esophagectomy for esophageal cancer and risk factors associated with readmission. Methods:Retrospective review of the American College of Surgeons' National Surgical Quality Improve-ment Program (NSQIP) 2011-12 database was performed to identify patients who underwentelective esophagectomy for esophageal cancer. Results: One thousand one hundred andthree patients satisfied study criteria. One hundred and thirty seven patients (12.4%) werereadmitted within 30 days of surgery. Readmitted patients were significantly older (meanage: 65.9 years vs. 63.8 years, p=0.02) and had a higher proportion of males (91.2% vs.83.2%, p=0.01) than patients who were not readmitted. There was no significant differencebetween the groups in terms of other peri-operative variables like cardiac disease, neo-adjuvant therapy (chemotherapy within 30 days and radiation within 90 days of surgery),type of esophagectomy performed and body mass index. Readmitted patients had a higherincidence of superficial surgical site infections (SSI) (13.1% vs. 4.9%, p<0.001), deep inci-sional SSI (8% vs. 1.8%, p<0.001), organ space infections (12.4% vs. 5.5%, p=0.002), sepsis(21.2% vs. 11.3%, p=0.001) and venous thromboembolism (11.7% vs. 3.9%, p<0.001).Readmitted patients had a significantly shorter mean length of index hospital stay (11.25vs. 14.75 days, p<0.001). On multivariate logistic regression analysis, significant risk factorsfor 30 day readmission were: male gender, history of pulmonary disease, diabetes mellitus(DM), hypertension (HTN), postoperative wound complications, sepsis and shorter hospitalstay. Patients who were readmitted had a significantly higher incidence of the followingpost discharge complications: SSI (7.3% vs. 1%, p<0.001), deep incisional SSI (3.6% vs.0.4%, p<0.001), organ space infections (5.1% vs. 1.9%, p=0.05), pneumonia (7.3% vs.2.1%, p=0.001) and venous thromboembolism (2.9% vs. 0.8%, p=0.02). Conclusions:Readmission rate after esophagectomy for esophageal cancer is around 12.4%. Patients, whoare male, have co-morbid conditions like DM, HTN and pulmonary disease are at higherrisk for readmission. Earlier discharge is not always ideal as it comes at the cost of a higherreadmission rate. Emphasis should be placed on optimizing modifiable peri-operative factorsnamely, comorbid conditions, tissue handling, wound care and pulmonary toilet as a meansto reduce readmission.

464

Immunoscoring for Prognostic Assessment of Colon Cancer: A NovelComplement to UltrastagingSimon Lavotshkin, John R. Jalas, Hitoe Torisu-Itakura, Junko Ozao-Choy, Rafay A.Haseeb, Alexander Stojadinovic, Zev Wainberg, Anton Bilchik

Introduction: Although AJCC/TNM staging remains the gold standard for prognostic assess-ment of colon cancer, it cannot explain variable outcomes among patients with the samestage of disease. Several groups have examined a prognostic immunoscore based on immuneinfiltrates in the primary tumor. We hypothesized that an immunoscore based on fiveimmune variables might improve the accuracy of ultrastaging in patients with colon cancer.Methods: Our study group comprised patients enrolled in an ongoing prospective trial ofultrastaging for colon cancer (RO1 CA090848). Resected tumor specimens were analyzedfor CD3, CD4, CD8, CD68, and FoxP3 in a blinded fashion by a pathologist. Areas positivefor tumor- infiltrating lymphocytes (TIL) were defined as hot spots and stratified as focalor diffuse based on their staining pattern on broad magnification. Hot spots were thenscored as high or low, based on the briskness of the lymphocytic response, in the centerof the tumor (CT) and in the invasive margin (IM). This categorical score was comparedwith a continuous score derived from analysis of 360 images on 36 patients with stage I-III colon cancer with ImageJ processing software. The immunoscore was then correlatedwith AJCC/TNM stage and with disease-free survival. RESULTS: The mean number of nodeswas 17. Fisher's exact test showed that the continuous variable scored by ImageJ analysissoftware matched the pathologist's categorical scoring system (p-value = 0.0048-0.0421 forall but CD68 and FoxP3). Mean TIL counts in the CT region were consistently higher instage I than in stage III tumors: CD3, CD4 and CD8 counts were 774, 872 and 745,respectively, in stage I tumors, as compared with 535 (p=0.05), 614 and 487, respectively,in stage III tumors. This increase was not observed for CD68 or FoxP3. Patients with adisease-free survival >5 years tended to have a higher CD8/CD3 ratio in both IM and CTregions, as compared to patients with disease-free survival <36 months (p=0.08). CONCLU-SIONS: This is the first study to validate an immunoscore using specimens and data froma prospective clinical trial in which surgery and pathology techniques were standardized.Our preliminary results suggest that an immunoscore based on CD3, CD4 and CD8 corre-sponds with earlier stage colon cancer and improved disease-free survival and should befurther examined for inclusion in the AJCC staging system.

465

Robotic Assisted Laparoscopic Total Pelvic ExenterationSanjay S. Reddy, Radhika K. Smith, Rosalia Viterbo, Cynthia A. Bergman, Eric I. Chang,Jeffrey M. Farma

The purpose of this video is to demonstrate the technique of a total pelvic exenterationusing a robotic assisted laparoscopic approach with gracilis flap reconstruction. We presenta case of a woman with recurrent anal squamous cell carcinoma invading the vagina andurethra. She had previously received chemoradiotherapy and presented with a recurrence.This procedure was done in coordination with surgical oncology, urology, gynecologiconcology, and plastic and reconstructive surgery. We present this multidisciplinary, mini-mally invasive approach to pelvic exenteration as a safe and effective modality of surgicaltherapy.

466

Laparoscopic Release of Median Arcuate LigamentAnkit Patel, Juan Toro, Nathan Lytle, S. Scott Davis, Edward Lin

Median arcuate ligament syndrome is a complicated condition usually characterized byabdominal pain and weight loss caused by compression of the celiac artery by the medianarcuate ligament. The anatomy of the ligament and its close proximity to the aorta makes

S-1015 SSAT Abstracts

the treatment difficult. The laparoscopic approach can provide excellent visualization fordissection in addition to the known benefits of a minimally invasive procedure. We presenta laparoscopic case in high-definition video.

467

Retrieval of the Eroded Gastric Band: A Hybrid Endoscopic and LaparoscopicApproachMonica Young, Nojan Toomari, Ninh T. Nguyen

This is a 64-year-old female with a history of morbid obesity and previous laparoscopicgastric banding six years ago. She was taken to the operating room for retrieval of an erodedand embedded gastric band. The cathether was identified and found to be encased in alarge inflammatory mass in the left upper quadrant. A hybrid endoscopic and laparoscopicapproach is utilized to mobilize, transect and remove the device.

468

Totally Laparoscopic Right Hepatectomy With Roux-en-Y HepaticojejunostomyMarcel C Machado, Rodrigo C. Surjan, Fabio F. Makdissi, Marcel Autran Machado

We present a video of a totally laparoscopic right hepatectomy with hilar dissection andlymphadenectomy, en bloc resection of extrahepatic bile duct and Roux-en-Y hepaticojeju-nostomy in a 58-year-old patient with intraductal papillary neoplasm of the right hepaticduct. Operative time was 400 minutes. Postoperative recovery was uneventful. Surgicalmargins were free. Patient is well with no evidence of the disease 14 months after theprocedure. Laparoscopic right hepatectomy with hepaticojejunostomy is feasible and safe,provided it is performed in a specialized center and staff with experience in hepatobiliarysurgery and advanced laparoscopic. It is reserved for selected cases.

469

Laparoscopic Redo Paraesophageal Hernia Repair With Collis Gastroplasty forShortened EsophagusRachel Jones, Carl Tadaki, Dmitry Oleynikov

Esophageal shortening can be seen in patients with chronic inflammation associated withgastroesophageal reflux disease (GERD) and paraesophageal hernias. During surgical treat-ment of these conditions it is important to address the esophageal shortening during theoperation for optimal outcomes. Ideally, 2.5 to 3 cm of tension free intraabdominal esophagusis recommended. During this video we show a redo paraesophageal hernia repair in whichwe were unable to achieve adequate esophageal lengthening despite extensive mediastinaldissection. We therefore proceeded with Collis gastroplasty with Toupet fundoplication.

470

Laparoscopic Excision of Leiomyoma of the Stomach and Distal EsophagusBernardo Borraez, Marco E. Allaix, Fernando Herbella, Marco G. Patti

44 years old woman 6 months history of progressive dysphagia and regurgitation Unclearlocalization in the diagnosis approach Procedure: Laparoscopic excision of leiomyoma ofthe stomach and distal esophagus, and partial fundoplication. Uneventful postoperativecourse Discharged on postoperative day # 3 after soft diet Pathology report: Leiomyoma

506

Peri-Operative Patient Reported Outcomes Predict Serious SurgicalComplicationsJuliane Bingener, Jeff Sloan, Paul Novotny, Barbara A. Pockaj, Heidi Nelson

Background: Decreased survival after colon cancer surgery has been reported in patientswith deficient baseline quality-of-life (QOL) as described in a recent secondary analysis ofthe COST(Clinical Outcomes of Surgical Therapy) trial. We hypothesized that deficits inbaseline QOL are also associated with postoperative complications. Patients and methods:A secondary analysis of the COST trial 93-46-53 (INT 0146) was performed. Patient demo-graphics, surgical complications (grade 0-4), composite and single item QOL scores wereused for univariate and multivariate analysis. QOL deficit was defined as an overall QOLscore <50 on a 100 point scale. Early changes in QOL were defined as changes from baselineto postoperative day 2 or day 14 (POD2 POD14). 416 patients provided the power toidentify + 5 points (0.5 standard deviation [STD]) difference in the global QOL scale witha 95% confidence interval. Results: Of the 431 patients who were enrolled in the QOLportion of the COST trial, 81 patients (19%) experienced complications prior to discharge.Of these, 42 complications (7%) were serious (grade 2-4) including two deaths (0.5%).Eighty-nine patients (24%) experienced late complications within 2 months of the operation,including readmission. 55 patients (13%) had a QOL score < 50 at baseline. Patients witha baseline QOL deficit were more likely to have a serious early complication than patientswithout a QOL deficit (16 vs 6%, p=0.0234). Patients who experienced early complicationsreported worse ‘appearance' (0.25 STD, p=0.0126), and worsening breathing (0.3 STD, p=0.033) on postoperative day 2. Patients with an early complication were 3 years older (p=0.03) and more likely ASA III (p=0.0034). Gender, race, tumor stage and laparoscopic oropen approach were not associated with an increased frequency of complications. Patientswith complications experienced a 3.5 day longer hospital stay (p=0.0001). After adjustingfor age, gender, race, tumor stage, ASA and operative approach, significant predictors forbeing readmitted to the hospital were baseline pain distress (OR 1.61, CI 1.11-2.34, p=0.0125), changes from baseline to day 2 in fatigue (OR 1.34 CI 1.03-1.74, p=0.032) andfrom baseline to postoperative day 14 in activity (OR 1.56 CI 1.07-2.29, p=0.0225), dailyliving (OR 2.08, CI1.23-3.51, p= 0.0063) and outlook (OR 2.78, CI 1.19-6.53, p=0.0187).

SS

AT

Ab

stra

cts