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a permanent stoma without reducing the need for bowel resection. Recent data demonstratethe usefulness of anti-TNFα therapy in inducing and maintaining remission in Crohn'sdisease, but its effect on pediatric colonic Crohn's patients is unclear. We hypothesized anti-TNFα therapy in conjunction with temporary fecal diversion would induce remission andreduce the need for bowel resection in medically refractory pediatric colorectal Crohn'sdisease, ultimately, allowing successful restoration of bowel continuity. Methods: FollowingIRB approval, records of Crohn's disease patients who underwent fecal diversion, betweenJuly 2006 and April 2011, at our institution were reviewed. Analysis focused on the clinicalcourse and medical therapy in the perioperative periods, and long term results. Outcomeswere analyzed using Fisher's exact test. Results: Eleven patients with colorectal or perianalCrohn's disease had undergone proximal fecal diversion with either ileostomy (81.8%) orcolostomy (18.2%) between July 2006 and April 2011. Average follow-up was 27.4 months(4.0-61.4 months) and average age at diversion was 15.1 years (7-21 years). A diversionprocedure reduced the number of patients requiring corticosteroids from 10 (90.9%) to 7(63.6%), but this was not statistically significant (p=0.3). Seven patients (63.6%) requiredsegmental colon resections and 2 (18.2%) required proctocolectomy. Restoration of continu-ity was performed in 8 (72.7%) patients after an average of 9.7 months (3.0-15.1 months).Four of the 5 patients (80%) treated with an anti-TNFα (Tumor Necrosis Factor) agent afterdiversion and 4 of the 6 patients (66.7%) off anti-TNFα therapy underwent restoration ofcontinuity (p=1.0). However, three patients (37.5%) required re-diversion (2 in the anti-TNFα group and 1 in the non-anti-TNFα-treated patients; p=1.0). At the conclusion of thefollow-up period only 5 (45.5%) of the patients retained intestinal continuity. Complicationssecondary to the original ostomy occurred in 9.1% of patients and in 66.7% of the re-diverted patients. Conclusions: Despite therapeutic advances, particularly the advent of anti-TNFα agents, fecal diversion in pediatric patients with colorectal or perianal Crohn's diseaseis ultimately associated with a low rate of restoration andmaintenance of intestinal continuity.Proximal diversion does not obviate the need for colonic resection in this patient population.Counseling families regarding temporary fecal diversion in pediatric patients with Crohn'scolitis requires tempered optimism in ultimately regaining intestinal continuity.

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Surgical Approach to Perineal Dissection Does Not Influence Radial MarginAfter Abdominoperineal ResectionSekhar Dharmarajan, Bashar Safar, James W. Fleshman, Matthew Mutch, Elisa H.Birnbaum, Steven R. Hunt

Purpose: Positive radial margins and intraoperative rectal perforation adversely affect outcomeafter abdominoperineal resection (APR) for low rectal cancer. Use of the prone jackknifeposition during the perineal dissection may improve exposure and therefore oncologicoutcome. Our purpose was to determine whether performing the perineal dissection of APRin prone jackknife versus lithotomy position improves radial margin clearance and reducesintraoperative rectal perforations. Methods: An IRB-approved retrospective review of 130cases of APRs over 8 years was performed after excluding patients with no radial marginreported, non-adenocarcinoma pathology, and pelvic exenterations. Primary endpoints ofradial margin and intraoperative rectal perforation were obtained from pathology reports.Data on patient demographics, preoperative staging, preoperative therapy, and intraoperativepositioning was obtained. Statistical analysis was performed using t test or Fisher's exacttest with significance set at p<0.05. Results: Perineal dissection was performed in pronejackknife position in 65 patients and in lithotomy position in 65 patients. There were nosignificant differences between these groups in terms of patient gender, age, percent receivingpreoperative therapy, distance of tumor from dentate line, or preoperative stage. There wasno significant difference in mean radial margin between patients whose perineal dissectionwas performed in the prone jackknife versus lithotomy position (0.54 cm vs. 0.56 cm, p=0.76). The percent of positive radial margins in each group was not significantly different(17% vs. 13%, p=0.62) and the percent of intraoperative rectal perforations in each groupalso did not differ (13% vs. 24%, p=0.35). There was a trend toward decreased operativetime in lithotomy (196 min vs. 222 min, p=0.12). Conclusions: APR with perineal dissectionperformed in prone jackknife position is associated with longer operative times comparedto lithotomy position and does not appear to confer any oncologic advantage with respectto radial margin clearance or intraoperative rectal perforation.

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Neoadjuvant Therapy Influences Lymph Node Ratios and Overall SurvivalWithout Decreasing Total Node HarvestRenato A. Luna, James P. Dolan, Brian S. Diggs, Nathan W. Bronson, Miriam Douthit,John G. Hunter

Background: There has been considerable debate around the influence of neoadjuvant therapyon lymph node harvest and the prognostic value of this information following esophagectomyfor esophageal adenocarcinoma. The purpose of this study was to evaluate the effects ofneoadjuvant therapy in the number of lymph node harvested, lymph node ratio and survivalafter esophagectomy. Methods: A single center retrospective analysis of 169 patients whounderwent esophagectomy for esophageal adenocarcinoma was performed. Patients weredivided in two groups: one group underwent neoadjuvant treatment prior to surgery (NEO)and another group underwent surgery only. (SURG). Results: One hundred and three patients(61%) underwent neoadjuvant therapy (NEO) prior to resection. The mean age was 66years (39-89), and 83 (82%) were treated with 2 or 3 field esophagectomy. Sixty six patientswere treated with surgery alone (SURG). The mean age was 70 years (39-89) in this group,and 28 (44%) were treated with 2 or 3 field esophagectomy (p<0.001). The median numberof nodes harvested in the NEO group and SURG group was 14.0 and 11.5 respectively (p=0.11). Looking soley at those undergoing 2 or 3 field esophagectomy in NEO to SURGgroups, the median number of lymph nodes harvested was 16 and 15.5 respectively. In theNEO group the median number of lymph nodes harvested was 14.5 for complete responders,16 for incomplete responders, 12 for non-responders, and 13 in those who were pathologic-ally upstaged (p=0.252). The in-hospital mortality was 5% in the NEO group and 3% inthe SURG group (p=0.56). The median lymph node ratio was 0 for complete responders,0 for incomplete responders, 0.055 for non-responders and 0.125 for upstaged patients

S-1054SSAT Abstracts

(p<0.001). Survival was influenced by the number of positive lymph nodes harvested inboth groups (p<0.001). Survival was significantly improved by neoadjuvant therapy in stageIII patients and in patients with N1 disease (p<0.001 and p=0.03, respectively). Conclusion:At esophagectomy, the total number of lymph nodes harvested was not significantly influ-enced by neoadjuvant treatment or by the pathologic response to treatment. The numberof positive lymph nodes was similar in both groups, but the lymph nodes ratio are inverselyrelated to the response to neoadjuvant therapy. The only negative prognosticmarker identifiedwas presence of nodal disease. Neoadjuvant therapy improved survival in this group.

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Esophagectomies Employing Thoracic Incisions Carry Increased PulmonaryMorbidityNeil H. Bhayani, Aditya Gupta, Ashwin A. Kurian, Maria A. Cassera, Kevin M. Reavis,Christy M. Dunst, Lee L. Swanstrom

INTRODUCTION: A thoracic approach is not required for all esophagectomies. Someresearch suggests an increased risk of pulmonary morbidity when a thoracic incision is used.We studied the impact of a thoracic incision on complications after esophagectomy througha national database. This represents the largest analysis of pulmonary morbidity after eso-phagectomy. METHODS: The National Surgical Quality Improvement Project (NSQIP) data-base was queried for non-emergent esophagectomies with reconstruction from 2005-2010.Patients with metastatic disease were excluded. Patient who underwent trans-hiatal eso-phagectomy (THE) were compared to those who had a thoracic incision. The THORACICgroup was patients with Ivor-Lewis (thoracic & abdominal incisions) or McKeown (cervical,abdominal & thoracic incisions) techniques. The primary outcome was pulmonarymorbidity;secondary outcomes were death, overall morbidity, infection, and thrombo-embolic com-plications. Multivariable regression models controlled for age, smoking, chronic obstructivepulmonary disease, hypertension, diabetes, American Society of Anesthesiology class 3 orhigher, malignancy, and preoperative weight loss. RESULTS: Of 1568 patients, 717 (46%)underwent THE and 851(54%) were in the THORACIC group (487 / 31% Ivor-Lewis &364 / 23% McKeown). The overall population was 80% male, with a mean age of 63 years.Patients undergoing THE were older (p=0.02). Pre-operative co-morbidities were similarexcept for more diabetes (16% v. 11%, p=0.02) in the THORACIC group. Malignancy wasmore common in THORACIC patients, 91% v. 87% (p=0.01). Overall, morbidity was 46.5%and mortality was 3.1% without a difference between groups. Length of stay was 1.6 daysshorter (p=0.009) for THE patients. On multivariable analysis, the use of a thoracic incisionwas associated with an increase in pneumonia (47%, p=0.007), ventilator dependence >48hours (34%, p=0.04), and septic shock (86%, p=0.001). Mortality, surgical site infections,and thrombo-embolic events were similar. On subgroup analysis of the THORACIC group,the McKeown approach increased the odds of superficial surgical site infection by 71% (p=0.02) but showed similar odds of septic shock compared to the Ivor-Lewis technique.CONCLUSION: Esophagectomies carry an acceptable mortality rate but have significantmorbidity. We show that the thoracic incision is associated with increased pneumonia,ventilator dependence, and septic shock. This septic shock is unlikely due to anastamoticleaks, given the similar among of septic shock between McKeown and Ivor-Lewis patients.When appropriate, avoiding a thoracic incision may decrease pulmonary morbidity andresulting septic shock. A limitation is the inability to distinguish between traditional versusthoracoscopic approaches; the impact of a minimally invasive thoracic approach remainsunclear.

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The Status of the Lower Esophageal Sphincter at Rest and the Degree ofEsophageal Acid Exposure in Patients With Gastroesophageal Reflux DiseaseShahin Ayazi, Jeffrey A. Hagen, Joerg Zehetner, Kimberly S. Grant, Michael Hermansson,Arzu Oezcelik, Steven R. DeMeester, John C. Lipham, Daniel S. Oh, Michael M. Kline,Tom R. DeMeester

Introduction: A manometrically normal lower esophageal sphincter (LES) is necessary toprotect the esophagus from exposure to gastric juice. Manometric measurements related tothe competency of the LES are resting pressure, overall length, and the length exposed tothe environmental pressure of the abdomen. We hypothesized that the magnitude of theesophageal acid exposure is related to the degree of permanent deterioration of the LES.Methods: The records of 2,723 patients referred to our esophageal function laboratory forthe assessment of reflux symptoms between 1998-2008 were reviewed. Those with a namedmotility disorder or previous foregut surgery were excluded. The study population consistedof the remaining patients, who had a detailed assessment of their LES with slow motorizedpull-through manometry and an abnormal 24-hour pHmonitoring study off acid suppressiontherapy. The LES was graded on a scale of 0-3, according to the number of abnormal LEScomponents on manometry using previously defined normal values for resting pressure(<5.1mmHg), overall length( < 2.7cm) and abdominal length (< 1.4cm). Grade 0 indicatedall components were normal; 1, only one component abnormal; 2, two components abnormal;3, all three components abnormal. Results: The final study group consisted of 918 patients(58% male, median age 53 and median BMI 28.3) who met the inclusion criteria and hadan abnormal 24-hour composite pH score as objective evidence for GERD. Of these 406(44%)had grade 0, 152(17%) grade 1, 272(30%) grade 2 and 88(9%) grade 3 LES. Correspondingvalues for the median (IQR) composite pH score were 30.9(20.6-46.5), 39.5(23.1-57.8),42.0(27.0-75.1) and 63.2(31.8-90.2) respectively (p<0.0001, Kruskal-Wallis test). Patientswith a normal LES at rest had less esophageal acid exposure compared to those with oneor more LES manometric abnormalities (30.9 vs. 42.2, p<0.0001, Mann-Whitney U-test).The values for all three LES components, irrespective of the LES grade, were inverselycorrelated to the composite pH score: total length (r= -0.23), abdominal length (r= -0.22)and resting pressure (r= -0.28), (p<0.0001 for all 3 analyses). The most common abnormalmanometric finding was a short overall length and the least common was a hypotensiveLES pressure. Conclusion: Permanent manometric abnormalities of the LES measured atrest are associated with increased esophageal acid exposure. The degree of acid exposure isrelated to the extent of the manometric abnormalities. Forty four percent of the GERDpatients have a normal LES measured at rest despite having increased esophageal acid

exposure. These patients have the lowest esophageal acid exposure and are likely to havetransient manometric abnormalities of the LES during periods of activity.

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Response to Neoadjuvant Therapy and the Lymph Node Ratio (Lnr) are theStrongest Prognostic Factors After Esophageal Resection for CancerFrank Makowiec, Peter Baier, Peter Bronsert, Jens Hoeppner, Hannes P. Neeff, TobiasKeck, Michael Henke, Ulrich T. Hopt

The exact role of neoadjuvant therapy (neoT) including its prognostic influence in esophagealcancer is still under debate. Pooled data (metaanalysis) suggest a prognostic advantage ofneoT but definitve data are lacking. We analyzed our institutional experience with resectedesophageal cancer including the effect of neodjuvant therapy on long-term outcome. Methods:We evaluated overall survival in 304 patients undergoing esophageal resection between 1988and 2010 (patients with hospital mortality excluded). 53% had squamous cell (SCC) and46% adenocarcinoma (AC). Indications for neoT were in general T-stage >2 and/or positivelystaged lymph nodes. Tumors were in the lower third in 64%. 66% of the patients underwentneoT (60% chemoradiation 36 Gy+FU+Cisplatin; 6% chemotherapy alone). The proportionof neoT increased from 16% in the first third to 78% in the last third of the study period.In pathological analysis the median number of examined nodes was 17; 43% were nodepositive. Survival was analyzed by the Kaplan-Meier- and Cox-models. Results: The propor-tion of patients with AC increased from 22% (first third) to 61% (last third of the studyperiod). After neoT 81% of the patients showed partial or total response. Patients withoutneoT had more frequently positive margins (13% vs 4% after neoT; p<0.01). Postoperativenodal disease was independent on neoT (40% after neoT vs 50% without neoT) althoughpatients in the neoT group had more frequently positive nodes in pretherapeutical staging(71% vs 39% in patients without neoT; p<0.01). Overall 5-year survival (5y-Surv) was 36%and improved clearly during the study period (5y-Surv 14% until 1994; 35% 1994-2001;49% since 2002; p<0.001), parallel to an increased use of neoT. This significant improvementin survival over time was also seen in the subgroups of patients with SCC (p<0.01) and AC(p<0.001). 5y-Surv in patients with response (any/total) was 52%/60%, but only 19% inpatients without response/without neoT (p<0.001). In further univariate analysis positivenodes (p<0.001), positive margins (p<0.001) and LNR>0.1 (p<0.001) significantly worsenedprognosis. In multivariate analysis a LNR>0.1 (p<0.001; RR 11), no response to neoT(p<0.01; RR 1.6) and SCC (p<0.02; RR 1.5) were independent negative prognostic factors.Compared to SCC patients with AC had higher rates of positive margins (10% vs 4%) andLNR > 0.1 (43% vs 16%). Conclusions: Tumorbiological parameters (histological type, LN-ratio) influenced prognosis after resection of esophageal cancer. Response to neoadjuvanttherapy independently improved the outcome and contributed to the clearly better outcomeachieved in the later study period.

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Surgical and Endoscopic Treatments for Achalasia: A Single InstitutionComparison of 190 PatientsAmy K. Yetasook, John G. Linn, Woody Denham, JoAnn Carbray, Michael B. Ujiki

Background: Controversy still remains as to whether an endoscopic or surgical approachshould be primary treatment for patients with achalasia. We report our experience withendoscopic and surgical treatments in patients with achalasia over a 10-year period. Methods:Retrospective analysis of electronic medical records was gathered from 190 patients withconfirmed achalasia between January 1, 2000 and August 9, 2011. Demographics, data frommotility studies, peri-operative intervention data, endoscopic intervention data, the use ofa proton pump inhibitor (PPI), and presence of symptoms (dysphagia and GERD-relatedsymptoms) throughout their course of treatment from clinical visits were collected. Results:In our surgical cohort, 72 patients underwent various types of procedures (surgical myotomywith or without a full or partial fundoplication), with 8 (11%) patients having more thanone surgical admission for a total of 80 surgical interventions. Thirty-two percent of thesurgical patients underwent prior endoscopic treatment. In our endoscopic cohort, 76 patientsunderwent only endoscopic treatments (balloon dilation, botulinum injection or both) with53 (70%) patients undergoing multiple treatments for a total of 174 endoscopic interventions.The remaining 42 patients did not have an endoscopic or surgical intervention, or did nothave adequate follow up. The endoscopic-only managed patients underwent a mean of 3(±2) and a median of 2 (range 1-8) interventions. There was no statistically significantdifference between groups when comparing BMI, smoking status, pre-intervention meanresting lower esophageal sphincter (LES) pressures, pre-intervention mean lower esophagealsphincter (LES) relaxation pressure, or use of a PPI. Patients in the surgical cohort weresignificantly younger at 56.3 years versus 72.7 years (P<0.001). Endoscopic-only managedpatients had both significantly more dysphagia (42.1% versus 16.7%, P<0.005) and GERD-related symptoms (72.6% versus 15.3%, P<0.005) throughout and after their course oftreatment as compared to the surgical group. The mean period between the first and secondendoscopic procedures was significantly less at 2.5 (±4.79) years as compared to 16.34(±15.9) years in between a first and second surgery for achalasia (P<0.05). Patients in theendoscopic cohort had comparable average follow-up course of 7.26 (±6.72) versus 7.35(±8.47) years compared to the surgical cohort. Thirty-day morbidity in the surgical cohortwas 6.9% (5 patients) versus 1.3% (1 patient) and there were no mortalities. Conclusion:Surgery may offer a more efficacious option for patients with achalasia than endoscopictreatment alone with less need for repeated interventions and significant relief of symptoms.

S-1055 SSAT Abstracts

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High Resolution Motility Assessment of the Esophageal Body in Patients WithParaesophagel Hiatal HerniaStefan Niebisch, Marek Polomsky, Candice L. Wilshire, Carolyn E. Jones, Virginia R. Litle,Christian G. Peyre, Thomas J. Watson, Jeffrey H. Peters

Introduction: The clinical management of patients with large type III paraesophageal hiatalhernia (PEH) in both elective and urgent circumstances has become quite common. Repairof PEH now accounts for 30-50% of fundoplications in high volume centers. Given theprimary focus on hernia repair, and not gastro-esophageal reflux (GERD), the utility ofesophageal motility in patients with PEH is unclear. Furthermore, the availability of eso-phageal motility testing, emergent presentation of patients and complex anatomy makingcatheter placement difficult, all limit the routine use of preoperative motility. The aim ofthis study was to characterize preoperative esophageal function in patients with PEH andto determine the prevalence of esophageal dysmotility which might impact surgical approach.Methods: Eighty patients (mean age 64.5 ±11.9 years; mean BMI 30.7 ±5.8; 65% female),with endoscopic and/or radiographic type III hiatal hernia, who underwent preoperativeHigh Resolution Manometry (HRM) from December 2006 to October 2011 formed the studypopulation. All studies were analyzed using current esophageal body motility classificationsand current analysis software (ManoViewTM v2.0.1). Assessment of the lower esophagealsphincter (LES) was possible in 21 patients (26%) in which the catheter was passed throughthe diaphragmatic crura into the intra-abdominal cavity. All manometry parameters werereferenced to normal-values previously established in our institution. Results: Esophagealbody function including wave propagation and circular muscle strength was normal in 35/80 (44%) of patients. A simultaneous/spastic contraction pattern (distal latency <4.5sec and/or contractile front velocity >9cm/s) was present in 14/80 (17.5%) and abnormal contractionstrength (overall distal contractile integral <500mmHg●cm●s, weak peristalsis with peri-staltic defects and/or frequent failed peristalsis) in another 14 (17.5%). Manometric evidenceof functional outflow obstruction (elevated intra-bolus pressure and/or elevated 4-secondintegrated relaxation pressure) was present in 29/80 (36.3%) of patients. One patient metthe manometric criteria for Achalasia. Manometric evidence of the sliding component of thePEH was present in 17/21 (81%) with a mean length of 4.1±2.1 cm. Overall LES lengthwas short in 14/21 (67%) patients, 19/21 (91%) had a shortened intra-abdominal segmentand 2/21 (10%) were hypertensive at rest. Conclusion: Significant abnormalities of esophagealbody function are present in a large percentage (56%) of patients with paraesophageal hiatalhernia. Nineteen percent have severely compromised circular muscle strength. These datasuggest that HRM should be included in the preoperative evaluation of patients with PEHwhenever possible.

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Efficacy and Safety of Self-Expanding Plastic Stent (SEPS) in the Managementof Esophageal DisordersYuk Law, Daniel K. Tong, Simon Law

Introduction Self-expanding plastic stent (SEPS) was introduced in recent years. Because itis easily removed endoscopically, it can be used to treat both malignant and benign disordersof the esophagus; including strictures, fistulae and perforations. The present study evaluatesour experience in the use of SEPS, assessing its efficacy and safety. Methods A prospectivelycollected database of the use of SEPS from 2007 to 2011 was retrospectively reviewed.Treatment efficacy was evaluated by comparing the pre- and post-stenting dysphagia scorein patients who had esophageal strictures. Success of sealing of fistulae and perforationswas also assessed. Short-term and long-term complications were analyzed. Results A totalof 30 stents were inserted for 23 patients (20 men and 3 women). The median age was 69yrs (range 51-85). Indications included benign stricture (20%, n=6), malignant stricture(20%, n=6), tracheo-esophageal fistula (10%, n=3), post esophagectomy anastomotic leak(16.7%, n=5) and benign perforation (33.3%, n=10). For patients with stricture (both benignand malignant, n=10), the median dysphagia score improved from a pre-treatment score of 3(liquid diet) to post-treatment score of 2 (semisolid diet), p<0.001. SEPS provided satisfactorysealing in all 3 patients who had tracheo-esophageal fistulae; none required additionalintervention. Of the 5 patients with anastomotic leak, 3 were successfully managed by SEPSwith sealing of leak after stenting. Closure was not achieved in the other 2, who requiredsubsequent surgical management. In the 5 patients who had benign perforation, all hadadequate sealing by SEPS and recovered. One patient required 5 stents in total becauseof repeated stent migration. Tracheal compression occurred in one patient under benignperforation group immediately upon SEPS deployment. The SEPS was removed and thelesion was successfully managed using another SEPS of shorter length. This was the onlyshort-term complication identified in present study. For delayed complications, migrationwas most frequently observed (40%, n=12). Other delayed complications included foodbolus obstruction (10%, n=3), erosion to surrounding structure (0%, n=0) and tumoringrowth (3.3%, n=1) were infrequently seen. Conclusion SEPS is a worthy alternative tometal stent in malignant disease and has emerged as a new tool for managing anastomoticleaks and benign perforations with a high success rate. Migration remains a major concern.

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Impact of Neoadjuvant Chemoradiotherapy on Survival in CarcinomaEsophagus: A Decade's ExperienceRajesh Gupta, Sunil D. Shenvi, Rakesh Kapoor, Surinder S. Rana, Deepak K. Bhasin

BACKGROUND: Neoadjuvant chemoradiotherapy followed by surgery has become standardof care at most of the centres. OBJECTIVE: To assess the impact of Neoadjuvant chemoradi-otherapy on survival in patients with locally advanced carcinoma esophagus. MATERIALSAND METHODS: From our prospectively maintained database, we retrospectively reviewedall patients who underwent Neoadjuvant chemoradiotherapy for resectable esophageal cancerbetween November 1999 and December 2010. RESULTS: Out of total 188 patients withcarcinoma esophagus, 117 patients underwent Neoadjuvant chemoradiotherapy

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