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Adhesional Small Bowel Obstruction After Open and Laparoscopic Colorectal Surgery: A Prospective Longer-Term Study
records of 200 patients (76 with gangrenous and 124 with acute, non-gangrenous cholecystitis) treated at The Mount Sinai Medical Center from March 2003 to September 2009 were retrospectively reviewed. Specifically, presenting symptoms, physical examination, laboratory values, radiographic findings (ultrasonography and computed tomography), perioperative data and pathological findings were recorded. Univariate analysis was carried out with a two-tailed chi-square test for each of the categorical variables, and a two-sample t-test with the Welch correction for the continuous variables. Multivariate analysis was then performed using a binary logistical linear regression model and the model of best fit was determined. P-values of 0.05 or less were considered to indicate statistical significance. SPSS for Windows (Version 18.0.2, 2010 Chicago: SPSS Inc.) was used for all analysis. Results: On univariate analysis, multiple comorbidities were associated with a significantly increased risk of GC, including age over 50 years (p=0.002), diabetes mellitus (p=0.002), coronary artery disease (CAD) (p<0.001), hypertension (p<0.001), hyperlipidemia (p=0.002) and steroid use (p= 0.008). In addition, gangrenous pathology presented more frequently with fever >38C (p= 0.010), elevated heart rate >100 (p=0.025), WBC >13,000 (p=0.002), and neutrophil shift >75% (p<0.001). Multivariate analysis confirmed that CAD, alcohol use, steroid use, nausea, leukocytosis, neutrophil shift and bilirubin levels displayed the highest predictive capacity for GC. Using a logistical regression model of best fit, we demonstrated that a scoring system utilizing the above factors could diagnose GC with a sensitivity of 81%, specificity of 77%, PPV 70% and NPV of 90%. GC was associated with a significantly higher rate of post-operative complications when compared to acute cholecystitis (OR=1.99, p=0.05). Discussion: GC represents a complex clinical problem which is frequently difficult to diagnose preoperatively and often results in poor clinical outcomes. This study shows that a host of risk factors are correlated with GC and, therefore, may potentially be used for diagnostic purposes. The high sensitivity of our prediction model shows that relatively few clinical variables may be used to objectively stratify patients at risk for GC and, thus, determine which individuals may benefit from prompt surgical intervention.
Meier method was used for cumulative probability of developing SBO. Results: From 01/ 03 to 11/10, 911 patients satisfied our criteria and underwent elective (52.6%) or emergency (47.4%) CRS (68.7% open and 31.3% laparoscopic). Median follow-up was 46.2 months (range 0.2 -115.0). Sixty-three patients (6.9%) experienced 83 SBO episodes and 22 required surgery (2.4%). There was a large variation in the time of first SBO occurrence, 43.9% occurred within 3 months, 29% between 3 and 12 months and 27% after 1 year. The risk of surgery at first admission for SBO 24% and the number of readmissions predicted the need of surgery. The risk of reoperation was greatest during the first year after CRS and steadily rised every year thereafter. SBO was higher after pelvic surgery or extensive resections compared to minor procedures (14% vs 3%; p<0.0001; HR 7.33). Likewise, SBO risk was higher after elective compared to emergency surgery (11.1% vs 6.9%; p=0.03; HR 2.0, but similar after open compared to laparoscopic surgery (9.9% vs 7.3%; p>0.05; HR 0.8). Any previous or additional surgery raised the overall risk of SBO from 5.4% to 16.4%. Incisional hernia development was slightly superior, after open surgery. Conclusions: Colorectal surgery results in significant ongoing risk of SBO according to the colorectal type of procedure. This risk seems to be similar between laparoscopic and open approach, higher after elective surgery and for patients with previous surgery. Number of readmissions for SBO predicts the need of surgery. Mo1590 A Critical Analysis of 28 Patients With Metachronous Peritoneal Dissemination From Colorectal Cancer Ashraf Haddad, Jesus Esquivel Background Peritoneal dissemination occurs approximately in 8 % of patients with colorectal cancer at the time of diagnosis and in about 25 % more at the time of disease recurrence. It has been traditionally seen as a universally lethal condition with no reasonable treatment options as most patients will present in an advanced stage. Methods We reviewed the records of all patients in our colorectal cancer with peritoneal dissemination database from 2005 to 2009. A retrospective analysis of key clinical and histopathological features including their TNM classification at the time of diagnosis of their primary tumor and their Peritoneal Surface Disease Severity Score (PSDSS) at the time of diagnosis of their peritoneal dissemination was carried out. Results Twenty eight patients with metachronous peritoneal dissemination were identified. There were 17 (61%) male patients. Mean age was 54 years. There were 7 patients with stage II (A or B) and 21 patients with stage III (A, B or C). Mean overall time to developing carcinomatosis was 27.8 months amongst all 28 patients. There were 6 patients with stage IIIC. Mean time to developing carcinomatosis was 16.8 months in this group and 5 out of 6 (83%), presented with a PSDSS of 4, making them not candidates for cytoreductive surgery and HIPEC. Conclusion It appears from these data that patients with stage IIIC colorectal cancer develop carcinomatosis at a faster rate and in a more virulent form when compared to other stages. Trials at preventing carcinomatosis in this group of patients are needed.
Mo1588 Can Whole Gut Scintigraphy Optimize Patient Selection and Outcomes in Slow Transit Constipation? Deborah Keller, Murali Pathikonda, Amit Khanna, Henry P. Parkman Introduction: Whole gut transit scintigraphy (WGTS) distinguishes isolated colonic from generalized GI motility disorders. Including WGTS in the pre-operative work-up allows appropriate diagnosis and management, and should be the standard of care for evaluation of colonic inertia. Our primary objective was to evaluate functional outcomes following colectomy for slow transit constipation in a single institution using preoperative scintigraphy. Secondary objectives were to describe predictive factors of outcome after surgery. Methods: After obtaining Institutional Review Board approval, we identified all patients who had surgery for colonic inertia from January 2003 to August 2010 using surgical billing codes and a GI departmental database. All patients who had WGTS prior to surgery were included in the analysis. Demographics, defecation, constipation details, pharmacologic treatment, symptoms, psychiatric medications, operation performed, and outcomes were extracted from a retrospective chart review and follow-up telephone interviews. Results: Fourteen patients had surgery for colonic inertia during the study period. Patients were mainly young females (86%, mean age 44.1 years) with a high coexistence of psychiatric disease (79%). The most common surgical intervention performed was total abdominal colectomy with ileoproctostomy (79%); 3 patients had an end ileostomy. WGTS results were available for 11 of 14 patients; 3 patients had their studies at an outside facility. All surgical patients had delayed 72-hour transit limited to the colon without coexistent gastric or small bowel delay on WGTS. Seven patients were available for follow-up interview at a median interval of 23 months. Post-operatively, 86% had complete resolution of pain and bloating, while 14% had considerable relief. Post-operative stool consistency was semi-solid in all patients. At follow-up patients reported between 2-5 bowel movements daily, while pre-operative frequency averaged one per week. No patients reported fecal incontinence or required antidiarrheal medication after surgery. All patients contacted for follow-up reported that they were overall satisfied with the outcome of their surgery, claimed to feel better than before surgery, and would make the decision to have the procedure again. Conclusion: The diagnosis of colonic inertia mandates careful patient selection and may be improved with WGTS. We believe appropriate patient selection can optimize surgical outcomes. A pre-operative diagnostic regimen of WGTS and anal manometry combined with surgical intervention was associated with high patient satisfaction and improvement in constipation, abdominal pain, and bloating. Total abdominal colectomy with ileoproctostomy provides a satisfactory outcome for patients with colonic inertia, however, this should be offered only after thorough evaluation of whole gut transit time.
Mo1591
Purpose. Total abdominal colectomy (TAC) with end ileostomy is the procedure of choice for patients with medically refractory ulcerative colitis (UC). A laparoscopic approach has been shown to be safe and effective and has become the preferred strategy in our practice. We report the evolved experience of a single colorectal surgeon (AF) and compare results of laparoscopic-assisted (LA) TAC, hand-assisted (HA) TAC and single incision laparoscopy (SIL) TAC. Methods. Since May 2010 ten consecutive patients with medically refractory UC underwent SIL TAC and were case matched by age, gender, BMI and smoking history to 10 LA TAC (from Feb 2003 to Jan 2007) and 10 HA TAC (from Feb 2006 to Apr 2010). Patient, disease and surgery-related factors were analysed and short-term outcomes were compared. Results. There were no statistical differences in age, gender, BMI and smoking history between the groups per the case match design. Disease duration, histologic disease activity, Mayo score for ulcerative colitis, nutritional and inflammatory parameters, steroid and anti-TNF therapies did not differ between groups. SIL TAC patients were more likely to have received immunosuppressive therapy within 30 days of the surgery (p=0.016) than the other groups. There were no conversion or intraoperative complications noted. The estimated blood loss did not differ between groups. The length of surgery was significantly shorter for SIL TAC (139.0+23.7 minutes) when compared with LA (270.9+45.4) and HA (182.8+31.6) (p<0.001). SIL TAC patients tolerated solid diet intake sooner (3.0+0.5 days) than the other groups (3.7+0.5) (p=0.019). Postoperative length of stay and short-term complication rates did not differ between groups. Conclusions. In this experience of a single surgeon, SIL TAC was associated with shorter procedure time, faster time to solid diet and was equally safe to traditional LA TAC and HA TAC. Additional study and experience will solidify this approach for future patients and surgeons.
Mo1589 Adhesional Small Bowel Obstruction After Open and Laparoscopic Colorectal Surgery: A Prospective Longer-Term Study Pierpaolo Sileri, Stefano D' Ugo, Luana Franceschilli, Giulio P. Angelucci, Mara Capperucci, Emanuele Picone, Paolo Gentileschi, Nicola Di Lorenzo, Vincenzo Formica, Mario Roselli, Achille Gaspari
Mo1592
Background: Open colorectal surgery (CRS) leads to high rates of adhesive small bowel obstruction (SBO) and incisional hernia development with large clinical impact and financial burden. We evaluated the cumulative incidence of access related complications in a cohort of patients who underwent open and laparoscopic CRS. Methods: We reviewed cases of elective or emergency CRS patients kept prospectively on a database and examined annually. Case notes were studied for SBO episodes requiring admission or reintervention. Development of incisional hernia with or without repair was also recorded. The diagnosis of SBO was defined by a combination of clinical criteria and imaging. Time interval of SBO, surgery type and setting, readmission length and findings at reintervention were recorded. Patients undergoing CRS for inflammatory bowel disease, patients with peritoneal carcinosis, or patients with SBO secondary to local or peritoneal recurrence during the follow-up were excluded. Patients who underwent other abdominal surgery during the follow-up were also excluded. Data were analyzed using Mann-Whitney U test and chi-square test. The Kaplan
Outcomes of Right Versus Left Colectomy for Colon Cancer Hossein Masoomi, Brian Buchberg, Phat T. Dang, Joseph C. Carmichael, Steven Mills, Michael J. Stamos Introduction: Colocolonic or colorectal anastomosis perceived as more technically challenging than ileocolic anastomosis. Therefore, right colectomy (RC) is generally believed to be a simpler operation with better outcomes than left colectomy (LC). Objectives: Our study was intended to compare outcomes between right and left colectomy in patients with colon cancer and identify factors that increase the risk of developing postoperative abdominal abscess or anastomotic leakage (abscess/leak) in these patients. Methods: Using the 2007 Nationwide Inpatient Sample (NIS) database, patients who underwent elective RC and LC (left hemicolectomy or sigmoidectomy) for colon cancer were examined. Patient characteristics,
S-1029
SSAT Abstracts
SSAT Abstracts
Total Abdominal Colectomy for Refractory Ulcerative Colitis. Evolution in Surgical Treatment Alessandro Fichera, Marco Zoccali, Carla Felice, David T. Rubin
Meier method was used for cumulative probability of developing SBO. Results: From 01/ 03 to 11/10, 911 patients satisfied our criteria and underwent elective (52.6%) or emergency (47.4%) CRS (68.7% open and 31.3% laparoscopic). Median follow-up was 46.2 months (range 0.2 -115.0). Sixty-three patients (6.9%) experienced 83 SBO episodes and 22 required surgery (2.4%). There was a large variation in the time of first SBO occurrence, 43.9% occurred within 3 months, 29% between 3 and 12 months and 27% after 1 year. The risk of surgery at first admission for SBO 24% and the number of readmissions predicted the need of surgery. The risk of reoperation was greatest during the first year after CRS and steadily rised every year thereafter. SBO was higher after pelvic surgery or extensive resections compared to minor procedures (14% vs 3%; p<0.0001; HR 7.33). Likewise, SBO risk was higher after elective compared to emergency surgery (11.1% vs 6.9%; p=0.03; HR 2.0, but similar after open compared to laparoscopic surgery (9.9% vs 7.3%; p>0.05; HR 0.8). Any previous or additional surgery raised the overall risk of SBO from 5.4% to 16.4%. Incisional hernia development was slightly superior, after open surgery. Conclusions: Colorectal surgery results in significant ongoing risk of SBO according to the colorectal type of procedure. This risk seems to be similar between laparoscopic and open approach, higher after elective surgery and for patients with previous surgery. Number of readmissions for SBO predicts the need of surgery. Mo1590 A Critical Analysis of 28 Patients With Metachronous Peritoneal Dissemination From Colorectal Cancer Ashraf Haddad, Jesus Esquivel Background Peritoneal dissemination occurs approximately in 8 % of patients with colorectal cancer at the time of diagnosis and in about 25 % more at the time of disease recurrence. It has been traditionally seen as a universally lethal condition with no reasonable treatment options as most patients will present in an advanced stage. Methods We reviewed the records of all patients in our colorectal cancer with peritoneal dissemination database from 2005 to 2009. A retrospective analysis of key clinical and histopathological features including their TNM classification at the time of diagnosis of their primary tumor and their Peritoneal Surface Disease Severity Score (PSDSS) at the time of diagnosis of their peritoneal dissemination was carried out. Results Twenty eight patients with metachronous peritoneal dissemination were identified. There were 17 (61%) male patients. Mean age was 54 years. There were 7 patients with stage II (A or B) and 21 patients with stage III (A, B or C). Mean overall time to developing carcinomatosis was 27.8 months amongst all 28 patients. There were 6 patients with stage IIIC. Mean time to developing carcinomatosis was 16.8 months in this group and 5 out of 6 (83%), presented with a PSDSS of 4, making them not candidates for cytoreductive surgery and HIPEC. Conclusion It appears from these data that patients with stage IIIC colorectal cancer develop carcinomatosis at a faster rate and in a more virulent form when compared to other stages. Trials at preventing carcinomatosis in this group of patients are needed.
Mo1588 Can Whole Gut Scintigraphy Optimize Patient Selection and Outcomes in Slow Transit Constipation? Deborah Keller, Murali Pathikonda, Amit Khanna, Henry P. Parkman Introduction: Whole gut transit scintigraphy (WGTS) distinguishes isolated colonic from generalized GI motility disorders. Including WGTS in the pre-operative work-up allows appropriate diagnosis and management, and should be the standard of care for evaluation of colonic inertia. Our primary objective was to evaluate functional outcomes following colectomy for slow transit constipation in a single institution using preoperative scintigraphy. Secondary objectives were to describe predictive factors of outcome after surgery. Methods: After obtaining Institutional Review Board approval, we identified all patients who had surgery for colonic inertia from January 2003 to August 2010 using surgical billing codes and a GI departmental database. All patients who had WGTS prior to surgery were included in the analysis. Demographics, defecation, constipation details, pharmacologic treatment, symptoms, psychiatric medications, operation performed, and outcomes were extracted from a retrospective chart review and follow-up telephone interviews. Results: Fourteen patients had surgery for colonic inertia during the study period. Patients were mainly young females (86%, mean age 44.1 years) with a high coexistence of psychiatric disease (79%). The most common surgical intervention performed was total abdominal colectomy with ileoproctostomy (79%); 3 patients had an end ileostomy. WGTS results were available for 11 of 14 patients; 3 patients had their studies at an outside facility. All surgical patients had delayed 72-hour transit limited to the colon without coexistent gastric or small bowel delay on WGTS. Seven patients were available for follow-up interview at a median interval of 23 months. Post-operatively, 86% had complete resolution of pain and bloating, while 14% had considerable relief. Post-operative stool consistency was semi-solid in all patients. At follow-up patients reported between 2-5 bowel movements daily, while pre-operative frequency averaged one per week. No patients reported fecal incontinence or required antidiarrheal medication after surgery. All patients contacted for follow-up reported that they were overall satisfied with the outcome of their surgery, claimed to feel better than before surgery, and would make the decision to have the procedure again. Conclusion: The diagnosis of colonic inertia mandates careful patient selection and may be improved with WGTS. We believe appropriate patient selection can optimize surgical outcomes. A pre-operative diagnostic regimen of WGTS and anal manometry combined with surgical intervention was associated with high patient satisfaction and improvement in constipation, abdominal pain, and bloating. Total abdominal colectomy with ileoproctostomy provides a satisfactory outcome for patients with colonic inertia, however, this should be offered only after thorough evaluation of whole gut transit time.
Mo1591
Purpose. Total abdominal colectomy (TAC) with end ileostomy is the procedure of choice for patients with medically refractory ulcerative colitis (UC). A laparoscopic approach has been shown to be safe and effective and has become the preferred strategy in our practice. We report the evolved experience of a single colorectal surgeon (AF) and compare results of laparoscopic-assisted (LA) TAC, hand-assisted (HA) TAC and single incision laparoscopy (SIL) TAC. Methods. Since May 2010 ten consecutive patients with medically refractory UC underwent SIL TAC and were case matched by age, gender, BMI and smoking history to 10 LA TAC (from Feb 2003 to Jan 2007) and 10 HA TAC (from Feb 2006 to Apr 2010). Patient, disease and surgery-related factors were analysed and short-term outcomes were compared. Results. There were no statistical differences in age, gender, BMI and smoking history between the groups per the case match design. Disease duration, histologic disease activity, Mayo score for ulcerative colitis, nutritional and inflammatory parameters, steroid and anti-TNF therapies did not differ between groups. SIL TAC patients were more likely to have received immunosuppressive therapy within 30 days of the surgery (p=0.016) than the other groups. There were no conversion or intraoperative complications noted. The estimated blood loss did not differ between groups. The length of surgery was significantly shorter for SIL TAC (139.0+23.7 minutes) when compared with LA (270.9+45.4) and HA (182.8+31.6) (p<0.001). SIL TAC patients tolerated solid diet intake sooner (3.0+0.5 days) than the other groups (3.7+0.5) (p=0.019). Postoperative length of stay and short-term complication rates did not differ between groups. Conclusions. In this experience of a single surgeon, SIL TAC was associated with shorter procedure time, faster time to solid diet and was equally safe to traditional LA TAC and HA TAC. Additional study and experience will solidify this approach for future patients and surgeons.
Mo1589 Adhesional Small Bowel Obstruction After Open and Laparoscopic Colorectal Surgery: A Prospective Longer-Term Study Pierpaolo Sileri, Stefano D' Ugo, Luana Franceschilli, Giulio P. Angelucci, Mara Capperucci, Emanuele Picone, Paolo Gentileschi, Nicola Di Lorenzo, Vincenzo Formica, Mario Roselli, Achille Gaspari
Mo1592
Background: Open colorectal surgery (CRS) leads to high rates of adhesive small bowel obstruction (SBO) and incisional hernia development with large clinical impact and financial burden. We evaluated the cumulative incidence of access related complications in a cohort of patients who underwent open and laparoscopic CRS. Methods: We reviewed cases of elective or emergency CRS patients kept prospectively on a database and examined annually. Case notes were studied for SBO episodes requiring admission or reintervention. Development of incisional hernia with or without repair was also recorded. The diagnosis of SBO was defined by a combination of clinical criteria and imaging. Time interval of SBO, surgery type and setting, readmission length and findings at reintervention were recorded. Patients undergoing CRS for inflammatory bowel disease, patients with peritoneal carcinosis, or patients with SBO secondary to local or peritoneal recurrence during the follow-up were excluded. Patients who underwent other abdominal surgery during the follow-up were also excluded. Data were analyzed using Mann-Whitney U test and chi-square test. The Kaplan
Outcomes of Right Versus Left Colectomy for Colon Cancer Hossein Masoomi, Brian Buchberg, Phat T. Dang, Joseph C. Carmichael, Steven Mills, Michael J. Stamos Introduction: Colocolonic or colorectal anastomosis perceived as more technically challenging than ileocolic anastomosis. Therefore, right colectomy (RC) is generally believed to be a simpler operation with better outcomes than left colectomy (LC). Objectives: Our study was intended to compare outcomes between right and left colectomy in patients with colon cancer and identify factors that increase the risk of developing postoperative abdominal abscess or anastomotic leakage (abscess/leak) in these patients. Methods: Using the 2007 Nationwide Inpatient Sample (NIS) database, patients who underwent elective RC and LC (left hemicolectomy or sigmoidectomy) for colon cancer were examined. Patient characteristics,
S-1029
SSAT Abstracts
SSAT Abstracts
Total Abdominal Colectomy for Refractory Ulcerative Colitis. Evolution in Surgical Treatment Alessandro Fichera, Marco Zoccali, Carla Felice, David T. Rubin