Gastric Greater Curvature Research Articles

How to Do It: Laparoscopic Total Abdominal Colectomy with Complete Mesocolic Excision (CME) for Transverse Colon Cancer in Ulcerative Colitis

BackgroundUlcerative colitis (UC) is a chronic mucosal inflammatory bowel disease of the colon and rectum. After 10 years of having the disease, there is a significant risk of dysplasia or cancer in the affected colon and rectum, and because of the often aggressive biology of these tumors, frequent endoscopic surveillance is warranted. Over a third of patients with UC will ultimately require an operation, and although for specific cases alternative operations can be pursued, most patients prefer an ileal pouch-anal anastomosis (IPAA) with J-pouch construction. CaseA staged IPAA removes the affected colon and rectum treating UC and also restores intestinal continuity. However, the standard colectomy for UC includes low ligations of the main colonic vascular pedicle branches (ileocolic, right colic, middle colic and inferior mesenteric) that does not address a proper oncologic operation. A high ligation of the named vessels as well as a proper resection of the affected colon with its mesentery and lymph node package are needed to treat colon cancer. Analogous to a total mesorectal exicision for rectal cancer, a more radical procedure to remove the tumor and lymph node packet for colon cancer is described as a complete mesocolic exision (CME) in efforts to increase disease free survival. DiscussionWe demonstrate a laparoscopic subtotal colectomy for UC, with an oncologic complete mesocolic excision for a left transverse colon carcinoma in the setting of chronic mucosal inflammation secondary to chronic UC as the first procedure in a 3-staged IPAA. In the video, it is also demonstrated how the lymph node dissection is extended towards the greater gastric curvature and comprising omentum and gastrocolic ligament. There were no postoperative complications in the 44-year old male patient.

Snare traction and endoscopic suturing can improve endoscopic management of gastrointestinal stromal tumors at the gastric greater curvature.

Snare traction and endoscopic suturing can improve endoscopic management of gastrointestinal stromal tumors at the gastric greater curvature.

Lymph node distribution in patients with remnant gastric cancer.

Remnant gastric cancer (RGC) is defined as a carcinoma that develops in the gastric remnant from 5years after gastrectomy, regardless of the primary gastric disease. The pattern of lymph node dissemination in these patients is not well understood. The present study aims to understand the lymph node distribution of patients with RGC in a single center. In a total of 1380 patients with gastric cancer, between 1998 and 2020, 43 patients operated on for RGC were analyzed. The pattern of lymph node dissemination was evaluated based on the number of dissected lymph node stations, the number of positive lymph node stations, the positivity index at each analyzed station, the number of dissected lymph nodes per patient, and the positivity index per lymph node station. A mean of 13.0 ± 8.1 lymph nodes were dissected. The incidence of lymph node involvement by dissected station was higher at Stations 19, 11p, 3, 4sb and 7 (50, 40, 37.5, 36 and 31.7%, respectively). Among the positive dissected stations, Station 3 with 52.2%, 4sb with 39.1% and 4sa with 34.8% were the most affected. There was no predilection for lymph node involvement when comparing the lesser and greater gastric curvature. The dissection of Stations 3, 4sb and 4sa is fundamental in surgical treatment with curative purposes. The totalization of gastrectomy with lymphadenectomy of the perigastric and supra-pancreatic stations should be the surgery of choice.

Spleen metastases secondary to gastric neuroendocrine carcinoma: case report.

Neuroendocrine carcinoma (NEC) in the stomach represents a rare and rapidly growing type of gastric tumors. They are considered a distinct entity of neuroendocrine tumors characterized by an aggressive behavior and high metastases rate. On the other hand, spleen metastases of neuroendocrine tumors are extremely rare. We report the first case of spleen metastases of gastric neuroendocrine carcinoma. The patient was a 54-year-old male who presented with a 10-month history of epigastralgia. Upper gastro-intestinal endoscopy revealed a 5 cm ulcerative lesion located in the greater gastric curvature. Biopsies with immunohistochemical staining revealed gastric neuroendocrine carcinoma. Abdominal computed tomography showed thickening of the stomach with two large solid spleen lesions. Abdominal Magnetic Resonance Imaging and 18-fluorodexyglucose positron-emission tomography revealed peritoneal carcinosis and splenic metastases with splenic vein invasion. Clinicians should keep in mind that splenic metastases can arise from gastric neuroendocrine tumors (NETs).

Solitary gastric Peutz-Jeghers polyp: a case report

Peutz-Jeghers syndrome is an inherited condition that is characterized by mucocutaneous pigmentation and hamartomatous polyposis in the gastrointestinal tract. It increases significantly the risk for developing of several cancers such as breast, colon, rectum, pancreas and stomach. Solitary Peutz-Jeghers polyp is defined as a unique hamartomatous polyp having the same histological features as Peutz-Jeghers syndrome polyps without associated intestinal polyposis, mucocutaneous pigmentation and family history of Peutz-Jeghers syndrome. Gastric solitary Peutz-Jeghers polyp is extremely rare. We found only 13 cases in the literature. We report a new case of solitary gastric Peutz-Jeghers polyp associated with a branch duct intraductal papillary mucinous neoplasm revealed by an acute pancreatitis. Computed tomography of the abdomen found a branch duct intraductal papillary mucinous neoplasm with a pedicled polypoid formation in the greater gastric curvature. Endoscopic resection was performed without complications. Histologic examination showed Peutz-Jeghers hamartomatous polyp. The risk of cancer remains unclear in this entity. Therefore, the follow-up of these patients is necessary because of the possible risk of malignancy.

A rare gastric polyp: MANET

A 79-year-old woman with a medical history of type 2 diabetes, hypertension, and chronic heart and kidney failure was admitted to the hospital because of cholangitis. She underwent ERCP, which incidentally showed a 25 × 10 mm pedunculated polyp with eroded tip located on the greater gastric curvature (Paris endoscopic classification of polyps 0-Ip) (A, B). Subsequent gastroscopy showed atrophic antral gastritis. The polyp was electroresected. Histologic analysis indentified a mixed neuroendocrine-noneuroendocrine neoplasm (MiNEN) composed of neuroendocrine tumor and tubular adenoma (MANET), with growth in the deeper part of the mucosa and submucosa.

A619 OAGB After LAGB Video Presentation

The technique used for R-OAGB/MGB is based on a 5-port approach . The gastric sleeve is dissected free from firm adhesion between the staple line and surrounding tissues, starting from the distal staple line and proceeding to the angle of His. The first step of R-OAGB/MGB involved a calibrated (36 F tube) sleeve using blue Endo GIA reloads removing all the excessive gastric tissue. For patients with previous LGB, the gastric band was freed from the surrounding capsule and adhesions and cut and extracted through the 15 mm port. The internal fibrous tissue between the band and the stomach was removed as well to prevent stenosis of the tube at this level. The gastric greater curvature was than completely freed starting at 4 cm proximal to the pylorus using LigaSure (Covidien, Minneapolis, MN, USA) along with the direct release of lower sac adhesions and scarring to the left crus. A sleeve gastrectomy was than performed as described above.

Laparoscopic Resection of Desmoid Type Fibromatosis of the Splenic Hilum Mimicking a Greater Curvature Gastric GIST.

Desmoid tumor, recently renamed as desmoid type fibromatosis, is an uncommon neoplasm. The mesentery is the usual origin of intra-abdominal desmoid-type fibromatosis and despite the fact there is no metastatic potential, it can infiltrate adjacent organs. There etiology remains unknown, preoperative diagnosis is difficult and differential diagnosis includes among other gastrointestinal stromal tumor (GIST). In resectable tumors, the mainstay of treatment is surgical resection with at least clean microscopic margins. We present a case of a 51-year lady who presented with a 6.2 x 4.5 x 3.3 cm neoplasm in the anatomic area of the greater gastric curvature, the splenic hilum and the tail of the pancreas that was diagnosed as GIST on the CT scan. The patient was submitted to laparoscopic excision of the tumor and histopathological examination revealed desmoid type fibromatosis of the splenic hilum infiltrating the spleen, pancreatic tale and greater gastric curvature. According to the authors' knowledge, this is the first reported case of a sporadic splenic desmoid tumor, which has been treated successfully by laparoscopic en block resection.

FA01.06: ON THE RELATIONSHIP BETWEEN HISTOLOGY, ESOPHAGEAL-GASTRIC INTESTINAL METAPLASIA, GREATER CURVATURE LYMPHATIC METASTASES AND SURVIVAL IN SIEWERT II ADENOCARCINOMA

Abstract Background In Siewert type II adenocarcinoma we investigated the relationship between adenocarcinoma subtypes and survival, histologic/biologic patterns related to the presence/absence of gastric greater curvature metastases. Methods 154 patients who underwent primary transthoracic esophageal resection, total gastrectomy, thoracic-abdominal lymphadenectomy according to a research prospective protocol were considered. Cases were categorized in intestinal and diffuse subtypes, in Barrett's-like, cardiopyloric-like, and gastric-like adenocarcinoma according to the presence/absence of intestinal metaplasia in esophagus and stomach. Cancer specific survival and gastric greater curvature metastases were studied in those categories. Results Pathological stage (7th TNM ed) was IA-IIA in 11%; IIB in 15.6%; IIIA-IV in 73.4%. Cases were: 59% intestinal-type, 41% diffuse-type; Barrett's-type 1.3%, cardiopyloric-type 65%, gastric-type 33.7%. Greater gastric curvature lymph node metastases were detected in 22%, in stage IIIa-IV only, intestinal type 47%; diffuse type 53%. The number of metastatic lymph nodes at station 4 was higher in cardiopyloric-like than in gastric-like type (P < .0001).Five years cancer-specific survival of 154 cases was 40.5%, 59.4.% for intestinal type, 0% for diffuse type; 5-year cancer-specific survival in the absence/presence of greater gastric curvature metastases was respectively 48.7% and 14.9%, for intestinal type it was 67.4% and 27.9%. Histological subtype was an independent prognostic factor. Conclusion The radical difference of 5 year survival between intestinal and diffuse types of Siewert type II adenocarcinoma after primary surgery, the relevant frequency and biologic patterns of station 4 nodal metastases do require further investigation in light of current indications for neoadjuvant therapy and total gastrectomy. Disclosure All authors have declared no conflicts of interest.

Клинический случай трихобезоара желудка, осложнившегося пептической язвой большой кривизны

Клинический случай трихобезоара желудка, осложнившегося пептической язвой большой кривизны

Uterine Metastasis From Gastric Adenocarcinoma Masquerading as Physiologic Endometrial Uptake in FDG PET/CT

A 44-year-old woman with newly diagnosed gastric adenocarcinoma by gastroscopy underwent F-FDG PET/CT to evaluate possible metastasis. The images demonstrated intense activity in the region of uterine corpus, as well as greater gastric curvature. Physiologic uptake of endometrium was initially suspected, given the rarity with which extragenital cancers metastasize to the uterus. Ultimately, the endometrium proved to be mucinous adenocarcinoma of gastric origin based on its shared histological features and compatible immunostaining profile.

Discussion on standardized implementation of laparoscopic radical lymphadenectomy for distal gastric cancer

Laparoscopic radical gastrectomy for gastric cancer has been widely applied in clinical practice, and its indications have been extended from early gastric cancer to advanced gastric cancer. It is acknowledged that laparoscopic radical gastrectomy is technically challenging because of the complexity of anatomy, rich blood supply, and extensive lymph node dissection. This paper primarily intends to share the experience of laparoscopic radical D2 gastrectomy for distal gastric cancer with details of choosing the location of Trocar, surgical approaches and the sequence of lymph node dissection. All the surgeries were performed at Department of General Surgery and Gastrointestinal Surgery, Guangdong General Hospital. The finding suggests that a correct laparoscopic Trocar placement is the foundation of adequate surgical field visualization. Under most circumstances, the observation hole should be around 2 cm below the umbilicus and the operating hole should be close to the bilateral clavicle midline. Furthermore, proper surgical approach and sequence of lymph node dissection are the prerequisites for successful laparoscopic radical D2 gastrectomy, as well as the reassurance of dissecting lymph node safely and comprehensively. The position of surgical team adopted in our center is that the surgeon stands to the left of the patient, with laparoscope operator stands in between patient's legs while the first assistant positions himself opposite the surgeon on the right side of the patient. This position correlates to the rules of sequential lymph node dissection, which is "from left to right", "from proximal to distal" and "from inferior to superior". Therefore, it is conductive to inferior and superior pylorus region dissection and it can effectively prevent subsidiary-injury. In our center, the procedure of lymph node dissection has been standardized: the initial step is to undergo station 4sb dissection and greater gastric curvature clearance; then change the patient's position to clean the sub-pyloric lymph node region and cut off the duodenum by linear stapler; followed by the clearance of inferior region of the pylorus and the upper margin of the pancreas; in the final step, the first and the third groups of lymph node dissection is performed. Although varied surgical approaches and sequences of lymph node dissection are applied in different hospitals, the techniques required for laparoscopic D2 radical gastrectomy for gastric cancer are sophisticated and advanced in general. Radical lymph node dissection is complicated, urging surgeons to familiarize themselves with the anatomy of gastric peripheral vascular system and characteristics of lymph node drainage. By designing and implementing effective strategies, such as formulating a regular team, positioning surgical team reasonably, changing a patient's posture during operation, choosing an appropriate surgical approach and following a logically sequence of lymph node dissection, surgeons can standardize the complete surgical procedure, which ultimately reduces bleeding during surgery and shortens the operative time.

Evaluation of the safety of irreversible electroporation on the stomach wall using a pig model.

The aim of the present study was to evaluate the effects of irreversible electroporation (IRE) on the stomach wall following the direct application of IRE onto the organ surface. IRE ablation was performed in 8 Tibetan mini-pigs, which were randomly assigned into two groups based on their ablated areas: Group A, gastric cardia, fundus of stomach, gastric body and group B, lesser gastric curvature, greater gastric curvature, stomach pylorus. Two IRE needles were placed in the space between the stomach wall and the liver (not inserted into the stomach tissue), and three lesions were created in each pig. Serum aminotransferase and white blood cell (WBC) levels were measured. Gastroscopy and endoscopic ultrasonography were performed. From each group, 2 pigs were sacrificed on day 7 post-IRE; the remaining pigs were sacrificed on day 28 post-IRE. There were no signs of perforation on the stomach wall. Serum aminotransferase and WBC levels increased in both groups on day 1 post-IRE and decreased gradually thereafter. The gastroscopy procedure revealed oval ulcers on day 7 post-IRE and smaller ulcers on day 28 post-IRE. Transmural necrosis, inflammation and fibrosis were observed at 7 days post-IRE. Healing ulcers were observed at 28 days post-IRE. In conclusion, IRE ablation caused damage to the stomach wall; however, IRE did not induce any perforation.

Impact of laparoscopic surgery on efficacy in the treatment of gastrointestinal stromal tumors in different anatomical locations

To investigate the efficacy of laparoscopic surgery in the treatment of gastrointestinal stromal tumors (GIST) in different anatomical locations. Clinical data of 133 patients with primary gastric GIST undergoing laparoscopic resection at our department from January 2006 to December 2014 were retrospectively analyzed. These patients were divided into favorable site group (F group, 90 cases), including gastric fundus, anterior wall and greater curvature of gastric body, and unfavorable site group (UF group, 43 cases),including gastroesophageal junction, posterior wall and lesser curvature of gastric body,antrum and pylorus, according to the 2014 version National Comprehensive Cancer Network Clinical Guidelines. Short-term and long-term efficacy between the two groups was compared. There were no significant differences between the two groups in the general clinicopathological parameters (all P>0.05). The operation time of F group and UF group was (107.3±52.3) min and (119±53.4) min respectively (P=0.21). The blood loss in F group and UF group was (35.2±34.2) ml and (35.2±31.2) ml respectively (P=1.00). In addition, there were no significant differences in time to first fluid diet, time to first flatus, postoperative hospital stay and hospitalization expenses between the two groups(all P>0.05). In F group and UF group, morbidity of postoperative complication was 6.7%(6/90) and 4.7%(2/43) respectively (P=0.72), morbidity of category I(-II( complication was 4.4%(4/90) and 2.3%(1/43) respectively (P=0.66),and morbidity of category III(-IIII( complication was 2.2%(2/90) and 2.3% (1/43) respectively (P=1.00). Median follow-up time of all the cases was 36(1 to 84) months. The 5-year overall survival rates of F group and UF group were 93.8% and 95.2% respectively, and 5-year relapse-free survival rates were 81.1% and 89.4% respectively, without significant differences(both P>0.05). Laparoscopic operation for gastric GIST in unfavorable sites can yield similar short- and long-term outcomes compared with those in favorable sites.

Laparoscopic surgical treatment of gastroesophageal reflux disease combined with severe obesity

Aims: to compare antireflux and bariatric effect of fundoplication by Floppy-Nissen with fundoplication in combination with gastroplication. Methods. Laparoscopic Surgery for severe obesity combined with gastroesophageal reflux disease. A pilot randomized two-arm controlled clinical study was conducted by comparison of standard Nissen fundoplication (LFN) on one side and plication of greater gastric curvature combined with Nissen fundoplication on the other side (LFN+LGP). The study included 114 patients with gastroesophageal reflux disease with BMI of 30-39.9 kg/m2. The following indices were used for efficiency criteria: 24-hour pH measurement with calculation of DeMeesster index, percentage of excess body weight reduction, and patients’ life quality evaluation, for which Bariatric analysis and reporting outcome system (BAROS) with Moorehead - Ardelt Quality of Life Questionnaire IIscoring key was used. Postoperative evaluation of life quality and dynamic of key GERD symptoms was conducted by GERD-HRQL questionnaire. Results. All operations were performed laparoscopically. Deaths and severe complications in both groups were not observed. The average time of hospital stay in both groups amounted to 4.291 ± 0.53 (P <0.0001). Antireflux function after surgery was without significant statistical differences. Bariatric effect was better in the first group (LFN + LGP) EWL72.99 ± 10.86, and EWL24.17 ± 8.8 (P <0.0001) in the second. A year after surgery BMI was 27.44 ± 1.56 in the first group, and 32.31 ± 1.95 (P <0.0001) in the second. Conclusions. The proposed laparoscopic surgical method is applicable for simultaneous treatment of obesity in conjunction with gastroesophageal reflux disease. Antireflux efficiency of the proposed restrictive gastroplication combined with fundoplication is identical to properties of standard Nissen fundoplication.

Single-incision laparoscopic splenectomy for massive splenomegaly combining gastroesophageal devascularization using conventional instruments.

Single-incision laparoscopic splenectomy has been reported and was proved to be feasible and safe. Yet reports on single-incision laparoscopic surgery (SILS) for massive splenomegaly is not seen, neither is SILS for gastroesophageal devascularization; another correlated procedure for patients complicated with bleeding esophageal varices. From February 2011 to March 2012, 6 male patients with a median age of 45.1 years (range, 25 to 65 y) who were diagnosed of liver cirrhosis, portal hypertension, splenomegaly, and hypersplenism underwent SILS by the same surgical team in our hospital. Of them, 4 patients who were indicated had combined gastroesophageal devascularization, except for 1 conversion to hand-assisted laparoscopic approach because of bleeding, the operations were performed uneventfully and the surgical outcomes were satisfactory. Preoperative diagnosis was hypersplenism secondary to liver cirrhosis, the surgical outcome was satisfactory. This video, Supplemental Digital Content 1 and 2, http://links.lww.com/SLE/A104 and http://links.lww.com/SLE/A105 illustrates the crucial steps regarding the SILS for massive splenomegaly combined with gastroesophageal devascularization. The preoperative diagnosis are, hepatitis B, the patient's liver function is Liver Child-Pugh grade A. The patient was placed in reverse Trendelenburg position, with the legs open. The surgeon was standing on the right side of the patient and an assistant standing in between the legs. One 20-mm incision was made under the umbilicus, a 10-mm Trocar (Johnson & Johnson Investment Co. Ltd., NJ) was introduced in the middle of the incision, and the abdominal cavity was explored with a 10-mm, 30-degree scope (Storz Co. Ltd., Germany). Then a 12-mm and a 5-mm trocar were introduced through the same incision, respectively, 45 degree to the 10-mm trocar at both sides to form a "∇" shape. The procedure started with the dissection of the splenocolic ligament at the lower pole of the spleen, followed by creating a window by dissecting the gastrocolic ligament. The secondary branches of splenic pedicle were dissected and divided. The dissection of splenogastric ligament was continued along the gastric greater curvature, and short gastric vessels were encountered and divided. The left gastric artery was clipped and secured, followed by gastroesophageal devascularization along the cardiac to the esophagus 5 cm away from the esophagocardia junction, with Ligasure device. The splenic artery was identified, clipped, and divided. The splenic vein was finally divided followed by intraoperative autologous blood transfusion technique by collecting the blood from the distal splenic vein. The spleen was removed from the umbilical incision in a sample bag after being sliced into pieces. A drainage was placed through the incision. The operation was successful and the patient recovered well postoperatively: the operation time was 265 minutes, and the intraoperative blood loss was 300 mL. The postoperative course was uneventful and the patient was discharged 13 days later. SILS combining gastroesophageal devascularization for massive splenomegaly is technically feasible in the hands of surgeons with experiences of laparoscopic splenectomy. Indeed, the relative large scale of operation field for laparoscopic splenectomy makes the conflicts of instruments less practically challenging; however, techniques and sequences of the laparoscopic procedures should be modified to facilitate it, given the unavoidable constriction of movements for each instrument.

Comparison of Gastric Fundus Invagination and Gastric Greater Curvature Plication for Weight Loss in a Rat Model of Diet-Induced Obesity

Gastric fundus invagination (GFI) is a novel weight loss procedure. The gastric fundus is invaginated inside the gastric lumen and anastomosed to the gastric antrum. In gastric plication (GP), the greater curvature is plicated inside the gastric lumen leaving a narrow gastric channel for food passage. This study compares GFI to GP in a diet-induced obesity rat model. Twenty Long-Evans male rats were fed a 60% high fat diet for 6 weeks. At 14 weeks of age, the rats underwent either GFI (N = 10) or GP (N = 10) surgery. Body weight and food intake were measured for 6 weeks. Serum adipokines and ghrelin hormone were assayed. Six weeks after surgery, all rats were euthanized and the stomachs examined. The two-sample t test was used to compare the results between the two groups. All GFI rats had an intact fundus invagination at 6 weeks following surgery. The greater curvature plication unfurled in three out of ten GP rats. Part of the fundus herniated through the plication suture line in one GP rat. There was no significant difference between the mean percent weight change for the GFI (4.2 ± 4.1%) and GP (8.8 ± 6.0%) groups. There was no difference in food intake between both groups. GFI was associated with a significant lower fasting ghrelin levels (101.1 ± 13.1 versus 137.3 ± 27.4; p = 0.044) compared with GP. GFI offers a more effective and more durable surgical alternative for weight loss than GP.

Malignant Gastrocolic Fistula: The Reported Case of Non-Surgical Fistula Closure

Purpose: Gastrocolic fistula (GCF) is a pathologic connection between the stomach and colon. GCF as a result of primary gastric lymphoma is extremely rare and usually treated surgically. We present the first case of malignant GCF as a complication of primary gastric lymphoma that resolved with medical therapy alone. A 55-year-old male presented with early satiety, weakness, weight loss, diarrhea, and feculent vomitus for 2 weeks. Past medical history was significant for diabetes, hypothyroidism, and GERD. He had no prior surgical history. He underwent EGD that illustrated a fungating gastric mass with diffusely thickened folds, and feculent matter was seen entering from a fistula at the greater curvature of the stomach. Endoscopic ultrasound was performed and the endoscope entered an opening at the distal greater curvature which led to colonic lumen confirming GCF. Biopsies showed diffuse large B-cell lymphoma. Thereafter, upper GI study and CT scan confirmed GCF. A bone scan was negative for metastasis, and nasojejunal tube was placed endoscopically for enteral nutrition. He was not a surgical candidate due to multiple comorbidities. CHOP therapy was started; however, rituximab was withheld due to risk of bowel perforation. After 3 weeks of tube feedings and medical management of primary gastric lymphoma, a repeat CT scan and EGD showed fistula closure. The gastric mass had decreased considerably in size with significant improvement in gastric wall thickening. Benign etiologies of GCF include peptic ulcer disease, inflammatory bowel disease, pancreatitis, tuberculosis, perforated diverticular disease and infections. GCF can rarely occur as a result of malignancy of the colon or stomach. A malignant GCF forms most commonly between the gastric greater curvature and the distal transverse colon, as was the case with our patient. Barium enema is the most reliable diagnostic test because retrograde contrast administration increases intraluminal pressure, leading to augmented filling of any fistulous tracts. CT with contrast and endoscopic ultrasound scan are used mainly for diagnosing malignant extraluminal disease and staging respectively. Treatment of GCF involves a two-step approach. First is the correction of nutritional, fluid, and electrolyte imbalances; second is the surgical removal of the fistulous tract. Surgery was previously preferred; however, medical management is recommended as the first line therapy in benign disease. Success of medical management for a malignant GCF has not been documented yet. Our case demonstrates that medical management alone may lead to malignant GCF closure in patients with localized primary gastric lymphoma who are poor surgical candidates.

Sp615 EUS-Guided Anterograde Ureteral Internal Drainage

Retrograde ureteral stent placement by cystoscopy is the standard in patients with malignant ureteral obstruction due to advanced bladder cancer. When this attempt fails, the most common procedure used is percutaneous nephrostomy. EUS-Guided Anterograde Ureteral Internal Drainage is an alternative and it has been described before. We report a case of a 62-year old man that presented with flank pain and hematuria. After clinical and imaging evaluation, he was diagnosed with locally advanced bladder cancer. At the time of diagnosis, he presented bilateral hydronephrosis and renal failure. He was submitted to a retrograde approach by cystoscopy that succeeded in stent placement at right side ureteral obstruction, but failed at left side ureteral stent placement. In this presentation, we will demonstrate a EUS-Guided Anterograde Ureteral Internal Drainage in a patient with failure at retrograde approach by cystoscopy. By a single-step procedure, the EUS linear equipment was positioned at gastric greater curvature and it was possible to observe the dilated proximal ureter. Doppler analysis was obtained to confirm the fact that it had not any vessels nearby the working area. After that, it was performed a proximal ureteral puncture using a 19-Gauge needle. Contrast media was injected in proximal ureter and an urethrography was obtained. A 0.035-inch guidewire was passed in the left ureter. By progression of the guidewire, its distal part passed through the obstructed area and was positioned inside the bladder. Over the guidewire and under radioscopic view, an 8.5 Fr double-pigtail hydrophilic-coated stent was placed. The stent was positioned with the proximal part inside the ureter and the distal part inside the bladder. EUS-Guided Anterograde Ureteral Internal Drainage was a feasible technique and the patient presented with improvement in renal function. EUS-Guided Anterograde Ureteral Internal Drainage is an alternative to the Percutaneous Nephrostomy, which can be considered for palliation of ureteral obstruction patients with advanced bladder cancer. Larger multicenter studies are needed to further assess this novel technique.

Options for pelvic floor reconstruction after extralevator abdomin-operineal resection (APR): Myocutaneous flap or porcine dermal collagen implant

S 979 procedure can be considered palliative in the majority of recurrences. Based on equal cancer treatment, the reduction of surgical trauma and preservation of anatomical integrity are an important result. Options for pelvic floor reconstruction after extralevator abdominoperineal resection (APR): Myocutaneous flap or porcine dermal collagen implant E. Cardone****, D. Rega*, D. Scala*, P. Tammaro*, C. Sassaroli*, S. Mori**, L. Montesarchio*, U. Pace*, P. Delrio* *Department of Colorectal Surgical Oncology, I.N.T. “G.Pascale” Foundation, Naples, Italy **Department of Soft Tissues and Melanoma Surgical Oncology, I.N.T. “G.Pascale” Foundation, Naples, Italy * Corresponding author: Eleonora Cardone, via I trav.casilli 4 cap 80144Napoli, Italy. Cell: +39 3384983621; fax: +39 0817541967. E-mail address: criceto81@live.it (E. Cardone). Background: Reconstruction of the pelvic floor after extralevator abdominoperineal resection (APR) for advanced low rectal cancer is a challenge for the colorectal surgeon. Different approaches have been described. Methods: We report our approaches to reconstruction using the modified vertical rectoabdominal myocutaneous (VRAM) flap and porcine dermal collagen implant (Permacol) in 8 patients, evaluating the drawbacks and advantages. All patients were operated on for advanced low rectal cancer treated by neoadjuvant chemoradiation; 4 patients underwent reconstruction with a modified VRAM flap and 4 with perineal insertion of a Permacol implant. The modified VRAM flap is a myocutaneous portion of the rectum of the abdomen with its posterior fascia, re-allocated at the perineal wound. The Permacol implant is sutured to the lateral cut edges of the levator ani, anteriorly to the vagina fascia (or prostatic fascia) and posteriorly to both sides of the coccyx. Results: Reconstruction with the modified VRAM flap was 90 minutes longer than with the Permacol implant. A plastic surgeon was required. Postoperative mobilization after the VRAM flap procedure was allowed at day 3 and at day 2 after reconstruction with the Permacol implant. Postoperative pain was lower in the patients who had received a VRAM flap presumably because of the absence of perineal sutures. Slight dehiscence of the VRAM flap occurred in 1 patient. Perineal seroma developed in 3 patients who had received a Permacol graft, and 1 patient developed a perineal abscess. No patients developed abdominal or perineal hernia in a mean follow-up time of 10 months. Conclusions: Both the modified VRAM flap and the Permacol graft are valid approaches in the reconstruction of perineal wounds after extralevator APR. A myocutaneos flap might offer better long-term results but it requires a more complex and longer operation. A biological implant might be considered for patients with previous abdominal scars and poor shortterm prognosis. Improving surgical technique in colorectal surgery: Complete mesocolic excision A. Cassiano*, T. Zurleni**, E. Gjoni*, A. Ballabio*, R. Casieri*, L. Armiraglio*, F. Zurleni* *Department of General Surgery, A.O. Circolo di Busto Arsizio, P.O. di Busto Arsizio, Italy * Corrisponding author: Tommaso Zurleni, Dipartimento di Chirurgia Generale Ospedla di Busto Arsizio (VA), Italy. Tel.: +0331/699 578 716; fax: 0331/699578. E-mail address: tzurleni@yahoo.it (T. Zurleni). Background: Advances in rectal surgery over the past 15 years have been gained with surgical techniques such as total mesocolic excision (TME). Hohenberger described a comprehensive method called complete mesocolic excision (CME) which involves complete excision of all mesocolic tissue and should be performed for any colectomy. Here we describe the difference between the traditional surgical method and CME, and provide data on the technique, morbidity, mortality and lymph node status in the CME procedure. Methods: From January 2009 to December 2011, 110 patients with tumors located from the caecum to the traverse colon were included in the study. The CME technique entails excision of all mesocolic tissue until the origin of the ileocolic artery, right colic artery, and medial colic artery for tumors of transverse colon; the Kocher maneuver is usually performed. The gastroepiplooic vessels are ligated at the origin and the gastrocolic ligament is excised from the greater gastric curvature. Surgery was performed using the CME method with central vascular excision in 77 cases. The control group was 33 cases with tumors located in the same sites for which surgery was performed with a traditional procedure. Results: Significantly more lymph nodes were retrieved in the CME group (35.07 13.96) than those in the control group (25.97 11.27) (P 0.05). There were no differences in hospital stay and postoperative complications between the two groups (P >0.05). No anastomotic leaks or deaths were recorded. The intraoperative operating time in the CME group was longer (CME 177 min vs. controls 150 min; P 11.7 ng/mL (P1⁄40.005). The preoperative cfDNAwas significantly higher in patients with recurrence after surgery than in those without recurrence: 75.1+105.4 ng/mL vs. 33.0+57.8 ng/mL; P1⁄40.019. A progressive increase in cfDNA values