstruction. Traditional teaching was to resuscitate and attend to the small bowel obstruction, with an enterolithotomy. Role of cholecystectomy, and repair of cholecystoduodenal fistula was selectively performed. Our patient not only had Gallstone Ileus, with acute cholecystitis and cholecystoduodenal fistula, but also concomitant choledocholithiasis. Given minimal co-morbidities all three problems were resolved with Laparoscopic enterolithotomy and fistula repair, followed by ERCP with CBD clearance. Case discussion: A 42 yr old female presented with abdominal pain, initially RUQ for 2 weeks and now diffuse with abdominal distension and vomiting. Abdomen was distended and tender with leukocytosis. CT revealed a large gallstone in the terminal ileum, with air in the gallbladder and thickened duodenum and possible stone in the CBD. She underwent laparoscopic enterotomy with stone removal and intracorporeal suture repair. Lap Chole was done and the fistula between gallbladder and duodenum was repaired with intracorporeal suturing with silk. IOC indicative of distal CBD stone, but extensive sclerosis of calot's triangle precluded Laparoscopic Common Bile Duct Exploration. She underwent ERCP the following day and CBD was cleared. Discharged on POD3 without any morbidity, and continued to do well at follow up.

Conclusion: With the present advances in perioperative care, it is possible to undertake laparoscopic approach with enterolithotomy, enterorrhaphy and also address gallbladder removal. The complexity of cases is rising, and so is our ability to diagnose and treat them. With Minimally invasive approach, the morbidity of surgery is less, and we can address the gallbladder after the stone removal, at the same time. This approach also facilitates enhanced recovery and early return to prior functional status. Multidisciplinary approach, with preoperative diagnosis by radiologic tests, and postoperative ERCP, contributed to the success of this particular procedure. Patient selection and planning is important for successful management of the conditions. We report this case and advocate for one stage approach to Gallstone Ileus. Introduction: Ten studies, representing over 2,500 patients, have found that up to 40% of patients report abdominal symptoms and pain 6-12 months after cholecystectomy. Whether these symptoms lead patients to regret their cholecystectomy has not been established. This study aimed to quantify decisional regret and examine the relationship between regret and gastrointestinal quality of life (GIQL) in patients post-cholecystectomy. Methods: We conducted a cross-sectional survey from January 2020 through May 2020 using Amazon's crowdsourcing platform, MTurk. Participants received a stipend of US $0.10 to complete a screening survey to determine gallbladder disease history and cholecystectomy status. Eligible participants ''post-cholecystectomy'' were offered a secondary survey for an additional US $2.50 which included the decision regret scale (DRS), scored from 0 ''No Regret'' to 100 ''High Regret'', and the abbreviated 10-question gastrointestinal quality of life index (GIQLI-10), scored from 0 ''Very Low'' to 40 ''High''.

Results: A total of 236 participants were survey eligible with 142 responses (97.2% of attempted). Respondents were 66.2% female with a mean age of 39 years (SD 11.9). The mean DRS score was 23.3 (SD 22.7) with 17.6% scoring as moderate/high regret. The mean GIQLI-10 score was 38.6 (SD 8.0) with 11.3% scoring as low/very low. GIQLI-10 and DRS scores were modestly correlated (r = -0. Introduction: Gallbladder dyskinesia is a common indication for laparoscopic cholecystectomy. It is a diagnosis made in those patients who have pain of biliary origin with normal imaging of the biliary tree and gallbladder. The exact pathological correlation of this phenomenon is unknown. [1] Our study investigates the pathological findings in specimens from laparoscopic cholecystectomy done for the indication of gallbladder dyskinesia. Methods and procedures: We performed a retrospective chart review of patients who underwent laparoscopic cholecystectomy at Easton Hospital from 2012 to 2018. We studied demographic variables such as age, sex, body mass index (BMI) as well as the diagnosis or indication for which laparoscopic cholecystectomy was performed. Gallbladder ejection fraction was also noted. Results: We found that most gallbladder specimens were normal on pathology. Some showed chronic inflammation and some showed cholesterolosis. When classified by ejection fraction, we found that those with normal gallbladder ejection fraction were normal in 39% of cases. Chronic inflammation was seen in 34.1% of cases. Of gallbladders with low ejection fraction, 39.5% were normal. The most common abnormality was chronic inflammation (41%). Of gallbladders with excessively high ejection fraction, 55.6% normal. Of the rest, they were equally distributed between various pathologies. Thus we see that a large number of patients who have gallbladder dyskinesia, do in retrospect, have some pathology of the gallbladder. Conclusion: Gallbladder dyskinesia is a predominantly functional phenomenon and pathological examination of the resected gallbladder specimens is often normal. [2] However, many of these patients have inflammation seen on pathological examination of the specimen and some of these patients have functional improvement with cholecystectomy. The exact correlation between pathology and functional improvement with cholecystectomy is as yet unclear and needs further study to determine who would benefit most from a cholecystectomy. [3] [4]

Transcystic laparoscopic common bile duct exploration and stricturoplasty in a patient with a Roux-en-Y gastric bypass at a rural hospital Anne Young; Clara Tan-Tam; Bassett Medical Center.

Introduction: Bariatric surgery is a known risk factor for creation of cholesterol stones. Symptomatic cholelithiasis has a reported incidence of 7% to 15% after bariatric surgery. Choledocholithiasis is estimated to occur in 5-20% of patients with gallbladder disease. Clearance of the obstruction can be achieved endoscopically or surgically. Case presentation: A 48 year old male presented with a one month history of intermittent epigastric pain. He had a past surgical history of a roux-en-y gastric bypass (RNYGB) for morbid obesity three years prior. Laboratory tests were significant for an elevated total bilirubin of 5.8 mg/dl with direct bilirubin of 4.3 mg/dl. CT scan of the abdomen showed gallbladder distention with gallstones, wall thickening, pericholecystic fluid and dilation of the common and intrahepatic bile ducts. The clinical picture was consistent with acute cholecystitis with choledocholithiasis. His anatomy was not conducive for endoscopic retrograde cholangiopancreatography (ERCP) because of his gastric bypass history. He, therefore, underwent a laparoscopic cholecystectomy with transcystic common bile duct exploration and stricturoplasty. Discussion: Exploration of the common bile duct in patients who are suspected to have choledocholithiasis can be accomplished endoscopically or surgically. The alteration of anatomy by a roux-en-y gastric bypass (RNYGB) makes it difficult to access the common bile duct endoscopically. Additionally, at a rural hospital such as ours, ERCP services are not always readily available. With the laparoscopic approach, two options include cannulation via the cystic duct or a choledochotomy. The latter option is more invasive and requires the placement of a T-tube. In patients with a previous history of RNYGB undergoing concomitant cholecystectomy, a retrospective review by Grimer et. Al showed that laparoscopic common bile duct exploration was most commonly used as it resulted in fewer invasive procedures and was more successful. Our case demonstrates that transcystic instrumentation of the common bile duct is an additional technique for management of the choledocholithiasis. Conclusion: Choledocholithiasis can be treated with a laparoscopic common bile duct exploration via a transcystic approach. This approach maintains the integrity of the common bile duct and is suited for patients who have altered anatomy preventing routine endoscopic access of the common duct. Gallstone ileus is an uncommon form of bowel obstruction that occurs when a large gallstone passes into the small bowel. This typically causes obstruction at areas of reduced caliber such as the terminal ileum. Early intervention in these patients is key as this condition can carry significant morbidity and mortality. Laparoscopy remains controversial for management especially in obese patients with most opting for an open or laparoscopic assisted technique. Here, we present a case of a 58 year old female with a BMI of 60.4 who underwent totally laparoscopic enterolithotomy using umbilical tape to control the dilated bowel and prevent spillage. This case demonstrates the efficacy of laparoscopic management of gallstone ileus in morbidly obese patients.

A study for correlation of clinical and histopathological spectrum of gall bladder disease Introduction: The gallbladder diseases are the most common gastrointestinal pathology worldwide including India. The commonest biliary pathology is gallstone disease and is a major cause of morbidity and mortality. Early carcinoma of gallbladder notoriously remains undiagnosed without histopathology as it neither produces clinical symptoms or signs nor provides any clues on ultrasound assessment. Aims and objectives: To study the clinical and histopathological spectrum in gallstone disease and to study the importance of histopathological diagnosis after every lap cholecystectomy and its correlation with clinical diagnosis.

Material and methods: The present prospective and observational study was conducted in 100 patients of documented benign gallbladder disease undergoing laparoscopic cholecystectomy.

Results: 3 cases of incidental carcinoma gallbladder were diagnosed on histopathology. Majority of cases were females with findings of multiple stones being the most common finding on ultrasound. Biliary colic was the most common presenting symptom. Chronic cholecystitis is the most common histopathological diagnosis.

Conclusion: It is concluded that routine cholecystectomy performed for a common condition like gallstone disease can result in a diverse and wide spectrum of histopathological lesions ranging from benign diagnosis to an unexpected gallbladder malignancy. No significant correlation was found between clinical and histopathological diagnosis. Therefore it obviates the need for histopathology for a confirmed diagnosis.

Intraoperative bile spillage as a risk factor for surgical site infection-a propensity score matched NSQIP analysis Introduction: The exact mechanism behind postoperative atelectasis remains uncertain, but a few reasons have been suggested, and one of those reasons is pain. In laparoscopic cholecystectomy, there is a noticeable difference in pain between patients who undergo elective procedures compared to emergent ones. Unfortunately, no previous research has been done to compare between the incidence of postoperative atelectasis in patients undergoing elective versus emergent laparoscopic cholecystectomy. Thus, this study was aimed to compare the incidence of postoperative atelectasis in patients undergoing emergent versus elective laparoscopic cholecystectomy in a large cohort of patients at a single tertiary referral hospital.

Methods: An IRB-approved retrospective chart review was performed on all patients who underwent laparoscopic cholecystectomy between January 2016-March 2017 and met the inclusion criteria. Patients who converted to open cholecystectomy or had symptoms of acute cholecystitis for more than four days were excluded. Incidence of atelectasis postoperatively in emergent versus elective laparoscopic cholecystectomy was identified, demographics of the patients, diagnosis, and outcomes were determined, and post-operative complications including atelectasis, pneumonia, infection, and coagulable state after the surgery were addressed. Frequencies and percentages were used for categorical variables, means and standard deviations were for continuous variables.

Results: In total, 839 patients underwent laparoscopic cholecystectomy, with postoperative atelectasis occurring in 26 patients (3.1%). Postoperatively, atelectasis was significantly higher in patients underwent emergent cholecystectomy compared to elective cases (P = 0.029), accounting for 4.6% of all emergent cases. Among patients who underwent non-emergent cholecystectomy, there was a significant association between length of stay and incidence of atelectasis (P = 0.01). Additionally, development of atelectasis was significantly higher in patients who were diagnosed preoperatively with cholecystitis (P = 0.015). A chi-square testing showed statistically significant association between hypertension and postoperative atelectasis (P = 0.027).

Conclusion: All in all, Postoperative atelectasis was significantly higher in patients who underwent emergent cholecystectomy compared to elective cases, this may be attributed to the pain or inflammatory process that is associated with emergent cases. A significant association between postoperative atelectasis and hypertension needs further investigation.

Clinical differences of young population underwent laparoscopic cholecystectomy Suk Won Suh Suh; Seung Eun Lee; Byung Kwan Park; College of Medicine, Chung-Ang University.

Introduction: Laparoscopic cholecystectomy (LC) in young population is relatively uncommon, despite being one of the most common surgical procedures in adults.

Although clinical characteristic of adult patients with gallbladder (GB) disease is well established, scanty information have been for youth. In the present study, we aimed to comprehensively review the young population underwent LC compared to older population. Methods: A total 2,115 patients who received LC for GB stones were retrospectively analyzed. The patients were categorized into two clinical groups according to the age of patients: (young (\ 24) group and the elder group). We compared two groups according to its clinical characteristics.

Results: In univariate analysis, significant factors between two groups were found in the concomitant of choledocholithiasis and American Society of Anesthesiologists score I/II. By multivariate analysis, the concomitant of choledocholithiasis (OR 1.152, 95% CI, 0.663 -2.001, p \ 0.001) were independent factors between young group and the elder group.

Conclusions: In our study, young population with gallstone disease had more prevalence of choledocholithiasis. Therefore, young patients with gallstone disease require special attention for choledocholithiasis.

Primary cecal diffuse large B-cell lymphoma Craig Johnson 1 ; Anthony De Gregorio 1 ; Sameer Alrefai, MD 2 ; 1 Edward Via College of Osteopathic Medicine; 2 Sentara Halifax Regional Hospital.

Introduction: Of all extra-nodal lymphoma, between 30 -50% are primary lymphomas of the gastrointestinal tract. Among colonic malignancies, evidence suggests primary colonic lymphoma occupies 0.3% of total cases. Even in the category of gastrointestinal lymphomas, colon involvement is unusual, harboring a prevalence of 3%. Of colorectal lymphomas, it is reported that the most common histological subtype is diffuse large B-cell lymphoma. Here we report a case of an 88-year old that presented to outpatient general surgery with a grossly visible right lower quadrant abdominal mass. Methods and procedures: Our patient is an 88-year-old male patient came to the office for abdominal mass, CT scan showed thickening of the cecum and right colon, colonoscopy was done showing Non-Hodgkin's Lymphoma. The patient has mild obstructive symptoms, laparoscopic right hemicolectomy with primary anastomosis was done, the patient was discharged home post-op day three. No other masses or metastasis were evident during surgery. Results: Pathology of the surgical specimen showed gross specimen was composed of a 10 9 8 x 3 cm large ulcerated pink-red to tan-white mass in the cecum that almost completely obstructed the lumen. Diagnosis revealed diffuse large B-cell lymphoma with full-thickness involving the serosa and appendix tip, without the involvement of lymph nodes. The patient was offered adjuvant chemotherapy, which he declined. Upon follow-up in the office two-years after surgery, there is no recurrence and the patient is without obstructive symptoms and with good quality of life.

Conclusions: Diffuse large B-cell lymphoma is the most common subset of primary colorectal lymphomas, a rare malignancy. At this time there are no clear guidelines for the treatment of these cases. We suggest further reporting and study of primary colorectal lymphomas with the intent to produce an algorithm to standardize treatment.

Long-term outcomes of laparoscopic low anterior rectal resection without diverting ostomy for low rectal cancer Javier Ernesto Barreras Gonzalez, PhD, MD; Jorge Gerardo Pereira, MD; Francisco Llorente, MD; Miguel Angel Martínez, PhD, MD; Rafael Torres, PhD, MD; National Center for Minimally Invasive Surgery Havana. Cuba.

Introduction: Low anterior resection with total mesorectal excision represents the gold standard for patients with low rectal cancer. Protective ileostomy or colostomy are commonly performed for low colorectal/coloanal anastomosis. There is much controversy regarding when used the diverting ostomy. The aim of this study is to analyse outcomes in our own patient population with low rectal cancer, focusing on morbidity associated without diverting ostomy and long-term outcomes. Methods and procedures: A prospective study was on 117 patients with low rectal cancer between January 2013 and August 2020 in a tertiary referral universityaffiliated center specializing in laparoscopic surgery. All resections were carried out by a team of dedicated colorectal surgery and standard protocol was used for all preand-post-operative care. All the patients underwent total mesorectal excision with colorectal/coloanal anastomosis without diverting ostomy.

Results: 117 consecutive patients (64 male, 53 female, mean age 60) underwent laparoscopic low anterior rectal resection without diverting ostomy procedure, 102 of them (87,1%) after neoadjuvant radiochemotherapy. The mean operation time was 176 min (range 90-360) and the mean estimated blood loss was 58 ml (range 10-200). The overall incidence of morbidity was 15,3% (18/117), 8,5% (10/117) of anastomotic leakage and 2,6% of mortality. The mean hospital stay was 6 days and the conversion rate of 0,9%. The recurrence rate was 7,7% (9/117), overall estimated 5-year survival was 85,6% included stage IV and 91% excluded stage IV. Conclusion: Laparoscopic low anterior rectal resection without diverting ostomy for low rectal cancer is a feasible and safe procedure. Introduction: here is no literature that mainly searched for rectal neuroendocrine tumor (rNET) using transanal minimal invasive surgery (TAMIS). We report our clinical experiences of TAMIS for rectal neuroendocrine tumors to evaluate the feasibility and safety. Methods and procedures: Between December 2010 and March 2020, the twentyfive consecutive patients with rectal neoplasma underwent the TAMIS procedure performed by single laparoscopic surgeon at the two hospitals. Of these, ten patients with rectal neuroendocrine tumors were reviewed retrospectively. The full-thickness excision down to the outer fatty tissues was completed using TAMIS technique. Clinicopathological findings, perioperative and postoperative complications were recorded.

Results: TAMIS for small rNET was successfully completed in all cases. There were seven cases with a tumor size of less than 10 mm, and three cases with a tumor size between 10 and 15 mm. Six patients underwent the primary tumor excision; the remaining four patients underwent resection for the scar after endoscopic procedure. The median surgical duration was 80.5 (53-124) minutes and the median blood loss was 1 (1-12) ml. All removed tumors in the 6 primary excisions were diagnosed as neuroendocrine tumor G1. The margins of specimens were completely free in all cases. Among the four patients after endoscopic procedure, all had no histological evidence of residual tumor. The median length of hospital stay was 7 days postoperatively. There was no post-operative mortality or severe complication. The median length of observation was 54 months. No recurrence, no local or distant metastasis and no mortality of all patients were observed. Conclusions: TAMIS is safety and feasible procedure for small rNET. Further experience and clinical trials are needed to fully define the advantages, disadvantages, and indications of TAMIS for rNET.

Patient and procedural characteristics associated with receipt of combined oral antibiotics and mechanical bowel preparation before elective colectomy Introduction: We hypothesized that both patient and procedural factors would be associated with disparities in receipt of combined preparation in patients undergoing elective colectomy. Combined administration of oral antibiotics and mechanical bowel preparation prior to elective colorectal surgery has been demonstrated to reduce the incidence of surgical site infection, anastomotic leakage, and readmission. As such, a number of surgical societies now recommend routine use of combined preparation. However, many patients still do not receive combined preparation, and the reasons for omission of combined preparation remain understudied.

Methods and procedures: The 2018 American College of Surgeons National Surgical Quality Improvement Program participant use file and targeted colectomy datasets were used to identify all patients undergoing elective colectomy. Patients diagnosed with an obstruction or ileus, assigned an ASA class 5, or with missing or unknown variable data (with the exception of race and ethnicity) were excluded. Combined preparation was designated as receipt of both preoperative oral antibiotics and mechanical bowel preparation. The associations of patient and procedural factors with receipt of combined preparation were performed using univariate analyses and forward stepwise multivariable logistic regression. After adjustment for patient and procedural factors, male sex, BMI 30-39 kg/m 2 , independent functional status, inpatient procedure class, and laparoscopic and robotic approaches were all significantly associated with receipt of combined preparation (all p \ 0.05). Asian race, hypertension, disseminated cancer, ASA class 4, and a diagnosis of inflammatory bowel disease were all significantly associated with omission of combined preparation (all p \ 0.05) ( Figure) . Conclusions: Both patient and procedural factors are associated with receipt of combined oral antibiotics and mechanical bowel preparation before elective colectomy. Implicit biases among surgeons, language or cultural barriers, and other factors may impact combined preparation administration. While these data highlight disparities in patients who received combined preparation, understanding differences in patients that are being offered combined preparation by surgeons deserves further study.

Diagnosis of diverticulitis is associated with increased risk of surgical wound dehiscence, compared to laparotomy for other intestinal indications: a cross-validated scoring system to predict patients at risk Background: Surgical Wound dehiscence (WD) is a relatively common complication associated with an increased hospital stay, morbidity, and mortality. Factors that are commonly associated with diverticulitis (e.g. impaired nutritional status, systemic inflammation, diabetes) are also known risk factors for WD. However, the risk of laparotomy WD in diverticulitis has not been established. Furthermore, risk factor-based models to identify patients with diverticulitis who are likely to develop post-laparotomy WD are unfounded. We aimed to address these limitations in the literature in a secondary data analysis.

Methods: De-identified data of patients with and without diverticulitis who have undergone open laparotomy for intestinal surgery were extracted from the CERNER database along with their age, sex, race, and BMI, presence of laparotomy wound infection, and history of diabetes and hypertension. Continuous variables were transformed into multiple overlapping categorical variables. The relative risk of WD in patients with vs. without diverticulitis was computed. The data of patients with diverticulitis was randomized into three subsets. A tenfold cross-validated elastic net model was applied on subset1 to predict WD using all available predictors using the caret package in R. A scoring system was developed and validated using subset2 and subset3, respectively. Results: Out of a sample of 37,090 patients who underwent laparotomy, 10,770/ 24,793 (30%) patients without diverticulitis, and 522/1,005 (34%) patients with diverticulitis had WD. The relative risk of WD in diverticulitis was 1.13 [1.06, 1.20] .

Scoring criteria were developed based on the predictive model (Table 1) . A score of [ 3 was determined as the best threshold to predict laparotomy WD in diverticulitis. In subset3 (i.e. testing subset), sensitivity, specificity, positive and negative predictive values of the scoring system were 79%, 40%, 37%, and 82%, respectively.

Conclusion: Diverticulitis appears to increase the risk of laparotomy WD by 13%. Underweight, age [ 70 years, hypertension, and Caucasian race emerged as risk factors for WD in laparotomy patients with diverticulitis. These risk factors and our scoring criteria should facilitate clinicians to identify at-risk patients to improve the outcomes of laparotomy in diverticulitis. Aim: To evaluate the use of Bakri balloon to prevent the resultant pelvic void after the pelvic exenteration or abdominoperineal resection or extended resections with wide pelvis, which is responsible for complications collectively termed as empty pelvis syndrome (EPS).

Methods: This is a case series of 21 successive patients undergoing open or laparoscopic, total or posterior pelvic exenteration or abdominoperineal resection or extended resections with wide pelvis for locally advanced rectal adenocarcinoma. The Bakri balloon was deployed in 21 patients and retained for variable time intervals postoperatively. Features of EPS were documented. Results: In the first patient, the Bakri balloon was completely deflated and removed on postoperative day (POD) 5, who developed subacute intestinal obstruction which resolved conservatively. In second and third patient, Bakri balloon was deflated sequentially, beginning on POD 8 and removed on POD 11. Both patients had no abdominal complaints. A postoperative CT scan of both these patients showed the small bowel loops above the pelvic inlet. The following 18 patients underwent deflation protocol similar to the second and third patient, out of which one patient had accidental unrecognised deflation of Bakri balloon and underwent exploration for intestinal obstruction on POD7. Remaining patients had uneventful recovery.

The Bakri balloon is a simple, safe and cost-effective method to reduce the complications of empty pelvis syndrome following pelvic exenteration.

Obesity is associated with a complicated episode of acute diverticulitis: a nation-wise study Najla Al Ghaithi; Daniel Marinescu; Safiya Al-Masrouri; Nancy Morin; Allison J. Pang; Carol-Ann Vasilevsky; Marylise Boutros; Jewish General Hospital.

Background: Acute diverticulitis is one of the most common emergency gastrointestinal conditions, and its incidence continues to rise in Western societies. At the same time, there is a constant rise in the incidence of obesity. Thus, it is important to understand the impact of this comorbidity on diverticulitis. There is limited data regarding the association of obesity and severity of acute diverticulitis. In this study, we aim to study the association between obesity and complicated acute diverticulitis. Methods: We obtained data from the Nationwide Inpatient Sample data from 2005-2016, for all admissions for adult patients with an acute episode of diverticulitis. Patient and disease factors, as well as co-morbidities (including hypertension, hyperlipidemia and diabetes) were detailed using ICD-9/10 codes. All elective admissions for surgery for diverticulitis were excluded, as well as patients with malignant neoplasms of the colon, carcinoids of the colon and inflammatory bowel disease. Obesity (ICD-9 278.00, ICD-10 E66.9) was the exposure of interest, while complicated diverticulitis (including obstruction, perforation, peritonitis, abscess percutaneous drain placement without a surgical procedure) was the primary outcome. Secondary outcomes included length of hospital stay (LOS) and cost of hospitalization. Crude and adjusted logistic and linear regressions were used to study the association of obesity and the outcomes of interest. Covariates for the models were chosen a priori based on clinical knowledge. Introduction: Surgeon dogma and hospital procurement contracts have long guided the selection of circular cutting (EEA) staplers in colorectal surgery. These anecdotally driven decisions behind the utilization of Ethicon or Covidien/Medtronic EEA staplers have not been evaluated by direct comparison of clinical outcomes.

Our study seeks to determine whether there is a significant difference in postoperative leak rates associated with use of the Ethicon circular stapler versus the Covidien/Medtronic EEATM circular stapler. Methods and procedures: A retrospective review was performed of all patients undergoing creation of an end-to-end left-sided colonic anastomosis using an EEA stapling device by a single surgeon from July 2012 to May 2020. Patient demographics, indication for surgery, anastomotic characteristics, and anastomotic leak were abstracted from chart review. Primary outcome of post-operative leak was defined as any clinical documentation specifying air or fluid collection surrounding the anastomosis requiring radiologic or surgical drainage. Univariate analysis was conducted using t-tests and chi-squared tests to compare the two stapler cohorts. A multivariate logistic regression analysis was used to compare patients with and without post-operative leaks to identify predictors of leak.

Results: In our single surgeon's experience, 257 patients underwent creation of an enteric end-to-end left-sided colonic anastomosis using an EEA stapling device. The Covidien/Medtronic EEATM circular stapling device was used in 82 cases and the Ethicon circular stapling device was used in 175 cases. Overall leak rate was 3.5% (n = 9). Univariate analysis revealed a greater percentage of patients with an ASA less than or equal to 2 in the Ethicon stapler cohort (60% vs. 35%, p \ 0.001), and a greater percentage of men in the Covidien cohort compared to the Ethicon cohort (71% vs. 55%, p = 0.02). There was no difference between the stapler cohorts in terms of malnutrition, diabetes, BMI, indication for surgery, anastomosis type, rates of neoadjuvant chemoradiation, or presence of a positive intraoperative air leak test (all p [ 0.05). On multivariate logistic regression, none of the variables (including stapler brand) were associated with anastomotic leak (p [ 0.05).

Conclusion: In this study, selection of circular stapling device did not impact anastomotic leak rate. However, as leak rate is typically low, a large, randomized controlled trial comparing stapler types may be the only way to confidently determine whether a true difference in stapler type exists. In the meantime, we recommend that stapler choice focus on availability, surgeon experience, ease of use, and cost efficiency.

Assessing the surgical outcomes of minimally invasive total mesorectal excision in the long term -going beyond the initial learning curve Introduction: The introduction of minimally invasive surgery in colorectal oncology created a need to train surgeons with these new techniques, and many studies in literature deal with the assessment of the learning curve of both laparoscopic and robotic surgery. The need to maintain skills and achieve acceptable outcomes in the long term is also essential. In this study, we have analyzed our initial learning curve and assessed the surgical outcomes of total mesorectal excision (TME) performed by minimally invasive surgery over the long term. Materials and methods: We performed a retrospective analysis of prospectively collected data of 726 patients who underwent TME by laparoscopy or robotic surgery over ten years. We excluded all patients who have undergone beyond TME or extended TME resections. The risk factors affecting surgical outcomes in laparoscopic and robotic surgery were ascertained. The failure probability of each surgical outcome was obtained based on data from our initial surgeries. The patient's risk scores were identified, and the un-adjusted CUSUM chart and adjusted CUSUM charts were created. The risk scores were estimated based on the multiple logistic regression model for each outcome and surgery independently. The CUSUM acceptable limits were obtained using the Markov chain procedure. All statistical analysis was done using the Cusum library from R -software.

Results: Age, pre-operative radiation (pre-op RT), sphincter preserving surgeries, and histology were seen to affect blood loss, whereas hospital stay was influenced by the type of surgery in the laparoscopy group. Pre-op RT had a significant effect on blood loss in the laparoscopy as well as the robotic group (p \ 0.0001 and p = 0.0045 respectively). Pre-op RT, age, and signet histology significantly influenced hospital stay, and low anterior resections were associated with blood loss. In laparoscopic surgery, the unadjusted and adjusted analysis showed the process was well within control. Interestingly a signal was attained in robotic surgery for unacceptable outcomes concerning blood loss and postoperative complications in unadjusted CUSUM, which disappeared in the adjusted analysis. There were deviations identified in both robotic and laparoscopy surgery after the learning process was complete; however, the deviations did not cross the limit.

Conclusion: This study emphasizes the need to assess the team's surgical performance in the long term long after conquering the learning curve. Identifying risk factors and calculating risk scores before analysis is essential to obtain accurate data on outcomes.

Joyce H Pang, MD; Sarah Popek, MD; University of New Mexico School of Medicine.

Introduction: Rectal cancer remains highly prevalent in the United States, with a projected 43,340 new diagnoses this year. 1 With increased use of neoadjuvant therapy and the increased use of minimally invasive techniques, more patients undergo sphincter preservation surgery for treatment of rectal cancer. 2 Patients who undergo a low anterior resection for the treatment of rectal cancer are at a risk of developing low anterior resection syndrome (LARS), which some studies estimate to occur in up to 80% of patients. 3 Symptoms of LARS include fecal urgency and incontinence, but also constipation and difficulty with evacuation. 3 A few small studies in Europe have demonstrated promise for the use of sacral nerve stimulation (SNS) for the treatment of fecal incontinence in LARS, but there are nearly no similar studies in the United States. 4 Here we describe a case of near complete resolution of LARS with implantation of a SNS.

Case description: A 58-year-old man underwent low anterior resection for stage III-A rectal adenocarcinoma and subsequent loop ileostomy reversal following adjuvant chemotherapy and radiation. Within one month following ileostomy reversal the patient presented to our clinic with alternating symptoms of fecal urgency, constipation, and sensation of incomplete evacuation, consistent with LARS. These symptoms had a significant impact on the quality of the patient's life and limited his ability to work. Non-operative therapy was initiated with fiber supplementation and antidiarrheals, and a course of pelvic floor physical therapy. One year after ileostomy reversal, the patient reported minimal improvement of his symptoms. He then underwent operative two-stage placement of SNS. At four-month follow-up, patient noted significant improvement in fecal urgency and frequency, but stated some continued symptoms of constipation and tenesmus. With improved management of his LARS symptoms following SNS placement, the patient has been able to return to full-time work, sleep through the night, and improve his overall quality of life. Discussion: Incidence and prevalence of LARS will continue to increase secondary to increasing use of minimally invasive techniques and more efficacious chemotherapeutic regimens for the treatment of rectal cancer. As we focus on cancer survivorship, SNS placement should be considered as a treatment for LARS. Larger scale and long-term studies need to be performed to longitudinally assess LARS symptom management with SNS.

Patients' outcome after emergent colonic surgery Background: Emergent colorectal surgery is being offered to a wide range of patients with curative or palliative intent. The complication rate after surgery is high due to nature of the diseases, the surgical procedures and patient related factors. Aim: The aim of this study was to determine short and long-term morbidity and mortality after emergent colonic surgery for benign, malignant and traumatic colonic lesions. Background: Fistula-in-ano is a debilitating condition for patients and is challenging for the surgeon to definitively manage and repair. Ligation of intersphincteric fistula tract (LIFT) has become widely accepted as a definitive repair option for patients with intersphincteric fistulas that cannot be treated with fistulotomy. Current literature reports a wide range of success as defined by complete closure of fistula (44-94%) with as many as 60% requiring multiple surgical interventions. We present here a series of patients in which we have modified the traditional LIFT procedure to include an intersphincteric interposition bioprosthetic mesh as an innovative method to improve outcomes and decrease fistula recurrence. Prospective data on a series of patients at the University of Tennessee Medical Center in Knoxville (UTMCK) were collected to evaluate the effectiveness of LIFT with interposition biologic mesh. Preliminary descriptive data and surgical outcomes are established from this database.

Methods: For this study we reviewed the charts of all patients who underwent the procedure from 2012 to 2020. Patients with inflammatory conditions (Crohn's, e.g.) and patients with complicated, branching anal fistulas were excluded. The primary endpoint was successful healing of the fistula without subsequent interventions after the LIFT with mesh placement. The secondary endpoint evaluated was the development of fecal incontinence and post-operative recurrence of fistula.

Preliminary results: Our preliminary dataset includes 14 men and 16 women. The mean age was 48 years. Of these, 77% had complete healing of the fistula; 23 had successful fistula closure with the two stage procedure alone, and 7 required additional operation with simple fistulotomy. No patients developed fecal incontinence.

No patients developed recurrent fistula tracts. Discussion: In the accepted literature the rate of successful fistula treatment with LIFT ranges from 44 -94% based on institution. The rate of recurrent fistula development after LIFT is reported as high as 15%. Based on our preliminary findings, our experience suggests LIFT with the addition of interposition biologic mesh has good success rate and improved rate of fistula recurrence post-operatively.

Incidence of perioperative hyperglycemia in colorectal surgery patients in ERAS protocol Conclusion: This study is limited by the small patient numbers but reveals the incidence of hyperglycemia in patients undergoing robotic colorectal surgery in an ERAS protocol is underestimated in non-diabetic patients. These Results suggest that it is safe to treat non-diabetic patients with perioperative hyperglycemia with sliding scale insulin without risk for clinically significant hypoglycemia. The final Conclusion suggests utilizing 7AM blood sugars as a marker for perioperative hyperglycemia may fail to identify over 50% of patients with hyperglycemia. The impact of treating hyperglycemia in non-diabetic patients on surgical outcomes in this population will require further evaluation. In managing low-rectal anastomosis leak, an open surgery approach for complications may deepen the problems a patient may experience during hospitalization. This is a case of a 41-year-old male, who underwent laparoscopic exploration, sigmoidectomy and hartmann's procedure for a ruptured diverticuli with peritonitis. The patient improved and discharged, was subsequently advised for laparoscopic reversal of hartmann's procedure. The patient was planned to undergo for an elective laparoscopic reversal of hartmann's procedure to which he tolerated and the surgery was uneventful. On the post-operative period, there were some episodes on tachycardia, fever and hematochezia during the early days, but gradually improved until discharge on day 5 with antibiotics. The closed-suction drain applied during surgery was maintained even after discharge. After six days, the patient sought ER consult and was admitted due to weakness, abdominal pain, fever and purulent discharge in the drain. The patient was diagnosed with localized peritonitis secondary to anastomotic leak. The patient was managed with intravenous fluid and antibiotics; and diagnostic imaging studies were requested which revealed abscess localization in the pelvic area. The drain was continued to be monitored and the decision for an open surgery was entertained. The patient partially improved but was still experiencing symptoms of an intraabdominal infection. The surgical team, intesively discussed the case with patient and presented all viable options for treatment. The team arrived at a decision to maintain the drain and perform colonoscopy with the intent of diagnosing the anastomotic leak, with the likelihood of placing a Self Expanding Metallic Stent with OVESCO clip application. Intraoperatively, there was a defect on approximately 30% of the entirety of the anastomosis. OVESCO clips were applied at the ends of the defect meeting at the midline but was not fully covered due to increased tension. The Self Expanding Metallic Stent was then applied and the drain was maintained. Post-operatively, the patient was monitored everyday with plain abdominal radiographic study, and on the second day, there was note of stent migration. The patient was again advised for an emergency endoscopic procedure with the intent of replacing the previously inserted SEMS with a more longer stent. After the procedure, the patient showed promising signs of treatment with no signs of stent migration and was improved. In Conclusion, identifying the critical role and window period of endoscopic management for anastomotic leak provides a safer approach in avoidance of significant patient morbidity and mortality.

Investigating the relationship between surgical approach and length of stay in elective colorectal surgery Post-operative ileus is common following colorectal surgery. It is a significant contributor to prolonged length of stay (LOS), and to morbidity and increased healthcare costs. The benefit of laparoscopic surgery in reducing rates of ileus and, ultimately, LOS has been well documented. The anti-inflammatory environment created by CO2 insufflation has been proposed to play a role in this. If the process of CO2 insufflation is intrinsically beneficial, we would expect the advantage to be conferred not only to laparoscopic operations, but also to converted procedures. Introduction: Midgut volvulus due to congenital intestinal malrotation classically presents in the neonatal period. Presentation in adulthood but has been reported, but is rare. We present a case of adult midgut volvulus with occult congenital malrotation, prompted by torsion of a massively distended colon due to Crohn's stricture causing chronic colonic obstruction. Case description: A 47-year-old woman with Crohn's colitis with a sigmoid stricture and progressive dilatation of her proximal colon presented to an outside hospital with retching, epigastric abdominal pain, and intolerance of oral intake. Computed tomography (CT) scan demonstrated massive gastric and duodenal dilation, with reversal of the normal relationship of the greater and lesser curvatures suggestive of organoaxial volvulus. There was one transition point in the distal duodenum, which did not cross the midline, as well as massive colonic distention proximal to the sigmoid stricture,with a large fecaloma measuring 18 9 13 9 7cm ( Fig. 1) . She was treated with nasogastric decompression, which resulted in spontaneous reduction of the volvulus and decompression of the stomach. EGD demonstrated duodenal mucosal atrophy associated with dilation of the bowel. Flexible sigmoidoscopy demonstrated a sigmoid ulcerated stricture. She was ultimately taken to the operating room and found to have a sigmoid stricture with associated fistula to the ascending colon. She had evidence of congenital malrotation and malfixation of the intestine with the majority of her colon on the right side of her abdomen and the majority of her small bowel on the left side of her abdomen covered in a congenital cocoon of peritoneum. There was a congenital defect in the left colon mesentery through which the ileum traversed to join the cecum. She underwent total abdominal colectomy with ileorectal anastomosis (Fig. 2) and fixation of the small bowel mesentery to the retroperitoneum. She had an uncomplicated recovery, was discharged home on postoperative day 4, and was doing well at last follow up.

Discussion: It appears that midgut volvulus in this case was prompted by rotation of the massively distended and heavy colon proximal to the sigmoid Crohn's stricture, which prompted complete volvulus in a patient with occult congenital malrotation. Total abdominal colectomy and fixation of the mesentery addressed both problems simultaneously.

Survival outcomes in patients with complete response after neoadjuvant chemoradiotherapy for locally advance rectal cancer Introduction: Ingestion of fish hook during eating is rare to cause acute supportive appendicitis.

Case: A 71 years old male, known case of ischemic heart disease complained of mild lower abdominal pain colicky pain for more than 8 days. The patient has not complained of anorexia, nausea, or fever. He had diarrhea for a few days then stopped spontaneously. The examination showed mild tender in the right iliac fossa area without any guarding or rigidity.patient had mild leucocytosis. An abdominal CT scan was done and showed acute supportive appendicitis with faecolith without abscess, phlegmon, or mass. He had an open appendectomy due to he has ischemic heart disease which cannot do laparoscopic surgery. We found the appendix tip mass like with fish hook inside this mass with minimal perforation found and few amounts of pus. After operation recovery patient doing well and discharged after 2 days postadmission.The histopathology showed supportive appendicitis and there was no malignancy.

Discussion: Ingestion of a foreign body is common and can cause acute appendicitis. Fishbones ingestion is the most foreign body ingestion. Almost of ingested objects are impacted in the cricopharyngeal area but more common to pass the gastroenterology tract without impaction or perforation. Other common sites of impaction in the terminal ileum, duodenum, caecum, and appendix. Sharp objects like pins or fish bones mostly case perforations. The peristaltic movement of the bowel pushed the ingested object from the small bowel to the caecum then to the appendiceal lumen. Careless eater like children, older poor vision, and mental disorders patients are likely to have acute appendicitis related to the ingestion of foreign bodies. Our patient developed symptoms after 8 days from ingestion and literature reported the symptoms appeared between 3-16 days post-ingestion. Foreign body ingestion most likely did not appear in the abdominal ct scan and showed no specific findings. In our case, the radiologist cannot differentiate between fish hook and faecolith. The appendectomy is the only curable of fishbone appendicitis. Conclusion: Fish hook ingestion is rare but can cause impaction, perforation, or acute appendicitis. Abdominal CT scan findings almost is not specific.

Mortality after colorectal surgery in veterans This case illustrates the utility of a combined endoscopic and laparoscopic approach for a rare cause of colocolic intussusception. Case report: A healthy 42-year-old male presented to the emergency room with a one-month history of intermittent constipation, ''colicky'' left lower quadrant pain and occasional bright red blood per rectum. He was hemodynamically stable with a distended, mildly tender abdomen. A CT scan confirmed a colocolic intussusception with a moderately sized (3 9 3.2 9 3.6) benign appearing soft tissue mass as a lead point in the descending colon ( Fig. 1) . A colonoscopy was performed the same day with reduction of the intussusception caused by a broad-based submucosal tumor (Fig. 2) . A limited laparoscopic left hemicolectomy was subsequently performed (Fig. 3 ). There were no complications and the patient was discharged on postop day 3. Final pathology demonstrated a submucosal lipoma measuring 3.2 X 3.0 X 1.8 cm.

The above case is unusual in many ways. Firstly, lipomas causing a colocolonic intussusception tend to occur in either the right colon or cecum, not the left colon. They also tend to occur in older patients and cause symptoms only if larger than 4 cm. Further, reduction of the intussusception with a colonoscope has been rarely reported. There is only one case report of an attempted colonoscopic reduction of a sigmoid lipoma which was unsuccessful. Early reduction of a left sided lesion is helpful as it allows for an elective procedure and minimizes the chances of an ostomy. While endoscopic resection of large lipomas has been described, this was not attempted given the uncertainty of the diagnosis and the broad base of the tumor.

In summary, we present a rare case of colocolonic intussusception secondary to lipoma. Endoscopic reduction should be considered followed by either endoscopic or surgical resection of symptomatic lipomas. Fig. 1 Sagittal view of the intussusception at the proximal sigmoid colon Introduction: The goal of this study was to evaluate the relationship between time from radiation completion to surgery and conversion from minimally invasive surgery (MIS) to open, case length, and estimated blood loss (EBL). Increasing adoption of total neoadjuvant therapy (TNT) prolongs the time between radiation completion and surgery. It is currently unknown whether prolonging this window increases pelvic fibrosis, leading to greater surgical complexity. This might increase rates of conversion from MIS to open, case length, or EBL. Methods: A retrospective chart review was conducted. Patients were included if they underwent an MIS procedure for rectal cancer at our institution between July 2012 and July 2020. Records were screened for patient characteristics, dates of radiation completion and surgery, and planned surgical approach. Patients who received radiation were grouped into tertiles based on time from radiation completion to surgery. A fourth group of patients who were not radiated was included for comparison. Primary endpoints were conversion from MIS to open, case length, and EBL. Descriptive statistics were performed, and significance was assessed using chi squared and ANOVA. Results: We identified 161 patients who met inclusion criteria. Of those, 83 were men (51.6%), with mean age of 57.40, 73 (45.3%) had low rectal tumors, 60 had a BMI [ 30 (37.3%), and 11 (6.8%) had clinical T4 tumors. There were 47 patients who did not receive radiation, 34 who had surgery within 0-56 days from radiation completion, 62 within 57-84 days, and 18 after 87 days. Surgery was planned laparoscopically in 115 cases (71.4%) and robotically for 46 (28.57%). In total, 38 cases (23.6%) were converted to open, of which 28 (24.36%) were laparoscopic and 10 (21.7%) were robotic. There was no significant association between time from radiation completion and conversion to open (p = 0.994), (Fig. 1 ). There was no association between time from radiation completion and case length in analysis of all MIS cases (p = 0.821), only laparoscopic cases (p = 0.137), or only robotic cases (p = 0.265). We found no association between time from radiation completion and EBL for MIS, laparoscopic, or robotic cases (p = 0.09, 0.197, and 0.877, respectively). Conclusion: Increasing adoption of TNT lengthens the time interval between radiation and proctectomy for locally advanced rectal cancer. We found no association between longer time from radiation completion and successful minimally invasive surgery. While other factors may contribute to the surgical decision-making process, our study suggests that TNT is a safe approach for surgically resectable rectal cancer.

Poorly differentiated T3N1M0 gastrointestinal stroma tumor from ascending colon, a case report We present the case of a 57-year-old male patient treated at a high speciality medical unit in Mexico City, in whom a suggestive evolution of tumor activity was detected. The objective of this works is to present the diagnosis approach and the laparoscopic and the laparoscopic approach treatment of an histological type of infrequent neoplasia at the colonic level.

The patient had a significant personal history of intense alcoholism and smoking, without any previous disease; he told us that in the family history his daughter had suffered from thyroid cancer. He began his condition two ears ago upon admission to our hospital with silent pain in the lowe abdomen, with an increase in intensity six months ago, fifteen days before he had a episode of hematochezia, he went to a medical doctor who indicated to perfomr a colonoscopy where it was identified tumor activity as regards third level oncology unit; the histopathological report of the endoscopic sampling revealed a tumor in the ascending colon 100 cm from the anal margin and 5 cm from the cecum, 5 cm in diameter with irregular borders and a normal mucosa pattern, at his evaluation we decided the immediate admission due to risk of intestinal occlusion for surgical treatment, upon admission with carcinoembryonic antigen of 1.55 ng/ml. A laparoscopic right hemicolectomy was performed, finding a tumor 5 cm from the hepatic flexure, occlusion of 80% of the colonic lumen, multiple lymphadenopathies in the transverse mesocolon, no evidence of tumor activity in the liver, peritoneum and the other gastrointestinal structures. Ileotransverse anastomosis was performed with a mechanical stapler with a 60-mm cartridge. The patient evolved favorably and was discharged home, thre was a pathology result seven days later with a report of a 55 9 55 mm unifocal and mesenchymal gastrointestinal stroma tumor with 46 mitoses in 50 fields with tumor activity in 50 of 50 lymph nodes, histological grade G2, with tumor-free resection margins; he was sent for evaluation by medical oncology and adjuvant therapy with chemotherapy and radiotherapy was started, currently the patient has disease-free survival.

The utility of total parenteral nutrition on a modern-day colorectal surgery service Introduction: Total parenteral nutrition (TPN) is often used as a supplement for patients with poor nutritional status or the inability to eat for extended periods of time. Often, TPN is used in a hospital setting as a bridge to surgery, to supplement or augment a patient's nutrition, or to allow a patient to have a better nutritional status for their future treatment. However, recent reports on the use of TPN specifically in patients admitted to a colorectal surgery service remain sparse. Given this sparsity of reports as well as recent advancements in perioperative management, we aim to look at the use of TPN on our colorectal surgery service. Methods: This is a retrospective review of patients admitted under the care of four colon and rectal surgeons at a large tertiary care center between July 2017 and July 2020. Results: We identified a total of 72 consecutive patients in our cohort. Almost half of the patients were female (35; 49%). The mean age was 55.4 years. The majority of patients were White (45; 62.5%), with 14% Black, 6% Asian-Indian, and 15% other. The most common admission diagnoses were inflammatory bowel disease (11; 15%), Small bowel obstruction (11; 15%) colon cancer (9; 12.5%) and fistula (9; 12.5%). The most common reasons for use of TPN were NPO status of the patient (31; 43%), nutritional optimization prior to surgery (18; 25%), and the patient met criteria for malnutrition (16; 22%). The mean albumin was 3.2 and the mean prealbumin was 12.6. Conclusions: An optimal supply of nutrients can help improve intestinal permeability, bowel motility, reduce inflammatory mediators, improve wound healing, and improve overall nutritional status. Although TPN must be infused via a central line, which may have some added morbidity, we believe that TPN is helpful as a supplement for patients who ultimately have been deemed to have poor nutritional status, a supplement for patients who are NPO for an extended period of time, and for nutritional optimization prior to surgery.

Open verus minimally invasive segmental colectomy for Crohn's colitis: A NSQIP retrospective review and analysis Michael L Horsey, MD 1 ; Richard Amdur, PhD 2 ; Matthew Ng, MD 3 ; Vincent Obias 3 ; 1 Walter Reed National Military Medical Center; 2 George Washington University Medical Faculty Associates; 3 George Washington University Department of Colon and Rectal Surgery.

Introduction: Operative management of colonic Crohn's disease depends on the extent of the disease process. For short segments of disease, a segmental colectomy is an appropriate management option. The primary aim of this study was to analyze and compare short-term outcomes of open and minimally-invasive surgical (MIS) approaches for partial colectomy for Crohn's disease limited to the colon using the targeted colectomy National Surgical Quality Improvement Program (NSQIP) database. Methods and procedures: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy data was queried for patients diagnosed with Crohn's disease or complications related to Crohn's disease who underwent segmental colectomy utilizing open or minimally-invasive (to include laparoscopic and robot-assisted) approaches between 2012 and 2018. Patients with ascites, disseminated cancer, pre-operative sepsis, ASA class 5, and patients requiring mechanical ventilation were excluded. Preoperative, intraoperative, and 30-day postoperative outcomes were compared between the groups using both univeariable analysis and multivariate logistical regression models, adjusting for pre-operative variables associated with procedure. SAS was used for data analysis with p \ 0.05 considered significant. Results: After exclusions, there were 528 patients with colonic Crohn's disease who underwent partial colectomy, 157 of whom underwent open surgery and 354 of whom underwent MIS. The mean age of patients was 43 ± 15, and mean BMI was 26. 55% of patients were female. Patients who underwent the open approach were much more likely to have undergone emergency surgery than those who underwent MIS (p = 0.0074). After adjusting for possible confounders with multivariable analysis, patients who underwent open surgery had a higher incidence of wound events (surgical site infection and dehiscence) (p = 0.03) and prolonged postoperative ileus (p = 0.008). Hospital length of stay was also significantly shorter in the MIS cohort compared to open (12.2 days vs. 15 days; p \ 0.0001). The rate of anastomotic leak was not significantly different comparing open and MIS approaches (p = 0.82).

Conclusions: This retrospective review of NSQIP demonstrates that minimallyinvasive partial colectomy is associated with equivalent or improved morbidity and shorter hospital stay than open surgery. Additional studies are needed to determine long-term outcomes of this approach. Introduction: Intussusception is a rare cause of intestinal obstruction in adults and only accounts for 1-5% of all mechanical small bowel obstructions. Intussusception is typically due to pathologic lead point within the bowel, which in adults is malignant in more than half the cases. The lead point is pulled forward by bowel peristalsis and causes telescoping of the affected bowel segment into another segment. Case description: This is a 26-year-old female who presented with 1-day history of abdominal pain. Her last bowel movement was the day of presentation and was passing flatus. Her past medical history was significant for asthma, and surgical history was significant for exploratory laparotomy and small bowel resection for intussusception secondary to hamartomatous polyps 9 years prior to presentation at an outside hospital. Her genetic testing was negative at that time for any syndromic polyposis disorders. In the emergency room her vital signs were within normal limits. Her white blood cell count was 13 K/mL and lactate was 1.2. On exam, a transverse scar in right lower quadrant was seen. Abdomen was tender to palpation in left lower quadrant without rebound or guarding. A computed tomography of the abdomen and pelvis showed proximal small bowel intussusception with apparent soft tissue mass as lead point with developing upstream small bowel obstruction. Patient was taken to the operating room and exploratory laparotomy confirmed the intussuscepted bowel into the previous jejunojejunal anastomosis and revealed several tethered intraluminal polyps at the lead point(Image 1-2). The remainder of the small bowel and colon were fairly unremarkable with no other polyps palpated and mesentery appeared normal with some slight lymphadenopathy. Small bowel resection including previous anastomosis was carried out with side-to-side stapled small bowel anastomosis. Patient had uneventful recovery post-operatively. Pathology showed Peutz-Jegher type hamartomatous polyps. Patient is currently under gastroenterological and genetic re-evaluation to exclude the diagnosis of Peutz-Jeghers syndrome. Discussion: Recurrent intussusception in adults is uncommon, and unlike in children, most often the etiology can be identified and treated with definitive surgery. To our knowledge this is the first report on recurrent hamartomatous polyps complicated by intussusception requiring surgical resection twice. Adult patients with intussusception often present with nonspecific symptoms including acute or chronic abdominal pain, nausea, constipation, and fever which can pose a challenge in diagnosis. Ultrasound or computed tomography might be useful for diagnosis.

Intracorporeal vs extracorporeal anastomosis: effect on 30-day readmission after minimally invasive right hemicolectomy Kristen Coleman, DO; Caroline Couch, MD; Angela N Fellner, PhD; Hamza Guend, MD; TriHealth.

Objective: The goal of this study was to evaluate the effects of anastomotic technique during elective, minimally invasive right hemicolectomy (RHC) on 30-day readmission and emergency department visits. As minimally invasive approaches to RHC are becoming the standard, exploring the potential benefits of intracorporeal (IC) vs extracorporeal (EC) anastomosis creation is a popular area of research. Multiple studies have shown decreased rates of short-term complications with IC anastomosis, including surgical site infection and length of stay. None have shown a significant difference in readmission rate. Methods and procedures: In this retrospective cohort study, medical records of 95 patients who underwent elective, minimally invasive RHC from 2014-2018 were reviewed. Procedures were performed by multiple surgeons at a single institution. Fifty-eight patients were in the EC group; 37 were in the IC group. We compared short-term outcomes using Fisher's Exact and Student's t tests. The primary outcomes were 30-day ED visits and readmissions. Results: Demographics, ASA class, and comorbidities were not significantly different between the two groups. More patients who underwent EC vs IC anastomosis were readmitted within 30 days (7 vs 0), p = 0.027. Thirty-day ED visits (p = 0.17), 30-day mortality (p = 0.611), incidence of leak (p = 0.133), and other short-term outcomes were not significantly different between the groups. This study, in conjunction with other available studies, suggests that creating an IC anastomosis may reduce some short-term complications, such as 30-day readmission. Conclusions: In this study, there was a statistically significant increase in 30-day readmissions in patients who underwent minimally invasive RHC with EC anastomosis versus an IC approach. All other short-term outcomes were not significantly different between the two groups.

Proper usage of access device to keep the surgical plane during the TaTME Purpose: Multiple advantages of transanal total mesorectal excision (TaTME) have been reported. The aim of this study was to evaluate efficacy of proper usage of access device to preserve the surgical plane during TaTME. Methods: We evaluated prospectively collected data of 73 consecutive patients with rectal cancer who underwent TaTME with reconstruction from November 2014 to March 2020. Intraoperative adverse events, blood loss, postoperative complications including dysuria, length of hospital stay, readmission rate within 30 days, quality of TME, and pathological findings were assessed. Surgical procedure: Full-thickness transection of rectum was performed circumferentially. For posterior dissection, access device was turned towards dorsal side, and dissection performed between parietal pelvic fascia and mesorectal fascia. Dissection proceeded between Denonvilliers fascia and mesorectal fascia for anterior wall, with access device directed towards prostate. The access device was turned towards 9 o'clock and rotated 45 degrees clockwise for right lateral portion and dissection proceeded between parietal pelvic fascia and mesorectal fascia, preserving right pelvic nerve. Likewise, access device was turned towards 3 o'clock and rotated 45 degrees counterclockwise for left lateral portion, and dissection proceeded between parietal pelvic fascia and mesorectal fascia, preserving left pelvic nerve. Finally, recto-sacral fascia in posterior side was dissected to connect to abdominal dissection cooperating with abdominal team. Results: Operation time was 359 min. Intraoperative adverse event occurred in 4 patients, including two visceral injuries, which were rectal and vaginal injury. No nerve injury or other complications occurred. The rate of postoperative complications was 21.9%, including two Clavien-Dindo grade IIIb cases, which were anastomotic leakage and outlet obstruction. There was no dysuria at one month after surgery. The mean length of hospital stay was 14 days. One patient had unplanned readmissions to the hospital within 30 days because of anastomotic bleeding. The rate of TME complete was 93.1%. Mean of retrieved nodes was 17.2. Lymph nodes metastasis identified in 20 patients. The rate of radial margin positive was 1.4%. Conclusions: The proper usage of access device is an important technique to preserve the surgical plane during the TaTME for patients with rectal cancer. Introduction: Minimally invasive surgery, and in particular the robotic platform, is increasingly used in the surgical treatment of rectal cancer. While the rate of converting to open has decreased with greater experience with minimally invasive surgery, conversion rates continue to be about 11.9%. We aim to determine perioperative risks factors for conversion to open for rectal cancer. Methods: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) proctectomy-targeted database for rectal cancer from 2017-2018 and identified patients had operations done robotically and laparoscopically. Unplanned conversions, both robotic and laparoscopic, to open were analyzed separately. Incomplete records without TNM staging for rectal cancer were excluded. Perioperative factors and postoperative complication rates were analyzed using univariate analysis (chi-square and t-test).

Results: A total of 1309 patients with rectal cancer who underwent proctectomy were identified of which there were 784 (59.9%) laparoscopic and 525 (40.1%) robotic. Unplanned conversion from laparoscopic occurred in 13.0% (n = 102), and 4.2% (n = 22) had unplanned robotic converted to open (p \ 0.01). Body mass index was higher in unplanned conversion group (30.4 ± 6.5) compared with laparoscopic (27.5 ± 5.5) and robotic groups (28.1 ± 6.1) (p \ 0.001). Preoperative hematocrit was lower in the conversion group at 38.0 ± 4.6 compared to the minimally invasive group (39.3 ± 4.5 (laparoscopic) and 39.0 ± 4.7 (robotic)) (p = 0.015). The majority of patients who had conversion were male at 73.4% (n = 91) (p = 0.013). Patients with preoperative clinical T4 disease had higher risk for conversion with 15.3% (n = 19) compared to the minimally invasive group (9.5% in laparoscopic and 14.5% in robotic) (p = 0.016). Also patients with preoperative clinical M1 disease were more likely to have conversion to open 10.5% (n = 13) (p = 0.006). Combining the robotic and laparoscopic conversion groups did not change the significant factors for the laparoscopic group. The unplanned conversion group had higher association with post-operative ileus at 29.0% (n = 36) compared with laparoscopic (3.2%) and robotic (3.2%) groups (p = 0.001). The unplanned conversion group were more likely to have superficial (10.5%, p = 0.008) and organ space surgical site infections (13.7%, p = 0.017) compared with the laparoscopic and robotic groups. Conclusion: Unplanned conversion to open surgery occurs significantly less in robotic procedures compared to laparoscopic for proctectomy performed for rectal cancer in the NSQIP database. Conversion occurs more often in patients with higher BMI, male sex, lower preoperative hematocrit, and preoperative clinical T4 and M1 disease. Those who do undergo conversions are also at higher risk for ileus, superficial and organ space SSI.

Synchronous breast and colonic cancers: a case report Multiple Primary Malignant Neoplasms (MPMNs) are increasingly diagnosed despite their rare occurrence. Related risk factors are familial syndromes and common exposures as smoking, however the pathobiology could be different for each. MPMNs are synchronous or metachronous, a can occur in a single or different organs.. Case presentation: A lady 68 years old, came with lump right breast with inverted nipple in and anaemia. No family history of breast, or bowel cancer. Breast imaging showed a mass with speculated margins measuring 4 9 3 cm and enlarged right axillary lymphadenopathy. The biopsy showed node positive, hormone ? ve, Her-2 -ve, grade 3 invasive carcinoma NST. Colonoscopy detected 50 mm ascending colon polyp, the biopsy showed moderately differentiated adenocarcinoma. The Breast MDT recommended that, she will require primary chemotherapy for the breast preceding any breast surgery. Comenced on hormonal blockade for breast cancer, and underwent laparoscopic right hemicolectomy, the histology indicated 31 mm moderately differentiated adenocarcinoma.The cancer was positive for MSH6 expression, this supports the Lynch syndrome diagnosis. After recovery the patient received her breast chemotherapy, followed by mastectomy, axillary clearance, this detected no residual invasive carcinoma however there was 1 mm DCIS, with two involved lymph nodes. Radiotherapy to the chest wall and SCF, hormonal manipulation with AI(Letrozole) and bisphosphonate were recommended. Discussion: When a second primary malignancy detected within 6 months from the diagnosis of the first tumour, they are called synchronous neoplasms, if the second tumour detected 6 months after the first diagnosed one, then the term metachronous neoplasms is applied. Lynch syndrome is due to gene MSH6 and PMS2 genes mutation. It is known to be associated with increased lifetime risk of developing colon, endometrial, ovarian and breast cancer. Few other cancers had been reported coexisting with breast malignancy as ovarian, renal, and thyroid cancers. On the other hand, colon cancer has been detected in coexistence with uterine, ovarian, and breast cancers. The diagnosis of MPMNs is becoming more encountered and reported, this could be as a result of increased life span, better diagnostic facilities and easier reporting system. The details of its bio-pathology still unclear however, some associated risk factors had been mentioned as exposure to carcinogens as smoking, radiation, hormonal therapy and immnuo-modulation. Conclusion: Confirmed MPMNs have to be assessed and staged separately, where the management plan should be agreed by the different specialities in view to achieve optimum treatment outcome. Objective: This is a Retrospective review of assessing the diagnostic accuracy of MRI in local T and N staging of rectal cancer in patients undergoing primary surgery with final histopathological staging. Secondary aim is to evaluate the preoperative staging after MDT discussions. Methods: Patients diagnosed with rectal carcinoma between January 2016 to July 2019 were identified who had were diagnosed with histologically proven rectal cancer, undergoing definitive surgery as the primary treatment. A comparison was made between the T and N staging from MRI, review of T and N staging in the MDT, and the final histo pathological staging using simple concordance. Results: A total of 66 patients with rectal cancer were included in the study. Mean age was 63 years. Tumours were located in the lower rectum in 33%, mid-rectum in 46%, and upper rectum in 21% of the cases. -There was 77% concordance between MRI and MDT staging. There was 47% concordance between MRI and MDT of T staging and 53% concordance of N staging.--There was 42% total concordance between MRI and histopathology staging. There was 43% concordance between MRI and histopathology T staging and 57% concordance of N staging.

-Interestingly -There was 42% concordance between MDT outcome and histopathological staging. There was 47% concordance between T staging and 53% concordance of N staging. To summarize: There was 43% concordance between initial MRI and final histology T staging, which increased to 47% after MDT review. In contrast the concordance for N staging, reduced from 57% with MRI to 53% following MDT. Furthermore, the initial MRI T stage was under staged in 29% of patients when compared with histology, but this reduced to 20% following MDT assessment. In comparison, the initial MRI N stage was under staged in 21% of patients, but this increased to 40% after MDT. Conclusion: MDT has a beneficial role in reviewing preoperative MRI staging of rectal cancers. N staging did not appear to benefit from MDT review, possibly a result of small sample size, although it is recognised that nodal status is difficult to accurately assess in these patients. It could be seen that MDT underestimated the nodal size. Early diagnosis and accurate preoperative staging are necessary to properly implement the neoadjuvant treatment protocol, and accurate radiologic imaging is essential for this.

Morning versus afternoon robotic colorectal procedures Yosef Nasseri, MD; Kimberly Oka, BS; Eli Kasheri, BS; Jason Cohen, MD; Joshua Ellenhorn, MD; Moshe Barnajian, MD; Surgery Group LA.

Background: Prior studies suggest an increased complication rate for afternoon compared to morning laparoscopic procedures. Robotic colorectal procedures require the successful collaboration of skilled surgical staff and the utilization of both laparoscopic and highly technical robotic instrumentation. We sought to evaluate whether morning versus afternoon start time matters. Methods: In a retrospective review of a prospective database, 198 robotic colorectal operations between February 2015 and August 2020 were grouped into 92 morning versus 106 afternoon cases. We defined morning cases as those starting prior to 12 p.m. and afternoon cases as those starting at 12 p.m. or later. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. A two-sample unequal variance t-test and Fisher's exact test were used for quantitative and categorical variables. A Mann-Whitney U test was used to analyze differences on a continuous scale. Results: Morning patients were significantly younger than afternoon patients (60.7 vs. 65.4, p = 0.03), but there were no significant differences in gender (52% vs. 53% male, p = 0.93), mean BMI ( There were no significant differences in indications for surgery or resection types. There were no significant differences in overall postoperative complications (0.60 vs. 0.71, p = 0.43), wound infection (4% vs. 8%, p = 0.24), anastomotic leak (0% vs. 0%, p = 1.00), ileus/small bowel obstruction (28% vs. 26%, p = 0.91), median length of stay (5 vs. 5 days, p = 1.00) or 30-day readmission (7% vs. 9%, p = 0.45). Conclusion: We found no outcome differences between morning and afternoon robotic colorectal operations. This can potentially be due to highly trained operating room robotic staff in a large volume tertiary center and decreased fatigue attributed to superior ergonomics of robotic surgery that in turn may have mitigated previously reported differences between morning and afternoon laparoscopic cases.

Metastatic lung carcinoma to the anus despite radiation theraphy for squamous cell carcinoma Michaelia S Sunderland, MD; Meagan Read, MD; Robert D Bennett, MD; University of South Florida.

Introduction: Lung cancer remains the leading cause of cancer related deaths worldwide. It frequently progresses to metastatic disease, associated with very poor overall survival. Metastatic spread to the anus and perianal region, however, is an extremely rare phenomenon. We present a case of a 69-year-old male, with multiple synchronous primary malignancies, who was found to have primary lung adenocarcinoma metastasis to the anus, despite radiation therapy for primary squamous cell carcinoma of the anus. Methods: We used online search engines including Pubmed, Cochrane, and Embase to review available published medical literature. We reviewed cases of primary lung cancer spread to the anus, as well as metastasis after chemoradiation for treatment of anal squamous malignancy. Results: There are thirteen reports of lung cancer metastasis to the anus. We did not find any reports of lung cancer spread to radiation sites after treatment for anal squamous cancer. Unfortunately, the reported survival in these patients was poor, all deaths occurring in less than one year. The majority were treated with chemoradiation as surgical resection for cure is not possible. Conclusions: This is the first report, to our knowledge, of metastatic lung adenocarcinoma to the anus after prior chemoradiation therapy for anal squamous carcinoma. This is now one of fourteen cases of metastatic lung cancer spread to the anus. He is being treated with chemotherapy and is currently recovering at home. His response to therapy and survival will be closely followed.

Not all cecal masses are cancers! Zachary A Spigel, MD, MPH 1 ; Christopher Sherry, BS 2 ; Gursimran Kochhar, MD 1 ; Richard Fortunato, DO 1 ; 1 Allegheny General Hospital; 2 Lake Erie College of Osteopathic Medicine.

Background: An otherwise healthy post-menopausal 53-year-old female underwent an initial routine screening colonoscopy. During her colonoscopy she was found to have a submucosal cecal mass at the appendiceal orifice ( Fig. 1 ). Biopsies were taken which revealed benign lymphoid aggregates without evidence of dysplasia. She had no abdominal or intestinal complaints or significant family history. Her past medical history was significant for endometriosis 17 years prior requiring three laparoscopic fulgurations but without hysterectomy or oophorectomy. A CT-enterography demonstrated a non-inflamed, foreshortened appendix and cecal mass without adenopathy (Fig. 2) . The patient was referred to Colorectal surgery for further management. She underwent a laparoscopic exploration which demonstrated a foreshortened appendix without other abnormalities, masses, or fluid. A laparoscopic cecectomy was performed without complication. Gross examination revealed a firm, polypoid, tan-pink submucosal mass measuring 1.6 9 1.9 9 0.9 cm present at the appendiceal orifice. Microscopic evaluation demonstrated small glands associated with scant spindle stroma forming a pseudo-nodule arising from the muscularis propria. Immunohistochemical stains were positive for PAX8, estrogen receptor and progesterone receptor, and the spindle stroma was positive for CD10-consistent with the diagnosis of endometriosis (Fig. 3) . The rest of the cecal mucosa was unremarkable and the mesentery was without lymph nodes or tumor deposits. Discussion: Appendiceal endometriosis has been reported in as many as 4% of patients with biopsy-proven endometriosis and transmural endometriosis has been reported across both the small and large bowel. This case is unique in that there was no external disease throughout the abdomen and the endometriosis arose directly from the muscularis propria of the appendiceal orifice, resulting in total endoluminal disease. While our patient remained asymptomatic for almost 2 decades, it is not known how long this mass was present and if it was a dormant version of endometriosis or became so when she transitioned to postmenopausal. Thus, unexplained digestive complaints in women with a history of endometriosis may be explained by total endoluminal endometriosis. Additional case reporting and research is required to further explain the pathogenesis and incidence of total endoluminal endometriosis. Fig. 1 Colonoscopic images delineating appendiceal orifice submucosal mass Introduction: Traditional management strategies of enterocutaneous fistulas (ECF) often result in prolonged periods of parenteral nutrition, electrolyte disturbances, and skin irritation because of high fistula output. These measures can dramatically impact the intestinal mucosa, resulting in impaired function. Impaired intestinal mucosal function has been shown to affect clinical outcomes, specifically increased infectious complications. Based on this theory, we hypothesized that patients undergoing small bowel resection (SBR) for ECF would have a higher rate of infectious complications compared to those undergoing SBR for non-ECF indications. Methods: All patients undergoing SBR in the 2006-2018 American College of Surgeons National Quality Improvement Program (ACS NSQIP) database were included. Patients who had documented anal, vaginal, or vesical fistulas as well as metastatic malignancy were excluded. Patients with documented ECF were matched 1:1 with non-ECF patients based on demographics, comorbidities, pre-operative nutritional status, liver dysfunction, and operative time (as a surrogate for complexity) using propensity scores. All-cause 30-day mortality, length of stay (LOS), and 30-day complication rates were compared between ECF and non-ECF patients. Results: Of 45,727 patients who underwent SBR, 3,043 had an ECF. After matching, 903 patients from each group were perfectly matched. Compared to patients without an ECF, patients with an ECF had lower overall mortality (1.1% vs 3.7%, p \ 0.001) but were more likely to require a length of stay greater than one week (67.5% vs 56.4%, p \ 0.001) and suffer at least one surgical complication (28.1% vs 20.8%, p \ 0.001). Further, ECF patients had higher rates of deep surgical site infections (5.2% vs 2.3%, p = 0.001), wound dehiscence (5.3% vs 1.7%, p \ 0.001), and sepsis (9.7% vs 7.0%, p = 0.034). ECF patients were also more likely to be readmitted (14.7% vs 9.7%, p = 0.013), with the leading causes of readmission being wound infection, persistent fistula, obstruction, dehydration, and sepsis/septic shock. Conclusions: Even when matching for traditional pre-operative predictors of surgical complications, patients with ECFs appear to be more susceptible to postoperative infectious complications after SBR than those without ECF. These data may support the notion of an underlying mucosal disorder that warrants further investigation. Introduction: The purpose of this study is to elucidate the etiologies of all primary ileostomy site malignancies published in the literature. Methods and procedures: A review of the literature was conducted following PRISMA guidelines by querying PubMed, Global Health, and Web of Science databases for articles published before 11/2020. Search criteria contained broad terminology for any ileostomy site neoplasm without language, date, or publication type limitations. A full-text review of the screened abstracts confirmed primary malignant pathologies, and references of selected publications were evaluated by hand/manual-searching for study inclusion. Results: Literature review resulted in 797 publications, with 77 articles meeting our inclusion and exclusion criteria. Among these 77 case reports and series, 92 patients possessed a primary pre-malignant (3, 3.3%) or malignant (89, 96.7%) lesion at an ileostomy stoma. The sample contained mostly males (49, 53.3%). The mean age at diagnosis is 61.9 ± 12.6, and the average age of stoma was 30.2 ± 13.0 (Range = 0.50, 63.0). The indications for ileostomy creation were inflammatory bowel disease (IBD) (69, 75.0%), familial adenomatous polyposis (FAP) (18, 19.6%), and other diseases (5, 5.4%) . Of the primary malignant lesions, adenocarcinoma (70, 76.1%) was the most common pathology, followed by squamous cell carcinoma (11, 12.0%), lymphoma (3, 3.3%), melanoma (3, 3.3%) , and other malignancies (2, 2.2%) . When comparing the sample with adenocarcinoma and squamous cell carcinoma, patients with adenocarcinoma were diagnosed at a younger age with a mean age of 59.4 compared to 71.8 (p \ 0.05), had a shorter duration with a stoma (29.6 vs. 38.1 years, p = 0.03), and most often had FAP as the indication for ileostomy creation (17, 24.3% vs. 0, 0%, p = 0.03). Similarly, when examining patients with IBD as the indication for their index surgery compared with FAP or any other indications, subjects with IBD developed neoplasms with a longer stoma duration (32.3 vs. 26.2 vs. 14.5 years, p \ 0.05) and were less likely to have adenocarcinoma at the ileostomy site compared to those with FAP (17, 94.4%, vs. 51, 73.9%, p = 0.012). Persons with FAP almost exclusively developed adenocarcinoma (17/18, 94.4%), while those with IBD developed eight of the nine pathologies recorded in the literature. Conclusions: Ileostomy surveillance should start at 15 and 20 years after creation for FAP and IBD patients, respectively. Surveillance should be performed at least every five years for all subjects and diseases.

Is a minimally invasive approach to diverticulitis with a colocesical fistula reasonable?

Rafael E Perez, DO, MBA; Emily Kunkel, MD; Paige C Adams, BA; Alvaro Mendez, MD; Henry P Schoonyoung, MD; John H Marks, MD; Lankenau Medical Center.

Background: Complex inflammatory surgery represents a significant challenge which many surgeons feel precludes minimally invasive surgery. An uncommon but significant complication of diverticulitis is a colovesical fistula. The literature regarding surgical approaches to this problem is scant. The purpose of this study is to examine if complex diverticulitis with colovesical fistula can be safely and effectively treated in a minimally invasive fashion. Methods: From a prospectively maintained minimally invasive database, all patients with diverticulitis were identified and the subgroup of elective colovesical fistulae were analyzed. All procedures were performed by a single surgeon at a tertiary referral center. Primary endpoints included ability to avoid a permanent stoma, conversion rate, success rate of bladder repair, anastomotic leak rate, morbidity and mortality. Results: Between 1996-2020, 728 of 2791 minimally invasive operations were performed for diverticulitis and 3.8%(N = 28) had colovesical fistulae. Mean age was 68.3yo(36-90), with 16 women. Conversion rate was 0% and anastomotic leak rate was 3.5%. 85.7%(N = 24) avoided a permanent colostomy. Bladder repair was without leak in 89.3%(N = 25). Overall morbidity was 50%(N = 14). There were no mortalities. Conclusion: Complex inflammatory surgery in the pelvis remains a challenging task. Our study finds that surgery for colovesical fistulae from diverticulitis is difficult and associated with significant morbidities. However, these can be operated on minimally invasively with high success of bladder repair, avoidance of stoma, and with low anastomotic leak rate and mortality. Minimally invasive surgery for colovesicular fistuale from diverticulitis can be performed safely and effectively.

Endoluminal vacuum therapy for colorectal anastomotic dehiscence: a simplified atlas for a complex problem Michaelia S Sunderland, MD; Anthony Dakwar, MD; Jaime E Sanchez, MD; University of South Florida. Purpose: Colorectal anastomotic dehiscence plague colorectal surgeons given the significant morbidity and mortality associated with this postoperative complication. Incidence of colorectal leaks or dehiscence is reported as high as 10-20% with an associated mortality up to 5-10%. Negative pressure vacuum therapy, or endoluminal vacuum therapy (EVAC), is quickly revolutionizing the management of anastomotic dehiscence in both foregut and hindgut surgery. Compared with traditional treatment options, improved luminal healing and shorter time to stoma reversal has been reported in the literature using EVAC. We will discuss the management of a colorectal anastomotic dehiscence (six centimeters from the anal verge) and a large presacral abscess to demonstrate the longitudinal clinical progression using EVAC in a patient following low anterior resection for severe infiltrating endometriosis.

Methods: After proximal diversion, we managed a large (6 9 4x9cm) presacral abscess cavity with EVAC. An endoluminal vacuum device was created using readily available supplies with the goal of collapsing the cavity and creating a mucosal seal for rectal healing. A white foam sponge was secured to the end of suction tubing with nylon suture, endoscopically placed into the presacral cavity, and connected to continuous negative pressure (75 mmHg) using a portable wound vacuum. The patient underwent six weeks of endoluminal vacuum therapy with sponge changes occurring biweekly. At each exchange, the progression of granulation tissue and mucosal healing was inspected, the cavity measured, and the size of the sponge adjusted according to the collapsing space. Treatment was managed as an outpatient. Sponge changes were performed without difficulty by surgical staff including residents at all levels of training.

Results: After six weeks of therapy, the large presacral cavity was healed. The progressive findings, both intraluminal and radiologic, were chronologically recorded to create an atlas of expected healing. The patient did not require reoperation following EVAC treatment of the colorectal anastomotic dehiscence. Her ileostomy was successfully reversed following completion of EVAC. Conclusion: Endoluminal vacuum therapy is transforming the management of esophageal and colorectal anastomotic leaks given the high rates of successful healing. Despite severe infiltrating endometriosis of the rectum, our patient was able to heal a low colorectal dehiscence and presacral abscess cavity in just six weeks. Management of even the most complex cases of anastomotic dehiscence with EVAC has demonstrated very promising Results. Colorectal surgeons should be aware of this alternative treatment modality.

Elective versus non-elective robotic colorectal surgery -deep dive in cost analysis and short-term outcome Ashwini Poola, MD; Laila Rashidi, MD; Prakash Gatta, MD; Multicare Health care system.

Background: With the increasing utility of robotic surgery, many studies have argued that the platform does not provide clinical benefit over increased cost. These studies have focused on elective cases and based their comparison on the standards of open and laparoscopic surgery. There are few studies that assess the utility of the robotic platform in the non-elective (NE) patient. This is a report specifically evaluating the cost and short term outcome of the robotic approach in elective versus non-elective colorectal surgery.

Methods: A single institution retrospectively-collected data from January 2019 to March 2020; set of all patients who underwent robotic colorectal surgery. This data set was subdivided into elective and non-elective cases. NE cases included emergent cases performed within 24 h of presentation, or urgent cases performed within one week of presentation. We assessed operative length of time (ORLOT), hospitalization length of stay (LOS), readmission rates, and complication rates for both elective and NE cases. We queried costs for anesthesia time, supplies costs and total hospital costs.

Results: 182 colorectal surgeries were performed over this study period with 34 performed in a NE fashion. Overall, the median age of patients was 58 years with a male preponderance 21 in NE cases.

In the NE cohort, the median OR time was 128.79 min vs. elective 111.41 min (p = 0.14) and the median LOS was 1.87 vs.1.53 (P = 0.38) days. There was one patient with a complication and three patients who required readmission in NE group.

The total hospital cost was $79,167 for NE vs. $ 73,200 in elective surgery (p = 0.38), anesthesia cost was $8,482 and supplies cost was $10,860 in NE group. When compared to the elective cases, there was no statistical difference between the two group.

Conclusion: Robotic surgery is feasible and safe for patients undergoing NE colorectal surgeries with no difference in short term outcome and cost.

Is laparoscopy safe in the treatment of acute appendicitis complications?

Ali Uzunkoy; Harran University.

Objective of the study: Although laparoscopic appendectomy can be used safely in the treatment of acute appendicitis, there are still reservations about its use in complications. In this study, it was investigated whether laparoscopic surgery can be used safely in acute appendicitis complications. Methods and procedures: The Results of 57 patients who presented with acute appendicitis complications and were treated with laparoscopic intervention were evaluated retrospectively. Thirty-nine patients presented with classical clinical findings of acute appendicitis and ruptures, 12 patients presented with atypical clinical findings, and 6 patients had recurrent chronic pain. Perforated appendicitis in 41 cases, periappendicular abscess in 9 cases and plastrone appendicitis in 7 cases were detected. Results: Appendectomy was performed laparoscopically with 3 trocars for all perforated appendicitis. In 2 cases, the 4th trocar insertion was required. Abscess drainage and laparoscopic appendectomy were performed in 7 of 9 cases with periappendecular abscess, while drainage was performed only in 1 case. Open method was used in one case and appendectomy and drainage were performed. While laparoscopic appendectomy was performed in 5 cases of plastrone appendicitis, only external drainage was applied in 2 cases of plastrone appendicitis. One patient with periappendecular abscess required percutaneous drainage with ultrasonography on the 7th postoperative day and was discharged in 5 days without any problem. Wound infection developed in 5 cases. These cases healed with antibiotherapy and drainage. Prolonged paralytic ileus was observed in 2 patients with 1 plastone appendicitis and 1 periappendicular abscess and resolved with medical treatment. Conclusion: Our Results show that laparoscopy can be applied safely for both diagnosis and treatment in acute appendicitis complications.

Acute colonic pseudo-obstruction -a complicated recovery Rohan Anand, MBA; John Griswold, MD; Texas Tech University Health Sciences Center. Acute Colonic Pseudo-Obstruction (ACPO), also known as Ogilvie's Syndrome, is a rare clinical condition characterized by gross distention of the large bowel in the absence of a mechanical obstruction. The pathophysiology remains poorly understood. Current theories postulate a dysfunction in parasympathetic innervation of the distal bowel, resulting in an excess of sympathetic drive. This leads to a nonfunctional, acutely dilated section of bowel. It is most often treated with medical decompression using neostigmine and scope decompression. In rare situations where medical management is not successful, surgical intervention may be necessary for decompression of the cecum. Delayed intervention poses a significant risk of bowel perforation and subsequent fecal peritonitis, making it a serious cause of morbidity and mortality in these patients. The incidence is rather low, making recognition of the subtle signs and symptoms, particularly in the setting of multiple comorbidities, particularly difficult. As such, the diagnosis of ACPO is often overlooked and delayed, with dangerous, possibly lethal consequences.

We present a case in which a 54-year old patient developed ACPO as a complication of burn injuries sustained during an oil field explosion. While the large bowel was successfully decompressed, the damage to the colon wall was too extensive, later necessitating a right hemicolectomy and end ileostomy. ACPO is particularly uncommon in burn patients. Treatment of the burn, both medically and surgically, may incite ACPO, or worsen an existing case of ACPO. As such, the management of both concurrently is complex, and often necessitates a more aggressive approach than in a non-thermally injured patient. This case emphasizes the importance of early recognition this rare condition, particularly in the setting of extensive burn trauma that further masks its symptoms, so that early management can prevent the patient from developing further, deadly complications.

Complete laparoscopic resection of a retrorectal tumor Kodai Nagakari, Dr; Toranomon hospital.

Background: Retrorectal tumors are rare entity with developmental cysts being the most common type. Usually, retrorectal tumors are removed by transsacrococcygeal approach, transabdominal approach, transabdominal approach, or combined abdomino-sacrococcygeal approach, according to the location and size of the tumor. Laparoscopic approach is rarely chosen because dissection of the tumor in the small space of the narrow pelvis is challenging. However, when laparoscopic approach is successfully accomplished, it can provide the benefit of minimally invasive surgery. Moreover, laparoscopic approach is advantageous when conversion to the rectal resection is required.

Here we report a case of a very low-lying retrorectal tumor successfully resected by laparoscopic approach alone. Case presentation: The patient is a 52-year-old woman who was found to have a rectorectal tumor during a physical examination. CeCT and MRI showed a 17 mm oval cystic tumor, located at the posterior rectum upon the levator ani. The presumptive diagnosis was tailgut cyst, and laparoscopic tumor resection was planned. Operative methods: The operation was started laparoscopically with 5 ports. The sigmoid colon was mobilized using a medial to lateral approach to preserve the left ureter and gonadal vessels. The mesorectum was carefully mobilized in the pelvis to preserve the hypogastric nerves and pelvic plexus. After broadly exposing the levator ani from the posterior side to the lateral sides, a smooth oval tumor sunk into the levator ani was detected. The tumor was easily dissected from the posterior rectum, and was resected together with a small amount of levator ani. The postoperative course was uneventful. The patient was discharged 4 days after the operation. The pathology showed no malignancy. Conclusion: Laparoscopic resection of retrorectal tumors is relatively challenging. However, when it is accomplished, it can provide benefits for the patients. In this case, we performed complete laparoscopic resection for a very low-lying lesion and the postoperative course was favorable. Laparoscopic approach can provide a feasible alternative to the conventional approaches for retrorectal tumors. Background: Resection of tumors that invade adjacent organs (T4b) is technically challenging. There is currently a paucity of data on the role of minimally invasive approaches in that setting. In this study, we explored characteristics of patients undergoing minimally invasive surgery (MIS) for T4b colon cancer, as well as the clinical factors associated with conversion to an open approach, by analyzing data from the National Cancer Database (NCDB). Methods: The NCDB was queried for patients undergoing potentially curative resection of colon cancer (2010) (2011) (2012) (2013) (2014) (2015) (2016) . In patients undergoing MIS, clinical factors associated with conversion to an open approach were assessed using Logistic-regression multivariable analysis (MVA). Results: Over the study period, 9030 patients underwent potentially curative resection for cT4b colon cancer in the NCDB. MIS approach was used in 27.5% (n = 2487) of the patients (robotic: 157, laparoscopic: 2330). Compared to open approach, MIS was used more in patients with right-side tumors (57% vs. 53%, P \ 0.001), patients with higher median income (C 48,000$: 61% vs. 55%, P \ 0.001), and those with private/managed-care insurance plans (36% vs. 32%, P = 0.002). Conversion to an open approach was noted in 801 (32%) patients undergoing MIS (robotic15%, laparoscopic 33%). On Univariable analysis, factors associated with lower rate of conversion to open approach included: more recent year of surgery (95%CI:0.864-0.943), neoadjuvant radiation therapy (95%CI:0.084-0.668), neoadjuvant chemotherapy (95%CI:0.418-0.880), use of robotic approach (95%CI:0.218-0.537), and surgeries done in Academic hospitals (95%CI:0.618-0.903). on MVA, recent year of surgery (95%CI:0.882-0.966), robotic approach (95%CI:0.228-0.575), and surgeries performed in Academic hospitals (95%CI:0.646-0.957) were associated with lower rates of conversion. MIS surgeries converted to an open approach were associated with a higher rate of positive resection margin (31% vs. 25%, P = 0.001), and a higher rate of 30-day readmission (12% vs. 9.5%, P = 0.045), compared to those who had no conversion.

Conversion to an open approach was not associated with a higher rate of 30/90-day mortality or worse 5-year overall survival (Table) . Conclusion: Minimally invasive resection of cT4b colon cancer is technically challenging and is associated with a high conversion rate in up to one-third of the patients, yet with no long-term adverse effects. The recent technological advances and the introduction of robotic surgery have helped to reduce the conversion rates on the National level. Whenever possible, patients with cT4b colon cancer should be treated in high volume academic centers. Introduction: Opioid analgesia is common but associated with important adverse effect on gastrointestinal(GI) recovery after colorectal surgery. Transversus abdominus plane(TAP) block may decrease postoperative opioid use, but evidence supporting surgeon-delivered TAP block in laparoscopic colorectal surgery remains unclear. Therefore, the objective of this study was to investigate the effect of surgeon-administered TAP block on opioid requirements and return of GI function after laparoscopic colectomy. Methods: This cohort (before-and-after) study involved consecutive adult patients undergoing elective laparoscopic colectomy without stoma creation and Pfannenstiel extraction at a single colorectal referral centre from 01/2017-12/2019. All patients were managed by a mature enhanced recovery pathway with a 3-day target length of stay(LOS). Starting in 01/2019, surgeon-delivered TAP block under laparoscopic guidance started being performed with 3 9 7 cc lateral to the rectus sheath bilaterally using 40 mL of 0.25% bupivacaine with 10 mg dexamethasone at the end of each case. Patients were grouped as TAP ? vs. TAP-. Opioid consumption in the post-anaesthesia care unit(PACU), and each postoperative day(POD) were converted into morphine milligram equivalents(MME). Additional outcomes included time to GI-3 (time to toleration of solid diet and passage of flatus or bowel movement), LOS, and in-hospital complications. Subgroup analysis were performed based on right vs. left colectomy. Results: A total of 152 patients were analyzed (TAP ? n = 75,TAP-n = 77). There were no between-group differences in age, gender, comorbid status, indication for surgery, right vs. left colectomy, and procedure duration Overall, there were no differences in MME between TAP ? and TAP- (Table) . There were an equal proportion in both groups that did not require any opioids on POD0(48%), 1(31%), and 2(44%). TAP ? was associated with shorter time to GI-3 and LOS, and no differences in complications. There were no differences in MME between TAP ? and TAP-in subgroup analyses for left or right colectomy. TAP was associated with faster return of GI function in left but not right colectomy. Conclusion: TAP was not associated with a difference in opioid consumption after laparoscopic colectomy, but an important proportion of patients did not require any opioids. However, TAP was associated with faster return of GI function. These data suggest that TAP may improve GI recovery. Introduction: In the private sector, emergency colectomy (EMC) accounts for up to 20% of colectomy cases, with morbidity and mortality rates approaching 38% and 13%, respectively. This study examines the profile and outcome of emergency colectomy in the US Veteran population compared to elective colectomy (ELC). Methods: Colectomies in the Veterans Affairs Surgical Quality Improvement Program database from 2008-2015 were analyzed. EMC was defined as cases within 12 h of admission or onset of illness. Demographics, clinical/operative details, and postoperative outcome were compared in EMC and ELC cases using Chi-square test for categorical variables, Student's t-test for continuous variables with parametric distribution, and Mann-Whitney test for continuous variables with non-parametric distribution. Logistic regression was performed to detect independent predictors of morbidity and mortality in EMC. P \ 0.05 was considered significant. Results: A total of 28,935 colectomies were studied (86% ELC, 14% EMC). Mean age was 65.5 years, 96% male, 84% ASA class C 3, and mean was BMI 28. Objective: This study aims to build novel prediction models using artificial intelligence (AI) which are more accurate than general statistical analysis for patients with Stage 2/3 colon cancer. Background: Among various surgeries, colorectal surgery is associated with the highest incidence of Surgical Site Infection, despite widespread practice of evidencebased practices to prevent them. Postoperative infection complications not only have a negative impact on prognosis, but also prolong postoperative stay and increase the cost of surgical practice. In recent years, the development of prediction models has become commonplace, and risk-prediction models based on data collected by SSI surveillance networks are useful to improve prediction of the risk of Surgical Site Infection for better infection control. And, various systemic inflammation and nutritional scores have been reported as useful SSI predictors. Therefore, we created an SSI prediction model for colorectal cancer surgery with a particular focus on systemic inflammation and nutritional scores. Methods: All of 763 patients who underwent radical surgery for Stage 2/3 colon cancer between 2000 and 2018 at our institute were retrospectively analyzed. Primary end point was the surgical site infection. Binomial logistic regression analysis was used to calculate the effect of variables on surgical site infection during hospitalization after curative surgery. Predictive accuracy was assessed by ROC and value of AUC. We used machine learning software, Prediction One (Sony Network Communications Inc.) to predict surgical site infection for Stage 2/3 colon cancer using the same model for normal statical analysis. To evaluate the accuracy of the AI model, we calculated the AUC using ROC the internal validation. Results: In multivariate analysis, C-reactive protein/albumin ratio was the independent risk factors for surgical site infection during hospitalization. The value of AUC was 0.744 (95% CI: 0.684-0.804). The value of AUC in the AI model was 0.851 which was great better than that of the multivariate model. Conclusion: We built the novel prediction model using artificial intelligence which is more accurate than normal statistical analysis for patients with Stage 2/3 colon cancer at our institute. This model can be used as an option to determine treatment strategy after curative surgery with conventional models.

An unusual cause of hematemesis with gallstone ileus including cecal perforation Katlin Mallette, MD 1 ; Thomas Mammen, MD, DNB, FRCPC 2 ; Sonny Dhalla, MD, FRCSC, FACS 2 ; 1 University of Saskatchewan; 2 Brandon Regional Health Centre.

Introduction: Gallstone ileus is a rare complication of cholelithiasis, which occurs in 0.3-0.5% of patients. Obstruction within the large intestine accounts for only * 4% of all gallstone ileus patients, resulting from a stone traversing the ileocolic junction or formation of a cholecystocolonic fistula. Here we report a complicated case of a patient presenting with an upper gastrointestinal bleed and subsequently found to have a sigmoid obstruction secondary to gallstone. Case Details: A 65-year-old, male presented with a two week history of poor appetite, coffee ground emesis and hypotension. CT scan reported a 10 cm segment of circumferential thickening of the proximal jejunum, and dilation of the extrahepatic bile duct terminating abruptly * 2.5 cm above a thickened ampulla. EGD demonstrated a large ampullary tumor with ulceration, with ulcerations along the 2nd/3rd portion of the duodenum. His white blood cell count and c-reactive protein gradually decreased, and he was discharged. * 1 week later he re-presented with evidence of a large bowel obstruction. CT scan demonstrated a tortuous sigmoid colon with an obstructing 2.7 cm gallstone, along with dilated proximal bowel. A gastrograffin enema was undertaken to dislodge the gallstone, which was deemed successful.

Repeat abdominal x-ray on PAD #1 demonstrated extensive pneumoperitoneum. On emergency exploratory laparotomy, he was found to have a perforated cecum, with 3 areas of focal necrosis to the small bowel. A large gallstone within the sigmoid colon was fractured by hand and pushed distally. A right hemicolectomy, along with a segmental small bowel resection was carried out. Post-operative CT scan demonstrated decreased intrahepatic bile duct dilatation and clearance of the gallstone. Discussion: The ''Rigler'' triad has been described as the classic abdominal x-ray findings of gallstone ileus. The individuals demonstrate pneumobilia, dilated small bowel with a paucity of air in the large bowel, along with an opacity. There are a variety of mechanisms for dealing with large bowel obstruction secondary to gallstone ileus. Attempt at endoscopic removal of the obstructing stone has been largely unsuccessful. There has been discussion about the use of extracorporeal shock wave lithotripsy. This requires placement of a metallic clip in proximity to the stone. For those that require operative intervention, a 2 stage operation is advocated. The first operation, involves relieving the obstruction via enterotomy with stone removal and management of the cholecystoenteric fistula/gallbladder during a second operation. The two stage operation leads to significantly less morbidity and mortality. Background: Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices. Methods: We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017. Results: Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis. Conclusions: Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short-and long-term outcomes in our study. However, our experience is limited, and appropriate indications must be established with more case registries.

Concomitant finding of sessile serrated adenoma in a diverticulous appendix in the setting of acute perforated sigmoid diverticulitis Cristhian A Valor, MD, MS; Steven P Schulberg, DO; Omkaar Jaikaran, DO; Nurfiza Nadak, MD; Sampath Kumar, MD; NYU Langone. Diverticulitis is one of the most common gastrointestinal conditions afflicting humankind. Right sided diverticular disease is uncommon and reported to occur in only 1-2% of surgical specimens in European and American series. Even rarer, appendiceal diverticula remain a widely unrecognized finding, only found in 0.004-2.1% of all appendectomies, and 0.2-0.66% of autopsy specimens. Here we present a case of a 72 year old male with a prior history significant for diverticulosis. He presented to our Emergency Department with bilateral lower quadrant pain present for 1 month, acutely worsening for the past 5 days, he had a leukocytosis with normal vitals, and was found to have a diffusely thickened sigmoid colon with a mural abscess, as well as a 5 9 4 cm pelvic abscess abutting the tip of the appendix. With no feasible window for percutaneous drainage, patient underwent a Hartmann's procedure with appendectomy. His surgical pathology revealed a perforated segment of sigmoid colon with a subserosal abscess and a diverticular appendix with a sessile serrated adenomatous polyp. This is an exceedingly rare pathological diagnosis and upon thorough review of the literature, only one report has documented these concurrent findings. The presence of appendiceal diverticula is associated with colonic and appendiceal neoplasms, this intraoperative finding should warrant histopathologic examination. Given the scarcity of reported cases in this topic, every effort should be made to document these findings in the literature in an attempt to establish a reliable incidence for appendiceal sessile serrated adenomas, and their association with appendiceal diverticula.

Predicting the need of laparoscopic total protocolectomy with ileoanal anastomosis in ulcerative colitis: a critical appraisal of clinical parameters Background: The aim is to predict the need of laparoscopic total protocolectomy with ileoanal anastomosis in patient of ulcerative colitis with help of clinical parameters like weight gain, frequency of stool, frequency of blood in stool and hemoglobin percentage. Material and methods: Patients presenting with histopathologically proven ulcerative colitis were including in the study (June 17 to June 19).Surgery consisted of laparoscopic total proctocolectomy with ileoanal anastomosis with a diverting ileostomy which was closed after 4 to 6 weeks. All parameters measured before laparoscopic procedure and after 1, 3, 6 month of ileostomy closure. Results: A total of 30 cases (male 21, female 9) were operated as laparoscopic total protocolectomy with ileoanal anastomosis with diverting ileostomy. All patient showed improved Results in the form of parameters like weight gain, frequency of stool per day, frequency of blood in stool and hemoglobin percentage as measured before and after 1 month of laparoscopic procedure. Conclusion: Laparoscopic total protocolectomy with ileoanal anastomosis with a diverting ileostomy (closed after 4 to 6 weeks) is worthwhile in patients needing surgical management of ulcerative colitis in terms of parameters like weight gain, frequency of stool, frequency of blood in stool, hemoglobin percentage. Introduction: Advantages of robotic surgery (RS) in colorectal procedures include improved visibility, ease of dissection within a narrow pelvis, improved intracorporeal suturing, and assessment of anastomotic blood flow. The aim of this study is to compare outcomes between elective colorectal RS and laparoscopic surgery (LS) at a community hospital. We hypothesize that RS is associated with decreased length of stay (LOS) and similar complication rates. Methods: A retrospective chart review was performed for patients who underwent elective minimally invasive colorectal surgery between 01/2018-12/2019. Exclusion criteria included epidural analgesia, open or emergent surgery, end colostomy, and age \ 18 years. Comparisons between RS and LS groups were made using Chisquare and Mann Whitney U tests. A multivariate analysis was performed using a multiple linear regression model to identify variables which predicted LOS. We also performed a subgroup analysis of only intra-abdominal colon surgeries. Results: A total of 246 patients met our inclusion criteria (122 RS, 124 LS cases). Rectal disease was more common in the RS group (18% vs 9%; p = 0.004). The RS group had a shorter median LOS (3 vs. 4 days; p = 0.001) and PACU LOS (81 vs. 97 min; p = 0.001). Operative time was greater in the RS group (208 vs 160 min; p = 0.001). Clear liquids were initiated a median of 1 day sooner in the RS group (p = 0.001). There were no statistical differences between the groups in modalities of analgesia, complications, and readmission rates. Subgroup analysis showed similar Results except for lower complication rates in the RS group (6% vs. 16%; p = 0.002). The multiple linear regression model identified the following independent predictors of LOS: Introduction: We had performed Neoadjuvant chemoradio therapy and laparoscopic surgery for local advanced rectal cancer for the purpose of further good prognosis and minimally invasive treatment. Aim: To assess the long-term outcome of patients with rectal cancer who received neoadjuvant chemoradio therapy (NCRT) with S-1 and Irinotecan. Patients and methods: From 2004 to 2010, 115 patients with clinical stage T3 or T4 rectal cancer received pelvic radiation therapy (45 Gy) plus concurrent S-1 (80 mg/ m 2 )/irinotecan (80 mg/m 2 ). After 8-10 weeks, we performed open surgery of TME and dissection of bilateral lymph nodes. After 2011, 107 patients without lateral lymph node metastasis received NCRT with expanded radiation field to lateral lymph node region and reduced dose of irinotecan (60 mg/m 2 ). And we performed laparoscopic TME after NCRT. Through the entire period, 20 patients with a clinical complete response (cCR) after NCRT, who had poor general condition or refused to receive operation, management by watch-and-wait approach emerged as a treatment option.

Result: In the early regimen, 24% of patients had a pathological complete response (ypCR). The local recurrence-free survival (LFS) was 93%, disease-free survival (DFS) was 79%, and overall survival (OS) was 80%. In the current regimen, ypCR rate was 20.6%, LFS was 92.5%, DFS was 72.0% and OS was 84.5%. In the both regimen, patients with histological response grade3 had good prognosis (DFS = 96.9% in the early regimen and 100% in the current regimen). There were no significant difference according to short-term outcome between open and laparoscopic surgery after NCRT. In the patients who received watch-and-wait approach, there were 2 cases received additional CRT, and one case of additional chemotherapy. Recurrence rate was 20.0% (4 patients), and all of these patients received laparoscopic /robotic salvage surgery within 2 months after recurrence. DFS was 82.3% and OS was 100% in watch and wait approach group. Conclusion: NCRT with S-1/irinotecan produced excellent long-term survival outcomes in patients with rectal cancer, and combination with laparoscopic /robotic surgery will provide low invasive treatment.

Does initial experience in ileocolonic intracorporeal anastomosis negatively impact postoperative outcomes? Table 1 . There was no 30-days mortality. The initial group (A) showed slightly higher rates in 30-days morbidity, 30% vs 24.1%, however, this difference was not significant (p = 0.613). Similarly, secondary variables such as Clavien-Dindo Scale C 3, Anastomotic-leak or Reintervention rate also were a little higher, but none was significantly different ( Table 2) . Conclusion: Despite postoperative outcomes were slightly impaired during ileocolonic IA initial experience, there was no significant difference between both groups. Introduction: Small bowel disease has long been a challenge to diagnose given limitations in visualization and tissue biopsy. Advances have been made including capsule endoscopy, however, making a diagnosis remain difficult. We describe a rare case of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) following partial small bowel resection secondary to a retained capsule endoscope. Case Report: Our patient is an 80-year-old male presenting to colorectal surgery clinic with concern for impacted capsule endoscope following a work-up for chronic anemia. Computed tomographic imaging revealed a metallic foreign body within the small intestine. The patient underwent laparoscopic assisted removal of the capsule with unsuccessful attempts to manipulate due to strictures or intraluminal webs entrapping the capsule. Subsequently, he required laparoscopic assisted small bowel resection with side to side functional end to end anastomosis. Intraoperative findings revealed short segment inflammatory changes, creeping fat, and antimesenteric fat concerning for Crohn's Disease. Interestingly, pathology demonstrated segments of strictures, shallow fissuring ulcers involving mucosa and submucosa, and focal pyloric metaplasia; compatible with multifocal stenosing ulcerations of the small intestine. Given the presence of disease primarily in the jejunum rather than ileum, shallow mucosal and submucosal ulcers without architectural distortion of the mucosa immediately adjacent, and normal mucosa between ulcers and strictures, other etiologies for the multifocal stenosing ulcerations of the small intestine were considered leading to the diagnosis of CMUSE. The patient was discharged on post-operative day two without complications.

Discussion: CMUSE is a chronic or relapsing disease exclusively of the small intestine resulting from multiple strictures with mucosal and submucosal ulcerations presenting with an array of vague abdominal symptoms. First described in 1964, CMUSE is a rare diagnosis with fewer than 100 cases reported in literature. Often, patients get misdiagnosed as irritable bowel disease, Crohn's disease, NSAID enteropathy, or intestinal tuberculosis with Crohn's disease being the most common.

A key differentiating factor with Crohn's disease involves sparing of the terminal ileum seen in CMUSE. Onset is commonly in adolescent and middle-aged populations, making our case unique. Initial therapy involves corticosteroids with surgery remaining a last resort given high rates of disease recurrence. Conclusion: We described a unique case of CMUSE diagnosed in an elderly patient following partial small bowel resection for a retained capsule endoscope. Further investigation is warranted to better understand the underlying pathophysiology and etiology; however, it remains important to keep on your differential as treatment may vary from other small bowel diseases.

Colonic stenting as a bridge to surgery in obstructing colorectal cancer. Five years' experience from Tertiary Referral Centre Introduction: Colonic stenting is used as an alternate way of ameliorating obstructive symptoms in the management of acute colonic obstruction. When successfully performed; it provides potential advantage to convert emergency to elective procedure leading to better short-term outcomes. We present our experience of utilization of colonic stent as bridge to surgery from single centre practice over five years.

Methods: Data was collected for all patients presenting between January 2015 to September 2020 with diagnosis of colorectal cancer in largest tertiary referral colorectal department of the country. All patients with obstructing colonic malignant lesions located between transverse colon and rectosigmoid region were included. Analysis performed for patients who underwent surgical resection with curative intent following the attempted stent procedures. Conclusions: Colonic stenting is associated with higher success rates for the relief of obstruction. It provides an opportunity to convert emergency to elective resection leading to significantly lower stoma formation, shorter length of stay and better disease-free survival in our study. Cecal mucosal bleeding is an undocumented and rare cause of lower gastrointestinal (GI) bleeding. We present a case of a 73-year-old woman with end stage renal disease and paroxysmal atrial fibrillation on apixaban who presented after three days of having maroon colored stool which progressed to hematochezia. She was found to have symptomatic, acute on chronic anemia with hemoglobin of 5.6 gm/dL requiring multiple packed red blood cell transfusions. Colonoscopy revealed a localized area of active, mucosal bleeding at the cecum without evidence of dieulafoy lesion, ulcer, mass, arteriovenous malformation, or diverticula. Hemostasis was achieved with epinephrine injection and the use of bipolar electrocautery. She was later resumed on her therapeutic anticoagulation without reoccurrence of bleeding. This case expands the differential of acute, lower GI bleeding to include cecal mucosal bleeding-a rare, and likely transient, cause that is amenable to endoscopic management.

Robotic management of rectourethral fistula The mean operative duration was 8, 12.5, and 14 h for DO, SO, and DE groups; and the mean estimated blood loss was 235, 200, and 466 mL, respectively. The mean length of stay was 6 (DO), 6 (SO), and 12 (DE) days.

Postoperatively, the number of patients who had a Clavin-Dindo grade complication of III or greater were 2 (DO), 1 (SO), and 0 (DE), and only 1 patient (DO) had a recurrence of rectouretheral fistula. Conclusion: Robotic-assisted approaches for the treatment of rectourethral fistulas appears safe and feasible with acceptable short term outcomes.

Complex multi-specialty management of an latrogenic rectospinal fistula Christopher Jacobs, MD; Patrick Underwood, MD; Thomas Huber, MD, PhD; Salvatore Scali, MD; Thomas Read, MD; University of Florida.

Introduction: Colorectal-spinal fistulas are an extremely rare entity, the most common etiologies being complications following colectomy, ruptured appendicitis, diverticulitis and post-radiation necrosis. The problem and its treatment are associated with substantial risk of morbidity, mortality and reoperation. Herein, we present a case of a recto-spinal fistula following iatrogenic injury during pelvic lymphadenectomy for recurrent prostate cancer, and describe the subsequent multispecialty treatment required. Case presentation: A 67-year old man underwent prostatectomy and radiotherapy for prostate adenocarcinoma in 2003. In 2018 he underwent robotic retroperitoneal lymph node dissection for nodal recurrence at an outside institution. There were unrecognized thermal injuries to the left common iliac artery and sigmoid. Ten days postoperatively, the patient suffered acute massive gastrointestinal hemorrhage. At operation, he was found to have a left common iliac to sigmoid colon fistula requiring left common iliac ligation, right to left femoral-femoral bypass and Hartmann resection of the sigmoid. Two months later he developed persistent bleeding from the rectal stump related to an intraabdominal phlegmon presumably from persistent infection from the aortic bifurcation with fistula to the rectal stump. He was then transferred to our institution and underwent a temporizing aorto-uniiliac (AUI) Cook stent graft to his right internal iliac artery with coil embolization of his left common, internal and external iliac system to effectively isolate his left hemipelvis. He did well over the next several months but then started complaining of severe low back pain and fevers. CT angiogram revealed gas around his left common iliac artery and rectum tracking to his spine. A rectospinal fistula was suspected due to occult rectal stump blowout. He was treated with intravenous antibiotics and ultimately underwent extra-anatomic bypass (right ax-fem) with AUI graft explantation and aortic ligation. He was found to have a chronic blowout of the rectal stump eroding into the L5-S1 disc space. With the assistance of neurosurgery the disc space was debrided and the rectal stump was resected to the mid-rectum and reclosed. The patient recovered without acute incident. His back pain resolved though he suffers from mild left leg claudication. Discussion: As illustrated in this case, management of acute arterial-colonic fistula, and subsequent rectospinal fistula can be complex. Colorectal-spinal fistulas are rare and of diagnostic interest. With a multidisciplinary approach in a tertiary care center, morbidity may be minimized and a good outcome may be achieved. Introduction: The laparoscopic rectal surgery has been proven non-inferior to open surgery in various randomised trials. As more expertise is gained along with better imaging, laparoscopic surgery will be used by surgeons for B-TME (beyond total mesorectal excision) and E-TME (extended total mesorectal excision). There are no randomized controlled trials for laparoscopic E-TME, but that does not negate the role of minimally invasive surgery for locally advanced rectal cancer. Here we present our experience of laparoscopic E-TME at Tata Memorial Hospital, Mumbai, India. Material and procedures: We report 35 cases of locally advanced carcinoma mid and lower rectum. After local imaging and metastatic workup, all patients were discussed at a multidisciplinary meeting. All patients were treated with neoadjuvant chemoradiotherapy. All perioperative and intraoperative data were collected retrospectively from prospectively maintained electronic data. Results: Between February 2014 and June 2020, 35 male and female patients with rectal adenocarcinoma were operated with laparoscopic extended TME. All data were collected from electronically maintained records. All patients received neoadjuvant chemoradiotherapy. 12 patients received additional neoadjuvant chemotherapy. The mean body mass index was 21.42 (range 14.9-32). Mean blood loss was 532 ml (range100-1800 ml). Mean duration of surgery was 327 min (range 200-620 min). Mean hospital stay was 7.97 days (range 4-25 days) 0.12 patients underwent prostate shaving. 9 patients underwent seminal vesicle excision. 12 patients underwent posterior vaginal wall excision. 4 patients underwent presacral fascia excision. 1 patient underwent sacrospinous ligament excision. In all patients, R0 resection was achieved. On the histopathology circumferential resection margin and the distal resection margin were negative in all patients. Overall postoperative morbidity was 49% (18/35). 30-day mortality was 0%. During postoperative stay 7 patients developed a perineal wound infection. 4 patients had urinary retention and required prolonged catheterization. 4 patients developed stoma related complications. 1 patient developed posterior vaginal wall gaping. 1 patient developed intestinal obstruction for which exploratory laparotomy was required. Of 35 patients, 20 patients have a minimum follow up of 12 months (range 12 months -73 months). During this period no patient developed local recurrence. 4 patients developed lung metastases (4/20, 20%). One patient died due to systemic disease. 1-year overall survival was 95.8%-and 1-year Disease-free survival was 80.3%. Conclusion: Laparoscopic E-TME is feasible and oncologically safe option compared to open E-TME. Careful selection of the patient is important for good oncological clearance.

Colorectal anastomosis leakage and the utility of modified dulk score in postoperative management Introduction: Colorectal anastomotic leak (CAL) is a life-threatening complication with high postoperative morbidity and mortality. In practice, some of objective methods have been used for early CAL diagnosis. In which, the modified DULK score is a simple method. This score can be used daily in order to alarm physicians to the CAL with significant value. However, it is lack of studies validating this score. Objectives: To analyze the value of mDULK score, determine the appropriate cutoff point and the correlation between mDULK score and CAL. Material and methods: A prospective cohort study was started from 01/06/2018 to 31/05/2019 at Binh Dan Hospital. Data of 261 patients with primary anastomosis were collected to our database and then analyzed with STATA and R. Results: 34 cases of anastomotic leaks (13.03%) were confirmed. The median time to diagnosis was post-operative day 5, the median delayed time was 2 days. For management, 12 relaparotomies were performed with stomal creation, and 22 remaining cases were treated conservatively. Both the mean and the highest of mDULK score was significantly related to CAL (p \ 0,001). With the multivariate linear regression, four components of the score significantly helped to predict CAL (p \ 0,0001). With the cut-off value mDULK = 3, the sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio ? were respectively 85.3%, 96.9%, 80.6%, 97.8%, 27.7. The area under the curve was 0.96 so this was a good score which can be used effectively in detecting colorectal CAL. Conclusions: The modified DULK score was proven to be effective and easily available method in postoperative management to help diagnosing CAL in an early phase. It is hoped this study will help to improve surveillance so that the postoperative mortality will be reduced. Moreover, the result of this study should be evaluated as a source for other study about postoperative management of colorectal anastomosis. Keywords: anastomotic leak, colorectal anastomosis, DULK score, modified DULK score P272 Minimally invasive right versus left colectomy for cancer Yosef Nasseri, MD 1 ; Eli Kasheri, BS 1 ; Kimberly Oka, BS 1 ; Brian Cox, MD 2 ; Jason Cohen, MD 1 ; Joshua Ellenhorn, MD 1 ; Moshe Barnajian, MD 1 ; 1 Surgery Group of LA; 2 Cedars-Sinai Medical Center.

Background: Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of minimally invasive RC and LC for cancer, with analyses of robotic and laparoscopic techniques. Methods: In a retrospective review of a prospective database, preoperative factors, intraoperative events, and 30-day postoperative outcomes were compared. Student's t-test and Fisher's exact Chi-square test were used for continuous and categorical variables. The Mann-Whitney U test was used to analyze differences in complications on a continuous scale. vs. 50.9 p = 0.032), but no differences in rates of ileus/SBO (27.9% vs. 19.1% p = 0.28) or wound infections (9.0% vs. 4.3% p = 0.34). Although not significant, the mean length of stay (LOS) was longer in RC vs. LC (7.7 vs 6.9 days, p = 0.47). There was no difference in time to first flatus/bowel movement (3.0 vs 2.7 days, p = 0.38) or in 30-day readmissions (9.0% vs 8.5%, p = 0.72). When adjusting for surgical technique, age, and gender, there was no significant difference in overall complications between RC and LC. When adjusted for age, gender, and side, laparoscopic surgery had a 2.5 times higher rate of complications than robotic surgery (p = 0.029). Robotic RC had shorter mean LOS compared to laparoscopic RC (6.3 vs 9.4, p = 0.046). Both robotic RC and LC had a significantly shorter time to first flatus/bowel movement compared to laparoscopic RC (2.4 vs. 3 .4 days, p = 0.037) and LC (2.5 vs. 3.7 days, p = 0.020), respectively. Conclusion: Previously reported outcome differences between laparoscopic RC and LC for cancer may be mitigated by robotic surgery.

Impact of facility volume on outcomes following operative management of non-metastatic rectal adenocarcinoma: an analysis of the National Cancer Database Michael L Horsey, MD 1 ; Andrew Sparks, MS 2 ; Matthew Ng, MD 3 ; Vincent Obias, MD 3 ; 1 Walter Reed National Military Medical Center; 2 George Washington University Medical Faculty Associates; 3 George Washington University Department of Colorectal Surgery.

The primary aim of this study was to investigate whether facility surgical volume affects short and long-term outcomes in patients with non-metastatic rectal cancer. Secondary aims were to examine demographic and clinicopathologic differences between high and low volume centers. Methods: The National Cancer Database was queried for patients with non-metastatic adenocarcinoma of the rectum or rectosigmoid junction who underwent surgical resection from 2010-2016. Cohorts were separated into low facility volume (\ 5 cases/year) and high facility volume ([ 10 cases/year). Demographic and clinicopathologic variables were then compared between cohorts. Propensity-score matching (PSM) was then utilized to balance potential confounding covariates between volume cohorts to elucidate the independent association between volume and outcome. Kaplan-Meier estimation and Cox-Proportional Hazards regression were used to analyze survival. Secondary outcomes were analyzed by way of logistic regression or Mann-Whitney U test. Results: Low and high volume inclusion criteria identified 3805 and 3986 patients, respectively, before matching. Patients treated at high volume centers tended to be younger, have a lower Charlson morbidity index score, have more private insurance, higher incomes, and received treatment at academic medical centers (respective p \ 0.05). Additionally, patients at high volume centers presented at higher clinical stage, received more chemotherapy and radiation, and were more likely to undergo a minimally-invasive surgical approach than patients at low volume centers (respective p \ 0.05). PSM resulted in 983 low volume patients matched to 983 clinicallysimilar high volume patients with adequate confounding covariate balance (all respective p [ 0.15). In comparing PSM high and low volume cohorts, no difference was detected in regional nodes positive C 4, negative circumferential margins, unplanned readmission, 30-or 90-day mortality, or days from surgery to adjuvant chemotherapy. High volume was significantly associated with increased odds of C 12 regional nodes examined (odds ratio = 1.92; p \ 0.001) and decreased odds of positive margins (odds ratio = 0.61; p = 0.013). Additionally, despite no difference in 30-or 90-day mortality, high volume was significantly associated with decreased mortality hazard for overall survival (hazard ratio = 0.72; p = 0.002). Conclusions: Rectal cancer is a complex disease that requires individualized and specialized care. Significant differences in demographics and clinicopathologic variables exist between specialized centers with high surgical volume and those with lower surgical volume. When matched for demographics and stage, patients who underwent surgery at high volume centers had improved chances of adequate lymphadenectomy, margin-negative resection, and long-term survival. These findings have implications for patient referral and centralization of the care of patients with rectal cancer.

Optimal timing for surgery following neoadjuvant chemoradiation in patients with Abdul Waheed, MD 1 ; Wazir Akbar, MBBS, FCPS 2 ; Sh A Hai, MD, FACS 3 ; Friedrick D Cason, MD, FACS 4 ; Michael H Albrink, MD, FACS 1 ; Veronica Tucci, MD 5 ; Noor Nama, MBBS 2 ; Kai Huang, MD 6 ; Ji Fan, MD 6 ; Asad Ullah, MD 7 ; Subhasis Misra, MD, FACS 6 ; 1 University of South Florida; 2 Bolan Medical College Quetta, Pakistan; 3 East Florida Division GME Consortium, Westside Regional Medical Center, Plantation, FL, USA; 4 San Joaquin General Hospital, French Camp, California, USA; 5 Oakhill Hospital, Florida, USA; 6 Brandon Regional Hospital, Brandon, Florida, USA; 7 Augusta University, Georgia, USA.

Introduction: While surgery remains the gold standard for treating rectal cancer, neoadjuvant fluoropyridine-based chemoradiation has been recommended by the National Institute of Health. However, the optimal timing of neoadjuvant chemotherapy and its impact on patient response rate remains controversial and limited to small cohort studies. This study sought to analyze neoadjuvant chemoradiation's role in incomplete patient response rates in rectal cancer patients. Methods: A comprehensive literature search of PubMed, Google Scholar, Medline, and the Cochrane Central Registry of Controlled Trials (1966-2019) was conducted. Keywords searched included rectal cancer, neoadjuvant chemoradiation, and surgery, and only articles written in English were included. The outcome analyzed was the incidence of complete patient response (pCR). Results: 13 studies involving 2,731 patients were included. Studies ranged from neoadjuvant chemoradiation completed 41 days before surgery to 12 weeks before surgery. 13 of the studies reported higher pCR rates following extended intervals between neoadjuvant chemoradiation and surgery, 5 of which were statistically significant. Results ranged from 27.1%-34.5% for extended intervals, compared to 15.3%-27.3% for shorter intervals between neoadjuvant chemoradiation and surgery. Conclusions: Prolonged interval between neoadjuvant chemoradiation and surgery is associated with significantly higher rates of pCR compared to shorter intervals. Prolonging the interval time between neoadjuvant chemoradiation and surgery may increase the chance of pCR; however, randomized control trials evaluating the impact of the prolonged interval between neoadjuvant chemoradiation and surgery on rectal cancer of various stages are required.

The effect of COVID-19 pandemic on current and future endoscopic personal protective equipment practices: a national survey of 77 endoscoposts Warren Sun, MD 1 ; Melanie El Hafid 2 ; Jerry T Dang, MD 1 ; Valentin Mocanu, MD 1 ; Gregory Lutzak, MD 1 ; Richard Sultanian, MD 1 ; Clarence K Wong, MD 1 ; Shahzeer Karmali, MD, MPH 1 ; 1 University of Alberta; 2 University of Toronto.

Introduction: Personal protective equipment (PPE) guidelines serve to protect healthcare providers and patients from harmful biohazards. With the rise of the 2019 SARS-CoV-2 disease (COVID-19), many institutions have mandated strictly enforced endoscopic PPE guidelines. We currently do not know how current practitioners perceive these mandates or how they will influence their practice long-term. We aimed to study the PPE practices among endoscopists across Canada and compare their perceived differences in practice between the pre-and post-pandemic eras. Methods and procedures: A 74-item questionnaire was emailed from June 2020 to September 2020 to all members of the Canadian Association of Gastroenterologists and the Canadian Association of General Surgeons through monthly newsletters. The survey was created by expert consensus and distributed using the REDCap software. Survey questions collected basic demographics of Canadian endoscopists, and differences between PPE practices pre and post COVID-19 pandemic eras. PPE practices were categorized into four endoscopic procedure types: diagnostic or therapeutic, and upper or lower gastrointestinal endoscopy. Individual outcomes were reported as rates, or ranges when evaluating for all procedure types. ). In the pre-pandemic era, the majority of endoscopists wore gowns (91.0-93.9%) and all endoscopists wore gloves (100%). However, the majority of endoscopists did not wear surgical masks (20.9%-31.3%), N95 respirators (1.5%-3.2%), face shields (13.4%-33.9%), eye protection (13.4%-21.3%), or hair protection (11.1%-12.5%). In the post-pandemic era, endoscopists reported a plan to dramatically change their pre-pandemic practices and adopt current PPE mandates. All endoscopists reported a plan to fully gown and glove (100%) with the majority reporting they will continue wearing surgical masks (87.7%-90.5%), face shields (57.8%-75.0%), and hair protection (50.8%-53.8%). However, the majority reported a plan to decrease universal use of N95 respirators (6.5%-23.7%) or eye protection (36.5%-40.0%). Overall, the top three PPE changes endoscopists reported implementing in the post-pandemic area include increasing routine use of surgical masks (50.6%-61.0%), face shields (32.5%-46.8%), and hair protection (32.5%-36.4%). Endoscopists also reported a plan to change gowns more frequently (13.0%-19.5%). Conclusion: The COVID-19 pandemic has changed the attitudes of many endoscopists regarding future PPE use in routine endoscopy. Ongoing studies comparing the rates of transmission of hospital-acquired infections in the setting of endoscopy are needed to develop a new post-pandemic PPE consensus.

Assessing medical priorities during a pandemic: has limiting inperson encounters during the COVID-19 pandemic negatively affected IBD patients? A survey-based evaluation of patients at a tertiary care centre Allison J. Pang; Yossef Levin; Daniel Marinescu; Nancy Morin; Carol-Ann Vasilevsky; Marylise Boutros; Jewish General Hospital.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has greatly affected all facets of medical care. Although inflammatory bowel disease (IBD) is a life-altering disease, IBD patients may not have been as highly prioritized as oncologic patients during this time. The purpose of this project was to evaluate the impact of COVID-19 on IBD patients who had their healthcare interrupted due to the pandemic. Methods: After institutional review board approval, a questionnaire was conducted at a tertiary care centre specializing in IBD. Patients with IBD who had their medical care directly affected by the COVID-19 pandemic (i.e. cancelled clinics, endoscopies, or surgeries), were invited to participate. The questionnaire was comprised of basic demographic information, as well as three standardized scoring systems to measure IBD-related symptoms (Harvey-Bradshaw Index (HBI)/partial mayo score), quality of life (gastrointestinal quality of life index, GIQLI), and degree of distress caused by the pandemic (impact of event score, IES-R score). Independent associations between covariates and the three different scoring systems were identified by multivariate logistic regression. Results: A total of 59 patients were included in the study. The average age was 51 ± 15.4 years and 47.5% were female. There were near equal numbers of patients with ulcerative colitis and Crohn's disease, and 54% were on biologics. More than half of the patients had a moderate or high concern regarding the COVID-19 pandemic. The majority (86%) of patients had virtual meetings with their gastroenterologist or colorectal surgeon. According to the HBI/partial mayo score, 44% were in remission, 29% had mild symptoms, and 27% had moderate symptoms. The mean GIQLI was 104.5 ± 22.4 points. The IES-R score measured the impact that the pandemic had on stress levels -27% had no distress, 37% had mild stress, 32% had moderate stress, and 3% had severe stress. On multiple logistic regression, male gender (OR 9.17, 95%CI 1.32-62.5), being unemployed (OR 6.54, 95%CI 1.05-40), and having a lower GIQLI score (OR 1.11, 95%CI 1.05-1.18) were independently associated with the presence of IBD symptoms. However, there were no clinically relevant covariates that were independently associated with a lower GIQLI score or a higher IES-R score. Conclusion: The stress caused by COVID-19 was not associated with an increase in IBD symptoms or lower quality of life. As the pandemic continues, this study supports the adoption and continuation of virtual meetings with IBD patients, despite the disruption to their normal medical care.

Double prevalence of appendicular peritonitis during COVID times Sergio Riveros, MD; Grecia Artigas; Martin Inzunza; Rolando Rebolledo; Alejandro Brañes; Nicolas Quezada; Fernando Crovari; Pablo Achurra; Pontificia Universidad Católica de Chile.

Background: The global health emergency due to COVID-19 spread worldwide on an unprecedented scale generating a change in the management of common surgical pathologies. The delay in medical attention can lead to increased morbidity and mortality, which has not been reported in the analysis of the collateral damage caused by this pandemic. Methods: A non-concurrent cohort study in a single center was designed. A comparison between the incidence of appendicular peritonitis during 2020 COVID pandemic against the same period in 2019. Demographic data and perioperative Results were analyzed. Introduction: the aim of this study is to identify the potential shift towards nonoperative management due to patient's preference or simply due to delayed presentation. The COVID-19 pandemic, declared by the WHO by early March of 2020, possibly influenced the presentation, management, and outcomes of patients with acute appendicitis presenting to a hospital in New York City where COVID-19 had the highest number of cases in the state. Methods and procedures: a retrospective chart review of General Surgery patients [ 13 years-old who were diagnosed clinically and radiologically with acute appendicitis during two different periods: March to June 2019 and March to June 2020 from a community-based hospital was performed. We examined and analyzed the demographics, socio-economics, clinical, pathologic, and therapeutic completion data of all patients. Results: Of 102 eligible patients, 68 presented for the 2019 cohort vs 34 during the 2020 cohort showing a decrease of one-third of patients presenting during the COVID-19 pandemic. The patients presented with a mean age of 37.9 (SD: 17) vs 36.7 (SD: 16) years old. Our population of study was mostly Hispanic (65% vs 82%). Our patients presented mainly with right lower quadrant pain, nausea and/or vomiting. It was noted that patients during 2019 presented later with a mean of 4.64 days in comparison to 1.73 days during 2020 (p = 0.016). Laparoscopic appendectomy was the main management for both cohorts (85% vs 76%), with no significant differences between the length of stay for the 2019 cohort of 2.6 days vs 2020 cohort 3.1 days (p = 0.2). No COVID infection presented during the 2020 cohort. There were 7% readmissions of patients within 30 days in the 2019 cohort but none readmission during the COVID-19 pandemic. No mortalities occur during either period. Conclusions: acute appendicitis is one of the most common operative emergencies, but the COVID-19 pandemic affected the decision process managing these patients. Possibly, the decrease in the numbers of patients presenting to the hospital compared to prior years may represent successful resolution of mild appendicitis treated symptomatically at home. Compared to 2019, during the pandemic, the patients presented earlier in the hospital, allowing surgical management in a timely fashion of uncomplicated acute appendicitis, with no hospital readmissions or concurrent COVID infection. These Results showed a contrast to what initially we thought of delayed presentation and more non-operative management during the COVID-19 pandemic in 2020.

Lockdown with a price: the impact of COVID-19 pandemic on the incidence and outcome of complicated appendicitis Yaron Rudnicki, MD; Hagai Soback, MD; Ori Mekiten; Shmuel Avital, MD; Meir Medical Center.

Introduction: Emergency departments (ED) attendance during the COVID-19 pandemic outbreak under ''Stay at home'' orders have decreased dramatically. The aim of this study was to assess the delay in ED presentation and the incidence and outcome of complicated appendicitis cases during that period. Methods: A retrospective study comparing the rate and severity of patients with complicated appendicitis during the COVID-19 outbreak social restrictions in March and April of 2020 (P20) and the corresponding period of March and April of 2019 (P19) in a single tertiary center in Israel. Results: Overall, 123 patients were diagnosed with acute appendicitis, 60 patients during P20, and 63 in P19. The rate of complicated appendicitis cases was much higher during the COVID-19 lockdown with 43.3% (26 pts) vs. 20.6% (13 pts) respectively (p = 0.007). The average time from onset of symptoms to ED presentation was 3.4 days in P20 vs. 2 days in P19 (p = 0.03). The length of stay was 2.6 days in P20 vs. 2.3 days in P19 (p = 0.4) and the readmission rate was 10% (6 pts) vs. 4.8% (3 pts) respectively. 47% (28 pts) required postoperative IV antibiotics in P20 compared with 32% (20 pts) in P19 (p = 0.09). As restrictions were lifted in May 2020 the rate of CA decreased to 30% (11/36 pts) compared to 38% (16/42 pts) in May 2019 (p = 0.5). Discussion: The effect of the COVID-19 pandemic and the ''stay at home'' orders may have discouraged patients with acute appendicitis from presenting to the ED as symptoms began, causing a delay in diagnosis and treatment which lead to a higher rate of complicated appendicitis cases and a heavier burden on health care systems. As restrictions were lifted in the following month the rate of complicated appendicitis declined and resembled the rate in the correlating period a year before. Conclusion: COVID19 lockdown and ''stay at home'' orders may have a detrimental effect on patients that are sick with other non COVID19 illnesses and should be taken under consideration before imposing them. Acute pancreatitis is associated with a variety of etiologies, many of which are viral. SARS-CoV-2, the virus responsible for the COVID-19 pandemic, was initially thought to be primarily responsible for respiratory illness, but as the disease has become more prevalent, it is clear that COVID-19 is a multisystem disease with a wide array of clinical manifestations. Previous studies have demonstrated an association with pancreatitis and the SAR-COV virus, however, understanding of how the SAR-COV-2 virus affects the pancreas is limited. Here we present a 27-year-old male diagnosed with COVID-19 who subsequently developed sharp epigastric pain and was ultimately diagnosed with idiopathic acute pancreatitis suspected to be secondary to COVID-19.

Colon ischemia and perforation: the aftermath of COVID-19

Danilo Tueme de la Peña, MD 1 ; Jorge Pérez Macías, MD 1 ; Antonio Morales, MD 1 ; Hugo Rangel, MD 2 ; Luis Salgado Cruz, MD 2 ; Alberto Chapa Lobo, MD 2 ; 1 Christus Muguerza-UDEM; 2 Hospital Á ngeles Valle Oriente. The coronavirus disease (COVID-19) is an infectious disease caused by the newly discovered coronavirus SARS-CoV-2. During the COVID-19 pandemic we have seen the wide spectrum of this disease and the consequences that may deteriorate the patient in the short term. The gastrointestinal tract is a key site of infection of SARS-CoV-2, where it may predispose to thromboembolic complications, such as acute mesenteric and colonic ischemia and perforation. Even though, the exact mechanism by which the COVID-19 induces mesenteric and colonic ischemia is not known, both of them have a high mortality rate. Therefore, prompt suspicion, early recognition and timely treatment are essential to improve the outcomes in such patients.

We hereby present our experience with a patient with colonic ischemia and perforation undergoing treatment for COVID-19. This case highlights the diagnostic barriers and treatment dilemmas in critically ill patients during the COVID-19 pandemic.

The first patient is a 36 yo male, with past medical history of COVID-19 pneumonia that presented with acute abdominal pain and distension, without any other symptoms. He was sent to colonoscopy, which showed multiple areas of ischemia without evidence of perforation.

An observational survey study on quality and efficacy of telemedicine in general surgery outpatient clinic during the COVID-19 pandemic Introduction: Telemedicine has been studied in many surgical subspecialties that showed feasibility and promising outcomes, but the population studied is largely based on patient preference. One randomized control trial conducted in Spain only targeted patients who needed general surgery follow up appointments after hospitalization. Recently, due to the rapid progression of SARS-CoV-2 (COVID-19), social distancing strategy has led many hospitals to restrict the amount of in-person clinic visits. During this time, MedStar Franklin Square Medical Center (MFSMC) provided telemedicine visits in the outpatient surgery clinics. The COVID-19 pandemic provided a unique situation where patients had no choice but to choose telemedicine if they needed a surgical clinic visit. Therefore, we saw an opportunity to study the quality and efficacy of telemedicine in a heterogeneous population and ultimately conducted an observational survey study in both patients and surgeons after each general surgery telemedicine visit. Methods: For surgeon's survey, the topics included satisfaction, suitability, necessity of physical exam and whether an in-person visit would change clinical decision. For patient's survey, the topics included confidence, trust, feasibility, suitability, satisfaction, and whether telemedicine would be chosen over in-person visits in the future. Additionally, patient demographics, nature of visits and clinical decisions were collected. Results: 64 general surgery telemedicine encounters were identified between April and May, 2020 at MFSMC. The most common reasons for the visits were gallbladder disease at 20.31% and hernias at 39.06%. Among all the visits, 51.56% were new patients and 25% were postoperative visits. Surgeons' survey response was 100% and rated satisfaction for 79.69% of the visits. Although most visits were rated suitable, 70.31% rated physical exam as necessary and 57.81% rated possible change in clinical decisions if the visit was inperson, which occurred mostly in hernia related visits. On the other hand, patients' survey response was 34.38% and rated satisfaction for 86.35% of the visits. The confidence level in telemedicine increased from 50% to 86.35% after the visit took place. When asked if patients would choose telemedicine over in-person visits in the future, 81.8 responded yes. Ultimately 39% and 0.05% of patients underwent elective and urgent surgery repsectively. Conclusion: Telemedicine is a feasible alternative for both new patient and follow up visits in general surgery, especially during the COVID-19 pandemic. Generally both surgeons and patients are satisfied with telemedicine visits. However, surgeons prefer to include a physical exam for hernia related visits because of its potential effect on surgical management. Introduction: The COVID-19 pandemic has disrupted surgical practice worldwide. There is widespread concern for surgeon and provider safety and the implications of hospital lockdown on patient care during epidemics. Our systematic review aims to assess all research literature related to changes in surgical practice during epidemics, especially during the COVID-19 pandemic. Methods and procedures: Medline, EMBASE, CENTRAL, and PubMed were systematically searched from database inception to July 1, 2020 and ongoing monthly surveillance will be conducted. We included studies that assessed postoperative patient outcomes or protection measures for surgical personnel during epidemics. Secondary outcomes included complication rates following non-operative procedures and clinic volumes in included studies. Results: We included 61 studies relevant to the COVID-19 pandemic and past epidemics across 17 countries. Lockdown measures were noted globally including cancellation of elective surgeries and outpatient clinics. The pooled postoperative complication rate during epidemics was 21.0% among 2095 surgeries. The pooled rate of minor complications (Clavien-Dindo Grades I-II) was 12.3%, the rate of major complications (CD III-IV) was 5.3%, and the rate of all-cause mortality (CD V) was 3.4%. The complication rate among surgeries during the COVID-19 pandemic alone was 20.9%. Mortality secondary to complications from COVID-19 infection was reported in 1.1% of postoperative patients during the COVID-19 pandemic. Thirty-one studies followed the health of surgical workers with the majority noting no adverse outcomes with proper safety measures. Of the 405 HCW included in the analysis, 6.2% were infected during epidemics. During the COVID-19 pandemic, 8.6% of included HCW were infected. The most common measure to prevent HCW infection was the modification of peri-operative processes, such as assigning lanes in the hospital to transfer patients suspected to be infected and limiting visitations for patients. Mandated PPE use was the next most frequently reported measure, with common PPE items including hair covers, N95 or PAPR masks, surgical masks, face shields, goggles, and waterproof gowns. Secondary outcomes demonstrated a pooled post-procedural complication rate of 14.5% for non-operative procedures such as endoscopy, tracheostomy, and peritoneal dialysis. Of studies reporting on surgical clinic volume, there was an overall reduction in volume by 50% to 75%. Eight studies, all during the COVID-19 pandemic, also reported the use of telemedicine and virtual care modalities for outpatient consults and follow-up appointments.

Conclusions: This review highlights postoperative patient outcomes during worldwide epidemics including the COVID-19 pandemic and identifies specific safety measures to minimize infection of healthcare workers. Introduction: The novel coronavirus (COVID-19) outbreak has resulted in restrictions like quarantine and stay-at-home orders, strategies that many countries adopted on the early pandemic phase that could potentially impact patients presenting with acute cholecystitis and /or biliary colic. Methods and procedures: All patients that underwent laparoscopic cholecystectomy between 2019 and 2020 were reviewed. Two groups were created: nonpandemic (Group A: March/2019 -October/2019) and pandemic (Group B: March/ 2020 -October/2020) the dates correlate when elective surgeries were placed on hold in Bogota-Colombia due to COVID-19. Acute cholecystitis incidence, disease characteristics, and surgical outcomes were compared between the groups. Data were analyzed using STATA 16.1 software for Pearson correlations and ANOVA analysis. Results: Of 557 acute cholecystitis/biliary colic patients that underwent laparoscopic cholecystectomy 343 were categorized in Group A and 214 in Group B. The two groups were not different in age, sex, or American Society of Anesthesiologists (ASA) physical status classification. We found a deep impact on Parkland Grading Scale (PGS) on surgical findings (p \ 0.01), higher during the pandemic, and surgical approach (p = 0.02), more conventional approaches to decrease aerosolization. There were no significant differences in the Tokyo grading scale, choledocholithiasis, cholangitis, pancreatitis, nor complications incidence. These Results could be explained by the fear of patients to attend to an emergency room, due to the risk of COVID infection. Conclusion: The decreased volume of surgical procedures and an increase in negative surgical findings in laparoscopic cholecystectomy during the pandemic time, are the result of delayed consultation for acute conditions due to worldwide quarantine and fear. Introduction: The coronavirus disease (COVID-19) pandemic continues to be a global threat, particularly in the United States. Research shows that COVID-19 in hospitalized children tends to be less severe and associated with lower mortality compared to adults. There is a paucity of data regarding the need for procedural interventions in children with COVID-19. The objective of this study was to evaluate procedural interventions and outcome of hospitalized children with COVID-19 admitted to United States (US) medical centers. Methods and procedures: The Vizient Clinical Database was queried for in-patient hospitalization of children (0-18 years) with ICD-10 diagnosis of COVID-19 between March and October 2020. Clinical outcome measures included demographics, length of stay, rate and type of common procedural interventions and inhospital mortality. Results: During the 8-month period, a total of 3,572 hospitalized pediatric patients with COVID-19 were included. The mean length of stay was 6.0 ± 9.8 days and the in-hospital mortality was 0.84%. The most common procedural interventions in this cohort included respiratory intubation (n = 335, 9.4%), central venous catheter insertion (n = 300, 8.4%), diagnostic spinal tap (n = 203, 5.7%), appendectomy (n = 81, 2.3%), Swan-Ganz catheterization (n = 57, 1.6%), thoracentesis or thoracostomy (n = 39, 1.1%), and bronchoscopy (n = 34, 1.0%). The overall in-hospital mortality for patients required procedural interventions was 5.5%: 8.6% for patients requiring intubation; 8.7% for Swan-Ganz catheterization; 8.1% for bronchoscopy; 12.8% for thoracentesis or thoracostomy; 16.7% for hemodialysis and 7.1% for gastrostomy. Pediatric patients requiring blood transfusion (n = 330, 9.2%) had an in-hospital mortality of 4.9% and patients requiring parenteral nutrition (n = 124, 3.5%) had an in-hospital mortality of 8.1%. Conclusions: In this retrospective analysis of hospitalized pediatric patients with COVID-19, the most common procedural interventions were respiratory intubation, central venous catheter insertion, and diagnostic spinal tap. In-hospital mortality increased dramatically with the need for any procedural interventions. Introduction: COVID-19 pandemic has drastically altered the way surgical units function. Many changes have been introduced to diminish the risk of viral transmission among patients and healthcare professionals. Much have been said about the burden of those changes on hospital employees in their daily struggle, but little has been published on the patient's perspective. Aim: The aim of this study is to determine what is the patient's perception of undergoing elective surgical procedure during COVID pandemic. Materials and methods: We surveyed 285 consecutive patients that were admitted for elective laparoscopic cholecystectomy to the General Surgery Department of St John Grande's Hospital in Krakow after the national COVID lock-down has been lifted. The survey focused on how patients see this situation and how it has determined their health related behaviors. Results: 285 consecutive patients admitted to the Surgical Department for elective laparoscopic cholecystectomy between May 1st and September 31st have been asked to fill out a survey on admission. 252 fully filled out surveys have been gathered. 33 surveys have been excluded from the study due to their incompletion. 40% of the patients have had their surgical planes altered in some way due to the pandemic. 88,8% of patients declare no fear or slight fear of the virus, however 54% feel less safe in the hospital than before the pandemic. Median evaluation of preparation of the hospital was 9 out of 10, average score was 8.72. Majority of the patients have no opinion on whether they should be tested for coronavirus before admission. Almost no one (3.2%) is willing to pay for a commercial test prior to admission, but the majority (76.6%) is willing to self-quarantine before surgery if needed. Conclusions: The pandemic doesn't seem to have greatly influenced patients' health-related behaviors. The general attitude towards the pandemic by patients is rather calm. Most of them feel less safe in the hospital than before the pandemic, but the level of fear is low. Very few have resigned from surgery solely because of the pandemic.

Emi P Manuia, MD; Alexander Ostapenko, MD; Shawn T Liechty, MD; Daniel E Kleiner, MD; Danbury Hospital.

Introduction: The aim of this study was to assess the incidence of symptomatic COVID-19 transmission in patients undergoing endoscopic procedures during the spring 2020 outbreak. Endoscopic procedures canceled due to the COVID-19 pandemic depleted hospital revenue and potentially worsened patient outcomes through disease progression. Despite numerous safeguards to resume elective procedures, patients remain apprehensive of contracting COVID-19 peri-procedurally. Methods: We retrospectively analyzed 192 patients undergoing endoscopic procedures between 3/16/20 and 6/2/20 at Danbury and Norwalk Hospitals of Fairfield County, Connecticut. These dates represent the peak COVID-19 period, during which elective procedures were canceled and then resumed for two weeks. COVID-19 infection was assessed through test Results or documented well-being within two weeks post-discharge. Variables studied were procedure classification, length of stay, and discharge disposition. Post-procedural COVID-19 incidence was analyzed using binomial tests comparing rates to state-mandated transmission data. Introduction: COVID-19 pandemic has claimed over 230,000 lives due to pneumonia and related complications. The ongoing pandemic has caused major shifts in health care resource allocation. This included a ban on elective surgery and a subsequent decrease in elective procedures during the early phase of the pandemic. However, the effects on Emergency General Surgery volumes have not been studied. We sought to quantify the effects on surgical volumes for some of the most common emergent general surgical procedures. Methods and procedures: We retrospectively analyzed data from February to April of 2020, the period of time that had a state-wide ban on elective surgery and compared it with same period in 2019. Data was obtained for procedures performed and for admission diagnosis. We performed two sample T-test with equal variances to compare the two groups. Results: There was a statistically significant drop in daily emergent operations between the study period ( 6.13/day vs 4.64/day). A statically significant decrease in number of appendectomy, cholecystectomy, sigmoid colectomy with anastomosis, small bowel resection, operation for incarcerated and reducible hernia procedures was observed (Table 1) . Additionally, there was a statistically significant decrease in hospital admissions for appendicitis, cholecystitis, diverticulitis, skin and soft tissue infections, small bowel obstruction and GI bleed ( Table 2) . Conclusion: While elective surgical procedures saw a noticeable decline in volume during the early phase of the COVID-19 pandemic, similar effect on emergency general surgery procedures and hospital admissions has not been examined. We found that at a major tertiary care referral center, there was a statistically significant decline in emergency general surgery volume and hospital admissions.

Improving safety during laparoscopic surgery -a new device to minimize exposure to COVID-19, HPV, and carcinogens Jonathan Hearn 1 ; Christopher R Idelson, PhD 2 ; John M Uecker, MD 3 ; 1 The University of Texas at Austin; 2 ClearCam Inc; 3 Dell Medical School.

The COVID-19 pandemic has rekindled concern for increased risk of healthcare worker exposure to aerosolized particles, including operating room personnel exposure to aerosolized viruses HPV, carcinogens, etc.) . This study identifies potential avenues of exposure in the laparoscopic operating room, with a new technology consideration to potentially mitigate such exposure. Benchtop experiments with current laparoscopic trocar-instrument configurations suggest clinically relevant opportunity for release of aerosolized particles into the OR via gas leaks through compromised trocar seal interactions with instruments. A prototype technology, referred to as the Vulcan, was designed to reduce gas leakage during laparoscopic surgery. It is a simple device that adapts to a variety of scope-trocar configurations, thereby making it widely applicable across procedures. Reducing gas leakage that may contain particles of aerosolized COVID-19, or other harmful particulates, offers a rapid opportunity to improve safety of OR healthcare workers.

Vulcan is a multi-axis adaptive sealing device. A compressive member maintains an effective seal against instruments of various diameters to reduce leakage. An adaptive elastic housing serves as the anchoring mechanism of the device to trocar ports of various sizes. While simple in description, the mechanisms that allow for Vulcan's successful versatility and high performance have proven nuance to solve an important OR related concern. While the device is capable of being added onto currently available trocar ports, it is also designed with the potential capability to replace current valve seals with enhanced performance and safety.

A custom benchtop setup simulated insufflation of a surgical cavity in the OR. Three configurations were tested: (1) a commercial scope and commercial trocar, (2) a commercial scope, commercial trocar, and a Vulcan add-on prototype, and (3) a commercial scope and a modified commercial trocar (trocar valve is entirely replaced by Vulcan prototype). Each configuration was tested in two scenarios: (i) a static ''best case'' scenario with an uncompromised seal, and (ii) a dynamic ''real-life case'' scenario with a seal that was compromised with dynamic trocar-instrument interactions.

As seen in the figure below, static testing of an ''uncompromised seal'' for each configuration shows highly comparable performance, which demonstrates leak of gases with static instruments. Results from dynamic ''compromised seal'' testing show increased leakage of gas through the trocar port. However, both configurations that include the Vulcan technology show substantial improvement in leak mitigation., and versatility of the design suggests strong promise as a future safeguard for healthcare workers in the OR.

Perioperative management of patients undergoing surgery during pandemic -guiding principles, challenges and outcomes Introduction: The emergency preparedness during pandemic has impacted surgical practice across the globe. Although, pandemic can affect the postoperative outcomes of surgical patients. Patients undergoing surgeries during pandemic go through aggressive preoperative investigation although the postoperative outcomes of these measures are unknown. Currently there is scare data on complications and outcomes of surgical patients during this global crisis. It is crucial to know the safety of surgical procedure and outcomes especially to weigh the risk and benefits of performing surgeries during pandemic. Objectives: To determine the preoperative COVID 19 status and screening performed pre, intra and postoperatively and its impact on patient related outcomes. Methods: We did the retrospective data review of all the patients underwent surgery for any reason during pandemic peak March 22nd to May 6th, 2020 in our tertiary care hospital in Midwest US. We have identified total 2658 patients of different specialties. To further narrow down the review and evaluation of patients we only included department of surgery and have identified 1052 patients. After excluding duplicate entries and lack of research authorization we have evaluated 951 patients for detailed perioperative variables, comorbidity, and post-operative outcomes after 14 days of dismissal. Results: Mean age was 53.7 years (range 0-98), female to male ratio 1.01, mean BMI 28.0 kg/m 2 (range 7.5-60.7), 942 patients were from USA, and 9 were international patients. Preexistent comorbidities included HLD (41%), ?HTN (40%), DM (25%), CKD (21.6), cancer (73.1%), and COPD (31%). Preoperative COVID swab performed in 644 patients out of 1 patient was COVID positive. Preoperative CT chest performed in 265 patients out of 1 patient was COVID positive. Majority of cases performed for acute care surgery (32%) followed by colorectal surgery (13.6%) and HPB surgery (13.2%). 91% patients received general anesthesia and 9% received MAC and regional. Mean ASA rating was 2.6. 72.2% patients got admitted and 27.8% remained as outpatient. Mean hospital stay was 5.4 days (range 0-150). 25 patients underwent COVID swab within 14 days of discharge from hospital due to symptoms but only one patient diagnosed COVID positive. 139 patients got readmitted within 14 days of discharge but remained COVID negative.

Conclusion: This study has demonstrated that with aggressive perioperative screening, evaluation, and standard practice, patients remained safe within 14 days of window period post discharge from hospital. Patients have achieved desired outcomes without cross contamination with COVID during and after hospital stay at peak of COVID pandemic. We have minimized the COVID spread using personal protective equipment, thorough preoperative evaluation, no visitors policy in our hospital, and cautious postoperative management. Introduction: The COVID-19 pandemic has had a dramatic impact on surgical education. One concern among the surgical community is if the virus can be transmitted to staff via aerosolized smoke used during minimally invasive surgery (MIS). As such, many have advocated for minimizing use of these techniques. Though this is a reasonable strategy in trying to minimize disease spread, it could negatively impact training for residents and fellows. Methods and procedures: The electronic medical record at a single institution was queried for operations completed by the MIS/general surgery service during three time periods: the seven weeks during the pandemic in which elective surgery was suspended, the seven weeks that followed when elective surgery was resumed, and the corresponding seven weeks from the prior year. The number of operations, proportion of MIS operations, and complexity of MIS operations were compared. Results: The operative volume during suspension of elective surgery fell to 38 cases from 113 during the corresponding timeframe the prior year. After resumption of elective surgery, volume rebounded to 88 cases. During the suspension of elective surgery, 26 (68%) cases were completed minimally invasively. This compares to 79 (70%) and 65 (74%) before and after this time period, respectively (p = 0.767). However, when bariatric cases were compared between groups, 0 were performed during suspension of elective surgery, which was significantly less than before (25, 32%, p = 0.010) and after (26, 40%, p \ 0.001) that time. When percutaneous endoscopic gastrostomy (PEG) was examined, 10 (38%) were performed during suspension of elective surgery, whereas 13 (16%, p = 0.031) and 4 (6%, p = 0.001) were performed before and after this time, respectively. Conclusions: Operative volume dropped greatly when the pandemic began, but the proportion of MIS operations remained unchanged. However, it appears the complexity of MIS cases diminished during this time. With a focus on discharging patients, PEGs were completed at a much higher rate, which helped to maintain an MIS presence. Unfortunately, more complex operations like gastric bypass were eliminated during that time negatively impacting resident and fellow learning. The pandemic, with anticipated additional waves, is not only reducing trainee operative volume, but also MIS complexity, which may leave many trainees ill-prepared for attending practice. Introduction: On March 16, 2020, elective surgeries were halted in New York City due to the COVID-19 pandemic. The order was lifted on June 9, 2020, and elective surgeries were resumed within the subsequent weeks. While this suspension of elective cases appropriately diverted healthcare resources to the pandemic, this forced interruption of elective cases was unprecedented, and we hypothesize the three-month limited case volume may have caused a decline in surgical skill as assessed by operative time and crowd-sourced skill assessment. Methods: Patients undergoing robotic sleeve gastrectomy between January 1 and March 16 (pre-suspension) and June 9 and August 31 (post-suspension) at a single health care system were captured in a prospective database. GEARS scores were assigned through crowd-sourced evaluators by a third party. A paired t-test was used to compare the mean operative time and GEARS score for each surgeon before and after the suspension. Two-tailed p-value \ 0.05 was considered significant. Results: Four surgeons and 39 patients were included for review; 22 patients (56%) underwent an operation pre-suspension and 17 (44%) post-suspension. Mean operative time was unchanged before vs after the suspension (53.5 ± 18.1 vs 59.3 ± 23.5 min, p = 0.48). GEARS scores significantly decreased after elective surgeries were resumed (20.3 ± 0.66 vs 20.0 ± 0.51, p \ 0.001). The GEARS subcomponent score bimanual dexterity was significantly reduced after interruption of elective surgeries (4.09 ± 0.16 vs 3.93 ± 0.13, p \ 0.001). There was insufficient evidence to demonstrate a change in the other subcomponents of the score, such as: robotic control (4.24 ± 0.18 vs 4.23 ± 0.14, p = 0.44); force sensitivity (4.22 ± 0.17 vs 4.14 ± 0.18, p = 0.82); efficiency (3.71 ± 0.14 vs 3.70 ± 0.19, p = 0.83); and depth perception (4.07 ± 0.21 vs 4.02 ± 0.16, p = 0.99). Conclusion: In our patient cohort, the mean operative time during robotic sleeve gastrectomy was not significantly impacted by the 3-month suspension in elective surgery; however, the GEARS score significantly decreased, a finding that was mainly driven by decreased bimanual dexterity. During periods of absence from the operating room, surgeons should attempt to engage in simulations to maintain robotic skills.

Effects of COVID-19 on emergency surgeries in a teaching hospital in Lahore, Pakistan Muhammad Imran Khokhar, Associate Professor Of Surgery 1 ; Suleman Asif, Senior Registrar 2 ; Muhammad Farooq Afzal, Professor of Surgery 1 ; 1 PGMI, AMC, LGH, Lahore; 2 LGH, Lahore.

Background: After outbreak in December 2019 in Wuhan China, Covid-19 was declared a public health emergency on January 30th, 2020 and later a pandemic. Since then it has significantly affected almost every field of life and certainly every domain in medical field. The schedules of the wards, the outpatient departments and the emergency wards, all have been disturbed and reshuffled. The surgical emergency wards in the teaching hospitals had huge changes in the number of cases and surgeries. Surgery departments all over the country have responded to the crisis by prioritizing the emergency surgical procedures. Methodology: This study was conducted for three months at Lahore General Hospital, Lahore from 01.03.2020 to 30.06.2020. All patients presenting in surgical emergency department were included in the study. The data was compared with similar data collected during same months of yester year. Specific precautionary measures had to be taken during management of these patients. The effect of Covid-19 was observed on total number of patients presenting in emergency, decision making about surgical management versus conservative management and their outcome. Results: There was obvious decrease in total anumber of patients presenting to surgical emergency. Due to lockdown, trauma patients were much less as compared to last year's data. Abdominal and other infections also declined, probably due to decrease in community acquired infections. Patients with malignancies suffered because more palliative procedures were performed during the said Covid-19 period. Introduction: In response to the COVID-19 pandemic, most elective surgical procedures have been delayed. Even with the implementation of surgical societies' recommendations, patient safety still remains a concern. Data reported in this field is limited. This study aims to evaluate the postoperative outcomes in patients undergoing bariatric surgery after reopening elective surgery during the COVID-19 peak era compared with a historical cohort. Methods and procedures: All patients who underwent primary and revisional bariatric surgery from September 2015 to July 2020 were identified from a prospectively maintained registry with Institutional Review Board approval. The pre-COVID-19 (PC) cohort included cases from September 15, 2015 to March 11, 2020. The re-opening (RO) cohort included a series of patients who tested negative to COVID-19 from June 1, 2020 to July 31, 2020, which corresponded with a period of active disease spread. Propensity score weighting was implemented to equate on baseline covariates when examining group comparisons on postoperative outcomes. Elective operations didn't occur in our institution during the first peak. After the development of guidelines to mitigate the disease spread have been implemented, elective procedures were resume. A policy was implemented to transfer all Covid-19 patients to another facilities, as well as mandatory PCR testing for all admitted patients. The UAE has instituted a number of policies to actively combat the COVID pandemic with fines up to 50,000 DHS (13,612 USD). Results: Our study included 1,076 patients, 64% were female with a mean age of 37 ± 11 years old and median Body Mass Index (BMI) of 41 ± 8 kg/m 2 . 804 (74.7%) cases were primary and 272 (25.3%) cases were revisions. 1,015 patients were in the PC cohort and 61 patients in the RO cohort. Both groups had similar demographics profiles. There were no statistically significant differences in 30 day peri-operative outcomes including Emergency Department visits (24.8% PC vs 19.7% RO, p = 0.492), re-admission (4.2% PC-19 vs 8.2% RO, p = 0.361), reoperation (2.6% PC vs 0% RO, p = 0.996), minor complications (5.4% PC vs 4.9% RO, p = 0.895) and major complications (4.0% PC vs 4.9% RO, p = 0.812). No patients from the RO cohort contracted COVID-19, had pulmonary complications or were admitted to the intensive care unit during the post-operative phase. Conclusions: With the appropriate policies and precautionary measures there appear to be no differences in the 30-day postoperative outcomes among patients who underwent bariatric surgery before and during the covid-19 pandemic. Introduction: Indigenous health has increasingly become a focus in improving Canadian health care. The Indigenous population is known to experience disparities including higher rates of chronic disease and lower life expectancy. However, disparities in surgical outcomes are less well described. The purpose of this literature review is to identify available studies comparing surgical outcomes among Indigenous and non-Indigenous populations in Canada to better characterize research in this area and the presence of any disparities. Methods: A systematic search was conducted using MEDLINE and Embase from database inception to October 2020 to identify all studies reporting comparative surgical outcomes for both Indigenous and non-Indigenous populations in Canada. Indigenous populations included those described as Indigenous, Aboriginal, Native or North American Indian, Eskimo, Inuit, First Nations, and Métis. Non-comparative studies, review articles, case reports, and studies reporting only non-surgical outcomes were excluded. Results: Sixteen studies were included. Five studies related to general surgery, five related to urology, three related to vascular surgery, and one related to each of cardiac, thoracic, and orthopedic surgery. Eleven studies reported a disparity in Indigenous patients, including worse short-and long-term postoperative outcomes. Areas of disparity included graft failure following hemoaccess procedures for dialysis, post-surgical infection risk, and rates of diabetes mellitus following kidney transplantation. One study reported a better outcome in Indigenous patients for phantom limb pain following lower extremity amputation. Conclusions: The majority of comparative studies reporting surgical outcomes in Indigenous and non-Indigenous Canadian patients demonstrate a negative disparity for Indigenous patients. Most of these studies have been in the areas of general surgery, urology, and vascular surgery. Only sixteen studies were found directly comparing outcomes in these populations, highlighting a paucity of research in this area. Further comparative studies including other surgical disciplines can help provide a broader picture of existing disparities and inform approaches to address these gaps.

Amina A Bouhelal, Dr; S Samlalsingh, Dr; Lorik Begolli; H Abdi; Queens Hospital. London, UK. No doubt great progressed have been achieved in term of diversity and equality.

In a country like the United Kingdom were we take pride in the battles won in social justice and inclusivity in the medicak field. We stand determint and understanding of the long way ahead toward true diversity and equal opportunity. We owe great deal of gratitude to those who came before us and paved the way to what we now enjoy. while we have no doubt we have accomplished great deal how much is much on the ground.

To evaluate how our doctor felt and how is the diversity and inclusivity we celebrate reflected in reality.

Anonymous questionnaire were filled by our doctors with objective, qualitative and quantitate data collected. The questionnaire was multi faceted covering age, gender, ethnicity, sexual orientation. instances where the trainee was at the receiving end of discrimination and how was that handled. We also investigated our trainees awareness of the local guidelines and escalation procedure, was the incidents reported and if not why not.

Exploring gaze markers to differentiate expertise based on navigation status during colonoscopy Wenjing He, PhD 1 ; Xin Liu, PhD 2 ; Bin Zheng, PhD 3 ; Krista Hardy, MD 1 ; Ashley Vergis 1 ; 1 University of Manitoba; 2 Beijing Science and Technology University; 3 University of Alberta.

Background: Endoscopy skill training has been traditionally focused on an individual's deliberate practice. With the evolution of technologies, virtual reality (VR) simulation training is now a reality for general surgery residents. In practicing endoscopic skills, it is important to monitor residents' skill levels with psychomotor evidences. Previous studies showed the moment of navigation lost (MNL) can be good behavioral markers for endoscopic expertise. In this study, we further explored gaze markers to differentiate experts and novices in a simulated colonoscopy procedure. Methods: Experts and novices performed a colonoscopy procedure in an Accutouch VR Simulator. The videos of their performance were annotated to identify MNL and non-MNL. Four experts and six novices' gaze data were compared. A list of eye gaze variables, including fixation, saccades and pupil size were compared between two levels of expertise and two navigation statuses using a mixed ANOVA with repeated measures on the second factor. Results: The mixed ANOVA revealed significant differences between navigation status on four dependent variables: saccade amplitude (p = 0.007), fixation traveling distance [0, 50] (pixels) (p \ 0.001), fixation traveling distance [0, 75] (pixels) (p \ 0.001), and fixation traveling distance [0, 100] (pixels) (p \ 0.001). Specifically, subjects in MNL had larger saccade amplitude (2.36 vs. 1.51) (degree) than in normal performance (non-MNL). Upon entering MNL, subjects have reduced amounts of long fixation compared to normal performance; measured by accumulated fixation travel distance longer than 50, 75, and 100 pixels. Adjusted Pupil Size (APS) showed a significant difference between navigation status (60.5 ± 1.95 vs. 4.24 ± 1.06, p = 0.033) in non-MNL. Significant differences were found on between expertise on three pupil variables: APS in trial (p = 0.006), APS in saccade (p = 0.004), and APS in fixation (p = 0.005). Specifically, subjects in MNL had a small APS in the trial (0.46 vs. 0.63), saccade (0.45 vs. 0.62), and fixation phase (0.46 vs. 0.63), compared to normal performance (non-MNL). No significant interaction was found between expertise and viewing conditions. Conclusion: Significant gaze differences were found in MNL and non-MNL. More behavior markers need to be explored on how experts transitioned from MNL to non-MNL. The gaze markers identified from this study could be used for skill training and assessment of learners in the future. Introduction: Adult learning involves active learning and structuring knowledge. Interactivity and engagement in groups learning or lectures are essential for active learning. Activities like retrieving information, correlating, justifying, applying, or using the previously learned material to facilitate building new knowledge while learning will facilitate engagement and enhance active learning. These activities are usually induced and encouraged by the moderators in group learning sessions or lectures. Different engagement-enhancing approaches are available. The simplest and most commonly used approach is asking the individual learners questions directly. However, this method can create an uncomfortable environment to the learners and may be demanding on the teachers' side due to time constraints. Moreover, the variability of the educational skills of faculty members may lead to inadequate use of these active learning enhancing activities. Method and results: To optimize active learning, student engagement and active participation can be enhanced by the anticipatory learning approach. The approach involves facilitating learners' anticipation of the educational materials or content a digital platform that students may use during lectures to promote adult active learning. E-learning is well-suited for student-directed independent learning. The prompts will stimulate learners to anticipate next learning points, Results, applications, correlations, connections, justifications, or Conclusions to enhance engagement in thinking and proactive learning, while maintaining a relaxed environment. Conclusion: The simple and practical approach of anticipation-facilitation engagement in learning through intermittent short prompts can maximize relaxed attention and interactive adult learning environment and outcomes. Background: There are individual differences in the learning curves of novice surgeons regarding laparoscopic surgery, but the cause remains unclear. It is important to shorten this learning curve from the viewpoint of safety and the medical economy. The aim of our study was to evaluate the surgical inefficiency of novice surgeons. Methods: To evaluate the surgical technique, we used the work analysis software OTRS10Ò (Broadleaf Co. Ltd.) for the first time to our knowledge. Twenty recorded operation videos of laparoscopic sigmoidectomy, performed by novice surgeons both ''Before'' (n = 10) and ''After'' (n = 10) qualified the Endoscopic Surgical Skill Qualification System in Japan, were evaluated. All videos were imported into OTRS10Ò and evaluated them dividing into three phases. Results: The result of covariance analysis in Phase 1 (working classification), a significant difference was found in ''Dissection'' time in ''Before'' and ''After'' (p \ 0.046). The coefficient of the linear model suggests that the average dissection time ''After'' is 651 s shorter than that of ''Before''. The multivariate Results in Phase 2 (efficacy classification), showed that ''Skill'' was significant (p = 0.025). MacNemar test revealed that ''Skill'', ''Development'', and ''Cooperation'' were all significant (p \ 0.001) and the odds ratio with good was 24.5, 6.73, 10.25, respectively. In Phase 3 (cause classification), ''Technique'' occupied the largest proportion of the time. Among the breakdown of ''Technique'', there was a significant difference between the ''Grasping and Traction'' and the other population of the time except for ''Separation''(Grasping and Traction vs Device technique: p \ 0.001, Grasping and Traction vs Separation: p \ 0.284, Grasping and Traction vs Suturing: p \ 0.002, Grasping and Traction vs Others: p \ 0.001). Conclusions: Although this study was preliminary, the Results of this new approach are expected to help us to shorten the learning curves of novice surgeons.

Perception-enhancing motion-picture-aided teaching Faiz Tuma; Central Michigan University College of Medicine.

Background: Processing new information and ideas is a mental activity that accompanies exposure to new information to formulate own conception and beliefs. It often involves creating mental images of the received and processed knowledge. The mental images move and change sequentially when they represent series of events or steps over time. Creating these mental images or motion-pictures is based on continuous decoding of series of information delivered by verbal words or textual signals in the traditional educational activities. The depth and comprehensiveness of this conceptualization process depends on the learner efforts in creating full sequence of images reflecting the topic. Hence, the level of understanding and clarity of the learned knowledge depends on the ability and accuracy of this conceptualization process. Frequently, learners face difficulty to formulate an accurate, clear, and comprehensive understanding and perception of the taught idea or concept. In these instances, learners will be less likely to engage or learn actively. Therefore, learning will be limited and may not be accurate. Method and results: Teaching intellectual topic can be aided by motion-pictures or videos that provide clear uncoded information of the taught materials and demonstrate the ideas and concepts accurately, sequentially, and comprehensively. Incorporating motion pictures to describe the details and flow of events and processes -including ideas and intellectual processes -assists learners to focus on understanding and creating clear and accurate mental images rather than on decoding textual information. It also eliminates unnecessary errors in understanding. The use of motion-pictures enhances learning not only by maintaining learner's attention but also by shifting the attention to the meanings and ideas rather than the hidden codes behind words. Highly descriptive, clear, and accurately decoding motion-picture is structured to accurately decode the knowledge transfer. The real benefit and purpose are to guide the mind and facilitate creating a clear, accurate, and complete perception of the topic. Conclusion: A significant window of error in coding and decoding of information during the knowledge transfer process can be eliminated by motion-picture aided teaching.

Supervised cognitive experiential training of surgical skills William C Durchholz; Faiz Tuma; Central Michigan University College of Medicine.

Background: Teaching surgical skills is demanding and occasionally challenging. Surgery educators and programs are continuously working on improving training quality and outcomes. A common issue of training on surgical skills is indoctrination. Mentors frequently advise their trainees to perform in a specific pattern that similar to the mentor's performance. Trainees may occasionally be criticized if they deviate from the recommended performance regardless of the quality of performance. Therefore, trainees choose to imitate and learn from their mentors the same techniques, approaches, skills, and applications. A deeper understanding of the underlying rationale and reasoning, alternative approaches, and other applications becomes unpredictable. Consequently, their cognitive learning of understanding, application, analysis, evaluation, and innovation skills will be limited. Therefore, a better approach to training surgical skills where trainees are prompted to evaluate and decide will likely improve learning quality. Methods: Learning opportunities for surgical skills are presented to promote understanding of the procedure and thoughtful selection of the approach. This is done in both the lab and the operative room. On performing surgical procedures or practicing in the SIM lab, the surgical trainee is prompted to answer sequential questions about the available options of doing the step/skill and why it should be done in a particular way-with giving proposals of alternatives. A wide range of training moments like dissecting, exploring, mobilizing, and repairing surgical skills are included. Prior preparation and structuring of the training experience enhance the outcomes. Results: Training by cognitive experiencing stimulates the trainee to think deeply and independently to decide and manage during the surgical procedure. The mental exercise initiates and scientifically guides the inquiry in the trainee's mind, which leads to a series of cognitive learning processes culminate in high intellectual learning and mastering of operative management. It also initiates the trainee's further search for improvement and innovation, especially with the actively evolving technology. The training approach can be similarly reproduced in the SimLab or a digital module format. The later ways are highly efficient in creating a fully shared curriculum for all trainees at different times and places. Conclusions: Training by supervised cognitive experiencing is a promising and valuable training approach. It enhances the development of thoughtful and innovative surgical approaches and skills. It is a practical and reproducible training approach.

Joy Obayemi, MD 1 ; John Donkersloot, MD 1 ; Keir Thelander, MD 2 ; Grace Kim, MD 1 ; 1 University of Michigan; 2 Pan-African Academy of Christian Surgeons.

Introduction: The Lancet Commission on Global Surgery highlighted the role of the workforce shortage in the global burden of surgical disease which disproportionately affects low-middle income countries 1 . The educational pipeline, which includes surgical residency training programs, is vital to the surgical workforce. The success and efficacy of surgical residency training has direct ramifications on the preparedness and adequacy of the surgical workforce. Surgical simulation has been suggested as a potentially beneficial educational modality in this setting 2,3 . However, the specific educational needs of surgical residency training programs with regard to simulation in low-middle income countries have not been well-defined. Methods and procedures: We conducted a survey of program directors and associate program directors in eleven general surgery training programs across eight lowmiddle income countries in Africa (Ethiopia, Kenya, Cameroon, Niger, Tanzania, Gabon, Malawi, and Egypt). A modified Delphi methodology was utilized over two rounds. Using an open-ended email survey, program directors were asked to identify psychomotor skills they felt would most benefit from surgical simulation. Initially submitted responses were then consolidated, categorized by specialty, and redistributed to the program directors to be ranked by priority. Results: Faculty from 8/11 programs responded. Upon the first round of the survey, 19 unique responses were received ranging within the broad areas of practice in general surgery, laparoscopy, wound care, trauma, Ob/Gyn, ENT, neurosurgery, and orthopedics. Upon the second round of the survey, the highest educational priorities in simulation were identified in laparoscopic skills, specifically the use of the angled laparoscope and advanced skills including intracorporeal suturing. 6/8 program directors ranked intracorporeal suturing as a top simulation priority.

Conclusions: A potential area of focus for curriculum development in surgical residency training programs in low-middle income countries is the simulation of laparoscopy including more advanced laparoscopic skills. Additionally, surgical educators in these low-resource settings had high interest in advanced laparoscopic surgical training, contrary to the expected traditional educational focus on open, broad-based skills and procedures. Inguinal hernia repair is one of the most common procedures performed by general surgeons. Current trends in surgical areas cover simulation and allows to develop skills before carrying out a practice on a real patient.

We searched opportunity areas in simulation, identifying the possibility of creating an inanimate model for performing a right TAPP laparoscopic inguinal hernia repair. There are other models of this type made of other materials such as the one presented by Ruiz A. 1 and Nishihara 3 ; however, we intend to present a new model as an alternative we consider low-cost and easily reproducible. The specific objectives are: Show the experience of the surgery residents in a third level care hospital at Mexico City and show the laparoscopic skills that can be acquired by practicing with this model. Material and methods: We create a new simulation model of a TAPP laparoscopic right hernia repair, reproducible, with easily accessible materials. On YouTubeÒ we presented a video in ''Víctor Pinto Angulo'' channel with the following link ''https://www.youtube.com/watch?v=U_XXHJz3sWA''.

In this video we present a step-by-step anatomic model which simulates the inguinal region with low-cost material that can be adequate to right or left inguinal hernia and can be reused multiple times.

Within Google ClassroomÒ 28 general surgery residents in a third level hospital reproduce this practice by creating a video, the videos were revised by the professor, identifying the main mistakes and difficulties during the practice.

We applied a survey using Google FormsÒ focusing in four subjects: general data, previous experience, model feasibility and integration. Results: Respect feasibility 85.7% refer easy access to materials, 57.1% invested less than an hour creating the model, and 46.4% refers taking the same time in the practice. Our model proves to be cost effective, 35.7% referred spending less than 100 Mexican pesos (5 USD). 42.9% thought the peritoneal flap closure was the most difficult step and 64.3% believes laparoscopic suture was the most developed skills. As a result, 85.7% considers this model improved their skills in a TAPP laparoscopic repair, while 96.4% would recommend the generalization of this model in general surgery courses. Conclusion: We create a low-cost simulation model with accessible materials, and easily to reproduce for every student. We know that we need more prospective studies where Results in a real patient can be evaluate before the practice with this model. Introduction: Surgical error is an act or omission that Results in a negative consequence or an increase in operative time. This study aims to describe errors reported in laparoscopic cholecystectomy (LC) videos by resident and attending surgeons. Methods and procedures: Participants graded LC videos (performed by attendings), identified and classified errors using Observational Clinical Human Reliability Assessment and provided free-text descriptions of errors. Results: Nine videos were assessed by 10 participants (4 junior, PGY 5-6, 3 senior, PGY 7-10, 3 attending). The median intraoperative grade was 1 (IQR = 3, maximum score 9), with excellent interrater agreement (ICC = 0.93, 95%CI = 0.82-0.98). Two participants (1 junior, 1 senior) were excluded leaving 550 errors for analysis. Positive linear relationships between intraoperative grade and error count (r2 = 0.157, p = 0.006), and case duration and error count (r2 = 0.284, p = 0.001) were identified. The table details error counts and subgroup analysis. Across all phases errors include inappropriate dissection (23%), bleeding (15%) and thermal injury (14%). Inappropriate dissection (16%), thermal injury (9%), bleeding (6.7%), failure to progress (6.7%) and omitting coagulation (1.6%) were reported in hepatocystic triangle (HCT) dissection. Inappropriate clipping (11%), inappropriate dissection (3.5%), inadequate visualisation of the CVS (3%) and clip failure (1.3%) were reported in ligation/division of cystic structures and in gallbladder dissection, bleeding (6.7%), thermal injury (4%), inappropriate dissection (3.6%) and poor economy of movement (2%).

Juniors reported more thermal injuries (5%) by excess force/speed/depth (4%) than seniors (0.7%) in HCT dissection. Attendings reported bleeding (2%) through excess force/speed/depth (1%) and omitting coagulation (2%) or poorly directed haemostasis (1.5%). During ligation/division of cystic structures, inadequately visualizing the Critical View of Safety (CVS) was reported by seniors (1.6%) and attendings (1.2%). Clipping prior to achieving, or failure to achieve CVS or incomplete HCT dissection were cited, respectively. During gallbladder dissection, bleeding and thermal injury were reported by junior residents (2%) and attendings (1.6%). Overall, attendings reported poor economy of movement (9%), by too much force/speed/depth (2%), or poorly directed instruments (6%). Juniors (0.7%) and seniors (1%) reported this less. Conclusion: This study suggests surgical experience influences classification of errors. Future research in error interpretation is required to explain these differences and how this may benefit surgical training. Introduction: The objective of this study is to estimate the impact of the COVID-19 pandemic on the operative exposure of General Surgery Fellowship trainees. The need to expand healthcare system capacity for patients with COVID-19 led to a shutdown of elective surgery in our region between March and June 2020, and prioritization of cancer and urgent operations. Minimally Invasive (MIS) and Bariatric Surgery fellowships include mostly elective operations, while Hepato-Pancreato-Biliary (HPB) and Colorectal fellowships have a high proportion of oncologic cases. Given the ongoing nature of this pandemic, estimating the impact of COVID-19 on general surgery fellowships is required to inform mitigation efforts. Methods and procedures: This study is a retrospective review of all emergency and elective procedures performed at the 3 sites of an academic health network between March and June in 2019 and 2020. Procedures performed by general surgeons and attended by fellowship trainees during the pandemic period (2020) and the prepandemic period (2019) were compared. Operating exposure was defined as (1) the total number of fellows present during the operations and (2) Conclusions: In our center, the pandemic shutdown had the greatest impact in MIS compared to bariatrics, HPB and Colorectal programs. Operative time was affected to a lesser extent, which may be due to prioritization of more complex cases or inefficiencies related to pandemic safety precautions. While case volume is only one aspect of competence, the one-year duration of MIS fellowships may result in a disproportionate impact of the pandemic on trainees in this specialty.

Leonardo Sosa Valencia, MD 1 ; Alain Garcia Vazquez, MD 1 ; Juan Verde, MD 1 ; Jerome Huppertz, MD 2 ; Lee Swanstrom 1 ; 1 Institute of Image-Guided Surgery of Strasbourg; 2 Nouvel Hopital Civil, Strasbourg.

Introduction: The appearance of EUS guided minimally invasive therapeutic interventions is transforming the management of malignant or benignant bile duct obstructions. Those endoscopic techniques currently are widely practiced but with a long learning curve available only in advocate centers; therefore, hands-on training using relevant models is needed to improve the ability of endoscopists in such techniques. This experimental study aims to develop a high fidelity in-vivo simulate animal model (HiFiSAM) with intra and extrahepatic bile duct dilation to be used during EUS hands-on training curriculums. Methods and procedures: Thirty-six large white pigs were involved, procedures were performed in an experimental hybrid operating room, under general anesthesia, animals underwent an endoscopic duodenal papilla clipping with several hemostatic metallic clips, after a survival period of 24 h. (group 1, n = 3) and 48 h. (group 2, n = 33), HiFiSAM's with an effective bile duct dilatation were included in a EUS hands-on training course. All animals survived during the creation of the model and were euthanized at the end of the training session. Results: The primary outcome was the assessment of the bile duct dilation by a contrasted computer tomography scan and EUS. An effective intrahepatic (n = 11) and extrahepatic bile duct (including gallbladder) dilation (n = 36) was achieved. No intraoperative complications were founded; the mean operative time to create the model was * 20 min. The secondary outcome was the ability of trainees to use the model to perform EUS drainage procedures during a hands-on course and the overall evaluation was: 71% excellent, 24% good, and 5% poor, thereby validating the experimental model.

We present a reliable and time-cost-effective HiFiSAM to develop a bile duct dilation that was tested in the context of EUS training curriculums; providing a meaningful training model for EUS-guided biliary procedures and potentially useful for other image-guided biliary interventions. Introduction: The advent and widespread adoption of competency-based education increased the need for objective and valid assessment tools of operative skill. Yet, commonly-used assessment tools in surgery are generic (e.g. OSATS), limiting their ability to assess and provide feedback for proficiency in specialized procedures. Video-assisted thoracoscopic lobectomy (VATS-L) is a complex procedure requiring knowledge and skills not captured by generic proficiency assessment tools. Therefore, the objective of this study was to identify and evaluate assessment tools of surgical proficiency in VATS-L. Methods and procedures: A systematic literature search was performed using Embase, Google Scholar, Ovid MEDLINE, PubMed, and Web of Science (1990-2020). The Results were analyzed according to PRISMA guidelines. Conference abstracts, letters to the editor, editorial commentaries, tools assessing bronchoscopy, open surgery, pneumonectomy and wedge resections, and those not measuring competence of surgical skills were excluded. Results: Of 523 unique publications, four met inclusion criteria. Of these, one article described the development of an 8-item assessment tool (''VATSAT'') by iterative Delphi consensus with 31 experts but did not describe any further validation. The VATSAT was then modified by the same research group to permit assessments of performance on a virtual reality VATS-L simulator (mVATSAT). This tool had high intra-class correlation coefficients for single (0.78, p \ 0.001) and average (0.91, p \ 0.001) measures and high test-retest reliability scores (G-coefficient = 0.79; Pearson's coefficient = 0.70, p \ 0.001), but the proposed cut score had high false passing (29%) and failing (43%) rates compared to predicted performance by level of clinical experience. The third tool, entitled Thoracic Competency Assessment Tool-Anatomic Resection for Lung Cancer (TCAT-ARC), comprised of 35 items scored on a 5-point Likert scale. This was developed by iterative expert consensus and tested in both simulated and clinical environments. TCAT-ARC had high discriminatory ability to differentiate novices from experts (Cronbach's alpha = 0.93, inter-observer reliability = 0.73, and correlation of TCAT-ARC with OSATS = 0.68). However, a threshold score indicative of competence was not determined since scores did not reflect surgeon takeover. The fourth used an error score to assess a porcine simulator but did not provide details regarding development or validation of the score. Conclusions: This review identified four procedure-specific assessment tools evaluating proficiency in VATS lobectomy, of which only one has validity evidence supporting its use in the clinical environment and none for which a reliable competence threshold score is reported. Further study is needed to refine proficiency assessment tools for VATS lobectomy.

The use of hybrid educational simulation technology in advance surgical skills training-optical port insertion is an example Mohamed K Kamel; Tuma Faiz; Department of General Surgery, Central Michigan University, MI, USA.

Background: Training on surgical skills continues to be challenging to trainees, instructors, and their training programs. The challenges involve multiple levels of difficulties including mentor availability and training opportunities. Therefore, the resulting competency is variable and unpredictable. Educational technology offers alternative training opportunities outside the OR. The currently available educational surgical videos follow the false educational principle of ''showing means training''. We are proposing an interactive digital module of a surgical procedure in multiple cases enhanced by educational illustrations and learners' interactive input and evaluation. The insertion of an optical port is a good example. We designed and constructed a hybrid simulation-video recording interactive module as an introduction to this approach of surgical training technology. Method and results: Training on various surgical skills like laparoscopic optical port insertion, endoscopic simple polypectomy or submucosal injection, stapler application, and closing enterotomies can be conducted using the hybrid simulationvideo recording interactive modules. Each component of the skill is aided with additional illustrations/edits to demonstrate the principles behind that part. Integrated questions are used to evaluate the cognitive aspect. In this exercise, multiple options are provided to choose from how to proceed with each step of the skill. The final hybrid simulation video will provide real-time feedback during the simulation session. Conclusions: Surgical skills hybrid simulation is a simple, interactive, and learnercentered training approach that uses simple educational technology. The structured modules are valuable for training and competency evaluation. They are easily transferable and reproducible. Proctorship and mentorship can be facilitated with these modules.

Virtual fundamentals of laparoscopic surgery (FLS) boot-camp using telesimulation: an educational solution during the COVID-19 pandemic Khaled T Ramadan, MD 1 ; Karen Chaiton 2 ; Azusa Maeda, PhD 2 ; Dimitra Labrakos 2 ; Jaime Burke 2 ; Allan Okrainec, MD, FRCSC 1 ; 1 University of Toronto; 2 University Health Network.

Introduction: The fundamentals of laparoscopic surgery (FLS) is an internationally recognized educational and certification program developed by SAGES. Successful completion of FLS is a training requirement of the American Board of Surgery. In previous years, the General Surgery residency program at the University of Toronto has organized an FLS boot-camp to teach PGY1 residents FLS technical skills. During the COVID-19 pandemic, in-person training sessions were not possible. The purpose of this project was to utilize telesimulation as an education solution for teaching FLS to local PGY1 residents during the COVID-19 pandemic. Methods: A virtual FLS program was established to replace in-person FLS manual skills training of PGY1 residents. A complete, easily portable FLS kit with all necessary components was distributed to participants and instructors to set up an FLS box at home and connect remotely using telesimulation. The program was delivered by 3 senior residents using the Zoom platform (Fig. 1) . Participants were split into 4 groups of 3-4 individuals. Three 1-h sessions were delivered, with each group receiving one session per week. Sessions were structured with initial demonstration of tasks followed by separation of participants into 'breakout' rooms where instructors gave individual coaching. The official FLS exam was administered in-person on the 4th week.

Pre and post-course surveys were administered to participants gauging selfreported efficiency, precision and confidence with FLS tasks, and overall course feedback. Anonymized FLS exam Results were collected. Results: Of 14 participants, 11 responded to the surveys. Participants had minimal experience with FLS tasks or laparoscopic surgery, prior to the course. Respondents reported that digital telesimulation set-up was easy and practical, and quality of virtual sessions met or exceeded expectations. Respondents also reported that their overall FLS skills proficiency (efficiency, precision, and confidence) significantly improved on a 5-point likert scale from 1.5 ± 0.5 pre-course to 4.0 ± 0.5 postcourse (mean ± SD). Respondents unanimously stated that having the FLS box at home to access anytime was valuable and enabled them to practice more outside of sessions. On the FLS exam, 13 of 14 participants passed the manual skills component.

We developed a practical and effective telesimulation hands-on FLS course as an alternative to in-person training. The course was well-received by participants, being preferred to traditional methods. With ever-expanding technological solutions, virtual telesimulation education is an attractive and underutilized method, not only in the setting of COVID-19, but also in mainstream educational programs. Fig. 1 Introduction: Total operative time can be used as a surrogate marker of performance. This study aims to compare the intraoperative phase times in laparoscopic cholecystectomy (LC) of an attending surgeon and their residents, over a 10-year period. Methods and procedures: Operative LC videos of an attending surgeon and supervised residents were uploaded to Touch Surgery Professional TM , a cloud-based video platform which provides automatic detection of intraoperative phase times. Intraoperative grade and Critical View of Safety (CVS) were assessed manually. Results: 159 videos were analysed (attending = 96, resident = 63). Intraoperative grade score (maximum 9, indicating most severe) was significantly higher in attending cases (attending: median = 2, IQR = 2 range = 0-6), resident: median = 1, IQR = 1, range = 0-5, Kruskall-Wallis = 2454, p = 0.0372). No significant difference between attending and residents CVS score was identified. Linear regression shows positive relationships between intraoperative grade (r2 = 0.1349, p = 0.0002) and dissection of hepatocystic triangle (HCT) (r2 = 0.01014, p = 0.0016) with total operative time. A negative relationship between CVS score (maximum 6, indicating CVS clearly visible) and total operative time (r2 = 0.1349 p = 0.0002) was found. No significant relationship between operative grade and CVS was found. The table details total operative and intraoperative phase times in matched groups with significant findings.

Possible reasons for phase variations include adhesionolysis, aberrant HCT anatomy, injury to cystic structure and iatrogenic gallbladder perforation, present in limited resident cases. Conclusion: We conclude that both total operative time and times to complete phased procedural elements are greater for residents, compared to an attending's. Technical skill and experience are likely accountable, however future research focussing on skills and error analysis is required to delineate these differences and how they may help support surgical training.

Basic laparoscopic simulation in Santa Cruz, Bolivia: improving access and confidence Erica Ludi 1 ; Alexandra Reitz 1 ; Constance Harrell Shreckengost 1 ; Diego Artunduaga 2 ; Esteban Foianini 3 ; Monica Vera Zalles 3 ; 1 Emory University; 2 Hospital San Juan de Dios; 3 Clínica Foianini.

Introduction: Simulation is a valuable tool for skill acquisition and improvement in laparoscopic surgery, providing a safe and low-risk environment for trainees and surgeons learning new skills. While still an emerging surgical technology in Bolivia, laparoscopy is becoming more available across the country. However, practice settings outside the operating room remain limited or cost prohibitive. This study analyzes pre-and post-course evaluations of a low-cost, basic laparoscopic skills workshop to understand the population attending the course and to assess improvements in skill confidence. Methods: A four-hour practical skills workshop with follow-up practice sessions was developed and included skill stations on peg transfer, precision cutting, plane dissection, intra-, and extra-corporeal knot-tying. Individualized instruction was provided during the workshop and practice sessions. A 17-question pre-course evaluation was administered within one week of course start, and a 17-item postcourse evaluation was completed by participants after the practice sessions finished. Results: A total of 39 persons participated in three workshops over four months with 76.9% (n = 30) and 56.4% (n = 22) of participants completing pre-and post-course evaluations, respectively. Average age was 31.2 years (n = 30), and 66.7% were male (n = 20). 46.7% (n = 14/30) were attending surgeons, 46.7% (n = 14/30) were surgery residents, and 6.7% (n = 2/30) were general physicians. 43.3% (n = 13/30) of participants reported ''almost never'' using laparoscopic surgery, 30% (n = 9/30) used it ''2-3x/month'' or ''1x/week,'' and 26.7% (n = 8/30) used it ''2-3x/week'' or ''almost every day.'' Through the course, significant improvements on a 5-point scale in confidence occurred in port placement (2.3 vs 3.4, p \ 0.01), instrument handling (2.0 vs 3.0, p \ 0.01), object transfers (2.1 vs. 2.9, p \ 0.01), intracorporeal knottying (1.4 vs 2.7, p \ 0.01), extracorporeal knot-tying (1.5 vs 2.9, p \ 0.01), and precision cutting (2.0 vs 3.2, p \ 0.01). 100% (n = 23/23) found the course to be useful, 100% (n = 23/23) would recommend it to a colleague, and 100% (n = 23/23) reported they would scrub more laparoscopic cases in the future. Conclusions: While the availability of laparoscopy expands in Bolivia, simulation options remain limited. This study demonstrates that a basic, skills-based course can improve providers' confidence and desire to perform minimally invasive surgeries. To ensure safe translation to practice, more advanced courses and a transition-toindependence mentorship program are being developed.

Transforming learning objects to learning processes Daniel Kronner; Faiz Tuma, MD, MEd, EdS, FACS, FRCSC; Central Michigan University College of Medicine.

Background: Adult learning is a process that involves active learning and building knowledge by the learners. This process uses learning materials to construct the schema of understanding. Various learning objects (LOs) are used for this purpose e.g.: books, journals, videos, etc. In addition to providing information, lectures are also used to induce and facilitate the process of learning. However, facilitating the process of learning is more important than providing the learning materials. Even though the difference between the two roles of the lecture is crucial, many teachers focus on delivering the information more than facilitating the learning process. This contradicts the goals of education and active learning. Methods and results: To cause learning, the learning process has to be induced and augmented by the educational activities. LOs and educational activities can be transformed to learning process by focusing on mental activities of the learners rather than purely providing materials. Structuring LOs and lectures to promote searching, applying, analyzing, evaluating, critical thinking, and concluding will transform LOs to learning processes. This transformation requires constructing new approach and format to establish a learning process that is centered on the mental activity of the learner. Learners go through a complex intellectual process of learning that involves multiple steps of exposure to information, processing, analysing, critiquing, and constructing own knowledge. For education to happen, the focus should be on the approach and steps taken to induce, facilitate, and optimize this process by identifying and filling gaps of knowledge, raising issues to wonder about (versus giving answers), sharing learning skills, encouraging comparing and finding connections, promoting concluding and creating new knowledge. Such approach and steps should be part of the LOs and activities to transform them to learning processes. Integrating these steps and components incite learners to actively lead and direct how and where to proceed, encourage them to set learning goals, and stimulate them to conclude and create their own knowledge that they can apply and build on. These integrated elements should be carefully selected to serve the particular purpose and group of learners. Efforts to monitor and fine tune the elements and process should be exerted on regular basis. Feedback and learners input guide the efforts of quality monitoring. Conclusions: Integrating specifically designed educational components and steps transforms learning objects to a learning process that could play the role of the educators rather than the source of information. Introduction: The disease of obesity is a major public health issue, with 43% of adults in the United States alone affected. Obesity plays a significant role in the morbidity and mortality from diabetes, cardiovascular disease, and cancer, where bariatric surgery is considered the most effective treatment. However, obesity is often viewed as a risk factor rather than a multifaceted disease. We hypothesized that the current curriculum does not supply medical students with the knowledge and confidence to deliver comprehensive obesity treatment to this growing population. Given the prevalence of obesity, all physicians regardless of specialty should have a comprehensive understanding of obesity and the treatment of obesity, including both medical and surgical care. In order to better characterize this gap between actual and ideal knowledge of obesity treatment, we compare medical students to current surgical residents, whose experience caring for bariatric surgery patients gives them a broader understanding of obesity care. Methods: We designed a set of paired surveys to assess knowledge, understanding, and attitudes around the disease of obesity and associated therapies, including bariatric surgery, with input from both an experienced bariatric surgeon as well as an expert surgical educator. Participation in these surveys was voluntary. General surgery residents at all levels at our institution and medical students participating in their core surgical clerkship were invited to participate. Medical students completed the survey immediately prior to their planned educational session on bariatric surgery and obesity treatment to capture baseline knowledge. Results: In total, 46 medical students and 36 general surgery residents at our institution completed the surveys. Medical students perceived bariatric surgery as both less safe and less effective than did general surgery residents (p \ 0.01 and p = 0.03, respectively). Medical students additionally reported significantly less confidence discussing surgical treatment of obesity, the impact of bariatric surgery on medications, and even discussing weight with patients (p \ 0.01, p \ 0.01, and p \ 0.01). Medical students were less likely than surgical residents to refer a patient with obesity for surgical therapy even if they met the appropriate criteria (p = 0.03). Conclusions: Our Results suggest that medical students are entering the physician workforce lacking key critical knowledge of obesity as a disease and a thorough understanding of available treatment options. Further work will utilize this needs assessment to drive curricular changes aimed at increasing student knowledge and enhancing skill sets to deliver comprehensive care to patients with obesity.

Innovative applications of educational technology in surgical training during the COVID-19 pandemic Faiz Tuma; Central Michigan University College of Medicine.

Background: Surgical education became more challenging during COVID-19 pandemic due to multiple restrictions. Educational technology (ET) offers alternative training opportunities to compensate. Using ET, digital learning objects (DLO) and modules tailored to the educational needs can be created and applied in various surgical educational activities. Three examples are discussed below. Participants-guided M&M rounds: Discussing surgical M&M cases is transformed to an engaging education using audience responses/polling. The cases are presented in sequential manner from the initial assessment by the surgical team. The ultimate presentation will be a cognitive simulation module of real scenarios. All the pertinent patient information including imaging, pathology, endoscopy, and interventional findings are shared. At the decision-making steps, the audience are asked how to proceed in management. Polling can be conveniently used on the virtual meeting platforms for input. Answers are displayed instantly on the screen and the options are discussed with input from the expert surgeons. This is an application of knowledge and decision-making learning exercise. Learning from the learner: Sharing learning experiences in a structured and goaldirected educational activity provides rich learning environment. Small group studying a topic through slideshow/ video-recording is recorded to include students' comments/ideas/interpretations/analyses/discussions. This recording/learning object (LO) is used by other learners via vodcast/podcast/other platforms. Learners use this LO as an adjunct or a frame to learn the topic and share their input. This LO provides stimulation, enhances attention, facilitates understanding, encourages critical thinking, and allows comparison to other learners in a social, interactive, and selfdirected way. Anticipation-facilitated learning: Facilitating the anticipating of next learning step or point of discussion of the lecture topic enhances proactive learning and engagement in a relaxed learning environment. Virtual meeting platforms provide the technology e.g. chat box or polling options to facilitate the process. Structuring and facilitating is based on 1) prompting learners during the lecture to anticipate the next step or point of discussion; 2) learners' responses received in short phrases or textual information; 3) anonymous and instant sharing of input; 4) further discussion and clarification are conducted accordingly. Conclusions: Innovative use of ET provides tremendous potentials for surgical education.

A socially distanced approach to surgical education: a hybrid web and simulator-based course for laparoscopic common bile duct exploration Matthew M Snyder, MD, MS 1 ; Eric S Hungness, MD 1 ; Bryon F Santos, MD 2 ; James C Rosser, MD 3 ; Brian J Dunkin, MD 4 ; Ezra N Teitelbaum, MD 1 ; 1 McGaw Medical Center of Northwestern University; 2 Dartmouth-Hitchcock Medical Center; 3 Gila Regional Medical Center; 4 Boston Scientific.

Introduction: The COVID-19 pandemic has had a profound impact on surgical education. Social distancing and travel limitations have made many large-scale inperson courses untenable. In light of these constraints, we adapted a laparoscopic common bile duct exploration (LCBDE) course into a ''hub-and-spoke'' model in which a central site led satellite centers using a hybrid web and hands-on simulatorbased mastery learning curriculum. Methods: Prior to the courses, faculty underwent a ''train-the-trainers'' curriculum focused on principles of simulator-based education and use of the rating scale. Daylong courses were then led by faculty in Chicago with content streamed via a webbased platform to satellite centers with local faculty and learners. A mastery learning model was employed, in which learners completed a simulator-based pre-test at the onset of the course. The subsequent course curriculum consisted of streamed lectures followed by hands-on deliberate practice using an LCBDE-specific simulator. The simulators were equipped with a flexible choledochoscope to facilitate a transcystic LCBDE approach. Faculty at each site provided learners with immediate performance feedback with a 2:1 learner to faculty ratio. Learners then completed an identical post-test on the simulator. The pre-and post-tests were assessed using a previously validated LCBDE procedural rating scale with a ''mastery standard'' that had been developed using a modified Angoff method. Results: Forty attending and fellow-level surgeon learners participated in the two courses held in Chicago and at 9 satellite locations. All learners were within driving distance of their course site. The learners had a mean of 9 years of post-training experience with 48% having B 5 years in practice. Most participants reported some exposure to the procedure during training but only 62% had previously performed LCBDE as an attending. On pre-testing, 88% of learners failed to meet the mastery standard (a score of C 31 out of 45). All 40 learners (100%) met or exceeded the mastery standard on post-testing and mean scores were significantly improved (pretest 24 ± 8 vs post-test 43 ± 2; scale 0-45, p \ 0.001). When analyzed separately, even the five participants who passed the pre-test had a significant increase in their post-test scores (36 ± 3 vs 43 ± 2, p \ 0.01). Conclusion: Using a multisite course design to overcome COVID-19 travel restrictions, we were able to train surgeons uniformly to a mastery standard in LCBDE. This hybrid web and hands-on simulator-based approach may serve as a model for other procedural curricula during the COVID-19 era and beyond.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study Background: Telesimulation helps overcome limitations in time and local expertise by eliminating the requirement for the learner and educator to be physically colocated, especially important during COVID19. We investigated whether teaching advanced laparoscopic suturing(ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room(OR). Methods: In this prospective feasibility study, three previously developed 3Dprinted ALS tasks were used: needle handling(NH), suturing under tension(UT), and continuous suturing(CS). General surgery residents(PGY4-5) were assessed in the 3 tasks using time-error metrics, and in the OR during a procedure requiring laparoscopic suturing using Global Operative Assessment of Laparoscopic Skills(GOALS, only suturing was assessed). Evaluations were conducted at baseline(A1) and 1-month later(pre-intervention, A2), the control period. Residents then underwent 1-month training, in which an expert educator at one site remotely trained residents at the other site in 2-3 sessions. Educators used the previously developed proficiency benchmarks and formative feedback tools(FFT) for guidance while teaching the 3 tasks. Remote sessions were done through Skype. After intervention, residents were assessed(post-intervention, A3) in both simulation and OR. Trainees completed questionnaires regarding educational value of simulation, and the telesimulation usability and educational value. Paired t-test was used to compare scores between the 3 assessment points. Results: Seven residents were recruited; due to COVID19, 2 couldn't complete the study. One only missed A3; their data is included in the analysis (6 residents median age 30; 83% male). Simulation(UT, CS) and OR scores improved post-intervention(A3) when compared to A1 and A2 (p \ 0.05 for all). NH scores improved during the control period, but did not significantly improve further post-intervention. During training, all residents reached pre-defined time-error proficiency benchmarks and FFT scores improved. All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, video and audio quality were high, had strong educational value, and want the system to be incorporated into their training. Conclusion: The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs, where trainees could be taught without the need for physical presence. Future research should focus on how telesimulation can be effectively incorporated into training programs. Background: Learners' intellectual processes are the core components of the educational practice. These intellectual processes are diverse and heterogeneous types and combinations in multiple dimensions and fields. These processes' sum and details can potentially be the core of the future educational activities structure, content, and flow. However, they are currently addressed to a limited extent due to educational practice's marginal progress and lack of an efficient, practical tool to gain insight into how learners learn during the particular educational event.

There is little known about the learner's mental actions and reactions to the educational event and the learning process. There are moderate efforts to explore and know more about this aspect. Tactics like asking learners questions directly, using an audience response system, and other ways of engagement are meant to aim in this direction as well as to facilitates interactive learning. Nevertheless, their effect and scope are limited for various reasons, the most important of which is that they were not aimed to explore and fully understand the intellectual learning process in the learners' minds. Methods and results: Using a practical digital platform enables learners to instantly share their perception, understanding, analysis, responses, and Conclusions during the educational event. With all the relevant information retrieval, this sharing will significantly inform educators understanding and ability to structure and conduct their teaching activities. This is made possible with a simple notes-platform with a list of prompts of reactions, reflections, voice recordings, agreeing/disagreeing scale options, and connections to other topics/lectures/facts/videos/sources. A rich library of feedback, learning needs, teaching progress, and flow pace is constructed from the accumulative experience. Examining and considering the input and feedback in the categories of comprehension, application, the fulfillment of expectations, and relevance to needs forms the basis of future educational curricula. Conclusions: Electronic instant detailed feedback from learners about the educational activity informs structuring future educational curricula. It should be the focus of future studies to understand the exact and specific reactions of learners to the variety of teaching activities and topics.

Assessing the relationships between spatial reasoning, VR motor mimicry, and robotic surgery simulation performance Introduction: In this pilot study, we sought to evaluate whether a priori spatial reasoning skills correlate with robotic simulation performance and if visual-spatial rehearsal can improve task performance. We aimed to (1) assess the relationship between baseline spatial reasoning skills and robotic surgery simulation performance and (2) evaluate the potentiating effect of VR motor mimicry on performance. Indeed, the ability to predict, teach, and optimize the performance of surgical trainees is of paramount importance. Methods and procedures: An IRB exempt, single-blinded randomized control study was conducted with 10 novice trainees. Subjects completed a 20 min validated spatial assessment (PSVT:R) and then participated in two days of simulation activities. During session 1, subjects completed 4 simulations using a DaVinci Si Console. During session 2, subjects were randomized to control (n = 5) or virtual reality (VR) (n = 5) groups. Using a VR headset, the intervention group observed a 5 min VR clip of a robotic surgical case and mimicked the hand motions seen in the console view. All subjects then completed two additional robotic simulation tasks. Statistical evaluations were performed in JMP15.0. Explanatory variables included spatial reasoning score and session 1 (baseline) task performance. Outcome variables included session 2 task completion time, economy of motion, and performance. After univariate analysis, multivariate stepwise linear regressions to predict each outcome were generated to account for covariation between explanatory variables. Each model contained no more than two explanatory variables given the limited number of study participants. Results: Control and VR groups had similar baseline spatial reasoning scores and simulation performance. In multivariate regression, session 2 task performance was associated with increased spatial reasoning scores (R 2 = 0.81; p = 0.0168) and demonstrated non-significant improvement with intervention (p = 0.093). Similarly, session 2 task completion time (R 2 = 0.54; P = 0.058) and economy of motion (R 2 = 0.75; P = 0.0116) were highly associated with spatial scores. Conclusions: Despite limited pilot study sample size, these data suggest that among novice trainees, baseline spatial reasoning scores predict overall robotic simulation performance and that there is a potential benefit to VR motor mimicry to enhance performance. Additional study participants will be recruited to determine if the benefit of intervention is due to chance, enhanced learning among those with higher spatial reasoning skills, or the intervention itself. Ultimately, the potential to predict a surgical trainee's facility with minimally invasive surgical skills may allow for customized or targeted training.

Evaluating the ergonomics of laparoscopic simulation training using a novel computer program Ian M Kratzke, MD 1 ; Guoyang Zhou, PhD 2 ; Prithima Mosaly, PhD 1 ; Denny Yu, PhD 2 ; Jason Crowner, MD 1 ; Timothy M Farrell, MD, FACS 1 ; 1 University of North Carolina at Chapel Hill; 2 Purdue University.

Introduction: Surgeon ergonomics during laparoscopy can affect both patient care and provider wellness, however, instruction in ergonomics remains informal and underemphasized during surgical residency. There is no standardized curriculum for teaching residents proper ergonomic positioning and technique. Assessment of residents' body positioning during laparoscopy or the incidence of physical symptoms that may be associated with laparoscopy-related strain have not been adequately studied. This study presents a novel computer vision technique to automate ergonomic assessments and demonstrates this approach through simulated laparoscopy. Methods: Surgical residents were video recorded performing tasks from the Fundamentals of Laparoscopic Surgery. Residents were divided in to two cohorts based on their years in training. Ergonomics were independently assessed by two raters using the Rapid Upper Limb Assessment (RULA) tool. A novel software program was then used to assess ergonomics from the video recordings (see Figure) . All participants completed a survey on musculoskeletal complaints that was graded by severity. RULA ratings and survey Results were compared to resident level using Pearson's chi-squared test, and comparison of human to computer scores was performed using the Cochran-Mantel-Haenszel test. Results: Ten surgical residents were recruited: five post-graduate year (PGY) 1, termed lower level (LL) residents and five PGY 2 or greater, termed upper level (UL) residents. All residents included in this study performed FLS in postures that exceeded acceptable ergonomic risks based on both the human and computerized RULA scores. LL residents scored worse than UL residents on the human graded RULA assessment, suggesting worse average ergonomics (p = 0.02). There was no difference in computerized RULA scores for UL versus LL residents (p = 0.43). Additionally, computerized scores did not correlate with human scores (p = 0.25). Shoulder and wrist position were the greatest contributors to higher computerized scores. Self-reported musculoskeletal complaints did not differ by UL versus LL resident (p = 0.19) and did not correlate to RULA scores (human grader p = 0.37, computer grader p = 0.99). All residents reported having at least one form of musculoskeletal complaint occurring ''often''.

Conclusions: General surgery residents demonstrated suboptimal ergonomics while performing laparoscopic tasks, with LL residents having significantly worse body positioning as measured by their human graded RULA score. A novel computerized program to measure ergonomics did not agree with the scores generated by the human raters; however, it concluded that resident ergonomics remain a concern, especially regarding shoulder and wrist positioning. The advantages of the computerized program include objectivity, automation, and identification of specific components of the RULA score. Introduction: Incisional hernia is one of the most common complications following laparotomy. It is a significant cause of post-operative morbidity, affecting 20-50% of patients. Incisional hernia risk is based on several factors, but surgical technique plays an important role. Currently, there is no dedicated laparotomy closure curriculum in surgical education. Additionally, with the ever-increasing prevalence of minimally invasive techniques, trainees have less exposure to laparotomy closure in the operating room and thus, fewer opportunities for skill development. Cadaver and animal labs can provide such opportunities, but are expensive and time consuming. To address this need, we created a simulation-based laparotomy closure curriculum. Materials and methods: Using a previously developed Closure of Laparotomy in Open Surgery-Instructional Trainer (CLOS-IT), a novel task trainer featuring a multi-layered silicone abdominal wall, a laparotomy closure curriculum incorporating didactic instruction and dedicated practice was developed. The curriculum was created using the following learning Objectives: selection of correct suture and needle type, performance of safe and proper tissue handling, formation of an appropriate number of square knots, and demonstration of proper laparotomy closure based on suture length to wound ratio with consistent bite size and travel distance. A criterion-referenced assessment for the dedicated practice was developed based on the learning objectives. The findings of the STITCH trial by Deerenberg et al. was used to guide curriculum development, specifically with the addition of small bite to the traditional large bite technique. This program was granted educational exemption by the Institutional Review Board. Results: The curriculum is targeted at medical students and junior surgical residents and consists of didactic material and dedicated practice. Didactic materials were chosen to represent the best evidence-based practices for laparotomy closure and consists of two articles and one video. Didactic materials are independently reviewed prior to dedicated practice. During dedicated practice, learners are provided a CLOS-IT system, assessment tool, and suture and surgical instruments for hands-on laparotomy closure training. Participants are instructed to initially measure and mark the simulated fascia to denote bite and travel distance in alignment with either a small or large bite technique. Learners must then complete two consecutive and five total iterations of dedicated practice, using each technique, without errors. Conclusion: We developed a novel simulation curriculum using the CLOS-IT system for surgical trainees to develop essential laparotomy closure skills. The curriculum is currently being implemented to determine its effectiveness when applied to novice learners.

The impact of COVID-19 on surgical education and distance education practices Connor Shea; Faiz Tuma, MD, MEd, EdS, FACS, FRCSC; Central Michigan University College of Medicine.

Background: COVID-19 pandemic caused significant impact on medical education. Many face-to-face educational activities became not easy after the limitation of healthcare services and the social physical distancing. Programs, educators, and students have to compensate. Distance education (DE) using educational technology (ET) is a valuable alternative. The sudden extensive application of DE and ET in medical education is unversed. Our knowledge of the extent, motives, diversity of application, challenges, and future development is limited. Exploring and examining the extent, depth, and applications diversity of DE and ET helps understanding and guiding the current and future applications. Methods: Analysing the experiences and applications of DE during the pandemic based on the principles of education and the use of ET enables formulating a baseline theory of the effectiveness and practicality of DE in medical education during and beyond the pandemic. Aligning the educational practices to serve the surgical curriculum objectives and milestones development will then be optimized. Results: The circumstances that significantly limited the available surgical clinical activities have forced programs, educators, and learners to willingly use the available education forms to compensate. This change could not have been adopted in the normal circumstances. Shared educational resources have been optimized. Learning objects like video lectures, animation, modules, seminars, and short courses have been extensively integrated. Virtual group meetings, lectures, conferencing, and discussions became widely, conveniently, and practically used and acceptable methods to learn, experience, discuss, and further develop learning schemas. Many companies and some institutions expanded their services to include curriculum building and application services. The biggest challenge was the hands-on practice of surgical procedures. It requires developing high observational skills, analysis, critical thinking and decision making then executing the necessary steps followed by evaluation of the result. The SIM lab and cognitive learning facilitated by a supervisor. Conclusions: Diverse DE applications are integrated into surgical education. The pandemic enhanced the acceptability and practicality of implementation. Re-evaluating the objectives and milestones of surgical education in the vision of the new educational practices need to be considered.

Identifying surgeons' opinions regarding peer coaching for cntinuous professional development-an international survey Sofia Valanci-Aroesty; Julio F Fiore Jr; Liane S Feldman; Lawrence Lee; Gerald Fried; Carmen Mueller; McGill University.

Background: The need for ongoing skills development is well recognized in surgery, but common learning opportunitiesinfrequently translate into real practice changes due to a lack personalized feedback. Peer coaching has been associated with higher rates of practice changes than traditional learning modalities, but uptake among surgeons is low. The purpose of this study was to explore international differences regarding surgeons' knowledge and opinions of peer coaching for continuous professional development.

Methods: A survey of 32 questions was developed using an iterative process based on previously published studies. Practicing surgeons in general surgery or related subspecialties were eligible to participate. Invitations to complete the survey were distributed through 13 surgical associations, as well as social media and personal email invitations; recruitment expanded using a snowballing method. Responses were obtained between June 1st -August 31st, 2020. Results: A total of 521 surveys were collected. The majority of participants practiced in North America (260;50%) with remaining respondents from: Asia (82;15.7%), Europe (32;6.1%), South America (22;4.2%), Africa (16;3.1%), and Oceania (6;1.2%). Duration of practice was equally distributed across 4 intervals (0-5yrs; 6-15yrs; 16-25yrs; [ 25yrs). Respondents most frequently identified as general surgeons (283;66%), and 390(75%) were male. Awareness of peer coaching was reported by 275(53%), yet of these 197(45%) never sought formal feedback from peers. The majority of respondents (372;84%) would be willing to participate in a peer coaching program as either coachee or coach, with monthly interactions the most desirable frequency reported (174;46%). Coaching in the operating room was preferred by most participants (360;86%) over remote or delayed interventions. Few respondents (44;10%) said they would accept coaching from someone unknown to them. Participants identified key coaching program elements as follows: personalized goal setting (285,68%); feedback kept private and confidential (267;63%); opportunity to provide feedback to the coach (247,59%); and option to choose one's own coach (205;49%). The most commonly cited potential barrier to participation was logistical constraints (339;65%) while fear of judgement by peers was cited by only a minority of respondents (93;18%). Conclusion: Surgeons infrequently seek formal peer feedback but would be willing to participate in peer coaching programs. This survey identified surgeon preferences and perceived barriers to coaching participation, which may be used to guide coaching program design. Introduction: The purpose of this study was to assess the perceived impact COVID-19 has had on general surgery residency programs within Canada, including resident utilization and novel training methods implemented during the pandemic. Methods and procedures: Data collected anonymously using Qualtrics, an electronic questionnaire. All Canadian general surgery residents were invited to participate through the Canadian Association of General Surgeons (CAGS) website and via their program directors. The questionnaire was developed to determine the perceived impact of the pandemic on exam preparedness, time away from service, exposure to training opportunities, and educational concerns. Online and alternative teaching methods were evaluated for effectiveness Descriptive statistics were used to analyze the data using SPSS. Research was approved by the local research ethics board (HREB File number 20210152). Results: 83 responses were received in total from 13 residency programs with representation from residents across all 5 years of postgraduate training. General themes that emerged in response to our survey were identified. Decreased work hours, as well as reduced clinics, procedural time and exposure to patient care represented the most significant concerns. Most residents believed that the pandemic posed a risk to their personal health and safety at work. Most agreed that the pandemic had negatively impacted their overall learning and development as a resident. The majority of learners felt their programs had made adaptations during the pandemic to improve exposure to learning such as moving teaching to online platforms, providing OR video recordings, and integrating simulation technology. Conclusions: The survey illustrated that teaching through online platforms was valuable and consideration should be given to continuing these modalities post-pandemic. Online teaching was found to be more conducive to learning while off-site, offered more convenience, elicited more staff participation and provided more scheduling flexibility for residents. Future studies should quantitatively examine whether virtual teaching and learning actually delivers equal or better Results for residents going forward.

The fundamentals of laparoscopic surgery in general surgery residency: fundamental for junior residents Ingrid S Schmiederer, MD 1 ; LaDonna E Kearse, MD 1 ; Tiffany N Anderson, MD, MHPE 2 ; Davis H Payne, BS 3 ; Daniel L Dent, MD, FACS 3 ; James R Korndorffer, Jr, MD, MHPE, FACS 1 ; 1 Stanford University; 2 University of Florida; 3 UT Health San Antonio.

Background: The implementation of the Fundamentals of Laparoscopic (FLS) program by Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has served a need for structure in education for laparoscopic skill within General Surgery training since 2004. This study looks at how FLS affects resident self-efficacy and operative independence. Methods: We conducted a national survey that was linked to the 2020 American Board of Surgery In-Training Examination (ABSITE), in which 9,275 residents in 325 US General Surgery Training Programs participated. The online survey included multi-modal questions that analyzed whether participants had performed the most commonly-logged resident laparoscopic operations, such as Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC) and Laparoscopic Right Hemicolectomy (LRH), without faculty assistance. It also asked if residents felt they had the ability to perform these operations independently at this moment in their training and provided a 5-point scaled assessment of self-efficacy (SE), ranging from ''not able to'' to ''definitely able to.'' Multivariate analysis was used to determine if completion of FLS made a difference for resident operative independence (OI) or self-efficacy (SE). To avoid confounding data with the expectation that senior residents gain increasingly more independence and also complete FLS, researchers analyzed variables by post-graduate year (PGY). Results: Of the residents who participated, 36% (n = 2300) reported completing FLS at the time of the survey. The percentage of FLS completion increased from PGY-1 to PGY-5 (4.2% n = 59, 85.8% n = 893). The 59 PGY-1 FLS-completers were distributed among 48 diverse institutions and demonstrated the most significant and consistent Results, both in OI and in SE, with FLS completion. There were positive correlations in those who had reported being allowed independence in LA and LC with FLS [r(1379) = 0.071, p \ 0.01 and r(1381) = 0.089, p \ 0.01] respectively. Additionally, in the ordinal regression of SE Score, the odds of PGY-1 FLS completers reporting a higher SE for LRH was 2.042 times (95% CI, 1.165 to 2.919) that of non-FLS PGY1s, a statistically significant effect, p \ 0.001. Ultimately, these FLS effects were less evident, or not statistically significant, in the more senior classes. Conclusions: Completion of FLS arguably has the greatest benefits for more junior residents, as it provides a structure for learning the instruments and establishing a foundation of laparoscopic knowledge and skill, upon which further residency training can build. This, in turn, leads to greater sense of ability, as well as more operative independence allowed. Introduction: Our surgical training program typically includes robust simulation and technical skills training consisting of multiple in-person skills labs throughout the year. This allows for technical skills practice on simulators as well as animate and cadaveric models with the opportunity for real time faculty feedback. As strict social distancing guidelines were implemented at our institution in response to the ongoing COVID-19 pandemic, we developed a ''mobile skills lab'' enabling residents to take equipment for laparoscopic skills practice home and access expert faculty coaching through real-time video conferencing. The aim was to refine this method for technical skills training in advance of the arrival of our incoming intern class. Methods: Residents were able to pick up a laparoscopic skills trainer (Ethicon TASKit) and schedule a coaching session with a faculty mentor. Coaching sessions utilized the screen share function of Zoom video conferencing to allow faculty to view the feed from the resident's laparoscopic trainer directly. Laparoscopic trainers were available to faculty who wanted to be able to demonstrate techniques to trainees during their sessions. Results: Both faculty and resident participants in the program found it a useful method for technical skills training for certain skills such as peg transfer and pattern cutting, though camera quality limited ability to deliver feedback on suturing skills. This method easily accommodated video recording of task for later self-review by trainees. The program had the additional benefit of building camaraderie between faculty and trainees during a challening period. Conclusion: This new training opportunity as well received by our pilot group, and we used the best practices discovered here to develop a formal remote coaching program for our newest residents that is now in progress. We hope to continue to utilize remote training as an adjunct to in person skills training moving forward.

Training on a simulator improves proficiency of percutaneous tracheostomy placement compared to didactic training: a doubleblinded, randomized controlled trial Alexis Jeannotte, MD, FRCSC; Alek Szmigielski, MD, CCFP; Gordie Kaban, MD, FRCSC; University of Saskatchewan. Rationale: Percutaneous tracheostomies (PT) are commonly performed by general surgeons as an alternative to open tracheostomy. Although a safe procedure, inherent with surgery on the airway, there is potential for complication and mortality. Acquisition of this skill in a general surgery residency could be improved by practice via simulation. We hypothesized that practicing on an inexpensive, low fidelity surgical simulator would improve skill acquisition and confidence for percutaneous tracheostomy for inexperienced learners. Methods: Medical students from the University of Saskatchewan were randomized to receive tracheostomy placement instruction from a video (control group) or apply hands-on practice on a simulator (intervention group). All students then performed an evaluative tracheostomy on a simulator. Time to correct tracheostomy placement was the primary outcome, and score from a confidence survey was the secondary outcome. The study was double-blinded. Results: 18 medical students participated in the study. Proficiency was measured by time to correct completion of the procedure. The median time to correct tracheostomy placement was significantly faster in the intervention group than the control group (320.5 s vs. 547 s, p \ 0.001). The median confidence score of the intervention group was higher in comparison to the control group (31/45 vs. 20/45, p = 0.052). Mann-Whitney test was performed using an alpha of 0.05. Conclusion: The study demonstrated to statistical significance that practice on the simulator led to improved proficiency in percutaneous tracheostomy placement on the simulator. It also showed that participant confidence was higher with the opportunity to practice first; although, this did not reach statistical significance.

Force application during colonoscopy as a marker of competence: development of a novel training device Jeffrey D Hawel, MD, MSc 1 ; Rajni V Patel, PhD 1 ; Terry Peters, PhD 2 ; Kerollos Wanis, MD, MSc 1 ; Anish Naidu, MD 1 ; Ran Xu, PhD 1 ; Ahmad Elnahas, MD, MSc 1 ; Nawar A Alkhamesi, MD, FACS 1 ; Christopher M Schlachta, MDCM 1 ; 1 Western University; 2 Roberts Research Institute, Western University. Colonoscopy is a technically challenging procedure to learn. The colonoscope is prone to forming loops in the colon, which can lead to patient discomfort and even perforation. We hypothesized that expert endoscopists use techniques to avoid loop formation, identify and straighten loops earlier, and thus exert less force.

Using a commercially available physical colon simulator model (Kyoto Kagaku), electromagnetic tracking markers (NDI Medical) were placed along the mobile segments of the colon (sigmoid, transverse) to measure the degree of displacement of the colon as the scope was advanced to the cecum. Displacement was used as a surrogate marker for force. The colon model was set for each participant to simulate a redundant alpha loop in the sigmoid colon. Gastroenterology and surgical trainees and attendings were assessed. Demographic data was collected for each participant.

Seventy-five participants were enrolled in the study. There were 17 (22.7%) attending physicians, and 58 (77.3%) trainees. Attending physicians advanced the scope to the cecum faster. The mean times required for procedure completion were 360.5 s and 178.4 s for the trainee and attending groups respectively (mean difference: 182.1 s, 95% CI: 93.0, 269.7; p = 0.0002). Attending physicians exerted significantly lower mean colonic displacement than trainees. The mean colonic displacement was 79.8 mm for the trainee group and 57.9 mm for the attending group (mean difference: 21.9 mm, 95% CI: 2.6, 41.2; p = 0.04). Maximum colonic displacement, velocity and acceleration did not differ between the groups. By specialty, gastroenterologists caused lower mean and maximum displacement of the colon compared to surgeons. Regarding endoscopic technique, those who used torque steering caused lower maximum colonic displacement than those who used knob steering.

We have shown that attending physicians advance the scope during colonoscopy in a manner that Results in significantly less colonic displacement than resident trainees. Although prior studies have shown a difference in force application between endoscopists and inexperienced students, ours is the first to differentiate across varying degrees of endoscopic skill. Our model uses software and technology available in most simulation centres, is comparatively cheaper than virtual simulators, and affords the trainee haptic feedback. Future studies will aim to define metrics for incorporation into endoscopic training curricula, focusing on techniques that encourage safety and comfort for patients.

Repeat preoperative endoscopy after regional implementation of electronic synoptic endoscopy reporting: a retrospective comparative study Introduction: Repeat preoperative endoscopy is common for patients with colorectal neoplasms. This can result in treatment delays, patient discomfort, and risks of colonoscopy-related complications. Repeat preoperative endoscopy has been attributed to poor communication between endoscopists and surgeons. In January 2019, mandatory electronic synoptic reporting (SR) for endoscopy was implemented in all Winnipeg hospitals to include elements consistent with quality indicators proposed in national guidelines. The aim of the present study is to assess whether the repeat preoperative endoscopy rate for colorectal lesions changed following SR implementation.

Methods: This is a retrospective before-and-after comparative study at a tertiary hospital in Canada specializing in colorectal surgery. 1429 patients who underwent elective colorectal resection for colorectal cancers or polyps between January 2007 and June 2020 were included. 115 had index endoscopies recorded via SR and 1314 by narrative report (NR). The primary outcomes were rates of repeat preoperative endoscopy and inclusion of colonoscopy quality indicators such as photo-documentation, tattoo placement, and bowel preparation score. Rates were compared via chi squared test and plotted over time by Shewhart chart. Results: The repeat preoperative endoscopy rate after endoscopies documented by NR was 29.07% (95%CI: 26.63-31.61) and 25.22% (95%CI: 17.58-34.17%) for SR. Patients whose index endoscopies where performed by a practitioner other than their operating surgeon had a re-endoscopy rate of 36.03% (95%CI: 32.82-39.33%) for NR and 38.81% (95%CI: 27.14-51.50%) for SR. Rates of tattoo placement, photodocumentation, and reporting of bowel preparation quality were all significantly increased with SR (p B 0.003).

Limitations: This is a single-centre retrospective study design with relatively small sample size. Conclusions: Endoscopy SR based on current guidelines was associated with a significant increase in inclusion of quality indicators, but was not associated with a decrease in rate of repeat pre-operative endoscopy at a high-volume colorectal cancer centre. Future study should examine guideline deficiencies for the purposes of lesion localization and make necessary modifications.

Hemostatic spray, a rescue to severe postpancreaticoduodenectomy hemorrhage -a novel technique to use Azka Naeem; Awais A Malik; Farooq Afzal; Lahore General Hospital. Pancreaticoduodenectomy is encountered with many postoperative complications leading to higher morbidity rates, one of which is post-pancreaticoduodenectomy hemorrhage(PPH).

A 52 year old female diagnosed with adenocarcinoma of ampulla of vater, underwent pylorus preserving pancreaticoduodenectomy (PPPD) and pancreaticogastrostomy. On 4th post-operative (POD) day she had an episode of malena followed by hematemesis leading to hemorrhagic shock notpreceded by any sentinal bleed. After adequate resuscitation, upper gastrointestinal (GI) endoscopy revealed, clotted blood in stomach, ulcerated surface of pancreatic stump visible in stomach, also clean based ulcers were seen at the anastomotic site of small intestine with stomach.

Hemostasis was achieved by using hemospray at the ulcerated site and no episode of Upper GI bleed was encountered. It hence, opens a new horizon of using hemospray successfully for life threatening PPH, as it has been used for a multitude of reasons of Upper GI bleeds but not for post pancreaticoduodenectomy hemorrhage. Objective: Upper gastrointestinal (UGI) perforations and leaks are life-threatening conditions that can lead quickly to septic shock, resulting in high morbidity and mortality. Tissue inflammation and remote anatomical location can make surgical repair challenging. Endoluminal vacuum-assisted closure (eVAC) therapy have been successful in the setting of rectal perforations, and has potential in treating UGI pathology as well. This study describes our institution's experience with the use of eVAC therapy in UGI perforations and leaks, and characterize the indications, and outcomes in our patient population. Methods/Procedures: This is a retrospective case series on patients treated with eVAC for UGI perforations or leaks at a single tertiary institute between 2017 and 2020. We describe the patient demographics, indications, details of eVAC therapy, and outcomes. Results: We present a case series of 10 patients who underwent eVAC therapy as treatment of UGI perforation or leak. Our series included 7 male and 3 female patients, and average age was 47 years. Average pre-operative albumin was 3.12, and Charlson Comorbidity Index was 2.3. Indications included gastric perforations from ulcer disease or volvulus (5), post-operative leaks (3), and iatrogenic injury from surgical procedures (2) . Notably, the three post-operative leaks were a result of medical tourism from operations performed outside of USA. Half of the patients had failed previous treatment, including endoscopic stenting, endoscopic suturing and surgical repair. Size of initial defect ranged from 2 to 60 mm. Average number of sponge changes was 3.1, and average length of stay was 26.8 days. We had an overall success rate of 90% in closure of the UGI perforations, confirmed with endoscopy and imaging. One patient ultimately required operation for persistent fistula tract. Long-term follow-up was inconsistent, but overall complications were low. One patient presented 7 months after treatment with an abdominal wall abscess around the site of the original enterocutaneous fistula that required bedside incision and drainage with subsequent resolution. Follow up available at 6 months demonstrated all patients were tolerating regular diet with no additional sequelae of their UGI pathology. Conclusion: Our institution has used eVAC successfully as both primary and secondary treatment of UGI injuries. In particular, our cohort supports the use of eVAC in the setting of post-operative complications from bariatric and foregut surgeries. This approach spare patients the morbidity of a surgical repair. Multicenter trials are needed to demonstrate superior outcomes in comparison to other interventions. Introduction: Over-the-scope-clips (OTSCs) perform best when fired in an ''endon'' position, meaning the scope, clip, and tissue are aligned along one axis. For accurate fistula identification and to assist in achieving the ''end-on'' position, the concept of cannulating the defect with a guidewire, backloading the endoscope onto the wire, and firing the OTSC over the wire with subsequent wire removal through the endoscope has been demonstrated. However, the safety of this technique has not been previously evaluated. Methods: An ex-vivo experimental model was utilized (Fig. 1) . Fresh porcine foregut was opened longitudinally so the mucosal surface could be accessed. A biopsy punch was used to create 3 mm diameter full-thickness GI tract defects through which a guidewire was threaded. An endoscope was backloaded over the wire and OTSCs (OVESCO, Tuebingen, Germany) were fired over the defect and wire. The wire was removed through the endoscope and the ease of removal was graded using a 5-point Likert scale. This process was repeated for each unique combination of nine OTSC types (10/3A, 10/3 T, 11/6A, 11/6 T, 12/6A, 12/6 T, 12/6 GC, 14/6A, 14/6 T), 2 wire types (0.035' Jagwire and 0.035' Braided Guidewire (Boston Scientific, Natick, MA)), 4 wire angles (0°, 30°, 60°, 90°), and 3 tissue locations (esophagus, stomach, duodenum). Statistical analysis was performed using t-test and ANOVA. Results: 216 OTSC firings with wire removal attempts were performed with the following Likert score breakdown: 1 -No difficulty (80.6%), 2 -mild difficulty (16.2%), 3 -moderate difficulty (2.3%), 4 -extreme difficulty (0.9%), and 5unable to remove (0%). The mean removal difficulty was 1.24 ± 0.5. Statistically significant differences were noted in removal difficulty between OTSC sizes (10 mm: 1.40 ± 0.7, 11 mm: 1.13 ± 0.3, 12 mm: 1.33 ± 0.6, 14 mm: 1.04 ± 0.2, p \ 0.05). No differences were identified between clip teeth types (p = 0.79), wire types (p = 0.16), tissue types (p = 0.82), and wire angles (p = 0.75). Conclusion: In this ex-vivo model utilizing 216 unique combinations of OTSC types, wire types/angles, and tissue types, the guidewire was successfully removed through the endoscope in all cases. The few difficult wire removals were potentially related to wire damage from repeated experimentation and would be unlikely to occur clinically when new wires are used in each case. This technique can be employed to facilitate OTSC closure of GI tract defects when achieving fistula identification or an ''end-on'' scope position would otherwise be difficult, but further study is indicated before wide clinical implementation.

Endoscopic removal of a large gastric bexoar using mechanical lithotripsy -a case report and review of management Peter Cmorej, MD; Choichi Sugawa, MD; Wayne State University School of Medicine/Detroit Medical Center.

Introduction: Bezoar is a rare entity detected in \ 0.5% of upper endoscopies and the culprit in 0.8-3.2% of intestinal obstructions. Depending on the composition, bezoars are classified into phytobezoars (plant materials), trichobezoars (hair), and pharmacobezoars (medications). Diospyrobezoar, a type of phytobezoar originating from persimmons, presents a therapeutic challenge due to its nearly seamless and firm external surface made up of polymerized tannins conferring substantial chemical and mechanical resistance. We present a case of a patient with large diospyrobezoar managed endoscopically by fragmentation with mechanical lithotripsy. Case report: A 52-year-old male with history of 15 cm GIST treated 14 years prior to presentation at another institution with distal gastrectomy, en bloc transverse colectomy, Billroth-I, and adjuvant chemotherapy. The patient presented with epigastric abdominal pain and fullness, vomiting, and anorexia. CT imaging revealed 10 9 8 cm intraluminal gastric mass, consistent with a bezoar, resulting in partial outlet obstruction. After nasogastric decompression, the stomach was lavaged with 3L of Coca-Cola over 12 h without clinical improvement. On gastroscopy, the brownish-black diospyrobezoar was hard-shelled, necessitating the implementation of fragmentation techniques. Mechanical lithotripsy of the phytobezoar was performed utilizing Olympus LithocrushV. The resulting pieces were removed using endoscopic snare and basket. Endoscopic treatment resulted in complete symptom resolution and tolerance of oral diet. Discussion: The most common symptoms of gastric bezoar are abdominal pain, discomfort, fullness, tarry stools, and anemia. The major predisposing factor is impaired gastric motility from prior gastric surgery, neuropathy, hypothyroidism, and other conditions. Complications include outlet obstruction, ulcerations from pressure necrosis, and upper GI bleeding. First-line therapy is chemical dissolution using Coca-Cola and similar carbonated beverages with [ 90% reported success rate, despite the absence of a standardized protocol. Alternative enzymatic therapies include papain (an ingredient in meat tenderizer) and cellulase, which are scarcely used due to poor side-effect profile and commercial unavailability, respectively. In cases when chemical dissolution is ineffective, endoscopic management is the next step. Most bezoars can be removed using common endoscopic devices including polypectomy snare, basket, and biopsy or alligator forceps. Large and hard-shelled bezoars (e.g. diospyrobezoars) require more advanced fragmentation techniques before piecemeal removal, including argon plasma coagulation, Nd:YAG laser, mechanical or electrohydraulic lithotripsy, and a novel guidewire-based bezoaratom kit. Trichobezoars are resistant to degradation and most fragmentation techniques but can be morcellated endoscopically using electrosurgical knives. When endoscopic techniques are insufficient, surgery is indicated. Either laparoscopic or robotic approach is possible in most cases and leads to better outcomes.

Solid organ injury during percutaneous endoscopic gastrostomy tube placement, a review of two cases Introduction: First described in 1980, percutaneous endoscopic gastrostomy (PEG) placement is one of the most common forms of durable enteral access today. The ''safe tract technique''utilizing an aspirating, liquid-filled syringe with simultaneous air return and endoscopic visualization-was developed to minimize complications of PEG placement. However, this technique has less utility for avoidance of solid organ injury. Transillumination may assist in avoidance of solid organs, but is less effective in obese or non-white patients. Despite utilization of such safety techniques, PEG placement is not without potential complication. Methods: We present the cases of two patients who underwent uncomplicated PEG tube placement. Both had multiple prior abdominal surgeries. On post-operative day one, due to clinical and laboratory findings consistent with post-operative SIRS response, each received a CT scan with water-soluble contrast. The PEG tubes were found to be traversing through the left hepatic parenchyma with the silicone retention dome within the stomach. There was no evidence of contrast extravasation or large hematoma. Results: After identification the patients were closely monitored for hemodynamic changes. Antibiotics were initiated. The bumpers, normally kept at 1 cm from the skin, were cinched down to ensure hemostasis. Tubes were secured to the skin to prevent inadvertent dislodgement. After the initial inflammatory response resolved, tube feeds were initiated and well-tolerated. Both patients recovered without further PEG complications and were discharged with PEG tube in place. There were no attempts to revise or replace the tubes.

We present these cases so that we may review the literature and describe management of these likely under-reported complications. We identified several case reports demonstrating transhepatic PEG placement. While rare, this risk must be recognized. Safe tract and transillumination techniques may reduce this complication, however neither can prevent all injuries. We stress the importance of reviewing preoperative imaging with attention to interposed organs prior to attempted PEG. Should solid organ injury occur, it is important not to dislodge the tube causing further parenchymal injury. We advise gentle compression from the bumper to ensure hemostasis. Patients should be monitored closely for signs of peritonitis or abdominal sepsis. If clinically stable, the tube may be used as normal. For removal, we recommend the PEG not be removed via the traction method, as this could disrupt the parenchymal tract. Alternatively, the tube should be removed by cutting the tube externally with per oral endoscopic removal of the transected tube.

A case of late presentation of a gastrocolocutaneous fistula following percutaneous gastrostomy migration Adam Swiger, DO; Peter DeVito, MD; Western Reserve Health Education. Percutaneous Endoscopic Gastrostomy (PEG) is a safe and effective method for long-term enteral feeding. Most patients only experience minor complications with a low mortality rate, but serious life threatening complications are also reported. We present a case of a complex Gastrocolocutaneous Fistula (GCCF) causing intermittent intractable nausea and diarrhea five months after placement. Serial CT imaging by the emergency department demonstrated intermittent tube migration to and from the stomach and transverse colon coinciding with the waxing and waning of the patient's symptoms. Subsequently, the PEG tube was removed, and a surgical gastrostomy was placed with closure of the GCCF.

An 86-year-old male with a past medical history significant for laryngeal cancer status post surgical excision and neck radiation, dementia, and GERD presented to the emergency department with an approximately two-week complaint of intermittent nausea, diarrhea, and foul-smelling drainage around his PEG tube. Patient underwent successful PEG tube placement 5 months prior and was tolerating tube feeds to date. The patient was treated with antidiarrheal medications without symptom alleviation. Documented tube length and PEG care had not changed.

The patient was hemodynamically stable, and physical examination demonstrated a soft, flat, nontender abdomen with slightly hyperactive bowel sounds, and minimal drainage surrounding the PEG tube, consistent with tube feeds. Laboratory studies were all within normal limits. A CT scan of the abdomen/pelvis was ordered demonstrating no acute intra-abdominal or pelvic inflammatory process with no evidence of enteric obstruction or free air. The tip of the PEG tube was documented within the lumen of the stomach (Fig. 1) . The length of the PEG was at 4 cm, unchanged from insertion. The patient was subsequently discharged.

The patient represented to the emergency department eleven days later with similar complaints of nausea, diarrhea, and drainage around the PEG tube site. Again, a preliminary diagnosis of PEG tube malfunction was made by the emergency department and another CT scan of the abdomen and pelvis was performed; Again, no inflammatory process was identified, and there was no free air or obstruction, but this CT demonstrated the PEG terminating within the lumen of the distal transverse colon with a tract between the stomach and transverse colon. This case is consistent with erosion of the PEG tube through the gastric wall into the colon (Fig. 2) . The patient subsequently underwent PEG removal with surgical gastrostomy insertion with suture closure of the gastrocolocutanous fistula and interposition of omentum.

Colonoscopy skills improvement (CSI) training improves patient comfort during colonoscopy Aim: We aimed to assess the effect of CSI training on patient comfort and sedation related complications during colonoscopy.

Introduction: The CSI program was implemented by The Canadian Association of Gastroenterology with the objective of improving colonoscopy quality. Previous investigation has shown an association between CSI training and lower sedation and analgesic dosing during colonoscopy. The current study is a follow up investigation to assess for impact on patient comfort and minor sedation related complications.

Methods: This retrospective cohort study was performed on 17 endoscopists practising in a tertiary care center in St. John's, Newfoundland who completed CSI training between October 2014 and May 2016. Data from 50 procedures immediately prior to, immediately after, and eight months following CSI training were included for each endoscopist. The primary outcome variable was intraprocedural comfort and secondary outcomes included intraprocedural hypotension and hypoxia. Comfort was assessed using nursing records and categorized as 'comfortable,' 'mild/moderate discomfort,' or 'significant discomfort.' Hypoxia was defined as an oxygen saturation of \ 85%. Hypotension was defined as less than 90 mmHg/50 mmHg or \ 20% of baseline. For the purpose of statistical analysis comfort score was simplified into two categories by grouping 'mild/moderate discomfort' and 'significant discomfort' together. Data were extracted from electronic medical records and analyzed using SPSS version 20.0. Univariate analysis and stepwise multivariable logistic regression were performed to determine if there was an association between patient comfort and predictors of these outcomes including patient age, gender, sedation use and dosing, procedure completion, quality of bowel preparation, endoscopist experience, specialty and CSI training. Results: 2533 colonoscopies were included in the study. The mean dose of sedatives was reduced immediately following CSI training and at 8 months for both Fentanyl (72.8 mcg v. 64.8 mcg v. 63.5 mcg, p \ 0.001) and Midazolam (2.49 mg v. 2.17 mg v. 2.11 mg, p \ 0.001) . The percentage of patients deemed to have a comfortable exam improved following endoscopist participation in CSI training and remained improved at 8 months (55.1% v. 70.2% v. 69.8%, p \ 0.001). No significant change in rates of intraprocedural hypoxia or hypotension were noted following CSI training. In multivariate analysis, improved patient comfort was associated with male gender, lower mean doses of Fentanyl, procedure completion and CSI training. Conclusion: CSI training is associated with improved patient comfort during colonoscopy.

Endoscopic internal drainage is a safe procedure to manage anastomotic leaks Introduction: Anastomotic leaks following foregut surgery pose a difficult scenario for surgeons. While definitive surgical options are more invasive and may result in diversion requiring subsequent surgeries, endoscopic management of these leaks has been shown to work as an alternative platform for management. An evolving option is endoscopic internal drainage. We have reviewed our experience using endoscopic internal drainage and report our outcomes. Methods: An institution review board approved prospectively gathered database was used to identify all patients undergoing endoscopic internal drainage following esophageal and gastric leaks. Patient demographics, sentinel operation causing the leak, and outcomes of therapy were collected. The rate of healing and complications with the drainage catheter in place were the primary endpoints. Results: Seventeen patients were identified (5 male, 12 female) that underwent endoscopic internal drainage with a mean age of 50 and mean BMI of 33. Overall success rate was 71% (12/17), where 5 patients required a definitive surgery. Of the 5 failures, 2 patients required esophagojejunostomy, 2 patients required a fistulojejunostomy, and one required a partial gastrectomy. A total of 12 patients (71%) had a prior endoscopic procedure that were unsuccessful. The mean duration of drainage catheter in place was 48 days. While the catheter was in place, 4 patients were allowed minimal PO intake in conjunction with total parenteral nutrition or tube feeds. The rest of the patients were strict NPO with other means of nutrition. There were no complications with the drainage catheters and no deaths reported. Conclusion: Leaks following esophagogastric surgery are difficult to manage; however, endoscopic therapies can be used to avoid additional surgery. We show here that endoscopic internal drainage is safe and feasible option to heal leaks in foregut surgery. Background: Chemotherapy is only treatment available in unresectable perihilar cholangiocarcinoma. However, only few patients were able to receive chemotherapy according to high level of bilirubin affected by biliary obstruction. Endoscopic retrograde cholangiopancreatography(ERCP) is often used to provide internal biliary drainage however some patients were failed to achieve clinical success. This study evaluated the factors associated clinical success of ERCP with biliary drainage in unresectable perihilar cholangiocarcinoma. Methods: We retrospectively evaluated the records of 81 unresectable perihilar cholangiocarcinoma patients who had undergone ERCP with biliary drainage from 2010 to 2018. Patients received unilateral or bilateral stents, plastic or metal. An unsuccessful biliary drainage was defined when serum bilirubin reduced less than 50% of prior serum bilirubin in 2 weeks. Student's t-test, Kruskal wallis test, Pearson's chi-square test, Fisher's exact test and logistic regression were used for analyses. Results: The rate of successful biliary drainage was 50.6%. The patients who had higher serum cholesterol had significant success rate comparing to the patients who had lower serum cholesterol.( p = 0.038) Bilateral biliary drainage had higher success rate than unilateral biliary drainage however there was no statistical significant.(68.8% vs 46.2%, p = 0.105) Elective biliary drainage had higher success rate than emergency biliary drainage however there was no statistical significant.(70.7% vs 52.5%, p = 0.091) The patients who had taken ursodeoxycholic acid had slightly lower success rate comparing to the patients who had not.(46.3% vs 65.0%, p = 0.091). Conclusion: Nowaday technical success in ERCP was high, whereas clinical success was doubtful. Higher serum cholesterol level was found to be an independent risk factor that affected the success rate of ERCP biliary drainage. This factor should be assessed to identify a patient who might benefit from other biliary drainage procedures. Introduction: Communication of the gastrointestinal (GI) tract via the abdominal wall can occur through planned surgical stomas or unplanned fistulization. In both cases, patients are at risk for untoward outcomes including high enteral output, stenosis, mucocutaneous disruption, and infection (superficial, deep, and organ space). Major operative reintervention is often required, which mandates a period of optimization that can be challenging for patients and surgeons alike. Herein, we present our experience with the use of percutaneously deployed endoscopic stents for the initial management of GI fistulae and stoma complications. Methods: An IRB-approved retrospective medical record review of cases performed from 12/2012-07/2020 was conducted. All patients who underwent percutaneous deployment of an endoscopic stent were included. Preoperative, operative, and postoperative data were collected and analyzed using descriptive statistics. Results: Ten patients were identified with the following profile: mean age 60.0 ± 9, 6 (60%) female, and mean ASA class 3.2 (range 3-4). Seven (70%) patients had percutaneous stent deployment across an ostomy, while 3 (30%) had percutaneous stent deployment across an enterocutaneous fistula. The location of the stent deployment was 1 (10%) stomach, 2 (20%) proximal-jejunum, 1 (10%) mid-jejunum, and 6 (60%) colon. The indications for stent placement were as follows: high-output fistula (2), mucocutaneous ostomy disruption with intraabdominal contamination (2), skin level stricture with obstruction (3), gastrostomy erosion (1), ostomy retraction with wound infection (1), and persistent fistula with distal stricture (1) . Stent types included 8 (80%) fully-covered esophageal stents, 1 (10%) fullycovered biliary stent, and 1 (10%) lumen-opposing metal stent. The mean number of days until stent removal was 28 (range 1-112); seven stents were removed intentionally, while 3 stents migrated out unintentionally. Five patients underwent repeat endoscopic intervention: 3 for new stent placement and 2 for stent repositioning. In seven (70%) cases, patients experienced clinical improvement after stent placement and no patients experienced stent-related complications other than migration which was amenable to endoscopic reintervention in all cases. Seven (70%) patients ultimately underwent definitive operative intervention, with a mean of 208 ± 203 days between stent placement and operation. Conclusion: The percutaneous deployment of endoscopic stents across fistulae and stomas is a safe, minimally-invasive therapy with promising Results both as definitive therapy and as adjunctive therapy during preoperative optimization. Close patient follow-up is required to detect stent migration and determine optimal timing of stent removal. Further study is required to determine best practices for patient selection. Introduction: The purpose of this study was to review and compare outcomes of PEG tubes placed by acute care surgeons and gastroenterologists. PEG tubes are placed by both gastroenterologists (GI) and surgeons throughout the country. At Rhode Island Hospital, before July of 2017, all PEGs were placed by GI. In July of 2017, in response to a growing need for PEGs in our institution, particularly in the ICUs, acute care surgeons (ACS) also began performing PEGs at the bedside throughout the ICUs in the hospital. Our hypothesis was that PEG tubes placed by ACS would result in more complications than GI due to ACS having less experience performing the procedure. Methods and procedures: Retrospective chart review of all patients who received a PEG placed by ACS or GI at the bedside in any ICU from December 2016 to September 2019. Charts were reviewed for the following outcomes and complications: Success rates of placing PEG, time to complete procedure, major complications, death. Secondary outcomes included discharge disposition, rates of CMO after PEG, time to CMO after PEG. Results: In 2017, 75% of PEGs were placed by GI and 25% surgery. In 2018, 47% were placed by GI and 53% by surgery. In 2019, 33% were placed by GI and 67% by surgery. There was no significant difference in success rates between surgery (146/ 156 93.6%) or GI (173/185 93.5%) (P 0.97). On average, GI performed the procedure faster than surgery (Median 10 (7-16) min vs 16 (13-21) mins respectively, p \ 0.001) There were no significant differences between groups in any of the PEG outcomes or complications investigated. Overall there was no significant difference in major complications such as dislodgement or malpositioned tube requiring any intervention (i.e. re-peg, VIR, or surgical intervention) between surgery (14/146) 9.6% vs GI (18/173) 10.4% (P 0.49). Conclusions: Bedside PEG tube placement appears to be a safe procedure in the ICU population. GI and Surgery had nearly identical success rates in placing PEGs. GI performed the procedure faster than surgery. There were no significant differences in the reviewed patient outcomes or complications between PEGs placed by ACS or GI in our patient population of ICU patients. Of note, when a complication occured, ACS PEG patients typically were managed in the OR while GI tended to re-PEG patients highlighting a potential difference in management that should be further investigated. Acute care surgeons are capable of safely performing this procedure. Introduction: Benign esophagobronchial fistulas are a pathology that remains difficult to treat. Classically, fistula tracts were managed via an open surgical technique. More recently, endoscopic techniques have emerged and offer a minimally invasive approach. Initial endoscopic approaches to treatment included mucosal abrasion, clip closure, and stent placement. While these techniques decrease morbidity there is only a 53% clinical success rate of fistula closure. Endoscopic mucosal resection has been reported with improved closure rates. We present two cases where we used a novel single lumen dual endoscopic approach for fistula closure. Methods: Two patients with benign esophagobronchial fistulas related to granulomatous lymphadenopathy presented for endoscopic management. Bronchoscopy and esophagoscopy were used to identify the fistula tract. Esophageal mucosal resection was initiated circumferentially around the fistula orifice. With the first patient, initial attempts to provide adequate retraction of the mucosa were unsuccessful using the ''clip in line'' technique due to clip dislodgement. A bronchoscope was then inserted into the esophagus alongside the primary gastroscope and forceps were used to provide additional retraction of the tissue for resection. The esophageal mucosal defect was closed using clips in the first case and covered with an esophageal stent in the second as submucosal fibrosis prevented successful application of clips. Results: Both patients had successful resolution of their tracheoesophageal fistulas. The first patient underwent esophagram and endoscopy for unrelated reasons demonstrating complete healing at 12 months. The second patient underwent esophagram and was asymptomatic with 8 months of follow-up. Our technique of using an additional scope to provide retraction demonstrated several distinct advantages over the previously described techniques: 1) increased ability to manipulate the tissue to a greater range and force, 2) increased directional control including pushing rather than just retraction, and 3) ability to re-grasp the tissue when dislodged rather than fashioning a new clip. Conclusion: Management of esophageal airway fistulas is challenging and increased success of closure has been demonstrated with mucosal resection. The technique described, utilizing an additional scope to provide retraction improved the quality of resection and speed of the procedure. We believe this approach is promising and can provide an additional resource when treating these fistulas and other pathology endoluminally.

A retrospective analysis of the effects of hiatal hernia repair on pulmonary function tests Xander Jacobson; Matthew Dale, MD; Venket Sahasranaman, MBBS; Kalyana C Nandipati, MBBS; Creighton University.

Introduction: Pulmonary function has been shown to be worse in patients with hiatal hernias. The impact of hiatal hernia repair on pulmonary function has been. The objective of the study is to assess the impact of hiatal hernia repair on pulmonary function. Methods and procedures: We identified 547 patients who underwent hiatal hernia (HH) repair between 2005-2019. We included 370 patients who had pre-operative and post-operative data available. All patients who had pre-and post-operative data were included in our study. Patients were stratified by the size and type of HH. Study parameters included demographics, status of dyspnea and pulmonary function tests. Dyspnea status was assessed as either no change, worsened, improvement, or resolution of dyspnea. Size of hiatal hernias was evaluated based upon imaging, endoscopy, and intraoperative assessment. Analysis utilized a two-tailed, paired t-test (a = 0.05). Results: Of 370 patients included in the study, 277 (66.43%) were females and the median age was 61 years old. There were 9 African American (2.43%), 8 Hispanic (2.16%), and 353 Caucasian (95.41%) patients. The hiatal hernia size and dyspnea status was included in Table 1 . Surgical repair of a Type II HH resulted in significant improvement in dyspnea and in the Type III and IV HHs for the overall group and moderate-large size. A total of eleven patients had undergone pre-and post-operative PFTs. Significantly increased ERV function was observed in patients less than 60 years old with an increase of 75.11% (Table 2) . Additionally, for those reporting improved dyspnea status, there was significantly increased RV.

Conclusions: Surgical repair of a HH Results in improvement in dyspnea. The factors that suggest clinical improvement in dyspnea include a moderate-large and a Type III or IV HH. However, our Results showed that improvement in dyspnea status is not directly related to changes in PFTs. The patients with improvement also show increases in the RV. Development of a hiatal hernia is a rare, but problematic sequelae in the postesophagectomy population that has the potential to become disastrous in cases of incarceration or strangulation. Literature regarding this occurrence is sparse, with current prevalence ranging from 0.69% to 19.4% [1, 2] . The intent of this study is to examine hiatal hernia incidence rates in our esophagectomy patients to further elucidate the incidence of this phenomenon, risk factors for development and method by which they are most durably repaired.

With institutional IRB approval, a total of 163 transhiatal esophagectomy cases over an 8-year period were reviewed. Three mortalities within a 30-day postoperative period were excluded, leaving 160 cases eligible for inclusion in this study. Forty-three (26.9%) patients underwent an open esophagectomy (OE) and 117 (73.1%) underwent a minimally invasive esophagectomy (MIE). Indications for surgery, type of surgery, oncologic outcomes, surgical outcomes, postoperative hiatal hernia occurrence and subsequent repair including outcomes were reviewed.

In four of the 160 (2.5%) esophagectomies performed, a hiatal hernia developed at a mean of 12 months postoperatively (with a range of 3 to 28 months) with symptomatology driving the diagnosis for three patients. The indication for surgery in all four cases was malignancy, with three patients receiving neoadjuvant therapy and all but one undergoing minimally invasive esophagectomy. Subsequently, two patients underwent open hiatal hernia repair with mesh reinforcement. There was one recurrence at 33 months postoperatively but no mortalities or conduit-related complications.

The rate of hiatal hernia after esophagectomy at our institution was found to be 2.5% overall, which is within the previously described range in the literature. The limited size of our study did not allow for us to make statistically significant determinations in regards to risk factors or preferred method of repair. The presence of clinically significant symptoms in most cases leads us to believe that the true prevalence of a hiatal defect is higher than reported, as clinically asymptomatic patients are not captured in our current literature. Introduction: Hermansky-Pudlak Syndrome (HPS) is a rare, hereditary disorder with a prevalence of 1 to 2 cases per million individuals worldwide. It is characterized by oculocutaneous albinism, bleeding diathesis, granulomatous colitis, gastroesophageal reflux disease (GERD), and pulmonary fibrosis. Pulmonary fibrosis in HPS often manifests at 30 -40 years of age, and lung transplantation remains the only treatment to prolong survival. GERD may exacerbate pulmonary fibrosis and potentially lead to post transplantation allograft rejection. This case series explores the role and optimal timing of anti-reflux procedures in two patients with HPS. Case description:Case 1: A 48-year-old female with a history of HPS, associated platelet dysfunction and pulmonary fibrosis, presented with symptomatic GERD one year following bilateral lung transplantation. Endoscopy showed evidence of hiatal hernia and LA Grade A reflux esophagitis, and pH probe analysis revealed significantly abnormal esophageal exposure to acid (DeMeester score of 66.5). Fluoroscopic examination, manometry and gastric emptying study were unremarkable. Patient underwent robotic-assisted hiatal hernia repair and Toupet fundoplication. Her postoperative course was unremarkable, and she continues to follow with lung transplantation with no evidence of rejection. Case 2: A 49-year-old female with a history of HPS, class I obesity (BMI 38), diabetes mellitus type II, and pulmonary fibrosis, presented with symptomatic GERD six months following bilateral lung transplantation. Gastric emptying study showed evidence of gastroparesis and pH probe analysis revealed significantly abnormal esophageal exposure to acid (DeMeester score of 50). CT chest demonstrated sequelae of aspiration. Fluoroscopic evaluation and manometry were unremarkable. In the setting of her associated comorbidities, laparoscopic Roux-en-Y gastric bypass with a possible hiatal hernia repair were recommended. She is currently undergoing preoperative work-up and will be scheduled for surgery in the near future. Conclusions: Patients with HPS pose a unique challenge in the surgical treatment of GERD. We propose that patients with HPS should undergo screening for GERD in early adulthood in order to delay, or potentially prevent, the progression of pulmonary fibrosis. Additionally, anti-reflux operations should be considered before or shortly after lung transplantation to minimize the potential risk of graft rejection and lung failure. Earlier intervention has the potential to improve outcomes in patients with HPS.

Short-term outcomes of single-incision distal gastrectomy and conventional totally laparoscopic distal gastrectomya randomized controlled trial So Hyun Kang; Sang Jun Lee; Yongjoon Won; Young Suk Park; Sang-Hoon Ahn; Yun-Suhk Suh; Hyung-Ho Kim; Seoul National University Bundang Hospital.

Introduction: Surgical skills and devices have evolved to a level that allowed the paradigm in minimally invasive surgery is to shift towards patient quality of life (QOL) and satisfaction. Such innovations allow technically demanding procedures such as single-incision distal gastrectomy (SIDG) to become more feasible. However, there have been no reports of a randomized trial comparing SIDG to multi-port gastrectomy. This study evaluates the postoperative outcomes and patient QOL of SIDG compared to conventional totally laparoscopic distal gastrectomy (TLDG). Methods: This study was designed as a prospective phase II randomized controlled study. Patients diagnosed with early gastric cancer in the distal 2/3rd of the stomach were randomized to either TLDG or SIDG group. All operations were performed by a single surgeon. Primary endpoint was pain score using the visual analogue scale on postoperative day (POD) 1. Other outcomes include operative data, complications, and patient QOL using the European Organization for Research and Treatment of Cancer C-30 and STO22 modules. Results: A total of 43 patients were enrolled to each group from September 2017 to February 2020. There was no statistical difference in age, sex, body mass index, and comorbidity score. Mean operation time was 157.4 ± 53.5 min in the TLDG group and 148.9 ± 50.1 min in the SIDG group (p = 0.445). There was no difference in POD1 pain scores between the two groups (TLDG. = 3.5 ± 0.8, SIDG = 3.4 ± 1.0, p = 0.818). No additional trocars were used in the SIDG group, and there was no conversion to an open procedure in both groups. One (2.4%) patient in each group had a postoperative complication that needed invasive intervention. Mean hospital stay was 6.2 ± 2.1 days in the TLDG group and 6.3 ± 2.8 days in the SIDG group (p = 0.829). Conclusion: There was no difference in POD1 pain scores between SIDG and TLDG. SIDG did not increase short-term morbidity compared to TLDG.

Time is money: reducing operative time with a modified but equally efective fundoplication Tayler J James, MD 1 ; Rachel Sargent, MD 1 ; Luke R Putnam, MD 1 ; Brian Hodgens, MD 1 ; Colin Dunn, MD 2 ; Caitlin C Houghton, MD 1 ; Nikolai A Bildzukewicz, MD 1 ; John C Lipham, MD 1 ; 1 University of Southern California; 2 Rutgers New Jersey Medical School.

Background: Since 2018, we have been performing a modified partial anterior fundoplication that is more efficient than traditional approaches with excellent subjective outcomes. The aim of this study was to investigate objective outcomes of this approach and compare them to outcomes after Toupet fundoplication. Methods: Data were collected on all gastroesophageal reflux disease (GERD) patients who underwent modified partial anterior or Toupet fundoplications from 2018-2020. The modified approach involves a 180-270 degree anterior wrap without dividing the short gastric vessels. Symptom control was measured by GERD healthrelated quality of life (GERD-HRQL) scores and daily acid suppressive medication (ASM). Thirty-day complications included readmissions and events resulting in delay in discharge. Parametric and non-parametric data are reported using means ± standard deviation and medians (interquartile range). Results: 135 patients were included: 65(48.1%) underwent modified partial anterior fundoplication and 70(51.9%) underwent Toupet fundoplication. Preoperative variables including age, gender, body mass index, symptom duration, DeMeester scores, and hiatal hernia size were similar between groups. About half the patients in each group had large paraesophageal hernias [ 5 cm (45% vs 56%, p = 0.142) . Objective follow-up with upper endoscopy and/or video esophagram was available in 85 patients (63%) at a median of 13 months. Operative time and hospital length of stay (LOS) were significantly reduced in the partial anterior group (Table) . Fewer patients in the partial anterior group experienced thirty-day complications and dysphagia requiring dilation, although these did not reach statistical significance. Symptom control and hiatal hernia recurrence were similar between groups. Conclusion: Our modified partial anterior fundoplication nearly halved our operative time and resulted in similar postoperative outcomes. A more definitive study such as a randomized trial with long term follow-up may help determine if this approach truly adds value to our care.

The role and safety of feeding jejunostomy tubes after oesophagogastric cancer resection Background: Feeding jejunostomy tubes (FJT) placed intra-operatively in patients undergoing oesophageal and gastric cancer resections are useful in providing early post-operative enteral nutrition. Their role is more vital if anastomotic leak occurs which can delay resumption of per-oral nutrition. However, FJT can cause complications which in turn can worsen patient outcomes. Aim of this study was to evaluate the role and safety of FJT in oesophageal and gastric cancer resections. Methods: All consecutive patients who underwent an Ivor-Lewis oesophago-gastrectomy or a total gastrectomy and had FJT inserted during surgery, in a tertiary centre in the UK over a three-year period, were included. Patients were placed in two groups (Group A: Witzel tunnelled jejunostomy and Group B: Stamm jejunostomy). Data were analysed retrospectively to review FJT associated complications, anastomotic leaks from the cancer surgery and role of FJT when anastomotic leaks occurred. Results: Of the 207 patients included, the overall complication rate from FJT was 7.2% with 2.9% complications being Clavien-Dindo grade 3 or above. Of these, one (0.48%) patient had feed related jejunal infarction and another had bowel obstruction secondary to tube placement. There was no FJT related mortality. Group A (n = 118) and Group B (n = 89) were statistically similar with regards to age, sex, history of smoking, body mass index and preoperative co-morbidities. There was no statistical difference in complications between Group A and B (p = 0.401). Only 20/207 (9.6%) cases developed an anastomotic leak following cancer resection in this study making FJT insertion necessary and useful. However, in 7 out of these 20 (35%) cases where FJT was necessary to provide enteral nutrition, further complications were caused by FJT.

Conclusions: This study demonstrates that prophylactically inserted FJT are not without complications and the complication risk is similar irrespective of the technique used. In retrospect, FJT were truly needed in only 9.6% cases that developed anastomotic leak. With these Results, routine use of prophylactic FJT during an oesophageal or gastric cancer resection is not recommended.

Vanessa Al-Feghali, DO; Raymond Laird, DO; Beaumont Hospital. Diaphragm disease is a rare cause of small bowel obstruction from the overuse of NSAIDs and stricture formation. We present a case of a 73-year-old female with a history of chronic back pain for which she used NSAIDs frequently and anemia who complained of nausea, vomiting, abdominal pain, diarrhea, and weight loss. She was initially diagnosed with collagenous colitis and underwent multiple endoscopies over the past several years. On EGD, she had mid-esophageal, pyloric and duodenal strictures with ulcerations that were dilated. Recent colonoscopy showed an ascending colon ulcer and chronic active ileitis concerning for Crohn's disease. She began treatment for such, but her symptoms persisted. She then underwent video capsule endoscopy, which demonstrated numerous small bowel ulcers and inflammation consistent with Crohn's; however, the PillCam did not reach the colon. After nearly a month without evacuation of the PillCam, CT enterography was performed and showed intussusception with possible small bowel mass. She continued to have abdominal pain, nausea, and vomiting over the next few months. Despite having bowel movements, she did not pass the PillCam. A decision was made for patient to undergo diagnostic laparoscopy with her gastrointestinal physician to perform push endoscopy through planned enterotomies. During the diagnostic laparoscopy, a GelPort wound protector was used to extracorporealize the bowel. Enterotomies were made and push endoscopy was performed until the area of intussusception and PillCam was palpated and visualized. The intussuscepted bowel appeared to encompass a mass 10 cm in size. Another enterotomy was made distal to the mass and push endoscopy was continued to the cecum with removal of the PillCam and one polyp. A total of about 14 strictures were visualized from proximal to distal of the mass. The small bowel was resected to include the entirety of the strictures, the area of intussusception, and the presumed mass. The patient did well following the procedure. The specimen was sent to the Cleveland Clinic where it was analyzed and identified as a large inflammatory small bowel fibroid polyp with associated mucosa ulceration, serositis and serosal adhesions consistent with intestinal intussusception and multiple diaphragm disease lesions. This case demonstrates that while diaphragm disease is a potential side effect of NSAID overuse, its rarity can make it overlooked with such common and nonspecific presenting symptoms. Acknowledgement of this disorder is important for patient education on discontinuation of NSAIDs to prevent ulceration, strictures, need for dilation, perforation, and even bowel resection.

Feeding practices with gastrostomy tubes: where is the evidence? Introduction: With the advent of placement of enteral feeding devices into the gastric cavity, management of feeding has evolved over the last two decades. There is variability in the method in which a conduit is placed (directly, with endoscopic guidance, or with radiologic guidance). Moreover, inconsistency exists regarding the time at which enteral nutrition should be initiated as well as the quantity and rate. Current literature is limited regarding protocols amongst general surgeons, however does show early feeding is safe and can have better outcomes. The objective of this questionnaire based study is to assess the common practices as well as reasoning of surgeons across the United States in relation to gastrostomy tube management. Methods: An online questionnaire was created to anonymously asses' clinician demographics, practice settings, methods, and reasoning when utilizing gastrostomy tubes. Introduction: Endoluminal functional lumen imaging probe (EndoFLIP) provides an objective measure of distensibility index (DI) during different portions of hiatal hernia repair. We wanted to determine if there was any correlation between shortterm outcomes and the change in the DI measurements after the creation of a barrier with different balloon volumes. Methods: We included patients who had hiatal hernia repair from 2018 to 2020 with EndoFLIP values recorded at the end of the case, with the patient placed in a supine position with 30 cc in the balloon (supine 30 DI) and 40 cc in the balloon (supine 40 DI). We used the change in DI at 30 cc and 40 cc of balloon volume and performed an analysis to determine if there was a correlation with clinical outcomes. Results: There were 103 patients who underwent hiatal hernia repair. There was an overall significant increase in DI with 40 cc in the balloon (supine 40 DI, DI = 1.7) compared to 30 cc in the balloon (supine 30 DI, DI = 1.4, p \ 0.001, Fig. 1) . A minority of patients had a decrease or no change in DI with an increase in balloon volume from 30 to 40 cc (n = 37, 36%). After one month, there was a significant decrease in the HRQL-GERD score to 4 from 23 (p \ 0.001) and a bloat score to 2 from 3 (p = 0.003) with a non-significant decrease in dysphagia score to 0 from 1 (p = 0.11) compared to scores before surgery. The analysis showed that the patients who had a decrease or no change in the DI with an increase in balloon volume from 30 to 40 cc had a significant decrease in dysphagia score by 2 points from before surgery to 1 month after surgery (scale 0-5, p = 0.04).

The decrease in the DI with an increase in the volume in the balloon after the formation of the barrier is associated with a significant reduction in dysphagia after surgery. The decrease in DI denotes the ability of the esophagus to create higher pressure relative to the change in the cross-sectional area with larger bolus across the gastroesophageal junction. The higher pressure may correlate with better esophageal function at the gastroesophageal junction. This measure may be a new marker that can predict short-term outcomes in patients undergoing hiatal hernia repair.

Gastric perforation following nasogastric tube placement Natalie Sirianni, MD 1 ; Ahmad Bosaily, MD 1 ; Jianlin Tang, MD, FACS 2 ; 1 The University of Toledo; 2 The University of Toledo Medical Center.

Introduction: Nasogastric tube (NGT) placement is a common medical procedure with scarce complications. Among the known complications are esophageal perforation, intracranial placement, pneumothorax, and trachea bronchopleural placement, though these are rare. Gastric perforation is not among the commonly known complications of NGT placement. Presentation of case: This is a 72-year-old female with no past medical history who was admitted with bilateral pulmonary emboli and new-onset A-fib. NGT was placed after she developed an ileus and maintained for enteral nutrition after ileus resolution. The initial placement was confirmed on X-ray. 16 days after placement, she developed abdominal pain, fever, and leukocytosis. CT scan revealed free air and fluid near the posterior gastric fundus with the tip of the NGT through the defect (Fig. 1, 2) . She underwent exploratory laparotomy and primary repair of gastric perforation with omental patch (Fig. 3) . Discussion: NGT perforation is a complication generally seen in infants, perforation of the esophageous being the most frequent anatomical location. Several risk factors are theorized to predispose a patient to delayed gastric perforation following NGT placement; severe gastritis, gastric ulceration, necrosis, or cancer, previous gastric surgery, or chronic steroid use. This patient did not have any of these risk factors. Diagnosis can be made with radiological imaging, but due to the emergent clinical presentation, it is most often diagnosed under direct visualization during laparotomy or endoscopy. Treatment of gastric perforation necessitates exploratory laparotomy and primary repair. Endoscopic clipping with percutaneous drainage is a possible alternative.

The important learning point of this case is despite NGT placement being a common procedure, placement and maintenance in all patients and especially those with risk factors should be carefully monitored. NGT gastric perforation should also be included as a differential diagnosis in patients with unexplained peritonitis and previous NGT placement. Background: Preduodenal portal vein (PDPV) is a rare anomaly in which the portal vein courses anterior to the second part of the duodenum. PDPV is often associated with other congenital anomalies such as polysplenia, malrotation and pancreatic anomalies. Methods: We report an 85 year old male with Stage IIB esophageal adenocarcinoma. Incidental findings on staging CT included an anomalous preduodenal and presplenic portal vein and polysplenia. More specifically, the patient was noted to have 2 spleens. He did not present with any symptoms related to these findings. After completing his neoadjuvant chemoradiation, the patient was scheduled for an Ivor Lewis esophagectomy. It was during the kocher maneuver intraoperatively that the portal vein was appreciated tracking anterior to both the pancreas and duodenum. Due to preoperative imaging review and close attention to detail during the procedure, inadvertent injury was avoided during our mobilization. The procedure was completed without any complications and the patient recovered well. A literature review of PDPV was performed. Results: Less than 100 cases of preduodenal portal vein have been published. Up to two-thirds of cases present in the first week of life where an estimated 50% of patients with PDPV are diagnosed incidentally. The combination of PDPV and polysplenia is even more rare as they are often coexisting with significant cardiovascular anomalies resulting in death before the age of 5. Portal vein anomalies are best diagnosed with delayed contrast CT. PDPV is thought to arise from abnormal rotation of the gastroduodenal loop and/or abnormal involution of the vitelline veins. In the pediatric population, they present as a duodenal obstruction with or without malrotation. In adults, DPDV is often asymptomatic and is more likely to be found incidentally.. Conclusion: Preduodenal portal vein is a rare anomaly of the portal venous system that is often an incidental finding in adults. If not appreciated on preoperative imaging or intraoperatively, it may lead to serious surgical complications. Heightened awareness of PDPV and other associated anomalies remains vital to a safe procedure in all ages.

Robotic approach to a mass within a gastro-gastric fistula after gastric bypass-leaving a gastric antral tube as future conduit Brianne Runyan, MD; Karolin Ginting, MD; Courtney Hanak, MD; Shyam Allamaneni, MD; The Jewish Hospital of Cincinnati. Gastric cancer after bariatric gastric bypass is extremely rare and has been previously reported in 17 patients.1 Diagnosis and treatment for gastric remnant malignancy can be challenging. The options include computed-tomography scan (CT scan), endoscopic ultrasound (EUS), esophagogastroduodenoscopy (EGD) with double balloon enteroscopy, and laparoscopic-assisted trans-gastric endoscopy. A gastro-gastric fistula was observed in multiple studies with incidence ranging from 0.2%-5%0.2 This was thought to be due to technical complications of inadequate division of the stomach. 3 We present a rare case of a gastro-gastric fistula with a large gastric mass. The patient is a 76-year-old female with a history of Barrett's esophagus and a Roux-en-Y gastric bypass in 2000 who was found to have a mass within a fistula from the gastric pouch to the remnant stomach on routine EGD. Pathology was suspicious for adenocarcinoma. A PET scan was completed that was consistent with malignancy in the proximal stomach. To complete the staging work-up, the patient underwent a CT scan, EGD and EUS. Final pathology showed intramucosal gastric adenocarcinoma and she was diagnosed with uT2N0M0 gastric cancer.

She underwent a robotic proximal gastrectomy and Janeway gastrostomy tube placement. To completely excise the gastro-gastric fistula and mass with adequate margins, a gastric pouch and proximal remnant gastrectomy was performed. Localization of the mass and margins evaluation were achieved with EGD and indocyanine green injection. Additionally, a regional lymph node dissection was performed. The patient then underwent esophago-jejunal anastomosis and creation of Janeway gastrostomy with the gastric antral tube. Rationale of Janeway gastrostomy tube placement was twofold: to allow for decompression and possible need for a gastric conduit if revision was indicated in the future. The patient's final pathology showed villous adenomatous lesion measuring 5.5 cm with foci of adenocarcinoma in situ. She recovered well post-operatively and was discharged home.

This case highlights the importance of routine EGD for patient with Barrett's esophagus after gastric bypass surgery and describes the rare finding of a gastric mass in the presence of gastro-gastric fistula. It also illustrates that a robotic partial gastrectomy with removal of gastric pouch and preservation of remnant gastric antrum is a feasible treatment. Gastroesophageal reflux disease (GERD) affects approximately 15-20% of individuals in the United States. While the majority of cases are managed medically, 10-40% do not achieve adequate symptom relief. Anti-reflux surgery was revolutionized by laparoscopic fundoplication in 1991, and has continued to evolve with refined diagnostic techniques and minimally invasive procedures. Tapping into a 12 year experience and prospectively collected database with [ 600 anti-reflux procedures, we present a comprehensive algorithm for the surgical approach to GERD (Fig. 1) .

Our indications for anti-reflux surgery and workup are consistent with SAGES guidelines: endoscopy should be performed first to verify objective reflux disease. We perform 96 h ambulatory pH testing in all our patients to establish baseline and to verify presence of acidic reflux. We also universally perform barium swallow. Manometry may not be necessary if a patient is morbidly obese, does not have dysphagia, and is amenable to gastric bypass. Otherwise we recommend manometry to identify occult motility disorders, as these findings will influence the operative recommendation.

While reducing acidic reflux decreases the incidence of esophageal pathologies such as stricture and Barrett's esophagus, the intervention's primary goal is to improve quality of life. Therefore our primary endpoint is patient satisfaction-we aim to improve patients' bothersome symptoms while minimizing dysphagia, bloating, and flatulence. Typically this means preferring a ''less is more'' approach. Patients without significant hiatal hernia, and without esophageal dysmotility, are candidates for anti-reflux mucosectomy (ARMS), an endoscopic anti-reflux procedure. Patients with normal esophageal motility and hiatal hernia primarily need normal anatomy restored. After hiatal hernia repair, they are candidates for magnetic sphincter augmentation or fundoplication. We use intraoperative impedance planimetry to determine if a NIssen or Toupet fundoplication would be more appropriate. Patients with esophageal dysmotility are recommended Toupet fundoplication, with or without hiatal hernia repair.

This overview of our approach to the surgical referral for GERD details rationale for the workup, justification for the anti-reflux procedures offered, and how we manage patients with negative 96 h ambulatory pH testing. We discuss how and why we use impedance planimetry for GERD patients, and other subtleties involved in recommending the appropriate procedure for the individual patient. Quality of life and outcomes data from our prospective database help illustrate and justify certain branch points in the algorithm. With many complexities arising from new techniques and technologies, we hope this algorithm pins down a reliable approach to the surgical patient with GERD. Introduction: We report mortality and post-operative complications from esophageal resection in the treatment of gastroesophageal adenocarcinoma or stricture, comparing a minimally invasive abdomen-only esophagectomy (MIAE) approach with a minimally invasive Ivor Lewis esophagectomy (MIILE) approach. While Ivor Lewis approaches remain popular for treatment of esophageal carcinoma, some patients may not be eligible due to pre-existing morbidities that would contraindicate thoracoscopy. We hypothesized that the MIAE approach, specifically confined to the abdomen, would be safe and feasible as a MIILE approach alternative in appropriately selected patients and feature no significant differences in outcome for the treatment of esophageal carcinoma or stricture. Methods and procedures: A single-center retrospective cohort study of patients with esophageal adenocarcinoma or stricture treated by either MIAE or MIILE was conducted. MIAE was offered for strictures less than five centimeters or cancers that were American Joint Committee on Cancer Stage B T2 without lymphadenopathy. Patients treated with these surgical techniques were analyzed to assess pre-operative risk, intra and post-operative variables, adverse events, and overall survival. Results: A total of 49 patients were included in this study, with 17 patients undergoing MIAE and 32 patients undergoing MIILE. Age, gender, BMI, and ASA classification were not significantly different between the two cohorts. There were a fewer median number of lymph nodes resected (p \ 0.001) and shorter operative duration (p \ 0.001) for MIAE compared to MIILE. MIAE patients also had significantly higher Charlson Comorbidity Index scores and ACS National Surgical Quality Improvement Program surgical risk values than MIILE patients (p \ 0.05). There were no differences in median estimated blood loss, length of stay, pulmonary or cardiac complications between groups. There was no significant difference in 90-day survival. Conclusion: A minimally invasive abdomen-only approach in a specific patient population is comparable in safety to a minimally invasive Ivor Lewis approach, with associated shorter median operative duration. MIAE patients had significantly greater pre-operative comorbidities and higher calculated peri-operative risk of complication but demonstrated similar post-operative outcomes. This suggests that MIAE may be a suitable surgical approach for treating gastroesophageal adenocarcinoma or stricture in patients deemed unsuitable for MIILE.

Pilot study: safety, feasibility and results of the mini-laparoscopic (3 mm) complete fixed non-deformable fundoplication Introduction: The complete fixed non-deformable fundoplication or posterior esophageal gastropexy or Gea fundoplication created for the treatment of GERD has the aim of ensure that the anatomical modifications around the LES remain indefinitely undeformable; fixing the stomach, the GEU and performing a complete fundoplication to the diaphragmatic aponeurosis and the crura using approximately 13-16 knots. It has proven comparable postsurgical pain, less short term dysphagia; less erosive GERD, less Deemester score, higher pressure and longer LES length, in long term, compared to other fundoplications. The development of minilaparoscopy has made it possible to perform procedures with less postoperative pain, less trauma to the abdominal wall, better cosmetic Results, best ergonomic to the surgeon. The aim of this study is to prove the safety and feasibility of the complete fixed non-deformable fundoplication using a complete mini-laparoscopic approach. Methods: A retrospective study was perform evaluating the minilaparoscopic Gea fundoplications done between May 2018-November 2020. Demographic, endoscopic, physiologic and surgical variables were evaluated. Surgery was performed using a 10 mm trocar for the telescope, two 3 mm trocars and a Nathanson liver retractor of 2.5 mm, with the dissection and procedure performed as the original technique, using extracorporeal Gea knots. Results: A total of 20 patients were included, 15(75%) were female and 5(25%) males, the mean age was 49.65(25-74) . All patients presented typical symptoms and 9(45%) atypical, the mean time of symptomatology was 94.8(24-360)months. The endoscopic findings were Grade C esophagitis in 4(23.53%) patients and 8(53.33%) presented Hiatal Hernia, mean length of 3.5(3-7)cm; Effective primary peristalsis median was 80(30-100), a mean length of the LES of 2.94(1-4)cm and a mean LES pressure of 10.36 (3.4-24.5) mmHg. The mean DeMeester score was 38.22(8. 1-144.9 ), patients with a normal DeMeester score had an abnormal exposition to Non acid reflux. All patients presented positive association index and probability of association. Eighteen(90%) were primary fundoplication with a mean operative time (OT) of 167.77(70-220)min and estimated blood loss (EBL) of 29.44(5-100)cc; 2(10%) were refundoplication with a mean OT of 337. 5(290,385) min and an EBL of 90(20,160)cc. All the primary patients were discharged the same day (ambulatory), while the re-fundoplications were discharged after 24 h of surgery. Patients required only 3-5 days of mild oral analgesics. Non transoperatory or postoperatory complications where reported. Conclusion: Minilaparoscopic(3 mm) complete fixed non-deformable fundoplication is a safe and feasible procedure; with lower use of analgesics, less EBL, smaller incisions, less trauma, and managed ambulatory; but with a higher operative time. Background: Malignant transformation of heterotropic pancreatic tissue is a rare entity with only several case reports published in scientific literature. Adjuvant chemotherapy following oncological resection for lesions with nodal metastasis has not been well described and there are no guidelines available to guide the management of these patients. Case presentation: We present a case of gastric heterotropic pancreatic carcinoma with nodal metastasis in a young patient with BRCA2 mutation. He had undergone a laparoscopic wedge resection for a gastric lesion initially thought to be a gastrointenstinal stroma tumour. Given the involvement of the wedge resection margins, the patient underwent a distal gastrectomy with oncological lymph nodal clearance. 1 out of the 33 harvested lymph nodes harboured micrometastasis while the main gastrectomy specimen did not have any residual malignancy. Following the histological diagnosis, he received an adjuvant chemotherapy regime was akin to that prescribed for locally advanced pancreatic adenocarcinoma with good response. There are no available literature on the efficacy of chemotherapy for adenocarcinoma arising from a heterotopic pancreas. This is to our knowledge, is also the first such case report in a patient with BRCA2 mutation. Conclusions: Adenocarcinoma arising from heterotropic pancreatic tissue as a result of a BRCA2 mutation is exceedingly rare. Pre-operative diagnostic confirmation is challenging and endoscopic procedures pose a significant false negative. Reports of nodal metastasis following oncological resection are limited and there are no guidelines regarding adjuvant therapies. We would recommend a chemotherapy regimen similar to that for primary locally advanced pancreatic carcinoma in patients found to have nodal metastasis. Background: Minor motility disorders of the esophagus are often missed on barium esophagram (BE) and many surgeons use BE to guide operative choice of fundoplication for anti-reflux surgery. This case series evaluates the outcomes of laparoscopic fundoplication in patients who were diagnosed with a minor esophageal motility disorder on high-resolution manometry (HRM) but had normal motility on barium esophagram (BE). Methods: This is a retrospective review of patients that underwent laparoscopic fundoplication by two surgeons at a single institution from 10/1/2015-6/29/2019. Patients who had pre-operative BE and HRM that were found to have normal motility on BE but evidence of a minor motility disorder on HRM were included in the study. Mean follow-up time was 28.4 months and median follow-up time was 27 months (Range 2 weeks -45 months). Results: 13 patients met the inclusion criteria. 13/13 (100%) patients underwent partial fundoplication due to HRM manometry findings. Minor esophageal dysmotility disorders missed by BE include: Ineffective motility in 6/13 patients (46.2%) and 2/13 (15.4%) had fragmented peristalsis. 12/13 patients (92.3%) had [ 50% incomplete bolus clearance and 9/13 (69%) patients had pre-operative dysphagia. Post-operatively: 1/13 (7.7%) patients complained of post-operative gas bloat, 2/13 (15.4%) patients had post-operative dysphagia and 1/13 (7.7%) patients required post-operative therapeutic EGD with dilation. 2/13 (15.4%) patients required re-operation for recurrent hiatal hernias and reflux disease, not for dysphagia. 3/13 (23%) patients were requiring acid suppression medications at their latest follow-up. Conclusion: All 13 patients had normal motility on BE, but were found to have esophageal dysmotility by HRM. All patients underwent partial fundoplications due to the dysmotility found. Despite this, there were still post-operative symptoms related to underlying dysmotility only found on HRM. Depending on surgeon preference, all these patients might have undergone a full Nissen fundoplication based on a normal BE. Although the majority of the patients had successful acid reduction and no worsening of their dysphagia symptoms this further emphasizes the need for preoperative HRM rather than reliance on the accuracy of BE to identify minor motility disorders in patients who are to undergo an anti-reflux operation.

A rare presentation of wild type of gist in the stomach Shivanshu Kundal, MD; Prem Chand; Savijot Singh; Rajindra Hospital Patiala. Gastrointestinal stromal tumors are the most common mesenchymal tumors. They are usually found in the stomach(40-60%), small intestine(20-30%), colon(15%). The most common presentation of GIST is intraluminal bleeding, very rarely painful. These tumors have a various genetic presentation, including various genes like c-kit or PDGFRA. The tumor marker associated is CD 117. About 90% of GIST are c-kit and PDGFRA sensitive, just 10% of the population has no association with c-kit and PDGFRA, these tumors are called a wild type of GIST.

Here we represent a case report of a 55-year-old male with the only presentation was anemia and dark tarry stools. After CECT whole abdomen and endoscopy preoperative diagnosis of GIST was made. The patient went for open laparotomy with surgical R0 resection of the tumor and roux en y gastrojejunostomy was done. The patient had negative tumor markers and histopathologically was diagnosed with GIST. Keywords: wild type of GIST, tumor markers, R0 resection.

Combining procedures for achalasia: laparoscopic Heller myotomy with EGD and balloon dilation -a durable solution for achalasia Introduction: Laparoscopic Heller myotomy and esophagogastroduodenoscopy (EGD) with esophageal balloon dilation are the two mainstays of achalasia treatment -this study examines the outcomes of a novel technique where the procedures are performed simultaneously with no esophageal wrap performed after myotomy. Laparoscopic Heller myotomy coupled with EGD and balloon dilation during the myotomy allows for safe blunt spreading of the muscle layers without the need for cautery. Methods and procedures: All patients undergoing laparoscopic Heller myotomy with EGD and balloon dilation from 2013-2020 were reviewed for demographic and procedural data, and to see if any additional procedures for achalasia had been performed. Each patient was then contacted and surveyed using the Eckardt score and the GERD quality of life score to assess the durability of repair. The patients were also asked if they were currently taking a proton pump inhibitor and if they had required any additional surgeries or procedures for achalasia. Descriptive statistics were used to assess the quality of life of patients using these two surveys and validated cutoff values. Results: During the study period 66 patients underwent laparoscopic Heller myotomy with EGD and balloon dilation. The median age was 59 with 63% having comorbidities such as hypertension, diabetes mellitus, and coronary artery disease, and an average BMI of 28. 29% of patients had previously had dilations or botox therapy for achalasia. All patients had undergone preoperative manometry and the vast majority of patients had type 2 achalasia. Post-operative complications were minimal with no esophageal perforations and a median LOS of 1 day. Based on survey Results and chart review 7 patients have required additional operations for achalasia (POEM, redo Heller, or thoracic Heller). 31 patients (47%) responded to the survey. The average Eckardt score was 2.9 (goal \ 4) with a mean GERD quality of life score of 14.4 (goal \ 25). The majority of patients (77%) surveyed were satisfied with their quality of life after Heller with balloon dilation. Conclusions: Laparoscopic Heller myotomy with simultaneous balloon dilation allows for a safe, durable repair of achalasia. Even without an esophageal wrap, there are minimal symptoms of reflux and the majority of patients are satisfied with their quality of life. Introduction: Laparoscopic cholecystectomy is the gold standard treatment modality for symptomatic gallbladder disease. In patients with more challenging presentations, the placement of a percutaneous cholecystostomy tube or a partial cholecystectomy are reasonable damage control options to minimize bile duct injuries. This study was undertaken to examine our single institutional Results with partial cholecystectomy and to compare our outcomes to those of patients undergoing cholecystectomy following previous percutaneous cholecystostomy. Methods: From December 2012-to-October 2020, 2,538 patients, underwent cholecystectomy and 71 patients underwent percutaneous cholecystostomy. With IRB approval, demographic data and perioperative outcomes were analyzed and compared between patients undergoing subtotal cholecystectomies and patients undergoing cholecystectomy status post percutaneous cholecystostomy drainage procedure. Statistical analysis was undertaken utilizing GraphPad Prism 8 TM software. Nominal data were analyzed using Chi-Square Analysis. Interval data were analyzed utilizing non-parametric testing of means through Mann-Whitney U-Test. Data are presented as median (mean ± SD). Results: Of all patients undergoing cholecystectomy, 15 (\ 1%) underwent subtotal cholecystectomy. Of the 71-patient that underwent percutaneous cholecystostomy, 11 (16%) underwent subsequent cholecystectomy. Time until subsequent cholecystectomy was 9(13 ± 13.8) months. Relative to patients undergoing cholecystostomy, patients who underwent subtotal cholecystectomy were significantly younger and had a lower ASA class, p = 0.006, p = 0.007, respectively. There was no difference in operative duration, estimated blood loss (EBL), or use of intraoperative cholangiogram (IOC), between patients who underwent subtotal cholecystectomy vs. laparoscopic cholecystectomy after percutaneous tube placement. (Table 1) . Sixty percent of subtotal cholecystectomies were converted to open, vs. 18% of laparoscopic cholecystectomies post percutaneous cholecystostomy (p = 0.03). Intraoperative drain placement in patients undergoing subtotal vs laparoscopic cholecystectomy post cholecystostomy was 80% vs. 27%, respectively (p = 0.007).

Postoperatively, outcomes between patients undergoing subtotal cholecystectomy vs. cholecystectomy post-cholecystostomy were not different, Table 1 . There was no difference in LOS, ICU LOS, postoperative complications, discharge with drain, nor readmissions with-in 30, 60, or 90 days. Conclusions: Damage control in acute cholecystitis can be obtained by either a percutaneous drain placement or a partial resection. Subtotal cholecystectomy is a feasible damage control option if adverse anatomy is encountered intraoperatively. Selecting patients to apply percutaneous cholecystostomy vs. laparoscopic cholecystectomy is of paramount importance. Laparoscopic cholecystectomy following a percutaneous cholecystostomy is associated with lower conversions to open, and trend towards decreased LOS and complications. Despite their differences both approaches may help minimize bile duct injuries. Introduction: Prior to laparoscopy, paraesophageal hernia repair (PEHR) was associated with significant morbidity largely due to the transdiaphragmatic approach. Surgical referrals were rare. Laparoscopy has improved the feasibility; however, the procedure remains complex and associated with significant morbidity. The purpose of this study is to assess the short-and long-term outcomes after laparoscopic paraesophageal hernia repair (LPEHR) in a large cohort of patients. Methods: All primary LPEHR performed in a single institute from January 2009 to December 2019 were retrospectively reviewed. We evaluated short term (30 days postoperative) outcomes including length of stay (LOS), perioperative morbidity and mortality. Long term outcomes ([ 1 year follow up) included clinical and radiologic recurrence rate, reflux symptom index (RSI) and GERD health related quality of life (HRQL) score. Results: LPEHR were performed in 1015 patients with 14 converted to open procedures. Median age was 69 years (IQR 60-76). Most patients (86.9%) presented with a type 3 PEH. Acute PEH occurred in 9.5% requiring urgent repair during index admission. LPEHR included fundoplication (79.4%), Collis gastroplasty (15.6%) and biologic mesh reinforcement (74.1%). Mortality was 0.5% (n = 5) for elective repair and 6% (n = 6) for emergent repair. Oral intolerance and dysphagia were the most common causes of readmission which was 6%. One year follow up was available for 539 patients, of which 85.1% had no recurrence at a median follow up of 23 months (IQR 15-33). Of those, 486 patients (90.2%) had a follow up upper gastrointestinal study (UGI) at a median of 12.8 months after surgery and 269 (50%) had an esophagogastroduodenoscopy (EGD) at a median of 19 months after surgery. The overall recurrence rate was 14.9%. Recurrences were asymptomatic in 4.1% and symptomatic in 10.8% of cases. Thirty-five patients (6.5%) required reoperation. One year after surgery, 60.5% of patients were not taking proton pump inhibitors. RSI and HRQL decreased by a median of 12 and 7 points, respectively after surgery. Conclusions: Over the past 20 years, LPEHR has replaced open PEH repair in experienced centers. This study represents the largest reported review of LPEHR and affirms that LPEHR is now the gold standard with fewer adverse events and superior clinical outcomes when performed in experienced centers.

Long term PEG tube fracture: endoscopic retrieval of broken inner bolster Asmita Chopra, MD; Samer O Alharthi, MD; Joseph Sferra, MD; University of Toledo.

Introduction: Percutaneous endoscopic gastrostomy (PEG) tube removal is considered safe once the tube track is mature, which is usually after 4-6 weeks of placement. It is also recommended to replace PEG tubes every 8 months to prevent skin infections. Until 20 years ago, removal of the PEG tube was done using the cut and push technique, which was associated with risk of obstruction. With the advent of newer tubes with soft mushroom bolster and balloons at the distal end, PEG tube removal can be done by either traction or deflation of the inner balloon. Methods/case: An 89-year-old female with past medical history of diabetes mellitus, chronic obstructive pulmonary disease and hypertension,, dementia, and dysphagia. A PEG tube was placed 2 years earlier for enteral feeding. The patient was admitted with sepsis and evaluated for PEG tube exchange, in view of 2 year old PEG tube showing signs of deterioration. She was hemodynamically stable on examination with a soft, non-tender abdomen. The CT (computed tomography) of the abdomen showed a PEG tube with inner bolster within the stomach (Image 1). At the time of attempted removal of the PEG tube by traction technique at bedside, the tubing broke away from the inner bolster, causing the bolster to be retained in the stomach (Image 2). A second 18Fr balloon gastrostomy tube was placed immediately through the previous tract, at bedside. The patient was planned for an urgent endoscopy, to avoid passage of the bolster through the pylorus.

The patient underwent an uneventful endoscopy and retrieval of the bolster (Image 3). Post-procedure, the patient was comfortable and was able to tolerate tube feeds, with no complications. Discussion: PEG tubes are a convenient mode of enteral access for decompression and feeding. Previous study at our institute showed low rates of complications associated with PEG tube insertion. While long term use of PEG tubes has been associated with infection at the PEG tube site, it is also associated with gradual deterioration. Our case suggests that degradation of PEG tube polymer over time can lead to fracture at the time of traction removal. This warrants frequent change of PEG tubes not only to prevent infection, but also to reduce risk of fracture at the time of removal. We also suggest consideration for endoscopy for retrieval of bolster in already degraded tubes.

Lon-term survival case of esophageal gastrointestinal stromal tumor after thoracoscopic enucleation Kohei Tajima, MD; Kazuo Koyanagi; Yamato Ninomiya; Kentarou Yatabe; Tadashi Higuchi; Miho Yamamoto; Kohei Kanamori; Soji Ozawa; Tokai University School of Medicine. We report a case of long-term survival after thoracoscopic esophageal enucleation for an esophageal gastrointestinal stromal tumor (GIST). Case report: We report a case of a male patient, 55 years-old. The patient was diagnosed with a submucosal tumor in the esophagus by endoscopic examination and referred to our hospital for further examination and treatment. Esophago-gastro-intestinal endoscopy revealed a submucosal tumor with a maximum length of 2.5 cm in the anterior wall of the middle thoracic esophagus which was 36 cm distant from incisor teeth. Endoscopic ultrasonography showed the tumor with relatively homogeneous echoic pattern and appeared to be of intrinsic muscle layer origin. EUS guided fine needle aspiration biopsy was performed from the same site. Histopathological examination showed dense convoluted growth of spindleshaped cells in hematoxylin and eosin staining. A mitotic count was only 1 in 50 high-power fields. Immunohistochemical Results were positive for c-KIT and CD34. The specimen was diagnosed as a low-risk GIST under the Fletcher's classification. No tendency to invade the surrounding organs was observed. Based on the above findings, we diagnosed a low-risk group of esophageal GISTs and planned a thoracoscopic esophageal enucleation because of the small size of the tumor and relatively lower risk. Four ports were inserted into the right thoracic cavity in the prone position, and the operation was started. A tumor was found in the middle thoracic esophagus through the pleura. The tumor was enucleated through an incision in the outer membrane muscle layer just above the tumor. The patient's postoperative course was uneventful, and he was discharged 9 days after surgery. He is now 10 years and 3 months postoperatively and is alive recurrence-free.

In the present study, we performed thoracoscopic esophageal enucleation for a low-risk esophageal GIST, and the patient has been alive for more than 10 years without recurrence.

Factors associated with minimally ivasive esophagectomy for esophageal cancer from the National Cancer Database Subepithelial tumors (SETs) are frequently encountered in the GI tract, the majority of which are asymptomatic and discovered incidentally. Characterized by location, size, and echogenicity, the gold standard of diagnosis for SETs is histology and immunohistochemistry, usually performed with fine or core needle biopsy by gastroenterologists. There is a spectrum of imaging modalities to diagnose these tumors with two major ones being esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS). They are operator-dependent though, in the right hands, EUS approaches a sensitivity of 92% and a specificity of 100%, being the most accurate method for differentiating SET location. Some cases, however, require other modalities to make a definitive diagnosis. Symptomatic masses should be resected independent of definitive diagnosis. In the case that a biopsy is not conclusive, imaging modalities along with patient symptoms are used to guide operative intervention.

Our case describes a 64-year-old female with uncontrolled diabetes, stage 4 chronic kidney disease and a history of a gunshot wound status-post exploratory laparotomy and splenectomy 30 years ago who presented with an exophytic, slow growth pattern of a mass on imaging that appeared to arise from the greater curve of the stomach. Heterogeneous properties and extrinsic compression were noted and a gastrointestinal stromal tumor was the most likely possible working diagnosis at the time. Multiple fine needle aspiration biopsies via EUS consistently showed nondiagnostic pathology. The location at the greater curvature of the stomach and its continual increase in size favored a neoplastic formation. However radiographic imaging features concurrently were suspicious for a hematoma formation. The patient was taken to the operating room with an en-bloc resection of the gastric mass and pathology thereafter was more definitive in the diagnosis of fibrosis surrounding an organizing hematoma. There have been multiple reports regarding troubleshooting upper abdominal masses with inconclusive biopsies and misdiagnosed imaging modalities that have then undergone definitive surgical intervention and were noted to have hepatic pathology or acute gastric hematomas. However, to the best of our knowledge this is the first case report regarding a chronic, enlarging gastric mass as an organizing hematoma. Based on current guidelines, it is important to use multiple diagnostic tools to help guide operative intervention for nondiagnostic subepithelial gastric mass pathologies, with surgery being the best definitive treatment option in symptomatic patients. Introduction: Primary and metastatic tumors of the small bowel are exceedingly rare, making up less than 3% of all tumors of the gastrointestinal tract. They can present with obstruction, intussusception, and GI bleeding; however, the more common symptoms are abdominal pain, nausea and vomiting. Many patients will be diagnosed retrospectively after exploratory laparotomy. The primary tumors of small bowel metastasis generally arise from breast, lung and melanoma but rarely from the stomach. We describe a case report of metastatic gastric adenocarcinoma found in the small bowel two years after initial diagnosis. Case report: A 42-year-old female with diabetes mellitus presented with nausea and vomiting secondary to gastric outlet obstruction. She had a 42-year-pack smoking history. She had experienced significant weight loss and undergone six esophagogastroduodenoscopies (EGD) in four months which repeatedly demonstrated a gastric ulcer, antral wall thickening, gastritis, and a distended stomach. The biopsies were negative for malignancy and she was diagnosed with diabetic gastroparesis. She presented to our facility with symptoms of gastric outlet obstruction. Given her persistent symptoms and unknown etiology, she underwent a subtotal gastrectomy with Roux-en-y reconstruction and gastrojejunostomy tube placement. Pathology of the gastric antrum showed invasive poorly differentiated diffuse-type adenocarcinoma (T4N1). Two months after completion of chemoradiation, the patient presented to the hospital with a newly diagnosed obstructing colon mass. A CT scan was obtained which showed thickening of the sigmoid colon and new peritoneal nodules. A colonoscopy showed an obstructing mass approximately 10 cm from the dentate line. She was then taken to surgery for a diverting colostomy. Biopsies taken at that time showed recurrent gastric adenocarcinoma. Patient again completed chemotherapy.

The patient continued to have multiple small bowel obstructions. Given her long complicated history, it was decided to once again take her to surgery. In the OR, there was a clear transition seen in the ileum. Just proximal to this, there was noted to be a thickened stricture which was resected. Pathology showed poorly differentiated adenocarcinoma consistent with metastatic gastric adenocarcinoma. She again underwent chemotherapy and subsequently died 7 months later. Conclusion: Primary and metastatic tumors of the small bowel are exceedingly rare, making up less than 3% of all tumors of the gastrointestinal tract. As described in this case report, many patients will be diagnosed retrospectively after exploratory laparotomy. The primary tumors of small bowel metastasis generally arise from breast, lung and melanoma but rarely from the stomach. Introduction: Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder attributed to primary (idiopathic) causes or secondary (mechanical) causes, including hiatal hernias (HH). Many consider primary EGJOO as a precursor/variant of achalasia. While patients with HH and EGJOO (HH ? EGJOO) may undergo HH repair without myotomy, it is unclear if an underlying motility disorder is missed by therapy which addresses only the secondary EGJOO cause. As such, the goal of this study was to determine if HH repair alone is sufficient management for HH ? EGJOO patients. Methods: A retrospective medical record review of patients who underwent HH repair between 01/2016-01/2020 at a single academic tertiary care referral center was performed. Adult patients who underwent high-resolution esophageal manometry (HREM) within 1 year prior to HH repair were included. Preoperative risk factors, operative details, and postoperative outcomes were compared between patients with and without EGJOO on preoperative HREM utilizing student's T-test and chi-square test. Results: Sixty-three patients were identified with the following profile: mean age 64.4 ± 11 years, 51 (81.0%) female, and 11 (17.5%) with prior foregut surgery. Preoperative HREM findings included: 43 (68.3%) normal, 13 (20.6%) EGJOO, 4 (6.3%) minor disorder or peristalsis, 2 (3.2%) achalasia, and 1 (1.6%) major disorder of peristalsis. The 13 EGJOO patients were compared to the 43 patients with normal manometry. No differences were found in preoperative demographics/risk factors, preoperative symptoms, and preoperative HREM, with the expected exception of higher integrated relaxation pressure in EGJOO patients (22.3 vs 3.3 mmHg, p \ 0.01). Use of robotic techniques (23.1% vs 4.7%, p = 0.04) and gastropexy (76.9% vs 32.6%, p \ 0.01) were more common in the EGJOO group, with no differences in rates of fundoplication, gastroplasty, or mesh use (p [ 0.05). No differences were noted in length of stay (2.8 vs 2.6 days), 30-day complications (7.7% vs 16.3%), long-term persistent symptoms (23.1% vs 14.0%), or recurrence (15.4% vs 7.0%) with a mean follow-up of 26-months (p [ 0.05). Of the 3 (23.1%) EGJOO patients with persistent symptoms, all 3 had radiographically-suggested esophageal motility disorders and 2 underwent HREM demonstrating persistent EGJOO. No patients required endoscopic/surgical myotomy during the follow-up period.

Conclusion: This study suggests that the majority of HH ? EGJOO patients experienced symptom resolution following HH repair alone and none required additional intervention to address a primary motility disorder. Further study is required to determine the optimal management of HH ? EGJOO patients with persistent EGJOO following HH repair, including the appropriateness of endoscopic myotomy.

Early experience with laparoscopic ischemic conditioning of the gastric conduit prior to gastropharyngeal anastomosis after total esophagectomy Domenech Asbun, MD; Steven P Bowers, MD, FACS; Mayo Clinic.

Background: Gastric tube reconstruction is a common option for reconstruction of the pharyngoesophageal junction after esophageal resection extending to the pharynx. However, necrosis of the gastric conduit is associated with significant morbidity and mortality. Ischemic conditioning of the gastric conduit prior to reconstruction after esophagectomy has been suggested as a way to decrease the risk of conduit necrosis and associated complications. We present our early experience using laparoscopic ischemic conditioning of the stomach prior pharyngoesophageal reconstruction with a gastric conduit. Methods: A retrospective review was done of four consecutive patients between 3/2019 and 3/2020 who underwent ischemic conditioning of the gastric conduit prior to esophagopharyngeal reconstruction with a gastric tube reconstruction at our institution. Esophagectomy was performed for both benign and malignant etiologies. Ischemic conditioning included laparoscopic ligation of the left gastric and short gastric vessels. Esophagectomy and associated procedures were performed at the time of gastropharyngeal anastomosis. Patient and disease-specific factors were recorded, along with perioperative details and outcomes. Results: Two patients underwent procedures for resection of malignant lesions, and two for severe strictures of the esophagus refractory to alternative management. Concomitant procedures were undertaken in patients at the time of gastric conditioning and at the time of esophagectomy. Time between gastric conditioning and esophagectomy spanned from 55 to 67 days. Operative times for the esophagectomy procedures lasted between approximately 7 h to over 12 h. There was no mortality nor major complication within 30 days of the procedure. Two contained anastomotic leaks were identified on postoperative imaging, which were managed without need for subsequent procedures or hospitalization. Conclusions: In our small cohort, ischemic conditioning of the gastric conduit prior to gastropharyngeal anastomosis was associated with acceptable outcomes in this high-risk patient population. Further studies are warranted to show reproducibility of favorable Results on a larger scale, and to delineate which patients may benefit most from this approach to esophagopharyngeal reconstruction.

Heller myotomy perforation: robotic visualization decreases perforation rate and revisional surgery is a perforation risk Abigail Engwall-Gill, MD 1 ; Tahereh Soliemani, MD 1 ; Sandra Engwall, MD 2 ; 1 MSU; 2 University of Minnesota.

Background: Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well-accepted, the relative benefits of laparoscopic versus robotic approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. Methods: A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of enterotomy during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 through October 2019, a robotic approach was employed. All enterotomies were recorded, as well as secondary outcomes of enterotomy location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple t-test were employed for data analysis. Results: During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of enterotomy (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of enterotomy (24%) (p value = 0.06). All enterotomies in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic enterotomy group (3.4 days) compared to the laparoscopic non-enterotomy group (1.2 days) (p value = 0.06). LOS for robotic was not significantly longer in the enterotomy group (2.8 days) compared to the robotic non-enterotomy group (1.5 days) (p value = 0.18). First time Heller myotomies showed a higher rate of enterotomy with laparoscopic (50%) vs robotic (11%) (p value = 0.003) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (p value = 0.0003) with a 60% enterotomy rate (p value = 0.04) and one associated, radiographically confirmed leak. Conclusions: Primary laparoscopic Heller myotomy related to more than four times the frequency of enterotomy than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid enterotomy. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for enterotomy during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.

A case report of non-surgical esophagocutaneous fistula closure: even a blind squirrel finds a nut Emily Zurbuchen; Jason Lizalek; Karin Trujillo; University of Nebraska Medical Center.

Introduction: Chronic esophagocutaneous fistulae are infrequent pathologic entity in adults. Their management is challenging and ranges from conservative to the more invasive approaches. Here we describe a chronic, recalcitrant esophagocutaneous fistula that was closed using an antibiotic-soaked bio-absorbable mesh. Case description: The patient is a 67-year-old female with a history of ''esophageal surgery'' as an infant and subsequently developed chronic esophageal stricture requiring serial dilatations throughout her adulthood. During a routine esophageal dilatation, she sustained an esophageal perforation. The patient underwent several operative procedures at an outside facility including a right thoracotomy, a pericardial patch, an intercostal muscle flap, several chemical pleurodeses, and gastrostomy and jejunostomy tube placements. A postoperative esophagram was negative for a leak, so the patient was discharged to rehabilitation facility on enteral feeds. Unfortunately, the patient developed purulent drainage from her thoracotomy wound, and she was transferred to our hospital for further treatment. An esophagram and CT chest with oral contrast demonstrated an esophageal stricture with contrast extravasation from the esophagus into the right thoracic cavity with communication to the right thoracotomy ( Fig. 1 and 2) . The patient declined an esophageal diversion and esophagectomy. Therefore, we attempted several less invasive measures to close the fistula, including keeping the patient NPO, covering the fistula with an esophageal stent, filling the thoracic space with muscle flaps, attempting closure with an endo VAC and T tube placement. While the muscle flaps helped decrease the space within the thoracic cavity, the fistula never closed. Having exhausted traditional methods, we placed doxycycline-soaked bio-absorbable mesh (Strattice) across the fistula like a plug, occluding the tract (Fig. 3) . The patient was kept NPO, the gastrostomy tube was placed to gravity, and enteral feeds were instilled through the jejunostomy tube. Six weeks later, flexible esophagoscopy revealed complete resolution of the fistula (Fig. 4 ). An esophagram confirmed these findings (Fig. 5) . Oral intake was permitted, and once the patient demonstrated sufficient intake and weight gain, the jejunostomy and gastrostomy tubes were removed. Conclusions: The method described permitted closure of a chronic esophageal fistula after traditional non-operative methods had failed. Although rare, there have been reports of esophagocutaneous or other foregut fistulae closure with bioabsorbable mesh following failure of traditional therapy. Our method required endoscopic placement of the mesh across the fistula in addition to nil per os, distal enteral nutrition and gastric decompression. This case demonstrates a non-surgical alternative for upper gastrointestinal tract fistulae.

Gastroesophageal reflux management and perceptions of antireflux surgery: a multi-specialty physician survey Mikhail Attaar, MD 1 ; Harry J Wong, MD 1 ; Hoover Wu, MD 1 ; Michelle Campbell, MD 1 ; Kristine Kuchta, MS 2 ; Woody Denham, MD 1 ; Steven Haggerty, MD 1 ; John Linn, MD 1 ; Yalini Vigneswaran, MD 3 ; Michael Ujiki, MD 1 ; 1 NorthShore University HealthSystem; 2 NorthShore University Research Institute; 3 University of Chicago Medical Center.

Introduction: Physicians in multiple specialties encounter patients with gastroesophageal reflux disease (GERD) and participate in their management. We hypothesize that there are differences in comfort in discussing anti-reflux surgery among primary care physicians, surgeons and specialists. This study aimed to analyze physician perceptions of GERD management and anti-reflux surgery and determine whether self-perceived knowledge and practice patterns differed among specialties. Methods and procedures: A prospective anonymous electronic survey was sent to all primary care physicians, gastroenterologists, surgeons, pulmonologists, allergy and immunologists and otolaryngologists at both a multicenter community-based academic hospital system and a large academic medical center between May and June of 2020. The survey was composed of demographic questions, followed by 16 questions utilizing a five-point Likert scale, with answers ranging from strongly disagree to strongly agree. Differences among specialties were compared using chisquare and Fisher's exact tests. Results: A total of 132 physicians responded to the survey, the majority being primary care physicians (54.6%), followed by subspecialists (24.3%), gastroenterologists (11.4%) and surgeons (9.9%). Of respondents, 70.8% either agreed or strongly agreed that anti-reflux surgery is valuable in the treatment of medicallyrefractory GERD with no significant differences between specialties. However, while 100% of gastroenterologists and 69.2% of surgeons agreed that they were familiar with the various surgical options for GERD, only 29.6% of primary care physicians agreed (p \ 0.001). Moreover, gastroenterologists and surgeons were significantly more confident in answering questions about and describing complications of anti-reflux surgery compared to primary care physicians (both p \ 0.001). In terms of referral patterns, surgeons were significantly more likely than physicians from other specialties to refer directly to a foregut surgeon for consideration for antireflux surgery (p \ 0.001). Additionally, significantly more surgeons and gastroenterologists would refer a patient unwilling to be on long-term proton pump inhibitor (PPI) therapy for anti-reflux surgery compared to primary care physicians (p \ 0.001). Of surgeons, 92.3% would refer a morbidly obese patient with GERD for Roux-en-Y gastric bypass, compared with 71.4% of gastroenterologists and 47.9% of primary care physicians (p = 0.003). Conclusions: There are significant differences in GERD management among specialties. A majority of physicians agree that anti-reflux surgery is a valuable tool, however, primary care physicians are less aware of the options, risks and benefits of anti-reflux surgery compared to surgeons and gastroenterologists. Educational strategies to address these differences are important to ensure patients are appropriately referred for anti-reflux surgery when indicated.

An alternative technique for preventing stent migration in esophagojejunal anastomotic leakage following gastric cancer surgery Hariruk Yodying, MD; HRH Princess Maha Chakri Siridhorn Medical Center (MSMC) Hospital, Srinakharinwirot University.

Background: Esophago-jejunostomy anastomosis leakage is a major complication after radical gastrectomy, with increased mortality rates and prolonged hospital stay after surgery. Endoscopic placement of self-expandable metallic esophageal stent has become the preferred primary treatment but complications may occur including stent migration. We present an alternative technique for the prevention of stent migration. Case presentation: A 45-year-old-female with a BMI of 35 had a proximal gastric adenocarcinoma. The patient underwent laparoscopic total gastrectomy with D2 lymphadenectomy and cholecystectomy. The esophagojejunostomy was performed using linear-stapled side-to-side with hand-sewn closure of the enterotomy.

On the 5th postoperative day, the patient began with fever and tachypnea accompanied by left pleural effusion. A chest drain was inserted. CT scan was performed, which suspected esophageal-jejunal anastomotic leakage. Esophagoscope found leakage at the staple line. The fully covered self-expanding metallic esophageal stent was placed and fixed to esophageal mucosa with clips. Follow up chest XRAY on day 1 showed distal migration of the stent to the jejunum. The endoscopic reposition of the stent was performed. To prevent stent migration, a nylon thread was passed through the lasso at the proximal, tied this thread to small gauze, and fixed to the patient nose. Parenteral nutrition was administered. The stent was removed after 6 weeks of placement, proving the absence of a residual fistula and initiating oral nutrition. The patient was recovered and discharged from the hospital.

Discussion: The use of fully covered self-expanding metallic esophageal stents for esophagojejunal anastomotic leakage is associated with high rates of migration. Various methods were investigated for preventing stent migration such as over-thescope clipping devices or endoscopic suturing. But some instruments may not be routinely available. Our experience suggests the external fixation using nylon thread is a simple and inexpensive method for the prevention of esophageal stent migration.

Phasix-ST mesh in large paraesophageal hernia repair may decrease early hernia recurrence Tayler J James, MD 1 ; Jocelyn F Burke, MD 2 ; Victoria Yin, BS 1 ; Aleeson Eka, BS 1 ; Nikolai A Bildzukewicz, MD 1 ; John C Lipham, MD 1 ; Reginald Bell, MD 2 ; Caitlin C Houghton, MD 1 ; 1 University of Southern California; 2 Institute of Esophageal and Reflux Surgery.

Background: Hiatal hernia (HH) recurrence rates after large paraesophageal hernia (PEH) repair are as high as 50%. Crural reinforcement with mesh is controversial. The aim of this study was to evaluate safety, feasibility, and early outcomes of crural reinforcement with Phasix-ST mesh in patients with large PEH compared to repair without mesh. Methods: Consecutive patients with large ([ 5 cm) PEH who underwent first-time PEH repair and fundoplication at three centers from 2016-2019 were retrospectively reviewed. All patients underwent primary suture approximation of the crura. Group one underwent crural reinforcement with Phasix-ST, and group two underwent repair without mesh. Symptom control was measured using GERD health-related quality of life (GERD-HRQL) scores. Parametric and non-parametric data are reported using means ± standard deviation and medians (interquartile range). Results: 85 patients with large PEH were included: 53(62.4%) underwent repair with Phasix-ST, and 32(37.6%) underwent repair without mesh. 55 cases (65.7%) were robot-assisted, and the remainder were laparoscopic. Mean age (68 vs. 70 years, p = 0.376), gender (31.2% vs. 32.1% male, p = 0.937), and BMI (29.2 vs. 29.2, p = 0.963) were similar between groups. While operative time was longer in the Phasix-ST group, postoperative mean GERD-HRQL score and proportion of patients requiring dilation or reoperation were reduced, although these did not meet statistical significance (Table) . Hiatal hernia recurrence was significantly reduced in the Phasix-ST group for patients with objective follow-up (22 patients in the Phasix-ST group and six in the no-mesh group) at an average of seven months. No mesh-related complications such as infection or erosion occurred. Postoperative GERD-HRQL score 3.9 ± 1.9 8.0 ± 8.6 0.084 

Our study suggests crural reinforcement with Phasix-ST mesh in large PEH repair is safe, feasible, and may decrease early HH recurrence. The study period coincided with the introduction of robot-assisted foregut surgery at our institutions, calling to question the generalizability of the operative times and difference between groups. Further studies with long term follow-up are warranted to assess the true effect of Phasix-ST on HH recurrence.

Global phospho-proteomic profiling of pathway-level molecular alterations in Barrett's esophagus Background and aims: Barrett's esophagus (BE) is a known major risk factor predisposing to esophageal adenocarcinoma (EAC), a highly morbid condition with low survival despite invasive interventions. Though studies have postulated genetic insults as markers of disease, they have yet to identify the specific sequence of molecular changes and events associated with the progression of normal esophageal tissue towards BE and its further progression to EAC. In the present study, we employed quantitative mass spectrometrybased techniques to map global protein perturbations in BE lesion biopsies compared to adjacent normal tissue. Our goal was to identify molecular pathways altered in BE lesions to glean insights into the molecular foundation that underlies disease progression. Methods: Specimen were collected during clinically indicated biopsies for patients undergoing diagnostic, endoscopic investigation. Patients were enrolled in an IRB approved protocol (2017P000203), after being given detailed information about the nature of the study and discussion with the research team. Specimens were collected as two cohorts (discovery and validation) with a total of 4 endoscopic biopsies (representing lesions or adjacent normal tissue) per patient; half of each sample was subject to liquid chromatography/mass spectrometry (LC/MS) analysis and the remainder was formalin fixed and sent for pathological analysis. Comparative analyses were performed between the BE and matched normal tissue for patients with known pathology, while healthy patients served as additional controls. Results: We identified and quantified the relative abundance of 7,018 proteins and 8,420 phosphosites in the discovery cohort, revealing hundreds of statistically significant (p \ 0.05, moderated t-test) differences in protein and phospho-site abundance between the BE and matched normal tissue. From the LC/MS profiles, we identified a robust proteomic signature that classified samples on disease status. Projection of this same signature against EAC tumor profiles obtained from the Cancer Genome Atlas was strongly predictive of survival outcomes. Pathway level analysis of BE and paired controls revealed dysregulation of key components of specific processes, including DNA repair/integrity, interferon signaling, and the cellular response to reactive oxygen species. Subsequent comparative analysis with published BE transcriptomic profiles provided independent evidence in support of these Results.

We identified a proteomic signature and pathway perturbations associated with BE which implicate clinically actionable targets in disease progression that warrant further assessment. Proteomic signature determined from (A) paired BE/Adjacent samples from the Discovery Cohort and (B) projected onto a plot with their corresponding P-value. Heatmaps based on the same protein signature.

Simultaneous intraperitoneal cisplatin chemotherapy may be considered as a treatment for far advanced gastric cancer who undergone surgery Eunju Lee, MD 1 ; So Hyun Kang, MD 1 ; Sangjun Lee, MD 1 ; Yongjoon Won, MD 1 ; Young Suk Park, MD 2 ; Sang-Hoon Ahn, MD 2 ; Hyung-Ho Kim, MD, PhD 1 ; 1 Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; 2 Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.

Introduction: Peritoneal seeding is the most common type of recurrence and cause of death for gastric cancer. Nevertheless, there is no established consensus for advanced gastric cancer with peritoneal seeding. This study aimed to analyze the effect of intraperitoneal (IP) cisplatin chemotherapy on the survival rate and oncological Results of advanced gastric cancer patients who have undergone surgery. Methods: Patients who underwent laparoscopic surgery including radical section, palliative surgery, and intraperitoneal chemotherapy for primary gastric adenocarcinoma in our institution were retrospectively reviewed. In the intraperitoneal chemotherapy group, 100 mg of cisplatin was administered intraperitoneally. The groups were propensity score matched in 1:1 ratio. The primary endpoint was survival rate and incidence of early postoperative complications.

Results: From January 2014 to December 2018, a total of 1373 patients underwent laparoscopic surgery, of which 50 were treated with intraperitoneal cisplatin chemotherapy. Because there were differences in the baseline characteristics between the conventional group and the IP chemotherapy group, propensity score matching (PSM) was performed. After PSM, each group comprised of 32 patients. There was no significant difference in the early postoperative complications between the two groups (conventional group 12.3%, IP chemotherapy group 10%, p = 0.786).

There was no statistical difference in overall survival between the conventional group and IP chemotherapy group (p = 0.75). In subgroup analysis, median survival was 15.7 ± 12.8 months in the conventional group and 18.6 ± 12.2 months in the IP chemotherapy group in stage IV gastric cancer.

Conclusion: This study showed that simultaneous IP cisplatin chemotherapy seemed to be considered a treatment option for advanced gastric cancer.

Predictors of recurrence after paraesophageal hernia repair: a single institution series Introduction: Paraesophageal hernia repair (PEHR) is associated with a relatively high rate of recurrence at short term follow-up. There are a variety of surgical approaches and techniques employed to decrease recurrence, making it difficult to determine the optimal surgical technique to prevent complications. We hypothesized that certain patient and surgical factors would be predictive of recurrence in patients who underwent PEHR. Methods and procedures: A retrospective chart review at a high volume, academic medical center was performed of all patients who underwent PEHR from 2017-2019. Patients were excluded if they had concurrent confounding operations at time of hernia repair or missing critical study variables including recurrence status. Primary outcome of interest was hernia recurrence at time of last follow-up. Univariate analysis was performed using Mann-Whitney U and chi-square to compare the relationship of demographic and surgical factors between the two outcome groups: non-recurrence vs recurrence. Results: 196 patients met inclusion criteria, there were 37 (18.9%) recurrences and 159 (81.1%) patients without recurrence at a median follow-up of 18 months. All patients underwent laparoscopic hiatal hernia repair. Of those with recurrence, 10 (27%) required a second operation vs 3 (1.9%) without recurrence. The two groups had similar demographic characteristics including age (p = 0.640), BMI (p = 0.437), active smoking status (p = 0.487) and co-morbidities (cardiovascular disease p = 0.630, pulmonary disease p = 0.957, and diabetes p = 0.269, respectively). There was also no difference in surgical factors between the two groups including elective vs urgent timing of surgery (p = 0.734), re-do operation (0.252), thoracic vs general surgeon specialty (0.831), mesh placement (0.233), fundoplication (0.257), and gastropexy (p = 0.214), Table. Conclusion(S): In a single institution case series of patients undergoing PEHR, there were no demographic or surgical factors predictive of hernia recurrence indicating that PEHR can be performed safely in a diverse patient population with varying surgical techniques without increased risk of recurrence.

Keouna Pather, MD 1 ; Shoshana Hacker, MD 1 ; Christina Guerrier, MBA 2 ; Rhemar Esma, MD 1 ; Heather Kendall 1 ; Ziad T Awad 2 ; 1 University of Florida Health-Jacksonville; 2 University of Florida.

Introduction: The aim of this study was to evaluate reoperations in a series of patients after minimally invasive Ivor Lewis esophagectomy (MILE). Methods and procedures: A single-center retrospective analysis of 124 patients undergoing MILE between September 2013 to September 2018 was performed. Endpoints included reoperation and mortality within 30 and 90 days. Factors associated with any reoperation after MILE were determined by multivariable logistic regression analysis. Results: MILE was performed in 124 patients (99 males, 65.7 ± 9.3 years old) of which 118 patients (95%) had esophageal malignancy and 6 patients had benign disease. The mean length of hospital stay was 10.4 ± 6.6 days. An anastomotic leak was observed in 6 patients (5%). In-hospital mortality occurred in 4 patients (3%). Reoperation during index admission was performed in 10 patients for volvulus of the conduit in 2% (n = 3), redundancy of the conduit in 2% (n = 2), conduit compression by excess omental flap in 1% (n = 1), delayed anastomotic reconstruction after intraoperative bleeding in 1% (n = 1), graft necrosis in 1% (n = 1), and small bowel infarction in 2% (n = 2). Within 30 days, mortality occurred in a further 3 patients (2%) after hospital discharge and 2 additional (2%) reoperations were performed for conduit detorsion and wound infection incision and drainage, respectively. Within 90 days, mortality increased by 3% (n = 4), and 3 additional (2%) reoperations occurred for post-esophagectomy hernia, lung decortication for empyema, and total colectomy for C. difficile colitis, respectively. Expectedly, 30-day and 90-day reoperations were associated with 30-(p = 0.002) and 90-day (p = 0.003) mortality, respectively; however, 30-day reoperations were not associated with 90-day mortality (p = 0.29). By multivariable analysis, baseline comorbidities of cardiovascular disease (odds ratio [OR] 8.1, 95% CI 1.3-52.4, p = 0.03) and chronic kidney disease (OR 1.3, 95% CI 1.1-11.8, p = 0.03) were independently associated with reoperation after MILE. However, the presence of postoperative anastomotic leak was not a predictor of reoperations following MILE (OR 0, p = 1.0).

The majority of reoperations after MILE occur within 30 days often during index hospitalization. Later reoperations are less frequent. Notably, anastomotic leaks do not significantly influence reoperation rates; however, reoperations following MILE are associated with postoperative mortality. Efforts to further optimize patient cardiovascular disease and chronic kidney disease should be considered in an attempt to minimize reoperations following MILE.

Laparoscopic sleeve gastrectomy with pyloroplasty significantly improves gastric emptying in patients with severe medically refractory gastroparesis Helmuth T Billy, MD 1 ; Masoud Chopan, DO 2 ; Terry Simpson, MD 1 ; Daniel Cottam, MD 3 ; 1 Ventura Advanced Surgical Associates; 2 Community Memorial Hospital Surgical Education; 3 Bariatric Medicine Institute, Salt Lake City Utah.

Introduction: There is no consensus with respect to effective surgical treatment of severe gastroparesis in patients who have failed medical management. We present a series of 6 patients presenting with severe, medical refractory gastroparesis who underwent pyloroplasty with simultaneous sleeve gastrectomy. Methods: Six patients referred for surgical treatment due to intractable gastroparesis, abdominal pain and vomiting were treated with sleeve gastrectomy and pyloroplasty. Data was collected retrospectively from electronic medical records including hospital records and clinic visits. We reviewed postsurgical outcomes of disease severity and compared it to preoperative symptoms, emergency department visits and frequency of hospital admissions. Results: Six patients presented with severe idiopathic or diabetic gastroparesis. All patients presented with severe vomiting. All patients completed preoperative gastric emptying studies. One patient had a prior gastrostomy tube, five patients had no previous gastric surgery. All patients had abnormal preoperative gastric emptying studies with a half life of greater than 200 min Two patients exceeded 1000 min. All patients underwent laparoscopic sleeve gastrectomy with pyloroplasty. Emergency department visits and hospitalizations were compared preoperatively and postoperatively. Patient number 1 had 24 ED visits preoperatively and was admitted 21 times with abdominal pain, nausea and vomiting. Patient number 2 had 14 ED visits preoperatively and was admitted 10 times for abdominal pain, nausea and vomiting, patient number 3 had 11 ED visits with 2 admissions for abdominal pain and vomiting. Patient number 4, 5 and 6 had less than 3 ED visits prior to surgery. Postoperatively ED visits and hospitalizations were decreased in all patients. There were zero admissions for vomiting and the most common ED visit was for chronic abdominal pain. Patients 4, 5 and 6 had no ED visits postoperatively.

Post operative gastric emptying studies normalized in 4 patients and had significant improvement in 2 patients. All patients were able to tolerate a regular diet without vomiting. Complications included a perforation due to a marginal gastric ulcer near the pyloroplasty that required re operation. Two patients were treated for Clostridium difficile infection. One patient had persistent post operative hiccups that resolved. Conclusion: Medically refractory gastroparesis is a challenging surgical disease. Sleeve gastrectomy with pyloroplasty resulted in normalization of gastric emptying in 4 patients and significant improvement in 2 patients. All patients were able to resume a regular diet without vomiting. Sleeve Gastrectomy with pyloroplasty appears to produce reliable and consistent short term improvement in patients with end stage symptoms of gastroparesis. Background: The Bravo TM catheter-free wireless pH monitoring system with measurement up to 96 h has been shown to be an effective and sensitive modality to accurately diagnose gastroesophageal reflux disease (GERD). We aimed to identify association between Bravo parameters and patient clinical and quality of life (QOL) outcomes after anti-reflux operations. Methods: A retrospective review of a prospectively maintained gastroesophageal quality database was performed. All patients with preoperative Bravo pH testing data who underwent anti-reflux operations were included. Clinical and QOL outcomes including Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), Dysphagia Scores and patient satisfaction were collected up to five years postoperatively. In case of Bravo capsule migration, pH data collected after the migration were excluded from analysis. Partial Spearman correlation coefficients (r) and multivariable logistic regression analysis were used compare Bravo parameters and patient outcomes while controlling for surgery type, complications and dysmotility. Results: A total of 72 patients were included in the study and 34.7% were male. Patients underwent various anti-reflux operations including laparoscopic Nissen fundoplication (33.3%), Toupet fundoplication (29.2%), anti-reflux mucosectomy (23.6%), and magnetic sphincter augmentation (13.9%). Mean duration of Bravo study was 83 ± 22 h. Mean DeMeester scores were 35.7 ± 24.6 (79.2% abnormal) on day 1, 27.8 ± 17.8 (80.0% abnormal) on day 2, 31.5 ± 22.8 (80.0% abnormal) on day 3, and 22.3 ± 14.5 (66.0% abnormal) on day 4. Bravo capsule migration occurred in 10 (13.9%) patients. Higher DeMeester scores on day 2 (r = 0.66, p = 0.027) and greater number of abnormal days (r = 0.68, p = 0.021) were associated with higher GERD-HRQL scores (more reflux) at 6 months postoperatively. Higher Symptom Association Index (SAP) and Symptom Index (SI) for regurgitation symptoms were associated with lower GERD-HRQL scores (less reflux) (SAP: r = -0.49, p = 0.053; SI: r = -0.83, p = 0.021), lower Dysphagia Scores (less dysphagia) (SAP: r = -0.49, p = 0.024; SI: r = -0.51, p = 0.036), and higher patient satisfaction (SAP: r = 0.55, p = 0.099; SI: r = 0.95, p = 0.001) up to 2 years postoperatively. Capsule migration was predictive of less symptom resolution postoperatively [OR 0.09 (95%CI 0.02-0.50), p = 0.006]. Conclusion: In addition to being a valuable diagnostic tool for GERD, prolonged Bravo wireless pH monitoring for up to 96 h can help predict patient outcomes after anti-reflux operations. This has the potential to help aid surgeons' decision-making process to proceed with appropriate anti-reflux surgery, optimize patient reflux control, and improve quality of life outcomes.

A novel phrenoesophageal membrane preserving robotic median arcuate ligament release John H Frankel, MD; Akshay Pratap, MD; University of Colorado.

Introduction: Median arcuate ligament syndrome (MALS) Results from compression of celiac artery (CA) by the fibrous attachments of the diaphragm. Robotic platform has become increasingly accepted as a modality for MALS release (RMALSR) due to the optimized visualization, ease of dissection, ergonomics and camera stability. Traditionally access to median arcuate ligament is obtained by disrupting the integrity of phrenoesophageal membrane (PEM) at the hiatus, which although is reconstructed at completion, may result in new onset of GERD and vagal injury. We describe a novel approach of MALS release by preserving the integrity of the PEM. Methods and procedures: A retrospective chart review was performed on patients who underwent robotic MALR from August 2017 to October 2020. Workup included history and physical examination, mesenteric Doppler ultrasound, and CT Angiogram. Outcomes included pain improvement, length of stay, operation duration, narcotic use, and postoperative complications. DaVinci XI with standard foregut port placement was used. The upper retroperitoneum was exposed by incision of the gastrohepatic ligament. The location of the common hepatic artery and left gastric artery were identified and each structure fully dissected to expose the adventitia. The arteries were then followed proximally to identify the trifurcation of the Celiac artery (CA). Next the splenic artery was exposed and all tissue surrounding the CA trifurcation removed. Careful dissection along the adventitial plane of the CA allowed elevation of the median arcuate ligament, which was divided until 3 cm of aortic surface was exposed proximal to the CA origin. Indocyanine green florescence was used to assess perfusion before and after MALS release. Phrenoesophageal membrane was preserved throughout the procedure. Results: Twelve patients underwent RMALSR. Patients' age ranged from 16 to 55 years (mean 25 years) and consisted primarily of females (85%). Most common presenting symptoms included postprandial pain (80%), weight loss (79%), nausea and vomiting (75%). Mean symptom duration was 5 years (range 1-7 years). There were no intraoperative complications or conversion to open surgery. The mean operative time was 110.6 min (range 86-130 min). Mean follow-up duration was 13.3 months (range 3-42 months). There were no 30 day readmissions. All patients experienced prompt symptom improvement. Two patients have had symptom recurrence during follow-up. Conclusion: Phrenoesophageal membrane sparing robotic MALR is a novel step further to safely perform an already challenging operation sucessfully without increasing the risk of reflux and inadvertent vagal nerve damage during conventional MALR.

Laparoscopic reduction, mesh repair with partial anchorage and gastropexy using per cutaneous gastrostomy (PEG) for a case of gastric volvulus with paraesophageal hernia-an early experience of our ingenious technique Santosh Koppal, DNB, FMAS; Gokul Kruba Shanker, MS, DNB, GI, SURG, MBA; VGM Gastro Centre.

Gastric volvulus herniating into thorax through paraesophageal defect is a rarest complication followed by Nissen's Fundoplication. We report a 52 year-male presenting with pain in the epigastrium since 2 months. CT scan revealed mesenterico-axial gastric volvulus herniating into left hemi-thorax through left hemi diaphragmatic defect. Patient underwent laparoscopic reduction, partial mesh repair and gastropexy using percutaneous endoscopic gastrostomy. Laparoscopic adhesiolysis done to pull the stomach back into abdomen, polypropylene mesh was placed over the defect and anchored partially to avoid injury to lower esophagus and abdominal aorta. PEG tube was inserted endoscopically to prevent re herniation of stomach.

Incidence of dumping syndrome after laparoscopic vagus nervepreserving distal gastrectomy for early gastric cancer So Hyun Kang; Sang Jun Lee; Yongjoon Won; Young Suk Park; Sang-Hoon Ahn; Yun-Suhk Suh; Hyung-Ho Kim; Seoul National University Bundang Hospital.

Objective: There is no consensus on what type of function-preserving gastrectomy can provide the best patient quality of life (QOL) for patients with gastric cancer. This study aims to evaluate the incidence of dumping syndrome after vagus nervepreserving distal gastrectomy (VPNDG). Methods: The study was designed as single-arm prospective observational phase II study with a follow-up period of 12 months. Patients diagnosed with early gastric cancer in the distal 2/3rd of the stomach were enrolled to undergo laparoscopic VPNDG with Roux-en Y gastrojejunostomy. Primary endpoint was incidence of dumping syndrome defined by Sigstad score C 7 after 12-months. Other outcomes include operative data, complications, and patient QOL using the European Organization for Research and Treatment of Cancer C-30 and STO22 modules. Results: One hundred patients underwent laparoscopic VPNDG from August 2017 to August 2019. Mean age was 60.1 ± 0.6 years with an average body mass index of 24.5 ± 3.1 kg/m 2 . Mean operation time was 167.0 ± 41.3 min, and blood loss was 26.8 ± 32.9 ml. After 12 months, 12 patients (12.0%) were classified as dumpers according to their Sigstad scores. Two patients had complication that needed invasive intervention. There was an increase in fatigue and diarrhea compared to preoperative QOL. Female gender was a significant risk factor for dumping syndrome in multivariate analysis (OR 4.37, 95% CI 1.31 -17.27, p = 0.022). Conclusion: About 12% of patients experienced dumping syndrome after laparoscopic VPNDG. Laparoscopic VPNDG can be performed safely with comparable outcomes on patient QOL after 1-year of follow-up.

Outcomes of endoscopic ablative theraphy and surgical management in Barrett's esophagus: development of a multidisciplinary database Hillary A Wilson 1 ; Pam Blakely 2 ; Warren Sun, MD 1 ; Jerry Dang, MD 1 ; Shahzeer Karmali, BSc, MD, MPH, FRCSC, FACS, FASMBS 2 ; Clarence Wong, MD, FRCPC, CAGF 2 ; 1 University of Alberta; 2 Alberta Health Services.

Introduction: Barrett's Esophagus (BE) is a precancerous condition in which epithelial cells of the esophagus undergo metaplasia from stratified squamous to simple columnar. This metaplasia predisposes the epithelial cells to a stepwise progression of dysplasia, and ultimately esophageal adenocarcinoma. The risk for developing malignancy increases with greater degrees of dysplasia; therefore, current intervention is focused on reducing the incidence and progression of dysplasia. There is good evidence that endoscopic therapies, such as resection and ablation, are effective at treating dysplasia in BE; however, the optimal modality to reduce recurrence is unclear. While proton pump inhibitors (PPI) remain the mainstay of medical treatment, fundoplication may be indicated for failure of medical therapy and patients with anatomical defects such as hiatal hernias. There is currently a lack of guidelines for optimal surgical and post surgical treatment for patients with BE who have received endoscopic treatment. Our aim is to create a novel multidisciplinary database of endoscopically and subsequently surgically treated patients with BE that will allow us to monitor long-term post surgical outcomes and disease progression. Methods and procedures: A systematic review on the impact of fundoplication on disease progression in patients with BE is underway. Using an existing database as a foundation, a prospective database of patients with BE was developed using Red-CAP, a secure cloud-based database. Feedback from subspecialized Gastroenterologists and General Surgery contributed to a database that is to our knowledge, the first to combine medicine and surgery. Results: As proof of concept, we entered seven participants' information into the database. The majority of participants had risk factors for BE, including caucasian ethnicity, male gender, age [ 50 years, and elevated BMI. Five came from the endoscopic ablation program and two were referred by surgery. Four patients underwent laparoscopic Nissen fundoplication, of which three had concurrent hiatal hernia repairs. Two have been seen for post-surgical surveillance. One remained dysplasia free PPI dose was reduced. The other demonstrated a reduction of BE, but continued the same dose of PPI and is scheduled to receive ablation therapy. Conclusions: Our preliminary Results indicate the database can successfully monitor both medical and surgical parameters of patients with BE. With additional participants and prospective data, we are positioned to provide evidence-based guidelines to treat and monitor patients with BE from both a surgical and medical perspective.

Learning curve for robotic hiatal hernia repair surgery Savni Satoskar, Dr 1 ; Sarang Kashyap, Dr 2 ; Avian Chang, Dr 3 ; Aanuoluwapo Obisesan, Dr 1 ; Vinay Singhal, Dr 1 ; 1 St Luke's University Health Network; 2 Beckley ARH Hospital; 3 Washington University St Louis.

Introduction: With the advent of robotic surgery, the learning curve for the performance of operations robotically has been found to affect operative time and outcomes. The exact number of operations required to be performed by a surgeon in order to attain expert performance is different for each operation. [1] [2] [3] The surgeon's overall total robotic surgical experience also needs to be considered. Methods: We tracked the operative time and complexity of 112 successive robotic hiatal hernia repair surgeries performed by a single surgeon at a single center community hospital. The size of the hiatal hernia was used as a surrogate measure of the complexity of the case. The surgeon who performed the surgeries was Fellowship trained in Minimally Invasive and Bariatric Surgery prior to the beginning of our study. Results: We found that the operative time did not differ throughout our study, when corrected for the size of the hiatal hernia (i.e. complexity of the case). Conclusion: The learning curve for robotic hiatal hernia repair appears to flatten out after a minimum number of cases. Further studies are required to define the number of instances of each operation that are required to be performed robotically in order to attain expert level skill. This will further help standardization of requirements for training programs in order to produce surgeons with a consistent skill set.

Morgagni hernia repair: a significant experience in one healthcare system Morcos A Awad, DO 1 ; Timothy Farrell, BS 2 ; Mark Dudash, MD 1 ; Anthony T Petrick, MD 1 ; Jon Gabrielsen, MD 1 ; Mustapha Daouadi, MD 1 ; Ryan Horsley, DO 3 ; Alexandra Falvo, MD 3 ; David M Parker, MD 1 ; 1 Geisinger Medical Center; 2 Geisinger Commonwealth School of Medicine; 3 Geisinger Community Medical Center.

Introduction: Morgagni hernia is a rare congenital diaphragmatic hernia in adults. We sought to determine outcomes of Morgagni hernia repair at our healthcare system. Methods and procedures: This is a multi-institutional retrospective analysis of all Morgagni hernia repairs performed in our healthcare system from January 2008 to January 2017. Demographics and short-term outcomes were analyzed. Results: Twenty-seven patients underwent Morgagni hernia repair: 15 electively and 12 emergently. Three (11.1%) patients required bowel resection. Average age was 61.5 ± 15.1 years. Average BMI was 33.5 ± 8.8 kg/m 2 . Presenting symptoms were gastrointestinal in 9 (33.3%) patients, respiratory in 8 (29.6%) patients, a combination of both in 8 (29.6%) patients, and 2 (7.4%) patients were asymptomatic. A laparoscopic abdominal approach was performed in 25 (92.6%) patients, while one patient had a laparotomy approach and one patient had a laparotomy and thoracotomy approach. Mean operative time was 147.0 ± 70.9 min. Morgagni hernia was predominantly located on the right side (74.1%). Hernia was incarcerated in 11 (40.7%) patients. The most common herniated organs were colon (74.1%) and omentum (55.6%). Less common contents were small intestines (29.6%) and stomach (14.8%). Sixteen (59.3%) patients had more than one organ in the hernia sac. The hernia sac was resected in 17 (63%) patients. The fascial defect ranged from 3.2 to 15 cm (n = 15). Mesh reinforcement was utilized in 17 (63.0%) patients. Median postoperative length of stay was 2.0 [interquartile range 1.1-3.8] days. Thirty-day readmission rate was 11.1%. Median follow up was 401 days, with 4 patients who underwent emergent surgery lost to follow up. Postoperative complication rate was 40.7%; including pericardial effusion, persistent pleural effusion, persistent diarrhea, hypoxic respiratory failure, heart failure exacerbation, retained hernia sac, incisional hernia, and recurrence. Of note, two (7.4%) asymptomatic recurrences were noted. Conclusion: This is the largest study of Morgagni hernia repaired through a laparoscopic abdominal approach. Our study demonstrates that Morgagni hernia can be safely repaired laparoscopically. • The sensitivity of endoscopy for detecting precursor lesions may not be adequate; obtain multiple random biopsies q6 -12 months at age 18.

• Prophylactic total gastrectomy should be considered at age 18.

• Lifetime risk of gastric cancer: 10 -15%. • SMAD4 mutations result in massive gastric polyposis requiring a more intense screen regimen and consideration of prophylactic gastrectomy. Screening should start at age 15 and repeated every 1 -2 years or contemporaneously with colonoscopy.

• Mutation-negative cases or BMPR1A ? should be screened starting between ages 15 -25, every 5 years or contemporaneously with colonoscopy.

• Liftime-risk of gastric cancer: 5 -13%. • These cancers are associated with Lynch syndrome are of Lauren's 'intestinal-type' tumor classification, resulting in a theoretically higher endoscopic surveillance yield.

• No high-level evidence exists that demonstrates a linked precursor lesion or benefit of screening.

• Helicobacter pylori synergism elevates gastric cancer risk.

Operative Strategy to Facilitate Reduced Morbidity: A minimally invasive surgical (MIS) approach to gastrectomy should be pursued to:

• Minimize the postoperative adhesion burden thus facilitating future operation in patients at risk for multiple visceral malignancies.

• Decrease blood loss, reduce postoperative pain, accelerate recovery Technical pearls • If gastrectomy is performed prior to colectomy, arrange the Roux limb in a retrocolic fashion to facilitate future colectomy.

• Optimize enteric limb lengths to minimize malnutrition and functional disorders • The biliopancreatic limb length should be as short as the patient anatomy will allow.

• The Roux limb should be between 40 and 60 cm in length.

• Create a jejunal J-pouch to improve small bowel capacitance and reliable emptying. Introduction: Laparoscopic placement of a gastric electrical stimulator (GES) has been shown to improve gastroparesis symptoms in patients with recalcitrant gastroparesis, however only 3 previous studies have investigated 70 or more patients and followed them for over 48 months out from surgery. Method(s): This retrospective case series identified 76 patients with recalcitrant gastroparesis who underwent laparoscopic GES placement at our institution from 2009 through 2017. The following data were collected pre-operatively and at the most recent follow up visit: weight; BMI; use of anti-emetics, promotility agents, and narcotics; and number of device explants, complications, and deaths. Scaled response scores were recorded pre-operatively and at the 3 most recent follow up visits using the Total Symptom Score for Severity (TSS-S) and Frequency (TSS-F) to describe the patient's gastroparesis symptoms (nausea, vomiting, epigastric pain, early satiety, and postprandial bloating) on a 20 point scale. Results: Gastroparesis was either idiopathic (n = 47, 62%), associated with diabetes (n = 27, 36%), or post-surgical (n = 2, 3%). At the most recent follow up visit (median 4.9 years, range: \ 1 month to 10.1 years), the GES remained implanted in 61/76 (80.3%) patients.

GES explanation was performed in 16/76 patients (21.1%) due to planned pregnancy (1), conversion to gastric bypass (1), need for Whipple for pancreatic cancer (1), pain at the generator (7), no response to treatment (4), infection of the generator (1), and need for MRI (1). In 8/76 patients (10.5%) complications occurred, which included pain (6), shocking/twitching (3), flipped generator (1), and infection (2). There were no deaths related to the device.

In 55 patients with scaled response data, TSS-S and TSS-F scores decreased in 75% and 80% after GES placement. Averaging scores from the 3 most recent follow up visits, there was also a significant decrease in the mean TSS-S (14.4 to 10.4) and mean TSS-F (14.1 to 11.00) (both, p \ 0.001).

At most recent follow up, 13/66 (19.6%) patients were able to discontinue antiemetics (p = 0.0031) and 30/50 patients (60%) were able to discontinue promotility agents (p = 0). For patients with initial BMI \ 26 (n = 39), the average BMI change was ? 2.4 (p \ 0.01) and the average weight change was ? 12.7 lbs (p = 0.03). Conclusions: Laparoscopic placement of a GES significantly improves symptoms in patients with recalcitrant gastroparesis in the long term. Though device placement is safe, non-life-threatening complications occur in 10.5% of patients, and ultimately 21.1% of patients have a device explant.

Laparoscopic distal gastrectomy for gastric cancer in elderly patients over 85 years of age Background: Few studies about laparoscopic distal gastrectomy (LDG) for gastric cancer in more elderly patients especially over 85 years of age were reported. The aim of this study was to analyze LDG for gastric cancer in elderly patients over 85 years of age in our institute. Methods: We retrospectively analyzed 9 consecutive patients who underwent LDG for gastric cancer in our institute between January 2012 and December 2018. Clinicopathological characteristics and perioperative outcomes were analyzed. Results: Mean age of the patients was 87.8 years (85-91 years). The ratio man and woman were 5:4. Mean body mass index was 19.9 (14.5-24) kg/m 2 . Mean hemoglobin level was 11.5 (9-14.8) g/dl. Mean serum albumin level was 3.6 (2.8-4.4) g/dl. The concurrent diseases had 7 cardiovascular disease, 3 brain disease, and 2 respiratory disease, respectively. The mean preoperative hospital stay was 26 (3-76) days. All patients underwent LDG with B-1 reconstruction. The mean duration of surgery was 232 (111-370) minutes, and the mean blood loss volume was 63 (5-250) mL. The postoperative complications included 2 postoperative delirium, one convulsions and anastomotic stenosis, respectively. The mean total hospital stay was 32 (11-97) days except one hospital stay patient. The postoperative pathological stage was 6 stage I, 1 stage Ib, 1 stage IIc, and 1 stage IV, respectively. One patient died from gastric cancer in pathological Stage IV at 93 years old 12 months after surgery. One patient died from cerebral infarction at 90 years old 42 months after surgery and another patient died from heart failure at 90 years old 6 months after surgery. Conclusions: LDG can be performed safely for gastric cancer patients over 85 years of age because of no severe postoperative complications and hospital death.

Duodenal diverticulosis presenting with obstruction Jack W Sample, BS 1 ; Ahmad J Bosaily, MD 1 ; Samer Alharthi, MD 1 ; Albert W Tsang, MD 2 ; Joseph J Sferra, MD, MBA 2 ; 1 University of Toledo College of Medicine; 2 ProMedica Toledo Hospital and University of Toledo College of Medicine.

Introduction: Duodenal diverticulosis is a common condition seen in approximately 20% of the population. These abnormalities of the intestinal mucosa and submucosa are often discovered incidentally and are rarely symptomatic, with a small percentage requiring definitive treatment. We present an unusual case of duodenal obstruction secondary to florid diverticulosis of the duodenum and proximal jejunum in a previously healthy male. Case report: A 48-year old male presented to the emergency department with a 6-day history of abdominal distension with nausea, vomiting, and abdominal pain. His medical history was unremarkable. Physical examination was significant for abdominal distension. Computed tomography of the abdomen and pelvis (Fig. 1) and upper gastrointestinal fluoroscopy (Fig. 2 ) demonstrated marked gastric distension and evidence of severe dilation of the duodenal bulb extending to the 4th part of the duodenum. Multiple irregular gas and fluid densities were noted throughout the duodenum and jejunum, suggesting extensive small intestine diverticula. He was admitted for management and a nasogastric tube was inserted for gastric decompression.

The following day, endoscopic evaluation with esophagogastroduodenoscopy was performed (Fig. 3) . There was narrowing and tortuosity of the duodenum and the presence of multiple diverticula precluding passage of the scope. The following day, the patient tolerated a liquid diet and was discharged with outpatient follow-up to discuss management options. Fig. 1 CT of abdomen and pelvis Discussion: We present the unique case of a previously healthy male presenting with duodenal obstruction secondary to florid duodenal diverticulosis, possibly with associated diverticulitis. Our initial diagnosis included more common causes of obstruction including pancreatic head mass and peptic stricture. Imaging modalities demonstrated evidence of duodenal obstruction in the presence of a highly tortuous and narrowed duodenum and proximal jejunum. Because of the nature of his diverticulosis, we recommended surgical intervention with gastrojejunal anastomosis to bypass the diseased segment and relieve the symptoms. This patient elected to be discharged the following day. In telemedicine follow-up, the patient reported that he was doing well and refused further treatment. Conclusion: Gastrointestinal obstruction is a rare complication of duodenal diverticulosis. Due to its low prevalence, there is no consensus regarding optimal management of duodenal obstruction secondary to florid duodenal diverticulosis. However, literature suggests surgical intervention may be indicated if complications are present. The case reported herein suggests that nonoperative management may be successful.

Minimally invasive paraesophageal hernia repair without intraoperative use of esophageal bougie is safe and effective: a case series from a community-based teaching institution David Seok, MD; Olives Nguyen, MA; Manu Kaushik, MD; Michael J Jacobs, MD, FACS; Ascension Providence Hospital, Southfield Campus.

Introduction: Laparoscopic paraesophageal hernia repair (LPHR) can be performed with an antireflux procedure. The routine use of an esophageal bougie is advocated for to avoid excessively tight wraps during laparoscopic Nissen fundoplication. However, the use of an esophageal bougie carries a very small risk of perforation as well as increased intra-operative time. Currently, some operators perform LPHR with fundoplication without the use of an esophageal bougie. The outcomes of this technical aspect have not been thoroughly investigated, and there is equivocal evidence for the use of an esophageal bougie in surgical literature. Methods: A retrospective review of patients who underwent LPHR with fundoplication without the use of an esophageal bougie during a period of 2010-2020 by a single surgeon at a community-based academic hospital was performed. Patients underwent preoperative evaluation with endoscopy and an upper gastrointestinal study with contrast. Patients with a diagnosis of achalasia, esophageal dysmotility or those who did not receive fundoplication with LPHR were excluded. Perioperative outcomes including operative time, recurrence, post-operative proton pump inhibitor use, stenosis, post-operative dilations, reoperation and mortality were reviewed. Results: A total of 174 patients (34 males, 140 females) underwent LPHR with fundoplication. The average age was 63.0 years-old. The average operative time was 110.9 min. Four patients (2.3%) developed a dysphagia with narrowing of the gastroesophageal junction, with one patient (0.6%) requiring postoperative esophageal dilation with bougie and eventual reoperation. Post-operative proton pump inhibitor use was 31.0% after 1 month. Overall hernia recurrence rate was 14.9% and the rate of reoperation was 6.3%. Overall mortality was 0.6%. Conclusion: Performing LPHR with fundoplication without an esophageal bougie is safe and efficient. It avoids the risks of esophageal injury, with comparable incidence of postoperative dysphagia and paraesophageal hernia recurrence. Introduction: Hiatal hernia re-approximation during primary anti-reflux surgery (ARS) has been shown to contribute approximately 80% of overall change in distensibility index (DI) and, potentially, compliance of the esophagogastric junction (EGJ), while sphincter augmentation contributes approximately 20% of total change. It is unclear if these characteristics are seen in re-operative ARS. We aim to quantify the physiologic parameters of the EGJ at each step of robotic re-operative ARS with hiatal hernia repair. Methods: Robotic ARS with hiatal hernia repair was performed on 177 consecutive patients with pathologic reflux utilizing EndoFLIP technology, of which 22 underwent re-operative repair. Intraoperative EGJ measurements, which included crosssectional area (CSA), pressure, distensibility index (DI), and high-pressure zone (HPZ) length were collected pre-repair, post-diaphragmatic re-approximation, postmesh placement, and post-sphincter augmentation (post-procedure). Results: The re-operative cohort consisted of 14 Toupet, 6 Nissen, and 2 Hill fundoplications. 19/22 (86%) had new biosynthetic mesh placed. Between preprocedure and post-sphincter augmentation (post-procedure), both CSA and DI decreased by 47.3 ± 37.8 mm^2 and 2.6 ± 2.6 mm^2/mmHg, respectively (p \ 0.05). Pressure increased by 9.1 ± 9.4 mmHg and HPZ increased by 1.5 ± 1.5 cm (p \ 0.05). Following diaphragmatic re-approximation, CSA decreased by a mean 25.7 ± 33.7 mm 2 , DI decreased by 1.8 ± 2.1 mm^2/mmHg, pressure increased by 5.5 ± 7.6 mmHg, and HPZ increased by 2.2 ± 2.4 cm (p \ 0.05). Following sphincter augmentation, CSA decreased by a mean 17.2 ± 26.3 mm 2 , DI decreased by 1.0 ± 1.2 mm^2/mmHg (p \ 0.05), pressure increased by 3.1 ± 5.5 mmHg (p = 0.07), and HPZ increased by 0.5 ± 2.3 cm(p \ 0.05). Diaphragmatic re-approximation led to a greater percent contribution to the change in each physiologic parameter than did sphincter augmentation (CSA: 66.9% vs 33.1%, pressure: 59.8% vs 40.2%, DI: 70.0% vs 30.0%, HPZ: 81.0% v 19%). Conclusions: During re-operative anti-reflux surgery, dynamic intraoperative monitoring can be used to quantify the effects of each step of the operation on EGJ physiologic parameters. Diaphragmatic re-approximation appears to have a greater effect on EGJ physiology than does LES sphincter augmentation during re-operative repair, similar to its effects during index anti-reflux surgery. Ongoing investigation into the utility of EndoFLIP during anti-reflux surgery is warranted to optimize patient outcomes.

Comparison of outcomes between patients undergoing paraesophageal hernia repair with mesh vs primary repair Rocio E Carrera Ceron, MD; Colette S Inaba, MD; Brant K Oelschlager, MD; Jay Zhu, MD; Robert B Yates, MD; Saurabh Khandelwal, MD; Judy Y Chen, MD; Andrew S Wright, MD; Department of Surgery, University of Washington.

Introduction: Use of biologic mesh in paraesophageal hernia repair (PEHR) has been associated with decreased short-term but not long-term recurrence. Our current practice is to selectively use mesh in patients considered high risk for recurrence. The aim of this study was to describe the demographic and clinical characteristics of patients who underwent PEHR with mesh vs primary repair, and to compare the outcomes between groups. Methods: We reviewed our prospective institutional database and performed a retrospective chart review of patients who underwent PEHR with biologic mesh vs. primary repair between October 2015-October 2018. The decision to use mesh was made intra-operatively by the surgeon (tension at the hiatus, poor tissue quality, or both). Recurrence was defined as the presence of [ 2 cm intrathoracic stomach on postoperative upper gastrointestinal (UGI) series. Results: 251 patients underwent PEHR during our period of study, including 169 (67.3%) patients undergoing first-time repair and 82 (32.7%) patients undergoing redo PEHR. Among first-time repair patients, 64% underwent a primary repair vs. 36% with mesh. Among redo-repair patients, 42.7% underwent a primary repair vs. 57.3% with mesh. There were no demographic differences between groups (age, sex, race, BMI, smoking, or DM). Median LOS was 1 (IQR 1-3) day for all groups. OR times were not significantly increased with use of mesh. There were no mesh-related complications. We obtained a postoperative UGI in 87 (51.5%) of the first-time repair group and in 43 (52.4%) of the redo repairs. Most UGI studies were obtained for routine postoperative follow-up (median follow-up was 130 days). Radiographic recurrence was statistically higher in primary repair compared with mesh repair (p \ 0.04 first-time, and p \ 0.02 for redo repair, Table 1 ).

Conclusions: Selective biologic mesh reinforcement of the hiatus in both first-time and redo laparoscopic PEHR is associated with reduced incidence of early postoperative radiographic recurrence. That mesh was only used in patients who the surgeon deemed were at increased risk for recurrence further highlights the potential benefit of mesh reinforcement of the hiatus at reducing short-term recurrence. Coupled with a zero incidence of complications associated with biologic mesh use, these findings suggest consideration of routine biologic mesh use in all patients undergoing first-time and redo laparoscopic PEHR.

Evaluating the oncologic effect of laparoscopic/VATS and open esophagectomy on lymph node dissection Sabri A Karatas, Dr, MD; Ö mer Günal, Prof, Dr, MD; Cumhur Yegen, Prof, Dr, MD; Marmara University, School of Medicine, Department of General Surgery.

Oncologic Results of open and laparoscopic esophageal surgery has still been debated. Total lymph node number and positive lymph node ratio harvested (LNR) are important for the staging of the disease. We aimed to compare the effect of surgical technique undergone on the lymph node dissection. Methods: 57 patients who had an esophagectomy due to esophageal cancer between November 1st, 2012 and November 1st, 2020 in Marmara University School of Medicine Training and Research Hospital were screened retrospectively. Patients were divided into two groups as Laparoscopic/Video Assisted Thoracoscopic (LS/ VATS) (n = 32) and Open Surgery (OS, n = 25). Pathology reports were scrutinized for tissue diagnosis, TNM stage, positive lymph node ratio (LNR), harvested total lymph node (tLN) and metastatic lymph node (mLN) amounts. Preoperative neoadjuvant chemoradiotherapy treatment (NAT) was also questioned All data were collected and analysed retrospectively. Results: Thirty six patients had squamous cell carcinoma, 20 patients had adenocarcinoma, 1 patient had GIST. 25 patients had neoadjuvant chemoradiotherapy. There was total regression in 8 patients and partial regression in 2 patients. Mean value of harvested tLN amount was 18,8 ± 8,6; was 19,2 ± 9,6 in the LS/VATS group and was 18,4 ± 7,4 in the OS group (p [ 0,05). This was 20,1 ± 7,7 and 17,1 ± 9,6 in patients who had not taken NAT and had taken NAT, respectively (p [ 0,05). Mean value of LNR was 0,13 ± 0,24 and 0,17 ± 0,28 in the LS/VATS and OS groups, respectively (p [ 0,05). There were no significant differences between the laparoscopic and open surgery groups as tLN amount or LNR. Conclusion: LS/VATS and OS techniques seemed to be statistically equal with respect to LNR and harvested tLN. Though, considering the proven advantages of LS/VATS such as short hospital stay, less postoperative pain, better cosmesis etc. could be reasons for the preference. Keywords: Esophageal cancer, Lymph node ratio, Laparoscopic thoracoscopic esophagectomy.

Introduction: Peroral Endoscopic Myotomy (POEM) is an endoscopic procedure that lyses the inner circular muscles of the lower esophageal sphincter (LES) in order to treat achalasia and other spastic esophageal disorders. It is a novel alternative to Heller Myotomy and requires no skin incisions. We seek to define the learning curve of POEM for a foregut surgeon with no formal endoscopic or POEM training by analyzing different intraoperative factors in a single series. Methods and procedures: The first 38 consecutive patients undergoing POEM by a single foregut surgeon were included in this retrospective study. Inverse curve regression models were used to analyze Total Operative Time (TOT), Total Operative Time Per Centimeter of Myotomy (TOT-CM), Number of Instrument Passes/ Exchanges Through the Endoscope (NIP), and Total Number of Clips Used for Tunnel Closure (TNC). Results: The total operative time (median 76 min, range 51-129) decreased significantly over the course of the series (R2 = 0.38, P \ 0.001), with a learning plateau at 70 min and a learning rate of 12 cases (Fig. 1) . Total Operative Time Per Centimeter of Myotomy (median 7.08 min/cm, range 4.25 to 15.38) decreased significantly over time (R2 = 0.45, P \ 0.001), with a learning plateau at 7 min/cm and a learning rate of 12 cases. The number of instrument passes (median 19, range 12-37) decreased significantly for consecutive POEM procedures (R2 = 0.47, P \ 0.001) with a learning plateau at 18 instrument passes and a learning rate of 14 cases. The Number of Clips Used (median 7 clips, range 4-12) decreased significantly (R2 = 0.47, P \ 0.001) over the series as well. Fig. 1 Total procedure time significantly decreased over the course of POEM procedures, with a learning plateau at 70 min and a learning rate of 12 cases Conclusion: The number of cases for a foregut surgeon to become proficient in a POEM procedure was found to be 12-14 cases. The learning curve of a POEM can be defined by analyzing the time to case plateau in Total Operative Time, Total Operative Time Per Centimeter of Myotomy, Number of Instrument Passes/Exchanges Through the Endoscope, and Total Number of Clips Used for Tunnel Closure. Based on these findings, the learning curve for a POEM in a foregut surgeon is similar to that of an expert intervention endoscopist. Background: Percutaneous endoscopic gastrostomy (PEG) is the most commonly performed method of durable enteral access; a necessity often found in patients with head and neck cancer (HNC). While the overall complication rate of PEG placement is well established, patients with HNC may have inherently higher risks due to their immunocompromised state and comorbid conditions such as tobacco abuse. This study compares PEG placement in HNC patients with non-HNC patients to identify patient or disease-related factors associated with complications. Methods: An institutional review board approved retrospective evaluation was performed of adult patients undergoing PEG for HNC at an academic medical center from September 2004 to February 2020. Preoperative risk factors, cancer characteristics, operative details, and postoperative and long-term outcomes were collected via electronic medical records. Complication rates in HNC patients were subsequently compared to a previously collected dataset of non-HNC patients using a twosample t-test. Patient risk factors and cancer characteristics were analyzed for association using a univariate model. Results: A total of 223 patients with HNC undergoing PEG met inclusion criteria (mean age 59 years, 80.7% male). Squamous cell carcinoma was the most common diagnosis (n = 201, 90.1%) with majority Stage 4, (n = 131, 58.7%). The vast majority of patients (n = 214, 95.9%) had at least one comorbidity beyond their HNC. Overall, 46 (20.6%) patients had complications, including 19 (8.52%) surgical site infections and 10 (4.48%) PEG dislodged. Nine patients (4.04%) required reoperation for PEG-related complications, but there were no mortalities. When compared to historical dataset of 420 patients undergoing PEG for non-HNC indications, patients with HNC had a statistically higher rate of complications (20.6 vs 12.9%, p = 0.0097). Univariate analysis demonstrated no significant associations between complications and comorbidities (smoking, cardiac, diabetes, COPD), cancer staging, chemoradiation timing, and timing of PEG (Table 1) . Conclusion: In this single center study, patients with HNC had a higher rate of complications following PEG compared to a cohort of non-HNC patients. We identified no specific patient or disease factors associated with the higher complication rate. The higher complication rate in HNC patients suggests that evidencebased risk mitigation practices (for example oral decontamination or endoscopic gastropexy) could be applied in this population. Further study is indicated to delineate the effectiveness of these interventions. Background: Fundoplication is a well-established treatment for paraesophageal hernia (PEH). Unfortunately, some patients develop a recurrence and revisional repair may be complicated with a high failure rate. For patients withma body mass index (BMI) [ 35, a conversion to a Roux en Y gastric bypass (RNYGB) may provide an alternative that allows weight loss, improvement in comorbidities, in addition to a more definitive treatment of the PEH and gastroesophaeal reflux disease (GERD). For patients in the lower BMI (LBMI) 30-35 range there is less supporting data for ideal surgical management of recurrent PEH. Objective: To compare patients with a BMI 30-35 to patients with a BMI [ 35 in regards to weight loss and outcomes following revision of a recurrent PEH repair to RNYGB. Methods: A retrospective chart review was performed at a single tertiary referral center identifying patients presenting with recurrent PEH who underwent conversion to RNYGB between March 2009 and October 2017. The review identified age, sex, BMI, presenting symptoms, time from index surgery, operative details, resultant weight loss at 30 days and long term postoperative outcomes. Results: Nine patients were included in the LBMI 30-35 cohort and 27 in the higher BMI (HBMI) [ 35 cohort. Average age of LBMI patients was 55.5 years with a BMI from 33.4 kg/m 2 preoperatively to 30.46 kg/m 2 at 30 days and 26.38 kg/m 2 at 11 months on average. Average age of HBMI patients was 52.4 years with a BMI 42.2 kg/m 2 preoperatively to 38.0 kg/m 2 at 30 days and 32.4 kg/m 2 at 25 months on average. The average biliopancreatic and roux limbs for the LBMI cohort were 45.6 cm and 123 cm, respectively and 48.1 cm and 154 cm for HBMI. LBMI patients had an average of 1.7 previous PEH surgeries in comparison to 1.07 in the HBMI cohort. No patients in either cohort required additional surgery for management of reflux. Two patients in the LBMI and four in the HBMI cohort required postoperative EGDs for evaluation of dysphagia or pain. Conclusions: Patients with obesity with a BMI [ 35 with recurrent PEH benefit from conversion to RNYGB. Management of patients BMI 30-35 is less well understood. Evaluation of this cohort of patients demonstrates that patients undergo on average 0.63 additional surgeries prior to undergoing conversion to RNYGB. This group demonstrates an improvement in weight loss, symptoms, in addition to long term PEH resolution, therefore, conversion to RNYGB may be considered earlier in LBMI group. Introduction: Muir Torre syndrome is a rare variant of Hereditary nonpolyposis colorectal cancer (Lynch) syndrome that predisposes patients to sebaceous skin tumors and visceral malignancies. While colon and urogenital cancers are most common, pancreatic and gastric malignancies are also included and therefore these patients require surveillance endoscopy at regular intervals. In undertaking gastric resection in this patient population, access to the duodenum for reasons of surveillance is a necessity given the increased risk of neoplasm. Methods: A 66-year-old gentleman with a history of Muir-Torre syndrome presented with gastric adenocarcinoma nineteen years after undergoing right hemicolectomy for colorectal adenocarcinoma. After performing an open gastrectomy with D2 lymphadenectomy in the standard fashion, a generous Roux limb of 75 cm was created, brought antecolic and reconstruction began with a 29Fr stapled end-to-side esophagojejunostomy. We then proceeded to create a hand-sewn end-toside duodenojejunal anastomosis using single layer running 3-0 PDS suture (Fig. 1) . Our anesthesia colleagues assisted us in performing an underwater immersion test by instilling air via the nasogastric tube positioned in our Roux limb without any evidence of leak. A 14Fr feeding jejunostomy tube was also placed approximately 10 cm distal to our jejuno-jejunostomy in a Witzel fashion. Conclusions: In patients with increased risk of multiple visceral malignancies due to underlying genetic syndromes such as Muir Torre and Familial Adenomatous Polyposis, consideration for future neoplastic processes is an integral part of surgical decision-making. We present a novel technique in allowing for duodenal access after total gastrectomy by adding a duodenojejunal anastomosis while performing Rouxen-Y reconstruction.

Introduction: Peritonitis secondary to perforated peptic ulcer (PPU) is an acute lifethreatening complication that requires emergent surgical management and is associated with increased morbidity and mortality. Minimally invasive or open Graham Patch repair remains the gold standard approach for the repair of PPU. Unlike the use of a tension-free pedicle of omentum to cover the perforation in Graham patch repair, the Cellan-Jones repair (CJR) describes closure of the ulcer primarily then the use of a pedicled omental patch over the repaired perforation. To our knowledge, there is a limited number of studies analyzing and characterizing laparoscopic CJR for PPU. This analysis reports the outcomes following laparoscopic CJR at a community teaching hospital. Methods: This is a retrospective observational study of laparoscopic CJR of patients aged 18-90 years, during 2016-2020 at a community teaching hospital by a single surgeon. Characterization of laparoscopic CJR was achieved in terms of patients' demographics, co-morbidities, intra-operative details, post-operative recovery, and short-term outcomes. Results: A total of 13 patients were identified [53.9% male, mean age 50.7 ± 8.4 years, mean BMI 22.3 ± 2.8, 53.2% had ASA class C III, 38.5% used NSAIDs recently, 69.2% alcohol drinkers and 92.3% current smokers]. The majority of patients had symptoms B 12 h (53.8%), and preoperative CT scan was obtained in 53.8%. 30% of patients had had previous abdominal surgeries. The duodenum was the most common site of perforation (69.2%), with size 1-2 cm in 76.9%. The ulcer was primarily repaired in all patients. Either the omentum or falciform ligament was used to patch the site of perforation. The EBL was 6.5 ± 2.4 ml. A JP drain was placed in 46% of patients. There were no conversions to open. The average operative time was 75.2 ± 56.1 min. Postoperatively, NGT was removed on POD1 (84.6%), with resumption of oral feed by POD 2 (84.6%). No upper GI studies were performed. Mean length of stay (LOS) was 3.8 ± 1.7 days, and morbidity rate was 15.4%, and no reported 30-day mortalities. The majority of the patients received empiric treatment for H. Pylori (92.3%) after the surgery. Patients were followed up to 3 months following surgery. Conclusion: The Laparoscopic CJR is a feasible method for repair of PPU, even in high-risk patients. This approach optimizes patient recovery and is associated with shorter LOS, and lower morbidity and mortality rates. Further comparative research with open approach is needed to validate these findings.

Comparison of perioperative outcomes and cost of laparoscopy compared to robotics for Heller Myotomy demonstrates equivalence Joel Chacko, MD 1 ; Steven G Leeds, MD 1 ; Christine E Sanchez, MPH 2 ; Gerald Ogola, PhD 2 ; Marc A Ward, MD 1 ; 1 Division of Minimally Invasive Surgery, Baylor University Medical Center; 2 Baylor Scott and White Research Institute.

Introduction: The use of robotic approach to foregut surgery has become more prevalent in America over the last10 years. We sought to find the differences in the clinical outcomes of robotic surgery compared to traditional laparoscopy in patients undergoing Heller myotomy. Methods: A retrospective population-based analysis was performed using the National Inpatient Sample (NIS) database for the span of 2010 to 2015. All patients who underwent laparoscopic or robotic Heller myotomy were included. Multivariable linear and logistic regression models were used to assess the impact of robotic surgery on patient outcomes. Results: There was a total of 2,321 patients with a median age of 54.2 years. 1171 (49.5%) of the patients were males. No significant differences were seen between the laparoscopic and robotic Heller myotomy groups in the incidence of post-operative complications or mortality. In the subset of high volume centers ([ 20 operations per year), the overall length of stay was shorter for those who underwent robotic surgery (1.5 days vs 2.0 days, p 0.04). In the subset of low volume centers (\ 6 operations per year), the overall charges per surgery were significantly higher in the robotic group ($47,000 vs $36,000, p \ 0.01), however costs were not significantly different in intermediate or high-volume centers. Conclusion: There are no significant differences in complications or mortality between those who underwent laparoscopic or robotic Heller myotomy. Robotic surgery appears to be more cost-efficient in high-volume centers.

Predictive factors for developing GERD after sleeve gastrectomy: is preoperative endoscopy necessary?

Omar Bellorin, MD 1 ; James C Senturk, MD, PhD 1 ; Mariana Vigiola Cruz, MD 2 ; Gregory Dakin, MD 1 ; Cheguevara Afaneh, MD 1 ; 1 New York Presbyterian-Weill Cornell Medical Center; 2 Northwestern Medical Group.

Introduction: Sleeve gastrectomy (SG) is the most common bariatric procedure performed in the United States. The rise in popularity of SG has been matched by growing concern for new onset gastroesophageal reflux disease (GERD) and the development of Barrett's esophagus (BE) post-operatively. Routine endoscopic screening of patients prior to bariatric surgery has the potential to influence surgical decision making, but remains controversial. We examined our experience at a highvolume accredited bariatric center and sought to identify preoperative endoscopic factors that may predict development of GERD following sleeve gastrectomy. Materials and methods: We prospectively evaluated 217 patients undergoing primary robotic-assisted sleeve gastrectomy from October 2015 to May 2019 with the approval of our institutional review board. Patients were followed for the development of GERD. All patients underwent endoscopic evaluation prior to SG as well as for-cause postoperatively. GERD was diagnosed by either biopsy-proven reflux esophagitis or a positive esophageal pH test. Patients with a positive pH test, visual LA Grade B or greater esophagitis, and patients found to have a hiatal hernia [ 5 cm on retroflexion were counseled to undergo Roux-en-Y gastric bypass and were not included in this study. Patients who ultimately underwent SG were separated postoperatively into two groups: Those who developed GERD (GERD group) and those who did not (No GERD group). Results: There were significantly more male patients in the No GERD group (25.6% vs. 8.1%; p = 0.02). There were more patients who endorsed heartburn symptoms at initial consultation in the GERD group (40.5% vs. 23.9%; p = 0.04). There was no significant difference in the incidence or size of hiatal hernia, nor in the rate of H. pylori infection between the groups. The visual presence of esophagitis was significantly more common in the GERD group (29.7% vs. 13.3%; p = 0.01), as was biopsy-proven esophagitis (24.3% vs. 11.1%; p = 0.03). On multi-variate analysis, the strongest predictors of developing GERD following sleeve gastrectomy were the visual presence of esophagitis (Odds ratio [OR] 2.79; 95% confidence interval [CI]:1.17-6.69; p = 0.02) and biopsy-proven esophagitis also a (OR 2.80; 95% CI 1.06-7.37; p = 0.04). Male patients were less likely than female patients to develop GERD after SG (OR 0.23; 95% CI: 0.06-0.85; p = 0.03). Conclusion: Our findings strengthen the rationale for routine preoperative endoscopy and bring into focus critical clinical and endoscopic criteria that should prompt consideration of alternatives to sleeve gastrectomy for weight loss.

Enhanced recovery after surgery (ERAS) program in a low volume centre improves clinical outcomes for minimally-invasive gastrectomy for gastric cancer: a randomized controlled trial Introduction: Enhanced recovery after surgery (ERAS) is a well established concept in colorectal surgery. Data on gastrectomy is scarce. The aim is to conduct a protocol-driven prospective randomized trial comparing the clinical outcomes in patients undergoing minimally invasive gastrectomy for gastric cancer with ''ERAS'' versus a ''conventional'' perioperative program. Methods: From 30th June 2016 to 29th June 2020, all patients aged between 18-75, with American Society of Anesthiologists I-III undergoing elective minimally-invasive gastrectomy were included. Patients who had preoperative chemotherapy or radiotherapy, known metastatic disease, previous history of midline laparotomy, gastric outlet obstruction, diabetes on insulin, coagulopathy and immunocompromised patients were excluded. The primary outcome of the study was the hospital stay. Secondary outcomes include time to tolerate diet, mobilization, pain scores, peak flow rate (PFR), complications and unplanned readmissions. Results: 50 patients were recruited to the study. 36 patients had laparoscopic/ robotic subtotal gastrectomy, 14 had laparoscopic total gastrectomy. The baseline demographics and oncological staging were similar in both groups. The ERAS group had a significantly shorter hospital stay and time to resumption of diet when compared to the conventional arm. The ERAS group also had significantly shorter time to walking independently. Results are shown as median(range) in Table 1 . There was no difference in complication rates and unplanned readmissions.

There was no difference in post-operative pain scores ( Fig. 1i and 1ii) . However, the PFR showed earlier improvement in the ERAS group. Figure 2 shows the trend of PFR for both groups. Conclusion: ERAS after minimally invasive gastrectomy for gastric cancer significantly shortened hospital stay, earlier to resumption of diet and mobilization without increasing complications or readmission rate. Although pain scores were similar, patients' peak flow rate recovered at a faster rate in the ERAS group. ERAS improved and hastened patient's recovery after gastrectomy. Introduction: The indication of laparoscopic anti-reflux surgery for GERD patients is difficult to be judged fairly. We have established simple ''Reflux Test '' as the tool to decide surgical indication for GERD patients.

Surgical indication:Reflux test: At the standing position a patient swallows 300 ml barium solution. After total solution goes into stomach, a patient lies down at the flat position. Then a patient changes the position to left lateral decubitus position, flat position, right lateral decubitus position and flat position again every 10 s in the order. During this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. If the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. The anti-reflux surgery was considered in the moderate and severe categories. Results: We have performed laparoscopic Nissen procedure in 116 cases. Median follow-up period of this study was 75 months (1-131 months) . In 15 cases (11.5%) PPI was restarted before 6 months after the anti-reflux surgery. In 28 cases (21.4%) PPI was restarted after the anti-reflux surgery during the whole follow-up period of this study. The Results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the PPI restarted group which was analyzed by our endoscopic esophagitis grading score (p \ 0.001).

Our stylized procedure with right side approach in laparoscopic Nissen fundoplication for gerd patients Introduction: Laparoscopic techniques in anti-reflux surgery for GERD patients are still considered complicated. We have established our simple anti-reflux surgery procedure with right side approach contributing to less bleeding and less operative time.

Surgical procedure:Setting: Our 5-trocar setting with patients in the reverse Trendelenburg's position is as follows: 12 mm trocar just below the navel (A), 5 mm trocar at the upper right abdomen for pulling up the liver, 5 mm trocar at upper right, 12 mm trocar at upper left (B), 5 mm trocar at middle left (C).

Step 1 Right Side Approach. Left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus of the diaphragma has been dissected free from the soft tissue around the stomach and abdominal esophagus. In this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid unnecessary bleeding. After cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. Then the inside and outside margins of the left crus of the diaphragma were recognized from the right side. The laparoscope uses trocar (A), the assistant uses trocar (B) to pull the stomach and the operator's right hand uses trocar (C).

Step 2 Flap Preparation. The branches of left gastroepiploic vessels and the short gastric vessels were divided. The left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was shown and widely opened. The laparoscope uses trocar (A) at the beginning of dividing left gastroepiploic vessels, trocar (B) when dividing short gastric vessels.

Step 3 Suturing. The right and left crus are sutured with interrupted stitches to reduce the hiatus. From the right side, the fundus of the stomach is grasped through the window behind the abdominal esophagus. Then the fundus of the stomach is pulled to obtain a 360 degree ''stomach-wrap'' around the abdominal esophagus. Stitches are placed between both gastric flaps. Results: We have performed this procedure in 116 cases. The mean operation time in recent 20 cases is 90 min. The patients are mostly satisfied with the postoperative Results because of stable food passage food and no reflux.

Ratio of lower esophageal sphincter to mid-esophageal diameter based on upper gastrointestinal study as an adjunct in the evaluation of reflux Introduction: The purpose of this study was to examine the utility of upper gastrointestinal series (UGI) in the pre-and post-operative evaluation of patients with gastroesophageal reflux disease (GERD) undergoing concomitant hiatal hernia repair with transoral incisionless fundoplication (cTIF). Hill grade, DeMeester score, LA grade of esophagitis, UGI imaging, and symptoms of GERD are commonly used to evaluate candidacy for anti-reflux surgery. The utility of UGI for pre-operative planning of anti-reflux surgery has previously been challenged. Although a fluoroscopic UGI can routinely demonstrate the presence of a hiatal hernia or provoked reflux, we believe an UGI can provide additional anatomic information that can be used as an indication for anti-reflux surgery, namely the construction of a gastroesophageal flap valve. We hypothesize that the ratio of lower esophageal sphincter diameter to mid-esophageal diameter (LESME) as measured on UGI correlates with other commonly utilized pre-operative evaluations for anti-reflux surgery. Methods and procedures: A single institution retrospective study was performed on patients undergoing cTIF. Inclusionary criteria were those with pre-and post-operative UGI, upper endoscopy, Hill grade, DeMeester score, and pH testing. Determination of mid-esophageal and lower esophageal sphincter (LES) diameter was performed by taking the mean of three measurements on the web imaging platform. Selection of images was based on those with the greatest distension of the esophagus and gastroesophageal junction. This was independently performed by one investigator and confirmed by a second investigator. A LESME ratio was calculated based on these values pre-and post-operatively. Pearson correlation and chi-squared tests were performed to determine correlation between LESME ratio, Hill Grade, DeMeester score, and LA Grade of esophagitis.

Results: Fifteen patients were included in this study. The median pre-operative LESME ratio was 0.69 (IQR, 0.51 -0.80), and the median post-operative LESME ratio was 0.23 (IQR, 0.17 -0.27). Following cTIF, there was a reduction in patients' LESME ratio by 67.5% (IQR 60.4 -74.2%). Pre-operative LESME ratio positively correlated with patients' Hill Grade (p = 0.017) and DeMeester score (r = 0.65, p = 0.009). Pre-operative LESME was not correlated with the LA Grade of esophagitis (p = 0.899).

Conclusions: In Conclusion, UGI imaging is a tool that provides additional anatomic information that correlates with other quantifiable measures of reflux. A high pre-operative LESME ratio greater than 0.5 suggests increased patulousness of the LES and can be used in conjunction with other pre-operative scoring metrics to identify patients that would benefit from anti-reflux surgery.

Efficacy of combined hiatal hernia repair and transoral fundoplication for large paraesophageal hernias

Anna K Gergen, MD; Mihir Wagh, MD; Akshay Pratap; University of Colorado.

Introduction: Fundoplication is a standard component of paraesophageal hernia (PEH) repair. However, performing a fundoplication is technically challenging in large PEH due to a thick sac at the GE junction after it is reduced from the mediastinum. Data is limited on simultaneous transoral fundoplication (TF) and hiatal hernia repair in PEH. We aimed to assess the safety, patient satisfaction, symptom resolution, and proton pump inhibitor use following the hybrid procedure with the third generation EsophyX Z Device (EndoGastric Solutions, Inc). Methods and procedures: All single session hybrid TF combined with laparoscopic hernia repairs performed between June 2017 and September 2020 were evaluated. Data was collected with regards to procedure indication, pre and post-procedure symptoms, PPI use, patient satisfaction, and complications. Hybrid procedure was performed in the operating room under general anesthesia with laparoscopic PEH reduction, no short gastric dissection, mediastinal dissection and diaphragmatic defect repair with biologic mesh followed by endoscopic TF. Introduction: Bulky antireflux prostheses were popularized in the 1970s but were later abandoned due to problems with device migration and erosion. Today's surgeons may not readily recognize complications of these older implants.

Case presentation: An 83-year-old male presented with six months of dysphagia to both solids and liquids, early satiety with occasional non-bilious emesis, and postprandial epigastric pain. He reported a past medical history of Parkinson's disease. His past surgical history consisted of an open appendectomy in the 1940s and a laparoscopic hiatal hernia repair in the late 1980s. Initial workup included routine blood tests, which were unremarkable, and a CT scan, which revealed a foreign body at the diaphragmatic hiatus (Fig. 1) .

Subsequent upper endoscopy and fluoroscopy revealed partial erosion of a foreign body into the stomach (Fig. 2) and malposition of the device below the gastroesophageal junction (Fig. 3) .

Although operative records for his remote original surgery could not be obtained, the foreign body was at this point determined to likely be an Angelchik antireflux device implanted during his hiatal hernia repair. The Angelchik device was a 45 g, fairly rigid, C-shaped silicone prosthesis designed to be secured into a ring around the gastroesophageal junction with a Dacron strap.

Given his surgical history and the device's current position, laparoscopic foreign body removal was planned via a transgastric approach to avoid dissection of the scarred hiatus. The entire anterior surface of the stomach was adherent to the abdominal wall, so a posterior gastrotomy was made to access the device inside the stomach (Fig. 4) .

Its connecting band was cut (Fig. 5) .

so that it behaved linearly; this allowed it to be removed from its pseudocapsule and delivered into the abdomen. The capsule of tissue with foreign body reaction was left in situ, representing an internalized gastro-gastric fistula of sorts (Fig. 6) .

The healthy stomach tissue at the gastrotomy was suture-closed (Fig. 7) . and the device (Fig. 8) .

was removed through a port site.

The patient's recovery was uneventful and he was discharged on postoperative day three tolerating a post-gastrectomy diet. He had full resolution of his symptoms at four weeks after surgery. Conclusions: Although antireflux prostheses like the Angelchik fell out of use decades ago, patients still present with late complications associated with these devices. Indeed, our patient presented over thirty years after implant. Younger surgeons should be aware of these devices and familiar with surgical options for their explantation.

Evaluating the long term integrity of transoral incisionless fundoplication in GERD patients using quantitative measures Marisa Sewell; Michael Murray, MD; University of Nevada, Reno School of Medicine.

Introduction: Gastroesophageal Reflux Disease (GERD) is a spectrum of disorders involving a variety of anatomic alterations that lead to reflux of gastric contents into the esophagus. Treatment typically includes lifestyle modification, medications, and finally procedural correction. Nissen fundoplication has historically been standard procedural treatment for GERD. However, this procedure is invasive and can lead to significant bloat from an overcompetent LES. Transoral Incisionless Fundoplication presents an endoscopic solution to surgical GERD correction and consists of an incomplete fundoplication of 270 degrees or less. TIF may be an option for treatment of GERD patients with limited hiatal hernia (\ 2 cm), distensible LES, and who may desire treatment earlier in the disease process. There is limited objective outcomes data available for TIF; in this study, we retrospectively examine quantitative measures of transesophageal fundoplication success in a small (n = 36) 2 year population of TIF patients. Methods: Patients underwent the TIF procedure with hiatal hernia repair between the years 2014 and 2020. Outcomes include DeMeester score and acid exposure time data obtained through pH probe placed via esophagogastroduodenoscopy (EGD). Data was examined via applied longitudinal analysis using the program SAS with preoperative values as reference. Results: DeMeester score was found to be significantly reduced at 6, 12, and 24 months postoperative (p \ 0.001, p = 0.0131, p = 0.0176) with an average preoperative score of 38 ± 4.5 SEM. Additionally, acid exposure time was also significantly reduced at 6, 12, and 24 months (p \ 0.001, p = 0.0006, p = 0.0036) with an average preoperative value of 11.8 ± 1.3 SEM. Patients were felt to have intact TIF anatomy at time of postoperative EGD evaluation. Conclusion: In this small case series of patients, TIF is an effective antireflux procedure at 6 months and 1 year postoperatively by proxy of Demeester score and acid exposure time. More data is needed to determine the long term integrity of TIF using objective pH data. Introduction: The objective of this study is to demonstrate the safety and feasibility of robotic assisted laparoscopic Roux-en-y gastric bypass for the treatment of massive paraesophageal hernias in the obese population. Paraesophageal hernias are particularly prevalent in the obese population and obesity adversely affects the longterm outcomes of all anti-reflux procedures. Methods and procedures: We performed a single center retrospective review of 16 obese adults between September 2019 and October 2020 who underwent robotic assisted laparoscopic Roux-en-y gastric bypass for the treatment of massive paraesophageal hernia. Massive paraesophageal hernia was defined as greater than 5 cm in a singular direction. We only included patients with a BMI greater than or equal to 30 and excluded patients under the age of 18. We reviewed and analyzed patient demographic data, postoperative symptom relief, weight loss, and postoperative complications. Data was analyzed using descriptive statistics, change from baseline, and comparison of proportions. Results -15 of 16 subjects reviewed were female. Median age was 46 years old and median BMI was 39. 5 (30 -49.26 ). The average size of the paraesophageal hernias on CT imaging was 5.55 9 6.41 9 6.19 cm. Pre-and post-operative symptoms are listed in the table below. Post-operative symptom follow-up was available on 14 of 16 patients. Median excess body weight loss percentage at 1 and 3 months were 15.6% and 36.3%, respectively. Three patients experienced adverse events requiring additional intervention (all Clavien-Dindo IIIa). There were no hernia recurrences or mortality.

Conclusion -This study demonstrates that robotic assisted laparoscopic paraesophageal hernia repair with Roux-en-y gastric bypass in obese patients is safe and feasible. Further investigation is needed to determine efficacy and long-term outcomes compared to standard surgical repair. Introduction: Many disciplines of surgery have demonstrated superior outcomes when a given procedure is performed by a physician who performs said procedure in ''high-volume''. Esophagomyotomy is a commonly performed procedure in the care of patients with achalasia, however it remains to be seen what constitutes the designation of ''high volume'' in this procedure, and if the volume to outcome relationships seen elsewhere apply. We identified all physicians performing esophagomyotomy in the state of Florida over the past five years, stratified them by the number of cases they performed, and examined their outcomes with the hypothesis that high-volume providers will be associated with shorter length of stay and decreased complication rates as compared to low-volume surgeons.

Methods: The 2015-2019 Florida Agency for Health Care Administration (AHCA) Inpatient dataset was queried for esophagomyotomy using ICD10 codes. Surgeons who performed 10 or more procedures during the study period were placed into the high-volume cohort, and those performing \ 10 into the low-volume cohort. Groups were then compared in regard to length of stay, patient disposition at discharge, and a number of postoperative complications. Patient demographics were evaluated using student's t-test and chi square test, p \ 0.05 considered significant.

Results: 662 procedures were identified (45 open, 471 laparoscopic, and 146 robotic), performed by 135 surgeons. The mean number of esophagomyotomies per surgeon was 4.9 over the study period (Range 1-147). The high-volume group (n = 12) performed 362 of the 662 procedures (55%), while the low-volume group (n = 123) performed the remaining 300 (45%). Patients of high-volume physicians had decreased length of stay (1.4 ± 0.8 days vs 4.9 ± 6.7 days, p = 0.01) and were more likely to be discharged to home or self-care following surgery (92.8% vs 86.0, p = 0.04). High volume physicians also had statistically significant differences in rates of urinary tract infection (1.4% vs 4.0%, p = 0.034), postoperative malnutrition (5.8% vs 11.0%, p = 0.015), and postoperative fluid and electrolyte disorders (5.5% vs 13.3%, p \ 0.0001). Conclusion: Surgeons who perform a higher volume of esophagomyotomies per year are associated with decreased patient length of stay, higher likelihood of patient discharge to home or self-care, and decreased rates of some postoperative complications. This research should prompt further inquiry into the role of high-volume centers in foregut surgery.

Is fundoplication necessary after hiatal hernia repair? A systematic review and meta-analysis Background: The laparoscopic approach for hiatal hernias (HH) is well established. There remain areas of controversy in the exact techniques used. One of these areas of controversy is the addition of an anti-reflux operation after large HH repair or in emergency situations. The original reports that indicated that an anti-reflux operation was needed are from the 1990's and were based on either open laparotomy cases or thoracotomies. We evaluated the outcomes of patients with and without fundoplication in the modern era.

Methods: A literature review of available clinical databases was performed. We used PubMed, Clinical Key and Google Scholar. Our search terms were: ''paraesophageal hernia'', ''paraesophageal hernia repair'', ''fundoplication'', ''emergency surgery'', ''no fundoplication''. We also limited our search to publications that had a majority of cases performed laparoscopically, which was from 1997 onwards. We excluded studies that were in languages other than English, abstracts and small case series (less than 10 patients). Pediatric patients were also excluded. Pooled estimates were obtained using the DerSimonian-Laird's random effects model. Results: There were a total of 22 articles included in this study, resulting in a total of 8,708 patients (72% females). Range of age and follow-up period was reported as 52-78 years and 1-132 months respectively. The pooled prevalence of fundoplication use after hiatal hernia was 68% (95% CI: 59%-78% 

The prognostic value of the preoperative neutrophil to lymphocyte ratio in advanced gastric cancer after radical resection: a multi-centre retrospective propensity score-matched study Alpha Ibrahima Balde, PHD; Polyclinique Mia.

Background: Advanced gastric cancer (AGC) has a high morbidity, recurrence rate and a poor prognosis. Although previous studies have reported the role of the neutrophil to lymphocyte ratio (NLR) in AGC, little is known about its impact after radical resection. Methods: A multi-centre, retrospective, 1:1 propensity score-matched study of advanced adenocarcinoma gastric cancer was conducted between 2012 and 2017 based on a cut-off value (2.945) calculated from a receiver operating characteristic (ROC) curve. Results: The recurrence rate was higher in the high NLR group (P \ 0.001). Serosal invasion (p = 0.049) and tumour differentiation (P = 0.011) were different.Univariate analysis showed that high NLR (P \ 0.001) and tumour invasion (P \ 0.001) were related to overall survival (OS). Multivariate analysis revealed that recurrence (p \ 0.001) was independently associated with OS. Well-differentiated tumours (P = 0.027) and a high NLR (P \ 0.001) were associated with recurrence, while the risk of tumour invasion was correlated with a high NLR ( P = 0.001) and stage IIIb (P = 0.043). Clinical assessment of 13.38 (± 9.07)-month revealed that OS (P \ 0.001) and RFS (P \ 0.001) were worse between matched group. Conclusions: These Results suggest that an elevated preoperative NLR could be a strong prognostic indicator for AGC. Keywords: Advanced gastric cancer; Neutrophil to lymphocyte ratio; Propensityscore matching; serosal invasion; Recurrence.

The use of autologous fenestrated cutis autograft in ventral hernia repair using laparoscopic extended totally extraperitoneal (ETEP) technique: a single surgeon case series . Median pre-operative hernia area was 5.9 cm 2 (range 4.0 -1.5 cm 2 ), with mean operating time 51.2 min (SD 34.4 min). A majority of cases (72%) were outpatient, with mean length of stay of 1 day (range 1 -3 days); no patient was discharged with narcotic pain control. Conversion to OVHR was necessary in one case. Overall complication rate was 14.3% (n = 2; mesh-unrelated anterior sheath defect recurrence in one patient and seroma formation in another). Conclusion: To our knowledge, this represents the first case series of robot-assisted hernia defect closure and PPOM using crosslinked biologic tissue for ventral and incisional herniae. Our outcomes-hernia recurrence rate (7.1%), non-recurrence complication rate (7.1%), and absence of infection or mesh explantation-compare favorably to Results using PPOM reported in the literature. Our experience also suggests that patient education and strategic use of XI-S ? crosslinked biologic tissue for hernia repair contributes to desirable patient outcomes.

Laparoscopic hiatal hernia repair: insights from a high-volume center Background: When a hiatal hernia (HH) becomes symptomatic, surgical repair is indicated. The surgical procedure can be safely carried out laparoscopically with good Results. However, it is unclear whether the size of the hernia affects perioperative outcomes. The aim of this study was to assess whether laparoscopic repair of large hiatal hernias (L-HH) has comparable Results to laparoscopic repair of small hernias (S-HH). Methods: After approval from the Institutional Review Board, a prospectively maintained database was reviewed for data on patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). HHs were defined as ''large'' when at least 50% of the stomach was herniated through the hiatus. Data on perioperative Results and mid-term follow-up were analyzed. The Clavien-Dindo (CD) classification was used to define complications. Results: Of 170 identified patients, 55 had L-HH; 115 had S-HH. Mean ages were 72 ± 10 for L-HH and 61 ± 11.3 years for S-HH (p \ 0.001). Median operative time was 95 (IQR, 80-110) and 75 min (IQR, 65-90) for L-HH and S-HH, respectively (p \ 0.001). L-HH patients had longer hospital stays (median 2 vs 1 days, IQR 1-2 for both; p = 0.001) and more complications (12/55 [21.8%] vs 4/115 [3.5%] ; p \ 0.001) than S-HH patients. Two L-HH patients had CD grades IIIb and IVa. At follow-up (20.9 ± 8.7 months), gastroesophageal reflux disease quality of life scores were comparable between groups (6.4 ± 11.7 vs 5.2 ± 0; p = 0.9).

Conclusions: Laparoscopic HH repair is safe and feasible; however, is more technically challenging and is associated with longer operative time, longer hospital stay, and increased morbidity when performed as treatment for L-HH (ie, at least 50% of the stomach herniated through the hiatus). Nonetheless, good quality of life outcomes can be achieved at mid-term follow-up in both patients with S-HH and patients with L-HH who undergo treatment by an experienced surgeon.

Comparative long-term effectiveness between ventral hernia repairs with absorbable and synthetic mesh Introduction: Alternative materials to permanent, synthetic mesh for ventral and incisional hernia repair (VHR) have been developed aiming to decrease incidence of short-term complications and ultimately hernia recurrence. The purpose of this study was to compare the long-term effectiveness of utilizing synthetic mesh versus absorbable mesh for ventral hernia repair. Methods and procedures: With IRB approval, consecutive cases of VHR (CPT codes 49, 560, 49, 561, 49, 565, and 49, 566 with 49, 568) performed between 2013 and 2018 at a single institution were reviewed. Local NSQIP data and electronic medical record review was utilized for demographics, perioperative characteristics, comorbidities, mesh type, defect size, postoperative wound events to six months, duration of follow up, and hernia recurrence. Longevity of repair was measured using Kaplan-Meier method and adjusted Cox proportional hazards regression.

Results: Of the 439 cases included in the analyses, absorbable mesh was used in 101 patients (23%) and synthetic mesh in 338 (77%). On average, absorbable mesh patients were older (57 years, SD = 13) than synthetic mesh patients (52 years, SD = 13; p = 0.008), and ASA Class C III was more common in absorbable mesh cases ( The present study show the lack of dissemination and knowledge of the basic concepts for performing LIHR and the heterogeneity of the surgical decisions. Therefore, it is important to emphasize the dissemination of these concepts and systematize the procedure with the aim of avoiding complications and increase the number of performed procedures.

Sister Mary Joseph's nodule as initial presentation of primary pancreatic adenocarcinoma Audrey Heldreth, MD; Indraneil Mukherjee; Staten Island University Hospital.

Introduction: Metastasis to the umbilicus, known as the Sister Mary Joseph Nodule, is a rare phenomenon, most often seen in gastrointestinal and gynecologic cancers. The prognosis associated with this finding is poor, with a survival of only 13.5% beyond 2 years. Umbilical metastasis in the setting of primary pancreatic adenocarcinoma is even more rare, only occurring in 7-9% of those presenting with Sister Mary Joseph Nodules. The average survival of patients with this finding is less than 4 months, making umbilical metastasis a significant finding to recognize due to the grim nature of the underlying disease course. Case Report: A 68-year-old female with no known history of cancer presented with a non-reducible umbilical bulge with overlying skin changes. She underwent a laparotomy for a suspected strangulated umbilical hernia. On pathology and imaging, it was found to be Sister Mary Joseph Nodule with pancreatic adenocarcinoma as the primary. Conclusion: This case of a primary pancreatic adenocarcinoma, initially managed as a strangulated umbilical hernia, highlights the need to keep umbilical metastasis as part of the clinician's differential. In a patient with no known history of cancer, an umbilical mass may serve as a rare initial presentation of an underlying, and likely advanced, malignant process. The number of case reports describing this phenomenon with a wide range of underlying pathology demonstrates how nonspecific umbilical metastasis is to a particular type of cancer. These findings should prompt clinicians to pursue a comprehensive workup for an underlying malignancy.

Total extraperitoneal (TEP) verus transabdominal preperitoneal (TAPP) repair among patients of inguinal hernia in tertiary care center: a prospective randomised comparative study Arti S Mitra, MS; Unmed Chandak, MS; Prasad Y Bansod, MS; Government Medical college, Nagpur, MAharashtra.

Introduction: Laparoscopic inguinal hernia repair is commonly done by Total extra peritoneal repair (TEP) and Transabdominal preperitoneal repair (TAPP). Both procedures have differences in approach and learning curves. It is important to establish the clinical effectiveness and efficiency of the procedures. In this study, we aim to compare various intra-operative and post-operative outcomes of TEP vs TAPP in patients with inguinal hernia. Material and methods: A prospective comparative study of 2-year duration at a tertiary care teaching hospital where total 80 patients of inguinal hernia underwent either TEP or TAPP. The enrolled patients were alternatively randomised and operated after which they were compared in terms of various intra-operative & postoperative parameters. Early postoperative findings, return to activities, duration of hospital stay, and post-operative complications were assessed. Results: There were 40 patients in each group. TEP Was associated with lower morbidity as compared to TAPP. Various parameters like duration of surgery, intraoperative blood loss, postoperative pain were seen significantly less in TEP as compared to TAPP. There was no need for conversion to open or any adverse intraoperative events noted in both the groups. Local complications and early recurrence was assessed. There was no surgical site infection. Average duration of stay was 3 days for TEP and 4 days in TAPP. Introduction:

The study objective was to analyze hernia recurrence rates of emergent and urgent ventral hernia repairs (VHRs) specifically comparing procedures which used mesh to those without mesh. Decision for emergent and urgent VHRs was driven by acute symptomatology, concern for incarceration and strangulation, and perforation. Methods and procedures: An Institutional Review Board-approved retrospective study of cases of emergent and urgent VHRs performed between 2013-2017 was conducted at a single academic institution. Chart review of an initial National Surgical Quality Improvement Program list of emergent or urgent open VHRs who survived (two deaths) to discharge, N = 94, was performed. Counts of six month post-operative emergency department visits, general surgery clinic visits, hospital readmission, and hernia recurrence were recorded. All patients included in the study were inpatient. Patients were grouped based on mesh utilization in the repair. Preoperative, operative, and outcome variables were compared between mesh groups using Chi-square, Fisher's exact, and t-tests.

Results: In a total of 94 patients, 41 (44%) received mesh and 53 (56%) did not. ASA class (p = 0.016) and bleeding disorder (p = 0.021) were higher in the no mesh group, as were emergent vs. urgent cases (p = \ 0.001). Preoperative SIRS/Sepsis was twice as likely in the no mesh group, and COPD and diabetes were higher as well, but none of these reached statistical significance. Hernia recurrence was higher in the no mesh group vs. the mesh group (24.5% vs. 7.3%, p = 0.03). There was no difference in wound complications (30%), but ED visits occurred almost twice as often in the mesh group (42% vs. 23%, p = 0.071) and general surgery clinic visits following surgery were more frequent with mesh placement ([ 1 visit 61% vs. 24%, p = 0.004).

Conclusions: Emergent and urgent ventral hernia repairs which utilized mesh during the procedure had fewer hernia recurrences compared to procedures without mesh, though no mesh was used in higher risk patients. Patients who received mesh had a higher burden of ED and office visits following surgery. Surgeons should consider the risk of hernia recurrence and advantages of using mesh for emergent hernia repair. More studies are needed to investigate the benefit of mesh in emergent cases.

Propensity score analysis of outcomes between the transabdominal preperitoneal and open Lichtenstein repair techniques for inguinal hernia repair: a single-center experience Alpha Ibrahima Balde, PHD; Polyclinique Mia.

Background: The mechanism of persistent chronic pain after TAPP and OLR remains controversial. Therefore, more prospective and well-designed studies are needed to determine the predictive risk factors that will lead to better pain prevention and possibly elimination. The aim of the present study was to investigate the risk factors of chronic pain after TAPP repair and OLR in a single institution.

Methods: A single-center, retrospective study of propensity score-matched patients who underwent TAPP or OLR surgery between 2008 and 2018 was conducted. To overcome selection bias, we performed 1:1 matching using 6 covariates to generate the propensity score.

Results: A total of 400 patients treated with TAPP and 424 patients treated with OLR were balanced to 400 pairs of matched patients. The patients' age (P \ 0.001), BMI (P \ 0.001), foreign body sensation within 3 months after surgery (P \ 0.001), and persistent sensation loss (P = 0.002) were different between the two groups. The OLR group had a shorter operative time than did the TAPP group (P \ 0.001).

The univariate analysis of factors predicting a difference in VAS between the preoperative assessment and the assessment 3 months after surgery showed that the type of surgery (P = 0.004), hernia grade (P = 0.001), type of mesh (P \ 0.001), presence of scrotal invasion (P = 0.024), and foreign body sensation within 3 months (P = 0.047) were risk factors. Background: Laparoscopic-assisted hiatal hernia (HH) repair has been reported to be safe and feasible. However, uncertainty exists regarding whether asymptomatic large HHs (L-HH) should be treated or if a watch-and-wait strategy should be used. The latter might expose the patient to the risk of progression and gastric incarceration. In this study, we investigated this issue by analyzing perioperative outcomes of patients who underwent HH repair at our high-volume center. Methods: After obtaining approval from the Institutional Review Board, we queried a prospectively maintained database for data on patients who underwent primary minimally invasive HH repair between August 2016 Results: In total, 170 patients met inclusion criteria. Mean age was 58.5 ± 11, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years for S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35), respectively (p \ 0.001). The mean operative time (minutes) increased by group as the HH size increased (69.6 ± 20.9, 83.5 ± 26.1, 99 ± 29.1, and 98.6 ± 24.9, respectively; p \ 0.001). Eight of 35 patients with G-HH (22.9%) were treated urgently due to gastric incarceration. Postoperative complications were significantly more common after L-HH and G-HH repair (Fig. 1 ). CD complications Grade II, IIIb, and IVa were observed only in patients with L-HH or G-HH. There was no mortality.

Conclusions: Patients with L-HH and G-HH are significantly older than those with S-HH or M-HH; this reflects the likely progressive nature of this pathology. Laparoscopic HH repair is associated with higher morbidity in patients with L-HH and G-HH. Furthermore, patients with G-HH are at risk of gastric incarceration, which requires emergency surgery. Our findings suggest that in patients with M-HH (even asymptomatic), a watch-and-wait strategy should be discouraged. Surgical repair, in experienced hands, is preferred. Figure 1 : Percentage of postoperative complications across groups.

Technical considerations for the management of appendicostomyrelated paraconduit hernias Colin G DeLong, MD; Eric M Pauli, MD; Penn State Health.

Introduction: The appendix is utilized as a surgical conduit in procedures such as the Malone antegrade continent enema (ACE) and the Mitrofanoff appendicovesicostomy. The most cited complication of an appendicostomy is stenosis requiring surgical revision. Para-appendicostomy, or paraconduit, hernias are very rarely reported in the literature and their uniquely challenging surgical management has never been detailed. Methods: We describe the case report of an adult patient with an ACE complicated by a para-appendicostomy hernia and discuss the technical considerations of operative repair. Results: The patient was a 58-year-old female with a history of spina bifida who underwent a right-lower quadrant ACE procedure for neurogenic bowel, 5 years prior. After developing a painful but reducible bulge, a CT scan demonstrated the ACE conduit had been formed lateral to the rectus muscle (at the level of the linea semilunaris) with a 2 cm paraconduit hernia containing omental fat. The patient initially underwent an open primary (suture) repair which was complicated by the development of an infected seroma requiring percutaneous drainage. Within one year, the patient developed a recurrent hernia. Consideration was given to resiting the appendicostomy but was deemed too high-risk given a tenuous blood supply. Ultimately, the patient underwent an open repair with bioabsorbable mesh in an onlay position. No recurrence has been noted with 39-month follow-up.

The management of para-appendicostomy hernias presents unique technical challenges. First, given the limited blood supply and small size of the conduit, dissection of the hernia sac and development of the mesh plane must be modified accordingly. Next, because complications such as mesh erosion could cause unsalvageable conduit damage, the selection of repair type must minimize the risk of conduit compromise and need for revision. Finally, several key operative techniques including appendiceal artery palpation, tissue-based repair strategies, and additional mesh fixation can achieve a safe, durable repair.

Robotic assisted laparoscopic repair of Petit's hernia with preperitoneal mesh Benjamin Yglesias, MD; Adam Swiger, DO; Sheetal Nijhawan, MD; Western Reserve Health Education, NEOMED.

Introduction: Lumbar hernias are rare abdominal wall hernias that occur in the posterolateral abdominal wall 1 . Intra-peritoneal or extra-peritoneal contents typically protrude through defects in one of two anatomical triangles. The superior lumbar triangle (Grynfeltt-Lesshaft triangle) is an inverted triangle bordered by the 12th rib superiorly, the internal oblique muscle laterally, and the erector spinae muscle medially 2 . The inferior lumbar triangle (Petit's triangle) is an upright triangle bordered by the iliac crest inferiorly, the external oblique muscle laterally, and the latissimus dorsi muscle medially 3 . Surgical repair has been described via open or laparoscopic approach. In this case report, we describe an incarcerated inferior lumbar hernia secondary to trauma which was repaired via robotic assisted laparoscopic approach with primary closure of the defect and placement of mesh in the preperitoneal space.

Case Report: A 69-year-old male patient presented with right flank pain and swelling. Patient was involved in a motorcycle accident 10 months prior, which likely resulted in the development of a traumatic lumbar hernia which was demonstrated on CT scan.

The hernia was clinically incarcerated, and the defect contains the cecum and ileocecal valve. The defect was noted just superior to the iliac crest, by definition, making this an inferior lumbar hernia or a petit's hernia. The hernia was repaired via robotic assisted laparoscopic transabdominal approach. A peritoneal flap was created exposing the fascial defect.

The fascia was primarily repair with suture. The defect was then reinforced with a 12 cm round polypropylene mesh in the preperitoneal space. Result: The patient tolerated the procedure well with no acute complications. He was discharged the same day as an outpatient with appropriate pain control. Shortterm follow up demonstrated no recurrent hernia present and symptoms resolved. Discussion: Lumbar hernias are a rare occurrence with no gold standard technique for repair. The benefits of laparoscopic approach have been described over the open approach. This case report describes utilizing a minimally invasive approach to primarily repair a lumbar hernia defect while also reinforcing the hernia with mesh in the preperitoneal space. Introduction: Transversus Abdominis Release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TARs are often associated with high healthcare utilization costs, especially in patients with pre-existing comorbidities. While age and BMI alone have been inconsistently linked to increased hospital and operating room (OR) costs, these risk factors effect on health-care costs in patients undergoing TAR have not been studied. Methods: This was a retrospective analysis of patients undergoing either an open or robotic TAR by two fellowship-trained abdominal wall specialists from 1/2018-2/ 2020. Patients were stratified by age (C or \ 60 years) and by both age (C 60) and BMI (\ 30, 30-35, and [ 35) . Demographic information and perioperative clinical data (operating time (OT), length of hospital stay (LOS), and defect size were collected. Cost data ($) for the index hospitalization was obtained from our hospital's Financial Department and included OR supply costs (instruments, implants, etc.) and in-patient costs (room and board (R&B), therapy (occupational/physical), laboratory, intensive care unit (ICU), and pharmacy). Patients undergoing combined procedures or biologic mesh-based repairs were excluded. Continuous data was analyzed with Mann-Whitney U and ANOVA tests and categorical data the Chi-Square test. Results: There were 211 patients included in the analysis (117 were C 60 years). Cohorts stratified by age were well matched (defect size (p = 0.6), BMI (p = 0.4), OT (p = 0.5), LOS (p = 0.4), and percent open procedures (p = 0.3)) as were those stratified by older age and BMI (defect size: p = 0.12; age: 0.55; OT: 0.22; and LOS: 0.50). No differences in cost data were noted in the two cohorts (Tables 1 and 2) . Conclusion: Age and BMI are poor predictors of health-care costs following a TAR. Based on these Results, improved screening criteria is needed to predict health-care cost utilization to better predict age-related risk factors following TAR.

Occult internal hernia causing oral aversion and parenteral nutrition dependence Ahmed M Ali, MD; Ryan Juza, MD; University Hospitals Cleveland Medical Center, Case Western Reserve University.

Introduction: Internal hernias can develop any time following Roux-en-Y reconstruction. They account for \ 1% of acute bowel obstructions but can be life threatening due to strangulation. 2, 3 They rarely present in a chronic fashion.Here we describe a case of occult internal hernia causing chronic abdominal pain and parenteral nutritional dependence. Methods: Herein, we evaluate the presentation and management of delayed recognition of a chronic internal hernia causing chronic abdominal pain, oral aversion requiring chronic total parenteral nutrition (TPN). A 36-year-old male with a history of multiple foregut operations since birth. His index operation was a laparoscopic Nissen fundoplication in childhood resulting in feeding intolerance. He underwent multiple reoperations to correct the feeding intolerance, but ultimately required total gastrectomy with esophagojejunostomy in his 20 s. Following that operation he developed chronic postprandial pain and subsequent oral aversion requiring TPN. Imaging was reportedly non-diagnostic. Endoscopic workup revealed no abnormalities. Splanchnic nerve radiofrequency ablation was attempted without improvement. He was diagnosed with malingering and maintained on TPN. On follow-up, an incisional hernia was found and he was referred to a hernia surgeon for evaluation. Review of CT revealed mesenteric swirling and fecalized small bowel in the left upper quadrant; chronic internal hernia was suspected. (Fig. 2) .

Results: He underwent an exploratory laparotomy revealing herniation of small bowel through Peterson's defect with chronic venous and lymphatic congestion but no ischemia. (Fig. 1) The bowel was reduced and the mesenteric defect closed. A feeding jejunostomy tube was placed and the abdominal wall hernia was repaired. Postoperatively he was started on soft diet and TPN was weaned on post op day (POD) 4. He was discharged on POD 6 on a regular diet with supplemental tube feeds. At one month follow up the patient's nausea and pain had resolved and he was tolerating 100% caloric intake by mouth. His tube feeds were stopped and jejunal feeding tube was discontinued two months post op. At one year follow up the patient continues to take all nutrition orally and his chronic abdominal pain has resolved.

Conclusion: Internal hernias are an increasingly common occurrence as the prevalance of gastrointestinal reconstruction goes up. They can be difficult to diagnose, particularly in a chronic fashion, but carry a high morbidity and mortality. Internal hernia should remain in the differential diagnosis of any patient with gastrointestinal reconstruction who presents with abdominal pain and oral intolerance as failure to diagnosis can have significant consequences. Background: Umbilical hernias are a common condition seen in the primary care setting.Umbilical ultrasound scans (US) have been described as a useful tool and an adjunct for abdominal wall hernia diagnoses.We postulate that an increased number of umbilical US being performed without proper indication as there is limited evidence as to whether routine umbilical US aid in surgical decision-making.The primary outcome of this study is to examine whether umbilical US and/or clinical exam affected surgical management and to what extent. The secondary outcome is to report the frequency of umbilical US ordered prior to general surgeon consultation. Methods: A retrospective chart review was performed on 136 consecutive patients referred to two general surgeons in the Calgary area for umbilical hernias between January 2017 and January 2018.A database was created to record the frequency of umbilical US performed within one year prior to general surgery consultation,presence of umbilical hernia on clinical exam,presence of umbilical hernia on US,and whether the patient proceeded to surgery. We compared the influence of umbilical US and clinical exam on surgical management. Introduction:The risk of developing inguinal hernia increases significantly in the elderly due to loss of strength of the abdominal wall and intra-abdominal conditions. The purpose of this study is to compare the postsurgical complications that occur in patients older and younger than 60 years, after an inguinal hernia plasty. Methods and procedures: Retrospective study of 266 patients who underwent surgery for unilateral or bilateral inguinal hernia with the open Lichtenstein-type technique or the transabdominal preperitoneal laparoscopic technique (TAPP) during the period 2016-2019. In group 1, 173 patients aged 60 years or older were included, in group 2 93 patients who did not exceed that age. The variables studied in the two groups of patients were: repair technique, postoperative complications such as surgical site infection, seroma, hematoma and inguinodynia, and severity according to the Clavien Dindo scale. Results: The TAPP laparoscopic surgical technique was the most applied in both groups, 82.8% in those under 60 years of age and in older adults in 64.7%. The incidence of complications was higher in the group aged C 60 (24%) compared to those B 60 (14%) (P \ 0.03), without significant differences between the groups in surgical site infection and inguinodynia (P \ 0.71). We also found a higher percentage in seroma and hematoma for the C 60 years grup (P \ 0.05). According to the surgical technique there was a lower frequency of complications in the TAPP technique 9.8% (17) compared to the open Lichtenstein technique 13.9% (24) in older adults. There was no significant difference between the complications presented between the adult group older vs \ 60 years group by this technique (P \ 0.98). Finally comparing the severity of complications between the groups with the Clavien Dindo Score there is not difference (P \ 0.32). Conclusion: In this study, it was determined that patients undergoing hernia surgery over 60 years old have more complications. However, there is no difference in the severity of these complications when compared with those of the \ 60 years group according to the Clavien Dindo classification. TAPP surgery is the most widely used in our center and the safest for both groups with a low percentage of complications. Age should not be a contraindication for performing a laparoscopic inguinal hernioplasty. Introduction: There are no reported series describing the incidence of gastrointestinal stromal tumors (GIST) in patients undergoing gastroesophageal reflux disease (GERD) surgery or paraesophageal hernia repair, despite the known prevalence of incidental tumors in the surgical vicinity. The objective of this study is to determine the incidence of subserosal GIST discovered incidentally during primary laparoscopic repair of paraesophageal hernia and GERD related hiatal hernia. Methods and procedures: This is a retrospective, single surgeon study of hiatal hernia surgeries during three consecutive calendar years. The study was reviewed and exempted from approval by the Institutional Review Board. Patient demographics included age, sex, race, and history of cancer. Tumor characteristics included histologic appearance, mitoses per high powered field, C-Kit testing, anatomical location, and tumor size. Results: A total of 184 patients underwent laparoscopic hiatal hernia repair in a three-year calendar timeframe. Of these cases, 121 had surgery performed for GERD and 63 for a paraesophageal hernia. Seven subserosal GIST were discovered, none of which were identified by pre-operative endoscopy. All tumors were classified as lowgrade lesions and confirmed by C-Kit. Median size of the lesions was 0.4 cm. The incidence of GIST was 2.5% and 6.3% among patients undergoing surgery for GERD and paraesophageal hernia, respectively. The overall incidence was 3.8%. GIST was found to be more common with advanced age (P = 0.010). Age was also related to risk of paraesophageal hernia (P = 0.037). The interaction term between age and paraesophageal hernia was found to be insignificant (P = 0.289) using twoway ANOVA analysis. Conclusions: The overall incidence of subserosal GIST is 3.8% in patients undergoing hiatal hernia repair. These are subserosal in location, and only detectable by the surgeon during laparoscopy. It appears that the natural history of this entity increases with age and may be discovered more often during paraesophageal hernia repairs. These tumors have malignant potential and must be recognized and resected. Introduction: Obturator hernias are rare and usually present as a surgical emergency with open primary repair most commonly performed. Given the morbidity and high recurrence of this approach, we reviewed the literature to evaluate the influence of operative approach on obturator hernia repair and whether a staged approach with delayed laparoscopic mesh placement is a viable option. Methods: A literature search via PubMed was performed. Inclusion criteria were studies that: (1) were written in English language and published within the last 10 years; (2) included as keywords ''obturator hernia '' and/or ''incarcerated'' and/or ''strangulated''; (3) reported the operative approach; (4) reported postoperative outcomes. Results: 225 studies were identified, 53 met the inclusion criteria. Data from 425 patients were pooled. Open repair without mesh was performed in 239(56.2%) patients, while 121(28.5%) had open repair with mesh, 44(10.4%) laparoscopic repair with mesh and 21(4.9%) laparoscopic repair without mesh. Open repair had mean hospital length of stay (LOS) of 13.4 days, 40.3% postoperative complications and 9.7% 30-day mortality rate while laparoscopic repair had mean LOS of 7.9 days, 3.1% postoperative complications and no deaths within 30 days. Small bowel resection was performed in 44.7% of open cases and 15.4% with laparoscopic repair. Patients with bowel resection with either open or laparoscopic approach demonstrated higher LOS, complication rate, and 30-day mortality rate compared to patients without bowel resection (17.7d vs 9.5d, 50.9% vs 16%, and 10.9% vs 3.17%, respectively). With patient that did not undergo bowel resection, laparoscopy demonstrated an advantage over open surgery in regard to LOS, complication, and 30-day mortality rate (6.5d vs 12d, 3.6% vs 25.3%, and 0% vs 5.6%, respectively). The overall recurrence rate was 7.7% with a mean follow up of 20.4 months. Only one recurrence was reported in mesh repair (0.7%), while 28 (12.1%) were reported with tissue repair. Conclusion: Laparoscopic obturator hernia repair is associated with enhanced postoperative recovery and the use of mesh was associated with less recurrence. Given that obturator hernias are most commonly repaired open without mesh, a staged elective laparoscopic repair with mesh should be considered to minimize recurrences, morbidity, and mortality. Objective: Component separation is performed for large complex ventral/incisional hernia repairs. Creating large myofascial flaps can be challenging. We investigated factors associated with reoperation within 30 days after such procedures. Methods: National Surgical Quality Improvement Program (NSQIP) database was queried between 2012-2018 to identify adult patients that underwent component separation (CPT 15, 734) for incisional/ventral hernias. Emergency and outpatient procedures were excluded. Patients that underwent other major abdominal procedures were excluded. Patients requiring reoperation within 30 days related to the index procedure were assessed. Factors identified on univariate analysis (p \ 0.1) were included in a multivariable logistic regression to recognize independent predictors of reoperation (p \ 0.05). Results: We identified 9417 patients (6.3%) that underwent component separation out of 148,434 patients with ventral/incisional hernias. Of these, 428 (4.5%) underwent reoperation within 30 days. Most common were wound related reoperations (53%). On univariate analysis, we found ASA, BMI, smoking status, operative time, wound class and specialty were associated with reoperation (Table) . On multivariable analysis, current smoker status -OR 1.62, p \ 0.001, increasing operative time -OR 1.0015, p \ 0.001, and increasing BMI -OR 1.03, p \ 0.001 were independent positive predictors whereas plastic surgeon performed procedure -OR 0.68, p = 0.04 was a negative predictor of reoperation. Conclusion: Wound related reoperations were most common within 30 days after component seperation. Smoking status, operative time, BMI and surgical specialty are independent drivers of reoperation. Introduction:Diaphragmatic hernias in adults are usually traumatic rarely it may be the late presentation of a congenital diaphramatic hernia( 2-3%), they are basically rare types found in adults. Based on the anatomic site of hernia it can be bochdalek(80-90%), morgagni (2-3%) ,larrey hernia, other anterior and central tendon defects,eventeration with gastric volvulus. It usually presents with non specific symptoms in adults like dyspnoea, cough, recurrent chest infection and rarely as life threatening emergencies like obstruction /perforation/ strangulation. Methods:A retrospective study of rare types of diaphragmatic hernia in adults presented to us in a period of five years was done. It included 2 larrys, 2 morgagini and 3 eventeration with gastric volvulus. All of them were managed laparoscopicaly. Preoperatively all the patients underwent adequate workup to find out the type, content and severity of the hernia. Postoperative follow up was done in all the cases.

Results:Laparoscopic management of rare types of diaphramatic hernia repair was the preferred choice in all the cases. Among which 2 were morgagini, 2 were larreys and 3 were diaphragmatic eventration with gastric volvulus. All the defects were repaired with dual mesh. All the patients were followed up postoperatively and was found to have an uneventful postoperative period.

Conclusion:Laparoscopic management of rare types of diaphragmatic hernia is a safe approach and should be the procedure of choice as it gives an excellent overview of the defect, safe reduction of content under vision and perfect repair of the defect with mesh hernioplasty. The recovery time is very short and the patient can return to work on post operative day 3. It avoids problems associated with long incisions requred in the open surgery.

Safety and feasibility of performing benign foregut procedures at a safety-net hospital Introduction: One-half of Americans have limited access to healthcare due to a variety of socioeconomic barriers. Care of these patients is often through safety-net hospitals, which are associated with worse medical outcomes. The aim of this study is to compare the outcomes of patients who received foregut surgery at a safety-net hospital to those at a private hospital or University hospital. We hypothesized that patients who receive surgery at a safety-net hospital will have a greater rate of radiographic recurrence and reoperations. Methods and procedures: A retrospective study was conducted on adult patients who underwent hiatal hernia repair or fundoplication for gastroesophageal reflux disease (GERD) at an affiliated safety-net hospital, private hospital, or University hospital from June 2015 to May 2020. Any patient undergoing concomitant gastrectomy, bariatric surgery, or myotomy were excluded. The primary outcome was radiographic recurrence. Secondary outcomes included reoperation and symptom recurrence. Analysis was performed using ANOVA, chi-square, and logistic regression.

Results: A total of 499 patients were identified: 157 at a safety-net hospital, 233 at a private hospital, and 119 at a University hospital. Median (interquartile range) follow-up was 16 (13) months. Compared to the other hospitals, the safety-net hospital had more Hispanics, females, and patients with comorbid conditions. In addition, large hiatal hernias were more common at the safety-net hospital and private hospital. Robotic surgery was performed more frequently at the University hospital. There was no difference in radiographic recurrence (13.4% vs 19.7% vs 17.6%, p = 0.269), reoperation (3.8% vs 7.2% vs 6.7%, p = 0.389) or recurrence of dysphagia symptoms (15.3% vs 12.6% vs 15.1%, p = 0.696). On logistic regression, there were no differences in outcomes among the three institutions (Table) .

Conclusion: This study suggests that despite the challenges faced at safety-net hospitals, it is feasible to safely perform minimally invasive foregut surgery with similar outcomes to private and University hospitals. Introduction: Umbilical Hernia is a common ventral hernia in adult population. Classical approach was represented by open repair, but during recent years laparoscopic treatment is increasingly adopted and it can present some intraoperative and post-operative advantages. Materials and methods: We retrospectively analysed 31 laparoscopic primary and incisional umbilical hernia repairs performed between 1 January 2018 to 1 January 2020. We collected data concerning age, sex, hernia defect size, operative time and complications according Clavien-Dindo Classification, recurrence at 6 months and 1 year follow up. All procedures were performed in Department of General Surgery of Civil Hospital in Adria (ULSS5 POLESANA-Rovigo Background: Microaspirations of gastric contents from reflux has been shown to allow entrance of gastric flora in the lungs, altering oropharyngeal and lung microflora when microflora immigration exceeds the patient's capacity for elimination by host defenses, cough, and microciliary clearance. Increasing reflux increases microaspiration and has been implicated in chronic lung disease exacerbations as repeated reflux leads to respiratory dysbiosis and a perpetual cycle of inflammation and microflora distortion. Reflux occurs commonly in patients with chronic lung diseases including Cystic Fibrosis (CF) and Interstitial Lung Disease (ILD) as frequent forceful coughing increases intra-abdominal pressure and the risk for recurrent reflux. Common surgical treatments for reflux include laparoscopic fundoplication. The purpose of this study was to observe the role of reflux and microaspiration on lung function and respiratory-related exacerbations and hospitalizations in patients with CF and ILD before and after laparoscopic fundoplication.

Methods: A retrospective cohort study of patients that had undergone laparoscopic fundoplication from 2009-2018 at a single institution was performed. Data were collected on baseline variables, lung function, days of respiratory-related hospitalization, and pharmacology used during respiratory-related hospitalizations. The Results of ILD patients and CF patients were compared. The patients were examined preoperatively for positive DeMeester scores and received either laparoscopic Nissen or Toupet fundoplication. The number of hospitalizations related to pulmonary complications, antibiotic use for lung infections, and lung function were followed for one year prior and one-year post repair. Results: Data from 21 patients (12 with CF and 9 with ILD) that met inclusion criteria was analyzed. In measures of lung function, the CF average preoperative FEV was 1.9 and postoperative 1.7; the average ILD preoperative FEV was 76.0 and postoperative 74.4 (p = 0.501 According to the current guidelines, the repair of bilateral inguinal hernia should be performed by an endoscopic method. The TAPP procedure is a laparoscopic approach that allows the surgeon to recognize and repair a hernia on the other side during a unilateral hernia procedure. In laparoscopic hernia procedure stage I and II, the mesh does not require fixation, whereas mesh fixation in Lichtenstein procedures is a standard. Both methods are comparable in terms of the rate of recurrences and perioperative complications.

The aim of the study is to compare the quality of life and the number of recurrences after bilateral inguinal hernia repair with TAPP and Liechtenstein procedures. Materials and methods: A retrospective analysis of 83 men with primary bilateral inguinal hernia operated between years 2016 and 2019 was performed. All patients were admitted to the hospital on the day of surgery. Epidemiological data, time of surgery, perioperative complications and time of hospitalization were analysed. Based on the telephone survey, data was obtained regarding the incidence of hernia recurrences and the quality of life assessed using the Carolinas Comfort Scale (CCS) and Short Form 36 (SF-36). Results: Bilateral inguinal hernia was simultaneously repaired in 52 patients performing TAPP and 31 performing Lichtenstein procedures. The average age of the patient was 54.2 years. Bilateral TAPP surgery time was shorter than the Liechtenstein method (52 vs 67 min) (p = 0.003). The mean hospitalization time in TAPP patients was 16 h and in Liechtenstein patients 21 h (p \ 0.05). One patient suffered from peritoneal bleeding after TAPP surgery, which was repaired laparoscopically. Hernia recurrence was observed in 2 patients after the TAPP method and 1 after the Liechtenstein method. Postoperative pain one week after surgery was reported in 11 patients (21%) after TAPP and in 13 (42%) after Liechtenstein. The average CCS and SF-36 Results one year after surgery were comparable. Conclusions: Bilateral inguinal hernia surgery using the TAPP method is faster and gives less pain in the perioperative period compared to the Liechtenstein method. The hospital stay is also shorter. The quality of life of patients in long follow-up is similar. The TAPP method is feasible in pateints with bilateral inguinal hernias.

Comparing perioperative outcomes and 1-year follow-up for primary and redo fundoplication surgery Komeil Mirzaei Baboli, MD; Deepika Razia, MD; Sumeet Mittal, MD; Norton Thoracic Institute.

Background: Laparoscopic anti-reflux surgery is the gold standard for symptomatic hiatal hernia. The aim of this study was to report perioperative outcomes and 1-year GERD-HRQL scores for primary and redo fundoplication. Methods: After IRB approval, a prospectively maintained esophageal surgery database was retrospectively reviewed to identify patients who underwent primary and redo fundoplication from September 2016 to July 2020. We retrieved perioperative outcomes (operative time, length of hospital stay, intraoperative and postoperative complications) along with GERD-HRQL scores at annual follow-up. Results: A total 246 patients (210 primary and 36 redo fundoplication) were included. Conversion rate was 0.47% in the primary group and 8.3% in the redo group (p = 0.001). There was significantly lower operative time, length of hospital stay, and ICU stay in the primary group. The rate of intraoperative and postoperative complications (Clavien-Dindo C II) in the primary group was significantly lower than the redo group (1.9% vs. 25% and 2.9% vs. 11%, respectively). There was significant and similar improvement of GERD-HRQL scores in both groups at 1 year after surgery (Table 1) . Conclusion: As we expected, perioperative measures were worse in the redo surgery group; however, the reoperation was as effective as primary surgery in improvement of HRQL score at 1 year after surgery. Results: Post-operative pain, surgical site infections and seromas did not differ between the totally laparoscopic and hybrid approach. The recurrence rates were 5.8% and 6.8% for the laparoscopic and hybrid group respectively, which were not significantly different. The time to recurrence was 15 months (range 8-12) in the laparoscopic group and 7 months (range 6-36) in the hybrid group, also not significantly different. The hernia defect size and BMI were significantly higher in the hybrid group, without increased wound complications. Conclusion: These Results suggest that open defect closure is a safe alternative to totally laparoscopic closure, and can be a helpful alternative in patients with higher BMI and larger hernia defects. The hybrid approach involves a less technically demanding fascial closure method combined with the benefits of laparoscopy for wide mesh overlap.

Comparing perioperative outcomes and 1-year follow-up for primary paraesophageal hernia repair surgery between mesh and non-mesh group Komeil Mirzaei Baboli, MD; Deepika Razia, MD; Sumeet K Mittal, MD; Norton Thoracic Institute.

Background: Recurrent hiatus hernia is the Achilles heel of antireflux surgery (ARS). Use of mesh for hiatus reinforcement has been debated. The aim of this study is to report perioperative outcomes, GERD-HRQL score, and recurrence rate at 1 year after surgery in patients with and without use of Bio-A mesh for hiatus reinforcement.

Methods: After IRB approval, our esophageal surgery database was retrospectively reviewed. Patients who underwent primary surgery for paraesophageal hiatal hernia from September 2016 to July 2020 were divided into 2 groups: mesh and non-mesh. We retrieved perioperative outcomes (operative time, length of hospital stay, intraoperative and postoperative complications) along with barium swallow/endoscopy findings, and GERD-HRQL scores at annual follow-up. Hernia repair using synthetic or biologic mesh materials can provide significant durability and longevity to the repair of defects in the abdominal wall and inguinal region. However, negative publicity surrounding the rates of recurrence and complications has lead to a rash of recent lawsuits, patient hesitancy, and increased dissatisfaction with repairs involving mesh. While the choice of mesh in elective hernia repair has traditionally been left to the discretion of the surgeon, the implementation of Shared Decision Making (SDM) has demonstrated favorable Results in regards to improving patient satisfaction with surgery.

In this study, we investigate the effect of implementing SDM into the selection of mesh material for elective hernia repair, specifically focusing on patient confidence in deciding to have surgery, as well as its influence on reassuring patients who are aware of negative publicity surround their mesh.

This study utilized a retrospective review from a single private-practice surgeon specializing in hernia repair. 325 patients were delivered an anonymous, depersonalized Qualtrics link, with instructions to complete a short anonymous online survey. Patients received surgical care of femoral, inguinal, and ventral hernias, and participated in SDM to select either a completely absorbable biologic mesh (Phasix), a completely synthetic nonabsorbable mesh (Bard), or a semi-absorbable biologic scaffold (Ovitex) for their hernia repair. Compared to the traditional approach of having a surgeon make the decision for them, SDM did not make patients feel any more uncomfortable with surgery in 97% of patients, even with knowledge of the lawsuits and risks associated with their mesh material. A majority (66%) of these patients felt SDM actually allowed them to be more comfortable and content with their decision to have surgery, compared to having the surgeon choose. 89% of patients agreed that SDM allowed them to make a more informed, and overall better decision to have hernia repair surgery.

These Results demonstrate that a large majority of patients find SDM to be beneficial in choosing to have surgery, and may help mitigate patient hesitancy with surgical and medical treatments that garner negative press. In an era of where misinformation can be propagated quickly and widely through social medial, SDM may serve as a valuable tool in surgery, not only in educating patients about their treatment, but also cultivating trust with physicians, and increasing patient satisfaction with the care they receive. Introduction: Flank hernias due to trauma are rare and challenging, but are more common than was previously recognized. There is a lack of consensus on the surgical management of flank hernias in trauma. The majority of studies on flank hernias are in the setting of blunt abdominal trauma, however, there exists a paucity of literature in penetrating trauma. Case presentation: We present a case report of a 39-year old male with a persistent left flank hernia after sustaining a penetrating abdominal wall trauma with a tree branch two years prior, and with multiple subsequent reconstructive surgeries including both open and minimally invasive approaches. Discussion: This case demonstrates the complexities of the traumatic flank hernia repair. Flank hernia repair is most commonly accomplished via mesh, can be done either open or minimally invasive, and may be done either at the time of trauma or delayed to a later time. Early detection and appropriately timed intervention remain paramount to positive outcomes. There is a developing school of thought that supports early non-operative management of traumatic hernias, and delaying surgical intervention when only symptomatic, as was the case in this patient. Keywords: flank hernia, trauma, abdominal wall, management, surgical.

Impact of the surgical repair in type IV paraesophageal hernias Introduction: Paraoesophageal hernias (Types II-III-IV) account for about 5% of hiatal hernias (HH) of which the most common type is type I hernia (95%). The peculiarity of PEH is the presence of a herniated sac that contains a more or less important part of the stomach, along with other abdominal organs in type IV. Surgical treatment is more complex since it requires a reduction not only of the herniated content but also the ''container'', namely the sac adherent to mediastinal structures. The difficulty of PEH repair is therefore related to the size of the hernia and to the potential complications of the herniated organs that can lead to visceral perforation, such as gastric volvulus, incarceration or strangulation. Type IV hernias are generally the largest and therefore potentially the most difficult to treat also due to the presence of additional herniated organs. Since type III and IV are mostly grouped together as large PEH the literature lacks in providing clear surgical outcomes and a management algorithm in type IV. This study aims to compare the outcomes in hernia type IV vs type III after surgical repair. Methods: Retrospective study of patients who underwent laparoscopic PEH hernia repair (LPEHR) in a single institution between 2006 and 2020. Patient baseline characteristics and surgical outcomes were analyzed. A subanalysis according to the hernia type was performed in order to identify the peculiarities of type IV PEH. Results: A total of 104 patients were included in the analysis. Patients presenting with type IV PEH (12/104) were significantly older than patients with type III (92/ 104) (75.25 ± 7.15, 67.02 ± 13.57 respectively (p = 0.044), more fragile with a higher Charlson Comorbidity Index (CCI) (4.25 ± 1.48, 2.98 ± 1.716, for type IV and III PEH respectively (p = 0.033)). Emergency repair for gastric volvulus was more frequent (25%) as compared to type III (9.78% p = 0.609). Operative time was significantly longer (type IV 243 ± 101.73 vs. type III 133.83 ± 60.91, p = 0.002) and postoperative morbidity was significantly higher in Type IV repair (6/12 (50%) vs 8/92 (8.7%) type III, p = 0.002). Conclusion: Patients with Type IV PEH appear to be older and frailer. The higher incidence of post-operative complications in patients with type IV PEH should advocate for careful indication for surgical treatment which should be performed in centers of expertise. Keywords: paraesophageal hernia; PEH; type IV; fundoplication; outcomes; complication; Nissen; esophageal lengthening; emergency surgery; gastric volvulus.

Should laparoscopic hernia repair be avoided in COPD patients?

Ashley L Chinn, MD; Dylan Russell, MD; Christopher Yheulon, MD; Tripler Army Medical Center.

Introduction: Laparoscopic approach is often avoided in chronic obstructive pulmonary disease (COPD) patients due to concern for increased risk of perioperative complications. The purpose of this study is to determine if there is a difference in outcomes between laparoscopic and open procedures for inguinal hernia patients with COPD. Methods and procedures: Data from the American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005-2018. COPD patients undergoing inguinal hernia repair were compared based on approach (open versus laparoscopic). The two groups were propensity score matched on demographic data and pre-operative risk factors. The primary endpoint was a composite outcome of major morbidity or death based on documented post-operative outcomes within the NSQIP database. Secondary endpoints were respiratory complications including post-operative pneumonia, failure to wean off the ventilator, and reintubation. Background: Opioid dependency and abuse is a prevailing issue in our nation that afflicts many patients of various backgrounds. One common use of opioid therapy is pain management following inguinal hernia repair. As the U.S. population ages rapidly, the proportion of elderly patients undergoing elective surgeries, such as inguinal hernia repair, has increased greatly. Previous studies have reported on opioid prescribing patterns for other procedures, but there remains a paucity of data surrounding unused opioid prescriptions and implications for elderly inguinal hernia patients. Methods: The 2013-2020 Abdominal Core Health Quality Collaborative (ACHQC) database was used to identify patients aged 65 or older undergoing inguinal hernia repair at a single institution who had both baseline and 30-day patient-reported outcomes data available. Patients were then re-identified for chart review to compare patient-reported postoperative opioid use to discharge prescriptions documented in the electronic medical record (EMR). Results: A total of 36 elderly patients undergoing inguinal hernia repair were included in the study. The analytic cohort was all male (100%) with a mean age of 71.2 years (± 5.7). The majority of the sample was white (n = 33, 91.7%) and had a mild (n = 12, 33.3%) or moderate (n = 19, 52.9%) ASA disease classification. All hernias were primary (n = 36, 100%). The most common opioid prescriptions were oxycodone (n = 24, 70.6%) and codeine (n = 8, 23.5%). 1 patient (2.9%) received hydrocodone and 1 patient received tramadol (2.9%). The mean number of opioid tablets prescribed was 11.6 (4.7), with nearly one quarter of the study sample (7, 20.6%) receiving a prescription of 16 pills or more. However, 23 patients (67.6%) reported taking 0 of their prescribed opioids after surgery, with another 8 (23.6%) reporting only taking 1-4 tablets. The mean morphine equivalent dose prescribed was 78.1 units (SD = 34.3).

Conclusions: This study found that nearly every elderly patient undergoing inguinal hernia repair were prescribed more opioids than they ended up taking. Over 90% of patients in this study took less than 4 tablets of their opioid prescription, despite receiving an average prescription of nearly 4 times that amount. As the opioid epidemic continues to raise significant public health concerns in the United States, there is a need to explore opioid-free alternatives in healthcare. Future studies should examine the efficacy of alternative pain management alternatives following inguinal hernia repair particularly in the vulnerable, older patient population. Introduction: Morgagni hernias are a rare form of congenital diaphragmatic hernia, commonly found on cross sectional imaging performed for complaints of pulmonary or gastrointestinal symptoms, and repaired electively. We report our acutely symptomatic case repaired urgently, along with eight previous cases repaired electively. The hernia contents included stomach, omentum, and transverse colon. All repairs involved primary tissue repair of the diaphragm with mesh reinforcement. The patients generally did well, were discharged one to two days post-operatively, and have no reported complications. Methods and procedures: A PubMed search was performed to find all reported adult cases of trans-abdominal Morgagni hernia repair in using a Robotic platform (DaVinci Xi, Intuitive, Sunnyvale, CA). We collected the presentation, technique, complications, and Results of all cases. Results: In our case, a 72 y/o female presented acutely with gastric obstruction. Two months prior she had a small bowel obstruction, underwent CT, diagnostic laparoscopy, lysis of adhesions, and takedown of the falciform ligament. At that operation a ''groove'' to the left of the falciform was noted, photographed, but not repaired. A follow up CT 11 days later showed no herniation into the defect. Upon re-presentation, her CT showed a Morgagni hernia with incarcerated left hepatic lobe and gastric antrum. NG decompression improved her symptoms. She was explored, found to have auto-reduced her stomach, but her liver required surgical reduction. There was no hernia sac, allowing free communication between the abdomen and right chest. The defect was sutured and reinforced with a coated mesh. She did well and was discharged postoperative day one. Our search found eight prior cases of robotic trans-abdominal Morgagni hernia repair. All were performed electively for a combination of pulmonary and foregut symptoms. Most cases are right sided and include herniated stomach, omentum, and/ or transverse colon and were repaired with mesh. There were no significant reported complications and patients were typically discharged within one to two days. Conclusions: A trans-abdominal, robotic-assisted tissue repair of the diaphragm with mesh reinforcement appears to be safe and effective for the Morgagni-type hernia. The robotic platform offers additional degrees of freedom, making retrosternal operating more ergonomic to the surgeon. The rapid progression of our patient to an acutely symptomatic hernia suggests caution should be advised when encountering incidental small diaphragmatic defects. Repair at the time of discovery should be considered so that the serious complications associated with incarceration might be avoided.

The role of routine groin ultrasounds in the management of inguinal hernias Gabriel Marcil; Jennifer Schendel; Ryan Tong; Philipp Mitchell; Neal Church; Artan Reso; Richdeep S. Gill; Estifanos Debru; University of Calgary.

Background: The diagnosis of inguinal hernias has historically been made through a thorough history and clinical exam.Recently, groin ultrasound scans (US) have been used as an adjunct to inguinal hernia diagnoses. However,there is limited evidence as to whether this affects surgical management. Objectives: The primary aim of this study is to examine whether groin US affect surgical management of inguinal hernias.The secondary goal is to estimate the frequency of groin US ordered prior to general surgery consultation. Methods: A chart review of 400 consecutive patients referred between January 2014 and January 2015 to four general surgeons in Calgary, Alberta, Canada for inguinal hernias was used to create a database for retrospective data analysis.For patients who were evaluated for bilateral groin hernias,each groin was entered as a separate entry into the database.The role of the clinical exam and groin US on surgical decision making was compared. Results: In 400 patients,476 groins were evaluated for a hernia.354 (88.5%) of the patients were male,46 (11.5%) were female and the mean age was 53.5 years old.-The frequency of groin US prior to general surgery consultation was 336/476(70.6%).Of the 476 groins evaluated for a hernia, 364/476(76.5%)were found to be clinically palpable.Out of the clinically palpable hernias,220/364 (62.9%) had a pre-consultation groin US.111 groins did not have a clinically palpable hernia(23.3%) and 103 of those 111 groins underwent a pre-consultation groin US (92.8%). A total of 315/476(66.2%) groins underwent an inguinal hernia repair. Of the clinically palpable hernias, 308/364(84.6%) proceeded to surgery. The frequency of clinically negative hernia but positive groin US finding that proceeded to surgery was 5/103(4.85%). 2/5(40%) of these patients had an inguinal hernia found in the operating room.There were no instances in which patients with non-palpable groin hernias and negative groin US findings proceeded to surgery.

Overall, decision to proceed with surgery based on clinical exam findings occurred 390/476 (81.9%) of the time. In comparison, decision to proceed with surgery based on groin US findings alone occurred 5/336 (1.48%) of the time. Conclusions: Groin US before inguinal hernia consultations are frequently being performed. However, the routine use of these scans in this context is unnecessary, as they infrequently affect the decision to treat surgically. Findings on clinical exam play a larger role in surgical decision-making than groin US Results. The cost associated with routine groin US is dramatic and as they do not significantly change surgical management most of the time, resources should be allocated elsewhere accordingly.

Transversus abdominis plane blocks for complex abdominal wall reconstruction decrease hospital length of stay compared to epidurals N L Petcka; K Alter-Troilo; E Hetzel; R M Higgins; K L Lak; J C Gould; T L Kindel; A S Kastenmeier; M I Goldblatt; Medical College of Wisconsin.

Background: Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM. Methods: A retrospective review of all patients who underwent an open ventral hernia repair with retrorectus mesh between 2016 and 2020 was conducted. Component separation, type of mesh, and type of pain regimen was at the discretion of the surgeons; however, liposomal bupivacaine only became available at our institution in 2019. LOS was used as the primary outcome. Secondary outcomes included postoperative pain and 90-day post-operative complications. Patients were also evaluated for previous hernias repairs and procedural details including component separation and mesh explantation. Results: An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. Significant comorbidity differences between the groups included chronic kidney disease, diabetes mellitus, and inflammatory bowel disease. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min, p \ 0.05) and larger area of mesh (461.85 vs. 338.17 cm 2 , p \ 0.05) when compared to the TAP block group. Hernia size, number of previous repairs, the need for component separation or mesh explanation, age, body mass index, sex, ethnicity, and wound classification were all similar. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; p \ 0.05). There was no statistical difference between the IVPM group and the TAP block group or epidural group. There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores, measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50, p \ 0.05). Conclusions: Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs.

Cory Banaschak, DO 1 ; Paul Szotek, MD 2 ; 1 Ascension St. Vincent Hospital; 2 Indiana Hernia Center. The objective of this study is to evaluate the outcomes of the reinforced biologic augmented repair (ReBAR) during robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair.

All patients with inguinal hernias undergoing rTAPP by a single surgeon at least 1 year out from repair were identified. Patients that received placement of the same reinforced biologic mesh were selected for review. Patients with prior hernia repairs and patients with bilateral repairs were also included. All repairs were completed utilizing the same rTAPP technique which included placement of a permanent anchoring stich in Cooper's ligament and two interrupted anchoring sutures on the anterior abdominal wall for fixation after deployment of the mesh. All patients were followed post-operatively utilizing a HIPAA compliant two-way messaging application for communication between the patient and surgeon regarding postoperative management and any concerns that developed at any time post-operatively.

From June 2018 to September 2019, a total of 86 patients undergoing the robotic assisted ReBAR of their inguinal hernias were identified. Of these patients, 6 had previously undergone repair. There were 30 left, 31 right, and 25 bilateral inguinal hernias, for a total of 111 repaired hernias. Some patients also had simultaneous repair of other conditions at the time of rTAPP, including ventral hernia repair (n = 7), hydrocelectomy (n = 6), and mesh or plug excision (n = 2). The mean follow-up duration was 374 days. During this period, 3 patients (2.7%) have been identified to develop recurrence. Also of note, 1 seroma required drainage and there was 1 small bowel obstruction in the immediate post-operative period.

These 111 inguinal hernia repairs are at least 1 year out from rTAPP repair utilizing the same reinforced biologic mesh. In this cohort, 2 hernias recurred almost immediately postoperatively. Interestingly, their initial operations were done within 3 days of each other. As every case was recorded, root cause analysis demonstrated technical variations of these two cases. One case had an improper mesh cut, and the other lacked a lateral fixation suture. The third recurrence took place 345 days postoperatively. Overall, a 2.7% recurrence rate is below many reported recurrence rates for laparoscopic inguinal hernia repair, of which many use a permanent synthetic mesh. In Conclusion, the use of a reinforced biologic mesh appears to be a viable option for rTAPP inguinal hernia repairs in patients who desire the minimally invasive technique while avoiding traditional permanent synthetic mesh. Continued long term follow up is warranted.

The use of fibrin sealant versus suture for mesh reinforcement in ventral hernia repairs Satya S Dalavayi, MD; Margaret Plymale; Crystal Totten, MD; Daniel L Davenport, PhD; J S Roth, MD; University of Kentucky.

Introduction: Large ventral hernia defects are commonly repaired with mesh reinforcement. Suture has predominantly been used for fixation due to accessibility, cost, and outcomes. A newer strategy has been the use of fibrin sealant for mesh fixation rather than suture and/or staples. There is growing evidence to suggest that fibrin sealant is associated with lower incidence of postoperative pain and comparable rates of recurrence in inguinal hernia repairs. However, there is a paucity of data to show similar outcomes with lower rates of postoperative pain in ventral hernia repairs. Analyzing the postoperative course following ventral hernia repairs with either the suture fixation or fibrin sealant will allow for better decision-making, fewer complications, and reduced healthcare costs. Methods and procedures: Patient chart data and National Surgery Quality Improvement Program (NSQIP) was used to retrospectively evaluate outcomes. The primary outcomes evaluated were recurrence rate, postoperative pain, seroma formation, drain output, surgical site infection, and abscess formation. Results: There were 135 patients included in the study, with 100 patients in the suture fixation group and 35 patients in the fibrin sealant group. There was no statistically significant difference between recurrence rate, surgical site infections, and pain control. There was 1 patient from each of the fibrin and suture group with a recurrence upon follow-up (p = 0.453) and no difference in drain output within the first 4 postoperative days. Conclusions: The use of fibrin sealant did not show any significant difference in primary outcomes compared to suture fixation. Due to the comparable outcomes, these Results warrant a prospective study to further evaluate cost effectiveness and value. Introduction: Parastomal hernias occur in up to 60% of ostomies, yet there is limited literature comparing open and laparoscopic repair techniques. The effects of ostomy revision and/or reversal versus stand-alone hernia repair on short-term outcomes are also not well described. The primary objective of our study is to compare short-term outcomes of laparoscopic vs. open parastomal hernia (PSH) repair and secondarily to determine whether revision/reversal affects these outcomes. Methods and procedures: The ACS-NSQIP database (2015-2018) was used to identify patients with an ICD-10 diagnosis of PSH undergoing a laparoscopic or open hernia repair. Given the differences in preoperative characteristics, coarsened exact matching was utilized to match the two groups. Outcomes such as morbidity, surgical site infection (SSI), length of stay (LOS), and operative times were compared. Multivariate logistic regression was performed on the entire group to determine whether revision/reversal is associated with SSI. Introduction: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is inferior to transabdominal preperitoneal (TAPP) repair from the perspective of minimal invasiveness and fascial anatomy clarity. To overcome these issues, we devised a TEP procedure that uses 5-mm ports. Methods: At the lower umbilical region, a small incision was made to the anterior lobe of the rectus abdominis sheath. A 5-mm visualizing trocar with a balloon was advanced, laterally avoiding the rectus abdominis. Confirmation of the characteristic pattern of the attenuated posterior rectus sheath (APRS) facilitated instantaneous access to its anterior aspect. A second 5-mm port is inserted at the lower abdominal midline after insufflation. In unilateral cases, an approach from the lateral aspect is taken. With a one-handed operation, the front aspect of the APRS is dissected to the side, up to the Spigelian line (SL). Further dissection in the direction of internal inguinal ring (IR) along the SL reveals a membrane-like structure that runs ventromedially between the inferior epigastric vessels and IR.

The APRS, which is thin and translucent around the structure, is incised to enter the PS up to the anterior superior iliac spine along the SL. A third port is then inserted and the hernia sac is treated with a two-handed operation. After parietalization of the spermatic cord components, the inner fascia is treated, as minimally as possible, to match the prosthetic mesh.

For bilateral cases, an approach from the medial aspect is taken. From the second port inserted up to the arcuate line, the APRS near the white line is incised using an electric scalpel. Subsequently, with a camera inserted from the second port, the PS is bluntly dissected to the lower umbilical region. The umbilical trocar is advanced dorsal to the APRS and a third port is added to the suprapubic region. Thereafter, preperitoneal space dissection is performed to treat the hernia sac.

The mesh is rolled and stored in the Penrose drain, and is pulled into the dissected cavity with care from the 5-mm port wound. Conclusion: Different optimal routes for unilateral and bilateral cases and novel mesh delivery techniques enabled a minimally invasive TEP with 5-mm ports. Also demonstrated were the convenience of a 5-mm camera that can be used with any port and the usefulness of keeping the surgical invasiveness to a single side.

The development and implementation of an online video library in the surgical training in miniinvasive hernia repairs Kryspin Mitura, PhD, MD; Siedlce University of Natural Sciences and Humanities.

Introduction: Safe and efficient performance of MIS surgical hernia repairs requires familiarity with various clinical cases. Methods: In 2019, a new online library was created containing videos from various stages of laparoscopic inguinal and ventral hernias. The videos are divided into thematic categories. The video collection includes both films presenting new operational techniques as well as lectures. The library includes both full videos without editing and only selected parts of the procedure that are the essence of hernia repair. Results: Materials posted on the internet are used in training surgeons, which is conducted live. Surgeons need to familiarize themselves with the video before the workshop, and then after the workshop a recording of the operations in which they participated is posted on the channel with additional feedback. In this work, we discuss the impact of the library channel on the effectiveness of training. Conclusion: Surgical training in MIS requires viewing as many valuable and verified video materials as possible. Adding to a live surgery training the tutorial included in the online video library allows one to improve the Results of the training.

Introduction: Minimally invasive extended totally extraperitoneal (eTEP) approach is gaining traction in the field of ventral hernia repair (VHR). Subcostal access to the retromuscular space and ideal position of this first trocar can be difficult to reach. We developed a scalable and standardized technique of ultrasound guided optical trocar (UGOT) entry to be used during eTEP VHR to facilitate retromuscular laparoscopic access, avoid entry-related complications and improve the workflow. Surgical technique and early experience are hereby described. Surgical technique: Intra-operative abdominal wall mapping is performed to identify the most cranial and lateral point of the rectus sheath. Hydro-dissection is achieved through local anesthetic infiltration between the transversus abdominis muscle and the rectus muscle. A 5 mm optical trocar is inserted at this point, and the correct plan of dissection is identified when encountering the hydro-dissected area. Retromuscular rectus sheath dissection is then completed as per standard through a combination of pneumatic and blunt dissection. Results: Seven patients underwent complete eTEP procedure after UGOT access including 5 single docking eTEP of which 4 with unilateral transversus abdominis release (TAR), and 2 double-docking eTEP with bilateral TAR. Mean duration of the access from ultrasound mapping to retromuscular space insufflation was 2 ± 1 min., as compared to mean total operation duration of 245 ± 79 min. Position of the trocars was deemed optimal in all seven patients, with all trocars positioned less than 1 cm from the rectus pedicle. No intra-or peri-operative complication was observed. Post-operative pain evaluation under a non-opioid regimen showed mean VAS of 1.2 ± 1.5 at day 0 and 1.0 ± 1.5 at day 1. Conclusion: Ultrasound guided optical trocar entry could improve eTEP access for VHR. In this early experience fast and certain identification of the optimal entry point were reached, avoiding dissection plan mistakes, and optimizing first trocar position.

A case of simultaneous abdominal wall reconstruction and creation of diverting ostomy in a ventral hernia with loss of domain Benjamin Yglesias, MD 1,2 ; Sameh Shoukry 2 ; Thomas Kerestes, MD 2 ; 1 Northeast Ohio Medical University; 2 Trumbull Regional Medical Center.

Introduction: Diverting ostomies are traditionally used as a bridge to primary resection in patients with an obstructing mass, or severe inflammatory bowel dis-ease1. In some cases, severe infections or non-healing wounds can be better managed after the diversion of fecal material away from the area2. In this case report, we discuss a patient who underwent a diverting loop colostomy placement through a ventral hernia defect with primary repair of the hernia in one procedure. Presentation of case: A 67-year-old female presented with a large, stage four sacral decubitus ulcer and an incarcerated ventral hernia. Overt fecal incontinence and the proximity of the wound to the anus necessitated a diverting ostomy procedure. She was taken to the operating room for a transverse loop diverting colostomy through a large, pre-existing ventral hernia. A midline incision was made along the border of the hernia and the ostomy site was passed through the ventral defect at the midline. The remainder of the ventral hernia was closed primarily, and the initial incision was stapled closed. At post-operative day 11, the ostomy remained functional and intact, with no hernia recurrence. The sacral decubitus ulcer appeared to be significantly improved with a clean base and granulation tissue throughout. Discussion: The large ventral hernia presented a significant obstacle during preoperative planning. It was decided that a midline stoma was to be created simultaneously with an abdominal wall reconstruction, as any other site to bring up the ostomy would have been too far laterally. Conclusion: The patient was discharged in stable condition and the primary goal of allowing her ulcer to heal was successfully achieved. This case presents a novel and viable method for the creation of an ostomy in patients with large ventral hernias. Further studies regarding long-term outcomes may be beneficial in establishing utility. Keywords: Surgery; Abdominoplasty; Reconstruction; Ostomy; Hernia Introduction: Pseudocyst formation post incisional hernia is a rare complication but underestimated incidence. Case: A 62 years old female had two previous incisional hernias repair last 8 years ago. First incisional hernia repair was done by laparoscope by inserting sub-lay mesh. The second one was done by open technique on -lay polypropylene mesh fixation. No past history of seroma or hematoma collections post operations. The patient complained of dull aching pain in the lower abdomen and heaviness without obstructive symptoms. The examination of the abdomen showed multiple hernia defects with a large mass in the lower abdomen shifted to the right iliac fossa area. An abdominal CT scan showed evidence of hernia repair with a 2.5 cm midline defect containing omentum and large subcutaneous 16*8.8cm seroma formation. The surgical operation showed multiple incisional hernias defects with large cystic lesion attached with old on-lay propylene mesh. Cystic lesion removed with old mesh carefully and repaired the defects by non-absorbable sutures. We found the part of mesh fixed with skin staplers and polypropylene sutures. Monofilament polyester onlay mesh fixed above the fascia after washing the field by saline and antibiotic. Two abdominal drains inserted, one removed after three days and the other after five days post-operation. The patient was not developed in the postoperation period any seroma, hematoma, or wound infection. Histopathology report showed pseudocyst with granulomatous forging body (mesh material) reaction. Discussion: The granulomatous cystic formation is one of the complications of hernia repair. The female to male ratio is 2:1. Etiologies of formation are unknown but possible causes are untreated hematoma and seroma post hernia repair especially polypropylene mesh. The duration of cyst formation varies between a few months up to years. It is a common post incisional hernia repair but also literature mentioned can be happened after inguinal hernia or Spigelian hernia. The only resection of pseudo-cyst is curative treatment. We think the treatment of seroma and hematoma can prevent this complication. Using another type of meshes instead of polypropylene mesh could reduce the formation of the cystic lesion. We need more studies to know the effects of seroma and hematoma with a specific type of meshes. Summary: The pseudo-granulomatous cystic lesion is a rare complication post hernia repair. Resection of the cyst is the only curable treatment. Prevent hematoma and seroma could be preventing to develop like this complication.

Novel robotic transabdominal preperitoneal reversed falciform ligament flap (RFLP) for repair of recurrent incisional hernias Anna K Gergen, MD; Akshay Pratap, MD; University of Colorado Background: Transabdominal preperitoneal (TAPP) repair is considered anatomically favorable with reduced complications from bowel adhesions to the mesh. However TAPP repair of a recurrent hernia done by intraperitoneal onlay mesh (IPOM) is challenging due to scarred peritoneum over the onlay mesh creating wide gaps which are often difficult to close. We present our experience with a novel technique of robotic reversed falciform ligament flap (RFLP) during TAPP repair of recurrent incisional hernias which addresses this problem by bridging large peritoneal gaps and isolates the mesh from the intraperitoneal contents. Methods and procedures: Twenty one recurrent ventral and incisional hernias repaired by either open or IPOM technique underwent RFLP technique. Between August 2017 and September 2020. Patient demographics, location and size of the hernia and surgical treatment were obtained from the hospital case-notes. Standard 3 lateral robotic ports were used. A peritoneal flap was started with a 5 cm overlap from the hernia defect. Fascial closure was performed followed by placement of a self-fixating polyester mesh. A pedicled falciform ligament flap was created by isolating the falciform ligament, round ligament, and overlying preperitoneal fat from the liver towards the umbilicus. The falciform ligament was stretched and sutured to the edges of the central peritoneal defect which underlay the prior IPOM mesh with excellent defect closure. Results: Twenty-one ventral and incisional hernias were treated by this method. Eighteen were incisional (15 midline, and two transverse), and three were paraumbilical hernias. Defect sizes ranged from 30 to 100 cm 2 and mesh sizes from 150 to 300 cm 2 . Mean operating time was 110 minutes. No conversion to retro rectus plane was done. Two patients developed seromas managed conservatively. All other cases achieved excellent long-term outcomes with a high degree of patient satisfaction at a mean follow up of 23 months (18-53 months) without clinical or radiological recurrence. Conclusion: RFLP is an innovative and useful method for repairing large ventral and incisional hernias when primary peritoneal closure is not achievable, combining a preperitoneal mesh repair with autologous tissue transposition across the peritoneal gap. This technique most importantly does not violate the holy plane of retro rectus layer which can be used for subsequent recurrent repairs if needed. Background: The large raw muscle surface and even larger potential space created during retromuscular hernia repairs make post-operative (PO) hemorrhage a feared complication. Despite a number of recent case series detailing retromuscular hernia repair outcomes, there is a paucity of literature regarding the management of retromuscular hemorrhage. This multicenter study reviews the management of a cohort of patients with this complication. Methods: Two prospectively maintained databases were retrospectively reviewed for PO hemorrhage in patients who had undergone retromuscular (retrorectus and/or transversus abdominus release) ventral hernia repairs. Hemorrhage was defined as clinical symptoms associated with a hematoma identified on CT. Demographic, operative, and surgical outcome data were analyzed with univariate statistics. Results: Eleven patients with PO hemorrhage were identified (mean age 54, 27.3% female, 72.7% male, mean BMI 30.4). Pre-operatively, 36.4% of patients required therapeutic anticoagulation (AC). Wound class was clean (90.9%, n=10) or cleancontaminated (9.1%, n=1). Operations were performed laparoscopically (36.4%) or open (63.6%), and macroporous reduced weight polypropylene mesh was used in all cases. Retromuscular drains were left in 63.6% of patients. Mean index operation estimated blood loss was 75cc (range 50-700cc). Mean length of stay was 6 days (range 0-23 days), with all laparoscopic patients being discharged on PO day 0. Therapeutic (AC) was required in 36.4% of patients PO, 18.2% received prophylactic AC, and 45.5% received no AC. Median day of hemorrhage was PO day 6, and 45.5% (n=5) were managed non-operatively. For patients requiring surgery (54.5%, n = 6) mean re-operation was performed on PO day 5. All reoperations were performed via laparoscopic access to the retromuscular space, with an identifiable source of bleeding only noted in one (16.7%) patient. All patients underwent clot evacuation (mean 1305cc, range 400-3575cc), irrigation, fibrin sealant application and retromuscular drain placement. Treatment with AC or antiplatelet therapy perioperatively was not significantly associated with a need for operative intervention (42.8% vs 75.0%, P=0.303). There was no statistically significant difference in transfusion requirements (2.0 vs 0.8 units, P=0.351), or complications (including seroma formation, surgical site infection, small bowel obstruction, respiratory complication, or mortality) in patients who were managed medically versus operatively (P.05). Conclusion: Hemorrhage following retromuscular hernia repair can be successfully managed both nonoperatively or with a minimally invasive surgical approach. Perioperative AC or antiplatelet therapy is not associated with a greater need for operative intervention when PO hemorrhage occurs.

Use of ovine reinforced tissue matrix in bridged incisional hernia repair George DeNoto, MD, FACS; St. Francis Hospital, Rosslyn Optimal surgical ventral hernia repair involves primary closure of the fascial defect supported by mesh to minimize the risk of recurrence. However, not all hernia defects can be closed primarily despite the use of preoperative botox and intraoperative components separation to increase musculofascial advancement for attempted defect closure. In these instances mesh needs to be placed as a bridge, leaving a gap in the fascia with only mesh to support the abdominal wall at the bridged portion of the repair.

In our tertiary referral center for complex abdominal wall reconstruction we repair many large defects that occasionally require bridging the fascia with mesh. In high infection risk cases the mesh of choice is an ovine reinforced tissue matrix (RTM) to avoid the risk of synthetic mesh infection. The RTM is made 4, 6 or 8 layers ovine rumen reinforced with either polyglycolic acid or polypropylene suture. In bridged cases we utilize 8 layered RTM with polypropylene suture. We present our Results to date with RTM in our bridged patients treated between November 2016 to November 2020.

Our experience includes 18 patients, 12 female and 6 male. The mean age was 59 years and 13 patients were obese. 14 patients underwent 1-5 prior repairs and 2 patients were bridged because of abdominal wall tumor removal. The size of the defects ranged from 6 x 10 cm to 20 x 28 cm with a mean size of 13 x 19 cm. The residual bridged defect after suturing in the underlay mesh and suturing the fascial edge to the mesh ranged from 1 x 5 to 8 x 20 cm for a mean residual bridge of 5x9cm. Mesh sizes ranged from 200 to 750 cm 2 (mean 450 cm 2 ). 6 patients (33%) experienced post-operative wound infections treated non operatively and without infection of or removal of the RTM. There were 3 recurrences (16.7%). One in a patient with a BMI of 38 kg/m 2 who developed a postoperative wound infection. The other 2 recurrences were in patients with BMI's of 50 and 55kg/m 2 . All 3 recurrences were diagnosed 6 months post-operatively. Follow up ranged from 1-45 months with a mean of 20 months.

Human and Porcine acellular dermal matrices have been shown to have a recurrence rates in bridged patients of 80% and 40% respectively. The recurrence rate of 16.7% in our experience in ovine RTM bridged hernia repair patients appears to be an improvement. We believe the reinforcement of the biologic mesh with polypropylene suture offers a stronger, more resilient repair. GERD Introduction: history of prior urologic pelvic operations, such as a prostatectomy is a classic contraindication for minimally invasive inguinal hernia repair. As the adoption of the robotics platform continues to grow, we aim to outline a feasible robotic-assisted inguinal hernia repair technique in patients with previous radical prostatectomies. We report the outcomes of nine patients who underwent repair at a single institution. Methods: this is a retrospective case series of nine patients who underwent robotic trans-abdominal preperitoneal approach (r-TAPP) repair of their inguinal hernias after prostatectomy. Demographics, intraoperative variables, and outcomes of our cases were evaluated for analysis. Results: nine patients, aged 63-78, all with a history of prostatectomy performed 2-18 years prior, were included in the cohort. Hernia defects were bilateral in 2 patients and unilateral in the rest. Operative time ranged from 96 to 267 min (Mean: 170.3 SD70.3). All patient's defects were repaired using a polypropylene mesh except for 1 case in which a monofilament polyester mesh. Sizes for mesh varied from 16 9 11 cm to 20 9 15 cm. Mesh was fixed in 8 out of 9 cases using vicryl suture for most of the cases (n = 6), but barbed suture (n = 1), and evicel (n = 1) were also utilized. Peritoneal closure was always performed using a continuous running barbed suture. There were no documented intraoperative complications. Post-operatively, only one seroma (n = 1) was documented during the follow-up as complications. There were no 30-day readmission or recurrences recorded. Introduction Ensuring a flat piece of mesh is one of the key tenets to hernia repair. This is commonly achieved by percutaneous transfascial suture fixation. Despite the widespread use, placement of these can be tedious and they have been associated with increased post-operative pain and length of stay. One alternative to these is use of a fibrin sealant for mesh fixation. Background: Spontaneous rupture of liver tumor is rare and associated with dismal prognosis. Emergency liver resection is often difficult and tolerated poorly. We hereby, report the management of a patient who presented with hemorrhagic shock and severe sepsis due to spontaneous rupture of liver tumor. Case Summary: A 36-year-old man presented to the emergency with abdominal pain and shock. He was resuscitated with blood transfusion, broad-spectrum antibiotics and mechanical ventilation. He developed severe sepsis with acute kidney injury. Computed tomography (CT) of abdomen showed a large right lobe liver tumor with rupture and hemo-peritoneum without any metastases. TACE could not be done due to acute kidney injury. He was taken up for damage control laparotomy after initial stabilization. Intra-operatively after evacuation of necrotic debris and lavage, the replaced right hepatic artery arising from superior mesenteric artery was ligated to prevent further bleeding. He improved postoperatively and follow-up CT scan showed the adequate remnant left lobe. After further optimization and recovery of renal function, he underwent definitive right hepatectomy on the 7th postoperative day. and later he had an uneventful course. Histopathology revealed primary carcinosarcoma of liver. At 2-year follow up he is asymptomatic and doing well. Conclusion: For ruptured hepatic tumours, which are potentially resectable, a staged approach to major hepatectomy may be a viable and safe surgical strategy, even though its a rare primary hepatic carcinosarcoma for achieving long term survival. Objective: Munchausen syndrome (MunS) is a psychological disorder of intentional recurring falsification or exaggeration of physical and/or mental signs and symptoms in oneself to assume the ''sick role'' and gain medical attention. These patients can pose a challenge to the surgeon as they tend to travel from one institution to another, present with a long, unexplained course of disease with multiple operations, and willingly accept or sometimes even ask for invasive diagnostic and therapeutic procedures. The aim of the study is to provide a snapshot of this population prior to diagnosis to understand warning signs and potential thresholds for provider suspicion. This is the first study to estimate population-based prevalence, describe the profile of a typical MunS patient at the time of initial diagnosis, and describe patterns of surgical care utilization among patients diagnosed with MunS. Conclusions: Caring for patients with Munchausen's is ethically and emotionally challenging and could be disruptive in the context of a busy academic or community surgical practice. Understanding the characteristics and behaviors of this unique patient population could increase provider awareness, assist in a timely MunS diagnosis, referral to behavioral treatment, and improved patient safety. The economic burden of managing MunS population falls on public insurance and community health centers, so it is imperative to improve our diagnostic ability, care coordination and health information exchanges among healthcare facilities.

A case report of a 78-year-old female with a jejunal diverticulum resulting in an obstructing enterolith Emily A Harris, MD; Conor Kinford, MD; Maria Osipova, MD; Amita Saint Joseph Hospital Chicago This case report highlights the rare occurrence of an obstructing small bowel enterolith in a 78-year-old female with a history of diverticulosis and hysterectomy, presenting with colicky epigastric discomfort, nausea, and emesis. Upon laparotomy, the patient was noted to have a 3 9 3 cm jejunal diverticulum, and distally in the ileum the corresponding 3 9 3 cm enterolith was located at the site of obstruction. The patient's gallbladder was noted to be intact with no abnormal adhesions to the stomach or small bowel. An incidental Mekel's diverticulum was noted more distally.

Laparoscopic management of perforated jejunal diverticulitis Lindsay Tse, DO; Care New England Kent Hospital Small bowel diverticular disease is an uncommon entity effecting less than one percent of the population. Overall, complication rates are low, ranging from 5-10% of cases. Small bowel diverticulitis resulting in perforation and the need for surgical intervention is even more rare. This patient is a 64 year old Female with a past medical history significant for GERD, and upper GI bleed secondary to NSAID use, who presented with a two day history of sudden onset, constant, left sided abdominal pain with nausea and diarrhea. She reported fevers to 101.6F, and was hemodynamically stable on arrival. Physical exam was significant for tenderness in the left mid abdomen with voluntary guarding but no rebound tenderness. Labs were remarkable for a WBC 15, but were otherwise normal. CT scan revealed a short segment of mid jejunum with wall thickening, surrounding inflammation, fat stranding, and a small focus of free air, suggesting a localized, contained segment of perforation. The patient was admitted to the hospital, made NPO, an NGT was inserted, she was started on broad spectrum antibiotics and serial abdominal exams were performed. The patients' abdominal pain resolved, however she continued to have an increasing leukocytosis. Repeat imaging demonstrated an intra -abdominal abscess. Interventional radiology aspirated 12 cc of purulent fluid. A 12 Fr catheter was left in place. The next day, the drain appeared enteric and a drain study revealed a direct connection between the abscess cavity and the jejunum. The patient was then taken to the operating room. An optical 5 mm trochar was used for laparoscopic entry, and immediately apparent was a segment of small bowel adherent to the anterior abdominal wall at the site of percutaneous catheter access. 2 additional 5 mm trochars and one 12 mm trochar was placed. The entire bowel was run starting proximally and several large, uninflamed diverticula were identified. A large, 5 cm perforated diverticulum with surrounding fatty infiltration was found. Viable margins on both sides of the site of perforation were identified and were transected with a 60 mm tan surgical stapler. A totally intra corporeal side to side stapled small bowel anastomosis was then performed, and approximately 1.5 feet of intestine was removed through the 12 mm port. Post operatively her diet was advanced and she was discharged home without complication. Pathology report confirmed the diagnosis of perforated small bowel diverticulitis. This case illustrates the successful treatment of a rare small intestine pathology using a minimally invasive approach.

Case report: intermittent small bowel volvulus causing severe jejunal diverticulosis Rebecca Barr, MD; John Culhane, MD; St Louis University Introduction: We present a case of an 83-year-old female with chronic abdominal pain, thought to be due to malrotation, found to have small bowel diverticulosis. Case report: An 83-year-old female with past medical history of chronic abdominal pain, nausea and early satiety, presented to our clinic after radiologic diagnosis of partial midgut volvulus, concerning for malrotation. She underwent exploratory laparotomy and was found to have normal rotational anatomy with prominent small bowel diverticulosis. 70 cm of small bowel was resected with a primary anastomosis.The patient recovered without complication (Fig. 1) . She was seen in follow up with complete resolution of her presenting symptoms. Discussion: Small bowel diverticulosis is exceedingly rare, making diagnosis difficult. This case highlights the importance of keeping a high index of suspicion for small bowel diverticulosis in the setting of chronic abdominal symptoms in a patient without a history of prior abdominal surgeries and non-specific imaging findings. We propose that her pathology was caused by chronic intermittent closed loop obstructions, leading to repeated periods of increased intraluminal pressure and the resultant severe small bowel diverticulosis. Symptomatic localized small bowel diverticulosis is best treated with resection of the entire involved portion of the small bowel with primary anastomosis. Fig. 1 Resected specimen of small bowel demonstrating multiple large small bowel diverticula on the mesenteric side of the bowel P519 Metastases of the duodenum and stomach a retrospective case series Amina A Bouhelal; Samrat Mukherjee, Dr; Queens Hospital. London, UK Background: Duodenal metastases are rare literature review suggest only 2% reported in time of autopsy. Reported occurring primaries are melanomas, lung cancer, carcinoma of the cervix and renal cell carcinoma. These patients usually present with obstruction or gastrointestinal bleeding. Typically at the time of diagnosis metastases to the duodenum carry a very poor prognosi

We aim to shed light on secondaries to the duodenum Methods: We carried out a retrospective case review of all duodenal cancers over a period of 10 years at a district general hospital in London, a centre for Upper Gastrointestinal cancers. All histopathology Results were reviewed, and the secondaries identified where the primary and site of biopsy were noted. We recorded the primary, presentation, management and survival from date of diagnosis. Results: 10 metastases to the duodenum were identified. The most common primary was breast (3), melanoma (2), colon (2), renal (2) and gastric (1) . All were initially diagnosed on staging CTs after the diagnosis of the primary cancers. The most common histopathology wereadenocarcinomas (4), carcinoma (4), melanoma (2) . Conclusion: Outcomes after the diagnosis of duodenal metastases were typically poor, with survival of \ 6 months. Although available Previously published literature has indicated the presence of GI bleed or anaemia to be reliable markers for metastases. None was applicable to our cohort. We found there was no presentation of duodenal metastases;all were diagnosed on staging CT scans performed due a previously treated primary.

Thymic carcinoma as a cause of syndrome of inappropriate antidiuretic hormone Pouya Hemmati, Dr; Stephen D Cassivi, Dr; Mayo Clinic-Rochester Thymic neuroendocrine tumors (TNET) are rare neoplasms, typically presenting as anterior mediastinal masses. Often, they present aggressively with locoregional and/or distant metastases. Paraneoplastic syndromes can also be associated with these tumors. A paucity of literature exists on these uncommon malignancies and their treatment options. In rare cases of localized tumors, surgical resection with curative intent may be considered. We present such a case with emphasis on preoperative workup and imaging, minimally invasive technique, and consideration for adjuvant therapies.

A 41 year old female with 3-month history of nausea, vomiting, and general weakness with known intractable hyponatremia and reportedly normal imaging at an outside hospital was hospitalized for electrolyte management. She underwent extensive evaluation that ultimately revealed an anterior mediastinal mass with FDG-avidity on Dotatate-PET/CT scan. This, along with a normal brain MRI, confirmed this solitary lesion to be the most likely trigger of her syndrome of inappropriate antidiuretic hormone (SIADH). This paraneoplastic process was leading to profound and refractory hyponatremia and debilitating symptoms. Following intensive preoperative fluid and electrolyte management to achieve eunatremia, she underwent a left thoracoscopic total thymectomy to fully resect the completely encapsulated intrathymic tumor.

Under general anesthesia with double-lumen endotracheal intubation, thoracoscopy with carbon dioxide insufflation was performed in right lateral decubitus position. The thymic lesion was identified and the left lower pole was dissected out. The mass was taken off of the pericardium posteriorly within its own capsule. Both upper poles were dissected to their most cephalad extent prior to division. The dissection was carried along the right lateral border down to the right lower pole with complete excision. No chest tube was used. Postoperatively, she remained eunatremic without further intervention. Final pathology revealed a TNET classified as a thymic small cell carcinoma. This is the first report of surgical resection of a thymic small cell carcinoma with associated SIADH. These carcinomas make up a small but highly aggressive portion of the uncommon TNETs. They typically present with regional or distant spread and can also be associated with various paraneoplastic syndromes, including SIADH. In the exceptional circumstance of early detection of localized disease, a curative-intent minimally invasive resection is safe and feasible following appropriate preoperative staging and management of paraneoplastic syndromes. It remains unclear whether adjuvant local or systemic therapies are indicated. However, they are likely to be offered due to the poor prognosis of this rare tumor, given that it often presents at later stages.

Hand-assist laparoscopic (HAL) adrenalectomy as an alternative surgical approach -best of both worlds? Arslan Pannu, Mr; Qaiser Jalal, Mr; Sabapathy Balasubramanian, Mr; Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK Aims: Published literature and anecdotal evidence on adrenal surgery suggests a dichotomous approach between laparoscopy and open surgery. However, hand-assist laparoscopy may be an alternative, preserving the benefits of both approaches. This study aimed to evaluate the effectiveness and outcomes of hand-assisted laparoscopic (HAL) adrenalectomy in a single tertiary centre. Methods: A retrospective review was carried out on all HAL adrenalectomies from 2010 to 2019 in a single centre. Medical records were accessed to obtain data on demographics, indications for surgery, operation details, pathology and postoperative outcomes. The primary outcome was Clavien-Dindo (CD) complication rates. Secondary outcomes were length of stay and re-admission rates. Results: Of 276 adrenalectomies performed, forty were included (70% male) with a median (range) age of 60 (29-82) years. Indications for surgery were non-functional lesions (57.5%), phaeochromocytoma and paraganglioma (30%) and hypercortisolism (12.5%). 50% of lesions were benign. 32.5% were planned HAL procedures while 57.5% were converted from conventional laparoscopy. Four patients had to be converted to open surgery (10%). The median (range) tumour size was 6.65 (1.7-18) cm. Self-resolving complications were noted in 12 patients and 5% had major complications (CD grade 3b and 4b). The median (range) length of stay was 6 (1-30) days. Readmission rates and perioperative mortality were 0%. Conclusion: HAL approach is a good alternative for either conversion from laparoscopy or as a primary procedure for large tumours. It maintains excellent laparoscopic views and provides tactile tissue feedback and reduces conversion to conventional open surgery.

Case study of potential progression of multiple skin lesions in one patient: epidermal inclusion cysts to pseudoepitheliomatous hyperplasia to pilomatrix carcinoma F A Morfesis, MD; Owen Drive Surgical Clinic/Fayetteville NC 80 year old, otherwise healthy, bald AA male presented with multiple skin lesions: 1) 5 cm. nodular lesion (pilomatrix cancer) with central necrosis and drainage,of posterior scalp, at point where his cap abraded posterior scalp; 2) 10 cm. long area of inflamed epidermal inclusion cysts at right groin area where underwear would abrade skin of medial-proximal thigh; and 3) lesion of pseudoepitheliomatous hyperplasia (prurigo nodularis, clinically) of left upper arm skin at point where short sleeve shirt would abrade skin of lateral upper arm. The location of the these lesions in the same person suggests etiologic factors for development and malignant transformation of lesions in this individual and suggest both inflammatory and solar components in the development of a rare cutaneous cancer: first, the lesions progress from benign to malignant consistent with increased sun exposure from right groin (benign #2), to arm hyperplastic lesion (#3), and then to posterior scalp cancer (#1); second, all three lesion are associated with constant abrasion/contact of skin with underwear edge (#2), short sleeve shirt edge (#3), and back of cap on post. scalp, which patient wears constantly (#3). No other skin lesions are present with absence of chronic disseminated conditions such as nodular acne or hidradenitis suppurativa. There are no other solar lesion on exposed face or hands suggesting it is solely the synergistic interaction between abrading clothing and sun exposure that leads to (first) benign inflammatory lesions which then (second) progress sequentially to a premalignant precursor and then (thirdly) a rare cutaneous malignancy. The patient is not diabetic nor does he smoke, and does not have any predilection for other cutaneous disease. Pilomatrix cancers (from hair matrix) are rare (\ 130 reported cases in world literature(1)) and little is known of their etiology. This patient was successfully treated with wide excision and refused adjuvant radiation; he has no evidence of metastatic disease. (1) Introduction: The incidence of splenic (SVT) and portal vein thrombosis (PVT) after splenectomy for massive splenomegaly is significant, regardless of the surgical approach employed. The aim of this study was to determine the impact of extended venous thrombosis prophylaxis following minimally invasive splenectomy for massive splenomegaly. Methods: An 11-year retrospective chart review was undertaken for all splenectomies for massive splenomegaly performed at the Peter Lougheed hospital. The incidence of SVT and PVT, as well patient demographics and perioperative complications were collected. STATA V.14.0 was used for analysis. Pearson v2 analysis was used where applicable. Data were presented as means and medians. Results: For the 39 patients who met our inclusion criteria, the majority had their surgery completed by a minimally invasively approach (conversion rate of 8%). The overall rate of morbidity was 33.3%, and the average post-operative length of stay was five days. All patients were discharged home on prophylactic dosing of low-molecular weight heparin (LMWH). Eighteen (46.2%) developed post-operative thrombosis. Most patients (61%) who developed a thrombosis were asymptomatic, with the rest presenting with abdominal pain. A significant association with thrombosis was seen in patients who underwent preoperative splenic artery embolization (p = 0.014). All patients who developed a thrombosis were managed with therapeutic dosing of anticoagulation and all had resolution of their thrombosis without long-term sequalae. Conclusion: Despite extended period of venous thrombosis prophylaxis with LMWH, the overall rate of thrombosis (SVT, PVT or both) was high, however, if aggressively treated this will resolve. We suggest intensive post-operative surveillance and aggressive treatment for this patient population. Background: Traumatic neuromas (TNs) are non-neoplastic peripheral nerve tumors that occur following axonal damage. Histopathology reveals a combination of axonal material, Schwann cells, and connective tissue. They are most commonly found in the extremities following surgery or traumatic injury. To our knowledge, only a few cases of abdominal and pelvic traumatic neuromas are described in the literature. We present a case of an incidental traumatic neuroma in a patient with recurrent abdominal symptoms (described with the informed consent of the patient). Case description: A 34-year-old female underwent diagnostic laparoscopy and hysterosalpingography in 2013 as part of an infertility workup. Laparoscopy was strongly suggestive of endometriosis and multiple biopsies of affected sacra-uterine ligaments were taken to confirm the diagnosis. Between 2014 and 2016, the patient underwent additional three laparoscopies due to persistent abdominal symptoms located in the right lower quadrant. Endometriosis was found to be the most likely cause of her persistent symptoms and the patient underwent hysterectomy with curative intent in 2016. In 2018 the patient presented again with acute abdominal pain and appendicitis-like symptoms. Diagnostic laparoscopy showed an unaffected appendix and mesenteric lymphadenitis was given as the most likely diagnosis.

In 2019 the patient was readmitted once again with nausea, vomiting, changes in bowel habits, and history of non-specific peri-umbilical abdominal pain radiating to the right iliac fossa. During the procedure, a well-demarcated peritoneal thickening was noted in the right iliac fossa. It was fully excised with a working differential diagnosis of recurrence of endometriosis despite the hysterectomy. The patient also underwent an appendectomy during this operation.

Histopathology of the specimens revealed a healthy appendix and the excised peritoneal tissue was identified as a traumatic neuroma. The patient recovered well and her abdominal symptoms resolved. She remains asymptomatic after follow-up at one, 6, and 12 months. Discussion: TN should be considered as a differential diagnosis in patients with persistent abdominal pain following multiple abdominal surgeries. Although usually asymptomatic, the resolution of abdominal symptoms following the last surgery suggests TN as the most likely cause of our patient's symptoms. To our knowledge, this is the first symptomatic and second overall case of TN reported following gynaecological surgery.

A rare case report of laparoscopic-assisted approach in management of small bowel obstruction secondary to B Lynch suture through small bowel serosa and mesentery Cecilia Nguyen, DO; Elena Kang, DO; Robert Christenson, DO; Dan Fegely; Alexander Gonzalez-Jacobo, DO; Narinder Paul Grewal, DO; St. John's Episcopal Hospital Our patient is a 37 year old female 6 weeks postpartum. She was visiting from Pennsylvania her terminally ill mother with her 6-week old son to give her mother the opportunity to see her grandson. For the last 48 h, patient complained of worsening abdominal pain associated with nausea and vomiting. She then decided to come into the ED. According to the patient, some complications with her initial c-section prolonged labor as well as c-section having been converted from epidural to general, and a prolonged ICU experience with multiple blood transfusions as per patient. Her WBC was elevated on admission, and CT demonstrated free fluid without free air, thickening of the small bowel, focal areas of stool burden concerning for acute process of the lower abdomen associated with her emergent c-section. She states she has been having irregular bowel movements most of her life but has been more irregular since the procedure. Since patient was having abdominal pain, significant to palpation, free fluid on CT, and leukocytosis, there was concern for possible obstruction vs. perforation.

Patient underwent diagnostic laparoscopy, enterolysis, and removal of uterine stiches adhered to small intestine. In the OR, a stitch from the uterus to small bowel serosa and mesentery causing small bowel obstruction, hemorrhagic fluid present in abdomen, adherions lysed and stitched removed. The small bowel was red and inflamed and upon release of adhesions,the small bowel became more pink in color and had good peristalsis. Complications following uterine compression suture placement appear to be rare. In our case report, patient had B lynch suture that went through the uterus and small bowel causing a small bowel obstruction, which was treated successfully laparoscopically. The patient recovered well. On post operative day 3, patient is tolerating diet, passing flatus, voiding on her own without issues and was surgically stable for discharge. Not only should laparoscopy assisted approach be attempted with complications of uterine compresson suture and small bowel obstruction but considered when accounting for shorter length of stay and faster recovery. Small bowel obstructions is one of the most common causes in hospital admission for acute abdominal pain. Open laparotomy treatment for is assocaited with postoperative adhesion and recurrence of small bowel obstruction. Laparoscopy has somewhat replaced traditional lapartomy as an elective treatment for a number of conditions. It has been associated with a lower rate of morbidity and shorter hospitality as seen in our patient.

Retroperitoneal lymphangioma; a rare cause of abdominal pain in adults Natalie Sirianni, MD 1 ; Amin Mohamed Ahmed, MD 1 ; Sarah Hill 1 ; Joseph Sferra, MD, FACS 2 ; 1 The University of Toledo; 2 ProMedica Toledo Hospital Introduction: Lymphangiomas are rare malformations of lymphatic channels. They predominantly present in infancy or childhood, and less than 10% are seen in adults. The head and neck are the most prevalent locations for these masses. Retroperitoneal lymphangiomas account for only approximately 1% of all lymphangiomas. We present a case of a retroperitoneal lymphangioma in an adult. Presentation of case: This is a 22-year-old female who presented with recurrent right upper quadrant abdominal pain of two years' duration. Initially this was attributed to ovarian cysts. Persistent symptoms warranted further imaging studies. This revealed a hypodense nonenhancing lobulated lesion measuring 12 9 2.5 9 7 cm posterior and inferior to the gallbladder (Figs. 1, 2, 3 ). Attempted US guided aspiration was unsuccessful. The patient subsequently underwent open resection and concomitant cholecystectomy (Fig. 4) . She tolerated surgery well and was discharged home. Pathology report revealed 11 9 5 9 1.6 cm cystic mass consistent with lymphangioma. Discussion: The etiology of lymphangiomas is unclear. These malformations may arise in any region containing lymphatic channels and are thought to be either congenital or secondary to inflammatory processes such as infection or trauma. Symptomatology varies widely, including asymptomatic presentation, pain, and/or obstructive symptoms due to compression of adjacent structures. Diagnosis is imaging-based, but definitive differentiation from other cystic pathologies requires histologic diagnosis. Operative resection is the treatment of choice for the symptomatic patient, with complete resection necessary to minimize the risk of recurrence. Conclusion: Lymphangiomas are rare masses that primarily present in childhood but are seen occasionally in adults with a variety of symptoms. Surgical resection of symptomatic lesions should be considered. Complete resection is imperative for prevention of recurrence, and intact specimens should subsequestly undergo histologic examination for definitive diagnosis. Fig. 1 Axial CT demonstrating Hypodense nonenhancing lobulated lesion measuring 12 9 2.5 9 7 cm posterior and inferior to the gallbladder Patients with this syndrome usually present with postprandial epigastric pain, nausea, weight loss and diarrhea. It is more common in young women. The treatment is surgical only, and it consists of open or laparoscopic decompression of the celiac trunk. Intraoperative color-Doppler ultrasound may be useful in assessing immediate blood flow increase after decompressing the vessel.

The aim of the study is to analyze the usefulness of intraoperative color-Doppler ultrasound in assessing completeness of dissection of the ligament fibers around the celiac trunk and blood flow optimalisation. Materials and Methods: The study included 7 consecutive patients (6 women, 1 man) operated between 2018 and 2020 in one surgical center. The mean age was 37.4 years, mean BMI was 22.4. The diagnosis was made on the basis of clinical symptoms and preoperative computed tomography angiography (CTA). Color-Doppler ultrasonography was performed transabdominally before the procedure and intraoperatively before and after the celiac trunk decompression. Results: The mean initial celiac stenosis degree assessed on CTA was 86%. The mean peak systolic velocity (PSV) intraoperatively before median arcuate ligament dissection was 285 cm/s and it dropped to 145 cm/s after the dissection. Celiac trunk diameter increase was confirmed in all cases after the decompression. Activities related to intraoperative ultrasound examination lasted 24 min on average. The mean operation time was 104 min, the mean hospitalization time was 1.9 days. No perioperative complications were observed. Conclusions: Intraoperative color-Doppler ultrasound allows to objectively assess the completeness of the dissection of the medial arcuate ligament. Although performing ultrasound during laparoscopic surgery extends the procedure, it guarantees optimal Results.

Risk factors for additional port insertion in single-port laparoscopic appendectomy Suk-Won Suh; Byung Kwan Park; Chung-Ang University College of Medicine Introduction: Recently, single-port laparoscopic appendectomy (SPLA) has been widely adopted to improve cosmetic outcomes and reduce surgical trauma. However, conversion to conventional laparoscopic appendectomy (CLA) might not lead to these advantages. We aimed to evaluate risk factors for conversion to CLA from SPLA in acute appendicitis. Methods: Between August 2015 and December 2016, the characteristics, operative data, and postoperative surgical outcomes of patients who underwent intended SPLA at Chung-Ang University Hospital were retrospectively reviewed. Conversion to CLA was defined as any insertion of additional port, and complicated appendicitis was defined as gangrenous or perforated appendicitis with or without fluid collection, abscess, or peritonitis in preoperative CT. Univariable and multivariable analyses were performed to identify predictive factors for conversion to CLA. Results: Of 409 patients, 65 (15.9%) were treated with additional port insertion. On univariable analysis, age, sex, body mass index, complicated appendicitis, preoperative serum platelet count, and C-reactive protein (CRP) level were associated with conversion to CLA. After multivariable analysis, old age (OR = 1.031; 95% CI, A 72 year old female patient who underwent Laparoscopic cystogastrostomy 4 years back for suspected pancreatic pseudocyst, presented with mass in abdomen of 2 months duration. On examination, mass was found to be intra-abdominal. The mass was diagnosed to be GIST on imaging and biopsy, confirmed intraoperatively to be Gastric GIST with normal pancreas. Even with meticulous and systematic clinical examination and judicious use of investigations for diagnosis of pancreatic pseudocyst, the possibility of GIST should be considered.

Introduction: The case report aims to emphasize to keep in mind the possibility of GIST in a patient with suspected pancreatic pseudocyst. Methods, procedures and results: A 72 year old female patient came to Surgery OPD with complaints of nausea, anorexia, pain in abdomen with mass in abdomen since 2 months. History of the patient revealed that she had similar complaints and was diagnosed with chronic pancreatitis with pancreatic pseudocyst 4 years back for which she underwent Laparoscopic cysto-gastrostomy. On examination, a firm lobulated mildly tender mass of size 15 cm 9 10 cm occupying the epigastrium, left hypochondrium, umbilical region was found. It was mobile transversely and dull to percuss. Abdominal CT scan revealed a 13.2 9 9.6 9 13.9 cm sized lobulated soft tissue lesion along the greater curvature of stomach likely suggestive of GIST. Endoscopy showed mass compression but no intraluminal growth. USG guided biopsy of the mass confirmed GIST.

On exploratory laparotomy, a 14 9 10 x 13 cm sized greyish brown, encapsulated, firm, lobulated mass was found arising from the posterior wall of the stomach abutting the transverse colon, duodenum, pancreas, spleen without signs of chronic pancreatitis. Total Gastrectomy with esophago-jejunostomy was done. Specimen showed that the tumor arised from previous cysto-gastrostomy site.

Based on the history and pre-op and intra-op findings, alongwith the fact that the pancreas appeared normal on imaging and exploration, it seems most likely that the patient was misdiagnosed to have pancreatic pseudocyst and treated accordingly, when she probably had GIST back then which was missed. Conclusion: Judicious use of investigations and intra-op frozen section biopsy of thick walled cystic lesion can help distinguish between GIST and pancreatic tumor and hence aid in appropriate and timely management of the patient.

Clinical outcomes of partial adrenalectomy in bilateral pheochromocytoma Purpose: Partial adrenalectomy is emerging in the management of bilateral pheochromocytoma to preserve adrenal function, but it can increase the risk of recurrence due to residual adrenal tissue. And bilateral pheochromocytoma is associated with hereditary disease, so it is important to get a genetic evaluation to detect hereditary tumor syndrome for the patient and their relatives. Herein, we described clinical outcomes and Results of genetic testing between partial adrenalectomy and total adrenalectomy groups in bilateral pheochromocytoma. Methods: We retrospectively reviewed medical records of patients with bilateral pheochromocytoma treated at Seoul National University Hospital from January 1998 to August 2020. Twenty-six patients who underwent bilateral adrenal surgeries were divided into partial adrenalectomy at least a unilateral side and bilateral total adrenalectomy group. Genetic mutation Results were obtained by direct sequencing or 10 gene panel technique. Clinical outcomes including adrenal function, recurrence and Results of genetic analyses were investigated. Results: Of the 26 patients, 23 patients underwent partial adrenalectomy and 3 patients underwent bilateral total adrenalectomy. Nineteen patients (73.1%) were found to have mutations. Twelve patients had mutations of RET (46.2%), 4 of VHL (15.4%), 3 of SDHD (11.5%) and 6 patients showed no mutation (23.1%). The Results of genetic testing were not obtained from 1 patients (3.8%). Eight patients (30.8%) had bilateral laparoscopic adrenalectomy and open adrenalectomy was performed in 18 patients (69.2%). Among the patients who had laparoscopic adrenalectomy, 6 out of 8 patients (75%) had the laparoscopic transabdominal anterior approach (LTA) and the posterior retroperitoneoscopic approach (PRA) was performed in 2 (25.0%) patients. Mean tumor size was larger in total adrenalectomy compare to partial adrenalectomy group. (6.3 ± 3.3 cm vs 5.1 ± 1.7 cm, p = 0.329). Seven patients (30.4%) required steroid hormone supplement therapy in partial adrenalectomy group and all patients (100%) in total adrenalectomy group become steroid dependent. There were 4 recurred patients (17.4%) in partial adrenalectomy group and 1 recurrence (33.3%) in total adrenalectomy group. Conclusion: Partial adrenalectomy reduced the need for chronic steroid hormone supplement therapy in the majority of patients and the risk of recurrence appears low. Therefore, partial adrenalectomy can be a safe and feasible option in bilateral pheochromocytoma.

Recognition and management of acquired hemophilia A: a case report Neelam Mulji 1 ; Thomas Crafton, BS 2 ; Jaron Butterfield, MD 1 ; Fernando Navarro, MD 1 ; 1 Prisma Health Midlands/University of South Carolina Department of Surgery; 2 University of South Carolina School of Medicine Background: A 57-year-old African American male presented for elective inguinal hernia repair with significant postoperative bleeding complications. Summary: Our patient's postoperative course was riddled with difficult to manage bleeding complications. He had no remote surgical history and no initial review of systems concerning for coagulopathy. He developed blood loss anemia and hematoma formation that necessitated multiple take-backs to the operating room. It was on further coagulopathy workup, that we discovered he had acquired hemophilia A, a rare but severe bleeding disorder due to autoantibodies against coagulation factor VIII. While the incidence of this disorder is very low, the complications and high associated morbidity and mortality warrant further education to assist with the recognition of future patients with similar presentations. An interdisciplinary approach is necessary for the diagnosis and treatment of this disease. This is the major point underscored in this case. Conclusion: While a rare disease, Acquired Hemophilia A is associated with increased morbidity and mortality in terms of surgical complications. We present a case highlighting the importance of interdisciplinary involvement and the need for immediate recognition and management. Keywords: Acquired hemophilia A, Hemorrhage, Surgery Management, Preoperative workup, nonoperative management P545 Robotic resection of adrenal pseudocyst and review of literature Fernando Lambreton, MD; Jennifer A Perone, MD; Alexander Perez, MD; Sarah Samreen, MD; University of Texas Medical Branch Adrenal cysts are uncommon lesions that are usually benign, with an incidence of 0.06-0.18%. Pseudocysts are the second most common type of adrenal cyst, and are characterized by an absence of a formal epithelium. These are more common in females and usually present in the 4th to 5th decade of life. Only 7% of adrenal pseudocysts are malignant, and the risk is higher in larger ones ([ 6 cm). Most are diagnosed incidentally, and are frequently mistaken for cystic lesions of the adjacent organs (pancreas, spleen, kidney, retroperitoneum, etc.) . They are usually asymptomatic and nonfunctional, but when large can complicate with hemorrhage, infection, rupture, and/or mass effect on adjacent structures. There are multiple imaging modalities that can aid in preoperative diagnosis, including CT, MRI, and EUS, but most will be definitively diagnosed on pathology after excision. Treatment is usually with surgical resection if there are symptoms or diagnostic uncertainty. We present a case of an atypical presentation of an adrenal pseudocyst which was excised using the robotic platform, Intuitive's DaVinci Xi, for the entirety of the case. A review of the available literature on adrenal pseudocysts was peformed, and found little to no published cases of robotic resection.

Percutaneous access to large intestine is feasible for submucosal dissection and suturing: an ex vivo porcine study Teijiro Hirashita; Shinya Urakawa; Yuka Hirashita; Lea Lowenfeld; Jeffrey W Milsom; Weill Cornell Medicine/New York Presbyterian Hospital Background: Endoluminal therapies, such as endoscopic submucosal dissection (ESD) are increasingly popular, and percutaneous access (PA) for upper GI tract tube placement is common and tumor excision is increasing. For safe endoluminal therapy of the colon, secure closure techniques for iatrogenic defect or perforation are required. We explored the hypothesis that PA to the colon may expedite complex endoluminal therapy, improve safety, and access sites can be reliably closed endoscopically. Methods: Using an ex-vivo model with fresh porcine colon placed in a human anatomic configuration and overlying abdominal wall, we passed a colonoscope to the transverse colon (T-colon). Under an endoscopic visualization. T-colon was secured to the abdominal wall with three T-fasteners and then two 8 Fr sheaths were inserted. Mucosal pseudo-lesions, 3 cm in diameter, were created in the T-colon and submucosal dissection was performed in two ways; (1) standard ESD: ESD group, and (2) laparoscopic grasper and electrocautery were used through PA: PA group. Next, ESD perforation model, which has 3 cm mucosal defect with 5 mm perforation at the T-colon was closed in two ways; (1) endoscopic clipping, and (2) suturing using 3-0 V-Loc with PA, and the procedural outcomes were compared. Puncture sites for PA were closed with endoscopic clips, and we measured the leak pressures. Results: In submucosal dissection, 12 lesions were removed successfully without perforation. PA group had significantly shorter procedure time (11.6 ± 2.4 min vs 35.4 ± 6.7 min, P \ 0.001) and fewer muscular injuries (0 vs 2.1 ± 1.6, P = 0.015) than ESD group. Regarding closing the mucosal defect and perforation, time of suturing was significantly longer than clipping (32.7 ± 10.2 min vs 14.7 ± 1.8 min, P = 0.002). Leak pressure of suturing was significantly higher than clipping (12.4 ± 16.0 mmHg vs 52.7 ± 10.0 mm Hg, P \ 0.001). Regarding closing the puncture sites, there was no leakage up to 60 mmHg in all cases. Conclusions: In an ex vivo porcine colon model, PA expedites complex endoluminal procedures (e.g. ESD of large ''polyp'') with fewer colon wall injuries than standard ESD methods. Mucosal defects and perforations can be firmly closed with PA, which may be helpful for establishing a safer and more secure endoluminal therapies. PA sites appear to be able to be reliably closed endoscopically. These methods should be evaluated further.

Prophylactic short-term stenting of high-risk esophageal anastomoses at the time of esophagectomy

Introduction: Prophylactic Esophageal stenting after Endoscopic Submucosal dissection (ESD) is increasingly used to prevent stricture formation. There is no published literature of prophylactic stent use after esophagectomy in humans. This is probably due to the reported catastrophic complications of erosion into the Aorta or bronchial tree. Procedures: We present three patients over a sixteen-month period who had insertion of prophylactic esophageal stents to protect high risk esophageal anastomoses at the time of esophagectomy following neoadjuvant chemotherapy. The modified Orringer technique of linear stapled esophago-gastric anastomoses was employed. All three patients underwent insertion of the EGIS (S & G Biotech, Korea) 18 mm diameter fully covered esophageal stent with antireflux valve (Fig. 1) .

The stent was fixed to the esophageal wall with two 2-0 Vicryl Rapide sutures (polyglactin 910) to minimise migration. The anastomoses were completely covered with Omentum. Daily Chest X-rays confirmed stent position. All patients were allowed water to drink as soon as they were extubated. The stents were removed endoscopically between day 12 and 20 and the patients were discharged the next day.

JG, a 62 year old lady who had presented with complete dysphagia due a locally advanced gastro esophageal junctional cancer underwent a two stage Ivor Lewis esophagectomy in July 2018. Her stent was removed on day 12 and she was discharged home on day 13. She developed brain metastases 4 months post-surgery and died 6 months later.

DW, a 42-year-old man underwent a two stage Ivor Lewis esophagectomy with extended superior mediastinal lymphadenectomy in February 2019. His stent was removed on day 20 and he was discharged on day 21. Remains well.

The third patient is SM, a 65 year old lady with mid esophageal adenocarcinoma underwent a thoracoscopic assisted three stage esophagectomy in November 2019. Her stent was removed on day 14 and she was discharged on day 15. Remains well. Discussion: Anastomotic leaks after esophagectomy are associated with prolonged hospital stay and decreased disease-free survival, not to mention the poor quality of life for patient and surgeon. These three case studies raise the hope of life without early anastomotic leaks or late strictures. The associated grave dangers of erosion into neighbouring vital structures can be minimised or eliminated by early planned stent removal. Improvements in stent materials and design technology might make this safer in the near future.

Robotic repair with dual-layer trans-fascial closure and intraperitoneal onlay mesh placement for large paramedian incisionalhernias after transplant Anastasios Mitsakos, MD; Fernando Brea, MD; David B Leeser, MD, FACS; Homayoun Pournik, MD, FACS; East Carolina University, Department of Surgery Introduction: Advances in minimally invasive and robotic surgery have brought to the surface a plethora of modern techniques in the operative management of complex abdominal wall reconstruction in high-risk patients with large defects. Especially in renal transplant patients, common comorbidities from previous procedures, immunosuppression, diabetes mellitus, old age, and obesity, can oftentimes present an insurmountable challenge to the surgeons treating postoperative incisional hernias. The primary objective of this study was to describe a new technique for robotic incisional hernia repair, which appears to have promising functional Results in the high-risk transplant patient population. Methods and procedures: Data from 2 patients who underwent robotic incisional hernia repair at an academic institution from a single surgeon were retrospectively collected using the electronic health record. Patients were previous renal transplant recipients via a paramedian ''hockey-stick'' incision at the right lower quadrant and they were on chronic immunosuppression at the time of the operation. The initial defect size was larger than 20 cm 9 10 cm in both patients. Patients underwent robotic repair of their postoperative incisional hernias in the same fashion. After reduction of the hernia sac and identification of the edges of the fascia, #1 polypropylene (non-absorbable) interrupted fully trans-fascial sutures were used to approximate the defect by bringing the sutures outside the patient's body through skin stab incisions and tying them after desufflating the abdomen. Subsequently, the abdomen was re-insufflated and a second inner layer was used to reinforce the fascial closure with a running absorbable v-lock suture. Lastly, a composite mesh was anchored with a running suture to the peritoneum in an intra-peritoneal onlay fashion (IPOM). Results: Both patients tolerated the procedure without acute intra-operative complications and were discharged home on the first postoperative day. On routine follow-up for 4 weeks, there have not been noted any signs of hernia recurrence, surgical site infection, or any other complication. Conclusions: In high-risk renal transplant patients with complex large paramedian incisional hernias, robotic repair in a dual-layer fascial closure (trans-fascial with additional intra-peritoneal reinforcement) with IPOM placement is a new technique with promising Results that could minimize complication rates in an already immunocompromised patient population. Introduction: An effective port closure after laparoscopy is an essential step in preventing port site hernia. Although many methods are described, they require special instruments or they are done not under direct vision. Aim & objective: Describe a simple, safe and cost-effective technique of laparoscopic port closure with any hollow needle. Technique: Here we describe our technique -ExInTra SPiN i.e., Extra and Intra corporeally guided Transfacially inserted Single sPinal Needle port closure technique (1) (6) The one end of the suture that was held before, is passed through the loop intracorporeally with the help of the grasper.

(7) The loop along with the end of the suture is withdrawn extracorporeally and knot is placed under vision.

Results: [ We have used this technique over 300 general, gastrointestinal and gynaecological procedures over last 2 years. No port site hernias were seen in the mean follow up of 12 months. Advantages of the procedure -Port closure is done under vision with maintenance of pneumoperitoneum during the entire procedure ensuring complete safety and assurance of transfascial closure. Only one spinal needle is required which is readily available in any operative room unlike many techniques requiring special port closure devices. Spinal needle enters even the scar tissues with ease so that it can be used even in previously operated scarred abdominal tissues. Conclusion: ExInTra SPiN technique is safe, easily performed reliable method of port closure under complete vision which doesn't require special instrument.

Effects of head-mounted display (HMD) use for laproscopic surgery: a pilot study Yaoyu Fu; Steven D Schwaitzberg, MD; Lora A Cavuoto; University at Buffalo Introduction: The goal of this study was to evaluate the influence of using a commonly available interactive augmented reality head-mounted display (HMD) as a replacement for conventional operating room monitors (both surgical field and patient vitals) for an extended duration, as required for surgery, on physical load, perceived workload, and performance. It was hypothesized that perceived workload would be higher when using the HMD, and that task performance would be equivalent between conditions. Methods and procedures: Eight medical students completed two experimental sessions, one using a traditional display (TD) and one using the Microsoft HoloLens for the surgical display (HMD). During each session, after a training and practice period, the participants were asked to perform an interrupted suturing task on a simulated bowel in a box trainer. While suturing, participants also monitored patient vitals that were presented on the display. The task continued for one hour. The presentation order of the sessions was balanced. Task performance was determined based on the number of knots completed. At the end of the session, participants rated their physical discomfort (on a 0-10 scale) and the visual load (using the Visual Fatigue Scale). Perceived workload was evaluated based on the NASA Task Load Index. Paired t-tests were used to compare the outcomes measures between sessions. Results: On average, participants were able to complete 6.6 knots (standard deviation = 2.3) in the TD condition compared to 4. 3 (1.8) in the HMD condition (p = 0.046). After approximately one hour, increases in discomfort were primarily reported for the head and upper back, with greater increases for the HMD condition (p = 0.041). There were similar ratings of eye tiredness for both conditions (3.4 (1.8) vs. 4 (2.7) out of 7, p = 0.42). Even with the increased discomfort, the average level of reported physical demand was equal (8.4 out of 20, p = 1.0). Perceived mental demand and effort were also statistically equivalent (p = 0.19 and 0.46, respectively). Participants did report higher levels of frustration with the HMD (p = 0.04). Conclusions: Despite popularity in the gaming community, HMD use over an extended duration led to elevated discomfort and frustration compared to a traditional display setup. In addition to the influence of a lack of experience with the HMD, these outcomes are attributed to the supported weight of the headset and the limited field of view available within the display. Exploring potential benefits of interactivity may yet yield value in this environment.

Success with novel combined endoscopic and fluoroscopic approach for distal small bowel obstruction Shinya Urakawa; Teijiro Hirashita; Yuka Hirashita; Kentaro Matsuo; Lea Lowenfeld; Jeffrey Milsom; Department of Surgery, Section of Colon & Rectal Surgery, Weill Cornell Medicine/New York Presbyterian Hospital Background and aim: Small bowel obstruction (SBO) often requires surgical management. We have successfully treated SBO by using combined endoscopy and fluoroscopy, 2/7 cases using a double-balloon interventional platform, (DEIP, Dilumen, Lumendi LLC). In this study, we evaluated the safety and feasibility of this therapy. Methods: Seven SBO patients who underwent endoscopic and fluoroscopic therapy were analyzed. The treatment steps were: (1) Colonoscopically get into the small bowel, using fluoroscopy, pass a guidewire (Boston Scientific) through the obstruction, (2) Advance the colonoscope (Olympus) along the guidewire and release the obstruction under the fluoroscopic imaging (Figure) .

The application of balloon dilation or DEIP depended on the cases. We evaluated procedure completions, complications, and recurrences. Results: All cases (age: 74 [62-85] ) had a history of abdominal surgery, and 2 of them underwent radiotherapy (Table) . 5 cases had the acute onset and required nasogastric tube decompression. Obstruction sites were all within 20 cm from the ileocecal valve/ ileocolonic anastomosis. All obstructions were released without complications or need for surgery. 4 cases required balloon dilation, and, in 2 cases, the DEIP shortened and stabilized the colon. One case had the recurrence at 3 months follow-up. Background: Pelvic actinomycosis is a rare, insidious chronic granulomatous disease that can be indistinguishable from abdominopelvic malignancies. Aggressive surgical resections are often undertaken with the presumption of a neoplastic process. We present a case wherein the diagnosis of actinomycosis was established during workup for suspected peritoneal carcinomatosis, with subsequent successful treatment with antibiotics hence avoiding unnecessary extensive surgical resection.

Case presentation: 53-year-old Chinese lady with large bilateral pelvic masses presumed to arise from the right adnexae associated with extensive peritoneal disease demonstrated -a 12 cm omental mass in the left lower abdomen, peritoneal nodules in the pelvis and paracolic gutters. Coupled with an elevated CA-125 of 39.3 U/ml, the initial impression a possible ovarian or appendiceal neoplasm with peritoneal metastases. Diagnostic laparoscopy was performed to assess the extent of disease and obtain histological confirmation of the diagnosis with a view for neoadjuvant systemic chemotherapy. Intraoperative findings were that of extensive omental caking over the left lower abdomen and midline, with the omental mass adherent to the anterior abdominal wall. Histologic assessment demonstrated dense inflammatory infiltrates with focal colonies of filamentous organisms and microbiology tests performed on the pus aspirated from the omental mass returned as Actinomyces israelii. Further history from the patient revealed that she had an intra-uterine contraceptive device in situ for 5 years which was recently removed. A Papanicolaou smear done after removal had also shown bacterial organisms suggestive of Actinomyces.

There remained a diagnostic dilemma wherein the histological sampling could have presented a false negative for malignancy and appropriate oncological treatment could be delayed. Appropriate antibiotics were initiated and computed tomography of the abdomen and pelvis after a month of treatment showed only residual soft tissue thickening and a bulky uterus but no pelvic masses.

In recent literature, most cases had an erroneous initial impression of pelvic malignancy and diagnosed after surgery based on the post-operative histology of the resected specimen, which often included en-bloc resection of surrounding pelvic organs. Confirming the diagnosis of actinomycosis before performing major resection is uncommon -there have been less than ten cases reported of which only two discussed utility of laparoscopic biopsy. Conclusion: Utilization of minimally invasive techniques for pre-operative diagnosis avoids the morbidity associated with radical surgery. This is pertinent in young nulliparous women to preserve fertility or those with significant comorbidities that preclude major surgery. Introduction: Current tendencies shift towards minimally invasive techniques for management of esophageal perforations. Efforts are made to identify candidates in order to avoid the morbidity of open repair. Authors describe the of endoscopic clip esophagoplasty (ECE) for poor stent candidates in setting of esophageal perforation in a tertiary center. Methods and procedures: Data from four adult esophageal perforations managed with ECE at the East Carolina University Division of Thoracic and Foregut Surgery was reviewed using electronic health record & operative videos. Patient demographics, characteristics, operative findings prompting decision of ECE instead of traditional stent placement, postoperative course and current follow-up were evaluated. The ECE was performed using Instinct TM Endoscopic Hemoclip (Cook Medical, Bloomington, IN) Results: All patients who underwent ECE had no immediate complications. One patient had prolonged length of stay due to social reasons unrelated to procedure. The patients are currently followed, up to 8 months at the time of this report. There were no recorded recurrent perforations or required conversion to open salvage esophageal repair. All patients are tolerating regular diet. Pre and post ECE Conclusion: Endoscopic clip esophagoplasty appears to be a safe and effective treatment for esophageal perforations, offering an alternative for patients whose anatomy or perforation site is not amenable to stenting. Individually tailored therapies based on the patient's condition and performed by experienced surgeons at large volume centers are necessary. Extensive clinical and radiologic follow up must be conducted, proving that minimally invasive esophageal approaches are more than small incisions and carry maximal surgeon involvement beyond the operative theater.

Introduction: Patient positioning has been found to be a simple technique to improve luminal distention and visualization during colonoscopy. We hypothesize that the right lateral position provides the best view of the cecum allowing for early detection of precancerous lesions. Methods: As part of a larger, recently published RCT involving 192 patients, a sample of 90 sets of cecal images were obtained from patients undergoing a nonurgent colonoscopy. Each set included cecal images of patients while lying in three different positions -right lateral decubitus, left lateral decubitus, and supine. Two authors reviewed these sets of images and excluded those that were incomplete or unclear. A third author, who was blinded to the patient position, selected the final 18 sets of images to be entered into a survey. Two experienced endoscopists completed the survey of each image set. They were asked to use the Boston Bowel Prep Scale to assess and score each image. The Boston Bowel Prep Scale was used as our primary outcome measure. The endoscopists also ranked each image set in terms of the best overall view of the cecum. Data were collected using the Qualtrics online survey program. Nonparametric tests were used to analyze the data using SPSS software (v.25). A p-value of B 0.05 was considered significant. Results: The Kruskal-Wallis Test was used to compare the three different positions using the Boston Bowel Prep Scale and showed a significant difference between patient positions (p = 0.005). The Mann-Whitney U test was used to compare each pair of images (Right vs Left, p = 0.002, Mann-Whitney U = 1499), (Right vs Supine p value = 0.035, Mann-Whitney U = 1826) and (Left vs Supine p value = .172, Mann-Whitney U = 1898). The U tests indicated that the right lateral position was ranked higher than either left lateral or supine positions. There was no difference in the left and supine patient positions. Cohen's Kappa value of 0.443 suggested moderate agreement between raters. In terms of the raters overall ranking of images, excluding ties, there is a clear preference favoring the right lateral position over the other positions (p \ .001). Conclusion: These Results indicate that positioning patients in the right lateral decubitus position provides the best view of the cecum during colonoscopy.

Artificial intelligence generated analytics from laparoscopic video estimates operative experience Thomas M Ward, MD; Daniel A Hashimoto, MD, MS; Yutong Ban, PhD; Guy Rosman, PhD; Ozanan R Meireles, MD; Massachusetts General Hospital Introduction: Artificial Intelligence (AI) can analyze and accurately recognize operative phases (steps) in laparoscopic and endoscopic procedures. With laparoscopic cholecystectomy as a model procedure, we investigated using AI-generated metrics to estimate a surgeon's years of operative experience. Methods: A dataset of 200 laparoscopic cholecystectomy videos was utilized. An AI model -Convolutional Neural Network plus Long Short-Term Memory -was trained to recognize operative phases on 80 labeled videos. The trained model then analyzed 120 different videos and generated, from the predicted likelihoods of different operative phases, forty-five metrics to quantify performance, such as the duration of phases, the model's certainty, and the number of phase transitions. We performed a multivariate analysis to estimate the surgeon's year of clinical practice from the metrics using Lasso-penalized regression as our variable selection technique. Results: Nineteen surgeons, with zero to thirty-three years of clinical practice, operated in the videos. Lasso-penalized regression of practice year selected six of forty-five AI-generated metrics for the highest-performing model. Post-selection inference showed that more experienced surgeons tended to clip the cystic duct first (p = 0.018), dissect the triangle of Calot more quickly (p = 0.004), and dissect out the cystic duct in a manner such that the AI model could recognize the action of clipping with higher certainty (p = 0.003). Conclusion: AI can generate, from surgical video alone, operative performance metrics that were associated with the operating surgeon's clinical experience. These personalized metrics could find use in surgeon training, real-time feedback, and certification.

Conservative management of placenta accreta using helium plasma focused radiofrequency energy: a surgical technique Peter Khamvongsa, MD, FACOG, FACS; Bianca Nguyen, BS; Diana Rodriguez, BS; Anthony Rodriguez, BS; Naiya Patel, BS; Florida International University Herbert Wertheim College of Medicine Background: The incidence of placenta accreta has been steadily rising secondary to increased cesarean section rates and advancing maternal age. Morbidly adherent placentas are associated with significant maternal morbidity and mortality and often result in cesarean hysterectomy due to life-threatening hemorrhage. The helium plasma device utilizes radiofrequency to ionize helium into a plasma beam capable of coagulating and fulgurating tissue with high precision and minimal thermal spread. This instrument is FDA approved for open and laparoscopic surgery but has not been evaluated in the treatment of placenta accreta during cesarean section. The purpose of this case was to apply conservative management by utilizing a helium plasma device to fulgurate placenta accreta. Methods: 35-year-old gravida 3 para 2 female with two prior cesarean sections presented with a partial placenta accreta. T2 MRI weighted imaging revealed a focal area of placenta accreta in the right lateral placenta. Repeat cesarean section with low transverse uterine incision and uterine exteriorization was performed at 38 weeks and 6 days gestation. The helium plasma radio frequency plasma device was utilized to fulgurate the placenta accreta at 40% power 4 L/min gas flow for 25 s, providing adequate hemostasis of retained tissue. Pathology revealed a placental disc weight of 391 g. Quantitative blood loss was 450 cc. Preoperative hemoglobin was 13.6 g/dL and postoperative hemoglobin was 12.7 g/dL. The patient remained hemodynamically stable without postoperative complications. Discussion: Obstetric hemorrhage and peripartum hysterectomy were avoided in our patient, allowing for future fertility. Safety of the helium plasma device in gynecologic surgeries has been documented and studies demonstrate a superior safety profile for this device in comparison to monopolar energy that has been previously utilized in the management of placenta accreta. The precision of plasma energy allows for optimal depth of penetration with minimal injury to surrounding healthy tissue. This approach minimizes the need for blood transfusions or other invasive and morbid procedures. Conclusion: The helium plasma device is a viable uterine and fertility-sparing option for management of a focal placenta accreta. To our knowledge, this is the first documented case of utilizing a helium plasma device during cesarean section for safe and effective treatment of placenta accreta. Further research is necessary to investigate the safety and surgical application of this tool in the treatment of abnormal placentation. This device provides a safe and novel option to potentially decrease maternal morbidity and mortality associated with morbidly adherent placenta.

Improved visibility during bariatric surgery with in situ laparoscopic lens cleaning Matt B Martin, MD; Central Carolina Surgery, PA Objective: When surgeons perform laparoscopic bariatric procedures, the scope is their sole means of visualizing the internal anatomy so they can work with safety, precision and efficiency. As they work, blood, oil, smoke and vapor can collect on the lens, blurring or obscuring their view. At that point, the scope is removed, a technician cleans the optics, and the scope is re-inserted and reorientation has to occur. This process, which can be even more challenging for the novice camera tech, is disruptive. Because this disruption can occur repeatedly throughout the procedure, it extends the duration of surgery and anesthesia time. The delay can be longer for very obese patients because it may take longer to remove, reinsert, and reposition: the scope.

To determine if an in situ lens cleaning device (ClickClean, Medeon Biodesign) would allow surgeons to improve visualization during bariatric surgery, reducing scope removals and surgical time, 8 bariatric procedures were performed using the device. Solution: ClickClean is an in situ lens cleaning device comprised of a sheath, a trigger box, and a transparent, biocompatible film that slides in front of the laparoscopic tip. The surgeon sees a normal, clear view through the film. When blood, oil, smoke or vapor soils the lens, the camera tech clicks the trigger and the device slides a clean length of film into place. Visualization is restored in seconds without removing the scope, so the surgeon can maintain orientation as well as clear view without blurring or delay. Data: In 2020, three surgeons performed eight bariatric procedures using Click-Clean. Six patients underwent a gastric sleeve procedure, while two patients had gastric bypass surgery. Surgeons performing sleeve gastrectomy used ClickClean roughly 5 times per procedure. During gastric bypass surgery, ClickClean was used an average 6 times per procedure. Users noted that ClickClean was easy to assemble, ''performed very well,'' saved several minutes of cleaning time per use, provided clear visibility, allowed surgery to continue uninterrupted, required less skill from camera operators, and often required only one click to attain a clear view.

Conclusions: ClickClean performed well during bariatric surgery, with all surgeons expressing appreciation for the clear view it provides very quickly. Users reported saving a few minutes for each use, which can translate to significant savings in OR time when multiplied by 5-6 uses per surgical procedure. ClickClean is an effective in situ cleaning device for the laparoscopic lens that reduces the duration of bariatric surgery and allows surgeons to work uninterrupted with continuously clear visualization.

Alternate site peritoneal dialysis catheter placement: a solution for problematic pelvic adhesions?

Introduction: Renal replacement therapy is a highly utilized intervention and thus is a large economic healthcare burden globally. In comparison to in center hemodialysis, peritoneal dialysis (PD) is more cost-effective and allows for increased patient flexibility. Surgeons are often tasked with placement of PD catheters and therefore must be able to troubleshoot associated complications and difficulties. Once such problem is that of a malfunctioning PD catheter due to pelvic adhesions. The aim of this case report is to describe a solution to this issue by alternate site placement. Case description: A 65 year old male with history of diabetes, HTN, CKD, and invasive urothelial carcinoma of the bladder s/p TURBT and cystectomy with ileal conduit diversion presented after several months of a malfunctioning peritoneal dialysis catheter. He had laparoscopic revision of his PD catheter on three previous occasions due to malfunction. The patient also endorsed a difficulty with constipation. He was scheduled for diagnostic laparoscopy and laparoscopic PD catheter revision. Upon entry into the abdomen, dense pelvic adhesions were encountered in addition to the ileal conduit. Mobilization was not attempted due to concern for possible bowel injury and likely reformation of adhesions that would prevent future dialysis efforts. An 8-mm trocar was inserted in the right upper quadrant and tunneled under the peritoneum in the caudal direction. The peritoneal dialysis catheter was introduced via this 8-mm port and the coiled in was tucked above the liver (Fig. 1) . The deep cuff was left in the preperitoneal space while the remainder of the catheter was tunnelled out medially. Upon completion, a liter of heparinized saline was dwelled in the abdomen with a return of that majority of that volume.

Upon follow up, the PD catheter was working well and was without issue. Conclusions: Peritoneal dialysis allows for patients to have greater independence and improved quality of life. PD catheters can malfunction for a myriad of reasons, including pelvis obstruction due to intra-abdominal adhesions or even constipation. Patients who experience difficulty with this may benefit from alternate site PD catheter placement, specifically above the liver. This case report demonstrates success with this technique. Introduction: Conventional endoscopy produces 2D colored video images, which do not provide surgeons an actual depth perception of the scene. 3D endoscopy can provide better depth perception and help surgeons achieve more precise operations. The current state-of-the-art is dual-lens 3D stereo endoscopy which synthesizes a stereo image from the images obtained with lens enclosed in a single endoscope tube. Such system has limitations including not simulating the convergence of human eyes, not suitable for wide angle camera, and expensive. Therefore, we propose a 3D MonoStereoÒ system that utilizes existing 2D endoscopic systems to render real-time stereoscopic images during surgeries. 3D MonoStereoÒ system is produced by Taiwan MedicalTek Co. Ltd. It consists of a fast and efficient processor which converts 2D real-time endoscopic images to 3D images using complex algorithms and displays them on high-definition monitors. The 3D images can be visualized after wearing a polarized light glass. The system already has the CE, Australia FDA, TFDA and FDA Certifications. Methods and procedures: This study retrospectively reviewed and analyzed the medical charts. Patients who underwent 3D endoscopic surgery from March to June 2020 are the subjects of this study. We collected surgeons' feedback data for statistical analysis to compare benefit of rigid endoscope and flexible endoscope. All statistical analyses were performed using SPSS version 24 and p value of \ 0.05 was considered to be statistically significant. Results: We performed a feedback survey of surgeons who utilized the stereoconversion system for clinical surgery. The scores of the stereo perception, fluency and comfort were not significantly higher in rigid endoscope than in flexible endoscope (P [ 0.05). Duration of seeing the 3D screen was significantly longer with rigid endoscope than with flexible endoscope (P \ 0.001).The flexible endoscope was mostly used in division of gastroenterology, while the rigid endoscope was mostly used in divisions of general surgery and urology. The stereo perception strength was almost used level 2 for flexible endoscopes, and was almost level 3 for rigid endoscopes. Conclusions: With availability of three dimensional and 4 K technologies, endoscopic procedures have potential to utilize the imaging techniques further. To evaluate the effectiveness of 3D MonoStereoÒ system for clinical surgery, it is necessary to compare 3D MonoStereoÒ system and 2D endoscopic system of the parameters such as blood loss, number of harvested LNs, number of used gauzes, operation time, etc.

Robotic resection of an insulinoma Brianne Runyan, MD; Shyam Allamaneni; The Jewish Hospital of Cincinnati The patient was a 41-year-old female who was diagnosed with an insulinoma. She originally presented to her primary care physician with complaints of disorientation, blurry vision, dizziness, headaches and nausea 4 h after eating a meal and resolution with food. She also was experiencing vague right-sided abdominal pain. She underwent a computed-tomography scan which showed a 1.5 9 1.5 cm mass in the neck of the pancreas. An EUS with biopsy confirmed a low-grade neuroendocrine tumor. Given her persistent symptoms, patient underwent a Robotic-assisted laparoscopic pancreatic tumor resection. Final pathology showed a well-differentiated neuroendocrine tumor.

Severe postpancreatectomy hemorrhage (PPH) over one year following Whipple procedure: a case report E O'Brien 1 ; B Evans 2 ; P Collingwood 1 ; J Ellsmere 2 ; M Hogan 1 ; 1 Memorial University of Newfoundland; 2 Dalhousie University Background: Postoperative hemorrhage is one of the most severe complications following pancreatoduodenectomy. PPH occurs in less than 10% of patients undergoing a Whipple procedure but accounts for 10-38% of perioperative mortality 1 . Onset is defined as early (B 24 h after the index operation) or late ([ 24 h) 2 . Median onset of delayed PPH has been recorded between 10-27 days, but rare case reports have documented PPH up to 240 days following the index procedure 3, 4 . Aim: To describe a rare case of PPH presenting as an upper gastrointestinal bleed (UGIB) over one year following pancreatoduodenectomy. Description: A 52-year-old man presented with hematemesis, hematochezia and hemodynamic instability 15 months following an uncomplicated pancreatoduodenectomy for a mucinous cystic neoplasm causing biliary and pancreatic obstruction. Past medical history revealed hypertension, type 2 diabetes, and hyperlipidemia. He had a 1 pack per day smoking history and consumed 2-3 drinks weekly. Following resuscitation and initial work-up, his hemoglobin level was 129 g/L, down from 159 g/L four months prior. Gastroscopy was performed urgently and revealed a large amount of clotted blood in the stomach. Gastrojejunostomy was visualized, afferent and efferent limbs were inspected. No active bleeding was seen. A Dieulofoy's lesion was suspected on the lesser curvature of the stomach which was treated with endoscopic clips and the patient stabilized with resuscitation. Fortyeight hours following admission, the patient developed hematemesis and became hemodynamically unstable once again. Repeat gastroscopy and CT angiography (CTA) were both unsuccessful at localizing the source of bleeding. The patient then developed a third episode of hemodynamic instability and was taken to the operating room. Laparotomy and anterior gastrotomy revealed clotted blood in the stomach, but the source was not localized. Bleeding persisted postoperatively and a repeat CTA revealed hemorrhage from the GDA stump into the pancreaticobiliary limb. Coil embolization was performed and bleeding was controlled (Fig. 1) . The patient fully recovered and was discharged several days later. Discussion: We have described a case of severe PPH 15 months following pancreaticoduodenectomy presenting as UGIB. Etiology of this bleed is uncertain but may be secondary to prior pancreatic leak weakening the GDA stump combined with ulceration or infection near the staple line. Physicians should consider early angiography in patients with UGIB following pancreatic surgery. Introduction: The Laparo-Endoscopic Single Site (LESS) approach has proven its cosmetic benefit. This study was undertaken to compare the application of the LESS vs. robotic approach for distal pancreatectomy and splenectomy utilizing propensity score matching (PSM). Methods: With IRB approval, we prospectively followed 136 patients who underwent the LESS or robotic approach for distal pancreatectomy and splenectomy. 22 patients who underwent the LESS approach were matched with 22 patients who underwent the robotic approach. Patients were matched by cell type, tumor size, age, sex, and BMI. For illustrative purposes, the data are presented as median(mean ± SD). Results: When utilizing PSM, patients undergoing the LESS vs. robotic approach were 66(64 ± 10.5) vs. 67(64 ± 10.3) years-old (p = NS) with a BMI of 25(25 ± 4.5) vs. 25(25 ± 4.2) kg/m 2 (p = NS). There were seven (with LESS) vs. two (with robot) conversions to 'open' (p = NS); operative duration was 180(180 ± 52.0) vs. 248(262 ± 78.5) minutes (p = 0.0002) and estimated blood loss (EBL) was 200(317 ± 394.4) vs. 100(128 ± 107.2) mL (p = 0.04) The LESS approach had one intraoperative complication (i.e., portal venotomy with venorrhaphy due to abutment of the tumor on the portal vein) vs. zero for the robotic approach (p = NS). There were four patients with the LESS approach (e.g., pneumonia, colonic leak, respiratory insufficiency) vs. one patient with the robotic approach with postoperative complications (p = NS). With the LESS vs. the robotic approach, length of stay was 4(7 ± 5.5) vs. 4(5 ± 3.5) days (p = NS), there were five vs. four readmissions within 30 days (p = NS), and there were zero in-hospital mortalities (p = NS). The hospital cost of the LESS approach was $15,962(21,557 ± 15,067) vs. $24,536(25,548 ± 11,192) for the robotic approach (p = NS). Conclusion: The robotic approach had a significantly lower EBL while the LESS approach had a shorter operative duration. Both approaches demonstrated similar salutary patient outcomes. We believe both should be adopted and situationally utilized.

Discharge opioid prescribing following laparoscopic sleeve gastrectomy and gastric bypass Sarah Diaz, DO; Alissa Dandalides, RD; Arthur M Carlin, MD; Henry Ford Macomb Hospital Background: Overprescribing of opioids after surgery increases new persistent opioid use and diversion contributing to the opioid epidemic. There is lack of evidence regarding discharge opioid prescribing after bariatric surgery. Methods: A total of 89 patients completed a questionnaire regarding discharge opioid use two weeks postoperatively. Michigan Automated Prescription System (MAPS) was used to evaluate perioperative opioid prescriptions. Five preoperative opioid users were excluded from analysis. Multimodal analgesia was used including 5 mg oxycodone pills as needed during hospitalization with five prescribed on discharge if requested. Results: The cohort of 84 patients included those having LSG (72) and LGB (12). Fifty-five patients (65%) received a prescription for opioids on discharge and 90% filled their prescription. Only 44% (22/50) of those filling their opioid prescription took any opioids. Opioid use on the surgical ward was predictive of opioid use after discharge with both univariate (OR 12.44, p \ 0.001) and multivariate (OR 2.48, p \ 0.001) analyses. The number of opioid pills taken in-hospital was positively correlated to the number of pills taken after discharge. Those who took none, 1 to 3, or 4 or more opioid pills on the surgical ward took 0.14 ± 0.48, 0.95 ± 1.71, and 3.14 ± 1.86 pills after discharge (p \ 0.001). No patients required a refill of their opioids within 90 days of surgery with MAPS confirmation. Conclusion: Postoperative in-hospital opioid use following laparoscopic bariatric surgery predicts opioid use after discharge. This can guide prescribing of opioids for a patient-specific quantity and mitigate diversion and chronic opioid use.

Instituting a colorectal enhanced recovery after surgery (ERAS) program in a community hospital setting Introduction: Recently, implementation of Enhanced Recovery After Surgery (ERAS) protocols have shortened postoperative stay and improved outcomes after colorectal surgery. It can be challenging to implement an ERAS protocol in a community setting, as resources tend to be more limited compared to academic centers. In this study, we aimed to evaluate outcomes of an ERAS protocol after elective open colorectal resection at a community-based hospital. Methods and procedures: This was a single-institution, single-surgeon, retrospective study of all patients in a community hospital who underwent open elective colorectal resection from 2014-2019 and utilized an ERAS protocol consisting of 23 standardized pre-operative, intra-operative, and post-operative interventions. The study population was divided into early (2014-2016) and late (2017-2019) cohorts. Outcomes were compared amongst the two cohorts, and to relevant studies published in the literature, using Fisher's exact test for categorical variables, and Student's t test for continuous variables. Primary endpoints were adherence to the ERAS protocol, length of hospital stay (LOS), and times to first flatus and bowel movement. Secondary endpoints were major 30-day perioperative morbidity, mortality, and reoperation. Results: Seventy-one patients were included; 38 in the early cohort and 33 in the late cohort. The most common indication for surgery was colon cancer (79%), and the most frequent operations performed were a right hemicolectomy (38%), and low anterior resection (34%). The median length of stay (3 days), 30-day complication rates (17.1%), readmission rate (9.9%), mortality (0%), and compliance with ERAS (greater than 80% compliance with 9 or more interventions) compared favorably with the literature from academic institutions. There was increased compliance with the ERAS protocol in the late cohort, with those patients more likely to receive celecoxib pre-operatively (45% vs. 21%) and post-operatively ( 55% vs 21%), postoperative gabapentin (61% vs. 29%), receive smaller volume of intravenous fluids (1600 cc vs. 2500 cc), start on a liquid diet on the first postoperative day (45% vs. 8%), be discharged on a non-narcotic pain regimen (85% vs. 29%), and were less likely to have a postoperative nasogastric tube placed (6% vs. 29%). The late cohort showed a trend towards a decreased median time to regular diet (2 vs. 3 days) and median postoperative length of stay (3 vs. 4 days) when compared with the early cohort. Conclusions: Implementation of an ERAS protocol is effective in the community hospital setting, and is associated with favorable outcomes with regard to LOS, complication rates, readmission rates, and mortality.

Chronic complications of common bile duct injuries in the era of laparoscopic cholecystectomy: is it time foa a national registry? Anastasios Mitsakos, MD; Fernando Brea, MD; Eric J DeMaria, MD, FACS; Janet E Tuttle-Newhall, MD, FACS; East Carolina University, Department of Surgery Introduction: Injuries to the extrahepatic biliary tree, also collectively referred to as common bile duct (CBD) injuries, are some of the least common complications of laparoscopic cholecystectomy. Current incidence of injury is reported to be 0.1%-0.5% in the literature. However, long-term impact of these injuries is not known. Previous literature has shown that long-term complications of creating enteric-biliary anastomosis can occur, such as biliary strictures, infectious cholangitis, secondary sclerosing cholangitis, and can complicate common surgical management of entities such as small bowel obstruction. Despite multiple regulatory requirements for data collection, there is currently no national standardized registry that gathers and monitors acute and chronic complications of CBD injuries after laparoscopic cholecystectomy and repair, as well as the management of their delayed presentation. Methods and procedures: An analytical literature review of a total of 31 original articles was performed using the PubMed medical library with regard to chronic complications of CBD injuries and associated repair after laparoscopic cholecystectomy. In addition, the search was extended in order to identify locoregional, national, or international registry systems that have been instituted to chronically follow patients with such complications in the United States or elsewhere. Results: Despite several locoregional prospective and retrospective institutional studies, case reports and series of patients describing delayed presentation and associated risk factors of chronic CBD injuries after laparoscopic cholecystectomy, no standardized data collection registry exists currently in the United States or in other national health systems. The actual consequences of these complex injuries, such as impact on life span, development of comorbidities and quality of life of these patients, remain unknown. Conclusions: Despite advances in electronic health records and standardized surgical registries regarding post-operative outcomes, there is paucity of data regarding acute and chronic consequences of CBD injuries after laparoscopic cholecystectomy. Due to the potentially harmful effect of these injuries in patients' quality of life and overall health care, a national surgical registry should be instituted across the United States to assess in a standard fashion the short-and long-term impact of CBD injuries, including delayed presentations, with the goal of quality improvement in surgical care and patient outcomes.

Adapting a tertiary-care hospital operating room ventilation system to maximize safety in COVID-19 patients Jacky Z Kwong, MD 1 ; Darin T Desmond, RN, BSN 2 ; Randall Dupuy, RN, BSN 2 ; Roger P Tatum, MD 1 ; Edgar J Figueredo, MD 1 ; 1 University of Washington; 2 Seattle VA Medical Center Background: Most operating rooms are positive pressure environments. National guidelines recommend caring for COVID-positive patients in negative pressure rooms as part of standard airborne infection prevention. Therefore, operating rooms would ideally be converted from positive to negative pressure to accommodate COVID-positive patients. Study design: This is a case report describing the method to adapt a standard, tertiary-care hospital operating room's ventilation system from positive to negative pressure. Three negative air exhaust machines and a prefabricated anteroom were used to create pressurization. Multiple monitoring devices verified the Results of the modifications. Results: The modified operating room achieved a pressure differential of -0.022 water column in inches, air flow volume differential of 382 cubic feet per minute, and 26 air exchanges per hour. Exhausted air was not recirculated and filtered prior to release outside. Overall costs were reasonable relative to alternative methods. Conclusion: The described method achieved negative pressurization that exceeded national guidelines. The modifications can be implemented relatively easily and inexpensively without significant changes to existing infrastructure. Healthcare facilities can quickly apply this strategy to safely care for COVID-19 patients.

The association between minimally invasive gastrointestinal cancer surgery and readmissions due to venous thromboembolism P581 Assessment of online patient education resources from MBSAQIP accredited bariatric centers in the United States Kevin K Seeras 1 ; Robert J Acho, DO 2 ; Elisabeth Ekkel, DO 2 ; Konstantinos Spaniolas, MD 1 ; Aurora D Pryor, MD 1 ; Salvatore Docimo, DO 1 ; 1 Stony Brook University Hospital; 2 Henry Ford Macomb Hospital Background: The American Medical Association (AMA) and the National Institutes of Health (NIH) have determined through several studies that patient information should be written at a sixth-grade reading level or below. The aim of this study is to evaluate the reading level of online patient material provided by MBSAQIP Accredited Bariatric Centers in the United States. Methods: The centers' general description of a sleeve gastrectomy was copied and pasted into the Readable.io service and the following readability tests were conducted: Flesch-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), Coleman-Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG). The four readability tests were compared to the recommended readability level (grade level B 6.9) utilizing a one-sample t-test. Results: Of 508 centers, one (0.2%) had met the recommended reading level in all four tests and 28 (5.5%) had fulfilled the recommended reading level in at least one of the four tests. The mean test scores for all centers (n = 508) were as follows: FKGL (10.94 ± 2.55), GFI (13.59 ± 2.96), CLI (11.9 ± 2.19) and SMOG (12.81 ± 2.16). All centers were compared to a value of 6.9 with a one-sample t-test revealing a p-value of well below 0.05 for all four tests and were considered statistically significant. The centers' readability scores for the four tests were categorized into easy (\ 6), moderate (6-10), Difficult (10-17) and Doctorate/ Master's Degree Level ([ 17) . The four tests were averaged and demonstrated that the majority of centers (76%) provided online patient education materials in the difficult category of readability.

Conclusions: The majority of MBSAQIP Accredited Bariatric Centers in the United States provide online educational materials at a reading level well above the recommendations provided by the NIH and AMA. Consideration should be placed on reworking patient education materials to limits barriers to care.

Advancing quality improvement in surgical capacity in Kenya: development of the Kenya Hospital assessment tool Dr. Jaymie Henry 1 ; Patrick Mwai 2 ; 1 Florida Atlantic University Department of Surgery, Boca Raton, FL; 2 International Collaboration for Essential Surgery Introduction: In Kenya, the Ministry of Health (MoH) estimates that 70% of the population lack access to safe, affordable surgical, obstetric, trauma, and anesthesia services. This has resulted in high cases of mortality and morbidity from conditions that could be treated surgically. However, despite the above estimate there was lack of County and facility based data specifically focusing on government facilities that MoH could use in decision making and policy formulation. This paper describes the initial steps towards the development of the Kenya Hospital Assessment tool by various stakeholders led by the MoH. Methods: The MoH appointed a multi-sectoral collaborative group which was tasked with localizing the existing World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) tool and the Situational Analysis Tool (SAT) developed by the Global Initiative for Emergency and Essential Surgical Care (GIEESC) office. These two tools were merged and adapted for local use through a series of focused group meetings with the participation of the Specialized Clinical Services Unit of the Kenya MoH. The surgical capacity study used Open Data Kit (ODK) to collect facility assessment data because it saves time, was easy to track collected data and improved the quality and accuracy of data collected. ODK is a free and open source android based application made up of a set of tools that enable organizations manage electronic data collection using a mobile phone based app. It is a flexible and standard based data collection kit. Results: The K-HAT comprises of 89 questions representing over 800 data points divided into 7 WHO Health Systems Strengthening (HSS) sections: Basic Facility Information, Human Resources for Health, Infrastructure and Equipment, Health Services, Leadership and Governance, Health Information Systems, and Health Care Financing. In terms of cost savings, the use of ODK eliminated the use of 8,785 hard copies which would have cost approximately KES 87,850 (USD 878.5) in printing costs. Conclusion: This new tool was used to collect reliable baseline national surgical capacity data that highlighted specific areas of improvement in level 4 hospitals in Kenya as well as provided critical baseline information for the development of the country's National Surgical Obstetric, Trauma and Anaesthesia Plan (NSOTA). This tool could be used as a guide by other countries that intend to collect facility based data for national planning and policy formulation.

Laparoscopic gastrectomy is associated with lower 30-day morbidity, including pneumonia, among elderly patients with gastric cancer Kyle D Klingbeil, MD, MS; Michael Mederos, MD; Daniela Markovic, MS; Victor Y Chiu, MD; Mark D Girgis, MD; Brian Kadera, MD; UCLA Ronald Reagan Medical Center Despite modest improvement in chemo-and immunotherapy, surgical resection for gastric cancer (GC) represents the best chance for durable remission. Laparoscopic gastrectomy (LG) has been shown to be a safe alternative to open gastrectomy (OG), yet is underutilized by most centers. The aim of this study was to provide an updated comparison of short-term outcomes for patients with GC who underwent either LG or OG.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried to identify patients with GC who underwent non-emergent LG or OG between Jan 2012-Dec 2018. Post-operative complications were compared between groups using inverse probability of treatment weighted (IPTW) regression models to balance baseline covariates. Multivariable regression models were performed to identify covariates associated with significant outcomes.

In total, 2,036 patients underwent gastrectomy for GC (LG n = 622, 23.4%). Within the IPTW analysis, LG demonstrated lower odds of any complication, pneumonia, surgical site infection (SSI) and readmission. When stratifying by age, elderly patients (70-89 years) underwent LG less often compared to younger adults (\ 50 years) (22.7% vs 30.0%, p = 0.01) and experienced higher rates of any complication (34.66% vs 21.88%, p \ 0.001). Among elderly patients, those who underwent LG had lower odds of any complication, pneumonia, SSI and readmission. Covariates associated with pneumonia included open approach (OR 2.67, p = 0.004), dyspnea (OR 1.96, p = 0.02), weight-loss (OR 2.24, p = 0.005), BMI [ 30 (OR 1.53, p = 0.059) and age C 70 years old (OR 1.66, p = 0.023).

LG is associated with lower overall 30-day morbidity and reduces the odds of pneumonia, SSI and readmission compared to OG. This effect appears to be most beneficial among elderly patients with GC, suggesting LG as the preferred approach in this subgroup. Introduction: A patient's journey through an elective surgical admission is a complex process involving multiple teams and disciplines. One area where multiple disciplines converge is the time spent in the operating room before and after the surgical procedure. With the introduction of a new bariatric surgery program in our institution, anticipating a learning curve associated with new equipment, procedures, positioning, induction technique, and patient flow, we incorporated a critical multidisciplinary process review during the surgical debrief at the end of each procedure. We hypothesized that progressive process improvement could be demonstrated by measuring non-operative room time as a surrogate of multidisciplinary OR efficiency.

Methods: Planning for the introduction of a new bariatric program at our institution an extensive process of multidisciplinary input included nursing and hospital staff from all areas of care, surgeons, and an anesthesia champion. Patient flow and perioperative care was standardized, as was surgical equipment and technique. A simulated patient walkthrough or surgical ''dress rehearsal'' concluded preparations. Beginning with program launch, data was prospectively collected following Internal Review Board-approved, provincially mandated, reporting requirements. For this assessment, the non-operative room time, representing the proportion of total room time excluding the incision to closure surgical time, was collected during the first 18-months of the program. Results: Two surgeons performed a total of 238 bariatric procedures comprising 200 laparoscopic Roux-en-Y gastric bypasses, 26 bypasses with other procedures, and 12 laparoscopic sleeve gastrectomies. Mean BMI was 47.1 ± 7.4 kg/m 2 . Mean skin to skin operating time was 116 ± 28 min for all procedures. As trainee involvement increased, the operating time for LRYGP alone increased slightly comparing the first 100 cases to the last 100 cases (109 ± 19 vs. 119 ± 26 min, p = 0.002) while BMI did not change significantly (46.0 ± 5.9 vs. 47.8 ± 8.1 kg/m 2 , p = ns). Mean daily non-operative room time was 30 ± 6% of total room time. There was a significant downward trend in non-operative room time over the first 18 months (r = -0.45, p = 0.035) with a 15% relative reduction between the first and last 100 cases. Conclusion: During the introduction of a new bariatric surgery program, a critical multidisciplinary process debrief led to significant continuous improvement in operating room efficiency as measured by gradual decline in non-operative room time.

Development and pilot-testing of an intra-operative smartphone application that can help surgeons prevent bile duct injury complication during laparoscopic cholecystectomy procedures Michael Dennis I dela Paz, MD 1 ; Calimag P Maria Minerva, MD 1 ; Miguel C Mendoza, MD 2 ; 1 University of Santo Tomas Graduate School; 2 Asian Hospital and Medical Center Laparoscopic cholecystectomy, the gold standard treatment for symptomatic gallstones, has a treacherous risk of bile duct injury (BDI). Since 1995, a universal culture of safety for cholecystectomy was established when Strasberg introduced the ''Critical View of Safety'' (CVS) which leads to various training and innovative programs whose main goal is to absolutely eliminate BDI. Gap still exists as estimated 3 out of 1000 cholecystectomies still lead to BDI. Development and internal validity analysis of a Smartphone Application that identify CVS intra-operatively through image recognition and involvement of the community of expert surgeons through real-time networking decision strategy can be of help to absolutely prevent BDI. Upon development of the Surgical Safety smartphone app, a mock pilot testing using doublet view CVS pictures of previous known-outcome laparoscopic cholecystectomies. Both the Results of the image recognition as well as the answer of the expert surgeons are at par with accuracy and precision of identifying the critical view of safety although both complimented well to each other. Recommendation that in the future, this surgical safety App can be used in actual laparoscopic cholecystectomy procedure as an interactive zero bile duct injury timeout procedure right before clipping or ligating any structures.

Limited scalability of single deep neural network for surgical instrument segmentation under different surgical environments Background: Surgical instrument segmentation and tracking for their tips are important underlying technology for robotics development and skill assessments. To clarify the scalability of a single surgical instrument segmentation network under different surgical environment from training set can be important benchmark for future research and development in terms of exploring possibility to reduce the annotation cost. The objectives of this study is to comprehensively evaluate the scalability of single deep neural network for surgical instrument segmentation, i.e., to clarify the difference of segmentation accuracy when single network is applied to different conditions including laparoscopic recording system, recognition target surgical instrument, and type of surgery.

Methods: This was a retrospective experimental observational study. Total of 5238 images extracted from 128 intraoperative videos were utilized for this study. The video dataset contained 112 cases of laparoscopic colorectal resection, 5 cases of laparoscopic distal gastrectomy, 5 cases of laparoscopic cholecystectomy, and 6 cases of laparoscopic partial hepatectomy. Deep learning-based surgical instrument segmentation were performed for following test sets. Test set-1: same condition as training set; test set-2: recognition target surgical instrument and type of surgery were same but videos were recorded with different laparoscopic systems; test set-3: laparoscopic recording system and type of surgery were same but type of recognition target laparoscopic surgical forceps were different; test set-4: laparoscopic recording system and recognition target surgical instrument were same but type of surgery were different. The mean AP (mAP) and the mean intersection over union (mIoU) were utilized as metrics to assess the model performance. Results: In surgical instrument segmentation task, the mAP/mIoU in test set -1, 2, 3, and 4 were 0.941/0.887, 0.866/0.671, 0.772/0.676, and 0.588/0.395, respectively, i.e., recognition accuracy were statistically significantly deteriorated even under slightly different conditions including type of laparoscopic recording system, type of surgical forceps, and type of surgery as image background. Conclusions: In order to enhance the generalization ability of the deep neural network in surgical field, it would be crucial to construct the training set as considering diversity of surgical environment in real world surgical setting.

Fellowship after general surgery residency: are left hand dominant residents drawn to robotic surgery? Mark Dalvin, MD; Thomas Kerestes, MD; Western Reserve Health Education Left handedness has been historically viewed as a disadvantage amongst surgeons [1] . This is often attributed to surgical instruments being created for right handdominant surgeons as well as the lack of left-handed surgeon role models for surgical residents to emulate [2] . Robotic surgery growing quickly in the realm of general surgery, and it is frequently being used for many procedures including colorectal surgery, bariatric surgery, herniorrhaphy, and cholecystectomies. Recent studies have shown that robotic surgery can reduce the severity of hand-dominance, lending itself to be theoretically more accessible to left hand-dominant residents compared to other surgical approaches such as open surgery and basic laparoscopic surgery [3, 4] . Left hand-dominance may have other implications such as increased creativity and ability to adapt to the environment [5, 6] . Left hand-dominance has also anecdotally been associated with increased use of video games as well as being more likely to play a musical instrument [7] . It is also thought that left hand-dominant people are more likely to have ambidextrous traits than right hand-dominant people [8] . With the potential for a decreased learning curve in robotic surgery and perhaps a natural advantage, it is possible left hand-dominant surgical residents may be more likely to favor robotic surgery compared to other subspecialties when choosing a fellowship after residency.

Constructing platform for the development of informationpowered surgery Nobuyoshi Takeshita, PhD 1 ; Hiro Hasegawa 1 ; Daichi Kitaguchi 1 ; Nobushige Takeshita 1 ; Shin Takenaka 1 ; Kimimasa Sasaki 1 ; Takahiro Igaki 1 ; Shigehiro Kojima 1 ; Kensaku Mori 2 ; Masaaki Ito 1 ; 1 National Cancer Center Hospital East, Japan; 2 Nagoya University, Japan The benefits of endoscopic surgery have been widely recognized in recent years, and the number of procedures performed has been increasing worldwide. On the other hand, endoscopic surgery requires a high level of skills, and disparities in outcomes between expert and novice surgeons have been reported. It is important to visualize ''tacit knowledge of surgery'' and make use of them for the development of novel surgical support systems and surgical education.

We are collecting surgical information from all over the country and build a large scale video database of endoscopic surgery to develop information-powered surgical systems with the funding of Japan Agency for Medical Research and Development (AMED). We call this project ''S-access JAPAN''. The surgical video database including colorectal resection, gastrectomy, hepatectomy, pancreatectomy, prostatectomy and cholecystectomy can be shared with the clinical, academic and industrial collaborators. By using this database, our collaborative team is developing information-powered surgical systems which consist of Information Rich Platform and Autonomous View Control. Artificial intelligence (AI), especially convolutional neural network (CNN)-based deep learning methods, has been introduced to develop the autonomous visual recognition system as elemental technologies for these works.

A total of 256 operative videos of laparoscopic left-sided colorectal resection were collected and utilized.

(1) Information Rich Platform: According to the progress of each operation, the anatomy, landmarks and risk factors such as bleeding are navigated to ensure the safety of operations. It also shares significant information of the surgical process with staffs inside and outside operating room during surgery.

(2) Autonomous View Control: Autonomous control of the endoscope using AI and other technologies can adapt a field of view in accordance with the progress of each surgical steps and the status of the operative field to perform operations efficiently.

In the recognition of the inferior mesenteric artery, ureter and hypogastricl nerve, the accuracy was evaluated by test images and the Dice coefficients were 0.704, 0.688 and 0.558, respectively. In the recognition of surgical instruments, the mean average precision was 0.985.

Using our database, we were able to achieve high accuracy recognition. Information-powered surgery by CNN-based deep learning methods has significant potential in multiple clinical applications in the future.

Emergent robotic versus laparoscopic surgery for perforated gastrojejunal ulcers: a retrospective cohort study of 47 patients Tyler D Robinson, MD, MPH 1 ; Jordan Sheehan 2 ; Pooja Patel 1 ; Andrew Marthy 1 ; Jessica A Zaman, MD 1 ; Tejinder P Singh 1 ; 1 Albany Medical Center; 2 Albany Medical College

Background: Perforated gastrojejunal ulcers are a known complication following Roux-en-Y gastric bypass (RYGB) surgery requiring emergent surgical repair. The robotic approach has not been evaluated for emergency general surgery. Methods: A retrospective cohort study from 2015 to 2019 was performed identifying all patients who underwent repair of perforated gastrojejunal ulcers after RYGB at a single institution. Patient characteristics and outcomes were compared by robotic or laparoscopic approach. Results: Of the 47 patients analyzed, there were 24 robotic and 23 laparoscopic repairs of perforated gastrojejunal ulcers. In-room to surgery-start time was significantly faster in the robotic group than the laparoscopic group (24.9 versus 31.8 min, p = 0.002), and there were significantly fewer complications (8.3% versus 34.8%, p = 0.027) in the robotic group than the laparoscopic group. Complication severity, operating time, hospital length of stay, conversion to open surgery, return to operating room, discharge to home, hospital length of stay and 30-day readmission were all improved in the robotic group, although these were not statistically significant. Both total inpatient and procedural costs were more in the robotic group than the laparoscopic group. Conclusion: Perforated hollow viscus is not a contraindication for the use of the surgical robot, which may improve outcomes.

Closed-loop control for a wireless magnetic actuated laparoscopic camera Hui Liu 1 ; Ning Li 1 ; Gregory J Mancini 2 ; Jindong Tan 1 ; 1 University of Tennessee; 2 

Introduction: Single-incision laparoscopic surgery (SILS) allows surgeons to perform surgery by sharing a single incision for instruments and laparoscope, which reduces trauma, scarring, and hospitalization. However, SILS sacrifices laparoscope workspace due to limited space. Besides, handling laparoscope causes extra burden for surgeons. In this work, we integrate a wireless laparoscope with a six DOF manipulator based on magnetic anchoring and guidance system (MAGS). To navigate the camera precisely, a force-position closed-loop control is proposed to generate proper torque and velocity. The system provides large workspace for laparoscope and lays foundation for autonomous surgery. Methods and procedures: In Fig. 1 , the camera is anchored against the abdominal wall and manipulated through magnetic coupling. A force torque sensor mounted onto the end-effector monitors the contact force generated by camera and patient tissue. The magnetic-based actuation mechanism is shown in Fig. 2 . Two internal permanent magnets (IPMs) locate inside the camera and the rotor can rotate around X R . The stator contains two external permanent magnets (EPMs) and is driven by a micromotor. Pan and translate motion are controlled by manipulator. An MPU sensor is integrated onto the rotor to estimate its' motion. Force-position control scheme is demonstrated in Fig. 3 .

Results and discussion: As illustrated in Fig. 4 , our rotor is compact with length of 80 mm and diameter of 12 mm. The rotor board is built around a Texas Instruments cc2541 wireless MCU. Analog video and digital sensing data are sent out through an AV transmitter and cc2541. The motor (1016M009SR, FAULHABER) inside stator integrated with a 256:1 ratio gearhead can generate 1Nm torque which is sufficient to drive the magnets. The setup is shown in Fig. 5 . Our camera is tested on URe5. The force sensor (ATI-9105-Axia80-m2m20) communicates with PC through Ethernet. The laparoscopic system is controlled with an operation interface through a PC, which can be further developed into autonomous camera guidance system.

Conclusions: This work proposed a closed-loop control for a wireless camera system in SILS. The camera is capable of tilting, panning and translating inside patient body, while the power consuming actuation part is left outside the cavity. The experiments showed the position control of the camera navigated by a manipulator is improved. Besides, the force control loop provides motion compensation to constrain the contact force between camera and patient tissue within a safe range. In the future, servo control and self-learning algorithm will be further applied to develop an intelligent assistant.

Impact of industry payments on volume and distribution of robotic-assisted surgery Justin Gray, MD 1 ; Ajay Myneni, MBBS, PhD, MPH 1 ; Lorin M Towle-Miller, MA 2 ; Aaron B Hoffman, MD, FACS 1 ; Steven D Schwaitzberg, MD, FACS 1 ; Katia Noyes, PhD, MPH 2 ; 1 UBMD; 2 SUNY at Buffalo Introduction: Despite evidence questioning its clinical benefit, the use of roboticassisted surgery (RAS) is increasing rapidly. In the US, almost a million RAS procedures are performed annually. While in the US surgeons are required to complete 5 RAS training cases prior to operating alone, other courtiers require at least 30-40 cases for optimal competence. Previously, strong evidence has documented the impact of financial incentives provided by pharmaceutical industry on clinician's prescribing patterns. In response, policies and regulations were enacted to mitigate this effect. Limited evidence exists linking surgical device industry (SDI) incentives to use and dissemination of surgical technology. This study examined the relationship between publicly reported SDI payments to providers and the current use of RAS in the US. Methods: Using 2014-2018 data from CMS ''Sunshine'' OpenPayments Database and New York State (NYS) Statewide Planning and Research Cooperative System, we tested temporal and spatial relationships between the categories of SDI payments and volumes of trunk RAS identified using CPT and ICD codes. We categorized 31 out of 62 NYS counties as ''metro'' ([ 50% of population living in urban regions) and the rest as ''rural'' using U.S. Census Bureau's definition. Results: Over 5 years, SDI paid surgical healthcare providers $173 M nationwide, of which 21% went to hospitals and 79% to individual surgeons. Between 2014 and 2018, the annual SDI payments increased by 28%. Majority (81%) of the payments were made for education and training including travel and meals (23%), and space rental (8%). Direct payments to physicians/RAS experts constituted 6% and research grants accounted for 0.4%. In NYS, total payments made to surgeons performing trunk RAS strongly correlated with trunk RAS volume but the case volume grew faster. While the annual payments increased by 54%, the number of RAS nearly doubled due to a larger number of surgeons performing few RAS cases. Approximately 93% of payments and 98% of trunk RAS in NYS occurred in metro counties, disproportionally greater than 91% of the population living in metro counties. Conclusions: The increase in SDI payments was followed by the growth in RAS volumes, and both were concentrated in large urban areas. Despite the growth in the number of RAS procedures and providers, reinvestment in education has faltered. Greater SDI investment in research may improve RAS quality of care. More research is needed to understand the role of industry incentives in disparities in access to robotic procedures between urban and rural patients.

Transitioning from laparoscopic to robotic techniques in a general surgeon's practice. Is it safe? Our outcomes and learning curve experience Ujwal R Yanala, MD 1 ; Bhavani Pokala, MD 1 ; Benjamin Grams, MD 2 ; Steven Buda, MD 2 ; 1 University of Nebraska Medical Center; 2 Nebraska Methodist Health System Introduction: Over the past few decades, the practice of a general surgeon has changed from open to minimally invasive procedures. Laparoscopic procedures constitute a significant proportion of general surgery practice with cholecystectomy being one of the most common procedures performed. Adopting laparoscopic techniques involved a steep learning curve. Similarly, robotic procedures are now gaining popularity with increasing penetrance into daily practice. Here we present a single surgeon's outcomes during the transition from laparoscopic (LC) to robotic cholecystectomy (RC) with our primary endpoint being operative safety. Methods: All patients who underwent cholecystectomy by a single surgeon at a community hospital between April and August of 2019 were identified and data was collected retrospectively. Information collected included age, sex, BMI, ASA score, pathology, length of stay (LOS), blood loss, readmission, reoperation, re-intervention, operative time, and wound class. Patients who underwent additional procedures at the time of cholecystectomy were excluded. Kruskal-Wallis test was used to compare laparoscopic versus robotic groups. Findings were considered significant for p \ 0.05. Results: The two study groups had similar sample size (LC = 34, RC = 28). All patient related variables including age, sex, BMI, ASA scores, wound class were similar between two groups (p-values 0.9, 0.8, 0.7, 0.4, 0.8 respectively). Both groups had a comparable number of elective versus non-elective cases (p = 0.37). Histologic findings were either inflamed or non-inflamed based on pathology reports, with no significant difference between groups (p = 0.77). Intraoperative blood loss was significantly higher in the laparoscopic group (LC:47.4 mL, RC = 13.9 mL; p = 0.0011). Operative time was significantly higher in robotic group (RC: 54 ± 12.8 min; LC: 44 ± 17.4 min; p = .0014. In the LC group, 3 patients required blood transfusions for symptomatic anemia postoperatively, 1 patient was taken back to OR for significant bleeding, and 1 patient required ERCP for choledocholithiasis. In the RC group, 1 patient was readmitted for postoperative ileus but no patients required postoperative transfusion or intervention. LOS was similar between approaches (p = 0.51). Conclusion: Our outcomes show a significant difference in operative times and intraoperative blood loss in similar population groups. Although LC is quicker, RC appears to be relatively safer with lower estimated blood loss, fewer blood transfusions, reoperations, and postoperative interventions. The significantly longer operative times for RC are likely due to the learning curve of the surgeon as well as operating room staff. Technological advantages inherent to the robotic platform such as firefly immunofluorescence technology and 3D visualization could contribute to the improved clinical outcomes associated with RC.

Intraoperative head-mounted display use for minimally invasive surgery-a literature review Yaoyu Fu; Lora Cavuoto; Steven D Schwaitzberg; University at Buffalo Introduction: The goal of this work is to review the literature on the use of headmounted displays (HMDs) during the minimally invasive surgical task, both in the operating room (OR) and in simulation settings, and to investigate the influence of using HMDs on performance and physical and cognitive workload compared to conventional monitors. Methods and procedures: The literature search was performed using the databases PubMed, MEDLINE, and Web of Science. The following search terms were used: (''head mounted display'' OR ''head up display'' OR ''face mounted display'' OR headset) AND (laparoscop* OR ''minimally invasive surgery'' OR endoscop*). No restrictions of language or publication year were applied at the search point. Results: Of the 420 publications initially identified, 54 publications were included in the final analysis. Most of the studies used virtual reality (VR) HMDs (n = 47 studies), 7 studies used optical see-through (OST) HMDs. Thirty-one studies used the HMDs in the OR, 14 reported wearing HMDs over 30 min and 11 (78.6%) of them had overall positive feedback regarding physical discomfort. Of the 28 studies that reported surgical outcomes, the procedures where HMDs were successfully performed without complications attributable to the use of HMDs, and most of the procedures completed within the normally expected operating times.

Twenty-three studies used the HMDs in simulated settings, 2 reported wearing HMDs over 30 min, 1 of them had positive feedback regarding physical discomfort. Of the 13 studies that reported the difference in performance between using an HMD and conventional monitor, 5 reported better performance on HMDs, 3 reported worse performance on HMDs, 5 reported mixed or no significant difference. Conclusions: HMDs have the potential of being used as a replacement for conventional monitors in surgery. It can provide a more neutral head posture for the surgeons, along with additional functions, such as multiple displays in the same system and real-time feedback. Reviewed studies that used HMDs in the OR had overall positive feedback of using HMDs, however, studies with larger user sample sizes are still needed. Studies of using HMDs for an extended duration are limited, especially the influence on physical workload. Most of the reviewed studies measured physical workload using a subjective rating, objective assessments with more controlled experiments are needed to support the current Conclusions. Introduction: Lumbar hernias are rare protrusions of intra-abdominal contents through the posterolateral abdominal wall. Primary lumbar hernias are associated with conditions that cause an increase in intra-abdominal pressure while secondary lumbar hernias are associated with trauma and previous retroperitoneal operations, known as incisional lumbar hernias. The main approaches to lumbar hernia repair include open tension free repair with mesh and minimally invasive surgery. Here, we present a successful case of robotic assisted transabdominal preperitoneal repair of a lumbar incisional hernia with mesh. Presentation of case: The patient is a 49-year-old female with pertinent past surgical history of an L3-L4 interbody fusion via left lateral approach. Patient developed a left lumbar incisional hernia 2 months postoperatively and presented with persistent discomfort with the hernia. Therefore, she was offered a robotic assisted incisional lumbar hernia repair with mesh. Patient was placed in right lateral decubitus position with the operating bed flexed, exposing the left flank region. Three 8 mm Da Vinci trocars were placed along the left midclavicular line 8 cm apart and 20 cm medial to the hernia defect, and the Da Vinci Xi robot was docked into position. Upon entry, a pre-peritoneal plane was created medial to the hernia defect. No hernia sac was seen but there was fat herniated through the defect. Once the fat was dissected and reduced, another 5 cm defect through the transversus abdominis and internal oblique muscle was seen. Both defects were then closed primarily with V-lock running sutures and a 10cmx15cm polypropylene mesh was placed into the preperitoneal plane and secured to the transversus abdominis with running sutures. The preperitoneal flap was closed with V-lock running sutures. Patient recovered unremarkably and was discharged home the same day. Discussion: Incisional lumbar hernias are rare but associated with 25% and 8% risk of developing incarceration and strangulation respectively, and therefore timely surgical management is indicated. However, due to the lack of adequate amount of fascia and complex anatomy surrounding the defect, surgical repair is difficult. Among the mainstream approaches for repair, many studies showed shorter length of stay, fewer wound complications and less postoperative pain in patients who underwent laparoscopic compared to open repair. However, there are very few studies on outcomes for robotic assisted repair, despite its superior technical adaptability and visualization. Conclusion: Robotic assisted repair of lumbar hernia is safe and feasible, but more studies need to be conducted to shine guidance on approach selection for repair.

Technical improvements of the anastomotic technique in robotic assisted minimally invasive esophagectomy (RAMIE) can significantly reduce anastomotic leak rates -experience of a German High-Volume Center Dolores T Müller, MD; Benjamin Babic, MD; Florian Gebauer, MD; Rabi R Datta, MD; Hans Schlößer, MD; Lars Schiffmann, MD; Wolfgang Schröder, MD; Christiane J Bruns, MD; Hans F Fuchs, MD; University of Cologne, Department for General, Visceral, Cancer and Transplant Surgery Introduction/aim: Minimally invasive surgery and lately the usage of robotic technology has reduced the invasiveness of procedures, leading to improved patient outcomes after esophagectomy. The esophagogastric anastomosis represents a crucial step of the Ivor-Lewis procedure, as technical errors may lead to anastomotic leakage and severe postoperative morbidity. Anastomotic integrity is influenced by many different factors and there is great technical variety among surgeons. We have previously shown that a standardized 28-mm circular stapled anastomosis is very safe in Hybrid Minimally Invasive Esophagectomy. The aim of this study was to present and evaluate our standardized robotic circular stapled anastomotic technique in comparison to our large Hybrid patient collective. Methods: Analysis of our prospectively collected, IRB approved database of hybrid, open, and robotic esophagectomies was performed. Starting 01/2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for our RAMIE cases at our academic center (Picture 1). Outcomes of patients undergoing this standardized robotic Ivor Lewis esophagectomy for esophageal cancer from 01/2019 -11/2020 were compared to our overall cohort from 06/2016-06/2020 (Hybrid/Open group). Pic 1: RAMIE with ICG usage @ UK Köln Results: A total of 615 patients were analyzed. A total of 96 patients underwent a robotic assisted Ivor Lewis esophagectomy. Of these, a total of 56 patients underwent a robotic thoracic reconstruction using the updated standardized circular stapled anastomosis. A total of 64 patients were operated using an open approach and 455 underwent a hybrid procedure with a circular stapled anastomosis (Hybrid/Open group). Demographic and oncological data is shown in Table 1 . Further details about postoperative complications are depicted in Table 2 . One patient developed an anastomotic leak in the robotic group, resulting in an anastomotic leak rate of 1.8%. In comparison 63 patients (12%) developed an anastomotic leak in the Hybrid/Open group (p = 0.0132). Median length of stay (LOS) was 13 days in the robotic group (range 7-52), compared to a median LOS of 15 days (range 9-99) in the open/hybrid group. Table 1 . Patients' characteristics and oncological data Table 2 . Anastomotic leak types and severity of postoperative complications. Severity of complications was signifcantly less in patients that underwent a standardazied robotic Ivor Lewis esophagectomy.

Conclusion: A standardized circular stapled anastomosis in RAMIE cases for esophageal cancer may result in very low anastomotic leak rates and thereby positively influence outcomes in selected esophageal cancer patients. Technical skill is associated with improved postoperative outcomes. Adoption of a formalised high-stakes assessment of surgical skill is technically challenging and limited by the financial and human resources available. Analysis of gaze behaviours has shown promise as an adjunctive assessment tool of surgical skill. This pilot study aimed to assess the ability to adopt gaze behaviour analysis as an adjunct assessment of surgical skill within live open inguinal herniorrhaphy.

This pilot study measured surgeons' gaze at a London hospital with Tobii Pro eye-tracking Glasses 2 (Tobii AB, Sweden). All grades of surgeons were included. Primary outcomes were dwell time (%) and fixation frequency (count/s), as markers of cognitive attention and importance, on areas of interest (AOI) correlated to mean Objective Skill Assessment of Technical Skill (OSATS) score. Secondary outcomes assessed effort and concentration levels through maximum pupil diameter (mm) and rate of pupil change (mm/s) correlated to perceived workload (SURG-TLX scale). Three distinct operative segments underwent analysis: mesh preparation, fixation and muscle closure. Spearman's and Pearson's correlation were performed according to distribution of data, with significance set at p \ 0.05.

In total 5 cases were analysed, totalling 270 min of video footage. All participants were senior surgical trainees or attendings and right-hand-dominant. The median number of hernia operations performed by the participants was 160 (range 100-500). The median ASA score of each patient participant was 2 (range 1-2). The median operation length was 45 min (range 40-90 min) ( Table 1 ). There were no statistically significant primary outcomes calculated from this pilot data (p [ 0.05).

This pilot study demonstrated the feasibility of recording gaze behaviours for comparison against formal skills assessment to determine the role of eye tracking in live high stakes technical skills assessment. Utilising this pilot data and literature review, a full study of 18 participants will now commence based on formal power calculation. Objective: To compare short-term surgical outcomes of robotic and laparoscopic distal gastrectomy. Background: Despite a lack of supporting evidence, robotic surgery has been increasingly adopted as a minimally invasive modality for the treatment of gastric cancer because of its assumed technical superiority over conventional laparoscopy. Methods: A retrospective, single-center comparative study was conducted. A total of 176 patients who had undergone distal gastrectomy for gastric cancer between March 2013 and June 2020 were analyzed. 88 patients had undergone robot-assisted gastrectomy (RADG) by da Vinci Xi. Other 88 patients had received 5-port laparoscopic gastrectomy (LDG). In RADG, suprapancreatic lymph node dissection was performed in robotic setting. These two groups' clinicopathological characteristics, operative details, short-term postoperative outcomes were compared. Results: The operation time was significantly longer in RADG group (183.23 ± 38.46 vs. 145.34 ± 33.43 min, respectively, p = 0.000). The EBL between two groups showed no significant difference. The number of retrieved lymph nodes from suprapancreatic area(the sum of LN7, 8a, 9, 11p, and 12a) showed significantly higher in RADG group than LDG group (11.27 ± 5.46 vs. 9.17 ± 5.19, respectively, p = 0.010). We compared some specific inflammatory markers after operation. The CRP level in POD1 and POD5 showed significantly higher in LG group than RADG group (POD1; RADG = 4.29 ± 2.38 vs, LDG = 5.11 ± 2.64, p = 0.030, POD5; RADG = 7.75 ± 5.17 vs. LDG = 9.86 ± 6.51, p = 0.019). Moreover JP amylase level in POD1 showed significant difference between the two groups (RADG = 1158.80 ± 1207.93 vs. LDG = 1954.16 ± 3102.38, p = 0.028). D-dimer level in POD5 is also significantly higher in LDG group than RADG group (RADG = 3.89 ± 2.49 vs. LDG = 5.09 ± 4.15, p = 0.030) and NLR(neutrophil-tolymphocyte ratio) in POD3 and POD5 are both significantly higher in LDG group than RADG group(POD3;RADG = 6.16 ± 2.91 vs. LDG = 7.44 ± 4.72, p = 0.031, POD5;RADG = 3.81 ± 1.87 vs. LDG = 4.87 ± 3.75, p = 0.020). Neither postoperative complications (CDC C 2 or CDC C 3) or postoperative hospital day showed any significant differences. Conclusion: Despite the longer operation time, robot-assisted gastrectomy is superior to conventional laparoscopic gastrectomy in terms of postoperative inflammation during the dissection of suprapancreatic lymph nodes.

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure

Management of biliary symptoms after bariatric surgery

EDGE in Roux-en-Y gastric bypass: How does it compare to laparoscopy-assisted and balloon enteroscopy ERCP: a systematic review and meta-analysis

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Efficacy of Surgical Simulation Training in a Low-Income Country

Postoperative incidence of incarcerated hiatal hernia and its prevention after robotic transhiatal esophagectomy

Hiatal hernia after esophagectomy: Analysis of 2,182 esophagectomies from a single institution

1%) patients had at least 1 complication, and no mortality was reported. Of patients with a reported complication, 4(23.6%) had minor complications (I-II) and 4(23.6%) had complications that required further intervention or reoperation (IIIa-b). The reasons for reoperation included: 1 esophageal leak, 1 chyle leak, and 1 incarcerated hiatal hernia. Mean ICU and hospital LOS was 3.1(± 4.2) and 11.2 (± 5.2) days, respectively. Conclusions: Minimally invasive esophagectomy for end-stage achalasia can be safely performed

Peroral endoscopic myotomy; what is the learning curve?

Laparoscopic Cellan-Jones repair for perforated peptic ulcers

Diverting Ostomy: For Whom, When, What, Where, and Why

Fournier gangrene associated with Crohn disease

Patients were divided into 2 groups: PEH and SH. Patients who underwent surgery without preoperative GERD symptoms were excluded. We retrieved perioperative outcomes (operative time, length of hospital stay, ICU stay, and intraoperative and postoperative complications), barium swallow/endoscopy findings, and GERD-HRQL scores at annual follow-up. Results: A total of 190 patients (104 PEH and 86 SH) were included. The most common procedure performed was a Toupet fundoplication in both groups

Hiatal hernia recurrence (size [1 cm) was higher in the PEH group (6.5% vs. 0%), but the difference was not significant. Mean intraoperative esophageal length in the recurrent group was 2.1±0.53 cm and in nonrecurrent group was 2.2±0.63 cm (p = 0.784). There was significant improvement of GERD-HRQL scores

In both groups, GERD-HRQL scores improved at 1 and 2 years after surgery. PEH SH P-value in midline laparotomy closure and use of prophylactic mesh reinforcement for prevention of incisional hernias: a nationwide survey

an anonymous, 15-question survey was administered to subscribers of several internet-based, professional, discussion boards, including American College of Surgeons Communities. Results: Of 161 U.S. respondents, 81% were aware of PMR and 24% had used it. Most frequent users were oncologists (33% respondents in multiple-answer question) and acute care surgeons (30%)

Methods: A retrospective chart review of 106 patients who underwent bilateral robotic inguinal hernia repair at Albany Medical Center from 2017-2018 was completed. Patient demographics and co-morbidities, hernia characteristics, concurrent procedures, peri-operative variables, and short-term post-operative outcomes were determined. Results: One hundred and six robotic bilateral IHRs were performed over 2 years. Mean age was 54.17 ± 14.1 years and BMI was 28.5 ± 6.0 kg/m 2 . Eighty-three percent of patients were male, 25.5% had a prior hernia repair, and 14.2% had a recurrent inguinal hernia. Concomitant primary umbilical hernia repair was performed in 43.3%, 12.3% underwent concomitant incisional hernia repair, and 1.8% underwent concomitant component separation (eTEP or TAR). One patient also underwent robotic prostatectomy. At 30-day follow-up, there were no readmissions or reoperations. A single emergency room visit was reported for. No early recurrences were reported. Pain score at 30 days averaged 1.7 using the numeric rating scale (NRS11), with 75% of patients reporting no pain at their follow-up visit

we enrolled 30 patients who underwent umbilical hernia repair using either laparoscopic or anterior approaches. We diagnosed RAD according to preoperative computed tomography. The outcomes of patients with umbilical hernia, the RAD group, and the non-RAD group were compared, especially in terms of recurrence. Results: Twenty-five of 30 patients (83%) presented with RAD. Three patients (12%) had a postoperative recurrence and were allocated to the RAD group. The median body mass index in the RAD group was 27.2 kg/m 2 . In the RAD group, a prosthesis mesh was used in 12 patients (48%), and nonabsorbable suture material was used in four patients (16%)

Mr 1

Professor 2 ; 1 Glan Clwyd Hospital; 2 Ain Shams University Hospital Background: Acute abdominal pain (AAP) is a medical emergency, characterized by pain arising from the abdominal area, of non-traumatic origin with a maximum duration of five days. It is the most common surgical emergency, one of the most common reasons for referral to an emergency department (ED) and the most common cause for non-trauma-related hospital admissions. Aim of the work: To evaluate the role of laparoscopy in the diagnosis and treatment of unexplained acute abdominal pain and establish it instead of conventional exploratory laparotomy. acute appendicitis, while least common causes were pelvic inflammatory disease and mickel's diverticulum equally. Laparoscopy was done in all cases (100%)

LA) is increasingly performed as a short-stay however, some patients require prolonged hospitalization because of postoperative ileus and pain; therefore we introduced clipless LA, using an ultrasonic energy device only for coagulation. A total of 1,013 patients (clipless LA; n = 290 and conventional LA; n = 723) who underwent LA at our hospital between

Azka Naeem

All patients had full thickness rectal prolapse and 5 patients (33%) had associated vault prolapse. 10 (66.7%) patients had relative constipation, 3 of them (20%) experienced incontinence and 5 patients (33%) presented with episodes of per rectal bleeding. 2 patients (13%) reported uncomplicated port site infection .3 week course of laxatives was prescribed on discharge. No patient develop sexual dysfunction, incontinence or dyspareunia. Conclusion: Laparoscopic Mesh Ventral Rectopexy can be performed safely by surgeons provided they have proper expertise and are trained to achieve Nerve sparing technique resulting in promising outcomes and lesser complications (bowel dysfuntion and sexual impairment) as

Methods: A single-center, multi-surgeon retrospective study was conducted of patients who underwent isolated splenectomy from 1997 to 2017. Patients with available pre-and post-operative hemoglobin A1C (HbA1c) and body mass index (BMI) were included. Those who had a simultaneous distal pancreatectomy or other procedures were excluded. Primary outcome included change in HbA1c and diabetic medication requirements. BMI change was a secondary outcome measure. Data: 44 patients met the study criteria with 19 (43%) with pre-operative diagnosis of T2D, of which 11 (57%) were on insulin. Most common indications for surgery were oncologic (27%), hematologic (23%), and trauma (11%). Mean time of follow up was 1.9 years (range 1 month to 8 years). A statistically significant increase in HbA1c was seen in the overall cohort without a significant change in weight (Table 1). Importantly, in the non-T2D cohort, 5 patients (20%) were diagnosed with T2D post-splenectomy with a significant increase in HbA1c and 4 requiring insulin therapy. Discussion: Splenectomy is associated with increased HbA1c in non-diabetic patients and new diagnosis of T2D without any changes in weight

Sergio Riveros; Tomás Basaure; Nicolás Quezada; Rolando Rebolledo; Rodrigo Muñoz; Mauricio Gabrielli; Alejandro Brañes

Methods: Retrospective analysis of institutional records. Patients who underwent surgery for acute adhesive SBO between 2013 and 2020 were reviewed. Exclusion criteria were ostomy and/or peritoneal carcinomatosis at the time of surgery. Patients were divided into two groups: laparoscopic surgery (LS) and open/converted surgery (OS). Demographic, perioperative, operative and follow-up variables were collected and compared. Results: 172 patients were included, 144 in the OS group and 28 in the LS group

Surgery within the first 48 h was performed in 81.9% of the OS group and in 82.1% of the LS group. Conversion to OS was needed in 15 patients (34.8%), being the most common reasons the need for small bowel resection (33%) and unsafe LS due to dilated bowel loops (33%). There were no differences in the number of accidental enterotomies and serosal tear between groups. A statistical significant difference in terms of median operative time was not seen between groups

Median follow-up was 36.8 and 29.4 months in the LS and OS groups, respectively. Regarding long term follow-up, patients in the OS group were most likely to be readmitted for SBO (15.3% vs. 0%; p = 0.027) and to complain of persistent symptoms after surgery (21.5% vs. 3.6%; p = 0.026). Conclusion: Laparoscopic surgery for SBO reduces postoperative morbidity and LOPS compared to open surgery. Moreover

MM 3 ; Haibo Gong

Zhejiang Provincial People's Hospital, Hangzhou Medical College; 2 Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College/Second Clinical Medical College, Zhejiang Chinese Medical University; 3 Department of Radiology, Zhejiang Provincial People's Hospital, Hangzhou Medical College; 4 Ningbo Chuangdao 3D Medical Technology Co

Surgical Resident 2

Professor of Medicine 1 ; Nicholas A. Fairbridge, Medical Researcher 1

Professor of Surgery 1 the minimally invasive (MI) fellowship-trained (FT) hepatic-pancreatic and biliary (HPB) surgeon: could the outcome of MI pancreatoduodenectomy for peri-ampullary tumors be better than open?

Elie Chouillard 1 ; 1 Centre Hospitalier Intercommunal

Fondazione Poliambulanza Istituto Ospedaliero; 4 Institut Mutualiste Montsouris

Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques. Methods: We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery. Results: From

Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p \ 0.001and p = 0.007, respectively. The mean operative time was longer for MIPD-PT (456 min) as compared to the OPD-PT (371 min), p \ 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97

This may result in decreased blood loss and length of hospital stay. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival

Methods and procedures: All NSQIP patients who underwent pancreatectomy from 2014-2018 were examined retrospectively. Robotic & laparoscopic approaches were compared for both distal pancreatectomy and pancreaticoduodenectomy. Univariate and multivariate analysis of patient factors and perioperative outcomes were performed. P-values \ 0.05 were significant. Results: Of 4887 patients undergoing distal pancreatectomy, 3662 (74.9%) underwent laparoscopic distal pancreatectomy (LD) and 1225 (25.1%) underwent robotic distal pancreatectomy (RD)

2%) underwent MIS and 32,453 (53.7%) underwent Open procedures. MIS patients were more likely to be electively admitted, younger, have less comorbid conditions, and less disease severity (all p \ 0.05). Open procedures had a higher rate of major complications (27.1% versus 22.9%, p \ 0.001), longer median length of stay (6 versus 3 days, p \ 0.001) and higher in-hospital mortality (1.7% versus 0.6%, p = 0.05) when compared to MIS ones. A total of 648 (1.09%) patients were readmitted within 90 days of surgery for VTE, of which 358 (0.60%) were readmitted for PE, and 290 (0.49%) for DVT. 90-day VTE readmission rates were 1.23% for open procedures, and 0.93% for MIS procedures

Conclusions: In this risk adjusted analysis using a national dataset, we found no difference in VTE readmission rates between open and MIS GI cancer procedures except for colectomies. These data should be considered when determining the surgical approach for patients with GI malignancies

AdventHealth Orlando Background: Hospitalized Inflammatory bowel disease (IBD) patients are at the highest risk for morbidity, mortality, and health care utilization costs. Variation in care and disease outcomes among hospitalized IBD patients is common across different centers. Our aim is to compare and assess the health outcomes in hospitalized IBD patients in the recent years

No significant difference seen between observed and expected values for readmissions and MLOS. Conclusion: Readmissions, PM and complications have declined for hospitalized IBD patients in recent years. Further research is needed to identify the underlying factors contributing to the trends. Appropriate inpatient care improvement strategies and quality improvement frameworks can lessen the burden of disease and associated mortality or morbidity in hospitalized IBD patients

Risk Calculator variables, procedure CPT codes, and post-operative complications within 30 days were collected and entered into the PSRC. The resulting predictions were compared with the actual postoperative outcomes. Receiver operator characteristics (ROC) analysis was used to estimate the predictive ability of the Risk Calculator as estimated by area under the curve (AUC). Results: Predictive values for each of 9 outcomes estimated by the PSRC are provided in Table 1. Using standard definitions of AUC

We reviewed our experience with robotic resection of gastric GIST. Methods: Records for patients that underwent resection of gastric GIST at our institution since 8/2017 were reviewed retrospectively under an institutional review board-approved protocol for demographics, type of surgery, clinicopathologic variables, length of stay (LOS), complications, recurrence, and survival. Results: After excluding incidental gastric GISTs resected during other operations (n = 4), the remaining 33 patients were 33% male with a median age of 66(31-85). Eleven patients underwent open partial gastrectomy for a median tumor size of 12 cm

Three MIS patients had pedunculated tumors amenable to stapled partial gastrectomy (one each in fundus, lesser, and greater curvature). The remaining tumors were resected with an approximately 1 cm margin with primary gastrostomy closure using V-loc sutures. This included readily accessible portions of the stomach (anterior body/antrum, n = 5; fundus, n = 4) and difficult to access areas such as the lesser curvature (Figure A;n = 7), and posterior body/antrum (B;n = 2). Two endophytic posterior tumors were removed via anterior gastrotomy and endoluminal stapling (C). One lesser curvature robotic surgery was converted to open for a 7.2 cm friable tumor post-neoadjuvant imatinib involving a replaced left hepatic artery

Focally/microscopically positive (R1) margins were seen in 3 (13%) MIS and 1(9%) R1 and 1(9%) R2 (comcomitant unresectable metastatic disease) for open. There were no anastomotic leaks in the MIS group and one in the open group. All patients were alive and without recurrence at a short median followup of 7

Conclusions: Robotic partial gastrectomy for gastric GISTs not amenable to stapled wedge resection is feasible, safe, and associated with a short LOS, rare complications and a low R1 margin rate. P600 Laparoscopic cholecystectomy, single-site robotic cholecystectomy and single-incision laparoscopic cholecystectomy: a prospective non

Patients and methods: 100 consecutive patients with gallbladder disease were included. 35 patients were subjected to SSRC, 35 patients to SILC and 30 control patients were subjected to conventional laparoscopic cholecystectomy. The SSRC cases were performed in the United States of America while the rest were performed at the University of Cairo, Egypt. We compared those techniques for feasibility, safety, operative time, technical difficulties, complications, conversion rates, postoperative pain, duration of hospital stay and finally, the aesthetic satisfaction. Pain was assessed via a 10-points VAS. Results: No mortality was reported. Operative time of SILC was considerably longer (94.85 ? 44.4 min) compared to SSRC (55.56 ? 12.7 min) and MILC (63.45 ? 30.2 min) and it inflicted a physical and mental toll on the operating surgeon

Objectives: This study aimed to provide a preliminary attempt of 5G-assisted remote guidance in laparoscopic simulation training using three-dimensional (3D) printed dry lab models. Methods: A resident surgeons (RS) was invited to complete a basic task of simple suture training and a model task of minimally invasive biliary enteric anastomosis and all performances were recorded for blinded video evaluation. The RS completed each task three times. All tasks were completed under the remote guidance through 5G technology. Tasks completion time and a 30-point Objective Structured Assessment of Technical Skills (OSATS) score were utilized to assess the Results of simulation training. Results: All remote guidance processes were completed smoothly without significant signal loss. For the basic task, the OSATS score was increased from 16 to 24 points, and the completion time was shortened from 1500 to 986 s after training with 5G-assisted remote guidance. For the model task, the OSATS score was improved from 15 to 26 points and the completion time was reduced from 1734 to 1142 s. Conclusions: The 5G-assisted remote guidance in laparoscopic simulation training may be feasible and may have certain training effectiveness.

Performance evaluation of a novel gastric stapler: blowing up the competition Arianne T Train, DO, MPH 1 ; Syed A Karim, MD 2 ; Christina M Sanders, DO, MBA 2 ; Aaron B Hoffman, MD 2 ; 1 Winn Army Community Hospital; 2 University at Buffalo Introduction: The industry standard for stapling in gastric resection is use of a powered 60 mm endocutter. Mechanical integrity of the staple line is essential to prevention of postoperative leaks and can be assessed by examining staple formation and measuring burst pressure. We measured and compared performance characteristics of the Echelon Flex TM GST (Ethicon), an industry standard stapler, against a novel 230 mm gastric stapler, the Titan SGS. Methods: Study design was a prospective, randomized controlled trial. Following IRB approval, 36 participants were enrolled and randomized to either the Ethicon (control) or Titan (intervention) group. Excised sleeve gastrectomy specimens were retrieved fresh for immediate testing. Tissue thickness was measured at multiple locations using a tissue measuring device (TMD) to determine reload cartridge selection of the experimental staple line (control group only). An experimental staple line was created with either Ethicon using a series of 60 mm reloads according to measured tissue thickness or Titan (single cartridge with varying staple heights). Two specimens resulted from creation of the experimental staple line and were sent for either industrial CT to assess staple formation and height ( Fig. 1 ) or pneumatic burst pressure which was performed immediately. Results: There were no differences in demographics or specimen tissue thickness between groups. Titan produced significantly fewer malformed staples compared to the control (percent malformed 0.2% vs 1.1%, p \ 0.01). After accounting for location, staple height in the Titan group was more closely correlated with tissue thickness than in the control group (R 2 0.87 vs 0.61). Staple lines created with the Titan burst at significantly higher pressures than the control (163 ± 55 mmHg vs 125.8 ± 45 mmHg, p = 0.046) (Fig. 2) , with minimum Titan burst pressure (81.5 mmHg) exceeding maximum tolerable gastric pressure in humans (24.1 mmHg) by a factor of 3. Burst location was similar in both groups, with most bursts occurring in the fundus and body. There were more bursts remote to the staple line in the Titan group which may underestimate the true staple line strength. Conclusions: Titan produced a robust staple line with very low theoretical potential for leak, potentially due to improved staple formation and elimination of crossing staple lines. The mechanical integrity of staple lines produced with the Titan in human gastric tissue are shown in this study to be at least equal if not superior to the current standard, despite use of a TMD to guide choice of staple cartridge in the control group.Introduction: Management of Toxic Megacolon (TM) remains a challenge for physicians and surgeons due to the potential systemic toxicity and complexity associated with the condition. Limited data demonstrating incidence and inpatient health outcomes is available for TM. Our aim is to assess and compare the health outcomes in hospitalized TM patients in rural and urban health centers. Methods: We queried the Premier Healthcare database for nationwide adult inpatient admissions between 2016-2018 with the following ICD10 diagnosis codes for TM: K59.3, K59.31 and K59.39. The study population was further classified into 2 groups based on healthcare facility setting: urban versus rural centers. We evaluated incidence of morbidity, readmissions, post-operative mortality (PM), Mean Length of stay (MLOS) and Cost per Case (C/C) in each of the two groups. Unpaired t-test was used to compare outcomes among groups. Results: Total 6609 inpatient admissions were identified, 5783 in the urban centers versus 826 in rural centers. Based on admission type, rural centers reported significantly lower morbidity compared to urban centers (Mean: 31.25% vs 41.36%; p = 0.004). Similarly, MLOS was also significantly lower in rural than urban centers (6.42 vs 7.99 days; p = 0.006). Readmissions and PM were higher in the rural centers versus urban centers, but the difference was not statistically significant. Conclusion: TM is associated with high morbidity especially in urban centers. Further research is needed to assess various risk factors, interdisciplinary team coordination and management strategies to optimize health outcomes in TM patients. Introduction: The purpose of this study is to investigate the compliance of NCCN guidelines for reflex genetic testing in colorectal cancer in a community hospital. Lynch syndrome remains the most common hereditary form of colorectal cancer. It accounts for 2-4% of all new colorectal cancer diagnoses. Patients with lynch syndrome develop colorectal cancer and other cancers at younger ages. A reflex testing strategy as recommended by the NCCN is one of the best tools for detection, treatment, and prevention for both the patient and their families. Methods: A 1-year retrospective analysis was performed for reflex testing of colorectal cancer tumors. Colorectal tumors were investigated using immunohistochemical (IHC) analysis for the presence of microsatellite instability (MSI) demonstrating a germline mutation for DNA mismatched repair (MMR) genes. Secondary testing of positive specimens with loss of MLH1 gene for BRAF mutation or hypermethylation was performed to rule out a sporadic mutation. Data was analyzed respect to NCCN guidelines. Compliance was analyzed for initial reflex testing, secondary testing for sporadic tumors and referral to genetic counseling of patients younger than age 50 and/or positive testing for MSI. Results: 88 cases of newly diagnosed colorectal cancer were reviewed for reflex testing between 2019 and 2020. 74/88 (84%) of patients had the recommended reflex testing for Lynch syndrome. 61/74 (82%) patients had normal IHC testing. 13 were \ age 50 and 1 had a positive family history, yielding 14 (23%) genetic referrals. 13/74 (18%) patients were found to be IHC positive for MSI. Three patients had gene mutations in MSH2/MSH6/PMS2, after genetic testing referral. Only 5/10 (50%) patients underwent additional testing for BRAF/hypermethylation to exclude sporadic mutations. Of those 5 patients, only 1 was BRAF negative and appropriate for genetic referral. Conclusion: This audit highlights improvement opportunities for compliance with NCCN guidelines for genetic testing in colorectal cancer tumors for Lynch syndrome. Introduction of pathology algorithms for reflex testing increases detection of mutations associated with Lynch syndrome. Increased awareness of risk factors such as age \ 50 can promote appropriate referrals for genetic counselling. Education of health care providers regarding NCCN guidelines for the detection of Lynch syndrome may increase genetic counseling referrals, improved detection, treatment and prevention of Lynch syndrome associated colorectal cancers Introduction: The purpose of this study was to reveal the safety and feasibility of single-port (SP) robotic right hemicolectomy for patients with right colon cancer. Methods and procedures: We reviewed the first five patients with right colon cancer who underwent SP robotic right hemicolectomy between July and September 2020. The colon mobilization, lymphadenectomy, and intracorporeal anastomosis were performed with SP robot platform without any interruption. Data regarding patient characteristics, perioperative and postoperative outcomes, and pathologic Results were analyzed. Results: Two patients received preoperative chemotherapy for advanced colon cancer. The median total operative time was 160 min (range, 150 -240 min). The median docking time was 4 min 40 s (range, 2 min 10 s to 5 min 10 s). The median console time was 105 min (range, 100 -120 min). There was no conversion to multiport or open surgery. The median hospital stay was 8 days (range, 6 -13 days). One patient experienced a wound infection. The median number of harvested lymph nodes was 41 (range, 39-50). Conclusion: SP robotic right hemicolectomy is safe and feasible. This new approach might offer patients potential benefits. Further comparative studies are needed to verify it can provide patients with significant benefits compared with multiport robotic surgery. P591 ROME (robotic msh explantation) A versatile approach utilizing the Robotic platform in symptomatic patients with chronic pain or recurrent hernias requiring mesh explantation Cosman C Mandujano, MD 1 ; Xavier Pereira, MD 1 ; Gustavo Romero-Velez, MD 1 ; Flavio Malcher, MD 1 ; Brian Jacob, MD 2 ; 1 Montefiore Medical Center/Albert Einstein College of Medicine; 2 Mt.Sinai Introduction: Chronic pain following hernia repair affects 10-12% of patients with an estimated 6-8% of mesh-related complications requiring explantation. Reoperation with mesh explantation poses a surgical challenge due to adhesions, scarring, and mesh incorporation to the surrounding tissues. Robotic technology provides a safe platform for enhanced exposure to tackle these complex cases. Methods: Observational Study of 29 patients who underwent a robotic mesh explantation (ROME) for mesh-related chronic pain or recurrent ventral hernias requiring mesh explantation betweenMarch 2016 and January of 2020. The patients were evaluated for resolution of mesh-related abdominal pain and early postoperative complications. Results: Twenty-four patients (82.7%) reported preoperative mesh-related abdominal pain. Eight patients (27.5%) with or without preoperative mesh-related pain required explantation during the repair of a recurrent ventral hernia. Plug/patch, TAPP, and eTEP were the most common index operations (20.6%, respectively). Seventeen patients (70.8%) reported the resolution of pain postoperatively. Mean BMI was 28.5, with predominantly ASA class 2 patients (65.5%). Five patients (17.2%) with a non-recurrent hernia required mesh reinforcement after explantation. Sixteen patients (55.1%) underwent mesh explantation with a primary repair or no mesh reinforcement. Mean OR time was 190.1 min, and mean follow up was 36.4 days. The most common postoperative complication was seroma formation (6.8%), with no recurrent hernias reported in the early postoperative period. Conclusion: Robotic mesh explantation in challenging cases with chronic scarring, adhesions, and mesh incorporation is safe and provides an advantageous platform for concomitant hernia repair in these complex cases.

Robotic and laparoscopic salvage lateral pelvic node dissection for the treatment of suspicious recurrent rectal cancer Hyejin Kim; Gyu-Seog Choi; Seung Ho Song; Jun Seok Park; Kyungpook National University Hospital, Daegu, Korea Background: The lateral pelvic sidewall is one of the major sites of local recurrence after radical resection of rectal cancer. Salvage lateral pelvic node dissection (LPND) can be the only way to cure lymph node recurrence at this site. However, only few studies on the safety and feasibility of the minimally invasive approach have been reported. Purpose: We aimed to describe the technical details of salvage LPND by the minimally invasive approach. We also aimed to demonstrate the safety and feasibility of robotic and laparoscopic salvage LPND for suspicious recurrent rectal cancer. Methods: Between 2011 and 2019, 36 patients who underwent salvage surgery for the recurrence at lateral pelvic lymph nodes (LPNs) were retrospectively analyzed. Patients' characteristics, MRI findings, and perioperative and pathologic findings were analyzed retrospectively. Index operations were also reviewed. Results: Of 36 patients, 11 patients underwent the salvage LPND by a robot and 14 underwent it by laparoscopy. Nineteen index operations were performed by laparoscopy and four were performed by a robot. The median interval between index surgery and salvage LPND was 20.8 months (range, 7.9-72.0). The median size of recurrent LPNs diagnosed through pelvic MRI was 10 mm (range, 6-25). There were four cases of open conversion during the laparoscopic approach due to uncontrolled bleeding. Metastatic LPNs in all those patients were suspected of iliac vessel invasion and were identified having larger size (median 15 mm; 12-20) than it in successful LPND by the minimally invasive approach (10 mm). The median operation time was 100 min (60-420), and the median estimated blood loss was 40 mL (10-300). Five patients underwent en bloc resection of iliac vessels for the safe removal of suspicious recurrent LPNs. The median number of metastatic LPNs was 1 (range, 0-3) and the median number of harvested LPNs was 6 (range, 1-16). A total of six patients (24.0%) experienced postoperative complications. During follow-up (median 34.2 months; 2.5-101.7), eight patients developed recurrences, mainly including the lung and para-aortic lymph nodes, and one patient developed pelvic sidewall recurrence after laparoscopic salvage LPND. Conclusion: Robotic and laparoscopic salvage LPND for treating local recurrence at LPNs is safe and feasible. Therefore, the robotic and laparoscopic approach can be considered a treatment option for local recurrence in selected patients. However, when the size of LPNs is larger than 15 mm and iliac vessel invasion is suspected through MRI, the approach should be carefully chosen before performing salvage LPND.Maki Sugimoto, MD, PhD, Prof; Innovation Lab, Teikyo University Okinaga Research Institute The conventional image-guided surgery was presented on a flat-screen, couldn't reproduce the actual depth of the anatomy. Also, the 3D monitors and stereoscopic glasses cause misunderstandings between the actual operating field and image diagnosis, making it impossible to accurately reproduce the surgical plan. Therefore, to enhance the spatial perception of surgeons, we applied extended reality (XR: VR/ AR/MR) technology, which is a holography-like 3D guide to organs, lesions, and procedures based on CT/MRI images of individual patients, to create a stereoscopic view in the real space above the surgical field to allow viewing in all directions. Methods: The geometry of each organ was polygonized from CT/MRI images and automatically converted into an XR application to simulate and navigate spatial understanding of anatomy within 10 min in the cloud through the Web. We applied commercially available XR headsets with binocular stereoscopic vision and head orientation tracking (OculusQuest2) and binocular transparent wearable glasses (HoloLens2, MagicLeap1) to view the virtual images. If necessary, AR markers were used to superimpose them on the surgical field. We evaluated the feasibility, usefulness, and effectiveness of surgical simulation and navigation in 25 cases (13 cancer, 12 benign) of endoscopic and robotic surgery of the esophagus, stomach, colon, rectum, liver, pancreas, and biliary tract. Results: In all surgeries, we could accurately reproduce the organs and lesions from the preoperative images as holography, and display the resection lines and guide for surgical procedures in the air. Intraoperative CT imaging using the hybrid OR was useful for real-time navigation, as it was able to reproduce the organ deformations along the process of the surgical procedure.These systems were set up at an average of 10 min and did not affect postoperative adverse events. The positioning error of superimposing virtual models was within about 3 mm. Discussion: The sterile glove allowed for gestural manipulation during the operation and superimposed displays in the surgical field. The holographic guidelines presented in the operating field were useful for on-the-job training, as surgeons were able to share their positions and movements of their hands. Compared with conventional expensive navigation systems, this system is far easier to introduce. The program is already certified as a medical device in Japan, allowing all clinical cases to be XR-application from all over the country for efficient telemedicine. It is better to presented virtual 3D models in the space between the monitors showing endoscopic view above the operative field than superimposing them on the actual surgical field, especially for endoscopic surgery.

Robotic assisted cholecystectomy iproves peri-operative outcomes when compared to laparoscopic cholecystectomy Adam H Petchers, MD; Woihwan Kim, MD; Richard Uhl, MD; Matthieu Cerf; Jessica Zaman, MD; Albany Medical Center Background: Laparoscopy is currently the standard approach for cholecystectomy in the elective and acute setting. Robotic assisted cholecystectomy, though gaining popularity, remains controversial as an alternative surgical approach, particularly as an acute or unplanned procedure. The most frequently cited drawbacks preventing widespread adoption of the robotic assisted approach are increased cost, increased duration of operating time, and equivalent outcomes. However, with increasing institutional experience in robotic techniques, this paradigm may shift over time. We aim to reassess the outcomes of robotic assisted cholecystectomy in the acute and elective settings. Methods: We performed a retrospective review of 1718 laparoscopic or robotic assisted cholecystectomies at our institution between January 2017 and December 2019. These were subdivided into planned and unplanned cases. The primary outcome was 30 day readmission rate. Additional outcomes included complication rate, conversion to open, procedure blood loss, length of hospital stay, and time in OR. Results: There were 185 robotic assisted cholecystectomies compared to 1533 laparoscopic cholecystectomies. 30 day readmission rate and conversion to open surgery rate were significantly lower in the robotic assisted group compared to the laparoscopic group (0% vs 4%, P = .004 and 1% vs 7%, P = .001). There was no significant difference in length of stay or time in OR. On subgroup analysis there was no significant difference in outcomes between laparoscopic and robotic assisted approaches in unplanned cases. Discussion: Our study demonstrates improved short term outcomes in robotic assisted cholecystectomy versus laparoscopic cholecystectomy. Lower 30 day readmission rates seen in the robotic assisted group may offset the increased cost of the approach. We did not observe a difference in operating room time as has been seen in earlier studies, possibly due to increased institutional experience with robotic techniques. Robotic assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy in both elective and unplanned settings and may be poised to overtake it as the standard approach for gallbladder disease.

Robotic plication of rectus diastasis: preliminary outcomes Jordan A Bilezikian, MD; Justin D Faulkner, MD; Viktor V Fedorov, DO; William W Hope, MD; New Hanover Regional Medical Center Rectus Diastases are caused by a weakening of the abdominal musculature and a widening of the linea alba. Some patients are often erroneously told that they are hernias. Despite the fact that they are not true hernias, they are often associated with true hernias and undergo concomitant repair. Robotic plication of these diastases has been gaining more widespread use in the past few years, but there is still limited literature regarding outcomes. This study was a small case series comprising patients who underwent robotic plication of abdominal rectus diastasis at a single institution between 2015 and 2019. Demographics, perioperative and short term outcomes were reviewed and descriptive analyses were performed.Eight patients were included in this study. 57% were female, 71% were Caucasian with an average age of 52 years (range 33-78). All diastases were plicated robotically with running barbed absorbable suture. One patient did not have an umbilical hernia, but had an associated uterine prolapse. Of the patients who had concomitant umbilical hernias that were repaired, 33% of them were 1 9 1 cm defects, 50% were 2 9 2 cm defects, and 17% were 4 9 4 cm 'swiss cheese' type defects. 67% of them had synthetic mesh and 33% of them had biologic mesh placed. All of the mesh was fixated with four transfascial sutures and several absorbable tacks. 100% of patients were present for 30 day follow up with a maximum follow up of 2 years. One patient developed a port site hernia, which was repaired laparoscopically. There were no mesh related complications, evidence of hernia recurrence, or chronic pain.The Results of this study suggest that robotic plication of rectus diastasis could be an acceptable surgical approach. Further study is required to assess outcomes in a larger group of patients and to assess which patients would most benefit from this type of repair. Introduction: We analyzed the introduction of robotic sleeve gastrectomy into a mature MIS bariatric practice, and we hypothesized that there is no significant difference in outcomes between robotic and non-robotic procedures. Robotic technology has become more prevalent in the field of surgery in recent years. The robotic platform offers an advantage in ergonomics and utilizes true 3D vision. However, any gains from the robotic platform should be weighed against other factors such as the loss of haptic feedback. While the robot may help to benefit surgeons without formal training in minimally invasive techniques, it may have lesser impact for those who have achieved more advanced levels.Methods: This was a retrospective study of all patients who underwent longitudinal sleeve gastrectomy (LSG) at UMass Memorial in 2019. Patients were sorted into two groups: robotic and standard laparoscopic. Data including time of operation, post-op length of stay, six-month weight loss, \ 30-day readmission, \ 30-day reoperation, and post-op hematocrit drops were all collected. We studied the long-term outcome measures percentage total body weight loss (%TBWL), resolution/development of GERD, and resolution of type 2 diabetes mellitus (T2DM) as quality metrics for LSG. Statistical analysis was performed using SAS, continuous data was analyzed using Student T tests. Results: There was no difference in average procedure time and 30-day readmission rate between groups. The average percent hematocrit drop was significantly lower in the robotic group (1.31% vs 3.58%, p = 0.011). The 6-month readmission rate was higher in the robotic group (10.7% vs 3.9%, p = 0.052). There was no difference in remission rates of GERD, development of/worsening of GERD, remission of T2DM and six month %TBWL between the robotic and standard laparoscopic groups. Conclusion: Robotic sleeve gastrectomy was successfully introduced into a mature bariatric surgery practice. There was no adverse impact observed on surgical time, 30-day readmission rate, weight loss, GERD, or T2DM. We did identify a lower Hct decrease after robotic LSG, which may lead to less transfusions and possibly reduced hospital readmissions in a larger data set. A higher 6-month readmission rate was observed, but the reason behind this is unclear. We plan to use this data set to define learning curves for experienced minimally invasive surgeons in an academic setting.