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Surgery in Complicated Sigmoid Diverticulitis: Retrospective Analysis
group of age matched healthy participants were also recruited. Exclusion criteria were patients already receiving vitamin B12 supplementation, pregnancy, anaemia, or those unable to give written consent. Ethical approval was obtained. Results Twenty-seven control patients were recruited, 22 male and 5 female, age 74+/-10 years (mean +/- standard deviation-SD). Twenty-eight surgical patients were recruited, 18 male, 10 female, age 74+/-8 years (mean+/SD). HCyst were 15.8+/-7 mmol/L in the surgical group 13.2+/-6.2 mmol/L in the control group (p=0.037). There was no difference in MMA, folate and active B12 levels between the two groups (p > 0.05). Conclusion Right hemicolectomy for malignancy is associated with a significant increase in HCyst levels. This may indicate a reduction in tissue levels of vitamin B12 although serum B12 is normal. This requires further study. Percentages have been rounded and they might not sum up to 100 Su1791 OUTCOMES OF WEEKEND ADMISSIONS FOR LOWER GASTROINTESTINAL HEMORRHAGE AFTER LEFT VENTRICULAR ASSIST DEVICE IMPLANTATION IN THE UNITED STATES Chung-Jyi Tsai, Rocio Lopez
Su1794
Background & Aims: Continuous-flow left ventricular assist devices (LVAD) are becoming the standard of care for managing refractory advanced heart failure. Adverse events in LVAD patients remain high. Lower GI hemorrhage (LGIH) after LVAD is a significant source of morbidity and mortality. Day of admission during weekdays or weekend (weekend effect) is associated with various clinical outcomes. It is unknown if weekend effect exists in LVAD patients with LGIH. Methods: Information on hospital admissions was collected from the Nationwide Inpatient Sample (NIS) from 2002 to 2011. NIS is the largest all-payer database within US with more than 1,000 hospitals sampled to represent approximately 20% of all hospital discharges each year. Patients were selected by querying all 15 procedural codes for the ICD-9-CM codes for LVAD. LGIH and obesity were defined using ICD-9-CM diagnosis codes. A modified Charlson Comorbidity Index (CCI) was calculated using the NIS Disease Severity Measure files. Logistic and linear regression models with SAS programming were used to analyze the effects. Results: A total of 13,607 patients had LVAD procedures from 2002 to 2011. 3,923 of these (29%) had LGIH during the same admission. 12% of these were weekend admissions while 88% were weekday admissions. Weekend admissions were more likely to be non-elective and in hospitals of larger bed size than weekday admissions. Patients admitted on weekends tended to have acute renal failure, acute respiratory failure, and use of mechanical ventilation for more than 96 hours. In the multivariable analysis, compared with patients admitted on weekdays, patients admitted on weekends had no significant differences in mortality rates, endoscopy therapy rates, and length of hospital stay. In-hospital endoscopy rates were not related to mortality rates. The in-hospital mortality among obese patients admitted on weekends (10.3%) was slightly higher than that (8%) of the non-obese but statistically insignificant. Conclusions: LVAD patients with LGIH admitted on weekends, compared with those patients admitted on weekdays, had similar mortality rates, endoscopy therapy rates, and lengths of stay. In-hospital endoscopy rates were unrelated to mortality rates.
Globally diverticulosis is considered as a western world or developed country disease with prevalance from 5% to 45%. Anatomically 90% diverticulosis involves distal or left sided colon and only 1.5% involves solely right colon. Although its uncommon in asian and african race, incidence increasing due to westerniztion in diet habit i.e. less vegetables or fibre rich food. In Asian scenario prevalance of right colon diverticulosis edges over left colon (1,2). Incidence increases with age perticularly in sigmoid diverticulosis i.e. 60% after age of 80 (3). In India with prevalance of 9% according to south Indian cohort(4) where as 3% as North Indian cohort(5). 46% from total had left colon disease, 40% with right colon and 13% detected with pancolic diverticulosis(4). Various complications can occur with this benign and silent disease namely Bleeding Perforation, Abscess, Fistula, Stricture, Obstruction, Ureteral Obstruction, Phlegmon (Inflammatory mass),Saint's Triad (Diverticulosis, cholelithiasis and hiatal hernia). Comlications occur in 10 - 25% of cases. It can also creates dilemma for differential diagnosis of malignancy hence requires vigilant attention. CECT abdomen gets grade A recommendation to clinch the diagnosis and guide the management while colonoscopy is detecting many incidental diverticulosis without much role in acute presentations. Paradigm of treatment is shifting more towards conservative approach avoiding emergency exploration and morbid multistage interventions like hartmann's procedure. Laparoscopy is preferable choice in elective procedure. A multicenter randomized of primary anastomosis or Hartmann's Procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis showed favorble results for primary anastomosis(6). We represent retrospective analysis and outcome in last 18 months of tertiary centre of South Gujarat where in 2445 colonoscopy we detected 198 diverticulosis (8%). Pancolic diverticuli were most common i.e. 44% (89/198) followed by left side (31%) and right side (23%). Total 21 patients admitted for symptomatic diverticular disease in which 18 admissions were for sigmoid diverticulitis with average age of 61 years. Most common presenting symptom was bleeding per rectum in our study. Emergency surgery was required in 16 patients, from which primary anastomosis with diverting stoma was done in 14 patients where as hartmann's procedure done in 2 patients. Two patients underwent elective surgery, one after putting pigtail and second for stricture. Mortality in one patient, who had second stage surgery for hartmann's reversal. To conclude, incidence of complicated sigmoid divertilculitis is more requiring intervention as compare to other parts of bowel. Primary anastomosis should be choice of surgery with or without diversion which depends on intra operative findings.
Su1793 MANAGEMENT STRATEGIES FOR SQUAMOUS CELL CARCINOMA OF THE RECTUM: IS THERE A ROLE FOR SURGERY? Paolo Goffredo, Aaron Scott, Irfan Rizvi, Imran Hassan Introduction: Squamous cell carcinoma of the rectum (RSCC) is a rare malignancy that accounts for approximately 0.01-0.025% of all colorectal cancers. As a result, published data regarding its management are mainly limited to small single institutional series. Our aim was to analyze the disease-specific survival (DSS) according to different treatment modalities for AJCC stage I, II, and III RSCCs in order to determine the optimal management strategy. Methods: We identified 1038 patients with stage I, II, and III RSCCs from the Surveillance, Epidemiology, and End Results (SEER) database treated between 1998 and 2013. Management strategies were categorized as radiation or local excision alone, radiation with local excision, and radiation with radical resection. These modalities accounted for ~85% of patients in the cohort. Stratified survival analyses were adjusted by gender, age, and race. Data were examined using simple summary statistics, chi-square and student's-T tests, Kaplan-Meier analysis, and Cox proportional hazards regression. Results: The majority of patients were white (85%) and female (65%). Mean age at diagnosis was 62±14 years. The 5-year DSS was 80% for stage I (530 pts), 61% for stage II (262 pts), and 61% for stage III (246 pts, p<0.001). In univariate analysis for patients with stage I and II disease, no difference was observed in the 5-year DSS among management strategies (p=0.94 and 0.29, respectively). However, for stage III disease, the combination of radiation and radical resection was associated with worse outcomes compared to radiation ± local excision (p= 0.017) (Table 1). After adjustment for available demographic confounders, the addition of local excision or radical resection to radiation was not associated with improved survival across all stages. Conclusions: Our data suggest that for stage I disease either radiation or local excision only may represent an adequate oncologic treatment. The addition of local excision or radical surgery to radiation for stage II and III disease was not associated with a survival benefit. Therefore, a treatment approach primarily based on radiation should be considered the optimal management strategy for squamous cell carcinomas of the rectum. Five year disease-specific survival by AJCC stage and Management Strategy
Su1795 THE NEGATIVE EFFECT OF THE LARGE AMOUNT OF PERITONEAL LAVAGE ON POST-OPERATIVE INTRA-ABDOMINAL ABSCESS FORMATION Miyako Tanaka, Fukashi Serizawa, Takuya Jimbo, Kazuki Kawashima, Takeshi Asakura, Hiroshi Otomo, Kenichi Yokota Background: Post-operative intra-abdominal abscess is one of the most critical complication after appendectomy, and effective managements to prevent intra-abdominal abscess is still controversial. We hypothesized the incidence of intra-abdominal abscess formation depended on the peritoneal lavage volume during surgery. Objectives: We enrolled 96 patients (63 males and 33 females) who were underwent appendectomies for gangrenous and perforated appendicitis from January 2007 to August 2016 at Kesennnuma city hospital. Patient`s age was 51.2 ± 2.0. Under the age of 18 and cancer related appendicitis cases were excluded. Patients were divided into 2 groups according to their development of post-operative intraabdominal abscess (intra-abdominal abscess group (IAA group, n = 17) and non-intraabdominal abscess group (non-IIA group, n = 79). Patient's background characteristics including age, sex, BMI, past history, stercolith, ascites, time to surgery from symptoms onset, pre-operative intra-abdominal abscess formation, anti-biotics agents, peritoneal lavage volume, white blood cell count (WBC), C-Reactive protein (CRP), pathological findings were compared between these two groups. The peritoneal lavage volume was corrected with body surface area. Results: The risk factors associated with post-operative intra-abdominal abscess formation were older age (p = 0.02), pre-operative intra-abdominal abscess formation (p < 0.01), high CRP values (p < 0.01) and lower serum albumin levels (p < 0.01). No significant difference was observed in the time from symptoms onset to surgery between IAA (66 ± 7 hours) and non-IAA (98 ± 27 hours) groups (p = 0.31, N.S.). The peritoneal lavage volume was larger in IAA group even though we corrected with body surface area (p < 0.01). Decreasing rates of WBC and CRP on 1 to 3 post-operative day were lower in IAA group (p < 0.01, each). Conclusions: Surgeons usually carry out the peritoneal lavage with large quantities of water if peritoneal severe pollution was found. However, simple lavage was not effective to prevent post-operative intra-abdominal abscess formation. Our findings may indicate a negative effect of a large amount of peritoneal lavage.
S-1257
SSAT Abstracts
SSAT Abstracts
SURGERY IN COMPLICATED SIGMOID DIVERTICULITIS: RETROSPECTIVE ANALYSIS Pankaj N. Desai, Dhaval Mangukiya, Keyur Bhatt
Su1794
Background & Aims: Continuous-flow left ventricular assist devices (LVAD) are becoming the standard of care for managing refractory advanced heart failure. Adverse events in LVAD patients remain high. Lower GI hemorrhage (LGIH) after LVAD is a significant source of morbidity and mortality. Day of admission during weekdays or weekend (weekend effect) is associated with various clinical outcomes. It is unknown if weekend effect exists in LVAD patients with LGIH. Methods: Information on hospital admissions was collected from the Nationwide Inpatient Sample (NIS) from 2002 to 2011. NIS is the largest all-payer database within US with more than 1,000 hospitals sampled to represent approximately 20% of all hospital discharges each year. Patients were selected by querying all 15 procedural codes for the ICD-9-CM codes for LVAD. LGIH and obesity were defined using ICD-9-CM diagnosis codes. A modified Charlson Comorbidity Index (CCI) was calculated using the NIS Disease Severity Measure files. Logistic and linear regression models with SAS programming were used to analyze the effects. Results: A total of 13,607 patients had LVAD procedures from 2002 to 2011. 3,923 of these (29%) had LGIH during the same admission. 12% of these were weekend admissions while 88% were weekday admissions. Weekend admissions were more likely to be non-elective and in hospitals of larger bed size than weekday admissions. Patients admitted on weekends tended to have acute renal failure, acute respiratory failure, and use of mechanical ventilation for more than 96 hours. In the multivariable analysis, compared with patients admitted on weekdays, patients admitted on weekends had no significant differences in mortality rates, endoscopy therapy rates, and length of hospital stay. In-hospital endoscopy rates were not related to mortality rates. The in-hospital mortality among obese patients admitted on weekends (10.3%) was slightly higher than that (8%) of the non-obese but statistically insignificant. Conclusions: LVAD patients with LGIH admitted on weekends, compared with those patients admitted on weekdays, had similar mortality rates, endoscopy therapy rates, and lengths of stay. In-hospital endoscopy rates were unrelated to mortality rates.
Globally diverticulosis is considered as a western world or developed country disease with prevalance from 5% to 45%. Anatomically 90% diverticulosis involves distal or left sided colon and only 1.5% involves solely right colon. Although its uncommon in asian and african race, incidence increasing due to westerniztion in diet habit i.e. less vegetables or fibre rich food. In Asian scenario prevalance of right colon diverticulosis edges over left colon (1,2). Incidence increases with age perticularly in sigmoid diverticulosis i.e. 60% after age of 80 (3). In India with prevalance of 9% according to south Indian cohort(4) where as 3% as North Indian cohort(5). 46% from total had left colon disease, 40% with right colon and 13% detected with pancolic diverticulosis(4). Various complications can occur with this benign and silent disease namely Bleeding Perforation, Abscess, Fistula, Stricture, Obstruction, Ureteral Obstruction, Phlegmon (Inflammatory mass),Saint's Triad (Diverticulosis, cholelithiasis and hiatal hernia). Comlications occur in 10 - 25% of cases. It can also creates dilemma for differential diagnosis of malignancy hence requires vigilant attention. CECT abdomen gets grade A recommendation to clinch the diagnosis and guide the management while colonoscopy is detecting many incidental diverticulosis without much role in acute presentations. Paradigm of treatment is shifting more towards conservative approach avoiding emergency exploration and morbid multistage interventions like hartmann's procedure. Laparoscopy is preferable choice in elective procedure. A multicenter randomized of primary anastomosis or Hartmann's Procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis showed favorble results for primary anastomosis(6). We represent retrospective analysis and outcome in last 18 months of tertiary centre of South Gujarat where in 2445 colonoscopy we detected 198 diverticulosis (8%). Pancolic diverticuli were most common i.e. 44% (89/198) followed by left side (31%) and right side (23%). Total 21 patients admitted for symptomatic diverticular disease in which 18 admissions were for sigmoid diverticulitis with average age of 61 years. Most common presenting symptom was bleeding per rectum in our study. Emergency surgery was required in 16 patients, from which primary anastomosis with diverting stoma was done in 14 patients where as hartmann's procedure done in 2 patients. Two patients underwent elective surgery, one after putting pigtail and second for stricture. Mortality in one patient, who had second stage surgery for hartmann's reversal. To conclude, incidence of complicated sigmoid divertilculitis is more requiring intervention as compare to other parts of bowel. Primary anastomosis should be choice of surgery with or without diversion which depends on intra operative findings.
Su1793 MANAGEMENT STRATEGIES FOR SQUAMOUS CELL CARCINOMA OF THE RECTUM: IS THERE A ROLE FOR SURGERY? Paolo Goffredo, Aaron Scott, Irfan Rizvi, Imran Hassan Introduction: Squamous cell carcinoma of the rectum (RSCC) is a rare malignancy that accounts for approximately 0.01-0.025% of all colorectal cancers. As a result, published data regarding its management are mainly limited to small single institutional series. Our aim was to analyze the disease-specific survival (DSS) according to different treatment modalities for AJCC stage I, II, and III RSCCs in order to determine the optimal management strategy. Methods: We identified 1038 patients with stage I, II, and III RSCCs from the Surveillance, Epidemiology, and End Results (SEER) database treated between 1998 and 2013. Management strategies were categorized as radiation or local excision alone, radiation with local excision, and radiation with radical resection. These modalities accounted for ~85% of patients in the cohort. Stratified survival analyses were adjusted by gender, age, and race. Data were examined using simple summary statistics, chi-square and student's-T tests, Kaplan-Meier analysis, and Cox proportional hazards regression. Results: The majority of patients were white (85%) and female (65%). Mean age at diagnosis was 62±14 years. The 5-year DSS was 80% for stage I (530 pts), 61% for stage II (262 pts), and 61% for stage III (246 pts, p<0.001). In univariate analysis for patients with stage I and II disease, no difference was observed in the 5-year DSS among management strategies (p=0.94 and 0.29, respectively). However, for stage III disease, the combination of radiation and radical resection was associated with worse outcomes compared to radiation ± local excision (p= 0.017) (Table 1). After adjustment for available demographic confounders, the addition of local excision or radical resection to radiation was not associated with improved survival across all stages. Conclusions: Our data suggest that for stage I disease either radiation or local excision only may represent an adequate oncologic treatment. The addition of local excision or radical surgery to radiation for stage II and III disease was not associated with a survival benefit. Therefore, a treatment approach primarily based on radiation should be considered the optimal management strategy for squamous cell carcinomas of the rectum. Five year disease-specific survival by AJCC stage and Management Strategy
Su1795 THE NEGATIVE EFFECT OF THE LARGE AMOUNT OF PERITONEAL LAVAGE ON POST-OPERATIVE INTRA-ABDOMINAL ABSCESS FORMATION Miyako Tanaka, Fukashi Serizawa, Takuya Jimbo, Kazuki Kawashima, Takeshi Asakura, Hiroshi Otomo, Kenichi Yokota Background: Post-operative intra-abdominal abscess is one of the most critical complication after appendectomy, and effective managements to prevent intra-abdominal abscess is still controversial. We hypothesized the incidence of intra-abdominal abscess formation depended on the peritoneal lavage volume during surgery. Objectives: We enrolled 96 patients (63 males and 33 females) who were underwent appendectomies for gangrenous and perforated appendicitis from January 2007 to August 2016 at Kesennnuma city hospital. Patient`s age was 51.2 ± 2.0. Under the age of 18 and cancer related appendicitis cases were excluded. Patients were divided into 2 groups according to their development of post-operative intraabdominal abscess (intra-abdominal abscess group (IAA group, n = 17) and non-intraabdominal abscess group (non-IIA group, n = 79). Patient's background characteristics including age, sex, BMI, past history, stercolith, ascites, time to surgery from symptoms onset, pre-operative intra-abdominal abscess formation, anti-biotics agents, peritoneal lavage volume, white blood cell count (WBC), C-Reactive protein (CRP), pathological findings were compared between these two groups. The peritoneal lavage volume was corrected with body surface area. Results: The risk factors associated with post-operative intra-abdominal abscess formation were older age (p = 0.02), pre-operative intra-abdominal abscess formation (p < 0.01), high CRP values (p < 0.01) and lower serum albumin levels (p < 0.01). No significant difference was observed in the time from symptoms onset to surgery between IAA (66 ± 7 hours) and non-IAA (98 ± 27 hours) groups (p = 0.31, N.S.). The peritoneal lavage volume was larger in IAA group even though we corrected with body surface area (p < 0.01). Decreasing rates of WBC and CRP on 1 to 3 post-operative day were lower in IAA group (p < 0.01, each). Conclusions: Surgeons usually carry out the peritoneal lavage with large quantities of water if peritoneal severe pollution was found. However, simple lavage was not effective to prevent post-operative intra-abdominal abscess formation. Our findings may indicate a negative effect of a large amount of peritoneal lavage.
S-1257
SSAT Abstracts
SSAT Abstracts
SURGERY IN COMPLICATED SIGMOID DIVERTICULITIS: RETROSPECTIVE ANALYSIS Pankaj N. Desai, Dhaval Mangukiya, Keyur Bhatt