research projects

Abstracts
PAGE
• General Surgery Forum, GSF-1 – GSF-9 . . . . . . . . . . . . . . . . . . 1
• Research Forum, RF-1 – RF-7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
• Podium Presentations, S1 – S69 . . . . . . . . . . . . . . . . . . . . . . . . . 8
• Posters, P1 – P400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Compliance with Process Measures in Patients with Identified Infections at
Baseline and Final Quarter of Auditing Tool Implementation
General Surgery Forum
GSF-1
UNDERSTANDING IMPLEMENTATION OF SURGICAL QUALITY
IMPROVEMENT: AUDITING TOOL FOR SURGICAL SITE INFECTION
PREVENTION PRACTICES.
E. M. Hechenbleikner, D. Hobson, J. Bennett, R. Demski, B. Safar,
S. Gearhart, S. Fang, J. Efron and E. Wick Johns Hopkins, Baltimore, MD.
Purpose: Surgical site infections (SSI) are a largely avoidable cause of
patient harm. Evidence-based process measures are effective for SSI reduction but for many hospitals implementation has failed to translate to
improved outcomes. Implementation science is an emerging field of study
focused on improving the process of translating research evidence to everyday practice. We developed a tool to evaluate and address defects in implementation of SSI process measures among colorectal surgery patients.
Methods: We identified best practices, beyond SCIP, for SSI reduction
using the comprehensive unit based safety program (CUSP) and developed
a tool to assess compliance with practices (https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx). All colectomy patients (FY13)
with identified SSIs in our ACS-NSQIP database were reviewed in the electronic medical record using the tool and non-compliance with process
measures were surfaced and addressed by a multidisciplinary group of
frontline providers (CUSP team).
Results: Our baseline SSI rate (FY12) was 20% (84/397patients). After
use of the tool our rate decreased to 12% (35/275patients); p<0.05. The tool
surfaced many defects with process measure implementation (Table 1). The
CUSP team analyzed defects and, with executive support, developed system fixes to improve compliance. Improvement was seen with use of preop forced air warming devices [electronic flag placed on OR schedule to
identify patients for warming], incision temperature >36 degrees Celsius,
cefotetan redosing [education of CRNAs], use of chlorhexidine washcloths
[specific electronic patient education] and mechanical bowel preparation
with oral antibiotics before surgery [electronic patient education and bowel
preparation materials provided to patient by clinic when surgery scheduled].
Conclusions: Understanding implementation science is essential to
improving care. The SSI investigation tool combined with learning from surfaced defects approach is a practical strategy to improve integration of new
processes and optimize clinical outcomes. This is an iterative process which
requires patient, frontline provider and executive engagement.
Denominator based on the number of patients who were evaluated and/or
eligible for measure (i.e., patients with pre-op bowel obstructions were not
considered in the denominator for bowel preparation)
GSF-2
PATIENT PERSPECTIVE ON SURGICAL APPROACH.
S. Langness, B. Cosman, E. McLemore and S. Ramamoorthy Surgery, UC
San Diego, San Diego, CA.
Purpose: Minimally invasive techniques have seen exponential growth
over the last 20 years, and the drive for yet smaller incisions has created
newer techniques such as single-site and natural orifice surgery. The proposed benefits of earlier return of bowel function, decreased pain and
shorter hospital stay have yet to be clearly demonstrated in the literature.
Without a clear advantage to the technique, patient’s preference may
become an important factor in preoperative planning. The aim of this study
was to understand the patient’s perspective on operative approach and to
determine which aspect of the surgical experience was most important to
them.
Methods: One-hundred and twenty-eight random participants were
surveyed at 2 sites from March 2011 through December 2012. Patients were
provided images demonstrating incision types (Open (O), Laparoscopic
(Lap), Single-Site (SS) and Natural Orifice (NOTES)) and data was collected
regarding scar attractiveness, incision preference and Likert scoring regarding factors influencing choice.
1
Abstracts
Table 1. Adjusted outcomes and independent risk factors for post-colorectal
resection Clostridium difficile infection
Results: Sixty males and 68 females participants were surveyed. 53%
were between 18-29 years old, and 35% had undergone a prior abdominal
surgery. 48% felt that the most attractive scar was achieved with NOTES,
32% with SS, 20% with Lap and 0% for Open. 39% stated that they would
prefer a NOTES technique, 34% SS, 24% Lap and 3% Open. For all incision
categories, success of surgery was the most important factor (76%), followed by concerns for complication (55%). Post-operative pain and cosmetic appearance were least important. 89% of participants would pursue
a minimally-invasive specialized surgeon, and 69% were willing to pay out
of pocket expenses for this service.
Conclusions: While patients find smaller incisions more attractive, their
primary concern is for a safe and efficacious operation. As such, minimally
invasive approaches, such as NOTES and SILS, may need to demonstrate
advantages other than improved cosmesis in order for patients to strongly
advocate for their use. Our research does suggest that the general population prefers a minimally invasive approach to colon surgery with a willingness to seek out specialty-trained surgeons and incur additional expenses
for the use of these novel techniques.
GSF-3
CLOSTRIDIUM DIFFICILE INFECTION AFTER COLORECTAL SURGERY:
A RARE BUT COSTLY OUTCOME.
R. N. Damle1, N. B. Cherng3, J. S. Davids2, J. A. Maykel2, P. R. Sturrock2,
W. Sweeney2 and K. Alavi2 1Center for Outcomes Research, UMass
University Medical Center, Worcester, MA, 2Division of Colorectal Surgery,
UMass University Medical Center, Worcester, MA and 3University of
Massachusetts Medical School, Worcester, MA.
Purpose: Clostridium difficile infection (CDI) is being increasingly
observed in patients with minimal risk factors (i.e. antibiotics, hospitalization, immunocompromise). The characteristics of CDI following colorectal
resection are poorly studied. We aimed to define the incidence, risk factors,
outcomes, and direct cost of CDI following colorectal resection.
Methods: The University HealthSystem Consortium database was
queried for adults who underwent colorectal resection between 2008 and
2012 for cancer, diverticular disease, inflammatory bowel disease (IBD) and
benign neoplasm. CDI was defined by ICD-9 diagnosis code on initial hospitalization or as the primary diagnosis on readmission within 30-days. Outcomes analyzed were mortality, length of stay, complications, total direct
cost and readmission.
Results: A total of 84,648 adults with a mean age of 60 years and equal
gender distribution met inclusion criteria. Most (34%) patients had segmental colectomies for a diagnosis of cancer. CDI occurred in 1,266 (1.5%)
patients over the study period, but there was a non-significant trend
towards increasing rates between 2010 and 2012 (n=289, 328, and 352,
respectively). Table 1 outlines adjusted risk factors and outcomes for CDI.
The strongest predictors of CDI were emergent procedure, IBD, and high
severity of illness. CDI was associated with a higher rate of complications,
ICU admission, readmission rate and death within 30 days. The index stay
was a mean of 8.4 days longer, and $14,130 higher for CDI patients. The 294
CDI patients readmitted within 30-days, were more likely to require a nonhome discharge and had a higher combined total direct cost, ($39,344 vs.
$27,296 p<0.001) than the non-CDI readmissions.
Conclusions: Emergent procedures, higher severity of illness and
inflammatory bowel disease are significant risk factors for post-operative
CDI in colorectal surgery patients. Once established, CDI is associated with
worse outcomes and higher costs. A trend towards increasing rates coupled with poor outcomes and increased cost highlight the importance of
prevention strategies targeting high-risk patients.
GSF-4
CAN READMISSION BE PREDICTED IN NEW ILEOSTOMATES? A BIINSTITUTIONAL COHORT STUDY.
D. R. Fish1, C. Mancuso3, J. Garcia-Aguilar1, J. Guillem1, S. Lee2, G. Nash1,
P. Paty1, T. Sonoda2, M. Weiser1 and L. Temple1 1Surgery, Memorial Sloan
Kettering Cancer Center, New York, NY, 2Surgery, New York Presbyterian
Hospital - Weill Cornell Medical College, New York, NY and 3Medicine,
Hospital for Special Surgery, New York, NY.
Purpose: Patients with new ileostomies are among those most frequently readmitted after colorectal surgery. Existing data on patients at risk
is limited. This study evaluates the burden of readmission (RA), identifies
risk factors, and focuses on dehydration as a potentially preventable cause.
Methods: One thousand one hundred and ten records located by CPT
code at 2 tertiary care institutions from 5/2010-11/2012 were reviewed to
identify patients undergoing their first ileostomy, excluding stoma for palliation or non-GI diagnoses. Primary outcome was all-cause RA within 60
days post-op. Chi-square and logistic regression were used to evaluate allcause RA and dehydration RA; significant risk ratios (RR) and 95% confidence intervals (CI) are reported.
Results: 407 patients underwent new ileostomy. No difference in demographics or RA rate was observed between institutions other than disease
distribution. Overall, 58% had cancer, 31% IBD, 11% other primary diagnoses. 49% underwent LAR, 27% partial/total colectomy, 14% proctocolectomy, 11% other operations. Median stay was 8 days; 96% saw a stoma RN
after surgery; 92% went home with RN visits. Post-discharge, 13% had an
emergency room visit without RA; 12% received IV hydration without RA.
All-cause RA rate was 28% (113 patients), occurring at a median of 12 days
after discharge. 47 RA patients had dehydration, 35 abscesses, 26 other
infections, 15 obstruction, 7 required stoma revision. Independent predictors of all-cause RA were Charlson Comorbidity Index (RR 3.4, CI 1.4-8.1)
and Clavien complication grade (RR 4.0, CI 1.9-8.3). Among dehydration RA,
21 had dehydration alone, 7 also had abscesses, 15 other infections. Dehydration was more common in later, longer, or repeated RA. Independent
predictors of RA with dehydration were comorbidity index (RR 9.3, CI 3.128), complication grade (RR 3.3, CI 1.2-8.8), living alone (RR 2.3, CI 1.1-5.0),
2
Abstracts
Adherence to Universal MSI testing in CRC patients
and loop stoma (RR 4.6, CI 1.1-19).
Conclusions: New ileostomy patients with high comorbidity or severe
complications are at elevated risk for RA. Those living alone or with loop
stoma are especially at risk for dehydration-related RA. The burden of RA
and dehydration is high, and these patients should be targeted prior to discharge for increased outpatient care.
GSF-5
CHALLENGES IN THE IMPLEMENTATION OF UNIVERSAL LYNCH SYNDROME SCREENING FOR COLORECTAL CANCER PATIENTS: AREAS
FOR QUALITY IMPROVEMENT.
A. L. Hill, K. Sumra, J. Yoo, C. Ko, M. M. Russell and A. Lin Department of
Surgery, University of California at Los Angeles, Los Angeles, CA.
Purpose: Lynch syndrome (LS) is the most common form of hereditary
colorectal cancer (CRC). Since patients with LS have a 70% lifetime risk of
CRC and a high risk of several other associated cancers, the 2009 Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working
Group recommended that all patients with CRC undergo screening for LS
through microsatellite instability (MSI) or immunohistochemistry (IHC). Our
health care system began universal screening for LS using MSI in 2009. The
study aim was to evaluate our compliance with universal MSI testing and
identify potential areas for quality improvement.
Methods: Retrospective analysis of a prospectively maintained Cancer
Registry at University of California at Los Angeles (UCLA) was used to identify patients treated for CRC between 2010 and 2013. Data collected
included patient demographics, pathologic features, surgeon specialty, and
type of hospital.
Results: 262 patients with CRC were identified over a four-year time
period. 74% were screened for LS using MSI testing. There were no statistical differences in MSI testing rates when comparing patient demographics,
tumor location, or receipt of neoadjuvant treatment. However, testing was
significantly lower (p<0.0001) among patients with no residual tumor in the
pathologic specimen, indicating a complete response to neoadjuvant therapy, and patients treated by a colorectal surgeon (p<0.002) in an academic
hospital (p< 0.0001) shown in Table 1.
Conclusions: Despite a universal LS screening protocol and after
excluding those patients who had a pathologic complete response after
chemoradiation, 22% of CRC patients are not receiving MSI testing. Potential targets for quality improvement include increased communication
between the multidisciplinary care team for screen-positive cases,
improved provider and patient education on the importance of follow-up
testing for screen-positive cases, routine notification of genetic counselor
for screen-positive cases, and reflex screening protocols when there is a
complete pathologic response (e.g. IHC performed on initial biopsy).
GSF-6
LYMPHOVASCULAR INVASION HAS DIFFERING PROGNOSTIC IMPLICATIONS IN COLON AND RECTAL CANCER.
K. Chang1, E. T. Burton1, N. P. Kelly1, J. Hogan1, E. T. Condon1, D. Waldron1
and J. C. Coffey2 1Department of Surgery, Limerick University Hospital,
Limerick, Ireland and 24i Centre for Interventions in Infection,
Inflammation and Immunity, Graduate Entry Medical School, University of
Limerick, Limerick, Ireland.
Purpose: The correlation of lymphovascular invasion (LVI) and prognosis of colorectal cancer has not been fully characterized. Studies evaluating
LVI to date have included patients with colon cancer (CC) and rectal cancer
(RC). This study aims to evaluate the difference in outcomes between CC
and RC when LVI is present in tumor specimens.
Methods: Following ethical approval and informed consent, consecutive patients surgically treated for CC or RC from 2007 to 2010 at the Limerick University Hospital were analyzed. Disease-free survival (DFS) and overall survival (OS) were assessed for CC, RC and combined (CRC). Chi-square
and Kaplan Meier survival estimates were used to assess the outcomes of
patients with respect to LVI. Log rank test was used to compare survival
curves.
Results: A total of 527 patients were included in this study (349 CC and
148 RC). Study cohorts were similar in terms of age, gender and disease
stage. Local recurrence was adversely affected by the presence of LVI in CC
(p<0.01) but not in RC (p=0.13). Conversely, systemic recurrence was
adversely affected by the presence of LVI in RC (p<0.01) but not in CC
(p=0.28). DFS (p<0.01) was significantly worse when LVI was present in both
CC and RC (p<0.01). Only OS was adversely affected by LVI in CC (p<0.01).
These findings were confirmed on multivariate analysis.
Conclusions: LVI adversely affects prognosis in colon and rectal cancer
in different manners. LVI in RC is associated with increased distal metastases, while LVI in CC is associated with increased local recurrence. The
extent of the oncological excision of mesocolon and mesorectum in current practice may explain these findings. Further study is warranted to evaluate the role of total mesocolic excision in the treatment of colon cancer.
3
Abstracts
erence, HIV status, and comorbidities (all, p=NS). The majority of patients
were asymptomatic: 21 patients (22%) reported anal symptoms prior to
biopsy; 6 (6.2%) complained of pain, 13 (13%) complained of bleeding, and
10 (10%) complained of pruritis. 41 patients (42%) presented with anal
lesions. Patients with high-grade dysplasia presented with anal lesions less
frequently than patients with low-grade dysplasia (RR 0.72), but there were
no differences comparing symptomatology between groups (Table).
Patients with a CD4 count <200 cells/ml had a higher incidence of highgrade dysplasia compared to those with a CD4 count ≥200 cells/ml (RR 2.64;
p=0.02), but were less likely to present with anal lesions (RR 0.31; p=0.02)
and were frequently asymptomatic (82%; Table).
Conclusions: Anal dysplasia is a silent disease. The majority of patients
with anal dysplasia, regardless of grade, will have no anal symptoms, and
anal lesions are not a reliable predictor of disease. Particularly, patients with
CD4 counts <200 are high-risk for having asymptomatic high-grade dysplasia, and thus may benefit from routine screening with HRA.
GSF-7
SMOKING IS DOMINANT RISK FACTOR FOR ANASTOMOTIC LEAK
AFTER LEFT COLON RESECTION.
R. Baucom, B. K. Poulose, A. J. Herline, R. L. Muldoon and T. M. Geiger
Surgery, Vanderbilt University Medical Center, Nashville, TN.
Purpose: Although some risk factors for anastomotic leak after colectomy, such as radiation therapy, male gender, and level of anastomosis,
have been identified, other risk factors have not been well-defined. This
study aimed to evaluate risk factors for clinical leak after left-sided anastomoses.
Methods: Using our institutional Procedural Outcomes Database, adult
patients who underwent left colectomy between the years 2008-2012 were
identified. Exclusion criteria included post-operative stoma, diagnosis of
inflammatory bowel disease and emergent operation. Potential risk factors
for leak were collected including: smoking status, body mass index (BMI),
sex, diagnosis of diabetes mellitus, indication for surgery, steroid use, level
of anastomosis, type of leak test performed, and pre-operative chemotherapy or radiation therapy. The primary outcome was anastomotic leak within
30 days which required percutaneous drainage or operative intervention.
Results: There were 246 patients who met inclusion criteria. The mean
age was 59 years, 44% (n=109) were male, and the majority underwent
resection for cancer (37%) or diverticular disease (53%). The anastomotic
leak rate was 6.5% (n=16). The modality of endoscopic leak test, BMI, and
indication for surgery did not predict leak. Importantly, 17% of smokers
developed a leak compared to 5% of non-smokers. Even after adjusting for
confounding factors, smokers had over five times greater chance of leak
than non-smokers (Table).
Conclusions: Among the many factors evaluated in this study, smoking
was strongly associated with anastomotic leak after left colectomy. Patients
should be counseled appropriately about the significant increase in leak
rate associated with smoking. Consideration should be given to delaying
elective left colectomy until smoking cessation is achieved.
Patient Symptomatology based on Anal Dysplasia and CD4 Count
GSF-9
DOES TNF INHIBITOR TREATMENT PRIOR TO SURGERY FOR SMALL
BOWEL CROHN’S DISEASE MODULATE DISEASE SEVERITY AND MINIMIZE SURGICAL INTERVENTION?
L. Maguire1, A. G. Olariu1, C. W. Hicks2, R. A. Hodin1 and L. Bordeianou1
1
Surgery, Massachusetts General Hospital, Boston, MA and 2Surgery, Johns
Hopkins University, Baltimore, MD.
Risk Factors for Leak After Left Colectomy
Purpose: Patients with Crohn’s disease are frequently treated with
tumor necrosis factor inhibitors (TNFIs) prior to surgery. It has been suggested that TNFIs decrease disease severity, resulting in the need for less
bowel to be resected.
Methods: Review of a prospectively maintained database identified 142
patients with Crohn’s undergoing ileocolonic resections (2008 -13). Demographics, medical history, operative reports, and pathology data were collected. Patients were grouped TNFI use in the 6 weeks prior to surgery. Univariate and multivariate analyses were used to compare the groups.
Results: 55 (39%) patients had preoperative exposure to TNFIs, the
majority (81%) on a maintenance regimen. TNFI-exposed patients were similar to TNFI-naive patients, without differences in comorbidities, stricturing
(74.7% vs 80.0, p=0.47) or penetrating (46.% vs 36.3, p= 0.26) disease behavior, inflammatory markers, Rutgeerts score (3.66 vs. 3.62, p= 0.81), concomitant steroid use (51.8% vs 54.6%, p= 0.75), or demographics, except for
older age in the no TNFI group (40.3 vs 35.2 years, p=0.005) . Indications for
ileocolectomy varied. Obstructive symptoms were the most common indication. 22% of cases were urgent, with no difference between groups, and
52% were performed laparoscopically. Concomitant strictureplasty rates
were similar (5.75% vs. 3.64%, p= 0.57). Complication rates were the same
in both groups (29.9 vs 21.8%, p= 0.29) and leak rates were low (1.15% vs
3.64%, p=0.26). On final pathology, there was no difference in the length of
small bowel resected. Furthermore, disease phenotype was unchanged.
There were no differences in the severity or type of inflammation (Table 1).
Subgroup analysis of patients on maintenance doses of TNFIs did not alter
results. On multivariate analysis, medical regimen did not alter pathological findings, presence of inflammation, or postoperative complications.
Conclusions: Pre-operative exposure to TNFIs in patients with ileocecal
Crohn’s disease does not alter resection length or disease severity. These
GSF-8
HIGH-GRADE ANAL INTRAEPITHELIAL NEOPLASIA: A SILENT DISEASE.
C. W. Hicks, J. Efron, S. L. Gearhart, B. Safar, E. C. Wick and S. H. Fang
Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
Purpose: High-resolution anoscopy (HRA) is becoming increasingly
advocated as a method of screening for anal dysplasia in high-risk patients.
However, national guidelines for routine screening do not exist, and indications for HRA in asymptomatic patients are poorly defined. Our aim was to
describe the association between patient symptomatology and anal dysplasia through HRA findings.
Methods: A retrospective review of our IRB-approved institutional HRA
database examined all patients undergoing HRA with biopsy (11/201110/2013). Patient demographics, symptoms, and pathology were recorded.
Univariate analysis was performed to evaluate 1)overall symptoms; 2)breakdown of symptoms based on high-grade vs. low-grade vs. no dysplasia; and
3)breakdown of symptoms by CD4 count.
Results: Over the 2-year study period, 179 HRA biopsies (1.85±0.11
biopsies/patient) were obtained from 97 patients (mean age 46.2±1.21
years, 60.8% male, 71.1% HIV-positive). 27 (28%) patients had high-grade
dysplasia, 26 (27%) patients had low-grade dysplasia, and 44 (45%) patients
had no dysplasia. All study groups had similar age, race, gender, sexual pref-
4
Abstracts
xenograft volume in the XRT + iCRT14 group was 174.71 mm3, vs. 728.59
mm3 for DMSO (P = 0.0001) and 240.04 mm3 for XRT alone (P = 0.04). Similar results were observed at day 13 for iCRT3. (See table).
Conclusions: Our results demonstrate that inhibitors of β-catenin
responsive transcription (iCRTs) augment response to radiation in both in
vitro and in vivo models of CRC. It is anticipated that use of these iCRTs in
combination with XRT may increase the percentage of patients with LARC
achieving a pCR.
data argue against initiation of TNFIs in patients who are already severely
symptomatic and likely to need surgery
Pathology Findings in Patients with and without TNFI Use
In vitro and In vivo results of XRT +/- iCRT3/14
P values for XRT and iCRT3 are vs. DMSO; P values for XRT + iCRT3/14 are vs. XRT
alone; *iCRT3 was held after Day 13 due to animal toxicity, therefore measurements
of xenograft volume are for day 13 vs. 264.5 mm3 for DMSO and 165.6 mm3 for XRT
alone
RF-2
APOLIPOPROTEIN A2 IS ASSOCIATED WITH RESISTANCE TO
CHEMORADIATION AND METASTATIC DISEASE IN COLORECTAL
CANCER.
G. Gantt1, Y. Chen2, K. DeJulius1, A. G. Mace1, J. Barnholtz-Sloan2 and
M. F. Kalady1 1Colorectal Surgery, Cleveland Clinic Foundation, Cleveland,
OH and 2Case Comprehensive Cancer Center, Cleveland, OH.
Research Forum
RF-1
Purpose: Metastatic disease and resistance to neoadjuvant chemoradiation (CRT) are poor prognostic indicators in colorectal cancer. Identifying
factors associated with resistance and metastases could provide novel therapeutic targets to improve patient outcomes. The aim of this study was to
identify genes associated with aggressive colorectal disease.
Methods: Pre-treatment rectal adenocarcinoma biopsies, primary colorectal specimens, and liver metastases were collected according to an IRBapproved protocol. Rectal cancer patients being evaluated for response to
therapy underwent long course neoadjuvant radiation and 5-FU based
chemotherapy followed by surgical resection. Resection specimens were
evaluated for response using American Joint Committee on Cancer (AJCC)
criteria. Tumor mRNA extracted from pre-treatment biopsies, colorectal
specimens, and liver metastases was evaluated for gene expression levels
using high-throughput microarrays on an Illumina platform. Gene expression values were compared between non-responders (AJCC grade 3), and
responders (AJCC grades 0-2), and between primary and metastases using
the Wilcoxon t-test. Genes which were significantly differentially expressed
were verified using qPCR. In silico analysis was performed using Oncomine.
Results: 33 matched pre-treatment biopsies and resection specimens,
and 14 matched primary and liver metastases were used to determine gene
expression levels by microarray. Apolipoprotein A2 (APOA2) was found to be
significantly over expressed in resistant rectal samples compared to partial
and complete responders (fold change=407, p=0.03). Similarly, APOA2 was
upregulated in liver metastases compared to primary tumors (fold
change=37.9, p=0.0002). Higher expression levels of APOA2 by microarray
were confirmed by qPCR (p<0.0001). As an independent validation, in silico
analysis confirmed APOA2 is upregulated in colorectal cancer distant
metastasis (p<0.0001).
Conclusions: APOA2 is associated with resistance to CRT and metastastic spread in colorectal cancer. APOA2 may be a potential therapeutic target to augment response to CRT and alter metastatic progression.
NOVEL INHIBITORS OF WNT/β-CATENIN RESPONSIVE TRANSCRIPTION AUGMENT RESPONSE OF HCT116 CRC CELLS TO RADIATION IN
VITRO AND IN VIVO.
H. G. Moore1, M. Murphy3, M. S. Flaherty3, K. Abhichandani3, K. Du2,
H. L. Pachter1 and R. DasGupta3 1Surgery, NYU School of Medicine, New
York, NY, 2Radiation Oncology, NYU School of Medicine, New York, NY and
3
NYU Cancer Institute, NYU School of Medicine, New York, NY.
Purpose: Preoperative chemotherapy and radiation (XRT) is indicated
for locally advanced rectal cancer (LARC), but only 25% achieve a pathologic complete response (pCR). The Wnt/β-catenin signaling pathway
appears to mediate, in part, radiation resistance in LARC. We have previously identified small molecule inhibitors of β-catenin responsive transcription (iCRTs) that show efficacy against colorectal cancer (CRC) in vitro and
in vivo. Our aim was to investigate the ability of iCRTs to augment radiation
response using HCT116 CRC cells and HCT116-derived murine xenografts.
Methods: HCT116 CRC cells (β-catenin mutated) were plated in six well
plates and exposed to 3 Gy XRT vs. no XRT. After 24 hours, cells were
exposed to 25 mM iCRT3 (or DMSO control) for 48 hours, followed by colony
count using a standard clonagenic assay and assessment of apoptosis by
FACS analysis using Annexin V and propidium iodide (50 mM iCRT3 used in
apoptosis assay). 5 x 106 HCT116 cells were injected in the SQ flank in
athymic nude mice and xenografts were allowed to reach approximately
145 mm3 (Day 6). Animals were then treated with 2 Gy XRT M-W-F x 2 weeks
vs. no XRT, as well as iCRT3 (75 mg/kg) or iCRT14 (50 mg/kg) intraperitoneal
qD x 5 for three weeks vs. DMSO control. Xenograft volume was measured
every 3-4 days. P values were calculated using unpaired t-test (GraphPad
Prism software).
Results: Total colony count was reduced by 21% with XRT vs. DMSO
(264 vs. 334, P = 0.015) and 47% following treatment with XRT + iCRT3 vs.
XRT alone (140 vs. 264, P = 0.0001). Similarly, apoptosis was increased by
2.7 fold following XRT + iCRT3 vs. XRT alone (68% vs. 25%). At day 24, mean
5
Abstracts
Conclusions: 1) The BMI1 and DCLK1 stem cell markers are elevated in
the mucosa of CD patients. This suggests a function for the utility of an
additional stem cell population in response to bowel injury. 2) In addition,
this mechanism seems to be limited to adult multipotent stem cells; the
embryonic stem cells do not appear to contribute to mucosal regeneration
in CD patients. 3) The observed reaction may represent a systemic intestinal event as these changes are similar in diseased and normal small bowel
in CD patients.
RF-3
PRECURSOR COLON CANCER STEM CELLS (PCCSC) EXHIBIT METASTASIS IN AN ORTHOTOPIC MURINE MODEL.
S. Chen1, R. C. Fisher1, L. A. Molina1, M. C. Rule1, T. A. Randi1,
H. D. Appelman2 and E. H. Huang1 1Department of Surgery, University of
Florida, Gainesville, FL and 2Department of Pathology, University of
Michigan, Ann Arbor, MI.
Purpose: We previously demonstrated that epithelia from human colitis initiate colon cancer in a heterotopic, subcutaneous implantation model.
These cells, known as pCCSCs, develop anaplastic tumors that, over serial
passaging, develop into poorly differentiated adenocarcinoma, mimicking
the development of colitis-associated cancer (CAC). Collectively, these studies strongly suggested for the first time that CAC is initiated and sustained
by a self-renewing stem cell population, which merits further investigation.
Here we demonstrate the metastatic capacity of pCCSCs in an orthotopic,
cecal implantation model. Further, we define metrics for evaluating severity of metastases, thus providing an important tool for investigating factors
influencing CAC metastasis.
Methods: We generated metastatic tumors by injecting either 5000
colon cancer stem cells (CCSCs) from sporadic colon cancer, or 5000 pCCSCs into the cecal wall of immunocompromised mice. Both pCCSCs and
CCSCs were transduced with firefly luciferase and the progression of tumor
development was monitored with in vivo bioluminescent imaging (BLI). The
mice were imaged intact, and again with organs exposed at necropsy.
Metastasis was confirmed by histology. The Pearson correlation coefficient
was applied to assess the correlation between imaging signal strength and
histology.
Results: Both pCCSCs (2 isolates, n=39) and CCSCs (2 isolates, n=83)
developed either or both lung and liver metastases (pCCSC=25%,
CCSC=82%). Both lymphatic and vascular invasion were observed. When
imaged with closed abdomen, signal strength from liver significantly correlated with histological severity (r=0.32, p<0.05). When imaged at necropsy,
BLI signal strength positively correlated with histological severity for both
liver (r=0.55, p<0.0001) and lung (r=0.33, p<0.01) metastases.
Conclusions: We demonstrate for the first time that CCSCs, and particularly pCCSCs have the capacity to metastasize in an orthotopic model of
colon cancer. We also validate that BLI not only confirms the histology but
also quantifies the spread of metastases, reaffirming the important role of
in vivo imaging in evaluating factors influencing colon cancer metastasis.
RF-5
LOSS OF THE ARYL HYDROCARBON RECEPTOR INCREASES SUSCEPTIBILITY TO COLON TUMOR FORMATION.
S. Ronnekleiv-Kelly1, M. Nukaya1, P. Geiger1, C. Diaz-Diaz1, S. Balbo3,
S. Hecht3, C. Bradfield2 and G. Kennedy1 1Department of Surgery,
University of Wisconsin School of Medicine and Public Health, Madison,
WI, 2McArdle Laboratory for Cancer Research, University of Wisconsin
School of Medicine and Public Health, Madison, WI and 3Masonic Cancer
Center, University of Minnesota, Minneapolis, MN.
Purpose: The aryl hydrocarbon receptor (AhR) is a multifunctional protein responsive to numerous exogenous and endogenous compounds. Certain chemicals that activate AhR are associated with lower incidence of
colon tumors. Additionally, AhR is integral for maintenance of colonic
epithelium integrity. Although protective within the colon, a correlation
between AhR and colon tumor formation has not been established. Therefore, we are investigating the role of AhR in colon tumorigenesis and
hypothesize that loss of AhR will result in increased susceptibility to colon
tumor formation.
Methods: At age 8 weeks, C57 BL/6J wild-type (WT), AhR global null
(AhRΔ2/Δ2) and triple receptor knock-out (TRKO) (Tnfrsf1a–/– / Tnfrsf1b–/–
/ Il1r1–/–) mice were given an intraperitoneal injection of azoxymethane
(AOM, tumor initiator), followed by dextran sodium sulfate (DSS, inflammatory inducer and tumor promoter), in drinking water on days 7-12. At age 5
months, the mice were sacrificed and colon harvested for evaluation. Fisher
exact and Wilcoxon rank sum tests were used for statistical analysis.
Results: After treatment, AhRΔ2/Δ2 mice incurred a 3-fold increase in
tumor number compared to WT mice (6.9±0.9 vs 2.4±0.5, p<0.01) (Figure
1). DSS exposure resulted in foreshortened colons, a marker for inflammation, in AhRΔ2/Δ2 mice (6.3±0.1 cm vs 8.2±0.2 cm, p<0.01) versus WT mice
which demonstrated no colon shortening (8.0±0.2 cm vs 8.2±0.3 cm). Additionally, inflammatory cytokines (IL-1β, IL-6, TNFα and MIP2) were increased
in the AhRΔ2/Δ2 mice. To test the role of inflammatory mediators in tumor
formation, TRKO mice were treated with the same protocol. Tumor multiplicity was decreased compared to WT mice (0.6±0.3 vs 2.8±0.5, p < 0.01)
(Figure 1).
Conclusions: DSS exposure resulted in greater inflammation in the
AhRΔ2/Δ2 group versus the WT mice, indicating that loss of AhR may predispose to increased inflammatory response and consequently heighten
susceptibility to tumor formation. Furthermore, mice lacking receptors for
the IL1-like inflammatory mediators demonstrated significantly decreased
tumor numbers. Future studies will focus on regulation of the intestinal
immune response by AhR.
RF-4
INTESTINAL STEM CELL ACTIVATION IN CROHN’S DISEASE: THE ROLE
OF QUIESCENT STEM CELLS.
E. Messaris1, L. Harris1, S. Deiling1, K. Vrana2, W. Koltun1 and N. CarkaciSalli2 1Colon and Rectal Surgery, Penn State University, Hershey, PA and
2
Pharmacology, Penn State University, Hershey, PA.
Purpose: To investigate the activation of intestinal stem cells in patients
with Crohn’s disease (CD).
Methods: Thirteen patients undergoing elective bowel resection (6 CD,
7 endoscopically unresectable polyps as controls) had full thickness biopsies and mucosa taken from the ileum of the resection specimens. In CD
patients, samples were obtained from diseased and non-diseased segments. Quantitative polymerase chain reaction (qPCR) was performed to
assess expression of stem cell related genes; LGR5, BMI1, OCT4, Nanog,
CD133, DCLK1, and MSI1. Immunohistochemistry was employed to detect
and quantify the stem cells.
Results: BMI1 and DCLK1, stem cell markers usually representative of
quiescence, were significantly higher in CD patients (p<0.05).The levels of
BMI-1 and DCLK1 were also increased in non-diseased bowel obtained from
CD patients compared to healthy controls (p<0.05). Embryonic stem cell
markers (OCT4, Nanog) were lower in CD compared to non-CD patients.
There were no differences in gene expression between the diseased and
non-diseased areas of bowel in CD patients (p>0.05).
6
Abstracts
RF-7
GENETIC DETERMINANTS ASSOCIATED WITH EARLY AGE OF DIAGNOSIS OF INFLAMMATORY BOWEL DISEASE.
T. M. Connelly1, A. S. Berg2, L. Harris1, D. Brinton1, S. Deiling1 and
W. A. Koltun1 1Division of Colon and Rectal Surgery, Milton S. Hershey
Medical Center, Penn State College of Medicine, Hershey, PA and
2
Department of Biostatistics, Milton S. Hershey Medical Center, Penn State
College of Medicine, Hershey, PA.
Purpose: Inflammatory Bowel Disease (IBD) is usually diagnosed at 2040 years of age, but very young vs elderly IBD patients may have differing
mechanisms of disease that could affect eventual treatment . To date, over
100 genes and 300 single nucleotide polymorphisms (SNPs) have been
associated with IBD. Our aim was to identify SNPs associated with age of
onset of either Crohn’s disease (CD) or ulcerative colitis (UC).
Methods: 328 CD patients and 307 UC patients were genotyped on a
custom microarray chip containing 332 SNPs known to be associated with
IBD. First, linear regression was used to assess age at diagnosis as a continuous variable. Patients were then sub-grouped by age at diagnosis: 60
CD/25 UC patients were <16 years old, 257 CD/260 UC were aged 16-60
and 11CD/22 UC were >60 years old and compared by Fischer’s Exact test.
Bonferroni correction was used in all analyses.
Results: The NOD2 SNP rs2076756 was associated with younger age at
diagnosis in CD (p=.00018 after correction). AA wild type homozygotes
(n=131) were diagnosed at the mean age of 31.9+/-1.23, AG heterozygotes
(n=136) at 25.6+/-.99 and GG at risk allele homozygotes (n=61) at 22.6+/1.32. The POUF5 associated SNP rs3130501 approached significance in the
linear model and was subsequently significantly associated with an age of
diagnosis < 16 when compared to >60 (p=.017 corrected). No genetic associations were seen between UC and linear age at diagnosis, however the G
allele of the LAMB1 SNP rs886774 was found to be associated with UC <16
vs >16 year old cohorts (p=.008).
Conclusions: This analysis re-affirms the association between NOD2, a
molecule of innate immunity, and early onset of CD. However this is the
first report of a possible association between early CD and the POUF5 gene
which interestingly is a stem cell marker and possibly associated with colorectal cancer, which has a known higher incidence in patients with longer
disease duration. The LAMB1 gene is associated with mucosal basement
membrane integrity and thus suggests a fundamentally different mechanism of early disease pathogenesis in UC vs CD.
Figure 1. Average colon tumor numbers after treatment with tumor protocol.
RF-6
HIGH EXPRESSION OF ZINC FINGER PROTEIN X-LINKED IS ASSOCIATED WITH TUMOR PROGRESSION AND POOR PROGNOSIS IN COLORECTAL CANCER.
H. Wang1, Y. Liu2, X. Gao1, Q. Liu1, W. Chang2, Y. Du2, G. Cao2 and C. Fu1
1
The Department of Colorectal Surgery, Changhai Hospital, Second
Military Medical University, Shanghai, China and 2The Department of
Epidemiology, College of Basic Medical Sciences, Second Military Medical
University, Shanghai, China.
Purpose: Zinc Finger Protein X-Linked (ZFX) expression level correlates
with aggressiveness and severity of multiple malignancies. However little is
known about its role in the development of colorectal cancer (CRC). The
purpose of this research is to investigate the expression of ZFX in CRC, and
explore its action mechanism in CRC.
Methods: Tissue microarrays were constructed from specimens of normal rectal mucosa (n=53), colorectal adenomatous polyps (n=50), CRC
(n=718), familial adenomatous polyposis (FAP) with coexisting CRC (n=16)
and metastatic CRC (n=21), and assayed for ZFX expression immunohistochemically. Correlations between ZFX expression and clinicopathologic features and patient overall survival (OS) were analyzed. ZFX expression in
DLD-1 CRC cells was silenced by lentivirus-mediated RNA interference
(RNAi) to elucidate its role and possible mechanism. Statistical analysis was
performed using Mann-Whitney U test, Kruskal-Wallis test, Kaplan-Meier
method, log-rank test, Cox proportional hazards model, Paired Wilcoxon
test, chi-square test and Student t test (SPSS 17.0). A p<0.05 (two-sided)
value was considered statistically significant.
Results: ZFX expression increased from normal mucosa, adenoma,
stage I to stage IV CRC (P<0.001), and was found to be significantly associated with lymph node metastasis (P=0.002), distant metastasis (P<0.001),
TNM stage (P<0.001), differentiation (P=0.002) and OS (P<0.001). Both univariate and multivariate analyses indicate that high ZFX expression was an
independent prognostic factor of poor OS (p=0.012 and p=0.035 respectively). ZFX expression in FAP increased from normal mucosa to adenoma
(P<0.001), and from adenoma to carcinoma (P=0.030). Furthermore, ZFX
knockdown in DLD-1 cells delayed cell proliferation, inhibited colony
growth, and induced cell cycle arrest at the S and sub-G1 (apoptosis) phase.
Conclusions: ZFX may be involved in the progression of CRC. ZFX could
be used as an independent prognostic factor and a therapeutic target for
CRC. ZFX silence may inhibit cell proliferation and promote apoptosis by
inducing S and sub-G1 phase arrest.
SNPs and Genes Associated with Age of Onset in IBD
NOD2=Nucleotide-binding oligomerization domain-containing protein 2 (also
known as CARD15)
POU5F1=POU domain, class 5, transcription factor 1 (also known as OCT 4)
LAMB1=Laminin subunit beta-1
7
Abstracts
S2
Podium Presentations
DOES ALVIMOPAN SHORTEN LENGTH OF STAY IN PATIENTS UNDERGOING LAPAROSCOPIC COLECTOMY?
D. Mullins2, K. Johnson1, W. Sardella1, P. Vignati1, J. Cohen1, K. Thurston1,
I. Staff1 and D. Burba1 1Surgery, Hartford Hospital, Hartford, CT and
2
Surgery, University of Connecticut School of Medicine, Farmington, CT.
S1
THE EFFECT OF TRANSVERSUS ABDOMINUS PLANE BLOCKS ON
POSTOPERATIVE PAIN IN LAPAROSCOPIC COLORECTAL SURGERY: A
PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND TRIAL.
D. Keller1, B. O. Ermlich2, N. Schlitz3, B. J. Champagne2, H. L. Reynolds
Jr2, S. L. Stein2 and C. P. Delaney2 1Colon and Rectal Surgery, Penn State
Hershey Medical Center, Hershey, PA, 2Colon and Rectal Surgery, University
Hospitals-Case Medical Center, Case Western Reserve University, Cleveland,
OH and 3Epidemiology and Biostatistics, Case Western Reserve University,
Cleveland, OH.
Purpose: This study was conducted to determine if alvimopan reduces
length of hospital stay and has an effect on return of gastrointestinal (gi)
function on patients following laparoscopic colon resection enrolled in a
fast-track recovery pathway (FRP).
Methods: Patients undergoing elective laparoscopic colonic resection
were randomly assigned to receive either alvimopan or placebo during
their hospital stay using a double-blind approach. Cubist provided funding
for the alvimopan and placebo. Both laparoscopic and hand-assisted surgeries were included in the study. Post-operatively, all patients were placed
on a FRP with early advancement in diet. Overall hospital length of stay,
calculated times from surgery to first flatus or first bowel movement, and
the time needed to ingest a diet sufficient for discharge were recorded and
compared using Wilcoxon Ranked Sum tests. A Cox Regression analysis was
used to account for potential confounds of gender and age. The rates of
major in-hospital complications, ileus and nasogastric tube insertion, and
30 day re-admission rates were also recorded and compared using Fisher’s
Exact test.
Results: 132 patients were included in the study, 63 of which received
alvimopan. There was no significant difference in the length of hospital stay
(4 days vs. 4 days, p = 0.74), time to flatus (3230 vs. 3081 minutes, p = 0.44),
time to first bowel movement (3421 vs. 3162 minutes, p = 0.71), or any gi
function (2973 vs. 2899 minutes, p =0.36) amongst the placebo and alvimopan groups, respectively. There was also no significant difference in time
to tolerance of discharge diet and any gi function (3424 min vs. 2979 min,
p=0.26) between placebo and alvimopan groups. Gender was not shown
to have any impact, while increasing age was an independent predictor for
delaying gi function (OR = 0.985, p = 0.045). The complication rate (2.9%
vs. 4.8%, p = 0.67), rate of ileus and ng tube insertions (2.9 vs. 3.2%, p =
1.00) or re-admission rate (4.3% vs. 7.9%, p = 0.48) also had no statistical
difference amongst the groups.
Conclusions: Alvimopan has not been shown to be an effective means
of promoting earlier discharge and gi recovery in patients following laparoscopic colectomy placed on a FRP.
Purpose: To determine whether transversus abdominus plane (TAP)
blocks improve early postoperative outcomes in patients undergoing
laparoscopic colorectal resection already on an optimized enhanced recovery pathway (ERP).
Methods: Consenting patients undergoing elective laparoscopic colorectal resection were randomized to either a TAP block (15ml 0.5% Marcaine to the left and right transversus abdominis space) or placebo (normal
saline) placed intraoperatively under laparoscopic guidance. All were managed with a standardized ERP. Patient demographic, perioperative procedural, and postoperative outcomes were collected. The main outcome
measures were post-operative pain and nausea/ vomiting (PONV) scores in
the post anesthesia care unit (PACU) and floor, opioid use, length of stay
(LOS), and 30-day readmission rates for the TAP and control groups. Linear
regression with a generalized estimating equation (GEE) approach was used
to model opioid use and pain scores longitudinally.
Results: The trial randomized 41 patients to TAP and 38 patients to the
control group. Demographic, clinical, and procedural data were not significantly different. In PACU, the TAP group had significantly lower pain scores
(p<.01) and used less opioids (p<.01) than controls; PACU PONV scores were
comparable (p=.99). TAP had significantly lower pain scores on postoperative day 1 (p=.04) and throughout the study period (p<.01). There was no
significant difference between groups in postoperative opioid use (p=.65)
or PONV (p=.79). The LOS (median 2 days TAP, 3 days control; p=.50) and
readmission rate (7% TAP, 5% control, p=.99) was also similar across cohorts.
Conclusions: In a randomized double-blinded controlled trial, TAP
blocks improved immediate short-term opioid use and pain outcomes. Pain
improvement was durable throughout the hospital stay. However, the TAP
blocks did not translate into less overall narcotic use, shorter LOS, or lower
readmission rates. Longer acting agents may further improve patient outcomes and healthcare utilization in addition to those realized by
laparoscopy and ERP.
S3
RANDOMIZED CLINICAL TRIAL OF GOAL-DIRECTED FLUID THERAPY
WITHIN AN ENHANCED RECOVERY PROTOCOL FOR ELECTIVE COLECTOMY.
S. Srinivasa, P. P. Singh, T. Yu, M. H. Taylor, M. Soop and A. G. Hill
Christchurch Public Hospital, Auckland, New Zealand.
Purpose: Goal-Directed Fluid Therapy (GDFT) has been compared to
liberal fluid administration in non-optimised perioperative settings. It is not
known whether GDFT is of value within an enhanced recovery protocol
incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy.
Methods: Patients undergoing elective laparoscopic or open colectomy
within an established enhanced recovery protocol (including fluid restriction) were randomised to GDFT or no GDFT. Bowel preparation was permitted for left colon operations at the surgeon’s discretion. Exclusion criteria
included patients with rectal tumours and stoma formation. The primary
outcome was a patient-reported surgical recovery score (SRS). Secondary
outcomes included clinical outcomes and physiological measures of recovery.
Results: Eighty-five patients were randomised with 37 patients in each
arm following exclusions. Nine (GDFT) and four (restriction) patients
received oral bowel preparation for either anterior resection (n=12) or
subtotal colectomy (n=1). Patients in the GDFT arm received more colloid
Figure 1 TAP vs Control Pain Scores over Time
8
Abstracts
(Mean: 591mL vs. 297mL) intra-operatively and had superior cardiac indices
(Mean corrected flow time 374ms vs. 355ms; p= 0.02). However, no differences were observed between the groups (Restriction vs. GDFT) with
regards to surgical recovery (Mean Day 7 SRS: 46 vs. 47; p=0.85), other secondary outcomes (Day 1 Mean Aldosterone-Renin ratio: 8 vs. 9; p=0.90),
total postoperative fluid (2400mL vs. 3750mL; p=0.60), length of stay (5 vs
6 days; p=0.57) or complications (27 vs. 26; p= 1.00).
Conclusions: GDFT did not provide clinical benefits in patients undergoing elective colectomy within a protocol incorporating fluid restriction.
NCT00911391
S5
EARLY REMOVAL OF URINARY CATHETERS AFTER RECTAL SURGERY
IS ASSOCIATED WITH INCREASED URINARY RETENTION WITHOUT
DECREASED RISK OF URINARY TRACT INFECTION.
M. Kwaan, J. T. Lee, D. A. Rothenberger, G. B. Melton and R. D. Madoff
Surgery, University of Minnesota, Minneapolis, MN.
Purpose: Urinary retention after rectal resection is common. Prior
research has shown that an indwelling catheter until post-operative day
(POD) 5 decreases the risk of urinary retention. However, prolonged urinary
catheterization is a well-established risk factor for urinary tract infection
(UTI), therefore the ideal timing for urinary catheter removal after rectal surgery remains unclear. We hypothesized that urinary catheter removal at or
before POD2 would be associated with urinary retention.
Methods: Patients undergoing rectal resection for any indication at a
tertiary care institution from 2005 to 2010 were identified using ICD9 codes
and reviewed retrospectively. Day of urinary catheter removal was not standardized over this time period and was determined from review of daily
progress notes. We defined urinary retention as the need for urinary
catheter re-insertion in the perioperative period. High EBL was defined as
>600 cc (>75th percentile for the cohort). A multivariable model was constructed with clinically and statistically (p <0.2) significant variables using
the Fisher’s exact test in SAS 9.2 (Cary, NC).
Results: We identified 205 patients, 44 (21.5%) of whom developed urinary retention. Rates of urinary retention for patient subgroups are shown
in the Table. While univariate analysis showed that long operative duration
>3 hours (p=0.17) and EBL>600 cc (p=0.03) were associated with urinary
retention, only male sex (Odds Ratio 3.5 [1.5-8.1]) and urinary catheter
removal on POD 2 or earlier (Odd Ratio 4.3 [1.4- 12.9]) were independently
associated with urinary retention on multivariable analysis. Early catheter
removal was not associated with decreased UTI rates (p=0.25) but was associated with shorter LOS (6.5 versus 8.9 days; p =0.005).
Conclusions: In our cohort of patients who underwent rectal surgery
for cancer or benign indications, higher rates of urinary retention were seen
in patients who were male, had rectal cancer, or had a difficult procedure
(high EBL, long procedure time). Foley removal at POD2 or earlier was independently associated with urinary retention and not protective against UTI.
S4
NURSE STAFFING, INTENSITY-OF-CARE, AND READMISSIONS IN COLORECTAL SURGERY.
A. Gbegnon, J. M. Monestina, T. S. Sebolt and J. W. Cromwell Surgery,
University of Iowa Hospitals & Clinics, Iowa City, IA.
Purpose: Hospitals with high patient-to-nurse ratios are assessed
higher levels of CMS readmission penalties nationally. The influence of
nurse staffing on readmission in surgical populations is not known. Using
financial and readmission data, we wished to determine whether nurse
staffing was associated with readmission or length-of-stay (LOS) for colorectal surgery (CRS) patients, while adjusting for the overall intensity-ofcare (IOC) being delivered on the surgical unit where these patients are
cared for.
Methods: Inpatient CRS encounters of patients discharged from a single surgery unit from January 2011 to June 2013 were studied with regard
to readmission rates and LOS. Related, unplanned readmission rates for
each month were obtained from NSQIP. LOS was measured using the LOS
index. The overall IOC on the surgical unit during each month of the study
was evaluated by using a measure that we call the weighted units-of-service (WUOS). This measure is based upon total units-of-service (UOS,
defined as 24-hours of patient care) delivered each month and the MS-DRG
weight for each patient. We determined the mean hours of nursing care
provided for each UOS each month. For further analysis, we stratified the
dataset into low and high intensity months using the WUOS, such that
there were 15 months represented in each strata. Linear regression was performed to determine whether hours of nursing care per UOS predicted
readmission rates and LOS index in both strata.
Results: There were 497 CRS encounters with a 15% readmission rate.
In months where the IOC on the surgical unit was high, there was a significant inverse relationship between hours of nursing care and CRS readmission rate (Figure). There was no relationship identified between nurse
staffing and LOS.
Conclusions: Readmission rates in CRS patients are strongly influenced
by nurse staffing level and the IOC being delivered throughout the surgical
unit where they receive their care. We describe a simple measure of the IOC
on a patient care unit, based upon units-of-service and MS-DRG weights.
Using such objective measures of intensity-of-care could support a
redesign of current surgical unit staffing models to achieve the outcomes
that we desire.
S6
A NATIONWIDE ANALYSIS OF EFFECTS OF HYPOALBUMINEMIA ON
OUTCOMES OF COLORECTAL SURGERY PATIENTS.
Z. Moghadamyeghaneh, J. C. Carmichael, S. D. Mills, A. Pigazzi,
M. O. Dolich and M. J. Stamos General Surgery, University of California,
Irvine, School of Medicine, Orange, CA.
Purpose: There are limited data regarding the effects of hypoalbuminemia on the outcomes of patients undergoing colorectal resection. We
9
Abstracts
sought to identify outcomes of patients with preoperative hypoalbuminemia following colorectal resections.
Methods: The National Surgical Quality Improvement Project (NSQIP)
database was used to evaluate all patients who had preoperative hypoalbuminemia (serum albumin<3.5mg/dl) before colorectal resection from
2005 to 2011. Multivariate regression analysis was performed to identify
the association of hypoalbuminemia with postoperative complications.
Results: We sampled a total of 78,841 patients undergoing colorectal
resection (total colectomy, partial colectomy, abdominoperineal resection
(APR), and pelvic exenteration), of which 16,238 (20.6%) had preoperative
hypoalbuminemia. The in-hospital mortality rate of patients who had
hypoalbuminemia was six times greater than patients without hypoalbuminemia (5.81 vs. 0.98, OR: 6.23, P<0.01). Postsurgical complications
affected by hypoalbuminemia include (P<0.01): ventilator dependency
more than 48hours (OR: 4.78), hospitalization more than 30 days (OR: 4.52),
unplanned intubation (OR: 3.43), unplanned readmission (OR:3.43), cardiac
arrest (OR: 3.37), acute renal failure (OR: 3.33), pneumonia (OR: 2.91),
myocardial infarction (OR: 2.26), wound disruption (OR: 1.99), urinary tract
infection (OR: 1.62), deep incisional surgical site infection (SSI) (OR: 1.56),
organ space SSI (OR:1.48), and superficial SSI (OR:1.14).
Conclusions: Hypoalbuminemia, with a prevalence of more than 20%,
is a common condition in patients undergoing colorectal resection. Patients
suffering from hypoalbuminemia are six times more likely to die following
colorectal resection. Postoperative pulmonary complications especially
ventilator dependency, and unplanned intubation also have strong associations with hypoalbuminemia. Large prospective trials should be planned
to confirm these findings and to evaluate if intervention in patients with
hypoalbuminemia is effective in decreasing postoperative complications.
hernia with use of SH/CMC (p=0.3). All surgeons subjectively felt closure
was easier in patients who had SH/CMC placed.
Conclusions: The use of SH/CMC in loop ileostomy creation significantly decreases operative time required for stoma closure. Results are
independent of patient factors, such as BMI, age, gender, or diagnosis and
there is no difference in complications with the use of SH/CMC.
S8
CAN WE USE NSQIP TO PROVIDE ACCURATE SURGEON SPECIFIC OUTCOMES?
A. K. Moss, P. Marcello, P. Roberts, T. Read, D. Schoetz, L. Rusin, J. Hall
and R. Ricciardi Lahey Clinic, Burlington, MA.
Purpose: The Institute of Medicine named the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) the “best in
the nation” for measuring and reporting surgical outcomes. We aimed to
determine the accuracy of NSQIP in identifying surgeon specific outcomes.
Methods: Surgeon specific NSQIP outcomes for 30-day mortality, reoperation, urinary tract infection (UTI), deep vein thrombosis (DVT), pneumonia, superficial surgical site infection (SSI), and organ space infection were
compared with all-inclusive institutional quality data on consecutive
patients undergoing a colorectal procedure from January 1, 2008 to
December 31, 2012. Annual and five-year surgeon specific outcomes were
calculated for the seven adverse events using NSQIP and institutional data,
and individual surgeons were categorized as high-outlier, average, or exemplary in relation to averages for the entire cohort. Concordance between
NSQIP and institutional data in identifying surgeon outliers was determined.
Results: A total of 6,459 operative encounters were identified in the
institutional data as compared to 1,786 NSQIP encounters (28% sampled).
NSQIP estimates of adverse events for the entire sampled cohort compared
well with institutional data. NSQIP sampled 22-35% of all individual surgeons’ cases. Yearly individual surgeon estimates were of little value due to
wide confidence intervals. Institutional and NSQIP five-year estimates
agreed in identifying surgeons as high-outlier, average, or exemplary for
adverse events in only 47% of cases. Concordance of surgeon specific
results was 57% for mortality, 43% for reoperation, 71% for UTI, 14% for
DVT, 14% for pneumonia, 71% for SSI, and 57% for organ space infection.
In 4 of 49 surgeon specific outcome categories (7 surgeons, 7 outcomes),
gross discordance was identified in which NSQIP identified a surgeon as a
high-outlier and the institutional database classified them as exemplary
(Table).
Conclusions: NSQIP sampling provided excellent hospital level results
for colorectal surgery. One-year surgeon specific estimates were of little
value. Five-year point estimates showed that NSQIP sampling does not provide accurate surgeon specific outcomes as compared to all-inclusive institutional data.
S7
USE OF SODIUM HYALURONATE/CARBOXYMETHYLCELLULOSE
BIORESORBABLE MEMBRANE (SEPRAFILM®) IN LOOP ILEOSTOMY
CONSTRUCTION FACILITATES STOMA CLOSURE.
D. M. Bertoni1, K. L. Hammond2, D. E. Beck1, T. C. Hicks1, C. B. Whitlow1,
H. Vargas1 and D. A. Margolin1 1Colon & Rectal Surgery, Ochsner Clinic,
New Orleans, LA and 2Section of GI and Laparoscopic Surgery, Medical
University of South Carolina, Charleston, SC.
Purpose: We hypothesized that the use of sodium hyaluronate/carboxymethylcellulose bioresorbable membrane (SH/CMC, Seprafilm®) placement at the time of loop ileostomy creation will decrease stoma closure
time without increased morbidity.
Methods: With IRB approval we retrospectively reviewed patients who
had loop ileostomy creation and closure between September 1999 and
December 2011. Patients were excluded for additional procedures at the
time of closure, midline laparotomy, or revision of stoma between surgeries. Patients were grouped based on SH/CMC placement around the
ileostomy at creation. Data was abstracted for age, gender, BMI, primary
diagnosis, reason for ileostomy, length of surgery, surgeon, interval
between surgeries, and post-operative morbidity. Statistical analysis was
performed using chi-square and t-tests.
Results: 408 patients were included in this review. 120 were excluded
based on our criteria. Group 1 (with SH/CMC) had 147 patients, and group
2 (no SH/CMC) had 145 patients. The groups were evenly matched according to age (49 vs. 48 ± 1.3), gender (76F:70M group 1, 66F:80M group 2;
p=1.3), BMI (25.2 ± 0.5 Group 1, 26.2 ± 0.48 Group 2, p=0.17), time interval
between creation and closure (111 days ± 12 Group 1, 117 ± 7 Group 2,
p=0.68) and diagnosis. The average surgical time required for stoma closure was significantly shorter in group 1 (46.4 minutes ± 2.7) compared to
group 2 (60 min ± 2.3) (p= .0001). There were no significant differences
between groups 1 and 2 in length of stay (4.6 vs. 4.9 days ± 0.2, p=0.42) or
wound infection at the stoma site. There were 8 infections in Group 1 (5%)
vs. 10 in group 2 (7%) (p=0.62). There was no increase in other complications including infections, ileus, bleeding, anastomotic leak, or stoma site
Urinary Tract Infection
10
Abstracts
Body Mass Index and Comorbidity
S9
OBESITY, REGARDLESS OF COMORBIDITY, INFLUENCES OUTCOMES
AFTER COLORECTAL SURGERY – TIME TO RETHINK THE PAY-FOR-PERFORMANCE METRICS?
I. Esemuede1, S. Lee-Kong1, D. Fowler2, D. Feingold1 and P. R. Kiran1
1
Colorectal surgery, New York Presbyterian Columbia University Medical
Center, New York, NY and 2General Surgery, New York Presbyterian
Columbia University Medical Center, New York, NY.
Purpose: An elevated body mass index (BMI) is associated with
increased morbidity and mortality after colorectal surgery. While the often
co-existent comorbid conditions are captured in some determinations of
case-severity, BMI is itself not factored into pay for performance (P4P) initiatives.
Methods: From the National Surgical Quality Improvement Program
database, obese (BMI>30 kg/m2) and non-obese (BMI<30 kg/m2) patients
with and without comorbidity undergoing colorectal resection from 20062011 were identified. Pre and intraoperative factors and postoperative outcomes were compared for obese and non-obese patients with and without
associated comorbidity.
Results: Of 60,987 patients, 31.7% were obese (Table). Most common
comorbidities were hypertension (51%) and diabetes (14.8%). Comorbid
conditions occurred in 74.4% obese and 65.1% non-obese patients. Among
obese patients, the rates of surgical site infection (SSI), wound dehiscence,
perioperative bleeding, reoperation, and various medical complications
were significantly higher for those with than without comorbidity. Obese
patients with comorbidity more commonly had renal failure, urinary tract
infection, failure to wean from the ventilator, overall SSI (18% vs. 12.8%,
p<0.001), wound dehiscence (2.9% vs 2%, p<0.001), and reoperation (9.6%
vs. 8.7%, p=0.004) than nonobese. Obese patients without comorbidity had
only increased failure to wean from the ventilator, overall SSI (14.6% vs.
10.7%, p<0.001) rates and wound dehiscence (1.7% vs 0.9%, p<0.001) than
non-obese patients. Patients without comorbidities, regardless of BMI, had
similar rates of perioperative bleeding and 30-day mortality (p=0.18 and
0.3, respectively).
Conclusions: After operations that involve colorectal resection,
although the comorbid factors associated with obesity determine outcomes, obesity itself in the absence of these factors leads to certain worse
outcomes. These findings support the inclusion of obesity as a factor in any
determination of case-severity, quality, and reimbursement after colorectal
surgery including P4P initiatives.
a= statistically significant for comparisons between BMI<30 with comorbidity
and BMI>/=30 with comorbidity
b= statistically significant for comparisons between BMI<30 without comorbidity
and BMI>/=30 without comorbidity
c= not statistically significant (p>0.05) for comparisons between BMI<30 with
comorbidity and BMI>/=30 with comorbidity
d= not statistically significant (p>0.05) for comparisons between BMI<30 without
comorbidity and BMI>/=30 without comorbidity
S10
PREOPERATIVE HOSPITALIZATION – A RISK FACTOR FOR VENOUS
THROMBOEMBOLISM AFTER COLORECTAL SURGERY: AN NSQIP
STUDY.
S. W. Greaves and S. D. Holubar Surgery, The Dartmouth Institute for
Health Policy & Clinical Practice, Lebanon, NH.
Purpose: Virchow’s triad states an important etiologic factor in venous
thromboembolism (VTE) is stasis; thus presurgical hospitalization may contribute to VTE risk. We hypothesized that pre-operative hospitalization is a
risk factor for VTE.
Methods: This study used the National Surgical Quality Improvement
Project (NSQIP) (2005-2011), limited to colorectal surgery patients (CPT’s
44xxx - 46xxx). Days from hospital admission to surgery were capped at 30
days and categorized as either same day surgery or pre-surgical hospitalization; analyses capped at 7 days were also performed. VTE was defined as
deep vein thrombosis (DVT) or pulmonary embolism (PE). Analysis included
univariate analyses, parsimonious multivariable logistic regression model
development and stratified propensity score analysis.
Results: We identified 348,221 colorectal surgery patients (mean age
54 years; 51.6% female; mean BMI 27.7) with 26.6% hospitalized pre-operatively. The overall rate of VTE was 1.51% (DVT only: 1.02%; PE only: 0.38%).
Both univariate and multivariable regression analyses showed a doseresponse relationship between pre-operative length of stay and risk of
post-surgical VTE (p<0.001). Strongest univariate predictors of post-operative VTE were unplanned intubation (2.15% [no VTE] vs. 13.5% [VTE],
p<0.001) and chronic steroid use (4.9% [no VTE] vs. 12.0% [VTE], p<0.001).
On multivariable analysis, the most predictive variables were return to operating room (1.72 OR, 95% C.I. 1.56 – 1.90, p<0.001) and unplanned intubation (1.69 OR, 95% C.I. 1.50 – 1.90, p<0.001). Pre-surgical hospitalization was
11
Abstracts
a major independent predictor of post-surgical VTE (1.39 OR, 95% C.I. 1.30
– 1.50, p<0.001) while laparoscopic surgery was the most protective independent factor (0.63 OR, 95% C.I. 0.58 – 0.69, p<0.001). Propensity score
stratification (n=100, AUROC = 0.71) indicated pre-surgical hospitalization
(up to 7 days) increased the odds of VTE (1.43 OR, 95% C.I. 1.29-1.58,
p<0.001).
Conclusions: Pre-operative hospitalization is an independent, doseresponsive risk factor for VTE after colorectal surgery. These data suggest
that hospitalized patients at highest risk will benefit from more aggressive
preventative measures.
Conclusions: Ileostomy patients are twice as likely to return to the hospital after discharge, often to hospitals other than primary institution. This
represents a higher rate of healthcare utilization than previously described.
As post-discharge healthcare utilization becomes a measured quality metric, it is increasingly important to help patients safely transition to home.
Further studies are required to assess efficacy of interventions such as nurse
education or prolonged fluid monitoring on HBAC rates.
S12
THE CLINICAL AND FINANCIAL IMPACT OF READMISSIONS FOLLOWING COLORECTAL RESECTION: AN ANALYSIS OF PREDICTORS, OUTCOMES AND COST.
R. N. Damle1, N. B. Cherng3, J. S. Davids2, J. A. Maykel2, P. R. Sturrock2,
W. Sweeney2 and K. Alavi2 1Center for Outcomes Research, UMass
University Medical Center, Worcester, MA, 2Division of Colorectal Surgery,
UMass University Medical Center, Worcester, MA and 3University of
Massachusetts Medical School, Worcester, MA.
Dose-response curve of the effect of increasing pre-operative length of stay on
risk of venous thromboembolism.
Purpose: Following passage of the Affordable Care Act, 30-day readmissions have come under greater scrutiny, with penalties levied for higher
than expected readmission rates. We aimed to identify high-risk patients
for 30-day readmission following colorectal resection and illustrate the
financial impact of readmissions on the healthcare system.
Methods: The University HealthSystem Consortium database was
queried for patients undergoing colorectal resection for cancer, diverticular
disease, inflammatory bowel disease (IBD), and benign neoplasm between
2008 and 2012. Predictors of 30-day readmission were assessed with multivariable logistic regression. Additional endpoints included time to readmission, readmission diagnosis, readmission length of stay (LOS), and readmission cost.
Results: A total of 70,484 patients met study inclusion criteria, 13.7%
(9,632) of which were readmitted at least once within 30 days of discharge.
Mean age was 59, 50% were male, and most (32%) patients underwent
colectomy for cancer. After adjusting for potential confounders, risk factors
for readmission were analyzed (Figure 1). The strongest of these predictors
were: LOS ≥4 days* (1.44; 1.32-1.57), stoma (1.54; 1.46-1.51), and non-home
discharge (1.68; 1.57-1.81). Of those readmitted, half occurred within 7 days
of discharge, 13% required ICU care, 6% had a reoperation, and 2% died
during the readmission stay. The median combined total direct hospital
cost for readmitted patients was about two times higher ($26,917 v.
$13,817; p<0.001) than non-readmitted patients. Those readmitted within
7 days were more likely to have a reoperation (8% v. 4%, p<0.001), be
admitted to the ICU (14% vs. 12%, p<0.001), and had a longer median readmission LOS (5d vs. 4d, p<0.001). *Risk ratios reported as: (Odds Ratio; 95%
CI)
Conclusions: Thirty-day readmissions following colorectal resection
occur frequently and incur a significant financial burden on the healthcare
system. Highest-risk patients include those with longer LOS, stoma, and
non-home discharge. Future studies aimed at targeted interventions may
reduce readmissions and curb escalating healthcare costs.
S11
ACUTE HEALTHCARE RESOURCE UTILIZATION FOR ILEOSTOMY
PATIENTS IS HIGHER THAN EXPECTED.
J. Tyler1, J. P. Fox2, I. Raiche1, S. J. Quade1, S. Dharmarajan1, M. L. Silviera1,
S. R. Hunt1, P. E. Wise1 and M. G. Mutch1 1Colon and Rectal Surgery,
Washington University School of Medicine, St. Louis, MO and 2Wright State
University School of Medicine, Dayton, OH.
Purpose: Prior studies regarding postoperative ileostomy care focus
only on same-institution inpatient readmission. This may under-estimate
true readmission rates and healthcare utilization. Our goal was to determine the actual rates of healthcare utilization of new ostomates within 30
days of discharge.
Methods: We examined four state-level databases maintained by the
Agency for Healthcare Research and Quality and identified patients who
underwent colorectal surgery with primary anastomosis, colostomy, or
ileostomy between 2009-2010. Hospital based acute care (HBAC) was
defined as hospital admission or emergency department (ED) visit ≤30 days
of surgery at any facility in those states. We assessed HBAC utilization relationships between groups using multivariate regression accounting for differences in comorbidities, surgical indication, and frequency of perioperative complications.
Results: Of the 75,136 patients, cancer (36.1%) and diverticular disease
(22.0%) were common diagnoses. Procedures included: primary anastomosis (79.3%), colostomy (12.8%) and ileostomy (8.0%). Patients with primary
anastomosis were significantly less likely to have an HBAC event (16.2%)
compared to patients with colostomy (18.8%; adjusted OR=1.23 [95%
CI=1.17-1.30]) and ileostomy (36.1%; AOR 2.28 [2.15-2.42]). This trend persisted when analyzed as ED visits and readmissions alone (Figure 1). Among
ileostomy patients HBAC events were often for postoperative infection,
renal failure, and dehydration. For every 100 discharges after ileostomy, 54.9
unplanned HBAC events occurred, compared to 23.5 and 35.4 for primary
anastomosis and colostomy respectively. 20% of HBAC events were at hospitals other than where the patient underwent surgery.
12
Abstracts
S14
TREATMENT OF T1 NODE POSITIVE COLON CANCER: AN ANALYSIS OF
NATIONAL TREATMENT PATTERNS.
A. M. Ganapathi1, P. J. Speicher1, B. R. Englum1, A. W. Castleberry1,
D. S. Hsu2 and C. R. Mantyh1 1Division of Colorectal Surgery, Department
of Surgery, Duke University, Durham, NC and 2Division of Medical
Oncology, Department of Medicine, Duke University Medical Center,
Durham, NC.
Purpose: Treatment of node positive (N+) colon cancer consists of adjuvant chemotherapy (AC), however randomized data supporting this practice was derived from lesions T2 or greater. Minimal data exists regarding
the use and need for AC in T1N+ disease. Using a large national database,
this study attempts to determine the treatment trends and effects of AC on
T1N+ colon cancers.
Methods: The National Cancer Database collects data from >1,500
United States cancer centers. We identified patients from 1998-2006 with
T1N+ disease, excluding those with metastatic disease or prior cancer.
Patients were stratified based on whether or not they received AC. Baseline
demographics, tumor, and cancer treatment characteristics were identified.
Categorical and continuous variables were compared with a chi-square or
student’s t-test respectively. Groups were then matched on propensity to
receive AC, creating two highly similar groups. Adjusted long-term survival
stratified by AC use was then compared using the Kaplan-Meier method
with the log-rank test.
Results: 3,266 patients were identified with T1N+ disease. 69%
(n=2,263) received AC. Unadjusted analysis of patient and tumor characteristics revealed that patients treated with AC were statistically younger,
healthier, had shorter post-operative length of stay, more likely to have private insurance, and more commonly had left-sided tumors (all p<0.01).
Unadjusted 5-year survival was significantly higher in patients receiving AC
(87.3% v. 59.0% in patients with no AC; p<0.01). Following propensity
adjustment the groups were well matched other than a significant difference in patient age. However, the survival difference remained on KaplanMeier analysis with 5-year survival of 83.2% and 59.0% in patients with or
without AC, respectively (Figure; p<0.01).
Conclusions: Given the rarity of T1N+ disease, previous large randomized controlled trials demonstrating the benefit of AC in colon cancer omitted this group of patients in their analysis. Using a large national cohort,
this study found a dramatic improvement in long-term survival in patients
receiving AC in T1N+ disease. Further investigations into predictors of the
use of AC, particularly insurance status, are warranted.
Figure 1. Adjusted Risk Factors for 30-Day Readmission
S13
AREA OF SUBMUCOSAL INVASION AND WIDTH OF INVASION PREDICTS LYMPH NODE METASTASIS IN pT1 COLORECTAL CANCERS.
E. Toh1, P. Brown1, I. Botterill2 and P. Quirke1 1Pathology, Leeds Institute of
Molecular Medicine, Leeds, United Kingdom and 2John Goligher Colorectal
Unit, St James’s University Hospital, Leeds, United Kingdom.
Purpose: The increased detection of pT1 colorectal cancers (CRC) in the
UK National Health Service Bowel Cancer Screening Programme (NHSBCSP)
raises new worries for clinicians in terms of treatment choices. Should these
CRC be treated with a radical resection as they normally do with higher Tstage cancers or would a local excision suffice? The aim of this study is to
investigate the phenotypic features and behaviour of pT1 CRC and to identify new high risk features that are associated with lymph node metastasis
(LNM).
Methods: Two hundred and seven pT1 CRC were obtained from Northern and Yorkshire Cancer Registry and Information Services database and
digitally scanned. Phenotypic features of the pT1 CRC were evaluated. LNM
status was known through official pathology reports and high risk phenotypic features were identified. Modified receiver operating characteristic
(ROC) curves were generated for significant phenotypic quantitative features.
Results: LNM was noted in 19 patients (9.2%). pT1 CRC with LNM had a
significantly wider area of invasion (p=0.001) and a greater area of submucosal invasion (p < 0.001) compared to pT1 CRC without LNM. Qualitative
features such as grade of differentiation (poor vs non-poor), vascular and
lymphatic invasion were also significant predictors of LNM
(p<0.0001,p=0.039 and p=0.018 respectively). Modified ROC curves generated cut-off values of 11.5mm for the width of invasion and 35mm2 for the
area of submucosal invasion. Width of invasion greater than 11.5mm was
predictive of LNM on univariate analysis (Odds ratio[OR]=9.46,Confidence
interval[CI]=2.13–42.07,p=0.003) but not on multivariate analysis
(OR=5.59,CI=0.92–34.12,p=0.062) analysis. Area of submucosal invasion
greater than 35mm2 was predictive of LNM on both
univariate(OR=20.9,CI=2.73–
159.74,p=0.003)
and
multivariate(OR=12.48,CI=1.44–108.07,p=0.022)analysis.
Conclusions: This study has shown that quantitative phenotypic features such as width of the invading carcinoma and area of submucosal invasion can be used as a valid parameter in predicting LNM. Together with the
other qualitative phenotypic features, these quantitative factors could be
used to decide the most appropriate treatment for pT1 CRC.
13
Abstracts
grade, local spread of tumor (defined as clinical T4, or perforating tumor),
obstruction, number of lymph nodes examined, lymphovascular invasion
(LVI), year of surgery, laparoscopic approach, and adjuvant chemotherapy.
Results: 1,484 patients were included with a mean follow-up of 8.2 ±
4.4 years. There were 812 (54.8%) men and the mean age was 67 ± 13 years.
LR was detected in 68 (4.6%) patients. Mean time to LR was 2.6 ± 2.5 years.
Factors associated with a statistically significant increase in LR rate on univariate analysis included overall disease stage, T and N stage, local spread
of tumor, moderate or poor differentiation, LVI, intraoperatively palpable
lymph nodes, and tumor size > 4cm. On multivariate analysis independent
factors significantly associated with an increased LR rate were disease stage,
local spread of tumor, and LVI. (Table)
Conclusions: LR in colon cancer remains a relatively rare event in a specialized center with adherence to oncologic surgical principles and is associated with tumor-dependent factors. Recognition of these factors can help
in guiding decisions regarding adjuvant chemotherapy and surveillance.
S16
PREOPERATIVE STAGING CT THORAX IN PATIENTS WITH COLORECTAL
CANCER; ITS CLINICAL IMPORTANCE.
C. O’Rourke2, J. Hogan1, N. Kelly2, J. Burke3 and J. C. Coffey1 1Department
of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland,
2
Graduate Entry Medical School, University of Limerick, Limerick, Ireland
and 3Centre for Interventions in Infection, Inflammation & Immunity (4i),
University of Limerick, Limerick, Ireland.
Purpose: Recent studies suggest there is little clinical benefit in routine
computed tomography (CT) thorax for staging colorectal cancer (CRC). The
aim of this study is to evaluate the clinical value of CT thorax by focusing
on patients who had a diagnosis of indeterminate or metastatic lung
lesions on staging CT.
Methods: This is a case control study with planned data collection of
patients diagnosed with CRC at our institution over a five-year period
(2006-2011). All patients who undergo colorectal surgery in our hospital
are prospectively registered, including patient, treatment, and histopathological characteristics; outcome; and follow-up. Since January 2007, routine
preoperative staging CT of thorax, abdomen and pelvis (TAP) for patients
with CRC has been performed as part of our regional guidelines. All
recorded variables were analysed to determine factors associated with the
presence of lung metastasis or indeterminate lung lesions at diagnosis. All
patients have a minimum two-year follow up
Results: 383 patients were identified. The mean age was 66.7±12.2
years. 235 were male (61.4%). 206 (53.8%) colonic and 177 (46.2%) rectal
tumours were involved. Evidence of distant metastatic disease was evident
in 71 patients (18.5%) based on staging CT-TAP. Staging CT-thorax revealed
pulmonary metastases in 25 patients (6.5%) and indeterminate lesions in
33 patients (9%). 60% of pulmonary metastases were not evident on preoperative chest x-ray. All patients who had evidence of lung metastases had
node positive disease (p=0.03). No other clinical or pathological factor at
diagnosis was independently associated with the presence of pulmonary
lesions. Overall survival did not differ between the patients with pulmonary
metastases and indeterminate lesions (p=0.35). 20% of the indeterminate
lesions had malignant transformation on follow up.
Conclusions: There is a low overall incidence of pulmonary metastasis
in newly diagnosed CRC. However, the majority require CT thorax for detection. The clinical value of staging CT is perhaps more important for indeterminate lung lesions, which showed a 20% malignant potential. This should
encourage more aggressive observation and treatment protocols for these
patients.
Multivariate Analysis of Factors Associated with 5-year LR Rate.
S18
DETERMINANTS OF EXTENT OF RESECTION FOR COLON CANCER IN
LYNCH SYNDROME.
J. Bikhchandani1, H. Salima2, A. O’Toole2, C. Snyder2, M. Stacey2 and
H. T. Lynch2 1Colon and Rectal Surgery, Mayo Clinic, Rochester, MN and
2
Preventive Medicine, Creighton University, Omaha, NE.
Purpose: The two main options for Lynch syndrome (LS) patients with
colon cancer are segmental colectomy or total abdominal colectomy.
Recent data has shown that patients who underwent segmental colectomy
required subsequent surgery for metachronous cancers. Nevertheless,
majority of LS patients undergo segmental colectomy when diagnosed
with colon cancer. The current study was designed with the aim to understand the various determinants for patients who carry a mismatch repair
gene mutation as to why they choose segmental over total colectomy.
Methods: The study protocol was approved by the IRB committee. An
8 point Likert-scale questionnaire was mailed to “mismatch repair gene”
positive patients enrolled in Creighton University Hereditary Cancer Center
Registry who had been diagnosed with colon cancer and underwent surgery. A total of 106 questionnaires were sent. Patients who failed to return
the responses by 3 months were called to complete the questionnaires telephonically. Responses were analyzed using Excel 2010.
Results: A total of 60 responses were obtained, a response rate of 57%.
Mean age was 44 years. Amongst the 60 patients, 46 (67%) patients had
segmental colectomy while 14 (23%) had total colectomy. The results were
as follows- 1) Only 13 patients (22%) reported that they knew the result of
their genetic test prior to surgery, of which 3 selected the option of total
colectomy. 2) Patients answered that the decisive factor for them was the
surgeon’s recommendations i.e. 96% and 85% patients in the two groups
respectively (Figure 1). 3) 57% of patients who underwent total colectomy
were operated by a colorectal surgeon (CRS) while those who had segmental, only 20% were operated by a CRS (p < 0.001). 4) Of the 46 patients who
S17
PROGNOSTIC FACTORS ASSOCIATED WITH LOCOREGIONAL RECURRENCE IN COLON CANCER.
D. Liska, L. Stocchi, F. Elagili, D. W. Dietz, M. F. Kalady, H. Kessler,
F. H. Remzi and J. Church Colorectal Surgery, Cleveland Clinic Foundation,
Cleveland, OH.
Purpose: Locoregional recurrence (LR) in rectal cancer has prompted
optimization of surgical techniques and use of multimodality approaches,
resulting in improved cancer outcomes. There are only few studies examining the rates and factors associated with LR in colon cancer. A better understanding of risk factors for LR in colon cancer is needed to achieve superior
outcomes.
Methods: All patients experiencing LR following colon cancer resection
with curative intent between 1994 and 2008 were identified from a
prospectively maintained colorectal cancer institutional database. All primary tumors were treated with oncologically radical surgery, including high
vascular ligation, and en bloc resection of attached organs. LR was defined
as any histological or clinical evidence of tumor regrowth near the primary
site, including the anastomosis and peritoneum. Univariate and multivariate analyses were used to determine associations between LR and a number of variables including age, sex, tumor site, TNM stage, histological
14
Abstracts
had segmental colectomy, 24 (52%) required subsequent colon resection(s)
due to metachronous cancer.
Conclusions: The most important factors which determined the extent
of colon resection for colon cancer in Lynch syndrome patients included
the unavailability of genetic test result, surgeons’ recommendation and the
surgeons’ speciality. Awareness of the general surgeon on various management options for Lynch syndrome associated colon cancer may have played
a role in the above findings.
S20
TEN-YEAR EXPERIENCE WITH SELF-EXPANDING METALLIC STENTS AS
A BRIDGE-TO-SURGERY WITH CURATIVE INTENT IN THE TREATMENT
OF COLORECTAL ADENOCARCINOMA PRESENTING WITH ACUTE
LEFT-SIDED COLONIC OBSTRUCTION.
G. Stern2, A. Saleem2 and J. Faria1 1Division of Colorectal Surgery, Jewish
General Hospital, Montreal, QC, Canada and 2Department of Surgery,
McGill University, Montreal, QC, Canada.
Purpose: The use of self-expanding metallic stents (SEMS) as a bridgeto-surgery with curative intent in acute, malignant left-sided colonic
obstruction has recently come under fire for possibly contributing to poorer
oncologic outcomes. This retrospective review aimed to assess the oncologic outcome of SEMS as a bridge-to-surgery with curative intent in the
treatment of colorectal adenocarcinoma (CRC) presenting with acute leftsided colonic obstruction, in a center where SEMS have been first line management for left-sided colonic obstruction for a decade.
Methods: Retrospective chart review was performed on patients who
underwent colonic stenting procedures using SEMS from May 2003 to July
2013.
Results: 265 SEMS procedures were performed in 229 patients, of which
76 were for bridge-to-surgery as curative intent for CRC without evidence
of metastases at time of initial treatment. Median follow-up was 29 (3-113)
months. Procedural success was achieved in 98.7% (75/76) and clinical success in 98.7% (74/75) of patients. 66 patients had primary and 10 had recurrent CRC. Stent related complications included 2 subclinical perforations, 3
stent migrations and 3 re-occlusions. 93.4% (71/76) of patients underwent
surgery with curative intent, 3.9% (3/76) were treated at another hospital,
and 2.6% (2/76) did not undergo surgery. Peritoneal carcinomatosis was
found in 7% (5/71) of patients at the time of surgery and 7% (5/71) had
unresectable rectal cancer. Rates of primary anastomosis were 85.9%
(61/71) with 3.3% (2/61) anastomotic leaks. Rates of temporary and permanent stomas were 8.5% (6/71) and 14.1% (10/71). Overall survival, median
and 5 year survival were 63.5%, 83 months and 50.4%, respectively. Excluding patients with incurable disease at surgery, overall survival, median and
5 year survival were 68.3%, 83 months and 58.1%, respectively. Overall disease-free survival (DFS) and 5 year DFS were 75.8% and 63.9%, respectively.
Conclusions: SEMS procedures as a bridge-to-surgery with curative
intent in acute left-sided CRC colonic obstruction can be performed with
good long-term oncologic outcomes.
Answer to the question “How did you decide which surgery to undergo”
S19
MISMATCH REPAIR STATUS PREDICTS NEED FOR FUTURE,
METACHRONOUS COLORECTAL SURGERY IN YOUNG INDIVIDUALS
UNDERGOING COLORECTAL CANCER RESECTION.
M. Aronson, S. Holter, K. Semotiuk, A. Pollett, S. Gallinger, Z. Cohen and
R. Gryfe The Zane Cohen Centre For Digestive Diseases, Mount Sinai
Hospital, Toronto, ON, Canada.
Purpose: Managing colorectal cancer (CRC) in young individuals
involves not only successful treatment of the presenting cancer, but also
requires consideration of the possibility of Lynch syndrome and the development of future, metachronous CRC.
Methods: Utilizing our clinical familial gastrointestinal cancer registry,
we identified 378 individuals diagnosed with CRC at ≤35 years. Patient, clinicopathologic and genetic factors associated with time to first, metachronous colorectal neoplasm requiring resection, excluding CRC recurrence,
were analyzed by univariate and multivariate analyses. Mismatch repair
(MMR) protein-deficiency was assessed by either CRC immunohistochemistry for the MSH2, MLH1, MSH6 and PMS2 proteins, or microsatellite instability (MSI).
Results: All individuals with CRC diagnosed at ≤35 years in the absence
of polyposis (N=270) were included for analysis. The 20-year resection rate
for new, non-recurrent, metachronous colorectal neoplasia (CRC =24, dysplasia =9) was 39.3% ±6.7%. MMR-deficiency was observed in 110/265
(42%) evaluable cases and significantly associated with an increased risk of
metachronous colorectal neoplasia resection (20-year rate: MMR-deficient=58.7% ±9.4%, MMR-proficient=13.6% ±6.32%; p=0.02). After adjusting for initial CRC stage and the extent of initial CRC resection, MMR-deficiency was associated with a hazard ratio of 2.68 (95% CI=1.18-6.06;
p=0.018) for future, metachronous colorectal neoplasia resection. Factors
not associated with significant differences in time to metachronous colorectal neoplasm requiring resection included gender, age at diagnosis,
CRC site, tumor grade, the presence of synchronous CRC, family or personal
history of prior CRC or other Lynch syndrome-associated cancers.
Conclusions: MMR-deficiency in young individuals with CRC is significantly associated with an increased risk of future colorectal neoplasia
requiring resection. Preoperative CRC MMR testing on endoscopic biopsies
is feasible and should be utilized to ensure appropriate discussion regarding the extent of initial CRC resection.
S21
VARIABILITY IN POSTOPERATIVE COSTS FOLLOWING COLECTOMY IS
A POTENTIAL TARGET FOR IMPROVING COST EFFICIENCY.
S. Tevis, D. D. Rivedal, E. F. Foley, B. A. Harms, C. P. Heise and
G. D. Kennedy Surgery, University of Wisconsin - Madison, Madison, WI.
Purpose: In 2013, Centers for Medicare and Medicaid Services (CMS)
introduced Bundled Payments for Care Improvement (BPCI) initiative. The
goal of bundled payments is to decrease costs while improving the quality
and coordination of patient care. A better understanding of what factors
contribute to cost variability and higher costs is needed in order to identify
areas for quality improvement aimed at improving efficiency of care. The
aim of this study was to evaluate cost variability following colectomy and
identify factors associated with increased operative and post-operative
costs.
Methods: A retrospective review of a prospectively maintained institutional American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database identified patients who underwent
colectomy for colon cancer from 2006 - 2012. Variability in both operative
and post-operative costs was assessed. Patient, operative and post-operative factors were evaluated for association with direct operative and postoperative costs.
Results: We identified 103 patients who underwent uncomplicated
colectomy for colon cancer by a colorectal surgeon. Post-operative costs
15
Abstracts
were found to have greater variability than operative costs (standard deviation $3,656 vs. $718). Predictors of increased operative costs included male
sex (OR 2.962, 95% CI 1.056-8.306) and laparoscopic colectomy (OR 7.153,
95% CI 1.691-30.265). Patient factors, such as more comorbidity (OR 7.747,
95% CI 2.066-29.056) and need for higher level of care at discharge (OR
18.356, 95% CI 2.976-113.231), were associated with increased post-operative costs.
Conclusions: Post-operative costs following colectomy are variable and
the post-operative period should be a target for quality improvement projects aimed at improving efficiency. Standardization of post-operative care
may decrease cost variability and improve both efficiency and quality of
patient care.
S22
TREATMENT OF COLONIC DIVERTICULITIS IS INCREASINGLY NONOPERATIVE: A POPULATION-BASED ANALYSIS OF EVOLVING PRACTICE
PATTERNS.
D. Li1, N. N. Baxter2, R. S. McLeod3, R. Moineddin4, A. Wilton5 and
A. B. Nathens6 1Division of General Surgery, University of Toronto, Toronto,
ON, Canada, 2Division of General Surgery, St. Michael’s Hospital, University
of Toronto, Toronto, ON, Canada, 3Division of General Surgery, Mount Sinai
Hospital, University of Toronto, Toronto, ON, Canada, 4Dalla Lana School
of Public Health, University of Toronto, Toronto, ON, Canada, 5Institute for
Clinical Evaluative Sciences, Toronto, ON, Canada and 6Division of General
Surgery, Sunnybrook Health Sciences Centre, University of Toronto,
Toronto, ON, Canada.
Figure 1: Unadjusted trends in diverticulitis management strategies, 2002-2012
S23
LAPAROSCOPIC PERITONEAL LAVAGE FOR HINCHEY III PERFORATED
DIVERTICULITIS: INITIAL EXPERIENCE.
S. Bertone, S. Bilbao, R. Mentz, C. Vaccaro and G. Rossi Hospital Italiano
Buenos Aires, Buenos Aires, Argentina.
Purpose: Recent reports suggesting a more benign natural history for
diverticular disease have prompted surgeons to reconsider conventional
treatment strategies. We hypothesized that practice patterns have evolved
to be increasingly non-operative.
Methods: This was a population-based retrospective cohort study.
Administrative discharge data were used to identify patients hospitalized
for a first episode of acute diverticulitis in Ontario, Canada (2002-2012). Secular changes in treatment and outcomes were evaluated. CochranArmitage was used to test for trends. Multivariable logistic regression was
used to adjust for patient and disease characteristics.
Results: There were 18,543 patients hospitalized with a first episode of
diverticulitis, median age 60 years (IQR 48-74), 53% female. From 20022012, there was an increase in the proportion of patients with complicated
disease (abscess, fistula or perforation): 32% to 38%, yet a smaller proportion underwent urgent surgical intervention (28% to 16%) (p<0.001). After
adjusting for changes in patient and disease characteristics over time, the
odds of urgent surgery decreased by 0.86 (95% CI: 0.85-0.88) per annum. In
those undergoing urgent surgery (n=3873), use of laparoscopy increased
(9% to 18%), as did use of bowel exteriorization (57% to 74%) (all p<0.001).
However, overall stoma rates in admitted patients declined (16% to 12%,
p<0.001). There was a reduction in in-hospital mortality (2.7% to 1.9%) as
well as median length of stay [5 days (IQR 3-9) to 3 days (IQR 2-6)] (all
p<0.001). During follow-up, rates of elective colectomy declined from 10%
over the first year post discharge in 2002, to 4% by 2011 (p<0.001). The
decline in elective surgery was most pronounced in younger patients <50
years (17% to 5%), and in those with complicated disease (29% to 8%) (all
p<0.001).
Conclusions: There has been a significant increase in the use of nonoperative management strategies in patients with diverticulitis; management of young patients and those with complicated disease have demonstrated the greatest change over time. During this period, a significant
reduction in in-hospital mortality and length of hospital stay was observed.
Purpose: Primary: to evaluate its feasibility (% of patients in whom the
procedure was completed laparoscopically) and its effectiveness (% of
patients in whom septic focus was resolved with no need of further treatment during admission). Secondary: to evaluate its applicability (% of
patients requiring emergency surgery who were treated with laparoscopic
lavage and drainage) as well as morbidity and mortality rates of laparoscopic peritoneal lavage for Hinchey III perforated diverticulitis.
Methods: A retrospective study of a prospectively-collected database.
Among all the patients who underwent surgery for acute abdomen caused
by diverticular disease between June 2006 and June 2013, only those who
were treated laparoscopically were deemed eligible. Exclusion criteria:
patients with Hinchey II or IV diverticulitis, intraoperative evidence of perforation and those treated with laparoscopic resection.
Results: Among 75 patients who underwent surgery for acute
abdomen caused by diverticular disease, 59 were treated laparoscopically.
46 of them (median age: 66, female 58.7%, median BMI: 25 kg/m2) fulfilled
the inclusion criteria and they constitute the study population (61% applicability). 2/46 patients had to be converted (96% feasibility). In 39 out of 44
patients treated with laparoscopic peritoneal lavage, an effective control of
the sepsis was achieved with no need of additional procedures during the
admission (89% effectiveness). Five therapeutic failures were registered and
they were resolved with open resection and primary anastomosis in 2 cases,
with laparoscopic resection and primary anastomosis with protective
ostomy in 1 case, and with Hartmann procedure in the remaining 2 cases.
Morbidity rate was 32% (50% major complications) and no mortality was
registered
Conclusions: Laparoscopic peritoneal lavage as a treatment for Hinchey
III perforated diverticulitis is a feasible and effective method that allows for
the septic process to be resolved with a low morbidity and mortality rate
in a high percentage of patients. This strategy was able to be applied in
more than half of the patients with acute abdomen caused by diverticular
disease in our series.
16
Abstracts
15.1% and 21.2% in females (NS). Gastroenterology was found to perform
biopsies at a higher rate: 0.92 vs 0.62 (NS), while GS had a higher rate of
adenomas biopsied: 0.42 vs 0.32 (NS).
Conclusions: General surgery residents under the supervision of general and colorectal surgical staff are capable of producing quality measures
equivalent to those of staff gastroenterologists at a single institution. The
ADRs and cecal intubation rates seen in this study are equivalent and are
consistent with those published in the literature. These findings appear to
contradict the previously published position that the ABS requirements for
general surgery residents will not reach the same quality metrics as gastroenterologists.
S24
PREDICTORS OF FAILURE WITH FECAL MICROBIOTA THERAPY FOR
RECURRENT CLOSTRIDIUM DIFFICILE COLITIS.
E. M. True1, S. S. Tsoraides1, H. Wang2, J. J. Farrell2 and J. P. Bonello1
1
General Surgery, University of Illinois College of Medicine at Peoria, Peoria,
IL and 2Medicine, Univeristy of Illinois College of Medicine at Peoria, Peoria,
IL.
Purpose: Fecal microbiota therapy (FMT) is often successful in treating
recurrent Clostridium difficile colitis where conventional treatments have
failed. Predictors of success or failure of FMT are lacking in the literature.
This study aims to identify these factors and aide in caring for this growing
patient population.
Methods: An IRB approved, systematic review was performed of consecutive patients treated with FMT for recurrent C diff colitis at a tertiary
care center between January 2008 and 2013. Clinical data was collected retrospectively and statistical analysis was conducted. Primary outcomes were
overall success of FMT, repeat treatment, progression to fulminant disease
necessitating colectomy, and mortality.
Results: Forty patients were treated with FMT via colonoscope during
the five year period. At the time of surgical consultation, seven (17.5%) were
in admitted to an ICU, 12 (30%) were general inpatients, and 21 (52.5%)
were outpatients. Overall, 28 patients (70%) had resolution of symptoms
with one or two treatments (45% and 25% respectively). ICU patients were
significantly less likely to have success with FMT (29% vs 78%, p=0.0026)
and had significantly higher risk of mortality (42.9% vs 9.1%, p=0.0228). This
group had a higher mean WBC count (30.8 vs 9.5, p=0.0028), and lower
mean temperature (36 vs 37.4 C, p=0.0376). ICU patients also had a trend
toward lower mean serum albumin that approached statistical significance
(2.19 vs 2.72, p=0.0715).
Conclusions: The current literature regarding FMT is often limited to
chronically ill outpatients and some inpatients. ICU patients represent a
special population in which WBC count is significantly higher, temperature
is significantly lower, and have a trend towards lower albumin. These
patients have a significantly higher risk of treatment failure and mortality
and are not ideal candidates for FMT.
S26
THE ACCURACY OF COLONOSCOPIC LOCALIZATION OF COLORECTAL
TUMORS: A PROSPECTIVE, MULTICENTERED OBSERVATIONAL STUDY.
S. Moug, M. S. Johnstone and A. S. Bryce Glasgow Royal Informary,
University of Glasgow, Glasgow, United Kingdom.
Purpose: In the era of the NHS Bowel Cancer Screening Programme and
laparoscopic colorectal resection, accurate pre-operative colorectal tumour
localisation is fundamental for surgical planning and optimising patient
outcomes. Colonoscopy plays a central role, but its accuracy for localisation
remains undetermined due to limitations of previously published work. The
objective of this study was to establish the accuracy of colonoscopic localisation and to determine how frequently inaccuracy results in altered surgical management.
Methods: A prospective, multicentered, powered observational study
recruited 79 patients with colorectal tumours identified during prearranged
colonoscopy that subsequently underwent curative surgical resection.
Patient and colonoscopic factors were recorded. Preoperative colonoscopic
and radiological lesion localisations were compared to intra-operative localisation using pre-defined anatomical bowel regions to determine accuracy,
with any change in planned surgical management documented.
Results: Colonoscopy accurately located the colorectal tumour in 64 of
79 patients (81%). 5 of the 15 inaccurately located patients required ontable alteration in planned surgical management. Preoperative imaging was
unable to visualise the primary tumour in 23.1% of cases, a finding that was
more prevalent amongst bowel screener patients compared to symptomatic patients (45.8% vs. 13%; p=0.003). When the lesion was seen on imaging, the accuracy of localisation was 88.3%.
Conclusions: Colonoscopic lesion localisation is inaccurate in 19.0% of
cases and occurred throughout the colon with a change in on-table surgical management in 6.3%. With CT unable to visualise lesions in just under a
quarter of cases, particularly in the screening population, preoperative
localisation is heavily reliant on colonoscopy. A further study is underway
to analyse potential influencing factors on accurate lesion localisation.
S25
EQUIVALENCE IN COLONOSCOPY QUALITY MEASURES BETWEEN
GASTROENTEROLOGISTS AND GENERAL SURGERY RESIDENTS.
M. Williams, E. Cleveland, J. Crossett, C. P. Smoot, K. Aluka, L. Coviello
and K. Davis William Beaumont Army Medical Center, El Paso, TX.
Purpose: Recently, multiple gastroenterology societies published a
position statement criticizing the American Board of Surgery (ABS) guidelines for training surgical residents in endoscopy. Their position stated that
the ABS requirements were inadequate to produce competency and the
training requirements were not to the same quality standard held by those
training gastroenterologists. We sought to assess endoscopy quality measures at a single institution where colonoscopies are performed by both staff
gastroenterologists and general surgery residents under the direct supervision of surgery staff.
Methods: After IRB approval, all records of patients who underwent
colonoscopy at a single institution over a 6-month period (January 2012
through June 2012) by either the gastroenterology or general surgery services were reviewed. Colonoscopy reports and medical records were
reviewed to identify patient demographic information, indication for procedure, number of biopsies, pathology, number of adenomas detected and
rates of cecal intubation.
Results: A total of 818 colonoscopies were performed during the study
period. 598 were performed by the gastroenterology service (GI) and 220
were performed by the general surgery service by surgical residents (GS).
Baseline demographics of the groups were similar. The cecal intubation
rates for GI and GS were 98.3% and 93.3% respectively. Adenoma detection
rate (ADR) was similar between both groups: 29.7% and 26.1% in males and
17
Abstracts
with stage I following neoadjuvant CRT and incomplete clinical response
managed by TEM.
Methods: Patients with distal rectal cancer cT2-4N0-2M0 underwent
5FU-based neoadjuvant CRT. Assessment of response was performed at
least 8 weeks from RT completion. Patients with complete clinical response
were not immediately operated. Patients with incomplete clinical response
were managed by surgery. Those with small (≤3cm) residual cancers (ycT02N0M0) were managed by transanal endoscopic microsurgery. Patients
undergoing local excision following CRT were compared according to baseline staging.
Results: Overall, 46 patients underwent CRT followed by TEM. 15 (32%)
of these were cT2N0 at baseline. Final ypT status was ypT0 in 3 (20%), ypT1
in 2 (13%), ypT2 in 9 (60%) and ypT3 (7%) in 10 patients. There were no differences in final ypT status when compared to patients with baseline cT3-4
or cN+ undergoing CRT followed by TEM (p=0.3). Local recurrence was
observed in 1 patient with baseline stage cI (7%) and in 7 patients (23%)
with stage II and III (p=0.18). There was a trend towards less risk of developing systemic recurrences among patients with baseline stage I (7% vs.
33%; p=0.05)
Conclusions: Patients with baseline stage I that develop incomplete
small (≤3cm) clinical response (ycT0-2N0) to neoadjuvant CRT frequently
present unfavorable pathological features for transanal local excision (ypT2
or 3 in >66%). In the presence of incomplete clinical response following
CRT, even patients with baseline cT2N0 may be inappropriate for local excision in a significant proportion of cases
S27
RECURRENCE AND SURVIVAL IN PATIENTS WITH UT2UN0 RECTAL
CANCER TREATED WITH NEOADJUVANT CHEMORADIATION AND
LOCAL EXCISION: RESULTS OF THE ACOSOG Z6041 TRIAL.
J. Garcia-Aguilar1, L. A. Renfro2, C. R. Thomas Jr3, E. Chan4, P. Cataldo5,
M. Jorge6, D. Medich7, C. Johnson8, S. Oommen9, B. Wolff2, A. Pigazzi10,
M. McNevin11, R. Pons12 and R. Bleday13 1Surgery, Memorial SloanKettering Cancer Center, New York, NY, 2Mayo Clinic, Rochester, MN,
3
Oregon Health and Science University, Portland, OR, 4Vanderbilt
University Medical Center, Nashville, TN, 5University of Vermont,
Burlington, VT, 6Tampa General Hospital, Tampa, FL, 7University of
Pittsburgh Medical Center, Pittsburgh, PA, 8St. Francis Hospital, Tulsa, OK,
9
John Muir Medical Center, Concord, CA, 10University of California, Irvine,
Irvine, CA, 11Holy Family Hospital, Spokane, WA, 12Hialeah Hospital,
Hialeah, FL and 13Brigham and Women’s Hospital, Boston, MA.
Purpose: LE alone is an effective treatment for selected uT1uN0 RCs;
however, for uT2uN0 RCs LE results in a higher local recurrence rate and
lower survival compared to total mesorectal excision (TME). The Z6041
phase II trial (NCT00114231) investigates the efficacy of CRT and LE for
treating uT2uN0 RC. Here we report the oncologic outcomes.
Methods: Patients (pts) with ultrasound-staged T2N0, ≤4 cm diameter,
RC located within 8 cm of the anal verge, and ECOG PS ≤2 were treated with
capecitabine (825 mg/m2 days 1-14 and 22-35) and oxaliplatin (50 mg/m2
weeks 1, 2, 4 and 5) during radiation (RT) (total dose 54 Gy) followed by LE.
Due to toxicity, the dose of RT was reduced to 50.4 Gy and capecitabine to
725 mg/m2 (5 days/week/5 weeks). Local and distant recurrences were
recorded. Disease-free survival at 3 years was calculated using Kaplan-Meier
analysis.
Results: Of the 90 pts accrued, 11 were considered ineligible or withdrew consent. Of the 79 eligible pts, 1 had TME and 2 had no surgery. Of
the 76 pts who had LE, 3 had ypT3 tumors and 1 had positive margins. They
were considered inevaluable from primary endpoint analysis per study protocol. The 72 evaluable pts were followed for a mean 4.2 (0.5 – 6.4) years.
At the end of follow-up 2 (3%) pts had developed local recurrence after LE;
both were salvaged with an R0 abdominoperineal excision (APE) of the rectum, but 1 developed recurrence after APE. Five (7%) pts have developed
distant metastasis (lung 3, liver 1, uterus 1). Six pts have died from unrelated causes during follow-up. The 3-year disease-free survival for the evaluable pts was 0.87 (0.79-0.95, 95% CI).
Conclusions: The treatment of uT2uN0 rectal cancer with CRT and LE is
associated with a low rate of local recurrence, but a higher rate of distant
metastasis. The 3-year disease-free survival falls above the unacceptable
level and close to levels deemed promising as defined by the study design.
Therefore, CRT and LE may be considered as an alternative to TME for
selected patients with uT2uN0 distal RC.
S29
FACTORS INFLUENCING THE USE OF LOCAL EXCISION FOR EARLY
STAGE RECTAL CANCER.
S. Gillern1, N. Mahmoud1 and E. Paulson2 1Department of Surgery,
Division of Colon and Rectal Surgery, The Hospital of the University of
Pennsylvania, Philadelphia, PA and 2Department of Surgery, Division of
Colon and Rectal Surgery, Philadelphia VA Medical Center, Philadelphia,
PA.
Purpose: Local excision(LE) of rectal cancer remains an attractive option
because it avoids the morbidity of radical resection(RR). Concerns have
arisen during the last decade, however, of substandard oncologic results.
We used SEER-Medicare data to examine patient, surgeon and hospital factors related to use of LE.
Methods: We performed a retrospective cohort study of 18,025 T0-T2
rectal cancer patients undergoing RR and LE between 2000-2009 using
SEER-Medicare. Multivariate logistic regression was performed to identify
patient (age, race, socioeconomic status, comorbidity score, cancer stage,
year of diagnosis); surgeon[colorectal(CRS) vs. general(GS) surgeon, year of
M.D. graduation] and hospital (NCI vs. Non-NCI, teaching vs. non-teaching
status) factors associated with LE.
Results: Patients who were older, female, with more comorbidities were
significantly more likely to undergo LE. White patients were more likely to
get LE than non-whites(OR 1.35, p < .0001). Being operated on by a CRS
increased the odds of LE by 1.5 times(p<0.001). Similar trends were seen in
patients operated on at NCI(OR 1.7, p<0.001) and teaching hospitals(OR 1.2,
p=0.006). Younger surgeons were more likely to perform LEs. For surgeons
graduating in 1980-89 or 1990+, the odds of LE were 1.31 (p=0.001) and
1.65 (p<0.001), respectively, compared to surgeons graduating before 1970.
Finally, the odds of undergoing LE if diagnosed between 2007-2009 were
almost half(OR 0.58, P<0.001) the odds of those diagnosed between 20002003, apparently driven by a decrease in LEs performed by CRS(Figure 1).
Conclusions: The odds of undergoing LE for early stage rectal cancer
decreased significantly between 2000-2009, coincident with evidence of
oncologic inferiority. However, there was still significant variation in its use.
The use of LE is related to patient factors that confer increased risk for major
surgery (age, comorbidity). There are also race and gender discrepancies in
its use. Additionally, type and age of the surgeon and type of hospital a
patient seeks out significantly affect the odds of LE. More studies are
S28
NOT ALL PATIENTS WITH BASELINE CT2N0 AND INCOMPLETE CLINICAL RESPONSE FOLLOWING NEOADJUVANT CRT ARE APPROPRIATE
CANDIDATES FOR TEM AS A DEFINITIVE SURGICAL PROCEDURE.
R. O. Perez1, A. Habr-Gama2, P. Lynn2, G. São Julião2, I. Proscurshim2,
A. Coelho1 and J. Gama-Rodrigues2 1Colorectal Surgery DIvision,
University of Sao Paulo School of Medicine, Sao Paulo, Brazil and
2
Colorectal Surgery, Angelita & Joaquim Gama Institute, Sao Paulo, Brazil.
Purpose: Studies suggest that patients with cT2N0 following neoajduvant CRT may be appropriate candidates for local excision alone. However,
oncological outcomes may vary significantly according to response to CRT.
Ultimately, patients with ypT0 may be associated with improved outcomes
and may not require surgery at all. On the other hand, the risk of lymph
node metastastases in ypT2 may reach up to 19%. The aim of the present
study was to determine pathological and oncological outcomes of patients
18
Abstracts
needed to better understand these variations in an attempt to better standardize its use in early stage rectal cancer.
Disease free survival (DFS) and Overall survival (OS) following radical surgery
S31
RADICAL SURGERY AFTER TEM: DOES TEM IMPACT OUTCOMES?
S. J. Quade, C. L. Klos, I. Raiche, P. E. Wise, M. G. Mutch, M. L. Silviera,
E. H. Birnbaum and S. R. Hunt Colon and Rectal Surgery, Washington
University St Louis, St Louis, MO.
S30
Purpose: Transanal Endoscopic Microsurgery(TEM) provides an alternative to radical resection for early stage rectal cancers. If unfavorable histologic features of the TEM specimen are present, interval radical resection
may be indicated. Aim of this retrospective study was to determine if outcomes of radical surgery are impacted by initial TEM.
Methods: All patients undergoing interval total mesorectal excision
(iTME) after initial TEM were identified out of a prospective database at our
institution from 2002-2012.Demographics, histologic features and oncologic survival data were obtained. Those with iTME were matched by age,
gender, distance from anal verge and AJCC stage to patients undergoing
primary TME (pTME) for rectal cancer. Matched pTME patients did not
receive neoadjuvant therapy. Primary outcome measures were surgical
complications (infection, reoperation and mortality) and long-term oncologic outcomes. Nominal values are compared by chi square test and continuous values are compared by student t test. Survival data are reflected
by Kaplan Meier curves and compared by logrank test.
Results: 22 iTME patients were identified out of 124 patients undergoing TEM for cancer. Indications for iTME included close margins, upstaging,
and high-risk histology. This group was matched to 22 pTME patients
undergoing radical surgery for rectal cancer. 102 patients with “TEM only”
for rectal cancer were included in our survival analysis. Mean follow up was
2.1 ± 0.3 years in the iTME group and 5.0 ± 0.5 years in the pTME group.
There was no difference in complications (p=0.22). Local recurrence was
significantly higher in those with iTME when compared to pTME (P=0.04,
Fig. 1a). Disease-free survival showed similar results (P=0.03, Fig. 1b). Overall survival was similar between iTME and pTME (Fig. 1c). Those with “TEM
only” showed no survival or recurrence difference compared to both
groups.
Conclusions: Local recurrence and disease-free survival after TEM and
interval radical surgery are worse than for primary TME. While iTME patients
may have had biologically unfavorable tumors, “TEM only” can be safe for
well-selected rectal cancer patients. Rigorous selection criteria and highquality staging are necessary before employing TEM for rectal cancer.
OUTCOMES OF SALVAGE SURGERY FOR CURE IN PATIENTS WITH
LOCALLY RECURRENT DISEASE AFTER LOCAL EXCISION OF RECTAL
CANCER.
J. Bikhchandani, G. Ong, E. J. Dozois and K. L. Mathis Mayo Clinic,
Rochester, MN.
Purpose: Local excision (LE) for early rectal cancer has gained widespread interest. Imaging modalities currently available have low sensitivity
to detect loco-regional disease, which may result in under-staging and a
high risk of recurrence after LE. The current study is designed to report our
experience in treating recurrences with radical resection after LE of rectal
cancer.
Methods: Patients with locally recurrent rectal cancer who had their
primary tumors treated by LE and then underwent a salvage operation for
cure between 1997 and 2012 formed the study cohort. Retrospective
review of patients’ charts was used to determine patterns of disease recurrence and outcomes. Log rank tests were used for overall and disease free
survival.
Results: Twenty-six patients were identified; mean age was 68 + 9 years.
The initial pathology of transanal excision was Tx (5 patients, no residual
cancer), T1 (17) and T2 (4). Patients with T2 lesion(s) did not undergo an
oncologic resection earlier due to patient’s refusal or delayed referral.
Median time to recurrence was 74 (range, 7–326) weeks. Recurrent disease
was luminal in 19 patients, nodal in 3, locoregional (luminal and nodal) in 2
and locoregional with distant in 2 patients. For salvage surgery, neoadjuvant chemoradiation was used in 12 (46%), radiation-only in 1. Sphincter
preserving surgery was performed in 6 (23%) patients. Five patients
required excision of uterus or vagina en bloc and one patient had a partial
bladder resection. R0 resection was achieved in 24 (92%) patients. Four
patients received intraoperative radiation therapy. Nine patients (35%) had
re-recurrence at a median time of 20 (7-27) months; 3 had local and 6 had
distant disease. Overall and disease free survival curves are shown in Figure 1.
Conclusions: Salvage resection for recurrence following LE of early rectal cancer is associated with a high R0 resection rate without the need for
pelvic exenteration in most patients. 5-year disease-free survival following
salvage surgery is low (49%) compared to results expected in these patients
had they undergone a standard oncologic resection for their early stage
cancers.
19
Abstracts
Table 1
S32
IMPACT OF MFOLFOX6 FOLLOWING CHEMORADIATION ON TUMOR
RESPONSE AND SURGICAL COMPLICATIONS IN PATIENTS WITH
LOCALLY ADVANCED RECTAL CANCER TREATED WITH TOTAL
MESORECTAL EXCISION: RESULTS OF A PROSPECTIVE TRIAL.
J. Garcia-Aguilar1, J. Marcet2, P. Cataldo3, M. G. Varma4, A. S. Kumar5,
S. Oommen6, T. Coutsoftides7, S. R. Hunt8, M. J. Stamos9, C. A. Ternent10,
D. Herzig11, A. Fichera12, B. Polite13, D. Dietz14, D. D. Smith15 and K. Avila1
1
Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, 2Tampa
General Hospital, Tampa, FL, 3University of Vermont, Burlington, VT, 4UCSF
Medical Center, San Francisco, CA, 5MedStar Washington Hospital Center,
Washington, DC, 6John Muir Medical Center, Concord, CA, 7St John’s
Hospital, Orange County, CA, 8Washington University, St. Louis, MO,
9
University of California, Irvine, Irvine, CA, 10Colon and Rectal Surgery, Inc.,
Omaha, NE, 11Oregon Health and Science University, Portland, OR, 12UW
Medical Center, Seattle, WA, 13University of Chicago, Chicago, IL,
14
Cleveland Clinic, Cleveland, OH and 15City of Hope, Duarte, CA.
1
1=none,10=max; 21=easy,10=difficult; 366 eligible patients; 4based on 66 eligible
patients
Purpose: A pathologic complete response (pCR) to CRT is associated
with improved prognosis in LARC patients (pts) treated with TME, but the
proportion of pts who achieve a pCR is relatively small. We investigated the
effect of adding cycles of mFOLFOX6 after CRT on pCR rate and surgical
complications in pts with LARC treated with TME.
Methods: Four sequential prospective phase II trials or study groups
(SGs) were conducted in pts with ultrasound or MRI Stage II and III LARC
(NCT00335816). All pts were treated with neoadjuvant 5-FU-based CRT, followed by 0 (SG1), 2 (SG2), 4 (SG3), or 6 (SG4) cycles of mFOLFOX-6 and TME.
Primary endpoint was pCR. Tumor response was assessed by pathologic
assessment of the surgical specimen and RECIST criteria. Pelvic fibrosis and
surgical difficulty were assessed using arbitrary scales. Surgical complications were graded according to Clavien-Dindo. A Simon’s two-stage design
was used to determine the smallest maximum number of pts needed for a
type I error of 5% and power of 90%. The study required for each SG to
reach a 10% increase in pCR before advancing to the next SG.
Results: A total of 291 pts (71 SG1, 74 SG2, 71 SG3, 76 SG4) were
accrued. In all, 32 pts were excluded from final analysis because they
received non-protocol treatment (13 pts), died during treatment (3 pts),
developed metastasis before surgery (4 pts), had local excision (5pts: 2 SG1,
3 SG4), or had no surgery (7 pts:1 SG1, 3 SG2, 1 SG3, 2 SG4). The demographics and tumor characteristics were similar between SGs. The clinical
characteristics, treatment compliance, tumor response, and surgical complications for the 260 eligible pts are shown in Table 1. Three additional pts
were diagnosed with metastasis during surgery, for a total of 7 pts (3 SG1,
2 SG2, 1 SG3, 1 SG4) with metastasis during treatment.
Conclusions: Adding increasing number of cycles of mFOLFOX6 after
CRT and delaying surgery increases the probability of achieving a pCR in
patients with LARC treated with TME, without increasing the risk of surgical
complications or tumor progression.
S33
CONSOLIDATION CHEMOTHERAPY DURING EXTENDED CRT LEADS
TO SUSTAINED DECREASE IN TUMOR METABOLISM WHEN COMPARED TO STANDARD CRT REGIMEN.
A. Habr-Gama2, R. O. Perez1, G. São Julião2, P. Lynn2, J. Gama-Rodrigues2,
I. Proscurshim2 and C. A. Buchpiguel2 1Colorectal Surgery DIvision,
University of Sao Paulo School of Medicine, Sao Paulo, Brazil and
2
Colorectal Surgery, Angelita & Joaquim Gama Institute, Sao Paulo, Brazil.
Purpose: Neoadjuvant CRT may lead to significant tumor regression in
patients with rectal cancer. Different CRT regimens with consolidation
chemotherapy may lead to increased rates of complete tumor regression.
The purpose of this study was to understand tumor metabolic activity following two different neoadjuvant CRT regimens using sequential PET/CT
imaging.
Methods: Patients with cT2-4N0-2M0 rectal cancer treated by standard
CRT (54Gy and 2 cycles of 5FU-based chemotherapy) or extended CRT
(54Gy and 6 cycles of 5FU-based chemotherapy) underwent sequential
PET/CT imaging at baseline, 6 weeks and 12 weeks from radiation completion. Patients were accrued from 2 different prospective trials (NCT completed and NCT ongoing). SUVmax was measured at each study and
recorded. Final PET/CT response and SUVmax variation were compared.
Patients with complete clinical response at 12 weeks were managed nonoperatively while patients with incomplete response underwent surgery.
Results: Overall 99 patients undergoing standard CRT were compared
to 12 patients undergoing extended CRT. Patients treated with extended
CRT had increased rates of complete clinical or pathological response (66%
vs. 23%; p<0.001). SUVmax variation between baseline and 6-weeks was
significantly more pronounced among patients undergoing extended CRT
with consolidation chemotherapy when compared to standard CRT (88%
vs. 63%; p<0.001; Figure 1). SUVmax variation between baseline and 12weeks was also more pronounced in the extended CRT group (90% vs. 57%;
p<0.001). There was no difference in SUVmax between 6 and 12 weeks following CRT in both regimens. An increase in SUVmax between 12weeks and
6 weeks was observed in 51% of patients undergoing standard and only
18% of patients undergoing extended CRT (p=0.04).
Conclusions: Most of the reduction in tumor metabolism after neoadjuvant CRT develops within the first 6 weeks from RT completion. In
patients undergoing extended CRT, the decrease in tumor is significantly
more pronounced within the first 6 weeks and sustained until 12 weeks.
However, in patients with incomplete clinical response, waiting until 12
weeks added little benefit in terms of tumor metabolism (2%).
20
Abstracts
lying rectal cancer, believed to require non-sphincter sparing surgery prior
to neoadjuvant therapy, can safely undergo a sphincter sparing procedure
after chemoradio therapy. It is our hypothesis that local recurrence rates
will be less than 5% in this subgroup of patients.
Methods: A subgroup analysis of two randomized prospective trials,
NSABP R-03 and German Rectal Cancer Study, was carried out evaluating a
group of patients who were evaluated pre-neoadjuvant therapy by a surgeon who declared whether an abdominoperineal resection would be the
standard of care. After neoadjuvant therapy, the same surgeon performed
the procedure he felt was the standard of care. The end point was local control of disease.
Results: 429 patients who had neoadjuvant therapy for low lying rectal
cancer who were judged prior to therapy to require non-sphincter sparing
surgery were included in this study. All patients were followed at least 5
years. 14 patients who ultimately did not undergo surgery were excluded.
Of the 129 patients who underwent non-sphincter sparing surgery, 7.6%
(10/129) developed local recurrence of their rectal cancer. In comparison,
3.5% of the 286 patients who underwent sphincter sparing surgery following neoadjuvant chemoradio therapy developed local recurrence within 5
years of their surgery.
Conclusions: Patients with low lying rectal cancer who are not considered candidates for sphincter sparing surgery may benefit from a sphincter
sparing procedure after neoadjuvant chemoradio therapy if the postneoadjuvant examination suggests adequate margins can be achieved with
a sphincter sparing procedure. Support: PHS grants U10-CA-37377, -69974,
-12027, and -69651, from the NCI, NIH, DHHS, and by Sanofi-Synthelabo Inc,
and Roche Laboratories, Inc
Reduction in SUVmax after Extended CRT is significantly more pronounced at
6weeks and sustained after 12 weeks. However, there is no significant decrease in
SUVmax between 6 and 12 weeks.
S34
LONG-TERM OUTCOME OF LOCAL EXCISION AFTER PREOPERATIVE
CHEMORADIATION FOR YPT0 RECTAL CANCER.
F. Stipa, A. Burza, E. Soricelli, P. Delle Site, E. Santini and C. Vitelli
Department of Surgery, Colorectal Surgical Unit, Azienda Ospedaliera San
Giovanni Addolorata, Rome, Italy.
Purpose: The aim of the study was to evaluate the long-term clinical
outcome of a selected group of ypT0 rectal cancer patients, submitted to
local excision with transanal endoscopic microsurgery (TEM) as a definitive
treatment
Methods: Between 1993 and 2013, 38 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a TEM procedure after a regimen of preoperative external beam radiation therapy with
5-fluorouracil (5-FU)-based chemotherapy. In all patients rectal wall penetration (uT stage) was preoperatively assessed by endorectal ultrasound
(ERUS) and/or magnetic resonance (MRI). Indications for CRT and TEM were:
patients refusing radical procedures (TME or Miles) or patients unfit for
major abdominal procedures
Results: In 25 patients partial or absence of tumour CRT response was
observed (66%). In thirteen patients (34%), no residual tumor in the surgical specimen was found (ypT0). In this ypT0 group, 2 patients had a temporary proctitis and 2 patients had a dehiscence of the rectal wound. One
patient was readmitted 18 days post-op for rectal bleeding which was
treated conservatively. Postoperative mortality was nil. After a mean followup of 85 months (range 5 -166), no local and distal recurrences were
observed. In all ypT0 patients no tumor related mortality was observed
Conclusions: Local excision with TEM can be considered a definitive
therapeutic option in patients with rectal cancer treated with preoperative
CRT, when no residual tumor is found in the specimen. In this selected
group local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, TEM should be considered as
a large excisional biopsy
S36
EFFICACY, COMPLIANCE AND SAFETY, OF NEOADJUVANT INTENSITY
MODULATED RADIOTHERAPY WITH CONCURRENT CAPECITABINE
AND TOTAL MESORECTAL EXCISION FOR LOCALLY ADVANCED RECTAL CANCER: UPDATED RESULTS FROM A PHASE II TRIAL (CHICTRTNC- 10001094).
L. Wang1, Y. Li2, Z. Li3, Y. Sun4, L. Sun3, Z. Li5, M. Li1, Y. Peng1, J. Gu1 and
Y. Cai2 1Colorectal Surgery, Peking University Cancer Hospital, Beijing,
China, 2Radiotherapy, Peking University Cancer Hospital, Beijing, China,
3
Pathology, Peking University Cancer Hospital, Beijing, China, 4Radiology,
Peking University Cancer Hospital, Beijing, China and 5Gastrointestinal surgery, Peking University Cancer Hospital, Beijing, China.
Purpose: We have prospectively studied a unique 22 fraction method
of neoadjuvant IMRT with concurrent capecitabine followed by TME surgery for locally advanced rectal cancer to assess efficacy, compliance, toxicity, and surgical complications in a phase II trial. Here, we report updated
results in 260 consecutive patients.
Methods: Patients with resectable clinical stage II-III mid-low rectal cancer received IMRT with gross targeting volume (GTV)/ clinical targeting volume (CTV) of 50.6 / 41.8 Gy in 22 fractions plus concurrent capecitabine
(825 mg/m2 twice daily) in 30 days. The interval from IMRT to surgery is 6
to12 weeks. The primary endpoints included pathological complete
response (ypCR) rate, compliance rate of treatment, acute toxicity and surgical complications were analyzed.
Results: A total of 260 patients received IMRT and surgery from December 2008 to May 2013. The median age was 55 years (range 21-87), and
31.5% were female. The median tumor height was 5cm (range 1-10). Pathological complete response occurred in 18.5% (48/260) of patients. The compliance of treatment is 99.6%, one patient discontinued treatment following 17 fractions of radiation for diarrhea. There was no Grade 4 toxicity
recorded. The incidence of Grade 3 toxicities is 5.8%, including: diarrhea
(4.2%), neutropenia (1.2%) and radiation dermatitis (0.4%). Thirty-day postsurgical complications rate was 26.9%. Anastomotic leakage rate was 2.6%
(4/152) in patients with sphincter preservation. Perineal wound infection
(20.8%, 20/96) or skin dehiscence (8.3%, 8/96) were main complications in
S35
IS IT SAFE TO ALTER A SURGICAL PROCEDURE AFTER NEOADJUVANT
THERAPY FOR RECTAL CANCER?
R. W. Beart1, A. McElrath-Garza1, S. Merkel2, M. Roh3, G. D. Yothers3,
M. O’Connell3, P. Vukasin1 and N. Wolmark3 1Surgery, Glendale Memorial
Hospital, Glendale, CA, 2Surgery, Erlangen University, Erlangen, Germany
and 3SURGERY, NSABP, Pittsburgh, PA.
Purpose: Some surgeons will offer a patient sphincter sparing surgery
after neoadjuvant therapy even if pre-treatment judgment suggested an
abdominal perineal resection was indicated. It is unclear whether down
staging results in concentric shrinkage of the tumor and no data currently
exists to confirm that local control is satisfactory in this specific situation.
The purpose of this study is to determine whether some patients with low
21
Abstracts
patients who received abdominoperineal excision. (Table 1.) No mortality
was recorded and three patients received surgical interventions (1.2%).
Conclusions: This high intensity regimen of neoadjuvant IMRT plus
concurrent capecitabine for rectal cancer achieved high rate of pCR, excellent compliance, minimal acute toxicity and acceptable rate of surgical
complications.
S38
AJCC REGRESSION GRADE: A NEW PROGNOSTIC FACTOR IN RECTAL
CANCER.
A. G. Mace1, R. Pai2, L. Stocchi1 and M. F. Kalady1 1Colorectal Surgery,
Cleveland Clinic, Cleveland, OH and 2Anatomic Pathology, Cleveland
Clinic, Cleveland, OH.
Purpose: Rectal cancer pathologic response to neoadjuvant chemoradiation (CRT) is reported according to the American Joint Commission on
Cancer (AJCC) tumor regression grading guidelines. Despite evidence that
complete responders have improved survival, there is no data regarding
outcomes associated with other response grades. This study evaluates the
prognostic significance of AJCC regression grading in neoadjuvant treated
rectal cancers.
Methods: Rectal cancer patients treated with neoadjuvant CRT
between 2000-2012 were reviewed from a prospectively maintained colorectal cancer database. Primary exclusion criteria were inability to determine AJCC grade, non-adenocarcinoma histology, and incomplete survival
data. AJCC regression grade was assigned to the resected specimen by a
gastrointestinal pathologist as follows: Grade 0:complete response; 1:isolated tumor cells remaining; 2:residual cancer outgrown by fibrosis; or
3:extensive residual cancer.
Results: 486 patients were included, of whom 97 (20.0%) were AJCC
grade 0, 156 (32.1%) were grade 1, 144 (29.6%) were grade 2, and 89
(18.3%) were grade 3. Patients with lower AJCC grades were significantly
more likely to have lower pathologic stage, smaller tumors, and lower incidence of angiolymphatic invasion. Kaplan-Meier analysis revealed AJCC
grade was associated with significant differences in overall survival
(p<0.001), disease-free survival (Figure A, p<0.001), and local recurrence
(Figure B, p=0.02). No local recurrences were observed in AJCC grade 0
patients. Five-year overall survival rates were 82%, 79%, 69%, and 49%
(p<0.001); five-year disease-free survival rates were 78%, 71%, 60%, and
42% (p<0.001); five-year local recurrence rates were 0%, 2%, 6%, and 10%
(p=0.03) for AJCC grades 0, 1, 2, and 3, respectively. After adjusting for significant covariates, including pathologic stage, AJCC grade remained an
independent predictor of overall survival (p=0.002), disease-free survival
(p=0.02), and local recurrence (p=0.049) in Cox regression analyses.
Conclusions: This is the first study to delineate AJCC regression grade
as an independent factor related to oncologic outcomes. This prognostic
information can be used in discussion with rectal cancer patients.
Table 1. Surgical complications following IMRT & TME
S37
PROGNOSTIC IMPACT OF MR-BASED PELVIMETRY AND TUMOR VOLUME ON MANAGEMENT OF RECTAL CANCER.
G. Atasoy1, S. Sokmen1, F. Obuz2, F. Dinc Elibol2, N. Arslan1, H. Ellidokuz3,
O. Sagol4 and E. Nasibov5 1Department of General Surgery, Dokuz Eylul
University, Izmir, Turkey, 2Department of Radiology, Dokuz Eylul University,
Izmir, Turkey, 3Oncology Institute, Dokuz Eylul University, Izmir, Turkey,
4
Department of Pathology, Dokuz Eylul University, Izmir, Turkey and
5
Department of Computer Science, Dokuz Eylul University, Izmir, Turkey.
Purpose: Aim of this study is to analyze the prognostic importance of
pelvic measurements, pelvic cavity index (PCI), and tumor volume determined by magnetic resonance(MR) on the final oncologic outcomes and
the surgical complications of non-metastatic rectal cancer.
Methods: A total of 125 patients who underwent elective curative radical surgery for primary rectal cancer were included in the analysis from a
prospectively collected database. Preoperative MR imaging data of the
patients were re-examined by two radiologists blinded to the design of the
study. Relationship between MR-based pelvimetric measurements, tumor
volume, tumor volume regression rate(TVRR), final oncologic outcomes and
surgical complications of the patients were analyzed.
Results: Age(p=0.010), stage(p=0.005), lymphatic invasion(p=0.043), circumferential resection margin(CRM)(p<0.001), pelvic depth(b)(p=0.014),
interacetabular distance(c) (p=0.026), PCI(p=0.005), tumor volume after
chemoradiotherapy(V2)/PCI(V2/PCI)(p=
0.028)
and
local
recurrence(p<0.001) were related with 5-year survival in univariate analysis.
Age(p=0.03), CRM(p<0.001), PCI(p<0.049), and stage(p=0.027) were found
as independent prognostic factors in multivariate analysis. Intertuberous
distance(c); the distance from sacral promontorium to S3-S4 space(e); and
TVRR were all highly predictive on surgical complications(Logistic RA).
While PCI(p<0.001) and pelvic depth(d)(p<0.033) were independent predictive factors on overall blood loss, PCI(p<0.001) was also an independent
predictive factor on operation time(Lineer RA). PCI and TVRR showed robust
prognostic impact on complications and local recurrence in discriminative
analysis. Correct prediction rates of complications and local recurrence
were 66% and 88%, respectively.
Conclusions: Pelvimetric measurements and tumor volume strongly
predict the final oncologic outcomes and the surgical complications preoperatively in management of locally advanced rectal cancer. These solid
measurements can help further to stratify the patients with controversial
prognostic stage(T3N0), independently of neoadjuvant chemoradiotherapy.
22
Abstracts
was 79.6%. Ex vivo CNB was performed in 43 patients. The false negative
rate was 28.6%. The overall accuracy for CNB was significantly higher than
forceps biopsy (76.7% vs. 34.1%; p<0.001) (table 1). The false negative rate
was significant higher good responder (TRG 3) than poor responder (TRG
≤2) in CNB group (47.1% vs. 5.9%; p=0.02). In vivo CNB guided by ERUS was
performed in 13 patents with good response. Ten patients had residual cancer cells, among whom 7 patients were biopsy negative, leading to a false
negative rate of 70.0%.
Conclusions: A routine forceps biopsy was of limited clinical value in
identifying a pCR after neoadjuvant CRT. CNB might further identify a subset of patients with small residual cancer cells from good responder after
neoadjuvant CRT.
The result of histopathological findings of biopsy samples compared with the
surgical specimen
S40
SURVEILLANCE AFTER NEOADJUVANT THERAPY IN ADVANCED RECTAL CANCER CAN HAVE COMPARABLE OUTCOMES WITH TME.
R. Smith1, R. D. Fry2, N. N. Mahmoud2 and E. C. Paulson3 1Department of
General Surgery, Temple University Hospital, Philadelphia, PA,
2
Department of Colon and Rectal Surgery, Hospital of the University of
Pennsylvania, Philadelphia, PA and 3Department of Colon and Rectal
Surgery, Philadelphia VA Medical Center, Philadelphia, PA.
Purpose: There are select rectal cancer patients who have no evidence
of malignancy after neoadjuvant chemoradiotherpay(CRT). Although the
standard of care remains total mesorectal excision(TME), there is evidence
to support surveillance alone. The purpose of this study is to review our
patients followed with surveillance for complete clinical response(cCR) and
compare them to patients who underwent TME with complete pathologic
response(cPR).
Methods: A review was conducted for all patients treated with rectal
cancer from 2001-2013. Patients were included if they had neoadjuvant
CRT, a documented cCR and opted for surveillance. We also reviewed
patients who underwent neoadjuvant CRT followed by TME who had a cPR.
Outcomes included complications, local recurrence (LR), and survival.
Results: We reviewed 18 cCR and 30 cPR patients with an average follow-up of 66.3 and 46.2 months. Surveillance included Q3month exam with
direct rectal visualization. cCr patients were younger than those with cPR
(62 vs. 60years), more likely to be male (41% vs. 29%), and had lower tumors
than the cPR patients (3.8 vs. 5.9cm, p=0.01). There were no major complications in the cCR group. Of the cPR patients, 5 developed infectious complications (3 abscesses requiring IR drainage, 2 wound infections), 4 developed hernias (2 stomal, 2 incisional) requiring repair, and 5 had significant
low anterior syndrome. One cPR patient had an anastomotic leak after
ileostomy reversal requiring diversion. One cCR patient developed a local
recurrence 1 year post-diagnosis treated with radical resection but with
subsequent pelvic recurrence. Another developed a lung metastasis 34
months post-diagnosis treated by wedge resection. Both are alive at 54 and
62 months. One cPR patient developed a lung metastasis 2 years after APR
(fig. 1). She died of unrelated causes 3 years post-diagnosis.
Conclusions: Non-operative management may be a suitable alternative in cCR patients with low rectal cancers that are easily surveyed. At our
institution, patients with a cCR managed with strict surveillance achieve
comparable outcomes to those patients with cPR undergoing TME but with
fewer complications.
Figure. Kaplan-Meier disease-free survival (Figure A, p<0.001) and cumulative
local recurrence (Figure B, p=0.02) curves for each AJCC tumor regression grade.
S39
ACCURACY OF CORE NEEDLE BIOPSY FOR ASSESSMENT OF PATHOLOGIC COMPLETE REMISSION IN LOCALLY ADVANCED RECTAL CANCER TREATED WITH NEOADJUVANT CHEMORADIOTHERAPY.
T. Jing-Hua1, A. Xin3, C. Mu-Yani2, L. Xi5, L. Guang-Yu4, S. Hong-Bo4,
L. Guo-Chen1, K. Ling-Heng1, L. Jun-Zhong1, C. Gong1, W. Xiao-Jun1,
W. De-Sen1, P. Zhi-Zhong1 and D. Pei-Rong1 1Department of Colorectal
Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China,
2
Department of Pathology, Sun Yat-sen University Cancer Center,
Guangzhou, China, 3Departments of Medical Oncology, Sun Yat-sen
University Cancer Center, Guangzhou, China, 4Department of Endoscopy
and Laser, Sun Yat-sen University Cancer Center, Guangzhou, China and
5
Department of Ultrasound & Electrocardiogram, Sun Yat-sen University
Cancer Center, Guangzhou, China.
Purpose: The study aimed to determine accuracy of routine endoscopic
forceps biopsy and core needle biopsy (CNB) for assessment of pathologic
complete remission in locally advanced rectal cancer (LARC) treated with
neoadjuvant chemoradiotherapy (CRT).
Methods: Patients with LARC treated with neoadjuvant CRT followed
by radical surgical resection entered this study. For routine endoscopic forceps biopsy group, patients received preoperative forceps biopsy 5 weeks
after completion of CRT. In order to evaluate the possible role of CNB in
assessment of pCR, CNB was first performed in resected specimens. After
confirmation of the role of in vivo needle core biopsy guided by endorectal
ultrasound (ERUS) was further performed in good responder after neoadjuvant CRT. Concordance rates for the histopathology status of the surgical
specimen and biopsy samples were evaluated.
Results: The positive predictive value was 100% for both biopsy
approaches in endoscopic forceps biopsy, ex vivo and in vivo CNB. Endoscopic forceps biopsy was performed in 61 patients. The false negative rate
23
Abstracts
S42
RISK OF CATHETER-ASSOCIATED DEEP VENOUS THROMBOSIS IN
INFLAMMATORY BOWEL DISEASE PATIENTS.
A. Bhakta, M. Ahmed, C. Abraham, M. Tafen, D. Bruce, B. Valerian and
E. Lee General Surgery, Albany Medical Center, Albany, NY.
Purpose: Inflammatory bowel disease confers a hypercoagulable state.
There is a growing number of IBD patients requiring central venous access
in the form of peripherally inserted central catheters (PICC) for long-term
intravenous therapies. Our clinical observations suggested that patients
with IBD who received PICC placement had a higher incidence of DVT than
that of the general population. We aim to study the relationship between
IBD patients and catheter-associated DVT (CADVT).
Methods: We conducted a retrospective chart review of all patients
who underwent PICC placement between 2009 and 2011. Patients with IBD
were identified and the risk of DVT in IBD patients was assessed. The risk of
CADVT in IBD patients was compared to known risk factors such as malnutrition, diabetes and tobacco use. A multivariate analysis was performed to
assess if IBD was an independent risk factor for the development of CADVT.
Finally, catheter size, indication for placement, and vein location of the DVT
were identified in the IBD population that suffered from CADVT.
Results: There were 7179 upper extremity PICCs placed during the
study period; the overall incidence of CADVT was 2.1% (148/7179). The incidence of CADVT among patients with IBD was 6.8% (9/132). Conversely, the
incidence of CADVT among non-IBD patients was 1.9% (139/7047) (RR: 3.5,
95% CI: 1.8-6.6, p<0.001). The incidence of CADVT was increased for
patients with malnutrition (4.8%, 30/628, p<0.001). For every 10 years
increase in age, the risk of CADVT increased 1.07 times (95% CI: 1.01-1.12,
p=0.016). There was no increased incidence of CADVT for patients with diabetes (1.6%, 25/1574, p<0.137) or tobacco use (1.6%, 31/1938, p=0.096).
After multivariate analysis, IBD, malnutrition, and increasing age were found
to be significant risk factors for the development of CADVT.
Conclusions: This is the first study to date that demonstrates IBD as an
independent risk factor to the development of CADVT. Furthermore, in concordance with previous studies, malnutrition and increasing age were also
found to be significant risk factors for the development of CADVT. PICC
placement in these patients should be utilized selectively and accompanied by anticoagulation and screening.
S41
TRANSANAL TOTAL MESORECTAL RESECTION BY TRANSANAL ENDOSCOPIC MICROSURGERY: TECHNIQUE AND PRELIMINARY ONCOLOGICAL RESULTS.
E. Lezoche, A. M. Paganini, S. Quaresima, A. Balla and G. D’Ambrosio
Department of General Surgery, Surgical Specialties and Organ
Transplantation “Paride Stefanini”, Policlinico Umberto I, Rome, Italy.
Purpose: Transanal Endoscopic Microsurgery (TEM) has proven to be
technically superior to conventional transanal approaches. The authors
have developed a new sphincter-preserving technique for ultra-low rectal
cancer: TATMR by TEM. Aim of this study is to evaluate the preliminary oncologic result at 30 months’ medium follow-up.
Methods: By TEM, the incision line starts 1 cm below the lower border
of the neoplasm and reaches the pelvic floor. The dissection follows the
mesorectal plane described by Heald. The abdominal step is performed by
a traditional laparoscopic technique with colo-anal anastomosis. Patients
were followed-up by digital rectal examination, tumor markers’ assay,
colonoscopy, pelvic MRI and total body CT every three months for the first
3 years and every six months for the next 2 years.
Results: From October 2008, TATMR by TEM was performed in ten
patients with rectal cancer (6 males, 4 females, median age 67 years, range
41-82). Preoperative staging was: T4N+ (5), T3N+ (3), T3N0 (1), T2N+ (1). All
patients underwent neoadjuvant radiochemotherapy (n-RCT). Eight
patients were no-responders to n-RCT, 1 had dowstaging and downsizing,
1 only downsizing. Mean tumor diameter was 4,7 cm (range 3 – 7 cm). Mean
operative time was 440 min (range 360-600 min). Mean tumor distance
from the anal verge was 2.9 cm (range 2-4 cm). In eight patients a protective ileostomy was performed. Final staging was pT3N0 (1), pT3N2 (1),
pT2N0 (3), pT0N0 (4), pT1N0 (1). Postoperative complications included anastomotic leakage (3) and temporary urinary incontinence (1). Mean hospital
stay was 16.6 days (range 9–22 days). Late complications included anastomotic stenosis (2) and recto-vaginal fistula (1) treated by stent. pT3 and pN+
patients underwent adjuvant chemotherapy. At mean follow-up of 30
months (range 4-60) one patient died for unrelated causes, one patient
developed liver metastases at 25 months and eight patients are diseasefree.
Conclusions: TATMR by TEM seems to be a safe and effective approach
for the treatment of ultralow rectal cancer. Larger patient series and at least
five years’ follow up are required to evaluate the oncologic results.
S43
ACCURACY OF CTE AND MRE IMAGING TO DETECT LESIONS PREOPERATIVELY IN PATIENTS WITH CROHN’S DISEASE.
K. P. Seastedt, K. Trencheva, F. Michelassi, D. Alsaleh, J. W. Milsom,
T. Sonoda, S. W. Lee, P. J. Shukla, K. A. Garrett and G. Nandakumar Weill
Cornell Medical College, New York, NY.
Purpose: CT enterography (CTE) and MR enterography (MRE) have
recently emerged as new imaging technologies for evaluation of the gastrointestinal tract in Crohn’s disease (CD). The aim of this study was to evaluate the accuracy of these two imaging modalities.
Methods: A retrospective chart review of patients (pts) who underwent
surgery for CD at a single institution from 2008 to 2013 with preoperative
CTE and/or MRE was performed. The number of stenoses, fistulae and
abscesses identified by CTE and/or MRE before surgery were compared to
the findings at the time of surgery. The accuracy, sensitivity, specificity, positive and negative predictive values of CTE and MRE were calculated.
Results: 74 pts with median age of 34 years and BMI 21 kg/m2 were
included. 46/74(62%) pts had prior abdominal surgery with 40/46 (87%) for
recurrent CD. 33 (44%) had a pre-operative CTE and 41(56%) MRE. A total
of 96 lesions consisting of abscesses, fistulae and stenoses were identified
on pre-operative imaging and 145 lesions were reported in the operative
reports. Sensitivity, negative predictive value (NPV) and accuracy of CTE
and MRE for stenoses and fistulae were very low with a high number of
false negative results (Table 1). Overall number of pts with false negative (
FN) imaging test for stenosis was 15/37( 40.5%) and for fistulae
24
Abstracts
10/58(17.2%). CTE sensitivity, NPV and accuracy for stenosis were 75%, 54%
and 76% and for fistula 50%, 85% and 79% respectively . MRE sensitivity,
NPV and accuracy for stenosis were 68%, 65% and 78% and for fistula 60%,
81% and 85% respectively. There was a significant difference in the number
of stenoses and fistulae identified preoperatively compared to the operative findings p =0.011 and 0.034 respectively. The planned surgical procedure was modified in 20 out of 74 pts (27%).
Conclusions: CTE and MRE in CD pts were accurate for the identification of abscesses, but not for fistula or stenosis. Even with CTE and MRE surgeons need to look for occult stenosis and fistula intra-operatively. Patients
should be appropriately counseled regarding need for unexpected interventions.
scopic steroid injection or individual endoscopist had no relationship with
the risk of having surgery. Significant factors associated with the requirement of surgery on multivariable analysis were younger age, shorter duration of Crohn’s disease, longer interval from last surgery, multiple previous
resections, steroid use before dilatation, and concurrent stricture (Table).
Conclusions: Endoscopic dilatation is a reasonable initial approach for
ileocolic anastomotic stricture in patients with Crohn’s disease. Patients
with long disease history, multiple previous resections and aggressively
recurrent disease should be preferentially offered surgery considering the
high balloon dilatation failure rate.
Table. Cox proportional hazard model for risk factors associated with requirement
of surgery after the first endoscopic dilatation
Table 1
S45
LEVEL OF AGREEMENT BETWEEN PREOPERATIVE BIOPSIES AND
PATHOLOGICAL FINDINGS IN IBD-ASSOCIATED NEOPLASIA.
A. Althumairi, E. Wick, S. Fang, J. Efron, M. Lazarev and S. Gearhart Johns
Hopkins Hospital, Baltimore, MD.
Purpose: To determine the correlation between preoperative endoscopic biopsies vs. whole specimen pathologic review in patients with IBDassociated neoplasia.
Methods: Patients with IBD-associated neoplasia who underwent colectomy from 2002-2013 for findings of dysplasia, Dysplasia-Associated Lesion
or Mass (DALM), or cancer on surveillance endoscopy were included.
Pathologists specializing in gastrointestinal disease reviewed endoscopic
biopsies and postoperative colectomy specimens. All specimens underwent
standardized examination every 10 cm with additional cuts at areas of interest. Pearson’s correlation coefficient was used to assess the relationship
between biopsy and final pathology.
Results: 59 patients with IBD associated dysplasia, DALM, or cancer on
the endoscopic biopsies were identified, 41 (69.5%) were male, mean age
was 54 years, and mean time with IBD was 19 years. 80% had total proctocolectomy, while 20% had subtotal or segmental resection. In the colectomy specimen, HGD was identified in 11 (19%), LGD was identified in 18
(30%), and no neoplasia was identified in 16 (27%) patients. Adenocarcinoma was identified in 14 (24%) patients of which 10 (17%) were unknown
at the time of colectomy. Agreement with preoperative biopsy findings
occurred in 22 (38%) patients (r=0.255, p=0.054). Table 1 shows the relationship between biopsy and final pathology for patients with indefinite
dysplasia, LGD without DALM, LGD with DALM, and HGD. The greatest
agreement was in patients with LGD without DALM, while patients with
indefinite dysplasia and LGD with DALM showed the least agreement (LGD
with or without DALM correlation with the final pathology, r=0.398,
p=0.027). On review of endoscopic procedure in patients who had a DALM,
only 1 out of the 16 patients had dysplasia identified elsewhere and 8
patients (50%) had a polypectomy performed.
Conclusions: Patients undergoing surgery for IBD associated neoplasia
should understand that agreement between preoperative endoscopic
biopsies and final pathology remains low and the risk of cancer remains
elevated. The low correlation among patients with LGD with DALM high-
All numbers are percentages
S44
ENDOSCOPIC BALLOON DILATATION OF ILEOCOLIC ANASTOMOTIC
STRICTURE FOR CROHN’S DISEASE: WHEN SHOULD THE SURGEON
TAKE OVER?
L. Lian, L. Stocchi, B. Shen and F. Remzi Cleveland Clinic, Cleveland, OH.
Purpose: Endoscopic balloon dilatation is frequently used for the management of anastomotic strictures in patients with previous ileocolic resection for Crohn’s disease. There is scant data on the incidence of surgery following endoscopic dilatation. The aims of this study were to analyze the
outcomes of patients initially approached with endoscopic dilatation and
factors associated with the need for surgery.
Methods: Patients undergoing endoscopic dilatation of ileocolic anastomotic stricture were identified between December 1998 and May 2013.
Technical failure was defined as inability to pass the endoscope through
the anastomosis after dilatation. Univariate and multivariate analyses were
used to assess multiple endoscopic and clinical factors associated with the
primary endpoint of need for surgery to treat anastomotic disease.
Results: One hundred and eighty-two patients underwent a total of 452
endoscopic dilatations of ileocolic anastomosis (46% females, mean age 43,
symptomatic stricture in 80%). The median number of per-patient dilatations was 2(1-3). Immediate surgery or within one month after initial dilatation was due to technical failure (n=1), endoscopic perforation (n=1), or
patient preference (n=4). During a mean follow up of 2.6 years, 26 (14%)
patients required hospitalization without surgery for stricture-related symptoms and 59 (32%) patients required surgery. Fistulizing abdominal disease
developed in 6 patients (3.3%). Medication use, type of anastomosis, endo-
25
Abstracts
lights the need for continued careful discrimination between sporadic adenoma and DALM.
S47
NATIONAL TRENDS OF THREE- VERSUS TWO-STAGE RESTORATIVE
PROCTOCOLECTOMY FOR CHRONIC ULCERATIVE COLITIS.
J. Bikhchandani, P. Stephanie, A. Wagie, E. Habermann and R. R. Cima
Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
Table 1. Pathological agreement
Purpose: Patients undergoing surgical treatment of chronic ulcerative
colitis (CUC) may undergo a 2 or 3 stage ileal pouch-anal anastomosis
(IPAA). While there is evidence for reduced complications in select patients
following 3-stage IPAA, recently published data suggested this approach is
overused. This study aims to identify the national trends in approach to
IPAA for CUC using the American College of Surgeons National Surgical
Quality Improvement Program.
Methods: Patients with CUC who underwent IPAA were identified from
the 2005 to 2011 ACS NSQIP database. Those who underwent colectomy
with IPAA were placed in the 2 stage cohort and those without simultaneous colectomy were part of 3 stage cohort. The index operation evaluated
was the first step of a 2 stage approach (total proctocolectomy with IPAA)
and the second step of a 3 stage approach (completion proctectomy with
IPAA). Emergent operations were excluded. Variation in procedure mix over
time was evaluated using a test of trend. Preoperative characteristics were
compared in 2 groups using T-tests for continuous and chi square tests for
discrete variables. P value less than 0.05 was considered significant.
Results: Of total 2002 patients undergoing IPAA in the study sample,
1452 (72.5%) and 550 (27.5%) patients underwent 2 and 3 stage IPAA,
respectively. In 2005 and 2006, the total number of IPAA were 43 and 112
respectively; 2 stage approach was pursued in 39.5% and 50.9 % patients.
Since 2007, the distribution of 2 vs 3 stage procedures has not changed
(p=0.66); approximately a quarter of patients each year have undergone 3
stage approach (Fig 1). Patients undergoing a 3 stage IPAA were younger
(39 vs 41 years, p=0.0009) and were less likely to have preoperative corticosteroid therapy, albumin <3 mg/dL, preoperative sepsis, and preoperative weight loss (all p<0.05). The 2 cohorts were similar with respect to gender, BMI, ASA status, diabetic status and wound class (all p>0.05).
Conclusions: National trends in the use of 2 vs 3 stage IPAA have
remained stable over the last 5 years. Patients who underwent 3 stage
approach appeared to be healthier at the time of IPAA, with decreased corticosteroid use, hypoalbuminemia, and weight loss.
S46
INITIAL SURGICAL MANAGEMENT OF ULCERATIVE COLITIS IN THE
BIOLOGIC ERA.
C. N. Budde, D. O. Herzig, B. S. Diggs, K. Keyashian, K. C. Lu and L. Tsikitis
Oregon Health and Science University, Portland, OR.
Purpose: When surgical treatment of ulcerative colitis (UC) is necessary,
the initial minimum operation is a total colectomy (TAC). For healthy
patients, a proctectomy is performed at the same time, either as definitive
management or as the first stage of a restorative proctocolectomy. For ill
patients, proctectomy is delayed. Since introduction of biologic medications in 2005, it has been reported that patients present acutely ill at the
time of initial operation. We hypothesized that the initial surgical intervention for UC has changed over time in light of the patient’s medical condition at presentation.
Methods: We reviewed the Nationwide Inpatient Sample (NIS) database
for all UC patients admitted from 1991 to 2011 (1,547,852). We examined
patients whose initial operation consisted of a total proctocolectomy (TPC)
with or without pouch versus TAC without proctectomy. To corroborate
these findings, we examined what operation was done at the time of the
construction of an ileoanal pouch: Patients who underwent colectomy and
pouch construction in the same hospitalization were compared to those
who received pouch formation at a subsequent hospitalization.
Results: UC-related admissions rose by 170% during the years examined, and number of patients who required TAC increased by 44%. During
the 20 year period, TAC without proctectomy as the initial operation performed increased by 15% as opposed to TPC (p <0.001)(Figure1). Furthermore, pouch construction at a subsequent operation, increased by 16%
(p<0.001). TAC without protectomy surpassed TPC as the most common initial surgical intervention for UC in 2008.
Conclusions: Ileoanal pouch is now more frequently constructed at an
operation subsequent to the initial colectomy, suggesting an increased
usage of a 3-stage procedure. These trends coincide with the initiation of
biologic treatments and imply patients are more likely to present acutely ill
at the time of initial operation.
Temporal trends in two versus three stage approach for Ulcerative Colitis
S48
20-YEAR OLD STAPLED POUCHES FOR ULCERATIVE COLITIS WITHOUT
EVIDENCE OF RECTAL CANCER: IMPLICATIONS FOR SURVEILLANCE
STRATEGY?
J. Silva Velazco, L. Stocchi, X. Wu, B. Shen and F. H. Remzi Colorectal
Surgery, Cleveland Clinic Foundation, Cleveland, OH.
Purpose: The risk of dysplasia and cancer after stapled ileal pouch-anal
anastomosis (IPAA) with preservation of the anal transitional zone (ATZ) for
ulcerative colitis might be cumulative over time. The aim of this study was
Trends in the initial surgical management of ulcerative colitis.
26
Abstracts
to assess the long-term incidence of ATZ dysplasia and its possible risk factors.
Methods: All patients undergoing stapled IPAA for ulcerative/indeterminate colitis between 1986-1992 were identified from a prospectively
maintained database. Recommended ATZ surveillance included serial
endoscopic biopsies at 1-2 year intervals. A number of demographic, clinical, surgical and pathological variables were assessed as possible factors
associated with ATZ dysplasia.
Results: Out of 285 patients undergoing ≥2 ATZ surveillance biopsies,
73 had ≥20 years of regular follow-up (figure). Indications for IPAA included
colorectal dysplasia or cancer in 35 (12%) and 5 (2%) patients, respectively.
ATZ dysplasia was diagnosed in 9 (3%) patients after a mean interval of 33
months (range 4-125) following IPAA. No additional dysplasia cases were
identified during subsequent follow-up. Seven patients died from causes
unrelated to cancer and 8 were lost and died after a mean follow-up of 93
months without dysplasia. Both preoperative and pathology findings of colorectal dysplasia/cancer were significantly associated with ATZ dysplasia
during surveillance (p=0.004 and p=0.018, respectively). Patients with ATZ
dysplasia were managed expectantly or with mucosectomy (5 and 4 cases,
respectively), depending on the number of positive biopsies and degree of
dysplasia (figure). Patients continued surveillance biopsies following their
latest detection of ATZ dysplasia or mucosectomy for a mean of 137 months
(range 9-256), during which no recurrent dysplasia or invasive adenocarcinoma developed.
Conclusions: Long-term follow-up provides corroborating evidence
supporting stapled IPAA as the restorative procedure of choice for ulcerative colitis, even when complicated by dysplasia or cancer. Future studies
should assess if a less intensive surveillance strategy is safe after 10 years
following IPAA.
colectomy with ileal pouch creation and diverting loop ileostomy. The second stage involves takedown of the loop ileostomy. Postoperative readmission rates and reasons for readmission were examined following both
stages. Univariate and multivariate analyses were performed to evaluate for
risk factors associated with 30 day readmission following stage I.
Results: Following stage I of restorative proctocolectomy, 18.2% (n=97)
of patients were readmitted within 30 days while 22.7% (n=121) were readmitted within 90 days. Younger patient age (OR 1.825, 95% CI 1.139-2.957),
laparoscopic approach (OR 1.943, 95 % CI 1.217-3.104) and increased length
of initial stay (OR 1.155, 95% CI 1.090-1.225) were all associated with 30 day
readmission. The most common reason for readmission was ileus/partial
bowel obstruction, with 10% of all patients readmitted for this reason alone
within 30 days of stage I.
Conclusions: Patients undergoing restorative proctocolectomy are at
high risk for readmission, particularly following the first stage of the operation. Novel treatment pathways to prevent ileus and subsequent dehydration as an outpatient may decrease the rates of readmission following
restorative proctocolectomy.
S50
FACTORS ASSOCIATED WITH 30-DAY READMISSION FOLLOWING
PROCTECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS: A
NATIONAL STUDY.
J. M. Sutton2, G. Wilson2, S. Shah2, D. Abbott2, B. R. Davis1, J. F. Rafferty1
and I. M. Paquette1 1Colon and Rectal Surgery, University of Cincinnati
College of Medicine, Cincinnati, OH and 2Surgery, University of Cincinnati
College of Medicine, Cincinnati, OH.
Purpose: Hospital readmission has been identified by many payors as a
surrogate for surgical quality. The 30-day readmission rate and factors associated with hospital readmission following proctectomy with ileal pouch
anal anastomosis (IPAA) are unknown.
Methods: The University Health Consortium Clinical Database (UHC)
was queried for patients > 18 years of age undergoing elective proctectomy with IPAA (ICD-9 code 45.95) between 2009-2012. Hospital and surgeon case volumes were stratified into quartiles (high, medium, low, and
lowest-volume) for further analyses. Multivariate logistic regression models
were used to identify patient and hospital-level factors associated with 30day readmission. A separate hierarchical logistic regression was used to
determine if patient or hospital-factors accounted for the variability in readmission across hospitals.
Results: A total of 4,952 patients were identified as having a proctectomy with IPAA. The median patient age was 43 years (IQR 30-54 years) with
81% of patients being Caucasian. The 30-day readmission rate was 22.8%
overall, although high volume centers performed significantly better than
low volume (high vs. lowest volume: 18.6% vs. 28.2%, p<0.001). Multivariate analysis identified male gender (OR 1.21, 95% CI 1.06-1.39, p=0.005),
government-based (vs. private) insurance (OR 1.31, 95% CI 1.11-1.56,
p=0.002), and higher pre-operative severity of illness (OR 1.51, 95% CI 1.032.21, p<0.032) to be associated with readmission. When controlling for confounding variables, a significant volume-dependent relationship on 30-day
readmission was identified (Table). Hierarchical regression modeling indicated that 31% of the variation in readmission rates among individual hospitals is accounted for by hospital volume, while only 3.5% of the variation
in hospital readmission rates is explained by differences in measurable
patient factors (p=0.0006).
Conclusions: This is the first national cohort study to show that 30-day
readmission after IPAA creation is very high. This high rate of readmission is
mitigated by centers performing the highest volume of cases and case volume accounts for 31% of the variation in readmission rates across all centers.
S49
CHARACTERIZING READMISSION IN ULCERATIVE COLITIS PATIENTS
UNDERGOING RESTORATIVE PROCTOCOLECTOMY.
T. P. Hanzlik1, S. E. Tevis2, P. A. Suwanabol2, B. A. Harms2, C. P. Heise2,
E. F. Foley2 and G. D. Kennedy2 1University of Wisconsin School of
Medicine and Public Health, Madison, WI and 2Department of Surgery,
University of Wisconsin School of Medicine and Public Health, Madison,
WI.
Purpose: Postoperative readmissions increase costs and affect patient
quality of life. Ulcerative colitis patients at our institution are at a high risk
for postoperative readmission following restorative proctocolectomy. We
aim to characterize patients undergoing restorative proctocolectomy with
respect to 1) the timeframe of readmission, 2) the reason for readmission
and 3) the risk factors associated with readmission.
Methods: Ulcerative colitis patients who underwent restorative proctocolectomy were identified from the prospectively maintained University of
Wisconsin Colorectal Surgery database. We evaluated 533 patients who met
our inclusion criteria. Restorative proctocolectomy at our institution is routinely performed as a 2-stage operation. The first stage involves a procto-
27
Abstracts
Multivariate logistic regression of the relationship between hospital volume and
readmission
mon tool used in clinical practice is the Cleveland Clinic Florida scale (CCF).
The CCF scale affords 0-4 points in each domain of solid, liquid, or gas
incontinence, as well as lifestyle alteration and pad usage. We hypothesized
that the CCF scale is useful at establishing baseline disease severity, but not
useful in demonstrating response to treatment. This is due to the large
number of patients who still wear a pad despite improved continence, as
well as the inability to track improvements in urgency, which is often the
main complaint of patients with fecal incontinence.
Methods: We reviewed our prospectively maintained database of
patients treated with sacral neuromodulation for fecal incontinence at two
institutions. Patient demographics and CCF scores were captured prospectively and the database was queried for the analyses in this study.
Results: A total of 115 patients were treated with sacral neuromodulation in our database. The median preoperative CCF score was 14. The
Median CCF score at 12 months was 3 (interquartile range 2-4). Of these
patients, 48.6% reported still wearing a pad after the procedure. The reason for wearing a pad was reported as residual fecal incontinence (41%),
habit, despite normal continence (35.3%), and urinary incontinence, with
complete fecal continence (23.5%). Of patients who report wearing a pad,
68.8% have falsely elevated CCF scores due to wearing a pad despite complete fecal continence. Additionally, 96.3% of patients reported improvement in fecal urgency, which would not be captured using the CCF score.
Conclusions: Although the CCF score is a validated scale, which is simple to use for baseline disease severity, it is less useful in tracking patient
improvement after treatment. Many patients have a falsely elevated CCF
score due to persistent pad use despite normal continence. Additionally,
the CCF score does not capture improvement in urgency. The ideal scoring
system would be easy to use in clinical practice, and would account for
improvement in fecal urgency.
S51
IMPACT OF PREOPERATIVE RADIATION ON SHORT-TERM OUTCOMES
IN ILEAL POUCH-ANAL ANASTOMOSIS.
B. E. Wertzberger, S. K. Sherman and J. C. Byrn Colorectal Surgery,
University of Iowa Hospitals and Clinics, Iowa City, IA.
Purpose: Series from specialized centers demonstrate a correlation
between preoperative pelvic radiation and poor long-term pouch function
after ileal pouch anal anastomosis (IPAA). Short-term complications also
correlate with poor long-term pouch function and quality of life, but the
rarity of the radiated pelvis IPAA patient limits conclusions on preoperative
radiation’s (PR) effect on operative outcomes in most series. To better
understand the impact of PR on IPAA outcomes, we retrospectively analyzed NSQIP data, hypothesizing that PR in IPAA patients would correlate
with higher short-term complication rates.
Methods: Non-emergent ileal pouch anal anastomosis procedures
included in NSQIP from 2005-11 were analyzed (CPT codes 44158, 44211,
45113, and 44157). Receipt of PR (within 90 days) was tested for correlation
with occurrence of NSQIP-recorded 30-day complications. Complications
showing univariate association were tested using multivariate logistic
regression to correct for differences in demographic and risk factors, with
significance at p<0.05.
Results: Included were 3172 patients receiving IPAA; 162 received PR.
Complication rates were not significantly different in patients receiving PR
vs. not (27.8 vs. 35.1%, see Table). When limited to only patients with cancer diagnoses (n=598), 157 received PR. In this group, complication rates
were not significantly different by radiation status. Patients receiving PR
had significantly lower rates of sepsis in both the overall and cancer-only
groups. The correlation between PR and lower rates of sepsis remained significant after multivariate correction for diagnosis, sex, age, race, smoking,
diabetes, steroid use, procedure performed, and history of cardiovascular
disease (p=0.01).
Conclusions: Unexpectedly, patients who received radiation prior to
IPAA had significantly lower rates of sepsis and no difference in 30-day complications compared to patients not receiving PR. These results support that
poor long-term pouch results in the irradiated pelvis are not due to higher
rates of short-term complications.
S53
THE MAGNETIC ANAL SPHINCTER IN PATIENTS WITH SEVERE FECAL
INCONTINENCE – RESULTS AFTER 22 IMPLANTATIONS.
F. Pakravan and C. Helmes CPZ Duesseldorf, Duesseldorf, Germany.
Purpose: Fecal incontinence (FI) is a distressing condition that can lead
to complete social isolation. If conservative treatment is unsuccessful, surgical treatment offers a last treatment option. The present study examines
the results of the magnetic anal sphincter (MAS) in patients with severe FI.
Methods: A MAS was implanted in patients with severe FI and failure
of conservative management. The implantation was performed with a single perineal incision. After tunneling and determining the size of the device,
the MAS was placed around the anal canal and closed. Data were collected
retrospectively with primary focus on reduction of CCIS and qualitiy of life
(FIQL).
Results: Between January 2012 and October 2013 22 patients received
an MAS. Patient characteristics: 18 female, 4 male, age 67±14, follow-up
474±161 days, prior peripheral nerve evaluation test in 11 (50%) patients
and 1 (5%) prior implantation of an artificial bowel sphincter (ABS). Mean
CCIS was 17.5±1.8. In all patients the implantation was performed without
intraoperative complications. The mean number of beats used for the
implantation was 18±1. No explantation was performed during the followup. Adverse events: 5 (23%) patients had pain and 5 (23%) patients had
swelling and erythema in both gluteal regions within the second and third
week after the implantation. By conservative treatment both dropped completely during further follow-up. Vaginal bleeding, that stopped spontaneously, was noticed in 1 (5%) patient. One (5%) patient had a transection
of the device during abdominal rectal prolapse surgery 18 months after the
implantation. CCIS and FIQL: CCIS decreased to 7.8 ± 4.4 and FIQL improved
in all 4 domains.
Conclusions: The magnetic anal sphincter shows good results for the
treatment of severe FI in this patient group. Compared to other possible
devices both implantation and support during further follow-up is easy.
Depending on patients individual compliance MAS might be considered as
a first choice option for surgical treatment of FI.
S52
IS IT TIME FOR A NEW SCORING SYSTEM FOR FECAL INCONTINENCE?
I. M. Paquette1, A. Abodeely2, B. Johnson1, M. Ferguson1 and J. Rafferty1
1
Colon and Rectal Surgery, University of Cincinnati College of Medicine,
Cincinnati, OH and 2Surgery, Adirondack Surgical Group, Saranac Lake,
NY.
Purpose: There are many systems used to grade the severity of fecal
incontinence. Many of these systems, such as the “Fecal Incontinence Quality of Life Scale” are too cumbersome for routine clinical use. The most com-
28
Abstracts
29(50.9%) patients retained the device (16 Group 1, 8 Group 2), 24 (42.1%)
of whom reported good function; 5 patients who had a second re-implantation had a non working device. Only 1/5 patients who were re-implanted
due to infection/erosion had a working device. Success rates were similar
between the groups (Chi-square 0.516, p=0.472). Kaplan-Meier Survival
Analysis showed no difference in the length of time a device was functional
between the groups (Chi-square 0.599, p=0.439).
Conclusions: The most common cause of ABS reimplantation is device
malfunction or migration, whereas a smaller percentage are due to infection. Re-implantation of ABS secondary to device malfunction is feasible
and safe. If reimplantarion is successful, short- and long-term outcomes are
comparable to those of initial implantation.
S54
INITIAL RESULTS OF A NEW BULKING AGENT FOR FECAL INCONTINENCE. A MULTICENTER STUDY.
G. Rosato2, L. C. Oliveira1, P. Piccinini3 and A. Habr-Gama4 1Anorectal
Physiology, CCP, Rio de Janeiro, Brazil, 2Colorectal Department, Hospital
Austral, Buenos Aires, Argentina, 3Colorectal Surgery, CEMIC, Buenos Aires,
Argentina and 4Colorectal Surgery, Instituto Angelita Gama, Sao Paulo,
Brazil.
Purpose: The aim of our study was to prospectively evaluate a selected
group of patients with minor to moderate fecal incontinence related to
sphincter injury.
Methods: Patients with anal incontinence that failed biofeedback and
other conservative measures entered our study. Inclusion criteria were:
minor incontinence as considered utilizing Wexner incontinence score, anal
manometry and endoanal ultrasound demonstrating a weak or disrupted
internal / external anal sphincter not greater than 30 degree.. Exclusion criteria included pregnancy, proctitis, active IBD, diabetes Type I, rectal cancer, radiotherapy. All patients were evaluated by the Wexner incontinence
score and the FIQL instrument, before the injection and after 3, 6 and 12
months. Injections of 2ml per site of polyacrylate polyalcohol copolymer
were performed under venous anesthesia, at the site of the defect or in the
4 quadrants. All patients received broad spectrum antibiotics bafore the
injections. Minor to moderate incontinence was considered a Wexner score
between 6-12 . Suboptimal results were considered when patients had less
than 50% reduction of episodes of incontinence.
Results: 58 patients ( 43 female) with a mean age of 45.8 ( 32-59 ) years
were prospectively enrolled in our multi center study. A significant improvement in quality of life and a reduction in incontinence episodes were
observed (p<0.05) Minor complications such as pruritus, urgency,anal pain
were observed in 17 patients(29%) and were managed conservatively. Four
patients were re-injected due to suboptimal results
Conclusions: Injection of the bulking agent polyacrylate polyalcohol
copolymer in selected patients could be a good option for minor to moderate incontinence. This treatment option has demonstrated a reduction in
incontinence episodes and an improvement in quality of life, that were sustained over a one year period.
S56
STABILITY OF RESPONSE AFTER NASHA/DX TREATMENT FOR FECAL
INCONTINENCE: LONG-TERM FOLLOW-UP OF A RANDOMIZED TRIAL.
M. Bernstein1, T. Hull2, A. C. Barrett3, K. E. Matzel4, A. Mellgren5 and
W. Graf6 1NYU Langone Medical Center, New York, NY, 2Cleveland Clinic
Foundation, Cleveland, OH, 3Salix Pharmaceuticals, Inc., Raleigh, NC,
4
Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen,
Germany, 5University of Illinois, Chicago, IL and 6Institution of Surgical
Sciences, Uppsala, Sweden.
Purpose: NASHA/Dx, an injectable bulking agent, has demonstrated
efficacy and safety for the treatment of fecal incontinence (FI) in a 6-month,
randomized, sham-controlled study. Another report indicated that the proportion of patients responding to treatment remained stable up to 36
months. However, for those who respond to treatment, the ability to maintain a response is not known. The objective of this analysis was to examine
the probability of maintaining a response in: 1) NASHA/Dx-treated patients
followed for 36 months, and 2) initially sham-treated patients injected with
NASHA/Dx at 6 months.
Methods: Patients with a Cleveland Clinic Florida Incontinence Score
(CCFIS) of ≥10, with ≥4 FI episodes/2 weeks were randomized to receive
either NASHA/Dx injection (n=136) or sham injection (n=70). Treatment success was defined as a reduction in number of FI episodes by ≥50% per week
compared to baseline (Responder50). Responders were followed under
open-label conditions for up to 36 months. Initial sham-injected patients
were offered open-label NASHA/Dx (Sham Crossover) at 6 months and followed for 24 additional months (30 months total).
Results: Baseline characteristics (age, gender, FI episodes/2 weeks and
CCFIS) were comparable between treatment groups. Responder50 rates
were 53% in the NASHA/Dx group vs. 32% in the sham group (p=0.0089) at
6 months. Of patients who were responders at 6 months (n=71), 78%, 72%,
and 70% were responders at 12, 24, and 36 months. Nearly 60% were
responders at all three follow-up intervals. In Sham Crossover patients
(n=61) treated with NASHA/Dx under open-label conditions after 6 months,
the Responder50 rate was approximately 50% at 6, 12, and 24 months postinjection. In Crossover patients who responded at 6 months (n=30), the
Responder50 rate was 93% and 83% at 12 and 24 months, with 80%
responding at both follow-up intervals.
Conclusions: The majority of patients with FI who achieve benefit with
NASHA/Dx at 6 months maintain this response for up to 3 years. The
improvement in FI episodes in the Sham Crossover subgroup replicates the
improvements observed with NASHA/Dx under controlled conditions.
S55
THE OUTCOMES OF REIMPLANTATION OF THE ARTIFICIAL BOWEL
SPHINCTER.
X. Wang, G. DaSilva and S. D. Wexner Colorectal Surgery, Cleveland Clinic
Florida, Weston, FL.
Purpose: Outcomes of implantation of the artificial bowel sphincter
(ABS) to treat severe fecal incontinence (FI) have been demonstrated. However outcomes of re-implantation remain less well known. This study aimed
to evaluate the feasibility, risk factors and outcomes of ABS re-implantation.
Methods: After IRB approval, medical records of patients who underwent ABS implantation and re-implantation between 1/1998-12/2012 were
reviewed. FI was evaluated using the Cleveland Clinic Fecal Incontinence
Score (CCF–FIS). Patients were divided in two groups: patients who had single ABS implantation (Group A); and patients who had >1 ABS re-implantation (Group B). Demographics, morbidities, and CCF-FIS were compared
between groups. Fisher’s exact, chi-square, and Student’s t-test were performed for statistical analysis.
Results: 79 operations in 57 patients (mean age 49.3±13.5 years, 44
females) were reviewed. Group A included 57 patients while Group B
included 17 with 22 re-implantations; 5/22 (8.8%) underwent a second reimplantation. Groups were similar for demographics, ASA score, etiology,
comorbidities, complications, length of operation, infection and explantation rates, time of discharge and FIS. Reasons for re-implantation included
device malfunction or migration in 17/22 (77.3%), and infection or erosion
in 5/22(22.7%) patients. At a median follow up of 29.5 (1-215) months,
29
Abstracts
Table 1: Indications, comorbidities and postoperative short-term outcomes
S57
IS LAPAROSCOPIC RECTOPEXY SAFE IN THE ELDERLY? THE ANSWER
FROM A NATIONWIDE DATABASE.
A. F. Gultekin1, M. Barussaud2, J. Podevin1, M. Boutami1, P. A. Lehur1 and
G. Meurette1 1Clinique de Chirurgie Digestive et Endocrinienne, University
Hospital of Nantes, Nantes, France and 2Service de Chirurgie Digestive,
University Hospital of Poitiers, Poitiers, France.
Purpose: Laparoscopic ventral mesh rectopexy (LR) is an established
procedure for the treatment of posterior pelvic organ prolapse (POP) in
Western Europe. This approach has been widely adopted by colorectal surgeons, gynecologists and urologists over the recent years even in case of
multicompartment prolapse. POP being age dependent, a high number of
elderly patients are operated for POP. Aim: to assess the effect of age on
the surgical outcome of patients operated on for LR in France.
Methods: All patients undergoing LR in 2010 were identified from the
French Medical Information System. Extracted variables included gender,
age, primary diagnosis, associated POP, comorbidities, length of stay (LOS),
postoperative complications and 30-day mortality. Study population was
stratified according to age: patients <70 (Gr A) and ≥70 (Gr B) years old.
Clavien-Dindo Grading System was used for evaluation of complications;
grade I-II minor, and grade III-IV major. Descriptive analyses are presented
as mean ± standard deviation (ranges) for quantitative data and as number
(percentage) of cases for categorical variables. Chi-square and students ttests were performed. Results were considered significant with p<0.05.
Results: Among 4303 patients (98.3% female) who underwent a LR,
1263 patients (29.4%) were ≥70 years old (Gr B). Main indication for surgery
was vault prolapse (Gr A 53%, Gr B 47%). Multicompartment prolapse was
observed in 30.3% and 25.6% respectively. Mean LOS was longer in Gr B
(5.6±3.6 vs. 4.69±1.8 days, p<0.001). Overall minor complications rate was
higher in Gr B (8.4% vs. 5%, p<0.001) whereas major complications rate was
similar (Gr A 0.7%, Gr B 0.9%, p=0.40) Postoperative 30-day mortality
occurred in one patient in each group. A more detailed analysis is presented
in Table1.
Conclusions: In this nationwide survey LR has been safe whatever the
patient’s age. Despite a greater rate of minor complications and a longer
LOS, LR was not associated to an increased risk and therefore should be discussed as a first option in POP even in the elderly.
S58
CLINICAL OUTCOMES OF PERINEAL PROCTECTOMY AMONG
PATIENTS OF ADVANCED AGE.
R. Tiengtianthum1, C. Jensen1, S. M. Goldberg1 and A. F. Mellgren2
1
Surgery, University of Minnesota, St. Paul, MN and 2Surgery, University of
Illinois at Chicago, Chicago, IL.
Purpose: Full thickness rectal prolapse occurs primarily in older
patients, who often have a number of comorbidities. With the aging of the
population, increasing numbers of elderly patients are presenting with rectal prolapse. The perineal approach is preferred for treating elderly patients
due to lesser perioperative risk than an abdominal procedure, but it is
unclear whether this procedure is safe in very old patients. Our study examines whether clinical outcomes after perineal proctectomy (PP) are similar
among very old patients versus patients of younger age.
Methods: A retrospective review was conducted of patients who had
PP for rectal prolapse from 1994 to 2012 in a large colorectal surgery group
operating in multiple hospitals. Patient were grouped according to age into
4 groups: ≤70 (A), 71-79 (B), 81-89 (C), and ≥90 years (D). Demographics,
operative data, postoperative complications, and survival time after the
date of operation were compared.
Results: 465 patients underwent 518 perineal proctectomies: group A,
n=113; group B, 113; group C, 208; group D, 84. The overall immediate complication rate was 5.6% and was only 8.3% in group D. The late complication rate was 3.5% (7.1%, 2.7%, 2.9% and 1.2% in A, B, C and D respectively).
Recurrence was 22.6% and was significantly different between groups, with
the lowest recurrence in group D, 14.3% (p=0.007). Reoperation was less
likely to be done in the oldest age group. The main type of reoperation was
perineal proctectomy (41.5%), but for group D, recurrence was usually managed nonoperatively (58.3%), which different from the other groups. The
median time from operation to death was 32 months in the advanced age
group.
30
Abstracts
healing time was (22.6 days in LIFT vs. 29.1 days in MAF, p= 0.02). After healing 3 of LIFT (11%) and 4 of MAF (13%) had recurrent anal fistulas (p=0.99).
Mean postoperative WS after 2 weeks was higher in MAF yet the difference
was not statistically significant (0.31 in MAF vs. 0.23 in LIFT, p=0.64). After 3
months mean WS was similar in both groups. QOL score didn’t differ neither after 2 weeks (77 in MAF vs. 79 in LIFT, p=0.38) nor 3 months.
Conclusions: LIFT procedure is superior to MAP in treatment of high
trans-sphincteric anal firstula in terms of early closure and less postoperative pain. However, recurrence, continence and QOL were more or less similar in both procedures.
Conclusions: Perineal proctectomy is the main operation performed for
rectal prolapse in patients of advanced age, and has few early and late complications. When selected appropriately, even patients 90 years of age or
older can have outcomes similar to patients of younger ages and therefore
age alone should not be a contraindication to surgery. In addition, patients
of advanced age have a median survival of almost three years after surgery,
so the risk of surgery can be worth the benefit accrued.
S59
BOWEL DYSFUNCTION AFTER RECTAL CANCER TREATMENT – A
STUDY COMPARING THE SPECIALIST’S VERSUS PATIENT’S PERSPECTIVE.
T. Yen-Ting Chen Aarhus University Hospital, Aarhus C, Denmark.
S61
OUTCOMES AFTER OPERATIONS FOR FISTULA-IN-ANO: RESULTS OF
A PROSPECTIVE, MULTICENTER, REGIONAL STUDY.
J. F. Hall1, L. Bordeianou2, N. Hyman3, T. Read1, C. Bartus4 and D. Schoetz1
1
Colon and Rectal Surgery, Lahey Clinic, Burlington, MA, 2Surgery,
Massachusetts General Hospital, Boston, MA, 3Surgery, University of
Vermont, Burlington, VT and 4Colorectal Surgery, Hartford Healthcare
Medical Group, Hartford, CT.
Purpose: Bowel dysfunction after sphincter-preserving rectal cancer
treatment, known as low anterior resection syndrome (LARS), is common.
We investigated how LARS is perceived by rectal cancer specialists in relation to the patient.
Methods: The LARS score is a five-item instrument developed and validated on 961 patients. Fifty-eight specialists (45 colorectal surgeons, 13
radiation oncologists) were asked to select, from a list of bowel dysfunction issues, five they considered to disturb patients the most. They were
then given a list of scores to assign to the LARS score items, according to
impact on quality of life (QOL).
Results: Four of the five LARS score issues (urgency, clustering, incontinence for liquid stool, frequency of bowel movements) had a high frequency of selection. However, the remaining issue (incontinence for flatus)
showed a low frequency. Scores assigned by specialists were significantly
different from the patient-derived scores (P < 0.01). They grossly overestimated the impact of incontinence for liquid stool and frequent bowel
movements, while markedly underestimated the impact of clustering and
urgency. Results did not differ between surgeons and oncologists.
Conclusions: : Rectal cancer specialists do not have a thorough understanding of which bowel dysfunction symptoms truly matter to the patient,
nor how these symptoms affect QOL.
Purpose: To determine the healing rate after operations for fistula in
ano in New England colorectal surgery practices.
Methods: A prospective, multicenter registry was created by the New
England Regional Chapter of ASCRS. Surgeons were invited to collect data
prospectively regarding patients operated upon for fistula in ano. Patients
were accrued between January 1, 2011 to August 1, 2013. Demographics,
Parks’ classification, number of tracts, smoking history, previous vaginal
deliveries, Crohn’s disease, Cleveland Clinic Fecal Incontinence Severity
Index (CCFI), and previous operations performed were recorded. The primary outcome was the proportion of patients that had healed fistulas at 3
months. Complications and continence scores were recorded at one and
three months after surgery.
Results: 16 surgeons submitted data regarding 238 fistulas. Mean age
was 45 ± 14 years. 158 (65%) patients were male. 110 (46%) had undergone
previous anorectal operation. 29 (12%) had Crohn’s disease. Fistulas were
classified as low transphincteric in 115 (49%), high transphincteric in 39
(17%), intersphincteric in 37 (16%), horseshoe in 28 (12%), and rectovaginal
in 4 (2%). 94 (39%) patients underwent a fistulotomy while the Ligation of
Intersphincteric Fistula Tract (LIFT) procedure was used in 43 patients (18%).
Use of advancement flap (6%) and fistula plugs (4%) was rare. The mean
preoperative CCFI was 4.6 ± 4.5. 9 patients (3.7%) had a complication. The
healing rates of fistulotomy, advancement flap and fistula plugs at three
months were 94% [95%CI 89-97%], 60% [95% CI 33-77%], and 20 % [95%
CI 5-50%] respectively. The healing rate of the LIFT procedure at three
months was 79% [95%CI, 65-88%]. Hospital site was the only variable associated with healing (p < .05). Hospitals that performed more LIFT procedures had higher healing rates at three months (p < .0001).
Conclusions: Use of the LIFT procedure was reported more frequently
than advancement flaps/fistula plugs and was associated with a lower early
failure rate. Centers that performed LIFT procedures more frequently had
higher healing rates. Fistulotomy remains a common and effective procedure for the management of anal fistulas.
S60
LIGATION OF INTERSPHINCTERIC FISTULA TRACT VERSUS MUCOSAL
ADVANCEMENT FLAP IN PATIENTS WITH HIGH TRANS-SPHINCTERIC
FISTULA-IN-ANO: A PROSPECTIVE, RANDOMIZED TRIAL.
K. Madbouly, W. ELshazly, K. Abbas and A. Hussein Department of
Surgery, University of Alexandria, Alexandria, Egypt.
Purpose: To compare, LIFT procedure with the mucosal advancement
flap (MAF) in the treatment of high transphincteric anal fistula in terms of
fistula closure rate, continence, morbidity, postoperative pain, recurrence
and quality of life
Methods: The study included patients >18 years with trans-sphincteric
anal fistulas involving the upper part of anal sphincter. Patients with inflammatory bowel disease, specific and recurrent fistulae were excluded.
Patients were randomized to either LIFT or MAF. Follow up was done at 1,
2,4,12 weeks, 6 months and one year. The primary outcomes of the study
were fistula closure, recurrence and continence. Continence will be evaluated using the Wexner incontinence score (WS) at 2 weeks and 3 months
postoperative. Secondary outcomes were postoperative pain, and QOL.
Postoperative pain score using visual analogue scale (VAS) was recorded
weekly till complete healing, while QOL using SF-36 questionnaire was
recorded after 2 weeks and 3 months.
Results: The study included 62 patients (31 in each group). Mean age
was 36.1 years in LIFT vs. 32.9, p= 0.33). Mean VAS after 1 & 2 weeks was
significantly higher in the MAF compared to LIFT (4.4 vs. 3.5 in first week,
p=0.04 and 2.6 vs. 1.4 in the second week, p=0.03), while no significant difference was found after 4 weeks (0.5 vs. 0.8 p=0.11). Primary healing was
achieved in (27 vs.29 patients in LIFT and MAP respectively, p= 0.67). Mean
31
Abstracts
The fistula tract is curetted. A loose seton is inserted between the external
opening and the iatrogenic opening, passing lateral to the sphincter complex. Postoperatively, the fistulotomy wound and the external & iatrogenic
openings are regularly irrigated with povidine iodine solution. On 12th day,
the seton is removed and the irrigation is stopped.
Results: 14 patients (M/F-11/3) were operated in the last 1 year. Mean
age was 41.8 ± 11.5 years and the median follow-up was 6 months. The
average operating time 29 minutes. 11 were recurrent fistula, 9 had associated abscess, 6 had multiple tracts and 12 had horseshoe fistula tracts. All
patients were discharged on the first postoperative day and all of them
resumed their normal activities by 3rd day. The internal opening got closed
with in 2 weeks and the fistulotomy wound closed by the 4th week. The fistula healed in 13/14(93%) patients. There was no change in pre-operative
and post operative incontinence scores (Vaizey) in any of the patients.
Conclusions: Perfact procedure is new method to treat complex fistulain-ano with high success rate. It is simple, easily reproducible, least morbid
and with no negative impact on incontinence. Multicentric trails with long
term results are needed to substantiate these findings.
S62
SYNTHETIC BIOABSORBABLE ANAL FISTULA PLUG: RESULTS IN A
PROSPECTIVE MULTICENTER STUDY.
M. J. Stamos1, M. Snyder2, B. Robb3, A. Ky4, M. Singer5, D. B. Stewart6,
T. Sonoda7 and H. Abcarian8 1Surgery, University of California, Irvine,
Orange, CA, 2Surgery, University of Texas Health Science Center at Houston,
Houston, TX, 3Surgery, Indiana University, Indianapolis, IN, 4Surgery, Mount
Sinai Medical Center, New York, NY, 5Surgery, NorthShore University Health
System, Highland Park, IL, 6Surgery, Penn State Milton S. Hershey Medical
Center, Hershey, PA, 7Surgery, Weill Medical College of Cornell University,
New York, NY and 8Surgery, University of Illinois at Chicago, Chicago, IL.
Purpose: Interest in sphincter-saving treatments for anal fistulae,
including fistula plugs and LIFT, is increasing, but little prospective data on
these approaches are available. We report outcomes achieved with a synthetic bioabsorbable fistula plug (GORE® BIO-A® Fistula Plug, WL Gore &
Associates, Elkton, MD) in 11 centers.
Methods: Between March 2011 and September 2013, 93 patients (71
men; mean age, 47 years) with cryptoglandular transsphincteric anal fistulae underwent implantation of the fistula plug. Exclusion criteria included
Crohn’s disease, local infection, a multitract fistula, and a wound-healing or
autoimmune disorder. Draining setons were used at the surgeon’s discretion (n = 73). The follow-up protocol specified clinical examinations at 1, 3,
6, and 12 months. The primary endpoint of the study was healing of the fistula, defined as drainage cessation plus and closure of the external opening. Secondary endpoints were fecal continence changes between baseline
and 6 months postoperatively and duration of drainage. Additional data
collected included complications and level of postoperative pain.
Results: Twelve patients were lost to follow-up. Fifty-three patients had
a 6-month and 37 a 12-month post-procedure assessment (follow-up continues for all patients enrolled). At 6 months follow-up, the fistula healing
rate was 33%. At 12 months post-procedure, the healing rate was 48%.
Complications included 11 infections, 4 extrusions of a piece of the plug,
and 6 total extrusions. At 6 months post procedure, the mean Wexner continence score had actually improved (compared to baseline, p = 0.0009; n
= 41). At both 6 and 12 months, 92% of patients had no or only mild pain.
Conclusions: Our findings indicate that implantation of the synthetic
bioabsorbable fistula plug is an efficacious treatment for transsphincteric
anal fistulae, especially given the simplicity and low morbidity of the procedure, including no decrement in fecal continence. Additionally, the
importance of long-term follow-up is suggested by increased healing rates
at 12 months. Our data may help surgeons in obtaining fully informed consent from patients considered good candidates for treatment with the
device.
S63
PERFACT Procedure
PROXIMAL FISTULOTOMY, EXTERIOR REPOSITIONING OF INTERNAL
FISTULA OPENING AND CURETTAGE OF TRACTS - A NEW SIMPLE
METHOD TO TREAT COMPLEX ANAL FISTULAS.
P. Garg1, P. Lakhtaria2 and M. Garg1 1G.Surgery, Indus Super Specialty
Hospital, Mohali, India and 2General Surgery, New York Hospital, New York,
NY.
S64
EVALUATION OF LIFT FOR TREATMENT OF COMPLEX FISTULA-IN-ANO
AS SPHINCTER-SAVING TECHNIQUE.
F. A. Firooz1, R. Azizi2, R. Behboo2 and A. Bijari2 1Department of Surgey,
Ayatollah Taleghani Hospital, Tehran, Islamic Republic of Iran and 2Rasool
Akram Hospital, Iran University, Tehran, Islamic Republic of Iran.
Purpose: PERFACT procedure is a novel method to treat complex anal
fistulas – fistula associated with multiple tracts, horse shoe fistulas, recurrent fistulas, anterior fistulas in females, fistula with long tracts and fistula
associated with abscess/ pus collections.
Methods: The internal opening and the sepsis in the intersphincteric
space are the factors responsible for persistence of a fistula-in-ano. To facilitate closure of internal opening, an iatrogenic opening is made at the anal
verge, distal to the lateral lower border of the sphincter complex. A fistulotomy is carried out with electrocautery between the internal opening and
the iatrogenic opening, incising only the mucosa and the internal sphincter. The infected granulation tissue at the internal opening and in the intersphincteric space is cauterized. The external sphincter is completely spared.
Purpose: Management of complex fistula has two important aims: long
term closure of the tract and preservation of sphincter complex function .
This study introduces a novel sphincter sparing technique called LIFT (ligation of intersphincteric fistula tract) with encourage results in controlling
the perianal sepsis, without any damage to sphincter complex.
Methods: All patients with complex fistula from January 2010 to January 2012 treated with LIFT were prospectively followed. Demographic data,
previous repair attempts, the type of treatment and score of fecal continence were collected. The procedure was performed by colorectal surgeons. The patients were followed for 6 to 24 months.
32
Abstracts
Results: A total of 35 patients underwent LIFT during 18 months. The
median age of the patients was 35 years and 50 % had two previous
attempts at surgery. A total of 25 patients (71%) had high transsphincteric
fistula. Median follow up was 15 months .Successful fistula closure was
achieved in 66% of the patients (23 of 35). Median time of recurrence was
4.5 weeks. One (2/8%) patient reported gas incontinence (score:3) after the
procedure.
Conclusions: LIFT is a novel treatment method for complicated fistulain ano. It’s success rate is comparable with other sphincter sparing procedures. Additionally LIFT is easy to learn and has very low cost of course.
More importantly, it appears a safe procedure. Durability and efficacy of the
procedure must be confirmed by long-term follow up and randomized control clinical trials.
S65
TARGETED ABLATION OF ANAL MARGIN HIGH-GRADE DYSPLASIA IN
MEN WHO HAVE SEX WITH MEN: 14 YEARS EXPERIENCE.
S. E. Goldstone, A. A. Johnstone and R. J. Silvera surgery, Icahn School of
Medicine at Mount Sinai, New York, NY.
Purpose: Current recommendations for treatment of AM HSIL (Bowen’s
Disease) are for mapping with wide excision with possible grafting while
anal canal (AC) lesions are often ablated. We examined our results of anal
margin HSIL ablation.
Methods: A retrospective chart review of MSM with AM HSIL from February 1998 to May 2012 treated with cautery (EC), laser or infrared coagulation.
Results: Of 456 HIV+ and 271 HIV- MSM with HSIL, 70 HIV+, median age
45 (range 28-67) years and 10 HIV-, median age 43 (range 27-68) years, had
AM HSIL. All but 2 HIV+ and 1 HIV- MSM had concomitant AC HSIL. Median
follow-up after first ablation was 4.6 (range 0.04-13.7) years for HIV+ and
3.5 (range 0.04-13.7) years for HIV- MSM. Median number of treatments was
4 (range 1-7) for HIV+ and 1 (range 1-7) for HIV- MSM (p=0.004). Most were
treated solely with EC. Kaplan-Meier probability of recurrence after first
treatment for HIV+ MSM at 1, 3 and 5 years was 38% (95% CI 26-50%), 59%
(95% CI: 47-72%) and 68% (95% CI: 55-81%) and it did not change with
retreatments. Only 1 HIV- MSM recurred 8 months post primary treatment,
was retreated and has been HSIL free for 3 years. Significant hazard ratios
(HR) for recurrence were HR 1.2 (95% CI: 1.1-1.3%) per increase for each AC
HSIL and each AM HSIL and CD4 count nadir 101-200 HR 3.6 (95% CI: 1.39.4%). Age, smoking, being monogamous, viral load, CD4 count at first
treatment and treatment method did not affect recurrence. In multivariable
analysis only each increase in AC HSIL significantly increased risk HR 1.1
(95% CI 1.0-1.3). HIV+ MSM had a relative risk of 3.7 [95% CI: 2.1 – 6.6] of
having AM HSIL compared to HIV-MSM. 3 HIV+ MSM developed AM cancer;
all had been treated and lost to follow up for 2.6, 3 and 4 years before developing cancer, were treated with chemo/radiotherapy and are alive at 2.5, 7
and 9 years post treatment.
Conclusions: AM HSIL can be treated successfully with targeted ablation but recurrence remains high in HIV+ MSM. Almost all have concomitant AC HSIL. Increased number of AC HSIL increases risk. HIV+ MSM are at
greatest risk of AM HSIL. Probability of recurrence does not change with
repeated treatments.
Kaplan-Meier curve for probability of recurrence free survival post first ablative
treatment for anal margin HSIL in HIV-positive MSM (n=70)
S66
HIGH RESOLUTION ANOSCOPY OR EXPECTANT MANAGEMENT OF
ANAL INTRAEPITHELIAL NEOPLASIA FOR THE PREVENTION OF ANAL
CANCER: IS THERE REALLY A DIFFERENCE?
B. Crawshaw, A. Russ, S. Stein, H. Reynolds, E. Marderstein, C. Delaney
and B. Champagne Colorectal Surgery, University Hospitals Case Medical
Center, Cleveland, OH.
Purpose: Anal squamous dysplasia is commonly found in patients with
anal condyloma. High resolution anoscopy (HRA) has been shown to
improve identification of anal intraepithelial neoplasia (AIN) but a reduction in progression to anal squamous cell cancer has not been substantiated when serial HRA is compared to traditional expectant
management.(EM). The objective of this study was to compare HRA vs. EM
for the surveillance of AIN and the prevention of anal cancer.
Methods: We reviewed the charts of all patients that presented with
anal squamous dysplasia, a positive anal pap, or anal squamous cell cancer
from 2006-2013. Within the colorectal group, some practitioners follow
pathway of HRA sequential biopsies and ablation at time of initial presentation, with any recurrence, or positive pap smear. Other surgeons perform
EM with initial EUA with field biopsy and ablation and then office based
management for minor recurrence and repeat EUA for significant disease
burden. Both groups treated dysplasia post-operatively with imiquimod
and followed patients every 6 months indefinitely. The rate of progression
to anal squamous cell cancer was the primary endpoint.
Results: From 2007-2013, 424 patients with anal squamous dysplasia
were seen in the clinic (HRA: 220, EM: 204). 79% of HRA, and 83% of EM
patients were HIV positive at presentation (p=0.32). The mean follow-up
was 4.2 years (HRA) and 3.7 years (EM). Three patients progressed to anal
squamous cell cancer (ASCC). (HRA: 1, EM: 2, p= 0.467) 1 HRA and 1 EM
patient who progressed were non-compliant with follow-up and with HIV
treatment. One SCC patient in the EM group was allergic to imiquimod and
refused to take topical 5-FU.
Conclusions: Patients with squamous cell dysplasia followed with EM
or HRA rarely develop squamous cell cancer if they are compliant to the
protocol. The cost, morbidity and value of HRA should be further evaluated
in lieu of these findings.
33
Abstracts
Results: The majority of patients were male (108:16); mean age was 27.1
years (range 14-67) and mean BMI was 29.4 (range 18-43). Most were nonsmokers (87%). Follow up averaged 28.7 months (2-64). The average number of postoperative office visits was 3.6 (1-21). Outcomes were analyzed
by primary versus salvage surgery and distance from anal verge. A single
recurrence occurred in patient who had hemophilia and no prior surgeries.
Prior surgical attempts increased complication rates, while distance from
the anal verge did not.
Conclusions: The cleft lift procedure is a straightforward technique with
a closed wound, simple postoperative care, limited follow up visits, reasonably few complications, excellent primary healing and very low recurrence
rate. Although salvage surgery was associated with increased complication
rates, overall outcomes were excellent. Therefore, we advocate the cleft lift
procedure for the primary treatment of most patients with pilonidal disease.
S67
IS THERE A BENEFIT TO ENDOSCOPIC ULTRASOUND IN DETECTING
LOCALLY RECURRENT ANAL SQUAMOUS-CELL CANCER?
C. Peterson1, M. R. Weiser1, P. B. Paty1, J. G. Guillem1, G. M. Nash1,
J. Garcia-Aguilar1, S. Patil2 and L. K. Temple1 1Department of Surgery,
Colorectal Service, Memorial Sloan-Kettering Cancer Center, New York, NY
and 2Department of Epidemiology & Biostatistics, Memorial SloanKettering Cancer Center, New York, NY.
Purpose: Current guidelines for patients with anal cancer after primary
treatment include routine evaluation with digital rectal exam (DRE) and
anoscopy. However, anal canal anatomy in these patients is often distorted
and examinations can be difficult. The purpose of this study was to evaluate if endoscopic ultrasound (EUS) in routine follow-up of anal cancer
patients improved detection of recurrent local disease.
Methods: We performed a retrospective review of patients followed
after primary treatment of nonmetastatic anal squamous cell carcinoma
from 1998 to 2012. 175 patients without persistent disease who had at least
one EUS and one post-treatment visit were included. DRE and EUS were
performed in sequence by colorectal surgeons and results recorded in real
time. Patient records were reviewed for any abnormal finding, perceived
change from previous exam, or increased size of lesion on DRE or EUS. Concordance, sensitivity, specificity, positive and negative predictive values
were calculated using biopsy as the gold standard.
Results: 855 EUS and 873 DRE were performed during 35 months
median follow-up. There were 108 abnormal exams; EUS detected 7 (0.8%)
mesorectal and 32 (3.7%) canal abnormalities; DRE detected no mesorectal
nodes and 69 (7.9%) canal abnormalities. We performed 40 anal canal biopsies on 33 patients, revealing locally recurrent disease in 8 patients, all
detected first with DRE before EUS was performed. There were no mesorectal recurrences and 10 distant recurrences. Patients with recurrence more
often had advanced disease at diagnosis (p<0.01), though there was no difference in age, gender, HIV status or primary treatment modality. The concordance of EUS and DRE in detecting recurrent disease was 0.37 (SE 0.08,
95% CI 0.21-0.54). There was no difference in crude cancer detection rate
(2.48% vs. 4.88%), sensitivity (0.29 vs. 0.35), specificity (0.98 vs. 0.94), negative predictive value (0.98 vs. 0.98) and positive predictive value (0.22 vs.
0.13) of EUS and DRE, respectively.
Conclusions: Endoanal ultrasound offers limited advantage over physical exam alone in improving the detection of recurrent anal cancers and
should not be recommended for routine surveillance.
Patients (n=124) +/- prior definitive surgery
S69
HEMORRHOIDAL ARTERY LIGATION PROCEDURE WITHOUT DOPPLER
TRANSDUCER IN GRADE III HEMORRHOIDAL DISEASE WITH
MUCOSOPEXY: A RANDOMIZED, CONTROLLED CLINICAL TRIAL.
S. S. Nahid, O. Faruque, K. Azad, A. Uddin and S. Gosh Department of
Surgery, Chittagong Medical College Hospital, Chittagong, Bangladesh.
Purpose: Transanal hemorrhoidal dearterialization (THD) is a minimal
invasive technique to treat hemorrhoids using a specially designed proctoscope for Doppler-guided transanal ligation of hemorrhoidal arteries. The
aim of this study is to assess the safety, efficacy and outcome of HAL &
mucosopexy without the use of Doppler transducer, and identify its possible advantages and limitations.
Methods: 53 patients were submitted to HAL and mucopexy procedure
during the period January, 2011 through september, 2012. The operation
consisted of hemorrhoidal dearterialization in all patients, with
mucosal/submucosal pexy. All the operation were done under spinal anesthesia. Preoperative and postoperative symptoms, postoperative pain, pruritus, time until return to normal activities, complications, and patient satisfaction and recurrence rates were all assessed prospectively. Following
surgery, patients were regularly evaluated at 1 week, 1 and 3 months, and
1 year after operation.
Results: Among the 53 patients 37 were male (69.81 %), mean operative time was 38 minutes, no intraoperative complications were recorded.
Postoperative morbidity included 3 (5.66%) haemorrhoidal thromboses (1
requiring intervention), 2 (3.77%) episodes of bleeding (1 requiring rubber
band ligation) and 5 patients (9.43%) had urinary retention requiring
catheterization. One patient (1.87%) complaints of incontinence for flatus.
Postoperative analgesic requirement and pruritus was minimum. After 1
year follow-up, 2(3.77%) patients complaint of Hemorrhoidal prolapse (one
found to have skin tags) Overall, long-term control of bleeding was
obtained in 51 patients (96.22%) and control of prolapse in 49 (92.45%).
Recurrence of hemorrhoidal disease requiring surgery was found in 2
patients (3.77%).
Conclusions: HAL without Doppler transducer with mucosopexy in
grade III hemorrhoidal disease appears to be safe, effective and a potential
treatment option for grade III hemorrhoids because of the excellent results,
low complication rate and minor postoperative pain. Clinical trials and
longer follow-up comparing it with Doppler guided HAL procedure are
needed to establish a possible role for this technique.
S68
CLEFT LIFT PROCEDURE AS FIRST LINE FOR PILONIDAL DISEASE.
J. Favuzza1, M. I. Brand1, A. B. Francescatti2, L. G. Jordano2, M. C. Mora
Pinzon3 and B. A. Orkin1 1Colorectal Surgery, Rush University Medical
Center, Chicago, IL, 2Surgery, Rush University Medical Center, Chicago, IL
and 3Surgery, Loyola University Medical Center, Chicago, IL.
Purpose: Pilonidal disease is a complex process arising in the sacrococcygeal region which primarily affects young males. Most patients undergo
many procedures due to poor wound healing and high recurrence rates.
The cleft lift procedure was first described by Hodges in 1880 and later
modified by Bascom. The cleft lift procedure is generally offered to patients
with recurrent disease. We advocate its use as a first line therapy for patients
with pilonidal disease.
Methods: A retrospective review was conducted on 124 consecutive
patients with pilonidal disease undergoing a modified cleft lift procedure
from January 2010 to October 2013. The procedure creates a flatter and
more stable natal cleft as the midline pits and the skin from the diseased
side of the natal cleft are removed. Healthy skin is then mobilized as a flap
to allow for apposition of the skin off the midline. Postoperative care
includes a drain for 4-5 days, compressive dressings for 2 weeks, and limited mobility for 6 weeks.
34
Abstracts
injury. A multi-disciplinary surgical approach including a plastic surgeon
was used in each procedure. Interposition flaps utilizing either gracilis muscle or local fasciocutaneous flaps (Singapore flaps) were used in all patients.
Results: The median patient age was 42 years, ranging from age 24-81.
Fistula closure was achieved in 13 (86%) of 15 patients after a mean of 2
operations. Median follow-up was 8 (1.5-14) months after transperineal
repair with tissue interposition. Recurrence rates after tissue interposition
were 20% and time to recurrence was 2.2 months. Fecal diversion was performed in nine patients prior to tissue interposition as a result of their
underlying condition or as an attempt to promote fistula healing; continuity was restored in 78% of patients. Tissue interposition was used as the initial strategy in all patients who were radiated with 100% fistula closure rate.
Conclusions: Rectovaginal fistulas encompass a wide variety of challenging problems. When primary repair using endorectal advancement
flaps fails, an autologous tissue flap in the form of gracilis muscle or fasciocutaneous flap from the perineum is a useful adjunct. It seems that interposition of vascularized flaps between the posterior vaginal wall and site
of rectal closure promote healing, reinforce the repair and prevent recurrence. In patients who have undergone radiation therapy use of vascularized tissue to buttress the initial repair should be strongly considered.
Posters
P1
THD DOPPLER PROCEDURE PLUS MUCOPEXY: A TAILORED AND
EFFECTIVE TREATMENT FOR HEMORRHOIDS.
C. Ratto, A. Parello, F. Litta, L. Donisi and G. Zaccone Surgical Sciences,
Catholic University, Rome, Italy.
Purpose: THD Doppler procedure is aimed to reduce the arterial overflow in patients with hemorrhoidal disease (HD). If necessary, the addition
of a rectal mucopexy (MP) solves the symptoms related to the prolapse
without tissue excision. Over the years, the adopted device has evolved,
and the technique changed from a “high-dearterialization” to a “distalDoppler-dearterialization” (DDD), concerning the level where the artery is
ligated in the rectum.
Methods: 614 pts (mean age 47.9 ± 12.3 years, 382 male)affected by
HD, who failed a conservative treatment, underwent a THD Doppler procedure between June 2005 and December 2012; 88 (14.3%), 436 (71%) and
90 pts (14.7) were affected by II-, III- and IV-degree hemorrhoids, respectively. The symptoms most frequently reported were: rectal bleeding (568
pts, 92.5%), hemorrhoidal prolapse (601 pz., 97.9%), need for manual reduction (533 pts, 86,8%), pain/discomfort (563 pts, 91,7%). In 57 pts (9.3%) the
HD was recurrent. Univariate and multivariate logistic regression models
were applied to identify the potential predictive factors of failure.
Results: One hundred and six pts (17.3%) underwent only dearterialization, while dearterialization and mucopexy were performed in 508 cases
(82.7%). Skin tags removal was the most frequent associated procedure
(63pts, 10.3%). The early (≤ 7 days) morbidity rate was 8.7% (53 cases),
including urinary retention, pain and rectal bleeding in 22 (3.6%), 21 (3.4%)
and 10 (1.6%) pts, respectively. The mean follow-up (FU) was 34.4 ± 22.1
months. No serious adverse events or disabling conditions were registered.
The overall failure rate (recurrence needing of a surgical therapy) was 6.9%
(42 pts), due to recurrent bleeding (2 pts, 0.3%), prolapse (20 pts, 3.3%), or
both bleeding and prolapse (20 pts, 3.3%), respectively. At the multivariate
analysis only a recurrent HD and the “high-dearterialization” were associated to a poor outcome. The hemorrhoidal degree was not related to recurrence.
Conclusions: THD Doppler procedure and mucopexy is a safe and effective treatment for HD. The dearterialization reduces the arterial hyperflow
and provides excellent long-term results; the tailored mucopexy can effectively treat the hemorrhoidal prolapse.
P3
CROHN’S ANAL FISTULA – TO CLOSE OR NOT TO CLOSE?
W. J. Graf1, M. Andersson2, J. Åkerlund3 and L. Börjesson4 1Department
of Surgery, Institution of Surgical Sciences, Uppsala, Sweden, 2Department
of Surgery, Örebro university, Örebro, Sweden, 3Department of Surgery,
Department of Clinical Sciences, Karolinska Institute, Stockholm, Sweden
and 4Department of Surgery, Insitute of Clinical Sciences, University of
Gothenburg, Gothenburg, Sweden.
Purpose: Treatment of Crohn’s anal fistula remains a challenge for colorectal surgeons and gastroenterologists and little is known about factors
associated with healing. The present study was made to assess the rate of
ultimate healing and analyse clinical variables related to healing.
Methods: All 119 (63 women, mean age 36, 16-69) patients undergoing a surgical procedure for Crohn’s anal fistula during a ten year period at
four main Swedish referral centers were included. All patients had
histopathologically verified Crohn’s disease. Baseline and treatment related
variables were recorded and analysed for association with fistula healing
(i.e. no symptoms, no evidence of fistula at clinical examination, and no
need for a permanent stoma) at final follow-up after mean 6.6 years (range
1.0-14.5) in uni- and multivariate analyses.
Results: Totally 63 (53%) experienced healing at final follow-up. Fourteen healed after one procedure, and the reamining 49 healed after further
mean 4 (range 2-20) procedures. Ten patients (8%) were subjected to a
proctectomy. In multivariate analyses, age, gender and smoking habits
were not related to healing whereas an uninflamed rectal mucosa
(p=0.011), an initial curative operation (laying open or advancement flap,
p=0.015), a low fistula (p=0.035), and a short disease duration (p=0.021)
were related to healing. Medical treatment was not associated with healing
(p=0.33).
Conclusions: Long term healing can be expected in about half of the
patients with Crohn’s anal fistula usually after staged surgical treatment.
The probability for cure was higher when an upfront curative operation was
performed particularly in low fistulas, without proctitis and a short duration of Crohn’s disease. An attempt to close a Crohn’s anal fistula is thus
often worthwhile.
P2
THE ROLE OF VASCULARIZED TISSUE INTERPOSITION IN RECTOVAGINAL FISTULA REPAIR.
R. J. Ellsworth1, T. Dinh2, W. A. Ellsworth2, J. D. Friedman2, H. Bailey1 and
M. J. Snyder1 1Colon & Rectal Clinic of Houston, University of Texas Medical
School at Houston, Houston, TX and 2The Institute for Reconstructive
Surgery, Houston Methodist Hospital, Houston, TX.
Purpose: Rectovaginal fistulas are a complex surgical challenge, often
requiring multiple surgical procedures to achieve complete resolution.
Chronic urinary tract infections, sexual dysfunction and social embarrassment are but a few of the problems potentially facing these women. The
aim of this study is to evaluate the efficacy of autologous vascularized tissue interposition for successful fistula closure.
Methods: A retrospective analysis of two senior surgeons’ patients with
rectovaginal fistulas diagnosed between 2007 and 2013 was performed. Fifteen patients who underwent rectovaginal fistula repair with tissue interposition were included. Etiologies of rectovaginal fistulas included obstetric injury, inflammatory bowel disease, anastomotic leak, and other perineal
35
Abstracts
Results: 276 patients (50% males; mean age: 63 years) were included in
the study. 105 (19%) had diverting ileostomy. Overall anastomotic leak rate
was 1.9% (11/551), requiring operative intervention in 9 (81%) patients.
There were no leaks in patients with ileostomy. The mean BMI was
27.1kg/m2 (15-55), tmean operative length 190 (50-510) min, and 20/551
(3.6%) had more than one stapler firing. Increased BMI was the only significant risk factor associated with increased leak risk (BMI >33; p=0.03). No
statistically significant risk was observed with other possible risk factors like
age, steroid or immunosuppressant usage, previous pelvic irradiation, albumin levels, splenic flexure mobilization status or intraoperative transfusions.
The most common indication for diverting ileostomy was presence of
abscess cavity or phlegmon. Other indications included prior pelvic surgery,
history of leak, steroid usage, presence of fistula, fragile/edematous tissue,
and dilated colon.
Conclusions: Risk of leak for M-HCRA is significantly low. Increased BMI
(>33kg/m2) is a risk factor for M-HCRA leak.
P4
MISCONCEPTIONS ABOUT URINARY RETENTION AFTER ANORECTAL
SURGERY.
S. Bibi, M. Zutshi, T. Hull and B. Gurland Colorectal Surgery, Cleveland
Clinic Foundation, Cleveland, OH.
Purpose: Urinary retention (UR) after anorectal surgery represents the
most common adverse event impacting patient care. The aim of this study
was to assess our rates of UR, to identify factors which may impact UR, and
to evaluate patient perception of education about UR after hemorrhoid surgery.
Methods: 742 patients, who underwent hemorrhoid surgery between
2008 and 2013, were identified from billing records and sent questionnaires. Patients with combined gynecological procedures and known urinary dysfunction were excluded. Data on demographics, surgery, intraoperative details, postoperative UR, urinary tract infection (UTI),
catheterization, patient education and PGIC (patient global impression of
change) score (range from 1-7) was collected through chart review and a
patient reported questionnaire. Points 5-7 reflect significant patient perception of positive change after intervention.
Results: 205/742 responded (28% response rate). 203 were eligible. M:F
was 99:104. Mean age at surgery was 58 years (range 25-90). Excisional
hemorrhoidectomy was performed in 107(53%), stapled hemorrhoidectomy 42(21%),and Doppler assisted hemorrhoid artery ligation in 54(26%).
Mean intraoperative fluid administration was 831 ml. 45 (22%) patients
reported urinary retention which was defined as difficulty passing urine
after surgery. 25 (56%) of patients with UR self reported voiding before
recovery room discharge. 25/45 patients (56%) underwent catheterization:
7 patients in the recovery room, 14 in an emergency room, and 4 in the
doctor’s office. Male gender (p= 0.006) was the only statistically significant
factor for UR. Anesthesia type, procedure type, intraoperative fluid administration were not statistically significant in patients with UR. Only 14 (33%)
patients reported that they received education about urinary retention.
80% of patients with UR reported satisfaction with surgery with a mean
PGIC score of 5.2 (3-7).
Conclusions: 1/5 of patients undergoing hemorrhoidectomy may
develop urinary dysfunction and early voiding is not indicative of normal
function. Improving nursing and patient education, thus setting expectations and strategies for handling UR may help to improve patient global
satisfaction and to dispel misconceptions about UR.
P6
SERUM ALBUMIN AS A PREDICTOR OF COMPLICATIONS IN ELECTIVE
COLONIC RESECTION.
D. Giesler, L. Fish, E. Heidel and B. J. Daley Surgery, University of
Tennessee Medical Center at Knoxville, Knoxville, TN.
Purpose: Albumin is a pre-operative predictor of surgical outcome by
NSQIP, historically predicting mortality. After our state NSQIP initiated postoperative interventions to improve colonic surgery outcomes, we sought
to determine the predictive value of pre-operative albumin levels in elective colonic resection.
Methods: After IRB approval, a 2 year retrospective review of 30 day
outcomes pre-interventions (2009 – 2010). We hypothesize low preoperative albumin levels will elevate 30-day mortality. Patients were segregated
for analysis -1) No complications 2) Infection 3) Anastomotic leak 4) Death
5) Other = LOS>30 days, readmission, ileus, ARF, dehydration, PNA. SPSS
Version 19 was used for statistical analysis.
Results: 186 patients were studied with a 30-day complication rate =
41.6%. Fifteen patients died (7.6 %, 6 from withdrawal). No significant
effects were seen between age (p = 0.37) and albumin level (p = 0.25) or
gender effects on albumin level (p = 0.65) or LOS (p = 0.21). There was a
significant effect for albumin and LOS (p = 0.001). In post-hoc analysis, only
in No complications vs. Infection (p = .01), No complications vs. Other (p <
0.001) and Anastomotic leak vs. Other (p = 0.03) were albumin levels significant. Pearson Correlation found a significant negative effect for albumin
level and LOS (r = -0.39, p < 0.001).
Conclusions: Colonic surgery is complicated with high morbidity. Low
pre-op albumin does lead to morbidity that extends LOS, but does not
increase mortality. Current colon surgery in low albumin levels averts death
but does so by increased resource consumption.
P5
OBESITY IS A RISK FACTOR FOR LEAK IN MID-TO-HIGH COLORECTAL
ANASTOMOSES.
R. Ganga, N. Severino, G. Dasilva, J. Jun, E. Choman, M. Patel and
S. D. Wexner Cleveland Clinic Florida, Weston, FL.
Purpose: Risk factors for mid-to-high colorectal anastomotic (M-HCRA)
leak are not well established, which may result in a higher incidence of
diverting stomas. Stoma creation and closure is associated with overall
complication rates of 20-70% up to 70% may retain their stomas >1 year.
This may be avoided if accurately risk factors for leak are established. This
study aimed to determine our M-HCRA leak rate and any associated risk
factors.
Methods: After IRB approval, 551 patients who underwent elective or
emergent left colonic, sigmoid, or rectosigmoid resection with M-HCRA
between 1/2008 and 12/2008 were identified from a prospective database.
Data included demographics, comorbidities, use of immunosuppressants,
diagnosis, procedure, type of anastomosis, procedure length, type and
number of staple firings, construction and indication for diverting stoma,
and incidence of leak and ensuing interventions. Leak was defined as clinical signs supported by radiological findings. Statistical analysis was performed using Fisher`s exact test and ANOVA test to identify risk factors for
leak.
P7
RISK OF RECURRENCE AND EMERGENCY SURGERY AFTER NONOPERATIVE TREATMENT OF ACUTE COLONIC DIVERTICULITIS - A SYSTEMATIC REVIEW AND META-ANALYSIS.
D. Li1, N. N. Baxter2, R. S. McLeod3, R. Moineddin4 and A. B. Nathens5
1
Division of General Surgery, University of Toronto, Toronto, ON, Canada,
2
Division of General Surgery, St. Michael’s Hospital, University of Toronto,
Toronto, ON, Canada, 3Division of General Surgery, Mount Sinai Hospital,
University of Toronto, Toronto, ON, Canada, 4Dalla Lana School of Public
Health, University of Toronto, Toronto, ON, Canada and 5Division of
General Surgery, Sunnybrook Health Sciences Centre, University of Toronto,
Toronto, ON, Canada.
Purpose: Long term outcomes following non-operative treatment of
acute diverticulitis remain poorly understood. It is unclear if elective (pro-
36
Abstracts
phylactic) colectomy is warranted. This study aimed to estimate the incidence of adverse events after initial non-operative management.
Methods: A systematic search was performed in Medline and Embase
to identify publications (1990-2013) reporting the incidence of recurrence
and/or emergency surgery following non-operative treatment of sigmoid
diverticulitis. Studies having less than 1 year of mean follow-up were
excluded. A random effects model was used to calculate pooled risk estimates; subgroup analyses were performed to examine risk for young age
and complicated disease.
Results: A total of 55 studies met inclusion criteria, encompassing data
from 63,354 patients. For all patients treated non-operatively, the overall
pooled recurrence estimate was 21.3% (95% CI: 18.2-24.8%); the risk of subsequent emergency surgery was 3.1% (95% CI: 2.0-4.8%). In subgroup
analysis, patients with uncomplicated diverticulitis had lower recurrence
than those with complicated disease (abscess, fistula, perforation) [19.0%
(95% CI: 14.8-24.1%) vs 34.6% (95% CI: 26.0-44.3%)]. Similarly, the risk of
emergency surgery was also lower for patients with uncomplicated disease
(1.9%, 95% CI: 0.9-4.0%) than complicated disease (7.5%, 95% CI: 2.2-22.4%).
Stratified by age, younger patients (<50 years) had higher recurrence rates
[30.8% (95% CI: 26.5-35.5%) vs 20.9% (95% CI: 17.7-24.4%)], as well as higher
risk of emergency surgery [4.3% (95% CI: 2.4-7.8%) vs 2.9% (95% CI: 1.74.9%)].
Conclusions: Patients with uncomplicated diverticulitis treated conservatively have a 1 in 5 chance of recurrence; younger patients and those with
complicated disease are at increased risk. The risk of developing perforated
diverticulitis is low, thus routine prophylactic colectomy to prevent emergency surgery is unnecessary for most patients. The decision to undergo
elective surgery should be individualized based on risk factors, symptoms,
and patient risk tolerance. Further studies comparing elective surgery to
conservative treatment for high risk patients are needed.
and complications were significantly lower in LP. CT scan was obtained on
12 (86%) LP patients and corresponded with intraoperative assessment in
7 (64%). Two patients in LP had prolonged ileus, one developed atrial fibrillation, and the fourth died from cardiomyopathy. 37 patients had complications in HP group (16 incisional hernias (31%) and 6 (12%) stoma complications). Six patients in LP (43%) developed recurrent diverticulitis and four
(29%) were subsequently managed with laparoscopic resection and anastomosis.19 patients had complications in PD group, 4 (7%) developed ECF
and 14 (23%) had recurrent disease. 26 (43%) required operation, 11 (18%)
requiring urgent HP.
Conclusions: Our analysis suggests that LP compares to HP in perforated non-feculent diverticulitis. LP patients are less prone to abdominal
wall complications and have shorter length of stay. Recurrences in LP were
managed with subsequent elective procedure. We propose that LP is suited
for patients with: 1) Hinchey II disease unamenable to PD who are not
improving 2) Hinchey III patients stable for laparoscopy. Preoperative CT
may be of utility in decision making. Additonal comprehensive studies are
required to evaluate patient selection in LP
Table 1
*Fisher exact test comparing LP vs HP
†Mann-Whitney U- test
Figure 1: Pooled estimates of emergency surgery risk following non-operative
treatment of uncomplicated and complicated diverticulitis
P8
P9
MANAGEMENT OF PERFORATED DIVERTICULITIS: AN ALGORITHM
INCORPORATING LAPAROSCOPIC PERITONEAL LAVAGE.
R. N. Mundy, E. Chabot, D. Penner, K. Wong, M. Kiely, K. Tyler, Z. Kutayli
and J. Romanelli Surgery, Baystate Medical Center, Springfield, MA.
LAPAROSCOPIC ILEAL POUCH-ANAL ANASTOMOSIS IS NOT ASSOCIATED WITH DECREASED RATES OF INCISIONAL HERNIA AND SMALL
BOWEL OBSTRUCTION WHEN COMPARED WITH OPEN TECHNIQUE:
LONG-TERM FOLLOW-UP OF A CASE-MATCHED STUDY.
C. Benlice, L. Stocchi, E. Gorgun, M. Costedio, H. Kessler and F. Remzi
Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland,
OH.
Purpose: Recent studies suggest that Laparoscopic Peritoneal Lavage
(LP) for perforated diverticulitis may be an acceptable alternative to Hartmann’s procedure (HP). However, appropriate patient selection is paramount. Our goal is to compare the outcome of patients undergoing LP, HP
and percutaneous drainage (PD) for perforated diverticulitis and to develop
a reasonable strategy for utilization of LP.
Methods: A retrospective review of patients who underwent intervention for perforated diverticulitis during 2007–2013 at a single institution
was performed. Patients’ demographic and clinical data were reviewed. IRB
approval was obtained. Data were compared with Mann Whitney U and
Fisher exact test.
Results: 140 patients were identified. Patients with feculent peritonitis
(Hinchey IV, n=15) were excluded, resulting in 14 (11%) in LP, 51 (41%) in
HP and 60 (48%). Patients were similar in age, gender and comorbidities.
Hinchey class was similar in both operative groups, whereas length of stay
Purpose: There is scant data on the presumed long-term advantages
of laparoscopic ileal pouch-anal anastomosis (IPAA), specifically reduction
of small bowel obstruction (SBO) and incisional hernia (IH). The aim of this
study was to compare long-term outcomes in open vs. laparoscopic IPAA
based on a previous study from our institution.
Methods: The original 1:2 case-match study examined 119 laparoscopic
and 238 open IPAA operated between 1992-2007. Long-term complications
including IH clinically detected by a physician, SBO and pouch excision
were retrospectively collected from a prospective database, office visits and
patient charts. Laparoscopic abdominal colectomy followed by rectal dis-
37
Abstracts
ics use (Table). At the time of RP, iTAC patients had decreased proximal
ileostomy rate (92.5% vs. 97.5%, P=0.023), shorter hospital stay (6.6 vs. 7.8,
P<0.001) and marginally decreased pelvic sepsis rate (6.2% vs. 11.1%,
P=0.05) compared with iRP patients. Patients in iTAC group were more frequently treated with laparoscopic surgery (53% vs. 39% of cases, P<0.001)
but still required longer total postoperative hospital stay (17 vs. 12 days,
P<0.001) and treatment span (10.4 vs. 5.7 months, P<0.001) to complete all
surgical stages. The iTAC group was also associated with increased overall
postoperative wound infection and hemorrhage rates, while pouchitis rates
were decreased after a shorter follow-up when compared to iRP. Pouch
function and QOL were comparable between the groups, except for slightly
increased nightly bowel movements in the iTAC group.
Conclusions: Patients requiring iTAC pay the price of longer treatment
time and TAC-associated complications, but ultimately experience comparable ileal pouch outcomes when compared to iRP.
section under direct vision (using lower midline or Pfannenstiel incision)
and converted cases were analyzed within the laparoscopic group.
Results: Groups were comparable with respect to age, gender, body
mass index and extent of resection (completion proctectomy vs. proctocolectomy), consistent with the original case-matching. Anti-adhesion barrier use had also been similar. Mean follow-up was significantly longer in
the open group (9.6 years vs. 8.1 years, respectively, p=0.008). The incidence
of IH, SBO requiring hospital admission, SBO requiring surgery, and pouch
excision were similar between the 2 groups (Table). A subgroup analysis
within the laparoscopic group comparing 69 patients with rectal dissection
under direct vision vs. 50 patients with laparoscopic rectal dissection indicated statistically similar incidence of IH (4.3% vs. 8%, respectively, p=0.45),
hospital admission and surgery for SBO (34.8% vs. 22%, p= 0.13 and 15.9%
vs. 6%, p=0.11, respectively).
Conclusions: Some of the anticipated long-term benefits of laparoscopic IPAA could not be demonstrated in this cohort. Lack of such longterm benefits should be discussed with patients when proposing a laparoscopic approach. Completely laparoscopic dissection should be assessed in
larger studies to detect possible long-term benefits.
Preoperative variables, composite morbidity, functional outcomes and quality of
life in iTAC vs. iRP after completion of all surgical treatment stages
Comparison of demographics and long-term results between laparoscopic and
open IPAA
Values are reported as mean (SD) or absolute values (%).
P10
TOTAL ABDOMINAL COLECTOMY PRECEDING RESTORATIVE PROCTOCOLECTOMY FOR MEDICALLY REFRACTORY ULCERATIVE COLITIS:
WHAT PRICE DO PATIENTS PAY IN THE END?
J. Gu, L. Stocchi, J. Ashburn and F. H. Remzi Colorectal Surgery, Cleveland
Clinic Foundation, Cleveland, OH.
TAC: total abdominal colectomy; RP: restorative proctocolectomy; WBC: white
blood cell; TNF:
Purpose: An initial total abdominal colectomy (iTAC) is required in
patients with ulcerative colitis (UC) who are not suitable for an initial
restorative proctocolectomy (iRP). The aim of this study was to assess how
iTAC affects patient outcomes after completion of all surgical treatment
stages.
Methods: Patients who completed RP for UC including ileostomy reversal between 2006 and 2012 were identified from an IRB-approved database.
Toxic megacolon and dysplasia/cancer were excluded. Demographics, perioperative outcomes, pouch function and quality of life (QOL) were compared between patients undergoing RP preceded by iTAC and patients
undergoing iRP.
Results: Out of 521 patients, 322 (62%) underwent iTAC and subsequent RP. The iTAC group was associated with more common preoperative
anemia, leukocytosis, hypoalbuminemia, severe colitis, steroids and biolog-
tumor necrosis factor; BM: bowel movement; CQGL: Cleveland Global Quality of
life
* includes both RP and ileostomy takedown
# includes 158 patients (49.1%) in iTAC group and 121 (60.8%) in iRP group
38
Abstracts
Methods: Data were collected from 394 patients who underwent SBR
for CD from 1991 - 2012 at our institution. Body mass Index (BMI) & modified nutritional risk index (mNRI = 1.519 x serum-albumin(g/L) + 41.7(present weight/ideal body weight)) were calculated as nutritional status. Low
body weight(BMI <18.5) & high risk for developed of nutrition related problem(mNRI <83.5) were regarded as poor nutritional status. In our data analysis, major independent variables were remnant small bowel length(r-SBL)
and remnant small bowel length-total small bowel length ratio(r-t SBL
ratio). Total small bowel length before initial small bowel resection was
checked in 298 case. In that case, we could calculate r-t SBL ratio. Cut-off
value of r-SBL & r-t SBL ratio/ currently active CD/ileostomy associated with
poor nutritional status were assessed.
Results: Univariated analysis showed that r-SBL 250cm was the most
reliable cut-off value to low BMI(<18.5) and low mNRI(<83.5), and other
result showed that r-t SBL ratio 0.6 was cut-off value to low mNRI(<83.5).Of
the 394 patients, currently active CD is a risk factor for low body weight(BMI
<18.5) & high risk malnutrition(mNRI <83.5). In non-active CD patients, our
analysis showed same cut-off value(r-SBL 250cm, r-t SBL ratio 0.6). Additionally, patients with ileostomy showed statistically higher risk for low
body weight (BMI < 18.5) in total patient(n =394). In exclusion group of currently active CD(n =283), patients with ileostomy showed higher risk for
low body weight(BMI <18.5) and major malnutrition(mNRI <83.5). Multivariated logistic regression analysis revealed that r-SBL 250cm, currently
active CD, ileostomy status were risk factor for poor nutritional status.
Conclusions: At the time of SBR in patients with CD, it is recommended
to preserve more than f-SBL 250cm/f-t SBL Ratio 0.6. Also, the existence of
currently active CD, ileosotmy and f-SBL≤250cm are risk factors affecting
poor nutritional status in patients with CD.
P11
LONG-TERM FUNCTIONAL OUTCOME OF IPAA IN PATIENTS PRESENTING WITH FULMINANT ULCERATIVE COLITIS: A MATCHED COHORT
STUDY.
G. Fasen1, E. Pavey3, D. W. Larson2, K. L. Mathis2, R. R. Cima2, E. J. Dozois2
and S. Y. Boostrom2 1General Surgery, Mayo Clinic, Rochester, MN,
2
Colorectal Surgery, Mayo Clinic, Rochester, MN and 3Biomedical Statistics
and Informatics, Mayo Clinic, Rochester, MN.
Purpose: To characterize long term functional outcomes in patients
presenting with fulminant ulcerative colitis (UC) after undergoing a 3staged proctocolectomy with ileal pouch anal anastomosis (IPAA).
Methods: A prospectively maintained database containing pouch function data identified patients having undergone IPAA between 1998 and
2008. A case matched cohort of patients presenting with fulminant colitis
and chronic was compared to a cohort of elective medically refractory UC
patients. Patients were constructed with similar demographics of age, gender, and follow up duration. Clinical and laboratory parameters, immunosuppressive medication use at time of surgery, and functional outcomes
were compared.
Results: 40 patients with fulminant colitis were identified and compared to 73 patients with chronic UC. Preoperative albumin, hemoglobin,
leukocyte count, and steroid dose were significantly different for those with
fulminant colitis. Average survey follow-up was 5.2 years for fulminant colitis and 6.7 years for chronic UC patients. Functional outcomes were not significantly different (Table 1). Fistula and stricture incidence were higher in
the group with fulminant colitis with a 3 year fistula-free rate of 91.4% vs.
98.6% and a 3 year stricture free rate of 79.3% vs. 87.2% for fulminant colitis vs. chronic ulcerative colitis patients, respectively.
Conclusions: Although fistula and stricture rates were higher, patients
undergoing proctocolectomy and IPAA for fulminant colitis have similar
long term functional outcomes, despite significantly worse presentation
when compared to patients with chronic UC. This study confirms that IPAA
is an appropriate long term treatment for patients with fulminant colitis.
P13
LAPAROSCOPIC RIGHT COLECTOMY VERSUS LAPAROSCOPICASSISTED COLONOSCOPIC POLYPECTOMY FOR ENDOSCOPICALLY
UNRESECTABLE POLYPS. A RANDOMIZED CONTROLLED TRIAL.
C. Lascarides1, P. I. Denoya1, J. Buscaglia2, S. Nagula2, J. Bucobo2,
M. Bishawi1, S. Palmer1 and R. Bergamaschi1 1Division of Colon and Rectal
Surgery, State University of New York, Stony Brook, Stony Brook, NY and
2
Division of Gastroenterology, State University of New York, Stony Brook,
Stony Brook, NY.
Post surgical pouch function
Purpose: A randomized controlled trial was conducted to test the
hypothesis that there is no difference in efficacy between laparoscopic right
colectomy (LRC) and laparoscopic-assisted colonoscopic polypectomy
(LACP) for endoscopically unresectable polyps.
Methods: This was a single-center randomized controlled trial (clinicaltrials.gov 144467). Patients with endoscopically unresectable polyps were
allocated to LRC or LACP. Patients with non-lift sign, high-grade dysplasia,
adenocarcinoma or familiar adenomatous polyposis were not included. Efficacy was a composite endpoint including diagnostic accuracy, complication rates, and length of hospital stay .
Results: Fourteen LRC patients were comparable to 14 LACP patients
for age (p=0.634), gender (p=0.58), BMI (p=0.95), ASA class (p=0.53), or previous abdominal surgery (p=0.151). There was no difference in preoperative morphology (p=0.50), location (p=0.264), size (p=0.474), and histology
of the polyps (p=0.199). LRC patients had longer operating time (179 vs. 95
min, p =0.001), more estimated blood loss (63 vs. 13 cc, p =0.001), and
required more IV fluids (3.1 vs. 2.1 liters p=0.049). LRC patients took significantly longer to pass flatus (2.88 vs. 1.44, p=0.002), resume solid food (3.94
vs. 1.69, p<0.001), and leave the hospital (4.94 vs. 2.63, p<0.001). Postoperative complications (p=0.381), readmissions (p>0.9), and reoperations
(p=0.515) did not differ. There was no difference in accuracy of diagnosis
(p=0.366), or size of polyps (p= 0.474).
Conclusions: This study did not show a difference in efficacy between
LRC and LACP for endoscopically unresectable polyps.
P12
FACTORS AFFECTING NUTRITIONAL STATUS AFTER SMALL BOWEL
RESECTION IN PATIENTS WITH CROHN’S DISEASE.
K. Jang, C. Yu, J. Kim, I. Park, Y. Yun and C. Kim Asan medical center, Seoul,
Republic of Korea.
Purpose: This study evaluates the correlation between remnant small
bowel length(r-SBL), the existence of currently active CD, ileostomy and
nutritional status in patients with CD who underwent SBR.
39
Abstracts
P14
P15
IMPACT OF ELECTIVE LAPAROSCOPIC SIGMOID RESECTION ON
QUALITY OF LIFE IN SIGMOID DIVERTICULITIS.
J. Silva Velazco, L. Stocchi and G. Ozuner Colorectal Surgery, Cleveland
Clinic Foundation, Cleveland, OH.
THE COMPARISON OF SHORT-TERM AND LONG-TERM BOWEL
OBSTRUCTIVE MORBIDITY BETWEEN LAPAROSCOPIC AND OPEN
COLORECTAL SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS.
T. Yamada, K. Okabayashi, H. Hasegawa, Y. Ishii, M. Tsuruta, R. Seishima,
S. Matsui and Y. Kitagawa Keio University School of Medicine, Shinjukuku, Japan.
Purpose: A number of reports have suggested that surgery for sigmoid
diverticulitis is frequently ineffective at improving quality of life (QoL). The
aim of this study was to assess changes in QoL following laparoscopic sigmoidectomy and evaluate possible factors associated with such QoL
changes.
Methods: Patients undergoing elective laparoscopic restorative resection for CT-proven sigmoid diverticulitis between 2000-2012 who answered
SF-36 surveys both preoperatively and at least 3 months postoperatively
were identified from a prospectively maintained database. Preoperative and
postoperative mental and physical component summary (MCS/PCS) scores,
including eight individual SF-36 domains (Vitality, Social Functioning, RoleEmotional, Mental Health for MCS, and Physical Functioning, Role-Physical,
Bodily Pain, General Health for PCS) were compared. A number of factors
were assessed for possible association with QoL including demographics,
comorbidities, previous diverticulitis episodes, clinical presentation, radiological findings, individual surgeon, surgical and pathological findings, and
postoperative morbidity.
Results: Out of 370 patients who were offered QoL questionnaires at
the time of elective laparoscopic resection, 282 provided QoL data and 56
fulfilled the inclusion criteria, of whom 38 (68%) had increased postoperative MCS scores whereas 42 (75%) had increased postoperative PCS scores.
Both overall MCS and PCS scores significantly increased after surgery (p =
0.001 and p <0.001, respectively). Specifically, all SF-36 individual domain
scores except physical functioning and role-emotional significantly
increased postoperatively when compared to preoperative scores (Table).
Preoperative lower gastrointestinal bleeding was significantly associated
with lack of improvement in PCS scores (p=0.012).
Conclusions: Elective laparoscopic restorative sigmoidectomy for sigmoid diverticulitis is generally effective in improving patient QoL. Patients
with gastrointestinal bleeding as one of their presenting symptoms should
be advised of its negative effect on QoL.
Purpose: Postoperative short-term and long-term bowel obstructive
disease still remain anxious problem for colorectal surgeons. Laparoscopic
surgery for patients with colorectal disease are gaining the global acceptance due to as faster recovery and better cosmesis compared to open surgery. Although it has been believed that laparoscopic surgery also reduce
postoperative adhesion formation, the impact of laparoscopic surgery on
postoperative short-term and long-term bowel obstructive disease has not
been validated. The aim of this meta-analysis is to compare laparoscopic
and open colorectal surgery with regard to short and long-term postoperative bowel obstructive morbidity.
Methods: MEDLINE, the Cochrane Library were searched systematically
to identify relevant studies. The outcomes of interest were defined as shortterm postoperative ileus and/or bowel obstruction, and long-term bowel
obstruction, and these data were extracted from each study. To obtain synthesized effect sizes, random-effects model meta-analysis were employed,
and then subgroup analysis and meta-regression analysis were conducted.
Results: 25 randomized control studies and 80 observational studies
were included in this meta-analysis, and they reported on the outcomes of
147371 patients. Laparoscopic surgery significantly decreased short-term
postoperative prolonged ileus and bowel obstruction (odds ratio [OR]
=0.608 [0.523–0.708], p<0.001), postoperative prolonged ileus (OR=0.613
[0.517-0.727], p<0.001), and postoperative bowel obstruction (OR=0.645
[0.486-0.857], p=0.002). On the other hand, there are no significant difference of long-term bowel obstructive morbidity between laparoscopic surgery and open surgery (OR=0.768 [0.537-1.099], p=0.149).
Conclusions: This meta-analysis shows that laparoscopic surgery for
colorectal disease reduces short-term postoperative bowel obstructive
morbidity, but doesn’t show significant difference in terms of long-term
morbidity. Consequently, in view of the decreased bowel obstructive morbidity, laparoscopic surgery for colorectal disease should be preferred.
Comparison of Preoperative and Postoperative SF-36 Component and Domain
Scores*
P16
RANDOMIZED TRIAL DEMONSTRATING THE IMPACT OF LAPAROSCOPIC VERSUS OPEN COLON RESECTIONS ON INFLAMMATORY
RESPONSE USING NOVEL MARKERS.
J. Tan1, S. Nair3, F. Koh2, L. Lim3, H. Schwarz3 and D. Koh4 1Yong Loo Lin
School of Medicine, National University of Singapore, Singapore,
Singapore, 2Department of Surgery, National University Health System,
Singapore, Singapore, 3Department of Physiology and Immunology
Programme, National University of Singapore, Singapore, Singapore and
4
Department of Surgical Oncology, National University Cancer Institute,
Singapore, Singapore.
Abbreviations: SF-36, Short Form 36; SD, standard deviation; MCS, Mental
Component Summary; PCS, Physical Component Summary.
Purpose: Studies comparing the immune responses between laparoscopic (LC) and open (OC) colorectal surgery patients have been controversial. We aim to compare the inflammatory response between LC and OC
through the study of inflammatory markers, in particular, that of CD137, IL8 and TGF-β.
Methods: Patients with non-metastatic right/left-sided colonic malignancies were prospectively randomized to undergo LC and OC. The inflammatory markers analyzed include CD137 and cytokines IL-1B, IL-6, IL-8, IL10, TGF-beta and TNF-alpha. Peritoneal fluid and venous blood samples
were collected peri-operatively. The inflammatory markers were compared
between LC and OC, and also correlated with post-operative outcomes.
* Domain scores are presented as Z scores, with the general population having 0
± 1; increases in postoperative scores reflect increases in QoL.
40
Abstracts
Table: Patient and tumor characteristics
Results: There were 13 and 12 patients who underwent LC and OC
respectively from June 2008 to May 2010. OC had higher levels of IL-8 and
IL-10 compared to LC (p=0.079 and p=0.056 respectively). One patient
required open conversion to laparotomy for an anastomotic leakage. His
serum IL-10 (p=0.001) and peritoneal IL-6, IL-8, IL-10, IL-1B, TNF-alpha
(p<0.001) were higher than other patients. Median patient follow-up duration was 28 (14-37) months, during which 4 patients developed recurrent
disease. The group which developed recurrence had higher values in the 6
hour post-operative peritoneal IL-10 (p=0.019) and IL-6 (p=0.010) concentration, as well as the 6 (p<0.001) and 24 (p=0.003) hour post-operative
peritoneal IL-1B levels.
Conclusions: Our study shows that IL-8 and IL-10 are more elevated in
the inflammatory cascade following open colorectal resections compared
to laparoscopic resections, indicating a higher inflammatory response.
Serum IL-10 may be predictive for anastomotic leakage. Peritoneal levels of
IL-10 and IL-6 may be predictive of future recurrent disease.
P17
SURGERY FOR ANORECTAL MALIGNANT MELANOMA: SINGLE CENTER EXPERIENCE.
E. Gorgun, E. Aytac, N. Okkabaz, M. F. Kalady, F. H. Remzi and T. L. Hull
Colorectal Surgery, Cleveland Clinic, Cleveland, OH.
* Determined by Kaplan Meier method
Purpose: Anorectal malignant melanoma (AMM) is a rare disease associated with poor survival. Currently, wide local excision is the commonly
performed initial surgical approach because of the dismal prognosis of the
disease. The aim of this study, was to review long-term outcomes in patients
who underwent radical or local resection at a high volume tertiary care center.
Methods: Patients who were diagnosed with AMM between12/1983
and 10/2012 were evaluated. Data were retrieved from the institutional
review board approved prospectively maintained database. Patients with
perianal malignant melanoma, metastatic disease at the time of diagnosis,
and patients who underwent a non-surgical treatment primarily were
excluded from the analyses. Patient characteristics and postoperative outcomes were compared between the patients undergoing radical surgery
(RS) and wide local excision (WLE).Quantitative data were reported as
median (range) and categorical data as numbers.
Results: There were 30 patients diagnosed with AMM within the study
period. Twenty-one patients met the study criteria. Ten patients underwent
RS and 11 patients underwent WLE with curative intent. The majority of the
patients (n=17) presented with rectal bleeding. Age, gender, co-morbid factors, American Society of Anesthesiologists score, location of disease, and
tumor characteristics were comparable between the groups (table). One
patient received neoadjuvant chemoradiation in the RS group. Perioperative morbidity was significantly higher after RS compared to WLE [n=6 (60
%) vs. n=0 (0 %); p=0.004]. In the RS group, one patient was re-operated
and two patients readmitted within 30 days after surgery. Numbers of
patients with local [n=4 (40%) vs. n=4 (36); p>0.999] and distant [n=4 (40%)
vs. n=2 (18%); p=0.362] recurrences were comparable after RS and WLE,
respectively. Mortality was similar between the groups [n=7 (70%) vs. n=6
(55%); p>0.999] at the time of last follow-up. Disease-free (8 vs. 9 months,
p=0.235) and overall survival (53 vs. 39 months, p=0.293) were comparable
between the groups.
Conclusions: When feasible wide local excision of anorectal melanoma
may provide similar oncologic outcomes with significantly decreased morbidity compared to radical resection.
ASA: American Society of Anesthesiologists, AV: anal verge, NA: not applicable
P18
ONCOLOGIC OUTCOMES AND SURVIVAL IN JUVENILE POLYPOSIS
SYNDROME PATIENTS WITH BMPR1A OR SMAD4 MUTATION.
E. Aytac, B. Sulu, B. Heald, M. O’Malley, L. LaGuardia, F. H. Remzi,
M. F. Kalady, C. Burke and J. M. Church Colorectal Surgery, Sanford R.
Weiss, MD, Center for Hereditary Colorectal Neoplasia, Digestive Disease
Institute, Cleveland, OH.
Purpose: Germline mutations in SMAD4 and BMPR1A, genes that disrupt the transforming growth factor β signal transduction pathway, are
associated with juvenile polyposis syndrome (JPS). Literature concerning
cancer outcomes as they relate to genotype in this syndrome, is sparse. This
study evaluated oncologic outcomes in JPS patients with SMAD4 or
BMPR1A gene mutations.
Methods: JPS patients were identified from an Institutional Review
Board-approved, prospectively maintained institutional registry. Only
patients with germline SMAD4 or BMPR1A mutations were included.
Patients who had no genetic testing or who had both SMAD4 and BMPR1A
mutations were excluded. The colorectal and gastric polyposis phenotype
was graded at the time of surgery or at the last observation.
Results: Thirty-five JPS patients had either BMPR1A (n=8) or SMAD4
(n=27) mutations (Table 1). Mean follow-up time after diagnosis of JPS was
12 years.While presentation of the colonic phenotypic was similar between
the groups, SMAD4 mutations were associated with high gastric polyp
numbers (p=0.04).Small bowel polyps were diagnosed in five patients with
SMAD4 mutation.They were diagnosed with routine upper gastrointestinal
endoscopy in four patients in the duodenum (n=2), jejunum (n=1) and
ileum (n=1). All small bowel polyps were juvenile polyps histologically.The
proportion of patients with rectal polyps was comparable between the
BMPR1A and SMAD4 groups (n=5 vs. n=17, p=1). While no patients were
diagnosed with cancer in the BMPR1A group, four men with SMAD4 mutations developed cancer:1 gastric, 1 small bowel, 1 with both a rectal neuroendocrine tumor and a gastric adenocarcinoma,and 1 with a testicular
tumor (intra-tubular germ cell neoplasia) and an oligoastrocytoma.The gastrointestinal cancer risk in JPS patients with SMAD4 mutations was 11%
(3/27).Two patients with a SMAD4 mutation died during follow-up,from
metastatic gastric cancer.Two patients with a SMAD4 mutation died due to
non-oncological causes including complications of end-stage renal disease
and thromboembolic events.
41
Abstracts
east had an early stage cancer with only 67.5% having an advance cancer
(p= <0.01). Furthermore, we appreciated a higher percentage of younger
patients, less than age 50, presenting with colon cancer in the South
(9.45%) compared to the Midwest, Northeast and West (7.66%, 8.15%,
8.74% respectively; p=<0.01). There was also the highest population of both
uninsured and underinsured (7.37%; p=<0.01) patients and African-American patients (57.1%; p <0.01) found in the South.
Conclusions: Patients living in the Southern United States appear to be
a potentially vulnerable population with a later stage of presentation of
colon cancer at earlier ages. Risk factors of late stage of presentation, low
socioeconomic status, and African American race have all been shown in
the literature to have an association with increased mortality. While not
proven by this study, this phenomenon may be related to access of care
among patients in the South with colon cancer. Further study of this patient
population is clearly warranted.
Conclusions: The SMAD4 genotype is associated with more aggressive
upper GI manifestations of JPS. Affected patients need more aggressive surveillance.
Table 1: Patient characteristics, disease phenotype and operations performed
P20
APICAL NODE STATUS IMPROVES PROGNOSIS PREDICTION OF THE
7TH EDITION OF TNM CLASSIFICATION IN STAGE III COLON CANCER.
H. Kawada1, N. Kurita2, J. Kawamura1, S. Hasegawa1, K. Kotake3,
K. Sugihara4, S. Fukuhara2 and Y. Sakai1 1Surgery, Kyoto university, Kyoto,
Japan, 2Healthcare Epidemiology, Kyoto university, Kyoto, Japan, 3Surgery,
Tochigi Cancer Center, Tochigi, Japan and 4Surgical Oncology, Tokyo
Medical and Dental university, Tokyo, Japan.
(§) in addition to juvenile polyps. JPS: Juvenile polyposis syndrome.
(*) Three patients had a total gastrectomy with a colonic resection
RP-IPAA: Restorative proctocolectomy with ileal pouch anal anastomosis
(†) Three patients in the BMPRA1 group and eight patients in the SMAD4 group
had no gastrointestinal surgery (p=0.69).
Purpose: To examine the prognostic value of the apical lymph node
metastasis, and the additive value of incorporating apical lymph node status to risk model based on the seventh editions of the TNM classification,
in colon cancer.
Methods: This was a cohort study of 1355 patients with Stage III colon
cancer who underwent tumor resection with dissection of regional (including apical) lymph node at 71 member hospitals of Japanese Society for Cancer of the Colon and Rectum (JSCCR) across Japan between 2000 and 2002.
Main exposure was pathologically confirmed apical lymph node metastasis. Primary endpoint was cancer specific death.
Results: Apical lymph node metastasis was present in 113 (8.3%) of the
patients. During 5,356 patient-years (median 5.0 year) of follow-up, 221
(16.3%) of cancer specific death was observed. After adjustment for tumor
and node classification in the seventh edition and other prognostic factors,
apical lymph node metastasis was independently associated with cancer
specific death (hazard ratio, 2.29; 95% confidence interval [CI], 1.49 – 3.52).
Incorporating apical lymph node metastasis into the prognostic model
based on the seventh TNM edition significantly improved discriminative
performance for cancer specific death (difference in concordance index
0.0146; 95% CI, 0.003 – 0.026) and risk reclassification for cancer specific
death at 5 years (category free net reclassification improvement 19.4%; 95%
CI, 5.0% - 33.4%), respectively.
Conclusions: The assessment of apical lymph node metastasis provided
independent prognostic information beyond the seventh TNM edition in
patients with Stage III colon cancer.
P19
THE REGIONAL VARIATION OF COLON CANCER: A REVIEW OF THE
NATIONAL CANCER DATABASE BENCHMARK REPORTS.
R. Smith, S. Jayarajan, A. Walchak and J. Sariego Temple University
Hospital, Philadelphia, PA.
Purpose: Many factors including race, insurance status, level of education, and socio-economic status have been implicated in a delayed stage at
diagnosis of colon cancer, yet few studies have measured the impact of
geographic variance as a factor of stage at presentation. By utilizing a
national registry, we hope to define regional trends in the incidence and
prevalence of colon cancer and investigate how this relates to geographic
practice patterns.
Methods: The American College of Surgeons National Cancer Database(NCDB) benchmark reports were queried on patients treated for colon
cancer from 2000-2011. Information collected included state of residence,
stage, race, gender, and insurance status. These data were then stratified
with regard to geographic region in accordance with the US Census Bureau
classifications. All variables were categorical and data were analysed using
the Cochran-Mantel-Haenzel for trend.
Results: In regard to stage of diagnosis, only 29.2% of patients in the
South had an early stage tumor (TIS or Stage I) while 70.8% presented with
either a Stage II, III, or IV lesion. In contrast, 32.5% of patients in the North-
42
Abstracts
siderably. Differences can be explained by the surgeon, the pathologist and
/ or the patient.
Methods: Number of retrieved lymph nodes in surgical specimen of 54
patients with colorectal cancer, who underwent surgery (01/2010–07/2011)
at a university hospital (hospital A), were compared to the number of
retrieved lymph nodes in specimen of 49 patients operated at a cantonal
hospital (hospital B) (08/2011–12/2012). All 103 operations were performed
by one surgeon with equal extent of tumor resection. Surgical and
histopathological parameters were compared.
Results: No significant differences between both cohorts were
observed for gender, BMI, tumor location, resected bowel length, tumor
stage and R-status. For all patients, the total number of resected lymph
nodes differed significantly with 17.8 +/- 7.9 in hospital A and 25.7 +/- 12.4
in hospital B (p<0.001). The difference was still observed in subgroup analysis of patients with colon cancer (19.9 +/-7.8 versus 27.5+/-12.9; p=0.015),
rectal cancer (16.1 +/-7.6 versus 22.7+/-10.0; p=0.014) and rectal cancer
after preoperative treatment (13.3+/-5.4 versus 19.4+/-9.5; p=0.046). Multivariable analysis confirmed the pathological institute (HR 6.22; 95%CI 2.1710.27; p=0.003) and the pT-category (3.42; 1.1-5.74; p=0.004) as independent prognostic factors for lymph nodes number.
Conclusions: Retrieved lymph node numbers differ significantly
between pathology institutes with highly experienced staff. This study confirms the pathologist and his technique as one of the most important reason for differences in lymph node numbers.
P21
LYMPHOVASCULAR MICROANATOMY OF THE COLON AND PREDICTION OF RISK IN PT1 COLORECTAL CANCER USING A 3D MODEL.
P. Brown1, E. Toh1, K. Smith1, P. Jones3, D. Treanor1, D. Magee4, D. Burke2
and P. Quirke1 1Pathology, Anatomy and Tumour Biology,, Leeds Institute
of Cancer and Pathology, Universtiy of Leeds, St James’s University
Hospital, Leeds, United Kingdom, 2Translational Anesthetic and Surgical
Science,, Leeds Institute of Cancer and Pathology, University of Leeds, St
James’s University Hospital, Leeds, United Kingdom, 3Section of Molecular
Gastroenterology,, Leeds Institute of Molecular Medicine, Universtiy of
Leeds, St James’s University Hospital, Leeds, United Kingdom and 4School
of Computing, University of Leeds, Leeds, United Kingdom.
Purpose: The proportion of pT1 colorectal cancers has tripled since the
introduction of the UK screening program. Risk of metastasis is predicted
by Kikuchi depth suggesting that access to deep lymphatic and blood vessels is important in this process. Our previous study on lymphatic vessels
showed significantly fewer vessels in the deepest third of the submucosa
compared to other layers. Here we have examined and similarly quantified
the vascular structures of colorectal mucosa. In addition, we have generated a novel 3D model to show the relationship between blood and lymphatic vessels with their surroundings.
Methods: Thirty samples of normal colorectal tissue were immunostained with CD31, a vascular endothelium marker allowing blood vessel
number, circumference, area and diameter to be digitally analysed. Vessels
were identified within analysis boxes of fixed area (0.2mm2) randomly
placed on the muscularis mucosa and underlying thirds of the submucosa;
sm1,2 and 3. The 3D model required serial sections and a double immunostain, using CD31 and D2-40.
Results: Significant differences were shown between submucosal layers for the number, circumference and area of vessels (p<0.001). The
mucosal layer contained the most vessels, median 11.79 vessels per unit
area of 0.2mm2 (IQR:9.06-17.17); with Sm2 the fewest, 6.92 vessels per unit
area(4.99-9.52). Vessels in sm2 had the largest median circumferences,
134.4mm(85.2-156.1mm) and median areas, 2086mm2(1007-4784mm2), with
those in the mucosa the smallest; 61.9mm(53.9-72.2 mm) and 247mm2(162373mm2). The accumulated vessel circumference and area increases for
blood and lymphatic vessels through sm1-sm3, but not at the reported rate
of increase of metastasis.
Conclusions: The number and size of blood and lymphatic vessels in
sm1-3 does not increase with depth of submucosa as hypothesised. Sm1
appears to be very important and may explain the predictive value of width
of invasion. The 3D model demonstrates the complex arrangement and
inter-relationships between blood and lymphatic vessels and colorectal
structures. Both demonstrate the importance of further investigation into
the phenotypic appearance of tumours and their risk of metastasis.
P23
QUALITY OF LIFE FOLLOWING MULTIVISCERAL RESECTION FOR
RECURRENT OR LOCALLY ADVANCED PELVIC MALIGNANCY.
R. Codd, M. D. Evans, D. A. Harris, D. Mark and J. Beynon Colorectal
Surgery, Singleton Hospital, Swansea, United Kingdom.
Purpose: A recent consensus statement endorsed by the ACPGBI and
the European Society of Coloproctology has identified a need for prospective assessment of quality of life (QoL) in patients undergoing exenterative
pelvic surgery. The aim of this prospective observational study was to evaluate health-related QoL in patients undergoing radical resection for recurrent or locally advanced pelvic malignancy.
Methods: Patients with either recurrent or locally advanced (T4) pelvic
malignancy were identified at the weekly pelvic oncology MDT meeting.
Surgery was undertaken between January 2011 and August 2012. Consent
was obtained and a baseline QoL score taken prior to commencing treatment using the EORTC QLQ C30 questionnaire. The same questionnaire was
used to measure QoL immediately post-operatively and at 3, 6 & 12 months.
Results: Twenty-five patients were included in this study. Global Health
Score was significantly lower at the immediate post-operative assessment
(p=0.0216). This score returned to a level similar to the baseline by 3months and remained at this level at 12-months (p>0.05). Role function
(work/daily activities) dropped significantly (p=0.0001) in the immediate
post-operative period but returned to a baseline level from 3-months
onwards. There was a significant drop in physical function immediately
post-operatively (p=0.0001) which was not regained even at 12-months
(p=0.0194). Similarly social function was significantly affected immediately
post-operatively (p=0.0004) and was not regained by 12-months (p=0.0333)
Conclusions: This study is the first to evaluate health related QoL in
patients who have undergone multi-visceral surgery for recurrent or locally
advanced pelvic malignancy. We have identified a significant initial overall
impact on Global health but this retured to baseline by 3-months. The effect
on work and daily activities followed a similar pattern. Physical and social
function deteriorated significantly in the immediate post-operative period
and these levels did not return to baseline even at 12-months. Our findings
demonstrate the significant initial impact on patient health and the prolonged recovery associated with multivisceral pelvic surgery.
P22
THE PATHOLOGIST INFLUENCES SIGNIFICANTLY THE NUMBER OF
LYMPH NODES AFTER STANDARDIZED COLORECTAL CANCER SURGERY.
R. Rosenberg1, S. Naumann1, U. Nitsche3, T. Kocher2, C. Moser2,
G. Singer4, J. Slotta-Huspenina4, R. Langer5, T. Schuster1, Y. Knoblauch1
and A. Keerl1 1Dpt. of Surgery, Kantonsspital Baden, Baden, Switzerland,
2
Institute of Pathology, Kantonsspital Baden, Baden, Switzerland, 3Dpt. of
Surgery, Klinikum rechts der Isar, Technische University Munich, Munich,
Germany, 4Institute of Pathology, Klinikum rechts der Isar, Technische
University Munich, Munich, Germany and 5Department of Epidemiology,
Biostatistics and Occupational Health, McGill University Montreal,
Montreal, QC, Canada.
Purpose: Although techniques of lymph node harvest in colorectal
tumor specimens have improved significantly, the numbers still vary con-
43
Abstracts
ure). Hispanic females also are less likely to be diagnosed initially with late
stage disease (see figure). White males have become somewhat more likely
to be diagnosed with later stage disease over the time period (see figure).
Conclusions: Screening tools for rectal cancer are becoming more
accessible to all portions of the US population. African Americans are now
less likely to be diagnosed with late stage disease. However, there remains
minority and non-minority groups that will likely benefit from increased
effort to improve rectal cancer screening. This could decrease the stage in
which patients begin therapy, and possibly improve outcomes. Databases
like the National Cancer Database provide a framework for analyzing at risk
and underserved populations nationally. This allows for tailored care to
these specific populations.
P24
ABDOMINOPERINEAL RESECTION FOR PERSISTENT OR RECURRENT
SQUAMOUS-CELL CANCER OF THE ANUS. IS SURVEILLANCE FOR
RECURRENCE PROTOCOLS YIELDING EFFECTIVE CURE RATES?
N. Severino1, L. Rosen1, S. Coiro1, E. Choman1, M. Berho2 and
S. D. Wexner1 1Cleveland Clinic Florida, Weston, FL and 2Pathology,
Cleveland Clinic Florida, Weston, FL.
Purpose: Patients failing chemoradiotherapy (CRT) for invasive squamous cell cancer of the anus (SCCA) can be salvaged for cure with timely
abdomino-perineal resection (APR). Survival is dependent on favorable
TNM stage. ASCRS guidelines suggest surveillance after CRT every 3-6
months for the first 24 months to detect persistent SCCA (<6 months) or
recurrence (>6 months). This study aimed to identify the interval from completion of CRT to salvage APR and TNM stage to determine the effectiveness of surveillance.
Methods: After IRB approval, electronic medical records identified all
patients with SCCA from 1/1/1992 to 12/31/2012 including those with APR..
The timeline from completion of CRT to persistent or recurrent SCCA, tumor
stage and survival were analyzed. Chi-square test was utilized.
Results: 151 consecutive cases of SCCA were reviewed. 43 were
Bowen`s disease and excluded, 108 were invasive, and 36 underwent salvage APR. There were 22 females and 14 males with a mean age of 59 years.
11 had persistent disease, 17 had early (6-24 months) and 8 had late recurrence (>24 months). 67% (24/36) were directly referred for salvage from
other institutions, and 33% (12/36) were followed after CRT in our department at a mean of every 2.8 months for the first 24 months. Overall, 18/36
(50%) had stage IIIA, IIIB or IV with significantly lower survival than 18 with
stage 0, I or II (p= 0.028). 61% (17/28) who underwent salvage APR for SCCA
in the first 24 months after completion of CRT had stage IIIA, IIIB or IV compared to 11 patients with stage 0, I or II (p=0.016) with respective survivals
of 31% (mean follow-up: 19 months) and 64% (mean follow-up: 28 months).
Conclusions: Patients who undergo salvage APR have significantly
worse survival with stage IIIA, IIIB or IV than stage 0, I or II. 61% (17/28) who
underwent salvage APR in the first 24 months had stage IIIA, IIIB or IV compared to earlier stages. Shorter follow-up intervals with clinical examination and periodic imaging may be warranted despite the initial appearance
of complete clinical/pathologic response in the first 24 months after CRT.
P25
TRENDS IN RECTAL CANCER FROM 2001 TO 2011 AND STAGE AT
PRESENTATION BASED ON RACE, GENDER, AND PAYER STATUS USING
THE NATIONAL CANCER DATABASE.
K. Butler, C. Shaw and S. Tan General Surgery, University of Florida,
Gainesville, FL.
Purpose: As treatment modalities for rectal cancer advance so too do
the potential positive outcomes. A major determining factor in outcome
will be stage at presentation. Screening modalities, such as colonoscopy
are mainstays of early detection of rectal lesions. Some portions of the population, specifically minorities, have experienced difficulty accessing even
basic screening care. We aim to examine the stage at presentation of
patients with rectal cancer with respect to race and payer status to determine whether access to screening from 2001-2011.
Methods: We utilized the Commission on Cancer National Cancer Database to analyze patients with rectal cancer from 2001 to 2011. We identified 232,314 cases of patients with rectal cancer. We then analyzed patients
based on race, sex, payer status, and stage at presentation. Patients were
stratified based on race and sex.
Results: Overall rates of rectal cancer have remained stable over the
study time period (mean: 23,231 per year, stdv: 345). Medicare or private
insurance covers the vast majority of patients (44% and 41% respectively).
When analyzing stage at presentation, African American patients have
become less likely to be diagnosed with late stage disease (stage III/IV) at
presentation when compared with early stage disease (stage I/II)(see fig-
44
Abstracts
Results: LS group consisted of 112 patients and open surgery(OS)
group did 86 patients, and the median follow up period was 60.0 months
and 44.1 months, respectively. Six patients (5.4%) demonstrated postoperative recurrence in LS group and sixteen patients (18.6%) in OS group. Multivariate analysis revealed that transverse diameter of pelvic outlet and the
N factor had significant correlation with postoperative recurrence in OS
group (p<0.05), while only T factor was a significant contributor to recurrence in LS group (p<0.01).
Conclusions: In case of OS for RC, “narrow pelvis” was a robust predictor of postoperative recurrence, on the other hand no relationship was
identified between narrow pelvic and postoperative recurrence in LS. Collectively LS could be possibly more feasible for RC in “narrow pelvis” comparing to OS.
P26
IMPLEMENTATION OF AN ELECTRONIC MEDICAL RECORD IMPROVES
THE QUALITY OF DOCUMENTATION IN A SUBSPECIALTY PRIVATE
PRACTICE.
M. Cusick1, S. T. McKnight2, D. Howell Jr2, H. Bailey2 and M. J. Snyder2
1
University of Texas-Houston Affiliated Hospitals, Houston, TX and 2Colon
& Rectal Clinic of Houston, P.A., Houston, TX.
Purpose: The use of electronic medical records (EMR) in the ambulatory setting has increased drastically over the last five years. However, little
has been reported on any changes in the quality of the documentation.
The purpose of this study was to investigate the effects of EMR implementation on new patient documentation in a large subspecialty private practice.
Methods: Ten randomly selected new patient visit charts from before
and after the implementation of the EMR were chosen from each surgeon
within the practice. Each chart was reviewed for necessary elements of Evaluation and Management (E/M) codes: chief complaint (CC), history of present illness (HPI), past medical history (PMH), family history (FH), social history (SH), review of systems (ROS), and physical examination (PE). The
components of documentation were compared - pre-EMR versus post-EMR.
Paired t-tests were used for comparisons.
Results: One hundred eighty charts were reviewed. The majority of
patients were seen with a CC of rectal bleeding (36%) or anal pain (35%).
Although there was no difference in the documentation of CC (100% preEMR vs. 100% post-EMR, p=NS) and 4 elements of HPI (98.9% pre-EMR vs.
100% post-EMR, p=NS), there was significant difference in documentation
of PMH (72.2% pre-EMR vs. 100% post-EMR, p<0.01), FH (56.7% pre-EMR vs.
98.9% post-EMR, p<0.001), SH (57.8% pre-EMR vs. 98.9% post-EMR,
p<0.001), and 10 point ROS (3.3% pre-EMR vs. 93.3% post-EMR, p<0.001).
Additionally, more comprehensive PE were documented post-EMR (6.7%
pre-EMR vs. 71% post-EMR, p<0.001).
Conclusions: Implementation of an EMR has resulted in more detailed
documentation for new clinic visits with a significant increase in the documentation of PMH, FH, SH, and ROS. Additionally, a more comprehensive
examinations was documented with the use of an EMR. Implementation of
an EMR in a large subspecialty private practice has resulted in more thorough and higher quality documentation.
P28
MARKETING A SURGICAL PRACTICE – A RANDOMIZED PROPSPECTIVE CONTROLLED EXPERIENCE.
R. W. Beart, A. McElrath-Garza, J. Anderson, B. Shubin-Galaif, P. Vukasin
and M. Barnajian Surgery, Glendale Memorial Hospital, Glendale, CA.
Purpose: Evolution in healthcare economics and practices has resulted
in decreasing patient visits to specialty surgical practices. We have noted
and measured these changes in our own community practice. Marketing of
a surgical practice has not been documented to predictably increase
patient visits. Furthermore, the effectiveness of varying types of marketing
has not been documented. We embarked on a prospective evaluation of
marketing our practice with the hypothesis that we could experience a
measureable growth in practice and a return on investment of greater than
zero.
Methods: Approximately ½ of physicians (PCP, GI, IM, OB/GYN) within
defined zip codes were chosen to receive marketing, the rest received no
marketing and served as a control group. Physicians with a record of frequent referrals to this practice were excluded. Marketing techniques
included direct mailing, evening educational dinners, small office lunches
and quarterly half day education seminars. New patients (NPT) to the practice was the metric evaluated and patients were asked to identify referring
doctors on presentation to the office. Expenses for marketing, including
personal costs were tracked and patient revenue was calculated to assess
cost effectiveness of the program.
Results: 885 physicians in 38 zip codes were identified. From 2011 to
2012 there was a 34.2% increase in NPT referrals from the marketed group
and 22% decrease from the non-marketed physicians. Effectiveness of each
of the marketing techniques was evaluated and clear efficacy differences
were noted. This was a cost effective program with an incremental return
on investment of greater than 12.
Conclusions: This is the first randomized, controlled marketing trial of
a surgical practice. Marketing of a surgical practice is effective and is cost
effective, particularly when the expenses are shared with the hospital .
Effectiveness varies with the marketing technique utilized.
P27
EXAMINATION ABOUT THE RELATION BETWEEN “NARROW PELVIS”
AND RECURRENCE IN ANTERIOR RESECTION FOR RECTAL CANCER.
T. Shimada, M. Tsuruta, T. Ishida, H. Hasegawa, K. Okabayashi, Y. Ishii,
H. Kikuchi, R. Seishima, H. Takahashi, S. Matsui, T. Yamada, T. Kondo,
M. Matsuda, M. Yahagi, Y. Yoshikawa and Y. Kitagawa Department of surgery, Keio University School of Medicine, Tokyo, Japan.
Purpose: Laparoscopic surgery (LS) for rectal cancer (RC) has not been
widely accepted as the standard strategy due to technical limitations. “Narrow pelvis” is considered one of the major anchors causing more blood loss
and longer operative time in anterior resection (AR) for RC, which possibility we have already elucidated in case of LS. Additionally it could potentially influence long term outcome after surgical procedure for RC. We
investigated the correlation with “narrow pelvis” and long-term postoperative results (i.e. relapse rate) in laparoscopic as well as open AR for RC.
Methods: We studied 198 consecutive patients who underwent laparoscopic or open AR for RC and obtained Curability A between January 2005
and October 2012 in our institution. We performed pelvimetry by measuring anteroposterior diameter and transverse diameters of pelvic inlet and
outlet, and pelvic depth from the 3D CT, which we constructed by using
‘OsiriX’ from the Dicom viewer of the open source in Macintosh (Apple Inc.,
California, USA). We investigated the correlation between clinicohistopathological factors including the results of pelvimetry and postoperative reoccurence as a long term outcome.
P29
INTRAOPERATIVE FLUORESCENCE ANGIOGRAPHY DOES NOT
DECREASE COLORECTAL ANASTOMOTIC LEAK RATES.
C. Kin, H. Vo and M. Welton Department of Surgery, Stanford University
Medical Center, Stanford, CA.
Purpose: Intraoperative fluorescence angiography allows surgeons to
assess tissue perfusion and has been applied in several clinical settings. Our
aim is to determine if intraoperative fluorescence angiography decreases
the anastomotic leak rate in colorectal operations.
Methods: Retrospective review of all colorectal operations performed
at an academic medical center was conducted. Abdominal colectomies and
proctectomies with a colorectal or coloanal anastomosis were included.
Results: Of 443 operations, surgeons used intraoperative fluorescence
angiography in 220. The rate of anastomotic leak did not differ between
45
Abstracts
Preoperative Colorectal Surgery SNF Discharge Score
the two groups (8.6% for the angiography group vs 8.5%). Poor perfusion
of the proximal colon seen on intraoperative fluorescence angiography
altered surgical management in 12 cases (5.5%) by additional colon resection to allow a more well-perfused segment to be used for anastomosis.
Two of these cases developed anastomotic leaks. There was no difference
in age, surgical indication and proportion of patients who underwent
neoadjuvant pelvic radiation therapy between the angiography group and
the non-angiography group. The angiography group had a higher proportion of diverting loop ileostomy (30% vs 19%) although there was no difference in the average distance of colorectal anastomoses from the anal
verge. The angiography group also had a greater proportion of colorectal
anastomoses performed in the side-to-end fashion (78% vs 37%) compared
to the end-to-end fashion that was more common in the non-angiography
group.
Conclusions: The use of intraoperative fluorescence angiography to
assess the perfusion of the colon to be used for anastomosis has not
improved anastomotic leak rates in colorectal surgery. In several cases, the
perfusion of the proximal colon as seen on fluorescence angiography differed from gross inspection of the tissue so much so as to influence surgeons to resect back to a better-perfused segment of colon, but it is
unknown whether these cases would have otherwise resulted in anastomotic leak. Perfusion is but one of multiple factors contributing to the
development of anastomotic leaks. Further analyses are necessary to determine whether this technology is cost-effective.
P30
PREOPERATIVE TOOL FOR PREDICTION OF DISCHARGE TO SKILLED
NURSING FACILITY FOLLOWING COLORECTAL SURGERY.
A. S. Rickles2, J. C. Iannuzzi1, K. N. Kelly2, K. Noyes2, J. R. Monson2 and
F. J. Fleming2 1Surgery, University of Rochester, Rochester, NY and 2Surgical
Health Outcomes & Research Enterprise, University of Rochester, Rochester,
NY.
P31
USING CHLORAPREP VERSUS DURAPREP OR ALCOHOL VERSUS NONALCOHOL BASED SKIN PREPARATIONS DOES NOT AFFECT THE INCIDENCE OF SURGICAL SITE INFECTIONS AFTER COLORECTAL OPERATIONS.
C. Kaoutzanis1, S. W. Leichtle1, M. S. Tam1, K. B. Welch2, R. Kuttner3,
A. Talsma3, J. F. Vandewarker1, R. Lampman1 and R. K. Cleary1
1
Department of Surgery, Saint Joseph Mercy Hospital Ann Arbor, Ann
Arbor, MI, 2Center for Statistical Consultation and Research, University of
Michigan, Ann Arbor, MI and 3School of Medicine, University of Michigan,
Ann Arbor, MI.
Purpose: Arranging for hospital discharge to a skilled nursing facility
(SNF) is often a complex and time consuming process. If started too late,
discharge to SNF can lead to prolonged hospital stay and considerable
increase in healthcare resource utilization. This study sought to develop a
pre-operative prediction tool for a SNF discharge following colorectal surgery to help streamline postoperative care and decrease hospital stay.
Methods: The 2011 ACS NSQIP database was queried for patients
undergoing colorectal surgery using relevant CPT and ICD-9 codes. Patients
who were transferred in from a nursing home, had a hospital stay <1 day,
or had a postoperative death were excluded. The dataset was divided at
random into two parts (2:1) for model development and validation. The
model’s primary outcome was discharge to new facility and preoperative
patient and operative factors were added by forward stepwise logistic
regression with inclusion criteria of p-value < 0.05. Variables in the final
model were chosen for maximizing predictive ability while maintaining a
simplistic score for clinical utility. Patients were then categorized into low
risk (<10%) moderate risk (10-30%) and high risk (>30%) for SNF discharge.
C-statistic was used for determination of model predictability.
Results: Overall, 37,913 colorectal cases met inclusion criteria with a
facility discharge rate of 10%. The final model included 7 pre-operative variables: operative approach, diagnosis, race, age, renal insufficiency, functional status, and ASA class (table 1). The model had high predictive validity and reliability (C-statistic=0.856 in developmental model and 0.854 in
validation model). The median score was 6 points, equating to a 4% risk.
68% of patients were low risk (<8 points), 22% were moderate risk (8-10
points), and 10% were high risk (≥11 points) for SNF discharge.
Conclusions: SNF discharge following colorectal surgery can be accurately predicted using 7 simple pre-operative clinical characteristics. Identification of patients at high risk for SNF discharge can be used for anticipatory guidance for patients pre and postoperatively and to help reduce
healthcare resource utilization.
Purpose: Surgical site infections (SSIs) are a major cause of morbidity
and mortality following colorectal operations, and increase costs as well as
length of hospital stay. Preparation of the surgical site with antiseptic solutions is an essential part of SSI prevention, and the National Quality Forum’s
practice guidelines recommend using alcohol based skin preparations prior
to surgery. However, there is no universal consensus about which preparation is most efficacious. This study compared ChloraPrep (2% chlorhexidine
with 70% isopropyl alcohol) versus DuraPrep (0.7% iodine provacrylex with
74% isopropyl alcohol) and alcohol based skin preparations (ABSP) versus
non-alcohol based skin preparations (NABSP) with regard to their efficacy
in preventing SSIs.
Methods: The Michigan Surgical Quality Collaborative combined with
the Perioperative Outcomes Initiative database was used to determine the
incidence of SSIs following clean-contaminated colorectal operations from
January 2010 to June 2012. ChloraPrep and DuraPrep, as well as ABSP and
NABSP, were compared using a propensity score model to adjust for differences in patient demographics, characteristics, co-morbidities and laboratory values. Outcomes of interest were the incidence of superficial SSIs, any
SSI (superficial SSI, deep SSI, organ/space SSI), any wound complication
(any SSI, wound disruption, other wound complications), and readmission
within 30 days from the index operation for SSI.
Results: When ChloraPrep (N=459) and DuraPrep (N=125) were compared, a total of 584 colorectal cases met inclusion criteria. When ABSP
(N=655) and NABSP (N=198) were compared, a total of 853 colorectal cases
met inclusion criteria. There was no significant difference in the propensity
adjusted odds for having a superficial SSI, any SSI, any wound complica-
46
Abstracts
tion, or readmission within 30 days for SSI when comparing ChloraPrep to
DuraPrep, and when comparing ABSP to NABSP (Table 1).
Conclusions: The use of ChloraPrep versus DuraPrep, or ABSP versus
NABSP, does not significantly influence the incidence of SSIs or readmission
within 30 days for SSIs after clean-contaminated colorectal operations.
P33
SACRAL NERVE STIMULATION IN PATIENTS WITH IRRITABLE BOWEL
SYNDROME AND FECAL INCONTINENCE.
F. Quinteros, B. Martin, H. Schoonyoung, G. Nassif, S. Atallah, M. Albert,
S. LaRach and T. DeBeche-Adams Colon and Rectal Surgery, Florida
Hospital, Orlando, FL.
Table 1
a
Purpose: Sacral Nerve Stimulation (SNS) is a newer modality in the USA
for treating Fecal Incontinence (FI). It has been FDA-approved only for FI
thus far, though in other nations there is evidence SNS reduces symptoms
related to Irritable Bowel Syndrome (IBS). In our experience using SNS to
treat FI in patients suffering from IBS, we have observed that SNS improves
not only FI but also the concomitant IBS symptoms. We performed a review
of our records to validate these initial observations.
Methods: We performed a retrospective review of our experience thus
far with SNS, totaling 46 patients. We primarily reviewed the 41 patients
who proceeded to stage II implantation via an IRB-approved review of the
electronic medical records (EMR) and follow-up phone surveys. Our primary
endpoint is improvement of IBS symptoms. Our secondary end-points are
complications associated with the procedure and improvement in FI symptoms. The data for the IBS symptoms was collected at the initial consultation and later via post-operative phone interview. In addition, the phone
interview and EMR review is used to assess their response to FI symptoms
and any complications arising from the procedure.
Results: Of the 41 patients who proceeded to stage II, we were able to
reach 27 via phone survey for long-term follow-up. 18 patients had significant IBS symptoms and an existing IBS diagnosis prior to their SNS procedure. 15 of these patients (83%) reported significant improvement in their
IBS symptoms after SNS implantation. The average follow-up for these
patients is 134 days. Secondarily, the average Wexner FI scores dropped
from 14 pre-operatively to 6 in short-term follow-up and then to 3.5 in follow-up greater than 6 months. 6 of 41 patients had minor complications
and 1 patient required removal and re-implantation of the device due to
infection.
Conclusions: SNS has become a very powerful tool in treating patients
with FI. Our experience suggests that there is a broader application for this
modality, showing a very strong benefit of SNS in patients with a combination of FI and significant IBS symptoms. Further studies need to be performed to evaluate SNS as a treatment of IBS, both with and without coexisting FI.
OR = Odds ratio for ChloraPrep versus DuraPrep.
b
OR = Odds ratio for non-alcohol versus alcohol based skin preparations.
c
95% CI = 95% confidence interval.
P32
A SINGLE INSTITUTIONAL REVIEW OF THE COMPRESSION ANASTOMOSIS RING DEVICE IN COLORECTAL ANASTOMOSIS.
J. M. Charbel, C. Ferguson and J. M. Hain General Surgery, Henry Ford
Health System, Detroit, MI.
Purpose: Purpose: Anastomotic leaks are a dreaded complication in colorectal surgery. New methods to reduce associated risks are continually
being explored. The compression ring anastomotic device has become a
recent alternative to standard stapled anastomoses. This study is a single
institution review of the compression ring anastomoses from a communitybased hospital.
Methods: Methods: We performed a retrospective analysis of patients
undergoing a sigmoid, left colectomy or reversal of end colostomy with end
to end rectal anastomosis using the compression ring. The procedures were
performed by four board certified colorectal surgeons and one general surgeon from October 2009 to April 2013. All morbidities related to the anastomosis were recorded. The endpoints evaluated include leak, intra-abdominal abscess, stricture, and length of stay.
Results: Results: A population of 113 patients underwent colonic resection with creation of a primary anastomosis utilizing the NITI compression
ring device. Ten of the 113 subjects were excluded due to level of rectal
anastomosis. No protecting ileostomies were performed. The results
demonstrated 3.88% (n=4) anastomotic leak, 0.97% (n=1) intra-abdominal
abscess formation, and 0.97% (n=1) stricture formation. The average length
of stay was 4.6 days.
Conclusions: Conclusion: The anastomotic leak rate reported at a single community-based institution using the compression ring for colorectal
anastomoses is acceptable and compares favorably to the current literature. We found the compression ring to be a safe and feasible alternative to
stapled anastomoses.
P34
DETECTION OF OCCULT FECAL INCONTINENCE WITH A BOWEL CONTROL SURVEY.
F. Quinteros, B. Martin, H. Schoonyoung, G. Nassif, S. Atallah, M. Albert,
S. LaRach and T. DeBeche-Adams Colon and Rectal Surgery, Florida
Hospital, Orlando, FL.
Purpose: Fecal incontinence (FI) is defined as the uncontrolled loss of
gas or liquid and solid feces from the bowel. The true prevalence of FI is
under-reported and patients can suffer for years before seeking help due
to embarrassment or lack of information about treatment options. A Bowel
Control Survey has been introduced recently as part of our patient-intake
forms to assist as an effective and reliable tool in the diagnosis of occult
fecal incontinence.
Methods: We conducted a retrospective study to assess the efficiency
of the Bowel Control Survey (BCS) in detecting patients with occult FI and
to record epidemiologic data about FI. The survey was handed out to all
patients that came to the office and reviewed over a two month period.
Exclusion criteria included those with a stoma and those whose chief complaint was fecal incontinence. The aim of this study was to detect occult
fecal incontinence. The survey had 7 questions addressing incontinence
symptoms, including one asking if they wished to discuss FI with their surgeon. We recorded the interventions and diagnostic workup for patients
who answered positively to this question. Additionally, we analyzed the
47
Abstracts
same data points in new and established patients coming to the office for
fecal incontinence as their main complaint during the study period.
Results: We collected 327 surveys during the study period and found
110 patients with chief complaints other than FI wishing to know more
about their bowel control symptoms (33.6%). Out of this subgroup, 14
patients were diagnosed with fecal incontinence (4.2%). During the same
period, 16 patients presented to the office for fecal incontinence as their
chief complaint (4.9%) and 15 patients were a follow up for fecal incontinence (4.5%). Patients newly diagnosed through the survey represented an
increase of 85% in the number of new FI patients seen as an outpatient.
Conclusions: The Bowel Control Survey is a useful tool for capturing
symptoms of FI, leading to the diagnosis and appropriate workup for these
patients. This form can easily be handed out to patients in every colorectal
practice, and warrants consideration in primary care, gastroenterology, and
obstetrics and gynecology practices as well.
P36
THE EFFICACY OF FIBRIN SEALANT IN PREVENTING ANASTOMOTIC
LEAKS.
M. Viamonte1, H. J. Lujan2 and M. Zeichen3 1Surgery, Jackson Memorial
Hospital, Miami, FL, 2Surgery, Jackson Memorial Hospital, Miami, FL and
3
Surgery, Jackson Memorial Hospital, Miami, FL.
P35
Purpose: Anastomotic leak is one of the most feared complications of
colonic surgery.The purpose of our study was to review a large experience
using a fibrin sealant to reinforce colonic anastomoses,and evaluate it’s efficacy in preventing anastomotic leaks.
Methods: We performed a retrospective case series review of 425
patients that underwent colon resection with primary anastomosis in a single specialty, colon and rectal surgery practice. We calculated leak rates
according to anastomosis location (low or high risk), disease state (benign
or malignant), and surgical procedure (laparoscopic, open, or robotic). We
compared our leak rates to those published in the literature. An anastomotic leak was defined as a positive CT Scan and/or clinical findings suggestive of leak. All anastomoses were tested intraoperatively. Conversions
and diverted patients were also assessed. Postoperative complications were
also recorded.
Results: Overall, colonic anastomoses leak rates reported in the literature range from 0-20%. High risk colorectal anastomoses leak rates range
from 12.7-20%. The overall leak rate for study of 425 patients was 1.41%.
High risk anastomoses leaks were 3.23%. Laparoscopic 364 (5 leaks 1.37%),
open 30 (1 leak 3.33%), robotic 31 (0 leaks). Overall postoperative complications rate were 18.35% of which abscess (3.53%), wound infections
(3.53%) and bleeding (2.82%) were the most common. When comparing
our leak rates to published data there were two studies that showed a statistical difference in overall leak rates using a 2-sided Chi-squared test with
1 degree of freedom (Monson and Kockerling). Although our overall and
high risk anastomotic leak rate was lower than most published data the p
values did not show significance due to the relatively small number of
patients in subcategories (level of anastomosis).
Conclusions: Fibrin sealants may reduce anastomotic leak rates. Our
favorable results suggest the need for larger, prospective, randomized trials
to confirm these findings.
TEMPORARY SACRAL NERVE STIMULATION IN PATIENTS WITH FECAL
INCONTINENCE DUE TO RECTAL HYPOSENSITIVITY.
K. Madbouly and A. Hussein Department of Surgery, University of
Alexandria, Alexandria, Egypt.
Purpose: To assess the therapeutic effect of temporary sacral nerve
stimulation (SNS) on patients with fecal incontinence (FI) due to rectal
hyposensitivity (RH).
Methods: Prospective randomized trial included 24 patients with FI due
to RH. Patients were randomized to either intermittent SNS (ISNS) (2 weeks
ON followed by one week OFF and finally one week ON) or continuous SNS
(CSNS). Patients were blinded to the stimulation sequence. SNS was performed unilaterally by a stimulating electrode inserted into S3 sacral foramen under local anesthesia for 4 weeks. Before SNS (PRE) and during each
crossover period we recorded first constant sensation (FS), defecatory
desire volume (DDV), maximum tolerated volume (MTV), anal pressures,
bowel diaries, Wexner incontinence score (WS) and FI quality of life score
(FIQOL) (embarrassment & depression).
Results: Study included 20 males with median age of 43 years. In both
groups there were significant decrease in DDV and MTV during ON period
(Table 1) while this decrease was not significant during OFF period in ISNS
(DDV Pre: mean 270 ml vs. OFF 241 ml; p=0.18 and MTV Pre: mean 357 ml
vs. OFF 331ml; p=0.09). DDV became normal during ON period in 11 vs. 10
patients in MTV. FS was not significantly affected by SNS (table 1). FI significantly improved during ON period in 22 patients (91%); (FI episodes from
mean of 5.3 to 1.1/week; P< 0.0001 and WS improved from mean of 13.3 to
1.7; P<0.0001). WS was zero in 14 patients during ON period while no significant change was reported during the OFF period in ISNS (Pre mean 13.3
vs. OFF 11.5; p= 0.08). Resting anal pressure and maximal squeeze pressure
significantly increased during ON period however during the OFF period
(table 1). There was significant improvement in studied scales of FIQOL during the ON period only (Image).
Conclusions: SNS can be effective in restoring continence and improving QOL in patients with FI due to RH. Improved continence might be
related to improvement of rectal sensation and/or increase of anal pressures. Although placebo effect of SNS could be rejected by the ISNS results,
yet the washout effect of SNS on the continence score, DDV and MTV after
cessation of stimulation needs to be explained.
P37
EXPLORING THE POTENTIAL OF FULL THICKNESS LOCAL EXCISION
FOR STAGE II AND III RECTAL CANCER FOLLOWING NEOADJUVANT
THERAPY: A 29-YEAR EXPERIENCE.
G. Montenegro, J. Frenkel, M. Shields, G. Marks and J. Marks Colon and
Rectal Surgery, Lankenau Medical Center, Wynnewood, PA.
Purpose: Downstaging of rectal cancer utilizing preoperative chemoradiation has led to major changes in patient management. While local excision (LE) has been utilized for stage I cancers, what is the role of LE for stage
II and III rectal cancers after a favorable response to neoadjuvant therapy?
We present our findings here.
Methods: A retrospective review of a prospectively maintained database of 1,093 rectal cancers treated from 1985-2013 was performed to find
all Stage II/III primary rectal cancers treated for cure with neoadjuvant radiation and LE. Stage II or III patients who on exam had tumor regression to
the rectal wall and size <3.0cm were offered local excision. Patients with
Table 1: Effect of SNS on rectal sensory thresholds and anal pressures
# indicates repeated measure ANOVA
48
Abstracts
ypT3 cancer were recommended for radical surgery. Oncologic outcomes,
morbidity and mortality were evaluated. Statistical comparisons using Student’s t-Test and survival rates were calculated using Kaplan Meier 5yr survival (KM5YAS).
Results: 66 patients were identified, 45 men, mean age 68.8yo (47-92).
On presentation, 57 Stage II and 9 Stage III, mean inferior level relative to
the anorectal ring was 2.4cm (-1.0 to 10.0), 77% of patients had cancers <
4.0cm. Mean radiation dose 5267cGy. Procedures performed: transanal
(N=16); transphincteric (N=6); transsacral (N=3), TEM (N=41). ypT stages: 0
= 23, 1 = 13; 2 = 23; 3 = 7. Chemotherapy concurrently used in 39 patients.
There was no perioperative mortality. Morbidity was 35% (wound separation 29%). With mean f/u of 62 months, overall local recurrence (LR) was
9% with survival of 78% (KM5YAS) and DFS of 66%. LR was 15% in the distal 2cm (6/39) compared to 0 in the cancers over 2cm (0/27, p=0.03). LR
with TEM was 2.4% (1/41) vs. non TEM 20% (5/25, p=0.02). LR with preoperative chemoradiation was 2.6% (1/39) vs. radiation alone 18.5% (5/27,
p=0.03).
Conclusions: LE after neoadjuvant therapy in Stage II and III rectal cancer patients has better results with chemoradiation than radiation alone
and TEM is a superior operative approach. Cancers in the distal rectum have
poorer outcome. This experience shows good oncologic outcomes with
selective application and argues for an expanded examination of this
approach.
P39
SINGLE INSTITUTE COMPARATIVE STUDY OF LONG-TERM ONCOLOGIC OUTCOMES TOTAL MESORECTAL EXCISION FOR RECTAL CANCER: OPEN SURGERY VERSUS MINIMALLY INVASIVE SURGERY. A RETROSPECTIVE COHORT STUDY.
M. Cho, S. Baek, H. Hur, B. Min, S. Baik and N. Kim Department of Surgery,
Yonsei university college of medicine, Seoul, Democratic People’s Republic
of Korea.
Purpose: OUR AIM IN THIS STUDY WAS TO COMPARE THE LONG-TERM
ONCOLOGIC OUTCOMES OF PATIENTS WHO UNDERWENT MINIMALLY INVASIVE SURGERY (MIS) AND THOSE WHO UNDERWENT OPEN SURGERY FOR
RECTAL CANCER.
Methods: WE PERFORMED A RETROSPECTIVE REVIEW OF PROSPECTIVELY-COLLECTED RECORDS FROM THE DATABASE OF THE DEPARTMENT
OF SURGERY, YONSEI UNIVERSITY HEALTH SYSTEM, SEOUL, KOREA, TO COMPARE THE LONG-TERM ONCOLOGIC OUTCOMES OF PATIENTS WHO UNDERWENT CURATIVE MINIMALLY INVASIVE VERSUS THOSE WHO UNDERWENT
OPEN SURGERY FOR RECTAL CANCER FROM JANUARY 2003 TO JUNE 2008.
AMONG 970 PATIENTS, WE IDENTIFIED A GROUP OF 211 PATIENTS WHO
UNDERWENT MINIMALLY INVASIVE SURGERY (MIS) FOR RECTAL CANCER;
THIS GROUP WAS MATCHED 1:2 WITH A GROUP OF 422 OPEN SURGERY
GROUP BY USING PROPENSITY SCORE MATCHING. THE MATCHING VARIABLES ARE INCLUDED AGE, SEX, BMI (BODY MASS INDEX), TUMOR LOCATION, OPERATIVE METHOD (WITH OR WITHOUT SPHINCTER PRESERVATION),
PREOPERATIVE CHEMORADIATION TREATMENT, ADJUVANT TREATMENT
AND PATHOLOGIC TNM STAGING.
Results: A TOTAL OF 633 PATIENTS (N=211 MIS, N=422 OPEN) WERE
ASSESSED. MEDIAN FOLLOW-UP WAS 64.4 MONTHS (RANGE 41.1 – 98.4).
PATIENT CHARACTERISTICS DID NOT DIFFER BETWEEN THE TWO GROUPS.
MIS WAS ASSOCIATED WITH A SHORTER HOSPITAL STAY (11.9 VS. 15.8 DAYS,
P < 0.001). POSTOPERATIVE COMPLICATION RATES DID NOT DIFFER
BETWEEN THE TWO GROUPS (MIS 7.6% VS. OPEN 10.0%, P = 0.330). CRM
INVOLVEMENT RATE DID NOT DIFFER BETWEEN THE TWO GROUPS (MIS
6.2% VS. OPEN 4.7%). THE 5-YEAR OVERALL SURVIVAL (OS), DISEASE-FREE
SURVIVAL (DFS), AND LOCAL RECURRENCE (LR) RATES WERE NOT SIGNIFICANTLY DIFFERENT BETWEEN THE TWO GROUPS (OS, 88.4% MIS, 85.3%
OPEN, P = 0.231; DFS, 80.7% MIS, 78.4% OPEN, P = 0.735; LR RATE, 5.7% MIS,
5.1% OPEN, P = 0.950).
Conclusions: WE FOUND NO SIGNIFICANT DIFFERENCES IN LONG-TERM
ONCOLOGIC OUTCOMES BETWEEN THE OPEN GROUP AND MIS GROUP. WE
SUGGEST THAT MIS IS A SAFE AND FEASIBLE TECHNIQUE WITHOUT
INCREASING OF SERIOUS COMPLICATIONS. OUR RESULTS MAY PROVIDE
DIRECTION FOR THE FURTHER IMPROVEMENT OF TREATMENT FOR RECTAL
CANCER.
P38
CAN MRI PREDICT PATHOLOGIC RESPONSE OF RECTAL CANCER
AFTER NEOADJUVANT TREATMENT?
C. Nahas, S. Nahas, C. Ortega, R. Azambuja, H. Joaquim, C. Marques,
U. Ribeiro, L. Bustamante L., P. Hoff and I. Cecconello Cancer Institute of
University of São Paulo Medical School, Sao Paulo, Brazil.
Purpose: To evaluate the ability of MRI to predict pathologic response
and involvement of circumferential margins in patients with rectal cancer
treated by neoadjuvant chemoradiation therapy (CRT).
Methods: In one year period, 134 consecutive patients with locally
advanced low or mid rectal underwent neoadjuvant CRT followed by total
mesorectal excision (TME). Chemotherapy consisted of 5-FU and leucovorin
IV bolus on days 1 to 5 concomitant to radiation in weeks 1 and 5. Total
dose of pelvic radiation was 5040 Gys given in 28 sessions. All patients were
staged and re-staged 8 weeks after completion of CRT by MRI of the pelvis.
The images were analyzed by 2 experienced radiologists. All patients had
curative or potentially curative TME. Restaging MRI results for T stage, N
stage, involvement of circumferential margin, and complete response were
compared to histopathological examination of the specimens. Agreement
between measures was estimated by weighted kappa statistics, and estimates of sensitivity, specificity, and predictive values were calculated.
Results: Ninety-five patients were included in the analyses (39 patients
were excluded because of any reason that caused significant delay on
restaging or surgery). Mean interval time for restaging was 8.3 (5.9-10.6)
weeks and mean interval time for surgery was 12.0 (10.9-13.9) weeks. MRI
showed an accuracy of 52% for yT stage (kappa agreement = 0.35). For yN
stage, MRI showed an accuracy of 70%, sensibility of 66%, and specificity of
71% (kappa agreement = 0.39). For detection of positive circumferential
margin, accuracy was 77%, sensibility was 74%, and specificity was 78%
(kappa agreement = 0.42). For complete pathologic response, accuracy was
82%, and specificity 99%, however sensibility was only 11% (positive predictive value 67%, negative predictive value 83%, and kappa agreement of
0.14).
Conclusions: Post CRT MRI showed fair to moderate concordance with
pathologic T stage, N stage, and circumferential margin involvement.
Despite the low sensibility to identify absence of tumor after neoadjuvant
CRT, a positive finding on MRI was strongly associated with persistence of
disease.
P40
NEOADJUVANT THERAPY DOES NOT AFFECT LYMPH NODE RATIO IN
RECTAL CANCER.
K. Chang1, N. P. Kelly1, G. P. Duff1, E. T. Condon1, D. Waldron1 and
J. C. Coffey2 1Department of Surgery, Limerick University Hospital,
Limerick, Ireland and 24i Centre for Interventions in Infection,
Inflammation and Immunity, Graduate Entry Medical School, University of
Limerick, Limerick, Ireland.
Purpose: Lymph-node ratio (LNR) is an emerging prognostic tool for
rectal cancer. Previous studies have demonstrated cut off values above
which survival is adversely impacted. Previous study by our group identified different LNR cut off values in colonic and rectal cancers. The effect of
neoadjuvant therapy on LNR and its prognostic values has not been evaluated. This study aims to evaluate the impact of neoadjuvant therapy on the
prognostic value of LNR.
Methods: Consecutive patients who underwent curative rectal cancer
resections from 2007-2010 were reviewed. LNR was stratified into five subgroups of 0, 0.01-0.17, 0.18-0.41, 0.42-0.69 and 0.7-1.0. The effect of neoad-
49
Abstracts
juvant therapy on lymph node retrieval, LNR, locoregional (LR) and systemic
recurrence (SR), disease-free (DFS) and overall survival (OS) was compared
between patients who did (Neoadjuvant) and did not (Surgery Alone)
receive neoadjuvant therapy. Chi square and binary logistic regression were
used to compare categorical data. Log rank test was used to compare survival curves.
Results: Neoadjuvant and Surgery Alone groups were comparable in
gender, age and tumor stage. There were fewer lymph nodes retrieved in
the Neoadjuvant group (p<0.01). However, LNR remained similar in both
groups (p=0.36). There was no statistical difference in the DFS and OS of
the Neoadjuvant and Surgery Alone groups at the various LNR cut off values in patients with AJCC Stage 3 tumors.
Conclusions: This is the first study to compare the prognosis of LNR in
patients who underwent neoadjuvant therapy and patients who underwent surgery alone. It shows that there is a preservation of the prognostic
significance of LNR in spite of the use of neoadjuvant therapy and potential reduced lymph node retrieval. This implies that LNR is more reliable in
patient stratification compared with lymph nodes retrieved.
P42
ANAL CONTINENCE AND QUALITY OF LIFE ONE YEAR AFTER PERIANAL FISTULA SURGERY.
S. A. Garcia Botello, M. Garcés Albir, A. Espí Macias, V. Pla Martí, D. Moro,
J. Martí Arevalo, A. Sanahuja and J. Ortega Serrano Colorectal Unit,
Department of General and Digestive Surgery, Hospital Clinico
Universitario, Valencia, Spain.
Purpose: Anal continence scores and quality of life (QOL) assessments
in patients with perianal pathology give useful information which helps
predict the impact of the disease and possible treatments on patient’s physical, emotional and social condition. The objective is to correlate the results
of perianal fistula surgery with incontinence severity and QOL one year
postoperatively.
Methods: A prospective, consecutive observational study was performed between December 2008 and December 2010. All patients were
diagnosed with perianal fistula and were treated by fistulotomy or rectal
mucosal advancement flap (RMAF). Patients were assessed preoperatively,
8 weeks postoperatively, 6 months and 1 year. Anal continence was
assessed with the Jorge and Wexner score and QOL with the SF-36 and
Fecal Incontinence QOL (FIQOL) scores.
Results: 70 patients were initially included in the study, 7 were lost to
follow-up. Finally a total of 63 patients completed the study (53 fistulotomies and 16 RMAF). 16 patients had deterioration in anal continence, half
of which already had some degree of incontinence preoperatively and 80%
had a score below 4 on the Jorge and Wexner scale. There was an overall
deterioration in all aspects of FIQOL after surgery which slowly recovered,
to slightly worse than preoperative values, one year after surgery. When the
various aspects of the SF-36 QOL score were analyzed, there was deterioration in the immediate postoperative period which improved up to the initial preoperative values at the yearly follow-up. For the fistulotomy group
of patients there is a more evident improvement in the body pain and emotional role scores with a significant difference one year postoperatively. One
patient from the fistulotomy group and three from the RMAF group had a
fistula recurrence.
Conclusions: Patients have practically recovered their quality of life and
the recurrence rate is low (6%) at yearly follow-up. The disturbances in anal
continence (26%) have been mild and of low impact on QOL.
P41
ENDORECTAL ADVANCEMENT FLAPS FOR ANORECTAL FISTULA IN
CROHN’S DISEASE IN THE ERA OF IMMUNE THERAPY.
S. Eisenstein, A. Ky, S. Kim, S. Khaitov and R. Steinhagen Colorectal
Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
Purpose: Fistulizing perianal Crohn’s Disease (CD) is difficult to treat.
Seton drainage has been the initial treatment of choice, and select patients
may undergo secondary repair, including endorectal advancement flaps
(ERAFs), LIFT procedures, or placement of biologic plugs. ERAF has been
moderately effective in CD, with a 64% success rate in a recent meta-analysis. The advent of thiopurine and anti-TNF therapy for CD has improved our
ability to treat perianal CD. We employed the ERAF as our secondary treatment and sought to evaluate its efficacy in patients with CD in the era of
immune therapy.
Methods: The surgical database of 4 colorectal surgeons was queried
for patients who underwent ERAF from 2007-13. Charts were retrospectively analyzed. Significance was determined using student’s T-Test or Chisquared analysis.
Results: 363 ERAFs were performed over 6 years, 25 (6.9%) in 24
patients with perianal CD. 19 (76%) were successful without recurrence, and
of the 6 treatment failures, fistulae ultimately closed in 5 (83%) including
one successful repeat ERAF. Therefore, the overall healing rate was 96%. 17
(71%) patients were taking either an anti-TNF or thiopurine drugs, however
both patients who recurred and who did not recur were equally likely to be
on these medications (83% v 67%, p=0.44). Patients whose fistulae did not
recur were on these medications on average of 99 more days, but this was
not significant (p=0.20). Both groups had similar numbers of procedures
prior to their ERAF, however recurrent patients trended towards having significantly more setons placed prior to ERAF (2.25 v 1.43, p=0.06).
Conclusions: To our knowledge, this is the largest series of patients
with CD undergoing ERAF. ERAF is an effective treatment for patients with
perianal CD. While it is difficult to predict which patients will undergo successful surgery, the addition of immune modulation has improved outcomes. The inability to demonstrate significant benefit for those on
immune therapy is likely the result of our small sample size. It does appear
that patients who are on immune modulation longer will do better, and
thus, delaying surgical treatment until patients are medically optimized
may prove prudent.
P43
PROLONGED OPIOID-SPARING PAIN CONTROL AFTER HEMORRHOIDECTOMY WITH LIPOSOMAL BUPIVICAINE (EXPAREL®).
A. B. Jetmore1 and D. Hagen2 1Midwest Hemorrhoid Treatment Center,
Leawood, KS and 2Department of Anesthesiology, Overland Park Surgery
Center, Lenexa, KS.
Purpose: To study duration of pain control, narcotic use, and patient
satisfaction after hemorrhoidectomy using liposomal bupivicaine
(EXPAREL®).
Methods: One surgeon performed 95 ambulatory hemorrhoidectomies,
with 20 cc (266 mg) liposomal bupivicaine (EXPAREL®) injected as an anal
block with no postoperative IV narcotic use. Interviews assessed postop
pain. Data: a) onset of first pain b) time to first oral narcotic c) number of
pain pills taken d) # of refills e) complications. Pain scores (0-10 scale)(0 =
no pain 10 = worst pain imaginable) recorded for 12, 24, 48 and 72 hrs
postop. Patients rated pain control satisfaction on a scale: 0 = not satisfied
at all 4 = perfectly satisfied.
Results: 95 pts had an average 2.7 hemorrhoids excised, 24% for acute
thrombosis or 4th degree. Avg onset of pain was 36 hrs (median 24hr). First
narcotic taken - avg 38 hrs (median 30hr). Median 8 pills were taken. 13
patients (14%) took NO postop narcotic. 88% required no Rx refills. Pain
scores: 12 hr 1.86, 24 hr 3.53, 48 hr 4.66, 72 hr 4.92. Patients scoring their
pain in the range 0 to 3: 12 hr 78%, 24 hr 51%, 48 hr 34%, 72 hr 35%. Pt satisfaction scores were: at 12 hr (3.49)(86% perfectly or very satisfied), at 24
hr (2.91)(71% perfectly or very satisfied), at 48 hr (2.62)(58% perfectly or
50
Abstracts
very satisfied), at 72 hr (2.52)(49% perfectly or very satisfied). Overall satisfaction score was 3.45 (75% perfectly or very satisfied). No urinary retention, cardiac toxicity or major adverse drug reaction to EXPAREL®, occurred.
Reoperations for: bleeding (1) fecal disimpaction (1) Three patients (3.2%)
had readmission at POD 4, 6, and 7 for constipation and pain. No patient
required readmission in <96 hours.
Conclusions: Injection of liposomal bupivicaine (EXPAREL®,) safely facilitated ambulatory hemorrhoidectomy, even in acute cases, eliminated need
for IV narcotics, and both delayed and minimized opioid use. Patient assessments show that EXPAREL® provided prolonged analgesia after hemorrhoidectomy and high satisfaction with pain control.
this study is to quantify the extent of the lesion to the internal anal sphincter (IAS) after RMAF using 3D-EAUS and correlate the result with incontinence and QOL scores.
Methods: A prospective observational study on consecutive patients
undergoing RMAF for high transphincteric fistula between December 2008
and December 2010. All patients were assessed pre and postoperatively by
the same member of the colorectal unit by physical examination, 3D-EAUS,
Jorge & Wexner Incontinence score and SF-36 and Fecal Incontinence QOL
(FIQOL) score. All tests except the 3DEAUS were repeated 6 months and 1
year after surgery.
Results: A total of 16 patients, 9 male and 7 female with a median age
of 44 years (range, 25-70) were included. Preoperative 3D-EAUS measurements of the anal sphincters are shown in Table 1. There was a significant
deterioration in anal continence between pre and postoperative values
(p=0.014) and after 6 month follow-up (p=0.005). However, 1 year postoperatively, only 3 patients showed a deterioration with no significant differences with the preoperative results (p>0.05). The FIQOL score showed a
deterioration in all aspects after surgery which slowly recovered to suboptimal levels 1 year later. The SF-36 QOL showed a deterioration in all areas
which fully recovered to initial values except in the mental health scale.
There were 3 fistula recurrences within this time frame (18.75%).
Conclusions: The majority of patients (87.5%) showed division of the
IAS over 66% after surgery as seen by 3D-EAUS. These patients showed a
mild deterioration in continence without any changes in the QOL parameters studied.
P44
MRI AND THREE-DIMENSIONAL ENDOANAL ULTRASONOGRAPHY
VERSUS FISTULOSCOPY IN THE DIAGNOSIS OF PERIANAL FISTULAS:
A COMPARATIVE AND PRELIMINARY STUDY.
A. Stazi1, C. Ghini1, G. Giarratano1, M. Estienne3, L. Mori2, M. Mazzi1,
C. Toscana1 and P. Meinero2 1General Surgery and Pelvic Center, CdC
Madonna delle Grazie, Velletri (RM), Italy, 2General Surgery, Asl 4
Chiavarese, Genova, Italy and 3Radiologic Unit, ASl 4 Chiavarese, Genova,
Italy.
Purpose: Video assisted anal fistula treatment (VAAFT) radically
changed the diagnostic and therapeutic approach to complex fistulas. The
purpose of this study is to evaluate the usefulness and effectiveness of the
simple diagnostic fistuloscopy comparing to endoanal ultrasonography
(EAUS) with the use of hydrogen peroxide (HPUS) and the MRI in patients
with simple and complex anal fistulas
Methods: From November 2011 to March 2013 we considered 33
patients (19 M and 14 F) affected by anal fistula. MRI examination and TDEAUS reconstruction with hydrogen peroxide enhancement (HPUS), were
performed in all patients during pre-operative time (Timing EAUS-HPUSMRI/ Fistuloscopy: 1-26 weeks) . The fistuloscopy was performed under
sedation at the time of surgical treatment
Results: The 33% of patients had a simple trans-sphincteric fistula, the
51.5% had a trans-sphincteric complex fistula, the 12,1% had a suprasphincteric fistula and one patient had a extra-sphincteric fistula. Diagnostic accuracy of fistuloscopy is better than that of MRI and TD-HPUS in the
diagnosis of secundary tracks (100% vs. 91.3% and 69.5% respectively) and
in the identification of internal openings (100 vs 81.8% and 75.5% respectively). In the diagnosis of abscesses the diagnostic accuracy of MRI is similar to that of fistuloscopy (100% in both cases).
Conclusions: Fistuloscopy, better than the MRI and the HPUS, allows
the assessment excellently all the basic features of a fistulas track. In all
patients examined the diagnostic efficacy of fistuloscopy allowed to always
highlight the presence of secondary tracks, of abscesses cavity, and always
identify with precision the position of the internal opening of the fistulas.
All of this information, plus obtained in real time and not in the pre-operative timing, allow the surgeon to immediately choose the type of surgical
strategy best suited to any situation, and this is especially crucial in patients
with recurrent disease or complex fistulas.
a. Preoperative 3D-EAUS measurements of the IAS and the EAS in patients
undergoing RMAF b. Level of the defect of the IAS and deterioration in anal
continence.
a: *mediana (rango)
b: *p>0.05
**Low: Inferior third of the IAS; Mid: Middle third of the IAS; High: Superior third
of the IAS.
P46
PIT PICKING SURGERY FOR PILONIDAL DISEASE: MID-TERM RESULTS.
I. Iesalnieks and S. Deimel Marienhospital Gelsenkirchen, Gelsenkirchen,
Germany.
Purpose: Minimally invasive procedures are increasingly used to treat
pilonidal disease. However, the mid- and long-term results have not been
evaluated extensively yet.
Methods: All patients of present study underwent pit picking surgery
as described by J. Bascom 1980. The surgery was performed under local
anesthesia. The technique of the procedure was: all primary pits in the midline were removed by excising a border of skin of <1 mm. An incision of 1
cm parallel to one side of the cleft opened the chronic abscess cavity. No
specific postoperative wound care was given. “Disease recurrence” was
defined as any need for further surgery.
Results: One hundred-and-fifty-two patients (126 males) underwent
157 Pit picking surgeries between 6/2007 and 11/2010. Follow-up information was available after 151 surgeries (95%), follow-up time was median 28
months. Thirty seven patients (25 %) developed disease recurrence; eight
more patients (5%) remained asymptomatic after second pit picking proce-
P45
RECTAL ADVANCEMENT FLAPS FOR THE TREATMENT OF
TRANSSPHINCTERIC PERIANAL FISTULAS: A THREE-DIMENSIONAL
ENDOANAL ULTRASOUND AND QUALITY OF LIFE ASSESSMENT.
S. A. Garcia Botello, M. Garcés Albir, A. Espí Macias, D. Moro, J. Martí
Arevalo, V. Pla Martí, A. Sanahuja and J. Ortega Serrano Colorectal Unit,
Department of General and Digestive Surgery, Hospital Clinico
Universitario, Valencia, Spain.
Purpose: Rectal mucosal advancement flap (RMAF) is a sphincter preserving technique for the treatment of perianal fistulas. Postoperative continence and recurrence results are variable in the literature. The objetive of
51
Abstracts
dure. By the multivariate analysis, smoking (Odds Ratio 2.9) and occurrence
of an abscess during the disease (OR 4.7) were statistically significantly associated with the disease recurrence after “Pit picking” surgery.
Conclusions: About three quarters of patients will benefit from minimally invasive pit picking surgery.
patients were excluded, three having synchronous laparoscopic right hemicolectomy and one patient having chronic urinary retention. Standardized
retrospective chart review was performed. The primary outcome was POUR
defined as the incapacity to void spontaneously in the first six hours after
TEM requiring catheterization or Foley insertion. Following factors were
studied to examine their impact on POUR: sex, age, comorbidities, tumor
height from anal margin, tumor localization, deficit closure, tumor diameter, duration of surgery, blood lost, intravenous fluid administration, previous pelvic surgery, benign prostatic hypertrophy history and the utilization
of intra-operative Foley catheter.
Results: A total of 174 patients were included in this study. 139 were
day surgeries (80%). 57% were male and mean age was 68 years. 55% were
located in the mid rectum, mean diameter was 4,36cm, tumor were uniformly located in the four quadrants. All lesions were removed using fullthickness excision (143 adenomas, 26 adenocarcinomas, 5 neuro-endocrine
tumors). Intra-operative Foley were used in 86% of patients. 33 patients
(19%) had POUR. None of the factors evaluated was individually predictor
of POUR. Nine patients with POUR required admission while the others
were discharge with a Foley catheter removed between 2 to 10 day. No
patient required prolonged catheter utilization.
Conclusions: The rate of POUR in our series appears to be higher than
previously reported. However 80% of the TEM procedures were planned as
a day surgery in our series, which represents a greater proportion in relation to other series.POUR is limiting day surgery procedures. Further studies are needed to identify patients at risk and implement targeted intervention to reduce the incidence of this complication.
P47
FIVE-YEAR SINGLE-CENTER PROSPECTIVE SEARCH FOR ANAL
INTRAEPITHELIAL NEOPLASIA AND HUMAN PAPILLOMAVIRUS INFECTION IN ALL HEMORRHOIDECTOMY AND FISSURECTOMY SURGICAL
SAMPLES.
I. Etienney1, J. Fléjou2, A. Si-Mohamed3, N. Mourra2, P. Bauer1 and
T. Proctological Prospective Diaconesses Group1 1Proctology, Groupe
Hospitalier Diaconesses Croix Saint-Simon, Paris, France, 2Pathology,
Saint-Antoine Hospital, Paris, France and 3Virology, European Georges
Pompidou Hospital, Paris, France.
Purpose: Whether or not all macroscopically normal hemorrhoidectomy surgical samples should be sent to pathology remains a topic of
debate. The purpose of this prospective study was to determine the prevalence of anal intraepithelial neoplasia (AIN) on macroscopically normal
operative specimens from hemorroidectomy and fissurectomy procedures.
Methods: A pathology examination was ordered for all surgical samples from procedures performed from October 1, 2005 to September 30,
2010.
Results: Among the 2997 procedures, 133 (4.4%) patients (mean age
47.4 years, range 24-73), including 19 HIV-positive patients (14%), had
macroscopically normal specimens. None of the patients had an overt history of anal condyloma; two women had had a conization. At the pathology examination, the 133 specimens presented unifocal (n=99; 74.4%) or
multifocal (n=34; 25.6%) lesions. Staging was AIN1 (n=65, 49%), AIN2 (n=40,
30%), and AIN3 (n=28, 21%); p16 was positive in 93 (70%), increasingly with
AIN stage. The overall prevalence was thus 2.17% low-grade lesions (AIN1)
and 2.27% high-grade lesions (AIN2-3). The samples for 132 patients were
read again by a second pathologist who confirmed the diagnosis of highgrade AIN in 96% (65/68) and the diagnosis of low-grade AIN in only 30%
(19/64). HPV genotyping tests were positive for 75 specimens (56.4%) with
HPV16 in 33/75 (44%); 65 patients (86%) had a high-risk genotype. Genotyping was positive in 24/27 AIN3 (89%), 30/40 AIN2 (75%) and 21/63 AIN1
(33%). Among the 36 patients whose final histology was considered normal, HPV genotyping was positive for 6 (17%). During the follow-up (20.7
months, range 0.6-73.7), one case of high-grade cervical intraepithelial neoplasia (CIN3) and one case of AIN2 15 were observed in two women. There
were no cases of anal canal invasive cancer during the follow-up.
Conclusions: This prospective single-center study showed that the
prevalence of infraclinical AIN lesions on macroscopically normal hemorrhoidectomy and fissurectomy specimens is not negligible: 4.4% at first
reading and 3.2% at second reading with 2.3% and 2.5% high-grade AIN
respectively.
P49
HEMORRHOIDS LASER PROCEDURE: MIDDLE-TERM OUTCOME IN
PATIENTS WITH II AND III DEGREE HEMORRHOIDS.
P. Giamundo, L. Esercizio, G. Fantino, M. Geraci, L. Tibaldi and M. Valente
General Surgery, Hospital Santo Spirito, Bra (CN), Italy.
Purpose: The HeLP procedure consists of a doppler-guided closure of
terminal branches of the superior rectal arteries by means of a 980nm diode
laser. The goal is achieved by reducing the arterial blood overflow into the
haemorrhoidal venous plexus with consequent resolution of hemorrhoidal
syndrome. The aim of this study was to evaluate middle-term clinical results
of this procedure in patients treated for symptomatic II and III degree haemorrhoids
Methods: 148 patients (64 Females) suffering from symptomatic II
degree (72) and III degree (76) hemorrhoids with moderate mucosal prolapse underwent the HeLP procedure. No anesthesia was required in 128
patients (86%) (light sedation or local anesthesia in the remaining). All
patients were treated as outpatients. Median follow-up was 22
months(range, 6-36). Patients were followed up at 1, 6, 12 and 24 months
postoperatively. Quality of life, pain, residual hemorrhoids, resolution of
symptoms and patients’ satisfaction were investigated. Patients who had
been treated more than 24 months before underwent a telephone interview. 15 patients were lost at longer follow-up
Results: Mean operative time was 10.5 minutes (range, 6-21). Morbidity
included: intraoperative bleeding requiring suture/ligation in 12 cases (8%),
immediate postoperative pain requiring use of iv analgesics in 10 cases
(6.7%). At 6 months, resolution of symptoms was reported in 90% of
patients (133/148). This only dropped to 84% (112/133) by a median of 22
months postoperatively. 94% of patients (134/148) returned to normal daily
activities within the 3rd postoperative day. Overall patients’ satisfaction was
reported in 86% of cases (114/133)
Conclusions: The HeLP is a novel, minimally invasive, safe, almost painless and effective procedure for symptomatic hemorrhoids. It has low morbidity and does not require anaesthesia or analgesia in most cases. The middle-term results of the current study confirm the overall satisfactory results
reported with this procedure in the short-term. It should be considered as
a viable option in the treatment of symptomatic hemorrhoids where no
associated mucopexy is required, especially when other treatments failed.
P48
POSTOPERATIVE URINARY RETENTION IS A FREQUENT COMPLICATION AFTER TEM LIMITING DAY SURGERY PROCEDURE.
A. Laliberte2, S. Drolet1, A. Lebrun2, P. Bouchard1 and A. Bouchard1
1
Centre Hospitalier Universitaire de Québec, Quebec City, QC, Canada and
2
General Surgery, Laval University, Quebec City, QC, Canada.
Purpose: Transanal endoscopic microsurgery (TEM) is performed more
and more as a day surgery procedure. Post-operative urinary retention
(POUR) remains a frequent complication limiting patient discharge. The aim
of this study is to assess the incidence and the risk factors of POUR after
TEM.
Methods: All 178 patients having resection of rectal tumor using TEM
in our center from April 2011 to September 2013 were included. Four
52
Abstracts
an issue of controversy and if required, the exact duration of bowel rest
remains unknown. Our study aims to determine if bowel rest is necessary
and if so, the ideal duration of bowel rest required for optimal patient outcomes.
Methods: A single centre retrospective cohort of patients diagnosed
with acute uncomplicated diverticulitis over a 5 year period (2007-2011)
was conducted. The primary outcome measures were acute complications
of diverticulitis and length of hospital stay (LOS). The secondary outcome
measure was recurrence of diverticulitis. The data collected was analysed
by first dividing patients into 2 groups using different cut-off durations of
bowel rest and analysed using Pearson Chi-square test (0 vs >0, ≤1 vs >1,
≤2 vs >2 and ≤3 vs >3 days). Kruskal Wallis test was then subsequently
applied to analyse multiple groups of patients according to specific days of
bowel rest (0, 1, 2, 3 and >3 days). Statistical significance was taken to be p
value <0.05.
Results: 217 patients were identified with a mean follow-up duration
of 17.1 months. 2 (0.92%) patients developed complications and 11 (5.07%)
patients had recurrence of diverticulitis. Regardless of the cut-off duration
of bowel rest, there was no statistical significance in complication or recurrence rates. There was however, significantly longer LOS when duration of
bowel rest was longer. Similar results were reproduced when analysed
according to specific days of bowel rest.
Conclusions: We conclude that bowel rest did not reduce complications or recurrence of diverticulitis. However, it inadvertently increased the
LOS. Our study supports developing evidence that the natural history of
acute uncomplicated diverticulitis is more benign than initially surmised
and that management can be less aggressive. We therefore do not recommend bowel rest in patients admitted for acute uncomplicated diverticulitis and this could possibly translate into lower healthcare cost for the institution and patient.
P50
DERMAL FLAP ADVANCEMENT COMBINED WITH CONSERVATIVE
SPHINCTEROTOMY IN THE TREATMENT OF CHRONIC ANAL FISSURE.
G. E. Theodoropoulos, V. Spiropoulos and G. Zografos Athens Medical
School, Athens, Greece.
Purpose: Lateral internal sphincterotomy (LIS) is considered the surgical treatment of choice for chronic anal fissure (CAF). Conventional LIS
(CLIS) up to the level of the dentate line may suffer as a technique due to
impaired postoperative continence. Limiting the height of the sphincterotomy up to the length of CAF or less may partially overcome continence
disturbances at the cost, though, of healing failures. Flap techniques for fissure coverage have the advantage of primary wound healing, potentially
providing better functional results and faster pain relief.
Methods: CLIS up to the dentate line (years, 2005-2008) was modified
by “tailoring” the LIS to the apex of the CAF, but never >1 cm, and by
advancing a dermal flap for coverage of the CAF (LIS+flap) following fissurectomy (years, 2009-2012). Thirty consecutive patients who underwent
“LIS+flap” were compared to 32 patients who had been previously treated
by CLIS. A modified, trapezoid-like Y-V flap from perianal skin was advanced
into the CAF base.
Results: “LIS+flap” required more operative time to be completed
(p<0.001). Pain VAS scores at the 1st POD were significantly less at the
“LIS+flap” group (p<0.01). The number of the early PODs required for the
patients’ relief of the “annoying” CAF pain was about 3 times less for the
“LIS+flap” compared to the CLIS group (p<0.001). Requirement for analgesics was less (p<0.01). “LIS+flap” related to less pain at defecation during
the first week. Objective healing was achieved faster (p<0.01) and soiling
episodes were less (p<0.05) after “LIS+Flap”. Minor incontinence episodes
persisted up to 6 months after CLIS and up to 2 months after “LIS+flap”. Two
partial flap break-downs were managed conservatively. Two recurrences at
the CLIS patients were successfully treated by the application of a dermal
flap. Long-term patients’ satisfaction rates were high for both approaches,
although a minor advantage was elicited for the combined procedure.
Conclusions: The addition of a dermal flap after “conservative” LIS
resulted in better healing and significantly less postoperative discomfort
than the isolated application of CLIS.
Table 1. Outcome analysis with Pearson Chi-square test using ≤ 1 day as the cutoff duration of bowel rest
P52
ENHANCED INTESTINAL ANASTOMOTIC HEALING WITH GELATIN
HYDROGEL SHEET INCORPORATING BASIC FIBROBLAST GROWTH
FACTOR.
K. Hirai1, Y. Tabata2, S. Hasegawa1 and Y. Sakai1 1Department of Surgery,
Kyoto University, Kyoto, Japan and 2Department of Biomaterials, Field of
Tissue Engineering, Institute for Frontier Medical Sciences, Kyoto University,
Kyoto, Japan.
Purpose: Anastomotic leakage is a common complication of intestinal
surgery. In a trial to resolve this issue, enhancement of anastomotic wound
healing was found to be promising. We have developed the controlled
release technology of basic fibroblast growth factor (bFGF) using gelatin
hydrogel sheet. The objective of this study was to investigate the effects of
this technology on intestinal anastomotic healing.
Methods: The small intestine of Wistar rats was cut, and end-to-end
anastomosis was performed. Rats were then divided into three groups;
bFGF group (anastomosis wrapped with a hydrogel sheet incorporating
bFGF n=30), PBS group (wrapped with a sheet incorporating phosphatebuffered saline solution n=30), and NT group (no additional treatment
n=30). To define the optimal bFGF dose and gelatin hydrogel sheet
biodegradability, the degradation profiles of gelatin hydrogels in vivo and
histological examinations were performed using gelatin hydrogels with various water content and bFGF concentration. The anastomotic wound healing process was evaluated by histological examinations, adhesion related
score and bursting pressure of the anastomosis.
P51
ACUTE UNCOMPLICATED DIVERTICULITIS: DURATION OF BOWEL
REST AND ITS IMPACT ON PATIENT OUTCOMES.
S. Chan, N. Teo, R. Wijaya, K. Sng and S. Tan Changi General Hospital,
Singapore, Singapore.
Purpose: The established mainstay treatment of acute uncomplicated
diverticulitis is antibiotics. Certain guidelines recommend bowel rest in
addition to antibiotics. However to date, the need for bowel rest remains
53
Abstracts
Results: We determined optimal water content of hydrogel and bFGF
dose at 96% and 30 mg / sheet. Application of bFGF significantly enhanced
neovascularization, fibroblasts infiltration and collagen production around
the anastomotic site when compared with the other two groups. The bursting pressure was significantly increased in the bFGF group. No significant
difference in the adhesion related score was observed among the groups.
Anastomotic obstruction and leakage was not observed.
Conclusions: Controlled release of bFGF enhanced the healing of intestinal anastomosis during the early postoperative period and is a promising
method to suppress anastomotic leakage.
tive studies are needed to elucidate and evaluate distinct differences
between RD and LD with the aim of establishing evidence-based guidelines for the management of acute uncomplicated RD.
P54
OVER THE SCOPE CLIP PLACEMENT FOR FISTULA AND ANASTOMOTIC LEAK CLOSURE.
P. Umamaheswaran1, R. Kratz1, D. Schembre1, K. Chuang2 and
A. Bastawrous1 1Colon & Rectal Surgery, Swedish Medical Center, Seattle,
WA and 2Department of Surgery, Sharp Rees-Stealy Medical Group, San
Diego, CA.
Purpose: Anastomotic sinuses and fistulae after colorectal resection
have reported rates up to 3-6% and post-operative rectovaginal fistula
(RVF) formation have a risk between 0.9-10%. These complications have
been associated with severe morbidity and decreased quality of life for
patients. Traditional management was surgical if the patient was systemically unwell or nil per os combined with image-guided drainage and supportive care if stable. Several endoscopic methods have been developed to
conservatively manage such complications, all with suboptimal outcomes.
A new OTSC has shown promise in closing postoperative fistulae and leaks
thus avoiding the need for repeat surgical intervention. The purpose of our
study is to determine the clinical and technical success of the OTSC during
conservative management of post-operative fistulae and leaks after colorectal surgery.
Methods: We performed a retrospective review of patients with colorectal sinus or fistula and RVFs that had OTSC clips placed as primary treatment from Oct 2011 to Jul 2013. The OTSC clips were placed endoscopically and the patients followed clinically. Data was collected from hospital
records to include technical success in deployment, clinical improvement
in symptoms, radiological evidence of fistula improvement subsequent
imaging, and complications associated with the OTSC.
Results: Ten patients underwent OTSC clip placement: 2 spontaneous
colonic fistulae after severe necrotizing pancreatitis, 3 RVFs after postoperative injuries, and 5 anastomotic sinuses. Five patients had rectal cancer, 1
with diverticulitis, 2 with endometriosis and 2 with severe necrotizing pancreatitis. There was an 80% technical success and a 75% clinical success of
those that had clip placement. Deployment was not successful in 2 patients
due to acute angulation of the sinus tract (duration = 58d) and rigidity of
the sinus tract wall (duration = 186d).
Conclusions: The placement of OTSC clips is a novel approach to the
treatment of GI fistulae and leaks. Clinical improvement of symptoms is
achieved in 75% of cases. The majority of clinical failures are in those
patients with chronic fistulae, and are attributed to epithelialization,
ischemia and persistent infection.
P53
ACUTE UNCOMPLICATED DIVERTICULITIS: THE DIFFERENCE
BETWEEN RIGHT AND LEFT.
N. Teo, S. Chan, R. Wijaya, K. Sng and S. Tan Changi General Hospital,
Singapore, Singapore.
Purpose: Guidelines exist for management of acute uncomplicated left
sided diverticulitis (LD) but are lacking for right sided diverticulitis (RD). This
is largely due to geographical variations in incidence of the disease, preventing comparative studies. This study aims to review and compare the
differences in presentation, treatment and outcomes between RD and LD
in a cohort of patients presenting with acute uncomplicated diverticulitis.
Methods: We performed a retrospective cohort study of patients who
presented with acute uncomplicated diverticulitis between 2007 and 2011.
Data collection included clinical variables at presentation, management
variables of duration of bowel rest and antibiotics, and outcome measures
such as length of stay, inpatient complications and rates of recurrence. Statistical analyses were performed using Chi-square test, Mann-Whitney U
test and t test where appropriate and a P value < 0.05 was taken as significant.
Results: We identified 178(78.1%) RD and 50(21.9%) LD who fulfilled
our study criteria. The mean age for RD was significantly younger (47.8 vs
62.4). There were no statistical differences in heart rate, white cell count
and temperature at presentation between both groups. In terms of management, duration of bowel rest was comparable. RD however received a
significantly shorter mean duration of intravenous antibiotics (3.43 days vs
4.20 days) and had a significantly shorter mean length of stay (2.87 days vs
3.56 days). Although there was a lower complication rate (0.60% vs 4.0%)
and a lower recurrence rate (3.9% vs 8%) for RD, the difference was not statistically significant.
Conclusions: It has been established that RD is more commonly
encountered in the Asian population and with a younger patient profile.
This study shows that duration of intravenous antibiotics and length of stay
is significantly shorter and there are lower rates of complications as well as
recurrence in acute uncomplicated RD. This may suggest that acute uncomplicated RD is a milder disease as compared to LD. Prospective compara-
P55
EVALUATION OF THE PATTERN OF TISSUE EXPRESSION AND CONTENT OF CLAUDIN AND OCCLUDIN IN COLONIC MUCOSA WITH AND
WITHOUT FECAL STREAM.
C. A. Martinez, M. R. Rodrigues, D. T. Sato, A. M. Dias, P. P. Silveira Júnior,
C. C. Ferreira, V. R. Carvalho and J. A. Pereira Surgery, São Francisco
University Medical School, Bragança Paulista, Brazil.
Purpose: To measure the tissue content and the pattern of expression
of the protein of intercellular tight junctions (claudin and occludin), comparing segments with and without intestinal transit after different periods
of exclusion.
54
Abstracts
Methods: Forty-five male rats were divided into 3 groups according to
the time of sacrifice: 6, 12, or 18 weeks after diversion of the fecal stream.
At the time of sacrifice, we removed segments with and without fecal
stream and subjected them to histological examination to diagnose colitis
and to evaluate the immunohistochemical expression of claudin and
occludin. Both proteins were quantified by assessing the crosses and their
total levels in the apical and basal regions along 3 integrity colon glands.
The evaluation was performed by 3 independent observers who did not
know details of the study. Tissue expression along the crypt was also determined in crosses. For comparison, we used Student’s t-test, the paired ttest, or ANOVA, as appropriate, with a significance level of 5% (p ≤ .05).
Results: There was a reduction in the total content of claudin in segments without fecal stream compared to those with colonic transit preserved, regardless of the time of exclusion (p<0.05). The reduction of
claudin in the apical regions of colon glands (p<0.0001) did not change
with the time of exclusion (p=0.99). The content of claudin in the crypt
region of the colonic glands did not change with time (p=0.82). We found
a reduction in the tissue content of occludin at the apex of the colonic
glands without compared to with fecal stream, regardless of the time of
exclusion. We also found variation in the content of occludin at the apex of
the crypts of the colon with fecal stream in relation to the time of exclusion
(p=0.001) between the sixth and twelfth weeks, though it stabilized thereafter.
Conclusions: The levels of claudin an occludin decrease in the colon
segments without fecal stream, mainly in the apical region of the colon
glands. The reduction in tissue content of both proteins in the apex of colic
glands devoid of intestinal transit highlights the importance of energy substrates for the integrity of the intestinal epithelium.
Conclusions: Patients with symptomatic diverticular disease have
increased thickness of their sigmoid colon, especially within the muscularis
propria layer. The number of colonic diverticula did not impact wall thickness. Further research will focus on correlation with abdominal symptoms
and measurements in patients with asymptomatic diverticular disease.
Table 1: Patient characteristics and sigmoid wall thickness
P57
TIMING OF CLOSURE FOR A TEMPORARY DIVERTING ILEOSTOMY:
EARLY CLOSURE VERSUS LATE CLOSURE.
N. Sung, S. Kim, D. Lee, H. Kwak, D. Kang, W. Ji, J. Kwak and J. Kim
Surgery, Korea University College of Medicine, Seoul, Republic of Korea.
Purpose: A temporary diverting ileostomy minimizes the consequences
of anastomotic leakage in colorectal and coloanal anastomosis. Closure is
often planned for 9-12 weeks, however, the morbidity with diverting
ileostomy can be significant, with an inferior quality of life. This study aimed
to identify the timing of closure for a temporary diverting ileostomy.
Methods: A prospective, randomized controlled study of 35 patients
who were operated with low anterior resection or intersphincteric resection for rectal cancer followed by temporary diverting ileostomy were
enrolled into two groups: early stoma repair group (ER; closure within 4
weeks) and late stoma repair group (LR; closure within 9 to 12 weeks). If
there was no radiological sign of anastomotic leakage, patients were randomized to ER or LR. The primary endpoints were peri-stoma adhesion and
edema. The second endpoints were postoperative complications.
Results: There was no significant difference in adhesion between the
ER and LR groups (P=0.865). Also, no significant differences were noted
between the two groups with respect to edema (P=0.190). Overall surgical
complication rate (33.3 versus 25.0 per cent; P = 0.589) was similar, and
wound infection rate was not different (6.7 versus 10.0 per cent; P = 0.727).
Small bowel ileus (13.3 versus 15.0 per cent; P = 0.889) and urinary dysfuction (13.3 versus 0 per cent; P = 0.093) were not significantly different.
Median (range) hospital stay was also similar (5 (3–10) versus 5 (3–12) days;
P = 0.866).
Conclusions: We concluded that early stoma closure is feasible and safe
in selected patients.
P56
HIGH FREQUENCY MINI-PROBE ULTRASOUND IN THE ASSESSMENT
OF COLONIC WALL THICKNESS IN PATIENTS WITH DIVERTICULAR DISEASE – A PILOT STUDY.
C. Kvasnovsky2, A. Haji1 and S. Papagrigoriadis1 1Department of
Colorectal Surgery, King’s College Hospital, London, United Kingdom and
2
Department of Surgery, University of Maryland Medical Center, Baltimore,
MD.
Purpose: Assessment of diverticular disease is routinely undertaken by
colonoscopy and Computed Tomography. Improvements in high frequency
ultrasound of the colon have enabled us to evaluate the colorectal wall
structure in detail. The aim of this study was to compare the thickness of
the sigmoid colon in patients with symptomatic diverticular disease and in
patients without diverticular disease.
Methods: Patients were recruited from the dedicated Diverticular Disease clinic at King’s College Hospital, a tertiary academic center. Control
patients were recruited from the outpatient endoscopy unit. All patients
underwent high frequency ultrasound of the sigmoid colon. 20 MHz ultrasound was undertaken to measure the thickness of the mucosa, submucosa, muscularis propria and total wall thickness. The thickness of colonic
wall between normal and diverticular patients was compared with Student’s t-test. We counted the number of diverticula encountered in the sigmoid colon, and divided patients into three categories, from <10, 10-15,
and >25 colonic diverticula. We compared mean colonic wall thickness in
these patients with ANOVA.
Results: Thirty-three patients underwent colonoscopic ultrasound, 18
with sigmoid diverticula and 15 control patients (Table 1). There was no difference in age or gender between groups. Patients with diverticular disease
had significant thickening in all layers of the colonic wall. The most marked
differences were seen in the muscularis propria, where controls had a mean
thickness of 0.80 mm (IQR 0.70-1.00) and patients with diverticular disease
had mean thickness of 2.95 mm (IQR 2.20-3.50), P < 0.0001. There was no
difference in mean wall thickness between patients with <10, 10-25, or >25
colonic diverticula, in any individual wall layer or in total thickness.
P58
COLECTOMY AFTER LIVER TRANSPLANTATION – WHAT IS THE LONGTERM OUTCOME?
D. Nicol1, S. Sutherland2, K. Roberts2, S. Bramhall2 and S. Radley2
1
Colorectal Surgery, Worcester Royal Hospital, Worcester, United Kingdom
and 2University Hospital Birmingham, Birmingham, United Kingdom.
Purpose: There is little data on the morbidity and mortality of patients
who have previously undergone orthotic liver transplantation (OLT) and
subsequently require colectomy. This study reviews the complication rates,
long term outcomes and survival in this challenging group of patients.
Methods: A retrospective review of all patients undergoing colectomy
either synchronously or following OLT in a single centre over a 15 year
period. Data was collected on indications for colectomy, complications,
length of stay, long term follow up and survival.
55
Abstracts
16 (25%) had more than one repair. Median time to hernia was 15 months
(range 3-108). No surgery was performed in 59% of patients with peristomal
hernia. Three other patients had stomal complications in the IP colostomy
group and these were 2 cases of colostomy necrosis in the early postop
period and one stomal prolapse at 18 months. Overall colostomy complication rate in the IP stoma group was 0.02%. In the EP colostomy group there
were 2 complications (0.51%) (p=NS). One patient had a bowel obstruction
at 2 months related to small bowel entering the extraperitoneal space and
a second patient had diverticulitis of the extraperitoneal segment which
required revision at 64 months. Bowel obstruction between IP/EP was not
significant.
Conclusions: Extraperitoneal colostomy provides a significant outcome
advantage with regard to peristomal hernia. It can be done with minimally
invasive techniques and should be the approach of choice for making a
permanent stoma.
Results: 3124 OLTs were performed during the study period (of which
310 were for PSC). 49 patients underwent subsequent colectomy. 37 had
undergone OLT for PSC (76%). 32 had known UC of which 21 underwent
colectomy for failed medical management, 6 for dysplasia and 5 for cancer.
12 colectomies were performed in patients with colorectal cancer (CRC)
alone. Colectomy was performed 0-206 months post OLT (median 80
months). 3 were synchronous and 3 were emergency resections. Colectomies included: 24 proctocolectomies, 9 subtotal, 8 segmental, 6 rectal
resections and 2 pouch excisions for cancer. All patients with IBD had proctocolectomy/subtotal colectomy. Laparoscopic resections were attempted
in 11 patients and converted in 4. Median LOS was 11 days (8 days in the
lap group). There were 6 readmissions, all in the UC group. 5 patients
required a return to theatre. 20% of patients had a minor (grade I/II) complication and 4 % had a grade 3 complication. There was one post-operative death (30 day mortality 2%). There were no complications in the lap
group. Long term follow up was 10 months to 15 years. There were 19
deaths (5 yr mortality 38%). There were 11 deaths in the UC (41%), 3 in the
UC and CRC (60%) and 5 in the CRC alone group (42%). Cause of death
included 5 from recurrent CRC and 5 from liver failure.
Conclusions: Colectomy following OLT is a safe procedure when performed in a tertiary referral unit where subspecialist and multi-disciplinary
care is available. Early complication and mortality rates are acceptable.
However long term outlook for this complex group of patients is poor and
survival is worst in patients with PSC, UC and CRC. Most deaths are result
of recurrent CRC or PSC.
P60
“GLOWING IN THE DARK”: A STUDY OF RADIATION RECEIVED BY
DESMOID PATIENTS UNDERGOING MULTIPLE CT SCANS.
X. Xhaja and J. Chuch Colorectal Surgery, Cleveland Clinic, Cleveland, OH.
Purpose: Patients with FAP related intra-abdominal desmoid disease
undergo multiple CT scans of abdomen, pelvis, and sometimes chest to
monitor the response to treatment and assess the possibility of recurrent
or new tumors. CT is generally preferred to MRI because of the better quality and more easily interpretable images. However there is concern about
the cumulative dose of radiation associated with multiple CT scans. This
retrospective study, was performed to assess the radiation exposure of FAP
desmoid patients related to CT scans
Methods: Patients with intra-abdominal desmoid disease related to FAP
managed in our department were accessed. The number of
abdominal/pelvic and chest CTs from the time of desmoid diagnosis to the
last imaging follow-up was totaled. When available, the radiation dose was
obtained, when not, an average dose was applied. Patient demographics
and the worst stage of the desmoid disease were noted. In this study we
report only the 22 patients with more than 13 CT scans over the time of
follow-up
Results: There were 22 patients 7 men and 15 women, with a mean age
at desmoids diagnosis of 28.4 +/- 1.0 years. Three desmoids were Stage II, 7
were stage III and 12 were stage IV. Mean follow-up was 111 months
(median 107, range 34 to 215). The mean total number of abdominal/pelvic
CT scans was 28 (median 31, range 14 to 42) and chest CT scans was 4.8
(median 3.5, range 0 to 18). The mean frequency of scans was every 4.5
months (median 3.9, range every 1 month to every 12 months). The mean
cumulative dose of radiation associated with abdominal/pelvic CTs was
491mGy*cm, equivalent to 491 mSv (0.491Sv). The highest dose in a patient
with a stage IV desmoid receiving 42 CT scans over 10.5 years was 574 mSv
(0.57Sv). One Sv is associated with a 0.055% chance of cancer. The additional dose associated with Chest CT was a mean of 265 mSv (0.26Sv)
Conclusions: In patients with advanced abdominal desmoid disease,
the total dose of radiation accumulated over a mean of 9 years follow up is
significant in terms of predisposing to cancer. This should encourage the
use of alternative forms of imaging such as MRI or at least a less frequent
use of CT scans
P59
PERISTOMAL HERNIA: THE CASE FOR EXTRAPERITONEAL
COLOSTOMY.
G. J. Blatchford, C. A. Ternent, A. G. Thorson, M. Shashidharan and
J. S. Beaty Department of Colon and Rectal Surgery, Creighton University,
Omaha, NE.
Purpose: Peristomal hernia continues to be a common issue following
creation of a permanent colostomy. This study compares the peristomal
hernia rate based on the approach used to create the stoma.
Methods: Retrospective chart review of patients undergoing abdominal perineal resection for cancer between June 2001 and July 2013. Comparison was made between patients undergoing an intraperitoneal (IP)
route for colostomy and those in whom an extraperitoneal (EP) approach
was used for colostomy formation. Stomal complications and reoperation
for any cause were evaluated.
Results: Abdominal perineal resection was done for cancer in 222
patients. Average age of the patients was 66 and median follow-up was 14
months (range 1-137). Follow-up was a median of 12 months for IP and 14
months for EP colostomy (p=NS). Open APR was performed in 208 and
laprascopic or robotic APR was done in 14 patients. IP colostomy was made
in 183 (82.4%) and EP colostomy was formed in 39(17.6%) patients. Of the
minimally invasive APR’s 57% of colostomies were IP and 43% were EP. No
hernias occurred when an EP colostomy was formed. Thirty-nine (21.3%) of
the 183 patients with IP colostomy developed a peristomal hernia
(p=0.005). Of these 16 (41%) underwent peristomal hernia repair and 4 of
P61
COLONOSCOPY-INDUCED ACUTE DIVERTICULITIS: MYTH OR REALITY?
E. Gorgun, O. Isik, M. Costedio, E. Aytac, G. Ozuner and J. Church
Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland,
OH.
Purpose: Intubation of the sigmoid colon during colonoscopy can be
difficult in patients with diverticulosis or diverticulitis, but few data exist
relating to the risk of colonoscopy activating diverticulitis. Our aim was to
56
Abstracts
evaluate the incidence, management and outcomes of acute diverticulitis
within 30 days of colonoscopy.
Methods: Patients who underwent a colonoscopy from 2003 to 2012,
and who were diagnosed with acute diverticulitis within 30 days, were
included. Patients with CT or pathologically proven diverticulitis, and those
with a clinical diagnosis of acute diverticulitis, were included. Patients’ past
history of diverticulitis and need for surgery examined.
Results: 236377 colonoscopies were performed. 68 patients were diagnosed with acute diverticulitis within 30 days of colonoscopy (2.9 per
10,000 colonoscopies). There were 43 females and 25 males with a median
age of 55.5 (34-92) years. Mean time from colonoscopy to diverticulitis was
12 days ± 8, and 30 patients needed hospitalization (median 3 days [1-21]).
29 patients had a polypectomy, 15 of them in the sigmoid. Twelve patients
had an abscess identified by CT or abdominal exploration during emergency surgery. 60 patients were treated with antibiotics, 2 needed percutaneous drainage (PCD), and 6 patients underwent emergency surgery. 10
patients were treated for another acute diverticulitis attack in their followup. All stomas were reversed successfully. 15 patients underwent elective
sigmoidectomy during their follow-up. Thirty-four (50%) patients had a history of diverticulitis. Colonoscopy was incomplete in 29.4% of patients with
a history of diverticulitis 29.4% vs. 8.8% in those without (p=0.03) Intubation was limited to the sigmoid colon in 9 patients and was associated with
more frequent surgery (61.5% vs. 25.5%, p= 0.02). Time interval between
recent acute diverticulitis and colonoscopy was shorter than 6 weeks in 6
patients, and surgery was needed in all of them (100% vs. 35.7%, p=0.006).
Conclusions: Colonoscopy should not be done within 6 weeks of an
acute attack of diverticulitis. Patients with sigmoid diverticuli severe
enough to make intubation impossible are at high risk of severe post exam
acute diverticulitis.
were no statistical significant differences for any of the domains in the JFIQL
between the two different age groups.
Conclusions: There were no significant difference of the FISI and JFIQL
score between the elderly and young patients group, which suggests that
chronologic age should not itself be as an exclusion criterion for hand-sewn
IPAA with mucosectomy.
Comparison of each scores of the JFIQL domain between the elderly and young
patients group. The median score and interquartile range are shown. (Mann Whitney
U test)
P63
THE EFFECT OF CHRONIC NARCOTIC USE ON CT SCAN YIELD IN
CROHN’S DISEASE.
N. M. Saur1, M. X. Traa1, B. Almussallam1, B. A. Orkin2 and D. A. Popowich3
1
Division of Colon and Rectal Surgery, Tufts Medical Center, Boston, MA,
2
Section of Colon and Rectal Surgery, Rush University Medical Center,
Chicago, IL and 3Department of Colon and Rectal Surgery, Icahn School of
Medicine at Mount Sinai Medical Center, New York, NY.
Purpose: Computed tomography (CT) is increasingly relied upon above
clinical examination as the modality of choice in determining management
of patients with Crohn’s disease presenting with new complaints. A CT of
the abdomen and pelvis exposes a patient to 10mGy/mSv radiation, which
has been correlated with a greater incidence of cancer. We aimed to identify factors that predict low-yield CT scans and to compare our data to previous work and our previously analyzed small-scale pilot study.
Methods: A retrospective chart review was conducted for 86 patients
with Crohn’s disease at Tufts Medical Center between May 2009 and October 2012. Data gathered included number of emergency department (ED)
visits; hospital admissions; operations; diagnostic studies performed (CT,
magnetic resonance imaging, small bowel follow through, endoscopy);
chronic narcotic use; attendance at surgery, gastroenterology, or pain clinic;
and number of missed visits. Chi-square comparisons were made with pvalues <0.05 considered significant.
Results: Compared to non-narcotic users, narcotic users were more
likely to have ED visits (93% vs 54%, p= 0.0067), hospital admissions (93%
vs 75%, p=0.178), and CT scans (100% vs 57% p=0.0015). Patients who are
on chronic narcotics represent 54 percent of the total CTs done for Crohn’s
patients despite only representing 19 percent of our Crohn’s population.
Additionally, chronic narcotic users’ mean ED visit frequency was 1.5-times
higher than those patients who do not use chronic narcotics and is associated with a two-fold higher likelihood of being admitted to the hospital.
Additionally, the ratios of CT scans to operation and CT scans to hospital
admission were higher in the chronic narcotic group, whereas the ratio of
ED visits to operation was identical between groups (Table 1).
Conclusions: We have identified chronic use of narcotics as a significant predictor of low-yield CT scans. Crohn’s patients who are on chronic
pain medications should be managed without a CT scan unless their pain
is significantly changed from their baseline. Reducing the scan burden in
this population will decrease both health care financial cost and ionizing
radiation risk to these patients.
P62
THE EFFECT OF AGE ON FUNCTIONAL OUTCOME AFTER HANDSEWN
ILEAL POUCH ANASTOMOSIS FOR ULCERATIVE COLITIS.
Y. Watadani, H. Ohge, S. Uegami, W. Shimizu, N. Shigemoto, H. Kitagawa
and T. Sueda Department of Surgery, Hiroshima University, Hiroshima,
Japan.
Purpose: Restorative proctocolectomy with ileal-pouch-anal-anastomosis (IPAA) for patients with ulcerative colitis (UC) is performed by a stapling
or a hand-sewn technique. Currently, stapled IPAA is favored as it technically easier and have the potential advantage of better functional results
than the hand-sewn IPAA. On the other hand, retention of the potentially
diseased rectal mucosa exposes UC patients not only to chronic inflammation but also to neoplastic lesions. The purpose of this study was to evaluate functional outcome in patients who underwent hand-sewn IPAA by the
use of validated questionnaires, also to explore possible differences related
to age.
Methods: Fifty-four subjects out of 212 patients underwent hand-sewn
IPAA with mucosectomy at Hiroshima University Hospital January 1985
through February 2012 were enrolled in the study. Patients were evaluated
with standardized questionnaires including Fecal Incontinence Severity
Index (FISI) and the Japanese version of the Faecal Incontinence Quality of
Life Scale (JFIQL). Patient groups younger and older than 60 years old were
compared with each other.
Results: Median age was 51.5 (range, 21-77) years and median follow
up time was48 (range, 5-240) months. Eleven patients had colorectal cancer at the time of surgery. Median bowel movements were eight times per
day and 43 patients (80%) took antidiarrheal medication at the time of the
survey. Of the 54 patients, 47 (87%) had FI symptoms and 37 had nocturnal
FI (68 %). There was no difference between the elderly (14 patients) and
young (40 patients) patients group with their follow up periods, bowel
movements per day, use of pads, use of anti-diarrheal medication, and
occurrence of pouchitis, anastomotic stricture. The median FISI score in
patients more and less than 60 were 17.5 and 18.5 respectively (NS). There
57
Abstracts
Table 1: Effect of Narcotic Use
P65
DIFFERENT SCOPES FOR DIFFERENT FOLKS? A COMPARISON OF
PATIENT POPULATIONS AND ADENOMA DETECTION RATES FOR OUTPATIENT CENTER AND HOSPITAL-BASED COLONOSCOPIES.
S. Jessula1, J. Motter1, A. Grunbaum1, A. Kezouh2, C. Vasilevsky1,
P. H. Gordon1, N. Morin1, G. Ghitulescu1, J. Faria1 and M. Boutros1
1
Surgery, McGill University - Jewish General Hospital, Montreal, QC,
Canada and 2Epidemiology and Biostatistics, McGill University - Jewish
General Hospital, Montreal, QC, Canada.
Purpose: In Canada, patients may opt for a private out-patient center
(OP) rather than a hospital-based (HB) colonoscopy. The aim of our study
was to compare patient populations and adenoma detection (AD) rates for
OP vs. HB colonoscopies. To our knowledge, no study has yet compared AD
rates in HB and OP colonoscopies.
Methods: From 2009-2012, an equal random sample of 4 endoscopists’
HB colonoscopies and all of the same 4 endoscopists’ OP colonoscopies
were reviewed. Demographic variables, symptoms, personal and family history, indications for colonoscopy, quality of preparation, cecal intubation,
and AD rates were collected. Due to the imbalance between HB and OP
variables, the propensity score of a HB vs. OP colonoscopy was estimated
using logistic regression with all covaraites. Matching between cases of AD
to 4 controls by quintile propensity scores was performed and a conditional
logistic model was constructed.
Results: 4347 colonoscopies (1162 OP and 3185 HB) were reviewed.
Patients who underwent HB compared to OP colonoscopies were older
(61.1 vs. 59.9, p=0.003) and more likely to be female (58.3% vs. 51.9%,
p=0.0002). Indications for HB and OP colonoscopies were significantly different: low-risk screening (26.8% vs. 96.6%, p<0.001), high-risk screening
(43.2% vs. 1.6%, p<0.0001) and diagnostic (33.6% vs. 1.7%, p<0.0001). HB
compared to OP colonoscopies had significantly less adequate preparation
(94.7% vs. 98.3%, p<0.0001) and cecal intubation rates (95.3% vs. 98.5%,
p<0.0001). For 3258 screening colonoscopies, crude HB and OP AD rates
were 22.2% and 12.3% (p<0.001), respectively. The propensity matched
odds of AD in HB compared to OP screening colonoscopy was 1.47 95%CI
(1.12 to 1.95).
Conclusions: OP colonoscopies were mostly performed for low-risk
screening. Patients who underwent OP colonoscopies were more likely to
be young, male and have an adequate preparation. Despite identical endoscopists and colonoscopy equipment, in a propensity matched cohort, AD
rates were higher for HB compared to OP colonoscopies.
P64
LAPAROSCOPIC ILEOCOLECTOMY IS UNDERUTILIZED IN CROHN’S
DISEASE: ANALYSIS OF A NATIONAL DATABASE.
L. M. Cannon1, P. L. Reavey3, M. Singer2, K. Umanskiy1 and M. K. Krane1
1
Section of General Surgery, University of Chicago, Chicago, IL,
2
Department of Surgery, Northshore University Healthcare System,
Evanston, IL and 3Institute of Reconstructive Plastic Surgery, New York
University-Langone Medical Center, New York, NY.
Purpose: A recent estimate suggests that laparoscopy is utilized in
48.5% of right-sided colon operations for non-inflammatory bowel diagnoses. We sought to investigate national estimates of the use of
laparoscopy in ileocecal Crohn’s disease (CD) and potential barriers to this
approach.
Methods: The Health Care Utilization Project National Inpatient Sample
database was queried for patients who principally underwent right colon
resection during 2009-2011 with a concomitant diagnosis of CD. Diagnosis
and procedure codes were examined in order to categorize patient variables including operative approach, conversion, comorbidities, (malnutrition, intra-abdominal process, fistulizing disease) and intraoperative factors
(need for stoma or enterolysis, fistula takedown, segmental colectomy or
bowel resection).
Results: From 2009-2011, 21464 patients with a diagnosis of CD underwent right colon resection. 38.5% of these operations began laparoscopically. 54.3% of all operations were elective. 93.8% of all operations occurred
at urban hospitals, and 62.5% at teaching hospitals. Multivariate analysis
demonstrated that patients approached laparoscopically were more likely
to be younger, electively admitted, and without complicating clinical factors. Non-elective admission status (OR 2.0), intra-abdominal process (OR
1.9), need for enterolysis (OR 2.3) or segmental colectomy (OR 2.1) were
most strongly associated with an open procedure (p <0.001). Using intention to treat analysis, laparoscopy was associated with significantly
decreased inpatient mortality (0.2 vs. 1.6%, p <0.001), and length of stay
(median 6.0 vs. 8.0 days, p < 0.001). Of 8269 laparoscopic procedures, 23.0%
were converted to an open approach. Fistula diagnosis (OR 2.3) complicating intraoperative factors (OR 1.7-3.3) and urgent/emergent status (OR 2.2)
were most strongly associated with conversion (p <0.001).
Conclusions: The laparoscopic approach remains nationally underutilized in ileocecal CD and is associated with high conversion rates compared
to contemporary colorectal surgery data for other indications. We believe
this is multi-factorial with complicating factors leading to decreased laparoscopic approach and increased conversion.
P66
COMPARISON OF PATIENT OUTCOMES IN LAPAROSCOPIC AND OPEN
PROCTOCOLECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS.
A. Brown, S. Tevis, E. Foley, B. Harms, C. Heise and G. Kennedy Surgery,
University of Wisconsin - Madison, Madison, WI.
Purpose: Restorative proctocolectomy (RP) is the definitive treatment
for patients with ulcerative colitis (UC) and familial polyposis syndromes
(FAP). Laparoscopic approach to RP has been shown to be associated with
decreased complications. The goal of this study was to determine if
laparoscopy was a predictor of decreased risk for readmission following RP.
Methods: We identified 320 patients who underwent RP from 20032013 from a single academic institution. Patients were classified as having
undergone open or laparoscopic procedures. Explanatory variables of interest included diagnosis (UC or FAP), demographic and co-morbid conditions.
Operative time and estimated blood loss (EBL) were evaluated as were
length of hospital stay (LOS) and return of bowel function. Readmission,
reoperation and complications were evaluated within 30 days of surgery.
Univariate analysis was performed using Fisher’s exact test and ANOVA.
Multivariate analysis was performed with binary logistic regression and univariate linear models. Statistical analyses were performed with SPSS v. 22
and p values ≤0.05 were considered significant.
58
Abstracts
Results: The majority of patients underwent laparoscopic RP (61%).
Operative time was longer for laparoscopic approach (516 min vs 373 min,
p ≤ 0.001). However, LOS (6.8 days vs 8.7 days, p ≤ 0.016), time to ostomy
output (2.6 days vs 4.4 days, p ≤ 0.001), time to tolerance of a liquid (3.6
days vs 4.9 days, p ≤ 0.014) and solid diet (5.1 days vs 6.4 days, p ≤ 0.023)
were shorter in the laparoscopic group. No difference in complication rate
was found between the techniques, but patients who underwent laparoscopic RP were less likely to be readmitted within 30 days of discharge (OR
0.368, 95% CI 0.151-0.898).
Conclusions: While laparoscopic approach to RP is associated with
longer operative times, LOS and time to return of bowel function were
shorter in the laparoscopic group. Readmissions within 30 days of surgery
were significantly less in the laparoscopic group. Further evaluation of long
term outcomes is needed to better compare laparoscopic and open RP.
P68
HIGH RATE OF PRIMARY SCLEROSING CHOLANGITIS DETECTED BY
LIVER BIOPSY IN INFLAMMATORY BOWEL DISEASE PATIENTS UNDERGOING COLECTOMY.
E. Steinhagen1, M. Widmar1, S. Eisenstein1, T. Schiano2, M. I. Fiel3 and
R. M. Steinhagen1 1Department of Surgery, The Mount Sinai Medical
Center, New York, NY, 2Department of Medicine, The Mount Sinai Medical
Center, New York, NY and 3Department of Pathology, The Mount Sinai
Medical Center, New York, NY.
Purpose: Patients with Inflammatory Bowel Disease (IBD) are at
increased risk for Primary Sclerosing Cholangitis (PSC). Approximately 2-7%
of IBD patients are thought to have PSC. Patients with both diseases may
have worse inflammatory and oncologic outcomes in addition to an
increased risk of pouch dysfunction following restorative proctocolectomy.
Most patients diagnosed with PSC while asymptomatic eventually have
symptoms or PSC-related complications. The purpose of this study was to
elucidate the rate of PSC in asymptomatic patients undergoing colectomy
for IBD via liver biopsies at the time of surgery.
Methods: Patients undergoing colectomy for IBD by a single surgeon
who consented to liver biopsy at the time of surgery were included.
Patients with known PSC were excluded. Demographic, clinical, surgical,
and pathologic data were reviewed. Liver biopsies were evaluated by a
hepatobiliary pathologist.
Results: Between 10/2009 and 9/2013, 29 patients met the inclusion
criteria; 16 were men. Most (55%) were Caucasian and 38% had a family history of IBD. Twenty-two patients (76%) had Ulcerative Colitis; 14% had
Crohn’s Disease; 10% had indeterminate IBD. The mean age at diagnosis of
IBD was 33.9 (range 11-65). At the time of colectomy, the mean age was
48.8 (range 4-84.3) with a mean duration of disease of 14 years (range <160). Indications for colectomy were refractory disease (55%), dysplasia
(20.7%), carcinoma (10.3%), stricture (10.3%), and fulminant IBD (3.4%).
Most (65.5%) patients were on ASA derivatives at the time of surgery; 48%
were on steroids, and 31% were on anti-TNF agents. There were no complications from liver biopsy. 79% of patients had pan-colitis on pathologic
examination and 24% had carcinoma. Nine patients (31%) had liver biopsies demonstrating PSC. There were no differences in demographic, clinical,
or surgical data between the patients with and without PSC
Conclusions: The rate of PSC detected by liver biopsy (31%) was significantly higher than the reported incidence of PSC in IBD patients. This suggests the need for larger trials to determine the incidence and natural history of the disease in asymptomatic patients undergoing colectomy for IBD.
P67
LAPAROSCOPY FOR FISTULIZING DIVERTICULITIS: ADVANTAGES OF
SUCCESSFUL LAPAROSCOPY.
S. Jung, G. Dasilva and S. D. Wexner Cleveland Clinic Florida, Weston, FL.
Purpose: Few studies address the outcomes of laparoscopy for fistulizing diverticulitis (FD). Purpose: To review outcomes of laparoscopic (LAP)
vs. conversion (Con) vs open (OP) surgery for FD.
Methods: After IRB approval, patients who had surgery for FD from
03/2001-05/2013 were identified. Demographics and perioperative data
were retrieved from medical records. Conversion was defined as an
unplanned, or earlier or larger incision than planned for specimen retrieval.
Comparisons were made using Chi-square for categorical and Student Ttest for continuous variables.
Results: 77 patients [45 females, mean age 67 (40-91) years] were identified: 29 in LAP (11 hand-assisted), 11 in Con and 37 in the OP groups.
ASA=3-4 (65% vs 36.4% vs 22.2%), pulmonary disease (32% vs 9% vs 7%)
and prior laparotomy (49% vs 27% vs 21%) were more common in OP vs
Con or LAP (p<0.05) patients. Distribution of abdominal fistulas was similar
among the groups, the most commonly colovesical (n=42) or colovaginal
(n=29). Operative time was longer in Con vs LAP or OP (297 vs 217 vs 239
min; p=0.027) group. Estimated blood loss was similar among the groups
(LAP: 248 ml vs. Con: 418ml vs OP: 325 ml; p=0.152). Resumption of bowel
function was earlier in LAP vs Con and OP group (3.0 vs. 5.1 vs 4.5 days;
p=0.039). Hospitalization was shorter in LAP vs Con and OP group (6.6vs
10.3 vs 9.1days; p=0.026). Overall postoperative morbidity (41.4% vs 63.6%
vs 45.9%) and readmission (6.9% vs 0% vs. 2.7%) rates were similar among
LAP vs Con vs OP groups. The most common complications were
ileus/obstruction (1 LAP vs 3 Con vs 7 OP) and wound infection (4 LAP vs 2
Con vs 4 OP). One postoperative leak manifested as enterocutaneous fistula in the LAP group. Readmission was due to anastomotic bleeding (1 LAP
vs 1 OP) and high stoma output (1 LAP). The only postoperative mortality
(LAP group) was due to aspiration.
Conclusions: Laparoscopy for FD is safe with advantages of significantly
shorter resumption of bowel function and length of hospitalization compared to open surgery. Longer operative times and hospitalization as well
as greater blood loss and morbidity following conversion highlight advantages of successful laparoscopy.
P69
INFLAMMATORY BOWEL DISEASE IN THE OBESE PATIENT: A TREND
TOWARD EARLIER DISEASE PRESENTATION AND OPERATIVE INTERVENTION.
R. N. Mundy, L. Khojayan, C. Arreola-Garcia, K. Tyler, Z. Kutayli, M. Kiely
and K. Wong Surgery, Baystate Medical Center, Springfield, MA.
Purpose: Obesity, once considered unusual in inflammatory bowel disease, is now much more common. Our goal in this study is to evaluate
whether obese status in patients requiring surgical intervention is associated with patient demographics, disease characteristics or surgical outcomes.
Methods: A retrospective medical record review of IBD patients who
underwent surgery by the colorectal surgery division during 2007 – 2012
at a single institution was performed. Patients’ demographic and clinical
data were reviewed. IRB approval was obtained. Data were compared with
Fisher Exact test.
Results: 331 patients with IBD were reviewed. 86 patients underwent
operative management. There were 69 patients (81%) in the non-obese
(BMI <30) and 16 patients (19%) in the obese group (BMI >30). Patients
were similar in age, gender, ethnicity, tobacco use, disease type and family
history. Non-obese patients had a statistically significant higher proportion
59
Abstracts
IgG4+plasma cells, only one (7.7%) sample showed infiltration deeper than
the submucosa. For CD and diverticulitis, 46.1% and 66.7% showed infiltration into the muscularis propria and/or subserosa, respectively; only 22%
of UC cases had infiltration deeper than the submucosa. Only diverticulitis
was more likely to be found deep to the submucosa vs. controls or UC
(p=0.002, 0.044).
Conclusions: This pilot study shows a significant elevation of IgG4+PC
in both stricturing and non-stricturing inflammatory intestinal diseases.
Infiltration was deeper in diseases that form strictures: almost 50% of CD
and almost 70% of diverticulitis. Although levels were not diagnostic for
IgG4-associated disease, depth of plasma cell infiltration may aid in the
histopathologic differentiation between Crohn’s and ulcerative colitis.
of ileal disease compared with obese patients (p=0.0108). Perioperative
medical therapy, operative treatment and postoperative complications did
not differ significantly among the groups. Presentation of disease and operative intervention occurred a decade earlier on average in the obese v nonobese group. These values approached clinical significance (p=0.0585 and
p=0.0645 respectively).
Conclusions: Currently, 35% of American adults are obese, a rate that
has more than doubled since 1980. The prevalence of obese IBD patients
remains lower than this, but nonetheless represents a significant portion of
patients presenting for surgery. Despite the increased risk obesity poses to
surgical patient our study confirms that obese operative IBD patients can
be managed effectively with similar outcomes to that of non-obese
patients. Our study suggests a trend toward earlier disease manifestation
and more varied disease distribution in our patients. As other studies have
suggested, obesity itself may be associated with a pro-inflammatory state
helping to explain this earlier age of disease onset and need for operative
intervention. Additional comprehensive studies are necessary to further
clarify the relationship between obesity and disease onset in IBD.
P71
NATURAL ORIFICE SPECIMEN EXTRACTION IN TOTALLY LAPAROSCOPIC RIGHT HEMICOLECTOMY WITH INTRACORPOREAL ANASTOMOSIS, TRANSVAGINAL SPECIMEN EXTRACTION.
M. A. Hernandez and M. E. Franklin Minimal Invasive Surgery, Texas
Endosurgery Institute, San Antonio, TX.
Purpose: Since the first laparoscopic approach for colonic disease, minimal access techniques have revolutionized colonic surgery. Natural orifice
specimen extraction (NOSE) offers the advantages of laparoscopic surgery
and allows performing the anastomosis and extraction of the surgical specimen without enlarging any trocar incision. This study was designed to evaluate the outcomes of patients who underwent to a totally laparoscopic
right hemicolectomy with intracorporeal anastomosis and transvaginal
specimen extraction. The predicted benefits of transvaginal extraction in
colorectal surgery are to reduce incision-related morbidity such as pain, a
reduced rate of surgical site infection and incisional hernias by avoiding
minilaparotomy for specimen extraction.
Methods: We analyzed a prospectively designed database of consecutive patients who underwent totally laparoscopic right colon surgery with
transvaginal extraction for different pathologies between April 2007 and
September 2013 at Texas Endosurgery Institute. The selection criteria for
the NOSE approach were based on a disease entities, site and size of the
tumors.
Results: A total of 31 patients underwent to right hemicolectomy with
NOSE approach and vaginal extraction. The operative time for the procedure was 159 ± 27.1 min and the estimated blood loss was 83.5 ± 14.4 ml.
Intraoperatively, trasvaginal extraction was associated with 2 complications;
with no post operative complications. The length hospital stay was 5.5±2.5
days.
Conclusions: The NOSE approach is possible with favorable short-term
surgical outcomes. This novel technical approach is feasible and safe, eliminates the need for extraction through minilaparotomy with a potentially
shorter recovery time, earlier ambulation, bowel function, fewer complications, decreased drugs use, and improved cosmesis; it might be considered
for patients requiring abdominal right hemicolectomy.
P70
IGG4-POSITIVE PLASMA CELL ELEVATION AND DEEP INFILTRATION
IN STRICTURING BOWEL DISEASES.
T. Witalka1, S. Al Diffalha2, M. Atieh2, S. Yong2 and D. Hayden1 1Surgery,
Loyola University Medical Center, Maywood, IL and 2Pathology, Loyola
University Medical Center, Maywood, IL.
Purpose: IgG4-positive plasma cell infiltration has been linked to sclerosing diseases of various organ systems. We evaluated infiltration of these
cells in stricturing and non-stricturing inflammatory diseases of the intestine.
Methods: Immunohistochemical staining for IgG4-positive plasma cells
(IgG4+PC) was performed on samples from 67 bowel resections for Crohn’s
disease (CD), ulcerative colitis (UC) and diverticulitis 2009-2013.
Results: Out of 16 CD, 12 UC, 17 diverticulitis vs. 14 small and 25 large
intestine controls examined, no differences in age and gender were found,
except CD cases were younger (45.4 vs. 58.4 years, p=0.032). 87.5% of CD,
75.0% of UC and 70.5% of diverticulitis samples had any IgG4+PC compared
to 32.0% of colon and 35.7% of small bowel controls. Mean IgG4+PC/HPF
was 10.9 (0-40) for CD, 11.9 (0-65) for UC and 11.2 (0-67) for diverticulitis.
Compared to controls, all three had higher mean IgG4+PC: CD vs. small
bowel controls (10.9 vs. 2.4, p=0.011), UC vs. large bowel controls (11.9 vs.
2.3, p=0.025) and diverticulitis vs. large bowel controls (11.2 vs. 2.3, p=0.02).
Means were not different between CD, UC or diverticulitis (p=0.985). If the
cutoff of >50 cells/HPF is diagnostic of IgG4-associated disorder, only one
UC and one diverticulitis case would be positive. Amongst all controls with
P72
SMALL BOWEL OBSTRUCTION: LAPAROSCOPIC OR OPEN LYSIS OF
ADHESIONS?
M. Okash, G. Dasilva, S. D. Wexner, E. Choman and E. G. Weiss Cleveland
Clinic Florida, Weston, FL.
Purpose: Adhesions are the leading cause of small bowel obstruction
(SBO). Lysis of adhesions (LOA) is the treatment of choice for patients failing conservative measures. Laparoscopic LOA (LLOA) has gained popularity
and is feasible with good short-term benefits. This study aimed to evaluate
the long-term outcomes of LLOA compared with open LOA (OLOA).
Methods: After IRB approval, patients who had LLOA or OLOA from
6/2003=5/2013 were identified from a prospective database. Demographics, surgery data [operative time, Seprafilm® use (open surgery only), bowel
60
Abstracts
efits are not sustained if conversion to laparotomy is required. This study
provides additional benefits of laparoscopy for colorectal surgical disorders.
resection, length of stay], and short- and long-term outcomes were
obtained from medical records. Long-term outcome was also assessed by
telephone questionnaire, evaluating recurring obstructive symptoms and
management (need for hospitalization or surgery). Outcomes between
groups were compared using Chi-square and one-way Anova test.
Results: 89 patients [40% males; mean age: 60 (14-95) years] were
included. Mean follow up was 5 (1-13) years. 49 (55.1%) underwent LLOA
and 40 (44.9%) had OLOA. 55 patients had surgery for acute SBO (28 LLOA
and 27 in OLOA) and 34 for chronic recurring SBO (21 in LLOA and 13 in
OLOA). SBO was caused by a single adhesive band in 23 (16 in LLOA and 7
in OLOA) whereas multiple adhesions were found in 66 (33 in LLOA and 33
in OLOA) patients.14/49 LLOA and 14/40 OLOA patients had synchronous
bowel resection (p=NS). Most common morbidities were pneumonia (2 vs.
6 p=0.07), wound infection (3 vs. 10; p=0.012) and ileus (5 vs 12; p=0.01) in
the LLOA vs OLOA, respectively. Mean length of stay was 5 and 11 days for
LLOA and OLOA groups, respectively (p=0.01). Overall SBO recurrence rate
was 24.5% (n=12) in LLOA vs. 25% (n=10) in OLOA group (p=0.9). 3(6.1%)
patients in LLOA and 6(15%) in OLOA group had reoperation for SBO
(p=0.1). 5/19 (26%) patients in whom Seprafilm® was placed developed
recurrence, compared to 5/21(23%) patients in whom it was not used
(p>0.8).
Conclusions: LLOA is equally effective in resolving SBO, with similar
long-term outcomes as OLOA. The laparoscopic approach offers benefits of
significantly less ileus, wound infection, and shorter length of stay
Comparison of different types of surgery in each HCAHPS domain (p Value)
P73
LAPAROSCOPIC SURGERY IMPACTS PATIENT SATISFACTION WITH
HOSPITAL CARE.
L. Duraes1, L. Stocchi1, J. Merlino1, T. Hull1, M. Zutshi1, D. Bokar2 and
B. Gurland1 1Colorectal Surgery, Cleveland Clinic Foundation, Cleveland,
OH and 2Office of Patient Experience, Cleveland Clinic Foundation,
Cleveland, OH.
P74
ENHANCED RECOVERY AFTER LAPAROSCOPIC COLECTOMY: DOES
LOCAL INFILTRATION OF LIPOSOMAL BUPIVACAINE INFLUENCE OUTCOMES?
R. Pedraza1, J. Nieto1, E. L. Lambert2, T. Pickron1 and E. M. Haas2
1
Colorectal Surgical Associates, Ltd, LLP, Houston, TX and 2Division of
Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The
University of Texas Medical School at Houston, Houston, TX.
Purpose: HCAHPS (Hospital Consumer Assessment of Healthcare
Providers and Systems) is a Medicare required standard questionnaire
designed to measure patients’ perception of their hospital care. Only the
most favorable “always” patient responses are considered for reimbursement allocation The aim of this study is to determine if the use of
laparoscopy in colorectal procedures influences HCAHPS scores.
Methods: HCAHPS questionnaires collected after patients’ discharges
from 2009 - 2013 following colorectal procedures were linked with a
prospectively maintained colorectal outcomes database. HCAHPS domains
evaluated were: how well nurses and doctors communicate with patients;
how responsive hospital staff are to patients’ needs; how well hospital staff
help patients manage pain; how well the staff communicates with patients
about new medicines; whether key information is provided at discharge;
hospital cleanliness; hospital quietness; hospital recommendation; and
overall hospital rating. Most favorable survey responses for domains were
compared for patients undergoing open (O), laparoscopically completed
(L), and laparoscopic converted to open procedures (C).
Results: 1937 HCAHPS questionnaires were linked to colorectal procedures. 1394 questionnaires (72%) corresponded to open cases (O), 498
(25.7%) were laparoscopic cases without conversion (L) and 45 (2.3%) were
from converted cases (C). Patients undergoing laparoscopy (L) were statistically more likely to respond favorably to “communication with doctors” and
“pain management” domains compared to O (p=0.01 and p=0.04, respectively). When laparoscopy was converted to laparotomy these significant
finding were not observed. For all cases which were started laparoscopically (L+C), the “communication with doctor” domain achieved better
scores, compared to O (p=0.02). The use of laparoscopy did not influence
the other HCAHPS domains, recommendation of the hospital, or overall
hospital rating.
Conclusions: Patients undergoing laparoscopic surgery without conversion report better physician communication and pain scores. These ben-
Purpose: Laparoscopic colectomy coupled with enhanced recovery
after surgery (ERAS) pathways have been shown to improve short-term outcomes. Liposomal bupivacaine is a depot formulation that prolongs the
local analgesic effects of bupivacaine for up to 72 hours. We recently incorporated local infiltration of liposomal bupivacaine as a multimodal postoperative analgesic regimen as a component of our ERAS pathway.
Methods: Over an 11-month period all patients who had right, left, or
total colectomy and injection of liposomal bupivacaine as a component of
ERAS were compared to patients who had the same procedures without
the use of the local analgesic. To reduce confounders, the groups were
matched based on gender, diagnosis, procedure, surgical approach, and
surgeon. All cases in both arms were placed on identical ERAS pathways.
Preoperative characteristics, demographics, and perioperative outcomes
were evaluated and compared.
Results: A total of 53 colectomies using liposomal bupivacaine were
identified and matched to 53 non-liposomal bupivacaine colectomies. All
cases were approached with single-incision laparoscopic surgery. Age, gender, history of abdominal surgery, BMI, and ASA score were similar between
groups. The most common diagnosis was diverticulitis (n=21), followed by
cancer (n=20), and benign disease (n=9. There were 30 left/sigmoid, 21
right, and 2 total laparoscopic colectomies. There were no differences in
regard to operative time, estimated blood loss, intraoperative complications, conversion to laparotomy, and incision length. Postoperative complications, readmissions, and reoperations were similar between groups.
Length of stay, however, was significantly reduced in the liposomal bupivacaine group (4.0 vs 3.0, p=0.002).
Conclusions: Local infiltration of liposomal bupivacaine may have a
beneficial role in those undergoing laparoscopic colectomy for benign and
61
Abstracts
malignant disease. The addition of this local infiltration to our enhanced
recovery pathway resulted in a significant reduction of length of stay by
one day. Utilization as a component of ERAS following lap colectomy may
be considered.
20 (IQR 13-22) with a median CRM of 1 cm (IQR: 0.5-1.6). Five of 8 patients
who underwent extra-regional LND, had confirmed lymph node metastases. Median hospital stay was 5 (IQR: 4-7) days. Postoperative morbidity
developed in 8 patients (33.3%), 4 pelvic abscess, 2 perineal wound dehiscence, 1 hematoma,1 bowel obstruction. There were no conversions.
Conclusions: Minimally invasive resection for low anorectal cancer surgery can be safely and effectively performed using the surgical robot. A
cylindrical APR may be performed in the standard lithotomy position. Additionally, minimally invasive resection may be extended to include extramesorectal lymph node or en-bloc multivisceral resection. Further study of
long term outcomes are ongoing.
Demographics and Perioperative outcomes
P76
OUTCOMES OF SINGLE-INCISION VERSUS CONVENTIONAL LAPAROSCOPIC ANTERIOR RESECTION FOR SIGMOID COLON CANCER: A
PROPENSITY SCORE MATCHING ANALYSIS.
C. Kim, S. Baek, H. Hur, B. Min, S. Baik and N. Kim Colorectal surgery,
Yonsei University College of Medicine, Severance Hospital, Seoul, Republic
of Korea.
Purpose: Single incision laparoscopic surgery (SILS) is a novel technique
in minimally invasive surgery. Many colorectal surgeons performed and
reported their experience already. However, few studies compared survival
between SILS and conventional laparoscopic surgery for sigmoid colon cancer. The aim of study is to compare oncologic outcomes as well as shortterm outcomes of single incision laparoscopic anterior resection (SILAR)
with conventional multiport laparoscopic anterior resection (CLAR).
Methods: A total of 285 consecutive patients with sigmoid colon cancer underwent laparoscopic anterior resection from September 2009
through April 2012 in Severance hospital. 52 patients among them received
SILAR, while 233 received CLAR. Propensity score matching analysis were
used to reduce imbalance of patient characteristics for the results with less
bias. Short-term and oncologic outcomes of them were analyzed.
Results: After propensity score matching with sex, age, body mass
index, alcohol intake, smoking, underlying diseases, previous abdominal
surgery, tumor location from anal verge, and combined resection, 1: 1
match was performed. No difference was observed except for time to soft
diet (3.5 ± 1.0 vs. 4.1 ± 1.2 day, p=0.005), and length of incision (3.2 ± 0.6 vs.
7.7 ± 0.7 cm, p=0.000) in SILAR and CLAR group. Median follow up period
was 30 months (9-50). 3-year overall survival rates and 3-year disease-free
survival rates were not significant different (93.8% vs. 96.0%, p=0.818;
85.1% vs. 91.6%, p=0.586, respectively).
Conclusions: SILS is a safe and feasible option for sigmoid colon cancer. However, well-designed, randomized controlled, prospective, comparative study is needed.
P75
ROBOTIC CYLINDRICAL APR: A TECHNICALLY FEASIBLE AND ONCOLOGICALLY SOUND APPROACH TO SURGICAL RESECTION OF
ANORECTAL CANCERS.
C. N. Clarke1, A. K. Agarwal2, Y. You1, M. A. Rodriguez-Bigas1, J. Skibber1,
E. Schlette1, S. Nguyen1 and G. J. Chang1 1Surgical Oncology, MD
Anderson Cancer Center, Houston, TX and 2General Surgery, Unitversity of
Texas - Houston, Houston, TX.
Purpose: The cylindrical approach to abdominoperineal resection (APR)
improves oncologic outcomes by reducing circumferential resection margin (CRM) positivity in patients with low anorectal cancers. It has been
advocated that this requires prone positioning during the perineal phase.
The robotic interface improves transabdominal visualization of the pelvic
floor to permit cylindrical resection in lithotomy. We sought to evaluate the
technical feasibility and short-term oncologic efficacy of robotic transabdominal cylindrical APR.
Methods: Consecutive patients undergoing robotic APR were identified from a prospective database of patients with anorectal cancer from
1/09 to 9/13 at a tertiary cancer center. Patients who underwent robotic
APR for adenocarcinoma or squamous cell carcinoma were identified. Operative parameters, pathologic findings and perioperative outcomes were
analyzed.
Results: Of a total of 24 patients, 12 underwent extended resections (8
extramesorectal lymph node dissection and 4 en-bloc resections) with a
median console operative time of 130 mins (interquartile range [IQR] 96152). Median tumor location was 1.5 cm (IQR 0.8-3.3) from the anal verge.
Median BMI was 28.9kg/m2 (IQR: 25.9-34.7). Twenty-one (87.5%) received
neoadjuvant chemoradiation. Median blood loss was 225 mL (IQR:115-385).
Resection was R0 in all patients with no patients having an incomplete
mesorectal resection. The median number of examined lymph nodes was
P77
LAPAROSCOPIC TECHNIQUE DECREASES IATROGENIC SPLENIC
INJURY RATES DURING COLORECTAL RESECTIONS.
O. Isik1, K. Snyder2, A. Erman1, H. Kessler1 and E. Gorgun1 1Colorectal
Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH and
2
Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
Purpose: Splenic injury can occur during colorectal surgery especially
in cases when splenic flexure is mobilized. The aim of this study is to analyze whether operative approach (laparoscopic versus open) was associated
with increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options.
Methods: All accidental injuries occurred during colorectal resections
performed at our Department between January 2010 and June 2013 were
identified from an administrative database. All patients with iatrogenic
splenic injuries were classified into two groups according to the operative
approach. Only procedures requiring splenic flexure mobilization were
62
Abstracts
included. Splenic injury management options and outcomes were compared.
Results: 2336 colorectal resections (1520 open, 816 laparoscopic) were
performed during the study period. There were 25 (1.1%) iatrogenic splenic
injuries. 23 out of 25 splenic injury occurred during open colorectal surgery. Overall, 16 (64%) patients were managed conservatively, 5 (20%) with
splenectomy and 4 (16%) with splenorraphy. 2 splenic injuries in the laparoscopic group were managed conservatively. Laparoscopic approach was
associated with a lower splenic injury rate (0.25% vs. 1.5%, p= 0.005) and a
lower need for splenectomy/splenorraphy (p=0.03).
Conclusions: Laparoscopic colorectal surgery is associated with a lower
risk of accidental splenic injury. Majority of the splenic injuries occurring
during colorectal resections may be managed with spleen preserving
approach.
P79
DOES THE ROBOT LEVEL THE PLAYING FIELD IN THE OBESE PATIENT
WITH RECTAL CANCER?
A. Pai, M. G. Hurtuk, J. J. Park, S. J. Marecik and L. M. Prasad Division of
Colon and Rectal surgery, Advocate Lutheran General Hospital, Park Ridge,
IL.
Purpose: Obesity presents challenges in the treatment of rectal cancer.
The outcomes of both open and laparoscopic surgery for rectal cancer in
the obese are less optimal than those in the nonobese patient. We compared the results of Robotic Total Mesorectal Excision (RTME) in the obese
and nonobese populace to determine if the robot with its ability to
enhance the surgeons’ abilities, neutralizes the impact of obesity with
respect to perioperative, short and long-term oncologic outcomes.
Methods: A prospectively maintained database at a tertiary referral
teaching hospital was reviewed. Clinicopathological data was collected on
all patients undergoing RTME for rectal cancer. Obese was defined as a
body mass index (BMI) greater than 30Kg/sq. meter. Data was analyzed
using SPSS 22.0 (IBM), statistical significance was defined as a p value ≤0.05.
Results: From August 2005 to August 2011, 86 patients undergoing
robotic resection for rectal cancer were identified. All patients were operated by a board certified colorectal surgeon. Sixty nine (80%) patients had
robotically assisted low or ultralow anterior resection and the remainder
17(20%) had an abdominoperineal resection. There were 27 obese [mean
BMI=34.5] and 59 nonobese patients [mean BMI 24.5]. Demographic data,
T stage and location were comparable between groups. Blood loss and
operative time were higher in the obese subgroup, though TME time
remained the same. Short term oncologic outcomes including circumferential margin positivity and lymph node yield were similar in both groups. The
conversion rate and anastomotic leak rate were similar. An analysis of longterm outcomes revealed a 3 year overall survival in obese patients of 88%,
versus 93% in the non obese [p =0.194]. The 3 year disease free survival was
68%, vs 88% in the obese and non-obese respectively [p=0.172]; indicating
similar long-term oncologic outcomes in both groups.
Conclusions: The performance of TME using Robotic assistance eliminates to a great extent the negative impact of obesity in rectal cancer surgery. We conclude that the robot does level the playing field in the obese
patient with rectal cancer and should represent the standard operation performed in these patients.
Distribution of colorectal resections and splenic injuries
P78
LAPAROSCOPIC VERSUS OPEN SURGERY IN PATIENTS WITH INTESTINAL BEHCET’S DISEASE.
S. Baek, C. Kim, M. Cho, H. Hur, B. Min, S. Baik, K. Lee and N. Kim
Department of Surgery, Yonsei University College of Medicine, Seoul,
Republic of Korea.
Purpose: Surgical treatment of intestinal Behcet’s disease (BD) is not
well established. In particular, it is still difficult to assess the clinical value of
laparoscopic surgery for it. We aimed to evaluate the clinical course and the
characteristics of laparoscopic surgery for intestinal BD comparing to open
surgery through our long-term experience.
Methods: We performed a chart review of 91 patients who underwent
surgical treatment for intestinal BD between January 1995 and December
2012, and compared the laparoscopic group (LG, n=30) and the open group
(OG, n=61) in terms of patient demographics, clinical features, operative
data, postoperative course, complications within 30 days after operation,
and long-term follow-up data retrospectively.
Results: Rate of female was higher in LG than in OG (63.3% vs. 36.1%,
p=0.014), and oral / genital ulcer was more frequent in LG (76.7% vs. 54.1%,
p=0.038; 60% vs. 36.1%, p=0.031). There were no differences in other demographics between groups. In terms of indication of operation, intractability
with medical treatment was dominant in LG (76.7% vs. 45.9%, p=0.02),
while intestinal perforation or fistula were in OG (10% vs. 44.3%, p=0.001).
Most patients received an ileocectomy (70% vs. 27.9%) or a right hemicolectomy (23.3% vs. 41.0%) as their first surgery, and emergency operation was similar in both groups (13.3% vs. 23.0%). In LG, the patients had
shorter operation time (162.0 vs. 228.5 min, p<0.001), and had lesser blood
loss (61.7 vs. 232.3ml, p=0.003) compared to patients who received open
surgery. There were no significances in post-operative complications, reoperation, mortality, and hospital stay between the groups. During follow-up
period, mean number of operation was lesser in LG than in OG (1.3 vs. 2.1,
p=0.011). The patient underwent operations over than twice was 20% in
LG and 50.8% in OG (p=0.005).
Conclusions: Laparoscopic surgery is feasible and safe in selective intestinal BD patients. In addition, LG provides improvements in post-operative
outcomes compared to OG.
Perioperative and short term oncologic outcomes of Robotic TME-Obese vs Non
obese patients
EBL=Estimated Blood Loss
LOS=Length Of Stay
CRM=Circumferential Resection Margin
P80
SHORT-TERM AND LONG-TERM ONCOLOGIC OUTCOMES OF ROBOTIC
CYLINDRICAL ABDOMINOPERINEAL RESECTION FOR RECTAL CANCER.
A. Pai, M. G. Hurtuk, J. J. Park, L. M. Prasad and S. J. Marecik Colon and
Rectal surgery, Advocate Lutheran General Hospital, Park Ridge, IL.
Purpose: Robotic cylindrical abdominoperineal resection [APR] is a new
technique in the armamentarium of the surgeon to treat low rectal cancers.
63
Abstracts
This technique reduces the rate of circumferential margin positivity and
iatrogenic perforation. We present our series of robotic AP Resections to
document the feasibility, safety, short term and long term outcomes .
Methods: 24 consecutive patients underwent a robotic assisted APR
with a standard technique and port position from April 2007 to July 2012.
Perineal dissection and specimen extraction was performed in the prone
position. Demographic data, perioperative, pathological and survival outcomes were analyzed.
Results: All patients had a robotic assisted APR for biopsy proven adenocarcinoma of the rectum, performed by a board certified Colo-Rectal surgeon. There were 15 males and 9 females. Mean age and BMI were 64.33
[Range 45-88] and 27.88 [Range 18-39] respectively. Stages were as follows:
Stage I [3 pts], Stage II [9 pts], Stage III [11 pts] and Stage IVa [1 pt]. All
except three patients received preoperative Chemoradiation. Perioperative
measures are shown in the table. There were no intraoperative complications. There was one elective conversion for lateral pelvic wall invasion. The
median length of stay was 6 days. Nine pts had procedural morbidity
including perineal wound problems [3pts], stoma problems [2 pts], small
bowel obstruction [3 pts] and one perineal hernia a year after surgery. The
average lymph node yield was 14.9. The Circumferential Resection Margin
[CRM] was positive in 4 patients, 3 of whom had extensive local disease,
necessitating multiorgan resections. True CRM positivity due to surgical
technique was therefore seen in only 1 out of 21 pts. There was one local
recurrence and 7 distant failures. With a median follow up of 26 months
[Range 1-66], the 3-year disease free and overall survival were 49% and 84%
respectively.
Conclusions: Robotic cylindrical APR is a technically feasible and safe
procedure. It is oncologically sound, provides superior visualization of the
pelvis and allows for controlled abdominal transection of the levators. It is
especially useful in locally advanced cancers in the narrow pelvis.
tively. ASA classification increased with age. O was less likely to receive
neoadjuvant/adjuvant therapy despite comparable tumor staging. There
was no difference in laparoscopy use, but conversions were significantly
more common in I and O, than in Y. Overall morbidity and mortality significantly increased with age. Multivariable analysis showed age, ASA, rectal
cancer, pelvic exenteration and open rather than laparoscopic surgery as
independent factors associated with increased perioperative morbidity.
While five-year overall survival was significantly decreased in older patients,
there were no significant differences in five-year cancer-specific survival
among the groups. Older age was associated with an increased overall
recurrence rate on univariable analysis (table), which was not confirmed on
multivariable analysis (p=0.27).
Conclusions: Although curative resections for colorectal cancer in
patients older than 80 years-old have higher perioperative morbidity and
mortality, they achieve long term cancer outcomes comparable to younger
patients. Age should not be a deterrent to offer the best treatment option
in octogenarians.
Patient characteristics by age group
Perioperative measures for Robotic APR
OR = Operating Room
EBL=Estimated Blood Loss
TME=Total Mesorectal Excision
P81
P82
SURGICAL AND ONCOLOGIC OUTCOMES FOR OCTOGENARIANS
WITH COLORECTAL CANCER.
L. Duraes1, L. Stocchi1, M. F. Kalady1, H. Kessler1, X. Liu2 and F. Remzi1
1
Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH and
2
Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH.
EFFECT OF PREOPERATIVE COLONOSCOPIC TATTOOING ON LYMPH
NODE RETRIEVAL IN T1 COLORECTAL CANCER.
J. Kang, I. Kim, K. Lee and S. Sohn Department of Surgery, Yonsei
University College of Medicine, Seoul, Republic of Korea.
Purpose: To identify the impact of preoperative colonoscopic tattooing
(PCT) on lymph node harvest in T1 colorectal cancer patients.
Methods: Included were 148 patients who underwent curative radical
resection and diagnosed as T1 colorectal cancer. These patients were categorized into 2 groups depending on whether preoperative india-ink tattooing had been performed. Clinicopathological findings were compared
between the two groups.
Results: The mean number of lymph node examined was 19.2 in the
tattooing group and 14.2 in the non-tattooing group (P = 0.002). The rate
of adequate lymph node harvest (retrieval of more than 12 lymph nodes)
was higher in the tattooing group than the non-tattooing group (77.8% vs.
58.5%, P = 0.018). PCT was significantly associated with the number of
nodes examined and adequate lymph node harvest in multivariate analysis.
Conclusions: Preoperative colonoscopic tattooing was associated with
higher lymph node yield in T1 colorectal cancer.
Purpose: Colorectal cancer is increasingly diagnosed in the elderly population. The contribution of age to postoperative morbidity and mortality
in elderly patients is not clearly defined. The aim of this study is to compare outcomes of curative colorectal resection in octogenarians to other
age groups.
Methods: An institutional database was queried to identify patients
with stages I-III colorectal adenocarcinoma, operated with curative intent
between 2000-2009. Exclusion criteria were emergency surgery, inflammatory bowel disease, hereditary colorectal neoplasia, and other malignancies. Three age-based groups were compared: younger (Y) if <65 y.o., intermediate (I) if ≥ 65 y.o. and < 80 y.o. and older (O) if ≥ 80 y.o. Univariable,
multivariable, and Kaplan-Meier survival statistical analyses were performed
to assess the independent influence of age on outcomes along with a number of other patient-related, disease-related and treatment-related factors.
Results: 1953 patients fulfilled the inclusion criteria (Y – 915, I – 785, O
– 253). The mean ages were 53.0, 72.4, and 84.6 y.o. for Y, I, and O respec-
64
Abstracts
Results: The study included 100 patients. Major operative complications occurred in 19% of patients with no post-operative mortality, reoperation was necessary in 14% of patients. The median overall survival rate and
progression-free survival rate were not reached yet., The overall survival
rates were: 90%, 70% and 68% at 3, 10 and 14 years respectively. The progression-free survival rates were 78%, 72% and 70% at 3, 10 and 14 years
respectively. Forty patients (40%) developed disease recurrence: in 77,5%
of cases it was localized to a single peritoneal area, while 9 patients presented recurrent diffuse peritoneal disease. Ten patients (25%) presented
multiple recurrences. Twenty-one patients (52,2%) recurred in the first year
after the CRS plus HIPEC procedure. Twenty-five patients (25%) underwent
a secondary extended CRS, associated, in 7 cases, to HIPEC, with similar
complications rate and mortality to the first treatment.
Conclusions: Cytoreductive surgery and HIPEC is the current standard
treatment for patients with PMP. Nevertheless, relapse is not unfrequent in
the first period after the procedure (52% of all recurrences within the first
year, in our experience). The repeated surgical exploration, including CRS
plus HIPEC, emerged as a significant factor for improved survival after the
first CRS plus HIPEC, as shown by 10 and 14 years overall and disease-free
survival, with acceptable complications and mortality rate.
P83
COLONIC STENTING FOR OBSTRUCTING RECTAL OR SIGMOID CANCER IS ASSOCIATED WITH A LOWER RATE OF COLOSTOMY.
A. Mabardy, J. Coury, R. Goldstein, P. Miller, A. Hackford and H. Dao Saint
Elizabeth’s Medical Center, Boston, MA.
Purpose: Patients presenting with acutely obstructing colon cancer can
be managed with the placement of a colonic stent as a palliative procedure, or as a bridge to eventual resection. The goal of our study was to use
a national database to analyze outcomes in patients with obstructing rectal or sigmoid cancer who underwent placement of a colonic stent.
Methods: For the year 2010, all patients with diagnoses of obstruction
and either rectal or sigmoid cancer were identified in the Nationwide Inpatient Sample (NIS) database. All patients undergoing placement of a colonic
stent were compared to non-stented patients for operative interventions,
as well as variables associated with complication and cost.
Results: In 2010, an estimated 478 patients underwent colonic stenting
for obstruction in the setting of rectal or sigmoid cancer. Patients with
obstructing cancer who underwent stenting were significantly less likely to
undergo resection or stoma creation during the same hospital admission
(14.9% vs. 42.4%, OR 0.24, 0.18-0.31). For those patients requiring an operative intervention, patients who received a stent were less likely to undergo
colostomy (14.1% vs. 42.5%, OR 0.22, 0.11-0.44). The median operative day
for stented patients was hospital day 6, versus hospital day 1 for patients
who did not have a colonic stent (p<0.0005). Stented patients were more
likely to undergo laparoscopic resection (21.1% vs. 9.3%, OR 2.61, 1.46-4.67).
When comparing all stented patients (including non-operative patients) to
operative patients without stenting, median total hospital charges ($43,208
vs. $71,194, p<0.0005) and length of stay (6 days vs. 10 days, p<0.0005)
were significantly lower.
Conclusions: Placement of a colonic stent for patients presenting with
obstructing rectal or sigmoid cancer is associated with a lower rate of
colostomy and a higher rate of laparoscopic resection. Many patients with
stents are discharged without surgical intervention, which likely contributes
to the decreased length of stay and total hospital charges for stented
patients. Further study is needed to identify patients who will benefit most
from stenting in this setting.
P85
THE PROGNOSTIC IMPACT OF “TUMOR BUDDING” AND ITS RELATIONSHIP WITH NEOADJUVANT CHEMORADIOTHERAPY IN PT2N0
AND PT3N0 RECTAL CANCER.
A. Sirin1, S. Sokmen1, M. Unlu2, N. Arslan1, H. Ellidokuz3, A. Canda1,
S. Sarioglu2 and M. Fuzun1 1Department of General Surgery, Dokuz Eylul
University, Izmir, Turkey, 2Department of Pathology, Dokuz Eylul University,
Izmir, Turkey and 3Oncology Institute, Dokuz Eylul University, Izmir, Turkey.
Purpose: : Aim of this study is to investigate the effect of neoadjuvant
chemo-radiotherapy(CRT) on prognostic impact of tumor budding.
Methods: The prospectively recorded database of patients with locally
advanced (pT2/pT3N0) rectal cancer who received neoadjuvant CRT(n=66)
and patients with early stage rectal cancer who did not receive neoadjuvant CRT(n=42) was reviewed. Isolated in a single cancer cell or a set of cells
formed fewer than five cancer cells were considered as “budding focus”. The
histologic examination was performed by x20 magnification of light
microscopy on selecting the area of maximum density of budding. “Budding intensity” was classified as mild (1 – 5), moderate (6-10), and severe (>
10) according to the intensity of the TB.
Results: The median follow-up was 23.4 months. The five-year overall
and disease-free survival rates were 83.5% and 77.5%, respectively. In the
multivariate analysis TB classification(OR=4.337) and distant
metastasis(OR=5.526) were independent prognostic factors for overall survival in all pT3N0 patients. For pT3N0 patients not treated with neoadjuvant CRT venous invasion(OR=11.250) was the only independent prognostic factor. Lymphatic invasion was highly significant as a prognostic factor
for disease-free survival in pT3N0 patients who were not treated with
neoadjuvant CRT(OR=5.247). While lymphatic invasion(OR = 8.222) was
identified as a strong prognostic factor in neoadjuvant CRT group, venous
invasion(OR= 15.600) was the only independent prognostic factor in
pT2/pT3-N0 cases who did not receive neoadjuvant CRT. Severe TB status(OR=4.401) and involved radial margin(OR=0.868) were also significant
for disease-free survival in pT2/pT3N0 patients who received neoadjuvant
CRT.
Conclusions: Tumor budding has an important impact on the prognostic stratification of rectal cancer. Neoadjuvant chemoradiotherapy enhances
the prognostic impact of this biological aggressive feature. It is essential to
estimate tumor budding, particularly in “controversial” so-called ‘early-stage’
patients with high-risk of local recurrence to tailor neoadjuvant therapy.
Colonic Stent for Obstructing Rectal or Sigmoid Cancer
P84
CYTOREDUCTIVE SURGERY AND HYPERTHERMIC INTRAPERITONEAL
CHEMOTHERAPY IN PATIENTS WITH PSEUDOMIXOMA PERITONEI
FROM APPENDICEAL TUMORS ORIGIN.
M. De Simone, M. Vaira, M. Robella and A. Mellano Unit od Surgical
Oncology, Scientific Institute for Cancer Research and Treatment, Candiolo,
Italy.
Purpose: Pseudomyxoma Peritonei (PMP) is a rare, low grade malignancy that usually originates from a ruptured mucinous appendiceal malignancy. Cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) is, nowadays, the treatment of choice.
However, a non negligible proportion of patients develop peritoneal recurrence: often they could benefit from a secondary CRS eventually associated
with HIPEC.
Methods: Patients affected by PMP who underwent CRS and HIPEC
from October 1995 to June 2013 in a single referral center were identified
from a prospective database. Overall survival, disease-free survival, morbidity and mortality rates were analyzed.
65
Abstracts
P86
P87
SAFETY, FEASIBILITY AND ONCOLOGIC OUTCOMES OF SYNCHRONOUS RESECTION OF COLORECTAL AND METASTATIC HEPATIC DISEASE.
K. Mathis, D. T. Colibaseanu, S. Y. Boostrom, D. M. Nagorney, E. J. Dozois
and B. G. Wolff Mayo Clinic, Rochester, MN.
PROTOCOLIZED CARE FOR PATIENTS UNDERGOING CURATIVE COLORECTAL CANCER SURGERY CAN OPTIMIZE THE SYSTEMIC INFLAMMATORY RESPONSE OF THE HOST.
G. Malietzis1, D. Scuppa1, A. Askari2, S. Nachiappan2, A. C. Currie2,
R. H. Kennedy1, O. Aziz2 and J. T. Jenkins1 1Colorectal Surgery, St Mark’s
Hospital, London, United Kingdom and 2Surgical Epidemiology, Trials and
Outcomes Centre, St Mark’s Hospital, London, United Kingdom.
Purpose: One fifth of patients diagnosed with colorectal cancer will
have liver metastases. When the disease is resectable, the most appropriate
sequence of therapies remains debated. Our aim was to determine
safety/feasibility and oncologic outcomes of synchronous resection of the
colorectal primary tumor and hepatic metastases.
Methods: We included all patients undergoing combined resection of
a colorectal primary tumor and hepatic metastases from 10/1999 to
11/2010. Patients were excluded if they underwent a staged approach or if
liver metastases were unresectable. Demographics, tumor/operative characteristics, and outcomes were recorded.
Results: One hundred sixty-nine patients (100 male) were included. Primary tumors were in the rectum in 88 and colon in 81. Fifty percent underwent neoadjuvant chemotherapy, and 21% also received external beam
radiation to the pelvis. The median number of lymph nodes (LN) was 17,
and 72% of patients had regional LN disease. The median number of presumed hepatic lesions preoperatively was 2, and the median number
removed was 2 (range 1-42); 46% had bilateral liver disease, 51% had at
least 3 liver segments removed, and 39% had 4 or more removed. Additional organs were resected in 35 patients, most commonly ovaries,
prostate, uterus, and vagina. Any 30-day morbidity occurred in 43% (Table
1), and 30-day mortality occurred in 1 patient (0.6%). Seventy-four percent
of patients went on to receive adjuvant chemotherapy. Median follow-up
time was 2.9 years, and 62% of patients developed a recurrence (liver most
common, 64% of those who recurred). Median overall survival (OS) was 5.3
years with 5-year OS at 51%. Median disease-free survival (DFS) was 1.4
years with a 5-year DFS of 31%. The single predictor of death was the need
to resect additional organs, and the single predictor of recurrence was the
presence of bilateral liver disease.
Conclusions: Synchronous resection of colorectal tumors with
resectable liver metastases is safe with very low mortality and acceptable
morbidity due to the joint expertise and prompt attention to surgical complications. This is our preferred approach to patients presenting with stage
IV disease and resectable liver metastases.
Purpose: A neutrophil to lymphocyte ratio (NLR) >3 has been shown to
be a surrogate marker of a host’s systemic inflammatory response and is
associated with poorer long-term oncological outcomes (disease-free and
overall survival) from curative colorectal cancer (CRC) surgery. There is however very little evidence on the factors that can be used to modify NLR to
<3 in the postoperative period. This study aims to examine these factors in
patients with primary operable colorectal cancer.
Methods: Prospectively collected data from consecutive patients with
a diagnosis of non-metastatic CRC undergoing elective surgical resection
between 2006 and 2011 were included. Laboratory blood test data collected within 4 weeks before and 6 to 8 weeks after surgery, included neutrophil, and lymphocyte count. Patients with preoperative value of NLR >3
that was changed to <3 postoperatively were considered to have a positive
change. Analysis considered predictive factors of “NLR optimization”, including age, sex, BMI, T and N stage, ASA, major complication (defined as
Clavien-Dindo >2), surgical approach and participation in an enhanced
recovery protocolized care pathway.
Results: 834 patients were included in the analysis with median age of
72 years [IQR, 63-81]. 183 patients (22%) had a positive change in their NLR
post-operatively. Multivariate regression analysis identified protocolised
care (OR 4.79, (95% CI 2.28 - 10.01) P<0.001) and BMI<25 kg/m2 (OR 2.31
(1.21 - 4.37) P=0.01) as an independent prognostic factors for “NLR optimization”.
Conclusions: From this cohort study, CRC patients treated with a protocolized care are more likely to have an optimised postoperative NLR.
Longer-term follow-up data is required to determine whether this can modify cancer outcomes in this patient group.
P88
NATIONAL COMPREHENSIVE CARE NETWORK GUIDELINES AS A
FRAMEWORK FOR RECTAL CANCER TREATMENT: AN ARGUMENT FOR
LESS AGGRESSIVE THERAPY IN SELECT PATIENTS.
B. Goslin1, M. May2, J. Pimiento2 and L. McCahill3 1Grand Rapids Medical
Education Partners, Grand Rapids, MI, 2Trinity Health, Grand Rapids, MI
and 3Metro Health, Grand Rapids, MI.
Table 1: 30-Day Morbidity and Mortality
Purpose: Compliance with National Comprehensive Care Network
(NCCN) treatment guidelines has been suggested as a measure of quality
of cancer care. We evaluated our cancer center’s compliance for patients
treated for adenocarcinoma of the rectum, specifically evaluating stage
specific compliance with recommended chemotherapy, surgery and radiation.
Methods: This was a retrospective cohort study (from a prospective
database) of patients who underwent treatment for a new diagnosis of rectal adenocarcinoma from 1/2010 to 10/2012. Patients were evaluated
prospectively in a multidisciplinary tumor board and clinic. Adherence to
NCCN guidelines and reasons for non-compliance was assessed by a nurse
quality specialist utilizing both clinical and pathologic staging.
Results: Twenty-six patients were treated for rectal adenocarcinoma of
which 8 were clinical Stage I, 6 Stage II, 10 Stage III, and 2 Stage IV. There
were 10 non-compliant events among 8 patients (30.8%). Age of non-compliant patients was 76.5 years vs. 53.6 years in compliant patients (p<0.05).
Reasons for non-compliance identified were 6 patients failing to undergo
radical surgical resection (median age 85 yo), 3 patients with non-compliant chemotherapeutic regimens (2 under-treatment,1 over-treatment) and
1 patient opted for hospice due to extensive disease.
66
Abstracts
Conclusions: Deviation from treatment guidelines for rectal cancer was
identified at our center, even when patients were evaluated prospectively
in a multidisciplinary fashion. Cause justification due to individual patient
conditions could be identified in all non-compliant patients. Compliance
assessment with national treatment guidelines alone may be a poor proxy
for quality of cancer care.
terns of treatment by geographic region, defined as: Northeast, Atlantic,
Southeast, Greatlakes, South, Midwest, West, Mountain, and Pacific. We also
evaluated patterns of treatment by facility type, defined as: Community or
Academic. A multivariable regression model was built to evaluate whether
differences in patterns of treatment exist when adjusting by stage, gender,
age and race.
Results: A total of 42,029 pts were analyzed. Sixty eight percent of all
patients with anal cancer and in particular, 88% of stage II and III (20150
pts), received chemoradiation. Age, gender, race and stage were all independent predictors of receiving chemoradiation. After adjusting for these
variables, chemoradiation treatment for stage II and III was not as widely
practiced in the West, Southeast (OR=0.76, 95% CI: (0.64, 0.90) and Mountain (OR=0.79, 95% CI: (0.64,0.98)) regions. Further, patients treated in academic based cancer programs were less likely to receive chemoradiation
compared to community cancer based programs (OR= 0.84 with 95% CI
(0.77,0.93).
Conclusions: When controlling for age, gender, race and stage, anal
cancer treatment practice pattern, discrepancy exists between geographical regions and facility types.
P89
LYNCH OR NOT LYNCH: CLINICAL TRANSLATION OF FINDINGS FROM
A PROSPECTIVE SURGEON-TRIGGERED PROGRAM TO UNIVERSALLY
SCREEN FOR MISMATCH-REPAIR DEFICIENCY IN PATIENTS WITH COLORECTAL CANCER.
Y. You, B. Bednarski, E. Vilar, G. J. Chang, B. W. Feig, J. M. Skibber, L. Ellis,
S. Bannon, M. Mork, P. M. Lynch and M. A. Rodriguez-Bigas University of
Texas MD Anderson Cancer Center, Houston, TX.
Purpose: Lynch Syndrome (LS) is defined by germline mutations in DNA
mismatch repair (MMR) genes and tumor microsatellite instability. Universal screening of colorectal cancers (CRC) for MMR deficiency (dMMR) is
being increasingly implemented to select patients for confirmatory
germline testing for LS. We describe the clinical determination of who
should be managed as LS based on tumor-based testing results.
Methods: A single-center surgeon-triggered prospective program of
universal screening for dMMR enrolled 1090 consecutive patients undergoing CRC resection with no prior diagnosis of hereditary CRC syndrome
between 2009 and 2013. Both MSI (PCR-based testing using a 7-marker
panel) and immunohistochemistry (IHC) for expression of MLH1, PMS2,
MSH2, and MSH6 proteins were performed. Secondary cascade testing
included MLH1 promoter methylation, BRAF mutation, and germline mutation testing of MMR genes as appropriate.
Results: The median age at surgery was 58 years (interquartile range:
50-67 years; range: 18 to 97 years). CRCs arose in the proximal colon in 281
patients (26%), distal colon in 273 (25%), and the rectum in 536 (49%).
Tumor testing was completed in 870 patients (80%), with both MSI and IHC
tested in 689 (79%), IHC only in 169 (20%) and MSI only in 12 (1%). Evidence
for MMR defect was found in 181 patients (21% of 870; 115 were MSI-high,
64 MSI-low, and 2 MSI-stable/abnormal IHC). Among those with MSI-high
CRC, 38 were due to MLH1 promoter methylation and/or BRAF mutation,
77 had presumed inherited dMMR. Germline mutation testing has completed in 68 patients. Pathogenic MMR mutations, or LS, were identified in
39 patients (57% of 68; MLH1: 14; MSH2: 8: MSH6: 15; PMS2: 2). Variants of
uncertain significance or uninformative negative results (6% and 37% of 68
respectively) were found in the remaining.
Conclusions: Universal tumor-based screening program identifies LS
patients with pathogenic MMR mutations. In the absence of somatic causes
of microsatellite instability, patients with presumed inherited dMMR but no
identifiable germline mutation should also be clinically managed as LS.
P91
THE NATURE OF SESSILE SERRATED ADENOMAS/POLYPS.
D. Liska and J. Church Colorectal Surgery, Cleveland Clinic Foundation,
Cleveland, OH.
Purpose: Sessile serrated adenomas/polyps (SSA/P) are precursor
lesions leading to CpG Island Methylator cancers, likely to be responsible
for most interval cancers in patients who fail colonoscopy screening.
Because these lesions are hard to detect endoscopically and the histological diagnosis has been subjective, the nature of SSA/Ps is incompletely
understood. In this large single endoscopist series of SSA/Ps, we eliminate
endoscopic variability in an attempt to establish the characteristics of
SSA/Ps and their association with synchronous and metachronous lesions.
Methods: This is a review of a single endoscopist’s polyp data collected
prospectively between 2004 (when pathology reporting of SSA/Ps became
acceptably reproducible) and 2013. All patients undergoing elective
colonoscopy where a lesion with a histological diagnosis of SSA/P was
found were included. Patients with serrated polyposis were excluded. Medical records and endoscopic reports were reviewed, and features of the
patients and the polyps were abstracted.
Results: A total of 441 SSA/Ps were removed from 272 patients. 148
(54%) of the patients were female and the mean age was 62 (± 11) years.
Indications for the exam at which the polyp(s) were found are in the table.
370 (84%) polyps were proximal to and including the splenic flexure, 54
(12%) were in the left colon, and 17 (4%) were in the rectum. Median size
for right sided lesions was 10.5mm (range 2-50) and for left sided lesions
was 7mm (range 3-25) (p < 0.001). 199 (45%) SSA/Ps were > 10mm. 30% of
patients had synchronous SSA/Ps, up to 5 in total. 57% had synchronous
adenomas and 52% had synchronous hyperplastic polyps. Cytologic dysplasia was found in 29 (6.6%) of the SSA/Ps and 19 (7%) of the patients had
a cancer. All polyps were either sessile or flat. All were removed by snare
(85%) or by cold biopsy excision (14%) without complications. 143 (53%)
patients underwent more than one colonoscopy (range 2-12), of which 39
(27%) had metachronous SSA/Ps.
Conclusions: SSA/Ps can be found in the proximal colon of relatively
young patients. They are often multiple, sometimes dysplastic, and synchronous and metachronous adenomas and hyperplastic polyps abound.
The risk for cancer in these patients is significant.
P90
PRACTICE PATTERNS FOR ANAL CANAL CANCER.
C. N. Budde1, L. Tsikitis1, J. S. Kim2, K. C. Lu1 and D. O. Herzig1 1Oregon
Health and Science University, Portland, OR and 2Portland State University,
Portland, OR.
Purpose: With just over 7000 cases per year in the United States, anal
canal cancer is a relatively uncommon disease when compared to other
gastrointestinal malignancies. Its treatment has evolved from a radical surgical treatment including abdominoperineal resection to a combined
chemoradiotherapy (CRT) (Nigro protocol) approach which allows for
sphincter preservation. The specific aim of this study was to examine practice patterns of treatment for patients with stage II and III anal cancer
among different geographic regions and facility types.
Methods: Patients with de-novo anal cancer were selected from the
National Cancer Database (NCDB) from years 1998-2010. We examined pat-
67
Abstracts
Indications for Colonoscopies
mary tumor (Group I) were case-matched with patients who underwent
treatment without initial resection (Group II) according to age, sex, ASA
classification, and number of organs involved with metastatic disease.
Results: 96 patients were matched from a total cohort of 249 patients
(215 Group I, 34 Group II) with stage IV RC. 54% were male and the mean
age was 60.3±11.2 years. Median survival times for Group I and Group II
were 15 (range 11-20) and 20.5 (6-29) months respectively (P= 0.54).Within
group I, 49 (73%) patients underwent anterior proctosigmoidectomy, 14
(21%) underwent abdominoperineal resection, 2 (3%) underwent Hartmann’s procedure, and 2 (3%) underwent total proctocolectomy with end
ileostomy. Treatment related mortality rate was 3% in Group I and 0% in
Group II. In Group I, post operative morbidity rate was 48 % (32 of 67
patients). In Group II, complications related to the unresected primary
tumor occurred in 2 patients: acute bowel obstruction requiring endoscopic
stenting (1) and rectovaginal fistula requiring stoma diversion (1). 4 patients
in Group II required palliative radiotherapy during the course of treatment
due to pelvic pain. The median number of in-hospital days during the
course of treatment was 10 (8-13) days in Group I and 1 (0-15) days in Group
II (p <0.001).
Conclusions: In patients presenting with minimally symptomatic Stage
IV RC, a treatment strategy of chemotherapy without resection of the primary tumor may minimize treatment-related morbidity, mortality, and days
spent in-hospital without adversely affecting survival. This may have important implications for quality of life in these patients with limited life
expectancy.
P92
TREATMENT OF ANAL CANAL SQUAMOUS-CELL CANCER IN A
SAFETY NET HOSPITAL: FACTORS INFLUENCING DIAGNOSTIC AND
TREATMENT DELAYS.
M. L. Leguyader1, S. Yerneny1, E. Bevier-Rawls1, G. Gagliardi2 and
G. R. Orangio1 1Department of Surgery, Louisiana State University, New
Orleans, LA and 2Department of Surgery, Tulane University, New Orleans,
LA.
Purpose: The aim of our study was to examine diagnostic and treatment delays and their correlation with demographic data, HIV status and
stage of disease in ACSCC patients treated at Louisiana State University
Interim Hospital (LSUIH).
Methods: Medical records of patients with the ICD 9 diagnosis of ACSCC
treated at LSUIH Between January 2008 and December 2012 were linked
with the Louisiana State Tumor registry and retrospectively analyzed for
diagnostic and treatment interval. Only patients with invasive ACSCC were
included.
Results: Of 29 patients (18 males; mean age 52.5 years) 14 (48%) were
African American, 15 were from high (>20%) poverty areas and 11 (38%)
were HIV positive, 10 of whom were males (MSM=9/10). There were 13
patients (45%) with localized disease (stage I-II) and 16 (55%) with
advanced disease (stage III-IV). Mean interval between onset of symptoms
and diagnosis was 52 weeks (±57.66 SD). Mean patient delay was 31 weeks
(±51.55 SD), mean health system delay was 19 weeks (±29.53 SD) and mean
treatment delay was 12 weeks (±1.89 SD). There was a correlation between
advanced stage of disease (stage III-IV) and shorter health system delay
(mean 8.313 ± 2.872 weeks for stage III-IV vs. 32.31 ± 10.84 weeks for stage
I-II; p=0.02). Diagnostic intervals were longer in HIV positive patients (mean
85.36 ± 23.08 weeks for HIV positive vs. 29.50 ± 6.553 for HIV negative;
p=0.01). This difference was largely due to longer health system delays
(mean 41.09 ± 11.63 weeks for HIV positive vs. 5.611 ± 1.755 weeks in HIV
negative; p<0.001). Longer diagnostic delays were also observed in males,
MSM and non-compliant patients. Treatment intervals were longer in HIV
positive patients (18.27 ± 4.415 weeks for HIV positive and 8.471 ± 1.240
for HIV negative; p=0.04).
Conclusions: Our study identified significant diagnostic and treatment
delays which were longer in HIV positive patients. Our findings suggest the
need of state-wide screening programs for HIV positive MSM. Moreover,
system changes need to be implemented in order to decrease diagnostic
delays in HIV positive patients.
Patients characteristic and matching variables
P94
HOW OFTEN ARE LARGE (≥10MM) HYPERPLASTIC POLYPS REALLY
SESSILE SERRATED POLYPS AND DOES IT MATTER? RESULTS OF A
RECLASSIFICATION ANALYSIS.
X. Wu1, J. M. Church1, M. F. Kalady1 and R. Pai2 1Colorectal Surgery,
Cleveland Clinic, Cleveland, OH and 2Anatomic Pathology, Cleveland
Clinic, Cleveland, OH.
Purpose: Sessile serrated adenomas/polyps (SSA/P) and hyperplastic
polyps are the two most common types of serrated colorectal lesions. While
SSA/Ps are a precursor lesion in the progression to CpG island methylator
phenotype cancer, hyperplastic polyps are generally not regarded as premalignant. These two types of polyps can be confused histologically and
several studies use 1cm right sided hyperplastic polyps as a surrogate for
SSA/P. This study was performed to see if this is reasonable.
Methods: Hyperplastic polyps ≥10mm on endoscopy were obtained
from a single endoscopist’s (JC) IRB approved polyp database. Histology
was reviewed bu one specialist GI pathologist and two groups created:
those where the histology report did not change (hyperplastic) and those
reclassified as SSA/P. Factors were analyzed by logistic regression to determine predictors for reclassification. Follow-up was analyzed by group to
determine the clinical significance of reclassification.
Results: There were 128 polyps from 112 patients. 68.0% of polyps were
reclassified as SSA/P in 66.1% of patients. Independent factors predicting
reclassification were the presence of synchronous SSA/Ps, polyp location
(proximal>distal) and polyp size. Follow-up data were available for 76
patients (see table). There was no difference in length of follow-up or the
number of colonoscopies between patients with hyperplastic polyps or
(reclassified) SSA/P. While the absolute rates of metachronous SSA/P and
P93
MANAGEMENT OF ASYMPTOMATIC STAGE IV RECTAL CANCER:
SHOULD THE PRIMARY TUMOR BE RESECTED?
F. Elagili, L. Stocchi, M. Kalady and D. Dietz Colorectal surgery, Cleveland
clinic, Cleveland, OH.
Purpose: The need for resection of the primary tumor in stage IV minimally symptomatic rectal cancer (RC) is controversial.
Methods: An IRB-approved cancer database and billing records were
queried to identify stage IV rectal cancer patients with a minimally-symptomatic primary tumor (no obstruction, perforation, or massive bleeding)
between 1980-2013. Patients who underwent initial resection of the pri-
68
Abstracts
adenomas were high, there was no difference between patients with an initial hyperplastic polyp and those with a sessile serrated adenoma/polyp.
Conclusions: Most serrated polyps 10mm or more in diameter are sessile serrated adenomas/polyps, and size is a reasonable surrogate for histology. However the histological diagnosis is less important than the size in
determining clinical significance.
P96
THE OUTCOME OF COLORECTAL NEUROENDOCRINE TUMORS
PATIENTS WHO CATEGORIZED BY NEW WORLD HEALTH ORGANIZATION GRADING SYSTEM.
T. Taketa1, S. Ohigashi1, N. Ishii2, Y. Fujita2, K. Suzuki3 and K. Ohta1
1
Gastrointestinal surgery, St Luke’s International Hospital, Chuo-ku, Japan,
2
Gastroenterology, St Luke’s International Hospital, Chuo-ku, Japan and
3
Pathology, St Luke’s International Hospital, Chuo-ku, Japan.
Follow Up.
Purpose: In 2010, WHO classification of NETs was updated based upon
morphological proliferation of tumor cells. Although this classification
seems to be useful to customize optimal treatment for CRNETs patients, literature is sparse for such patients. The aim of this study is to examine the
outcome of CRNETs who categorize by WHO grade system.
Methods: Between 2001 and 2011, we identified 53 CRNETs patients
who underwent surgical or endoscopic resection in our prospective database. All patients had reassessment of Ki-67 labeling index and mitotic rate.
We categorized them to Low grade (G1), Intermediate grade (G2) and neuroendocrine carcinoma (G3) based on 2010 WHO classification. Patients
with synchronus colorectal adenocarcinoma were excluded in this study.
Results: The median age was 54 years (range, 31-81), 35 patients
(66.0%) were male. Thirty-nine lesions (73.6%) were located in lower rectum and 11 lesions (20.8%) in middle rectum. Only 3 patients had colon
lesions. The median tumor size in greatest dimension was 5mm (1.5-65mm).
Forty-nine patients (92.5%) were classified as stage I, 2 patients as stage II
and 2 patients as stage IV according to AJCC 7th edition. In WHO classification, the number of patients with G1, G2 and G3 were 50 (94.3%), 1 (1.9%)
and 2 (3.8%), respectively. Of 50 patients with G1, 47 (94.0%) who had stage
I confirmed by imaging studies underwent endoscopic resection, and curative resection rate was 93.6% (44/47). Three patients with G1, one with G2,
and two with G3 were treated by surgical resection. Fifty-two out of total
53 patients remain alive at a median follow-up of 42.8 months (95% CI: 29.755.9). One patient who classified as G3 with liver metastasis died after 1.3
months of surgery. Meanwhile, one patient who classified as G2 with live
metastasis remain alive >10 years of surgery.
Conclusions: Our data suggests that endoscopic resection appears reasonable for patients who classified as G1 with stage I. Even if patients with
G1 or G2 have stage IV tumor, it may be possible to cure completely by surgical resection. However patients with G3 should be consider multimodal
treatments because of poor survival outcome.
P95
ANALYTIC VALIDATION OF PCR-BASED GENETIC TEST FOR PROGNOSTIC PREDICTION IN KOREAN STAGE II COLON CANCER PATIENTS: PRELIMINARY RESULTS.
B. Min, S. Bae, M. Cho, S. Baek, H. Hur, S. Baik and N. Kim Surgery,
Department of Surgery, Yonsei University College of Medicine, Seoul,
Republic of Korea.
Purpose: Evidences have shown that there are ethnic differences in
regards to genetic characteristics of colon cancer. This study aims to determine whether PCR-based genetic test with markers used in OncotypeDx is
valid in Korean stage II microsatellite stable colon cancer patients.
Methods: To make statistically significant results, enrollment more than
95 patients were necessary. Fifty six patients with both complete clinical
records and cryopreserved fresh snap-frozen tumor sample were enrolled
retrospectively and remaining 39 patients were enrolled prospectively.
Quantitative PCR were performed with 12 markers used in OncotypeDx and
Recurrence Score (RS) was calculated based on the expression of genetic
markers. Patient characteristics and recurrence prognostic factors were
analysed.
Results: Fifty six patients were enrolled retrospectively and 39 were
enrolled prospectively. Distribution of recurrence risk group determined on
calculated RS showed none in high risk group, 31 (32.6%) in intermediate
group, and 61 (67.4%) in low risk group. In 56 retrospective group, 4 (7.1%)
had recurrence. Three (7.3%) recurrence occurred in low risk group and 1
(6.7%) in intermediate group. Multivariate analyses including RS as well as
clinical parameters revealed that RS was not significant prognostic factor..
Conclusions: This is a preliminary study and available results are limited at this point. However, the distribution of recurrence risk group seems
to be significantly different from previous validation studies, which may
reflect ethic difference in genetic characteristics. For Korean colon cancer
patients, PCR-based genetic test in OncotypeDx may need to be further
evaluated.
P97
MUCINOUS COLORECTAL CANCERS: CORRELATION OF MICROSATELLITE INSTABILITY WITH CLINICOPATHOLOGICAL FEATURES AND SURVIVAL.
Y. Yoon1, C. Kim1, S. Hong2, I. Park1, S. Lim1, C. Yu1 and J. Kim1 1Surgery,
Asan Medical Center, Seoul, Republic of Korea and 2Pathology, Asan
Medical Center, Seoul, Republic of Korea.
Purpose: Colorectal adenocarcinoma with microsatellite instability
(MSI) has a characteristic clinicopathological profile, typically forming rightsided, younger onset, better prognosis, and frequent histology of poor or
mucinous differentiation. Mucinous adenocarcinomas (MAC) of the colorectum in general have been linked to slightly adverse prognosis in many studies. The purpose of this study was to evaluate association of MSI with clinicopathological features and oncologic outcomes in patients with MAC.
Methods: Tumor tissue samples obtained during curative surgery were
analyzed using MSI assay. As histological differentiation, patients were
divided into MAC and adenocarcinomas (AC). Clinicopathological parameters and survival outcomes were compared according to histological differentiation and MSI status. The median follow-up period was 43 months.
Results: Among 2025 patients, 84 patients (4%) were MAC and 202
patients (10%) were MSI. Patients with MAC were frequent in MSI tumors
(12%) than in microsatellite stable (MSS) tumors (3%, P < 0.001). Patients
with MAC had tumors characterized by younger age onset, right-colon
69
Abstracts
predilection, large-size, and high frequency of MSI compared with those
with AC (P < 0.001). Patients with MSI-MAC had characteristics of rightcolon predilection, large-size, and remarkably infrequent lymph node
metastasis compared with those with MSS-MAC (P < 0.001-0.005). Patients
with MSI-MAC showed lower 4-year recurrence rates and better overall survival rates than those with MSS-MAC (P = 0.018 and P = 0.046).
Conclusions: Clinicopathological characteristics of MAC were closely
related with MSI. The outcome for MSI-MAC tumor is better than that of
MSS-MAC, although this finding did not reach statistical significance in multivariate analysis.
Methods: All patients were treated using TEO© device and harmonic
scalpel according to Buess technique. We prospectively collected demographic, tumor characteristics and complication information using ClavienDindo classification.
Results: Fifty three patients were treated. There was no mortality. Overall morbidity rate was 50%. Patients with lesions under the first rectal valve
complicated more than de higher ones (p=0,034). Patients submitted to
neoadjuvant chemoradiotherapy (CRT) had 24 times more chance of presenting grade II complications (p=0,002), and 7,03 times more chance of
grade III complications (p=0,098). When the defect was treated using the
TEM device to perform or help with the rectal suture there was a 16 times
less chance of having grade III complications (p=0,043). There was no specific complications time behavior.
Conclusions: TEM post operative complications are acceptable and
usually self-limited. Patients submitted to neoadjuvant CRT, with distal
lesions, and submited to conventional suture deserve a higher attention.
Aparently, there was no time behavior of complications.
P98
CLINICOPATHOLOGIC CHARACTERISTICS OF PRIMARY COLORECTAL
LYMPHOMA.
J. L. Lee, C. Yu, K. Chang, W. Chae, J. Choi, C. Kim and J. Kim Surgery,
University of Ulsan, College of Medicine, Asan Medical Center, Seoul,
Republic of Korea.
P100
Purpose: The aim of this study is to summarize and analyze the clinicopathologic characteristics and therapy of PCL.
Methods: A retrospective study of patients who were diagnosed with
primary colorectal lymphoma (PCL) according to the criteria established by
Dawson et. al. at Asan Medical Center between 1996 and 2010, was conducted. Patients with previous treatment of PCL, other malignancy, and
patients with less than 24 months follow-up were excluded.
Results: Of 158 patients, 43 patients were excluded and 75 patients
were included. This group of patients was composed of 61 cases of B-cell
lymphoma and 14 cases of T-cell lymphomas, with a male to female ratio
of 2.3:1, and the median age at diagnosis was 54 year old. The common
symptoms encountered were abdominal pain (41.3%), hematochezia (20%),
diarrhea (18.6%). Among the 61 cases of B-cell lymphoma, 38 cases (62.3%)
were diagnosed as diffuse large B-cell lymphoma. Of the 61 cases, 43 cases
(70.5%) were of early stage (IE and IIE), and the 5-year overall survival (5OS)
rate was 82.5%, while those of stage IIIE and IVE comprised 18 cases (29.5%)
with a 5OS rate of 58.3% (P = 0.02). Among the 14 cases of T-cell lymphoma,
6 cases (42.9%) were diagnoses as NK/T-cell lymphoma and 5 cases (35.7%)
were of early stage with a median survival of 46 months and 8 cases (57.1%)
were stage IVE with a median survival of 1 months (P = 0.04). Surgery was
employed in 49 patients (65.3%), 14 patients (18.7%) received chemotherapy alone. Among the T-cell lymphoma, 3 patients (4%) were not treated
due to unstable condition. Nine patients (12%) received emergent operation due to bowel perforation and of 9 patients, 5 patients (6.7%) during
chemotherapy and 4 patients (5.3%) before diagnosis received emergent
surgery. Radical surgery following chemotherapy did not significantly
increase the patients’ 5OS, as compared with the chemotherapy alone
group (P = 0.2).
Conclusions: B-cell lymphoma, male predominance, and DLBCL in Bcell subtype, NKT in T-cell subtype are most encountered manifestation in
clinics. Cell types and stages had the greatest influence on 5OS. Tailored
surgery can reduce the emergent condition of the patients related to the
bowel perforation during chemotherapy.
SARCOPENIA IS NOT PREDICTIVE OF ANASTOMOTIC LEAK OR
LENGTH OF STAY FOLLOWING SURGERY FOR COLORECTAL CANCER.
K. Klingbeil, M. Brar, I. Datta, J. Heine, W. Buie and A. MacLean University
of Calgary, Calgary, AB, Canada.
Purpose: Sarcopenia is the loss of skeletal muscle mass, and has been
associated with worse outcomes in several conditions. However, the effect
of sarcopenia on short term outcomes following resection for colorectal
cancer remains unknown. Normalized psoas cross-sectional area (NPCSA)
on CT is a correlate of total body muscle volume, a measure of sarcopenia,
and may be predictive of a patient’s nutritional reserves. The purpose of
this study was to assess for an association between NPCSA and anastomotic
leak (AL) and length of stay (LOS) after colorectal cancer (CRC) surgery.
Methods: All patients aged 18-75 with CRC undergoing surgery from
2008-2010 in our health region were identified. Patients without a perioperative abdominal CT, no recorded height, stage 4 disease, or who did not
have an anastomosis were excluded. Risk factors of AL (age, gender, BMI,
comorbidities, anastomotic type) were abstracted from patient charts.
Patients were classified as having an AL based on radiologic or operative
findings. Total psoas area was measured at the superior limit of the L4 transverse processes, and was normalized by height. Average psoas density
(APD) was also recorded. NPSCA and other risk factors for AL were then analyzed in predicting AL and LOS.
Results: 439 patients were included, of which 40 patients had an AL.
Type of anastomosis is significantly associated with AL (p=0.001) on multivariate analysis, while NPCSA (p=0.09), APD (p=0.34), BMI (p=0.49), patient
age (p=0.49), gender (p=0.39) and comorbidities (p=0.22) are not. AL rate
is significantly higher in colorectal anastomosis below the peritoneal reflection (18%) than ileocolic (6%) or colocolic and colorectal anastomosis above
the peritoneal reflection (4%) (p<0.001). AL (p<0.001) and patient age
(p=0.002) are associated with LOS, while NPCSA (p=0.54), APD (p=0.71), BMI
(p=0.45), gender (p=0.41) and patient comorbidities (p=0.09) are not.
Conclusions: Sarcopenia, as defined by NPCSA, is not predictive of AL
or prolonged LOS following resections for CRC. Colorectal anastomoses
below the peritoneal reflection are high risk anastomoses. Advancing
patient age and presence of an AL predict an increase in the length of postoperative stay.
P99
POSTOPERATIVE TEM COMPLICATIONS FOR THE TREATMENT OF RECTAL NEOPLASIA ARE FREQUENT BUT MILD. RISK FACTORS AND TIME
BEHAVIOR STUDY.
C. F. Marques, C. S. Nahas, U. Ribeiro, L. L. Bustamante, R. A. Pinto,
E. K. Mory, I. Cecconello and S. C. Nahas Colorectal Division Digestive
Surgery Department, ICESP/HCFMUSP, São Paulo, Brazil.
Purpose: This study was designed to evaluate risk factors associated
with post operative complications after TEM local resection for rectal neoplasia.
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Abstracts
P101
USE OF WOUND RETRACTOR SYSTEM WITH DOUBLE GLOVES “THE
MEDANTA HANDPORT TECHNIQUE” FOR HAND-ASSISTED LAPAROSCOPIC COLECTOMY.
A. Singh, D. Sharma, M. S. Sharma and A. Chaudhary GI Surgery, GI
Oncology and Minimal Access Surgery, Medanta the Medicity, Gurgaon,
India.
Purpose: Hand assisted laparoscopic colonic resections offer some distinct advantages over the conventional laparoscopy. One of the common
criticisms with this is the additional cost of the hand port. We share our
experience with our simple technique of using wound retractor with double gloves as Handport, which we have described as “The Medanta Handport Technique”
Methods: After diagnostic laparoscopy to rule out distant metastases,
we place wound retractor (Alexis R, Applied Medical) through premarked 5
cm periumbilical incision. Surgeon wears a normal pair of gloves followed
by latex free green gloves (Ansell Dermaprene R ultra) on non dominant
hand. These gloves are preferred as they are thick and help in maintaining
pneumoperitoneum. The non dominant hand with double gloves is then
introduced into peritoneal cavity and the outer pair of green glove is rolled
back around the outer ring of the wound retractor. Ports are then placed in
right lower and mid abdomen. The surgery then proceeds as with conventional handport and the same handport is used for specimen extraction,
anvil placement and stapler firing at the end of dissection.
Results: Between Oct 2010 to Oct 2013, 210 patients underwent laparoscopic left colectomy at our institution. Out of these, 170 (81%) were performed using this indigenous handport. Malignancy was the most common
indication (150, 88%). Adjacent organ resection was performed in 18
patients with malignancy in view of the advanced disease. In 15 patients,
there was history of prior abdominal surgery with intra abdominal adhesions which could have otherwise not possible with pure laparoscopy. The
average operative time was 58 minutes (range 40-80 minutes) with lymph
nodes harvest of 14 (8-22). The distal transaction was performed by endoscopic linear stapler (one firing in 85%, two in 15%).
Conclusions: The benefits of hand assist laparoscopy as compared to
pure laparoscopy can be offered to patients with colorectal cancers maintaining the oncological parameters and at a lesser cost as compared to pure
laparoscopy by using this simple “The Medanta Handport Technique”
Position of handport and the technique
P102
MODERATE BLOOD TRANSFUSION TRIGGERS AND SURGICAL SITE
INFECTIONS IN COLORECTAL SURGERY.
C. W. Hicks1, J. O. Wasey2, S. M. Frank2, J. A. Freischlag1, M. A. Makary1 and
E. C. Wick1 1Department of Surgery, The Johns Hopkins Hospital, Baltimore,
MD and 2Department of Anesthesiology/Critical Care Medicine, The Johns
Hopkins Hospital, Baltimore, MD.
Purpose: The decision to transfuse can be difficult given the potential
concern for ongoing bleeding in the context of physiologic fluid shifts following major surgical procedures. Guidelines support restrictive hemoglobin (Hb) transfusion triggers (7-8 g/dL) following major surgical procedures
based on randomized trials demonstrating equivalent outcomes and observational studies showing decreased infections compared to higher transfusion triggers (10 g/dL). Our aim was to evaluate the association between
moderate transfusion triggers (7-9g/dL) and surgical site infections (SSI).
Methods: We prospectively followed all patients undergoing colorectal
surgery at an academic tertiary medical center (07/2010-11/2012). SSI and
blood utilization (blood transfusions and Hb prior to transfusion) were
measured using ACS-NSQIP and institutional blood utilization databases.
Multivariate regression was used to determine impact of transfusion on SSI.
Results: 337/829 (38%) colorectal surgery patients had a nadir Hb of 79 g/dL during hospitalization. Transfused patients (35.9%, 121/337) were
71
Abstracts
older (61±16 vs. 52±16 years; p<0.0001) with a higher proportion of males
(47.1% vs. 34.3%; p=0.02) and higher mean ASA class [3 (IQR 3,3) vs. 3 (IQR
2,3); p<0.0001] compared to non-transfused patients. There were no differences in race, body mass index, wound classification, smoking history, or
COPD between groups. On univariate analysis, SSI incidences were similar
between transfused and non-transfused patients (Table). The risk-adjusted
odds of SSI after transfusion was 1.1 (95% CI 0.63, 1.89; p=0.74) after
accounting for standard general surgery NSQIP risk factors for SSI.
Conclusions: Use of a moderate hemoglobin transfusion trigger (7-9
g/dL) does not increase risk of SSI. Blood transfusions can be used judiciously without increased risk of morbidity in colorectal surgery.
Univariable Analysis of Surgical Site Infections (SSI) and RBC Transfusion
P103
THE POSTOPERATIVE BURDEN OF HOSPITAL ACQUIRED CLOSTRIDIUM DIFFICILE INFECTION.
Z. Abdelsattar1, G. Krapohl1, L. Alrahmani2, M. Banerjee1, R. Krell1,
S. Wong1, D. Campbell Jr1 and S. Hendren1 1Department of Surgery,
University of Michigan, Ann Arbor, MI and 2Obstretics and Gynecology,
Wayne State University, Detroit, MI.
P104
CT SCANS IN CROHN’S DISEASE: PREDICTORS OF YIELD.
K. Wallace, D. Popowich, D. Chessin, J. Deliz, S. Gorfine and J. Bauer
Department of Surgery, Icahn School of Medicine at Mount Sinai, New
York, NY.
Purpose: Clostridium difficile infection (CDI) is a common hospital
acquired infection. Previous reports on CDI’s incidence & risk factors in the
surgical population are limited by small numbers or the use of administrative data. This prospective study examines the burden of postoperative CDI
at 52 Michigan Surgical Quality Collaborative hospitals.
Methods: We prospectively identified patients with laboratory-confirmed postoperative CDI after 40 different general, vascular, or gynecologic
surgeries at 52 academic & community hospitals between 7/2012-9/2013.
To rule out community acquired CDI, we excluded patients with a positive
result ≤72 hours of admission. We used multivariate regression models with
robust standard errors to identify CDI risk factors and assess CDI’s association with resource utilization.
Results: Of 35,363 patients, 179 (0.51%) developed postoperative CDI.
The highest rates of CDI were after lower extremity amputation (2.6%), followed by bowel resection/repair (0.9%) and gastric/esophageal surgery
(0.7%), while gynecologic and endocrine surgery had the lowest rates (0.1
& 0%, respectively). On multivariate analyses, only older age, hypoalbuminemia (≤3.5 g/dL) and preoperative sepsis were independent patient risk
factors for CDI. Use of prophylactic antibiotics was not associated with CDI,
neither was sex, BMI, surgical priority, weight loss or 20 other co-morbid
conditions. 3 procedure groups had higher odds of postoperative CDI:
Lower extremity amputations (OR=3.5, p=0.03), gastric/esophageal surgery
(OR=2.1, p=0.04) & bowel resection/repair (OR=2, p=0.04). Postoperative
CDI was independently associated with resource utilization measures
(Table), including length of stay (mean 13.7 vs 4.5 days, OR=4.8), emergency
room presentations (18.9 vs 9.1%, OR=1.6) & readmissions (38.9 vs 7.2%,
OR=2.8).
Conclusions: Incidence of postoperative CDI varies by surgical procedure. Older age, hypoalbuminemia, preoperative sepsis & specific procedures carry markedly elevated risks for the development of CDI. Postoperative CDI is also associated with higher rates of extended length of stay,
emergency room presentations & readmissions, which places a potentially
preventable burden on hospital resources.
Purpose: Computed tomography (CT) is increasingly being utilized in
the evaluation of Crohn’s (CD) patients, despite its significant cost and radiation burden. Two previous studies at centers with low numbers of CD
patients/year, indicated that there is a subset of CD patients who received
a disproportionate number of CT scans. We aimed to investigate if these
findings held true at our institution, which sees a large volume of CD
patients/year. Identification and proper management of this subset of
patients may help avoid unnecessary CT scans and therefore reduce the
patient’s radiation exposure, and cost of management.
Methods: A retrospective chart review was conducted for patients
treated at Mount Sinai Hospital from 2000-2013. Inclusion criteria were
patients with abdominal CD who underwent at least one surgery and had
at least one CT scan during the study period. High CT utilizers (HCTUs) was
defined as ≥ 4; low CT utilizers (LCTUs) was defined as CTs ≤ 3 during the
study period. Data collected included total number of CT scans, surgeries,
emergency room (ER) visits, admissions, endoscopies, and pain clinic visits.
A CT scan ‘leading’ to a surgical intervention was one being done within 3
months of intervention.
Results: A total of 203 patients met the inclusion criteria. Within this
cohort, 26.1% were classified as HCTUs. HCTUs accounted for 59.9% of all
CT scans performed and 38% of all surgeries. Within the HCTUs, 31.0% of
all CT scan led to surgical intervention, compared to 49.8% of CT scans performed for LCTUs. HCTUs accounted for 79.4% of all pain clinic visits, 58.0%
of all ER visits, 44.4% of all admissions, and 42.9% of all
endoscopies/colonoscopies.
Conclusions: Our data is similar to previous reports in that there is a
subset of CD patients who obtain a greater amount of low yield CT scans.
In particular, our data shows that although HCTUs account for 26.1% of the
cohort, they are responsible for a disproportionately larger amount (59.9%)
of CT scans; with a smaller percentage (31.0%) of their scans leading to surgical intervention. HCTUs are more likely to be followed in pain clinics and
72
Abstracts
pose of this study was to determine how the combined implementation of
these programs affected outcomes at a single institution.
Methods: This was a retrospective cohort study. Institutional National
Quality Improvement Program (NSQIP) data files were used to identify
patients undergoing major CRS (including partial colectomy, Hartmann
procedure, total abdominal colectomy with or without proctectomy, low
anterior resection, abdominoperineal resection, proctectomy, and pelvic
exenteration) at our institution from 9/06 to 3/13. Only elective surgeries
performed by board certified colorectal surgeons were considered. Two
major quality improvement initiatives were implemented during the study
period: 1) the ERP in 2/10 and 2) the SSI bundle in 7/11. To evaluate the
combined affect of these programs, the cohort was divided into to two
groups: Pre-ERP and SSI bundle (Pre-E&B) (9/06-12/09) and Post-E&B (1/12–
3/13). The groups were then propensity matched on the following covariates: age, sex, BMI, procedure type, laparoscopy, diabetes, and recent
chemo- or radiotherapy. NSQIP outcomes were then determined and compared between the two groups.
Results: 518 patients included in the study: 328 Pre-E&B and 210 PostE&B. After propensity matching, the two groups were of equal-size with balanced baseline characteristics. Following ERP and SSI bundle implementation, there was significant reduction in length of stay (6 days Pre-E&B vs. 4
days Post-E&B, P<0.001), unplanned reoperation (9% vs. 3.8%, P=0.47),
superficial SSI (19.5% vs. 5.2%, P<0.001), organ space SSI (6.7% vs. 1.9%,
P=0.027), and sepsis (8.1% vs. 0.5%, P<0.001).
Conclusions: Implementation of the ERP and SSI bundle has resulted in
faster recovery and reduced wound infection complications after colorectal
surgery. Furthermore, the reduced rates of unplanned reoperation, organ
space infection, and sepsis indicate a lower rate of major complications
after the advent of these programs.
have more ER visits. These two factors may therefore be significant predictors of low-yield CT scans.
P105
WHAT FACTORS PREDICT HOSPITAL READMISSION AFTER COLORECTAL SURGERY?
B. Almussallam, P. W. Marcello, P. L. Roberts, T. D. Francone, T. E. Read,
J. F. Hall, D. J. Schoetz and R. Ricciardi Colon and Rectal Surgery, Lahey
Hospital & Medical Center, Burlington, MA.
Purpose: There is a growing interest in hospital readmission rates as an
indicator of healthcare quality. We defined factors associated with hospital
readmission following colorectal surgery, so that determinations of outcome can be properly risk adjusted.
Methods: We ascertained the rate of readmission in consecutive
patients who underwent colorectal surgery using our electronic medical
record merged with University HealthSystem Consortium data from July
2007 through June 2011. We examined the risk of readmission in relation
to age, sex, tobacco use, alcohol use, cohabitation, comorbidity score, use
of anxiolytics, ASA score, socioeconomic factors, inpatient procedure, elective surgery, procedure classification, stoma creation, surgeon of record,
complication, and discharge destination. Then, we developed multivariate
models to test for associations between readmissions and the preceding
risk factors.
Results: In a cohort of 4,879 patients who underwent colorectal surgery, 492 patients (10%) were readmitted to the hospital within 30 days of
discharge. In univariate analysis, patient factors associated with risk of readmission were female sex (11%), age greater than 60 (12%), multiple comorbid conditions (19%), and use of anxiolytics (17%). Procedural factors associated with risk of readmission included stoma creation (22%), pouch
surgery (22%), and total proctocolectomy (30%). Postoperative factors associated with risk of readmission were discharge to rehabilitation (24%) and
postoperative complication (28%). In multivariate analysis, use of anxiolytics, comorbidity score, inpatient surgery, postoperative complication, and
stoma creation but not surgeon of record were all associated with risk of
readmission (Table).
Conclusions: Several patient, procedural, and postoperative factors are
associated with risk of readmission. Exceedingly high rates of readmission
were noted following stoma creation, pouch procedures, and proctocolectomy. Surgeon of record was not associated with risk of readmission, indicating little value to the use of readmission as a physician-specific indicator
of quality.
Table: Adjusted outcomes after propensity-matching of patients undergoing
major colorectal surgery pre- and post- implementation of the ERP and SSI bundle
Table. Readmission Rates by Risk Factor (n=4879)
Groups propensity-matched for use of the ERP and SSI bundle, matching on the
following covariates: patient age, sex, BMI, procedure type (partial colectomy, low
anterior resection, abdominoperineal resection, total abdominal colectomy with or
without proctectomy, isolated proctectomy, Hartmann procedure, or pelvic
exenteration), laparoscopic vs. open approach, diabetes, recent chemotherapy, and
recent radiotherapy. ERP=enhanced recovery pathway; SSI=surgical site infection;
E&B=ERP and SSI Bundle; Q1=first quartile; Q3=third quartile.
P106
THE ENHANCED RECOVERY PROGRAM AND SURGICAL SITE INFECTION BUNDLE MARKEDLY IMPROVES OUTCOMES IN COLORECTAL
SURGERY.
J. E. Keenan, P. J. Speicher, J. Migaly, C. R. Mantyh and J. Thacker Surgery,
Duke University Medical Center, Durham, NC.
Purpose: Enhanced recovery programs (ERP) have improved outcomes
in colorectal surgery (CRS). In addition, preventative surgical site infection
(SSI) bundles have reduced wound complications following CRS. The pur-
73
Abstracts
post-discharge cardiac complications. The incidence of deep venous thrombosis (DVT) during the hospital stay (2.8%) and post discharge (1.4%) was
significantly higher (p<0.05) in the UC group compared to the other groups.
The 30-day readmission rate in patients with UC (22.2%) was significantly
(p<0.001) greater than in patients with colorectal cancer (11.7%), CD
(16.3%) and DD (9.3%). Significant predictors for 30-day readmission on
multivariate logistic regression included preoperative radiation therapy,
operative time, postoperative wound and organ space infections, UC, DVT
and acute renal failure.
Conclusions: Among patients undergoing elective colorectal resection,
UC comprise a high-risk group who are at increased risk for readmission
because of higher post discharge complications. Given that the incidence
of in hospital and post discharge DVT in UC is higher than colorectal cancer, role of post discharge chemical DVT prophylaxis in UC warrants further
investigation.
P107
PERIOPERATIVE USE OF TAMSULOSIN SIGNIFICANTLY DECREASES
RATES OF URINARY RETENTION IN MEN UNDERGOING PELVIC SURGERY.
V. Y. Poylin, T. Curran, T. Cataldo and D. Nagle Colon and Rectal Surgery,
Beth Israel Deaconess Medical Center, Boston, MA.
Purpose: Urinary retention (UR) is a common complication of pelvic surgery, leading to urinary tract infection and prolonged hospital stay. Tamsulosin is an alpha blocker that works by relaxing bladder neck muscles and
is used to treat benign prostatic hypertrophy and UR. We aim to investigate
the potential benefits of preemptive tamsulosin use on rates of UR in men
undergoing pelvic surgery
Methods: This a retrospective review of all men undergoing pelvic surgery at a single institution from 2004 to 2013. Patients prescribed baseline
alpha blockade and those with a need for prolonged urinary monitoring
(i.e. bladder repair) were excluded. Patients given 0.4 mg of tamsulosin 3
days prior and for at least 3 days after surgery at discretion of the surgeon
starting in 2007 (study group) were compared to patients receiving expectant post-operative management (control group). Rates of post-operative
UR as well as other complications were reviewed
Results: 185 patients were included in the study (Study group: N=30;
Control group: N = 155). Study group patients were younger (50.1 vs. 56.8
years) and more likely to be operated for cancer (77 vs. 47%) while control
group patients were more likely to be operated for ulcerative colitis (44%
vs. 20%). Overall UR rate was 22% with significantly lower rates in study
group as compared to controls (6.7 vs. 25%, p=0.029). Rates of other complications were similar between groups. Study group had higher rates of
minimally invasive surgery (MIS) (61 vs. 29.7%), however, this did not impact
UR rate (20.6 vs. 22.7% for MIS vs. open surgery; p=0.852). UR increased
length of stay (7.9 vs. 6.1 days; p=0.008). Independent predictors of UR
included lack of preemptive tamsulosin (OR: 7.67; 95%CI: 1.4-41.7) and cancer location in the distal third of the rectum (OR: 18.8; 95%CI: 2.1-172.8).
Study group inclusion showed a trend for lower UR rate in patients with
distal rectal cancers (55.6 vs. 83.3%, p=0.058)
Conclusions: Preemptive perioperative use of tamsulosin may significantly decrease the incidence of UR in men undergoing pelvic surgery. This
may play a role in improving length of stay through avoidance of UR particularly in patients with distal rectal cancer
post discharge complication
P109
IDENTIFICATION OF PERIOPERATIVE CHARACTERISTICS ASSOCIATED
WITH SSI AFTER COLECTOMY: A TEMPLATE FOR QUALITY IMPROVEMENT AT THE INSTITUTIONAL LEVEL.
V. O. Shaffer1, C. D. Baptiste3, Y. Liu2, J. K. Srinivasan1, J. R. Galloway1,
P. S. Sullivan1, C. A. Staley1, J. Sharma1, T. W. Gillespie1 and J. F. Sweeney1
1
Surgery, Emory University, Atlanta, GA, 2Biostatistics, Rollins School of
Public Health, Emory University, Atlanta, GA and 3School of Medicine,
Emory University, Atlanta, GA.
Purpose: A study of U.S. hospitals estimated the number of healthcareassociated infections to be over 1.7 million. Surgical site infections (SSI)
accounted for 22% of these infections. The purpose of this study was to
determine factors associated with SSI.
Methods: Combining data from the American College of Surgeons
National Surgical Quality Improvement Project (NSQIP) with medical record
abstraction, we evaluated 365 patients who underwent colorectal resection from January 2009 to December 2012 at a single institution. Of the 365
patients, 84 developed SSI. We compared the two groups using Chi-square
test, ANOVA, and logistic regression.
Results: Covariates: age, gender, BMI, ASA, hematocrit, glucose, smoking, diabetes, albumin, Charlson comorbidity score, colostomy/ileostomy
status, surgeon volume, intraop temperature, surgical prep, preop antibiotic, redosing, steroid use, transfusion, cancer, operative time, and wound
class. On univariate analysis, risks associated with SSI included: cancer,
ileostomy or colostomy at the start of the case; lack of timely intraop redosing of antibiotics; patient temperature <36°C for > 60 mins and higher glucose values within 48 hrs postop. The median number of cases per surgeon
was 36, and a case-volume below the median was associated with a higher
risk of SSI. Operative time >191 mins and contaminated wound class were
also associated with developing SSI. The association was also tested by univariate logistic regression (Table 1). In the multivariate analysis, risks associated with SSI included: cancer [OR=4.11, P<.001]; transfusion ≥5 units
within 72 hrs preop [OR=3.29, P=.031]; operative time >191 mins [OR=2.44,
P=.004]; surgeon volume <36 cases [OR=1.83, P=.048]; higher glucose levels [OR=1.06, P=.019] (Table 1).
Conclusions: In this study, SSI was most highly associated with patient
characteristics- cancer and transfusion, operative conditions- length of
operation and surgeon volume, and postop conditions- glucose control.
Identifying risk factors enables targeting areas for intervention to improve
P108
DETERMINANTS OF READMISSION AFTER ELECTIVE COLORECTAL
SURGERY.
A. Sundaram, C. A. Ternent, S. Baker, J. S. Beaty, N. L. Bertelson,
G. Blatchford, M. Shashidharan, A. Forse and A. G. Thorson Surgery,
Creighton University, Omaha, NE.
Purpose: Determine 30-day readmission rates after elective colorectal
surgery and evaluate risk factors for readmission.
Methods: Retrospective review of the American College of Surgeons’
National Surgical Quality Improvement Program (NSQIP) 2011 database was
performed to identify patients who underwent elective colorectal resection
for colorectal cancer, Crohn’s disease (CD), Ulcerative colitis (UC) and diverticular disease (DD).
Results: Eleven thousand and eighty nine patients satisfied study criteria [colorectal cancer (8632), CD (1137), UC (931), DD (389)]. Patients with
colorectal cancer (median: 66.2 years) were significantly older than the
other groups and more likely to have a history of cerebrovascular disease.
No difference in history of cardiac disease existed between the groups.
Patients with CD (41%) and UC (47%) were more likely (p<0.001) to be on
steroids preoperatively than patients with colorectal cancer (2%) or DD
(2.1%). Thirty-day mortality and readmission rates for the study population
were 1.3% and 13%, respectively. Incidence of certain post-discharge complications was significantly greater in patients with UC as depicted in the
Table. No significant difference between the groups was noted in terms of
74
Abstracts
Adjusted odds ratios and 95% confidence intervals for 30-day outcomes by MELD
the quality of care and patient outcomes, and also improves informed decision-making by patient and physician.
Table 1. Risk Factors Associated with SSI
*Logistic regression model controlling for age, gender, race, body mass index,
diabetes, tobacco, alcohol use, congestive heart failure, cardiac disease, pulmonary
disease, recent weight loss, functional status, disseminated cancer, surgical indication,
colectomy vs proctectomy, wound class, preoperative hematocrit, preoperative
albumin, dialysis, hypertension, American Society of Anesthesiologists (ASA) class,
ascites, varices, bleeding disorder, operative year, laparoscopic vs open approach,
operative time
P110
30-DAY MORBIDITY AND MORTALITY FOR ELECTIVE COLORECTAL
RESECTION IN PATIENTS WITH LIVER DISEASE: AN ACS-NSQIP STUDY.
E. O. Lange, C. C. Jensen, G. B. Melton, R. D. Madoff and M. R. Kwaan
Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN.
MELD, Model of End-stage Liver Disease; OR, odds ratio; CI, confidence interval
P111
HOSPITAL STAY < 4 DAYS FOLLOWING RESECTION FOR COLORECTAL
CANCER IS ASSOCIATED WITH DECREASED VENOUS THROMBOEMBOLIC EVENTS.
A. C. Pellet, P. Callas and J. Moore Fletcher Allen Health Care/ University
of Vermont, Burlington, VT.
Purpose: Patients with liver disease face significant risk of complications and death when considering elective colorectal resection for benign
or malignant indications. However, incomplete data limits our ability to
counsel these patients to make informed treatment decisions. We sought
to determine the relationship between Model of End-stage Liver Disease
(MELD) score and 30-day outcomes in patients undergoing elective colorectal resections.
Methods: Adult patients who underwent elective colorectal resection
for benign or malignant indications from 2005-2011 were identified from
the National Surgical Quality Improvement Program (NSQIP) database.
Patients who were missing laboratory values necessary to calculate the
MELD score were excluded (61% of 81,346 cases identified). Differences in
patient- and disease-related characteristics by MELD categories were
assessed with Chi-square analyses. Thirty-day mortality and major morbidity were examined using logistic regression.
Results: Of 31,950 patients undergoing elective colorectal resections
(61% open approach, 14% including proctectomy), most (60%) were performed for colon or rectal cancer; other benign indications included diverticulitis (20%), polyp (10%), and inflammatory bowel disease (10%). 58% of
patients had a MELD score of 7 or greater. Increasing MELD score was associated with older age, higher BMI, higher ASA class, lower albumin, and
higher rates of diabetes, pulmonary and cardiac disease, hypertension, and
dependent functional status. In univariate analysis, patients with higher
MELD scores had a greater risk of 30-day mortality (MELD <7, 0.69%; 7-11,
1.62%; 11-15, 4.52%; >15, 5.01%; p<0.0001). After controlling for other
comorbidities, MELD score remained a significant predictor of 30-day mortality and respiratory complications (Table).
Conclusions: Consistent with prior reports, patients with liver disease,
as measured by MELD score, have a significantly higher risk of death and
major morbidity in the thirty days following elective colorectal resection.
These results can facilitate a more informed discussion with patients when
considering an elective operation, particularly for benign or otherwise
asymptomatic conditions.
Purpose: Using Fast-Track Protocols, patients can be ready for discharge
2-4 days after surgery for colorectal cancer. In this group, a prolonged
course of VTE chemoprophylaxis may decrease the risk of VTE. As patients
are discharged sooner, the duration of routine inpatient prophylaxis is often
truncated. Additionally, with early discharge there is an assumption that
patients will not be sedentary at home. We aim to identify if we are inadvertently increasing VTE incidence with shorter length of stay and VTE prophylaxis.
Methods: Using the NSQIP database we looked at all patients who
underwent resection for colorectal cancer between 2008-2011. Patients
with complications other than VTE were excluded. Patients were classified
into length of stay (LOS) <4 days or LOS ≥4 days. 2764 (8%) patients with
LOS>14 days were excluded. 30 day postop incidence of DVT & PE was
assessed.
Results: 29,710 patients met inclusion criteria. 4,076 had a LOS<4 days,
25,634 had a LOS≥4 days. There were 9 occurrences (0.2%) of DVT in the
LOS< 4 group compared to 200 (0.8%) in those with a LOS ≥4 (P < 0.001).
There were 4 occurrences (0.1%) of PE in those with LOS<4 days compared
to 133 (0.5%) for LOS ≥4 days (P < 0.001). There was a significantly higher
proportion of patients with ASA class>1 in the LOS ≥4 days cohort. Differences in VTE remained highly significant after adjusting for functional status.
Conclusions: We found that uncomplicated patients with hospital stays
<4 days after resection for colorectal cancer incur fewer VTE events. Despite
shortening the duration of routine inpatient VTE prophylaxis with early discharge it is encouraging that we are not inadvertently increasing their likelihood of a VTE. On average patients with LOS< 4 days tended to be healthier than those with longer stays. Being healthier they may have been more
ambulatory. However, adjustment for functional status did not change the
odds ratio for VTE. It is unlikely most of those with shorter stay received
75
Abstracts
questionnaire, and the social activities questionnaire were used. The effects,
nutritional status, and health of the patients after the two procedures were
investigated.
Results: More than 87.5% patients in both groups were satisfied with
the surgery. More than 90.0% of the patients were improved 6 months after
surgery. The number of cases with frequent bowel movements in both
group decreased with the time passing by. The number in group IRA at 12
months, and the number in the group CRA at 6 months after surgery
decreased significantly when compared with the number in their own
groups at 3 months after surgery (P < 0.01, and P < 0.05 respectively). The
patients with anti-diarrhoica application at 12 months after surgery in both
groups decreased significantly when compared with their own groups at 3
months after surgery (P < 0.01, and P < 0.05 respectively). Postoperative
levels of hemoglobin, total protein level, albumin, and percentage of lymphocytes in IRA group were higher than CRA group (P < 0.05). There was
no difference of MNA Assessment and postoperative general condition
questionnaire in both groups (P > 0.05). The scores of the health condition,
emotion, and feeling for life in both groups were only 68.8% to 82.4% of
highest score.
Conclusions: The symptoms can be relieved by either IRA or CRA surgeries. Both IRA and CRA surgeries are compliant for the treatment of STC.
continued VTE prophylaxis after discharge, however further studies are necessary to quantify its use and its effect on thromboembolic events.
Odds ratios for VTE, adjusted for functional status
P112
FACTORS AFFECTING REFERRAL TO A COLORECTAL SURGEON BY
GASTROENTEROLOGISTS.
A. Kumar, A. Gabay, M. Caldararo, D. E. Stein and J. L. Poggio
Department of Surgery. Division of Colon and Rectal Surgery, Drexel
University, Philadelphia, PA.
Purpose: Colorectal surgeons receive virtually all of their patient inflow
via gastroenterologist referral. While factors influencing referral choice have
been studied extensively in other specialties, no scientific data has been
collected on referral patterns of gastroenterologists to colorectal surgeons.
This referral relationship is unique and deserves study. The purpose of the
study was to survey gastroenterologists in a specific geographic area and
determine patterns of referral.
Methods: Modeling other referral studies, we developed a brief questionnaire for gastroenterologists to complete. We chose the Greater
Philadelphia area as our sample, contacting all gastroenterologists within a
10-mile radius of Hahnemann University Hospital. 95 gastroenterologists
were contacted, with a response-rate of 80%. We expected statistically
meaningful differences in each factor’s influence on gastroenterologists’
referral choices. We also expected different subgroups of gastroenterologists to have different preference patterns (M.D. vs. D.O., etc.). 20 factors
were analyzed, using Z and T distribution confidence intervals.
Results: Our study showed the most important factors to gastroenterologists in choosing a colorectal surgeon were proficiency, experience
and reputation. These were followed by (greatest-to-least) availability, proximity, office communication skills, bedside manner, in-house op/on, patient
feedback, board certification, personal friendship, patient insurance compatibility, back-referral likelihood, practice type, cultural similarity to
patient, language, degrees, ethnicity, and then gender. Subgroups of gastroenterologists based on gender, ethnicity, degree type, and practice type,
etc. were also compared showing significant differences in preference patterns.
Conclusions: This study shows that there is no unique pattern of referral from Gastroenterologists to a Colorectal Surgeon. Several factors play a
role in this referral process. This study is the first to investigate gastroenterologists’ referral patterns, which directly shape colorectal surgeons’
patient inflow. Colorectal surgeons have a vital interest in these results, as
it may influence future behavior and practice management.
P114
PREDICTING READMISSION AFTER COLORECTAL SURGERY: A POINTBASED SCORE.
K. N. Kelly, J. C. Iannuzzi, C. T. Aquina, C. P. Probst, L. Zhang, K. Noyes,
J. Monson and F. J. Fleming Surgical Health Outcomes and Research
Enterprise, Department of Surgery, University of Rochester Medical Center,
Rochester, NY.
Purpose: With the recent focus on unplanned readmission after surgery
as an indicator of quality inpatient care, it has become critical to identify
patients who are at an increased risk in order to efficiently enact interventions. The aim of this study was to determine factors predictive of readmission following colorectal surgery and subsequently develop a risk score to
anticipate readmissions in these patients.
Methods: Patients undergoing colorectal resection were selected from
the 2011-2012 ACS NSQIP database using CPT codes. The primary endpoint
was 30-day postoperative unplanned readmissions. The database was randomly split with two thirds used for model development and one third
used for validation. Forward stepwise logistic regression was utilized to create and validate a point system. Factors were maintained in the model
based on a p-value <0.05 and clinical importance. The c-statistic was utilized to determine predictive ability.
Results: Overall 64,347 colorectal resections were performed with an
unplanned 30-day readmission rate of 11.5%. Pre-discharge factors within
the risk score included: age, ASA class, preoperative comorbidities, steroid
use, obesity, functional status, smoking, operation type and duration, blood
transfusion, and discharge destination. Table 1 displays the results of the
multivariable model(c-statistic=0.64 and 0.63, development and validation
groups respectively) and points assigned to each risk factor. Patients were
stratified into 4 groups based on risk score: low risk (0-5 points) with a 6.6%
readmission rate, moderate risk (6-9 points) with an 11.2% readmission rate,
high risk (10-14 points) with a 16.2% readmission rate, and very high risk
(15+ points) with a 21.2% readmission rate.
Conclusions: This study represents the first readmission risk score in
colorectal surgery providing a valuable pre-discharge tool to help target
readmission prevention strategies. With increasing emphasis placed upon
the reduction of unplanned readmissions in order to improve patient care
and decrease health care costs this risk score allows for the prediction of
high-risk patients and subsequent allocation of appropriate post-discharge
resources.
P113
OUTCOMES OF PATIENTS WITH SLOW TRANSIT CONSTIPATION
TREATED BY TOTAL COLECTOMY WITH ILEORECTAL ANASTOMOSIS
OR SUBTOTAL COLECTOMY WITH CECORECTAL ANASTOMOSIS.
B. Liu, F. Li and T. Fu Department of GI Surgery, Daping Hospital, Third
Military Medical University, Chongqing, China.
Purpose: To investigate the influence of total colectomy with ileorectal
anastomosis (IRA) and subtotal colectomy with cecorectal anastomosis
(CRA) on effects, nutritional status, and health of the patients with slow
transit constipation (STC).
Methods: There were 40 patients in IRA group with mean follow-up
period of 63.9 months and 32 patients in CRA group with mean follow-up
period of 33.2 months. The 36-item short-form health survey (SF-36), the
Mini-Nutritional Assessment (MNA), the postoperative general condition
76
Abstracts
Table 1: Multivariable Logistic Regression and Risk Score
were adjusted based on gender, type of hospital, disease severity, and surgeon specialty.
Results: A total of 65,864 colectomies were identified. The proportion
of colectomies in the different academic year quartiles were: 23,7%, 24.4%,
26.2%, and 25.7%, respectively. Patients in the July-September group were
significantly older. Gender distribution was similar among groups. After
adjusting parameters, the rates of transfusion, complication, and mortality
did not differ among groups. However, the July-September group resulted
in significantly longer length of stay (9.5 days, 9.1 days, 9.1 days, and 8.9
days, respectively, p<0.001). Furthermore, hospital costs were significantly
higher in the July-September group ($22,271; $21,998; $21,987; and
$21,438, respectively).
Conclusions: This large population-based study showed that colectomy
early in the academic year results in similar complications as compared with
colectomy performed later in the academic year. However, length of stay
and hospital costs are significantly higher early in the academic year.
P116
NEGATIVE PRESSURE WOUND THERAPY AND DELAYED PRIMARY
CLOSURE FOR THE MANAGEMENT OF CONTAMINATED ABDOMINAL
WOUNDS.
R. N. Mundy and A. Doben Surgery, Baystate Medical Center, Springfield,
MA.
Ref=reference category OR=Odds ratio CI=confidence interval BMI=body mass
index
* Age categories organized by quartile.
** Preoperative comorbidities include: Cardiac: congestive heart failure, history of
myocardial infarction, previous percutaneous coronary intervention, previous cardiac
surgery, history of angina, rest pain; Neurologic: impaired sensorium, history of
transient ischemic attacks, cerebral vascular accident, CNS tumor, quadriplegia; Renal:
acute renal failure, dialysis; Pulmonary: COPD, current pneumonia; Hepatic:
esophageal varices, ascites
Purpose: Contaminated surgical abdominal wounds are prone to surgical site infection (SSI). These infections can be a morbid and costly complication. Closure by secondary intention with outpatient wound care
decreases infection risk but comes at considerable monetary and time cost.
This study describes a novel technique of negative pressure wound therapy (NPWT) and delayed primary closure (DPC) to manage these wounds.
Methods: A retrospective review of patients who underwent emergent
open abdominal surgery by a single surgeon over a three year period was
queried. Closure of the fascia followed by intermittent skin closure every 34cm with staples was performed. A NPWT device was then placed. The
device was removed on POD 5 and delayed primary closure (DPC) accomplished with either sutures or steri-strips. Patients were reviewed with
respect to age, co-morbidities, and complications. The primary outcome
measure was development of a surgical site infection as defined by the Centers for Disease Control and Prevention’s National Healthcare Surveillance
Network. Cost of inpatient NPWT was compared to average cost of SSI and
average cost of visiting nurse assistance for outpatient wound care.
Results: 10 patients underwent NPWT and DPC. Wound classifications
were: four clean contaminated (40%), two contaminated (20%) and five
dirty (40%) cases. 1 SSI (10%) was noted. Cost of NPWT averaged $283.65
compared to $2,785.15 for visiting nurse care.
Conclusions: NPWT and DPC has potential to mitigate the risk of SSI
development in the at risk abdominal wound. Further evaluation regarding
the efficacy of NPWT & DPC in prevention of SSI remains to be done. Current data indicates substantial cost savings to the health care system.
P115
DOES ACADEMIC SEASON INFLUENCE COLECTOMY OUTCOMES?
RESULTS FROM A COHORT OF 65,000 PATIENTS.
R. Pedraza1, E. L. Lambert2, J. A. Moreno1, T. Pickron1, A. Mahmood1 and
E. M. Haas3 1Colorectal Surgical Associates, Ltd, LLP, Houston, TX, 2Division
of Minimally Invasive Colon and Rectal Surgery, Department of Surgery,
The University of Texas Medical School at Houston, Houston, TX and
3
University General Hospital, Houston, TX.
Purpose: Surgical and medical training are subject of personnel
turnover during the first month of the academic season. It has been theorized that during this period of the academic year (July-September), surgical outcomes are inferior as compared with the rest of the year: “The July
Effect.” However, there is no data specifically evaluating the influence of
academic season on colectomy outcomes. We conducted a populationbased study to compare outcomes following colectomy based on academic
season.
Methods: The data were obtained from the Premier database -from
October 2005 to June 2011. Only data from teaching hospitals were
retrieved. Right, left, and sigmoid colectomies were included. Four groups
were established based on the academic year quartile (July-September;
October-December; January-March; April-June). Postoperative outcomes
77
Abstracts
P118
THE EVOLUTION OF SURGICAL RESEARCH - 20-YEAR TRENDS IN PUBLICATIONS FROM THREE PEER-REVIEWED SURGICAL JOURNALS.
R. R. Shawhan1, Q. Hatch1, J. Bingham1, E. Fitzpatrick1, R. S. McLeod3,
E. Johnson1, J. Maykel2 and S. R. Steele1 1Surgery, Madigan Army Medical
Center, Fort Lewis, WA, 2Surgery - Colon and Rectal, UMass Memorial
Medical Center, Worcester, MA and 3Department of Surgery and Health
Policy Management and Evaluation, University of Toronto, Worcester, ON,
Canada.
Purpose: In 1993, Solomon et al. published “Clinical Studies in Surgical
Journals – Have We Improved”, examining study designs in three surgical
journals from 1980 and 1990. We aimed to evaluate subsequent trends in
the published literature, focusing on study design and quality of evidence.
Methods: All published articles from Diseases of the Colon & Rectum
(DCR), Surgery (Surg), and British Journal of Surgery (BJS) during 2000 and
2010 were classified by study design (clinical vs. non-clinical) to determine
the overall frequency and strength. Non-clinical studies were sub-stratified
by animal/lab, surgical technique, editorial/review or miscellaneous articles.
Clinical articles were categorized as case or comparative studies, and classified by study design (Table 1). Strength of comparative studies was
assessed using a modified 10-point scale, and we used random sample to
compare inter-observer reliability.
Results: We evaluated 1,911 articles (967 clinical; 17% comparative).
Over time, clinical studies showed a statistically significant increase in multicenter studies from 12 to 27% (p<0.0001), and in the mean number of
patients per study [326 to 6,775 (p<0.05)]. The use of administrative databases in clinical studies also increased from 14 to 43% (p< 0.0001). Overall,
there was a decrease in case reports from 16 to 7% (p<0.001), and an
increase in comparative studies from 14 to 21% (p= 0.001). The percentage
of randomized controlled trials did not increase over this period (8.5% in
2000 vs.10% in 2010, p=0.44). In Surg and BJS, there was a trend away from
case control studies (Table 1). Mean 10-point score for all comparative studies was 6.7 for both years (p=NS), with good inter-observer agreement in
the classification of studies (k=0.70), and moderate agreement in scoring
comparative studies (k=0.47).
Conclusions: The trends witnessed may be a result of technologic
advances that facilitate collaboration and impact the design and size of surgical research projects. With no increase in randomized controlled trials and
similar data quality, further efforts should be made to increase the level of
present and future scientific inquiry.
P117
PREOPERATIVE ANEMIA - A STRONG PREDICTOR OF ADVERSE OUTCOMES AFTER COLORECTAL SURGERY: AN NSQIP STUDY.
K. A. Newhall1, J. B. Wallaert1, A. Shander2, M. T. Harris3 and
S. D. Holubar1 1Surgery, Dartmouth-Hitchcock Medical Center, Lebanon,
NH, 2Anesthesiology, Englewood Hospital and Medical Center, Englewood,
NJ and 3Surgery, Englewood Hospital and Medical Center, Englewood, NJ.
Purpose: Despite near-universal screening of preoperative hemoglobin
levels in surgical patients, the impact of anemia on postoperative outcomes
in colorectal surgery remains unclear. We hypothesized anemia (hemoglobin (Hgb in mg/dL <12) is associated with post-operative adverse events.
Methods: We retrospectively reviewed ACS National Surgical Quality
Improvement Program (NSQIP) database from 2005-2010 using ICD-9 codes
to identify patients undergoing colorectal surgery (N=348,211). Patients
who had anorectal surgery (codes 49xxx), and those without preoperative
Hgb (N=17,126) were excluded. Patients were categorized as having normal Hgb (12-16), mild (10-12), moderate (8-10) or severe anemia (<8), or as
having markedly elevated Hgb (>16). Associations between preoperative
Hgb and the primary outcomes of death, cardiac (MI or cardiac arrest) and
septic complications (sepsis or septic shock) were analyzed using backwards-stepwise logistic regression.
Results: In total 312,612 patients were studied; of these 30.3%
(N=94,905) were classified as anemic (29.1% mild, 7% moderate, 1% severe)
based on Hgb drawn a mean of 4.7 days prior to operation (SD 10.5 days).
Patients with normal Hgb or mild anemia had, on average, a lower incidence of comorbidities such as diabetes, CHF, CAD, and COPD than those
with moderate-to-severe anemia (data not shown). After adjustment for
demographic, comorbidities, and operative characteristics, preoperative
anemia remained an independent predictor of post-operative complications, with degree of anemia directly related to degree of risk (Table 1). For
example, patients with severe anemia had two-to-three times the risk of
septic complications (OR 2.1, 95% C.I. 1.5-3.0, P<0.001), cardiac complications (OR 2.6, 95% C.I. 1.7-4.1, P<0.001) and death (OR 3.1, 95% C.I. 2.7-3.6,
P<0.001) compared with patients with a normal preoperative Hgb.
Conclusions: Preoperative anemia is common and associated with
increased risk of postoperative mortality, cardiac, and septic events in
patients undergoing colorectal surgery. Given the elective nature of many
colorectal procedures, and anemia as a modifiable risk, earlier preoperative
diagnosis and more aggressive therapy of anemia are warranted.
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Abstracts
Table 1. Characteristics of procedures and patients according to the presentation
of postoperative complications after excisional hemorrhoidectomy
P120
THE IMPACT OF COMPLICATIONS ON LENGTH OF STAY IN PATIENTS
UNDERGOING ELECTIVE COLORECTAL RESECTION.
H. Miyagaki, J. Arkenbosch, V. Cekic, H. Guend, S. Naffouje, N. Gandhi,
M. Alvarez-Downing and R. L. Whelan Colorectal Surgery, St. Luke’s
Roosevelt Hospital Center, New York, NY.
Table 1: Values expressed as percent of all clinical studies per year in that
particular journal.
P119
Purpose: Length of stay (LOS) impacts the cost of colorectal resection,
thus, there is interest in better understanding factors that prolong hospitalization. The effect of individual complications on LOS has not been well
studied. This review was undertaken to determine the relationship between
complications and LOS.
Methods: The ACS-NSQIP database was queried from 2005 to 2011 for
patients undergoing colorectal resection. The exclusion criteria included
preoperative ventilator dependence, SIRS, or sepsis as well as ASA 4 or 5
status and emergent surgery. Demographic parameters, comorbidities,
complications and LOS were assessed. The statistical methods used were
least-square methods for Linear regression model.
Results: A total of 83968 patients were identified (cancer, 50.7%; benign
tumor, 13.7%, diverticulitis, 22.8%; IBD, 10.5%; other, 2.5%). The 30 day overall postoperative complication rate was 20.4%; 11.3 % were noted before
discharge. The overall LOS was 6.7±5.8 days (mean±SD); without complications it was 5.7±3.4 days and for patients with complications it was
14.3±11.8 days. Linear regression model estimate how long each complication extended the LOS. What follows is a list, in frequency order, of the individual complications followed by the pre-discharge incidence (%) and the
estimated delay in LOS associated with that complication; superficial SSI
(3.11%,3.6 days), sepsis (2.3%, 4.9days), UTI (1.9%, 3.0days), organ space SSI
(1.8%, 9.9days), postop bleeding/transfusion (1.7%, 1.3days), pneumonia
(1.5%, 4.3days), unplanned intubation (1.2%, 5.4days), septic shock (0.9%,
7.9 days), wound disruption (0.6%, 7.1days), DVT (0.46%, 5.5sya), myocardial infarction (0.34%, 2days), and pulmonary embolus (0.34%, 4.3days).
Conclusions: Only 55% of colorectal resection related complications
occur prior to discharge. Except for bleeding/transfusion, the most common complications were associated with a discharge delay ranging from
2.3 to 9.9 days. The complications associated with the longest LOS extension were organ space SSI and septic shock. UTI and superficial SSI were
associated with a delay of 3 and 3.6 days, respectively. Clearly, complications have a profound impact on LOS.
DAY-CASE SURGERY FOR HEMORRHOIDAL DISEASE IN A SINGLE
EUROPEAN CENTER: CAN WE PREDICT POSTOPERATIVE COMPLICATIONS?
D. Parés1, L. Estalella1, F. Collado-Roura1, J. Gil-Sánchez2, J. Lopez-Negre1,
J. Urgellés1, R. Mir1 and H. Vallverdú1 1Department of General and
Digestive Surgery, Universitat de Barcelona. Parc Sanitari Sant Joan de
Deu, Sant Boi de Llobregat (Barcelona), Spain and 2Anaesthesiology,
Universitat de Barcelona. Parc Sanitari Sant Joan de Déu, Sant Boi de
Llobregat (Barcelona), Spain.
Purpose: Nowadays, excisional hemorrhoidectomy (EH) is usually carried out as day-case surgery. Complications and the need for reintervention could lead to unplanned admissions that prolong the length of stay
and increase the cost of the procedure. This troublesome situation is difficult to predict. The aim of this study was to analyze the results of EH in a
single European center and to identify the clinical pattern of patients who
developed postoperative complications requiring unplanned admission
and surgical reintervention.
Methods: A prospective analysis was performed of the results of EH
(Milligan-Morgan technique) carried out in our hospital by 3 colorectal surgeons from July 2010 to December 2012. The variables studied were biodemographic data, year of surgery, number of haemorrhoids resected, 30-day
postoperative complications, unplanned hospital admissions, and surgical
reinterventions for complications.
Results: A total of 131 patients underwent EH during the study period.
Of these, 99 patients (75.6%) (49 women; mean age [standard deviation]:
52.34 [11.8] years) who underwent day-case surgery were included in the
final analysis. Complications occurred in 15 patients (15.2%): rectal bleeding in 6, pain due to postoperative anal fissure in 5, uncontrollable anal pain
in 3, and fever in 1. Unplanned hospital admission was required in 5
patients (5.1%). Reoperation was required in 4 patients (4.0%) due to hemorrhage in 2 patients, persistent pain in 1 patient and fever in 1 patient. No
differences were found in patient characteristics or clinical variables
between patients with and without postoperative complications (Table 1).
Conclusions: Hemorrhoidectomy can be successfully performed on an
outpatient basis. Postoperative complications, unplanned admission, and
surgical reoperation are rare and without a typical clinical pattern.
P121
FECAL INCONTINENCE AND MULTIMODAL PELVIPERINEAL REHABILITATION.
F. López-Köstner1, C. Estay1, M. Venegas3, B. Fuentes3, T. Harwardt4,
U. Kronberg1, R. Quera2, A. J. Zarate1, A. Larach1 and C. Wainstein1
1
Colorectal Unit, Clinica las Condes, Santiago, Chile, 2Gastroenterology,
Clinica Las Condes, Santiago, Chile, 3Pelvic Floor Specialties Center, Clinica
Las Condes, Santiago, Chile and 4CiREP, Santiago, Chile.
Purpose: To evaluate our results of multimodal pelviperineal rehabilitation (MPPR) in patients diagnosed with fecal incontinence (FI).
Methods: Historic cohort study using a prospectively maintained database from patients with FI that underwent MPPR (Pelvic muscle training,
79
Abstracts
biofeedback, electrical stimulation) between years 1999 and 2012. We classify FI according to Jorge-Wexner scale (Mild: 3-8; Moderate: 9-14; Severe:
15-20), at the beginning (Winitial) and the end (Wfinal) of treatment. In July
2013 we did a telephonic survey to measure follow-up Wexner score (Wfollow-up) and pelvic muscle training. Significant p value <0.05.
Results: During the period mentioned above 135 patients were
selected for MPPR, from them 113 (84%) completed treatment, median age
67 years-old (r: 24-91) and 83% female. FI was classified as mild, moderate
and severe in 51 (45%), 49 (43%) and 13 (12%), respectively. Median scores
for Winitial and Wfinal were 9 points (r: 3-19) and 3 points (r: 0-13), respectively (p <0.001). After treatment 97% of the patients improved their Winitial, none of them had a worse score and only 3 patients (2.6%) had no score
changes (2 mild and 1 moderate FI). Forty-four patients (39%) end with normal continence (score 0-2) and 73% improve at least in one category of
severity. In July 2013, 68 (61%) patients were able for survey with a median
follow-up of 4 years. Wexner score at the beginning, end and follow-up
were as follows: 9 (i: 3-19), 3 (i:0-12) and 4 (i:0-19), respectively. There were
significant differences between Winitial and Wfollow-up (p <0,001), with
similar results between Wfinal and Wfollow-up. Most of these patients (81%)
maintained their better scores comparing inicial and follow-up Wexner and
38% obtained scores for normal continence. Twenty-nine percent of the
patients maintained their training for pelvic muscles and 71% very rarely or
never. It was the latter group who showed an increased risk to obtaine
worst score in Wfollow-up compared to Wfinal (OR=3.89; CI 95%: 1.26-11.9;
p = 0.0175).
Conclusions: Patients with FI and MPPR has good short-term results.
Regular training of pelvic muscles is a protective factor to maintain these
results in mid-term.
surgical site infection. None of the patients had gastrojejunostomy related
complications. All patients preferred perineal neoanal status over abdominal stoma. Continence for solid stools was achieved by all patients, while
9/10 patients had continence for liquid stool. Antimotility drugs used by all
patients initially were stopped with time. All patients frequented pads for
duodenal mucosal secretions. The median resting and squeeze pressures
were 19.5 mmHg (16-62) and 56.6 mmHg (36-113) respectively. Incontinence scores varied from 7 to 14 and all patients had improved postoperative physical and mental component scores. EMG activity was recorded on
neural stimulation in all patients.
Conclusions: Neural anastomosis of the perineally transposed APV for
total anorectal reconstruction improves the functional outcomes in
selected patients of end stage fecal incontinence. However larger long term
studies are required.
P123
SACRAL NERVE STIMULATION FOR TREATMENT OF VARIOUS ETIOLOGIES OF FECAL INCONTINENCE, ONE SURGEON’S EXPERIENCE.
S. Gillern, M. Fejka and J. I. Bleier Department of Surgery, Division of
Colon and Rectal Surgery, Pennsylvania Hospital, Philadelphia, PA.
Purpose: Fecal incontinence (FI) is a devastating and prevalent problem with a variety of etiologies. Until recently, there were limited surgical
options with suboptimal duration of success and high morbidity. Sacral
nerve stimulation (SNS) offers a safe and effective means of treating FI. The
purpose of this study was to show the effectiveness of SNS for an expanding array of etiologies of FI with previously limited treatment options.
Methods: This is a retrospective review of consecutive patients operated on by a single surgeon at a single institution from October 2011 to
October 2013. Patient demographics, etiology of FI, previous treatments,
quantification of FI episodes, dates and complications were recorded.
Patient response to treatment based on follow-up data was classified as no
response (NR), minimal response (MR), good response (GR), near perfect
response (NPR) and perfect response (PR).
Results: There were 47 patients who underwent Stage I. Forty-three
(92%) proceeded to Stage II and follow-up information was available for 38
patients. The mean age was 64 (range 23-91). There were 33 women (70%)
and 14 men (30%). The average number of days between Stage I and Stage
II was 13.24 (range 4-77). PR was seen in 9/38(24%), 15(48%) experienced
NPR, 10(26%) reported GR and only 4(11%) reported MR. The etiologies of
FI and clinical outcomes are displayed in Table 1. Of the 42 patients who
underwent at least Stage I with follow-up, there were only 8 complications
(19%). The infection rate was 11.9% (5/42). Only 1/8 complications, an infection, occurred after Stage I. In addition, there was 1 device migration and 2
mechanical failures.
Conclusions: Our preliminary experience demonstrates the profound
success of SNS for an expanding array of etiologies for FI. Half of our
patients experienced either a perfect- or near-perfect response, and almost
90% had at least a good response. Although a small sample size prevents
statistically significant conclusions, our results show a slightly improved
success over current reported rates as well as success with a widening
range of etiologies of FI. Further experience is needed to investigate who
can benefit from this therapy.
Change in severity category after MPPR in patients with fecal incontinence
P122
PERINEAL ANTROPYLORIC TRANSPOSITION WITH INFERIOR RECTAL
NERVE ANASTOMOSIS FOR END-STAGE FECAL INCONTINENCE: NEUROLOGICAL AND FUNCTIONAL OUTCOMES.
A. Chandra1, V. Gupta1, M. Noushif1, H. S. Malhotra2, R. K. Garg2,
V. Kumar3 and U. C. Ghoshal4 1Surgical Gastroenterology, King George’s
Medical University, Lucknow, India, 2Neurology, King George’s Medical
University, Lucknow, India, 3Plastic Surgery, King George’s Medical
University, Lucknow, India and 4Gastroenterology, SGPGIMS, Lucknow,
India.
Purpose: Use of antropyloric valve (APV) for total anorectal reconstruction has shown suboptimum results due to inadequate voluntary control.
In an attempt to improve this, inferior rectal nerve (IRN) anastomosis to the
anterior vagus nerve (AVN) of the transposed APV has been reported by us
recently. We now report the initial outcomes of patients who underwent
neurovascular antropyloric perineal transposition with IRN anastomosis.
Methods: Ten patients [abdominoperineal resection for anorectal cancer (n=8); congenital absence of anal sphincter (n=1); perineal injury (n=1)]
underwent the procedure. APV with its intact AVN branch was transposed
to perineum based on left gastroepiploic arterial pedicle. This AVN was
anastomosed by epineural technique to IRN in the perineum. A diverting
proximal colostomy was maintained for 6 months. Functional assessment
was performed after colostomy closure using St.Mark’s fecal incontinence
scores, manometry, and quality of life assessment (SF-36 and personal questionnaire). Neurological assessment was done using pyloric EMG after perineal USG guided neural stimulation.
Results: The median age of patients was 35 years (range 15-60) (males
= 8, females = 2). 1 patient had stricture at distal end of graft and 2 had
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Abstracts
Table 1.
Table 1-The relationship between FISI and SIBDQ
P125
EARLY EXPERIENCE AND OUTCOMES WITH SOLESTA FOR FECAL
INCONTINENCE.
J. M. Conner1 and M. J. Snyder2 1Colon and Rectal Surgery, UT Houston
and Affiliated Hospitals, Houston, TX and 2Colon and Rectal Surgery,
Houston Methodist Hospital, Houston, TX.
* Did not proceed to Stage II because of no response during Stage I
P124
THE IMPACT OF FECAL INCONTINENCE AND DISEASE-RELATED
ACTIVITY ON QUALITY OF LIFE IN PATIENTS WITH CROHN’S DISEASE.
L. Neill, T. Osler and N. Hyman Surgery, University of Vermont College of
Medicine, Burlington, VT.
Purpose: Solesta is an injectable treatment for fecal incontinence which
recently received approval in May 2011 by the FDA. It is indicated for fecal
incontinence that has failed conservative therapies, and is a bridge for
symptom relief prior to surgical therapy. Our goal was to delineate our initial experience with Solesta in our practice, outlining short term outcomes.
Methods: A retrospective analysis of seventeen patients treated with
Solesta over a period between 2012-2013 were included. Injections were
performed according to manufacturer guidelines by three senior surgeons
who manage fecal incontinence regularly within the practice. Demographic
information, preoperative symptom duration, previous incontinence operations, and other studies were included when performed. Post procedure
symptom relief, recurrence, complications and repeat procedures were also
analyzed.
Results: 17 patients were included in the analysis, which captures all
patients treated by the clinic in a two year time period. Average age was
65, 18% were male (3), 82% were female (14). Average symptom duration
was 3.88 years; five patients had prior sphincteroplasty, incontinence
episodes ranged from once every six weeks, to six to eight episodes per
day. Average follow-up was 6.2 months. 5/17 (29%) patients had no symptom recurrence with an average of 3.6 months of follow-up. 10/12 had a
qualitative decrease in frequency of incontinence after treatment. 2/12 had
no change in symptoms at all. 3/12 received a repeat Solesta injection, none
of which had full symptom relief. One patient who had a previous j-pouch
with 6-8 episodes of incontinence per day with an intact sphincter did
receive partial relief of symptoms.
Conclusions: Solesta is a safe treatment for fecal incontinence, and
does not carry the risk typical of more significant procedures such as a
sphincteroplasty. We were able to achieve complete symptomatic relief
with short term follow-up in 29% of those treated. 88% of patients received
some reduction of symptoms qualitatively with a zero complication rate in
the time studied. We feel that Solesta can provide relief in patients as a
bridge between conservative and surgical therapy, and in patients who
have failed surgical therapy.
Purpose: Fecal incontinence can be a devastating symptom, especially
for patients with Crohn’s disease who are often young and commonly suffer with chronic diarrhea. The goal of this study was to determine the relationship between fecal incontinence and disease related symptoms to the
overall and disease specific quality of life of patients with Crohn’s Disease.
Methods: 36 consecutive outpatients with Crohn’s disease were
recruited from the Digestive Disease Center at an academic medical center
between 7/1/13-9/30/13 by an independent investigator not previously
involved in their care. Demographics and distribution of disease were
recorded. Patients completed the Crohn’s Disease Activity Index (CDAI),
Fecal Incontinence Severity Index (FISI), Short Quality of Life in Inflammatory Bowel Disease Questionnaire (SIBDQ), Short Form 12 (SF12), Female
Sexual Function Index (FSFI), and International Index of Erectile Function
(IIEF). A Pearson product-moment correlation coefficient was used to measure the degree of linear dependence between FISI/CDAI and the quality of
life measures.
Results: Mean patient age was 39.9 yrs and 47.2% were males. Mean
CDAI was 156 and FISI was 20.4. The predominate pattern of disease was
ileocolic-16 pts, perianal-10 pts, small bowel-8 pts, large bowel only-2 pts.
FISI was inversely related to the SF-12 (Mental component summary: Pearson correlation coefficient (rho) -0.43, p=.008 and physical component summary: Pearson correlation coefficient (rho) -0.44, p=.007). FISI was also
inversely related to SIBDQ (Pearson correlation coefficient (rho) -0.53,
p=.0009, Figure 1). No correlation was observed with the IIEF or FSFI. A similar relationship was observed with the CDAI.
Conclusions: Both fecal incontinence and disease related activity impair
the quality of life of patients with Crohn’s disease in a linear manner. Interestingly, both male and female sexual function appeared largely unaffected
by these symptoms.
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Abstracts
P126
P127
COMPARISON OF PUDENDAL NERVE TERMINAL MOTOR LATENCY
AND INVASIVE ELECTROMYOGRAPHY IN MEN VERSUS WOMEN WITH
FECAL INCONTINENCE.
B. Shanker, A. Ferrara, B. Murray, M. Soliman, S. DeJesus and J. Gallagher
Colon and Rectal Surgery, Colon and Rectal Clinic of Orlando, Orlando, FL.
VOLUMETRIC MODIFICATIONS OF THD GATEKEEPER IMPLANTS IN
FECAL INCONTINENT PATIENTS.
C. Ratto, L. Donisi, A. Parello and F. Litta Surgical Sciences, Catholic
University, Rome, Italy.
Purpose: THD Gatekeeper is a self-expandable implant for fecal incontinence (FI) treatment. Aim of this study was to evaluate volumetric changes
of prostheses after implantation.
Methods: In 25 FI patients six prostheses were implanted into uppermiddle intersphincteric space, at 1, 3, 5, 7, 9, and 11 o’clock of anal canal.
Thereafter, patients were studied with clinical and physical examination,
and three-dimensional endoanal ultrasound, at 1 week, 1 month, and 3
months after implant. Prostheses volumes were calculated over the follow
up period, and compared to pre-implantation volumes.
Results: Volume measurement was made in 150 prostheses implanted.
Mean volume was 66.0 mm3 before implant, 286.9±87.6 mm3 at 1-week,
298.3±79.0 mm3 at 1-month, and 322.0±78.5 mm3 at 3-months after the
implant. Statistically significant differences were found between baseline
value and measurements at 1-week (p<0.0001), 1-month (p<0.0001), and
3-months (p<0.0001) after implant; however, volume variations between 1week to 1-month and 3-months were not significant (p>0.05). Three months
after implant, mean prosthesis volume increased 487% of baseline dimension. 3D-EAUS did not find any sign of prostheses degradation or migration
over the study period.
Conclusions: Dimensional stability and neither degradation nor migration of implanted prostheses seems interesting features, promising significant clinical efficacy in FI patients.
Purpose: Maintaining continence is a complex interaction between
many factors including sphincter tone, rectal sensation, & anorectal reflexes.
Investigating fecal incontinence (FI) involves diagnostic testing to evaluate
these aspects. Currently, studies investigating pudendal nerve terminal
motor latency (PNTML) and invasive EMG in the evaluation of FI are lacking. The purpose of our study was to compare differences in invasive EMG
and PNTML in men and women with FI.
Methods: This is a retrospective cohort study between 2007-2013. 23
men & 22 case matched women were evaluated with FI. Anorectal manometry, PNTML, and invasive and noninvasive EMG were selectively used to
evaluate these patients. Cleveland Clinic Fecal Incontinence (CCFI) scoring
system, lifestyle impact score and clinical characteristics were obtained. Statistical analysis used a paired Student’s t test for comparison of means. Data
are presented as mean and standard error of the mean (SEM). Significance
was accepted at p <0.05.
Results: The characteristics of 23 men and 22 women were evaluated.
There were no statistical differences in age of first evaluation (66.4 men, 66
women) or BMI (30.7 men, 28.5 women). Men had more anorectal surgery
and more lumbar disc pathology. Women had more non gynecologic
abdominal surgery, and a majority of the women had vaginal delivery. Men
had a lower CCFI score compared to women (9.8 +2; 12.7 +0.8; p=0.04).
Lifestyle Impact score was not significant between the two groups. The
included table compares men and women with invasive EMG, noninvasive
EMG and anorectal manometry. Both groups had delayed PNTML, and an
abnormal MUP, but the women had a significantly higher MUP percentage
– suggesting denervation. Anal manometry and noninvasive EMG also
shows that women had lower squeeze pressures, sphincter asymmetry, and
decreased net strength and endurance of their internal sphincter.
Conclusions: Differences between women and men are demonstrated
with invasive EMG, sphincter contraction and endurance, sphincter asymmetry, and squeeze pressure. PNTML is abnormal in both groups. This suggests that overall women have worse sphincter function and nerve denervation.
Comparison of Anorectal Manometry, Invasive and Non-Invasive EMG in Men
versus Women with Fecal Incontinence
P128
MALE FECAL INCONTINENCE: WHO IS SEEKING EVALUATION AND
TREATMENT?
J. N. Cohan, A. Chou and M. G. Varma Surgery, University of California
San Francisco, San Francisco, CA.
Purpose: The prevalence of fecal incontinence (FI) in the community is
similar between men and women. However, the vast majority of patients
presenting to specialty centers are women. We sought to characterize the
differences between men and women with FI presenting to a tertiary referral center in order to understand why men with FI do not seek evaluation
and treatment.
Methods: This was a cross-sectional study of adult patients with selfreported FI seen at the UCSF Center for Pelvic Physiology between 2004
and 2012. Subjects provided demographic and symptom data, underwent
physical examination and anorectal manometry, and completed the Fecal
Incontinence Severity Index (FISI) and the Fecal Incontinence Quality of Life
Instrument (FIQL).
Results: The study population consisted of 250 men and 1,298 women.
Men were slightly younger than women (average 55.7 vs 58.6 years p=.017).
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Abstracts
Results: The study included 228 consecutive pregnant women. Ninetythree patients (40.8%) had some episode of FI: 15 patients mainly with solid
stool, 6 with liquid stools, and 72 with flatus in the 4 weeks prior to the survey. In these patients, the mean Wexner score was 3.82 (range 2-13). In
patients with FI, quality of life was significantly affected in most subscales
of SF-36 (Figure1). There were no significant differences in the following
variables between patients with FI and those without, respectively: age
(mean age 30.13 years vs. 31.41 years, p=0.090), body mass index (mean
25.27 kg/m2 vs. 26.24 kg/m2, p=0.094), history of previous deliveries (nulliparous 38.3% vs. previous deliveries 43.1%, p=0.492), trimester of pregnancy (35.6% in the first trimester vs. 42.6% in the third trimester, p=0.361)
and BSFS (p=0.388).
Conclusions: The prevalence of FI is high during pregnancy (prior to
delivery) with a notable impact on quality of life. There was no specific clinical pattern during pregnancy that could define patients at risk for FI during this period of life. A prospective follow-up will be performed to determine whether there are any changes in fecal continence after delivery.
Men were less likely to view FI as their main complaint (74% vs 84% p<.001)
and were more likely to report constipation (34% vs 26% p=.006). Men were
more likely to report a history of colon (17% vs. 8% p<.001) or anorectal
surgery (27% vs. 19% p=.004). On exam, men more frequently had normal
resting tone (64% vs 50% p<.001) and standard squeeze (41% vs 10%
p<.001), but were more likely to have an equivocal or paradoxical puborectalis response to valsalva (62% vs 33% p<.001). Men were less likely to have
an external (6% vs 10% p<.001) or internal sphincter defect (10% vs 18%
p=.022) by endoanal ultrasound. As shown in Table 1, the manometry
results differed significantly by gender. In addition, symptoms as measured
by the FISI were less severe in men than women. Although the total score
on the FIQL indicated that overall quality of life was similar, women had
worse scores on the coping and embarrassment subscales.
Conclusions: Men with FI presenting to a tertiary referral center have
less severe symptoms of FI, characterized more often by constipation and
less sphincter dysfunction. Accordingly, they experienced higher quality of
life, specifically coping and embarrassment, compared to women. This may
partially explain why men present less often for specialty care for FI. Future
studies should focus on these factors in men with FI in the community.
Table 1: Survey Scores and Anorectal Manometry Results, by gender
P130
ASSESSMENT OF BRAIN ACTIVATION DURING VOLUNTARY ANAL
SPHINCTER CONTRACTION THROUGH A NEW MODEL USING FUNCTIONAL MAGNETIC RESONANCE IMAGING: A COMPARATIVE STUDY
IN WOMEN WITH AND WITHOUT FECAL INCONTINENCE.
M. Martinez-Vilalta3, H. Ortiz4, J. Pujol2, C. Soriano-Mas2, Y. Maestre3,
L. Grande3 and D. Parés1 1General and Digestive Surgery, Universitat de
Barcelona. Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat
(Barcelona), Spain, 2Department of MRI, CRC Hospital del Mar, Barcelona,
Spain, 3Department of Surgery, Hospital del Mar, Barcelona, Spain and
4
Department pf Engineering Design, Universitat Politecnica de Barcelona,
Barcelona, Spain.
*P<.05 using T-test with unequal variance; **p<.005 using Wilcoxon Ranked Sum
Test
P129
PREVALENCE OF FECAL INCONTINENCE IN WOMEN DURING PREGNANCY: A LARGE CROSS-SECTIONAL STUDY.
D. Parés1, E. Martinez-Franco2, N. Lorente2, L. Estalella1, H. Vallverdu1,
J. Lopez-Negre1, J. Urgellés1, J. Viguer2 and J. Méndez2 1General and
Digestive Surgery, Universitat de Barcelona. Parc Sanitari Sant Joan de
Deu, Sant Boi de Llobregat (Barcelona), Spain and 2Obstetrics and
Ginaecology, Universitat de Barcelona. Parc Sanitari Sant Joan de Déu,
Sant Boi de Llobregat (Barcelona), Spain.
Purpose: Voluntary anal sphincter contraction plays an important role
in fecal incontinence. This function is driven by an extended network of
nervous system structures, most of which are unknown. We present the
results of a novel manometry-based functional magnetic resonance imaging (fMRI) protocol to evaluate patients with continence problems.
Methods: The study included 12 healthy women (mean age: 53 years)
and 12 women with fecal incontinence (mean age: 56 years). A series of 120
whole-brain EPI-BOLD images were obtained in a GE 1.5T MRI scanner. During imaging, subjects were cued to perform eight 10-seconds of voluntary
anal sphincter contractions spaced by 20-seconds of rest periods. An MRIcompatible anal manometer was developed in-house and was used to register voluntary external anal sphincter contraction. Image analysis was done
using SPM8 software. Individualized general linear models (GLM) were built
using the anal manometry recordings as a regressor. The brain structures
that were linked to anal sphincter contractions were identified by fitting
the GLM to the fMRI images and subject-wise activation strength maps
were obtained. Second-level analysis provided group statistics.
Purpose: Pregnancy and delivery are risk factors for urinary and fecal
incontinence (FI) in later life. Although some studies have analyzed the
prevalence of urinary incontinence during pregnancy, there are scarce data
on the frequency and severity of FI during this period. The aim of this study
was to determine the incidence and severity of FI during pregnancy, to
evaluate its impact on quality of life, and to identify whether there is a specific clinical pattern that could identify patients at risk.
Methods: A prospective cross-sectional study was conducted. All
patients attending our maternity unit for obstetric ultrasound examination
during the first trimester and third trimester were eligible for inclusion.
Selected patients completed a self-reported questionnaire that included
items on FI symptoms, Wexner score and stool consistency measured by
the Bristol Stool Form Scale (BSFS). Quality of life was assessed using the
SF-36 questionnaire.The characteristics of patients with FI were compared
with those without symptoms.
83
Abstracts
RESTRICTION, THE MEAN PRE-CRT TUMOR VOLUME AND THE MEAN POSTCRT TUMOR VOLUME WERE SIGNIFICANTLY DIFFERENT BETWEEN THE TWO
GROUPS. PRE-CRT TUMOR VOLUME (≤ 15.0 CM2), POST-CRT TUMOR VOLUME (< 4.0 CM2), DWI WITHOUT RESTRICTION AND MRI-TRG (≤ 2) WERE SIGNIFICANTLY ASSOCIATED WITH PCR IN UNIVARIATE ANALYSIS. HOWEVER,
MRI TRG (GRADE < 2) WAS ONLY FOUND TO BE INDEPENDENT PROGNOSTIC FACTOR (HR 4.296, 95% CI 1.211 – 15.236, P = 0.024) IN MULTIVARIATE
ANALYSIS.
Conclusions: THE POST-CRT COLONOSCOPY FINDINGS MAY BE POTENTIALLY USEFUL ASSESSMENT TO EVALUATE PATHOLOGIC COMPLETE
RESPONSE. MRI-TRG (GRADE < 2) WAS A PREDICTOR FOR PATHOLOGIC
COMPLETE RESPONSE IN THIS STUDY. IT MAY BE HELPFUL, IN COMBINATION
WITH THE POST-CRT COLONOSCOPY FINDINGS, IN SELECTING PATIENTS
FOR A MORE CONSERVATIVE PROCEDURE, SUCH AS LOCAL EXCISION
RATHER THAN RADICAL SURGERY.
Results: fMRI analysis in healthy women revealed significant activations
in medial primary motor cortices (peak activation T value=10.5;p<0.0001),
bilateral insula (T=9.6;p<0.0001), supplementary motor area
(T=8,4;p<0.0001), bilateral putamen (T=7.9;p<0.0001) and cerebellum
(T=11.8;p<0.0001). We created a control pattern which was subsequently
compared with the pattern in the group of patients with fecal incontinence.
The ratio of activation pattern of two main cerebral areas involved in the
model (primary motor area and supplementary motor area, Fig.) was significant different between groups (control group:0.76±0.26 vs. patient
group:1.32±0.32,p=0.001).
Conclusions: This fMRI-anal manometry model was able to map the
brain regions linked to voluntary anal sphincter contraction in healthy participants. Compared with women with fecal incontinence, healthy women
did not have the same cerebral activation profile.
P132
A DECADE EXPERIENCE WITH THE GRACILIS FLAP AT A TERTIARY
COLORECTAL SURGERY UNIT.
P. Elliott1 and M. A. Abbas2 1Surgery, Kaiser, Los Angeles, CA and 2Digestive
Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab
Emirates.
Purpose: To date a paucity of data exists on the outcome of patients
who undergo gracilis flap reconstruction of complex anorectal fistulas or
perineal wound defect coverage. The purpose of this study was to review a
tertiary colorectal surgery unit’s experience with this operation.
Methods: A retrospective chart review was conducted of all patients
who underwent gracilis flap surgery over a 10 year period [2003-2013]. All
operations including the flap harvest and reconstruction were conducted
by one colorectal surgeon.
Results: 18 patients underwent a total of 19 flaps. There were 10
females (55.6%) and median age was 60 years [range 25-72]. 13 patients
(77.2%) had prior radiation therapy [external beam 10 and brachytherapy
3]. The most common indication for radiation was prostate carcinoma
(38.9%) and 6 patients had rectal or anal carcinoma (33.3%). Indications for
operation were complex fistulas in 14 patients (77.8%) [rectovaginal fistula
7 (38.9%), rectourethral fistula 6 (33.3%), urethrocutaneous 1 (5.6%)] or
wound defect closure in 4 patients (22.2%) [abdominoperineal resection 3,
pelvic exenteration 1]. 6 patients (33.3%) had failed prior fistula repair. All
patients had an established stoma or underwent stoma placement at time
of the gracilis flap operation [temporary intent 12, permanent 6]. Median
length of stay was 5 days [range 3-20]. Post operative complications
occurred in 3 patients (16.7%) and the readmission rate was 11%. Flap failure was noted in 3 patients (16.7%) [2 rectourethral fistulas and 1 rectovaginal fistula]. Both patients with rectourethral fistula healed after additional intervention. During a median follow-up time of 24 months [range
1-81], 11 out of the 12 temporary stomas were closed or awaiting closure
and 1 was converted to a permanent colostomy.
Conclusions: The gracilis flap is a good option for the treatment of complex anorectal fistulas or perineal wound defect closure in selective
patients.
Images of brain activation using voluntary anal sphincter contraction model
(structural MNI template superimposed acquired with functional magnetic resonance
(fMRI); same activation threshold (T=4.0) and scaling). The two cases are a healthy
subject as a control (left) and a patient with fecal incontinence (right). Control shows
stronger activation in supplementary motor area (SMA), whereas patient show
dominant activation in primary motor cortex (M1).
P131
PREDICTION OF PATHOLOGIC COMPLETE RESPONSE BY
COLONOSCOPY FINDINGS AND THREE-DIMENTIONAL MAGNETIC
RESONANCE PARAMETERS IN RECTAL CANCER PATIENTS AFTER PREOPERATIVE CHEMORADIATION FOLLOWED BY TOTAL MESORECTAL
EXCISION.
M. Cho1, H. Kim2, S. Baek1, H. Hur1, B. Min1, S. Baik1, J. Lim2 and N. Kim1
1
Department of Surgery, Yonsei university college of medicine, Seoul,
Democratic People’s Republic of Korea and 2Department of Radiology,
Yonsei university college of medicine, Seoul, Democratic People’s Republic
of Korea.
Purpose: THE AIM OF THIS STUDY WAS TO DETERMINE THE CORRELATION BETWEEN CLINICALLY COMPLETE RESPONSE (CCR) ASSESSED BY
COLONOSCOPY FINDINGS WITH THREE-DIMENTIONAL MAGNETIC RESONANCE PARAMETERS AND PATHOLOGIC COMPLETE RESPONSE (PCR) IN
RECTAL CANCER PATIENTS UNDERGOING PREOPERATIVE CHEMORADIATION
THERAPY (CRT)
Methods: A TOTAL OF 67 PATIENTS WHO UNDERWENT PREOPERATIVE
CRT FOLLOWED BY CURATIVE RESECTION WERE PROSPECTIVELY ENROLLED
IN THE STUDY. PATIENTS WERE CATEGORIZED INTO TWO GROUPS ACCORDING TO YPTNM STAGING: PCR (+) VS. PCR (-). MRI PARAMETERS INCLUDED
WERE CHANGES IN PRE- OR POST-CRT TUMOR SIZE, TUMOR REGRESSION
GRADE (TRG), TUMOR REDUCTION RATE, DIFFUSION-WEIGHTED MRI (DWI).
WE ALSO DEFINED CCR AS NO VISUALIZATION OF TUMOR, WHITE SCAR AND
RED SCAR BY POST-CRT COLONOSCOPY FINDINGS.
Results: EIGHTEEN PATIENTS (26.9%) WERE FOUND TO HAVE CLINICALLY
COMPLETE RESPONSE ACCORDING TO POST-CRT COLONOSCOPY FINDINGS.
NINETEEN PATIENTS (28.4%) WERE FOUND TO HAVE A PATHOLOGIC COMPLETE RESPONSE IN THE OPERATIVE SPECIMEN. SENSITIVITY AND SPECIFICITY WERE 15/18 (83.3%) AND 45/49 (91.8%), RESPECTIVELY. ACCURACY
ASSESSED BY COLONOSCOPY FINDINGS WAS 89.5%. PPV AND NPV WERE
78.9% AND 93.7%, RESPECTIVELY. MRI-TRG, DWI WITH OR WITHOUT
P133
FLAP COVERAGE AFTER ABDOMINOPERINEAL EXCISION FOR RECTAL
ADENOCARCINOMA MAY NOT DECREASE WOUND DEHISCENCE: AN
ANALYSIS OF THE NSQIP DATABASE.
A. T. Hawkins, D. Berger, P. C. Shellito, P. Sylla, M. Hutter and
L. Bordeianou Massachusetts General Hospital, Boston, MA.
Purpose: Abdominoperineal Excision (APE) for rectal adenocarcinoma
is associated with high morbidity, including perineal wound dehiscence.
Recent trends toward extra-levator excisions (ELAPE) will likely only increase
wound complications. Flap coverage has been considered as a way to
84
Abstracts
of Colon and Rectal Surgeons recently developed a Rectal Cancer Safety
Checklist (RCSC) to standardize and improve the quality of care for rectal
cancer surgery. This study compared the degree to which synoptic and narrative operative (OR) reports document items on the RCSC.
Methods: Two reviewers independently reviewed: (1) 80 synoptic OR
reports for elective rectal cancer surgery and (2) a case-matched historical
cohort of 80 dictated OR reports. Reports were reviewed for documentation of performance of pre- and intra-operative items on the RCSC. Time to
abstract data was also recorded.
Results: Synoptic reports scored significantly higher than dictated
reports on the overall checklist score (mean adjusted score +/- standard
deviation 12.8 +/- 1.1 vs 5.8 +/- 1.9, total possible score 18, p < 0.001). Synoptic reports also scored higher on each individual sections of the checklist, including pre-operative evaluation, intra-operative care and reconstructive cases (see table). Synoptic reports were also significantly faster to
abstract data from (min:sec +/- standard deviation 2:45 +/- 1:42 vs. 4:56 +/2:40, p < 0.001). Inter-rater reliability between users was high for both
checklists (data not shown).
Conclusions: Synoptic reports were associated with reliable and more
quickly abstractable data, and more complete documentation of OR safety
checklist items for rectal cancer surgery. Although our current templates
require some refinement, synoptic reports offer a real opportunity to standardize OR reporting and improve measurement of safety and quality indicators for rectal cancer surgery.
reduce this morbidity. Our goal was to evaluate the impact of flap coverage on postoperative outcomes in patients treated with APE for rectal adenocarcinoma.
Methods: The ACS 2005-2010 NSQIP database was used to determine
the 30-day morbidity of patients undergoing APE for rectal adenocarcinoma. Univariate logistic regression was used to assess significance of predictive variables for 30-day mortality and morbidity including wound complications and urinary tract infection (UTI). Separate multivariate logistic
regression analyses were then performed for each outcome adjusting for
all independently predictive risk factors, including chemotherapy and radiation.
Results: 2,180 APEs for rectal adenocarcinoma were identified. The
mean age was 63.8 ± 13.2 and 781 (35.8%) were female. 70 (3.2%) patients
had APEs with flap reconstruction of the perineum. Patients undergoing
flap coverage were younger, more likely to be female, less likely to be
obese, and were more likely to have undergone pre-operative radiotherapy. Mean operative duration was longer in the flap group (452 vs 241 min;
P< 0.001). 30-day wound complication rate was 20.5% and the rate of
wound dehiscence was 2.8%. After adjustment, the odds of wound dehiscence were increased in the flap group (OR 3.26, 95% CI 1.30-9.19, P=0.01).
All other complications including 30-day mortality, superficial wound infection, deep wound infection, organ space infection and UTI were similar
between groups.
Conclusions: After adjusting for preoperative factors, patients receiving flap coverage with APE for rectal adenocarcinoma had higher odds of
wound dehiscence, though we could not reliably exclude all confounding
variables (e.g. posterior vaginectomy). This data suggests that surgeons
cannot compensate for wider ELAPEs with flap coverage alone. Other closure methods including biologic mesh need to be investigated.
Comparison of synoptic and dictated reports for documentation of checklist
safety items
Scores are reported as (mean adjusted score +/- standard deviation)
Not all items apply to all reports.
P135
SELECTIVE LATERAL PELVIC LYMPH NODE DISSECTION IN ADVANCED
LOW RECTAL CANCER BASED ON PRETREATMENT IMAGING.
T. Akiyoshi, M. Ueno, Y. Fukunaga, S. Nagayama, Y. Fujimoto, T. Konishi,
T. Yamaguchi and T. Muto Cancer Institute Hospital, Tokyo, Japan.
Purpose: The significance of lateral pelvic lymph node (LPLN) metastasis in patients with advanced low rectal cancer is uncertain.
Methods: We reviewed 272 consecutive patients with clinical or pathological stage II-III low rectal cancer (within 8 cm from the anal verge) who
underwent curative total mesorectal excision (TME) from 2004 to 2010.
Baseline multidetector row computed tomography (MDCT) images were
retrospectively reviewed for the presence of suspicious LPLN involvement
in the internal iliac or obturator area based on the long-axis diameter more
than 7 mm. Outcomes were compared between patients with MDCTdetected suspicious LPLN (suspicious LPLN group, n=55) and without suspicious LPLN (negative LPLN group, n=217).
Results: Forty-one patients (75%) in the suspicious LPLN group and 97
patients (45%) in the negative LPLN group received neoadjuvant therapy.
LPLN dissection (LPLD) in addition to TME was performed in 45 patients
(82%) in the suspicious LPLN group and 13 patients (6%) in the negative
LPLN group. Pathological LPLN metastasis was confirmed in 29 patients
(37%) in the suspicious LPLN group and none (0%) in the negative LPLN
group. Among patients with pathological LPLN metastasis, 25 patients
(86%) received neoadjuvant therapy. The 3-year relapse-free survival was
not significantly different between the suspicious LPLN group (79.7%) and
the negative LPLN group (72.9%, P = 0.1543). The 3-year local recurrence
P134
OPERATIVE REPORTING AND DOCUMENTATION OF RECTAL CANCER
SAFETY INDICATORS: A COMPARISON OF SYNOPTIC AND NARRATIVE
REPORTS.
R. Maniar, P. Syntik, D. Wirtzfeld, D. Hochman, A. McKay, B. Yip,
P. Hebbard and J. Park University of Manitoba, Winnipeg, MB, Canada.
Purpose: Implementation of surgical checklists based on best practices
improves patient safety and outcomes, but documenting and measuring
performance of these practices can be challenging. The American Society
85
Abstracts
Multivariate Analysis of Risk Factors for Anastomotic Leakage following ISR
rates were 5.6% in the suspicious LPLN group and 7.2% in the negative
LPLN group (P = 0.4895). None (0%) in the suspicious LPLN group and 6
patients (2.8%) in the negative LPLN group had the local recurrence developed at LPLN.
Conclusions: The local recurrence developed at LPLN in patients without suspicious LPLN was low, suggesting that LPLD can be omitted in these
patients. However, considerable percentage of patients with suspicious
LPLN had pathologically positive LPLN even though most patients received
neoadjuvant therapy. Because local control and survival for patients with
pathological LPLN metastasis treated with neoadjuvant therapy and LPLD
were excellent, LPLD should be considered for selected patients with suspicious LPLN on preoperative imaging.
P136
ISR, intersphincteric resection; CI, confidence interval; ASA, American Society of
Anesthesiolosists; IMA, inferior mesenteric artery; LCA, left colic artery.
RISK FACTORS FOR ANASTOMOTIC LEAKAGE FOLLOWING INTERSPHINCTERIC RESECTION.
M. Yokota, N. Saito, Y. Nishizawa, A. Kobayashi and M. Ito Colorectal surgery, National Cancer Center Hospital East, Kashiwa, Japan.
P137
OUTCOMES OF RECURRENT RECTAL CANCER AFTER TRANSANAL
EXCISION.
S. Vaid, C. Buzas, J. Park and R. Sinnott Colon and Rectal Surgery, Lehigh
Valley Hospital, Breinigsville, PA.
Purpose: Intersphincteric resection (ISR) has recently been considered
as an alternative surgical option of abdominoperineal resection to avoid
permanent colostomy for selected patients (pts). The aim of this study was
to evaluate the risk factors for anastomotic leakage (AL) following ISR.
Methods: We analyzed retrospectively 381 pts who underwent ISR in a
single center between February 2000 and June 2013. AL was defined as
leakage of fecal material, gas, or contrast material from the anastomotic
site into the abdominal or pelvic cavity. All complications including AL
occurring up to 90 days after surgery were graded according to the ClavienDindo classification (CD). Univariate and multivariate analyses were conducted.
Results: A total of 381 pts (262 men) underwent ISR for low rectal cancer (n=378) and for neuroendocrine tumor (n=3). The median age of the
pts was 60 years (27-80) and the mean body mass index was 22.7 (±3.1)
kg/m2. Rectal cancer pts were stage I (n=155), stage II (n=75), stage III
(n=101), stage IV (n=47). Tumor location was 3.8 (±1.3) cm from the anal
verge, and 102 pts (27%) underwent complete resection of the internal
sphincter. 65 pts (17%) developed AL, and 41 pts (63%) of them classified
into CD grade III/IV. CD grade III/IV postoperative complications except for
AL occurred in 46 pts (12%) in total. Among them, the most common complications were pelvic abscess (17 pts) and ileus (17 pts). There were no mortalities due to postoperative complications including AL. In multivariate
analysis, significant independent predictors of AL were ASA classification,
body mass index, high inferior mesenteric artery ligation (above left colic
artery), preoperative serum albumin level. Protective stoma was constructed in 62 pts with AL and 299 pts without AL. The 1-year stoma closure rate of pts with AL was significantly worse than those without AL
(50.6% v 76.2%, respectively; p<0.01). Furthermore, pts with AL had a significantly higher incidence of anastomotic stricture compared to those
without AL (41.5% v 3.2%, respectively; p<0.01).
Conclusions: We identified risk factors that predispose pts to developing AL. These risk factors should be considered before and during the surgical care of pts undergoing ISR.
Purpose: Transanal excision of early rectal cancers has become an
accepted alternative to radical surgery in select patients. Several studies
have questioned the validity of local excision for these cancers, citing unacceptably high recurrence rates and decreased overall survival. Successful
surgical salvage of these patients has historically been considered feasible,
but results vary. We intend to examine our experience in surgical salvage
of locally recurrent rectal cancers after transanal excision.
Methods: Retrospective chart review of patients undergoing salvage
radical surgery for locally recurrent early stage rectal cancer after transanal
excision from March1990-March 2008.
Results: Seventy-eight patients underwent transanal excision for T1 rectal cancer between 1990 and 2008 at our institution. The average age of
patients was 68.3 years. Recurrence occurred in 17 patients (21.8%). Mean
time to recurrence was 40.1 months (2-132 months). Of these 17 patients,
13 were deemed eligible for surgical salvage. 10 patients underwent APR,
while 3 underwent repeat local excision. Disease-free survival after salvage
surgery was 41.2% (7/17), with a median follow-up of 6.1 years from the
original surgery, and 4 years from the time of recurrence. Disease-specific
mortality was 58.8% (10/17), with a median survival of 5.7 years (1.8-12.9
years) from the original surgery, and 23 months (1-62 months) from the
time of recurrence. 5-year survival for all patients who recurred was 64.7%
(11/17).
Conclusions: Transanal excision for T1 rectal cancer carries a high risk
of recurrence as well as poor overall survival, even in patients deemed eligible for salvage surgery. Long-term surveillance is encouraged, as recurrence can be seen even after 10 years from initial treatment. Local excision
can still be considered for high-risk patients with reasonable outcomes, as
survival can extend beyond 5 years even in patients with recurrent disease.
P138
ENDOLUMINAL LOCOREGIONAL RESECTION BY TRANSANAL ENDOSCOPIC MICROSURGERY: TRICKS TO DECREASE THE SUTURE LINE
DEHISCENCE RATE.
E. Lezoche, G. D’Ambrosio, A. Balla, S. Quaresima and A. M. Paganini
Department of General Surgery, Surgical Specialties and Organ
Transplantation “Paride Stefanini”, Policlinico Umberto I, Rome, Italy.
Purpose: Dehiscence rates after full-thickness TEM and ELRR are 13%
and 11.5%, respectively. The authors have developed a technique during
ELRR to reduce this risk. Aim was to evaluate the results in terms of dehiscence rate reduction.
86
Abstracts
HOWEVER, POSTOPERATIVE COMPLICATIONS RATE WAS SIGNIFICANTLY
HIGHER IN THE ≥ 12 LN GROUP (14.6% VS. 29.1%, P = 0.002)
Conclusions: LESS THAN 12 LN IN RECTAL CANCER PATIENTS TREATED
WITH NEOADJUVANT CHEMORADIATION DOES NOT AFFECT LONG-TERM
ONCOLOGIC OUTCOMES IN THIS STUDY. WHEREAS, POSTOPERATIVE COMPLICATIONS WERE SIGNIFICANTLY ASSOCIATED WITH MORE THAN 12 LN
RETRIEVED.
Methods: The latest series of 50 patients undergoing ELRR was divided
in two consecutive groups. In Group A, 25 patients (12 males, 13 females,
mean age 72.1 years, range 47-88) underwent ELRR by TEM according to
the authors’ standard technique. In Group B, 25 patients (16 males, 9
females, mean age 69.2 years, range 35-87) also underwent ELRR, but the
perirectal residual cavity was filled with a hemostatic agent (Floseal, Baxter
Healthcare Corporation, Deerfield, Illinois, USA) prior to rectal wall closure,
and the rectal ampulla was stuffed with sponges after suture completion
to avoid perirectal fluid collection, by enlarging the volume of the residual
rectal ampulla, together with transanal Foley catheter for gas evacuation.
Results: No significant differences in mean distance of the tumor from
the anal verge, mean lesion diameter, mean operative time and pathological staging between the two groups were observed. Neoadjuvant
Radiochemotherapy (n-RCT) was performed in 8 patients (Group A n=6,
Group B n=2). Suture line dehiscence in Group A occurred in 3 (12%)
patients, none of whom had received n-RCT, and in group B it was nil. In
patients who experienced a dehiscence, mean lesion diameter was 6.3 cm
(range 6 - 7 cm).
Conclusions: Suture line dehiscence after ELRR by TEM is probably
related to the size of the residual cavity and to the formation of a postoperative perirectal fluid collection after rectal wall closure, with subsequent
bacterial overgrowth draining through the suture line. In this study the
suture line dehiscence rate decreased from 12% to 0%. Wide dissection
along the mesorectal plane and full thickness closure of the rectal wall
defect are key to reduction of suture line tension. Obliteration of the residual perirectal space with a hemostatic agent and enlargement of the residual rectal ampulla volume may decrease the suture line dehiscence rate by
reducing perirectal abscess formation.
P140
THE ASCRS RECTAL CANCER CHECKLIST: DO COLORECTAL SURGEONS HAVE HIGHER ADHERENCE RATES IN NSABP PROTOCOL R-04?
A. L. Hill1, P. A. Ganz1, G. Yothers2, M. O’Connell2, R. Beart2, C. Ko1 and
M. M. Russell1 1Department of Surgery, University of California at Los
Angeles, Los Angeles, CA and 2National Surgical Adjuvant Breast and
Bowel Project, Pittsburg, PA.
Purpose: Rectal cancer surgery is complex and surgical quality impacts
patient outcomes. The American Society of Colon & Rectal Surgery (ASCRS)
recently developed a Rectal Cancer Checklist to improve both the standardization and quality of rectal cancer care. Our study aim was to evaluate
the adherence to the intraoperative checklist items through data abstraction from dictated operative reports.
Methods: Operative reports were obtained from the National Surgical
Adjuvant Breast and Bowel Project (NSABP) Protocol R-04 for locally
advanced (Stage II-III) rectal cancer that accrued patients from July 2004 to
August 2010. Data were abstracted from a random sample of operative
reports (N=100) as a pilot study. Colorectal surgeons were identified using
the ASCRS Directory. Adherence to the intraoperative items on the ASCRS
Rectal Cancer Checklist was defined as a dichotomous variable:1=measure
performed and 0=measure not performed (or not documented).
Results: 100 operations were performed by 52 surgeons at 30 hospitals. 69% of patients underwent sphincter-sparing surgery. 65% of patients
underwent surgery by a colorectal surgeon. There was significant variation
in adherence to intraoperative checklist items ranging from a low of 6% for
documentation of completeness of resection to a high of 100% for documentation of handsewn vs. stapled anastomosis as shown in Table1. There
were no differences between colorectal surgeons and non-colorectal surgeons.
Conclusions: In this pilot evaluation of the ASCRS Rectal Cancer Checklist, we identified significant room for improvement with respect to documentation of adherence to intraoperative items. Ongoing evaluation of the
full R-04 sample will permit examination of adherence associated with surgeon characteristics (e.g. specialty, rectal cancer surgery volume, years in
training), as well as determine if higher adherence improves patient outcomes including morbidity, local recurrence, disease-free survival, and quality of life. Examination of adherence rates in a national sample of surgeons
may be an important first step in identifying areas in need of improvement
that will inform future interventions.
P139
ONCOLOGIC IMPACT OF LESS THAN 12 LYMPH NODES IN PATIENTS
WHO UNDERWENT NEOADJUVANT CHEMORADIATION FOLLOWED
BY TOTAL MESORECTAL EXCISION FOR LOCALLY ADVANCED RECTAL
CANCER.
M. Cho, S. Baek, B. Min, S. Baik and N. Kim Department of Surgery, Yonsei
university college of medicine, Seoul, Republic of Korea.
Purpose: A NUMBER OF HARVESTED LYMPH NODE IS FREQUENTLY
ASSOCIATED WITH NEOADJUVANT CHEMORADIATION. THE ONCOLOGIC
IMPACT OF LESS THAN THE ACCEPTED STANDARD OF 12 REMAINS
UNCLEAR. THE AIM OF THIS STUDY IS TO ANALYZE THE IMPACT OF LESS
THAN 12 LYMPH NODES IN TERMS OF LONG-TERM ONCOLOGIC OUTCOMES
IN PATIENTS WHO UNDERWENT NEOADJUVANT CHEMORADIATION FOLLOWED BY TOTAL MESORECTAL EXCISION
Methods: FROM JANUARY 1989 TO DECEMBER 2009, A TOTAL OF 370
CONSECUTIVE PATIENTS WITH RECTAL CANCER WHO UNDERWENT NEOADJUVANT CHEMORADIATION FOLLOWED BY CURATIVE RESECTION WERE ELIGIBLE FOR THIS STUDY. PATIENTS WERE CATEGORIZED INTO TWO GROUPS
ACCORDING TO THE NUMBER OF RETRIEVED LN: LESS THAN 12 VERSUS
MORE THAN 12 LN. TWO GROUPS WERE COMPARED WITH RESPECT TO
PATIENTS DEMOGRAPHICS, PATHOLOGIC CHARACTERISTICS, PERIOPERATIVE OUTCOMES AND ONCOLOGIC OUTCOMES.
Results: THE MEDIAN FOLLOW-UP WAS 55.2 MONTHS (RAGE 21 – 145).
PATIENT CHARACTERISTICS DID NOT DIFFER BETWEEN THE TWO GROUPS.
THE MEDIAN NUMBER OF RETRIEVED LN WAS 15 (RAGE 5-30) AND 123
(32.3%) PATIENTS WERE FOUND TO HAVE LESS THAN 12 LN. PATHOLOGIC
COMPLETE RESPONSE RATE WAS NOT SIGNIFICANTLY DIFFERENT BETWEEN
THE TWO GROUPS (13.8% VS. 8.5%, P = 0.145). SPHINCTER PRESERVING
RATE DID NOT DIFFER BETWEEN THE TWO GROUPS (65.0% VS. 68.8%, P =
0.481). THE 5-YEAR OVERALL SURVIVAL (OS), DISEASE-FREE SURVIVAL (DFS),
LOCAL RECURRENCE (LR) RATES AND SYSTEMIC RECURRENCE (SR) RATE
WERE NOT SIGNIFICANTLY DIFFERENT BETWEEN THE < 12 LN GROUP AND
THE ≥ 12 LN GROUP (OS, 69.1% VS. 69.2%, P = 0.767; DFS, 60.0% VS. 64.0%,
P = 0.496; LR, 17.1% VS. 19.1%, P = 0.975; SR, 34.8% VS. 29.2%, P = 0.350).
87
Abstracts
Adherence to ASCRS Intraoperative Rectal Cancer Checklist Items
of the pilonidal cyst itself and drainage of any underlying abscess are
important prerequisites. Initial in-office wound debridement and depilation are important for sucessful healing. Further prospective doubleblinded trials are required.
OUTCOMES WITH TOPICAL 10% METRONIDAZOLE IN NON-HEALING PILONIDAL
INCISIONS
P142
SETON MANAGEMENT FOR TRANSSPHINCTERIC FISTULA-IN-ANO:
HARM OR CHARM?
D. R. Rosen and A. M. Kaiser USC Colorectal Surgery, Univ Southern
California, Los Angeles, CA.
Purpose: Transsphincteric perirectal fistulas remain a complex challenge: one needs to strike a balance between eradication of the fistula and
preservation of fecal control. Cutting setons are a fairly old tool that - for
many - has come out of vogue. We hypothesized that the concept remains
a reliable and safe tool with results that exceed reported results for numerous more recent methods. For that purpose, we performed a retrospective
review of a single institution’s experience.
Methods: We retrospectively reviewed patients who presented in a 12
year period (2001-2013) with a transsphincteric fistula and were treated
with seton management. Excluded were patients with Crohn’s disease or
fistulae related to malignancy and patients whose fistula was treated with
another method. Data collection included demographics, duration of the
disease, duration of the treatment, outcome, and incontinence.
Results: 107 patients (M/F 68/39, mean age 39.9±12.1yrs, range 18-76)
with a mean follow-up of 4.7±3.1 months (range 1-24) were included in the
analysis. The median symptom duration was 5 months (range 1-60). Forty
two patients (39%) had failed other fistula surgeries; 12% of patients had
complex fistulas with >1 tract. 36% of patients had other health issues. Surgery entailed: opening the epithelial layer between main primary and secondary opening, reaming of tracts, placement of elastic vessel loop as cutting seton; additional draining setons were used in complex fistulas and
removed once induration and suppuration had resolved. The cutting seton
was subsequently tightened in clinic in monthly intervals, on average 3
times. This was well tolerated and did not require anesthesia/sedation.
Median healing time was 3 months (range 1-18). Nine patients (8%)
required further surgery, but eventually 104 patients (97%) had a complete
resolution of the fistula. Incontinence symptoms decreased from 19.6% preoperatively to 13.1%: 15/107 preexisting resolved, new onset in 8/107
(7.5%, see table 1).
Conclusions: The concept of cutting setons was intended/confirmed to
be slow but as a result proved to be safe and highly successful (fistula eradication and preservation/reconstitution of fecal control). The results compare very favorably with other techniques.
Support: PHS grants U10-CA-37377, -69974, -12027, and -69651, from the NCI,
NIH, DHHS, and by Sanofi-Synthelabo Inc, and Roche Laboratories, Inc.
P141
EFFICACY OF TOPICAL 10% METRONIDAZOLE IN CHRONIC NONHEALING PILONIDAL INCISIONS.
E. King, L. Armstrong, L. A. Parry and D. N. Armstrong Georgia Colon &
Rectal Surgical Clinic, Atlanta, GA.
Purpose: To determine efficacy of topical 10% metronidazole (SLA
Pharma; Leavesden UK) in chronic non-healing pilonidal incisions
Methods: A 5 year retrospective review of patients with chronic nonhealing pilonidal incisions was performed. Each patient had undergone
prior excision of the primary pilonidal cyst, and/or drainage of any pilonidal
abscess. Non-healing was defined as a persistent non-healed wound, at
least 30 days after surgery. Patients underwent gentle in-office debridement and depilation of the pilonidal area, before commencing treatment.
Topical 10% metronidazole was applied BID to the non-healing incision.
Sucessful response was defined as complete healing of the pilonidal incision. The following variables were recorded: Age (yrs); gender (M/F); number of prior surgeries; recurrence after metronidazole teatment (Y/N); time
to healing or recurrence (weeks/months) .
Results: Twenty-one patients with non-healing pilonidal incisions were
treated with topical 10% metronidazole. Follow-up was 2-5 years. Of the 21
patients, 17 (81%) demonstrated complete healing of the pilonidal incision
after an average treatment course of 3-8 weeks (median 4 weeks). Three
patients (14%) recurred after 4-24 months (median 14 months). These
patients underwent repeat in-office debridement and a further course of
topical metronidazole treatment. One patient (5%) failed to respond to topical metronidazole treatment and eventually underwent surgical drainage
of a previously undiagnosed underlying abscess.
Conclusions: Topical 10% metronidazole is effective in treating nonhealing pilonidal incisions. Long-term healing occured in 81% of cases and
repeat surgery was avoided in 95% of cases. Long-term recurrent symptoms occured in 14% of cases and were sucessfully treated by repeat inoffice debridement and a further course of topical metonidazole. Excision
Seton Management and Fecal Incontinence
88
Abstracts
vious Pap screening test, but 93% reported feeling comfortable discussing
having a Pap test with an MD. A paired-samples t test was calculated to
compare the mean pretest to the mean posttest exam score. The mean on
the pretest was 43.14 (sd = 11.69), and the mean on the posttest was 91.96
(sd = 10.05). A significant increase pretest to posttest was found (t(101) = 29.797, p < .001).
Conclusions: The findings of this study indicate that educational programs tailored to the needs of targeted high risk populations are effective
in raising awareness and promoting potentially life-saving screening of anal
cancer among those populations..
P143
SUPERFICIAL FISTULA FOLLOWING ANAL SPHINCTEROTOMY.
N. Goulet1, C. C. Jadlowiec1, K. McHugh2, J. L. Cohen3, K. H. Johnson3,
W. V. Sardella3, P. V. Vignati3 and C. M. Bartus2 1UCONN, Farmington, CT,
2
The Hospital of Central Connecticut, New Britain, CT and 3Hartford
Hospital, Hartford, CT.
Purpose: Anal sphincterotomies are one of the most common treatments for anal fissures. Superficial fistulas are one of the complications following an anal sphincterotomy but recent studies either do not report fistulas as a complication or report an incidence of less than three percent.
The aim of this study was to investigate the incidence of superficial fistula
formation as a complication following an internal sphicterotomy among 5
colorectal surgeons within one group.
Methods: This is a retrospective review from 2005-2012 examining the
incidence of superficial fistula formation following an anal sphincterotomy
in 299 patients from an urban, multicultural environment.
Results: In 299 patients who underwent an internal sphincterotomy, 37
patients developed a superficial fistula afterwards (12.4%). Of those 37
patients, 31 underwent a fistulotomy in the operating room for the fistula,
5 were lost to follow-up, and 1 patient was treated non-operatively. There
was no significant difference found in the BMI, age, gender or comorbidities of patients who developed fistulas versus those who did not. The mean
time to diagnosis of the fistula after sphincterotomy was 45.8 days with a
median of 40 days. Of the 299 patients, 64 patients developed abscesses
afterwards. Thirty-three of the 37 patients (89.2%, p=0.003) who formed a
fistula had an abscess develop prior. Of those 33 patients, 25 were treated
with antibiotics only, 5 were treated with antibiotics followed by incision
and drainage, and 3 patients only had incision and drainage.
Conclusions: In comparison to reported statistics on the incidence of
fistula formation following sphincterotomy, we found our incidence to be
much higher at 12.4%. We feel that fistula formation is an underreported
complication of this surgery. It is, however, a significant complication following this operation because in the majority of cases, it requires surgical
intervention in the operating room.
P145
PREDICTORS OF MORBIDITY IN PATIENTS WITH DIVERTING
COLOSTOMIES FOR NONHEALING SACRAL, PERINEAL AND ISCHIAL
WOUNDS.
A. Ratnasekera1, L. Derr2, D. Berg2 and M. Finnegan2 1Rowan University
School of Osteopathic Medicine, Stratford, NJ and 2Lourdes Medical Center,
Camden, NJ.
Purpose: Treatment of non-healing sacral, perineal, or ischial wounds
often requires fecal diversion to promote wound healing. There is a paucity
of literature evaluating risk factors for morbidity related to creation and
reversal of colostomies in the select population of patients undergoing
fecal diversion for non-healing wounds. The purpose of this study was to
identify risk factors for morbidity and rates of colostomy reversal after fecal
diversion in such patients. Complications related to type of colostomy (loop
stoma, LS vs. end sigmoid, ES) were analyzed.
Methods: A retrospective chart review was conducted on all patients
with non healing wounds who underwent diverting colostomies from
1/2008 to 12/2012.
Results: The study population (n=66) was 63% male, 37% female;
median age 61. Of 66 stomas, 8% were unknown type; 15% end sigmoid;
24% transverse loop; and 53% loop sigmoid. 27% of all stomas required
revision. Stoma revision was required in a higher proportion (33%) of all LS
as compared to all ES (10%)[OR(95%CI) 4.5(0.52-38.49)] Figure 1. During the
study period, 26% of diverted patients went on to have a myocutaneous
flap. The stoma reversal rate was 5% (3/66). However, 2 of those 3 patients
required re-diversion. Complications occurred in 32% of patients. The most
common complication was parastomal hernia (20%). Other complications
included: Small bowel obstruction, 8%; stoma prolapse, 6%; stoma bleeding in 5%; and stoma retraction, 5%. Patients with LS had a higher rate of
overall complications as compared to ES [37% vs.10 %, OR 5.34 (0.6245.53)], Figure 1.
Conclusions: Stoma-related complications and need for colostomy revision due to those complications was most prevalent for LS. In addition,
most patients who underwent diversion for non-healing wounds did not
ultimately undergo stoma reversal. Based on the findings of this study, consideration should be given to fashioning end sigmoid colostomies as the
diverting stoma for fecal diversion in patients with non-healing wounds.
This study is limited by its retrospective nature, small sample size, and lack
of long-term follow up.
P144
HAPPY HINEY HEALTH: EFFICACY OF AN ANAL HEALTH AND SCREENING AWARENESS PROGRAM FOR TARGETED HIGH RISK POPULATIONS.
E. Schochet1, E. Fenkl2 and S. Gracia Jones2 1Holy Cross Hospital, Fort
Lauderdale, FL and 2Florida International University, Miami, FL.
Purpose: The incidence of anal cancer continues to rise, particularly
among targeted high risk populations such as men who have sex with men
(MSM) and HIV infected individuals, Outreach to those populations can be
challenging. Development of awareness programs tailored to the needs
and culture of MSM and HIV infected populations is central to increasing
earlier screening. Happy Hiney Health is an inspiring, educational, and often
humorous lecture about anal health, physician developed and presented
worldwide.
Methods: The efficacy of the Happy Hiney Health program was statistically evaluated.This study was descriptive and exploratory in nature. IRB
approval was obtained through Florida International University. The study
participants were recruited in October 2012 during a chartered cruise for
HIV infected individuals and their partners/friends (POZ cruise). The educational session was advertised and during the cruise. An investigator-developed pre- and post- test was administered to the attendees with a four day
lapse between program participation and post-testing. The sample
included 102 participants. Most all of the attendees identified as MSM and
reported being HIV positive.
Results: In this sample of 100 males and 2 females with a mean age of
51 years, 96% reported identifying as gay and 93% as HIV positive. This was
a well educated sample with 83% reporting college education. 83% also
reported being currently sexually active. 51% reported no history of a pre-
89
Abstracts
tural abnormalities, anal or pelvic floor muscle spasm, or anal strictures.
Diagnosing this problem after IPAA can be challenging. The aim of this
study was to assess possible factors associated with outlet constipation
from paradox (Px) after IPAA unrelated to strictures or structural abnormalities.
Methods: All patients with Px after IPAA inclusive of Px pressures on
anal physiology were identified from our prospectively maintained database. Patients with endoscopic or digital evidence of strictures or other
anatomic abnormalities were excluded. A number of demographic, clinical
and perioperative factors were tested for possible association with Px,
including prior abdominal operations, history of pouchitis, need for anal
intubation, diagnosis of small bowel obstruction (SBO) and radiological
findings at the time of Px diagnosis.
Results: There were 40 patients (17 females) with overall mean age of
39 years (range 17-60), and mean follow-up of 15 (range 1-28) years since
IPAA creation. Pathologic diagnoses at the time of IPAA were ulcerative colitis (n=27), indeterminate colitis (n=11), Crohn’s disease and familial adenomatous polyposis (1 case each). A total of 15/40 (37%) patients were diagnosed with SBO before their Px diagnosis, 8 of whom underwent surgery,
which revealed diffusely dilated small bowel without intraoperative identification of any transition point. Time from IPAA creation to Px diagnosis was
significantly longer in patients receiving a diagnosis of SBO than in the
remaining Px patients (7.2 vs. 2.6 years, p <0.001). No other factors were
significantly associated with Px.
Conclusions: Patients with IPAA can develop Px, which can be mistaken
for SBO. Therefore, Px should be considered in the differential of IPAA
patients without classic findings of mechanical SBO.
P146
DEFINING DIVERTICULAR FISTULA THROUGH INPATIENT ADMISSIONS: A POPULATION STUDY.
M. Ostrowski1, T. Markossian2, M. Mora Pinzon1, M. Slogoff1,
J. Eberhardt1, T. Saclarides1 and D. Hayden1 1Surgery, Loyola University
Medical Center, Maywood, IL and 2Public Health Sciences, Loyola University
Medical Center, Maywood, IL.
Purpose: Although diverticular fistula is a rare manifestation of diverticular disease, it is a common indication for surgery. Literature is extremely
limited in defining its incidence and demographics.
Methods: Secondary analysis of the 2011 Nationwide Inpatient Sample
(NIS) was performed. Hospital discharges were identified using ICD-9 and
ICD-9-CM codes for diverticular disease, surgery and diverticular-associated
fistula.
Results: In 2011, 318,871 discharges for diverticular disease and 5,088
discharges for diverticular-associated fistula were identified. For fistula
admissions, mean age was 66.9 years (25-96) with a female predominance
(61.4%). Most common type was colovesical (56.9%), then fistula between
colon and female genital tract (30.7%) and colocutaneous (12.4%). Divided
by type, colovesical fistula was more common in males (58.9%). Majority of
admissions were elective (60.6%); 39.4% were emergent/urgent. When evaluated separately, colocutaneous fistula admissions were twice as likely to
be emergent (43.7%) than other types. During 42.8% of hospitalizations,
surgery was performed. Mean length of stay (LOS) for all fistula admissions
was 9.0 days (0-143); 10.3 including surgery, 8.1 when surgery was not performed. When compared to discharges for non-fistulizing diverticular disease, mean age was older (66.9 vs. 64.1, p=0.000) and more were female
(61.4 vs. 56.9%, p=0.000). Admissions were more likely elective (60.6 vs.
17.2%, p=0.000) and a higher percentage included surgery (42.8 vs. 10.6%,
p=0.000). Overall LOS was longer for fistula compared to non-fistulizing
diverticular disease (9.0 vs. 4.6 days, p=0.000); however, if surgery was performed during the admission, the LOS was just slightly different (10.3 vs.
9.9 days, p=0.032).
Conclusions: Inpatient admissions for diverticular fistula differ from
those for non-fistulizing diverticular disease: the population is older, more
likely to be female and admissions more often are elective and include surgery. Our study is amongst the first to shed light on inpatient admissions
for diverticular fistulas on a population level and further analysis will continue to define this surgical disease.
P148
IS PERCUTANEOUS DRAINAGE OF DIVERTICULAR ABSCESS DEFINITIVE DISEASE MANAGEMENT IN SOME PATIENTS?
V. P. Poola1, S. Tsoraides2 and J. Rakinic1 1Colon and Rectal Surgery,
Southern Illinois University School of Medicine, Springfield, IL and
2
Univeristy of Illinois College of Medicine Peoria, Peoria, IL.
Purpose: Percutaneous drainage of diverticulitis-related abscess is performed with the aim of avoiding urgent surgery and allowing subsequent
elective colon resection without stoma creation. We have noted an increasing number of patients who do not have resection after successful abscess
drainage. We evaluated our patients who required percutaneous drainage
of diverticular abscesses to gain a better understanding of the outcome of
diverticular abscess management.
Methods: All patients with diverticular abscess treated with percutaneous drainage in a large university-associated hospital from Dec 2004June 2013 were identified. Abscesses from other etiologies were excluded.
Patient demographics, procedural details of percutaneous drainage and
subsequent surgical procedural details including postoperative outcomes
were retrospectively analyzed.
Results: Seventy-four patients (42 women) were identified. Mean age
was 60.7 yrs. Mean BMI was 30.7. Mean size of abscess was 5.6 cm. Comorbidities included diabetes (11%), cardiovascular disease (26%), and COPD
(34%); patients who had urgent resection had a higher incidence of diabetes (50%) and cardiovascular disease (67%). Nine patients (12%) required
urgent resection; 8 had Hartmann’s, one had sigmoidectomy without
stoma. Thirty five (47%) patients had elective resection; 29 sigmoidectomy
alone, 3 sigmoidectomy with proximal diverting stoma, 3 Hartmann’s. Thirty
patients (40%) did not undergo resection. Eleven patients of the entire
group (15%) required repeat abscess drainage. Of these, 8 had elective
resection; 3 did not have resection.
Conclusions: Percutaneous drainage of diverticular abscess prevented
urgent or emergent resection in most patients in this study. Stoma creation
remained necessary in a high proportion of patients operated urgently
(89%) or electively (21%). Forty six percent of patients who did not require
urgent resection did not undergo resection during the study period. Study
of the longer-term outcomes of patients managed non-operatively is
P147
IS IT REALLY SMALL BOWEL OBSTRUCTION IN PATIENTS WITH PARADOX AFTER IPAA?
J. Silva Velazco, T. Hull, L. Stocchi and E. Gorgun Colorectal Surgery,
Cleveland Clinic Foundation, Cleveland, OH.
Purpose: The etiology of outlet obstruction in patients with ileal J
pouch-anal anastomosis (IPAA) is multifactorial and can depend on struc-
90
Abstracts
Comparison of Patients with Severe Symptomatology Following IPAA Surgery
with 2-Stage vs. 3-Stage Procedures
needed to understand if percutaneous drainage may be definitive management in some patients.
Surgical Procedures
P149
TWO- VERSUS THREE-STAGE IPAA FOR ULCERATIVE COLITIS PATIENTS
REQUIRING URGENT COLECTOMY: EFFECTS ON BOWEL AND SEXUAL
FUNCTION.
C. W. Hicks2, R. A. Hodin1, L. R. Savitt1 and L. Bordeianou1 1Department
of Surgery, Massachusetts General Hospital, Boston, MA and 2Department
of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
P150
Purpose: To compare bowel and sexual function among ulcerative colitis (UC) patients following 2- vs. 3-stage IPAA.
Methods: 207 patients undergoing IPAA for active UC at a high volume
IBD center (09/2000-03/2013) were mailed functional outcome validated
surveys [Memorial Sloan-Kettering Cancer Center Bowel Function Scale
(MSKCC), Fecal Incontinence Quality of Life (FIQL) instrument, Fecal Incontinence Severity Index (FISI), Female Sexual Function Instrument (FSFI), International Index of Erectile Dysfunction (IIED)]. Univariable and multivariable
analyses were used to compare results in patients undergoing 2- vs. 3-stage
IPAA.
Results: 90 (43%) survey responders (age 37.4±1.4 years, 54% male,
92% white, follow-up time 4.36±0.30 years) were similar to non-responders
from the standpoint of post-operative complications and rates of 2-stage
procedures (80% vs 83%, p=0.30). 2-stage vs. 3-stage patients had similar
demographic characteristics and anti-TNF exposure, but were more frequently treated with 6-MP or imuran (36% vs. 11%, p=0.05). 3-stage patients
underwent more urgent surgery (78% vs. 30%, p=0.0003). There were no
differences in overall post-operative complications between groups
(p≥0.44). After controlling for differences in surgical urgency and
immunomodulator use, there were no significant differences between 2 vs.
3-stage patients for any of the overall post-operative bowel or sexual function scores measured. Furthermore, the proportion of patients with severe
post-operative frequency, urgency, and need for dietary modification
(MSKCC subscales < 3), severe fecal incontinence (FISI >24), and poor quality of life (FIQL subscales <3) were similar between groups (Table). Females
and males also had similar rates of sexual dysfunction regardless of surgical staging (FSFI <26.6 for females; IIED erectile dysfunction <26 for males).
Conclusions: In a high volume center, performance of an immediate
urgent IPAA reconstruction does not decrease post-operative bowel or sexual function compared to a more cautious approach that starts with a
subtotal colectomy.
CANCER IN ILEAL POUCHES FOLLOWING RESTORATIVE PROCTOCOLECTOMY.
S. R. Gorfine, K. Wallace, S. Eisenstein, D. Chessin, D. Popowich, J. Deliz,
A. Nanna and J. J. Bauer Surgery, Mount Sinai Medical Center, New York,
NY.
Purpose: We report 5 patients who developed pelvic adenocarcinoma
after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis
(IPAA) and review previously published cases.
Methods: Cases were derived from our practice database of 1223
patients who underwent RPC and IPAA between 1980 and 2013. We also
reviewed previously published cases.
Results: The average age of our 5 patients at the time of colitis diagnosis was 23.6 years (17-33 years), and the average duration of colitis prior to
RPC was 10.6 years (2-28 years). No patient was known to have primary sclerosing cholangitis or other recognized cancer risk factors other than colitis
of more than 8 years duration. Surgical pathology at the time of colectomy
revealed neoplastic lesions in 3 of 5 patients (T2N0 cancer in one, high
grade dysplasia/DALM in two) and only colitis in the other two. All five
patients underwent mucosectomy with handsewn IPAA. The average interval from RPC to discovery of pelvic cancer was 12.1 years (2-22 years). Three
of these patients have died during follow-up. One is receiving treatment
for pleural and lung metastases 3.5 years after pouch excision, and one is
without evidence of disease five months after pouch excision. Since 1984,
51 cases of pelvic adenocarcinoma discovered after RPC with IPAA have
been reported, including three of the patients presented here. Of 53 cases,
the average interval between RPC and discovery of cancer was 10.0 years.
Of the reported cases, 70.2% had neoplastic lesions in the original colectomy specimen (dysplasia 37.8%, cancer 32.4%) and 29.7% had only colitis.
Mucosectomy with handsewn anastomoses were performed in 61.1% and
stapled anastomoses were performed in 38.9% of cases where anastomotic
technique was reported.
Conclusions: With the addition of these cases, 53 cases of pelvic cancer
following RPC have been reported. The average time interval from RPC to
cancer discovery was 10.0 years. Two of our cases and 29.7% of all cases
had no obvious risk factors for development of subsequent carcinoma
other than colitis of long duration. Mucosectomy does not eliminate the
risk of subsequent pelvic carcinoma. Long term surveillance of all patients
undergoing RPC may be indicated.
91
Abstracts
sporadic rectal cancer and CARC (Figs 1a and 1b). However, among patients
with CARC, those with Crohn’s Disease who underwent proctectomy alone
had significantly reduced disease-free survival compared to patients who
underwent total proctocolectomy (Fig 1c). Similarly, there was a trend
toward reduced disease-free survival in Crohn’s CARC patients undergoing
proctectomy compared to patients who underwent proctectomy for sporadic rectal cancer (Fig 1d).
Conclusions: Crohn’s CARC patients who undergo proctectomy have
reduced disease-free survival compared to CARC patients undergoing proctocolectomy and to sporadic rectal cancer patients undergoing proctectomy. While overall and disease-free survival did not differ significantly
between patients with sporadic rectal cancer and CARC, the subset of
patients with Crohn’s CARC undergoing proctectomy had significantly
worse outcome, warranting further study and suggesting that proctocolectomy should be the preferred surgical approach in these patients.
P151
ONE- OR TWO-STAGED ILEOCOLIC RESECTION FOR PATIENTS WITH
PENETRATING CROHN’S ILEITIS?
I. Iesalnieks1 and S. Fichtner-Feigl2 1Marienhospital Gelsenkirchen,
Gelsenkirchen, Germany and 2University of Regensburg, Regensburg,
Germany.
Purpose: Ileocolic resections for penetrating Crohn’s ileitis are associated with an increased rate of postoperative complications. Some authors
proposed a two-staged surgery to this high-risk population. The present
study was conducted to compare the one- and two-staged approach in
patients with penetrating Crohn’s ileitis.
Methods: A retrospective analysis was conducted. All patients undergoing ileocolic resection for penetrating Crohn’s ileitis were included.
Patients with a concomitant colitis were excluded. Group 1 consisted of
patients undergoing resection followed by primary anastomosis. In group
2 (two-staged approach), an end-ileostomy was created after ileocolic
resection. The stoma was reversed few months later after complete recovery from the first surgery. Two-staged approach was used when patients
were estimated to be at high risk of postoperative complications. The term
postoperative “intraabdominal septic complications” (IASC) was used for
anastomotic leaks, intraabdominal abscesses, peritonitis, any intestinal fistulae, leaks of intestinal stumps.
Results: Between 1992 and 2013, 278 ileocolic resections for penetrating ileitis were performed. Resection with primary anastomosis (Group 1)
was performed in 234 patients; a two-staged approach (Group 2) was used
in 44 patients. Postoperative IASC rate was 25% in Group 1 and 7% in Group
2 (p=0.005). Reversal of the ileostomy was attempted in 40 of 41 Group 2
patients, median 3.9 months after first surgery (3 patients lost). After reversal procedure, IASC occurred in 5 patients (12%): 3 of them needed a second attempt to reverse the stoma. Two patients were stoma-carriers at the
time of the last contact. When postoperative IASC rate was calculated by
summing up both procedures, there were no statistically significant difference between groups anymore (Group 1: 25%, Group 2: 18%, p=0.4). However, postoperative death occurred only in Group 1 patients (n=4).
Conclusions: There is still a considerable postoperative morbidity in
patients with penetrating Crohn’s ileitis undergoing two-staged ileocolic
resections; however, the complications seem to be less severe than in
patients with primary anastomosis. Ileostomy could be reversed in vast
majority of patients
P153
ELDERLY PATIENTS HAVE COMPARABLE SHORT-TERM OUTCOMES TO
YOUNGER PATIENTS AFTER LAPAROSCOPIC CANCER SURGERY.
C. Kvasnovsky, M. Sideris, K. Adams, J. Laycock, A. Haq and
S. Papagrigoriadis Department of Colorectal Surgery, King’s College
Hospital, London, United Kingdom.
P152
Purpose: Colorectal cancer frequently affects the elderly and published
studies report age as a risk factor for major surgery. We aimed to investigate if laparoscopic surgery for colorectal cancer can be performed as safely
in patients over 80 years old as in younger patients.
Methods: We prospectively collected data on 166 consecutive elective
laparoscopic resections for cancer from 07/2009 to 09/2013. We compared
short-term outcomes in elective operations for patients older than 80 at
time of surgery. We used the Clavien-Dindo classification for complications,
with a Grade 3 complication or greater considered a major complication.
Results: 32 patients (19.3%) were at least 80 years of age at surgery
(Table). Elderly patients were more likely to be female (78.1% vs 38.1%,
P<0.001). Elderly patients were otherwise similar to younger patients with
regard to pathologic cancer stage (P=0.94), ASA grade (P=0.09), and BMI
(P=0.22). One younger patient had intraoperative pulmonary complications
as a result of pneumoperitoneum, resulting in conversion to open surgery.
All other patients tolerated laparoscopy physiologically. Mean operative
times were similar between groups (251 minutes, P=0.34), as were conversion rates to open surgery (18.1%, P=0.53). Major complication rates were
also similar between groups (12.7%, P=0.57). On multiple logistic regression, there was no predictor of major complication, including age, gender,
BMI, ASA, radiotherapy, pathologic stage, or conversion to open surgery.
End colostomies were the most frequent type of defunctioning in the eld-
PROCTECTOMY FOR COLITIS-ASSOCIATED RECTAL CANCER IS ASSOCIATED WITH REDUCED DISEASE-FREE SURVIVAL.
C. Klos, B. Safar, P. E. Wise, S. R. Hunt, M. G. Mutch, E. H. Birnbaum,
M. L. Silviera, J. W. Fleshman and S. Dharmarajan Section of Colon and
Rectal Surgery, Washington University School of Medicine, Saint Louis, MO.
Purpose: The surgical management and outcomes of patients with rectal cancer in the setting of inflammatory bowel disease (IBD) is not well
defined. The aim of this study was to determine long-term oncologic outcomes of colitis-associated rectal cancer (CARC) compared to sporadic rectal cancer.
Methods: Patients with confirmed IBD and CARC who underwent surgery between 1993 and 2012 were matched (1:2) to patients with sporadic
rectal cancer from a prospectively maintained database. Criteria used to
match patients included age at surgery, gender, neoadjuvant chemoradiation and AJCC stage. The primary outcomes measured were disease-free
and overall survival. Secondary outcomes studied included type of surgery
(proctectomy vs. proctocolectomy) and histopathologic features.
Results: 27 patients with CARC were matched to 54 sporadic rectal cancer patients. Patients with CARC underwent proctocolectomy [21 (78%) vs.
3 (6%) p<0.001] and had mucinous tumors [11 (40.7%) vs. 12 (22.3%)
p=0.03] more frequently than sporadic rectal cancer patients. There was no
difference in either overall or disease-free survival between patients with
92
Abstracts
Conclusions: Our findings are in line with the published literature to
date. Robotic TME is safe and feasible. ROB conversion rate and EBL was less
than LAP, but OT is longer. ROB may have some technical advantages and
subjective surgeon benefits; but ROB and LAP have similar short-term outcomes. Longer follow-up and large-scale, prospective, randomized trials are
needed to demonstrate if robotic rectal resection will improve recurrence
rates and survival.
erly (70%), whereas younger patients underwent more varied procedures.
Notably, no patient over 80 proceeded to stoma reversal.
Conclusions: Elderly patients have similar short-term outcomes to
younger patients but they are not likely to proceed to stoma reversal. Preoperative counseling should include consideration of stoma duration.
Table: Baseline characteristics of elderly patients with short-term outcome
measures.
P155
A CASE-MATCHED ANALYSIS OF SINGLE-INCISION VERSUS HANDASSISTED LAPAROSCOPIC COLON RESECTION FOR MALIGNANT DISEASE.
J. Nieto1, M. Ragupathi1, S. Ibarra1, E. Lambert2, A. Mahmood1,
T. B. Pickron1 and E. M. Haas3 1Colorectal Surgical Associates, Ltd, LLP,
Houston, TX, 2Division of Minimally Invasive Colon and Rectal Surgery,
Department of Surgery, The University of Texas Medical School at Houston,
Houston, TX and 3University General Hospital, Houston, TX.
Purpose: Single-incision laparoscopic colectomy (SILC) has garnered
interest as a minimally invasive approach. Initial series have reported safety
and feasibility with benefits of improved cosmesis and potential for
decreased pain, and length of stay. We present a comparative analysis of
the safety, efficacy and outcomes of SILC versus hand assisted laparoscopic
colectomy (HALC) for malignant colorectal disease.
Methods: Between July 2009 and October 2013, 406 consecutive
patients who underwent SILC were entered into an IRB approved database.
Sixty-nine of these patients with malignant disease were case-matched
with HALC based on four matching-criteria: gender, age, pathology, and
procedure. Demographic data, intraoperative parameters, and postoperative outcomes were recorded and assessed.
Results: A total of 138 patients (SILC=69, HALC=69) were matched
based on four criteria (see table). The majority of patients underwent right
colectomy. When comparing SILC vs HALC, there were no significant differences in the mean operative time (130.19±42.41 vs 149.09±78.57 min,
p<0.08), or conversion rate (5 vs 6, p<0.76), but there was significant differences in estimated blood loss (57.75±58.65 vs 209.55±555.64 mL, p<0.03),
and overall mean length of stay (4.2±3.27 vs 5.64±4.08 days, p<0.02). There
was a statistical significant difference in postoperative complications, 7
(10%) in the SILC group and 22 (32%) in the HALC group (p<0.002), and in
readmissions, 1 (1%) in the SILC group and 7 (10%) in the HALC group
(p<0.03). As for reoperations, there was no significant difference between
SILC vs HALC (5 vs 2, p<0.25). The mean lymph node extraction rate
exceeded 12 in both groups.
Conclusions: SILC is a safe and promising alternative to HALC as it
avoids multiple trocar sites and offers improved cosmesis without significantly increasing operative time, conversion rate or reoperation. Furthermore, SILC offers an advantage compared to HALC in terms of EBL, LOS,
readmission and complication rates. Randomized controlled trials may be
necessary to elicit additional benefits and potential limitations.
P154
ROBOTIC VERSUS LAPAROSCOPIC RECTAL RESECTION FOR CANCER:
EARLY EXPERIENCE AND OUTCOMES.
H. J. Lujan1, F. Alvarez1, M. Gimenez1, V. H. Maciel2, B. X. Rivera1,
G. Rivera1, M. Viamonte III1 and G. Plasencia1 1Jackson South Community
Hospital, Miami, FL and 2St. Vincent Hospital, Indianapolis, IN.
Purpose: To compare our recent experience with Robotic (ROB) and
Laparoscopic (LAP) total mesorectal excision (TME) for rectal cancer.
Methods: From January 2006 to July 2013, 104 patients underwent rectal resection for cancer by three board certified colon and rectal surgeons.
Thirty-nine ROB (33 LAR / 06 APR) and 65 LAP (59 LAR / 06 APR). Conversion was defined as the use of the laparotomy wound-extraction site for
any portion of the rectal dissection. Data was prospectively recorded and
retrospectively reviewed.
Results: Both groups were similar in age, sex, BMI, ASA (≤3), and TNM
stage. Conversion rate was 7.7% for ROB vs. 15.4% for LAP (p=0.221). Mean
estimated blood loss (EBL) was 125.8 ± 132.4 ml ROB vs 160.7 ± 54.7 LAP
(p<0.001). Mean operative time was 280.1 ± 90.0 ROB vs. 165.9 LAP (<0.001).
The length of stay (LOS), lymph node harvest (LN), and specimen length
were similar. Proximal and distal margins were free of tumor for all patients.
Recurrence rate for LAR was 3.0% ROB vs. 8.5% LAP (p=0.913). Short-term
oncologic results were similar.No intra-operative complications occurred
and postoperative complicationsresults were similar.
93
Abstracts
P157
LYMPH NODE YIELD AFTER COLECTOMY FOR CANCER: IS ABSENCE
OF MMR A FACTOR?
T. Samdani, M. Schultheis, Z. Stadler, J. Shia, T. Fancher, J. Mishloy,
M. Weiser, J. Garcia Aguilar and G. Nash Colorectal Surgery, Memorial
Sloan Kettering, New York, NY.
Purpose: Factors such as tumor grade, size, location, length of resected
colon and Mismatch Repair gene (MMR) deficiency have been associated
with the number of lymph nodes retrieved in colectomy specimen. In this
study, we analyze correlation of various factors to number of lymph nodes
retrieved as well as test the hypothesis that colorectal cancers arising in
MMR deficient tumors are associated with increased lymph node (LN) yield.
Methods: Pathology database between 1999 to 2012 was reviewed to
analyze colectomy specimens with available Immunohistochemistry (IHC)
for MMR genes. Prior to 2006, IHC was done at request of oncologist or colorectal surgeon. In addition since 2006, IHC was routinely performed on
colectomy specimen for patients under 50 years of age. We measured the
association of clinical and pathological features with LN quantity. Fourteen
predictors and confounders were jointly analyzed in a multivariable linear
regression model
Results: Out of total 256 colectomy specimens reviewed, 94 were found
to have MMR deficiency. In a univariate analysis, MMR deficiency was associated with a lower malignant LN yield (mean 24.8 vs. 26.9 LN, P = 0.12),
older patient age, right sided tumors and poor differentiation. (Table1)
Using a linear regression model, five variables were found to have an independent linear relationship with LN yield: patient age, specimen length, LN
ratio, perineural invasion (PNI) and tumor size. With respect to LN yield, positive relationship was observed with tumor size, specimen length and presence of PNI, whereas remaining showed negative correlation. Tumor location was found to have a more complex, nonlinear, quadratic relationship
with LN yield; proximal tumors were associated with higher LN yield than
more distal lesions. MMR deficiency was not independently associated with
LN yield
Conclusions: In this study, we found that patient age, length of bowel
resected, LN ratio, PNI, tumor size and tumor location were significant predictors of LN yield. Contrary to literature review, we found that MMR protein expression is not a biological predictor of LN yield, when controlling
for surgical and pathological factors.
* Matching criteria, plus pathology (Malignant cases)
SILC: Single-incision laparoscopic colectomy, HALC: Hand-assisted laparoscopic
colectomy, BMI: Body mass index, ASA: American Society of Anesthesiologists
P156
LAPAROSCOPIC SUTURE RECTOPEXY FOR RECTAL PROLAPSE: IS A
MESH NECESSARY?
T. Yamana, K. Morimoto, S. Takahashi, M. Sassa, A. Kanazawa, Y. Kaneko
and R. Sahara Department of Coloproctology, Social Health Insurance
Hospital, Tokyo, Japan.
Purpose: Recently, laparoscopic ventral mesh rectopexy has been
widely performed in the treatment of rectal prolapse. However, attaching a
non-absorbable mesh to the rectum and vagina may result in significant
complications, such as rectal or vaginal erosion, fistulation, or stricturing,
which are difficult to treat. The aim of this study was to evaluate the safety
and efficacy of laparoscopic suture rectopexy without a mesh.
Methods: A retrospective review of all 116 patients who had undergone laparoscopic suture rectopexy using a standardized simple suture
technique at a single institution from October 2010 to August 2013 was
analyzed. Patient characteristics, previous treatment, operating time, blood
loss, hospital stay, complications, bowel habits, and recurrence were
reviewed.
Results: The study included 10 men and 106 women with a mean age
of 69 (range 14-91). Thirteen patients had undergone rectal prolapse surgery previously. The average operating time was 151 minutes and the average blood loss was 9 ml. Only 2 patients needed a mini-laparotomy during
surgery due to difficult fixation. The average hospital stay was 9.2 days. In
the early postoperative period, 1 patient developed port site hernia requiring surgical repair. No other significant postoperative complications were
encountered, such as intra-abdominal sepsis, bleeding, or bowel obstruction. No patient complained of difficult evacuation or significantly increased
constipation postoperatively. During the follow-up, recurrence developed
in 6 patients (5.2%). Among the 6 patients, 4 patients presented with
mucosal or short length prolapse less than 3 cm. Among the 6 recurrent
patients, 4 patients underwent subsequent procedures including 3 Thiersch operations and 1 Delorme operation, and no recurrence occurred after
the second procedure.
Conclusions: This study shows that laparoscopic suture rectopexy without a mesh is a safe and effective treatment for patients with rectal prolapse, comparable to laparoscopic ventral mesh rectopexy, with low morbidity and low recurrence rates. Potential mesh-related complications can
be avoided using this procedure.
Linear Regression Model of Lymph Node Yield
*Additional lymph nodes per unit of variable, e.g. 1 .19 additional LNs per 1cm
increase in size and 0.16 fewer lymph nodes per increase year in age.
** Tumor location has a non-linear relationship in model.
94
Abstracts
monary metastases developed after colorectal cancer surgery. Data on various clinico-pathological factors were retrospectively analyzed.
Results: The mean disease free interval (DFI) between initial resection
of primary CRC and identification of pulmonary metastases was 24.1 ± 15.6
(range, 4-85) months. Thirty (23.6%) patients had undergone curative
hepatic resection for liver metastases at colorectal resection. Solitary pulmonary metastasis was found in 77 (60.6%) patients, and the mean of maximal tumor diameter was 14.4 ± 10.5 mm. After pulmonary metastasectomy, 3-year disease free survival rates and 5-year overall survival rates were
39.3% and 63.9%, respectively. DFI, number and distribution of pulmonary
metastases, and concurrent hepatectomy at colorectal surgery represented
significant prognostic factors for overall and 3-year disease free survival. On
multivariable analysis, DFI (P = 0.018) and number of tumor (P =0.001) were
identified as independent prognostic factors for disease free survival rates.
In addition, patients with multiple lesions (P = 0.017) and history of hepatic
metastasectomy (P = 0.048) had worse 5-year overall survival rates.
Conclusions: Pulmonary metastasectomy has potential survival benefit
for patients with metastatic colorectal carcinoma. Surgical resection for pulmonary metastases should be considered in patients with longer DFI, solitary lesion and no history of previous hepatic metastasectomy.
P158
COLORECTAL CANCER IS ASSOCIATED WITH A POSITIVE FAMILY HISTORY OF BREAST CANCER.
A. Mabardy, L. Ozcan, N. Garland, J. Coury, P. Miller, A. Hackford and
H. Dao Saint Elizabeth’s Medical Center, Boston, MA.
Purpose: Several studies have recently suggested that breast cancer is
related to Lynch syndrome. We sought to investigate the relationship
between colon cancer and a family history of breast cancer using a national
database.
Methods: For the year 2009, patients were identified using the Nationwide Inpatient Sample database who had a diagnosis of colorectal cancer.
The incidence of a family history and personal history of breast cancer in
this group was then compared to the general population of hospitalized
patients. Patients presenting with breast cancer were then analyzed for a
family history of gastrointestinal cancer.
Results: In 2009, an estimated 236,260 admissions were associated with
colon or rectal cancer. For these patients, there was a significantly higher
incidence of a positive family history of breast cancer when compared to
the general hospitalized population (0.5% vs. 0.2%, OR 2.89, 2.71-3.05).
Patients also more frequently had a personal history of breast cancer (1.8%
vs. 1.3%, OR 1.41, 1.37-1.45). Those patients presenting with cancers of the
cecum, ascending colon, or hepatic flexure had an even higher incidence
of a positive family history of breast cancer (0.6% vs. 0.2%, OR 3.62, 3.234.05) and personal history of breast cancer (2.6% vs. 1.3%, OR 1.98, 1.872.10). Of note, patients presenting with colon cancer who had a personal
history of breast cancer had a significantly older median age than those
patients without a personal history of breast cancer (76 y.o. vs. 68 y.o.,
p<0.0005). An estimated 178,523 admissions were associated with breast
cancer. For these patients, there was a significantly higher incidence of a
positive family history of gastrointestinal cancer when compared to the
general hospitalized population (0.9% vs. 0.2%, OR 3.95, 3.76-4.15).
Conclusions: Patients with breast cancer are more likely than the general hospitalized population to have a family history of gastrointestinal cancer. In addition, patients with a diagnosis of colorectal cancer are more
likely to have a positive family history of breast cancer and a personal history of breast cancer, although the later may be related to the advanced
age of the population.
P160
DOES ACHIEVING NEGATIVE SURGICAL MARGINS IN THE TREATMENT
OF PERIANAL PAGET’S DISEASE MATTER, OR IS IT JUST THE TIP OF
THE ICEBERG?
O. Isik1, E. Aytac1, J. Brainard2, M. Valente1 and E. Gorgun1 1Colorectal
Surgery, Cleveland Clinic, Cleveland, OH and 2Anatomic Pathology,
Cleveland Clinic, Cleveland, OH.
Purpose: Perianal Paget’s disease (PPD) is a rare intraepithelial adenocarcinoma of the perianal skin and the second most common localization
of extra mammary Paget’s disease. This study was designed to evaluate the
natural history of Perianal Paget’s Disease (PPD) and to assess factors affecting survival in patients with PPD.
Methods: After obtaining institutional review board approval, we identified patients who were treated for PPD between 1981 and 2013. Patient
demographics, family history, associated malignancies, treatment
approach, histopathological features, need for re-operation, and long-term
outcomes were documented. Survival estimates were analyzed using the
Kaplan-Meier method.
Results: Our study cohort consisted of 15 male and 10 female patients
with a median age of 67 (40-83). PPD was treated with wide local excision
(14 patients), local excision (5 patients), abdominoperineal resection (4
patients) and radiotherapy (2 patients). Four patients had concurrent
anorectal adenocarcinoma (2 anal canal, 2 rectal) at the time of PPD diagnosis and 5 patients developed invasive carcinoma (3 anal canal, 1 vulvar, 1
perianal squamous cell carcinoma) during follow-up. Interval time to the
diagnosis of invasive carcinoma was 5 (2- 9) years, and 3 of them had a positive surgical margin at initial excision. Thirteen patients required re-operation and 15 patients needed a reconstructive procedure. There were no differences in survival between patients treated with wide local excision and
local excision, regardless of surgical margins at initial excision (p= 0.75)
Median follow-up time was 60 (3- 299) months.
Conclusions: Achieving negative surgical margins may not have a significant impact on long-term outcomes in PPD. A larger concern for PPD
patients appears to be the disease’s significant association with invasive
cancers. Close surveillance is required due to the risk of invasive cancer
development, and potential need for further surgical management.
Hospital Admissions Related to Cancer of the Cecum, Ascending Colon, or
Hepatic Flexure
P159
CURATIVE PULMONARY METASTASECTOMY FROM COLORECTAL
CANCER: ANALYSIS OF SURVIVAL RATES AND PROGNOSTIC FACTORS.
M. Ihn1, D. Kim1, S. Kang1, H. Oh1, S. Lee1, H. Yang2, S. Jheon2, K. Kim2
and S. Cho2 1Surgery, Seoul National University Bundang Hospital,
Seongnam-si, Republic of Korea and 2Thoracic and Cardiovascular
Surgery, Seoul National University Bundang Hospital, Seongnam-si,
Republic of Korea.
Purpose: Lung metastases from colorectal cancer (CRC) occur in
approximately 10-25% of all CRC patients. This study was to determine the
survival rates and prognostic factors in patients with CRC who underwent
pulmonary metastasectomy.
Methods: Between June 2003 and December 2011, a total of 127
patients with CRC were included, who underwent curative resection of pul-
95
Abstracts
Table I: Treatment strategy and patient status at last follow-up
P161
COLORECTAL SQUAMOUS-CELL CARCINOMA: A RARE TUMOR WITH
POOR PROGNOSIS.
E. Aytac1, G. Ozuner1, A. Bennett2 and E. Gorgun1 1Colorectal Surgery,
Cleveland Clinic, Cleveland, OH and 2Anatomic Pathology, Cleveland
Clinic, Cleveland, OH.
Purpose: Primary squamous cell carcinomas of the colon and rectum
are extremely rare, with an incidence of less than 0.25 percent of colorectal
malignancies. Data on this entity is limited. Therefore, our aim in this study
was to evaluate patient characteristics, treatment strategy and postoperative follow-up of patients with colorectal squamous cell carcinoma.
Methods: We reviewed our institutional review board approved,
prospectively-maintained colorectal cancer database for all patients who
were diagnosed with colorectal squamous cell carcinoma between January
1990 and April 2009. Only those patients with primary colorectal squamous
carcinoma, in addition to the following characteristics, were analyzed:
absence of primary squamous cell carcinoma in any other organ, absence
of squamous-lined fistulous tracts, and a distinct demarcation of the tumor
from the squamous epithelium of the anal canal.
Results: Eleven patients (8 female) met the study criteria. Median age
at the time of diagnosis was 64 (43-82). Median BMI was 27.6 (18.8-46.6).
Presenting symptoms included change in bowel habits (n=5), abdominal
pain (n=3), rectal pain (n=2), anemia (n=1), obstruction (n=1) and rectal
bleeding (n=1). Two patients had a history of pelvic radiotherapy. Tumors
were localized in the rectum (n=8), right colon (n=2) and sigmoid colon.
Ten of the 11 patients underwent a colorectal resection. Pathologic disease
stage was I (n=1), II (n=4), III (n=3) and IV (n=3). Treatment strategy and
patient status at last follow-up are summarized in the table I. Median follow-up after diagnosis was 42 months (12-96). Three patients developed
recurrence after curative surgery. Five patients died from metastatic disease
during follow-up.
Conclusions: This is one of the largest, single institution series in the
literature to report on primary squamous colorectal cancers. Squamous colorectal cancer can be detected in any part of the colon, generally presents
at a later stage and is associated with a poor prognosis. Surgery is the mainstay of treatment. Various adjuvant chemoradiation treatments appear not
to influence the outcome. Further cases need to be analyzed in order to
find more effective treatment regimens.
(*): Curative surgery, ‡: Recurrent disease,
APR: Abdominoperineal resection, CISP: Cisplatinum, NED: No evidence of
disease, FU: Fluorouracil, LAR: Low anterior resection, MMC: Mitomycin-C.
†: This patient had six months follow-up after colon resection, had an isolated
liver metastasis and receiving adjuvant chemotherapy
P162
RECTAL ADENOCARCINOMA AT AN URBAN PUBLIC HOSPITAL PRESENTS AT A YOUNGER AGE AND LATER STAGE.
M. Wong1, R. Cui1, H. Talus2, M. Muthusamy2 and T. McIntyre2 1Surgery,
SUNY Downstate Medical Center, Brooklyn, NY and 2Surgery, Kings County
Hospital Center, Brooklyn, NY.
Purpose: We aim to characterize our experience treating rectal adenocarcinoma at a large urban public hospital that serves a predominately lowincome and minority population.
Methods: This retrospective chart review evaluated all cases of rectal
adenocarcinoma diagnosed at Kings County Hospital from January 2002 to
October 2012. Data on demographic, geographic, pathologic and clinical
variables were collected and compared with national statistics from the Surveillance Epidemiology and End Results (SEER) database by chi-square test
and t-test as appropriate.
Results: Ninety-two patients diagnosed with rectal adenocarcinoma
were identified. Patients were predominately African-American (84%), and
the race-specific mean per capita income of the represented patient by census tract was $19,195.15. The mean age at diagnosis was 61.5 years. When
subdivided by decade and compared to the SEER database, more of our
patients presented between 50-59 years of age (38.0% v. 22.8%, p = 0.0005),
and fewer after 80 years of age (7.6% v. 17.0%, p = 0.01). 82.1% of patients
presented with bleeding or anemia and only 9.5% presented after screening colonoscopy. Fewer patients presented with AJCC stage 1 disease (8.1%
vs 31.3%, p < 0.001), and more presented with stage 4 disease (33.9% vs
17.8%, p = 0.001) compared to nationwide SEER data.
Conclusions: Rectal adenocarcinoma patients at our urban public hospital present at younger age and later stage than the national average.
These findings suggest a role for initiating screening at a younger age in
this population.
96
Abstracts
It is unclear which is the optimal option. The aim of our study is to review
the outcome of the primary closure vs reconstruction of pelvic floor and to
compare different reconstructive techniques
Methods: A systematic literature search was conducted using the Medline, Embase and Cochrane databases up to January 2013. Primary endpoint was the rate of overall complications. Secondary end-points were
length of hospital stay, major and minor wound complications. A fixed
effect model or random effect model was used depending on the heterogeneity among the studies. Comprehensive Rev Men version 5.2 was used
for the statistical calculations
Results: 700 articles were identified; 31 articles (9 case control and 23
cohort studies) were selected for qualitative synthesis and 7 case-control
studies for the meta- analysis. The patients were divided into two groups:
the primary closure (PC, 525 pts) and the reconstruction (R, 607 pts) group.
Overall complication rate was 34.1% vs. 39.7% in the PC and R group
respectively (p=NS). The meta-analysis showed a significant difference in
favour of reconstruction (OR 2.29, 95% CI 1.44-3.64, p<0.001). Lenght of
hospital stay was in favour of R group (p=0.03). Major complications were
18.4% in the PC group and 15.1% in the R one (p=NS) Minor complications
were 17.7% in PC group and 24.1% in the R group (p<0.001). Reconstructions with muscle flaps (M, 352 pts), muscle sparing flaps (Ms, 168 pts) and
mesh group (Me, 87 pts) were analysed. The complications rate was 44.8%,
33.9% and 29.8% in the M, Ms and Me group respectively (p=NS). The metaanalysis of Me vs. non mesh (M or Ms), showed a significant difference in
favour of the Me group (OR 0.15, 95% CI 0.03-0.80, p=0.03)
Conclusions: Our results showed the superiority of perineal reconstruction over primary closure after eLAPE in terms of overall complications, hospital stay and minor wound complications. Randomised trials are needed
to define the best reconstructive technique
P163
CLINICAL RISK FACTORS FOR LATE RECTAL TOXICITY AFTER RADIOTHERAPY: A SYSTEMATIC REVIEW.
Q. Qin, Q. Zhong, T. Ma and L. Wang Colorectal Surgery, Sixth Affiliated
Hospital, Sun Yat-sen University, Guangzhou, China.
Purpose: Late rectal toxicity after radiotherapy (LRTAR) significantly
lowers the quality of life in an increasing number of cancer survivors. Clinical factors which play an important role in the prediction of toxicity remain
controversial. The aim of this study was to clarify which clinical factors are
associated with an increased risk of LRTAR.
Methods: Studies addressing clinical factors for moderate/severe LRTAR
were identified through electronic databases and by hand-searching. Effect
estimate and 95% confidence interval (CI) were extracted from a multivariate analysis with preference. A meta-analysis of Odds ratios (OR) with random effects model was performed for selected risk factors. This study was
registered and the protocol was published.
Results: Of 2298 studies initially identified, 8 studies were included. Diabetes (OR 4.73; 95% CI 2.45-9.12), acute rectal toxicity (OR 2.34; 95% CI 1.862.95) were associated with a higher risk of LRTAR. Smoking (⭌1 pack/ day)
(HR 2.20; 95% CI 1.44-3.36) and low weight (body-mass index < 22 kg/m2)
(HR 1.74; 95% CI 1.14-2.64) were identified in only one study. History of
abdominalpelvic surgery, androgen deprivation for prostate cancer and
hypertension showed no association with the risk of LRTAR.
Conclusions: Diabetes and acute rectal toxicity during radiotherapy
indicate a higher risk of LRTAR, while smoking habit and low weight of
patient require further investigation to ensure the predictive value.
P165
DOES AN ENHANCED RECOVERY PROGRAM IN COLORECTAL SURGERY CHANGE READMISSION PATTERNS?
A. V. Hayman, K. T. Behm, A. E. Wagie, E. B. Habermann, J. K. Lovely,
R. R. Cima and D. W. Larson Mayo Clinic, Rochester, MN.
Purpose: The shorter lengths of stay achieved by enhanced recovery
programs (ERP) are balanced by concerns of increased readmissions rates.
Moreover, patient-specific factors and readmission patterns after ERP have
not been examined. Therefore, we compared the number of, reasons for,
and timing of all readmissions in matched cohorts before and after the initiation of an ERP for colorectal surgery.
Methods: Patients who were included in both our institutionally maintained prospective ERP database and our ACS-NSQIP sample from 3/22/1012/19/11 (n=413) were analyzed. Historical NSQIP controls (pre-ERP),
matched by procedure and diagnosis, were obtained from our institution’s
sample from 9/13/06-11/2/09 (n=412). Variables included demographics,
diagnosis, procedure, length of stay, and readmission within 30 days of surgery. Indication for readmission was abstracted from chart review. Days
from surgery to readmission were calculated. We then analyzed differences
in these outcomes between the two groups using chi square and t- tests.
Results: There was no significant difference in age, sex, procedure, or
primary diagnosis between the ERP group and matched controls (Table 1).
Readmission rate was 12% for both groups (n=101). The most common reasons for readmission were bowel obstruction and surgical site infection, but
the incidence differed between the two groups. Mean days to readmission
were similar between groups. Mean and median lengths of stay were significantly shorter for the ERP group. However, among subjects subsequently
readmitted, they were equal.
Conclusions: Implementing ERP reduced lengths of stay without earlier or more frequent readmissions when compared to historical controls.
The non-ERP group had significantly more readmissions for infectious reasons and a trend towards fewer bowel obstructions. ERP can be safely
implemented in a colorectal surgical practice with the potential to significantly benefit patients without incurring more readmissions.
P164
PERINEAL
RECONSTRUCTION
AFTER
EXTRALEVATOR
ABDOMINOPERINEAL EXCISION FOR LOW RECTAL CANCER: SYSTEMATIC REVIEW AND META-ANALYSIS.
P. De Nardi1, V. Summo2, G. Capretti1, A. Vignali1, M. Klinger2 and
C. Staudacher1 1Department of Surgery, San Raffaele Scientific Institute,
Milano, Italy and 2Humanitas Research Hospital, Rozzano, Italy.
Purpose: The extended Extralevator Abdominoperineal Excision
(eLAPE) requires techniques to manage the large perineal wound. Primary
closure, reconstruction with flaps and biological mesh have been described.
97
Abstracts
were no differences in overall satisfaction, sexual/body image, stoma function, or skin irritation scores between groups.
Conclusions: Effective ostomy education is important in minimizing
anxiety and improving satisfaction. Younger patients respond more favorably to a platform including electronic media and online resources. While
most patients initially note this as a preference, older patients were not as
satisfied. A tailored approach based on age may be most apt in improving
satisfaction and QoL. The impact of this approach on stoma-related complications and expense requires further study.
Table 1. Demographic and Satisfaction Data from Survey
P166
OSTOMY EDUCATION VIA ELECTRONIC MEDIA IMPROVES SATISFACTION IN YOUNGER PATIENTS.
C. B. Aarons, R. B. Broach, A. Preston, W. Falone, J. Bleier and
N. N. Mahmoud Department of Colon & Rectal Surgery, University of
Pennsylvania Health System, Philadelphia, PA.
P167
Purpose: Patients requiring an ostomy need effective education that
will meet their needs. We aim to evaluate the impact of an electronic platform of concise ostomy education on patient satisfaction and quality of life
(QoL).
Methods: A pilot study using portable electronic media was developed
based on adult learning theories. An ostomy nurse reviewed this preoperatively with patients needing a new ostomy (group A). Continued education
was encouraged through online resources distributed via the electronic
medical record. Demographic and medical information were obtained. Surveys assessing satisfaction and short-term QoL using the Stoma Quality of
Life Scale (SQOLS) were then given and compared to patients who received
more conventional (printed materials) education (group B).
Results: Surveys were completed by 38 patients (group A=23). Both
groups were similar in age, education, and diagnoses. Both groups identified similar usage of and access to computers and portable devices. Most
patients noted a preference for education via electronic media vs printed
materials (50% vs 11%). Satisfaction with the organization, clarity, and usefulness of education was higher in group A. All of these patients were at
least “very satisfied” with the preparation the material provided vs 86% in
group B. Analysis based on age showed that more younger patients
(<50yrs) were at least “very satisfied” with their preparation in group A
(100%) vs group B (67%). Conversely, more older patients (>50yrs) were at
least “very satisfied” with their preparation in group B (100%) vs group A
(85%). The mean time to administration of the SQOLS was 4 weeks. There
TO IDENTIFY HOSPITAL READMISSION RATES AFTER LOOP
ILEOSTOMY CREATION AND TO EVALUATE THE EFFICACY OF A
PROSPECTIVE MANAGEMENT PROTOCOL TO DECREASE READMISSION RATES FROM DEHYDRATION.
K. Muddasani1, A. L. Stoddard2, J. Holder2, B. Styles2, C. Jadlowiec1,
P. Vignati2, W. Sardella2, C. Bartus3, K. Johnson2, K. Thurston2 and
J. Cohen2 1General surgery, University Of Connecticut, Farmington, CT,
2
Colorectal surgery, Hartford Hospital, Hartford, CT and 3Colorectal
Surgery, The Hospital of Central Connecticut, New Britan, CT.
Purpose: To identify readmission rates after loop ileostomy creation
and to evaluate efficacy of a prospective management protocol to decrease
readmission rates from dehydration
Methods: Readmission rates and trends for 70 patients from Jan 2009
to May 2012 discharged with an ileostomy were evaluated and a benchmark was established. A discharge protocol was established which included
aggressive hospital education prior to discharge, routine use of Imodium
as an outpatient, close clinical and biochemical follow-up in outpatient setting. Intent of this protocol was to avoid dehydration and reduce readmission rates. Patients discharged with ileostomy after July 2012 were enrolled
in study and data collected prospectively. All patients noncompliant with
protocol were excluded
Results: 63 patients were enrolled in the study from July 2012 to September 2013. 7 patients were excluded for noncompliance. Average age of
patients in the baseline group and the protocol group were 40.51(± 14.77)
98
Abstracts
and 52.79 (± 16.06) (P < 0.0001) respectively. There was no significant difference in sex distribution, steroid and diuretic use among both groups.
There was no difference in timing of ileostomy reversal in days between
both groups, 84.50(± 50.37); 85.92 (± 52.94), (P=0.9019). Overall 90 day readmission rate was reduced, but did not achieve statistical significance, baseline group - 25 (35.7%); Protocol group - 11 (19.6%), (P=0.0770). 90 day
readmission rate from dehydration was reduced from 14 (56%) to 2 (18.2%),
(P=0.0354). There was no significant change in readmission rates from infection and postoperative bleeding. 90 day readmissions from bowel obstruction were increased from 5 (20%) to 8 (72.7%) (P =0.0064)
Conclusions: Use of a prospective protocol was effective in reducing
readmission rates from dehydration after an ileostomy. Although we did
notice an increase in readmissions from bowel obstruction, none of these
patients required surgery. We conclude that a rigorous pre and post discharge protocol for new ileostomy patients is a safe and effective way to
manage complications related to dehydration leading to hospital readmissions
P169
DIVERTING STOMAS: ARE YOU IN THE LOOP?
P. M. Shah, D. Mauro, C. Friel and T. Hedrick Surgery, University of Virginia,
Charlottesville, VA.
Ileostomy protocol outcomes
Purpose: Diverting stomas are frequently employed for various clinical
indications. The diverting loop stoma is advantageous for its ease of reversal. Given that the two ends of the bowel are at the skin level, the subsequent surgery to reverse the stoma can typically be accomplished through
the peristomal incision, foregoing the need for a laparotomy. However, traditional surgical folklore would lead us to believe that a diverting loop
stoma is inadequately diverting. Theoretically, there is concern that stool
will spill over into the distal limb to contaminate the bowel downstream of
the stoma. We hypothesize that a diverting loop stoma is completely diverting with no efflux into the distal limb.
Methods: We performed a systematic review of consecutive patients
undergoing loop colostomy or ileostomy as defined by CPT code (44187,
44188, 44153, 44155-58) between 4/1/02 and 10/12/10. We identified
patients who subsequently underwent CT scan with oral contrast. These CT
scans were reviewed independently by a radiologist to evaluate for the
presence of oral contrast in the distal limb of the ostomy.
Results: Of the 202 patients that underwent the aforementioned procedures during the study period, 41 patients (20%) underwent CT scan of
the abdomen and pelvis following surgery. Three scans were excluded from
study due to rectal contrast administration or retention of contrast in the
distal limb from a radiologic test performed prior to ostomy formation. Of
the remaining 38 patients, only 2 patients (5%) with a loop colostomy had
possible evidence of contrast in the distal limb. No patients with a loop
ileostomy had evidence of contrast in the distal limb.
Conclusions: Loop stomas provide adequate diversion for the vast
majority of patients. Given ease of reversal, shorter hospital stay, and
quicker recovery time, loop ostomies should strongly be considered as the
procedure of choice for temporary diversion.
P168
PROTOCOL FOR FOLEY CATHETER ON POSTOPERATIVE DAY ONE FOR
COLORECTAL PATIENTS.
E. McKeown1, N. Hendrickson4, R. Menon2, A. Bastawrous2, R. Kratz2,
D. Rossi3 and R. Billingham2 1Swedish Medical Center, Seattle, WA,
2
Department of Colon and Rectal Surgery, Swedish Medical Center, Seattle,
WA, 3Colorectal Surgery, Geisinger Health System, Wilkes-Barre, PA and
4
Colon and Rectal Surgery, Overlake Hospital Medical Center, Seattle, WA.
Purpose: Foley catheters are routinely used in major colorectal surgery.
The most recent Surgical Care Improvement Project (SCIP) guidelines seek
to ensure that Foley catheters are removed on postoperative day 1 or 2
(POD 1 or 2). The exception has been in patients undergoing pelvic surgery
or if otherwise documented to be medically necessary. We studied the
safety and efficacy of removal of Foley catheters on POD 1 in colorectal
patients.
Methods: A protocol was developed at our institution in which patients’
Foley catheters were removed on POD1 after abdominal and pelvic surgery.
Patients were followed prospectively. Exclusion criteria included patients
with <250cc of urine output in 8 hours, need for continuous urine output
monitoring, a history of requiring manual catheterization one month prior
to their operations and those with a colovesical fistula.
Results: A total of 117 patients were enrolled in the study. The Foley
catheter was removed on POD1 in 93 patients who met the protocol criteria. Seventy-nine (85%) of these patients required no further catheterization. Fourteen (15%) patients required re-catheterization after the Foley was
removed. Of these, three (3%) patients required discharge home with the
Foley and, ultimately, all 3 were removed within 10 days. There were no urinary tract infections.
Conclusions: Foley catheters may be safely removed POD 1 in the
majority of patients after major colorectal surgery, regardless of the presence of an epidural catheter.
P170
RISK STRATIFICATION OF COLECTOMY FOR CANCER AND THE INCREMENTAL BENEFIT OF LAPAROSCOPY: A NATIONAL PERSPECTIVE
USING ACS-NSQIP.
T. P. Nickerson1, C. Shubert1, K. Thomsen2, E. Habermann2 and R. Cima1
1
Colorectal Surgery, Mayo Clinic Rochester, Rochester, MN and 2Health
Care Policy and Research, Mayo Clinic Rochester, Rochester, MN.
Purpose: We hypothesized that colectomies can be stratified into low
and high risk categories based on postoperative morbidity and sought to
determine the benefit of laparoscopic surgery specific to high risk and low
risk resections.
Methods: ACS-NSQIP was reviewed for outcomes after colon and rectal
resection for colorectal cancer from 2005 - 2011, identified by CPT codes.
“High risk” was defined by univariate analysis of major morbidity per procedure, and sub-grouped as open or laparoscopic. Chi-square tests and
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Abstracts
multivariable logistic regression were utilized to assess the impact of extent
and type of resection on outcomes.
Results: 20,784 patients were identified who received open (64%) or
laparoscopic (36%) colectomy for cancer. Based on comparisons of morbidity within open operations, total colectomy(TC), total proctocolectomy
(TPC) and left colectomy with diversion (LCD) were grouped as “high risk”;
right colectomy (RC) and left colectomy without diversion (LC) were
grouped as “low risk”; proctectomy (P) operations were grouped as “moderate risk.” Within lap operations, TC, TPC, LCD, and P were grouped as “high
risk”; RC and LC were grouped as “low risk.” Within open or laparoscopic
operations, low risk procedures had lower rates of severe infection and morbidity (p<0.001). Differences in thirty-day mortality between procedure risk
groups were observed for open (p<0.001) but not for lap (p=0.52). Comparing high risk open and laparoscopic procedures via multivariable logistic regression, open procedures were independently associated with
increased: mortality (OR 2.54), major morbidity (OR 1.23), any morbidity (OR
1.31), and sepsis/septic shock (OR 1.40). In the low risk group, open procedures were independently associated with increased: mortality (OR1.68),
major morbidity (OR 1.43), any morbidity (OR 1.49), sepsis/septic shock
(OR1.54), and organ space infection (OR 1.44).
Conclusions: In this analysis of colorectal cancer resections categorized
by risk, laparoscopic operations were associated with better outcomes
across all risk categories. We recommend all patients with colorectal cancer
be referred to providers offering minimally invasive approaches.
Methods: A retrospective analysis of patients undergoing enteric fistula surgery over a five year period was conducted. For categorical demographic and outcome variables, chi-squared test or Fisher’s exact test was
performed. For the age and BMI, t-test was used. Logistic regression models were used to compare complications adjusting for past surgical history
and ASA status. Major complications included MI, stroke, unplanned admission to ICU, and additional surgical or interventional radiology procedures.
Minor complications included wound infections, UTI, respiratory tract infections and organ space abscesses treated with antibiotics alone.
Results: A total of 63 patients (26 open, 37 laparoscopic) were included.
There were five conversions (13.5%). There was no difference in age, gender, BMI and comorbidities between the two groups. Patients in the open
group had higher incidence of prior abdominal surgeries and higher ASA
class which were adjusted in logistic regression analysis. There was no statistically significant difference in major and minor complications, readmission rates, and operative time. Laparoscopic group had a statistically shorter
length of stay and EBL.
Conclusions: Our study suggests that treatment of complex enteric fistulae may result in the loss of some short term benefits seen with conventional laparoscopic surgery. While laparoscopy had favorable length of hospital stay and reduced blood loss, our study did not show significant
benefits in major or minor complications and readmission rates.
Patient demographics and outcomes.
Outcomes of laparoscopic versus open colectomies stratified by risk category.
P172
OUTCOMES AFTER LAPAROSCOPIC COLECTOMY IN THE “REALWORLD”: REAL AND SUSTAINED BENEFIT?
I. Esemuede1, S. A. Lee-Kong1, D. Fowler2, D. Feingold1 and P. R. Kiran1
1
Colorectal surgery, New York Presbyterian Columbia University Medical
Center, New York, NY and 2General Surgery, New York Presbyterian
Columbia University Medical Center, New York, NY.
OR; odds ratio comparing multivariate results of lap versus open by risk stratified
groups. Results reported as percentages or OR with [95% confidence interval].
P171
SHORT-TERM OUTCOMES OF LAPAROSCOPIC VS. OPEN TREATMENT
OF INTERNAL ENTERIC FISTULAS – A LOGISTIC REGRESSION ANALYSIS.
R. Huang1, A. Harzman1, M. Arnold1, N. Hendrickson1, M. Abdel-Rasoul2
and S. Husain1 1Division of Colon and Rectal Surgery, Ohio State
University, Columbus, OH and 2Center for Biostatistics, Ohio State
University, Columbus, OH.
Purpose: Laparoscopy has been shown to improve short term outcomes and reduce complications compared to open surgery. The purpose
of this study is to evaluate if these benefits are retained in complex abdominal fistula surgery.
Purpose: That laparoscopic colectomy (LC) has benefits over open
colectomy (OC) has been elucidated by multiple clinical trials and singleinstitution studies, but in these circumstances patients undergo LC by welltrained specialist laparoscopic surgeons. The aim of this study is to evaluate the ‘real-world’ translatability of these benefits for any patient who
undergoes colorectal resection at the current time and particularly whether
the results remain sustained without a reactive increased readmission following discharge.
Methods: From the National Surgical Quality Improvement Program
database, only patients undergoing colorectal resection in 2011 were identified. LC and OC patients were compared for patient and disease factors,
medical and surgical complications, and readmission rates. A multivariate
analysis controlling for significant factors was performed to evaluate factors associated with readmission.
Results: For 30,019 patients undergoing colorectal resection, 59.5%
underwent OC and 40.5% LC. While both groups had similar gender and
body mass index, OC patients were older, more commonly had chronic
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Abstracts
obstructive pulmonary disease, diabetes mellitus, and emergency operation (table). Length of stay (LOS) after LC was shorter than OC. LC was associated with a significantly lower rate of surgical site infections (SSI), bleeding, reoperation and 30-day mortality as well as medical complications
(such as pneumonia and urinary tract infection) than OC. Risk of readmission was greater for patients undergoing proctectomy than colectomy, but
was lower after LC than OC for both procedures even after multivariate
analysis controlling for various confounding factors.
Conclusions: The recovery benefits of laparoscopy demonstrated in trials are translated to patients currently undergoing colorectal resection at
American College of Surgeons-NSQIP participant institutions. Despite its
technical complexity, LC can be performed without concerns for increased
complications. Since readmissions after LC continue to be lower than OC,
these immediate postoperative benefits of LC also continue to be sustained
over time.
Demographics and Outcomes
P173
CAN LOW CURRENT ELECTRICAL STIMULATION OF THE ANAL
SPHINCTER ATTRACT EXOGENOUSLY ADMINISTERED MESENCHYMAL STEM CELLS?
L. Sun1, J. Yeh4, J. Pizarro Berdichevsky2, M. Penn3, M. Damaser2 and
M. Zutshi1 1Department of Colorectal Surgery, Cleveland Clinic
Foundation, Cleveland, OH, 2Biomedical Engineering, Cleveland Clinic
Foundation, Cleveland, OH, 3Summa Cardiovascular Institute, Summa
Cardiovascular Institute, Akron, OH and 4Department of Gynecology and
Obstetrics, Cleveland Clinic Foundation, Cleveland, OH.
Purpose: We have previously optimized electrical stimulation (ES)
parameters of current and duration to significantly upregulate gene and
protein expression of Stromal Derived Factor 1 ( CXCL12) and Monocyte
Chemotactic Protein 3 (CCL7), two mesenchymal stem cell homing cytokine
in the anal sphincter in a rat model. The aim of this study was to investi-
gate if low current ES can chemoattract mesenchymal stem cells (MSC) to
the anal sphincter.
Methods: 42 virgin female age and weight-matched Sprague Dawley
rats were randomly allocated into three groups: intravenous (IV) (n=20),
intraperitoneal (IP) (n=8), and intramuscular (IM) (n=14) based on routes of
luciferase-labeled MSC delivery. IV and IP injections were performed for 3
consecutive days preceded by either ES (0.25mA, 60 minutes duration, 1
hour time lapse) or sham stimulation (SS, electrode placement without
active current) on the same days; IM injection was performed once following ES. Within each group rats were randomly allocated into two subgroups:
ES group using the optimized parameters and SS group. To assess MSC
homing response, in vivo and ex vivo imaging was performed. This was done
12 and 24 hours after ES and IV or IP MSC injection, and 48 hours after ES
and IM MSC injection to quantify the bioluminescence in the trunk and
pelvic region as well as in the anal sphincter complex of each rat. Statistical
significance (p<0.05) was determined using paired t-test.
Results: No statistically significant difference was detected between the
ES group and the SS group in, in vivo and ex vivo bioluminescence after
serial ES and IV (p=0.33) or IP (p=0.13) MSC delivery. However, statistically
significant difference (p = 0.03) in MSC retention was detected between the
ES group and the SS group following a one-time IM MSC injection (Fig).
Conclusions: In this animal study, ES of anal sphincter complex using
optimized parameters preceding local IM injection of MSC may significantly
promote MSC retention. Future studies will incorporate an injury model to
study muscle regeneration following ES and MSC injection. Clinical applications include anal sphincter regeneration using ES with cell-based therapies at a time remote from injury.
Representative in vivo bioluminescence of the pelvic region 2 days after
intramuscular injection of luciferase-labeled MSC preceded by electrical stimulation
(A) or sham stimulation (B) and corresponding ex vivo images of the anal sphincter
complex as black and white photographs (C, D) and overlay with bioluminescence (E,
F). The higher bioluminescence (average ± SEM) of the anal sphincter complex (G) in
the electrical stimulation group (n=7) compared to that of the sham stimulation
(n=7) is statistically significant (p = 0.03 on paired t test). 95 percent confidence
interval for difference of means: 556 - 8700.
P174
TREATMENT OF CHRONIC CONSTIPATION – THE ROLE OF SACRAL
NERVE STIMULATION.
F. Pakravan, C. Helmes and K. Wolff CPZ Duesseldorf, Duesseldorf,
Germany.
Purpose: Chronic constipation is an often condition not only in elderly
patients. Traditional surgical procedures for severe constipation are associated with variable outcome and severe morbidity. This study evaluates the
effect of sacral nerve stimulation (SNS) in patients with intractable constipation in our own patient population.
Methods: A retrospective analysis for all patients, who were treated by
SNS in case of severe constipation and previous unsuccsessful conservative
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Abstracts
management, was performed. Preoperative all patients had a colonoscopy
including biopsies and a colonic transit time. A temporary stimulation lead
was implanted in the sacral foramen showing the best response. After 2
weeks the electrode was removed and in case of an improvement in constipation (> 2 bowel movements per week) a permanent sacral nerve stimulating system was implanted.
Results: Between October 2005 and October 2013 a total of 107 peripheral nerve evaluation (PNE) tests were performed, in 12 cases for severe
constipation, 10 adults, 2 adolescents. In 2 (17%) patients a neuronal intestinal dysplasia (NID) was approved by biopsy. After peripheral nerve evaluation only 2 (17%) patients, one with NID, reported an improvement of constipation with a reduction of the Wexner constipation score from 19 and 23
to 10 and 12, a permanent stimulating system was implanted. 10 (83 %)
patients still suffered from constipation, Wexner score 22 (range 16-27).
Conclusions: Instead of other positive reports with success rates of
more than 50% our own results suggest, that only a small number of
patients with severe constipation will have a benefit by SNS. Because of its
minimal invasiveness and very low risk it still should be considered as an
option for this very difficult to treat disease.
P175
BIOFEEDBACK THERAPY FOR FECAL INCONTINENCE. PREDICTIVE
FACTORS AND SHORT TIME OUTCOME.
S. M. Murad-Regadas1, M. T. Oliveira1, F. S. Regadas1, L. V. Rodrigues1,
A. C. Caetano2, F. S. Regadas Filho2, I. D. Dealcanfreitas1, G. O. Fernandes1
and J. Macedo Jr2 1Surgery, School of Medicine of the Federal University
of Ceara-Brazil, Fortaleza, Brazil and 2Colorctal Surgery, Sao Carlos
Hospital, Fortaleza, Brazil.
Purpose: Biofeedback is well established as a treatment for fecal incontinence but the results are controversy and little is known about factors
that may be associated with its successful. The aim of this study was to evaluate the short–term outcomes of biofeedback therapy for fecal incontinence and identify predictive factors for successful treatment.
Methods: All patients with fecal incontinence who underwent biofeedback therapy from 2011-2013 were identified from a prospective database.
Symptoms were evaluated using Cleveland Clinic fecal incontinence score
before and 3 months after the completion of therapy. Age, incontinence
score, parity, number of vaginal delivery, previous anorectal surgery, hysterectomy, anal pressures by anorectal manometry and sphincter defect by
3D ultrasound were analyzed and correlated with the percentage of
response after treatment. The patients were grouped according to the successful of the treatment (response percentage ≥50%): GI: FI score reduced
≥50% and GII: score reduced less than 50%. Patients with sphincter defect
with indication for surgery treatment and patients who did not complete
treatment were excluded.
Results: 61 female patients were included, of them 28(46%) in GI and
33(54%) in GII. Patients from GI and GII had similar ages (mean 65 vs 64y,
p=0.85), parity (nulliparous 21 vs 6 %, p=0.13) number of vaginal delivery
(mean 2.5 vs 2.9, p=0.56), previous anorectal surgery (32 vs 54 %, p=0.12),
hysterectomy (11 vs 6 %, p=0.65), the resting pressure (37 vs 35 mmHg,
p=0.51), maximum squeeze pressure (82 vs 80 mmHg, p=0.82) and evidence of sphincter defect (external and/or internal anal sphincter) (36 vs
42 %, p=0.61). FI score was lower in GI than GII (mean 8.5 vs. 12.2, p=0.85)
and 71% of patients from GI had score ≤10 and only 30% in GII.
Conclusions: Biofeedback therapy is an effective treatment with 50%
of reduced FI score in half of female patients and the factor associated with
unsuccessful outcome include the FI score >10. There was no correlation
between age, parity, number of vaginal delivery, previous anorectal surgery, hysterectomy, anal pressures, sphincter defect and a greater risk of
unsuccessful treatment.
P176
STANDARD PROTOCOL TO REDUCE POSTOPERATIVE INFECTION
RATES FOR IMPLANTATION OF SACRAL NERVE STIMULATORS FOR
FECAL INCONTINENCE.
A. Abodeely and C. Mandeville Adirondack Surgical Group, Saranac Lake,
NY.
Purpose: Infection rates following sacral nerve simulation have been
reported to be between 2%-6%. Wound infections following implantation
can be very serious often require explantation. There are currently no formal guidelines for the use of perioperative antibiotics during the implantation of sacral nerve stimulators. We report a single surgeons experience and
protocol to help reduce the incidence of postoperative wound infections
during both stage 1 and stage 2 of sacral nerve stimulation.
Methods: Ninety patients underwent a standard perioperative protocol. All patients showered the evening before and morning of surgery with
chlorhexidine gluconate. Patients received perioperative antibiotics
(cephalexin 1gm or clindamycin 600mg if penicillin allergic). Patients were
all prepped with DuraPrep™ and draped in a sterile fashion including the
use of 3M™ Ioban™ Antimicrobial Incise Drape. The pocket sites of the
extension lead and generator sites were irrigated with cephalexin (1gm in
1 liter NS) or clindamycin (600mg in 1 liter NS). All incisions were dressed
with Dermabond. For both stage 1 and stage 2, patients were given a 3 day
postop course of levofloxacin (500mg PO daily). Patients were followed
postoperatively for any postoperative infections.
Results: Ninety patients underwent treatment for their fecal incontinence with sacral nerve stimulation. Eighty nine of 90 patients experienced
success with stage 1 and subsequently went on to stage 2 (generator placement). Patients were followed for signs of infection for 1 month postop.
One patient (1.1%) developed a postoperative wound infection. This patient
required explantation of her generator and lead due to a methicillin resistant staphylococcus aureus (MRSA) infection.
Conclusions: There are currently no recommendations regarding the
use of prophylactic antibiotics to prevent infections for the use of sacral
nerve stimulation for fecal incontinence. We report a 1.1% infection rate
using a standard protocol to prevent postoperative wound infections.
P177
USE OF 3D ULTRASONOGRAPHY TO ASSESS RECTAL CANCER IN A
MULTICENTER TRIAL: DOES IT AFFECT MANAGEMENT DECISIONS?
S. M. Murad-Regadas1, F. S. Regadas1, R. M. Almeida2, P. G. Oliveira2,
R. Barreto3, J. B. Barreto3, D. R. Lima4, G. Kurachi4 and L. V. Rodrigues1
1
Surgery, School of Medicine of the Federal University of Ceara-Brazil,
Fortaleza, Brazil, 2Surgery, School of Medicine of the Federal University of
Brasilia, Brasilia, Brazil, 3Surgery, School of Medicine of the Federal
University of Maranhao, Sao Luis, Brazil and 4Colorectal Surgery,
Gastroclinica Cascavel, Cascavel, Brazil.
Purpose: The aim of this study was to determine the impact of 3D ultrasonography(3D-US) on the staging and management of rectal cancer and
compare 3D-US to pathological findings(pTN).
Methods: 90 consecutive patients with rectal cancer from 4 Brazilian
colorectal centers were referred to 3D-US for staging and distributed into
two groups. GI:early-stage and underwent resection only and GII:advanced
stage and required neoadjuvant radiochemotherapy(RCT). Patients from GII
were not restaged on 3D-US after RCT, but residual tumor and lymph nodes
were identified. The tumor length(L), length reduction ratio(LR), and distance(D) between the distal tumor edge and the proximal border of the
sphincter(cm) or anal canal invasion were quantified before and after RCT.
The selection for sphincter preservation(SP) or abdominoperineal resection(APR) was based on 3D-US measurements. The 3D-US and pTN were
compared.
Results: GI included 18 patients, mean age 56y(uT0=12, uT1=3, uT2=1,
uT3=2 and N1=1), submitted to endoscopic(n=5) or surgical
resection(n=13). The agreement between pTN and 3D-US was almost per-
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Abstracts
fect for T0 (K=0.87), T2, T3 and N1 (K=1) and substantial for T1(K=0.77). GII
included 72 patients, mean age 60y, pre-RCT stating was uT2=5, uT3=59,
uT4=8, N1=37, 13 of whom presented anal canal invasion. After RCT, 24
underwent APR, 44 SP (including low anterior resection and intersphincteric and/or coloanal anastomosis) and 4 underwent watch and wait strategy. A correlation between RL ratio and pT was observed. After RCT, L was
significantly shorter, D was longer and RL was greater in SP patients than in
APR(Table). The agreement between pathological and post-RCT 3D-US was
substantial for the identification of residual tumor or complete
response(K=0.63) and moderate for lymph node(K=0.42). The pathological
examination revealed free distal margins. The mean follow up was 2y
(range,3m-6y).
Conclusions: Rectal cancer was accurately staged and managed using
3D-US. After RCT, complete response was observed, or residual tumor was
quantified. The most important parameter for the selection of patients for
SP was the distance between the tumor and the sphincter. Safe distal margins should be at least 1 cm.
rence and mortality were not different for patients who had tumor scatter,
their distant recurrence was higher. Defining the clinical significance of
tumor scatter may help contribute to our understanding of irradiated rectal cancer behavior.
P179
LAPAROSCOPIC VERSUS OPEN TOTAL MESORECTAL EXCISION FOR
MID OR LOW RECTAL CANCER AFTER NEOADJUVANT CHEMORADIOTHERAPY: COMPARISON OF PERIOPERATIVE AND ONCOLOGIC OUTCOMES.
S. Bae, S. Baek, H. Hur, B. Min, S. Baik and N. Kim Surgery, Department of
Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
3D-US measurements after neoadjuvant radiochemotherapy (cm)
*Distance between the distal tumor edge and the proximal border of the
sphincter
P178
RECURRENCE AND SURVIVAL AFTER TUMOR SCATTER: A FOLLOW-UP
STUDY.
D. Hayden1, M. Mora Pinzon1, A. Francescatti2, M. Brand2, S. Jakate3 and
T. Saclarides1 1Surgery, Loyola University Medical Center, Maywood, IL,
2
General Surgery, Rush University Medical Center, Chicago, IL and
3
Pathology, Rush University Medical Center, Chicago, IL.
Purpose: Although we are just starting to understand what happens to
rectal cancer cells after radiation, our previous study showed that tumor
cells may scatter outside the residual ulcer in an unpredictable fashion. We
will report on the recurrence and survival of these patients.
Methods: Chart review was performed for the 74 patients included in
the original study who had follow-up. Local and distant recurrence, survival
and associated factors were collected and analyzed using SPSS (Chicago,
IL).
Results: 74 patients were included in this study; mean age at time of
surgery was 58.9 (range 28-88); 34 (45.9%) were female. There were 19 (25.7
%) complete pathologic responders. Of the 55 with residual cancer, 28
patients had tumor found within the gross ulcer only and 27 had tumor
cells outside the residual ulcer (scatter group). Mean duration of follow-up
was 29.7 months. Overall, three (4.1%) patients had local recurrence, 10
(13.5%) had distant recurrence and seven (9.5%) died during the follow-up
period. There were no recurrences or deaths amongst complete pathologic
responders. Distant recurrence was significantly higher in those patients
that had tumor scatter 2 cm outside the ulcer in any direction (p=0.046).
For patients with scatter at 2 cm in the distal direction, there was no significant difference in recurrence rates or survival. Tumor cells found 1 cm outside the residual ulcer in any direction did not predict higher recurrence or
mortality. Although the association between perineural invasion and distant recurrence trended toward significance (X2=3.5, p=0.082), other factors such as nodal involvement, differentiation, lymphovascular involvement and mucin production did not correlate with local or distant
recurrence or death.
Conclusions: Our study shows that complete pathologic responders
have excellent two-year recurrence and survival rates. Although local recur-
Purpose: The use of neoadjuvant chemoradiation(nCRT) currently is
incorporated into the multimodal treatment of stage 2 or 3 rectal cancers.
However, surgery after nCRT has been associated with the tissue edema
and fibrosis and increased postoperative morbidity. The aim of the study is
to investigate the feasibility of laparoscopic total mesorectal excision(TME)
for rectal cancer after nCRT and to compare its short and mid-term oncologic outcomes with those of conventional open TME.
Methods: Between January 2004 and December 2010, the study group
included 109 patients who underwent a minimally invasive TME(MITME)
and 231 patients who underwent an open TME(OTME) for cT3-T4N0-2 mid
or low rectal cancer after nCRT. The propensity scoring matching for age,
tumor location, and ypTNM stage produced 103 matched pairs.
Results: Demographic characteristics of the two groups were similar in
term of age, gender, preoperative CEA, American Society of Anesthesiology
class, BMI, tumor location and final AJCC staging. The mean time to soft
diet (MITME: 4.5 vs. TME: 7 days, p= 0.002) and possible length of stay without complication (8.1vs. 11.7 days, p<0.001) were significantly shorter in
MITME group and the mean operative time was significantly longer in the
MITME group than in the open group (331.3 vs. 275.4 minutes, p<0.001).
The procedure was converted to open surgery in 7 of 109(6.4%) patients
assigned to undergo MITME. According to the Clavien–Dindo classification,
the numbers of complications for grade 1, 2, and 3 were 6, 14, and 12 after
MITME and 6, 14, and 12 after OTME. The anastomotic leak rate after a TME
was 13.7% and 5.9%, respectively (p=0.060). The 3- year overall survival
rates of two groups were 91.8% and 86.1% (p=0.201), respectively and the
3- year disease-free survival rates was 78.9% and 59.5% (p=0.003), respectively.
Conclusions: MITME following nCRT for mid or low rectal Cancer cancer is feasible and has the advantage over an OTME of better short-term
outcomes and minimally invasive approach was associated with better 3year disease-free survival when compared to an open approach.
P180
LONG-TERM ONCOLOGIC OUTCOMES OF ROBOTIC TOTAL MESORECTAL EXCISION FOR RECTAL CANCER.
A. Pai, M. G. Hurtuk, J. J. Park, S. J. Marecik and L. M. Prasad Colon and
Rectal surgery, Advocate Lutheran General Hospital, Park Ridge, IL.
Purpose: Robotic Total Mesorectal Excision (RTME) has emerged as an
important modality for resection of rectal cancer, but there is insufficient
data to recommend it from an oncologic perspective, with regard to longterm oncologic outcomes. We evaluated and analyzed perioperative, shortterm oncologic outcomes, recurrence and survival after RTME for rectal cancer.
Methods: A prospectively maintained database at a tertiary referral
teaching hospital was reviewed. Clinicopathological data was collected on
all patients undergoing Robotic TME. Data was analyzed using SPSS 22.0
(IBM); statistical significance was defined as those with a p value ≤0.05.
Results: Between August 2005 and June 2012, 102 consecutive patients
underwent RTME, performed by a board certified colorectal surgeon for
stage I-IV rectal cancer. There were 66 men and 36 women, with a mean
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Postoperative level of division of the EAS and deterioration in anal continence. a.
Divided by thirds. b. Divided in 2 subgroups (over or below 66%).
age of 62 years. There were 43 (42%) low anterior resections, 20 (19%)
ultralow anterior resections, 14 (14%) intersphincteric dissections and 25
(25%) abdominoperineal resections, with 61% of resections performed for
low rectal cancers. There were 2 conversions to an open procedure. The
stage distribution was 19 (19%), 34 (33%), 41 (40%) and 8 (8%) for stages IIV, respectively. Neoadjuvant Chemoradiation was given to 76% of patients.
The mean blood loss was 157 ml (range 5-650ml) and the mean operative
time was 330 min (range 155-540 min). A diverting ileostomy was performed in 59% patients. There was a 6.6% anastomotic leak rate, The 30day mortality rate was 1%. The average lymph node yield was 14.5 (range
2-45). A positive distal resection margin was found in 2 patients, and a circumferential radial margin was positive in 5% of the patients. Local recurrence was seen in 3 (3%) patients. Distant metastasis occurred in 11 (11%)
patients. The median length of follow up was 30 months (range 1- 99). The
3-year overall and disease free survival for stages I-III were 92% and 78%,
respectively.
Conclusions: RTME can be safely performed with short and long term
oncologic outcomes similar to open and laparoscopic rectal resection and
our results compare favorably with published series of robotic assistance
for rectal cancer resections. .
a: *p=0.049
**Low: lower 1/3 of the EAS (≤33%); Mid: middle 1/3 of the EAS (33-66%); High:
superior 1/3 of the EAS (≥66%)
b: *p=0.018
P182
P181
A NEW PROMISING PROCEDURE FOR PERIANAL FISTULA DISEASE:
RADIAL EMITTING LASER.
C. Terzi1, H. Sari1, A. Canda1, N. Arslan1 and F. Obuz2 1Surgery, Dokuz Eylul
University School of Medicine, Izmir, Turkey and 2Radiology, Dokuz Eylul
University School of Medicine, Izmir, Turkey.
IS IT SAFE TO DIVIDE THE INFERIOR TWO THIRDS OF THE EXTERNAL
ANAL SPHINCTER DURING FISTULOTOMY? AN ENDOANAL THREEDIMENSIONAL ULTRASOUND AND QUALITY OF LIFE SCORES ASSESSMENT.
S. A. Garcia Botello, M. Garcés Albir, A. Espí Macias, D. Moro, J. Martin
Arevalo, V. Pla Martí, A. Sanahuja and J. Ortega Serrano Colorectal Unit,
Department of General and Digestive Surgery, Hospital Clinico
Universitario, Valencia, Spain.
Purpose: Fistulotomy is the most frequently employed technique for
the treatment of simple perianal fistulas. The fistula height which can be
treated with this technique is constantly under debate. The objective of this
study is to classify fistulas using 3D-EAUS and QOLS and use this in fistulotomy decision making.
Methods: A prospective observational study with consecutive patients
included between December 2008 and December 2010 was performed. All
patients underwent 3D-EAUS performed by the same colorectal surgeon
preoperatively and eight weeks after surgery. The amount of sphincter
involved preoperatively and divided postoperatively was assessed. Anal
continence was assessed with the Jorge and Wexner scale, the SF-36 and
Fecal Incontinence Quality of Life Score (FIQOLS) preoperatively, and 6 and
12 months postoperatively.
Results: 49 patients median age 49 years (range, 21-77) 37 male and 12
female underwent fistulotomy and were included. Significant differences
were found when the level in thirds of the external anal sphincter division
was assessed with 3D-EAUS (Likehood ratio=0.049). 8 of 41 patients with
division of the external anal sphincter below 66% showed deterioration in
anal continence (Table 1). No significant differences in anal continence were
found before and after surgery. There was 1 recurrence. There was deterioration in QOL in the immediate postoperative period which returned to normal at 1 year follow-up.
Conclusions: Pre and postoperative analysis of QOL shows that in the
absence of risk factors for fecal incontinence division of the lower two thirds
of the sphincter is safe during fistulotomy.
Purpose: Fistula laser closure (FiLaC TM, Biolitec, Germany) is a novel
non-invasive procedure for the treatment of perianal fistula disease. Primary closure of the fistula tract is obtained using laser energy emitted by a
radial fiber connected to a diode laser. The aim of this study is to determine
the effectiveness of this new technique in the treatment of perianal fistula.
Methods: Between April 2012 and September 2013, 44 consecutive
patients with primary or recurrent perianal fistula underwent FiLaCTM procedure. The surgical procedure was sealing of the fistula tract by laser
energy. Phase array pelvic MRI was performed in all patients for preoperative classification and postoperative follow up. The primary outcome was
the cure of the disease.
Results: Total 43 patients were treated in day surgery unit. The median
operative time was 25 (5-40) minutes. There was no perioperative complication. Median follow-up was 9.3 (1.5-18) months. Only 3 patients were lost
to follow up. Twenty two of 43 patients had recurrent fistula. Horseshoe fistula was seen in 9 patients and 17 patients had multiple fistula tracts. Types
of the fistulas were intersphincteric in 21 patients, transsphincteric in 19
patients, superficial in 3 patients and extrasphincteric in 1 patient. Complete healing was observed in 12 (29%) patients (8 primary, 4 recurrent), 13
(31%) patients had slight drainage with minimal symptoms (6 primary, 7
recurrent), 15 (36%) patients had persistent symptomatic drainage (11 primary, 4 recurrent), 2 (4%) patients had painful symptomatic drainage (1 primary, 1 recurrent).
Conclusions: This new approach for perianal fistula is a non-invasive,
safe and simple procedure. Regarding half of the patients had recurrent fistulas; a cure rate of 29% was acceptable. Moreover, we achieved significant
symptomatic control in 1/3 of the patients. Despite the relatively good
results of our study, larger series and randomized trials are needed to have
a final decision on the effectiveness of this new procedure.
104
Abstracts
P183
ANATOMIC CHARACTERISTICS OF ANAL FISTULA ON 3D ULTRASONOGRAPHY. HOW MUCH THE GOODSALL’S RULE IS TRUE?
S. M. Murad-Regadas1, I. D. Dealcanfreitas1, F. S. Regadas1,
L. V. Rodrigues1, G. O. Fernandes1, F. S. Regadas Filho1, D. M. Lima2,
R. G. Barreto2 and E. C. Holanda2 1Surgery, School of Medicine of the
Federal University of Ceara-Brazil, Fortaleza, Brazil and 2Colorectal Surgery,
Sao Carlos Hospital, Fortaleza, Brazil.
Purpose: According to Goodsall’s rule, an posterior external
opening(EO) seen posterior to a line drawn transversely the perineum
across will originate from an internal opening(IO) in the posterior midline
(curved tracts) while the anterior EO will originate in the nearest crypt
(straight). We aimed to correlate the course of the anal fistula tract(T), location of the EO and IO in anterior(A) and posterior(P) hemicircunferemce
using 3D-US according to Goodsall’s rule.
Methods: A total of 220 patients with cryptoglandular fistulas were
examined with 3D-US and compared with surgical finding. The type of
T(straight or curved), Park’s classification, EO and IO were identified and
divided into 3 Groups(G): GI:EO and IO are located in A position; GII:EO and
IO are located in P position and GIII:OE and OI are located in the opposite
position and analyzed concerning to genders, type of T and compared with
Goodsall’s rule.
Results: 103(47%) were included in GI, of them, 65(63%) were male
(55/85% had straight T and 10/15% curved) and 38(37%) female (19/50%
had straight T and 19/50% curved). In GII included 89(40%), of them,
66(74%) were male (56/85% had straight T and 10/15% curved) and
23(26%) female (19/83% had straight T and 04/17% curved). 28(13%) in GIII,
22(78%) were male and 6(22%) female and all of them had curved tract.
Transsphincteric was identified in 73(71%) from GI, 64(72%) from GII and
14(50%) from GIII. Intersphincteric in GI=30(29%), GII=24(27%) and
GIII=12(43%) and suprasphincteric in GII=1(1%) and GII=2(7%). Secondary
tract was found in 43(19%). The overall concordance between 3D-US and
surgical finding was 99% for main, secoundary T and IO
Conclusions: Transphincteric T is the most prevalent in both locations
and gender. The straight T is prevalent in both A and P hemicircunferemce
in male. The 3D-US found that Goodsall’s rule is accurate in describing the
course of anal fistula with anterior EO in male with straight T in 85% but is
inaccurate in posteiror EO tracked in a curved manner in only 15%. It is also
inaccurate in female in both hemicircunferemce in which fistula with anterior EO had straight manner in 50% and in case of posterior EO location,
the T was curved in only 17%
P184
CLINICAL SHORT-TERM OUTCOMES OF LASER HEMORRHOIDOPLASTY: A MULTICENTER STUDY.
H. Chong1, A. C. Roslani1, S. Kumar1, A. A. Malik1, C. Law1, S. Chan3,
V. Rajasingam2 and J. Kasipillai2 1Surgery, University of Malaya Medical
Center, Kuala Lumpur, Malaysia, 2Surgery, Assunta Hospital, Petaling Jaya,
Malaysia and 3Surgery, Pantai Hospital Ampang, Kuala Lumpur, Malaysia.
Purpose: Laser hemorrhoidoplasty (LHP) utilizes thermal energy generated by a diode laser to treat symptomatic internal hemorrhoids. Early
series have reported promising results, with little post-operative pain, short
operating time, few serious post-operative complications and low recurrence rates. However, there are variations in the technique utilized. The aims
of this study are to determine the short-term clinical outcomes of LHP and
to ascertain if outcomes differed between patients with, and without, pedicle ligation.
Methods: Patients from three institutions who underwent LHP between
December 2011 and October 2013 were identified from a prospective database. Data analysed included demographics, severity, symptoms, operative
technique, post-operative pain, complications and recurrence. Sub-analysis
of patients with concurrent pedicle ligation, and without, was conducted.
Statistical analysis was performed using the χ2 test, with p values <0.05
considered statistically significant.
Results: A total of 102 patients (59.8% male) of a mean age of 45 years
were evaluated. The majority (62.7%) had third degree hemorrhoids.
Median operative time was 24 (10-60) minutes and post-operative length
of stay was 26 (2-168) hours. The median pain score 24 hours post-operatively was 0/10. The overall complication rate was 26.5%, but most were
self-limiting. The most common complication was post-operative swelling
(16 patients; 15.7%). Post-operative bleeding was seen in nine patients
(8.8%) at a median of 7 (1-14) days, three of whom required surgery and
readmission. Four patients (3.9%) had moderate-to-severe pain (pain score
of > 5/10) and two patients (2.0%) developed ulceration. Three patients
(2.9%) had recurrence which was treated conservatively. Patients with pedicle ligation had a higher incidence of complications (33.3% vs. 7.4%;
p=0.01), predominantly bleeding and swelling.
Conclusions: LHP shows promising short-term results with low complication and recurrence rates. Additional ligation of pedicles does not offer
added benefits but may worsen outcomes.
P185
PATIENT FACTORS PRECLUDING PURSUIT OF GENETIC COUNSELING
FOR LYNCH SYNDROME.
V. W. Hui, R. A. Levy, D. A. Goldman, E. R. Riedel, A. J. Markowitz,
G. M. Nash, P. B. Paty, L. K. Temple, M. R. Weiser, J. Garcia-Aguilar and
J. G. Guillem Memorial Sloan-Kettering Cancer Center, New York, NY.
Purpose: Lynch syndrome (LS) is associated with risk for developing colorectal and endometrial cancers and, to a lesser degree, cancers of the
stomach, urologic tract, among others. In an effort to increase diagnosis of
LS, immunohistochemistry (IHC) is used to identify patients with tumors
deficient in mismatch repair (MMR) protein expression and in need of
genetic counseling (GC) and testing (GT). However, not all patients opt to
undergo recommended referral for GC and GT. We explore possible patient
factors precluding pursuit of GC and GT.
Methods: Medical records of patients with tumors that underwent
MMR testing via IHC at a single institution from 2006-2013 were retrospectively reviewed. To test the association between patient factors and pursuit
of GC, Pearson’s chi square and Fisher’s exact tests were performed for categorical variables, and Wilcoxon rank sum test for continuous variables.
Results: A total of 530 patients were identified to have MMR deficient
tumors. Of these, 116 (22%) had been referred for GC prior to MMR screening due to clinical suspicion of LS. Two hundred thirty-two (44%) patients
were referred for GC after tumor MMR deficiency was discovered and 139
(60%) underwent GC. LS was confirmed in 37 of 128 (29%) patients who
underwent genetic and/or germline testing, with deleterious germline
mutations found in MLH1 (8), MSH2 (21), MSH6 (4), and PMS2 (4) genes.
Clinical information was available for 230 of the 232 patients referred for
GC after detection of tumor MMR deficiency and they were stratified
according to whether or not they pursued GC (see table).
Conclusions: Factors precluding patients from pursuing GC and GT for
evaluation of LS following identification of tumor MMR deficiency are likely
multifactorial, but may include older age, unemployment, and insurance
status. These factors should be considered when referring patients for GC
and GT for LS evaluation.
105
Abstracts
IQR: interquartile range.
P186
BENEFITS OF A MULTIMODAL REGIMEN INCLUDING LIPOSOMAL
BUPIVACAINE FOR POSTSURGICAL PAIN IN COLORECTAL SURGERY.
D. E. Beck1, D. A. Margolin1, S. F. Babin2 and C. T. Russo2 1Colon and Rectal
Surgery, Ochsner Clinic Foundation, New Orleans, LA and 2Pharmacology,
Ochsner Clinic Foundation, New Orleans, LA.
Purpose: To assess post-operative outcomes in patients undergoing
colon rectal surgery using a multimodality regimen including liposomal
bupivacaine (Exparel®, Pancira Pharmaceuticals) administered to the surgical site in comparison to conventional therapies relying primarily on intravenous opioids.
Methods: Retrospective case matched chart review of 179 patients
undergoing major colorectal surgery from Oct 2011 - Jan 2013 at an academic colorectal teaching center. 81 patients received 266 mg of liposomal
bupivacaine intraoperatively and postoperative multimodality pain management minimizing intravenous opioids and 98 received conventional
treatments. Comparisons made using students t-test and chi square anaylsis using SAT view (SAS, Carrey NC).
Results: Patients that had liposomal bupivacaine injected in the surgical site at operation had a lower post-operative pain scores, used significantly less opioids at 12,24,36,48,60, and 72 hours (p<0.03), and required
less non opioid pain medication (p<0.0007) after major colon rectal procedures. Liposomal bupivacaine patients also had a significantly decreased
risk of opioid related adverse events (ORAE) as evidence by decreased use
of anti-pruritic medications (0.4 vs. 4.47 doses per patient, p<0.03) and antiemetic medications (2.7 vs. 6.7 doses per patient, p<0.012) postoperatively.
There was also significant decrease in length of postoperative hospital stay
in the liposomal bupivacaine group (7.2 vs 9.0 days, p<0.04). Further supporting the efficacy of liposomal bupivacaine, we found no difference in
pain medication use and ORAE between the laparoscopic (34) and open
procedures (47) who received liposomal bupivacaine.
Conclusions: The use of liposomal bupivacaine as part of multimodality pain management during major colorectal surgeries resulted in significantly lower pain scores, decreased opioid and non opioid pain medicine
use, less opioid related adverse effects, and decrease lengths of postoperative hospital stay.
P187
LOW ANTERIOR RESECTIONS FOR SEVERE ENDOMETRIOSIS: ASSESSING THE PREOPERATIVE EXAM.
C. P. Bird1, R. K. Mangal2, H. R. Bailey1 and M. J. Snyder1 1University of
Texas Affiliated Hospitals, Houston, TX and 2Fertility Specialists of Houston,
Houston, TX.
Methods: This study is a retrospective review utilizing both electronic
office and hospital medical records. We reviewed 111 patients that underwent laparotomy for severe endometriosis with concurrent rectal involvement between between March 2011 and October 2013.
Results: One hundred eleven patients underwent exploratory laparotomy for severe endometriosis. 62 (55.9%) patients underwent low anterior
resection due to their endometriosis. 49 (41.1%) patients underwent local
excision of their rectosigmoid endometrial implants. The mean age was
36.4 (±7.0) years. On preoperative physical exam, 80 (72.1%) patients were
noted to have cul-de-sac nodularity on physical exam. Rectal tethering was
noted on 21 (18.9%) patients. While cul-de sac nodularity did not demonstrate a significant role in the prediction of surgical outcomes (present in
75.8% vs. 67.3% in the respective groups), the presence of rectal tethering
did demonstrate a 66.7% positive predictive value for low anterior resection.
Conclusions: Preoperative physical exam can be a valuable tool in predicting which patients will require a low anterior resection amidst the surgical care of their endometriosis. While rectal ultrasound, barium enema,
CT and MRI have all been utilized to demonstrate the extent of colorectal
involvement in endometriosis, assessing for cul-de-sac nodularity and rectal tethering on physical exam can serve a vital role in the operative planning of endometriosis.
P188
PRIMARY ANASTOMOSIS OR HARTMANN PROCEDURE TO TREAT LEFT
COLON PURULENT OR FECAL DIVERTICULITIS: LESSONS LEARNED IN
TEN YEARS.
P. Sileri, L. Franceschilli, F. Giorgi, F. Perrone, I. Capuano and A. L. Gaspari
surgery, University of Rome Tor Vergata, Rome, Italy.
Purpose: The surgical management of the left-sided colonic perforation with purulent or faecal peritonitis is continuously under debate. Comparison of primary anastomosis (PA) versus Hartmann procedure (HP) is
biased since patient groups are usually different for age, comorbidity, ASA
score and disease severity. However increasing literature data support a PA
as the procedure of choice. In this study we evaluated the surgical outcomes of patients with perforated diverticulitis who underwent HP or PA
with or without proximal diversion.
Methods: Since 2004, all data of colorectal patients treated at our institution are prospectively entered in a database. Records of all patients
admitted for sigmoid diverticulitis between 01/04 and 06/13 were retrieved
and analyzed. For the purpose of this study only patients with diffuse purulent or faecal peritonitis (Hinchey III and IV) were considered. Mortality and
morbidity were compared in relation to type of surgery, ASA classification,
age, gender, Mannheim Peritonitis Index (MPI), Hinchey score and surgery
duration. In all cases of PA, intraoperative colonic lavage was performed.
Results: A total of 88 patients underwent emergency surgery with
purulent or diffuse faecal peritonitis. Of those 55% (48 out of 88) underwent one stage left colon resection and PA with (90%, 43 out of 48) or without (10%, 5 out of 48) protective proximal diversion, while 45% underwent
HP procedure (40 out of 88). Overall mortality was 10% (9 patients), being
6% after PA and 15% after HP procedure. Major postoperative complications occurred in 27% of the patients, being 17% after PA and 40% after HP.
After PA, anastomotic leak occurred in 2 cases (4%).
Conclusions: Our experiences suggest that PA compares favourable
with HP in terms of complications and mortality. The lowest complication
rate can be observed when the PA is protected by a diverting proximal
stoma.
Purpose: A multidisciplinary approach between gynecology and colorectal surgery has been utilized to optimize outcomes in treating severe
endometriosis with rectal involvement. This study was designed to evaluate the predictive value of the physical exam by an experienced colorectal
surgeon prior to laparotomy for severe endometriosis that led to either low
anterior resection or local excision of rectal wall endometrioma.
106
Abstracts
P189
P190
OBESITY DOES NOT IMPACT PERIOPERATIVE OR POSTOPERATIVE
OUTCOMES IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE.
J. Holder-Murray1, E. Carchman3, J. Guardado1, A. Danicic1, C. Rivers2,
D. Binion2, S. Javier1, A. Watson1, J. Celebrezze1 and D. Medich1 1Colon &
Rectal Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA,
2
Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA
and 3Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH.
SHOULD IMMUNOMODULATORS ALTER SURGICAL MANAGEMENT IN
PATIENTS WITH RECTOVAGINAL FISTULA AND CROHN’S DISEASE?
R. Narang1, T. Hull2, J. S. Garcia1, S. Perrins1 and S. D. Wexner1 1Colorectal
Surgery, Cleveland Clinic Florida, Weston, FL and 2Colorectal Surgery,
Cleveland Clinic Foundation, Cleveland, OH.
Purpose: The prevalence of obesity in inflammatory bowel disease (IBD)
patients is rapidly increasing. Obesity has been linked to adverse outcomes
in elective non-IBD colorectal procedures, yet there is little data in IBD
patients. We aim to investigate the effects of obesity on perioperative and
postoperative outcomes in IBD patients.
Methods: This is a retrospective analysis of an IRB approved IBD registry at the University of Pittsburgh. From this registry, patients were identified who have undergone abdominal intestinal surgery between the years
of 2000 to 2012. Exclusion criteria included the operation performed at an
outside institution and no BMI recorded within 30 days of surgery. Preoperative patient demographics, operative variables and postoperative complications were collected. The patients were divided into groups based on BMI:
underweight (UW) BMI <18.5, non-obese (NW) BMI 18.5-29.9, and obese
(OB) BM I>30. Intraoperative and postoperative outcomes were compared.
Results: Laparoscopic or open abdominal intestinal surgery was performed on 286 IBD patients, of whom 210 patients were included who
underwent 272 surgeries (25 UW, 203 NW, and 44 OB). No differences were
observed in preoperative patient demographics, type of IBD, preoperative
steroid or biologic mediator use, or mean laboratory values. No differences
were observed in percent operative procedures with anastomosis
(p=0.767), surgeries converted to open (p=0.539), estimated blood loss
(p=0.387), and intraoperative complications (p= 0.58). Mean operative time
was significantly longer in obese patients (p=0.045). On logistic regression
analysis, no factors predicted conversion to open surgery. Length of stay
was similar (p=0.89). No significant differences were observed for 30 day
postoperative complication rates including total complications (p= 0.577),
wound infection (p=0.208), or anastomotic leak (p = 0.710). On multivariate
analysis, obesity was not an independent risk factor for postoperative 30
day complications.
Conclusions: While obesity increases mean operative times, obesity
does not affect other intraoperative variables nor does obesity worsen postoperative complication rates in IBD patients.
Postoperative complications
Purpose: Management of rectovaginal fistula (RVF) in women with
Crohn’s Disease (CD) is exceptionally challenging. This study aimed to investigate the relationship between immunomodulators and healing of RVF in
women with CD.
Methods: From July 1997 – 2013, a retrospective review was performed
to identify patients who underwent RVF repair with underlying history of
Crohn’s Disease. After IRB approval, demographics, symptoms of RVF, healing, type of repair, use of setons, stomas, immunomodulators, and probiotics was obtained from the medical records. Follow-up telephone survey
was conducted to identify variables associated with healing.
Results: Ninety nine patients agreed to participate in the study. The
average age was 43.3 +/- 11.9 years, mean follow-up was 39.1 +/- 52.2
months, and the, average BMI was 26.2 +/- 5.6. Procedures performed
included mucosal advancement flap (52 patients), transvaginal repair (18),
episioproctotomy (9), muscle interposition (9), sphincteroplasty (3), biologic
agents (3), proctectomy (2), and other (3). 63/99 patients (63%) reported
healing with no statistical significance in healing among types of repair. The
median number of repairs in the healed group was 2 (1-3) and in the
unhealed group was 3 (1-5) (p=0.9). Thirty-six (36) patients had fecal diversion, of whom 53% had healing after repair (p = 0.13). 43 of the 63 patients
in whom healing was achieved had received infliximab and 10 received
adalimumab. These treatments did not exhibit a statistical significance in
the outcome of surgical repair. The post-episiotomy RVF was more likely to
heal than were others (p = 0.002). Healing was not affected by age, BMI, comorbidities, preoperative seton, preoperative stoma diversion, number of
repairs, or probiotic use.
Conclusions: The use of immunomodulators does not negatively
impact the success of surgical repair in women with CD and RVF. Endorectal advancement flap is an acceptable method of repair in these patients.
Surgical repair is most likely to be successful in women with CD and RVF
secondary to childbirth injury.
P191
COLONOSCOPY IN PATIENTS AGED 80 YEARS AND OLDER IS SAFE
AND EFFECTIVE.
S. F. Shawki, M. A. Valente and J. M. Church Colorectal Surgery, Cleveland
Clinic, Cleveland, OH.
Purpose: Concerns about patient safety and the clinical significance of
yield restrict the availability of colonoscopy to octo- and nonagenarians.
We performed a retrospective analysis of a consecutive series of colonoscopies performed in patients over 80 years old, to document yield and
complications.
Methods: A prospectively maintained colonoscopy database containing 14502 examinations performed from 1990 to 2013 was queried for
patients aged 80 years and older. The indications, complications, yield, additional procedures performed, and follow-up were abstracted.
Results: 823 colonoscopies were performed in 595 patients, with an
average age of 83.2 years (range, 80-98). 304 patients (51%) were male. Indications for evaluation include: history of adenoma in 32.1%, history of colorectal cancer in 23.8%, screening in 18.3%, bleeding/anemia in 12.2%, and
other symptoms (diarrhea, constipation, and pain) in 13.4%. The overall rate
of incompletion was 3.1% (26/823) but in 6 cases incompletion was caused
by disease (4 carcinomas, 2 strictures). Overall complication rate was 1.3%
(11/823) which included post procedure bleeding in 7 and perforation in 2.
Polyps were found in 317/595 patients (53.2%), and 228 (72%) of these were
advanced adenomas. 38/228 (16.6%) of polyps found were intramucosal
carcinoma, which were all treated with snare polypectomy. In the patients
107
Abstracts
with polyps, 145/317(45.7%) had a personal history of adenomas, 79/317
(24.9%) had a personal history of colorectal cancer, and 93/317 (29.3%) had
no previous polyp or cancer history. Colorectal carcinoma was diagnosed
in 26/595 (4.3%) patients, all treated with surgical excision. In patients
newly diagnosed with cancer, 14/26 (53.8%) had a prior colorectal cancer
or adenoma, 7/26 (26.9%) had symptoms of either bleeding or pain, and
5/26 (19.2%) were screening exams or follow up to a positive barium
enema.
Conclusions: Colonoscopy should not be withheld from patients
because of their age. Colonoscopy in patients 80 years and older can be
performed safely, with a high degree of completion, and can reveal significant pathology, especially in those patients with symptoms and those with
a previous history of polyps or colorectal cancer.
P192
RESTORATIVE PROCTOCOLECTOMY WITH A HANDSEWN ILEAL
POUCH-ANAL ANASTOMOSIS: S POUCH OR J POUCH?
X. Wu, H. T. Kirat and J. M. Church Colorectal Surgery, Cleveland Clinic,
Cleveland, OH.
Purpose: When disease dictates that the anal transitional epithelium
needs to be stripped, the choice of pouch configuration is up to the surgeon. We hypothesize that the efferent limb on the S pouch fits well into
the anal canal while the body of the pouch lies on the levators. In contrast,
the blunt end of a J pouch may be distorted as it is forced into the muscular tube of the stripped anus (Figure). The different anatomy and fit of the
spout or pouch opening into the anus may be reflected in differences in
outcome. We compare the clinical outcomes and quality-of-life (QOL)
between S and J pouch patients with a hand-sewn ileal pouch-anal anastomosis (IPAA).
Methods: Patients undergoing a primary hand-sewn IPAA from 19832012 were identified using an IRB-approved database. Demographics, operative details, functional outcomes and QOL were abstracted.
Results: A total of 502 patients, including 169 S pouch patients (33.7%)
and 333 J pouch patients (66.3%), met our inclusion criteria. 55.8% (n=280)
were men, and the mean age at pouch construction was 37.8±12.5 years.
The underlying disease was colitis in 437 patients (87.1%), FAP in 58 (11.6%)
and others in 7 (1.4%). S pouch patients were younger (P=0.004), but had a
higher body mass index (P=0.035) at time of IPAA surgery. There was no
significant difference between S and J pouch patients in other demographics. The frequencies of short-term complications in the two groups were
similar (P>0.05), however fewer patients with S pouch developed pouch fistula or sinus (P=0.047), pelvic sepsis (P=0.044), postoperative partial small
bowel obstruction (P=0.003) or required postoperative pouch-related hospitalization (P=0.021) in the long-term. At a median follow up of 12.2(4.320.1) years from IPAA, S pouch patients were found to have fewer bowel
movements (P<0.001), less frequent pad use (P=0.001) and a lower fecal
incontinence severity index score (P=0.015) at the most recent follow-up.
The pouch failed in 62 patients (12.4%) but neither univariate nor multivariate analysis showed a significant association with pouch configuration.
Conclusions: We recommend using an S pouch when constructing an
ileal pouch-anal anastomosis with hand-sewn technique.
P193
CONVERSION RATES ARE LOWER WITH ROBOTIC THAN WITH
LAPAROSCOPIC COLORECTAL SURGERY.
M. S. Tam1, C. Kaoutzanis1, A. J. Mullard2, K. B. Welch2, G. Krapohl2,
S. W. Leichtle1, J. F. Vandewarker1, R. M. Lampman1, A. J. Stefanou1,
J. C. Eggenberger1, S. Regenbogen2, S. Hendren2 and R. K. Cleary1
1
Colorectal Surgery, St. Joseph Mercy Ann Arbor, Ann Arbor, MI and
2
University of Michigan, Ann Arbor, MI.
Purpose: The application of robotics for the management of colorectal
disease is rapidly progressing. Single institutional experiences have demonstrated robotic safety and efficacy when compared to laparoscopy. Until
randomized studies mature, large multicenter database analysis may better
define the role of robotic colorectal surgery. This study compares laparoscopic (LAP), hand-assisted laparoscopic (LAP-HA), and robotic abdominal
(ABD) and pelvic (PLV) colorectal operations.
Methods: The Michigan Surgical Quality Collaborative (MSQC) was
queried for colorectal operations from July 1, 2012 to June 30, 2013.
Propensity score quintiles modeled on patient demographics, general
health factors and preoperative co-morbidities were used to compare riskadjusted outcomes.
Results: 713 LAP (522 ABD, 191 PLV), 334 LAP-HA (266 ABD, 68 PLV),
and 158 robotic (96 ABD, PLV 62) colorectal operations were identified.
Robotic operations were more often performed in the pelvis (LAP 26.8%,
LAP-HA 20.4%, robotic 39.2%). Conversion rates were significantly lower
with robotic when compared to LAP and LAP-HA operations (ABD 6.8% vs.
22.6%, p<0.001; PLV 7.5% vs. 28.9%, p<0.001). Adjusted LOS was shorter for
robotic than for Lap (Mean LOS for robotic 4.14d CI 3.71-4.62 vs Lap 4.425.03d, p = 0.06) and Lap HA (Mean LOS for robotic 4.14d CI 3.71-4.62 vs Lap
HA 4.71d CI 4.42-5.03, p < 0.05) abdominal operations, though the former
did not reach statistical significance. For PLV operations, there was no difference in LOS between robotic and LAP-HA (5.09d CI 4.40-5.87 vs. 4.36d CI
3.79-5.01, p=0.46) and robotic and LAP (LAP 4.59d CI 4.24-4.97, p=0.54). The
frequency of postoperative complications was not different for ABD operations but approached significance in the pelvis (p=0.05) without an obvious pattern to specific complications (Table 1).
Conclusions: In this large database analysis, robotic colorectal surgery
was associated with fewer conversions and shorter LOS without an increase
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Abstracts
in complications for ABD surgeries. There was a trend towards more complications for robotic operations in the pelvis but this did not reach significance. Randomized trials may serve to further elucidate these findings.
Table 1: Post-Operative Complications Comparing Laparoscopic and Robotic
Techniques
Conclusions: Robotic technique may improve TME. Major advantages
of the robotic surgery can be appreciated in males, in narrow and deep
pelvis following the neoadjuvant chemoradiation.
P195
QUALITY OF LIFE FOLLOWING LAPAROSCOPIC RECTOSIGMOID
RESECTION FOR ENDOMETRIOSIS: ONE-YEAR FOLLOW-UP.
A. Vignali1, E. Garavaglia2, S. Ferrari2, A. Inversetti2, I. Tandoi2, P. De
Nardi1, M. Candiani2 and C. Staudacher1 1Department of Gastrointestinal
Surgery, Scientific Institute S.Raffaele Hospital -Vita e Salute University,
Milan, Italy and 2Obstetrics and Gynecology Department, Scientific
Institute S.Raffaele Hospital -Vita e Salute University, Milan, Italy.
P194
LAPAROSCOPIC VERSUS ROBOTIC SPHINCTER PRESERVING TOTAL
MESORECTAL EXCISON FOR MALE PATIENTS WITH LOWER RECTAL
CANCER FOLLOWING NEOADJUVANT TREATMENT.
E. Kunduz1, O. Asoglu1, B. Bakir2, K. Serin1, Y. Kapran4, E. Oral3 and
S. Saglam5 1General Surgery, Liv Hospital, Istanbul, Turkey,
2
Radiodiagnostic, Liv Hospital, Istanbul, Turkey, 3Radiation Oncology, Liv
Hospital, Istanbul, Turkey, 4Pathology, VKV American Hospital, Istanbul,
Turkey and 5Medical Oncology, IStanbul Bilim University Medical Faculty,
Istanbul, Turkey.
Purpose: To determine the benefits of the robotic rectum resection
comparing with laparoscopic technique according to short term oncological outcomes.
Methods: Between 2005-2013, 306 rectal cancer cases were performed
laparoscopic / robotic total mesorectal excision (TME) by single surgeon
(OA). 79 cases, who were males, had locally advanced mid or distal rectal
cancer requairing neoadjuvant chemo-radiation and were suitable for
sphincter preserving prosedure included to the study group. The study
group datas were evaluated retrospectively, duo to prospective builded
computerized data base. Sixty five ( 82% ) of the cases were operated
laparoscopically and 14 cases ( 18 %) were operated laparoscopic / robotic
technique. Robotic resection technique included laparoscopic medial to lateral dissection and ligation of the vessels and roboic pelvic dissection. Only
one docking of the robot was done for pelvic dissection.
Results: Median age was 54,5 (41-71) years for robotic and 57 (28-80)
for laparoscopic groups (p:0.054). The demographic datas such as body
mass index (BMI) and American Society od Anesthesiology Score (ASA).
Operation times were140 minutes in laparoscopic and 182 minutes in
robotic surgery groups (p:0.033). There is no differences according to bowel
functions and hospital stay between each group. According to pathological results, circumferantial surgical margin (CRM) was statistically longer in
robotics group (laparoscopic 6.5 mm, robotic 10 mm) ( p:0.047). Also total
lymph node count laparoscopic 23, robotic 32 ) (p:0,08) and distal surgical
margin (laparoscopic 15 mm, robotic 27.5 mm) (p:0,014) were longer in
robotic group. Mesorectum integrity secured in robotic group(imcomplet
mesorectum robotic %0 laparoscopic %20)There was no differances according to mesorectum integrity.
Purpose: The current study aims to evaluate quality of life (QOL) in
patients before and 1 year after laparoscopic excision of deep pelvic
endometriosis with rectal involvement.
Methods: A prospective observational cohort study was conducted on
50 consecutive women with deep pelvic endometriosis with rectal involvement.Preoperative work-up included trans vaginal ultrasound, pelvic MRI
and rectal ultrasound. In patients who underwent rectal or sigmoid resection a QOL SF-36 questionnaire was administered before (QOL0) and 12
months following surgery (QOL12). At the same time intervals all patients
completed a 100-point rank questionnaire on intestinal and extra intestinal
symptoms.
Results: Mean (range) age was 33 (26-43) years. A laparoscopic colorectal resections were performed in 21 cases (9 rectosigmoid, 12 low rectal
resection), sigmoid and rectal nodal excision in 29 cases. A ghost ileostomy
was fashioned at primary operation in 7 cases. Additional procedures were
necessary in 18 cases. Conversion rate was 8%: severe pelvic disease (n= 2),
ureter reimplantation (n = 2). Anastomotic leak occurred in one case. No
vaginal fistula occurred. No recurrence of colorectal endometriosis was
found at a mean (range) follow-up period of 52 (19-72) months. Significant
improvements were observed in all domains of the SF-36 throughout the
study period. The role physical, pain and role emotional subscales evidenced the most substantial increases between QUOL0 and QUOL12 (P =
0.02, P=0.002, P= 0.003, respectively). Similarly physical functioning, general health, vitality, social functioning and mental health domains had a significant improvement (p < 0.05). The analysis of the 100-point rank questionnaire on intestinal and extra intestinal symptoms at one year following
surgery evidenced a significant decrease of dysmenorrheal (p=0.001), dyspareunia (p=0.003), sexual activity (P=0.001), non menstrual pelvic pain
(p=0.003), abdominal pain (p=0.02), proctorrhagia (p=0.01) and constipation (p=0.01),
Conclusions: Laparoscopic resection for deep endometriosis with rectal involvent significantly improved QOL and reduced endometriosisrelated symptoms as well as digestive symptoms.
P196
LAPAROSCOPY AND REDUCED SURGICAL SITE INFECTION AFTER
COLORECTAL SURGERY: DELAYED PRESENTATION RATHER THAN
ACTUAL REDUCTION?
I. Esemuede1, S. Lee-Kong1, W. Middlesworth2, D. Feingold1 and
P. R. Kiran1 1Colorectal Surgery, New York Presbyterian Columbia University
Medical Center, New York, NY and 2Pediatric Surgery, New York
Presbyterian Columbia University Medical Center, New York, NY.
Purpose: Laparoscopic surgery has been reported to be associated with
reduced postoperative wound problems including surgical site infection
(SSI) after colorectal surgery. Considering the shorter hospitalization and
smaller incisions after laparoscopic (LS) when compared to open surgery
(OS), the timeline of SSI occurrence may simply have been shifted postoperatively from the hospital to the patient’s home.
Methods: From the National Surgical Quality Improvement Program
(NSQIP) database, patients undergoing colorectal resections from 2006-
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Abstracts
2011 by OS and LS were identified. Risk of occurrence of SSI, whether this
occurred as an inpatient or after discharge, and time to development of SSI
was compared after LS and OS.
Results: Of the patients who underwent colorectal resection, 40,221
(66%) underwent OS and 20,706 (34%) had LS (table). LS patients were
younger (60.5 vs. 62.4 years, p<0.001) and less likely to have diabetes
(12.4% vs 16.1%, p<0.001). Mean length of stay was longer in OS than LS
(10.9 vs. 6.1 days, p<0.001). SSI occurred more commonly after OS than LS
(15.8% vs. 9.4%, respectively, p<0.001). SSI was more commonly diagnosed
after discharge rather than as inpatient for LS (5.6% vs. 3.5%, p<0.001) as
against OS, where the majority of SSI were detected prior to discharge
(9.5% vs. 6.6%, p<0.001). Only 40.4% of LS patients had SSI diagnosed in
the inpatient setting.
Conclusions: Although laparoscopy is associated with a lower risk of
SSI than open surgery for colorectal resection, there is a shift to the occurrence of SSI to the outpatient post-discharge phase after LS. Systems that
do not carefully monitor and follow patients post-discharge with the same
rigor of follow-up as the American College of Surgeons-NSQIP cannot
ensure an accurate determination of this quality metric and will hence lead
to under-reporting of SSI rates after laparoscopic colectomy.
procedure-related adverse events were predominantly grade 1-2 and of
short duration. No significant difference was found with regard to overall
median survival between younger (8.4months; 95% CI=6.2-10.6) or elderly
patients (8months; 95% CI=4.5-11.4, p=0.35). In another subgroup analysis,
the cohort was divided according to the median NLR of 4.6, 52 patients had
a high NLR (≥4.6) and 55 patients had a normal NLR. The median survival
of patients with high NLR was 5.3 compared with 10.6 months for patients
with normal NLR; a significant difference was found in overall survival (logrank test, p=0.001). On multivariate analysis of the entire cohort, high NLR
(HR: 1.93, 95% CI=1.20-3.09, p=0.006) and presence of extra-hepatic disease
(HR: 1.667, 95% CI= 1.02-2.71, p=0.04) remained independently associated
with increased risk of death.
Conclusions: NLR is a simple, inexpensive, and useful biomarker to predict outcome. In addition, radioembolization appears to be as well tolerated and effective for the elderly as it is for younger patients with mCRC.
Age alone should not be a discriminating factor for the management of
patients with mCRC.
Patient demographics and clinical data
Time to SSI table
* Those receiving both bevacizumab and cetuximab also included.
SSI: surgical site infection
** CEA response defined as a reduction in CEA ≥50% of pretreatment value
P197
NEUTROPHIL-LYMPHOCYTE-RATIO, BUT NOT AGE, PREDICTS POOR
OUTCOME AFTER RADIOEMBOLIZATION IN PATIENTS WITH
METASTATIC COLORECTAL CANCER.
S. Tohme1, D. Sukato1, G. Nace1, A. Zajko2, N. Amesur2, D. Geller1 and
A. Tsung1 1General Surgery, University of Pittsburgh, Pittsburgh, PA and
2
Radiology, University of Pittsburgh, Pittsburgh, PA.
*** RECIST criteria used to compare baseline measurements just prior to first Rx
with radiologic response during 1-6 months follow-up imaging
Purpose: To evaluate factors that can predict outcome in patients with
unresectable colorectal cancer metastases undergoing hepatic radioembolization.
Methods: A retrospective review of 107 patients with unresectable
metastatic colorectal cancer (mCRC) who were treated with radioembolization between 2002 and 2012. Demographics, clinical and survival data were
examined.
Results: Using univariate analysis, presence of extra-hepatic disease,
pulmonary nodules, previous liver-directed therapy, and neutrophil-lymphocyte ratio (NLR) were factors associated with increased risk of death. On
subgroup analysis, the cohort was divided according to age with 44
patients in the elderly (≥70 yrs) and 63 patients in the younger group (<70
yrs). Both groups had similar previous extensive chemotherapy and liverdirected therapy. Using RECIST criteria, either stable or partial response was
seen in 65% of the younger vs. 76% of the elderly patients (p=0.357).
Radioembolization was equally well tolerated in both groups and common
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Abstracts
Conclusions: The rate of morbidity and mortality in patients with Stage
IV CRC undergoing resection of their primary tumor is similar to published
benchmarks regarding all patients undergoing colorectal surgery. There is
an increase in major complications with advancing age, peritoneal metastasis and more than one site of metastatic disease. This data can help identify patients with Stage IV disease who serve to benefit most from resection of their primary tumor.
P198
THE PROPORTION OF TUMOR STROMA IS A PROGNOSTIC FACTOR
FOR PREDICTING LYMPH NODE METASTASIS IN pT1 COLORECTAL
CANCERS.
E. Toh1, P. Brown1, I. Botterill2 and P. Quirke1 1Pathology, Leeds Institute of
Molecular Medicine, Leeds, United Kingdom and 2John Goligher Colorectal
Unit, St James’s University Hospital, Leeds, United Kingdom.
Purpose: Histopathological features such as grade of differentiation,
lymphatic and vascular invasion are important and well-known prognostic
factors for lymph node metastasis (LNM) in pT1 colorectal cancers (CRC).
This study is aimed to assess whether the relative proportion of tumour
stroma (PoTS) could be used as a prognostic factor for LNM.
Methods: The PoTS in the invasive front was measured by point counting 300 spots on digital microscopy in a series of 207 pT1 CRC cases. The
relationship of PoTS and other histopathological parameters (grade of differentiation, lymphatic and vascular invasion) to LNM were analysed. Modified receiver operating characteristic (ROC) curves were constructed to
determine the optimum cut-off PoTS value for LNM.
Results: In this series, LNM rate was 9.2% (19 cases). Cases with LNM
had a significantly higher PoTS compared to cases without LNM (48.3% vs
39.5%, p = 0.005). The modified ROC curves generated a cut-off PoTS value
of 43.5%. High PoTs (≥43.5%) was predictive of LNM at univariate level
(Odds Ratio [OR] = 5.78, 95% Confidence Interval [95% CI]=1.85 – 18.08).
Together with lymphatic invasion (OR=9.49, 95% CI = 1.51 – 59.74, p=0.017)
and grade of differentiation (OR=11.6, 95% CI = 2.36 – 57.06, p = 0.003),
high PoTS maintained its significance on multivariate analysis (OR=4.34,
95% CI = 1.3 – 14.47, p=0.017).
Conclusions: This study has shown that PoTS could be a potentially useful prognostic factor for LNM in pT1 CRC. This low-cost and reproducible
method of calculating tumour stroma could be valuable in identifying high
risk pT1 CRC.
P199
MORBIDITY AND MORTALITY WITH RESECTION IN STAGE IV COLORECTAL CANCER.
E. Teeple, K. Kimonis, A. Madenci, R. Bleday and J. Goldberg Colorectal
Surgery, Brigham and Women’s Hospital, Boston, MA.
Purpose: Resection of the primary tumor in Stage IV CRC may increase
survival but remains controversial. We retrospectively examined postoperative morbidity and mortality in patients with Stage IV CRC to identify
patients who would benefit most from this approach.
Methods: A retrospective review was undertaken using the Dana Farber Cancer Institute (DFCI) database. All patients with Stage IV CRC who
presented between 2000-2012 and underwent resection of their primary
tumor were analyzed. Patients were excluded for non-adenocarcinoma
pathology, emergent surgery, recurrent disease and the absence of Stage
IV disease at presentation. Primary endpoints were 30 day post-operative
morbidity and mortality. Major postoperative morbidities included PNA,
CHF, ARDS, AMI, PE, DVT, ARF, anastomotic leak, intra-abdominal sepsis,
early SBO requiring reoperation and liver failure. Minor postoperative morbidities included wound infection and UTI. 30 day readmission and LOS
were also measured. Outcomes were compared to known benchmarks.
Using SAS version 9.3, Chi-square tests or Fisher’s exact tests were used to
assess categorical variables and Mann-Whitney U tests to assess continuous variables. Multivariable logistic regression modeling was performed for
the primary endpoints.
Results: There were 633 patients included. Post-operative morbidity
approached 31%: 19.6% had a major complication, 19.7% had a minor complication. Post-operative mortality was 3%. There was an increase in major
complications with increasing age (P<0.01), the presence of peritoneal
metastasis (p=0.03) and more than 1 site of metastasis at presentation
(p=0.048). Grade, size of tumor, LN positivity, kras status, CEA level were not
associated with an increase in perioperative complication rate.
P200
SEVERITY OF HIV IS NOT PREDICTIVE OF FAILURE OF CHEMORADIATION IN ANAL SQUAMOUS-CELL CANCER.
J. Blumetti, V. Chaudhry, J. Harrison, J. Cintron and H. Abcarian Stroger
Hospital of Cook County, Chicago, IL.
Purpose: Outcomes of treatment in the HIV patient with anal squamous
cell carcinoma (SCC) have been shown to be equivalent to those without
HIV, if the patient is able to complete treatment. However, there continue
to be treatment failures within the HIV population. This study aims to evaluate whether severity of HIV disease influences the treatment failure within
an HIV positive population with anal SCC.
Methods: After IRB approval, a retrospective review of patients with
SCC from 2000-2013 was performed. Patients with HIV and SCC were
included. Data was collected on demographics, CD4 count/viral load, stage,
treatment, and outcome, defined as initial complete response with
chemoradiation (CRT). SPSS software (version 22) was used for analysis.
Results: 132 patients with anal SCC were identified. 50 patients had HIV
and anal SCC; 14 were excluded due to incomplete overall staging information. Mean age was 45. 81% were African American, 11% Caucasian, 8% Hispanic. 89% were men, 5.5% women, 5.5% transgender. Median CD4 and
viral load at diagnosis were 182 (range 3-844) and 1447 (range 40-750,000).
92% were on HAART therapy during treatment. Median follow-up was 25.5
months (range 3-102). 32 patients had data on response to CRT. 3/36 were
excluded due to local excision alone; 1 died prior to assessing response.
CD4 count, viral load, stage, interruptions in CRT and response is demonstrated in the table. 19/32 patients had complete response with CRT(59%).
Interruptions occurred due to neutropenia in 6 patients, non-compliance
in 8, and delay due to colostomy in 2. Interruptions occurred in 9 patients
with CD4<200, 6 with CD4>200 and 1 with unknown CD4; interruptions
occurred in 11 patients with viral load >100, 4 with viral load <100 and 1
with unknown viral load. There was no significant difference in complete
response to treatment by CD4 count, viral load, or interruption in treatment.
Complete response occurred less frequently in patients with larger tumors
or higher stage, but this did not reach statistical significance.
Conclusions: Complete response to treatment is not affected by severity of HIV disease. All patients with HIV and SCC should be offered CRT
regardless of HIV status.
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Abstracts
Squamous Cell Cancer of the Anal Canal: Relationship of CD4, Viral load, stage
and treatment interruptions with treatment response.
P201
GASTROINTESTINAL STROMAL TUMORS IN THE RECTUM AND ANUS:
A RETROSPECTIVE SINGLE-INSTITUTION ANALYSIS.
J. Wolf, E. Pappou, C. Hicks, L. Schwartz, T. Magruder, S. Fang, E. Wick,
B. Safar, S. Gearhart and E. Jonathan Surgery, Johns Hopkins Hospital,
Baltimore, MD.
Purpose: Gastrointestinal stromal tumors (GIST) have been sporadically
reported in the anorectum, but there are few clinicopathologic series. In
this study, we analyzed the characteristics of anorectal GISTs diagnosed and
treated at our institution.
Methods: A total of 17 patients diagnosed with anorectal GIST between
January 2001 and December 2012 were identified and retrospectively
reviewed. Data were collected from clinical and pathology records.
Results: The GISTs occurred in adults with the age range of 28-71 years
(median 60.4 years) with a significant male predominance (68%). Eightyone percent of tumors were larger than 5 cm, average size being 7.8 cm.
All 17 were documented as c-KIT (CD117)- and CD34-positive, and all were
negative for S-100 protein. Primary surgical treatment was local excision
(7), abdominoperineal resection (8), and exenteration (2). R0 resection was
achieved in 87% of patients. Three patients received neoadjuvant imatinib
therapy, two of these patients had an incomplete response and one did not
respond at all. The latter was also the only patient who developed a distant
metastasis (liver). Two patients developed local recurrences, both after two
years (mean follow-up 22 months).
Conclusions: Similar to GIST tumors arising elsewhere in the gastrointestinal tract, complete resection of anorectal GIST is recommended to
achieve local disease control. In this series, size at presentation and cellular
grade do not seem to be associated with outcome. More data are required
to determine whether neoadjuvant treatment with imatinib helps to minimize local and distant disease recurrence.
P202
LONG-TERM OUTCOME AFTER CURATIVE RESECTION FOR RECTAL
CANCER IN SAUDI ARABIA.
S. ALHomoud, M. Mohammed, N. Al Sanea, L. Ashari and A. Abdul
Jabbar The King Faisal Specialist Hospital and Research Centre, Riyadh,
Saudi Arabia.
Purpose: Evaluate the survival and local recurrence rates after curative
treatment for rectal cancer delivered by a specialized colorectal unit at a
tertiary care center in Saudi Arabia over the past 10 years
Methods: All records of patients at King Faisal Specialist Hospital
&Research Centre –Riyadh who underwent a potentially curative treatment
for rectal cancer between 01 January 2000 and 31 December 2011 were
retrospectively reviewed. Radical surgery was performed by four specialized colorectal surgeons. Demographic data, tumor characteristics, neoadjuvant and adjuvant treatment rendered, local recurrence and survival data
were all retrieved
Results: Out of 345 patients, 241 underwent anterior resection; whereas
104 underwent abdominoperineal excision. Male to female ratio was 1.1:1
with a median age at operation of 57 years. Neoadjuvant chemoradiation
and neoadjuvant radiation were given to 58% and 30% of patients, respectively. Adjuvant chemotherapy was given to 67% of the patients. The
median follow-up was 53 months and complete resection with negative
margins was achieved in 96.3%. Local recurrence rate was 9.8%. Total recurrence rate was 21%. Overall 5-year survival rate was 81.5% and 5-year disease-free survival rate was 70%. Positivity of lymph nodes and depth of
tumor invasion had significant impact on overall and disease-free survival
rates (P. value < 0.001, 0.008, versus 0.003, 0.032, respectively) in multivariate analysis. The rate of clinical and radiological leak and stenosis in our
patients was 5.4% and 5% respectively.
Conclusions: Curative treatment for rectal cancer in Saudi Arabia had
long-term outcome similar to international results
P203
REDUCTION OF COSTS FOR PELVIC EXENTERATION IN FEMALE
PATIENTS PERFORMED BY HIGH VOLUME SURGEONS: ANALYSIS OF
THE MARYLAND HEALTH SERVICE COST REVIEW COMMISSION DATABASE.
A. Althumairi, J. Canner, M. Gorin, S. Fang, S. Gearhart, E. Wick,
T. Bivalacqua and J. Efron Johns Hopkins Hospital, Baltimore, MD.
Purpose: To evaluate the outcomes and cost of pelvic exenterations
performed in the state of Maryland and determine predictors of cost reduction.
Methods: The Maryland Health Services Cost Review Commission database (HSCRC) was queried for patients who had a pelvic exenteration
between 2000 and 2011. Patients were compared for age, sex, race, and
medical complexity/mortality risk as defined by the validated stratification
method of All Patient Refined Diagnosis Related Groups. Hospitals and surgeons were stratified by volume: high volume hospitals >50 cases; high volume surgeons >10 cases. Insurers were grouped as Medicaid/other government insurers, Medicare, private, or none. The differences in length of
hospital stay (LOS), length of intensive care unit (ICU) stay, procedurerelated cost, and total cost was compared for surgeon volume and hospital
volume controlling for all other factors. Chi-square, student’s t-test and
ANOVA were used to compare the outcomes; further, multivariate linear
regression was used to adjust patient and procedure characteristics.
Results: 335 patients underwent a pelvic exenteration (Table1). 126
patients (38%) had surgery at high volume centers and 209 (62%) at low
volume centers. 115 (34%) had surgery by high volume surgeons (4 total)
and 220 (66%) by low volume surgeons. When controlling for all other factors having surgery performed by a high volume surgeon was associated
with a decrease in LOS (-1.5 days, p=0.164), ICU stay (-1.3 days, p=0.001),
operating room cost (-$3643, p=0.001), and total cost (-$10327, p=0.002).
Hospital volume did not significantly impact the LOS (-0.4 days, p=0.74),
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Abstracts
ICU stay (0.70 days, p=0.12) or total cost ($3101, p=0.39); but did have a
small effect on operating room cost (-$1678, p=0.02). Insurance type had
no effect on outcomes.
Conclusions: Pelvic exenteration performed by high volume surgeon is
significantly associated with lower operating room cost, total cost, LOS and
ICU stay, even after adjusting for mortality risk and medical complexity.
How this correlates with outcomes requires futher study.
Table 1. Patient demographics, outcomes and costs
neoadjuvant CRT until assessment of tumor response and final surgical
management decision.
Results: Tumor-specific chromosomal rearrangements (TSCR) were
selected from 5 patients with rectal cancer and subsequently validated by
Sanger sequencing. TSCRs were detected in all pre-treatment serum samples. Post-treatment serum samples from patients presenting complete
clinical or pathological response nCRT were negative for TSCR. Post-treatment samples from patients with incomplete pathological response
revealed the presence of TSCR.
Conclusions: TSCR monitoring may help identify residual cancer following neoadjuvant chemoradiation for distal rectal cancer and select ideal
candidates for alternative treatment strategies.
Tumor-specific chromosomal rearrangements for 5 patients identified for the
selection of personalized biomarkers for response to CRT
P205
P204
THE USE OF PERSONALIZED BIOMARKERS FOR THE ASSESSMENT OF
TUMOR RESPONSE AND DETERMINE FINAL MANAGEMENT IN RECTAL CANCER PATIENTS TREATED WITH NEOADJUVANT CHEMORADIATION.
P. Carpinetti2, R. O. Perez1, A. Habr-Gama4, J. Gama-Rodrigues4,
E. Donnard2, F. Koyama2, F. Bettoni2, R. Parmigiani2, P. Galante2 and
A. Camargo3 1Colorectal Surgery DIvision, University of Sao Paulo School
of Medicine, Sao Paulo, Brazil, 2Centro de Oncologia Molecular, Hospital
Sírio Libanês, Sao Paulo, Brazil, 3Ludwig Institute for Cancer Resarch, Sao
Paulo, Brazil and 4Angelita & Joaquim Gama Institute, Sao Paulo, Brazil.
Purpose: Neoadjuvant chemoradiation may lead to complete tumor
regression in a proportion of patients with rectal cancer.However, assessment of response remains a challenge due to the limitations of clinical and
radiological findings. Identification of personalized biomarkers capable of
assessing tumor response would allow accurate selection of patients for
alternative treatment strategies following apparent complete clinical
response. Circulating DNA carrying tumor-specific genetic alterations can
be found in the cell-free fraction of the blood and have been used to monitor tumor dynamics. Recent advances in sequencing technologies have
enabled the rapid and cost effective identification of genetic alterations in
individual tumors. Tumor-specific chromosomal rearrangements, can then
be used as personalized biomarkers to monitor treatment response, overcoming the problem imposed by the absence of a universally recurrent
genetic alteration in solid tumors.
Methods: Pre-treatment biopsies were prospectively collected from
patients with distal rectal adenocarcinoma (cT2-4N0-2M0) undergoing
neoadjuvant CRT. DNA was extracted from specimens after confirmation of
≥80% cancer cells. Whole genome sequencing was performed using matepair reads and identified tumor-specific chromosomal rearrangements
(TSCR). Serum samples from patients were collected prior to and following
IMPACT OF SURGICAL SITE INFECTION REDUCTION STRATEGY IN
COLORECTAL RESECTIONS.
C. Foppa, E. Kazi, S. K. Palmer, J. Karas, N. Desai, P. I. Denoya and
R. Bergamaschi Division of Colon and Rectal Surgery, State University of
New York, Stony Brook, Stony Brook, NY.
Purpose: This study was performed to determine the impact of a surgical site infection (SSI) reduction strategy on SSI rates following colorectal
resection.
Methods: NSQIP data were utilized and supplemented by IRB-approved
chart review. Primary endpoint was superficial and deep incisional SSI
defined by CDC National Nosocomial Infections Surveillance system. Inclusion criterion was colorectal resection. SSI reduction strategy consisted of
preoperative (blood glucose, bowel preparation, shower, hair removal),
intraoperative (prophylactic antibiotics, antimicrobial incisional drape,
wound protector, wound closure technique), and postoperative components (wound dressing technique). SSI reduction strategy was prospectively
implemented and compared with historical controls (pre-SSI strategy arm).
Statistical analyses included Pearson’s chi-square test, and student t-tests
performed with SPSS software.
Results: 379 patients were in pre-SSI strategy arm and 311 patients in
SSI strategy arm. Study arms were comparable for age (p=0.85), BMI
(p=0.33), gender (p=0.23), ethnicity (p=0.224), smoking (p=0.59), alcohol
abuse (p=0.76), steroids (p=0.66), hypoalbuminemia (p=0.80), ASA class
(p=0.30) and co-morbidities (p=0.73). Preoperative wound class (p=0.13),
operative time (p=0.28), type of resection (p=0.94), stoma creation (p=0.23),
did not differ significantly. More patients underwent laparoscopic surgery
in SSI strategy arm (p<.01). Overall SSI rate was significantly decreased in
the SSI strategy arm (32.19% vs. 18.97%) (122 vs. 59, p<.01). Superficial SSI
rate was lower in SSI strategy arm (23.48% vs. 8.04%) (89 vs. 25, p<.01).
Deep SSI (2.37% vs. 2.89%) and organ space rates (6.07% vs. 7.72%) did not
differ.
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TABLE 1 Short-term Postoperative Outcomes Associated with Visceral Obesity
Conclusions: The implementation of SSI reduction strategy resulted in
a 41% decrease in SSI rates following colorectal resections.
P206
IMPACT OF VISCERAL OBESITY ON 30-DAY POSTOPERATIVE OUTCOMES IN PATIENTS WITH ULCERATIVE COLITIS FOLLOWING PRIMARY SURGERY.
Z. Ding, L. Lian, E. Remer, L. Stocchi, F. Remzi and B. Shen Colorectal
Department, Digestive disease institution, Cleveland, OH.
Purpose: Surgical treatment has assumed a pivotal position in the management of ulcerative colitis(UC). The aim of this study was to determine
whether visceral obesity, as determined by computed tomography (CT)
imaging measurements, is associated with worse postoperative outcomes
after primary surgery in patients with UC.
Methods: Patients who underwent subtotal abdominal colectomy with
end ileostomy (STC/EI) or proctocolectomy and ileal pouch-anal anastomosis (IPAA) for severe UC, and who had preoperative abdominal CT scans
between 2011 and 2013 were included. Clinical variables and 30-day postoperative outcomes were recorded. Visceral fat was measured at the lumbar 3 level on CT cross-sectional images. Visceral obesity was defined as a
visceral fat area (VFA) ≥ 130 cm2.
Results: One hundred and twenty-nine patients met the inclusion criteria. Forty-eight patients (37.2%) met our visceral obesity criterion. The
patients with visceral obesity were significantly older (53.9±15.5 vs.
37.4±14.7, P < 0.001), and more likely developed hypertension (24.2% vs.
4.8%, P = 0.001) than those without. Ninety-seven out of 129 patients
underwent STC/EI (75.2%). Among the 97 patients, patients with visceral
obesity were more often treated with open surgery (52.9% vs. 25.4%, P =
0.007) and suffered increased blood loss during surgery (120±71 ml
vs.389±361 ml, P = 0.006). The other 32 patients underwent IPAA and had
comparable intraoperative outcomes. From the pathological standpoint,
there was no difference in disease extent between the patients with or
without visceral obesity. Incidence of backwash ileitis was higher in patients
without visceral obesity (16.0% vs. 2.1%, P =0.014); however, more patients
with visceral obesity had surgery for dysplasia (22.9% vs. 8.6%, P =0.024).
Neither univariate analysis nor multivariate analysis adjusting for age,
comorbidities, medical therapy and procedure technique showed that visceral obesity was not associated with significant differences in short-term
postoperative outcomes (P > 0.05).
Conclusions: Visceral obesity as measured by CT scan does not
adversely influence 30-day postoperative outcomes for patients undergoing STC/EI or IPAA for UC.
a Data expressed as Mean ± Standard Deviation; IPAA, Ileal pouch-anal
anastomosis; TAC/EI, Total abdominal colectomy with end ileostomy
P207
IMPACT OF ALVIMOPAN IN COMBINATION WITH EPIDURAL AS PART
OF ENHANCED RECOVERY PROGRAM IN COLORECTAL SURGERY.
M. Abdelgadir Adam1, P. J. Speicher1, L. Lee2, J. Migaly3, C. Mantyh3 and
J. M. Thacker3 1General Surgery, Duke University Medical Center, Durham,
NC, 2Pharmacy, Duke University Medical Center, Durham, NC and
3
Colorectal Surgery, Duke University Medical Center, Durham, NC.
Purpose: Alvimopan, a peripheral m-receptor antagonist, has been
reported to decrease length of stay (LOS) following colorectal surgery (CRS)
by mitigating the negative effects on peripheral opioids receptors. Thoracic
epidurals block the sympathetic efferent and nociceptive afferent nerves
resulting in decreased opioid use, ileus, and LOS. It is unclear if there is a
benefit to combining alvimopan with epidural in CRS.
Methods: From a prospectively maintained database, patients undergoing CRS in an enhanced recovery program (ERP) between 2011-13 were
included. The primary variables were use of alvimopan and thoracic
epidural catheter. Patients with no epidurals received IV patient-controlled
analgesia for pain control. Primary endpoints were LOS and opioid requirement, measured as IV morphine equivalents (IVME). The independent
effects of each strategy were then estimated with multivariable linear
regression, adjusting for patient and procedure-specific variables.
Results: Of all 346 patients, 108 had epidural only, 30 alvimopan only,
176 epidural and alvimopan, and 32 none. Baseline characteristics including age, sex, baseline opioid tolerance, type of surgical approach utilized
were similar between groups. There were more patients undergoing
abdominoperineal resections in the combined epidural and alvimopan
group compared to other groups. After adjustment, epidural use was associated with reduced opioid requirement by -15% (p=.014), but no effect on
LOS (p=.84); conversely, alvimopan significantly reduced LOS by 16%
(p=.002), but not opioid requirement (p=.24). Combining alvimopan with
epidural had an independent synergistic effect on reducing LOS by an average of -26% (p=.007) but not opioid requirement (p=.35), Table 1.
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Abstracts
Conclusions: In patients undergoing CRS with ERP, thoracic epidural
use was associated with a marked reduction in opioid requirement, but no
impact on LOS. Alvimopan use resulted in reduced LOS, and this effect was
enhanced further when alvimopan was combined with epidural analgesia.
These findings suggest alvimopan may play a role in enhancing recovery
after CRS in patients receiving epidurals under ERP; however, larger
prospective studies should be undertaken.
Short-term (30-day) Post-operative outcomes After Enhanced and Standard
Recovery in IBD and CRC Patients
Table 1. Results of multivariable linear regression.
P209
IVME: IV morphine equivalents.
LOS: Length of stay.
P208
ENHANCED RECOVERY AFTER SURGERY: DOES A DIAGNOSIS OF
INFLAMMATORY BOWEL DISEASE PREDICT INCREASED LENGTH OF
STAY?
S. D. Holubar1, M. C. Kwa1, C. A. Siegel2 and M. D. Koff3 1Colon & Rectal
Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH,
2
Gastroenterology & Hepatology, Dartmouth-Hitchcock Medical Center,
Lebanon, NH and 3Anesthesiology, Dartmouth-Hitchcock Medical Center,
Lebanon, NH.
Purpose: Enhanced recovery after surgery (ERAS) lowers complications
and shortens lengths of stay (LOS) compared with standard recovery.
Although widely studied after surgery for colorectal cancer (CRC), little if
any data exist regarding applicability and outcomes of ERAS after surgery
for inflammatory bowel disease (IBD). We hypothesized that in the setting
of ERAS practice, IBD patients would have similar outcomes compared to a
control group of CRC patients.
Methods: We performed a retrospective review of consecutive patients
undergoing elective abdominal surgery by a single ERAS-trained colorectal
surgeon at an academic medical center from 1/1/2012 – 8/15/2013. Demographics, operative data, and short-term (30-day) outcomes are presented.
Univariate and multivariate analyses assessed predictors of post-operative
LOS with Bonferroni’s correction. Results are reported as median (interquartile range) or frequency (proportion).
Results: Eighty-five patients were included: 34 (40%) with IBD [24
Crohn, 11 CUC] and 51 (60%) CRC [20 colon, 21 rectal, 5 other]. IBD patients
were younger (41.6 vs. 61.5 years old, p<0.0001), with lower BMI (24.5 vs.
29.3, p=0.002). Similar proportions received ERAS (64.7% vs. 65.3%, p=0.95),
MIS surgery (59% vs. 76%, p=0.08), an anastomosis (58.8% vs. 68.6%,
p=0.35), or stoma (41.2% vs. 43.1%, p=0.85), but more CRC patients had
proctectomy (17.6% vs. 39.2%, p=0.05). Short-term outcomes are shown in
Table 1. The median LOS for IBD was 5 (4-7) vs. 4.5 (3-7) days for CRC,
p=0.15. However, in an exploratory univariate subgroup analysis, compared
with standard recovery, CRC-ERAS patients had a shorter LOS (3 vs. 6 days,
p<0.0002), but IBD-ERAS patients did not (5 vs. 5.5 days, p=1.0). Furthermore, linear regression adjusting for recovery pathway, diagnosis, demographic, perioperative variables, and major complications showed only a
diagnosis of IBD predicted longer LOS (+0.98 days, p=0.04).
Conclusions: In the setting of an ERAS practice, a diagnosis of IBD was
an independent risk factor for longer LOS. Further study is warranted to
determine if ERAS protocols can be modified to address the special needs
of this at risk population.
REVERSAL OF LOOP ILEOSTOMY UNDER AN ENHANCED RECOVERY
PROTOCOL; IS THE STAPLED TECHNIQUE STILL BETTER THAN THE
HANDSEWN ANASTOMOSIS?
G. Markides, M. McMahon, I. Wijetunga, A. Subramanian, P. Gupta,
P. Holdsworth, S. Anwar and M. Saeed Colorectal Surgery, Calderdale and
Huddersfield NHS Trust, Huddersfield, United Kingdom.
Purpose: Recent literature evidence has suggested that a stapled anastomotic (SA) technique for the reversal of loop ileostomy (LI) may be beneficial in terms of reduced risk of small bowel ileus and shorter hospital stay
as compared to the handsewn anastomosis (HA). The aim of this study was
to determine whether this was still the case when both groups were cared
for under an enhanced recovery programme (ERP).
Methods: Adherence to ERP modules and 30 day postoperative complications were assessed via retrospective review of patient case notes
between January 2008 and December 2012. All adult patients undergoing
elective reversal of loop ileostomy via SA or HA were included.
Results: 108 patients were included, 61 in the SA group and 47 in the
HA group. There were no demographic differences between the two
groups. ERP module compliance was satisfactory (>80%) in 11 of the 14
modules with no difference in individual module compliance between the
two groups. There was no difference between the two groups for operating times (p=0.35), mortality (p=0.44), anastomotic leak (p=1.00), intraabdominal collection (p=0.65), small bowel obstruction (p=1.00), reoperation (p=0.65), ileus (p=0.14) and significant complications (Clavien-Dindo >
2) (p=0.08). A significantly longer total length of hospital stay (TLOS) was
found in the SA group (med 3 Vs 4 days, p=0.009).
Conclusions: Reversal of LI under an ERP appears to potentially negate
the perceived benefits of SA over HA i.e. reduced risk of small bowel ileus
and shorter hospital stay.
P210
INADEQUATE STAGING AND TREATMENT IN RECTAL CANCER: A SEERMEDICARE ANALYSIS.
J. Hrabe1, M. Charlton2 and J. Cromwell1 1General Surgery, University of
Iowa, Iowa City, IA and 2College of Public Health, University of Iowa, Iowa
City, IA.
Purpose: Preoperative combined modality therapy of Stage II/III
tumors, as per careful pretreatment locoregional staging, is now the preferred treatment for rectal cancer. This practice is recommended by NCCN
and ESMO guidelines, as well as ASCRS practice parameters. Because wide
variation in rectal cancer outcomes has been reported, we sought to determine whether patients diagnosed with Stage II or III rectal cancer receive
the appropriate preoperative staging and treatment.
Methods: We analyzed Surveillance, Epidemiology, and End Results
(SEER)-Medicare data from 2000-2009, identifying patients with stage II or
III rectal adenocarcinoma who underwent surgery. Patients with Stage I and
IV disease, rectosigmoid tumors, and previous cancer were excluded. Only
patients with continuous Medicare Parts A & B coverage for one year before
and after diagnosis were included. We calculated rates of locoregional staging (as indicated by claims for endorectal ultrasound or pelvic MRI), distant
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staging (claims for CT abdomen, MRI abdomen, or PET), and preoperative
chemotherapy and radiation therapy. We also evaluated rates of sphincter
preserving surgery.
Results: Data for 5642 patients were available. Rates of claims for staging and treatment modalities are shown in the Figure. Claims for appropriate locoregional staging studies were present in a minority of patients,
peaking at 36% in 2009. Claims for distant staging studies indicate these
were more frequently performed, with 84% of patients in 2009 having evidence of getting either CT, MRI, or PET of the abdomen. Over time, an
increasing rate of patients received neoadjuvant chemotherapy (49% in
2009) and radiation (54% in 2009). The rate of procedures associated with
sphincter preservation did not dramatically differ.
Conclusions: In a national Medicare population with Stage II and III rectal cancer, available claims indicate that only 36% of patients received recommended locoregional staging studies in 2009. In addition, many did not
undergo complete distant staging, and nearly half had no evidence of
receiving neoadjuvant chemoradiotherapy. Reasons for the inadequate preoperative workup and treatment of these patients, as well as the effects on
cancer outcomes, are being investigated.
P211
LAPAROSCOPIC TME FOR RECTAL CANCER: OUTCOMES WITHIN AN
ERAS PATHWAY.
H. Vaccarezza, R. E. Mentz, V. M. Im, C. A. Vaccaro, G. M. Ojea Quintana
and G. L. Rossi Surgery, Hospital Italiano de Buenos Aires, Buenos Aires,
Argentina.
Purpose: The enhanced recovery after surgery (ERAS) strategies in
laparoscopic colonic resections have proved to fasten recovery, shorten
hospital stay and improved medical care. However, the ERAS strategies on
laparoscopic TME for rectal cancer have not been extensively applied. Moreover, hospital stay and readmission rate reported reach-up 7-10 days and
20%. The main goal was to analyze surgical outcomes in laparoscopic TME
for rectal cancer under an ERAS pathway. A secondary goal was to examine
feasibility of a 3 day hospital stay.
Methods: 221 patients that underwent a laparoscopic TME for rectal
cancer between 2005 and 2013 were analyzed. In all cases an ERAS pathway and standardized discharge criteria were used. Patients were grouped
according hospital stay was 3 days (Group A) or longer (Group B). Data was
analyzed based on intention to treat. To identify independent predictive
factors related to a shorter hospital stay, a multivariate analysis was performed.
Results: Median hospital stay was 3 days. Group A represented 51 % of
this series with a had higher rate of females (54.9% vs. 34.3%; P=0.002) and
mean distance to the anal verge (10cm vs. 8cm; P=0.04), a lower mean BMI
(25.3 vs. 26.4; P=0.046) and ASA III-IV (15.9% vs. 28.7%; P=0.02) Group A was
associated with a higher rate of high anterior resections (27.4% vs. 15.5%;
P=0.035) a lower operative time (203 min vs. 237 min; P<0.001) and a lower
intra and postoperative complications (2.7% vs. 23.1%; P=<0.01 and 10.6%
vs. 21.3%; P=0.03 respectively). Overall conversion rate was 15 %. Group A
had a lower conversion (4.5% vs. 21.3 %; P<0.001) and reoperation rate
(3.1% vs. 12.8%; P=0.014). There were no differences in the readmission rate
between groups (8.3% vs. 11.4 %; P= 0.49). Multivariate analysis of laparo-
scopically completed cases showed high resections, intra-operative complications, mayor postoperative complications and reoperation were independently associated with lenght of hospital stay.
Conclusions: These results suggest that laparoscopic TME for rectal cancer within an ERAS pathway leads to a short hospital stay with low complication and readmission rate.
P212
OUTCOMES FOLLOWING SUBTOTAL COLECTOMY FOR FULMINANT
CLOSTRIDIUM DIFFICILE COLITIS.
K. Mathis, S. Y. Boostrom and E. J. Dozois Surgery, Mayo Clinic, Rochester,
MN.
Purpose: Our aim was to determine the morbidity and mortality associated with emergent subtotal colectomy and ileostomy for the management of fulminant Clostridium difficile colitis in a single tertiary care institution in the modern era.
Methods: We identified all patients meeting these criteria from September 2007 through August 2012. Data points regarding presentation,
preoperative condition, postoperative outcomes and stoma reversal were
retrospectively recorded.
Results: Forty-nine patients were included (26 female, median age 69
years). Clostridium difficile colitis (CDC) was confirmed in all. CDC was hospital or nursing-home acquired in 28 patients. Co-morbidities were common and 11 patients were on immunosuppressive medications. Forty
patients had antibiotic exposure within 4 weeks of the diagnosis of CDC.
Thirty-nine (80%) required intensive care unit (ICU) admission prior to surgery, and 37% required vasopressors and/or intubation. Median time
between hospital admission and surgical consultation was 1 day (range 0
to 63), and time between surgical consultation and operation was 0 days
(range 0 to 15). Any morbidity occurred in 76% (Table1) with reoperation
required in 22%. 30-day mortality was 20%. The only significant risk factor
for in-hospital death as well as for postoperative morbidity was preoperative ICU admission. Twelve patients required new nursing home admission
at discharge. Of the 40 surviving patients, 23% underwent stoma reversal
during the follow-up period.
Conclusions: Morbidity and mortality following subtotal colectomy for
CDC remain significant in the modern era.
P213
EFFECTS OF THD GATEKEEPER IN FECAL INCONTINENCE TREATMENT.
C. Ratto, A. Parello, L. Donisi, F. Litta and V. De Simone Surgical Sciences,
Catholic University, Rome, Italy.
Purpose: THD Gatekeeper (GK) has been introduced as a therapeutic
option in selected patients with fecal incontinence (FI). This minimally invasive surgical procedure provides the implant of self-expandable prostheses
into the intersphincteric space of the upper-middle anal canal. Endoanal
ultrasound (EAUS) can guide the implantation. Safety and efficacy of
implanting prostheses were evaluated in this study.
Methods: Twenty consecutive FI patients (10 female; mean age: 59.9
+/-14.5 years) met the following inclusion criteria and entered the study:
older than 18 or younger than 80 years; FI duration of at least 6 months
resistant to conservative management; soiling or incontinence to liquid
and/or solid stools more than once a week; intact anal sphincters or limited lesions of internal anal sphincter +/- external anal sphincter, assessed
at EAUS. Under local anesthesia, patients underwent implant of 6 GK prostheses, at 1,3,5,7,9 and 11 o’clock of the anal canal. EAUS guided the implantation. Daily continence diary, ability to defer defecation, feeling of incomplete evacuation, rectal discrimination, constipation, Cleveland Clinic FI
Score, Vaizey Score, and EAUS were assessed before and during the follow
up (scheduled at 1,3,6,12 months and, then, once a year).
Results: There was no intra- or postoperative complication. Mean follow up was at 6.9+/-4.4 months. Compared to baseline data, there was a
significant decrease of mean week number of incontinence episodes to fla-
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Abstracts
tus (from 8.6+/-10.6 to 2.2+/-4.7; p< 0.03), liquid stools (from 2.2+/-3.9 to
0.4+/-1.2; p< 0.05), solid stools (from 1.8+/-3.4 to 0.5+/-1.6; p<0.05), and
soiling (from 6.4+/-6.6 to 0.4+/-0.8; p<0.001). Ability to defer defecation (for
>5 minutes), referred by 6 patients preoperatively, was reported by 16
patients follow up (p<0.05). Seven patients needed to wear pads at baseline, while 3 patients at follow up. Mean Cleveland Clinic and Vaizey FI
scores significantly decreased (p<0.001), respectively, from 11.2+/-5.3 to
4.6+/-4.1, and from 14.0+/-5.9 to 5.9+/-5.1. Six patients were fully continent.
No any new case of constipation was reported.
Conclusions: Implantation of THD Gatekeeper prostheses seems to be
a promising, safe and effective option to treat selected patients with FI.
P214
CLINICAL VALUE OF ANORECTAL MANOMETRY FOR PREDICTION OF
FECAL INCONTINENCE BEFORE ILEOSTOMY REVERSAL: A LONGITUDINAL STUDY AFTER SPHINCTER-PRESERVATION SURGERY FOR RECTAL CANCER.
M. Ihn, S. Kang, D. Kim, H. Oh and S. Lee Surgery, Seoul National
University Bundang Hospital, Seongnam-si, Republic of Korea.
Purpose: There is no report on clinical value of anorectal manometry
for the prediction of fecal incontinence before ileostomy reversal. The aim
of this study is whether anorectal manometry predicts fecal incontinence
before stoma reversal in patients who underwent sphincter-preserving surgery for rectal cancer.
Methods: Between January 1, 2005 and December 31, 2009, 105
patients who underwent ileostomy reversal after sphincter-preserving surgery for rectal cancer were analyzed. We compared the clinical and physiologic factors between consecutive 63 patients with continence or minor
incontinence (<25) and 42 patients with major fecal incontinence (≥25),
classified by Fecal Incontinence Severity Index 12 months after stoma reversal.
Results: Mean resting pressure (MRP) and mean resting vector volume
(MRVV) were lower in major fecal incontinence group compared with continence or minor incontinence group before ileostomy reversal (34.2 ± 14.3
mmHg vs. 23.3 ± 12.2 mmHg, P < 0.001; 199572 ± 199680 vs. 113089 ±
86636, P = 0.003). The other manometric parameters were similar between
before and 12 months after ileostomy reversal, except asymmetry for the
resting and squeeze sphincter. Regarding the receiver operating curve cutoffs, MRP and MRVV predicted major fecal incontinence in less than 26
mmHg and 98000, respectively (MRP, sensitivity 72.6%, specificity 62.8%,
accuracy 68.6%, P < 0.001; MMVV, sensitivity 64.5%, specificity 44.2%, accuracy 56.2%, P = 0.023). MRP showed higher sensitivity, specificity and accuracy than MRVV.
Conclusions: This study shows that anal resting pressure may be a predictor of long-term fecal incontinence before ileostomy reversal in patients
who underwent sphincter-preserving surgery for rectal cancer.
optimize ES parameters for expression of CXCL12 and CCL7 to plan future
cell based therapy.
Methods: 105 virgin female age and weight-matched Sprague Dawley
rats were randomly allocated to different groups based on stimulation
parameters. ES parameters were optimized by testing three variables: electrical current (0.25/0.50 mA), stimulation duration (30/45/60 minutes), and
time lapse (1/24/96 hours following ES). Frequency (40 Hz) and pulse duration (100ms) were held constant. Sham stimulation (SS) involved electrode
placement with no current. Anal sphincter specimens (n=3) from each combination of stimulation parameters were harvested, and CXCL12 and CCL7
gene and protein expressions were analyzed using real-time polymerase
chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA),
respectively. H&E staining was performed to characterize histological
changes following ES. The three parameters were treated as categorical
variables to assess pairwise differences in population means across groups
using Kruskal-Wallis One Way ANOVA on Ranks followed by a Dunn’s
Method post-hoc test.
Results: Both CXCL12 and CCL7 gene and protein expressions were
shown to be dependent on each of the three variables tested (p<0.001).
Specific parameter combinations were shown to significantly upregulate
gene expression for both CXCL12 (341 fold) and for CCL7(137 fold ) and protein expression for CXCL12 (10 fold) (p<0.05) (Table). Histology demonstrated leukocyte infiltration in the region of the internal and external anal
sphincter muscle following ES compared to no infiltration in SS and nonmanipulated controls.
Conclusions: ES with lower current and longer duration significantly
upregulates both gene and protein expression of CXCL12 and only gene
expression of CCL7 in the anal sphincter. Local inflammation is demonstrated after electrical stimulation of the anal sphincter in the rat model.
Gene and Protein Expression of CXCL12 and CCL7 by RT-PCR following electrical
stimulation with a combination of stimulation parameters
P215
OPTIMIZATION OF ELECTRICAL STIMULATION PARAMETERS TO
STUDY UPREGULATION OF EXPRESSION IN THE ANAL SPHINCTER OF
A RAT MODEL.
L. Sun1, J. Yeh4, M. Kuang2, M. Penn3, M. Damaser2 and M. Zutshi1
1
Department of Colorectal Surgery, Cleveland Clinic Foundation,
Cleveland, OH, 2Biomedical Engineering, Cleveland Clinic Foundation,
Cleveland, OH, 3Summa Cardiovascular Institute, Summa Cardiovascular
Institute, Akron, OH and 4Department of Gynecology and Obstetrics,
Cleveland Clinic Foundation, Cleveland, OH.
Purpose: We have previously demonstrated that electrical stimulation
(ES) of the anal sphincter significantly upregulates homing cytokines of
mesenchymal stem cells (MSC), namely Stromal Derived Factor 1 (CXCL12)
and Monocyte Chemotactic Protein 3 (CCL7). The aim of this study was to
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P216
LONG-TERM PATIENT SATISFACTION AND SEXUAL FUNCTION AFTER
STAPLED TRANSANAL RECTAL RESECTION.
A. McClure1, M. Ferrara2, A. Ferrara1, M. Parker2, J. Gallagher1, G. Guiulfo1,
K. Lopiano3, P. Williamson1 and S. Dejesus1 1Colon and Rectal Clinic of
Orlando, Orlando, FL, 2Alabama Colon and Rectal Institute, Birmingham,
AL and 3Statistical and Applied Mathematical Sciences Institute (SAMSI),
Research Triangle Park, NC.
Purpose: The purpose of this study was to assess the long term clinical
outcomes of patients undergoing the STARR procedure, specifically with
regards to sexual function, sexual satisfaction, overall satisfaction, and postoperative obstructed defecation scores (ODS).
Methods: A retrospective review of 224 patients over the past 10 years
who underwent the STARR procedure at two institutions was performed.
Sexual and overall satisfaction, along with post-operative obstructed defecation scores (ODS), were measured by follow up telephone questionnaires.
The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire
(PISQ-IR), a validated scale, was used to assess sexual satisfaction and function, while a score ranging from “not satisfied” to “completely satisfied” was
used to assess overall satisfaction with the procedure.
Results: Of the 224 patients who underwent the STARR procedure, 75
completed the survey (33%). The average age was 56 in both the sexually
active (SA) and non-sexually active (NSA) group (p=0.9). The post-op ODS
scores in the SA and NSA groups were 7.75 and 5.85, respectively (p=0.13).
The sexual satisfaction of the SA and NSA groups were 2.07 and 2.47,
respectively (p=0.08). The overall satisfaction with the procedure was 3.56
and 3.53 in the SA and NSA groups, respectively (p=0.95) (see Table 1).
Overall, the sexual and overall satisfaction of patients was not negatively
affected by the STARR procedure. The mean pre-operative ODS score was
16 with an average post-operative score of 6 (p=0.23). The majority of
patients (92%) experienced a decrease in the overall ODS score, with a
median decrease of 11 and a maximum decrease of 20.
Conclusions: Following the STARR procedure, ODS scores decreased
significantly. Both overall satisfaction and sexual satisfaction scores were
similar between the SA and NSA groups, showing that the STARR procedure did not negatively impact overall or sexual satisfaction, but did provide significant long term improvement of obstructed defecation.
Table 1. Sexual and Overall Satisfaction of Sexually Active and Non-Sexually
Active Patients Undergoing the STARR Procedure.
P217
SNARE EXCISION FOR LARGE RECTAL POLYPS.
J. T. Garvin and J. M. Church Colorectal Surgery, Cleveland Clinic,
Cleveland, OH.
Purpose: Options for treatment of large rectal polyps include transanal
excision, transanal snare, transanal endoscopic microsurgery, anterior resection, endoscopic submucosal dissection and snare polypectomy. The most
convenient and least expensive option, avoiding the need for anesthesia or
hospital stay, is snare polypectomy, and it has not been well studied. Here
we present a series of patients undergoing piecemeal polypectomy of large,
endoscopically benign rectal polyps.
Methods: Patients with large rectal polyps that were not frankly malignant (polyps that were soft, not fragile, not irregular or ulcerated) were
treated with colonoscopic snare. No pre-injection with adrenalin was used.
Patients and outcomes were prospectively recorded.
Results: 63 polypectomies were performed from 2002 to 2012, 49 were
office based and 14 were performed in the operating room. Mean polyp
size was 47.0mm +/- 26.6mm. Median polyp size was 40mm (range 12mm
to 150mm). 4 (6.3%) suffered postpolypectomy hemorrhage, 2 of whom
required admission. 38 of the 63 patients were followed up in the Cleveland Clinic, the remaining 25 were followed up by their referring institution.
The polyp recurred in 12 of 38 patients (31.6%) but was cleared with further polypectomy in all 12. The median number of procedures required to
clear recurrent polyps was 2. No patient developed cancer or required surgical resection. Factors significantly associated with recurrence included
larger polyp size (60.9 +/- 32.1mm versus 40 +/- 16.3mm), presence of
severe dysplasia (9/26 in the no recurrence group versus 7/12 in the recurrence group) and piecemeal resection (18/26 in recurrence free group versus 12/12 in the recurrence group) (see table).
Conclusions: Colonoscopic removal of large rectal polyps is well tolerated, safe and effective for polyps as large as 150cm. Some recurrence is
acceptable and treatable once follow-up is meticulous.
P218
ABDOMINOPERINEAL EXCISION: IS RECONSTRUCTION OF THE
DEFECT REALLY NECESSARY?
T. J. Royle, R. Pande, K. Futaba, T. Ismail and C. Keh Colorectal Surgery,
University Hospitals Birmingham NHS Foundation Trust, Birmingham,
United Kingdom.
Purpose: Cylindrical prone perineal excision (e.g. eLAPE) for low rectal
carcinoma has been shown to have lower rate of local recurrence compared
with conventional abdomino-perineal excision (APE). However currently a
number of reconstructive techniques are performed to prevent perineal
hernia following cylindrical excision. The aim of this study was to evaluate
outcomes of APEs performed at a large Tertiary Referral Centre focusing on
perineal complications following various reconstructive techniques and
conventional primary closure.
Methods: A retrospective analysis of patients undergoing APE between
April 2008 and May 2013 was performed. Electronic patient records were
interrogated to identify operation type, reconstructive technique and perineal wound complications. Herniae were identified from follow-up clinical
letters and CT reports.
Results: 69 patients underwent APE (40 male, median age 67 years (2987). 58 procedures were for adenocarcinoma, 4 for squamous cell carcinoma, 5 for melanoma and 1 carcinoid. The abdominal part was completed
laparoscopically in 11 cases, 7 cases were converted to open. Prone perineal excision was performed in 35 patients with perineal reconstruction in
29 (25 mesh, 4 myocutaneous flaps). Of the 40 patients who underwent
simple primary closure, the perineal hernia rate was 20.7% compared to
3.4% in the reconstructed group (p=0.068). However the majority of perineal hernias did not appear to cause significant symptoms. Complications
from perineal hernia e.g. small bowel obstruction requiring re-operation
only occurred in 2 patients, both in the non-reconstructed group. Delayed
wound healing was similar in all subgroups (23% overall), 75% having
undergone neo-adjuvant radiotherapy.
Conclusions: Although this represents a relatively large series from a
single Insitution, the numbers are too small for meaningful comparison of
subgroups. However, despite a much higher rate of perineal hernia in the
non-reconstructed group, complication rate was very low. A large Randomised Trial is needed to establish the most appropriate closure technique
following APE.
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P219
P220
A PROSPECTIVE, MULTICENTER CLINICAL TRIAL OF EXTRALEVATOR
ABDOMINOPERINEAL EXCISION FOR LOCALLY ADVANCED LOW RECTAL CANCER.
Z. Wang1, J. Han1, Q. Qian2, Y. Dai3, Z. Zhang4, J. Yang5, F. Li6, X. Li7, Z. Gao1
and Y. Du1 1General Surgery, Beijing Chaoyang Hospital, Capital Medical
Univerisity, Beijing, China, 2General Surgery, Zhongnan Hospital of Wuhan
University, Wuhan, China, 3General Surgery, Qilu Hospital of Shangdong
University, Jinan, China, 4General Surgery, The first Hospital of Huairou,
Beijing, China, 5General Surgery, The People’s Hospital of Daxing, Beijing,
China, 6General Surgery, Xuanwu Hospital, Capital Medical University,
Beijing, China and 7General Surgery, Luhe Hospital, Capital Medical
University, Beijing, China.
THE ANALYSIS OF PREDICTOR FOR PATHOLOGIC COMPLETE
RESPONSE IN RECTAL CANCER PATIENTS WHO RECEIVED PREOPERATIVE CHEMORADIATION THERAPY FOLLOWED BY TOTAL MESORECTAL EXCISION.
Y. Han, M. Cho, S. Baek, H. Hur, B. Min, S. Baik and N. Kim Department of
Surgery, Yonsei University College of Medicine, Seoul, Democratic People’s
Republic of Korea.
Purpose: To demonstrate the feasibility of extralevator abdominoperineal excision (ELAPE) for locally advanced low cancer in China.
Methods: A prospective multicenter clinical trial was carried out by
seven general hospitals across China from August 2008 to October 2011. A
total of 102 patients (60 men and 42 women) underwent ELAPE for primary
locally advanced low rectal cancer. The patients’ characteristics, complications and prognosis were recorded.
Results: All patients underwent the ELAPE procedure successfully. The
median operating time was 180 (110~495) min and median Intraoperative
blood loss was 200 (50~1000) ml. The rates of sexual dysfunction, perineal
complications, urinary retention, and chronic perineal pain were 40.5%,
23.5%, 18.6% and 13.7%, respectively. Chronic perineal pain was associated
with coccygectomy (12 months postoperatively, t=8.06, P<0.001), and the
pain might gradually ease over time. Reconstruction of pelvic floor with
biologic mesh was associated with lower rate of perineal dehiscence
(χ2=13.502, P=0.006) and overall perineal wound complications (χ2=5.836,
P=0.016) compared with primary closure. A positive circumferential margin
(CRM) was demonstrated in 6 (5.9%) patients, and intraoperative perforations occurred in 4 (3.9%) patients. All CRM involvement and intraoperative
perforation located at anteriorly and anterolaterally. The local recurrence
was 4.9% at a median follow-up of 35 months (range, 18-58 months).
Conclusions: ELAPE performed in the prone position for low rectal cancer leads to a reduction in CRM involvement, intraoperative perforations,
and local recurrence, but it might result in a little high rate of perineal
wound related complications. Reconstruction of pelvic floor with biologic
mesh might lower the rate of perineal wound complications.
Table 1 Postoperative complications in relationship to perineal reconstruction
techniques and coccygectomy.
Purpose: AS PREOPERATIVE CHEMORADIATION THERAPY (CRT)
ACCEPTED ONE OF THE STANDARD TREATMENT OF LOCALLY ADVANCED
RECTAL CANCER, INTEREST IN PATHOLOGIC COMPLETE RESPONSE (PCR)
HAS BEEN INCREASED. THIS STUDY AIMED TO ANALYZE CLINICAL FACTORS
AFFECTING PATHOLOGIC COMPLETE RESPONSE IN RECTAL CANCER
PATIENTS AFTER CHEMORADIATION THERAPY FOLLOWED RADICAL SURGERY
Methods: FROM JANUARY 1989 TO DECEMBER 2012, WE PERFORMED
A RETROSPECTIVE REVIEW OF PROSPECTIVELY-COLLECTED RECORDS FROM
THE DATABASE OF THE DEPARTMENT OF SURGERY, YONSEI UNIVERSITY
HEALTH SYSTEM, SEOUL, KOREA, TO INVESTIGATE PROGNOSTIC FACTORS
FOR PATHOLOGIC COMPLETE RESPONSE IN RECTAL CANCER PATIENTS WHO
UNDERWENT PREOPERATIVE CHEMORADIATION THERAPY FOLLOWED BY
TOTAL MESORECTAL EXCISION. PATIENTS WERE CATEGORIZED INTO THE
TWO GROUPS ACCORDING TO PATHOLOGIC TNM STAGING: PCR GROUP
VERSUS NON-PCR GROUP.
Results: A TOTAL OF 477 PATIENTS (N = 94 PCR GROUP, N= 383 NONPCR GROUP) WERE ASSESSED. THE MEAN PRE-CRT CEA WAS SIGNIFICANTLY
HIGHER IN NON-PCR GROUP (4.31 ± 7.19 NG/ML PCR GROUP VS. 12.22 ±
36.69 NG/ML NON-PCR GROUP, P = 0.042). LOWER TUMOR LEVEL (HR 1.784
95% CI 1.065-2.990, P = 0.028), HISTOLOGY (G1/G2) (HR 2.671 95% CI 1.0916.539, P = 0.031) AND PRE-CRT CEA LEVEL ( ≤ 5.0 NG/ML, P = 0.009) WERE
FOUND TO BE INDEPENDENT PROGNOSTIC FACTORS FOR PCR IN MULTIVARIATE ANALYSIS.
Conclusions: WE DEMONSTRATED A SIGNIFICANT ASSOCIATION
BETWEEN LOWER TUMOR LEVEL ( < 5.0CM), HISTOLOGY (G1/G2), PRE-CRT
CEA LEVEL (≤ 5.0 NG/ML) AND PATHOLOGIC COMPLETE RESPONSE. IT MAY
BE IMPORTANT DETERMINANTS IN ACHIEVING A PATHOLOGIC COMPLETE
RESPONSE. HOWEVER, FURTHER STUDIES ARE MANDATORY TO EVALUATE
THE IMPACT ON THE PREDICTIVE VALUE OF THESE FACTORS FOR PATHOLOGIC COMPLETE RESPONSE IN RECTAL CANCER
P221
THE IMPACT OF HIV STATUS ON HEALING AFTER CONDYLOMA SURGERY.
J. Coralic1, N. Mantilla2, J. Blumetti1, J. Harrison1, V. Chaudhry1, J. Cintron1
and H. Abcarian1 1Colon and Rectal Surgery, Stroger Cook County
Hospital, Chicago, IL and 2Colon and Rectal Surgery, University of Illinois
at Chicago, Chicago, IL.
Purpose: Anorectal surgery in Human immunodeficiency virus (HIV)
infected patients has undergone many changes since the 1980s. The evolution to treat HIV infected and non-infected patients in a similar manner
began with the introduction of highly active antiretroviral therapy (HAART)
and arbitrary selection of CD4 count to be above 200. However, question
of difference in healing time in anorectal surgery in regards to HIV status as
well as in regards to the CD4 count, viral load and HAART medications in
HIV patients, still remains to be answered. Our study focuses on condyloma
surgery attempting to answer those questions.
Methods: A retrospective study of patients who presented with condyloma to a tertiary care County Hospital was reviewed from 2008 to 2012.
All patients with condyloma were treated with excision and fulguration by
a board certified colon and rectal surgeon. Data was collected on demographics, HIV status (viral load, CD4 count, HAART), and healing status
within one month postoperatively. Statistical analysis was performed using
SPSS (Version 22.0; IBM Corporation, Armonk, NY).
119
Abstracts
patients followed via a telephone call. This may reflect complexity of fistula
and multiple procedures done to achieve healing and should be discussed
with patients.
Results: There were 177 patients with the mean age of 33 (range 1760). 166 (93.8%) were men and the most common race was African American (71.8%), followed by Caucasian (20.3%), Hispanic (4.5%) and other
(3.4%). 66.1% of the patients were HIV-positive, 31.6% were negative and
2.3% of unknown status. Healing status at one month postoperatively was
not impacted by HIV status and for the HIV positive patients, by CD4 count,
viral load, or whether they were on HAART or not (Table 1).
Conclusions: Our study shows no difference in healing time after
condyloma surgery in regards to patients’ HIV status, severity of HIV disease, or HAART, indicating that there might be other factors influencing
healing in this specific group of patients. In addition, our study suggests
that there is no reason to defer surgery in HIV patients regardless of the
status of their disease. Furthermore, we show an important increased incidence of the disease in young African American men, which does not correspond with the demographics of the patient population in our institution, indicating that more awareness and education is needed in this
specific group of patients.
Outcomes of fistula based on anatomy and surgical procedure
Table 1: Healing status within one month after condyloma surgery
RAF=Rectal advancement flap, LIFT= Ligation of interspincteric tract, FI=
Fecal incontinence
P223
EFFECT OF TRICLOSAN COATED SUTURES ON SURGICAL SITE INFECTION RATE IN PILONIDAL SINUS DISEASE: SINGLE-BLINDED RANDOMIZED TRIAL.
N. Arslan1, C. Terzi1, G. Atasoy1, T. Altintas1, A. Sirin1, M. Haciyanli2 and
A. Canda1 1Department of General Surgery, Dokuz Eylul University, Izmir,
Turkey and 2Department of General surgery, Ataturk Training and Research
Hospital, Izmir, Turkey.
P222
TREATING COMPLEX ANAL FISTULA IS NOT WITHOUT RISKS.
S. Bibi, B. Gurland, T. Hull and M. Zutshi Colorectal Surgery, Cleveland
Clinic Foundation, Cleveland, OH.
Purpose: Complex fistula-in-ano are often treated with rectal advancement flap (RAF) or ligation of intersphincteric tract (LIFT). Concerns remain
about postoperative continence and long term healing. The aim was to
asses healing rate, incidence of incontinence and patient satisfaction after
RAF or LIFT for complex fistula-in-ano.
Methods: Retrospective review of patients treated for complex fistula
in ano with either RAF or LIFT procedure between 2005 and 2012. Fistulas
associated with underlying disease or rectovaginal fistulas were excluded.
Data on demographics, fistula anatomy, surgery and healing were gathered
by electronic medical records. A follow up phone call was made to asses
healing, pain and fecal incontinence (FI) via a questionnaire.
Results: 64 patients M:F (45:19) with mean age of 47 were evaluated.
Follow up was done at median of 13 months (range 1-48) after surgery. Procedures were classified as RAF in 51(80%) and LIFT in 13(20%) patients. 58
patients had a prior seton. Primary healing occurred in 33/51 (61%) after
RAF. Fourteen patients under went further treatment, 4 healed after second RAF and 1 patient each healed after LIFT and fistulotomy. Primary healing occurred in 7/13 (46%) after LIFT. Five under went further treatment, 1
patient healed after a second LIFT procedure, 1 patient each, healed after
RAF and fistulotomy. Overall healing rate (primary and recurrent) for RAF
repair was 72% (39/51) and for LIFT was 76% (10/13). 37/64 patients were
reached via the telephone. Mean pain score was 1/10. Postop FI was
reported by 35% (13/37). Incontinence for flatus was reported in 2 (1 RAF, 1
LIFT), solid stool in 10 (8 RAF, 2 LIFT), and liquid stool in 1(1 RAF). Mean
number of previous surgeries for anal fistula including seton were 2.5 in
patients who reported FI. 31/ 37 (84%) patients were happy with the results
of their surgery. Out of 6 unhappy patients, 4 had unhealed fistula and 2
achieved healing after multiple procedures.
Conclusions: Surgery for complex fistula has an acceptable healing
rate; however in this study fecal incontinence occurs in about 1/3 of
Purpose: In vivo and in vitro studies have shown that triclosan coated
sutures (TCS) may decrease bacterial colonization in surgical site, but the
efficacy of TCS remains controversial. Several studies including two metaanalyses have reported different results in terms of the incidence of surgical site infections (SSI) between triclosan-coated and uncoated suture
groups. In this study we aimed to investigate the effect of TCS on SSI in
pilonidal sinus disease.
Methods: Between January 2010 and January 2013, 177 patients with
primary pilonidal sinus disease were randomized into 2 groups: TCS group
(n=86) and control group (n=91). All patients underwent excision and primary closure, drain was not used. In TCS group triclosan-coated polydioxanone anti- microbial suture (PDS Plus, Ethicon) was used as retention
sutures, triclosan-coated polyglactin 910 antimicrobial suture (Vicryl Plus,
Ethicon) was used for closing subcutaneous tissue and triclosan-coated
poliglecaprone 25 antimicrobial suture (Monocryl Plus; Ethicon) was used
for skin closure. In control group monofilament polypropylene 1/0 (Prolene,
Ethicon), polyglactin 3/0 (Vicryl, Ethicon) and monofilament polypropylene
3/0 (Prolene, Ethicon) sutures were used for retention suture, subcutaneous
tissue and skin closure respectively. Patients were followed up postoperative 30 days for SSI and 1 year for healing of pilonidal disease by a surgeon
blinded to randomization.
Results: Demographic, clinical and surgical features were similar
between groups. Overall SSI rate was 14.7% (n=26). SSI rate in triclosan and
control groups were 9.3% (n=8) and 19.8% (n=18), respectively (p=0.039).
Overall seroma rate was %16.9 (n=30). Seroma rate in triclosan group was
significantly higher than control group (23.3% vs 11%, p=0.030). In 1 year
follow-up, primary healing rates were 80.2% and 76.9% in TCS and control
groups, respectively (p=0.592).
Conclusions: In our study, TCS demonstrated a significant beneficial
effect in the prevention of SSI after surgery for pilonidal disease. Larger
series and multicentric randomized controlled trials are needed to decide
the efficacy of TRCs on SSI.
120
Abstracts
P224
SURGICAL MANAGEMENT OF RADIATION-INDUCED RECTOVAGINAL
FISTULA: A SINGLE-INSTITUTION EXPERIENCE.
Q. Zhong, T. Ma, Q. Qin, H. Wang, J. Wang and L. Wang Department of
Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University,
Guangzhou, Guangdong, China, Guangzhou, China.
Purpose: Radiation-induced rectovaginal fistula (RVF) can severely
affect quality of life. However, its management remains controversial, particularly due to the lack of data after the application of modern surgical
techniques. The aim of this study was to review our initial experience with
treatment of radiation-induced RVF, focusing on the quality of life and clinical outcomes of patients having resection procedures.
Methods: This study is a retrospective review of all patients who underwent surgery for radiation-induced RVF from our institution between July
2007 and October 2013. Data collected included demographics, cause, procedure type, presentation, operative details, morbidity, and evaluations at
each follow-up. Telephone follow-up was conducted to evaluate symptom
relief and EORTC QLQ-C30 scores.
Results: 23 female patients treated for radiation-induced RVF were
included. Fecal diversion alone was performed in 14 patients (61%), while
resection and anastomosis, with diversion was performed in 9 patients
(39%). The mean follow-up was 26.6 months (3-44) for diversion alone
group and 12.3 months (3-59) for resection group. For the resection group,
one patient (11%) required a surgical procedure for retrorectal abscess due
to anastomotic leakage (AL) and another two (22%) needed watchful waiting for asymptomatic AL. Four patients (44%) required anastomotic dilatation for anastomotic stricture. There were no instances of recurrence of
hemorrhage, fistulas, perineal pain or tenesmus. Based on the QLQ-C30,
both groups had significantly improvement in global health, physical and
role functional domains, fatigue and pain symptomatic domains. Mean
investigator’s satisfaction score was 2.3(14/14) for diversion alone group
and 3.0 (9/9) for the resection group 6 months postoperatively; 1.9(12/14)
and 1.25 (5/9) 12 months postoperatively (1: very satisfied, 2: satisfied, 3:
moderately satisfied, 4: dissatisfied, 5: very dissatisfied).
Conclusions: For select cases of radiation-induced RVF (Such as the
absence of metastatic disease of their primary tumor, less medical comorbidities and younger age), resection and anastomosis procedure is a valuable and safe option that seems to improve patients’ quality of life.
P225
THREE DIMENSIONAL ENDOANAL ULTRASOUND FOR THE DIAGNOSIS OF PERIANAL FISTULAS.
M. Garcés Albir, S. A. Garcia Botello, A. Espí Macias, V. Pla Martí, D. Moro,
J. Martin Arevalo, A. Sanahuja and J. Ortega Serrano Colorectal Unit,
Department of General and Digestive Surgery, Hospital Clinico
Universitario, Valencia, Spain.
Purpose: 3D-EAUS is considered a valuable tool for diagnosing certain
anorectal conditions and giving additional information to that obtained
through 2D-EAUS. The objective of this study is to evaluate the accuracy of
3D-EAUS as compared to 2D-EAUS and physical examination (PE) in the
diagnosis of perianal fistulas and correlate these three techniques with the
intraoperative findings.
Methods: A prospective observational, consecutive study was carried
out between December 2008 and December 2010. PE, 2DEAUS and 3DEAUS
was performed by the same colorectal surgeon at the outpatient clinic prior
to surgery. The results of the different examinations were compared to the
intraoperative findings. Data regarding location of the internal opening (IO),
primary tract, secondary tract, and the presence of abscesses or cavities
were analyzed.
Results: 70 patients with a median age of 47 years (range 21-77), 51
male were included. The low transphincteric fistulas were the most frequent
type (33, 47.1%) followed by high transphincteric (24, 34.3%) and finally
intersphincteric fistulas (13, 18.6%). Table 1 shows the results of the con-
cordance between the different diagnostic techniques and the intraoperative findings. The COR curves for the diagnosis of transphincteric fistulas
show that both ultrasound techniques are adequate for the diagnosis of
low transphincteric fistulas, 3D-EAUS is superior for the diagnosis of high
transphincteric fistulas and PE is weak for the diagnosis of both types.
Conclusions: 3D-EAUS shows a higher accuracy than 2D-EAUS for
assessing the height of the primary tract in transphincteric fistulas. Both
techniques show a good concordance with the examination under anesthesia for the diagnosis of primary tracts. However, 3D-EAUS is somewhat
superior.
Concordance grade and Kappa coefficient (K) between the intraoperative
findings and the different diagnostic technqieus used.
K<0: no agreement; k=0: concordance due to chance; k=0-0.19: insignificant;
k=0.2-0.39:low; k=0.4-0.59: moderate; k=0.6-0.79: good; k=0.8-0.1: very good.
*p>0.05
P226
EFFECTIVENESS OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION FOR CHRONIC ANAL FISSURE. A PILOT STUDY.
J. A. Villanueva-Herrero, S. U. Perez-Escobedo, L. M. Castro-Vigil, L. RojasMondragón, Y. L. Alarcon-Bernes and B. Jimenez-Bobadilla
Coloproctology Unit, Hospital General de Mexico, Mexico City, Mexico.
Purpose: Although there are many nonoperative treatments for chronic
anal fissures, partial lateral internal sphincterotomy remains the treatment
of choice for refractory fissures. Recently neurostimulation was used as an
alternative treatment option for this disease. This pilot study was designed
to investigate the safety and effectiveness of transcutaneous electrical
nerve stimulation (TENS) in the treatment of anal fissures.
Methods: Anal ultrasonography and anal manometry were performed
before and after treatment. Patients were treated with a nerve stimulator
(Durtech 1200 Durtech System Corp). Carbon electrodes were placed over
each ischiorectal fossae with 2 different programs for 30 minutes per day, 2
times per week during 6 weeks.
Results: Six female patients with a single posterior fissure were included
in the study. The mean age was 44.8 (SD 5.3) years, 3 patients suffered from
constipation, 2 of them had anismus during the manometry. The length of
clinical history of the fissure was more than 15 months in 5 patients and
the anal fissure was associated with sentinel pile in the 6 patients. Five
patients were without bleeding after the second session and without pain
after the sixth session. One patient persist with symptoms after the sixth
session, she underwent lateral internal sphincterotomy before a 7th session of TENS. The fissure was completely heal in 4 patients at week 6. We
have no complications and 2 patients report minor headaches during the
first two weeks after the procedure. The mean resting anal pressure (MRAP)
of the overall series was 94.7 mm Hg, with criteria of anal hypertonia in
100% of them. After the treatment the overall MRAP was 74.8 mmHg. Anal
manometry before and after the procedure showed a significant reduction
in MRAP (p minor 0.05), We did not have continence disturbances in our
patients.
Conclusions: These results suggests that TENS is an effective, safe and
easy conservative procedure comparable to other nonoperative therapies
which decreases anal resting pressure and achieves good symptom control
in a short period of time. Further investigation of the effect of TENS on anal
fissure are needed to confirm these encouraging results.
121
Abstracts
P228
NONSURGICAL MANAGEMENT OF CHRONIC FISSURE-IN-ANO WITH
HIGH SUCCESS RATE: A SIMPLE NOVEL CONCEPT IN THE TREATMENT
OF CHRONIC FISSURE-IN-ANO.
P. Garg1 and P. Lakhtaria2 1G.Surgery, Indus Super Specialty Hospital,
Mohali, India and 2General Surgery, NEW YORK HOSPITAL OF MEDICAL
CENTER OF QUEENS, New York, NY.
P227
INTRAOPERATIVE PUS SWAB CULTURES FOR PERIANAL ABSCESSES
SHOULD BE ABANDONED.
I. Seow-En, J. Ngu, C. Chong and S. Tan General Surgery, Changi General
Hospital, Singapore, Singapore.
Purpose: Routine swab cultures for perianal abscesses remain commonplace in surgical practice. However, after surgery patients are often discharged prior to the culture results being made available. Consequently,
intraoperative swab cultures rarely impact subsequent treatment and outcomes. We aim to show that routine swab cultures are unnecessary in the
management of perianal abscesses.
Methods: The electronic records and case notes of all patients admitted to our institution for the diagnosis of perianal abscess from January
2011 to December 2011 were reviewed. After exclusion of patients with
recurrent or complicated perianal abscesses, the medical records and postoperative progress of patients were analysed. The use of intraoperative
swab cultures, microbiological results, and prescription of post-operative
antibiotics were also recorded.
Results: Out of 207 patients admitted for perianal abscess, 172 were
included in our study. Of these, 137 patients had swab cultures taken intraoperatively and 108 were discharged with a course of outpatient antibiotics. The majority of patients were discharged prior to culture results being
made available. During initial admission and subsequent outpatient followup, most of these swab culture results were not documented to be noted
by the attending physicians. Wound healing was uneventful for most
patients, and the use of postoperative antibiotics did not make any statistical difference in outcome.
Conclusions: Routine swab cultures for perianal abscesses should be
abandoned. They do not alter postoperative management, and potentially
add to rising healthcare cost.
Purpose: The reason for initiation of a fissure in acute fissure-in-ano and
the persistence of the same in Chronic Anal Fissure (CAF) is repeated shearing trauma, most commonly due to constipation (hard fecolith). In chronic
cases, superimposed subclinical infection in the lesion also adds to the
symptoms. So logically, if we remove the subclinical infection by giving a
short course of antibiotic and strictly avoid constipation (recurrent episodic
shearing trauma) for 6 months, the fissure should heal. However, this may
not be effective in cases where the fissure has already deepened sufficiently
to form a fissure-sinus or a fissure-fistula.
Methods: Patients suffering from chronic anal fissure (CAF) were
recruited prospectively. Anal tone was assessed clinically on an objective
scale and patients categorized as CAF with normal anal tone (CAF-NT) &
CAF with high anal tone (CAF-HT/ acute on chronic fissure). Antibiotics –
Ciprofloxacin-500 mg & Ornidazole-500mg, was given twice daily for 7 days.
Along with this, a strict regimen of 30 grams Ispaghula husk (Psyllium fiber)
6 tsf was prescribed to be taken with at least 600 ml of water. One tsf of
Liquid paraffin was added to the patients with severe constipation. Diltiazem cream three times a day and sitz bath were additionally prescribed
for the patients with high anal tone. Patients were assessed at weekly intervals. Those who didn’t respond in 2 weeks underwent a MRI to look for signs
of fissure deepening (sinus or fistula).
Results: 50 patients (M/F- 29/21) were recruited over a period of 14
months. Mean age was 37.3 ± 11.8 years. On conservative management, fissure healed in 38/49 (78%), 5/49 (10%) had no/minimal relief and MRI
revealed a fissure sinus/tract in these. Four out of these underwent surgery
(laying open of the sinus). Six (12%) patients had episodic recurrence of
symptoms which started after they had an episode of constipation (passage of hard stools).
Conclusions: Conservative management- a short course of antibiotics
and strict avoidance of hard stools- is an effective way to treat chronic fissure-in-ano. Long term studies are needed to substantiate these findings.
CHRONIC ANAL FISSURE (CAF)- CONSERVATIVE MANAGEMENT
CAF- Chronic Anal Fissure
Median Follow-up - 8 months
Lost to follow up- 1 patient
Definition of CONSERVATIVE MANAGEMENT- Antibiotics for 7 Days + Strict
avoidance of constipation (Passage of hard fecolith)for the next 6 months
122
Abstracts
had the addition of fibrin glue with the ERAF (30%). The addition of fibrin
glue did not improve results in patients with IBD.
Conclusions: The addition of fibrin glue to endorectal advancement
flaps seems to improve results in patients with transsphincteric fistulas who
do not have inflammatory bowel disease.
P229
IMPACT OF CT SCAN IN THE EVALUATION OF ACUTE ANORECTAL
ABSCESS: ARE WE OVERDOING IT?
K. G. Cologne, K. Chouliaras, L. Calcote, G. T. Ault, A. M. Kaiser and
A. E. Ortega Surgery, Division of Colorectal, University of Southern
California Keck School of Medicine, Los Angeles, CA.
Purpose: Acute anorectal infections are a common reason for presentation to an emergency room. The need for CT scan imaging in the evaluation of these patients is unknown and perhaps overutilized.
Methods: Our administrative database was queried for anorectal
abscess in fiscal years 2011 and 2012. Records were cross-referenced in the
radiology database for undergoing CT scan during the same period. Medical records were retrospectively reviewed. Known disease-specific infections (such as Crohn’s) were excluded. Each case was evaluated by a colorectal specialist for appropriateness of adjunctive imaging, type of
infection identified, and overall clinical utility of the information obtained
from the CT scan.
Results: Thirty-one cases fulfilled the inclusion criteria query, of 1022
patient visits with anorectal abscess (ICD-9 code 566). After review, the
listed indication for adjunctive CT scan was considered appropriate (38%),
indeterminate (52%), and inappropriate (10%). Two cases had normal imaging studies and five had alternate diagnoses discovered. The remaining 24
cases of cryptoglandular origin were classified as perianal (50%), ischioanal
(17%), intersphincteric (13%), submucosal (4%), and supralevator (21%). CT
scan confirmed isolated anatomic involvement of a single anatomic space
in 29% of patients. The majority (71%) had multiple space infections and/or
fistulous trajectories. The overall clinical utility of imaging was considered
marginal (23%), potentially significant (32%), or highly significant (45%) by
the evaluating surgeon. Adjunctive imaging in cases with signs of sepsis
but a paucity of clinical findings (n=11) was considered highly significant in
10/11 cases and potentially significant in 1/11 patients.
Conclusions: Adjunctive imaging with CT scan is potentially useful for
the evaluation of acute anorectal abscess, especially in cases where a
paucity of physical findings exist. Patients with complex infections, supralevator extension, and multiple space infections derive the most benefit from
CT scan, though it is difficult to identify these patients based on clinical
grounds alone.
P230
ENDORECTAL ADVANCMENT FLAPS WITH FIBRIN GLUE: A USEFUL
TREATMENT FOR TRANSSPHINCTERIC FISTULAS IN PATIENTS WITHOUT INFLAMMATORY BOWEL DISEASE.
A. McClure, A. Ferrara, J. Gallagher, A. Syski, W. Strutt, P. Williamson and
S. Dejesus Colon and Rectal Clinic of Orlando, Orlando, FL.
Purpose: The purpose of this study was to evaluate the outcomes of
endorectal advancement flaps (ERAF) with and without the use of fibrin
glue, in the treatment of transsphincteric fistulas in patients with and without inflammatory bowel disease (IBD).
Methods: A retrospective review was conducted of all patients who had
undergone an ERAF from 2008-2013 at a single institution. The patients
were divided by those that had fibrin glue injected into the external opening of the fistula at the time of surgery (ERAF+FG) and those who had not
(ERAF). The patients were randomly assigned to one or the other treatments
according to different surgeon preference. Data points included recurrence,
complications, location of fistula, previous anorectal surgery, inflammatory
bowel disease (IBD), and reoperation rate.
Results: A total of 55 patients were included in the study, 29 who
underwent ERAF (53%) and 26 who underwent ERAF +FG (47%). Median
follow up was 8 months in the ERAF group (1-43months) and 3.5 months
(1-32 months) in the ERAF +FG group. In the ERAF group, 13/29 (45%) had
recurrences, while in the ERAF+FG group, 9/26 (35%) had recurrences (see
Table 1). The lowest recurrence rate was found in the non-IBD patients that
Table 1. Recurrences overall and in the IBD and non IBD group.
P231
THREE-DIMENSIONAL ENDOANAL ULTRASOUND ASSESSMENT OF
PERIANAL FISTULA AND FISTULOTOMY. A COMPARISON WITH PREOPERATIVE FINDINGS.
M. Garcés Albir, S. A. Garcia Botello, A. Espí Macias, J. Martin Arevalo,
V. Pla Marti, D. Moro, A. Sanahuja and J. Ortega Serrano Colorectal Unit,
Department of General and Digestive Surgery, Hospital Clinico
Universitario, Valencia, Spain.
Purpose: Fistulotomy is the most frequently used technique for the
treatment of low or simple perianal fistula. The introduction of 3DEAUS to
assess perianal pathology allows quantitative measures of the amount of
sphincter involved pre and post-operatively. The objective of this study is
to quantify the extent of sphincter involvement preoperatively and compare these results with sphincter division assesses with 3DEAUS postoperatively.
Methods: Patients with a simple perianal fistula due to undergo fistulotomy were included consecutively in a prospective observational study
between December 2008 and December 2010. All patients had 3D-EAUS
pre-operatively and 8 weeks after surgery by the same colorectal surgeon.
Quantitative measurements were taken of the External Anal Sphincter
(EAS), Internal Anal Sphincter (IAS), of the length of sphincter the fistula
crossed preoperatively and the length of sphincter divided postoperatively.
Results: 49 patients underwent fistulotomy, 37 male and 12 female with
a median age of 49 years (range 21-77 ). Pre and postoperative 3D EAUS
measurements of the IAS and EAS are shown in Table 1. There is a strong
correlation between the preoperative length of sphincter involvement and
the postoperative 3D-EAUS fistulotomy measurement with no significant
differences between pre and postoperative measurements (Spearman’s correlation, IAS Rho=0.639; EAE Rho=0.633, p<0.001).
Conclusions: 3D- EAUS is a valuable tool for quantifying the extent of
sphincter involvement pre and postoperatively giving objective and quantitiative measurements. The exact percentage of involved sphincter by the
fistula can be defined and the amount divided during fistulotomy can be
checked, confirming that only the absolute necessary amount of sphincter
has been divided. The strong correlation between 3D – EAUS and intraoperative measurements validates the technique.
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Abstracts
3D-EAUS measurements of preoperative sphincter involvement and
postoperative sphincter division after fistulotomy (a) percentage (b) absolute
numbers
a: Median % (range); p>0.05
b: Median mm. (range); p>0.05
P232
THE PRIMARY SUTURE REPAIR AFTER PILONIDAL SINUS EXCISION
USING RUBBER TUBE.
S. Lee Department of Surgery, Korea University College of Medicine, Seoul,
Republic of Korea.
Purpose: The wound closure for pilonidal sinus excision is difficult and
a few methods had been suggested including flap reconstruction. We
developed new technique for preventing wound dehiscence using rubber
tubes without flap.
Methods: On prone position under spinal anesthesia, the lesion was
excised completely. The non-absorbable monfilament (Nylon) was applied
interruptedly along the wound as full thickness without tie ligation and a
closed suction drain was applied. Fat and subcutaneous tissue were closed
with multiple absorbable interreupted sutures. After applying rubber tubes
under the Nylon sutures, it was tied loosely as vertical mattress fashion. The
closed suction drain was removed 3rd to 7th postoperative day and the
suture was removed at 10th to 14th postoperative day.
Results: From 2010 to 2013 6 patients had received wide excision for
pilonidal sinus including one recurrent patient who received operation in
other hospital. One patient developed minimal inflammation on 14th postoperative day which had improved at 21st postoperative day. All other
patients were recovered successfully without dehiscence.
Conclusions: Primary closure with rubber tubes is a feasible and an
effective method for pilonidal sinus operation
P233
HEMORROIDHAL DISEASE AND DEFECATORY HABITS DURING PREGNANCY: ARE THERE ANY DIFFERENCES BETWEEN THE FIRST AND
THIRD TRIMESTERS?
D. Parés1, E. Martinez-Franco2, N. Lorente2, M. Moneta1, L. Estalella1,
H. Vallverdú1, J. Lopez-Negre1, J. Urgelles1, J. Viguer2 and J. Méndez2
1
General and Digestive Surgery, Universitat de Barcelona. Parc Sanitari
Sant Joan de Deu, Sant Boi de Llobregat (Barcelona), Spain and
2
Ginaecology and Obstetrics Department, Universitat de Barcelona. Parc
Sanitari Sant Joan de Deu, Sant Boi de Llobregat (Barcelona), Spain.
Purpose: Pregnancy has been described as a risk factor for haemorrhoidal disease (HD) with a reported prevalence of up to 25% in this population. The possible mechanisms of HD in pregnancy include increased
intra-abdominal pressure and disturbances in bowel habits. Consequently,
there is widespread belief that HD is more common in the third trimester.
However, there is a lack of comparative studies providing detailed description of the clinical characteristics of patients with HD during these two periods. The aims of the present study were to analyze the prevalence of HD in
pregnant women and to study the clinical characteristics of this disorder. In
addition, bowel habits, including stool consistency, were prospectively
investigated.
Methods: A prospective observational study was conducted. All pregnant women attending our hospital (Group 1 = less than 13 weeks of pregnancy) and third trimester (Group 2= up to 28 weeks of pregnancy) were
eligible for inclusion. All included women completed a self-reported questionnaire. Main variables: biodemographic data, Body Mass Index (BMI),
presence of symptomatic HD, HD symptoms, and bowel habits including
stool consistency. To evaluate stool consistency,Bristol Stool Form Scale
(BSFS) was used. BSFS comprises a simple visual chart accompanied by a
text description that classifies stools in 7 forms.
Results: During study period, 224 consecutive pregnant women were
eligible for the study. A random selection of cases was included: group 1
(n=59) and group 2 (n=60). There were no differences in age between two
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Abstracts
groups (p=0.812). BMI was significant higher in Group 2 (Third trimester)
(p=0.005). The overall prevalence of HD was 16.8% (group 1: 8/59 [13.6%]
vs. group 2: 12/60 [20%], p=0.463). The main symptoms were similar in the
two groups (p=0.194). Defecatory habits and the BSFS were also similar in
both groups (Table 1).
Conclusions: There were no differences in the prevalence of HD or
bowel habits between the first and third trimesters. Prospective trials aiming to study hormonal factors rather than the effect of high abdominal
pressure or altered bowel habit during pregnancy are warranted to determine the causes of HD in pregnant women.
Characteristics of subjects in 1st (Group 1)and 3rd trimester (group 2) of
pregnancy.
P235
DEEPLY INFILTRATING ENDOMETRIOSIS REQUIRING COLORECTAL
RESECTION: NO CHALLENGE ANYMORE?
J. Gu1, T. Falcone2, F. H. Remzi1 and H. P. Kessler1 1Colorectal Surgery,
Cleveland Clinic Foundation, Cleveland, OH and 2Obstetrics and
Gynecology, Cleveland Clinic Foundation, Cleveland, OH.
P234
LOOSE SETON MANAGEMENT OF ANAL FISTULA: A MULTICENTER
STUDY OF 200 PATIENTS.
M. Kelly, H. Heneghan, S. Martin and D. Winter Surgery, St Vincent’s
University Hospital, Dublin, Ireland.
Purpose: Peri-anal abscesses and fistulae-in-ano are common anorectal
complaints causing significant distress to patients, while representing a
considerable challenge to the treating surgeon. Core management principal is achieving closure of the fistula while maintaining continence. There
are numerous treatment approaches with variable success leading to the
debate about which method is “ideal”. Our aim was to assess the tolerance
and efficacy of loose seton placement in the treatment of fistula-in-ano.
Methods: A retrospective multi-centre review of the management of
anal fistulae with loose seton placement over a three-year period was performed. All patients underwent a standardized operative day-case procedure, and were rescheduled for an elective change of seton until the fistula
tract had healed. The patients’ demographics, medical history, co-morbidities, overall number and time interval between seton placements, tolerance
and morbidity of the procedure were recorded.
Results: 200 consecutive patients had loose seton placement. 69.5%
(n=139) were male, mean age was 42.6 years. (See Figure 1 For Classification of Fistula in the Study). The median number of setons required for each
patient was 3 (Range 1-8, Mean 2.84). The mean interval between seton
changes was 3.08 months (range 2-4 months). All patients had successful
clearance of fistula. The procedure was well-tolerated in 96% of patients
(n=187), while 3% (n=6) had a local reaction requiring seton material to be
changed. Only 1% (n=2) could not tolerate the presence of seton due to
significant discomfort. Fistula recurrence rate was 6% (n=12).
Conclusions: The management of anal fistulae remains largely influenced by individual experience and preference. Traditionally, seton placement was the mainstay of treatment with the assumption that it facilitated
drainage of associated abscess, while promoting resolution of the fistula
tract by inciting an inflammatory reaction. Recently, newer treatment
modalities have been reported with enthusiasm. However, there remains a
lack of strong statistical evidence of efficacy to support their use. Overall,
seton placement remains a key, well tolerated, pragmatic low-cost solution
to this common and difficult condition.
Purpose: Low postoperative complication rates after surgical treatment
for colorectal endometriosis using a variety of surgical procedures have
been reported. However, data on postoperative complications of bowel
resection for deeply invading endometriosis (DIE) are still limited. The aim
of this study is to observe the outcome after such bowel surgeries.
Methods: All patients with colorectal resection for DIE were identified
from the pathology report database. Patients who only underwent superficial nodule or disc excision were excluded. Demographics, history of previous treatment, operation details and postoperative outcomes were collected by retrospective chart review.
Results: From July 1992 until July 2013, forty patients (age: 38.8 ± 8.9
years) underwent colonic or rectal resection for DIE. Chronic pelvic pain
(95%), dyschezia (45%) and chronic infertility (35%) were the most common preoperative findings. Twenty-eight patients (70%) had undergone 45
previous operations for endometriosis including 6 hysterectomies and salpingo-oophorectomies. Twenty seven patients (67%) underwent laparoscopic bowel resections, six of them (22%) were converted to open due to
heavy adhesion and extensive disease involvement. As shown in the table,
17 patients (43%) underwent low anterior resections five (29%) of them
with diverting ileostomy. In all patients, lysis of adhesions was performed,
30 patients (75%) also underwent excision of pelvic endometriosis independently on bowel resection. Concomitant hysterectomies and/or salpingo-oophorectomies and urological procedures were performed in nine
and six patients, respectively. The intraoperative complication rate was 5%.
Mean postoperative stay was 5.1 days, which was significantly shorter after
laparoscopic surgery (4.2 ± 2.5 vs. 7.0 ± 2.7 days, P=0.003). The overall postoperative complication rate was 20%. Three patients (8%) were readmitted
and one of them required reoperation for right ureter injury.
Conclusions: In patients with extensive spread of pelvic endometriosis
and lesions deeply invading colon and rectum, segmental bowel resection
is indicated, often leading to individualized and complex procedures.
Laparoscopic approach is associated with a recovery benefit.
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Abstracts
P237
COLORECTAL COMPRESSION ANASTOMOSIS USING THE NITI DEVICE
VERSUS CIRCULAR STAPLER.
Q. Gonzalez, O. Aldana, J. Bahena and J. Sánchez Hospital Angeles
Pedregal, Mexico City, Mexico.
* including 1 combined ileocolic resection and 3 combined appendectomies
# Concomitant hysterectomy and/or salpingo-oophorectomy
P236
SHORT-DURATION RESTRICTIVE DIET REDUCES MESENTERIC FAT IN
THE MORBIDLY OBESE.
E. M. Cleveland, G. S. Peirce, J. D. Freemyer, W. V. Rice, L. Lee, K. Aluka
and K. Davis William Beaumont Army Medical Center, El Paso, TX.
Purpose: Obesity continues to be an epidemic in the United States, and
the number of operations on the morbidly likewise increases. Numerous
bariatric surgeons have reported the reduction of hepatic volume with a
preoperative low calorie diet, thereby making laparoscopic surgery technically easier. We sought to determine if mesenteric fat could likewise be
reduced secondary to a brief, calorie restricting pre-operative diet.
Methods: After IRB and human use protocol approval, 40 patients with
BMI over 35 and scheduled for bariatric surgery were enrolled in this
prospective study. The patients followed a 1000 kCal/day diet for 14 days
prior to surgery. Patients recorded daily caloric intake via a journal and
answered a short survey at the completion of the diet. Patients had
height/weight measurements, laboratory tests, and an abdominal ultrasound on days 1 and 14 of the diet. The ultrasound was used to calculate
mesenteric fat volume. Mesenteric fat burden pre and post-diet were then
compared using these measurements.
Results: Of the 40 patients, 38 patients (95%) lost weight on the calorie
restricting diet. The average weight loss was 5.0 lbs, with a median of 4.2
lbs. The average caloric intake per day recorded was 894 kCal/d, and
patients were compliant with the diet 86% of the time. Twenty-five patients
(63%) had a reduction in mesenteric fat volume. The average mesenteric
fat volume lost was 2.83 cm3, which is 1.13% of the mesenteric fat of a typical bariatric patient (250cm3). The majority of patients (N=32) said the diet
was easy or somewhat easy to follow.
Conclusions: A preoperative calorie restricting diet was well tolerated
and resulted in weight loss in 95% of patients. This weight loss led to a less
consistent reduction in mesenteric fat, however. A short preoperative
restrictive diet results in a reduction in mesenteric fat. It remains to be seen
if this mesenteric fat reduction could result in technically easier laparoscopic operations involving bowl mesentery such as laparoscopic small
bowel or colon resection.
Purpose: To decrease the leakage rate in the early postoperative and
the stricture rate in the mid-term follow up a new device has been developed to realize colorectal anastomosis.
Methods: From May to December 2012 a total of 20 patients distributed in 2 groups,A (NiTi) with 9 patients and B (circular) with 11 patients
were analyzed,demographic data was analyzed (in group B the male sex
64% and in A 44% with a mean age of 50 years old for both groups),in
group A 11% had a comorbidity(DM),and in B 27% had albumin of 3.6 gr/dl
and hemoglobin of 14.5 gr in both groups.
Results: The main surgical indication in both groups was complicated
diverticular disease 34% in group A and 55% in group B,bleeding due to
diverticular disease 22%(group A) and 9% (group B),colon cancer
22%(group A) and 9%(group B),rectal prolapse 11% and colorrectal
endometriosis 11% in the group A while in the group B 9% had UC,FAP and
sigmoidocele,respectively. The main surgical procedures in the group A
were left hemicolectomy with primary end to end compression anastomosis 33.5% and left hemicolectomy with LAR 33.5%, total colectomy with
ileo-rectum anastomosis,Frykman-Goldberg and reversion of Hartmann
procedure 33%, performed via open surgery 44%, single port 44%and 12%
hand-assisted, with no conversions.Complication rate was 22% that consist
in wall and anastomotic dehiscence, and 1 minor complication corresponding to soft tissue infection.One patient with ileo-rectum anastomosis had
dehiscence at day 4 and requires a reintervention with a new anastomosis
with a circular stapler.Any patient notice the expulsion of the device and
during the follow up there was no evidence of stricture.For the group B the
main surgical procedure was left hemicolectomy with LAR 38%,left hemicolectomy 28%,total proctocolectomy 18%,total colectomy and left hemicolectomy with intestinal resection 18%.The main approach was SILS 55%,
laparoscopic 17% and open surgery 28% with no conversions.Two patients
present complications(18%),soft tissue infection and perianal abscess,55%
had diverting loop ileostomy vs 0% in the group A with no leakage but with
one stricture.
Conclusions: We can conclude that both devices are effective and safe
for the management of colorectal anastomosis.
OPERATIVE AND POSOPERATIVE DATA
P238
ACUTE UNCOMPLICATED DIVERTICULITIS: DOES AGE MAKE A DIFFERENCE?
N. Teo, S. Chan, R. Wijaya, K. Sng and S. Tan Changi General Hospital,
Singapore, Singapore.
Purpose: Concrete data on the natural history and outcomes of acute
uncomplicated diverticulitis in the young patient is lacking. This study aims
to review and compare the differences in presentation, management and
outcomes between young patients (YP: age < 50) and older patients (OP:
age ≥ 50) presenting with acute uncomplicated diverticulitis.
Methods: We performed a retrospective cohort study of patients who
presented with acute uncomplicated diverticulitis between 2007 and 2011.
Data collection included clinical variables at presentation, management
variables of duration of bowel rest and antibiotics, and outcome measures
such as length of stay, inpatient complications and recurrence rates. Statis-
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Abstracts
Patient factors, operative details, and outcomes.
tical analyses were performed using Chi-square test, Mann-Whitney U test
and t test where appropriate and a P value < 0.05 was taken as significant.
Results: We identified 110 (48.2%) YP and 118 (51.8%) OP who fulfilled
our study criteria. Numbers of YP and OP were comparable (P=0.596), but
YP had significantly higher rates of right sided diverticulitis (89.1% vs
67.8%). In comparing clinical variables at presentation, YP had significantly
higher mean heart rate (91 vs 86) and mean white cell count on arrival (13.2
vs 11.8). In terms of management, duration of bowel rest was similar but
mean duration of intravenous antibiotics (2.77 vs 3.25 days) and the mean
length of stay (3.12 vs 4.05 days) was significantly shorter in YP. There were
no differences in inpatient complication and recurrence rates between the
two groups.
Conclusions: Acute uncomplicated diverticulitis affects both YP and OP
equally though YP have a higher incidence of right sided diverticulitis in
our study cohort which is an Asian population. Although YP have a higher
mean heart rate and white cell count at presentation suggestive of more
severe sepsis and inflammation, they do not progress to a more severe clinical course but in fact required shorter durations of intravenous antibiotics
and length of stay and had similar recurrence rates. More prospective comparative studies are needed to elucidate and evaluate distinct differences
between YP and OP with the aim of establishing evidence-based guidelines
for the management of acute uncomplicated diverticulitis in YP.
P239
IMPACT OF POSTOPERATIVE CLOSTRIDIUM DIFFICILE INFECTION
AFTER COLON AND RECTAL OPERATIONS.
W. Gaertner1, R. Madoff2, A. Mellgren3, M. Kwaan2 and G. Melton2
1
Division of Colon & Rectal Surgery, ABC Medical Center, Mexico City,
Mexico, 2Division of Colon & Rectal Surgery, University of Minnesota,
Minneapolis, MN and 3Division of Colon & Rectal Surgery, University of
Illinois at Chicago, Chicago, IL.
Purpose: The incidence of Clostridium difficile infection (CDI) following
surgery is increasing. The aim of this study was to review and compare outcomes of patients with and without CDI after elective colon and rectal operations.
Methods: Retrospective review of patients diagnosed with CDI after
elective abdominal colon and rectal operations from 2007 to 2012 (Group
A). Postoperative CDI was defined as a positive CD toxin assay up to 30 days
postoperative. Outcomes were compared to those of patients with a negative CD toxin assay performed for postoperative diarrhea or high stoma output (Group B) and non-CDI patients without a CD toxin assay (Group C)
matched by operative indication and procedure during the same time
period.
Results: 44 patients (25 men, median age 53 years) developed CDI postoperatively (Group A) at a median time of 6 (range, 2-29) days after surgery.
Seven patients (16%) received antibiotic therapy beyond 24 hours postoperative (median duration, 11 days), 7 (16%) had previous history of CDI, 18
(41%) were chronic proton-pump inhibitor (PPI) users, and 21 (48%)
received a full bowel preparation. Fourteen patients (32%) had SSIs. Median
length of hospital stay was 8 days. There was no 30-day mortality. No operative therapy or fecal transplantation was required. While no significant differences were observed between Group A (CDI) and Group B (diarrhea/high
stoma output with negative CD toxin assay) patients, Group A patients were
more likely to have a history of CDI, chronic PPI use, and to have undergone bowel preparation compared to Group C (control) patients. Both
Group A and Group B patients had significantly more superficial SSIs, longer
hospital stays, and more readmissions compared to Group C (control)
patients with no CD toxin assay.
Conclusions: No significant differences were found between postoperative CDI patients and those patients with postoperative diarrhea or high
stoma output and a negative CD toxin assay. Postoperative diarrhea and
high stoma output, whether in patients that are CD positive or not, impact
postoperative outcomes. Identifiable risk factors for postoperative CDI may
include history of CDI, chronic PPI use, and bowel preparation.
NA: not applicable; NS: not significant; †Two most frequent indications and
operations; *statistically significant; ASA: American society of anesthesiologists; CDI:
clostridium difficile infection; PPI: proton pump inhibitor; IBD: inflammatory bowel
disease; HALS: hand-assisted laparoscopic surgery.
P240
MORPHOFUNCTIONAL EVALUATION OF WOMEN SUFFERING FROM
DEEP INFILTRATING ENDOMETRIOSIS WITH RECTAL INVOLVEMENT.
D. M. Lima2, S. M. Regadas3, F. S. Regadas3, G. Kurachi1, K. C. Ebrahim2,
C. D. Santos1, A. M. Fusioka2 and U. E. Sagae4 1Gastroclínica Cascavel
Ltda, Cascavel, Brazil, 2Faculdade Assis Gurgacz, Cascavel, Brazil,
3
Universidade Federal Do Ceara, Fortaleza, Brazil and 4Universidade
Estadual Do Oeste Do Parana, Cascavel, Brazil.
Purpose: To perform a morphofunctional evaluation of women suffering from deep infiltrating endometriosis with rectal involvement.
Methods: Prospective study involving 34 women diagnosed with deep
infiltrating endometriosis and intestinal constipation referred by the gynecologist to an outpatient coloproctology service. Patients with endometriotic foci in the rectal wall on 3D-US were evaluated clinically, then submitted to anorectal manometry (ARM) with water-perfused catheter performed
by an experienced colorectal surgeon (GK) at the department of anorectal
physiology. The measured ARM parameters included pressure at rest (40-70
mmHg), pressure during contraction (100-200 mmHg), presence of rectalsphincter reflex / rectal sensitivity (10-30 mL), and presence of anismus. The
3D-US evaluation was performed by an experienced colorectal surgeon
(DMRL) using a B&K Medical scanner. Based on this scan, sphincter integrity
and width were determined by another researcher (KCE). Patients with orificial disorders (hemorrhoids, fissure, fistula or anorectal abscess), inflammatory bowel disease, neoplasia or history of radiotherapy were excluded.
Results: The average age was 35.9 years (range: 25-49). The observed
lesions affected the perirectal fat or infiltrated the rectal muscle layer. One
patient (2.9%) had hypotonic sphincter at rest, while 11.7% had hypotonic
sphincter during contraction. The corresponding figures were 20.5% and
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Abstracts
Top 7 Altered Genes From Qiagen Wound Healing Array
23.5% for hypertonic sphincter. Anismus was observed in 18 patients
(52.9%). Pressure during contraction and rectal sensitivy increased in 2
(5.8%) and 13 (38.2%) patients, respectively. A questionnaire (QDF) was
administered postoperatively by telephone, collecting information on
bowel function, fecal consistency, dyspareunia, incomplete evacuation, use
of laxatives, rectal pain, low abdominal pain and infertility. The maximum
score (8) was assigned to 20.5%, scores 7 and 6 to 8.8%, 5 and 4 to 14.7%, 3
and 2 to 2.9%, and 1 to 14.7%.
Conclusions: Morphofunctional evaluation in women suffering from
deep infiltrating endometriosis with rectal involvement provides information relevant to the choice of treatment.
P241
SURGICAL DIVERTICULITIS IS NOT ASSOCIATED WITH DEFECTS IN
EXPRESSION OF WOUND HEALING GENES.
T. M. Connelly1, A. S. Berg2, L. Harris1, D. Brinton1, S. Deiling1 and
W. A. Koltun1 1Division of Colon and Rectal Surgery, Milton S. Hershey
Medical Center, Penn State College of Medicine, Hershey, PA and
2
Department of Biostatistics, Milton S. Hershey Medical Center, Penn State
College of Medicine, Hershey, PA.
Purpose: Diverticulitis appears to be due to an interplay of environmental and host, possibly genetic, factors. We have previously shown an
association of TNFSF15, an immune mediator, with surgical diverticulitis
(SD). Others have suggested a role for extracellular wound healing and
inflammatory proteins. Our aim was to evaluate the tissue expression of
well known wound healing genes in youthful SD pts where a possible
genetic defect would be most evident.
Methods: 16 youthful SD patients (mean age 38 years, 11=phlegmaceous, 5= perforating/abscess) and 15 Controls (mean age 52.9 years, 2=
dysmotility, 1= volvulus, 1=endometriosis, 3=FAP, 1=HNPCC and 7=colorectal cancer) were identified from our divisional Biobank. MRNA expression
of 82 genes associated with extracellular matrix/cellular adhesion, growth
factors, inflammatory cytokines and signal transduction was evaluated in
pulverized full thickness specimens of sigmoid colon using a QiagenTM
wound healing array. Vitronectin(VTN), the gene with the lowest p value in
this array, was then further investigated using a Taqman assay with the
addition of 20 SD (36 total) and 4 Control (19 total) patient samples. Mann
Whitney was used for statistical analysis.
Results: After Bonferroni correction, there was no statistically different
mRNA expression between the 16 youthful SD and 15 Controls in the 82
genes. The VTN gene had the greatest suggested down regulation (2.8 fold
in the SD group vs 4 non-neoplastic Controls before correction, p=.001).
However on TaqMan analysis of VTN in the larger studied groups, the mean
DS RQ value was 1.02±0.5 vs Control of 1.0 ±0.3, p=.49. In all subset comparisons (youthful vs elderly, perforating vs phlegmaceous) no significant
up or down regulation of the VTN gene was seen.
Conclusions: This analysis demonstrates a lack of significant dysregulation of traditionally associated wound healing genes in young patients with
SD. This suggests that extracellular matrix and growth factor associated
genes play a minor role in the possible genetic defects predisposing youthful individuals to diverticulitis.
VTN=Vitronectin, CXCL2=Chemokine (C-X-C motif ) ligand 2, CSF3=Colony
stimulating factor 3 (granulocyte), F13A1=Coagulation factor XIII, A1 polypeptide,
MMP7= Matrix metallopeptidase 7, F3= Coagulation factor III, EGF= Epidermal
growth factor
P242
IS THE USE OF AN INTRAPERITONEAL PHISIOMESH MESH USING THE
SUGARBAKER TECHNIQUE ADVISABLE TO PREVENT PARASTOMAL
HERNIAS?
J. I. Jorge-Barreiro, I. Garcia Bear, G. Pire Abaitua, J. Otero Diez, L. Garcia
Florez and R. Arias Pacheco General Surgery, Hospital San Agustín, Avilés,
Spain.
Purpose: Parastomal hernias are a very common complication, ocurring in excess of 50%. Only a few studies deal with the prophylactic use the
mesh to prevent parastomal hernia and show promising results.
Methods: Twenty nine patients undergoing elective rectal surgery with
a permanent colostomy, one with an ileostomy and two needing surgical
correction of a pre-existing colostomy were enrolled in a prospective study.
A specially designed mesh was implanted prophylactically using a physiomesh intraperitoneal mesh as described. Patients were followed for a
median of 16 months, range 2-28 months, trough clinical examination every
3 months.
Results: No infection or any other adverse effect was observed and no
parastomal hernia or stoma protrusión were detected clinicaly. Twenty five
patients had a rutine computed tomography after 12 months, which also
confirmed the absence of hernia formation
Conclusions: The prophylactic use of a physiomesh is a safe and effective procedure preventing stoma complications such as hernia formation
or prolapse, at least in the short term.
P243
CLOSTRIDIUM DIFFICLE INFECTION: INDICATIONS FOR SURGERY.
M. Julien, P. Meade, R. Khoo and K. Halm general surgery, geisinger medical center, Danville, PA.
Purpose: Clostridium difficle (C. diff ) is a spore-forming, gram-postive
bacteria that produces a broad spectrum of clinical presentations ranging
from mild diarrhea to fulminant colitis necessitating surgical intervention.
Surgical treatment has been demonstrated to improve outcomes in
patients with C. diff colitis, but in practice the proper timing and criteria for
operative intervention have not been clearly defined in literature to date.
The aim of the study is to demonstrate whether the University of Pittsburg
School of Medicine’s (UPMCs) proposed indications for operative management in patients with C. diff infection accurately predict the need for surgery.
Methods: This is a retrospective review of all patients who had a surgery for C. diff colitis at Geisinger Medical Center between January 2007
and July 2012. Outcome measurements included UPMCs indications for
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Abstracts
operative management in patients with C. diff colitis, 30-day mortality, ICU
admission and length of stay.
Results: Fifty six patients underwent surgical intervention for C. diff
infection. All patients were diagnosed with C. diff infection by positive toxin
assays and 75% also had a CT scan consistent with C. diff colitis. All surgical
patients met criteria for indications for operative management as per
UPMCs indications for operation. Over 63% of our surgical population had
6 or more criteria before surgery according to UPMCs indications. Lastly,
patients who required mechanical ventilation, vasopressors, who had mental status changes, and a white blood cell count had an associated mortality after surgery for C. diff colitis.
Conclusions: We have concluded that our surgical patients met criteria
put forth by the University of Pittsburg School of Medicine’s indications for
operative management in patients with C. diff colitis. However we feel that
does not accurately predict the need for surgery because of its broad inclusion criteria. A need for specific criteria met is necessary in order to adequately guide the operative verses non-operative management of patients
with C. diff infection. The next step will be to compare patients with C. diff
colitis who did not have operative intervention and determine whether or
not they met the UPMC criteria for surgery.
P244
SURGICAL RESECTION AS DEFINITIVE TREATMENT FOR SEGMENTAL
COLITIS ASSOCIATED WITH DIVERTICULOSIS.
J. Lei, S. Lei, R. Rolandelli and Z. Nemeth Surgery, Morristown Medical
Center, Morristown, NJ.
Purpose: Mucosal inflammation isolated to a segment of colon affected
by diverticular disease with rectal sparing refers to Segmental Colitis Associated with Diverticulosis (SCAD). Its clinical resemblance to inflammatory
bowel disease (IBD) represents a diagnostic challenge for clinicians and misdiagnosis can lead to its mismanagement. The current treatment of SCAD
includes medications, surgery, or a combination of both. We propose that
early segmental colonic resection is a superior alternative to chronic antiinflammatory and immunosuppressive maintenance therapy.
Methods: We performed a systematic review of the literature including
meta-analyses and combined it with our clinical experience. We sought to
determine the clinical, endoscopic, and pathologic outcome of patients
with SCAD as well as the recurrence rates following medical and/or surgical
therapy.
Results: Our meta-analysis yielded seventeen studies with 240 patients.
Of these, 169 patients were managed medically, and 85 patients required
surgery. Study duration ranged from 0 to 15 years. Recurrence rate in the
medically managed cohort was 26.0% (44/169) compared to the surgical
cohort 10.5% (9/85). In our database, we found a total of seven patients (5
males and 2 females; mean age 62.9) all with biopsy diagnosed acute-onchronic colitis associated with diverticular disease. Two patients underwent
Hartmann’s procedure, and ficw underwent segmental colectomy with primary anastomosis. Follow up ranged from 0-5 years, and four patients had
surveillance colonoscopies that were negative for recurrence.
Conclusions: Due to their clinical and histological similarities, SCAD and
IBD patients may benefit from similar medical treatment modalities. Despite
recent optimism in inducing remission with immunosupressive agents,
long-term maintenance therapy with these agents has undesired side
effects. We believe that medical treatment does not alter the natural history of SCAD, and more aggressive subtypes will recur or develop complications. In our experience, early surgical intervention following a short
treatment course of sulfasalazine treatment will afford patients a definitive
treatment with a low morbidity and an improved quality of life.
P245
EARLY OUTCOMES FOR A STANDARDIZED PROTOCOL FOR THE MANAGEMENT OF COMPLICATED DIVERTICULITIS.
T. P. Nickerson, M. Khasawneh, R. Cima, H. Chua, E. Dozois, D. Larson
and K. Mathis Colorectal Surgery, Mayo Clinic Rochester, Rochester, MN.
Purpose: Complicated diverticulitis is associated with high morbidity
and mortality rates. We developed a practice management guideline to
standardize management of complicated diverticulitis, taking effect in January 2012. All patients were to be managed by the colorectal surgery service (CRS); drainable abscesses were referred for percutaneous drainage; and
all patients were asked to return in 6 weeks for colonoscopy and consideration for elective resection. Our aim was to evaluate morbidity, mortality,
intervention rate, and follow-up of this patient population following a standard process.
Methods: We performed a retrospective review of all patients admitted
to CRS with complicated diverticulitis for the year of 2012. Patients were
grouped according to initial management approach; medical management
(MM), percutaneous drainage (PD) and operative (OR). Univariate analysis
was performed using χ2.
Results: 35 patients were identified; CT scan was performed in 94%,
and this was the first episode of diverticulitis in 58%. 54% were managed
medically with antibiotics and bowel rest, 34% underwent percutaneous
drainage, and 12% were managed operatively. There were no differences in
age, sex, comorbidities, vital signs on admission, or leukocytosis between
groups. BMI and abscess size were significantly different between groups.
There were no 30 day mortalities. Overall morbidity was 29%, with the highest morbidity in the operative group (MM 26% v PD 17% v OR 75%, p=0.09).
The most common complications were infectious. 54% had a follow up
colonoscopy, and colorectal pathology was found in 48%; 6 patients had
polyps (54%) and one patient had cancer(9%). 48% underwent elective
resection, with sigmoidectomy and primary anastomosis performed in 88%
with (25%) or without (63%) diversion.
Conclusions: Morbidity rates with complicated diverticulitis remain
high in this review despite standardization of management. Morbidity following emergent operative intervention was high at 75%. Only 11% of
patients were managed operatively, and the majority were successfully
managed medically. 48% underwent elective resection, with the most common operation being one stage resection.
Table 1. Results by initial management strategy.
Results presented as number (% per treatment arm) or Median [interquartile
range] for continuous variables. MM = Medical management. PD = percutaneous
drainage. OR = operative intervention. Abscess size= largest diameter in cm. Febrile =
temp >38 C on admission. WBC presented as 10^9/L, reference range 3.510.5x10^9/L.
129
Abstracts
(18 days), were more likely to be readmitted (9%), and the most likely to be
discharged to a SNF (48%). Patients treated with intraoperative manipulation/fixation of the colon had the lowest mortality, risk of stoma formation,
length of stay, and likelihood of discharge to SNF but the highest risk of
subsequent procedures for volvulus (26%) over a follow-up that ranged
from 0 to 687days (Table).
Conclusions: The vast majority of patients undergoing surgery for
volvulus had a resectional procedure. The subset that did not undergo
resection had favorable initial outcomes, but were at relatively high risk of
undergoing subsequent procedures for volvulus. Despite the high risk of
subsequent procedures for volvulus with intraoperative manipulation/fixation of the colon, the relatively good outcomes of this technique may indicate that it has potential applicability in a subset of patients.
P246
PROXIMAL INTESTINAL DIVERSION INCREASES MORBIDITY AND
MORTALITY IN PATIENTS UNDERGOING ELECTIVE COLECTOMY FOR
DIVERTICULAR DISEASE.
K. B. Wise1, A. Merchea2, R. R. Cima3, D. T. Colibaseanu2, K. M. Thomsen4
and E. B. Habermann4 1Department of Surgery, Mayo Clinic, Rochester,
MN, 2Section of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, FL,
3
Division of Colon & Rectal Surgery, Mayo Clinic, Rochester, MN and
4
Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
Purpose: Elective colectomy for diverticular disease is common. Subsets of patients undergo primary resection with proximal diversion in an
effort to mitigate morbidity associated with anastomotic leak. We sought
to determine the impact of proximal intestinal diversion on outcomes in
patients undergoing elective colon resection for diverticulosis.
Methods: The American College of Surgeons-National Surgical Quality
Improvement Program (ACS-NSQIP) database was queried. All patients
undergoing elective resection for diverticulosis from 2005 to 2011 were
analyzed, while patients undergoing emergency operations were excluded.
Thirty-day outcomes were reviewed. Factors predictive of undergoing
diversion and the risk-adjusted odds of postoperative morbidity with and
without proximal diversion were determined by multivariable logistic
regression models.
Results: 17,726 patients were identified, of whom 613 (3.5%) underwent proximal diversion. The mean age at presentation was 57 years. Variables found to be predictive for undergoing proximal diversion included
age ≥65 years, BMI ≥30, current smoking status, steroid use, and serum
albumin <3.0 g/dL. Multivariable analysis demonstrated that diversion significantly (p < 0.05) increased the risk-adjusted odds of surgical site infection (OR 1.54), acute renal failure (OR 5.68), deep venous thrombosis (OR
4.77), pneumonia (OR 1.98), urinary tract infection (OR 1.66), sepsis or septic shock (OR 1.64), and length of stay greater than 7 days (OR 4.87). Proximal diversion was associated with higher 30-day mortality (1.8% vs. 0.4%,
OR 2.72, p < 0.001).
Conclusions: Proximal diversion in the setting of elective segmental
colectomy for diverticulosis is uncommon. However, it is significantly associated with increased postoperative morbidity and mortality and prolongs
length of stay. Surgeons should use discretion when considering proximal
diversion in this setting.
OUTCOMES OF VOLVULUS SURGERY
P248
TYPE I/TYPE III COLLAGEN RATIO AND THE CORRELATION WITH
DIVERTICULOSIS.
E. M. Cleveland, S. R. Brown, J. L. Creamer, J. Crossett, S. Suitron,
C. Deeken, K. Aluka and K. Davis William Beaumont Army Medical Center,
El Paso, TX.
P247
WHAT ARE THE RESULTS OF VOLVULUS SURGERY?
R. Ricciardi, P. W. Marcello, P. L. Roberts, T. E. Read, T. D. Francone,
J. F. Hall and D. J. Schoetz Lahey Clinic, Burlington, MA.
Purpose: Operative results of volvulus are largely unknown because of
rare disease incidence. In this study, we examined the results of operative
intervention for colonic volvulus in the state of California.
Methods: We merged trackable inpatient discharge data from the California Inpatient Database and the Supplemental Files for Revisit Analyses
from 1/1/2005 through 12/31/2007. Next we identified all patients with
colonic volvulus who underwent one of four surgical procedures: 1) intraoperative manipulation/fixation of the colon, 2) right colectomy, 3) left
colectomy, or 4) total colectomy. During the 36-month study period we
determined risk of mortality, stoma formation, length of stay, readmission,
discharge to skilled nursing facility (SNF), and risk of subsequent procedures for volvulus.
Results: We identified 1,768 patients with a diagnostic code of colonic
volvulus and a procedure code for either intraoperative manipulation/fixation of the colon (n=203, 12%), right colectomy (n=728, 41%), left colectomy (n=781, 44%), or total colectomy (n=56, 3%). Patients treated with
intraoperative manipulation/fixation of the colon were younger, more likely
to be female, and more likely to have private insurance. Patients who underwent total colectomy had the highest risk of mortality (21%), were more
likely to have a stoma created (64%), experienced the longest length of stay
Purpose: Despite the widespread nature of diverticulosis, the pathogenesis of this disease is incompletely understood. Type I collagen
decreases with age leading to a decreased Type I to Type III collagen ratio.
We hypothesized that this decreased collagen ratio predisposes patients to
diverticulosis and complications thereof. We sought to quantify the collagen ratio in patients with complicated diverticulitis requiring surgical intervention.
Methods: Fifty-three patients with a total or partial colectomy in the
last six years at a single institution were enrolled in this retrospective study.
A control group (N=18) of patients who underwent a colon resection for
cancer or volvulus, with no pathological evidence of diverticulii were compared with patients having a resection for diverticulitis (N=35). Both diverticulitis patients under the age of 50 (N=15) and diverticulitis patients over
the age of 50 (N=20) were compared to the control group. A sub group
analysis was done between all male patients (N=38) and female patients.
Slides were prepared and stained with Sirius red/fast green and photographed at 400A magnification. Ten photos were taken of each specimen
and photo analysis software was used to quantify the amount of type I collagen (red) and type III collagen (green) by calculating the area. The ten
photos were then averaged and analyzed for a difference between the
groups. Statistical significance was determined using a one-way ANOVA
and Fisher’s LSD post-test.
Results: The Type I/Type III collagen ratio in the control group was
3.82mm2, while the under 50 diverticulitis group was 5.04 mm2, and the
over 50 diverticulitis group was 3.69 mm2 (NS). The Type I/Type III ratio in
all patients under 50 years of age was 4.87 mm2 while those over 50 years
of age was 3.74 mm2 (p= 0.038). Collagen ratio of all males was 4.35 mm2,
while females was 3.51 mm2 (p = 0.024).
Conclusions: The collagen ratio decreases as patients age, but this does
not correlate with the development of colonic diverticulii requiring surgery.
The collagen ratio alone does not explain why diverticulosis is more commonly seen in patients over the age of 50, nor does it contribute to more
complicated diverticulii requiring surgery.
130
Abstracts
P249
THE ANALYSIS OF COLORECTAL CANCER WITH CROHN’S DISEASE
AND PILOT STUDY OF CANCER SURVEILLANCE BY MULTICENTER
ANALYSIS IN JAPAN.
A. Sugita1, K. Futami2, R. Nezu3, H. Ikeuchi4, S. Furukawa5, H. Haneda6,
K. Watanabe7 and M. Watanabe8 1Surgery, Yokohama Municipal Hospital,
Yokohama, Japan, 2Surgery, Fukuoka University Chikushi Hospital,
Fukuoka, Japan, 3Surgery, Nishinomiya Municipal Central Hospital,
Nishinomiya, Japan, 4IBD center, Hyogo Medical University, Nishinomiya,
Japan, 5Colorectal, anal surgery, Social Insurance Chuo General Hospital,
Tokyo, Japan, 6Surgery, Tohoku University Graduate School of Medicine,
Sendai, Japan, 7Gastroenterology, Osaka City University, Osaka, Japan and
8
Gstroenterology, Tokyo Medical and Dental University, Tokyo, Japan.
Purpose: The incidence of colorectal cancer(CRC) with Crohn’s disease(CD), especially anorectal cancer, is gradually increasing in Japan and
prognosis of these patients are poor. This study was undertaken to identify
the clinical course of CRC with CD in our institute and the establishment
for cancer surveillance program by multicenter analysis in Japanese
patients as a study of IBD research group in Japanese Ministry of Welfare.
Methods: 1) Of 1316 patients with CD in Yokohama Municipal Hospital,
27 patients were diagnosed intestinal cancer (2.1%) in which 23 patients
with anorectal cancer (1.7%)(rectum or anal canal:17, anal fistula:6) were
included. 2)Pilot study was conducted for cancer surveillance in IBD
research group by Japanese Ministry of Welfare and Labor. The biopsy or
cytology is performed for the CD anorectal lesions with more than 10 years
persistence by endoscopy or local surgery in this study.
Results: 1) Rectal cancer (17 cases): In 70% of patients, change of symptoms such as progress of stricture was the clue for diagnosis and median
duration of CD was 19 years. Cancer in previously diverted rectum for
anorectal disease was found in 24% of the patients.. Patients were classified into 3stage I, 7 stage II, 2 stage III, 4 stage IV (one patient: missing) and
survival rate was 59% on 34 months after surgery (APR: 16, PE:1). Cancer in
anal fistula(6 cases): In 67% of patients, change of symptoms such as
increasing mucus dischage was the clue for diagnosis and median duration
of CD was 23 years. Cancer stage was 2 stage II, 2 stage IV (2patients: missing) and survival rate was 67% on 36 months after treatment (APR: 4, resection of tumor:1, chemotherapy:1). 2) Pilot study: Of 252 patients collected
until December, 2012, 12 patient with anorectal cancer were reported
(4.8%). This study is ongoing and more patients’ data is needed.
Conclusions: Anorectal cancer including cancer in anal fistula is common cancer with Crohn’s disease in Japan and biopsy, cytology for suspicious lesion is necessary to find cancer in longstanding CD patients. The
optimal cancer surveillance program for Crohn’s anorectal lesions is necessary.
P250
CHARACTERIZATION AND OUTCOMES OF PEDIATRIC PATIENTS WITH
ILEAL POUCH-ANAL ANASTOMOSIS.
J. E. Keenan1, H. Fasanya-Uptagraft2 and T. Julie1 1Surgery, Duke
University Medical Center, Durham, NC and 2Medicine, Duke University
Medical Center, Durham, NC.
Purpose: The rising incidence of medically refractory ulcerative colitis
and an increasing recognition of familial adenomatous polyposis syndrome
(FAP) have resulted in greater need for proctocolectomy with ileal pouch
anal anastomosis (IPAA) in the pediatric population. The aim of this study
was to characterize and determine outcomes of pediatric patients undergoing this procedure.
Methods: This was a single-center, retrospective study of pediatric
patients potentially indicated for proctocolectomy with IPAA from June
2008 to June 2013. All surgeries were preformed by board certified colorectal surgeons. Patient demographics, clinical factors, and outcomes were
determined.
Results: Twenty-six patients met study criteria, seven with FAP and 19
with indeterminate or ulcerative colitis. The mean age was 16.5 years. The
average age at diagnosis in patients with colitis was 13.6 years. Of this
group, 89.4% had received biologic therapy within three months, 78.9%
were on steroids, and 37.9% were receiving TPN. In the FAP group, all
patients received an IPAA at the index operation, and one was completed
without a diverting ileostomy (DLI). In the colitis group, no one-stage procedures were performed, and six patients underwent total abdominal
colectomy with end-ileostomy as their index operation. There were four
clinically significant anastomotic leaks. All were managed with percutaneous drainage, and one required transanal repair. Two patients had
asymptomatic radiographic evidence of leak. In total, 17/19 patients with
colitis have been reconstructed with IPAA and 15 have had their ostomies
reversed (two are pending ostomy reversal). The two patients who have not
been reconstructed with IPAA had indeterminate colitis at the time of index
of operation. One of these patients was subsequently diagnosed with
Crohn’s disease.
Conclusions: The observed leak rates in this small pediatric cohort are
similar to IPAA in adults, suggesting that extrapolation of adult algorithms
may usually suffice for IPAA in children. However, further study is needed
to define the pediatric colitis population, optimal preoperative medical
management, and the effect of timing of surgical referral.
Table: Factors around pediatric IPAA
FAP=Familial Adenomatous Polyposis; TPN=Total Parenternal Nutrition; IPAA=Ileal
Pouch Anal Anastomosis; DLI=Diverting Loop Ileostomy; TAC=Total Abdominal
Colectomy; SBO=Small Bowel Obstruciton; SD=Standard Deviation; Q1=first
quartile;Q3=third quartile
P251
RISK OF CANCER IN ENDOSCOPICALLY BENIGN POLYPS UNSUITABLE
FOR ENDOSCOPIC REMOVAL.
E. Gorgun, C. Benlice and J. Church Colorectal Surgery, Digestive Disease
Institute, Cleveland Clinic, Cleveland, OH.
Purpose: Endoscopic polypectomy techniques are an adequate means
of polypectomy; however, formal resection may be required for some
polyps. In polyps that look benign endoscopically, some will be malignant.
Should resection be radical, or can a colotomy be performed? The aim of
this study is to estimate cancer risk in this group of patients.
131
Abstracts
Methods: Patients with an endoscopic diagnosis of a benign adenoma
judged inappropriate for endoscopic removal and who underwent a colectomy between 1997 and 2012 were accessed from a prospectively collected
database. Colonoscopy, pathology and operative reports were assessed.
Patients with preoperative diagnoses of invasive cancer, inherited polyposis syndrome, inflammatory bowel disease and synchronous pathology
requiring surgery were excluded.
Results: A total 439 patients [220 (50.1%) men; mean age 66 years]
underwent colectomy for endoscopically unresectable colonic polyps. Most
of the polyps were located in the right colon (89.7%) and the majority of
these were in the cecum (199, 45.3%). Of the 439 patients, 346 (79%) underwent preoperative endoscopy at our institution. Preoperative biopsy
showed tubulovillous (n=234), tubular (n=116), villous (n=52) and serrated
(n=23) adenoma. 57.4% of polyps were sessile. High grade dysplasia was
seen in 88 (20%) patients. Mean colonoscopic and postoperative polyp sizes
were 3.3+1.5 and 3.1+1.9 cm. Final pathology revealed invasive cancer in
37 (8.4%) patients [stage I (23 patients), stage II (11) and stage III (3)]. Two
patients had recurrence (1 lung; 1 liver) after a mean duration of 27 months.
Mean overall survival was 52 months. One patient died from cancer. Polyp
location, morphology and histologic types were similar between the benign
and malignant polyps. Only pathologic polyp size was significantly higher
in malignant polyps (p=0.01) but the scattergram of endoscopic polyp size
(Figure) shows an almost complete overlap of polyp size between benign
and malignant lesions.
Conclusions: All apparently benign polyps undergoing resection
should have oncologic surgery.
P252
LONG PERIODS OF MEDICAL THERAPY INCREASE SURGICAL COMPLICATIONS IN PATIENTS WITH SEVERE ULCERATIVE COLITIS.
H. Kimura1, R. Kunisaki1, K. Tatsumi2, K. Koganei2, A. Sugita2 and I. Endo3
1
Inflammatory Bowel Disease Center, Yokohama City University Medical
Center, Yokohama, Japan, 2Inflammatory Bowel Disease Center,
Yokohama Municipal Citizen’s Hospital, Yokohama, Japan and
3
Gastroenterological Surgery, Yokohama City University Graduate School
of Medicine, Yokohama, Japan.
Purpose: The aim of this study was to clarify the optimal timing of surgery for severe ulcerative colitis (severe UC).
Methods: A total of 301 consecutive patients who had undergone primary surgery for UC between 2000 and 2013 were reviewed. We identified
91 patients (M:56, F35,, age at surgery 38 [11-76]) who had undergone surgery for severe UC. Surgical indications of severe UC were severe condition
(defined by Trulove and Witts’s criteria) with drug invalidity (41 cases), massive bleeding (34), toxic megacolon (11), and perforation of the colon (5).
Results: Eighty nine (98%) patients had steroid. Rescue therapy was
instituted in 28 patients (25%), of whom 26 were treated with cyclosporin
and 9 with tacrolimus. Infliximab was not used for severe UC in our institution. Total proctocolectomy, ileal pouch-anal anastomosis was performed
in 32 cases (28 [31%] without ileostomy and 4 [4%] with ileostomy), subto-
tal colectomy with ileostomy in 58 (64%), total proctocolectomy,
abdominoperineal resection in 1 (1%). Surgical complications (ClavienDindo Grade >=3) were seen in 20 cases (22%). These included bowel
obstruction (6), anastomotic leakage (4), intrapelvic abscess (3), bleeding
(duodenal ulcer, abdominal wall) (3), pneumonia (2), wound defiscence (2),
endocarditis (1) (Those with duplication). There was one operative mortality. A median period of rescue therapy was 13 days. Rescue therapy did not
make surgical complications increase. The period of medical therapy from
severe attack to surgery tended to be long in surgical complication (+)
group (34 vs 20), and the cases with over 30 days were significantly higher
in complication (+) group (p=0.008).
Conclusions: In patients with severe UC, the rescue therapy was not
related to increase surgical complications. But long period of medical therapy including steroid therapy increased surgical complications. Surgery
should be performed immediately after the failure of the medical therapy
for severe UC.
P253
FUNCTIONAL OUTCOMES IN PATIENTS UNDERGOING ILEAL POUCHANAL ANASTOMOSIS WHO HAD ABNORMAL POUCHOGRAPHY
PRIOR TO ILEOSTOMY REVERSAL.
S. R. Kelley, E. J. Dozois and S. Baek Colon and Rectal Surgery, Mayo Clinic,
Rochester, MN.
Purpose: Pouchography is used to preoperatively identify abnormalities that can lead to ileal pouch anal anastomosis (IPAA) related complications prior to defunctioning loop ileostomy (DLI) closure. Little data exist to
support, or reject, the routine use of pre-closure contrast enema evaluation. The aim of our study was to assess the overall functional outcomes in
patients that had an abnormal pouchogram prior to DLI reversal for their
2-stage IPAA.
Methods: All patients who underwent a two-stage IPAA and pouchography prior to DLI closure at our institution between 1990 and 2008 were
identified and reviewed. Demographics, diagnosis, type of anastomosis,
length of time from IPAA to pouchogram and DLI closure, pouchography
findings and clinical and functional outcomes were reviewed.
Results: 1697 patients were identified, of which 341 (20.1%) had abnormal pouchograms. The mean age at the time of IPAA construction was 36.5
years, 43% (148) were female, chronic ulcerative colitis was the predominant diagnosis (91%), stapled anastomoses were constructed 54% (184) of
the time, and the mean time for DLI closure was 122.3 days. Abnormalities
included anastomotic stricture / stenosis (63%), sinus tract (18%), mucosal
irregularity (12%), anastomotic leak (5%), and fistula (0.2%). Pouch excision
occurred in 2.1% (7), and permanent ileostomy with pouch retention was
present in 0.9%. Most averaged between 5 and 6 bowel movements per
day, 70% experienced full daytime continence, 39% reported occasional
nocturnal incontinence with most experiencing 1-2 episodes per night,
40% wore a pad, and 59% would wear a pad 1 to 2 times or more per week.
Most experienced semi-liquid stools (74%), perianal skin irritation was
reported in 44%, and full sensation was present in 69%.
Conclusions: Our findings suggest pouchography performed prior to
ileostomy closure helps to identify pouch abnormalities that could result in
higher morbidity (pelvic sepsis, pouch loss, chronic fistulas, etc.) if intestinal
continuity were reestablished before the problem was corrected.
132
Abstracts
P254
SURGICAL TREATMENT AND OUTCOMES IN PATIENTS WITH INTESTINAL BEHCET’S DISEASE: LONG-TERM EXPERIENCE OF A SINGLE
LARGE-VOLUME CENTER.
S. Baek, C. Kim, M. Cho, H. Hur, B. Min, S. Baik, K. Lee and N. Kim
Department of Surgery, Yonsei University College of Medicine, Seoul,
Republic of Korea.
Purpose: Treatment of intestinal BD remains largely empirical. In particular, few studies have examined the clinical efficacy of surgical treatment
for intestinal BD. We aimed to evaluate the clinical course after surgery and
to determine the appropriate surgical options for intestinal Behcet’s disease (BD) through our long-term experience.
Methods: We performed a chart review of 91 patients who underwent
surgical treatment for intestinal BD between January 1995 and December
2012. Patient demographics, clinical features, operative data, postoperative
course, complications within 30 days after operation, and long-term followup data were reviewed.
Results: The mean age of the patients at the time of diagnosis of BD
was 35.9 years, and their first operation was performed at a mean age of
40.5 years. Patients primarily received an operation due to intractability
with medical treatment (56%), and 19.8% of patients underwent an emergency operation. Surgery was performed laparoscopically in one-third of
patients. Most patients received an ileocecectomy (39.6%) or a right hemicolectomy (34.1%). Post-operative morbidities were experienced by 28
patients (30.8%), and 8 patients (8.8%) underwent reoperation. Operations
were performed more than twice in 37 patients (41.7%), for which recurrence of disease in 32 patients. Among those requiring a second operation,
53.1% were segmental colonic resections that included the previous anastomosis. There were three mortalities.
Conclusions: Surgical treatment of intestinal BD frequently has postoperative complications and has a high risk of recurrence; therefore, careful
management and postoperative follow-up are necessary.
P255
COLONOSCOPIC POLYP AND ADENOMA DETECTION RATE IN THE
AVERAGE RISK POPULATION OF COLORECTAL CANCER AND ITS AGE
DISTRIBUTION: RETROSPECTIVE ANALYSIS OF DATA FROM A SINGLE
TERTIARY MEDICAL CENTER IN SHANGHAI CHINA.
Z. Zhao1, J. Li2, Y. Shan1, F. Yan1, H. Wang1, Z. Lou1, C. Fu1 and E. Yu1
1
Department of Colorectal Surgery, Shanghai Changhai Hospital,
Shanghai, China and 2Management Unit of Postgraduate, Shanghai
Changhai Hospital, Shanghai, China.
Purpose: To evaluate the colonoscopic polyp detection rate (PDR) and
adenoma detection rate (ADR) in average risk population of colorectal cancer and its age distribution, and to provide evidence for determining the
starting age for screening colonoscopy in China.
Methods: Retrospective analysis was applied. The data of the patients
who accepted screening colonoscopy in the Digestive Endoscopic Center
of Changhai Hospital during March 2010 and Febrary 2013 was collected.
PDR and ADR was calculated by different genders, age groups and bowel
preparation scores. The test was used to compare the PDR and ADR
between different groups.
Results: A total of 1928 subjects received complete colonoscopies. The
total PDR was 19.55% (IC 17.78%-21.32%), and 23.87% and 10.00% for men
and women respectively. PDR of men was significantly higher than that of
women between 40 and 69 year-group (p<0.05). The total ADR was 11.48%
(IC 9.69%-13.28%), and 14.68% and 5.11% for men and women respectively.
ADR of men was significantly higher than that of women between 40 and
69 year-groups (p<0.05) . the ADR of well preparation group was significantly higher than that of compromised preparation group(p<0.05).
Conclusions: A total of 1928 subjects received complete colonoscopies.
The total PDR was 19.55% (IC 17.78%-21.32%), and 23.87% and 10.00% for
men and women respectively. PDR of men was significantly higher than
that of women between 40 and 69 year-group (p<0.05). The total ADR was
11.48% (IC 9.69%-13.28%), and 14.68% and 5.11% for men and women
respectively. ADR of men was significantly higher than that of women
between 40 and 69 year-groups (p<0.05) . the ADR of well preparation
group was significantly higher than that of compromised preparation
group(p<0.05).
Table 1. Comparation of PDR in subjects with different genders and ages
* P value, difference of PDR between men and women within the same age
group.
**P value, difference of PDR within 5 age groups.
P256
LOCAL APPLICATION OF TACROLIMUS FOR REFRACTORY POUCHITIS
IN PATIENTS WITH ULCERATIVE COLITIS.
M. Uchino1, H. Ikeuchi1, H. Matsuoka1, N. Tomita2 and Y. Takesue3
1
Inflammatory Bowel Disease Center, Hyogo College of Medicine,
Nishinoniya, Japan, 2Lower gastroenterological surgery, Hyogo College of
Medicine, Nishinomiya, Japan and 3Infection Control and Prevention,
Hyogo College of Medicine, Nishinomiya, Japan.
Purpose: Pouchitis is the most common complication that leads to
pouch failure after surgery for ulcerative colitis. Oral antibiotic administration is the main treatment for pouchitis; however, in some cases, refractory
pouchitis may develop, requiring further medical therapy. We investigated
the local applicability of tacrolimus for refractory pouchitis in this phase 1
study.
Methods: Patients with refractory pouchitis were treated for 8 weeks
with a daily tacrolimus (0.08 mg/kg) enema. The efficacy of the treatment
was assessed by comparing Pouchitis Disease Activity Index (PDAI) scores.
A PDAI score ≥ 7 suggests a diagnosis of pouchitis. Complete remission and
clinical response were defined a clinical subscore of 0 points and a clinical
subscore decrease of more than 3 points, respectively. The safety of local
tacrolimus treatment was assessed by the measurement of whole blood
tacrolimus trough levels.
Results: Ten patients with refractory pouchitis were enrolled. No severe
adverse events occurred. The median values of tacrolimus were 2.6 ng/mL
(range 1.2-7.0) at 48 h after application, 3.1 ng/mL (range 1.3-13) at 7 days,
and 3.8 ng/mL (range 1.2-8.2) at 8 weeks. The mean scores decreased from
15.9±0.8 (clinical:5.5±0.4, endoscopic:5.4±0.2, histological:4.9±0.3) to
7.8±0.8 (clinical:0.8±0.6, endoscopic:3.9±0.2, histological:2.9±0.4), during 8
weeks of treatment (P<0.01). Although nine patients recovered from their
clinical symptoms, and 3 patients recovered from pouchitis, no patients
could be achieved complete remission. Although the 9 patients flared up
after stopping tacrolimus use, they recovered the responsibility for antibiotics. During 12months following after this treatment, 4 patients were
treated with infliximab and 6 patients with continuous antibiotics administration.
Conclusions: This study demonstrates that the use of topical tacrolimus
for the treatment of refractory pouchitis was safe and effective in the shortterm for clinical symptoms. This treatment may have early rescue efficacy
in the treatment of antibiotic-refractory pouchitis. Efficacy of maintenance
therapy with thiopurines or long-term administration of tacrolimus should
be considered in future studies.
133
Abstracts
P257
FEASIBILITY AND SAFETY OF INTRAOPERATIVE COLONOSCOPY
AFTER SEGMENTAL COLECTOMY AND PRIMARY ANASTOMOSIS.
R. King1, E. Simmerman1, Z. Klaassen1 and V. Hooks III2 1Surgery, Medical
College of Georgia, Georgia Regents University, Augusta, GA and 2ColonRectal Surgery Associates, University Health Care System, Augusta, GA.
Purpose: The aim of this study is to demonstrate the feasibility and
safety of intra-operative total colonoscopy after primary anastomosis following segmental colectomy in the management of patients who are
unable to receive preoperative colonoscopy secondary to obstructive
symptoms.
Methods: PATIENTS AND METHODS: This was a retrospective cohort
study of patients undergoing single-stage segmental colectomy and anastomosis at a single tertiary care institution in the United States. Among 168
consecutive patients who underwent segmental colectomy and primary
anastomosis, 78 patients (46%) who were unable to receive preoperative
colonoscopy due to obstructive symptoms received intraoperative
colonoscopy after the anastomosis. Main outcome measures include: detection rates of proximal synchronous lesions, occurrence of post-operative
anastomotic leak and other complications, operative time, and length of
hospital stay.
Results: Intraoperative colonoscopy detected synchronous adenomatous polyps in 19 patients (24.4%), diverticular disease in 15 patients (19%),
and colitis/proctitis in 2 patients (2.5%). The overall morbidity in the intraoperative colonoscopy group was 12.8%, with anastomotic leakage in 1
patient, wound infection in 4 patients, and postoperative ileus in 5 patients.
The risk of these complications was not significantly increased when compared to those patients who did not undergo intraoperative colonoscopy
after segmental colectomy and primary anastomosis. (Intraoperative: 29%
vs. Preoperative: 37% p= 0.01) The operation time was 19 minutes longer
in the intraoperative group, but overall length of hospital stay was not significantly different between the two groups (Intraoperative: 6.4±2.9 days
vs. Preoperative: 7.3±4.6 days )..
Conclusions: In patients who are unable to receive preoperative
colonoscopy due to obstructive symptoms, intraoperative colonoscopy
after segmental resection and primary anastomosis is both a feasible and
safe strategy for detecting proximal synchronous lesions. This technique
does not appear to cause an increase in anastomotic leak rates, postoperative complications, or length of hospital stay
P258
COLONOSCOPY FOR RECTAL BLEEDING IN PATIENTS UNDER 50
YEARS OF AGE: ARE WE STAMPING OUT DISEASE OR SPINNING OUR
WHEELS?
J. Harrison1, A. Tolan2, J. Blumetti1, V. Chaudhry1, J. Cintron1 and
H. Abcarian1 1Surgery, John Stroger Hospital of Cook County, Chicago, IL
and 2Surgery, Kaiser Permanente, Oakland, CA.
Purpose: To determine the incidence of significant findings (malignancy, adenomatous polyps, evidence of inflammatory bowel disease) with
diagnostic colonoscopy performed in patients under 50 (blacks under 45)
presenting with symptoms of outlet bleeding or apparent benign anorectal pathology.
Methods: We performed a retrospective review of colonoscopy results
from April 2007 to September 2013 in patients under 50 for indications of
rectal bleeding or benign anorectal disease without other findings such as
weight loss, abdominal pain, bloating, known anemia, new onset constipation, or diarrhea. We recorded age, indication, sex, race/ethnicity, findings,
pathology results, and location of pathology. This study was done under
IRB approval in a major county hospital and all colonoscopies were performed by board certified colorectal surgeons.
Results: 935 patients met the inclusion criteria. 81% of the patients had
isolated bleeding, and the remainder had fissure, hemorrhoids, fistula, or
condyloma with or without rectal bleeding. Results are summarized in table
1. Of the three adenocarcinomas detected, one was in a 1 centimeter polyp,
located in the rectum. The other 2 were larger tumors, both near the rectosigmoid junction, and both patients admitted to associated changes in
bowel habits or weight loss once diagnosed. Unsuspected inflammatory
bowel disease was diagnosed in only one patient whose indication for
colonoscopy was anal fistula. Of the 65 adenomatous polyps, only 10 were
1 centimeter or larger. Of those, only 2 were beyond reach of sigmoidoscopy.
Conclusions: Incidence of pathologic findings in this selected population was low. The majority of neoplasms were within reach of a sigmoidoscope. In the era of cost containment consideration should be given to limited evaluation of the colon in this group of patients. As always, physical
exam including careful digital rectal exam and a stringent history focused
on detecting associated changes in bowel habits, character of the bleeding, bloating or abdominal pain, and weight loss, is crucial.
Table 1: Pathologic findings by age and race
P259
EFFICACY OF INFLIXIMAB COMBINDED WITH SURGERY IN THE TREATMENT OF PERIANAL FISTULIZING CROHN’S DISEASE.
B. Yang, Q. Lin, H. Chen, G. Sun, P. Zhu and Y. Gu Department of
Colorectal Surgery, the Affiliated Hospital of Nanjing University of TCM,
Nanjing, China.
Purpose: To evaluate the the effective of infliximab combined surgery
in the treatment of perianal fistulízing Crohn’s disease (CD).
Methods: A prospectively maintained database was used to identify
patients with fistulizing perianal CD receiving infliximab combined with surgery in the Affiliated Hospital of Nanjing University of Chinese Medicine
from March 2010 to May 2013 were analyzed. One week after operation, all
the patients received infliximab infusion thrice at week 0, 2 and 6, and followed by maintenance therapy every 8 weeks ×3 times. Crohn’s disease
activity index (CDAI), perianal Crohn’s disease activity index (PDAI), body
mass index (BMI), routine blood text and endoscopy were evaluated at
week 0, 30. Adverse reactions and healing time were recorded.
Results: Twenty-eight patients (23 male, median age 25.9±6.9 (range
13-36) years) were treated with infliximab for Peranal Crohn’s fistulae and
the median follow-up time was 26.4 mons. All of the patients underwent
pre-operation MRI scans and 16 patients had MRI scans post-operation.
There were 23 complex fistulae and 5 simple fistulae. At week 30, the
response rate was 100% with 89.3% (25/28) complete responders. The
mean healing time was 32.45 (20-45) days. Anorectal stenosis in 4 patients
were significantly improved. At week 30, CDAI decreased to 70.07±77.54
from 205.47±111.13 (t=9.94, p=0.000) after IFX treatment. PDAI decreased
to 0.93±2.08 from 8.54±4.89 (t=8.59, p=0.000), and BMI increased to
(21.36±2.94) kg/m2 from (18.52±2.84) kg/m2 (t=-6.447, p=0.000). C-reactive
protein (CRP), erythrocyte sedimentation rate (ESR), platelet and neutrophil
were significantly decreased from baseline. Intestinal mucosa of intestinal
healed completely in one patient. There were no serious adverse events
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Abstracts
except hypopotassaemia in one patient and severe infusion reaction in
another.
Conclusions: Infliximab combined with with surgery is effective and
safe for perianal fistulizing CD.
P261
EVALUATION OF A HIGH-RISK PATIENT REMINDER SYSTEM FOR
COLONOSCOPY SURVEILLANCE.
W. Grimes2, A. D. Grimes1, P. A. Cole2 and S. Swistak2 1Surgery- Colon &
Rectal, LSU School of Medicine, Shreveport, LA and 2LSU Health Shreveport,
Shreveport, LA.
P260
MESH PEXY IN THE MANAGEMENT OF POUCH PROLAPSE FOLLOWING ILEAL POUCH-ANAL ANASTOMOSIS.
E. M. Changchien, P. W. Bossart, M. E. Murday and J. A. Griffin Colon and
Rectal Surgery, St Mark’s Hospital, Salt Lake City, UT.
Purpose: The management of pouch prolapse following restorative
proctocolectomy with ileal pouch-anal anastomosis is challenging. To date,
the few reported transabdominal methods of repair have primarily involved
suture pexy. The purpose of this study is to examine our experience with
mesh pexy for this rare complication.
Methods: Retrospective chart reviews were performed on 3 patients (2
females, ages 45 and 26; 1 male, age 56) who were treated with mesh
pouchpexy. Indications for restorative proctocolectomy, time to prolapse,
surgical technique, and postoperative outcomes (recurrence of prolapse
and resolution of presenting symptoms) were analyzed.
Results: All three patients had a diagnosis of chronic ulcerative colitis,
having undergone a stapled J-pouch ileal-anal anstomosis. Time from
pouch formation to development of full-thickness pouch prolapse was 2, 4,
and 17 years. One patient had previously undergone two failed suture pexy
operations for pouch prolapse. Another patient had a suture pexy for pouch
volvulus 2 years prior to her clinical presentation for prolapse. All patients
underwent mesh pouchpexy using a modification of Well’s technique, in
which biologic mesh is wrapped around the posterior aspect of the pouch
and affixed to the presacral fascia. At the time of this study (10 years, 6
years, and 6 months postoperatively) there have been no recurrences of
pouch prolapse. The three patients have an average of 2.7 bowel movements per day and no complaints of fecal incontinence.
Conclusions: Pouch prolapse can occur several years following creation
of an ileal pouch-anal anastomosis. Mesh pouchpexy is a durable and safe
option for the management of this rare complication, and may have less
recurrence rates compared to suture pexy.
Modification of Well’s technique: pouchpexy using biologic mesh in the
treatment of pouch prolapse following IPAA.
Purpose: Colonoscopy has been accepted to reduce both the incidence
and mortality of colon and rectal cancer. Surveillance recommendations are
dependent upon the patient adhering to follow up colonoscopy recommendations. A previously published EMR-based randomized study found
22.6% of the patients in the control arm had follow up procedures schedule with 17.8% having the procedure performed. With automated letters to
the PCP and patient along with an ultimate call to the patient, 44.7% scheduled an exam with 33.5% completing the procedure.
Methods: An automated reminder system for colonoscopy recall system has been in practice for eight years. High-risk patients were identified
with findings of colon or rectal cancer or polyps, a history of colon or rectal
cancer, a history of polyps, or a family history of colon or rectal cancer or
polyps. Billing records were used to identify potential high-risk patients.
The clinical records for these patients were reviewed.
Results: In 2006, four physicians performed 1776 colonoscopies. Seven
hundred and ninety-five high risk patients were identified that were under
80 years of age at the time of their colonoscopy. The records for these
patients were reviewed with a primary endpoint of follow up within 12
months of their recommended surveillance date. On time follow up endoscopies were performed on 540 patients (67.9%)
Conclusions: Adherence to recommendations for follow up endoscopy
is important for high-risk patients. A prospective recall system based upon
automated letters to patients is demonstrated to achieve a high level of
compliance.
P262
3- VERSUS 2-STAGE IPAA IN SEVERE ULCERATIVE COLITIS.
K. G. Cologne, M. Folse, G. T. Ault, A. E. Ortega and A. M. Kaiser Surgery,
Division of Colorectal, University of Southern California Keck School of
Medicine, Los Angeles, CA.
Purpose: Use of 3 stage pouch creation has been advocated for severe
ulcerative colitis to decrease the risk of complications and perform pouch
creation under optimized circumstances. Data are lacking on the validity of
this assumption. We aimed to assess whether the 3-stage approach was
associated with fewer complications and better outcomes. We analyzed our
experience, which includes a high proportion of severe ulcerative colitis on
long term immunosuppression
Methods: We retrospectively analyzed patients admitted at two institutions who underwent surgery for presumed ulcerative colitis. Procedures
were classified as 2- or 3-stage. The two groups were compared for steroid
and TNF use, total length of stay, complication and leak rates, and ultimate
function.
Results: 36 patients (47% female, mean age 45 ±12yrs, range 22-60,
with no differences between groups) were analyzed, of which 44% underwent a 3-stage procedure. Median duration of steroid use prior to surgery
was 6 weeks for 2-stage vs. 10 weeks for 3-stage. TNF agents were used preoperatively in 25% vs. 37.5%. Cytomegalovirus or C. difficile infections complicated presentation in 5% of 2-stage vs. 31% of 3-stage procedures. 37.5%
had an attempted laparoscopic procedure, with 1 conversion in each group.
Average cumulative length of stay (adding all planed admissions) was 11
days (2-stage) vs. 16 days (3-stage). Readmission rates were 25% vs. 37.5%.
Anastomotic leak occurred in 20% vs. 31%. Cumulative complication rates
were 50% vs. 81%. The most common complications were (2-stage): hypoadrenal events despite initial stress dose (7/20), high ileostomy output (3/20);
and (3-stage): high ileostomy output (6/16), infectious (5/16), and obstructive problems (2/16). Pouch dysfunction (>10 stools/day at baseline)
occurred in 25% vs. 12.5%.
135
Abstracts
Conclusions: Surgery for severe ulcerative colitis has a high complication rate regardless of whether a 2 or 3 stage approach is used. A trend
toward improved pouch function was seen with a 3 stage approach in our
patients. Further study is required to provide better insight as to the best
management approach for these patients.
Table: Baseline characteristics of patients with colorectal cancer surgery initiated
laparoscopically, with short-term outcome measures.
P263
SEVERE OBESITY INCREASES CONVERSION RATES AND COMPLICATIONS IN LAPAROSCOPIC COLORECTAL CANCER SURGERY.
C. Kvasnovsky, K. Adams, M. Sideris, J. Laycock, J. Nunoo-Mensah and
S. Papagrigoriadis Department of Colorectal Surgery, King’s College
Hospital, London, United Kingdom.
Purpose: Laparoscopic colorectal surgery is thought to offer obese
patients the advantage of reduced risk of wound infections and incisional
ventral hernias. We aimed to examine whether laparoscopic surgery is as
technically feasible in severely obese patients undergoing colorectal resection for cancer.
Methods: Prospectively collected data on consecutive elective laparoscopic resections for cancer from 07/09 to 09/13. We compared short-term
outcomes in elective operations for one lesion completed either laparoscopically to those that were converted to open surgery or lap-assisted. We
considered very obese and very severely obese patients together as
BMI.>35. We considerd a Clavien-Dindo complication Grade 3 or greater as
major.
Results: Over the study period, 166 operations were performed. 136
cases (81.9%) were completed laparoscopically and 30 cases (18.1%) converted to open or laparoscopic assisted (Table). There was no difference in
conversion rates depending on gender (54.2% male, P=0.91), age at surgery (mean 68.3 years, P=0.71), ASA grade (P=0.06), stage (P=0.57), rectal
lesion (P=0.08), BMI class (18.4% BMI>35, P=0.29), and use of neo-adjuvant
radiotherapy (in 14.1%, P=0.22). When these factors were considered in a
multiple logistic regression (MLR), however, severely obese patients were
4.1 times as likely to require conversion to open surgery (95% CI 1.1-15.1,
P=0.03). There was no other significant predictor of conversion to open surgery. Mean operative times, however, were similar between severely obese
and other patients (median 251 minutes, P=0.10), as were wound infections
(in 12.5%, P=0.14). Major complications were more common after conversion (23.3% vs 10.3%, P=0.05), and on MLR, BMI >35 was the only predictor
of major complication (P=0.03). Hospital stay was also longer after conversion (8 vs 12.5 days, P=0.02).
Conclusions: Colorectal cancer surgery in the severely obese is difficult
and results more frequent conversion to open surgery. This does not have
an effect on operative duration but results in increasing complications and
hospital stay. This information should be included in the consent process
for improved transparency.
N (%) or median (IQR). Fischer’s exact test or exact Wilcoxon two-sample test,
where appropriate.
P264
LAPAROSCOPIC APPROACH FOR T4 COLON CANCER– A DECADE OF
EXPERIENCE.
P. J. Shukla, K. Trencheva, L. Maggiori, C. Merchant, F. Michelassi,
T. Sonoda, S. W. Lee, G. Nandakumar and J. W. Milsom Weill Cornell
Medical College, New York, NY.
Purpose: Use of laparoscopy for surgical treatment of T4 cancers
remains a concern mostly associated to technical feasibility, high conversion rate, inadequate oncological clearance and surgical outcome. This
study evaluates the short and long term clinical and oncological outcomes
after laparoscopic (LAP) surgery for T4 colon cancers.
Methods: A retrospective chart review of all patients with T4 colon cancer (pT4) who underwent surgery at a single institution from 1998 to 2010
was done. The inclusion criteria were patients with pathologically proven
T4 disease (pT4), without metastasis (M0) and who had either LAP or open
surgery. Variables collected were: demographics, surgical approach, conversion rate, postoperative morbidity and mortality, tumor location, pathological tumor stage, lymph nodes harvested, residual tumor, tumor recurrence and survival.
Results: 83 cases (46 Female) with median age 70 years and median
BMI 24.8 kg/m2 were included in the study. LAP surgery was performed on
61 and open on 22 pts. Out of the 61 (LAP) pts., 44 had straight LAP and 17
hand-assisted laparoscopic (HALS) surgeries. Conversion to open technique
was 14(23%). The groups were similar in overall staging p=0.461 with
35(42%) of the pts. with stage 2 and 48(58%) with stage 3. A complete R0
resection was achieved in 61 (100%) of the LAP and in 21 (96%) in the open
group pts., p=0.265. The average number of lymph nodes (LN) harvested
was 21 in LAP and 24 in the open groups, p=0.202 with no difference in
terms of positive LN, p=0.670. Postoperative morbidity within 30 days was
similar between the groups, p=0.467 and mortality was zero. Three year
Overall Survival between the groups was LAP 82% [71-93%], Open: 81%
[61-100%], p=0.525 and Disease Free Survival was LAP 67% [54-79%], Open:
64% [43-86%], p=0.848. The follow-up time in months was 40±25 in LAP
and 34±26 in the open group, p=0.325
Conclusions: The results of our study show that LAP surgery is feasible
in the majority of T4 colon cancers. With comparable short and long term
clinical and oncological outcomes, this study suggests that laparoscopy
136
Abstracts
may be considered as an alternative approach for T4 colon cancers. However, larger studies confirming selection criteria are needed.
Results: A total of 35 patients between 10/2012 and 08/2013 underwent LVMR with biological mesh. All were female. Median age was 45 years
(range 25-72). There was a significant improvement in ODS scores following surgery (pre 26.45, post 7.82, p<0.001). Digitation and laxative use was
also globally improved. Quality of life and constipation scores measured by
PAC-QOL were significantly improved after LVMR (pre 3.53, post 0.94,
p<0.001). Few complications were encountered during early follow-up.
There were two readmissions - one patient with bleeding and another with
pain requiring inpatient analgesia. There were no mesh erosions, recurrences or other mesh-related complications identified.
Conclusions: LVMR with biological mesh appears safe in the early follow-up period, with significant improvement in functional outcome scores
and quality of life. No early mesh erosions were encountered during followup but further data is required to confirm longer term efficacy of the procedure compared with synthetic mesh.
P267
P265
LAPAROSCOPIC MONITORED COLONOSCOPIC POLYPECTOMY FEASIBILITY AND SAFETY IN THIS TECHNIQUE: LONG-TERM FOLLOW-UP.
M. A. Hernandez and M. E. Franklin Minimal Invasive Surgery, Texas
Endosurgery Institute, San Antonio, TX.
Purpose: Colonoscopy is widely used to remove benign polyps. However, a variety of ‘‘difficult polyps’’ are not accessible for colonoscopy
removal because of their size, broad base, or difficult location (impossible
to see the polyp’s base, polyps behind mucosal folds or in tortuous colonic
segments). The aim of the study was to evaluate the long-term follow-up
and oncologic safety of laparoscopically monitored colonoscopic polypectomy (LMCP).
Methods: From May 1990 to September 2013, all the patients undergoing LMCP were analyzed and prospectively followed with colonoscopy
studies at 6 months, 1 year, and every year thereafter.
Results: A total of 320 polyps were removed in 270 patients: 142 men
(52.6%) and 128 women (47.4%). The mean age was 74.7 years (range 46–
99 years). During a mean follow-up of 63.37 months (range 6–196 months)
and median follow- up of 65 months, there has been no recurrence.
Conclusions: Long-term follow-up demonstrated that a combined
endoscopic-laparoscopic approach is safe and effective. Malignant lesions
identified during LMCP can be treated laparoscopically during the same
operation, avoiding the need of a second procedure, with good long-term
oncologic outcome.
P266
USE OF BIOLOGICAL MESH FOR LAPAROSCOPIC VENTRAL MESH RECTOPEXY: COULD IT REDUCE MESH EROSION?
P. Waterland1, F. Khan2 and M. Farmer2 1Colorectal Surgery, Birmingham
Heartlands Hospital, Stoke on Trent, United Kingdom and 2Colorectal surgery, University Hospital of North Staffordshire, Stoke on Trent, United
Kingdom.
Purpose: Conventional laparoscopic ventral mesh rectopexy (LVMR)
using synthetic mesh carries a small risk of mesh erosion into the rectum
or vagina. This devastating complication is associated with significant additional morbidity and may potentially be avoided by performing LVMR using
biological mesh. Porcine acellular dermal matrices provide a scaffolding for
tissue growth without the typical foreign body response (encapsulation,
fibrosis, extrusion) which may be seen with synthetic mesh. This study
assesses short term outcomes of LVMR using biological (Strattice tm) mesh
for patients with obstructed defecation syndrome (ODS).
Methods: All patients undergoing LVMR with biological porcine mesh
were enrolled into a prospective database. Basic demographic data, functional outcome scores, readmission rate and complications were recorded
and assessed.
EXPERIENCE WITH LIPOSOMAL BUPIVACAINE IN MINIMALLY INVASIVE COLON SURGERY.
E. McKeown, A. Bastawrous and K. Chuang Swedish Medical Center,
Seattle, WA.
Purpose: Traditionally, narcotics have been a mainstay of therapy in
pain control of the postsurgical patient. However, side-effects have tended
to increase hospital stay and patient morbidity. Adjunctive methods from
epidural catheters to local blocks have been used to address acute postoperative pain control. We evaluate the use of liposomal bupivacaine
(LB)(Exparel®, Pacira Pharm) on pain control, PCA use, narcotic use, and
length of stay.
Methods: A retrospective nonrandomized chart review was performed.
17 patients undergoing colon or rectal resections who received LB perioperatively were compared to 17 case matched controlled patients. Those
patients with complex comorbidities, those who received an epidural for
pain control peri-operatively, and those with a history of chronic pain were
excluded from our study. Pain scores and narcotic use, standardized to oral
hydromorphone equivalents, were recorded by standard nursing protocol.
For patients in our control arm, a PCA was routinely begun in the PACU. For
our patients in the LB arm, hydromorphone was administered on a PRN
basis. All patients were offered a full liquid diet the night of surgery and
advanced if they had no nausea or distention the next day.
Results: We found that, on POD0 and 1, pain scores were significantly
lower in the LB patients (for POD0, control arm 20 +/- 5, LB arm 17 +/- 6;
POD1, control arm 23 +/- 6, LB arm 16 +/-5). Narcotic use was significantly
lower on POD1 for the LB arm (control arm 83 equivalents versus 59 equivalents, p<0.01). We found that length of stay was decreased in the LB arm,
though that did not reach statistical significance. Only 3 of 17 patients in
the LB arm required a PCA. There were no adverse events in either arm
related to local anesthetic or liposomal bupivacaine.
Conclusions: The use of liposomal bupivacaine in this patient population is beneficial, both in patient-rated pain scores and in narcotic usage.
The lack of difference shown on post-operative day two between the two
arms is, we believe, due to the routine addition of oral narcotics. Randomized controlled trials are needed to further evaluate cost-benefit ratios as
well as to elucidate possible differences in length of stay.
P268
LEARNING CURVE FOR ROBOTIC-ASSISTED LAPAROSCOPIC SURGERY
DOES NOT COMPROMISE ONCOLOGIC AND CLINICAL OUTCOMES IN
RECTAL CANCER RESECTION.
J. L. Agnew, F. Chory, P. Strombom, G. Bonomo, K. Melstrom and J. Martz
Dept of Surgery, Beth Israel Medical Center, New York, NY.
Purpose: Robot-assisted laparoscopic surgery is being utilized more frequently for minimally-invasive management of rectal cancer, and is associ-
137
Abstracts
stipation. Comparisons of means and frequencies were performed by STATA
10 with significance at p<0.05.
Results: A total of 31 procedures were performed; 18 laparoscopic, 8
open, and 5 robotic. We followed patients for an average of 12 months
(range 3 to 45 months). We found no significant differences in operative
time, time to incision, blood loss, hospital length of stay, 30-day postoperative complications, or long-term complications between or within laparoscopic, open, and robotic groups. Interestingly, sex, BMI, resection rectopexy, or concomitant urogynecologic procedure did not significantly
influence operative time, regardless of operative approach. Hospital length
of stay was significantly longer in patients with BMI>35 (p=0.03). Complications, need for additional procedures, recurrence, and functional complaints
did not vary significantly with treatment approach.
Conclusions: Our early experience with robotic rectopexy is shown in
this study to be as safe a procedure as laparoscopic and open approaches,
and does not confer significantly longer set up and operative times as many
believe.
ated with a three-phase learning curve to incorporate into practice. The
objective of this study is to analyze whether clinical and oncologic outcomes of patients undergoing rectal cancer resection via a hybrid laparoscopic-robotic approach are affected by the learning curve.
Methods: A single-institution, retrospective review of a rectal cancer
database was performed. Patients who underwent robotic-assisted laparoscopic resection from 2011-2013 were included. Patient demographics evaluated were gender, age, body mass index, ASA score, tumor location,
neoadjuvant treatment, and history of abdominal surgery. Clinical and
oncologic outcomes evaluated were conversion rate, operative time, length
of stay, complication rate, circumferential and distal resection margin
involvement, and number of lymph nodes collected. Patients were subdivided into 3 chronologic cohorts, and analysis of variance (ANOVA) compared outcomes between initial and later cases.
Results: Fifty-seven patients with rectal cancer underwent laparoscopic-robotic resection, utilizing the robot to complete the total mesorectal excision (TME). Conversion to open occurred in 2 cases (3.5%). Mean
operative time was 265.2 ± 47.7 mins. Mean number of lymph nodes harvested was 17 ± 13.8 nodes. The distal resection margin was uninvolved in
all specimens, while the circumferential resection margin was positive in
one specimen (1.8%). Mean length of stay was 4.6 ± 2.7 days. Thirty-day
complication rate was 14%. ANOVA analysis of the 3 chronologic cohorts
(19 patients each) revealed no statistically significant variation in clinical or
oncologic outcomes when comparing initial to later cases.
Conclusions: Although technically demanding, hybrid laparoscopicrobotic resection is an effective and safe approach for management of rectal cancer. Given the confines of the pelvis, robotic TME is an appropriate
method to achieve acceptable oncologic outcomes in a minimally-invasive
fashion. Safety and efficacy is not compromised during the learning curve
of robotic colorectal surgery.
Comparisons among Rectopexy Techniques
P270
AN ANALYSIS OF BMI AND CONVERSION RATES OF SINGLE-INCISION
ROBOTIC COLON SURGERY.
R. Laird and V. Obias Surgery, George Washington University, Washington,
DC.
Analysis of Variance (ANOVA) Comparison of Chronologic Learning Curve
Subgroups
P269
EARLY EXPERIENCE WITH ROBOTIC RECTOPEXY: A SINGLE INSTITUTION’S COMPARISON TO LAPAROSCOPIC AND OPEN TECHNIQUES.
M. B. Grodsky, E. V. Thompson, K. Kirthi, J. M. Quiogue, J. M. Ayscue,
T. J. Stahl, A. S. Kumar and J. F. Fitzgerald Colon and Rectal Surgery,
MedStar Washington Hospital Center, Washington, DC.
Purpose: Minimally invasive colorectal surgery is beneficial in decreasing post-operative pain and hospital length of stay. Despite offering superior visualization, laparoscopy restricts the surgeon’s range of motion.
Robotic surgical instrumentation may alleviate this limitation by offering 7
degrees of freedom and three dimensional visualization, which is especially
crucial in the restricted space of a narrow bony pelvis when performing rectopexy procedures for prolapse. We review our early experience with
robotic rectopexy and compare it to both laparoscopic and open techniques.
Methods: We conducted a retrospective review of all rectopexy cases
for prolapse performed by colorectal surgeons at our institution from 2007
to 2013. We analyzed patient demographics, operative details, short and
long-term complications. Follow up detailed recurrence of prolapse, further
surgical procedures, and the presence of Rome Criteria for functional con-
Purpose: Single incision robotic surgery is gaining popularity among
advanced laparoscopic surgeons in the United States. Body Mass Index
(BMI) is a variable that is associated with an increased conversion and complication rate in single incision laparoscopic surgery. This study documents
patient demographics, clinical outcomes, complications, and conversion
rates associated with BMI.
Methods: A consecutive series of single incision robotic colectomies
was performed from 2010 to 2013 and were included in the analysis. A
prospective database was created to record age, gender, BMI, conversions,
complications, operative times, estimated blood loss, length of stay, and
surgery performed. Data was analyzed using a t test and statistical significance was defined as p < 0.05.
Results: 31 patients have undergone single incision robotic colectomies. A BMI greater than 30 was used as the definition of obesity and was
named group A. All statistically significant values are defined as p < 0.05.
The mean age in years was 55.0 + 15.7 in group A versus 53.7 + 10.8. There
were 8 males and 5 females in group A versus 7 males and 11 females.
Group A had 7 left and 6 right colectomies performed compared to group
B which had 11 left and 7 right colectomies performed. The average BMI in
group A was 37.3 + 8.2 versus 26.1 + 2.2. There were 2 robotic single ports
converted to open in group A versus 2 robotic single ports converted to
standard laparoscopic in group B. The estimated blood loss in group A was
306 mL versus 145 mL. Operative time varied from 220 + 105 minutes in
the obese group versus 204 + 108 minutes in group B. The average length
of stay in days was 4.31 + 2.1 in group A versus 4.44 + 1.9. There were 6
complications noted in each group within the 30 day postoperative period.
Conclusions: Robotic single incision colectomy is safe in patients with
a BMI greater than 30. Operative time and length of stay was similar
between the two groups. In our robotic series, high BMI was not associated
with an increase in complications or conversion rates as is usually seen in
standard laparoscopy.
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Abstracts
P271
LAPAROSCOPIC-ASSISTED COLECTOMY AND MODIFIED DUHAMEL
PULLTHROUGH PROCEDURE FOR IDIOPATHIC MEGACOLON IN
ADULTS.
W. Tong and X. Zhang General surgery, Daping hospital, Chongqing,
China.
Purpose: Idiopathic megacolon is an uncommon and poorly characterised condition in adults. To date, no laparoscopic operative experience
has been reported in adults. The aim of this study was to describe our initial experience of laparoscopic-assisted technique for magacolon in adults.
Methods: Between October 2006 and November 2013, 12 patients
diagnosed with idiopathic megacolon who underwent the modified
Duhamel procedure were enrolled in this study. The diagnosis was suspected on the basis of the typical medical history of lifelong constipation.
The diagnosis was confirmed by anorectal manometric studies and/or rectal biopsy. Main outcome measures included the operative time, blood loss,
conversion to open procedure, postoperative hospital stay, and complications.
Results: This group consists of 11 female and one male. The mean laxatives dependent duration was 16.3 years. Ten patients underwent laparoscopic-assisted total colectomy and modified Duhamel pullthrough procedure with ileo-retrorectal anastomosis. Two patients underwent
laparoscopic-assisted sigmoid colectomy and descending colon-retrorectal
anatomosis.The mean operative time was 186 min. The mean estimated
blood loss was 110 ml. The mean day of first time to flatus was 2.7 days,
and the mean hospital stay was 9.5 days. There was no coversion to an open
procedure and no surgical mortality. No infections or related complications
were observed. Severe diarrhea was the most prominent complications during the early period postoperatively in patients with total colectomy. However, three months postoperative, all patients gradually got adaptation to
the diarrhea.
Conclusions: Laparoscopic-assisted colectomy and modified Duhamel
procedure seems a safe and reliable technique in the treatment of idiopathic megacolon in adults.
and LP, respectively) underwent emergency operation (27.6%, 5.4%, 3.4%,
and 1.8%, p<0.001) and had ASA level of 3-5 (p<0.001). Overall SSI rates
after OC, OP, LC and LP were 15.1%, 17.9%, 9.1% and 10.3% respectively
(p<0.001). For obese patients, corresponding SSI rates were 18.8%, 21.7%,
11.5%, and 13.9% (p<0.001). On multivariate analysis, factors associated
with increased SSI were BMI>30, ASA class 3-5, tobacco use, steroid use,
resident involvement, emergent operation, hypertension, and diabetes. For
proctectomy, LP was associated with similar SSI as LC (OR: 1 vs. 0.95, p=0.3)
and significantly lower SSI than OC or OP (OR: 1.16 and 1.44 respectively,
p<0.005 for both). In both non-obese and obese patients, open surgery was
associated with greater SSI than laparoscopy; SSI being highest in the obese
undergoing OP.
Conclusions: In colorectal surgery, an already high-risk outlier for SSI,
obesity and proctectomy are associated with the highest risk for SSI.
Despite the particular technical challenges of laparoscopy in these circumstances, the minimally invasive approach attenuates the risk of SSI in these
high-risk patients and thus should be strongly considered during treatment
planning.
Multivariate analysis of factors associated with surgical site infection (SSI)
P272
THE MINIMALLY INVASIVE APPROACH MAXIMALLY BENEFITS
PATIENTS AT THE HIGHEST RISK FOR COMPLICATIONS.
I. Esemuede, S. Lee-Kong, D. Feingold and P. R. Kiran Colorectal surgery,
New York Presbyterian Columbia University Medical Center, New York, NY.
Purpose: While laparoscopy has traditionally been reserved for less
technically challenging circumstances, the minimally invasive approach
may in fact maximally benefit patients at greatest risk for complications.
Since obesity and proctectomy pose particular technical challenges to
laparoscopy and are associated with the greatest risks of complications, we
evaluate the role of laparoscopy in minimizing surgical site infection (SSI)
in such patients.
Methods: From the National Surgical Quality Improvement Program
(NSQIP) database, outcomes for obese (BMI>30 kg/m2) and nonobese
(BMI<30 kg/m2) patients undergoing colectomy or proctectomy from 20062011 by laparoscopic (LC, LP) or open (OC, OP) approaches were compared.
A multivariate analysis determined the influence of laparoscopy within each
group on SSI.
Results: Of 60,927 patients, 52% were female, mean age was 61.8 years,
29,568 (48.5%) underwent OC and 5840 (9.6%) LP. Mean BMI for LP vs OC
was 27.9 versus 28.1 kg/m2 (p=0.02). OC patients more likely (than OP, LC,
P273
OUTCOME COMPARISON OF ROBOTIC VERSUS LAPAROSCOPIC
RESECTION FOR SIGMOID DIVERTICULITIS WITH FISTULIZATION.
P. Elliott1 and M. A. Abbas2 1Surgery, Kaiser Permanente, Los Angeles, CA
and 2Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi,
United Arab Emirates.
Purpose: Robotic colorectal surgery is growing in the absence of significant outcome data. To date, there is no study comparing robotic to laparoscopic surgery for diverticulitis with fistulization. The aim of this study was
to compare the outcomes of these two techniques.
Methods: A retrospective review was conducted of all consecutive
patients who underwent robotic assisted excision for sigmoid diverticulitis
with fistulization over a 1 year period. All operations were performed by 1
139
Abstracts
surgeon at a tertiary care center. Group comparison was undertaken with
the prior 20 consecutive cases done laparoscopically by the same surgeon.
Results: 31 patients were analyzed [Group 1: robotic, Group 2: laparoscopic]. Table 1 highlights demographics, intra-operative and post-operative outcomes. There were no significant differences demographically.
Colovesical fistula was the most common fistula in both groups. A higher
percentage underwent anterior resection in the robotic group (73% vs.
45%, p=0.14). There was little difference in median operative time (250 minutes vs. 247 minutes, p=0.53). The robotic group was associated with more
conversions to open surgery (18% vs. 0%, p=0.05) and stayed longer in the
hospital (7 days vs. 4 days, p=0.01). Overall complication and readmission
rates were similar. No mortality was noted in either group and all 31
patients healed their fistula as of their last follow-up.
Conclusions: In this study, both laparoscopic and robotic surgery were
effective techniques for treating chronic sigmoid diverticulitis with fistula.
However, the conversion rate to open surgery and length of stay were
higher in the robotic arm.
Robotic [Group 1] vs. laparoscopic [Group 2] fistula resection
laparoscopic TAC (OR=0.24, p<0.01) and TC (OR=0.36, p=0.01) were associated with decreased mortality compared to open TAC and TC. Compared to
the control group, laparoscopic TAC/TC had an increased risk of developing
one complication (OR=1.3, p<0.01), and similar mortality (0.44% vs.0.42%,
p=0.93). Laparoscopic TAC/TC was associated with a longer length of stay
(LOS) compared to the control group (5.2 vs. 4.4 days, p<0.01), but shorter
when compared to the open cohort (5.2 vs. 7.2 days, p<0.01). Hospital
charges were greater with laparoscopic TAC/TC compared to the control
group ($46,379 vs. $38,813, p<0.01), although less than the open cohort
($46,379 vs. $50,494, p<0.01).
Conclusions: Complex laparoscopic colectomy is associated with
improved outcomes, lower mortality, and decreased LOS and hospital
charges compared to an open approach. When compared to more common laparoscopic procedures, there is a higher morbidity rate, though similar mortality. Further efforts may help optimize patient selection and operative approach.
P275
LAPAROSCOPIC VERSUS OPEN ILEOSTOMY REVERSAL: IS THERE AN
ADVANTAGE TO A MINIMALLY INVASIVE APPROACH?
G. Menon, M. Young, M. D. Jafari, F. Jafari, E. Perez, J. Carmichael, S. Mills,
M. Stamos and A. Pigazzi Surgery, University of California Irvine Medical
Center, Orange, CA.
P274
IS A MINIMALLY INVASIVE APPROACH JUSTIFIED FOR COMPLEX
COLECTOMY? A NATIONWIDE COMPARISON.
A. T. Schlussel1, E. K. Johnson2, J. A. Maykel3 and S. R. Steele2 1General
Surgery, Tripler Army Medical Center, Honolulu, HI, 2Colon & Rectal Surgery,
Madigan Army Medical Center, Fort Lewis, WA and 3Colon & Rectal Surgery,
University Hospital Case Med Center, Cleveland, OH.
Purpose: Despite wide reports of improved outcomes with laparoscopy
for colonic procedures, technically complex surgeries including transverse
colectomy (TC) and total abdominal colectomy (TAC) are often excluded
outside of specialized centers. We compared outcomes of laparoscopic
TAC/TC versus an open approach using a population database.
Methods: ICD-9-CM codes identified laparoscopic and open TC and TAC
from the 2008-2011 Nationwide Inpatient Sample (NIS) databases. Laparoscopic right, left, and sigmoid colectomy were used as a control group for
added comparisons. Multiple linear and logistic regression analyses were
used to compare outcome measures.
Results: We identified 45,771 admissions, (mean age 59.2 years; 47%
male), including 2,486 in the study group [laparoscopic TC (n=1,175) and
TAC (n=1,311)]. Overall morbidity was lower with laparoscopic TAC/TC than
with open (17.3% vs. 27.4%, p<0.01), including decreased infectious
(OR=0.41, p<0.01), mechanical wound (OR=0.55, p<0.01), pulmonary
(OR=0.34, p<0.01), GI tract (OR=0.77, p<0.01), and cardiovascular (OR=0.51,
p<0.01) complications. Accounting for demographics and comorbidities,
Purpose: Ileostomy reversal is a commonly performed procedure after
colon and rectal operations. Laparoscopic assistance with lysis of adhesions
is an increasingly used modality, with potential benefits over conventional
open surgery. The aim of this study was to compare outcomes of laparoscopic and open ileostomy reversal.
Methods: 133 consecutive patients undergoing ileostomy reversal
between June 2009 and August 2013 were analyzed using a retrospective
database. The cohort was comprised of 79 laparoscopic and 54 open cases,
performed by 4 surgeons at a single institution. Data was analyzed for operative characteristics, postoperative outcomes and 30-day morbidity and
mortality.
Results: Both groups had comparable ASA scores, BMI and gender distribution. Operative parameters studied included duration of surgery, estimated blood loss, repair of coexistent hernia, whether lysis of adhesions
was performed, duration of lysis of adhesions, type of intestinal anastomosis and technique of ostomy site closure. The laparoscopic group had a significantly longer duration of surgery (109 versus 93 minutes, p=0.03); however performed more lysis of adhesions (59% versus 26.5%, p=0.0001) and
completed more hernia repairs (32.7% versus 7.6%, p=0.0002). The laparoscopic group included 43 (79.6%) extra-corporeal and 11 (20.4%) intra-corporeal anastomoses. The majority of wounds were closed by purse string in
both open and laparoscopic cohorts (86% and 85% respectively). There was
no significant difference in estimated blood loss (31 versus 39 ml) or
median length of stay (4.0 versus 4.0 days). Post-operative outcomes studied included readmission rates, urinary retention, urinary tract infections,
bleeding, ileus, sepsis, cardiac complications, surgical site infections (SSI)
and overall mortality and morbidity. Superficial and deep SSI together were
significantly higher in the open cohort (8.8% versus 0%, p=0.04). No significant difference was noted in any other variables and no mortality was
noted in either group.
Conclusions: Laparoscopy is safe and effective in ileostomy reversal,
with potential benefits in terms of concomitant hernia repair, lysis of adhesions and lower wound infection rate.
140
Abstracts
P276
LAPAROSCOPIC RECTOPEXY FOR RECURRENT RECTAL PROLAPSE.
S. Sharp, J. K. Francis, B. T. Valerian, J. J. Canete, D. A. Chismark and
E. C. Lee Colon and Rectal Surgery, Albany Medical Center, Albany, NY.
Purpose: The aim of this study was to evaluate the safety and clinical
outcomes of laparoscopic rectopexy for recurrent rectal prolapse compared
to primary laparoscopic repair at a single institution.
Methods: This is a single institution retrospective analysis from 20042013 of laparoscopic rectopexy for rectal prolapse. Data was gathered via
review of medical records and questionnaires for patients with less than 24
months of follow up. The following criteria were evaluated: age, gender, primary versus recurrent rectal prolapse, type of laparoscopic procedure
(resection rectopexy versus rectopexy alone), duration of operation, open
conversion rate, previous perineal operations, hospital length of stay, ASA
score, smoking status, 30-day mortality rate, morbidity, total follow-up time,
recurrence rate (full thickness and mucosal prolapse), and time to recurrence.
Results: A total of 85 patients who had laparoscopic rectopexy for rectal prolapse were identified. Of these, 20 (24%) had surgery for recurrent
prolapse. For the patients with recurrent prolapse, previous perineal repair
had been attempted in 11 (55%). Comparing the recurrent versus primary
rectal prolapse patients, mean operative time was 82 minutes (range 33161 minutes) vs. 102 minutes (range 37-223 minutes). Open conversion rate
was 5.0% vs. 3.0%, morbidity rates were 3% vs. 21%. There were no differences in age, ASA class, hospital length of stay, or follow up time. Mean
overall follow-up time was 22 months. The questionnaire response rate
including follow-up phone calls was 66% (33/50). Recurrence rates were
similar, 20% (4/20) vs. 20% (13/65). Difference in time to recurrence was statistically significant, 21.5 vs. 43.8 months.
Conclusions: Laparoscopic rectopexy for recurrent rectal prolapse is a
safe procedure and can be performed with minimal risk. Rectal prolapse
recurs sooner in patients with a history of previous repair. The overall rate
of recurrence is not affected by previous history of repair but was higher
than historical estimates in this single institution review.
P277
REGULATION OF 18F-FDG ACCUMULATION BY COLORECTAL CANCER
CELLS WITH MUTATED KRAS.
M. Iwamoto1, K. Kawada1, Y. Nakamoto2 and Y. Sakai1 1Surgery, Kyoto
University, Kyoto, Japan and 2Imaging and Nuclear Medicine, Kyoto
University, Kyoto, Japan.
Purpose: Positron emission tomography (PET) with 18F-Fluorodeoxyglucose (FDG) has been widely used in the management of colorectal cancer (CRC). We recently demonstrated FDG accumulation is significantly higher in CRC with KRAS mutation than in those with wild-type
KRAS by a retrospective study with 51 CRC patients. The purpose of this
study is to investigate the molecular mechanisms how FDG is accumulated
in CRC, especially focusing on KRAS gene.
Methods: Using paired isogenic CRC cell lines that differ only in the
mutational status of KRAS gene, we measured FDG accumulation in vitro
under normoxic and hypoxic conditions. We also investigated the roles of
glucose transporter 1 (GLUT1) and hexokinase 2 (HK2), which are major constituents of FDG accumulation, and hypoxia inducible factor-1a (HIF1A),
which play a major role in responses to hypoxia. In addition, we evaluated
FDG accumulation in vivo in a xenograft mouse model using small animal
PET scanner, and also investigated distribution of hypoxic lesions and
expressions of HIF1A, GLUT1 and HK2 within tumor xenografts by immunohistochemical analysis.
Results: In in vitro assays, CRC cells with mutated KRAS showed significantly higher FDG accumulation compared with their isogenic cells with
wild-type KRAS in normoxic condition. The expression levels of GLUT1 and
HK2 were higher in CRC cells with mutated KRAS, and FDG accumulation
was decreased by knockdown of GLUT1. Hypoxic induction of HIF1A was
much higher in CRC cells with mutated KRAS, which resulted in higher
GLUT1 expression and FDG accumulation. In in vivo assays, small animal
PET showed that FDG accumulation was significantly higher in the
xenografts with mutated KRAS than in those with wild-type KRAS. Immunohistochemical staining of HIF1A and GLUT1 were colocalized with hypoxic
lesions (revealed by pimonidazol staining), and these intensities were
higher in the xenografts with mutated KRAS.
Conclusions: KRAS mutation in CRC cells causes higher FDG accumulation possibly by up-regulation of GLUT1, and HIF1A also contribute to
increased FDG accumulation in hypoxic lesions. FDG-PET might be useful
for predicting the KRAS status of CRC noninvasively.
P278
SECONDARY PROCTECTOMY AND ILEAL POUCH-ANAL ANASTOMOSIS IN PATIENTS WITH FAMILIAL ADENOMATOUS POLYPOSIS: IS
DEFUNCTIONING ILEOSTOMY NECESSARY?
X. Wu, M. F. Kalady and J. M. Church Colorectal Surgery, Cleveland Clinic,
Cleveland, OH.
Purpose: Many studies have examined the effect of omitting an
ileostomy on the outcomes of primary ileal pouch-anal anastomosis (IPAA),
but few have looked at this question in secondary IPAA. Absence of a colectomy may make for less ileus and a quicker recovery. We compared pouch
outcomes and quality-of-life between FAP patients with and without an
ileostomy at the time of secondary proctectomy and IPAA.
Methods: FAP patients undergoing a secondary IPAA were identified
from an IRB approved polyposis database. Patients with a stapled anastomosis who were generally well, without cancer or anemia, and who had an
uneventful surgery, intact anastomotic donuts and a negative leak test were
candidates for an undiverted pouch.
Results: Seventy-three patients, 58 (79.5%) with a defunctioning
ileostomy and 15 (20.5%) without, were included. There were 42 men
(57.6%). Mean age at IPAA surgery was 11.9 years. Median time from IRA to
IPAA was 19.4(9.8-27.5) years. Indications for secondary IPAA were uncontrolled polyps in 46 (63.0%), high grade dysplasia in 11 (15.1%) and cancer
in 16 (21.9%). Sixty-two patients (84.9%) had a J pouch and 11 (15.1%) had
an S pouch. All undiverted patients had a stapled IPAA while a third of those
with diversion were hand sewn (P=0.008). There was no difference between
the two groups in other demographics. Overall median follow-up was
10.2(4.2-15.4) years, 10.8(4.0-15.5) years in diverted patients and 9.5(4.414.0) years in undiverted (P=0.73). Rates of short-term and long-term pouch
complications were similar (see table). Patients without ileostomy had a
longer hospital stay than those with an ileostomy(7.0[6.0-10.0] days vs.
10.0[7.0-11.0] days, P=0.042). Cleveland global quality-of-life scores were
similar between the two groups.
Conclusions: In selected patients with FAP, one stage secondary IPAA is
safe. However the prolonged length of stay seen with one stage primary
IPAA is not avoided.
141
Abstracts
Short and long-term complications.
P280
THE PROGNOSTIC VALUE OF “TUMOR BUDDING” IN PATIENTS WITH
LOCALLY ADVANCED RECTAL CANCER AFTER NEOADJUVANT
CHEMORADIOTHERAPY.
A. Sirin1, S. Sokmen1, N. Arslan1, M. Unlu2, T. Bisgin1, H. Ellidokuz3,
S. Sarioglu2 and M. Fuzun1 1Department of General Surgery, Dokuz Eylul
University, Izmir, Turkey, 2Department of Pathology, Dokuz Eylul University,
Izmir, Turkey and 3Oncology Institute, Dokuz Eylul University, Izmir, Turkey.
P279
TRANSSPHINCTERIC APPROACH TO DIFFICULT RECTAL PATHOLOGY.
K. Johnson2, R. Khalaf2, W. J. Strutt1, W. Lutfiyya1, R. Mueller1, S. Dejesus1,
J. Gallagher1, A. Ferrara1 and P. Williamson1 1Colon and Rectal Clinic of
Orlando, Orlando, FL and 2University of Central Florida, Orlando, FL.
Purpose: The transsphincteric approach (TSA) is a valuable surgical
access technique for complex pathology of the rectum. The technique and
experience using the TSA for benign and selected malignant tumors of the
rectum as well as for rectourethral fistulas is described and reviewed.
Methods: In this retrospective study of a single institution, the medical
records of 51 patients who underwent the TSA from 1990 to 2013 by one
surgeon were reviewed. Information about patient baseline characteristics,
pathology, as well as morbidity of the surgical approach and surgical outcomes were collected.
Results: In this study, 51 subjects with complex rectal pathology underwent the transsphincteric approach. Of these 26 female and 25 males subjects with an average age of 63.2 years, 41 patients underwent a TSA for
rectal tumors, four for a rectourethral fistula, and six for other benign rectal
masses. 85% of patients with rectal tumors were preoperatively staged with
endorectal ultrasound. Post-operative tumor pathology revealed 11 invasive malignancies and 30 benign masses specifically 25 adenomas and 5
carcinoma-in-situs. The average diameter of the rectal masses was 6.2 x 4.2
cm and encompassed at least 90 degrees of the bowel circumference with
an average of 173.2 degrees. Mean hospital stay was 6.5 days. Average follow-up was 32 months (range, 0 – 142 months). Morbidity of the TSA was
21.5%. Five patients had wound infections, three patients had mild incontinence (gas, liquid stool), two patients experienced wound dehiscence, and
one had an enterocutaneous fistula. There were no deaths at 30 day follow
up. Overall recurrence rate was 14.6% for benign and malignant rectal
tumors and 25% for rectourethral fistula.
Conclusions: Transsphincteric approach can be used successfully with
low morbidity, low recurrence rate, and avoidance of a more radical resection for difficult rectal pathology. The TSA can be a useful technique and
part of the armamentarium of colorectal surgeons for difficult cases.
Purpose: Aim of this study is to investigate the prognostic value of
tumor budding(TB) in rectal cancer patients who were treated or not
treated with neoadjuvant chemo-radiotherapy(CRT).
Methods: Prospectively recorded traditional clinicopathological data
and final oncological outcomes of patients with cT3N0-T4N0 or any cTN(+)
(locally advanced) rectal cancer who received neoadjuvant CRT(n=117) and
patients with cT2N0-T3N0 rectal cancer who did not receive neoadjuvant
CRT(n = 113) were analyzed. Isolated in a single cancer cell or a set of cells
formed fewer than five cancer cells were considered as “budding focus”. The
histologic examination was performed by x20 magnification of light
microscopy on selecting the area of maximum density of budding. “Budding intensity” was classified as mild (1 – 5), moderate (6-10), and severe (>
10) according to the intensity of the TB.
Results: The median follow-up time was 40.12±27.5 months. The fiveyear overall and disease-free survival rates were 66% and 62%, respectively.
Multivariate analysis of overall survival in all patients showed that TB
score(OR=2.3888/18.661/8.971), CRT-non-treated status(OR=2.487), and
radial margin(RM) distance(OR=0.805) were independent prognostic factors. TB score(OR=3.129/OR=25.364/OR=21.071), RM distance(OR=0.859),
and venous invasion(OR=7.729) were determined as strong prognostic factors in patients who did not receive CRT, whereas it was only RM distance(OR=0.709)
in
patients
who
received
CRT.
TB
score(OR=3.687/OR=3.979/OR=115.693),
pN
involvement(OR=0.626/OR=5.178), and RM distance(OR=0.088) were highly
significant for disease-free survival in CRT group whereas TB
score(OR=2.927), RM(OR=3.235), and venous invasion(OR=3.747) were
robust prognostic factors in patients who did not receive CRT. TB
score(OR=4.337) and distant metastasis(OR=5.526) were independent prognostic factors for overall survival in controversial T3N0 stage.
Conclusions: Tumor budding is a robust prognostic factor as strong as
involvement of lymph nodes and radial margin. Tumor budding should be
included in the TNM classification and be used in adjuvant therapy planning.
P281
SURVIVAL OUTCOMES FOR TUMORS OF THE SPLENIC FLEXURE.
S. Koller and M. M. Philp Department of Surgery, Temple University,
Philadelphia, PA.
Purpose: Splenic flexure tumors are rare. Surgical management is controversial, due to the variable blood supply of the area. Our goal was to
determine if there were any survival differences for patients undergoing
various types of surgical resection for splenic flexure tumors.
Methods: The Surveillance, Epidemiology, and End Results (SEER) 2012
dataset was used. Cases from 1998 to 2010 were included. Patients with
multivisceral resections were excluded. SPSS 19.0 was used for statistical
analysis. Kaplan-Meier and Cox regression was used to calculate survival
statistics.
Results: 826,983 cases of colorectal cancer were identified. 21,006
splenic flexure tumors were found (2.54%). 9,571 patients underwent at
least partial colectomy, and were included in the analysis. Hemicolectomy
was the most commonly performed operation (54.5%), followed by partial
colectomy (43%), and total colectomy (2.5%). 53.6% of patients were male,
the mean age at diagnosis was 69 (± 13.6), and 78.4% were white. For
patients undergoing partial colectomy, hemicolectomy, and total colectomy the mean number of lymph nodes examined was 12.5, 14.5, and 22.4
142
Abstracts
respectively. The mean numbers of positive lymph nodes was 1.52, 1.65,
and 1.62. Patients undergoing total colectomy had worse survival across all
stages (Figure 1). In Stage II cancers, mean survival was 60.9 months with
partial colectomy, and 62.6 months with hemicolectomy. For Stage III cancer, it was 56.1 and 55.6 months respectively. Neither of these differences
was statistically significant. When controlling for age, sex, lymph nodes
examined, and stage, patients undergoing total colectomy had worse odds
of survival than partial colectomy (OR 1.62, CI 1.21-2.19, P=0.001). There
was no survival difference between hemicolectomy and partial colectomy
(OR 1.04, CI 0.94-1.15, P=0.443).
Conclusions: Total colectomy for splenic flexure cancer appears to be
associated with worse survival across all stages. Survival is similar for both
partial colectomy and hemicolectomy.
(1/34) and 16.3% (7/43), respectively (p=0.071). The median overall survival
(OS) and progression free survival (PFS) of all patients were 26 and 12
months, respectively. The median local recurrence free survival (LRFS) was
not reached in all patients. There were no statistically significant differences
in OS, PFS and LRFS between two groups.
Conclusions: Neoadjuvant radiotherapy did not improve LRFS and OS
of all stage IV rectal cancer with or without metastasectomy. Neoadjuvant
radiotherapy could be recommended for selected patients at high risk of
local recurrence or for palliative symptoms.
Fig 1. Overall survival of patients by radiotherapy and metastasectomy status
P282
THE ROLE OF NEOADJUVANT RADIOTHERAPY IN STAGE IV RECTAL
CANCER.
S. Kim, S. Jung, J. Lim, J. Jung, M. Roh and J. Kim Department of Surgery,
Yeungnam University Medicial Center, Daegu, Republic of Korea.
Purpose: The radiotherapy was recommended as a part of the adjuvant
or neoadjuvant treatment for stage IV rectal cancer. The aim of this study is
to evaluate the role of neoadjuvant radiotherapy in rectal cancer with synchronous metastases.
Methods: Between September 2001 and August 2011, a total of 99 consecutive patients with metastatic rectal cancer were recorded prospectively.
This is a retrospective review of a prospectively collected consecutive series.
Inclusion criteria were 1) histologically proven rectal adenocarcinoma; 2)
location of the primary rectal cancer in the low or mid-rectum; 2) locally
advanced disease (clinically T3-4 or N1-2); 3) histologically or radiological
proven distant metastasis ; and 4) no history of prior pelvic radiotherapy
other malignancy. Finally, a total of 86 patients were enrolled in this study.
Of 86 patients, 40 patients received neoadjuvant radiotherapy with
chemotherapy (RTX group) and the remaining 46 patients received only
systemic chemotherapy (NRTX group). The radiotherapy was long-course
schedule (45.0~50.4 Gy, 25-30fractions, 5 days per a week). All patients
underwent curative resection of primary rectal cancer.
Results: The patients in the RTX group were younger, had more lowlying lesions. The patients in the NRTX group had more lymph-node metastases and had more harvested lymph node. Of 86 patients, 23 (57.5%)
patients of RTX group and 14 (30.4%) patients of NRTX group received synchronous or staged metastasectomy. The patients with positive circumferential margins were 6 (15%, 6/40) in RTX group and 3 (6.5%, 3/46) in NRTX
group. The local recurrence rate in the RTX group and NRTX group was 2.9%
P283
THE SIGNIFICANCE OF PRETREATMENT NEUTROPHIL/LYMPHOCYTE
RATIO AS A PROGNOSTIC MARKER IN COLORECTAL CANCER
PATIENTS.
Y. Özdemir, M. L. Akin, I. Sucullu, A. Z. Balta and E. Yucel GATA
Haydarpasa Training Hospital, Istanbul, Turkey.
Purpose: The evidence on the role of inflammation in carcinogenesis
has been growing recently, and the presence of a systemic inflammatory
response has been proposed as having prognostic significance in colorectal cancers. The aim of the study was to assess the prognostic value of pretreatment neutrophil-to-lymphocyte ratio (NLR) in predicting survival in
patients with colorectal cancer.
Methods: A total of 281 colorectal cancer patients, operated between
January 1999 and December 2012 at a single institution, were evaluated
retrospectively. The impact of NLR and other potential prognostic factors
on OS was assessed with the Kaplan-Meier method and multivariate Cox
regression analysis.
Results: 193 patients (68.7%) had a high pretreatment NLR, with NLR >
2.2 considered as high according to receiver operating characteristic curve
analysis. In univariate analysis, high pretreatment NLR (p = 0.001), pathologic nodal stage (p < 0.001) and advanced pathologic TNM stage (p <
0.001) were predictive of shorter survival. In multivariate analysis, advanced
pathologic TNM stage (p = 0.001) and high pretreatment NLR (p = 0.005)
remained independently associated with poor survival.
Conclusions: A high pretreatment NLR is a significant independent predictor of shorter survival in patients with colorectal cancer.
143
Abstracts
P284
COLON INSPECTABILITY INDEX: A MEASURE OF THE DIFFICULTY OF
EXAMINING THE COLONIC MUCOSA.
J. M. Church, A. Mills, M. Berlin and E. Berlin Colorectal Surgery, Cleveland
Clinic Foundation, Cleveland, OH.
Purpose: Adenoma detection rate is an established quality indicator for
colonoscopy. Its relationship with withdrawal has led to standard inspection times. However this does not take into account differences in the
“inspectability” of the colon. The purpose of this research is to identify,
examine and quantitate factors that influence “inspectability”, and to assess
the degree to which these vary between patients.
Methods: Patients undergoing elective outpatient colonoscopy by one
examiner were eligible. Data were gathered prospectively in real time and
were entered into a database. An “Inspectability Index (II)” was constructed
using 10 factors, each measured on a separate Likert scale of 1(lowest or
least) to 10 (maximum); depth of haustral folds, tortuosity, presence of
adhesions, bubbles, bile, remaining stool, overall quality of bowel preparation, severity of diverticulosis and pain during the withdrawal. All factors
were assessed on withdrawal, after all standard insertion techniques for
shortening the colon and cleansing the colon had been applied.
Inspectability factors were assessed for the ascending colon, transverse
colon, descending colon and sigmoid colon. Factors were summed to
obtain the II.
Results: There were 209 patients, 88 men and 110 women; their mean
age was 61 +/- 12.1 years. Inspectability data are given in the table, showing considerable variation in segmental and overall inspectability. The sigmoid had the highest scores for haustral folds, tortuosity, adhesions,
spasms and diverticula while the ascending was reported highest in the
categories of bubbles, bile and stool. Analyzing the data by gender, age
and BMI revealed that many aspects of inspectability were similar for both
sexes but there were significant differences related to BMI. Inspectability
Index was regressed against time of withdrawal in normal colons, but no
significant relationship was found (p=0.627).
Conclusions: Inspectibility of the colon can be measured. It varies
within each colon by segment, and between each patient, according to
gender, age and body habitus. Colonoscope withdrawal times cannot be
standardized.
assessment of at least 12 lymph nodes for rectal cancer staging. Despite
this, several studies have demonstrated that nodal harvest is highly variable and often inadequate using routine pathological techniques. Recent
studies showed that ex-vivo injection of methylene blue dye into the inferior mesenteric artery of rectal cancer specimens might improve lymph
node harvest. This study evaluates pathological lymph node assessment
using this recent technique compared to conventional pathological techniques.
Methods: Methylene blue solution (50 mg in 15-20 ml of 0.9% saline in
the ratio 1:3) was injected ex-vivo into the inferior mesenteric artery of 25
rectal cancer specimens using the plastic tube portions of standard 16-20G
IV catheters, lymph node assessment was performed after formaline fixing
overnight. The results were compared to data obtained from a control
group of 25 rectal cancer specimens which underwent conventional pathological lymph node assessment.
Results: Methylene blue injection was successfully performed in all
cases of the stained group. A total number of 383 and 157 lymph nodes
were detected in the stained and unstained groups with a mean of 15.3 ±
4 and 6.3 ± 3, respectively (p< 0.001). The difference was most pronounced
in lymph nodes measuring ≤4 mm in diameter (p< 0.001). Metastases were
found in 154 and 37 lymph nodes occurring in 18 and 10 cases with a mean
of 6.2 ± 7 and 1.5 ± 3, respectively (p= 0.003). LNR was calculated for the
cases that were finally staged as stage III showing no significant difference
between the two groups.
Conclusions: Ex-vivo methylene blue injection into the inferior mesenteric artery is a simple, easy and safe method that significantly improves
lymph node harvesting in rectal cancer, especially small-sized lymph nodes.
This improvement in nodal harvest can be even achieved in cases treated
with neoadjuvant therapy. This eventually leads to a more accurate rectal
cancer staging via improved detection of metastatic lymph nodes.
Table: Average of the Inspectability Indices for 209 Patients
P286
P285
EX-VIVO METHYLENE BLUE INJECTION INTO THE INFERIOR MESENTERIC ARTERY TO IMPROVE LYMPH NODE HARVEST IN RECTAL CANCER.
H. A. Elwan, K. S. Abbas, W. G. Elshazly and M. S. Ellabishi Department of
Surgery, Colorectal Surgery Unit, Alexandria Main University Hospital,
Alexandria, Egypt.
Purpose: Exact lymph node staging is essential for prognosis estimation and treatment stratification in rectal cancer. The American Joint Committee on Cancer and the International Union Against Cancer recommend
DIAGNOSTIC ACCURACY AND PROGNOSTIC IMPACT OF RESTAGING
BY MAGNETIC RESONANCE IMAGING IN PATIENTS WITH RECTAL CANCER AFTER PREOPERATIVE CHEMORADIOTHERAPY.
J. Huh, H. Kim, Y. Park, Y. Cho, S. Yun, W. Lee and H. Chun Surgery,
Samsung Medical Center, Sungkyunkwan University School of Medicine,
Seoul, Republic of Korea.
Purpose: Prognostic role of restaging rectal magnetic resonance imaging (MRI) in patients with preoperative CRT has not been established. The
goal of this study was to evaluate the diagnostic accuracy and prognostic
role of radiological staging by rectal MRI after preoperative chemoradiation
(CRT) in patients with rectal cancer.
Methods: A total of 231 consecutive patients with rectal cancer who
underwent preoperative CRT and radical resection from January 2008 to
December 2009 were prospectively enrolled. The diagnostic accuracy and
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Abstracts
prognostic significance of post-CRT radiological staging by MRI was evaluated.
Results: The sensitivity, specificity, positive predictive value, and negative predictive value of radiological diagnosis of good responders (ypTNM
stage 0-I) were 65%, 69%, 32%, and 90%, respectively. The overall accuracy
for good responders by MRI was 68%. The 5-year disease-free survival rates
of patients with radiological TNM stage 0-I and stage II-III were 95% and
76%, respectively and 5-year disease-free survival rates of patients with
pathological TNM stage 0-I and stage II-III were 90% and 73%, respectively
(P = 0.011 and P = 0.003, respectively). On multivariate analysis, post-CRT
radiological staging by MRI was an independent prognostic factor for disease-free survival.
Conclusions: Radiological staging by MRI after preoperative CRT may
be an independent predictor of survival in patients with rectal cancer.
P287
THE IMPACT OF HEPATIC STEATOSIS ON THE INCIDENCE OF LIVER
METASTASIS FROM COLORECTAL CANCER.
T. Kondo, K. Okabayashi, H. Hasegawa, Y. Ishii, M. Tsuruta, T. Ishida,
S. Matsui and Y. Kitagawa Keio, Sinjyuku-ku,Tokyo, Japan.
Purpose: Non-alcoholic fatty liver disease (NAFLD) is defined as fat
accumulation exceeding 5% to 10% by the weight of the liver, and is
strongly associated with metabolic syndrome. It remains unclear how much
impact such excessive local fat accumulation has on the development of
hepatic tumor metastasized by colorectal cancer (CRC). The objectives of
this study is to clarify the influence of fatty liver on metachronous liver-specific recurrence after curative surgical resection of CRCs.
Methods: Between 2005 and 2010, patients who had a curative surgical resection for CRC were included in this study. The mean attenuation values (in Hounsfield units) of the liver and spleen were obtained on a preoperative plain CT slice. The patients with liver–spleen attenuation ratio lower
than 1.1 were objectively defined as hepatic steatosis (HS). To distinguish
the influence of excessive fat accumulation in the whole body, the analysis
were conducted by preoperative body mass index (BMI), which was categorized into obese (BMI more than 25kg/m2) or non-obese (BMI less than
25kg/m2).
Results: A total of 602 CRC patients were enrolled, comprised of 136
obese and 466 non-obese. In non-obese patients, 5-year liver-specific disease-free survival (DFS) rate in HS was significantly poorer than non-HS (HS
86.2% vs. non-HS 94.2%, log-rank p=0.031). HS significantly promoted liverspecific recurrence compared to non-HS (HR=0.403, 95%CI 0.171 to 0.950;
p = 0.038). However, this effect was not evident in the group of patients in
obese (HR=1.948, 95%CI 0.223 to 16.99; p = 0.546). Fractional polynomial
analysis demonstrated that the relationship between HS and liver-specific
recurrence were seriously different.
Conclusions: The impact of HS on hepatic recurrence after curative surgical resection of CRCs were significantly different between obese and nonobese CRC patients. These findings indicated that HS occurred in non-obese
population might be a favorable microenvironment for liver metastasis.
L/S ratio - Hazard Ratio
P288
THE ROLE OF PALLIATIVE RESECTION FOR ASYMPTOMATIC PRIMARY
TUMOR IN PATIENTS WITH UNRESECTABLE STAGE IV COLORECTAL
CANCER.
J. Yun, J. Park, J. Huh, Y. Park, Y. Cho, S. Yun, H. Kim and W. Lee
Department of Surgery, Samsung Medical Center, Sungkyunkwan
University School of Medicine, Seoul, Republic of Korea.
Purpose: The prognostic role of surgical resection of primary tumor is
not well-established in patients with asymptomatic unresectable stage IV
colorectal cancer.
Methods: Between January 2000 and December 2008, a total of 416
patients (218 resection and 198 non-resection) without any obstruction or
perforation who were diagnosed as unresectable stage IV colorectal cancer
were retrospectively reviewed. Among them, 113 patients who underwent
palliative resection of primary tumor were 1:1 matched to 113 patients
without resection with a propensity matched score.
Results: The rates of liver (p=0.006), lung (0.018) and distant lymph
node (<0.001) metastasis were significantly higher in non-resection group.
Furthermore, clinical M stage was more advanced and initial CEA level was
more elevated in non-resection group. Peritoneal metastasis frequently
occurred in resection group (22.0 vs 12.6%, p=0.012). Well to moderately
differentiated histopathologic type was observed more frequently in resection group (78.9 vs 90.4%, p=0.002). After propensity score matching, the
resection and non-resection groups did not differ in terms of variable prognostic factors including sex, age, BMI, tumor location, site of metastasis,
clinical stage, initial CEA level and histologic type of differentiation. The 5year overall survival rate significantly decreased for patients with peritoneal
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Abstracts
metastasis and clinical M1b stage in univariate analysis (4.8 vs 0.0%,
p=0.003 and 5.3 vs 1.8%, p=0.023). Palliative resection didn’t show any significant difference (4.9 vs 3.5%, p=0.271). In multivariate analysis, peritoneal
metastasis was only significant prognostic factor affecting long-term overall survival (p=0.024, HR=1.625, 95% CI=1.067-2.474). In subgroup analysis
in the patients with clinical M1a disease, there were no significant differences according to site of metastasis between resection and non-resection
groups.
Conclusions: Peritoneal metastasis was significant prognostic factor
affecting overall survival in asymptomatic patients with unresectable stage
IV colorectal cancer. Resection of the primary tumor in these patients was
not associated with an improvement in overall survival.
P289
CHARACTERISTICS OF COLORECTAL CANCER IN THE ELDERLY.
H. Kobayashi and K. Sugihara Department of Surgical Oncology, Tokyo
Medical and Dental University, Tokyo, Japan.
Purpose: The developed counties are aging. However, the characteristics of colorectal cancer in the elderly have been unclear. The aim of this
study is to clarify the characteristics of colorectal cancer in the elderly.
Methods: The 1572 patients who underwent surgery for colorectal cancer at a single institution between 1991 and 2007 were reviewed. The characteristics of patients with colorectal cancer were compared between
group A (age<75) and B (age = 75 or older). The outcomes after surgery
were also compared among group C (70-74), group D (75-79), and group E
(80 or older).
Results: The number of patients in the group A and B was 1259 and
313, respectively. The median age of the group A and B was 62 and 79,
respectively. There were differences in histologic type (P = 0.023), location
of tumor (P = 0.0001), and cancer stage (‘P<0.0001) between group A and
B. There were differences in survivals of patients with stage I (P = 0.0018)
and II (P<0.0001) colorectal cancer between group A and B. However, there
were no differences in survivals of patients with stage III and IV colorectal
cancer. The outcomes after surgery among group C, D, and E did not differ
in each cancer stage (stage I, II, III, and IV). The rate of preoperative comorbidity in the group C and the group D+E was 37.6% and 46.5% (P = 0.13).
The rate of postoperative comorbidity in the group C and the group D+E
was 30.7% and 38.3%, respectively (P = 0.18). The rate of preoperative cardiovascular diseases in the group D+E was higher than that in the group C
(P = 0.019). There were no differences in the rates of postoperative surgical
site infection, anastomotic leak, and ileus between group C and D+E. The
length of postoperative hospital stay in the group E was longer than that
in the group C+D (P = 0.012).
Conclusions: The elderly patients are more likely to have well differentiated colon cancer without lymph node and hematogenous metastases. In
the patients of 70 or older, there were no differences in survivals and postoperative comorbidities between each age-group. The longer hospital stay
in the patients of 80 or older should be explained before the treatment.
P290
LAPAROSCOPIC COLECTOMY FOR COLON CANCER IN THE ELDERLY:
ANALYSIS OF RISK, PERIOPERATIVE OUTCOMES, AND COST.
E. B. Sneider, N. B. Cherng, R. N. Damle, D. Baldor, P. R. Sturrock,
J. A. Maykel, J. S. Davids, W. Sweeney and K. Alavi Surgery-Colorectal,
University of Massachusetts Medical School, Worcester, MA.
Purpose: Colectomy for colon cancer in the elderly poses significant
challenges for both the surgeon and the healthcare system. As third-party
payers aim to limit reimbursement based on poorly defined quality metrics, the benefits of laparoscopy in this group need to be evaluated against
a backdrop of escalating healthcare costs. The purpose of this study is to
evaluate the overall risks, benefits, and cost of laparoscopic surgery for
colon cancer in the elderly patients.
Methods: A retrospective review was performed of all patients ≥75
years of age with non-metastatic colon cancer who underwent colectomy
at a tertiary care center from 2005-2009. Patients were grouped into the
laparoscopic colectomy (laparoscopic and laparoscopic converted to open
based) (LC) and open colectomy (OC) groups. The primary outcome was 30day morbidity. Secondary outcomes included complication rate, length of
stay (LOS), discharge status, readmission rate, hospital charges and 30-day
mortality.
Results: A total of 82 patients met inclusion criteria, 34 (42%) of which
were in the LC group. Demographic characteristics (mean age, gender, and
race) were similar between groups. Patients who underwent OC were more
likely to be diabetic (p=0.03), otherwise baseline clinical characteristics
were similar between groups. No difference was detected in presenting
symptoms, preoperative lab values, tumor pathology, resection type, number of lymph nodes harvested or estimated blood loss between groups. Following colectomy, complication rates, LOS, hospital readmissions, 30-day
mortality, and total hospital charges were similar between groups. (Table
1) Finally, the LC group was more likely to be discharged home than to a
rehabilitation facility (p=0.009).
Conclusions: Laparoscopic colectomy for colon cancer in the elderly
compares favorably to open surgery with similar complication and mortality rates, LOS, and overall cost. There appears to be a decrease in resource
utilization as evidenced by reduced rates of non-home discharge in the LC
group. Laparoscopic colectomy for cancer in the elderly is safe and well tolerated and should be considered the procedure of choice in this high-risk
population.
Values are given as mean (standard deviation) or n (percentage) unless otherwise
stated
P291
PREDICTION OF COMPLETE TUMOR REGRESSION OF RECTAL CANCER
AFTER NEOADJUVANT CRT BY MIRNA EXPRESSION OF MIR-21-5P
THAT TARGETS A MULTIDRUG RESISTANCE GENE.
C. Ramos2, R. Parmigiani2, R. O. Perez1, A. Habr-Gama4, J. GamaRodrigues4, B. Quevedo4, F. Bettoni2, F. Koyama2, N. Felicio4 and
A. Camargo3 1Colorectal Surgery DIvision, University of Sao Paulo School
of Medicine, Sao Paulo, Brazil, 2Centro de Oncologia Molecular, Hospital
Sírio Libanês, Sao Paulo, Brazil, 3Ludwig Institute for Cancer Resarch, Sao
Paulo, Brazil and 4Angelita & Joaquim Gama Institute, Sao Paulo, Brazil.
Purpose: Neoadjuvant chemoradiation may lead to complete tumor
regression in a proportion of patients with rectal cancer. It has been suggested these patients could avoid TME.Currently these patients are selected
based on imprecise clinical and radiological findings. Tumor molecular
markers capable of predicting complete response to CRT would allow better selection of candidates for this strategy. The purpose of this study was
to identify differentially expressed miRNA between rectal cancers that
develop complete or incomplete response to neoadjuvant CRT.
Methods: Pre-treatment biopsies were prospectively collected from
patients with rectal adenocarcinoma prior to neoadjuvant CRT. Reassessment of tumor response was at least 8 weeks from CRT. Patients with complete clinical response were not immediately operated. Patients with
incomplete clinical response were managed by radical surgery. Patients
with incomplete pathological response were compared to patients with
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Abstracts
sustained complete clinical response (≥18 months of follow-up) or pCR.
Patients with initial complete response and early tumor recurrence were
considered as separate group for comparison.
Results: An initial training set of 27 patients identified 4 differentially
expressed miRNAs that could partially distinguish between complete and
incomplete responders. Validation of these 4 miRNAs in an independent
group of 12 patients confirmed differential expression of miR-21-5p as a
predictor of response. Overall sensitivity and specificity of miR-21-5p
expression in predicting a complete response to CRT was 78% and 88%
respectively. In addition, miR-21-5p expression showed incomplete
response pattern in all 4 patients with initial cCR followed by early local
tumor recurrence.
Conclusions: In conclusion, miR-21-5p expression may serve as a
potential predictive biomarker capable of predicting response to neoadjuvant CRT. miR-21-5p expression may aid in the selection of patients with
complete clinical response that are ideal candidates for alternative treatment strategies to radical surgery.
using the DESeq2 package in the R statistical computing environment to
identify differentially expressed miRNAs (FDR < 0.001, log2fold change >
1.0). External validation was executed using The Cancer Genome Atlas
(TCGA) rectal cancer samples. We also compared our results with previously
published miRNA rectal cancer signatures generated using microarrays.
Results: We identified 35 up-regulated and 10 down-regulated miRNAs.
The signature showed significant enrichment (hypergeometric p-value <
0.001) and high expression correlation with the TCGA data set (Figure). Upregulated miRNAs in our validated signature include novel miRNAs (miR19a, miR-29a), and others that have been reported in previous studies (miR135b, miR-424, miR-17, miR-21). Down-regulated miRNAs that have been
reported previously include miR-375 and miR-145. Ingenuity Pathway
Analysis of the differentially expressed miRNAs implicated p53, BRAF, and
Akt pathways.
Conclusions: We identified a miRNA profile that delineates rectal cancer from normal rectal tissues in the largest LARC sample set to date, and
validated it in TCGA rectal cancer samples. Our validated signature will now
be utilized to identify molecular profiles associated with LARC response to
chemoradiation.
Differential Expression of miR-21-5p between patients with sustained complete
clinical/pathological response, incomplete response or early recurrence after a initial
complete clinical response. (p<0.05)
P292
IDENTIFICATION OF A MICRORNA SIGNATURE IN LOCALLY
ADVANCED RECTAL CANCER USING HIGH-THROUGHPUT SEQUENCING AND VALIDATION WITH THE CANCER GENOME ATLAS.
O. S. Chow1, R. Pelossof2, J. J. Smith1, C. Chen1, Z. Chen3, C. Leslie2 and
J. Garcia-Aguilar1 1Department of Surgery, Memorial Sloan-Kettering
Cancer Center, New York, NY, 2Computational Biology Program, Memorial
Sloan-Kettering Cancer Center, New York, NY and 3Department of
Molecular Genetics, City of Hope National Medical Center, Duarte, CA.
Purpose: The response of locally advanced rectal cancer (LARC) to
neoadjuvant chemoradiation (CRT) varies dramatically and the ability to
identify non-responders prior to treatment is challenging. MicroRNAs
(miRNA) regulate gene expression and may be useful as biomarkers. In this
study, we sought to identify and validate a miRNA signature in LARC using
high-throughput sequencing.
Methods: Pre-treatment tumor tissue was collected from 89 patients
with stage II and III LARC treated with CRT and total mesorectal excision,
and compared with normal adjacent rectal tissue. Microdissection was performed on formalin-fixed, paraffin-embedded tissues and miRNA was
extracted. The Illumina Hiseq-2000 platform was used for sequencing and
reads were aligned to a transcriptome of all known mature human miRNAs
(miRBase 20 and the Burrows-Wheeler Aligner). Analysis was carried out
P293
A NOVEL MICRORNA EXPRESSION SIGNATURE IS ASSOCIATED WITH
NODE POSITIVE RECTAL CANCER.
C. Cellini1, K. Chuang4, M. Lunt2, C. Whitney-Miller2, A. Almudevar3,
T. Godfrey5, C. T. Barry4 and J. R. Monson1 1Colorectal Surgery, University
of Rochester, Rochester, NY, 2Surgical Pathology, University of Rochester,
Rochester, NY, 3Biostatistics, University of Rochester, Rochester, NY,
4
Surgery, University of Rochester, Rochester, NY and 5Surgery, Boston
University, Boston, MA.
Purpose: Preoperative radiological assessment of lymph node (LN) status is important in choosing treatment strategies for patients with rectal
cancer. However, LN staging is inaccurate in 20% of cases and more accurate staging would clearly be of benefit. Novel methods of determining LN
status are therefore required. MicroRNAs (miRNAs) are small noncoding
RNAs that regulate the expression of protein-encoding genes and are
involved in the development, progression and prognosis of a number of
malignancies. The objective is to identify a microRNA expression signature
that correlates with LN status in rectal cancer.
Methods: Forty-two patients identified from a cancer database underwent formal resection for rectal adenocarcinoma without prior radiation
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Abstracts
therapy between 2004 and 2012. MiRNA was purified from formalin fixed
paraffin embedded blocks of the primary tumors and hybridized to
Affymetrix microarrays containing all known human miRNA targets. The
association of miRNA expression with LN metastasis was assessed using
Wilcoxon sum testing to select for miRNAs with false discovery rates of
<0.25.
Results: Of the 42 patients, 19 had negative LNs on final pathology
while 23 had positive LNs. Overall pathological staging was stage I or II in
45% of patients. Thirteen individual human miRNAs were found to be differentially expressed in rectal cancer tumors depending on LN status.
Twelve miRNAs (miR-490-3p, miR-143, miR-145, miR-1468, miR-181a, miR490-5p, miR-328, miR-3647, miR-194-star, miR-2052, miR-4661, miR-140)
were overexpressed and 1 (miR-4483) was underexpressed in LN positive
tumors compared to LN negative tumors. Three of these miRNAs have been
previously reported to be up regulated in colorectal tumors.
Conclusions: Our data indicate that the expression of individual human
miRNA species is significantly associated with LN status in rectal adenocarcinomas. While further studies are needed to verify this signature, the inclusion of such an assessment of individual tumor biology in pre-treatment
tumor biopsies would greatly facilitate surgical decision making and help
direct adjuvant therapies.
* denotes known association with colorectal cancers as documented in the
literature
P294
CYTOPATHIC EFFECTS ON HUMAN COLON CANCER CELL LINES BY
NEWLY ISOLATED HUMAN ENTERIC ADENOVIRUSES.
J. Tashiro1, S. Yamaguchi1 and K. Mitani2 1Gastroenterological Surgery,
Saitama Medical University International Medical Center, Hidaka, Japan
and 2Gene Therapy, Saitama Medical University, RCGM, Hidaka, Japan.
Purpose: Oncolytic viruses, which selectively kill cancer cells but not
normal cells, have been drawing attentions as a new strategy for cancer
therapy. Adenoviruses are the most commonly used oncolytic viruses, but
most of them have natural tropisms for airways and eyes. In order to
develop more efficient oncolytic virus for digestive cancer, we analyzed
recently isolated novel enteric adenovirus serotypes, which were recently
isolated from patients with viral diarrhea, on their abilities to infect and
replicate in human cell lines.
Methods: Three human cell lines, HT29 (colorectal adenocarcinoma),
A549 (lung adenocarcinoma) and HDF (human dermal fibroblasts), were
infected with new enteric adenovirus serotypes (Ad61, 65, 67), classical
enteric adenovirus 41 (Ad41) and Ad5, which is widely used as gene therapy vectors. To analyze the infection and replication efficiencies of each
serotype on these cell lines, the TCID50 (tissue culture infective dose for
fifty percent) method, which is based on development of cytopathic effects
(CPE) using end-point dilutions, was performed.
Results: CPE with Ad5, Ad61, Ad65 and Ad67 was observed in each cell
line, with the exception of Ad41. Low infectious titers were observed in
each cell line with Ad61 (average TCID50 = 1.1x103), whereas Ad5 showed
higher infectious titer (average TCID50 = 5.5x1010) than Ad67 (average
TCID50 = 1.4x106) and Ad65 (average TCID50 = 4.9x106). For Ad65 and
Ad67, the highest infectious titers were obtained with HT29. The relative
titer ratios of HT29/HDF and HT29/ A549 were higher with Ad65 (158.5 and
316.2) and Ad67 (7.9 and 31.6), respectively, suggesting selective infection/replication of these serotypes on colon cancer cells.
Conclusions: Selective cytopathic effect of human colon cancer cells
but not normal cells by the newly discovered Ad65 & 67 might indicate
oncolytic potential of these serotypes and would provide an attractive tool
for cancer therapy in the future.
P295
TAK-1 AND THIOREDOXIN METABOLISM INHIBITION: A POTENTIALLY
POWERFUL COMBINATION THERAPY FOR KRAS-MUTATED COLON
CANCERS.
J. Hrabe1, F. Domann3, D. Spitz3 and J. J. Mezhir2 1Department of Surgery,
University of Iowa, Iowa City, IA, 2Department of Surgery, Division of
Surgical Oncology, University of Iowa, Iowa City, IA and 3Department of
Free Radical and Radiation Oncology Biology, University of Iowa, Iowa City,
IA.
Purpose: TGF-β-activated kinase-1 (TAK-1) is critical to survival in many
Kras-mutated colon cancer cells. Inhibiting TAK-1 has been shown to
increase reactive oxygen species and cell death. While cells have multiple
antioxidant mechanisms, our preliminary work indicates that TAK-1 inhibition preferentially affects thiol redox systems. Auranofin is a drug currently
in clinical trials; it inhibits the activity of thioredoxin reductase, a critical
part of cells’ thiol antioxidant mechanisms. We hypothesized that auranofin
could potentiate the effects of TAK-1 inhibition and lead to an effective
colon cancer therapy.
Methods: We treated two Kras-mutated colon cancer cell lines (HCT 116
and SW 620) with 5 um 5Z-7-oxozeaenol, a commercially available TAK-1
inhibitor, with or without 500 nM of auranofin. Cell growth and clonogenic
survival were measured in vitro. Differences between means were compared with ANOVA.
Results: The combination of auranofin plus TAK-1 inhibitor significantly
reduced cell growth compared to TAK-1 inhibition alone, Figure. When compared to control treatment, HCT 116 cells treated with TAK-1 inhibitor and
auranofin had an 8.5-fold decrease in growth vs. a 2.5-decrease for TAK-1
inhibitor alone, p<0.05. SW 620 cells treated with TAK-1 inhibitor and auranofin had a 7.2-fold decrease in growth vs. a 2.4-fold decrease for TAK-1
inhibtor alone, p<0.05. Clonogenic survival was similarly affected, with an
88% decrease in HCT 116 and a 99% decrease in SW 620 cells treated with
both TAK-1 inhibitor and auranofin vs. control, p=0.0002. This was significantly greater than for cells treated with TAK-1 inhibitor alone (48% and
59% vs. control, HCT 116 and SW 620 respectively, p=0.0002).
Conclusions: TAK-1 inhibition impairs cell growth and clonogenic survival in Kras-mutated colon cancer cells. These results show that combination therapy with auranofin reduces cell survival by at least three times
more than TAK-1 inhibition alone, and similarly impairs clonogenic survival.
TAK-1 inhibition likely renders its effects via thiol-related oxidative stress. In
combination with auranofin, this may represent a potential novel therapy
for these treatment-resistant cancers.
148
Abstracts
P296
STAT3 UPREGULATES EXPRESSION OF MICRORNA-135B IN COLON
CANCER.
R. N. Khatri and S. N. Subramanian Surgery, University of Minnesota,
Minneapolis, MN.
Purpose: MicroRNAs (miRNAs) are small regulatory RNAs that are dysregulated in cancer and can downregulate important tumor suppressors.
We examine microRNA-135b (miR-135b), which is highly expressed in colon
adenocarcinoma and adenomas and can decrease APC expression. This
study potentially reveals an important connection between inflammatory
stromal signals via the transcription factor STAT3 and the early downregulation of APC. In colon cancer, activation STAT3 is correlated with poor outcome. We hypothesize that in response to growth signals transduced via
STAT3, miR-135b primes the colonic epithelium for transformation by targeting the tumor suppressor APC even in absence of somatic mutations.
Methods: Colon cancer lines HT29 and Hct116 were cultured using in
McCoy’s Modified Media and SW480 cancer cells and HEK293T human
embryonic kidney cells with Dulbecco’s Modified Eagle Media, all with 10%
fetal bovine serum. Cancer lines were treated with a small molecule
inhibitor of STAT3, LLl12. Cells were assessed 24 hours after treatment. Viability was assessed using CCK-8 assay. Total RNA was isolated using Ambion
mirVANA kit. cDNA was generated using Qiagen MiScript II. Quantitative
PCR was performed using SYBR Green with normalization of gene transcripts against GAPDH and miRNA transcripts against U6.
Results: miR-135b expression levels are significantly elevated in all
tested colon cancer lines compared to normal colon epithelium. Treatment
of cancer cells with STAT3 inhibitor LLL12 results in 75% loss of cell viability
at 24 hours when compared to controls. miR-135b levels were reduced by
40% in HT29, SW480, and Hct116 cells when treated with STAT3 inhibitor
LLL12.
Conclusions: The transcription factor STAT3 is activated in response to
IL-6 and IL-10. IL-6 is known to be elevated in patients with inflammatory
bowel disease as is miR-135b expression in mouse models of colitis.
Through the regulatory effect of STAT3 on miR-135b in colon cancer, we
suggest a potential link between inflammatory stromal signals and early
downregulation of the tumor suppressor APC even in the absence of
somatic mutations or epigenetic changes.
P297
IMMUNOHISTOCHEMICAL DETECTION OF P53 EXPRESSION IN
PATIENTS WITH PREOPERATIVE CHEMORADIATION FOR RECTAL CANCER: ASSOCIATION WITH PROGNOSIS.
J. Huh, W. Lee, Y. Park, Y. Cho, S. Yun, H. Kim and H. Chun Surgery,
Samsung Medical Center, Sungkyunkwan University School of Medicine,
Seoul, Republic of Korea.
radical surgery. Patients were categorized into two groups according to p53
expression: low p53 (<50% nuclear staining) and high p53 (≥50%) groups.
Results: p53 expression was significantly associated with tumor distance from the anal verge (P = 0.036). In univariate analysis, p53 expression
was not associated with either disease-free survival (P = 0.118) or local
recurrence-free survival (P = 0.089). A multivariate analysis revealed that
tumor distance from the anal verge (P = 0.006), ypN category (P = 0.011),
and perineural invasion (P = 0.048) were independent predictors of diseasefree survival; tumor distance from the anal verge was the only independent predictor of local recurrence-free survival. When the low and high p53
groups were subdivided according to ypTNM category, disease-free survival
differed significantly according to p53 expression for ypN+ disease (P =
0.027) only.
Conclusions: Expression of p53 in pathologic specimens as determined
by immunohistochemistry has a significant prognostic impact on survival
in patients with ypN+ rectal cancer after preoperative chemoradiation.
However, it was not an independent predictor of recurrence or survival.
P298
EFFECTS OF INSTITUTIONAL MULTIDISCIPLINARY CONSENSUS CONFERENCES AS IT RELATES TO THE TREATMENT OF RECTAL CANCER
AND DELIVERY OF CARE.
H. Hakiman, J. Fleshman, L. Richards, M. Reddy, S. Pappu, A. Patel,
K. Calhoun and S. Boostrom Surgery, Baylor University Medical Center,
Dallas, TX.
Purpose: The complex treatment of rectal cancer (RC) requires a multidisciplinary approach with collaboration between surgeons, medical and
radiation oncologists, imaging radiologists, and pathologists. This allows
for standardization of care. Currently, some centers deliver RC treatment in
a fragmented method allowing for possible flaws in the overall care, ultimately affecting outcome. We aim to report on a multidisciplinary approach
in the evaluation and overall treatment of RC patients with emphasis on
quality improvements in the standardization.
Methods: A biweekly RC multidisciplinary team (MDT) conference was
instituted at Baylor University Medical Center in January 2013. A prospectively maintained database identified all patients presented at MDT and
were compared to a cohort of patients not discussed at MDT from an earlier time period of January to December 2012. Preoperative evaluation and
treatment, surgical management and pathological findings were compared,
as well as outcomes.
Results: 72 patients were included in the study. 45 were treated in 2012
(Pre-MDT) and 27 patients were treated after the institution of MDT and
were discussed at the conference (Post-MDT). Comparing Pre vs. Post MDT
groups, full colonoscopy was performed, or the report was reviewed in 42
patients (95%) vs. 27 patients (100%), (p=0.5219). Pre-operative imaging
was performed or reviewed in 39 patients (89%) vs. 27 patients (100%)
(p=0.1489).The completeness of total mesorectal excision (TME) was
reported in the pathology report of none of the patients (0%) compared to
15 patients (65%), (p<0.0001). Local recurrence was seen in 2 patients (5%)
compared to 2 patients (7%) (p=0.6320) and distant recurrence was seen in
4 patients (9%) compared to 1 patient (4%) (p=0.6430).
Conclusions: The MDT conference appears to allow for improvement in
preoperative evaluation and treatment, surgical management, and pathological reporting. The impact of MDT conference was greatest for reporting
TME following resection for rectal cancer. The impact on survival, both disease-free and overall, will require further evaluation with longer follow up.
Purpose: The prognostic significance of p53 expression in rectal cancer
remains unclear. This study evaluated the expression of p53 in rectal cancer
patients after preoperative chemoradiation, its relationship with the clinicopathological characteristics, and its potential prognostic significance.
Methods: p53 expression was measured using immunohistochemical
methods in pathologic specimens from 210 patients with locally advanced
rectal cancer who had undergone preoperative chemoradiotherapy and
149
Abstracts
P299
THE PREVALENCE AND PROGNOSTIC IMPACT OF NEGATIVE
HISTOPATHOLOGY IN SURGICAL SPECIMENS FROM PATIENTS
TREATED WITH CYTOREDUCTIVE SURGERY AND HIPEC.
M. Enblad, H. Birgisson, L. Ghanipour, F. Sköldberg and W. Graf
Department of Surgery, Institution of Surgical Sciences, Uppsala University,
Uppsala, Sweden.
Purpose: The proportion and prognostic impact of patients, with no
neoplastic cells in surgical specimens after cytoreductive surgery (CRS) and
hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC), is not known. The purpose of this study was to investigate the
prevalence of negative histopathology (PC0) in surgical specimens after
CRS and HIPEC and to analyse the prognostic impact of PC0.
Methods: Data, including routine clinical histopathology, were
extracted from all 497 patients scheduled for CRS and HIPEC at Uppsala
University Hospital, Sweden, between January 2004 and December 2012.
Patients with previous CRS (n=57), inoperable PC (n=33) and patients
undergoing debulking surgery (n=21) were excluded. Chi square or MannWhitney U Test was used for comparisons and log rank test to calculate differences in survival.
Results: Of 386 included patients (166 men, mean age 55, range 13-78),
59 had PC0 (15%) and 327 had positive histopathology (PC1). The projected
5 year overall survival was longer in PC0 compared with PC1 (83% vs. 39%,
P<0.0001). When the PC0 group was excluded, the 5 year survival decreased
from 45 to 39%. Low grade pseudomyxoma peritonei, was more common
in PC0 (41%) than in PC1 (24%, P=0.0095). 30% of patients with PC0 had
received preoperative chemotherapy compared with 46% in PC1 (P=0.037).
There were no significant differences in age, gender or prior surgery score
(PSS) between the groups. Prior appendectomy was more common in PC0
(41%) than in PC1 (15%, P<0.001). Tumour markers (CEA, CA19-9, CA72-4
and CA-125), peritoneal cancer index and completeness of cytoreduction
score were lower in PC0 (P<0.0001).
Conclusions: A significant proportion of patients undergoing CRS and
HIPEC have negative histopathology in surgical specimens. These patients
have better prognosis and retention of this group in reported series could
results in a seemingly improved prognosis. Appendiceal neoplasms and low
levels of preoperative tumour markers increase the likelihood of PC0. It is
important that researchers report the proportion of patients with PC0 and
try to identify these patients to spare them possible morbidity.
P300
PREDICTIVE FACTORS OF ONCOLOGIC OUTCOME IN STAGE III COLON
AND INTRAPERITONEAL RECTAL CANCER: THE ROLE OF TWO NEW
RATIOS.
G. Rizzo, E. Vernes, A. Verbo, C. Mattana, A. Manno, D. P. Pafundi,
F. Santullo, S. Rubino and C. Coco Surgical Sciences, Università Cattolica
Sacro Cuore, Rome, Italy.
Purpose: Survival of stage III colorectal cancer is variable. Hypothesizing that size of tumor is an important prognostic factor, especially if related
to lymph node ratio (ratio between number of metastatic lymph nodes and
the number of all harvested lymph nodes), we conducted a retrospective
study to identify predictive factors of overall survival (OS) and disease-free
survival (DFS). Aim of the study was to evaluate the prognostic role of two
ratios, including tumor size, lymph node ratio and pT stage.
Methods: All III stage colorectal cancer patients treated in our division
between 2000 and 2010 entered the study. A statistical analysis was performed to identify variables predicting OS and DFS. The role of 2 variables
was evaluated: Lenght-Node Ratio (LN Ratio: maximal lenght of the tumor
divided by the lymph node ratio) and Lenght-Node-Tumor Ratio (LNT Ratio:
maximal lenght of the tumor divided by the product of lymph node ratio
and pT stage). A subgroup analysis was performed on patients receiving
post-operative chemotherapy.
Results: 118 patients (66 M; median age: 65 years) entered the study.
The median maximal tumor lenght was 4 cm. The median lymph node ratio
was 0.154. The most frequent pT stage was pT3 in 82 patients. Median value
of LN Ratio and LNT Ratio were respectively 27.083 and 8.889. Post-operative morbidity was 23.7%. 103 patients underwent to adjuvant chemotherapy. Median follow-up was 48 months. The actuarial 5-year OS and DFS
were respectively 71% and 66.1%. At multivariate analysis the male sex, the
occurrence of post-operative complications and a value lower than median
of LN and LNT Ratios were identified as factors predicting worse OS. A value
lower than median of LN and LNT Ratios were identified as factors predicting worse DFS. The same variables were identified as predicting worse OS
and DFS also in patients receiving post-operative chemotherapy.
Conclusions: LN and LNT ratios are simple to obtain and seem to be
highly related with the oncologic outcome. Patients with a low value of LN
Ratio and LNT Ratio, especially males who experienced post-operative complications, seem to be more at risk for cancer recurrences.
P301
MANAGEMENT OF COLORECTAL NEOPLASIA DURING PREGNANCY
AND IN THE POSTPARTUM PERIOD.
E. Aytac, G. Ozuner, O. Isik, E. Gorgun and L. Stocchi Colorectal Surgery,
Cleveland Clinic, Cleveland, OH.
Purpose: Colorectal cancer during pregnancy is rare.As two patients
with possibly conflicting interests need to be managed,many ethical, psycho emotional and medical issues need to be addressed
simultaneously.This study reports our experience in this group of patients.
Methods: Patients who were diagnosed with colorectal cancer during
pregnancy,or in the immediate postpartum period,between 8/1997 and
4/2013,in our department were included.Patient characteristics,operations,fetal heath and follow-up during pregnancy,type of delivery and
oncologic outcomes were analyzed.
Results: 8 patients met our study criteria.Median age at the time of
diagnosis of colorectal cancer was 31 (24-38).Median follow-up after surgery was 36 months (0.2-192).The presenting symptoms, duration of symptoms,tumor location and treatment strategy are listed in the table.Median
duration of symptoms before diagnosis was 18 weeks.Three patients were
diagnosed with colorectal cancer during pregnancy and underwent surgery prior to delivery.These cases included 1 anterior resection with an end
colostomy in the 18th week,1 low anterior resection in the 24th week and
1 subtotal colectomy during the 8th week of pregnancy.5 patients were
diagnosed with colorectal cancer within a median of 2.1 months after delivery.1 synchronous low anterior resection and liver resection,1 extensive left
colectomy,1 transanal resection,1 ileocecal resection, and 1 right colectomy
were performed on those patients. None of the patients received adjuvant
treatment during pregnancy.No adverse neonatal outcomes were noted.
All deliveries were term, except for one patient who had a low anterior
resection during pregnancy (34th week) and delivered preterm.2 patients
underwent cesarean section.
Conclusions: Because there is a significant overlap of symptoms and
signs between colorectal malignancy and a normal pregnancy, including
rectal bleeding,abdominal pain and anemia,such symptoms should not be
overlooked.Most cancers in this group of patients present at a later
stage.There has been a significant delay in the diagnosis of these
tumors,which may affect overall prognosis.Surgical intervention did not
adversely affect neonatal or maternal outcomes in this group of patients.
150
Abstracts
Table I: Treatment strategy and patient status at last follow-up
P303
A COMPARISON OF CIRCULATING TUMOR CELL DETECTION
BETWEEN HEPATIC PORTAL SYSTEM AND PERIPHERAL BLOOD VESSEL IN COLORECTAL CANCER PATIENTS.
B. Park and G. Son Pusan National University Yangsan Hospital, Yangsan,
Republic of Korea.
NCRT: Neoadjuvant chemoradio therapy, NED: No evidence of disease.
(*): Curative surgery, †: Diagnosed during pregnancy, §: Diagnosed after
pregnancy,
‡: Recurrent disease.
Second and third patients received adjuvant chemotherapy after delivery.
P302
COMPUTED TOMOGRAPHY– DEFINED VISCERAL FAT AS AN EMERGING PROGNOSTIC INDICATOR IN PRIMARY OPERABLE COLORECTAL
CANCER.
G. Malietzis1, N. Johns3, M. Giacometti1, R. H. Kennedy1, O. D. Faiz2,
O. Aziz1, K. Fearon3 and J. T. Jenkins1 1Colorectal Surgery, St Mark’s
Hospital, London, United Kingdom, 2Surgical Epidemiology, Trials and
Outcomes Centre, St Mark’s Hospital, London, United Kingdom and
3
Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United
Kingdom.
Purpose: Excess visceral fat is associated with increased gastrointestinal cancer risk. The body mass index (BMI) criteria are not suitable for determining visceral obesity. The aim of this study was to evaluate if body composition (BC) parameters, specifically visceral fat, assessed from diagnostic
computed tomography (CT) scans, is of prognostic value in patients with
colorectal cancer.
Methods: Data from 393 consecutive patients diagnosed with nonmetastatic CRC undergoing elective curative surgical resection between
2006 and 2011 were included. Cut-offs for low muscularity normalised for
stature and visceral adiposity were based on previous CT-based BC analysis
studies for cancer patients. Cox regression models were used to determine
the role of BC parameters after stratification by several clinicopathological
factors including BMI.
Results: Median follow-up was 40 months [IQR, 28-50]. Multivariate Cox
regression analysis identified high visceral fat as an independent prognostic factor for overall survival (OR 3.94, (95%CI 1.13-13.8) P= 0.032) but not
for disease-free survival (OR 1.53, (95%CI 0.69-3.39) P=0.300).
Conclusions: Excessive visceral fat in patients with CRC is an occult condition but can be identified using CT scans. This new anthropometric measure is an independent adverse prognostic indicator that should be considered for clinical stratification of patients’ and personalised care.
Purpose: Circulating tumor cell (CTC) has proposed an useful factor to
predict the prognosis of human cancers. CTC of colorectal cancer is usually
examined using peripheral blood and CTC count may be underestimated
due to cancer cell filteration effect of liver. It was assumed the more abundant CTC could be detected in the hepatic portal system. Hence, we compared the CTC counts between hepatic portal system and peripheral blood
vessel in colorectal cancer patients.
Methods: We employed immunomagnetic beads, flow cytometry and
immunofluorescence staining to detect CTC. EpCAM, cytokeratin, CD 45
and CD 133 were applied as biomarkers. At first, we used healthy adult
blood mixed with cancer cell line to verify detection rate of CTC in laboratory study. Next, we conducted a prospective clinical study with 24 colorectal cancer patients, 5 colonic diverticulitis, and 4 healthy people. Blood
samples were drawn from peripheral vein, and the hepatic portal system
during the surgery.
Results: In laboratory study, cancer cells were counted according to
EpCAM (+), cytokeratin (-) and CD 45 (-) expression patterns, and cancer cell
detection rate was around 7%. When 10000 cancer cells were mixed with
blood, around 50 cancer cells were confirmed under confocal microscope,
and the detection rate was 0.5%. In clinical study, mononuclear cells with
EpCAM and CD 133 (+) pattern were detected in 30% of the patients with
stage I-III and 100% with stage IV before surgery. After cancer resection,
CTC was positive as 16.7% at stage III and 77.8% at stage IV. CTC detection
rate was not higher in the hepatic portal system than the peripheral vein.
In the colon diverticulitis patients, suspected CTC were somewhat more
than in colorectal cancer patients. However they decreased sharply after
the operations.
Conclusions: CTC was detected in similar level between hepatic portal
system and peripheral blood. The detection rates of CTC were diverse considerably according to protocols, and cytomorphologically identification
rate of CTC was unexpectedly low. In light of these, further studies are
needed to develop more trustworthy and cancer specific method for CTC
detection for clinical application.
P304
LONG-TERM FOLLOW-UP OF COLONS WITH POLYPS: DECREASING
RATE OF NEW POLYP FORMATION WITH AGE.
A. M. Jarrar and J. Church Colorectal Surgery, Cleveland Clinic Foundation,
Cleveland, OH.
Purpose: Predictors of adenoma recurrence have been studied with follow-up intervals ranging from 1-8 yrs. No studies were found in the literature to focus on change in the rate of formation of new polyps within the
same group of patients at different time intervals over long term surveillance starting from 7 yrs and above. This is the aim of the study.
Methods: Patients under endoscopic polyp surveillance by a single
endoscopist were retrieved from a prospectively entered IRB approved
database. Those with >7 years of follow-up and at least three exams were
eligible for the study. Patients with hereditary colon cancer were excluded.
A “Colonic Fertility Index” (CFI) was calculated as the number of polyps
found at a follow-up colonoscopy divided by the number of years between
the previous exam and the current exam. CFI was calculated for all polyps,
adenomas and hyperplastic polyps (HP). Change in CFI through the surveillance periods for each subject was assessed using the slope of an estimated
linear regression line for the relation between CFI at interval colonoscopies
and time from baseline. A negative value means a decrease in the rate of
new polyp formation over the surveillance period. In addition the percent-
151
Abstracts
age of patients with polyps at the site of a previous polyp was calculated
for the left and right colon, different follow-up intervals and polyp types.
Results: 93 patients were followed for a mean of 10.6 yrs. Mean age was
60 years and mean number of colonoscopies 4.2. The mean interval
between colonoscopies was 3.1 years. Overall, CFI Slope was –ve for 61% of
patients. The mean CFI Slope was -0.10, indicating a decrease in rate of
polyp formation over time (Wilcoxon signed rank P=0.005). Similar results
were shown for adenomas and HPs separately. The percentage of patients
with polyps found at the site of the index lesion in those with 6 follow-up
colonoscopies was: (adenomas: 70% left sided and 23% right sided, HPs:
33% left sided and 29% right sided).
Conclusions: Starting from the 5th decade of life, the rate of new polyp
formation tended to decrease over time. This could affect the surveillance
recommendations.
4.78 in the control group (ns). There was no significant difference in postoperative complications.
Conclusions: Exparel is a safe and effective form of postoperative pain
control. Intravenous narcotic requirements were significantly reduced after
single injection. A larger sample size may be needed to demonstrate a difference in LOS. Exparel should be considered as a viable option in a multimodal approach to postoperative pain control.
Postoperative opioid use
P306
IS THERE A ROLE FOR EPIDURAL ANALGESIA IN LAPAROSCOPIC
COLECTOMY?
C. Tadaki, N. Molacek, R. Jones, M. Humphreys and S. Langenfeld
University of Nebraska Medical Center, Omaha, NE.
P305
MULTIMODAL PAIN MANAGEMENT: DOES THE USE OF EXPAREL
(BUPIVACAINE EXTENDED-RELEASE LIPOSOME INJECTION) MINIMIZE
POSTOPERATIVE NARCOTIC REQUIREMENTS IN COLORECTAL
PATIENTS UNDERGOING ABDOMINAL OPERATIONS.
E. Boland1, M. A. Gillespie2 and G. Y. Apostolides2 1CVPH, Plattsburgh, NY
and 2Colorectal Surgery, GBMC, Towson, MD.
Purpose: Narcotic medication for postoperative pain relief is associated
with significant side effects. Multimodal approach to postoperative pain
relief combines opioid and non-opioid analgesics. Single injection of
Exparel, an extended-release liposome injection of bupivacaine can provide pain relief up to 72 hours. It can improve pain control and minimize
narcotic use and side effects to promote faster recovery. Our aim was to
examine the effect of Exparel injection on narcotic requirements and length
of hospital stay (LOS) in patients undergoing abdominal surgery.
Methods: Data was collected on two sequential patient cohorts, each
over a 6-month period. Abdominal operations were performed by two colorectal surgeons. Postoperative narcotic requirements in hospital, LOS and
complications were recorded. Exparel 1.3%, 20 ml was used as a single intraoperative injection. It was diluted in up to 280 ml of normal saline to
accommodate for incision size.
Results: There were 40 patients in the Exparel group, and 41 in the control. Average ages were 65.6 years and 62.6. Twenty six underwent laparoscopic operations in the study group, and 25 in the control group. Most
common diagnoses in both groups included colorectal cancer and diverticulitis. Postoperative narcotic regimens included Morphine intravenous (IV),
Hydromorphone IV and oral, lortab and percocet. There was a statistically
significant reduction in intravenous narcotic requirements in the Exparel
group (p 0.004). There was no significant difference in oral narcotic pain
medications. Postoperative LOS was 4.13 days in the Exparel group, and
Purpose: Epidural analgesia offers several potential benefits in select
patients undergoing open colectomy, but its role in laparoscopic colectomy
is controversial. The aim of this study is to compare short-term outcomes
between epidural analgesia and conventional intravenous analgesia for
patients undergoing laparoscopic colectomy.
Methods: The University Health System Consortium (UHC), an alliance
of more than 300 academic and affiliate institutions, was reviewed for the
time period of October 2009 through October 2013. International Classification of Disease 9th Clinical Modification (ICD-9CM) codes for laparoscopic
colectomy (right 17.33, left 17.35, total 45.81) and for epidural catheter
placement (03.90, 03.91) were used to identify patients.
Results: A total of 26,034 patients underwent laparoscopic colectomy
during the study period. One hundred twenty five (0.48%) of those patients
were identified as having an epidural catheter placed for analgesia. Baseline patient demographics were similar for the epidural and conventional
analgesia groups. Total charges were significantly higher for patient receiving an epidural ($52,998 vs. $41,731; p<0.0001). Median length of stay was
longer in the epidural group (6 vs. 5 days; p<0.001). Urinary retention was
higher in the conventional analgesia group (5% vs. 0.8%; p=0.03). There was
no statistical difference between the epidural and conventional analgesia
groups in death (0% vs. 0.61%; p=0.85), urinary tract infection (0% vs. 0.1%;
p=0.99), ileus (12% vs. 14.%; p=0.42), or readmission rate (9.6% vs. 11.3%;
p=0.83).
Conclusions: Use of epidural analgesia for laparoscopic colectomy is
uncommon. When compared to conventional analgesic techniques,
epidural analgesia does not reduce the rate of postoperative ileus, and it is
associated with increased cost and increased length of stay. Routine use of
epidural analgesia for laparoscopic colectomy should be abandoned.
152
Abstracts
EPIDURAL VS. CONVENTIONAL ANALGESIA AFTER LAPAROSCOPIC COLECTOMIES
General and wound-related complications
P307
EFFECTS OF A NEW POCKET DEVICE FOR NPWT ON SURGICAL
WOUNDS IN CROHN’S DISEASE.
G. Pellino, G. Sciaudone, G. Candilio, F. Campitiello, F. Selvaggi and
S. Canonico Department of Medical, Surgical, Neurological, Metabolic and
Ageing Sciences, Second University of Naples, Naples, Italy.
Purpose: Surgical site infections(SSI) affect costs of care and prolong
length of stay. Crohn’s disease(CD) is an independent risk factor for SSI. The
risk can be further increased by immunosuppressants and poor performance status at the time of surgery. We compared a portable device for
NPWT(PICO, Smith & Nephew, London,UK) to conventional gauze dressings
in patients undergoing surgery for stricturing CD.
Methods: This is a prospective non-randomized controlled trial.
Hypothesizing a 50% reduction in SSC with NPWT,12 patients for each arm
were needed to reject the null hypothesis that SSI rates for experimental
and control subjects were equal(power= 80%, type I error probability= 5%).
We enrolled 30 patients undergoing surgery for stricturing CD between
January 2010 and November 2011, who were assigned to treatment with
either PICO(n=13) or conventional dressings(n=17). Each patient completed
3-month follow-up. Demographic data, surgical details and complications
were collected. SSI and wound complications were evaluated on postoperative-day 3, 7 and 30 according to CDC criteria and Global ASEPSIS score,
respectively. The POSAS and a 10-cm Visual Analogue Scale were used to
assess cosmetic results at 3-month follow-up. After discharge, follow-up visits were at 7, 15 and 30 days, then every two weeks for 3 months. In selected
cases, PICO was continued on at home.
Results: Patients receiving PICO experienced significantly less postoperative wound complications (p=0.001) and SSI(p=0.017) compared with
those who received conventional dressings. This resulted in shorter hospital stay(0.0007). The number needed to treat(NNT) was 3 (1.5-8.6 95%CI);
however, when considering only patients receiving steroids, half of patients
would benefit from PICO (NNT 2, 0.9-1.7 95%CI). No significant differences
in cosmetic results were found. No adverse events were recorded in
patients receiving PICO at home.
Conclusions: Our data suggest that PICO allows faster and safe discharge by reducing the incidence of SSI and wound-related complications
in selected patients undergoing surgical intervention for stricturing CD. This
could be particularly useful in patients receiving steroids. NPWT home care
with PICO is safe, effective and easy-to-handle.
CDC: Centers for Disease Control and Prevention; SSI: Surgical Site Infections; SD:
Standard Deviation
P308
SUPERIORITY OF END-TO-SIDE ANASTOMOSIS AFTER LAPAROSCOPIC
RIGHT HEMICOLECTOMY UNDER A FAST-TRACK PROGRAM: A COMPARATIVE STUDY WITH SIDE-TO-SIDE ANASTOMOSIS.
K. Lee, H. Oh, S. Lee, S. Lee, M. Ihn, D. Kim and S. Kang Department of
Surgery, Seoul National University Bundang Hospital, Seoul National
University College of Medicine, Seongnam-si, Republic of Korea.
Purpose: Stapled side-to-side (SS) anastomosis has been preferred to
stapled end-to-side (ES) or other methods after laparoscopic right hemicolectomy. We aimed to compare postoperative outcomes between ES and
SS stapled anastomosis after laparoscopic right hemicolectomy under a
fast-track program.
Methods: Between September 2009 and November 2012, 90 patients
who had received laparoscopic right hemicolectomy, which were under a
fast-track program including early mobilization and early oral feeding, were
grouped to ES (n = 44) and SS (n = 46) according to changing of anastomotic method from SS to ES since July 2011. The primary outcome was
complication rate, and secondary outcomes were operative time, hospital
stay and recovery time, measured with criteria of tolerable diet for 24 hours,
safe ambulation, analgesic-free, and afebrile status without major complications.
Results: Baseline characteristics, which included sex, body mass index
and pathologic stage, were well-balanced except for age (ES group, 62.3 ±
12.3 vs SS group 66.9 ± 8.8; P = 0.043). The complication rate was less in the
ES group than in the SS group (4.5% vs 21.7%, respectively; P = 0.027),
which was strongly related to postoperative ileus (2.3% vs 13.0%, respectively; P = 0.267). There was no complication requiring reoperation. Operative time was less in the ES group (median [interquartile range], 147.5 [135164] min vs 169 [145-185] min; P = 0.007). Postoperative hospital stay was
less in the ES group (6 [5-7] days vs 7 [6-9] days; P = 0.03). Recovery time
was similar between ES and SS groups (117 [97-143] hr vs 136 [85-184] hr;
P = 0.292).
Conclusions: This study demonstrates that stapled ES anastomosis produce better postoperative recovery and less complication than SS anastomosis in patients undergoing laparoscopic right hemicolectomy under a
fast-track program.
153
Abstracts
P309
AN UPDATED EVALUATION OF POSTOPERATIVE ILEUS IN COLON SURGERY - ASSOCIATIONS AND OUTCOMES.
J. K. Thacker1, W. K. Mountford2, M. Mythen3, M. R. Krukas2 and
F. R. Ernst2 1Surgery, Duke University, Durham, NC, 2Premier Inc.,
Wilmington, NC and 3University College London, London, United Kingdom.
Purpose: To report the current rate of postoperative ileus, (POI), and to
compare associated factors and outcomes during hospitalization for elective colon operations.
Methods: Study included all inpatients (age≥18) with elective colon
procedure (ICD-9 codes 17.3x, 45.52, 45.7x, 45.8x, 45.92, 45.93) January
2008 through June 2012 as captured in the U.S.-based Premier research
database. POI was defined using ICD-9 codes 997.4x and 560.1. Hospital
length of stay, in-hospital mortality, total hospital costs, and 30 day readmission rates were evaluated. Patient charge master data provided intravenous fluid, (IVF), billed for each patient. Patients with POI were compared
to patients without POI and chi-squared or t-tests were used to determine
statistical significance.
Results: Among 84,722 patients having colon surgery in 524 hospitals,
14,972 (17.7%) patients had POI. Patients with POI had significantly longer
mean (±SD) length of stay (10.0±8.5 vs. 5.5±4.7 days; p<0.0001) and greater
mean total hospital costs ($20,734±14,506 vs. $13,865±8,315; p<0.0001). In
addition, POI patients had significantly higher rates of in-hospital mortality
(1.6% vs. 0.6%; p<0.0001) and 30-day readmissions (13.7% vs. 9.4%;
p<0.0001), as well as greater mean perioperative IVF fluids (17.6±24.2 vs.
10.3±10.4 liters; p<0.0001).
Conclusions: POI drives length of stay and increased costs in colorectal
resection. POI incidence in this contemporary study is lower than in previous smaller reviews; perhaps this reflects increased use of laparoscopy procedures. POI is still associated with outcome differences, including twice
the LOS and a 50% increase in total hospital costs. Additionally, patients
with POI have a higher readmission rate, the costs of which are not included
in this study. While POI may be a causative factor to increased IVF, current
fluid management literature suggests excessive IVF could contribute to POI.
Future research is required to better understand the causal relationship
between POI and perioperative IVF.
P310
INCISIONAL NEGATIVE PRESSURE THERAPY REDUCES PERINEAL
SUPERFICIAL WOUND INFECTIONS FOLLOWING ABDOMINOPERINEAL RESECTION.
A. F. Chung1, S. A. Vogler2, S. R. Finlayson1 and B. Sklow2 1Surgery,
University of Utah, Salt Lake City, UT and 2Surgery, University of Minnesota,
Minneapolis, MN.
Purpose: Perineal wound infection rates following abdominoperineal
resection (APR) have been reported in the range of 13-60%. The use of incisional negative pressure wound therapy (NPWT) has been described to
decrease rates of superficial surgical site infection (SSI) in orthopedic, cardiac, vascular, and laparotomy incisions, but its use in perineal incisions has
not been studied to date. The purpose of this study is to compare the rate
of perineal incisional SSI in APR patients treated with NPWT to a cohort of
patients receiving standard wound care.
Methods: A retrospective cohort study of consecutive APR patients
from May 2009 to September 2013 was completed. Operations were performed by two colorectal surgeons in an academic, tertiary care setting.
Patients treated with incisional NPWT had the closed perineal incision covered with a non-adherent dressing and a KCI NPWT dressing (Kinetic Concepts, Inc.) that was maintained until the fifth postoperative day. The cohort
group received normal post-operative perineal wound care. Patient comorbidity and risk factors for SSI were analyzed to identify confounding factors. Cox proportional hazard models and Kaplan Meier graphs were
employed for analysis.
Results: A total of 51 patients were identified, 5 of which were excluded
due to paraplegia (n=2), lack of data (n=2), and foreign body in the wound
(n=1). Forty-six patients were therefore included in the analysis: 24 in the
non-NPWT group and 22 in the NPWT group. The observed SSI rate of 9.1%
in the NPWT group was significantly lower than the non-NPWT rate of
41.7% (p = .012, Chi-square). Gender, body mass index (BMI), and operative
time were different between groups, but only gender emerged as a statistically significant confounding variable. In the Cox regression model, NPWT
was protective against SSI compared to normal wound care (HR=0.14, 95%
CI: 0.03-0.68, p=.01).
Conclusions: The use of NPWT on APR perineal incisions significantly
reduces the risk of superficial SSI, and could be used to prevent the substantial discomfort, inconvenience, and costs associated with such infections.
Kaplan-Meier graph of probability of superficial surgical site infection (SSI).
P311
ARE PATIENTS AT RISK OF READMISSION WITH ANASTOMOTIC LEAK
AFTER EARLY DISCHARGE?
A. J. Lunt, T. J. Royle, A. A. Bajwa and S. B. Pandey Colorectal Surgery,
Worcestershire Royal Hospital, Worcester, United Kingdom.
Purpose: Enhanced Recovery Programmes (ERPs) in colorectal surgery
enable shorter length of post-operative hospital stay (LOS). This has generated concerns that patients may re-present with anastomotic leak following early discharge. The aim of this study is to evaluate the outcomes of
procedures involving anastomosis within our ERP focusing on anastomotic
leak and LOS.
Methods: A prospectively compiled ERP database was used to identify
patients undergoing a colorectal procedure involving an anastomosis
between January 2011 and May 2013. Patients with any evidence of collections (pelvic or adjacent to anastomosis) were included in the study.
Patients who required a further operation following leak were analysed as
a separate sub-group. Outcomes for these two groups were analysed and
compared to the overall population.
Results: Some 388 patients (216 male, median age 68) were identified
as having undergone colorectal surgery involving an anastomosis. 34.8%
of procedures were right hemicolectomies with anterior resections and sigmoid colectomies making up 29.9 and 16% respectively. Evidence of anastomotic leak was demonstrated in 29 patients (7.5%) with 15 patients (3.9%)
requiring a further operation. 14 (12.1%) anterior resections demonstrated
evidence of anastomotic leak, with 8 patients requiring re-operation. Overall median LOS was 6 days (range 2-162) with 37.4% of patients discharged
≤day 5. Median LOS for patients who had evidence of anastomotic leak was
18 days (range 3-162) compared to 5 days in the non-leak group (p<
0.0001). Median LOS for patients who required a further operation following leak was 25 days (range 3-162) compared to 6 days (range 2-44) for the
non-operated ‘leak’ subgroup (p< 0.0001). Overall readmission rate was
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Abstracts
9.1%. Only 1 patient readmitted following early discharge (LOS=4 days)
required an operation for anastomotic leak.
Conclusions: Readmission with anastomotic leak following early discharge is very low within our Unit. Patients who suffer anastomotic leak
have a significantly longer index admission. We feel that that this demonstrates that patients that go on to experience anastomotic leak are not
those who are deemed eligible for early discharge.
pathology /laboratory services, pharmacy, respiratory/ pulmonary and
physical therapy. Surgery time was longer in OB and MOB patients (p=0.02).
Length of stay and morbidity did not differ between groups.
Conclusions: Obesity increases the inpatient cost of care for rectal cancer patients with the morbidly obese having the greatest costs. This trend
may be related to increasing co-morbidity in obese patients.
P314
P312
SURGICAL TRAINEE TURNOVER DOES NOT NEGATIVELY IMPACT COMPLIANCE WITH ENHANCED RECOVERY PATHWAYS.
D. W. Larson, A. Hayman, J. Lovely, M. Burton and E. Dozois Surgery,
Mayo Clinc, Rochester, MN.
THE VENOUS THROMBOEMBOLISM RATE IN GENERAL SURGERY
PATIENTS IS NOT AS HIGH AS NSQIP REPORTS.
C. Kin, H. Vo, L. Welton, K. Rhoads and M. Welton Department of Surgery,
Stanford University Medical Center, Stanford, CA.
Purpose: The implementation and execution of enhanced recovery
pathways (ERP) are critical for optimizing postoperative outcomes. Little is
known about the impact of new surgical trainees, who are naïve to ERP, but
responsible for execution of ERP, have on overall pathway compliance.
Methods: All surgical inpatients from May 1, 2013 through August 31,
2013 were evaluated for ERP compliance. A prospectively maintained database was utilized to evaluate this cohort. In July 1st, 2013, new surgical
trainees (naïve group), all of whom received education, training, and feedback on compliance regarding our institution’s ERP process and standards,
replaced the outgoing trainees (experienced group). Patient demographics, outcomes and compliance with ERP were compared between these two
groups.
Results: A total of 592 patients were evaluated. There were no significant differences in ERP compliance in patients being cared between experienced trainees (88%) and naïve trainees (90%) (p=0.53). Patient age, gender, ASA class, and operative times were statistically equivalent during both
time periods. Compliance with 6 individual elements (preoperative: acetaminophen, gabapentin, celecoxib; and postoperative: diet, fluid management, and NSAID use) of ERP ranged between (43-85%) and was not statistically different between the two time periods. Readmissions were equal
during both time periods (14% versus 12%, p=0.3). Median length of stay
was one day longer during July and August (experienced group, 3days vs.
naïve group, 4 days; p=0.024).
Conclusions: We have found that with education, training and oversight, new surgical trainees can effectively implement and execute ERP protocols with high compliance. In the setting of effective and standardized
process measures, consistent quality patient care can be assured despite
provider transitions.
Purpose: The National Surgical Quality Improvement Project (NSQIP)
identifies postoperative deep venous thrombosis (DVT) and pulmonary
embolism (PE) as preventable adverse events. However, postoperative portal and mesenteric venous thrombosis are neither proven to be clinically
significant nor preventable. The purpose of this study is to determine the
actual rate of venous thromboembolism (VTE) within a group of patients
identified by NSQIP as positive for VTE.
Methods: We performed a retrospective review of charts identified by
NSQIP abstracting guidelines as having postoperative VTE after general surgery operations in an academic hospital from 2008 to 2013.
Results: The sample of general surgery patients examined by NSQIP
revealed 18 postoperative VTE events. The main outcome measure was the
proportion of patients with a DVT or PE within the group of cases identified by NSQIP as having those diagnoses. We excluded one patient as an
error because she not only underwent an emergency operation for perforated viscus but also had a known pre-existing lower extremity DVT. Of the
remaining 17, four cases (24%) were portal or mesenteric venous thromboses occurring after colorectal operations, three of which were for the
indication of medically refractory ulcerative colitis. Three cases (18%) were
upper extremity DVTs associated with central venous catheters. Five cases
were lower extremity DVTs (29%) and the remaining five were PEs (29%).
Conclusions: Fewer than 60% of cases identified by following NSQIP
abstraction guidelines as postoperative VTE were true DVT/PE events. Fortytwo percent of cases were either thrombi in the the upper extremity due
to the presence of a central venous catheter, or thrombi in the portal or
mesenteric veins; neither of these events is proven to be preventable. In
particular, portal or mesenteric venous thrombosis carries no risk for PE.
The NSQIP definition of DVT needs refinement to improve its specificity and
potential reliability as a quality indicator.
P315
P313
IMPACT OF OBESITY ON COST OF RECTAL CANCER SURGERY.
F. Elagili, L. Stocchi and D. Dietz Colorectal surgery, Cleveland clinic,
Cleveland, OH.
Purpose: Understanding factors that influence costs of care will be
increasingly important as healthcare payers shift to bundled reimbursement models. This study aimed to assess the impact of obesity on costs of
treatment for patients undergoing proctectomy for rectal cancer.
Methods: Rectal cancer patients undergoing elective proctectomy from
January 2010 - November 2012 were identified and grouped based on
accepted ranges of body mass index (BMI). Intraoperative, complication,
length of stay, and cost data were compared between groups. Direct cost
data was obtained from the institution business office.
Results: 252 patients were included in the study (76 normal weights,
BMI 20- <25 (NW), 89 overweight, BMI 25- <30, 76 obese, 30- <40 (OB), and
11 morbidly obese≥40 (MOB)). Groups were similar in age, gender, tumor
stage and surgical procedure. The diabetes, cardiac co-morbidities was significant higher with increased BMI (P=0.001, P=<0.001).Both OB and MOB
patients had higher mean total costs than NW patients (OB = 10%, p= 0.01;
MOB = 40%, p=0.03). Differences were accounted for by costs related to
SURGICAL SITE INFECTIONS AFTER STOMA REVERSAL: RISK FACTORS
AND PROTECTIVE STRATEGIES.
D. I. Chu1, C. R. Schlieve1, D. T. Colibaseanu2, P. J. Simpson1, A. E. Wagie1,
E. B. Habermann1 and R. R. Cima1 1Division of Colon and Rectal Surgery,
Mayo Clinic, Rochester, MN and 2Division of Colorectal Surgery, Mayo
Jacksonville Florida, Jacksonville, FL.
Purpose: To determine the incidence and risk factors for SSIs in a large
cohort of colorectal patients undergoing SR.
Methods: Our institutional National Surgical Quality Improvement Program (NSQIP) database from 2006-2011 was queried for all patients undergoing SR and thirty-day SSI. Records were additionally reviewed for nonNSQIP elements including ostomy type, anastomotic technique, skin
closure and subcutaneous drain placement. Predictors of SSI were identified using chi squares and multivariable logistic regression.
Results: From 528 patients who underwent SR, 36 patients developed
a SSI (6.8%). Most patients underwent SR after operations for ulcerative colitis (38.6%) and cancer (27.8%). Stomas consisted of loop ileostomies
(76.5%), end colostomies (11.6%), end ileostomies (9.3%) and loop
colostomies (2.5%). SRs were done through the stoma site (76.9%) or a midline laparotomy (22.9%). Patients with SSI and no-SSI were similar in age,
155
Abstracts
gender, BMI, race, and wound classification with no difference in rates of
preop antibiotic administration, primary skin closure or handsewn anastomoses (p>0.05). SSI patients had fewer subcutaneous drains (36.1 vs. 59.6%,
p<0.05) compared to patients having no-SSI and had significantly higher
rates of smoking (30.6 vs. 13.4%), ASA 3-4 class (38.9 vs 21.9%), fascial dehiscence (16.7 vs. 6.3%), end stomas (36.1 vs 19.7%) and laparotomies at SR
(47.2 vs. 21.1%) (p<0.05). SSI patients also had increased 30-day morbidities in sepsis, wound disruptions, unplanned intubations, ventilation >
48hrs, and returns to the operating room (p<0.05) compared to no-SSI
patients. On multivariable analysis, subcutaneous drain placement was suggestive of SSI protection (odds ratio [OR] 0.52, 95% confidence interval [CI]
0.2-1.1), but only smoking was significantly associated with an increased
risk for SSI (OR 2.4, 95% CI 1.1-5.4).
Conclusions: SR is a commonly performed procedure and SR SSIs are
associated with significant morbidity. While subcutaneous drain placement
may be protective for SR SSIs, our study shows that smoking significantly
increases the risk for SSI by over two-fold and should be a part of any SR
SSI risk reduction strategy.
creation of diverting ileostomy, rate of ileostomy reversal, time to diagnosis
of anastomotic sinus, presence of symptoms at the time of diagnosis, treatment approaches, and overall failure rates, defined by creation of end
stoma.
Results: 23 patients developed an anastomotic sinus during the study
period. All patients underwent diverting ileostomy at the index procedure,
with the majority (n=20) eventually undergoing stoma closure. There were
15 males with mean age 51.4 years. Anastomotic sinus was diagnosed on
average 61 days after the initial procedure and was symptomatic at the time
of diagnosis in 13 (56.5%) patients. 9 had the sinus identified on routine
preoperative gastrograffin enema prior to ileostomy closure. The sinus was
managed with observation in 11, IR drainage in 13, sinus closure in 3,
unroofing in 3, and diverting stoma in 5 patients. Overall, sinus healing was
achieved in 15 patients. Observation resulted in healing of sinus in 6 (26%)
patients.
Conclusions: Anastomotic sinuses are a rare complication after LAR and
IPAA procedures. Our results demonstrate that the majority of asymptomatic sinuses will heal with observation over time. Sinuses that develop as
a result of symptomatic leaks, however, are more likely to require at least 1
surgical or endoscopic intervention, with a small proportion of patients progressing to failure of the anastomosis.
P316
SIGNIFICANCE OF INTRAOPERATIVE PERITONEAL WASHING CYTOLOGY IN COLON CANCER.
T. Ishii, S. Yamaguchi and J. Tashiro Gastroenterological Surgery, Saitama
Medical University International Medical Center, Hidaka, Japan.
P318
Purpose: We investigated the incidence of free cancer cells in the peritoneal washing cytology ( CY ) of patients who had undergone colon cancer resection to evaluate its influence and relationship of prognosis.
Methods: One thousand sixty-seven patients ( 628 males, 440 females,
average 67.9 years old ) of CY during colon cancer resection were included
in this study. Recurrence rate were compared between cancer positive
cytology groups ( CY+ ) and negative cytology groups ( CY- ).
Results: Twenty-seven cases ( 2.5% ) were determined as CY+. According to the classification by the depth of invasion, T4 patients were more frequent CY+ than T1-T3 ( 11.8% VS 0.80% ). With reference to histological
type, CY was predominantly positive in poorly differentiated adenocarcinoma ( 19.2% VS 2.0% ). The rate of CY+ in the cases with peritoneal dissemination positive was significantly higher than peritoneal dissemination
negative ( 38.1% VS 1.1% ). The peritoneal recurrence rate were significantly
different in CY+ ( 26.7% ) and CY- ( 1.4% ) ( p<0.001 ). Disease free survival
rates ( DFS ) were significantly different in CY+ and CY- ( CY+: 3-year DFS
57.2%, 5-year DFS 57.2% CY-: 3-year DFS 85.4%, 5-year DFS 80.8% Logrank
test: p<0.001 ).
Conclusions: These results suggest that the peritoneal washing cytology for colon cancer was one of the important risk factor of peritoneal
recurrence and also prognostic factor.
P317
OUTCOMES OF ANASTOMOTIC SINUSES AFTER RESTORATIVE PROCTOCOLECTOMY AND LOW ANTERIOR PROCEDURES.
A. Siripong, D. Margolin, C. Whitlow, T. Hicks, D. Vargas and D. Beck
Ochsner Clinic, New Orleans, LA.
Purpose: Anastomotic sinuses are a rare complication after low anterior resection (LAR) and ileal pouch anal anastomosis (IPAA) procedures.
However, the optimal treatment strategy for this difficult problem is challenging and not standardized. The current study describes the treatment
and outcomes of anastomotic sinuses that developed after LAR and IPAA
at a single institution.
Methods: IRB approved retrospective chart was performed to identify
patients that underwent LAR or IPAA between 2005 to 2013. Patients who
developed anastomotic sinuses were identified by CPT code and chart
review. Anastomotic sinus was defined as a blind-ending tract that originated from the anastomosis based on radiographic imaging. In addition to
demographics, collected data included type of procedure (LAR vs. IPAA),
INSURANCE STATUS AND SURVIVAL OUTCOME FOR COLORECTAL
CANCER PATIENTS AT AN URBAN ACADEMIC CENTER.
J. Y. Son1, J. B. Oliver1, A. Bongu1, S. P. Anandalwar1, M. F. Demyen3 and
R. J. Chokshi2 1Department of Surgery, Rutgers - New Jersey Medical
School, Newark, NJ, 2Division of Surgical Oncology, Rutgers - New Jersey
Medical School, Newark, NJ and 3Division of Gastroenterology, Rutgers New Jersey Medical School, Newark, NJ.
Purpose: Multiple studies have reported on healthcare disparities that
impact treatment and survival for colorectal cancer (CRC) patients. However, these studies are often multi-institutional without uniform practice
patterns. In an effort to examine our own institute’s disparities, we reviewed
the relationship between insurance status of CRC patients and the stage of
diagnosis, therapies received, and survival outcomes.
Methods: Retrospective review of records from the cancer center tumor
registry was cross-matched with the pathology database to identify
patients who underwent treatment for colorectal cancer between the years
2001-2011. Demographic information, treatments received, and survival
outcomes were analyzed by stratifying the patients by insurance status at
time of diagnosis (Private, Medicare, Medicaid, or Uninsured). Data was
compared and analyzed using Chi-square test, Kruskal-Wallis ANOVA,
Kaplan-Meier with log-rank test, and Cox Proportional Hazard.
Results: The historical cohort consisted of 513 CRC patients. Demographics and treatments are shown in the table. The groups differed based
on age (p<0.001) and race (p=0.01), but had similar cancer stage at diagnosis (p=0.28) and similar sex distribution (p=0.52). The proportion of individuals who underwent surgery (p=0.06) or had chemotherapy as part of the
treatment plan (p=0.10) did not significantly differ between the groups.
Insurance type was not significantly associated with survival in univariate
(p=0.06) or multivariate analysis (p=0.62). The significant predictors of survival were age at diagnosis (p<0.001), AJCC stage (p<0.001), and inclusion
of chemotherapy as part of treatment plan (p=0.01).
Conclusions: In our experience at an urban academic center, we found
that patients with CRC received equitable level of care regardless of insurance status with no significant survival differences. Although this study
looks at an urban academic tertiary care center, this may help to expose
the complex disparities issues that may arise from differing practice patterns and hospital policies across the United States.
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Abstracts
Patient characteristics and specific complications
P319
ASSESSMENT OF SHORT-TERM OUTCOMES FOLLOWING MESH
HERNIORRHAPHY WITH SIMULTANEOUS COLORECTAL SURGERY: A
CASE-MATCHED STUDY FROM THE ACS NSQIP.
C. Benlice, E. Gorgun, E. Aytac, G. Ozuner and F. Remzi Colorectal
Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
Purpose: Ventral hernia repair (VHR) with mesh is controversial when
performed in the colorectal surgery (CS) setting, due to the significant risk
of surgical site infection following colorectal operation. The aim of the present study was to evaluate the impact of concurrent CS and ventral hernia
repair with mesh comparing short-term outcomes, using a large, nationwide database.
Methods: Patients who underwent simultaneous CS and VHR between
2005 and 2010 were identified from the American College of Surgeons
National Surgical Quality Improvement Program (ACS-NSQIP) database by
using primary and secondary procedure current procedural terminology
(CPT) codes. Patients with a body mass index (BMI) of 18 – 50 kg/m2 and
an American Society of Anesthesiologists (ASA) score of I-IV were included
in the analysis. Patients who underwent VHR with mesh were case-matched
to patients who underwent VHR with no mesh (1:2). Case-matching criteria
were as follows: type of colorectal procedure, primary colorectal disease
and ASA score. Short-term (30-day) postoperative morbidity and mortality
were compared between the groups.
Results: We identified 2250 patients who had VHR with a simultaneous
colorectal operation. 262 patients who underwent VHR with mesh were
matched with 524 patients who underwent VHR without mesh. Patient
demographics, BMI and comorbidities were similar between the groups
(table). Mean operating time was significantly longer in patients who
underwent VHR with mesh (195.8 +/-98.7 vs.164.3 +/-84.4 minutes;
p<0.001). Postoperative morbidity (30 vs. 32 %; p=0.58), surgical complications (24 vs. 24 %; p>0.99), medical complications (15 vs. 17 %; p=0.53),
reoperation (8 vs. 10 %; p=0.48), length of hospital stay (9 vs. 9 days; p=0.71)
and mortality (2 vs. 3 %; p=0.27) were comparable between the groups.
Conclusions: Short-term analysis of nationwide data suggests that ventral hernia repair with mesh does not increase postoperative mortality,
medical and surgical morbidity including surgical site infections in the colorectal surgery setting.
P320
30-DAY RISK FACTORS FOR READMISSION AFTER COLECTOMY FOR
COLON CANCER: RESULTS FROM THE ACS NSQIP DATASET.
M. B. Bailey1, D. Davenport1, S. McKenzie2, S. Beck1 and J. Hourigan1
1
General Surgery, Univeristy of Kentucky, Lexington, KY and 2Surgical
Associates of Austin, Austin, TX.
Purpose: As of 2015, the Centers for Medicare & Medicaid Services will
penalize institutions for readmission after surgery. The purpose of this
analysis was to identify potential predictors of readmission after colectomy
for colorectal cancer using a national inpatient sample.
Methods: Using the ACS NSQIP database during the years 2011-2012,
we identified all readmissions for colon cancer resections. As of 2011, NSQIP
began classifying readmissions as planned or unplanned with unplanned
readmissions further stratified as related or unrelated to the index procedure. Rates of unplanned readmissions related to the procedure (UPRRP)
were calculated for open and endoscopic procedures and analyzed. Multivariable logistic regression was performed to determine independent risk
factors for UPRRP.
Results: A total of 2684 colorectal cancer resections were identified.
Perioperative deaths (n=50, 1.9%) and hospital stays ≥30 days were
excluded from subsequent analysis. Of the remaining 2603 patients, 30-day
readmission occurred for 271 (10.4%) patients, of which 13 (0.5%) were
planned, 84 (3.2%) were unplanned unrelated to the procedure, and 174
(6.7%) were UPRRP. The most common reason for UPRRP was infection
(n=53, 31.0%). Reoperations occurred in 15.1% (39/258) of unplanned readmissions. Readmissions were more frequent in open versus laparoscopic
resections and were more often related to the procedure (P’s <.001). Independent predictors of UPRRP included: history of CHF, overweight and
obese class I BMI, bleeding disorder (including unknown timely discontinuance of blood thinners), open procedure, in-hospital deep SSI, and in-hos-
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Abstracts
Table 1.- Unadjusted rates of thromboembolic events per disease
pital AMI. Increased length of initial hospital stay proved the only independent predictor with a protective effect on UPRRP.
Conclusions: Based on our analysis, unplanned readmissions can be
anticipated in at least 6% of patients with up to 15% requiring reoperation.
Performance of a laparoscopic procedure when feasible, optimization of
cardiac risk factor modification and hypocoaguable states, a conservative
approach to early discharges, and increased focus on preventing postoperative infection are strategies that will likely decrease the incidence of UPRRP.
P322
EVALUATION OF FACTORS ASSOCIATED WITH HOSPITAL READMISSION FOLLOWING ILEOSTOMY CREATION.
J. V. Manchio2, S. Shah1, F. Lane1, R. B. Melbert1 and B. M. Tsai1 1Kendrick
Colon and Rectal, St. Francis Health System, Indianapolis, IN and
2
Department of Surgery, Indiana University, Indianapolis, IN.
P321
ANALYSIS OF THROMBOEMBOLIC EVENTS AFTER COLORECTAL SURGERY IN PATIENTS WITH VARIOUS COLORECTAL DISEASES.
L. Rashidi, J. Benarroch-gampel and A. H. Gajjar UTMB, Galveston, TX.
Purpose: To compare the incidence of post-operative thromboembolic
events (TEE) in patients undergoing elective colon resection for colorectal
cancer, inflammatory bowel disease (IBD) or benign disease.
Methods: Using the National Surgical Quality Improvement Program
(NSQIP) database (2005-2012) we selected a total of 51,847 patients with
colon cancer, IBD or benign colorectal disease who underwent elective
colon resection. The association between various colorectal diseases (IBD
vs. colon cancer vs. benign colorectal disease) and incidence of TEE, specifically deep vein thrombosis (DVT) or pulmonary embolism (PE) within 30
days of surgery was evaluated using univariate and multivariate logistic
regression models.
Results: A total of 5,527 (10.7%) patients had operations for IBD, 15,391
(29.7%) for benign disease, and 30,929 (59.6%) for colorectal cancer. Compared to the other 2 groups, patients with IBD were younger, had significantly fewer comorbidities, and were more likely to be on steroids and/or
have weight loss prior to surgery. A total of 742 patients (1.43%) had a postoperative TEE. Unadjusted rates for post-operative TEE are shown in table
1. When compared to patients with benign colorectal disease, those with
IBD (OR=2.1, 95%CI=1.7–2.8) or colorectal cancer (OR=1.8, 95%CI=1.5–2.2)
were more likely to have post-operative TEE. In multivariate models
adjusted for patient demographics and clinical characteristics, patients with
IBD were more likely (OR=2.2, 95%CI=1.6–3.0) than those with benign disease to have a TEE after elective colorectal surgery. In a lesser extent,
patients with colorectal cancer were also more likely to have a TEE (OR=1.4,
95%CI=1.1–1.7) compare to patients with benign disease. Similar differences were seen in multivariate models evaluating DVT alone while models evaluating PE alone did not reach statistical significance.
Conclusions: Patients undergoing elective colon resection for IBD
should be considered at high risk for post-operative TEE. Perioperative
thromboprophylaxis protocols for patients with IBD should be similar as
those for colorectal cancer patients.
Purpose: Ileostomies are intended to improve patients’ quality of life
and reduce postoperative complications. Recent data suggest a high rate
of hospital readmission following ileostomy creation. With changes in
health care economics, hospital readmission rates are being intensely scrutinized. Additionally, the complications leading to readmission detract from
the intended benefits of ileostomy creation. The aim of this study was to
examine hospital readmission in ileostomy patients in order to identify
potential risk factors and reasons for readmission.
Methods: We performed a retrospective review of patients receiving an
ileostomy at our institution between March 2011 and June 2013. Patient
demographics, perioperative factors, and hospital readmission data were
collected. Patients were then stratified based on readmission diagnosis.
Variables were analyzed using either X2 test or student’s t-test, p<0.05 considered statistically significant.
Results: Forty-nine (36.0%) out of 136 ileostomy patients were readmitted while they had ileostomies. Admitting diagnoses included small bowel
obstruction (SBO) or ileus (32.6%), infectious complications (24.5%), dehydration (22.4%), ostomy problems (10.2%), and surgical complications
(8.1%). The following factors had no effect on readmission: preop chemoradiation, preop ostomy education, preop creatinine, postop home health
care, and stoma volume at discharge. Patients readmitted with dehydration
were significantly older (66.2 vs 55.1 yrs, p=0.009) than those not readmitted. The most common preop diagnoses included malignancy (53.6%),
inflammatory bowel disease (IBD) (17.6%), colonic inertia (12.5%), and
diverticulitis (5.9%). Readmission for infectious complications were more
likely to have cancer or IBD and readmission for SBO/ileus were more likely
to have colonic inertia (Table 1).
Conclusions: Hospital readmission rates for patients with ileostomy are
high. While dehydration is a concern for ileostomy patients, it was only the
third most common readmission diagnosis. There is a correlation between
certain disease states with readmission diagnosis. These data will help elucidate strategies to minimize hospital readmission in ileostomy patients.
Reason for readmission by diagnosis
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Abstracts
sion. Multivariate analysis revealed that cystectomy had the highest risk of
readmission, followed by proctectomy (See Table 1)
Conclusions: Postoperative complications were associated with readmission more than demographic factors and comorbidities. Cystectomy
and proctectomy were associated with the highest risk of readmission,
among the procedures studied. Focused analysis of these higher risk procedures may provide insight into strategies for risk reduction, with subsequent downstream effects on readmission rates and overall patient care.
P323
PATIENTS WITH HISTORY OF NARCOTIC USE PERCEIVE LOWER QUALITY OF HOSPITAL CARE.
E. Carchman, B. Gurland, T. Hull, M. Zutshi and J. Merlino Colorectal
Surgery, Cleveland Clinic, Cleveland, OH.
Purpose: Hospital Consumer Assessment of Healthcare Provider and
Systems (HCAHPS) survey provides data on patient’s perception of their
hospital care. The aim of this study was to assess HCAHPS survey responses
and patient characteristics for patients who provided the most favorable
responses to the pain management questions.
Methods: Data on patients who underwent colorectal surgery and
completed HCAHPS surveys from 10/2009- 6/2012 at a single center was
collected. The pain management domain is defined as “Top Box” when the
patient answers “always” (most positive) to the pain related questions. Top
box responses and patient characteristics were compared to patients who
provided any response other than “always”. Demographics, narcotic use,
procedure, surgeon, pain management consultation, post-operative pain
regiments were collected. Categorical data was compared using Chi-Square
or Fisher’s exact test. Means were compared using student’s t- test.
Results: 768 surveys were evaluated (180 (23%) top box and 568 (75%)
non-top box). Mean patient age was 53.7 (19-91) with 408 (53%) females.
There were no significant differences in demographics between the two
groups. Patients with a history of previous narcotic use were significantly
more likely to report dissatisfaction with pain control (143 (18.5%) p<.001).
20 surgeons performed 768 procedures: 518 (67%) abdominal: 177 (34.1%)
laparoscopic and 383 (73.9%) open, 72 (9.3%) anorectal and 178 (34.3%)
stoma operations. Neither surgeon, procedure, or surgical approach statistically impacted responses. Preoperative pain consultation, local use, IV narcotic alternatives, epidural, or PCA did not statistically affect responses. A
postoperative pain management consult was statistically associated with
lower scores (p<.001). Patients who self-reported good health were more
likely to give higher scores (p <.001). Top box patients responded more
favorably to all of the other HCAHPS domains (p < .001) and were more
likely to respond Top Box for overall hospital rating (p <.001).
Conclusions: Previous narcotic use is more likely to result in reported
dissatisfaction with pain control as measured by the HCAHPS survey, and
also reported lower HCAHPS scores overall.
Table 1 – Readmission Risk by CPT Category. CPT categories with OR > 2 on
multivariate analysis. Appendectomy included for relative comparison.
P325
SURGICAL CARE IMPROVEMENT PROJECT INF-9 OF EARLY URINARY
CATHETER REMOVAL: RISK FACTORS FOR FAILURE IN COLORECTAL
SURGERY.
X. Wang, G. DaSilva, R. Zhao, S. D. Wexner and E. G. Weiss Cleveland
Clinic Florida, Weston, FL.
P324
MAJOR OPERATIONS WITH HIGHEST RISK OF READMISSION.
K. R. Kasten, P. W. Marcello, P. L. Roberts, T. E. Read, D. J. Schoetz, J. F. Hall,
T. D. Francone and R. Ricciardi Lahey Clinic, Burlington, MA.
Purpose: There has been an accelerated effort to reduce hospital readmissions despite lack of data regarding risk factors associated with this metric. We used data from the American College of Surgeons National Surgical
Quality Improvement Program (NSQIP) to identify risk factors associated
with postoperative readmission.
Methods: We retrospectively analyzed NSQIP data from 1/12011
through 12/31/2011 . We identified all patients who underwent one of 31
targeted NSQIP procedures spanning general, colorectal, vascular, hepatobiliary, thoracic, plastic, urology, and neurosurgery. We developed multivariate regression models of risk for readmission with the inclusion of targeted procedure codes, demographic variables, preoperative variables,
intraoperative variables, and postoperative adverse events.
Results: Of 442,149 patients in the 2011 NSQIP participant user file,
242,899 (55%) had targeted procedure codes and were included in the
analysis. Demographic factors (age, body mass index, race) and comorbidities (diabetes, heart failure, and chronic obstructive pulmonary disease) had
minimal effect on the risk of readmission. However, adverse events such as
pulmonary embolism (OR 7.0; CI 6.0-8.1), wound infection (OR 6.3; CI 5.77.1), organ space infection (OR 4.9; CI 4.5-5.3), and myocardial infarction (OR
3.2; CI 2.8-3.7) were associated with significantly increased risk of readmis-
Purpose: The risk of catheter-related urinary tract infection (UTI)
increases with longer duration of indwelling urinary catheterization. To
decrease catheter-related UTI, the Surgical Care Improvement Project (SCIP)
added a new measure (SCIP-Inf-9) recommending removal of the urinary
catheter within 2 postoperative days (POD). Some patients may fail these
measures requiring catheter re-insertion, increasing the risk for urinary tract
injury and infection. This study aimed at evaluating the risk factors associated with SCIP-Inf-9 failure in patients undergoing colorectal resection.
Methods: After IRB approval, medical records of patients undergoing
colorectal resection managed according to SCIP between 10/2009- 6/2013
were reviewed. Demographics, diagnosis, co-morbidities, complications,
pain management, and surgery-related data were compared between
patients who had successful urinary catheter removal by POD# 2 and those
who did not, requiring catheter re-insertion.
Results: 855 patients had major colorectal resection and were included
in this study. The urinary catheter was removed in 530 within 2 POD per
SCIP-INF-9 guidelines; of these 30(5.7%) required reinsertion. No differences
were noted relative to gender, age, body mass index, ASA, history of benign
prostate hyperplasia, low rectal or pelvic resection, method of pain management, surgical approach, length and site of incision, or intraoperative
complications. By uni- and multivariate analyses, the only factor significantly associated with the need for catheter re-insertion was length of surgery: patients who had procedures > 147.5±67.3 minutes were more likely
to fail catheter removal by POD 2. UTI rate of patients who had the urinary
catheter removed after POD 2 vs those within POD 2 was significantly
higher, including those requiring catheter reinsertion [60/325 (18.5) vs.
27/530 vs. 2/30 (6.7%) p=0.000].
Conclusions: Removal of the urinary catheter within 2 POD is feasible,
safe, and cost-effective. Patients who undergo longer surgery may be at
higher risk for re-insertion. The UTI rate is still significantly lower than those
who retain the urinary catheter after POD 2.
159
Abstracts
P326
IS LAPAROSCOPIC COLECTOMY A CLINICALLY AND ECONOMICALLY
FAVORABLE APPROACH IN THE ELDERLY POPULATION: RESULTS
FROM A COHORT OF 8,000 PATIENTS.
R. Pedraza1, M. Casasanta2, A. Mahmood1, T. Pickron1 and E. M. Haas3
1
Colorectal Surgical Associates, Ltd, LLP, Houston, TX, 2Division of
Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The
University of Texas Medical School at Houston, Houston, TX and 3University
General Hospital, Houston, TX.
Purpose: It is currently estimated that as many as 45% of non-emergent colectomies are performed laparoscopically. However, there are no
population-based studies investigating the role of laparoscopic colectomy
in octogenarians. We aimed to evaluate the current status of laparoscopic
colectomy in octogenarians and older population and to compare outcomes to those following open colectomy.
Methods: Utilizing Premier Inc. database, from October 2008 to June
2011 we identified either open or laparoscopic right, left, and sigmoid
colectomies in the non-emergent setting. Patients older than 79 years old
were included. Demographics, clinical, and financial outcomes were analyzed. Using regression analysis, postoperative outcomes were adjusted
based on age, gender, type of hospital, disease severity, and disease
process.
Results: A total of 8,303 colectomies were performed during the study
period, of which 93.5% were open and 6.5% were laparoscopic. The disease
severity distribution was similar between groups in regard to minor, moderate, and major severity of disease; however, there more extreme severity
cases in the open colectomy group. There was a significantly higher proportion of laparoscopic colectomy for cancer but a lower incidence of
laparoscopy for diverticular disease. The surgeon specialty distribution was
similar between groups. A significantly higher proportion of open colectomies were performed in teaching facilities as compared with laparoscopic
colectomy. Unadjusted outcomes showed that laparoscopic colectomy
resulted in significantly lower transfusions (26.1% vs 20.1%) and significantly shorter length of stay (9.8 vs 7.9). Complications, mortality, and costs
were similar between groups. After adjusting outcomes, laparoscopic colectomy resulted in significantly reduced transfusion rates and length of stay.
Conclusions: This large, population-based study shows that laparoscopic colectomy in performed in only a minority of the elderly population.
Laparoscopic colectomy resulted in lower transfusion rates and enhanced
recovery with shorter length of stay with similar clinical and financial outcomes as compared to open colectomy.
P327
IMPACT OF PREOPERATIVE CHRONIC END STAGE RENAL DISEASE ON
COLORECTAL SURGERY OUTCOMES: AN ACS-NSQIP STUDY.
C. J. Chow, H. Kunitake, R. D. Madoff, D. A. Rothenberger and
M. R. Kwaan Department of Surgery, University of Minnesota, Minneapolis,
MN.
Purpose: Over 800,000 US patients have ESRD, but the impact of dialysis on colorectal surgery outcomes has not been well characterized in a riskadjusted fashion.
Methods: We identified 166,973 patients who underwent colorectal
surgery between 2005-2012 in the ACS-NSQIP PUF. Baseline characteristics
were compared by dialysis status. Concurrent acute renal failure and dialysis (17.8% of dialysis patients) was not considered to be a chronic dialysis.
The impact of chronic dialysis on major complications and mortality was
examined using multivariate logistic regression, adjusting for demographics, comorbidities and surgical indication.
Results: Of this cohort, 1848 (1.1%) patients were on chronic dialysis
and were more likely to be older (64.4 vs 61.3 years; p<0.0001), black (29.9%
vs 9%; p<0.0001), septic (37.7% vs 7.4%; p<0.0001), require emergency surgery (53.2% vs 15.5%; p<0.0001), have acutely ischemic bowel (17.6% vs
1.8%; p<0.0001) or have perforation/peritonitis (16.5% vs 4.6%; p<0.0001).
They were less likely to have a laparoscopic (13.3% vs 37%; p<0.0001) or
rectal procedure (12.3% vs 28.9%; p<0.0001) and less likely to have colorectal cancer (14.8% vs 36.8%, p<0.001). Dialysis patients also had higher unadjusted mortality (24.1% vs 3.3%; p<0.0001), major complications (57.4% vs
22.4%; p<0.0001) and median LOS (10d vs 6d, p<0.0001). Additional unadjusted comparisons are shown in the TABLE. In emergent cases (n=26539),
multivariate logistic regression models demonstrate higher mortality risk
for dialysis patients (OR 1.45; 95% CI 1.19-1.78) but not for major complications (OR 1.07; 95% CI 0.89-1.3). Models for dialysis patients undergoing
elective surgery demonstrated similar effects on mortality (OR 2.09; 95% CI
1.55-2.8) and major complications (OR 1.08, 95% CI 0.90-1.29).
Conclusions: Chronic dialysis significantly increases mortality but not
morbidity after colorectal surgery, an effect that is more prominent in elective cases. The risk of postoperative death must be considered in this population in the decision to operate.
160
Abstracts
Table: Dialysis vs Non Dialysis Patients Undergoing Colorectal Surgery
Table 1. Comparison of Observed and Expected Resident Intraoperative
Performance Scores for Common Colorectal Procedures
P328
A COMPARISON OF ATTENDING EXPECTATIONS WITH OBSERVED
RESIDENT INTRAOPERATIVE AUTONOMY DURING COLORECTAL PROCEDURES.
K. L. Sherman1, E. N. Teitelbaum1, M. F. McGee1, B. C. George2, A. Boller1,
J. P. Fryer1, D. A. DaRosa1 and A. L. Halverson1 1Department of Surgery,
Northwestern University, Chicago, IL and 2Department of Surgery,
Massachusetts General Hospital, Boston, MA.
Purpose: The level of intraoperative autonomy that general surgery residents achieve during colorectal procedures has not been systematically
measured. We developed and validated a smart phone-based system to collect intraoperative resident performance data in real time for colorectal procedures. We then compared attending surgeon expectations with actual
observed performance for common colorectal procedures.
Methods: Intraoperative resident performance was assessed using a 4point scale measuring necessary attending involvement as a surrogate for
resident autonomy (1=show and tell, 2=active help, 3=passive help, or
4=supervision only). Baseline expectations for resident autonomy by postgraduate year (PGY) were assessed via survey of surgeons who perform colorectal procedures at a single residency program. During the study period,
attendings rated the observed resident autonomy after each procedure
using a smart phone app.
Results: Attending expectations for resident autonomy increased by
PGY level and reached the passive help (right/left hemicolectomy,
colostomy takedown) or supervision only level (appendectomy, abscess
drainage, hemorrhoidectomy) for PGY5 residents (Table 1). Between October 2012 and September 2013, performance scores were collected by 21
attending surgeons for 29 residents during 364 colorectal procedures. PGY5
residents performed at the supervision only level in 37 appendectomies
(56%), 2 right hemicolectomies (8%) and 2 abscess drainages (67%). For
PGY1-2 residents, performance significantly exceeded expectations for
appendectomy and left hemicolectomy (p≤0.01) and met expectations for
all other procedures (p>0.05). For PGY3-5 residents, mean expected performance was significantly less than expected for all colorectal procedures
(all p<0.05) except perirectal abscess drainage (p=0.25) and colostomy
takedown (p=0.10).
Conclusions: Attending surgeons did not expect PGY5 residents to
achieve the supervision only level for all procedures, yet PGY5 resident
autonomy often failed to meet expectations. Further investigation is
required to understand and address this gap between expectations and
actual resident performance.
*Mean expected score based on attending survey responses for common
colorectal procedures using 4-point scale below. **Using 4-point scale for measuring
necessary attending involvement as a surrrogate for resident automomy where
1=show and tell, 2=active help 3=passive help and 4=supervision only. P values were
calculated using one-sided Wilcoxon Rank-Sum test. PGY, post graduate year; SD,
standard deviation.
P329
TRANSANAL MINIMALLY INVASIVE SURGERY: REVIEW OF THE FIRST
100 PATIENTS.
B. Martin-Perez, M. Albert, S. Atallah, T. deBeche-Adams, G. Nassif,
F. Quinteros, H. Schoonyoung, L. Hunter and S. Larach Center for Colon
and Rectal Surgery, Florida Hospital, Altamonte Springs, FL.
Purpose: Transanal minimally invasive surgery (TAMIS) was developed
as an alternative to local excision and transanal endoscopic microsurgery
for local excision of neoplasms. This technique has rapidly been adopted
by many surgeons worldwide and the surgical and oncologic outcomes are
currently being defined.
Methods: We retrospectively analyzed data from the first consecutive
100 patients undergoing TAMIS at our center in a 48 months period.
Patients presented with early-stage rectal cancer and benign neoplasms, or
selected T2 or T3 lesions. The primary endpoints included the feasibility of
TAMIS, resection quality, and mid-term clinical outcomes.
Results: 100 patients underwent TAMIS resection from July 2009 to July
2013. 56 malignant lesions, 5 neuroendocrine tumors and 36 benign neoplasms were excised. Average age was 64 years old (36-93) and average BMI
was 27 kg/m2 (17.7-55). The mean operative time was 67 minutes (20-192).
86% of the patients were discharged within 24 hours. Average distance
from anal verge was 7.5 cm (3-15) with an average tumor size of 2.5 cm (0.35.5). 8 cases showed positive margins on final pathology and 7 patients
needed further resections because of positive margins or preoperative
understaging. There was no mortality and the rate of early complications
was 8% with one reintervention for a non healing wound on a previously
radiated patient. During the median follow up of 32 months, 4 patients
showed mild incontinence and only 1 patient died from unrelated cause.
161
Abstracts
The overall recurrence rate was 7%. For patients who underwent TAMIS for
malignancy, 2 out of 56 (3.6%) recurred during the follow-up period.
Conclusions: TAMIS is an advanced transanal platform that can be
safely used for resecting benign neoplasms and early-stage tumors of the
mid and distal rectum as an alternative to other transanal procedures,
obtaining favorable surgical and oncologic outcomes on a mid-term follow-up. Additionally, data from carefully selected advanced cases shows
favorable results, enabling these patients to benefit from the minimally
invasive approach provided by TAMIS.
P330
IMPROVED POSTOPERATIVE OUTCOMES WITH A MODIFIED GI DIET
AFTER LAPAROSCOPIC COLORECTAL RESECTION.
A. J. Russ1, S. S. Stein2, B. Crawshaw3 and B. Champagne4 1Surgery,
University Hospital Case Medical Center, University Heights, OH, 2Surgery,
University Hospitals Case Medical Center, Cleveland, OH, 3Surgery,
University Hospitals Case Medical Center, Cleveland, OH and 4Surgery,
University Hospitals Case Medical Center, Cleveland, OH.
Purpose: Enhanced recovery pathways (ERP) have radically changed
the management of surgical patients. However, the rate of post-operative
ileus (POI) after laparoscopic colorectal resection remains greater than 10%
in most large published series. We hypothesized that a modified ERP
adjusted with delayed initiation of diet post-operatively effectively reduced
the rates of POI and readmission rates after laparoscopic colorectal resection without significantly affecting length of stay.
Methods: We conducted a retrospective chart review from 2007-2013
of surgeons performing laparoscopic colorectal resections (LCR) at an affiliate private hospital. In an effort to minimize risk of POI after LCR, a modified post-operative diet within the traditional ERP was used for all patients
undergoing LCR. The modified GI diet allowed patients to take 200 ml of
clear liquids per shift on POD1, followed by unlimited clear liquids on POD2,
and a regular diet on POD3, as opposed to the traditional ERP, in which
patients were given a regular diet on POD1. Post-operative ileus was
defined as the inability to advance the patient’s diet due to bloating, distension, nausea, vomiting, or abdominal pain.
Results: Four hundred twenty-four patients underwent successful
laparoscopic colorectal resection during the defined study period, including right colectomy (28%), sigmoid colectomy (26%), low anterior resection
(22%), total colectomy (11%), resection rectopexy (7%), and APR (6%). The
overall rate of POI was 2.7%. Mean length of stay was 3.1 days +/- 3.5. Eighteen patients (4%) were re-admitted within 30 days. Five patients (1%)
underwent re-operation (anastomotic leak (4), wound infection (1)).
Conclusions: A less aggressive post-operative GI diet within a traditional ERP resulted in a POI rate of 2.7%. Mean length of stay was consistent with reported ERP data of 3.1 days despite delay of initiation of a regular diet until POD3. Readmission rates remained low at 4%. This more
conservative pathway may be an effective option for reducing the incidence of POI for surgeons covering multiple hospitals in an era with heavily scrutinized outcomes.
portending poor outcomes have not been widely investigated. We aimed
to evaluate the factors associated with an increased risk of developing
adverse outcomes following colectomy.
Methods: Utilizing Premier Inc. database, from October 2005 to June
2011 we identified right, sigmoid, and left colectomies. Demographics, clinical, and financial outcomes were analyzed. Adverse outcome was predefined as the presence of postoperative complications, length of stay
greater than 10 days, or mortality. The adjusted relative risks were obtained.
Results: A total of 186,991 colectomies were identified during the study
period. Quarter of the year in which the procedures were performed were
not associated with poor outcomes, however, hospital geographic location
in west, south, and Midwest USA were associated with significant risk
reduction for adverse outcomes. Older age, male gender, and black race
were associated with increased risk of poor outcomes. Type of hospital
(urban/rural or teaching/non-teaching) was not associated with increase
risks for poor outcomes. The insurance status was associated with significant increased risk for adverse outcomes were Medicare, Medicaid, and self
pay. The type of admission was associated with increased risk for urgent
and emergent, as compared with elective admission. Laparoscopic colectomy resulted in a reduction of the relative risk for developing adverse
events.
Conclusions: Several factors are associated with increased relative risk
of developing adverse outcomes following colectomy. It is imperative to
identify such factors to predict the complications and establish a variable
plan of care. Factors associated with increased risk of poor outcomes
include male gender, older age, black race, benign disease, and condition
requiring urgent or emergent intervention, open colectomy, and government insurance status.
Patient and hospital factors associated with development of adverse outcomes
following colectomy
P331
FACTORS ASSOCIATED WITH ADVERSE OUTCOMES FOLLOWING
COLECTOMY: RESULTS FROM A COHORT OF 186,000 PATIENTS.
R. Pedraza1, J. Moreno1, M. Casasanta2, A. Mahmood1, T. Pickron1 and
E. M. Haas3 1Colorectal Surgical Associates, Ltd, LLP, Houston, TX, 2Division
of Minimally Invasive Colon and Rectal Surgery, Department of Surgery,
The University of Texas Medical School at Houston, Houston, TX and
3
University General Hospital, Houston, TX.
Purpose: Colectomy has been associated with high complication rates
and slow recovery as compared with other common general surgery procedures. Factors associated with improved outcomes include the laparoscopic surgery and enhanced recovery protocols. However, other factors
162
Abstracts
P332
P333
VISCERAL OBESITY, NOT ELEVATED BMI, IS STRONGLY ASSOCIATED
WITH INCISIONAL HERNIA AFTER COLORECTAL SURGERY.
C. T. Aquina1, A. S. Rickles1, C. P. Probst1, K. N. Kelly1, K. I. Noyes1,
J. Monson1, H. N. Langstein2 and F. J. Fleming1 1Surgical Health Outcomes
and Research Enterprise (SHORE), University of Rochester Medical Center,
Rochester, NY and 2Plastic & Reconstructive Surgery, University of
Rochester Medical Center, Rochester, NY.
IMPACT OF TRREMS PROCEDURE ON SYMPTOMS DUE TO
OBSTRUCTED DEFECATION SYNDROME. PREDICTIVE FACTORS AND
OUTCOME.
S. M. Murad-Regadas1, F. S. Regadas1, F. S. Regadas Filho2,
L. V. Rodrigues1, D. P. Morano2, J. A. Macedo Jr2, F. P. Mano2, A. R. Peixoto1
and F. S. Rodrigues1 1Surgery, School of Medicine of the Federal University
of Ceara-Brazil, Fortaleza, Brazil and 2Colorectal Surgery, Sao Carlos
Hospital, Fortaleza, Brazil.
Purpose: High body mass index (BMI) is often used as a proxy for obesity and has been considered a risk factor for developing an incisional hernia after abdominal surgery. However, BMI does not accurately reflect muscle mass or fat distribution. This study aims to examine the relationship
between different obesity measurements and the risk of incisional hernia.
Methods: A single-center retrospective chart review was performed for
patients undergoing surgical resection for colorectal cancer (2003-2010).
Pre-operative CT scans were used to measure waist circumference, visceral
fat volume (VFV), subcutaneous fat volume, and total fat volume. Chisquare, Student’s T-test, and Kaplan-Meier analysis were used to compare
pre-operative patient and surgical characteristics with incisional hernia
development. Patients who died or were lost to follow-up less than 6
months from the date of surgery or who had a prior hernia repair with mesh
were excluded. A diagnosis of incisional hernia was made either through
physical exam in medical record documentation or CT scan.
Results: Overall, 194 patients met inclusion criteria with 41 patients
developing an incisional hernia (21.1%). The median time to hernia was 12.8
months. On univariate analysis, VFV, history of inguinal hernia, open resection, and COPD increased the risk of subsequently developing an incisional
hernia (p<0.05). VFV>1660 cm3 was significantly associated with incisional
hernia (OR=2.13, p=0.03). On Kaplan-Meier analysis, viscerally obese
patients were more likely to develop an incisional hernia over a shorter
period of time (p<0.05, figure). BMI>30 was not significantly associated with
incisional hernia development on univariate and Kaplan-Meier analyses.
Conclusions: Visceral obesity, inguinal hernia, COPD, and open resection are significantly associated with subsequent development of an incisional hernia, whereas BMI is poorly associated with hernia development.
Incisional hernia occurs frequently after colorectal cancer resection with 1
in 5 patients suffering from this endpoint. These findings suggest that new
strategies, such as prophylactic mesh placement, should be considered in
this high-risk patient population.
Purpose: TRREMS procedure(transanal repair of rectocele and rectal
mucosectomy with a single circular stapler) is able to remove large bands
of rectal mucosa and reinforce the anterior anorectal wall using a single circular stapler for treatment of rectocele associated or not with intussusception. The aim was to evaluate the impact of TRREMS procedure on treatment of ODS and identify the predictive factors for unsuccessful treatment.
Methods: Females from a prospective database and complaining of
ODS due to rectocele grade II or III identified by dynamic ultrasonography
underwent to TRREMS. Functional outcomes were assessed using improvement of Cleveland Clinic constipation score(reduction ratio-%) and complications. Indications to surgery included a constipation score >10 after medical treatment and biofeedback(BIO) in patients with anismus associated.
Menopausa, anismus, coexisting intussusception and/or mucosa prolapse,
post-operative complications and type of stapler used were analyzed and
correlated with the improvement.
Results: 72 were included, mean age 58y and mean follow-up 24m(639m). Of them, 32% with grade II and 78% grade III rectocele, associated
intussuception and/or mucosa prolapse in 64% and anismus in 35%. The
mean postoperative score reduced from 13 ±2.0 to 4 ±1.3 (p<0.00). 70(90%)
had ≥50% and 49(68%) had ≥70% of symptoms improvement. 19/26%
reported complications, of them 3% early bleeding and thrombosis and
24% complained of tenesmus(7), stenosis(6) and mucosa prolapse(4) after
1m and were treated by digital dilation(4), endoscopic stricturectomy(2)
and rubber band ligation(4). The constipation score improvement was similar in those patients with intussusception and/or mucosa prolapse associated, complications, menopause and type of stapler used but patients previous BIO for anismus had reduction on improvement of the constipation
score (61% x 71%, p>0.00).
Conclusions: TRREMS procedure demonstrated significant improvement of the ODS symptoms and the factor associated with a greater risk of
unsuccessful treatment includes association with anismus even previously
treated by BIO. The surgical successful is also associated with an accurate
selection of patients.
P334
EVALUATION OF DEFECATORY FUNCTION FOLLOWING ANTERIOR
RESECTION FOR RECTAL CANCER: PROSPECTIVE, RANDOMIZEDCONTROLLED TRIAL OF HIGH TIE OR LOW TIE.
K. Matsuda, T. Hotta, K. Takifuji, S. Yokoyama, Y. Oku and H. Yamaue
Second Department of Surgery, Wakayama Medical University,
Wakayama, Japan.
Figure: Kaplan-Meier function comparing cumulative proportion of subjects
without hernia for patients with and without visceral obesity.
Purpose: The level of arterial ligation in rectal cancer is controversial in
terms of oncological considerations and postoperative complications. Defecatory functions following anterior resection for rectal cancer are often
poor. The denervation of neorectum is reported as one of the cause of
impaired defecatory function, and high tie is reported as one of the cause
of poor defecatory functions.
Methods: Between 2008 and 2011, one hundred patients who underwent anterior resection for rectal cancer were randomized to perform high
tie or low tie. Postoperative defecatory functions and complications were
compared. This RCT was registered at clinicaltrials.gov NCT00701012.
Results: There were no differences between the groups in terms of clinical data except for tumor stage. Although there were no differences in the
number of harvested lymph nodes and the depth of tumor invasion, there
163
Abstracts
were more advanced stage patients in the high tie group(p=0.046). There
were no differences in the defecatory function, self-assessment of defecation, FIQL score and Wexner’s score at 3 months and 1 year between the
both groups. The rate of symptomatic anastomotic leakage is 15.7% in high
tie group and 10.2% in low tie group, and there was no significant difference(p=0.415).
Conclusions: .The level of arterial ligation in rectal cancer did not influence on the defecatory function and postoperative complications. However, high tie might contribute to accurate tumor staging.
P335
TRANSPERINEAL RECTOCELE REPAIR WITH POLYGLYCOLIC ACID
MESH: RESULTS OF 282 CONSECUTIVE PATIENTS WITH SPECIAL
EMPHASIS ON QUALITY OF LIFE.
S. Leventoglu1, B. Mentes2, B. Ege3, M. Gulen2, A. Yildiz1 and M. Oguz1
1
Department of Surgery, Gazi University Medical School, Ankara, Turkey,
2
Division of Surgery, Acibadem Ankara Hospital, Ankara, Turkey and
3
Division of Surgery, Koru Hospital, Ankara, Turkey.
Purpose: The aim of this study was to evaluate the efficacy and safety
of transperineal rectocele repair with the polyglycolic acid mesh in patients
with predominant rectocele.
Methods: Two-hundred and eighty-two consecutive patients with
stage II or stage III posterior wall prolapse and with symptoms of outlet
obstruction underwent transperineal polyglycolic acid (PGA) mesh repair
of rectocele, and they were followed for 23.47±20.11 months, using standardized charts of validated scoring systems and questionnaires.
Results: At 6-month’s recordings, the mean total Watson score was significantly lower than the preoperative score (p<0.0001), and 270 of the 282
patients (95.8 percent) were evaluated as anatomically cured. A significant
improvement in the total GIQLI score was found postoperatively
(141.19±2.38 vs. 114.56±7.06 preoperatively; p<0.001). The surgical complication rate was 9.5 percent, but no mesh-related complications were noted
at any time. The subjective cure rate was 94.3 percent within the time limits of the study. Only four recurrences (1.4 percent) were recorded.
Conclusions: In patients with posterior vaginal wall prolapse, transperineal PGA mesh repair is highly successful in eliminating the symptoms, it
improves QoL, and it is free of significant complications.
P336
SEARCH FOR THE IDEAL RECTAL PROLAPSE SURGERY: LAPAROSCOPIC VENTRAL MESH RECTOPEXY, STARR OR PELVIC ORGANS SUSPENSION?
P. Sileri, L. Franceschilli, F. Giorgi, F. Perrone, I. Capuano, I. C. Ciangola
and A. L. Gaspari surgery, University of Rome Tor Vergata, Rome, Italy.
Purpose: Laparoscopic Ventral Mesh Rectopexy (LVR) corrects rectal
prolapse (RP), improving both obstructed defecation symptoms (ODS) and
faecal incontinence. Similarly, Stapled Trans-Anal Rectal Resection (STARR)
treats ODS. Moreover, recently laparoscopic pelvic organs prolapse suspension (POPs) with or without STARR has been proposed. We present our
experience with these procedures, tailored according to patients’ symptoms
and radiologic findings, in order to search the ideal surgery and propose
an algorithm.
Methods: Prospectively collected data on patients with RP were
analysed. All patients underwent preoperative evaluation with proctography or pelvic dynamic MRI. Concomitant middle and anterior compartments prolapses were considered. End-points were complications and functional results expressed as Wexner Constipation Score (WCS) and Faecal
Incontinence Severity Index (FISI).
Results: One-hundred-seventy consecutive patients underwent RP surgery: 100 LVR, 62 STARR and 8 POPs. After LVR, conversion rate was 1%.
Overall complications rate was 18%. At the end of the follow-up, FISI score
significantly improved to 3+/-2 from preoperative 8+/-3 (p 0.003). Inconti-
nence improved in 86% and was cured in 72%. Similarly, WCS score significantly improved to 7+/-5 from preoperative 18+/-6 (p 0.002). Constipation
improved in 92% and cured in 80%. Fourteen patients (14%) experienced
recurrence. After STARR, overall complication rate was 21%. At the end of
the follow-up the FISI score significantly improved to 3+/-2 from preoperative 9+/-4 (p 0.04). Incontinence improved in 61% and was completely
cured in 53%. Similarly, WCS score significantly improved to 6+/-5 from preoperative 18+/-11 (p 0.03). Constipation improved in 82% and cured in 62%.
Recurrence rate was 22%. After POPs, overall complication rate was 37.5%.
At the end of the follow-up the FISI score significantly improved to 4+/-4
from preoperative 9+/-4 (p 0.04). Incontinence improved in 80% and cured
in 100%. Similarly, WCS score significantly improved to 9+/-5 from preoperative 18+/-5 (p 0.05). Constipation improved in 87.5% and cured in 75%.
Conclusions: A tailored surgical approach should be guided by a preoperative algorithm.
P337
COMBINATION RESECTION RECTOPEXY AND SACROCOLPOPEXY IS A
SAFE AND EFFICACIOUS PROCEDURE IN WOMEN WITH PELVIC
ORGAN PROLAPSE AND OBSTRUCTED DEFECATION SYNDROME.
B. Murray1, B. Shanker1, K. Jones2, A. Ferrara1 and J. Gallagher1 1Colon
and Rectal Surgery, CRC Orlando, Orlando, FL and 2Urogynecology,
Orlando Urogynecology, Orlando, FL.
Purpose: Both resection rectopexy and sacrocolpopexy are effective in
isolation in the treatment of pelvic organ prolapse. There is limited published research on the outcomes for these combined procedures. The purpose of this study is to review the safety and efficacy of combination resection rectopexy and sacrocolpopexy in women with pelvic organ prolapse
and obstructed defectation syndrome (ODS).
Methods: A retrospective review of women undergoing mesh sacrocolpopexy and resection rectopexy between July 2006 and October 2012
was performed. All women underwent pelvic floor evaluation, including
urodynamics, defecography, anal manometry, and electromyography, prior
to intervention. The primary outcome measurements were post-operative
complications and patient satisfaction as gauged by pre- and post- operative questionnaires. Post-operative complications were graded according
to the Clavien-Dindo classification. Statistical analysis was done using a
paired student’s t test for comparison of means.
Results: A total of 25 cases were reviewed. The median age was 59 (4580). Pre-operative ODS score was 9.3 + 3.9, compared to post-operative
score of 6.4 + 7.4 (p=0.6). On defecography, the majority of patients had
rectocele (58%), sigmoidocele (58%), and intussusception (67%). Median
duration of follow-up was 12 months (1-58). There was a difference in preand post- operative pelvic floor distress inventory questionnaire short form
20 scores (152.3 + 64.0 vs 28.7 + 31.9, p=0.001). There were 2 thirty-day
complications (8%), grades III (recognized ureteral injury requiring reimplantation) and I (surgical site infection). There were no anastomotic
complications, nor was there any peri-operative mortality. There were two
late, vaginal mesh erosions, one of which required re-operation.
Conclusions: Combination sacralcolpopexy and resection rectopexy is
an effective and safe approach to patients with pelvic organ prolapse and
obstructed defecation, as demonstrated by a significant decrease in the
pelvic floor distress inventory questionnaire score.
P338
THREE-DIMENSIONAL ANALYSIS OF PELVIC FLOOR DISORDERS - A
REAL DIAGNOSTIC TOOL FOR INDIVIDUAL THERAPY IN OBSTRUCTIVE
DEFECATION SYNDROME PATIENTS.
M. Kowallik, P. Prohm, E. C. Bästlein and J. H. Hofer Magen Darm
Zentrum Wiener Platz, Cologne, Germany.
Purpose: The diagnostic options for obstructive defecation syndrome(s)
are MR-defecography (gold standard), proctological examination and
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Abstracts
anamnesis with using of standarized questionnaire (scores) to evaluate the
symptoms. A difficult determination of often manifold and varying symptoms many times corresponds to the often non-satisfing results of the
applied therapy. Our hypothesis: this is due to the indirect unphysiological
(supine position) examination method and frequently imprecise and
patient-side misunderstood surveys. EUS can reliably detect all pathological changes of the pelvic floor.It is a cost-efficient method and easy to perform. With this technique all three pelvic floor compartments can be seen
in real-time and individual therapy concepts for each patient can be developed.
Methods: 480 female patients with ODS-Syndrome have been examinated by using dynamic 3D ultrasound scanner Focus ® Pro with the transducers 2052, 8802 and 8848 (BK Medical). The aim was to compare the findings of pelvic floor disorders regarding to the examination position (supine
vs. sitting).
Results: we found in 480 examinated patients a rectocele 146 (supine
39,4%) vs. 370 (sitting 100%), cystocele 59 (supine, 21,4%) vs. 275 (sitting,
100%), enterocele 1 (supine, 6,25 %) vs. 16 (sitting, 100%), perineal descensus 166 (supine, 38,8%) vs. 427 (sitting, 100%), intussusception 1 (supine,
33,3 %) vs. 3 (sitting, 100%) and anismus 0 (supine, 0%) vs. 15 (sitting,
100%).
Conclusions: The patient position during the examination seems to be
crucial for detecting pelvic floor disorders. The dynamic 3D EUS on pelvic
floor offers a solid, easy to perform, cost-effective and most importantly
(due to physiological examination position), a meaningful method to evaluate all pelvic floor disorders. It allows to select an indi-vidual therapy concept or surgical procedure for each patient. This could offer an improvement of the outcome of conservative and surgical treatment options. The
results of MR Defecography (untill now gold standard examination) should
be reevaluated regarding our findings because of the not physiological
supine position during the examination
detected pelvic floor disorders in 480 female
P339
FEMALE SEXUAL DYSFUNCTION AFTER LAPAROSCOPIC VENTRAL
RECTOPEXY: DOES MESH TYPE MAKE A DIFFERENCE?
P. Waterland1, F. Khan2 and M. Farmer2 1Colorectal Surgery, Birmingham
Heartlands Hospital, Birmingham, United Kingdom and 2Colorectal surgery, University Hospital of North Staffordshire, Stoke-on-Trent, United
Kingdom.
Purpose: Laparoscopic ventral mesh rectopexy (LVMR) is commonly
performed for full thickness external rectal prolapse and obstructed defecation syndrome (ODS due to a symptomatic rectocele or intussusception.
LVMR involves opening the rectovaginal plane down to the pelvic floor
where a mesh is fixed from the low rectum to the sacral promentory. Use
of mesh can cause local fibrosis and result in dysparunia which a patient
may not feel comfortable discussing with the surgeon. This study assesses
female sexual dysfunction after LVMR with both synthetic and biological
mesh.
Methods: All patients undergoing LVMR were enrolled into a prospective database. Basic demographic data, functional outcome scores and
Female Sexual Function Index (FSFI) scores were recorded pre and post procedure.
Results: 34 patients underwent LVMR between 11/2012 and 09/2013.
Biological (Strattice tm) mesh was used for 18 and synthetic mesh in 16
patients. Overall median age was 63 years (range 24-78) with no statistical
difference between either group (p=0.44). ODS scores were significantly
improved following surgery (p=0.001, means pre 20.2 post 7.5). FSFI scores
overall were significantly worse after surgery (p=0.001, means 27.98, 17.56).
There was no significant difference in variation of FSFI scores between synthetic or biological mesh. (p=0.91, synthetic 10.2, biological 10.63)
Conclusions: LVMR produces a statistically significant deterioration in
female sexual function with both synthetic and biological mesh in the short
term. This should be considered in younger sexually active patients with
obstructed defecation syndrome prior to surgery.
P340
VENTRAL RECTOPEXY: THE LEARNING CURVE IS A SLIPPERY SLOPE.
B. Gurland, M. Zutshi and T. Hull Colorectal Surgery, Cleveland Clinic,
Cleveland, OH.
Purpose: To evaluate the complications during the first 5 years of performing VR at a single institution using different techniques.
Methods: Patients who underwent VR from 2008- 2013 were entered
into a prospective Redcap database. Patient demographics, operative
details, postoperative complications and long term results were recorded.
Results: 81consecutive patients; 79 females with a mean age of 58
(range 21-90) years at the time of surgery underwent VR. Full thickness prolapse was present in 67(83%) and internal prolapse in 14 (17%). VR was performed: Robotically 48 (60%), Laparoscopic 18(22%), Open 11(13%), and
Converted 4(5%). Biologic mesh was used in 54 (67%) and synthetic
polypropylene mesh in 27 (33%). 52 (64%) patients underwent concomitant gynecologic procedures and 29 (36%) were strictly VR. There were no
complications in 51 (63%) patients. Urinary dysfunction, transient arrhythmia, wound related issues, and ileus were reported in 25 (30%). Major medical complications included: pulmonary embolism 2 (2%) and sacral discitis
2(2%) which responded to medical therapy. Rectal vaginal fistula (RVF)
occurred in 2 (2%) women who had a history of multiple (>3) prior vaginal
surgeries and who were supported with biological mesh. Recurrence of full
thickness prolapse occurred in 5 (5%) Two elderly women with extensive
full prolapse (>5 cm) who underwent multiple abdominal and perineal procedures prior to VR reoccurred within 6 months. These women elected to
forgo additional repair. One patient underwent proctectomy and coloanal
anastomosis, Two women were successfully treated with delorme rectal
mucosal resection. Mucosal prolapse was identified in 8 (10%) which
responded to banding or mucosal resection.
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Abstracts
Conclusions: Reoccurrence rates after VR correspond to other published series. However, VR may result in complications such as discitis or
RVF that are uncommonly reported after posterior rectopexy. We have since
modified our technique to avoid any tension on the mesh, minimized dissection in the rectal vagina space with women who may have devascularized tissue as a result of multiple vaginal procedures, and avoid deep suture
placement in the disc space.
P341
REFERRAL PATHWAY OF FUNCTIONAL BOWEL DISORDERS.
R. Pande, A. Torrrance, Y. Perston, K. Futaba and S. Radley Queen
Elizabeth Hospital, Birmingham, United Kingdom.
Purpose: Functional bowel disorder often presents one of the most difficult challenges for a colorectal surgeon. Patients present with worsening
symptoms impacting on them both functionally and psychologically. Due
to the increasing number of referrals and the long waiting times, we aimed
to streamline investigations to improve efficiency at a tertiary referral centre.
Methods: A retrospective analysis of patients referred between
1/9/2011 to 31/8/2013 were included. Patient demographics, investigations
and results were obtained from the hospital’s electronic patient records.
Standard statistical tests were used to obtain the median and range values.
Results: 148 patients were referred; 17M:141F; 54(20-91)years; 15.2%
were internal referrals, 53.8% from other units and 31% General Practitioners. 33.1% from colorectal teams, 21.6% gynaecology, 8.8% gastroenterology, 3.4% urology, 3.4% neurology. 45% were referred with faecal incontinence, 18% obstructive defecation, 20% chronic constipation and 10% with
prolapse. 30.4% had previously been treated on a separate episode. 29.1%
had investigations performed prior to referral, of these 93.4% required further investigation. 45% patients presenting with constipation had a proctogram, 24% underwent anal physiology and endoanal USS, endoscopy
and transit studies. No investigation was carried out in 31%.79% patients
presenting with incontinence had anal physiology, 31%requiring proctograms or 37% endoscopy. Obstructive defecation was investigated in
most with a proctogram (92%) with almost half requiring anal physiology
(42%) and a third endoscopy (35%)with a small number requiring transit
studies (12%). Those with a demonstrable prolapse had proctograms (73%)
and endoscopy (43%).
Conclusions: Time to investigation and subsequent treatment in
patients with functional bowel disorders are significantly longer compared
to the target for cancer treatment in the UK. Yet the impact on quality of
life for these patients can be significant. With the result of our data, we present a patient management pathways for a variety of functional bowel disorders which we hope will streamline their investigations and management
leading to improved patient care.
were of ASA grade III and IV(Table1). The median hospital stay was longer
in Altemeier’s group (4(3-7) days vs. 3(2-4) days; P=0.01).After a mean follow-up of 14±14 months, the rate of recurrent prolapse was 13 %
(Delorme’s: 14% vs. Altemeier’s 9%, P=0.71). The overall postoperative complication rate was 43 % (n=30) (Altemeier’s14 (64%) vs. Delorme’s 16(34%)
P=0.04).There was no mortality. The pre-and postoperative mean fecal
incontinence scores and constipation severity index for each group is listed
in Table I. The Cleveland global quality of life (CGQL) scores in each group
were 0.6 ± 0.2 and 0.5 ± 0.3 respectively (P=0.59) and did not change preand postoperatively.
Conclusions: In patients where abdominal repair of rectal prolapse is
judged to be unwise, a Delorme procedure offers short term control of the
prolapse without a high risk of complications and with reasonable function. In addition patients that recur after a Delorme’s procedure can
undergo another similar transanal procedure without compromising the
vascular supply of the rectum Surgeons preference should determine the
type of repair.
Characteristics of patients undergoing the Delorme’s and Altemeier’s procedures
ASA: American Society of Anesthesiologists
BMI: Body Mass Index
P342
COMPARING PERINEAL REPAIRS FOR RECTAL PROLAPSE: DELORME
VERSUS ALTEMEIER.
F. Elagili, G. Ozuner and J. Church Colorectal surgery, Cleveland clinic,
Cleveland, OH.
Purpose: Choice of techniques for perineal repair of rectal prolapse lies
between two operations: Delorme and Altemeier (perineal rectosigmoidectomy). Data comparing surgical outcomes and quality of life (QOL) following these procedures are limited. The aim of our study was to compare the
short term outcome and quality of life (QOL) of two perineal procedures in
patients with rectal prolapse.
Methods: Data for patients with primary full thickness rectal prolapse
who underwent Delorme and Altemeier procedures from 2005 to 2013 in
our institution were obtained. Short term outcomes and QOL were evaluated.
Results: 70 patients (93% female) underwent rectal prolapse surgery,
48 Altemeier’s and 22 Delorme’s, mean age 71 ± 15 years,64% of patients
166
Abstracts
Conclusions: “The Thinker” position seems to be a more efficient
method for defecation than the vertical position. This defecation technique
may be helpful when retraining patients with constipation.
P343
SHORT-TERM OUTCOME OF LAPAROSCOPIC VENTRAL MESH RECTOPEXY AND SACROCOLPOPEXY USING TWO MESHES.
A. Gupta1, C. Phillips2 and A. Venkatasubramaniam1 1Colorectal Surgery,
Basingstoke and North Hampshire Hospital, Basingstoke, United Kingdom
and 2Urogynaecology, Basingstoke and North Hampshire Hospital,
Basingstoke, United Kingdom.
Purpose: There is ample evidence for Laparoscopic VMR to be an effective treatment modality in obstructive defaecatory syndrome (ODS).
Patients with vaginal vault prolapse (apical prolapse) in association with
ODS were offered laparoscopic VMR and sacrocolpopexy as a joint procedure using two separate meshes secured to sacral promontory. There is limited data available on the outcome of the procedure. We present the outcome of the first 21 cases of laparoscopic VMR with sacrocolpopexy within
our unit.
Methods: All patients had a preoperative Magnetic Resonant defaecatory proctogram. Case notes of all women who had laparoscopic VMR and
sacrocolpopexy were reviewed. All patients were seen and examined 3
months post-operatively and then contacted 6-12 months post-operatively
when symptoms and satisfaction scores were assessed.
Results: Mean: Age - 59 years (SD 9.1) Parity - 2.5 (SD 1) BMI - 29.3 (SD
4.4) Mean operating times demonstrated a learning curve: First 3 cases: 183
minutes Last 3 cases: 128 minutes. Length of stay: 1 day in 69% Morbidity/Complications: One case of severe post-op constipation in a woman
with pre-existing constipation. One woman had a minor wound infection.
No cases of de novo stress urinary or faecal incontinence and no mesh erosions. Outcomes: Median follow up was 10 months. Symptoms were
assessed from departmental questionnaires. 3 month follow up on the
Baden Walker scale showed significant improvement in anterior apical and
posterior vaginal prolapse (P<0.002) Bowel symptoms: All patients had an
improvement in the ODS scores after operation. 2 women who had faecal
incontinence preoperatively reported resolution of their symptoms.
Conclusions: Laparoscopic VMR and sacrocolpopexy appears safe and
efficacious in the short term. Further long-term evaluation is needed.
“The Thinker”
P345
COMBINED COLORECTAL AND UROPROCEDURES FOR PELVIC FLOOR
DYSFUNCTION.
A. Murawska1, G. Abraham1, R. Narang1, G. W. Davila2, V. Aguilar2,
S. D. Wexner1 and D. R. Sands1 1Cleveland Clinic Florida, Weston, FL and
2
Urogynecology, Cleveland Clinic Florida, Weston, FL.
P344
INFLUENCE OF BODY POSTURE ON DEFECATION: A PROSPECTIVE
STUDY FOR “THE THINKER” POSITION.
S. Takano and D. R. Sands Department of Colorectal Surgery, Cleveland
Clinic Florida, Weston, FL.
Purpose: Reports in the literature indicate that the squatting position
is superior to the sitting position for defecation. We hypothesized that
bending the upper body into what we have termed “The Thinker” position
facilitates defecation. The aim of this study was to assess the influence of
“The Thinker” position on defecation.
Methods: 48 patients who underwent cinedefecography between January and June 2013 were enrolled in this study. Cinedefecography was first
performed in the vertical position; if the patient was unable to evacuate
the paste within 30 seconds, films were then taken in “The Thinker” position. Patients who were unable to evacuate the paste within 30 seconds
were excluded from the study. Anorectal angle (ARA), perineal plane distance (PPD), and puborectalis length (PRL) during straining in both positions were measured from the radiographs.
Results: 22 patients could not evacuate within 30 seconds in the vertical position and continued onto the Thinker position. 17 patients were
female, with an average age of 56 (range: 22-76) years. “The Thinker” position had significantly wider ARA than the vertical positon (113 vs. 134o,
respectively; p = 0.03), larger PPD (7.1 vs. 9.3 cm, respectively; p = 0.02),
and longer PRL (12.9 vs. 15.2 cm, respectively; p = 0.005) during straining.
11 patients could evacuate completely within 30 seconds in “The Thinker”
position and the average time spent to empty the bowel was 21.9 (range:
12-30) seconds.
Purpose: Multiple pelvic floor conditions frequently coexist and can be
either simultaneously or sequentially treated. This study aimed to review
outcomes of combined colorectal (CR) and urogynecological (UG) procedures.
Methods: Patients who underwent combined procedures for pelvic
floor dysfunction from 09/2002-12/2012 were identified from an IRBapproved database. Data included demographics, comorbidities, primary
CR or UG diagnosis, type of procedure, medical and surgical history, operative time, intra- and postoperative complications, blood loss, hospital stay,
pre- and postoperative symptoms, and complications.
Results: 79 females were included in this study [mean age: 64 (32-97)
years), mean BMI: 25 kg/m2 (13: ≥ 30, 25: 25-29.9, and 4:18.5-24.9); mean
ASA: 2 (1-3)]. All patients had multiple UG and CR diagnoses, FI most common in CR (n=55) and vaginal prolapse for UG (n=61). 56 patients had multiple CR and 21 had multiple UG diagnoses. Mean operative time was 229
(67-503) minutes, mean blood loss was 132 (50-500) ml, and mean hospital
stay was 4.5 (1-17) days. Most frequent CR and UG procedures were overlapping sphincteroplasty (n=30) and pubovaginal sling placement (n=37),
respectively. Procedures were performed by 12 abdominal, 6 perineal, and
21 combined approaches. Mesh was used in 57 patients; 20 experienced
early postoperative complications, with the most being urinary retention in
4 and wound infection, hematoma or bleeding in 4. 48(61%) patients
reported significant improvement within 2 months of combined procedures including 37 (71.2%) with preoperative FI. 6 (7.6%) additional patients
reported some improvement in FI and significant improvement in urinary
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Abstracts
incontinence, while 4 had persistent urinary incontinence and 2 had persistent constipation. At mean follow up of 10.5 (0.5-76) months, 9 patients
reported persistent urinary urgency, and 8 FI.
Conclusions: Combined procedures for treatment of pelvic floor dysfunction are feasible and offer patients the ability to address all of their
symptoms in one operative setting.
P347
IS MORE PATHOLOGICAL COMPLETE RESPONSE RATE OBSERVED
WHEN SURGERY IS DELAYED 12 WEEKS AFTER COMPLETION OF
CHEMORADIOTHERAPY COMPARED TO 8 WEEKS? PRELIMINARY
REPORT.
C. Terzi1, A. Canda1, M. Bingul1, N. Arslan1, M. Unlu2, I. Gorken3, F. Obuz4
and I. Oztop5 1Surgery, Dokuz Eylul University School of Medicine, Izmir,
Turkey, 2Pathology, Dokuz Eylul University School of Medicine, Izmir,
Turkey, 3Radiation Oncology, Dokuz Eylul University School of Medicine,
Izmir, Turkey, 4Radiology, Dokuz Eylul University School of Medicine, Izmir,
Turkey and 5Medical Oncology, Dokuz Eylul University School of Medicine,
Izmir, Turkey.
P346
POSTERIOR PELVIC FLOOR DYSFUNCTIONS. IS THERE CORRELATION
BETWEEN SYMPTOMS AND PELVIC ORGAN PROLAPSE QUANTIFICATION?
S. M. Murad-Regadas1, J. A. Vasconcelos Neto2, C. T. Vasconcelos1,
L. R. Bezerra3, S. L. Karbage4, K. L. Augusto2, I. F. Parente2 and
I. D. Dealcanfreitas1 1Surgery, School of Medicine of the Federal University
of Ceara-Brazil, Fortaleza, Brazil, 2Urogynecology, General Hospital of
Fortaleza, Fortaleza, Brazil, 3Urogynecology, General Hospital of Cesar
Calls, Fortaleza, Brazil and 4Urogynecology, Fortaleza University, Fortaleza,
Brazil.
Purpose: The aim of this study was to correlate the fecal incontinence
and/or obstructed defecation symptoms with the severity of posterior vaginal wall prolapse.
Methods: Consecutive female patients with symptoms of pelvic floor
dysfunctions were evaluated using Pelvic Organ Prolapse Quantification
(POP-Q) and distributed in 2 groups: GI: POP-Q point Bp (posterior vaginal
wall prolapse) ≥ 2 and GII: POP-Q point Bp <2. All of them completed standardized questions that surveyed pelvic floor symptoms and correlated
with patient characteristics, severity of prolapse, urinary incontinence, fecal
incontinence and/or obstructed defecation symptoms.
Results: 265 female were included, of them 116 (44%) in GI and
149(56%) in the GII. There was no difference between the groups in the categories of income (p=0.52) and education (p=0.68). Symptoms of stress urinary incontinence (p=0.16) or urge incontinence (p=0.97) were similar in
both groups. 77% of patients in GI had POP-Q point Ba (anterior vaginal
wall prolapse) ≥ 2 and 54 % in the GII (p=0.00), with OR = 2.7 (95% CI: 1.6
to 4.6). 20% of GI had apical prolapse ≥ 2 and 9.4% in the GII (p = 0.00), with
OR = 2.6 (95% CI: 1.2 to 5.6). The groups were similar in the following ratings: Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ)
(p=0.35), PERFECT (p=0.53), International Consultation on Incontinence
Questionnaire-Short Form (ICIQ-SF)(p=0.06), fecal incontinence score
(Cleveland Clinic score) (p=0.92) and constipation score (Cleveland clinic
score)(p=0.64). There were differences between the GI and GII: age (56.0 x
50.9, p = 0.00), number of pregnancies (5.2 x 4.3, p=0.01), number of births
(4.4 x 3.7, p = 0.02), BMI (27.8 x 29.8, p = 0.00). In the evaluation of the Short
Form 36 Health Survey Questionnaire (SF-36) difference was found in only
one domain, general health perception (GI= 48 x GII=56, p=0.02).
Conclusions: There is no correlation between several specific symptoms with increasing compartment–specific defects. The severity of posterior vaginal wall prolapse does not increase the fecal incontinence and/or
obstructed defecation and there is no correlation with worst levels quality
of life.
Purpose: The aim of this study is to assess whether greater pathological complete response (pCR) rate occurs when surgery is delayed to 12
weeks after completion of chemoradiotherapy (CRT) compared to 8 weeks.
Methods: Between January 2011 and October 2013 patients with
locally advanced (stage II and III) rectal cancer were randomized before CRT
(45-50 Gy in 1.8-2 Gy fractions and concomitant 5-FU infusion of 225
mg/m2/day) to two groups according to the neoadjuvan CRT-surgery interval: 8 weeks (Group 1) and 12 weeks (Group 2). The primary outcome measure is to determine the pCR rate.
Results: The groups were similar in terms of the demographic and clinical characteristics. 4 (13.3%) out of 30 patients had pCR in Group 1 compared to 8 (22.2%) out of 36 patients had pCR in Group 2 (P>0.05). Pathological features of the patients were summarized in Table. There was no
perioperative mortality and postoperative morbidity rates were similar in
two groups. Sphincter-preserving surgery was performed in 24 patients in
Group 1 and 25 patients in Group 2 (P>0.05).
Conclusions: Twelve-week interval between completion of neoadjuvant CRT and surgery may result in a modest increase in pCR rate without
increasing complications in patients undergoing total mesorectal excision
for l