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T1713 Prospective Study On the Management of Acute Diverticulitis
0.05). Bowel frequency was not significantly different at the other time points, but LCNpreserved group tended to have better functions at any observing time points assessed. Conclusions: We have revealed the LCN preserving LAR expressed better bowel function at the early postoperative period compared with the conventional procedure irrespective of LPA. LCN preservation may be one of the feasible procedures for improving the postoperative bowel function after LAR.
T1715 Laparoscopic Appendectomy for Complicated Appendicitis Pierpaolo Sileri, Paolo Gentileschi, Giuseppe S. Sica, Piero Rossi, Luana Franceschilli, Federico Perrone, Achille Lucio Gaspari Background: Laparoscopic appendectomy (LA) is associated with less postoperative pain and earlier return to normal activity. However its role in the management of complicated appendicitis remains undefined and the choice of the operative approach is mostly at surgeon's discretion. In this prospective study we compared the laparoscopic and the open approaches in terms of safety and efficacy for complicated appendicitis. Patients and methods: Consecutive patients who underwent appendectomy for acute appendicitis from January 2003 to November 2007 at our teaching Institution were studied. Patient's data including demographics, operative time, short term complications (including surgical site infectionsSSI), length of stay and access-related longer-term complications (small bowel obstruction, incisional hernia) were prospectively recorded and entered in a database. Data from patients who underwent OA or LA for complicated appendicitis were compared. These data were also matched with OA or LA for uncomplicated appendicitis (controls). Complicated appendicitis was defined as gangrenous or perforated appendicitis with or without the presence of abscess. Exclusion criteria were: age <14 years, patients presenting with generalized peritonitis or patients requiring additional surgery to appendectomy. Student's t-test, Mann-Whitney U test and the Fisher exact test were used for statistical analysis. Results: A total of 260 patients (124 M, 136 F, mean age 29+/-12 years) underwent appendectomy during the study period. Eighty-two (31.5%) were complicated appendicititis: 38 patients underwent open appendectomy (OA) while 44 underwent LA. Conversion rate to OA complicated appendicitis rate was significantly increased compared to uncomplicated (15.4% vs 2.2%; p<0.003). No significant differences were observed in terms of mean operative time or length of stay between OA and LA for complicated appendicitis and results were similar to OA and LA performed for uncomplicated controls. Overall complication rate was higher (but not significant) after OA compared to LA for complicated appendicitis (7.9% vs 4.5%). Both rates were also similar to uncomplicated controls. Overall incidence of SSI was 3.1% and infections were equally distributed between groups (complicated vs uncomplicated: 2.4% vs 3.4%; OA vs LA: 4.5% vs 2.2%). One patient of OA group experienced incisional hernia. Conclusions: complicated appendicitis is associated with an increased need of conversion to open technique. However this study failed to show significant differences between LA and OA performed for complicated appendicitis.
T1713 Prospective Study On the Management of Acute Diverticulitis Pierpaolo Sileri, Vito M. Stolfi, Paolo Gentileschi, Giuseppe S. Sica, Girolamo De Andreis, Alessandra Di Giorgio, Alberto Galante, Achille Lucio Gaspari Acute diverticulitis (AD) is the most common presentation of diverticular disease with high morbidity and mortality. We report our experience with the management of AD and we examined several clinical parameters in order to evaluate their predictive role for early discharge or prolonged hospitalization/surgery. Patients and methods: We prospectively evaluated all patients with AD admitted to our teaching Institution between January 2005 and October 2007. AD requiring admission was defined by the presence of lower abdominal pain and tenderness and/or guarding in left iliac fossa associated with systemic inflammatory response as shown by the presence of one or more of the following: fever (>38°C),WBC count > 12.000 or CRP elevation (>20 mg/dl). Patient's related data including age, gender, co-morbidities, onset and duration of symptoms before admission as well as clinical data were prospectively entered in a database and analyzed to assess their predictive role for prolonged hospitalization/surgery. Results: According to our criteria, 146 patients were identified (68 M, 78 F; mean age 64 years, range 27-91). Duration of symptoms before admission averaged 5 days (1- 30 days). At admission, fever was present in 58.2% of patients, increased WBC count in 61% and raised CRP in 78.1%. Nine-two patients (63%) had a previous diagnosis of diverticular disease, 31 (21.2%) had one or more previous admission for AD. Ten patients (6.8%) required immediate surgery, while the remaining were initially treated conservatively (analgesia, bowel rest and appropriate antibiotics). Medical treatment alone was effective in 94.1% of patients and 84.6% were discharged within 4 days. Twentyone patients required prolonged hospitalization (average 11 days, range 5-112). Two patient required abscess percutaneos drainage . Medical treatment failed in 6 patients (4.4%) after 5.5 days+/-3.5 days. Overall, 16 patients (11%) underwent surgery: 9 Hartmann's procedure, 5 bowel resections with primary anastomosis , 1 subtotal colectomy and 1 laparoscopy with abscess drainage. Overall mortality and morbidity rates were 2.1% and 12.3%. Surgical mortality and morbidity were 12.5 % and 56.2% including intra-operative bleeding managed with Mikulicz packing (1), surgical site infections (5), pneumonia (2) and cardiac arrhythmia (1). Previous AD, duration of symptoms before admission(>3 days), obesity, and steady elevation of CRP predicted prolonged hospitalization or surgery. Conclusions: After admission for AD the risk of hospitalization or surgery is significantly higher if patient is obese, experienced previous similar admissions or if CRP mantains steady elevation.
T1716
Purpose: Small intestinal bacterial overgrowth (SIBO) is a condition associated with irritable bowel syndrome (IBS) and a variety of autonomic symptoms. The SIBO breath test has been found to be positive in 84% of patients with IBS vs 20% of controls. We hypothesized that SIBO would be more prevalent in patients with IBS-like symptoms who have undergone previous abdominal surgery due to adhesions and potential for stasis. Methods: A retrospective review of patients from a tertiary colorectal surgery clinic was performed to identify patients with SIBO considered in the differential diagnosis. Demographics, past medical and surgical history, presenting symptoms, and diagnostic evaluations were recorded. SIBOpositive patients were compared SIBO-negative patients in case-control fashion. Multiple regression analysis was performed to identify etiologic factors for SIBO. Results: Seventy subjects were identified during a 36-month period (2004-2007). 18 patients were excluded due to noncompliance with testing, and 2 were excluded due to a decision to treat for SIBO without formal testing. Common presenting symptoms included chronic abdominal pain (52%), bloating (46%), constipation (66%), and diarrhea (12%). Mean symptom duration was 45 months (range 2-216). Mean age was 52 years (range 17-91), weight 152 lb (range 93-264), and 86% were female. The majority of patients were Caucasian (81%) and Hispanic (17%). 80% of patients had previous abdominal surgery, mean 2 procedures (range 0-6), 18% of which involved foregut, 12% midgut, 27% hindgut, and 43% female reproductive organs. Prior surgery was performed laparoscopically in 20% of patients vs open in 80%. 8% of patients had a history of small intestinal obstruction. 76% of patients tested positive for SIBO, 78% with previous surgery vs 70% without previous surgery. SIBO-positive patients were older than SIBO-negative patients: mean age 56 vs 44 yrs, (p< 0.01). Logistic regression analysis did not reveal any clinically significant independent factors associated with SIBO. Symptoms resolved in 50% of patients treated with GI tract antibiotics. Conclusions: SIBO is very common in a colorectal surgery population presenting with lower GI complaints. Although a past history of abdominal and pelvic surgery was not associated with a statistically higher incidence of SIBO, the high prevalence of SIBO-positive breath tests was greater than historical control rates. While further study is needed to assess the risk of SIBO after abdominal surgery, SIBO should be considered in the differential diagnosis of patients with normal anatomic findings and chronic lower gastrointestinal complaints.
T1714 Incidence of Adhesional Small Bowel Obstruction (SBO) After Colorectal Surgery Pierpaolo Sileri, Alessandra Mele, Vito Maria Stolfi, Nicola Di Lorenzo, Paolo Gentileschi, Giuseppe S. Sica, Achille Lucio Gaspari Background: Colorectal surgery (CRS) leads to high rates of access-related complications. Adhesive small bowel obstruction (SBO) is reported as high as 35% with large clinical impact and financial burden. In this study we evaluated the cumulative incidence of adhesive SBO in a cohort of patients after CRS. We also assessed the role of laparoscopy as adhesion prevention strategy. Methods: Data on patients undergoing elective or emergency CRS (either open or laparoscopic) were prospectively entered in a database. Adhesive SBO episodes requiring admission or reintervention were recorded. The diagnosis of SBO was defined by a combination of clinical criteria and imaging. Time interval of SBO, surgery type and setting, readmission length and findings at reintervention were recorded. Patients undergoing CRS for inflammatory bowel disease, patients with peritoneal carcinosis, or patients with SBO secondary to local or peritoneal recurrence during the follow-up were excluded. Patients who underwent other abdominal surgery during the follow-up were also excluded. Data were analysed using Mann-Whitney U test and chi-square test. The Kaplan Meier method was used to calculate the cumulative probability of developing SBO. Results: from 1/03 to 10/07, 426 patients satisfied our criteria and underwent elective (48.6%) or emergency (51.4%) colorectal surgery (73.7% open and 26.3% laparoscopic). Mean follow-up was 28 months. Eleven (2.6%) patients experienced 14 SBO episodes and 8 (1.9%) required surgery. There was a large variation in the first readmission interval, 54% occurred within 3 months, 38.5% between 3 and 12 months and 14.3% after 1 year. At first admission 54.5% of patients underwent surgery. Seven patients required adhesiolysis and 1 patient needed resection for small bowel ischaemia. The risk of readmission for SBO was higher during the first postoperative year and the cumulative risk steadily increased every year thereafter. The risk of reoperation was related to the number of readmissions for SBO, doubling at the second readmission and reaching 100% after the third. Mean length of stay was 8 and 15 days respectively for non-operative and operative treatment. SBO risk was significantly higher after pelvic surgery/extensive resections compared to minor procedures (5.2% vs 2,6%; p< 0.03), after open compared to laparoscopic (3.2% vs 0.9%; p< 0.001) but similar after emergency surgery compared to elective (NS). Conclusions: Colorectal surgery results in significant ongoing risk of SBO depending from the colorectal procedure. The number of readmissions for SBO predicts the need of surgery. Laparoscopy seems to minimize the risk of adhesive SBO.
T1717 Contemporary Surgical Management for Ileosigmoid Fistulas in Crohn's Disease Genevieve B. Melton, Luca Stocchi, Elizabeth Wick, Kweku A. Appau, Victor W. Fazio BACKGROUND: Ileosigmoid fistula (ISF) in Crohn's disease (CD) is a challenging clinical condition. The current role of diagnostic modalities and specific surgical management options for ISF in CD are not well characterized. METHODS: Patients from a prospectively collected CD database who underwent surgery for ISF during 2002-2007 were included. Demographics, disease extent, diagnostic modalities, operative approach, perioperative outcomes, concurrent medication use, and smoking status were retrospectively reviewed. Overall length of hospital stay included any postoperative readmission and stoma reversal. Converted cases were considered as laparoscopic procedures in an intent-to-treat analysis. RESULTS: A total
A-883
SSAT Abstracts
SSAT Abstracts
Small Intestinal Bacterial Overgrowth Is Common in Patients with Lower Gastrointestinal Symptoms and a History of Previous Abdominal Surgery Grant G. Sarkisyan, Maura Fernandez, Eileen A. Coloma, Patrizio Petrone, Gabriel Akopian, Adrian E. Ortega, Howard S. Kaufman
T1715 Laparoscopic Appendectomy for Complicated Appendicitis Pierpaolo Sileri, Paolo Gentileschi, Giuseppe S. Sica, Piero Rossi, Luana Franceschilli, Federico Perrone, Achille Lucio Gaspari Background: Laparoscopic appendectomy (LA) is associated with less postoperative pain and earlier return to normal activity. However its role in the management of complicated appendicitis remains undefined and the choice of the operative approach is mostly at surgeon's discretion. In this prospective study we compared the laparoscopic and the open approaches in terms of safety and efficacy for complicated appendicitis. Patients and methods: Consecutive patients who underwent appendectomy for acute appendicitis from January 2003 to November 2007 at our teaching Institution were studied. Patient's data including demographics, operative time, short term complications (including surgical site infectionsSSI), length of stay and access-related longer-term complications (small bowel obstruction, incisional hernia) were prospectively recorded and entered in a database. Data from patients who underwent OA or LA for complicated appendicitis were compared. These data were also matched with OA or LA for uncomplicated appendicitis (controls). Complicated appendicitis was defined as gangrenous or perforated appendicitis with or without the presence of abscess. Exclusion criteria were: age <14 years, patients presenting with generalized peritonitis or patients requiring additional surgery to appendectomy. Student's t-test, Mann-Whitney U test and the Fisher exact test were used for statistical analysis. Results: A total of 260 patients (124 M, 136 F, mean age 29+/-12 years) underwent appendectomy during the study period. Eighty-two (31.5%) were complicated appendicititis: 38 patients underwent open appendectomy (OA) while 44 underwent LA. Conversion rate to OA complicated appendicitis rate was significantly increased compared to uncomplicated (15.4% vs 2.2%; p<0.003). No significant differences were observed in terms of mean operative time or length of stay between OA and LA for complicated appendicitis and results were similar to OA and LA performed for uncomplicated controls. Overall complication rate was higher (but not significant) after OA compared to LA for complicated appendicitis (7.9% vs 4.5%). Both rates were also similar to uncomplicated controls. Overall incidence of SSI was 3.1% and infections were equally distributed between groups (complicated vs uncomplicated: 2.4% vs 3.4%; OA vs LA: 4.5% vs 2.2%). One patient of OA group experienced incisional hernia. Conclusions: complicated appendicitis is associated with an increased need of conversion to open technique. However this study failed to show significant differences between LA and OA performed for complicated appendicitis.
T1713 Prospective Study On the Management of Acute Diverticulitis Pierpaolo Sileri, Vito M. Stolfi, Paolo Gentileschi, Giuseppe S. Sica, Girolamo De Andreis, Alessandra Di Giorgio, Alberto Galante, Achille Lucio Gaspari Acute diverticulitis (AD) is the most common presentation of diverticular disease with high morbidity and mortality. We report our experience with the management of AD and we examined several clinical parameters in order to evaluate their predictive role for early discharge or prolonged hospitalization/surgery. Patients and methods: We prospectively evaluated all patients with AD admitted to our teaching Institution between January 2005 and October 2007. AD requiring admission was defined by the presence of lower abdominal pain and tenderness and/or guarding in left iliac fossa associated with systemic inflammatory response as shown by the presence of one or more of the following: fever (>38°C),WBC count > 12.000 or CRP elevation (>20 mg/dl). Patient's related data including age, gender, co-morbidities, onset and duration of symptoms before admission as well as clinical data were prospectively entered in a database and analyzed to assess their predictive role for prolonged hospitalization/surgery. Results: According to our criteria, 146 patients were identified (68 M, 78 F; mean age 64 years, range 27-91). Duration of symptoms before admission averaged 5 days (1- 30 days). At admission, fever was present in 58.2% of patients, increased WBC count in 61% and raised CRP in 78.1%. Nine-two patients (63%) had a previous diagnosis of diverticular disease, 31 (21.2%) had one or more previous admission for AD. Ten patients (6.8%) required immediate surgery, while the remaining were initially treated conservatively (analgesia, bowel rest and appropriate antibiotics). Medical treatment alone was effective in 94.1% of patients and 84.6% were discharged within 4 days. Twentyone patients required prolonged hospitalization (average 11 days, range 5-112). Two patient required abscess percutaneos drainage . Medical treatment failed in 6 patients (4.4%) after 5.5 days+/-3.5 days. Overall, 16 patients (11%) underwent surgery: 9 Hartmann's procedure, 5 bowel resections with primary anastomosis , 1 subtotal colectomy and 1 laparoscopy with abscess drainage. Overall mortality and morbidity rates were 2.1% and 12.3%. Surgical mortality and morbidity were 12.5 % and 56.2% including intra-operative bleeding managed with Mikulicz packing (1), surgical site infections (5), pneumonia (2) and cardiac arrhythmia (1). Previous AD, duration of symptoms before admission(>3 days), obesity, and steady elevation of CRP predicted prolonged hospitalization or surgery. Conclusions: After admission for AD the risk of hospitalization or surgery is significantly higher if patient is obese, experienced previous similar admissions or if CRP mantains steady elevation.
T1716
Purpose: Small intestinal bacterial overgrowth (SIBO) is a condition associated with irritable bowel syndrome (IBS) and a variety of autonomic symptoms. The SIBO breath test has been found to be positive in 84% of patients with IBS vs 20% of controls. We hypothesized that SIBO would be more prevalent in patients with IBS-like symptoms who have undergone previous abdominal surgery due to adhesions and potential for stasis. Methods: A retrospective review of patients from a tertiary colorectal surgery clinic was performed to identify patients with SIBO considered in the differential diagnosis. Demographics, past medical and surgical history, presenting symptoms, and diagnostic evaluations were recorded. SIBOpositive patients were compared SIBO-negative patients in case-control fashion. Multiple regression analysis was performed to identify etiologic factors for SIBO. Results: Seventy subjects were identified during a 36-month period (2004-2007). 18 patients were excluded due to noncompliance with testing, and 2 were excluded due to a decision to treat for SIBO without formal testing. Common presenting symptoms included chronic abdominal pain (52%), bloating (46%), constipation (66%), and diarrhea (12%). Mean symptom duration was 45 months (range 2-216). Mean age was 52 years (range 17-91), weight 152 lb (range 93-264), and 86% were female. The majority of patients were Caucasian (81%) and Hispanic (17%). 80% of patients had previous abdominal surgery, mean 2 procedures (range 0-6), 18% of which involved foregut, 12% midgut, 27% hindgut, and 43% female reproductive organs. Prior surgery was performed laparoscopically in 20% of patients vs open in 80%. 8% of patients had a history of small intestinal obstruction. 76% of patients tested positive for SIBO, 78% with previous surgery vs 70% without previous surgery. SIBO-positive patients were older than SIBO-negative patients: mean age 56 vs 44 yrs, (p< 0.01). Logistic regression analysis did not reveal any clinically significant independent factors associated with SIBO. Symptoms resolved in 50% of patients treated with GI tract antibiotics. Conclusions: SIBO is very common in a colorectal surgery population presenting with lower GI complaints. Although a past history of abdominal and pelvic surgery was not associated with a statistically higher incidence of SIBO, the high prevalence of SIBO-positive breath tests was greater than historical control rates. While further study is needed to assess the risk of SIBO after abdominal surgery, SIBO should be considered in the differential diagnosis of patients with normal anatomic findings and chronic lower gastrointestinal complaints.
T1714 Incidence of Adhesional Small Bowel Obstruction (SBO) After Colorectal Surgery Pierpaolo Sileri, Alessandra Mele, Vito Maria Stolfi, Nicola Di Lorenzo, Paolo Gentileschi, Giuseppe S. Sica, Achille Lucio Gaspari Background: Colorectal surgery (CRS) leads to high rates of access-related complications. Adhesive small bowel obstruction (SBO) is reported as high as 35% with large clinical impact and financial burden. In this study we evaluated the cumulative incidence of adhesive SBO in a cohort of patients after CRS. We also assessed the role of laparoscopy as adhesion prevention strategy. Methods: Data on patients undergoing elective or emergency CRS (either open or laparoscopic) were prospectively entered in a database. Adhesive SBO episodes requiring admission or reintervention were recorded. The diagnosis of SBO was defined by a combination of clinical criteria and imaging. Time interval of SBO, surgery type and setting, readmission length and findings at reintervention were recorded. Patients undergoing CRS for inflammatory bowel disease, patients with peritoneal carcinosis, or patients with SBO secondary to local or peritoneal recurrence during the follow-up were excluded. Patients who underwent other abdominal surgery during the follow-up were also excluded. Data were analysed using Mann-Whitney U test and chi-square test. The Kaplan Meier method was used to calculate the cumulative probability of developing SBO. Results: from 1/03 to 10/07, 426 patients satisfied our criteria and underwent elective (48.6%) or emergency (51.4%) colorectal surgery (73.7% open and 26.3% laparoscopic). Mean follow-up was 28 months. Eleven (2.6%) patients experienced 14 SBO episodes and 8 (1.9%) required surgery. There was a large variation in the first readmission interval, 54% occurred within 3 months, 38.5% between 3 and 12 months and 14.3% after 1 year. At first admission 54.5% of patients underwent surgery. Seven patients required adhesiolysis and 1 patient needed resection for small bowel ischaemia. The risk of readmission for SBO was higher during the first postoperative year and the cumulative risk steadily increased every year thereafter. The risk of reoperation was related to the number of readmissions for SBO, doubling at the second readmission and reaching 100% after the third. Mean length of stay was 8 and 15 days respectively for non-operative and operative treatment. SBO risk was significantly higher after pelvic surgery/extensive resections compared to minor procedures (5.2% vs 2,6%; p< 0.03), after open compared to laparoscopic (3.2% vs 0.9%; p< 0.001) but similar after emergency surgery compared to elective (NS). Conclusions: Colorectal surgery results in significant ongoing risk of SBO depending from the colorectal procedure. The number of readmissions for SBO predicts the need of surgery. Laparoscopy seems to minimize the risk of adhesive SBO.
T1717 Contemporary Surgical Management for Ileosigmoid Fistulas in Crohn's Disease Genevieve B. Melton, Luca Stocchi, Elizabeth Wick, Kweku A. Appau, Victor W. Fazio BACKGROUND: Ileosigmoid fistula (ISF) in Crohn's disease (CD) is a challenging clinical condition. The current role of diagnostic modalities and specific surgical management options for ISF in CD are not well characterized. METHODS: Patients from a prospectively collected CD database who underwent surgery for ISF during 2002-2007 were included. Demographics, disease extent, diagnostic modalities, operative approach, perioperative outcomes, concurrent medication use, and smoking status were retrospectively reviewed. Overall length of hospital stay included any postoperative readmission and stoma reversal. Converted cases were considered as laparoscopic procedures in an intent-to-treat analysis. RESULTS: A total
A-883
SSAT Abstracts
SSAT Abstracts
Small Intestinal Bacterial Overgrowth Is Common in Patients with Lower Gastrointestinal Symptoms and a History of Previous Abdominal Surgery Grant G. Sarkisyan, Maura Fernandez, Eileen A. Coloma, Patrizio Petrone, Gabriel Akopian, Adrian E. Ortega, Howard S. Kaufman