Su1513 Stoma Reversal in Patients Who Underwent Low Anterior Resection and Diversion Stoma for Rectal Cancer

Su1512 Impact of Obesity on Operation Performed, Complications and Long Term Outcomes in Terms of Restoration of Intestinal Continuity for Patients With Mid and Low Rectal Cancer Erman Aytac, Ian C. Lavery, Matthew F. Kalady, Pokala R. Kiran Purpose: The impact of obesity per se on the surgical strategy i.e. sphincter sacrifice (abdominoperineal resection, APR) vs. restorative rectal resection (RRR), perioperative outcomes, and long-term maintenance of intestinal continuity has been poorly studied in patients with mid and low rectal cancer. We compare these outcomes for obese and non-obese patients with mid and low rectal cancer undergoing surgery. Methods: All patients undergoing curative surgery for mid or low rectal adenocarcinoma at a single institution from 1976-2011 were identified from a prospective cancer database. Obese and non-obese patients were matched 1:2 for age, gender, ASA class, location (low or mid rectum) and stage of tumor. Demographics, use of neoadjuvant chemoradiothrapy (NCRT) and adjuvant therapy, operative and perioperative outcomes, pathology, longterm outcomes including oncologic outcomes and whether or not restoration of intestinal continuity was performed were compared. Results: 157 obese patients and 314 non-obese patients, mean age 62 years at proctectomy were included. The groups were similar for matched characteristics. NCRT rate was higher in obese patients (p=0.048). A similar proportion of non-obese and obese patients underwent RRR (p=1) while postoperative hospital stay (p=0.23) and 30-day postoperative reoperation (p=0.83), mortality (p=1) and readmissions (p=0. 13) was similar. Non-obese and obese patients also had similar tumor differentiation (p=0.92) and lymph nodes examined (p= 0.64). Anastomotic leak was greater in obese patients (p=0.0003). End colostomy could not been reversed in 8 cases (3 obese and 5 non-obese, p=1) after a Hartmann's procedure which was performed as the initial curative intervention. During follow up, a loop ileostomy was created after an ileal pouch anal anastomosis, because of pouch failure and two cases (1 obese and 1 nonobese, p=1) received a permanent stoma after secondary operations for recurrences. Cancer specific mortality (p=0.55) and local recurrence (p=0.56) were similar for non-obese and obese patients after similar mean follow up time of 5 years for both groups (p=0.4). Conclusion: At a high-volume specialized colorectal unit, proctectomy can be performed with similar longterm oncologic outcomes and ability to restore intestinal continuity in obese patients when compared with the non-obese. The increased technical complexity expected in obese patients likely explains the associated increased use of NCRT and occurrence of anastomotic leak in obese when compared with non-obese patients. Characteristics of the groups

ASA: American Society of Anesthesiologists. BMI: body mass index. IPAA: ileal pouch anal anastomosis. Lap: laparoscopic. * Due to the conservative nature of interaction analysis, the significance level used for identifying interactions was 0.10, which is warranted to achieve a prudent balance of probabilities between type I and type II errors. Su1510

SSAT Abstracts

Pre-Operative Colonoscopic Localization of Tumour With Tattoo: A Re-Audit of Current Practice at a District General Hospital Akshay Kansagra, Sofoklis Panteleimonitis, Ugo Ihedioha, Alison Luther, John Isherwood, John Evans, Peter Kang Introduction: Preoperative localisation of tumour is an essential requirement in Laparoscopic colorectal surgery. Tattooing guidelines should be simple to follow and consistent for all lesions irrespective of the location of the tumour. Our recommendations were: To place at least two spots of tattoo distal to each lesion, and clearly document site of tattoo with respect to tumour in the endoscopy report. Method: We conducted a prospective audit of endoscopic tattooing of colorectal tumours resected in our hospital from February 2010 to January 2011. It was felt that the current guidelines were too complicated, leading to higher rates of inaccurate tattooing. Thereafter new guidelines were developed and subsequent practice reaudited. Results: 2010: 37 patients in total were identified. 14 were not tattooed. 3 patients had a tattoo which was inaccurate. 13 had accurate and well documented tattoos. 7 patients had tattoos of unknown accuracy. 2011: 24 patients in total were identified. 6 patients were not tattooed. 4 patients had no tattoos visible at operation. 1 patient had a tattoo which was inaccurate. 11 patients had accurate and well documented tattoos. 2 patients had tattoos of unknown accuracy. Of those patients which were tattooed and seen at surgery, 78.6% were accurate and clearly documented in 2011 compared to 56.5% in 2010 (p=0.2124) Of those patients which were tattooed and seen at surgery, 14.2% had unknown accuracy (not clearly documented) in 2011, compared to 30.4% in 2010 (p=0.3032) Of those patients which were tattooed and seen at surgery 7.14% were deemed inaccurate (tattoo in wrong place) in 2011, compared to 13.04% in 2010 (p=0.6043). Conclusion: The simpler method of tattooing all tumours distally has improved the accuracy of tattooing. Su1511 Right Sided Diverticulitis (RSD) - Highly Successful Non-Operative Management and Low Recurrence Rate Juan E. Arminan, George Roxin, Jennifer D. Stanger, Anthony R. MacLean, William D. Buie Background RSD, defined as diverticulitis involving the colon proximal to the splenic flexure, is uncommon in western countries. A low index of suspicion could affect the diagnosis and management of these patients. The purpose of this study was to examine presentation, treatment and outcome of patients admitted with RSD in a large urban area. Methods The health records of all patients admitted with diverticulitis between January 2007 and March 2010 were reviewed and the subset of patients admitted with RSD was identified. Records were reviewed looking at demographic, clinical, radiologic, treatment and outcome factors. Results 715 patients presented with acute diverticulitis, 68 had RSD (9.5%). Median age was 45 years (range 19 to 92yrs), 58.8% were female, median follow up 29.5 months (range 12 to 50). 60 patients (88.2%) presented with uncomplicated and 8 (11.8%) with complicated diverticulitis. 59 patients (86.7%) had a CT scan. 10 of these (14.7%) required surgery due to diagnostic uncertainty (2 incidental appendectomies, 8 segmental resections). 49 patients (83.1%) had CT diagnosis of RSD and were successfully treated non-operatively. 9 patients (13.2%) had surgery without imaging for presumed appendicitis (4 incidental appendectomies, 5 segmental resections). Post-operative morbidity was only 2.8%. Of the 55 patients whose RSD was treated without segmental resection, 1 was readmitted with recurrent diverticulitis at 2 weeks and underwent elective resection. 33 patients (60%) underwent subsequent colonoscopy at a mean of 3.5 months from admission, no alternate diagnoses found. Conclusions CT scan is accurate at diagnosing RSD. Once diagnosed, it can be successfully treated non-operatively. Risk of recurrent RSD following non operative management is very low.

SSAT Abstracts

‡median (range) * The cases, which had no anastomosis, excluded from the leak percentage calculation Su1513 Stoma Reversal in Patients Who Underwent Low Anterior Resection and Diversion Stoma for Rectal Cancer Wong-Hoi She, Jensen T. Poon, Wai-Lun Law, Joe K. Fan Background: Defunctioning ileostomy or colostomy is usually used to protect a high-risk anastomosis after low anterior resection for rectal cancer. Although the stoma is usually considered temporary, many a time, closure of the stoma is not performed because of various reasons. We aimed to review the incidence of reversal of stoma in patients after low anterior resection (LAR) with a diversion stoma. The factors associated with non stomal closure were analyzed. Methods: Five hundred and eighty-five patients who underwent LAR and diversion stoma from January 1999 to December 2010 were reviewed from our prospective collected database. LAR was performed with either laparoscopic or open approach. Diversion stoma was performed when the anastomosis was within 5 cm from the anal verge. Contrast enema was performed to assess the integrity of the anastomosis before closure. Patients' characteristics, disease status, operative details and adjuvant treatment were reviewed. The

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reasons for not closing the stoma were also studied. Results: Closure of stoma after initial LAR was performed in 469 patients. The median age was 67.3 months and duration between the two operations was 6.1 months. The remaining patients (n=111, 19.1%) did not undergo stoma closure. The reasons for unable underwent closure were broadly divided into two categories, anastomotic-related (47.7%) and non-anastomotic-related (52.3%). Of those anastomotic-related, persistent leakage, fistula and stricture composed 79.2% (n=42/53); while disease progression (n=39/58, 67.2%) predominated in non-anastomotic related group. Preoperative radiotherapy significantly decreased the chance of subsequent closure of stoma(26/ 84, 31.0%, p=0.001). Adjuvant chemotherapy did not have any adverse effect to the closure of stoma nor post-operative complications. The result of closure of ileostomy and colostomy were similar in terms of the types and incidences of post-operative. Conclusions: The temporary stoma after low anterior resection may become permanent in some patients. Over half of the patients who did not undergo closure of stoma were due to reasons other than anastomotic complications. Preoperative radiation therapy is associated with a higher chance of not closing the stoma. Thus a careful assessment of the disease status and general condition of the patient before deciding the use of a diversion stoma is recommended.

Su1516 Quality of Life of Patients Presenting With Hemmorhoidal Disease. the Importance of Using the Right Tool for the Right Question to Get the Right Answer Vriti Advani, Margaret Boehler, Jan Rakinic, Imran Hassan

Su1514 Robotic Low Anterior Resection With Trans-Anal vs. Trans-Abdominal Extraction Christopher R. Oxner, Julian Sanchez, Rebecca Nelson, Joseph Kim, Julio Garcia-Aguilar Background: Recently, there have been many studies initiated to validate robotic TME. Also, there have been a variety of minimally invasive extraction techniques for protocolectomy ranging from trans-abdominal to trans-vaginal. However, there has been little comparison of robotic techniques combined with completely minimally invasive approach. The goal of this study was to describe our experience with robotic TME for very low rectal adenocarcinoma and compare trans-abdominal vs. trans-anal extraction. Methods: This is a single institution, retrospective review comparing patients from December 2005 till August 2011who underwent robotic TME for rectal adenocarcinoma with coloanal anastomosis. The patients were stratified into two groups, trans-abdominal extraction or trans-anal extraction. Data were then collected on operative outcomes, complications, pathological specimen, etc. These groups were then compared using chi-square and t-test. Results: Fifty four patients underwent robotic TME with low anastomosis. 40 had a trans-abdominal extraction and 14 a trans-anal extraction. Patient demographics, BMI, blood loss, ileus, anastomotic leak rate, hospital stay, and days to regular diet were not significantly different. However, there was a significant difference observed in operative time and distance from the anal verge (pvalue < 0.05). Operative time for trans-anal was 350 ± 71 minutes compared to 290 ± 80 minutes for trans-abdominal. The trans-anal group average distance from the anal verge was 4.8cm while the average distance for the trans-abdominal group 6.8cm for the with a pvalue of 0.0196. Hospital stay differed from 4.6 ± 3 days vs. 7.7 ± 8 days for the trans-anal and trans-abdominal groups respectively but did not reach clinical significance. Conclusions: The feasibility of robotic TME has already been proven while its validity although early is comparable to laparoscopic TME. Furthermore, very low tumors amenable to sphincter preservation can lend themselves to a trans-anal extraction without compromising on operative and short term outcomes. In light of these equivocal results, this technique may be a more favorable option in patients when it is more difficult to get an adequate distal margin such as patients with a narrow pelvis (men), patient subsets with larger body habitus, or very low tumors. While the feasibility of trans-anal extraction is clear, larger numbers, prospective data, and patient stratification will be required to prove if there exists patient benefit to this technique. Demographic and Operative Comparisons

Su1517 Impact of Opioid-Related Adverse Events (ORAE) on Length of Stay (LOS) and Hospital Costs in Patients Undergoing a Laparoscopic Colectomy Sonia Ramamoorthy PURPOSE: Laparoscopic colectomy results in decreased postoperative ileus, pain, and disability, and can therefore lead to a shorter length of hospital stay (LOS) and reduced costs of care. As opioids are often used in the treatment of postsurgical pain, this retrospective analysis, a subset of data from a large health economics and outcomes research project, examined the impact of opioid-related adverse events (ORAEs) on LOS and hospital costs for patients who underwent laparoscopic colectomy procedures. METHODS: Over a 2-year period, 9/1/2008 through 9/30/2010, approximately 10 million annual hospital discharges were reviewed from a large national database including over 450 hospitals. Data on opioid usage, ORAEs, LOS, and hospital costs were reviewed for some of the most common surgeries in the US: open colectomy, laparoscopic colectomy, laparoscopic cholecystectomy, total abdominal hysterectomy and hip replacement, and populations were matched at a 3:1 ratio for age, gender, and APR severity of illness. Statistical analysis was performed on 181,283 matched hospital discharges after surgery, including 12,620 matched laparoscopic colectomies. RESULTS: Of the 12,620 matched laparoscopic colectomies reviewed, mean unadjusted LOS for patients who had an ORAE was 7.7 days compared to 6.2 days for patients without an ORAE (P<0.0001). Similarly, unadjusted mean total costs for patients with an ORAE were significantly higher than for patients who did not have an ORAE ($18,322 vs $15,720, respectively; P<0.0001). CONCLUSION: Patients who had a laparoscopic colectomy and experienced an ORAE had a longer LOS and higher total cost than similar patients who did not experience an ORAE. As the benefits of laparoscopic surgery include reduced LOS and cost, reducing the use of opioids and their consequent ORAEs would be expected to result in greater maintenance of those benefits. Su1518 Role of Fecal Diversion in Pediatric Colorectal Crohn's Disease in the Era of Anti-TNF-α Therapy Artur Chernoguz, Richard Falcone, Jaimie D. Nathan, Shehzad A. Saeed, Lee Denson, Daniel von Allmen, Jason Frischer Purpose: Colonic Crohn's disease is a therapeutic challenge in up to 80% of pediatric patients. Temporary fecal diversion aims to induce remission and avoid colonic resection by providing bowel rest. This mantra has been historically scrutinized for the potential risk of retaining

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SSAT Abstracts

SSAT Abstracts

INTRODUCTION: Based on clinical experience hemmorhoidal disease (HD) is considered to have a significant impact on patient quality of life (QOL). However there have been only two published studies that have measured QOL in patients with HD and both were unable to detect a significant impact of HD on QOL using generic QOL instruments. We hypothesized that HD and its related symptoms have a negative impact on patient QOL and that this could be detected if the appropriate QOL instrument was used. METHODS: All patients seen in the academic practice of two colorectal surgeons were administered the EORTCC30 questionnaire between January 2009 and October 2011. The EORTC-C30 is a disease specific questionnaire that was designed to measure QOL in cancer patients but has also been used extensively to measure QOL of patients with benign colorectal diseases. Four hundred and ninety-four surveys were returned (response rate 78%). One hundred and twenty four patients were evaluated for complaints related to HD and represented the study cohort while 61 patients who were asymptomatic as measured by the symptom scales were used as the control group (majority of these patients had presented for screening colonoscopies). The minimally important difference (MID) which is defined as the smallest difference in scores of a QOL instrument that is considered clinically significant, was estimated by calculating the Cohen's D effect size of the mean differences. RESULTS: Gender, age and marital status were similar between the 2 groups. Mean difference in functional scales between patients with HD and asymptomatic patients was 16 points and corresponded to a mean Cohen's D of 0.42 (moderate effect size) and was considered the MID. Patients with HD had significantly worse QOL on all measured functional scales compared to asymptomatic patients (Table). Common presenting complaints for HD included rectal bleeding (67%), pain (38%), change in bowel habits (21%) and discharge (10%). Among the patients with HD there were no clinically significant differences in overall QOL of patients with and without symptoms of rectal bleeding (70 vs. 70), rectal pain (65 vs. 73) and rectal discharge (59 vs. 71). However patients with change in bowel habits had clinically significant worse overall QOL compared to patients not reporting this symptom (57 vs. 73). CONCLUSION: HD and its related symptoms have a negative impact on patient QOL that is measurable with the use of the appropriate QOL instruments. Monitoring resolution of symptoms during treatment of hemmorhoidal disease is essential to offset their impact on QOL. Comparison of QOL of Patients with HD versus Asymptomatic Patients