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Transvaginal Notes Cholecystectomy: Retrospective Analysis of ImmediatePost-Operative PainStephanie Wood, Nalini Vadivelu, Mikhael Hosni, Susan Dabu-Bondoc, Feng Dai, LucianPanait, Robert Bell, Andrew Duffy, Walter Longo, Kurt E. Roberts

Introduction: Transvaginal cholecystectomy (TVC) is the most common Natural OrificeTransluminal Surgery (NOTES) performed in women to date yet there is a paucity of dataon intraoperative and immediate post operative pain management. Previous studies havedemonstrated that NOTES procedures are associated with less post-operative pain andfaster recovery times. We analyzed the intraoperative and postoperative opioid use for TVCcompared to traditional 4-port laparoscopic cholecystectomies (LC) during the last 2 yearsin our facility. Methods: We performed a retrospective analysis of the last 20 TVC to thelast 20 LC patients at our facility.We compared demographics, intraoperative and postoperat-ive opioid use and times in the operating room and in the Post Anesthesia Care Unit (PACU).The opioid use is described in the morphine equivalent (mg). We obtained data fromelectronically recorded anesthesia records of the perioperative period. Results: There wereno significant differences between the average age and BMI between the LC (41years, 30kg/m2) vs. TVC (40years, 30kg/m2) groups (p=0.9; p=0.88). The average time of patient inthe operating room was significantly greater for the TVC (115.3 +/- 20.2 min) comparedto LC (88.4 +/- 21.6 min, p=0.002). The OR preparation time (TV: 36.2 +/- 8.1min vs. LC:22.5 +/- 5.1; p<0.001), operative time (TV: 115.3 +/- 21.6 min vs. LC: 82.4 +/- 19.8 min;p<0.001) and emergence time (TV: 17 min vs. LC: 10.5 min; p=0.04) were significantlygreater for the TVC compared to LC. The OR opioid use was significantly greater for theTV group (TV: 31.8 +/- 10.7mg vs. LC: 25.6 +/- 6.9mg; p=0.04), however, after adjustingfor OR time the difference in OR opioid between two groups becomes non-significant (p=0.09). Interestingly, while the average (PACU) time was significantly greater for the TVCgroup (195.7 +/- 88.9 min vs. 141.7 +/- 61.6 min, p=0.03), the average opioid use withsignificantly less for the TV group (0mg, range 0-2.5) compared to LC group (6.3mg, range0-9.5), p=0.01. The overall opioid use (OR + PACU) was not significantly different betweenthe groups (TV: 33.6 +/- 10.1mg vs. LC: 31.6 +/- 7.3mg; p=0.48). The average PACU painVisual Analogue Pain Score was not statistically significantly different between the TVC andLC groups (p=0.51). Conclusion: There was significantly less use of opioids in the PACUperiod for the TVC group despite no difference shown in Visual Analogue Pain scores.Additionally, significantly greater OR prep, operative, emergence and PACU timewas requiredfor patients undergoing the TVC approach. This retrospective analysis of transvaginal cholecy-stectomy patients suggests that there is indeed less postoperative pain measured by thereduced opioid use after transvaginal NOTES cholecystectomy.

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Follow-up of Ultrasound-Detected Gallbladder Polypoid LesionsAmir Kambal, Chris Brown, Ramesh Y. Kannan, Omer Jalil, Abu Feroz, Ashraf M.Rasheed

Objectives: Gallbladder polyps are reported in 5% of screening ultrasonography (US). Themajority are benign, however some do have a malignant potential. The preoperative confirma-tion of the nature of these lesions is "difficult" and the optimal management remains to beill-defined Aims: To determine the nature and assess the current clinical pathways for theultrasound-detected gallbladder polyps (GBP) and propose a follow -up and a therapeuticstrategy based on size and symptomatology Methods: A retrospective search of the USdatabase for "polyp" in gallbladder for the period between January 1st 2009 and Dec 31st2010 was conducted. A database was then constructed including demographics, clinicalpresentation, principal symptoms, management and pathology. Histologic findings wereanalyzed in patients who underwent cholecystectomy. The electronic medical records weresearched to check the clinical outcome, pathologic data and follow-up arrangements Results:Ultrasound detected gallbladder polyps were reported in 347 patients, 214 female and 133males with an age range between 14-93 yrs, (Median 5, IQR=41-58). Polyps were foundduring the course of investigation for the possibility of gallbladder disease in 125 patients(36%). The rest were incidental finding during investigation of other illnesses. The majorityof referrals for the US came from primary care (60%), the rest came from hospital physiciansin (24%) and surgeons in (13%) of cases. Forty two percent of the reports made no mentionof polyp actual size and 39% reported the polypoid lesion to be <10mm without giving theactual size. The actual size was reported in only 12% of cases. Eighteen patients (5%)underwent laparoscopic cholecystectomy revealing neoplastic polyps (adenoma) in 2 casesand one case turned out to be invasive adenocarcinoma. Sixty six cases (19%) were underpoorly defined surveillance and only 5 had follow up scans and more than 70% of thepatients had no plans for follow up Conclusion: Our preliminary data confirm that themajority of the US detected ‘polypoid lesions' are incidental findings and are not trueepithelial polyps. Themajority of patients with symptomatic polyps who underwent cholecys-tectomy had cholelithiasis on histology. The current management strategy of asymptomaticpolyps relies on its size and hence must be included in the US report which was poorlycomplied with in this series. Small (<10 mm) asymptomatic polyps need better characteris-ation by magnetic resonance imaging (MRI) and/or endoluminal ultrasound (EUS), whilethose > 10 mm should be offered cholecystectomy. A well defined long term follow up ofpatients is necessary to allow better understanding of this pathological entity and a nationwideregistry or large longitudinal observational study is warranted as these might represent amissed opportunity for early detection of cancer

S-1050SSAT Abstracts

Su1503

Incidence of Cystic Duct Stones During Laparoscopic CholecystectomyAmir Kambal, Tomos Richards, Harsha Jayamanne, Zeyad A. Sallami, Ashraf M. Rasheed,Taha R. Lazim

Objective: With the advent of the Laparoscopic Cholecystectomy (LC) era, the loss of tactileelement hindered the detection of cystic duct stones (CDS) during surgery. These stonesare implicated in the post cholecystectomy pain syndrome, failure of the insertion of intra-oprative cholangiogram (IOC) catheter and the subsequent development of common bileduct (CBD) stones. The preoperative imaging rarely detects their presence. The aim of thisanalysis is to quantify the frequency of the incidental finding of CDS during LC and toemphasise the importance of the awareness of it in our routine practise. Method: A cohortof consecutive patients undergoing LC during the period from November 2006 to May 2010were included. Data was collected prospectively. Their liver function tests were documentedin the preoperative period. The procedure entailed careful dissection of the cystic duct tothe proximity of common bile duct. A clip was then placed at the gall bladder and cysticduct junction. If an IOC was required, the cystic duct was opened in the routine fashion.A partially closed endoclip was then used to milk the cystic duct towards the gallbladder;any CDS encountered were retrieved and documented. If IOC was not indicated, the cysticduct was milked prior to the application of gallbladder/cystic clip. Results: The study included330 patients; 80 male and 250 females. Age ranged between 16 to 88 years (Median 50,IQR: 36,62). In 266 patients no CDS were detected. However, in 64 (19%) patients CDSwere identified using the above technique; 28 (45%) having a single stone. The remaining36 (55%) patients had more than one stone with a maximum detected number of 7 stonesin the cystic duct. Preoperative imaging failed to detect CDS in the majority of cases. Ofthose 64 patients with CDS, 47 (75%) showed deranged liver function tests at some stageof their disease prior to surgery. In comparison, of the 266 patients with no CDS, 152(57%) also demonstrated abnormal liver function tests. Discussion: The results demonstratethe fact pre-operative investigations are not helpful in diagnosing cystic duct stones. Theiroccurrence is common. In order to detect CDS, specific intra-operative vigilance is needed.Careful upward milking of the cystic duct before applying clips is a simple, safe and effectiveway of detecting and extracting these stones. This study changed our practice as thisprocedure is now included in all our Laparoscopic Cholecystectomies.

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Biliary Stone Disease (BSD) and Its Complications in Patients Under 25 YearsAnibal Rondan, Rafael A. Redondo, Mauricio Ramirez, Mariano Gimenez, MarceloFasano, Alberto R. Ferreres

Introduction: BSD is one of the most frequent disorders affecting the gastrointestinal tract;its incidence in the adult population is above 25% for females and around 10% for males.Race and ethnicity play a major role in its development, more frequent in hispanics andnative descendents. In some latinamerican countries (Chile, Bolivia, Colombia) the incidenceof gallbladder cancer is the highest in the world. A high incidence of these conditions andits complications has been found in the younger population. Objective: analyze the incidence,clinical presentation and course and prognosis of BSD in patients under 25 years. Methodsand materials After approval of our institutional IRB a retrospective analysis of medicalrecords of patients who underwent admission for BSD at our single institution betweenJanuary 2005 and January 2011 was performed. 5377 patients were admitted for BSD and/or its complications, being 591 (10.99 %) under 25 years with a median age of 20 (range12/24). 449 ( 76 %) were female and 9 patients were pregnant at the time of clinical onsetof symptoms. Our guidelines included a minimal invasive approach for treatment of illnessand complications. Results: 457 ( 77.33 %) patients were admitted for elective surgery(laparoscopic cholecystectomy with intraoperative cholangiogram and/or CBD exploration)and the previous medical history included: acute pancreatitis in 56 (12.25 %), pancreaticpseudocysts in 3 (0.65 %), acute cholecystitis in12 (2.62 %), common bile duct stones in32 (7.00%). Laparoscopic cholecystectomy was completed in 433 (94.74%), intraoperativecholangiography was achieved in 397 cases (86.66%). The remaining 24 patients requiredconversión through a right subcostal incisión due to:Mirizzi's síndrome (3), cholecystocolonicfistula (2), cholecystoduodenal fistula (2), CBDmultiple stones, intense adhesions, intraoper-ative complications (bleeding, liver laceration). The other 134 (22.67 %) were admitted asemergency cases. The initial diagnosis was: acute cholecystitis (75), acute colangitis (55),liver abscess (4). The treatment was the following: laparoscopic cholecystectomy 75, ERCPwith papillotomy and stone removal, and percutaneous drainage. Postoperative complicationswere the following:surgical site infection (5%), intraabdominal collections (2%), retainedCBD stones (1%). No bile duct injuries were registered. Conclusions: the spectrum of BSD,its progress and complications in the young population imposes a prompt diagnosis andsurgical treatment in order to correct symptoms, prevent complications and avoid sequelaeand disability. Pregnant patients poises a clinical management and challenge, mainly in thefirst trimester pregnancies.

Su1505

The Prognostic Value of Plasma TIMP-1 in Resectable Colorectal Cancer: AProspective Validation StudyHans J. Nielsen, Nils Brünner, Ib J. Christensen

Background: Results from retrospective studies show that preoperative plasma TIMP-1 andCEA levels carry independent prognostic information of patients with primary CRC. Thepurpose of the present, prospective study was to validate the prognostic value of preoperativeplasma TIMP-1 and CEA in patients with primary CRC. Methods: Blood samples werecollected before surgery from 297 patients with stage I-IV disease. TIMP-1 and CEA levelswere determined in ETDA plasma using an automated platform (ArchitectÒ, Abbott Laborat-ories, Chicago, USA). The Cox proportional hazards model was used with TIMP-1 and CEAon a continous scale (log base 2) adjusted for clinical covariates. The endpoints were overallsurvival (OS) and disease-free survival - time from operation to any event (DFS). Results:Of the 297 patients 118 were females and 179 males with a median age of 70 (32-79) years.