2005 SAGES Abstracts

POSTER ABSTRACTS
SAGES 2005
200 http://www.sages.org/
that were successfully treated by hand-assisted laparoscopic
surgery (HALS). Two patients, a 56-year-old woman and a 60-
year-old man, were admitted to our department for the treatment
of a huge submucosal tumor of the stomach. After gastrointestinal
endoscopy, US, CT, and MRI, we suspected that
the masses measuring 7.0 cm and 8.0 cm in diameter, respectively,
were GISTs in the stomach. However, we preoperatively
could not rule out the possibility of a malignant neoplasm
because they had been bleeding or gradually growing. Handassisted
laparoscopic wedge resection was safely performed
for the diagnosis and treatment of the submucosal tumor of
the stomach. The duration of surgery was 85 minutes and 91
minutes, respectively. The intraoperative blood loss was
insignificant. Intra- and postoperative course was uneventful.
An immunohistological diagnosis was GIST with low-grade
malignancy of the stomach. Two patients remain well with no
sign of recurrence of GIST. HALS may be a good indication for
huge GISTs of the stomach that are difficult to diagnose preoperatively
whether they are malignant or benign.
P282–Esophageal/Gastric Surgery
LAPAROSCOPIC GASTRIC RESECTION: THE RESULTS OF
NINETEEN CONSECUTIVE CASES, Laurent Layani MD, Craig j
taylor MD, Robert Winn MD,michael ghusn MD, John Flynn
Gold Coast Hospital, Queensland Australia
INTRODUCTION. Whilst the benefits of the laparoscopic surgery
in the management many intra-abdominal pathologies
such as cholelithiasis are well established, the benefit and feasibility
of laparoscopic gastrectomy, particularly for gastric
malignancy, remain uncertain. We sought to investigate this
by reporting our experience with totally intracorporeal gastric
resection (LGR)
METHODS. All lap gastric resections performed by a single
surgeon were retrospectively analysed.
RESULTS. Between March 2000 and August 2004, 19 patients
(median age 74 years) underwent LGR. Pathologies included
11 adenocarcinomas, 2 malignant GIST tumours, 4 benign
GIST tumours, 1 incomplete dysplastic polypectomy, and 1
gastroparesis. Seven of 13 patients with malignancy were
treated with curative intent. Two total gastrectomies, 8 subtotal
gastrectomies, and 9 wedge resections were performed.
Median operative time was 154 minutes. There were no conversions
to laparotomy and no postoperative deaths. A median
of 25 lymph nodes were retrieved in curative malignant
resections. Fluid and solid food intake was recommenced at a
median of 16 hours and 3 days respectively. Median length of
hospitalisation was 4.5 days. (range 3-15) The median return
to usual preoperative activities was 17 days. One radiological
anastomotic leak occurred and was successfully managed conservatively.
There was no major morbidity. No port site recurrences
occurred. Two patients (10%) underwent reoperation
for laparoscopic re-resection of microscopically involved margins.
One patient with locally advanced adenocarcinoma died
17 months post resection. The remaining 12 patients with gastric
malignancy were still alive at a median of 15 months.
CONCLUSION. Totally laparoscopic gastric resection is technically
feasible and confers the established benefits of minimal
access surgery, particularly low postoperative morbidity and
short convalescence and is set to become the procedure of
choice for benign and palliative gastric pathology. Whilst large
randomised trials are needed to confirm its safety in potentially
curative gastric malignancy, our results indicate that an
oncologically sound resection can be achieved.
P283–Esophageal/Gastric Surgery
IDENTIFICATION OF A LARGE SYMPATHETIC NERVE AT THE
GASTROESOPHAGEAL JUNCTION DURING LAPAROSCOPIC
NISSEN FUNDOPLICATION., Cyrus Vakili MD, Departments of
Surgery, University of Massachusetts Affiliated Hospitals,
Gardner MA, and Leominster MA
Functional symptoms such as gas bloat, flatulence, early satiety,
inability to belch, epigastric fullness, and dysphagia frequently
occur following Nissen fundoplication. The cause of
these symptoms in the majority of cases has not been determined.
This author has performed 449 laparoscopic Nissen
fundoplications between January 1993 and June 2004. A relatively
large sympathetic nerve supplying the gastroesophageal
junction (GEJ) was observed during video laparoscopy. This
nerve is a branch of the left greater splanchnic nerve. It exits
through the left true crus, and enters the most distal part of
the esophagus, just above the angle of His. At first glance it
looks as a fibrovascular structure. Upon biopsy on multiple
occasions, its histology and identity was verified. The diameter
of the nerve varies from 0.8 mm to 1.4 mm. There is no contralateral
sympathetic innervation from the right side.
Interestingly, this sympathetic nerve to the GEJ has not been
depicted or described in surgical literature. There are also a
couple of smaller sympathetic nerves, parallel but more cephalad
to the GEJ nerve, which exit through the true left crus and
enter the distal esophagus. Classically, the sympathetic innervation
of the distal esophagus and the stomach has been
described as fine nerve fibers traveling along large arteries
such as the left gastric artery. Compared to the parasympathetic
nerves, less information is available regarding the function
of the sympathetic system on the lower esophageal
sphincter and the fundus of the stomach. During Nissen procedure,
these sympathetic nerves are often transected to facilitate
mobilization of the distal esophagus, and to develop a
window behind the esophagus for fundoplication. In my experience,
preservation of these sympathetic nerves did not
change the rate of gas bloat, or flatulence. However, its preservation
seems to have shortened the period of post operative
dysphagia. Considering the relative large size of the GEJ
nerve, and its anatomic location, investigation into its function
is warranted, particularly when the parasympathetic nerves
are preserved.
P284–Esophageal/Gastric Surgery
FEASIBILITY OF LAPAROSCOPIC FUNDOPLICATION AFTER
FAILED ENDOSCOPIC ANTIREFLUX THERAPY, YKS Viswanath
RN, P Cann MD,P Davis MS,PP Vassallo,K Subramanian,
Department of Surgery and Medicine, James Cook University
Hospital
Background and aims: The intraoperative difficulties and post
operative outcome after failed endoscopic Enteryx polymer
injection therapy (EEPIT) to improve the reflux symptoms is
unclear .We assessed the feasibility and safety of undertaking
the Laparoscopic Nissen-Rossetti fundoplication (LNRF) after
failed EEPIT.
Methods: Eleven among a total of 22 patients failed to respond
to EEPIT. Hitherto 6 among 11 patients had undergone LNRF.
All patients had Upper GI endoscopy, oesophageal manometry
and pH profiles prior to EEPIT. At surgery care was taken to
identify any distortion in the normal anatomy and to identify
any areas of fibrosis and abnormal foreign material.
Results: All patients underwent successful LNRF. In five
patients there were dense perioesophageal adhesions and two
of them had foreign body granulomata anterior to the gastrooesophageal
junction obliterating the left sub hepatic space.
The remaining 1 had no significant adhesions. Median hospital
stay 1.5 days. The procedures were event free and all had
excellent control of reflux symptoms in a median follow up of
5 months.
Conclusion: Laparoscopic fundoplication following failed EEPIT
injection is feasible and is not associated with increased postoperative
morbidity.
P285–Esophageal/Gastric Surgery
LAPAROSCOPIC IVOR LEWIS ESOPHAGECTOMY IN THREE
PATIENTS WITH ABERRENT RIGHT SUBCLAVIAN ARTERIES,
Tracey L Weigel MD, Anna Ibele MD,Joseph Bobadilla
MD,Loay F Kabbani MD,Niloo M Edwards MD, University of
Wisconsin
Introduction: An aberrent right subclavian artery is a common
anomaly often referred to as “dysphagia lusoria” if symptomatic.
In patients with a resectable gastroesophageal junction
carcinoma, an aberrent right subclavian that courses posterior
to the esophagus, even if an incidental finding on chest CT,
poses a challenge to safe resection and reconstruction.
Methods: Three patients with gastroesophageal junction carcinomas
were found to have an aberrent right subclavian artery
on preoperative chest CT and were approached with a laparoscopic
Ivor Lewis esophagectomy. Diagnostic laparoscopy was