was found in post-operative survival between cirrhotic and non-cirrhotic patients. ConclusionAlthough cirrhotic patients have a greater number of complications than their non-cirrhoticcounterparts after cholecystostomy, there is no significant difference in survival between thetwo types of patient. Cirrhosis does not appear to be a contraindication to performingcholecystostomy, which is an appropriate temporizing procedure for cirrhotic patients withgallbladder disease. 1. Mansour A, WatsonW, Shayani V, Pickleman J. Abdominal operationsin patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122(4):730-735;discussion 735-736.

Tu2048

Dome-Down Dissection is a Safe and Practical Primary Approach toLaparoscopic Cholecystectomy: Results of a Ten Year ExperienceDylan Nieman, Neil Ghushe, Jacob Moalem, Marabel D. Schneider, Kendra Klein, D.Owen Young, Brandon Stein, Luke O. Schoeniger

PURPOSE: To audit our experience with a dome down technique for laparoscopic cholecys-tectomy (DDLC) regarding clinical outcomes, safety, and demonstration of the critical viewof safety (CVS). METHODS: We reviewed a prospectively collected data set of all patientswho underwent cholecystectomy(CCY) from 2000 through 2010 by a single surgeon. Allpatients were planned for primary DDLC and transection of the cystic artery with a HarmonicScalpel. Electronic records were queried for additional data. RESULTS: 715 consecutivepatients (72% female) underwent CCY; 581(74%) elective, 134(26%) acute. One(0.14%)required conversion to open CCY; all others underwent DDLC. Five (0.69%) had minorcomplications: ileus in 2 cases, trocar site hernia in 1. Biloma was found in 2 patientshowever there were no bile duct injuries or biliary strictures on subsequent evaluation. Asingle enterotomy occurred during Hasson canula placement in a patient with extensiveadhesions; this led to the sole conversion to open CCY. Estimated blood loss was minimalin all cases. Most patients(84%) were discharged on the day of surgery. Length of stay andcomplication rate did not vary between patients who had acute or elective indications forsurgery. The CVS was identified in all (566) patients since 2001, when we began documentingidentification or non-identification of the CVS. In cases for which precise operative timeswere available, DDLC averaged 37 minutes. Intra-operative cholangiogram (IOC) was neverneeded to clarify the anatomy in Calot's triangle. Planned IOC was performed in 58cases(8.1%): 34 for gallstone pancreatitis, 10 for choledocolithiasis, 9 for biliary colic, 3 forcholangitis, and 1 for primary biliary sclerosis. CONCLUSIONS: This 10 year, single-operatorexperience demonstrates that DDLC is a safe and practical approach to CCY in a diversegroup of patients and can be used as a primary approach to laparoscopic cholecystectomy(LC) with a low complication rate. We hypothesize that because this approach requirescircumferential visualization of the contents of Calot's triangle, the CVS is readily identifiedin all cases. Improved visualization enhances the safety of this approach and has causedsome to advocate DDLC as a way to avoid conversion to open CCY in patients with “difficultgallbladders”. We posit that the high rate of bile duct injuries associated with the dawn oflaparoscopy, may have been a byproduct of the shift from dome-down to bottom-up infund-ibular dissection rather than the shift from open to laparoscopic techniques, per se. Whilewe acknowledge that experienced surgeons should continue to use techniques with whichthey have experienced success, we propose a greater role for DDLC as an initial approachto LC in surgical training, to demonstrate the CVS and to allow a safe laparoscopic cholecystec-tomy in all circumstances.

S-1105 SSAT Abstracts

The Critical View of Safety in Dome Down Laparoscopic Cholecystectomy: (A) cystic artery(B) cystic duct (C) common bile duct (D) infundibulum of gallbladder (E) gallbladder fossa.

Tu2049

Use the Duodenum, It's Already There: A Retrospective Cohort StudyComparing Biliary Reconstruction to the Either the Jejunum or DuodenumJohn B. Rose, John A. Ryan, Thomas R. Biehl

Background: Surgical reconstruction of the biliary system is required for a variety of reasons.Roux-en-Y jejunal anastomoses (RJA) are the current gold standard for repair. Direct duodenalanastomoses (DDA) are a less common approach, however it has the benefit of operativesimplicity and ease of endoscopic evaluation. We compared the outcomes of non-palliativeDDA to RJA. Methods: A retrospective cohort study was performed at a single tertiarycare center comparing DDA to RJA between the years 2000 and 2010. Standard patientdemographics, complications rates, mortality rates, need for endoscopic or radiologic inter-ventions, and long term outcomes were compared. Results: A total of 105 non palliativereconstructions were performed between 2000 and 2010. 67 DDA and 38 RJA reconstructionswere performed in an end-to-side fashion for either bile duct injury, cholangiocarcinoma,choledochal cysts, or benign strictures. The groups were similar with regard to demographics,preoperative diagnoses, postoperative length of stay (7 days vs. 7.5 days), postoperativemortality rates (1.7% vs. 2.9%; P=0.72), and overall (Grade III or greater) complication rates(47.1% vs. 47.1%; P=0.83). However, anastomotic related complications (leaks, abscesses/bilomas, or strictures) were fewer in the DDA cohort (11.7% vs. 35.3%; P=0.01). Of thosedeveloping stricture, 5 of 6 in RJA cohort required percutaneous transhepatic access formanagement, as opposed to only 1 of 3 in the DDA cohort. Conclusion: Direct duodenalanastomosis is a safe and often preferable method for biliary reconstruction. It may havedecreased anastomotic complication rates, while benefiting from easier postoperative endos-copic management.

Tu2050

Gynecologic and Fertility Issues in Notes Colposcopic ProceduresAnibal Rondan, Rafael A. Redondo, Marcelo Fasano, Mariano Gimenez, MauricioRamirez, Alberto R. Ferreres

Background: the clinical application of NOTES procedures have raised issues regarding theways of access to the abdomen. The transvaginal access has been long and widely used andeliminates the disadvantages and risks associated with other NOTES approaches. With thedevelopment of laparoscopic techniques, the vagina was used not only as a port of entrybut also as an excellent channel for removal of surgical specimens. The easy closure of theincision and the minimal risk of infection represent some of the benefits of this access,outweighting the other NOTES alternatives. Objective: to present the followup of our first107 patients who were operated on through a hybrid NOTES transvaginal access Methodsand materials: after institutional IRB approval a program of NOTES surgery was started atour single institution in august 2007. Between that date and august 2009 107 procedureswere attempted (100 cholecystectomies and 7 appendectomies) with a colposcopic NOTESapproach with hybrid technique. The average age was 33.5 years with ranges between 22to 46. After discharge, refrain from sexual activity was prescribed for 15 days (first 30patients) and for 30 days in the following patients, due to inobservance. The postoperativefollow up included gynecologic assessment at postoperative days 7, 30, 60, 180 and 360.The evaluation included: guided questionnaire, physical examination and colposcopy toassess healing, presence of anatomical injuries, vaginal secretion and other alterations. Results:the cholecystectomy with the NOTES colposcopic hybrid technique could be completed in99 of the 100 patients (95 %). In the remaining case the operation had to be performedlaparoscopically due to pelvic adhesions (5 previous cesarean sections). One case ( # 6)required a minilaparotomy through a previous Pfannestiel incision for checking hemostasisof the vaginal cul de sac and 8 required the placement of an additional 2.5 mm trocar. Theappendectomy was completed in all 7 cases, in 2 with the placement of an additional 2.3mm trocar. No major complications were attained. The systematic assessment provedadequate healing of the vaginal access with no local complications as well as absence ofgranulomas, hematomas, adhesions or retractions. None of the patients refer dyspareunia.Thirteen patients (12%) got pregnant after the procedure, 10 with a normal birth deliveryand 3 cesarean sections, without complications due to the previous access Conclusions: thecolposcopic NOTES access has proved to be safe, with excellent outcomes, no complications

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and void of sequelae in the gynecologic and sexual aspects. The risks of rectal injury,infection and sexual or pregnancy dysfunctions are considered to be minimal.

Tu2051

Gallbladder Wall Changes in Patients With and Without Metabolic SyndromeMaria Fernanda Gonzalez-Medina, Antonio Ramos-De la Medina, Jose Remes-Troche,Gustavo M. Melgarejo Ortiz, Peter Grube Pagola, Isabel Ruiz Juárez, Alfonso Perez-Morales, Joaquin Valerio-Ureña, Federico B. Roesch

Background: Recent research has described that obesity and high carbohydrates intakeincreases fat content of the gallbladder, decreases its motility and mucosal absorption, leadingto a condition known as steatocholecystitis. Gallstone disease (GD) and the metabolicsyndrome (MS) share common risk factors. Objective: To identify if MS contributes tothe development of functional disorders and wall changes of the gallbladder. Methods: AProspective study was conducted from August 2010 to July 2011 on patients with sympto-matic gallbladder disease undergoing laparoscopic cholecystectomy. Forty two patients wereincluded and divided into two groups; 22 patients with MS and 20 patients without MS.Family history, risk factors, anthropometric, clinical and laboratory variables were evaluatedbefore surgery. Gallbladder specimens were analyzed, measured and graded by two patholo-gists at 3 standardized areas (cystic duct, liver bed, free margin and fundus). Results: Thirtythree patients who underwent cholecystectomy were female. A family history of GD andMS were present in 90% of patients. Chronic cholecystitis was the most frequent diagnostic(93%). Median weight was 75.5kg±14.3 and 67.1kg±9.2 for MS and No-MS groups respect-ively. Gallbladder wall thickness was significantly increased (P=0.012) in the MS group.This thickness was secondary mainly observed in the cystic duct area of patient withMS. The percentage of fatty infiltration of the gallbladder wall, muscle degeneration andcholesterolosis did not show significant differences between groups. Conclusions: MS isassociated with an increased gallbladder wall thickness. Muscle fibrosis in the cystic ductwas the most important wall modification in these patients. In our series, MS was notassociated to fat infiltration of the gallbladder wall or cholesterolosis.

Tu2052

5-HT3 and 5-HT4 Receptors Promote Colonic Peristalsis via DifferentMechanisms in Guinea PigsIrena Gribovskaja-Rupp, Jung-Myun Kwak, Toku Takahashi, Kirk A. Ludwig

Background: Pelvic surgery may damage extrinsic nerves, resulting in colonic dysmotilityand constipation. Adaptation restores motility after extrinsic denervation. We showed thatintrinsic 5-HT3 and 5-HT4 receptors are upregulated to compensate for the loss of extrinsic5-HT3 receptors after parasympathetic denervation in rats (J Surg Res 2011, 171:510-516).However, the specific mechanism of action of these receptors remains unclear. We studiedthe role of 5-HT3 and 5-HT4 receptors in colonic transit and peristalsis in guinea pigs InVivo and In Vitro. Methods: For In Vivo colonic transit study, 51Cr was infused into theproximal colon after saline, ondansetron (a 5-HT3 receptor antagonist; 1 mg/kg), or GR125487 (a 5-HT4 receptor antagonist; 1 mg/kg) injection. Three hours later, geometric center(GC) of the 51Cr distribution in the entire colon was calculated. For In Vitro studies, distalcolonic segments were laid flat in an organ bath with Krebs-Henseleit buffer. Oral ends ofsegments were connected to an infusion syringe, and anal ends to a pressure transducer.Pressure changes in response to luminal infusion (0.2 ml) were recorded in the presenceof ondansetron (3x10-6 M) or GR 125487 (3x10-6 M). In another setting, oral and anal endswere opened and the peristaltic reflex in response to pellet insertion or luminal ballooninflation was studied. Results: Colonic transit was impaired by ondansetron (GC=4.5±0.3,n=6, p<0.01) and GR 125487 (GC=5.3±0.3, n=7, p<0.01) compared to controls (GC=6.8±0.3, n=10). Ondansetron reduced intraluminal pressure increase by 40±9% (n=4,p<0.01), whereas GR 125487 increased it by 76±28% (n=7, p<0.01) (Fig. 1). Pellet transittime was 46±9 sec (n=5) in controls, which was completely abolished by ondansetron (n=4) and prolonged by GR 125487 to 137±41 sec (n=8, p<0.05). In response to balloondistention, contractions observed at the anal side were smaller than those at the oral side(n=8). Ondansetron reduced the magnitude of oral and anal contractions in response toballoon distention. In contrast, GR 125487 reduced oral contractions and increased analcontractions. As a result, the ratio of anal/oral contractions was increased to 1.4±0.2 by GR125487, compared to controls (0.6±0.1; n=9, p<0.01). Similarly, L-NAME (a nitric oxideinhibitor, 10-4 M) significantly increased anal contractions (Fig. 2).Conclusion:Ondansetronimpairs colonic transit by lowering the magnitude of peristaltic contractions. GR 125487impairs colonic transit by generating potent contractions on the anal side. Because L-NAMEhas a similar effect with GR 125487, it is suggested that 5-HT4 receptors stimulate nitricoxide release distally. In contrast, 5-HT3 receptors stimulate excitatory neurotransmissionproximally. Our study offers new insight into the function of 5-HT3 and 5-HT4 receptorsin regulating colonic peristalsis.

S-1106SSAT Abstracts

Figure 1. Luminal infusion-induced pressure increase in the presence of ondansetronand GR 125487 of the guinea pig distal colon. Ondansetron reduced, while GR 125487increased motor responses to luminal infusion (**p<0.01, n=4-7).

Figure 2. Magnitude of oral and anal contractions in response to balloon distention ofthe guinea pig distal colon. Ondansetron significantly reduced both anal and oral contrac-tions. In contrast, GR 125487 or L-NAME significantly decreased the magnitude of oralcontraction and increased anal contractions, compared to controls (*p<0.05, **p<0.01, n=4-7).

Tu2054

Tumor Growth is Stimulated After Sham Laparotomy and is Associated WithEnhanced Tumor Angiogenesis and Elevated Serum PDG-BB Levels in MiceXiaohong Yan, Joon Ho Jang, Daniel D. Kirchoff, Sonali A. Herath, Linda Njoh, C. M.Shantha Kumara H, Samer Naffouje, Richard L. Whelan

Introduction: Surgical trauma-related increased rates of metastasis formation and tumorgrowth have been noted in murine models. In humans, major abdominal surgery has beenassociated with persistent proangiogenic plasma protein changes and postoperative plasmabeen shown to promote Endothelial cell (EC) proliferation, migration, and invasion. Thecurrent murine study was done to determine: 1) if tumor angiogenesis and growth wasincreased after sham laparotomy (SL) vs. anesthesia alone (control, AC) and 2) to assesspostoperative (postop) serum levels of four proangiogenic proteins. Methods: Fifty BALB/cJ mice were subcutaneously inoculated with syngeneic CT26 colon adenocarcinoma cellson Day 1. On Day-15 the mice were randomized into 2 groups (n=25/group), one underwentSL and the other anesthesia alone (AC). Tumor Study: On Day-29 the mice were sacrificedand the tumors excised, measured, and weighed. The tumor microvessel density was deter-mined via IHC CD34 staining. Serum Study: Blood samples were taken and serum harvestedfrom a second group of mice that underwent SL or anesthesia alone (total n=84). Thesampling points were: preoperative (Preop), POD1, 3, 5, 7, 10, and 14. Serum levels ofFGF, VEGF, sVCAM and PDGF-BB were determined via ELISA. Results: The median tumorvolume of the SL group (625.9 mm3) was significantly larger than the AC group result(510.2 mm3, p=0.01). Also, the SL group's median tumor mass (0.55g) was greater thanthat of the AC group (0.35g, p=0.04). Lastly, a higher microvessel density was found in theSL group tumors (8.5/field) than in the AC group (6.7/field, p=0.001). Elevated serumPDGF-BB levels were observed in the SL group on POD5 (SL, median level 15.40 ng/ml,vs AC, 8.90 ng/ml, p=0.002) and POD7 (SL, median 10.85 ng/ml, vs AC, 7.59 ng/ml, p=0.02). Conclusion: Tumor growth was increased after SL as was tumor angiogenesis andserum PDGF-BB levels. These results support the hypothesis that increased tumor growthafter SL may, at least in part, be due to proangiogenic plasma protein alterations that promotetumor angiogenesis.