ESSR ABSTRACTS 2010

ESSR ABSTRACTS 2010

ESSR ABSTRACTS 2010

The 45th Congress of the European Society for Surgical Research takes place this year in Geneva, Switzerland, 9–12June 2010, under the presidency of Mustafa Cikirikcioglu, MD, PhD

Poster Session I

P1A Organ and cell Transplantation – Biomaterialsand Artificial Organs 1

P1A-1 Hug’s hpp machine: a new mobile perfusion device whichmakes feasible nuclear magnetic resonance evaluation of perfusedkidneys

R. Ruttimann1, F. Lazeyras3, A. Nastasi1, L. Buhler2, P. Morel2,J-B. Buchs1

1Research and Development Laboratory, Visceral and Transplantation Service,University Hospital of Geneva, Geneva, Switzerland 2Visceral and TransplantationService, University Hospital of Geneva, Geneva, Switzerland 3Service of Radiology,University of Geneva and University Hospital of Geneva, Switzerland

Objectives: With the shortage of brain dead donors for kidney transplantation,marginal donor organs are increasingly considered. The use of oxygenatedhypothermic pulsatile perfusion (O2+HPP) machine has been clearly associatedwith improved transplant function. Moreover, if cold static storage (CSS) comesafter a long warm ischemic time (WIT) and then followed by HPP, HPP hada deleterious effect on tissue structure. Hence the necessity of a mobile systemto perfuse kidney immediately once removed. To date, renal vascular pressureis the most helpful functional parameter for kidneys during perfusion but is stilldiscussed. Consequently better viability assessment is required. As shown lately,Magnetic Resonance Imagery (MRI) and Magnetic Resonance Spectroscopy(MRS) provide unique physiological insight non-invasively.Methods: We have developed a safe pneumatically controlled system ableto perfuse kidneys under specifics conditions related to NMR. The perfusionmodule is made so as to receive two kidneys.Results: Pulsatile flow (between 50 and 15 mmHg pressure) is supplied thanksto a pneumatic pump. The entire device is moveable. The perfusion moduleand its ‘‘igloo’’ made of ice can be separated with a 7 meters long ‘‘umbilicalcord’’. The perfusate, (KPS-1), is maintained between 2 and 4°C under oxygenpartial pressure of > 100 kPa through a hollow fiber oxygenator. MRI/MRS isperformed with home made 31P interface and surface coil.Conclusion: There are in the market a number of machines, but none haveincorporated the possibility of a NMR diagnosis. HUG’s HPP machine is ahelpful tool to measure the physiological state of the marginal kidneys andthereby enlarging criteria of acceptability for such organs as well as improvingtheir postoperative functions.

P1A-2 Experimental study of the salvapump system for pulsatileperfusion in cardiopulmonary bypass

J. Herreros1, M. Ubilla1, E. J. Berjano2, J. Garcıa3, J. E. Vila Nunez3,J. A. Paramo4, J. Sola5, S. Merce3

1Cardiovascular Surgery Department, Cl´ınica Universidad de Navarra, Pamplona,

Spain 2Institute for Research and Innovation on Bioengineering, UniversidadPolitecnica de Valencia, Valencia, Spain 3Research and Development Department,Merce V. Electromedicina S.L., Valencia, Spain 4Hematology Department, Cl

´ınica

Universidad de Navarra, Pamplona, Spain 5Pathology Department, Cl´ınica

Universidad de Navarra, Pamplona, Spain

Objective: To assess the platelet dysfunction and damage to organs afterextracorporeal circulation using the Salvapump pumping system (MerceElectromedicina, Valencia, Spain). This pump provides a continuous flow bymeans of a centrifugal mechanism, and adds a pulsatile component by means of apulsating inner membrane, which is pneumatically controlled by an intra–aorticcounterpulsation balloon console.Methods: Six pigs were subjected to a partial cardiopulmonary bypass lasting180 minutes. The continuous total flow ranged from 2 to 3 L/min, andthe pulsatile component was of 37·5 mL with a frequency of 60 bpm. Thehematological study included the measurement of hematocrit, hemoglobin,leukocytes and platelet function. Animals were sacrificed 60 minutes afterextracorporeal circulation was suspended, and then, a morphological studyincluding biopsy of the heart (free left ventricular wall), liver, lung, and kidney,was conducted.Results: The pump under test did not significantly alter either platelet countor platelet function. In contrast, hematocrit and hemoglobin were significantlyreduced during extracorporeal circulation (approximately 5% p=0·011, and2 g/dL p=0·01 respectively). The leukocyte count during extracorporealcirculation showed a tendency to decrease but this was not significant. Ingeneral, the short–term use (4 hours) of the pump did not cause any seriousmorphological damage to heart, lung, kidney or liver.Conclusion: The findings suggest that the hemodynamic performance of thenew pump is similar to a conventional centrifugal pump and could therefore beappropriate for use in extracorporeal circulation.

P1A-3 Protection against liver ischemia-reperfusion injury in ratsby silymarin or glutamine

A. Demirag1, M. Kisakurek2, A. Sepici3, S. Karakayali2

1Yeditepe University Hospital, Istanbul, Turkey 2Department of Surgery, AnkaraTeaching Hospital, Ankara, Turkey 3Department of Biochemistry, Gazi UniversityHospital, Ankara, Turkey

Objective: Liver injury after cold or warm ischemia followed by reperfusionremains one of the major obstacles in transplantation. Supplementation withglutamine (GLN) and silymarin (SLY) have been shown to have protectiveeffects against injury, but there is no information about the comparative effectsof these drugs. The aim of this study was to evaluate preventive effect of SLYand GLN supplementation against I-R injury.

While every effort is made by the Editorial Team and the Publishers to avoid inaccurate or misleading information appearing in BJS, data within theindividual abstracts are the responsibility of the Authors. The BJS society, the Publishers and members of the Editorial Team accept no liability whatsoeverfor the consequences of any such inaccurate or misleading data, opinion or statement.

Copyright 2010 British Journal of Surgery Society Ltd British Journal of Surgery 2010; 97(S4): S59–S121Published by John Wiley & Sons Ltd

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S60 ESSR ABSTRACTS 2010

Methods: Rats were assigned to four groups: (i) sham (Group I); (ii) controlwith hepatic ischemia and reperfusion; (Group II); (iii) SLY+ischemia (GroupIII); (iv) GLN+ischemia (Group IV); SLY and GLN were given 2 hours beforeischemia. Blood samples and the liver were obtained after 45 min, 2 hoursand 24 h of reperfusion and malondialdehyde (MDA), superoxide dismutase(SOD), tumor necrosis factor (TNFα) levels and histopathologic findings wereevaluated.Results: The liver MDA, SOD, and serum TNF-α(p < 0·05) levels weresignificantly different in Group III and IV than in Group II at 45 min, 2hand 24h of reperfusion. While the effect of GLN on tissue MDA levels wassignificantly prominent than SLY group in all time frames (p < 0·05), thedifference between these two groups was less significant for SOD. The TNF-αlevels were lower at 45 min and 2 h in group III compared with group IV. Bothdrugs decreased histopathological injury. The most prominent ischemic injurywas observed in Group III.Conclusion: These results suggest that GLN and SLY are effective inattenuating liver I-R injury and antioxidant effect of both medications could beresponsible for the cytoprotection.

P1A-4 [Hpp+O2-mr-compatible] machine: its ‘‘clinical’’ application inmarginal kidneys’ viability evaluation. Experimental study

J-B. Buchs 1, F. Lazeyras 2, S. Moll3, L. Buhler 4, A. Nastasi 1,R. Ruttimann 1, P. Morel 4

1Research and Development Laboratory, Visceral and Transplantation Service,University Hospital of Geneva, Switzerland 2Service of Radiology (CIBM), UniversityHospital of Geneva, Switzerland 3Department of Pathology, University Hospital ofGeneva, Switzerland 4Visceral and Transplantation Service, University Hospital ofGeneva, Switzerland

Objectives: Marginal kidneys’ viability is underrated. Marginality includesolder donors [risk of transmission of cancers] and NHBD [long ischemiaincreasing the ischemic lesions]. Our objective was the development of aperfusion machine and of a technology allowing extensive Magnetic Resonanceanalysis to establish a score of viability for those organs.Method: Pigs’ kidneys have been studied. During perfusion, organs have beentested by T2 sequence for the research of tumor or of another major pathology.T1 fast mapit sequence for the analysis of Cortico-Medullar distribution ofperfusion that changes in case of ischemic lesions. P31 NMR spectroscopyhas been applied to measure ATP resynthesis, the proof of organs’ viability.Gadolinium-perfusion was realized to visualize the arteries and the perfusionof the organs. Gd-perfusion lets measure the redistribution of flow betweenCortex and Marrow and the leakage of Gadolinium in the interstitial space asa consequence of ischemic lesions. The MR results have been compared withhistological evaluation of the organs following the Groningen score.Results: Score realized before the transplantation of a viable organ:Absence of tumor or of a major pathology [T2]; T1 fm: preservation of theC-M gradient of flow [300 ms]; ATP resynthesis; Gd-perfusion: nearly no Gdleakage [absence of shunt effect] and normal vascular anatomy.The results obtained and compared with the histological score were in totallyagreement.Conclusion: For the first time we can evaluate, in real time, the marginalorgans during their necessary perfusion of reanimation. The concordancewith the histological evaluation would allow in the future to suppress thetransplantation in the animal as proof.

P1A-5 Preoperative fasting induces protection against renal ischemiareperfusion injury by a corticosterone independent mechanism

T. M. van Ginhoven1, J. W. van den Berg1,2, W. A. Dik2,J. N. M. IJzermans1, R. W. F. de Bruin1

1Department of Surgery, Erasmus MC, Rotterdam, Netherlands 2Department ofImmunology, Erasmus MC, Rotterdam, Netherlands

Objective: One of the inevitable factors negatively influencing the outcomeafter kidney transplantation is ischemia-reperfusion injury (I/R). We havepreviously shown that preoperative fasting is able to protect against renal I/R.We hypothesized that the protection afforded by fasting against renal I/R injury

is mediated by increased levels of corticosterone, induced by the stress of fooddeprivation.Methods: Male C57BL/6 mice were fasted for three days after whichcorticosterone levels were determined. Next, mice underwent a bilateraladrenalectomy (ADX) ten days prior to fasting and I/R or were given acorticosterone receptor antagonist during fasting. Survival and kidney functionwere determined.Results: Three days of fasting increased corticosterone levels significantlyfrom 298, 2 ± 39, 99 nmol/L in ad libitum fed animals to 1287 ± 167, 1 nmol/Lafter fasting. Following ADX corticosterone levels remained below normalafter 3 days of fasting. Ten days after ADX, mice were subjected to a threeday fast prior to renal I/R injury, only 10% survived whereas all sham ADXoperated mice survived. We subsequently showed that after ADX and fasting,70% of the mice subjected to a laparotomy without renal ischemia-reperfusioninjury succumbed to the surgical procedure. Following glucocorticoid receptorblockage, by mifepristone, all animals survived renal I/R after three days offasting and kidney function was unaffected by Mifepristone.Conclusion: Three days of fasting affords protection against potentially lethalrenal I/R injury. Although fasting leads to increased serum corticosteronelevels, glucocorticoid receptor blockade does not interfere with the protectiveeffects of fasting. Protection against renal I/R injury is therefore mediated bycorticosterone independent mechanisms.

P1A-6 Comparison of intestinal cold preservation injury on pituitaryadenylate cyclase-activating polypeptide (PACAP) knock-outand wild-type mice

A. Ferencz1, K. Nedvig1, E. Volgyi1, T. Fekecs1 D. Reglodi1, I. Takacs1,G. Weber1

1University of Pecs, Pecs, Hungary

Objective: Tissue injury caused by cold preservation remains an unsolvedproblem during small intestinal transplantation. Pituitary adenylate cyclase-activating polypeptide (PACAP) is present and plays a central role in theintestinal physiology. The aim of our study was to compare the cold ischemicinjury on PACAP-38 knock-out and wild-type mice after small bowel coldstorage.Methods: Cold ischemia was produced with small bowel preservation inUniversity of Wisconsin solution at 4°C in PACAP-38 knock-out (n=20) andwild-type (n=20) mice. Group I: sham operated, no-ischemia; GII: 1 hourischemia; GIII: 3 hours ischemia; GIV: 6 hours ischemia. Small bowel biopsieswere collected after laparotomy (control) and at the end of the ischemiaperiods. To determine oxidative stress parameters, malondialdehyde, reducedglutathione, and superoxide dismutase were measured. Tissue damage wasanalyzed by qualitative and quantitative methods on hematoxylin/eosin stainedsections.Results: In PACAP-38 knock-out animals tissue lipid peroxidation waselevated. These changes were significant after 6 hours (153·04 ± 7·2 umol/g)compared to sham-operated (110·44 ± 5·5 umol/g) and compared to wild-typeresults (120·0 ± 1·1 umol/g, p<0·05). Meanwhile, the capacity and activityof endogenous antioxidant system decreased significantly after 3 and 6 hourspreservation (GSH: 808·7 ± 5·2; 720·4 ± 8·7 versus 910·4 ± umol/g; SOD:125·1 ± 1·4; 103·3 ± 1·9 versus 212·11 ± 5·8 IU/g). Qualitative and quantitativehistological results showed destruction of the mucous, submucous and muscularlayers and crypts in knock-out mice compare to wild-type tissues. Theseprocesses were dependent on the time of the cold preservation periods.Conclusion: Our present study showed that PACAP-38 has a key role in theprotection against intestinal cold preservation injury. (Supported by OTKAPD77474, K72592, 73044; Bolyai Scholarship)

P1A-7 Effect of ischemic postconditioning on the oxidative stressand tissue injury in the intestinal warm ischemia/reperfusion model

A. Ferencz1, I. Takacs1, Sz. Horvath1, S. Ferencz1, Sz. Javor1,T. Fekecs2, K. Shanava1, B. Balatonyi1, Gy. Weber1

1Department of Surgical Research and Techniques, 2Department of Dermatology,Venereology and Oncodermatology, University of Pecs, Hungary

Copyright 2010 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2010; 97(S4): S59–S121Published by John Wiley & Sons Ltd

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ESSR ABSTRACTS 2010 S61

Objective: Intestinal ischemia/reperfusion (I/R) injury is resulting from somepathological and surgical procedures. We aimed to investigate the effect ofischemic postconditioning (IPO) in the warm I/R intestinal model.Methods: Warm ischemia was performed by occlusion of superior mesentericartery for 1, 3 and 6 hours on white domestic pigs (n=30). Reperfusion lasted3 hours in all groups. Before reperfusion intestine were postconditioned by3 cycles of 30-seconds ischemia and 30-seconds reperfusion. Small intestinetissue was collected after laparotomy (control) and at the end of the reperfusionperiods. Tissue damage were evaluated by qualitative (Park’s classification) andby quantitative methods (software Scion Image) on hematoxylin/eosin-stainedsections. From oxidative stress markers tissue value of malondialdehyde (MDA)and reduced glutathione (GSH), and the activity of superoxide dismutase (SOD)were determined.Results: According to qualitative and quantitative analysis showed thattissue injury increased by the duration of warm ischemia time. In the6 hours group severe destruction of the mucosal and muscular layers, andthe Departmenth of crypts have been seen at the end of the reperfusion (Grade5). IPO significantly decreased this injury in each group (Grade 3, p<0·05).Biochemical results showed that IPO significantly decreased the reperfusion-ended lipidperoxidation’s value (169 ± 5·8 versus 136 ± 8·4 umol/g; p<0·05).Moreover, the capacity and activity of endogenous antioxidant protectivesystems (GSH: 700 ± 9·2 versus 1100 ± 8·4 umol/g; SOD: 81 ± 12·6 versus133 ± 10·2 IU/g; p<0·05) remained higher in IPO groups.Conclusion: IPO prior to reperfusion mitigated the oxidative stress andhistological damages in our experimental warm I/R model. (Supported byOTKA PD77474, Bolyai Scholarship of MTA).

P1A-8 The Airdrive: a disposable hypothermic oxygenated machineperfusion system for the liver

M. C. Dirkes1, I. C. Post1, T. M. van Gulik1

1Department of Experimental Surgery, Academic Medical Centre, Amsterdam,Netherlands

Objective: Machine perfusion (MP) is gaining acceptance as a method tounlock a potential larger donorpool of organs for transplantation. In our aim tobuild a low-cost MP system we devised the Airdrive, a disposable MP systemwhich has recently demonstrated its value in kidney preservation. Here weintroduce the Airdrive as an oxygenated hypothermic dual MP system for theliver.Methods: A liver MP system should cover several main elements. Firstly, itmust operate at hypothermic temperatures. Secondly, a pump must provideboth continuous and pulsatile flow to the portal vein and hepatic artery,respectively, adjusting flow and pressure to increasing vascular resistance (VR).Lastly, a precise oxygen level must be maintained to balance between anoxicand hyperoxic damage.Results: We devised the Airdrive as a portable and disposable MP system thatuses a standard 2 litre oxygen container for three subsystems: it drives a uniquelow-energy consumption pump, oxygenates circulating perfusate and inducesoverpressure in the organ chamber to maintain sterility. Coolpacks keep thetemperature stable at 6 ± 2°C. The pump produces 12 ± 0·6 mmHg pressure,adjusting the flow to the total VR, not exceeding 200 ml/min. With a maximumallowed VR of 0·7 the system can function 24 hours. A disposable membraneoxygenator keeps the pO2 at 450 ± 50 mmHg. Flow, pressure, VR, temperatureand time data are all continuously stored and can be retrieved on demand.Conclusion: The Airdrive is a new hypothermic oxygenated MP systemsuitable for liver preservation, allowing users to choose between single perfusionor dual perfusion of the portal vein and hepatic artery upon activation.

P1A-9 Flupirtine induced hepatic failure requiring orthotopic livertransplantation

F. Klein1, M. Glanemann1, B. Rudolph2, D. Seehofer1, P. Neuhaus1

1Department of General, Visceral, and Transplantation Surgery, Charite CampusVirchow, Universitatsmedizin Berlin, Germany 2Department of Pathology, ChariteCampus Mitte, Universitatsmedizin Berlin, Germany

Objective: Flupirtine is a non-opioid analgesic drug widely used in acute andchronical pain situations. Varying degrees of an additive hepatotoxic effect onthe grounds of a preexisting liver damage have been reported. We herewithreport the case of a 48 year-old male otherwise healthy patient suffering from apseudoradicular pain syndrome who required urgent liver transplantation dueto acute liver failure after flupirtine treatment.Methods: After three months of daily flupirtine intake the patient presentedwith signs of jaundice and hepatic encephalopathy. The laboratory resultsrevealed elevated liver transaminases (AST – 2089 U/l, ALT 2902 U/l). Theliver histopathology was supportive of the assumed drug induced liver injury.Other possible causes of an acute liver failure were excluded and the patient waslisted for urgent liver transplantation at Eurotransplant in Leyden, Netherlands.Results: The patient received a 21 year-old male liver graft. The preservationinjury was severe as indicated by AST (1301 U/l) and ALT (761 U/l) valuespostoperatively. Despite a rejection episode on day 11 which was successfullytreated by steroid pulse therapy the postoperative course was uneventful and thepatient fully recovered. He was discharged three weeks after transplantation.Conclusion: To the best of our knowledge this is the first report on livertransplantation in acute liver failure after flupirtine intake. Clinicians should beaware of potential hepatotoxicity with flupirtine treatment also in adults withno underlying liver damage. Therefore liver function tests should be carefullymonitored. If an elevation of serum liver enzymes is observed flupirtine therapyshould be discontinued immediately otherwise acute liver failure may result.

P1A-10 Gynecologic symptoms and sexual function in womenkidney – allograft recipients

V. Genc1, R. Karayalcin2, D. Oztuna3, N. Huseynova4, S. Ersoz1

1Department of Surgery, Ankara University School of Medicine, Ankara, Turkey2Department of Endoscopic Surgery, Dr Zekai Tahir Burak Women Health Researchand Education Hospital, Ankara, Turkey 3Department of Biostatistics, AnkaraUniversity School of Medicine, Ankara, Turkey 4Department of Surgery, ScientificSurgical Center named after M.A.Topchubashov, Baku, Azerbaijan

Background: There is a little information about changing menstrual pattern,sexuality and fertility after kidney transplantation in literature. The purpose ofthis study was to describe gynecological symptoms, menstrual characteristics,sexual functions, details of pregnancies and gynecological care in women whounderwent renal transplantation at before and after transplantation period.Mehods: A detailed Turkish questionnaire was prepared for gynecologicevaluation. Fifty women of reproductive age who underwent renal transplan-tation took part in this study. The questionnaires were applied at the time ofpostoperative follow-up period.Results: The mean age and body mass index of all study participants atthe time of interview was 33·9 years (range 18–52) and 23·5 kg/m2 (range16·5–33·3), respectively. There was statistically no difference between beforeand after transplantation in terms of bleeding between periods, heavy period,painful period and period duration. Eight women leaved active working lifeafter grafting with their own demand. Thirteen women ceased sexual activityafter transplantation. None of the women reported pregnancy after grafting. Atotal of 98% of women reported that they were never instructed about regulargynecological care.Conclusion: We realized that restriction of transplanted kidney women’s lifeinclude ceasing sexual activity and leaving active working life because of thearising fear related to possible organ damage. Kidney transplanted women mustbe informed about related posttransplant sexual life and requirement of regularexamination by a gynecologist. Hence close collaboration should be constitutedamong patient, primary care physician and gynecologist.

P1B Cardiac Surgery 1

P1B-1 Myocardial revascularization in patients with severe leftventricular dysfunction: Is on pump beating the preferable technique?

M. Abdel-Aal1, N. ElNahal1, M. Sabban1, Y. A. AlRahman1,B. M. Bakir1, A. Alsaddique1, M. Fouda1, A. A. Alshaer1

1King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh,Kingdom Of Saudi Arabia


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Objective: It remains unclear how cardioplegic arrest affects surgical resultsafter coronary artery bypass grafting. This study compares early outcomeafter on-pump beating-heart coronary revascularization and conventionalrevascularization in patients with ejection fractions of less than 30%.Methods: From 2005 to 2008, 167 patients with ejection fraction less than30% underwent CABG. On-pump beating-heart CABG was carried out in 75patients (group 1) and 92 patients had the conventional technique (group2).Results: Both groups were otherwise similar in their risk on-pump beating-heart CABG group (4% versus 4·34%). Twelve patients in the conventionalCABG group required insertion of intra-aortic balloon pump initiatedintraoperative or postoperative, whereas only 2 patients required it in the on-pump beating-heart CABG group. The ventilation time in hours was longer inthe conventional group (10 ± 12·3 versus 7·6 ± 11·7). No significant differencewas found in morbidity including stroke and renal failure. The incidence ofpostoperative atrial fibrillation was significantly less in on pump beating groupcompared to conventional group occurring in 6 versus 21 patients in group 2.The duration of intensive care unit stay and the hospital stay were significantlyshorter in the on-pump beating-heart CABG group.Conclusions: On-pump beating-heart CABG can be performed safely in high-risk patients. Use of cardiopulmonary bypass and the elimination of cardioplegicarrest may be of most benefit to hemodynamically unstable patients.on-pump beating CABG - ischemic heart disease - EF < 30%.

P1B-2 Coronary Artery Bypass Grafts Surgery In Elderly Patients: APropensity Matched Analysis Of Outcome And Resources Utilization

B. Al-Alao1, E. Mcgovern1, M. Tolan1, V. K. Young1

1Department of Cardiothoracic Surgery, St James’s Hospital, Dublin, Ireland

Objectives: We examined the influence of an elderly population undergoingfirst time isolated coronary artery bypass grafts surgery on hospital resourcesand complications rate in comparison to a younger counterpart in a propensitymatched cohort.Methods: A retrospective analysis of prospectively collected data was conductedon 2804 CABG patients. Two age groups older and younger than 75 weregenerated. Potential differences in demographic, baseline, pre-operative andintra-operative characteristics were investigated. A propensity score based onthese differences was calculated and used to create matched set of patients.Major post-operative complications were recorded and data on indicators ofresources utilization were collected.Results: 311(11·1%) patients were identified as older than 75. Observedcomplications rate was significantly higher in overall, pulmonary, cardiac,renal, gastrointestinal (GI), neurological, infective and mortality (p<0·0001).Observed hospital resources utilization were significant in the elderly groupin terms of initial stay in intensive care unit (ICU) and re-admission to ICU(p<0·05) and in all pre-operative, post-operative, cardiac surgery and totalhospital stays (p<0·001). However, after propensity matching to 311 patientsof the younger group, overall post-operative complications rate maintained itssignificance (p<0·0001), in addition to, atrial fibrillation, neurological, renaland GI complications (p<0·05). Elderly patients required longer duration ofventilation post-operatively, longer post-operative stay cardiac surgery stay,total hospital stay and maintained higher surgical mortality rate (6·1% versus2·6%)(p<0·05).Conclusions: Elderly patients undergoing CABG had significantly higherrates of post-operative complications. Their prolonged hospital stay andconsequent higher resources utilization need to be adequately highlightedto heath care officials and appropriately addressed.

P1B-3 Cardiopulmonary bypass model in rats: A new mini-invasivemodel with a low-volume circuit.

G. Lebreton1,2, F. Doguet1,2, J.-M. Baste1,2, J.-P. Bessou1,2

1Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital,France 2INSERM U644, Rouen University Medical School, France

Background: Many models of cardiopulmonary bypass (CPB) in rats havebeen described but frequently deviate from conditions in human clinical use,

making them difficult to use. We have developed a miniaturized model of CPBin the rat.Method: This study was performed on male Wistar rats 450–500 g dividedinto a control group (n = 10), and a CPB group (n = 10). In the CPB group,after femoral cannulation, rats undewent a CPB (100 ml/kg/min) for 90 minutesand then were monitored for 60 minutes. The control rats were cannulated andmonitored 150 minutes. The circuit’s volume was 10 mL. During the procedurethe rats were ventilated and hemodynamically monitored. The CPB flow wasgradually increased to 100 mL/kg/min. A measure of TNF-α was performedat T0 (cannulation) and T1 (euthanasia), and histology was performed on lungand intestinal samples at T1.Results: No rats died was during the procedure. The values of TNF-α atT1were significantly (p<0·0001) higher in the CPB group than in the controlgroup, and higher than those measured at T0 in both groups. There is asignificant leukocyte infiltration of lung and intestinal tissues in the CPB group.Conclusion: The model of CPB in the rat developed allows to study the effectsof cardiopulmonary bypass. It offers the advantages of low volume CPB circuit,with a minimal surgical aggression and low mortality, making it usable to studythe inflammation.

P1B-4 The Correlation Of Peroperative Serum Lactate And CreatinineLevels With Postoperative Results In Pediatric Heart Surgery

H. Yaliniz1, U. Gocen1, A. Atalay1, Y. Guzel, O. K. Salih1

1University of Cukurova, Faculty of Medicine, Department of Cardiovascular Surgery,Adana, Turkey

Objective: The systems, drugs, and electrolytes used during cardiopulmonarybypass bring about changes in the metabolism and organ functions at cellularlevel, causing changes in normal physiology as well. We aim to find the changesduring cardiopulmonary bypass and to be able to correctly pre-evaluate thepost-operative morbidity and mortality of congenital heart patients.Methods: In this study, we took arterial blood samples from 30 congenitalheart patients with a history of cardiopulmonary bypass at the preoperativephase (Episode 1: after the anesthesia has been applied), at the fifth minute ofthe cooling phase of cardiopulmonary bypass (Episode 2), at the fifth minuteof the heating phase of cardiopulmonary bypass (Episode 3) and at the sixthhour during post-operative intensive (Episode 4), and increased the correlationbetween lactate and creatinine levels of these samples.Results: 26 patients discharged uneventfully after the study-based surgery wereadmitted as Group I, and 4 patients who developed exitus due to multiorganinsufficiency resulting from low heart rate during the 7·5, 9, 13, 18. minutes ofthe intensive care were admitted as Group II. It was observed that the lactatevalues in Group I increased during cardiopulmonary bypass (Episode I, EpisodeII) and decreased during intensive care. However, we found salient differencesbetween lactate and creatinine values in Groups I and II.Conclusions: The increase in lactate values stems from oxygen shortagecaused by tissue perfusion impair and anaerobic metabolism at cellular level.The increase in creatinine, on the other hand, is the result of the tissue perfusionimpair at a later phase leading to dysfunction in the kidneys.

P1B-5 Maniac episode following open heart cardiac surgery: clinicalcase and literature review

R. G. Demaria1, V. Pignay-Demaria2, J. M. Frapier1, P. Battistella1,P. Rouviere1, B. Albat1

1Cardiovascular Surgery Unit, Arnaud de Villeneuve Teaching Hospital, MontpellierUniversity I, France 2Psychiatry, Lapeyronie Teaching Hospital, MontpellierUniversity I, France

Objective: Psychiatric disorders are frequent in the postoperative cardiacsurgical period. They are more often anxiety or depressive disorders. Wepresent the case of patient who developed a maniac episode in the outcomes ofopen heart cardiac surgery.Methods: A 59 year old patient presents a third aortic valve procedure withimplantation of a mechanical valvular prosthesis. Immediate follow up wassatisfactory but one month after surgery, he developed a maniac episode with


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psychic instability. Psychiatric evolution was satisfactory under treatment. Aliterature review was realized.Results: Psychiatric maniac episode following open heart cardiac surgery canoccur when there is a history of mood disorder for the patient or his family. Thetaking care of maniac access is urgent because it can impair the postoperativeprognosis by comportment disorders induced.Conclusion: Psychiatric maniac episode following open heart cardiac surgeryis an unusual complication and is rarely described in literature. The psychiatrist’shelp is useful and cares must be taken in hospital before and after cardiac surgery.

P1B-6 The use of cell salvage in routine cardiac surgery is ineffectiveand not cost effective and should be reserved for selected cases

S. Attaran1, D. McIlroy1, I. Johnson1, M. P. Poullis1, D. A. Chung1,R. Williams1, N. Medirata1, E. Griffiths1, B. M. Fabri1, D. M. Pullan1

1Division of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK

Objectives: The reported benefits of cell salvage are decreased requirement forblood transfusion and cost-effectiveness. This study was designed to challengethis hypothesis. We assessed intra-operative blood loss and the use of cell saverin selected patients in our institution.Methods: Data for 377 consecutive patients undergoing first-time cardiacsurgery (OPCAB = 178, ONCAB/valve ± CABG = 199), in a 12-monthperiod, was collected and analysed prospectively. We studied the amount ofautologous blood transfusion, and transfusion rate in this group. Prospectively,we measured the intra-operative blood loss, as well as cell salvaged bloodtransfusion in another 50 patients (OPCAB = 11, ONCAB/valve ± CABG=39).Results: In only in 40 cases (7·5%) was the volume of blood loss sufficientenough to be washed and returned (mean=447 mL). The number of unitstransfused was not significantly different in either the cell salvaged group or thenon-salvaged group (p value=0·87). Furthermore, Cardiopulmonary bypass didnot influence the use of cell saver (p value=0·45). The average intra-operativeblood loss measurement, was only 206 mL i.e. not enough to be processed bythe cell saver.Discussion: Cardiac surgery is generally associated with a minimal blood loss.Reduced priming volumes; intra-vascular shunt and drugs minimise bleedingduring the procedure. Our study demonstrates that in 92·5% of cases insufficientblood was shed for processing by the cell saver.We conclude that the routine use of cell savers in all cardiac operations affordsno benefit and consumes additional revenue. We recommend that the systemonly be considered in selected high risk cases or complex procedures.

P1B-7 Effects Of Genetic Variations On Success Of Serum IrrigatingRadiofrequency Ablation

C. Atik1, H. Deniz1, O. Ozcaliskan1, H. Ustunsoy1

1Gaziantep University Medical School, C.V.S. Department., Gaziantep, Turkey

Introduction: Serum irrigating radiofrequency ablation (SIRFA) is one ofsurgical techniques can be applied for the treatment of atrial fibrillation (AF)with confidency and it’s success is associated with in the some certain factors.In this study, minK S38G gene and ACE gene polymorphisms’ role wereinvestigated in the success of SIRFA surgery.Material and Methods: Between September 2003–August 2008 patientswith valve disease and applied SIRFA and valve surgery with the diagnosis ofAF, under 60 years of age, left atrial diameter is less than 6 cm, and withoutCAD were studied. After SIRFA surgery, with 30 patients have sinus rhythmwere classified as group I, 30 patients with continued AF as group II, 30 patientswith preoperative valve disease in sinus rhythm as a control group (group III).5 cc venous blood taken into EDTA tubes for the DNA analysis, mink S38Ggene andACE gene polymorphism analysis standardization were performed at geneticlaboratory.Results: The mean age was 48·74 ± 10·07 years respectively. Demographicfindings were similar between groups. As a result of the studies done on the MINK 38G allele, in patients with GG genotype SIRFA success was lower (p<0·03).With ACE gene, in patients with I/D genotype, SIRFA success was lower but

not statistically significant (P<0·38). Left atrial thrombuses were more in AFgroup and this situation is revealed on the low success of SIRFA (P<0·01).Conclusions: We considered that the factors in reducing SIRFA surgerysuccess, genetic factors should be evaluated.

P1C Cardiac Surgery 2

P1C-1 What should be the location of thoracal drains following openheart surgery, substernal or intercostal?

M. Ozcan1, C. Camcy2

1Department of Cardiovascular Surgey, Hospital of Acybadem, Kayseri, Turkey2Department of General Surgey, Hospital of Acybadem, Kayseri, Turkey

Objective: In general, following open heart surgery performed with mediansternotomy, drains can be used substernally or intercostally on the midaxillaryline. This preferences base upon on clinical experiences. In this study we wouldlike to present our clinical results for comparison among each way.Method: In this study patients were divided into 2 groups, randomly, eachcontained 20 patients. Coronary by-pass surgery with using internal mammaryartery were performed for all patients. In Group I, one of two drains (32 G)was placed into mediastinum via substernally, remained was placed intercostallyinto thoracal space on mid-axillary line, whereas in Group II, both drains wereplaced into either mediatinum and thoracal space via substernally. Patients wereasked to note their pain status on Visual Analog Scale postoperatively. Painkillernecessity was also assessed. All patients were evaluated for atelectasis with chestP-A X-ray.Results: Postoperative pain was significantly lower in Group II. Similarly, thenecessity for analgesic agents was lower in Group II. Atelectasis was seen inGroup I, whereas there was noted no atelectasis in Group II.Conclusion: Early mobilization of patient following open heart surgeryis important issue. The placement of drains is also beign related for earlymobilization. These drains affect respiratory functions and postoperative pain.We conclude that, substernally placed drains are superior for early mobilizationof patients and have better respiratory functions and have advantages to controlpostoperative pain

P1C-2 Ex-Vivo Expanded Umbilical Cord Blood Stem Cells RetainCapacity for Myocardial Regeneration

D. Wiedemann1, N. Bonaros1C. Kittinger2, A. Jandrositz3,J. C. Huber4, K.-H. Preisegger3 and A. A. Kocher1, B. Schlechta1

1University Clinic Of Cardiac Surgery, Innsbruck Medical University, Innsbruck,Austria 2Medical University of Graz, Graz, Austria 3EccoCell Biotechnology Inc,Graz, Austria 4Division of Gynaecological Endocrinology and Reproductive Medicine,Medical University, Vienna, Austria

Objective: Umbilical cord blood (UCB) is a source of human hematopoieticprecursor cells (HPCs), a stem cell (SC) type that has been used in severaltrials for myocardial repair. A certain minimal number of cells is requiredfor measurable regeneration and a major challenge of SC-based regenerativetherapy constitutes ex-vivo expansion of the primitive cell compartment. Theaim of this study was to investigate the ex-vivo expansion potential of UCB-derived HPCs and the ability of these expanded cells to migrate to the siteof damage and improve ventricular function in a rodent model of myocardialinfarction (MI).Methods and Results: UCB-derived HPCs, defined by coexpression ofCD133 and CD34, were expanded using various cytokine combinations. MIwas induced by left anterior descending artery ligation in nude rats. Cells wereinjected intravenously 2 days after infarction. The combination of SC factor,thrombopoietin, flt3-ligand and interleukin-6 was found to be the most effectivefor inducing proliferation of HPCs. The migratory capacity of expanded HPCswas similar to that of non-expanded HPCs and improvement of ejection fractionwas significant in both groups, with a relative increase of > 60%.Conclusions: UCB-derived HPCs can be reproducibly expanded ex-vivo andretain their potential to improve cardiac function post-MI.


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P1C-3 Mitral and tricuspid valve repair using a biodegradableannuloplasty ring for the treatment of acute native valve infectiveendocarditis

E. Pektok1,2, J. Sierra1, M. Cikirikcioglu1, H. Muller3, P. O. Myers1,4,A. Kalangos1

1Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva,Switzerland 2Department of Cardiovascular Surgery, Yeditepe University, Istanbul,Turkey 3Department of Cardiology, University Hospital of Geneva, Geneva,Switzerland 4Division of Cardiac Surgery, Brigham and Women’s Hospital, HarvardMedical School, Boston, USA

Objective: Conventional annuloplasty (AP) rings consist of woven, non-degradable prosthetic material, and their use should theoretically be limited inacute infective endocarditis (IE). Novel biodegradable AP rings implanted intothe annulus may have theoretical advantages, but have never been evaluated forfeasibility and long-term results in patients with acute IE.Methods: Between 2004 and 2009, 17 consecutive patients with acute IE (age:35·0 ± 22·9 years [11–82], 8 males) had mitral (n=14) and/or tricuspid (n=4) APto conclude valve repair. Prospectively collected clinical and echocardiographicdata were analyzed retrospectively.Results: Main indications for surgery were heart failure (n=9; 52·9%),hemodynamic instability (n=8; 47%) and persistent infection despite antibiotics(n=6; 35·3%). Mitral and/or tricuspid repair was performed by completeexcision of the infected tissue, valvar reconstruction and AP using Bioring(Bioring , Lonay, Switzerland). Three patients died on POD-1; 2 and 34because of massive gastrointestinal bleeding; heart failure and pneumonia;sepsis and acute renal failure, respectively. During a median follow-up of thesurvivors of 29·8 (1·5–51·0) months, no mortality, recurrent IE or reoperationoccurred. At follow-up, TTE revealed no or trivial regurgitation in 11 and mildin 3 patients. There was favourable left ventricular remodelling with significantregression of left ventricular diameters.Conclusions: Mitral and tricuspid valve repair using Bioring showed goodstructural and functional properties up to 4 years after repair. Implantationof this biodegradable ring is feasible and effective in patients with acute IE.Intra-annular implantation of Bioring, which hinders direct blood contact andthe associated risk of bacterial colonisation, represents a theoretical advantagein such patients. Larger comparative studies are needed for further conclusions.

P1C-4 The reoperations that performed for bleeding after open heartsurgery

S. Huseyin1, S. Gurkan1, S. Canbaz1, T. Ege1, K. Arslan1,M. Dikmengil1, E. Duran1

1Department of Cardiovascular Surgery, Medical Faculty of Trakya University,Edirne, Turkey

Objective: In cardiac surgery, one of the most seen complication that causemortality and morbidity in early postoperative period are the reoperations.In this retrospective study, we observed the patients that were performedreoperation for bleeding in early postoperative period.Method: Between 1999–2009, open heart surgery were performed in 1952patients. Ninetyeight (5·02%) of these underwent early reoperation because ofbleeding.Results: Eightyone (58·2%) of patients were male and 17 (42·8%) were female(59·8 ± 11·219 to 78 years). Seventy (71·4%) of patients were CABG, 18 (18·3%)were valvuloplasty, 7 (7·1%) were CABG + valvuloplasty, 3 (3·06%) were leftatrial mixoma and left ventricular free wall rupture and CABG + axillobifemoraloperations. No bleeding origin were obtained in 45 (45·9%) of the patients.The most source of bleeding sites were LYMA and its branches 25 (25·5%).The mean duration for reoperation was 6 hours ± 20 minutes (10 minutes-23 hours), mean drainage was 914 ± 464 ml, heat was 35·3°C. Fifty (51·02%)of the patients did not have any preoperative antiaggregant or anticoagulantdrug use. Hospital mortality was approximately 13·2% (13 patients). Eight werelow cardiac output, 1 were mediastinitis, 2 were acute renal failure in earlypostoperative period and 2 patients with right and left ventricular rupture weredied for intraoperative massive bleeding.Conclusion: Reoperations are urgent and the reason for increased morbidityand mortality. Mostly, there is no specific focus of bleeding. We consider

that, providing careful surgical hemostasis, stopping the antiaggregant andanticoagulant drugs preoperative, reduce morbidity, mortality, and the need ofreoperation.

P1C-5 A Case Report : Giant Right Atrial Myxoma

M. Zengin1, Y. Ozen1, O. Bayezid1

1Department of Cardiovascular Surgery, Antalya Medicalpark Hospital, Antalya,Turkey

Objective: Right-sided cardiac myxomas are extremely rare 70% of the cardiactumors are benign and %90 of them are myxomas. 75% of the myxomas arelocated in the left atrium, more less are in the right atrium. The right atrialmyxomas have larger base attachment to inter atrial septum than the ones onthe left atrium. The rules we have to care about effect the success of surgery.Methods: In this case report, we present a case 21 years old female patientwho had admitted with weakness and fatique complaint and had been operatedwith the diagnosis of right atrial myxoma. The surgical approach to themyxoma was the right atrium. After the mild hypothermia and cardiac arrestby cold cardioplegy, it was seen a 7,5 × 3,5 × 2,5-cm mass located in the rightatrium. Complete surgical removal of the right atrial myxoma was successfullyperformed. Histologic investigations of the primary tumor revealed benignmyxoma.Results: The patients were asymptomatic and in New York Heart Associationfunctional class I in the early postoperative period up to midterm follow-up. Thesize of the resected tumor was 7,5 × 3,5 × 2,5-cm. Postoperative hospitalizationwas 5 days. Histological examination of the resected materials confirmed theechocardiographic and intraoperative diagnosis of cardiac myxoma.Conclusion: Surgical resection of the right atrial myxoma is a safe and effectivetreatment, with a low risk of recurrence. After uncomplicated resection, itprovides excellent results.

P1C-6 Retrospective case series of 18 patients with mesentericischaemia post cardiac surgery in a regional cardiothoracic surgicalcentre

Y. W. Yap1, C. W. Ho1, G. Berg2, I. Colquhoun2

1Medical School, Faculty of Medicine, University of Glasgow, Glasgow, UK2Department of Cardiothoracic Surgery, the Golden Jubilee Hospital, Clydebank,Glasgow, United Kindgom

Objective: Mesenteric ischaemia following cardiothoracic surgery is a rarecomplication, but carries a high mortality rate. The pre-operative, operativeand post-operative variables have been investigated in patients with mesentericischaemia after cardiac surgery, comparing and contrasting our data withprevious studies.Methods: A retrospective case note and database review was carried outfor patients undergoing cardiac surgery at the Western Infirmary and GoldenJubilee National Hospital (GJNH) between April 1998 and August 2009. Duringthis period, post-operative mesenteric ischaemia was reported in 18 patientsfollowing cardiac surgery from a total of 11009 cases.Results: Pre-operative factors in patients with NYHA grades of II (33%),III (28%) and IV (28%), tripe vessel disease (67%), hypertension (78%) andhyperlipidaemia (67%) were found to be the most prevailing in this patientgroup. These factors direct towards a generalized atherosclerosis process thatunderlies the pathophysiology behind mesenteric ischaemia. Post operative,poor perfusion due to prolonged mechanical ventilation and a low cardiacoutput as evident from the need for inotropic support and post operative renalfailure describes the generalised organ hypoperfusion post operative state ofthese patients.Conclusion: The incident of mesenteric ischaemia following cardiac surgeryis very low. Nonetheless, delay in identifying and treating affected patients canprove fatal. In agreement with previous studies, a highly index of suspicionis required when patients with the highlighted risk factors presented withworsening GI symptoms. A suggested management approach has been drawnup. Expeditious intervention such as mesenteric angiogram or laparotomy canoften improve chances of survival.


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P1D Gastrointestinal Surgery 1

P1D-1 Venous mesenteric infarction: preventing short bowelsyndrome by laser doppler flowmetry and spectrometry

S. Kaser1, P Abitabile, C. Maurer1

1Department of General, Visceral, Vascular and Thoracic Surgery, Hospital of Liestal,affiliated with the University of Basel, Switzerland

Objective: Laser doppler flowmetry and spectrometry are established methodsfor measuring micro vascular blood flow and oxygen utilisation of human tissues.Methods: Revision laparotomy after radical right hemicolectomy showed anextensive infarction of the small bowel. Aiming to avoid short bowel syndromewe decided to use laser doppler flowmetry and spectrometry to spare as muchbowel as possible.Results: 80 cm from Treitz’ ligament, where we initially intended to definethe dissection site, we measured good perfusion values. So we moved the probefurther distally until the range of measured values reached critical values. Thenew dissection site was located 190 cm from Treitz’ ligament. The examinationof the specimen by the pathologist showed only 5 mm of vital mucosa to be leftdistal to the dissection margin. No further interventions were necessary.Conclusion: Clinical parameters for estimating the blood supply mightbe hazardous. By means of laser doppler flowmetry and spectrometry wesuccessfully spared 110 cm of small bowel, thus probably avoiding short bowelsyndrome.To our knowledge we are the first to publish the combined application of thesemethods in a case with venous mesenteric infarction.

P1D-2 The effect of hepatic ischaemic preconditioning on intestinalischemia-reperfusion injury and level of leptin in peripheral blood

A. Demirag1, C. Sogukpinar2, N. Guvener Demirag3, A. Sepici4,N. Altan4

1Department of Surgery, Yeditepe University Hospital, Istanbul, Turkey 2Departmentof Surgery, Ankara Teaching Hospital, Ankara, Turkey 3Division of Endocrinology,Baskent University Hospital, Ankara, Turkey 4Department of Biochemistry, GaziUniversity, Ankara, Turkey

Objective: Ischaemia-reperfusion injury (IRI) of the intestine occurscommonly during solid organ procurement and continues to be a significantobstacle in small bowel transplantation. Hepatic ischemic preconditioning(HPC) provides a way of protecting the organ from damage inflicted by IR. Theaim of this study was to investigate the protective effect of HPC on intestinalIRI, development of distal organ dysfunction and to find out the role leptin (LP)in IRI.Methods: Rats were allocated to three groups: (1) sham, (2) IR (3) HPC beforeIR. Histological grading, tissue MDA, MPO and serum TNFα, LP levels wereassessed at 0 min, 2 hr, 24 hr and 48 hr of reperfusion.Results: Histological evaluation of small intestine showed that Gr.III hadsignificantly reduced inflammatory reaction compared to Gr. II (p<0·05). At2hr, 24hr, and 48hr of reperfusion, MDA and TNFα levels were significantlylower in Gr.III than in Gr.II (p=0·009). The lung MPO showed that HPCsignificantly ameliorated the lung injury induced by IRI. The serum LP in Gr IIincreased significantly compared to Gr.I at 0 min, 24 hr and 48 hr of reperfusion(p<0·05). In Gr.III, the LP were significantly lowered than Gr II at 0 min and48 h (p<0·05). The severity of histological injury showed a positive correlationwith the LP which increased less significantly in Gr III than in Gr II.Conclusion: IR-induced gut and distal organ dysfunction can be improvedby HPC. HPC can potentially be useful in organ procurement and LP has atime-and injury dependent response to acute inflammatory stimuli, acts like acytokine.

P1D-3 Appendectomy for overweight patients

T. Uchida1, K. Hirayama1, Y. Nakajima1, K. Saitou1, R. Saitou1

1Department of Surgery, Hiraka General Hospital, Maegou Aza Yatsukuchi 3-1,Yokote Akita, Japan

Objective: The influence of overweight was investigated in cases ofappendectomy for appendicitis.Methods: 242 patients with appendectomy for appendicitis in last 6 years wereclassified to two groups depending on Body Mass Index (BMI). 1: overweight,BMI was 25 or more; 2:normal, BMI was less than 25. Clinical findings, bloodanalysis, pathologic findings and complications were assessed in each group.Results: 47 (19·3%) patients were overweight. Mean BMI in each group(Overweight versus Normal) was 26·9 versus 20·8. BMI was more than 30 in only4 patients. Overweight patients ware elder, mean age was 53·4 versus 44·0 years(p<0·001); symptomatic period was longer, 1·71 versus 2·23 days (p=0·0680);CRP was higher, 8·63 versus 6·18 (p=0·0410); and blood glucose level washigher, 133 versus 124 (p=0·0383). Gangrenous appendicitis and abdominalabscess were more common in Overweight. Operation duration was longer,78·8 versus 64·1 min (p=0·0101); blood loss was more in overweight patients,51·4 versus 36·3 ml (p=0·0436). All patients had open appendectomy. Medianor para-rectal incision was more common in Overweight, 37 (73·4%) versus 112(57·5%) (p=0·0438). SSI was more common in overweight, 8 (19·0%) versus 18(9·94%) (p=0·0977). Hospital stay was same, 8·69 versus 9·44 days (NS).Conclusion: The influence of overweight was obvious even in appendectomybut it is yet relatively slight in our country. As growing number of obesepopulation, adverse influence by overweight can become clearer. Overweightpatients look like easy to advance of inflammation or difficult to diagnoseappendicitis. Social effort to prevent overweight will be needed especially formiddle-aged population in this view.

P1D-4 Overweight and hernioplasty for hernia in inguinal region

Y. Nakajima1, K. Hirayama1, K. Saitou1, S. Tsukamoto1, Y. Enomoto1,T. Uchida1

1Department Of Surgery, Hiraka General Hospital, Yokote, Akita, Japan

Objective: The influence of overweight on hernioplasty for hernia in inguinallesion was investigated. Overweight population is increasing in our country.Methods: 347 hernias in inguinal lesion (inguinal hernia or femoral hernia)treated surgically in the last four years were classified to two groups: 1.Overweight: Body Mass Index (BMI) was 25 or more; 2. Normal: BMI was lessthan 25. Clinical features, operative courses and post-operative complicationswere assessed in each group.Results: 60(17·3%) patients were overweight. Mean BMI in overweight versusnormal group was 26·6 versus 21·7. None of the patient’s BMI was more than30. Gender (80% patients were male) and age (mean age was 69 years) werealmost the same. Symptomatic period was longer in overweight, 133 versus46·9 months (p=0·231). Almost half of the hernias were right sided, 10%were bilateral. Indirect inguinal hernias were more common in overweight,21(35·0%) versus 53(19·1%) (p=0·0225), Mesh plug repairs were common withour patients. Overweight patients needed longer operation duration, 78·9 versus72·8 min (p=0·0439) and more blood loss, 20·4 versus 12·7 ml (p=0·0233). SSIand postoperative infection were same in each group. Postoperative hospitalstay was longer in overweight, 6·45 versus 5·75 days (p=0·323).Conclusion: Adverse influence of overweigh is evident even in herniolasty,which needs more indirect hernia repair, longer operation duration, more bloodloss and longer hospital stay. Severity of overweight is yet slight in our country,but these disadvantages can be more obvious as the obese patients are increasingin number.

P1D-5 Comparison Of Lovastatin And Seprafilm On ExperimentalCreated Peritoneal Adhesion Model In Rats

Y. Aritas1, E. Arslan1, A. Akcan1, I. Soyuer2, R. Saraymen3, H. Akyildiz1,E. Sozuer1

1Departments of 1Surgery, 2Pathology and 3Biochemistry, Erciyes University Schoolof Medicine, Kayseri, Turkey

Aim: The effect of Seprafilm on preventing intraabdominal adhesions has beenproven in many studies. The aim of this experimental study is to compare theeffectiveness and reliability of Lovastatin and Seprafilm.Materials and Methods: Thirty two rats were divided into four groups whichwere containing 8 rats. In the study caecum, ileum and right corn of uterus was


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abraded and created bleeding points in style and only serosal injury was createdwith the help of lancet. In sham group; caecum, ileum and right corn of uteruswas palpabled and abdomen was closed. In control group; the experimentalmodel was performed and 5 cc salin was given intraperitoneal before theclosing abdomen. In the study groups, the experimental model were performedand 30 mg/kg lovastatin and 30 × 20 mm seprafilm was applied intraperitonealrespectively before the closing abdomen. The rats were sacrificed and assesseddevelopment of adhesion. For this purpose, adhesion violence scoring andhistopathologic evaluation was used. NO (nitrous oxide), malondialdehyde(MDA) and tPA (tissue plasminogen activator) parameters were examined atbiochemical evaluation.Results: Adhesion violence score and microscopic adhesion formation weresignificantly lower at sham and study groups than control group (p<0·05).Nitrous oxide, tPA, and MDA values were statistically significant differences ingroups.Conclusion: Lovastatin and Seprafilm are equally effective to preventpostoperative intraabdominal adhesions. Study groups are showing significantsuperiority to control group.

P1D-6 A Computer (USB) assisted diagnosis of Crohn’s Disease!

C. R. Garnham1, J. I. Wilson1 and G. Kaur1

1Department of Surgery, Scunthorpe Hospital, Scunthorpe, North Lincolnshire, UK

Introduction: About 80–90% of ingested foreign bodies reaching the stomachpass through the gastrointestinal (GI) tract uneventfully, however, preexistingGI disease can predispose to complications. It is advisable to rule out underlyingGI pathology in patients who present with symptoms after ingesting a foreignbody that has not passed through. We highlight this in our report detailing aunique presentation of Crohn’s disease.Methods: A 46-year-old man presented with central abdominal pain, diarrhoeaand vomiting, associated with the inadvertent ingestion of the lid of a UniversalSerial Bus (USB) mass storage device. He was not aware of passing it in his stooland denied any previous or family history of bowel pathology. A subsequentCT scan revealed thickened terminal ileal loops with localised perforation andlymphadenopathy, suggestive of inflammatory bowel disease.Results: At laparotomy a large perforated Crohn’s mass was found with ilealperforation on the mesenteric side of the bowel. A limited ileocolic resection wasperformed. He made an uneventful postoperative recovery and was commencedon a 5-ASA medication. Histology showed marked thickening of the terminalileal bowel wall; within its lumen was a piece of clear plastic 30 mm maxdimension, consistent with the cover of a USB stick. Microscopic features wereconsistent with Crohn’s disease.Conclusion: This interesting presentation of Crohn’s disease emphasizes thenecessity of ruling out underlying gastrointestinal pathology in patients whopresent with a retained foreign body. Also, as the overall rate of perforation dueto blunt foreign body ingestion has been estimated to be less than 1%, this caseis truly unique.

P1D-7 A prospective audit of the natural history of stomas

E. Ewart1, T. Wilson1 and G. Kaur1


Introduction: There is still a high incidence of stoma formation in colorectalpractice. Surprisingly, there is very little data on stoma complications, bothimmediate and remote to the surgery. Our colorectal team of three surgeonswith 3 stoma nurses decided to perform a prospective audit of our stoma patientsto identify complications and improve our practice.Methods: The stoma nurses collected the data-60 patients so far. At the initialvisit, the stoma was inspected and described, grading each description. Thesame data was collected at discharge and at first postoperative clinic visit at6 weeks.Results: Surgery was elective in 37 patients-27 cancer, 7 diverticular diseaseand 11 IBD patients. Stomas were permanent in 15. The consultant wasthe stoma surgeon in 18 of the 28 patients that were operated on byconsultant surgeons. The main initial visit problems (28 patients) appear tobe related to separation, retraction, leakage, underactivity and bag problems.

Not unsurprisingly, at discharge, this remained largely unchanged (exceptunderactivity), since we have an enhanced recovery program, which facilitatesearly discharge. At 6 weeks, the only problems encountered (13 patients) wererelated to retraction (2), leakage (5) and bag problems (4).Conclusions: At the initial postoperative visit, 45% patients had some stomacomplications; this decreased to 22% at 6 weeks. The major problems at 6 weekswere related to bag fitting due to retraction and leakage. This audit providesinsight into the natural history of stomas and shows significant improvementin stoma problems at first clinic visit as compared to both initial and dischargevisits.

P1D-8 Critical length of the small intestine to introduce homeparenteral nutrition (HPN) in patients with Crohnfs disease (CD)having ileostomy

S. Haneda1, H. Ogawa1, K. Miura1, T. Naito1, T. Ando1, N. Yazaki1,K. Watanabe1, H. Karasawa1, C. Shibata1, I. Sasaki1

1Tohoku University Graduate School Of Medicine, Department Of Surgery, Sendai,Japan

Objective: Some patients with CD having polysurgery finally necessitateHPN because of short bowel syndrome. The aim of the present study was toinvestigate critical length of the small intestine to introduce HPN in patientswith CD having ileostomy.Methods: Medical records of 30 patients (18 men and 12 women) whounderwent surgery and have ileostomy for CD in our hospital from 1993 to2008 were reviewed.Results: Mean small intestine length was 285 ± 92 (range: 85–430) cm for allpatients. There were seven patients undergoing HPN therapy (HPN group),while remaining 23 patients were free from HPN therapy (non-HPN group).Mean age (30 ± 6·1 (19–39) vs. 28·9 ± 4·9 (21–40) years) and postoperativefollow-up period (11·4 ± 3·4 (9–16) vs. 10·6 + 4·2 (1–16) years) did not differbetween 2 groups. Length of the small intestine was 177 ± 51·8 (113–270) cmfor HPN group & 268 ± 91·8 (85–430) cm for non-HPN group, respectively(p<0·05). Four of 5 patients (80%) whose length of the small intestine wasless than 150 cm, while only three of 25 patients (12%) whose small intestinewas longer than 150 cm, needed HPN therapy. Mean number of surgery was4·4 ± 1·3 (2–6) in HPN group, while 2·2 ± 0·9 (1–4) in non-HPN group. HPNwas performed in 6 of 8 patients who underwent surgery 4 times or more.Conclusion: These results suggest critical length of the small intestine forHPN was considered 150 cm, & patients undergoing surgery for more than 4times are likely to necessitate HPN therapy in CD.

P1D-9 Clinical trial of a new pulsatile pump for cardiopulmonarybypass: preliminary findings

J. Martınez Leon1, J. Herreros2, J. Garcıa3, J. E. Vila Nunez3,J. Fontana1, E. J. Berjano4, S. Merce3

1Cardiac Surgery Department, Valencia University General Hospital, Valencia, Spain2Cardiovascular Surgery Department, Cl

´ınica Universidad de Navarra, Pamplona,

Spain 3Research and Development Department, Merce V. Electromedicina S.L.,Valencia, Spain 4Institute for Research and Innovation on Bioengineering, UniversidadPolitecnica de Valencia, Valencia, Spain

Objective: To study the clinical feasibility of the Salvapump pumping system(Merce Electromedicina, Valencia, Spain) in extracorporeal circulation duringcardiac surgery.Methods: Patients with aortic stenosis and acute coronary disease undergoingcardiopulmonary bypass (CPB) were randomly classified into two groups(18 + 18): group A with Salvapump (age 64–81 years), and group B withBiopump (Medtronic, USA) (age 65–71 years). In the group A, pulsatilecomponent of the flow was of 40 mL, while that in the group B the flow wascontinuous. Both pumps were driven by the Bio-console560 (Medtronic, USA).The most important outcome was the renal function, which was assessed by thecreatinine blood levels basal and post-CPB (24 and 96 hours). Secondarily,hepatic function was assessed by GOT, GPT, Gamma-GT and alkalinephosphatase. We also conducted a platelet analysis (count and prothrombin


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time), and additionally we measured the inflammation response by the C-reactiveprotein.Results: We present the preliminary results with four patients in Group A andthree in Group B. No differences were found in basal values between groupsfor all the measured parameters. The creatinine levels showed an increasein both groups 24 post-CPB (0·20 mg/dL and 0·28 mg/dL for groups A andB respectively) and 96 post-CPB (0·34 mg/dL and 0·19 mg/dL for groups Aand B respectively) but there was no significant differences. Platelets and liverenzymes levels decreased in both groups but without differences between them.C-reactive protein equally increased in both groups.Conclusion: The preliminary results suggest that the Salvapump system couldbe equally safe than a conventional centrifugal pump.

P1D-10 Effects of biliary and pancreatic juice diversions into the ileumon gastrointestinal motility and gut hormone secretion in consciousdogs

M. Sato1, C. Shibata1, M. Kakyo1, M. Kinouchi1, N. Tanaka1,D. Kikuchi1, F. Ikezawa1, H. Imoto1, I. Sasaki1

1Division of Biological Regulation and Oncology, Department of Surgery, TohokuUniversity Graduate School of Medicine, Sendai, Japan

Objective: The aim of the present study was to investigate the effects of biliaryand pancreatic juice diversion on upper gut motility and gut hormone secretion.Methods: Used were dogs equipped with strain gauge force transducers tomeasure upper gut moility. Dogs were divided into 5 groups; control, shamoperation, biliary diversion (BD), pancreatic juice diversion (PJD), and bilio-pancreatic juice diversion (BPD). Interdigestive and postprandial upper gutmotility was analyzed. Postprandial plasma concentrations of insulin, gastricinhibitory polypeptide (GIP), and peptide YY (PYY) were also measured.Results: Occurrence and migration velocity of migrating motor complex in theinterdigestive state was reduced in BD and BPD groups compared to the otherthree groups. In BD and BPD groups, postprandial contractions in the upper gutand the length of the postprandial contractions in the proximal jejunum, whichcorrelates with gastric emptying, was significantly short compared with otherthree groups. Plasma insulin did not differ among groups. Plasma concentrationsof GIP were suppressed in BD, PJD, and BPD groups, while plasma PYY levelwas increased in BD group.Conclusions: These results indicate that influence on upper gut motility andgut hormone secretion is greater for biliary diversion than pancreatic juicediversion.

P1D-11 The role of laparascopic cholecystectomy in alleviatinggastrointestinal symptoms

S. Mehrvarz1, S. A. Fanaei1, S. A. Ziaee2

1Department. Of Laparascopic surgery, Assosiate Prof. of Surgery, Baqyiatallah Uni.Of Medical Science, Tehran, Iran 2Emergency Department, Erfan Hospital, Tehran,Iran

Objective: Laparoscopic cholecystectomy is the standard treatment forsymptomatic gall stone disease. This study aimed to assess the effect of theoperation on patients’ symptoms.Methods: 175 unselected consecutive patients admitted for laparoscopiccholecystectomy between June 2007 and June 2008 was recruited into the study.A standard questionnaire examined pain other dyspeptic symptoms (nausea,vomiting, heartburn, food intolerance, and Globes sensation and bloating.Histories of psychiatric disturbances were also evaluated.Results: Bloating, Glubus sensation and Regurgitation was not cured bylaparoscopic cholecystectomy. The cure rates for vomiting and non typical painwere in excess of 70%.Conclusions: Our study confirms that some symptoms are not alleviatedby the operation. Furthermore, surgeons should be aware that the subgroupof patients whose preoperative symptoms include bloating, regurgitation andGlubus sensation and who have required psychotrophic drugs may in fact have‘silent gall stones’ and irritable bowel syndrome. Such patients are unlikely tobenefit from laparoscopic cholecystectomy.

P1E Gastrointestinal Surgery 2

P1E-1 The effects of exercise on portal venous systemin splenectomised adults

M. Ozban1, V. Genc1, A. Tuzuner1, S. Karaca1, O. A. Cetinkaya1,D. Oztuna2

1Department of Surgery, Ankara University Medical School, Ankara, Turkey2Department of Biostatistics, Ankara University Medical School, Ankara, Turkey

Objective: Splenectomy is a common operation in surgical clinics andrecognized as a cause of portal vein thrombosis. Intensive exercise increasesblood flow to the contracting muscles, causes hypercoagulability andvasoconstriction in the splanchnic area, hence portal vein diameter, bloodvelocity and blood flow decrease. This study was designed to assess the effectsof exercise on portal venous system in splenectomised adults.Methods: Forty adults took part in this study. Subjects had been trained to runfor 20 minutes with a velocity of 6 km/h on a 10 degree of elevated treadmill.We compared white blood cell count, portal vein diameter, portal vein bloodvelocity and portal vein blood flow between splenectomised (n=20) and healthyadults (n=20) before and after exercise.Results: After exercise blood leukocyte number was significantly increased andportal vein diameter was significantly reduced in both groups (p<0·001), butthere was no statistically significant differences between two groups. Portal veinblood velocity and flow rates in splenectomy group significantly lower than incontrol group (p<0·001). Furthermore these rates in both groups significantlyreduced after exercise (p<0·001).Conclusion: Addition to splenectomy, exercise itself may cause problemsincluding decrease of splanchnic flow and increase of blood viscosity. So thatsplenectomised adults ought to do exercises carefully.

P1E-2 Internal Hernias require a high index of suspicion for successfulmanagement

C. R. Garnham1, V. Kumar1 and G. Kaur1


Introduction: Internal hernias involve protrusion of viscera throughperitoneum or mesentery into a compartment in the abdominal cavity. They areuncommon (0·2%–0·9% of autopsies, 0·5%–4·1% of small bowel obstruction(SBO)). Pathologic defects of mesentery and visceral peritoneum, causedby congenital mechanisms, surgery, trauma, inflammation, and circulation,are potential herniation orifices. Preoperative diagnosis is difficult becausesymptoms range from intermittent mild digestive complaints to acute-onsetintestinal obstruction. Therefore, in patients suspected to have internal hernias,early diagnosis (with CT scan) and surgical intervention is indicated to reducemorbidity and mortality rates. We describe our recent clinical experience withinternal hernias and discuss their management.Methods: A 49 year old lady presented with diarrhoea, central abdominalpain and weight loss and no previous surgical history. Examination suggestedSBO. CT scan showed SBO and a pelvic caecum with ‘‘whirling’’ of branchesof mesenteric vessels - raising the possibility of SB internal herniation.Results: During laparotomy, a left paraduodenal internal hernia with ischaemicmultiply-perforated mid-jejunum and distal ileum (120 cms) was seen; resectionand a double- barrel stoma fashioned; she made a good post-operative recovery.Conclusion: Internal hernias are uncommon and rarely diagnosed preoper-atively. The most common clinical presentation is bowel ischemia with SBO.Imaging plays an important role if an accurate CT can be obtained. However,the clinical presentation may be intermittent. During asymptomatic intervals,clinical or radiologic studies may reveal no abnormality. A high index of suspi-cion must be entertained in patients with SBO due to no apparent cause sincedelay in diagnosis leads to strangulation and increased mortality.

P1E-3 COX2: A Target for Prevention and Treatment of Esophagealcancer-clinical and experimental study

N. Hashimoto1

1Kinki University, Center for Health Affairs, Ashiya, Japan


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Objectives: The incidence of esophageal carcinoma has risen dramatically inthe past 20 years. Given the dismal prognosis of this neoplasm, the developmentof preventive and novel treatment strategies is essential. We report experimentaland early clinical evidence indicating that COX2 represent a potential moleculartarget for the treatment and prevention of esophageal cancer.Method: Experiment (A): Thirty 8 week old male wistar rats were exposed toduodenal content esophageal reflux. All animal underwent an esophagoduodenalanastomosis (EDA) with total gastrectomy in order to produce chronicesophagitis. In ten rats the sham (Control). They were sacrified at the 35th

week.. Their esophagi were examined for HE, COX2 and PCNA.Clinical (B): The expression of COX2 was examined for 68 specimens ofesophageal squamous cell carcinoma (ESCC) and the correlation of COX2expression with clinicopathologic features was examined.Result: A: After 35 weeks of reflux, columnar dysplasia, squamous cellcarcinoma and adenocarcinoma were found. PCNA LI was higher in dysplasticand cancer tissue than that of normal. Overexpression of COX2 were shownin EDA group. COX2 may play an important role in esophageal cancer byduodenal content reflux.(B)COX2 immunoreactivity was weak in 27(40%) and strong in 41(60%) of thecarcinomas. This study showed that strong expression of COX2 was correlatedwith tumor progression and poor differentiation inESCC.Conclusion: Our study suggests that COX2 may play a role in esophagealcarcinoma development and progression, COX2 inhibitors may be potentialagents for the prevention or treatment of human esophageal carcinoma.

P1E-4 Assessment of inflammatory markers as diagnostic adjunctin acute appendicitis

S. Mehmood1, S. U. Rehman2, S. Anwar2, J. Ahmed2, S. Khan2,M. Tayyab1, N. El-Barghouti2, E. P. Perry2

1Academic Surgical Unit, Castle Hill Hospital, Hull and East Yorkshire NHSTrust, Hull, UK 2Department of General Surgery, Scarborough General Hospital,Scarborough and North East Yorkshire NHS Trust, Scarborough, UK

Objective: Appendicitis is the most common abdominal surgical emergency.Mainstay of diagnosis is clinical assessment. This study aims to evaluate the roleof acute inflammatory markers White Cell Count (WCC), Neutrophil Count(NC) and C-reactive Protein (CRP) in establishing the diagnosis of appendicitis.Methods: A retrospective analysis of all patients who underwent appen-dicectomy in 2008. Patients were included if two of WCC, NC and CRPwere recorded. Following values were considered high; WCC > 11 × 109/L,NC>8 × 109/L and CRP > 6 mg/L. Histological diagnosis was considered forthe purpose of Sensitivity, Specificity, Positive Predictive Value (PPV) andNegative Predictive Value (NPV) analysis.Results: A total of 101 patients were included in the study; 61 males and40 females. Median age was 29 years (range: 8 to 83). Histological diagnosiswas confirmed in 90% (n=91) thereby negative appendicectomy rate was 10%.WCC and NC were recorded in all and CRP in 95 (94%) patients. Elevatedlevels of WCC, NC and CRP had a Sensitivity of 73%, 78% and 75% witha PPV of 95%, 96% and 95% respectively. The Specificity of WCC, NC andCRP was 70%, 70% and 62% respectively. NPV of above was 22%, 26% and20%. However, Sensitivity of combined WCC, NC and CRP assessment wasconsiderably higher at 84% with specificity of 100%, PPV 100% and NPV50%.Conclusion: High sensitivity and PPV of combined measurement of threeinflammatory markers provides diagnostic accuracy in acute appendicitis.Elevated levels of an inflammatory marker alone are less sensitive and should beinterpreted with caution.

P1E-5 Home parenteral nutrition (HPN) : A Welsh experience

N. Srinivasaiah1, W. Magambo2, A. Jukes2, S. Harwood2,H. Mottershead3, R. Hargest 1, A. B. Hawthorne2

1Department of Surgery, Cardiff University, Cardiff, UK 2Department ofGastroenterology, UHW, Cardiff, UK 3Medical student, Cardiff University, Cardiff,UK

Objectives: Since establishment of HPN training in Wales, there has been arapid increase in numbers on long-term HPN, from 7·3/106 in 2002, to 20/106

currently. We review here the outcomes and complications of HPN.Methods: 50 patients have been managed at home on HPN since 2000. Datawere collected from the HPN database, electronic results reporting and clinicalnotes. Infection rates are presented for the year April 2008–Mar 2009.Results: Of the 50 patients, 8 have died (only 1 death was HPN-related(haemorrhage due to anticoagulation following multiple large vein thromboses).HPN was stopped after planned restorative surgery in 7 patients, and 2 wereable to manage on subcutaneous fluids and magnesium without HPN. Theremaining 33 are still on HPN. 19 (57·6%) female, with a median age of57 years (range 17–77).Complications: Over the year 2008–9, 6 (20%) had documented CRI. 4occurred in out-patients giving a rate of 0·43 CRI/1000 feed days, with 3 treatedwith antibiotics and catheter salvage & only 1 requiring line replacement. 2significant infective complications were cervical discitis & cervical osteomyelitis.Five patients have severe symptomatic osteoporosis with kyphosis and/orfractures. ALK and GGT were raised in 8 (24%) and 18 (54%) respectively.AST was high only in 2 (6%) patients. There was hyperbilirubinaemia withjaundice in a minority 3 (9%).Conclusion: We have had a rapid increase in Welsh patients on HPN, and ourunit has demonstrated low levels of serious complications. Metabolic sequelaeare common & require regular monitoring within a specialized service.

P1E-6 Evaluation of frequency of fecal incontinence in womenafter menopause and in men after andropause

R. Chrzan1, T. Kulpa1

1Department. of General and Oncological Surgery, District Railway Hospital,Wroclaw, Poland

Objective: The reasons of anal sphincter insufficiency may be divided intoneurogenic, intestinal, poor condition of the sphincter system and multifactorial.The most frequent reason of injuries of peripheral motor neurons is chronicvulvar nerve stretching, such a situation occurs in persons suffering fromchronic constipations and in multiparas. The reasons of intestinal originoccur in ulcerating large intestine enteritis, in Crohn’s disease, in biliary saltmalabsorption syndrome, in irritable colon syndrome and after rectal surgeries.Diseases of the sphincteral system include congenital defects, for instance,absence of sphincters or injury after infection, trauma or due to malignantinfiltration.The purpose of this work was evaluating the frequency of fecal incontinencesymptoms in men and women diagnosed and treated in the local hospital.Methods: a group of 46 men and women treated and diagnosed in the localcentre in 2007 was examined. In addition, they suffered from fecal incontinence.Their average age was 68·4±8 years for women and 66·2 ± 7 years for men.Studies were performed in the form of an author’s anonymous survey. Thepatients were asked about occurrence of constipations, symptoms of intestinalsphincteral insufficiency and defects of the sphincteral system according tothe reasons mentioned above. The women were additionally asked about thenumber of former deliveries. The degree of gas and fecal incontinence intensitywas evaluated according to the Wexner scale. Statistical analysis was performedby means of the t-Student test.Results: it was found that fecal incontinence was more frequent in womenwho gave birth by natural forces three or more times. By comparing a group ofwomen who did not give birth by natural forces or, in general, with a group ofmen, no statistical differences in the occurrence of the disease were found. Inboth sexes the frequency of fecal incontinence was found to increase in personswith senile dementia and with the irritable colon syndrome.Conclusions: the number of natural deliveries, dementia and irritable colonsyndrome does not result in a significant increase of the frequency of fecalincontinence symptoms.


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P1E-7 Learning from the reconstruction of a catastrophic abdomen

J. Ceballos1, C. Rosas1, E. Lopez-Tomassetti1, J. R. Hernandez1,V. Nunez1

1General Surgery Department, Hospital Insular de Gran Canaria, Las Palmas deGran Canaria, Spain

Objective: Unnoticed traumatic injuries produce avoidable morbidity,mortality and a higher medical cost. This is an oral presentation of thereconstruction of a catastrophic abdomen.Method: We present a 26 year old woman with blunt thoraco-abdominaltrauma secondary to a road traffic accident. Despite several lower left rib, L1and L2 fractures; a fast echo without solid organ injury was seen. On the thirdday, surgery was required due to septic shock with diffuse peritonitis. Simplesuture of a jejunal laceration, distal pancreatectomy due to body-tail section andpacking without closure of the abdomen was performed. She developed severalintestinal and colonic fistulae. Over 40 surgical procedures were performed andshe was discharged 9 months later with parenteral nutrition, a closed abdomenby secondary intention and intestinal fistulae. She was readmitted a year laterfor reconstruction. We performed monoblock resection of the abdominal walland the fistulized loops, subtotal colectomy and bowel transit reconstructionwith three enteroenteric and an ileosigmoid anastomosis, leaving 1,8 m of smallbowel. Abdominal plastia with Permacol mesh was also performed.Results: Surgical time was 420 minutes, oral tolerance was initiated on the 7th

postoperative day. She was discharged on the 14th day postop. Fever secondaryto infection of a central venous catheter on the 3rd day was the only complication.Conclusions: Treatment of the consequences of unnoticed traumatic injuriesis a great challenge for the surgeon. The proper timing, approach and correcttechnique are pivotal for success.

P1E-8 Stomas and pregnancy – controversies in management

G. Kaur1

1Scunthorpe General Hospital, Scunthorpe, North Lincs, UK

Introduction: Pregnancy in women with stoma poses some challenges. Fewobstetricians have experience of the pregnant ostomate. Likewise, few colorectalsurgeons have much experience of managing stomas during pregnancy. Wepresent the course of pregnancy of two of our stoma patients and review stomaproblems during pregnancy.Methods: One was an ulcerative colitis patient who fell pregnant after totalcolectomy/ileostomy prior to pouch formation. She had recurrent subacute smallbowel obstruction in last trimester. She was successfully managed conservatively;later vaginally delivered at term. We also report a successful pregnancy in apatient with a colostomy; she had undergone parastomal hernia repair andconversion to end colostomy of a hugely prolapsed sigmoid loop colostomy thathad been fashioned following rectal injury during a previous caesarean section.We closely monitored her uneventful pregnancy and planned caesarean section.Results: Stomal problems that occur during pregnancy include intestinalobstruction, stoma prolapse, narrowing and bleeding. These can usually bemanaged conservatively. As the abdomen enlarges, the stoma may changeshape, become oval and become shorter or longer. It may be necessary tochange the pouch type to avoid damage to both skin and stoma. When thebaby’s head is directly beneath the stoma, routine ultrasound scans performedduring pregnancy may not be easy, necessitating vaginal scan.Conclusions: Literature search revealed scarce information about stomas inpregnancy. Early antenatal care requires extra vigilance for pregnant womenwith stomas. Coloproctologists and obstetricians should also both be awareof the potential complications of this high-risk pregnancy and delivery; theirinterdisciplinary cooperation is essential for a successful outcome.

P1E-9 Comparison of laparoscopic versus open repair of herniaof the groin

S. A. Fanaei1, B. Khorasani 2, S. A. Ziaee 3

1Baqyiatallah University of Medical Science, Tehran, Iran 2Uni of Welfare&Rehabilitation Science, Tehran, Iran 3Erfan Hospital, Emergency Department,Tehran, Iran

Background: There is a controversy in repair of inguinal hernia. In this studywe compare of laparoscopic technique with open in terms of recurrence andcomplication.Methods: We randomly assigned men with inguinal hernias at 281 patientsto either open mesh or laparoscopic mesh repair. The primary outcome wasrecurrence of hernias at one year. Secondary outcomes included complications.Results: Of the 281 patients who were randomly assigned to one of the twoprocedures, Recurrences were more common in the laparoscopic group (3 of 133patients [2·2 percent]) than in the open group (1 of 148 patients [0·6 percent];.The rate of complications was higher in the open-surgery group than in thelaparoscopic-surgery group. The laparoscopic-surgery group had less pain thanthe open-surgery group on the day of surgery and at two and trhee weeks andreturned to normal activities one day earlier.Conclusions: The laparoscopic technique is superior to the open techniquefor mesh repair of primary hernias

P1E-10 Controversies In The Management Of Anal IntraepithelialNeoplasia

J. I. Wilson1, G. Kaur1

1Department of Surgery, Scunthorpe General Hospital, Scunthorpe, UK

Introduction: The natural history of anal intraepithelial neoplasia (AIN) isuncertain. It is believed to be a precursor of squamous cell cancer (SCC)with increasing incidence in certain high-risk groups. Treatment of AIN hascomplications; despite treatment, invasive cancers do occur. Follow-up has beenattempted with SCC tumour-associated antigen, CEA, anal-rectal cytology,with little success. This study reviews our experience with the managementof AIN.Methods: All patients with a diagnosis of anal SCC, AIN (I–III), Bowen’sor Paget’s disease were followed-up with 6 monthly full-thickness clockfaceanal biopsies. EUA rectum and punch biopsies were performed under generalanaesthetic. Predisposing and localized lesions were completely excised. Allpatients underwent outpatient follow-up 6–8 weeks postoperatively.Results: Only one of our cohort of patients is immunocompromised (HIVpositive). One patient with previous SCC had synchronous Bowen’s disease; 2others had anal condylomata and were found to be HPV positive. One patientexperienced delayed wound healing (post Radiotherapy). We have not identifiedany new SCC within our patient group; 3 patients progressed from low gradeAIN to AIN III.Discussion: AIN III has a low potential for malignant transformation inimmunocompetent patients; immunosuppressed and HPV positive patients aremore likely to have extensive AIN III and greater risk of malignant change.Surgery is associated with significant morbidity and recurrence. The anorectalsurgeon must maintain a high index of suspicion when evaluating lesions of theanus. There is no standard management for AIN. Long-term follow-up of thesepatients is essential until the natural history of AIN becomes clearer.

P1F Hepatobiliary and Pancreatic Surgery 1

P1F-1 Determination of minimal residual disease in pancreatic cancer- clinical benefit

D. Klos1, J. Srovnal2, M. Lovecek1, M. Hajduch2, C. Neoral1, R. Havlik1

1University Hospital Olomouc, Palacky University Olomouc, Department of SurgeryI., Czech Republic 2University Hospital Olomouc, Palacky University Olomouc,Department of Pediatrics, Laboratory of Experimental Medicine, Czech Republic


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Objective: The minimal residual disease (MRD) in patients with pancreaticcancer is definated as the presence of isolated tumor cells in the patient’s body,in which the primary tumor was removed and is currently without clinical signsof disease. These isolated tumor cells we can describe as the precursors ofmicrometastases. Assessment of MRD in patients with this highly malignantdisease could eliminate burdensome implementation of surgery in patients withsystematic dissemination of molecular disease and more precise prognosis.Methods: The study to date included 72 patients operated on with curativeintent for carcinoma of the pancreas. The method of real-time PCR to measurethe expression of hTERT (telomerase), EGFR1 (receptor for epidermal growthfactor) and CEA (carcinoembryonic antigen) examined samples of peripheraland portal blood, bone marrow, and peritoneal lavage and the tumor. Readingsexpression of markers tested were correlated of with clinicopathologicalcharacteristics and survival parameters.Results: We found a statistically significant assosiation between EGFRexpression levels in the portal blood and clinical stage – patients with advanceddisease have a higher expression of EGFR in the portal stream and the peritoneallavage in contrast to patients without the presence of metastases.Conclusion: The results of this pilot study demonstrated a high sensitivityand specificity of the RT-PCR method for detection of circulating tumor cellsin patients with pancreatic cancer, extending this methodology, we are able toprovide prognostic value of minimal residual disease and its significance for theindication of radical surgery for pancreatic cancer.

P1F-2 Operative experience of traumatic liver injuries in a tertiaryhospital in Singapore over the last decade

J. Ong1, A. Chung1

1Department of General Surgery, Singapore General Hospital, Singapore

Objective: A retrospective review of all patients who underwent surgery fortraumatic liver injuries over a period of ten years in the Singapore GeneralHospital was done to audit and analyse our operative results, paying particularattention to factors that may impact survival.Methods: The trauma registry and hospital records of patients with traumaticliver injuries were reviewed. Patient demographics, mechanism of injury, gradeof liver injury, injury severity score (ISS), abbreviated injury scale of othersystems (AIS), blood pressure on arrival, Glasgow Coma Scale (GCS) on arrival,findings on laparotomy, type of laparotomy procedures performed, duration ofhospital stay and ICU stay were extracted, analysed and correlated with survival.Results: 61 patients with traumatic liver injuries underwent laparotomy in thisperiod. 51 patients had low grade liver injury while 10 patients had high gradeliver injury. Statistical analysis revealed that patients who suffered from blunttraumatic injury, were hemodynamically unstable after injury, had a GCS ≤ 8on arrival, ISS ≥ 25 as well as patients with severe head injury or chest injury(AIS ≥ 4) were more likely to die. (P<0·05) Grades of liver injury and the typeof laparotomy procedure performed were not significant prognostic factors forsurvival.Conclusion: The mortality of patients seen in our centre tends to be due toexsanguinations and concomitant injuries rather than related to the liver injuryitself. Attention must be paid to prevent deaths from concomitant injuries inpatients with traumatic liver injuries.

P1F-3 Routine gastrostomy tube for gastric decompression in 55consecutive pylorus-conserving pancreatoduodenectomy: safetyand efficacy retrospective analysis.

E. Hornez 1, L. Beyer 2, T. Monchal 1, R. Calvary 1, V. Moutardier 2,C. Brunet 2, S. V. Berdah 2

1Department of Digestive Surgery, HIASainte-Anne, Toulon, France 2Departmentof Digestive Surgery, Hopital Nord, Marseille, France

Objective: A retrospective study was performed to assess the performance, thesafety and the tolerance of a routine gastrostomy for gastric decompression inpylorus-conserving pancreatoduodenectomy.Background: Delayed gastric emptying is the most frequent post-operative complications after duodenopancreatectomy and prolonged gastricdecompression is a commonly admitted procedure. The nasogastric tube is

commonly used for gastric decompression but has been associated with manyinconveniences for patients.Methods: A retrospective study was performed in a non selected serie of 55consecutive patients. All patients with a peri ampullary mass were treated by apancreaticoduodenectomy and a drainage gastrostomy was performed routinely.Elective data concerning the drainage gastrostomy were analysed.Results: All patients had a pancreaticoduodenectomy with a per-operativegastrostomy tube for gastric decompression. The mean time for stomachdrainage was 17 days. The median time for oral fluid intake was 11 days. 11patients (20%) presented a delayed gastric emptying. No patients needed anasogastric tube insertion due to a dysfonctionning of the gastrostomy. Therewas no elective complication due to the gastrostomy.Conclusions: Gastrostomy is a safety and effective way for gastricdecompresion after pylorus saving duodenopancreatectomy. Its routine per-operative placement permits the treatment of prolonged DGE. The electivecomplications due to GT are rare and the patient’s acceptance good.

P1F-4 Effects of the estradiol on the necrotizing pancreatitis in rats

E. Alhan1, S. Turkyylmaz1, C. Ercin2, B. Kural1

1Karadeniz Technical University, Medical Faculty, Department Of Surgery, Trabzon,Turkey 2Kocaeli University, Medical Faculty, Department of Pathology, Kocaeli,Turkey

Objective: The aim of this study was to investigate the influence of estradiolon acute necrotizing pancreatitis (ANP) in rats.Methods: ANP was induced by an intravenous infusion of cerulein5 µg/kg/hour over six hours superimposed on a standard infusion of 1·2 ml/kgglycodeoxycholic acid 10 mmol/L into the biliary-pancreatic duct for 10 minutesat 30 mm Hg. The rats were divided into four groups. Sham + saline, Sham+ estradiol, ANP + saline and ANP + estradiol. Research parameters aremortality rate, blood pressure, urine output, blood gas, pancreatic functionalcapillary density (FCD) with orthogonal polarization spectral imaging system,serum amylase, urea, calcium, alanine transferase (ALT), interleukin 6 (IL6),lactate dehydrogenase (LDH) in broncoalveolar lavage (BAL) fluid, pancreatichistology and tissue activity of myeloperoxidase (MPO) and malondialdehyde(MDA) in the pancreas and lung.Results: The induction of ANP resulted in a significant increase in mortalityrate, pancreatic necrosis and serum activity of amylase, ALT, LDH in BAL,IL6, serum concentration of urea, tissue activity of myeloperoxidase (MPO) andmalondialdehyde (MDA) in the pancreas and lung, and a significant decrease ofconcentrations of calcium, blood pressure, urine output, p02 and FCD. The useof estradiol did not change these changes.Conclusions: Estradiol demonstrated no effect on the course of ANP in rats.Therefore, it has no value in the treatment during acute pancreatitis in rats.

P1F-5 Clipless technique of cystic duct closure using the harmonicscalpel: Experimental clinical study

B. Kavlakoglu1, R. Pekcici2, S. Oral1

1Divison of General Surgery, Ankara Oncology Training and Research Hospital,Ankara, Turkey 2Divison of General Surgery, Ankara Training and ResearchHospital, Ankara, Turkey

Objective: Harmonic scalpel(HS) using on other structures was started otherthan blood vessels with little data about their efficacy or safety. The excellentresults of HS for closure of blood vessels encouraged surgeons to use theseinstruments for other structures like bile ducts. As a result, this study was tocompare between the safety and efficacy of HS and surgical clip in achievingsafe closure of the cystic ducts after the laparoscopic cholecystectomy.Methods: In this study, 60 patients were operated with laparoscopic technicand gallbladers were divided into two groups(n=30). Gallbladders were removedin first group with surgical clips(SC) and in second group(HS) with sealed cysticduct. Then twenty gauge catheters were applied to fundic parts of gallbladderand fixed with 3/0 silk sutures ex-vivo and catheters were connected to thearterial line transducer set. Bursting pressures were measured. Results werewritten down to SPSS table. Differences between HS vs SC group werecalculated with paired-samples t-test.


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Results: In this study, the mean cystic duct bursting pressures were332·46 ± 4·62 mm Hg with SC and 343·06 ± 4·28 mm Hg with HS. Differencesof the mean cystic duct bursting pressures between HSvsSC groups wereindicated HS’s superiority.Conclusions: .HS sealer could be an alternative method for cystic duct closureavoiding the clip displacement and migration of the clip. HS technique was asreliable as SC technique and was up to the accepted standard in our set up ascompared to national and international data. Single device usage was one of themost important advantages of this technique.

P1F-6 A serious look at safe and effective maneuvers of open surgeryin the era of laparoscopic cholecystectomy. Harmonization with opensurgery.

S. Nazari1,2,3, S. M. Khosroushahi1, J. Rezaii8, S. H. Saba7, A. Amini4,5,S. Agah6, H. Khedmat6, H. R. Sarie6

1Department of Surgery, Erfan Hospital, Tehran, Iran 2Department of Surgery,Madaen Hospital, Tehran, Iran 3Department of Surgery, Milad Hospital, Tehran,Iran 4Department of Emergency medicine, Imam Hosain Hospital, Tehran, Iran5Department of Emergency medicine, Erfan Hospital, Tehran, Iran 6Department ofGastroenterology, Erfan Hospital, Tehran, Iran 7Department of Internal Medicine,Erfan Hospital, Tehran, Iran 8Department of Surgery, AmirAlam Hospital, Tehran,Iran

Background: Isolation of the cystic duct is the first dangerous part inlaparoscopic cholecystectomy (LC). In LC, bile duct injuries are greater thanopen surgery, yet. Nowadays, many surgeons prefer to do LCs in patients withhigh levels of difficulties. Now, acute cholecystitis, gangrenous gallbladders,Mirrizi syndrome, gallstone pancreatitis are not absolute contraindications forLC. So, it seems that the incidence of bile duct injury in LC rose again,today, in the hands of expert laparoscopic surgeons. In conventional opencholecystectomy, maneuvers like fundus-down approach (FDA) and partialcholecystectomy (PC) are well recognized safe procedures during difficultcholecystectomies (DC) because it minimizes the risks of damage to thestructures in or around Calot’s triangle. In spite of this, FDA and PC arenot widely practiced in LCs.Methods: The purpose of this study was to evaluate the feasibility and safety ofPC and FDA in DCs. The study included 540 patients treated over 36 monthswho underwent LC by one surgeon. The inclusion criterion was the presenceof ultrasound proven gallstones.Results: FDA was started in 45 patients; 40 procedures were completedlaparoscopically. Five of the cases were further converted to open surgery.PC was done in 24 patients; all PCs were completed laparoscopically. Themean operative time was 95–130 minutes, which is significantly greater thanconventional LC (range 20–40 minutes).PC and FDA were performed withoutimmediate or late complications.Conclusion: FDA and PC appear to be safe procedures, and have the potentialsto decrease the risk of injury to bile ducts and reduce the conversion rate inDCs.

P1F-7 The portal vein contributes significantly to blood flow throughthe peribiliairy plexus

J. C. Slieker1, J. de Jonge1, W. R. Farid1, C. H. van Eijck1, G. Kazemier1

1Department of Surgery, Erasmus Medical Centre Rotterdam, Netherlands

Introduction: Biliairy complications are a common cause of graft loss afterliver transplantation. Their occurrence is partly attributed to hepatic arterythrombosis. However, it is unknown whether disturbances in the portal venousblood flow contribute to the formation of biliairy lesions. The aim of this studywas to analyze the contribution of the portal vein to the blood flow in theperibiliairy plexus.Methods: Blood flow in the peribiliairy plexus was determined in 12 patientsundergoing pancreaticoduodenectomies. In this procedure the common bileduct (CBD) is transected as it is in liver transplantation. The blood flow throughthe CBD was measured combining laser Doppler flowmetry and reflectancespectrophotometry. Blood flow was measured during baseline situation, after

clamping the portal vein, clamping the hepatic artery, and clamping both. Aftertransection of the CBD these four measurements were repeated.Results: Compared to baseline measurements the blood flow through theCBD decreased by an average of 31·8% after clamping the portal vein, 48·7%after clamping the hepatic artery, and 67·5% after clamping both. Once theCBD was transected, the blood flow decreased by an average of 36·8%, 67·1%,and 77·9% respectively. All the procentual changes in blood flow compared tobaseline measurements were statistically significant.Conclusion: Historically, the hepatic artery was considered solely responsiblefor biliairy blood flow. We show that the portal vein contributes to an importantpart of the blood flow through the CBD, even when the hepatic artery is open.This study emphasizes the importance of the portal vein with regard to theblood flow through the peribiliairy plexus.

P1F-8 Hepatectomy for metastases from gastric cancer: Analysisof indication for favorable results

H. Kiyochi1, S. Kajiwara1, K. Okada1, K. Yamamoto1, Y. Imai1, E. Ito1,N. Ishida1, M. Yamashita1, K. Tamura1, Y. Ueno1

1Department of Surgery, Uwajima City Hospital, Ehime, Japan

Objective: Patients with liver metastasis from gastric cancer are rarelycandidates for local therapy, and the criteria for hepatic resection has notbeen clarified. The purpose of this study was to assess our outcome of hepaticresection for hepatic metastases of gastric cancer and to identify suitablecandidates for hepatectomy.Methods: Patients who underwent hepatectomy for hepatic metastases ofgastric cancer between 1990 and 2006 at our institute were assessed regardingthe survival rate and the clinicopathological factors of prognostic value; age,gender, Departmenth of invasion and hisitological differentiation of primarylesions, grade of lymph node metastasis, number of hepatic metastases, timingof operation: synchronous or metachronous.Results: The number of patients who underwent hepatectomy for gastricmetastasis was 12, which comprised 0·8% of the total number of patients whounderwent operation for gastric cancer.The overall 5-year survival rate after hepatectomy was 27·8% and two patientssurvived for more than 10 years without recurrence. The post operativerecurrence rate was 66·7% and all recurrent cases died within 2 years afterhepatectomy. The number of metastases, less than 3, was the only significantfactor for the favorable prognosis. Age, gender and the factors associated withprimary lesion including the Departmenth of invasion, differentiation and lymphnode metastasis were not significant.Conclusion: In conclusion, hepatectomy for hepatic metastases is beneficialfor the patients properly selected. Less than 3 metastases is a good indicationfor hepatectomy.

P1F-9 Importance of evaluating preoperative degree of ER stress forhepatectomy – Effect of experimental ER stress on liver regenerationin mice

K. Kudoh1, H. Uchinami1, M. Kume1, Y. Yamamoto1

1Department of Gastroenterological Surgery, Akita University Graduate School ofMedicine, Akita, Japan

Objective: Recently liver resections in patients after preoperative chemother-apy and/or with steatohepatitis have been increasing. It is known that thelivers of these patients are damaged by endoplasmic reticulum (ER) stress. Weinvestigated whether ER stress affected liver regeneration after hepatectomy.Methods: C57/BL6J mice were injected with TM (0·25, 0·5, and 1·0 mg/kg)or vehicle intraperitoneally. Induction of ER stress in the liver by TM wasconfirmed by a BiP expression using Western blot. Transcripts of HGF andcMet in the liver and the serum level of HGF were quantified by real timeRT-PCR and ELISA, respectively. After 48 hours of TM injection, 70%hepatectomy was performed. Liver regeneration was assessed by a liver/bodyweight ratio (LBWR) and BrdU incorporation. Apoptosis was evaluated byTUNEL staining.Results: Forty-eight hours after TM injection, mRNA of HGF and cMetin the liver and serum HGF were increased significantly in every dosage.


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In the 0·25 mg/kg TM-treated mice, LBWR and BrdU incorporation werehigher than those in the control mice. However, the mice treated with 0·5 and1·0 mg/kg TM died in early period after hepatectomy, and their survival ratewas 50% and 0%, respectively. Massive apoptosis of hepatocyte was confirmedin the remnant liver of these mice.Conclusions: ER stress by TM induced regenerative factors like HGF andcMet but low- and high-dose TM has opposite effect on liver regeneration.Although severe ER stress was harmful, moderate one enhanced liverregeneration. These data suggested an importance of evaluating preoperativedegree of ER stress for the safety of liver resection.

P1G Hepatobiliary and Pancreatic Surgery 2

P1G-1 Enhanded restitution of the liver volume by adeno-mediatedhuman Bcl-xL gene transfer in a mouse model of 70% hapatectomy

T. Fujita1, T. Tohyama1, K. Honda1, Y. Takada1

1Department of Hepato-biliary-pancreatic Surgery and Transplantation, EhimeGraduate School of Medicine, Ehime, Japan

Objective: Liver regeneration is an important factor which decides theprognosis of the patients in liver surgery, as well as in management of variousliver diseases. The human Bcl-xL gene was introduced into the mouse liverusing a newly developed adenovector to investigate the role of anti-apoptoticBcl-xL protein in liver regeneration.Methods: C57BL mice (n = 6) received intravenous injections of AxCAhBcl-xL (Bcl-xL group), Null adenovector (Null group), or PBS (PBS). Three daysafter injection, the mice underwent 70% hepatectomy. The residual liver andblood samples were collected 1, 3, 5, and 7 days after hepatectomy. The liverweight was measured and the restituted liver mass was calculated. PCNA index,serum TNF-alpha, serum TGF-beta 1, and liver tissue HGF were estimated.Changes of the expression of aurora kinase A, TPX2, PRC1, and aurora kinaseB, which were selected by expression profiling using a RNA microarray, weredetermined by real time PCR.Results: The restituted liver mass of the Bcl-xL group was larger than thePBS group and the Null group at day 5 and day 7. The expression of PRC1was extremely elevated at day 1 and gradually decreased, while aurora kinase A,TPX2, and aurora kinase B tended to increase in the Bcl-xL group.Conclusion: The overexpression of Bcl-xL in the mouse liver enhanced therestitution after 70% hepatectomy. Different from the 3 other genes, PRC1 wasexcessively expressed at day1 after hepatectomy.

P1G-2 Management of hepatocellular adenoma during pregnancy

S. M. van Aalten1, J. E. Noels1, D. J. van der Windt1, N. F. M. Kok1,R. A. de Man2, T. Terkivatan1, J. N. M. IJzermans1

1Department of Surgery, Erasmus Medical Centre, Rotterdam, Netherlands2Department of Hepatogastroenterology, Erasmus Medical Centre, Rotterdam,Netherlands

Objective: To establish the management of hepatocellular adenoma (HCA)during pregnancy based on our own experience and literature.Methods: Twelve women with documented HCA were closely monitoredduring a total of 16 pregnancies between 2000–2009. Their files were reviewed.Results: In 4 cases HCA’s grew during pregnancy, requiring a Caesareansection in 1 patient (2 pregnancies) at 36 and 34 weeks because of an assumedhigh risk of rupture. In 1 case radiofrequency ablation therapy was used in thefirst trimester of pregnancy to treat a hormone sensitive HCA, thereby excludingpotential growth later on in pregnancy. No intervention was performed in theother cases and all pregnancies had an uneventful course with a successfulmaternal and fetal outcome.Conclusion: HCA in pregnant women requires special considerations becauseof the risk of hormone induced growth and rupture of the adenoma. As thebiological behavior may be less threatening than presumed, a wait and seemanagement may be advocated in pregnant women presenting with a HCA.In women who have large tumours or experienced complications of HCA inprevious pregnancies, surgical resection may be recommended. Thus it may nolonger be necessary to discourage pregnancy to women with smaller adenomas.

P1G-3 Results of 2000 cases of Laparoscopic cholecystectomy

K. Tamura1, H. Kiyochi1, S. Kajiwara1, K. Okada1, Y. Imai1,K. Yamamoto1, E. Ito1, N. Ishida1, M. Yamashita1, Y. Ueno1

1Department of Surgery, Uwajima city Hospital, Uwajima, Japan

Objective: Less invasive laparoscopic cholecystectomy (LC) has becomethe standard surgical approach to cholecystectomy. Here, we examined theoutcomes of 2000 LC procedures over a period of 16 years at our institutionto determine whether LC is effective for treating acute cholecystitis on anemergency basis.Methods: We analyzed the age, sex, surgical duration, length of hospital stay,original diseases, complications and conversion rates among 2000 patients whounderwent LC at our institution between July 1991 and December 2007. Wealso compared the outcomes of the first 1000 (early) with the latter 1000 (late)procedures.Results: The mean age of all of the patients was 60·6 ± 14·6 years (range, 12to 104 years) and they comprised 1108 females and 892 males. The averagesurgical duration was 78·8 ± 40·4 minutes (range, 25 to 335 minutes). The meanhospital stay was 14·6 ± 9·3 days. The overall conversion rate was 7·8%. Themajor intraoperative complications included gallbladder perforation (14·6%)and damage to the bile duct (0·6%) and intestine (0·3%). Major postoperativecomplications included infection at the surgical site (0·9%), bile leakage (0·7%)and bile duct stenosis (0·05%).Incidence of cholecystitis increased among the 1000 late patients (28·7% vs.16·8%), but the average surgical duration and length of hospital stay weresignificantly shorter, and the amount of postoperative complications decreased.Conclusions: Indications for LC have expanded from simple cholelithiasis tocomplicated acute cholecystitis. However, outcomes have improved and LC hasbecome an essential emergency procedure at our institution.

P1G-4 Cystic duct stones - a basis to transductal cholangiogramand common bile duct exploration

A. Bhattacharjee1, T. R. Lazim1, A. Rasheed1

1Department of General Surgery, Royal Gwent Hospital, Newport, UK

Objectives: Establishing basis of selective per operative cholangiography(OTC) and common bile duct (CBD) exploration by correlating incidence ofcystic duct (CD) and CBD stones.Methods: Data of 240 elective laparoscopic cholecystectomy patients for2007–2008 was prospectively collected. CD was skeletonised during eachoperation to demonstrate its course and junction with CBD; it was milked withits contents towards gall bladder and excised to ensure free flow of bile priorto application of clips. OTC was performed in all cases revealing stones/sludgefrom excised CDs. OTC showing filling defect or dilatation of CBD hadtrans-cystic exploration or simple manipulation i.e saline flush and glucagoninjection.Results: 39 patients (16%) revealed CD stones and/or sludge during routinelaparoscopic cholecystectomy. CDs in 16 patients were visibly dilated - 13showed concomitant CBD dilatation/filling defect on OTC, 10 of which hadlaparoscopic radiological trans-cystic exploration of CBD - eight revealedstones, two did not, two failed and had to be opened;. These two patients hadpost operative ERCP- one revealed multiple stones. Three cases had stonesflushed with saline and glucagon injection after OTC with post operative ERCPrevealing no stones.Conclusions: CDs should be routinely skeletonised, milked and excised duringlaparoscopic cholecystectomies to reveal their contents prior to application ofclips. If contents reveal stones and/or sludge after excision, OTC is imperativeto investigate CBD stone/sludge. A per-operative trans-cystic manipulation orexploration is usually successful in clearing these obstructions. This can minimiserisks of potential complications from extra hepatic biliary tree obstruction bygall-stones in cases of laparoscopic cholecystectomies.


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P1G-5 Recombinant Adiponectin Treatment Ameliorates Acute LungInjury In Acute Pancreatitis In Rats

M. Kerem1, H. Pasaoglu2, K. Dikmen1, M. Alper3, O. Pasaoglu2,O. Sakrak1

1Gazi University Medical Faculty, General Surgery Department, Ankara, Turkey2Gazi University Medical Faculty, Biochemistry Department, Ankara, Turkey3Diskapi Education and Training Hospital, Department of Pathology, Ankara, Turkey

Objective: Serum adiponectin, the primary anti-inflammatory adipokine, isassociated with functional polymorphisms in the adiponectin and inverselyassociated with severe acute pancreatitis. The aim of this study was to determinethe effects of recombinant adiponectin on Acute Lung Iinjury associatedwith AP.Methods: Rats were randomly divided into 3 groups. Animals were given asingle intraperitoneal (i.p.) injection of 2 ml saline in the sham group. AP wasinduced by the i.p. injection of cerulein (50 µgr/kg) four times, at 1-h intervals.Rats received a single i.p. recombinant adiponectin (RA) (RA group) or 2 mlsaline (AP group) after cerulein injections. Experimental samples were collectedfor biochemical and histological evaluations at 24 h and 48 h after the inductionof AP or saline administration.Results: Cerulein injections resulted in severe AP. In the RA group, serummacrophage inflammatory peptide, soluble intercellular adhesion molecule-1,tumor necrosis factor-α, and interleukin-1β levels, pancreatic myeloperoxidaseactivity, CD40 expression in pancreas and lung tissues, and nitric oxide level inthe lung tissue were lower compared to those in the AP group. Histologically,there was reduced pancreatic and lung damage following RA administration.Conclusion: These results suggest that exogenous RA attenuates inflammatorychanges, and reduces pro-inflammatory cytokines, nitric oxide levels, and CD40expression in cerulein-induced AP and may be protective in AP associated ALI.

P1G-6 Expression and Significance of Integrin Linked Kinasein Pancreatic Carcinoma

X. Cong1, G. Ma1, R. Shi1, Y. Cheng1, N. Liu1

1Department of General Surgery, First city hospital of Shenyang, Dadong DistrictShenyang, China

Objective: To explore the expression and clinical significance of IntergrinLinked Kinase (ILK) in pancreatic carcinoma.Methods: Intergrin Linked Kinase (ILK) protein was detected by immuno-histochemistry and western blotting in 60 cases of pancreatic carcinoma and 32cases of normal pancreatic tissue, and their relationship to clinicopathologicalcharacteristics were analyzed.Results: (1) The positive rate of Intergrin Linked Kinase (ILK) protern was65%(39/60) in pancreatic carcinomas is stronger than 18·75% (6/32) in normalpancreatic tissues(P < 0·05). (2) In pancreatic carcinomas, the expression ofIntergrin Linked Kinase (ILK) was correlation to clinical stage and lymphmetastasis(P < 0·05), and noncorrelation to differentiation(P > 0·05).Conclusion: The level of Intergrin Linked Kinase (ILK) protern in pancreaticcarcinomas is stronger than in normal pancreatic tissues. Intergrin LinkedKinase (ILK) plays an important role in adhesion and invasion of pancreaticcarcinoma, the expression of Intergrin Linked Kinase (ILK) was correlation totumor grade. Detected the expression of intergrin linked kinase (ILK) may playan important role in the diagnose and therapy of pancreatic carcinoma patients.

P1G-7 Splenectomy ameliorated established murine hepatic fibrosisinduced by thioacetamide administration for a long period

A. Yada1, Y. Iimuro1, T. Okada1, Y. Yoshida1, K. Suzumura1,N. Uyama1, T. Sugimoto1, S. Saito1, T. Hirano1, J. Yamanaka1,J. Fujimoto1

1Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan

Objective: We have reported that laparoscopic splenectomy is useful totreat patients with hypersplenism induced by HCV-related liver fibrosis. Inthese patients, liver function reserve seems to be improved in addition to theattenuation of thrombocytopenia. However, whether established hepatic fibrosis

is really ameliorated by splenectomy or how the fibrosis is attenuated is stillobscure. The aim of present study was to investigate the effect of splenectomyon established hepatic fibrosis in an animal model.Methods: To induce hepatic fibrosis, thioacetamide (TAA) (300 mg/L) wasadministrated to male C57BL6 mice in drinking water for 32 weeks. Afterthe TAA treatment, splenectomy was performed with mini-laparotomy underanesthesia. After the splenectomy, TAA administration was continued. Themice were sacrificed 1, 7, and 28 days after the splenectomy, and blood samplesand liver tissues were collected. TAA-treated control mice underwent shamoperation. Changes in platelet counts and liver fibrosis after splenectomy wereassessed.Results: TAA-administration for 32 weeks induced remarkable hepaticfibrosis including bridging fibrosis between portal area and central veins,and significantly decreased platelet counts (pre 1054 × 103/mm3; post 805 ±195 × 103/mm3, P<0·05) After the splenectomy, platelet counts significantlyincreased compared to those in the TAA control mice at day 7 (TAAcontrol 878·5 ± 115 × 103/mm3; TAA+splenectomy 1345 ± 115 × 103/mm3,p<0·05). Hepatic fibrosis assessed by Sirus red staining was graduallyameliorated after the splenectomy, and fibrotic area accessed by image analysiswas significantly reduced at day 28.Conclusion: Splenectomy ameliorated established hepatic fibrosis in a murinemodel, in addition to the attenuation of thrombocytopenia.

P1G-8 Evaluation of safety in laparoscopic cholecystectomyfor cirrhotic patients

K. Ohashi, Y. Iimuro, T. Okada, J. FujimotoDepartment of Surgery, Hyogo College Of Medicine, Nishinomiya, Japan

Objective: Laparoscopic cholecystectomy (LC) in cirrhotic patients has beenbelieved to be relative contraindication because of its difficulty in bleedingcontrol. In recent years, with advances in the technic and devices in laparoscopicsurgery, there are some reports concerning LC in cirrhotic patients while itssafety is still controversial. In the present study, we investigated whether LCcan be safely performed even in cirrhotic patients retrospectively.Methods: From December 2006 to August 2008, LC was performed in 9cirrhotic patients with Child-Pugh A (n=7) or B (n=2) in our department. Inall of cases, laparosonic coagulation shears (LCS) was mainly used for dissectionof tissues. In these patients, safety of LC was retrospectively assessed. Twentynon-cirrhotic patients were analysed as control.Results: The average operative time was 90 ± 32 min in cirrhotic patients,and 51 ± 12 min in non-cirrhotic patients, respectively (P<0·01). The amountof bleeding was little in all cases. None of the patients was converted to opensurgery. The mean postoperative stay was 8·9 days in cirrhotic patients (6·7 daysin non-cirrhotic patients, P=0·228). Except for one patient with Child-Pugh Bwho stayed for 21 days because of prolonged ascites, no other complication wasdetected. No mortality was observed.Conclusion: LC can be safely performed even in cirrhotic patients with Child-Pugh A using LCS despite longer operative time. However, because one patientwith Child-Pugh B had a complication, further investigations concerning safetyof LC in these patients is required.

P1H Methodology and Historyof Surgical Research

P1H-1 Chest trauma management under general surgeons

S. Mustafa1, L. Kidd1, T. V. Chandrasekaran2

1Department of General Surgery, Morriston Hospital, ABM University NHS HealthBoard, Swansea, UK

Objective: Acute emergency general surgical care is increasingly provided byspecialist GI surgeons in the UK. In our institute, which is a major traumacentre, patients with chest trauma are managed by the general surgeons. Theaim of this study was to analyse the management of patients with chest trauma,and its relevance to general surgical practice and training.


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Methods: A prospective data collection of rib fracture referrals to thegeneral surgeons between September 2007 and 2008 was gathered concurrentlyfrom Accident & Emergency (A&E) notes, intensive care register, emergencyadmissions register and checked using electronic database.Results: There were 2805 acute surgical admissions, of which chest traumaconstituted 133 (4·5%). The median age was 60 years (range 16–97) (M : F ratio7 : 5). The median hospital stay was 5 (range 0–65). 68 (51%) patients had onlysoft tissue injury with no radiological evidence of rib fracture or pulmonarycomplications.59 patients had rib fracture. The associated complications included surgicalemphysema 13 (22%), pneumothorax 15 (25%) and effusion/haemothorax 27(45%). Three (5%) had flail chest. Four patients (7%) had chest drain insertionsin A&E, none of which were carried out by the on call surgical trainee. Thecare of 21 patients (35%) was taken over by other specialties for associated moresignificant injuries or underlying medical illness which precipitated the traumaincident.Conclusion: Majority of patients with chest trauma have associated medicaland social issues, which does not require expert general surgical care.General surgical trainees do not get any training opportunity to insert chestdrains.

P1H-2 Immunomodulation of Recombinant Vaccinia Virus - Vector asa cancer vaccine

N. Raafat1, C. Mengus1, M. Heberer1, G. Spagnoli1, P. Zajac1

1Basel University Hospital, Basel, Switzerland

Objective: Possible limitation to recombinant vaccinia viral (r.VV) vectorsis due to either prior systemic immunity to poxviruses or immunodominanceof viral antigens which may reduce the induction of immune response againstweaker tumor antigens expressed by r.VV. To address this issue, we developedr.VV expressing Herpes simplex virus (HSV) protein ICP47. It down-regulatesMHC class-I antigen presentation by blocking transporter associated withantigen processing (TAP).Methods: US12 gene, coding for infected cell protein (ICP47), wasintroduced into wild type VV and into r.VV expressing MART-1/Melan-A27–35, endoplasmic reticulum-targeted epitope. Following infection withnon-replicating recombinant virus, effect of ICP47 expression on cell surfaceMHC-class-I, MHC class-II and co-stimulatory molecules was characterized byantibody staining and FACS analysis. Human T-lymphocytes were stimulatedin vitro with autologous CD14+ cells infected with r.VV-US12, r.VV-Mart-US12 or control virus. Responsiveness of specific CD8+ and CD4+ to viralproteins and recombinant epitopes were monitored by MHC-multimer stainingand interferon gamma (IFNg) expression analysis.Results: Cells infected with HSV-US12-r.VV, demonstrated a decreasedability of presenting MHC class-I antigens to CD8+ T cells whereas MHC-class-II restricted presentation to CD4+ T cells remained unaffected. Co-expression of ER-Melan-A/Mart-127–35 appeared to partially compensate forthe ICP47 related surface MHC class-I molecule down-regulation and preservea strong capacity to induce CTL response against the TAA derived peptide.Conclusion: Viral vectors expressing ICP47 confirmed a diminished TAP-dependant processing of endogenous class-I restricted epitopes while theimmunogenic potential of recombinant epitopes directly targeted to the ERwas enhanced. Such reagents could become of high relevance especially inmultiple-boost vaccine protocol required in cancer immunotherapy.

P1H-3 Jaundice-Should ‘‘yellow’’ be a red code?

K. Kontzoglou1, A. Angelousi2, K. Spyridopoulou3, M. Stamatakos4

12nd Department of Propaedeutic Surgery, Medical School, University of Athens,Laiko Hospital, Athens, Greece 2Department of Internal Medicine, Medical school,University hospital of Lausanne, Switzerland 3Departement of microbiology, MedicalSchool, University of Athens, Laiko hospital, Athens, Greece 44th Department ofSurgery, Medical School, University of Athens, Attikon Hospital, Athens, Greece

Objective: Jaundice is the clinical manifestation, of hyperbilirubinemia. Itis considered as a sign of either a liver disease or, less often, of a hemolyticdisorder. It can be divided into obstructive and non obstructive type, involving

increase of indirect (non-conjugated) bilirubin or increase of direct (conjugated)bilirubin, respectively, but it can be also manifested as mixed type.Methods: This article updates the current knoweledge concerning thejaundice’s etiology, pathophysiological mechanisms, and complications anttreatment by reviewing of the latest medical literature. It also presents anapproach of jaundice’s treatment and pathogenesis, in special populations as inneonates and pregnant women.Results: The treatment is consistent in the management of the subjectivediseases responsible for the jaundice and its complications. The clinical prognosisof the jaundice depends on the etiology. Surgical treatment of jaundiced patientsis associated with high mortality and morbidity rates. Studies have shown thatthe severity of jaundice and the presence of malignant disease are importan riskfactors for post-operative mortality.Conclusions: Early detection of jaundice is of vital importance because of itsinvolvement in malignancy or in other benign conditions requiring immediatetreatment in order to avoid further complications.

P1H-4 Definition of basal blood sample in intraoperative monitoring ofPTHi in Primary Hyperparathyroidism (HPT). Where and when it mustbe obtained

A. Gomez Palacios, J. Gomez Zabala, B. Barrios, Ma T. Gutierrez,N. Partearroyo, S. Leturio, S. Ruiz, I. Iturburu, J. MendezClinical Management Unit of General Surgery and Digestive Tract (EndocrinalSurgery Unit), Basurto Hospital, Bilbao, Professorship of Surgery, School of Medicine,University of the Basque Country

Objectives: 1. Assess the effectiveness of PTHi monitoring. 2. Define whereand when the basal blood sample must be obtained.Method: Prospective study (2005–2009), 48 women and 7 men. Beforesurgery, 4 antebrachial blood samples were obtained, determining the PTHiconcentration. 1. ‘‘Standard’’, before anaesthesia. 2. ‘‘Pre-exeresis’’, uponidentifying the adenoma. 3. At 10 and 25 minutes after the parathyroidectomy.Criterion of therapeutic effectiveness: Decrease > 50% of the PTHi post-exeresis with respect to the basal. Regarding curation: Normalization of thecalcemia. We assessed the reliability of the basal samples identifying their trueand false positives and negatives. The statistical comparison of the post-exeresisresults with the basal samples was done by analyzing the variance (p<0·05).Results: Basal mean: ‘‘Standard’’ 262·52 pg/dl (sd 226·72). ‘‘Pre-exeresis’’mean: 256·52 (sd 314·74). Post-exeresis mean: PTHi at 10′, 46·21 pg/dl (sd52·66). At 25′, 26·19 (sd 24·00). The gradients of descent were > 50% inthe resolved parathyroidectomies (true positives) (p<0·001) and < 50% whennot all the pathological tissue was excised (true negatives). Gradients of drop:Compared with the ‘‘Standard’’, at 10′ it was 81·55% (sd 11·41). At 25′, 88·90%(sd 7·84) (p<0·001). There was one false negative and 7 true negatives, with nofalse positives. Compared with the ‘‘Pre-exeresis’’, at 10′ , 73·29% (sd 18·45).At 25′, 83·96% (sd 11·32) (p<0·001). There were 8 false positives and 8 falsenegatives.Conclusions: 1. The gradient of descent > 50% indicates diagnostic,therapeutic and curation effectiveness (normalization of the calcemia). 2. The‘‘Standard’’ basal sample, easy to obtain, is safer and more reliable than the‘‘Pre-exeresis’’.

Prospective study Basal ‘‘standard’’ Basal ‘‘pre-exeresis’’(2003–2008)Total patients: 55 10 minutes 25 minutes 10 minutes 25 minutes

True positives 47 48 41 47True negatives 7 7 4 2False positives 0 0 3 5False negatives 1 0 7 1


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P1H-5 Necessity of the routine abdominal drainage after laparoscopiccholecystectomy (LC)

L. Szpaszkij1, T. Vanca1, B. Berenyi1, I. Dudas1, A. Zsirka-Klein1,P. Lukovich1

11st Department of Surgery and Radiology, Semmelweis University, Budapest,Hungary

Introduction: The patients after transvaginal hybrid cholecystectomies(NOTES) - owing to the lesser pain - are discharged 4–6 hours after theoperation. There is no facility to leave drain after this procedure.Methods: Data of 100 patients having undergone LC beginning from01·09·2009 were collected in a prospective study. The quality and the volumeof the fluid emptied through the abdominal drain were analyzed. On the1st. postoperative day the drain was removed and ultrasound was made todemonstrate residual liquid in the abdominal cavity. The pain of the patientswas recorded by a numeric scale (1–10 points).Results: The average fluid in the drain was 25 ml. The ultrasound could notsee any liquid in 85% and less than 10 ml liquid in 15% of the patient. Theaverage pain was 5·5 on the day of the operation, which decreased to 4·0 on the1st and was irrelevant on the 2nd day. 93% of the patients signalled that thedrain caused pain while inside and during removal. One patient was reoperatedbecause of bleeding, but only minimal blood was detected in the drain, in spiteof the correct position of the drain which was detected by CT.Conclusion: The drain and its removal is painful for the patients. Based onthe data of our prospective study it is not necessary to leave a drain routinelyafter LC.

P1H-6 Has the quality of abstracts of randomized controlled trialsimproved after dedicated consort guideline? A survey of mainanaesthesia journals

O. S. Can1, A. A. Yilmaz1, M. Hasdogan1, F. Alkaya1, S. Cakar1,M. F. Can2, Z. Alanoglu1

1Department of Anaesthesiology and Intensive Care, Ankara University Faculty ofMedicine, Ankara, Turkey 2Division of Gastrointestinal Surgery, Department ofSurgery, Gulhane School of Medicine, Ankara, Turkey

Objective: Randomized controlled trials (RCT) represent the highest levelof evidence in health care research. To improve the quality of RCT abstractspublished in conference proceedings and journal articles, the CONSORT grouppublished a dedicated checklist in January 2008. This study assessed whetherthere has been an improvement in the quality of RCT abstracts published inmain anaesthesia journals after the new guideline was introduced.Methods: The study compared RCT abstracts published in four anaesthesiajournals (Anaesthesia, Anesthesiology, Anesthesia & Analgesia, EuropeanJournal of Anaesthesiology) from October 2005 through September 2006(older group/OG) with those published from October 2008 through September2009 (newer group/NG). Abstracts were randomly assigned to five reviewers inblinded fashion and reviewed based upon checklist items recommended by theCONSORT guideline.Results: After excluding animal studies, trials of healthy volunteers, cadaversand cost effectiveness, some 527 RCT abstracts (OG n=275, NG n=252) wereincluded in the final analysis. In the majority of abstracts, study interventions(73·1% and 73·8%, ratio of suitable abstracts from OG and NG, respectively),objective (91·3% and 90·1%), and conclusion (72·4% and 68·3%) were reportedsatisfactorily. There also were significant improvement in the reporting qualityof abstract title (20·1% to 29%), methods outcome (22·9% to 30·6%), blinding(18·2% to 29%), and study harms (31·6% to 42·1%), while poor reportingquality for trial design, participants, randomization, recruitment, outcomes,trial registration and funding still remained unchanged.Conclusions: Despite some promising improvements, adherence of authorsconducting and publishing anaesthesia-related RCTs to the CONSORTchecklist for reporting abstracts appears to be poor and warrants more attention.

P1I Inflammation and Infection

P1I-1 Suppression Of Colit Process In Concequnce Of Effects Of EthylPyrivate On The Experimental Colitis Model On Rats

B. Oz1, E. Sozuer1, A. Akcan1, H. Akgun2, S. Muhtaroglu3, M. Akyuz1,H. Akyildiz1

1Departments of 1General Surgery, 2Pathology and 3Biochemistry, Erciyes UniversitySchool of Medicine, Kayseri, Turkey

Aim: In this study, the effects of ethyl pyrivate (EP), an antiinflammatory andan antioxidant agent, have been investigated on the inflammatory process of theexperimental colitis model.Materials and Methods: In this study, 24 rats were used. Rats were dividedinto 3 groups randomly, each including 8 (control, colitis and treatment groups).Normal saline (SF) were given to control group rectally. To the colitis group,trinitrobenzene sulfonic acid and ethanol mixture (TNBS-E) instillated rectallyfor colitis formation. Finally; to the treatment group, after instillation of TNBS-E, 100 mg/kg of EP administered intraperitoneally every day during 10 days.Blood samples were taken on the days 3st and 10th. On the 10st day, bloodsamples were taken from vena cava inferior and santrifugated, and the left colonwas resected. Microscopic and macroscopic findings of specimens evaluatedand graded. Myeloperoksidase (MPO), malondialdehyde (MDA), advancedoxidation protein products (AOPP), glutathion (GSH) levels of the colonictissues, and tumor necrosis factor-α (TNF-α), CRP levels of blood samplesmeasured.Results: In terms of macroscopic and microscopic grades, colitis and treatmentgroups’ grades were statistically different (p<0·05). In the treatment group,tissue MPO, MDA and AOPP levels were significantly lower than colitis group(p<0·05). TNF-α, CRP levels were decreased significantly in treatment groupwhen compared to colitis group (p<0·05). Treatment group’s GSH levels weresignificantly higher than the colitis group (p<0·05).Conclusion: According to histopathological and biochemical findings,administration of EP reduced the inflammation on TNBS-E colitis formatedrats. Results suggest that the inflammation formation in colitis group, decreasedsignificantly in treatment group by the effects of EP.

P1I-2 GR1+ macrophages are the primary producers of TNF followinginjury

F. O’Leary1,G. Tajima1, K. Ikedea1, A. Delisle1, J. Mannick1,J. Lederer1

1Brigham And Women’s Hospital Harvard Medical School, Bristol, UK

Background: Excessive activation of the innate immune system contributesto mortality in major trauma or sepsis. GR1+ macrophages have been reportedto suppress T cells and block immune surveillance in murine cancer models.In these studies, we examined the contribution of macrophage subsets (GR1+versus GR1−) to the production of pro-inflammatory cytokines following burninjury.Methods: WT C57BL/6, CD4 knockout (−/−) mice, anti-CD25 antibody,anti-Ly6G antibody and control Immunoglobulin antibody treated WT B6mice were used in these experiments. Mice underwent sham or burn injury andwere killed at day 1 or day 7. Splenocyte suspensions were prepared and surfacestained with F4/80, GR1, CD11b, Ly6G or Ly6c. Spleen cells were stimulatedwith LPS (TLR4). Bead array assays and intracellular cytokine stains were usedto determine TNF production.Results: Burn-injury caused a significant increase in the percentage of GR1+macrophages. We found that GR1+ macrophages were the primary source ofLPS induced TNF production. The absence of CD4 T cells or Tregs had nosignificant influence on the burn-induced increase in GR1+ macrophages.However intracellular staining and bead arrays showed that burn-injuredCD4−/− and WT produced more TNF compared with shams. Burn injuredmice treated with anti-Ly6G-antibody challenged with in vivo LPS at day 10exhibited lower TNF expression in GR1+F4/80+ macrophages compared withcontrol-IgG treated burn injured mice.Conclusion: These findings suggest that GR1 macrophages represent theprimary innate cell type mediating the pro-inflammatory phenotype following


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severe injury. Understanding the source of excessive innate immune activationmay provide therapeutic insights for patients in the critical care setting.

P1I-3 Comparison of antimicrobial agents in the treatment ofexperimental endocarditis due to methicillin-resistant Staphylococcusaureus

M. Sacar1, S. Sacar2, N. Cevahir3, G. Onem1, Z. Teke4, A. Asan2,H. Turgut2, F. Adali1, I. Kaleli3, I. Susam5, Y. Tolga Yaylali5,A. Baltalarli1

1Department of Cardiovascular Surgery, Faculty of Medicine, Pamukkale University,Denizli, Turkey 2Department of Infectious Diseases and Clinical Microbiology, Facultyof Medicine, Pamukkale University, Denizli, Turkey 3Department of Microbiology,Faculty of Medicine, Pamukkale University, Denizli, Turkey 4Department of GeneralSurgery, Faculty of Medicine, Pamukkale University, Denizli, Turkey 5Departmentof Cardiology, Faculty of Medicine, Pamukkale University, Denizli, Turkey

Objective: The aim of the present study was to evaluate the therapeutic efficacyof teicoplanin, linezolid and quinupristin-dalfopristin (Q-D) with regard tovancomycin as a standard therapy of endocarditis in an experimental endocarditismodel.Methods: Aortic endocarditis was induced in rats by insertion of apolyethylene catheter into the left ventricle, followed 24 hours later byintravenous inoculation of 106 CFU MRSA. Forty-eight hours after bacterialchallenge, treatments with vancomycin, teicoplanin, linezolid or Q-D werebegun. There were five groups: uninoculated controls; inoculated untreatedcontrols; vancomycin treated group (40 mg/kg/12h); teicoplanin-treated group(20 mg/kg/12h after a loading dose of 40 mg/kg); linezolid-treated group(75 mg/kg/8h on the first day, on the following days 75 mg/kg/12h); Q-D-treated group (30 mg/kg/12h and an additional 10 mg/kg dalfopristin over 6- to12-h periods of time in order to compensate its short life span in serum in rats).At the end of the treatment, rats were sacrificed and aortic valve vegetationswere evaluated microbiologically.Results: Any of the drugs used significantly reduced vegetation bacterial titersin comparison with the untreated contaminated control group. Vancomycin,teicoplanin and Q-D were found to be equally effective in the reduction of thequantitative bacterial cultures of aortic valve vegetations. Additionally, therewas no difference in the efficacy of teicoplanin, Q-D and linezolid. On the otherhand, vancomycin achieved a significant reduction in bacterial counts comparedto the reduction with linezolid.Conclusions: Our experimental model showed that each of the investigatedantimicrobials teicoplanin, linezolid and Q-D appeared to be a potentiallyeffective drug in the treatment of infective endocarditis.

P1I-4 Human skin tissue fluid/lymph cytokines and growthfactors - their role in skin inflammation

M. Zaleska1, M. Cakala, Waldemar L. Olszewski1,2

1Department of Surgical Research & Transplantology, Medical Research Center, PolishAcademy of Sciences, Warsaw, Poland 2Department. of Transplantation Surgery,Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, Poland

Objective: Tissue fluid/lymph (TF) contains cytokines, chemokines, growthfactors originating from blood, parenchymatous and infiltrating cells. Theseproteins regulate immune processes but also influence cellular events in lymphnodes draining inflammatory tissues.Aim: To measure concentration of pro- and anti-inflammatory cytokines andchemokines in human lower limb skin tissue fluid/lymph in normal subjects,patients with rheumatoid arthritis, obstructive lymphedema without and withbacterial dermatitis.Methods: TF was collected from lymphatics in lower leg and cytokinesmeasured with ELISA. Results. 1) pro- and anti-inflammatory (IL1β, TNFα,IL1Rα, MIP1α, MCP1, IL6, IL12, TGF β), 2) regulating epidermal and dermalcellular (KGF, MMP9, TIMP 1 and 2, PDGF BB) and 3) lymphatic structure(VEGF, VEGF C, CCL21 and 27) were measured in patients: A) withoutany dermal conditions (N), B) with rheumatoid arthritis (RA), C) lymphedemawithout dermatitis (LD), D) lymphedema complicated by dermatitis (L). 1)Level of proinflammatory cytokines was highest in RA. In all patients groups it

was higher than in N. IL10 and 12 levels were low. 2) KGF, MMP9 and TIMPSconcentration was significantly higher than in N in all groups, 3) VEGFs andCCL21 and 27 were much elevated in lymphedema but not so much in RA.Conclusions: Concentration of cytokines in tissue fluid/lymph variesdepending on the type of processes in skin. Most of cyto- and chemokinesare produced locally and their level exceeds that of serum. Measuring humoralfactors in TF gives insight into tissue events that is not possible with measuringserum concentrations.

P1I-5 Microbiological isolations in patients with colostasisafter preoperative biliary drainage. Considerations to be appliedin the antimicrobial therapy

C. Gonzalez Serrano1, I. Iturburu Belmonte1, E. Etxebarrıa Beitia1,M. Garcıa Carrillo1, A. Escobar Martınez1, V. Atın del Campo1,J. Sustatxa Manzarraga1, P. Gomez Garcıa1, J. J. Mendez Martın1

1Department of Surgery, University of Basque Country, Hospital of Basurto, Bilbao,Spain

Objective: To investigate the microbiology in patients undergoingpreoperative biliary drainage.Method: Observational study of 29 patients with obstructive jaundice forperiampulary tumors and preoperative bile duct stent, during 18 months.Results: Mean age 72 years (range 45–83), 69% male, 31% female. Diagnosticdistribution: 13 pancreatic adenocarcinomas, 9 cholangiocarcinomas, 6ampullary carcinomas, 1 ampullary adenoma. Resectability rate: 96·6%. Meantime between stent placement and surgery: 24 days (range 5 to 82).Microbiology: Intraoperative bile cultures 100% positive, 86% polymicrobial,14% monomicrobial. Total microorganisms: 68, 17 enterococcus spp. (25%), 14klebsiella spp. (20·6%), 8 Enterobacter cloacae (11·8%), 6 E.coli (8·8%), 2 BLEAS(+), 1 yeasts 3·4%.Intraoperative prothesis cultures 100% positive, 83% polymicrobial, 17%monomicrobial. Total microorganisms: 55, 17 enterococcus spp. (31%), 13klebsiellas (23·6%), 7 Enterobacter cloacae (12·7%), 6 E.coli (10·9%), 2 BLEAS(+), 6 yeasts (10·9%).Conclusions: Preoperative biliary drainage leads to bacterial contaminationof bile ducts in 100% of cases.By frequency order stand out: Enterococcus spp, klebsiella spp, Enterobacter cloacae,E.coli and yeasts.Note the relevance of the following microorganisms due to their complexmanagement: Enterococo faecium, E.coli BLEA (+) and fungi.Yeasts are isolated in high proportion in cultures of the prothesis.Given these results, antimicrobial policies applied to patients with periampullarytumors and preoperative stent should be modified considering the surgery highlycontaminated by very high pathogenic microorganisms.The identification of the microorganisms and the analysis of their resistanceswould allow to determine in the future the microbiological spectrum of ourhospital.

P1I-6 Changes in leukocyte surface markers during treatmentof critically ill patients

J. Lantos1, C. Csontos2, D. Muhl2, V. Foldi2, B. Suto2, L. Bogar2,G. Weber1, E. Roth1

1Department of Surgical Research and Techniques, University of Pecs, Hungary2Department of Anaesthesia and Intensive Therapy, University of Pecs, Hungary

Objective: Surgical trauma, polytrauma, burn injury induce pathologicleukocyte activation and recruitment. The significance of different leukocytesurface markers in this process is less well studied therefore the purpose of thisstudy was to follow the time course of CD11a, CD49d adhesion molecule, andCD97 inflammation marker expressions on leukocytes in patients with burninjury (BI), polytrauma (PT), severe sepsis, and acute lung injury (ALI).Methods: Blood samples were collected from 26 BI, 14 septic, 13 PT, and 22ALI patients on ICU admission, and 3–5 consecutive days thereafter. Bloodsamples from healthy volunteers (n=19) served as control. Leukocyte surfacemarker expressions were measured by flowcytometry.


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Results: Granulocyte CD11a were significantly diminished in patients withBI, PT and ALI on admission, and increased during treatment. Lymphocyte andmonocyte CD11a was significantly diminished during the whole observationperiod. Granulocyte CD49d was significantly decreased only in patients withPT on admission and increased in each group during treatment. Lymphocyteand monocyte CD49d levels were significantly depressed during the wholeobservation period. Granulocyte CD97 was significantly diminished in patientswith BI and PT on admission, and was significantly elevated in septic ones. Anincreasing tendency was observed during treatment both in BI and PT patients,while it stagnated in septic and ALI ones. Lymphocyte and monocyte CD97 onadmission was significantly depressed in patients with BI, PT and ALI, and wassignificantly elevated in septic ones.Conclusion: Our results showed trauma specific alterations in leukocytesurface markers during treatment of critically ill patients reflecting thedisturbance in leukocyte activation and recruitment.

P1I-7 Stimulation of TLR7 prior to polymicrobial sepsis improvesthe immune control of the inflammatory response in adult mice

P. Koerner1, T. Traeger1, H. Mehmcke1, K. Cziupka1, W. Kessler1,A. Busemann1, S. Diedrich1, G. Hartmann2, C.-D. Heidecke1, S. Maier1

1Department of Surgery, Ernst Moritz Arndt Universitat, Greifswald, Germany2Institute of Clinical Pharmacology, Rheinische Friedrich-Wilhelms-Universitat,Bonn, Germany

Objective: The role of Toll-like receptor 7 (TLR7), so far regarded as areceptor for viral RNA, was investigated in a murine polymicrobial mousemodel.Methods: To analyze immune function in the septic organism we used theColon Ascendens Stent Peritonitis model (CASP) in female C57b/6 mice. Sepsiswas induced 24 hours after repeated i.v. application of the TLR7 agonist R-848 (Resiqiumod). Different cell populations were isolated from the spleen bymagnetic cell separation 6 and 12h following CASP and the expression of TLR7was visualized by immunofluorescence staining and verified by RT-PCR. Wedetermined levels of cytokines in serum and organs 12h following CASP by CBAdetection kit and apoptotic events in spleen and thymus by TUNEL-staining.Results: The expression of TLR7 on B-lymphocytes, dendritic cells andmacrophages was upregulated 6h and 12h following CASP compared to thenon-septic control group. TNF and IL-6 release was significantly elevated in theperitoneum but reduced in the spleen of TLR7-stimulated septic mice comparedto the septic non-treated control group. Furthermore, apoptosis in thymus andspleen during polymicrobial sepsis was significantly decreased following TLR7agonist application.Conclusion: TLR7 seems to be essential for pathogen defence not only in viralbut also in bacterial infections. Pharmacological stimulation of this receptorprior to induction of sepsis improves the host’s capacity to cope with pathogensand could open a prophylactic approach for severe infectious diseases.

P1I-8 Pathogenic role of myeloperoxidase in acute pancreatitis

S. Chooklin1, A. Pereyaslov1, I. Bihalskyy1

1Department of Surgery, Medical University, Lviv, Ukraine

Objective: Myeloperoxidase (MPO) has been implicated in promoting tissuedamage in various inflammatory diseases. However, MPO blood levels inrelation to the severity of acute pancreatitis (AP) and its time-course have notbeen studied. The present study aimed to determine the role of MPO in AP.Methods: We studied 86 patients with AP (48 patients with mild and 38 withsevere pancreatitis) and 18 controls (volunteers). The relations of serum MPOlevels to cytokine level, severity, and time-course of pancreatitis were studied.The serum level of MPO and cytokines were measured by MPO-EIA andcytokines ELISA, respectively.Results: The highest level of MPO was noted at the first day in patients withsevere AP. A decrease of MPO blood level occurred during the first three daysin all patients with necrotizing pancreatitis. The development of pancreatitis-associated lung injury and purulent complications was accompanied by increasedMPO levels. Administration of pentoxifylline significantly reduced the MPO

blood level, which was clearly correlated with the levels of proinflammatorycytokines in the two groups of patients.Conclusion: The results of the present study showed the MPO blood level isdependent on the severity of AP and on cytokine blood levels. Pentoxifylline inthe complex management of severe AP may improve the results of treatment.

P1I-9 Celastrol, a novel triterpenoid antioxidant, markedly reduces rathepatic ischemia and reperfusion injury

A. Bedirli1, O. Sakrak1, H. Pasaoglu 2, M. Alper3, C. Y. Demirtas2

1Department of General Surgery, Gazi University Medical School, Ankara, Turkey2Department of Biochemistry, Gazi University Medical School, Ankara, Turkey3Department of Pathology, Diskapi Training and Research Hospital, Ankara, Turkey

Objective: The nuclear factor-kappaB (NF-κB) exerts a pivotal role in thepathogenesis of hepatic ischemia/reperfusion (I/R) injury. We investigated therole of the prophylactic administration of the celastrol, a novel triterpenoidantioxidant and a potent inhibitor of NF-κB, on hepatic I/R injury in rats.Methods: Rats were subjected to 60 min of hepatic ischemia followed byreperfusion. The animals were randomised to receive either a celastrol (2 mg/kg)or an equal volume of saline by intraperitoneally before ischemia. Serum AST,ALT, proinflammatory cytokines (TNF-α, IL-6 and IL-1β), oxidative stressmarkers (MDA, MPO, NO, total antioxidant capacity), and liver histology wereassessed.Results: Animals submitted to ischemia showed a marked increase of AST andALT after reperfusion, but with lower levels in celastrol group. Compared withthe control group, the celastrol pretreatment group showed significantly lowerserum NO and total antioxidant capacity, and reduced TNF-α, IL-6 and IL-1β

levels. Tissue MDA and MPO levels were partially recovered with celastrolpretreatment. The histological damage score was higher in the liver of animalssubmitted to I/R compared to the celastrol group.Conclusion: Celastrol pretreatment protecs the liver against the I/R injury viathe prevention of oxidative stress and the downregulation of proinflammatorycytokines release. These results provide compelling data for the furtherinvestigation of the use of celastrol in hepatic I/R injury.

P1I-10 The effects of toll like receptor-4 antagonist on pulmonarymicrocirculatory disorders in a rat model of endotoxin-inducedabdominal sepsis

O. Yuksel1, O. Gulbahar2, P. Korkusuz5, M. Alper6, A. Dikmen3,S. Ercan4

1Department of Surgery, Gazi University Medical School, Ankara, Turkey2Department of Biochemistry, Gazi University Medical School, Ankara, Turkey3Department of Public Health, Gazi University Medical School, Ankara, Turkey4Department of Pharmacology, Gazi University Medical School, Ankara, Turkey5Department of Histology-Embriology, Hacettepe University Medical School, Ankara,Turkey 6Department of Pathology, Diskapi Training and Research Hospital, Ankara,Turkey

Objective: TLR-4 takes part in the synthesis and the release of theinflammatory mediators in sepsis. We aimed to investigate the effects of TLR-4antagonists over the microcirculatory disorders in lung injury.Methods: LPS was given for the abdominal sepsis. Eritoran as the antagonistwas given just after the LPS in group IV, and 6 hours later in group V. SF wasgiven instead of eritoran just after the LPS in group II and 6 hours later in groupIII. Laparotomies and thoracotomies were performed after 12 hours in groupII and IV, after 24 hours in group III and V. Blood flow was measured in lungtissue by Laser doppler flowmeter. TNF-α and MDA levels in blood samplesand the levels of TNF-α, MDA and NFκB in lung tissues were measured. Theratio of fresh lung weight to body weight, histopathologic injury levels of lungtissue, and endothelial cell injury in electron microscope were evaluated.Results: Blood flow was significantly higher in study groups (p<0·05). Serumand tissue levels of TNF-α and MDA, and tissue levels of NFκB were foundto be lower in study groups (p<0·05), these parameters in group V were lowerthan the group IV (p<0·05). The ratio of fresh lung weight to body weight,histopathologic injury levels of lung tissues, endothelial cell apoptosis, and


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endothelial cell injury and as a result of this endothelial GAP permeability weredecreased by eritoran treatment.Conclusions: Inhibition of TLR-4 by eritoran, lung injury related withLPS can be reduced by control of inflammatory response and regulation ofmicrocirculation.

P1J Medical Imaging and Simulations - NewSurgical Techniquesand Tools 1

P1J-1 Finite Element Model To Optimize Stentless Prosthesis SizingDuring Aortic Valve Replacement

P. Totaro1, S. Morganti2, C. Ngo Yon1, M. Conti2, A. D’Armini1,F. Auricchio2, M. Vigano1

1Cardiac Surgery IRCCS Foundation S Matteo Pavia, Italy 2Department of StructuralMechanic University of Pavia, Italy

Objective: Optimal sizing of stentless bioprosthesis during aortic valvereplacement is not always easy. Here we propose a finite element model toreproduce aortic root physiology following stentless bioprosthesis which couldbe helpful in optimize stentless sizing.Materials and methods: Our reproduction of aortic root physiologyincluded 3 steps: 1) Creation of the model of the aortic root based on patient’smeasurements; 2) Creation of the model of the bioprosthesis based on technicalspecifications; 3) Simulation of bioprosthesis implantation using different sizeand evaluation of postimplant physiology of the aortic root using two parameters:the height of coaptation (Hc) and the percentage of coaptation (Lc) of leaflets.Physiological condition was considered for Hc at 100% of sinus height and Lc30–50% of leaflets length.Results: Two aortic root models were created according the parameters of2 different patients. The model of a stentless bioprosthesis was created forsize from 19 to 25. Post implant simulation was obtained for each size ineach patient. Values of Hc and Lc increased according the increased size ofprosthesis, however, optimal physiological match was detected for size 21 inpatient #1 and size 23 in patient #2. Further prosthesis increasing caused an Hc> 120% of sinus height and non physiological leaflet coaptation with Hc > 60%and marked surface irregularity.Conclusion: Finite element reconstruction of aortic root and aortic prosthesisis feasible and can be useful in predicting postoperative physiology of aorticroot. Our model, furthermore, could have a clinical impact as it could be usefulto optimize surgeon’s size prosthesis choice avoiding the risk of oversizing.

P1J-2 Differences in MRI liver clearance of ferucarbotranand ferumoxide

F. Ris1,3, L. A. Crowe2, M. Lepetit-Coiffe2, C. Toso1,3, Ph. Morel1,3,D. Bosco1, J.-P. Vallee2, T. Berney1,3

1Cell Isolation and Transplantation Center, Geneva University Hospitals, Geneva,Switzerland 2Department of Radiology, Geneva, University Hospitals, Geneva,Switzerland 3Department of Visceral and Transplantation Surgery, Geneva,University Hospitals, Geneva, Switzerland

Objectives: Ferucarbotran (Resovist) and ferumoxide (Endorem) are twocommercially available iron oxide nanoparticles used in islet tranplantationimaging. These agents, suitable for islet cell labeling, have similar size, magneticand toxicity properties, but different coatings. Cell uptake and persistence is animportant property for labeling and the post-tranplantation follow-up. The aimof this study is to evaluate the clearance from the liver and to define the mostappropriate available nanoparticles for this indication.Methods: Sprague-Dawley rats (n=6) were injected with SPIO at 280ug/mliron concentration. Volume was identical to cell transplantation. Imaging, fromday 0–125, used a clinical 1·5T MRI scanner (Philips Achieva) and 4·7 cm-diameter circular coil. To visualize SPIO induced signal loss in the liver, a T1weighted fast field echo (T1w FFE) was performed. 60 mm saturation bandswere placed above and below the imaging plane to reduce artifacts. To calculateT2 decay, a 16 echo spin-echo acquisition was obtained. Iron clearance wasfollowed up to 125 days.

Results: After 10 days, the ferucarbotran (carboxydextran coating) livers showno significant difference from normal signal levels (p=0·05). For ferumoxide(dextran coating) at 125 days, the liver signal is only half way recovered.Conclusion: Despite the similar size and magnetic properties of these agents,the difference in coating has a significant effect on their clearance from the liver.Ferumoxide is not cleared efficiently, reducing its suitability for longitudinalstudies of cell rejection. Ferucarbotran would therefore be the agent of choice.

P1J-3 A New Method for Hepatic Resection and Hemostasis:Absorbable Plaque and Suture

M. T. Ozer1, A. I. Uzar1, M. Eryilmaz1, K. Coskun1 S. Demirbas1,O. Kozak1

1Gulhane Military Medical Academy, Ankara, Turkey

Objective: Elective and traumatic hepatic resections and haemostasisnecessitate both surgical experience and technological equipment. Therefore,the demand for an affordable and easy method for hepatectomies andhaemostasis that could be applied by all centres still exists.Method: We have developed the method of hemorrhage control via suturationssupported by absorbable plaques that provide an effective compression andprevent the suture from cutting the tissue during the application of suturationin the treatment of such fragile organs as the liver.Results: We used the method on four pigs. The hepatic hemorrhages we haddeveloped in two subjects were successfully restrained. Two resections wereperformed on the right and left lobes of the other two subjects in 45 minuteswithout hemorrhagia and postoperative complications. The liver function testswere normal on the postoperative 30th day. We sacrificed the subjects onpostoperative 6 months. The plaques and sutures were absorbed and the injuredtissues were healed completely.Conclusions: In conclusion, we believe that the method can be used safely inhepatic resections or traumatic hemorrhages in proper localizations.

P1J-4 A Novel Laparoscopic Suction Device For Applying PreciseAspiration During Laparoscopic Surgery: Sponge Tip Suction Tube

M. T. Ozer1, A. I. Uzar1, M. Eryilmaz1, O. Altinel1, S. Demirbas1,I. Arslan1, T. Tufan1

1Gulhane Military Medical Academy, Ankara, Turkey

Objective: Aspiration of the intra abdominal fluid and debris is usually neededduring different stages of the operation. This is necessary in order to protectthe intra abdominal space from contamination and/or to remove blood ortissue fluids occurring during the operation. It’s also essential for obtaining aclean surgical area. Aspiration of the intra abdominal fluid is relatively becomemore difficult in laparoscopic surgery because of suctioning the omentum andintestine with the aspirator. In this study a new suction device (Sponge TipSuction Tube = STST) has been reported which allows the surgeon easiersuctioning intra abdominal fluid. STST has an additional sponge tip and airchannel which prevents the device from suctioning intra abdominal organs suchas the intestine and omentum.Methods: We tested the efficacy of STST in a simulated intraabdominal spacesuch as a large transparent plastic bag with fresh sheep intestine-omentum andwith 2000 cc of physiologic saline solution and 14mmHg. air pressure.Results: While the suctioning of all the fluid was difficult and time consumingwhen the conventional suction unit was used, all of the saline solution was easilyand quickly suctioned when STST was used.Conclusions: In conclusion STST provides a safe, fast and complete fluidextraction.

P1J-5 Perioperative real-time monitoring of indocyanine green(ICG)video-blood perfusion and thermography of gastric tube duringesophageal reconstruction

M. Ohara1, T. Ishidate1, Y. Kimura1, K. Komuro1, M. Doumen1,Y. Nakanishi1

1Department of surgery, National Hakodate Hospital, Hakodate, Japan


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Objective: The leakage of anastomosis between esphagus and gastric tubein the operation of esophageal carcinoma sometimes concernsblood supply ofgastric tube. We would like to know the blood flow in the anastomosis area. Thepurpose of this study is to evaluate anew intraoperative angiography techniqueand classical method.Methods: Fluoreseent ICG dye is excited with dispersed laser light to createan angiographic depiction of the gastric tube. Thermography is classicalmethod which relate to the blood flow of the reconstruction area. Eightpatients underwent ICG angiography and thermograpy during the operation ofesophageal carcinoma.Results: We could recognize good angiographic depiction area in ICGangiography in all cases. On the other hand, we could not recognize hotarea clearly in some cases by thermography. Thermography was often affectedby surrounding temperature. We choosed good angiographic depiction area foranastomosis. There was no anastomotic leakage in the eight cases.Conclusions: Thermography has tendency to receive various factors. ICGintraoperative angiography reveals the blood flow of the gastric tube incomparison with thermograpy more clearly. ICG intraoperative angiography isuseful for sure anastomosis of esophageal reconstruction.

P1J-6 Open management of infected pancreatic necrosis - pulsatilejet irrigation and vacuum mesh-foil laparostomy

V. Mutaftchijski1, N. Vladov1, K. Kjossev2

1Department of Hepato-biliary and Pancreatic Surgery, Military Medical Academy,Sofia, Bulgaria 2Department of Abdominal Surgery, Military Medical Academy, Sofia,Bulgaria

Objective: The most difficult decision in the management of the patients withsevere necrotizing pancreatitis is whether surgery is required and which of thecomplementary approaches to necrosectomy and drainage is appropriate. Thisstudy evaluates the results of pulsatile jet irrigation and subsequent laparostomyfor open pancreatic necrosectomy.Methods: Ten patients presenting proven infected/non-infected pancreaticnecrosis during course of acute pancreatitis and not responding to radiologicalor laparoscopic drainage were prospectively offered necrosectomy using pulsatilejet irrigation. In all patients, 1 to 3 tube drainages were placed duringnecrosectomy for continuous postoperative lavage. Mesh-foil laparostomy wasapplied for relief of abdominal compartment syndrome.Results: No perioperative complications were recorded with a medianoperative time of 62 ± 34 minutes. No blood transfusions were needed. Nosurgical postoperative morbidity and mortality were recorded. In 7 cases twosessions of necrosectomy were sufficient to completely clear the necrotic tissues.Another 5 patients with extended retroperitoneal necrosis required 3 irrigationprocedures. Necrosectomy using pulsatile jet irrigation was successful in allpatients.Conclusions: Application of pulsatile jet irrigation for necrosectomy is apromising technique for infected necrotizing pancreatitis and should be regardedas a valid therapeutic option for necrotizing pancreatitis. Although this techniqueis still evolving in open abdominal surgery, it is proven to be safe and efficientand should be evaluated against existing standards of treatment.

P1J-7 Preliminary results of a clinical trial based on a suturelessradiofrequency-assisted device for transection of the liver

F. Burdıo1, E. Berjano2, A. Navarro3, R. Quesada 1, I. Poves 1,L. Grande1

1Department of Surgery, Hospital del Mar, Barcelona, Spain 2Institute for Researchand Innovation on Bioengineering (13BH), Universitat Politecnica de Valencia,Valencia, Spain 3Department of Surgery, Hospital Cl

´ınico Universitario Lozano

Blesa, Zaragoza, Spain

Objective: In liver surgery, a combination of instruments is usually required toadequately address both parenchyma division and hemostasis. This combinationrequires considerable training and skills to achieve bloodless liver transection.Our objective was to evaluate the clinical feasibility of a new technique forliver resection based on a radiofrequency-assisted device that has shown high

performance in the animal setting in both transection speed and blood loss pertransection area.Methods: The study was registered and audited by the Spanish Agency forMedication and Medical devices (AGEMED 312/08 EC). From September2007 to May 2008, 8 patients with colorectal hepatic metastasis underwent 11partial hepatectomies using exclusively the proposed device for both parenchymadivision and hemostasis. Main outcome measures were blood loss per transectionarea and transection speed.Results: No other instruments (including sutures or clips) were employedin any of the cases nor was temporary vascular occlusion performed. Noblood transfusions were required and no mortality or morbidity linked to thehepatic procedure was observed. The median blood loss per transection areaand the median transection speed were 0·79 mL/cm2 (range 0·05–7·37) and1·28 cm2/minute (range 0·49–1·87), respectively. The median postoperativetime was 6 days (range 4–33). During the follow-up period (ranging from 4to 12 months) no late complications were detected and post-operative patientswere free from hepatic recurrence.Conclusion: The proposed RF-assisted device was shown to achieveparenchymal division and hemostasis simultaneously, resulting in extremelyreduced blood loss.

P1J-8 Hybrid rezius and laparotomy approach operation for obturatorhernia

K. Suzuki1, T. Sutoh1, S Tanaka1, N. Yasuda1, K. Katayama1,C. Osawa1, K. Saitoh1, K. Morohara1, T. Negishi1, N. Hattori1

1Department of Surgery, Isesaki Municipal Hospital, Isesaki Gunma, Japan

Objective: Today CT scan established diagnosis of obturator hernia. In thesefive years we treated ten cases of preoperatively diagnosed obturator hernia.Many obturator hernias present as mechanical small bowel obstruction, leadingto laparotomy. In our series, laparotomy was performed in all cases. But it isdifficult to directly visualize obturator canal from peritoneal cavity. Recurrencessometimes occurred. Treating an obturator hernia varies. Hernia defect shouldbe inspected from preperitoneal approach. What would be the best approachfor both bowel obstruction and hernia repair?Methods: In recent case we could approach obturator canal from ReziusCavity through low midline incision. We made low midline incision anddissected Rezius Cavity and found peritoneal protrusion into the obturatorcanal. With finger dissection, hernia sac was reduced. Ischemic change wasobserved with hernia sac, followed by laparotomy from median peritoneumto inspect the intestine. Necrotic bowel was not observed. Damaged sac wasresected and opened peritoneum was sutured. Direct Kugel Patch was laidcovering obturator canal, femoral ring, internal inguinal ring and Hesselbachtriangle.Results: An enteral diet was tolerated three days after surgery, and recoverywas uneventful. She was discharged five days later. No recurrence occurreduntil now.Conclusion: We can at first approach Rezius Cavity and next enter abdominalcavity though low midline incision. When we approach obturator canal viainguinal canal, dissection around inguinal canal cannot be avoided. By ourhybrid approach we can clearly expose obturator canal and enter abdominalcavity easily to inspect intestine. This method is good for both radical herniasurgery and bowel obstruction.

P1J-9 Magnetic compression anastomosis for rectal anastomoticstenosis: report of a case

K. Ashikawa1, H. Komoriyama1, R. Kumano2, E. Yamanouchi2

1Department of Surgery, St. Marianna University Yokohama City Hospital,Yokohama, Japan 2Department of radiology, St. Marianna University YokohamaCity Hospital, Yokohama, Japan

Objective: Rectal anastomotic stenosis is one of the complication, andsometimes difficult to treat with balloon dilation or reoperation. We reporta case of magnetic compression anastomosis (MCA; Yamanouchi’s method)repair performed and successfully cured.


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Methods: A 66-year-old man underwent low anterior resection for rectalcancer at another hospital, but transverse colostomy was required becauseof anastomotic leakage. Thereafter, stenosis of the anastomosis occurred.Endoscopically-guided balloon dilatation was repeated unsuccessfully. He wasreferred to our Department of Surgery. MCA was performed using two magnets20 mm in diameter and 5 mm thick. The daughter magnet was transportedfrom the colostomy by using a guide wire and the parent magnet was insertedmanually. The magnets were inserted near the staples at the site of stenosis.After 12 days, the mated pair of magnets was punched out through the stenosis.Results: Good healing was achieved, bowel movements resumed, and thepatients returned to a normal diet.Conclusion: Magnetic compression anastomosis is good indication for theobstinacy rectal anastomotic stenosis.

P1K Orthopaedic Surgery

P1K-1 Case report – Subclavian vessel injury by malpositionof chest-drain

K. J. Barlas1, P. Jani1

1Division of Trauma & Orthopaedics, Dianna Princess of Wales Hospital, Grimsby,UK

Objective: Thoracic injuries account for 25% deaths due to trauma. Drainageof pleural space by chest tube is commonest intervention in thoracic traumaproviding definitive treatment in majority cases. This report identifies risk andoutcome of injury to subclavian vessels caused by chest tube. Mal-positioningof chest-tube can lead to various iatrogenic injuries but rupture of subclavianand cephalic vein, punctured subclavian artery are absent in recent literature.Method: A 26yr patient involved in motor-cycle accident was admitted withopen fracture lateral 1/3rd Left clavicle. X-ray confirmed off-ended fracturewith left-sided pneumothorax. Chest-tube was inserted in 2nd intercostalspace mid-clavicular line. Immediate post-insertion left hand fingers werecyanosed with absent radial pulse. Feeble pulse returned upon repositioningof arm. Patient operated for wound toilet, plating of clavicular fracture.Intra-operative haematoma noted surrounding chest drain. Vascular surgeonsprovided assistance and detected ruptured cephalic and subclavian veins andpunctured subclavian artery. Artery was repaired and both veins tied. Chest-tuberepositioned in 4th intercostal space at mid-axillary line.Results: Repeat chest x-ray confirmed better inflation of lungs. Left sidedradial pulse returned to good volume and character. Patient made uneventfulrecovery.Conclusion: Mid-axillary and mid-clavicle lines at 4th and 2nd intercostalsspace respectively are important landmarks for insertion of chest-tube. Fromour experience, we recommend that open fractures of clavicle can disturb landmark for insertion of chest tube at mid-clavicle line 2nd intercostal space. Hence,in such cases strict adherence to ATLS principles for chest tube(ie mid-axillaryline 4th intercostal space) insertion minimizes iatrogenic complications.

P1K-2 Outcome of orthopaedic implant infections due to differentstaphylococci

D. Teterycz1, I. Uckay1,2, T. Ferry2, M. Assal1, P. Hoffmeyer1

1Service of Orthopaedic Surgery, 2Service of Infectious Diseases, Geneva UniversityHospitals, Geneva, Switzerland

Objective: To assess features of all orthopaedic implant infections due tomethicillin-sensitive S. aureus (MSSA), methicillin-resistant S. aureus (MRSA)and coagulase-negative staphylococci (CoNS).Methods: Retrospective study in the Geneva University Hospitals.Results: There were 44 episodes due to MRSA, 58 due to MSSA, and 61due to CoNS. Cure was achieved in 57% (25/44), in 72% (42/58), and in82% (50/61), respectively. In the subgroup of arthroplasty infections, cure wasachieved in 39% (7/18), in 60% (15/25), and in 77% (30/39), respectively. Inmultivariate logistic regression analysis, arthroplasty (odds ratio (OR) 0·2,95%CI 0·1–0·6) and MRSA infections (OR 0·3, 0·1–0·9) were inverselyassociated with cure, whereas CoNS infection (OR 3·0, 1·2–8·0) and the

insertion of a new implant (OR 4·5, 1·6–13·1) enhanched cure. Methicillin-resistance, immunosuppression, sex, age, duration of antibiotic therapy, implantremoval, the proportion of one-stage revision, rifampin use and the number ofsurgical interventions did not influence cure.Bacteraemia, a hallmark of S. aureus infection, was unseen in CoNS disease.Two patients died because of S. aureus bloodstream infection. MRSA-infectedpatients had significantly more sequellae than MSSA or CoNS patients (χ2-test13/44 versus 93/119, odds ratio 3·4, 95% confidence interval 1·3–8·9, p =0·004).Conclusion: In orthopaedic implant infections, S. aureus is more virulent thanCoNS, MRSA has the worst outcome and CoNS the best. The explanation forlower cure of MRSA infections partially lies in the lower proportion of newimplants inserted.

P1K-3 Postoperative Pro-Calcitonin and C-reactive levels in patientswith orthopaedic infections

I. Uckay1,2, L. Tovmirzaeva1, P. Hoffmeyer1

1Service of Orthopaedic Surgery, 2Service of Infectious Diseases, Geneva UniversityHospitals, Geneva, Switzerland

Objective: The value of postoperative Pro-Calcitonin (PCT) levels in thefollow-up of infected patients is unknown. The objective of this study was tocompare the postoperative ultra-sensitive serum PCT and C-reactive protein(CRP) levels in infected orthopaedic patients and assess the utility of PCT inpredicting the need for surgical re-intervention.Methods: Retrospective study including adult orthopaedic patients at theGeneva University Hospital.Results: A total of 165 paired PCT and CRP samples were retrieved in60 patients (median age, 58 years, 17 females). Twenty-four patients requiredsurgical re-intervention. Postoperative PCT values were elevated only in 15patients. Median PCT levels exceeded normal only on the first postoperativeday, despite a clinically active infection. PCT values did not differ betweenpatient groups with one or more surgical interventions (Wilcoxon-ranksum-test, p=0·33). CRP was elevated in 54 patients (90%), and normalized by thetenth day. Although paired samples, both markers correlated poorly with eachother (Kendall-tau-test 0·47).Conclusion: PCT has no predictive value for surgical re-interventions inpatients with localized orthopaedic infections.

P1K-4 Antegrade insertion of a retrograde intramedullary femoral nailfor the treatment of a subtrochanteric pathological femoral shaftfracture in a patient with pre-exsisting coxa vara.

M. Shakokani1, P. Jani1, D. Smart1, M. Eltayeb1

1Division of Trauma & Orthopaedics, Diana Princess Of Wales Hospital, Grimsby,UK

Objective: We report the unorthodox use of a retrograde intramedullary nailvia antegrade technique for the treatment of a subtrochanteric pathologicalfemur fracture in the presence of significant coxa vara. No similar use has beendocumented previously in literature.Methods: A standard approach to the proximal right femur was performed andstandard antegrade technique used to introduce a guide wire into the proximalfemur after which the femoral shaft was reamed. A 38 cm long 10 mm diameterretrograde nail was attached to the retrograde insertion and targeting device asif to perform a left sided retrograde femoral nailing. The nail was then insertedantegrade into the proximal right femur and locked.Results: The patient made a good recovery without complications and wasfollowed up regularly at the clinic until complete healing of the fracture.Conclusion: We believe that a retrograde intramedullary nail insertedantegrade, enabling proximal locking with screws passing into the femoral head,provides a mechanically sound fixation of a subtrochanteric fracture, where areduced neck – shaft angle precludes the use of a standard cephalo-medullarynail.


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P1K-5 Short antibiotic treatment for nocardial arthritis

I. Uckay1,2, K. Bouchuiguir-Wafa3, L. Tovmirzaeva2, B. Ninet3,M. Assal1

1Orthopaedic Surgery Service, 2Service of Infectious Diseases, 3Laboratory ofBacteriology, Geneva University Hospitals, Geneva, Switzerland

Objective: Often antibiotic therapy for nocardial arthritis is prescribed forseveral months in order to prevent recurrences. We report the first humaninfection (and arthritis) due to a novel Nocardia species and the possibility of arelatively short antibiotic treatment.Case report: A 40 year-old epileptic patient subsided to a car accident inFrance. He revealed open fractures (grade-IIIb) of both ankles that werestabilised with intramedullar nailing. The patient received an empirical antibiotictreatment of amoxicillin/clavulanate during five days. After his transfer toGeneva University Hospitals, an elective revision was performed because ofincongruence of articular surfaces. Both nails were removed and the ankles werestabilised with external fixation devices. Four days after, the patient witnessednew pain, erythema and a purulent discharge out of the scar of his right ankle.During lavage, pus was seen inside the talo-tibial articulation and all foreignbody material was removed. The Gram-staining and microscopic examinationdid not show any pathogens or crystals. The patient was treated empiricallywith intravenous vancomycin 2g/d and ceftriaxon 2g/d. Five days later thecultures grew Nocardia spp that subsequent analysis identified as a novel species( GenBank Accession no. GQ281125). The antibiotic treatment was changedto intravenous cotrimoxazole (160 mg trimethroprim, 800 mg sulfamethoxazol)for 5 days, followed by oral cotrimoxazole bid for a total of 8 weeks. Duringa forth and last lavage, the surgical site was sterile. Cure was complete andthe patient has no recurrence up to a follow-up of 18 months by now. Nounderlying immunosuppression could have been detected.Conclusion: Contrary to traditional beliefs, a short course of antibiotictreatment of only 8 weeks for nocardial arthritis is possible after surgicaldrainage.

P1L Surgical Anatomy

P1L-1 Transumbilical access for pneumoperitoneum is anatomicallysafest

N. Harvey1, D. Evans2, P. Farrands1, A. Gaunt2, J. Clark1

1Brighton and Sussex University Hospitals Trust, UK 2Brighton and Sussex MedicalSchool, UK

Objective: Controversy exists about the safest method for gaining the firstport entry to gain pneumoperitoneum for laparoscopy. Statistically, both closedand open methods expose the patient to the same risk of visceral or vasculardamage. The objective of this study was to investigate anatomical variations ofthe umbilicus which may play a role in conferring a theoretical risk benefit ofusing a transumbilical technique.Methods: The umbilical structures were examined in formalin- and alcohol-fixed cadavers.Results: 22 cadavers (12 female) with a mean age of 83 years were examined.A peritoneal recess was present beneath the umbilicus in 55% (n=13) of cases.This recess consistently showed strong fascial connections to the umbilicalcicatrix and had a mean Departmenth of 6 mm and mean diameter of 4 mm.No adhesions or congenital attachments to the umbilicus were found.Conclusions: Because the risk to first port entry is small it is difficult toprove statistical benefit of one technique over the other. However, entry risk issignificant and any attempt at reduction should be sought. The modified Hassonprocedure utilises a peritoneal recess present in 55% of patients conferring atheoretical advantage to this group. It is suggested that at operation if this recessis not then present a traditional Hasson technique should be employed throughthe same incision.

P1L-2 Morphologic and functional modeling of cylinder-shaped jointsin humans: interests of a comparative approach within mammals

J. M. Le Minor1, F. Billmann2

1Institut d’Anatomie Normale, Faculte de Medecine, Universite de Strasbourg, 4,Strasbourg, France 2Department of General, Visceral and Endocrine Surgery, St.Vincentius Kliniken, Karlsruhe, Germany

Objective: The general shape of synovial joints has been widely used toclassify them because the three-dimensional morphology of the articular facetsdetermines the joint mechanics. Joints presenting a convex (= male) cylinderrotating in a concave (= female) cylinder are classically defined as trochoidjoints (= pivot joints). They presents only one degree of freedom (monoaxialjoint) corresponding to medial/lateral rotation. In humans, typical examples arethose observed for the median atlanto-axial joint and the proximal and distalradio-ulnar joints. The purpose of this study was to use comparative anatomyin order to increase the functional comprehension of these structures.Methods: Skeletons representing the various locomotor modes in Primatesand running mammals (principally Artiodactyles and Perissodactyles) werestudied and modelled: 1) quadrupedal walk (arboreal or terrestrial), 2) leaping,3) brachiation (and derived knuckle-walking), 4) bipedal walk.Results: Cylinder-shaped joints, which are monoaxial joints, could allowfor movements around only one of the three elementary orthogonal axes. 1)Longitudinal (= vertical) axes of the cylinders, corresponding to the classicaltrochoid joints, allowed medial/lateral rotation (or left/right rotation for medianstructures). 2) Transversal (= medio-lateral) axes of the cylinders, correspondingto the classical hinge joints (= ginglymi) for which the Departmenth of the pulleyis quite inexistent, allowed flexion/extension. 3) Sagittal (= antero-posterior)axes of the cylinder allowed abduction/ adduction.Conclusion: Comparative anatomy is a helpful approach for understandingthe functional and biological significance of morphological structures and forgeneral modeling of joints and in particular cylinder-shaped joints.

P1L-3 Variants of the articular facets of the human elbow: functionaland biological significance using a comparative approachwithin mammals

F. Billmann1, J. M. Le Minor2

1Department of General, Visceral and Endocrine Surgery, St. Vincentius Kliniken,Karlsruhe, Germany 2Institut d’Anatomie Normale, Faculte de Medecine, Universitede Strasbourg, 4, Strasbourg, France

Objective: The elbow joint is a complex synovial joint between the humerus,radius, and ulna. The purpose of this study was to define the variants of thisjoint and to interpret their significance.Methods: The articular facets of 588 humeri, 731 ulnae, and 582 radii ofadult humans were observed. CT-scans of 50 human individuals were studied.Skeletons representing the various locomotor modes in Primates and runningmammals (principally Artiodactyles and Perissodactyles) were also observed: 1)quadrupedal walk (arboreal or terrestrial), 2) leaping, 3) brachiation (and derivedknuckle-walking), 4) bipedal walk.Results: The various morphological characteristics of the humeral trochlea,which is classically compared to a pulley, were particularly determining forelbow stability: 1) Departmenth, 2) height, 3) torsion, 4) asymmetry, 5) angularamplitude, 6) orientation. The relative height of the radial head, as well asvariable articular heights around the radial head circumference, were alsofound to be related to the more or less marked joint stabilization. In thehuman species, two specific nonmetric variants were moreover of biological andfunctional interest: 1) the articular facet of the trochlear notch of the ulna wassingle in 334 out of the 731 cases studied (45·7%) and bipartite in 397 cases(54·3%); 2) the accessory articular facet of the radial head was present in 91 outof the 582 cases studied (15·6%) and absent in 491 cases (84·4%).Conclusion: Morphological traits and variants of the elbow joint appeared tobe linked to functional specificities and particularly to the degree of evolutionaryspecialization in flexion-extension and to the necessity of joint stabilization.


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P1L-4 Characterization of the porcine anatomy as an educationalstrategy for experimental general surgery

M. Aponte-Rueda1, R. Saade-Cardenas1, S. Navarrete-Aulestia1

1Endoscopy Surgery Unit, Service of Surgery 2, Caracas University Hospital, CentralUniversity Of Venezuela

Objective: To identify the anatomical differences between humans and pigs,focusing on the key surgical anatomy of pigs as a model for experimental generalsurgery.Methods: A total of 22 pigs of the Landrace breed, specifically pathogen free,with no congenital defects were examined and dissected at the ExperimentalSurgery Institute of the Central University of Venezuela under veterinarysupervision, following the bioethic norms for animal experimentation, asdescribed in the Guide for the Care and Use of Laboratory Animals. Thepigs’ weights ranged between 25 to 35 kilograms and were aged between 3 and4 months.Results: The characterization of the porcine surgical anatomy was structuredby neck; axilla; abdominal wall; digestive tract: small and large bowel, stomachand spleen, liver, biliar tract, gastrocolic omentum, pancreas and duodenum;abdominal vascular anatomy: arterial system, portal venous system and venoussystem of the inferior vena cava; and adrenal glands.Conclusion: The knowledge of comparative porcine anatomy for use as anexperimental model allows the development of skills and refinement of thesurgical techniques. At the same time, the better anatomical understandingof the pigs make them ideally suitable for teaching certain general surgicalprocedures but inadequate for others.

P1L-5 Anatomical study on the surgical technique used forheterotopic heart transplantation : the pig xenotransplantation option(a preliminary study)

G. Dimitrakakis1

1Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK

Objective: heterotopic heart transplantation was initially developed andperformed in the laboratory for experimental tranplantation and researchmethods. Heterotopic heart transplantation is currently reserved for highlyselected patients. The pig heart is an ideal graft for orthotopic cardiacxenotransplantation and has emerged as the most likely source for humanreplacement organs.This preliminary study should verify which anatomical differences between pigsand human hearts require special attention from the surgical point of view,reqarding the heterotopic heart xenotransplantation. Therefore some technicalaspects will be discussed and analysed.Methods: we transplanted (in theory) four (4) pig hearts into a human thorax ofa cadaver. The theoretical implantation has been performed using the modifiedBarnard’s technique according to Khaghani et al. [1]Results : the thin walled pulmonary artery tended to kink and narrow. Theleft azygous vein of the pig heart should be ligated. Assessment of the problemsrelated to the position of the heart and relationships with the outflow/inflowangles of the great vessels. Suggestion of a new technique coping with the aboveproblems.Conclusions: the introduction of porcine xenotransplantation in the futuremay increase the interest in the technique of heterotopic heart transplantationas a bridge to a potential heart recovery (acting as LV and or RV assist device)or even orthotopic heart transplantation in selected patients. Keeping in mindthe porcine anatomical particularities, technical surgical problems related withthe porcine hearts to humans can be avoided.1. A. Khaghani, R. Casula, N.E. Khan, M.H. Yacoub. Heterotopic hearttransplantation through a right thoracotomy Ann Thorac Surg 1999; 68 : 2334-2336

P1L-6 Polysplenia syndrome: a rarty which must be known in surgery

P. De Wailly1, J.-P. Faure1, B. Roussel1, G. Goudard1, J.-P. Richer1

1Service Chirurgie Viscerale Digestive Et Endocrinienne, CHU, Poitiers, France

Stating background: Preduodenal portal vein is a rare congenital anomaly,usually asymptomatic and thus detected only incidentally in adults. It isoften associated with other anomalies which can be included into polysplenicsyndrome.Methods: In this case, a 56-year-old-female was admitted for a degenerativeampullome. The preoperative work-up shows a preduodenal portal vein, theabsence of inferior vena cava retro-hepatic and the presence of an anastomosisbetween the inferior vena cava and the azygos system and a complete commonmesentery.Discussion: Such a discovery is often incidental and of little import; however,it takes on major importance for surgeons because the accidental damage ofPDPV can lead to serious consequences.Conclusion: The aim of this study, based on the embryology of the portalvein (PV) focused on a rare anomaly to keep it in mind because this anomaly incase of digestive surgery may need to adjust surgical techniques.

P1L-7 Clinical importance of infratemporal and pterygopalatinefossae from anatomical and surgical point of view

K. Lovasova1, I. Sulla 2, J. Babik 3, D. Kluchova1

1Department of Anatomy, Faculty of Medicine, P. J. Safarik University, Kosice, SlovakRepublic 2Department of Neurosurgery, Faculty of Medicine, P. J. Safarik University,Kosice, Slovak Republic 3Department of Burns and Reconstructive Surgery, 1st PrivateHospital in Kosice-Saca, Kosice-Saca, Slovak Republic

Objective: The knowledge of pterygomandibular, pterygomaxillary andpterygopalatine spaces is important to understand the indications andexpectations associated with a possible surgery in the infratemporal fossa. Theinfratemporal fossa, and continuous pterygopalatine fossa, represent an complexregion where a number of neoplastic, inflammatory and vascular diseases candevelop. Soft tissue injuries can result in damage to nerves, vessels and musclesto result of decrease or loss of appropriated function. This study was focused onthe detailed display of neurovascular structures and their clinical importance inthe areas which are crucial from a clinical point of view.Methods: The topography was studied in adult male and female cadaver heads.The extended lateral transmandibular and transsphenoidal approaches providewide access to the infratemporal and near pterygopalatine fossa. Because both offossae are small spaces, detailed picture and high resolution imaging techniquesare required to evaluate the topography of neurovascular structures located inthem.Results: The precise preparative technique revealed detailed pictures ofneurovascular structures in this irregular region. Predominantly sensory nervesof the second and third division of the trigeminal nerve or chorda tympani,maxillary artery and its branches, and pterygoid venous plexus were depicted.Conclusion: The infratemporal fossa is one of the most difficult regions ofskull base to access surgically. The anatomical knowledge gained in this regionis important not only for the basic orientation for medical students but it is alsoa real asset to the professional growth of the maxillofacial and neurosurgeons,plastic and reconstructive surgeons in a daily practice.This study was supported by grant KEGA 3/7291/09

P1M Plastic and Reconstructive Surgery andRegenerative Medicine

P1M-1 A study of 8 years with Cook-Swartz Doppler in Free-Flapoperations, Macro, Micro and Re-exploration results

A. Schmulder1

1Plastic Surgery, Hand Surgery And Burn Center, RWTH, University Hospital,Aachen, Germany

Objective:1. The efficacy of this modality, in Macro and in Micro aspects: each of the

branched microsurgical divisions, comparing results of overall success andfailure rates to the control group.

2. Re-exploration operations: time taken place, finding outcomes, sensitivityand specificity of this modality.

3. Learning curve of the staff.


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4. Examining the widespread view that this modality is recommended for buriedfree-flaps.

Methods: In a retrospective study, tracking the admission and usage of theimplantable Doppler in the microsurgical unit (2000–2007), we evaluatedall parameters mentioned from 523 consecutive patients, underwent 608microsurgical proceduresResults:1. The overall success rates are promoted by this device, from 90·02%

to 95·72%. Most effective in E.N.T (94·6% versus 83·43%), Breastreconstruction (94·6% versus 77·5%) and Orthopaedic oncology (97·15%versus 93·45%). Showed no necessity in Re-animation operations (both100%), also less success in Trauma/Orthopaedics.

2. Higher rate of microsurgical revisions monitored by implantable Dopplerversus the control group (12·84% versus 8·54%). Nevertheless, achievedtremendous success rates: 87·9% versus 46·6%, especially due toearlier detecting time of blood interference/occlusion (1–1·18 days versus2·5–2·7 days). 100% Sensitivity and 91·6% specificity for this modality.

3. Conspicuous learning curve (reducing operation time by an average of3 hours and one hour shorter for revisions).

Conclusions: It’s the first research branching Macro results into Micro-divisions. The implanted Doppler was found most beneficial in E.N.T,Breast reconstruction and Orthopaedic oncology; not effective in Re-animationoperation, though it’s a buried free-flap. In divisions with no or less success, wesuggest cutting costs and transferring this modality to recommended divisions.

P1M-2 Cosmetic Surgery in Non-Caucasian Patients in the UK–AnIndividual Surgeon’s Experience

R. Mahapatra1, A. J. K. Patel1, C. M. Malata1

1Addenbrooke’s Hospital, Cambridge, UK

Objective: Ethnic minorities have traditionally avoided aesthetic surgery forreasons that may include concerns over adverse scarring and socio-economicfactors/barriers. American data suggest a dramatic rise in non-Caucasianaesthetic surgery over the last decade, but there is little published aboutthe UK.Methods: A case note study of the senior author’s British non-Caucasianpatients undergoing aesthetic surgery over a 10-year period.Results: Fifty-four Private and 22 NHS patients were identified. The majority(n=33) were from the Indian subcontinent (‘‘Indians’’) or of African ethnicity(n=17), the remainder being mixed race (n=12), Middle-Eastern (n=8) andOriental (n=6). Most patients were female.Common procedures included abdominoplasty (n=27), 18 of which werein ‘‘Indians’’; liposuction (n=22); and rhinoplasty (n=14), of which 6 wereMiddle-Eastern. Most rhinoplasties (Afro-Caribbean/Middle-Eastern) soughta more Caucasian-looking nose and 3 Oriental patients requested eyelid‘Westernisation’. Many private patients underwent more than one proceduretype, often sequentially.There were relatively few female breast reductions (n=8), and breastaugmentations (n=4). Facial rejuvenation surgery was conspicuous by itsabsence.Hypertrophic scarring occurred infrequently and was treated successfully withsteroid injections and topical silicone. There were no new keloids.Conclusion: Ethnic cosmetic surgery may be on the increase. Certain ethnicgroups were more likely than others to request particular operations. The highnumber of abdominoplasties reflects the predominance of ‘‘Indian’’ patients, anethnic group in which central obesity is prevalent. The low number of breastreductions (which are commonly requested by African Americans) reflects thesocio-economic barriers faced by many Afro-Caribbeans in the UK. The reasonsfor these and other trends merit further study.

P1M-3 Cardiac tissue engineering. Benefits of cell seeded matrixassociated to intramyocardial cell therapy in ischemiccardiomyopathy.

J. Herreros1, J. C. Trainini2, N. Lago2, J. C. Chachques3,S. Mastrobuoni1, O. Masoli2

1Cardiovascular Surgery Department, Cl´ınica Universitaria, University of Navarra,

Pamplona, Spain 2Cardiovascular Surgery Department, Hospital Presidente Peron,Avellaneda, Argentine 3Cardiovascular Surgery Department, Hopital GeorgesPompidou, Paris, France

Objective: To assess the benefitsof a cell seeded matrix associated tointramyocardial cell therapy in patients with ischemic cardiomyopathy.Methods: In 45 patients with ischemic cardiomyopathy, ejection fraction< 45%, myocardial scars and indication of coronary bypass surgery, stemcell therapy was associated to revascularization surgery. The patients weredistributed in four groups: Group I (11), 202 ± 11 × 106 bone marrow cellswere injected into the scar; Group II (12), 230 ± 80 × 106 myoblasts wereinjected into the scar; Group III (11), 716 ± 324 × 106 bone marrow cells wereinjected into the scar (40%) + were used for seeded the collagen matrix (60%);Group IV (11), 380 ± 70 × 106 myoblasts were injected into the scar (40%) +were used for seeded the collagen matrix (60%).Results: There was no mortality, nor any related adverse events (followup of 327 ± 176 days). The NYHA class (p< 0, 0001) and the ejectionfraction improved in all the groups: Group I, 26, 8 ± 6, 0% to 36, 3 ± 12, 2%(p< 0, 0001); Group II, 30, 4 ± 5, 0% to 40, 2 ± 6, 2% (p< 0, 002); GroupIII, 31, 6 ± 14, 9% to 39, 3 ± 18, 4% (p< 0, 01); Group IV, 29, 7 ± 4, 8% to43, 7 ± 6, 1% (p< 0, 0001). The left ventricular diastolic diameter showed areduction in Groups III (63, 2 ± 8, 7 mm to 60, 2 ± 9, 7, p< 0, 02) and Group IV(64, 2 ± 9, 1 mm to 58, 6 ± 7, 2 mm, p< 0, 001), with no significant changes inGroup I (63, 5 ± 9, 2 mm to 60, 5 ± 9, 1 mm, ns) and Group II (64, 1 ± 9, 4 mmto 60, 1 ± 9, 3, ns).Conclusions: Stem cell therapy with bone marrow cells and myoblasts is afeasible and safe treatment with improvement of the functional capacity andsystolic function. The bone marrow cells or myoblasts seeded collagen matriximproves diastolic function, limiting ventricular remodeling.

P1M-4 Epigastric hernia following DIEP flap breast reconstruction:Complication or coincidence?

K. Conroy1, S. Dwerryhouse2, C. Malata3

1Clinical School of Medicine, Cambridge University, Cambridge, UK 2UpperGastrointestinal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHSFoundation Trust, Cambridge, UK 3Department of Plastic and Reconstructive Surgeryand Cambridge Breast Unit, Addenbrooke’s Hospital, Cambridge University HospitalsNHS Foundation Trust, Cambridge, UK

Objective: Donor site hernias are a rare but well recognised complication ofdeep inferior epigastric perforator (DIEP) flap breast reconstruction but thereare no reported cases of epigastric hernias after such surgery. We report threepatients who developed symptomatic epigastric hernias within 2–8 months afterdischarge from follow-up.Methods: Patients who were referred to the Breast Plastic Surgery Clinic withsymptomatic epigastric hernias following DIEP flap breast reconstruction wereretrospectively reviewed.Results: The three patients were aged between 50 and 70 years. Their meanBMI was 29 and none were smokers or diabetic. The incidences of otherpredisposing factors were: previous abdominal surgery (1/3), heavy lifting (2/3)and multiparity (2/3). They were successfully treated laparoscopically (2) or byopen technique (1) confirming the CT scan findings.Conclusion: The aetiology of epigastric hernias is obscure in general. Theassociation with DIEP flap harvest may be purely coincidental. However itappears that abdominal flap harvest predisposed these patients to epigastrichernias. one or more of the following factors may have caused either weaknessof the anterior abdominal wall or increased intraabdominal pressure:

• Short-term partial denervation of the rectus abdominis muscle• Heavy lifting


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• Previous surgery, obesity and multiple pregnancies• Tight plication of the infraumbilical rectus sheath and muscle

This series of 3 symptomatic epigastric hernias following DIEP flap breastreconstruction is interesting as it documents donor site morbidity at a sitedistant from the exact site of flap harvest; this subject merits further detailedinvestigation.

P1M-5 Differential regulation of rat myocardial genes in the unloadedheart: a time course study

M. N. Giraud1, H. Brinks2, I. Breyer1, S. Krajinovic1, T. P. Carrel1,W. Koch2, H. T. Tevaearai1

1Department of Cardiac and Vascular Surgery, Inselspital University Hospital, Berne,Switzerland 2George Zallie and Family Laboratory, Center for Translational Medicine,Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA

Objective: Mechanical unloading results in progressive atrophy associatedwith gradual loss of cardiomyocytes, shift of the myocyte/connective tissue ratioand increase in myocardial stiffness as well as time dependent modificationsof the ventricular contractile capacity. Accordingly, we hypothesized thatunloading regulates genes involved in extracellular matrix remodeling, fetalreprogramming, muscle activity and apoptosis/autophagy in a time dependentmanner.Methods: Heterotopically transplanted normal rat hearts were harvested at 0(control) 3, 8, 15, 30, 60 and 90 days. Total RNA was purified and 47 genes wereanalyzed using microfluid cards. Accurate housekeeping genes were identifiedusing GeNorm, followed by ��Ct calculations and one way ANOVA/HSDpost hoc test.Results: Eighteen genes showed statistically significant differential regulationafter time-course unloading. Genes involved in myocyte contractility wererapidly downregulated within 3 days, but recovered toward control levels withincreased duration of unloading (ATPase, cardiac alpha actin, myocardin,alpha-myosin heavy chain. Troponin T, Alpha PPAR). Expressions of fetalgenes (beta-myosin heavy chain, ANF, Troponin C and FGF-2) were highlyupregulated for all unloading durations. 18S rRNA levels were upregulated withincreased unloading duration. mRNA levels of the main anti-apoptotic genebcl2 was initially downregulated. However, apoptotic transcripts bax, caspase 3,6 and 9 were not modified up to 30 days.Conclusion: Our results suggest that unloading-induced atrophy is mainlyassociated with a rapid decline followed by early recovery of the expressionof genes regulating myocardial contractile apparatus. Our results may explainthe previously documented maintenance of functional capacity. The potentialmechanisms involved will be further investigated.

P1M-6 Antimicrobial treatment of skin and soft tissue infectionsof the hand

J. Long, A. IsmailPlastic Surgery Department, Selly Oak Hospital, Birmingham, UK

Introduction/Aims: Hand infections represent a significant proportion ofadmissions to the emergency department and may result in significant disabilityand long-term morbidity. Antimicrobial prescribing in these infections is ofteninconsistent despite the introduction of hospital guidelines. This study aimedto review antibiotic prescribing practices in all hand infections presenting to acentral UK teaching hospital over a one-year period.Materials/Methods: A retrospective review of all patients presenting to theEmergency Department (ED) between 2007/2008. Data was collected from EDadmission cards and medical notes.Results: 274 patients were identified and included in the study, median age40 years(r = 16–91). Of these, 42% had no clear aetiology, 17% were due toinfected lacerations, 15% due to insect bites and 7% due to foreign bodies.140/274(51%) patients presented with frank pus, yet only 70 patients requiredadmission. Of these, 58 had surgical intervention, with 22 undergoing multipleprocedures. 74% were discharged from the ED with no specialist follow-up.Over a quarter of all patients underwent incision and drainage in the ED,principally for paronychias.

Microbiology was obtained for 28% of patients (84% of inpatients).Staphylococcus aureus(33%), mixed skin organisms(13%) and MRSA(8%) weremost common. There was no consistent approach to oral antibiotic prescribingin the ED, or to IV therapy on admission, with varying antimicrobials, dosesand courses.Conclusions/Clinical Reference: Hand infections are a significantcontribution to the workload of the ED and the hand surgeon. Werecommend a thorough assessment, rigorous microbiology sampling protocol,a comprehensive antimicrobial prescribing protocol and early specialist reviewin more severe cases.

P1M-7 Factors predicting complication rates following BilateralBreast Reduction – A retrospective analysis of 222 patients

A. Hakeem1, E. Stefanidis1, R. Hardy1, L. Martin1

1Breast Unit, Aintree University Hospital, Liverpool, UK

Objective: Bilateral Breast Reduction (BBR) is regarded as a safe procedurewith high patient satisfaction. But some studies have recorded complicationrates as high as 43 to 52%. The aim of our study is to identify factors whichdetermine adverse outcomes following BBR.Methods: Patients who underwent BBR between Jan 2001 and Oct 2009 wereincluded in the study. Demographic and perioperative data were collected, aswere details of complications. Fisher’s Exact Test was used to identify factorspredicting adverse outcome.Results: The sample size for this analysis was 222 patients (444 breastreductions). Mean age was 39·3 (17–66) years and follow-up duration was 2to 106 months (Median = 56 months). The mean weight removed from eachbreast was 640 gms (range, 120–1300 gms). There were no complicationsneeding major revision. 58 patients had some minor complications (26·1%) and12 patients needed minor revision (5·4%). Minor complications included woundinfection (n=16, 7·2%), T-junction breakdown (n=10, 4·5%), dog ear (n=8,3·6%), hypertrophic or keloid scarring (n=8, 3·6%), fat necrosis (n=7, 3·1%),decreased nipple sensation at long-term follow-up (n=6, 2·7%), asymmetricnipple (n=1, 0·4%), inverted nipple (n=1, 0·4%) and haematoma (n=1, 0·4%).The significant predictors for complications (p<0·05) included age > than40 years (p=0·0374, OR=1·9000), BMI > than 27 (p=0·0062, OR=2·3180) andaverage mass removed per breast > than 800 grams (p=0·0399, OR=2·0040).Smoking status, pre-operative bra size and pedicle type had no influence on thecomplication rate.Conclusions: Higher the age, overweight/obese patients and larger breasttissue excised are significant predictors of complications following BBR.

P1M-8 Where in epidermis are keratinocyte stem cells located?

M. Przestrzelska1, W. L. Olszewski1,2, A. Domaszewska-Szostek1,M. Zaleska1

1Department of Surgical Research & Transplantology, Medical Research Center, PolishAcademy of Sciences, Warsaw, Poland 2Central Clinical Hospital, Ministry of InternalAffairs, Warsaw, Poland

Objective: We documented that human skin preserved in anhydrouspulverized sodium chloride for months and transplanted to skin mice andhumans is taken by the recipient (Transplantation 2006; 81: 1583–1588). Thegrafts were characterized by aggressive proliferation of keratinocytes (KC)seen on immunohistochemical section stained for BrdU. Clinically there wasevident hyperkeratosis. Dehydration in sodium chloride stopped proliferationand transplantation brought about restarting of mitoses. This model allowed toidentify cells that first undergo mitosis after contact with the recipient. Wouldthese cells be the spore-like stem cells?Aim: To identify KERATINOCYTE STEM CELLS in anhydric-sodium-chloride-preserved epidermis.Materials & methods: Fragments of normal human leg skin harvestedduring elective vascular surgery were preserved in anhydrous pulverized sodiumchloride. After 7 days they were rehydrated, the epidermis was separated andKC were isolated. They were cultured for 31 days. Viability of cultured KC wastested in Live/Dead Viability/Cytoxicity test every three days of culture.


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Results: The morphological shape of KC was totally preserved. Among thewhole population single large cells resembling by shape those from stratumspinosum and granulosum revealed full enzymatic activity even after 31 days ofculture. These cells did not express p63, CD29 and did not proliferate and maybelong to the so-called ‘‘spore-like’’ KC stem cells. Studies on their phenotypesare carried out.Conclusions: Preservation of KC in anhydrous pulverized sodium chloridedoesn’t stop some single cells’ to display enzymatic activity upon setting inculture. This method may help to identify KC of highest proliferative capacityprobably belonging to the so called spore-like stem cells.

P1M-9 Abdominoplasty as a tool for revision of complicatedurostomies – A case series

Z. Mickute1, Y. Chen2, C. Malata2

1School of Clinical Medicine, University of Cambridge, Cambridge, UK 2Departmentof Plastic and Reconstructive Surgery, Addenbrooke’s University Hospital, Cambridge,UK

Objective: Our aim was to describe the indications, surgical technique andoutcomes of abdominoplasty as a novel tool for revising complicated urostomies.Methods: Four patients (3F:1M; mean age/BMI = 56 years/32 kg/m2) whounderwent abdominoplasty for urostomy revision between Dec2007 andDec2009 were identified. Ileal conduits had been performed following ablativeor diversion surgery for cervical carcinoma, bladder carcinoma, interstitialcystitis and neuropathic bladder. A postal questionnaire was used to determinepreoperative and postoperative stoma function.Results: All had longstanding problems with urostomy appliance fittingcausing urinary leakage, skin irritation and embarrassment. Abdominoplastyindications included previous failed revisions (n=3), multiple abdominal scars(n=2), large abdominal apron (n=4) or deep skin creases (n=2). The joint plastic-urological operations lasted a mean of 188 min, with no major postoperativecomplications. Patients were discharged 8 days later. Three reported improvedappliance fitting and reduced urinary leakage; one, with intermittent leakagedue to a persistent abdominal fold superiorly, is scheduled for reverseabdominoplasty. All patients were satisfied with their functional and aestheticimprovement.Conclusion: Abdominoplasty is a viable option for improving the urostomydysfunction of intractable mechanical leakage by creating a flatter surfacefor appliance fitting. It widens the functional indications for aestheticabdominoplasty.

P1M-10 Induction of hind limb ischemia in mice: comparisonof different models for therapeutic arteriogenesis

A. A. Hellingman1, A. J. N. M. Bastiaansen1, M. R. de Vries1,L. Seghers1, J. W. Jukema2, J. F. Hamming1, P. H. A. Quax1

1Department of vascular surgery, Leiden University Medical Center, Leiden,Netherlands 2Department of cardiology, Leiden University Medical Center, Leiden,Netherlands

Objective: The aim of this study was to develop a hind limb ischemia mousemodel for testing cell therapies for PAD, which offers a therapeutic windowthat is large enough to detect improvements of blood flow recovery.Materials and Methods: Different surgical approaches for hind limbischemia were performed in C57Bl6 mice: single coagulation of femoral arteryor iliac artery, total excision of femoral artery and double coagulation of bothfemoral artery and iliac artery. Blood flow restoration was measured withLaser Doppler Perfusion Imaging (LDPI). Immuno-histochemical stainings,angiography and micro-CT-scans were performed for visualisation of collateralsand capillaries.Results: After single coagulation of the femoral- or iliac artery, blood flowalready restored 100% in 7 days, in contrast to a significant delayed flowrestoration after double coagulation (54% blood flow recovery after 28 days,P<0·001). After total excision, blood flow was 100% recovered within 28 days.Histological analyses, angiographs and CT-scans showed more collaterals andcapillaries in the ischemic hind limb. Compared to total excision in whichthe connections to the pre-existing collateral bed are completely disrupted,

double coagulation displayed more pronounced corkscrew-like vessels typicalfor collateral arteries on angiographs.Conclusion: The extent of the arterial injury is associated with differentpatterns of perfusion restoration. For testing new therapeutic approaches, thedouble coagulation model, most closely resembling multilevel PAD, might bethe optimal model. This model provides a substantial therapeutic window tostimulate blood flow restoration.

P1M-11 Transfemoral tissue engineered pulmonary valved stentimplantation

A. Metzner1, U. A. Stock3, A. Uebing2, K. Iino1, J. Boldt1, J. Cremer1,G. Lutter1

1Department of Cardiovascular Surgery, Christian-Albrechts-University of Kiel,School of Medicine, Kiel, Germany 2Department of Pediatric Cardiology, Christian-Albrechts-University of Kiel, School of Medicine, Kiel, Germany 3Department ofThoracic, Cardiac and Vascular Surgery, Eberhard Karls University of Tuebingen,University Hospital, Tuebingen, Germany

Objective: Percutaneous implantation of heart valves has been introducedclinically. Tissue engineered valved stents might pursued to overcome thepresent limitation of calcification.Methods: Porcine pulmonary heart valves and small intestinal submucosa wereobtained from a slaughterhouse and the intestinal submucosa used to cover theinside of the porcine pulmonary valved stents. Endothelial cells (EC) andautologous myofibroblasts (MF) were obtained from carotid artery segmentsof juvenile sheep. After the following MF-seeding, constructs were placed ina dynamic bioreactor system and cultured for 16 days. After EC seeding, thetissue engineered valved stents were deployed into the pulmonary valve annularsite. Angiography was performed at implantation and at the end of the study(4 weeks). The size of the stent was controlled by angiography at the timeof implantation and explantation. Constructs were analyzed by post morteminvestigation, microscopically and radiographically (mammogram).Results: Orthotopic position of the stents (n=6) was observed at the timeof implantation and explantation, one heterotopic position was found at thetime of explantation. Two out of nine sheep showed an endocarditis whichwas excluded from the study. Post mortem investigation confirmed excellentopening and closing of all leaflets. Strong expression of α-smooth muscleactin in neo-interstitial cells and of v Willebrand-Factor and PECAM-1 inendothelial cells was revealed by immunocytochemistry. The stent was analyzedby mammography and v Kossa-staining and showed mild calcification. CD68,characteristically for macrophages, demonstrated no signs of inflammationConclusions: This study demonstrates good function of all leaflets of thepercutaneous implanted tissue engineered pulmonary heart valved stents after4-week follow-up.

P1M-12 Flow charts for improving efficiency and education duringbilateral complex reconstructive surgery of the breasts

R. Som1, L. Fopp1, C-M. Malata1

1Department of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Objective: Microvascular free flap surgery for breast reconstruction isnow routine and has even been safely extended to ‘‘challenging’’ groups ofpatients like the obese, the elderly and those with multiple abdominal scars.However, bilateral immediate free flap breast reconstruction remains technicallydemanding and lengthy surgery. For junior doctors, anaesthetists, scrub nursesand other theatre staff, the operative process is logistically confusing, largelybecause it involves multiple steps and theatre teams. We aimed to simplify theprocess and improve its efficiency by designing diagrammatic representationsof the operative procedures.Methods: For bilateral deep inferior epigastric perforator (DIEP) and glutealartery perforator (GAP) free flaps, flow-charts outlining each major step of theoperation were designed and implemented. The flow-chart explains, amongstother things, the positioning of the patient and what each surgeon is doing atwhat time. These charts are colour-coded, and laminated copies are handed out


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to relevant members of the theatre staff prior to the surgery. A master copy isdisplayed in the operating theatre in a prominent place at all times.Results: Theatre staff felt better prepared for each step of these operations, aswell as more confident about the procedure as a whole. Their understanding ofwhat each step entails, and why it was being performed, was much improved.Conclusion: The use of flow-charts conceptually and visually simplify complexreconstructive surgical procedures thereby improving acceptance among nursingand auxiliary staff with consequent increase in operative efficiency. The generalprinciple of using flow-charts can be applied to any complex surgery outside ofthe field of breast reconstruction.

P1N Robotic and Minimal Invasive Surgery

P1N-1 Basic course of experimental microsurgery for residentsin general surgery. A pilot experience

L. Dall’Olmo1, C. Castoro1, M. Cagol1, S. Merigliano2, E. Ancona1,2

1Istituto Oncologico Veneto - IRCCS - Padua, Italy 2Department of SurgicalGastroenterological Science ‘‘Pier Giuseppe Cevese’’ Padua University, Italy

Microsurgery constitutes the basis of modern surgery in many specialties, suchas neurosurgery, ophthalmology and plastic surgery. Moreover, according tosome authors, microsurgery can be considered part of the education of a generalsurgeon.Objective: Aim of this project was to set up a basic course of experimentalmicrosurgery for residents in general surgery at Padua University.Methods: The course was organized in two full-time days (10 h/day) at theInterdepartmental Center of Experimental Surgery – Padua University. AnAesculap basic microsurgical instrumental set, two operative microscopes andEtichon sutures (Ethilon 10/0 and Prolene 8/0) were used. The course wasorganized in theoretical and pactical sessions, based on the use of the chickenleg as an ex-vivo model for practicing microanastomoses (arterial, venous andnervous anastomoses using the femoral vessels and nerve)Results: Twenty residents in general surgery followed the microsurgical coursein its first year (Nov 2008–Oct 2009). The course fully satisfied the residents’expectations. The ex-vivo animal model used showed various advantages: it ischeap, easy to obtain, reflecting clinical reality and neither living animals noranesthesia are required. The anastomotic patency and the extravascular leakagecould be evaluated at the end of the pactical sessions by infusion of methyleneblue and saline solution into the vessels. However, this model failed to evaluateeither vascular trombosis or the effectiveness of nervous anastomosis.Conclusions: This microsurgical course helps residents in surgery to learnbasic skills for microsurgery. We believe that a similar training could be offeredto medical students interested in a surgical career.

P1N-2 Transgastric and transvaginal interventions with hybridNOTES – animal study

S. Horvath1, K. H. Fuchs2, I. Takacs1, S. Javor1, B. Balatonyi1,A. Ferencz1, S. Ferencz1, K. Shanava1, G. Weber1

1Department. of Surgical Research and Techniques, Medical Faculty, University ofPecs, Hungary 2Department. of Surgery, Markus-Krankenhaus, Frankfurt am Main,Germany

Objective: The Natural Orifice Transluminal Endoscopic Surgery (NOTES)is the newest trend of the minimal invasive surgery. This technique is preferredbecause of less pain, shorter hospitality, quicker recovery and procedures canbe performed without skin incision. The aim of this study was to carry outtransvaginal cholecystectomy (TC) and transgastric bowel resection (TG).Methods: The first NOTES procedure - transvaginal cholecystectomy - inHungary was performed in our Institute in 2008 on 8 domestic pigs, and inthe beginning of this year transgastric small bowel resection was performedon 14 animals. Both procedures were carried out with hybrid technique usinglaparoscopic and endoscopic instruments.Results: In the TC group the average operation time was 70 minutes (40–145)and in the TG group was 90 minutes (60–145). One animal died on the 6thpostoperative day in the TG group because of mechanical large bowel ileus,

however during the operations and follow-up period (3 months) surgery relatedcomplications and mortality were not detected.Conclusions: According to our experiences both procedures can be safelycarried out on animal model, but further refinement of devices is necessary.

P1N-3 Precondition can reduce surgical stress following laparoscopicprocedures

S. Javor1, K. Shanava1, S. Horvath1, I. Takacs1, B. Balatonyi1,S. Ferencz1, A. Ferencz1, M. Kurthy1, E. Roth1, G. Weber1

1Department of Surgical Research and Techniques, Medical Faculty, University ofPecs, Pecs, Hungary

Objective: Laparoscopy is more beneficial technique in surgery thanconventional open technique, but the used pneumoperitoneum has some badischemic effect. Aim of our investigation was to evaluate the beneficial effect ofprecondicioningMethods: 40 female Wistar rats were used for the experiment. Animals weredivided into 4 groups: I. group (n=10): control (only anesthesia), II. group(n=10) pneumoperitoneum (PP), III. group (n=10) 2 cycle of desuflation andinsuflation + pneumoperitoneum (2×ID+PP), IV. group (n=10) desuflationand insuflation + pneumoperitoneum (ID+PP).Pneumoperitoneum was created by Veress needle inserted transvaginaly intothe abdominal cavity. Blood samples were taken 30 minutes after procedure.Within oxidative stress markers superoxide-dismutase (SOD) activity, reducedglutathione (GSH), sulfhydryl groups (SH-) and malondialdehid (MDA)concentration was measured.Results: SOD activity, GSH concentration was decreased in PP groupcomparing to control and 2×ID+PP and ID+PP group. There was nodifference between the groups in SH- and MDA concentrations. In ID+PPgroup was the mildest surgical stress.Conclusion: Based on our results short time insuflation and desuflation canreduce negative effects of pneumoperitoneum. This method has also importantclinical implication.

P1N-4 The effects of post-conditioning during the creationof pneumoperitoneum

K. Shanava1, S. Javor1, S. Horvath1, I. Takacs1, B. Balatonyi1,S. Ferencz1, A. Ferencz1, M. Kurthy1, E. Roth1, G. Weber1

1Department of Surgical Research and Techniques, Medical Faculty, University ofPecs, Hungary

Objective: There are several reports of ischemic complications in the clinicalpractice after the laparoscopy. The conditioning has a good effect for a variousischemic diseases. This experimental study was designed to investigate theeffects of post-conditioning in the creation of pneumoperitoneum.Methods: Thirty-two rats were divided into four groups. Pneumoperitoneumwas created by CO2 insufflation under a pressure of 10mmHg. Rats in the firstgroup (control) were subjected to only anesthesia for 100 min. Second group(Pp) was subjected to pneumoperitoneum for 60 min followed by 30 min ofdesufflation. Third group (Pp-post-5 min) was subjected to pneumoperitoneumfor 60 min followed by 5 min of desufflation, 5 min of insufflation and againfollowed by 30 min of desufflation. Forth group (Pp-post-2cycles) was subjectedto pneumoperitoneum for 60 min followed by 2·5 min of desufflation and2·5 min of insufflation repeated in two cycles and then followed by 30 min ofdesufflation. Blood was collected from every animal after final desufflation ineach group.oxidative stress markers malondialdehyde (MDA), superoxide dismutase (SOD),reduced glutathione (GSH) and sulfhydryl groups (SH) levels have beendetermined.Results: In third(Pp-post-5 min) group levels of the oxidative stress markersin blood were significantly ameliorated than in Second (Pp) and Forth (Pp-post-2cycles) groups.Conclusions: post-laparoscopy conditioning may reduce the oxidative injuryfollowing laparoscopic procedures.


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P1N-5 Laparoscopic versus open incisional hernia repair: arandomised clinical trial

H. Eker1, M. Buunen1, B. Hansson2, P. Klitsie1, H. Jeekel1, J. Lange1

1Erasmus Medical Center, Rotterdam, Netherlands 2St. Radboud ziekenhuis,Nijmegen, Netherlands

Objective(s): The ongoing debate about the merits of endoscopic versus openincisional hernia repair prompts the need for a level 1 randomised controlledtrial. In this trial, quality of life outcomes, postoperative pain, operative data,hospital admission and recurrence rates in the two techniques are analysed.Methods: Two-hundred-and-six patients with an incisional hernia larger thanthree cm and smaller than 15 cm were randomized equally to laparoscopicor open mesh repair. Quality of life was assessed with EuroQoL 5-D, SF-36questionnaires, pain and nausea with Visual Analogue Scales. Follow-up controlsat the outpatient clinic were performed at six weeks, one and five years.Results: The quality of life was equal in both groups. The theatre time forthe laparoscopic group was longer (96 min versus 72 min, p<0·001). Blood lossduring the operation was less in the laparoscopic group (39 ml versus 63 ml,p=0·04), as well as the number of patients receiving a wound drain (3% versus43%, p<0·001). At a follow-up period of 44 months recurrence rates were equal(16% versus 17% p=0·32). The defect size was found to be an independentpredictor for recurrence (< 0·001).Conclusions: Laparoscopic surgery appears to have no advantage in healthrelated quality of life compared to open surgery. During the operation thereis less blood loss and less often need for a wound drain. The theatre time is,however, longer in the laparoscopic group. Recurrence appears to be equal withboth techniques. The defect size is found to be an independent predictor forrecurrence.

P1N-6 Transmediastinoscopic bronchial resection (Azorin procedure)as a first step in left pneumonectomy

C. Paleru1, R. Matache1

1Department of Thoracic Surgery, ‘‘Marius Nasta’’ Institute of Pulmonology, ‘‘CarolDavila’’ University of Medicine and Pharmacy, Bucharest, Romania

Objective: To present a rare mediastinoscopical minimal invasive techniquethat was never used to resect per primam the left main bronchi in a left lungsuppuration. The Azorin procedure was first presented in 1996 by Azorin-Francein order to resect the long bronchial stump after left pneumonectomy.Methods: We present the case of an oligofrenic patient of 22 y old whichwas admitted in our Department. with an chronic left sided empyema anddestructed lung. As the lung was completely destructed and retracted withno elastic remaining capability as a first step he was drained and washed andafter 2 weeks we have performed a Elloeser procedure(3 ribs) for daily opendebridement. The infection was unsolved in order to clean the pleural cavity, andwe intend to resect the left destructed lung. In order to perform this resectionin a clean environment we have used the transmediastinoscopic approach of theleft main bronchus.That approach permitted to have a bronchial stump healed in the moment ofthe resection procedure. After 2 weeks we completed the pulmonary resection(left pneumonectomy).From this point entire pleural cavity was cleaned and we achieved in 2 weeks tothe closure of the elloeser windows associated with a thoracoplasty technique.Conclusion: The risk of bronchial fistula is very high when the pulmonaryresection is realized in an infected environment. The transmediastinoscopicapproach of the left main bronchus permitted a safety resection from the pointa view of that risk.

P1O Surgical Oncology 1

P1O-1 Spleen preservation in radical surgery for gastric cancer

S. Turanli1, Y. Pirhan1, A. Cetin1

1Ankara Oncology Education and Research Hospital, Ankara, Turkey

Objective: To investigate the effect of spleen preservation on survival followingradical resection for gastric cancer.

Methods: We reviewed the records of 218 patients with gastric cancer whounderwent radical resection with D2 or D3 lymphadenectomy between January2007 and December 2008. Only 86 dead patients classified according to thepreservation of spleen or not. The groups were examined and comparedaccording to patients’ and tumor characteristics, treatment, and overall survival.Patients’ and tumor characteristics were compared in the groups by using theChi-square test or Fisher’s exact test. Kaplan-Meier curves for overall survivalwas estimated according to splenic preservation.Results: Of the 86 patients with radical gastrectomy, 16 underwentsplenectomy (group I) and 70 had splenic preservation (group II). The medianfollow-up time was 14·5 months (range; 9–19 months). The two groups weresimilar when age (p:0·06), gender (p:0·10), preoperative serum tumor markerlevels (p:0·85), serum albumin levels (p:0·26), hemoglobulin levels (p:0·23),histopatological diagnosis according to WHO or Lauren classifications (p:0·92),differentiation (p:0·95), tumor size (p:0·48), Departmenth of invasion (p:0·16),perineural invasion (p:0·77), lymphatic and/or blood vessel invasion (p:0·12),total number of metastatic lymph node (p:0·46), and total number of lymphnode removed (p:0·06) compared. Gastric cancer with corpus localization washigh in the latter group (p.0·001). The median overall survival was 14 versus15 months (p:0·75) respectively.Conclusion: Splenectomy does not seem to improve survival of patients whoundergo curative resection for gastric cancer in this study. Thus, the spleenshould be preserved in patients without direct cancer invasion of the spleen.

P1O-2 Retroperitoneal Leiomyosarcomas: An Asian Experience

S. Y. Lee1, B. K. P. Goh1, M. H. Chew1, L. L. P. J. Ooi2, W. K. Wong1,K. C. Soo2

1Department of General Surgery, Singapore General Hospital, Singapore2Department of Surgical Oncology, National Cancer Centre, Singapore

Introduction: The study was conducted to evaluate the clinical results ofresection for retroperitoneal leiomyosarcomas in a single institution and identifyany prognostic factors. Soft tissue sarcomas are rare and account for less than1% of all malignancies. Leiomyosarcoma, a rare malignancy of smooth muscle,is the most common subtype of retroperitoneal sarcoma after liposarcoma andfibrosarcoma.Material and Methods: A retrospective review of departmental recordswas used to identify 14 patients with primary retroperitoneal leiomyosarcomastreated between 1990 and 2005.Results: Fourteen patients with primary retroperitoneal leiomyosarcomasoperated on for curative intent (6 Males, 8 Females; mean age: 42·4 years, range:14–58) were evaluated. The median tumor burden was 36 cm (20–45 cm).Median follow-up time was 69 months. There was no peri-operative mortalityand morbidity occurred in 2(14·3%) patients. Surgical margins were involvedin 2(14·3%) patients. Resection of contiguous organs was required in 9(64·3%)to achieve gross surgical margins. Seven out of the 14(50%) of the patients hadrecurrence of the tumor.Conclusion: An aggressive surgical approach in retroperitoneal leiomyosar-comas is associated with long-term survival. Local control continues to bea significant problem. However as new surgical options are limited, furtheroutcome improvement requires novel adjuvant therapies.

P1O-3 Hurthle cell neoplasm of the thyroid

S. Turanli1, A. Cetin1

1Department of General Surgery, Ankara Oncology Education and Research Hospital,Demetevler, Ankara, Turkey

Objective: Hurthle cell neoplasm subdivided into benign Hurthle celladenomas (HCA) and malignant Hurthle cell carcinomas (HCC). The aimof this study was to investigate the clinico-pathologic characteristics, treatmentand outcome of Hurthle cell neoplasm.Methods: Between January 2000 and Novamber 2009, 20 patients (14 patientswith carcinoma and 6 patients with adenoma) with Hurthle cell neoplasmwere treated and monitored at the Ankara Oncology Education and ResearchHospital. At surgery, lymp node metastases was present in one patient anddistant metastases were not detected. All of the carcinoma group patients


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underwent 131I ablation after total thyroidectomy. The patients with HCA twounderwent thyroid lobectomy and four had total thyroidectomy.Results: The majority of patients were woman (64·3% for HCC, 66·7% forHCA, p:0·91) and median age was 53 years and 44 years respectively (p:0·58).The average tumor size 3·9 cm, with malign tumors being significantly largerthan benign tumors (5·1 versus 2·2 cm, p:0·03). No difference was foundfor multisentric tumor (p:1). The median follow-up time was 101·5 months(range;3–244 months) for HCC, and 7·5 months (range; 2–18 months) forHCA. Among the 14 patients with HCC, 6 (42·8%, three had both localrecurrence and distant metastases, three had only local recurrence) developedrecurrent disease 26–60 months after thyroidectomy (median 43 months), and14·3% percent of the patients with HCC died of thyroid carcinoma duringfollow-up, wheres there were no deaths related to thyroid carcinoma among thepatients with HCA.Conclusion: Age, gender and multisentrisity have not been associated withmalignancy but, tumor size is strongly predictive of malignancy.

P1O-4 Expression Of HGF, TGFα And IL6 Genes In FNH

O. Kornasiewicz1, K. Zieniewicz1, M. Krawczyk1

1Department of General, Transplant and Liver Surgery, Medical University ofWarsaw, Poland

Background: Focal nodular hyperplasia (FNH) is a rare benign conditionof the liver for which the pathogenesis remains unclear. In practice FNH issometimes difficult to diagnose and the majority are detected incidentally inasymptomatic patients. Specific changes in expression of the demonstrated genesin FNH remain unknown and may play an important role in tumour growth.Aim: To measure genes relative expression level of major growth factors: HGF,TGFα and IL6, in FNH compared to surrounding normal non-tumours liverparenchyma.Methods: To gain insight into the pathogenesis of FNH, we performed aquantitative study of gene expression in FNH. Samples were obtained fromthirteen patients during hepatic resection. Surgical resection was for abdominalpain and uncertainty in diagnosis. Gene expression was evaluated by Real TimePCR (TaqMan, Applied Biosystems, USA) in FNH tumours and compared tothe expression level of corresponding surrounding normal liver (control group).Results: The expression of IL6 gene within FNH was unchanged compared tonormal liver. There was increased gene expression of TGFα and HGF (4·2-foldand 2·4-fold respectively) in FNH compared to nearby normal tissue.Conclusion: Our data suggests that expressions of cytokines involved in thetumours growth such as TGFα, HGF are altered on transcriptional level inFNH compared to adjacent normal liver tissue. This might lead to changes in theprotein level or play a role in regulating tumour progression. Our findings maybe useful for understanding features of this distinct non-specific hyperplasticreaction of liver.

P1O-5 Tissue levels of proteinases in colorectal cancer pathologyand survival

E. A. Baker1, N. Robinson1, M. A. Tabaqchali1, D. J. Leaper2

1Professorial Unit of Surgery, University Hospital of North Tees, Stockton on Tees,UK 2Wound Healing Research Unit, Cardiff University, UK

Objective: The levels of matrix metalloproteinase (MMP) and plasminogenactivator (PA) system components were determined in paired tumour andnormal tissue samples and correlated with the tumour pathology and five yearsurvival.Methods: MMP and PAS expression was determined in paired tumour andnormal tissue samples from 101 colorectal cancer patients by a variety oflaboratory techniques; MMPs-1, 2, -3 and -9 and the tissue inhibitors, TIMPs-1 and -2, urokinase and tissue type PA (uPA and tPA), the PA inhibitors, PAI-1and -2 and the receptor for uPA, uPAR. Tissue levels were correlated withtumour pathology; Dukes stage, differentiation, tumour Departmenth, vascularand lymphatic invasion (P<0·05, Spearman’s correlation) and five year survivalanalysis was performed (p<0·05 Kaplan Meier).Results: The levels of all studied MMPs, uPA, uPAR, TIMP-1 and PAIs weresignificantly greater in colorectal tumour tissue than normal mucosa (P<0·05

Mann Whitney) e.g. MMP-1: tumour, median 10·6(range, 0·1–86·9) ng/mgtotal protein; normal, 0·2(0–15·2). However tPA levels were significantly greaterin normal mucosa.Tumour levels of MMPs, uPA, uPAR and PAI-1 significantly correlated withDukes’ stage e.g. TIMP-1: Dukes A, 24(2–351); Dukes B, 37(2–187); DukesD, 70(10–212). PAI-1 and uPA tumour levels also significantly correlated withlymphatic invasion, TIMP-1 and PAI-1 with tumour Departmenth and PAI-2with vascular invasion.There was no significant difference between tissue levels of these factors andsurvival.Conclusion: Proteinase and inhibitor expression in colorectal tumourscorrelates to tumour pathology but not five year survival.

P1O-6 Mcl-1 Expression in Cholangiocarcinoma

Y. Nakanishi1, H. Hashida1, Y. Miyauchi1, M. Yoshimura1, M. Yoshida1,M. Yoshitomi1, M. Tada1, S. Ueda1, H. Terajima1, N. Osaki1

1Department of Gastroenterological Surgery and Oncology, Kitano Hospital, TheTazuke Kofukai Medical Research Institute, Osaka, Japan

Objective: The resistance of TRAIL-induced apoptosis is modified in the stateof overexpression of Mcl-1, which is a member of anti-apoptotic Bcl-2 families,in cholangiocarcinoma (CC). Sorafenib is a one of multikinase inhibitors, whichcontrol tumor growth through Raf-associated cascades, and the expressionpattern of Mcl-1 in CC was investigated to examine whether sorafenib can be acandidate as a new therapeutic agent for CC.Methods: The expression patterns of Mcl-1 were evaluated by immuno-histopathological study in both normal bile ducts and cancer tissues in theresected 64 cases of CC, and were also compared with clinicopathologicalcharacteristics of the patients.Results: Mcl-1 expression was positive in 6 cases (9%) on the normal bileduct epithelium, while on the cancer tissue, it was positive in 56 cases (88%).The positive expression rete of Mcl-1 in the cancer part of CC was significantlyhigher in the advanced stage of cancer progression (UICC TNM classification).Conclusion: The Mcl-1 expression in the cancer tissue positively correlatedwith the stage of cancer progression in CC. There may be a possibility ofanti-tumor effect in sorafenib for advanced CC.

P1O-7 Immunization with immobilized non-proliferating cc531 cellsattenuates proliferation of implanted tumor cells

W. L. Olszewski1,2, M. Gewartowska1, M. Moscicka-Wesolowska1,O. Buyanovskaya1

1Department of Surgical Research & Transplantology, Medical Research Center, PolishAcademy of Sciences, Warsaw, Poland 2Department. of Transplantation Surgery,Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, Poland

The CC531 tumor cell line is frequently used for studies of metastasisformation due to its high proliferating and colonizing capacity. Interestingly,intraperitoneal immunization with CC531 cells with Freund adjuvant does notevoke detectable humoral or cellular response in the host. This may be explainedby low antigenicity and rapid proliferation and colonization of peritoneum, liverand lungs. The question arises as to whether the NON-proliferating tumorcells present in the host may evoke albeit weak but still detectable response andcompromise growth of metastases.Objective: To topically immunize host with CC531 cells pretreated withpulverized NaCl (mummified) and observe proliferation tempo of normalsubsequently implanted CC531 cells.Material and methods: WIS rats and CC531 cells preserved in pulverizedNaCl were used. NaCl treated tumor cells retained their morphological andmolecular structure. Group1. WIS were injected into paw with 10(6) tumorcells on day 0 and 14 and were followed until d 21. Group 2. WIS injected intopaw with 10(6)NaCl pretreated tumor cells on day 0 followed by injection ofnormal CC531 cells on d 14 and followed until d 21.Results: There was no increase in host PBM cytotoxicity toward CC531,however, proliferation of paw implanted cells at the immunization site (group2) was compromized, with PBM infiltrates, necrotic central areas and fibrosisaround. In contrast, there was a rapid tumor growth in non-immunized group 1.


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Conclusions: A weak but detectable local cytotoxic response to CC531was observed after prior implantation of non-proliferating NaCl-treated(mummified) tumor cells.

P1O-8 Comparative effects of portal vein embolisation and ligationprocedures on colorectal liver metastases growth rate in rats.

L. Maggiori1, F. Bretagnol1, M. Zappa2, A. Sibert2, N. Guedj3,V. Vilgrain2, V. Paradis3, Y. Panis1

1Department of Colorectal Surgery, 2Department of Radiology, 3Departement ofPathology, Beaujon Hospital (AP-HP), 100 boulevard du General Leclerc, Clichy,France

Objective: Preoperative portal vein ligation or embolization (PVL or PVE) hasbeen proposed to decrease the risk of severe postoperative liver failure in patientswith expected insufficient remnant liver volume after partial hepatectomy forcolorectal liver metastases (LM). But the positive effect of portal occlusion onliver function must be weighed against the potential negative side-effects interms of tumor growth in both occluded and non-occluded liver lobes. Thisstudy aimed to compare the use of PVL and PVE in terms of LM tumor growthrate.Methods: LM were induced in 70 BDIX rats by injecting 0,5 million DHDK12cells into the portal vein at day 0 and by injecting 1 million of DHDK12 cellsdirectly into the left medial liver lobe at day 7. At day 8, all rats were divided into3 groups i.e. rats undergoing a 70% left portal vein embolisation (PVE group),rats with a 70% left portal vein ligation (PVL group), and rats without anyprocedure (Control group). At day 37, all rats were sacrificed for pathologicalassessment and tumor volume measurement was performed.Results: At day 37, compared to the control group, the left occluded livertumor volume was significantly decreased in the PVE group (128 ± 20 versus248 ± 9 mm3, P=0·006) and increased in the PVL group (565 ± 233 versus248 ± 9 mm3, P=0·001). Compared to control rats, the right non-occludedtumor volume was significantly increased in both PVE and PVL groups (17 ± 9versus 5 ± 8 mm3, P=0·01 and 26 ± 22 versus 5 ± 8 mm3, P=0·01), respectively.Comparing the PVE and PVL groups, there was no significant difference interms of non-occluded liver tumor growth rate.Conclusion: Both PVL and PVE induced significant changes on LM tumorgrowth rate. PVL was associated with an increase of tumor volume in bothoccluded and non-occluded liver lobes. Following PVE, the LM tumor volumedecreased in the occluded liver lobe whereas an increase of LM tumor growthwas noted in the non-occluded liver.

P1O-9 Surgical procedures and outcome in high or intermediate riskneuroblastoma: preliminary report

Y. Koksal1, E. Gunel2

1Selcuk University, Selcuklu Faculty of Medicine, Department of Pediatric Oncology,Konya, Turkey 2Selcuk University, Meram Faculty of Medicine, Department ofPediatric Surgery, Konya, Turkey

Objective: To evaluate the outcome, serious surgical complications such astumor rupture, and the need for blood transfusion during postoperative periodin high or intermediate risk neuroblastoma.Methods: Patients with high or intermediate risk neuroblastoma were enrolledin this study. At the time of diagnosis, if complete resection was not possible,delayed surgery was performed after the chemotherapy regimen on the riskfactor status. All patients’ operation findings, complications and the outcomeswere evaluated retrospectively.Results: There were 6 girls and 3 boys with a median age of 31 months(range, 12–102 months) at diagnosis. All patients had abdominal disease. Themajority of the patients was in high risk group (n:7) and stage IV (n:7).In two patients, the tumors were removed totally before the chemotherapy.No complication was determined in these patients. In 7 patients, biopsy wasperformed, and the biopsies were not associated with any adverse events. Afterintensive chemotherapy, the tumors were resected totally in this group. Sixof them had radiotherapy after the surgery. In one patient with intermediaterisk, ileus developed and the patient was reoperated for ileus. Inferior venacava injury was seen in one patient. Tumor rupture was not determined in

any patient. Tumor control was achieved in all patients. Only one patient withDown syndrome died from severe pulmonary infection. Median follow up timewas 18 months (range, 7–32 months).Conclusions: Both primary and delayed surgery with intensive chemotherapyand/or radiotherapy have been successful for primary tumor control inintermediate and high risk neuroblastoma patients.

P1P Vascular Surgery

P1P-1 Is Retrograde Distal Vascularisation Of Forearm Veins FromCubital Fossa Arteriovenous Fistulae Useful For Haemodialysis

H. Y. Lam, K. C. B. Yeoh, B. A. Abdul Kareem, K. MoissinacDepartment of Cardiothoracic, Hospital Penang, Penang, Malaysia Department ofGeneral Surgery, Hospital Penang, Penang Medical College, Penang, Malaysia

Objective: Although the wrist arteriovenous fistula (AVF) is assumed as thestandard, non maturation in up to 40% have been reported. The next option,the cubital fossa fistula normally allows only proximal antegrade flow (as valvesprevent retrograde distal flow) thus not utilizing the forearm veins for dialysis.To induce retrograde distal flow from a cubital fossa AVF into the forearm veins,valve destruction in the forearm veins was undertaken. As there has been noprevious evaluation of this, hardly, if at all previously undertaken nor describedstrategy, a study was thus undertaken to determine whether valve destruction toallow retrograde distal flow from a cubital fossa fistula into forearm veins waseffective for haemodialysis.Methods: Those who underwent forearm vein valve destruction to vasculariseforearm veins from a cubital fossa AVF with retrograde distal flow, wereevaluated during outpatient follow up and/or haemodailysis to determine thefunctional patency of the retrograde distal flow forearm vein segment, whichwas compared with functional patency of controls with upper arm antegradeproximal flow cephalic and basilic vein segments.Results: Of 136 included patients with forearm vein retrograde flow, theretrograde flow forearm vein segments were a) being used for haemodialysisarterial extraction in 52 (28·2%) and haemodialysis venous return in 18 (13·2%),b) previously used for arterial extraction in 8 (5·9%) and venous return in 3(7·2%) and c) deemed usable (but not used) for arterial extraction in 19 (14·0%)and venous return in 23 (16·9%). In 13 (9·6%) the distal retrograde forearmvein segment did not to mature. On Kaplan Meier Survival Analysis, functionalpatency of the retrograde distal flow forearm vein segment was similar to thecontrols with antegrade proximal flow cephalic and basilic vein segments.Conclusion: Retrograde distal flow forearm vein segments were being usedfor haemodialysis in a substantial proportion. Another substantial proportionhad forearm vein segments which were deemed usable but not used, perhapsbecause functioning antegrade proximal flow upper arm vein segments wereavailable for use. Although sample size is modest, the study illustrates thatvalve disruption to create retrograde distal flow in forearm veins provides anadditional vein segment for haemodialysis.

P1P-2 The new surgical technique (mes-tech) in the left subclavianartery blockage that accompany the coronary artery disease.

M. Ozcan1

1Department of Cardiovascular Surgery, Hospital of Acibadem, Kayseri, Turkey

Objective: The optimal surgical strategy for patient with subclavian arteryblockage that accompany the coronary artery disease has not yet beenestablished. A few reports exist regarding the management of patients whohave both occlusive disease. In this case, a new surgical technique was used.Methods: A 60 years old male patient came with complaints of numbness on theleft arm, pain and cold feeling during rest. The left subclavian artery, beginningat the origin of descending aorta was totally occluded, determined on the DSA.In the coroner angiography, 80% stenosis in left anterior descending artery,70% stenosis in proximal circumflex artery, 70% stenosis in right coronary arterywas determined. Remembering the patient’s complaints a surgical interferencewas planned for both symptoms in the same operation with a single incision.Under open heart surgery conditions, median sternotomy was performed andleft internal mammarian artery was harvested with cardiopulmonary bypass,


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saphenous vein was used and bypass was completed on LAD, OM andRCA. LIMA’s distal end was anastomozed to ascending aorta. Ascendingaorta – LIMA – left subclavian artery.Results: This method provided blood supply to the subclavian artery viathe left internal mammarian artery from ascending aorta. Control DSA thatwas done a year after the operation showed effectively functioning ascendingaorta–LIMA–left subclavian artery anastomosis.Conclusion: The cases where the left subclavian artery blockage thataccompany the coronary artery disease, when left internal mammarian arteryis suitable, this method offers a simple, effective and handy solution for; 1-notrequiring the second incision, 2-not requiring a prosthetic graft, 3-LIMA beingused as graft, 4-solving two problems with one operation.

P1P-3 Prospective observational study for assessment of validity,sensitivity and responsiveness of Short Form 8 (SF8) questionnairefor generic quality of life (QOL) evaluation in patient with intermittentclaudication (IC) due to femoro-popliteal disease.

F. Mazari1, J. Khan1, M. Abdul Rahman1, K. Mockford1, T. Mehta1,P. Coughlin1, P. McCollum1, I. Chetter1

1Academic Vascular Surgical Unit, University of Hull, Hull, UK

Objectives: Generic quality of life (QOL) assessment is routinely performedto report outcomes of clinical trials for lower limb ischaemia. Most commonlyused instrument is SF36 that generates eight domain scores. More recently,SF8 questionnaire has been used increasingly in similar situations. This studyaimed to test sensitivity and validity of SF8 and its responsiveness to changefollowing intervention in patients with intermittent claudication (IC) due tofemoro-popliteal disease.Methods: 49 patients (30males) undergoing non-surgical intervention for ICwere recruited. Assessments were performed pre-intervention and at 1, 3, 6& 12 months post-intervention. At each visit, clinical indicators of lower limbischaemia (ABPI,ICD,MWD,PRWD) were recorded and patients completedSF8 &SF36 questionnaires. Correlation analysis was performed between SF8domain and summary scores and clinical indicators using non-parametric tests.Comparisons were made with SF36 domain scores at all time points.Results: SF8 showed statistically significant improvement in physical andmental domain & summary scores at all time points as a result of intervention(Friedman test, p<0·001). Maximum benefit was seen at 3 months with mostsignificant improvement in physical domains (Mann Whitney test, p<0·05).SF8 correlated moderately with ICD and PRWD in all domains except bodilypain(Spearman rank, r=0·442–0·705, p<0·001). No significant correlation wasseen with ABPI.SF8 showed strong correlation with SF36 at all time points in all likedomains(r=0·690–0·853, p<0·001) demonstrating convergent validity andresponsiveness to change.No missing data was seen in SF8 considerably reducing the administrativeburden.Conclusion: SF8 is valid, sensitive and responsive quality of life instrumentthat can be used for generic QOL assessment in patient with lower limbischaemia.

P1P-4 Protection of vitamin E on reperfusion injuries in reconstructivevascular operations

E. Arato1, L. Sinay1, M. Kurthy2, P. Hardi1, M. Shafiei1, Z. Miklos1,E. Roth2, G. Jancso1

1Department of Surgery, University Of Pecs, Hungary 2Department of SurgicalResearch, University Of Pecs, Hungary

Introduction: The challenge against reperfusion injury and tissue oxidativestress, especially in vascular surgical interventions has essential importanceto reach optimal clinical result. In our study we monitored the effect ofcontinuous preoperative treatment with vitamin E, on oxidative stress and tissueinflammation reactions developed after reconstructive operations.Patients and methods: 32 patients have been involved in a randomized,prospective study, all suffering from AFS occlusion proved by angiography, andall undergone supragenual reconstruction. In the group treated with E-vitamin,

we administered 1 × 200 mg of vitamin E p/o from the preoperative day till the7th post operative day. Patients of the second group did not receive vitamin E.Materials and methods: Peripheral blood samples were collectedimmediately before operation and at the end of the second reperfusion hour. Latereperfusion period has been monitored by analyzing blood samples taken at 24th

hour and 7th day next to operative ischemia. Among oxidative stress parameters,direct measurement of reactive oxygen intermediator (ROI) and determinationof antioxidant state (GSH, Total-SH group, SOD) have been performed.Malondialdehyde was chosen as marker for lipidperoxidation. Inflammationreactions were monitored up on expression of adhesion molecules (CD11a andCD18). We also controlled the oscillation of myeloperoxidase (MPO) activity.Results: Our study has proved that preoperative administration of 200 mgvitamin E could reduce the level of oxidative stress developed after ischemic-reperfusion insult. According to our results, the prooxidant-antioxidantimbalance also diminished in the group with E-vitamin treatment. We provedthat elective administration of vitamin E could decrease the WBC activity andits consequential local inflammation process, during early reperfusion.

P1P-5 Increased tissue pressures, an integral part in venous ulcerdisease

G. Gemayel1, J. T. Christenson1, J. Jolou1

1Department of Surgery, Division of Cardiovascular Surgery, Faculty of Medicine,University Hospital of Geneva, Switzerland

Objective: The interstitial hydrostatic pressure is affecting fluid movementsat the microvascular level. A disturbance in the Starling equilibrium results inedema formation. The effect of venous reflux on the interstitial fluid pressuressubcutaneously and intramuscularly and its relation to disease severity andpathology has been studied.Methods: Subcutaneous (sc) and intramuscular (im) tissue pressures weremeasured in: 10 healthy legs [Gr.1], 14 legs with primary varicose veins (pvv)without venous ulcer (C 2–4) [Gr.2], 45 legs pvv with ulcer (CEAP class 5 to 6)[Gr.3], 10 legs with secondary varicose veins (svv PTS) without ulcer (C 2–4)[Gr.4] and in 24 legs with svv PTS, with ulcer (C 5–6) [Gr.5].Pressure measurements were performed in standing positioning in the non-weight-bearing extremity using a 19-gauge needle connected to a pressuretransducer and recorder. The needle was placed first into the subcutaneoustissue 25 cm below the knee joint and pressure was measured at rest during4 minutes. The needle was then pushed into the posterior compartment andpressure was recorded.Results: Subcutaneous pressure was higher in Gr.1 compared to Gr. 2 to 5,p<0·001 and higher in Gr.4–5 compared to Gr. 2–3, p=0·034. Intramuscularpressures were higher in Gr.2–5 compared to controls (Gr.1), p<0·001 andhigher in Gr. 4–5 compared to Gr 2–3, p<0·001.Conclusions: Subcutaneous pressures are significantly elevated in limbs withvaricose veins compared to controls. Intramuscular pressures are significantlyelevated in legs with severe primary venous disease and even more so in post-thrombotic limbs. There is an excellent correlation between intramuscular tissuepressures and severity of the venous disease.

P1P-6 Influence of aneurysm wall stiffness and the presence ofintraluminal thrombus on the wall movement of an aneurysm.An in-vitro study

W. M. P. F. Bosman1, J. W. Hinnen1,2, W. H. Kopp1,T. J. v. d. Steenhoven1,3, B. L. Kaptein4, J. F. Hamming1

1Department of Surgery, Leiden University Medical Center, Leiden, Netherlands2Department of Surgery, Medical Center Haaglanden, The Hague, Netherlands3Department of Surgery, St. Elisabeth Hospital, Tilburg, Netherlands 4Department ofOrthopaedics, and the division of Image Processing, Department of Radiology (LKEB),Leiden University Medical Center, Leiden, Netherlands

Objective: Purpose of this in-vitro study was to investigate the influence ofaneurysmal wall stiffness on the wall motion. Furthermore we were interestedif the presence and elastic properties of intraluminal thrombus (ILT) have aprotective ‘cushioning’ effect on the extent of wall-movement.


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Methods: Three latex aneurysms were used, which each had a differentwall stiffness. The aneurysms, equipped with 20 tantalum markers, wereattached to an in-vitro circulation model. Fluoroscopic roentgenographic stereophotogrammetric analysis (FRSA) was used to measure marker movementduring 6 cardiac cycles. The radius of 3 circles drawn through the markerswas measured. This was measured at three different systemic pressures:90/60 mmHg, 120/90 mmHg and 160/90 mmHg.To investigate the influence of ILT on wall-movement, we repeated the sameexperiment with one of the aneurysms. The aneurysm sac was then filled withtwo in E-moduli differing thrombus analogues (Novalyse 8 & 20) or withperfusate as a control.Results: The mean radius (mm) and the amplitude of the wall movementincreased significantly as the compliance of the wall increased (p<0,05). TheE-modulus of ILT had no influence on the mean radius of the wall movement,but influenced the amplitude of wall movement (p<0,05).Conclusion: Compliance of the aneurysmal wall influences wall-movement. Ifthe stiffness of the wall increases, the wall movement diminishes. Intraluminalthrombus has a limited cushioning effect. Wall movement and thereby wallstress diminishes if the stiffness of the intraluminal thrombus increases.

P1P-7 A short posterior flap for below knee amputations- a techniquefor doing it by ‘‘halves’’

A. Chaudhuri1

1Bedford Hospital NHS Trust, Bedford, UK

Objective: A pilot study to assess the initial wound healing results of a modified3 : 2 long posterior flap in below knee amputations.Methods: 19 patients (age 48–90, mean age 73·8 years; 11 diabetic, 8 non-diabetic) underwent a below knee amputation using a posterior flap thatwas 1·5 times the length of the anterior flap, which was measured as ahemicircumference. Wounds were examined at weeks 1 & 2 postoperatively andclassified as I. Healthy, II. Redness and swelling of edges, III. Suture abscess IV.Spreading wound infection, and V. Wound breakdown. Drains were not usedand all patients were given intravenous antibiotics for 5 days.Results: All patients underwent successful below knee amputation withoutthe need for revision. Wound scores at week 1 were Grade I=17, Grade II=2,and at week 2 this was Grade I=18, grade II=1 (cellulitis which responded toantibiotic treatment). Analysis of total flap length revealed total length to be1/12 of the limb circumference longer than that achieved with a Burgess flap.Soleus trimming was required only in one young, muscular male patient. Therewere no dog-ears.Conclusion: A posterior flap that is 1·5 times the anterior is adequate withoutdog-ear formation or need for revision and can potentially replace traditionalBurgess flaps. It is potentially convenient when there is ascending tissue lossor infection along the posterior aspect of the leg that would preclude havinga longer, traditional posterior flap. It can be taught to trainees and is now theauthor’s preferred method of performing below knee amputations.

P1P-8 Impaired renal function following endovascular aneurysmrepair (EVAR) for abdominal aortic aneurysm (AAA)

M-F. Abdelhamid1,2, R-S-M. Davies1,2, R-K. Vohra2, A-W. Bradbury1,D-J. Adam1

1University Department of Vascular Surgery, Heart of England NHS FoundationTrust, Birmingham, UK 2Department of Vascular Surgery, University HospitalBirmingham NHS Foundation Trust, Birmingham, UK

Objective: To determine the effect of EVAR on renal function using serumcreatinine (sCr), estimated glomerular filtration rate (eGFR) and cystatin c(CC).Methods: 22 patients undergoing elective EVAR for AAA were prospectivelyrecruited. sCr, eGFR and CC were measured pre-operatively, one day, one andsix months following EVAR. Data were analysed using one-way ANOVA andWilcoxon signed rank t-test.Results: Mean Pre-operative levels were 133·7, 53·7 and 1·353 for sCr, eGFRand CC respectively. There was no statistical difference in sCr and eGFRat 24 hours, one or six months (135·8, 135·2 and 139·2 for sCr; 52·25, 53·9

and 50·30 for sGFR respectively). However, CC showed statistically significantincrease at the same intervals in comparison to pre-operative values (1·495,1·529 and 1·552; p 0·0038, 0·011 and 0·0034 respectively). CC was significantlycorrelated to sCr (p<0·001 at the four time points). None of the patientsrequired renal replacement therapy at six months post EVAR.Conclusion: These novel data demonstrate that EVAR causes a renal insult,represented by icreased Cystatin C, which starts on the first post-operative dayand continues at six months.

P1P-9 Clinical study of functional end-to-end anastomosis using theEthicon Echelon 60 Endopath stapler and cutter in surgery of coloncancer

S. Yamamoto, Y. Inoue, M. YamamotoDepartment of Gastroenterology, Tokyo Women’s Medical University, Japan

Objective: Functional end-to-end anastomosis (FEEA) is becoming a commonprocedure for surgery of colon cancer. We evaluated the results of FEEA at ourhospital.Methods: We assessed 155 cases (83 men, 72 women, average age 67·0 years)in which FEEA was used among 375 cases of colon surgery between April 2007and November 2009. FEEA was performed as follows. The intestine was cuton the oral side and the anal side of the lesion using the Ethicon Echelon 60Endopath stapler and cutter (Ethicon Japan, Johnson and Johnson) and smallopenings were made on the opposite side of the mesenterium through whichthe stapler fork was inserted to perform side-to-side anastomosis. To preventinvolving the mesenterium, two sutures were placed on the intestine for tractionafter inserting the stapler. The blind edge was anastomosed, suture to theanterior and posterior wall was performed, and a buried suture was applied tothe blind edge of the intestine.Results: Celiotomy was performed in 60 cases and laparoscopic surgery in 95cases. The location was as follows: cecum: 21 cases, ascending colon: 40 cases,transverse colon: 39 cases, descending colon: 24 cases, sigmoid colon: 31 cases.Postoperative complications were as follows: subcutaneous abscess: 16 cases(10·3%), anastomotic leakage: 3 cases (1·9%), ileus 4 cases (2·5%), subileus 1case (0·06%). No cases required re-operation because conservative treatmentwas remissive. There were no cases of recurrence or anastomotic bleeding.Conclusions: FEEA was found to be a useful and easy procedure.

P1P-10 Treatment with somatostatin of a Persistent Chyloperotoneumfollowing Abdominal Aortic surgery

S. Karaca, G. Gemayel, M. Cikirikcioglu, A. KalangosUniversity Hospital of Geneva, Departement of Cardiovascular Surgery, Geneva,Switzerland

Objective: Chyloperitoneum is an uncommon but serious complicationfollowing abdominal aortic surgery. The production of chylous ascites followingaortic surgery is the result of a lymphatic fistula of traumatic origin betweencisterna chili or adjacent major lymphatic trunks and the peritoneal cavity.The patient may present massive lymph drainage; which will induce criticallosses of fluid, lymphocytes, proteins, anticoagulation factors and antibodiesthus increasing morbidity and mortality. Concerning the treatment there isno uniformity in the literature. Chirurgical exploration may provoke a newtrauma and conservative treatments like low-fat-diet containing medium chaintriglycerides or total parenteral nutrition have slow effects without guarantee ofsuccess. This case report shows a management option of this uncommon clinicalproblem and the treatment with somatostatin.Methods: Four patients (m=3, f=1, mean age ±58y) were operated forabdominal aortic aneurysm. The patients presented postoperatively a milkyodorless ascites fluid in the abdominal drain > 400 ml/day collected byparacentesis with elevated triclyceride > 2·25 mmol/l (mean ±6·5 mmol/l) andthe increased lymphatic cells (mean ±68%). The treatment with fat free or richin medium chain triglyceride diet was not satisfactory and we marked importantdrain loss > 300 ml/day under conservative diet treatment. And we decided tostart with the somatostatin treatment as a continuous infusion up to 3·5 µg/kg/h.Result: Mean duration of the somatostatin treatment was ±5·5 days. Up to thesecond day of the treatment drain loss decreased < 150 ml/day. The abdominal


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drain could get off after mean ±7 days. The mean somatostatin dosis was±7·5 µg/kg/h. At the follow-up time (3–6 month) all patient showed goodgeneral condition without any signs of occurrence of chylo ascites or leak.Conclusion: These cases show a successful treatment with somatostatin of achyloperitoneum following abdominal aortic surgery. There are no guidelinesfor management of the chyloperitoneum in the literature and reporting of newcases is useful for sharing valid experiences.

P1P-11 Effects of revascularization of the deep femoral artery on thenutritional skin microcirculation

L. ClaeysDepartment of Vascular Surgery, University Hospital Herne, Ruhr-University ofBochum, Germany

Objective: The role of isolated revascularization of the deep femoral artery(DFA) in the management of chronic critical limb ischemia is controversial. Westudied the effects of revascularization of the DFA on the nutritional skin bloodflow in patients with chronic critical limb ischemia (CCLI).Methods: Isolated revascularization of the DFA was performed in 25 patientswith CCLI. All patients had foot ulceration or gangrene and rest pain. Pain reliefand improved microcirculatory blood flow, were defined as clinical success.Capillaroscopy was used to assess capillary density (CD) and red blood cellvelocity (RBCV) in the nail fold capillaries of the toes. The ankle-brachialindex (ABI) was used as macrocirculatory parameter. ABI and microcirculatorymeasurements were obtained before and within 1 week of the intervention.Results: Significant pain relief was observed in 70% of the patients asdemonstrated by visual analogue scale. Clinical improvement in terms ofpain relief was confirmed by improved microcirculatory blood flow. Capillaryperfusion improved significantly as shown by an increase in CD from23·2 ± 8·2 mm2 to 42·2 ± 11·5 mm2 (p<0·0001) and an increase in RBCVfrom 0·29 ± 0·12 mm/sec to 0·54 ± 0·17 mm/sec (p<0·0001). Ulcer healingwas observed in 57% of the patients, mean follow-up of 6·2 months.Conclusion: Isolated revascularization of the DFA improves microcirculatoryblood flow at the level of the nutritional blood flow. With relief of rest painquality of life improved. Ulcer healing is the result of an improved nutritionalblood flow.

Poster Session II

P2A Anaesthesiology and Intensive Care

P2A-1 Comparison of the effects of intravenous lornoxicam andparacetamol on the endocrine stress response and analgesia in thepostoperative period

C. Ozhan1, M. O. Ozhan2, M. A. Caparlar3, M. A. Suzer2, N. Cekmen4,M. B. Eskin5, I. Kati1

1Department of Anesthesiology and Reanimation, 100. Yil University, School ofMedicine, Van, Turkey 2Department of Anesthesiology and Reanimation, TDV 29Mayis Hospital, Ankara, Turkey 3Department of General Surgery,100. Yil University,School of Medicine, Van, Turkey 4Department of Anesthesiology and Reanimation,Guven Hospital, Ankara, Turkey 5Department of Anesthesiology and Reanimation,Gulhane Military Medical Faculty, Ankara, Turkey

Objective: We aimed to compare the effects of intravenous lornoxicam andparacetamol on the endocrine stress response and analgesia in the postoperativeperiod in patients who underwent thyroidectomy under general anesthesia.Methods: After obtaining informed consent, 60 ASA I–II women wererandomly assigned to lornoxicam (Group L; n=30) and paracetamol groups(Group P; n=30). The anesthesia was induced with propofol and fentaniland maintained with sevoflurane. 8 mg lornoxicam was given IV to group Pat the time of extubation and postoperative 12. hours (total 16 mg). 1000 mgparacetamol was given IV to group L at the time of extubation and with 8 hoursintervals in postoperative 24 hours (total 4 grams). Blood samples were takenbefore the surgery, at extubation and postoperative 1. and 24. hours to measure

ACTH, cortisol, insulin and growth hormone (GH) levels. Postoperative painwas evaluated with VAS (Visual Analogue Scale).Results: The levels of the hormones were in normal range before the surgery.ACTH, GH and cortisol levels were elevated at the extubation and remainedhigh at the postoperative first hour but then decreased and finally returned tonormal range at the end of the study. The level of insulin reduced at extubationand postoperative first hour then increased and returned to normal range. Thesechanges were more significant and VAS scores were lower in lornoxicam groupcompared to paracetamol (p<0·05).Conclusion: Surgical stress has significant effects on stress hormone responseand may be restored with effective pain therapy. Lornoxicam is superior for thispurpose attributable to its anti-inflammatory properties.

P2A-2 Doppler-Ultrasound Screening For Central-line AssociatedThrombosis Outside the Intensive Care Unit: Preliminary Results AfterTen Months Follow Up.

C. Inan1, V. Cartier1, W. Zingg2, M. Righini3, D. Pittet2, F. Clergue1,B. Walder1

1Division of Anesthesiology, 2Infection Control Program, 3Division of Angiology,University of Geneva Hospitals (HUG), Switzerland

Objective: Central line-associated thrombosis (CLAT) is related to insertionsite and localization of the tip. Especially at risk are critically ill patients, orpatients with cancer or onco-hematologic illness. CLAT has been described asa risk factor for central-line associated bloodstream infections (CLABSI).Methods: Based on an ongoing surveillance system every central venouscatheter (CVC) in place for more than 10 days among patients outside theintensive care unit was prospectively identified. Doppler colored ultrasound ofthe CVC insertion site was performed by two anesthesiologists. CLAT wasdefined as follows: 1) Echogenic intraluminal mass; 2) no vein compression;3) absence of diameter alteration during respiratory movements.Results: A total of 1115 patients with 1622 central lines were enrolled duringthe 10 months. Of these, 639 catheters among 526 patients were placed byanesthesiologists. 240 of these catheters were in place for more than 10 days(median [IQR]: 21 [16–28]). In total, 343 Doppler-Ultrasound screenings wereperformed.16 subclinical CAT episodes were found of which most were found with theright jugular internal vein:During the same period, 35 CLABSI were documented with an incidence densityof 2·3/1000 catheter-days. None of the 16 CVCs identified with subclinicalCLAT had CLABSI.Conclusion: CLAT episodes can be detected outside the ICU and they rarelymake clinical signs. Although we found more CLAT among CVCs in placefor 20 days, this trend is not significant. The reason for this is the yet smallsample size. The complete absence of CLABSI among patients with CLAT issurprising and contradicts studies that have found such association.

P2A-3 Family centred rounds (FCR) in the pediatric intensive care unitat the aga khan university pakistan - a new cultural concept for adeveloping country.

L. Ladak1,2, S. Premji2,3, A. Haq1, K. Ajani2, F. Siddiqui4,M. Amanullah1

1The Aga Khan University Hospital, Karachi, Pakistan 2The Aga Khan University-School of Nursing, Karachi, Pakistan 3University of Calgary, Calgary, Canada4Singapore Clinical Research Institute, Singapore

Objective: In Pakistan, parents of the hospitalized children receive informationafter the medical team has completed bedside rounds or some other time of theday. Hence, FCR is a new concept in our institution and is intended to providetimely information to parents so they can take decisions accordingly. Theobjective of this study was to determine whether in Pakistan, FCR implementedin the PICU and PCICU would improve parents’ and health care professionals’satisfaction, decrease patients’ length of stay, and improve time utilization.Methods: This is a non-randomized control trial. During phase I (April toMay, 2009) traditional bedside rounds were practiced. During phase II (Juneto July, 2009) FCR was practiced. A convenient sample of 41 parents and 25


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health care professionals were recruited in each phase. Data was collected onthe second day of consecutive morning rounds.Results: Parents were satisfied with traditional as well as FCR; howeverparents’ ratings during the FCR were significantly higher, about the use ofsimple language during the rounds (p=0·002), and their preference for FCR(p=0·000). No significant differences were found in health care professionals’opinion between the two rounds. Patients’ length of stay was significantlyreduced in FCR group while no difference was found in the time durationof rounds. FCR served as an opportunity for parents to ensure accuratedocumentation of patient’s history and progress.Conclusion: FCR were a resource for parents reflecting their need forinformation, communication, and involvement in decision making during theirchild’s hospitalization. The use of FCR as means to improve quality care requiresfurther exploration.

P2A-4 The role of gender and sex steroids on the respond of muscletissue to hypocalcemia

S. Tekin1, S. Kokcam1, M. Sahin1, M. Ayaz1, F. Acar1

1Selcuk University Meram Medical Faculty and Selcuk Medical Faculty, Konya,Turkey

Objective: To investigate effects of gender and sex steroids on hypocalcemicsymptoms.Methods: 26 Male 26 Female, Sprague-Dawley rats were divided in 8 groups.To investigate effect of gender, male (E) and Female (D) rats were used. Toinvestigate the effect of sex steroids absence, gonadectomized and sex steroiddeprived male (E-) and female (D-) rats were used. Gonadectomized andestradiol applied male rats (EX) and gonadectomized and testosteron appliedfemale rats (DX) were used to observe effect of sex stereoid on opposite sexes.Gonadectomized and vehicle applied male and female rats were used to observeeffect of hormon vehicle. At the end of 30 day followup rats were sacrified andsoleus muscle flaps were prepared and placed in organ bath and stimulated withneedle electrode in varying frequencies. Contraction and tetanic contractionresults were recorded.Results: The results of females and males were minimally effected fromchange of calcium concentration. Contrary to males there is a significant changein responses of female muscle flaps concomitant with calcium concentrationchange. While the change in values is increased gonadectomized males,change in response values were significantly decreased in testosteron appliedgonadectomized female rats.Conclusions: Testosteron increases resistence of muscle tissue for hypocal-cemia. Higher levels of testosteron in males may be the cause of rarepostoperative hypocalcemic symptoms compared to frequent occurance ofthese symtoms in female patients.

P2A-5 A prospective survey of accidental catheter and tube removalin a surgical intensive care unit

M. F. Can1, M. Urkan1, G. Yagci1, I. H. Ozerhan1, A. Harlak1, C. Ates1,A. Simsek1, T. Tufan1

1Department of Surgery, Gulhane School of Medicine, Ankara, Turkey

Objective: Accidental catheter removal (ACR) in surgical intensive care unit(sICU) can result in inadequate treatment or monitoring of patients. Thesepatients can also face some complications related to catheter reinsertion. Whitthis study we aimed at identifying rate and features of ACR encountered inpatients cared for in sICU.Methods: This observational study took place in a 16-bed sICU at a tertiarycare center from 01 October 2009 through 01 January 2010. Four researchersobserved and recorded accidental removal of catheters and tubes. sICU staffwere unaware of observation. ACRs were classified as patient-related and healthcare staff-related incidents. Both vascular and non-vascular catheter and tubeswere surveyed. A comparison was made between busy (no of pts ≥ 8) and calm(no of pts ≤ 7) periods of sICU.Results: In 798 patient days a total of 394 patients were observed. Overall 61(7·6%) incidents were recorded. Of these, 45 (5·6%) were patient-related and 16(2%) were health care staff-related. ACRs occurred significantly less frequently

(4·4%) within the calm periods than within the busy periods (15·4%)(p<0·001).Sub-specific evaluation revealed that peripheral vein catheters and non-vasculartubes as a general subgroup were removed accidentally more often in busierdays than in calmer days (p=0·008 and < 0·001, respectively). There was nodifference between the periods for arterial lines or central venous catheters.Conclusions: The results of the study suggest that accidental catheter removalin sICU has a high incidence to the extent that it requires close monitoring, andthat the probability of facing an accidental removal increases when the numberof patients accommodated is large.

P2B Organ and cell Transplantation – Biomaterialsand Artificial Organs 2

P2B-1 Polymeric neurotubes for regeneration of damaged peripheralnerves – on animal model.

K. Kowalska1, B. Grobelski1, J. Ca3a2, M. Kołodziejczyk3, R. Wach4,Z. Pasieka1

1Department of Experimental Surgery, Medical University of Lodz, Poland 2Clinicof Endocrine and General Surgery, Medical University of Lodz, Poland 3Institute ofTechnical Biochemistry, Technical University of Lodz, Poland 4Institute of AppliedRadiation Chemistry, Technical University of Lodz, Poland

Objective: The goal of experiment is to develop and analyze in vivo both,tubulization method as well as novel polymeric materials (natural and synthetic)for reconstruction of damaged peripheral nerves. Analyzed neurotubes are tolimit the formation of neurinoma and fasten the process of regeneration moreeffectively comparing to standard surgical methods.Methods: The project is performed on Wistar rats (femoral nerve) and issubjected to elaboration of implantation method, as well as development ofneurotubes production mode. Materials under investigation include tubes madeof modified bacterial cellulose, highly biocompatible natural polymer producedby bacteria Gluconacetobacter xylinus. Alternatively, tubes made of syntheticpolymers (polylactic acid mixed with poly(trimethylene carbonate)) are beingevaluated. As a control traditional end-to-end anastomosis is applied. Materialsare estimated according to observation of animals after operation and histologicalanalysis of explanted samples.Results: Both types of tubes applied in vivo significantly lower the formationof neurinoma. However, motor recovery does not proceed faster than in thecase of end-to-end connection.Autocannibalism, being probably an evidence of neurotrophic factorsaccumulation was observed in both experimental groups but not in control.Biocompatibility of applied polymers slightly differs. Microbial cellulose ismore susceptible to host tissue overgrowing and gives less granulation tissueformation at the implant site.Conclusion: Investigated tubulization method effectively prevents theformation of neurinoma. The tubes are of good biocompatibility (especiallybiocellulose) and allow the accumulation of neurotrophic factors inside, thus,facilitating the process of nerve regeneration. Both, the type of materials andstabilization technique may be successfully applied in this type of surgicaltreatment.

P2B-2 Prospective randomized controlled trial to compare titaniumstaples and prolene sutures for securing the mesh in Lichtenstein’singuinal hernia repair

R-T. Kochupapy1, G. Ranganathan1, H. Sumrien1, G. Lucitt1,D. Taylor1, V. Rajesh1, D-J. Shanahan1

1Department of General Surgery, Prince Phillip Hospital, Llanelli, Wales, UK

Objective: The Lichtenstein tension free repair for inguinal hernia is one ofthe commonest procedures in day-care surgical units. This study compared twomethods of mesh fixation.Methods: Between September 2006 to December 2009, 70 patients undergoingprimary unilateral inguinal hernia under the general anesthesia and inguinalnerve block were selected and randomized. The prolene mesh was fixed in acontrol group with 2/0 prolene sutures and multifire versa tack titanium stapleswere used in the study group. Duration of mesh fixation was recorded. Standard


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validated pain questionnaire with visual analogue scale was given to the patientand returned after 30-days. The study was a single blinded and pain nursespecialist analyzed pain questionnaires.Results: 56 patients returned the questionnaire and 14 patients were contactedthrough telephone. Majority of them was male (n-69). Direct and indirect herniawas equally distributed. The operation was significantly shorter by 11 minutes(p=0·000) in the stapled group. There was statistical difference (p value < 0·05)in postoperative pain scores, clinically the stapled group had increased painscores and dissatisfaction. One patient in a stapled group had marked testicularatrophy.Conclusion: The use of titanium staples to secure mesh has significantlyreduced the duration of operation so that more cases can be done in a session.Even though there is a reduction in time for surgery, there is a statisticallysignificant increase in postoperative pain scores in the stapled group. Theycomplained more pain over the pubic tubercle area. Study concludes tightfixation of mesh using staples leads to more pain.

P2B-3 Bacterial infections are one of the common complications insimultaneous pancreas-kidney transplantation (SPKTx)

D. Kawecki1, A. Kwiatkowski2, G. Michalak3, A. Sawicka-Grzelak1,W. Rowinski2, M. Durlik4, M. Luczak1, A. Chmura2, G. Mlynarczyk1

1Department. Of Medical Microbiology, Medical University of Warsaw, Poland2Department. of General Surgery and Transplantation, Medical University ofWarsaw, Poland 3Department. of Emergency Medicine, Bielanski Hospital Warsaw,Poland 4Department. of Transplant Medicine and Nephrology, TransplantationInstitute, Warsaw, Poland

Objective: This study aims at evaluation of the frequency of microbial isolatesand their susceptibility profiles; cultured from clinical samples obtained fromblood, urine, stool, surgical site of 26 simultaneous pancreas-kidney (SPKTx)recipients suspected of bacterial infections in the early post - transplant period.Patients and methods: The study covered 26 adult patients undergoingSPKTX transplantation between September 2001 and December 2006. All thepatients were followed prospectively for bacterial infections from the SPKTXdate and during the first four weeks after surgery. The microorganisms werecultured and identified in accordance with standard bacteriological procedures.Susceptibility testing was carried out using Clinical and Laboratory StandardsInstitute (CLSI) procedures.Results: All the patients were followed prospectively for the first four weeksafter surgery. In total: 168 microbial isolates from clinical samples from ‘‘surgicalsite’’, 23 from ‘‘blood and tips of vessel catheters’’, 30 from ‘‘urine’’. Themost commonly isolated were: Gram-positive bacteria with domination ofstaphylococci: with presence of MRCNS, MRSA strains and enteroccocii:with presence of, HLAR, VRE strains. Gram-negative bacteria: among themwere isolated extended spectrum beta-lactamase producers - ESBL(+) andcarbapenems resistant strains.In conclusion in our study predominated Gram(+) bacteria. The increasedproportion of isolation MDR bacteria to antimicrobial agents may be due to thefrequent use of these agents for prophylaxis of bacterial infections in patients.MDR strains can caused severe bacterial infections in patients after SPKTX.

P2B-4 No synergistic effect of carbon monoxide and oxygen duringhypothermic liver preservation

M. Koetting1,2, F. Dombrowski3, T. Minor1

1Divison of Surgical Research, University Hospital of Bonn, Germany 2Clinic forGeneral, Visceral & Transplantation Surgery, University Hospital Essen, Germany3Institute of Pathology, University Greifswald, Germany

Objective: The benefit of carbon monoxide and/or oxygen as applied bycontrolled, continuous gaseous persufflation during liver preservation onpostischemic graft recovery was investigated in an isolated rat liver model.Methods: Livers from male Wistar rats were retrieved 30 min after cardiacarrest of the donor and subjected to 18 h of cold storage. Some grafts weresubjected to gaseous persufflation during static cold storage either with oxygen,with carbon monoxide (CO-50 ppm, dissolved in nitrogen) or with CO dissolved

in Oxygen. Graft viability was assessed thereafter upon warm reperfusion invitro.Results: CO(in N2)-persufflation significantly reduced cellular enzyme lossand functional recovery (bile production and ATP recovery) upon reperfusionby about 50%. The effect was associated with a reduction of vascular perfusionresistance and improved mitochondrial ultrastructure. Similar or better resultswere obtained by persufflation with pure oxygen, while no additive benefit ofCO and oxygen could be seen in our model. The upregulation of ICAM-1mRNA in the liver grafts was reduced only after persufflation with oxygen.Conclusion: Viability of cold stored liver grafts can be notably augmented bygaseous ex vivo application of CO to the isolated organ but no superiority oradditive effect is seen with respect to persufflation with oxygen.

P2B-5 Can paediatric Renal transplantation be performed by ‘adult’surgeons?

D. van Dellen1, J. Ellis1, M. Field1, J. Nath1, A. Hamsho1, A. R. Ready1,S. J. Mellor1, N. G. Inston1

1Department of Renal Transplantation, Queen Elizabeth Hospital, Birmingham, UK

Objective: Transplants have historically been performed by Surgeonsoperating on adult and paediatric patients unselectively. Despite the advent ofsub-specialization, the international paucity of dedicated Transplant Surgeonshas resulted in paediatric transplants being performed by Surgeons who operateon both adult and paediatric patients. In recent years, paediatric transplantationhas also become offered in fewer centres.Methods: A retrospective review of regional paediatric renal transplant andoutcomes over 18 years by ‘adult’ Renal Transplant Surgeons was performed.Demographic data, graft and patient survival at 1, 5 and 10 years was assessedand compared with established national guidelines. Creatinine at 1 year and lastrecorded follow up was collated.Results: 181 renal transplants were performed on 169 patients (101 M; 68 F;1991–2008). There were 22 live related and 159 cadaveric donors. There was a12% (23/181) graft loss in the first year, equivalent to published adult transplantloss in the first year. Creatinine values at 1 year and last recorded follow up were115 ± 15·7 µmol/l (range 40–327) and 191 ± 21·2 µmol/l (range 32 to 1434)respectively (Mean follow up 62·6 ± 4·0 months; range 4–170.) 5- and 10-yeargraft survival was 83% and 73% and compares favourably with national data foradult and paediatric transplantation (81% and 64% respectively.)Conclusion: ‘Adult’ Transplant Surgeons performing paediatric transplantsdemonstrate results equivalent to standards for adult and paediatric programmes.This occurred despite confounding paediatric factors such as non-complianceand greater technical requirements. Specialized paediatric expertise is not anecessity for a successful paediatric transplantation programme. This couldhave profound effects on service provision for transplantation.

P2B-6 Induction Of Different Types Of Cell Death After NormothermicLiver Ischemia-Reperfusion

R. Cursio1,2, P. Colosetti1, M.-C. Saint-Paul3, P. Gounon4,P. Auberger1, J. Gugenheim1,2

1INSERM U895, Equipe 2 C3M, IFR 50, Faculte de Medecine Pasteur, Universitede Nice Sophia Antipolis, Nice, France 2Service de Chirurgie et TransplantationHepatique, Hopital l’Archet 2, Universite de Nice Sophia Antipolis, Nice, France3Service d’Anatomo-pathologie, Hopital Pasteur, Universite de Nice Sophia Antipolis,Nice, France 4Centre Commun de Microscopie Appliquee, Faculte des Sciences, Nice,France

Objective: Normothermic liver ischemia-reperfusion (I-R) may inducehepatocellular autophagy, apoptosis, and necrosis. The aim of this study was todetermine the extent of these three types of death in normothermic liver I-R inrats.Methods: A segmental normothermic ischemia of the liver was induced for 120minutes. Liver autophagy was evaluated by transmission electron microscopyand LC3 immunohistochemical studies. Liver apoptosis was assessed by FLIVOand TUNEL assays. Liver necrosis was determined by optical microscopyexamination.


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Results: Autophagy was increased in ischemic liver lobes 6 h after reperfusion,compared with non-ischemic lobes. FLIVO method showed that in situ caspase−3 and −7 specific activity was increased in ischemic liver lobes after 6 hafter reperfusion, compared to non-ischemic lobes. Quantitative analysis ofapoptotic cells evaluated by TUNEL method showed a clear significant increasein ischemic liver lobes 6 h after reperfusion, compared with non-ischemic lobes.Necrotic cell death was significantly increased in ischemic liver lobes 6 h afterreperfusion, compared with non-ischemic lobes (p<0·005).Conclusions: 120 min normothermic liver I-R resulted in increasedautophagic, apoptotic and necrotic cell death.

P2B-7 Ischemic postconditioning reduces kidney damage in healthybut not in hypercholesterinaemic rats

M. Kurthy1, G. Jancso2, Zs. Miklos1, P. Degrell3, E. Rantzinger1,J. Lantos1, S. Ferencz1, Sz. Horvath1, G. Weber1, E. Roth1

1Pecs University Medical School, Surgical Research and Techniques Kodaly Z, Pecs,Hungary 2Pecs University Medical School Faculty of Surgery, Rakoczi u 2, Pecs,Hungary 3Pecs University Medical School, 2nd Department of Internal Medicine andNephrology Center, Pecs, Hungary

Objective: Ischaemic pre-, and postconditioning protect against ischaemia/reperfusion injury. Metabolic alterations, such as diabetes mellitus reduce orabolish the beneficial effects of these maneuvers. In this study we aimed toinvestigate the effect of postconditioning in healthy and hypercholesterolemicrats after ischaemia/reperfusion injury in the kidney.Methods: Male Wistar rats (n=30) were fed by either normal or highcholesterol (1·5%) containing chow for 8 weeks. Following pretreatment period,both groups were divided into two subgroups, where under general anesthesiaboth kidneys were exposed either to 45 min ischemia followed by 2 hoursof reperfusion, or to additional 4 × 15 sec postconditioning cycles. Serumcreatinine, carbamide, oxLDL levels, PMA-induced free radical productionwas determined before and after surgery. After euthanasia both kidneys wereremoved for TNF-α immunohistochemistry, and for PAS and HE staining.Results: Cholesterol feeding resulted in a significant elevation in serumcholesterol and triglyceride levels (p<0·05).In the control rats significant elevation was observed in free radicalproduction (p<0·01), lipidperoxidation (p<0·01), and serum TNF-α levels(p<0·05), following ischaemia and reperfusion, which were markedly reducedby postconditioning. However, we didn’t reveal any beneficial effect ofpostconditioning in the cholesterol fed rats. Tissue TNF-α level was significantlyhigher in cholesterol fed, than in control animals, and this high level did notchange in response to postconditioning. In healthy animals postconditioningcaused a significant reduction (p<0·05) in tissue TNF-α level.Conclusion: Postconditioning proved to be a very effective defense againstkidney ischemia/reperfusion injury in healthy animals, but it was ineffective inhypercholesterolemic ones.The study was supported by OTKA-K-78434 Grant and OTKA-K-67731

P2B-8 Simultaneous hemiface and vascularized bone marrowtransplantation in rats

D. Zamfirescu1, I. Lascar1, M. Climov, A. Bularda I1, C. Popoviciu1,A. Stefanescu1, A. Lupu1, M. Simionescu2,M. Lanzetta M3,4

1‘‘Carol Davila’’ Bucharest Medical University, Bucharest, Romania 2Institutes ofCellular Biology and Pathology, Bucharest, Romania. 3Italian Institutes for HandSurgery and Microsurgery, Monza, Milan, Italy 4University of Canberra, Australia

Obiective: Clinical application of composite tissue allograft transplants openeddiscussion on the restoration of facial deformities by allotransplantation. Theauthors introduce a hemifacial allograft transplant plus femur transplantation as avascularized bone marrow model to investigate the rationale for the developmentof functional tolerance across the major histocompatibility complex barrier.Methods: Ten rats in two groups were studied. The composite hemifacialallotransplantations including the ear and scalp and femur allotransplantationwere performed between Lewis-Brown Norway (RT1l+n) and Lewis (RT1l)rats. Hemiface allotransplantation alone controls (n = 5) and both hemifaceand femur allograft (n = 5) were treated with cyclosporine A 16 mg/kg/day

during the first week; this dose was tapered to 2 mg/kg/day over 4 weeks andmaintained at this level thereafter.Results: The number of rats that reject under cyclosporine A monotherapyprotocol and the interval free of rejection was significant different between thetwo groups.Conclusions: These facts demonstrate the contribution of the superiormicrochimerism levels in induction of a partial tolerance in the group withsimultaneous hemiface and vascularized bone marrow transplantation.

P2B-9 Human hepatoma cell line conditioned medium increasesmigration of multipotent mesenchymal stromal cells

C. Gonelle-Gispert1, S. Clement2, P. Morel1, D. Bosco1 and L. Buhler1

1Surgical Research Unit, Department of Surgery, CMU, Geneva 2Division of ClinicalPathology, University Hospitals, Geneva

Objective: Multipotent mesenchymal stromal cells (MSC) are used clinicallyfor treatment of bone diseases or graft versus host disease. Molecular mechanismsunderlying MSC migration to inflammatory or tumor environments are notunderstood. The present study aimed to investigate the molecular pathwaysresponsible for MSC migration.Methods: We analysed migration of human MSC using transwell chambermigration assay and live-cell imaging. Recombinant factors and Humanhepatoma cell line (Huh-7) conditioned medium (CM) have been tested for theireffect on MSC migration. To identify responsible factors mediating migrationof MSC in Huh-7 CM, we tested cytokines which were increased in Huh-7 CM compared to control condition. We applied Western Blotting to identifysignalling pathways implicated in Huh-7 CM induced migration.Results: Huh-7 CM triggered 3·5-fold increase of MSC migration comparedto control medium. Platelet derived growth factor BB (PDGF-BB), used aspositive control, induced a 6-fold increase. Live-cell imaging revealed thatboth Huh-7 CM and PDGF-BB increased directional migration. Combinationof Huh-7 CM and PDGF-BB had no additional effect on transwell migration.Further, the factors, identified in the Huh-7 CM, added alone or in combination,did not induce migration. Erk pathway was activated after exposition to PDGF-BB and Huh-7 CM whereas Focal adhesion kinase (FAK) was activated onlyin MSC exposed to Huh-7 CM. Presence of MAPK/ERK kinase inhibitor,PD98059, did not reduce migration induced by Huh-7 CM and PDGF-BB.Conclusions: Huh-7 CM activates migration of MSC. So far, we have notidentified factors inducing MSC migration. We will further investigate whetheractivation of FAK induced by Huh-7 CM is relevant in MSC migration.

P2B-10 Transplantation liver cells and multipotent mesenchymalstromal cells for correction and treatment of hepatic failure

M. Shagidulin, N. Onishchenko, M. Krasheninnikov, I. Iljinsky,N. Mogeiko, A. Lundup, E. Nemets, V. Sevastjanov, S. GautierFederal V. Sumakov Research Center of Transplantology and Artificial Organs,Moscow, Russia

Background: Cell therapy has provided exciting prospects for cell-basedtissue engineering and regeneration and is a new perspective method treatmentof hepatic failure. Safe and prolonged cell cultivation in vivo for regulatorypeptides production and functional support of damaged liver forms the base ofthis method. This investigation was undertaken on correction and treatment ofhepatic failure by a method of transplantation of liver cells (LC) and multipotentmesenchymal stromal cells (MMSC), immobilized on biodegradable 3-Dmatrixes into an organism.Methods: Adult dogs (28–30 kg) were used as donors of LC and MMSC.The survival of LC and MMSC, immobilized on biodegradable matrixesElastoPOB-3D (prepared on the basis of β-hydroxybutyrate and β-oksyvaleratecopolymer), dynamics of reduction of hepatic failure was investigated. MMSCwere obtained by standard procedure and cultivated during 7 days in the mediumwhich was changed in 4 days at constant control of cell viability. Hepatic failurewas modeled by resection of 50% of liver. Isolated LC were obtained by standardprocedure with 0,12% collagenase solution. The suspension of MMSC andisolated LC was applied on matrixes as 2,0–4,0 × 106 cells/cm3. Co-cultivationof LC and MMSC was made within 3 days. After that matrixes with LC and


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MMSC were implanted into small bowel mesentery of animals. The dynamicsof reduction of hepatic failure (biochemical indices), cell proliferation in matrixpores and cell vitality in matrixes were investigated in 30, 60 and 90 days.Morphological structures of LC, MMSC and surrounding tissue were studiedusing hematoxylin and eosin stain. Vessels were studied using PAS staining.Results: Cell viability measured after isolation was: LC – 76 ± 4%,MMSC – 94 ± 2%. On the 5th day after implantation of the LC and MMSCseeded on matrixes all biochemical indices (ALT, AST, LDH, albumen) andsodium lactate returned to norm. In control group only for 18 day. We haveshow viable and proliferative activity of LC, MMSC and have detected neogenicplethoric vessels, growing through matrixes for a long time (90 days afterimplantation).Conclusion: Our preliminary studies have shown that the proposed method iseasy and effective for correction and treatment of hepatic failure.

P2C Cardiac Surgery 3

P2C-1 Endovascular Approach to Patients with Aortic Aneurysms andDissections Unfit For Conventional Surgery; Report of One Year StudyFrom a Single Center

C-L. Onar1, M. Akyildiz1, T. Aksoy2, Y. Zorman1, E. Erturk1,B. Erden1, B. Dagdeviren3, H. Arbatli1

1Department of Cardiovascular Surgery, Maltepe University Faculty of Medicine,Istanbul, Turkey 2Department of Anesthesiology and Reanimation, Maltepe UniversityFaculty of Medicine, Istanbul, Turkey 3Department of Cardiology, Maltepe UniversityFaculty of Medicine, Istanbul, Turkey

Objective: Endovascular stent grafting (EVSG) is a minimally invasiveapproach which can be used for thoracic and abdominal aortic aneurysms(AAA), dissections, and ruptures [1]. It is well known that the patients withaortic aneurysms or dissections have comorbidities including hypertension,coronary artery disease, chronic obstructive pulmonary disease, obesity andthere is often a history of smoking [3]. Considering these risk factors of aorticaneurysm patients, many of them are unfit for conventional aortic surgery.Methods: Since Janurary 2009 we operated 6 patients with comorbid factorswhich may lead objection for open aortic surgery. Two patients had type Baortic dissections, one was a morbidly obese patient who had a descending aorticaneurysm, two patients with AAA were underwent coronary by-pass procedurerecently and one had serious pulmonary problems. Intentional coverage of theleft subclavian artery was carried out in all three patients with thoracic stent-grafting and one of them received left carotid to left subclavian by-pass greftbefore the stent-greft deployement. Aorto-bi-iilac stent-grafting was done inthree patients with AAA.Results: No mortalities and morbidities were observed, no blood productswere used and intensive care unit stay was less than 18 hours. Thrombosis ofthe aneurysmc sac and the false lumen were confirmed in all patients. The earlysuccess rate for the endovascular repair was excellent in our patient group.Conclusion: Endovascular approach to patients with aortic pathologieswhowere unfit for open repair may be cured via endovascular route with lessmorbidity and mortality.

P2C-2 Giant Floating Thrombus Localized in the Ascending Aorta

M. Akyildiz1, Y. Zorman1, T. Aksoy2, M. S. Yilmazer3, E. Erturk1,C. L. Onar1, A. Midi4

1Department of Cardiovascular Surgery, Maltepe University Faculty of Medicine,Istanbul, Turkey 2Department of Anesthesiology, Maltepe University Faculty ofMedicine, Istanbul, Turkey 3Department of Cardiology, Maltepe University Facultyof Medicine, Istanbul, Turkey 4Department of Pathology, Maltepe University Facultyof Medicine, Istanbul, Turkey

We report the case of a 32-year-old male patient with symptoms ofcerebrovascular accident manifested with dysarthria. Magnetic resonanceimaging detected a non-hemorrhagic infarct in the left cerebral hemisphere,corona radiate, and the basal ganglia. Transesophageal echocardiographyshowed a floating, pedunculated mass originating from the ascending aortaand extending into the aortic arch and multislice computerized tomography

confirmed the diagnosis. Patient was operated and the floating thrombus wasexcised duing a short period of total circulatory arrest without cross clampingthe aorta. Pedunculated and fragile mass was seen just near the right coronaryostium. Its size was measured 7·7 × 1·0 × 1·5 cm. The postoperative course wasuneventful.The removed mass has been analysed histopathologygically and found to be thecause of neurologic findings with an uncertain underlying etiology.Although it is rare, the embolic source in the ascending aorta may be theunderlying etiology of ischemic cerebrovascular events in some patients.

P2C-3 Role of Glutathione S-tranferase in the signal pathwaysin cardiac myocytes under oxidative stress conditions

B. Balatonyi1, V. Kovacs1, I. Takacs1, Sz. Horvath1, Sz. Javor1,Gy. Weber1, N. Marczin2, B. Gasz3, E. Roth1

1Department of Surgical Research and Techniques, Medical Faculty, University ofPecs, Hungary 2Faculty of Medicine, Imperial College London, UK 3Department ofCardiac Surgery, Zala County Hospital, Zalaegerszeg, Hungary

Objective: Myocardial ischemia-reperfusion injury is crucially involved in thepathogenesis of cardiovascular diseases which remain the leading cause of deathin both developed and developing countries. The main objective of this studywas to identify the effect of GST inhibition (with administration of EA) onthe members of the signal pathway when cells are exposed to various stresscomponents of ischaemia and reperfusion (I/R).Methods: Primary culture of neonatal cardiomyocytes was prepared anddivided in 6 groups, according to the different exposers the followings:Ethacrynic acid (EA), H2O2, I/R, or the combinations of these. Non-treatedcells served as control. JNK, p38, Akt/PKB, ERK/p42-p44 transcription factorswere monitored with flow cytometry.Results: JNK activation increased markedly by EA exposure to cardiacmyocytes and significantly augmented the activation of JNK both when cellswere co-treated with H2O2 or when cells were exposed to I/R. Inhibition ofGST led to significant increase in p38 activation versus non-treated cells. BothH2O2 incubation and ischaemia-reperfusion resulted in significant increaseof p38 MAP kinase activation. EA administration during I/R or incubationtogether with H2O2 increased markedly the level of phosphorilated p38.ERK phosphorylation increased in GST inhibited groups (incubated with EA)either treated with H2O2 or exposed to I/R.H2O2 treatment resulted in pronounced decrease of Akt phosphorilation whenGST was inhibited by EA.Conclusions: GST plays an important role as regulator of MAP kinasepathways in ischemia-reperfusion injury.This work was supported by the Hungarian Science Research Fund OTKA-K78434.

P2C-4 Effect of oxidative stress of Glutathione S-tranferasein cardiomyocyte cell culture

V. Kovacs1, B. Balatonyi1, S. Ghosh2, I. Takacs1, Sz. Horvath1,Sz. Javor1, N. Marczin3, Gy. Weber1, E. Roth1, B. Gasz4

1Department of Surgical Research and Techniques, Medical Faculty, University ofPecs, Hungary 2Department of Anaesthesia and Intensive Therapy, Medical Faculty,University of Pecs, Hungary 3Faculty of Medicine, Imperial College London, UK4Department of Cardiac Surgery, Zala County Hospital, Zalaegerszeg, Hungary

Objective: Cardiovascular diseases cause accounting for roughly 20% of allworldwide deaths per year. Recent studies highlight the potentially unique roleof Glutathione-S- Transferase (GST) enzymes as crucial determinants of thedevelopment of I/R.Methods: Primary culture of neonatal rat cardiomyocytes was prepared anddivided in 6 groups. Group I, control, Group II, Ethacrynic acid (EA) alone,Group III, cells exposed to H2O2, Group IV, cells exposed to ischemia-reperfusion (I/R), Group V, cells treated with H2O2 together with Ethacrynicacid, Group VI, cells exposed to I/R and Ethacrynic acid. MTT assaywas performed to measure the absolute number of living cells in differentgroups. Ratio of apoptosis was evaluated after double staining with fluorescein


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isothicyanate (FITC)-labeled annexin V and propidium iodide using flowcytometry.Results: Ethacrynic acid alone reduced the ratio of living cells. Both I/R andH2O2 alone caused marked reduction in amount of living cells. The effectof cell death was significantly stronger upon administration of EA in groupstreated with H2O2 or exposed to I/R. EA administration decreased the amountof living and increased the percentage of apoptotic cells. A significant increaseof apoptotic cells was observed in both the H2O2-treated and I/R groups witha lower number of living cells. When EA was added in groups treated with thequantity of apoptotic cells was further increased with reduced amount of livingcells. Interestingly, EA raised the amount of necrotic cells during I/R with adecreased number of living cells.Conclusions: GST activity is required for survival of cultured cardiomyocytesunder stress conditions.This work was supported by the Hungarian Science Research Fund OTKA-K78434.

P2C-5 The effects of intravenous aminoacid infusion onthermogenesis, gastrointestinal system functions and surgical stresresponse in abdominal aortic surgeries

A. Baysal1, A. Sasmazel2, M. Ozkokeli2, A. Tuncer2, M. Turhan2,T. Kocak2, R. Zeybek2

1Anesthesiology and Reanimation, 2Division of Cardiovascular Surgery KartalKosuyolu Research and Training Hospital, Istanbul, Turkey

Objective: The incidence of mesenteric ischemia is reported to bebetween 1·1 to 10%. Complications related to hypothermia such as bleedingtendecy is commonly reported. The infusion of intravenous aminoacids ingeneral anesthesia was shown to increase protein synthesis and to produceheat generation in humans. Our goal was to investigate the effects ofintravenous aminoacid infusion on surgical stres response, thermogenesis andgastrointestinal functions.Methods: 30 consecutive patients undergoing abdominal aortic surgery wererandomly divided into two groups in a prospective study design. Group 1received general anesthesia and intravenous aminoacid infusion (Group AA(+),n=15) and Group 2 received general anesthesia and intravenous saline (GroupAA(−), n=15). Patients with diabetes mellitus were excluded. Aminoacidsolution (8%, 80g/L, 500 mL) was infused at a rate of 2·5 ml/kg/hour. Fora total of 8 hours to give an energy supply of 4 kJ/kg/hour. Esophagealtemperature, blood sugar and cortisol levels were recorded before operation(control), postoperatively on the first and 24th hour. Flatus, defecation timesand complications were recorded.Results: The demographic data including age, gender, NYHA class, operationtimes were not different between groups. Esophageal temperature recordingswere similar between groups intraoperatively and postoperatively. In comparisonof blood glucose and cortisol levels there was no statistical differencebetween groups. No differences were recorded for flatus, defecation timesand complications between groups (p>0·05).Conclusions: In abdominal aortic surgery, infusion of perioperative aminoasidintravenously under general anesthesia did not show any significant effects ontemperature, gastrointestinal system functions, blood glucose and cortisol levelsintraoperatively or in early postoperative period.

P2C-6 Comparison of Ischemic Mitral Valve Repair in Compromisedand Uncompromised Left Ventricular Functions

R. Zeybek1, A. Sasmazel1, A. Baysal2, F. Buyukbayrak1, T. Karaahmet3,O. Findik1, A. Fedakar1, O. Bugra1, H. Erdem1

1Kartal Kosuyolu Research and Training Hospital, Division of Cardiovascular Surgery,Istanbul, Turkey 2Kartal Kosuyolu Research and Training Hospital, Division ofAnesthesiology and Reanimation, Istanbul, Turkey 3Kartal Kosuyolu Research andTraining Hospital, Division of Cardiology, Istanbul, Turkey

Background: In patients with ischemic mitral valve (IMR) repair, the outcomeresults of diminished left ventricular functions were compared to the patientswith normal left ventricular functions during the early and midterm follow-up

periods. Our aim was to determine predictors of survival in patients with IMRin five years follow-up period.Methods: We retrospectively analyzed 105 patients (mean age: 62·29 ±11·88 years; 64 males) who had operation from January 2003 to June 2009 forIMR. The primary end points were early in-hospital and late follow-up deaths.Uncompromised (UC) group and compromised (C) group were establishedbased on preoperative left ventricular ejection fraction (pLVEF) cut-off value.Results: In the compromised group (C) (n=34), pLVEF was less than orequal to 40% whereas, it was greater than 40% in the uncompromised group(UC) (n=71). Nine patients died in-hospital and 14 patients died in thefollow-up period. Univariate analysis revealed that age, pLVEF, postoperativeNYHA, postoperative mitral regurgitation (MR) and postoperative LVEFwere associated with increased risk of reaching the primary end point. Coxproportional hazard regression analysis identified pLVEF (hazard ratio 1·5;95% confidence interval 1·4 to 5 p<0·008) as the only independent predictorof the primary end point. The pLVEF cut-off value revealed 40% with highestsensitivity of 76% and specificity of 70%.Conclusion: In ischemic mitral valve surgery, the pLVEF of 40% shows animportant prognostic marker for early and mid-term survival.

P2C-7 Renal function and inflammatory responseto phosphorylcholine coated extracorporeal circulation circuitsfollowing coronary bypass surgery

A. C. Hatemi1, K. Ceviker1, M. Canikoglu1, A. Kaya2, A. Cakiris3,Z. Yigit4, D. Ustek3, E. Kansiz1

1Department of Cardiovascular Surgery, Institute of Cardiology, Istanbul University,Istanbul, Turkey 2Biochemistry Laboratory, Institute of Cardiology, IstanbulUniversity, Istanbul, Turkey 3Department of Molecular Genetics, Institute forExperimental Medical Research, Istanbul University, Istanbul, Turkey 4Departmentof Cardiology, Institute of Cardiology, Istanbul University, Istanbul, Turkey

Background: Phosphorylcholine-coated circuitswere postulated to dimin-ishhazardous inflammatorycomplications of extracorporeal circulation (ECC),including renal injury. Neutrophil gelatinase-associated lipocalin (NGAL) hasrecently been described as an inflammatory protein and also seemed to monitoracute kidney injury (AKI) postoperatively.Methods: Thirtytwo consecutive patients were randomly assigned to Group A[ECC with PC circuits (n=17)] and to Group B [ECC with non-coated circuits(n=15)]. Immunologic (TNF-alfa, IL-1b, IL-6, IL-8), heamotologic (WBC,HCT, PLT), biochemical (NGAL, BUN, Creatinine, ALT, AST, uric acidand bilirubin) parameters were analyzed; preoperatively, following crossclampremoval, at the end of ECC, 6 hours post-ECC and on the 1st postoperativeweek.Results: Preoperative serum BUN and creatinine levels were normal inboth groups [(Group A; BUN= 17, 94 ± 5, 53 Group B; BUN= 20, 09 ± 8, 87(p>0,05), Group A; creatinine=1, 00 ± 0, 19 Group B; creatinine= 0, 98 ± 0, 17(p>0,05)]. At the end of ECC; serum NGAL levels were elevated 5-fold in GroupA while, this increase was 8-fold in Group B [(Group A= 264, 06 ± 105, 15,Group B= 416, 50 ± 174, 13 (p<0,05)]. On the 1st postoperative week serumNGAL levels were similar in both groups [(142, 71 ± 50, 87 vs 141, 09 ± 64, 08(p>0,05)].Conclusions: PC ECC systems seem to provoke an unexpected renal injurywith a silent clinic. Despite pre-, per- and post-operative normal BUNand creatinine values, we think that NGAL levels can signalize renal injurybefore clinical evidence. Following ECC, raise of BUN and creatinine valueswereinsufficient to diagnoserenal injury although a significant rise in serumNGALwere noticed during the same time intervals.


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P2D Cardiac Surgery 4

P2D-1 Simple and useful tips for tricuspid De Vega Annuloplasty

R. Zeybek1, D. Cevirme2, M. Bulent Rabus1, A. Sasmazel1, N. Kayalar3,M. Gunday2

1Department of Cardiovascular Surgery, Kartal Kosuyolu Yuksek Ihtisas EducationAnd Research Hospital Ystanbul, Turkey 2Department of Cardiovascular Surgery,Ahi Evren Thoracic and Cardiovascular Surgery Education And Research HospitalTrabzon, Turkey 3Department of Cardiovascular Surgery, Numune Hastanesi Konya,Turkey

Objective: De Vega Tricuspid annuloplasty repair is an important techniqueused simply for functional tricuspid regurgitation. This has been an effectiveand preferred method because of being a short and simple way especially duringmitral and aortic valve surgery. As a modification, we passed a 50 ml injectorthrough annulus while tying annuloplasty suture to ensure the adequacy ofannular orifice as a useful and safe tool.Methods: In our study, 41 patients were investigated to confirm if ourtechnique of TDVA were effective and safe. Twenty patients were male and21 were female with an mean age of 55·34 ± 14·5 (min12–max 81). Theavarage EuroSCORE was 8:52 ± 3·47 (min 2–max 17) and preoperative NYHAaveraged 3·1 ± 0·59 (min 2–min 4). All 41 patients had mitral valve pathology.Preoperative tricuspid insufficiency was moderate in 20 patients (48·8%) andsevere in 21 patients (51·2%). Mitral valve replacement with a mechanical valvewas performed in 18 patients and mitral valve repair in 23. Concomitant aorticvalve replacement was performed in 3 patients.Results: The postoperative NYHA level, tricuspid valve functions andsymptoms of right heart failure were evaluated and the results showedimprovement of symptoms within 1 year. Functional tricuspid regurgitationand NYHA class improved significantly during postoperative period (p<0·001).Conclusion: The effective correction of functional tricuspid insufficiencyis very important in patients with multiple valve disaese. But adjustment ofadequate annulus diameter can be problematic during De Vega annuloplasty.The diameter of the 50 cc injector as a standardized size for all patients is used inour technique. Right heart failure and tricuspit insufficiency was very effectivelycorrected upon postoperative follow up. This is a very simple and effective wayof adjusting tricuspid annular size during De Vega annuloplasty.

P2D-2 Octreotide as a Therapeutic modality for Managementof Chylothorax After congenital Cardiac Surgery

T. Tatar, D. Kilic, M. Ozkan, S. AslamaciBaskent University, Faculty of Medicine, Department of Cardiovasculary and ThoracicSurgery, Ankara, Turkey

Objective: Chylothorax is a rare but serious complication of congenital cardiacsurgery, with a poor prognosis unless treated properly. We present the use of theoctreotide (a somatostatin analogue) in the treatment of congenital chylothoraxin a patient who had underwent heart surgery and evaluate treatment modalitiesof the chlothorax.Methods: Between March 2006–December 2009, 12 patients were treated forchylothorax due to congenital cardiac surgery. Five female and 7 male, meanage was 16·6 months (7 days–36 months) were analyzed. The patient improvedrapidly after initiation of octreotide with complete resolution after 5 days ofcontinuous therapy (6–10 microg/kg per hour).Results: The chylothorax was successfully treated in mean 6·3 days (6–11 days)by means of octreotide administration and a diet that contained medium-chaintriglycerides.Conclusion: Octreotide, a long-acting somatostatin analog, is an effective andsafe agent for the treatment of postoperative chylothorax and may reduce theneed for reoperation.

P2D-3 Coronary artery lesion and Ventricular septal defect dueto blunt Chest trauma in a 7-year-old child

T. Tatar, M. Ozkan, D. Kilic, S. AslamaciBaskent University Faculty of Medicine, Ankara Teaching and Medical ResearchCenter, Department of Cardio-Thoracic Surgery, Ankara, Turkey

Objective: Blunt cardiac injury has been less frequently reported pediatric thanin the adult population. Moreover post infarct VSD due to LAD thrombosis isa rare but highly lethal injury in the pediatric group. We present a 7-year-oldpatient who underwent VSD repair and coronary artery bypass grafting ofLAD diagnosis with posttraumatic VSD due to thrombotic occlusion of LADfollowing blunt chest trauma.Material and Methods: A 7-year-old child who was suffered blunt chesttrauma cause of traffic accident. Echocardiography showed 18 mm VSD inanterior portion of mid muscular septum. Median sternotomy was done andpatient was put on CPB with bicaval cannulation. The defect was observedabout 20 mm in size and located in the anterior portion of the muscular septum.Although it was 8th day following the accident, the margins of the defectwere fibrotic. The LAD lesion was bypassed with saphenous vein, which washarvested from right leg. Right ventriculotomy was repaired primarly.Results: Postoperative course was uneventful and the patient was dischargedon 6th day following surgery.Conclusions: A high index of suspicion and early use of the appropriateimaging studies are essential for the timely diagnosis and surgical treatment ofthis condition.

P2D-4 Randomized comparison of multi-polar, duty-cycled,bipolar-unipolar radiofrequency versus conventional catheter ablationfor treatment of common atrial flutter

K. M. Burgazli1, R. Chasan1, A. Erdogan1

1Department of Cardiology, University Clinic of Giessen, Germany

Introduction: Radiofrequency (RF) catheter ablation has been established asan effective and curative treatment for atrial flutter (AFL). Approved methodsinclude a drag-and-drop method, as well as a point-by-point ablation technique.The aim of this study was to compare the acute efficacy and procedural efficiencyof a multi-polar linear ablation catheter with simultaneous energy delivery tomultiple catheter electrodes against conventional RF for treatment of AFL.Methods: Patients presenting to our department with symptomatic, typicalAFL were enrolled consecutively and randomized to conventional RF ablationwith an 8 mm tip catheter (ConvRF) or a duty-cycled, bipolar-unipolar RFgenerator delivering power to a hexapolar Tip-Versatile Ablation Catheter(T-VAC) group. For both groups, the procedural endpoint was bidirectionalcavotricuspid isthmus block.Results: Sixty patients were enrolled, thirty patients each assigned toConvRF and T-VAC groups. Total procedure time (40·2 ± 15·8 min. vs.60, 5 ± 12, 7 min.), energy delivery time (8·5 ± 3·7 min. vs 14·7 ± 5·2 min.),radiation dose (14·5 ± 3·5 cGy/cm2 vs. 31·7 ± 12·1 cGy/cm2), and the minimumnumber of RF applications needed to achieve block (4·2 ± 2·4 vs. 8·9 ± 7·2)were significantly lower in the T-VAC group. In seven patients treated withthe T-VAC catheter, bidirectional block was achieved with less than three RFapplications, versus no patients with conventional RF energy delivery.Conclusion: The treatment of typical AFL using a hexapolar catheter witha multi-polar, duty-cycled, bipolar-unipolar RF generator offers comparableeffectiveness relative to conventional RF while providing improved proceduralefficiency.

P2D-5 GRACE - Risk - Score as Predictor of In-hospital Mortalityin Patients with Chest-Pain

K. M. Burgazli1, R. Chasan1, A. Erdogan1

1University Clinic Giessen, Department of Cardiology/Angiology, Giessen, Germany

Introduction: Chest pain and chest discomfort are common problems in theacute care setting.Life-threatening causes of chest pain must be quickly differentiated from otherless serious causes. There is a need to stratify risk rapidly in patients presentingto the emergency department (ED) withchest pain. This study evaluates the relationship between the GRACE score(GRS) and in-hospital mortality in patients presenting to the ED with chestpain of all causes.Methods: We conducted a prospective study of a consecutive sample of 1014patients with chest pain and chest discomfort presenting to the medical ED of


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the University Clinic in Giessen, Germany. The GRS was calculated for eachpatient at admission. Additionally the reason for admission into the hospital andthe diagnosis on discharge or diagnosis of death were recorded. The relative riskbetween the risk groups was assessed and the functional dependency betweenthe GRS and observed in-hospital death was analyzed.Results: A total of 94 patients died during the stay in the hospital, 83 patientswith high risk, 9 with medium risk and two patients with low risk. The riskof in-hospital death was 24·5% for high risk patients, 2·6% for medium riskpatients and 0·6% for patients with low risk. The correlation between the GRSand in-hospital mortality is strongly positive (p<0·01).Conclusion: This study shows that the GRS accurately stratifies risk of intra-hospital mortality in patients presenting to the emergency department withchest pain and can guide patient triage and management.

P2E Gastrointestinal Surgery 3

P2E-1 The diagnosis and treatment of primary duodenal tumors

S. Song1, X. Cong2, K. Guo1

1Department of General Surgery, First University Hospital of China MedicalUniversity, Shenyang, China 2Department of General Surgery, First City Hospital ofShenyang, Shenyang, China

Objective: To investigate the diagnosis and therapeutic methods of primarytumors of duodenum (PTD).Methods: Clinical data of 124 patients with primary duodenal tumors who werehospitalized in the First Affiliated hospital of China Medical Univerity and FirstCity Hospital of Shenyang from 2001 to 2007 were analyzed retrospectively.Of all the tumors, 10 cases were benign tumors and 114 cases were malignanttumors. Diagnosis was established on endoscopy and radiography.Results: Common clinical manifestations include upper abdominal pain,jaundice, weight loss and poor appetite. Most of the lesion located in thedescending portion. Endoscopy � ERCP and ultra-endoscopy had highpreoperative diagnostic rate. The 5-year survival rate of benign PTD was100%. Among the malignant PTD cases, standard pancreaticoduodenectomy� pylorus preserving pancreaticoduodenectomy, simple tumor resection, andsegmental duodenectomy and bypass operation were done.Conclusions: Patients with PTD usually lack specific clinical manifestations,but combination of endoscopy, ultra-endoscopy, ERCP and other eximinationscan improve the preoperative positive diagnosis rate. For primary malignanttumors of duodenum, pancreaticoduodenectomy should be done, and bypassoperation is suitable for late-stage patients to improve survival rate and life-quality.

P2E-2 Feasibility of Laparoscopic Cholecystectomies ten years postIvor-Lewis Oesophagectomies for Cancer?

M. I. Arshad1, N. Rajendran1, A. Patel1, E. M. Chisholm1

1Upper Gastrointestinal Surgical Department, St. Peter’s Hospital, Surrey, UK

Objective: There is no published data to assist in the informed consentprocess for patients ten years post Ivor-Lewis Oesophagectomy for cancer. Thisretrospective case series assists surgeons carrying out informed consent as tothe; feasibility, safety and efficiency of a Laparoscopic Cholecystectomy in theabove patient group.Methods: Surviving patients, who underwent a Laparoscopic Cholecytectomy,more than ten years post Ivor- Lewis Oesophagectomy for cancer, were studied.A single Upper Gastrointestinal Consultant Surgeon carried out both theoriginal cancer operations and the Laparoscopic Cholecystectomies.Results: Number of Patients: 1 Male and 1 FemaleAges: 49 and 78Operating Time: 45 and 50 minsNumber of ports: 3 in eachFindings: In both, midline adhesions were encountered when placing the OpenHasson Cannula. These were easily dissected freely with blunt finger dissection.Conversion Rate: 0%Hospital stay: 1 day eachComplications: None.

Conclusions: This case series assists surgeons consenting this specializedgroup of patients. Laparoscopic Cholecystectomy is a safe procedure with noincrease in; conversion rate, operating time, number of ports, hospital stay orcomplication rates.Ivor- Lewis; Oesophagectomy; Oesophageal Cancer; Laparoscopic Cholecys-tectomy and Consent

P2E-3 Difficult Duodenum: Treatment with Biliogastric Diversion plusSerosal Patch

O. Buyuka yk1, A. O. Hasdemir1, C. Col1

1Abant Yzzet Baysal University, Medical Faculty Department of General Surgery,Bolu, Turkey

Objective: Large chronic ulcer perforations, complicated kissing ulcers,firearm injuries, iatrogenic duodenum wounds with a neighboring infectionand abscess, and duodenal fistulas should be considered as comprising cases of‘‘difficult duodenum’’. In these cases fistula formation, peritonitis due to sutureline dehiscence and the development of intraabdominal abscesses are frequentlyseen after duodenal repair.Methods: In this study, three cases are presented: those that have beentreated with biliogastric diversion and serosal patch (BGD-SP) for duodenalperforation due to chronic ulcers, kissing duodenal ulcers with gastroduodenalartery bleeding, and iatrogenic duodenal perforation respectively. All patientspresented with duodenal wall defects size > 3 cm, edematous and fragileduodenal wall, absence of suture safety after primary repair and a risk ofserious narrowing.Results: In patient with iatrogenic duodenal perforation, a pure pancreaticfistula developed on the 4th day postoperatively (150cc/day). The fistulaclosed on the 15th day postoperatively. None of the patients developed latecomplications.Conclusion: The BGD-SP method prevents the activation of pancreaticenzymes by separating biliary and pancreatic secretions which worsen theperitonitis and decrease the possibility of fistula closure. This method can beused in the treatment of selected cases that are evaluated as ‘difficult duodenum’.

P2E-4 PULSE granuloma, unusual localisation: appendix

G. Simsek1, H. Bulus2

1Ankara Kecioren Research and Training Hospital Department of Pathology, Ankara,Turkey 2Ankara Kecioren Research and Training Hospital Department of GeneralSurgery, Ankara, Turkey

Pulse granulomas are rare foreign body reactions to vegetable materialcharacterized by hyaline rings or starch granules. Pulse granulomas have beenreported before in association with lung aspirations, in the oral cavity witha history of oral procedures and less frequently in intestinal fistulae, colonicdiverticulae or stomach ulcers. Also two cases involving the skin have beenreported in a patient with jejunocutaneous and ileocutaneous fistulae. It isusually seen in the periapical or in the sulcus areas of oral cavity. We report thecase of pulse granuloma located in the appendix serosa.Case Presentation: 37 years old male patient referred to the emergencyservice of the hospital with the complaints of abdominal pain and noisea for2 days. In his history pain had started first from epigastric region and resited tothe right lower quadrant. In the clinical examination right guadrants reboundand defanse findings were found in that region. In the oscultation, intestinalmovements were decreased in all quadrants.Light microscopical examination marked the findings of acute appendicitis andperitoneal nodules. Histological examination of these peritoneal nodules showedepithelioid cell granulomatous inflammation, with multinucleated giant cells ofeither Langhans’ or foreign body type. In the centre of the non-necrotisinggranulomata there were roundish or oval starch granules. they containedoval microspheres and a homogeneous eosinophilic substance between themicrospheres. Most starch granules showed signs of degradation.The granules were periodic acid Schiff positive after diastase treatment.Conclusion: Cellulose plant-cell walls were present and led to the correctdiagnosis. However when such components are less conspicuous, or whencrystalline material predominates, the diagnosis may be less obvious.


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P2E-5 Rhomboid excision and limberg flap for managing pilonidalsinus short-term results

H. Bulus1, M. Dogan1, A. Coskun1

1Ankara Kecioren Research and Training Hospital Department of General Surgery,Ankara, Turkey

Objective: Pilonidal sinus is a common chronic disease of the sacrococcygealregion. The treatment for a pilonidal sinus varies according to the clinicalpresentation of the disease.Although many surgical methods have been suggested, an ideal method isstill lacking because of high recurrence rates. This study aim is to present ofrhomboid excision and limberg flap for managing pilonidal sinus short-termresults.Material and Methods: This prospective study includes 32 (M/F 21/11)patients who were treated with the use of a rhomboid excision and Limberg flapclosure for chronic and subacute sacrococcygeal pilonidal sinus. The follow-upperiod ranged from 04 to 09 months.Results: The mean hospital stay was 1 days and the operative mean time towas 68 minute (range, 52–77). Early wound complications were encountered in02 patients. No recurrence was noted on maximum of 06 months of follow-up.Conclusions: The results favor rhomboid excision and Limberg flap closurein the treatment of sacrococcygeal pilonidal sinus, especially in patientswith extensive involvement. Low recurrence rates, shorter hospital stay, lowcomplications and time off from work may outweigh the disadvantages relatedto unfavorable cosmetic appearance.

P2E-6 Influence of demographic characteristics on survival in patientswith gastrointestinal stromal tumors

S. Mrowiec1, B. Jabłonska1, Ł. Liszka2, J. Pajak2, M. Leidgens3,A. Sandecka4, P. Lampe1

1Department of Digestive Tract Surgery, University Hospital of the Medical Universityof Silesia, Katowice, Poland 2Department of Histopathology, Medical University ofSilesia, Katowice, Poland 3Division of General Surgery, City Hospital, SiemianowiceOl1skie, Poland 4Withybush Hospital Fishguard RD Haverfordwest, UK

Objective: The aim of paper was to asses influence of demographiccharacteristics on survival in patients with gastrointestinal stromal tumors(GISTs).Methods: Between January 1989 and December 2008, one hundred seventeenpatients were operated for GISTs. Retrospective analysis of two prognosticfactors (age, gender) was performed. Two years and five years survival rateswere assessed. Prognostic factors and survival rates were correlated usingCox regression proportional hazard model. Kaplan-Meyer survival curves wereconstructed. A value < 0·05 was considered statistically significant.Results: According to univariate analysis, male gender (p=0·007) was asignificant poor prognostic factor. Age (p=0·11) did not influence statistically onsurvival in patients with GISTs in our study. Multivariate analysis revealed thatmale gender (p=0·028) was an independent poor prognostic factor in patientsoperated for GISTs.Conclusions: A male gender is an independent poor prognostic factors forsurvival in patients with GISTs. Age is not a prognostic factor for survival inpatients with GISTs.

P2E-7 Effect of PPI on reflux esophagitis after total gastrectomy

N. Hashimoto1, H. Imamoto1

1Department of Surgery, Kinki University, Osaka, Japan

Objectives: Reflux esophagiutis was successfully produced in all rats operatedby total gastrectomy and esophagoduodenostomy. Reflux of the duodenalcontent with total gastrecgtomy has been reported to contribute to thedevelopment of esophageal mucosal damage and inflammation. Esophagitisafter total gastrectomy has been associated with biliary and pancreatic refluxinto the esophagus.The purpose of this study is to clarify the effect of PPI on these factors in theesophagitis.

Methods: Wistar male rats (8 to 10 weeks old) underwent total gastrectomyand esophagoduodenostomy to induce esophageal reflux of duodenal juice.One week following surgery, they were treated with control, Rabeprazole(Pariet) (100 mg/kg/day). 3 weeks after operation, all rats were killed and theesophagus was evaluated histologically. Esophageal injury was evaluated bymacroscopic (ulcer index, area) and microscopic findings, and expression ofCOX2 and PGE2 were determined by PCR. Esophageal washing was aspiratedfor the evaluation of trypsin and bile acid activity.Results: At 3 weeks after surgery, duodenal reflux induced esophageal erosionsand ulcer formation as well as marked thickening of the esophageal wall.Histological study showed an increase of thickness of the esophageal mucosa,hyperplasia of the epidermis and basal cells, ulcer formation, and markedinfiltration of inflammatory cells. The macroscopic ulcer score and histologicalulcer length were significantly reduced by treatment with Rabeprazole. Theenhanced expression of COX2 and PGE2 in the control group was also markedlyinhibited in the Rabeprazole-treated group. The trypsin and bile acid activity inthe esophageal lumen was significantly increased in the control group, and thisincrease was significantly inhibited in the Rabeprazole-treated group.Conclusion: With this model, we have demonstrated that Rabeprazolesignificantly reduces inflammation and hyperplasia in the esophageal mucosa.These results indicate that trypsin and bile acid, which is inhibited byRabeprazole, plays an important role in the mucosal damage induced byduodenal reflux.

P2E-8 The heat shock protein 32 response to intestinal ischemiaand ischemia/reperfusion injury

E. Ozturk1, N. Kahveci2, A. Oral3, K. Ozluk2, T. Yilmazlar1

Departments of General Surgery1, Physiology2and Biochemistry3, Uludag UniversitySchool of Medicine, Bursa, Turkey

Objective: The aim of this study was to clarify tissue and systemic blood heatshock protein (HSP) 32 response to intestinal ischemia and ischemia/reperfusioninjury in rats.Methods: 21 rats were divided into control group (CG), ischemia group(IG) and ischemia/reperfusion group (RG). Following laparatomy under etheranesthesia, superior mesenteric bundles (S.M.B.) of the rats were prepared. Asilk suture was placed around the SMB of the rats in CG. A permanent knot inthe I.G. and a slip knot in the R.G. were placed on the SMB. The free endsof the silk sutures were taken throughout the abdominal walls and then thelaparotomies were closed. Reperfusion was established by pulling out the freeends of the silk sutures after one hour in RG. Relaparatomy was performed toall the rats on the 6th hour of the initial laparatomy and small intestines wereremoved. Blood samples were taken. Rats were sacrificed by cardiac puncture.HO-1 (Rat) StressXpress ELISA Kit was used to measure HSP 32 in intestinaltissue and systemic blood samples Kruskal Wallis test or chi-square test wasused to compare group variables. P<0,05 was considered to be significant.Results: Tissue HSP 32 levels were significantly increased in IG and RG whencompared to the C.G. (p=0,0017). However, there was no difference betweenIG and RG (p=0,48). The median blood HSP 32 levels showed no differencebetween three groups (p=1).Conclusion: The tissue HSP. 32 levels increased similarly following a 6-hourintestinal ischemia and ischemia/reperfusion in rats; however, this increase didnot reflect to the systemic circulation.

P2E-9 Does metastatic lymph node ratio accept as a prognosticfactor in the patients underwent inadequate lymphadenectomy forgastric cancer?

S. Demirbas, I. Sucullu, A. I. Filiz, K. Coskun, N. Ersoz, M. T. OzerGATA, Ankara, Turkey

Objectives: There is an association between the number of resected lymphnode and the number of metastatic lymph nodes in gastric cancer, suggestingthat pN category could be influenced by the extension of the lymphadenectomy.The necessity of accurate lymph node staging has been stated a vital whileevaluating different treatment consequences. This study evaluates use of ratio oflymph nodes as a prognostic factor in the patients with gastric cancer underwentthe surgery with less than average 14 lymph nodes.


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Method: Review of 88 patients, average age 64·3 and mostly female withgastric cancer. The association between the number of resected lymph nodesand the number of metastatic lymph nodes was analysed according to 2 differentstaging systems and evaluated against the other prognostic factors too. Pearsoncorrelation of the variables and multivariate analysis then ROC curve analysiswere used to collate the ratio and the pN stage.Results: The number of lymph node metastases increased with the numberof resected lymph nodes. Thought the lymph node ratio suppose to be a betterprognostic factor than the number of metastatic lymph nodes no difference hadbeen exposed favored the ratio of lymph nodes in the study. ROC curve of bothvariables did not show difference (0·692, 0·709) but both variables was used as asignificant prognostic factor (p<0·0001). According to the multivariate analysisthe hazard ratio for the pN stages showed a significant increase (p=0·006,HR=1·8, 1,184–2,671 in 95%CI) with significant difference, which favored pNstages as a better prognostic factor against the ratio.Conclusions: The ratio of the lymph nodes seems not to be a good prognosticfactor in the patients underwent lymphadenectomy with 15 lymph nodes orlower. However it needs further evaluation.

P2E-10 What Should Be The Treatment Modality In Benign AnorectalDiseases Accompanying Rectocele?

O. Yuksel, H. Koksal, S. Leventoglu, K. Dikmen, H. Bostanci, B. BulentMentesGazi University Medical School, Department of Surgery, Ankara, Turkey

Objectives: Benign anorectal diseases are not rare in women complainingfrom rectocele. The role of rectocele in here is still on debate. In this studyrectocele surgery and its effects on benign anorectal diseases are discussed.Patients and Methods: The patients suffering from chronic anal fissurewith/without external or grade III/IV internal hemorrhoidal disease and alsoplanned to undergo surgery for rectocele are included in this study. All patientswere documented on the previously prepared forms. The diagnosis of rectocelewas performed with the presence of symptoms (straining and incompletedefecation, sense of vaginal mass, perineal digitations, dysparonia), bimanuel(rectal and vaginal) physical examination, and defecography. Transperinealrepair technique with PGA soft mesh (polyglycolic acid) was the preferredsurgical method. No other surgical procedure was performed for the otheranorectal diseases. The follow-up controls were in postoperative 1st, 3rd, 6thand 12th months.Results: All patients were followed up for more than 1 year (12–36 months).Preoperatively together with rectocele; in 9 patients chronic anal fissure, in 4patients grade III internal hemorrhoidal disease, in 2 patient grade IV internalhemorrhoidal disease, in 4 patients external hemorrhoidal disease were detected.In 3 patients both grade III internal hemorrhoidal disease and chronic anal fissurewere examined with rectocele. It was observed that after the postoperative 3rd

month there were clinically and objectively significant improvements in thecomplaints of the patients.Conclusion: In cases of rectocele that accompany chronic anal fissurewith/without hemorrhoidal disease, after the surgical intervention performedfor rectocele, the symptoms of other benign anorectal diseases were observedto be recovered without any surgical procedure, if not, underlying pathologiesshould be searched for obstructive constipation.

P2E-11 Cecal lumen obliteration in rats

N. Ozlem1, A. Gurer1

1Ataturk Education And Research Hospital, Ankara, Turkey

Objective: If the cecal lumen obliteration in rat model can be achieved. Thissucces may transfer to use to oblitere the appendiceal lumen of the otheranimals.Methods: Some chemical agents (isotonic saline, polidocanol, 98% ethanol,80% phenol solution) were used to obliterate cecal lumen of fifty one wistaralbino rats. Twelve cecal mucosae also sealed with adhesive substance. The ratswere maintained for 8 weeks. The extent of mucosal ablation was graded on ascale of 0–4. The degree of fibrosis caused by the chemical was also recordedon a similar scale.

Results: A microscopic examination of the cecal mucosae ablated with only3% polidocanol showed only one degree mucosal ablation, second degree offibrosis. The cecal mucosae exposed to a mixture of 3% polidocanol plus % 98ethanol has 2° mucosal ablation but no fibrosis. If the caecum was flushed withNAC solution then exposed to same mixture caecum mucosa was ablated in agrade 3 and the cecal wall has grade 3 fibrosis. The agents; NAC, phenol andcyanoacrylate used to ablate and sclerose of the cecal mucosae of rats result milddestruction and fibrosisConclusion: An ablation and sclerosing of cecal mucosa with various chemicalagent is possible. NAC, phenol and cyanoacrylate were most effective inachieving complete mucosal destruction and fibrosis.

P2F Gastrointestinal Surgery 4

P2F-1 Effect of previous abdominal operations on laparoscopiccolorectal surgery. A cohort study

N. Naguib1, A. Saklani1, P. Mekhail1, A. Masoud1

1Department of colorectal surgery, Prince Charles Hospital, Merthyr Tydfil, UK

Objective: To assess the effect of previous abdominal operations on theoutcome of laparoscopic colorectal procedures (LCP).Methods: Retrospective study including patients underwent LCP between2001 and 2009. Patients were divided into group A; patients with no previousabdominal surgery and group B; patient with previous abdominal surgery.Statistical analysis performed using Fisher’s exact test and student ‘‘t’’ test.Results: 146 patients underwent LCP, 103 in group A and 43 in group B. 34multi-segmental and stoma procedures were excluded. The mean operative timein group A was 193 minutes (range: 28–457) compared to 232 minutes (range:45–389) in group B (p = 0·0003). No intra-operative accidental enterotomyoccurred in group A compared to 2 in-group B, 1 of them was not recognisedat the time of surgery, p = 0·085. In group A, 3 cases had post-operative ileuswhile in group B, 1 case had mechanical obstruction. There was no significantdifference in morbidity between both groups (11 in group A and 6 in group B,p = 0·58). The rate of conversion in group A was 10·7% while, it was 16·3%in group B (p = 0·4). The median hospital stay was 6 and 5 days in groups Aand B respectively (p = 0·895). 2 mortalities (non-surgical) occurred in group Acompared to 1 surgical-related mortality in group B (p = 1).Conclusion: Although previous abdominal operations seem to have asignificant influence on the time-length of LCP, they did not show a significanteffect on the outcome in terms of morbidity, rate of conversion, hospital stay,and mortality.

P2F-2 Argon Plasma Coagulation (APC)-Is there any role in advanceupper GI cancer? A single unit experience

N. Altaf1, S K P John1, R. Lochan1, Y. K. S. Viswanath1

1Upper Gastro-Intestinal Surgery, James cook University Hospital, Middlesborough,UK

Objective: Increasing number of unfit/elderly patients are being diagnosedwith advanced upper GI cancer. No large prospective studies have quantifiedthe role of APC in this cohort of patients. The study aims to assess whethera standardised approach can be implemented in this cohort of patients andwhether there is any survival benefit?Methods: A prospectively collected database (EndoSoft) on all patientsundergoing APC was retrieved. Upper GI cancer pathologies were only includedin the analysis. Indications for APC, Number of procedures and interval betweenprocedures, were analysed. Outcome measured by being discharged from followup and or death. Cause of death was verified with death certificates and onlythose who died of cancer was analysed on Kaplan Meir analysis. Episodes ofAPC were correlated to outcome. P<0·05 was considered significant.Results: From January 2000 to May 2008, there were 42 patients (male 29,Female 13) who underwent APC treatment. 60% were oesophageal, 26% gastricand 14% Junctional. Primary indication was blocked stent (38%), followed byrecurrent disease in 14%. 25(55%) patients required stenting in some stage ofthe cancer progression. Fifty percent of patients had stage 4 disease. MedianAPC episodes were 2 (range 1 to 10). Stage 4 disease patients had some


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survival benefit on increased APC episodes, log rank (mantel-cox) p=0·044.This significance was however not noted in the non-stage four patients.Conclusion: While APC has been used in advanced upper GI cancers, theirbenefit other than symptom palliation (eg: blocked stent, bleeding tumour etc)is only seen in stage 4 diseases by slight increase in survival.

P2F-3 The use of transrectal ultrasound scan in assessment of rectallesions suitable for transanal endoscopic microsurgery

L. Radmore1, P. Bevis1, J. Wheeler1, N. Borley1

1Department of Gastrointestinal Surgery, Cheltenham General Hospital, Cheltenham,UK

Objectives: To assess the accuracy of Transrectal ultrasound scan (TRUS)in the assessment of benign rectal lesions suitable for transanal endoscopicmicrosurgery (TEMS).Methods: Three hundred and sixty eight patients with a significant rectalneoplasm were assessed at a regional TEMS centre between April 2005 andOctober 2008. Only patients unfit for any subsequent procedure were excludedfrom assessment. TRUS findings were compared with subsequent pathology toallow determination of TRUS sensitivity and specificity as ‘work up’ for TEMSin this centre.Results: Following TRUS 192 patients underwent TEMS, 95 anteriorresection, 8 abdomino-perineal resection, 3 Hartmann’s procedure, 4 perianalexcision, 1 colonoscopic polypectomy, and 48 underwent no intervention. Of the192 patients undergoing TEMS, 15 (7·8%) went on to have further intervention;13 anterior resections, 1 abdominoperineal resection and 1 panproctocolectomy.TRUS incorrectly staged only four malignant lesions as benign disease. Twopatients assessed as uT3 were found to have y0N0 pathology after treatmentwith radiotherapy and TEMS. The sensitivity for TRUS for the detection ofbenign disease in this operated group was found to be 92·8% and the specificitywas found to be 87·3%.Conclusion: TRUS is a sensitive and specific test in the assessment of rectallesions being considered for treatment by TEMS.

P2F-4 Effects of pyrrolidine dithiocarbamate and ischemicpreconditioning on intestinal ischemia-reperfusion injury

Z-K. Bulut1, M-R. Pekcici1, A. Hasanodlu1, N. Dindar2, H. Ustun3,O. Guler1

1Department of 1st General Surgery Clinic, Turkish Ministry of Health, AnkaraTraining and Research Hospital, Ulucanlar, Ankara, Turkey 2Department ofBiochemistry, Turkish Ministry of Health, Ankara Training and Research Hospital,Ulucanlar, Ankara, Turkey 3Department of Pathology, Turkish Ministry of Health,Ankara Training and Research Hospital, Ulucanlar, Ankara, Turkey

Objective: Intestinal ischemia-reperfusion injury (IIRI) can cause multiorganfailure by means of increased mucosal permeability. Nitric oxide (NO) is oneof the most important factors responsible from IIRI. Ischemic preconditioning(IP) and Pyrrolidine dithiocarbamate (PDTC) were shown to decrease NOsynthesis by inhibition of inducible nitric oxide synthase (INOS). The aim ofthis study was to evaluate the potential effects of IP and PDTC on intestinalmucosal damage developed by IIRI.Methods: Wistar type, male 30 rats were divided into 5 groups as laparotomy,ischemia-reperfusion (IR),IP,IP+IR, and PDTC+IR groups. Ischemia andreperfusion was obtained by clamping and declamping of the superior mesentericartery. PDTC was given on the dose of 200 mg/kg iv. The ileum was excised forbiochemical (levels of nitrate nitrite, malonyl dialdehyde and myeloperoxidase)and pathologic analyses (mucosal damage, inflammation, hyperemia-bleedingand immunohistochemical analysis of INOS) and 3 ml of blood from the heartsof the rats were taken.Results: Mucosal damage score was the lowest in PDTC+IR group (p<0·05).Inflammation and hyperemia-bleeding scores were lowest in laparotomy andPDTC+IR groups (p<0·05). INOS density and penetration on the ileum tissuewere not significantly different between the groups on immunohistochemicalanalysis (p>0·05). Nitrite levels were not significantly different between thegroups.Nitrate levels were lowest in PDTC+IR group significantly (p<0·05).Myeloperoxidase levels were lowest in laparotomy and PDTC+IR groups.

Malonyl dialdehyde levels of the ileal tissue were lowest in PDTC+IR groupwhereas plasma levels of malonyl dialdehyde were lowest in laparotomy group.Conclusions: PDTC+IP was shown to superior than IP alone eitherbiochemically or pathologically on intestinal ischemia. PDTC could be usedto reduce reperfusion damage preoperatively or may be postoperatively forintestinal ischemia situations.

P2F-5 The diagnostic yield of colonoscopy for chronic diarrhoea

N. Pawa1, B. Murtagh1, J-K. Lawrence11, P. Cathcart1, M-G. Tutton1

1Department of Laparoscopic and Gastrointestinal Surgery, Colchester Hospital,Colchester, UK

Objective: Chronic diarrhoea remains one of the most common reasons forreferral to the outpatients clinic. Its prevalence in the Western population isestimated between 4–5%. With a change in bowel frequency being characteristicof irritable bowel syndrome it is essential not to inappropriately investigate suchpatients. The aim of this study was to assess the diagnostic yield of colonoscopyfor patients with chronic diarrhoea.Methods: A retrospective analysis was performed from a prospectively collateddatabase of all patients who underwent colonoscopy for chronic diarrhoea(symptoms > 4 weeks) between March 2008 and November 2009. Patientdemographics, colonoscopic and biopsy findings were analysed together withresults from further investigations.Results: A total of 361 patients underwent colonoscopy for chronic diarrhoeaduring this period. The mean age was 58·5 years with a male: female ratio of139 : 222. A histological diagnosis was made in 96 (26·5%) patients. Biopsieswere negative in 170 (47%) patients. A total of 12 patients were found to haveadenocarcinomas (3·3%) with inflammatory bowel disease diagnosed in 29 (8%)patients. Microscopic colitis was identified in 23 (6·3%).Conclusion: This study has shown colonoscopy and biopsy to yield a higherdiagnosis (26·5% cases) in comparison to previous suggestions (15–20%).Investigations should be age stratified according to the risk of neoplasia. Athorough initial assessment and less invasive investigations should be performedto exclude other causes such as the small intestine, pancreas and endocrineabnormalities, and further reduce unnecessary colonoscopies.

P2F-6 Efficacy on anastomotic healing and oksidative-antioksidativestatus of early different enteral diets in protein energy malnutritionin rats

O. Yuksel1, O. Gulbahar2, A. Dikmen3, M. Akin1, K. Dikmen1,M. Oguz1

Department of Surgery1, Department of Biochemistry2, Department of PublicHealth3Gazi University Medical School, Ankara, Turkey

Objective: Protein energy malnutrition can deteriorate the balance betweenthe reactive oxygen species and protective mechanisms. It was aimed to evaluatethe effects of the different diets given in the early postoperative period onanastomotic healing and oxidative and antioxidative capacity in malnutrition.Methods: Each study groups were formed with 10 rats. Each rat receivedprotein energy malnutrition diet for 15 days. While the rats in group Iwere sacrificed after the malnutrition, the rats in group II, III, IV and Vwere underwent left colonic anastomosis after the malnutrition. Group IIreceived standard diet, group III received diet only with fiber, group IVreceived high energy diet and group V received high energy diet with fiberafter the anastomosis. After 7 day nutrition, anastomotic burst pressure andhydroxyproline levels in the samples from the anastomosis were measured.Beside the antioxidative enzymes like superoxide dismutase (SOD), catalase,glutathion reductase, antioxidative capacity were evaluated in the blood samples.Results: Anastomotic burst pressure in group IV and V were similar, the burstpressure were higher in group IV was compared especially with group I, II andIII (p<0·05). The tissue hydroxyproline levels were higher in group V whencompared with the other groups (p<0·05). While the antioxidative enzymesand antioxidative capacity were found to be higher in group IV when comparedwith group II (p<0·05), the results were similar when compared with the othergroups (p>0·05).


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Conclusions: High energy diet in the protein energy malnutrition duringthe early postoperative period can be effective in anatomotic healing andimprovements of oxidative-antioxidative capacity.

P2F-7 The late diagnosis of traumatic diaphragm hernia: A case report

I. Sert, M. Karadeniz, S. SalimogluService of Visceral Surgery, Tepecik Educational Hospital, Izmir, Turkey

Objective: Early diagnosis of diaphramatic rupture after trauma may bedifficult and may result an increased morbidity and mortality. We presented acase of delayed diagnosis of traumatic hernia (TDH) with colonic obstructionbecause of two different defect located in left diaphragm.Case Report: A 29 year old-male patient who experienced penetrating traumaand had diagnosis of TDH nearly 9 months later. According to the pasthistory, the patient suffered from abdominal pain, vomiting, constipationand dispnea after that trauma. These symptoms increased for last two daysbefore his hospital admission. The patient was referred to our emergencyroom complaining of intestinal obstruction symptoms. Physical examinationdemonstrated abdominal distention, tenderness, defense and rebaund. Thechest X-ray demostrated intestinal structures in the thoracic cavity. Computedchest tomography revealed fluid level formed by the abdominal organs in the lefthemithorax. During abdominal exploration, two different diaphragmatic defects(approx 10 cm) located in left diaphragm were observed. Stomach was foundherniated through the medial defect and transvers colon, omentum and spleenwere found herniated through the lateral diaphragmatic defect. The spleen wasnot viable therefore splenectomy was carried out. The diaphragmatic defectswere repaired with non absorbable sutures. The patient was discharged on thepostoperative eight day.Conclusion: Traumatic diaphragmatic hernias usually result from blunt orpenetrating injury. A history of trauma must be investigated to diagnose thepatients with delayed TDH. Diaphragmatic injury, when overlooked, can causecomplications and even death.

P2F-8 Pancreatico-colonic fistula: A rare complication of acutepancreatitis

B. Kumar1, A. Nikkar-Esfahani1, S. Wakefield1

1Division of Colorectal Surgery, The James Cook University Hospital, Middlesbrough,UK

Objective: Pancreatico-colonic fistula (PCF) is a rare complication of acutesevere pancreatitis and usually occurs following pseudocyst formation. Wereport a case and review the literature of PCF in a patient who had an attack ofgallstone pancreatitis who was successfully treated conservatively.Methods: Using the keywords pancreatico-colonic fistulae and acutepancreatitis, the Pubmed database was searched to review the literature presenton previous cases of PCF secondary to acute pancreatitis. In addition, thereference lists from the included studies were screened for additional reports.Results: Fistulae to the colon following acute pancreatitis is rare with very fewprevious reported cases of such fistulae in the absence of pancreatic necrosisor pseudocyst formation. A 51 year old man presented with persistent LUQpain having had an attack of severe gallstone pancreatitis, treated by ERCPand laparoscopic cholecystectomy 9 months before. A CT scan was performedon this admission showed normal pancreatic enhancement with no necroticchanges. No evidence of pseudocyst was seen. A gas tract was noted trackingbetween the descending colon and tail of the pancreas passing into the leftsubphrenic area suggestive of a PCF. The patient was managed conservativelyand remains well to date.Conclusion: PCF is a potentially life threatening complication of acutepancreatitis and occurs as a result of spreading inflammation through theperitoneal reflection arising from the anterior surface of the pancreas towardsthe colon. Our case remains unique as fistula formation has occurred in theabsence of a pseudocyst. In the absence of septic symptoms conservativemanagement can be successful in these patients.

P2F-9 Sutureless colonic anastomosis with cyanoacrylate inexperimental study

A. UzunkoyDepartment of General Surgery, Harran University School of Medicine, Sanliurfa,Turkey

Objective: In this study, it was aimed to investigate sutureless colonicanastomosis with cyanoacrylate is safe or not.Methods: Twenty Wistar Albino rats were divided into two groups. All therats were operated on under ether anesthesia. At the operation, a 3 cm ilealsegment was resected up to 10 cm proximal to the ileocecal valve. In the groupone end to end anastomosis were performed by using 2-octyl cyanoacrylate. Inthe group two, single layer anastomosis were performed with 5·0 polipropylenesutures. The rats were sacrificied 14 days later following operation. Integrityof the anastomosis and existence of perianastomotic abscess or peritonitis wereevaluated. Anastomotic ileal segments were resected and anastomotic burstingpressures were measured in all rats for evaluating anastomotic wound healing.Results: There was not observed anastomotic leakage in the two groups. Therewere no statistical significant between two groups about bursting pressures andintraperitoneal findings (p>0·05).Conclusion: This study was shown that sutureless colonic anastomosis withcyanoacrylate is safe under experimental conditions but we need additionalexperimantal and clinical studies for clinical use.

P2F-10 Effective weight loss in morbidly obese patients: comparisonbetween laparoscopic Roux-en-Y gastric bypass (LRYGB)and laparoscopic sleeve gastrectomy (LSG)

P. C. Nett1, Y. Borbely1, J. M. Heinicke1, D. Candinas1

1Divison of Viscerale and Transplant Surgery, University Hospitals of Berne,Switzerland

Objective: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as aprocedure for the treatment of morbid obesity. Its indications and long-termresults are currently under evaluation. Initially started as a first-stage procedurefor superobese patients (BMI > 50 kg/m2), it is now emerging as a standaloneprocedure in bariatric surgery. Early results suggest that, at the end of thefirst year, weight loss and resolution of comorbidities with LSG is comparableto laparoscopic Roux-en-Y gastric bypass (LRYGB). Whether LSG alone canreplace LRYGB as a standard bariatric procedure is questionable. The aim of thisstudy is to compare the results, resolution of comorbidities, and complicationsbetween LSG and LRYGB.Methods: A retrospective comparative analysis was done of 20 patients in eacharm who underwent LSG and LRYGB. Both groups were matched for age,sex, and body mass index. The resolution of comorbidities, percentage of excessweight loss (EWL), and complications were studied at 6 months and 1 year inour study.Results: The resolution of most comorbidities such as type 2 diabetes,hypertension, dyslipidemia, sleep apnea, joint pains, and percentage of EWLin both groups was comparable at the end of 6 months and 1 year. Thoughearly resolution of type 2 diabetes was seen to be better in the LRYGB group,the results matched up at 1 year. On the other hand, there was an increasedincidence of gastroesophageal reflux disease in LSG patients.Conclusion: Long-term studies are needed to evaluate the efficacy of LSGalone as a procedure for the treatment of morbid obesity and its comorbidities.


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P2G Genetics - Gynaecological Surgery andUrology

P2G-1 Identification and characterization of CGI-121, a novel PRPK(p53-related protein kinase)-binding protein

A. Miyoshi1, K. Kito2, T. Mizumoto1, Y. Yonenaga1, J. Watanabe1,Y. Kojima1, T. Tooyama1, F. Kushihata1, K. Honda1, Y. Takada1

1Department of Hepato-biliary-pancreatic Surgery and Transplantation, EhimeUniversity School of medicine, Shitsukawa, Toon-city, Japan 2First Departmentof Pathology, Ehime University School of Medicine, Shitsukawa, Toon-city, Japan

Objective: PRPK (p53-related protein kinase) has been reported as a novelprotein kinase which binds to the tumor suppressor protein p53 and inducesphosphorylation of p53 at Ser 15. To identify cellular proteins that are involvedin the PRPK-signaling pathway, a yeast two-hybrid screening was performedusing PRPK as the bait.Methods: We isolated cDNA fragments, which encoded a 20-kDa protein,that were identical to CGI-121 cDNA that had been deposited in the GenBankas an expressed sequence tag. Further library screening based on PCR revealedtwo more alternative splicing variants of CGI-121.Results: In eleven human cell lines, distinct mRNA transcripts correspondingto the splicing forms were observed; however, only CGI-121 protein, andnot the other alternative splicing variants, was expressed. CGI-121 wasimmunocytochemically identified in both the nucleus and cytosol.Conclusion: We demonstrated the protein-protein interaction of CGI-121with PRPK in vivo and in vitro. In contrast to the successful demonstrationof an interaction between PRPK and p53, several attempts to demonstratean association between CGI- 121 and p53 were unsuccessful. In addition,coprecipitation of p53 using recombinant PRPK was inhibited by addingrecombinant CGI-121 in vitro, suggesting that CGI-121 could act as a potentinhibitor of the binding of PRPK to p53.

P2G-2 Electroporation-mediated delivery of functional genes – apromising approach for nonviral-based gene therapy of the failingheart

S. Eigeldinger-Berthou1, P. Buntschu1, A. Frobert1, M. Fluck2,H. Tevaearai1, A. Kadner1

1Clinic for Cardiovascular Surgery, Clinic of Cardiology, University Hospital of Berne,Switzerland 2Institute for Biomedical Research into Human Movement and Health,Manchester Metropolitan University, UK

Objective: Alterations of β-adrenergic receptor signaling is a hallmark of heartfailure (HF). Gene therapy may represent a promising therapeutic strategy.Here, we aim to establish and to utilize an electroporation-based viral-freesystem to transfect the β-adrenergic receptor kinase inhibitor (βARKct) inmyocardial muscles in vivo to restore β-adrenergic receptor normal function.Methods: Electroporation (EP) was performed with the reporter plasmid(pCMV GFP), as control, and the gene of interest (pUB βARKct). The geneswere electroporated in vitro in neonatal rat cardiomyocyts, and in vivo, on thebeating heart of anesthetized Lewis rats. In vitro, EP efficiency was quantified byFACS and quantitative RT-PCR. Expression of the proteins was also assessedby Western blot. In vivo, gene expression was assessed seven days and threeweeks post-intramyocardial EP by fluorescence, immunohistology and Westernblot.Results: Electroporation was technically easy to apply and comparatively safe.Serial assessments of gene expression demonstrated cellular and intramyocardialexpression of the reporter gene and βARKct. Expression pattern showed in vivostrongest expression areas around electrode placement zones.Conclusion: Electroporation is a promising therapeutic approach for non-viral-based gene therapy for HF. It is easy to apply and without harmfulside-effects. However further functional analyses are necessary to demonstrateβARKct expression up to three weeks and to confirm the positive effects ofrestoring the long-term β-adrenergic signaling for improvement of HF.

P2G-3 The role of COP9 signalosome during adipogenesis

S. Rogalla1, C. F. Geier2, X. Huang2, J. Ordemann1, J. M. Muller1,W. Dubiel2

1Department of General, Visceral, Vascular and Thoracic Surgery, Charite UniversityMedicine Berlin, Berlin, Germany 2Department of General, Visceral, Vascular andThoracic Surgery, Divison of Molecular Biology, Charite University Medicine Berlin,Berlin, Germany

Objective: Obesity is one of the most seroius health problems of the 21st

century. It is associated with the expansion of fat tissue which requiresagiogenesis. Adipogenesis is stimulated by different adipokines, which inducethe production of vascular endothelial growth factor (VEGF). The COP9signalosome (CSN) is a protein complex that plays a role in cell differentiation.In tumor cells it controls the production of VEGF.Methods: LiSa-2 is a stable cell line derived from liposarcoma. Inserum free medium containing insuline, cortisol and triiodthyronine LiSa-2cells differentiate into adipocytes in approximately 20 days. Curcumin andpiceatannol are known to inhibit CSN-associated kinases. For permanenttreatment with curcumin we used 10 µM The appropriate concentration ofpiceatannol was 12·5 µM. Direct influence of the CSN was detected by usinga transient transfection of siRNA against CSN5. The VEGF production wasquantified by ELISA assay. Changes of the CSN and transcription factor proteinlevels were assessed by Western blotting.Results: Treatment of LiSa-2 cells with curcumin and piceatannol did notchange protein levels up to 8 days. However, after this period proteins suchas p53 and c-Jun were changed and the VEGF production was significantlyreduced. In parallel, the intracellular accumulation of fat droplets in adipocyteswas decreased. Overexpression of CSN5 increased the VEGF production inLiSa-2 cells by 30%. Downregulation of CSN5 led to a reduction of VEGF byapproximately 15% accompanied by a decrease of c-Jun level.Conclusion: Our preliminary results show an influence of the CSN on LiSa-2cell differentiation and VEGF production.

P2G-4 Etanercept causes regression of endometriotic implants:an experimental rat model

G. Yildirim1, R. Attar1, F. Ozkan2, C. Ficicioglu1, A. Karateke1,B. Yilmaz3, N. Yesildaglar1

1Department of Obstetrics and Gynecology, Yeditepe University Hospital, Istanbul,Turkey 2Department of Pathology, Yeditepe University Hospital, Istanbul, Turkey3Department of Physiology, Yeditepe University Hospital, Istanbul, Turkey

Objective: To determine the effects of etanercept (anti-TNF-α) on surgicallyinduced endometriosis in a rat endometriosis model.Methods: This experimental study was done in the Experimental ResearchCenter of Yeditepe University. Thirty female non-pregnant, nulligravid Wistar-Hannover albino rats were used. The induction of endometriosis was performedin the first operation. After 2 weeks of estradiol treatment (except for the secondcontrol group (10 rats), the second operations were performed. Then estrogenwas discontinued and 20 rats were randomized into etanercept (n=10) andfirst control (n=10) groups; 2 mg/kg sc etanercept three times per week wasadministered for 2 weeks. After the third operation, etanercept was terminatedand estrogen was initiated again (except for the second control group). Twoweeks later all the rats were euthanized and the recurrence of endometriosis wasassessed.Results: One hundred and twenty uterine horns were implanted in 30 rats.Endometriosis was completely formatted in 112 lesions (93·3%). No ratswere lost. In the Etanercept group the lesions’ volume were 83·9 ± 13·1 mm3,47·2 ± 8·4 mm3, and 96·7 ± 34·8 mm3 pre-treatment, post-treatment and atthe end of sixth weeks respectively (P=0·007). Histopathologic score were2·3 ± 0·2, 1·7 ± 0·2, and 1·9 ± 0·1 respectively (P=0·08). The changes in theother groups were not statistically significant.Conclusions: Etanercept, a fusion protein consisting of human recombinantsoluble TNF receptor-2, neutralizes TNF activity. In our study, the size andscore of the lesions were decreased with Etanercept. Anti-TNF therapy couldbe a new non-hormonal therapeutic option for treatment of endometriosis inhumans.


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P2G-5 The research on the correlation between the anthropometrymeasures and the penile length of 250 turkish boys aged 0 to 5 yearsold

H. AkderePrivate General Hospital, Cerkezkoy, Turkey

Objectives: To update the normal stretched penile length values for childrenyounger than 5 years of age. We also evaluated the association between penilelength and anthropometric measures such as body weight, height, symphisispubis height and intraspinal length.Methods: The study was performed as a cross-section study. The stretchedpenile lengths of 250 white uncircumcised male infants and children 0 to 5 yearsof age were measured, and the mean length for each age group and the rateof increase in penile length were calculated. The correlation between penilelength and weight, height, symphisis pubis height and intraspinal length of thechildren was determined by Pearson analysis.Results: The stretched penile length was 3,85 ± 0, 76. A significant correlationwas found between penile length and the weight, height, intraspinal length andsymphisis pubis of the boys (r=0·651, r=0·387 r=0·512, r=0·341, r=0·452 andr=0·082 respectively).Conclusions: The age-related values of penile length must be known to beable to determine abnormal penile sizes and to monitor treatment of underlyingdiseases. Our study has provided updated reference values for penile lengthsfor Turkish and other white boys aged 0 to 5 years. The anatomical relation(embryological) between the pubis height and the penile radix can describe thesignificant correlation especially between 0 to 5 year-old children.

P2G-6 Artificial Urinary Sphincter based on smart materials

M. Valerio1, P. Tozzi2, M. Wieland2, P.-A. Conus3, P. Thevenaz3,A. R. Mundy4, D. Hayoz5, P. Jichlinski1

1Department. of Urology, University Hospital Lausanne, Lausanne, Switzerland2NanoPowers SA, Research & Development, Lausanne, Switzerland 3Center forTechnology Transfer, University of Applied Sciences Western Switzerland, Yverdon-les-Bains, Switzerland 4University College London Hospitals NHS Foundation Trustand Institute of Urology at University College London, UK 5Department. of InternalMedicine, Fribourg Hospital, Fribourg, Switzerland

Objective: There are only a few established artificial urinary sphincters fortreatment of incontinence. We have developed a new device composed by threeparts: the actuator, three contractile rings and a control unit. The actuator ismade of Nitinol fibers, driven by microprocessor. The fibers are linked to therings placed around the urethra. They function with alternance in their openand closed position. This concept is called piano concept. With this set-up, theconstant compression on the urethra is strongly reduced.Methods: Six male sheep have been used for this study. The sphincter wasopen each hour for a period of 10 min., to guaranty urination. The bladder wasfilled with water while one cuff was closed and bladder pressure was monitored.The animals were sacrificed. Two biopsies around two cuffs of each explant andall three cuffs from each explant including urethra were analyzed. Urethra notsurrounded by a cuff was taken as control.Results: The pressure exerted by the sphincter around the urethra providedcontinence. Simulated incontinence occurred at a pressure of 1bar measuredon the bladder wall using a pressure probe. The closing force of the cuff wasapprox. 0·7N. No difference in tissue structure and organization of the urethrawith and without artificial sphincter was observed.Conclusions: This device has several advantages compared to other urinarysphincters. It is easy to implant, has no hydraulic nature and reduces ischemicinjury of the urethra by the alternance of urethral part compressed. Proof ofconcept in vivo has been demonstrated. Other studies are planned to determinelong-term outcome.

P2G-7 Expression of Programmed Death-1 in CD8+ T cells frompatients bearing PCA upon stimulation with common γ-chaincytokines

C. Mengus1, C. Le Magnen1, A. Bachmann2, M. Heberer1, G. Spagnoli1

and S. Wyler1,2

1Institute of Surgical Research and Hospital Management (ICFS), Basel UniversityHospital, Basel, Switzerland 2Department of Urology, Basel University Hospital, Basel,Switzerland

Objective: Immunosuppressive mechanisms in benign prostate hyperplasia(BPH) and prostate cancer (PCA) patients are not clarified. We analyzedhomeostatic proliferation of CD8+ cells to IL-2, IL-7 and IL-15 cytokines.CD8+ cells exhaustion was assessed by evaluating Programmed Death-1 (PD-1)and its ligand PD-L1 expression in PBMC and tissue infiltrating CD8+ cells.Methods: 62 BPH, 84 PCA patients were enrolled. Gene expression wasquantified by Real-Time-PCR. T cell proliferation was evaluated by CFSEdilution. Protein expressions were assessed by flow cytometry.Results: IL-7 and IL-15 gene expression were significantly increased in PCAtissues as compared to BPH (p=0·024; p=0·031). No significant differenceswere observed for IL-2. A trend towards a lower CD8+ cells proliferation toIL-15 in PCA as compared to BPH patients was detectable. No differences werenoticed for the expression of α and common-γ (CD132) and -β (CD122) chainsof cytokine receptor in CD8+ cells. In BPH and PCA, percentage of CD8+PD-1+ and of CD8+PD-L1+ cells were increasing upon culture with homeostaticcytokines. In freshly isolated CD8+ cells, PD-1 and PD-L1 expressions weresimilar in BPH and PCA patients. A large majority of CD8+ cells infiltratingBPH or PCA tissues were PD-1+ (83 ± 22% and 88 ± 17%, respectively),whereas PD-L1 was expressed in 51 ± 43% and 37 ± 39% of infiltrating CD8+T cells in BPH and PCA, respectively.Conclusion: PCA patients display decreased responsiveness to IL-15 ascompared to BPH. High percentages of CD8+ cells express PD-1. PD-1and PD-L1 are highly expressed in tissue infiltrating CD8+ cells, thus raisingthe issue of the role of T cells exhaustion in PCA.

P2G-8 Evaluation of an antibiotic coated popypropylene mesh forprolapse surgery in an original rabbit vaginal infectious model: a pilotstudy.

P. Mourtialon1,2, V. Letouzey2, J-P. Lavigne3, G. Aya4, X. Garric5,R. De Tayrac2

1Department of Obstetrics and Gynaecology, Bocage University Hospital, Dijon,France 2Department of Obstetrics and Gynaecology, Caremeau University Hospital,Nimes, France 3INSERM ESPRI 26, Universite de Montpellier 1, Nimes, France4Department of Anesthesia, Caremeau University Hospital, Nimes, France 5Faculty ofPharmacy, CRBA, UMR CNRS 5473, University Montpellier 1, Montpellier, France

Objective: The use of prosthetic reinforcement in vaginal surgery allows aguarantee of anatomical results over time, but serious complications limit its use.One cause of these complications can be intraoperative bacterial colonizationof the implant. Objective was to reduce polypropylene mesh infection in aninfectious model of vaginal surgery in rabbits by polypropylene mesh coatingwith a polymer matrix containing ofloxacin.Methods: Addition of ofloxacin has been made possible by its dispersion in amixture of acetone and PLA50. Study of fixation and release was performed onHPLC. In all 20 rabbits underwent vaginal surgery and were implanted withpolypropylene mesh or polypropylene mesh coated with ofloxacin. Bacterialinoculation was done at concentration of 106 CFU of E. coli high virulence ifanimal was in an infected group. Grafts were harvested 1 month later and wereprocessed for bacteriology and histology to evaluate bacterial colonization anddegree of tissue incorporation within the grafts.Results: 4 mg of ofloxacin deposited on mesh were released in 48 hours. Thecoating of polypropylene is feasible and shows a real effect in vitro.In vivo, ofloxacin coating pemits to reduce significantly bacterial colonizationand complications at one month in our infectious vaginal model in rabbits. Wefound a statistically significant association between infection and erosion.Conclusion: This work shows the interest of the coating by ofloxacin ingynecological surgery. The model of vaginal surgery in rabbits is promising andrepresents an excellent model for study of vaginal erosion and mesh exposure.


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P2G-9 Characterization of Cancer-Initiating Cells derivedfrom prostate malignancies

C. Le Magnen1, C. Rentsch2, A. Bachmann 2, M. Heberer1,G. Spagnoli1, S. Wyler2, C. Mengus1

1Institute of Surgical Research and Hospital Management (ICFS), Basel UniversityHospital, Basel, Switzerland 2Department of Urology, Basel University Hospital, Basel,Switzerland

Objective: Cancer-Initiating Cells (CIC), also called Cancer Stem Cells,might represent novel targets of therapeutic relevance. However their relativerarity and the frequently small size of prostate cancer (PCA) clinical specimensavailable prevent their use in studies addressing functional features and sensitivityto drugs. In this context, the use of established cancer cell lines could representa convenient alternative. Here, we aim at investigating the presence and thecharacterization of CIC in PCA cell lines and clinical specimens.Methods: In vitro studies were performed on PC3, Du145 and LNCaPPCA cell lines. Surface marker expression was assessed by flow cytometry,and Aldehyde dehydrogenase (ALDH) activity with Aldefluor technology.Expression of ‘‘stemness’’ genes such as OCT4A and KLF4 was evaluatedby quantitative rtPCR. In vivo experiments were performed by sub-cutaneousinjection of tumor cells in NOD/SCID mice. Clinical specimens (BenignProstate Hyperplasia and PCA), were used directly for gene expression studiesor digested overnight in an enzyme cocktail, prior to functional analysis.Results: Expression of CIC markers and of stemness genes was found tobe heterogeneous among the different cell lines and the clinical specimensinvestigated. ALDH1 bright DU145 cells expressed higher levels of stem-associated genes and displayed an increased tumorigenic capacity in vivo, ascompared to the ALDH1 low sub-population. Interestingly, a sizeable ALDH1bright population could also be detected in PCA clinical specimens.Conclusions: These results indicate the possible presence of CIC cells inestablished PCA cell lines. Expression of CIC markers appears to be associatedwith stem-properties and a higher expression of stemness genes of potentialclinical significance.

P2G-10 Outcome of inguinal herniorrhaphy performed during roboticassisted radical prostatectomy.

J. Hauser, N. Fleury, A. Caviezel, V. Sarbach, C. IselinDepartment Of Surgery, Urologic Surgery Clinic, Geneva University Hospital,Switzerland

Objective: There is few reported outcome on the feasibility of prostheticmesh inguinal hernia repair during Da Vinci robotic assisted laparoscopicprostatectomy (RALP). We review here our experience with this procedure.Method: All patients operated of RALP were scrutinized to depict simultaneousherniorraphy. For each patient we evaluated period of hernia diagnosis and itsside. All cures were performed using a non absorbable mesh coated with anti-adhesion material on the abdominal side (Parietex Composite). Mesh was fixedwith absorbable staples (Absorbatack) and non absorbable suture. Peri-operativefeatures included hernia repair time, hospital stay, occurrence of short and longterm complications. Assessment was performed on a semestrial basis by clinicalcontrol during oncologic follow-up.Results: From November 2007 to October 2009, 111 RALP were performed.15 patients had simultaneously an inguinal hernia. Mean follow up was 9(0–24) month. In 12 cases diagnosis was pre-operative, and per-operative in 3cases. Seven hernias (46%) were on right side, 4 (27%) on left and 4 (27)%bilateral. Thirteen were direct hernias, 1 indirect and 1 mixed. Mean herniarepair time was 24 (5–42) minutes. No differences were observed in termsof hospital stay (4 days) between RALP without hernia repair and the herniarepair Group. No complication related to herniorrhaphy was encountered.During follow-up, no inguinal or scrotal pain was reported. No recurrence wasrecorded.Conclusion: Inguinal herniorrhaphy during RALP is feasible, efficient anddeprived of comorbidities, although this procedure is performed in a sterile-contaminated environment. These data should encourage urologists to alwaysassociate hernia repair with radical prostatectomy when needed.

P2H Hepatobiliary and Pancreatic Surgery 3

P2H-1 NK4 gene therapy with chemotherapy suppresseshepatocellular carcinoma in mice

H. Sueoka1, T. Hirano1, Y. Uda1, Y. Iimuro1, J. Yamanaka1, T. Okada1,J. Fujimoto1

1Department of Surgery, Hyogo College of Medicine, Japan

Objective: Hepatocyte growth factor may promote cancer developmentthrough cell-motility-promoting and angiogenic effects. NK4, a fragment ofhepatocyte growth factor, acts as its receptor antagonist. We assessed effects ofNK4 gene therapy with fluorouracil against human hepatocellular carcinomacells (HUH7) tranplanted into mice.Methods: NK4 gene transduction was mediated by recombinant adenovirus(AdCMV.NK4). AdCMV.LacZ was used as a control vector. HUH7 cellswere subcutaneously injected in nude mice to establish s.c. tumors, and tumorbearing mice were treated in the following ways: Group 1, AdCMV.LacZ;Group 2, AdCMV.NK4; Group 3, AdCMV.LacZ with fluorouracil; Group4, AdCMV.NK4 with fluorouracil. Seven days after tumor inoculation, theanimals were injected 109 pfu of AdCMV.NK4 or AdCMV. LacZ into tumor.Fluorouracil was administered i.p. at 500 ug per body for six times.Results: NK4 obviously suppressed growth of transplanted subcutaneoustumors. As the result of immunohistochemical staining of CD31, angiogenesiswas obviously inhibited in the tumor that was transfected NK4. These effectswere boosted by additional of fluorouracil.Conclusions: NK4 inhibited tumor angiogenesis, greatly suppressing growthof HUH7 tumors transplanted into mouse. Combination with fluorouracilboosts therapeutically effects. This therapy thus showed apparent promise fortreatment of hepatocellular carcinoma.

P2H-2 Timing of laparoscopic cholecystectomy for acute cholecystitis

H. Bulus1, A. Coskun1

1Ankara Kecioren Research and Training Hospital Department of General Surgery,Ankara, Turkey

Early laparoscopic cholecystectomy has been advocated for the managementof acute cholecystitis, but little evidence exists to support the superiority ofthis approach over delayed-interval operation. Aim to study the timing oflaparoscopic cholecystectomy for patients with acute cholecystitis.Materıal and Methods: Patients were divided into two groups, as Group Iwhich includes the patients operated in first 72 hours from the begining of thesymptoms with prediagnosis acute cholecystitis and as Group II which includesthe patients operated 6–10 weeks later. Both groups were compared accordingto time of staying in the hospital, operating time, rate of turning open operation,mortality and morbidity rates.Result: Group I was consisted of 76 (F/M 49/27) patients, Group II wasconsisted of 132 (F/M 89/43) patients. The rates of turning open operationwere evaluated in Group I as 17% (13/76), and in Group II as 8,3% (11/132).Whereas operating time was evaluated 93 minutes (30–200) in Group I and113 minutes (60–220) in Group II, the time of staying in hospital was foundrespectively 6,2 (2–28) days and 4,1 (1–19) days.Conclusion: Laparoscopic cholecystectomy can be applied in early andlate period in the treatment of acute cholecystitis. However late period oflaparoscopic cholecystectomy has been found more advantagous in terms ofturning open operation, staying in the hospital, operating time and rate ofcomplication.

P2H-3 Pancreaticojejunostomy using a technique of two layersanastomosis (end-to-side anastomosis) without a stenting tube

M. Fujisawa1, S. Yoshimura1, T. Uomori1, K. Takehara1, S. Kawano1,R. Tanaka1, S. Matsumori1, S. Miyano1, M. Nasu1, M. Machida1,T. Kitabatake1, K. Kojima1

1Division of General and Breast Surgery, Juntendo University School of MedicineJuntendo Nerima Hospital, Japan


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Objective: We present a pancreaticojejunostomy technique of two layersanastomosis (end-to-side anastomosis) for patients with soft pancreas and smallpancreatic ducts.Methods: This study included 12 patients, 8 men and 4 women, average age63 years, who underwent pancreaticoduodenectomy at our hospital. Endo-to-side pancreaticojejunostomy was performed with a pancreatic duct smaller than3 mm without a stenting tube. In the first place, the outer layer encompassesthe posterior wall of the remnant pancreas and the jejunal seromusucularisseparately using 4-0 nonabsorbable sutures. The inner layer encompasses thecapsular parenchyma of the pancreas and the jejunum through all layers of thebowel continuously using 4-0 absorbable sutures.Results: There was no mortality in any of the 12 patients. Postoperativepancreatic fistula was evaluated using an international study group (ISGPF)definition. Three of the patients did not develop postoperative pancreaticfistula, and 9 of the patients developed pancreatic fistula; Grade A:6, GradeB:3, Grade C:0. Six patients (Grade A) developed very low-output pancreaticfistula, it healed of short duration with conservative management. Three patients(Grade B) were required to stay longer, but all of them healed with conservativetherapy. None of the patients developed postoperative intra-abdominal bleedingand delayed gastric emptying.Conclusion: The incidence of fistula has been considerably decreased by thetechnique of anastomosis for patients with soft pancreas and small pancreaticducts.

P2H-4 What Is The Modality Of Surgical Treatment In PancreaticCancer Associated Pancreatitis?

O. Yuksel1, P. U. Gocun2, H. Koksal1, K. Dikmen1, M. Sare1

Gazi University Medical School Department of Surgery1, Department of Pathology2,Ankara, Turkey

Objective: Pancreatic cancer associated with acute pancreatitis is very rare.In this situation, modality of treatment for pancreatic cancer is undeterminedbecause of inflammatory and neoplastic changes in pancreatic tissue. The aim ofthe study is to determine the choice of surgical treatment in pancreatic cancerassociated with acute pancreatitis.Patient and Method: 58 years old male patient, had been history of jaundice,abdominal pain and weight loss for 15 days. He had no history of any medicationsand alcohol intake. In physical examination, he had hidropic gallbladderand epigastric sensation. Body temperature was 38·5°C and leucocyte count14 × 103/ mm3. He had high level of direct bilirubin, amylase and lipase. Inabdominal computed tomography, he had acute necrotizing pancreatitis andmass located on pancreatic head. CA 19·9 level was 150 U/mL. At this pointthis patient was managed for pancreatitis and then endoultrasonography andcomputed tomography-angiography was performed for evaluation of pancreaticmass.Results: After symptomatic treatment the patient was operated. In operation,a mass which was 2 cm in diameter in pancreas head was found withhemorrhage and necrotizing of all pancreatic tissue. Total pancreatectomywas performed. In histopathological evaluation, pancreatic adenocancer andhemorrhagic necrotizing pancreatitis was diagnosedConclusion: In concomitance of inflammatory and neoplastic changes, correctdiagnosis and planning of suitable surgical treatment is very difficult. Historyof the patient, careful evaluation and correct diagnosis are very important forsuccessful surgical treatment.

P2H-5 Spontaneus rupture of the spleen in the presentation ofcronicmyeloid leukemia

A. Koyuncu1, H. Bulus1, G. Simsek2, D. Bulus3

1Ankara Kecioren Research and Training Hospital Department of GeneralSurgery, Ankara, Turkey 2Ankara Yildirimbeyazit Research and Training HospitalDepartment of Pathology, Ankara, Turkey 3Ankara Kecioren Research and TrainingHospital Department of Pediatric Oncology, Ankara, Turkey

Introduction: Spontaneous rupture of spleen in the leukemia is very rare,but potentially life-threatening complication. Spontaneous rupture of spleenoccured and was related to subcapsular infarction and hemorrhage.

Case Report: A 82-year-old man, presented to the emergency department withgeneralized abdominal pain and abrupt drop in hemoglobin. Initial examinationof the abdomen revealed diffuse abdominal tenderness and hypoactive bowelsounds.Within 6 hours of the initial presentation, the patient gradually becamehypotensive (blood pressure 70/45 mmHg), more anemic (hemoglobin5·9 g/dL), His WBC count was 98 × 103 mm3 and presence of philadelphiachromosome. Serial abdominal examination also revealed increasing abdominaldistension and diminished bowel sounds findings suggestive of an acuteabdomen. He was taken to have a computed tomography scan, which revealedmassive hemoperitoneum from a splenic rupture. The patient underwentsurgery for an emergent exploratory laparotomy and splenectomy with completerecovery.Conclusion: Splenic rupture presents universally with abdominal pain. Thedefinitive treatment for spontaneous splenic rupture is emergent splenectomy.Without splenectomy, mortality in these patients approaches 100%.

P2H-6 A Usual Presentation Of The Liver Cystadenocarcinoma/ACase Report

O. Sakrak1, M. Kerem1

1Gazi University, Medical Faculty, Department of Surgery, Ankara, Turkey

Background: Cystadenoma and cystadenocarcinomas are extremly rare lesionswhich can be poorly defined and should be differetiated from other cystic lesions.Patient and Method: We report a case of 44-year old woman who referredto our department for evaluation of recurrent cystic mass in her liver. She had ahistory of 3 surgical interventation for so called hydatid disease of liver over theprevious six years at another hospital. Physical examination revealed a diffusefullness in the right upper quadrant. Diagnostic imaging tecniques (abdominalUS and CT) demonstrated a non-homogeneous cystic mass, 16 cmin dimention,with multiple septations and projections, occuping the entire left lobe of theliver. Echinoccal serologic testing gave negative results, and CA-19-9 and CEAlevels were within normal limits. At operation, a large mass with multiplesatellite lesions filling the entire left lobe and extending to right lobe of the liverwas found. Complete resection of the lesion was achieved by an extended lefthepatectomy, which included the entired lesion and margins of normal tissueof 2 cm. Histologic examination revealed a low grade cystadenocarcinoma withpapillary growth pattern. The patient had an uneventful postoperative courseand remains asemptomatic for 2 years without recurrence.Conclusion: owing to fact that clinical and labartory features of these lesionsare similar to those of other cystic lesions of the liver, establishing the correctdiagnosis is too hard, therefore, special attention and investigations are necessaryto preform the best option for treatment.

P2H-7 A novel intraoperative liver cancer screening method usingindocyanine green fluorescence imaging

T. Tohyama, J. Watanabe, T. Fujita, T. Mizumoto, A. Miyoshi,Y. Yonenaga, F. Kushihata, K. Honda, Y. TakadaDivision of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department ofSurgery, Ehime University School of Medicine, Toon City, Japan

Objective: Indocyanine green (ICG) is a near-infrared fluorescent dye that wasapproved for liver function testing. ICG is excreted into the bile immediatelyafter intravenous injection, but it remains at the site where the bile flow isstagnated. Recently, an ICG fluorescence imaging system (PDE; HamamatsuPhotonics) was developed for observing blood and lymph flow. We evaluatedthe efficacy of the PDE system for liver cancer screening during surgery.Method: The subjects included eight patients with hepatocellular carcinoma(HCC) and three patients with metastatic colorectal carcinoma (CRC). ICG(0·5 mg/kg) was administered intravenously as a liver function test two to fivedays before surgery. During the operation, we searched for cancerous lesionsusing the PDE system.Result: Seven of eight HCC nodules in eight patients and six of sevenmetastatic CRC nodules in three patients were detected as fluorescent masses.A tumor only 5 mm diameter was observed, while one poorly differentiatedHCC and one metastasis 20 mm below the surface were difficult to detect. False


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positives occurred in patients with regenerating cirrhotic nodules, cicatrices aftertranscatheter arterial chemoembolization (TACE), and inflammatory fibroticnodules. In the resected specimens, all of the lesions diagnosed histologically asHCC or metastatic CRC were positive, and two early HCC lesions that weredifficult to identify macroscopically were visualized. A lymph node metastasis ofHCC was also visualized.Conclusion: Although the specificity was affected by the presence ofregenerating nodules, cicatrices after TACE, and inflammatory fibrotic nodules,ICG fluorescence imaging appears to be a useful examination tool for thescreening for tumors in the liver.

P2H-8 Acute pancreatitis: have the management guidelines improvedclinical outcome.

J. Butt, Y. Shaukat, N. Pawa, A. JamesColchester Hospital, University Foundation Trust, Colchester, UK

Objectives: The aim of this study was to analyse the impact of the BritishSociety of Gastroenterology (BSG) guidelines for the management of acutepancreatitis (2003) on the clinical outcomes of these patients.Method: A retrospective analysis of admissions with acute pancreatitis toa district general hospital (1999–2008). The admissions were divided into2 groups, before and after the introduction of such guidelines i.e. group A(1999–2003) and group B (2004–2008). The primary outcome measure was30 day mortality, with secondary outcome measures including length of stayand < 28 day readmission rate.Results: A total of 740 cases were admitted during this time period. Group Acomprised of 305 cases and Group B 435 cases (p-0·0419). Group A mean agewas 61 years and Group B mean age was 58 years. The mean 30 day mortalityfor Group A was 8·0% and that of Group B 6·6% (p-0·5790). The mean lengthof stay for Group A was 8·0 days and 9·7 days for Group B (p-0·1998). Thereadmission rate for Group A was 9·8% and 14·0% for Group B (p-0·1572).Conclusion: In our hospital, the BSG guidelines for management of acutepancreatitis were implemented in early 2004. Our study shows no significantimprovements in group B in comparison to group A (despite a statisticallysignificant increase in admissions of Group B) after implementation of theguidelines in terms of < 30-day mortality rate, length of stay and < 28-dayreadmission rate. More multi-centre studies are needed to identify furtherimprovements in the management of this potentially complex group of patients.

P2I Inflammation and Infection – Wound Healing

P2I-1 Exogenous methane improves intestinal microcirculatorydysfunction and biochemical signs of ischemia-reperfusion injury indogs

D. Erces1, G. Varga1, J. Kaszaki1, K. Kupai2, M. Ghyczy1, M. Boros1

1Institute of Surgical Research, Faculty of Medicine, University of Szeged, Hungary2Department of Biochemistry, Faculty of Medicine, University of Szeged, Hungary

Objective: Previously we have shown enhanced levels of methane in theexhaled air after the reoxygenization of hypoxic tissues, and hypoxia-inducedgeneration of methane has been demonstrated in isolated mitochondria also(FASEB J 17, 2003, Shock 30, 2008). To understand the significance ofnon-microbial methane formation, we have investigated the in vivo effects ofexogenous methane administration on tissue ischemia-caused haemodynamic-and biochemical changes.Methods: Anaesthetized dogs were randomly allocated into sham-operated(n=5), complete mesenteric ischaemia/reperfusion (IR) with methane (n=5), orwithout methane treatment (IR+methane, n=5) groups. Superior mesentericartery occlusion was maintained for 1 hr then reperfusion was monitored for3 hrs. The animals were mechanically ventilated and 5 min before reperfusionartificial air was administered with our without 2·5% methane for 10 min.Macrohaemodynamics and small intestinal PCO2 gap changes were regularlyrecorded, peripheral blood samples were taken for blood gas and plasma nitricoxide (NOX) analyses. Tissue superoxide (SOX) and nitrotyrosine (NT) levelsand myeloperoxidase (MPO) enzyme activity changes were determined in smallintestinal biopsy samples.

Results: Methane inhalation did not influence macrohaemodynamics butsignificantly reduced intestinal PCO2 gap changes (from 136 ± 19 mmHgto 67 ± 12 mmHg) referring indirectly to the improvement of the mucosalmicrocirculation. Besides, methane treatment significantly decreased theintestinal SOX and NT levels, reduced mucosal MPO activity, and increasedplasma NOX concentrations.Conclusion: In contrast to established knowledge methane is bioactive, andbeneficially affects IR-induced mesenteric circulatory disturbances due to therelative sparing of NO and the reduction of leukocyte activation.

P2I-2 Exogenous methane influences the formation of nitrogen- andoxygen-derived free radical products in the rat

B. Fazekas1, D. Erces1, G. Varga1, K. Kupai2, J. Kaszaki1, M. Ghyczy1,M. Boros1

1Institute of Surgical Research, Faculty of Medicine, University of Szeged, Hungary2Department of Biochemistry, Faculty of Medicine, University of Szeged, Hungary

Objective: Peroxynitrite (PN) is produced by the diffusion-controlled reactionof nitric oxide (NO) with superoxide radicals; and PN-induced tyrosinenitration correlates with the severity of circulatory shock or heart failure(Szabo C: Nat Rev Drug Discovery, 2007). Previously we have shown decreasedsuperoxide and increased NO levels after exogenous methane administrationin ischemia-reperfusion conditions. In the current setup, PN was administeredinto anesthetized rats to reveal the components of a so far unknown biochemicalreaction after increasing circulatory methane levels.Methods: The animals were randomized to control (n=8), PN withoutmethane (n=8) or PN with methane in the inspired air (n=8) groups. Treatmentwith 2·5% methane started after baseline haemodynamic measurements andlasted for 10 min, followed by iv. infusion of PN (200 µM in 1 ml) and2 hrs monitoring. Blood and intestinal superoxide levels were assessed bychemiluminescence; intestinal and pulmonary NO levels by Griess reaction.Plasma and tissue samples (intestines and lung) were analyzed for nitrotyrosine(EIA), myeloperoxidase and xanthine oxidase enzyme activities (fluorometry).Results: PN increased superoxide production both in the blood and intestinaltissue, while in methane-treated animals the elevation was alleviated. TissueNO levels were higher in methane-treated animals and methane inhalationeffectively decreased the PN-induced elevation in the inflammatory enzymeactivities and nitrotyrosine levels.Conclusion: Methane treatment prevents the overproduction of superoxideradical and the nitration of plasma and tissue proteins induced by exogenousPN. These effects may be explained by an in vivo reaction between methane(CH4) and PN (ONOO−), probably forming CO2+NO+H2O, which leads tothe reduction of inflammatory enzyme activation.

P2I-3 P-selectin-mediated leukocyte recruitment plays an importantrole downstream of trypsinogen activation in acute pancreatitis

H. Hartman1, D. Awla1, A. Abdulla1, B. Lindkvist2, S. Regner1,H. Thorlacius1

1Department Of Surgery, Malmo University Hospital, Lund University, Sweden2Department of Gastroenterology, Sahlgrenska University Hospital, Sweden

Objective: To study the role of P-selectin - a key adhesion molecule inneutrophil recruitment - in inflammation and protease activation in a model ofsevere acute pancreatitis (AP).Methods: C57BL/6-mice were subjected to retrograde intraductal infusionof taurocholate or sodium chloride in the pancreas. Sham operated animalsserved as negative controls. Subgroups received an anti-P-selectin or controlantibody. Animals were sacrificed 2, 6 and 24 hours post taurocholate infusion.Pancreatic levels of myeloperoxidase (MPO) and macrophage inflammatoryprotein-2 (MIP-2) as well as histological changes were determined. Serumlevels of trypsinogen and trypsinogen activation peptide (TAP) were analyzedin an in-house RIA.Results: Taurocholate challenge caused a significant increase in MIP-2and MPO levels as well as neutrophil infiltration, pancreatic necrosis andedema formation at 24 hours. Moreover, taurocholate enhanced serum levels oftrypsinogen and TAP. Immunoneutralization of P-selectin reduced MPO levels


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neutrophil infiltration, edema formation, tissue necrosis and serum trypsinogen24 hours post taurocholate infusion but no effect of P-selectin inhibition onMIP-2 formation or serum levels of TAP was observed.Conclusion: P-selectin plays an important role in regulating pro-inflammatoryactivities and tissue injury in acute pancreatitis. However, inhibition of P-selectindoes not affect trypsinogen activation in the pancreas, suggesting that proteaseactivation is a process upstream of leukocyte recruitment in AP.

P2I-4 Micro-dispersed oxidized cellulose as a new potential carrierfor topical antimicrobials

P. Lochman1,2, J. Paral1,2

1Department of Field Surgery, Faculty of Military Health Sciences, University ofDefence, Hradec Kralove, Czech Republic 2Department of Surgery, Teaching Hospital,Hradec Kralove, Czech Republic

Objective: The aim of this study was to examine the effect of topically-appliedgentamicin attached to a new biodegradable carrier formed by micro-dispersedoxidized cellulose in micro- and nanofibre form in the treatment of acute woundinfections and to assess the influence of this carrier on the healing process.Methods: A model of a full-thickness infected dermal wound was created inlarge laboratory animal. Twelve female domestic pigs were used in our study.The effectiveness of topical gentamicin with micro-dispersed oxidized cellulosecarrier was tested in acute wound infections caused by Staphylococcus aureus,Pseudomonas aeruginosa and Escherichia coli.Results: The effectiveness of nanofibre micro-dispersed oxidized cellulosewith gentamicin was proved according to microbiological culture findings.When macroscopically assesed, 100% of infected wounds treated by gentamicinattached to nanofibre micro-dispersed oxidized cellulose had no signs oflocal infection. When microfibre micro-dispersed oxidized cellulose wasused, cultures demonstrated residual bacteria despite the absence of clinicallyrecognized infection in 94,4% of treated wounds.Conclusion: Micro-dispersed oxidized cellulose carrier with a sufficientconcentration of an attached antibiotic (as proven in nanofibre form of MDOCwith gentamicin) seems to be effective for treatment of full-thickness skininfections. The positive influence of micro-dispersed oxidized cellulose on thehealing process of a dermal wound was shown, and a resulting good hemostaticeffect was confirmed.

P2I-5 Depression as a problem of patients treated for fissura ani

R. Chrzan1, T. Kulpa1

1Department. of General and Oncological Surgery, District Railway Hospital,Wroclaw, Poland

Fissura ani as a recurrent disease is difficult for treatment for the patent aswell as the doctor. It adversely affects the patient’s psyche, resulting malinyIn depression. In recent years, depressions accompanying surgical illnesses is afrequent problem faced by surgeons.The purpose of this work is the assessment of the frequency of depression anddetermination of it’s degree in patients treated for fissura ani.Material & Methods: 15 patients treated from 2005–2007 were examined.They filled anonnymously the Beck Depression Inventory Questionaire.Participation in the examination was voluntary.Results: from among 15 subjects examined by means of BDI 45%demonstrated depression disturbances. Most patients were not aware of theiradditional ailment. Mild intensity depression occured in 30% patients andmedium intensity depression occured in 15% patients. No relationship betweenthe age, gender and depression was found.Conclusions: fissura ani contributes to various degrees of depression whichremains undiagnosed the problems tormenting the patients and working out acomplex therapeutic procedure, including psychotherapy.

P2I-6 Effect of platelet-rich plasma on gastrointestinal anastomotichealing in rats – PRP concentration is a key factor–

R. Yamaguchi1, H. Terashima1, S. Yoneyama1, S. Tadano1,N. Ohkohchi1

1Department of Surgery, Graduate School of Comprehensive Human Sciences,University of Tsukuba, Tsukuba city, Japan

Objective: There were few reports that evaluated the effects of platelet-richplasma (PRP) on gastrointestinal anastomotic healing. The applied preparationmethods and PRP concentrations were all different. Therefore, the positiveeffects of PRP on anastomotic healing process remain unsettled. The aim ofthis study is to examine the influence of PRP concentrations on intestinalanastomotic healing.Methods: From SD rat blood, three different concentrations of plasma wereprepared: highly-concentrated PRP (H-PRP: platelet count 5 × 106/ mm3),low-concentrated PRP (L-PRP: 2 × 106/ mm3), and platelet-poor plasma(PPP). Male SD Rats underwent proximal jejunal anastomosis and centralvenous catheterization. Rats were divided into four groups (N=12, respectively):Control, PPP, L-PRP, and H-PRP group. PPP or PRP (0·21 ml) were appliedto the anastomosis line except control group. TPN solutions were administered(151 kcal/kg/day). Five days after surgery, anastomotic bursting pressure (ABP)in situ and hydroxyproline concentration (HYP) in anastomotic tissue wereevaluated.Results: The ABP values of Control, PPP, L-PRP, and H-PRP group were171 ± 20, 175 ± 23, 189 ± 17, and 148 ± 25 mmHg, respectively. The HYPvalues of four groups were 516 ± 130, 495 ± 123, 629 ± 120, and 407 ± 143µg/gdry tissue, respectively. When compared with the other groups, L-PRP groupwas significantly higher in both ABP and HYP, and H-PRP group wassignificantly lower in those. As a result, L-PRP promoted anastomotic woundhealing, but H-PRP had an adverse effect.Conclusions: Our study is the first report to demonstrate that PRPconcentrations play a key role in the positive effects of PRP on intestinalanastomotic healing. Further studies are needed to clarify the optimal PRPconcentration that allows for maximally enhanced anastomotic wound healing.

P2I-7 Effects of diosmin-hesperidin on anastomotic wound healingin colon

M. Basar1, M. R. Pekcici2, A. Hasanoglu2, O. Guler2, B. Kavlakoglu3,N. Dindar4, H. Ustun5

1Department of general surgery, Goksun State Hospital, Kahramanmaras, Turkey2Department of 1st general surgery Clinic, Ankara Training and Research Hospital,Ankara, Turkey 3Department of 3rd general surgery clinic, Oncology Training andResearch Hospital, Ankara, Turkey 4Department of biochemistry, Ankara Trainingand Research Hospital, Ankara, Turkey 5Department of pathology, Ankara Trainingand Research Hospital, Ankara, Turkey

Objective: The part of the gastrointestinal system presenting the greatest riskfor anastomotic leak is colon. Flavonoids are known to have anti-inflammatoryproperties as well as having corrective effects on lymphatic drainage andmicrocirculation. The aim of this study was to investigate whether a diosmin-hesperidin preparation would have a positive effect on anastomotic healing incolon.Methods: Wistar rats (female, n=24) were randomly assigned to one of 4groups: groups 1 and 3 underwent colon anastomosis without pretreatment,groups 2 and 4 received diosmin-hesperidin (60 mg/kg/day p.o.) for 7 days, thenunderwent colon anastomosis. Rats were sacrificed on postoperative days 3 and7. Anastomotic healing was evaluated via measurements of bursting pressure,tissue hydroxyproline levels, and microscopic examination of perianastomotictissue.Results: In all groups, bursting pressure was higher on postoperative day 7than on day 3. In the groups that received diosmin-hesperidin (groups 2 and4), bursting pressure was significantly higher than that in the correspondinggroups that underwent anastomosis without pretreatment (groups 1 and 3). Inrats which received diosmin-hesperidin preoperatively, anastomosis burstingpressure was significantly increased on postoperative days 3 and 7 comparedto controls, without tissue hydroxyproline levels or histopathologic parametersbeing correspondingly improved.


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Conclusisons: It seems that diosmin-hesperidin affects wound healingpositively in colonic anastomosis but more detailed studies are needed toelucidate the drug’s variety of possible mechanisms by which it increasesmechanical strength in healing anastomoses.Diosmin-hesperidin; colon; anastomosis; wound healing; rat

P2I-8 Non invasive measurement of advanced glycation endproducts:a new risk factor for incisional hernia formation?

J. J. Harlaar1, W. Vrijland2, H. Eker1, A. Van der Ham2, M. CastroCabezas3, W. C. Hop4, G. J. Kleinrensink5, J. F. Lange1

1Department of Surgery, Erasmus University Medical Center Rotterdam, Netherlands2Department of Surgery, St Franciscus Gasthuis, Rotterdam, Netherlands3Department of Internal Medicine, Center for Diabetes and Vascular Medicine, StFranciscus Gasthuis, Rotterdam, Netherlands 4Department of Biostatistics, ErasmusUniversity Medical Center, Rotterdam, Netherlands 5Department of Neuroscience andAnatomy, Erasmus University Medical Center, Rotterdam, Netherlands

Objective: Incisional hernia is a frequent complication of abdominal surgery,although an individual risk factor is lacking. The physiological formation of‘advanced glycosylation endproducts’ (AGE) during aging is the result of nonenzymatic synthesis of sugar with free amino acids, lipids or nucliacids. TheseAGEs, also known as non-enzymatic collagen crosslinks are correlated withhyperglycemia, hyperlipidemia and oxidative stress on connective tissue ofthe entire body. Studies have shown that there is a relation between AGEindirectly measured with autofluorescence in the skin and the progression ofdiabetes, arteriosclerosis and endstage renal failure. Non-invasive measurementof skin autofluorescence of AGEs in the skin with the AGEreaderTM was anopportunity to investigate the relation between AGEs and incisional hernia.Methods: 18 patients with incisional hernia after midline incision and 16patients with no clinical diagnostically incisional hernia after midline incisionwere compared in a case-control study on autofluorescence in the skin of theunderarm. Patients were matched for age. Data was analyzed with multipleregression.Results: There was a significant difference (p=0,020 t-test) in AGEs(measured in AutoFluoresence) between incisional hernia patients (mean 2,84AF ±0, 12[sem]) and normal healed patients (2,46 AF ±0, 10[sem]). Correctedfor age, sex and time between operation and measurement, the differencewas 0,36 AF (95% CI:05–0,67; p=0,024, multiple regression). There was nosignificant difference between ASA-class, cardiovascular disease and diabetesbetween both groups.Conclusion: AGE accumulation measured in the skin, indirectly measuredwith autofluorescence, may be a risk factor for the development of incisionalhernia. Prospective trials should confirm this, to select high risk patients fortailor made clinical approach.

P2I-9 Response to bacterial infection of collagen bioprostheses.An experimental in vivo study

G. Pascual2, R. Garcıa-Pumarino1, M. Rodrıguez1, S. Sotomayor1,J. Bujan2, J. M. Bellon1

1Department of Surgery, Faculty of Medicine, University of Alcala, NetworkingResearch Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN),Alcala de Henares, Madrid, Spain 2Department of Medical Specialities, Facultyof Medicine, University of Alcala, Networking Research Center on Bioengineering,Biomaterials and Nanomedicine (CIBER-BBN), Alcala de Henares, Madrid, Spain

Objective: To examine the behaviour of three implanted collagen prostheses,Permacol (Pe), Surgisis (SIS) and Collamend (Coll) in the presence ofStaphylococcus aureus (Sa) or Staphylococcus epidermidis (Se) infection with referenceto that of a standard ePTFE mesh.Methods: Leaving the parietal peritoneum intact, 3 × 3 cm defects werecreated in the anterior abdominal wall on either side of the midline in NewZealand White rabbits. These defects were then repaired using the differentbiomaterials. Groups of 12 animals implanted with two biomaterials each(ePTFE/Pe or SIS/Coll) were then established and inoculated with 106 cfu Saor Se. Animals with non-inoculated prostheses served as controls. At 14 and

30 days, the implants were assessed by microscopy (light and scanning electron),morphometry (mesh shrinkage) and biomechanical tests.Results: Large purulent abscesses were produced in the Sa infected prosthesesand smaller abscesses in those infected with Se. Control meshes showed similarhost tissue ingrowth. SIS induced an intense inflammatory reaction. Bothbacteria were able to penetrate the pores of Coll and Pe or were depositedon the sheets comprising SIS. No bacteria were observed within the ePTFEstructure. Greatest shrinkage was detected in the SIS and ePTFE meshescontaminated with Sa. Tensile strengths were variable due to the thick fibrouscapsule enveloping the infected biomaterials.Conclusions: a) The control collagen meshes showed similar tissue ingrowthto control ePTFE; b) intense bacterial infiltration was observed in the laminarcollagen meshes or those requiring rehydration; and c) in the presence ofinfection, no benefits were offered by the collagen over the ePTFE implants.

P2I-10 The effect of peritoneal wrapping on colonic anastomosishealing in rats with impaired wound healing due to superiormesenteric artery occlusion

M. Emirdogan1, C. Daphan1, F. Agalar1 K. Aydinuraz1, F. M. Comu2

Departments of 1General Surgery and 2Physiology, Kirikkale University, School ofMedicine, Kirikkale, Turkiye

Objective: Anastomotic leakage is a major complication of colorectal surgery.Ischemia and reperfusion affects healing negatively. The effect of peritonealwrapping on colonic anastomosis healing in rats with impaired wound healingdue to superior mesenteric artery occlusion was studied.Methods: Wistar rats weighing 200–250 g were used. Rats were allocated intothree groups having 10 animals each. In group S, superior mesenteric artery(SMA) was isolated but not occluded, left colon was transected and anastomosiswas performed. In group C, SMA was occluded for 20 minutes then left colonicanastomosis was performed. In group E, SMA was occluded for 20 minutes thenleft colonic anastomosis was performed and anastomosis line was covered witha perioneal flep removed from the left abdominal wall. At 7th day all animalswere sacrified and colonic segments including the anastomosis were resected.Anastomosis bursting pressures and hydroxyproline levels were measaured.Results: Mean bursting pressures were 178·72 mmHg (±25·07) for group S,112·02 mmHg (±58·46) for group C, and 225·19 mmHg (±46·74) for groupE. Differences between the groups were statistically significant (p<0·05). Meanhydroxyproline levels were 7·39 (±1·07) mg OH/gr-tissue for group S, 3·62(±1·08) mg OH/gr-tissue for group C, and 6·72 (±1·66) mg OH/gr-tissue forgroup E. Differences between the groups were statistically significant (p=0·001).Conclusion: Peritoneal wrapping can improve anastomotic healing of colonicanastomosis in which wound healing is impaired due to ischemia and reperfusioninjury after SMA occlusion.

P2J New Surgical Techniquesand Tools 2

P2J-1 Laparoscopic treatment for Mirizzi syndrome, primary closureof common bile duct followed by endoscopic retrograde biliarydrainage

H. Kawada1, T. Izumi2, K. Ohara3, Y. Kawamura3, T. Gomi3, Y. Wada3,M. Ohtoshi3, Y. Sakai1

1Department of Gastrointestinal Surgery, Kyoto University, Kyoto, Japan2Department of Gastroenterology, Himeji Medical Center, Himeji, Japan3Department of Surgery, Himeji Medical Center, Himeji, Japan

Objective: Mirizzi syndrome is an unusual presentation of prolongedcholelithiasis. Laparoscopic treatment for this disease is challenging andsometimes said to be even a contraindication. After excision of stones, thecommon bile duct becomes ragged because of the inflammation due to stonesand the manipulation of the surgeon, and T-tube drainage is often necessary.But T-tube drainage remarkably spoils the patient’s quality of life and extendshospital stay. To overcome this difficulty, We propose a new approach: primaryclosure of the common bile duct followed by endoscopic retrograde biliarydrainage (ERBD).


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Methods: Instead of T-tube drainage, we put ERBD-tubes preoperativelyor postoperatively for bile drainage in order to reduce the incidence ofpostoperative complications like bile leakage or common bile duct stricture.So the only thing we have to do in the operation is to cut the thickening wall ofthe bile duct due to the prolonged inflammation transversely, excise the stoneand close the hole.Results: We have performed this procedure in two cases. These patients hadno surgical complication and recovered rapidly.Conclusions: Our initial experience shows that laparoscopic primary closureof the common bile duct followed by ERBD for Mirizzi syndrome is a feasibleand less invasive procedure, and it improves patient’s quality of life.Conclusion: Preconditioning with Ghrelin prevents critically perfused tissuefrom ischemic necrosis. Tissue protection is the result of an iNOS dependentimprovement of the microhemodynamics and a VEGF-mediated angiogenicresponse.

P2J-2 Development of an ultra mini-oxygenator for use in low-volumeperfusion circuits

S. L. Longnus1, M. Berner2, M. Stadelmann1, M. Kistler3, Y. Boone1,T. P. Carrel1, H. T. Tevaearai1

1Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern,Switzerland 2Department of Thoracic Surgery, Inselspital, Bern University Hospital,Bern, Switzerland 3Institute for Surgical Technology and Biomechanics, University ofBern, Bern, Switzerland

Background: Small animal models are widely used in basic research. However,experimental systems requiring extracorporeal circuits are frequently confrontedwith limitations related to size of existing equipment. This is particularly truefor oxygenators in blood-perfused systems. Additionally, in autologous bloodperfused systems, blood volume is limited – particularly in experiments withmice and rats – and glassware typically used for oxygenation can cause hemolysis.Objective: To develop and validate an ultra mini-oxygenatorMethods: We have developed an ultra mini-oxygenator using a tubing shell,with one inlet and one outlet for perfusate, which contains approximately190 aligned microporous polypropylene hollow fibers. The fibers are sealedtogether at each extremity to separate the perfusate- (outside fibers) and gas-(inside fibers) compartments. With this construction, gas passes through thehollow fibers, while perfusate circulates around the fibers in a counter-currentmanner. Oxygenation capacity of the ultra mini-oxygenator was tested in aperfusion circuit with blood- or crystalloid buffer- perfusate. Oxygen partialpressure, gas and perfusate flow rates, perfusate pressure and temperature weremeasured.Results: Ultra mini-oxygenators possess low priming volumes (approximately1·4 mL). Preliminary results indicate that effective oxygenation (oxygen partialpressure of at least 300 mmHg) is achieved with both blood- and crystalloidbuffer- perfusates and is maintained for flow rates of at least 50 and 100 mL/min,respectively. Effective oxygenation is observed for perfusate pressures of upto 250 mmHg and can be maintained for at least 2 hours with continuouscirculation.Conclusion: Our ultra mini-oxygenator appears efficient and reliable andshould thus open possibilities for the development of further pre-clinicalprotocols.

P2J-3 The effect of harmonic scalpel, electrocautery and scalpel useon early wound complications after modified radical mastectomy

B. Anlar1, N. Karaman1, L. Dogan1, C. Ozaslan1, C. Atalay1,M. Altinok1

1Department of General Surgery, Ankara Oncology Education and Training Hospital,Ankara, Turkey

Objectives: To compare early postoperative complications of harmonicscalpel, electrocautery and scalpel use after modified radical mastectomy.Methods: One hundred and twenty patients operated between May 2008and February 2009 enrolled for the study. The groups were defined withthe instruments used for flap preparation and 41 patients operated withelectrocautery, 40 patients operated with scalpel and 39 patients operated

with harmonic scalpel formed three groups. The need for closed suction drains,the amount and duration of seroma, surgical site infection, hematoma and flapischemia and necrosis were evaluated.Results: The amount of intraoperative blood loss in electrocautery andharmonic scalpel groups was 560 and 500 mL respectively and it was increasedto 750 mL in scalpel group and this difference was statistically significant(p=0·001). Total drainage values of scalpel and harmonic scalpel groups were894 ve 908 mL respectively and it was increased to 1113 mL in electrocauterygroup and the difference was statistically significant (p=0·0033). Seromaincidences in scalpel, electrocautery and harmonic scalpel groups were 45%,65% and 28% respectively and this difference was statistically significant(p=0·003). The differences between groups in relation to the duration ofsurgery, breast volume and weight, the areas of flap dissection, duration ofclosed suction drainage and the amount of early drainage were not statisticallysignificant. There was also no difference between groups about hematoma, flapnecrosis and ecchymosis and infection rates.Conclusion: Although the use of harmonic scalpel reduces the risk of seromaformation and intraoperative blood loss, further studies are needed to verify thereal impact of such technique.

P2J-4 Audit of performance of day case surgical unit in a districtgeneral hospital

M. J. Akbar1, S. Mehmood2, N. Qayyum1, O. E. Klimach1

1Glen Clwyd Hospital, Betsi Cadwaladr University Local Health Board, Rhyl, Clwyd,UK 2Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, EastYorkshire, UK

Objective: Day case surgery has become an integral part of modern surgicalservices. Our aim was to assess the performance of DCU in the light ofrecommendations by the British Association of Day Surgery (BADS).Methods: A retrospective audit of DCU over one year for three surgicalprocedures. The procedures included in this audit were LaparoscopicCholecystectomy, Primary Inguinal Hernia Repair and Primary Varicose VeinSurgery. BADS recommendations were considered as standard.Results: A total of 826 cases were listed in DCU. Six percent (48/826) werecancelled therefore 778 cases were included in the analysis. Procedures included:Laparoscopic Cholecystectomy 28% (n=222), Primary Inguinal Hernia Repair38% (n=294) and Primary Varicose Vein Surgery 34% (n=262).Out of 222 Laparoscopic Cholecystectomy operations, 79% (n= 176) wereperformed as day case as compared to BADS recommendation (90%). Of294 patients who had Primary Inguinal Hernia Repair, 90% (n=265) weredone as day case (BADS recommends 100%). Performance of DCU was mostsatisfactory in Primary Varicose Vein Surgery as 97% (n=256) were performedas day-case which is close to BADS recommendations of 100%. Commonestreason for cancellation was patient did not arrive (23%, n=11), other reasonswere theatre list over run 16% (n=8), bed not available 13% (n=6), cancelledby anaesthetist 13% (n=6), unfit for surgery 10% (n=5), emergency work 10%(n=5) and miscellaneous 15% (n=7).Conclusions: Our day case unit’s performance is comparable to therecommendations set by BADS in commonly performed elective surgicalprocedures. Further improvement is achievable by careful planning while listingthe patients and pre-operative assessment of all patients.

P2J-5 ‘‘Base First’’ Technique in laparoscopic appendectomy

G. Piccinni1, A. Sciusco1, E. Poli1, D. Lardo1, A. Gurrado1, C. Serrao1,M. Testini1

1Department for Application in Surgery of Innovative Technologies, University MedicalSchool of Bari, Italy

Objectives: Appendicitis is the most common cause of acute abdomen inadults and appendectomy is the most common emergency surgical procedureperformed. Laparoscopic appendectomy is becoming widespread in recent years,even though the comparison with traditional surgery is still debated. Aim of thisstudy is to show a new laparoscopic appendectomy technique performed witha mechanical linear stapler (ATW 35 Ethicon, Cincinnati Ohio) with a directapproach to appendix basis.


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Methods: In the period 2007–2009 fifty patients were operated on at ourGeneral Surgery Unit. Firstly we opened the avascular triangle located amongappendix, cecum and appendicolar vessels. Appendix is easily resected at itsorigin from cecum by using an endo-stapler. Then it is easily dissected fromsurrounding structures and from the retroperitoneum also in presence ofphlegmones or gangrenous process. The mesenteriole is sectioned with a ATW35. A drain is always left in the pelvis.Results: Mean duration of surgery was 10 minutes after initial learning curve of10 cases (range 5–15 min). Mean hospital stay was 2 days (range 2–3 days). Onlyone patient had intra-operative hemorrhage from the mesenteriole. Conversionrate was 0%. No appendiceal stump leaks or wound infections occurred.Conclusions: The use of linear mechanical stapler seems to be associatedwith a severe drop in complications on appendicular stump. The latest scientificreports seem to agree on the appendectomy performed with laparoscopictechnique as the best choice in uncomplicated appendicitis in women and inobese subjects. The ‘‘BASE-FIRST’’ technique is a fast, safe and comfortableprocedure.

P2J-6 New and simple operative technique to treat ingrown toenailswithout no recurrence

H. Alptekin1, H. Yilmaz1, M. Sahin1

1Selcuklu Medycal Faculty, Selcuklu, Konya, Turkey

Objective: There is no consensus on the best operative technique to treatingrown toenails. In this suty, new operative tecnique and its clinical result atingrown toenail treatment is presented.Methods: Seventy-four patients with stage 2 and 3 ingrown toenails operatedbetween January 2007 and December 2009 were included in this study.All patients were operated on under local anesthesia. Proximal digital block wasperformed with 1% lidocaine without epinephrine. A reverse triangle shaped ofsoft tissue, including the lateral nail fold with granulation tissues and adjacenthealthy skin, was removed on affected side of the nail. Base of the triangleconsisted of lateral nail fold and hill of the triangle was adjacent to the plantarsite of toe. No nail avulsion or excision and matricectomy was performed.Pitfall of tecnique is poorly excision of subcutaneous faty pad. The defect wasclosed with simple interrupted 2-0 polypropylene sutures. Oral antibiotics andanalgesics were started in the postoperative period for all patients. Sutures wereremoved at 14 days.Results: There were 41 men and 33 women, with a mean age of 26·4 years(range 16 to 64). Mean postoperative follow-up was 19·4 months (range1–37 months). No major complications were dedected in this series duringthe study period. No recurrence was occured.Conclusion: This study shows that ingrown toenail can be treated withoutmatricectomy and nail avulsion or excision. The surgical tecnique has shortlearning period. The mean advantages of this tecnique are preservation of theanatomy of the nail and excellent cosmetic results with no recurrence.

P2J-7 The effects of Botox injection to salivary glands on weight loss

M. Sahin1, B. Erenoglu2, H. Yilmaz1, H. Esen3, A. Tolu4, F. Acar1,H. Alptekin1

1Department Of General Surgery, Selcuk University, Selcuklu Medical Faculty,Konya, Turkey 2Meram State Hospital, Konya, Turkey 3Meram Medical Faculty,Konya, Turkey 4Baskent Hospital, Alanya, Turkey

Objective: To investigate, the effects of botox injection to submandibulersalivary glands on weight gain at rabbitsMethods: Fourty-five male rabbits included in this study. There were threegroups conssist of 15 rabbits. Salivary glands were dissected at anesthethizedrabbits.Group I: Sham procedureGroup II: 50 IU Botilinium Type A toxin was injected to left submandibularglandGroup III: 50 IU Botilinium Type A toxin was injected to each (left and right)submandibular glandsUnlimited water and 240 kcal/kg/day solid food pellet were given at optimalconditions. Rabbits were sacrificed at the end of 6th month. Tissue samples

from submandibular glands and proximal small intestines were taken. EGFreceptors in the submandibular glands were counted by immuno histochemicalstaining. Villus lengths of small intestine were measured.Results: An average increase of 65·2% in GroupI and decrease of 12·1%in groupII and 30·6% in groupIII were detected between the initial and thelast weights of the groups. Weight loss in groupII and III were statisticallysignificant (p<0·05). The average count of EGF-R was 527·1 in groupI, 267·8in GroupII, 260·2 in groupIII. Decrease of EGF-R in groupII and III wasstatistically significant (P<0·01). The average villus lengths were measured893·4 µ in groupI, 712, 7 µ in GroupII and 624, 1 µ in groupIII. Decreases ofvillus lengths in GroupII and III were statistically significant (P<0·01).Conclusion: Botox injection to submandibular gland lead to weight loss inrabbits. Botox may find clinical application areas at the treatment of obesityafter controlled experimental studies.

P2J-8 Histological examination of surgical resected breast cancerafter radiofrequency abration

K. Onishi1, M. Nakai1, F. Ishida1, K. Hanami2, Y. Ohno2, S. Itoyama2,H. Kuroda3

1Department of Breast And Endocrine Surgery, Siatama Medical Center, SiatamaMedical University, Kawagoe, Japan 2Department of Pathology, Saitama MedicalCenter, Saitama Medical University, Kawagoe, Japan 3Department of Pathology,International University of Health and Welfare Hospital

Objective: Radiofrequency ablation (RFA) treatment for small breast cancerwere reported in several phase II trials. Classical NADH-diaphrase (NADPH)staining with frozen section was utilized for evaluation of the ablation margin.Furthermore the histological thermal effects of RFA concerning ER, PR andHER2 expression were not yet clarified. We performed to assess tumor viabilityusing HADPH stain and single stranded DNA (ss-DNA) staining with paraffinsection to evaluate DNA damage.Methods: Mean ablation time was performed 7·65minutes using mean ablationpower 56·5 W, and mean final temperature was 87·3°C. 20 patients were treatedwith RFA and were surgically resected immediately. All patients had invasiveor non-invasive carcinoma of 2 cm or less (mean 14·6) in diameter. Tumortissue was examined histologically with hematoxyline-eosin (H·E) staining andNADH and ss-DNA staining.Results: H.E staining showed various degree of cell death, nucleolus pyknosisand lineal deformity, basophilic change in stoma tissue. The NADPH stainingshowed no viable tumor cell areas from 16 patients (80%). Four patients (20%)had a microscopic focus as entensive intraductal component at the periphery ofthe tumor. Surgical cut end was positive in three cases of our 20 cases. ss-DNAstaining showed patchy appearance in tumors and did not serve as a surrogatefor non-viability. Expression of ER, PR and HER2 by IHC staining was almostpreserved after RFA in 10patients pre-RFA CNB were available. ER, PR andHER2 status were same result except one case, which changed to negative forER and PR weekly expressed before RFA.Conclusion: NADPH staining still remains reliable method for determiningtumor viability of margin assessment using core biopsy. Further studies areneeded to determine whether RFA lead to breast-conserving treatment withoutsurgery.

P2J-9 Perspectives On The Direct Observation Of Procedural Skill InSurgical Training

A. Abood1, W. Bhat2

1Department of Plastic, Reconstructive and Burns Surgery, Pinderfields Hospital,Wakefield, UK 2Department of Plastic and Reconstructive Surgery, Castle HillHospital, Hull, UK

Objectives: To evaluate the perceptions of trainees and Consultants towardsthe Direct Observation of Procedural Skill (DOPS) as a Workplace-BasedAssessment (WBA) tool in surgical training.Methods: Questionnaires and a focus group were used to gain feedback fromsurgical trainees and Consultants in relation to key components of DOPSassessment (Providing feedback; as a learning tool in the acquisition of practicalskills; Training in undertaking DOPS). A total of forty-five respondents took


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part. Responses to direct questions on questionnaires were analysed, as were thethemes emerging from open-comment responses and focus group discussion.Results: Forty-five responses were obtained overall with a twenty-two percentresponse rate from the electronic survey and thirty-one percent from the ‘‘faceto face’’ questionnaire. Forty-four percent of respondents regularly carried outDOPS assessments within their department (> 3 month−1) but had received noformal training, rarely repeated the exercise on the same trainee and felt thatthey did not have enough time to provide useful feedback.Conclusions: DOPS assessment has been shown to be an effective tool in coremedical training. Responses from this pilot study suggest that the same efficacyhasn’t been achieved with its application to surgical training. Suggestions areprovided as to how it is implementation and efficacy could be improved.

P2J-10 An evaluation of the reliability and effectiveness of endoluminalcompression anastomosis ring after left colon anastomosis in pigs

M. F. Can1, N. Ersoz1, I. H. Ozerhan1, G. Yagci1, S. Cetiner1

1Division of Gastrointestinal Surgery, Department of Surgery, Gulhane School ofMedicine, Ankara, Turkey

Objective: New products are being developed for safer and easier constructionof intestinal anastomoses. This study assessed the reliability and effectivenessof endoluminal compression anastomosis ring in an experimental anastomosismodel.Methods: Under general anesthesia, two pigs underwent segmental resectionof the left colon followed by end-to-end anastomosis made using specificallydesigned compression anastomosis ring. After seven days the anastomosedsegment was removed. Anastomosis burst pressure, ratio of under-pressurediameter of anastomosis both to the diameter of neighbouring colon segment(DA/DC) and to the diameter of anastomosis ring (DA/DR) were recorded.Results: No complications were seen during the seven-day follow-up period.The mean value of anastomosis burst pressure was 250 mmHg. The mean valuesof DA/DC and DA/DR were 0·85 and 2·10, respectively.Conclusion: The results of the study suggest that it is ease and reliable toconstruct an anastomosis using endoluminal compression anastomosis ring,preventing anastomotic stenosis thanks to its ability to stretch under pressure.

P2K OTO-Rhino-Laryngologyand Neurosurgery

P2K-1 A 10-year review of neurosurgical management of temporallobe abscesses: the role of adjuvant ENT surgery

R-K. Mathew1, C. Vaughan1, T. Zahoor2, D. Crimmins1

1Department of Neurosurgery, Leeds General Infirmary, Leeds, UK 2Department ofENT, Leeds General Infirmary, Leeds, UK

Objective: Temporal lobe abscess carries a 10% mortality and up to 50% ofpatients suffer persistent seizures. Management lacks consistency, with onlyisolated case reports available in the literature. Chronic otitis media andmastoiditis are recognised risk factors but the value of adjuvant ENT surgeryremains unknown. Our objectives were to determine the role of peri-operativemastoid drainage or mastoidectomy in reducing neurosurgical re-operative ratesand outcome.Methods: A single centre, retrospective case note and database audit from1999–2009. Microbiologically proven temporal lobe abscesses that underwentburrhole drainage or craniotomy and excision were included. Data collectedincluded demographics, neurosurgical procedure, radiological findings pre-and post-operatively, organism(s) isolated, ENT procedure and timing,neurosurgical re-operation rate, length and route of adjuvant antibiotic therapy,and outcome.Results: 26 patients were identified from 1999–2009 that met our inclusioncriteria. There was a male preponderance. A wide array of organisms wasisolated. All patients had antibiotic therapy. Radiological evidence of middle earor mastoid involvement was reported prior to surgery in most patients. Somepatients underwent ENT procedures in addition to management of the abscess.A number of patients underwent repeat neurosurgery. Statistical significancewas determined using Chi-square testing. Preliminary results show patients

that underwent adjuvant ENT surgery had lower re-operation rates and betteroutcomes.Conclusion: This review will be the first audit to determine the role of adjuvantENT surgery in the management of temporal lobe abscesses with co-existingmiddle ear or mastoid infection.

P2K-2 The role of IL-10 and C3 Toxin in nerve regenerationin an end-to-side nerve repair model

M. Sakalidou, G. B. Stark, V. PennaDepartment of Plastic and Hand Surgery, University Medical Center, Freiburg,Germany

Objective: The role of IL-10, an anti-inflammatory cytokine and C3fusiontoxin, a Rho-GTPase inhibitor, was investigated in an end-to-sideperoneal nerve lesion model of the rat.Methods: Thirty rats were used and divided into 3 groups: (1) Controlgroup, end-to-side nerve repair of the peroneal nerve onto the tibial nerve;(2) intrafasciculary injection of 125 ng/100 µl IL-10; or (3) 10 µg/ml C3fusiontoxin into the repair site. After 8 weeks, the outcome was assessed,by evaluation of the Peroneal Functional Index (P.F.I), analysis of the nerveconduction velocities (NCVs), measurement of collagen levels using picrosiriusred staining, and by evaluation of myelination using methylene blue staining.Results: There weren’t any statistical significant differencies in the P.F.I. andNCV measurements. Histologic studies revealed a thicker myelin sheath anda lower G-ratio in group 2, indicating a better myelination with differenciesbeing respectively statistically significant among all groups (p<0,001). In group3, a significant higher number of axons compared to groups 1 and 2 was found.Morphologic analysis demonstrated significant lower collagen levels in group 2(p<0,001), suggesting lower scar formation.Conclusion: These results suggest that a low dose of 125 ng/100 µl IL-10has a favorable effect in the nerve regeneration process in an end-to-sideneurorrhaphy and reduces scar formation. This finding could help to enhanceclinical nerve surgery.

P2K-3 Comparison of 2D-Schwann Cell-Neuron-Culture with3D-Schwann Cell-Neuron-Spheroids - effect on Neurite Outgrowthand Length

V. Boyle, G. B. Stark, V. PennaDepartment of Plastic and Hand Surgery, University Medical Center Freiburg,Freiburg, Germany

Introduction: The 2D-Co-Culture of Schwann Cells (SC) with neurons leadsto an increased outgrowth of neurites and an increase of neurite length. Both,the cell-cell contacts as well as the secretion of neurotrophic substances areimportant factors. This study aims to investigate whether the spheroidal 3DCo-Culture of SC and Neurons with its intensified cell-cell contacts leads tohigher rates of neurite outgrowth and length compared to the 2D Co-culture.Material and Methods: SC were cultivated from sciatic nerves of neonatalrats; the neural cell culture NG108-15, a hybrid cell line from mouseneuroblastoma and rat glioma was purchased. SC+NG spheroids werefabricated and embedded in collagen. 2D-Co-Cultures of SC and NG cells werecultivated on flasks. Using the microscope Axioplan (Zeiss) and the softwareAxiovision (Zeiss) both the 2D-culture and the 3D-culture were analyzed after10 days of incubation in regard to neurite outgrowth and neurite length.Results: Both Co-Cultures (2D and 3D) showed considerable neuriteoutgrowth after 10 days of incubation. The direct comparison of both Co-cultures revealed a significantly higher number of neurites and significantlyhigher neurite lengths in the SC-NG-spheroids. Furthermore myelinisationprocesse could be observed in this 3D Co-Cultures.Conclusion: By simply transferring a 2D into a 3D culture with multiplicationof cell-cell contacts a significant increase of neurite reaction can beachieved. This, together with the observed myelinisation processes couldmake the spheroidal Co-culture a close-to-reality model for further studiesof neuroregenerative mechanisms.


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P2K-4 Primary hyperparathyroidism and thyroids disease

J. R. Hernandez1, C. Rosas1, I. Gutierrez1, F. Garcıa Anguiano1,I. Rodrıguez1, V. Vega1, V. Nunez1

1General Surgery Department, Hospital Insular de Gran Canaria, Las Palmas deGran Canaria, Spain

Objective: Thyroid and parathyroid pathology may coexist, classically,in multiple endocrine neoplasia. Other non syndromic scenarios result inpathologies of these endocrine organs. This can create a challenge in the clinicaldecision making and management of these patients. It is optimal to deal withboth problems in one operative procedure, if surgery is required.Method: A retrospective review of all cases (225 patients), that underwentoperation in the last 14 years (1995–2008) with primary hyperparathyroidismand concomitant thyroid disease was done. The surgical outcomes,complications and pathologies findings were analyzed.Results: Of the 225 patients, 173 (76,8%) had no clinical manifestationsof primary hyperparathyroidism or concomitant thyroid disease. 73 (32,4%)of them had concomitant thyroid disease. Of these 73 patients, 15 (16,4%)had malignant nodules (papillary carcinoma), 37 (54,2%) had only benignnodules and 21 patients (29,4%) had diffuse goitre (multinodular goitre, chronicthyroitis). Different surgical procedures were performed, we found a parathyroidadenoma in the vast majority, 219 (97·4%), and only 6 of them (2·6%) hadhyperplasia.Conclusions: According to our findings it is important to consider theassociation between thyroid and parathyroid disease. All the patients withprimary hyperparathyroidism should be investigated to rule out concomitantthyroid disease in order to deal with these conditions at the same timeWith the developing trend toward minimally invasive parathyroidectomywithout intra-operative thyroid gland palpation, thyroid pathology may bemissed. The authors consider it necessary to revisit the issue of thyroid pathologyfound at neck exploration for primary hyperparathyroidism

P2K-5 A new flap to obliterate the bone cavities and/or for repairingthe bone defects: composite multi-fractured osteoperiosteal flap*

C. Ucar1

1ENT Department, Private Turkiye Hospital, Darulaceze cad, Istanbul, Turkey

Objective: To obliterate the bone cavities and to repair the bone defects bya composite multi-fractured osteoperiosteal flap (CMOF), original and newsurgical approach.Methods: CMOF was used to obliterate the mastoidectomy cavity in fourtyfour patients, the frontal sinus in four rabbits and to repair the tibial bone defectin four sheep. While creating the osteoperiosteal flap, much attention is paid tothe lamellar bone cortex tissue under the periosteal layer of the flap to be bothnot more than 1 mm. in thickness and multifractured as many as possible. Andthen, the cavity or bone defect is filled with sponges and closed by the CMOF.Postop both first day and at the end of the third month, the lesions has beenCT-scanned. Beside this, at the end of the third month, the bone tissue newlydeveloped under the CMOF has been evaluated histologically.Results: The CT-scans taken at the end of the third month showed the defectto be filled by the new bone tissue developing from and under the CMOF.Histological evaluation of the new bone tissue at the third month showedosteoblastic activities.Conclusion: We have utilized the neo-osteogenesis growing behind theCMOF to obliterate the cavity and to repair the bone defect in three studies.*some part has been published.

P2K-6 Results of Radiofrequency Low Temperature-ControlledBipolar Ablation (Coblation) in inferior Turbinate Hypertrophies

B. Acar1, K. S. Tuncay1, M. A. Babademez1, H. Karabulut1,R. M. Karasen1

1Kecioren Training and Research Hospital Department of Otorhinolaryngology,Ankara, Turkey

Objective: Chronic nasal obstruction caused by inferior turbinate hyper-trophies are a common clinical condition. Several surgical techniques are

currently available including cryosurgery, electrocautery, total or partial tur-binectomy, submucous resection, turbinoplasty, laser assisted turbinoplasty andargon plasma surgery. Radiofrequency thermal ablation has become popular inrecent years when patients refractory to the medical treatments. The aim ofthis study is to evaluate the efficacy of Low Temperature-Controlled BipolarAblation (Coblation) of inferior turbinate hypertrophies.Methods: A total of 14 patients with chronic nasal obstruction caused by onlyinferior turbinate hypertrophy were treated with coblation. This applicationwas performed 14 patient’s 19 hypertrophic inferior turbinate depending onphysical examination and magnetic resonance imaging (MRI). The resultswere evaluated subjectively by preoperative and postoperative a short formnasal symptom questionnaire (Likert scale) and objectively by MRI. Statisticalanalysis was made by paired-samples t test.Results: 12 weeks after treatment nasal symptoms that were evaluated withLikert scale were significantly decreased (p<0·0001). A significant recoveryin nasal volumes that were evaluated with MRI were detected 12 weeks aftertreatment (p<0·001). Postoperative complication depending on this applicationas epistaxis, infection, synechia, dryness, foul odour, pain and bone necrosis didnot occurred in this study.Conclusions: This study suggests that thermal ablation with radiofrequencyenergy is an useful, reliable and effective technique in treatment of inferiorturbinate hypertrophy that is refractory to the other medical treatments. Thismethod can be preferred in treatment of inferior turbinate hypertrophy becauseit makes controlled tissue reduction in low temperature.

P2K-7 Prescribing for otolaryngological emergencies in pregnancy

R. Mudduwa1, I. Smillie1, N. Kara2

1Department of Otolaryngology and Head & Neck Surgery, James Cook UniversityHospital, Middlesbrough, UK 2Department of Otolaryngology and Head & NeckSurgery, Freeman Hospital, Newcastle upon Tyne, UK

Objective: Prescribing in pregnancy presents a unique challenge to anyclinician; more so in the emergency setting, where the underlying conditionneeds to be treated within a limited period of time, whilst ensuring both maternaland foetal wellbeing.Otolaryngological emergencies often present in pregnancy, and there needs tobe clear and accessible guidance in prescribing, especially for surgical trainees.The authors aim to propose guidelines for prescribing in Otolaryngologicalemergencies based on current evidence.Methods: Recommendations from The British National Formulary, SanfordAntibiotic Guidelines, American Academy of Otolaryngologists-Head & NeckSurgeons and Food and Drug Administration (USA) were taken into account,together with local and national guidelines such as NICE and SIGN, to assessthe safety of the most commonly used drugs in Otolaryngological emergencies.Results & Conclusion: It is undisputed that drugs should only be prescribedif the expected benefits to the mother is thought to be greater than the risk tothe foetus, however strict adherence to avoiding drug prescribing in the firsttrimester may not be practical. Although relatively few drugs have been shownto be conclusively teratogenic in humans, it is good practice to limit prescribingto those that have been extensively used and appear to be safe.

P2L Surgical Oncology 2

P2L-1 Retrospective analysis of surgically resected gastrointestinalstromal tumors in Japan

H. Esakki1, M. Awane1, K. Taki1, S. Tsunekawa1, N. Inoue1, Y. Miura1,Y. Asao2, S. Matusue2, T. Yoshimura2

1Department of surgery, Kansai Electric Power Hospital, Osaka, Japan 2Departmentof abdominal surgery, Tenri hospital, Tenri, Japan

Objective: Gastrointestinal stromal tumor (GIST) is a relatively rare mes-enchymal tumor of gastrointestinal tract. We analysed the clinocopathologicalfeatures of resected GIST to evaluate the known prognositic factors in Japan.Methods: Surgically resected GIST patients at the two hospitals from 1996to 2008 were subject to analysis. We retrospectively collected the patientdemography, operative findings, tumor size, histological findings and the


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outcome. The effect of NIH risk classification system and high risk surgicalfindings (tumor rupture, peritoneal dissemination, tumor invasion, and distantmetastasis) on the outcome was examined.Results: The 94 patients with a mean age of 63·1 years included 3 esophageal,64 gastric, 7 duodenal, 16 small intestinal, no colonic, 3 rectal GISTs and onefrom unclear origin. The mean diameter of the gastric and small intestinal GISTwere 5·8 cm and 8·2 cm, respectively. The small intestinal group was classifiedas NIH high risk more frequently (56%) than the gastric group (34%). The5-year overall and disease free survival rate was 90% and 77·8%, respectively.The survival rate of high risk group was significantly lower than those ofintermediate risk and low risk group, but the last two groups were similar. Thehigh risk surgical findings showed strong negative impact on both overall anddisease free survival.Conclusion: The risk classification system reflected the survival of surgicallyresected GIST patients, but the prognosis of Japanese intermediate group wasexcellent. Modification of the risk classification is required to distinguish highrisk patients who need adjuvant chemotherapy.

P2L-2 Expression of argininesuccinate synthetase in humancolorectal cancer and colorectal cancer liver metastases

M. Mielczarek-Puta1, W. Grabon1, W. Otto2

1Chair & Department of Biochemistry, 2Chair & Department of General, Transplant& Liver Surgery, Warsaw Medical University, Poland

Study objective: Presumably arginine plies important role in cell proliferationas shown by increasing level of serum arginase in patients with colorectalmalignancies. The question, whether the tumor cells are auxotrophic for arginineseems to be important not only from the metabolic point of view.Method: Expression of argininesuccinate synthetase (ASS) has been studiedon mRNA level in the tissue of colorectal malignancies obtained duringsurgery from 21 patients with colorectal carcinoma (CRC) and 21 patientswith colorectal liver metastasis (CRCLM). Total RNA was isolated from tissuesample (TRIzol Reagent) and ASS expression was determined using RT-PCR(reverse transcriptase PCR) analysis. The regular colon mucosa taken from6–7 cm out of the tumor border was used as a control.Results: The level of ASS-mRNA in CRC accounted for 0·82 ± 0·31 (median0,76) and in CRCLM for 0, 81 ± 0·31(median 0,75) (p<0·05). The data weresignificantly lower compared to the normal colon mucosa (1·06 ± 0·35) (median0,97).Conclusions: The expression of ASS in the tissue of CRC and CRCLMindicates that these tumors are non-auxotrophic for arginine and are able tosynthesize arginine from citrulline. The significant decrease in ASS expressioncompared to normal colon mucosa may result in diminished arginine synthesisin tumor cells in favor of extracellular uptake of this amino acid.

P2L-3 Changes in serum levels of IL-6, HGF and TGF-α in patientswith liver haemangioma in relation to the extent of liver resection

O. Kornasiewicz1, Z. Lewandowski2, B. Najnigier1, K. Zieniewicz1,K. Kobryn1, M. Krawczyk1

1Department of General, Transplant and Liver Surgery, Medical University ofWarsaw, Poland 2Department of Epidemiology, Medical University of Warsaw,Poland

Background: Despite a large interest in regeneration processes, there hasbeen a shortage of data describing the relationship between postoperative serumIL-6, HGF and TGF-α levels in benign liver tumours and the extent of liverresection.Aim: of the study was to analyse IL-6, HGF and TGF-α serum concentrationsduring the first week post-operatively from two groups (minor vs. major liverresection).Methods: The study was comprised of 9 patients, who underwent liverresection for benign haemangioma (6 minor and 3 major resections). Majorresection was defined as a resection of more than 3 segments using any resectiontechnique. In order to study the levels of cytokines and growth factors, bloodserum was drawn at six time different points pre and post-operatively. Thesamples were then analysed by ELISA essay.

Results: Only HGF concentrations were found to provide convincing proofof differentiated response to the extent of surgical resection. In patients aftermajor resection, the concentration of HGF was significantly higher during thefirst day after surgery (p<0·0004). No similar response was found in the case ofIL-6 concentrations. There was a tendency for higher TGF-α concentrationsin patients after major resection, but this was not statistically significant.Conclusion: After resection of haemangioma, the serum levels of HGFdiffered according to the extent of hepatic resection and were higher after amajor resection. No similar response was found in the case of IL-6 and TGF-αserum concentration.

P2L-4 Coupled stimulation of cell migration and seprase expressionin human ehdothelial cells by sphingosine 1-phosphate

H. Okamoto1, Y. Yatomi2, K. Satoh2, T. Yamane3, Y. Ozaki2, H. Fujii1

1Department of Surgery, 2Department of Clinical Laboratory Medicine, 3Departmentof Pathology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan

Objective: Sphingosine 1-phosphate (Sph-1-P), a bioactive lysophospholipidpresent in the plasma, is released from activated platelets. Our previous studydemonstrated that Sph-1-P promoted the spreading on and migration of humanumbilical vein endothelial cells (HUVEC) through the extracellular matrix(ECM), suggesting a possible induction of cell surface proteases in the Sph-1-Pactivated endothelial cells. Here we provide the evidence that seprase, a typeII transmembrane serine protease (TTSP) usually absent in tissue cells, can beinduced in endothelial cells activated by Sph-1-P.Method & Result: We show by immunoblot analysis using anti-seprasemonoclonal antibodies (mAbs) that Sph-1-P enhanced expression of seprase in atime-and dose-dependent manner in HUVEC. The Sph-1-P inducible seprasecould be blocked by pertussis toxin and by C3 transferase, which inactivateGi-type heterotrimetric G proteins and Rho, respectively.Conclusion: These results show that Sph-1-P can regulate migration ofendothelial cells by inducing seprase expression, which, in turn, is mediatedthrough a Gi-coupled cell surface receptor and the Rho protein.

P2L-5 Spontaneous Rupture of the Spleen in the Presentationof Cronic Myeloid Leukemia

A. Koyuncu1, H. Bulu 1, D. Bulu 2, A. Co ku1

1Department of General Surgery, Ankara Kecioren Research and Training Hospital,Ankara, Turkey 2Department of Pediatri, Ankara Dy kapy Research and TrainingHospital, Ankara, Turkey

Spontaneous rupture of spleen in the leukemia is very rare, but potentiallylife-threatening complication. Spontaneous rupture of spleen occured andwas related to subcapsular infarction and hemorrhage. Chronic MyeloidLeukemia (CML) is an disorder characterized by leucocytose (white bloodcount 98 × 103 mm3) of the peryferal blood and presence of philadelphiachromosome. A 82-year-old man with stable CML and moderate splenomegalypresented to the emergency department with generalized abdominal pain andabrupt drop in hemoglobin. Abdominal imaging revealed splenic rupture andemergency splenectomy was undertaken, with complete recovery.

P2L-6 The value of resection of primary tumor in gastric cancerpatients with liver metastases

S. Turanli1, S. Aslan1, A. Cetin1

1Department of General Surgery, Ankara Oncology Education and Research Hospital,Ankara, Turkey

Objective: Surgery for gastric cancer with synchronous liver metastasis isapplied for palliation. The aim was to determine whether surgical removal ofthe primary tumor provides a better survival and disease progressionMethods: Sixty-two patients are classified according to the primary tumor wereremoved or not. Patients and tumor characteristics, removal of the primarytumor are examined as the factors that were affecting overall survival andmetastatic progression-free survival.


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Results: The mean follow-up time was 243 ± 23 days. The mean survivalof the resection and nonresection groups were 422 ± 50 and 170 ± 16 days(p = 0·0001), respectively. After adjustment for other covariates, resection wasassociated with a trend toward improvement in overall survival (p=0·003; relativerisk RR: 0·34; 95% confidence interval (CI): 0·17–0·66) and improvement inmetastatic progression-free survival (p=0·07, RR=0·51; 95% CI: 0·25–1·07).Conclusions: Excision of the primary tumor has effect on metastaticprogression-free survival and overall survival

P2L-7 Influence of the radiation field on anastomotic complicationsafter chemoradiation followed by surgery in esophageal carcinoma

C. Vande Walle1, W. Ceelen1, T. Boterberg2, K. Geboes3, S. Laurent3,D. Vande Putte1, Y. Van Nieuwenhove1, O. Varin1, P. Pattyn1

1Department of Gastro Intestinal surgery, University hospital, Ghent, Belgium2Department of Radiotherapy, University hospital, Ghent, Belgium 3Departmentof Gastroenterology, University hospital, Ghent, Belgium

Objective: Preoperative chemoradiation might improve long-term survivalin esophageal cancer, but the influence on postoperative morbidity remains aconcern. This study evaluated the radiation dose on the surgical anastomosisduring induction chemoradiation and the influence on postoperative morbidity.Methods: In this retrospective cohort study, patients received inductionchemoradiation (36 Gy, Cisplatinum and 5-Fluorouracil), followed by IvorLewis esophagectomy. The location of the anastomosis was determined onthe postoperative contrast radiography and CT. The proximal side of theanastomosis (esophagus) and the fundus were contoured as separate targetvolumes on the preoperative CT planning for radiotherapy. Dose-volumehistograms were analysed to calculate the D50 (maximal dose on 50% of thevolume) and V30 (percentage of volume receiving 30 Gy). Non-parametric testswere applied.Results: The radiation dose was evaluated in 54 patients.In 7 patients (13%), an early anastomotic complication (i.e. leakage) occurred.The radiation dose on the proximal esophagus did not differ significantly,however, the dose on the fundus was significantly higher in patients withcomplications (median D50 = 32, 98 Gy vs. 17,82 Gy, P = 0,024). ROC-analysis suggested following dose-limits: D50 < 29 Gy and V30 < 46% (AUC= 0,77, P = 0,02).Six patients (11%) developed a stricture. The fundus in these patients receiveda significantly higher dose (median D50 = 33, 03 Gy vs 15,76 Gy, P = 0,007).ROC-analysis suggested following dose-limits: D50<27 Gy and V30<44%(AUC = 0,83, P = 0,01).Conclusions: A high radiation dose on the gastric fundus is related to a higherrisk of early and late anastomotic complications. Applying dose limits couldreduce postoperative morbidity.

P2L-8 Wide local excision and sentinel node biopsy for breastcancer – feasibility of day case surgery

R. Clancy1, D. Bunting1, R. Watkins1

1Derriford Hospital, Plymouth, UK

Aims: To assess the feasibility of performing wide local excision (WLE) ofsmall invasive breast cancers combined with dual technique sentinel lymph nodebiopsy (SLNB) as a day case procedure.Methods: In 2007, an ambulatory surgical pathway for patients undergoingWLE and SLNB was developed. Procedures were performed under generalanaesthesia.Results: Of 104 women, 74 required pre-operative localisation (wire-guidedor ultrasound). 75 (72%) patients were discharged on the day of surgery. Nopatients required unplanned readmission. Of 37 women undergoing surgery inthe morning 6 (16%) required unscheduled overnight stay compared with 23(34%) of 67 having surgery after midday (p=0·04, Fisher exact probability test).Reasons for overnight stay were delayed recovery from anaesthesia, nausea andvomiting. In 2009 an unplanned overnight stay was required in only 7 of 43patients (16%) compared with a rate in the initial two year period of 36% (22 of61 patients) (p=0·02, Fisher exact probability test).

Conclusions: WLE and SLNB can be performed successfully as a day caseprocedure. Scheduling cases for mornings rather than afternoons should allowgreater compliance with the new pathway. Extension of theatre recovery facilitiesmay allow more patients to be discharged on the day of surgery.

P2M Surgical Oncology 3

P2M-1 Distribution of CD4 (+)CD25(+) Regulatory T-cells andexpression of Foxp3 and CD127 in tumors and tumor-draining lymphnodes in patients bearing advanced colorectal cancer

J. Han1,2, Y. Yang1, H. Yin1, H. Fan1, Z. Liu1, A. Lu1

1Shanghai East Hospital of Tongji University, Shanghai, China 2Institute ofSurgical Research and Hospital Management (ICFS), Basel University Hospital,Basel, Switzerland

Objective: Increased populations of regulatory T cells (Tregs) in the tumorenvironment show potential roles in inhibiting anti-tumor immune response.And the transcription factor Foxp3 plays a key role in CD4+CD25+ regulatoryT cell function and represents a specific marker for those cells. Meanwhile,the IL-17 receptor-chain (CD127) has been reported as a biomarker forhuman Tregs and the expression of CD127 is inversely correlated with thesuppressive function of CD25high Tregs. Here we investigated the distributionof CD4+CD25+ regulatory T-cells and explored its correlation with expressionof Foxp3 and CD127 in tumor tissues and tumor-draining lymph nodes inpatients bearing advanced colorectal cancer (CRC).Methods: Percentages of CD4+, CD4+CD25+ T-cells and CD4+CD25+/CD4+ were checked by Flow Cytometry and expression of Foxp3 and CD127were analyzed by Real-time PCR in peripheral blood mononuclear cells(PBMCs), tumor tissues and tumor-draining lymph nodes of 22 CRC patients atTNM stage II and III. The colon tissues and the lymphoglandulae mesentericaeof 10 non-tumor patients were also used as a control.Results: Percentages of CD4+CD25+ T-cells and CD4+CD25+/CD4+ intumor-infiltrating lymphocytes and tumor-draining lymph nodes of the CRCpatients were significantly higher than in PBMCs and those of the controlgroup. Also percentages of CD4+CD25+ T-cells, CD4+CD25+/CD4+ andexpression of Foxp3 in tumor tissues were higher than in lymph nodes(P<0·05).Furthermore, the percentages of CD4+CD25+ T-cells in lymph nodes adjacentto the tumor were higher than those marginally distant from the tumor(P<0·05),while expression of CD127 showed an opposite trend as compared to Foxp3expression. There was no difference between the different pathological stagesin percentages of CD4+CD25+ T-cells, CD4+CD25+/CD4+ and expressionof Foxp3 and CD127. Expression of CD127 showed a negative correlation withpercentages of CD4+CD25+ T-cells.Conclusions: Percentages of CD4+CD25+ T-cells, CD4+CD25+/CD4+and expression of Foxp3 and CD127 in tumor tissues and tumor-draining lymphnodes were correlated with the distance from the tumor in advanced colorectalcancer.

P2M-2 The feasibility of sentinel lymph node biopsy after neoadjuvantchemotherapy in breast cancer

T. Uomori1, K Takehara, Y. Mitugi1, M. Matida1, T. Kitabatake1,M. Fujisawa1, K. Kojima1, Y. Aoki2, K. Ogura2, T. Matumoto2

1Departments of Surgery, Juntendo Nerima Hospital, Tokyo, Japan 2Departments ofPathology, Juntendo Nerima Hospital, Tokyo, Japan

Objective: It has been said sentinel lymph node (SLN) surgery afterchemotherapy results in fewer positive SLNs and decreases unnecessary axillarydissections. Therefore, we investigated the feasibility of sentinel lymph nodebiopsy for breast cancer patients after neoadjuvant chemotherapy (NAC).Methods: Between July 2005 and July 2008, A total of 92 patients underwentsurgery after NAC, 78 patients of them with clinically node negative T1-T3 breast cancer were underwent SLNB after NAC. SLNB according to astandardised protocol that used a combination of radiopharmaceutical 99mTc-albumin colloid and indigocarmine. Sentinel lymph node biopsy followedby a full axillary lymph node (AXLN) dissection (ALND) was performed


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in all patients. Sentinel lymph nodes (SLN) were sent for a frozen-sectionexamination.Results: @SLN could be identified in 67 of 78 patients (identification rate86%), false negative rate was 14%, in 9 patients of them. As a result of havingexamined with a frozen-section, we recognized micrometastasis to SLN in 2 of9 and metastasis to AXLN in remaining 7 patients.Conclusion: It is thought that we should not be still better to omit ALND ifthe SLNB afeter NAC is negative.

P2M-3 The increase of B3/B4 following the introductionof mammotome for diagnosing breast lesions.

H. Khout1, R. Veeratterapillay1, K. Clark1

1Department of Surgery, Queen Elizabeth Hospital, Gateshead, UK

Objective: To evaluate the impact of introducing mammotome on the increaseof indeterminate histological result B3/B4 and therefore the increase in guidewire biopsies to determine the nature of these lesions.Methods: Retrospective review of core biopsies results the years from2002–2007; two years before introducing mammotom to our unit and fouryears after. Indeterminate Core biopsies results B3 (most likely benign) and B4(suspicious) were reviewed for every year.Results: 264 patients had indeterminate core biopsy result B3/B4 in periodfrom 2002 until 2007·70 patients had suspicious core biopsy result B4 and 194patients had B3 (most likely benign) result. All of these patients underwentguide wire biopsy to confirm the diagnosis.54 patients had B3/B4 in 2002 and 2003; 27 patient per year. on the other hand,210 patients had B3/B4 in the years 2004 to 2007; 52·5 patient per year. thisshows a 194% increase in B3/B4 biopsies.Conclusions: Introducing mammotome to breast units increased the B3/B4rate and therefore increased the need for guide wire biopsies. There is needfor a national guide line to address this problem. We believe that a multipleVacuum assisted core biopsy (VACB) might reduce the B3/B4 rate, however,Larger multi centre studies would add support to this.

P2M-4 Mastectomy for C5 cytology- is it safe practice?

H. Khout1, R. Frame1, A. Mooney1, K. Clark1

1Department of Surgery, Queen Elizabeth Hospital, Gateshead, UK

Objective: To evaluate the accuracy of cytological diagnosis of breast cancersgreater than 11 mm in detecting invasive cancers and therefore the ability touse fine needle aspiration (FNA) as the sole diagnostic parameter.Methods: Retrospective review of 98 patients in our breast unit in theperiod from April 2005 until September 2008 who underwent mastectomy withaxillary lymph node sampling/clearance following a diagnostic FNA showingmalignancy C5. All of the patients had cancers greater than 11 mm.Results: 95 patients had mastectomy with axillary lymph node sampling orclearance. All the patients were females with mean age of 65. Final histologyconfirmed invasive malignancy in all patients. 75 patients had invasive ductalcarcinoma, 15 had lobular carcinoma, 3 patients had other invasive cancers (1tubular, 1 medullary, 1 metaplastic) and finally two patient had mixed ductal andlobular carcinoma. 51 patients had negative axillary lymph nodes, 44 patientshad positive lymph nodes. The average Nottingham prognostic index was 4·44.Conclusions: Mastectomy with axillary surgery following C5 cytologydiagnosis for greater than 11 mm cancers can be safely carried out withoutcore biopsy. In our study none of the patients had carcinoma in situ. None ofour patients diagnosed using FNA alone had unnecessary surgery.

P2M-5 Prox1 is one of the tumor suppressor and Prox1 knockdowninhibits IFN-γ induced apoptosis in esophageal squamous cellcarcinoma cells

M. Akagami1, G. Watanabe2, H. Takagi1, Y. Shimada3, A. Itami1,K. Kawada1, S. Nagayama1, H. Kubo1, Y. Sakai1

1Department of Surgery, Kyoto University, Japan 2Department of Home PalliativeCare, The Japan Baptist Hospital, Japan 3Department of Surgery, Toyama University,Japan

Background: We have reported that IFN-γ stimulation induces apoptosis inapproximately 30% of human esophageal squamous cell carcinoma cell lines(KYSE series). IFN-γ is known to have anticancer activity, but the underlyingmolecular mechanism remains unknown. The transcriptional factor STAT1is one of the downstream IFN- γ receptors. IFN-γ stimulation can activateSTAT1, resulting in translocation into nuclei and expression of IFN-γ targetgenes. On the other hand, the homeobox gene Prox1 is one of the target genesof RNA editing. We previously reported that RNA editing occurs in esophagealcancer cell lines with the highest frequency among the several other cancercell lines examined, suggesting that Prox1 may function as an anti-oncogene inesophageal cancer cells. The aim of this study was to assess correlations betweenIFN-γ signaling and Prox1 and to examine the roles of Prox1 in squamous cellcarcinoma cell lines.Results and conclusions: First, we reconfirmed that IFN-γ inducedapoptosis in KYSE 510 cells, and that Prox1 mRNA increased with IFN-γstimulation. These reactions were inhibited in cells in which STAT1 dominantnegative genes had been introduced, suggesting that Prox1 is a target geneof IFN-γ - STAT1 pathway. We analyzed Prox1 function in IFN-γ inducedapoptosis, using Prox1 knockdown cells by the siRNA technique. We foundthat IFN-γ induced apoptosis was inhibited in Prox1 knockdown cells andoverexpression of Prox1 inhibited proliferation. Our findings suggest thatProx1 plays an important role in the IFN-γ induced apoptosis in esophagealcancer cells. Our results will hopefully provide a basis for the development ofnew cytokine therapies.

P2M-6 The surveillance of surgical site infections after modifiedradical mastectomy

S. Turanli1, S. Aslan1, A. Cetin1

1Department of General Surgery, Ankara Oncology Education and Research Hospital,Ankara, Turkey

Objective: Determination of the incidence of Surgical Site Infections (SSI)after Modified Radical Mastectomy (MRM), risk factors on SSI and surveillanceof SSI was aimed in this study.Method: One hundred ninetyseven women patients diagnosed as breastcarcinoma from July 2006 through May 2008 in the First Department ofGeneral Surgery, Ankara Oncology Training and Research Hospital wereincluded in the study. MRM was applied to all patients as a standart procedure.The dependent parameters were as follows: age, body mass index, smoking,the presence of hypertension and diabetes mellitus, American Society ofAnesthesiologist (ASA) classification, preoperative hospital stay, postoperativehospital stay, total hospital stay. All other factors such as duration of operation,perioperative transfusion, transfusion number, tumor size, total lymph nodenumber, metastatic lymph node number, rate of metastatic lymph node(%),TNM staging, avarage of drain amount, timing of drain removal, preopeativechemoterapy, associated with operation were determined as well.Result: While SSI did not ocur on 179 patients, SSI was observed on 18patients. Overall SSI rate was detected as %9,1. Risk factors after multivariateanalysis which have significant effects were determined as respectively, timingof drain removal (P<0·001), avarage drain amount (P<0·001), transfussionnumber (P=0·009) and ASA classification (P=0·018).Conclusion: It was concluded that to prevent SSI after MRM, preoperativepreparation of patients and modification of surgical technique by means ofdecreasing wound complications and timing of drain removal are crucial factors.For that purpose it is considered that surveillance studies would contribute thisconclusion.


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P2M-7 The surgical tact in case of complicated gastric cancerof profuse bleeding

K. Kashibadze1, A. Beridze1, E. Diasamidze2, V. Tedoradze2

1Department Of Surgery, Shota Rustaveli State University, Batumi, Georgia 2CentralClinical Hospital of Batumi, Batumi, Georgia

In the departments of the general surgery urgently cases, which causes thecomplication of gastric cancer is averagely define as 1–2·5%. Above mentionedwe discuss the different localization and feature histomorphological of thestomach cancer, complicated profuse gastro-duodenal bleeding, perforationof the stomach and (pillory or other) stenosis with the development of highobstruction.As it is known from the sources of literature between such kind of patients (thevarious types) are 22–38% and the mortality among the complicated patientscame a cross 44-6-% which is really a high indication. And definitely demandsthe studying of the condition of improvement existing results.During the 2000–2008 in the surgical department of Clinical Hospital of ShotaRustaveli State University were treated 238 patients, among them 156 (65·5%)is considered to be gastric cancer with complicated profuse gastro-duodenalbleeding. 62 (26%) patients – complicated perforation of the stomach and 20(8·8%) – stenosis with the development of high articles we will take into accountonly cases of complication gastric cancer by bleeding. In the group of bleedingthe majority of patients were male −129 (%), then their average, age was 472,13.

P2M-8 Influence of allogeneic blood transfusion on outcomein patients with Dukes B stage of colorectal cancer.

D. Zdravkovic1, D. Bilanovic1, T. Randjelovic1, M. Granic1,B. Djukanovic1, D. Nikolic1, N. Ivanovic1, S. Dikic1, B. Toskovic1,M. Zdravkovic2

1Department of Surgery, University Medical Centre ‘‘Bezanijska kosa’’, Faculty of2Medicine, Belgrade, Serbia 2Department of Internal Medicine, University MedicalCentre ‘‘Bezanijska kosa’’, Faculty of Medicine, Belgrad, Serbia

Objective: The relationship between allogeneic blood transfusion andoutcome in patients with Dukes B of colorectal cancer stage was studied.Methods: Between January 2000 and December 2004 110 patients witha diagnosis of colorectal cancer were evaluated for study inclusion criteria.Inclusion criteria were B stage according to Dukes classification operativetreatment and curative resection. Exclusion criteria were: polyposis syndromes,nonpolyposis syndromes, preexisting disease (inflammatory bowel disease,autoimmune disease etc), previous blood transfusion, preoperative mortalityand other cause of death during follow-up. Patients were divided into twogroups: Group 1-transfused (75) and group 2-nontransfused (35) patients.We analyzed influence of preoperative, intraoperative or postoperative bloodadministration on outcome of all patients. All operations were performed asopen laparotomies by senior surgeons. Follow up was 5 year.Results: Allogeneic blood transfusion did not influence patients’ outcome(χ2 = 0, 24 p>0·05), neither local recurrence (χ2 = 0·08, p>0·05) nor distantmetastasis (χ2 = 0·45, p>0·05). Also, The Kaplan-Meier survival curves werecalculated, and long-rank test didn’t show survival difference between these twogroups (log rank=0·064, p>0·05). ‘‘Cut off’’ values calculated by ROC curveswere 4 intraoperative blood units for local recurrence (sp 72,3% sn 74,7%) and4 postoperative blood units for metastasis (sp 71·8% sn 68·1%). and mortality(sp 69·8% sn 65·1%).Conclusion: Three or less allogeneic blood untis does not influence onoutcome in patietns with Dukes B stage of colorectal cancer. Four untis ofallogeneic blood transfusion is cut off value for poorer outcome with releiblesensitivity and specifity.

P2M-9 Localization of Dukes B colorectal cancer and requirementfor allogeneic blood transfusion

D. Zdravkovic1, D. Bilanovic1, T. Randjelovic1, M. Granic1,B. Djukanovic1, D. Nikolic1, N. Ivanovic1, S. Dikic1, B. Toskovic1,M. Zdravkovic2

1Department of Surgery, University Medical Centre ‘‘Bezanijska kosa’’, Faculty of2Medicine, Belgrade, Serbia 2Department of Internal Medicine, University MedicalCentre ‘‘Bezanijska kosa’’, Faculty of Medicine, Belgrade, Serbia

Objective: This study was undertaken to evaluate the influence of localizationof colorectal cancer in Dukes B stage on requirement for allogeneic bloodtransfusionsMethods: One hundred fifty one patients with a diagnosis of colorectal cancerwere evaluated for study inclusion criteria. Inclusion criteria were Dukes Bstage, curative resection and allogeneic blood transfusion. Exclusion criteriawere: polyposis and nonpolyposis syndromes and previous blood transfusion.Patients were divided into three groups according to cancer affected part oflarge intestine: group 1-right colon, group 2-left colon, group 3- rectum. Rightcolon was defined as cecum, ascendens and proximal two thirds of transversum.Left colon was defined as distal transversum, descendens and sigmoid colon.Follow up was 5 years.Results: The largest number of blood units was administrated to patients ingroup 3 (4·42 ± 2·778, mediana 3·50) and significantly lower incidence of bloodunits was in group 1 (3·55 ± 2·384, mediana 3·00) and in group 2 (3·12 ± 2·027,mediana 2·00). (Kruskal Wallis, χ2 = 6·413, df 2, p=0·40). Requirementsfor preoperative blood transfusion were significantly higher in group 1(χ2 = 16·768, df 2, p=0·000) compared to other groups. Patients in group3 have had significantly higher requirement for intraoperative (χ2 = 13·398, df2, p=0·001) and postoperative blood transfusion (χ2 = 8·273, df 2, p=0·016).Local recurrences (p=0·02) as well as mortality (p=0·01) were associated withpatients in group 3. Metastasis were the most frequently diagnosed in patientsin group 2 (p=0·04).Conclusions: The biggest requirements for blood transfusion are necessaryfor surgery of rectal cancer while preoperative blood transfusion is mostlyassociated with cancer of right colon.

P2N Thoracic Surgery

P2N-1 Acid and Alkali Burns of the Esophagus: An Experimental Study

A. Nadir1, O. Katracioglu1, E. Sahin1, M. Kaptanoglu1, S. Arici2,V. Ozbek1, S. Kizilgedik2

1Department of Thoracic Surgery, Cumhuriyet University, Sivas, Turkey2Department of Pathology, Cumhuriyet University, Sivas, Turkey

Objective: The purpose of the study was to evaluate esophageal burn in arat model using varying concentrations of acid and alkali substances commonlyused in daily life.Methods: Wistar Albino rats were used in this experimental model (n=35). Onecontrol group and four working groups were designated with 7 animals in each.The control group was given serum physiologic into the esophagus; Groups Iand II were administered sodium (Na) hypochloride (acid) in concentrationsof 2·5% and 5%, respectively; and Groups III and IV were administeredNa hydroxide (alkali) in concentrations of 2·5% and 5%, respectively. After24 hours, samples were taken from the esophagus and the damage was evaluatedin submucosa, muscularis mucosa and tunica muscularis, and the total burnscores were determined.Results: Total burn score in the control group was 0·28 ± 0·48, in GroupI 2·28 ± 0·95, in Group II 2·43 ± 0·78, in Group III 3·00 ± 0·57, and inGroup IV 3·57 ± 0·53. Significant differences were determined in total burnscore between all study groups compared with the control group. There weresignificant differences between Group I and Group IV and between Group IIand Group IV regarding muscularis damage (p<0·05).Conclusion: When the data were evaluated, there was more definite esophagealburn in both acid and alkali groups than in the control group. When the acidand alkali groups (of same concentrations) were compared, damage in the alkaligroup was greater. In conclusion, the type of substance given to esophagus aswell as its concentration is important in esophageal burns.


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P2N-2 The effect of insulin intake during lung resections-first results

J. Dolezel1, A. Pestal1, V. Jedlicka1, M. Vesely1, P. Divis1, I. Capov1,D. Zvonickova2, Z. Rucka3, I. Krontorad-Koutna3

11st. Department of Surgery, St. Anne University Hospital, Brno, Czech Republic2Department of Anestesiology-Resuscitation, St. Anne University Hospital, Brno, CzechRepublic 3Centre for Biomedical Image Analysis, Masaryk University, Brno, CzechRepublic

Objective: The operability of bronchogenic cancer is about 11% in CzechRepublic. One reason of all is low cardiorespiratory reserve. The aim of thisproject is the answer, if the insulin have an influence on the value of blood gasesduring lung resection.Methods: The patients, who are undergoing lung resection are divided intotwo groups – the first with insulin administration, the second without. Insulin(insulinum humanum rapid) is administered since the beginning of operation inthe dose that would keep glycemia on its corresponding level before operation.The levels of blood gases are determined from arterial blood taken before thestart of selective ventilation and at the end of operation. The project is supportedby IGA NS 9681-4 and proposed until 2011.Results: The comparison was done in 19 patients in 2009. In observed groupwas made lobectomy-10, pneumonectomy-2, segmentectomy-2, in controlgroup lobectomy-4 a segmentectomy-1. The averrage consumption of theinsulin was 23,4 unit for one resection. The insulin was administered in 14patients, 5 patients was operated witout insulin. The change of observedparameters was calculated as difference of examination values (output minusinput). The comparison was made by double t- test on p- value 0·05.Conslusion: We dont prove statistical important changes of bood gases onp-value(0·05) with and witout insulin intake during lung resection. Statisticalimportant decreasing of values HCO3- (p = 0·014) and BE (p = 0·019). Thesubgoup of ‘‘insulin’’ patiens we will compare in next two years, when thesubgoups will contain higher volume.

P2N-3 The Effects of Chlorhexidine Gluconate and Silver Nitrateon Rabbit Lung: An Experimental Study

E. Sahin1, A. Nadir1, S. Karadayi1, B. Celik1, M. Kaptanoglu1,S. Elagoz2, Y. Akkas1

1Department of Thoracic Surgery, Cumhuriyet University, Sivas, Turkey2Department of Pathology, Cumhuriyet University, Sivas, Turkey

Aim: To investigate the effects of chlorhexidine gluconate and silver nitrateon the lungs and to determine its efficiency in the operations for pulmonaryhydatid cyst.Methods: Thirty New Zealand rabbits were used in the study and divided intothree groups. In the first (control) group, normal saline (%0·09); in the secondgroup, silver nitrate (0·5%), and in the third group, chlorhexidine gluconate(0·04%) was administered intrathraceally. Thirty days after the procedure,the tracheabronchial and parenchymal changes in the subjects were evaluatedhistopathologically. Tracheabronchial changes were evaluated with respect totracheal pathology and peribronchial lymphocytic infiltration and parenchymalchanges were evaluated with respect to interstitial lymphocytic infiltration,hemorrhage-edema, fibrosis and pneumonitis.Results: The rate of interstitial lymphocytic infiltration was higher in thechlorhexidine gluconate group than in the control group, and the rates offibrosis and fibrin accumulation were higher in the SN group than in thecontrol group. No statistically significant differences in other parameters werefound between the groups.Conclusion: The results of the study have indicated that chlorhexidinegluconate (0·04%) has minimal negative effect on the rabbit lung andtracheabronchial mucosa and is a more reliable agent than silver nitrate.

P2N-4 Early to intermediate survival after Extrapleuralpneumonectomy for malignant pleural mesothelioma in Wales

A. Ajzan1, M. Ashour1

1Department of Cardiothoracic Surgery, Morriston Hospital, Swansea, Wales

Objectives: Epithelial type Pleural mesothelioma is by far the most prevalentform of mesothelioma. The surgical technique of extrapleural pneumonectomy(EPP) was first described in the late 1940s and was used this resection forthe treatment of tuberculous empyema. Data on Extrapleural Pneumenectomymortality and morbidity were published in the UK as early as 1976. aim of thisstudy is to follow-up survival after this procedure.Methods: 15 patients (n=15) underwent planned extrapleural pneumonectomysince 2005 (range 2–48 months)(mean 33 months), diagnosis was using videoassited throracoscopic surgery (VATS), all procedures were done via musclesparing posterolateral thoracotomy incision with no rib ressection, Extrapleuraldissection and Diaphragmatic and pericardial resection with division of thepulmonary vessels and bronchus and removal of specimen en bloc. Gore-Texpatch reconstruction of pericardium and diaphragm.Results: 10 males(66·7%) and 5 females (33·3%), age was 57–80 years (mean67·4) underwent this procedure, time from surgery was 2–48 months (mean33·8 months), mean diagnosis to surgery time was (2·8 weeks), all underwentpost operative chemotherapy/radiotherapy, Disease was on the right (40%)and left (60%), histopathology showed mixed type (13·3%) and epithelial type(86·6%), total number of recurrence was 4 cases (26·6%), stage I (53·3%),stage II (26·6%) and stage III (20%). Post operative complication includedAtrial Fibrillation (26·6%), Seroma (26·6%), paralytic illus (6·6%). HospitalStay was 7–15 days (mean 10·1 days). There was no perioperative mortality, orin-hospital mortality, mortality at 30 days and 90 days were nil, 1 year survivalwas (94·4%), at 2 and 3 years was (80%) for our sample.Conclusion: Extraplueral pneumonectomy still gives the best survival rates(from our sample that of other authors) for Epithelial type malignant pleuralmesothelioma, we acknowledge that our sample of patient is relatively small ascompared to other studies but it reflects the prevalence of the disease in wales.

P2N-5 Bipolar cheap cuting and dissecting devices in thoracicsurgery, a modern way of surgical practice

C. Paleru1, I. Cordos1, C. Bolca1, O. Danaila1, A. Istrate1

1National Institute Of Pneumology Marius Nasta Th Surg Department, Bucharest,Romania

Objective: To implement, promiote and demonstrate the surgical capabili-tiesand surgical use of bipolar scissor and tripodal (coagulating and cutting onestep) device in open general thoracic surgery.Material And Method: Lung dissection, vessel dissection nerve dissection,nodal dissection using bipolar scissors. Shortening the dissection time and verysure dissection near very special organs.Tripodal use in vessel sealing muscle resection and hemostasis in difficult zones.The tripodal device use simple bipolar electric power available at any unit ofelectrosurgery.Different cases with image and film presentation for each case. Difficulttuberculosis and fibrosis cases presented.Discussion: Difficult dissection in very sensible zone like pericaval space orsub carinal space needs a very precise and simultaneous clean dissection. Clasicaluse of forceps scissors and monopolar or simple bipolar forceps include timeconsumption, blood oozing anda supplimentar help. Using bipolar dissectionscissor you can master a clean and fast dissection in very sensitive areas.Tripodal devices prevent a lot of peripheral knots, fasten muscle dissection inparietal tumours using very chap devices.Conclusion: Bipolar cheap dissecting and cutting devices can modify thetechnique of dissection, shorten and secure operative steps. Disseminating thisknowledge is an important step in surgery progression.

P2N-6 The incorporated silicone airway stent: an alternativemanagement of stenosis following metallic airway stenting

Y.-H. Liu1, C.-Y. Liu1, Y.-C. Wu1, M.-J. Hsieh1, Y.-K. Chao1,C.-Y. Wu1, P.-J. Ko1, H.-P. Liu1

1Department of Surgery, Chang Gung Memorial Hospital, and School of MedicineChang Gung University, Taiwan


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Objective: Severe airway granulation after metallic stent insertion can causecritical tracheal obstruction. The treatment of refractory granulation tissueremains big challenge to patients and their physicians.Methods: Various maneuvers to treat the obstruction after metal stentplacement were reported. Techniques include ballon dilation, laser therapy,electrocautery/argon plasma coagulation, photodynamic therapy, cryotherapy,stent-within-a-stent technique (incorporated silicone airway stent), and removalof metallic stents.Results: Three patients were successfully treated by incorporated siliconeairway stent (which inserted the silicone stent into metallic stent) with completerelief of airway obstruction without peri or post-operative complications.Conclusion: Incorporated silicone stent is a good option for a severe airwaygranulation (over upper, lower trachea, and main stem bronchi) after metallicstent insertion.

P2N-7 Granulation tissue formation following airway stenting:The influence of the stent diameter

P.-J. Ko1, C.-Y. Liu1, Y.-C. Wu1, M.-J. Hsieh1, Y.-K. Chao1,C.-Y. Wu1, Y.-H. Liu1, H.-P. Liu1

1Department of Surgery, Chang Gung Memorial Hospital, and School of MedicineChang Gung University, Taiwan

Objective: To determine whether the stent diameter influences granulationtissue following stent placement for major airway stenosis.Methods: Forty-two stent procedures (32 tracheal stents, 3 carinal stents, and7 bronchial stents) (Novatech, Grasse, France) were performed in 39 patients.Seventy-nine stent edge regions (62 tracheal, 17 bronchial stents) were evaluatedin this study.Results: Granulation tissue formation was encountered at in 11 patients(28·21%). Of the 34 upper ends of tracheal stents evaluated, granulation tissueformation was observed in 6 (17·65%), whereas granulation tissue formationwas observed in 2 (7·14%) of the 28 lower ends of tracheal stents evaluated. Ofthe 17 bronchial stent edge regions, granulation tissue formation occurred in 3(17·65%) (P = 0·4352). The rate of granulation tissue formation was higher inthose patients with a stent-to-airway diameter ratio of > 90% (P<0·0001).Receiver operating characteristic curve analysis further demonstrated thata cut-off stent-to-airway diameter ratio of 90% was effective in predictinggranulation tissue formation (AUC:0·897, Std. Error=0·036, P<0·0001, 95%CI=0827–0·968, N=79).Conclusion: A stent-to-airway diameter ratio of 90% was found to be thecritical cut-off point for predicting granulation tissue formation. Therefore,the optimal stent-to-airway diameter ratio should be ensured before stentplacement.

P2N-8 The Value of Systematic Mediastinal Lymphadenectomyin Surgery of Lung Metastasis- first results

J. Dolezel1, V. Jedlicka1, A. Pestal1, M. Vesely1, I. Capov1,M. Szkorupa2, J. Vodicka11st Department of Surgery, St. Anne’s University Hospital, Brno, Czech Republic 21stDepartment of Surgery, University Hospital, Olomouc, Czech Republic 3Departmentof Surgery, University Hospital, Pilsen, Czech Republic

Object: The effect of systematic mediastinal lymphadenectomy duringpulmonary metastasectomy is uncertain. Today is the lymph nodes samplingof the most frequent type of mediastinal lymphadenectomy during pulmonarymetastasectomy. The published rate of mediastinal lymph node metastasisharvested during pulmonary metatasectomy is varying from 9% to 29%. Theaim of this project is evaluation of lymph node metastasis rate during pulmonarymetastasectomy for metastasis of sarcomatous and carcinomatous origin.Method: We performed systematic mediastinal lymphadenectomy (the sametechnique as in non- small cell lung cancer) during pulmonary metastasectomyto exact evaluation of metastatic involvement of mediastinal lymph nodes. TheProject is supported by Grant IGA NS 10095-4Results: In 2009, we performed pulmonary metastasectomy in 33 patients, sixtimes for sarcomatous and in 27 cases for carcinomatous origin. Six times weperformed bilateral lung metastasectomy. There were 18 patients with solitary

metastasis. The averrage diameter of metastasis was 26 mm. The averragenumber of harvested lymph nodes was 15. Mediastinal lymph node metastasiswas found in 9%. There origin was Grawitz tumor once, malignant fibroushistiocytoma once and metastatic typic carcinoid once. All our patients withcolorectal origin of lung metastasis don’t have any mediastinal metastasis.Conclusion: The number of metastatic involved mediastinal lymph nodeharvested during lung metastasectomy is similar like in literature. We expectedhigher lymph node involvemnet in lung metastasis of colorectal origin.The systematic mediastinal lymphadenectomy should be done during lungmetastasectomy for staging and following treatment. The project is planned for3 years with following surviving calculation by Kaplan-Meier metod.

P2N-9 Extracellular fluid type lung preservation solution may enableprolonged preservation of the graft in lung transplantation

H. Oishi1, Y. Okada1, Y. Matsuda1, T. Sado1, M. Noda1, Y. Hoshikawa1,A. Sakurada1, C. Endo1, T. Kondo1

1Department of Thoracic Surgery, Institute of Development, Aging and Cancer,Tohoku University, Sendai, Japan

Objective: The lung transplantation recipients in Japan often have denseintrathoracic adhesions due to primary disease, and the surgery time for lungtransplantation is often long. As a result, the graft ischemic time is longer inJapan than other countries. It is thought that longer graft ischemic time is one ofthe risk factors of primary graft dysfunction (PGD) after lung transplantation. Atthe time of lung transplantation, we use the extracellular fluid type solution (EP-TU solution) which we developed as lung preservation solution. We analyzedthe availability of the extracellular fluid type lung preservation solution in thelung transplantation cases with more than ten hours graft ischemic time.Methods: The graft ischemic time was more than 10 hours using EP-TUsolution in 6 cases. We retrospectively examined clinical data such as PGD,30 days mortality in these cases.Results: Idiopathic Pulmonary arterial hypertension (2 patients), obliterativebronchiolitis (1 patient), bronchiectasis (1 patient), lymphangioleiomyomatosis(1 patient), diffuse panbronchiolitis (1 patient) were the primary diseases oflung transplantation recipients. In all cases, bilateral lung transplantation wasperformed. Mean graft ischemic time was 672 ± 40·9 minutes (range 634–728).According to PGD grade of the international society for heart and lungtransplantation, 3 patients had grade 1 (PaO2/FiO2:> 300), 2 patients hadgrade 2 (PaO2/FiO2: 200–300), 1 patient had grade 3 (PaO2/FiO2:< 300). Onepatient with grade 3 died of PDG on postoperative day 10.Conclusion: Since the severity of PGD was comparatively slight by theextracellular fluid type lung preservation solution, prolonged preservation ofthe lung graft may be possible.

P2N-10 An Experimental Model to Study Pneumothorax in Rats

M. Kaptanoglu1, Y. Akkas1, A. Nadir1, E. Sahin1, C. Gumus2

1Department of Thoracic Surgery, Cumhuriyet University, Sivas, Turkey2Department of Radiology, Cumhuriyet University, Sivas, Turkey

Aim: Researches have used various techniques to form pneumothorax in animals,but to date, no standard method or rate of pneumothorax has been defined. Wetried to develop a standart and a safe method of pneumothorax model in thisstudy.Material and Methods: 12 female Wistar rats weighing 200–220 grams wereused. Two groups (6 rats in each) were formed. Open pneumothorax was formedby 0·5 cm incision through the right, 5th intercostal space. The first group washeld in open pneumothorax position for 1 minute, and the second group, for 2minutes, and the incisions were sutured. After 48 hours, computed tomographyof the rats was obtained, and the pneumothorax rates were measured.Results: The mean pneumothorax value was greater in Group II (13·89%)than in Group I, and it was statisticaly significant (p<0·05).Conclusions: The above mentioned method produces low rates ofpneumothorax (10–15%), without injuring lung tissue. It should be usefull forresearchers, who plan to study lung physiology with low rates of pneumotohorax.


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P2N-11 Factors Affecting The Morbidity And Mortality In Flail Chest;Comparison Of The Anterior And Lateral Localisation

D. Kilic1, A. Findikcioglu1, T. Tatar1, A. Hatipoglu1

1Baskent University, Faculty of Medicine, Department of Thoracic Surgery, Ankara,Turkey

Objective: Flail chest is one of the most challenging problems for thoracicsurgeons. In this study we evaluate treatment modalities for flail chest accordingto the effects of localization of trauma on mortality and morbidity.Methods: Between March 2003–January 2009, 24 patients were treated forflail chest after blunt thoracic trauma. Three female and 21 male, mean age was45(16–70 year-old) were analyzed for age, sex, chest wall localization of trauma,mechanical ventilation support, prognosis and Injury Severity Score. Internalfixation was used in three patients.Results: The major cause of flail chest was car crush in 19 of 24 patients(%76), falling from high 4 patients (%19), and subsidence 1 patient (%5).Mechanical ventilation support was carried out in 14 patients; (%60·8), 12 of14 were fallowed with tracheostomy. Injury severity score was 62·8 (30–75) for

whole patients. The patients with flail chest who have bilaterally costa-condralseparations ‘‘anterior location of the chest’’ (group I) have significantly higherISS than, single side postero-lateral flail chest (group II). (ISS: 70/55, p=0·02).Needing for mechanical ventilation support is also higher in bilaterally costa-chondral separation. Morbidity rate is higher in group I than group II but thereis no statistical significant (p=0·198). However mortality rate is significantlyhigher in group I (p=0·08). The patients with cranial trauma and flail chesthave a higher mortality rate (%19) then only flail chest (no mortality). MeanISS is 75 in cranial trauma and flail chest where as only flail chest ISS is 55·7(p=0·001). Sepsis and sub-arachnoid bleeding are the major causes of mortality.Conclusion: Early intubation and mechanical ventilation is paramountin patients with flail chest. Prolonged mechanical ventilation is associatedwith the development of poor outcome. Tracheotomy and frequent flexiblebronchoscopy should be considered to provide effective pulmonary toilet.When cranial trauma accompanied to flail chest mortality and morbidiy ratesincrease, bilaterally costa-chondral seperations is also increased morbidity andneeding for mechanical ventilation in patients with flail chest.


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ESSR ABSTRACTS 2010

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