- Email: [email protected]
623 Visceral Adipose Tissue Changes After Surgery in Colorectal Cancer Patients May Have Prognostic Implications
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(1) that the chrysin-induced cell death in colon tumor cells is due to apoptosis and (2) the apoptosis mediated by chrysin in these cell lines requires AHR. Current work is focusing on elucidating the mechanism by which AHR participates in the induction of apoptosis. If chrysin will prove to be a novel chemotherapeutic in the future remains to be determined.
End of the Road for a Dysfunctional End-Organ: Gastrectomy for Refractory Gastroparesis Neil Bhayani, Ahmed M. Sharata, Christy M. Dunst, Ashwin A. Kurian, Kevin M. Reavis, Lee L. Swanstrom INTRODUCTION Gastroparesis is a functional disorder resulting in debilitating nausea, overflow esophageal reflux & abdominal pain and is frequently refractory to medical treatment. Surgical therapies such as pyloroplasty and neurostimulators aim to facilitate emptying. When treatments to facilitate gastric emptying fail, subtotal gastrectomy has been employed with varying success. Herein, we examined outcomes after gastrectomy for diabetic and idiopathic gastroparesis. METHODS A prospective database was queried for gastrectomies with Roux-en-Y reconstruction performed for gastroparesis from 1993-2013. Primary outcomes were improvements in pre- versus post-operative symptoms at last followup, measured on a 5-point scale. Secondary outcome was operative morbidity. RESULTS Thirty-five patients underwent total or near-total gastrectomies for idiopathic (23%), post-operative(43%), or diabetic (34%) gastroparesis. Anti-emetics and pro-kinetics afforded no relief in 34.5% of patients. There were no operative mortalities. Six patients suffered a leak requiring anastomotic revision. With a median follow-up of 11.4 months, nausea improved or resolved in 70% after surgery. Chronic abdominal pain improved or resolved in 69% of patients. Belching and bloating resolved for 75% & 81%, respectively (p<0.01). CONCLUSIONS Regardless of etiology, medically-refractrory gastroparesis is a chronic and devastating disease. Surgery can ameliorate, and often relieve symptoms of nausea, excessive belching and gas bloat. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can palliate symptoms of gastroparesis.
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PURPOSE: Several authors have investigated the relationship between carcinoembryonic antigen (CEA) and pathologic complete response; however to date there is no clear consensus regarding its predictive value. The purpose of this study is to examine the association of pre-treatment and post-treatment CEA with pathologic complete response. METHODS: After institutional review board approval, we conducted a retrospective chart review of a prospectively maintained database of all patients who underwent primary rectal cancer resections after having completed neoadjuvant treatment from 1/07 -11/13. Patients were divided into three groups based on final pathology: pathological complete response (PCR), defined as T stage of 0 in the operative specimen, partial response (PR), and no response (NR). Pretreatment CEA was measured at the initial visit with the oncologist or surgeon, while posttreatment CEA was measured after completing neoadjuvant treatment and prior to surgery. In our laboratory, a normal CEA ranges from 0-3.0 ug/L. Chi-square, student's t and wilcoxon rank sum tests were used for univariate analyses for categorical, normally distributed continuous and non-normally distributed continuous variables, respectively. All variables with a p<0.15 on univariate analysis were included in a multivariate logistic regression model. RESULTS:141 (63 years, 60.4% male) patients underwent primary rectal cancer resections after completing neoadjuvant treatment (56% external beam, 44% brachytherapy). Of those, 28 (19.96%) achieved PCR, 43 (30.5%) had PR, and 69 (48.9%) had NR. Univariate analysis revealed that patients with PCR had similar demographic, pretreatment tumor characteristics, staging, pretreatment CEA levels and CEA ratios (posttreatment/ pretreatment). For patients with an initial elevated CEA (n=85, 60%), posttreatment CEA was significantly lower for patients with PCR compared to those with partial or no response (median 2.2 [IQR1.00,2.90] vs median 3.3[IQR1.9,6.3]), p<0.03. On multivariate logistic regression, in patients with an initial elevated pretreatment CEA and taking into account age, gender, poorly differentiated tumors, and smoking status, a normal post-treatment is a highly significant predictor of PCR (OR 59.2 (95%CI 1.66, ∞). CONCLUSIONS: In patients with an initially elevated CEA, a normal post- neoadjuvant treatment CEA is a highly significant predictor of pathologic complete response.
621 Aryl Hydrocarbon Receptor Is Required for Induction of Apoptosis by the Flavonoid Chrysin in Colon Tumor Cells Sean Ronnekleiv-Kelly, Manabu Nukaya, Patrick Carney, Gregory D. Kennedy Introduction: The aryl hydrocarbon receptor (AHR) is a ligand-binding transcriptional receptor that has been implicated in a number of GI malignancies including colon and rectal cancer. Chrysin, a member of the family of natural flavonoids isolated from propolis, is an AHR ligand and has been found to induce cell death or arrest cell proliferation in various tumor cell lines in vitro. We have hypothesized that chrysin will inhibit growth of colon cancer cells and that this inhibition is dependent upon the AHR. Methods: The cell viability, cytotoxicity and apoptosis in colon tumor cells were measured by XTT assay (Life technologies, Carlsbad, CA) and ApoTox-Glo™ Triplex Assay system (Promega, Madison, WI). The apoptotic cells were detected by TUNEL assay (Promega). The si-scramble (control) and siAHR expression HCT116 cells were generated by stable transfection of small interferingRNA (si-RNA) expression vectors. The transcriptional activity of AHR was measured by dual-luciferase reporter gene assay system (Promega). Statistical analysis was performed with GraphPad Prism 5 for Windows. Results: We found a dose dependent increase in AHR transcriptional activity (increase of Cyp1a1 mRNA by 8 fold over control, P<0.05). This effect was confirmed using an AHR responsive luciferase reporter assay. Cell viability was reduced in all three colon tumor cell lines exposed to chrysin (Figure 1A) and this seemed to be due to an increase apoptosis (200% of apoptosis compared to control, P<0.05, Figure 1B). Stably transfected cells expressing si-AHR were resistant to chrysin-induced cell apoptosis compared to si-Scramble expressing cells (80% viability v. 60% viability, P<0.05). Conclusion: Using three different colon tumor cell lines and creating AHR si-RNA cells, we have found
623 Visceral Adipose Tissue Changes After Surgery in Colorectal Cancer Patients May Have Prognostic Implications Eun Kyung Choe, Heung-Kwon Oh, Sang Hui Moon, Seung-Bum Ryoo, Kyu Joo Park Purpose> Although studies suggested the possible relationship between the amount of visceral adipose tissue and prognosis in colorectal cancer (CRC) patients, there are few studies assessing the changes in body component after colectomy. We intended to verify the adipose tissue area changes before and after surgery to determine their clinical relevance. Methods> CT assessed adipose tissue areas (subcutaneous, SAT; visceral, VAT) were measured before and annually after curative resection in stage I to III CRC patients. Patients who had total colectomy or stoma were excluded. Demographic and clinical characteristics were reviewed in prospectively collected cohort of patients. Changes in adipose tissue area were assessed by calculating the difference of adipose tissue area between preoperative and most recent postoperative CT without any findings of recurrence. Adipose tissue obesity was defined as amount of more than 50 percentiles. Results> The study cohort included 447 males and 254
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SSAT Abstracts
SSAT Abstracts
Normalization of Carcinoembryonic Antigen Levels Post-Neoadjuvant Therapy Is a Strong Predictor of Pathologic Complete Response in Rectal Cancer Ariella Kleiman, Nancy Morin, Philip H. Gordon, Te Vuong, Abbas Kezouh, Julio Faria, Gabriela Ghitulescu, Marylise Boutros
females (age 62.0±10.8 years). Median follow up period was 67.3+/-17.8months (range:12.3102.2months). CT scans were available in 651 patients (CT follow up duration : median 44.6months, range 12.3-82.8months). Preoperative VAT obesity was observed in 323 patients (49.4%) and SAT obesity in 266 (47%). Preoperative VAT obesity was associated with earlier TNM stage (p=0.042) and negative venous invasion (p=0.02). After surgery, 266 patients (53%) showed increase in VAT, and 358 patients (63.3%) in SAT after surgery. Chemotherapy did not influence in VAT or SAT changes (p=0.086). Increase in VAT amount after surgery was associated with pathologic differentiation and increase in SAT with T stage and TNM stage. By Kaplan Meier analysis, increased VAT and SAT after surgery showed higher OS (p=0.001, 0.03) and DFS (p=0.004, 0.02) in stage 3. On univariate analysis, TNM stage, pathologic differentiation, perineural invasion, preoperative CEA level, postoperative VAT and SAT change were significant predictors of OS and DFS. Preoperative VAT obesity was not associated with OS (p=0.148) and DFS (p=0.615). By multivariate Cox regression analysis, TNM stage (p=0.049), differentiation (p=0.006), perineural invasion (p=0.000) and postoperative VAT change (HR, decrease : increase = 1 : 0.493, p=0.012) were significant predictors for OS and DFS. Conclusions> In contrary to other studies, preoperative visceral obesity was not a predictor for poor prognosis in our cohort of patients. Instead, the increase in visceral fat amount after surgery was a significant positive predictor of overall and disease free survival in CRC patients undergoing curative resection.
procedures having highest scores and those undergoing burn/trauma/acute care procedures having the lowest scores. Dramatic differences were seen in surgeon rating as a function of each care domain examined. Specifically, those patients who reported adequate information giving before surgery, participation in shared decision making, and effective patient-surgeon communication rated their surgeons most highly (Table). Conclusion: The Surgical Care Survey is a new patient satisfaction measure that is a valid tool to elucidate patient satisfaction specific to surgeons. Further, it demonstrates the essential domains that impact patient ratings of their surgeons: effective communication, shared decision-making, adequate preparation for surgery, and surgeon attentiveness on the day of surgery. This information helps surgeons to identify potential areas for improvement that will positively affect the surgical patient experience.
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SSAT Abstracts
Implementation of Best Practices in Colorectal Surgery at a Safety Net Hospital: Facilitators and Barriers Zeinab Alawadi, Uma Phatak, Isabel Leal, Burzeen E. Karanjawala, Stefanos G. Millas, Julie Holihan, Tien C. Ko, Lillian Kao BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathway is known to reduce complications and length of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible at a safety-net hospital. The aim of this study is to identify local barriers and facilitators to implementation of ERAS pathway for colorectal surgery patients at a safety-net hospital. METHODS: Semi-structured interviews were conducted to assess current practice, knowledge of the evidence, willingness to adopt the pathway, and perceived barriers and facilitators to change. Stratified purposive sampling was used. Interviews with 8 anesthesiologist, 5 surgeons, 6 nurses and 10 patients were audiotaped, transcribed verbatim and coded using qualitative content analysis. To ensure rigor in data analysis we developed a coding frame to review all transcripts; used participant's quotes; and employed analytic triangulation to establish credibility. RESULTS: Medical staff addressed factors specific to ERAS implementation, while patients spoke to those related to general recovery. The categories identified across the different medical professions as facilitators were: 1) feasibility, alignment with current practice, 2) smallness of community, 3) good working team and communication, and 4) caring for patients. The barriers were: 1) adapting to change, 2) lack of coordination between different departments, 3) special patient population, 4) limited resources, and 5) rotating residents. Medical staff were familiar with the majority of the ERAS pathway, although practice was not routine. Exceptions included preoperative carbohydrate loading which was perceived to have limited evidence by most surgeons and anesthesiologists, and early mobilization and preoperative education, which were considered important for patient recovery but were not utilized secondary to limited resources. The categories identified in patient interviews as facilitators of overall recovery were: 1) welcoming a speedy recovery, 2) comfort, being well-cared for, and 3) good social support. The barriers were: 1) need for prolonged rest and 2) lack of quiet and private space. Both medical staff and patients expressed an overwhelming positive attitude and support for implementation of ERAS. CONCLUSION: Use of a qualitative approach accessed what key stakeholders identified as the most important factors on the organizational, practitioner and patient level, impacting improvements in outcomes and efficiency of care. While limited hospital resources is perceived to be a barrier to ERAS implementation at a safetynet hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. The findings of this qualitative study serve as a basis for modifying and designing interventions targeted to the needs of this population and hospital setting.
626 A Randomised, Single-Blinded Trial Assessing the Effect of a Two Week Preoperative Very Low Calorie Diet on Laparoscopic Cholecystectomy Procedure in Obese Patients Nicholas Burr, Katherine Burnand, Rajiv Lahiri, John M. Bennett, Michael P. Lewis Background - A very low calorie diet (VLCD) before bariatric surgery has been shown to decrease liver volume and improve laparoscopic operative access and is often a routine part of the preoperative workup for bariatric procedures. During laparoscopic cholecystectomy the effect of a VLCD could ease dissection of the gall bladder, improve operative views and reduce hepatic bleeding from surgical trauma. The aims of this study were to investigate whether a 2 week calorie restricted diet before surgery can reduce operative time and postoperative complications. The primary outcome measure was operation time. Secondary outcomes were length of stay, operative complications and day case rates. Methods - Patients with BMI >30kg/m2, aged between 18-70 years with symptomatic gallstone disease attending for elective laparoscopic cholecystectomy at the Norfolk and Norwich University Hospital, UK were invited to take part in the study. Patients were recruited between May 2011 and May 2013. Exclusion criteria were previous abdominal surgery, common bile duct stones, type I or type II diabetes mellitus and liver disease. Patients were randomised at preassessment to a VLCD or normal diet for two weeks prior to cholecystectomy. Comprehensive food diaries were used to document dietary intake in both groups. A single surgeon, blind to the intervention group, performed all operations. An a priori power calculation determined that 23 patients were required in each group to detect a clinically significant difference in operation time of 2.5 minutes at 80% power with 95% confidence intervals. Results - 21 cases and 25 controls were recruited into the study. One patient (control group) withdrew and was analysed on an intention to treat (ITT) basis. There was no significant difference in age, gender, BMI and co-morbidity between the study groups. The VLCD was well tolerated and resulted in a mean weight loss difference of 2.5 kg (95% CI, 1.4-3.6) compared to normal diet. There was a significant reduction in median operative time of 6 minutes (p=0.004) for patients taking the VLCD compared to controls (25 minutes (range 18-40.5 minutes) versus 31 minutes (20-170)). There were no differences in secondary outcome measures (complication rate, length of stay, or day case rates) between the groups. Discussion - This is the first study to investigate the use of VLCD before laparoscopic cholecystectomy in obese patients. The key finding was a statistically significant reduction in operation time for the intervention group (p=0.004). Low calorie diet can be offered to patients before cholecystectomy as a safe, well tolerated intervention to reduce operative time but also to reduce weight and thus protect against future weight related morbidity.
625 The Surgical Care Survey Is an Accurate Measure of Patient Satisfaction Across Surgical Care Domains Ryan K. Schmocker, Linda Cherney Stafford, Alexander Siy, Glen Leverson, Emily Winslow Background: With the introduction of the Affordable Care Act, the patient experience has been increasingly emphasized. Patient satisfaction outcomes are currently measured using the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey, however this tool does not assess information specific to surgical patients. The American College of Surgeons-sponsored and National Quality Forum-endorsed Surgical Care Survey focuses on the characteristics of surgical care that impact the patient experience. We set forth to identify which factors impact overall surgeon rating. Methods: All patients undergoing a general surgical operation at our institution from 6/13-11/13 were sent the Surgical Care Survey within 3 days of discharge. Secondary mailings were sent to nonresponders for the first 226 patients. Survey responses were entered into an ongoing database, as part of a prospective study examining surgical readmissions. Data was analyzed using the highest response as the "Topbox" score. Data analysis was generated using SAS software, with appropriate application of χ2 and t-tests for univariate analysis. Results: The response rate for the 1123 surveys sent was 40.4%. The average age was 59±16 yrs, length of stay was 4.0±6.6 days, and 23% had unscheduled operations. 27.1% of patients were treated by colorectal surgeons, 27.1% by burn/trauma/acute care surgeons, 16.7% by minimally invasive surgeons, and the remainder by breast, hepatobiliary, and endocrine surgeons. Of those who responded to the overall surgeon rating item ("What number would you use to rate all your care from this surgeon?"), 72% (315) rated their surgeon as the best surgeon possible (10 = highest score). Elective operations (p < 0.0001) and older patient age (p = 0.014) were associated with higher ratings. Additionally, there were differences between practice groups and satisfaction (p < 0.0001), with those undergoing endocrine or hepatobiliary
SSAT Abstracts
627 The Treatment and Revised Classification of Gallbladder Perforation in Acute Cholecystitis: The Importance of Intrahepatic and Abdominal Abscess Formation Lygia Stewart, Gary Jarvis, J. McLeod Griffiss Background: Intrahepatic and abdominal abscess is a rarely reported complication of acute cholecystitis. Prior perforated cholecystitis classification systems have not included hepatic abscess as an entity. We reviewed our series and report risk factors, and treatment outcomes of perforated cholecystitis with a focus on a the presentation of cases with an associated abscess. Methods: 618 patients with gallstones were studied; there were 536 men, 82 women; average age 62 (range 17-104). Among these patients, 241 had acute cholecystitis. Gallstones, bile, and blood (as applicable) were cultured, Stone type recorded. Illness severity was classified as: none (no inflammatory manifestations), SIRS (fever, leukocytosis, tachycardia), severe (abscess, cholangitis, empyema), or MODS (bacteremia, hypotension, organ failure).
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(1) that the chrysin-induced cell death in colon tumor cells is due to apoptosis and (2) the apoptosis mediated by chrysin in these cell lines requires AHR. Current work is focusing on elucidating the mechanism by which AHR participates in the induction of apoptosis. If chrysin will prove to be a novel chemotherapeutic in the future remains to be determined.
End of the Road for a Dysfunctional End-Organ: Gastrectomy for Refractory Gastroparesis Neil Bhayani, Ahmed M. Sharata, Christy M. Dunst, Ashwin A. Kurian, Kevin M. Reavis, Lee L. Swanstrom INTRODUCTION Gastroparesis is a functional disorder resulting in debilitating nausea, overflow esophageal reflux & abdominal pain and is frequently refractory to medical treatment. Surgical therapies such as pyloroplasty and neurostimulators aim to facilitate emptying. When treatments to facilitate gastric emptying fail, subtotal gastrectomy has been employed with varying success. Herein, we examined outcomes after gastrectomy for diabetic and idiopathic gastroparesis. METHODS A prospective database was queried for gastrectomies with Roux-en-Y reconstruction performed for gastroparesis from 1993-2013. Primary outcomes were improvements in pre- versus post-operative symptoms at last followup, measured on a 5-point scale. Secondary outcome was operative morbidity. RESULTS Thirty-five patients underwent total or near-total gastrectomies for idiopathic (23%), post-operative(43%), or diabetic (34%) gastroparesis. Anti-emetics and pro-kinetics afforded no relief in 34.5% of patients. There were no operative mortalities. Six patients suffered a leak requiring anastomotic revision. With a median follow-up of 11.4 months, nausea improved or resolved in 70% after surgery. Chronic abdominal pain improved or resolved in 69% of patients. Belching and bloating resolved for 75% & 81%, respectively (p<0.01). CONCLUSIONS Regardless of etiology, medically-refractrory gastroparesis is a chronic and devastating disease. Surgery can ameliorate, and often relieve symptoms of nausea, excessive belching and gas bloat. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can palliate symptoms of gastroparesis.
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PURPOSE: Several authors have investigated the relationship between carcinoembryonic antigen (CEA) and pathologic complete response; however to date there is no clear consensus regarding its predictive value. The purpose of this study is to examine the association of pre-treatment and post-treatment CEA with pathologic complete response. METHODS: After institutional review board approval, we conducted a retrospective chart review of a prospectively maintained database of all patients who underwent primary rectal cancer resections after having completed neoadjuvant treatment from 1/07 -11/13. Patients were divided into three groups based on final pathology: pathological complete response (PCR), defined as T stage of 0 in the operative specimen, partial response (PR), and no response (NR). Pretreatment CEA was measured at the initial visit with the oncologist or surgeon, while posttreatment CEA was measured after completing neoadjuvant treatment and prior to surgery. In our laboratory, a normal CEA ranges from 0-3.0 ug/L. Chi-square, student's t and wilcoxon rank sum tests were used for univariate analyses for categorical, normally distributed continuous and non-normally distributed continuous variables, respectively. All variables with a p<0.15 on univariate analysis were included in a multivariate logistic regression model. RESULTS:141 (63 years, 60.4% male) patients underwent primary rectal cancer resections after completing neoadjuvant treatment (56% external beam, 44% brachytherapy). Of those, 28 (19.96%) achieved PCR, 43 (30.5%) had PR, and 69 (48.9%) had NR. Univariate analysis revealed that patients with PCR had similar demographic, pretreatment tumor characteristics, staging, pretreatment CEA levels and CEA ratios (posttreatment/ pretreatment). For patients with an initial elevated CEA (n=85, 60%), posttreatment CEA was significantly lower for patients with PCR compared to those with partial or no response (median 2.2 [IQR1.00,2.90] vs median 3.3[IQR1.9,6.3]), p<0.03. On multivariate logistic regression, in patients with an initial elevated pretreatment CEA and taking into account age, gender, poorly differentiated tumors, and smoking status, a normal post-treatment is a highly significant predictor of PCR (OR 59.2 (95%CI 1.66, ∞). CONCLUSIONS: In patients with an initially elevated CEA, a normal post- neoadjuvant treatment CEA is a highly significant predictor of pathologic complete response.
621 Aryl Hydrocarbon Receptor Is Required for Induction of Apoptosis by the Flavonoid Chrysin in Colon Tumor Cells Sean Ronnekleiv-Kelly, Manabu Nukaya, Patrick Carney, Gregory D. Kennedy Introduction: The aryl hydrocarbon receptor (AHR) is a ligand-binding transcriptional receptor that has been implicated in a number of GI malignancies including colon and rectal cancer. Chrysin, a member of the family of natural flavonoids isolated from propolis, is an AHR ligand and has been found to induce cell death or arrest cell proliferation in various tumor cell lines in vitro. We have hypothesized that chrysin will inhibit growth of colon cancer cells and that this inhibition is dependent upon the AHR. Methods: The cell viability, cytotoxicity and apoptosis in colon tumor cells were measured by XTT assay (Life technologies, Carlsbad, CA) and ApoTox-Glo™ Triplex Assay system (Promega, Madison, WI). The apoptotic cells were detected by TUNEL assay (Promega). The si-scramble (control) and siAHR expression HCT116 cells were generated by stable transfection of small interferingRNA (si-RNA) expression vectors. The transcriptional activity of AHR was measured by dual-luciferase reporter gene assay system (Promega). Statistical analysis was performed with GraphPad Prism 5 for Windows. Results: We found a dose dependent increase in AHR transcriptional activity (increase of Cyp1a1 mRNA by 8 fold over control, P<0.05). This effect was confirmed using an AHR responsive luciferase reporter assay. Cell viability was reduced in all three colon tumor cell lines exposed to chrysin (Figure 1A) and this seemed to be due to an increase apoptosis (200% of apoptosis compared to control, P<0.05, Figure 1B). Stably transfected cells expressing si-AHR were resistant to chrysin-induced cell apoptosis compared to si-Scramble expressing cells (80% viability v. 60% viability, P<0.05). Conclusion: Using three different colon tumor cell lines and creating AHR si-RNA cells, we have found
623 Visceral Adipose Tissue Changes After Surgery in Colorectal Cancer Patients May Have Prognostic Implications Eun Kyung Choe, Heung-Kwon Oh, Sang Hui Moon, Seung-Bum Ryoo, Kyu Joo Park Purpose> Although studies suggested the possible relationship between the amount of visceral adipose tissue and prognosis in colorectal cancer (CRC) patients, there are few studies assessing the changes in body component after colectomy. We intended to verify the adipose tissue area changes before and after surgery to determine their clinical relevance. Methods> CT assessed adipose tissue areas (subcutaneous, SAT; visceral, VAT) were measured before and annually after curative resection in stage I to III CRC patients. Patients who had total colectomy or stoma were excluded. Demographic and clinical characteristics were reviewed in prospectively collected cohort of patients. Changes in adipose tissue area were assessed by calculating the difference of adipose tissue area between preoperative and most recent postoperative CT without any findings of recurrence. Adipose tissue obesity was defined as amount of more than 50 percentiles. Results> The study cohort included 447 males and 254
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SSAT Abstracts
SSAT Abstracts
Normalization of Carcinoembryonic Antigen Levels Post-Neoadjuvant Therapy Is a Strong Predictor of Pathologic Complete Response in Rectal Cancer Ariella Kleiman, Nancy Morin, Philip H. Gordon, Te Vuong, Abbas Kezouh, Julio Faria, Gabriela Ghitulescu, Marylise Boutros
females (age 62.0±10.8 years). Median follow up period was 67.3+/-17.8months (range:12.3102.2months). CT scans were available in 651 patients (CT follow up duration : median 44.6months, range 12.3-82.8months). Preoperative VAT obesity was observed in 323 patients (49.4%) and SAT obesity in 266 (47%). Preoperative VAT obesity was associated with earlier TNM stage (p=0.042) and negative venous invasion (p=0.02). After surgery, 266 patients (53%) showed increase in VAT, and 358 patients (63.3%) in SAT after surgery. Chemotherapy did not influence in VAT or SAT changes (p=0.086). Increase in VAT amount after surgery was associated with pathologic differentiation and increase in SAT with T stage and TNM stage. By Kaplan Meier analysis, increased VAT and SAT after surgery showed higher OS (p=0.001, 0.03) and DFS (p=0.004, 0.02) in stage 3. On univariate analysis, TNM stage, pathologic differentiation, perineural invasion, preoperative CEA level, postoperative VAT and SAT change were significant predictors of OS and DFS. Preoperative VAT obesity was not associated with OS (p=0.148) and DFS (p=0.615). By multivariate Cox regression analysis, TNM stage (p=0.049), differentiation (p=0.006), perineural invasion (p=0.000) and postoperative VAT change (HR, decrease : increase = 1 : 0.493, p=0.012) were significant predictors for OS and DFS. Conclusions> In contrary to other studies, preoperative visceral obesity was not a predictor for poor prognosis in our cohort of patients. Instead, the increase in visceral fat amount after surgery was a significant positive predictor of overall and disease free survival in CRC patients undergoing curative resection.
procedures having highest scores and those undergoing burn/trauma/acute care procedures having the lowest scores. Dramatic differences were seen in surgeon rating as a function of each care domain examined. Specifically, those patients who reported adequate information giving before surgery, participation in shared decision making, and effective patient-surgeon communication rated their surgeons most highly (Table). Conclusion: The Surgical Care Survey is a new patient satisfaction measure that is a valid tool to elucidate patient satisfaction specific to surgeons. Further, it demonstrates the essential domains that impact patient ratings of their surgeons: effective communication, shared decision-making, adequate preparation for surgery, and surgeon attentiveness on the day of surgery. This information helps surgeons to identify potential areas for improvement that will positively affect the surgical patient experience.
624
SSAT Abstracts
Implementation of Best Practices in Colorectal Surgery at a Safety Net Hospital: Facilitators and Barriers Zeinab Alawadi, Uma Phatak, Isabel Leal, Burzeen E. Karanjawala, Stefanos G. Millas, Julie Holihan, Tien C. Ko, Lillian Kao BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathway is known to reduce complications and length of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible at a safety-net hospital. The aim of this study is to identify local barriers and facilitators to implementation of ERAS pathway for colorectal surgery patients at a safety-net hospital. METHODS: Semi-structured interviews were conducted to assess current practice, knowledge of the evidence, willingness to adopt the pathway, and perceived barriers and facilitators to change. Stratified purposive sampling was used. Interviews with 8 anesthesiologist, 5 surgeons, 6 nurses and 10 patients were audiotaped, transcribed verbatim and coded using qualitative content analysis. To ensure rigor in data analysis we developed a coding frame to review all transcripts; used participant's quotes; and employed analytic triangulation to establish credibility. RESULTS: Medical staff addressed factors specific to ERAS implementation, while patients spoke to those related to general recovery. The categories identified across the different medical professions as facilitators were: 1) feasibility, alignment with current practice, 2) smallness of community, 3) good working team and communication, and 4) caring for patients. The barriers were: 1) adapting to change, 2) lack of coordination between different departments, 3) special patient population, 4) limited resources, and 5) rotating residents. Medical staff were familiar with the majority of the ERAS pathway, although practice was not routine. Exceptions included preoperative carbohydrate loading which was perceived to have limited evidence by most surgeons and anesthesiologists, and early mobilization and preoperative education, which were considered important for patient recovery but were not utilized secondary to limited resources. The categories identified in patient interviews as facilitators of overall recovery were: 1) welcoming a speedy recovery, 2) comfort, being well-cared for, and 3) good social support. The barriers were: 1) need for prolonged rest and 2) lack of quiet and private space. Both medical staff and patients expressed an overwhelming positive attitude and support for implementation of ERAS. CONCLUSION: Use of a qualitative approach accessed what key stakeholders identified as the most important factors on the organizational, practitioner and patient level, impacting improvements in outcomes and efficiency of care. While limited hospital resources is perceived to be a barrier to ERAS implementation at a safetynet hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. The findings of this qualitative study serve as a basis for modifying and designing interventions targeted to the needs of this population and hospital setting.
626 A Randomised, Single-Blinded Trial Assessing the Effect of a Two Week Preoperative Very Low Calorie Diet on Laparoscopic Cholecystectomy Procedure in Obese Patients Nicholas Burr, Katherine Burnand, Rajiv Lahiri, John M. Bennett, Michael P. Lewis Background - A very low calorie diet (VLCD) before bariatric surgery has been shown to decrease liver volume and improve laparoscopic operative access and is often a routine part of the preoperative workup for bariatric procedures. During laparoscopic cholecystectomy the effect of a VLCD could ease dissection of the gall bladder, improve operative views and reduce hepatic bleeding from surgical trauma. The aims of this study were to investigate whether a 2 week calorie restricted diet before surgery can reduce operative time and postoperative complications. The primary outcome measure was operation time. Secondary outcomes were length of stay, operative complications and day case rates. Methods - Patients with BMI >30kg/m2, aged between 18-70 years with symptomatic gallstone disease attending for elective laparoscopic cholecystectomy at the Norfolk and Norwich University Hospital, UK were invited to take part in the study. Patients were recruited between May 2011 and May 2013. Exclusion criteria were previous abdominal surgery, common bile duct stones, type I or type II diabetes mellitus and liver disease. Patients were randomised at preassessment to a VLCD or normal diet for two weeks prior to cholecystectomy. Comprehensive food diaries were used to document dietary intake in both groups. A single surgeon, blind to the intervention group, performed all operations. An a priori power calculation determined that 23 patients were required in each group to detect a clinically significant difference in operation time of 2.5 minutes at 80% power with 95% confidence intervals. Results - 21 cases and 25 controls were recruited into the study. One patient (control group) withdrew and was analysed on an intention to treat (ITT) basis. There was no significant difference in age, gender, BMI and co-morbidity between the study groups. The VLCD was well tolerated and resulted in a mean weight loss difference of 2.5 kg (95% CI, 1.4-3.6) compared to normal diet. There was a significant reduction in median operative time of 6 minutes (p=0.004) for patients taking the VLCD compared to controls (25 minutes (range 18-40.5 minutes) versus 31 minutes (20-170)). There were no differences in secondary outcome measures (complication rate, length of stay, or day case rates) between the groups. Discussion - This is the first study to investigate the use of VLCD before laparoscopic cholecystectomy in obese patients. The key finding was a statistically significant reduction in operation time for the intervention group (p=0.004). Low calorie diet can be offered to patients before cholecystectomy as a safe, well tolerated intervention to reduce operative time but also to reduce weight and thus protect against future weight related morbidity.
625 The Surgical Care Survey Is an Accurate Measure of Patient Satisfaction Across Surgical Care Domains Ryan K. Schmocker, Linda Cherney Stafford, Alexander Siy, Glen Leverson, Emily Winslow Background: With the introduction of the Affordable Care Act, the patient experience has been increasingly emphasized. Patient satisfaction outcomes are currently measured using the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey, however this tool does not assess information specific to surgical patients. The American College of Surgeons-sponsored and National Quality Forum-endorsed Surgical Care Survey focuses on the characteristics of surgical care that impact the patient experience. We set forth to identify which factors impact overall surgeon rating. Methods: All patients undergoing a general surgical operation at our institution from 6/13-11/13 were sent the Surgical Care Survey within 3 days of discharge. Secondary mailings were sent to nonresponders for the first 226 patients. Survey responses were entered into an ongoing database, as part of a prospective study examining surgical readmissions. Data was analyzed using the highest response as the "Topbox" score. Data analysis was generated using SAS software, with appropriate application of χ2 and t-tests for univariate analysis. Results: The response rate for the 1123 surveys sent was 40.4%. The average age was 59±16 yrs, length of stay was 4.0±6.6 days, and 23% had unscheduled operations. 27.1% of patients were treated by colorectal surgeons, 27.1% by burn/trauma/acute care surgeons, 16.7% by minimally invasive surgeons, and the remainder by breast, hepatobiliary, and endocrine surgeons. Of those who responded to the overall surgeon rating item ("What number would you use to rate all your care from this surgeon?"), 72% (315) rated their surgeon as the best surgeon possible (10 = highest score). Elective operations (p < 0.0001) and older patient age (p = 0.014) were associated with higher ratings. Additionally, there were differences between practice groups and satisfaction (p < 0.0001), with those undergoing endocrine or hepatobiliary
SSAT Abstracts
627 The Treatment and Revised Classification of Gallbladder Perforation in Acute Cholecystitis: The Importance of Intrahepatic and Abdominal Abscess Formation Lygia Stewart, Gary Jarvis, J. McLeod Griffiss Background: Intrahepatic and abdominal abscess is a rarely reported complication of acute cholecystitis. Prior perforated cholecystitis classification systems have not included hepatic abscess as an entity. We reviewed our series and report risk factors, and treatment outcomes of perforated cholecystitis with a focus on a the presentation of cases with an associated abscess. Methods: 618 patients with gallstones were studied; there were 536 men, 82 women; average age 62 (range 17-104). Among these patients, 241 had acute cholecystitis. Gallstones, bile, and blood (as applicable) were cultured, Stone type recorded. Illness severity was classified as: none (no inflammatory manifestations), SIRS (fever, leukocytosis, tachycardia), severe (abscess, cholangitis, empyema), or MODS (bacteremia, hypotension, organ failure).
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