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and 15 cm length using a laparoscopic grasper. If resistance was encountered during passage,the test was considered a failure. To test the feasibility of using variably sized extractiontubes, the specimen was also passed through 15 cm long PVC-tubing segments with 1.25inch (3.1 cm) and 2 inch (5.1 cm) diameters. Associations between patient variables andability of the specimen to pass through the TES proctoscope were tested using a bivariatePearson's correlation. RESULTS: Extraction tests were performed on 21 resected colonspecimens. Indication for resection was colon cancer or polyps in 10 cases, recurrentdiverticulitis in 9 cases, Crohn's disease in 1 case, and ulcerative colitis in 1 case. Theanatomy of the resection was the sigmoid colon in 13 cases, a hemicolectomy in 5 cases, atotal proctocolectomy in 2 cases, and a proctectomy in 1 case. Mean patient age was 55±14, BMI was 26 ±6 kg/m2, 13 (62%) were female, and 15 (71%) had received preoperativemechanical bowel preparation. Mean colon specimen length was 30 ±33 (range 10-150) cmand mean width (including mesentery) was 5.6 ±1.9 (range 3-9) cm. Nine (43%) specimenswere able to pass through the 4 cm diameter TES proctoscope without significant resistance.Six (29%) were able to pass through the 3.1 cm diameter tube, while 14 (67%) passedthrough the 5.1 cm diameter tube. Specimens from patients with higher BMIs were lesslikely to pass through the TES proctoscope (r =-.48, p=.03) and wider specimens were alsoless likely to pass (r = -.51, p=.03). Longer specimens were less likely to pass successfullyat a trend level (r = -.39, p=.08). CONCLUSIONS: In an ex-vivo experiment, less than 50%of colon specimens were able to be passed through a standard TES proctoscope. Increasedspecimen width and length, as well as patient BMI, were predictive of passage failure. Useof a TES proctoscope to facilitate transanal specimen extraction may not be a feasibletechnique for the majority of colon resections.

Su1800

Upper Endoscopy and Barrett's Esophagus: Back to BasicsBernardo Borraez, Marco E. Allaix, Vani J. Konda, Matthew Stier, Robert T. Kavitt, GabrielLang, Marco G. Patti

Background: Endoscopy is the key test for the diagnosis of Barrett Esophagus (BE). Thediagnosis is based on the visualization of salmon colored mucosa on the background of thesquamous epithelium, and on properly executed biopsies for pathologic confirmation. AimsThe aims of this study were to determine: (a) the sensitivity of visual inspection for thediagnosis of BE as compared to the pathology results; and (b) how often a proper descriptionof the BE was done. Methods: Review of a prospectively set database. We evaluated theendoscopic findings of 243 patients in whom the endoscopist thought that BE was presentand compared them to the pathology results. In addition, we assessed how often the suspectedBE was described and the proper biopsy protocol followed. Results: The presence of BE wasconfirmed in 93 of the 243 patients (38.3%). Metaplasia was present in 88.2% and lowgrade dysplasia in 11.8%. The length of the segment was described in 68.3% of patients(63.4% short segment and 4.9% long segment). In 31.7% of patients the endoscopist thoughtthat BE was present but no description was given. An average of 3.5+2.3 biopsies weretaken. Conclusions: The results of this study showed that: (a) the visual inspection for thediagnosis of BE had a low sensitivity; (b) a proper description of the BE was not done in1/3 of patients. This study suggests the need for more strict observation of the AGA guidelinesby physicians performing upper endoscopy.

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A Large, Single-Surgeon Experience With Laparoscopic Redo Fundoplication:Operative Technique and Long-Term OutcomesRoberto A. Estrada Gómez, Wolfgang Gaertner, Martín Vega de Jesús, Jorge G. ObregónMéndez, Alfonso Arias Gutiérrez, Beatriz de Rienzo, Cesar Decanini

BACKGROUND: Gastroesophageal reflux (GER) is one of the most common gastrointestinalcomplaints worldwide with more than 24,000 anti-reflux operations being performed annu-ally in the US. Approximately 10% of these patients require reoperation. The aim of thisstudy was to review the outcomes of patients undergoing laparoscopic redo fundoplication.METHODS: Retrospective review of patients undergoing laparoscopic redo fundoplicationfrom 1999 to 2011 by a single surgeon. RESULTS: 135 patients (70 men, mean age 42[range, 26-68] years) underwent laparoscopic redo fundoplication following a standardizedtechnique (figure). Operative indications included dysphagia (n=67, 50%), recurrent GER(n=62, 46%), and bubble syndrome (n=6, 4%). Median time to reintervention was 25months. Median operative time was 120 (range, 45-270) minutes, intraoperative complicationrate was 11%, and conversion rate was 4% (n=6). All patients underwent intraoperativeendoscopy. The most common cause of operative failure was proximal migration of thegastroesophageal junction and fundoplication (41.5%). 77% underwent a redo 360° fundopli-cation and 23% a 270° wrap. Median hospital stay was 3 (range, 2-8) days. At a medianfollow-up of 28 months, 6% of patients were receiving proton-pump inhibitors; and nodysphagia or symptoms of bubble syndrome or delayed gastric emptying were reported. Nocorrelation was found between preoperative symptoms and type of operative failure (table).CONCLUSIONS: Laparoscopic redo fundoplication is a feasible, safe, and effective treatmentfor persistent and recurrent symptoms after primary anti-reflux surgery. Following a standard-ized operative technique with intraoperative endoscopy, we have shown good results atlong-term follow-up.Essential Operative Steps

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GE: gastroesophageal; *according to the Horgan classification

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Endoscopic Suturing Versus Endoclip Closure of Mucosotomy in POEM: ACase-Control StudyRadu Pescarus, Maria A. Cassera, Eran Shlomovitz, Ahmed Sharata, Kevin M. Reavis,Christy M. Dunst, Lee L. Swanstrom

INTRODUCTION Per-oral endoscopic myotomy (POEM) is establishing itself as an elegantminimally invasive treatment of achalasia. One of the crucial steps of the procedure isobtaining adequate mucosal closure. Traditionally, endoclips have been used for a secureclosure but these can be difficult to apply in some situations. A recently described alternativeclosure is endoscopic suturing using proprietary devices. This abstracts illustrates our experi-ence with the OverStitch endoscopic suturing device during POEM cases. METHODS Endo-scopic suturing was used during 10 of the 105 POEM cases in our series (9.5%) for a varietyof indications. In order to evaluate the efficacy and cost of this new technology, a retrospectivecase-control study was performed. Of the 10 cases, 5 cases were eliminated for the followingreasons: in 2 cases the mucosotomy was closed with endoscopic suturing and clips, in 2cases a concomitant inadvertent mucosotomy was also sutured, and in 1 case the closuretime was not recorded. The 5 cases in which the mucosotomy was repaired with theOverStitch device were included in the study. These were matched to 5 cases in whichconventional closure of the mucosotomy was obtained with clips. The matching criteriaincluded: (1) patient age (±10 years), (2) surgery within 12 months, (3) achalasia Chicagotype, and (4) achalasia pre-operative stage. For the 5 POEM with endoscopic suturing closureand the 5 controls we collected demographic information, pre-operative achalasia type andstage, closure time, number of clips or sutures, short/long term complications, length ofstay (LOS), instrument-related and operating room (OR)-related costs. Independent samplet-test and chi square were performed when appropriate. RESULTS The OverStitch andcontrol group were not statistically different in terms of age (p=0.71), BMI (p=0.36), Eckardtscore (p=0.5), achalasia type (p=1.0), achalasia score (p=1.0) and LOS (p=0.21). The averagenumber of clips used was 5 (range 3-7) and the average number of figure-of-eight OverStitchsutures was 2 (range 1-3). No closure-related complications were recorded. The closuretime was significantly shorter with endoclips (16±12 min) than with OverStitch (33±11min) with a p=0.047. The total closure cost showed a trend towards lower cost with clips($1502±849) vs. OverStitch ($2521±575) with a p=0.057. CONCLUSION Adequate closureof POEM mucosotomy can be obtained both with conventional endoclips and OverStitch.Overall, closure time is shorter and instrument cost is lower with endoclip closure. A caveatis that suture closure in our series was mainly used for cases where clip closure was consideredto be difficult or not possible. Endoscopic suturing may therefore be best used for difficultmucosotomy closures or full-thickness perforations in which endoclip closure could bedifficult, impossible or more tenuous.