e15668 Background: CRS followed by HIPEC is an invaluable tool in the management of peritoneal carcinomatosis (PC). Our objective was to analyze the efficacy and treatment related morbidity/mortality at our cancer program. Methods: A retrospective analysis of a prospective data base was done. 66 patients with PC were treated between 1/99 and 2/2013. Perioperative morbidity/mortality data along with long-term follow-up data was collected. Eight patients had more than one procedure. Patients were treated with curative and palliative intent. Adverse events were recorded according to Dindo's classification. Median follow-up was 47 months. Results: 66 patients underwent CRS + HIPEC. M/F ratio was, 28/38. Median age was 57years. Primary diagnoses were, Appendiceal (47), Colorectal (15), Ovarian, mesothelioma, liosarcoma and PMP(1)each. Mean Peritoneal Cancer Index (PCI) was 22.8 (4-39). Mean OR time was 741 min (300-1200). Mean blood loss 689.2 ml. Grade III/IV toxicities were seen in 15% of the patients. The common toxicities were, respiratory (33%), GI (31%) and hematologic (20%). Complete/Near complete resection was achieved in 72% of the cases. 30 day mortality was 4.5% (3/66). All 3 deaths were from sepsis. Average length of stay was 15.4 days ( 6-37). Mean overall survival for all the patients was 657.6 days (14-4822). The overall survival was depended on the diagnosis and the PCI. Conclusions: CRS and HIPEC is an effective tool in the management of PC for appropriately selected patients and can be performed even at community cancer programs with required expertise. Our efficacy and safety data correlates well with the other published studies.

e15698 Background: Neo-adjuvant approach is emerging as a standard in the management of BR pancreatic cancer patients and various strategies have been described in the literature. We report our experience with a combination of nab-Paclitaxel and Gemcitabine followed by concurrent Capecitabine and radiation therapy in BR pancreatic cancer patients. . Methods: A prospectively maintained database of patients with BR pancreatic cancer undergoing neo-adjuvant treatments at our center between 01/2013- 6/2015 was reviewed. Pts were treated with Gemcitabine(1gm/m2) and nab-paclitaxel (125mg/m2) given on D1/8/15 every 28 days . Pts. were re-assessed after 2 cycles and the responding pts received 2 additional cycles. Pts. continuing to respond after 4 cycles were treated with capecitabine (825mg/m2) and radiation treatments (50.4Gy). Results: A total of 15 patients with PS 0/1 were treated. Median age was 57 yrs (46-71) and M/F ratio was 12:3. After 2 cycles of Gem/nab-paclitaxel, none of the pts. had progressive disease. All patients completed 4 cycles of Gem/nab-paclitaxel. All 15 patients (100%) received capecitabine and radiation treatments. Responses with the neo-adjuvant treatments were; 0 CR, 4 PR, 10 SD, 1 PD. Eleven patients (73%) underwent planned resection, 3 had PD and 1 had decline in PS. Nine out of eleven (81%) patients undergoing surgery had a R0 resection. Grade-III/IV toxicities with the neo-adjuvant treatments were seen in 40% and 6 % of the pts., respectively. There was no 30 day post-op mortality, pancreatic leaks or re-operations. 12/15 (80%) patients are alive with a median follow-up of 10 months range: (4-26months). Of the 11 patients who had surgery,10 (90%) are alive, 8 (72%) have no evidence of disease and one died after 22 months. Conclusions: Nab-Paclitaxel and Gemcitabine followed by Capecitabine and radiation treatment is an effective neo-adjuvant strategy with acceptable toxicity-profile in the management of patients with good performance status diagnosed with BR pancreatic cancer.

The altered anatomy of Roux-en-Y gastric bypass presents a challenge when duodenal access is required for ERCP. One technique, laparoscopic transgastric ERCP, was first described in 2002. Since that time, a total of 77 laparoscopic or percutaneous transgastric ERCPs have been reported. The largest case series includes 26 ERCPs, and no reports specifically address complications. We reviewed our experience with 85 transgastric ERCPs and report the limitations and complications associated with access and ERCP.

We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy.

Flexible endoscopy has become an integral part of managing many surgical problems that in the past required open or laparoscopic surgical interventions. Stents, clips, suturing devices, glues, and vacuum systems can be used to control perforations, leaks, and fistulas in properly selected patients. Stents have gained place in the treatment algorithm for patients with esophageal perforation from various causes. Endoscopic clips are being used to close perforations in the gastrointestinal tract in addition to their use for bleeding. The technology is slowly evolving and larger clips are available for over-the-scope use. Early perforations and leaks can be managed with clips. Various suturing devices are available for endoscopic suturing mainly for upper gastrointestinal tract. Many of the devices were initially designed for antireflux procedures and are used for closure of perforations and fistulas. The research in closure techniques for enterotomies in natural orifice surgery has expanded its role in the management of iatrogenic perforations. In this article, we review the current literature and describe the role of flexible endoscopy for treatment of leaks and fistulas.

The introduction of laparoscopic cholecystectomy (LC) inthe USA in 1989 marked the beginning of what has becomeknow as the ‘‘laparoscopic revolution’’ [1–4]. It was quicklyadopted among surgeons in private practice. The Society ofAmerican Gastrointestinal Endoscopic Surgeons (SAGES)was the first organization to take the lead in ensuring patientsafety by insisting on quality training through certifiedtraining courses, establishing guidelines, and introducingcredentialing criteria for laparoscopic surgery. More thantwo decades later, it is time for SAGES to assume a lead-ership role in addressing two major and troublesome issuesthat remain in laparoscopic biliary surgery relating topatient safety and high-quality outcomes.Bile duct injuryA bile duct injury (BDI) rate of 0.2 % was reported in theera when open cholecystectomy (OC) was the standard [5].Currently, LC BDI rates ranging from 0.2 to 0.5 % aremore the norm in large population-based studies [6–9].Although the laparoscopic BDI rate may be lessening withthe passage of time, BDI is still more likely with LC thanwith OC, and remains a real danger in the learning curve ofevery surgeon [10]. After 25 years of LC, it appears thatthe risk of laparoscopic BDI is approximately twice what itwas in the OC era. Even in the hands of competent sur-geons, it is unlikely that BDI can ever be completelyeliminated because inflammation and anatomic variationdistort and obscure the anatomy. However, misidentifying

Objective:To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. Methods:A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. Results:There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Purpose Gastrointestinal (GI) lipomas are rare, benign, slowly growing, submucosal tumors, which can either be incidentally found as silent tumors of the GI tract or be the cause for GI bleeding, anemia, intussusception, and bowel obstruction. Endoscopic removal is a valid alternative to surgical resection of these tumors. In the recent past, many submucosal lipomas were for the most part resected surgically due to the risk of perforation using endoscopy. There are newer techniques available to allow safe endoscopic removal of these lesions. We present 3 successful techniques tailored to the location of the lipoma and size. Methods In our unit, 3 symptomatic GI lipomas were referred to us for surgical resection, 2 originating from the duodenum and 1 from the cecum were diagnosed and resected under endoscopic ultrasound and endoscopy. We performed 3 different techniques to remove these lipomas. One of the lipomas in the duodenum was in the duodenal bulb. It was mobile and 3 cm in size. We attempted to remove this broad-based lipoma by snare and cut technique after its borders were elevated with injection of saline and epinephrine. The second duodenal lipoma was 1.5 cm. This pedunculated lipoma was located in the second portion, on the pancreatic side of the duodenum proximal to ampulla. This lipoma was lifted up with a snare and its base was cauterized resulting in successful removal. The third GI lipoma was 3.5 cm in size pedunculated and located in the cecum. The base of this pedunculated lipoma was ligated with poly loop device and endoclip resulting in ischemia and spontaneous separation of the lipoma from the colonic wall. All cases were revisited with follow-up endoscopy. All 3 methods, when used selectively, were found to be very safe and effective. Results All 3 lesions were successfully removed and histopathologically confirmed to be lipomas. After endoscopic removal, no complications were observed. Conclusions Carefully selected GI lipomas, which in the past have required surgical resection due to high risk for perforation can be endoscopically removed with great success.

BACKGROUND:Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. The authors describe their technique, indications, and outcomes for this group of patients.METHODS:Data were collected by a retrospective chart review of the experience two surgeons had with laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) from July 2004 to October 2008 at a single institution. This review identified 22 cases. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in 18 patients and recurrent pancreatitis in four patients. Adhesions were lysed, and a purse-string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery, and a 12 mm trocar was inserted. It was secured with a purse-string suture. A side-viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. The intended interventions were sphincter of Oddi manometry, sphincterotomy, placement of a pancreatic duct stent, and injection of botulinum toxin if indicated.RESULTS:Laparoscopic access to the remnant stomach was sufficient for ERCP in 21 cases. One patient required conversion to an open procedure. A total of 12 patients had undergone prior open upper abdominal surgery. One retroperitoneal perforation was noted, with precut sphincterotomy and cannulation of the minor duodenal papilla and no clinical repercussions. Manometry was performed for 18 patients. The pancreatic duct cannulation rate for manometry was 89%, and the rate of bile duct cannulation for manometry was 94%. The manometry studies for 12 patients yielded abnormal results. Eight patients had transient improvement, and three patients had long-term improvement or resolution of symptoms after the index procedure. With additional treatment, two of the transient responders had long-term resolution of symptoms.CONCLUSIONS:The findings demonstrate that gastric bypass patients with biliary pain can be successfully evaluated endoscopically by laparoscopic transgastric ERCP for sphincter of Oddi dysfunction. The rate for technical success and complications does not appear to be significantly greater than for standard ERCP. A few helpful techniques were noted during this experience. Comparison of efficacy with that of a prior study was limited.

PURPOSE:Gastrointestinal (GI) lipomas are rare, benign, slowly growing, submucosal tumors, which can either be incidentally found as silent tumors of the GI tract or be the cause for GI bleeding, anemia, intussusception, and bowel obstruction. Endoscopic removal is a valid alternative to surgical resection of these tumors. In the recent past, many submucosal lipomas were for the most part resected surgically due to the risk of perforation using endoscopy. There are newer techniques available to allow safe endoscopic removal of these lesions. We present 3 successful techniques tailored to the location of the lipoma and size. METHODS:In our unit, 3 symptomatic GI lipomas were referred to us for surgical resection, 2 originating from the duodenum and 1 from the cecum were diagnosed and resected under endoscopic ultrasound and endoscopy. We performed 3 different techniques to remove these lipomas. One of the lipomas in the duodenum was in the duodenal bulb. It was mobile and 3 cm in size. We attempted to remove this broad-based lipoma by snare and cut technique after its borders were elevated with injection of saline and epinephrine. The second duodenal lipoma was 1.5 cm. This pedunculated lipoma was located in the second portion, on the pancreatic side of the duodenum proximal to ampulla. This lipoma was lifted up with a snare and its base was cauterized resulting in successful removal. The third GI lipoma was 3.5 cm in size pedunculated and located in the cecum. The base of this pedunculated lipoma was ligated with poly loop device and endoclip resulting in ischemia and spontaneous separation of the lipoma from the colonic wall. All cases were revisited with follow-up endoscopy. All 3 methods, when used selectively, were found to be very safe and effective. RESULTS:All 3 lesions were successfully removed and histopathologically confirmed to be lipomas. After endoscopic removal, no complications were observed. CONCLUSIONS:Carefully selected GI lipomas, which in the past have required surgical resection due to high risk for perforation can be endoscopically removed with great success.