SSAT Abstracts T1600 Ventral Hernias: A Six Year Outcome Analysis from a Rural Teaching Hospital Vikas Singhal, Burt Cagir, Mathew Thomas, Keyur Chavda, Thomas J. VanderMeer, Douglas R. Trostle Background: In the paucity of large studies comparing treatment outcomes for ventral hernias, surgical technique still largely remains a matter of personal preference and expertise. We carried out a large analytical study of current practice in the setting of a large community hospital with the aim to assess treatment strategies and determine factors influencing out- comes. Method: Electronic medical records of all patients who had a ventral hernia repair from January 2001 to October 2006 at our hospital were retrospectively analyzed. The time of follow-up ranged from 7.5 years to 18 months (median of 4.5 years). Results: A total of 223 ventral hernia repairs were performed during the study period of which 73 (32.7%) were done laparoscopically and 150 (67.3%) were open procedures. Of the 223 procedures, 144 (64.6%) were primary hernias and 79 (35.4%) were recurrent hernias. Significantly more, 32 of 79 (40.5%) patients with a recurrent hernia were found to have a Swiss-cheese defect as opposed to only 33 of 144 (22.9%) who had a primary hernia (chi-squared p= 0.006). A recurrence occurred in 54 of 223 (24.2%) patients. Co-morbid conditions and hernia size did not have a significant association with hernia recurrence. Significantly, a recurrence occurred in only 10 of 73 (13.6%) patients who had a laparoscopic repair compared to 44 of 150 (29.3%) patients who had an open repair (chi-square p= 0.011). A recurrent hernia was noted in 22 of 68 (32.3%) patients in whom repair was carried out without use of a mesh, as compared to 32 of 152 (21.1%) patients in whom a mesh repair was done, however this was not statistically significant (p= 0.072). Post-operative short term complications occurred in 31.4% of patients including recurrences in 11.7%, wound infections in 5.4%, and symptomatic seromas in 4.5% patients. Conclusion: A significantly higher percentage of patients who had a recurrent hernia repair were noted to have a Swiss cheese defect. This finding suggests either an inherent weakness of the abdominal wall predisposing to recurrence or that a defect in the fascia was missed during previous repair. Our recurrence rate was significantly lower after laparoscopic repair as compared to an open repair. This again supports the hypothesis that laparoscopic repair improves visualization and enables wider coverage of the anterior abdominal wall with mesh and hence may result in repair or prevention of additional defects in the abdominal wall musculature. We conclude that even in the setting of a community hospital there seems to be more justification for carrying out laparoscopic repair of ventral hernias in order to reduce recurrence rates. T1601 Prognostic Impact of ERCC1 Gene Polymorphisms in Gastric Cancer Ralf Metzger, Ute Warnecke-Eberz, Elfriede Bollschweiler, Jan Brabender, Daniel Vallbohmer, Arnulf H. Hölscher PURPOSE: ERCC1 is a key enzyme of the nucleotide excision and repair (NER) complex to prevent DNA inter- and intrastrand crosslinks. Genetic alterations of ERCC1 gene are involved in the development and progression of gastrointestinal tumors. We analyzed the prognostic impact of ERCC1 gene polymorphisms in gastric cancer. PATIENTS AND METHODS: There were 112 patients (m:71, f:41) with locally advanced gastric cancer; median age was 66 years (min:31, max:87). All patients underwent standardized gastrectomy with D2 lymphadenectomy. R0 resection rate was 92%; the median number of resected Lymph nodes was 36. For analysis of single nucleotide polymorphisms (SNPs) genomic DNA was extracted from paraffin-embedded tissues. Allelic discrimination was performed by quantitative real-time PCR. Two allele-specific TaqMan probes in competition were used for amplification of ERCC1 (rs11615). Allelic genotyping was correlated with survival. RESULTS: ERCC1 gene polymorphisms for all patients showed the following expression pattern: ERCC1 polymorphism (rs11615) CC: n=41 (36.6%), TT: n=23 (20.5%), CT: n= 48 (42.9%). There was no correlation of ERCC1 gene polymorphisms with pT- and pN- category. 5-year survival rate (5-YSR) for all patients was 46%. Gender specific analysis of ERCC1 polymorphisms identified CC genotype for male patients as a significant predictor of a worse survival. Whereas patients with CT- and TT-genotype had a 5-YSR of 53% and 64% respectively, male patients with CC genotype had a 5-YSR of 18% (p=0.015). CONCLUSION: Analysis of ERCC1 gene polymorphisms in gastric cancer reveals for male patients with CC genotype a significant decline of survival. Whereas the 5-YSR of all patients was 46%, male patients with CC genotype had a 5-YSR of 18% only (p=0.015). There was no correlation with pT- and pN-category. Single nucleotide polymorphisms of ERCC1 (rs11615) could be applied to further estimate prognosis in male patients with gastric cancer. T1602 Multi-Center Report of the Use of Polypropylene Mesh for Laparoscopic Adjustable Gastric Banding (LAGB) Allows for Minimum Post-Op Pain, Less Use of Narcotics, and Less Pain During Adjustments Carson D. Liu, Terry Simpson, Sunil Bhoyrul Introduction: Outpatient bariatric surgery is a viable option for patients thinking about weight loss surgery. We describe our technique of 2066 patients who have undergone Laparoscopic Adjustable Gastric Banding (LAGB) without using fixation sutures at the port in three different centers. The implantation of polypropylene mesh allows for very little post-op pain and the lack of narcotic use post-operatively. Patients who had LAGB and mesh implantation experienced minimal pain without the need for admission to a hospital inpatient setting. Methods: All patients undergoing LAGB underwent implantation of mesh sewn to the posterior aspect of the port device. Polypropylene mesh was placed over the 15 mm trocar site with coverage of the fascial defect. Prolene sutures were used to sew the hernia mesh to the port device. The port was placed in a superficial subcutaneous pocket (n=1158) or on top of the fascia (n=908) to allow for easier access of port. Results: Two patients out of 2066 had a peri-port infection requiring re-siting of port. One port has flipped with the mesh technique. All other patients did not require narcotic pain medications to control post-op pain. Patients tolerated liquid acetaminophen for pain control in the post- op period. Pain scores are zero to 1 out of 10 with the mesh technique, and 4 out of 10 A-920 SSAT Abstracts for the fascial suture technique. Conclusion: Implantation of mesh at the port site allows for removal of all post-op pain and the ability to remove all post-op narcotics as reported by three surgeons at different institutions. The use of non-narcotic pain medication decreases nausea and dysphoria after surgery. Patients also had all lap band adjustments under local anesthesia in a clinic setting as the port was easier to palpate in the more stable position. The mesh prevents rotation of the port which has been reported as a common problem with LAGB. T1603 Long-Term Outcomes of Combined Endoscopic/Laparoscopic Intragastric Excision of Gastric Stromal Tumors Kevin El-Hayek, Matthew Walsh Background: Treatment of myogenic neoplasms of the stomach consists of surgical resection, the extent of which is controversial given their variable malignant potential. Previous reports on the technique and results of a combined endoscopic/laparoscopic intragastric excision of these tumors showed excellent perioperative recovery and short-term outcomes. We present here our long-term outcomes of this minimally invasive approach. Methods: Using a prospective registry of gastric stromal tumor resections, we identified all patients who underwent surgery from 1999-2008. Data collected included patient demographics, pre- senting symptoms and diagnostic work-up, operative and perioperative course, and long term follow-up. Results: Sixteen gastric lesions were resected from 15 patients over a ten year period using combined endoscopic/laparoscopic intragastric excision. Mean age was 61.5 years (range 36-85) and seven patients were female. All patients underwent preoperative endoscopy for a variety of symptoms and signs including abdominal pain (n = 4), dyspepsia (n = 5), and anemia (n = 6). Endoscopic ultrasound (EUS) was performed on 11 patients (73.3%) to further evaluate tumor size and depth of involvement. Five lesions were located at the gastroesophageal junction, seven in the proximal body, two at the mid-body/greater curvature, and two at the incisura. Eleven tumors were biopsied endoscopically, all of which were negative for malignancy. A standard endolaparoscopic approach was performed on all patients. Complete submucosal enucleation was achieved on eight (50%) lesions while the remaining required transmural excision. There were no major operative or post-operative complications or deaths. Average length of stay was 4.3 days (range 1-11). Mean tumor size was 3.5 cm (range 1.5-7.0), and all were benign on final pathology. Follow-up studies included EGD, EUS, and capsule endoscopy. At a mean follow-up of 32 months (range 0.5- 90), there have been no recurrences. Fourteen patients (93.3%) are alive to date, with one death secondary to cardiovascular causes. Conclusions: Initial reports describing the com- bined endoscopic/laparoscopic intragastric technique showed promising short-term out- comes. This study represents one the largest series of myogenic tumor excision using this combined technique. Our experience indicates that this is a safe and effective approach for small-to-moderate size tumors with excellent long-term oncologic results. T1604 Laparoscopic Biliopancreatic Diversion with Duodenal Switch for Medically Complicated Obesity: Learning Curve and Perioperative Outcomes in a Singe Institution Michael L. Kendrick, Juan Camilo Barreto Andrade Background: Laparoscopic biliopancreatic diversion with duodenal switch (LBPD-DS) is an established, effective operation for treatment of obesity, especially in patients with super obesity (BMI>50). The limits of the procedure are the technical demands and operative time which exceed other bariatric procedures. Aim: To define the initial experience with LBPD- DS with regard to operative time and perioperative outcome at a single institution. Methods: Review of a prospectively collected database for all patients undergoing LBPD-DS from 2004 through 2008. Patients were separated into groups: group 1 included the first 25 patients; group 2 included from patients 26 to 50; group 3 from patients 51 to 75; group 4 from patients 76 to 97. RESULTS: For the 97 patients, 64 were female (66%) and the mean age was 45.5 years (range, 22-70). Mean preoperative weight was 167 kg (range, 110-311); mean preoperative BMI was 56.7 kg/m(2) (range, 37-83), with 78 (80%) of the patients being super obese (BMI > or =50 kg/m2). All cases were completed laparoscopically, except for case no. 4, that required conversion to an open procedure due to intraabdominal adhesions. Mean operating room time was 248 minutes (range, 124 - 546), with a mean of 326 minutes in Group 1, 246 minutes in Group 2, 214 minutes in Group 3 and 199 minutes in Group 4. Mean hospitalization time was 3.4 days (range, 2 - 17), 4.36 days in Group 1, 3.4 days in Group 2, and 2.9 days in Groups 3 and 4. Mortality occurred in 1 patient (1%), due to a cardiac arrythmia (patient 19). Perioperative complications occurred in 13 patients (13%). The rate of complications was similar the four groups: it was 16% in groups 1, 2 and 4 and 4% in group 3. However, serious complications were more common in the first cases, including 2 leaks (2%), both of which presented in Group 1 (patient 2 and 19), 1 intraabdominal abscess (1%), prolonged ventilation (1%), acute renal failure (1%), anastomotic ulceration (1%). No complications related to GI bleeding, stomal obstruction, pneumonia, PE or DVT were identified. Conclusion: LBPD-DS is a technically complex procedure, however significant reduction in operative times and complication rates are observed with experience. After an initial 20 procedures, operative times continue to decrease and anastomotic leak rate and mortality were zero. T1605 Inaccuracy of Endoscopic Anastomotic Measuring Techniques Faiz Tuma, Leena Khaitan Introduction: One of the major reasons identified for failure to lose weight in gastric bypass surgery is size of the anastomosis at the gastrojejunostomy. There is no standard technique for measurement of this anastomosis by endoscopy. Therefore, many treatment regimens may lead to ineffective intervention. This study was performed to identify the most accurate method to endoscopically measure the lumen diameter at the anastomosis to allow better