- Email: [email protected]
Salvage reoperations for complications threatening the viability of ileal pouch-anal anastomosis (IPAA)
M1934
rats received either vehicle (control) or streptozotocin (65 gm/kg) to induce diabetes. After 8 weeks, rats from each group were subjected to heat stress by placing them in a closed, heated, humidified and ventilated chamber until their core body temperature reached 41.5~ for 6 minutes followed by passive cooling for 4 hours. Additional rats from each group received either enteral vehicle or glutamine (3 gm/kg) administered by a carmula placed in the pylorns and advanced into the duodenum. Rats were allowed to recover for 6 hours. In all groups, sections of mid-small intestine and hver were taken and analyzed for HSP72 protein levels using Western Blot Analysis and normahzed to 13-actin. Results: Basal expression of HSP-72 was low in both control and diabetic rats. Heat stress increased HSP72 levels in both the liver and the intestine in controls while diabetic rats did not survive the procedure. In contrast, glutamine significantly increased in HSP-72 levels in both controls and diabetics; however, the levels were less than those achieved in response to heat stress. In addition, the increase in liver HSP-72 in diabetics was significantly less than in controls. Conclusion: Enteral glutamine induces HSP-72 in the liver and intestine of eontro[ and diabetic rats. The demonstrated ability of HSP-72 expression to protect against subsequent insults and the susceptibility of diabetic patients to clinical stressors suggests that enteral glutamine may be a beneficial adjuvant in these patients.
Small Bowel Adenocarcinoma in Celiac Disease: Features and Outcomes D. D. Potter Jr., Joseph A. Murray, David M. Nagorneyl Jonathan A. Van Heerden, Matthew F. Plevak, Alan R. Zinsmeister, Lawrence J. Burgart, John H. Donohue Purpose: Celiac Disease (CD) is an inflammatory condition of the small bowel caused by dietary gluten and associated with adenocarcinoma of the small bowel (SBC). The aims of this study were 1) to identify characteristics of CD patients with SBC, 2) determine longterm outcomes for SBC in CD and 3) compare these results to SBC in patients without CD. Methods: All CD patients with SBC were retrospectively reviewed and 3 age- and gendermatched SBC control patients identified for each CD patient. Results: Between July, 1960 and August, 2002, 18 patients with SBC and CD were treated. The mean age (_+ SD) of CD diagnosis was 52.7 (-+ 19.7) years and for SBC 59.9 (-+ 13.5) years. Operative (n=4) or postoperative (n=4) diagnosis of CD occurred in 44% of patients. Men comprised 56% of each cohort. The tumor did not involve the serosa in 4 cases in the CD group compared to 1 case in the controls. Lymph nodes were involved in 50% (n = 9) in the CD group and 59.3% (32) of the control group. A palhative operation was performed in 17% of CD and 33% of controls. Table 1 summarizes relevant cancer data. SBC in CD patients was more commonly diagnosed at an earlier stage (stage 1 and 2) than controls (p<0.05). Diseasefree and 5-year survivals were not significantly different for patients with CD compared to controls that were age- and gender-matched. Stage of SBC correlated with survival in control patients (p
HSP-72/B. Control ControlHeat ControlGluDiabetic DiabeticGlu. actin Vehlde Stnm tamine Vehlde tandM InfuSe 1.6,0.6 31.0~7.3" 10.5,1.3" 1.0,1.0 15.5-'4.8" Liver 1.7~0.9 22.6~6.4" 17.4~3.1" 1.1~0.6 6.2d.4*r Values are means ~ SEM; "p<0.05vs ControlVehicle;q)p<0.05vs ControlGlutarnine
M1937 Influence of Common Channel Length on Weight Loss After Duodenal Switch Operation for Morbid Obesity Reginald V. Lord, Gary J. Anthone, Peter F. Crookes, Nahid Hamoui, Liya Abramyan, Giuseppe Purtale, Gideon Almogy, Mikhad Chilingaryan, I.elan F. Sillin, Robert Harrison Introduction: The duodenal switch for morbid obesity involves a 75 percent greater curvature subtotal gastrectomy and long limb Roux-en-Y duodeno-ileostomy with the dual purpose of restricting caloric intake and diverting bile to induce fat malahsorption. Fat absorption mostly occurs in the common channel where bde mixes with the alimentary stream. This study was undertaken to investigate the significance of common channel length and other small bowel lengths on postoperative weight loss and features of absorption Methods: Review of prospectively collected data from all patients who underwent duodenal switch as the primary operation for the treatment of morbid obesity during the 10 year period beginning September 1992 at a single institution. Small bowel lengths were measured intraoperatively with the bowel relaxed and not stretched. Weight loss was measured as percent excess body weight loss (percent EBWL). Results: Primary duodenal switch operation was performed in 702 patients. The median preoperative BMI was 56 (range 36-100). Percent EBWL was significantly greater during the first postoperative year in patients with a common channel length less than 100cm (55 percent of patients) compared to patients with a common channel 100cm or longer (45 percent of patients), but there was no significant difference after 12 months. Neither the biliopancrcatic nor the alimentary limb length was significantly associated with percent EBWL Total length of the small bowel was not significantly associated with any preoperative measure of obesity nor with percent EBWL. Bowel frequency (bowel movements per day) was significantly higher in patients with a common channel length less than 100cm during the first 6 postoperative months, but there was no significant association between common channel length and bowel frequency after 6 months. Patient perception of dietary volume was not significantly influenced by any small bowel length. Conclusions: Long term weight loss is not significantly different in patients with a longer (at least 100 cm) common channel compared to patients with a shorter common channel. In another study we have shown that vitamin D and calcium levels are significantly higher in patients with a 100 cm common channel compared to those with 50 cm or 75 cm lengths. We now routinely construct the common channel at least 100 cm in length.
Comlmtson of Stud BowelAdenocerdnoma =age of ca,cer 1 2 3 4 Sundv-I Total Dtseau-free 5.]feat
CD (18)
Controls (54)
22.2% (4) 27.8% (5) 22.2% (4) 27.8% (5)
0% (0) 18.5% (10) 5O%(27) 29.6% (16)
4.3 years 2 years 49.2% (95% CI, 29.5-82.3)
2.3 years 0,8 years 29.1% (95% CI, 18.9-44.9)
M1935 Robotic Assisted Biliary Pancreatic Diversion With Duodenal Switch Ranjan Sudan, Debra Sudan Background: Minimally invasive (MI) surgical techniques decrease length of hospitalization and morbidity for general surgery procedures. Application of MI techniques to obesity surgery had previously been limited to stapled techniques and primarily for the Roux en Y gastric bypass. We present here the first series of totally intracorporeal robotic assisted biliary pancreatic diversion with duodenal switch (BPD/DS) using 5 ports for peritoneal access. Methods: Sixteen patients underwent DaVinci assisted BPD/DS between November 2000 and January 2002. The mean preoperative body mass index was 44.4 -+ 3.3 with mean excess body weight 52.9 _+ 9.5kg. The mean age of patients in this study was 37.8 -+ 8.6 years. Surgical patients had a minimum of 5 co-morbid conditions present. Results: Thirteen of the 16 BPD/DS procedures were completed intracorporeafly with a mean operative time of 9.7 hours (range 6.3-13.3 hours). Mean length of initial hospitalization was 5.9 -+ 1.6 days. Median loss of excess body weight is 88.3% (range 67-120%) with a mean follow-up of 1.37 -+ 0.4 years. Eighty-five percent of co-morbid conditions have completely resolved postoperatively. Three patients had minor surgical complications. No patient required reoperation or re-hospitalization. At one year follow-up all patients had normal hemoglobin, femtin, vitamin 812, folate, cholesterol and triglyceride levels. Three patients had mildly decreased vitamin A and D levels. Liver function tests are completely normal in all patients. Mean albumin level is 4.1 _+ 0.4g/dL Conclusions: Minimally invasive surgery can be applied to complex abdominal surgeries including biliary pancreatic diversion. The DaVinci surgical robot allows for hand sewn bowel anastomoses in a manner similar to the open technique. The BPD/DS procedure provides for acceptable weight loss, resolution of comorbidities and minimal nutritional deficiencies. With increased experience operative times have decreased to 1.5 times a normal open procedure.
M1938 Salvage Reoperations for Complications Threatening the Viability of Ileal PouchAnal Anastomosis (IFAA) Nidal Dehni, Roger Dozois, Genevieve Remacle, Emmanuel Tiret, Rolland Parc BACKGROUND:IPAAis successful in over 90% of patients but 10% may fail essentially due to sepsis, technical errors or a Crohn s disease. Salvage ileal pouches operations that might otherwise have been excised or diverted due to poor pouch function may be performed either through a transanal approach (TAA) or through a combined abdomino-perineal approach (CAPA). Our aim was to assess the results of these complex revisional operations. PATIENTSAND METHODS: between 11/1992 and 2/2002, 64 patients (76% referred, CUC = 40; FAP = 23; Hirschpmng s disease = 1) underwent revisional surgery for pouch failure. Mean number of previous reoperation was (SD) = 2,3 (1,2). Mean age : 36 (14) years. Six patients had initially straight IPAAand 28 had stapled IPAAwithout mucosectomy. Indication for salvage surgery was ; sepsis : 47/64, mechanical dysfunction : 10/64, complications on residual glandular cuff : 3/64, intraoperative difficulties : 4/64. The pouch was diverted in 33/64 patients. The TAA was performed for limited lesions to the perianastomotic area with good pouch capacity and consisted of pouch advancement. The CAPA was a combined approach for mobilizing the pouch, IPAAdisconnection; pouch repair or construction of a new pouch and a new 1PAAwas then performed. The CAPA was employed when TAA was unfeasible because of extended lesions or small pouches. RESULTS Forty-five patients underwent a CAPA and 19 a TAA. Mean foUow-up was 30 months. In the CAPA group, the initial pouch was retained and repaired in twenty patients with six pouch enlargement. A new pouch was constructed in 25 patients. Postoperative mortality was nil. At long term, one patient in TAA and two in the CAPA had pouch excision for establishment of Crohn s disease. Two patients in CAPA had poor continence; one had a graciloplasty and the other pouch diversion. At last follow-up 60/64 patients had functional pouches. CONCLUSION : Salvage reoperations can be performed either transanaly or through a
M1936 Enteral L-Glutamine Induced Heat Shock Protein 72kDa (HSP-72) in Diabetic Rats in vivo
Christopher Swiecki, Sunny Kim Whiteman, Harry Dawson, Aiping Zhao, Terez SheaDonohue Background: HSP-72 is a highly conserved mechanism of cellular protection. We showed that HSP-72 can protect against the oxidative stress of intestinal ischemia/reperfusion (IR) (Stojadinovic et al, 1995) and that diabetic rats exhibit an increased sensitivity to intestinal mesenteric IR (Lawson et aL 2001). Gfutamine, a conditionally essential amino acid, has beneficial effects on the intestinal tract, is the preferred fuel for enterocy'~es and is a nonthermal, non-toxic inducer of HSP-72 in vitro and in vivo when given intravenously (Wischmeyer et al, 2001). Aim: To determine the ability of enteral glutamine to induce HSP-72 in the intestine and liver of control and diabetic rats in vivo. Methods: Male Sprague-Dawley
A-815
SSAT Abstracts
combined abdominoperineal approach depending on the problem at hand and technical feasibility'. Careful selection of patients should provide them an acceptable bowel function.
M1941
Evaluation of Charlson-Age Comorbidity Index as Predictor of Morbidity and Mortality in Patients with Colorectal Carcinoma James R. Ouellette, David Small, Paula Termuhlen
Long.term functional results lifter pouch salvage Pararm~an Bowal movementWday Bowel movemente/nlght Nocturnal soiling Uq~ency Protentlve pad Medication to alow (ranslt Frequent incontinence Satizfaction : high/excellent *= $.O.
CAPA~n,,40 6.8 (3.8)* 1,3 (1,3)* 16/40 10/40 27/40 33/40 4/40 27/40
TAAr n=t6 5.6 (1.8)* 1 (1)* 9/16 6/16 11/18 11/18 4/18 13/18
Purpose: Determination of surgical risk in cancer patients is difficult and imprecise. Risk assessment involves the evaluation of performance status, comorbid conditions, cancer stage, and the operation planned. The Charlson-Age Comorbidity Index (CACI), assessing 20 premorbid conditions, is a validated tool used to predict patient outcomes. We evaluated the CACI to predict morbidity and mortality in colorectal carcinoma patients. Methods: Records of 279 consecutive colorectal cancer patients initially operated between 1997 and 2001 were reviewed. Data collected included patient demographics, cancer stage, perioperative complications, tumor characteristics, comorhid diseases, performance status, length of stay (LOS), disposition, and mortality. The CACI was determined from the preoperative history and physical. Perioperative morbidity was graded for severity. Results: Ninety-seven percent of patients were Caucasion with a male to female ratio of 1:1.2. Median age was 72 years (range 22-95). Initial AJCC Stage: Stage 0 (3.2%) Stage I (28.3%) Stage II (24.4%), Stage III (24.4%), and Stage IV (19.7%). Median length of stay was 7.0 days (range 1-56). Perioperative mortality was 17/279 (6.1%). Overall mortality was 31.9% at a median followup of 19.7 months (range 1-65 months). Both CACI scores and AJCC Stage correlated to LOS and overall mortality. Only the CAC[ correlated with severity of complication (including perioperative mortality) and disposition. Discussion: Patients with higher CACI scores determined by cumulative number of weighted comorbid conditions are at higher risk for perioperalive morbidity and overall mortality. This simple scoring system is also a signtlicant predictor of disposition (home vs. extended care facility) and length of stay. The CACI can be a useful tool to preoperatively assess and counsel patients undergoing surgery for colorectal carcinoma.
M1939 Management Of Retained Rectal Foreign Bodies: Predictors Of Operative Extraction jeffrey P. Lake, Rahila Essani, Andreas Kaiser, Robert W. Beart Jr. PURPOSE: The aim of our study is to review a single facility's experience wath retained colorectal foreign bodies. We hypothesized that we could predict the need for operative intervention based on the size and location of the retained rectal foreign body. METHODS: Admission records at Los Angeles County + University of Southern California General Hospital from October, 1993 through October, 2002 were reviewed SLxty-three cases of rectally introduced retained foreign bodies (FB) were selected for review. Data collected included patient demographics, FB extraction method, location of FB, type of FB retrieved, and post-extraction course and surveillance. RESULTS: Of the 63 cases reviewed, bedside extraction was attempted in 57 patients, and was successful in 46 (80.7%). Ultimately, 14 patients were taken to the operating room for extraction of their retained rectal FB. Of these patients, 5 were treated with an exploratory laparotomy while the remaining 9 underwent examination under anesthesia (EUA). Of the patients undergoing an exploratory" laparotomy, 1 initially underwent an attempted extraction with an EUA. In the five patients who underwent exploratory laparotomy, three required colotomies for retrieval of the FB. One patient presented v,ath peritonitis and required bowel resection, colostomy formation, and primary repair of the injured bowel. The remaining patient required a laparotomy to assist m transanal removal of the foreign body. A majority of the FB were located in the rectum (91.4%). Nevertheless, the FB was located in the stgmoid colon in 21.4% of the operative cases, and in 4.5% of cases successfully treated at the bedside (p=0.085). tn our review, 43.5% of the patients underwent sigmoidoscopy following extraction of their FB. Of these patients, 593% had mucosal abrasions, 11.1% had mucosal lacerations, and 25.9% had no injury" No post operative complications were found in any of the patients in our review. CONCLUSIONS: This is the largest single institution series of retained rectal foreign bodies. Though foreign bodies located in the sigmoid colon require operative extraction more frequently, we were unable to predict the need for operative intervention based on the size or location of the foreign body.
Table CACl AJCC Stql
Severity of Complication p <0,004 NS
LO6 p <0.001 p <0.005
Dlzlmltlon p <0.031 NS
OverallMortal~ p< 0.013 p <0.010
M1942
Significant Inhibiting Effect of The Intraperitoneal (i.p.) Versus Intravenous (i.v.) Application of Taxol on Tumor Growth in Experimentally induced Peritoneal Carcinomatosis Amdt Hribaschek, Matthias Pross, Karsten Ridwelski, Frank Meyer, Waiter Halangk, Harts Lippert Peritoneal carcinomatosis in colorectal carcinoma[Ca] is still an unsolved problem in oncological treatment since there is no established treatment protocol available. The ,aim of the study was to investigate whether i] Taxol & ill mode of drug application may ~enerate an impact on tumor growth. Methods: l.p. tumor[Tu] growth was induced by transfer of Tu cells [5x1.000.000] of a colon Ca cell line [CC-531] into abdominal cavity of WAG rats ]weight, 250-260g]. The rats were diwded into 3 groups[gr.] [n = 6 per gr.]. Taxol [170mg/ qm] was administered either via i.p. or i.v. route. Gr. 1: No chemotherapy[Tx]; gr.2: ChemoTx on day[dl 5,10&15; gr.3: ChemoTx on diS,20&25 to mimic early [gr.2] & late [gr.3] postinterventional chemoTx in the postoperative course. Late i.p. administration of antineoplastic substances was achieved using a port-a-cath, which was implanted into the abdominal wall immediately after Tu cell transfer. On the 30th d after Tu cell transfer, rats were sacrificed & subsequently Tu weight of greater omentum & the mesenteric site, No. of metastases, volume of ascites, & Tn-specific characteristics ]using histologic investigation] were determined. Results: Table [see below]. Using early i.p. administration of Taxo[, a significant reduction of Tu-associated parameters such as No. of nodal Tu lesions at the peritoneum, hepatic & pulmonary metastases as well as volume of ascites was achieved. Summary: Taxol generated a significantly inhibitory effect on peritoneal Tu growth. Direct i.p. administration of Taxol induced a distinct inhibition of peritoneal carcinomatosis compared with i.v. mode of chemotherapeutic drug application, l.p. administration of Taxol is more effective using the early postoperative regimen. Conclusion: Taxol appears to be a potential chemotherapeutic drug providing a significant effect in the therapeutic management of peritoneal carcinomatosis under experimental conditions. The effect might be optimized by combining Taxol with other antineoplastic drugs after previous determination of the maximal tolerable dose, the profile of side effects, & its effect on the healing of wounds & anastomoses.
M1940 Biofeedback Therapy After Sphincteroplasty - Sphincter Pressures, Incontinence Score and Quality of Life Tobias Meile, iVlartin E Kreis, Eckehard C. Jehle, Tilman T. Zt~tel Background: Biofeedback therapy is an established treatment for anal incontinence. However, there is only one publication on biofeedback after sphincteroplasty, reporting on relatively young females (mean age 34 y). Specific Aims: To evaluate the effects of biofeedback after spfuncteroplasty iu older patients. Methods: 20 consecutive patients (18 females, 2 males, mean age 55 -+ 3, range 33-73 y) vath incontinence fnr stool and a sphincter defect proven by endosonography uuderwent overlapping sphincteroplasty and temporary colostomy between 2000 and 2002 Starting 4 weeks after spfuncteroplasty, patients received biofeedback therapy for 3-6 months+ using a datalogger that records each training session of the patient (maximum squeeze EMG signal, tzV). Anorectal manometry, an incontinence score (Rock'wood) and a quality of life score (personal global well-being score, PGWI3) were evafuated preop, 4 weeks postop and 3 months after co[ostomy closure. Results: Colostomy closure (CC) was performed 265 _+ 32 (89 - 510) days after sphincteroplasty. One patient did not want CC and could not be reevafuated for anal incontinence. The maximum EMG signal recorded during biofeedback increased by 5 2 2 8 % at 3 and by 94+8% increase at 6 months after CC (p<0.001 vs start of biofeedback for each timepoint). The incontinence score improved from 45 +_ 5 (21 - 6[) preop to 14 -+4 (0 - 27) at 3 months after CC (p<0.001). Minimum squeeze pressure (MSP) significantly increased during biofeedback, but not compared to preoperatively Lpreop 26-+6 mmHg, 4 weeks 19+-_3 mmHg, 3 months after CC 2 4 ~ 5 mmHg, p<0.0]). Minimum resting pressure (MRP) decreased postoperatively and did not increase during biofeedback (preop 55-+ 7 mmHg, 4 weeks 38-+ 6 mmHg, 3 months after CC 35 _+6 mmHg). No correlations between biofeedback EMG signal and trainmg intensity or the incomtnence score were found. Despite improved continence, the PGWB score did not improve after sphincterplasty (preop 73 -+ 4 (57 - 82), 4 weeks 49 +- 7 (30 - 59), 3 months after CC 66 -+ 6 (41 - 91)). Conclusion: Spbmcteroplasty with postoperative biofeedback therapy resulted in an increased EMG signal and an improved incontinence score. However, anorecta[ manometry and a quality of life score did not improve postoperatively, and there was no correlation between EMG signal and incontinence score or training intensity, indicating that these measures are unsuitable to predict functional outcome after sphincteroplasty
Tu v~ght dependingon locationof the lenlon & modeof chemoTx
xuWEmmb] Greateromentum Gr.1 4.58:0.55 Gr.2 i.p. 0.94~0.68 * Gr.2 Lv. 3,05 +0,47 Gr.3 i.p. 3.92 ~0.22 Gr.3 i.e. 4.01,0.17 *, P.~O.05It test; SPSSfor Windows]
Mesentericsite 5.26~0.62 2,57~0.16 * 3.76-~0.25 4,68~0.24 4,98,0,37
M1943 Total Proctocolectomy and Ileal Pouch-Anal .mam.~emusis for Ulcerative Colitis Following Orthotopic Liver Transplantt'mn Clifford S. Cho, Merril T. D a y t o n . . ~ i ~ l g l ~ l ~ s o n , Waiter A. Kohun, James R. Starling, Bruce A. Harms 1NTRODUCTIO~ I l l I'~h ssoclation between primary sclerosmg cholangitis (PSC) and ulcerative colitilm~E ~ten mandates their contemporaneous management. Orthotopic liver
SSAT
Abstracts
A-816
rats received either vehicle (control) or streptozotocin (65 gm/kg) to induce diabetes. After 8 weeks, rats from each group were subjected to heat stress by placing them in a closed, heated, humidified and ventilated chamber until their core body temperature reached 41.5~ for 6 minutes followed by passive cooling for 4 hours. Additional rats from each group received either enteral vehicle or glutamine (3 gm/kg) administered by a carmula placed in the pylorns and advanced into the duodenum. Rats were allowed to recover for 6 hours. In all groups, sections of mid-small intestine and hver were taken and analyzed for HSP72 protein levels using Western Blot Analysis and normahzed to 13-actin. Results: Basal expression of HSP-72 was low in both control and diabetic rats. Heat stress increased HSP72 levels in both the liver and the intestine in controls while diabetic rats did not survive the procedure. In contrast, glutamine significantly increased in HSP-72 levels in both controls and diabetics; however, the levels were less than those achieved in response to heat stress. In addition, the increase in liver HSP-72 in diabetics was significantly less than in controls. Conclusion: Enteral glutamine induces HSP-72 in the liver and intestine of eontro[ and diabetic rats. The demonstrated ability of HSP-72 expression to protect against subsequent insults and the susceptibility of diabetic patients to clinical stressors suggests that enteral glutamine may be a beneficial adjuvant in these patients.
Small Bowel Adenocarcinoma in Celiac Disease: Features and Outcomes D. D. Potter Jr., Joseph A. Murray, David M. Nagorneyl Jonathan A. Van Heerden, Matthew F. Plevak, Alan R. Zinsmeister, Lawrence J. Burgart, John H. Donohue Purpose: Celiac Disease (CD) is an inflammatory condition of the small bowel caused by dietary gluten and associated with adenocarcinoma of the small bowel (SBC). The aims of this study were 1) to identify characteristics of CD patients with SBC, 2) determine longterm outcomes for SBC in CD and 3) compare these results to SBC in patients without CD. Methods: All CD patients with SBC were retrospectively reviewed and 3 age- and gendermatched SBC control patients identified for each CD patient. Results: Between July, 1960 and August, 2002, 18 patients with SBC and CD were treated. The mean age (_+ SD) of CD diagnosis was 52.7 (-+ 19.7) years and for SBC 59.9 (-+ 13.5) years. Operative (n=4) or postoperative (n=4) diagnosis of CD occurred in 44% of patients. Men comprised 56% of each cohort. The tumor did not involve the serosa in 4 cases in the CD group compared to 1 case in the controls. Lymph nodes were involved in 50% (n = 9) in the CD group and 59.3% (32) of the control group. A palhative operation was performed in 17% of CD and 33% of controls. Table 1 summarizes relevant cancer data. SBC in CD patients was more commonly diagnosed at an earlier stage (stage 1 and 2) than controls (p<0.05). Diseasefree and 5-year survivals were not significantly different for patients with CD compared to controls that were age- and gender-matched. Stage of SBC correlated with survival in control patients (p
HSP-72/B. Control ControlHeat ControlGluDiabetic DiabeticGlu. actin Vehlde Stnm tamine Vehlde tandM InfuSe 1.6,0.6 31.0~7.3" 10.5,1.3" 1.0,1.0 15.5-'4.8" Liver 1.7~0.9 22.6~6.4" 17.4~3.1" 1.1~0.6 6.2d.4*r Values are means ~ SEM; "p<0.05vs ControlVehicle;q)p<0.05vs ControlGlutarnine
M1937 Influence of Common Channel Length on Weight Loss After Duodenal Switch Operation for Morbid Obesity Reginald V. Lord, Gary J. Anthone, Peter F. Crookes, Nahid Hamoui, Liya Abramyan, Giuseppe Purtale, Gideon Almogy, Mikhad Chilingaryan, I.elan F. Sillin, Robert Harrison Introduction: The duodenal switch for morbid obesity involves a 75 percent greater curvature subtotal gastrectomy and long limb Roux-en-Y duodeno-ileostomy with the dual purpose of restricting caloric intake and diverting bile to induce fat malahsorption. Fat absorption mostly occurs in the common channel where bde mixes with the alimentary stream. This study was undertaken to investigate the significance of common channel length and other small bowel lengths on postoperative weight loss and features of absorption Methods: Review of prospectively collected data from all patients who underwent duodenal switch as the primary operation for the treatment of morbid obesity during the 10 year period beginning September 1992 at a single institution. Small bowel lengths were measured intraoperatively with the bowel relaxed and not stretched. Weight loss was measured as percent excess body weight loss (percent EBWL). Results: Primary duodenal switch operation was performed in 702 patients. The median preoperative BMI was 56 (range 36-100). Percent EBWL was significantly greater during the first postoperative year in patients with a common channel length less than 100cm (55 percent of patients) compared to patients with a common channel 100cm or longer (45 percent of patients), but there was no significant difference after 12 months. Neither the biliopancrcatic nor the alimentary limb length was significantly associated with percent EBWL Total length of the small bowel was not significantly associated with any preoperative measure of obesity nor with percent EBWL. Bowel frequency (bowel movements per day) was significantly higher in patients with a common channel length less than 100cm during the first 6 postoperative months, but there was no significant association between common channel length and bowel frequency after 6 months. Patient perception of dietary volume was not significantly influenced by any small bowel length. Conclusions: Long term weight loss is not significantly different in patients with a longer (at least 100 cm) common channel compared to patients with a shorter common channel. In another study we have shown that vitamin D and calcium levels are significantly higher in patients with a 100 cm common channel compared to those with 50 cm or 75 cm lengths. We now routinely construct the common channel at least 100 cm in length.
Comlmtson of Stud BowelAdenocerdnoma =age of ca,cer 1 2 3 4 Sundv-I Total Dtseau-free 5.]feat
CD (18)
Controls (54)
22.2% (4) 27.8% (5) 22.2% (4) 27.8% (5)
0% (0) 18.5% (10) 5O%(27) 29.6% (16)
4.3 years 2 years 49.2% (95% CI, 29.5-82.3)
2.3 years 0,8 years 29.1% (95% CI, 18.9-44.9)
M1935 Robotic Assisted Biliary Pancreatic Diversion With Duodenal Switch Ranjan Sudan, Debra Sudan Background: Minimally invasive (MI) surgical techniques decrease length of hospitalization and morbidity for general surgery procedures. Application of MI techniques to obesity surgery had previously been limited to stapled techniques and primarily for the Roux en Y gastric bypass. We present here the first series of totally intracorporeal robotic assisted biliary pancreatic diversion with duodenal switch (BPD/DS) using 5 ports for peritoneal access. Methods: Sixteen patients underwent DaVinci assisted BPD/DS between November 2000 and January 2002. The mean preoperative body mass index was 44.4 -+ 3.3 with mean excess body weight 52.9 _+ 9.5kg. The mean age of patients in this study was 37.8 -+ 8.6 years. Surgical patients had a minimum of 5 co-morbid conditions present. Results: Thirteen of the 16 BPD/DS procedures were completed intracorporeafly with a mean operative time of 9.7 hours (range 6.3-13.3 hours). Mean length of initial hospitalization was 5.9 -+ 1.6 days. Median loss of excess body weight is 88.3% (range 67-120%) with a mean follow-up of 1.37 -+ 0.4 years. Eighty-five percent of co-morbid conditions have completely resolved postoperatively. Three patients had minor surgical complications. No patient required reoperation or re-hospitalization. At one year follow-up all patients had normal hemoglobin, femtin, vitamin 812, folate, cholesterol and triglyceride levels. Three patients had mildly decreased vitamin A and D levels. Liver function tests are completely normal in all patients. Mean albumin level is 4.1 _+ 0.4g/dL Conclusions: Minimally invasive surgery can be applied to complex abdominal surgeries including biliary pancreatic diversion. The DaVinci surgical robot allows for hand sewn bowel anastomoses in a manner similar to the open technique. The BPD/DS procedure provides for acceptable weight loss, resolution of comorbidities and minimal nutritional deficiencies. With increased experience operative times have decreased to 1.5 times a normal open procedure.
M1938 Salvage Reoperations for Complications Threatening the Viability of Ileal PouchAnal Anastomosis (IFAA) Nidal Dehni, Roger Dozois, Genevieve Remacle, Emmanuel Tiret, Rolland Parc BACKGROUND:IPAAis successful in over 90% of patients but 10% may fail essentially due to sepsis, technical errors or a Crohn s disease. Salvage ileal pouches operations that might otherwise have been excised or diverted due to poor pouch function may be performed either through a transanal approach (TAA) or through a combined abdomino-perineal approach (CAPA). Our aim was to assess the results of these complex revisional operations. PATIENTSAND METHODS: between 11/1992 and 2/2002, 64 patients (76% referred, CUC = 40; FAP = 23; Hirschpmng s disease = 1) underwent revisional surgery for pouch failure. Mean number of previous reoperation was (SD) = 2,3 (1,2). Mean age : 36 (14) years. Six patients had initially straight IPAAand 28 had stapled IPAAwithout mucosectomy. Indication for salvage surgery was ; sepsis : 47/64, mechanical dysfunction : 10/64, complications on residual glandular cuff : 3/64, intraoperative difficulties : 4/64. The pouch was diverted in 33/64 patients. The TAA was performed for limited lesions to the perianastomotic area with good pouch capacity and consisted of pouch advancement. The CAPA was a combined approach for mobilizing the pouch, IPAAdisconnection; pouch repair or construction of a new pouch and a new 1PAAwas then performed. The CAPA was employed when TAA was unfeasible because of extended lesions or small pouches. RESULTS Forty-five patients underwent a CAPA and 19 a TAA. Mean foUow-up was 30 months. In the CAPA group, the initial pouch was retained and repaired in twenty patients with six pouch enlargement. A new pouch was constructed in 25 patients. Postoperative mortality was nil. At long term, one patient in TAA and two in the CAPA had pouch excision for establishment of Crohn s disease. Two patients in CAPA had poor continence; one had a graciloplasty and the other pouch diversion. At last follow-up 60/64 patients had functional pouches. CONCLUSION : Salvage reoperations can be performed either transanaly or through a
M1936 Enteral L-Glutamine Induced Heat Shock Protein 72kDa (HSP-72) in Diabetic Rats in vivo
Christopher Swiecki, Sunny Kim Whiteman, Harry Dawson, Aiping Zhao, Terez SheaDonohue Background: HSP-72 is a highly conserved mechanism of cellular protection. We showed that HSP-72 can protect against the oxidative stress of intestinal ischemia/reperfusion (IR) (Stojadinovic et al, 1995) and that diabetic rats exhibit an increased sensitivity to intestinal mesenteric IR (Lawson et aL 2001). Gfutamine, a conditionally essential amino acid, has beneficial effects on the intestinal tract, is the preferred fuel for enterocy'~es and is a nonthermal, non-toxic inducer of HSP-72 in vitro and in vivo when given intravenously (Wischmeyer et al, 2001). Aim: To determine the ability of enteral glutamine to induce HSP-72 in the intestine and liver of control and diabetic rats in vivo. Methods: Male Sprague-Dawley
A-815
SSAT Abstracts
combined abdominoperineal approach depending on the problem at hand and technical feasibility'. Careful selection of patients should provide them an acceptable bowel function.
M1941
Evaluation of Charlson-Age Comorbidity Index as Predictor of Morbidity and Mortality in Patients with Colorectal Carcinoma James R. Ouellette, David Small, Paula Termuhlen
Long.term functional results lifter pouch salvage Pararm~an Bowal movementWday Bowel movemente/nlght Nocturnal soiling Uq~ency Protentlve pad Medication to alow (ranslt Frequent incontinence Satizfaction : high/excellent *= $.O.
CAPA~n,,40 6.8 (3.8)* 1,3 (1,3)* 16/40 10/40 27/40 33/40 4/40 27/40
TAAr n=t6 5.6 (1.8)* 1 (1)* 9/16 6/16 11/18 11/18 4/18 13/18
Purpose: Determination of surgical risk in cancer patients is difficult and imprecise. Risk assessment involves the evaluation of performance status, comorbid conditions, cancer stage, and the operation planned. The Charlson-Age Comorbidity Index (CACI), assessing 20 premorbid conditions, is a validated tool used to predict patient outcomes. We evaluated the CACI to predict morbidity and mortality in colorectal carcinoma patients. Methods: Records of 279 consecutive colorectal cancer patients initially operated between 1997 and 2001 were reviewed. Data collected included patient demographics, cancer stage, perioperative complications, tumor characteristics, comorhid diseases, performance status, length of stay (LOS), disposition, and mortality. The CACI was determined from the preoperative history and physical. Perioperative morbidity was graded for severity. Results: Ninety-seven percent of patients were Caucasion with a male to female ratio of 1:1.2. Median age was 72 years (range 22-95). Initial AJCC Stage: Stage 0 (3.2%) Stage I (28.3%) Stage II (24.4%), Stage III (24.4%), and Stage IV (19.7%). Median length of stay was 7.0 days (range 1-56). Perioperative mortality was 17/279 (6.1%). Overall mortality was 31.9% at a median followup of 19.7 months (range 1-65 months). Both CACI scores and AJCC Stage correlated to LOS and overall mortality. Only the CAC[ correlated with severity of complication (including perioperative mortality) and disposition. Discussion: Patients with higher CACI scores determined by cumulative number of weighted comorbid conditions are at higher risk for perioperalive morbidity and overall mortality. This simple scoring system is also a signtlicant predictor of disposition (home vs. extended care facility) and length of stay. The CACI can be a useful tool to preoperatively assess and counsel patients undergoing surgery for colorectal carcinoma.
M1939 Management Of Retained Rectal Foreign Bodies: Predictors Of Operative Extraction jeffrey P. Lake, Rahila Essani, Andreas Kaiser, Robert W. Beart Jr. PURPOSE: The aim of our study is to review a single facility's experience wath retained colorectal foreign bodies. We hypothesized that we could predict the need for operative intervention based on the size and location of the retained rectal foreign body. METHODS: Admission records at Los Angeles County + University of Southern California General Hospital from October, 1993 through October, 2002 were reviewed SLxty-three cases of rectally introduced retained foreign bodies (FB) were selected for review. Data collected included patient demographics, FB extraction method, location of FB, type of FB retrieved, and post-extraction course and surveillance. RESULTS: Of the 63 cases reviewed, bedside extraction was attempted in 57 patients, and was successful in 46 (80.7%). Ultimately, 14 patients were taken to the operating room for extraction of their retained rectal FB. Of these patients, 5 were treated with an exploratory laparotomy while the remaining 9 underwent examination under anesthesia (EUA). Of the patients undergoing an exploratory" laparotomy, 1 initially underwent an attempted extraction with an EUA. In the five patients who underwent exploratory laparotomy, three required colotomies for retrieval of the FB. One patient presented v,ath peritonitis and required bowel resection, colostomy formation, and primary repair of the injured bowel. The remaining patient required a laparotomy to assist m transanal removal of the foreign body. A majority of the FB were located in the rectum (91.4%). Nevertheless, the FB was located in the stgmoid colon in 21.4% of the operative cases, and in 4.5% of cases successfully treated at the bedside (p=0.085). tn our review, 43.5% of the patients underwent sigmoidoscopy following extraction of their FB. Of these patients, 593% had mucosal abrasions, 11.1% had mucosal lacerations, and 25.9% had no injury" No post operative complications were found in any of the patients in our review. CONCLUSIONS: This is the largest single institution series of retained rectal foreign bodies. Though foreign bodies located in the sigmoid colon require operative extraction more frequently, we were unable to predict the need for operative intervention based on the size or location of the foreign body.
Table CACl AJCC Stql
Severity of Complication p <0,004 NS
LO6 p <0.001 p <0.005
Dlzlmltlon p <0.031 NS
OverallMortal~ p< 0.013 p <0.010
M1942
Significant Inhibiting Effect of The Intraperitoneal (i.p.) Versus Intravenous (i.v.) Application of Taxol on Tumor Growth in Experimentally induced Peritoneal Carcinomatosis Amdt Hribaschek, Matthias Pross, Karsten Ridwelski, Frank Meyer, Waiter Halangk, Harts Lippert Peritoneal carcinomatosis in colorectal carcinoma[Ca] is still an unsolved problem in oncological treatment since there is no established treatment protocol available. The ,aim of the study was to investigate whether i] Taxol & ill mode of drug application may ~enerate an impact on tumor growth. Methods: l.p. tumor[Tu] growth was induced by transfer of Tu cells [5x1.000.000] of a colon Ca cell line [CC-531] into abdominal cavity of WAG rats ]weight, 250-260g]. The rats were diwded into 3 groups[gr.] [n = 6 per gr.]. Taxol [170mg/ qm] was administered either via i.p. or i.v. route. Gr. 1: No chemotherapy[Tx]; gr.2: ChemoTx on day[dl 5,10&15; gr.3: ChemoTx on diS,20&25 to mimic early [gr.2] & late [gr.3] postinterventional chemoTx in the postoperative course. Late i.p. administration of antineoplastic substances was achieved using a port-a-cath, which was implanted into the abdominal wall immediately after Tu cell transfer. On the 30th d after Tu cell transfer, rats were sacrificed & subsequently Tu weight of greater omentum & the mesenteric site, No. of metastases, volume of ascites, & Tn-specific characteristics ]using histologic investigation] were determined. Results: Table [see below]. Using early i.p. administration of Taxo[, a significant reduction of Tu-associated parameters such as No. of nodal Tu lesions at the peritoneum, hepatic & pulmonary metastases as well as volume of ascites was achieved. Summary: Taxol generated a significantly inhibitory effect on peritoneal Tu growth. Direct i.p. administration of Taxol induced a distinct inhibition of peritoneal carcinomatosis compared with i.v. mode of chemotherapeutic drug application, l.p. administration of Taxol is more effective using the early postoperative regimen. Conclusion: Taxol appears to be a potential chemotherapeutic drug providing a significant effect in the therapeutic management of peritoneal carcinomatosis under experimental conditions. The effect might be optimized by combining Taxol with other antineoplastic drugs after previous determination of the maximal tolerable dose, the profile of side effects, & its effect on the healing of wounds & anastomoses.
M1940 Biofeedback Therapy After Sphincteroplasty - Sphincter Pressures, Incontinence Score and Quality of Life Tobias Meile, iVlartin E Kreis, Eckehard C. Jehle, Tilman T. Zt~tel Background: Biofeedback therapy is an established treatment for anal incontinence. However, there is only one publication on biofeedback after sphincteroplasty, reporting on relatively young females (mean age 34 y). Specific Aims: To evaluate the effects of biofeedback after spfuncteroplasty iu older patients. Methods: 20 consecutive patients (18 females, 2 males, mean age 55 -+ 3, range 33-73 y) vath incontinence fnr stool and a sphincter defect proven by endosonography uuderwent overlapping sphincteroplasty and temporary colostomy between 2000 and 2002 Starting 4 weeks after spfuncteroplasty, patients received biofeedback therapy for 3-6 months+ using a datalogger that records each training session of the patient (maximum squeeze EMG signal, tzV). Anorectal manometry, an incontinence score (Rock'wood) and a quality of life score (personal global well-being score, PGWI3) were evafuated preop, 4 weeks postop and 3 months after co[ostomy closure. Results: Colostomy closure (CC) was performed 265 _+ 32 (89 - 510) days after sphincteroplasty. One patient did not want CC and could not be reevafuated for anal incontinence. The maximum EMG signal recorded during biofeedback increased by 5 2 2 8 % at 3 and by 94+8% increase at 6 months after CC (p<0.001 vs start of biofeedback for each timepoint). The incontinence score improved from 45 +_ 5 (21 - 6[) preop to 14 -+4 (0 - 27) at 3 months after CC (p<0.001). Minimum squeeze pressure (MSP) significantly increased during biofeedback, but not compared to preoperatively Lpreop 26-+6 mmHg, 4 weeks 19+-_3 mmHg, 3 months after CC 2 4 ~ 5 mmHg, p<0.0]). Minimum resting pressure (MRP) decreased postoperatively and did not increase during biofeedback (preop 55-+ 7 mmHg, 4 weeks 38-+ 6 mmHg, 3 months after CC 35 _+6 mmHg). No correlations between biofeedback EMG signal and trainmg intensity or the incomtnence score were found. Despite improved continence, the PGWB score did not improve after sphincterplasty (preop 73 -+ 4 (57 - 82), 4 weeks 49 +- 7 (30 - 59), 3 months after CC 66 -+ 6 (41 - 91)). Conclusion: Spbmcteroplasty with postoperative biofeedback therapy resulted in an increased EMG signal and an improved incontinence score. However, anorecta[ manometry and a quality of life score did not improve postoperatively, and there was no correlation between EMG signal and incontinence score or training intensity, indicating that these measures are unsuitable to predict functional outcome after sphincteroplasty
Tu v~ght dependingon locationof the lenlon & modeof chemoTx
xuWEmmb] Greateromentum Gr.1 4.58:0.55 Gr.2 i.p. 0.94~0.68 * Gr.2 Lv. 3,05 +0,47 Gr.3 i.p. 3.92 ~0.22 Gr.3 i.e. 4.01,0.17 *, P.~O.05It test; SPSSfor Windows]
Mesentericsite 5.26~0.62 2,57~0.16 * 3.76-~0.25 4,68~0.24 4,98,0,37
M1943 Total Proctocolectomy and Ileal Pouch-Anal .mam.~emusis for Ulcerative Colitis Following Orthotopic Liver Transplantt'mn Clifford S. Cho, Merril T. D a y t o n . . ~ i ~ l g l ~ l ~ s o n , Waiter A. Kohun, James R. Starling, Bruce A. Harms 1NTRODUCTIO~ I l l I'~h ssoclation between primary sclerosmg cholangitis (PSC) and ulcerative colitilm~E ~ten mandates their contemporaneous management. Orthotopic liver
SSAT
Abstracts
A-816