SSAT Abstracts Trends in receipt of surgery, chemotherapy, or MMT were compared. Kaplan-Meier curves were used to evaluate survival based on treatment modality. RESULTS: A total of 39,441 patients were identified. The mean age of the cohort was 68.1+11.6 years. 73.6% were white; 40.1% were treated at a community center/cancer program. 22.8% of patients received no treatment. Patients ≥76 years of age had lower receipt of treatment compared with those aged 15-55 years (54.8% vs. 90.6%) (p<0.0001). Community cancer programs (68.8%) and community cancer centers (72.1%) were less likely to treat patients than NCI-designated Cancer Cancers (85.2%, p<0.0001). Of 30,445 treated patients, 29.8% underwent only surgical resection, 23.9% received chemotherapy only, and 46.3% received MMT. Receipt of MMT increased from 31.3% of the overall cohort in 2004 to 37.9% in 2011 (p<0.0001)(Fi- gure 1). Chemotherapy was delivered in the neoadjuvant setting in 4.5% of patients receiving MMT in 2004 and 16.7% in 2011 (p<0.0001). Neoadjuvant therapy comprised a greater proportion of MMT at NCI cancer centers (16.8%) compared to community cancer programs (5.6%) and comprehensive community cancer centers (7.9%). In patients who underwent surgery at the initial treatment modality (N=21,633), 58.1% received adjuvant therapy; adjuvant therapy decreased from 68.4% of patients 18-55 to 38.3% of patients >76 years who underwent surgery first. Regardless of the timing of chemotherapy, patients had improved survival if they received MMT; 2-year survival was 46.9% for MMT (46.5% adjuvant vs. 49.5% neoadjuvant). CONCLUSION: In this contemporary cohort, receipt of MMT increased over time, but remained underutilized. Older patients and patients treated in community programs were more likely to be untreated. Despite multiple single-institution reports, MMT is still most commonly delivered in the adjuvant setting, though the proportion of MMT delivered in the neoadjuvant setting is increasing. When surgery is the initial treatment modality, a third of patients do not go on to receive adjuvant therapy with the greatest disparity occurring in older patients. 451 Transanal Minimally Invasive Surgery (TAMIS): Tips, Tricks, and Troubleshooting Sujata Gill, Jamil L. Stetler, Ankit Patel, S. Scott Davis, Edward Lin, Patrick S. Sullivan Transanal minimally invasive surgery (TAMIS) is fast becoming the procedure of choice for the resection of benign and early stage malignant rectal lesions. The data published thusfar is short term but promising. TAMIS is safe, cost effective and requires basic laparoscopy skills and equipment to perform. The objective of this video is to demonstrate some tips, tricks and ways to troubleshoot for this procedure in order to make the operative steps of exposure, excision and defect closure easy to learn and efficient to complete. 452 Concurrent Robotic Abdominoperineal Resection and Prostatectomy in a Patient With Synchronous Primary Adenocarcinomas Anna Weiss, Ryan C. Broderick, Luis C. Cajas-Monson, Janos Taller, Sonia Ramamoorthy, Marc Chuang, Daniel D. Klaristenfeld We present a unique case of synchronous rectal and prostate primary adenocarcinomas. A 61 year old man presented with 3 weeks of rectal bleeding, and perianal pain. Past medical history was significant for a diagnosis of prostate adenocarcinoma 4 years ago. On physical exam there was a rectal tumor in the left anterior position, starting at the dentate line and extending beyond the finger. On magnetic resonance imaging he had T3N1 disease of the rectum. He underwent neoadjuvant chemoradiation and eight weeks later concurrent robotic abdominoperineal resection and prostatectomy. His surgical pathology revealed two primary adenocarcinomas, one of 16 nodes positive for prostate adenocarcinoma. 453 High-Risk TEM: Large Anterior and Upper Rectal Lesion With Peritoneal Entry Winta T. Mehtsun, Patricia Sylla We describe TEM excision of a nearly 7 cm large pedunculated tubulovillous adenoma of the upper rectum. The patient is a 87 year-old female with extensive cardiac co-morbidities, who on diagnostic colonoscopy, was found to have multiple colonic adenomas that were removed, as well as a large and floppy villous lesion with a wide stalk located along the S-1108 SSAT Abstracts anterolateral rectal wall. Biopsies and staging CT scans were negative for malignancy despite a CEA being 5.5. In an effort to avoid radical resection, she was offered TEM full-thickness excision, which was performed in prone position, given the high risk for peritoneal entry during dissection. Transanal endoscopic resection was performed using a rigid TEM platform, and the lesion was located in the upper rectum, approximately 12 cm from the anal verge. The lesion was first scored circumferentially and the long stalk identified along the right lateral rectal wall. Full thickness rectal dissection of the lesion was performed circumferen- tially, which resulted in sizeable peritoneal entry with a wide defect along the right lateral rectal wall. The prone position significantly helped prevent excessive loss of pneumorectum into the abdomen, by tamponading the abdominal cavity against the operating room table. The lesion was entirely resected and extracted transanally, and the full-thickness defect through the rectal wall was closed using continuous and interrupted absorbable sutures. Following full-thickness closure of the large rectal wall defect, the rectal lumen remained patent and the transanal endoscopic platform was removed. The patient was discharged home on postoperative day 2, and pathology demonstrated a 6.5 cm tubulovillous adenoma with focal features of serrated adenoma but no evidence of dysplasia. 454 Laparoscopic Cattell-Braasch Maneuver Thomas Schnelldorfer The operative technique of the laparoscopic Cattell-Braasch maneuver will be demonstrated in two patients with a duodenal and a proximal mesenteric tumor. This video emphasizes the technique of a safe laparoscopic resection with good visual exposure of the entire duodenum, proximal small bowel mesentery, and retroperitoneum despite of this anatomi- cally difficult-to-reach area. It further demonstrates a superior and an inferior approach to the laparoscopic Cattell-Braasch maneuver best utilized depending on the underlying pathology. 473 Pathophysiology of Gastroesophageal Reflux in Patients With Chronic Pulmonary Obstructive Disease Is Linked to an Increased Transdiaphragmatic Pressure Gradient Not a Defective Esophagogastric Barrier Leonardo M. Del Grande, Fernando A. Herbella, Marco G. Patti Introduction: The association of gastroesophageal reflux disease (GERD) and pulmonary diseases is well known. Chronic pulmonary obstructive disease (COPD) is probably the main pulmonary disease that lacks a satisfactory number of studies dealing with evaluation of esophageal motility and objective evaluation of acid exposure by esophageal function tests. This study aims to evaluate in patients with COPD: (1) esophageal motility; (2) thoracic and abdominal pressures, and (3) incidence of GERD diagnosed by ambulatory pH monitoring. Methods: We studied 48 patients (56% females, age 66 years). All patients underwent a high resolution manometry and esophageal pH monitoring. Patients were group according to the presence of GERD based on a DeMeester score >14.7. Results: GERD + comprised 21 (44%) patients (57% males, age 67 years). GERD - comprised 27 (56%) patients (33% males, age 65). There was no difference between groups in regard to gender (p=0.1), age (0.5), body mass index (p=0.8), and COPD severity (p =0.9). Manometric parameters are depicted in table 1. Thoracic pressure was lower in GERD + patients with a higher transdiaphragmatic pressure gradient and lower LES retention pressure (LES basal pressure -transdiaphragmatic gradient) in this group. Conclusions: Our results show that: (1) almost half of COPD patients have GERD on pH monitoring, and (2) esophageal motility is not different in COPD GERD + and COPD GERD -. COPD patients have a higher incidence of GERD whose physiopathology is linked to an increased transdiaphragmatic pressure gradient not a defective esophagogastric barrier. Manometric parameters LES: lower esophageal sphincter * statistic significance 474 Both Pre-Transplant and Early Post-Transplant Anti-Reflux Surgery Prevent Development of Early Allograft Injury After Lung Transplantation Wai-Kit Lo, Jon Wee, Piero Marco Fisichella, Walter W. Chan Background: Anti-reflux surgery (ARS) has been associated with improved lung transplant outcomes. Pre-transplant ARS has been shown in small studies to improve pulmonary function among transplant candidates with gastroesophgeal reflux disease (GERD). Although early post-transplant ARS has been more effective than later ARS in reducing chronic rejection, the optimal timing of ARS in transplant recipients remains unclear. Aim: To evaluate the