esophagectomies. None of the patients had evidence of a leak clinically or on routine post-operative barium swallow. The pylorus was dilated during subsequent endoscopy for post-operative symptoms in 11/144 (8%) patients. Postoperative dumping syndrome was seenin 2 (1%) patients. No complications related to the procedure have occurred. ConclusionStapled pyloroplasty is an alternative to standard pyloroplasty with esophagectomy and isassociated with no graft shortening and no post-operative leak rate. It can be done rapidlyduring both open and minimally invasive esophagectomy, and may be less disruptive tothe pyloric function than a standard pyloroplasty.

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Mucosal Stripping Vagal Sparing Esophagectomy for END Stage AchalasiaEmmanuele Abate, Farzaneh Banki, Patrick T. Flanagan, Shahin Ayazi, Arzu Oezcelik,Joerg Zehetner, Weisheng Chen, Jeffrey A. Hagen, Steven R. DeMeester, John C. Lipham,Tom R. DeMeester

Objectives Mucosal stripping vagal sparing esophagectomy removes the esophageal mucosawhile preserving the esophageal muscular wall. This procedure is an option in patients withend-stage achalasia and megaesophagus, and avoids a thoracotomy as well as the risk ofsignificant bleeding that can occur with a transhiatal resection in these patients. The aimof this study is to assess the in hospital characteristics and long term outcome of patientswho underwent mucosal stripping vagal sparing esophagectomy. Methods Retrospectivereview of the charts and symptomatic follow-up of all patients who had mucosal strippingvagal sparing esophagectomy for end stage achalasia from 1993-2008. Results There were19 patients (7 males/12 females) with a median age of 49 years. Previous myotomy wasperformed in 10/19 (53%) and previous dilatation in 16/19 (84%). Gastric pull-up wasperformed in 10 (53%) and colonic interposition in 9 (47%). There were no perioperativedeaths. The median operative blood loss was 800 ml and the median hospital stay was 13 days.No patient had mediastinal bleeding requiring thoracotomy. Perioperative complicationsincluded: mediastinal fluid collection in 4 and an abscess between the native esophagealmuscle and the gastric pull-up in 1. Four patients required reoperation including: evacuationof mediastinal hematoma in 1, VATS for multiloculated pleural effusion in 1, chronic colonicischemia requiring take down of conduit in 1 and repair of anastomotic breakdown in 1patient. At a median follow-up of 6 years, 18/19 (95%) patients were alive. Six patients(32%) had nocturnal regurgitation but none required reoperation (4 colon interposition and2 gastric pull-up). On symptomatic follow-up 16/19 (84%) were free of dumping and 16/19 (84%) were free of diarrhea. The median weight loss was 7 pounds in 10/19 (53%)patients and the weight returned to the preoperative value in 9/19 (47%). ConclusionsMucosal stripping vagal sparing esophagectomy can be performed safely in patients withend-stage achalasia and megaesophagus with minimal mediastinal bleeding. Placement ofthe graft within the native esophageal muscular tube minimizes redundancy and displacementof the graft. Regurgitation is more significant after colon interposition, and gastric pull-upis now favored. Mucosal stripping vagal sparing esophagectomy should be considered inthe surgical treatment of patients with end stage achalasia and megaesophagus.

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Laparoscopic Heller Myotomy with Dor Fundoplication (HM+Dor) forAchalasia: Miltichannel Intraluminal Impedance (MII)-pH Recording andRelux EventsRiccardo Rosati, Roberta Barbera, Uberto Fumagalli, Camilla Gambaro, Ilaria Algieri,Alberto Malesci

HM+Dor fundoplication is generally considered as the operative procedure of choice foresophageal achalasia. Post treatment complications include persistent or recurrent dysphagia,and gastroesophageal (G-R) reflux with related complications. One of the goals of instrumentalfollow-up in these patients is to evaluate silent reflux which can be present in up to 20%of patients. Aim of the present study was to characterize reflux events after HM + Dor inpatients treated for achalasia, using MII-pH monitoring Seventeen consecutive patients whounderwent HM+Dor fundoplication for achalasia (9 female; median age 39 (range 24-77yrs;) underwent a clinical and physiopathological (esophageal stationary manometry andMII-pH impedance) evaluation after a median of 24 months after surgery (range 6-109).All patients were asymptomatic for acid reflux and none was on antisecretory therapy. Threepatients reported persistent dysphagia for solid at follow up (Eckardt 2). Median Eckardtscore was 7 (range 2-11) and 1 (0-3) respectively before and after surgery (p: 0.0001). Meanpressure of lower esophageal sphincter was 37 mm Hg (SD + 19,6) and 9,2 mm Hg (SD +4,1) before and after HM. All but one had a residual pLes < 4 mmHg. The MII -pH dataafter HM + Dor in achalasia patients are reported in Table. Esophageal acid exposure is inthe normal range after surgery in this cohort of patients. We found a pathological numberof non acid reflux, mainly in patients complaining of residual dysphagia (Fisher's exact testp<0,05), in spite of a normal bolus clearance time. Conclusions: Dor fundoplication is avalid option after HM for achalasia to prevent G-R reflux. In these patients reflux eventsare mostly non acid and may be positively correlated with dysphagia. More data are neededto confirm the role of MII pH in patients with motility disorder.

A-929 SSAT Abstracts

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A Safe and Reproducible Anastomotic Technique for Minimally Invasive IvorLewis Esophagectomy - the Circular Stapled Anastomosis with the TransoralAnvil.Rene Ramirez, Jessica K. Smith, Sofia Peeva, Garrett R. Roll, Pierre Theodore, DavidJablons, Guilherme M. Campos

Background: Esophageal adenocarcinoma is the most common subtype of esophageal cancerin the U.S. In most of these cases, an Ivor Lewis approach permits a complete resectionand dissection of abdominal and mediastinal lymph nodes. Although an esophago-gastricanastamosis that is hand-sewn or created with a linear stapler usually provides a low rateof strictures and leaks, it can be technically challenging and time consuming, particularlywhen minimally invasive techniques are used. Objective: To present the initial results of astandardized 25mm/4.8mm circular stapled anastomosis using a transorally placed anvil.Methods: We evaluated a prospective cohort of consecutive patients offered minimallyinvasive Ivor Lewis esophagectomy in a tertiary referral medical center. The esophago-gastricanastomosis was done using a 25mm anvil (Orvil, Autosuture, Norwalk, CT) passed trans-orally, in a tilted position, and connected to a 90cm long PVC delivery tube through anopening in the stapled esophageal stump. The anastomosis was completed by joining theanvil to a circular stapler (EEA XL 25mm with 4.8mm Staples, Autosuture, Norwalk, CT)inserted in the gastric conduit. Primary outcomes were leak and stricture rates. Results:Twenty-two patients (mean age 68 years; range 42 to 84) with distal esophageal cancer(n=19) or high-grade dysplasia in Barrett's Esophagus (n=3) underwent an Ivor LewisEsophagectomy between Oct. 2007 and Nov. 2008. Eight patients had received neo-adjuvanttherapy. The abdominal portion of the operation was completed laparoscopically in 17patients (77%). The thoracic portion was completed using a mini-thoracotomy in 13 patients(59%) and thoracoscopic technique in 9 (41%). Proximal and distal margins were negativein all patients. A median of 16 lymph nodes (range 8 to 29) were dissected from eachspecimen, with a median of 2 (range 0 to 15) histologically positive nodes. No intra-operativetechnical failures of the anastomosis, post-operative leaks, pleural space infections, or deathsoccurred. Twelve general complications occurred in 8 patients (36%); the most commonwas atrial fibrillation. The average hospital stay was 11 days (range 8 to 17). Two patientshad stricture at 21 and 25 days post-operatively, and were successfully treated with a singleendoscopic dilation. Conclusions: The circular stapled anastomosis with the transoral anviltechnique eliminates the need to insert and secure the anvil into the esophageal stump, andallows for a safe and reproducible anastomosis. This straight-forward technique is particularlysuited to the thoracoscopic approach.

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Comparing Esophagectomy Techniques At a Single Center: Transthoracic vsTranshiatal vs Minimally Invasive EsophagectomyStephanie G. Worrell, Brittany L. Willer, Seemal Mumtaz, Sumeet K. Mittal

Objective: To compare the operative outcomes between different open and minimally invasiveesophageal resection techniques. Methods: All patients undergoing esophageal resection wereentered in to a prospectively maintained database. After approval from Institutional ReviewBoard the database was queried to extract data on patients who underwent esophagectomywith gastric pull-up. Results: Ninety-four patients underwent esophageal resection and gastricpull-up with cervical esophago-gastric anastomosis between 2003 and 2008. Of these therewere 28 open transthoracic (TTE), 39 open transhiatal (THE), and 27 minimally invasiveesophagectomy (MIE). The age of patients undergoing THE was significantly higher thanthe TTE and MIE groups. There was no significant difference in sex or co-morbiditiesbetween the 3 groups. . 60% of THE, 64% of TTE and 74% of MIE patients underwentneoadjuvant therapy. There was significantly higher blood loss in THE (857cc) andTTE(785cc) as compared to the MIE group (430 cc) resulting in a significantly higherpercentage of patients in TTE (82%) and THE (69%) requiring blood products as comparedto MIE (26%) group. The operation duration were all significantly different with TTE beingthe longest in duration at 502.6min, followed by MIE at 429.1min, and 328.3min. Therewere significantly more lymph nodes removed in the TTE verse THE group (p=0.001) with19.4 (range 39-11)and 12.9 (range 25-3) respectively. There was on average 15.6 (range42-1) lymph nodes removed in the MIE patients which was not significantly different fromeither THE or TTE. Post-operatively there was one death in each the THE and MIE groupsand no post-operative deaths in the TTE group. There was no significant difference in meanhospital stay between the groups, with the median stay being 13,13 and 14 days in theTTE, MIE, and THE groups. There were significantly higher complications in THE comparedto TTE and MIE groups. Conclusions: There is significantly decreased blood loss andrequirement for blood transfusion along with decreased morbidity with MIE compared toTTE and THE.

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Minimally Invasive Esophagectomies (MIE) At a Non University Tertiary CareCenter (NUTTC): Feasibility and OutcomesAmit S. Khithani, David E. Curtis, Christos A. Galanopoulos, John Jay, D. RohanJeyarajah

Introduction: Minimally invasive surgery has been applied in a number of ways to esophagec-tomy. Newer techniques have improved patient outcomes while maintaining oncologicalprinciples, however, mortality still exists. The aim of this study was to asses the feasibilityof performing MIE with a combined thoracoscopic and laparoscopic approach at a NUTCC.Methods: Minimally invasive esophagectomies (MIE) in the form of combined thoracoscopicand laparoscopic esophageal resections that were performed cooperatively by two surgeonsbetween September 2005 and August 2008 were retrospectively reviewed. The records werereviewed with respect to preoperative and postoperative data, thirty-day mortality, morbidityand histopathology data. Results: Thirty four(34) patients underwent minimally invasiveesophagectomy for esophageal disorders, 61% for adenocarcinomas, 21% for squamouscarcinomas, and 9% for high-grade dysplasia with Barrett's.3 patients underwent MIE for

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