- Email: [email protected]
W1499 Laparoscopic-Assisted Versus Open Ileocolic Resection for Crohn's Disease: Long Term Results of a Prospective Randomized Trial
a very severe retroperitoneal sepsis which needed reoperation with fecal diversion. The STARR technique showed less postoperative pain in this study with a similar outcome with regard to ODS compared to Block, but had higher costs, longer hospital stay and showed the possibility of life threatening complication.
472 cases were analyzed after various exclusions. Age-adjusted incidence rates were 0.04 per 100,000 for 1973-2005 (95% CI 0.04-0.04). There was a 1.66% overall increase in total cases diagnosed from 1975 to 2005 amounting to an annual increase of 2.21% (p value <0.05). There were 290 (61.4%) females and 182 (38.6%) males. Mean age at diagnosis was 68 (median 71; range 21-100). Patients above the age of 80 were more likely to be females (P = 0.03). 402 patients were white, 24 black, 45 other (American Indian/AK Native/ Asian/Pacific Islander) and the rest were of unknown race. Stage of disease was localized in 34%, regional in 25%, distant in 25% and unstaged in 14%. Common sites were rectum (33%), anus and anal canal (26%), over lapping lesions of anorectum (21%) and esophagus (8%). While the rectum was the most common site in either gender (34% in each), 71.5% of anorectal melanomas were found in females while 68% of stomach and 71% of small intestinal melanomas presented in males (P = 0.0004). Significantly greater proportion of men (68 %) than women (43 %) were married while more women were widowed (37.5%) than men (7%) (P < 0.0001). 1-year and 5-year relative survival were 61% and 18% respectively (median survival 16 months). On univariate analysis, age and stage were significant variables with worst survival noted in age > 80 (P = 0.015) and distant disease (P < 0.0001). On multivariate analysis other race was prognostic of better survival (P = 0.02), while distant stage predicted worse survival (P = 0.01). There was no significant difference in survival based on site of tumor. Conclusion: While primary gastrointestinal melanoma continues to be rare, the incidence has steadily increased. Overall prognosis is poor and as in most malignancies, advanced age and stage of disease continue to be predictors of worse survival. Chances of survival may improve with earlier detection.
W1499 Laparoscopic-Assisted Versus Open Ileocolic Resection for Crohn's Disease: Long Term Results of a Prospective Randomized Trial Emma J. Eshuis, Frederik Slors, Miguel A. Cuesta, Robert Pierik, Pieter Stokkers, Mirjam A. Sprangers, Willem Bemelman Background: Four meta-analyses exist evaluating the short term results of laparoscopic versus open ileocolic resection for Crohn's disease. Little is known about the long term results of both procedures with respect to surgical recurrence rate, overall reoperation rate, incidence of incisional hernia, adhesive small bowel obstruction, quality of life (QOL) and Body Image (BI) and cosmesis. Aim: The objective of this study is to determine the long term results of a randomized multicenter study comparing laparoscopic with open ileocolic resection for Crohn's disease. Materials and methods: Sixty patients who participated in this trial were prospectively followed in the outpatient clinic. Patients had an ileocolic resection between 1999 and 2003. Primary outcome parameters were overall reoperation and readmission rate and re-resection rate for recurrent Crohn's disease. Secondary outcomes were QOL, BI and cosmesis. Results: Five patients, 1 from the laparoscopic group and 4 from the open group were lost to follow up. The groups were comparable for characteristics as sex, age, and maintenance therapy. Mean follow-up was 6.8 years. Overall, 16/29 (55%) and 16/26 (62%) patients remained relapse-free after the ileocolic resection in the laparoscopic and open group respectively (p=NS). Resection of recurrent Crohn's disease occurred in 2/29 (7%) and 3/26 (12%) patients (p=NS). Two reoperations for incisional hernia were done in the open group (2/26= 8%) vs. nil in the laparoscopic group. Reoperation for adhesive small bowel obstruction was done twice in the open group (2/26=8%) vs. nil in the laparoscopic group. Overall reoperation rate was 2/29 (7%) versus 7/26 (27%) in the laparoscopic and open group respectively (p=0.047). QOL was similar in both groups. BI and cosmesis scores were significantly higher in the laparoscopic group (p=0.029 and p=0.000 respectively). Conclusions: Surgical recurrence and QOL after laparoscopic and open ileocolic resection for Crohn's disease are comparable. Overall reoperation rate was significantly higher in the open group. Laparoscopic-assisted ileocolic resection was associated with a significantly better BI and cosmesis.
W1502 Malignancy in Fistulous Anorectal Crohn's Disease - A Systematic Review of Literature Amit Sharma, Mathew Thomas, Burt Cagir, Thomas J. VanderMeer Introduction: Malignant transformation of perineal fistulas in Crohn's disease (CD) has rarely been reported in literature. We systematically reviewed all such cases of cancer reported since 1950 in order to further characterize this rare complication of CD. Methods: Ovid MEDLINE was searched for pertinent case reports using a combination of the keywords “fistula”, “cancer” and “Crohn's disease”, and limited to the English language. Relevant results included both case series and individual case reports by 30 primary authors. The reference lists of the collected articles were also screened for further relevant citations. A patient of ours with similar diagnosis was also included in the series for review. All selected cases were then analyzed by age, gender, duration of CD and fistula, location of fistula, presenting symptoms, delay in diagnosis, method of diagnosis, histopathology and outcome. Results: In addition to our patient, literature review revealed 57 other cases of carcinomas associated with perineal fistulas in CD. The cohort contained 36 females and 22 males. The mean age at the diagnosis of cancer was 47.4 years for females and 52.9 years for males. Mean duration of CD prior to detection of cancer was 17.5 years in females and 24.8 years in males (p = 0.0008). Average duration of fistula prior to cancer transformation was 10 years for females and 20 years for males (p = 0.003). Adenocarcinoma was the most common histology (52%) followed by squamous cell carcinoma (36%). There was no difference in gender distribution for adenocarcinoma and squamous cell carcinoma. Patients mostly presented with complaints of pain (34.5%) while the most frequent finding on examination was an abscess (43%). On initial examination malignancy was suspected in only 24 % of patients. In 78% of patients the fistula was perianal or anorectal in location. Observed survival rate was 71% at 1 year and 61% at 2 years. Conclusion: Incidence of cancer in perineal fistulas of CD is rare compared to non-fistulous CD. Overall prognosis appears to be poor. Diagnosis can be often delayed due to non-specific symptoms and findings. While cancer appears to be associated with the duration of CD as well as fistula, this complication can present much earlier than anticipated. A high suspicion for malignancy in chronic perineal fistulas associated with CD should therefore be maintained in spite of negative biopsies. Especially in women, the shorter duration of CD and fistulas prior to malignant degeneration necessitates an aggressive approach to detect cancer at the earliest.
W1500
SSAT Abstracts
Impact of Perioperative Immunosuppression On the Complication Rate After Abdominal Surgery for Crohn's Disease (CD) Markus A. Küper, Tobias Meile, Judith Junginger, Dörte Wichmann, Joachim Unterholzner, Alfred Konigsrainer, Jorg Glatzle Background: Patients with CD have a lifetime risk of 80-90% for undergoing surgery due to their disease. Many of these patients are set on immunosuppression [IS] at the time point of surgery. Serious side-effects of IS are wound complications, which have been shown in solid organ transplantation both in clinical trials and in animal models. Aim of this study was therefore to evaluate the rates of post-surgical complications after abdominal surgery for CD in patients with or without perioperative IS (steroids [S] or azathioprine [A]). Methods: We retrospectively analyzed 484 consecutive abdominal operations in 374 patients with CD from January 1995 until June 2008 (152♂, 222♀, 39.1±7.9 years). We focused on the following post-surgical complications: Wound infection, pneumonia, urinary tract infection, thrombosis/embolism [M = major complication], surgical revision [M], anastomotic leakage [M], intraabdominal abscess [M] or death [M]. Furthermore, we analyzed the following sub-groups: rectal resection, colonic resection or small bowel resection. Results: There were 69 rectal resections, 137 colonic resections and 172 small bowel resections. 241 operations (=49.8%) were performed under perioperative IS. The overall complication rate [OCR] was 18.6% (n=90), the major complication rate [MCR] was 8.7% (n=42) and the anastomotic leakage rate [ALR] was 3.3% (n=16). There was no significant difference between patients without immunosuppression [-IS] compared to those with either steroid [+S], azathioprine [+A] or combined [+SA] medication (OCR: -IS 17.7%, +S 20.9%, +A 13.5%, +SA 19.6%; MCR: -IS 7.0%, +S 11.8%, +A 5.4%, +SA 9.8%). Also patients with a highdose steroid-therapy (≥20mg/d) had no increased OCR, MCR or ALR. Patients with rectal or colonic resection had a higher complication rate than patients with small bowel resection, but there was also no increase with IS. However, patients on IS were treated significantly longer inpatiently than those without IS despite same complication rates (17±20 vs. 13±8 days, p=0.01). Conclusion: Patients with rectal or colonic resection for CD have an increased risk for post-surgical complication than patients with small bowel resection. Nearly 50% of the patients undergoing abdominal surgery for CD are on IS during surgery. However, perioperative medication with steroids (even high-dosage) or azathioprine does not alter the post-surgical complication rate in CD patients. Therefore, IS should not be the key factor for decision-making when surgery is performed.
W1503 Medina Catheter Use Following Ileal Pouch-Anal Anastomosis: Quality of Life and Functional Outcome Simon D. McLaughlin, Susan K. Clark, Zarah L. Perry-Woodford, Paris P. Tekkis, Paul J. Ciclitira, Ralph. J. Nicholls Background: Intubation of the pouch is required by some patients with failure of spontaneous defaecation after ileal pouch-anal anastomosis (IPAA). We assessed function, social, work and dietary restrictions, and quality of life (QOL) in patients who were using a Medina catheter to evacuate. The Cleveland global quality of life score (CGQOL) has been reported to be 0.8 in the global IPAA population. Method: 31 IPAA patients prescribed a Medina catheter were identified from the pouch database and were sent a questionnaire by post. CGQOL and data on function, social, work and dietary restrictions were recorded. Results: 23 (74%) of 31 patients [median age 56 years; male 15(68%)] returned the questionnaire.. Pouch configurations were: J:8, W:10, S:5. The median duration of catheter usage was 9 (0.5-30) years. 22 (71%) patients reported improved QOL after starting regular intubation. Median 24hr bowel frequency was 4 (range 2-14). 16 (48%) of patients used the catheter for every defaecation, 8 (26%) experienced social or work-life restriction, 7 (22%) reported catheter blockage and 12 (52%) reported dietary restriction. The median CQOL score was 0.72. Conclusion: Medina catheter usage is tolerated in the long term and is associated with satisfactory quality of life of IPAA patients with outflow obstruction. Frequency of defaecation and CGQOL scores are comparable with the global IPAA population.
W1501 Esophagus to Anus: Epidemiology of Primary Melanomas of the Digestive Tract Mathew Thomas, Burt Cagir, Thomas J. VanderMeer Background: Primary melanomas of the digestive tract excluding oral cavity and nasopharynx are rare cancers and population based studies are sparse. We analyzed the Surveillance, Epidemiological and End Results (SEER) database in order to characterize this malignancy. Methods: SEER 17-registries database was analyzed for malignant melanomas of the digestive tract (the esophagus to the anus) from 1973-2005. Demographic variables analyzed included age, sex, race and marital status. Tumor variables included site, stage at diagnosis, treatment and histology. SEER*Stat and XLSTAT software were used for statistical analysis. Results:
SSAT Abstracts
A-926
472 cases were analyzed after various exclusions. Age-adjusted incidence rates were 0.04 per 100,000 for 1973-2005 (95% CI 0.04-0.04). There was a 1.66% overall increase in total cases diagnosed from 1975 to 2005 amounting to an annual increase of 2.21% (p value <0.05). There were 290 (61.4%) females and 182 (38.6%) males. Mean age at diagnosis was 68 (median 71; range 21-100). Patients above the age of 80 were more likely to be females (P = 0.03). 402 patients were white, 24 black, 45 other (American Indian/AK Native/ Asian/Pacific Islander) and the rest were of unknown race. Stage of disease was localized in 34%, regional in 25%, distant in 25% and unstaged in 14%. Common sites were rectum (33%), anus and anal canal (26%), over lapping lesions of anorectum (21%) and esophagus (8%). While the rectum was the most common site in either gender (34% in each), 71.5% of anorectal melanomas were found in females while 68% of stomach and 71% of small intestinal melanomas presented in males (P = 0.0004). Significantly greater proportion of men (68 %) than women (43 %) were married while more women were widowed (37.5%) than men (7%) (P < 0.0001). 1-year and 5-year relative survival were 61% and 18% respectively (median survival 16 months). On univariate analysis, age and stage were significant variables with worst survival noted in age > 80 (P = 0.015) and distant disease (P < 0.0001). On multivariate analysis other race was prognostic of better survival (P = 0.02), while distant stage predicted worse survival (P = 0.01). There was no significant difference in survival based on site of tumor. Conclusion: While primary gastrointestinal melanoma continues to be rare, the incidence has steadily increased. Overall prognosis is poor and as in most malignancies, advanced age and stage of disease continue to be predictors of worse survival. Chances of survival may improve with earlier detection.
W1499 Laparoscopic-Assisted Versus Open Ileocolic Resection for Crohn's Disease: Long Term Results of a Prospective Randomized Trial Emma J. Eshuis, Frederik Slors, Miguel A. Cuesta, Robert Pierik, Pieter Stokkers, Mirjam A. Sprangers, Willem Bemelman Background: Four meta-analyses exist evaluating the short term results of laparoscopic versus open ileocolic resection for Crohn's disease. Little is known about the long term results of both procedures with respect to surgical recurrence rate, overall reoperation rate, incidence of incisional hernia, adhesive small bowel obstruction, quality of life (QOL) and Body Image (BI) and cosmesis. Aim: The objective of this study is to determine the long term results of a randomized multicenter study comparing laparoscopic with open ileocolic resection for Crohn's disease. Materials and methods: Sixty patients who participated in this trial were prospectively followed in the outpatient clinic. Patients had an ileocolic resection between 1999 and 2003. Primary outcome parameters were overall reoperation and readmission rate and re-resection rate for recurrent Crohn's disease. Secondary outcomes were QOL, BI and cosmesis. Results: Five patients, 1 from the laparoscopic group and 4 from the open group were lost to follow up. The groups were comparable for characteristics as sex, age, and maintenance therapy. Mean follow-up was 6.8 years. Overall, 16/29 (55%) and 16/26 (62%) patients remained relapse-free after the ileocolic resection in the laparoscopic and open group respectively (p=NS). Resection of recurrent Crohn's disease occurred in 2/29 (7%) and 3/26 (12%) patients (p=NS). Two reoperations for incisional hernia were done in the open group (2/26= 8%) vs. nil in the laparoscopic group. Reoperation for adhesive small bowel obstruction was done twice in the open group (2/26=8%) vs. nil in the laparoscopic group. Overall reoperation rate was 2/29 (7%) versus 7/26 (27%) in the laparoscopic and open group respectively (p=0.047). QOL was similar in both groups. BI and cosmesis scores were significantly higher in the laparoscopic group (p=0.029 and p=0.000 respectively). Conclusions: Surgical recurrence and QOL after laparoscopic and open ileocolic resection for Crohn's disease are comparable. Overall reoperation rate was significantly higher in the open group. Laparoscopic-assisted ileocolic resection was associated with a significantly better BI and cosmesis.
W1502 Malignancy in Fistulous Anorectal Crohn's Disease - A Systematic Review of Literature Amit Sharma, Mathew Thomas, Burt Cagir, Thomas J. VanderMeer Introduction: Malignant transformation of perineal fistulas in Crohn's disease (CD) has rarely been reported in literature. We systematically reviewed all such cases of cancer reported since 1950 in order to further characterize this rare complication of CD. Methods: Ovid MEDLINE was searched for pertinent case reports using a combination of the keywords “fistula”, “cancer” and “Crohn's disease”, and limited to the English language. Relevant results included both case series and individual case reports by 30 primary authors. The reference lists of the collected articles were also screened for further relevant citations. A patient of ours with similar diagnosis was also included in the series for review. All selected cases were then analyzed by age, gender, duration of CD and fistula, location of fistula, presenting symptoms, delay in diagnosis, method of diagnosis, histopathology and outcome. Results: In addition to our patient, literature review revealed 57 other cases of carcinomas associated with perineal fistulas in CD. The cohort contained 36 females and 22 males. The mean age at the diagnosis of cancer was 47.4 years for females and 52.9 years for males. Mean duration of CD prior to detection of cancer was 17.5 years in females and 24.8 years in males (p = 0.0008). Average duration of fistula prior to cancer transformation was 10 years for females and 20 years for males (p = 0.003). Adenocarcinoma was the most common histology (52%) followed by squamous cell carcinoma (36%). There was no difference in gender distribution for adenocarcinoma and squamous cell carcinoma. Patients mostly presented with complaints of pain (34.5%) while the most frequent finding on examination was an abscess (43%). On initial examination malignancy was suspected in only 24 % of patients. In 78% of patients the fistula was perianal or anorectal in location. Observed survival rate was 71% at 1 year and 61% at 2 years. Conclusion: Incidence of cancer in perineal fistulas of CD is rare compared to non-fistulous CD. Overall prognosis appears to be poor. Diagnosis can be often delayed due to non-specific symptoms and findings. While cancer appears to be associated with the duration of CD as well as fistula, this complication can present much earlier than anticipated. A high suspicion for malignancy in chronic perineal fistulas associated with CD should therefore be maintained in spite of negative biopsies. Especially in women, the shorter duration of CD and fistulas prior to malignant degeneration necessitates an aggressive approach to detect cancer at the earliest.
W1500
SSAT Abstracts
Impact of Perioperative Immunosuppression On the Complication Rate After Abdominal Surgery for Crohn's Disease (CD) Markus A. Küper, Tobias Meile, Judith Junginger, Dörte Wichmann, Joachim Unterholzner, Alfred Konigsrainer, Jorg Glatzle Background: Patients with CD have a lifetime risk of 80-90% for undergoing surgery due to their disease. Many of these patients are set on immunosuppression [IS] at the time point of surgery. Serious side-effects of IS are wound complications, which have been shown in solid organ transplantation both in clinical trials and in animal models. Aim of this study was therefore to evaluate the rates of post-surgical complications after abdominal surgery for CD in patients with or without perioperative IS (steroids [S] or azathioprine [A]). Methods: We retrospectively analyzed 484 consecutive abdominal operations in 374 patients with CD from January 1995 until June 2008 (152♂, 222♀, 39.1±7.9 years). We focused on the following post-surgical complications: Wound infection, pneumonia, urinary tract infection, thrombosis/embolism [M = major complication], surgical revision [M], anastomotic leakage [M], intraabdominal abscess [M] or death [M]. Furthermore, we analyzed the following sub-groups: rectal resection, colonic resection or small bowel resection. Results: There were 69 rectal resections, 137 colonic resections and 172 small bowel resections. 241 operations (=49.8%) were performed under perioperative IS. The overall complication rate [OCR] was 18.6% (n=90), the major complication rate [MCR] was 8.7% (n=42) and the anastomotic leakage rate [ALR] was 3.3% (n=16). There was no significant difference between patients without immunosuppression [-IS] compared to those with either steroid [+S], azathioprine [+A] or combined [+SA] medication (OCR: -IS 17.7%, +S 20.9%, +A 13.5%, +SA 19.6%; MCR: -IS 7.0%, +S 11.8%, +A 5.4%, +SA 9.8%). Also patients with a highdose steroid-therapy (≥20mg/d) had no increased OCR, MCR or ALR. Patients with rectal or colonic resection had a higher complication rate than patients with small bowel resection, but there was also no increase with IS. However, patients on IS were treated significantly longer inpatiently than those without IS despite same complication rates (17±20 vs. 13±8 days, p=0.01). Conclusion: Patients with rectal or colonic resection for CD have an increased risk for post-surgical complication than patients with small bowel resection. Nearly 50% of the patients undergoing abdominal surgery for CD are on IS during surgery. However, perioperative medication with steroids (even high-dosage) or azathioprine does not alter the post-surgical complication rate in CD patients. Therefore, IS should not be the key factor for decision-making when surgery is performed.
W1503 Medina Catheter Use Following Ileal Pouch-Anal Anastomosis: Quality of Life and Functional Outcome Simon D. McLaughlin, Susan K. Clark, Zarah L. Perry-Woodford, Paris P. Tekkis, Paul J. Ciclitira, Ralph. J. Nicholls Background: Intubation of the pouch is required by some patients with failure of spontaneous defaecation after ileal pouch-anal anastomosis (IPAA). We assessed function, social, work and dietary restrictions, and quality of life (QOL) in patients who were using a Medina catheter to evacuate. The Cleveland global quality of life score (CGQOL) has been reported to be 0.8 in the global IPAA population. Method: 31 IPAA patients prescribed a Medina catheter were identified from the pouch database and were sent a questionnaire by post. CGQOL and data on function, social, work and dietary restrictions were recorded. Results: 23 (74%) of 31 patients [median age 56 years; male 15(68%)] returned the questionnaire.. Pouch configurations were: J:8, W:10, S:5. The median duration of catheter usage was 9 (0.5-30) years. 22 (71%) patients reported improved QOL after starting regular intubation. Median 24hr bowel frequency was 4 (range 2-14). 16 (48%) of patients used the catheter for every defaecation, 8 (26%) experienced social or work-life restriction, 7 (22%) reported catheter blockage and 12 (52%) reported dietary restriction. The median CQOL score was 0.72. Conclusion: Medina catheter usage is tolerated in the long term and is associated with satisfactory quality of life of IPAA patients with outflow obstruction. Frequency of defaecation and CGQOL scores are comparable with the global IPAA population.
W1501 Esophagus to Anus: Epidemiology of Primary Melanomas of the Digestive Tract Mathew Thomas, Burt Cagir, Thomas J. VanderMeer Background: Primary melanomas of the digestive tract excluding oral cavity and nasopharynx are rare cancers and population based studies are sparse. We analyzed the Surveillance, Epidemiological and End Results (SEER) database in order to characterize this malignancy. Methods: SEER 17-registries database was analyzed for malignant melanomas of the digestive tract (the esophagus to the anus) from 1973-2005. Demographic variables analyzed included age, sex, race and marital status. Tumor variables included site, stage at diagnosis, treatment and histology. SEER*Stat and XLSTAT software were used for statistical analysis. Results:
SSAT Abstracts
A-926