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Mo1631 Can a Diverting Ileostomy Be Safely Closed in Patients With an Asymptomatic Radiologic Leak After Pelvic Bowel Anastomosis?
without adhesions (p = 0.60). In the multivariable analysis, factors independently decreasing the risk for having CPAP were higher age (OR 0.97; p 0.001) and BMI (OR 0.93; p 0.006), lower preoperative anxiety and depression symptom score (OR 0.32; p 0.045), and usage of a median incision (OR 0.52; p 0.006) (table 1). The presence of pain longer than three months (OR 3.99; p 0.000), preoperative usage of opioid analgesia (OR 3.54; p 0.001), a higher minimal NRS value on postoperative day 2 (OR 1.23; p 0.004) and severe adhesions underneath the incision (OR 1.63; p 0.040) showed to independently increase the risk for having abdominal pain 6 months after surgery. Conclusion 1 in 3 patients will have CPAP 6 months after elective abdominal surgery. The duration of preoperative pain, preoperative usage of opioid analgesia and the severity of acute postoperative pain and severe adhesions underneath the incision increase the risk for having CPAP 6 months after surgery. Older age and lower preoperative anxiety and depression symptom score showed to be protective for CPAP. These results can be used for improving patient counseling. Table 1 Multivariable logistic regression analysis for having chronic postoperative abdominal pain* (CPAP)
All lengths expressed in centimeters (cm) Mo1631 Can a Diverting Ileostomy Be Safely Closed in Patients With an Asymptomatic Radiologic Leak After Pelvic Bowel Anastomosis? Sharon Z. Koh, Cindy Kallman, Karen N. Zaghiyan, Edward H. Phillips, Phillip Fleshner Aim: There is currently no consensus with regards to management of patients who present with asymptomatic leaks after a colorectal, coloanal or ileal pouch-anal anastomosis protected with a diverting ileostomy (DI). It is recommended that closure of DI should only be performed in the presence of a healed anastomosis, generally about 8 weeks later. Delaying closure until anastomotic healing prolongs the inherent morbidity of DI and subjects patients to additional radiation exposure to confirm radiologic healing. We aim to demonstrate safety and efficacy in the restoration of bowel continuity in the presence of a stable radiologic leak (RL) on repeat gastrograffin enema (GGE). Methods: A single center retrospective analysis of all patients with a RL after a pelvic bowel anastomosis from January 2004 - October 2014 was performed. Patients with fistulous tracts arising from the RL to other organs were excluded. Clinically stable RL were defined by lack of symptoms of pelvic sepsis (fever, lower abdominal pressure or pain or genitourinary symptoms) and stable size on repeat imaging. DI were closed in patients meeting these criteria. Results: 14 patients had a median age of 59 (range, 21-88) years and included 9 (64%) males. Index surgical procedures included colorectal (n=3), ileorectal (n=2), coloanal (n=2) and ileal pouch-anal (n=7) anastomoses. None of the patients became symptomatic or had enlargement of the leak during the observation period. 4 (29%) patients had resolution of the RL on follow-up GGE. Comparison of patient groups that had or did not have spontaneous leak resolution demonstrated that only size of the abscess cavity on the initial GGE predicted resolution of the leak. Median area (measured in 2 standard axes) of the leak in those with resolution of the RL (79mm2) was significantly smaller than those that did not resolve (410mm2) (p=0.03). Morphology, lengths and location of the sinus and/or fistulous tracts between the RL and the pelvic anastomoses were not predictive factors for the resolution of the RL. The median time to takedown of the DI from RL recognition was 20 (1-153) days with 9 patients (64%) having closure within 1 month from the last GGE. The delay in closure in one patient was due to a postoperative development of an enterocutaneous fistula from a small bowel anastomosis. None of the patients developed pelvic sepsis requiring takedown of the pelvic anastomosis after reversal of the DI during the median follow up of 3 (range 0.9-30) months. One patient in the group with residual RL required a DI performed due to radiation proctitis 10 months after restoration of bowel continuity. Conclusion: Closure of the DI in asymptomatic patients with a RL appears to be safe. There may not be a need to repeat GGE to ensure resolution of a stable RL prior to DI reversal, hence minimizing unnecessary delay and additional radiation.
*Chronic abdominal pain was defined as abdominal pain impacting social functioning or worse; Explanation special characters; †: as measured by the preoperative mental health subscale of the SF-36; |: Severe adhesions were defined as grade 3 and 4 adhesions as classified by the Zühlke classification; ‡: the minimal NRS (Normative Rating Scale) value reported by patients on postoperative day 2
SSAT Abstracts
Mo1630 Length of Bowel Distal to a Diverting Ileostomy (DI) Does Not Influence the Risk of Dehydration After Ileal Pouch-Anal Anastomosis (IPAA) Sharon Z. Koh, Cindy Kallman, Christopher Watterson, Karen N. Zaghiyan, Edward H. Phillips, Phillip Fleshner
Mo1632 Readmission Following Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Carcinomatosis — Can We Predict (or Avoid) Them? Alexander S. Martin, Daniel E. Abbott, Dennis J. Hanseman, Jonathan E. Sussman, Alexander Kenkel, Richard P. Greiwe, Noor Saeed, Samar Ahmad, Jeffrey Sussman, Syed Ahmad
Purpose: As the most common early postoperative surgical complication, readmission for dehydration after creation of DI with IPAA ranges between 5-15%. There are no studies that assess whether the length of the afferent limb (AL) or pouch length (PL) influences the rate of readmission prior to closure of the DI. We hypothesized that longer lengths of the AL and PL would increase the risk of readmission for dehydration due to an overall decreased length of absorptive bowel. Aim: To determine if AL or PL measured at the time of pouchogram is associated with severe dehydration necessitating readmission to the hospital. Methods: Patients undergoing IPAA with DI between January 2003 and May 2013 were identified. All patients had a pouchogram before DI reversal. AL, PL and combined length (CL=AL+PL) were measured by study personnel blinded to the primary study endpoint. We identified patients with the readmitting diagnosis of dehydration within 60 days of DI creation based on high ileostomy output (>/=1500 ml on the day of readmission) and/or biochemical abnormalities of dehydration (elevated blood urea nitrogen or creatinine). Patients with known renal impairment, previous radiotherapy to the pelvis or prior small bowel resection were excluded. Results: Of the 327 study patients, 320 (98%) had surgery for IBD and 7 (2%) underwent surgery for colonic polyposis. 30 (9%) were readmitted for significant dehydration a mean (SD) of 11.8 (±13.5) days after hospital discharge. Clinical features between patients with or without dehydration requiring readmission were comparable except for 2 factors: indication for surgery and number of stages of IPAA. The readmission rate for dysplasia/cancer (20%) was significantly higher than that for medically refractory disease (7%) (p=0.009). In addition, the readmission rate of 2-stage IPAA (12%) was significantly higher vs. 3-stage IPAA (5%) (p=0.03). Mean (SD) lengths of the AL, PL and CL were 50 (±20) cm, 15 (±4) cm, and 65 (±20) cm in the readmitted patient group vs. 45 (±17) cm, 13 (±4) cm and 58 (±17) cm in the non-readmitted group (all p=NS). Conclusion: Risk of readmission due to dehydration prior to reversal of DI is higher in patients undergoing IPAA for dysplasia/cancer and a 2-stage IPAA. The lengths of the afferent limb and pouch do not predict readmission for dehydration after IPAA with DI. It is possible that patients undergoing 3-stage IPAA become more adept at managing their stoma output during the initial subtotal colectomy with end ileostomy prior to undergoing IPAA compared with patients having a 2-stage procedure. Similarly, patients with medically refractory IBD may have a natural history of more severe or prolonged diarrhea and possibly be better at managing their fluid balance.
SSAT Abstracts
Purpose: CRS/HIPEC for peritoneal carcinomatosis is a morbid endeavor. Despite improvement in perioperative management of these patients, there are subsets of patients requiring hospital readmission after discharge. Because the current health care climate demands an understanding of causative or explanatory factors of readmission, we sought to identify variables associated with readmission rates for CRS/HIPEC. Methods: We conducted a retrospective review of CRS/HIPEC cases at a single institution between 1999 and 2014. Patient, tumor and treatment specific characteristics including completeness of cytoreduction (CCR), length of surgery, estimated blood loss (EBL), peritoneal cancer index (PCI), postoperative complications, length of hospital stay, readmission rates, length of readmission hospital stay, and reasons for readmission were included in the final dataset. Univariate analyses were used to understand the association between patient and outcome-specific variables and 7, 30 and 90-day readmission. Results: Of 215 CRS/HIPEC patients, the 7, 30 and 90 day readmission rates were 9.8% (n=21), 14.9% (n=32), and 21.4% (n=46) respectively. The most common reasons for 30-day readmission included abdominal pain (n = 14), intraabdominal abscess (n = 9), malnutrition/failure to thrive (n = 8), bowel obstruction (n = 7), and fever (n = 5). The primary factor associated with readmission at all time points (7, 30 and 90 days) was presence of an enterocutaneous fistula (ECF, p<0.01). Six patients (2.8%) had multiple readmissions; 3 of these had ECF. 24 (11.2%) and 112 (52.1%) patients underwent small bowel and colon resections, respectively; the ECF rate for these populations was 8.3% and 4.5%. Factors not associated with higher admission rates included sex, age, race, EBL, pancreatectomy, liver resection, and postoperative complications of wound infection, line infection and thromboemboli. Conclusions: In patients undergoing CRS/ HIPEC, readmission was primarily associated with ECF and its attendant electrolyte/fluid abnormalities. Patients with ECF were also disproportionately readmitted multiple times. These data should inform clinicians about patients at high-risk for readmission after CRS/ HIPEC, and encourage more comprehensive coordination of post-discharge planning and care for specific patient populations.
S-1156
All lengths expressed in centimeters (cm) Mo1631 Can a Diverting Ileostomy Be Safely Closed in Patients With an Asymptomatic Radiologic Leak After Pelvic Bowel Anastomosis? Sharon Z. Koh, Cindy Kallman, Karen N. Zaghiyan, Edward H. Phillips, Phillip Fleshner Aim: There is currently no consensus with regards to management of patients who present with asymptomatic leaks after a colorectal, coloanal or ileal pouch-anal anastomosis protected with a diverting ileostomy (DI). It is recommended that closure of DI should only be performed in the presence of a healed anastomosis, generally about 8 weeks later. Delaying closure until anastomotic healing prolongs the inherent morbidity of DI and subjects patients to additional radiation exposure to confirm radiologic healing. We aim to demonstrate safety and efficacy in the restoration of bowel continuity in the presence of a stable radiologic leak (RL) on repeat gastrograffin enema (GGE). Methods: A single center retrospective analysis of all patients with a RL after a pelvic bowel anastomosis from January 2004 - October 2014 was performed. Patients with fistulous tracts arising from the RL to other organs were excluded. Clinically stable RL were defined by lack of symptoms of pelvic sepsis (fever, lower abdominal pressure or pain or genitourinary symptoms) and stable size on repeat imaging. DI were closed in patients meeting these criteria. Results: 14 patients had a median age of 59 (range, 21-88) years and included 9 (64%) males. Index surgical procedures included colorectal (n=3), ileorectal (n=2), coloanal (n=2) and ileal pouch-anal (n=7) anastomoses. None of the patients became symptomatic or had enlargement of the leak during the observation period. 4 (29%) patients had resolution of the RL on follow-up GGE. Comparison of patient groups that had or did not have spontaneous leak resolution demonstrated that only size of the abscess cavity on the initial GGE predicted resolution of the leak. Median area (measured in 2 standard axes) of the leak in those with resolution of the RL (79mm2) was significantly smaller than those that did not resolve (410mm2) (p=0.03). Morphology, lengths and location of the sinus and/or fistulous tracts between the RL and the pelvic anastomoses were not predictive factors for the resolution of the RL. The median time to takedown of the DI from RL recognition was 20 (1-153) days with 9 patients (64%) having closure within 1 month from the last GGE. The delay in closure in one patient was due to a postoperative development of an enterocutaneous fistula from a small bowel anastomosis. None of the patients developed pelvic sepsis requiring takedown of the pelvic anastomosis after reversal of the DI during the median follow up of 3 (range 0.9-30) months. One patient in the group with residual RL required a DI performed due to radiation proctitis 10 months after restoration of bowel continuity. Conclusion: Closure of the DI in asymptomatic patients with a RL appears to be safe. There may not be a need to repeat GGE to ensure resolution of a stable RL prior to DI reversal, hence minimizing unnecessary delay and additional radiation.
*Chronic abdominal pain was defined as abdominal pain impacting social functioning or worse; Explanation special characters; †: as measured by the preoperative mental health subscale of the SF-36; |: Severe adhesions were defined as grade 3 and 4 adhesions as classified by the Zühlke classification; ‡: the minimal NRS (Normative Rating Scale) value reported by patients on postoperative day 2
SSAT Abstracts
Mo1630 Length of Bowel Distal to a Diverting Ileostomy (DI) Does Not Influence the Risk of Dehydration After Ileal Pouch-Anal Anastomosis (IPAA) Sharon Z. Koh, Cindy Kallman, Christopher Watterson, Karen N. Zaghiyan, Edward H. Phillips, Phillip Fleshner
Mo1632 Readmission Following Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Carcinomatosis — Can We Predict (or Avoid) Them? Alexander S. Martin, Daniel E. Abbott, Dennis J. Hanseman, Jonathan E. Sussman, Alexander Kenkel, Richard P. Greiwe, Noor Saeed, Samar Ahmad, Jeffrey Sussman, Syed Ahmad
Purpose: As the most common early postoperative surgical complication, readmission for dehydration after creation of DI with IPAA ranges between 5-15%. There are no studies that assess whether the length of the afferent limb (AL) or pouch length (PL) influences the rate of readmission prior to closure of the DI. We hypothesized that longer lengths of the AL and PL would increase the risk of readmission for dehydration due to an overall decreased length of absorptive bowel. Aim: To determine if AL or PL measured at the time of pouchogram is associated with severe dehydration necessitating readmission to the hospital. Methods: Patients undergoing IPAA with DI between January 2003 and May 2013 were identified. All patients had a pouchogram before DI reversal. AL, PL and combined length (CL=AL+PL) were measured by study personnel blinded to the primary study endpoint. We identified patients with the readmitting diagnosis of dehydration within 60 days of DI creation based on high ileostomy output (>/=1500 ml on the day of readmission) and/or biochemical abnormalities of dehydration (elevated blood urea nitrogen or creatinine). Patients with known renal impairment, previous radiotherapy to the pelvis or prior small bowel resection were excluded. Results: Of the 327 study patients, 320 (98%) had surgery for IBD and 7 (2%) underwent surgery for colonic polyposis. 30 (9%) were readmitted for significant dehydration a mean (SD) of 11.8 (±13.5) days after hospital discharge. Clinical features between patients with or without dehydration requiring readmission were comparable except for 2 factors: indication for surgery and number of stages of IPAA. The readmission rate for dysplasia/cancer (20%) was significantly higher than that for medically refractory disease (7%) (p=0.009). In addition, the readmission rate of 2-stage IPAA (12%) was significantly higher vs. 3-stage IPAA (5%) (p=0.03). Mean (SD) lengths of the AL, PL and CL were 50 (±20) cm, 15 (±4) cm, and 65 (±20) cm in the readmitted patient group vs. 45 (±17) cm, 13 (±4) cm and 58 (±17) cm in the non-readmitted group (all p=NS). Conclusion: Risk of readmission due to dehydration prior to reversal of DI is higher in patients undergoing IPAA for dysplasia/cancer and a 2-stage IPAA. The lengths of the afferent limb and pouch do not predict readmission for dehydration after IPAA with DI. It is possible that patients undergoing 3-stage IPAA become more adept at managing their stoma output during the initial subtotal colectomy with end ileostomy prior to undergoing IPAA compared with patients having a 2-stage procedure. Similarly, patients with medically refractory IBD may have a natural history of more severe or prolonged diarrhea and possibly be better at managing their fluid balance.
SSAT Abstracts
Purpose: CRS/HIPEC for peritoneal carcinomatosis is a morbid endeavor. Despite improvement in perioperative management of these patients, there are subsets of patients requiring hospital readmission after discharge. Because the current health care climate demands an understanding of causative or explanatory factors of readmission, we sought to identify variables associated with readmission rates for CRS/HIPEC. Methods: We conducted a retrospective review of CRS/HIPEC cases at a single institution between 1999 and 2014. Patient, tumor and treatment specific characteristics including completeness of cytoreduction (CCR), length of surgery, estimated blood loss (EBL), peritoneal cancer index (PCI), postoperative complications, length of hospital stay, readmission rates, length of readmission hospital stay, and reasons for readmission were included in the final dataset. Univariate analyses were used to understand the association between patient and outcome-specific variables and 7, 30 and 90-day readmission. Results: Of 215 CRS/HIPEC patients, the 7, 30 and 90 day readmission rates were 9.8% (n=21), 14.9% (n=32), and 21.4% (n=46) respectively. The most common reasons for 30-day readmission included abdominal pain (n = 14), intraabdominal abscess (n = 9), malnutrition/failure to thrive (n = 8), bowel obstruction (n = 7), and fever (n = 5). The primary factor associated with readmission at all time points (7, 30 and 90 days) was presence of an enterocutaneous fistula (ECF, p<0.01). Six patients (2.8%) had multiple readmissions; 3 of these had ECF. 24 (11.2%) and 112 (52.1%) patients underwent small bowel and colon resections, respectively; the ECF rate for these populations was 8.3% and 4.5%. Factors not associated with higher admission rates included sex, age, race, EBL, pancreatectomy, liver resection, and postoperative complications of wound infection, line infection and thromboemboli. Conclusions: In patients undergoing CRS/ HIPEC, readmission was primarily associated with ECF and its attendant electrolyte/fluid abnormalities. Patients with ECF were also disproportionately readmitted multiple times. These data should inform clinicians about patients at high-risk for readmission after CRS/ HIPEC, and encourage more comprehensive coordination of post-discharge planning and care for specific patient populations.
S-1156