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Are stapled anastomoses in GI surgery justifield?
GASTROENTEROLOGY Vol. 114, No. 4
A1390 SSAT ABSTRACTS
• S0075 ARE STAPLED ANASTOMOSES IN GI SURGERY JUSTIFIED? K.A. Gawad. J.R. Izbicki. S.B. Hosch. S. Ouirrenbach, W.T. Knoefel. H.-U. Ktipper*. C.E. Broelsch. Department of Surgery, University of Hamburg and Institute of Controlling*, Universitiy of Munich, Germany.
S0077 ENDOSCOPIC PLACEMENT OF AN IMPROVED LONG INTESTINAL TUBE IS SUCCESSFUL IN 85% OF PATIENTS WITH SMALL BOWEL OBSTRUCTION. G.F. Gowen, Pennsylvania Hospital, Philadelphia, PA 19107.
Introduction: Limited financial resources require thoughtful expenditures even in socialised health care systems. Therefore a prospective randomized study was performed to evaluate the efficiency and cost effectiveness of hand sewn vs. stapled anastomoses in GI surgery. Material and Methods: All patients with elective GI surgery (except Crohn's disease or ulcerative colitis) were elegible to be enrolled in the study. Patients were randomly allocated to either group only if both ways of reconstruction were applicable after resection. Patients were especially followed for anastomotic insufficiencies or strictures, postoperative bleeding and motility. The cost was calculated considering not only the suture material used but also the cost for the staff involved to perform a certain anastmoses or operation. Results: A total of 324 anastomoses (170 stapled vs. 158 hand sewn) were performed during 200 operations in 200 Patients (80 female: 120 male) with a mean age of 60.2 (21-90) years. Of these operations 20.5% were gastrectomies, 14% gastric resections (BII), 15% Whipple's procedures, 4% segmental colonic resections, 18% right-sided -, 4% left-sided hemicolectomies, 22% sigmoid- or anterior rectal resections and 2.5% total colectomies with pouch-anal anastomoses. Postoperative hospitalization was comparable in both groups. Postoperative motility (time to full oral diet, time with NG tube) was also comparable. Anastomotic insufficiencies were observed in 2.1% of all patients, 5 of those after stapled, 2 after hand sewn anastomoses. Hospital mortality was 1.5%, one patient died after insufficiency of her handsewn anastomoses, the others of diseases unrelated to the operative technique. All stapled reconstructions were performed significantly faster (p<0.001). The cost of material for stapled anastomoses though was significantly higher (p<0.001) resulting in significantly higher (p<0.00l) total expenses for all stapled anastomoses. The total operative time was not significantly different (aside from stapled gastrectomy) for the two groups. All operations performed with a stapled reconstruction were therefore more expensive than those with sutured reconstruction, reaching significance for the gastrectomy (p<0.01), colonic resection (p<0.01) and sigmoid- and anterior rectal resection (p<0.001) groups. Conclusion: Stapled and sutured anastomoses in GI surgery are equally efficient. Stapled anastomoses are not cost -effective though and should be reserved to individual indications.
In properly selected patients with small bowel obstruction long tube decompression can restore normal function without an operation. In the last 20 years two important advances have been developed. 1. The technique of endoscopic placement of the long tube into the jejunum and 2. the development of an improved tube with six advantages including improved flow rate, control of the balloon, sump port and guide wire included, suture at the tip for endoscopic pick-up and no need for mercury or fluoroscopy. Method: In a consecutive personal series of 38 episodes of obstruction in 36 patients endoscopic placement of four tubes was performed. Results: In 1983-88 the Miller Abbott, Dennis and Anderson Tubes 8/17 = 48% success. In 1989-97 the Gowen Tube 18/21 = 85% success. Conclusion: Endoscopic placement of an improved long intestinal tube can relieve the obstruction in 85% of properly selected patients. Further application of long tube decompression is recommended.
• 80076 THE ROLE OF TRANSFORMING GROWTH FACTOR BETA-1 (TGF-[31) IN PERITONITIS-INDUCED ADHESIONS. A. M. Ghellai. N. Che~ini. O. Dou ], J.M. Kaseta 2, J.W. Burns2, K.C. Skinner 2. A. F. Stucchi and J.M. Becker. Department of Surgery, Boston University School of Medicine, Boston, MA; 2Genzyme Corporation, Cambridge, MA and qnstitute for Wound Research, University of Florida, Gainesville, FL. Peritonitis results in significant intra-abdominal adhesion formation with an associated high morbidity. TGF-131, a potent chemoattractant, stimulates collagen and fibronectin synthesis by fibroblasts and may play a role in the formation of adhesions. Hence, we hypothesized that TGF-131 would be upregulated in peritonitis and may contribute to adhesion formation. To test this hypothesis, peritonitis was induced in rats by cecal ligation and puncture while controls were sham operated. Adhesions were scored and harvested from both groups at days 0, 1, 2, 4, and 7. Expression of TGF-[31 m-RNA was determined by quantitative reverse transcriptase polymerase chain reactions normalized to 13-actin. Peritonitis was associated with a significantly greater incidence of abdominal adhesions compared with shams. Peritonitis also resulted in a significant increase in the expression of TGF-[31 mRNA at days 2, 4 and 7 with a 9-fold peak on day 4 compared with shams (Table). Immunohistochemical detection of TGF-131 protein in adhesions also reached maximum by day 4 and subsided by day 7 further supporting the expression of TGF-~I mRNA. These results suggest that peritonitis is associated with upregulation of TGF-[31 which may exacerbate adhesion formation. ~me
Number of Adhesions Sham Tre~ed D~ 0 0 0 D~I 0 8.0±1.6" D~2 0 8.0±0.5* D~4 0 9.8±1.1" D~7 0 10.5±1.1" Mean +_SEM *p -< 0.05 compared *p <_0.05 compared
TGF-~lmRNA Levels Sham Tweed 0.9±0.3 0.9±0.3 0.5±0.3 0 1.0±0.2 5.8±1.4"* 1.4±0.2 13±1.8"* 1.0±0.3 3.0±0.4"* with day 0 with sham
This research was funded, in part, by the Genzyme Corporation, Cambridge MA.
S0078
GENETIC RISK FACTORS IDENTIFY MOST PATIENTS WITH COLORECTAL CARCINOMA/ADENOMA. G.F. G0wen. Pennsylvania Hospital, Philadelphia PA. Searching for six genetic risk factors can identify patients with increased risk not only for Congenital Polyposis, HNPCC, and Juvenile Polyposis but also for those with sporadic adenomas causing 95% of colorectal carcinoma (ColoCa). Material & Methods: 386 patients 56 with carcinoma, 61 with villous adenomas, and 269 with tubular adenomas had colonoscopy, colon resections, and a family history of cancer obtained by the author. A computer software program has been developed to analyze this data. Results: 10% of the patients with ColoCaladenoma have other cancers. 11% had multiple ColoCa; 3/56 synchronous, 3/56 metaehronous. 40% with ColoCa/adenomas have synchronous adenomas and 60% have metachronous adenomas. 40% of the patients with ColoCa/adenomas have a first degree relative with ColoCa and 15% will have two or more with ColoCA. 40% of ColoCa/adenomas are proximal to the splenic flexure and also their segmental distribution is the same. 44% of cancers in first and second degree relatives of patients with ColoCa/adenomas will be colorectal carcinoma vs. 10-15% for other cancers. Conclusion: Colorectal carcinoma and adenomas are but different stages of the same genetic mutational disease. To remove an adenoma or a colorectal carcinoma does not remove the mutation therefore: 1. complete colonoscopy is essential for both adenomas and Ca to find synchronous lesions. 2. Surveillance colonoscopy, tailored to each patient's need is necessary to find metachronous lesions. 3. A diligent ongoing search for other cancers in both groups is indicated. 4. Search the family tree to identify relatives at increased risk who can benefit from screening colonoscopy. 5. The genetic risk factors are superior to signs, symptoms, and x-rays in identifying patients at increased risk for ColoCa who are at the curable and preventable stages of the disease. • S0079 CLINICAL SUBTYPES OF CROHN'S DISEASE ACCORDING TO SURGICAL OUTCOME. S. E. Greenwav. M. A. Buckmire. R. H. Rolandelli: Allegheny University of the Health Sciences, Philadelphia, PA. A classification proposed for patients with Crohn's disease (CD) consists of two groups, perforator and non-perforator. The perforator group presents with acute perforation, fistulae, and abscess formation. The non-perforator group presents with stricture, obstruction, or unresponsiveness to medical therapy. In addition, up to one third of patients with CD present with perianal disease. Our purpose was to investigate whether patients who present with perianal disease constitute a separate group of CD in respect to surgical outcome. Ninety-one patients underwent 232 operations for CD. Following each surgery, patients were classified into one of three groups: perforator, nonperforator, and perianal disease, based on operative findings. Perforating complications presented with the highest Crohn's Disease Activity Index (CDAI), followed by non-perforators and then patients with perianal disease (p < 0.02). The perianal disease group had the most rapid rate of postoperative recurrence (p < 0.02) and subsequent surgery (p < 0.05), followed next by the perforator group and then the non-perforator group. Recurrence rate and subsequent operation intervals for the perforator group appeared to lengthen from 1.7 +/- 2.2 years and 2.3 +/- 2.2 years respectively, when treated post-operatively with Amino-salicylic acid (ASA) and/or antimicrobials, to 5.8 +/- 5.7 years and 6.4 +/- 7.5 years when treated with steroids and/or immunosuppressants. Recurrence rate and subsequent operation intervals for the non-perforator group were significantly lengthened from 3.8 +/- 4.4 years and 3.8 +/- 4.0 years respectively, when treated postoperatively with steroids and/or immunosuppressants, to 11.7 +/- 6.4 years (p < 0.01) and 12.9 +/- 6.8 years (p < 0.005) when treated with ASA and/or antimicrobials. Recurrence rate and subsequent surgery interval for the perianal disease group increased from 2.0 +/- 1.8 years and 2.9 +/- 1.7 years respectively, when treated with steroids and/or immunosuppressants, to
A1390 SSAT ABSTRACTS
• S0075 ARE STAPLED ANASTOMOSES IN GI SURGERY JUSTIFIED? K.A. Gawad. J.R. Izbicki. S.B. Hosch. S. Ouirrenbach, W.T. Knoefel. H.-U. Ktipper*. C.E. Broelsch. Department of Surgery, University of Hamburg and Institute of Controlling*, Universitiy of Munich, Germany.
S0077 ENDOSCOPIC PLACEMENT OF AN IMPROVED LONG INTESTINAL TUBE IS SUCCESSFUL IN 85% OF PATIENTS WITH SMALL BOWEL OBSTRUCTION. G.F. Gowen, Pennsylvania Hospital, Philadelphia, PA 19107.
Introduction: Limited financial resources require thoughtful expenditures even in socialised health care systems. Therefore a prospective randomized study was performed to evaluate the efficiency and cost effectiveness of hand sewn vs. stapled anastomoses in GI surgery. Material and Methods: All patients with elective GI surgery (except Crohn's disease or ulcerative colitis) were elegible to be enrolled in the study. Patients were randomly allocated to either group only if both ways of reconstruction were applicable after resection. Patients were especially followed for anastomotic insufficiencies or strictures, postoperative bleeding and motility. The cost was calculated considering not only the suture material used but also the cost for the staff involved to perform a certain anastmoses or operation. Results: A total of 324 anastomoses (170 stapled vs. 158 hand sewn) were performed during 200 operations in 200 Patients (80 female: 120 male) with a mean age of 60.2 (21-90) years. Of these operations 20.5% were gastrectomies, 14% gastric resections (BII), 15% Whipple's procedures, 4% segmental colonic resections, 18% right-sided -, 4% left-sided hemicolectomies, 22% sigmoid- or anterior rectal resections and 2.5% total colectomies with pouch-anal anastomoses. Postoperative hospitalization was comparable in both groups. Postoperative motility (time to full oral diet, time with NG tube) was also comparable. Anastomotic insufficiencies were observed in 2.1% of all patients, 5 of those after stapled, 2 after hand sewn anastomoses. Hospital mortality was 1.5%, one patient died after insufficiency of her handsewn anastomoses, the others of diseases unrelated to the operative technique. All stapled reconstructions were performed significantly faster (p<0.001). The cost of material for stapled anastomoses though was significantly higher (p<0.001) resulting in significantly higher (p<0.00l) total expenses for all stapled anastomoses. The total operative time was not significantly different (aside from stapled gastrectomy) for the two groups. All operations performed with a stapled reconstruction were therefore more expensive than those with sutured reconstruction, reaching significance for the gastrectomy (p<0.01), colonic resection (p<0.01) and sigmoid- and anterior rectal resection (p<0.001) groups. Conclusion: Stapled and sutured anastomoses in GI surgery are equally efficient. Stapled anastomoses are not cost -effective though and should be reserved to individual indications.
In properly selected patients with small bowel obstruction long tube decompression can restore normal function without an operation. In the last 20 years two important advances have been developed. 1. The technique of endoscopic placement of the long tube into the jejunum and 2. the development of an improved tube with six advantages including improved flow rate, control of the balloon, sump port and guide wire included, suture at the tip for endoscopic pick-up and no need for mercury or fluoroscopy. Method: In a consecutive personal series of 38 episodes of obstruction in 36 patients endoscopic placement of four tubes was performed. Results: In 1983-88 the Miller Abbott, Dennis and Anderson Tubes 8/17 = 48% success. In 1989-97 the Gowen Tube 18/21 = 85% success. Conclusion: Endoscopic placement of an improved long intestinal tube can relieve the obstruction in 85% of properly selected patients. Further application of long tube decompression is recommended.
• 80076 THE ROLE OF TRANSFORMING GROWTH FACTOR BETA-1 (TGF-[31) IN PERITONITIS-INDUCED ADHESIONS. A. M. Ghellai. N. Che~ini. O. Dou ], J.M. Kaseta 2, J.W. Burns2, K.C. Skinner 2. A. F. Stucchi and J.M. Becker. Department of Surgery, Boston University School of Medicine, Boston, MA; 2Genzyme Corporation, Cambridge, MA and qnstitute for Wound Research, University of Florida, Gainesville, FL. Peritonitis results in significant intra-abdominal adhesion formation with an associated high morbidity. TGF-131, a potent chemoattractant, stimulates collagen and fibronectin synthesis by fibroblasts and may play a role in the formation of adhesions. Hence, we hypothesized that TGF-131 would be upregulated in peritonitis and may contribute to adhesion formation. To test this hypothesis, peritonitis was induced in rats by cecal ligation and puncture while controls were sham operated. Adhesions were scored and harvested from both groups at days 0, 1, 2, 4, and 7. Expression of TGF-[31 m-RNA was determined by quantitative reverse transcriptase polymerase chain reactions normalized to 13-actin. Peritonitis was associated with a significantly greater incidence of abdominal adhesions compared with shams. Peritonitis also resulted in a significant increase in the expression of TGF-[31 mRNA at days 2, 4 and 7 with a 9-fold peak on day 4 compared with shams (Table). Immunohistochemical detection of TGF-131 protein in adhesions also reached maximum by day 4 and subsided by day 7 further supporting the expression of TGF-~I mRNA. These results suggest that peritonitis is associated with upregulation of TGF-[31 which may exacerbate adhesion formation. ~me
Number of Adhesions Sham Tre~ed D~ 0 0 0 D~I 0 8.0±1.6" D~2 0 8.0±0.5* D~4 0 9.8±1.1" D~7 0 10.5±1.1" Mean +_SEM *p -< 0.05 compared *p <_0.05 compared
TGF-~lmRNA Levels Sham Tweed 0.9±0.3 0.9±0.3 0.5±0.3 0 1.0±0.2 5.8±1.4"* 1.4±0.2 13±1.8"* 1.0±0.3 3.0±0.4"* with day 0 with sham
This research was funded, in part, by the Genzyme Corporation, Cambridge MA.
S0078
GENETIC RISK FACTORS IDENTIFY MOST PATIENTS WITH COLORECTAL CARCINOMA/ADENOMA. G.F. G0wen. Pennsylvania Hospital, Philadelphia PA. Searching for six genetic risk factors can identify patients with increased risk not only for Congenital Polyposis, HNPCC, and Juvenile Polyposis but also for those with sporadic adenomas causing 95% of colorectal carcinoma (ColoCa). Material & Methods: 386 patients 56 with carcinoma, 61 with villous adenomas, and 269 with tubular adenomas had colonoscopy, colon resections, and a family history of cancer obtained by the author. A computer software program has been developed to analyze this data. Results: 10% of the patients with ColoCaladenoma have other cancers. 11% had multiple ColoCa; 3/56 synchronous, 3/56 metaehronous. 40% with ColoCa/adenomas have synchronous adenomas and 60% have metachronous adenomas. 40% of the patients with ColoCa/adenomas have a first degree relative with ColoCa and 15% will have two or more with ColoCA. 40% of ColoCa/adenomas are proximal to the splenic flexure and also their segmental distribution is the same. 44% of cancers in first and second degree relatives of patients with ColoCa/adenomas will be colorectal carcinoma vs. 10-15% for other cancers. Conclusion: Colorectal carcinoma and adenomas are but different stages of the same genetic mutational disease. To remove an adenoma or a colorectal carcinoma does not remove the mutation therefore: 1. complete colonoscopy is essential for both adenomas and Ca to find synchronous lesions. 2. Surveillance colonoscopy, tailored to each patient's need is necessary to find metachronous lesions. 3. A diligent ongoing search for other cancers in both groups is indicated. 4. Search the family tree to identify relatives at increased risk who can benefit from screening colonoscopy. 5. The genetic risk factors are superior to signs, symptoms, and x-rays in identifying patients at increased risk for ColoCa who are at the curable and preventable stages of the disease. • S0079 CLINICAL SUBTYPES OF CROHN'S DISEASE ACCORDING TO SURGICAL OUTCOME. S. E. Greenwav. M. A. Buckmire. R. H. Rolandelli: Allegheny University of the Health Sciences, Philadelphia, PA. A classification proposed for patients with Crohn's disease (CD) consists of two groups, perforator and non-perforator. The perforator group presents with acute perforation, fistulae, and abscess formation. The non-perforator group presents with stricture, obstruction, or unresponsiveness to medical therapy. In addition, up to one third of patients with CD present with perianal disease. Our purpose was to investigate whether patients who present with perianal disease constitute a separate group of CD in respect to surgical outcome. Ninety-one patients underwent 232 operations for CD. Following each surgery, patients were classified into one of three groups: perforator, nonperforator, and perianal disease, based on operative findings. Perforating complications presented with the highest Crohn's Disease Activity Index (CDAI), followed by non-perforators and then patients with perianal disease (p < 0.02). The perianal disease group had the most rapid rate of postoperative recurrence (p < 0.02) and subsequent surgery (p < 0.05), followed next by the perforator group and then the non-perforator group. Recurrence rate and subsequent operation intervals for the perforator group appeared to lengthen from 1.7 +/- 2.2 years and 2.3 +/- 2.2 years respectively, when treated post-operatively with Amino-salicylic acid (ASA) and/or antimicrobials, to 5.8 +/- 5.7 years and 6.4 +/- 7.5 years when treated with steroids and/or immunosuppressants. Recurrence rate and subsequent operation intervals for the non-perforator group were significantly lengthened from 3.8 +/- 4.4 years and 3.8 +/- 4.0 years respectively, when treated postoperatively with steroids and/or immunosuppressants, to 11.7 +/- 6.4 years (p < 0.01) and 12.9 +/- 6.8 years (p < 0.005) when treated with ASA and/or antimicrobials. Recurrence rate and subsequent surgery interval for the perianal disease group increased from 2.0 +/- 1.8 years and 2.9 +/- 1.7 years respectively, when treated with steroids and/or immunosuppressants, to