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M1623 Portal Venous Thrombus (PVT) Following Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis (IPAA) for Ulcerative Colitis (UC): Does the Laparoscopic Approach Increase the Risk of PVT?
resection by high-volume surgeons was an independent predictor of decreased morbidity (odds ratio [OR]: 0.91; 95% CI 0.85-0.97) and mortality (OR: 0.75; 95% CI 0.65-0.86). Mortality was lowest among patients operated on by high-volume surgeons in high-volume hospitals (2.2% vs 3.9%; OR 0.56; 95% CI 0.46-0.68). Resection by high-volume surgeons was also associated with a decreased length of stay and reduced hospital charges. Conclusions: In patients undergoing elective resection of colon cancer, procedures done by high-volume surgeons are associated with decreased morbidity and mortality.
M1624 Electroacupuncture for Postoperative Ileus After Laparoscopic Colorectal Surgery: An Interim Analysis of a Randomized Sham-Controlled Study Simon S. Ng, Wing Wa Leung, Cherry Y. Wong, Janet F. Lee Background: Postoperative ileus remains a significant medical problem after colorectal surgery that adversely influences patients' recovery and prolongs hospital stay. Acupuncture is widely accepted as an effective treatment option for postoperative nausea and vomiting, but its role in treating postoperative ileus is unclear. We report interim analysis of a randomized shamcontrolled study that aimed to investigate the efficacy of electroacupuncture in reducing the duration of postoperative ileus and hospital stay after laparoscopic colorectal surgery. Methods: Consecutive patients undergoing elective laparoscopic resection of colonic and upper rectal cancer without the need of stoma creation or conversion were randomly allocated to one of the three groups receiving either electroacupuncture (EA), sham acupuncture (SA), or no acupuncture (control). The acupoints Zusanli, Sanyinjiao, Hegu, and Zhigou were used. Patients randomized to the EA and SA groups underwent one session of acupuncture daily (15 minutes each) from postoperative day 1 till day 4. The primary outcome was time to defecation. Secondary outcomes included time to resume diet and hospital stay. Results: Between October 2008 and October 2009, 108 patients (35 EA, 38 SA, 35 control) were recruited. The demographic data were similar between groups. Comparing with the control group, the EA group had significantly shorter time to defecation (94.7 hours vs. 118 hours, P = 0.042), time to resume normal diet (4.1 days vs. 5.1 days, P = 0.018), and duration of hospital stay (7.3 days vs. 9.1 days, P = 0.041). The time to defecation of the EA group was also shorter than that of the SA group (94.7 hours vs. 108.6 hours), but the difference did not reach statistical significance (P = 0.210). The time to resume normal diet and the duration of hospital stay did not differ significantly between the EA and SA groups. No adverse event related to acupuncture was noted. Conclusion: This interim analysis suggests that EA is more effective than no acupuncture in reducing the duration of postoperative ileus and hospital stay after laparoscopic colorectal surgery, whereas there are no significant differences between EA and SA. A larger trial size is required. This study is supported by the Health and Health Services Research Fund, Food and Health Bureau, The Government of the Hong Kong SAR (Reference Number 06070371).
M1622 Real Time PCR Based Approach for Rapid and Specific Diagnosis of Culture Negative Gastrointestinal Tuberculosis and Characterization of Its Host Immunological Features Kewal K. Maudar, Arpit Bhargava, Subodh Varshney, Pradyumna K. Mishra Background: The gastrointestinal (GI) tract is the sixth commonest extra-pulmonary site to be affected by Mycobacterium tuberculosis complex (MTBC) infections, yet it is often underrated. This form of TB has an insidious course like any other chronic infectious disease without any specific laboratory, radiological or clinical signs and symptoms. Any kind of delay in prompt initiation, leads to treatment failure or develops antibiotic resistance. Due to this non-specificity and difficulties associated with its diagnosis, development of a rapid and more specific investigative method is an urgent need of hour. Objective: To identify the culture negative MTBC infections in endoscopic biopsies and formalin-fixed, paraffinembedded tissues of gastrointestinal tract using a fluorescence resonance energy transfer (FRET) hybridization probe based real-time polymerase chain reaction (PCR) approach and characterization of its host immunological features. Materials and methods: The present study included three groups (A) control (n=24) with no previous signs of Mycobacterium tuberculosis complex (B) patients (n=28) with known TB origin (C) patients (n=50) with clinical and histo-pathological signs of TB but was culture and AFB negative. Real time PCR assay using Roche Light Cycler (LC) 2.0 with FRET probes was performed for the specific amplification of 159 bp region of mycobacterium genome. Later host immune characterization of the PCR positive samples was performed through immuno-phenotyping and Th1/Th2 cytokine profiling using flow cytometry. Students' t-test was employed for statistical analysis using SPSS software and p value of ≤ 0.05 was considered to be significant. Results: All the samples (n=24) of group A were found to be negative while in group B 27 out of 28 reported positive by LC PCR. In group C out of total 50 cases studied 18 were found to be positive showing a positivity of 36 %. The sensitivity and specificity of the test was 97.87 % and 100 %. The positive predictive value was 100 % and the negative predictive value was 98 %. On immune characterization of the LC PCR positive group C cases a depleted CD4+ count and increased levels of IFN-g and TNF-a were observed. Conclusion: Application of FRET probe based real-time PCR based diagnosis offer's a better approach for rapid and specific identification of culture negative tuberculosis infections in the gastro-intestinal tract. In addition, understanding host immunological response against such infections might provide specific therapeutic strategies for prevention and treatment of the infection in future.
M1625
Purpose: Evidence is lacking whether an abscess associated with anastomotic leak after ileal pouch-anal anastomosis should be drained by transanal or CT guided drainage. In order to clarify their relative potential implications on subsequent anastomotic healing, development of extrasphincteric fistulae and long term pouch retention, we compare outcomes after the two techniques for drainage. Methods: Patients who underwent IPAA from 1984-2009 and diagnosed with a pelvic abscess associated with an anastomotic leak on imaging studies were identified. Choice of operative or image-guided drainage was based on surgeon preference. Differences between patients undergoing transanal (Group A) and CT-guided drainage (Group B), for demographic, preoperative, and operative details, functional outcomes, and quality of life were determined. Results: Group A (n=56 ) and group B (n=19) had similar age (32.3 ±13.9 vs.29.6 ±12.2 years,, p=0.53), gender (male:75% vs. 70%, p=0.67), BMI (27.4 ±6.6 vs. 27.9 ±4.5 kg/m2, p=0.31), diagnosis (ulcerative colitis, 64.7% vs. 63.2%, p= 0.15), steroid use (51% vs. 57.9%, p=0.61), albumin level (4.1 ±0.6 vs. 4.3 ±0.2 g/dl, p= 0.28), defunctioning ileostomy (92.3% vs. 85%, p=0.39), length of hospital stay (days, 9.4 ± 5.3 vs. 13.9 ± 12.1) and follow up time (5.2 ±4.6 vs. 4.3 ±4.8 years,, p=0.48). Size of abscess was greater in Group B (5.3±2.6 vs. 8.5±3.4 cm, p=0.007). Site of CT-guided drainage was mainly gluteal (n=12). Two patients (10.5%) developed fistula at CT-guided drainage site. Both healed after conservative treatment and drainage of associated gluteal abscess, respectively. Seven patients (12.5%) in group A and 4 patients (21%) in Group B (p=0.4) had pouch failure and underwent redo pouch surgery, pouch excision or permanent diversion despite drainage of the abscess. At most recent follow-up, Groups A and B had similar bowel frequency (p=0.57), incontinence rate (p=0.46), urgency (7.9% vs. 15.4%, p=0.46), seepage (p=0.39) and pad usage (p=0.92). Quality of life (p=0.6), happiness with surgery (p=0.34), dietary (p=0.32), social (p=0.91), sexual (p=0.62), and work restrictions (p=0.92) were also similar. Conclusion: There is a risk of development of a fistula at the site of CT guided drainage of pelvic abscess associated with anastomotic leak following IPAA. Transanal and CT-guided drainage however result in similar long-term outcomes.
M1623 Portal Venous Thrombus (PVT) Following Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis (IPAA) for Ulcerative Colitis (UC): Does the Laparoscopic Approach Increase the Risk of PVT? Kelly D. Gonzales, Avneesh Gupta, Jaroslaw N. Tkacz, Arthur Stucchi, Jorge Soto, Stephen M. Sentovich, Francis A. Farraye, James M. Becker INTRODUCTION: Restorative proctocolectomy (RPC) with IPAA has become the procedure of choice for surgical management of UC. Although patients with UC have a three times greater risk of venous thrombotic events than the general population, those patients who have undergone RPC and IPAA are at an even higher risk for life-threatening venous prothrombotic events. PVT has been increasingly observed after IPAA and can be one of the more serious post-operative complications. PVT usually presents with a spectrum of clinical symptoms including abdominal pain, fever, and/or leukocytosis. The aim of this study was to determine the incidence of confirmed portal and mesenteric venous thrombi in UC patients following either laparoscopic (LAP-RPC) or open-RPC and IPAA and to characterize their clinical presentation. METHODS: Between 6/2003 and 1/2008, 85 consecutive UC patients who underwent laparoscopic or open RPC-IPAA by a single surgeon were retrospectively evaluated. Any patient who received an abdominal/pelvic contrast enhanced computed tomography (CT) scan postoperatively was included. The symptoms necessitating radiologic evaluation were recorded. CT images were reviewed by two radiologists for the presence of PVT using a 5-point scale system and the location, if present, in one or more of the portal vessels (main portal vein, intrahepatic portal vein branches, superior mesenteric vein and inferior mesenteric vein) was recorded. RESULTS: Eighty-five patients (ages 1472, 52% male) underwent RPC-IPAA for UC of which 15 were LAP-RPC (18%). Twentyseven patients that underwent open RPC-IPAA (32%) and six that underwent LAP-RPC (7%) subsequently underwent a contrast enhanced CT scan of the abdomen/pelvis for various presentations: abdominal pain (33%), fever (21%), follow up (15%), rectal pain (6%), nausea/ vomiting (6%), and other (18%). In the cohort of 15 patients who underwent LAP-RPC, all 6 patients (40%) who went on to have a CT scan were diagnosed with PVT. Of the 20 patients (24%) identified with PVT, 15 were discovered within 6 weeks of surgery (18%) including all 6 patients who underwent LAP-RPC. CONCLUSION(S): PVT appears to be a more frequent finding following LAP-RPC than open RPC for UC. Patients considering elective surgery should be counseled regarding this potential risk and for those still interested in LAP-RPC, a pre-operative hypercoagulable work-up should be considered. Post-operatively, early screening with a coagulation panel and abdominal imaging studies at two and six weeks is recommended for either surgical approach.
M1626 The Relationship Between Inflammation Based Pathologic and Biochemical Prognostic Criteria and Site of Recurrence Following Curative Resection of Colorectal Cancer Jonathan J. Platt, Campbell S. Roxburgh, Paul G. Horgan, Donald C. McMillan Objective: To examine the relationship between the pre-operative systemic inflammatory response (modified Glasgow Prognostic Score, mGPS), the peritumoral inflammatory response (Klintrup score) and site of recurrence in patients undergoing curative resection for colorectal cancer. Background: Although known to have prognostic value, the pattern of disease recurrence associated with the mGPS and Klintrup score has not been examined. Methods: 291 patients between 1997 and 2007 were studied. mGPS was derived from routine preoperative blood tests. Routine pathology specimens were scored according to Klintrup criteria. Recurrence was defined as liver alone (intrahepatic), other sites (extrahepatic) and combined (intra- and extrahepatic). Results: Both the mGPS (HR 1.53, 1.19-1.97, p=0.001) and Klintrup score (HR 2.11, 1.23-3.63, p=0.007) were independently associated with 3 year recurrence free survival. However, only the mGPS was significantly associated with an intrahepatic site of recurrence (p<0.01). Of those patients with an intrahepatic recurrence, 66% had an elevated mGPS of 1 or 2. In contrast, 44% patients with extrahepatic recurrence had an elevated mGPS of 1 or 2 and 30% of patients with intra-and extrahepatic
S-869
SSAT Abstracts
SSAT Abstracts
Transanal Versus CT-Guided Drainage for Pelvic Abscess Following Anastomotic Leak in Patients With Ileal Pouch-Anal Anastomosis Hasan T. Kirat, Pokala R. Kiran, Bo Shen, Feza H. Remzi
M1624 Electroacupuncture for Postoperative Ileus After Laparoscopic Colorectal Surgery: An Interim Analysis of a Randomized Sham-Controlled Study Simon S. Ng, Wing Wa Leung, Cherry Y. Wong, Janet F. Lee Background: Postoperative ileus remains a significant medical problem after colorectal surgery that adversely influences patients' recovery and prolongs hospital stay. Acupuncture is widely accepted as an effective treatment option for postoperative nausea and vomiting, but its role in treating postoperative ileus is unclear. We report interim analysis of a randomized shamcontrolled study that aimed to investigate the efficacy of electroacupuncture in reducing the duration of postoperative ileus and hospital stay after laparoscopic colorectal surgery. Methods: Consecutive patients undergoing elective laparoscopic resection of colonic and upper rectal cancer without the need of stoma creation or conversion were randomly allocated to one of the three groups receiving either electroacupuncture (EA), sham acupuncture (SA), or no acupuncture (control). The acupoints Zusanli, Sanyinjiao, Hegu, and Zhigou were used. Patients randomized to the EA and SA groups underwent one session of acupuncture daily (15 minutes each) from postoperative day 1 till day 4. The primary outcome was time to defecation. Secondary outcomes included time to resume diet and hospital stay. Results: Between October 2008 and October 2009, 108 patients (35 EA, 38 SA, 35 control) were recruited. The demographic data were similar between groups. Comparing with the control group, the EA group had significantly shorter time to defecation (94.7 hours vs. 118 hours, P = 0.042), time to resume normal diet (4.1 days vs. 5.1 days, P = 0.018), and duration of hospital stay (7.3 days vs. 9.1 days, P = 0.041). The time to defecation of the EA group was also shorter than that of the SA group (94.7 hours vs. 108.6 hours), but the difference did not reach statistical significance (P = 0.210). The time to resume normal diet and the duration of hospital stay did not differ significantly between the EA and SA groups. No adverse event related to acupuncture was noted. Conclusion: This interim analysis suggests that EA is more effective than no acupuncture in reducing the duration of postoperative ileus and hospital stay after laparoscopic colorectal surgery, whereas there are no significant differences between EA and SA. A larger trial size is required. This study is supported by the Health and Health Services Research Fund, Food and Health Bureau, The Government of the Hong Kong SAR (Reference Number 06070371).
M1622 Real Time PCR Based Approach for Rapid and Specific Diagnosis of Culture Negative Gastrointestinal Tuberculosis and Characterization of Its Host Immunological Features Kewal K. Maudar, Arpit Bhargava, Subodh Varshney, Pradyumna K. Mishra Background: The gastrointestinal (GI) tract is the sixth commonest extra-pulmonary site to be affected by Mycobacterium tuberculosis complex (MTBC) infections, yet it is often underrated. This form of TB has an insidious course like any other chronic infectious disease without any specific laboratory, radiological or clinical signs and symptoms. Any kind of delay in prompt initiation, leads to treatment failure or develops antibiotic resistance. Due to this non-specificity and difficulties associated with its diagnosis, development of a rapid and more specific investigative method is an urgent need of hour. Objective: To identify the culture negative MTBC infections in endoscopic biopsies and formalin-fixed, paraffinembedded tissues of gastrointestinal tract using a fluorescence resonance energy transfer (FRET) hybridization probe based real-time polymerase chain reaction (PCR) approach and characterization of its host immunological features. Materials and methods: The present study included three groups (A) control (n=24) with no previous signs of Mycobacterium tuberculosis complex (B) patients (n=28) with known TB origin (C) patients (n=50) with clinical and histo-pathological signs of TB but was culture and AFB negative. Real time PCR assay using Roche Light Cycler (LC) 2.0 with FRET probes was performed for the specific amplification of 159 bp region of mycobacterium genome. Later host immune characterization of the PCR positive samples was performed through immuno-phenotyping and Th1/Th2 cytokine profiling using flow cytometry. Students' t-test was employed for statistical analysis using SPSS software and p value of ≤ 0.05 was considered to be significant. Results: All the samples (n=24) of group A were found to be negative while in group B 27 out of 28 reported positive by LC PCR. In group C out of total 50 cases studied 18 were found to be positive showing a positivity of 36 %. The sensitivity and specificity of the test was 97.87 % and 100 %. The positive predictive value was 100 % and the negative predictive value was 98 %. On immune characterization of the LC PCR positive group C cases a depleted CD4+ count and increased levels of IFN-g and TNF-a were observed. Conclusion: Application of FRET probe based real-time PCR based diagnosis offer's a better approach for rapid and specific identification of culture negative tuberculosis infections in the gastro-intestinal tract. In addition, understanding host immunological response against such infections might provide specific therapeutic strategies for prevention and treatment of the infection in future.
M1625
Purpose: Evidence is lacking whether an abscess associated with anastomotic leak after ileal pouch-anal anastomosis should be drained by transanal or CT guided drainage. In order to clarify their relative potential implications on subsequent anastomotic healing, development of extrasphincteric fistulae and long term pouch retention, we compare outcomes after the two techniques for drainage. Methods: Patients who underwent IPAA from 1984-2009 and diagnosed with a pelvic abscess associated with an anastomotic leak on imaging studies were identified. Choice of operative or image-guided drainage was based on surgeon preference. Differences between patients undergoing transanal (Group A) and CT-guided drainage (Group B), for demographic, preoperative, and operative details, functional outcomes, and quality of life were determined. Results: Group A (n=56 ) and group B (n=19) had similar age (32.3 ±13.9 vs.29.6 ±12.2 years,, p=0.53), gender (male:75% vs. 70%, p=0.67), BMI (27.4 ±6.6 vs. 27.9 ±4.5 kg/m2, p=0.31), diagnosis (ulcerative colitis, 64.7% vs. 63.2%, p= 0.15), steroid use (51% vs. 57.9%, p=0.61), albumin level (4.1 ±0.6 vs. 4.3 ±0.2 g/dl, p= 0.28), defunctioning ileostomy (92.3% vs. 85%, p=0.39), length of hospital stay (days, 9.4 ± 5.3 vs. 13.9 ± 12.1) and follow up time (5.2 ±4.6 vs. 4.3 ±4.8 years,, p=0.48). Size of abscess was greater in Group B (5.3±2.6 vs. 8.5±3.4 cm, p=0.007). Site of CT-guided drainage was mainly gluteal (n=12). Two patients (10.5%) developed fistula at CT-guided drainage site. Both healed after conservative treatment and drainage of associated gluteal abscess, respectively. Seven patients (12.5%) in group A and 4 patients (21%) in Group B (p=0.4) had pouch failure and underwent redo pouch surgery, pouch excision or permanent diversion despite drainage of the abscess. At most recent follow-up, Groups A and B had similar bowel frequency (p=0.57), incontinence rate (p=0.46), urgency (7.9% vs. 15.4%, p=0.46), seepage (p=0.39) and pad usage (p=0.92). Quality of life (p=0.6), happiness with surgery (p=0.34), dietary (p=0.32), social (p=0.91), sexual (p=0.62), and work restrictions (p=0.92) were also similar. Conclusion: There is a risk of development of a fistula at the site of CT guided drainage of pelvic abscess associated with anastomotic leak following IPAA. Transanal and CT-guided drainage however result in similar long-term outcomes.
M1623 Portal Venous Thrombus (PVT) Following Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis (IPAA) for Ulcerative Colitis (UC): Does the Laparoscopic Approach Increase the Risk of PVT? Kelly D. Gonzales, Avneesh Gupta, Jaroslaw N. Tkacz, Arthur Stucchi, Jorge Soto, Stephen M. Sentovich, Francis A. Farraye, James M. Becker INTRODUCTION: Restorative proctocolectomy (RPC) with IPAA has become the procedure of choice for surgical management of UC. Although patients with UC have a three times greater risk of venous thrombotic events than the general population, those patients who have undergone RPC and IPAA are at an even higher risk for life-threatening venous prothrombotic events. PVT has been increasingly observed after IPAA and can be one of the more serious post-operative complications. PVT usually presents with a spectrum of clinical symptoms including abdominal pain, fever, and/or leukocytosis. The aim of this study was to determine the incidence of confirmed portal and mesenteric venous thrombi in UC patients following either laparoscopic (LAP-RPC) or open-RPC and IPAA and to characterize their clinical presentation. METHODS: Between 6/2003 and 1/2008, 85 consecutive UC patients who underwent laparoscopic or open RPC-IPAA by a single surgeon were retrospectively evaluated. Any patient who received an abdominal/pelvic contrast enhanced computed tomography (CT) scan postoperatively was included. The symptoms necessitating radiologic evaluation were recorded. CT images were reviewed by two radiologists for the presence of PVT using a 5-point scale system and the location, if present, in one or more of the portal vessels (main portal vein, intrahepatic portal vein branches, superior mesenteric vein and inferior mesenteric vein) was recorded. RESULTS: Eighty-five patients (ages 1472, 52% male) underwent RPC-IPAA for UC of which 15 were LAP-RPC (18%). Twentyseven patients that underwent open RPC-IPAA (32%) and six that underwent LAP-RPC (7%) subsequently underwent a contrast enhanced CT scan of the abdomen/pelvis for various presentations: abdominal pain (33%), fever (21%), follow up (15%), rectal pain (6%), nausea/ vomiting (6%), and other (18%). In the cohort of 15 patients who underwent LAP-RPC, all 6 patients (40%) who went on to have a CT scan were diagnosed with PVT. Of the 20 patients (24%) identified with PVT, 15 were discovered within 6 weeks of surgery (18%) including all 6 patients who underwent LAP-RPC. CONCLUSION(S): PVT appears to be a more frequent finding following LAP-RPC than open RPC for UC. Patients considering elective surgery should be counseled regarding this potential risk and for those still interested in LAP-RPC, a pre-operative hypercoagulable work-up should be considered. Post-operatively, early screening with a coagulation panel and abdominal imaging studies at two and six weeks is recommended for either surgical approach.
M1626 The Relationship Between Inflammation Based Pathologic and Biochemical Prognostic Criteria and Site of Recurrence Following Curative Resection of Colorectal Cancer Jonathan J. Platt, Campbell S. Roxburgh, Paul G. Horgan, Donald C. McMillan Objective: To examine the relationship between the pre-operative systemic inflammatory response (modified Glasgow Prognostic Score, mGPS), the peritumoral inflammatory response (Klintrup score) and site of recurrence in patients undergoing curative resection for colorectal cancer. Background: Although known to have prognostic value, the pattern of disease recurrence associated with the mGPS and Klintrup score has not been examined. Methods: 291 patients between 1997 and 2007 were studied. mGPS was derived from routine preoperative blood tests. Routine pathology specimens were scored according to Klintrup criteria. Recurrence was defined as liver alone (intrahepatic), other sites (extrahepatic) and combined (intra- and extrahepatic). Results: Both the mGPS (HR 1.53, 1.19-1.97, p=0.001) and Klintrup score (HR 2.11, 1.23-3.63, p=0.007) were independently associated with 3 year recurrence free survival. However, only the mGPS was significantly associated with an intrahepatic site of recurrence (p<0.01). Of those patients with an intrahepatic recurrence, 66% had an elevated mGPS of 1 or 2. In contrast, 44% patients with extrahepatic recurrence had an elevated mGPS of 1 or 2 and 30% of patients with intra-and extrahepatic
S-869
SSAT Abstracts
SSAT Abstracts
Transanal Versus CT-Guided Drainage for Pelvic Abscess Following Anastomotic Leak in Patients With Ileal Pouch-Anal Anastomosis Hasan T. Kirat, Pokala R. Kiran, Bo Shen, Feza H. Remzi