ISUCRS XXII Biennial Congress - International Society of University

Transcription

XXII BIENNIAL CONGRESS
OF
THE INTERNATIONAL SOCIETY OF
UNIVERSITY COLON & RECTAL SURGEONS
CONGRESS PROGRAM
September 13 - 17, 2008
Manchester Grand Hyatt
San Diego, California
United States
The International Society of University Colon & Rectal Surgeons (ISUCRS)
11300 W. Olympic Blvd., Suite 600
Los Angeles, CA 90064
USA
Phone: +1-310-909-0107
Fax: +1-310-437-0585
www.isucrs.org
Table Of C o n t e n t s
4 General Information
5 CME Worksheet
6 About ISUCRS
7 Manchester Grand Hyatt Floorplan
8 ISUCRS Leadership
8 Congress Convener, Elliot Prager, MD
10 Congress Leadership
11Director General, Indru T. Khubchandani, MD
12President, Robert W. Beart, MD
11 Keynote Orators
11Khubchandani Orator, Marvin L. Corman, MD
12Harry E. Bacon Orator, Ed Schneider, MD
12Fidel Ruiz-Moreno Orator, Daniel Azoulay, MD, PhD
13 Scientific Program
28 Faculty List
29 Faculty & Presenter Disclosures
31 Exhibit Hall Floorplan
32 Exhibitor Profiles
35 Abstract Book
35Podium Papers
66Video Papers
67Poster Papers
THANK YOU TO OUR CORPORATE SUPPORTERS!
Platinum Level Donors
OLYMPUS AMERICA, INC.
USC Department of Colorectal Surgery
Silver Level Donor
CENTOCOR
ETHICON ENDO-SURGERY, INC.
Bronze Level Donors
COVIDIEN
GYRUS ACMI, INC.
RICHARD WOLF MEDICAL INSTRUMENTS Additional Donors
BACON FOUNDATION
POWER MEDICAL INTERVENTIONS
SURGRX, INC.
GlaxoSmithKline/Adolor
KARL STORZ ENDOSCOPY
www.isucrs.org/
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Gener a l I n f o r m a t ion
XXII Biennial Congress of the International Society of University Colon & Rectal Surgeons
September 13 - 17, 2008, Manchester Grand Hyatt, One Market Place, San Diego, CA 92101, USA
On-site Registration Hours (Manchester Foyer)
Saturday, September 13, 2008 Sunday, September 14, 2008 Monday, September 15, 2008 Tuesday, September 16, 2008 Wednesday, September 17, 2008 11:00 - 17:00
06:30 - 17:30
06:30 - 12:30
06:30 - 17:30
07:00 - 11:30
Exhibit Hall Hours (Manchester G-I, 2nd Floor)
Sunday, September 14, 2008
Exhibit Hall Open
11:30 - 16:00
Monday, September 15, 2008
Exhibit Hall Open
Breakfast in Exhibit Hall Morning Break in Exhibit Hall Evening Reception 07:00 - 13:00
07:00 - 08:00
10:30 - 11:00
17:30 - 18:30
Tuesday, September 16, 2008
Exhibit Hall Open
Morning Break in Exhibit Hall Coffee and Dessert in Exhibit Hall Afternoon Break in Exhibit Hall 10:00 - 16:15
10:30 - 11:00
13:30 - 14:00
15:30 - 16:00 Speaker Ready Room Hours (Manchester F, 2nd Floor)
Saturday, September 13, 2008 11:00 - 17:00
Sunday, September 14, 2008 06:30 - 17:30
Monday, September 15, 2008 06:30 - 12:30
Tuesday, September 16, 2008 06:30 - 17:30
Wednesday, September 17, 2008 07:00 - 11:30
Official Language
The official language of the conference is English. Simultaneous translation will not be offered.
Educational Objectives
This congress is designed to provide surgeons with in-depth and up-to-date knowledge
relative to surgery of the colon, rectum and anus, with special emphasis on worldwide
exchange of knowledge and techniques related to patient care, teaching and research. Presentation formats include formal papers, panel discussions, poster sessions and an
audio-visual program. The purpose of all sessions is to enhance individual knowledge in
order to improve the quality of care of patients with diseases of colon, rectum and anus. At the conclusion of this event, participants will be able to:
• Discuss the newest diagnostic and therapeutic alternatives in the management of rectal cancer.
• Understand the current standards of medical and surgical management of inflammatory bowel
disease.
• Prioritize the evolving alternatives in the use of minimally invasive techniques to manage
benign and malignant disease.
• Identify 5 new useful technologies for the management of colorectal diseases.
• Integrate into ones clinical practice new therapeutic options for the management of anorectal
fistula disease.
Accreditation Statement
4
This activity has been planned and implemented in accordance with the Essentials and Standards
of the Accreditation Council for Continuing Medical Education through the joint sponsorship of
the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). SAGES is accredited
by the ACCME to provide continuing medical education for physicians. SAGES designates this
Continuing Medical Education activity for 26 AMA PRA Category 1 Credit(s)™. Physicians
should only claim credit commensurate with the extent of their participation in the activity.
ISUCRS XXII BIENNIAL CONGRESS
I SUCR S C M E Wo r k s he e t
Fill in the number of hours you attended each activity in the chart below to track your CME credits.
CME WORKSHEET FOR ISUCRS XXII BIENNIAL CONGRESS:
This is not your CME credit form. Please use the worksheet below to track the number of CME
hours you attend for each activity. Your CME credit form can be found inside your registrant bag.
TO RECEIVE YOUR CME CREDIT:
Turn in your CME form at registration to have your CME certificated mailed
to you after the meeting. Please allow 4 - 6 weeks for processing.
SATURDAY, SEPTEMBER 13, 2008
Activity
Postgraduate Course: Metastatic Disease – When to Intervene and Who to Call?
Total Credits Available for Saturday, September 13, 2008:
Credits Available
4.0
4.0
Hours Attended
Credits Available
1.5
0.5
1.5
2.0
1.5
7.0
Hours Attended
Credits Available
1.0
1.5
0.5
1.5
3.5
Hours Attended
Credits Available
1.0
1.5
0.5
1.0
0.5
1.5
1.5
7.5
Hours Attended
Credits Available
1.5
1.5
3.0
26
Hours Attended
SUNDAY, SEPTEMBER 14, 2008
Activity
Challenges in Rectal Cancer Management
Khubchandani Oration: “The Surgeon and the Daughters of Mnenosyne and Zeus”
Free Paper Sessions (10:30 - 12:00)
The Illeal Pouch – Thirty Years On
Total Credits Available for Sunday, September 14, 2008:
MONDAY, SEPTEMBER 15, 2008
Activity
Controversies in Laparoscopic Colon and Rectal Surgery
Harry E. Bacon Oration: “Nutrition for the Ages”
Innovative Technologies
Total Credits Available for Monday, September 15, 2008:
TUESDAY, SEPTEMBER 16, 2008
Activity
Mixed Plenary Scientific Session
Fidel Ruiz-Moreno Oration: “Liver Resection for Colorectal Metastasis: Latest Progress”
Plenary Scientific Session: Best Papers
ISUCRS Presidential Address: “Pushing the Rock Uphill – A 30 Year Perspective”
Total Credits Available for Tuesday, September 16, 2008:
WEDNESDAY, SEPTEMBER 17, 2008
Activity
Anorectal Disease
Total Credits Available for Wednesday, September 17, 2008:
TOTAL CREDITS
www.isucrs.org/
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About The Internat i o n a l S o c i e t y O f
Un iv ersity Colon & Rect al Sur geons
The Society was founded in Mexico City, Mexico on November 24, 1962. Founding
members were Harry E. Bacon, MD, Stuart E. Ross, MD and Fidel Ruiz-Moreno, MD.
Mission Statement
The purpose of the Society is to contribute to the progress of Colon and Anorectal Surgery, and to
hold congresses and meetings throughout the world in order to interchange scientific knowledge.
Why Join ISUCRS?
• Networking with world-renowned colon and rectal colleagues.
• Free access to the World Journal of Colon and Rectal Surgery, ISUCRS’ official on-line, open
access journal. The unique format allows rapid publication of articles of any length, with color
pictures and even video clips. The journal will enable members to keep abreast of all pertinent
topics with a just a click of a button.
• Reduced registration fees for ISUCRS’ biennial congress.
• Quarterly newsletter with updates about the society and colon and rectal surgery activities.
Stop by the ISUCRS Membership booth or visit www.isucrs.org to apply today!
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ISUCRS BIENNIAL CONGRESS HISTORY
YEAR
VENUE
1966
Tokyo
Tadashi Kodaira
1968
Rome
Paride Stefanini
1970
São Paulo
Paulo Daher Cutait
1972
Rhodes
Nicolas Georgiadis
1974
New Orleans
Patrick H. Hanley
1976
Salzburg
Alfred Zangl
1978 Kyoto Dennosuke Jinnai
1980
Melbourne
Peter Ryan
1982
Munich
Franz P. Gall
1984
Strasbourg
Louis F. Hollender
1986
Dallas
Gray H. Carter
1988
Glasgow
Hugh B. Crum
1990
Graz
Leo Kronberger
1992
Crete
Sofoklis Mavrantonis
1994
Singapore
Hak-Su Goh/S-S Ngoi
1996
Lisbon
Antonio M. De Almeida
1998
Malmö
Goran R. Edelund
2000 São Paulo
Jose Alfredo Reis-Neto
2002
Osaka
Katsuhise Shindo
2004
Budapest
Adam Balogh
2006
Istanbul
Kemal Alemdaro lu
CONGRESS CONVENOR
Manchester Grand Hyatt Floorplan
www.isucrs.org/
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IS UCR S L e a d e r sh ip
Executive Board
President: Robert W. Beart, MD
Director General: Indru T. Khubchandani, MD
President-Elect: Angelita Habr Gama, MD
Past President: Ahmed Shafik, MD
Vice-President: Jae-Ghab Park, MD
Secretary General: Philip F. Caushaj, MD
Secretary of Treasury: Bruno Roche, MD
Director of International Advisory Affairs: Zoran Krivokapic, MD
Associate Director General: Donato F. Altomare, MD
Associate Secretary General: Johann Pfeifer, MD
Associate Treasurer: Bruce P. Waxman, MD
Associate Director of International Advisory Affairs: Narimantas E. Samalavicius, MD, PhD
Member-at-Large: Kenichi Sugihara, MD
Member-at-Large: Roberto Bergamaschi, MD
Member-at-Large: Adam Dziki, MD
Member-at-Large: P. Ronan O’Connell, MD
Regional Vice-Presidents
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Africa/Middle East: Paul Goldberg, MD
Central Europe: Bela Lestar, MD
Central North America: Leela M. Prasad, MD
China: Shu Zheng, MD
Eastern Asia: Fumio Konishi, MD
Eastern Europe: Dainius Pavalkis, MD
Egypt: Ali M. Shafik, MD
Korea: Seung Kook Sohn, MD
Mexico Central America: Fidel Ruiz-Healy, MD
Middle East: Dursun Bugra, MD
New Zealand: Mark W. Thompson-Fawcett, MD
North Midwest: Anthony Senagore, MD
Northern South America: Jose Alfredo Reis Neto, MD
Northern South America & Caribbean: Ricardo Escalante, MD
Northeastern North America: Jeff Milsom, MD
Northwestern North America: Anders Mellgren, MD
Russia: Gennady Vorobyov, MD
Singapore: Francis Seow Choen, MD
South Midwest: Freza Ramzi, MD
Southern Europe: Ezio Olof Ganio, MD
Southern South America: Mario Salomon, MD
Southern North America: Sergio Larach, MD
Southwestern North America: Clifford Simmang, MD
Spain: J. Manuel Devesa, MD
United Kingdom: David Bartolo, MD
Taiwan: Tzu-Chi Hsu, MD
Western Asia (India): Parvez Sheikh, MD
Western Europe (France): Jean-Pierre Arnaud, MD
Western Europe (Scandinavia): Per-Olof Nystrom, MD
Western North America: Michael Stamos, MD
Regional Secretaries
Australia/New Zealand: Frank Frizelle, MD
Central Europe: Istvan Zollei, MD, PhD
Eastern Asia: Koutarou Maeda, MD
Indonesia: Hermansyur Kartowisastro, MD
Northeastern North America: Linda Lapos, MD
Northern Europe: Thomas Oresland, MD
Northern South America: Flavio Quilici, MD
Russia: Yuri A. Shelygin, MD
Southern Europe & Mediterranean: Donato F. Altomare, MD
Southern South America: Hector Baistrocchi, MD
Western Asia: Vithya Vathanophas, MD
2008 Program Committee
Chair Indru T. Khubchandani, MD
Congress Convenor Elliot Prager, MD
Adam Balogh, MD
Robert W. Beart, MD
Roberto Bergamaschi, MD
Philip F. Caushaj, MD
James Celebrezze, MD
Bruno Cola, MD
Helio Moreira, MD
Jose Paulo Moreira, MD
Tetsuichiro Muto, MD
Jae-Ghab Park, MD
Sonia Ramamoorthy, MD
Fidel Ruiz-Healy, MD
Katsuhisa Shindo, MD
Rune Sjodahl, MD
Steven D. Wexner, MD
Shu Zheng, MD
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Cong r e ss L e a d e r s h ip
Robert W. Beart, MD, ISUCRS President
Dr. Robert Beart was born in Kansas City Missouri, raised in Chicago, had his undergraduate
education at Princeton University where he graduated with honors, and graduated from
Harvard Medical School having won the Alumni Award in 1971. He did his general surgical
training at the University of Colorado and completed a transplantation fellowship in kidney
and liver transplantation in 1976. He moved to the Mayo Clinic where he joined the staff and
subsequently decided to take another fellowship in Colorectal Surgery. He was Chairman
of the Department of Colorectal Surgery at the Mayo Clinic in Rochester, Minnesota from
1978 to 1986 when he moved to Scottsdale, Arizona and became the Chairman of the
Department of Surgery of Mayo Clinic in Scottsdale. In 1992 he joined the faculty at the
University of Southern California as a tenured Professor of Surgery. He is currently Chairman
of the Department of Colorectal Rectal Surgery at the University of Southern California,
the first Colorectal Surgery Department in an academic institution in the United States.
Dr. Beart has published over four hundred and twenty (420) publications and has been
Chairman of the Commission of Cancer of the American College of Surgeons and President
of the major colorectal surgical societies in the United States including the American
Society of Colon and Rectal Surgeons, the Society for Surgery for Alimentary Tract and
the International Society for University Colorectal Surgeons. His research interests include
laparoscopic colon resections, continence preservation, the use of gene therapy in the
management of recurrent colon cancer, and the treatment of recurrent rectal cancer.
He is married to Cindy, they live in Pasadena and have 3 married daughters
and 3 grandchildren. Together they enjoy biking, skiing and hiking.
Indru T. Khubchandani, MD, ISUCRS Director General
10
Indru T. Khubchandani, MD was educated at St. Xavier’s & Jai Hind and Grant
Medical College in Bombay, India. He came to the United States and was
trained at Temple University Medical Center under Harry E. Bacon, MD.
In addition to his busy Practice as a Colon and Rectal Surgeon, Dr. Indru T. Khubchandani
is a Professor of Surgery at Pennsylvania State University/Hershey Medical Center
and at Hahnemann Medical School/Drexel University, Philadelphia, PA.
Dr. Khubchandani has been a Past President of the Pennsylvania Society of Colon and
Rectal Surgeons, NorthEast Society of Colon and Rectal Surgeons, and Indian Association
of Colon and Rectal Surgeons. He has been an examiner for the American Board of Colon
and Rectal Surgeons and on the Editorial Board of various journals, including American,
Italian, Brazilian, and Indian, and he is a Referree for the British Journal of Surgery.
He serves as Director General of the International Society University of Colon and Rectal
Surgeons (1980-present). Recognized as a renowned expert in his Specialty, Dr. Khubchandani
is an honorary member of eight international societies, including Brazilian Society of
Coloproctology, Chilean Society of Colon and Rectal surgeons, Venezuelan Society of
Colon and Rectal Surgeons, International Gastroenterology Society of Egypt, Galactia
Society of Gastroenterology of Spain, Brazilian Society of Colon and Rectal Surgery, La
Sociedad Cubana de Coloproctogia, University of Belgrade School of Medicine, Belgrade,
Yugoslavia, and University of Guadalajara, Jalisco, Mexico. He has served as President
of the Medical Staff at Lehigh Valley Hospital and has been a member of the Board of
Trustees for sixteen years. He is also a past President of Lehigh County Medical Society.
To date, Dr. Khubchandani has written 107 articles for peer review journals
and seventeen textbook chapters. Locally, nationally, and internationally, Dr.
Khubchandani has made over 560 presentations as a Visiting Professor.
Dr. Khubchandani is active in teaching at Hershey Medical School where, in
2005, Penn State University endowed a Khubchandani Chair in Colon and Rectal
Surgery for teaching and research at Lehigh Valley Hospital. He has been awarded
several Teacher of the Year citations. He is also included, by invitation, in Who’s
Who in America, Who’s Who in the World, and Who’s Who in Medicine.
C o ngress L e a d e r sh i p
Elliot Prager, MD, Congress Convenor
Dr. Elliot Prager was educated at Dartmouth College and Harvard Medical School and trained in
General Surgery at Roosevelt Hospital and in Colon and Rectal Surgery at the Lahey Clinic. He
was Chief of Surgery at the Sansum Clinic in Santa Barbara till his retirement in 2001. During that
time he was Director of the Colo-Rectal Fellowship for 15 years as well as Director of the General
Surgery Residency Program at Cottage Hospital for two years. He served as member and Chair of
the Residency Review Committee for Colon and Rectal Surgery, gave Boards in Colon and Rectal
Surgery for many years, and is a Past Vice-President of the American Society of Colon and Rectal
Surgery. Dr. Prager continues to be active in surgical education at USC and at Cottage Hospital.
K eynote O r a t o r s
Marvin L. Corman, MD
Khubchandani Orator
Marvin Corman is Professor of Surgery in the Division of Surgical Oncology at Stony
Brook University. He is also Adjunct Professor at Albert Einstein College of Medicine
and former Professor of Surgery at UCLA and the University of Southern California.
Dr. Corman is Board certified in Colon and Rectal Surgery and in General Surgery. He
received his undergraduate and medical degrees from the University of Pennsylvania
and completed his residency training in general surgery at the Boston City Hospital
(Harvard Surgical Service) and spent a year as Senior Registrar and Visiting Lecturer
at the University of Leeds and the General Infirmary in Leeds, England.
Dr. Corman has been the recipient of a numerous honors and awards, including the O. H. Perry
Pepper Prize from the University of Pennsylvania and the Hoffman-LaRoche Award. He won
First Prize from the Medical Writers Association for his textbook, Colon and Rectal Surgery
(1985); the book is now in its fifth edition and has been established for 20 years as “the gold
standard in its discipline” (JAMA). Moreover, he is the recipient of the John C. Goligher
Memorial Medal of the Association of Coloproctology, Great Britain and Ireland, and the Section
of Coloproctology of the Royal Society of Medicine (1999). He was the Testimonial Honoree at
the 25th Annual Awards Ceremony of the Crohn’s and Colitis Foundation of America (2000).
He has often been a named lecturer or visiting professor all over the world and is an honorary
member of the Royal College of Surgeons, the Royal Australasian College of Surgeons, the
Argentine Society of Coloproctology, and the Mexican Society of Colon and Rectal Surgeons.
Dr. Corman is a member of numerous surgical organizations and has served in important
offices and committees within these organizations. A few of these include Fellowship in the
American College of Surgeons, American Society of Colon and Rectal Surgeons, the Society
for Surgery of the Alimentary Tract, the American Surgical Association, and numerous other
national and international societies. He has served as President of the American Board of
Colon and Rectal Surgery and President of the Residency Review Committee for Colon and
Rectal Surgery. He has been Vice-President of the American Society of Colon and Rectal
Surgeons and is Regional Vice-President of the International Society of University Colon
and Rectal Surgeons. He is a member of the American College of Medical Quality.
Dr. Corman is internationally known for his work in colon and rectal surgery. He is
the author of numerous journal articles, book chapters, scientific exhibits and video
presentations. He is a consultant to a number of pharmaceutical and device manufacturers
and has completed many clinical trials on the applications of these products to the
field of colon and rectal surgery. Dr. Corman’s practice at Stony Brook focuses on the
management of diseases of the small bowel, colon, rectum and anus, including colon,
rectal and anal cancer, diverticulitis, familial polyposis, ulcerative colitis, Crohn’s Disease,
reconstructive anorectal surgery, and the management of rectal incontinence, including
the Secca procedure, Acticon Artificial Anal Sphincter and muscle transposition.
www.isucrs.org/
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Keyno t e O r a t o r s
Edward Schneider, MD
Harry E. Bacon Orator
Edward Schneider, M.D. is Dean Emeritus of the Leonard Davis School of Gerontology at the
University of Southern California, the nation’s only School of Gerontology. Before joining USC
in 1986, Dr. Schneider was the Deputy Director of the National Institute on Aging and the Chief
of the Laboratory of Molecular Genetics, Gerontology Research Center, National Institute on
Aging. He served as Dean of the Leonard Daivs School of Gerontology and Executive Director
of the Ethel Percy Andrus Gerontology Center for almost 18 years from 1986 to 2004.
A respected leader in the field of gerontology for more than three decades, he has published
over 180 research articles and edited 12 books. He is also the co-author of AgeLess: Take
Control of Your Age and Stay Youthful for Life as well as What Your Doctor Hasn’t Told You and
Health Store Clerk Doesn’t Know: The Truth About Alternative Medicines and What Works.
Dr. Schneider currently serves on the Leadership Council of Los Angeles County Aging
Organizations (LAOAC), the board of scientific directors for The American Federation for Aging
Research (AFAR), and the advisory board for The Center for Health Aging. He has also been
on the editorial boards of more than half a dozen journals and was the first recipient of the
William and Sylvia Kugel Chair of Gerontology at the University of Southern California.
Dr. Schneider received his undergraduate degree from Rensselaer Polytechnic
Institute and graduated cum laude from the Boston University School of Medicine,
from which he received the Distinguished Alumnus Award in May of 1990.
Dr. Schneider is a sought-after lecturer and has been interviewed by numerous media
outlets, previously appearing on Good Morning America, CNN, CBS, NBC and BBC, and in
print stories by Forbes, Newsweek, The New York Times, and The Wall Street Journal.
Daniel Azoulay, MD, PhD
Fidel Ruiz-Moreno Orator
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Daniel Azoulay, MD, PhD is a Professor of Surgery at the Paul Brousse Hospital in Paris,
France. Dr. Azoulay received his doctorate from the Paris Hospitals and was educated at
the University Hospital of Besançon. His surgical internships at various Parisian hospitals
specialized in hepato-biliary surgery and liver transplantation. In addition to his current
professorship, Dr. Azoulay has been a full-time Senior Surgeon for the past 14 years at the
Hepato-Biliary Center, directed By Henri Bismuth. Dr. Azoulay has published over 150 articles
and is a member of several surgical societies including the French Association for the Study
of the Liver, the French Society of Intensive Care and the European Surgical Association.
SCIENTIFIC PROGRAM
SATURDAY, SEPTEMBER 13, 2008
SATURDAY-AT-A-GLANCE
TIME
EVENT
LOCATION
08:00 - 16:00
UCSD HANDS-ON COURSE: ROBOTIC
COURSE IN COLORECTAL SURGERY
OFFISITE UCSD LAB
13:00 - 17:00
POSTGRADUATE COURSE: METASTATIC DISEASE–
WHEN TO INTERVENE AND WHO TO CALL?
MANCHESTER C
13:00 - 17:00 Postgraduate Course: Metastatic Disease –
When To Intervene And Who To Call?
Course Chair: Fumio Konishi, MD
Course Moderator: Michael J. Stamos, MD
Course Description:
In patients with stage 4 colorectal cancer, treatment of any present metastatic disease represents
the only chance of potential cure. Appropriate patient selection and appropriate timing have
always been important factors to determine. Newer tools, particularly new imaging modalities
have apparently improved the outcome of many patients, primarily due to better patient
selection. More recently, improvements in our adjuvant therapy armamentarium have also
opened up the possibility and hope for patients previously deemed incurable. This symposium
will help synthesize these issues and others important in the care of the stage 4 colorectal cancer
patient, and help understand the possibilities offered by multidisciplinary interventions.
Course Objectives:
At the conclusion of this course, participants will be able to:
MANCHESTER A-B
• Understand currently accepted criteria for defining resectability of liver metastases
• Understand the impact and importance of extra hepatic metastases in the treatment algorithm
of patients
• Understand the role of oophorectomy and resection of peritoneal implants
• Identify patients with presently unresectable liver metastases that could be downsized and
made resectable through appropriate treatment and understand these treatment options
Follow-up After Apparently Successful Colorectal Cancer Surgery.
What Is Appropriate? Robert W. Beart, MD
The CEA Level Is Rising. What Do I Do Now? Zuri Murrell, MD
A CT Scan Shows a Solitary Liver Met. What Do I Do Now? Bruno Cola, MD
Isolated Ovarian Metastasis: Current Management Strategy and Should We Be Considering Prophylactic Oophorectomy Routinely? B
ruce P. Waxman, MD
Peritoneal Metastases: Current Management Strategy
and Should We BeConsidering Debulking/ Peritonectomy/
Intraperitoneal Chemotherapy? Andrew M. Lowy, MD
Multi-Site Recurrent Disease: Is an Aggressive Approach
Warranted? If So, When? Isolated or Dominant Liver Metastases:
Current Therapeutic Options
Raul Cutait, MD
Daniel Azoulay, MD, PhD
Isolated But Extensive Liver Metastases: Is Down Staging and
Cure Possible? What Is The Data? ISUCRS ACKNOWLEDGES AN UNRESTRICTED EDUCATIONAL GRANT IN
SUPPORT OF THIS COURSE FROM ETHICON ENDO-SURGERY, INC.
www.isucrs.org/
David Imagawa, MD
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SCIENTIFIC PROGRAM
SUNDAY-AT-A-GLANCE
TIME
EVENT
LOCATION
07:15
CONTINENTAL BREAKFAST
MANCHESTER FOYER
07:45 - 08:00
WELCOME & INTRODUCTION
MANCHESTER A-B
08:00 - 09:30
CHALLENGES IN RECTAL CANCER MANAGEMENT
MANCHESTER A-B
09:30 - 10:00
KHUBCHANDANI ORATION: “THE SURGEON AND
THE DAUGHTERS OF MNENOSYNE AND ZEUS”
MANCHESTER A-B
10:00 - 10:30
MORNING BREAK
MANCHESTER FOYER
10:30 - 12:00
FREE PAPERS: COLORECTAL CANCER AND RESEARCH I
MANCHESTER A-B
FREE PAPERS: COLORECTAL CANCER AND RESEARCH II
MANCHESTER C
11:30 - 16:00
EXHIBIT HALL & POSTER VIEWING
MANCHESTER D-I
12:00 - 13:00
LUNCH ON YOUR OWN
13:00 - 15:00
FREE PAPERS: COLORECTAL CANCER, BENIGN
COLORECTAL DISEASE & FECAL INCONTINENCE
MANCHESTER A-B
FREE PAPERS: COLORECTAL CANCER,
INFECTIONS AND STOMAS
MANCHESTER C
15:00 - 15:45
AFTERNOON BREAK
MANCHESTER D-I
15:45 - 17:15
THE ILEAL POUCH - THIRTY YEARS ON
MANCHESTER A-B
17:30 - 19:30
WELCOME RECEPTION
HYATT POOL
4TH LEVEL
07:45 - 08:00
08:00 - 09:30
Welcome & Introduction
MANCHESTER A-B
Challenges in Rectal Cancer Management MANCHESTER A-B
Panel Chair: Helio Moreira, MD
Panel Moderator: Angelita Habr-Gama, MD
Panel Description:
This panel will deal with some yet controversial aspects of rectal cancer management.
Is already laparoscopic surgery for rectal cancer been proved to offer similar results as
conventional surgery? Is it ready for prime time? Up-to-date local excision indication for
rectal cancer surgery and also TME in the era of neoadjuvant chemoradiation therapy and the
current status of radical lymph node resection. Care and tips for achieving better functional
results after rectal cancer operation and finally, the rationale of assuming non-operative
management for distal rectal cancer after neoadjuvant chemoradiation will be present.
Panel Objectives:
At the conclusion of this panel, participants will be able to:
• List the biggest challenges in rectal cancer management
• List the experts’ recommendations while facing these challenges
14
ISUCRS XXII BIENNIAL CONGRESS SCIENTIFIC PROGRAM
HPV in Anal Epidermoid CA Jae-Gahb Park, MD
Laparoscopic Surgery for Rectal Cancer Roberto Bergamaschi, MD
Current Status of Radical Lymph Node Dissection Local Excision Of Rectal Cancer
Tetsuichiro Muto, MD
Seung Kook Sohn, MD
The Role of Non-Operative Management for Distal
Rectal Cancer After Neoadjuvant Chemoradiation Angelita Habr-Gama, MD
ISUCRS ACKNOWLEDGES AN UNRESTRICTED EDUCATIONAL GRANT FROM
ETHICON ENDO-SURGERY, INC.
09:30 - 10:00
Khubchandani Oration: “The Surgeon And The Daughters Of Mnenosyne And Zeus”
Marvin L. Corman, MD, Stony Brook University, Stony Brook, NY, USA
Chairman: Tetsuichiro Muto, MD
Introduction by Elliot Prager, MD
10:00 - 10:30 Morning Break
10:30 - 12:00
FREE PAPERS
www.isucrs.org/
MANCHESTER A-B
MANCHESTER FOYER
COLORECTAL CANCER AND RESEARCH I
COLORECTAL CANCER AND RESEARCH II
MANCHESTER A-B
MANCHESTER C
Chairperson: J. Manuel Devesa, MD
Moderator: P. Ronan O’Connell, MD
Chairperson: Shu Zheng, MD
Moderator: Sonia Ramoorthy, MD
S001 OBJECTIVE CRITERIA FOR GRADE 3 IN EARLY INVASIVE
COLORECTAL CANCER, Hideki Ueno PhD, Yojiro Hashiguchi PhD,
Yoshiki Kajiwara MD, Kazuo Hase PhD, Hidetaka Mochizuki PhD,
National Defense Medical College
S002 PROGNOSTIC VALUE OF PERITONEAL CYTOLOGY AND
PERITONEAL DISSEMINATION IN COLORECTAL CARCINOMA,
Takeshi Nishikawa MD, Toshiaki Watanabe PhD, Eiji Sunami
PhD, Hirokazu Nagawa PhD, Department of Surgical Oncology,
the University of Tokyo
S003 WITHDRAWN
S004 RISK FACTORS OF THE NODAL INVOLVEMENT IN T2
COLORECTAL CANCER, Yoshiki Kajiwara MD, Hideki Ueno PhD,
Masayoshi Miyoshi PhD, Yojiro Hashiguchi PhD, Kazuo Hase
PhD, Hidetaka Mochizuki PhD, Department of Surgery, National
Defense Medical College
S005 DIRECT HERPES SIMPLEX VIRUS 1 (HSV-1) DELIVERY
INTO RECTAL ADENOCARCINOMA IN MICE RESULTS IN AN
EFFICIENT ANTI-TUMOR EFFECT, Yair Edden MD, D Kolodkin-Gal
PhD, G Zamir MD, E Pikarsky MD, A Panet PhD, A J Pikarsky MD,
Hadassah Hebrew University Medical Center, Hebrew University
- Hadassah Medical School, Jerusalem, Israel
S006 FACTORS PREDICTIVE OF LONG TERM FAILURE OF
ARTIFICIAL BOWEL SPHINCTER. , H Ying Jin MD, V Ka Ming
Li MD, Nestor Pulido MD, Benjamin Person MD, H Wang MD,
D Sands MD, E Weiss MD, J Nogueras MD, S Wexner MD,
Cleveland Clinic Florida
S007 MICROMETASTASES IN BONE MARROW OF COLORECTAL
CANCER PATIENTS: NO EVIDENCE OF MALIGNANCY, D F
Altomare MD, G Guanti MD, J Hoch MD, M Vician MD, Z
Krivokapic MD, R Bergamaschi MD, Forde Health System, Forde,
Norway; Bari University, Bari, Italy
S008 EARLY ARTIFICIAL BOWEL SPHINCTER INFECTION: CAN IT
BE AVOIDED? A MULTIVARIATE ANALYSIS. , H Yin Jin MD, V Ka
Ming Li MD, N Pullido MD, B Person MD, H Wang MD, D Sands
MD, E Weiss MD, J Nogueras MD, S Wexner MD, Cleveland
Clinic Florida
S009 EFFECT OF COMPLETE REGRESSION AS A PROGNOSTIC
FACTOR AFTER NEOADJUVANT CHEMORADIATION THERAPY
IN LOCALLY ADVANCED RECTAL CANCER, Jonghyeon Park MD,
Jiyeon Kim PhD, Department of Surgery, Chungnam National
University Hospital, Daejon, Korea
S010 FACTORS AFFECTING THE PROGNOSIS OF PATIENTS
WHO UNDERWENT RESECTION OF PULMONARY METASTASES
FROM COLORECTAL CANCER, Keiichiro Ishibashi PhD, Masaru
Yokoyama PhD, Kouki Kuwabara MD, Masatsugu Ishii MD, Toru
Ishiguro MD, Tomonori Ohsawa MD, Norimichi Okada PhD,
Moriyuki Matsuki PhD, Hideyuki Ishida PhD, Department of
Digestive Tract and General Surgery, Saitama Medical Center,
Saitama Medical University
S011 EGFR EXPRESSION IN COLORECTAL CANCER, Ji-Hoon Kim
MD, Jae-Im Lee MD, Hyung-Jin Kim MD, Won-Kyung Kang MD,
Seong-Taek Oh MD, Yoon-Suk Lee MD, Sang-Chul Lee MD, JongKyung Park MD, Department of Surgery, The Catholic University
of Korea
S012 ONCOLOGICAL OUTCOMES OF CURATIVE COLECTOMY VIA
MINILAPAROTOMY FOR STAGE I, II AND III COLON CANCER,
Keiichiro Ishibashi PhD, Masaru Yokoyama PhD, Kouki Kuwabara
MD, Masatsugu Ishii MD, Toru Ishiguro MD, Tomonori Ohsawa
MD, Norimichi Okada MD, Tatsuya Miyazalki PhD, Moriyuki
Matsuki PhD, Hideyuki Ishida PhD, Department of Digestive Tract
and General Surgery, Saitama medical Center, Saitama Medical
University
S013 ELECTROPHYSIOLOGIC CHARACTERISTICS OF HUMAN
COLONIC SMOOTH MUSCLE, KJ Park PhD, EK Choe MD, JS
Moon, Seoul National University College of Medicine, Seoul,
South Korea
S014 MOTILITY PATTERNS IN SHORT SEGMENT OF HUMAN
COLONIC TISSUE, EK Choe MD, KJ Park PhD, JS Moon, Seoul
National University College of Medicine, Seoul, South Korea
S015 IDENTIFICATION OF MITOCHONDRIAL F1F0-ATP SYNTHASE
INVOLVED IN LIVER METASTASIS OF COLORECTAL CANCER, Min
Ro Lee PhD, Jong Hun Kim PhD, Department of Surgery, Chonbuk
National University Medical School
S016 5-FLUOROURACIL-RELATED GENE EXPRESSION IN
PRIMARY SITES AND HEPATIC METASTASES OF COLORECTAL
CARCINOMAS, Shinichi Sameshima PhD, Shinichiro Koketsu PhD,
Toshiyuki Okada PhD, Toshio Sawada PhD, Gunma Cancer Center
15
SCIENTIFIC PROGRAM
11:30 - 16:30
12:00 - 13:00
Lunch On Your Own
13:00 - 15:00 FREE PAPERS
COLORECTAL CANCER, BENIGN
COLORECTAL DISEASE &
FECAL INCONTINENCE
MANCHESTER A-B
Chairperson: Parvez Sheikh, MD
Moderator: Leela Prasad, MD
S017 RISK FACTORS ASSOCIATED WITH LOCAL RECURRENCE
AFTER NEOADJUVANT CHEMORADIATION COMBINED WITH
TOTAL MESORECTAL EXCISION FOR LOCALLY ADVANCED
RECTAL CANCER, Nam-Kyu Kim MD, Young-Wan Kim MD, ByungSoh Min MD, Ki-Chang Keum MD, Jin-Sil Seong MD, Jung-Bai
Ahn MD, Jae-Kyung Roh MD, Hoguen Kim MD, Department of
Surgery, Yonsei University College of Medicine, Seoul, Korea
S018 THE LONG-TERM RESULTS OF SURGERY FOR COLON
CANCER IN JAPAN, Takashi Hirai PhD, Yukihide Kanemitsu MD,
Koji Komori PhD, Tomoyuki Kato PhD, Aichi Cancer Center
S019 MOLECULAR PROGNOSTIC MARKERS IN COLORECTAL
CANCER, Krasimir Ivanov MSc, Nikola Kolev PhD, Anton Tonev
MD, Gergana Nikolova PhD, Anton Tonchev, Ivan Krasnaliev,
Kalin Kalchev, University Hospital “St. Marina”, Medical
University - Varna, Bulgaria
S020 ADJUVANT THERAPY FOR COLORECTAL CANCER
PATIENTS RECEIVING NON-CURATIVE SURGICAL RESECTION,
Giichiro Tsurita PhD, Takeshi Nishikawa MD, Yoshiki Takei PhD,
Shinsuke Saito PhD, Takamitsu Kanazawa PhD, Shinsuke Kazama
PhD, Eiji Sunami PhD, Hirokazu N Tsuno PhD, Hirokazu Nagawa
PhD, Department of Surgical Oncology, the Graduate School of
Medicine, the University of Tokyo
S021 OUTCOME OF PATIENTS WITH CLINICAL STAGE II
OR III RECTAL CANCER TREATED WITHOUT ADJUVANT
RADIOTHERAPY, Shin Fujita MD, Seiichiro Yamamoto MD,
Takayuki Akasu MD, Yoshihiro Moriya MD, National Cancer
Center Hospital
S022 LONG TERM OUTCOME OF ALTEMEIER’S PROCEDURE
FOR RECTAL PROLAPSE, Donato F A MD, Gianandrea Binda
MD, Ezio Ganio MD, Paola De Nardi MD, Marcella Rinaldi MD,
Aldo Infantino MD, Giuseppe Dodi MD, Nicola Tricomi MD,
Diego Segre MD, Giuseppe Di Giuro MD, Paolo Giamundo MD,
Mario Pescatori, Dept of Emergency and Organ Transplantation,
University of Bari, Italy
S023 SURGICAL TREATMENT OF FISTULA-IN-ANO IN SINGAPORE
- A RETROSPECTIVE STUDY OF 457 PATIENTS, Law Chee Wei,
Iwan Kristian, Charles Tsang Bih-Shiou, Dean Koh Chi Siong,
Cheong Wai Kit, Division of Colorectal Surgery, Department of
Surgery, National University Hospital of Singapore
S024 RECTAL IRRIGATION (RI) IS A BOON FOR CHRONIC
CONSTIPATION - A PROSPECTIVE REVIEW, N Srinivasaiah MD,
J Marshall RN, A Gardiner RN, G S Duthie MD, 1. Academic
Surgical Unit, Castle Hill Hospital, University of Hull, Cottingham,
United Kingdom
S025 SPHINCTER REINFORCEMENT WITH A SIMPLE PROSTHETIC
SLING FOR ANAL INCONTINENCE, José Manuel Devesa MD,
Rosana Vicente MD, Pedro Lopez-Hervas MD, Hospital Ruber
Internacional. Madrid. Spain
S026 ANAL ELETROMANOMETRY AND BI-DIMENSIONAL
ULTRASOUND EVALUATION OF FECAL INCONTINENCE: IS THERE
A CORRELATION?, Jose Paulo T Moreira MD, Hélio Moreira Jr
MD, Hélio Moreira PhD, Almeida C Arminda MD, Issac R Raniere
MD, Coloproctology Service, Federal University of Goiás, Brazil
S027 FACTORS AFFECTING THE SUCCESS OF SACRAL NERVE
STIMULATION FOR FECAL INCONTINENCE, Donato F Altomare
MD, Marcella Rinaldi MD, Pierluigi Lobascio MD, Pierluca
Sallustio MD, Fabio Marino MD, Ramona Giuliani BS, Vincenzo
Memeo MD, Dept of Emergency and Organ Transplantation,
16
ISUCRS XXII BIENNIAL CONGRESS MANCHESTER D-I
COLORECTAL CANCER,
MANCHESTER C
Chairperson: Fumio Konishi
Moderator: Randolph M. Steinhagen, MD
S028 INTERSPHINCTERIC RESECTION VERSUS STAPLED COLOANAL
ANASTOMOSIS FOR LOW RECTAL CANCER, Bong Hwa Lee MD,
Hyoung-Chul Park MD, Hallym University College of Medicine, Seoul,
South Korea
S029 LONG-TERM FUNCTIONAL CHANGES AFTER LOW ANTERIOR
RESECTION FOR RECTAL CANCER COMPARED BETWEEN A
COLONIC J-POUCH AND A STRAIGHT ANASTOMOSIS, Jin-ichi Hida
MD, Takehito Yoshifuji MD, Fumiaki Sugiura MD, Masako Takemoto
MD, Takashi Hattori MD, Kazuki Ueda MD, Eizaburou Ishimaru MD,
Tadao Tokoro MD, Masayuki Yasutomi MD, Hitoshi Shiozaki MD,
Kiyotaka Okuno MD, Department of Surgery, Kinki University School
of Medicine, Osaka, Japan
S030 ACCURACY OF MAGNETIC RESONANCE IMAGING AND
TRANSANAL ULTRASONOGRAPHY TO PREDICT PATHOLOGIC
STAGE AFTER PREOPERATIVE CHEMORADIOTHERAPY FOR RECTAL
CANCER, Sang Nam Yoon MD, Chang Sik Yu MD, Ah Young Kim MD,
Dae Dong Kim MD, Ui Sup Shin MD, Jin Cheon Kim MD, Colorectal
Clinic, Department of Colon and Rectal Surgery, and Radiology,
University of Ulsan College of Medicine and Asan Medical Center
S031 EFFECTS OF SURGICAL TIMING ON PROCTECTOMY
COMPLICATIONS AFTER LONG COURSE NEOADJUVANT THERAPY,
Emre Balik MD, Metin Keskin MD, Suleyman Bademler MD, Burak Ilhan
MD, Sumer Yamaner MD, Turker Bulut MD, Yilmaz Buyukuncu MD,
Necmettin Sokucu MD, Ali Akyuz, Dursun Bugra, Istanbul University,
Istanbul Faculty Of Medicine, General Surgery Department
S032 THE FREQUENCY OF MICROSATELLITE INSTABILITY IN
MULTIPLE PRIMARY COLORECTAL CANCER AND METACHRONOUS
COLORECTAL CANCER, Toshimasa Yatsuoka MD, Kiwamu Akagi MD,
Tsutomu Ishikubo MD, Shinichi Asaka MD, Yoji Nishimura MD, Hirohiko
Sakamoto MD, Yoichi Tanaka MD, Division of gastroenterological
surgery and cancer genetic diagnosis, Saitama Cancer Center
S033 SURVEILLANCE OF ANAL CANCER PRECURSOR LESIONS IN
HIV POSITIVE AND HIV NEGATIVE PATIENTS, Ricardo A Alfonzp MD,
Luis H Angarita MD, Juan C Sierra MD, Hospital de Clinicas Caracas,
Caracas, Venezuela
S034 WITHDRAWN
S035 INTERMEDIATE RESULTS OF A PROSPECTIVE RANDOMIZED
STUDY ASSESSING A BRIEF COURSE OF PERIOPERATIVE
INTRAVENOUS ANTIMICROBIAL PROPHYLAXIS IN RECTAL CANCER
SURGERY, kouki kuwabara MD, Keiichiro Ishibashi MD, Masatsugu
Ishii MD, Toru Ishiguro MD, Tomonori Ohsawa MD, Norimichi Okada
MD, Masaru Yukoyama MD, Tatsuya Miyazaki MD, Moriyuki Matsuki
MD, Hideyuki Ishida MD, Department of Digestive Tract and General
Surgery, Saitama Medical Center, Saitama Medical University
S036 COMPARATIVE ANALYSIS OF PROTECTIVE ILEOSTOMY
CLOSURE AFTER INITIAL LAPAROSCOPIC VS. OPEN COLORECTAL
SURGERY, Homero Rodriguez MD, Roberto Ramos MD, Sofia Sanchez
MD, Omar Vergara MD, Manuel Moreno MD, Hector Tapia MD, David
Velazquez PhD, Quintin Gonzalez MD, Instituto Nacional de Ciencias
Médicas y Nutrición Salvador Zubirán (INCMNSZ)
S037 RESULTS OF ILEOSTOMY CLOSURE AFTER RECTAL CANCER
RESECTION, Shigeki Yamaguchi PhD, Masatoshi Ishii MD, Jo Tashiro
MD, Yoshihide Otani MD, Isamu Koyama, Shuji Saito MD, Masayuki
Ishii MD, Department of Gastroenterological Surgery, Saitama
Medical University International Medical Center & Shizuoka Cancer
Center
S038 THE EVALUATION OF A FECAL DIVERTING DEVICE AS A
SUBSTITUTE FOR A DEFUNCTIONING STOMA: AN ANIMAL STUDY,
Jaehwang Kim MD, Sang Hun Jung MD, Daegu, Korea
SCIENTIFIC PROGRAM
15:00 - 15:45
Afternoon Break
15:45 - 17:15
The Ileal Pouch – Thirty Years On
Panel Chair: Ali A. Shafik, MD
Panel Moderator: P. Ronan O’Connell, MD
Panel Description:
In 1978 Alan Parks and John Nicholls published their seminal paper on ileal pouch anal
anastomosis. 30 years later IPAA is routine in the surgical management of ulcerative
colitis. The operation may have grown up but with maturity come new questions
and challenges. This panel addresses some of the more topical issues of today.
Panel Objectives:
At the conclusion of this panel, participants will be to:
MANCHESTER D-I
MANCHESTER A-B
• Discuss the role and timing of targeted therapy in management of acute colitis
• Understand current technical advances in the treatment of ulcerative colitis
• Understand up-dates on how to manage surgery for colitis in the obese patient
• Identify the effects of ileal pouch surgery on female fertility and the outcomes on childbirth on
ileal pouch function
• Assess the effects of aging on continence and ileal pouch function
Acute Colitis: Do Biologics Simply Postpone the Inevitable? IPAA Technique: Lap or Lap-assist, One Stage or Two? Obesity: A Growing Problem in Ileal Pouch Surgery Fertility, Pregnancy and Mode of Delivery The Aging Pouch Walter A. Koltun, MD
Joel J. Bauer, MD
Philip F. Caushaj, MD
Feza H. Remzi, MD
John H. Pemberton, MD
17:30 - 19:30
Welcome Reception
Join us as we welcome you to the XXII Biennial Congress of the International Society
of University Colon & Rectal Surgeons. This event will feature cocktails and light hors
d’oeuvres. This event is free to all scientific session attendees and registered accompanying
persons. Extra tickets may be purchased for $25 USD at the registration desk.
www.isucrs.org/
HYATT POOL, 4TH LEVEL
17
SCIENTIFIC PROGRAM
MONDAY-AT-A-GLANCE
18
TIME
EVENT
LOCATION
07:00
MANCHESTER D-I
07:00 - 13:00
MANCHESTER D-I
07:30 - 08:30
FREE PAPERS: COLORECTAL CANCER
AND FUNCTIONAL DISEASE I
MANCHESTER A-B
AND FUNCTIONAL DISEASE II
MANCHESTER C
08:30 - 10:00
CONTROVERSIES IN LAPAROSCOPIC
COLON AND RECTAL SURGERY
MANCHESTER A-B
10:00 - 10:30
HARRY E. BACON ORATION:
“NUTRITION FOR THE AGES”
MANCHESTER A-B
10:30 - 11:00
MORNING BREAK
MANCHESTER D-I
11:00 - 12:30
INNOVATIVE TECHNOLOGIES
MANCHESTER A-B
12:30
LUNCH ON YOUR OWN
13:00 - 14:30
SAN DIEGO AFTERNOON SEAL TOUR: GROUP A
SEAPORT VILLAGE
15:00 - 16:30
SAN DIEGO AFTERNOON SEAL TOUR: GROUP B
SEAPORT VILLAGE
17:30 - 18:30
WINE & CHEESE RECEPTION IN THE EXHIBIT HALL
MANCHESTER D-I
07:00 - 13:00
Exhibit Hall & Poster Viewing
07:30 - 08:30
FREE PAPERS
08:30 - 10:00
MANCHESTER D-I
COLORECTAL CANCER AND
FUNCTIONAL DISEASE I
FUNCTIONAL DISEASE II
MANCHESTER A-B
MANCHESTER C
Chairperson: Donato F. Altomare, MD
Chairperson: Katsuhisa Shindo, MD, PhD
Moderator: Anthony Dippolito, MD
Moderator: Joel J. Bauer, MD
S039 CLINICAL APPLICATION OF IN-VITRO CHEMOSENSITIVITY
TEST FOR COLORECTAL CANCER USING MTT ASSAY IN KOREA,
Seong-soo Kim MD, Byuong-wook Min PhD, Jun-won Um PhD,
Hong-young Moon PhD, Department of Surgery, Korea university
College of Medicine, Seoul, Korea
S040 ULTRALOW ANTERIOR RESECTION AND HAND-SAWN
COLOANAL ANASTOMOSIS: ONCOLOGIC AND FUNCTIONAL
OUTCOMES, Byung Soh Min MD, Hyuk Hur MD, Jin Soo Kim MD,
Seung Kook Sohn PhD, Chang Hwan Cho MD, Seung Hyuk Baik
MD, Nam Kyu Kim PhD, Yonsei University Health System, Seoul,
Korea
S041 VOIDING & SEXUAL DYSFUNCTION AFTER RADICAL
EXCISION OF THE RECTUM, Galal M AbouElnagah MD, Ahmed
Hussin MD, Colorectal surgical Unuit, Alexandria University,
Egypt
S042 DEFECATORY DISORDER DUE TO DENERVATION/ MOTILITY
DISORDER OF THE NEORECTUM FOLLOWING ANTERIOR
RESECTION FOR RECTAL CANCER, K Koda MD, H Yasuda MD,
M Yamazaki MD, T Tezuka MD, C Kosugi MD, R Higuchi MD, M
Sugimoto MD, Y Yagawa MD, Department of Surgery, Teikyo
University Chiba Medical Center
S043 ROLE OF SACRAL NERVE STIMULATION(SNS) IN CHRONIC
CONSTIPATION, N Srinivasaiah MD, P W Waudby RN, G S Duthie
MD, 1. Academic Surgical Unit, University of Hull, Cottingham,
UK
S044 URINE N1N12-DI-ACETYL SPERMINE (DIACSPM) AS A
NOVEL CANCER MARKER FOR COLORECTAL CANCER, Keiichi
Takahashi MD, Kyoko Hiramatsu PhD, Tatsuro Yamaguchi MD,
Hiroshi Matsumoto MD, Daisuke Nakano MD, Youzou Suzuki MD,
Takeo Mori MD, Masao Kawakita PhD, Department of Surgery,
Tokyo Metropolitan Komagome Hospital
S045 IMPACT OF RADIOTHERAPY ON COMPLICATIONS AND
SPHINCTER PRESERVATION AFTER COLOANAL ANASTOMOSIS
FOR DISTAL RECTAL CANCER, Hyuk Hur MD, Byung Soh Min,
Jin Soo Kim MD, Nam Kyu Kim MD, Seung Kook Sohn MD,
Chang Hwan Cho MD, Yonsei University College of Medicine,
Department of Surgery
S046 THE IMPACT OF ANORECTAL ELETROMANOMETRY IN
163 CONSECUTIVE PATIENTS EVALUATED IN A COLORECTAL
PHYSIOLOGY LABORATORY, José Paulo T Moreira MD, Hélio
Moreira Jr MD, Hélio Moreira PhD, Geanna R Guerra MD,
Arminda C Almeida MD, Coloproctology Service, Federal
University of Goiás, Brazil
S047 NON-STIMULATED GRACILOPLASTY - WILL IT BECAME
THE METHOD OF CHOICE? Roman Herman PhD, Piotr Walega
PhD, Anna Gierada MD, 3rd Department of Surgery, Cracow
S048 ROLE OF SACRAL NERVE STIMULATION (SNS) IN CHRONIC
PELVIC PAIN (CPP), N Srinivasaiah MD, Phillip Waudby RN, B
Culbert, G S Duthie MD, 1. Academic surgical unit, Castle Hill
Hospital, University of Hull, Cottingham, UK. 2. Department of
Anaesthetics, Castle Hill Hospital, Cottingham, UK
Controversies In Laparoscopic Colon
And Rectal Surgery
MANCHESTER A-B
Panel Chair: Jose Alfredo Reis Neto, MD
Panel Moderator: Marvin L. Corman, MD
Panel Description:
The panel members will present a discussion in five areas: diverticular disease, ulcerative
colitis, rectal cancer, rectal prolapse and Crohn’s disease--emphasizing the controversial
aspects of utilizing minimally invasive surgery for the treatment of these conditions.
The risks and benefits will be addressed with the expectation that one may avoid
the pitfalls in the application of laparoscopy in the treatment of this condition.
Panel Objectives:
• To determine the appropriateness of the laparoscopic approach for the surgical management of
these five conditions
• To integrate one’s knowledge so that the complications associated with these operations may
be minimized
• To predict the likelihood of accomplishing a successful laparoscopic procedure
Diverticular Disease Ulcerative Colitis/ Crohn’s Disease Rectal Cancer Rectal Prolapse www.isucrs.org/
ISUCRS ACKNOWLEDGES AN UNRESTRICTED EDUCATIONAL
GRANT FROM ETHICON ENDO-SURGERY, INC.
Anthony Senagore, MD
James W. Fleshman, MD
John H. Marks, MD
Conor P. Delaney, MD, PhD
19
SCIENTIFIC PROGRAM
10:00 - 10:30
Harry E. Bacon Oration: “Nutrition For The Ages”
Ed Schneider, MD, Emeritus Dean of the Andrus Gerontology
Center; Professor of Gerontology, Medicine, and Biological Science,
Demographics and Health Care, University of Southern California
Chairman: Angelita Habr-Gama, MD
Introduction by Robert W. Beart, MD
10:30 - 11:00
Morning Break w/Exhibits & Posters
11:00 - 12:30
Innovative Technologies
Panel Chair: Bruno Roche, MD
Panel Moderator: Steven D. Wexner, MD
Panel Description:
This panel on Innovative Technologies will provide attendees with information on some of
the newest and most challenging themes within colorectal surgery. The panel will specifically
describe robotic colectomy, natural orifice translumenal endoscopic surgery (NOTES™).
Panel Objectives:
1. When the panel is completed, participants will have an understanding of the status of robotic
approaches to colorectal surgery.
2. Participants will understand the evolution and current status of natural orifice translumenal
endoscopic surgery (NOTES™) relative to colorectal disorders.
3. Participants will evaluate the indications and results of endorectal ultrasound and pelvic
disorders, and endorectal ultrasound in pelvic disorders, and doppler hemorrhoid ligation.
4. Participants will assess the safety and efficacy of Doppler hemorrhoid ligation.
Robotic Colectomy Mark A. Talamini, MD
Natural Orifice Transluminal Endoscopic Surgery (NOTES™) Santiago Horgan, MD
Anal Fistula Plug (Surgisis) in Complex Fistula in Ano Endorectal Ultrasound for Pelvic Disorders
Doppler Hemorrhoid Ligation Robotics
20
Parvez Sheikh, MD
Zoran Krivokapic, MD
Pier Paolo Dal Monte, MD
Leela M. Prasad, MD
ISUCRS ACKNOWLEDGES AN UNRESTRICTED EDUCATIONAL
GRANT FROM RICHARD WOLF MEDICAL INSTRUMENTS
12:30
Lunch On Your Own
13:00 - 16:30
San Diego Seal Tours
Enjoy an afternoon in San Diego by land and sea! This 90-minute fully-narrated amphibious
sightseeing tour will take you past San Diego’s major aquatic attractions and you might even get
to see a sea lion or two. Tours depart from Seaport Village, the outdoor shopping complex right
behind the hotel. This event is free to all scientific session attendees and accompanying persons.
Tour required advance registration to secure your seat. Group A is scheduled
from 13:00 - 14:30. Group B is scheduled from 15:00 - 16:30. Please be
sure to arrive 15 minutes prior to departure. Buses depart across from
the Harbor House Restaurant behind the hotel in Seaport Village.
17:30 - 18:30
Wine & Cheese Reception with Exhibitors ISUCRS XXII BIENNIAL CONGRESS SEAPORT VILLAGE
MANCHESTER D-I
SCIENTIFIC PROGRAM
TUESDAY-AT-A-GLANCE
TIME
EVENT
LOCATION
07:00
MANCHESTER FOYER
06:30 - 07:30
ISUCRS BUSINESS MEETING
MANCHESTER A-B
07:30 - 08:30
MIXED PLENARY SCIENTIFIC SESSION
MANCHESTER A-B
08:30 - 10:00
AND COLORECTAL EMERGENCIES
MANCHESTER A-B
FREE PAPERS: COLORECTAL CANCER AND
INFLAMMATORY BOWEL DISEASE
MANCHESTER C
10:00 - 10:30
FIDEL RUIZ-MORENO ORATION: “LIVER RESECTION
FOR COLORECTAL METASTASIS: LATEST PROGRESS”
MANCHESTER A-B
10:00 - 16:15
MANCHESTER D-I
10:30 - 11:00
MORNING BREAK
MANCHESTER D-I
11:00 - 12:00
PLENARY SCIENTIFIC SESSION: BEST PAPERS
MANCHESTER A-B
12:00 - 12:30
ISUCRS PRESIDENTIAL ADDRESS: “PUSHING
THE ROCK UPHILL- A 30 YEAR PERSPECTIVE”
MANCHESTER A-B
12:30 - 13:30
LUNCH ON YOUR OWN
13:30 - 14:00
COFFEE & DESSERT IN THE EXHIBIT HALL
MANCHESTER D-I
14:00 - 15:30
AND ANORECTAL DISEASES I
MANCHESTER A-B
AND ANORECTAL DISEASES II
MANCHESTER C
15:30 - 16:00
AFTERNOON BREAK
MANCHESTER D-I
16:00 - 17:30
AND SURGICAL TECHNIQUES I
MANCHESTER A-B
AND SURGICAL TECHNIQUES II
MANCHESTER C
GALA DINNER
SAN DIEGO AIR & SPACE
MUSEUM
19:00 - 22:00
www.isucrs.org/
21
SCIENTIFIC PROGRAM
06:30 - 07:30
07:30 - 08:30
ISUCRS Business Meeting
MANCHESTER A-B
Mixed Plenary Scientific Session
MANCHESTER A-B
Chairperson: Jose Paulo Moreira, MD
Moderator: Elliot Prager, MD
V001 LAPAROSCOPIC TOTAL ABDOMINAL COLECTOMY WITH RECTAL HARTMANN’S POUCH AND CONSTRUCTION OF END BROOKE
ILEOSTOMY, Badma Bashankaev MD, Christina Seo MD, Jared Frattini MD, Paula Denoya MD, Marwan Moussa MD, Steven D
Wexner MD, Department of Colorectal Surgery, Cleveland Clinic Florida
V002 EMERGENCY LAPAROSCOPIC RIGHT HEMI-COLECTOMY IN ILEO-COLIC INTUSSUSCEPTION PATIENT DUE TO CECAL CANCER,
Koo Yong Hahn MD, Jeoung Hwan Keum MD, Yong Geul Joh PhD, Seon Hahn Kim PhD, Deprtment of Surgery, Seongnam Central
Hospital
V003 PERINEAL RECTOSIGMOIDECTOMY AND VAGINAL HYSTERCTOMY IN A PATIENT WITH RECTAL PROCIDENTIA AND VAGINAL
PROLAPSE, Eduardo Brambilla MS, Paulo Roberto Dal Ponte MD, Marcos Antonio Dal Ponte MD, Viviane Raquel Buffon MD,
University of Caxias do Sul
S049 LAPAROSCOPIC VS. OPEN TOTAL MESORECTAL EXCISION, Quintin Gonzalez MD, Homero Rodriguez MD, Jose Moreno MD,
Omar Vergara MD, Hector Tapia MD, Roberto Ramos MD, Roberto Castañeda MD, Instituto Nacional de Ciencias Medicas y Nutrición
“Dr. Salvador Zubirán”. Mexico City
S050 CLEVELAND CLINIC FLORIDA RECTAL CANCER EXPERIENCE, B Santoni MD, P Denoya MD, E Stone MD, D Sands MD, J
Nogueras MD, E Weiss MD, S Wexner MD, Cleveland Clinic Florida
S051 DIAGNOSTIC ACCURACY OF PREOPERATIVE AND FOLLOW-UP PET/CT IMAGING FOR COLORECTAL CANCER, Yoshiko Bamba
MD, Michio Itabashi MD, Yusuke Tada MD, Tomoichiro Hirosawa MD, Shimpei Ogawa MD, Akiyoshi Seshimo MD, Shingo Kameoka
MD, Department of Surgery II, Tokyo Women’s Medical University, School of Medicine, Tokyo, Japan
08:30 - 10:00
22
FREE PAPERS
COLORECTAL EMERGENCIES
MANCHESTER A-B
MANCHESTER C
Chairperson: Robert W. Beart, MD
Moderator: Ali A. Shafik, MD
Chairperson: Helio Moreira, MD
Moderator: Bruce Waxman, MD
S052 MICROSATELLITE INSTABILITY AND 18Q ALLELIC IMBALANCE
IN YOUNG PATIENTS WITH COLORECTAL CANCER, Akifumi Kuwabara
MD, Takeyasu Suda MD, Haruhiko Okamoto MD, C. Richard Boland
MD, Katsuyoshi Hatakeyama MD, Digestive and General Surgery,
Niigata Graduateschool Medical and Dental Sciences
S053 SCREENING FOR HEREDITARY COLORECTAL CANCER IN CHINA,
Shu ZHENG MD, Yanqin HUANG MD, Ying YUAN PhD, Shanrong CAI
PhD, Suzhan ZHANG PhD, Cancer Institute (The Key Laboratory of
Cancer Prevention and Intervention, China National Ministry of
Education), the 2nd Affiliated Hospital, Zhejiang University
S054 GASTROINTESTINAL MALIGNANCY AND PREGNANCY, YW
Yun MD, JY Kim MD, HK Chun MD, HR Yun MD, YB Cho MD, HC 1
Kim MD, SH Yun MD, WY Lee MD, WY Chang MD, Department of
Surgery, Samsung Medical Center, Sungkyunkwan University School
of Medicine, Seoul, Korea, Department of Surgery, Cheju University,
Cheju, Korea
S055 THE PROGNOSIS FOR ADVANCED RECTAL CANCER UNDERWENT
PREOPERATIVE CHEMORADIOTHERAPY, SH JUNG MD, HJ KIM MD,
JS KIM MD, JH KIM MD, JH KIM MD, MC SHIM, Department of
Surgery, College of Medicine, Yeungnam University, Daegu, Korea
S056 THE INFLUENCE OF SURGICAL PROCEDURES TO THE
POSTOPERATIVE URINARY FUNCTION AFTER AUTONOMIC NERVE
PRESERVING OPERATION IN RECTAL CANCER SURGERY, Masahiro
Tsubaki MD, Yuiti Ito MD, Masanori Fujita MD, Masakatu Sunagawa
MD, First Department of Surgery, Dokkyo Medical University, School
of Medicine
S057 ULTIMATE ANUS PRESERVING OPERATION INCLUDING
INTERSPHINCTERIC RESECTION FOR LOWER RECTAL CANCER
EXTREMLEY CLOSE TO ANUS, Kazuo Shirouzu MD, Yoshito Akagi
MD, Yutaka Ogata MD, Shinjiro Mori MD, Department of Surgery,
Kurume University Faculty of Medicine, Japan
S058 HISTOLOGICAL FACTORS CONTRIBUTING TO A HIGH RISK
OF RECURRENCE OF SUBMUCOSAL INVASIVE CANCER (PT1) OF
THE COLON AND RECTUM AFTER ENDOSCOPIC THERAPY, Ichiro
Nakada MD, T. Tabuchi MD, T. Nakachi, A. Takemura MD, M. Katano
MD, T. Tabuchi MD, Department of Surgery, Tokyo Medical University
Kasumigaura Hospital
S059 15-YEAR EVOLUTION OF PENETRATING COLON MANAGEMENT
AT A LEVEL I TRAUMA CENTER; WHAT HAVE WE LEARNED?, Elie
Schochet MD, Indru T Khubchandani MD, Timothy S Misselbeck
MD, Michael Matos BA, Sherrine Eid MPH, Lehigh Valley Hospital,
Division of Colon and Rectal Surgery
S060 FUNCTION PRESERVING SURGERY FOR LOWER RECTAL CANCER
INVOLVING LOWER URINARY TRACT IN MALE PATIENTS, Norio Saito
MD, Takanori Suzuki MD, Masanori Sugito MD, Masaaki Ito MD,
Akihiro Kobayashi MD, Toshiyuki Tanaka MD, Yusuke Nishizawa MD,
Masaaki Yano MD, Yasuo Yoneyama MD, Yuji Nishizawa MD, Nozomi
Minagawa MD, National Cancer Center Hospital East
S061 RADIOTHERAPY IN RECTAL CANCER - IS IT TIME FOR CHANGE?
A QUALITATIVE ANALYSIS OF THE SURVEY OF MEMBERS OF ACPGBI
ON PRELIMINARY MRC-CRO7 RESULTS, N Srinivasaiah MD, B
Joseph MD, J Gunn MD, J Hartley MD, J R Monson MD, 1. Academic
Surgical Unit, Castle Hill Hospital, University of Hull, Cottingham, UK
S062 INSUFFICIENT LYMPHNODE DISSECTION IS AN INDEPENDENT
RISK FACTOR FOR POSTOPERATIVE MORTALITY IN PATIENTS WITH
STAGE II / DUKES B COLORECTAL CANCER, Mitsuru Ishizuka MD, Hitoshi
Nagata MD, Kazutoshi Takagi MD, Keiichi Kubota MD, Department of
Gastroenterological Surgery, Dokkyo Medical University
S063 COMBINED MANAGEMENT OF THE PERIANAL LESION IN THE
CROHN’S DISEASE, José María Gallardo, Valle García Sanchez,
Federico Gomez Camacho, Reina Sofía Hospital
S064 IS THERE AN INFLAMMATION TENDENCY IN ASYMPTOMATIC
PATIENTS WITH PELVIC ILEAL POUCHES FOR ULCERATIVE COLITIS
AND FAMILIAL ADENOMATOUS POLYPOSIS?, Raquel F Leal MD,
Marciane Milanski MS, Maria Lourdes S Ayrizono MD, Luciana R
Meirelles PhD, João J Fagundes MD, Lício A Velloso PhD, Cláudio S Coy
PhD, Coloproctology Unit, Dept of Surgery, and Cellular Signalization
Laboratory, Campinas State University, São Paulo, Brazil
S065 PULSE GRANULOMAS DISCOVERED IN SETTING OF CROHN
DISEASE, Sukrit Narula, Yong-son Kim MD, Adelina T Luong MD,
Janet C Nakamura MD, Dylan M Bach MD, Mark L Wu MD, University
of California, Irvine School of Medicine
S066 SERUM ADIPONECTIN LEVEL IS POSSIBLY ALTERED IN
INFLAMMATORY BOWEL DISEASE WITH SOME DIFFERENCE
BETWEEN ULCERATIVE COLITIS AND CROHN’S DISEASE, Natsuko
Ue MD, Giichiro Tsurita PhD, Joji Kitayama PhD, Hirokazu Nagawa
PhD, University of Tokyo Hospital
S067 LONG-TERM RESULTS OF ILEOCAECAL STRICTUREPLASTY
IN THE TREATMENT OF CROHN’S ILEITIS, Francesco Tonelli° MD,
Marilena Fazi* MD, Tatiana Bargellini° MD, Francesco Giudici° MD,
Giuseppe Canonico° MD, Carmela Di Martino° MD, ° Department
of Clinical Phisiopathology, * Department of Medical and Surgical
Critical Care
10:00 - 10:30
Fidel Ruiz-Moreno Oration: “Liver Resection For Colorectal Metastasis:
Latest Progress”
Daniel Azoulay, MD, PhD, Paul Brousse Hospital, Villejuif, France
Chairman: Sergio Larach, MD
Introduction by Indru T. Khubchandani, MD
10:00 - 16:15
Exhibit Hall & Poster Viewing
MANCHESTER D-I
10:30 - 11:00
Morning Break MANCHESTER D-I
11:00 - 12:00
Plenary Scientific Session: Best Papers
Chairperson: Saul Sokol, MD
Moderator: Carlos Rodriguez, MD
MANCHESTER A-B
MANCHESTER A-B
S068 TREATMENT OF FISTULA-IN-ANO BY ANAL FISTULA PLUG: A PROSPECTIVE STUDY FROM ASIA, Pankaj Garg MS, Fortis Super
Specialty Hospital, Mohali, Punjab, India
S069 IDEAL BOWEL RESECTION AND MARGINS IN COLON CANCER, Yojiro Hashiguchi MD, Hideki Ueno MD, Yoshiki Kajiwara MD,
Jiro Omata MD, Koichi Okamoto MD, Toru Kubo MD, Tomomi Fukazawa MD, Kazuo Hase MD, Hidetaka Mochizuki MD, Department
of Surgery, National Defense Medical College
S070 LONG-TERM RESULTS OF TREATMENT WITH BOTULINUM TOXIN TYPE A FOR OBSTRUCTIVE OUTLET CONSTIPATION ARE
VERY DISAPPOINTING. , B Santoni MD, D Vivas MD, B Safar MD, J Nogueras MD, E Weiss MD, S Wexner MD, D Sands MD,
S071 DIVERTICULITIS IN THE UNITED STATES: 1991 - 2005 CHANGING PATTERNS OF DISEASE, TREATMENT, David A Etzioni MD,
Andreas M Kaiser MD, Robert W Beart MD, Thomas M Mack MD, University of Southern California
S072 MANAGEMENT OF ACUTE MALIGNANT LARGE BOWEL OBSTRUCTION WITH SELF-EXPANDING METAL STENT, J-P Arnaud
MD, S Mucci-Hennekinne MD, K Meunier MD, E Lermite MD, C Teyssedou MD, A Hamy MD, Department of Visceral Surgery, ChuAngers, France
S073 METASTATIC OVARIAN AND COLORECTAL CANCER: TWO ORGANS, ONE DISEASE, J D Terrace MD, R J Skipworth MD, C
Bourne MD, D N Anderson MD, Academic Unit of Coloproctology, University of Edinburgh
12:00 - 12:30 ISUCRS Presidential Address: “Pushing The Rock Uphill – A 30 Year Perspective”
Robert W. Beart, MD, USC Keck School of Medicine, Los Angeles, California, USA
Chairman: Jae-Gahb Park, MD
Introduction by Anthony Senagore, MD
12:30 - 13:30
Lunch On Your Own
13:30 - 14:00
Coffee & Dessert In The Exhibit Hall
www.isucrs.org/
MANCHESTER A-B
MANCHESTER D-I
23
SCIENTIFIC PROGRAM
14:00 - 15:30 15:30 - 16:00
24
FREE PAPERS
COLORECTAL CANCER AND ANORECTAL
DISEASES I
COLORECTAL CANCER AND ANORECTAL
DISEASES II
MANCHESTER A-B
MANCHESTER C
Chairperson: Indru T. Khuchandani, MD
Moderator: Fidel Ruiz-Healy, MD
Chairperson: Kenichi Sugihara, MD
Moderator: TBD
S074 EXAMINATION OF ANAL PRESERVATION WITH ANAL
SPHINCTERIC RESECTION FOR VERY LOW RECTAL CANCER,
Yoshito Akagi MD, Kazuo Shirouzu MD, Yutaka Ogata MD, Naruya
Ishibashi MD, Masataka Ushijima MD, Hidetugu Murakami MD,
Department of Surgery, Kurume University
S075 INCIDENCE OF COLONIC POLYPS AFTER BARIATRIC
PROCEDURES., B Bashankaev MD, M Khaikin MD, D Melero
MD, D Vivas MD, B Santoni MD, D Sands MD, E Weiss MD, J
Nogueras MD, S Szomstein MD, R Rosenthal MD, S Wexner MD,
S076 OBSTRUCTIVE COLORECTAL CANCER, PROGNOSIS AND
COST-EFFECTIVENESS ACCORDING TO THERAPEUTIC OPTIONS,
Ui Sup Shin MD, Chang Sik Yu MD, Sang Nam Yoon MD, Dae Dong
Kim MD, Jin Cheon Kim MD, Department of Surgery, University
of Ulsan College of Medicine and Asan Medical Center, Seoul,
Korea
S077 CHRONIC ANAL FISSURE IN YOUNG MALES, Constantine
P Spanos MD, Theodore Syrakos MD, Dimitris Kiskinis MD, 1st
Department of Surgery, Aristotelian University, Thessaloniki,
Greece
S078 TREATMENT OF HEMORRHAGIC RADIATION PROCTITIS
WITH FORMALIN APPLICATION UNDER DORSAL PERINEAL
BLOCK. , Narimantas E Samalavicius PhD, Alfredas Kilius, Darius
Norkus, Arvydas Burneckis, Konstantinas P Valuckas, Oncology
Institute of Vilnius University, Santariskiu 1, Vilnius, Lithuania
S079 FLAPS IN COLORECTAL SURGERY - A PLASTIC SURGEONS
VIEW, Stephan Spendel PhD, Johann Pfeifer PhD, Michael V
Schintler PhD, Gerhard Kreuzwirt RN, Bengt Hellbom PhD, Erwin
Scharnagl PhD, Division of Plastic and Reconstructive Surgery,
Medical University Graz, Austria
S080 FISTULA-IN-ANO IN INFANTS: OPERATIVE OR
NONOPERATIVE MANAGEMENT? Shota Takano MD, Shin
Namikawa MD, Yoriyuki Tsuji MD, Kazutaka Yamada MD,
Masahiro Takano MD, Coloproctology center Takano Hospital
S081 PATIENT’S SELF-IRRITATING SETON INDWELLING DURING
MODIFIED HANLEY OPERATION FOR HORSESHOE FISTULA,
Nahmgun Oh PhD, Hyuk-Jae Jung MD, Department of Surgery,
Pusan National University Hospital, Busan, South Korea
S082 VALIDATION OF USEFULNESS OF LYMPH NODE DISSECTION
FOR COLORECTAL CANCER IN JAPAN, USING THE REDUCTION
RATE OF LYMPH NODE RECURRENCE, Hirotoshi Kobayashi MD,
Masayuki Enomoto MD, Tetsuro Higuchi MD, Masamichi Yasuno
MD, Hiroyuki Uetake MD, Satoru Iida MD, Toshiaki Ishikawa
MD, Megumi Ishiguro MD, Takatoshi Matsuyama MD, Haruhiko
Aoyagi MD, Sayaka Shimizu MD, Satoshi Okazaki MD, Kenichi
Sugihara MD, Tokyo Medical and Dental University, Dept of
Surgical Oncology
S083 RESULTS FROM PELVIC EXENTERATION FOR LOCALLY
ADVANCED COLORECTAL CANCER WITH LYMPH NODE
METASTASES, Jin-ichi Hida MD, Takehito Yoshifuji MD, Fumiaki
Sugiura MD, Masako Takemoto MD, Takashi Hattori MD,
Kazuki Ueda MD, Eizaburou Ishimaru MD, Tadao Tokoro MD,
Masayuki Yasutomi MD, Hitoshi Shiozaki MD, Kiyotaka Okuno
MD, Department of Surgery, Kinki University School of Medicine,
Osaka, Japan
S 084 P R E O P E R AT I V E
V E R S U S POSTOPERATIVE
CHEMORADIOTHERAPY FOR RECTAL CANCER, Sung Il Choi MD,
Jae-Chang Lee MD, Suk-Hwan Lee MD, Kil-Yeon Lee MD, SungEun Hong MD, Kyunghee University Hospital
S085 A QUALITATIVE ANALYSIS OF A FOCUS GROUP
DISCUSSION ON PATIENT DECISION MAKING IN CANCER
CARE, N Srinivasaiah MD, B Joseph MD, J Gunn MD, J Hartley
MD, J R Monson MD, 1. Academic Surgical Unit, University of
Hull, Cottingham, UK
S086 STARR PROCEDURE FOR OBSTRUCTED DEFAECATION
SYNDROME (ODS): 12 MONTH FOLLOW-UP, David G Jayne MD,
Oliver Schwandner MD, Leonardo Lenissa MD, Angelo Stuto MD,
University of Leeds, Caritas Krankenhaus Str. Josef, Casa di Cura
San Pio X, Ospedale S. maria degli Angeli
S087 A NOVEL CONCEPT FOR THE SURGICAL ANATOMY OF THE
PERINEAL BODY, Ali A Shafik MD, Cairo University
S088 HYPERBARIC OXYGEN FOR CHRONIC ANAL FISSURE LONG TERM OUTCOME, N Srinivasaiah MD, Cundall J MD, Laden
G, K Chapple, G S Duthie, 1. Academic Surgical Unit, Castle Hill
Hospital, Cottingham, UK HU16 5JQ. 2. Hyperbaric Unit, Classic
Hospital, Anlaby, Hull, United Kingdom
S089 A RETROSPECTIVE STUDY OF 144 CASES OF RECURRENT
& COMPLEX FISTULA IN ANO, Parvez Sheikh, P. N. Joshi, Charak
Clinic, Mumbai, India
Afternoon Break
ISUCRS XXII BIENNIAL CONGRESS MANCHESTER D-I
SCIENTIFIC PROGRAM
16:00 - 17:30
FREE PAPERS
COLORECTAL CANCER AND SURGICAL
TECHNIQUES I
COLORECTAL CANCER AND SURGICAL
TECHNIQUES II
MANCHESTER A-B
MANCHESTER C
Chairperson: Temelko Temelkov, MD
Moderator: Adil H. Al-Humadi, MD
Chairperson: TBD
Moderator: Emre Balik, MD
S090 COMPARISON OF MACROSCOPICAL AND PATHOLOGICAL
STUDY BETWEEN PREOPERATIVE RADIOTHERAPY AND
RADIOCHEMOTHERAPY FOR ADVANCED RECTAL CANCER, Koji
Yasuda MD, Giichiro Tsurita PhD, Tomomitsu Kiyomatsu PhD,
Hirokazu Nagawa PhD, The Department of Surgical Oncology,
the Graduate School of Medicine, The University of Tokyo
S091 THE SIGNIFICANCE OF TUMOR VOLUME REDUCTION
RATE AND DIGITAL RECTAL EXAMINATION AS TUMOR
RESPONSE PREDICTIVE MARKERS IN THE PATIENTS WITH
LOCALLY ADVANCED RECTAL CANCER AFTER PREOPERATIVE
CHEMORADIATION, Jung Hyun Kang MD, Jeong Yoen Kim MD,
Nam Kyu Kim MD, Seung Kook Sohn MD, Chang Hwan Cho MD,
Byung Soh Min MD, Yonsei University Health System, Seoul,
Korea
S092 ROLE OF ADJUVANT RADIOTHERAPY AFTER TOTAL
MESORECTAL EXCISION IN PATIENT WITH STAGE II RECTAL
CANCER, JinSoo Kim MD, NamKyu Kim MD, ByungSo Min
MD, Hyuk Hur MD, ChoongBae Ahn MD, KiChang Keum MD,
SeungKook Sohn MD, JangHwan Cho MD, Department of Surgery,
Medical Oncology, Radiation Oncology, Yonsei University College
of Medicine, Seoul, Korea
S093 WITHDRAWN
S094 ENDOSCOPIC
SUBMUCOSAL DISSECTION FOR
COLORECTAL NEOPLASIA: EARLY EXPERIENCES 94 CASES Eunjung Lee MD, JaeBum Lee MD, Suk Hee Lee MD, Do Sun Kim MD,
Doo Han Lee MD, Eui Gon Youk MD, Daehang Hospital
S095 SHOULD COMPLETELY INTRACORPOREAL ANASTOMOSIS
BE CONSIDERED IN OBESE PATIENTS UNDERGOING
LAPAROSCOPIC COLECTOMY FOR BENIGN OR MALIGNANT
DISEASE OF THE COLON?, I Raftopoulos MD, R Bergamaschi
MD, Saint Francis Hospital and Medical Center, Hartford,
Connecticut
S096 KSHAAR-SOOTRA (HERBAL MEDICATED THREAD) IN THE
MANAGEMENT OF RECURRENT FISTULA-IN-ANO, Harshit S
Shah MD, Sejal H Shah MD, Anand Kshaar Sootra Clinic
S097 PELVIC EXENTERATION WITH RECONSTRUCTION OF
URINARY AND ANAL SPHINCTER FUNCTIONS FOR PATIENTS
OF COLORECTAL CANCERS NORMALLY REQUIRING TPE, K Koda
MD, H Yasuda MD, M Suzuki MD, M Yamazaki MD, T Tezuka MD,
C Kosugi MD, R Higuchi MD, M Sugimoto MD, Y Yagawa MD, H
Tsuchiya MD, Teikyo University Chiba Medical Center
S098 THE PROGNOSTIC SIGNIFICANCE OF ERBB FAMILY
EXPRESSIONS IN PATIENTS WITH CURATIVE RESECTION FOR
COLORECTAL CANCERS, Byung-Wook Min, Seong-Soo Kim,
Sang-Hee Kang, Jun-Won Um, Department of Surgery, Korea
University College of Medicine, Seoul, Korea
S099 BRAIN METASTASES FROM COLORECTAL CANCER, JiHoon Kim MD, Jae-Im Lee MD, Hyung-Jin Kim MD, Sang-Chul
Lee MD, Yoon-Suk Lee MD, Won-Kyung Kang MD, Jong-Kyung
Park MD, Chang-Hyeok Ahn, Seong-Taek Oh MD, Department of
Surgery, The Catholic University of Korea
S100 COLORECTAL SURGERY IN CIRRHOTIC PATIENTS.
ASSESSMENT OF OPERATIVE MORTALITY AND MORTALITY,
J-P Arnaud MD, K Meunier MD, S Hennekinne-Mucci MD, R
Azoulay MD, A Hamy MD, Department of Visceral Surgery, ChuAngers, France
S101 ABDOMINAL STAPLED SIDE-TO-END ANASTOMOSIS
(BAKER TYPE) IN LOW AND HIGH ANTERIOR RESECTION:
EXPERIENCE AND RESULTS IN 96 CONSECUTIVE PATIENTS AT
A REGIONAL GENERAL HOSPITAL IN JAPAN, Ichiro Nakada MD,
T. Satani MD, T. Kasuga MD, Y. Watanabe MD, T. Tabuchi MD,
Department of Surgery, Tokyo Medical University Kasumigaura
Hospital
S102 DOES TOTAL MESORECTAL EXCISION REQUIRE A
LEARNING CURVE? ANALYSIS FROM DATABASE OF SINGLE
SURGEON’S EXPERIENCE, Seung Yeop Oh MD, Ok Joo Paek MD,
Kwang Wook Suh MD, Department of Surgery, Ajou University
School of Medicine
S103 DE-EPITHELIALIZED PUDENDAL-THIGH-(SINGAPOUR)FLAP FOR THE TREATMENT OF LOW RECTO(ANO-) VAGINAL
FISTULAE, Johann Pfeifer MD, Stephan Spendel* MD, Michael
Schintler* MD, Department of General Surgery, *Department of
Plastic Surgery
S104 ABDOMINAL WALL COMPONENTS SEPARATION
TECHNIQUE FOR CLOSURE OF VENTRAL DEFECTS - INITIAL
EXPERIENCE AND LESSONS LEARNT, Bruce Waxman MSc,
S Jassal, L Dandie, D Goodall-Wilson, M Fisher, Dandenong
Hospital, Southern Health
S105 TRANSACRAL RESECTION WITH SACRECTOMY IN THE ERA
OF TEM, Bong Hwa Lee MD, Hyoung-Chul Park MD, Soo Hyung
Kim MD, Sung Wook Cho MD, Taeik Um MD, Hallym University
College of Medicine, Seoul, South Korea
19:00 - 22:00
Gala Dinner At The San Diego Air & Space Museum
Spend an enchanted evening at the San Diego Air & Space Museum. The museum
showcases some of the greatest triumps in aviation history including the Apollo 9
Command Module and a full scale reproduction of the Wright Flyer. Our gala event
will “take flight” as we dine and dance among these awe-inspiring creations of the
sky. This event is free to all scientific session attendees and registered accompanying
persons. Extra tickets may be purchased for $100 USD at the registration desk.
Buses depart from the lobby at 18:45.
www.isucrs.org/
25
SCIENTIFIC PROGRAM
WEDNESDAY-AT-A-GLANCE
TIME
EVENT
LOCATION
07:30
MANCHESTER FOYER
08:00 - 09:30
AND LAPAROSCOPIC SURGERY I
MANCHESTER A-B
AND LAPAROSCOPIC SURGERY II
MANCHESTER C
09:30 - 10:00
MORNING BREAK
MANCHESTER FOYER
10:00 - 11:30
ANORECTAL DISEASE
MANCHESTER A-B
08:00 - 09:30
26
FREE PAPERS
LAPAROSCOPIC SURGERY I
LAPAROSCOPIC SURGERY II
MANCHESTER A-B
MANCHESTER C
Chairperson/Moderator: Glenn T. Ault, MD
Chairperson/Moderator: Don R. Read, MD
S106 YOUNGER AGE AND MORE DISTAL CANCERS - CHANGE
IN THE EPIDEMIOLOGY OF COLORECTAL CANCER AND
IMPLICATION FOR SCREENING, Bruce Waxman MSc, Mikhail
Fisher, Dandenong Hospital, Southern Health
S107 INFLAMMATION-BASED PROGNOSTIC SCORE PREDICTS
POSTOPERATIVE OUTCOME IN PATIENTS WITH LIVER
METASTASES FROM COLORECTAL CANCER, Mitsuru Ishizuka MD,
Tokihiko Sawada MD, Mitsugi Shimoda MD, Junji Kita MD, Kyuu
Rokkaku MD, Masato Kato MD, Keiichi Kubota MD, Department of
S108 LAPAROSCOPIC VS. OPEN REVERSAL OF HARTMANN’S
FOR DIVERTICULITIS, B Safar MD, S Shawki, MD, H Wang MD, S
Cera MD, D Efron MD, D Sands MD, E Weiss MD, A Vernava MD,
J Nogueras MD, S Wexner MD, Cleveland Clinic Florida
S109 WITHDRAWN
S110 LAPAROSCOPIC TOTAL PROCTOCOLECTOMY FOR
ULCERATIVE COLITIS AND FAMILIAL ADENOMATOUS
POLYPOSIS. EXPERIENCE IN MEXICO, Federico López Rosales
MD, Quintin González Contreras MD, Hector Tapia Cid de León
MD, Hómero Rodríguez Zetner MD, Omar Vergara Fernández MD,
Department of colorectal surgery. Instituto Nacional de Ciencias
Médicas y Nutrición Salvador Zubirán. Mexico City
S111 INDUCTION OF LAPAROSCOPY ASSISTED COLORECTAL
SURGERY IN A JAPANESE GENERAL HOSPITAL. , Toru Tonooka
PhD, Jun Yasutomi PhD, Shinichiro Irabu MD, Daigo Nobumoto
MD, Takahiro Nishida MD, Yuko Tashima MD, Masanari Matsumoto
PhD, Takahiro Kasagawa PhD, Kimihiko Kusashio PhD, Ikuo
Udagawa PhD, Masaru Suzuki PhD, Tatsushi Fukao PhD, Masaru
Miyazaki PhD, Department of Surgery, Chiba Rosai Hospital
S112 THE EFFECTS OF NEOADJUVANT THERAPY ON
LAPAROSCOPIC SURGERY FOR RECTAL CANCER, Emre Balik
MD, Metin Keskin MD, Burak Ilhan MD, Sumer Yamaner MD,
Turker Bulut MD, Buyukuncu Yilmaz, Necmettin Sokucu, Ali
Akyuz, Bugra Dursun MD, Istanbul University, Istanbul Faculty of
Medicine, General Surgery Department
S113 COMPARISON OF CONVENTIONAL AND HAND-ASSISTED
LAPAROSCOPIC SURGERY IN COLON CANCER, HR Yun MD, HK
Chun PhD, WY Lee PhD, YB Cho MD, WY Chang MD, RJ Lee MD,
YK Cho MD, HC Kim PhD, H Yoo MD, SH Yun MD, JH Park, WY
Chang MD, Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea,
Department of Surgery, Cheju University, Cheju, Korea
S114 RISK FACTORS AND MANAGEMENT OF ANASTOMOTIC
LEAK FOLLOWING RESTORATIVE RESECTION FOR RECTAL
CANCER IN THE ERA OF NEOADJUVANT THERAPY, Alexis L
Grucela MD, David B Chessin MD, Nicole DeRosa MD, Alex J
Ky MD, Sanghyun A Kim MD, Tomas Heimann MD, Randolph M
Steinhagen MD, Mount Sinai School of Medicine
S115 HISTOCLINICAL CHARACTERISTICS OF COLORECTAL
CARCINOMA WITH LYMPHOVASCULAR INVASION, Romarico
M Azores Jr. MD, Alma N Aquilizan MD, Cynthia A Mapua MS,
Francisco V Narciso MD, St. Luke’s Medical Center, Quezon City,
Philippines
S116 FEMALE FERTILITY AND COLORECTAL CANCER,
Constantine P Spanos MD, Apostolos M Mamopoulos MD,
Apostolos Tsapas MD, 1st Department of Surgery, Aristotelian
University, Thessaloniki, Greece
S117 EFFICACY OF LAPAROCSOPIC COLORECTAL RESECTION
FOR HIGH RISK PATIENTS, Jo Tashiro MD, Shigeki Yamaguchi
MD, Masatoshi Ishii, MD, Takahiro Sato MD, Shutaro Ozawa
MD, Yoshihide Otani MD, Isamu Koyama MD, Saitama Medical
University International Medical Center Department of
Gastroenterological Surgery
S118 TWO DIFFERENT LAPAROSKOPIC TECHNIQUE ON RECTAL
PROLAPSUS, Turker Bilgin MD, General Surgeon, Etimesgut
Military Hospital, Dept. of Surgery. Ankara, Turkey
S119 USE FULNESS OF FALS IN LAPAROSCOPY ASSISTED
COLORECTAL SURGERY, Jun Yasutomi MD, Toru Tonooka MD,
Ikuo Udagawa MD, Kimihiko Kusashio MD, Masanari Matsumoto
MD, Masaru Suzuki MD, Katashi Fukao MD, Department of
Surgery, Chiba Rosai Hospital
S120 MINIMAL INVASIVE SURGERY FOR RECTAL CANCER.
SHORT TERM RESULTS OF SINGLE CENTER, Emre Balik MD,
Metin Keskin MD, Burak Ilhan, Sumer Yamaner MD, Turker Bulut
MD, Yilmaz Buyukuncu, Necmettin Sokucu MD, Ali Akyuz, Dursun
Bugra MD, Istanbul University, Istanbul Faculty of Medicine,
General Surgery Department
S121
LAPAROSCOPIC
ASSISTED
INTERSPHINCTERIC
RESECTION FOR VERY LOW RECTAL CANCER, Yoshiya Fujimoto
MD, Hiroya Kuroyanagi MD, Masatoshi Oya MD, Masashi Ueno
MD, Takashi Akiyoshi MD, Toshiharu Yamaguchi MD, Tetsuichiro
Muto MD, Department of Gastroenterological Surgery, Cancer
Institute Hospital, Tokyo, Japan
09:30 - 10:00
Morning Break
10:00 - 11:30
Anorectal Disease Panel Chair: Fidel Ruiz Healy, MD
Panel Moderator: Philip F. Caushaj, MD
Panel Description:
For most colorectal surgeons, anorectal diseases occupy the majority of their practice. This panel
will include assorted and innovative topics on anorectal disorders by world-wide experts.
Panel Objectives:
At the conclusion of this panel, participants will be able to:
MANCHESTER FOYER
MANCHESTER A-B
• Discuss recommendations regarding a variety of anaorectal disease treatments
Outpatient Treatment Fecal Incontinece Radiation Proctitis Donato F. Altomare, MD
Narimantas E. Samalavicius, MD, PhD
Rectovaginal Fistula Sphinctoroplasty Rectocele and Surgical Treatment Using Mesh Technique www.isucrs.org/
J. Manuel Devesa, MD
Johann Pfeifer, MD
Petr Tsarkov, MD
27
FACU LT Y L I ST I N G
Adil H. Al-Humadi, MD, Olean, NY, USA
Donato F. Altomare, MD, Bari, Italy
Jean-Pierre Arnaud, MD, Angers, France
Glenn T. Ault, MD, Los Angeles, CA, USA
Daniel Azoulay, MD, PhD, Villejuif, France
Emre Balik, MD, Istanbul, Turkey
Joel J. Bauer, MD, New York, NY, USA
Robert W. Beart, MD, Los Angeles, CA, USA
Roberto Bergamaschi, MD, Allentown, PA, USA
Philip F. Caushaj, MD, Pittsburgh, PA, USA
Bruno Cola, MD, Bologna, Italy
Marvin L. Corman, MD, Stony Brook, NY, USA
Raul Cutait, MD, Sao Paulo, SP, Brazil
Pier Paolo Dal Monte, MD, Bologna, Italy
Conor P. Delaney, MD, PhD, Cleveland, OH, USA
J. Manuel Devesa, MD, Madrid, Spain
Anthony Dippolito, MD, Bethlehem, PA, USA
James W. Fleshman, MD, St. Louis, MO, USA
Angelita Habr-Gama, MD, Sao Paulo, Brazil
Santiago Horgan, MD, San Diego, CA, USA
David K. Imagawa, MD, PhD, FACS, Orange, CA, USA
Indru T. Khubchandani, MD, Allentown, PA, USA
Walter A. Koltun, MD, Hershey, PA, USA
Fumio Konishi, MD, Saitamaken, Japan
Zoran Krivokapic, MD, Belgrade, Serbia & Montenegro
Sergio Larach, MD, Orlando, FL, USA
Andrew M. Lowy, MD, FACS, La Jolla, CA, USA
John H. Marks, MD, FACS, FASCRS, Wynnewood, PA, USA
Helio Moreira, MD, Goiania, GO, Brazil
Zuri A. Murrell, MD, Los Angeles, CA, USA
Tetsuichiro Muto, MD, Toyko, Japan
P. Ronan O’Connell, MD, FRCSI, FRCS (Glas), Dublin, Ireland
Jae-Gahb Park, MD, Seoul, South Korea
John H. Pemberton, MD, Rochester, MN, USA
Johann Pfeifer, MD, Graz, Austria
Elliot Prager, MD, Santa Barbara, CA, USA
Leela M. Prasad, MD, Niles, IL, USA
Sonia Ramamoorthy, MD, San Francisco, CA, USA
Don R. Read, MD, Dallas, TX, USA
Jose Alfredo Reis Neto, MD, Campinas, SP, Brazil
Feza H. Remzi, MD, Cleveland, OH, USA
Bruno Roche, MD, Geneva, Switzerland
Carlos Rodriguez, MD, Caracas, Venezuela
Fidel Ruiz-Healy, MD, Mexico City, Mexico
Narimantas E. Samalavicius, MD, PhD, Vilnius, Lithuania
Edward Schneider, MD, Los Angeles, CA, USA
Anthony Senagore, MD, Grand Rapids, MI, USA
Sohn Seung-Kook, MD, Seoul, South Korea
Ali A. Shafik, MD, Cairo, Egypt
Parvez Sheikh, MD, Mumbai, India
Katsuhisa Shindo, MD, PhD, Higashi-Osaka, Japan
Saul Sokol, MD, Dallas, TX, USA
Michael Stamos, MD, Orange, CA, USA
Randolph M. Steinhagen, MD, New York, NY, USA
Kenichi Sugihara, MD, Tokyo, Japan
Mark A. Talamini, MD, San Diego, CA, USA
Temelko Temelkov, MD, Varna, Bulgaria
Petr V. Tsarkov, MD, Moscow, Russian Federation
Bruce P. Waxman, MD, Dandenong, VIC, Australia
Steven D. Wexner, MD, Weston, FL, USA
Shu Zheng, MD, Hangzhou, Zhejiang, China
28
F aculty & Pr e se n t e r Dis c lo s ur e s
The following faculty & presenters do not have any relevant financial relationships or significant commercial
interests associated with their participation at the XXII Biennial Congress of the International Society of
University Colon & Rectal Surgeons. If name is not listed below, please refer to the following pages.
Galal M Abouelnagah
Yoshito Akagi
Donato F Altomare
Jean-Pierre Arnaud
Romarico M Azores Jr.
Daniel Azoulay
Emre Balik
Yoshiko Bamba
Robert Beart
Roberto Bergamaschi
Turker Bilgin
Eduardo Brambilla
Law Chee Wei
Philip Caushaj
Sung Il Choi
Bruno Cola
Marvin Corman
Raul Cutait
José Manuel Devesa
Yair Edden
David A Etzioni
Yoshiya Fujimoto
Shin Fujita
José María Gallardo Valverde
Pankaj Garg
Quintin H Gonzalez
Quintin González Contreras
Alexis L Grucela
Angelita Habr-Gama
Koo Yong Hahn
Yojiro Hashiguchi
Jin-Ichi Hida
Takashi Hirai
Hyuk Hur
Keiichiro Ishibashi
Mitsuru Ishizuka
Krasimir Ivanov
Sung-Youp Jung
Yoshiki Kajiwara
Sang-Hee Kang
M Khaikin
Indru Khubchandani
HJ Kim
Jeong Yoen Kim
Ji-Hoon Kim
Jinsoo Kim
Jiyeon Kim
Young-Wan Kim
Hirotoshi Kobayashi
K Koda
Fumio Konishi
Zoran Krivokapic
Akifumi Kuwabara
Kouki Kuwabara
Sergio Larach
Raquel F Leal
Bong Hwa Lee
Eun-Jung Lee
Min Ro Lee
José Paulo T Moreira
Tetsuichiro Muto
Ichiro Nakada
Sukrit Narula
Takeshi Nishikawa
P. Ronan O’Connell
Nahmgun Oh
Ok Joo Paek
Jae-Gahb Park
KJ Park
John Pemberton
Johann Pfeifer
Elliot Prager
I Raftopoulos
Feza Remzi
Bruno Roche
Homero Rodriguez Zentner
Fidel Ruiz-Healy
B Safar
Norio Saito
Narimantas E Samalavicius
Shinichi Sameshima
B Santoni
Elie Schochet
Sohn Seung-Kook
Ali A Shafik
Harshit S Shah
Parvez Sheikh
Ui Sup Shin
Kazuo Shirouzu
Constantine P Spanos
Stephan Spendel
N Srinivasaiah
Michael Stamos
Kenichi Sugihara
Keiichi Takahashi
Shota Takano
Jo Tashiro
J D Terrace
Francesco Tonelli
Toru Tonooka
Petra Tsarkov
Masahiro Tsubaki
Giichiro Tsurita
Natsuko Ue
Hideki Ueno
Bruce Waxman
Shigeki Yamaguchi
Koji Yasuda
Jun Yasutomi
Toshimasa Yatsuoka
Cho Seon Yeon
H Yin Jin
H Ying Jin
Sang Nam Yoon
Hae Ran Yun
Shu Zheng
The following faculty & presenters provided information indicating they have a financial relationship with a
proprietary entity producing health care goods or services, with the exemption of non-profit or government
organizations and non-health care related companies. (Financial relationships can include such things as
grants or research support, employee, consultant, major stockholder, member of speaker’s bureau, etc.)
NAME
COMMERCIAL INTEREST
WHAT WAS RECEIVED
FOR WHAT ROLE
Ricardo A Alfonzp
Honorarium
Honorarium
Speaking and/or Teaching
Badma Bashankaev Covidien
Honorarium
Consulting
Joel Bauer
Salary
Speaker’s Bureau
Pier Paolo Dal Monte GF srl, Italy
Consulting Fee
Consulting
Conor Delaney
Adolor
Honorarium/Research Funding
Consulting/Research Covidien
Consulting/Research Ethicon
Consulting/Research
James Fleshman
Ethicon
Honoraria
Innocoll
Honoraria
NITI
Honoraria
Surg RX
Honoraria
Independent Contractor
Advisory Committee/Board
Independent Contractor
Consultant, Speaker’s Bureau,
Teaching Engagements,
Ventrus Biosciences
Honoraria
Roman Herman
Other Financial Benefit
Other Financial Benefit
Other Activities
Santiago Horgan
Novare Surgical
USGI Medical
Honorarium
Consulting Fee
Speaker
Consulting
Ethicon
www.isucrs.org/
29
Facult y & Pr e se n te r Dis c lo s ur e s
NAME
COMMERCIAL INTEREST
WHAT WAS RECEIVED
FOR WHAT ROLE
David Imagawa
Anglodynamics
Grant
Research on Liver Cancer
David G Jayne
Consulting Fee
Consulting Fee
Consulting
Jaehwang Kim
Intellectual Property Rights
Intellectual Property Rights Independent Contractor
Walter Koltun
Innocoll
Consulting Fee
Consulting
Andrew Lowy
Genzyme Corporation
OSI Pharmaceuticals Inc.
Consulting Fee
Honorarium
Member Focus Group
Speaking
John Marks
Covidien
Ethicon
Strylar
SurgiQuest
Richard Wolf
Honoraria
Honoraria
Honoraria
Ownership Interest
Honoraria
Consultant, Speakers Bureau
Scientific Advisory Board
Leela Prasad
Applied Medical
Covidien
Enseal
Ethicon
Intuitive
Honorarium
Honorarium
Honorarium
Honorarium
Honorarium
Speaker
Fellowship
Consulting
Consulting
Consulting
Edward Schneider
ASH
Consulting Fee
Alternative Medicine
Anthony Senagore
Adolor Corporation
Ethicon Endosurgery
Stipend
Stipend
Advisory Board
Advisory Board
Mark Talamini
Ethicon, Inc.
Commitment for sponsored
Intuitive, Inc.
Visit to Intuitive Surgical
Olympus Inc.
Frontiers of Endoscopy 2006 Annual Meeting
Stryker, Inc.
Dinner sponsored by Stryker
Steve Wexner
30
Baxter AG
Cook
Covidien
Covidien
CR Bard
CRH Medical
Ethicon Endo-Surgery
EZ Surgical
Incontinence Devices
Intuitive Surgical
Karl Storz Endoscopy America Inc.
Karl Storz Endoscopy America Inc.
Neatstitch
Olympus
Power Medical Interventions
Salix Pharmaceuticals Inc.
SurgRx
SurgRx
Torax Medical Inc.
Ventrus Biosciences
Consulting Fee
Travel Support
Consulting Fee
Educational Support
Consulting Fee
Stock Options
Educational Support
Stock Options
Consulting Fee
Stock Options
Institutional Grants/
Educational Support
Consulting Fee
Stock Options
Travel Support
Honoraria/Stock Options
Consulting Fee
Consulting Fee/Stock Options
Institutional Grants/
Educational Support
Honorarium
Consulting Fee
Consulting
fellowship for 1 year
Participant
Lecturer
Participant
Consulting
Educator
Consulting
Educator
Consulting
Consulting
Educator
Consulting
Consulting
Consulting
Educator
Consulting
Consulting
Educator
Consulting
Consulting
Consulting
Educator
Advisory Board
Consulting
Exhibit H a l l F l o o r pla n
Exhibit Hall Hours
Sunday, September 14, 2008
Exhibit Hall Open
11:30 - 16:00
Monday, September 15, 2008
Exhibit Hall Open
Breakfast in Exhibit Hall
Morning Break in Exhibit Hall Evening Reception 07:00 - 13:00
07:00 - 08:00
10:30 - 11:00
17:30 - 18:30
Tuesday, September 16, 2008
Exhibit Hall Open
Morning Break in Exhibit Hall
Coffee and Dessert in Exhibit Hall
Afternoon Break in Exhibit Hall
10:00 - 16:15
10:30 - 11:00
13:30 - 14:00
15:30 - 16:00 www.isucrs.org/
31
Exhib i t o r Pr o f i l e s
Adolor Corporation / GlaxoSmithKline
#18
Calmoseptine, Inc.
#6
700 Pennsylvania Drive
Exton, PA 19607
(484) 595-1500 (T)
(484) 595-1520 (F)
www.adolor.com
16602 Burke Lane
Huntington Beach, CA 92647
(714) 840-3405 (T)
(714) 840-9810 (F)
www.calmoseptineointment.com
Adolor Corporation is a biopharmaceutical company
specializing in the discovery, development and
commercialization of novel prescription pain management
products. For more information, visit www.adolor.com.
Calmoseptine Ointment is a multi-purpose moisture
barrier that protects and helps heal skin irritations
from moisture, such as urinary and fecal incontinence.
Calmoseptine Ointment temporarily relieves
discomfort and itching. Free samples at our booth!
GlaxoSmithKline offers a number of programs to
support effective health management strategies
and improve patient care. Visit our exhibit for
information about our products and programs.
Advanced Infusion, Inc.
Cook Medical
#17
P.O. Box 390122 Snellville, Georgia 30039
770-979-3379 (T)
770-979-0015 (F)
www.advancedinfusion.com
#5
Bristol-Myers Squibb welcomes you to San
Diego. We invite you to visit our exhibit and
learn of the products and servicesBristol-Myers
Squibb has to offer to your specialty.
Covidien is a leading global healthcare company
that creates innovative solutions for better patient
outcomes and delivers value through clinical
leadership and excellence. Covidien manufactures a
range of industry-leading products in five segments
including Surgical and Energy-based Devices.
CS Surgical
As a new generation medical company, Applied Medical
responds to evolving clinical needs with advancements
such as the GelPort® laparoscopic system, Direct Drive®
atraumatic graspers and the new Fios® first entry.
GelPortSM colectomy workshops offer a minimally
invasive approach to traditional open procedures.
P. O. Box 4500
Princeton, NJ 08543-4500
(609) 897-2000 (T)
(609) 897-6722 (F)
www.bms.com
#14
15 Hampshire Street
Mansfield, MA 02048
(508) 261-8000
www.covidien.com
22872 Avenida Empresa
Rancho Santa Margarita, CA 92688
(800) 282-2212
www.appliedmed.com
Bristol-Myers Squibb
750 Daniels Way
Bloomington, IN 47402
www.cookmedical.com
Covidien
Advanced Infusion manufactures and sells
disposable infusion pumps and catheters for all
surgeries. We will be highlighting our Patented,
One of A Kind Attachable Hemorrhoid Catheter.
Applied Medical
#10
#11
#16
662 Whitney Drive
Slidell, LA 70461
(985) 781-8292 (T)
(985) 781-8244 (F)
www.cssurgical.com
CS Surgical is your leading supplier of surgical
instruments and supplies for the Colon & Rectal Surgeon.
Our exhibit will feature deep pelvic retractors, the newest
Cima-St. Marks Retractor for hand assisted laparoscopic
deep pelvic surgery, our table mounted retractor system,
hemorrhoidal ligators, suction ligators, anascopes, rectal
retractors, intestinal clamps, scissors, needle holders,
probes, directors, crypt hooks, and Welch Allyn products.
Deltex Medical Inc.
#15
330 East Coffee Street
Greenville, SC 29601
864-527-5913
864-527-5914
www.delexmedical.com
The CardioQ™ Esophageal Doppler Monitor
Deltex Medical’s CardioQ™ monitor uses disposable
ultra-sound probes inserted into the esophagus to
determine the flow of blood leaving the heart with
every beat; and consequently, can detect any reduction
in circulating blood volume early and in real-time.
32
Exhibito r Pr o f i l e s
Ethicon Endo-Surgery, Inc. #2
4545 Creek Road
Cincinnati, OH 45242
800-USE-ENDO
www.ethiconendo.com
Ethicon Endo-Surgery develops advanced medical devices
for minimally invasive and open surgical procedures. The
company focuses on procedure-enabling devices for the
interventional diagnosis and treatment of conditions in
general surgery, bariatric surgery, gastrointestinal health,
plastic surgery, gynecology, and surgical oncology.
MAST Biosurgery
#9
6749 Top Gun St., Ste. 108
San Diego, CA 92121-4151
(858) 550-8050 (T)
www.mastbio.com #7
#19
Prometheus Laboratories Inc. is a specialty
pharmaceutical company committed to developing
new ways to help physicians individualize patient
care. Prometheus focuses on the treatment, diagnosis
and detection of gastrointestinal, autoimmune
and inflammatory diseases and disorders.
Richard Wolf Medical Instruments Novadaq Technologies develops medical imaging
and image guidance systems for the operating
room. Novadaq’s SPY® Imaging System enables
intra-operative assessment of vascular and microvascular blood flow and related tissue and organ
perfusion. SPY provides real-time images in the
operating room allowing surgeons to make informed
decisions and therefore optimize procedures.
3500 Corporate Pkway
Center Valley, PA 18034
“Power Medical Interventions®, Inc. is a pioneer in the
design, development and manufacturing of computerassisted, power-actuated surgical stapling products. PMI’s Intelligent Surgical Instruments™ enable less
invasive surgical techniques that benefit surgeons,
patients, hospitals and healthcare networks. PMI
manufactures durable recyclable technology to reduce
medical waste and help keep the planet clean. To
learn more about Power Medical Interventions®, Inc.
and its products, please visit http://www.pmi2.com”
9410 Carroll Park Drive
San Diego, CA 92121
(888) 423-5227 (T)
(858) 824-0896 (F)
www.prometheuslabs.com
2585 Skymark Ave., Suite 306
Mississauga, Ontario, Canada, L4W 4L5
905-629-3822 ext. 216 (T)
www.novadaq.com
Olympus America Inc.
#12
2021 Cabot Blvd. West
Langhorne, PA 19047
(267) 775-8100 (T)
(267) 775-8123 (F)
www.pmi2.com
Prometheus Laboratories Inc.
The SurgiWrap Bioresorbable Protective Sheet is
designed to support and reinforce soft tissues and
minimize soft tissue attachments (STAs) to the
device, FDA Cleared for both open and laparoscopic
procedures. MAST Biosurgery is a leader in the
design, development, and production of bioresorbable
polymer implants, and emerging technologies.
Novadaq Technologies Power Medical Interventions
#8
353 Corporate Woods Parkway
Vernon Hills, IL 60061
(847) 913-1113 (T)
(847) 913-6959 (F)
www.richardwolfusa.com
#4
Richard Wolf offers a complete line of laparoscopic
products including: Panoview Plus distortion-free
laparoscopes; modular and single piece forceps;
RIWO-ART trocars; insufflators and 3 chip video
camera systems. Richard Wolf also offers complete
instrument set for Transanal Endoscopic Microsurgery,
including the only stereo scope in the market.
www.isucrs.org/
33
Exhib i t o r Pr o f i l e s
Saunders/Mosby-Elsevier
#13
3473 Sitio Borde
Carlsbad CA 92009
760-944-9906 (T)
760-944-9926 (F)
The world leader in Medical Publishing including the new
Keighley –Textbook of Colon Rectal Surgery. Please stop
by our booth for Publisher Prices and free shipping.
Surgin Inc.
#3
37 Shield
Irvine, CA 92618 USA
(714) 832-6300 (T)
714-832-2020 (F)
www.hemoccluderpin.com
Surgin manufactures the Hemorrhage Occluder™
Pin (HOP) with an easy-to-use Applicator that stops
PRESACRAL BLEEDING. The HOP is available in two sizes,
10mm and 14mm pinhead sizes. A Salgado™ Driver is
now available to help insert the HOP into the sacrum.
34
SurgRx, Inc.
#1
101 Saginaw Drive
Redwood City, CA 94063
877-7-SURGRX (T)
650-482-2473 (F)
www.surgrx.com
In an industry of choice, it’s time to clear the air among
vessel sealing devices…The EnSeal Difference is Clear.
“Clearly Strong” – Seal strengths up to 75%
stronger compared to other vessel sealers…
“Clearly Cool” – Minimal thermal spread,
no char, sticking or smoke…
“Clearly Versatile” – A grasper, dissector, scissor
and vessel sealing device all in one…
“Clearly Innovative” – Introducing EnSeal PowerTIPwith
unique bipolar/monopolar tip for cutting and
coagulating tissue. EnSeal. The Clear Choice.
ABSTRACT BOOK
Podium Papers
COLORECTAL CANCER AND RESEARCH I
S003 WITHDRAWN
S001 OBJECTIVE CRITERIA FOR GRADE 3 IN EARLY
INVASIVE COLORECTAL CANCER, Hideki Ueno PhD, Yojiro
Hashiguchi PhD, Yoshiki Kajiwara MD, Kazuo Hase PhD, Hidetaka
Mochizuki PhD, National Defense Medical College
Background: In early invasive colorectal cancer, many
authors reported that histological feature of grade 3 (G3)
was a trustworthy risk factor of nodal involvement and
was indicating the necessity of additional lapalotomy after
endoscopic polypectomy. However, the standardized criteria
for objective definition of G3 have not been well documented.
Aim: To determine the objective criteria to judge T1 colorectal
cancer (CRC) as G3. Patients and Method: A total of 238 T1 CRC
patients who underwent curative survery with nodal dissection
were retrospectively reviewed pathologically. The extent of
the component of poorly differentiated carcinoma (POR) and
that of mucinous carcinoma (MUC) was classified into 3 levels,
respectively. The standards used for the categorization were the
presence of the POR or MUC component fully filled a microscopic
filed of a 40x objective lens, and the number of poorly differentiated
clusters. Results: The incidence of nodal involvement was most
efficiently stratified when G3 was applied to tumors which had
10 or more poorly differentiated clusters in a microscopic field
of 4x objective lens, or mucinous component fully occupied a
microscopic field of 40x objective lens. It was 28. 0% in G3 tumors
(n=77) and only 3. 7% in non-G3 tumors (n=162) (P<0. 0001).
Multivariated analysis revealed that G3, vascular invasion and
tumor budding were independently relevant to increasing risk of
nodal involvement. Regarding these three factors as the risk of
nodal involvement, the incidence of nodal involvement was 21. 7%
(25/115) in risk-positive tumors, whereas it was only1. 6% (2/123)
in no-risk tumors. Conclusions: We can have the criteria for the
judgment of G3 by evaluating the number of poorly differentiated
clusters and the area of mucin producing area using a microscopic
field as standard, which promise to be useful to be standardizing
the assessment of risk of nodal involvement of T1 CRC.
S004 RISK FACTORS OF THE NODAL INVOLVEMENT IN
T2 COLORECTAL CANCER, Yoshiki Kajiwara MD, Hideki Ueno
PhD, Masayoshi Miyoshi PhD, Yojiro Hashiguchi PhD, Kazuo Hase
PhD, Hidetaka Mochizuki PhD, Department of Surgery, National
Objective: To identify the risk factors related to the nodal
involvement of patients with T2 colorectal cancer. Patients and
Methods: A total of 244 patients who consecutively underwent
curative resection of T2 colorectal cancer were pathologically
reviewed. The parameters examined with new definition were: 1)
tumor budding (BD) (an isolated cancer cell or a cluster composed
of fewer than 5 cells), 2) poorly differentiated component (POR)
(a region in which a cancer has no glandular formation), and 3)
myxoid cancer stroma (MCS). Each parameter was evaluated with
2-grades system: BD+ (10 or more budding foci in a microscopic
field of x200) and BD- (the others); POR+ (POR fully occupied the
microscopic field of x400 and/or 10 or more solid cancer nests
composed of 5 or more cells in a microscopic field of x40) and POR(the others); MCS+ (MCS region fully occupied the microscopic
field of x400) and MCS- (the others). Results: Nodal involvement
was observed in 54 patients (22. 1%). The parameters which were
significantly associated with nodal involvement were lymphatic
invasion (the incidence of nodal involvement: low-grade, 18. 8%;
high-grade, 57. 1%; p<0. 0001), BD (BD-, 16. 3%; BD+, 29. 4%; p=0.
015), POR (POR-, 8. 4%; POR+, 29. 2%; p=0. 0002), and MCS (MCS-,
16. 9%; MCS+, 36. 4%; p=0. 0011). In multivariate analysis, highgrade lymphatic invasion, POR+, and MCS+ were independent
risk factors for nodal involvement. In T2 lower rectal cancer (85
patients), the nodal involvement rate was 32% in patients with
risk factors (15% in 35 patients with one factor, 58% in 12 patients
with two factors, and 100% in 4 patients with three factors),
which was significantly higher than that in 35 patients with no
risk factors (6%; p=0. 008). Conclusions: In T2 colorectal cancer,
the important risk factors of nodal involvement were high-grade
lymphatic invasion, POR+, and MCS+. Local resection as a gtotal
biopsyh, which could evaluate the risk of nodal involvement
before laparotomy, may be one of the treatment strategies for
poor-risk patients with T2 lower rectal cancer
S002 PROGNOSTIC VALUE OF PERITONEAL CYTOLOGY
AND PERITONEAL DISSEMINATION IN COLORECTAL
CARCINOMA, Takeshi Nishikawa MD, Toshiaki Watanabe PhD,
Eiji Sunami PhD, Hirokazu Nagawa PhD, Department of Surgical
Oncology, the University of Tokyo
Background: The significance of peritoneal cytology as earlier
prognostic marker has been examined in cancer of several organs,
especially in gastric cancer. However in colorectal cancer the
meaning of positive peritoneal cytology remains controversial.
The aim of this study was to reveal the prognostic significance
of peritoneal cytology in colorectal cancer and the association
between peritoneal dissemination and peritoneal cytology.
Methods: From January 1997 to December 2005, 1128 colorectal
cancer patients who underwent laparotomy in our department
were studied. Intra operative peritoneal cytology was performed
on 410 patients whose cancer had invasion of the serosal surface
or beyond. Results: 31 patients (7. 6%) showed positive peritoneal
cytology. Patients with negative peritoneal cytology revealed a
significantly better cancer-specific survival rate at 5 years than
those with positive peritoneal cytology (negative cytology: 62. 5%,
positive cytology: 21. 7%, P<0. 0001). However, among patients
with positive cytology, 60. 0% of patients without peritoneal
dissemination and liver metastasis achieved 3years disease-free
survival. Intra operative peritoneal cytology was performed on
42 patients with peritoneal dissemination. Among 20 patients
with peritoneal dissemination and positive cytology, no one
achieved three years survival after operation. However, among 22
patients with peritoneal dissemination and negative cytology, 13
patients had received curative resection and 4 patients (30. 8%)
achieved three years disease free survival. Conclusion: Patients
with negative peritoneal cytology showed a significantly better
5year survival rate than those with positive peritoneal cytology.
Furthermore, regarding patients with positive peritoneal cytology
and no peritoneal dissemination or patients with peritoneal
dissemination and negative peritoneal cytology, when curative
resection was performed, long-term cancer-free survival can be
expected.
www.isucrs.org/
S005 DIRECT HERPES SIMPLEX VIRUS 1 (HSV-1) DELIVERY
INTO RECTAL ADENOCARCINOMA IN MICE RESULTS
IN AN EFFICIENT ANTI-TUMOR EFFECT, Yair Edden MD, D
Kolodkin-Gal PhD, G Zamir MD, E Pikarsky MD, A Panet PhD,
A J Pikarsky MD, Hadassah Hebrew University Medical Center,
Hebrew University - Hadassah Medical School, Jerusalem, Israel
Purpose: Cancer of the rectum is a common clinical problem.
Because of its anatomical location in the pelvis and the proximity
to the anal sphincters, rectal cancer poses a complex therapeutic
challenge. The current standard of care combining neoadjuvant
therapy followed by surgery has been shown to confer good
survival rates and low local recurrence rates. This approach allows
preserving sphincter function thus enhancing quality of life. We
have recently shown that HSV-1 preferentially infects human
colon cancer compared to normal colonic mucosa suggesting
that HSV-1 based therapy may offer a novel therapeutic modality
for rectal cancer. To determine the oncolytic effect of HSV-1 in a
clinically relevant setting, we examined the effect of intra-tumoral
delivery of HSV-1 into rectal adenocarcinoma in mice. Methods:
Orthotopic rectal tumors were established by injecting mice
colon adenocarcinoma cells (CT-26), stably transfected ex-vivo
to express luciferase, directly into the submucosa of the distal
rectum. The tumor response to viral therapy was assessed by
imaging of luciferase expression in-vivo. Results: Intra-tumoral
injection of HSV-1 resulted in complete arrest in tumor growth.
HSV-1 increased animal survival by two folds. Histological analysis
of the tumors injected with HSV-1 revealed a massive apoptotic
response signifying a combined direct oncolytic and bystander
effect. There was no HSV-1 gene expression or notable damage
in the adjacent colonic mucosa or distant organs. Conclusions:
These results demonstrate the efficacy of HSV-1 delivery into
orthotopic rectal cancer and may provide the basis for a novel
clinical therapeutic neoadjuvant modality for rectal cancer.
35
ABSTRACT BOOK
Podium Papers
S006 FACTORS PREDICTIVE OF LONG TERM FAILURE OF
ARTIFICIAL BOWEL SPHINCTER. , H Ying Jin MD, V Ka Ming
Li MD, Nestor Pulido MD, Benjamin Person MD, H Wang MD, D
Sands MD, E Weiss MD, J Nogueras MD, S Wexner MD, Cleveland
Clinic Florida
Background: Artificial bowel sphincter (ABS) implantation is
one of many operative treatments for fecal incontinence (FI).
Late stage complications of ABS such as erosions and skin and
rectal ulcerations and device malfunction may result in device
explantation. This study aimed to assess the risk factors for latestage complications associated with ABS implantation. Methods:
All patients who had an ABS implanted for FI were included in
the study. Those patients whose ABS was explanted prior to
device activation were excluded from analysis. Kaplan Meier
survival curve was applied to evaluate the cumulative risk of the
ABS explantation. Cox regression was applied to analyze the risk
factors related to explantation. Results: From January 1998 to
May 2007, 51 ABS devices were implanted in 47 patients; 18 were
explanted prior to activation because of early stage infection.
Thus, 33 (64. 7%) functional ABS device implantations were
included in the study. The mean age was 49+13 (19-79) years; 7
(21. 2%) were male. The mean Cleveland Clinic Florida (CCF) FI
score was 18+1. 4 (16-20). In 18 patients (54. 5%), the etiology
of FI was secondary to imperforate anus, 8 (24. 4%) patients had
obstetric injury or anorectal trauma, 3 had low anterior resection
for rectal cancer, 3 were secondary to neurogenic causes, and 2
were related to spinal injury. 10 (30. 3%) patients had prior ABS
implantation and 18 (54. 5%) had a history of sphincteroplasty,
perineal reconstruction, or sphincter repair; 6 had a preoperative
stoma. During a mean follow up of 39+28 (5-108) months, 9
patients had device malfunction and recurrent FI, 6 developed
skin or rectal erosion, 5 had persistent perianal pain, 2 developed
device migration, 2 suffered from constipation, and 1 developed
a hematoma over the labia majora. 13 (39. 4%) ABS devices were
explanted for late-stage complications. Evaluation with KaplanMeier survival curve showed that the one and two year cumulative
risk of ABS explantation was 9. 7% and 13%, respectively. After 2
years, the risk of ABS explantation sharply increased and the third
and fourth year risk increased to 47% and 53%, respectively. 5
year cumulative risk was 58%. Cox regression analysis showed
that explantation of ABS was not related to patient’s age, gender,
etiology of FI, CCF FI score, body mass index, history of perianal
procedure or infection, presence of a defunctioning stoma, or
the timing of the procedure. Conclusion: The number of ABS
devices explanted increased over time. The majority of late
stage complications were technical and related to the device
and no predictive patient-related factors were identified. Further
refinement of the device itself and for the technique may be
necessary.
S007 MICROMETASTASES IN BONE MARROW OF
COLORECTAL CANCER PATIENTS: NO EVIDENCE OF
MALIGNANCY, D F Altomare MD, G Guanti MD, J Hoch MD,
M Vician MD, Z Krivokapic MD, R Bergamaschi MD, Forde Health
System, Forde, Norway; Bari University, Bari, Italy
Background: To investigate whether disseminated epithelial
cells (DEC) in the bone marrow (BM) of colorectal cancer patients
are cancer cells clonal with the primary tumor and impact rates of
liver metastases (LM). Methods: Prospective data on colorectal
cancer patients were collected from five centers. BM aspirates
were taken at laparotomy before primary tumor was resected
for cure. Specimens were sent to a single lab. Colorectal cancer
patients with LM at surgery were excluded. 3 x 106 bone marrow
cells per patient were processed with monoclonal antibodies
against cytokeratin 20. Mutations of APC or p53 genes and
microsatellite instability (MSI) were assessed in primary tumor
by single-strand conformation polymorphism. DEC in BM of
primary tumor mutation or MSI-positive patients were isolated
with immunobeads coated with magnetically labeled anti-HEA
antibody and DNA screened for mutations. Cox proportional
hazards regression analysis and Fisher’s exact test were used to
assess statistical heterogeneity. LM-free curves were generated
and compared using the Kaplan-Meier method and log-rank test,
respectively. Variables were estimated by the maximum likelihood
method. Results: 199 patients were enrolled. 162 patients were
36
ISUCRS XXII BIENNIAL CONGRESS available for analysis. No patient was lost to follow-up. A median
of 24 (1-170) DEC were found in the BM of 117 patients. 22 patients
developed LM at a follow-up of 36 months. APC or p53 mutations
or MSI were found in primary tumor of 79 patients. Mutations and
MSI were not found in DEC of BM of the same 79 patients. After
excluding center 3 (12 patients), there was homogeneity on LM
rates among centers with LM for age (p=. 5182) and center (p=.
1382). There was heterogeneity between centers with LM (145
patients) and one center without LM (5 patients) for pN (p=. 002).
DEC in BM had no impact on LM rates (p=0. 14) Mutations of APC
(p=0. 2115), P53 (p=0. 6354), or MSI (p=0. 8947) in primary tumor
had no impact on LM rates. Conclusion: DEC in BM of colorectal
cancer patients are not clonal with primary tumor, and, therefore,
not malignant and have no impact on LM rates.
S008 EARLY ARTIFICIAL BOWEL SPHINCTER INFECTION:
CAN IT BE AVOIDED? A MULTIVARIATE ANALYSIS. , H Yin
Jin MD, V Ka Ming Li MD, N Pullido MD, B Person MD, H Wang
MD, D Sands MD, E Weiss MD, J Nogueras MD, S Wexner MD,
Background: Artificial bowel sphincter (ABS) implantation
can greatly improve function in appropriately selected patients
with fecal incontinence (FI). However, the published rate of
postoperative complications is more than 40%, the most serious
of which is infection, ranging in incidence from 15 to 40%. The
factors contributing to postoperative infection have not been
clearly identified. Early stage infection (before ABS activation)
may be related to the patient’s underlying condition, technical
issues, and immediate postoperative events. This study focused
on factors related to early stage infection with an aim to identify
any avoidable factors for ABS infection. Methods: Factors
related to the patient’s background, operative procedure, and
postoperative events were analyzed. Chi square and Student t
test were used for univariate analysis and logistic regression was
used to multivariate analysis. Results: From January 1998 to May
2007, 51 ABS devices were implanted in 47 patients of a mean age
of 48. 8+12. 5 (19-79) years; 43 (84. 3%) were female. The mean
Cleveland Clinic Florida (CCF) FI score was 18+2 (16-20). 21 (41.
2%) patients developed infection, 18 (35. 3%) of who developed
early stage and 3 (5. 9%) late stage infection. Of the latter group,
one was related to erosion and the other 2 were secondary to
fistula formation. All 18 patients with infection had their ABS
devices explanted. Univariate and multivariate analysis found
that the time to the first bowel movement (<2 days) and a history
of perineal infection were related to early stage ABS infection.
Conclusion: The time to first postoperative bowel movement and
a history of perineal infection were risk factors for early stage ABS
infection with the time to first postoperative bowel movement as
an independent risk factor. A better regime of bowel preparation
and a specially designed postoperative wound care program may
be necessary to improve outcomes.
COLORECTAL CANCER AND RESEARCH II
S009 EFFECT OF COMPLETE REGRESSION AS A
PROGNOSTIC
FACTOR
AFTER
NEOADJUVANT
CHEMORADIATION THERAPY IN LOCALLY ADVANCED
RECTAL CANCER, Jonghyeon Park MD, Jiyeon Kim PhD,
Department of Surgery, Chungnam National University Hospital,
Daejon, Korea
Purpose: Neoadjuvant chemoradiation therapy (NCRT) for
locally advanced rectal cancer has tumor downstaging, which
enhances curative resection and decreases local recurrence. The
aim of this study is to evaluate the prognostic factor as tumor
regression grade (TRG) after NCRT and radical surgical resection
of locally advanced rectal cancer. Methods: From 1999 to 2003,
140 consecutive patients with biopsy proven, locally advanced
rectal cancer (T3 or T4, or lymph node positive) were treated with
5-fluorouracil based chemotherapy and radiation, followed by
radical surgical resection. The total radiation dose was 5040 cGy
over 6 weeks. The radical surgical resection with total mesorectal
excision was done 6 to 8 weeks after the completion of NCRT.
Overall survival, disease free survival, local recurrence rate, and
distant metastasis rate were investigated as TRG, retrospectively.
Results: 126 patients (90%) were responded to radiation therapy.
no response, partial response and complete response were 14
ABSTRACT BOOK
Podium Papers
(10%), 98 (70%) and 28 (20%), respectively. Overall survival and
disease free survival of 3 years (n=140) were 91. 43% and 74. 29%,
and those of 5 years (n=117) were 81. 20% and 67. 52%. Overall
survival of 3 and 5 years of complete response group (CR group)
were no statistically difference from those of residual group (92.
86% and 92. 31% vs 91. 07% and 78. 02%; p=0. 78, p=0. 10). Disease
free survival of 3 and 5 years of CR group were significantly better
than that of residual group (89. 29% and 88. 46% vs 70. 54% and
61. 54%; p=0. 048, p=0. 013). Conclusions: Complete remission
after NCRT and radical surgical resection has its oncologic benefit
in disease free survival in our study.
S010 FACTORS AFFECTING THE PROGNOSIS OF PATIENTS
WHO
UNDERWENT
RESECTION
OF
PULMONARY
METASTASES FROM COLORECTAL CANCER, Keiichiro
Ishibashi PhD, Masaru Yokoyama PhD, Kouki Kuwabara MD,
Masatsugu Ishii MD, Toru Ishiguro MD, Tomonori Ohsawa MD,
Norimichi Okada PhD, Moriyuki Matsuki PhD, Hideyuki Ishida
PhD, Department of Digestive Tract and General Surgery, Saitama
Medical Center, Saitama Medical University
Purpose: This retrospective study investigated factors affecting
the prognosis of patients who underwent resection of pulmonary
metastases from colorectal cancer. Patients and Methods: A
total of 50 patients with pulmonary metastases from colorectal
cancer underwent pulmonary resection between May 1990 and
August 2007. Patients age ranged from 39 to 91 years (median: 64
years), and the male-to-female ratio was three to two. The sites
of the primary lesions were colon in 28, and rectum in 22. pTNM
stage at resection of the primary lesion was as follows: stage II in
20, stage III in 9, and stage IV in 16Cand unknown in 5 The number
of pulmonary metastatic lesions was one in 35 and two or more
in 15. Twelve patients had undergone hepatectic metastatectomy
prior to thoracotomy. The prognostic factors related to diseasefree and overall survival were analyzed by univariate and
multivariate analysis. Results: The median three-year diseasefree survival and median 5-year overall survival were 40% and
41%, respectively. On univariate analysis by logrank test, patients
with rectal cancer (P=0. 07) and elevated CEA level at thoracotomy
(p=0. 07) tended to show a shorter disease-free survival. Patients
with hepatic lesion(s) prior to thoracotomy (p<0. 01) and those
with stage III/IV disease (p=0. 07) at resection of the primary
lesion showed longer or tended to show longer overall survival.
Multivariate analysis by Cox proportional hazard model showed
that the presence of hepatic lesion(s) was the only determinant
factor affecting overall survival (p<0. 01). Conclusion: Resection
of pulmonary metastases from colorectal cancer should be
carefully indicated for patients with prior surgery for hepatic
metastasis.
S011 EGFR EXPRESSION IN COLORECTAL CANCER, JiHoon Kim MD, Jae-Im Lee MD, Hyung-Jin Kim MD, Won-Kyung
Kang MD, Seong-Taek Oh MD, Yoon-Suk Lee MD, Sang-Chul Lee
MD, Jong-Kyung Park MD, Department of Surgery, The Catholic
University of Korea
Purpose: Epidermal growth factor receptor (EGFR) is a
transmembrane cell surface receptor which has tyrosine kinase
activity stimulated upon EGF or TNF-r binding. And it is known to
regulate signal transduction, cell growth and apoptosis. Recently,
the monoclonal antibody targeting EGFR was developed. In this
study, we are trying to find out how many colorectal cancers
express EGFR and the expression of EGFR has a relationship
with other known prognostic factors. Materials and Methods:
We carried out the immunohistochemical staining in surgical
specimen of primary colorectal cancer from December, 2006 to
September, 2007. One pathologist reviewed the slides and scored
positive if more than 1% of the cells were stained. And the status
of EGFR expression was compared to other prognostic factors.
Result: There were 88 men and 61 women, and the average age
of the patients was 63 years old (35-89). Among 149 specimens,
110 specimens (74%) were scored as EGFR positive. And there
were no correlation between the status of EGFR expression and
other prognostic factors such as sex, age, preoperative CEA
levels, size of the tumor, location of the tumor, cell type of the
tumor, TNM stage, neural invasion, venous invasion, or lymphatic
invasion. Conclusion: EGFR immunohistochemical staining in
the specimen of primary colorectal cancer was positive in 74% of
www.isucrs.org/
the patients. But the expression of EGFR has no correlation with
other prognostic factors.
S012
ONCOLOGICAL
OUTCOMES
OF
CURATIVE
COLECTOMY VIA MINILAPAROTOMY FOR STAGE I, II AND
III COLON CANCER, Keiichiro Ishibashi PhD, Masaru Yokoyama
PhD, Kouki Kuwabara MD, Masatsugu Ishii MD, Toru Ishiguro MD,
Tomonori Ohsawa MD, Norimichi Okada MD, Tatsuya Miyazalki
PhD, Moriyuki Matsuki PhD, Hideyuki Ishida PhD, Department of
Digestive Tract and General Surgery, Saitama medical Center,
Saitama Medical University
Background and Purpose: The feasibility, safety, and
minimal invasiveness of our minilaparotomy method for colon
cancer has been reported (Surgical Endosc 19:316-20, 2005).
However, little is known about the oncological outcomes after
this type of surgery. This retrospective study was performed
to clarify the validity of our surgical approach in terms of
oncological aspects. Patients and Methods: A total of 165
patients with colon cancer underwent curative surgery via
minilaparotomy (skin incision, 6-7cm) between July 2000 and
December 2006. Of these@patients, 126 (age:40-89 years, male/
female=76/50) were histologically confirmed to have stage I/II/III
cancer (stage I;66, stage II;37, stage III;23). Sites of recurrence,
disease-free survival, and overall survival were estimated.
Results: A total of 6 patients developed recurrence (one in
stage I, three in stage II, three in stage III). The initial sites of
recurrence were the liver in one, lung in one, lymph node in
one, peritoneum in two, liver + lung in one. Liver + peritoneum
+ bone in one. Malignant tumor(s) other than colon cancer
developed in three patients. The cumulative 3-year disease-free
survival rate and overall survival rate were 94. 3% and 92. 6%,
respectively. These rates were identical to those for stage I/II/III
patients who underwent conventional open surgery performed
before Introduction: of the minilaparotomy. Conclusion: Our
minilaparotomy is considered to be oncologically safe even for
patients with stage I/II/III colonic cancer although longer follow-up
is needed to conclude this issue.
S013 ELECTROPHYSIOLOGIC CHARACTERISTICS OF
HUMAN COLONIC SMOOTH MUSCLE, KJ Park PhD, EK Choe
MD, JS Moon, Seoul National University College of Medicine,
Seoul, South Korea
Background: In human colon, two distinct electric pacemaker
activities exist: one at the submucosal layer; and the other at the
myenteric borders of the circular muscle layer. Purpose: The
present study was undertaken to characterize the spontaneous
electrical activity in the human colonic smooth circular (CM) and
longitudinal muscle (LM) in the absence of any drugs. Materials
and Methods: Muscle flaps were obtained during elective colon
resections for nonobstructive neoplasms. Mucosal layer was
removed (submucosal layer was left intact) and the muscles were
transferred to an electrophysiological chamber perfused with
Krebs-Ringer bicarbonate solution (KRB) in 37. 5C and pinned
down. Parallel and cross-sectional flaps were used for CM and
LM, respectively. Inner CM (n=11), outer CM (n=13) and LM (n=14)
cells were impaled with glass microelectrodes filled with 3 M
KCl with resistances ranging from 50 to 80 M¥Ø respectively.
Transmembrane potential was measured by high-input impedance
amplifier and outputs were displayed on an oscilloscope. Results
were stored and analyzed by clampex soft ware. Measured
parameters were resting membrane potential (RMP), amplitude,
spike amplitude and frequency. Results: RMP, spike amplitude
showed no difference in three layers. Regularly occurring waves
were observed in all 3 layers, but there were significant difference
in frequency between inner and outer CM (4. 85+/-2. 69/min vs
20. 40+/-3. 76/min; p=0. 00), inner CM and LM (4. 85+/-2. 69/min
vs 23. 01+/-4. 36/min; p=0. 00), but not between outer CM and
LM (p=0. 18). The amplitude of these regularly occurring waves
also showed significant difference between inner and outer CM
(22. 17+/-10. 872mV vs 12. 02+/-10. 01mV; p=0. 02), and between
inner CM and LM (22. 17+/-10. 872mV vs 11. 52+/-4. 23mV, p=0.
01), but not between outer CM and LM (p=0. 98). Comparison of
right and left colon showed that spike amplitude in outer CM was
significantly higher in the right colon (right 25. 58+/-11. 80 vs left
15. 99+/-7. 17; p=0. 005), while spike amplitude in inner CM was
higher in the left colon (right 18. 98+/-10. 01 vs left 21. 18+/-11.
37
ABSTRACT BOOK
Podium Papers
20; p=0. 005). Conclusion: We have demonstrated that inner CM
has distinct that electrophysiologic characteristic compared to
outer CM and LM. Our results confirm that there are two distinct
pacemaker activities (submucosal and myenteric border) and that
these two pacemakers generate different electrical activities with
resultant different electrical activities in the neighboring smooth
muscle fibers.
S014 MOTILITY PATTERNS IN SHORT SEGMENT OF HUMAN
COLONIC TISSUE, EK Choe MD, KJ Park PhD, JS Moon, Seoul
National University College of Medicine, Seoul, South Korea
Background: Studies of human colon motility have usually been
performed using small strips of muscle tissue, either circular
(CM) or longitudinal (LM) muscles. However, overall motility is
determined by progression of contractile activities within each
layer and/or interaction between CM and LM layers. The present
study was undertaken to characterize the motility patterns in a
short segment of human colonic tissue. Method: Whole layer of
2X4cm sized segment of colon tissue containing taenia coli were
obtained during colon resections for nonobstructive neoplasms.
A stainless steel rod was place parallel to longitudinal muscle and
placed at the organ bath which was perfused with Krebs-Ringer
bicarbonate (KRB) solution and maintained at 36+/-1¡É. CM
tension was recorded at three (oral, middle, aboral) sites and LM
tension was recorded by perpendicular traction. Tension recording
was performed using isometric strain gauge and transduced to
Acknowledge soft by clips and SPSS T-test was used for analysis.
Results: Total of 23 tissues were available for analysis. Dominant
Regular waves (DRW) were identified in all cases and occurred
with frequency of 0. 38+/-0. 32/min (amplitude: 16. 74+/-10. 28mN)
in CM and invariably resulted in anterograde propagation (from
oral to aboral side) in the CM layer, and also propagated to the
LM layer resulting in similar frequency of contraction (0. 36+/-0.
37/min; amplitude 23. 21+/-14. 62mN). In 5 tissues, non-dominant
waves (NDW) were identified in addition to DRWs (frequency: 0.
23+/-0. 10/min, amplitude: 22. 77+/-12. 40mN). The frequency (0.
51+/-0. 41/min) and amplitude (19. 07+/-19. 57mN) of the NDWs
tended to be similar to DRWs, and some of the NDWs showed
retrograde propagation (aboral to oral side), but none of these
waves propagates antergradely nor resulted in contraction of the
LM layer. No difference between right and left side of the colon
was noted. Conclusion: In segment of human colon, regular
contraction patterns propagating from oral to anal side in the CM,
and consequently resulting in contraction of the LM was noted.
On the other hand, in some of the tissues, non-propagating,
or retrograde propagating contractions in the CM without
contractions in LM were identified. Our results indicate that there
is continuous contractile activity to move the colonic contents
from oral to anal side in the short segment of human colon and
that time sequenced CM to LM contraction may contribute to this
purpose.
S015 IDENTIFICATION OF MITOCHONDRIAL F1F0ATP SYNTHASE INVOLVED IN LIVER METASTASIS OF
COLORECTAL CANCER, Min Ro Lee PhD, Jong Hun Kim PhD,
Department of Surgery, Chonbuk National University Medical
School
Liver metastasis is a major cause of poor survival of colorectal
cancer patients. In order to identify the proteins associated with
liver metastasis in colorectal cancer, we have performed 2-DEbased comparative proteomic analysis of normal colon mucosa,
primary colon cancer tissue, and corresponding metastatic tumor
tissue in liver and the proteins identified were has been further
validated by using immunohistochemical analysis of 67 triplet
samples of normal colon-primary colorectal cancer-synchronous
liver metastasis, and 251 colorectal cancers (a total of 318 colon
cancers, 67 normal colons, and 67 synchronous liver metastasis)
as well as in vitro invasion assay of the human colon cancer cell
line, SNU-81. From the proteome assessment, the mitochondrial
F1F0-ATP synthase (ATP synthase) a-subunit was identified as
a protein that is up-regulated in liver metastasis, compared to
the primary tumor. Immunohistochemical analysis confirmed
a significant increase in expression of ATP synthase a- and
d-subunits in synchronous liver metastasis, compared to primary
tumor and normal mucosa, respectively. ATP synthase a- and
d-subunits were overexpressed in 197 (78. 5%) and 190 (75. 7%)
38
ISUCRS XXII BIENNIAL CONGRESS out of 251 colorectal cancers, respectively. The overexpression
of the a-subunit and d-subunit were significantly associated
with liver metastasis (P<0. 05), as well as low histologic grade
(P<0. 0001). The d-subunit also correlated with venous invasion
(P=0. 026) and distant metastasis (P=0. 032). In stage III cancers,
d-subunit expression was independently associated with poor
survival (P=0. 017). Furthermore, transfection of siRNA targeted to
the suppression of ATP synthase d-subunit resulted in a decreased
of in vitro invasiveness of the human colon cancer cell line. Our
overall findings demonstrate that increased of ATP synthase is
associated with liver metastasis of colorectal cancer.
S016 5-FLUOROURACIL-RELATED GENE EXPRESSION
IN PRIMARY SITES AND HEPATIC METASTASES OF
COLORECTAL CARCINOMAS, Shinichi Sameshima PhD,
Shinichiro Koketsu PhD, Toshiyuki Okada PhD, Toshio Sawada
PhD, Gunma Cancer Center
Aim: The aim of this study was to investigate the correlation
of the mRNA expressions of 5-fluorouracil-related genes in the
primary sites and liver metastases of colorectal carcinomas.
Materials and Methods: Patients with liver metastases
from colorectal carcinomas were included (n=43). The
expression ratios of mRNA to ƒÀ-actin of thymidine synthase
(TS), dihydropyrimidine dehydrogenase (DPD), thymidine
phosphorylase (TP), and oroteta phophoribosyl transferase (OPRT)
were measured in primary and liver metastases of colorectal
carcinomas by laser-captured microdissection and real time PCR.
Results: The ratios for the expression of mRNA of TS, DPD, TP
and OPRT between paired primary sites and liver metastases were
significantly correlated. The mRNA expression ratios of DPD and
TP showed a significant correlation in primary sites and in liver
metastases. Conclusions: Enzymes of the primary colorectal
carcinomas can be used in predicting the therapeutic efficacy of
5FU against liver metastases.
COLORECTAL CANCER, BENIGN COLORECTAL
DISEASE & FECAL INCONTINENCE
S017 RISK FACTORS ASSOCIATED WITH LOCAL
RECURRENCE AFTER NEOADJUVANT CHEMORADIATION
COMBINED WITH TOTAL MESORECTAL EXCISION FOR
LOCALLY ADVANCED RECTAL CANCER, Nam-Kyu Kim MD,
Young-Wan Kim MD, Byung-Soh Min MD, Ki-Chang Keum MD,
Jin-Sil Seong MD, Jung-Bai Ahn MD, Jae-Kyung Roh MD, Hoguen
Kim MD, Department of Surgery, Yonsei University College of
Medicine, Seoul, Korea
Objective:
Preoperative
chemoradiotherapy
is
more
advantageous than postoperative chemoradiotherapy in patients
with clinical T3 or T4 or node-positive disease, especially in terms
of reducing local recurrence rate and enhancing anal sphincter
preservation. However, local recurrence is still a devastating
problem, which is closed related to poor oncologic outcomes and
patients’ quality of life. The purpose of this study is to investigate
patterns of local recurrence and risk factors affecting local
recurrence in patients with locally advanced rectal cancer who
received preoperative chemoradiotherapy in combination with
total mesorectal excision (TME). Methods: Between January 1994
and December 2004, medical records of 145 patients with locally
advanced rectal cancer who received neoadjuvant chemoradiation
(5-FU based chemotherapy and 5040Gy of radiation) with TME
surgery were collected from the prospective colorectal database.
All tumors were initially staged as cT3 or T4 regardless cN stage
at the multidisciplinary team meeting on the basis of physical
examination, abdominal computed tomography, and pelvic
magnetic resonance imaging. Results: 26 patients (17%) had
a local recurrence. Mean follow-up period was 40 months (3145 months), Mean time to local recurrence was 13 months
(5-93 months). Patterns of local recurrence were ten cases (38.
5%) of pelvic wall recurrence, six cases (22. 2%) of anastomotic
recurrence, and two cases of bladder recurrence. 3 year disease
specific survival is 40. 5% in local recurrence group and 78. 8%
in non-local recurrence group (p<0. 001). 50% of local recurrence
occurred within 13 months and 92% of local recurrence was
occurred within 3 years after surgery. On multivariate analysis,
factors affecting local recurrence are less than 50 years of age
(p=0. 039), positive circumferential resection margin (p=0. 001)
ABSTRACT BOOK
Podium Papers
and lymphatic vessel invasion (p=0. 003) Conclusion: In patients
with locally advanced rectal cancer who received neoadjuvant
chemoradiotherapy with TME, Age younger than 50 years,
positive circumferential margin, and lymphatic vessel invasion
were statistically significant factors for local recurrence. For better
oncologic outcomes, adjuvant intensified chemotherapy, intraoperative radiotherapy, or extensive surgery should be considerd
in these patients having risk factors.
S018 THE LONG-TERM RESULTS OF SURGERY FOR COLON
CANCER IN JAPAN, Takashi Hirai PhD, Yukihide Kanemitsu MD,
Koji Komori PhD, Tomoyuki Kato PhD, Aichi Cancer Center
Operative procedures for colon cancer standardized in Japan
by establishing “the Japanese classification for colon and rectal
cancer” in these three decades. The level of curability that we
have arrived at, and surgical factors to contribute to the results are
evaluated. With those basic data of standardized surgical outcome,
we are able to presume who may obtain the profit from which
of postoperative adjuvant therapies. Patients and Methods:
1289 patients with single primary colon cancer excluding in situ
carcinoma who underwent curative operation in our hospital
during 1970 and 2003 are evaluated. None of the patients are lost
to follow up. They are divided to the three period groups by year,
the early period; 166 patients (1970-79), the middle period ; 341
patients(1980-89), the late period; 782 patients(1990-2003). Time
trends in surgical treatment (especially extent of lymph node
dissection), chemotherapy, and other oncological factors are
studied. To estimate the effect of the factors on survival, KaplanMeier method, Cox hazard model were used. Results: Overall
survival (OS) and disease free survival(DFS) improved over
the study period: the five year OS and DFS ( the early, middle,
late period, respectively) were Dukes Ai88%, 96%i26 ptsjA89%,
98% (61 pts)A93%, 98% ( 263pts ), N. S. , Dukes Bi78”, 82%i95
ptsjA87%, 86%i154 ptsjA86%, 91%i270ptsjj, N. S. , Dukes Ci60%,
62%i45ptsjA69, 70%i126ptsjA81%, 81%i249ptsjj, p<0. 05. The ratio
of wide lymph node dissection which is consisted of the adequate
resection of the colon and apical node dissection has increased
from 34. 6% to 90%. The mean number of harvested lymph nodes
has increased from 15 to 25. The curative surgical treatment of
recurrent tumor varied a little (3%, 5. 3%, 4. 7%, respectively).
Factors with impact on DFS by Cox hazard model were Dukes
classification, a period, preoperative CEA. The wide lymph node
dissection was not significant. But among wide lymph node
dissection, 5-year survival in late period was superior(84% vs
71%) to the other. We presume that the procedure advancement
in wide lymph node dissection obscured the result in multivariate
analysis. Conclusion: The surgical treatment of colon cancer have
chronologically resulted in improving the oncological outcome.
Especially wide lymph node dissection for stage III might have
largest impact on the improvement. But multivariate analysis
could not prove the efficady of the wide lymph node dissection.
S019
MOLECULAR
PROGNOSTIC
MARKERS
IN
COLORECTAL CANCER, Krasimir Ivanov MSc, Nikola Kolev
PhD, Anton Tonev MD, Gergana Nikolova PhD, Anton Tonchev,
Ivan Krasnaliev, Kalin Kalchev, University Hospital “St. Marina”,
Medical University - Varna, Bulgaria
Introduction: Despite the modest improvements in patient
survival from colorectal cancer in the last few decades, the
overall five-year survival rate remains at 40 to 45 percent. Surgical
resection is the mainstay of treatment for colorectal cancer;
however, nearly one-half of all patients who undergo a potentially
curative resection will relapse because of undetected metastasis.
The fact that the overall survival rate remains poor strongly
suggests that the dissemination of these cells occurs early in the
disease process and emphasizes the need for finding feasible
diagnostic methods with sufficient sensitivity and specificity for
evaluation of tumor aggressiveness. The p-53, MUC-2, Ki-67,
VEGF, Bax, Bcl-2, Stat, MMP2 are markers, which could describe
all the stages of carcinogenesis. There some questions remaining
about their clinical value and hence most recent studies are
utilizing a combination of factors. Aim: To clarify the usefulness
of immunohistochemical molecular markers in predicting the
metastatic potential and tumor behavior of colorectal cancer.
Material and Methods: We evaluate the expression of those
markers in group of 72 patients with colorectal carcinoma.
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We observed the relations between: 1) type of operation; 2)
histological type; 3) clinical stage; 4) individual risk index (IRI),
based on evaluated expression of tumor markers. Results:
Achieving 100% successful rate in our study, we statistically
analyzed the data received from marker’s expression. Based
upon that, we calculated an IRI for every patient and divided the
patients in 3 groups. A Group A, formed by 28 (38%) patients,
which are with low clinical stage and worse molecular prognosis.
A Group B, formed by 20 (27%) of patients had low tumor
aggression and III or IV clinical stage and Group C, formed by the
other 26 (35%) of the patients where is a correlation between the
molecular and clinical stage prognosis. Conclusion: Multivariate
analysis revealed that the IRI is independent prognostic factor for
the tumor outcome. There were many evidences for the need of
alteration of the surgical behavior in different stages according
to biological nature of the tumor. Analysis of a combination of
immunohistochemical molecular markers with the conventional
diagnostic methods for colorectal cancer allows better prediction
of the patients’ prognosis and more accurate and individualized
therapeutic strategy. That could decrease the incidence of
recurrence-rate and increse the survival.
S020 ADJUVANT THERAPY FOR COLORECTAL CANCER
PATIENTS
RECEIVING
NON-CURATIVE
SURGICAL
RESECTION, Giichiro Tsurita PhD, Takeshi Nishikawa MD,
Yoshiki Takei PhD, Shinsuke Saito PhD, Takamitsu Kanazawa PhD,
Shinsuke Kazama PhD, Eiji Sunami PhD, Hirokazu N Tsuno PhD,
Hirokazu Nagawa PhD, Department of Surgical Oncology, the
Graduate School of Medicine, the University of Tokyo
Aim: To investigate the prognosis of patients receiving noncurative surgical resection for colorectal cancer. Patients: Among
the primary colorectal cancer patients treated at our surgical
department in the period between January 2001 and March 2006,
67 patients receiving non-radical (excluding cases with complete
resection A and B) surgery were chosen. Rectal cancer cases
receiving pre-operative irradiation were excluded. Method 1:
Patients were divided into: FL group (n=32), i. e. , cases receiving
intravenous 5-FU/Isovorin as the primary chemotherapy, oral
chemotherapy group (n=5), i. e. , cases receiving either 5-FU/
leucovorin or TS-1 p. o. , FF group (n=11), i. e. , cases receiving
FOLFOX or FOLFIRI, and CT(-) group, i. e. , cases not receiving
any kind of chemotherapy. The effectiveness of the treatment,
the survival period, and the development of side-effects were
compared among these groups. Result 1: Regarding the
effectiveness of the treatment and the survival period, cases in the
FF group showed better results compared to the other 3 groups.
Additionally, the cases in the CT(-) group had significantly poorer
prognosis. Method 2: The patients receiving chemotherapy
were divided, according to surgical procedure, into the following
groups: resected group (n=33), i. e. , cases in which the primary
lesion was resected, stoma group (n=8), i. e. , cases in which the
primary lesion left, and non-surgery group (n=7), which included
patients not receiving surgical resection, and the prognosis
compared among them. Result 2: The survival period of the
stoma group was significantly shorter than the other 2 groups.
Conclusion: Chemotherapy should be preferentially indicated
for patients with colorectal cancer in which radical resection is not
feasible, especially when the primary lesion is left unresected.
S021 OUTCOME OF PATIENTS WITH CLINICAL STAGE II
OR III RECTAL CANCER TREATED WITHOUT ADJUVANT
RADIOTHERAPY, Shin Fujita MD, Seiichiro Yamamoto MD,
Takayuki Akasu MD, Yoshihiro Moriya MD, National Cancer Center
Hospital
Purpose: To clarify the indications for preoperative adjuvant
radiotherapy for rectal cancer, the outcome of patients who
underwent curative surgery without adjuvant radiotherapy was
investigated. Methods: A total of 817 consecutive patients
who underwent curative surgery for clinical stage II or III rectal
cancer without preoperative adjuvant radiotherapy between 1988
and 2002 were reviewed. Results: The actuarial five-year local
recurrence rate in the examined patients was 6. 2%. Univariate
analysis showed that sex, pathological T classification (pT), clinical
N classification (cN), pathological N classification (pN), tumor site,
distance from the anal verge, type of surgery, pathological stage, a
positive radical margin, lymphatic invasion, and venous invasion
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were significantly correlated with local recurrence. Multivariate
analysis of preoperative factors identified cN, distance from the
anal verge and sex as statistically significant risk factors for local
recurrence. In patients with rectal cancer located less than 5 cm
from the anal verge and with positive cN, the local recurrence rate
was more than 10%. Conclusions: Patients with rectal cancer
located less than 5 cm from the anal verge and with clinically
positive lymph nodes should be given preoperative adjuvant
radiotherapy.
S022 LONG TERM OUTCOME OF ALTEMEIER’S PROCEDURE
FOR RECTAL PROLAPSE, Donato F A MD, Gianandrea Binda
MD, Ezio Ganio MD, Paola De Nardi MD, Marcella Rinaldi MD,
Aldo Infantino MD, Giuseppe Dodi MD, Nicola Tricomi MD,
Diego Segre MD, Giuseppe Di Giuro MD, Paolo Giamundo MD,
Mario Pescatori, Dept of Emergency and Organ Transplantation,
Introduction: Many abdominal and perineal operations have
been proposed for treating full-thickness rectal prolapse, but
the best operation and correct indications have never been
established. Perineal rectosigmoidectomy was proposed in 1976
by Altemeier butrarely applied in European countries, and its long
term reliability is uncertain due to the low number of patients
treated in each center. Patients and Methods: 93 patients
(female/male ratio 7. 45, median age 77 years) underwent perineal
rectosigmoidectomy and levatorplasty according to Altemeier,
under general (30 pts), spinal (53 pts) or loco regional anesthesia
(10 pts). In 14 of them the prolapse had previously been treated
by other surgery; 68% suffered from major fecal incontinence, 6%
from soiling. The mean duration of the operation was 125 min
and the median length of the rectocolonic resected specimen
was 15 cm. Coloanal anastomosis was fashioned manually in all
but 3 cases where a 31mm circular stapler was used. Results:
There was no postoperative mortality. Six major complications
were observed (3 pelvic hematomas, one requiring surgical
revision, 1 anastomotic dehiscence, one sigmoid perforation
both requiring diversion, 1 pararectal abscess, and 2 late anal
strictures), and 13 minor complications (5 transient anal pain and
burning sensation, 2 a high temperature, 2 urinary retention, 2
cystitis, and 2 rectorrhagia). Mean post-operative hospital stay
was 6 days (range 1-25). At a mean follow-up of 41 months (range
12-112 months) there was a complete recurrence rate of 18%
(17 patients), treated with a repeated Altemeier’s operation in 6
cases, with a Delorme’s operation in 1, with a Wells’ rectopexy
in 1, post anal repair in 1, anal bulking agents in 2 and SMN in
2, (4 patients were not re- operated). Incontinence had improved
postoperatively in 30 cases (48%) (soiling or no incontinence),
while in 2 pts it had deteriorated. Four of the patients with normal
preoperative continence had postoperative soiling, which was
transient in 1 patient. Conclusions: Perineal rectosigmoidectomy
for full thickness rectal prolapse is a safe and effective treatment
particularly for frail and old patients, with minimal postoperative
morbidity, although the recurrence rate is not negligible and the
restoration of continence unpredictable.
S023 SURGICAL TREATMENT OF FISTULA-IN-ANO
IN SINGAPORE - A RETROSPECTIVE STUDY OF 457
PATIENTS, Law Chee Wei, Iwan Kristian, Charles Tsang BihShiou, Dean Koh Chi Siong, Cheong Wai Kit, Division of Colorectal
Surgery, Department of Surgery, National University Hospital of
Singapore
Objective: To evaluate the outcomes of patients who underwent
surgical treatment for fistula-in-ano (FIA) from 2002 to 2006.
Patients and Methods: All patients who underwent various
types of surgery for FIA were studied retrospectively. All fistulae
were classified using Parks’ classification and type of surgery
performed was recorded. Specific end points studied included
patient demographics, type of surgical procedure correlated with
type of fistula, healing and recurrence rates. Results: 457 patients
with a mean age of 41. 2 years were assessed. Male to female ratio
was 4:1. Ethnic distribution was as follows: Chinese 66. 3%; Indian
16. 2%; Malay 13. 1% & others 4. 4%. 8. 5% of the patients had comorbidities (7. 2% diabetes mellitus; 0. 7% inflammatory bowel
disease; 0. 4% rectal cancer & 0. 2% HIV positive). 45. 5% of them
were evaluated preoperatively with endoanal ultrasonography.
The distribution based on classification was as follows: inter-
40
ISUCRS XXII BIENNIAL CONGRESS sphincteric 209 (47. 3%), transs-phincteric 220 (49. 8%), suprasphincteric 2 (0. 5%), extra-sphincteric 4 (0. 9%) and horseshoe 7
(1. 6%). 26 patients (5. 7%) had secondary extension of fistulous
track. 10 patients (2. 2%) had fistula operation performed prior to
their presentation to our hospital. Fistulotomy was predominantly
performed for low inter-sphincteric (85%) & low trans-sphincteric
fistulae (71%). For higher complex fistulae, seton insertion
followed later by definitive surgery was performed for high intersphincteric (69%) & high trans-sphincteric (68%) , supra-sphincteric
(50%), extra-sphincteric (100%) & horseshoe fistulae (100%). The
mean time before definitive surgery after seton insertion was 8.
9 weeks. The mean time to complete wound healing following
surgery was 15 weeks. Fistulae persistence occured in 29 patients
(6. 3%) whilst complete healing was achieved in 428 patients
(93. 7%). The number of operations required for complete
healing of the fistulae were distributed as follows: 1 operation:
333 (72. 9%), 2 operations: 76 (16. 6%), 3 operations: 15 (3. 3%)
and 4 operations: 4 (0. 9%). After a mean follow up of 25 weeks,
recurrence was noted in 12 patients (2. 6%). Conclusions: Our
prevalence and distribution of FIA were similar to other studies.
The outcomes following surgery guided by Park’s classification
was satisfactory.
S024 RECTAL IRRIGATION (RI) IS A BOON FOR CHRONIC
CONSTIPATION - A PROSPECTIVE REVIEW, N Srinivasaiah
MD, J Marshall RN, A Gardiner RN, G S Duthie MD, 1. Academic
Surgical Unit, Castle Hill Hospital, University of Hull, Cottingham,
United Kingdom
Introduction: RI is used in faecal incontinence to relieve
symptoms & improve quality of life. Literature on its role in
constipation is limited. We aim to evaluate the causes for referral,
efficacy & acceptability of RI using health outcome measures and
assess effect on constipation. Methods: Review of prospective
database of RI between 2002 & 2005. Symptom quantification
using general standardized questionnaire (GSQ) determined
efficacy. SF-36 & FIQL determined acceptability. Results: 175
patients’ data is used. 111(63%) patients found RI useful & 64(37%)
unhelpful. The median follow up is 20 months. 79 of 175 patients
were referred for constipation. 39 (49%) had success with RI.
Patients who had successful RI, 56% said that they were
“doing well” or “good improvement”, 26% said “dramatic
improvement” whilst 17% said “limited” improvement
using RI. Up to one third of the patients had RI once a day.
GSQ, SF 36 and FIQL were analyzed pre & post RI for the
whole group. Analysis is done only on successful cases.
GSQ: Showed significant improvement in symptoms of straining,
incomplete emptying, wind & urinary leak on stress post RI
(95% CI). Visual Analog Scales show reduction in the severity
of the problem. SF36: 71 of 111 patients completed SF36 pre
RI & 43 of these also completed it post RI. In the whole group
the median value for MCS increased from 43 to 55 and PCS
increased from 47 to 66. PCS is significant (p value of 0. 03). In
the group of patients with constipation the percentage increase
in MCS & PCS is 20% and 33% respectively post RI. FIQL: Slight
improvement in QOL is measured, but statistically insignificant.
Conclusions: Constipation accounted for nearly half of referrals.
RI was successful in nearly half of the referred population. SF- 36
demonstrates a significant improvement in the PCS. Generally
speaking, RI offers symptomatic improvement & most patients
find it acceptable. Abbreviations: MCS - Mental Component
Score, PCS: Physical Component Score
S025 SPHINCTER REINFORCEMENT WITH A SIMPLE
PROSTHETIC SLING FOR ANAL INCONTINENCE, José
Manuel Devesa MD, Rosana Vicente MD, Pedro Lopez-Hervas
MD, Hospital Ruber Internacional. Madrid. Spain
Purpose: Different ways of management of fecal soiling or minor
degrees of incontinence are usually unsuccessful. We report the
technique and results of anal encirclement with a simple prosthetic
sling, never used before as that, as a safe, easy to perform and
cheap alternative option. Methods: Between 2004 and 2007, 12
patients (6 female) aged 18 to 73, underwent the technique here
described for treating fecal soiling or incontinence of different
etiology ( iatrogenic 4, obstetric 2, traumatic 2, neuropatic 2, mixed
2) after failure of previous sphincteroplasty and conservative
management. Patients were assessed preoperatively and at
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regular intervals clinically and functionally (manometry, JorgeWexner Fecal Incontinence Score, amount and episodes of leakage,
each person serving as his or her own control). All patients were
operated on by the same surgeon and data were recorded by an
independent coordinator. The operation is performed under local
or regional anaesthesia in the lithotomy position. Through four to
five small perianal incisions the flat part of a Jakson-Pratt ® drain
is inserted 2 cm deep encircling the anus. The technical details of
the procedure are shown. Results: Complications were related
to local infection requiring removal (2), breaking of the sling
requiring replacement (1) and fecal impaction (1). In 3 patients
a neoencirclement was performed. Pre- and postoperative mean
resting pressure were 54 mm Hg (range 8 -88) and 72 mm Hg
(range 52-90) respectively. No differences were found between
mean pre and postoperative squeeze pressures (108 mm Hg and
108 mm Hg respectively). Jorge- Wexner mean preoperative score
was 14. 6 (range 2-20) while postoperative score was 3 (range 1-7).
All but 1 patient improved the clinical status. Conclusions: This
is a simple technique which may improve the continence status in
patients with soiling and variable degrees of incontinence, when
other alternatives have failed or more sophisticated techniques
are not available.
S026 ANAL ELETROMANOMETRY AND BI-DIMENSIONAL
ULTRASOUND EVALUATION OF FECAL INCONTINENCE:
IS THERE A CORRELATION?, Jose Paulo T Moreira MD, Hélio
Moreira Jr MD, Hélio Moreira PhD, Almeida C Arminda MD, Issac
R Raniere MD, Coloproctology Service, Federal University of
Goiás, Brazil
Introduction: The complex mechanism of anal continence occurs
due to the neuromuscular integrity of the anal canal, consistency
of the intra-rectal content, rectal capacity and sensibility. Fecal
incontinence is a common occurrence among women and may
be developed after anal surgical procedures, anal traumas such
as during vaginal delivery, or due to idiopathic neuropathy of the
pudendal nerves. New advances in anorectal physiology tests
allowed a better evaluation of these patients, especially anorectal
eletromanometry as anal US. Aim: Evaluate the correlation
between Anal Eletromanometry and Anal US in patients with
fecal incontinence. Methods: 61 patients with fecal incontinence
who had undergone EMN and Anal US were analyzed from our
database program between jun/2006 to sept/2007. Resting and
squeeze pressures, and muscular anatomy of the 3 thirds of the
anal canal were recorded and evaluated. Results: Approximately
75% of the patients have had sphincter defects of anal US. Defects
of the external sphincter of the anus were the lesions observed
more frequently (almost half of the patients). Defects of the
internal anal sphincter isolated were detected in about 1/3 of
the patients and the majority of the cases were due to iatrogenic
etiology, such as surgical procedures. The correlation between
defects of the internal and external anal sphincter (observed by
anal US) with resting and squeeze pressures of the anal canal
(observed by EMN) was 71% and 73% respectively. About 20%
of the patients who had any grade of sphincter defect by anal
US had normal resting and squeeze pressures by EMN, showing
pure correlation between the tests. Among the patients without
sphincter defect by anal US, in 1/3 of them the EMN showed low
anal sphincter pressures. Conclusion: EMN and anal US were
elucidative methods in the investigation of patients suffering
for fecal incontinence (the correlation between both tests is up
to 70%). However, 20% of patients with sphincter defects had
normal anal pressures. Therefore, we conclude that both tests
are important and complimentary in the evaluation patients with
fecal incontinence.
S027 FACTORS AFFECTING THE SUCCESS OF SACRAL
NERVE STIMULATION FOR FECAL INCONTINENCE,
Donato F Altomare MD, Marcella Rinaldi MD, Pierluigi Lobascio
MD, Pierluca Sallustio MD, Fabio Marino MD, Ramona Giuliani
BS, Vincenzo Memeo MD, Dept of Emergency and Organ
Transplantation, University of Bari, Italy
Sacral Nerve Stimulation (SNS) is a recognized and effective
treatment for fecal and urinary incontinence. Nevertheless, up to
30-50% of the tested patients are unresponsive to this technique
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for unknown reasons and since SNS is an expensive procedure,
identification of the factors predictive of success is highly
desirable. (PNE test). Patients: 76 patients (female/male ratio= 0.
77, mean age 57 y) with fecal incontinence have been tested for
SNS. 41 with passive incontinence and 28 with urge incontinence,
while the remaining cases had a mixed or undetermined type
of incontinence. The cause of incontinence was idiopathic in 36,
iatrogenic in 26, neurologic (including spinal lesions) in 9. We
tested 43 pts with a temporary monopolar electrode while 33 had
a quadripolar electrode implanted. All under local anesthesia.
Three of them had already had an unsuccessful dynamic
graciloplasty and one an artificial bowel sphincter. The severity of
fecal incontinence was tested with the AMS and Wexner’s score. A
positive test is defined as a reduction by at least 50% in at least one
of the severity scores. Results: A positive test was obtained in 38
pts (50%) and 30 (39. 5%) of them were definitely implanted with a
permanent stimulator (Interstim Medtronic Italia). The remaining
patients refused the implantation (3), or no longer complained of
fecal incontinence after removal of the temporary test (2), or else
are awaiting implantation. Accidental removal was recorded in 6
of the monopolar electrodes, infection in one of them. The test
was positive in 6 of the 10 patients with diabetes but only 4 of
them were definitely implanted. The 2 groups were comparable
regarding age, duration of incontinence, anal manometry, PNTML,
AMS score and diabetes. The monopolar electrode test (PNE test)
was able to elicit positive responses in 18/43 patients (42%), while
the new quadripolar electrode test was positive in 20/33 (61%)
p=0. 01. Passive incontinence responded to this treatment in 21/41
cases (54%), while urge incontinence had a good outcome in
13/28 (46%), p=NS. A positive response to the SNS was obtained
in 33. 3% of the males compared with the 47. 1% of the females
p= NS. Patients with idiopathic incontinence had significantly
higher response rate p=0. 022. Multivariate logistic regression
analysis shows that only the use of a quadripolar electrode was
the single independent variable predicting the outcome with an
OR of 5. 58. A trend toward significance was observed for the
female sex, idiopathic cause and Wexner’s score. Conclusions:
Female patients with passive, idiopathic incontinence may have
better probability to respond to temporary SNS but the use of the
self retaining quadripolar electrode is the only factor significantly
related to the success rate.
COLORECTAL CANCER,
S028 INTERSPHINCTERIC RESECTION VERSUS STAPLED
COLOANAL ANASTOMOSIS FOR LOW RECTAL CANCER,
Bong Hwa Lee MD, Hyoung-Chul Park MD, Hallym University
College of Medicine, Seoul, South Korea
Purpose: Local control and functional results of intersphincteric
resection are controversial in Asian - low BMI patients, even
though it might provide chance to avoid permanent colostomy. We
tried to evaluate functional and oncologic risk of intersphincteric
resection, compared with stapled coloanal anastomosis, in
patients of low rectal cancer. Methods: Patients with low rectal
cancer underwent intersphincteric resection with hand-sewn
anastomosis (ISR) or coloanal anstomosis with staple (stapled
CAA) were retrospectively analyzed. Results: From 1999 to 2006,
85 patients were enrolled. The distance between anal verge and
lower margin of tumor was 3. 4 -0. 8 cm (Range 2-5 cm) in ISR
group and 4. 9 -0. 8 cm (Range 3-7 cm) in stapled CAA. The mean of
body mass index was 23 (Range 18-32). The patients complained
intolerable anal incontinence (Kirwan뭩 class >2) in 35% of
ISR group and 9% in stapled CAA (P<0. 02) postoperatively. Local
recurrence rate was greater in ISR group (15%) than in stapled
CAA (2%, P<0. 04). There was no significant difference in distant
metastasis between both groups. The disease free survival rate
was 80. 8% and 91. 2% at three years in ISR group and stapled
CAA, respectively. Complications such as urinary incontinence and
sexual function in male patients were not different significantly
in both groups. Conclusions: Intersphincteric resection with
hand-sewn anastomosis could be worse than stapled coloanal
anastomosis in function and local recurrence. This may indicate
that careful selection should be required for intersphincteric
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resection even if stapled anastomosis cannot be applied due to
narrow distal resection margin.
Local Recur and Distant Metastasis after Operation
Operation
Operation
ISR
Stapled CAA
P-value
Local Recur
6/41 (15%)
1/44 (2%)
0. 04
Metastasis
6/41 (15%)
4/44 (15%)
NS
S029 LONG-TERM FUNCTIONAL CHANGES AFTER LOW
ANTERIOR RESECTION FOR RECTAL CANCER COMPARED
BETWEEN A COLONIC J-POUCH AND A STRAIGHT
ANASTOMOSIS, Jin-ichi Hida MD, Takehito Yoshifuji MD,
Fumiaki Sugiura MD, Masako Takemoto MD, Takashi Hattori MD,
Osaka, Japan
Purpose: We prospectively compared changes in function
between colonic J-pouch and straight anastomoses from 1 to
5 years after low anterior resection for rectal cancer. Methods:
At 1, 3, and 5 years after surgery, functional outcome was
compared between 48 patients with J-pouch reconstruction (J
group) and 51 with straight anastomosis (S group), using a 17item questionnaire (overall best, 0; overall worst, 26). Reservoir
function was evaluated manovolumetrically. Results: At 5 years,
patients with ultralow anastomoses (less than 4 cm from anal
verge) had fewer bowel movements during day or night, and less
urgency and soiling in the J than S group. At that time, patients
with low anastomoses (5 to 8 cm above the verge), had fewer
bowel movements at night and less urgency in the J than S group.
Manovolumetric results were better in the J than S group for both
anastomotic levels. Functional scores improved significantly over
time for both anastomotic levels, especially in the S group. Mean
scores with ultralow anastomoses were J group, 5. 6 at 1 year vs. 5.
3 at 3 years (P=0. 0304) vs. 3. 7 at 5 years (P<0. 0001); and S group,
10. 2 at 1 year vs. 9. 6 at 3 years (P=0. 0063) vs. 7. 3 at 5 years (P<0.
0001). Mean scores with low anastomoses were J group, 3. 4 at 1
year vs. 3. 1 at 3 years (P=0. 0052) vs. 2. 1 at 5 years (P=0. 0003);
and S group, 5. 2 at 1 year vs. 3. 8 at 3 years (P<0. 0001) vs. 2. 7 at
5 years (P<0. 0001). Manovolumetric results improved overtime in
both groups. Conclusions: Functional outcome improved in the
J and especially the S group over 5 years. However, function was
better in the J than S group at all time points.
S030
ACCURACY
OF
MAGNETIC
RESONANCE
IMAGING AND TRANSANAL ULTRASONOGRAPHY TO
PREDICT PATHOLOGIC STAGE AFTER PREOPERATIVE
CHEMORADIOTHERAPY FOR RECTAL CANCER, Sang Nam
Yoon MD, Chang Sik Yu MD, Ah Young Kim MD, Dae Dong Kim MD,
Ui Sup Shin MD, Jin Cheon Kim MD, Colorectal Clinic, Department
of Colon and Rectal Surgery, and Radiology, University of Ulsan
College of Medicine and Asan Medical Center
Background: Preoperative chemoradiotherapy (PCRT) is currently
the main neoadjuvant therapy used to treat locally advanced
middle and low rectal cancer. Preoperative magnetic resonance
imaging (MRI) and transanal ultrasonography (TUS) was hoped to
provide information about the effects related to PCRT. Purpose:
The aim of this study was to evaluate the correlation between
pathologically verified tumor stages and clinical stages predicted
by MRI and TUS after PCRT. Methods: The study subject was 165
patients with mid or low rectal cancer who underwent surgery
after PCRT between January 2006 and June 2007 and for whom
both MRI and TUS were tested. The total dose of radiotherapy
was 50 Gy and it was delivered to the patients with 2 Gy per
day and 5 times per week for 5 weeks. Chemotherapy regimen
was oral Xeloda (1, 650 mg/m2 divided by 2) for 5 weeks during
radiotherapy and a standard regimen with 5-fluorouracil with
leucovorin was also used for some patients. Results: The overall
predictive accuracy of MRI and TUS in T stage was 45. 5% and
44. 8%, respectively, whereas overstaging and understaging
occurred in 50. 3% and 4. 2% in MRI and 49. 1% and 6. 1% in TUS.
In N stage, accurate staging of MRI and TUS was noted in 43. 6%
and 66. 7%, respectively, whereas overstaging and understaging
occurred in 50. 3% and 6. 1% in MRI and 13. 3% and 20% in TUS.
42
ISUCRS XXII BIENNIAL CONGRESS Conclusions: There was poor agreement between clinical staging
by MRI and TUS after PCRT and pathologic staging in both T and
N stages. Most of the inaccuracy in T and N stages was caused by
overstaging, especially with T0-T2 tumors. The problem might be
that it cannot completely differentiate fibrosis from viable residual
tumors after preoperative chemoradiotherapy. Key words:
Rectal cancer, Preoperative chemoradiotherapy, MRI, Transanal
ultrasonography
S031 EFFECTS OF SURGICAL TIMING ON PROCTECTOMY
COMPLICATIONS AFTER LONG COURSE NEOADJUVANT
THERAPY, Emre Balik MD, Metin Keskin MD, Suleyman Bademler
MD, Burak Ilhan MD, Sumer Yamaner MD, Turker Bulut MD,
Yilmaz Buyukuncu MD, Necmettin Sokucu MD, Ali Akyuz, Dursun
Bugra, Istanbul University, Istanbul Faculty Of Medicine, General
Surgery Department
Aim: Our aim was to find out the alterations of the early and the
late-term postoperative complications between the two groups of
rectal cancer patients having been operated at the end of either the
4th, or the 8th week following neoadjuvant therapy (NAT). Method:
146 patients who had been operated following neoadjuvant
chemo-radiotherapy for rectal cancer between October 2002 and
November 2007 were investigated retrospectively. According
to the time of operation after the Rx&Cx, surgical technique,
intra-operative, early and late postoperative complications were
evaluated. Results: Seventy five patients (51%) were operated
at the end of the 4th week and 71 patients (49%) were operated
at the end of the 8th week following NAT. The mean follow-up
period was calculated to be 24 months(1-62 months). The group
of 75 patients operated at the end of the 4th week consisted of
41 male (54. 5%) and 34 female (45. 5%) individuals with a mean
age of 54 (19-84). The group of 71 patients operated at the end
of the 8th week consisted of 40 male (56%) and 31 female (44%)
individuals with a mean age of 51, 9 (20-77). No intra-operative
or early postoperative mortality was observed. In the “4th week
group”, the intra-operative complication rate was 9, 3% (n=7) ,
the early postoperative complication rate was 21, 3% (n=16) and
the late-term complication rate was found to be 8% (n=6). The
major complications were considered to be anastomotic leakage
and abdominal wound dehiscence (4 patients) whereas the other
complications were accepted to be minor. On the other hand, in
the “8th week group”, the intra-operative complication rate was 5,
6% while the early postoperative complication rate was calculated
to be 28% and the late-term complication rate was found to be
12%. Conclusion: Although a definitive conclusion can not be
reached because of the limited number of patients and the lack
of the complete exact late-term results, it can be stated that no
statistically significant difference could be established due to the
intra-operative, early postoperative and late-term complications
between these two groups of patients that had been operated
either at the end of the 4th, or the 8th week following their
neoadjuvant theraphy
S032 THE FREQUENCY OF MICROSATELLITE INSTABILITY
IN MULTIPLE PRIMARY COLORECTAL CANCER AND
METACHRONOUS COLORECTAL CANCER, Toshimasa
Yatsuoka MD, Kiwamu Akagi MD, Tsutomu Ishikubo MD, Shinichi
Asaka MD, Yoji Nishimura MD, Hirohiko Sakamoto MD, Yoichi
Tanaka MD, Division of gastroenterological surgery and cancer
genetic diagnosis, Saitama Cancer Center
Background: Some colorectal cancer (CRC) patients have
multiple primary colorectal cancers (MPCRCs) and metachronous
CRCs (MCRCs). Aim: We evaluate the current status of MPCRC and
MCRC with primary colorectal cancer. This study has examined
the proportion of MSI tumors in patients with MPCRC and MCRC
compared with primary solitary CRC. Methods: Five hundred
and ninety-eight colorectal cancer patients treated between 2000
and 2004 were analyzed. A total of 100 patients with MPCRC and
16 MCRC patients with invasive colorectal cancer were identified.
Evaluable tumors were tested for MSI, hypermethylation of the
MLH1 promoter and mutation of both KRAS and BRAF. Using
a panel of microsatellite markers including mononucleotide
and dinucleotide repeats recommended by the National Cancer
Institute workshop on MSI, tumors were classified as high level
(MSI-H), low level (MSI-L) or stable (MSS). Results: Out of
the 598 patients in the study, 218 (36%) had a family history of
ABSTRACT BOOK
Podium Papers
HNPCC-related malignancy, but only one fulfilled the Amsterdam
II criteria. Forty of 598 tumors (6. 7%) were MSI-H. Among 100
MPCRCs, gastric cancer was the most common occurrence (47%)
followed by prostate cancer (11%) and lung cancer (9%) in the 57
male patients. In the 43 female patients, breast cancer was the
most common site (31%) followed by gastric cancer (23%) and
cervix cancer (20%). These cancers were commonest diseases
in Japan. The frequency of MSI-H was significantly greater in
the metachronous CRC, 5 out of 16 (31%) compared with the
solitary cancers, 26 out of 482 (5. 4%), P=0. 018. MSI-H was more
prevalent in multiple primary CRC, 9/100 (9%) than in solitary
cancers (5. 4%), P=0. 168. Patients with MSI-H tumors were in
older female predominantly. Germ line mutations of MMR genes
(MLH1, MSH2 and MSH6) were confirmed in 13 out of 40 patients
(33%) with MSI-H tumor and the methylation of hMLH1 promoter
was identified in 19 (48%). Twelve CRCs (30%) with MSI-H showed
BRAF V600E mutation. Conclusions: MSI-H is more commonly
identified in patients with multiple primary colorectal cancers and
metachronous colorectal cancers.
S033 SURVEILLANCE OF ANAL CANCER PRECURSOR
LESIONS IN HIV POSITIVE AND HIV NEGATIVE PATIENTS,
Ricardo A Alfonzp MD, Luis H Angarita MD, Juan C Sierra MD,
Hospital de Clinicas Caracas, Caracas, Venezuela
Anal cancer affects the squamous epithelium of the anal canal
and the perianal skin region. The incidence of anal cancer has
increase in the past 30 years. There is evidence that Human
Immunodeficiency virus (HIV) positive patients are more likely to
present with Human Papiloma Virus (HPV); and patients with HPV
are more likely to present with anal cancer. Here we attempt to verify
the importance of the surveillance for HPV for the population that
visits the colon and rectal clinic at the Hospital de Clinicas Caracas.
Materials and Methods: Between 1999 and 2006 we studied
1444 patients that visited our clinic, all patients were screen for
HPV with cytology and polymerase chain reaction (PCR) . The
population was divided in HIV positive and negative. Each group
was subsequently divided according to the cytology results; in
Carcinoma, low grade dysplasia, high grade dysplasia. Then both
groups were compared. Results: There were 612 patients in the
HIV negative group and 832 patients in the HIV positive group.
Carcinoma in situ was present in 1. 1% of the HIV negative group
and in 3. 7% of the HIV positive group. High grade dysplasia was
present in a significant portion of both groups. The HIV positive
patients also were positive for HPV in 90% of the cases. The HIV
negative patients were positive for HPV in 64% of the cases. These
results were confirmed with by PCR. Conclusion: We found that
for the population that visits the colon and rectal surgery clinic at
the Hospital de Clinicas Caracas there is a very high incidence of
HPV in both HIV positive and negative patients. In both groups
high grade dysplasia was comparable and HIV positive patients
are more likely to present with carcinoma in situ. There for we
now routinely screen for HPV all the patients that visit our clinic.
S034 WITHDRAWN
S035 INTERMEDIATE RESULTS OF A PROSPECTIVE
RANDOMIZED STUDY ASSESSING A BRIEF COURSE
OF PERIOPERATIVE INTRAVENOUS ANTIMICROBIAL
PROPHYLAXIS IN RECTAL CANCER SURGERY, kouki
kuwabara MD, Keiichiro Ishibashi MD, Masatsugu Ishii MD, Toru
Ishiguro MD, Tomonori Ohsawa MD, Norimichi Okada MD, Masaru
Yukoyama MD, Tatsuya Miyazaki MD, Moriyuki Matsuki MD,
Hideyuki Ishida MD, Department of Digestive Tract and General
Surgery, Saitama Medical Center, Saitama Medical University
We report the intermediate results of a prospective randomized
study assessing a brief course of intravenous antimicrobial
prophylaxis in combination with chemical bowel preparation
in rectal cancer surgery. A total of 190 patients who underwent
elective surgery for rectal cancer were enrolled, and 181 patients
were eligible. All eligible patients were given kanamycin and
erythromycin orally after mechanical cleansing, which started
within 24 hours of surgery. Those patients were randomized to
receive intravenous flomoxef on the day of surgery (Group A,
n=87) or for three days (Group B, n=94). The rate of surgical site
infection was 12. 6% in Group A and 16. 0% in Group B (p=0.
52). The rate of MRSA infection was 5. 7 % in Group A and 7.
www.isucrs.org/
4% in Group B (p=0. 87). In addition, the leukocyte counts and
C-reactive protein levels on postoperative days 1, 4, and 7 did
not significantly differ between the groups. These results suggest
that use of methods of perioperative antibiotics, according to
CDC guideline could be well applied for rectal cancer surgery in
Japan.
S036
COMPARATIVE
ANALYSIS
OF
PROTECTIVE
ILEOSTOMY CLOSURE AFTER INITIAL LAPAROSCOPIC
VS. OPEN COLORECTAL SURGERY, Homero Rodriguez
MD, Roberto Ramos MD, Sofia Sanchez MD, Omar Vergara MD,
Manuel Moreno MD, Hector Tapia MD, David Velazquez PhD,
Quintin Gonzalez MD, Instituto Nacional de Ciencias Médicas y
Nutrición Salvador Zubirán (INCMNSZ)
Introduction: Loop ileostomy is traditionally indicated to avoid
anastomotic leakage or dehiscence in colorectal surgery. They
are especially indicated in the presence of risk factors such
as an anastomosis site less than 5 cm from the anal margin,
radiotherapy, bowel obstruction, wound infection or poor
surgical expertise Aims: To determine differences regarding
surgical time, postoperative complications, hospital stay length
and surgical reintervention frequency between patients who
underwent loop ileostomy after laparoscopic (LS) or open (OS)
colorectal surgery. Methods: 71 medical charts of patients in
whom protective loop ileostomy was performed after a primary
LS or OS colorectal surgery from 2003 to 2007 at our institution
by a single surgical team were reviewed. Data was collected and
tabulated for every included patient by one colorectal surgeon .
Descriptive and statistical analysis was performed using SPSS
8. 0 according to each variable scaling. Results: Thirty-seven
were female (52. 1%) and 34 male (47. 9%). In 43 cases (60.
6%) the primary approach was OS and in 28 (39. 4%) a LS was
performed. Gender, age and indications for primary surgery were
not statistically different among these two groups (p≥0.
05). As expected, surgical time for ileostomy closure and length
of hospital stay were generally shorter in patients with previous
LS than OS (p  0. 001). Only patients with OS exhibited
reintervention in 6 cases (14. 2%) but none with LS (p=0. 001).
Additionally, LS cases showed a decreased complication rate
(only 3 patients or 10. 7%) when compared with patients with OS
colorectal surgery (13 patients or 30. 2%, p= 0. 003). Conclusions:
Our data clearly demonstrates that performing an ileostomy
closure after initial LS has several advantages over performing it
after an initial OS. We hypothesize that this is due to the intrinsic
tissue manipulation which could be considerably less traumatic
during LS than OS. This is directly proportional to the presence
of postoperative adhesions. An initial LS approach might have
impact in the secondary ileostomy closure in terms of surgical
time, hospital stay and the incidence of surgical reinterventions
or complications. Key Words: Protective ileostomy, laparoscopic
colectomy, ileostomy closure.
S037 RESULTS OF ILEOSTOMY CLOSURE AFTER RECTAL
CANCER RESECTION, Shigeki Yamaguchi PhD, Masatoshi Ishii
MD, Jo Tashiro MD, Yoshihide Otani MD, Isamu Koyama, Shuji
Saito MD, Masayuki Ishii MD, Department of Gastroenterological
Surgery, Saitama Medical University International Medical Center
& Shizuoka Cancer Center
Purpose: While sphincter saving operation for rectal cancer
is increased, patients with diverting stoma are increased, too.
Ileostomy is chosen in most of our patients. One of the reasons
is easiness of stoma closure. This study was assessed short term
results of ileostomy closure. Technique: Suturing and lapping
stoma was never performed before skin incision. Dissection from
abdominal wall underwent using scissors or bipolar scissors.
Until September 2004, single layer hand-sewn anastomosis was
performed, and then functional end to end anastomosis (FEEA)
using linear stapler was standard method. The reason we changed
anastomotic method was functional end to end anastomosis had
wider anastomotic diameter and would take less operating time.
Results: Ninety patients who received ileostomy closure were
included since September 2002 to December 2006. Mean overall
operative time (OT) was 63. 3 minutes. Also mean OT was 62. 3 min.
in FEEA and 63. 8 min. in hand-sewn anastomosis, respectively.
Mean blood loss count was 31 g. Median postoperative hospital
stay was 7 days. Postoperative complications were; intestinal
43
ABSTRACT BOOK
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obstruction 14 (15. 6%), wound infection 2 (2. 8%), and no
anastomotic leakage. Intestinal obstruction was seen in 6. 5%
(2/31) of FEEA, and 20. 3% (12/59) of hand-sewn anastomosis.
Conclusion: Diverting ileostomy is safe because it is easy to
close, and less intestinal obstruction was seen in functional end
to end anastomosis than in hand-sewn anastomosis.
S038 THE EVALUATION OF A FECAL DIVERTING DEVICE
AS A SUBSTITUTE FOR A DEFUNCTIONING STOMA: AN
ANIMAL STUDY, Jaehwang Kim MD, Sang Hun Jung MD,
Daegu, Korea
Purpose: The safety of a newly developed fecal diverting device
(FDD) that can replace a temporary stoma was confirmed in a
preliminary animal study. In this study, we evaluated the positive
effect of the FDD in protecting against anastomotic leakage.
Methods: This was a randomized prospective study. The FDD is a
long, silicon tube with a thick head and a thin tail. Two outer balloons
are mounted on the head of the FDD for fixation to the bowel wall.
If inflated, the head looks like a dumbbell. An extracolonic mesh
band, located 5 cm proximal to the anastomotic area, can hold
the head of the FDD. Fecal content proximal to the head of the
FDD can be drained out of the anus thorough the tail of the FDD.
Twenty mongrel dogs (5 males with a median weight of 19 kg)
were divided into 2 groups of 10 each. Under general anesthesia,
a low midline incision was made and wide devascularization was
enhanced on the colon to generate ischemia at the anastomotic
site after resection. A circular stapler was applied to resect and
perform the anastomosis. The decision to apply the FDD (Group
1) or not to apply the FDD (Group 2) was made by the flip of a
coin. Follow-up observations was recorded until the animal’s
death or the FDD was spontaneously expelled in Group 1. The
mongrels without a FDD (Group 2) were sacrificed after 3 weeks.
At the time of necropsy, we evaluated intraperitoneal findings,
the anastomotisis, and the FDD fixed mesh area grossly and
microscopically. Results: Mortality occurred in 5 dogs in Group
2. The average survival time of these dogs was 3. 6 days. The
cause of death was generalized peritonitis due to anastomotic
leakage in all of the dogs. The FDD was spontaneously expelled
after an average of 21. 5 days (range, 6-41days) in Group 1. The
cause of FDD expulsion was most often spontaneous deflation
of the dumbbell-shaped outer balloons. In the necropsy findings,
a sealed off abscess cavity was noted in 4 dogs in Group 1 and
2 dogs in 5 survived mongrels in Group 2. Erosion of the mesh
band was noted in 2 dogs in Group 1. Conclusions: A newly
developed fecal diverting device was shown to be safe and
effective in the protection against generalized peritonitis from
anastomotic leakage due to induced ischemia. The fecal diverting
device was maintained in situ and functioned for more than 3
weeks in the animal colon without any major complications,
except two erosions.
FUNCTIONAL DISEASE I
S039
CLINICAL
APPLICATION
OF
IN-VITRO
CHEMOSENSITIVITY TEST FOR COLORECTAL CANCER
USING MTT ASSAY IN KOREA, Seong-soo Kim MD, Byuongwook Min PhD, Jun-won Um PhD, Hong-young Moon PhD,
Department of Surgery, Korea university College of Medicine,
Seoul, Korea
Background: In colorectal cancer, surgical treatment is
fundamental but pre or postoperative chemotherapy and
radiotherapy are widely accepted and many chemotherapic agent
is available. In Korea, 5-FU, oxaliplatin and irinotecan are most
widely used but these agent are applied to the each TNM stage
because of the restriction in medical insurance system. Purpose:
The MTT chemotherapy response assay is a well-documented and
feasible technology for individualizing chemotherapy in cancer
patients. We evaluate the assay’s success rate and the suitability
of chemotherapeutic agent according to assay result. Method:
Tumor samples were collected from 124 patient. In 108 patients,
cultures were succed. Tumor specimens were cultured for 7 days
on collagen gel sponge in RPMI medium with chemotherapeutic
agents. Then the inhibitory concentration was determined by MTT
assay. The result was also confirmed by immunohistochemistry
for Ki-67, P53, and BCL-2. (Results) The assay success rate was
44
ISUCRS XXII BIENNIAL CONGRESS 87. 1%(108/124). The mean age of the patients was 62. 9 years,
and the male-to-female ratio was 1. 1:1. l. The sites of cancer
were ascending colon 21(20. 5%), transverse colon 2(1. 7%),
Descending colon 6(5. 4%), sigmoid colon 27(25%), and rectum
50(48. 2%). According to TNM stage, there were 12 cases of stage
I, 45 cases of stage II, 35 cases of stage III, and 16 cases of stage IV.
In
case
of
differentiation,
moderate
differentiation
was
most
frequent
(88
case,
81.
5%).
Among the 108 cases, the positive chemosensitivity cases to
5-FU, oxaliplatin, irinotecan were 56, 49, and 44 respectively.
The number of patients received chemotherapy was 88, but
appropriate chemotherapy to chemosensitivity result was 25/48
in 5-FU regimen, 9/30 in FOLFOX4 regimen, and 6/10 in FOLFIRI
regimen. Conclusion: A study evaluating the predictive value
of MTT drected therapy is needed to determine the clinical
usefulness of the test.
S040 ULTRALOW ANTERIOR RESECTION AND HANDSAWN COLOANAL ANASTOMOSIS: ONCOLOGIC AND
FUNCTIONAL OUTCOMES, Byung Soh Min MD, Hyuk Hur
MD, Jin Soo Kim MD, Seung Kook Sohn PhD, Chang Hwan Cho
MD, Seung Hyuk Baik MD, Nam Kyu Kim PhD, Yonsei University
Health System, Seoul, Korea
Background: Ultralow anterior resection and hand-sawn
coloanal anastomosis has been a standard surgical treatment
for low rectal cancer. Despite many published results, there are
few concerning Asian populations. The aim of this study was
to investigate oncologic and functional outcomes of ultralow
anterior resection and hand-sawn coloanal anastomosis for the
treatment of rectal cancer and to analyze clinicopathological
factors affecting the outcomes. Patints and Methods: From
a prospective colorectal cancer surgical database, 134 patients
who received ultralow anterior resection and hand-sawn coloanal
anastomosis for the treatment of rectal cancer were identified and
their clinicopathological features were reviewed. For evaluating
functional outcomes, Wexner score and BM frequency were
analyzed. Results: The mean age of the patients was 54. 7 years.
Forty-two patients (32. 1%) received preoperative chemoradiation,
whereas 57 (42. 5%) received postoperative chemoradiation and
35 (25. 4%) received neither. Colonic J-pouch anal anastomosis
was performed in 95 patients (70. 9%) and straight in 39 (29.
1%). Postoperative morbidity was in 23 patients (16. 4%), voiding
difficulty being the most frequent (6. 0%) followed by intestinal
obstruction (5. 2%), and anastomosis leakage (3. 0%). Three-year
disease-free survival rate according to stage was 100% for stage
0, 96. 3% for stage I, 89. 3% for stage II, and 57. 4% for stage
III (p<0. 001). uni- and multivariate analyses revealed that T3/4
tumors (OR=6. 773; P=0. 010), < 40 years (OR=4. 352; P=0. 015), <
Anal Verge 5cm (OR=2. 656; P=0. 024), and N(+) (OR=3. 541; P=0.
048) were significant prognostic factors. Wexner score and BM
frequency were observed to decrease 3 years after the surgery.
Within 6 months after surgery, BM was more frequent when the
patient had received preoperative chemoradiation (p=0. 048) and
straight anastomosis (p=0. 042). Conclusion: Ultralow anterior
resection and hand-sawn coloanal anastomosis for the treatment
of rectal cancer showed acceptable range of postoperative
morbidity and satisfactory oncologic and functional outcomes.
Early functional impairment is more severe in the patient who
received preoperative chemoradiation and straight anastomosis,
but it may improve after 3 years.
S041 VOIDING & SEXUAL DYSFUNCTION AFTER RADICAL
EXCISION OF THE RECTUM, Galal M AbouElnagah MD, Ahmed
Hussin MD, Colorectal surgical Unuit, Alexandria University,
Egypt
Introduction: Bladder and erectile dysfunction are well
recognized after radical excision for patients with operable cancer
rectum. Reported rates varies from 10% to 60%. Most common
complains are urgency, retention, neurogenic bladder, impotance
and retrograde ejaculation. Method: Prospective study were
conducted on 50 consecutive operable cancer rectum patients.
All underwent abdominoperineal radical excision of the rectum.
Urodynamics studies were done before, one month and three
months after operation, it include: spontaneous flowmetry,
residual urine, cystometry, detrusor pressure, urinary flow
and urethral pressure profile. Results: 31 men and 19 women,
ABSTRACT BOOK
Podium Papers
mean age 43. 2. Twenty patients were having urinary complains
Preoperatively, in the form of hesitancy, frequency, dysurea and
nocturnal frequency. Post operatively only 8 patients still had it; 6
temporary, one benign prostatic hyperplasia and one neurogenic
bladder. Duke’s Staging of excised tumours were: 54% B, 40% C,
6% D. There were no statistical differences between preoperative
and postoperative urodynamic studies. Gender, learning curve,
and depth of tumor exerted an independent influence on urinary
or sexual dysfunction. Conclusion: Voiding disturbances
following rectal surgery are usually transit, sexual dysfunction
is difficult to be determined and compared. It is not essential to
apply preoperative urodynamic study in non symptomatic cancer
rectum patients. Postoperative urodynamic studies are useful
in symptomatic patient only after a period of conservative trial.
Most of pre operative urinary complains are due reflex effect of
tumor anorectal manifestation on urinary tract. These are usually
improved after rectal excision specially with large size tumors.
S042 DEFECATORY DISORDER DUE TO DENERVATION/
MOTILITY DISORDER OF THE NEORECTUM FOLLOWING
ANTERIOR RESECTION FOR RECTAL CANCER, K Koda MD,
H Yasuda MD, M Yamazaki MD, T Tezuka MD, C Kosugi MD, R
Higuchi MD, M Sugimoto MD, Y Yagawa MD, Department of
Surgery, Teikyo University Chiba Medical Center
Introduction: Healthy rectum and sigmoid colon were double
innervated with ascending fibers from the pelvic plexus and
descending fibers that run along the internal mesenteric artery
(IMA). Therefore, the neorectum in anterior resection for rectal
cancer is constructed using a denervated colonic segment of a
length that varies from case to case. We evaluated the motility
of the neorectum which may potentially be associated with
postoperative defecatory disorders. Patients and Methods:
Eighty-two patients (48 men and 34 women; median age, 61) who
underwent anterior resection for rectal cancer were enrolled in
the present study. There were 21 ultra-low anterior resections, 46
low anterior resections, and 15 high anterior resections included.
Reconstruction methods were a colonic J-pouch (n=12), a sideto-end anastomosis (n=12), and an end-to-end anastomosis
(n=58). The interval between initial surgery and the time when the
physiological study was carried out was 1 year in 46 cases (56%)
and more than 2 years in 36 cases (44%). Colonic motility was
measured using a specially manufactured pressure transducer
that consisted of 4 sensors 20cm apart inserted at the time of the
postoperative colonoscopy. Colonic transit time was determined
using Sitzmarks capsules, which consisted of 20 radiopaque
markers within a gelatin capsule. Postoperative defecatory
functions were evaluated with a self-administered questionnaire.
Results: Of 82 patients, both IMA and descending nerve fiber were
preserved in 30 cases that were categorized in gshort denervation
(S) grouph, since the neorectum of these patients are thought
to be composed of short denervated colonic segments. In the
remaining 52 cases, either IMA were cut (n=36) or in case IMA was
preserved, the surrounding tissue was removed for lymph node
dissection (n=16); they were categorized in glong denervation
(L) grouph. Propagation of contraction wave to neorectum was
observed in 25/30 cases for S-group, whereas 27/52 cases in
L-group showed propagations (p=0. 005). Spastic contractions of
neorectum were observed in 7/30 for S-group, 25/52 for L-group
(p=0. 035). In patients to whom low/ ultra low anterior resection
was performed (n=67), colonic transit time trough sigmoid colon/
rectum was significantly longer in L-group than in S-group (5. 9 vs.
3. 3 hrs, p=0. 03). In these patients, there was a tendency that both
urgency and Wexner’s score are better in S-group than in L-group,
however they did not reach statistical significance (p=0. 17, 0. 14,
respectively). Conclusion: The glongh denervated neorectum
may cause motility disorders in the neorectum following anterior
resection for rectal cancer. Denervation to the neorectum may
be one possible factor that indirectly relates with postoperative
function.
S043 ROLE OF SACRAL NERVE STIMULATION(SNS) IN
CHRONIC CONSTIPATION, N Srinivasaiah MD, P W Waudby
RN, G S Duthie MD, 1. Academic Surgical Unit, University of Hull,
Cottingham, UK
Introduction: Chronic constipation can be extremely difficult
to treat affecting one’s QOL. SNS has been tried when other
www.isucrs.org/
treatments have failed. However, reports of this procedure are
limited, so we reviewed our experience in order to determine
whether it is a worthwhile procedure. Methods: Patients who
underwent SNS for chronic constipation were identified (Aug
2005 - Oct 2007). This is a retrospective review of a prospectively
maintained SNS database and the notes reviewed. Results: There
were 12 patients with chronic constipation who were referred
to be considered for SNS. The mean age was 39 years. All the
patients were females. Under the category of constipation were
also included 3(25%)patients who had constipation with overflow
incontinence following laxatives and bowel movement. Majority
of them were idiopathic slow transit constipation, with 2(16%) of
them secondary to spinal traumatic neuropathy. Nearly 1/3rd of the
patients complained of abdominal discomfort, pain, bloating, lack
of motivation, embarrassment and depression impacting on their
QOL and making them socially isolated. The average frequency
of bowel movements were 3-5 /month assisted with enormous
amounts of laxatives, bulking agents, suppositories, enemas,
biofeedback, rectal irrigation and ante grade continent enema.
Out of the 12 patients who were referred for SNS, there were
9 (75%) temporary and 6 (50%) permanent SNS procedures
performed. 3 (25%) of them are awaiting a temporary SNS
procedure. All the 6 (50%) who had permanent SNS procedures
have had success. There was failure in 1(8%) following 2 temporary
SNS procedures, refusal in 1(8%) without trial SNS and return
to normal bowel habit in 1(8%) after a failed temporary SNS.
Assessment of the bowel diaries among successful patients,
showed an improvement in bowel movements to once/day - 3
times/week. They also demonstrated improvement in abdominal
symptoms and QOL. One (8%) patient had pain on urination
following the SNS procedure who had her settings changed and is
awaiting to be reviewed. Conclusions: We would conclude that
SNS for chronic constipation in our experience offers an option,
when other treatments have failed.
FUNCTIONAL DISEASE II
S044 URINE N1N12-DI-ACETYL SPERMINE (DIACSPM) AS
A NOVEL CANCER MARKER FOR COLORECTAL CANCER,
Keiichi Takahashi MD, Kyoko Hiramatsu PhD, Tatsuro Yamaguchi
MD, Hiroshi Matsumoto MD, Daisuke Nakano MD, Youzou Suzuki
MD, Takeo Mori MD, Masao Kawakita PhD, Department of Surgery,
Tokyo Metropolitan Komagome Hospital
Backgrounds: For colorectal cancer screening fecal-occult blood
test (FOBT) is the standard screening test all over the world. But
the positive predict value (PPV) in colorectal cancer is about 60%.
Fecal DNA analysis is too expensive and is difficult to use colorectal
cancer screening in clinical practice. It is necessary to combine
another non-invasive new test with FOBT to improve the PPV. In
this paper we clarified the possibility to use urine N1N12-di-acetyl
spermine (DiAcSpm) for colorectal cancer screening. Methods:
DiAcSpm increases for several kinds of cancer. We succeeded the
quantity of DiAcSpm by ELISA method. In this paper we examined
urine DiAcSpm(normal range : 0~0. 25 ƒÊmol/gEcreatinine) and
serum CEA(normal range : 0~5. 0ng/ml) for 243 colorectal cancer
patients preoperatively and urine DiAcSpm for 53 normal controls.
Results: Only 2 persons (3. 7%) were positive for normal controls
in urine DiAcSpm. Positive rate of each stage in 243 cases was
as followsGstage I (N=36) F 47. 2% for urine DiAcSpm and 11.
1% for serum CEA respectively, stage II (N=60) F68. 3% and 51.
7%, stage III(N=102) F81. 4% and 43. 1%, stage IV(N=45) F93. 3”
and 82. 2%. In proportion to staging, the positive rates for both
markers became high. Especially urine DiAcSpm level for stage
I colorectal cancer showed statistically significant higher than
serum CEA (p<0. 0001). The results of statistical analysis of urine
DiAcSpm for colorectal cancer were 75. 3% for sensitivity, 96. 2%
for specificity, 98. 9% for PPV and 45. 9% for negative predictive
value. Conclusions: The positive rate of Urine DiAcSpm was
higher than that of serum CEA for colorectal cancer, especially for
early staged patients. It suggested that the combination of FOBT
and urine DiAcSpm realized the improvement of colorectal cancer
screening.
45
ABSTRACT BOOK
Podium Papers
S045 IMPACT OF RADIOTHERAPY ON COMPLICATIONS
AND SPHINCTER PRESERVATION AFTER COLOANAL
ANASTOMOSIS FOR DISTAL RECTAL CANCER, Hyuk Hur
MD, Byung Soh Min, Jin Soo Kim MD, Nam Kyu Kim MD, Seung
Kook Sohn MD, Chang Hwan Cho MD, Yonsei University College
of Medicine, Department of Surgery
Introduction: Coloanal anastomosis(CAA) has improved the rate
of sphincter preservation for rectal cancer. But, radiotherapy(XRT)
occasionally produce complications and result in failure of
sphincter preservation and formation of permanent colostomy.
The aim of this study was to assess the impact of radiotherapy
on complications and colostomy-free survival of patients after
CAA. Materials and Methods: A total of 107 patients underwent
CAA between 1999 and 2006: 70 patients received XRT(28
preoperative(Group I) and 42 postoperative(Group II)); 37 patients
did not receive XRT(Group III). Complications and the colostomyfree survival rate were assessed by retrospective review of
patients records. Results: The most frequent complication was
an anastomotic stricture with others(fecal incontinence, fistulas,
anastomotic leakage, abscesses, and bowel obstruction). Patients
receiving XRT had a higher rate of complications compared with
patients not receiving XRT; Group I(10/28, 35. 7%), Group II(15/42,
35. 7%), Group III(7/37, 18. 9%). 14 patients required permanent
colostomy(Group I: 4/28(14. 3%), Group II: 8/42(19%), Group III:
2/37(5. 4%)). 10 patients required colostomy because of anorectal
dysfunction (incontinence, stricture, fistula, leakage or abscess); 1
patients because of bowel obstruction; 3 patients because of local
or systemic recurrence. Patients receiving XRT(Group I and Group
II) had a lower 5-year colostomy-free survival rate compared
with patients not receiving XRT(Group III)(71. 6% vs. 93. 2, P=0.
034). Conclusion: Althouth CAA was performed for sphincter
preservation for rectal cancer, preoperative or postoperative XRT
may increase the incidence of complications and the need for a
permanent colostomy.
S046 THE IMPACT OF ANORECTAL ELETROMANOMETRY
IN 163 CONSECUTIVE PATIENTS EVALUATED IN A
COLORECTAL PHYSIOLOGY LABORATORY, José Paulo T
Moreira MD, Hélio Moreira Jr MD, Hélio Moreira PhD, Geanna
R Guerra MD, Arminda C Almeida MD, Coloproctology Service,
Federal University of Goiás, Brazil
Introduction: In the past 20 years we have seen an increasing
availability of anorectal physiologic tests among colorectal
surgeons. Anal eletromanometry (EMN) is the most used by
physicians in Brazil. Aim: Evaluate the results of EMN and its
impact on decision making in patients with anorectal diseases.
Method: 163 consecutive patients were evaluated by EMN at
the Physiology lab of Coloproctology Service at the Federal
University of Goiás, between nov/2006 and sept/2007. Results:
163 consecutive patients were analyzed, with median age of 40
(range, 2-87 years). Clinical symptoms of the patients that indicated
EMN were: fecal incontinence (n=40), chronic anal fissure (n=23),
constipation (n=77), others (n=23). Patients with fecal incontinence
presented with median resting and squeeze pressure of 43 mmHg
and 108 mmHg, respectively. Meanwhile, 45% of the patients had
low resting pressures. Rectal sensitivity was abnormal in 70% of
the patients and in half of the cases, rectal capacity was below the
expected values. Forty seven out of 77 constipated patients had
positive serology for Chagas´ disease, despite of no radiological
megacolon. Moreover, a positive inhibitory anorectal reflex (IARR)
46
ISUCRS XXII BIENNIAL CONGRESS was observed in 15 cases (32, 5%), excluding the possibility of
Chagas´ colopathy. Ten children from the constipated group were
evaluated for the possibility of congenital megacolon. The IARR
was present in all cases, excluding Hirschsprung´s disease. For
the remaining patients with constipation, the median resting
pressures was 62 mmHg and squeeze pressure 120 mmHg, with
positive IARR in all of them. In the chronic anal fissure group,
the resting and squeeze pressures were above normality in 47,
8% and 43, 4% of the patients, respectively. Conclusion: In the
assessment of the incontinent patients, the EMN was important to
graduate the severity of sphincter tone as well to identify possible
muscular injuries. In the constipated group, the EMN was very
useful in the subgroup of positive serology for Chagas´ disease,
with no radiological megacolon as well to exclude congenital
megacolon in children. In patients with chronic anal fissure, this
test was important as an objective method for evaluating patients
who really have elevated anal canal pressures. Therefore, EMN
provided useful information in 70% of the evaluated patients.
S047 NON-STIMULATED GRACILOPLASTY - WILL IT
BECAME THE METHOD OF CHOICE?, Roman Herman PhD,
Piotr Walega PhD, Anna Gierada MD, 3rd Department of Surgery,
Cracow
Objective: Graciloplasty is a well-established surgical treatment
method of feacal incontinence (FI). Because of the complexity
of this procedure it is reserved for patients with end-stage
fecal incontinence. We aimed at comparison between standard
dynamic graciloplasty and non-stimulated graciloplasty.
Patients: Seventeen patients (11 women, 6 men) with end stage
fecal incontinence due to sphincter injuries (13) and congenital
absence (4) underwent graciloplasty (GP) between 2000 and 2007
in 3rd Department of Surgery of Jagiellonian University School
of Medicine. Method: The procedures were made following the
method proposed by Pickrell-Baeten with /split-sling/ modification
proposed Cavina-Rosen with intraoperative anal manometry to
archive optimum tension of the muscle. Following examinations
were made in all cases before and 6, 12 and 24 months after
surgery: surface electromyography, anal manometry, Feacal
Incontinence QoL and assessment of severity of incontinence using
Fecal Incontinence Severity Index (FISI); electrically stimulated
muscle transformation procedure was conducted on 5 patients,
in 12 cases procedure of non stimulated GP was performed with
subsequent transanal electro-stimulation. Results: In all patients
significant improvement of defecation self-control was observed,
with parallel life quality and overall psychosocial functioning
improvement. No statistically significant differences in life
quality between patients with DGP and non-stimulated GP were
observed. Conclusion: End-stage fecal incontinence treatment
effects can be considered as satisfactory in both groups. Non
stimulated graciloplasty seems to be recommendable technique
for end-stage fecal incontinence due to significantly lower costs
and avoidance of stimulator related complications and similar
functional results.
S048 ROLE OF SACRAL NERVE STIMULATION (SNS) IN
CHRONIC PELVIC PAIN (CPP), N Srinivasaiah MD, Phillip
Waudby RN, B Culbert, G S Duthie MD, 1. Academic surgical
unit, Castle Hill Hospital, University of Hull, Cottingham, UK. 2.
Department of Anaesthetics, Castle Hill Hospital, Cottingham, UK
Introduction: Sacral nerve stimulation has revolutioned the
treatment of various pelvic floor disorders. The remit of its use has
been increasing to include a number of pelvic disorders. Chronic
pelvic pain (CPP) is a disorder which can be extremely difficult
to treat affecting one’s QOL. SNS has been tried in the treatment
of CPP when other treatments have failed. The reports of this
procedure for CPP are limited, so we reviewed our experience in
order to determine whether it is a worthwhile procedure. Methods:
Patients who underwent SNS for chronic pelvic pain were
identified (Aug 2005 - Oct 2007). This is a retrospective review of a
prospectively maintained SNS database and the notes reviewed.
Results: There were 7 patients who received SNS for chronic
pelvic pain. The mean age was 50 years. Female to male ratio was
6:1. Referrals were from the pain clinic, followed by gynaecology.
Under the broad category of pelvic pain were rectal and upper
anal canal pain, Ischial tuberosity and coccygeal pain, rectal
spasms, Buttock pains, Vulvodynia and Non specific pelvic pain.
ABSTRACT BOOK
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Three of them attributed their problem to an injury sustained
either by trauma or pelvic surgery. More than half of them had
other associated pelvic problems like rectocele, cystocele, uterine
prolapse, irritable bladder and abnormal pelvic anatomy. Two
patients had low resting squeeze pressures and pudendal nerve
dysfunction on Endo-anal ultrasound and neurophysiology. Failed
treatments included analgesics, antispasmodics, antiepileptics,
antidepressants, botox injections, TENS and caudal blocks. In
total 11 temporary SNS devices were used. 2 (28. 5%) patients
had successful outcome and five failed. Among the successful
ones PACS / BPI assessment showed an improvement of 70% 80 % at the end of two weeks of temporary test stimulation. The
successful ones are waiting for a permanent SNS to be implanted.
Among those who had failed SNS, worsening pelvic pain was
seen in two of them. Conclusions: We would conclude that
SNS for chronic pelvic pain with our limited experience offers an
option, when other treatments have failed. However, the success
rates one could achieve might be less.
S049 LAPAROSCOPIC VS. OPEN TOTAL MESORECTAL
EXCISION, Quintin Gonzalez MD, Homero Rodriguez MD, Jose
Moreno MD, Omar Vergara MD, Hector Tapia MD, Roberto Ramos
MD, Roberto Castañeda MD, Instituto Nacional de Ciencias
Medicas y Nutrición “Dr. Salvador Zubirán”. Mexico City
Background:
Laparoscopic
total
mesorectal
excision
(LTME) for rectal cancer has been proposed to have
several
short-term
advantages
in
comparison
with
open total mesorectal excision (OTME). However, few
prospective randomized studies have been performed.
Objectives: The main purpose was to evaluate whether relevant
differences in safety and efficacy exist after elective LTME for
the treatment of rectal cancer compared with OTME in a tertiary
academic medical center. Methods: This comparative nonrandomized prospective study analyzes data in 56 patients with
middle and lower rectal cancer treated with LAR or APR from
November 2005 to November 2007. Descriptive and statistical
analysis was performed using SPSS 8. 0 according to each variable
scaling. Statistical significance was considered whenever a p value
was equal or less than 0. 05 for a two-tailed distribution. Results:
28 patients underwent LTME and 28 patients underwent OTME.
The mean operative times for LTME and OTME procedures were
181. 3 min and 206. 1 min p<0. 002. The mean operative blood
loss was 139. 2 ml and 231. 8 p<0. 003. There was a significant
difference in time to reinstitute oral intake in the LTME (2) versus
OTME (3) p< 0. 05. Postoperative hospital stay was shorter in the
LTME group (5. 5 days) versus the OTME group (7. 9 days) p< 0.
04. A significant difference in terms of recovered lymph nodes
was found in the LTME (12. 1 +-2) versus OTME (9. 3+-3) p< 0. 05.
There was no 30-day mortality. Morbidity was lower in the LTME
group compared to the control group (17% vs 32%). Return of
bowel motility was observed earlier after laparoscopic surgery.
Mean
follow-up
time
was
12
months
(range
9-24
months).
No
local
recurrence
was
found.
Conclusion: LTME is a feasible procedure with acceptable
postoperative morbidity and low mortality, however it is technically
demanding. This series confirms its safety, while oncologic results
are at present comparable to the OTME published series with the
limitation of a short follow-up period. Key words: Laparoscopy rectal cancer- Total Mesorectal Excision.
S050 CLEVELAND CLINIC FLORIDA RECTAL CANCER
EXPERIENCE, B Santoni MD, P Denoya MD, E Stone MD, D
Sands MD, J Nogueras MD, E Weiss MD, S Wexner MD, Cleveland
Clinic Florida
Objective: The aim of the study was to evaluate
the
effects
of
neoadjuvant
chemoradiotherapy
on
downstaging
and
short-term
surgical
complications.
Method: After IRB approval, patients with a diagnosis of
rectal cancer who underwent surgery between January 2001
and October 2007 were identified from prospectively collected
databases. Charts with incomplete or missing pre- and postoperative staging were excluded. Age, comorbidities, pre- and
post-operative staging, pos-operatory complications and hospital
stay were all examined. Result: 87 patients were identified,
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49 of whom received neoadjuvant chemoradiation therapy.
The median age was 63, ranging from 29 to 93 years, and the
operations performed included abdominoperineal resection
(18), anterior resection (42), transanal excision (14), sigmoid
resection (1) and proctocolectomy(12). 23 patients received a
colonic J-pouch reconstruction, and 19 patients had a diverting
ileostomy. Postoperative ileus was experienced by 20% of
patients who received neoadjuvant therapy and by 5% of those
who did not receive neoadjuvant therapy (p=0. 03). 18% of the
neoadjuvant group and 5% of the non-neoadjuvant group had
medical complications (p=0. 06). Frequency of wound and surgical
complications was similar in both groups. The average length of
stay was 13. 8 days for the neoadjuvant group, and 6. 7 days for
the non-neoadjuvant group (p=0. 07). In subgroup analysis of the
62 patients for whom preoperative and postoperative staging
data were available, 54% were downstaged after neoadjuvant
therapy (p=0. 01). Conclusion: Neoadjuvant chemoradiotherapy
was significantly associated with postoperative ileus resulting in
longer hospitalizations and increased postoperative morbidity.
The pathology in over half of the patients who received
neoadjuvant therapy showed downstaging. In select patients the
adverse effects of neoadjuvant therapy may be outweighed by
the benefits.
S051 DIAGNOSTIC ACCURACY OF PREOPERATIVE
AND FOLLOW-UP PET/CT IMAGING FOR COLORECTAL
CANCER, Yoshiko Bamba MD, Michio Itabashi MD, Yusuke Tada
MD, Tomoichiro Hirosawa MD, Shimpei Ogawa MD, Akiyoshi
Seshimo MD, Shingo Kameoka MD, Department of Surgery II,
Tokyo Women’s Medical University, School of Medicine, Tokyo,
Japan
Purpose: We studied the diagnostic accuracy of preoperative
and follow-up PET/CT imaging for colorectal cancer. Materials
and Methods: Two hundred nine preoperative patients and
94 follow-up patients were examined by PET/CT. The results
demonstrated the accuracy of clinical diagnosis, including
diagnosis of metastasis to other organs. Results: Preoperative
examination The main colorectal tumor was detected in 195
cases (93. 1%) by PET/CT. All tumors not detected in PET/CT
were less than 25 mm in diameter. To detect paracolic lymph
nodes, sensitivity was 25. 0%, specificity was 91. 7%, and
positive predict value (PPV) was 58. 3%. For mesocolic lymph
nodes, sensitivity, specificity and PPV were 100%. The average
diameter of lymph nodes detected by PET was 11. 3 mm. On
the other hand, that of nodes that were not detected was 5. 63
mm. Liver metastasis was detected in 22 cases, with sensitivity
of 100% and PPV of 95%. Peritonitis carcinomatosa was detected
in 10 cases, representing sensitivity of 50% and PPV of 100%.
Follow-up examination Ninety cases were examined for recurrence
or by whole-body assessment. Twenty-eight cases were examined
after radiation therapy or chemotherapy. Liver metastasis was
detected in 30 cases, with sensitivity of 96. 7%, specificity of 100%
and PPV of 100%. Lung metastasis was detected in 23 cases, with
sensitivity of 43. 5%, specificity of 100% and PPV of 100%. The
average diameter of the lung metastases detected by PET was 14.
8 mm, while that of lesions that were not detected by PET was 10.
6 mm. Local metastasis was detected in 14 cases, with sensitivity,
specificity and PPV of 100% for all. Peritonitis carcinomatosa was
detected in 10 cases, with sensitivity of 70%, specificity of 100%
and PPV of 100%. Conclusions: Preoperative and follow-up
PET/CT imaging for colorectal cancer is very useful for detecting
metastasis or recurrence.
COLORECTAL EMERGENCIES
S052 MICROSATELLITE INSTABILITY AND 18Q ALLELIC
IMBALANCE IN YOUNG PATIENTS WITH COLORECTAL
CANCER, Akifumi Kuwabara MD, Takeyasu Suda MD, Haruhiko
Okamoto MD, C. Richard Boland MD, Katsuyoshi Hatakeyama MD,
Digestive and General Surgery, Niigata Graduateschool Medical
and Dental Sciences
Background: Colorectal cancer (CRC) can be classified according
to genetic instability selectively affecting microsatellite DNA
sequences (microsatellite instability, or MSI) or the chromosome
number and structure (chromosomal instability, characterized by
47
ABSTRACT BOOK
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aneuploidy and loss of heterozygosity or LOH). The relationships
between MSI and LOH, and the clinicopathological significance of
MSI and LOH in young patients with CRC, are unclear. Methods:
The clinical records of all patients 40 years of age or younger
admitted to the Niigata Univ. Hospital between 1972 and 1992 for
CRC were reviewed. The original pathological specimen could
be retrieved on 49 of these patients, which served as the study
population. A panel of 5 markers recommended at the Bethesda
conference was used to detect MSI. Six additional markers
(D18S64, D18S69, p53MEL, TGF ƒ ÀRII(A)10, IGFIIR(G)8, BAX(G)8)
were used to examine both LOH and the MSI status. Results: The
patients were 13 to 40 years old (median age: 36 y. o. ; average:
34. 9 y. o. ). MSI (i. e. , 2 or more microsatellites were mutated)
was found in 15 (31%) of 49 tumors, and frameshift mutations of
the TGF ƒ ÀRII gene were detected in 11 (73%) of these 15 tumors.
LOH at one or more loci was found in 27 (55%) of the tumors. The
MSI genotype was associated with a better prognosis than the
LOH genotype, but the difference was not statistically significant.
Three (6%) tumors showed overlap between MSI and LOH,
and the patients’ Esurvival curve was similar to that of the LOH
group. Ten tumors (20%) demonstrated neither MSI nor LOH, as
assessed by the 11 markers, and the survival curve of the patients
was similar to that of the MSI group. The five-year survival rate
for patients bearing the TGF ƒ ÀRII(A)10 frameshift mutation was
91%, as compared to 52% for patients with only wild type alleles
(p<0. 04). The five-year survival rate of patients who retained
the 18q allelic markers was 71%, as compared to 36% of those
showing loss of the 18q alleles (p<0. 03). Four patients only in the
MSI group had metachronous CRCs and primary cancers at other
organs after postoperative 5 years. The rate of cancers in a first
degree relative (67%) was significantly higher in the MSI group.
Conclusions: Retention of 18q alleles and microsatellite shifts
of the TGF ƒ ÀRII(A)10 gene were associated with a significantly
better outcome in young patients with CRC. Analysis of MSI and
LOH would suggest the useful information for the postoperative
surveillance.
S053 SCREENING FOR HEREDITARY COLORECTAL CANCER
IN CHINA, Shu ZHENG MD, Yanqin HUANG MD, Ying YUAN
PhD, Shanrong CAI PhD, Suzhan ZHANG PhD, Cancer Institute
(The Key Laboratory of Cancer Prevention and Intervention,
China National Ministry of Education), the 2nd Affiliated Hospital,
Zhejiang University
PART
1:
Detecting
hMSH2/hMLH1
mutation
in
clinically
diagnosed
Chinese
HNPCC
Objective: To identify germline mutations of hMLH1 and hMSH2
in HNPCC kindred fulfilling Chinese HNPCC criteria. Method:
14 HNPCC fulfilling Chinese HNPCC criteria probands and 14
kindreds peripheral blood DNA samples were obtained. PCR
amplified 35 exons of two main MMR (hMLH1 and hMSH2).
DHPLC followed by DNA sequencing was used to detect and
confirm mutations. Multiplex RT-PCR was used to detect large
genomic rearrangement of hMSH2/hMLH1. Result: 12 single
nucleotide changes were identified in 14 probands. Among them,
3 were germline pathological mutations. One of the 14 probands
was found with deletion of hMSH2 exon 1-7. 5/7-6/7 relatives of
mutation carriers carried the same mutation. Conclusion: Valid
mutations of hMLH1 and hMSH2 genes were identified in onethird HNPCC kindreds fulfilling Chinese HNPCC criteria. Incidence
of mutation carriers is more than 1/2. PART 2: Comparing the
MSI Subtype Cancers between Colorectal Cancer and Gastric
Cancer in Chinese Population. Objective: The purpose of this
study is to discover clinic-pathological features as well as the
genetic and epigenetic causes of both MSI-H CRC and MSI-H GC
in Chinese population. Method: A total of 303 CRC and 288 GC
unselected patients were involved in this study. Instability of both
BAT25 and BAT26 were used to define MSI-H tumor. Mutation of
hMSH2/hMLH1 and methylation of hMLH1 promoter region were
detected in every MSI-H tumors. Result: MSI-H CRC and MSI-H GC
account for 10. 2% and 6. 6% of unselected CRC and GC patients
respectively. Genetic and epigenetic analysis resulted in 6/31
MSI-H CRC & 0/19 MSI-H GC with pathological mutation and 6/31
MSI-H CRC & 15/19 MSI-H GC with methylated hMLH1 promoter.
Conclusion: most of MSI-H GC in Chinese population is mainly
caused by methylation of hMLH1. But neither methylation nor
somatic mutation is main cause of MSI-H CRC. Clinic-pathological
48
ISUCRS XXII BIENNIAL CONGRESS features of MSI-H GC is relatively indefinite. PART 3: FAP clinic
phenotype¡ªCHRPE as a screening FAP case/carrier ¡®marker¡¯
from the kindreds. Total 33 FAP family resources were collected
including 26 CFAP, 4AFAP and 3 SAFAP families, the CHRPE were
found in 90. 91% families¡¯ kindreds. The appearance of CHRPE
was more frequent in CFAP (94. 12) compared to that AFAP (66.
67%). With the CHRPE a screening model was set up. Its sensitivity
and specificity to both FAP and mutation gene carrier were 91.
84% and 100% respectively.
S054
GASTROINTESTINAL
MALIGNANCY
AND
PREGNANCY, YW Yun MD, JY Kim MD, HK Chun MD, HR Yun
MD, YB Cho MD, HC 1 Kim MD, SH Yun MD, WY Lee MD, WY
Chang MD, Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea,
Department of Surgery, Cheju University, Cheju, Korea
Colorectal cancer during pregnancy is rare, with a reported
incidence of approximately 0. 002%. The frequency of gastric
cancer during pregnancy seems to be higher than colorectal
cancer and has been reported as 0. 026% in Japan. Recently,
we experienced six cases of colorectal cancer and three cases
of gastric cancer during pregnancy. The chief complaints were
various gastrointestinal symtoms, such as abdominal pain,
discomfort, hematochezia, vomiting, melena, and so on. Delayed
diagnosis was common, because of the similarity beween the
sign of gastrointestinal cancer and the symptoms relevant to
pregnancy. The diagnosis of cancer was confirmed by endoscopic
biopsy. When these cancers were diagnosed during the first half
of pregnancy, cancer surgery was performed promptly, without
disturbing the pregnancy when possible. With diagnosis later in
pregnancy, consideration was given to delaying treatment until
the infant is viable, proceeding with radical surgery after cesarean
or induced vaginal delivery. Six cases with colorectal cancer
and two cases with gastric cancer received curative operation,
while one case with gastric cancer received palliative operation.
Although the duration of follow-up is different among cases, all
six cases with colorectal cancer have been alive. One case with
gastric cancer has been alive for 34 months, and another case
was followed until 29 months postoperatively. Another one
case who received palliative operation died at three months
postoperatively.
S055 THE PROGNOSIS FOR ADVANCED RECTAL CANCER
UNDERWENT PREOPERATIVE CHEMORADIOTHERAPY, SH
JUNG MD, HJ KIM MD, JS KIM MD, JH KIM MD, JH KIM MD, MC
SHIM, Department of Surgery, College of Medicine, Yeungnam
University, Daegu, Korea
Purpose: Although the advent of rectal cancer treatment,
its prognosis is very widely. Radical surgery is cornerstone
for rectal cancer treatment. Multiple randomized trials have
established the role of neoadjuvant and adjuvant radiotherapy
and chemotherapy in advanced rectal cancer. The purpose of this
study is to identify clinical and pathological prognostic factors
and recurrence pattern for advanced rectal cancer underwent
preoperative chemoradiotherapy following abdominal radical
lymphadenectomy. Patients and Methods: Between 1995 and
2004, 189 patients with rectal cancer located within 12 cm from
the anal verge were enrolled finally. Preoperative staging was
performed by rectal examination, abdominopelvic CT. They all
were performed RTX (5 weeks, radiation dose: 4500-5030 cGy)
and concomittent chemotherapy (5-FU:425mg/mm2 & LV:20mg)
using 24 hrs continuous infusion method for 5 days, twice).
Surgery was performed at 5-6 weeks after CCRT. Median F/U was
65 mo (range 7-140 mo). Results: Male and female was 98 and
91, respectively. Median agewas 60 years (range 27-86 years). The
mortality was 4 (2. 1%) and anastomotic leakge was 5 (2. 6%).
The pathologic stage was as following: no residual tumor (NRT)
33 (17. 5%), I 55 (29. 1%), II 54 (28. 6%), III 47 (24. 9%). Overall
recurrence rate was 17. 5% andlocal recurrence rate was 4. 8%.
Most frequent distant metastasis organ was lung (14), liver (12),
and other organs were distant LN (3), bone (3), carcinomatosis (1),
brain (1), adrenal (1). The site of local recurrence was presacral
space (4), pelvic wall(3), perineum (1), and anastomosis site (1).
The multivariate analysis was concluded that T3/4 (HR:4. 2, 95%
CI:1. 47-12. 24) and nodal metastasis (HR:3. 7, 95% CI: 1. 28-10.
42) were independent prognostic factors for recurrence. Tumor
ABSTRACT BOOK
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regression status was not prognostic factor. The 5-year diseasefree survival for each stage was NRT (90. 9%), I (89. 9%), II (83.
7%), III (64. 4%), respectively, (P=0. 009). The 5-year cancerrelated survival was NRT (90. 6%), I (92. 7%), II (88. 8%), III (74.
2%), respectively (P=0. 03). Conclusions: The management of
preoperative chemoradiotherapy for advanced rectal cancer
revealed excellent results and morbidity and mortality were low.
Besides pathologic stage III, survival difference within NRT, I, II
was not.
S056 THE INFLUENCE OF SURGICAL PROCEDURES
TO THE POSTOPERATIVE URINARY FUNCTION AFTER
AUTONOMIC NERVE PRESERVING OPERATION IN RECTAL
CANCER SURGERY, Masahiro Tsubaki MD, Yuiti Ito MD,
Masanori Fujita MD, Masakatu Sunagawa MD, First Department
of Surgery, Dokkyo Medical University, School of Medicine
Aim: The aim of this study is to clarify the influence of surgical
procedures to the postoperative urinary function after autonomic
nerve preserving operation (ANP) for the entire plexus in
rectal cancer surgery. Material and Methods: 175 cases of
rectal cancer operated from April 1998 to December 2006 were
reviewed. All cases underwent curative surgeries. T0 carcinoma
was excluded in this study. Tumor specific mesorectal excision
(TSME) was performed for rectosigmoid and middle rectal
cancers. When the cancers were located in the lower rectum or
had the lowest margin below the peritoneal reflection with over
T3 and or lymph node metastases, pelvic lymph node dissection
was performed. In this procedure, three types of autonomic nerve
preserving operation were performed. AN4+lat was ANP for the
entire plexus, AN2 was ANP for the bilateral pelvic plexus and
AN1 was ANP for the unilateral pelvic plexus only. The influence
of the surgical procedures to the postoperative urinary function
was evaluated by the rate of the patients who had spontaneous
urination on the day of discharge. In addition, 12 patients in
TSME and 11 patients in AN4+lat operation were questioned by
International Prostate Symptom Score (IPSS) preoperatively and
postoperatively (at least one year after operation). Results: TSME
was performed in 125 cases and pelvic lymph node dissection was
performed in 50 cases. The AN4+lat operation was performed in
24 cases. The local recurrence rate was 4. 0 % for all cases. All
cases with TSME completely maintained their urinary function.
96. 0% of patients with preservation of autonomic nerves and
pelvic lymph node dissection maintained urinary function on the
day of discharge. Postoperative IPSS scores of the patients in
AN4+lat operation were worse than in TSME. And postoperative
IPSS scores of the patients in Milesf operation were worse than
in sphincter preserving operation. Conclusion: We conclude
preservation of autonomic nerves, even if pelvic lymph node
dissection is performed, is important to maintain postoperative
urinary function. However the postoperative urinary function
would be influenced by the surgical procedures even if the entire
plexus was preserved.
S057
ULTIMATE ANUS
PRESERVING
OPERATION
INCLUDING INTERSPHINCTERIC RESECTION FOR LOWER
RECTAL CANCER EXTREMLEY CLOSE TO ANUS, Kazuo
Shirouzu MD, Yoshito Akagi MD, Yutaka Ogata MD, Shinjiro
Mori MD, Department of Surgery, Kurume University Faculty of
Medicine, Japan
Background: For a lower rectal cancer which was extremely
near to the anus, an abdominoperineal resection (APR) has been
generally performed for a long time. However, many patients
do not hope a permanent colostoma even though they contract
such cancers. Purpose: To avoid a permanent colostomy,
we introduce an ultimate anus-preserving operation (UAPO)
including intersphincteric resection (ISR) for such lower rectal
cancer. Methods: Between 1982 and 2005, we encountered 219
patients with APR. Firstly, we pathologically examined about
invasion or metastasis into the anal canal structures in the surgical
specimens of APR. Then, we performed UAPO and investigated
the oncologic and functional results. Pathologic results : When
the lowest edge of the tumor was located above the dentate line
(Pa cancer), the invasion and/or metastasis were rarely beyond
the internal sphincter muscle (ISM). When the lowest edge was
located below the dentate line (Pb cancer), then invasion and/or
metastasis tended to be highly detected into the external sphincter
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muscle (ESM) beyond the ISM. Therefore, three different types
of operation method were considered. One is intersphincteric
resection (ISR) which is applied for Pa cancer, second is external
sphincter resection (ESR) for Pb cancer, and another is combined
resection of ESR+ISR for some of Pb cancer. Clinical results : We
have just started the new operation since 2001. There were 13
patients with stage 1, 19 patients with stage 2, 6 patients with
stage 3a, 5 patients with stage 3b, and 1 patient with stage
4. Twenty patients received ISR, 14 patients, ESR+ISR and 10
patients, ESR. Three patients had anastomotic leakage and one of
those had an anastomotic stenosis. One patient had the necrosis
of the reconstructive colon. Temporary ileostoma closure was
performed for 40 patients on schedule between 3 and 10 months
after initial operation. Patients with either ISR or ESR+ISR had
relatively better anal function compared to patients with ESR. All
patients were satisfied with successful anus preservation. We had
recurrence in 3 patients with ISR, 1 with ESR+ISR, and in 2 with
ESR. Anastomotic recurrence was not found in all patients. Overall
the 4-year disease-free survival rate in the curative cases was 81.
3%. Conclusion: ISR and ESR are excellent new procedures for
anus preservation. The anal function and the oncologic results
were acceptable.
S058 HISTOLOGICAL FACTORS CONTRIBUTING TO A
HIGH RISK OF RECURRENCE OF SUBMUCOSAL INVASIVE
CANCER (PT1) OF THE COLON AND RECTUM AFTER
ENDOSCOPIC THERAPY, Ichiro Nakada MD, T. Tabuchi MD,
T. Nakachi, A. Takemura MD, M. Katano MD, T. Tabuchi MD,
Department of Surgery, Tokyo Medical University Kasumigaura
Hospital
Objective: To analyze the histological high-risk factors
for
recurrence
of
submucosal
invasive
carcinomas
(pT1) of the colon and rectum after endoscopic therapy.
MATERIALS and METHODS: We examined pT1 cancers treated
primarily by endoscopic resection within a 23-year period. We
compared recurrent and non-recurrent cancers, evaluating the
following high-risk factors of the primary lesion: massive invasion,
a surgical margin < 2 mm but negativity for cancer in the cut end,
poorly differentiated adenocarcinoma (PD) (G3), undifferentiated
carcinoma (G4), and/or positive angio-lymphatic invasion. We
compared the ages, gender, location of the lesions, macroscopic
type, size, histological type, angio-lymphatic invasion,
desmoplastic response(DR) in the cancer stroma, and the surgical
margin of the excised specimens between the patients with and
those without recurrence. The following histological factors
were defined as predictive of a low risk: minimum invasion,
a surgical margin >2mm, well and moderately differenciated
adenocarcinoma (G1, G2), and negative angio-lymphatic invasion.
Results: We analyzed the records of 37 patients with pT1 cancers,
including 15 with high-risk factors who underwent subsequent
resection. Local recurrence with or without liver metastases
developed in 4 of these 15 patients. The histological type was
PD in three (75%) of the four recurrent lesions. All four (100%)
lesions showed a desmoplastic response (DR). On the other hand,
only 1 (9%) of the 11 patients without recurrence after subsequent
surgery had a lesion with a small component of PD, and only
three (27%) lesions showed a mild DR. We found no significant
differences between recurrent and non-recurrent cases, although
there were differences in the histological findings of the cancer
stroma, particularly in the PD component and the DR between the
two groups. Conclusion: Endoscopic therapy is inadequate for
pT1 cancers with a histological PD component, and/or a DR in the
cancer stroma.
S059 15-YEAR EVOLUTION OF PENETRATING COLON
MANAGEMENT AT A LEVEL I TRAUMA CENTER; WHAT
HAVE WE LEARNED?, Elie Schochet MD, Indru T Khubchandani
MD, Timothy S Misselbeck MD, Michael Matos BA, Sherrine
Eid MPH, Lehigh Valley Hospital, Division of Colon and Rectal
Surgery
Introduction:: The management of penetrating colon trauma
has undergone great change over the last century as wartime
and urban experiences have supported a “repair first, and
divert only when necessary” attitude as evidenced by multiple
evidence-based guidelines adopted over the last ten years. We
examine our 15-year experience at a level 1 trauma center to
49
ABSTRACT BOOK
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see if the adoption of these guidelines has improved outcomes.
Methods: An IRB-approved review of a prospectively gathered
trauma registry revealed 198 patients admitted from 1993 to
2007 with injuries to the colon. 57 (29%) patients were eligible
following exclusions for serosal tears only, rectal injuries, death
within 24 hours of presentation, and age <10. The database was
compiled chiefly from trauma registry with individual charts and
records examined when needed. Data was analyzed using SPSS.
Results: Primary repair (PR) was performed on 16, resection and
primary anastomosis (R+PA) was performed on 19, and repair
or resection with diversion (DC) was performed on 22. Patients
were predominantly male (84. 2%), young (mean 32 yrs), and
injured by penetrating trauma (69%). Average ISS in the PR, R+PA
and DC groups were 14, 18, and 19. 7 respectively with 72% of
patients having other intrabdominal injuries. Average ICU LOS
and hospital LOS were 4. 1 and 11 days, 14. 7 and 24 days, and 14.
4 and 23 days in the PR, R+PA, and DC groups respectively. Early
morbidity occurred in 20% of the PR, 37% of the R+PA, and 53% of
the DC group (NS when controlled for ISS), while late morbidity
occurred in 10%, 26% and 0% respectively (p=. 005). Five patients
in the RPA group needed eventual re-admission for SBO (n=2),
ventral hernia (n=2), and anastomotic stricture (n=1). One patient
required a stoma revision and 84% of patients followed underwent
stoma reversal at a mean of 4. 6 months post-admission. While
the rate of PR’s remained stable, the number of diversions has
decreased and the rate of R+PA has almost doubled since 1998.
Conclusions: The management of penetrating colon trauma
remains a challenge. Although the number of diversions has
decreased at our hospital in the ten years since the implementation
of evidence-based guidelines, the high number of complications
in the R+PA group is concerning. The small numbers in each group
make direct comparisons difficult, however it would appear that
in our institution, diversion remians a tried and tested modality
with little morbidity and high reversal rates.
S060 FUNCTION PRESERVING SURGERY FOR LOWER
RECTAL CANCER INVOLVING LOWER URINARY TRACT
IN MALE PATIENTS, Norio Saito MD, Takanori Suzuki MD,
Masanori Sugito MD, Masaaki Ito MD, Akihiro Kobayashi MD,
Toshiyuki Tanaka MD, Yusuke Nishizawa MD, Masaaki Yano MD,
Yasuo Yoneyama MD, Yuji Nishizawa MD, Nozomi Minagawa MD,
National Cancer Center Hospital East
Purpose: Total pelvic exenteration (TPE) is the standard surgical
procedure for patients with advanced low rectal cancer involving
lower urinary tract organs such as the prostate and the urethras.
We evaluated the feasibility of bladder and anus-sparing
surgery as an alternative to TPE. Methods: Sixteen patients
with advanced lower rectal cancer, involving involving the
prostate and seminal vesicles or the urethral, underwent bladdersparing extended rectal resection with radical prostatectomy.
The anus-preserving was also performed using intersphincteric
resection (ISR) or very low anterior resection, if possible. These
sixteen patients were general candidates for TPE. Oncologic
outcomes and postoperative urinary and anal functions were
estimated. Results: The surgical proadures were ISR with radical
prostatectomy (n=9), very low anterior resection with radical
prostatectomy (n=1), and abdominoperineal resection (APR) with
radical prostatectomy (n=6). Cyst-urethral anastomosis (CUA) was
performed in twelve patients, four patients received cystostomy
on suspicion of cancerous invasion to the membranous urethral.
Anal sphincter-preserving surgery was done in ten patients
(Colo-anal anastomosis : 9, colo-anal canal anastomosis : 1).
All patients had cancer-free surgical margins. There was no
mortality. After a median follow-up period of 34 months, ten
patients were alive without disease and three were alive with
distant metastasis, although local recurrence was developed in
two patients and distant metastasis in six. Twelve patients with
CUA had satisfactory voiding function, and seven with preserving
anus had acceptable bowel function after diverting stoma closure.
Conclusions: These procedures as an alternative to TPE may
yield improved postoperative functions without compromising
oncologic outcomes.
50
ISUCRS XXII BIENNIAL CONGRESS S061 RADIOTHERAPY IN RECTAL CANCER - IS IT TIME
FOR CHANGE? A QUALITATIVE ANALYSIS OF THE SURVEY
OF MEMBERS OF ACPGBI ON PRELIMINARY MRC-CRO7
RESULTS, N Srinivasaiah MD, B Joseph MD, J Gunn MD, J
Hartley MD, J R Monson MD, 1. Academic Surgical Unit, Castle
Hill Hospital, University of Hull, Cottingham, UK
Introduction: : The role of Neoadjuvant therapy (NAT) in
management of rectal cancers has not reached a consensus
in the UK . A survey of ACPGBI members indicated 39% have
changed practice based on preliminary evidence from CRO7
trial. Change in clinical practice is driven by a number of factors.
Aim: To find out factors influencing changing clinical practice in
context to use of radiotherapy in rectal cancer. Methods: A postal
questionnaire was sent to 400 members of the ACPGBI. Data
for this subset of results is derived from the comments section
on the questionnaire. Qualitative methodology was adopted to
analyze the comments section. Results: Of 400 questionnaires,
200(50%) were returned. Of these only 52(26%) surgeons
completed comments section. Themes emerging from thematic
analysis are Patient-groups, Treatment, Evidence-based-practice
(EBP), Professional-consensus and Service-provisions. Outcomes
derived are individualize treatment, provide safer/less harmful
treatment, increase role of MDTs, increase awareness of current
evidence-based-literature, develop protocols/ guidelines, shorten
delay in implementing evidence-based-practice and improve
service provisions. Conclusions: Change is a slow and complex
process influenced not only by data/ scientific evidence but by a
combination of other factors. Some of them are Clinical decision
making, Evidence based practice / Education, Research Translation
and Organizational factors with Infrastructure / Resources. The
derived outcomes would help in early implementation of EBP.
S062 INSUFFICIENT LYMPHNODE DISSECTION IS AN
INDEPENDENT RISK FACTOR FOR POSTOPERATIVE
MORTALITY IN PATIENTS WITH STAGE II / DUKES B
COLORECTAL CANCER, Mitsuru Ishizuka MD, Hitoshi Nagata
MD, Kazutoshi Takagi MD, Keiichi Kubota MD, Department of
Background: Recent progressison of radical colorectal surgery
and chemotherpy decreasing postoperative mortality for stage
II / Dukes B colorectal cancer (CRC). However, there are still
postoperative mortality due to CRC. Objective: To investigate
the risk factor of postoperative mortality for the patients with
pathologically diagnosed stage II / Dukes B CRC. Methods:
Prognostic significance was analyzed by Kaplan-Meier analysis,
log rank test and univariate analyses using clinicopathological
factors. Results: A total of 132 patients were evaluated. Univariate
analyses using factors including sex, age, site of tumor, tumor
number, type of tumor, maximum size of tumor, depth of tumor,
lymph duct infiltration, venous infiltration, differentiation of
tumor, the level of lymph node dissection, operational curability,
C-reactive protein, albumin, serum CEA and administration of
postoperative chemotherapy revealed that only insufficient lymph
node dissection was associated with postoperative mortality (odds
ratio 4. 818 95% C. I. 1. 394 - 16. 654 P = 0. 0130). Kaplan-Meier
analysis and log rank test revealed that the group of insufficient
lymph node dissection predicted a higher risk of postoperative
mortality than the group of sufficient lymph node dissection group
(P = 0. 0021). Conclusions: Insufficient lymphnode dissection is
an independent risk factor for postoperative mortality in patients
with stage II / Dukes B CRC.
S063 COMBINED MANAGEMENT OF THE PERIANAL
LESION IN THE CROHN’S DISEASE, José María Gallardo, Valle
García Sanchez, Federico Gomez Camacho, Reina Sofía Hospital
Introduction: 54% of the patients with Crohn disease (CD) have
suffered, suffer or will suffer some perianal complication. In spite
of the advances in the medical treatment until 80% of the patients
require surgery. Objective: To evaluate a combined protocol
of medical and surgical therapy in perianal CD. Patient and
Methods: 22 patients were included. They were applied a protocol
diagnosis-therapeutic agreed that it understood: 1) combined
exploration in consultation, 2) Calculation of the modified
index of perianal activity (MIPA), 3) Exploration endoscópica of
the rectum. If pain or perianal fluctuation: 4) image technique
ABSTRACT BOOK
Podium Papers
(pelvic Resonance and rectal Ultrasonography) and later on, 5)
Exploration under anesthesia. Fistulas were defined according to
the Park classification. Equally, they were subdivided in simple
and complex. It was defined as remission and response to the
total closing of all the fistula or, 50% of them respectively, in two
revisions separate 4 weeks. Results: Time from the diagnosis
of the CD until the CP was 46. 6±44, 8 months. 88. 9% was in
treatment with inmunomoduladores (azatioprina). The average
number of fistulas was of 1. 94±1, 77. 8% complex. The seton
without knotting was the procedure more employee (72. 2%) with
a permanency of 18. 09±5 weeks. Treatment with biological was
used in 84. 3%. The remission and response percentage to the 2
months were 47. 1% and to the 6 months of 81. 8% (remission 17.
1% and answer 64. 7%). The MIPA passed to the 6 months of 6.
25+2. 5 to 1. 92+1. 7 (P=0. 002). Conclusions: The collaboration
between gastroenterologists and surgeons seems indispensable
to optimize the management of these patients.
S064 IS THERE AN INFLAMMATION TENDENCY IN
ASYMPTOMATIC PATIENTS WITH PELVIC ILEAL POUCHES
FOR ULCERATIVE COLITIS AND FAMILIAL ADENOMATOUS
POLYPOSIS?, Raquel F Leal MD, Marciane Milanski MS, Maria
Lourdes S Ayrizono MD, Luciana R Meirelles PhD, João J Fagundes
MD, Lício A Velloso PhD, Cláudio S Coy PhD, Coloproctology Unit,
Dept of Surgery, and Cellular Signalization Laboratory, Campinas
State University, São Paulo, Brazil
Background: Pouchitis after total retocolectomy is the
commonest complication in ulcerative colitis (UC) patients,
while is quite rare in familial adenomatous polyposis (FAP).
The immunopathogenesis of pouchitis is unclear and has been
associated to the same UC inflammatory pathway. High levels of
transcription factor STAT-1 are found in UC and are activated by
INF-gama, being one of the TNF-alfa transcription factors. Aim: To
evaluate the inflammatory activity in normal ileal pouch mucosa,
by determining STAT-1 activation, and expressions of INF-gama,
the suppressor factor SOCS-3, and the anti-inflammatory cytokine
IL-10, in patients operated by UC and FAP. Methods: Eighteen
asymptomatic patients submitted to total retocolectomy and J
pouch, were evaluated, being nine with UC and nine with FAP.
The control group consisted of nine individuals with normal ileocolonoscopy examinations. The endoscopic biopsy specimens
were snap-frozen in liquid nitrogen. The activation of STAT-1
and expressions of INF-gama, SOCS-3, IL-10 were determined by
immunoblot of total protein extracts. A routine hematoxilin-eosin
analysis was performed. The absence of pouchitis was assessed
by clinical, histologic and endoscopic parameters, according to
the Pouchitis disease activity index. The patients were not taking
any medications. ANOVA and Tukey-Kramer Test were applied.
The local ethical committee approved the study and informed
consent was signed by all participants. Results: STAT-1 activation
was increased in patients with UC, when compared to FAP and
controls (p<0. 05). Higher levels of INF-gama expression were
observed in UC patients when compared to control group (p<0.
05). Otherwise, SOCS-3 and IL-10 expressions were similar in all
groups (p>0. 05). Conclusion: Studying inflammatory activity
in asymptomatic ileal pouches may explain the pathogenesis of
the pouchitis, by determining a tendency of increased levels of
INF-gama and STAT-1 in patients with UC, even without clinic and
endoscopic evidence of pouchitis. These findings could explain
a higher susceptibility to this inflammatory complication in UC
when compared to FAP. The fact of SOCS-3 and IL-10 levels had
no difference in all studied groups suggests that biopsy samples
were taken from normal mucosa, and a balanced inflammatory
activity between pro and anti-inflammatory cytokines may exist.
S065 PULSE GRANULOMAS DISCOVERED IN SETTING OF
CROHN DISEASE, Sukrit Narula, Yong-son Kim MD, Adelina T
Luong MD, Janet C Nakamura MD, Dylan M Bach MD, Mark L Wu
MD, University of California, Irvine School of Medicine
Pulse granulomas are peculiar reactions to vegetable matter
characterized by collagenous hyaline rings, inflammation, and
vegetable matter. For unknown reasons, pulse granulomas
rarely occupy the colorectum. The diagnosis of Crohn disease
is challenging in cases that lack demonstrable transmural
inflammation or sarcoid-type granulomas. Pulse granulomas
deep to the muscularis propria would provide direct evidence
www.isucrs.org/
for transmural inflammation and might facilitate a diagnosis of
Crohn disease. We recently encountered 3 cases involving pulse
granulomas occurring in the setting of Crohn disease. All cases had
typical features of Crohn disease, including creeping fat, fissures,
fistulae, architectural disarray, or sarcoid-type granulomas. The
cases involved a 17-year-old boy, a 24-year-old woman, and a
36-year-old woman. Pulse granulomas occupied the subserosa of
the colorectum or appendix in all cases. Surprisingly, 1 case also
had pulse granulomas in 2 lymph nodes. All pulse granulomas
had collagenous hyaline rings and chronic inflammation,
and were with or without vegetable matter or barium-laden
histiocytes. Some pulse granulomas were large enough to be
seen at low magnification, while other pulse granulomas were
tiny and appreciated only at high magnification. Rare pulse
granulomas were overlooked initially because vegetable matter
failed to polarize light. We present the first series of cases
involving pulse granulomas occurring in the setting of Crohn
disease. Pulse granulomas may be difficult to detect when tiny
or when associated with nonpolarizable vegetable matter. Pulse
granulomas in the subserosa or in lymph nodes are surrogate
markers of transmural inflammation and can facilitate a diagnosis
of Crohn disease.
S066 SERUM ADIPONECTIN LEVEL IS POSSIBLY
ALTERED IN INFLAMMATORY BOWEL DISEASE WITH
SOME DIFFERENCE BETWEEN ULCERATIVE COLITIS AND
CROHN’S DISEASE, Natsuko Ue MD, Giichiro Tsurita PhD,
Joji Kitayama PhD, Hirokazu Nagawa PhD, University of Tokyo
Hospital
Background: Diet and lifestyle are known to change the adipose
tissue metabolism. Adiponectin (ADP), an emerging mediator
of immune response and inflammation, secreted by adipose
tissue, could be a key to pathogenesis of inflammatory bowel
disease (IBD) and a potential therapeutic drug, but little is known
yet. Purpose: To see if ADP level is altered in IBD. Methods:
Patients with ulcerative colitis (UC) or Crohn’s disease (CD) were
examined for serum ADP levels. Clinical records were reviewed
for clinical disease severity and inflammatory biomarkers, white
blood cell count (WBC), high-sensitivity C-reactive protein (CRP),
and erythrocyte sedimentation rates (ESR). We examined for their
possible association. We also compared data with those of patients
with other diseases (OT), acute appendicitis or acute diverticulitis.
Results: Total of 34 patients, 18 with UC (male/female of 6/12,
median age of 43. 5), eight with CD (5/3, 31. 0), and eight with
OT (4/4, 63. 5), were examined. (1) Median total ADP level (tADP)
did not show significant difference among disease groups (5. 33
in UC, 5. 17 in CD, 4. 34 in OT), nor in sex, nor in age. Percentage
of high, medium, or low molecule ADP was correlated with tADP
and neither showed significant difference among disease groups.
(2) Patients with more aggressive disease with higher levels of
WBC, CRP, or ESR tended to show relatively lower tADP levels in
UC, but relatively higher in CD. There seemed to be no tendency
in OT, all in which were with significantly higher CRP than IBD
cases (101. 90 vs 5. 90 mg/l). (3) When IBD patients experienced
flares, serum tADP level seemed to shift in a short time in a small
range, and was inversely correlated with clinical activity, CRP
or ESR, both in UC and CD. Conclusion: Serum ADP level, in
acute phase of IBD, probably changes in inverse correlation with
severity of inflammation and ADP is possibly down-regulated
constitutively in chronically severe UC; These two results are
consistent with our previous knowledge on ADP. Interestingly,
however, ADP seems to be up-regulated in chronically severe CD.
This encourages us for future study on ADP in IBD, for it may
be a clue to molecular mechanism of IBD, the difference of CD
from UC, in association with distinct adipose tissue or impact of
specific diet and lifestyles.
S067
LONG-TERM
RESULTS
OF
ILEOCAECAL
STRICTUREPLASTY IN THE TREATMENT OF CROHN’S
ILEITIS, Francesco Tonelli° MD, Marilena Fazi* MD, Tatiana
Bargellini° MD, Francesco Giudici° MD, Giuseppe Canonico° MD,
Carmela Di Martino° MD, ° Department of Clinical Phisiopathology,
* Department of Medical and Surgical Critical Care
From October 1996 to May 2000 13 patients (5 male and 8 female,
mean age 39 yrs/range 23-55) affected by Crohn’s Disease (CD)
of the terminal ileum have been operated adopting a personal
51
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technique of ileocaecal Finney-shaped strictureplasty. Eight of
these pts presented also other localization of CD: proximal ileum
(4), colon (2 caecum, 1 transverse, 1 left/transverse) and rectum
plus caecum (1 pts). Twelve pts were at the first surgical treatment,
while 1 pt was resected for a jejunum-ileal form of CD 8 years before.
The ileitis was characterized by a single long stricture in 12 cases
and by two strictures (9 and 2 cm long) in the other one patient.
At the end of the surgical procedure the length of the ileo-caecal
strictureplasty was as mean of 16 + 2 cm (range 6-30). In the 4
pts with associated proximal ileal strictures we have performed
respectively in two pts single and multiple (3) sxpl according to
Heineke-Mickulicz, in the third a side-to-side isoperistaltic sxpl and
in the last one a Finney sxpl. During the p. o period no morbidity or
mortality were recorded. Mean length of stay in hospital was of 9. 9
+ days (range 7-13). At discharge mesalazine was prescribed in all
patients. At a mean follow-up of 10 yrs (range 90 -134 months) we
have observed in 4 pts recurrence at the site of the ileocaecal sxpl.
In three instances symptoms were controlled by medical therapy,
while a surgical procedure (resection of the previous ileocaecal
sxpl) was necessary in the other pt after 68 months. Other two
pts with associated colonic disease complain symptoms related
to active colitis controlled by means of medical therapy. The
results of the present series show that pts undergoing ileocaecal
strictureplasty are no more likely to require further operation than
those who have a resection as first procedure.
PLENARY SCIENTIFIC
SESSION: BEST PAPERS
S068 TREATMENT OF FISTULA-IN-ANO BY ANAL FISTULA
PLUG: A PROSPECTIVE STUDY FROM ASIA, Pankaj Garg
MS, Fortis Super Specialty Hospital, Mohali, Punjab, India
Purpose: The aim of this study was to determine the efficacy of
the Surgisis® AFP™ (anal fistula plug) in the treatment of fistulain-ano. Methods: Over a period of one and a half years, 28 patients
presenting with cyrptoglandular fistula-in-ano were prospectively
studied. The number of tracts, fistula location, number of previous
procedures, and co-morbid conditions that could potentially affect
outcome were noted. Fistula tract passing through the upper twothirds of external sphincter complex (defined as the tissue between
pubo-rectalis sling and lower end of anal canal) were taken as high
fistula. All procedures were performed under regional anesthesia
with the patient in the lithotomy position. After washing the tract
with hydrogen peroxide, a seton was used to guide the AFP™ into
the fistula tract. The plug was anchored with 2-0 Vicryl® suture at
the primary and secondary openings. The secondary opening was
kept partially open to allow any residual drainage. Results: Two
patients had insufficient follow-up and one was lost to follow-up.
For the remaining 25 patients, mean age was 41±9. 1 years and
follow-up ranged from 4-15 months (mean= 226 days). 18 patients
had single tracts, and 7 patients had multiple tracts with a total of
34 tracts. 20/25 had high fistulae and 13/25 had recurrent fistulae.
Overall, final patient success rate, defined by closure of all fistula
tracts was 72% (18/25). The success rate was 83% in patients with
a single fistula tract (15/18) compared to 43% in patients with
multiple tracts (2/6) (p = 0. 06, Fisher’s exact test). Patient with
Diabetes Mellitus had lower (1/4, 25%) cure rates than non diabetic
patients(17/21, 81%)(p= 0. 052, Fisher’s exact test). The fistula
location, high - 14/20(70%) versus low fistulae 4/5(80%), (p=1.
0, Fisher’s exact test) and previous procedures done, recurrent8/13(62%) versus non-recurrent fistulae- 10/12(83%), (p=0. 37,
Fisher’s exact test) had no significant bearing on the outcome. The
surgical procedure was safe and well tolerated, with minimal pain
and morbidity in majority of patients. Conclusions: Closure of
fistula-in-ano with the Surgisis® AFP™ was successful in 72% of
the patients. Patients with multiple tracts and diabetes had poorer
results but it was not significant. Recurrent fistula and location of
fistula didn’t affect the outcome. The procedure is well tolerated,
with minimal pain and morbidity. Although long-term results are
awaited, use of the Surgisis® AFP™ appears to be a safe and
effective alternative to more traditional invasive procedures.
S069 IDEAL BOWEL RESECTION AND MARGINS IN COLON
CANCER, Yojiro Hashiguchi MD, Hideki Ueno MD, Yoshiki
Kajiwara MD, Jiro Omata MD, Koichi Okamoto MD, Toru Kubo
MD, Tomomi Fukazawa MD, Kazuo Hase MD, Hidetaka Mochizuki
52
ISUCRS XXII BIENNIAL CONGRESS MD, Department of Surgery, National Defense Medical College
Background: The ideal extent of a bowel resection is defined
by removing the blood supply and the lymphatics at the level of
the origin of the primary feeding arterial vessel. It is suggested in
General Rules for Clinical and Pathological Studies on Cancer of the
Colon, Rectum and Anus (the 7th Edition) published by Japanese
Society for Cancer of the Colon and Rectum that 10 cm of normal
bowel on either side of the primary tumor should be removed.
Furthermore, if two feeding vessels are identified within 10 cm
of normal bowel, both vessels should be excised at their origin.
In United States Guidelines 2000 for Colon and Rectal Cancer
Surgery published by the National Cancer Institute suggested that
5 cm of normal bowel on either side of the primary colon tumor
appears to be adequate. [Purpose] We retrospectively analyzed
466 pathologic specimens of patients with curatively resected
colon cancer from 1988 to 1997 at our institution, to clarify the
ideal bowel resection and margins. [Results]The incidence of
epicolic lymph node (LN) metastases within the size of the primary
tumor was 29%. The incidence of LN metastases within 5 cm of
normal bowel on oral side of the primary tumor was 15% and that
on anal side 11%. The incidence of metastases from 5 cm to 10
cm on oral side was 0. 5% and that on anal side 1. 6%. Incidence
of metastases more than 10 cm on oral side was 0. 2% and that on
anal side 0%. The incidence of lymph node metastases along two
feeding vessels from one primary tumor was only 1. 3% (3 cases).
All these three patients died within a year after surgery, indicating
extremely poor prognosis for patients with such aggressive
colon cancers. [Conclusion] Removal of 5 cm of normal bowel on
either side of the primary colon tumor appears to be adequate.
Excision of one feeding vessel is adequate unless primary tumor
is equidistant from two feeding vessels.
S070 LONG-TERM RESULTS OF TREATMENT WITH
BOTULINUM TOXIN TYPE A FOR OBSTRUCTIVE OUTLET
CONSTIPATION ARE VERY DISAPPOINTING. , B Santoni
MD, D Vivas MD, B Safar MD, J Nogueras MD, E Weiss MD, S
Wexner MD, D Sands MD, Cleveland Clinic Florida
Hypothesis: This study aimed to assed the long-term results
in patients with outlet obstructive evacuation who underwent
Botulinum toxin type A injections. Methods: Following IRB
approval, a retrospective chart review was undertaken from
1992-2006 including all patients who received Botulium Toxin
Type A injections into the puborectalis muscle for obstructive
outlet constipation. Charts with incomplete data were excluded.
Age, gender, anal manometry, pudental nerve latency and EMG
studies, defecography, previous pelvic surgery and other types of
treatment were all examined. Patients were contacted by telephone
and postal survey and asked to complete a questionnaire to
assess the satisfaction with the result of the treatment. Results:
55 patients (35 women) of mean aged 59. 6 (range 25-94) years
were identified as having obstructive outlet constipation who
underwent Botulinum toxin injection. 29 patients replied to
the questionnaire. Before the Botulinum toxin injection, 4 with
neurological disturb; 4 with psychological problems; 9 with rectal
pain. Before the Botulinum toxin injection, 2 underwent ostomy;
1 STARR procedure; 1 sigmoidectomy with rectopexy; 4 total
abdominal colectomy with ileorectal anastomosis. Paradoxical
puborectalis contraction was noted in 20/29 EMG exams and
in 19/23 defecographic evaluations. 25 of the 29 patients had
failed 0-10 sessions of biofeedback therapy and 16 patients
were laxative dependent. 24 patients underwent 1-2 injections of
Botulinum toxin interim 5 patients received 3-5 injections. At a
mean follow-up of 35. 8 (range 1-103) months. 3 patients reported
fecal incontinence, 3 had urinary incontinence and 14 continued
to require laxatives to evacuate. Only 8/29 patients (28%) were
satisfied with the results. Conclusion: Despite initial enthusiastic
results, longer-term follow-up revealed very poor results. Between
limited efficacy and the potential morbidity of both urinary and
fecal incontinence. The role of Botulinum toxin type A injection
for paradoxical puborectalis contraction is very limited.
S071 DIVERTICULITIS IN THE UNITED STATES: 1991 2005 CHANGING PATTERNS OF DISEASE, TREATMENT,
David A Etzioni MD, Andreas M Kaiser MD, Robert W Beart MD,
Thomas M Mack MD, University of Southern California
ABSTRACT BOOK
Podium Papers
Objectives: Diverticular disease imposes an impressive clinical
burden to the US population, with over 300, 000 admissions and
1. 5 million days of inpatient care annually. Consensus regarding
the treatment of diverticulitis has evolved over the last decade,
with increasing advocacy of primary anastomosis for acute
diverticulitis, and non-operative treatment of recurrent mild/
moderate diverticulitis. We sought to analyze whether these
changes are reflected in patterns of practice in a nationallyrepresentative patient cohort. Methods: We used the 1991-2005
Nationwide Inpatient Sample to analyze the care received by
381, 000 patients admitted with acute diverticulitis and 51, 000
patients operated electively for diverticulitis. Census data were
used to calculate population-based incidence rates of disease
and surgical treatment. Weighted logistic regression with cluster
adjustment at the hospital level was used for hypothesis testing.
Results: Between 1991-1995 and 2001-2005, population-adjusted
rates of admission for acute diverticulitis increased by 18%, but
dramatically within patients aged 18-44 (116% increase). Rates
of elective operations for diverticulitis rose more quickly, with a
51% increase in rate within the overall population and massive
increase (188%) in individuals aged 18-44.
the ovaries in colorectal malignancy is prognostically poor.
Furthermore, macroscopic and histochemical similarities make
differentiation between primary mucinous and metastatic
deposits to the ovary difficult. We examined this complex picture
of metastatic ovarian cancer in association with colorectal
malignancy. Methods: Pathological database and case note
review of consecutive patients, referred to a single centre over
an 8 year period, with primary ovarian cancer and a previous,
or subsequent, history of colorectal adenocarcinoma. Each
carcinoma was defined histologically/immunologically from
resected specimens. Results: 26 cases were identified. 8 patients
(31%, median age 60 years) had colectomy prior to oophrectomy
(median time lapse 17 months, range 3-60 months). In this group,
colonic metastatic adenocarcinoma to the ovary was observed in
75%. 18 patients (69%, median age 55 years) had oophrectomy
prior to colectomy (median time lapse 11 months, range 3-60
months). In these patients, colonic metastatic adenocarcinoma
was identified in the ovaries of 4 (22%) and mucinous ovarian
carcinoma in 3 (17%). 8 patients (44%) receiving oophrectomy
first, presented with altered bowel habit and/or rectal bleeding,
including all with mucinous or metastatic ovarian carcinoma. Only
2 were referred, following oophrectomy, for colonic visualisation,
identifying their primary cancer. Conclusions: Ovarian neoplasia
following colorectal cancer is indicative of metastatic disease
and avoidable through prophylactic oophrectomy. Colonic
investigation should be performed in all cases of ovarian tumours
with suspicious bowel symptoms and considered in mucinous
ovarian carcinoma.
ANORECTAL DISEASES I
Multivariate analysis found no evidence that primary anastomosis
is becoming more commonly used. Conclusions: We are the first
to report dramatic changes in rates of treatment for diverticulitis
in the US. The causes of this emerging disease pattern are
unknown, but certainly deserve further investigation. For patients
undergoing surgery for acute diverticulitis, there was little change
over time in the likelihood of a primary anastomosis.
S072 MANAGEMENT OF ACUTE MALIGNANT LARGE
BOWEL OBSTRUCTION WITH SELF-EXPANDING METAL
STENT, J-P Arnaud MD, S Mucci-Hennekinne MD, K Meunier
MD, E Lermite MD, C Teyssedou MD, A Hamy MD, Department of
Visceral Surgery, Chu-Angers, France
Background: colorectal stents are being used for palliation and
as a “bridge to surgery” in obstructing colorectal carcinoma.
The purpose of this study was to review our experience with
self-expanding metal stents (SEMS) as the initial interventional
approach in the management of acute malignant large bowel
obstruction. Methods: between February 2002 and May 2006, 67
patients underwent the insertion of a SEMS for an obstructing
malignant lesion of the left-sided colon or rectum. Results: in
55 patients, the stents were placed for palliation, whereas in 12,
they were placed as a bridge to surgery. Stent placement was
technically successful in 92, 5% (n=62), with a clinical success rate
of 88% (n=59). Two perforations occurred during stent placement
treated by an emergency Hartmann operation. In intention to treat
by stent, the peri-interventional mortality was 6% (4/67). Stent
migration was reported in 3 cases (5%) and stent obstruction
in 8 cases (13, 5%). Of the nine patients with stents successfully
placed as a bridge to surgery, all underwent elective singlestage operations with no death or anastomotic complication.
Conclusions: stent insertion provided an effective outcome in
patients with malignant colonic obstruction as a palliative and
preoperative therapy.
S073 METASTATIC OVARIAN AND COLORECTAL CANCER:
TWO ORGANS, ONE DISEASE, J D Terrace MD, R J Skipworth
MD, C Bourne MD, D N Anderson MD, Academic Unit of
Coloproctology, University of Edinburgh
Introduction: Whilst oophrectomy is routinely performed in post
menopausal women during gynaecological surgery, prophylactic
oophrectomy during colorectal cancer resection remains
controversial. Synchronous or metachronous involvement of
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S074 EXAMINATION OF ANAL PRESERVATION WITH
ANAL SPHINCTERIC RESECTION FOR VERY LOW RECTAL
CANCER, Yoshito Akagi MD, Kazuo Shirouzu MD, Yutaka Ogata
MD, Naruya Ishibashi MD, Masataka Ushijima MD, Hidetugu
Murakami MD, Department of Surgery, Kurume University
In our department, we have adopted a preservation of anus
with resection of internal or external sphincter resection for the
lower rectal canceriISR, ESRj that a inferior border of tumor
is present in a vicinity of dentate line. We report the clinical
results of this operative method which we experienced in our
department until now and examine problems by the present.
Subject and Methods: For 52 cases that we have performed
ISR or ESR from 2001 to 2006, we reviewed oncological results
and anal function. Results: Postoperative complications: The
complication after operation were acknowledged 19. 2% (10/52),
3 cases of anastomosis leakage, 3 cases of intrapelvic abscess, 2
cases of anastomotic region mucosal necrosis 2, a constructed
bowel necrosis and ileus. Anal Function: On anal pressure
examination after one year from closure of temporary ileostomy,
Maximum resting pressure(MRP) with 36. 3cmH2O was lower
than its value before closure of ileostomy. But, the Maximum
squeeze pressure(MSP) gradually recovered with 119. 6cmH2O.
The recurrence rate after curative resection was 11. 5% (6/52).
The local recurrence was 7. 7%(4/52) of 2 cases in lateral lymph
node and 2 cases of intra pelvic space. Distant metastasis was
each one case to liver and to lung. Conclusion: It seems that
ISR and ESR for very low rectal cancer are acceptable at present
time seeing from an oncology and an anal function. However, it
is necessary for us to devise the prevention of complications and
a recurrence.
S075 INCIDENCE OF COLONIC POLYPS AFTER BARIATRIC
PROCEDURES. , B Bashankaev MD, M Khaikin MD, D Melero
MD, D Vivas MD, B Santoni MD, D Sands MD, E Weiss MD, J
Nogueras MD, S Szomstein MD, R Rosenthal MD, S Wexner MD,
Background: There are data showing increased risk of colorectal
cancer in the obese population. Colon polyps have proven to be
a premalignant stage in the development of colorectal cancer.
Aim: To evaluate the incidence of colonic polyps in patients who
underwent bariatric surgery and to compare this incidence to the
nonbariatric surgery population. Methods: After the IRB approval,
retpospective review of the prospectively entered bariatric surgery
and endoscopy databases was performed to identify all patients
53
ABSTRACT BOOK
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who had bariatric surgery and colonoscopy over a period from
February 2000 to April 2007. This Surgical, Morbidly Obese Group
(SMOG) was matched to the group of colonoscopy patients
without surgery, who didn’t have morbid obesity (Non-Obese
Group, NOG) by age and gender. BMI before surgery and at time
of colonoscopy, age, gender, type of procedure, colonoscopy
findings and pathology results were recorded. Results: 70 patients
of the 2332 bariatric surgery patients (SMOG) were identified and
compared to 70 out of 2165 patients from the endoscopy database
(NOG). There were no differences between the groups in age and
gender. However, there was statistically significant difference in
BMI at time of colonoscopy (31 vs. 28. 4, p=0. 036). 21. 4% patients
in the SMOG and 25. 7% in the NOG were high risk patients.
SMOG colonoscopy was postoperatively performed after a mean
period of 23. 2 (1-55) months. Two third of patients in both groups
had no polyps (70% SMOG, 77% NOG). Most polyps were single
and equally distributed between the right and the left colon. Half
of the polyps in both groups were hyperplastic polyps of 3 - 4
mm in size. There was no cancer identified in the NOG, however,
in the SMOG adenocarcinoma was found in 2 patients (8. 3%), 1
in the cecum and 1 in the sigmoid colon. Both patients had no
high risk of colorectal cancer and postoperative colonoscopy was
performed in 55 and 33 months, respectively. Conclusions: The
incidence of colorectal polyps and cancer was not signifacantly
different between SMOG and NOG patients during the mean
postoperative period of 2 years. However polyp distribution and
pathologic characteristics were similar between both groups.
Although wasn’t stastically significant, this study shows a trend
to develop malignant polyps in morbidly obese group. Long term
follow-up with preoperative and postoperative colonoscopy are
needed to accurately determine any role of bariatric surgery in the
development of colorectal cancer.
and finally surgical sphincterotomy if these methods fail. This
study was designed to compare pharmacologic therapy using
glyceryl trinitrate with lateral internal sphinchterotomy in young,
otherwise healthy males. Methods: From March 2005 to August
2007, 30 consecutive young males (age range 21 to 40 years) with
a chronic anal fissure, were randomized to be managed by either
topical glyceryl trinitrate or lateral internal sphincterotomy. Pretreatment, pain scores were obtained using a numerical scale
and continence scores were obtained using the Cleveland Clinic
scoring system. Post-treatment, pain scores were assessed on
post-treatment day 2 , 7 and 28, continence and fissure healing
at 3 months postoperatively. Patient satisfaction with therapy was
assessed at 3 months using a numerical scale. Compliance with
pharmacological therapy was also assessed. Results: 15 patients
underwent pharmacological therapy by topical application of
glyceryl trinitrate (4mg/g, twice daily). 15 patients underwent
lateral internal sphinchterotomy utilizing in an ambulatory
setting. In both groups, the mean age was 30±6 years. Pain scores
were significantly lower in the surgical group on post-treatment
days 2 (1. 5± 0. 27 versus 5. 0±1. 2, p<0. 05) and 7 (0. 4±0. 16
versus 2. 9±0. 7, p<0. 05). Pain scores on post-treatment day 28
were not significant. Patients in both groups achieved similar
continence scores at 3 months. In the surgical group all fissures
had healed at 3 months. In the pharmacologic group the healing
rate was 67% at 3 months. Patient satisfaction scores were
significantly higher in the surgical group (3. 7±0. 4 versus 1. 5±0.
3, p<0. 05). Sixty percent of patients in the non-surgical group
were totally compliant with pharmacologic therapy, 20% were
partially compliant and 20% were non-compliant. Conclusion:
Lateral internal sphinchterotomy may be offered as the first line
of therapy in carefully selected young, otherwise healthy male
patients.
S076 OBSTRUCTIVE COLORECTAL CANCER, PROGNOSIS
AND COST-EFFECTIVENESS ACCORDING TO THERAPEUTIC
OPTIONS, Ui Sup Shin MD, Chang Sik Yu MD, Sang Nam
Yoon MD, Dae Dong Kim MD, Jin Cheon Kim MD, Department
of Surgery, University of Ulsan College of Medicine and Asan
Medical Center, Seoul, Korea
Background: The aim of this study was to compare treatment
outcomes and cost-effectiveness among the stage operation,
on-table lavage, and stent insertion. Methods: We reviewed the
medical records of 116 patients who received curative operation
for obstructive colorectal cancer from 1992 to 2007. Sixty-six
patients underwent the stage operation (diversion group), 23
patients underwent on-table lavage (lavage group), and 27 patients
underwent the stent insertion (stent group). Median follow-up
period was 21 months (1~130 months). Results: There was no
significant difference in age, comorbidity, stage, and histologic
grade among the three groups. Compared with the other groups,
however, significantly higher incidence of lymphovascular
invasion was observed in the stent group (p<0. 05). The diversion
group has higher postoperative complication rates in the areas
such as wound infection and intestinal obstruction (p=0. 003).
Operation times and hospital days were significantly longer in
the diversion group and no significant difference was observed
between the lavage and stent groups (p<0. 001). The mean of total
costs was U$15, 762 for the diversion group, U$10, 543 for the
lavage group, U$10, 838 for the stent group (p<0. 001). Although
we could not find any significant difference, stent group has a
lower 2 year relapse free survival rate than those of the diversion
and lavage groups. Tumor recurrence and survival rates were not
significantly influenced by therapeutic options. Conclusions:
Compared with the traditional stage operation, on-table lavage
and stent insertion had no negative impact on the recurrence
and survival rates with less complications and better costeffectiveness. But long term follow up and case accumulation is
needed to evaluate the oncologic safety of stent insertion.
S078 TREATMENT OF HEMORRHAGIC RADIATION
PROCTITIS WITH FORMALIN APPLICATION UNDER
DORSAL PERINEAL BLOCK. , Narimantas E Samalavicius PhD,
Alfredas Kilius, Darius Norkus, Arvydas Burneckis, Konstantinas
P Valuckas, Oncology Institute of Vilnius University, Santariskiu
1, Vilnius, Lithuania
Aim of the study was to evaluate results of treatment of
hemorrhagic radiation proctitis with formalin application under
dorsal perineal block in patients, who received radiation therapy
for prostate cancer. Patients and Methods: During two years,
2006-2007, 29 patients underwent formalin application under
dorsal perineal block for hemorrhagic radiation proctitis. All
patients were irradiated of prostate cancer. Age 60-76 years,
on an average 70 years. In one case hemorrhage occurred 1
week after treatment, in rest of the cases 3 to 24 months after
treatment, on an average 10 months. 15 patients reported daily
blood in stools, 14 - 2 or 3 times a week. 2 patients received blood
transfusions for severe anemia, one even underwent colostomy
to control severe bleeding. According to endoscopic classification
of chronic radiation-induced proctopathy, 6(20, 7%) had grade I,
16 (55, 2%) grade II and 7 (24, 1%) grade III proctitis. All patients
were referred for formalin therapy after failure of noninvasive
management. Formalin application has been performed as a
day case in an operating theatre, dorsal perineal block achieved
injecting a mixture of lidocaine and bupivacaine solution. A gauze
soaked with 4% formalin has been applied to the whole diseased
rectal mucosa for 4 minutes. If patient had no improvement after 4
weeks, he was advised to repeat the procedure. 21 (72, 4%) patients
underwent single procedure, and 8 (27, 6%) - two. Results: 2 to
26 months after treatment, patients 25 were interviewed (4 lost to
follow-up). 14 (56%) reported complete cure, 5 (20%) significant
improvement, and 6 (24%) no change (3 of them underwent single,
and 3 two applications). One patient, who underwent colostomy
for previous episodes of bleeding from radiation proctitis, was
cured and colostomy was closed. One patient developed rectal
mucosal damage after second application, due to which received
prolonged conservative management, though bleeding stopped
completely. Conclusion: Application of 4 % formalin for 4
minutes for hemorrhagic radiation proctitis under dorsal perineal
block in patients who received radiation therapy for prostate
cancer was simple, safe and effective, and 76% of patients were
cured or markedly improved after treatment.
S077 CHRONIC ANAL FISSURE IN YOUNG MALES,
Constantine P Spanos MD, Theodore Syrakos MD, Dimitris
Kiskinis MD, 1st Department of Surgery, Aristotelian University,
Thessaloniki, Greece
Purpose: Chronic anal fissure is a relatively common disorder
in young males. Standard therapy algorithms begin with
conservative treatment, followed by pharmacologic treatment
54
ISUCRS XXII BIENNIAL CONGRESS ABSTRACT BOOK
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S079 FLAPS IN COLORECTAL SURGERY - A PLASTIC
SURGEONS VIEW, Stephan Spendel PhD, Johann Pfeifer PhD,
Michael V Schintler PhD, Gerhard Kreuzwirt RN, Bengt Hellbom
PhD, Erwin Scharnagl PhD, Division of Plastic and Reconstructive
Surgery, Medical University Graz, Austria
Introduction: Exstirpative operations of the perineum often
include preoperative or postoperative radiation therapy. Without
vascularized tissue reconstruction, these wounds often break down,
becoming problem wounds. Morbidity associated with the non
healing perineal wound remains the most common complication
after proctectomy. Muscle and musculocutaneus flaps can solve
these problems. For defects due to trauma or infections in the
abdominal and perineal region reconstruction with flaps may also
be necessary. Patients and Methods: A consecutive series of 31
patients were retrospectively reviewed between 2002 and 2007.
All patients were operated interdisciplinary with the colorectal
surgeon specialist. Flaps were used in patients with rectovaginal
and chronic anal fistulas, infections, malignant skin tumors, sacral
and rectal tumors, tumors of the genital region and in patients
with incontinence for preliminary measures for implantation of
artificial bowel sphincters. Results: 35 flaps in 31 patients were
performed. Types and frequency of flaps using for reconstruction
as follows: rectus abdominis flap (8), groin flap (2), glutaeus
maximus flap (2), tensor fascia latae flap (3), gracilis flap (6),
pudendal thigh flap (5), free scapular flap (1), local transposition
flap (8). In all patients no flap was lost, minor early complications
took place in 14%, partial flap necrosis in 10%. Reoperation was
necessary in 18%. Conclusion: In our clinic minor flaps such
as the house flap, martius flap etc. are commonly done by the
colorectal surgeon. In some special cases complex reconstruction
is required and thus we recommend an interdisciplinary approach
with a plastic surgeon.
S080 FISTULA-IN-ANO IN INFANTS: OPERATIVE OR
NONOPERATIVE MANAGEMENT? Shota Takano MD, Shin
Namikawa MD, Yoriyuki Tsuji MD, Kazutaka Yamada MD, Masahiro
Takano MD, Coloproctology center Takano Hospital
Background: Nonopetation management is mainly selected
in treatment of fistula-in-ano in infants recently. However, not
few parents of the patents want to undergo surgery early time,
because repeated pain and high fever of infant are to be mental
fatigue of their patients. In our institution, we perform fistulotomy
for patients under 12 months if their parent wants. Fistulotomy is
the accepted treatment for infants with fistula-in-ano. We analyzed
fistulotomy of fistula-in-ano by comparing with nonoperating
management. Methods and Results: A retrospective review
was done of 93 infants with fistula-in-ano between the years 1997
and 2007 in our institution. All patients were boy. 40 patients were
performed fistulotomy. 53 patients were underwent conservative
management. Mean age at onset of symptoms was 3. 7 +/- 2. 5
months. In the group of fistulotomy, mean age at operation was 6.
7 +/- 4. 2 months. The mean duration between onset of symptom
and operation was 2. 9 +/- 2. 1 months. None of patients who
were performed fistulotomy had recurrent fistula during followup period. But 6 patients (14. 3%) is followed by new fistula-in-ano
in other part. 3 patients of them were underwent re-operation.
Conclusions: Fistula-in-ano and perianal abcess give children
pain and high fever. And then, it gives their patients mental fatigue
and time burden. Fistulotomy for under 12 months patients is an
effective method if their patients want. Surgical management is
more effective in respect to the mental and time factor.
S081 PATIENT’S SELF-IRRITATING SETON INDWELLING
DURING MODIFIED HANLEY OPERATION FOR HORSESHOE
FISTULA, Nahmgun Oh PhD, Hyuk-Jae Jung MD, Department of
Surgery, Pusan National University Hospital, Busan, South Korea
Purpose: Fistula is a condition that can usually be treated by
surgery, but has problems of recurrence, fecal incontinence, and
postoperative wound infection. The modified Hanley operation
which is usually applied for the treatment of horseshoe fistula
showed reduced anal sphincter injury compared to the classic
Hanley operation, but still involves a long wound healing duration,
during which long-term outpatient treatment is required, making
the daily life of a patient inconvenient. Hence, in order to reduce
inflammation at fistulotomy wound sites, the present authors have
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developed a pulsatile self-irrigating seton procedure for use in
the modified Hanley operation. In order to analyze clinical results
after surgery for an existing simple drainage seton procedure and
the newly modified self-irrigating seton procedure in the modified
Hanley operation, the present study was performed. Subjects
and Method: This study was performed on 24 horseshoe fistula
patients who have received surgery in the present hospital for
a period from January 1999 to December 2005. For comparison,
the 24 patients who have received the modified Hanley operation
were divided two groups: Group A consisting of 12 patients
subjected to the existing simple drainage seton procedure; and
Group B consisting of 12 patients subjected to the self-irrigating
seton procedure. In Group A, general outpatient treatment was
performed therein, and in Group B, the patients themselves who
have been discharged from the hospital after surgery performed
pulsatile irrigation daily with normal saline containing antibiotickanamycin dissolved by personal manual infusion. During the
study, the two groups were comparatively analyzed for purulent
discharge duration, seton indwelling duration and recurrence rate.
Results: In the comparison between the two groups, the purulent
discharge duration was 29. 75 ¡¾ 4. 27 days for Group A and 18.
75 ¡¾ 2. 90 days for Group B, and the seton indwelling duration
was 32. 58 ¡¾ 3. 70 for Group A and 21. 58 ¡¾ 3. 09 for Group B.
Also, the recurrence occurred in 2 cases (16. 7%) for Group A and
1 case (8. 3%) for Group B. The present method having a pulsatile
irrigation in addition to the role of the drainage seton procedure
which has previously been used is considered to be significantly
effective in reduction of purulent discharge duration and seton
indwelling duration compared to the case of performing surgery
using only drainage seton, and seems to be a recommendable
method in performing the modified Hanley operation for treating
horseshoe fistula. Conclusion: This pulsatile self-irrigation seton
is considered to be a new effective modification for drainage of
deep-seated curettage site in complicated high anal fistula.
ANORECTAL DISEASES II
S082 VALIDATION OF USEFULNESS OF LYMPH NODE
DISSECTION FOR COLORECTAL CANCER IN JAPAN, USING
THE REDUCTION RATE OF LYMPH NODE RECURRENCE,
Hirotoshi Kobayashi MD, Masayuki Enomoto MD, Tetsuro Higuchi
MD, Masamichi Yasuno MD, Hiroyuki Uetake MD, Satoru Iida MD,
Toshiaki Ishikawa MD, Megumi Ishiguro MD, Takatoshi Matsuyama
MD, Haruhiko Aoyagi MD, Sayaka Shimizu MD, Satoshi Okazaki
MD, Kenichi Sugihara MD, Tokyo Medical and Dental University,
Dept of Surgical Oncology
Background: The aim of this study was to clarify the usefulness
of lymph node dissection for colorectal cancer, using the reduction
rate of lymph node recurrence. Method: We enrolled 512 patients
who underwent curative resection for colorectal cancer between
January 1991 and December 2000 at the Tokyo Medical and
Dental University. The reduction rate of lymph node recurrence
was defined as follows: RLN = X/(X + Y). gXh is the number of
patients with positive lymph node metastasis who had no lymph
node recurrence. gYh is the number of patients with lymph node
recurrence. Results: The numbers of patients with colon and
rectal cancer were 365 and 147, respectively. The reduction rates
of lymph node recurrence in patients with T1, T2, T3, and T4 colon
cancer were 100%, 92. 3%, 93. 5%, and 93. 0%, respectively. Those
with T1, T2, and T3 rectal cancer were 100%, 90. 9%, and 92. 7%.
The reduction rate of lymph node recurrence in patients with T4
rectal cancer could not be calculated, because there was no patient
with lymph node metastasis in this population. The rate of lymph
node recurrence in patients with positive pericolic lymph node
alone was significantly less than that with positive lymph node
along the course of major vessels that supply the colon (p = 0.
011). However, there was no difference in the rates of lymph node
recurrence among the locations of positive nodes in patients with
rectal cancer. Conclusion: When the curative resection with the
Japanese standard lymphadenectomy for colorectal cancer was
performed, the reduction rates of lymph node recurrence were
more than 90% in any T category. The lymph node dissection may
be useful in patients with colon cancer who have only pericolic
nodal involvement.
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ABSTRACT BOOK
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S083 RESULTS FROM PELVIC EXENTERATION FOR
LOCALLY ADVANCED COLORECTAL CANCER WITH LYMPH
NODE METASTASES, Jin-ichi Hida MD, Takehito Yoshifuji MD,
Osaka, Japan
Purpose: We examined the survival benefit of pelvic exenteration
for locally advanced colorectal cancer with lymph node metastases,
because this issue remains controversial. Methods: Medical
records of 50 patients who underwent curative pelvic exenteration
for colorectal cancer were reviewed retrospectively. Nodal
metastases were examined by the clearing method in 29 patients
and by the conventional manual method in 21 patients. Results:
Invasion to contiguous pelvic organs was present in 40 patients
(80%) and absent in 10 patients (20%). Node metastases were
present in 33 patients (66%). Operative morbidity and mortality
rates were 22% (11 patients) and 6% (3 patients), respectively.
Respective 5-year survival rates were 60 and 80% in the groups
with and without organ invasion (no significant difference). Fiveyear survival rates in patients with nodal metastases was 54. 6%
but was significantly higher, 82. 4%, in patients without nodal
metastases. Five-year survival in 28 patients with both organ
invasion and nodal metastases was 53. 6%. Conclusions: Longterm survival was afforded by pelvic exenteration for locally
advanced colorectal cancer with nodal metastases.
S084
PREOPERATIVE
VERSUS
POSTOPERATIVE
CHEMORADIOTHERAPY FOR RECTAL CANCER, Sung Il
Choi MD, Jae-Chang Lee MD, Suk-Hwan Lee MD, Kil-Yeon Lee
MD, Sung-Eun Hong MD, Kyunghee University Hospital
Purpose:
Postoperative
chemoradiotherapy(XRT)is
the
recommended standard therapy for patients with locally advanced
rectal cancer. In recent years, encouraging results with preoperative
XRT have been reported. We compared preoperative XRT with
postoperative XRT for locally advanced rectal cancer. Methods: We
reviewed 132 rectal cancer patients with curative resection in stage
II, III who received either preoperative or postoperative XRT. The
preoperative treatment consisted of 5040cGy delivered in fractions
of 180cGy per day, five days per week, and fluorouracil, given at
a dose of 350mg/m2 during the first, fifth weeks of radiotherapy.
Surgery was performed 5weeks after the completion of XRT.
One month after surgery, four or five-day cycles of fluorouracil
were given. XRT was identical in the postoperative treatment
group, except for the presence of levamisol in chemotherapy.
The primary end point was disease free survival. Results: Sixty
two patient received preoperative XRT, and 70 patients received
postoperative XRT. Their clinicopathological factors were no
difference in age and sex ratio. The median follow up period were
37. 3, 41. 7 months respectively. Postoperative complications
were intestinal obstruction, wound infection, voiding difficulty,
bleeding and anastomosis leakage. Postoperative complications
were 19 cases(30. 6%) in preoperative XRT and 16 cases(22. 9% )
in postoperative XRT(p=0. 38). The disease free five-year survival
rates were 61. 7% and 69. 6% respectively(p=0. 44). The local
recurrence rates were 7 cases (11. 3%) in preoperative XRT and
3 cases (4. 2%) in postoperative XRT(p=0. 13). The side effects
including acute toxic effects occurred in 41. 9% of the patients
in the preoperative treatment group, as compared with 58. 6%
of the patients in the postoperative treatment group(p=0. 02).
Conclusions: Preoperative XRT, as compared with postoperative
XRT, did not show improved local control and disease free survival,
but was associated with remarkably decreased toxicity.
S085 A QUALITATIVE ANALYSIS OF A FOCUS GROUP
DISCUSSION ON PATIENT DECISION MAKING IN CANCER
CARE, N Srinivasaiah MD, B Joseph MD, J Gunn MD, J Hartley
MD, J R Monson MD, 1. Academic Surgical Unit, University of
Hull, Cottingham, UK
Introduction: Patient preferences should play an important role
when decision making in cancer care. Literature is increasingly
demonstrating that surgeons and physicians have divergent
preferences for treatment options compared with their patients
and with each other. Cancer psychology is an important aspect of
56
ISUCRS XXII BIENNIAL CONGRESS cancer care. Qualitative research is a gateway to explore this. We
aim to explore opinions and thoughts among surgical colleagues
about “patient decision making in cancer care”. Methods: A pilot
focus group discussion among members of the academic surgical
unit involving 4 consultants, 3 registrars and 3 research fellows.
The discussion was audio-taped and transcribed. Qualitative
methodology was adopted for analysis. Thematic analysis using
framework approach was done thereby identifying Themes
& Outcomes. Results: Themes that emerged are Evidence
based clinical practice, Knowledge, Decision making, Patient
Information, Risk, Communication, Consent, Socioeconomic
factors and Patient empowerment, Outcomes derived are to
increase the evidence base, Increase the clinician and patient
knowledge, provide adequate information, Decisions to be based
on patients best interest, Communicate risk in a understandable
manner, Take patients views, knowledge and demands into
consideration, Conclusions: Patient decision making in cancer
care is slowly evolving, where decisions are not only made taking
into account patients views, knowledge and demand but are also
driven by them in a minority. Time is a factor and in years to come
the patients will play an increased role in their treatments taking
into account tradeoffs and risks between survival and quality of
life.
S086 STARR PROCEDURE FOR OBSTRUCTED DEFAECATION
SYNDROME (ODS): 12 MONTH FOLLOW-UP, David G Jayne
MD, Oliver Schwandner MD, Leonardo Lenissa MD, Angelo Stuto
MD, University of Leeds, Caritas Krankenhaus Str. Josef, Casa di
Cura San Pio X, Ospedale S. maria degli Angeli
Purpose: A European registry was set-up to determine the
short-term safety and efficacy of the STARR procedure for
obstructed defaecation syndrome (ODS). 12 month follow-up was
completed in February 2008. Methods: STARR registries in Italy,
Germany and the UK were designed to allow pooling of results
for combined analysis. Recruitment commenced in February
2006. Data collection included a symptom severity score (SSS),
obstructed defaecation score (ODS), Cleveland clinic incontinence
score, symptom-specific (PAC-QoL) and generic (ED-5Q utility
and VAS) quality of life (QoL) scores. STARR was performed
using the double stapling PPH-01 technique. All complications
were recorded. Data collection was performed at baseline, 6
weeks, and 6 and 12 months. Data management and analysis
was performed by an independent body (MedAlliance, Brussels).
Results: 1817 patients were recruited and eligible for analysis.
292 (16. 1%) were male. The mean age was 54 yrs (range: 17-92).
Defaecating proctography was performed in 92. 7% and showed:
rectocele (55%), mucosal prolapse (53. 8%), intussusception (49.
7%), enterocele (5. 5%). Mean operative time was 44mins (range:
15-210). Average length of stay was 3 days (range:1-36). 953 (52%)
and 606 (33%) has completed data for analysis at 6 and 12 mths
respectively. A significant symptomatic improvement was seen
between baseline and 6 mths and maintained at 12 mths (SSS:
baseline 15. 2 (95%CI: 14. 9, 15. 5) v’s 12 mths 3. 7 (95%CI: 3. 4, 4.
1), p<0. 001; ODS: baseline 15. 7 (95%CI: 15. 3, 16. 0) v’s 12 mths
6. 1 (95%CI: 5. 2, 7. 0), p<0. 001. This was reflected in a significant
improvement in both PAC-QoL and ED-5Q QoL scores at both 6
and 12 mths. Incontinence scores improved from 3. 1 (95%CI: 2.
9, 3. 3) at baseline to 2. 4 (95%CI: 2. 2, 2. 7) at 6 mths and 2. 0
(95%CI: 1. 7, 2. 3) at 12 mths (p<0. 001). 962 minor and major
complications were reported in 581 (32%) patients, of which the
most frequent were: unexpected pain (7. 7%), urinary retention
(6. 3%), bleeding (4. 1%), stapled line complications (3. 5%),
sepsis (1. 1%), incontinence (1. 3%). Postoperative defaecatory
urgency was reported in 16. 2%. There was 1 rectovaginal fistula
and 1 diverting stoma. No mortality was reported. Conclusions:
The STARR procedure for ODS is safe and effective and results
in a significant improvement in QoL. The benefits appear to be
maintained at 12 months.
S087 A NOVEL CONCEPT FOR THE SURGICAL ANATOMY
OF THE PERINEAL BODY, Ali A Shafik MD, Cairo University
Purpose: Perineal body is considered by investigators
as a fibromuscular structure that is the site of insertion
of perineal muscles. We investigated the hypothesis
that perineal body is the site across which perineal
muscles pass uninterrupted from one side to the other.
ABSTRACT BOOK
Podium Papers
Methods: Perineal body was studied in 56 cadaveric specimens
(46 adults, 10 neonatal deaths) by direct dissection with the
help of magnifying loupe, fine surgical instruments, and
bright light. Results: Perineal body consisted of three layers:
1) superficial layer, which consisted of fleshy fibers of the
external anal sphincter extending across perineal body to
become the bulbospongiosus muscle; 2) tendinous extension of
superficial transverse perineal muscle crossing perineal body to
contralateral superficial transverse perineal muscle, with which
it formed a criss-cross pattern; and 3) tendinous fibers of the
deep transverse perineal muscle; the fibers crossing perineal
body decussated in criss-cross pattern with the contralateral
deep transverse perineal muscle. A relation of levator ani or
puborectalis muscles to perineal body could not be identified.
Conclusions: Perineal body (central perineal tendon) is not the
site of insertion of perineal muscles but the site along which
muscle fibers of these muscles and the external anal sphincter
pass uninterrupted from one side to the other. Such a free passage
from one muscle to the other seems to denote a Bdigastric
pattern^ for the perineal muscles. Perineal body is subjected to
injury or continuous intraabdominal pressure variations, which
may eventually result in perineocele, enterocele, or sigmoidocele.
[Key words: Perineal muscles; External anal sphincter;
Bulbospongiosus; Perineocele; Enterocele; Sigmoidocele]
histology. The wounds took 45-90 days for complete healing. The
average hospitalization was 3. 4 days. 23 (16%) patients required
a further minor procedure during their healing. 7 (4. 9%) patients
had recurrence. 3 patients required another surgery, while 4
patients needed 2 more surgeries for complete cure. None of the
patients had incontinence to solid stools. Conclusions: Clinical
examination provides more information than any investigation;
investigations are not always necessary. It is necessary to destroy
the anal gland to prevent recurrence. Supralevator tracts can
sometimes deter the surgeon, & may lead to an incomplete
surgery. They need to be tackled during the primary surgery itself.
A close follow up of the wound is needed to ensure optimum
healing. A clear understanding of the pathology is the key to a
successful surgery.
SURGICAL TECHNIQUES I
S088 HYPERBARIC OXYGEN FOR CHRONIC ANAL FISSURE
- LONG TERM OUTCOME, N Srinivasaiah MD, Cundall J MD,
Laden G, K Chapple, G S Duthie, 1. Academic Surgical Unit, Castle
Hill Hospital, Cottingham, UK HU16 5JQ. 2. Hyperbaric Unit,
Classic Hospital, Anlaby, Hull, United Kingdom
Introduction::Optimal treatment of the patient with a chronic
anal fissure (CAF) is unclear. Medical therapy has poor longterm outcome whilst surgery may have significant associated
morbidity. We have previously shown, in a small pilot study, that
hyperbaric oxygen (HBO) is an effective treatment for CAF. Since
long-term outcome is unknown, we investigated a cohort of CAF
patients at least 5 years after HBO therapy. Methods: Patients
with CAF who had failed both medical and surgical management
underwent HBO therapy (fifteen 90 minute treatments of 100%
oxygen at 2. 4 atmospheres). Peri-anal symptoms were assessed
at least 5 years after HBO therapy using a patient questionnaire.
Results: 8 patients (4 male, 4 female, median age 58 [range 2782] years) were identified. Median symptom duration prior to HBO
treatment was 2. 5 (IQR 1. 3-4. 6) years. A single patient required
further surgery (Rotation flap) and another patient has occasional
pain and bleeding. One patient died from un-related causes.
The remaining five patients have required no further treatment
and are totally asymptomatic. Conclusion: HBO therapy has
long-term effectiveness in the treatment of CAF unresponsive to
conventional therapy.
S090
COMPARISON
OF
MACROSCOPICAL
AND
PATHOLOGICAL
STUDY
BETWEEN
PREOPERATIVE
RADIOTHERAPY
AND
RADIOCHEMOTHERAPY
FOR
ADVANCED RECTAL CANCER, Koji Yasuda MD, Giichiro
Tsurita PhD, Tomomitsu Kiyomatsu PhD, Hirokazu Nagawa PhD,
The Department of Surgical Oncology, the Graduate School of
Medicine, The University of Tokyo
Purpose: We studied the macroscopical and pathological effect of
preoperative radiotherapy and radiochemotherapy for advanced
rectal cancer. Object: This is a retrospective study including
patients with preoperative radiotherapy group(RT group, n=82)
and preoperative radiochemotherapy group(CRT group, n=41)
which are performed radical operation after neoadjuvant therapy.
Result: We set an original standard of the macroscopical effect
due to neoadjuvant therapy. We classified them into three groups.
One group is the macroscopically CR group which satisfy with that
the reduction rate is over 75% by Barium enema examination and
the circumference of tumor is completely flatten by endoscopic
examination. The second group is the macroscopically small CR
group which satisfy with one of the two item above. The third
group is except the macroscopically CR and small CR group.
Result: The cases of the macroscopically CR were 6 cases(7.
3%) of the RT group and 7 cases(17. 1%) of the CRT group. The
case of the macroscopically small CR were 10 cases(12. 2%) of
the RT group and 8 cases(19. 5%) of the CRT group. The grade 3
cases in the macroscopically CR were 2 cases(33. 3%) of the RT
group and 4 cases(57. 1%) of the CRT group. And all cases of the
macroscopically CR and small CR group had the pathological effect
over the grade 2. Conclusion: The CRT group had a tendency
to have more effective macroscopically and pathologically .
And there were interrelation macroscopical effect between
pathological effect.
S089 A RETROSPECTIVE STUDY OF 144 CASES OF
RECURRENT & COMPLEX FISTULA IN ANO, Parvez Sheikh,
P. N. Joshi, Charak Clinic, Mumbai, India
Purpose: To identify the causes of recurrence & device successful
management strategies with minimal complications to treat fistula
in ano. Methods: 144 cases of recurrent cryptoglandular fistula
in ano were operated over a 5year period in a colorectal referral
centre. Most of the cases were complex fistulae with multiple
tracts & external openings as widespread as anterior abdominal
wall & thigh. All the patients had undergone 1-5 surgeries in
the past. No special investigations were ordered, though some
patients were referred after an MRI. During the surgical procedure,
the cause of recurrence was recorded. The procedures done were
fistulotomy, fistulectomy, coring out & endoanal advancement
flap. The causative anal gland was always destroyed. Any large
divided muscle mass was primarily sutured. No seton, fibrin
glue or anal plug was used. No colostomy was created. All the
patients were followed up closely till complete healing was
established. Results: 29 patients (20%) had more than 1 cause
for recurrence. The common causes for recurrence were- anal
gland was left behind in 94 (65%), supralevator tract in 34 (24%),
residual tracts in 43 (30%) & 2 (1. 4%) patients had tuberculosis on
S091 THE SIGNIFICANCE OF TUMOR VOLUME REDUCTION
RATE AND DIGITAL RECTAL EXAMINATION AS TUMOR
RESPONSE PREDICTIVE MARKERS IN THE PATIENTS
WITH LOCALLY ADVANCED RECTAL CANCER AFTER
PREOPERATIVE CHEMORADIATION, Jung Hyun Kang MD,
Jeong Yoen Kim MD, Nam Kyu Kim MD, Seung Kook Sohn MD,
Chang Hwan Cho MD, Byung Soh Min MD, Yonsei University
Health System, Seoul, Korea
Background: Preoperative chemoradiation (preop-CRT) is
accepted as a standard treatment for locally advanced rectal
cancer enhancing sphincter preservation and local control.
It spans, however, a wide spectrum of tumor response from
complete disappearance of cancer (pCR) to progression of the
disease. An accurate prediction of tumor response after preopCRT is essential to understand patients¡¯ prognosis and to plan
treatment strategies. Thus, the aim of this study is to evaluate the
significance of tumor volume reduction rate (TVRR) and digital
rectal examination (DRE) as tumor response predictive markers in
the patients with locally advanced rectal cancer after preoperative
chemoradiation. Patients and Methods: we prospectively
enrolled 25 patients with biopsy-confirmed rectal cancer. All
patients underwent preoperative chemoradiation irradiating 5040
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57
ABSTRACT BOOK
Podium Papers
cGy for 5 weeks. Concurrent chemotherapy was performed using
either 5-FU/LV or TS-1/CPT-11 regimen. DRE and rectal MRI was
performed initially and 5-6 weeks after preop-CRT. TVRR was
calculated using 3D MR volumetery. Total mesorectal excision
was given 6 weeks after preop-CRT to all patients and tumor
response grade (TRG) was scored as suggested by Mandard et
al. The correlation between histopathologic parameters (TRG
and T-/N-downstaging) and clinical parameters (TVRR and DRE)
was analyzed. Results: The mean age of the enrolled patients
was 56. 3 years. TRG1 was observed in 7 patients, TRG2 in
6, TRG3 in 5 and TRG4 in 5 respectively. Pathologic stage was
ypT0 in 7 patients, ypT1 in 1, ypT2 in 8, ypT3 in 8, and ypT4 in 1,
respectively and ypN0 in 23 ypN1 in 2 patients. DRE-responder
(either disappearance of mass or becoming mobile on DRE) was
68%(N=17/25). The mean TVRR was 65. 8%. TRG was simplified
into complete regression (TRG1) and partial regression (TRG2-5).
DRE-responder was significantly associated with T-downstaging
(p=0. 037) but it was not associated with TRG and N-downstaging
(p=0. 819; p=0. 356). TVRR was significantly correlated with TRG
(p=0. 045), but not with T- and N-downstaging (p=0. 356; p=0. 702).
Conclusions: The results from the current study suggested that
TVRR from 3D MR volumetery and DRE by expert surgeons may
have significance as predictive markers for tumor response after
preop-CRT for locally advanced rectal cancer.
S092 ROLE OF ADJUVANT RADIOTHERAPY AFTER TOTAL
MESORECTAL EXCISION IN PATIENT WITH STAGE II
RECTAL CANCER, JinSoo Kim MD, NamKyu Kim MD, ByungSo
Min MD, Hyuk Hur MD, ChoongBae Ahn MD, KiChang Keum MD,
SeungKook Sohn MD, JangHwan Cho MD, Department of Surgery,
Medical Oncology, Radiation Oncology, Yonsei University College
of Medicine, Seoul, Korea
Introduction: Because the curative rectal surgery is performed
in narrow and complicated anatomic pelvic structure, tumor
cells can be implanted easily during the surgery. In result, local
recurrence is major problem in rectal cancer. In the 1990s, several
randomized trials reported the benefit of postoperative adjuvant
chemoradiotherapy (CRT) for low local recurrence. CRT became
the standard treatment for postoperative adjuvant therapy. In
the era of total mesorectal excisioin (TME), it has improved
local recurrence markedly. Therefore the benefit of adjuvant
CRT associated with TME is under debate especially in patients
with stage II rectal cancer. The aim of this study was to evaluate
adjuvant CRT effect for local recurrence, survival, and radiation
complications in stage II rectal cancer patients who underwent
TME. Patients and Methods: Between 1989 and 2004, patients
with stage II rectal cancer underwent adjuvant chemotherapy
(CT, n=32) and CRT (n=121) following TME were enrolled
retrospectively. Both two groups received 5-fluorourcil and
leucovorin based chemotherapy. We analyzed clinicopathologic
data, recurrence rate, and survival between the two groups.
Complications associated with radiation were also examined.
Results: There were no differences in clinicopathologic data such
as age, sex, operative method, tumor size, number of retrieved
lymph node, tumor differentiation between two groups. With a
median follow-up of 72. 1 months, one patient (3. 1%) had local
recurrence in the CT group and 12 patients (9. 9%) in the CRT
group. However, there was no significant difference (P=0. 303).
The 3-year and 5-year cancer specific survival showed 96. 8%, 86.
8% in the CT group and 89. 1%, 80. 9% in the CRT group (P=0.
854). Complications associated with radiation were proctocolitis
(5. 0%), stricture (2. 5%), enteritis (2. 5%), rectovaginal fistula (1.
7%), and vaginal dryness (0. 8%). Conclusion: Postoperative
CT and CRT following TME in stage II rectal cancer resulted in
comparable recurrence and survival rates. Additionally CRT group
had relatively high complications. These findings suggest that
postoperative radiation is not necessary in patients with stage
II rectal cancer if TME was performed. However, randomized
prospective trials are warranted to support this suggestion.
S093 WITHDRAWN
S094 ENDOSCOPIC SUBMUCOSAL DISSECTION FOR
COLORECTAL NEOPLASIA: EARLY EXPERIENCES 94
CASES Eun-jung Lee MD, JaeBum Lee MD, Suk Hee Lee MD,
Do Sun Kim MD, Doo Han Lee MD, Eui Gon Youk MD, Daehang
Hospital
58
ISUCRS XXII BIENNIAL CONGRESS Purpose: In the endoscopic treatment of a tumor, en bloc
resection is one of the basic principles for an accurate pathologic
diagnosis. Endoscoic Mucosal Resection(EMR) is a useful
therapeutic technique for colorectal tumors. However, the
physical size of the snare limits en bloc resection of colorectal
neoplasia larger than 20 mm. Endoscopic Submucosal Dissection
(ESD), a recently introduced endoscopic technique, makes it
possible to perform an en bloc resection of a lesion, which could
not be carried out by EMR. The aim of this study was to report
the early experiences of colorectal ESD performed in our hospital.
Methods: Between October 2006 and January 2008, ninety-four
consecutive colorectal neoplasia in 94 patients were enrolled.
After submucosal injection with hyaluronic acid, mucosal incision
was done around the tumors and submucosal dissection under
the tumors was made by cutting devices. The clinical outcomes
were investigated. Results: Mean size of resected tumors was
24. 1(10-45)mm. Overall endoscopic and pathologic en bloc
resection rates were 86. 2%(81/94) and 85. 1%(80/94) respectively.
Perforation occurred in twelve cases out of ninety-four(12. 8%). In
nine patients, perforation was managed by endoscopic clipping
without salvage surgery and the other three patients received
laparoscopic operation. Mean procedure time was 70. 1(15-180)
min. Pathologic examination showed 57 benign neoplasms(60.
6%) and 37 adenocarcinomas(39. 4%). Three patients with sm
2 invasion and one patient of sm1 invasion with unfavorable
pathologic findings received additional laparoscopic surgery.
Conclusion: ESD is a technically challenging procedure with a
substantial risk of perforation and long procedure time. But ESD
has an advantage in en bloc resection of large colorectal tumors.
As experience with the technique accumulates, ESD will gradually
replace piecemeal EMR and surgery in the majority of cases.
S095
SHOULD
COMPLETELY
INTRACORPOREAL
ANASTOMOSIS BE CONSIDERED IN OBESE PATIENTS
UNDERGOING LAPAROSCOPIC COLECTOMY FOR BENIGN
OR MALIGNANT DISEASE OF THE COLON?, I Raftopoulos
MD, R Bergamaschi MD, Saint Francis Hospital and Medical
Center, Hartford, Connecticut
Purpose: This study was performed to assess the outcome
of laparoscopic colectomy with completely intracorporeal
anastomosis (LCIA) in obese and nonobese patients. Methods: 45
consecutive patients who underwent LCIA for benign or malignant
disease of the colon between 11/03 and 12/05 were prospectively
reviewed. Colon mobilization, bowel and mesenteric division,
and anastomosis were performed intracorporeally without
exteriorization until specimen extraction at end of procedure.
Body mass index (BMI) >30 kg/m2 defined obesity. Incision length
was measured immediately after wound closure. Continuous
and categorical variables were compared with Student’s t-test
and chi-square, respectively. P<0. 05 was considered significant.
Results: There were 24 (53. 3%) males and 21 (46. 7%) females
with a mean age of 67. 2 (46-84) years. Of the 45 LCIA, 10 (22. 3%)
involved the left colon and 35 (77. 7%) the right colon. Mean BMI
was 26. 7 (15. 5-37. 9) kg/m2; 13 (28. 9%) patients were obese. One
(2. 2%) obese patient was converted to a laparoscopic-assisted
right hemicolectomy. Preoperative localization of lesion with
endoscopic India ink injection was used in 24 cases (53. 3%), and the
tattoo was identified laparoscopically in all cases. Mean operative
time (OT), estimated blood loss (EBL), and length of stay (LOS)
were 217. 9 (110-420) min, 82. 3 (50-250) ml, and 4. 9 (2-11) days,
respectively. There was significant reduction in OT (181. 1 vs. 253
min, p=0. 0003) in the last 22 cases. Mean lengths of larger incision
(extraction site) and sum of all port incisions were 3. 9 (2. 5-8) cm
ABSTRACT BOOK
Podium Papers
and 7. 2 (5. 5-10. 4) cm, respectively. Complications occurred in
8/45 (17. 8%) patients. Leak, obstruction, reoperation, pulmonary
complication, and mortality rates were zero. A 5 cm tumor-free
margin was accomplished in all patients with benign or malignant
tumors without need for additional resections. Mean number of
harvested lymph nodes per specimen was 11. 3 (3-24). Obesity
had no significant effect on OT (obese: 231. 5 vs. nonobese: 212. 6
min), incision length (3. 9 vs. 4. 0 cm), number of ports used (4. 2
vs. 4. 2), EBL (100 vs. 75. 6 ml), complications (16. 7 vs. 18. 75%),
LOS (4. 9 vs. 5. 0 days), or number of harvested lymph nodes per
specimen (12. 4 vs. 10. 9). At mean follow up of 5 (1-18) months,
there were no port-site hernias, and of patients with malignancy,
none developed port-site metastases. Conclusion: Smaller
incisions achieved by a completely intracorporeal approach may
decrease risk of pulmonary complications and port-site hernias.
S096 KSHAAR-SOOTRA (HERBAL MEDICATED THREAD)
IN THE MANAGEMENT OF RECURRENT FISTULA-IN-ANO,
Harshit S Shah MD, Sejal H Shah MD, Anand Kshaar Sootra
Clinic
As you know that the anal fistula is a notorious disease due
to its anatomical situation and recurrences even with skilled
surgeons. Its location and tendency to recur many a times
brings discredit frustration to the surgical fraternity. The
condition of complicated, recurrent and high fistula-in-ano,
although not a major surgical task; but always remains a
nagging issue not only to the patient but to the surgeon as well.
The present method of KSHAAR-SOOTRA treatment in anal
fistula has been found efficacious and have been accepted by
many countries in world. This method is described in ancient
Indian surgical science. This research paper aimed to evaluate
the following points. 1. Healing time of the fistulous track. 2.
Recurrence rate of fistula. 3. Side effect and complications. 4.
Time of HospitalizationKSHAAR-SOOTRA was inserted in the
O. P. D. The patient was placed in the lithotomic position and
after aseptic preparation of the part probing was done under
local anesthesia. With specially designed probes the sterile silk
thread was passed through carefully in the fistulous track; tied
and left in situ (Primary threading). A week later the silk thread
was replaced by KSHAAR-SOOTRA by the railroading technique
and tied snugly outside the anal orifice. Among the 106 patient
who completed treatment, 7 patients failed to attend follow-up
schedule. Remaining 99 patients completed one year follow-up.
Among these recurrence rate was 4% in 52 patient treated with
KSHAAR SOOTRA as compared to 13% of 47 in the Surgery series.
The initial length of fistulous track was recorded by measuring
the length of the silk thread. After insertion of KSHAAR-SOOTRA,
the patient was sent home and advised to continue his normal
routine work. The thread was changed at weekly intervals till the
thread fell out spontaneously and the track healed.
S097 PELVIC EXENTERATION WITH RECONSTRUCTION
OF URINARY AND ANAL SPHINCTER FUNCTIONS FOR
PATIENTS OF COLORECTAL CANCERS NORMALLY
REQUIRING TPE, K Koda MD, H Yasuda MD, M Suzuki MD,
M Yamazaki MD, T Tezuka MD, C Kosugi MD, R Higuchi MD, M
Sugimoto MD, Y Yagawa MD, H Tsuchiya MD, Teikyo University
Chiba Medical Center
Purpose: Total pelvic exenteration (TPE) is a formidable
procedure involving double stoma for faecal and urinary
excretion, which degrades patient’s quality of life. We presented a
novel reconstruction method for patients normally requiring TPE
and evaluated their long term outcome. Method: Tumours were
removed en bloc with internal iliac artery and lateral lymph nodes.
The urethra was transacted at the urogenital diaphragm, and the
rectum at the anal canal. An ileal neobladder was constructed
and anastomosed with urethra. A colo-anal anastomosis
was performed by double-stapling technique. We usually set
major omentum between colo-anal and neobladder-urethral
anastomoses so as to prevent a fistula formation between the two
anastomoses. A transgastric ileus tube was used as an intestinal
stent to prevent ileus. Results: Since 1998, we have performed
this operation to 13 patients (12 males, 1 female) among 27
patients requiring TPE. Twelve of them had a primary colorectal
cancers and 1 pelvic recurrence. There was no operation-related
death. Median operation time was 650min [540-840min], and
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blood loss was 1200gram [600-6300gram]. Histological invasion to
urine bladder, seminal vesicle, or prostate was seen in 10 patients
out of 13 treated; massive inflammation or abscess formation
was noted in the remaining 3 cases. No patients had bloodborne metastases at the time of operation; 9 patients showed
lymph node metastasis. Out of 13 patients treated, 11 patients
remain alive without recurrence at the median follow up period
of 1699 days [302 - 3495 days]. Recurrent diseases were seen in 2
patients: one died of the disseminated disease 8 months after the
operation; another had metachronous lung metastasis which was
surgically removed 5 years ago. Faecal continence was preserved
in 11 patients whose diverting colostomies were closed. All 13
patients were able to void urine spontaneously with daytime
continence. All but one who died of the disease were mobile in
the community. Conclusion: Stomaless pelvic exenteration may
be considered for patients normally requiring TPE. Long term
postoperative quality of life was fair.
SURGICAL TECHNIQUES II
S098 THE PROGNOSTIC SIGNIFICANCE OF ERBB FAMILY
EXPRESSIONS IN PATIENTS WITH CURATIVE RESECTION
FOR COLORECTAL CANCERS, Byung-Wook Min, Seong-Soo
Kim, Sang-Hee Kang, Jun-Won Um, Department of Surgery,
Korea University College of Medicine, Seoul, Korea
Background and Purpose: The ErbB family; ErbB1(EGFR),
ErbB2(Her2/neu), ErbB3, and ErbB4, is associated to cell growth,
differentiation, cell survival, apoptosis, cell cycle progression,
angiogenesis, drug and radiation sensitivity. In this study,
the expression of ErbB family of colorectal cancer specimen
were investigated to determined the correlations between the
clinicopathologic characteristics and the expression of ErbB
family in the curative resection for colorectal cancers, icluding
cancer specific survival. Patients and Method: One hundred
ninety six patients who underwent the curative surgery for
colorectal cancers from January 1997 to December 2000 at
Korea University Medical Center were enrolled in this study.
The tumor and normal samples were obtained from paraffinembedded blocks of specimen and studied by tissue microarray.
Immunohistochemical stains for ErbB family were performed for
each specimen. The clinical relationship between the expression
of ErbB family and clinicopatholoic characteristics were anlyzed.
Results: There was no significant relationship of the expression
of ErbB family to clinicopathologic characteristics. However in
respect to survival analysis, 5-year survival rates of patients with
the positive expression of ErbB1 was lower than those of the
negative expression of ErbB1(65% vs. 92%, p <0. 05). Moreover
5-year survival rate of the positive expression of ErbB1 was lower
in well differentiation subgroup(70% vs. 98%), node negative
subgroup(90% vs. 95%), node poitive subgroup(40% vs. 78%), and
T3 subgroup(65% vs. 90%). Conclusion: This study did not show
the relations of ErbB family expression with the clinicopathologic
characteristics. However the positive ErbB1 expression of
colorctal cancer was one of poor prognostic factors in patients
with colorectal cancer.
S099 BRAIN METASTASES FROM COLORECTAL CANCER,
Ji-Hoon Kim MD, Jae-Im Lee MD, Hyung-Jin Kim MD, Sang-Chul
Lee MD, Yoon-Suk Lee MD, Won-Kyung Kang MD, Jong-Kyung
Park MD, Chang-Hyeok Ahn, Seong-Taek Oh MD, Department of
Surgery, The Catholic University of Korea
Purpose: Brain metastasis is infrequent in colorectal cancer
patients. And the prognosis of brain metastasis is known to
be poor. The purpose of this study is to analyze the survival
and the prognostic factors in patients with brain metastasis
from colorectal cancer. Methods: Between 1997 and 2006, we
retrospectively identified 39 patients with brain metastasis from
colorectal cancer and who were survived longer than 1 month.
The data were collected with regard to patient characteristics,
location and stage of primary tumor, extent and location of
metastatic diseases and the type of treatment. Results: The
mean age of the 16 women and 23 men was 59 years (40-81).
Rectum was more frequent primary tumor site than colon (22 vs
17). The stages of primary tumor were stage 2 in 2 cases, 3 in 17
cases and 4 in 9 cases. The mean interval from the time of primary
59
ABSTRACT BOOK
Podium Papers
cancer surgery to the diagnosis of brain metastases was 32. 3
months. Most of the patients (87. 2%) had pulmonary metastases
before brain metastasis and brain was the only metastatic site in
only one patient. The most frequent symptoms were weakness
(18/39), headache (11/39) and dysarthria (4/39). Lesions were
solitary in 22 cases, unilateral in 26 cases, and located in cerebral
in 26 cases. Overall mean survival was 7. 95 months; the 1-year
and 2-year survival rates were 21. 76% and 9. 07%, respectively.
Survival was not affected by gender and age, location or stage of
the primary tumor, and size or location of metastatic disease. But
serum CEA level greater than 5 ng/ml (p=0. 0082) and multiple
metastatic lesions in brain (p=0. 0302) were the poor prognostic
factors. And the mean survival time after the diagnosis of brain
metastasis was longer significantly in patients who underwent
surgical excision (18. 70 months) than who were treated with
whole brain irradiation, sterotatic radiosurgery, and conservative
care (6. 42, 6. 34 and 2. 78 months) (p=0. 0039). Conclusion:
The results of the present study indicate that aggressive surgical
resection in patients with brain metastases from colorectal cancer
may increase the survival. And analysis of prognostic factors in
these patients shows that multiple metastatic lesions in brain and
serum CEA level greater than 5 ng/ml were also associated with
a poorer survival.
S100 COLORECTAL SURGERY IN CIRRHOTIC PATIENTS.
ASSESSMENT
OF
OPERATIVE
MORTALITY
AND
MORTALITY, J-P Arnaud MD, K Meunier MD, S HennekinneMucci MD, R Azoulay MD, A Hamy MD, Department of Visceral
Surgery, Chu-Angers, France
Surgery for colorectal diseases has an elevated morbidity. For
cirrhotic patients, there is a high risk of mortality and morbidity
following surgery. The aim of this study was to evaluate
morbidity, mortality and prognostic factors regarding colorectal
surgery in cirrhotic patients. From 1993 to 2006, 41 cirrhotic
patients who underwent 43 colorectal procedures were included.
Both univariate and multivariate analyses were carried out so as
to identify those variables influencing morbidity and mortality.
Postoperative morbidity was 77% (33/43). Postoperative mortality
was 26% (11/43) among which 6 patients (54%) underwent
emergency surgery. In this study, four factors influenced mortality
in the univariate analysis : emergency (p<0. 05), postoperative
complications (p<0. 04), postoperative infections (p<0. 01) and
total colectomy procedures (p<0. 02). In the multivariate analysis,
the only factor influencing mortality was postoperative infection
(p<0. 04). The only factor influencing morbidity was the existence
of preoperative ascites (p<0. 04). Colorectal surgery for cirrhotic
patients is at high risk in terms of morbidity and mortality. The
prognosis is linked to the septic, urgent and extensive nature
of surgery and the ascitic decompensation of cirrhosis. An
improvement in the results can be achieved through better
selection and preparation of patients.
S101 ABDOMINAL STAPLED SIDE-TO-END ANASTOMOSIS
(BAKER TYPE) IN LOW AND HIGH ANTERIOR RESECTION:
EXPERIENCE AND RESULTS IN 96 CONSECUTIVE
PATIENTS AT A REGIONAL GENERAL HOSPITAL IN JAPAN,
Ichiro Nakada MD, T. Satani MD, T. Kasuga MD, Y. Watanabe MD,
T. Tabuchi MD, Department of Surgery, Tokyo Medical University
Kasumigaura Hospital
Purpose: The technique of trans-anally introducing a circular
stapled device to accomplish colorectal anastomosis has been
widely used. However, the widespread popularity of this technique
may have created the potential of anal sphincter injury during
trans-anal insertion of the anastomosing stapler. Thus, to avoid
the risk of anal sphincter injury during anal manipulation, we have
been performing an abdominal approach, namely abdominal
stapled side-to-end anastomosis (ASSEA) using a Purstring and
premium curved EEA stapler in low and high anterior resection.
This study will present our experience and results of consecutive
resections. Methods: ASSEA following a resection of the
rectum for carcinomas was consecutively performed between
October 1998 and October 2006. Age, gender, pre-operative anal
function, the TNM classification by the UICC rules, postoperative
morbidity, mortality, anal function, and bowel frequency were
evaluated. Results: Ninety-six consecutive patients underwent
a resection of the rectum with ASSEA. The mean age was 65. 5
60
ISUCRS XXII BIENNIAL CONGRESS years (range 26-96 years). There were 57 men and 39 women.
There were five (5. 2%) clinical anastomotic leakages in the cases
studied. Anastomosis that was located above the peritoneal
reflection leaked in two (3. 6%) of 56 cases, while anastomosis
below the peritoneal reflection leaked in three (7. 5%) of 40
cases. A diverting stoma was performed in five (12. 5%) of the 40
cases with low anastomosis. During the same period, fourteen
abdominoperineal excisions (25. 9%) were performed because of
very advanced carcinomas. Postoperative anal function was stable
without soiling or fecal leakage. Bowel frequency two months
after surgery was less than four times a day in all 84 patients.
There was no postoperative mortality related to the anastomosis.
Conclusion: Abdominal stapled side-to-end anastomosis (Baker
type) was found to be a safe and relatively easy method in both
low and high anterior resection in association with a good quality
of life.
S102 DOES TOTAL MESORECTAL EXCISION REQUIRE
A LEARNING CURVE? ANALYSIS FROM DATABASE OF
SINGLE SURGEON’S EXPERIENCE, Seung Yeop Oh MD, Ok
Joo Paek MD, Kwang Wook Suh MD, Department of Surgery, Ajou
University School of Medicine
Purpose: Total mesorectal excision (TME) has been regarded
as a standard treatment for the rectal cancer. However, grasp of
technical adequacy is also formidable. This study was conducted
to determine whether TME requires a learning curve to grasp a
technical expertise. Methods: This was a retrospective analysis
of 195 patients with true rectal cancer who underwent TME with
curative intention between August 1998 and December 2003 in
Ajou University Hospital. To examine if a learning curve for proper
TME procedure was necessary, patients were divided into four
groups: group 1 included 50 consecutive patients from August
1998. Group 2, 3, and 4 included next 50 consecutive patients,
respectively. Local recurrence(LR) rate was compared between
groups. To examine the learning curve was a meaningful prognostic
factor, univariate and multivariate analyses were conducted.
Results: Overall LR rate was 11. 3%. The LR was 20% (group 1),
14% (group 2), 8% (group 3) and 2. 2% (group 4), respectively. The
cumulative risk of LR at 60 months following initial operation was
23. 6%, 15. 9%, 8. 7% and 2. 9%, respectively. LR was significantly
higher in group 1 when compared with the other groups (P=0.
002). Between group 2, 3 and 4, there was no significant difference
in LR. It was found that a learning curve in performing adequate
TME is necessary, and experience of at least 50 cases is the critical
point to grasp technical adequacy. In univariate analysis, lymph
node metastasis, early period of learning curve (group 1), and
depth of tumor invasion were significant prognostic factors. In
multivariate analysis, lymph node metastasis and early period of
learning curve still proved significant. Since the technical bias was
identified, risk factors for LR could be different when the whole
study population was separated as to learning curve. In subset
analysis, tumor size, location, regional lymph node metastasis, and
operative time proved as significant risk factors in the inadequate
TME group (group 1, N=50). Lymph node metastasis and depth
of primary tumor invasion were significant in the adequate TME
group(groups 2, 3, 4, N=144). However, the regional lymph node
metastasis was constantly significant in both adequate and
inadequate TME groups. Conclusion: Even though the principle
of TME is strictly obeyed, a learning curve is necessary to grasp a
technical expertise and trainees need to perform more than fifty
cases to get learning curve. Lymph node metastasis is the most
important prognostic factor and the technical adequacy is also an
independent prognsotic factor. Vigorous training and assessment
of each surgeon are important to reach the highest point of
learning curve and further multinstitutional study is warranted.
S103
DE-EPITHELIALIZED
PUDENDAL-THIGH(SINGAPOUR)-FLAP FOR THE TREATMENT OF LOW
RECTO(ANO-) VAGINAL FISTULAE, Johann Pfeifer MD,
Stephan Spendel* MD, Michael Schintler* MD, Department of
General Surgery, *Department of Plastic Surgery
Introduction: The causative effect of a low recto- and anovaginal
fistula is often an obstetric injury. The surgical problem is that
the length of the fistula is usually very short and simple closure
leads often to recurrence. On the other side patients are often
young, still sexually active and may have dyspareunia if a thick
ABSTRACT BOOK
Podium Papers
well perfused tissue flap (like the gracilis muscle) is interposed
into the rectovaginal septum to avoid fistula recurrence. Patients
and Methods: All consecutive patients with a low anovaginal
or recto-vaginal fistula are included into the study. The first
operative step is to open the rectovaginal space and to close the
fistula on the rectal and vaginal side. Then a 12cm x 4 cm long
skin/subcutis flap with its nutritional vessels is mobilized. Part
of the flap must be de-epithelialized and then rotated into the
rectovaginal space. Finally with some absorbable sutures the flap
is held in place and the perineum closed. A protective stoma is
often not nescessary. Results: From June 2006 to December 2007
5 patients with a low anorectal or recto-vaginal fistula have been
operated with this method. Three patients had together 8 failed
local repairs (even one patient had had already a stoma). Fistulae
in four patients healed without any complications (follow-up 1- 15
months), in one patient the operation was not successful. This
patient had an early recurrence probably due to improper fixation
of the flap. In the acute situation a stoma was performed and the
flap re-fixated. This patient has currently still the stoma (waiting
for take down) but clinically the fistula has healed. Conclusion:
Low recto-vaginal or ano-vaginal fistulae can be treated in most
cases successfully with the de-epithelialized pudendal-thigh(Singapour)-flap.
S104 ABDOMINAL WALL COMPONENTS SEPARATION
TECHNIQUE FOR CLOSURE OF VENTRAL DEFECTS INITIAL EXPERIENCE AND LESSONS LEARNT, Bruce
Waxman MSc, S Jassal, L Dandie, D Goodall-Wilson, M Fisher,
Dandenong Hospital, Southern Health
Purpose: The Abdominal Wall Components Separation Technique
(AWCST), allows closure of ventral defects by transposition of the
abdominal wall muscle(1, 2). The aim of this audit of our initial
experience was to evaluate the technique for repairing defects
after removal of infected mesh or for uncomplicated incisional
hernia. Methodology: A prospective audit was conducted on
the initial experience of 18 consecutive patients having AWCST,
under the care of the Colorectal Unit, Dandenong Hospital, for the
twelve month period from August 2006 to July 2007. Results: Of
the 18 patients, 5 had infected mesh and 13 had large incisional
hernias. The median follow up was 96 days range 25 - 360 days.
Significant wound infections occurred in 5 patients requiring
re-operation. In all 5 the abdominal wall repair remained in
tact. One patient has developed a recurrent incisional hernia.
Conclusion: AWCST is a useful procedure for the closure of
large abdominal wall defects, and may avoid the use of mesh.
We recommend avoiding primary skin closure after removing
infected mesh and follow the principle of delayed primary
closure. No specific conclusions can be made from this small
series with a short follow up, but the technique has merit and
requires further evaluation. Reference: 1. Ramirez OM et al
“Components Separation” Method for Closure of Abdominal-Wall
Defects: An Anatomic and Clinical Study Plastic & Reconstructive
Surgery 1990; 86: 519 – 526 2. de Vries Reilingh TS et alAutologous
tissue repair of large abdominal wound defectsBJS 2007; 94: 791
– 803.
S105 TRANSACRAL RESECTION WITH SACRECTOMY IN
THE ERA OF TEM, Bong Hwa Lee MD, Hyoung-Chul Park MD,
Soo Hyung Kim MD, Sung Wook Cho MD, Taeik Um MD, Hallym
University College of Medicine, Seoul, South Korea
Background: Local resection of presacral and rectal mass was a
good option to avoid morbidity relevant to the major operation.
The aim of this study is to describe the technique and experience
of removal of presacral and rectal mass through trans-sacral route
with midline incision and lower sacrectomy (S4, S5). Methods:
We present an approach for local excisions of 21 cases of lesions.
The diagnoses were large epidermal cyst, GIST, high grade
adenoma and early cancers in mid rectum. Results: Epidural
anesthesia was appropriate to perform the whole procedures.
There was one case of recto-cutaneous fistula among 21 cases
as a postoperative complication. In one case of submucosal
cancers, multiple metastasis occurred in 24 months without local
recurrence. Comments: In our experience. trans-sacral resection
with lower sacrectomy is a good option which provides wide and
direct surgical exposure for the removal of presacral mass. Good
bowel preparation was mandatory.
www.isucrs.org/
Final Pathology of Specimen after TSR (n=21)
Specimen
Pathology
Operation
epidermal cyst
Excision
adenocarcinoma submucosa
FT excision
proper muscle
FT excision
GIST (1)
FT excision
Others (3)
FT excision
FT excsion = full thickness rectal wall excision
Follow-up
no recur
mets in 1/2
no recur
no recur
LAPAROSCOPIC SURGERY I
S106 YOUNGER AGE AND MORE DISTAL CANCERS CHANGE IN THE EPIDEMIOLOGY OF COLORECTAL CANCER
AND IMPLICATION FOR SCREENING, Bruce Waxman MSc,
Mikhail Fisher, Dandenong Hospital, Southern Health
Purpose: To determine whether pattern of patients presenting
with colorectal cancer (CRC) in the last 2 years differs significantly
from that previously reported. Methodology: We examined
demographic and pathological characteristics of 145 consecutive
CRC patients treated in our institution in calendar years 200607. Comparisons were made with data on 12536 CRC patients
obtained from The Australasian Association of Cancer Registries
(AACR) for the year 2003, most recent available. Results: In our
series distribution of colon, rectal and rectosigmoid cancers was
40%, 35. 0% and 24. 8% respectively, which differs significantly
(p<0. 01) from 64. 9%, 26. 9% and 8. 2% in the AACR data. Our
cohort of patients was significantly younger: mean age 65. 4
± 12. 1 vs 69. 5 ± 12. 3 years (p<0. 001). In both groups rectal
cancer patients were the youngest: mean 62. 4 ± 11. 8 vs 67. 2
±12. 7 years (p <0. 001). These differences were most pronounced
amongst females: 63. 0 ± 12. 7 vs 70. 3 ± 13. 0 years (p<0. 001)
overall and 59. 9 ± 9. 5 vs 67. 8 ± 13. 8 years (p<0. 001) in the rectal
cancer subgroup. Furthermore, we treated significantly higher
proportion of patients <55 years of age (20% vs 13%; p = 0. 018)
or <60 years (33. 1% vs 21. 5%; p = 0. 001). Conclusions: Our
small series shows a more distal distribution for CRCs from that
seen previously in the Australian population. Of greatest concern
is a higher proportion of patients aged <60 (33%), especially
females (41%). Younger patients are also more likely to have
more aggressive and advanced cancers. These findings may have
important implications for refining screening strategies and on
demand for radiotherapy services.
S107 INFLAMMATION-BASED PROGNOSTIC SCORE
PREDICTS POSTOPERATIVE OUTCOME IN PATIENTS
WITH LIVER METASTASES FROM COLORECTAL CANCER,
Mitsuru Ishizuka MD, Tokihiko Sawada MD, Mitsugi Shimoda
MD, Junji Kita MD, Kyuu Rokkaku MD, Masato Kato MD, Keiichi
Kubota MD, Department of Gastroenterological Surgery, Dokkyo
Medical University
Background: Recent studies have revealed that the Glasgow
prognostic score (GPS), an inflammation-based prognostic score
that includes only C-reactive protein (CRP) and albumin, is a useful
tool for predicting postoperative outcome in cancer patients.
However, few studies have investigated the GPS in patients with
liver metastases from colorectal cancer (LM-CRC). Objective:
To demonstrate the significance of the GPS for postoperative
prognostication of patients with LM-CRC. Methods: The GPS
was calculated as follows: patients with both an elevated level of
CRP (>10 mg/l) and hypoalbuminemia (Alb <35 g/l) were allocated
a score of 2, and patients showing one or neither of these
blood chemistry abnormalities were allocated a score of 1 or 0,
respectively. Prognostic significance was analyzed by KaplanMeier, univariate and multivariate analyses. Results: Ninetythree patients were evaluated retrospectively. Kaplan-Meier
analysis and log rank test revealed that a higher GPS predicted
a higher risk of postoperative mortality (P <0. 0001). Univariate
analysis revealed that sex (P = 0. 0334), number of hepatectomy
(P = 0. 0427), number of tumors (P = 0. 0206), synchronous lung
metastasis (P = 0. 0275) and CRP (P = 0. 0477) were associated
with postoperative mortality. Multivariate analysis revealed that
times of hepatectomy (odds ratio, 0. 313; 95% C. I. , 0. 108-0. 906;
P = 0. 0322), number of tumors (odds ratio, 0. 348; 95% C. I. , 0.
61
ABSTRACT BOOK
Podium Papers
128-0. 943; P = 0. 0379), synchronous lung metastasis (odds ratio,
0. 281; 95% C. I. , 0. 088-0. 895; P = 0. 0318) and CRP (odds ratio,
1. 792; 95% C. I. , 1. 119-2. 870; P = 0. 0153) were associated with
postoperative mortality. Conclusions: GPS, especially CRP, is
considered an important predictor of postoperative mortality in
patients with LM-CRC.
S108 LAPAROSCOPIC VS. OPEN REVERSAL OF
HARTMANN’S FOR DIVERTICULITIS, B Safar MD, S Shawki,
MD, H Wang MD, S Cera MD, D Efron MD, D Sands MD, E Weiss
MD, A Vernava MD, J Nogueras MD, S Wexner MD, Cleveland
Clinic Florida
Purpose: Hartmann reversal can be a technically challenging
operation associated with significant morbidity. Laparoscopy
has been associated with some definitive short term advantages
and possibly long term advantages. The aim of this study was to
determine whether laparoscopic Hartmann reversal provides any
advantages as compared with the open technique. Methods: After
IRB approval, patients who underwent laparoscopic Hartmann
reversal for diverticulitis were identified in our prospectively
collected database. These patients were case matched by age,
gender, body mass index and diagnosis to control patients who
underwent the same operation through an open technique.
Intraoperative data and postoperative outcomes were recorded.
Results: Thirty one laparoscopic Hartmann reversals were
identified, 27 of which were performed for diverticulitis. These
were case matched with 27 open Hartmann reversal operations for
diverticulitis. The laparoscopic group (Mean age, 63; 52% Female;
Mean BMI 27) were similar to the open group (Mean age, 62; 52%
Female; Mean BMI 27). The conversion rate in the laparoscopic
group was 37%; most conversions were due to failure to progress
as a result of dense adhesions. Overall the operative time in the
laparoscopic group (n=27) was longer than the open group (n=27)
(235 ± 11 min vs. 195 ± 12 min, P=0. 02). There were no significant
differences between the groups in time to regular diet (5. 0 ± 0. 4
d vs. 5. 3 ± 0. 5 d, P=0. 73), time to first bowel movement (5. 3 ±
0. 4 d vs. 5. 2 ± 0. 4 d, P=0. 92), length of hospital stay (5. 9 ± 0. 5
d vs. 7. 1 ± 0. 5 d, P=0. 11), or post operative morbidity (7/25 vs.
11/27, P=0. 34). Conclusion: Laparoscopic reversal of Hartmann
operation for diverticulitis is equivalent to open technique in
terms of postoperative morbidity. It is associated with longer
operative times and does not seem to confer the short term gains
afforded to patients who undergo laparoscopy for other colorectal
pathology.
S109 WITHDRAWN
S110 LAPAROSCOPIC TOTAL PROCTOCOLECTOMY FOR
ULCERATIVE COLITIS AND FAMILIAL ADENOMATOUS
POLYPOSIS. EXPERIENCE IN MEXICO, Federico López Rosales
MD, Quintin González Contreras MD, Hector Tapia Cid de León
MD, Hómero Rodríguez Zetner MD, Omar Vergara Fernández MD,
Department of colorectal surgery. Instituto Nacional de Ciencias
Médicas y Nutrición Salvador Zubirán. Mexico City
Background: Since the introduction of laparoscopic colectomy
in 1991, experience in laparoscopic bowel surgery has gradually
increased. Several reports have demonstrated that laparoscopic
colorectal resections are feasible, safe, and with good functional
outcome, providing an acceptable alternative to laparotomy for
a variety of diseases including ulcerative colitis (UC) and familial
adenomatous polyposis (FAP). Proctocolectomy with IPAA is one
of the most extensive colorectal procedures and performing such
an operation in a laparoscopic fashion is even more demanding.
The aim of this study is to report our initial experience with
this procedure at the Instituto Nacional de Ciencias Medicas y
Nutrición Salvador Zubirán (INCMNSZ) in Mexico City. Methods:
All the patients in the authors’ institution who underwent a one- or
two-stage laparoscopic total proctocolectomy with IPAA between
June 2005 and December 2007 were included in the study. All
the operations were performed by the same surgeon, who had
already completed the learning curve for colorectal laparoscopic
procedures. Results: Fifteen patients underwent a laparoscopic
proctocolectomy with IPAA by a single surgeon. Thirteen patients
62
ISUCRS XXII BIENNIAL CONGRESS underwent a one-stage procedure, whereas two patients with
severe colitis underwent a two-step procedure (urgent subtotal
colectomy followed by an elective proctectomy with IPAA). All
the cases were managed with a diverting loop ileostomy. Eleven
patients underwent a standard double-stapled IPAA anastomosis,
two patients with FAP underwent a mucosectomy with a manual
IPAA anastomosis, and two patients with UC underwent a
handsewn IPAA anastomosis due to failure in the stapling devices.
The mean operative time was 172 min, and the mean blood loss
was 65 ml. There were two postoperative complications. One
patient presented with an early small bowel obstruction due
to an internal hernia, which required reoperation. The other
complication was a wound infection. The mean return to oral
intake was 1. 5 days, and the mean length of hospital stay was 3. 4
days. Conclusion: Even though this was not a comparative study
and its limitations due to sample size, with this preliminary data,
we conclude that the laparoscopic approach to UC and FAP at
our institution is safe, feasible, and effective. However, to achieve
the benefits in postoperative outcome, this procedure should be
performed only by experienced laparoscopic surgeons.
S111
INDUCTION OF
LAPAROSCOPY
ASSISTED
COLORECTAL SURGERY IN A JAPANESE GENERAL
HOSPITAL. , Toru Tonooka PhD, Jun Yasutomi PhD, Shinichiro
Irabu MD, Daigo Nobumoto MD, Takahiro Nishida MD, Yuko
Tashima MD, Masanari Matsumoto PhD, Takahiro Kasagawa
PhD, Kimihiko Kusashio PhD, Ikuo Udagawa PhD, Masaru Suzuki
PhD, Tatsushi Fukao PhD, Masaru Miyazaki PhD, Department of
Introduction: Although laparoscopy assisted surgery is a low
invasive treatment for benign and malignant colorectal diseases,
induction of this technique requires education and experience.
Furthermore, the quality of oncological curability must not be
lower than traditional open surgery. The aim of this study is
to demonstrate the short term results of laparoscopy assisted
colorectal surgery (LAC) in our hospital. Methods: The 126
consecutive series of LAC between January 2003 and August
2007 performed at our institution were examined. Age, gender,
diagnosis of the colonic disease, colonic site of the disease,
surgical procedure were reviewed. Operative time, laparoscopy
time, blood loss, history of previous abdominal surgery,
conversions, pathological stage (pStage) and lymph nodes (LN)
harvested in malignant cases, length of stay, morbidity and
mortality were also assessed. Results: No obvious tendencies
were seen in age and gender. There were 105 colorectal cancer
patients (83. 3%) among all. Major sites of the colonic diseases
were sigmoid colon (27. 0%) and rectum (29. 4%). The percentage
of LAC patients increased and more advanced pStage cases were
indicated as time progression. The mean number of LN was 14,
similar to ordinary open colectomies. Operative time and blood
loss showed no tendency, while laparoscopy time was increasing
as more advanced and complex laparoscopic procedures were
adopted. The frequency of patients who had previous abdominal
surgery was 27. 8%, while conversions were necessary only for
9. 5%. Major complications were surgical site infection (4. 8%)
and ileus (3. 2%). Anastomotic leaks occurred in 2 patients (1.
6%) but no mortality case was present. Conclusions: We started
inducing LAC in benign cases or early staged malignancies. As
more advanced laparoscopic procedures were adopted, almost
the same quality of surgery could be provided without severe
complications.
S112 THE EFFECTS OF NEOADJUVANT THERAPY ON
LAPAROSCOPIC SURGERY FOR RECTAL CANCER, Emre
Balik MD, Metin Keskin MD, Burak Ilhan MD, Sumer Yamaner
MD, Turker Bulut MD, Buyukuncu Yilmaz, Necmettin Sokucu, Ali
Akyuz, Bugra Dursun MD, Istanbul University, Istanbul Faculty of
Medicine, General Surgery Department
Purpose: The comparison of the surgical outcomes of
laparoscopic resections performed for rectal cancer between
the two groups of patients either having received neoadjuvant
therapy (NAT) or not. Methods: From October 2003 to October
ABSTRACT BOOK
Podium Papers
2007, 146 patients with rectal cancer were treated by laparoscopy.
56 (38, 3%) patients received NAT preoperatively (NAT group)
whereas 90 (61, 7%) patients underwent direct surgery (Non-NAT
group). All patients were followed prospectively for survival and
complications. Results: Laparoscopic surgery for rectal cancer
was performed in 146 patients. Low anterior resection was
performed in 116 and Miles operation in 27 patients whereas 3
patients were only laparoscopically explored. The mean operating
time was 2, 9 (0, 5 - 5, 0) hours. The operating time was also found
to be 2, 9 hours both in the NAT and Non-NAT groups. Conversion
to open surgery was required in 13 of 146 patients (9, 3%).
Intraoperative additional surgical intervention was required only
in three patients all of whom were in the NAT group. TAH+BSO
was performed in two of these patients and ureter reconstruction
was performed in one single patient. The overall morbidity was
21%, anastomotic leakage occurred in 6 of 146 patients only one
single patient of whom was in the NAT group (4, 1%). There was
no postoperative mortality. A mean of 18 (4-89) lymph nodes was
removed having calculated to be 18 also both in the NAT and
the Non-NAT groups. The mean distance of distal margin from
tumor was 3 cm in the entire study group. In one patient there
was microscopic invasion of the distal margin. Mean hospital
stay was 7 (2-45) days both in the NAT and Non-NAT groups as
well. Conclusions: Laparoscopic rectal surgery is feasible and
oncologically radical. When compared between patients having
received neoadjuvant therapy preoperatively and patients directly
having undergone surgery without receiving NAT, it can be stated
that similar surgical outcomes are encountered revealing no
statistically significant differences. Preoperatively administered
NAT can be considered to be a safe method as long as indicated.
S113 COMPARISON OF CONVENTIONAL AND HANDASSISTED LAPAROSCOPIC SURGERY IN COLON CANCER,
HR Yun MD, HK Chun PhD, WY Lee PhD, YB Cho MD, WY Chang
MD, RJ Lee MD, YK Cho MD, HC Kim PhD, H Yoo MD, SH Yun
MD, JH Park, WY Chang MD, Department of Surgery, Samsung
Medical Center, Sungkyunkwan University School of Medicine,
Seoul, Korea, Department of Surgery, Cheju University, Cheju,
Korea
Background: Hand-assisted laparoscopic surgery (HALS)
has been introduced as an alternative to the conventional
laparoscopic surgery (CLS). This study evaluates the efficacy
and short-term clinical outcome of hand-assisted laparoscopic
surgery as compare with conventional laparoscopic surgery
for colon cancer. Methods: Between May 2000 and December
2006, 351 patients underwent elective colon cancer operation
(153 HALS and 198 CLS). The collected data included intraoperative, oncologic, early clinical outcomes and short term
oncologic results. Results: The tumor margins were clear in
all the patients. The operation time of HALS group resulted in a
significantly shorter than CLS group (151. 2¡¾40. 3min vs. 164.
6¡¾34. 9 min; p= 0. 001). On a subgroup analysis according to
the site of tumor, in right colon cancer, there was no statistical
significance in operation time between groups (158. 8¡¾ 27. 3min
vs. 151. 0¡¾28. 0 min; p=0. 251). For the left colon cancer, HALS
group had shorter operation time and smaller tumor size than CLS
group (149. 4¡¾ 42. 7min vs. 167. 6¡¾35. 7 min; p<0. 001 and 3.
5¡¾1. 8cm vs. 2. 9¡¾1. 8cm; p=0. 007, respectively). There were no
statistical differences in intra-operative, oncologic, early clinical
outcomes and short term oncologic results except operation time.
For the stage III colon cancer, there was no difference in overall
survival and disease free survival (p=0. 320 and p=0. 472,
respectively). Conclusion: The findings suggest that HALS had
shorter operative time, especially in left sided colon cancer but
the oncologic and clinical outcome in HALS was similar with CLS.
HALS was thought be an effective alternative operative technique
in colon cancer.
LAPAROSCOPIC SURGERY II
S114
RISK FACTORS
AND
MANAGEMENT
OF
ANASTOMOTIC
LEAK
FOLLOWING
RESTORATIVE
RESECTION FOR RECTAL CANCER IN THE ERA OF
NEOADJUVANT THERAPY, Alexis L Grucela MD, David B
Chessin MD, Nicole DeRosa MD, Alex J Ky MD, Sanghyun A Kim
www.isucrs.org/
MD, Tomas Heimann MD, Randolph M Steinhagen MD, Mount
Sinai School of Medicine
Introduction: Surgical resection remains the only curative
treatment for rectal cancer. Although some patients require
permanent fecal diversion, recent trends have increased the
number of restorative resections. Anastomotic leak is a substantial
concern following these procedures. We evaluated patients
with rectal cancer undergoing restorative resection to identify
risk factors and management of anastomotic leak. Methods:
We identified 96 consecutive patients who had a low anterior
resection for rectal adenocarcinoma. We defined anastomotic
leak as clinical or radiographic evidence of leak. We compared
demographic, pathologic, and clinical factors to determine risks for
anastomotic leak. Results: There were no perioperative deaths.
Eight patients (8. 3%) had an anastomotic leak. Risk factors for
leak are compared in the Table.
Risk Factor
No Leak (n=88)
Leak (n=8)
p-Value
Male Gender
45 (51. 1%)
5 (62. 5%)
0. 7
Age >60
46 (52. 3%)
1 (12. 5%)
0. 06
Diabetes
5 (5. 7%)
1 (12. 5%)
0. 4
Preop Radiation 14 (15. 9%)
1 (12. 5%)
0. 1
DAV < 5 cm
29 (33. 0%)
3 (37. 5%)
0. 1
In those patients with a leak, one (12. 5%) required percutaneous
drainage, while four (50%) required reoperation with fecal
diversion. Of the diverted patients, all had reversal of their stoma
(mean of 7. 25 months from initial operation). Conclusion: 8. 3%
of patients undergoing restorative resection for rectal cancer may
leak. Notably, distance from the anal verge and use of preoperative
radiation were not significant risk factors for leak. Routine fecal
diversion in patients treated with preoperative chemoradiation is
not warranted, even for distal anastomoses.
S115 HISTOCLINICAL CHARACTERISTICS OF COLORECTAL
CARCINOMA
WITH
LYMPHOVASCULAR
INVASION,
Romarico M Azores Jr. MD, Alma N Aquilizan MD, Cynthia A
Mapua MS, Francisco V Narciso MD, St. Luke’s Medical Center,
Quezon City, Philippines
Purpose: Lymphovascular invasion (LVI) in colorectal cancer is
significantly associated with nodal metastasis. We studied our
data from the Colorectal Cancer Data Bank of the Bioinformatics
Department, Research and Biotechnology Division of St. Luke’s
Medical Center and determined the histoclinical characteristics of
colorectal cancer with LVI. Methods: We studied data bank record
from October 2006 to April 2007 of 490 patients with colorectal
cancer. There were 212 evaluable cases, 118 cases of which had
LVI and 94 cases had no LVI. The following cancer-related factors
were assessed: age and gender, stage of the disease, tumor
differentiation, site of lesion, and TNM stage. Results: Age and
gender seemed to be not associated with LVI (p<0. 05). 64% of
those without LVI were in the early stage of the disease while
73% of those with LVI were in the late stage of the disease. The
observed difference was significant (p<0. 01). 15. 4% of those with
LVI had poorly differentiated tumor as opposed to 2. 2% of those
without LVI. The difference was significant (p=0. 004). The site of
the lesion seemed to be not related to LVI. 92. 1% of those with LVI
had T3 and T4 tumors against 73. 8% of those without LVI and the
difference was significant (p=0. 004). Only 30. 6% of those with LVI
and 64. 8% of those without LVI had negative nodal metastasis. It
was very significant (p<0. 001). 24. 6% of those with LVI and only
10. 2% of those without LVI had distant metastasis. The difference
was significant (p=0. 009). By multivariate regression analysis, the
following were the predictors of LVI: male patient, poor histologic
grade, depth of invasion and nodal status. Conclusion: LVI puts
the disease into high risk cancer.
S116 FEMALE FERTILITY AND COLORECTAL CANCER,
Constantine P Spanos MD, Apostolos M Mamopoulos MD,
Apostolos Tsapas MD, 1st Department of Surgery, Aristotelian
University, Thessaloniki, Greece
Purpose: It is estimated that the incidence of cancer in women
aged under 40 is 8%. Females under the age of 40 are in their
childbearing years. In the Western World, colorectal cancer
(CRC) is the most common malignancy of the gastrointestinal
tract. It is the third most commonly diagnosed cancer and the
63
ABSTRACT BOOK
Podium Papers
2nd leading cause of cancer-related death in the United States.
The incidence of CRC in patients under 40 is 3-6%. Over the past
decades, there has been a significant improvement in survival
rates due to progress in cancer treatment, including CRC. This
has been achieved with advances in adjuvant chemotherapeutic
regimens. In the case of locally advanced rectal cancer, radiation
therapy is also used. Treatment for CRC may have adverse
effects on female fertility. The purpose of this paper is to
discuss effects of treatment of CRC on female fertility, as well
as options for fertility preservation. Methods: A review of the
relevant English language articles was performed on the basis
of a MEDLINE search of the keywords: female, fertility, fecundity,
colon, rectal cancer, fertility preservation, chemotherapy and
radiation. Results: Surgical resection for colon cancer possibly
has no effect on female fertility. Resection below the peritoneal
reflection may adversely affect fertility, based on lower fertility
and fecundity rates associated with pelvic surgery for ulcerative
colitis (UC) and familial adenomatous polyposis (FAP). Standard
5FU-based chemotherapy may not have significant effects. The
advent of oxaliplatin in adjuvant chemotherapy may be more
harmful. Adjuvant and neoadjuvant radiation therapy may cause
premature ovarian failure using current dosing schedules. The
effect of pregnancy and female hormones on the incidence,
progression and recurrence of CRC remains unclear. Established
methods for fertility preservation include ovarian transposition
and embryo cryopreservation. Oocyte cryopreservation has
yielded inferior results. An investigational fertility preservation
method is ovarian tissue cryopreservation, with promising results.
Ovarian suppression and the use of apoptotic inhibitors are also
investigational at present. Conclusion: Young female patients
need to be informed about the effects of treatment on fertility and
options for fertility preservation. A multidisciplinary approach for
appropriate consultation of these patients is mandatory.
S117 EFFICACY OF LAPAROCSOPIC COLORECTAL
RESECTION FOR HIGH RISK PATIENTS, Jo Tashiro MD, Shigeki
Yamaguchi MD, Masatoshi Ishii, MD, Takahiro Sato MD, Shutaro
Ozawa MD, Yoshihide Otani MD, Isamu Koyama MD, Saitama
Medical University International Medical Center Department of
Purpose: Minimal invasiveness of laparoscopic resection has
a possibility of decreasing postoperative complications for high
risk patients. This study was assessed short term results of
laparoscopic colorectal resection for high risk patients. Patients:
Seventy patients of colorectal cancer resection were enrolled in
this study since April 2007 of opening hospital to January 2008.
Mean age was 66. 4 year-old. 50 patients were colon cancer and
20 patients were rectal cancer. There was no conversion in those.
According to ASA classification, grade 2 or more of grisk grouph
was 41 patients, 3 or 4 of ghigh risk group h was 9 patients,
and gno risk grouph was 29 patients. Factors of gender, age,
lymphadenectomy, operating time, blood loss count, postoperative
complication, postoperative hospital stay were assessed between
three groups. Results: Mean age was 70. 1 in risk group, 76. 1
in high risk group and 60. 6 in no risk group. No risk group was
younger than others. There were no difference of mean operating
time and blood loss count, however more lymphadenectomy was
performed in no risk group. Postoperative complications occurred
in five patients. Those were 2 anastomotic leak , 2 anastomotic
bleeding, and 1 intestinal obstruction. There was no difference
of complication frequency in each group. Median postoperative
hospital stay was 7 days in all groups and no difference.
Conclusion: Even though patient was high risk, laparoscopic
resection was performed safely without increasing complication
and postoperative hospital stay.
S118 TWO DIFFERENT LAPAROSKOPIC TECHNIQUE ON
RECTAL PROLAPSUS, Turker Bilgin MD, General Surgeon,
Etimesgut Military Hospital, Dept. of Surgery. Ankara, Turkey
Purpose: The laparoscopic approach promises to become
the gold standart for the transabdominal management of full
thickness rectal prolapsus. The aim of this study was to review our
experience and to highlight the functional results achieved with
this two technique. Method: Data were prospectively collected
and analyzed on 48 patients who underwent laparoscopic
rectopexy without resection for full-thickness rectal prolapsus
64
ISUCRS XXII BIENNIAL CONGRESS between 2001-2008. These were two major group each group
had 24 patients. One patient had undergone to open surgery
from laparoscopy. Mean age was 48 (range, 20-74) years. The
preoperative and postoperative course of each patient was
followed up , with attention paid to first bowel movement ,
hospital stay, duration of surgery fecal incontinence , constipation,
recurrent prolapsus, morbidity and mortality . Follow-up was
made by clinic appointments and, if necessary by telephone
review. Results: 48 patients were available for follow-up. The
follow-up time was 9 years. In both groups the results are really
similar but the main difference was on the long therm results.
Eighty percent of patients reported alleviation of their symptoms
after the operation. Sixty-nine percent of the constipated patients
experienced an improvement in bowel frequency. Four (2. 5%)
patients had full-thickness rectal prolapsus recurrence. Mucosal
prolapsus recurred in 2(1. 8%) patients. Mean duration of surgery
was 75 (range, 50-150) minutes. Postoperatively, the median time
for first bowel movement was nearly twenyfour hour. Median
hospital stay was four (range, 2-6) days. Postoperative morbidity
included a port site hernie (1 case), and a superficial wound
infection (one case). Conclusion: Laparoscopic suture rectopexy
without resection is both safe and effective in this frequently frail
population and offers a minimally invasive approach that may
have potential advantages for selected groups of patients with
full-thickness rectal prolapsus but long therm following series the
classic abroach like posterior rectopecsi was much effective then
the suture rectopexy. Laparoscopic techniques must to be the
same plan with classic accepted surgical procedures.
S119 USE FULNESS OF FALS IN LAPAROSCOPY ASSISTED
COLORECTAL SURGERY, Jun Yasutomi MD, Toru Tonooka MD,
Ikuo Udagawa MD, Kimihiko Kusashio MD, Masanari Matsumoto
MD, Masaru Suzuki MD, Katashi Fukao MD, Department of
FALS : finger assisted laparoscopic surgery is a novel technique
in the laparoscopy assisted colorectal surgery. Especially in
laparoscopic low anterior resection for rectal carcinomas, we often
find difficulty in making a fine view of the surgical field during
pelvic dissection, gut clamping for rectal washout, intracorporeal
anastomosis and so on. Between January 2003 and February
2008, we performed 147 laparoscopy assisted colorectal surgeries
including 37 sigmoid colon resections, 45 anterior resections, 1
abdomino-perineal resection and 3 total procto-colectomies.
Initially, we immediately converted laparoscopic into open surgery
once we found difficulty in laparoscopic procedures. Since we
adapted this new technique, we have been able to perform the
advanced and complex laparoscopic procedures. FALS is an easy
and helpful method using the abdominal wall sealing device :
ALEXIS WOUND RETRACTOR ( Applied Medical, Rancho Santa
Margarita, CA) and surgical gloves, that makes it possible to
apply almost all kinds of instruments for open surgery. Using this
simple technique, we can easily set up additional trocars, and also
insertion of the instruments such as uterine retractor, intestinal
forceps or intestinal clamps and variety of devices for open
surgery has become possible. Especially, the Doyen intestinal
forceps with curved blades is useful, which we can insert into
intraperitoneal cavity without cutting off the finger parts of the
surgical glove. Furthermore, we can switch from laparoscopic
to open surgery and also open to laparoscopic surgery under
re-pneumoperitoneum. We would like to present some useful
techniques in laparoscopy assisted anterior resections, such as
in TME ( total mesorectal excision ), in intra-rectal lavage (rectal
washout), in DST (double stapling technique) anastomosis and in
intra-pelvic lavage including the test for anastomotic leakage etc.
S120 MINIMAL INVASIVE SURGERY FOR RECTAL CANCER.
SHORT TERM RESULTS OF SINGLE CENTER, Emre Balik MD,
Metin Keskin MD, Burak Ilhan, Sumer Yamaner MD, Turker Bulut
MD, Yilmaz Buyukuncu, Necmettin Sokucu MD, Ali Akyuz, Dursun
Bugra MD, Istanbul University, Istanbul Faculty of Medicine,
General Surgery Department
Aim: Laparoscopic treatment of rectal cancer has gained favor
in the recent years but there is no consensus about rectal cancer
disease on this technique as colon cancer . The aim of this study
is to assess the reliability of laparoscopic anterior resection (LAR)
abdominoperineal resection (APR) and the analysis short-term
ABSTRACT BOOK
Podium Papers
outcomes o the rectal cancer. Methods: The charts of 146 rectal
cancer disease patients data’s were collected retrospectively
after resection for rectal adenocarcinoma performed by minimal
invasive access between October 2003 and 2007 . Patients
undergoing emergency surgery were excluded. Demographic,
conversion rates, functional, oncologic and early surgical
outcomes were analyzed. Results: LAR and APR was performed
in 143 patients, and conversion to laparotomy was required in 13
(8. 9%) cases. Fifty two patients’ tumors were located at proximal
rectum, 29 were in the middle and the rest of them located at distal
rectum. Fifty six underwent long course neoadjuvant therapy
before the surgery. Avarege operation time for nonconverted
patients was 185 minutes (overall 238 minutes). Total mesorectal
excision (TME) was performed in tumors of the mid and low
rectum in 96 patients. Only 50 patients needed temporary stoma.
The mean length of hospital stay (LOS) was found 7 days. There
was no mortality in the first 30 days. Overall morbidity rate was
21%. Morbidity of anterior resection included 6 anastomotic leaks
after laparoscopic surgery. The mean distal surgical distance was
3 cm. The mean incision length was 5. 5 cm and the mean number
of nodes collected was 18. Conclusions: The outcomes of this
study suggest laparoscopic surgery for rectal cancer is a reliable
procedure. Oncologic requirements were respected; parameters
such as length of distal margin, number of node, functional
outcomes retrieved were acceptable. Data’s and multicenter trials
are needed for long term results.
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S121 LAPAROSCOPIC ASSISTED INTERSPHINCTERIC
RESECTION FOR VERY LOW RECTAL CANCER, Yoshiya
Fujimoto MD, Hiroya Kuroyanagi MD, Masatoshi Oya MD,
Masashi Ueno MD, Takashi Akiyoshi MD, Toshiharu Yamaguchi
MD, Tetsuichiro Muto MD, Department of Gastroenterological
Surgery, Cancer Institute Hospital, Tokyo, Japan
Introduction: Laparoscopy-assisted surgery for rectal cancer has
been shown to be both technically feasible and a safe alternative
to laparotomy. In addition, intersphincteric resection (ISR) has
recently been reported as a promising method for sphincterpreserving operation in selected patients with very low rectal
cancer to avoid a permanent stoma. Methods: From July 2005 to
December 2007, 22 patients with very low rectal cancer underwent
laparoscopy-assisted total mesorectal excision (TME) with ISR
followed by hand-sewn coloanal anastomosis and diverting
ileostomy. Seven patients received preoperative chemoradiation
therapy. Results: The average age of the patients was 58. 8 years
(range 33 to 79), and 59. 1% were male. The median tumor size
was 27. 5 mm (range 10 to 90) and distance from the dentate line
was 1 cm (range 0 to 3). The median operation time was 280 min
(range 195 to 374), and blood loss was 70 ml (range 0 to 235).
There was no mortality. The complications were occurred in
3 cases, comprised of one with wound infection and two with
obstructions, and no anastomotic leakage was observed. They
recovered with conservative therapy. The median duration of
postoperative hospitalization was 17. 5 days (range 11 to 121).
Lymph node metastases were present in 9 cases. Pathological
stage I according to UICC classification was confirmed in 10
cases, stage II in 1, stage III in 9, and no cancer (histopathological
findings showed complete response) in 2. One patient underwent
radiation therapy and chemotherapy due to positive resection
margin, but died of recurrent disease. The other developed
lung metastasis. Remaining 20 patients were still alive without
recurrence. Conclusions: The current study demonstrated
laparoscopic TME and ISR is both technically feasible and a
safe alternative to laparotomy in the short term with favorable
postoperative outcome.
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VIDEO Papers
V001 LAPAROSCOPIC TOTAL ABDOMINAL COLECTOMY
WITH RECTAL HARTMANN’S POUCH AND CONSTRUCTION
OF END BROOKE ILEOSTOMY, Badma Bashankaev MD,
Christina Seo MD, Jared Frattini MD, Paula Denoya MD, Marwan
Moussa MD, Steven D Wexner MD, Department of Colorectal
Surgery, Cleveland Clinic Florida
This video depicts a case of a 15 year old female with mucosal
ulcerative colitis (MUC). She was diagnosed 3 years ago and failed
conservative treatment. She has already sustained multiple bone
fractures. She and her family are quite apprehensive about lifelong
commitment to multiple immunosuppressive medications. The
patient’s choice was to have a laparoscopic subtotal colectomy
with rectal Hartmann’s pouch and end Brook ileostomy. Surgery:
Abdominal access was performed with the Hasson technique.
Four additional 10 mm ports were placed through horizontal stab
wounds lateral to the left epigastric vessels, one in each upper
quadrant and one in each lower quadrant. With a combination of
head up, head down, left side up and left side down, the entire
colon was carefully mobilized along the line of Toldt. The left and
right ureters, duodenum, and pancreas were carefully reflected
posteriorly out of harms way. The entire small bowel appeared
normal without any evidence of Crohn’s disease. The entire colon
appeared diseased consistent with mucosal ulcerative colitis.
The division was undertaken from the terminal ileum, around
to the rectosigmoid junction carefully protecting and preserving
the ileocolic, superior rectal, and inferior mesenteric vessels.
The rectosigmoid junction was divided stapler. The previously
identified right ileac fossa ileostomy site was re-identified, and a 2
cm disk of skin was excised. An additional 10 mm port was placed,
and the staple line at the distal sigmoid was gently grasped and
the entire specimen withdrawn through the stoma site. After
verification of appropriate orientation of the small bowel and its
mesentery, irrigation and verification of meticulous hemostasis,
all port sites were closed with 3-0 Vicryl with the Neat-stitch
device under direct vision. The stoma was then primarily matured.
Patient tolerated surgery well and discharged on a postoperative
day 3.
V002
EMERGENCY LAPAROSCOPIC
RIGHT
HEMICOLECTOMY IN ILEO-COLIC INTUSSUSCEPTION PATIENT
DUE TO CECAL CANCER, Koo Yong Hahn MD, Jeoung Hwan
Keum MD, Yong Geul Joh PhD, Seon Hahn Kim PhD, Deprtment
of Surgery, Seongnam Central Hospital
Objectives: Intussusception of large bowel in adult is rare
and associated with malignancy in 70% of patients. To avoid
66
ISUCRS XXII BIENNIAL CONGRESS tumor emboli spread during surgery, an attempt of reduction of
intussusception should be excluded. For that reason, surgical
complete resection is appropriate for treatment. Owing to huge
mass, adhesions of surrounding structures such as ileo-colic
vessels, ureter and duodenum, it is very hard to handle by
laparoscopically. Method: A 39-year-old female patient visited
emergency department due to right lower quadrant pain and
abdominal distension. A computerized tomography(CT) revealed
right lower quadrant mass, bowel inflammation and edema.
Under the impression of ileo-colic type intussusception, we did
laparoscopic right hemicolectomy. Result: The operation time
was 250minutes and blood loss was 100cc. The first gas passage
was postoperative 2nd day and stool passage was 3rd day. The
first sips of water was postoperative 3rd day. The pathologic
report demonstrated that the tumor was mucinous carcinoma and
extended to subserosa. The 3 lymph nodes metastasis was found
(3/25). Patient was discharged postoperative 11th day without
complication. Conclusion: We conducted laparoscopic right
hemi-colectomy in ileo-cecal intussusception patient successfully.
The application of laparoscopic surgery in intussusception
depands on laparoscopic expertise of surgeon, extent of disease,
patient condition.
V003 PERINEAL RECTOSIGMOIDECTOMY AND VAGINAL
HYSTERCTOMY IN A PATIENT WITH RECTAL PROCIDENTIA
AND VAGINAL PROLAPSE, Eduardo Brambilla MS, Paulo
Roberto Dal Ponte MD, Marcos Antonio Dal Ponte MD, Viviane
Raquel Buffon MD, University of Caxias do Sul
Introduction: Rectal procidentia is relatively rare and more
common in older and female patients. In this group, other pelvic
floor disturbs can also be associated. Once the ethiology as well
as its treatment are doubtful, many are the surgical alternatives.
Perineal procedures are considered attractive due to the low
morbidity rate specially in this group. Case Report: A 74-yearold patient, hypertense, with a brain damage caused by a brain
stroke has manifested over the past 6 months reducible rectal
procidentia, which is exteriorized by walking. The patient reported
chronic constipation with some episodes of faecal incontinence. By
examining the patient, rectal procidentia and third-grade uterine
prolapse was presented. Perineal rectosigmoidectomy associated
with vaginal hysterctomy was the therapy performed. There
were not any complications during the trans and postoperative
period. After 60 days accompanying the patient, this one did not
present any reincidence of prolapse or constipation. The faecal
incontinence became less frequent.
ABSTRACT BOOK
Poster Papers
Anorectal Diseases
P001 A MODIFICATION IN LONGO’S TECHNIQUE
SIGNIFICANTLY IMPROVES THE RESULTS OF STAPLER
ANOPEXY IN HIGHER GRADE HEMORRHOIDS, Pankaj Garg
MS, Fortis Super Speciality Hospital, Mohali, India
Purpose: High recurrence rates in patients with higher grade
hemorrhoids are being reported with Stapler anopexy. The prime
reason for this is the limiting capacity of stapler PPH03 to excise
the adequate amount of mucosa which leads to residual prolapse
and recurrence. So in these cases, stapler anopexy converts higher
grade of hemorrhoids into a lower grade which subsequently
require banding or injection sclerotherapy for treatment. In our
study, we assessed the patient on the operating table immediately
after completing the stapler anopexy. If the residual prolapsing
hemorrhoids were found, they were ligated with 2-0 vicyl and cut.
So a procedure required later on for treating recurrence was done
with primary procedure only. Methods: A total of 42 patients
were recruited over 2 years. 19 patients with grade 3&4 (Standard
group) and 12 patients with grade 2 hemorrhoids (Gr 2 group)
were operated by standard Longo’s technique to serve as controls
and compared with 11 patients with grade 3&4 hemorrhoids
operated by modified technique in which the residual prolapsing
hemorrhoids were ligated and cut (Ligated group). The three
groups were matched for age and sex. The patients were
assessed on satisfaction scale and checked for recurrence at 3, 6
and 12 months. Results: The mean age was 46. 1, 51.3 and 48.7
years and the mean follow up was for 412, 464 and 405 days in
three groups, Grade 2, Standard and Ligated groups respectively.
The hospital stay (mean-1.42, 1.21 and 1.3 days), painful days
in post-operative period (mean-10.3, 7.05 and 8.68 days) and
days required to resume normal work (mean- 17.0, 8.4 and 12.7
days) were not significantly different in the three groups, Grade
2, Standard and Ligated groups respectively. [p>0.05, ANOVA].
Recurrence rates were significantly lower in Ligated group (1/11,
9.1 %) compared to Standard group (12/19, 63.2 %) [p<0.0067,
ANOVA]. Percentage of patients highly satisfied by the procedure
was significantly higher in Ligated group (10/11, 90.1 %) compared
to Standard group patients(6/19, 31.2%) [p<0.0024, ANOVA].
Incontinence (urge, gas or liquid) and anal stenosis was similar in
all three groups. Conclusions: In higher grade of hemorrhoids,
compared to doing stapler anopexy alone, performing ligation
and cutting of the residual hemorrhoids on the operating table
after doing stapler anopexy significantly reduced recurrence rates
and improved satisfaction rates. Larger long term studies are
needed to substantiate this.
P002 CONDYLOMA ACUMINATUM IN THE RECTUM, Sonny
S Wang MD, Sefik Gokaslan MD, Yomi Fayiga MD, Saul Sokol MD,
University of Texas Southwestern Medical Center, Dallas, Texas,
USA
Introduction: Anal condylomas are usually found in the distal
anal mucosal tissue, anoderm, or proximal perianal margin.
Human papillomavirus (HPV) is the cause of condyloma
acuminata and is often associated with HIV infection. We present
a rare case of condyloma acuminatum located in the rectum.
Method/Case Report: A 43 year-old Caucasian male presented
to our gastroenterology service with a chief complaint of bright
red blood per rectum for several weeks. His past medical history
is significant for HIV and hepatitis B diagnosed 20 years ago.
There was prior history of anal receptive intercourse. Our patient
was on highly active antiretroviral therapy (HAART) for HIV with
a CD4 count of 138 cells/ mL at the time of his evaluation. An
ensuing colonoscopy revealed a 2 cm anterior midline mass
at 5 centimeters away from the anal verge. Biopsy revealed
rectal condyloma acuminatum with moderate (high grade)
squamous dysplasia. Patient was subsequently referred to us for
further management. The diagnosis of rectal condyloma was a
surprise because of its location. Further digital and proctoscopic
examination confirmed the previous endoscopic findings. The
mass, however, had fungating and friable features suggestive
of neoplasm. We repeated the rectal biopsy due to the unusual
condyloma location in the initial diagnosis but also to exclude
neoplasm. We also undertook complete fulguration of the visible
mass at the time of repeat biopsy. Final pathology was again high
grade squamous dysplasia arising from condyloma acuminatum
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in the rectum. On postoperative follow up, our patient recovered
uneventfully. We plan to follow this patient closely and to rebiospy the area if the mass returns or neoplastic features arise.
Conclusion: Condyloma acuminatum in the rectum is an
uncommon diagnosis. To our knowledge, only one other
condyloma acuminatum located in the rectum has been reported.
Patel et al reported a 66 year-old Caucasian heterosexual nonHIV male diagnosed with rectal condyloma. 1 Clinicians need
to be aware that such a diagnosis exists. The management of
condyloma acuminatum in the rectum is similar to anal condyloma
that includes local excision and destruction usually by fulguration.
Reference: 1. Patel PH et al. Condyloma Acuminata Presenting
as Rectal Polyps in a Heterosexual Man: Importance of CT Scan of
the Pelvis. The American Journal of Gastroenterology. 1987: Vol.
82, No. 5, pp. 479-481.
P003
DOPPLER-GUIDED
HEMORRHOIDAL
ARTERY
LIGATION AND RECTOANAL REPAIR(DG-HAL & RAR) AS
A TREATMENT OF INTERNAL HEMORRHOIDS, Sung Wook
Cho MD, Soon Sup Chung MD, Ryung Ah Lee MD, Kwang Ho
Kim MD, Ewha Womans University Medical School Department
of Colorectal Surgery
Backgrounds: Hemorrhoidectomy is widely used as the
procedure for the treatment of internal hemorrhoids. However,
the problems with conventional hemorrhoidectomy consist
of postoperative pains, and delayed wound healing. For this
reason, minimally invasive procedure (ex. Rubber band ligation,
sclerotheraphy, laser treatment) or PPH were developed, but,
they also have some fatal complications. Purposes: To introduce
Doppler-guided hemorrhoidal artery ligation and Rectoanal
repair(DG-HAL & RAR) as a new treatment of internal hemorrhoids
and report a preliminary experience of this procedure. Methods:
From November 2007 to January 2008, 23 patients who don’t
have other anal problems (ex. Anal fisula, anal fissure) except
internal hemorrhoid grade II-IV were treated by DG-HAL & RAR.
Firstly, under the litotomy position, the proctoscope with an
incorporated Doppler probe was inserted and identified location
of hermorrhoidal artery. Once located, the artery was ligated
with a ‘figure of eight’ absorbable suture into submucosa. And
then prolapsed hemorrhoidal pile was lifted at rectal mucosa
by continuously suturing to 5mm above dentate line and tying.
The procedure was repeated at the 1, 3, 5, 7, 9, and 11 o’clock
position. We analysed hospital day, postoperative pain, time of
returning to work, and recurrence. Results: The patient’ mean
age is 48.3¡¾14 and they consist of 23 (Grade II: 8, Grade III: 11,
Grade IV: 4). Ten patients were male and 13 female. The mean
operation time was 35 minutes and postoperative hospital stay
was 1.4 days. The mean time of returning to work was 1.8 days.
There was no severe pain requiring injection of analgesics. Some
patients had only tenesmus and minor bleeding. After one month,
2 patients still had prolaping symptoms. Conclusions: Dopplerguided hemorrhoidal artery ligationand Rectoanal repair(DGHAL & RAR) is safe and less painful procedure comparing with
conventional hemorrhoidectomy. DG-HAL & RAR is an effective
alternative for the treatment of internal hemorrhoids.
P004 TRANSPOSITION OF GRACILIS MUSCLE IN THE
TREATMENT OF RECTOVAGINAL FISTULA RECURRENT.
REPORT A CASE, Carlos G Torres MD, Dina L Gil MD, Pedro
Gonzalez MD, Luis A Suarez MD, Hospital Sor Juana Ines de la
Cruz, Merida, Venezuela
Background:
The rectovaginal fistulas recurrent are
communication to invest with mucosa between the rectum and
the vagina. There are many treatments by location, size and
etiologies. They may be inflammation, infection, iatrogenic,
neoplasia or trauma. Objective: Give to know experience of a
case with transposition of gracilis muscle in the treatment of the
rectovaginal fistula recurrent in the type I Hospital the Sor Juana
Ines of Cruz in Merida Venezuela. Methods: Is a descriptive study
a clinic case of a female patient with 29 year old, who the patient
referred transit of gas and feces into the vagina of three months
after genital trauma. She referred had three preview surgery. This
case is a technique of transposition of gracilis muscle how definitive
option in the treatment of the rectovaginal recurrent. The patient
evolution good after closure colostomy after comprobation closure
of fistula. Key words: rectovaginal fistula, muscle gracilis.
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ABSTRACT BOOK
Poster Papers
P005 WHITEHEAD’S HEMORRHOIDECTOMY: DO WE HAVE
TO ABANDON THIS PROCEDURE?, Ok Joo Paek MD, Seung
Yeop Oh MD, Kwang Wook Suh MD, Department of Surgery, Ajou
University School of Medicine, Suwon, Korea
Introduction: Whitehead’s operation provides the only chance of
removing all hemorrhoids, giving the least possibility to relapse
and is highly cost effective. Analyzing personal data, we were to
answer the question: whether the Whitehead operation should be
abandoned or not. Patients and Methods: From March 1991 to
January 2007, 210 patients with grade 4 hemorrhoids underwent
Whitehead’s hemorrhoidectomy by the author. The ¡®grade
4¡¯ means the complex of internal and external hemorrhoids
occupying entire perimeter of anal verge, which are always
prolapsed. All patients were complaining additional symptoms
such as tenesmus, narrow or deformed stool, or the sense of
blockade during the defecation. The outcome of the operation
was retrospectively assessed by reviewing medical records with
regard to total blood loss during the procedure, operation time,
hospital stay, and types of complications. On the second visit (4
weeks postoperatively), degree of the anal stricture was measured
with Hegar dilator. On April 2007, 196 of all patients (93.3%) were
contacted. The patients were asked if there were any long-term
complications and to choose a point of satisfaction from 0(the
worst) to 10(the best). Results: Average operating time was 20.9
minutes and blood loss was 51cc. No patient required transfusion.
Urinary dysfunction (83.3%) and mild fecal incontinence (85.7%)
were noted. In average, the fecal incontinence disappeared
by the second week in all patients. All patients pointed out the
¡®pain¡¯ was the most notable complication and in fact the
parenteral opioids were required for all patients. When asked
if the stool caliber was small, all patients replied positively. Ten
patients complained some defecation difficulty but patients
who had passed more than 12 months after the operation did
not complain defecation difficulty whatsoever. For the objective
assessment of anal stricture, Examining by Hegar dilators, mean
diameter was 7.8 +/- 5.5 mm. Mean satisfaction score was 7.0
+/- 2.3. Two patients (0.95%) complained recurrent hemorrhoid.
Four patients complained difficulties in the defecation revealed
pinpoint narrowing. They were admitted again and were
successfully treated by stricturotomy. One patient underwent
anoplasty. Conclusion: We think the hemorrhoid is the benign
disease and therefore, it should be treated as conservative as
possible. However, when it reaches the end stage in which anal
dysfunctions are combined, we must decide the optimal type of
surgical treatment. Radical, circumferential hemorrhoidectomy
should remain as one of the operative choices.
P006
COMPLETE
CLEARANCE
OF
INTRA-ANAL
CONDYLOMA ACUMINATUM: PODOPHYLLIN APPLY
THROUGH ANOSCOPY COMPARED WITH SURGERY, SeokGyu Song MD, Woo-Jung Nam MD, Do-Yeon Hwang MD, JongKyun Lee PhD, Proctology Department, Song-Do Medical Center,
Seoul, South Korea
Purpose: Condyloma acuminatum which is usually sexual
transmitted and caused by Human Papilloma Virus. The incidence
of anal condyloma acuminatum has been increasing because
homosexual and bisexual behavior are not uncommon. Condyloma
acuminatum has been known for high recurrence rate after
treatment. Especially condyloma acuminatum affected to intraanal area has been higher recurrence and complication. Despite
the perianal condyloma acuminatum has been managed by many
different methods, main treatment for intra-anal condyloma
acuminatum is still surgery. The aim of this study is to investigate
the outcomes after podophyllin apply through anoscopy to
intra-anal condyloma acuminatum. Methods: From June 2006
to December 2007, total 105 patients visited our clinic for anal
condyloma acuminatum. Among these patients, the focus of the
present study was the 62 patients who had intra-anal condyloma
acuminatum confirmed by pathology department and who had
follow up at least 4 weeks after treatment. Of the 62 patients, 39
patients underwent surgery and 23 patients received podophyllin
treatment. The treatment method was selected by patients. The
surgical treatment was excision and elctrocoagulation under
local or spinal anesthesia. The podophyllin was applied to intraanal lesion through the anoscopy with no anesthetics or mucosal
68
ISUCRS XXII BIENNIAL CONGRESS protective agent. We performed one time per week at outpatient
clinic. Comparison between the treatments were analysed by the
Chi-squared test. Significance was defined as P<0.05. Results:
The complete clearance were 26 for 39 patients in the surgery and
14 for 23 patients in the podophyllin treatment(surgery: 66.7%,
podophyllin: 60.8%, P>0.05). There was no significant difference
in complete clearance rate between the two groups. Age and sex
distribution were similar in the two groups. The mean follow
up periods were 9.5 weeks after surgery and 8.7 weeks after
podophyllin treatment. In treated wih podophyllin, the mean
frequency of treatment were 4.2 times. There was no specific
complication after podophyllin application, but four patients
underwent surgery had anal fissure which were resolved with
conservative treatment. Conclusions: Podophyllin application is
safe and effective office based procedure for intra-anal condyloma
acuminatum. It has less complication and acceptable recurrence
rate compared to surgery. Our results support podophyllin
application can be an alternative treatment method for intra-anal
condyloma acuminatum.
P007 STRAINING DIAGNOSIS FOR HEMORRHOIDAL
DISEASES, Naoto Saigusa PhD, Jun-ichi Saigusa PhD, Sumio
Saigusa PhD, Saigusa Clinic of Coloproctology
Purpose: The examinations for anorectal diseases are customarily
performed with the patient lying down on an examinating table.
However, usually internal hemorrhoids are classified if they are
prolapsed or not during defecation. Therefore, in order to make
a correct diagnosis for hemorrhoidal diseases it would be ideal
to inspect the buttocks during straining in accordance with
gravity while the patient is in a position of squatting or sitting
on a toilet seat. We determine the usefulness of this diagnostic
method which was introduced 80 years ago in our clinic.
Methods: Following four data on our examination flow were
prospectively investigated at the patients’ first office visit at
Saigusa Clinic during the period from January 2003 to May
2007; 1) voluntarily expressed chief complaints of patients, 2)
interviewed subjective degree of hemorrhoids by questioning
whether they are aware of their prolapse ani or not, 3)
objective degree of hemorrhoids observed under conventional
proctoscopy with the patient in a spine lithotomy position, 4)
objective degree obtained at an inspection of the buttocks using
a hand mirror during the patient straining in toilet (straining
diagnosis). This diagnostic procedure was carried out by three
senior proctologists who have more than 15 years’ clinical
experience. Paired t-test was applied for statistical analysis.
Results: We had 1000 patients who presented symptomatic
hemorrhoids of more than the first degree during that period.
Among them, 570 patients had two or more subjective complaints.
Only 592 patients (59%) voluntarily complained prolapse ani. Anal
bleeding and pain were presented in 494 (49%) and 202 (20%)
patients respectively. The value of subjective degree of hemorrhoids
carefully interviewed at office was significantly higher than that
of self-stated one with their mean of 2.24 vs. 1.97 (p<0.01). The
objective degree diagnosed at straining was significantly higher
than that of under anoscopy with their mean of 3.02 vs. 2.97(p<0.01).
Conclusions: A considerable number of patients were not
aware of their prolapse. The conventional examination only by
use of anoscope is not sufficient. Even if the physicians were
well clinically trained and experienced, they could not always
make a correct diagnosis without using the straining technique.
Affirmative questioning to the patients and straining diagnosis
are essential for accurate evaluation of hemorrhoidal diseases in
order to choose adequate treatment.
P008 THE METHOD OF TREATMENT EXTRA- AND
TRANSSPHINCTER RECTAL FISTULAS, Tengiz F. Bochoidze
MD, Iuri D. Tavdidichvili MD, K. Eristavi National Center of Surgery,
Tbilisi., Georgia
The goal of the work is improvement of surgical treatment
results of extra- and transsphincter fistulas in ano. Methods:
The method of closed intrafistular coagulation includes
introduction of proper sized silver probe through the external
opening up to internal opening of the fistulous tract. The probe
is connected with coagulator and under the visual control
electro cauterization with definitive regime is carried out.
ABSTRACT BOOK
Poster Papers
After coagulation and excising of the internal opening Latex
drainage is placed through the all length of the fistulous tract.
The internal opening is closed with suture and plastic operation
on rectal mucous wall by Judd - Robles is performed. External
opening is excised and kept open. In case of multichannel
fistula, separate cauterization of each channel is indicated.
Drainage stays for 2 - 4 days, after what washing of the wound
by antiseptics and antibiotics is done. Healing of the fistula
takes 7 - 10 days. Results: Postoperative period passes without
complications. 32 patients underwent surgery be abovementioned
method. The patients have no compliance, complication and
recurrence after 2 years of operation. Conclusion: The method
is less invasive and allows eradicating the fistula in ano without
compromising anal sphincter function which is restored just after
removing of gas derivation tube and tampons from the rectum.
P009 SPECTRUM OF ANORECTAL DISEASES IN AN
INDUSTRIAL TOWNSHIP, Sunil Kumar Gupta MS, Main
Hospital, Bharat Heavy Electricals Limited, Ranipur, Haridwar,
Uttarakhand, India
Spectrum of anorectal disorders prevalent in industrial
township population where the author is practising as
consultant surgeon is analysed for a period of two years. 481
patients afflicted with anorectal problems attended special
weekly clinic. 43.8% (n=211) presented with haemorrhoids of
varying degrees. 25.1% (n=121) had fissure-in-ano. Fistula-inano constituted 12.6% (n=61). 6.4% (n=31) patients presented
with perianal suppuration. Pilo-nidal sinus comprised 4.9%
(n=24) in the study group. 4.5% (n=22) patients had pruritis
ani. Rectal prolapse was encountered in only 1.45% (n=7) and
rectal cancer was seen in only 0.83% (n=4) patients. Anorectal
injuries were not included in the study due to non availability
of proper information about these patients. Patients were
questioned about their bowel and food habits. Spicy food stuff
and straining at stools were found to be main causative factors
in patients with piles, fissure-in-ano and rectal prolapse while
poor hygiene, straining at stools were chiefly responsible
for pilo-nidal sinus, perianal suppuration, fistula-in-ano and
pruritis ani. Management of all the patients who comprised
the above mentioned group depending upon the disease entity
and extent of the disease is discussed along with their followup and outcome. Various treatment modalities in patients with
haemorrhoids, pilo-nidal sinus and fistula-in-ano are discussed.
P010 BANDING? NO. HIGH MACRO BANDING, Jose A
Reis Neto PhD, Jose A Reis Junior MD, Odorino Kagohara MD,
Joaquim Simões Neto MD, Sergio Bassi MD, CRN (Clinica Reis
Neto)
Since the last decade the idea of intervening higher in the anal
canal to impede the downward displacement of the hemorrhoidal
cushions, acting at its origin, has becoming more and more
accepted. The strategy of removing a segment of the anal canal to
eliminate the zone with degeneration of the collagen and elastic
tissue stroma and suspending the lower anal canal has shown to
be effective for hemorrhoidal disease grades II and III. Based on
the same principle a new technique of ligature was developed
based in two aspects: 1. to promote a better fibrosis and fixation
by banding a bigger volume of tissue;2. to perform this fixation at
the origin of the hemorrhoidal cushion displacement, preventing
the cushion to slip through the anal canal. Technique: No
especial preparation is necessary. If properly performed the High
Macro banding is painless. However to facilitate the banding is
recommended to inject 1. 5 ml of lidocaine at the submucosa
of the anal canal with a fine needle. This injection must be
performed, higher in the anal canal, 4 to 5 cm above the pectinate
line, according to location of internal piles. If the patient has more
than one pile, two or more areas could be injected. This maneuver
facilitates the suction of the mucosa. The banding instrument for
High Macro ligature consists of a double drum thirty millimeters
(3 centimeters) in length and fifteen millimeters (1, 5 centimeters)
in diameter. The bands are 2 millimeters in diameter when
unexpanded and 1. 5 cm when loaded onto the drum. The suction
device is adapted to a suction pump and the pile is drew downward
by sucking the mucosa of the anal canal; with this method the
surgeon can hold the anoscope with one hand and use the other
one to release the bands. It is recommended to utilize a longer and
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wider anoscope to obtain a better view of the anal canal which
will facilitate to inject the submucosa higher in the anal canal
and to insert the rubber band device. The pile must be banded
higher in the anal canal (4 to 5 cm above the pectinate line). The
mucosa, previously injected, is gently suctioned at the same time
that the rubber band device is slowly moved downward, parallel
to the anoscope, for just a small distance. It is preferable to treat
all the hemorrhoids in one single session (maximum of three).
When using the macro rubber-band, it is preferable to band the
existent piles at different levels, to avoid stricture of the anal canal.
Sequential single banding can be performed, but at least 30 days
should elapse between the sessions Results: It was observed the
following complications in 825 patients treated: edema in 1, 57%,
tenesmus in 0, 6%, pain (need for parenteral analgesia) 1, 57%,
small bleeding in 5, 45%, profuse bleeding in 0, 6% and urinary
retention in 0, 12% of the patients. None of the patients needed
hospitalization for the observed complications. Recurrence of the
symptoms occurred in 3, 87% of the patients, all of them treated
by a new banding.
P011 AMBULATORY ANAL SURGERY FOR BENIGN
DISEASE: SEDATION WITH LOCAL ANESTHESIA, Jose
Q Reis Neto PhD, Jose Q Reis Jr, Odorino Kagohara, Joaquim
Simoes Neto, Sergio Banci, CRN
Introduction: The aim of this paper is to evaluate the results
obtained with this technique in xxx patients operated on from
2002 to 2007. Technique: Sims (left lateral) position with the pelvis
raised on a sandbag is the best position for the procedure. The
lithotomy position should be avoided. . Sedation is achieved with
Midazolan (2 to 5 mg), Petidine Cl. (50 to 100 mg) and Propofol
(10 to 20 mg). Local anesthesia is performed Ropivacaíne Cl. 0,
75% (20 to 40 ml, according to patient weight). Nalozone Cl. (0,
1 to 0, 4 mg. is used to revert the effect of Petidine Cl., at the
end of the procedure. Meloxicam (or similar) is used at the end of
the surgery to prevent immediate post-operative pain. Results:
evaluation of 1805 patients operated on this scheme showed that
all of them had a post-operative without immediate complications
and needed hospitalization. Of these patients, 79% were operated
on from heorrhoidal disease, 8.4% of chronic anal fissure, 5.4%
of anal fistula (fistutomy) and the others from various benign
anal disease. Complication: It was observed: late post-operative
hemorrhage in two patients (0, 11%) operated on of hemorrhoids,
urinary retention in three patients (0.16%) patient and wound
infection in four patents (0, 22%). However, none of those
patients required hospitalization. Conclusion: the procedure of
sedation with local infiltration proved to be an excellent method
for treatment of benign anal diseases. Ambulatory surgical
procedure, independently of the etiology, but of the surgical care
and surgeon expertise, with adequate selection of patients, is
nowadays one better cost/benefit approach for most of the benign
anal diseases.
Benign Colorectal Diseases
P012
ZIONE
(ALTA)
INJECTION
THERAPY
FOR
HEMORRHOID & PROLAPSE: DIRECTLY ADMINISTERED
INTO HEMORRHOIDS BY METHODS OF FOUR-STEP
INJECTION TECHNIQUE, Mitsuyo Kosugi MD, Toshihiro Ono,
Chief of Proctology Center, Saitoh Clinic, Toyama,Japan
Four-step Injection Technique: ALTA Injection is directly
administered into hemorrhoids by the 4-step method injection,
and this procedure is important for the efficacy and safety of
ALTA Injection therapy. Methods of 4-step Injection: ALTA
Injection is directly administered into hemorrhoids by the
4-step method injection. Since this procedure is important for
the efficacy and safety of ALTA Injection therapy, and you need
a sufficient experience and practice of proctology. The 1st step
is injection into the submucosal layer of the upper polar region
of a hemorrhoid, giving usually a total of 3ml. The 2nd step is
injection into the submucosal layer of the central region, giving
the standard dose volume is 1ml higher than hemorrhoid
volume, usually a total of 2-4ml. The 3rd step is injection into
the lamina propria mucosae of the central region, giving about
half volume of the 2nd step, while slowly pulling back the needle
tip following the 2nd step. The 4th step is injection into the
submucosal layer of the lower pole. The needle tip is inserted
69
ABSTRACT BOOK
Poster Papers
at the region 0. 1-0. 2 cm above the dentate line, giving 1-3ml.
After the completion of the injection into all major hemorrhoids,
all injected regions are massaged well for a few minutes to fully
diffuse the drug solution. Proct-speculum for 4-step Injection:
We use the cylindrical proct-speculum for administration to the
adequate points by 4-step method. Cautions: You need a sufficient
experience and practice of proctology. 1) Follow to comply with
4-step method by dose and injection regions with 2% solution. 2)
Avoid complications; the following points should be paid attention
to. gProstatitis, epididymitis, orchitish gHemorrhoids necrosish
gPain of the anush gindurationh gRectal ulcer/ necrosish gRectal
stenosish etc. 3) Appearance rate of adverse reactions occurred in
19% in OC-108 group at phase III protocol and 10. 25% (462cases
in 337/3287) at PMS of ALTA.
70
of ALTA Injection: ALTA Injection is directly administered
into hemorrhoids by the 4-step method. Since this procedure is
important for the efficacy and safety of ALTA Injection therapy,
and you need a sufficient experience and practice of proctology.
Efficacy and Results of ALTA Injection Therapy: ALTA
Injection is effective for prolapse, the main symptom of developed
hemorrhoids, which were previously surgically treated. In the
phase III study, verification of the efficacy of ALTA Injection
on prolapsed hemorrhoids and a survey of surgery (MilliganMorgan hemorrhoidectomy) was performed and the outcomes
were compared. Disappearance rate of prolapse on the 28th
day, recurrence rate in 1 year after treatment and postinjection
complications were checked. As for hemorrhage, ALTA Injection
exhibited a high effect earlier than surgery. Release from prolapse
is similar to surgery. The mean duration of hospitalization was
shortened, compared to surgery. However the recurrence rate 1
year after ALTA administration was 16%, mainly occurred in cases
of third degree hemorrhoid of Goligher classification, and some
abnormalities were reported. Summary: Sclerosing therapy with
ALTA Injection was evaluated, effective and useful treatment in
patients with prolapsed internal hemorrhoids.
P013 XANTHOGRANULOMATOUS INFLAMMATION OF
COLON: TWO CASES REPORT, SH Jung MD, JS Hwang MD,
HJ Kim MD, JH Lee, JH Kim, MC Shim, Department of Surgery,
College of medicine, Yeungnam University, Daegu, Korea
Xanthogranulomatous inflammation(XGI) is chronic inflammatory
condition that characterized by aggregation of lipid-laden foamy
macrophages (xanthoma cells). This entity was first described by
Christensen and Ishak in 1970 and has attracted particular attention
in recent years, especially regarding the clinicopathological
aspects. Clinically, it can be difficult to differentiate from infiltrative
cancer because XGI might be presenting as an irregular mass-like
lesion with a severe extension of fibrosis and inflammation to the
surrounding tissues, and thus, often mimics infiltrative cancer.
This disease entity is well recognized in the kidney and gallbladder,
and three cases for the involvement of colon have reported. We
report two cases XGI involving colon considering for diagnostic
& therapeutic challenge. One, a 55-year-woman presented fever,
right lower abdominal painand mass was revealed huge masslike lesion with severe infilteration on CT scan. Enbloc resection
(right colon, abdominal wall, retroperitoneal soft tissue, ovary
and lateral femoral nerve) was performed and finally, cecal cancer
(T3N0M0) with XGI was confirmed. She suffered from right thigh
flexion limitation for 6 months, postoperatively. Two, a 66-yearman presented fever, upper abdominal mass during 10 days
was revealed infilerative T-colon malignant mass on CT, barium
enema and PET. The T-colon mass with severe adhesion to upper
abdominal organs was identified and transverse colectomy was
performed. Finally, XGI originated from transverse colon serosa
was demonstrated and he suffered from postoperative pancreatitis
for 20 days. XGI may rarely arise in the large bowel. However, like
gallbladder and kidney, XGI could be clinically and radiologically
misinterpreted as an infiltrative cancer and is indistinguishablefrom
inflammatory colon lesions with/or perforation. Therefore, any
excessive operative stress and morbidity are difficult to avoid and
need diagnostic and therapeutic challenges.
P015 THE INFECTED MUCINOUS CYSTADENOMA OF
APPENDIX MISDIAGNOSED INTRA-PELVIC ABSCESS, Ji
Hoi Koo PhD, Sung Hoon Yang MD, Dept. of Surgery, Incheon
Medical Center, Incheon, Korea
Appendiceal mucinous cystadenoma is a rare entity found in only
0.3% of appendiceal specimens. It is the most classification of
what has been generally termes ¡°mucocele¡± of the appendix.
A mucocele of the appendix is an obstructive dilatation of
the appendix caused by intraluminal accumulation of mucoid
material. It may caused by 1 of 4 processes: retention cyst,
mucosal hyperplasia, mucinous cystadenoma, or mucinous
cystadenocarcinoma. The most presenting symptom has
been abdominal pain, however, one-fourth of patients are
asymptomatic and are found incidentally. Other reported
symptoms are bleeding, intussuseption, and local invasion into
surrounding structures are described. But the abscess formation
of the mucinous cystadenoma is extremely rare. A 80-year-old
women presented with a 3-days history of pain in the right lower
quadrant of the abdomen. On physical examination, tenderness
and rebound tenderness were checked, and palm-sized mass was
palpable in the right lower abdomen. Computed tomography
presented a huge intra-pelvic abscess measuring 110 X 113 mm.
At laparotomy a huge infected cystic mass involved cecal wall of
appendix was found, and an right colectomy was perfomed. The
final pathologic diagnosis was atypical mucinous cystadenoma
consistent with borderline mucinous neoplasm with inflammation.
The patient was discharged at 10th post-operated day without
any complications.
P014 ZION E ( A LTA ) I N JEC TI O N TH E R A P Y F O R
HEMORRHOID & PROLAPSE ZIONE: A NOVEL SCLEROSING
AGENT OF ALUMINUM POTASSIUM SULFATE AND TANNIC
ACID(ALTA) FOR HEMORRHOID AND PROLAPSE, Mitsuyo
Kosugi MD, Takashi Ono, Toshiro Ono, Chief of Proctology Center,
Saitoh Clinic, Toyama, Japan
The ZIONE (ALTA) is a novel sclerosing agent, and ALTA Injection
therapy for prolapsed internal hemorrhoid shows good results
compared with surgery, Milligan-Morgan hemorrhoidectomy.
What is ALTA? The ALTA is a novel sclerosing agent with aluminum
potassium sulfate and tannic acid and an abbreviation of it as
active components, which was the Xiaozhiling in China researched
and modified by Mitsubishi Tanabe Pharma. Corporation, Japan.
Mechanism and Fundamental Examination of OC-108, ALTAThe
main component, aluminum injection into hemorrhoids controls
bleeding by reducing blood flow and induces acute inflammation.
Repairing reactions post-inflammation scleroses hemorrhoids
and resolves prolapsed hemorrhoids. Tannic acid inhibits excess
acute inflammation induced by aluminum potassium sulfate, and
reduces secondary tissue injury. Fundamental studies in rats by
microscopic observation show that all blood flow arrest within 10
minutes and without conspicuous change in blood vessel diameter
by OC-108 (phase III protocol solution of ALTA). And repairing
reactions post-inflammation shows that formation of fibrosis and
epithelioid granuloma in hist-pathological examination. Methods
P016
ZIONE
(ALTA)
INJECTION
THERAPY
FOR
HEMORRHOID & PROLAPSE: OUTCOME OF SCLEROSING
THERAPY BY THE ALTA INJECTION: PHASE III PROTOCOL
AND POST-MARKETING SURVEILLANCE (PMS), Mitsuyo
Kosugi MD, Hiroyuki Irie, Toshihiro Ono, Takashi Ono, Chief of
Proctology Center, Saitoh Clinic, Toyama, Japan
Phase III Protocol and Post-Marketing Surveillance (PMS): We show
the outcome of sclerosing therapy by the OC-108 (clinical study
solution of ALTA for Phase III Protocol) and PMS of ALTA after 3
years marketing in Japan. Phase III Protocol: Aims: Patients with
prolapsed internal hemorrhoids were treated with OC-108 and
results were compared with surgery. Objectives: Patients were
studied by OC-108(n=105) and surgery group (n=87) during Oct.
2000-Oct. 2002 by totally 16 coloproctology surgeons in Japan.
Results and Conclusion: 1) OC-108 was effective for bleeding
at defecation early after treatment. 2) The recurrence rate 1 year
after treatment was 16% (12/73 OC-108 group). 3) Hospital stay
(mean) was 3.6 days, shorter than 10.9 days in surgery group. 4)
Some adverse reactions occurred in 19%in OC-108 group. PMS:
Objectives and Surveillance: Patients(n=2500) with prolapsed
internal hemorrhoids, treated by ALTA Injection were surveyed by
central registration and prospective method during March, 2005 to
March, 2007 at Pharmacovigilance & Quality Assurance Division
of Pharmacovigilance Department, Mitsubishi Tanabe Pharma
Corporation. Injection Dose: Injection dose was <=20mL (64%),
ISUCRS XXII BIENNIAL CONGRESS ABSTRACT BOOK
Poster Papers
<=40mL (34%) for second degree (24%), third degree (67%), forth
degree (7.6%) hemorrhoid in Goligher classification. Results and
Conclusion: 1) ALTA injection was effective for prolapse in 98.2%
at evaluation time of 28 days after injection. 2) The recurrence rate
more than 2 years after treatment was 5.6% (2/36 in the second
degree), 17.3% (26/156 in the third and forth degree) and totally
15% (28/192). 3) Appearance rate of adverse reactions occurred
in 10. 25% (462cases in 337/3287). Summary: Sclerosing therapy
with ALTA Injection was evaluated, effective and useful treatment
in patients with prolapsed internal hemorrhoids to a similar extent
as surgery. It is spreading in nationwide in Japan as an important
treatment for hemorrhoids and used for more than fifty thousand
cases.
P017 INCIDENCE OF RECTAL PROLAPSE AND OUR
EXPERIENCE IN DELORME’S OPERATION, Dr. Ponniah
Sivalingam MS, Dr. K. S. Mayilvaganan MS, Dr. . Vadamalayan
Sivalingam MD, Dr. Sabaretnam Mayilvaganan MS, Governmet
Rajaji Hospital and Vadamalayan Hospitals, Madurai, India
Many operative procedures were reported for the treatment of
rectal prolapse which perhaps indicated unsatisfactory result.
Search is on for a better one. The experience with 111 operations
performed with Delorme’s surgical technique is presented here.
Between January 1983 and September 2007, 214 patients reported
with complete rectal prolapse at Govt. Rajaji Hospital and as private
patients of authors. One hundred and thirty six patients were
below 41yrs. The youngest patient was girl of 12yrs and oldest
a woman 85yrs. Male/ Female ration was 3: 1. All 214 patients
presented with a complaint of mass protruding through the anus.
Mucous discharge was present in 50 (23. 36%) bloody discharge
in 47 (21. 9%) pruritus ani in 20 (12. 1%) and constipation in 12
(5. 6%). Of these141 patients were operated, 111 Delorme and 28
per abdomen (Roscoe - Grahams Repair 24: Charles Wells Ivalon
sponge technique -4) and perineal rectosigmoidectomy -2. Of 111
cases operated by Delorme’s procedure, 77 patients were below
41years. Pre operation preparation surgical technique and post
operative care will be discussed. Post operative complications
were encountered in 18 out of 111 operated cases. Two had
secondary haemorrhage and four had infection (Collection of pus
in the submucous plane of rectum). In 6 cases there was gross
stenosis. Recurrence has occurred in 6 cases. Discussion: In our
series the occurrence of complete rectal prolapse in males versus
females was 3. 4: 1 which is in fair contrast to Western reports of
1: 6. In the Western countries prolapse rectum is a disease of the
old in the 6th decade, where as we found 63. 6 our patient below
40yrs. Constipation, a common symptom in western reports was
present only in 12 cases (5. 6%) of our cases. Delorme’s operation
is a simple procedure, which gives comparable results as of
abdominal operations advised for prolapse. Presacral dissection to
mobilize the rectum from the sacral curvature either per abdomen
or by perineal route may cause damage to the nerves resulting
in bladder and sexual dysfunction. Conclusion: The incidence
of prolapse is more in male, it occur more in the younger age
(below 40 years) and so a surgery which does not require the pre
sacral dissection is more desirable. Constipation associated with
prolapse is only 5. 6% of cases.
P018 PERIPARTUM DIVERTICULITIS- A HORMONAL
CAUSE?, E D Wietfeldt MD, Jan Rakinic MD, Southern Illinois
University Dept. of Surgery, Section of Colorectal Surgery
Question: Colonic diverticulitis is uncommon in the peripartum
period, with fewer than five cases reported in the English
literature. Therefore, when we were faced with this problem
twice in the same patient, questions were raised about possible
causes and safest therapy. Our patient had two episodes of
uncomplicated diverticulitis during two separate peripartum
periods, but has not had any related symptoms at any other time.
This raised questions about the possible effects of pregnancy on
diverticulosis. Constipation is a common complaint during late
pregnancy. Female sex hormones exert significant influence on
intestinal function. Fluctuations in intestinal transit time (TT)
can be related to the human menstrual cycle. The longest TT is
shown to be during the luteal phase, when progesterone is high,
as it is during pregnancy. Progesterone decreases colonic muscle
contraction by a regulatory effect on G proteins. When treated in
vitro with progesterone, normal human colonic myocytes exhibit
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down-regulation of the contractile G-alpha q and G-alpha i proteins
and up-regulation of G-alpha s proteins which mediate relaxation.
Overexpression of progesterone receptors appears to be a key
component. This is similar to observations in women with chronic
constipation. The oxytocin-mediated inhibition of colonic muscle
contraction in the rabbit colon via generation of nitric oxide is
also potentiated by progesterone. We postulate that the effects
of both progesterone and oxytocin may contribute to increased
constipation during pregnancy and the peripartum period. With
an increasing number of women bearing children in their 40s,
we postulate that this could lead to an increased, although still
small, incidence of diverticulitis in the peripartum period. We
urge physicians to include this entity in the differential diagnosis
when evaluating peripartum women with lower abdominal
pain. We also urge proper fluid intake and fiber supplements in
pregnant women in an attempt to keep the diverticulitis risk from
constipation at a minimum.
P019 RECTAL PROLAPSE TREATMENT - THE CHOICE OF
TECHNIQUE, Bruno Roche MD, Karel Skala MD, Guillaume
Zufferey MD, Joan Robert-Yap MD, Unit of Proctology, University
Hospital of Geneva
Introduction: Over 160 different procedures have been described
to treat rectal prolapse. Recent studies favor anterior fixation over
simple posterior rectopexy. In our institution the gold standard
operation consists of a laparoscopic posterior dissection with
simple suture fixation of the rectum. From January 2003 to
December 2006 we performed a comparative randomized study
between posterior rectopexy without mesh (PR) and anterior
mesh promonto-fixation (AMP). Inclusion criteria: patient consent
to participate in the study, female with total rectal wall perineal
prolapse, clinical signs and defecography or MRI imaging.
Exclusion criteria were recurrent prolapse, emergency situations,
associated utero-vaginal prolapse and/or bladder prolapse.
Material and Methods: We included 53 patients in group
PR, median age 69. 2 y (34-94) and 53 patients in group AMP,
median age 69. 4 y (20-96). 26 patients in PR and 27 in AMP had
a previous hysterectomy. Results: Median operative time was
94min for PR and 132min for AMP with a difference of 38 min.
Surgical approach was open in 2 patients PR and 6 patients in
AMP; laparoscopy for the other procedures. Conversion rate was
1 per group. Complications- PR (1. 9%): 1 bleeding of the presacral
veins with conversion, AMR (5. 7%): 1 parietal haematoma, 1
anterior rectal perforation with re-operation on day 2 (Hartmann),
1 small gut laceration with peritonitis and re-operation on day 1.
Recurrences at one year after the procedure were 1 in PR, and 2
in AMP. Conclusion: Simple rectopexy (PR) with sutures is a safe
and quick procedure. Complications are rare (1. 9%), with no reoperations. Promontofixation (AMP) leads to a longer operating
time and more complications (5. 7%) with 2 re-operations. There
is no need for a mesh when not indicated.
Colorectal Cancer
P020 HYPERPLASTIC POLYPS OF THE RIGHT AND LEFT
SIDE OF THE COLON: IS THERE A DIFFERENCE IN THE
MOLECULAR PATHWAY?, M Oviedo MD, J Carrozzo MD, M
Cruz-Correa MD, Dana Sands MD, E Weiss MD, J Nogueras MD, S
Wexner MD, M Berho MD, Cleveland Clinic Florida
Introduction: DNA hypermethylation is described in SA and
sporadic MSI-H CRC. DNA hypermethylation translates in loss
of expression of the MLH gene protein product. This alteration
may occur in HP although its frequency is unknown. Although
no malignant potential has been ascribed to HP there is some
evidence that on occasion these “innocent” polyps could be
the precursors to adenocarcinoma. Objectives: The purpose of
this study was to compare the differential expression of a set of
morphological and immunohistochemical properties between
HP polyps of the right and left side. Material and Method: 75
patients with hyperplastic polyps, diagnosed between 2005 2006 were selected retrospectively from a pathology database.
The polyps were divided according to the location into right
and left side of the colon. The following histomorphological
parameters were recorded: size, thickness, serration, dilatation,
basal membrane thickness, nuclear stratification, goblet cell,
nuclear atypia and apoptosis. Paraffin blocks were cut and
71
ABSTRACT BOOK
Poster Papers
stained by immunohistochemical techniques for hMLH1 and
hMSH2, CEA and Ki 67. Results: A total of 99 polyps were
obtained. The average age was 59. 5 years and a mean of 1. 45
polyps per patients. Right-sided polyps have increased thickness
more glandular dilatation and more nuclear stratification when
compared to left sided polyps. There was no difference noted
for either intensity or distribution when samples were stained
by any of the functional markers. Conclusion: Right and Left
sided HP are distinguishable on basis of morphological features
identified through examination of routine diagnostic slides but
do not differ with respect to potential functional markers usually
associated with malignant neoplasms suggesting that when strict
morphological criteria are applied right sided hyperplastic polyps
may not be different from left side polyps.
P021 NEO-ADJUVANT RADIOTHERAPY FOR LOCALLY
ADVANCED RECTAL CANCER: DOES IMRT(INTENSITY
MODULATED RADIATION THERAPY) IMPROVE OUTCOMES
AS COMPARED TO 3-D CONFORMAL RADIOTHERAPY?,
Hao Wang MD, Bashar Safar MD, Steven D Wexner MD, Badma
Bashankaev MD, Dana Sands MD, Juan Nogueras MD, Eric Weiss
MD, Mariana Berho MD, Christopher Chen MD, Cleveland Clinic
Florida
Purpose: Neoadjuvant radiotherapy may adversely affect anal
function after restorative proctectomy or low anterior resection.
The recently developed IMRT technique applies more fields than
traditional 3D technique. It delivers the same radiation dose to the
rectal cancer and pelvis and spares the adjacent organs, mainly
small bowel and bladder. The aim of this study is to investigate
whether IMRT has any sphincter sparing effects in addition to its
other advantages. Methods: From 1998 to 2007, patients with
primary rectal carcinoma and standard neoadjuvant therapy were
identified. The neoadjuvant therapy consisted of a total dose of
50. 4Gy of radiation and 5-Fu based chemotherapy. The tumor
regression grade(TRG) was identified by reviewing postoperative
pathological slides(TRG1-5: TRG1 = complete pathological
response and TRG5 = no response). The anal function was
assessed for the cases with coloanal anastomosis by the
Cleveland Clinic Florida Fecal Incontinence Score(CCF - FIS) and
evacuation parameters by telephone questionnaire. Statistical
analysis was performed using Mann-Whitney Test and Student’s
T-test. Results: A total of 114 patients were identified including
33 cases in the IMRT group (starting from 2003) and 81 cases in
the 3D group. There were no significant differences in either TRG
(P=0. 785, n=114) or in lymph node harvest between the IMRT
and 3D groups (P=0. 475, n=64). Forty-four patients (16 cases in
IMRT group and 28 cases in 3D group) answered the anal function
questionnaire with a mean follow-up of 17months (range, 2-52).
The follow-ups between two groups were similar (P=0. 640).
There were no significant differences in either fecal incontinence
scores (P=0. 293) or evacuation scores (P=0. 293). IMRT resulted in
less alteration in life style (component of FIS) compared with 3D
(P=0. 038) and was also associated with tendency to have fewer
bowel movements (P=0. 057), which may indicate better small
bowel function. Conclusions: IMRT had similar therapeutic
outcomes as 3D. Moreover, IMRT had minimal advantage over 3D
with respect to anal sphincter preservation and function. Further
prospective research is warranted.
P022 DIFFERENTIAL EXPRESSION OF MLH1 AND MSH2
PRODUCTS IN ADENOCARCINOMAS OF THE LEFT AND
RIGHT COLON, M Oviedo MD, R Mather MD, H Wang MD, D
Sands MD, E Weiss MD, S Wexner MD, J Nogueras MD, M Berho
MD, Cleveland Clinic Florida
Mucinous adenocarcinoma (MA) is a histologic subtype of
colorectal carcinoma characterized by pools of extracellular mucin
representing more than 50 % of the tumor body. It accounts for
10 to 15% of colorectal carcinomas and appears to occur more
often in the right colon and rectum than other parts of the colon.
Mucinous carcinomas are commonly seen in hereditary nonpolyposis colorectal cancer (HNPCC) associated tumors as well as
in sporadic colorectal neoplasms showing microsatellite instability
(MSI). The hallmarks of HNPCC are abnormalities in the mismatch
repair gene products MLH and MSH and others. Expression of
these proteins and underlying molecular pathways in mucinous
carcinomas that occur outside the setting of HNPCC has not been
72
ISUCRS XXII BIENNIAL CONGRESS clearly defined. Aim: To evaluate the differential expression of
MLH1 and MSH2 products in adenocarcinomas of the left and
right colon. Material and Methods: After IRB approval, 45
consecutive patients with mucinous carcinomas were identified
retrospectively from a pathology database. Twenty-three cases
correspond to the right colon and 22 cases from the left colon.
Paraffin blocks were selected and stain with antibodies against
MLH and MSH. Results were being scored as positive, negative or
equivocal. Cases with negative or equivocal were evaluated for,
BRAF-1 mutation and hypermethylation of the MLH1 promoter.
Patients fulfilling criteria for FAP and HNPCC were excluded.
Results: Females represented 51. 1 % of the cases. The mean
age was 57 years in the group from the right sided tumors and 67
years in the patients from the left (p< 0. 02). Pathological TN stage
was not significant different between right and left side tumors.
All tumors stained with MSH. Overall, MLH1 protein expression
was absent in 14 of 45 carcinomas (31. 1%), 8 from the right and 6
from the left colon, five of the 8 right side tumors (62. 5 %) and 1/6
cases (16. 6%) of the left side tumors showed hypermethylation
of the MHL promoter and BRAF mutation. Conclusion: Loss of
MLH expression was not significantly different in right vs left side
tumors; however hypermethylation of the MLH promoter and
Braf-1 mutation appears to be more common in right side lesions
compared to the left side tumors. Although the significance of this
finding is unclear, the possibility of different molecular pathways
between right and left side lesions that result in loss of MLH
expression needs to be considered.
P023 EFFICIENCY OF SENTINEL LYMPH NODE BIOPSY FOR
ULTRA-STAGING OF COLORECTAL CANCER PATIENTS,
Masayoshi Miyoshi MD, Yojiro Hashiguchi MD, Hideki Ueno MD,
Yoshiki Kajiwara MD, Hidetaka Mochizuki MD, Surgery 1, National
Purpose: Accurate staging of colorectal cancer patients is
prognostically and therapeutically important to identify those
patients who would most benefit from adjuvant chemotherapy.
Lymphatic mapping and sentinel node analysis enable a focused
review of the lymph nodes which are most likely to harbor
metastases. It may be feasible to apply ultra-staging techniques,
such as immunohistochemistry to sentinel lymph node (SLN).
The aim of this study is to evaluate efficiency of sentinel
lymph node biopsy (SLNB) to detect nodal micrometastases of
colorectal cancer. Methods: Between 2000 and 2004, twentyseven colorectal cancer patients who underwent curative surgery
and SLNB, were diagnosed as no nodal metastasis based on
hematoxylin-eosin stained specimen. A total of 624 lymph nodes
from the 27 patients were examined to detect micrometastases
by immunohistochemistry. About SLNB, Indian ink was injected
intraoperatively to 3 patients, and 99mTc Tin colloid was injected
20-24 hours before operation to 24 patients. Five 4-micrometerthick serial sections were obtained from each lymph node.
One section was stained using the hematoxylin-eosin method
for routine histopathological examination and the other four
sections further stained for AE1/AE3 anti-cytokeratin antibodies.
We defined micrometastases as metastases not detectable by
routine histological examination with hematoxylin-eosin staining
but detected by immunohistochemistry evaluation with AE1/AE3.
Results: There were 15 colon cancer patients and 12 rectal cancer
patients. A total of 98 SLNs were harvested (3. 6 SLNs per a patient).
Micrometastases were detected by immunohistochemistry in 8
lymph nodes (8/623, 1. 3%) from 6 patients (6/27, 22. 2%). Of all 8
micrometastatic lymph nodes, 7 nodes were SLNs and one was
non SLN (87. 5% vs. 12. 5%, p=0. 010). Conclusions: Majority
of micrometastatic lymph nodes were included to SLNs. SLNB
may be a useful technique to efficiently detect micrometastases
for ultra-staging of colorectal cancer.
P024 INTERSPHINCTERIC RESECTION WITH QUADRANT
RESECTION OF UPPER EXTERNAL SPHINCTER IN CASES
OF THE VERY LOW RECTAL CANCER, Nahmgun Oh PhD,
Hyuk-Jae Jung MD, Hyunsung Kim MD, Department of Surgery,
Pusan National University Hospital, Busan, South Korea
Purpose: In the treatment of rectal cancer, sphincter saving
operation is increased but low anterior resection is limited in
treatment for low rectal cancer situated below 4cm from the
ABSTRACT BOOK
Poster Papers
anal verge. In other reports intersphincteric resection for T2
cancer can allow an oncologically safe resection margin and
have good functional results in very low rectal cancer. The
purpose of this study is to evaluate the morbidity, mortality,
oncological and functional results of intersphincteric resection for
T2 and T3 rectal cancer situated below 4cm from the anal verge.
Methods: Between 2000 and 2004, 62 patients (mean age 52
years, range 34-74) with adenocarcinoma of the rectum underwent
abdomino-intersphincteric resection with a colonic J-pouch and
diverting ileostomy. After preoperative radiochemotherapy,
patient with overt T2 lesion was 24 cases and received traditional
intersphincteric resection (Group I: simple intersphincteric
resection), and patient with borderline cases or T3 lesion was
38 cases and received extended intersphincteric resection with
quadrant resection of upper external sphincter and primary repair
of the external sphincter(Group II: extended intersphincteric
resection). Results: The mean distance between the tumor and
anal verge was 3. 4 (range 2. 4-4. 0) cm. Over 3mm lateral surgical
margin was 79. 1%, 84. 2% of Group I and II. 1 case of inferolateral
recurrence(4. 0%) was occurred in Group I and 1 case of pelvic
recurrence(2. 6%) in Group II. Systemic recurrence was 2 cases(8.
3%), 3 cases(7. 9%) in Group I and II. Perineal wound infection
was 25. 0%, 26. 3%, and mild anastomotic stricture was 25. 0%,
26. 3% in Group I and II. The grade I, II of continence by Kirwan
classification was 83. 3%, 81. 5% in Group I and II. Under 3 times
stool frequency per day was 54. 2%, 63. 2% in Group I and II. There
was no postoperative mortality.
P025 OPTIMAL LIGATION LEVEL OF THE PRIMARY
FEEDING ARTERY AND BOWEL RESECTION MARGIN
IN COLON CANCER SURGERY: THE INFLUENCE OF THE
SITE OF THE PRIMARY FEEDING ARTERY, Jin-ichi Hida MD,
Takehito Yoshifuji MD, Fumiaki Sugiura MD, Masako Takemoto
MD, Takashi Hattori MD, Kazuki Ueda MD, Eizaburou Ishimaru
MD, Tadao Tokoro MD, Masayuki Yasutomi MD, Hitoshi Shiozaki
MD, Kiyotaka Okuno MD, Department of Surgery, Kinki University
School of Medicine, Osaka, Japan
Purpose: In colon cancer surgery, it is recommended that en bloc
resection involving extended lymphadenectomy, characterized as
a hemicolectomy, be performed by ligating the primary feeding
artery at a high position and resecting proximal and distal with
5-cm to 10-cm bowel margins. However, there is little evidence to
unequivocally support such extensive lymphovascular resection.
Methods: The distribution of nodal metastases was obtained by
the clearing method in 164 patients with colon cancer. Results:
For pericolic spread, for pT1 tumors, the distance from the primary
tumor to a diseased node was 2. 5cm; for pT2, the distance was
less than 5cm; for 97. 0% of pT3 tumors and 93. 3% of pT4 tumors
with nodes involved, the distance was less than 7cm. For central
spread, for pT1 tumors, the rate of spread to central nodes
was 0%; for pT2, the rate of spread was 20. 0% to intermediate
nodes (for tumors more than 5cm from the feeding artery, the
rate for central nodes was 0%); for pT3, the rate was 30. 6% to
intermediate nodes and 15. 3% to main nodes; for pT4, the rate
was 44. 4 % to intermediate nodes and 22. 2% to main nodes. For
curative resection cases with pT3 tumors more than 7cm from the
feeding artery, the rate to central nodes was 0%. Conclusions: In
T1 tumors, central node dissection is not required, but resection
with proximal and distal 3-cm margins are required; in T2, central
node dissection that includes the intermediate node should be
performed in addition to resection with proximal and distal 5-cm
margins. In T3 and T4, central node dissection that includes the
main node should be performed in addition to resection with
proximal and distal 7-cm margins. However, for T2 more than
5cm from the primary feeding artery, and for T3 more than 7cm
from the primary feeding artery, proximal and distal resection
alone may be adequate.
P026 VALUE OF INTRAOPERATIVE SENTINEL MAPPING,
Krasimir Ivanov MSc, Valentin Ignatov PhD, Nikola Kolev PhD,
Anton Tonev MD, University Hospital “St. Marina”, Medical
University - Varna, Bulgaria
Background/Aims: The presence of metastasis is the most
important prognostic factor for the patients with colorectal cancer.
In about 30% of those without metastases which have been
radically operated recurrences are observed and these patients die
www.isucrs.org/
from cancer. This requires improvement of the surgical methods
as well as a more accurate determination of the indications for
adjuvant chemotherapy administration. Material and Method:
Between August 2004 and April 2007 we assigned 472 consecutive
patients with colorectal cancer. We applied routinely the method
intraoperative sentinel mapping in 336 patients that intraoperavely
was evaluated as I and II clinical stage. We used the dying method
with Patent Blue V. An algorithm, proposed and applied by us
was worked out for the entire group of patients. Results: The 159
men and 177 women had a median age of 62 years. Localization
was spread as 172 patients with colon carcinoma and 164 with
rectum carcinoma. The median number of SNs and total lymph
nodes examined were 3 and 14. 5, respectively. The sensitivity
of lymphatic mapping and SN analysis was 97% and the falsenegative rate was 3%. We increased the volume of the surgical
intervention in 24 (7%) of the patients and upstaged 37 (11%) of
patients by means of ultrastaging with immunohistochemistry.
We followed a group 152 patients for a period of 2 year with
recurrence incidence of 47 (14 %) of the patients. Conclusions:
Intraoperative sentinel lymph node mapping in colorectal cancer
is a diagnostic method which is convenient for the surgeons
allowing them for an individualized approach toward each patient.
The method shows good results and has its own significance for
decreasing the recurrence rate and eventually increasing the
survival rate in patients with colorectal cancer.
P027
HEPATIC LYMPH
NODE
INVOLVEMENT
IN
PATIENTS WITH SYNCHRONOUS LIVER METASTASIS
OF COLORECTAL CANCER, Keiichiro Ishibashi PhD, Kouki
Kuwabara MD, Masatsugu Ishii MD, Toru Ishiguro MD, Tomonori
Ohsawa PhD, Norimichi Okada PhD, Masaru Yokoyama PhD,
Tatsuya Miyazaki PhD, Moriyuki Matsuki PhD, Hideyuki Ishida
PhD, Department of Digestive Tract and General Surgery, Saitama
medical Center, Saitama Medical University
Background and Purpose: This study was performed to examine
the status of hepatic lymph node metastasis in patients with
synchronous liver metastasis of colorectal cancer, and to consider
the significanceof the presence of metastasis in the treatment of
those patients. Patients and Methods: Hepatic lymph nodes
were removed from 61 patients (17: resectable, 44: unresectable)
with synchronous liver metastases of colorectal cancer during
resection of the primary tumor. The relationships between
the incidence of hepatic lymph node metastases and various
clinicopathological factors and overall survival were examined.
Results: Hepatic lymph node metastasis was detected in three
patients (18%) with resectable lesions and 13 patients (30%) with
unresectable lesions. For the resectable cases, the serum level of
CA 19-9 (p<0. 01), and the numbers of lymph node metastasis of
the primary lesion (p=0. 08) were higher in patients with hepatic
lymph node metastases (n=3) than in those without (n=14). There
were no significant relationships between hepatic lymph nodes
metastasis and other clinicopathological factors. The median
overall survival for patients without metastasis was better than
that for patients with metastasis (43 months vs 11 months, p=0.
06). For the unresectable cases, the serum level of CEA (p=0. 08)
was higher in those with than in those without (n=31). The median
overall survival for patients without metastasis was better than
that for patients with metastasis (16 months vs 8 months, p=0. 04).
There were no significant relationships between hepatic lymph
nodes metastases and other clinicopathological factors, including
the volume of liver metastases. Conclusion: The incidence of
hepatic lymph node metastases should be considered in selecting
the optimal treatment of liver metastases of colorectal cancer,
regardless of the respectability of hepatic lesions.
P028 SPHINCTER PRESERVING SURGERY IN PATIENTS
WITH RECTAL CANCER LOCATED WITHIN LESS THAN 3
CM OF THE ANAL VERGE, S. -C. Park MD, D. -W. Kim MD, S. -Y.
Jeong MD, J. -G. Park MD, Department of Surgery, Seoul National
University Hospital, Seoul, Korea
Aims: To evaluate the current status of sphincter preservation
for distal rectal cancers located within less than 3 cm from the
anal verge. Methods: Between January 2001 and December
2007, 120 patients underwent surgery for primary rectal
adenocarcinoma located within less than 3 cm of the anal verge
at the Department of Surgery, Seoul National University Hospital
73
ABSTRACT BOOK
Poster Papers
and the Center for Colorectal Cancer, National Cancer Center
by single surgeon, J-G Park. Clinical data were retrospectively
reviewed, including pathologic stages, operation types, and
preoperative chemoradiotherapy (CRT). Results: Of 120 patients
with rectal cancers located within less than 3 cm of the anal
verge, 73 underwent preoperative CRT followed by surgery (CRT
group), and 47 underwent surgery first (non-CRT group). Overall
sphincter preservation rate was 38% (47/120 patients). In CRT
group, sphincter preservation was 51% (37/73) and non-CRT
group was 21% (10/47) (p = 0. 02). Operation types were transanal
excision (n=9), low anterior resection with double-stapled
anastomosis (n=2), low anterior resection with upper sphincter
excision and colo-anal anastomosis (n=27), low anterior resection
with intersphincteric resection and colo-anal anastomosis (n=9),
and abdominoperineal resection (n=72). Recent 3 years, the
sphincter preservation rate was 62% (31/50 patients). Combining
preoperative chemoradiation and low anterior or intersphincteric
resection with colo-anal anastomosis may contribute to increase
the sphincter preservation rate. But this retrospective study
is hard to analyze the effect of the each contributing factor for
sphincter preservation. Conclusion: During 7 years, overall
sphincter preservation rate was 38%, and recent 3 years the
sphincter preservation rate was 62% for the rectal cancer located
within less than 3cm from anal verge.
P029 OUTCOMES OF LATERAL LYMPH NODE DISSECTION
IN DUKES C LOW RECTAL CANCER, Harunobu Sato MD,
Koutarou Maeda MD, Tsunekazu Hanai MD, Yoshikazu Koide MD,
Hidetoshi Katsuno MD, Masuo Funabashi MD, Department of
Surgery, Fujita Health University
Purpose: This study was performed to identify patients
who benefit from lateral lymph node dissection (LND) for
Dukes C low rectal carcinoma according to the number,
the side and the site of positive lateral node (PLN).
Patients and Methods: The study comprised 146 patients with
Dukes C low rectal carcinoma undergoing LND. Three parts of
lymph nodes, area A, B and C, were dissected for grade T2 or
more advanced tumors. The area A is corresponding to TME area.
The dissection of area B (the space between autonomic nerve and
internal iliac artery) and C (the obturator space) was defined as
LND. The patients were retrospectively divided into two groups;
patients without PLN (group I) and patients with PLN (group II).
Furthermore, group II was subdivided into two groups respectively
according to the number, the side and the site of PLN; group IIA1
(patients with less than 4 PLN) and group IIA2 (patients with more
than 4 PLN), group IIB1 (patients with PLN in unilaterally) and
group IIB2 (patients with PLN bilaterally), group IIC1 (patients with
PLN in either area B or area C) and group IIC2 (patients with PLN
in both area B and C). Clinical outcomes were studied in terms of
recurrence and prognosis. Results: Recurrence (RR) and 5-year
survival rate (5SR) were 37. 8% and 70. 3% in group I. RR rate
and 5SR were significantly worse in group IIA2 (100% and 0%)
than IIA1 (55. 8% and 46. 5%), in group IIB2 (93. 8% and 11. 2%)
than IIB1 (54. 2% and 45. 7%), and in group IIC2 (90. 9% and 11.
2%) than IIC1 (50% and 50. 7%). Group IIA2, IIB2 and IIC2 were
thought to be high risk groups for LR and poor prognosis. RR rate
and 5SR were 44. 7% and 54. 2% in patients who do not belong to
any high risk groups (group NR). Although RR rate and 5SR were
significantly better in group NR than in patients who belonged
to only one high risk group (92. 3% and 12. 3%), there were no
significant differences in RR and prognosis between group I and
NR. There was no 5-year survivor in patients who belonged to
equal to or more than two high risk groups. Conclusion: LND
for low rectal carcinoma was effective for patients with PLN in
patients who do not belonged in any high risk groups. However,
LND gave no survival benefit for patients who belonged to equal
to or more than two high risk groups.
P030 ANALYSIS OF REGIONAL LYMPH NODE METASTASES
FROM RECTAL CARCINOMA BY THE CLEARING METHOD:
JUSTIFICATION OF THE USE OF SIGMOID COLON IN
J-POUCH CONSTRUCTION AFTER LOW ANTERIOR
RESECTION, Jin-ichi Hida MD, Takehito Yoshifuji MD, Fumiaki
Sugiura MD, Masako Takemoto MD, Takashi Hattori MD, Kazuki
Ueda MD, Eizaburou Ishimaru MD, Tadao Tokoro MD, Masayuki
Yasutomi MD, Hitoshi Shiozaki MD, Kiyotaka Okuno MD,
74
ISUCRS XXII BIENNIAL CONGRESS Department of Surgery, Kinki University School of Medicine,
Osaka, Japan
Purpose: It has been reported that functional outcome following
low anterior resection of rectal cancer is improved by construction
of a colonic J-pouch compared with straight anastomosis. Hence,
we tried to justify use of the sigmoid colon in the construction
of a J-pouch by the analysis of regional lymph node metastases.
Methods: A total of 198 patients underwent resection for
rectal cancer. Node metastases were examined by the clearing
method. According to Japanese General Rules (JGR), nodes were
classified into the perirectal nodes (PR-N), pericolic nodes (PC-N),
central intermediate nodes (C-IM-N), central main nodes (C-M-N).
Results: Metastatic rate (number of patients with node
metastases/total number of patients) of PR-N was 56.
6%. Metastatic rate of C-IM-N was 19. 2% and that of
C-M-N was 8. 6%. Metastatic rate of PC-N was only 1. 0%.
Conclusions: In low anterior resection, high ligation of the
inferior mesenteric artery and dissection of C-M-N, C-IM-N and
PR-N are necessary. Resection of sigmoid colon is not required,
and therefore, a J-pouch can be constructed using the sigmoid
colon.
P031 SHORT TERM RESULTS OF LOWER RECTAL CANCER
ACCORDING TO PROCEDURE, Toshimasa Ishii MD, Shigeki
Yamagutchi MD, Jo Tashiro MD, Takahiro Sato MD, Syutarou
Ozawa MD, Yoshihide Otani MD, Isamu Koyama MD, Saitama
Medical University International Medical Center
Purpose: Since April 2007 of hospital opening, we tried to perform
intersphincteric resection (ISR) and laparoscopic resection (Lap)
for lower rectal cancer. This study was assessed short term results
for recent 10 months. Patients: Nineteen patients of curative
lower rectal cancer resection were included in this study. There
are 13 males and 6 females. Each number of procedure was; low
anterior resection (LAR) 6, ISR 5, Abdomino-perineal resection
(APR) 8. Five patients underwent lapraoscopic resection and
12 patients received lateral lymphadenectomy (LLA). All cases
of LAR and ISR had diverting stoma. Results: Mean operating
time, mean blood loss count, and mean postoperative hospital
stay were LAR 291min., 204g, 10. 8days, ISR 400min., 387g, 11.
4days, APR 332min., 501g, 19. 7days, respectively. Regarding
postoperative complication rates, anastomotic leakage, intestinal
obstruction, and wound infection were LAR 0%, 20%, 0%, ISR
0%, 20%, 0%, APR 0%, 22%, 33%. There were no difference of
postoperative complications between open and Lap in LAR and
ISR. However mean postoperative hospital stay and mean blood
loss count were 12. 2days, 419g in open and 10. 0days, 172g in
Lap. Lap was shorter hospital stay and less blood loss than open
resection. Conclusion: Short term results of ISR were similar to
that of LAR, and wound infection was seen more in APR. Lap was
less invasive than open resection concerning hospital stay.
P032 VARIOUS APPROACHES TO TREATMENT OF
PATIENTS WITH THE COMPLICATED CURRENT OF A
CANCER OF THE LEFT HALF OF LARGE INTESTINE. , S. V.
Vasilyev, D. E. Popov, A. V. Semenov, V. A. Kiselev, St. Petersburg
State Pavlov’s Medical University, Center of Coloproctology, St.
-Petersburg, Russia
The purpose. To estimate experience of surgical treatment
in patients with colorectal cancer complicated with intestinal
impassability. Materials and Methods: 240 patients with
obstructing left colonic and rectal cancer were operated in
period of last 5 years. All patients were divided into three
groups depending on the degree of expressiveness of
intestinal impassability: compensated, subcompensated and
decompensated. To all patients have been executed various
surgical interventions: diverting colostomy (laparoscopic
or from miniapproach) - 32; obstructive resection of large
intestine with a tumor - 115; subtotal colectomy - 21; primary
- reconstructive resections of large intestine with use of the
technique of intraoperative intestinal lavage - 72. Results:
Various complications were developed in 25%. Mortality has
made 3, 2%. In 95 cases (39, 6%) the intestinal continuity is
restored primarily. Anastomotic leakage was not in one case.
All patients with preliminary formed diverting stomas operated
in the scheduled order in two-four weeks. Conclusion: The
choice of operative intervention depends on localization of
ABSTRACT BOOK
Poster Papers
the tumor, prevalence of tumor process, the general condition
of the patient and degree of expressiveness of intestinal
impassability. Use of the set for intraoperative irrigation of
large intestine, which realization occupies about 20-50 minutes,
relieves of necessity to provide any multistep surgeries.
P033 STANDARDIZED LAPAROSCOPIC INTRACORPOREAL
RIGHT
COLECTOMY
FOR
CANCER:
SHORT-TERM
OUTCOME IN 111 UNSELECTED PATIENTS, A D Dippolito
MD, R Bergamaschi MD, Lehigh Valley Hospital, Allentown,
Pennsylvania
Objectives: This study was performed to evaluate the impact
of a standardized laparoscopic intracorporeal right colectomy
on short-term outcome of patients with neoplasia. Method:
Consecutive patients with histologically proven right colon
neoplasia underwent standardized laparoscopic intracorporeal
right colectomy with medial-to-lateral approach encompassing ten
sequential steps: 1) ligation of ileocolic vessels, 2) identification
of right ureter, 3) dissection along superior mesenteric vein, 4)
division of omentum, 5) division of right branch of middle colic
vessels, 6) transection of transverse colon, 7) mobilization of right
colon, 8) transection of terminal ileum, 9) ileocolic anastomosis,
10) delivery of specimen. Values were medians (range). Result:
From January 2002 to June 2005, 111 laparoscopic intracorporeal
right colectomies were attempted with a 5. 4% conversion rate.
57 women and 54 men aged 64. 9 (40-85) years had BMI 33 (2043), ASA score 2 (2-4), 36. 9% co-morbidities, and 37. 8% previous
abdominal surgery. Indication for surgery was cancer in 109
patients. Operative time was 120 (80-185) minutes. Estimated
blood loss was 69 (50-600) ml. Overall skin incision length was
66 (60-66) mm. 29 (2-41) lymph nodes were harvested. Length of
stay was 4 (2-30) days. Complication rate was 4. 5%. Conclusion:
Standardized laparoscopic intracorporeal right colectomy resulted
in favorable short-term outcome in unselected patients with
neoplasia of right colon.
P034 A CASE OF ASCENDING COLON CANCER IN A
PATIENT WITH HYPERPLASTIC POLYPOSIS OF THE
COLON, Kazuhito Sasaki MD, Giichiro Tsurita PhD, Shinsuke Saito
PhD, Hirokazu Tsuno PhD, Hirokazu Nagawa PhD, Department of
Surgical Oncology Graduate School of Medicine, The University
of Tokyo
Here, we report a case of ascending colon cancer, which was
suspected to be originated from hyperplastic polyposis, and
describe the genetic and histopathologic findings. The patient was
a 75-year-old man, without familial history of colonic diseases.
He had a past history of surgical treatments for appendicitis
and cholelithiasis. The colonoscopic examination at 55-year
age revealed no abnormalities. Complaining of abdominal pain
and diagnosed as anemy, he was introduced to our surgical
department for investigation. Colonoscopy revealed type 2 tumor
of the ascending colon, occupying all the luminal circumference.
The histopathology revealed well-differentiated adenocarcinoma.
Multiple hyperplastic polyps, as well as tubular and serrated
adenomas were found in the total colon. Distant metastases
were not found by CT. Subtotal colectomy and ileo-sigmoid
colon anastomosis was indicated, in an attempt to preserve the
anal sphincter function. The polyps of the remaining colon were
colonoscopically removed immediatly after the operation. The
removed specimes were genetically, immunohistochemically and
histopathologically analyzed, and will be presented.
P035 RETROSPECTIVE ANALYSIS OF PATIENTS TREATED
WITH CETUXIMAB PLUS FOLFIRI FOR PREVIOUS
IRINOTECAN COMBINED CHEMOTHERAPY IN METASTATIC
COLORECTAL CANCER, Park Jae Woo MD, Moon Sun-Mi MD,
Hwang Dae-Yong MD, Korea Cancer Center Hospital
Purpose: Many reports about the cetuximab efficacy of the
prolongation of survival rate has been published. Especially, the
combination of cetuximab and FOLFIRI has a high activity even
in prior irinotecan refractory mCRC. Beside small number of
patients, we would evaluated the efficacy and safty of cetuximab
combined with FOLFIRI prior irinotecan chemotherapy failure
patients. Methods: Retrospective analysis of 26 patients
treated with cetuximab with FOLFIRI from July 2006 to August
2007 was done. All patients were already treated wth FOLFIRI
www.isucrs.org/
chemotherapy in 1st line or 2nd line regimen for mCRC. Initial
dose of cetuximab 400 mg/m2 at 1st week and next 250 mg/m2
weekly plus FOLFIRI biweekly was done. We defined 1 cycle as 8
weeks and studies were performed at this week. Results: Median
follow-up period was 6. 2 (1. 1-13. 9) months. After 8 weeks, 50%
patients had partial response and disease control rate was 57.
5%. Median time to progression was 3 months. EGFR expression
and tumor response had no correlation (P=0. 07). Skin reaction
and tumor response(median time to progression) had significant
correlation (P=0. 022). cetuximab did not increase the toxicity
associated with FOLFIRI except acneiform rash. Conclusions:
Cetuximab combined with FOLFIRI chemotherapy was effective
in metastatic colorectal cancer, who progressed after FOLFIRI
regimen chemotherapy.
P036
INDICATIONS
FOR
COLONIC
J-POUCH
RECONSTRUCTION AFTER ANTERIOR RESECTION FOR
RECTAL CANCER: DETERMINING THE OPTIMUM LEVEL
OF ANASTOMOSIS, Jin-ichi Hida MD, Takehito Yoshifuji MD,
Osaka, Japan
Purpose: Functional outcome after anterior resection for rectal
cancer is improved by colonic J-pouch reconstruction compared
with straight anastomosis. The indications for colonic J-pouch
reconstruction have yet to be determined. Therefore, we
attempted to determine the level at which J-pouch reconstruction
provides an advantage over straight anastomosis. Methods:
A total of 48 patients who underwent 5-cm colonic J-pouch
reconstruction (J-pouch group) and 80 patients who underwent
straight anastomosis (straight group) underwent functional
assessment one year postoperatively. Results: The functional
outcome in the J-pouch group was significantly better than that
in the straight group when the distance of the anastomosis from
the anal verge was less than 8cm. The difference was particularly
obvious when the level of the anastomosis was below 4cm.
However, functional outcome in the straight group when the
anastomosis was between 9 and 12cm from the anal verge was
also satisfactory and did not differ from that in the J-pouch group
when the anastomosis was between 5 and 8cm from the anal
verge. Conclusions: Colonic J-pouch reconstruction is indicated
when the distance of anastomosis from the anal verge is less than
8cm, and it is essential when the distance is less than 4cm.
P037 EXAMINATION OF NODAL METASTASES BY
A CLEARING METHOD SUPPORTS PELVIC PLEXUS
PRESERVATION IN RECTAL CANCER SURGERY, Jin-ichi
Hida MD, Takehito Yoshifuji MD, Fumiaki Sugiura MD, Masako
Takemoto MD, Takashi Hattori MD, Kazuki Ueda MD, Eizaburou
Ishimaru MD, Tadao Tokoro MD, Masayuki Yasutomi MD, Hitoshi
Shiozaki MD, Kiyotaka Okuno MD, Department of Surgery, Kinki
University School of Medicine, Osaka, Japan
Purpose: In rectal cancer surgery preservation of urinary and
sexual function is attempted by means of operations preserving
the autonomic nerves of the pelvic plexus. Emergence of residual
cancer because of a more shallow plane of dissection is a problem
of concern with these methods, so we examined indications
for pelvic plexus preservation. Methods: We studied 198
patients with rectal carcinoma who underwent abdominopelvic
lymphadenectomy. Lymph nodes along the superior hemorrhoidal
artery and middle hemorrhoidal artery medial to the pelvic plexus
were defined as perirectal nodes, and nodes along the middle
hemorrhoidal artery lateral to the pelvic plexus and along the
internal iliac artery represented lateral intermediate nodes. Node
metastases were examined by the clearing method. Results:
Metastasis to perirectal nodes occurred in 12. 5% in patients
with pT1 tumors, 28. 9% of those with pT2 tomors, and 50. 0% of
those with rectosigmoid junctional cancer. Metastasis to lateral
intermediate nodes was absent in patients with pT1 or pT2 and
was as low as 2. 5% in patients with rectosimoid junctional cancer.
Conclusions: In patients with T1, T2, and rectosigmoid junctional
cancer, perirectal node dissection is necessary, but chances of
residual cancer should remain minimal when the pelvic plexus
is preserved.
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P038 PSEUDO-MEIG’S SYNDROME CAUSED BY OVARIAN
METASTASIS FROM COLORECTAL CANCER: REPORT OF
4 CASES AND REVIEW OF THE JAPANESE LITERATURE,
Masatsugu Ishii MD, Keiichiro Ishibashi PhD, Masaru Yokoyama
PhD, Kouki Kuwabara MD, Toru Ishiguro MD, Tomonori Ohsawa
MD, Norimichi Okada PhD, Tatsuya Miyazaki PhD, Moriyuki
Matsuki PhD, Hideyuki Ishida PhD, Department of Digestive Tract
and General Surgery, Saitama medical Center, Saitama Medical
University
Pseudo-Meig’s syndrome is characterized by rapid improvement
of ascites and hydrothorax, which is cured by removing ovarian
or pelvic tumors, with the exception of ovarian fibroma. However,
little is known about the characteristics of this syndrome
when caused by ovarian metastases of colorectal cancer. We
encountered four cases of pseudo-Meig’s syndrome caused by
ovarian metastasis of colorectal cancer, three of which have been
published elsewhere. Including our four cases, 17 cases were
collected from the Japanese literature (11 from articles, and 5 from
meeting abstracts, JMEDICINE: 1986-2007) and analyzed. Patient
ages ranged from 32 to 75 years, and the sites of the primary lesions
were cecum in one, the ascending colon in one, descending colon
in one, sigmoid colon in ten, and rectum is three. Histological
examination demonstrated well-differentiated adenocarcinoma
in seven, moderately differentiated adenocarcinoma in six, and
unknown in four. Hypothorax was found bilaterally in three
cases, right-sided in seven, left-sided in four, and unknown in
three. Ovarian metastasis was detected synchronously in ten and
metachronously in seven. Bilateral ovaries were involved in six,
right in five, and left in six. All patients underwent colectomy and
oophorectomy. Three-year survival rate after oophorectomy was
53%. Our findings indicate that surgical treatment for pseudoMeig’s syndrome caused by ovarian metastasis from colorectal
cancer can improve the prognosis.
P039 CARCINOSARCOMA OF THE COLON: A CASE
REPORT, Jung G Kang MD, Suh J Kim MD, Yoon J Choi* MD,
Department of Surgery and *Pathology, National Health Insurance
Corporation, Ilsan Hospital 1 Yonsei University
Introduction: Carcinosarcoma is a rare tumor that contains
malignant epithelial and mesenchymal element. It was usually
detected in the head and neck, the respiratory tract and the
female reproductive tract. Carcinosarcoma is a rare case in GI
tract, especially in colon and has very poor prognosis despite
massive treatment. Result: A 65 years old male patient admitted
to our surgical department because of abdominal pain for 1
year. Preoperative evaluations revealed far advanced colon
cancer involving the ascending colon and pneumoperitoneum
with ascites in right subhepatic space and perisplenic space,
suggesting panperitonitis on abdomen and pelvic cat scan and
plain X-ray film. Emergency right hemicolectomy was carried
out. At operation, the ascending colon showed a huge serosally
protruding mass. On opening, an ulcerofungating and annular
constrictive mass about 11x9cm was noted, which was 8cm apart
from the ileocecal valve. On microscopicc examination, the tumor
showed areas of poorly differentiated adenocarcinoma partly
covered by normal mucosa, and areas of pleomorphic giant
and short spindle cells favoring sarcomatous differentiation.
Conclusion: A carcinosarcoma is a rare malignant tumor in
colon, composed of mixed malignant epithelial and mesenchymal
cells, and also has poor prognosis. Early diagnosis and aggressive
managment of radical surgery with adjuvant chemotherapy and
close follow - up should be considered.
P040 QUALITY OF LIFE IN PATIENTS TREATED WITH
ABDOMINOPERINEAL
RESECTION
OR
ANTERIOR
RESECTION FOR RECTAL CANCER, Jin-ichi Hida MD,
Takehito Yoshifuji MD, Fumiaki Sugiura MD, Masako Takemoto
MD, Takashi Hattori MD, Kazuki Ueda MD, Eizaburou Ishimaru
MD, Tadao Tokoro MD, Masayuki Yasutomi MD, Hitoshi Shiozaki
MD, Kiyotaka Okuno MD, Department of Surgery, Kinki University
School of Medicine, Osaka, Japan
Purpose:
Patients with rectal cancer who undergo
abdominoperineal resection (APR) are physically burdened by
the presence of a permanent colostomy. We compared physical
conditions of patients treated by APR with those of patients
76
ISUCRS XXII BIENNIAL CONGRESS treated by anterior resection (sphincter-saving operation) and
found out whether the choice of operation technique had any
influence on their social and psychologic conditions. Methods:
Using a questionnaire, we compared the postoperative physical,
social, and psychologic conditions of 40 patients who underwent
APR with those of 116 patients who underwent anterior resection.
Results: Physical conditions in the APR group were significantly
worse than those in the anterior resection group. There were
no significant differences in social conditions between the two
groups, and social conditions were satisfactory in both groups.
However, the will to live in the APR group was significantly
less than that in the anterior resection group. Conclusions:
Although most patients who undergo APR return to their normal
level of social condition after surgery, their will to live is less
because of physical discomforts, including bowel dysfunction,
urinary dysfunction, and sexual dysfunction. The quality of life is
influenced by multiple factors, one of which may be the presence
of the colostomy.
P041 EFFECT OF PREOPERATIVE VERSUS POSTOPERATIVE
CHEMORADIOTHERAPY ON FUNCTIONAL OUTCOME
AFTER SURGERY FOR RECTAL CANCER, Alexis Grucela MD,
Roger Li BA, David B Chessin MD, Randolph M Steinhagen MD,
Mount Sinai Medical Center
Introduction: Until recently, the standard of care for stage
2 and 3 rectal cancer patients involved the administration of
postoperative chemoradiotherapy. However, in recent clinical
trials, preoperative chemoradiotherapy has been shown to result
in equal long term survival with the potential for better functional
results without an increase in perioperative complications.
Therefore, we evaluated our experience with chemoradiotherapy
and surgery for rectal cancer to evaluate functional results
and postoperative complications. Methods: We queried the
prospectively maintained surgical database to identify all patients
with rectal cancer treated between 1999-2007. Only those patients
whose surgery consisted of radical resection with curative intent
and reestablishment of intestinal continuity were included.
A comprehensive chart review of the included patients was
performed to evaluate the nature and frequency of postsurgical
complications. In addition, symptoms regarding bowel function
were recorded and a novel Bowel Dysfunction Score (BDS) was
calculated for each patient. Results: 43 consecutive patients
meeting the inclusion criteria were identified. Data concerning
the incidence of post-operative complications indicate that
preoperative chemoradiotherapy results in fewer complications
than does postoperative or no therapy. Preoperative patients had
an average of 0. 89 postsurgical complications, postoperative
patients had 1. 29, and patients with no therapy had 1. 2. Patients
that received neoadjuvant chemoradiation were found to
have a lower BDS than postoperative and no therapy patients.
Conclusion: Preoperative chemoradiotherapy results in fewer
postsurgical complications and leads to better bowel function
than postoperative chemoradiotherapy or no therapy. Combined
with equal long term survival, this adds additional evidence that
neoadjuvant therapy should be considered the standard of care
for the treatment of locally advanced rectal cancer.
P042 DIETARY CHANGE AND THE INCREASE OF
COLORECTAL CANCER IN KOREA AND JAPAN, Sun-Il Lee
MD, Jung-Myun Kwak MD, Dong-Jin Choi MD, Sung-Soo Kim MD,
Hwan-Soo Kim MD, Jun-Min Joe MD, Jin Kim MD, Byung-Wook
Min MD, Jun-Won Um MD, Seon-Hahn Kim MD, Hong-Young
Moon MD, Department of Surgery, Korea University College of
Medicine
Epidemiologic studies showed that colorectal cancer is related
to the dietary environment especially to meat consumption.
The change to westernized diet has been found in many Asian
countries including Korea and Japan, and it is supposed that the
dietary change would influence on the incidence of colorectal
cancer in these countries. In this study, we investigated the
change of meat and cereal consumptions and the change of colon
and rectal cancer between two countries. The consumptions of
meat and cereal in Japan (1950 to 2002) and Korea (1970 to 2003),
and the colorectal cancer incidences in Japan (1975 to 1998) and
Korea (1992 to 2002) were collected from the national published
data which were studied nationwide in those two countries. The
ABSTRACT BOOK
Poster Papers
age-adjusted incidences were compared with time differences.
Meat consumption had been increased about 2. 5 times during
1970 to 1980 and colorectal cancer had increased more than 2. 5
times during 1992 to 2002 in Korea. We found that the changes in
meat and cereal consumption as well as the increases in incidence
of colon and rectal cancer were similar in those two countries
with the 20 years of time difference. However, the increase of
rectal cancer in Korea especially for women was higher than that
of Japan, and further studies are required. The similarities and
differences between Korea and Japan could be helpful to predict
future colorectal cancer incidences for Korea and even for other
Asian countries.
with over-the-counter medications. They included hemorrhoidal
creams and supposiories, laxatives, medication for colitis and
intestinal amebiasis. In this group, patient delay mean average
was 31 weeks. (range 2 wees to 3 years). Conclusions: This study
showed that most patients presenting rectal cancer symptoms,
erroneously credited them to common colorectal diseases. Self
treatment resulted in a patient delay average of over 7 months.
Delayed diagnosis of rectal cancer has remained a world wide
constant for decades. The principal cause appears to be a lack
of knowledge in the meaning of rectal cancer symptoms. Health
education regarding rectal cancer, needs to be more emphasized
in the general population.
P043 EPIDEMIOLOGY OF COLON & RECTAL CANCER IN
IRAQ, Z. Al-Bahraini MD, Adil H Al-Humadi MD, State University
of New York at Buffalo and University of Baghdad, Iraq
Purpose: This study evaluates the descriptive epidemiology
and clinical aspects of colorectal cancer in the Iraqi population.
Method: Records of patients diagnosed with colorectal cancer
for a period of thirty years from 1965 to 1994 in Baghdad Medical
City Teaching Hospital were reviewed. The material was analyzed
retrospectively to study the epidemiological increase of cancer
of the colon and rectum in the Iraqi population. Results: There
were 511 patients diagnosed with colorectal cancer between
1965-1994. The male/female incidence was 1. 4/1 for colon cancer
and 1. 1/1. 0 for rectal cancer. The highest incidence was seen at
the median age of 50. A total of 21. 1 percent of patients were
younger than 40 years of age. The population of Iraq in 1993
was 19 million composed of 15. 5 million Arabs and 2. 5 million
Kurds with the incidence ratio of 6/1 for colon cancer and 5. 3/1 for
rectal cancer. The most common symptom was change in bowel
habits with obstructions for colon cancer (51%), rectal bleeding
and change in bowel habits for rectal cancer (71. 5%). The rectum
was the most common site 47% followed by the left colon and
sigmoid colon 27% and the right colon at 26%. The predisposing
factors related to adenomatous polyps 3%, familial polyps 5%
and ulcerative colitis 3%. Pathological classification was Duke’s
D lesion 56. 9%, Duke’s C leson 71. 3%, Duke’s B and Duke’s A
7%. Discussion: Comparatve studies in the Iraqi Cancer Registry
during the 30 year period (65-94) showed an increased incidence
of colorectal cancer from 25% to 50% and a decrease of gastic
cancer from 78% to 50%. The incidence of colorectal cancer in
Iraq is 2. 6% compared to 6-13% in the developed countries and
17-51. 1% in the industriaized nations. Conclusion: Iraq shares
the epidemiological characters of developing countries in the
Middle East. There is a shift towards the western-style of living
that has probably lead to the increase of colon and rectal cancer in
the Iraqi population. This increased incidence in colon and rectal
cancer coincides with the decreased incidence in gastric cancer.
The expected change in pattern of this disease in Iraq is probably
related to the rapid change in dietary habits.
P045 MALE URINARY DYSFUNCTION AFTER TOTAL
MESORECTAL EXCISION, Hideyuki Ike MD, Yoshiro Fujii
MD, Satoshi Hasegawa MD, Akio Ashida MD, Kenichi Matsuzu,
Saiseikai Yokohama City Nanbu Hospital
Purpose: To investigate urinary dysfunction after total mesorectal
excision using electric cautery for rectal cancer. Patients and
Methods: A total of 67 patients with lower rectal cancer who
underwent total mesorectal excision between April 2005 and
December 2007 at our department were included. Of these, 28
underwent low anterior resection, 10 Hartmannfs operation, and
29 abdomino-sacro-abdominal resection. Lateral lymphnode
metastases were found in 7 patients. Pelvic autonomic nerves
were completely preserved macroscopically during operation.
Post-operative urinary status was evaluated. Results: Average
age was 65 years, and number of male patients was 43 and female
was 24. Average operation time was 3 hours and 51minutes,
average blood loss was 353 ml and no patients received blood
transfusion. There was no patients who needed clean intermittent
catheterization, however 12 patients (17. 9%) received medicine
for urinary dysfunction. Urinary dysfunction was found in only
male patients. Incidence of urinary dysfunction according to the
operation were 14. 3% in low anterior resection, 20% in Hartmannfs
operation, and 20. 7% in abdomino-sacro-abdominal resection,
respectively. Conclusion: Urinary dysfunction may occur in male
patients with lower rectal cancer after total mesorectal excision
using electric cautery.
P044 PATIENTS DELAY IN THE DIAGNOSIS OF
SYMPTOMATIC RECTAL CANCER, Fidel Ruiz Healy MD,
Marta G Vargas Saldaña MD, Abel Jalife Montaño MD, Service of
Coloproctology, Dept. of Surgery, Centro Hospitalario “Sanatorio
Durango”, Mexico City, Mexico
Introduction: Despite modern diagnostic tools and protocols,
symptomatic patients with rectal cancer continue to delay
diagnosis. As a result, patients are treated during advance stages
of disease. Patients’ delay plays an important part in late diagnosis.
Methods: A retrospective chart review of patients with rectal
cancer was performed. Parameters include age, patient behavior
during initial symptoms, diagnosis, treatment and time from
onset of symptoms to a first visit to physician. Results: Forty
patients (m/f 24/16) of a mean age of 62. 3 (range, 27-90) years
were included. The most common symptom was rectal bleeding
(72. 5%). Other symptoms included rectal pain (30%), constipation
(7. 5%) and diarrhea (5%). Weight loss, rectal secretion and fecal
impaction were also reported. Several patients presented multiple
symptoms. Patients responded to symptoms in two ways. The first
group with three patients (7. 5%) went to a physician. Patient delay
mean average was 19 days. (range 4 - 35 days). The second group
with 37 patients (92. 5%) diagnosed thmselves as hemorrhoidal
diseases in 29, colitis in 3, intestinal amebiasis in 2, intestinal
constipation in 2 and anal fissure in 1 patient. Treatment consisted
www.isucrs.org/
P046 TOTAL PELVIC EXENTERATION FOR LOWER RECTAL
CARCINOMA ASSOCIATED WITH VON MEYANBURG
COMPLEX, Ryohei Watanabe MD, Y Saida MD, Y Nakamura MD,
T Enomoto MD, K Takabayashi MD, A Otsuji MD, M Katagiri MD,
S Nagao MD, S Kusachi MD, M Watanabe MD, J Nagao MD, Toho
University Ohashi Medical Ctnter Third Department of Surgery
Lower rectal carcinoma, as it has no serosa, often infiltrates
neighboring organs including seminal vesicle, prostate gland,
urinary bladder and vagina. In this study, we report a case of
rectal carcinoma with a suspicion of direct invasion to the prostate
gland and urinary bladder based on the preoperative imaging.
A 75-year-old male with chief complaint of melena came to our
clinic. Colonoscopy detected a circumferential type 2 lesion in
the lower rectum. Abdominal CT and MRI described the swelling
of regional lymph nodes (No. 251) and direct invasion to the
prostate and bladder as well as diffuse cystic lesion in the liver.
The cystic lesion was diagnosed as von Meyenburg complex,
which was to be examined by intraoperative biopsy. Preoperative
diagnosis was lower rectal cancer (Rb) with metastasis to other
organs (Ai: bladder and prostate), N0, H0, P0, M0; Stage Vb. The
patient was determined to undergo total pelvic exenteration
with lateral lymph node dissection, ileal conduit and stoma
creation on February 15 2007. Intraoperatively, white and yellow
nodules diffusing on the surface of the liver was observed. The
lateral segmental branch of the liver was biopsised, which was
diagnosed von Meyenbur complex by intraoperative pathology.
As H-factor is negative, we performed the operation mentioned
above. Intraoperative pathology revealed inflammatory episode
of the bladder and prostate that had been suspected to be direct
invasion according to preoperative CT and MRI. In addition, in
the prostate gland, small cancerous lesions of prostate were
observed. Postoperative diagnosis was A, N0, H0, P0, M0; Stage U
and the patient is alive with no recurrence for 12 months after the
surgery. In this case, adhesion and induration of rectal peripheral
tissue was remarkable so that en-bloc resection was applied to
improve curability. As von Meyenburg complex was difficult to
77
ABSTRACT BOOK
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distinguish from diffuse hepatic metastasis preoperatively, not
only preoperative MRI but also pathological diagnosis utilizing
intraoperative liver biopsy would be feasible.
P047
DISSEMINATED
METASTASIS
OF
OVARIAN
CARCINOMA IDENTIFIED THROUGH A SUBMUCOSAL
RECTAL TUMOR, Ayako Otsuji MD, Y Saida MD, Y Nakamura MD,
T Enomoto MD, K Takabayashi MD, R Watanabe MD, M Katagiri
MD, S Nagao MD, S Kusachi MD, M Watanabe MD, J Nagao MD,
Toho University Ohashi Medical Center, Third Department of
Surgery
In general, metastatic rate of ovarian cancer to large intestine is
about 30%. As large intestine neighbors to ovaries, it is not rare.
However, many cases of metastatic colorectal cancer especially
in cases of disseminated matastasis, have macroscopically
demonstrated nodular lesion on serosal surface and rubber
and focal hypertrophy on mucosal surface, and few cases have
demonstrated mucosal tumor and Type-1 or Type-2 tumor.
In this study, we report a case of colonoscopically detected
disseminated metastasis of ovarian carcinoma during the
examination of submucosal carcinoma in lower rectum. A female
patient in her late sixties was indicated positive occult blood
reaction at medical check -up. In addition, a surface smooth
subumucosal tumorous lesion was colonoscopically detected
in the rectum. It was diagnosed as adenocarcinoma by biopsy.
Under the suspection of rectal cancer, the patient was referred to
our hospital. Endoscopic Ultrasonography (EUS) demonstrated a
depressed image throughout all the layers. Abdominal Computed
Tomography (CT) and pelvic Magnetic Resonance Imaging
(MRI) described a 4x4x8cm tumor located in the right side of
lower rectum, which compressed rectum. In right ovary, there
was a solid tumor, 2cm in size. Tumor markers were high level;
Carbonhydrate antigen (CA) 19-9: 53. 4; CA125: 788, though
Carcinoembryonic Antigen (CEA) was in normal level. Based on
these results, although there could be a possibility of rectal cancer
and intrapelvic mass, we performed an open procedure under the
preoperative diagnosis of metastatic ovarian carcinoma of rectum.
Intraoperatively, a tumor 2cm in size was observed in right ovary.
Intraoperative pathology determined it was ovarian carcinoma.
In the omentum, many small nodular peritoneal disseminated
lesions were observed. So, we performed total hysterectomy,
birateral adnexectomy and omentectomy. Submucosal tumor in
lower rectum was identified as an erastic hard surface smooth
tumor 8cm in size, which located on the caudal to peritoneal
reflection and on extrinsically right rectal posterior wall. We
performed Hartmann’s operation with the inclusion of tumor.
The patient’s prognosis has been well and she has undergone
chemotherapy at gynecology department.
P048 NEO-ADJUVANT THERAPY FOR CANCER OF THE
LOWER RECTUM: LATE RESULTS: , jose a reis neto PhD, Jose
A Reis jr MD, Odorino Kagohara MD, Joaquim Simoes Neto MD,
Silvio A Ciquini, Sergio Banci, CRN, PUCCampinas
Aims: Pre-operative radiotherapy as adjuvant treatment for
cancer of the Lower Rectum, although recognized as effective
on controlling the interval-free of rectal cancer, has not been
utilized as frequently as expected. The objective of this trial is
to analyze the results of radiotherapy as adjuvant treatment
for Cancer of the Lower Rectum. Methodology: From
1978 to 2007, a total of 358 patients with rectal cancer were
submitted to preoperative radiotherapy. Only patients with rectal
adenocarcinoma situated in the lower rectum ( between the
pectinate line and 10 cm above it) classi-fied as TNM stages II and
III were included in this study. There was no gender, race and age
distinction. Preoperative radiotherapy was performed according
to the follow-ing scheme: 200 cGy / daily for 4 consecutive weeks
up to a total of 4000 cGy, by means of a Linear Megavoltage
Accelerator (25 MeV), in anterior and posterior pel-vic fields.
All patients were operated on after conclusion of the irradiation
according to tumor stage observed post-irradiation. According to
the anatomopathological finding on surgical specimen, patients
classified as TNM stages I received no further treat-ment; those
considered as stages II or III after surgery, were submitted to
adjuvant therapy (5FU and leucovorin - 8 cycles). Results: Of the
358 patients, 64, 5% were classified as TNM stage I at surgery.
Statis-tical analysis of the whole group showed that pre-operative
78
ISUCRS XXII BIENNIAL CONGRESS RDT does decrease the incidence of local recurrence: 3, 48 %.
Moreover, the frequency of undifferentiated cells diminished after
irradiation. Pre-operative RDT reduces tumoral volume and wall
invasion, as well as the mortality rate due to local recurrence (2,
43%) and alters long-term survival rate (80, 17%). Preoperative
radiotherapy is really effective in reducing the number of
undifferentiated cells and in diminishing the carcinomatous
infiltration of the rectal wall. Consequently local recurrence rate is
decreased and mortality due to local recurrence declines.
P049 GASTOROINTESTINAL STROMAL TUMOR(GIST) IN THE
COLON AND THE RECTUM CLINICAL CHARACTERISTICS
AND THERAPY IN SIX CASES, Toshihiro Fujita MD, Michio
Itabashi MD, Shingo Kameoka MD, Department of Surgery, Tokyo
Women’s University School of Medicine
Gastrointestinal stromal tumors (GIST) in the colon and rectum
are a relatively rare. We experience 6cases of GIST in the colon
and rectum between 1993 and 2008. There are four men and
two women with a median age of 53 years (range: 43-81)at the
diagnosisi. 4cases in the rectum, one in the sigmoid colon, one in the
retroperitoneum. The most frequent symptoms were abdominal
pain. The median tumor size was 6 centimeters(range: 3cm-20cm).
Two patients underwent abdominoperineal resection(APR), 1
underwent transanal endoscopic microsurgery(TEM)1 had a
resection of sigmoid colon. 4 patient received imatinib treatment
before or after operation. 2 cases having local recurrence or distant
metastasis, 48 months and 92 months after surgery, respectively.
The former died 63 months after the operation. one died of tumor
rupture 9 mounths after diagnosis. one died of other disease
1month after surgery. On the occasion of these six observations,
we will investigated the clinicopathologic characteristics of them.
Colorectal Emergencies
P050 SELF-EXPANDABLE METALIC STENT COLON AND
RECTUM, Y Saida MD, Y Nakamura MD, T Enomoto MD, K
Takabayashi MD, M Katagiri MD, S Nagao MD, S Kusachi, M
Watanabe MD, Y Sumiyama MD, J Nagao MD, Toho University
Ohashi Medical Center
Purpose: In the treatment of obstructive colorectal cancer,
we first should relieve ileus in the same time that we pursue
improvement of operative curability and safety when we could
perform the curative surgery. To avoid emergency operation and
stoma creation, and improvement of patients’ Egeneral condition,
we use self-Expandable Metallic Stent (EMS) placement. We report
the result of this therapy in our institution. Methods: Since 1993,
we have proactively performed EMS placement for the treatment
of obstructive colorectal cancer associated introducing a guide
wire under radiographic guidance and utilizing colonoscopy.
Results: A total of 116 patients underwent EMS placement
for colorectal stenosis during October 1993 and January 2008.
Those included 84 bridge to surgery cases, 28 palliative purpose
cases for unresectable malignant diseases and 5 anastomotic
stricture cases. The stent insertion was able to be successfully
performed in 108 cases (successful rate: 93%). Complications at
the time of insertion were; 3 perforation cases in sigmoid colon
(3%) and 2 migration in descending colon and rectum (2%). The
surgery enabled 98% of total case to EMS insertion of bridge to
surgery. The duration of preoperative EMS placement was 3-27
days (mean: 6. 7 days). Postoperative complications included
1 wound infection, 1 ileus, 1 abdominal abscess and 1 leakage.
These results are considered to be relatively favorable. The rate of
stoma creation after bridge to surgery insertion was 12%, which is
lower than the rate of 70% from the cases that EMS could not be
placed. Circumferentially obstructive colorectal cancer often gives
us difficult preoperative treatment, risk of contaminated operation
and the need for secondary operation. But EMS enables us to
obtain wider lumen to decrease the pressure of proximal intestine.
For palliative purpose, all patients ileus were released quickly. But
we have 10% of re-obstruction required re-stent. Conclusions:
To treat colonic obstruction, EMS placement therapy gives us
significant meanings in the improvement of surgical results due
to preoperative insertion, or the avoidance of excess invasion
and the improvement of patients’ EQOL in palliative treatment.
Therefore, we believe that this procedure should be more and
more employed and improved.
ABSTRACT BOOK
Poster Papers
P051 IS ONE-STAGE PROCEDURE IN THE EMERGENCY
LEFT COLECTOMY SAFE?, J. O Kim MD, S. K Kee MD, O.
K Kwon MD, S. Y Nam MD, Department of Surgery, Kumi Cha
Hospital, Pochon Cha University
Background: It is well known that the emergent left colon
surgery increases morbidity and mortality. The paradigms in
the surgical management of the emergent left colon surgery
like obstruction and perforation are changing. The aim of this
retrospective study is to define whether one stage colectomy
without intraoperative colon preparation and/or protecting stoma
is acceptable in low risk patients. Methods: From March 2006
to January 2008, the cases of a total 14 patients(5 men and 9
women) with a mean age of 66(18-91 years old) underwent the
emergency left colectomy. 6 cancer obstructions(2 descending
colons, 3 sigmoid colons, and 1 rectum), 4 cancer perforations(1
sigmoid and 3 recta), 2 sigmoid diverticualr perforations, and
2 sigmoid stercoral perforations were included. Results: 6
cancer obstruction patients and 5 perforation(3 cancers and 2
diverticulars) patients with localized peritonitis received resection
and anastomosis(2 hemicolectomies, 5 anterior resections, 2 low
anterior resections, and 2 segmental sigmoid resections) without
colonic irrigation and/or protecting stoma. These patients had
good general conditions and stable vital signs before surgery.
Malecot catheter was introduced per anus for decompression in
case of 3 sigmoid colon cancer and 1 rectal cancer obstructions. 1
total colectomy and ileorectal anastomosis(stercoral perforation)
and 2 Hartmann¡¯s procedures(1 rectal cancer and 1 stercoral
perforation) were performed. These 3 patients were already
septic and had massive fecal contamination with generalized
peritonitis and died postoperative day 1, 7, 16 respectively. Of 11
resection and anastomosis, there was no anastomotic leakage
and mortality. Only one patient had partial intestinal obstruction
who improved with conservative treatment. They started sip¡¯s of
water on mean postoperative day 4. 5(3-7th day). Conclusion:
One stage resection and anastomosis without colonic lavage and/
or protecting stoma in emergency left colectomy can be safely
performed in patients with low anesthetic risks(ASA 1 and 2).
But our series are small. Large prospective trials are needed to
confirm these results.
P052 COLITIS ISCHEMIC, Giuseppe Accarpio s Accarpio
MD, Puglisi R. s Puglisi MD, Zaffarano R. Zaffarano MD, ColonProctology Hospital Villa Scassi, Genoa, Italy
Purpose: This Study was indicated factors to treatment in the
acute and chronic fhaseand long term follow-up. Methods:
Retrospective study of 23 patients with ischemic colitisafter
endoscopic bipsyor medical treatment from 1997 to 2007. Female
13, and 10 males. Results: All patients presented intestinal
bleeding (10) or Diarrhea(13). two patients underwent immediate
surgery. One patients died from cardiovascular disease. The
treatment shock in three patients. for patients with acute colitis, 19
with chronic colitis. Conclusions: Multivariate analysis identified
three factors: The age over 70 years, radiations for other cancer
uterus, ovarias, prostat, cancer rectum colon. Anticoagulation or
antiarrhithmic therapyin 58 % of patients. the therapy: treatment
cardiac ad medical deseaseand solution fenol 5% enema.
Controversial Subjects
P053
EFFECT
OF
MOSAPRIDE
CITRATE
ON
POSTOPERATIVE ILEUS AFTER SURGICAL RESECTION
OF COLON CANCER, Akira Tsunoda PhD, Yuko Tsunoda PhD,
Makoto Watanabe PhD, Nobuaki Matsui MD, Kohji Takenaka MD,
Kazuhiro Narita PhD, Mitsuo Kusano PhD, Department of General
and Gastroenterological Surgery, Showa University School of
Medicine
Purpose: Mosapride citrate (mosapride) is a serotonin
5-hydroxytryptamine 4 receptor agonist that is known to promote
gastric emptying and large intestinel motility. We assessed the
effect of mosapride on postoperative ileus (POI) following colon
surgery. Methods: The subjects were colon cancer patients who
underwent hand-assisted laparoscopic colectomy (HALC). The
subjects were randomly assigned to a mosapride group (M group)
or control group (C group). The M group was given mosapride
with 50 ml of water three times a day starting on postoperative day
(POD) 1. The C group was given only 50 ml of water on the same
www.isucrs.org/
schedule. Patients were allowed to resume oral feeding following
on the evening of POD 2. Postoperative gastric emptying was
evaluated by the [13C]-acetate breath test. Results: The maximal
gastric emptying rate as determined by the breath test 48 hours
postoperatively was significantly earlier in the M group than in
the C group. Resolution of bowel movement was significantly
earlier in the M group than in the C group. Conclusions: Gastric
emptying was improved by mosapride. The results suggested that
the period of POI following HALC can be shortened by treatment
with mosapride.
P054 AMENDMENT OF ROME III F. FUNCTIONAL
ANORECTAL DISORDERS, Masahiro Takano BA, Coloproctology
Center, Takano Hospital
Purpose: Newly published Rome III is improved in F. Functional
Anorectal Disorders regarding the adoption of physical findings and
the data of laboratory examinations. However, it still has the following
drawbacks in 1. F2a1. Levator ani syndrome and 2. F2b. Proctalgia
fugax and the amendments are necessary in the following revision.
Subjects: 1. One hundred and ten cases of chronic anorectal
pain were examined to define tender areas in their pelvis with
digital examination. 2. Sixty-eight cases of proctalgia fugax were
examined to find tender areas when they were free of pain attack.
Result: 1-1. Naming of levator ani syndrome is delusive because
the same name is used to express the pathological status of
hypertrophy of the levator resulting in difficult evacuation as stated
by Wassermann. 1-2. According to the diagnostic criteria of F2a1.
Levator ani syndrome, tenderness is cased by posterior traction
on the puborectalis. However, when I tried the procedure, cases
with tenderness limited on the puborectalis were only 4 among
the 110 cases (4%), cases with tenderness overlapping the muscle
and pudendal nerve were 28 (24%) and cases with tenderness only
on the latter were 84 (78%). The above-mentioned data show the
tender areas are mainly not the levator but the pudendal nerve. 2.
In Rome III, the pathology of F2b. Proctalgia fugax is not clarified
but only estimated to be abnormal contraction of the smooth
muscle, induced by stress or anxiety for which no effective and
curative measures are found. However, when I examined and
palpated the pelvis, 55 of the 68 cases complained of tenderness
on the pudendal nerve. The evidences show the origin of the pain
is the pudendal nerve and the pathological entity is pudendal
neuropathy. Conclusion: Although new Rome III F item is better
than that of Rome II in adoption of findings as the criteria, it is
not complete in the pursuit of the pathogeneses. For example,
pudendal neuropathy exists on the bases of F2a and F2b.
P055 CROSS-MATCHING IN COLORECTAL SURGERY: A
VALUABLE RESOURCE WASTED, J D Terrace MD, D N Anderson
MD, Academic Unit of Coloproctology, University of Edinburgh
Introduction: Guidelines for blood cross-matching in surgery
vary widely between centres. Increasing pressure on transfusion
service resources mean that a consensus approach to blood
ordering is overdue. This study aimed to examine the patterns
of red cell cross-matching and transfusion in colorectal surgery,
with the hypothesis that excessive cross-matching remains
prevalent. Methods: Regional transfusion service database
and case note review of consecutive colorectal operations (one
consultant) in a single centre over a 30 month period. Benign and
malignant disease was identified histologically from resected
specimens. Results: 277 cases were identified. 101 patients
had benign disease (51% IBD, 27% diverticular disease). 176
patients had colorectal malignancy (52% left-sided and 32%
right-sided colectomy). There were no significant differences in
transfusion or cross-matching levels for benign versus malignant
or left versus right sided lesions. However, significant differences
were observed for ulcerative colitis compared with other benign
or malignant disease (mean 2. 4 versus 1. 1 transfused units
per operation; mean 5. 2 versus 3. 6 cross-matched units per
operation). Similarly, significant variation was apparent when
comparing emergency and elective surgery (mean 2 versus 0. 9
u. p. o transfused; mean 4. 7 versus 3. 3 u. p. o cross-matched).
Of the total 1088 units cross-matched, only 359 were transfused.
Conclusions: Although emergency and UC surgery had twice
the transfusion requirement of other procedures, excessive
crossmatching was prevalent in all operations, with serious
financial and resource implications.
79
ABSTRACT BOOK
Poster Papers
Fecal Incontinence
Eur Surg Res 1993; 25: 399-405.
P056 CLINICAL AND PHYSIOLOGICAL EVALUATION OF
ANAL SPHINCTER RADIOFREQUENCY REMODELING - 12
MONTHS EXPERIENCE, Roman M Herman PhD, Piotr Walega
PhD, Michal Nowakowski PhD, Katarzyna Smeder MD, Jerzy
Salowka MD, Dorota Zelazny MD, Jakub Kenig MD, 3rd Department
of General Surgery Jagiellonian University Collegium Medicum
Background: The main doubt reducing enthusiasm for the
radiofrequency remodeling technique (secca) was based on
lack of physiological studies, which may explain the possible
pathomechanism of improvement of symptoms. Aim: The aim
of this study was clinical physiological evaluation of the anorectal
function prior and during 12 months follow-up after the secca
procedure. Material: 16 fecal incontinence (FI) patients (4 male and
12 female, mean age 59 ranged 41-78 years) have been enrolled
into the study. The standard technique and secca device was used
(Curon Medical, Freemont, CA USA). The following parameters
were evaluated at baseline, 3, 6 and 12 months after the procedure:
continence (CCF-FI, FI-SI scores), improvement (FI-QoL, patient
diary, VAS), electromyography (EAS-superficial, IAS-needle),
rectal electro- and thermosensitivity, barostat, anal manometry,
morphology (endoanal ultrasound). Results: Comparing to
baseline, 1, 3, 6 and 12 months average results were as follows:
CCF-FI 12, 1 - 10, 4 - 9, 1 - 9, 3 - 6, 8; FI-SI 36, 9 - 38, 6 - 34, 9 - 35,
2 - 30, 8; compliance 5, 6 - 5, 6 - 4, 0 - 4, 2 - 4, 0; manometry BAP 30,
6 - 34, 23 - 39, 3 - 42 - 43, SAP 73, 15 - 75, 53 - 86, 07 - 96, 69 - 96, 3;
electrosensation 23 - 53 - 52 - 41 - 37, thermosensation 0, 7 - 0, 28 0, 3 - 0, 4 - 0, 4, respectively. In FI-Qol scale significant improvement
in 4 of 4 measures was observed, as well as IAS and EAS
electromyography improvement. Conclusions: Secca remodeling
is safe and seems to be effective method of FI treatment. It reduces
the frequency and severity of FI symptoms, and improves patient’s
quality of life. This effect seems to be related to restored anorectal
sensitivity and recto-anal coordination, however effect on IAS
morphology and function is also detectable.
P058 ARTIFICIAL SOFT ANAL BAND - RESULTS OF
METHOD APPLICATION IN POLAND, Roman M Herman PhD,
Piotr walega PhD, Michal Nowakowski PhD, Katarzyna Smeder
MD, Jerzy Salowka MD, Dorota Zelazny MD, Jakub Kenig MD, 3rd
Department of General Surgery Jagiellonian University Collegium
Medicum
Background: For patients with severe, irreparable fecal
incontinence, the surgical options are limited. The last-step
procedure is Artificial Bowel Sphincter (ABS) implantation. Aim:
The aim of this study is to present preliminary results of artificial
bowel sphincter (A. M. I. ) implantation in Poland, around the
natural anus and around the ostomy. Material: Eight patients (3
female and 5 male, age 27-55) with IVth grade fecal incontinence
were qualified to the procedure and two patients with an
ostomy: (1 female after the Miles procedure and 1 male after
perinaeal injury). Between January 2006 and December 2007 in
8 patients the anal band was implanted around the natural anus.
In two patients the band was implanted around the ostomy in
the abdominal wall. Soft Anal Band (SAB) is a modified bowel
sphincter physiological shape and with modified connections with
pump. Results: No intraoperative complications were observed.
In two patients SAB was removed due to the local infection
after 15 weeks and 6 weeks, respectively, one with subsequent
reimplantatation. In two patients the system needed to be recalibrated after 4 and 5 months. In one patient, 4 weeks after the
surgery, due to perineal suture line dehiscence, additional stitches
were placed with satisfaction outcome. Comparing to baseline, 3
and 6 months average results were as follows: CCF-FI 12 - 9, 2 - 7,
8; FI-SI 47, 33 - 34, 8 - 32, 8; manometry BAP(deflatedSAB) 31, 4 53 - 52; SAP(inflatedSAB) 57, 3 - 86 - 94. In FI-Qol scale significant
improvement in 4 of 4 measures was observed. Conclusions:
Artificial anal band implantation is the effective procedure for
majority of patients with IVth stage sphincters injury and improves
QoL. Anal band implanted around the ostomy allows controlling
the time and place for intestine emptying.
P057 NEOSTIGMINE INJECTION FOR THE TREATMENT OF
PARTIAL FECAL INCONTINENCE, Ismail A. Shafik MD, Cairo
University
Background/Aim: The treatment of partial fecal incontinence
(PFI) after internal anal (IA) sphincterotomy for chronic anal fissure
(CAF) is problematic. Prostigmine (PROS) (neostigmine methyl
sulphate) inhibits acetylcholine destruction and thus prolongs the
physiological actions of AC, and facilitates impulse transmission
across the myoneural junction. Therapeutically, PROS stimulates
muscle contraction. The current study investigated the hypothesis
that PROS effects cure of PFI following IA sphincterotomy
for CAF. Methods: Forty-eight patients with FI following IA
sphincterotomy for CAF received PROS injection into internal anal
sphincter (IAS) once/2 weeks for 12 weeks. Eighteen patients with
PFI after IA sphincterotomy for CAF acted as controls. Subjects
were administered IAS injections at 3 and 9 o’clock position of 0.
25 mg prostigmine in almond oil (patients) or placebo (almond oil)
(controls). Anorectal manometry was performed before and after
injection. Results: PROS effected significant elevation of both
maximal resting and maximal squeezing pressures and of IAS EMG
activity in all PROS-injected patients up to the 18th post-injection
week with no effect in controls. All PROS-injected patients became
continent. At the 24th week, patients were divided into 3 scores:
score 1 (complete continence) comprised 39 patients. Score 2
included 9 patients who were incontinent to flatus; they were reinjected and are now continent in score 1. No patient had score 3
(incontinent to fluid stools and flatus). Conclusion: Prostigmine
injection into IAS significantly increased maximal resting and
maximal squeezing pressures as well as IAS EMG and effected
fecal control in patients with PFI. References: 1. Shafik A. A new
concept of the anatomy of the anal sphincter mechanism and the
physiology of defecation. XVIII. The levator dysfunction syndrome.
A new syndrome with report of seven cases. Coloproctology 1993;
5: 159-165 2. Shafik A. Perianal injections of autologous fat for
treatment of sphiincteric incontinence. Dis Colon Rectum 1995; 38:
583-587. 3. Shafk A. Detrusor sphincter dyssynergia syndrome. A
new syndrome and its treatment by external sphincter myotomy.
Eur Surg Res 1990; 22: 243-248. 4. Shafik A. Anorectal tightening
reflex. The description of a reflex and its role in fecal incontinence.
80
ISUCRS XXII BIENNIAL CONGRESS P059 ROLE OF SACRAL NERVE STIMULATION (SNS) IN
ILEO-ANAL POUCH INCONTINENCE, N Srinivasaiah MD, P
Waudby RN, G S Duthie MD, 1. Academic Surgical Unit, University
of Hull, Cottingham, UK
Introduction: Sacral nerve stimulation has revolutioned the
treatment of various pelvic disorders. The remit of its use has been
increasing. An ileo-pouch anal anastomosis (IPAA) has become
the gold standard procedure for ulcerative colitis and familial
adenomatous polyposis. However, the operation may adversely
impact the patient’s continence and quality of life. Studies have
shown deterioration of continence and soiling. Treatment of Ileoanal Pouch incontinence can be difficult. The reports of the use of
SNS in the treatment of Ileo-anal pouch incontinence are limited.
We reviewed our experience in an isolated individual case in order
to determine whether it is a worthwhile procedure. Methods: We
aim to describe an isolated case of pouch incontinence who had
a successful outcome with SNS. A prospectively maintained SNS
database, was used for gathering the data. Results: Case report: A
53 year old male, was referred from a tertiary unit to consider SNS
for pouch incontinence. He had undergone Subtotal Colectomy in
2001 and Ileo-anal pouch reconstruction in 2002. He was troubled
with increased frequency of bowel movements from his Ileo-Anal
Pouch and also Faecal Incontinence associated with Urgency,
Frequency and Leakage. All these were affecting his quality of
life significantly. Having failed the conservative treatments and
collagen Injections, he was referred for considering SNS. Having
undergone assessment for SNS, he had a temporary SNS on the
left S2 nerve root. Bowel diaries showed good response with
reduction in frequency of bowel movements from 9-10 times/
day to 2-3 times/day and on 3 days no leakage of stool. Patient
described improved quality of life. Patient is awaiting a permanent
SNS. Conclusions: Although results might be far less predictable
since there is no benefit from parasympathetic neuromodulation
(subtotal Colectomy), there may be a direct contact effect on the
pouch. We conclude that SNS for pouch incontinence with our
limited experience offers a satisfactory outcome, when other
treatments have failed. However, we would like to see the long
term outcomes.
ABSTRACT BOOK
Poster Papers
P060 ROLE OF SACRAL NERVE STIMULATION FOR
INCONTINENCE AFTER RECTAL PROLAPSE REPAIR, Joan
Robert-Yap MD, Guillaume Zufferey MD, Karel Skala MD, Bruno
Roche MD, Unit of Proctology, University Hospital of Geneva
Introduction: Fecal Incontinence is the most common symptom
of a full thickness rectal prolapse. One year after surgery, 20%
of patients may continue to have symptoms of incontinence.
Management of persistent symptoms of incontinence is difficult
consisting of conservative therapy and/or surgery. One of these new
treatments is sacral nerve stimulation (SNS), which stimulation
of the sacral nerve by an electronic pulse generator, similar to a
cardiac pacemaker. This results in a sensory and motor effect on
the pelvic floor and its organs, which can improve bowel function
in incontinence and/or constipation. Materials and Method:
From January 2003 to December 2007. 9 female patients median
age 62 years, range 42 - 86 years have been tested. Patients had
incontinence symptoms despite rectal prolapse repair. Inclusion
Criteria: Fecal incontinence occurring 7 days or more in a 21 day
period, intact external anal sphincter +/- surgical repair, failed
medical therapy, failed biofeedback/physiotherapy and, minimum
1 year after procedure. We reviewed all 9 SNS test operations
performed in post rectal prolapse repair patients in the University
of Geneva Hospital, Unit of Proctology. Of these 9 patients, 4 had
Wells rectopexy procedures, 5 had Marti-Zaccharin procedures (
Rectopexy + total perineal repair). Additional previous procedures
included 1 sphincteroplasty and 1 sigmoidectomy. 7 on 9 patients
tested with incontinence had a positive Result: 78% success rate.
Wexner incontinence score decreased from 14 in pre-implantation
to 5 in post-implantaion. Conclusion: SNS is a minimally invasive
procedure. It shows 78% success rate in 9 cases of incontinence in
failed rectal prolapse repair. SNS has the advantage of testing to
assess efficacy. It is a good treatment option to offer patients who
have ongoing symptoms after rectal prolapse surgery.
FUNCTIONAL DISEASE
P061 ROLE OF SACRAL NERVE STIMULATION (SNS) IN
VULVODYNIA, N Srinivasaiah MD, P Waudby RN, B Culbert,
G S Duthie MD, 1. Academic Surgical Unit, University of Hull,
Cottingham, UK. 2. Department of Anaesthetics, Castle Hill
Hospital, Cottingham, UK
Introduction: Vulvodynia is difficult to treat seriously affecting
QOL. There are no reports of SNS in vulvodynia. We have
reviewed our experience in two cases to determine whether it is a
worthwhile procedure. Methods: Patients were identified from our
prospectively maintained SNS database and the notes reviewed.
Results: Case 1: A 62yr female cook was diagnosed to have
vulvodynia when she was aged 20. Symptoms affected her QOL
significantly. She experienced high intensity spasms lasting for 1-2
mts with worsening pain. With insignificant past medical history,
aetiology has not been ascertained. Having failed analgesics,
antiepileptics, antidepressants, phenytoin infusions and caudal
blocks (Short lived), she was referred by the pain team for SNS.
Following assessment for SNS, She had a temporary SNS
on the left S2 root. Spasms were less severe lasting only 3040 seconds. On a PACS / BPI assessment there was 70% relief
at the end of two weeks. Patient described improved QOL
and is extremely happy with the outcome. The temporary
wires were removed and the patient is awaiting permanent
implant. Case 2: A 43 yr female dress designer was diagnosed
vulvodynia associated with left buttock and perineal pain.
With insignificant past medical history, aetiology has not been
ascertained. Having failed analgesics, gabapentin and caudal
blocks, she was referred by the pain team for considering SNS.
Following assessment for SNS, She had 3 temporary SNS
procedures done. The first one was a temporary SNS placed
on right S3 nerve root. Not entirely satisfied with the marginal
improvement she had, a second temporary SNS was done
on the left involving S3. Following the failure of second SNS,
unsatisfactory assessment on the right S3 led to a repeat right
S3 test, which was successful. PACS / BPI assessment showed
a reduction in pain of 60% after day 1 and 80% improvement at
the end of 1st and 2nd week. Patient is extremely happy with the
outcome and is awaiting for a permanent implant. Conclusions:
SNS for vulvodynia with our limited experience offers a satisfactory
outcome, when other treatments have failed.
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P062 LAPAROSCOPIC RESTORATIVE PROCTOCOLECTOMY
AND ILEAL POUCH ANAL ANASTOMOSIS; HAVE WE
PROGRESSED?, A Belizon MD, S Shawki MD, E Weiss MD, J
Nogueras MD, D Sands MD, S Wexner MD, Cleveland Clinic
Florida
Restorative proctocolectomy and Ileal pouch anal anastomosis
(IPAA) is the procedure of choice for patients with umcerative colitis.
Laparoscopy has been applied to this procedure. This study set
out to report our short-term results with laparoscopic restorative
proctocolectomy and IPAA and compare it with a matched group
of patients undergoing open surgery. Methods: All patients who
underwent laparoscopic restorative proctocolectomy and IPAA
were retrospectively reviewed using our prospectively maintained
database. Charts were reviewed for demographics, operative
time, blood loss, length of hospitalization, morbidity, and
mortality. A group of 60 patients who underwent open restorative
proctocolectomy and IPAA and were selected for comparison to
the laparoscopic group. The patients were well matched for BMI,
ASA, diagnosis, and age. Results: All 61 patients underwent
laparoscopic restorative proctocolectomy and IPAA between
1991 and 2007. Including 5 patients in whom an operation was
performed hand assisted. There were 4 conversions to laparotomy
and fecal diversion was employed in all cases. The operative time
in the matched group of 60 patients was significantly shorter than
in the laparoscopic group (208 minutes vs. 276 minutes, P<0. 05).
However the major morbidity rate was similar (7. 2% vs. 6. 2%) and
the length of hospitalization was significantly longer (7. 6 vs. 5. 9;
P<0. 05). There were no mortalities in either group. Conclusion:
Laparoscopic IPAA may decrease the length of hospitalization and
without increasing the morbidity. As technology improves and
laparoscopic skills are refined this procedure may prove to be the
treatment of choice for select patients. Further study is needed to
evaluate the laparoscopic approach in a prospective randomized
fashion.
P063 ROLE OF SACRAL NERVE STIMULATION FOR
CONSTIPATION AFTER RECTAL PROLAPSE REPAIR J.
ROBERT-YAP, Guillaume Zufferey MD, Karel Skala MD, Bruno
Roche MD, Unit of Proctology, University Hospital of Geneva
Introduction: Constipation is a common symptom after abdominal
surgery for of a full thickness rectal prolapse. Management of
persistent symptoms of constipation is difficult and consists of
conservative therapy and/or eventual surgery. One of these new
treatments is sacral nerve stimulation (SNS). It involves stimulation
of the sacral nerve by an electronic pulse generator, similar to a
cardiac pacemaker. It is a minimally invasive procedure which is
performed in 2 stages. It results in a sensory and motor effect in
the pelvic floor and its organs and has been shown to regulate
bowel function in incontinence and/or constipation. Materials
and Method: From January 2003 to December 2007, 5 female
patients median age 67 years, range 53 - 86 years had been tested.
Patients had constipation symptoms despite rectal prolapse repair.
We reviewed all 5 SNS test operations performed in post rectal
prolapse repair patients in the University of Geneva Hospital,
Unit of Proctology. Of these 5 patients, 3 had Wells rectopexy and
2 had Marti-Zaccharin procedures ( Rectopexy + total perineal
repair). Additional previous procedures included 1 sigmoidectomy
and 2 vaginal suspensions by promontofixation. Results: 4 on
5 patients tested with constipation had positive results: an 80%
success rate. The Wexner constipation score decreased from 18
in pre-implantation to 10 in definitive implantation. There were
no complications. Conclusion: SNS is a minimally invasive
procedure. Our results show an 80% success rate using SNS
in 5 cases of constipation after rectal prolapse repair with no
complications. SNS has the advantage of a test phase to assess
efficacy. It is a good treatment option to offer patients who have
ongoing symptoms after rectal prolapse surgery.
Infections
P064 WITHDRAWN
P065 COLONOSCOPIC DIAGNOSIS AND TREATMENT
OF PERIAPPENDICULAR ABSCESS, Mette Christoffersen
MS, Orhan Bulut MD, Per Jess DO, Gastroenterology Surgical
Department, Hilleroed Hospital, Helsevej2, 3400 Hilleroed,
Denmark
81
ABSTRACT BOOK
Poster Papers
Appendicitis is one of the most common diseases of the abdomen,
and the diagnosis often can be difficult to make in atypical
presentation. Periappendicular abscess, as a common complication
to appendicitis, (2-6%) often requires long hospitalization.
Colonoscopic diagnosis and treatment of asymptomatic acute
appendicitis and periappendicular abscess are exceedingly
rare. We present an atypical case of periappendicular/pericecal
abscess that was drained during colonoscopy. Case Report: The
patient was an 80-year-old woman without obvious symptoms
of appendicitis admitted for colonoscopic polyp control. Physical
examination was non-remarkable, except for slight tenderness at
palpation in the lower abdomen. Laboratory tests at admission
showed a marginally high white blood cell count of 10, 600/mm3
and a normal C-reactive protein level. Colonoscopy revealed a
smooth- surfaced, ill-demarcated and sessile protrusion in the
coecum. We attempted to obtain biopsies with regular instruments
without success. Afterwards we managed to perforate the mass
with the tip of a snare and a whitish fluid began to drain into the
colon. The perforation was then dilated and a catheter was inserted
to aspire pus for bacteriological examination, which later yielded
E. coli and Bacteriodes fragilis. Multiple biopsies were obtained
for histological examination as well. These showed normal
colonic mucosa without malignancies or inflammation. After
drainage the mass obviously disappeared. An acute abdominal
ultrasound and CT scan was performed hereafter. Here the
appendix was not visible and there was no free fluid or abscess
formation. It showed a hypoeccoic oblong process, approx. 3, 5
cm. in the right fossa and inflammatory reaction around coecum.
The patient was hospitalized for 5 days for observation and and
discharged without symptoms and with normal laboratory tests.
Three months later a new ultrasonographic examination showed
a thickened oblong process in relation to coecum, most likely
the rest of the previous abscess cavity. One-year follow up there
was no sign of recurrence. Conclusion: Colonoscopic drainage,
especially in combination with endosonographic examination
seems to be a good option in the management of periappendicular
or pericecal abscess in the elderly with surgical risk.
P066 FEMORAL VENOUS CATHETER IS A MAJOR RISK
FACTOR FOR CENTRAL VENOUS CATHETER RELATED
BLOODSTREAM INFECTION IN COLORECTAL SURGERY. ,
Mitsuru Ishizuka MD, Hitoshi Nagata MD, Kazutoshi Takagi MD,
Keiichi Kubota MD, Department of Gastroenterological Surgery,
Dokkyo Medical University
Background: Central venous catheter related bloodstream
infection (CVC-RBSI) is a major complication that is associated
with CVCs. However, there are few studies on the risk factors
for CVC-RBSI in the patients who underwent colorectal surgery
(CRS). Purpose: To disclose the risk factors for CVC-RBSI in CRS.
Methods: CVC-RBSI was evaluated from the database of patients
who underwent CRS retrospectively. Catheters were removed
whenever fever (>380C) occurred or if symptoms of infection were
present, such as skin redness and pus discharge at the insertion
point, and then blood culture and culture of the catheter tip were
done to diagnose any CVC-RBSI. Either blood culture positivity
or catheter culture positivity were defined as CVC-RBSI. Results:
Three hundred-fifty patients received 423 CVCs for a total of 7760
catheter-days. Thirty-nine cases were diagnosed as CVC-RBSI (5.
03, per 1000 catheter-days). There were no significant differences
in the backgrounds between the cases with or without CVC-RBSI,
except for the period of catheter insertion (24. 6 } 7. 0 vs17. 7 } 0. 6,
P = 0. 0151). However, univariate analysis using the factors such as
sex, age, troubles of insertion, length of inserted catheter, period
of catheter insertion, performance of chemotherapy, performance
of total parenteral nutrition (TPN), insults of operation and type
of catheter revealed that femoral venous catheter (FVC) was an
independent risk factor for CVC-RBSI (odds ratio, 4. 706; 95% C. I. ,
1. 008-1. 062; P = 0. 0156). Conclusions: FVC is a major risk factor
for CVC-RBSI in CRS.
Inflammatory Bowel Disease
P067 INFLIXIMAB IN THE TREATMENT OF PERIANAL
CROHN DISEASE. , Roman M Herman PhD, Tomasz Cegielny
MD, Jakub Kenig MD, Marcin Nowak PhD, Piotr Walega PhD, Jacek
Sobocki PhD, IIIrd Department of General Surgery, Jagiellonian
University Collegium Medicum
82
ISUCRS XXII BIENNIAL CONGRESS Introduction: Perianal fistulas are most frequent complication
of Crohn’s disease. Conservative therapy and surgical procedures
showed little success in the treatment of perianal fistulas.
Infliximab, monoclonal anti-TNFalfa IgG’s has become more
available method in therapy of complicated Crohn disease. Aim:
Present the preliminary report of the perianal fistulas treatment
with infliximab. Methods: 48 patients with Crohn’s have been
treated in the period of last five years. 16 patients had perianal
Crohn disease with draining simple or complex perianal fistulas.
9 patients (4 females and 5 males, at the age of 16-45) have
been enrolled to IFX treatment. 7 patients underwent surgical
procedures before or during IFX therapy. Endorectal ultrasound
examination (ERUS) with the use of H2O2 have been used as
diagnostic procedure. Results: Every patient involved in the
study showed clinical response to therapy with IFX. Acute phase
reactants (CRP) were normalized, as well as Crohn Disease
Activity Index. CDAI reduced by 109 (+/-16, 4) points. More than
50% of fistulas tract closed spontaneously in 8 patients (88%).
Non-cuting setons were taken off by 5-8th week of therapy. In 5 of
the patients there was no fistula visualized in ERUS in 10th week.
7 patients were qualified for further maintenance therapy with
IFX. Conclusions: The use of IFX is indicated in patients showing
no response to standard therapeutic procedures. The use of IFX
should be used as the bridge to immunosuppressant therapy. The
results of clinical experience will be presented in future as the
study on the use of IFX in patients with Crohn’s continues.
P068
ENDORECTAL
ULTRASOUND
IMAGING
IN
EVALUATION OF CROHN’S PERIANAL FISTULAS. , Roman
M Herman PhD, Marcin Nowak PhD, Tomasz Cegielny MD, Jakub
Kenig MD, Piotr Walega PhD, IIIrd Department of General Surgery,
Jagiellonian University Collegium Medicum
Introduction: The three-dimensional ultrasound imaging
enables evaluate the topography of the fistula. Endorectal
ultrasound imaging is very useful in patients selection to both:
surgical procedures and biological therapy with infliximab. Aim:
To evaluate efficiency of ultrasound imaging in the diagnosis and
monitoring of perianal fistulas treatment. Methods: 48 patients
has been treated due to Crohn’s disease since 2003. 16 patients
presented perianal complications of the disease including
fistulas. 2 female patients were diagnosed with recto-vaginal
fistula. Fistulography, endorectal ultrasound examination (ERUS)
with hydrogen peroxide were used in the diagnostic procedure.
9 patients (4 females, 5 males, at the age ranging 16-45) were
involved into the study with IFX management. Images were
performed before the onset and 10 weeks following therapy to
assess the effectiveness of the treatment. ERUS was performed
right before the administration of the first dose of IFX to rule out
perianal retention. Ultrasound device BK Medical was used to
perform the 2D and 3D ultrasound imaging. Results: 9 patients
(100%) treated with IFX responded to therapy. Closure of more than
50% fistula’s tract was observed in 8 cases (88%). In 5 (55%) of the
patients there was no fistula on ERUS images 10 weeks after the
onset of therapy. There was neither retention nor fluid visualized
on ERUS. 7 patients were qualified for the further maintenance
therapy with IFX. Conclusions: Endorectal ultrasound imaging
is an excellent tool in both: diagnosis and monitoring therapy of
perianal fistulas in patients with Crohn’s disease. Repeatability and
3D imaging makes it even more attractive regarding the complete
visualization of the topography of fistula itself and it’s canal.
P069 HEALING AFTER SURGICAL MANAGEMENT OF
CROHN’S ANAL FISTULA/ABSCESS, KJ Park PhD, IS Lee
MD, EK Choe MD, Seoul National University College of Medicine,
Seoul, South Korea
Background: Crohn’s anal fistula/abscess is notorious for
delayed wound healing and high rate of recurrence after surgical
management. However, few reports concerning the detailed
analysis of healing time are available. In this study, we intend
to review the healing rate and time for Crohn’s anal fistula
and/or perianal abscess and access any determining factors.
Methods: We analyzed the follow-up data of 25 Crohn’s anal
fistula patients (35 operations) who underwent operation by
one surgeon. Anal fistula/abscess was into 2 groups simple
(superficial, intersphincteric, low-transsphincteric) and complex
(high transsphincteric, extrasphincteric, suprasphincteric, horse-
ABSTRACT BOOK
Poster Papers
shoe). Results: Mean age of the patients was 26. 8+/-7. 1 years
and there were 5 simple (14. 3%) and 30 (85. 7%) complex fistula/
abscess. All patients with simple type healed without recurrence,
and there was no difference in healing time compared with
non-Crohn’s patients in the simple type group (42. 4+/-21. 4 vs.
41. 9+/-16. 8 days, P=0. 969). Of the 30 in the complex group,
only 22 (73%) healed and there was a significantly prolonged
healing time compared with non-Crohn’s patients (207. 2+/-159.
3 vs. 96. 5+/-74. 2 days, P=0. 004). The mean follow-up time for
the unhealed patients (N=8) was 607. 2days (range 180 days
~ 1560days) despite multiple surgical interventions. Neither
Crohn’s disease activity index (CDAI) value (mean: 141. 6) nor the
extent of intestinal inflammation (including rectal inflammation)
had relationship with healing time (P=0. 392, P=0. 911). All
patients used azathioprine during treatment and infliximab nor
prednisolone medication had no statistical significance in healing
time (P=0. 73, 0. 59). After healing of primary surgical wound, four
(4/22=18%) patients in the Crohn’s complex anal fistula/abscess
group had recurrence (at a mean of 877 days) as compared to
1. 7% (2/115) in non-Crohn’s patients with complex type anal
fistula/abscess. Conclusion: Postoperative course in simple type
of Crohn’s anal fistula/abscess was same as that of non-Crohn’s
anal fistula. On the other hand, there was delayed healing and
more frequent recurrence regardless of extent of gastrointestinal
involvement or medical treatment in the complex type of Crohn’s
anal fistula/abscess.
Takehito Yoshifuji MD, Jin-ichi Hida MD, Kiyotaka Okuno MD,
Hitoshi Shiozaki, Div. of Laparoscopic & Colorectal Surgery, Dept.
of Surgery, Kinki University School of Medicine
Introduction: We started performing laparoscopic colorectal
surgery (LAC) in 1995, since then more than 221 cases have
been done at our institution. For the first 3 years, we used
laparoscopic procedure only for early stages of colorectal
cancer until T1 and therefore we had expanded indications for
advanced stage of colorectal cancer. Proposed here is our series
of patients undergoing LAC and the description of the learning
curve. Method: All the patients undergoing LAC until December
2007 were entered into a database and the following parameters
were collected: demographic, blood loss, complications, hospital
stay and post-operative follow up. Only patients having all the
parameters were then analyzed. Results: Out of 220 patients 91
were analyzed. This corresponded to all cases were consecutively
performed from January 2005 to December 2007 when a tighter
data collection was adopted. There were 56 (61%) male and 35
(39%) female; the mean age was 66+/-10 y. o. (33-87 y. o. ) The
annual clinical data was indicated as for the table.
Laparoscopic Surgery
P070 WITHDRAWN
P071 ROBOTIC ANTERIOR RESECTION OF THE RECTUM,
Slawomir J Marecik MD, Leela M Prasad MD, John J Park MD,
Advocate Lutheran General Hospital, Park Ridge, IL, University of
Illinois Medical Center, Chicago, IL
Purpose: Robotic surgery has gained wide acceptance in urology.
This technology allows for fine dissection within confined
pelvic space. There is growing literature on the use of the new
generation robots in major colon and rectal resections. The
authors’ goals were to assess the feasibility, safety and efficiency
of robotic technology in 35 rectal dissections. Methods: This
is a retrospective study of patients undergoing roboticallyassisted resections at a single institution from August 2005 to
January 2008. Following IRB approval, the hospital and office
charts of 36 patients were reviewed. Data extraction sheets were
used to collect information on demographics, operative details,
and postoperative course. Results: There were 35 patients (20
female, 15 male), with an average age of 55. 6 (range 28-86), and
an average BMI of 29. 8. Of these, 12 patients were operated for
cancer, 4 for polyps (including 3 familial adenomatous polyposis
cases), 12 for diverticulitis (1 colovaginal fistula, 1 abscess), 5
for rectal prolapse, and 2 for ulcerative colitis. There were 14
anterior resections (AR) with splenic flexure mobilization (SFM),
8 low anterior resections (LAR) with SFM, 5 AR with rectopexy
(RPX), 5 total proctocolectomies (TPC, pouch procedures)
and 3 abdominoperineal resections (APR). There were 14
total mesorectal excisions performed and 10 rectal reservoir
reconstructions. The average operative times were 294 min (AR
SFM), 364 min (LAR SFM), 195 min (AR RPX), 461 min (TPC) and
375 min (APR), respectively. The average blood loss was 120 cc.
The average lymph node harvest from rectosigmoid was 15. 7. The
average length of stay was 5. 5 days for AR, 6. 9 for LAR, 4 days
for AR RPX, 5. 2 days for TPC, and 8 days for APR. There were no
intraoperative complications or mortalities. There were 5 major
postoperative complications (4 small bowel obstructions with one
requiring reoperation and 1 pelvic abscess). Five patients (14%)
developed superficial surgical site infections, including 3 cases of
perineal wound. Conclusion: In the authors’ experience, rectal
resections using the current generation of robots can be safely
performed without intraoperative complications. This technique
is most applicable and very helpful for total mesorectal excision
and resection rectopexy.
P072 LAPAROSCOPIC SURGERY FOR COLORECTAL
CANCER AT OUR INSTITUTE; CAN WE PERFORM A
CODIFIED SURGICAL PROCEDURE?, Kazuki Ueda MD,
Haruhiko Imamoto MD, Tadao Tokoro MD, Eizaburo Ishimaru MD,
www.isucrs.org/
There were 3 cases (3. 3%) of postoperative anastomotic leak
in these 3 years, however, we did not experience any in 2007.
The improved tasks were identified in: technical proficiency,
understanding of local anatomy, codified procedure, environmental
arrangement in the OR (the distribution of clinical engineer), and
the education for scrub nurse. Conclusions: Surgeons who
perform laparoscopic surgery will need skills and anatomical
understandings that improve with time and experience. Moreover,
we believe that a good OR arrangement, the distribution of clinical
engineer and a full education for scrub nurse will be mandatory to
perform stress-free laparoscopic surgery.
P073 LAPAROSCOPIC HAND-ASSISTED SURGERY IN THE
MANAGEMENT OF COMPLICATED DIVERTICULITIS WITH
COLOVESICAL FISTULA, Megan Brenner MD, James Yoo MD,
UCLA
Introduction: Laparoscopic techniques are gaining popularity
in the surgical management of colorectal diseases. Handassist devices have been shown to reduce operative time and
conversion rates for laparoscopic procedures, and may play
an important role in the surgical management of patients with
complicated pathology. However, indications for its use are still
being defined. Objective: To investigate the use of hand-assisted
laparoscopic surgery (HALS) in the surgical management of
patients with diverticulitis and a colovesical fistula. Participants:
Five consecutive patients who presented with diverticulitis
and a colovesical fistula over a 10-week period underwent a
laparoscopic, hand-assisted sigmoid colectomy and takedown
of a colovesical fistula by a single colorectal surgeon at UCLA
Medical Center. Data was gathered prospectively. Results: The
mean age of the patients was 68. 8 years. One patient had a BMI of
40, two patients had a history of prior lung transplant and were on
immunosuppressive medications, and one patient was 90 years
old with aortic stenosis and Waldenstrom’s macroglobulinemia.
Four of the five patients had a history of prior abdominal surgery.
The diagnosis was suspected by pneumaturia and fecaluria,
and confirmed by CT scan in all patients. In addition to sigmoid
colectomy, simple closure of the cystotomy was necessary in three
patients. There were no conversions. Mean operating time was
236. 6 min; mean EBL 237 cc. Average length of stay was 7. 2 days.
One patient developed a wound infection. There were no deaths
and no recurrences. Conclusions: Laparoscopic hand-assisted
surgery may play a role in the management of high-risk patients
with diverticulitis and a colovesical fistula. Pure laparascopic
techniques for sigmoid diverticulitis are performed; however, the
HALS technique may reduce operative times and conversion rates,
and may be even more beneficial for complicated diverticulitis.
83
ABSTRACT BOOK
Poster Papers
P074 A CASE REPORT OF LAPAROSCOPIC EXCISION OF
RETRORECTAL CYSTIC TERATOMA, Won-Kyung Kang PhD,
Jong-Kyung Park PhD, Seong-Taek Oh PhD, Eung-Kook Kim
PhD, Suk-Kyun Chang PhD, Department of Surgery, The Catholic
University of Korea
Retrorectal or presacral tumors are rare masses. Its incidence is
reported to be 0. 01%. Generally, these tumors have non specific
symptoms, and are likely to be found incidentally on CT or MRI
scans. Among all presacral masses about 2/3 are congenital,
and also about 2/3 are benign. Benign presacral tumors are
surgically resected. On the other hand, treatment modalities
for pathologic proven malignant tumors include chemotherapy,
radiation, or surgery. Based on careful preoperative studies and
surgical planning, the anterior or posterior surgical approach is
chosen. Although cystic teratomas usually involve the ovaries,
few cases report their occurrence in the presacral area. To our
knowledge and the references including the Pubmed, no case
reports on the laparoscopic excision of presacral cystic teratomas
were perceptible, and therefore we present this original case.
<case> A 31 year old female patient complaining of right hip pain
visited our orthopedics outpatient department. Although simple
X-ray did not show any abnormality, MRI revealed a 6. 6 x 5. 7
x 6. 5 cm sized cystic mass (T1; high, T2; low signal) in the right
presacral region. Colonoscopy did not show any discernible
intra-luminal lesion. Considering the benign nature indicated
by imaging studies, the risk of cutaneous fistula and the young
age, laparoscopic excision was performed. A ureteral catheter
was inserted through a cystoscope just before the operation.
Dissection to the presacral area was made in the same manner
as the total mesorectal excision. Frozen section biopsy identified
a benign mass. Tumor contents were then removed after the
dissection of the presacral area. The cyst wall was removed
employing an 11 mm port on Right lower quadrant. Permanent
pathology confirmed cystic teratoma as expected. The patient
recovered without any significant postoperative complication and
was discharged in good condition.
P075 LAPAROSCOPIC COLECTOMY FOR COLONIC
INERTIA, J Sanjay MD, B Safar MD, D Sands MD, E Weiss MD, J
Nogueras MD, S D Wexner MD, Cleveland Clinic Florida
Aim: Total abdominal colectomy (TAC) is the treatment of choice
for patients with colonic inertia refractory to medical therapy.
Laparoscopic segmental colectomy has been shown to have
certain advantages over open colectomy such as decreased length
of stay (LOS), however, its role in colonic inertia has not been
well described. Therefore the aim of this study was to compare
laparoscopic TAC as compared to standard open TAC. Methods:
After IRB approval, a retrospective review was undertaken of all
patients prospectively entered into a database at our institution
who underwent laparoscopic or laparoscopic attempted TAC
(LTAC) for colonic inertia matched with patients who underwent
open TAC (OTAC) for colonic inertia from the same registry. Age,
gender, BMI, prior abdominal surgery, operative time, complication
rate, and LOS were evaluated. Results: 12 females underwent
LTAC and were well matched with 12 patients who underwent
OTAC. The mean age was 43. 8 years for the LTAC vs. 39. 4 years
for the OTAC (p=0. 53). The mean BMI for the LTAC was 21 vs. 21.
8 for the OTAC (0. 61). One person had prior surgery in the LTAC
vs. 2 in the OTAC (p=0. 56). The mean LOS was 8. 25 days for LTAC
vs. 8. 33 days for OTAC. Mean operative time was 243. 8 minutes
for LTAC vs. 164. 2 minutes for OTAC (p=0085). There were 3
complications in LTAC, none in OTAC and one operation was
converted from laparoscopic to open. Conclusion: LTAC can be
safely performed for colonic inertia, however the operative time
and complication rate is significantly higher than OTAC. LTAC for
colonic inertia does not offer the advantages that laparoscopic
colorectal surgery for other pathologies offers.
P076 LAPAROSCOPIC PROPHYLACTIC COLECTOMY FOR
FAMILIAL ADENOMATOUS POLYPOSIS PATIENTS, Tetsuro
Higuchi MD, Hirotoshi Kobayashi MD, Masayuki Enomoto MD,
Kenichi Sugihara MD, Department of Surgical Oncology, Tokyo
Medical & Dental University, Graduate School
Introduction: Familial adenomatous polyposis (FAP) is an
autosomal dominant disease caused by a germline mutation
84
ISUCRS XXII BIENNIAL CONGRESS in the APC gene located at chromosome 5q21. Patients with
FAP develop hundreds to thousands of adenomatous polyps,
and they are at a nearly 100% risk of colorectal cancer. Surgical
management includes prophylactic proctocolectomy with ileopouch anal anastomosis (IPAA) or total colectomy with ileorectal
anastomosis (IRA). IPAA has been accepted as the standard
operation for FAP patients. However, the operation requires
extremely complex procedures, and has a high incidence of
postoperative complications, compared with IRA. Moreover,
this radical operation affects the stool habit of the patients
and compromises their quality of life. To monitor the possible
development of rectal carcinoma after IRA, it is important to
continue periodic follow-up of the remaining rectum. Aims and
Methods: Between 1998 and 2006, laparoscopic prophylactic
surgery was performed in 14 patients, 11 male, average age 26
years (range 20 -E65 years). We reviewed some clinical factors
in the perioperative period. Results: We have performed 12
IRA and 2 IPAA. Among them, invasive carcinomas developed
in the remnant rectal mucosa of 2 IRA cases, one patient had
laparoscopic low anterior resection, another had laparoscopic
IPAA. We present the technique of laparoscopic prophylactic
surgery for FAP. Conclusion: Laparoscopic prophylactic surgery
for FAP is a technical alternative of conventional open surgery. By
this technique, it is possible to provide a better quality of life in
postoperative period and better cosmetic result.
P077 CEREBRAL ISCHEMIA AFTER LAPAROSCOPIC
OPERATION, Thomas Auer MD, Friedrich Herbst MD, B. Sima
MD, G. Gruber MD, B. Salehi MD, KH der Barmherzigen Brüder
Wien, Medical University of Graz
Case Report: A 47 yrs old female patient was operated on lap.
Ileo-cecal resection due to extended ileitis based on a years lasting
crohn`s disease. A fistula was found from the ileum to the sigma.
The patient was brought to Lloyd-Davis position for the procedure.
The preparation of the cecum, ascending colon and sigmoid was
performed in a 35° Trendelenburg`s position for approx. 90 minutes.
After ileocecal resection, excision of the fistula, ileo-ascendostomy,
cholecystectomy was performed due to gallstones. Duration of
the operation was 190 minutes. In the early postoperative period,
the patient experienced double vision, divergence of the bulbi
was observed. Since immediate CT-scan showed no change,
MRI 3 days later showed ischemic lesions of the right thalamus.
By MR angiography, dissection of the right vertebral artery was
found in the V2 and V3 segment. Neurological examination after
8 hours found the patient symptoms free, so she was thereafter.
Discussion: Stroke, seizure, cerebral circulatory disorders are
the mostly reported cerebral complications after laparoscopic
operations. Venous blood congestion, reduction of cerebral tissue
saturation, vasospasm could be the causes. Vascular risk factors,
duration of pneumoperitoneum and Trendelenburg`s position
should be serious factors of risk calculation.
P078 LAPAROSCOPIC DIVERTING ILEOSTOMY IS USEFUL
FOR THE SURGICAL TREATMENT OF PERIANAL PAGET’
DISEASE, Makoto Watanabe PhD, Akira Tsunoda PhD, Kentaro
Nakao PhD, Nobuaki Matsui MD, Mitsuo Kusano PhD, Showa
University School of Medicine Department of General &
Perianal Paget’s disease is a rare entity. The standard treatment
for extramammary Paget’s disease is surgical excision, and
wide local excision of the skin and subcutaneous tissue in the
perianal region is the recommended treatment for noninvasive
intraepithelial perianal Paget’s disease in vast majority of reported
cases. When we performed reconstruction using skin flaps to
cover these areas of tissue loss, we created a diverting ileostomy
to avoid wound complication. Generally a mini laparotomy
is needed to identify the terminal ileum surely in a diverting
ileostomy. We used laparoscopic techniques to obviate the need
for laparotomy while creating a diverting ileostomy. In this report
we present our experience with laparoscopic diverting ileostomy
that was performed for the surgical treatment of perianal Paget’s
disease. Surgical Technique: A pneumoperitoneum was
established using a closed method with a blunt port, with CO2
insufflation at a rate of 6 L/min. The intra-abdominal pressure was
maintained at 10mmHg. A diagnostic laparoscope was placed
ABSTRACT BOOK
Poster Papers
through the umbilical port for initial exploration of the abdominal
contents. A 5mm trocar was placed in the left inferior abdomen for
introduction of a blunt dissecting instrument to grasp the terminal
ileum. After a segment of terminal ileum was identified, this
bowel segment was raised against the right anterior abdominal
wall at the site of the stoma. A 3cm incision was made in the
skin which the ileum was raised against the abdominal wall.
The ileum could be extracted under direct visualization through
the abdominal wall to create a loop ileostomy. The ileostomy
was then matured in the standard manner, and operation was
completed. We have performed laparoscopic diverting ileostomy
in three patients with perianal Paget’s disease. The mean time
of the creation of diverting ileostomy by laparoscopic techniques
was 30(25-35) minutes. The postoperative course was uneventful,
and all the patients began a regular diet from the next day after
operation. Laparoscopic approach for diverting ileostomy reduced
postoperative discomfort and ileus, and is useful for the surgical
treatment of perianal Paget’s disease.
Profilaxis
P079
ANAL CYTOLOGY:
EXPERIENCE
OF
THE
COLOPROCTOLOGY UNIT FROM CARACAS UNIVERSITARY
HOSPITAL DURING 2007. , Carlos Sardiñas MD, Patricia Bravo
MD, Yaycira Guillen MD, Nahir Castillo MD, Carlos Rodriguez
MD, Katyana Alvarez MD, Yuleiby Flores MD, Norma Oviedo
MD, Coloproctology Unit. Caracas University Hospital. Central
University of Venezuela
Goal: Clinic and cytologic detection of malignat (M) and
premalignat (PM) lesions of the anal conduct in patients assisting
to the Coloproctology Unit. Place of Elaboration: Examination
ward of the Coloproctology Unit at the Caracas University
Hospital. Methods: Cytomorfologic analysis of Cytologies taken
after being processed with the Papanicolaou technique. Results:
During 2007, 284 anal cytologies were processed. 217 Females and
67 males. 224 Resulted with no lesions. Samples inadequate were
25. Premalignant lessions resulted 31 and malignant resulted 4. In
premalignant lessions, 4 were females and 27 males. In malignant
lesions 2 were females and 2 males. Conclusions: Anal cytology
was usefull in detecting up to 14% of lessions from the hole
population studied. 88% Of premalignant and 12% of malignant
lessions. Innadequate cytologies were 9% which is accord with the
experience during the act of taking and processing the sample. We
would encourage the coloproctologists and even other specialists
to make of the anal cytology a first line profilaxis instrument in
anorectal premalignat and malignant deseases.
Research
P080 ROLE OF SACRAL LIGAMENT CLAMP IN THE
PUDENDAL EUROPATHY (PUDENDAL CANAL SYNDROME):
RESULTS OF CLAMP RELEASE, Olfat El Sibai, Menoufia
University
Objectives: Pudendal canal syndrome (PCS) is treated by PC
decompression. We investigated the hypothesis that failure
of PCD to relieve anal and perianal pain could result from
compression of pudendal nerve not only in PC but also in sacral
ligament clamp (SLC), i. e. in space between sacrotuberous and
sacrospinous ligaments. Methods: SLC release was performed
in 21 patients with proctalgia who had not improved after
PCD. Pudendal nerve terminal motor latency (PNTML) was
higher than normal. SLC release operation comprised entering
ischiorectal fossa through a paraanal incision, identifying PN
and division of sacrospinous ligament. Results: Treatment was
successful in 17 patients and failed in 4. The former showed pain
disappearance and improvement in fecal incontinence, perianal
sensation and anal reflex. Conclusions: Clinical manifestations
and investigative results improved after SLC release in 80. 9%
of cases. Assumingly these results denote traumatization of
the PN not only in PC but also in SLC. References: 1. Shafik A.
Pudendal canal syndrome. Description of a new syndrome and its
treatment. Report of 7 cases. Coloproctology 1991; 13: 102-109.
2. Shafik A. Pudendal canal decompression in the treatment of
idiopathic fecal incontinence. Dig Surg 1992a; 9: 265-271. 3. Shafik
A. Pudendal canal decompression for the treatment of fecal
incontinence in complete rectal prolapse. Amer Surg 1996; 62:
339-343. 4. Shafik A. Pudendal canal syndrome: a new etiological
www.isucrs.org/
factor in prostatodynia and its treatment by pudendal canal
decompression. Pain Digest 1998b; 8: 32-36.
P081 ADEQUACY OF PROPOFOL ALONE AS SEDATIVE
AGENT FOR COLONOSCOPY, Shahrun Niza ABDULLAH
Suhaimi MS, MD. Lukman Mohd Mokhtar MD, Mohd Zailani Mat
Hassan MS, AZMI MD Nor MS, International ISLAMIC University
Malaysia
Background: The aim of this study was to assess the efficacy
of propofol as sedative agent compared with a combination of
tramadol and midazolam as sedo-analgesia for colonoscopy. We
assess the degree of tolerance and satisfaction among patients
with regards to both methods of colonoscopy using sedation or
sedoanalgesia as well as the time needed to reach the caecum
and post colonoscopy recovery period. Methods: 65 patients
underwent colonoscopy from 1st october 2006 till 30th April
2007. They were randomly assigned to 2 medication regimens.
For the propofol group, an initial intravenous bolus of 0. 5mg/kg
was given, followed by an intermittent bolus of 10mg (1cc) when
necessary. This drug was administered by an Anaesthetist. For
tramadol and midazolam group, an intravenous tramadol 25mg
and midazolam 2mg was given initially and then the dosage
was increased depending on the patients tolerance towards the
procedure. The drug was administered to its maximum dose
according to the patients body weight. The colonoscopy time was
calculated from the time the instrument entering the anus till it
reached the caecum. Patient assessments of pain and tolerance
were obtained at the time of discharge using visual analog scales
of 1 to 5. (1= no pain and 5 worst pain imaginable). Results: 65
patients were randomized in this study ( 34 propofol, 31 tramadol
and midazolam). 41 (63. 1%) of the patient were males and 24
(36. 1%) of the patients were females. Malay comprised of 61. 5%
Chinese 29. 2%, Indians 4. 6% and others 4. 6%. Conclusions:
Using propofol a sedation in colonoscopy provide better tolerance
in patients compared to conventional use of tramadol and
midazolam. The time for the procedure is shorter when propofol
is used. The recovery time from propofol is statistically shorter
than the recovery time from tramadol and midazolam (p=0. 044).
P082 COLORECTAL ANASTOMOTIC STRICTURE: IS IT
CAUSED BY INADEQUATE COLONIC MOBILIZATION?, P
Denoya MD, S Shawki MD, D Sands MD, J Nogueras MD, E Weiss
MD, S Wexner MD, Cleveland Clinic Florida
Anastomotic stricture is a complication which can be seen following
intestinal anastomoses. The etiology includes anastomotic
ischemia and tension. Splenic flexure mobilization and inferior
mesenteric vessel division are methods which are often used
to gain length and ensure a tension-free colorectal or coloanal
anastomosis. Objective: The study aimed to evaluate whether
patients who developed anastomotic strictures after left sided
colon resection had the splenic flexure mobilized and the inferior
mesenteric vessels divided at the first operation. Methods:
Patients referred for reoperation for colorectal anastomotic
stricture between 2001 and 2007 were identified through a
prospectively-collected perioperative database. Operative
reports were reviewed to identify the incidence of splenic flexure
mobilization and inferior mesenteric vessel ligation. Results:
22 patients were identified, with mean age of 61 years(29 to 78)
and mean BMI of 25. 6. Previous operations included anterior
resection(8), sigmoid resection(8), and proctectomy with coloanal
anastomosis(6). Previous diagnoses were rectal cancer(11),
diverticulitis(8), radiation proctitis after prostate cancer(1),
gunshot wound(1), and unknown(1). 18 patients had not had both
splenic flexure mobilization and inferior mesenteric vessel ligation
previously performed, while 2 patients had only had vessel
ligation. Thus, 91% of patients with anastomotic stricture had
incomplete left colonic mobilization. The operations performed
included excision of the previous anastomosis with a colorectal
anastomosis in 8, end-to-end or end-to-side coloanal anastomosis
in 3, coloanal anastomosis with colonic pouch reconstruction in 6,
and end colostomy in 5. 14 patients were diverted and 12 patients
had pelvic drains placed. Conclusion: While this study is limited
by its retrospective nature, as only patients who developed
strictures requiring surgery were evaluated, the data suggest that
lack of complete mobilization of the left colon at the time of first
operation is associated with anastomotic stricture formation. This
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retrospective study identified a 10: 1 incidence of incomplete left
colonic mobilization in patients with anastomotic stricture.
P083 ARE THERE DIFFERENCES IN POLYP TYPE AND
DISTRIBUTION IN MORBIDLY OBESE PATIENTS: A COHORT
COMPARATIVE STUDY, B Bashankaev MD, M Khaikin MD, R
Landmann MD, D Melero MD, Cleveland Clinic Florida
Data suggests an increased risk of colorectal cancer in the obese
population. The aim of the study is to compare the incidence
of colon polyps between obese patients undergoing bariatric
surgery versus a non-obese patient cohort. After IRB approval, a
retrospective review of prospectively maintained bariatric surgery
and endoscopy databases was performed identifying all patients
who had bariatric surgery and colonoscopy between February,
2000 to April, 2007. This Surgical Morbidly Obese Group (SMOG)
was matched to a Non-Obese Group (NOG) of patients undergoing
colonoscopy by age and gender. BMI before surgery and at time
of colonoscopy, age, gender, procedure, colonoscopic findings,
and pathology were reviewed. Seventy case-matched patients
were gathered from the 2332 patient bariatric surgery (SMOG)
and the 2165 patient endoscopy (NOG) databases. There was a
statistically significant difference in BMI at time of colonoscopy
(31 vs. 28, p<0. 04). The SMOG and NOG were equally balanced
for high-risk patients (21. 4% vs 25. 7%). SMOG colonoscopy
was postoperatively performed after a mean period of 23 (1-55)
months. Two-thirds of patients in both groups had no polyps (70%
SMOG, 77% NOG). Most polyps were single and were equally
distributed between the right and the left colon. Half of the polyps
in both groups were hyperplastic measuring 3 - 4mm. No cancer
was identified in the NOG; however, adenocarcinoma was found
in 2 patients (8. 3%) in the SMOG - 1 each in the cecum and
sigmoid. Both patients were not high risk for colorectal cancer and
postoperative colonoscopy was performed at 55 and 33 months,
respectively. The incidence of colorectal polyps and cancer was
not significantly different between SMOG and NOG patients
during a mean postoperative period of 2 years. Furthermore,
polyp distribution and pathologic characteristics were similar
between both groups. Though not statistically significant, this
study shows a trend towards development of malignant polyps in
morbidly obese patients. Long-term follow-up with preoperative
and postoperative colonoscopy is needed to accurately determine
any role of bariatric surgery in the development of colorectal
cancer.
Stomas
P084 PREOPERATIVE STOMA MARKING WITH HENNA:
IMPROVEMENT OVER PERMANENT TATTOOING, J Sanjay
MD, B Safar MD, S Shawki MD, H Marquez MD, M Boyer MD, J
Genua MD, D Sands MD, E Weiss MD, J Nogueras MD, S Wexner
MD, Cleveland Clinic Florida
Stoma creation is a common surgical procedure. Preoperative
stoma marking and education by an enterostomal therapist
has been shown to decrease postoperative stoma related
complications. We propose the use of henna as an improvement
over permanent tattooing for preoperative stoma site marking.
Methods: A prospective non-randomized pilot study was
performed in which 20 consecutive patients were preoperatively
marked with henna. Patient satisfaction and the effectiveness of
henna were evaluated. Results: Twenty patients (10 females)
were enrolled; mean age 55. 1. Seventeen of 20 markings were
visible at surgery. Two of the three failures were poorly visible;
one was not visible at surgery. All patients stated henna was
an improvement over permanent tattooing. Conclusion:
Preoperative stoma marking with henna is a safe and effective
alternative to permanent tattooing with India ink. Henna use
should strongly be considered for patients scheduled for surgery
with possible ostomy creation within 2 to 14 days of preoperative
stoma marking by enterostomal therapist.
P085 NEW SKIN CARE ELEMENT FOR PERI-STOMAL SKIN
ULCER WITH IBD, Katsuhisa Shindo, MD PhD, Satoru Numata
BA, Tetsuji Iwasaki MS, Kinki University School of Medicine,
Osaka Japan and Alcare Co. , Ltd. , Tokyo Japan
Purpose: Ileostomy with IBD makes often the skin trouble that is
not controlled by a dermatologist or an ET. Ceramide involved in
86
ISUCRS XXII BIENNIAL CONGRESS the skin barrier is to be evaluated for the treatment of peristomal
ulcer. Methods: Fundamental skin tests in five cases with normal
peristomal skin of about 20 years history and in two IBD cases
with ulcerated peristomal skin of several years history: Skin
surface pH by F-15 pH meter with a skin probe (HORIBA), Transepidermal water loss (TEWL) by AS-TW2 (ASAHI BIOMED), and
Macro/Derma-scopic inspection, before and after application of
the ceramide vs. conventional skin barriers. Results: (1) Ceramide
kept skin surface pH constant in all tested skins in spite of fecal
contamination: PH 4. 9 - 5. 1, (2) Ceramide put TEWL lower value
(16. 4 - 19. 6g/m²h) in all tested skin while reuse of the conventional
skin barrier recovered the skin to the usual one (26. 0 - 30. 9g/m²h)
in spite of wide range TEWL 10. 5 - 84. 7 before the ceramide
application, (3) All peristomal skin ulcer healed completely with
ceramide but reuse of the conventional skin barrier made ulcer
recur. Conclusions: Skin barrier with ceramide is effective for
the treatment of peristomal ulcer by keeping skin pH normal and
TEWL lower due to maintaining intercellular lipids intact.
Surgical Techniques
P086 LAPAROSCOPIC COLECTOMY COMBINED WITH
MINILAPAROTOMY APPROACH FOR SAFETY OPERATION
IN PATIENTS WITH COLORECTAL CANCER. , Kyoji Yamada
MD, Keiichirou Onoda MD, Shinichirou Noda MD, Norihio
Okamoto MD, Reina Kyoui, Ryuiichi Ohshima, Kiyoshi Narahashi
MD, Hideaki Kaneko MD, Takehito Ohtubo MD, Dept. G. I. Surg
and General Surg. Kawasaki Munincipal Tama Hospital
Laparoscopic colectomy have been rapidly improved for
advances of surgical technique and instruments. Although
many japanese medical institutes apply this surgery, Several
technical difficultes are still exsist. For example lymphnodes
dissection or intracorporeal anastomosis are difficult for beginner
of laparoscopic surgery. These difficulties are related with
operative complication of bleeding or anastomotic leackage.
Minilaparotomy approach for abdominal operation is one of less
invasive surgery. This operation use several unique instrument
and technique. Our institutes performed Laparoscopic colectomy
combined with minilaparotomy for safety operation. We introduce
this right hemicolectomy techinique for colon cancer. (Operative
method) i1jInsertion of laparoscopic trocher (4ports). i2jLigation
of Ireocecal artery under laparoscopic procedure. i3jMobilization
of the right colon from the retroperitoneum. i4j4~5cm length
median incision (minilaparotomy). (5)Division of oral and anal
side intestine using moving window method (6)Lymphonodes
dissection for the root of middle colic artery form minilaparotomy.
(7)Intestinal anastomosis. We have performed 20 cases of this
operation for colororectal cancer. There was no complication
without wound infection. This operation is less invasive similar to
laparoscopic surgery. We recommend this operation for beginner
of laparoscopic surgery.
P087 THE CIRCULAR STAPLER IN COLORECTAL SURGERY
- 30 YEARS ON, Bruce Waxman MSc, T C Nguyen, M Fisher,
Dandenong Hospital, Southern Health
Background: Whereas Russian engineers and surgeons were
the first to produce a circular stapler, with a single row of staples,
that simultaneously created a circumferential row of staples, and
resected two rings of bowel to produce an end to end inverted
anastomosis, the USA version, with a double row of staples was
released in 1977 and data first published in 1978, 30 years ago.
Discussion: This review will discuss the progress over the last
30 years with an emphasis on terminology, the effect of design
on anastomotic healing and complications specific to the circular
stapler (CS). Terminology: We recommend the terminology
described by Waxman et al in 1995. Design: The original design
of the bridge and has changed little over 30 years, as an identical
anastomosis is produced now as 30 years ago, viz., an inverted
anastomosis that heals by secondary intention, with fibrous
scar tissue. Most design changes have been in the staples, the
shape of the body and handle, the introduction of a spike and
disposability. Complications unique to the CS are: 1. Anastomotic
stenosis 2. Failure of staple closure. Conclusion: Little has
changed in the basic design of the circular stapler at the “firing
line”. Complications unique to the CS are related to the design
and with regard to stenosis have not been addressed. A CS with
ABSTRACT BOOK
Poster Papers
a single row of absorbable staples would solve the problem. We
may need to wait another 30 years. References: 1. Waxman BP,
Yii HK, Pahlman L Stapling in colorectal surgery In: Surgery of the
colon rectum and anus. Eds. Mazier WP, Levien DH, Luchtefeld
MA, Senagore AJ W. B. Saunders Coy. Philadelphia 1995 pp. 778
– 811
P088 CLINICAL CHARACTERISTICS OF HAND-SEWN
CIRCUMFERENTIAL MUCOSECTOMY IN HEMORRHOIDS,
Jung G Kang, Hong J Shim MD, Jong T Park MD, Yoon J Choi*
MD, Surgery and *Pathology, Ilsan Hospital, National Health
Insurance Corporation, Yonsei University
Purpose:
Stapler hemorrhoidectomy (hemorrhoidopexy)
does not excise hemorrhoid tissue, but instead repositions the
prolapsed hemorrhoid. We introduced hand-sewn circumferential
mucosectomy under direct vision as a new hemorrhoidectomy
method and evaluated its safety and effectiveness for the surgical
treatment of hemorrhoids. Method: We performed 108 handsewn circumferential mucosectomies between June 2003 and
December 2006. We evaluated the operating time, postoperative
course, and complications. Pain was evaluated using a visual
analog scale. Results: The mean patient age was 48 years and the
proportions of males and females were similar. The most common
indication was third-degree hemorrhoids. The mean operating
time was 37. 7 minutes and most of the operations took between
20 and 40 minutes. The average postoperative pain score was
5. 0 on the day of surgery and 3. 9 on the second postoperative
day. The time to the first bowel motion and the length of the
hospital stay averaged 1. 3 and 2. 5 days, respectively. The mean
time to return to work was 5. 2 days. There were no serious
complications with the hand-sewn circumferential mucosectomy.
Postoperative complications occurred in 31. 5% of cases. Urinary
complications were the most common. Conclusions: A handsewn circumferential mucosectomy is safe for the treatment
of hemorrhoids and there are no serious complications. The
operative pain, postoperative course, time to return to work, and
nature of complications are acceptable, although the operating
time is longer. A hand-sewn circumferential mucosectomy is
considered an effective new alternative for the surgical treatment
of hemorrhoids.
P089 ONE CASE OF PRIMARY POSTERIOR PERINEAL
HERNIA REPAIRED BY AN EXTRAPERITONEAL TECHNIQUE,
T Wada MD, M Hisada MD, Y Mori MD, K Katsumata, A Tsuchida,
T Aoki, Tokyo Medical University
Perineal hernia is a rare disease and, there are various
surgical procedures for it, including laparotomy, episiotomy,
and combination of laparotomy and episitomy, and recently,
laparoscopic surgery has also been performed. Herewith, we
report that we experienced primary perineal hernia repaired by
an extraperitoneal technique and a good outcome was obtained.
Case: A 63 year-old female. Paroxysmal spontaneous pain was
noted in the left gluteal region, an approximately 10-cm tumor
mass was detected in the left gluteal region with the patient in the
upright position, which was elastic soft and could easily return to
the pelvic cavity when pushed, and an approximately 4-cm hernial
orifice was palpated. Under general anesthesia, an approximately
10-cm-long incision was made in the median lower abdomen with
an upper margin on the pubis at the lower end, and subcutaneous
fatty tissue was incised with an electric scalpel. Rectus abdominis
fascia was incised in the median line to reach the anterior
peritoneal cavity. Bluntly detaching below the left rectus along
the left pelvic side-wall, a hernial sac penetrating the pelvic floor
to prolapse in the left rectum was found. The adhesion between
the hernial sac and surrounding tissues was sharply detached.
Thereby, the levator ani muscle was exposed, and there was a
gap in the ischial region and pubic region, and when the gluteal
skin was pushed from outside, this gap was penetrated, which
revealed this to be the herniac orifice. This gap was sutured
and closed with 3-0 Vicryl. Moreover, a ø10-cm polypropylene
mesh (Bard Modified Kugel TM Patch, Davol, Inc. ) was placed to
completely cover the hernial orifice, and the levator ani muscles
above and below the gap were fixed with a 3-0 Vicryl stitches. The
postoperative course was good, and the patient was able to walk
the next day and take meals. Left gluteal pain disappeared, and no
signs of recurrence have been detected to date.
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P090 OUTCOME OF DELORME PROCEDURE FOR
TREATMENT OF RECTAL PROLAPSE, Mohammad Sadegh
Fazeli MD, Amir H. Lebaschi MD, Ali Reza Kazemeini MD, Imam
Medical Complex
Objective: To evaluate the outcome of Delorme procedure
(transanal mucosal reefing) in treatment of patients with
rectal prolapse. Patients and Methods: In the department of
colorectal surgery at Imam Medical Complex (Tehran University
of Medial Sciences), in a prospective fashion, 48 patients with
rectal prolapse underwent transanal mucosal reefing. After the
procedure the patients were followed up. Results: There were
26 males and 22 females. Then mean age was 39 years (range:
17-78 years). Thirteen (27%) patients had only a history of chronic
constipation as the underlying condition. Nineteen (39%) had a
history of previous coloractal/anorectal surgery. Twelve (25%)
patients had fecal and/or gas incontinence. After the procedure,
the patients were followed up for a mean period of 24 months.
One patient (2%) reported recurrence of the prolapse, who then
underwent perineal sigmoidectomy. There were 3 new cases of
fecal/and or gas incontinence, and all resolved within 1 year postprocedure. Of the 12 patients with baseline incontinence, only 2
patients were still incontinence after 24 months. There were no
cases of sexual or urinary dysfunction. Conclusion: Although
Delorme procedure is said to be useful only in selected cases of
rectal prolapse, this study indicates a very high rate of success in
unselected patients. Delorme procedure may be used as the initial
surgery for these patients.
P091 AN IRRIGATION TECHNIQUE TO AID IN THE MUCOSAL
DISSECTION IN THE DELORME OPERATION, Bruce Waxman
MSc, T C Nguyen, W M K Teoh, M Fisher, Dandenong Hospital,
Southern Health
Background: The difficult part of the Delorme procedure is
dissecting a plane between the mucosa and internal sphincter
particularly if there is bleeding or scar tissue. Moreover, it is
best to avoid full thickness dissection of the rectal wall. We
have developed an irrigation technique to aid in this dissection.
Method: Patient is placed in the lithotomy position. The rectum
is prolapsed with several Babcock forceps. The submucosa is
infiltrated with 0. 5% Marcaine with 1/200, 000 adrenaline using
a 23 gauge needle in a circumference 2 cm from the dentate
line. Diathermy dissection with a needle point tip is commenced
at the same site as the infiltration. The free edge of the mucosa
is grasped with Babcocks and irrigation commenced with 1. 5%
glycine delivered with a urology giving set attached to a mixing
cannula at body temperature. The irrigation fluid is directed at the
line of dissection using the mixing cannula allowing diathermy
without the problem of electrolysis. Clear views of the “white”
line at the junction of the sphincter and the “pink” mucosa are
obtained. Moreover, the gravity feed of the irrigation provides a
degree of hydro-dissection which further opens up the planes.
Results: We have used this technique in the last 15 patients
without any full thickness rectal defects Discussion: We believe
the advantages of this irrigation technique are: 1. Providing
improved visualisation of the plane. 2. Hydro-dissection. 3.
Washing away of any blood. 4. Potentially reducing the chance of
a full thickness defect.
P092 RESEARCH AND APPLIANCE OF REUSABLE PPH
STAPLER, Gang Ma MD, GuiSheng Liu MD, XiangLong Liu MD,
Tianjin UMC, China
The most difficult problem to popularize the use of PPH technique
in developing country like China is the expensive cost owing to
the gun is impossible to be re-used. China now has produced
the PPH gun but they only produce the disposable gun, then it
is still in relatively expensive price and the disposed gun is also
a source of pollution. In order to avoid such defect, we designed
a new reusable PPH gun and have used it to perform the PPH in
408 cases all with satisfactory result. The design of the reusable
stapler has used metal EEA stapler of USSC as reference, it¡¯s
disposable cartridge and shape are similar to EEA gun, but its
long central rod can be totally pull out from the body of stapler.
The construction of this new PPH stapler is more compact, light in
weight, easily handle, simply strip down and sterilize after usage,
mounting of the new staples is not difficult, then one gun could be
87
ABSTRACT BOOK
Poster Papers
used repeatedly for many times. This new device is more feasible
for developing country, even though for developed country.
P093 DIAGNOSTIC YIELD OF COLONOSCOPY IN PATIENTS
WITH COLORECTAL SYMPTOMS, zailani Mat-Hassan MD,
Junaini Kasian MD, Khairussaleh Jalaludin MD, Yan Yang Wai
MD, Harbhajan Singh MD, Kyaw Tin Hla MD, Nasser MuhamadAmjad MD, Azmi Md-Nor MD, Department of Surgery, Faculty
of Medicine, International Islamic University Malaysia (IIUM),
Kuantan, Pahang, Malaysia
Background and Study Aims: Colonoscopy is the gold
standard for the diagnosis of colorectal diseases. The clinician
rely on patients symptoms, clinical signs, laboratory data, expert
knowledge of the literature and personal experience to decide
which patients require colonoscopic examination. Certain clinical
indications produce a higher diagnostic yield at colonoscopy
than others. We conducted a prospective study to evaluate the
yield of colonoscopy in patients with colorectal symptoms and
to determine which symptom(s) has a higher yield in detecting
neoplastic lesion. Our study aims to determine the relationship
between the colorectal symptoms with the colonoscopic findings
and identify which symptoms have more weightage in term of
clinical significance. Patients and Methods: A total of 583
patients with symptoms of colorectal neoplasm, namely; per rectal
bleeding, altered bowel habit and abdominal pain were included
in the study. Diagnostic yield was defined as the ratio between
significant findings detected during colonoscopy and the total
number of procedures performed for that indication. Results: In
the study, 55. 7 % of patients were male. According to age, there
were 48. 4% of patients were between 50 and 70 years of age,
39. 6% were between less than 50 years of age and 12. 0% were
more than 70 years old. According to the study, a combination
of per rectal bleeding and alteration in bowel habit constitutes
majority of cases who underwent colonoscopic examination (32.
4% and 26. 6% respectively). Among the patients who underwent
colonoscopy, 53. 7% of patients had positive findings and less than
one third of them were diagnosed to have either malignant growth
or polyps. Among those with positive findings, 29. 4% presented
with per rectal bleeding and 19. 4% had alteration in bowel habits.
Conclusion: The symptoms of rectal bleeding and alteration in
bowel habit have a higher diagnostic yield among symptomatic
patients who underwent colonoscopic examination.
P094 TRANSANAL ENDOSCOPIC LOCAL EXCISION OF
RECTAL TUMORS - CLINICAL AND FUNCTIONAL RESULTS
OF 90 PATIENTS. , Piotr Walega PhD, Roman M Herman PhD,
Jakub Kenig MD, Tomasz Cegielny MD, Marcin Nowak PhD,
Michal Nowakowski PhD, 3rd Department of General Surgery
Jagiellonian University Collegium Medicum
Transanal endoscopic excision of rectal tumors is an
accepted sphincter preserving technique in rectum surgery.
Detailed preoperative diagnostic procedures (histopathology,
endosonography) and functional assessment (manometry,
electromyography) are crucial for proper patients selection.
Aim: To determine clinical and functional results of patients
undergoing local excision for benign and malign lesions.
Material and Methods: 90 patients (54 male, 46 female, mean
age 68. 4) treated for rectal tumor with transanal endoscopic
rectal microsurgery technique at Department of Surgery. To
avoid postoperative sphincter dysfunction NO ointment was
routinely applied. Results: 75 patients were operated on for
benign rectal tumors, 6 for malign disease (T1) and 4 patients
due to miscelanous reasons (solitary ulcers, rectum stenosis,
rectovaginal fistula). Full-thickness excision was performed on 76
patients and submucosal local excision on 14. The mean distance
from the anal verge was 10. 6 cm. 34% of the lesions were located
on the anterior wall, 40% on the posterior and 17% on the side
wall. The mean operative time was 80 min (range 30-180 min).
Average blood loss was 45 ml (range 0-150 ml). The mean length
of stay was 3. 6 days (range 1-11 days). Peri- and postoperative
mortality was 0, 0%. Complication included urinary retention (4),
bleeding (2), wound dehiscence (1), rectocutaneous fistula (1).
Postoperative fecal incontinence was observed in 3 patients. In
the follow-up time between 6 and 46 months local recurrence rate
reached 6, 7% in the adenoma group and up to 30% in the malign
diseases group. Conclusions: Transanal endoscopic rectal
88
ISUCRS XXII BIENNIAL CONGRESS operation is a safe and cost efficient procedure for local excision
of selected patients with recital tumors. It significantly reduces
the number of postoperative functional disturbances what allows
to maintain good quality of life with acceptable local recurrence
rate and postopeative morbidity. Sphincter protection using
nitroglicerin ointment reduces also almost entirely possibility of
sphincter damage due to introduction of operational rectoscope.
P095 THE EFFICACY OF INTRAOPERATIVE COLONOSCOPY
FOR STAPLED ANASTOMOSIS IN THE TREATMENT OF
RECTAL CANCER, Toshiyuki Enomoto MD, Y Saida MD, Y
Nakamura MD, K Takabayashi MD, R Watanabe MD, A Otsuji
MD, M Katagiri MD, S Nagao MD, S Kusachi MD, M Watanabe
MD, J Nagao MD, Toho University Ohashi Medical Center Third
Department of Surgery
We have performed intraoperative colonoscopy for colorectal
resection with transnanal stapled anastomosis to eliminate
intra- and postoperative complications since January 2006. In
this study, we report the efficacy of this technique based on the
evaluation of cases that could successfully avoid complications.
Fifty-three cases of transanally stapled anastomosis from a total
of 68 rectal cancer cases of our department during January 2006
and December 2007 were evaluated. We performed intraoperative
colonoscopy for all of the 53 transanlly stapled anastomosis cases.
This technique is beneficial because staple line and bleeding
of anastomosis can be examined under direct inspection. We
experienced three abnormal findings(5. 7%). We created diverting
ileostomy for Two cases with imperfect anastomosis. The other
case with anastomotic lesion bleeding was treated with clipping.
P096 RECONSTRUCTION OF ANAL CUSHION LIKES TO
TREAT ANAL INCONTINENCE DEVELOPING AFTER TOO
EXTENSIVE HEMORRHOIDECTOMY: REPORT OF A CASE,
In-Geun Seo MD, Arumdaun Woori Clinic
Purpose: Fecal incontinence after hemorrhoidectomy may
occur and is socially incapacitating. There has been no report
of effective treatment for fecal incontinence caused by loss
of the anal mucosal folds and cushions. The author reports
a case, which underwent reconstruction of anal cushions for
management of anal incontinence complication after too extensive
hemorrhoidectomy. A Case Report: A 39-year-old male patient
presented to my clinic with profuse foul-odor discharge and pain
after hemorrhoidectomy, which was performed using laser under
spinal anesthesia for prolapsing hemorrhoids at another clinic
three days previously. Rigid proctosigmoidoscopy revealed an
extensive operative wounds and multiple thrombi in the anus.
To relieve painful anal symptoms, operative removal of thrombi
was performed under local anesthesia by the author. He had
no bowel movement after the hemorrhoidectomy, while he had
regular bowel movement everyday before. Eleven weeks after the
previous henorrhoidectomy he visited my clinic and complained
anal incontinence. Fecal soiling was noted 8 times since the
previous henorrhoidectomy. Digital examination and rigid
proctosigmoidoscopy revealed flat extensive hard scar tissue
without any prominent anal cushions or mucosal folds. Saline test
revealed anal leakage of saline. Anal ultrasound revealed no defect
in the internal and external sphincters. Therefore reconstruction
of anal cushion like folds was performed under local anesthesia
by the author. The reconstruction technique included longitudinal
division of the mucosa and anoderm with transverse closure. He
had not complained fecal soiling since the reconstruction surgery.
There was no anal leakage of saline on saline test performed
nineteen days after the reconstruction. Anal cushions are a part
of normal anorectal anatomy and are important in the continence
mechanism. Therefore, extensive removal may result in varying
degrees of incontinence. The reconstruction of anal cushion likes
is an effective treatment for anal incontinence resulting from loss
of anal cushions after extensive hemorrhoidectomy.
P097 A NEW STAGED APPROACH FOR THE THROMBOSED
CIRCUMFERENTIAL HEMORRHOIDS WITH ANAL FISSURE
TO AVOID COMPLICATIONS AND TO REDUCE OFF-WORK;
REPORT OF A CASE, In-Geun Seo MD, Arumdaun Woori Clinic
Purpose: In an attempt to avoid devastating complications such
as anal stricture, incontinence, and wet anus after the one-stage
surgery, I utilized a simplified procedure in step-by-step approach.
ABSTRACT BOOK
Poster Papers
In a case of the thrombosed circumferential hemorrhoids with
anal fissure, the one-stage hemorrhoidectomy can be associated
with significant morbidity. The one-stage hemorrhoidectomy
has been associated with severe postoperative pain, anal
stenosis and deformity with widespread fibrosis, ectropion or
incontinence. The author reports a case of ambulatory staged
operation under local anesthesia, which avoided these problems.
A Case Report: A 41-year-old man presented with severe anal
pain, swelling and anal bleeding. Physical examination revealed
thrombosed circumferential hemorrhoids and anal fissure. On
the day of the first visit, anal fissure operation and extracting
thrombi with a skin punch were performed under local anesthesia
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on outpatient basis. Seven days after this operation, the swelling
was resolved. Therefore the second procedure including excision
and ligation of the hemorrhoids was performed under local
anesthesia on outpatient basis. During and after these staged
procedures, no parenteral analgesic were required. A few doses
of oral analgesics were used. He could return to usual activity the
next day after operation. The result after the staged procedure
was an accurate reconstruction of a normal state with respect
to anatomy and function. Staged approach is effective to avoid
surgical complications. I recommend staged operation if there is
any risk of complications after the one-stage operation or when a
patient needs early return to work.
89
Notes
90

ISUCRS XXII Biennial Congress - International Society of University

Transcription

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