an aggressive tumor due to higher incidence of lymphovascular and serosal invasion whichare responsible for poor prognosis. Aggressive approach with radical surgical resection isrecommended in the absence of distant metastasis. Surgery followed by combined adjuvantchemoradiation is recommended despite the absence of adequate data to support this strategy.

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Laparoscopic Bariatric Surgery is Safe in Patients With Mild to ModeratePulmonary HypertensionHernan Urrego, William S. Richardson, James Wooldridge

Background: Pulmonary hypertension (PH) has significant perioperative risks that mayoutweigh the benefit of elective surgery. There is very little data on laprascopic surgery inthe setting of PH. Our objective was to look at our outcomes of bariatric surgery in patientswith PH. Methods: A retrospective review of a prospectively gathered database of all bariatricprocedures was conducted for patients treated from 2007-2011. All patients with PH whounderwent a bariatric procedure were reviewed for their preoperative evaluation, intra-operative monitoring and management, post-operative care, and clinic follow up. Results:809 bariatric procedures were performed from 2007-2011, 5 patients (0.6%), 3 males and2 females, had PH. 2 patients had Type 1 PH, 2 had Type III PH, and the final patient didnot have information on the etiology. The mean PAP of the 5 patients was 40 mmHG (range25-60). The mean age of the patients was 58 years of age, and the mean BMI was 52. 3laparoscopic Roux-N-Y, 1 laparoscopic sleeve gastrectomy, and 1 laparoscopic band wereperformed. Invasive monitoring, arterial line and/or pulmonary catheter, was used in 2patients with mean PAP ≥ 40. There were no intra-operative complications and only onepatient had a long term complication; band slipped and underwent removal. The meanlength of stay was 2 days and mean follow up was 8 months. Mean excess body weightloss (EBL) at 3 months was 29% (N=5), at 6 months was 42% (N=4), and at 1 year 35%(N=2). Over an average of 6 months, exercise tolerance in all 3 Roux-N-Y patients wasdoubled in terms of length of exercise time and distance walking, and remained the samein the other two. Postoperative pulmonary hypertension follow up with 2d echo was onlyperformed in one patient. A decrease of mean PAP from 39 to 26, 1 year after surgery,without concomitant change in medical therapy was demonstrated. Conclusions: Laparo-scopic surgery seems safe in patients with pulmonary hypertension without significantmorbidity, mortality or increased length of stay. Invasive monitoring in patients with meanPAP > 25mmHG<40mmHG may not be necessary. Exercise tolerance improves in mostpatients. EBL was modest but few patients had 1 year follow up. Further research is neededto determine long term weight loss, improvement in comorbidities and improvement in PH.

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Recurrence Pattern of Gastric Cancer After Curative GastrectomyWee Boon Tan

Radical surgery with D2 extended lymphadenectomy together with various regimens of peri-or post-operative adjuvant therapy have been shown to be effective for advanced gastriccancer. We aim to evaluate the outcomes of patients who underwent intended curativegastrectomy in our institution and our recurrence rate and pattern. All patients who under-went radical gastrectomy with curative intent were selected from a prospective gastric cancerdatabase at the National University Hospital, Singapore. Each patient was discussed at amultidisciplinary tumor meeting where decision on adjuvant therapy was made. Patientswere followed up at regular intervals. Postoperative complications and recurrence wererecorded. Survival and cause of death were confirmed with national registry. Between year2000-2010, 645 patients with gastric cancer were treated in our hospital. 274 patientsunderwent radical surgery with curative intent. The median age was 69 (range: 19-89) and67% are males. Most tumors were in antrum (53%) or body (28%) and proximal tumorswere found in 19% of patients. Subtotal and total gastrectomies were performed in 70%and 30% of patients respectively. R0 resection was achieved in 252 patients (92%). 195(71%)and 79(29%) patients underwent extended lymphadenectomy (D2 or D1+) or limited lymph-adenectomy (D1) respectively, according to Japanese Gastric Cancer Treatment Guideline2010. There were 7(2.5%) peri-operative deaths. Lymph nodeswere harvested by pathologistsand the median number was 25 for D2/D1+ (range: 15-64) and 18 (range: 3-25) for D1respectively. Pathological staging (American Joint Committee on Cancer [AJCC] 7th edition)was as follows: I, 24%; II, 22%; III, 43%; IV, 10%. Peri-operative chemotherapy, postoperativechemo-radiotherapy and postoperative chemotherapy were received by 23, 39 and 21 patientsrespectively. Median follow-up was 25 months. Tumor recurrence occurred in 31% of ourpatients and the sites of recurrence were: local (29%); lymph nodes (15%); peritoneum(23%); hematogenous (33%). The overall median survival and recurrence free survival are25 and 21 months respectively. Factors predictive of recurrence pattern will be analyzedand the results will be presented. Prognosis of gastric cancer remains poor despite earlierdetection and improvement in treatment modalities. Recurrence is the most important factorassociated with death after curative gastrectomy. Various disease and treatment factors mayhelp to predict the pattern of recurrence and thus provide a tailored treatment guide forour patients.

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Surgical Treatment of Gastrointestinal Stromal Tumors (GIST) of the Stomach- Data Analysis of the East German Gastric Cancer Study (“Eggc Study '02“)Meyer Frank, Karsten Ridwelski, Lutz Meyer, Uwe Schmidt, Henry Ptok, Hans Lippert,Ingo Gastinger

Background: Within the East German Gastric Cancer Study (“EGGC 02”), 1,199 gastrictumor lesions were documented. As a separate tumor entity, gastrointestinal stromal tumors(GIST, n=55) were compared with gastric adenocarcinomas. The evaluation aimed, in particu-lar, on early postoperative and oncosurgical outcome as a parameter for the quality of surgicalresults. In near future, data of a re-initiated, currently ongoing study over a 3-year timeperiod (n=approximately 300 patients) can be compared to elucidate what (neo-)adjuvant

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treatment can additionally achieve with regard to the oncosurgical outcome of gastric GISTpatients. Patients and methods: A systematic clinical multicentre observational study designwith prospective items in a well characterized area (East Germany) was used includinghospitals of each level of surgical care. Results: From January 01 to December 31, 2002,data of 1,199 patients with gastric tumor lesions from 80 hospitals were documented. Ninetyfive % of 1,139 gastric carcinomas were preoperatively diagnosed with histologic investigationwhereas this rate was 47.3 % in 55 GISTs. 61.8 % of the GIST patients were treated withlocal wedge resections or with a limited approach. The rate of radical surgical interventions(30 %; e.g., gastrectomy, multivisceral resection) was relatively high. The surgical resultsachieved by operation alone showing i) a hospital mortality of 1.8 %, and ii) a 5-year-survival rate of 78 % (follow-up investigation period, 67 months; including 90.9 % of allpatients) compared with gastric carcinoma (30.6 %, 70 months and 87.4 %, respectively)are acceptable. Discussion: Results achieved by surgical intervention alone as reported canserve as an appropriate basis for the initiation and comparison of multimodal therapeuticconcepts with the (neo-)adjuvant use of the tyrosin kinase inhibitor Imatinib according tothe currently relevant guidelines (as being expected soon by novel data on patients treatedsurgically including [neo-]adjuvant protocols). Related to the exclusively surgical aspects ofgastric GIST treatment, it appears to be indicated to achieve a reduction of the, in part,surgical overtreatment using such protocols including a significant improval of the preoperat-ive diagnostic rate in clarifying gastric GIST appropriately for an adequate therapeuticapproach.

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Management of Synchronous Primary Adenocarcinoma and Carcinoid Tumorof the StomachMaithao Le, Rebecca Nelson, Rebecca Wiatrek, Steven L. Chen, Joseph Kim

Introduction: Patients with gastric adenocarcinoma with concurrent primary gastric carcinoidare rarely observed. Since little is known about the course of synchronous disease, ourobjective was to compare the outcomes of patients with concurrent gastric adenocarcinomaand primary gastric carcinoid with patients harboring isolated gastric adenocarcinoma.Methods: Patients surgically treated for concurrent primary gastric adenocarcinoma andcarcinoid tumors from1973 to 2008 were identified from the Surveillance, Epidemiology,and End Results (SEER) database. These patients were case-matched 3:1 with isolated gastricadenocarcinoma patients for year of diagnosis, age, stage, type of surgery, and receipt ofradiation. Clinical and pathologic characteristics and survival were compared between thetwo cohorts. Results: Our investigation identified 32 patients treated for concurrent gastricadenocarcinoma and primary gastric carcinoid. During the same period, 84 932 cases ofisolated gastric adenocarcinoma were diagnosed. After case-matching, patient demographicsand tumor characteristics were similar, with the exception of gender, whereby synchronoustumor patients were more likely to be female (p=0.038). Kaplan-Meier curves were con-structed to compare survival between the 2 cohorts, but no difference in survival wasobserved (5-year survival, 60 vs 47 months, p=0.52). Univariate and multivariate analysisshowed that synchronous disease was not a predictor of poor outcome (p=NS). Conclusions:Development of synchronous gastric adenocarcinoma and carcinoid tumor is extremely rare.Nevertheless, our results indicate that patients with synchronous disease fare similarly topatients with isolated gastric adenocarcinoma. Therefore, our results suggest that the pro-gnosis of patients with synchronous disease is primarily driven by appropriate managementof gastric adenocarcinoma.

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Laparoscopic Resection of Gastric Gastrointestinal Stromal Tumours is Safeand EffectiveRabih Wassel, Yasser Abdulaal, Haythem Ali, Ashraf M. Rasheed

Minimal access surgical therapy is the emerging gold standard technique for treatment ofgastric gastrointestinal stromal tumours (GISTs). Despite the above there continue to belack of guidance or standardisation of the techniques. Objectives: To assess the safety,effectiveness and functional outcomes of a minimal access surgical strategy for gastric GISTs.Methods: Thirty eight symptomatic gastric GISTs diagnosed during the years 2006-2010satisfied the inclusion criteria for minimal access surgical resection. All procedures wereperformed according to an agreed surgical strategy based on the anatomical location of thegastric lesions. The size, site, histology, resection margin, complications, hospital stay,functional outcome, recurrence rate, survival and mutational analysis of the 38 consecutiveresections were maintained on a prospective computerised database. All entered data wasvalidated by the operating surgeon and the reporting pathologist. Results: Twenty ninepatients (76%) underwent a laparoscopic extra-gastric tangential resection while sevenpatients (18%) underwent a posterior trans-gastric resection, and two had a distal gastrectomy(5%). There were no conversions to open, no major intra-operative complications and noepisodes of tumour rupture. There were no major immediate or early complications ofsurgery. Complete resection (R0) was achieved in 100% of cases with a mean lesion size of44mm (range 20-90mm). There was no peri-operative (30 day or in-hospital) mortality andthe mean post-operative length of stay was 5.6 days. The median follow-up for the survivingpopulation (37/38 or 97.4%) is 24.5 months with a range of 4-77 months without anyreported dysphagia, reflux, dumping syndrome or any CT evidence of disease recurrence.25/26 (96.2%) of the low risk group remain alive with a median follow up of 24.5 months(range 4 -77 months). The 8 patients in the intermediate risk group remain alive (100%)with a median follow-up of 51 months (range 20-77 months) and the 4 high risk grouppatients remain alive (100%) with a median follow-up of 15 months (range 8-24 months).The only death in this series occurred in the low risk group at 11 months secondary to adissecting thoracic aneurysm. Conclusion: Most gastric GISTs are resected by simple tangen-tial excision. Lesions close to gastro-oesophageal junction are best suited for laparoscopicintra-gastric excision to ensure complete resection while maintaining oesophageal patencyand sphincteric competency. Juxta-pyloric endophytic lesions are best treated via an anteriorgastrotomy or by extra-gastric tangential excision if exophytic. This anatomic and function-based strategy for minimal access surgical resection of gastric GISTs conserve the organ and

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