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M1630 Chronic Sinus After Ileal Pouch-Anal Anastomosis (IPAA): Implications for Pouch Retention
recurrence had an elevated mGPS of 1 or 2 (p<0.01). Conclusions: The results of the present study demonstrate that the modified Glasgow Prognostic Score is independently associated with the pattern of recurrence, to the liver in particular, in patients undergoing potentially curative resection for colorectal cancer. In contrast, the Klintrup score was not associated with any specific pattern of recurrence.
M1629 Preoperative Biopsy Findings Correlate Poorly With Postoperative Findings in IBD-Associated Neoplasia Susan L. Gearhart, Elizabeth C. Wick, Nita Ahuja, Elizabeth A. Montgomery, Jonathan E. Efron Preoperative biopsy findings of neoplasia in inflammatory bowel disease (IBD) do not always correlate with postoperative pathology. The aim of this study was to determine the pathologic correlation rate between preoperative biopsies and postoperative pathology. From 2002 2009, patients presenting for colectomy for IBD associated neoplasia underwent review of preoperative biopsies and colectomy specimens by pathologist specializing in gastrointestinal disease at our institution. All specimens underwent standardized examination at 5 micron intervals in areas of interest. 35 patients with IBD-associated neoplasia were identified. 6 patients had a biopsy proven mass consistent with invasive cancer and were excluded. Of the remaining 29 patients, 22 (76%) were male, mean age was 50 yrs, mean time with IBD was 16 yrs, 23 underwent restorative proctocolectomy (RP). The average histology sections examined per patient following RP was 36.4 (range 22 - 66). 3 patients had invasive cancer on routine surveillance biopsy. High grade dysplasia (HGD) was identified in 8 patients and low grade dysplasis (LGD) with or without a dysplastic associated lesion or mass (DALM) was identified in 17 patients. 1 patient was indefinite for dysplasia. Overall, the rate of cancer in the final pathology specimen was 14%, the rate of no neoplasia was 24%, and correlation with preoperative biopsy was 41%. In patients with an intial biopsy demonstrating cancer, one patient had no identifiable cancer in the colectomy specimen. Among patients with HGD, unknown cancers were found in 12.5% of patients and preoperative biopsies correlated with the final postoperative pathology in 50% of patients. Among patients with LGD, unknown cancers were identified in 5.9% of patients and preoperative biopsies correlated with the final postoperative pathology in 35.3% of patients. With no associated lesion (DALM) and LGD, the correlation rate was 57% (see table). Correlation between preoperative biopsies and final pathology among patients with IBD-associated neoplasia, especially if a DALM is present, remains low even among pathologist specializing in inflammatory bowel disease. The cancer risk remains elevated, which suggests that surgery remains indicated for both HGD and LGD.
M1627 C-Reactive Protein as a Predictor of Postoperative Infective Complications Following Curative Resection in Patients With Colorectal Cancer Jonathan J. Platt, Robin A. Crosbie, Paul G. Horgan, Donald C. McMillan Background: Infective complications represent a major cause of morbidity after colorectal cancer resection. Diagnosis is often late, when the patient is exhibiting signs of sepsis. Although it is known that C-reactive protein (CRP) is a sensitive marker of inflammation, it is unclear whether it could be used for early identification of patients developing postoperative infective complications. We analysed the diagnostic accuracy of serial serum CRP levels to detect infective complications after colorectal cancer resection. Patients and Methods: CRP was routinely measured perioperatively in 477 consecutive patients undergoing colorectal cancer resection with curative intent. Postoperative complications were recorded using clinical, laboratory and radiological data. Median CRP results were compared using the Mann-Whitney U test. The diagnostic accuracy of CRP was analysed by receiver operating characteristics (ROC) curve analysis. On follow up, 125 patients developed postoperative infective complications (28 intraabdominal, 97 extraabdominal) in the first 14 days. Results: The uncomplicated patients CRP peaked on postoperative day 2 (POD 2), with a median CRP of 170mg/L and gradually decreased thereafter. In contrast, although the patients with infective complications CRP also peaked on POD 2 (median 213mg/L), it remained elevated thereafter. The CRP was significantly higher in the infective complication group from POD 2 until POD 7 (p<0.001). ROC analysis demonstrated that the increased CRP levels on POD 3 were associated with postoperative infections. The optimal cut off value was 180 (sensitivity 73%, specificity 73%). The area under the ROC curve was 0.77 (p<0.001). For those with intraabdominal infections, the area under the curve was 0.83 (p<0.001). Conclusions: Serial CRP measurements are useful in the early detection of postoperative infections following colorectal cancer resection. An elevated CRP value greater than 180 mg/L on POD 3 should be investigated. M1628
SSAT Abstracts
Referral Pattern and Establishment of Diagnosis at Subspecialty Pouchitis Clinic Angelina Postoev, Christopher A. Ibikunle, Pokala R. Kiran, Feza H. Remzi, Bo Shen Background: With an increasing number of patients with inflammatory and non-inflammatory complications of the ileal pouch, in 2002 CCF Digestive Disease Institute established a subspecialty Pouchitis Clinic for diagnosis and management of pouch-associated disorders. A cursory review of our referral pattern revealed that pouchitis may be misdiagnosed and mistreated. Aim: To identify patient groups and reasons for misdiagnosis. Methods: A historical cohort of 245 patients from the Pouchitis Clinic were included. The clinical variables evaluated included: age, sex, age at onset of disease, year of IPAA, reason for the operation, comorbidities such as diabetes, steroid use, smoking, NSAID use, pre-referral diagnosis, pre-referral treatment regimen, endoscopic findings, pathological results, postreferral diagnosis and post-referral treatment regimen. Results: Of the 245 patients (51% were females, median age 50 years, 87% with a preoperative diagnosis of ulcerative colitis, 3% CD, 4% FAP, 0.5% indeterminate, 5% other) with presumed pouchitis and other pouch disorders, 117 (48%) had the diagnosis revised to most commonly irriable pouch syndrome (IPS) or Crohn's disease (CD) of the pouch. Of the 101 patients referred from outside hospitals, 57 (56%) had a revision of diagnosis. 136 patients had diagnosis of pouchitis before referral, and 69 patients had diagnosis of pouchitis post-referral. IPS was diagnosed in 22 patients pre-referral, and 123 post-referral. Conclusion: Our findings suggest that it is important to use clinical, endoscopic and histological assessment to establish accurate diagnosis. The subspecialty care would optimize patients' care Future Topics : Recognition of IPS; accurate diagnostic and treatment algorithm for pouchitis, cost benefit analysis of management of pouch related disorders in a tertiary center. Preoperative diagnosis
M1630 Chronic Sinus After Ileal Pouch-Anal Anastomosis (IPAA): Implications for Pouch Retention Lei Lian, Pokala R. Kiran, Bo Shen, Feza H. Remzi, Victor W. Fazio Background:Chronic sinus is a form of anastomotic leak that occurs in patients undergoing IPAA as a blind-ending track. The disease course of a sinus is poorly defined and its management can be challenging. Methods:Patients with chronic sinus were identified from a prospectively-maintained pelvic pouch database from 1997 to 2009. Patients with Crohn's disease of the pouch were excluded. Data pertaining to diagnostic modality, symptom, management, and outcomes were collected by chart review. Results:57 patients(66.1% male) were identified. Mean age at pouch surgery was 40±12.2 years. While 37 patients with chronic sinus underwent 2 or 3-stage primary pouch construction, 20 developed a chronic sinus after redo pouch. 33(57.9%) patients had a previous anastomotic leak or pelvic abscess. Initial diagnostic modalities were endoscopy(57.9%), gastrografin enema(33.3%), and exam under anesthesia(8.7%). MRI was used in 10 patients for further evaluation. 27 patients had sinus before LI closure with 21 having delayed ileostomy closure (median time to closure 197 days, range 119-756). The management of these patients included observation, drainage, unroofing, proximal diversion, and pouch excision. In total 40(70.2%) patients had complete healing of the sinus, 15 (26.3%) had pouch failure. Pouch failure rate was similar between patients who developed sinus before and after ileostomy closure(8/27 vs.7/ 30,p=0.59). For patients with sinus before ileostomy closure, pouch failure rate was significantly higher in patients without delayed ileostomy closure compared to patients with delayed closure (5/21 vs. 3/4,p=0.047). 30 had sinus after LI closure and 21 were symptomatic including diarrhea(n=12), anal pain(n=3), urgency(n=3), drainage(n=2), and fever(n=1). Pouch failure for the symptomatic patients was high (6/21: 28.6%). Conclusion:A chronic sinus after IPAA may be associated with pouch failure. Better management of the sinus before ileostomy closure may improve pouch retention. M1631
Revision in diagnosis
Long Term Conditional Survival in Esophageal Cancer: A SEER Database Analysis Attila Dubecz, Rudolf J. Stadlhuber, Hubert J. Stein BACKGROUND: For esophageal cancer patients 5-year survival rates are generally reported in the literature. It is not clear however, that in patients who already survived a certain period of time what probabilities of surviving an additional 5 years apply. METHODS: Clinical stage, surgical and non-surgical treatments, age, and race of patients with cancer of the esophagus were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988-2004). SEER identified a total of 25,306 patients with esophageal cancer (average age: 65.0 years, male-to-female ratio: 3.1). Overall five and ten-year survival of patients through all stages and the relative conditional survival (CS) of patients surviving
24 pts had double dx (IPS+SBBO, or CD+fistula/stricture)
SSAT Abstracts
S-870
M1629 Preoperative Biopsy Findings Correlate Poorly With Postoperative Findings in IBD-Associated Neoplasia Susan L. Gearhart, Elizabeth C. Wick, Nita Ahuja, Elizabeth A. Montgomery, Jonathan E. Efron Preoperative biopsy findings of neoplasia in inflammatory bowel disease (IBD) do not always correlate with postoperative pathology. The aim of this study was to determine the pathologic correlation rate between preoperative biopsies and postoperative pathology. From 2002 2009, patients presenting for colectomy for IBD associated neoplasia underwent review of preoperative biopsies and colectomy specimens by pathologist specializing in gastrointestinal disease at our institution. All specimens underwent standardized examination at 5 micron intervals in areas of interest. 35 patients with IBD-associated neoplasia were identified. 6 patients had a biopsy proven mass consistent with invasive cancer and were excluded. Of the remaining 29 patients, 22 (76%) were male, mean age was 50 yrs, mean time with IBD was 16 yrs, 23 underwent restorative proctocolectomy (RP). The average histology sections examined per patient following RP was 36.4 (range 22 - 66). 3 patients had invasive cancer on routine surveillance biopsy. High grade dysplasia (HGD) was identified in 8 patients and low grade dysplasis (LGD) with or without a dysplastic associated lesion or mass (DALM) was identified in 17 patients. 1 patient was indefinite for dysplasia. Overall, the rate of cancer in the final pathology specimen was 14%, the rate of no neoplasia was 24%, and correlation with preoperative biopsy was 41%. In patients with an intial biopsy demonstrating cancer, one patient had no identifiable cancer in the colectomy specimen. Among patients with HGD, unknown cancers were found in 12.5% of patients and preoperative biopsies correlated with the final postoperative pathology in 50% of patients. Among patients with LGD, unknown cancers were identified in 5.9% of patients and preoperative biopsies correlated with the final postoperative pathology in 35.3% of patients. With no associated lesion (DALM) and LGD, the correlation rate was 57% (see table). Correlation between preoperative biopsies and final pathology among patients with IBD-associated neoplasia, especially if a DALM is present, remains low even among pathologist specializing in inflammatory bowel disease. The cancer risk remains elevated, which suggests that surgery remains indicated for both HGD and LGD.
M1627 C-Reactive Protein as a Predictor of Postoperative Infective Complications Following Curative Resection in Patients With Colorectal Cancer Jonathan J. Platt, Robin A. Crosbie, Paul G. Horgan, Donald C. McMillan Background: Infective complications represent a major cause of morbidity after colorectal cancer resection. Diagnosis is often late, when the patient is exhibiting signs of sepsis. Although it is known that C-reactive protein (CRP) is a sensitive marker of inflammation, it is unclear whether it could be used for early identification of patients developing postoperative infective complications. We analysed the diagnostic accuracy of serial serum CRP levels to detect infective complications after colorectal cancer resection. Patients and Methods: CRP was routinely measured perioperatively in 477 consecutive patients undergoing colorectal cancer resection with curative intent. Postoperative complications were recorded using clinical, laboratory and radiological data. Median CRP results were compared using the Mann-Whitney U test. The diagnostic accuracy of CRP was analysed by receiver operating characteristics (ROC) curve analysis. On follow up, 125 patients developed postoperative infective complications (28 intraabdominal, 97 extraabdominal) in the first 14 days. Results: The uncomplicated patients CRP peaked on postoperative day 2 (POD 2), with a median CRP of 170mg/L and gradually decreased thereafter. In contrast, although the patients with infective complications CRP also peaked on POD 2 (median 213mg/L), it remained elevated thereafter. The CRP was significantly higher in the infective complication group from POD 2 until POD 7 (p<0.001). ROC analysis demonstrated that the increased CRP levels on POD 3 were associated with postoperative infections. The optimal cut off value was 180 (sensitivity 73%, specificity 73%). The area under the ROC curve was 0.77 (p<0.001). For those with intraabdominal infections, the area under the curve was 0.83 (p<0.001). Conclusions: Serial CRP measurements are useful in the early detection of postoperative infections following colorectal cancer resection. An elevated CRP value greater than 180 mg/L on POD 3 should be investigated. M1628
SSAT Abstracts
Referral Pattern and Establishment of Diagnosis at Subspecialty Pouchitis Clinic Angelina Postoev, Christopher A. Ibikunle, Pokala R. Kiran, Feza H. Remzi, Bo Shen Background: With an increasing number of patients with inflammatory and non-inflammatory complications of the ileal pouch, in 2002 CCF Digestive Disease Institute established a subspecialty Pouchitis Clinic for diagnosis and management of pouch-associated disorders. A cursory review of our referral pattern revealed that pouchitis may be misdiagnosed and mistreated. Aim: To identify patient groups and reasons for misdiagnosis. Methods: A historical cohort of 245 patients from the Pouchitis Clinic were included. The clinical variables evaluated included: age, sex, age at onset of disease, year of IPAA, reason for the operation, comorbidities such as diabetes, steroid use, smoking, NSAID use, pre-referral diagnosis, pre-referral treatment regimen, endoscopic findings, pathological results, postreferral diagnosis and post-referral treatment regimen. Results: Of the 245 patients (51% were females, median age 50 years, 87% with a preoperative diagnosis of ulcerative colitis, 3% CD, 4% FAP, 0.5% indeterminate, 5% other) with presumed pouchitis and other pouch disorders, 117 (48%) had the diagnosis revised to most commonly irriable pouch syndrome (IPS) or Crohn's disease (CD) of the pouch. Of the 101 patients referred from outside hospitals, 57 (56%) had a revision of diagnosis. 136 patients had diagnosis of pouchitis before referral, and 69 patients had diagnosis of pouchitis post-referral. IPS was diagnosed in 22 patients pre-referral, and 123 post-referral. Conclusion: Our findings suggest that it is important to use clinical, endoscopic and histological assessment to establish accurate diagnosis. The subspecialty care would optimize patients' care Future Topics : Recognition of IPS; accurate diagnostic and treatment algorithm for pouchitis, cost benefit analysis of management of pouch related disorders in a tertiary center. Preoperative diagnosis
M1630 Chronic Sinus After Ileal Pouch-Anal Anastomosis (IPAA): Implications for Pouch Retention Lei Lian, Pokala R. Kiran, Bo Shen, Feza H. Remzi, Victor W. Fazio Background:Chronic sinus is a form of anastomotic leak that occurs in patients undergoing IPAA as a blind-ending track. The disease course of a sinus is poorly defined and its management can be challenging. Methods:Patients with chronic sinus were identified from a prospectively-maintained pelvic pouch database from 1997 to 2009. Patients with Crohn's disease of the pouch were excluded. Data pertaining to diagnostic modality, symptom, management, and outcomes were collected by chart review. Results:57 patients(66.1% male) were identified. Mean age at pouch surgery was 40±12.2 years. While 37 patients with chronic sinus underwent 2 or 3-stage primary pouch construction, 20 developed a chronic sinus after redo pouch. 33(57.9%) patients had a previous anastomotic leak or pelvic abscess. Initial diagnostic modalities were endoscopy(57.9%), gastrografin enema(33.3%), and exam under anesthesia(8.7%). MRI was used in 10 patients for further evaluation. 27 patients had sinus before LI closure with 21 having delayed ileostomy closure (median time to closure 197 days, range 119-756). The management of these patients included observation, drainage, unroofing, proximal diversion, and pouch excision. In total 40(70.2%) patients had complete healing of the sinus, 15 (26.3%) had pouch failure. Pouch failure rate was similar between patients who developed sinus before and after ileostomy closure(8/27 vs.7/ 30,p=0.59). For patients with sinus before ileostomy closure, pouch failure rate was significantly higher in patients without delayed ileostomy closure compared to patients with delayed closure (5/21 vs. 3/4,p=0.047). 30 had sinus after LI closure and 21 were symptomatic including diarrhea(n=12), anal pain(n=3), urgency(n=3), drainage(n=2), and fever(n=1). Pouch failure for the symptomatic patients was high (6/21: 28.6%). Conclusion:A chronic sinus after IPAA may be associated with pouch failure. Better management of the sinus before ileostomy closure may improve pouch retention. M1631
Revision in diagnosis
Long Term Conditional Survival in Esophageal Cancer: A SEER Database Analysis Attila Dubecz, Rudolf J. Stadlhuber, Hubert J. Stein BACKGROUND: For esophageal cancer patients 5-year survival rates are generally reported in the literature. It is not clear however, that in patients who already survived a certain period of time what probabilities of surviving an additional 5 years apply. METHODS: Clinical stage, surgical and non-surgical treatments, age, and race of patients with cancer of the esophagus were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988-2004). SEER identified a total of 25,306 patients with esophageal cancer (average age: 65.0 years, male-to-female ratio: 3.1). Overall five and ten-year survival of patients through all stages and the relative conditional survival (CS) of patients surviving
24 pts had double dx (IPS+SBBO, or CD+fistula/stricture)
SSAT Abstracts
S-870