Mo2133 Management of Splenic Cysts: Does Size Really Matter?

clearance margin with a median diameter of 5.1 cm (range 4.5-6.3 cm). Postoperative recovery in survival animals was uneventful and post-mortem examination demonstrated well-healed resection sites with no evidence of intra-abdominal infection or inadvertent organ damage. Endoscopic evaluation of anastomoses at post-mortem examination excluded stenosis. Histological assessment of the partial circumferential anastomosis showed primary closure by mucosal abuttal and regeneration together with restoration of continuity of submucosa. Conclusions: This proof-of-concept survival study has demonstrated the feasibility of safely achieving full thickness colonic specimens exceeding 5 cm in diameter. Accurate placement of endoscopic BBs ensures completeness of excision, reducing the risk of recurrence or residual disease while laparoscopic overview avoids collateral damage. This is the first localized excision technique described to date suitable for translational study in humans as an alternative to hemicolectomy. The ability to preserve mesenteric vasculature and colonic length is likely to result in less morbidity and mortality, reduced treatment costs and better functional outcomes.

analyzed using Chi-square or Fisher's exact test for categorical variables, Mann-Whitney U test for continuous variables. A multivariate analysis was carried out by logistic regression. P-values ,0.05 were considered statistically significant, and Odds Ratios were calculated with a 95% confidence interval. Results: Complete data were obtained from a total of 167 patients, with a median age of 50 years (i: 15 - 90), and a slight male predominance (55%). POI was observed in 24/167 patients (14,3%). On univariate analysis, some preoperative factors were significantly related to POI, such as higher age (p= 0,0007), higher ASA status (p=0,003), preoperative diagnose (cancer vs. no cancer; p=0,002), and history of previous abdominal surgery (p=0,019). BMI was not related to POI, neither as continuous variable nor as categorized factor ( ,30 vs. .=30). Among the intra- and postoperative factors, a longer OR time (p=0,003) as well as a lower postoperative potassium level (p=0,0004) were observed in patients suffering from POI. Neither the amount of intraoperative opioids nor the use of postoperative morphin-based PCA was related to POI. On multivariate analysis, previous abdominal surgery (OR 2,83, CI 1,067 - 7,832), OR time (OR 1,007; CI 1,0011 - 1,0142) and postoperative potassium levels (OR 0,0199; CI 0,064 - 0,6219) showed to be independently associated to POI. Conclusion: POI after laparoscopic colectomy is associated with specific preoperative, intraoperative and postoperative factors. Minimizing or addressing these factors may be expected to reduce the incidence of this common complication. Mo2132

Introduction Recognition of overwhelming post-splenectomy infection in splenectomized patients led to greater efforts to conserve splenic tissue following blunt trauma. Nonoperative management (NOM) of splenic trauma has emerged as a means to enhance splenic salvage. Accurate assessment of haemodynamic stability and injury severity are prerequisites to safety of such approach. Identification of splenic injuries that require early surgical repair or removal is vital. Aim To study the management of traumatic splenic injury at our institution and compare it against published guidelines from SSAT (Society for Surgery of the Alimentary Tract) and AAST (American Association for Surgery in Trauma) in relation to assessment, indications for splenectomy and role of NOM in absence of associated injuries. Methods A retrospective database was constructed to include splenic injuries admitted over a 10 year period. Cases were captured by searching the electronic CT scan reports database for those containing the words "splenic injury/rupture/haematoma/laceration" and the surgical database for operations coded as "Splenectomy/Splenorrhaphy". Cases were cross-checked against splenic pathology specimens' reports. Cases not associated with traumatic injury were excluded. A range of parameters were assessed and compared against published guidance from both SSAT and AAST. All index and follow up CT images were re-reviewed and regraded by a radiologist blinded to the outcome. The neo-CT reports with haemodynamic and haematologic status was compared with actual management and final outcome. Results: 48 cases of blunt traumatic splenic injury were identified; RTA was the most frequent mechanism of injury. 38 underwent splenectomy while 10 were managed conservatively. CT assessment was performed in all cases bar 4 who were taken straight for resuscitative laparotomy. AAST grading of the severity of splenic injury was reported in 8.3% of cases. Repeat imaging was sought in 60% of those cases initially managed conservatively with 7.8% having subsequent splenectomy. Average duration of observation was 0.8 days (0 8) in splenectomy group verses 10.1 days (3 - 23) in the successful conservative management group. There was a single mortality in this cohort due to associated head injury. Conclusions CT grading of splenic injury is under-reported and splenectomy is over-represented in this cohort. Protocol-based management and CT grading of all splenic injuries is recommended and will aid in identifying those who may benefit from a safe conservative approach.

Figure 1: Full-thickness colonic specimen with APC marks delineating clearance margin

Mo2133 Management of Splenic Cysts: Does Size Really Matter? Christopher Kenney, Yumiko E. Hoeger, Amy K. Yetasook, John G. Linn, Woody Denham, JoAnn Carbray, Michael B. Ujiki Purpose: To observe the natural history of splenic cysts and evaluate their management options. Methods: One hundred and eighty-two patients were identified from an IRBapproved database search with radiologic evidence of a splenic cyst over an 11-year period. We subdivided these patients into those who underwent intervention and those who did not. The patients who were observed with serial imaging were further divided into those whose cyst size was greater or less than 5 cm. All patient records were reviewed for history, diagnostic studies, operative intervention and outcomes. Results: In the current study, 182 patients were diagnosed with a splenic cyst and eight (4.4%) were included in the intervention group. In this group, all were female with mean age and cyst size of 27 years and 7.3 cm respectively. Five of these patients underwent percutaneous aspiration as a first intervention, all of which eventually were operatively resected or drained. Pathologic examination of resected specimens demonstrated benign lesions in all cases. The non-intervention group was comprised of 174 patients who were stratified by cyst size greater or less than 5 cm. One hundred and fifty-one patients had a cyst size less than 5 cm. The male to female ratio was 1:1.6 and the average age and cyst size were 56 years and 1.7 cm respectively. Seventyseven of these patients underwent follow up imaging over a mean period of 29 months. Average cyst size decreased to 1.5 cm yielding a growth rate of -0.23 cm/month. There were no complications related to the presence of the cyst during the observation period. Twentythree patients had a cyst size greater than 5 cm. The male to female ratio was 1:3 and the average age and cyst size were 50 years and 7.8 cm respectively. Sixteen of these patients underwent follow up imaging over a mean period of 45 months. Average cyst size decreased to 7.4 cm yielding a growth rate of -0.04 cm/month. One patient, a 95 year-old female, with a stable cyst size at 15 months follow up later presented with a ruptured cyst and died during the same admission. Her cause of death was not confirmed to be related to cyst rupture. Conclusions: This study presents the largest single series to date of patients with splenic cysts managed by aspiration, operative intervention, or observation. We noted, as

Figure 2: Endoscopic examination of the excision site 8 days post procedure Mo2131 Risk Factors for Postoperative Ileus in Patients Undergoing Laparoscopic Colorectal Surgery Udo Kronberg, Vivian Parada, Alejandro J. Zarate, Magdalena Castro, Valentina Salvador, Claudio Wainstein, Francisco López-Köstner Introduction: Postoperative ileus (POI) after laparoscopic colorectal surgery leads to increased anxiety for patients and caregivers, and is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate pre-, intra- and postoperative risk factors associated with the development of POI in patients undergoing laparoscopic colorectal surgery. Patients and Methods: Patients undergoing laparoscopic colectomy between January 2008 and January 2012 were identified from a prospectively maintained laparoscopic database. Clinical, metabolic and pharmacologic data were obtained retrospectively by reviewing the clinical charts. Patients with rectal resection were excluded. POI was defined as absence of bowel function for 5 or more days, or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction. Factors associated with POI were

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SSAT Abstracts

SSAT Abstracts

Accurate Haemodynamic and Image Based Assessment of Blunt Traumatic Splenic Injury May Identify Those WHO Will Benefit From a Conservative Approach Chris Brown, Rami Radwan, Karen Litton, David Fleming, Ashraf M. Rasheed

have others, that percutaneous drainage has a high recurrence rate. In addition, we did not find any malignant lesions in the operative specimens and noted a negative growth rate in those cysts that were followed with serial imaging. Our data suggest that the management of splenic cysts should be comprised of reserving aspiration for those who are not surgical candidates, resecting lesions that are truly symptomatic and observing those that are not, regardless of size. Tu1507 Online Transparency, Validation and Implementation of Research Findings Cornerstones in Building a Quality Registry. Report From the Swedish Registry of Gallstone Surgery and ERCP Lars Enochsson, Gunnar Persson Background: Cholecystectomy (laparoscopic or open) is one of the most frequent operations performed by general surgeons. Since the complication rate is low it has been difficult to evaluate the effects of different treatment strategies on the outcome due to lack of statistical power. This is in contrast to major surgery like in pancreatic or esophageal cancer where high complication rates make it easier to analyze the effects of major treatment changes. The Swedish Registry of Gallstone Surgery and ERCP (GallRiks) started in 2005 in order to be able to monitor the effect of different treatment strategies on the outcome. The aim of this paper is to present the impact that data from the registry has had in changing treatment strategies in cholecystectomy in Sweden. Methods: GallRiks is Supported by The National Board of Health and Welfare and The Swedish Surgical Society. There are approximately 60,000 cholecystectomies and 40,000 ERCP registered in the database during the period 2005-2011. Data are validated at every hospital in Sweden every third year to ensure good data quality. Each hospital has access to online reports where the outcome of their cholecystectomies and ERCP is compared with Sweden as a whole. The compliance of the registry in Sweden is good ( .85%). Results: This validated database has led to the initiation of many research projects. The results are published in peer-reviewed scientific journals as well as presented at local meetings for users and general presentations at the annual Swedish surgical week. The findings appear to have an impact on treatment strategies. Thus,the use of antibiotic prophylaxis decreased in Sweden from 23 % to 14 % after the publication of Lundström(2) that showed this to be ineffective in elective cholecystectomy. The administration of thromboembolic prophylaxis has decreased by 18% after presentation of a study by Persson (4) proving this to increase bleeding complications in laparoscopic cholecystectomy. Conclusions: A transparent validated national registry with good compliance is a valuable tool to analyze and improve treatment strategies in benign surgery with low complication rates. REFERENCES 1. Enochsson L et al. Gastrointestinal endoscopy 2010;72(6): 1175-1184, 1184 e1171-1173. 2. Lundstrom P et al. Journal of gastrointestinal surgery 2010;14(2): 329-334. 3. Palsson SH et al. ISRN gastroenterology 2011;2011: 507389. 4. Persson G et al. The British journal of surgery 2012;99(7): 979-986. 5. Tornqvist B et al. BMJ 2012;345: e6457.

Oblique view from the top of the device Tu1509 Gallstone Ileus - Impact of Cholecystectomy During the Initial Hospital Visit Greg Burgoyne, Richard Heitmiller Introduction: Gallstone ileus is a challenging and uncommon disease process. No guidelines have been established regarding the timing of cholecystectomy in the management of gallstone ileus. We review a national database to evaluate the impact patients undergoing cholecystectomy in their initial hospital stay. Methods: The Nationwide Inpatient Sample was searched for gallstone ileus patients (ICD-9 = 560.31) from 1998-2010. Only patients who underwent intestinal enterotomy (ICD-9 45.00-45.03) were included in this study. Variables studied were age, sex, length of stay, hospital teaching status, hospital charges, mortality, diagnoses and procedures. Data for patients who underwent cholecystectomy during their hospital stay (ICD-9 51.21-51.24) were compared to patients who did not. Results: Over 13 years, 4,253 patients were hospitalized with gallstone ileus and had an intestinal enterotomy with a mean of 327 cases per year. Mean age was 74.9 years; 1,234 were male (29%) and 3,019 were female (71%). 861 patients (20.2%) underwent cholecystectomy during the same hospital visit. 89.8% underwent open cholecystectomy, 6.3% open partial cholecystectomy, 3.5% laparoscopic cholecystectomy and 0.5% laparoscopic partial cholecystectomy. Mean mortality rate was 6.1%. Diagnoses and mortality rates associated with increased risk of death were aspiration pneumonia (37.3%), septicemia (31.3%), respiratory failure (28.1%), pneumonia (27.5%), acidosis (19.9%), heart failure (16.9%), COPD (14.4%), mental disorders (12.6%), atrial fibrillation (12.0%) and post-operative infection (11.1%). Conclusion: Gallstone ileus is more common in older women and was mostly treated by enterotomy alone. However, 20% of patients underwent cholecystectomy during their initial hospital visit. Most patients who underwent cholecystectomy underwent an open procedure. The length of stay, hospital charges and mortality rate were all greater in patients who underwent a cholecystectomy during their initial hospital stay. The mortality rate is also increased in patients who have underlying co-morbid conditions or who develop infectious complications such as septicemia, pneumonia and wound infections. Comparison of Cholecystectomy and No Cholecystectomy

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SSAT Abstracts

Creation and Evaluation of a Novel Device for Rapid and Safe Removal of the Gallbladder Through Laparoscopic Port Sites Joshua M. Judge, Gina Petroni, William H. Guilford, Craig L. Slingluff, Peter T. Hallowell Objective: To obtain preliminary data on the safety and usefulness of a novel device for extracting large and difficult-to-remove gallbladders during laparoscopic cholecystectomy. Background: A common source of frustration during laparoscopic cholecystectomy involves extraction of the gallbladder through a port site smaller than the gallbladder itself. Current techniques risk rupture of the bag or gallbladder and can be time consuming, leading to increased procedural cost. We developed and tested a novel device for the safe, minimal enlargement of laparoscopic port sites to extract large, stone-filled gallbladders from the abdomen. This device is a stainless-steel device with a vertical retraction blade and a linear aperture in the handle that admits a scalpel, which can be advanced along the back side of the vertical blade, enabling a controlled sharp enlargement of the laparoscopic port site and rapid removal of the gallbladder. Additionally, we sought to estimate the proportion of patients whose gallbladders are difficult to extract from the abdomen. Methods: This IRBapproved, single institutional, single surgeon study was offered to patients presenting for laparoscopic cholecystectomy with diagnoses high risk for difficult gallbladder extraction (those with cholelithiasis with or without complicating features). When gallbladder extraction was attempted, if successful without enlargement of the port site, the device was not used. If the gallbladder could not be removed with gentle traction on the specimen bag, and enlargement of the port site was considered, the device was used. The time required for extraction, from insertion of the device until complete specimen removal, was recorded. The study surgeon provided Likert scores for perceived utility of the device in each case. Patients were seen in follow-up irrespective of device use and assessed for pain level, cosmetic effect, and infectious complications. Results: Thirty-nine patients were enrolled in the study. For twenty (51%) there was difficulty extracting the gallbladder, requiring use of the device. Average extraction time for the first 8 patients was 120 seconds. After a planned interim analysis, an improved device was produced and used in the next 12 patients, for whom the average extraction time was 24 seconds. There were no adverse events. Post-operative pain rating and incision cosmesis scores were comparable between patients with or without use of the device. No wound infections or other wound complications were encountered. Conclusion: Difficult gallbladder extraction during laparoscopic cholecystectomy occurs in a large proportion of patients. The study device can safely and rapidly extract impacted gallbladders through the abdominal wall port site and is judged a useful tool by the study surgeon. Time for extraction of gallbladder with use of extraction device

SSAT Abstracts

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