56.01 Screening For Anal Dysplasia With Anal Pap Smears: Clinical Follow-up And Correlation

Posted on January 31, 2019

J. Son1, E. Lawson1, S. Selvaggi2, B. Harms1, E. Carchman1, R. Striker3, C. I. Voils1, C. B. Geltzeiler1, C. B. Geltzeiler1  1University Of Wisconsin,Colorectal Surgery,Madison, WI, USA 2University Of Wisconsin,Pathology,Madison, WI, USA 3University Of Wisconsin,Infectious Disease,Madison, WI, USA

Introduction:

Anal dysplasia screening and surveillance guidelines are poorly defined and based on little data. Although recommendations on type of surveillance are controversial, most practitioners recommend follow-up clinical examination for patients with an abnormal anal pap smear. Our objective was to determine how often an anal pap was followed by clinical exam at our institution and how often histology correlated with pap cytology.

Methods:  

All anal pap results at a single tertiary academic center from 2008 to 2018 were collected. Retrospective chart review was performed on all patients with cytology results demonstrating dysplasia (high-grade squamous intraepithelial lesions (HSIL) or low-grade squamous intraepithelial lesions (LSIL)). We examined patient risk factors as well as their clinical follow-up within 1 year. Clinical exam was defined as digital rectal examination, anoscopy, or high resolution anoscopy (HRA). We also examined if cytology accurately predicted histologic dysplasia. 

 

Results:

A total of 327 anal pap smears demonstrated dysplasia (25% HSIL and 75% LSIL) in 182 patients. 92% of patients were male, 97% HIV positive, and 73% had documented anal receptive intercourse. 75% of dysplastic anal paps were followed by clinical exam within 1 year and 50% were biopsied. Of the 45 HSIL anal paps that were followed by biopsy, only 38% confirmed high-grade disease on histology, 24% demonstrated low-grade disease, and the remaining were negative. In contrast, of the 119 LSIL anal paps that were followed by biopsy, 44% confirmed low-grade disease on histology, 22% were upgraded to high-grade disease. 3% had invasive squamous cell carcinoma on biopsy after LSIL pap.

Conclusion:

This single center study demonstrates that only 75% of abnormal anal paps were followed up with clinical exam within 1 year and only 50% were biopsied for histologic confirmation. When biopsied, only 66% of dysplastic paps demonstrated dysplasia or invasive disease on histologic examination. There is room for improvement in our institution to consistently follow-up with clinical exam after abnormal pap. Our data suggests this is especially important considering anal pap cytology is an imperfect predictor of histologic dysplasia and invasive disease. Clinical exam may be more important as the initial screening test.

49.20 Advanced age does not preclude good outcomes during surgical treatment of colovesical fistula

Posted on January 31, 2019

B. J. Resio1, J. Reguero Hernandez1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:

It is commonly believed that surgical treatment of colovesical fistula in the elderly carries an increased mortality and morbidity. Thus, patients are often not referred to surgeons for definitive repair and risk undergoing urgent fecal diversion when presenting with urosepsis. The objective of this study was to evaluate current outcomes of colovesical fistula repair in the elderly population with specialized care by colorectal surgeons at an academic tertiary referral hospital and across the country.

 

Methods:

Consecutive patients age 65 and older who underwent surgery for colovesical fistula were identified from chart review of an academic, tertiary referral hospital (2012-2018) and from the National Surgical Quality Improvement Project (NSQIP) Database (2016). Main outcome measures included surgical approach, complications and mortality. More granular outcomes of permanent ostomy, recurrence, anastomotic leaks, complication type, conversion to open and temporary diverting ostomy were analyzed among patients available for chart review at the tertiary referral hospital.

 

Results:

A total of 209 elderly patients underwent elective, partial colectomy for vesico-intestinal fistula at NSQIP hospitals in 2016. Fifty-six percent of cases were laparoscopic, complications occurred in 26% of patients and mortality was 2.4%. Eleven elderly patients presented with sepsis, 82% had complications and mortality was 9%.

 

A total of 21 elderly patients underwent surgery at a single, academic, tertiary referral hospital. Eighteen patients underwent elective surgery, 94% underwent laparoscopic approach, 6% converted to open and 11% underwent a temporary diverting ostomy with primary anastomosis. There was 1 permanent ostomy among the elective group.There were no mortalities, anastomotic leaks or recurrences with a median follow up of 12 months (IQR:4-34). One elderly patient had major complications (arrhythmia, COPD exacerbation, pneumonia) and 22% had minor complications (ileus most common). Three patients presented with urosepsis, underwent urgent diverting colostomy and 2 of 3 were not subsequently reversed (ages 92,96).

 

Conclusions:

Elderly patients who present with urosepsis from colovesical fistula and require urgent surgery may have a higher risk of permanent ostomy, mortality and complications. Elective repair is safe in the elderly across the country, with a low rate of mortality and morbidity. Chances of permanent ostomy or open approach are low at a tertiary center. Surgical treatment of colovesical fistula should be offered to elderly patients.

 

49.19 Incomplete Colonoscopy After Diverticulitis Is Associated With Elevated Rate of Surgical Intervention

Posted on January 31, 2019

A. Studniarek1, J. Nordenstam1, K. Kochar3, V. Chaudhry2, A. Mellgren1, G. Gantt1  2Cook County Health and Hospitals System,Division Of Colon And Rectal Surgery,Chicago, IL, USA 3Advocate Lutheran General Hospital,Division Of Colon And Rectal Surgery,Park Ridge, IL, USA 1University Of Illinois At Chicago,Division Of Colon And Rectal Surgery,Chicago, IL, USA

Introduction:

Current clinical guidelines recommend performing a colonoscopy after resolution of diverticulitis to confirm the diagnosis and to exclude malignancy or other pathology. Incomplete colonoscopies have limited yield of significant pathologies. The aim of this study is to evaluate the relative risk of surgical intervention after incomplete diagnostic colonoscopies in comparison to complete colonoscopic evaluations after diverticulitis.

Methods:

This is a retrospective descriptive analysis of patients who underwent diagnostic colonoscopy after an episode of acute diverticulitis between November 2005 and August 2017 at three major teaching hospitals in Chicago, Illinois. Demographics, computed tomography scans, endoscopy findings, and surgical pathologies were evaluated. Complete colonoscopy was defined as a full cecal intubation, with visualization of the appendiceal orifice and the ileocecal valve. Severity of diverticulitis was classified based on Hinchey classification during the patient’s initial presentation. The primary outcome of this study was surgical intervention following colonoscopic evaluation.

Results:

584 patients (298 male; 51%) underwent a colonoscopy for a history of diverticulitis after resolution of acute symptoms. Median patient age was 53 (range, 22-88) years. Colonoscopy was complete in 488 patients (83%). 82 patients (17%, 82/488) underwent surgery and 406 (83%, 406/488) did not require surgical intervention. Out of those who underwent surgery with complete colonoscopies, 44 patients (54%, 44/82) presented with Hinchey 1 or 2 diverticulitis. Colonoscopy was incomplete in 96 patients (16%, 96/584). 46 of these patients (48%, 46/96) underwent surgery. 31 patients (67%, 31/46) were classified as Hinchey 1 or 2 on the initial presentation. Patients with incomplete colonoscopies had higher relative risk of undergoing surgical intervention (RR ,2.85; 95% CI, 2.14-3.80) than patients with complete colonoscopies (RR, 0.35; 95% CI, 0.26-0.47).

Conclusion:

Diagnostic colonoscopy following an episode of diverticulitis has a high rate of incomplete examinations. The patients who undergo an incomplete colonoscopy after an episode of diverticulitis have a higher probability of undergoing surgical intervention in comparison to the patients who had a complete colonoscopy. A more accurate diagnostic modality and further prospective studies may help avoid unnecessary surgical procedures.

 

49.18 Are Enhanced Recovery After Surgery Pathways Applicable to Patients with Obesity?

Posted on January 31, 2019

A. C. Kale1, D. Gunnells2, M. S. Morris1, J. A. Cannon1, D. I. Chu1, G. D. Kennedy1  1University Of Alabama at Birmingham,Gastrointestinal Surgery,Birmingham, Alabama, USA 2Ochsner Foundation Hospital,Colorectal Surgery,New Orleans, LOUISIANA, USA

Introduction:
Enhanced recovery after surgery (ERAS) pathways are multimodal, perioperative approaches to patient management that have been shown to reduce length of stay (LOS), postoperative complications, and readmissions. Our group has previously shown that ERAS decreases racial/ethnic disparity in outcomes following colorectal surgery.  While it is encouraged to apply these pathways to all patients, it remains to be determined if all principles of the pathways are safe in all patient populations.  Here we have examined outcomes following surgery and ERAS guided management in patients with obesity. We hypothesized that patients with obesity would have worse outcomes and higher rates of complications.

Methods:
This single center, retrospective study utilized the NSQIP database to identify patients who were managed via an ERAS pathway at our institution between 2015-2017. Patients’ BMI was stratified into NIH categories and chi squared and Wilcoxon tests were performed to determine differences in outcomes between obese and normal/overweight categories; patients classified as underweight were excluded. Analyses were also performed to delineate the impact of ERAS on the outcomes of patients with obesity using a BMI matched, pre-ERAS cohort from 2012-2014. Primary outcome was LOS. Secondary outcomes included all 30-day post-operative ACS-NSQIP complications.

Results:
A total of 1000 ERAS and 685 pre-ERAS patients were included in this study. Among ERAS patients, 61% (606/1000) were classified as normal or overweight, while 39% (394/1000) suffered from obesity. Pre-ERAS patients had comparable BMI distributions. We found that patients managed on the ERAS protocol had a significantly shorter postoperative LOS regardless of BMI compared to the Pre-ERAS patient group (5.5 vs. 7.5 days, p<0.01). While Pre-ERAS patients with obesity had higher rates of superficial surgical site infections (SSI) compared to non-obese Pre-ERAS patients, patients with obesity that were managed with ERAS had no difference in SSIs in comparison to the normal/overweight ERAS cohort (Table 1). Overall, patients who received ERAS guided care experienced a higher incidence of wound disruption in comparison to the Pre-ERAS cohort (3 vs. <1%, p<0.01). ERAS patients with obesity demonstrated significantly higher rates of this complication in comparison to non-obese, ERAS patients (Table 1).

Conclusion:
Patients with obesity have similar outcomes as patients who have normal or overweight BMIs when managed on an ERAS protocol. The use of ERAS pathways may decrease SSIs in patients with obesity, but these patients may be more susceptible to wound disruption. These data suggest that the ERAS pathway is safe and benefit all patients regardless of BMI.
 

49.17 Use of Neoadjuvant Chemotherapy in the Treatment of Locally Advanced Rectal Cancer

Posted on January 31, 2019

M. Simpson1, J. Blank1, A. Szabo2, D. Eastwood2, K. Hu1, K. Ludwig1, C. Peterson1, T. Ridolfi1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction: Standard treatment for locally advanced rectal adenocarcinomas (stage II-III) includes neoadjuvant chemoradiation followed by surgical resection and adjuvant chemotherapy. Following this standard treatment scheme 10%-30% achieve a complete response (CR) with no primary tumor remaining on either clinical or pathologic exam. To improve CR rates novel treatment approaches of systemic chemotherapy in addition to neoadjuvant chemoradiation have been suggested. In recent studies, these approaches have been shown to improve CR rates, tumor downstaging, and patient compliance. This study aims to quantify the incidence of neoadjuvant chemotherapy use at our institution, determine patient and tumor characteristics associated with the use of neoadjuvant chemotherapy, and evaluate tumor response to neoadjuvant chemotherapy compared to standard treatment.

Methods: A retrospective chart review was conducted on patients with locally advanced rectal cancer treated at the Medical College of Wisconsin between January 1, 2008 and June 6, 2018. Patient demographics, tumor characteristics, staging information, and treatment modalities were abstracted from the electronic medical record. CR was recorded and included both pathologic CR (pCR), defined as no residual tumor in resected samples, and clinical CR (cCR), defined as no evident disease detected on imaging or examination. The association between neoadjuvant chemotherapy and other variables was assessed with chi-square tests for categorical variables and F tests for continuous variables. Statistical significance was defined as a p-value < 0.05.

Results: A total of 835 patients with rectal cancer were identified, of which 178 met inclusion criteria. 134 patients (75%) underwent standard therapy while 44 (25%) underwent neoadjuvant chemotherapy. 93% of patients receiving neoadjuvant chemotherapy had node-positive disease and 30% had T4 disease, compared to 70% with node-positive disease and 9% with T4 disease in the standard therapy group. In the first half of the study period (2008-2012), 3 of 87 patients received neoadjuvant chemotherapy (3%) while in the second half of the study (2013-2018) 41 of 91 patients received neoadjuvant chemotherapy (45%). Among those receiving standard treatments, 26/134 (19%) achieved a CR, while 16/44 (36%) who received neoadjuvant chemotherapy achieved a CR.

Conclusion: The use of neoadjuvant chemotherapy for locally advanced rectal adenocarcinomas was increasingly utilized at our institution from 2008 to 2018. Patients chosen for neoadjuvant chemotherapy typically had more advanced disease yet achieved CR at a higher rate compared to those undergoing standard therapy. These data confirm trends seen at other institutions and provide rationale for further study into the use of neoadjuvant chemotherapy in the treatment of rectal cancer.

49.16 Impact of Enhanced Recovery After Surgery (ERAS) on outcomes following Colorectal Surgery

Posted on January 31, 2019

D. M. Jomaa1, H. Wasvary1,2  1Oakland University William Beaumont School Of Medicine,Department Of Colorectal Surgery,Royal Oak, MI, USA 2Beaumont Health System Research Institute,Department Of Colorectal Surgery,Royal Oak, MI, USA

Introduction: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary program that incorporates best practice guidelines into the perioperative process. Previous studies show adherence to ERAS protocols improve outcomes with respect to hospital stays, complication rates and patient satisfaction.  In August 2015, the Department of Colon and Rectal Surgery implemented an ERAS program at Beaumont Hospital, Royal Oak at the same time the department introduced minimally invasive robotic procedures into their curriculum. Both processes were felt to be important in improving outcomes following colorectal surgeries. The aim of our project was to look at how the implementation of an ERAS program impacted outcomes with respect to length of stay (LOS), and if the method of surgery had any impact on this outcome.

Methods:  Elective colon and rectal procedures between June 2013 and June 2017 (n=654) were reviewed. Patients undergoing surgery prior to ERAS implementation were labeled Pre ERAS (n=102) and those after implementation were labeled Post ERAS (n=452). Charts were reviewed for patient demographics, ASA scores, LOS, BMI, wound class, surgical date and method of surgery. ERAS participants underwent a preoperative evaluation and were educated with regards diet, exercise and best practice processes. During surgery, ERAS patients were given medications to enhance bowel motility, and fluids and narcotics were guided by protocol. Postoperatively, early ambulation, early resumption of food and judicious use of narcotics was followed for the ERAS participants.

Results: No significant differences were noted between the Pre and Post ERAS groups with respect to age, BMI, ASA or gender. Significant differences existed when comparing the two groups for LOS with a median stay of 5 and 4 days for the Pre and Post ERAS groups, respectively (p<0.0001).  The wound classification identified a significantly higher proportion of “contaminated” cases in the Post ERAS era (p<0.001). A higher percentage of robotic cases were done in the Post ERAS era (42%) compared to Pre ERAS (25%) (p<.001). All variables were measured against the outcome of LOS via regression analysis. A univariate analysis showed LOS was significantly reduced for younger, male patients with lower ASA scores and undergoing robotic surgery during the Post ERAS period. No significant differences existed for BMI or wound class.  A multivariate analysis showed higher ASA scores (p=0.003) and female gender (p=0.05) independently predicted a longer LOS (p=0.003). ERAS independently predicted a shorter LOS (p<0.0001). Robotic procedures did not impact LOS when all variables were considered.

Conclusion: The inception of an ERAS program is an independent predictor for reduction in the LOS following surgical resection and this improvement was not influenced by the method of surgery. This data is important when rationalizing the need to put continued resources into the further development of best practice initiatives.

 

49.15 The Significance of Caudal-to-Cranial Approach in Lymphadenectomy in Laparoscopic Right Colectomy

Posted on January 31, 2019

L. Zou1, B. Zheng2, Y. He1, L. Zou1  1Guangdong Hospital of Traditional Chinese Medicine, Zhuhai,Department Of General Surgery,Zhuhai, GUANGDONG, China 2Brookdale Hospital and Medical Center,Department Of General Surgery,Brooklyn, NEW YORK, USA

Introduction: Currently? the medial-to-lateral approach is widely used in laparoscopic right colectomy. However, this approach is unable to dissect lymph nodes located posterior to the superior mesenteric vessels. Our aim is to discuss the necessity and clinical significance of using the caudal-to-cranial approach in laparoscopic right colectomy.

Methods: This is a prospective cohort study. A total of 78 consecutive patients (between 2014 and 2017) with advanced right colon cancer (TNM stage I: 17; stage II: n = 23; stage III: n = 38) requiring a curative right colectomy were subjected to laparoscopic caudal-to-cranial approach. All patients received preoperative nanocarbon injections around the tumor via colonoscopy. Lymph nodes were then analyzed and the positive rate of the lymph nodes was calculated.

Results: In this follow-up study, 45 male and 33 female patients(age 63.6±10.59 years old ) with mean body mass index of 21.7±2.87 kg/m2. The mean operation time was 153.9±25.36 min, and the mean blood loss was 82.0±19.21 ml. The mean tumor size was 5.3±1.1 cm and the mean number of harvested lymph nodes was 19.68±7.56 with an average of 1.53±2.75(7.8%) positive lymph nodes . Of these positive lymph nodes, 1.1±4.69  were posterior to superior mesenteric vessels, with a positive rate of 1.3%. All procedures were successful without any serious intraoperative complications, conversion to open surgery, or surgical mortalities.

Conclusion: There are positive lymph nodes posterior to the superior mesenteric vessels in progressive right colon cancers. We suggest a complete dissection of these lymph nodes to reach radical treatment by using a caudal- to-cranial approach.

 

49.14 Standardized Laparoscopic Surgery for Diverticular Colovesical Fistula

Posted on January 31, 2019

K. Tomizawa1, S. Matoba1, N. Okazaki1, K. Hiramatsu1, Y. Hanaoka1, S. Toda1, H. Kuroyanagi1, H. Kuroyanagi1  1Toranomon Hospital, Gastroenterological Surgery,Tokyo, Japan

Introduction: Colonic diverticular disease is widespread, and its incidence increases with aging. Patients suffering from diverticulitis and colovesical fistula are also increasing. Diverticular colonic resections are frequently more technically demanding than colon cancer due to inflammation. This study aimed to evaluate the safety and efficacy of our standardized laparoscopic procedure. 

Methods: A retrospective analysis was reviewed of 44 consecutive patients undergoing laparoscopic surgery for colovesical fistula during the period October 2006 to July 2018. 

Results:The median age was 61 years and the patients comprised 40 men and 4 women. Surgical procedures were sigmoidectomy: thirty-eight, Hartmann's operation: four, low anterior resection: two, respectively. The median operating time was 201 minutes and the estimated blood loss was 65.5mL. There were no intraoperative complications and conversion to open surgery. No bladder wall repairs were required. Six patients had minor postoperative complications comprising a postoperative abscess and three cases of superficial wound infection and three cases of anastomotic bleeding. The median length of postoperative stay was 11days. No patients had recurrence of diverticulitis or fistula at median follow-up of 5.6 years. 

Conclusion:We demonstrated that laparoscopic surgery for colovesical fistula can be safely performed. Because of its minimally invasive, laparoscopic approach appears to be the ideal choice especially for the colovesical fistula. To our knowledge, this is the largest study of colovesical fistula treated with laparoscopic procedure.

 

49.13 Colon Cancer Survival by Sub-site: a Retrospective Analysis of the National Cancer Database

Posted on January 31, 2019

D. Yu1,2, M. Stem2, J. Taylor2, S. Chen2, B. Safar2, S. Fang2, S. Gearheart2, J. Efron2  1Queen’s University,General Surgery,Kingston, ONTARIO, Canada 2The Johns Hopkins University School Of Medicine,Colorectal Surgery,Baltimore, MD, USA

Introduction:
Recent studies report a shift in the anatomical site of origin of colon cancer from the distal to the proximal colon. The objective of this study was to assess sub-site specific differences of colon adenocarcinomas with respect to patient and tumor characteristics, treatment trends, and overall survival (OS).

Methods:
This study was conducted using data from the National Cancer Database (2004 – 2015). Adult patients > 18 years old diagnosed with stage I to IV colon adenocarcinoma were stratified by primary site of cancer (right, transverse, left, or sigmoid). Primary outcome of interest was 5-year OS analyzed using Kaplan-Meier survival curves and Cox proportional hazard models.

Results:
A total of 642,983 cases were included [right: 330,872 (51.46%), transverse: 66,621 (10.36%), left: 63,947 (10.36%), sigmoid: 181,543 (28.23%)].  A small but significant increase in diagnosis from 2004 to 2015 was found in right-sided and transverse colon cancers (right: 8.04% to 8.57%, transverse: 7.80% to 8.99%, p-value <0.001 for both). Right and transverse colon cancer patients tended to be female, older, have higher frequencies of poorly differentiated tumors (right: 20.99%, transverse 18.82%, left: 14.27%, sigmoid 11.68%, p-value <0.001), and tumors > 5cm (40.51%, 35.76%, 33.77%, 29.79%, respectively, p-value <0.001). When stratified by stage, sigmoid cancer patients were more likely to receive multimodal therapy compared to other sub-sites across all stages. In the unadjusted analysis, right and transverse colon cancers had the worst 5-year OS (53.30%, 54.01%, 55.93%, 58.39%, respectively, p-value <0.001). Similar trends persisted when stratified by stage (FIGURE). In the adjusted Cox analysis, right, transverse, and left colon cancers all had significantly increased risk of mortality in comparison to sigmoid cancer when all stages were combined (sigmoid ref: HR: 1.10, 95% CI 1.08-1.12, HR 1.16, 95% CI 1.13-1.19, HR 1.12, 95% CI 1.09-1.15, p-value <0.001 for all). When stratified by stage, right and transverse colon cancers had the greatest risk of death in stages III and IV (sigmoid ref, stage III: transverse HR 1.21, 95% CI 1.16-1.26, p-value <0.001, stage IV: right HR 1.28, 95% CI 1.24-1.31, p-value <0.001)

Conclusion:
Right-sided and transverse cancers show an increasing trend over the study period. These patients tended to be female, older, have higher frequency of poor differentiation, and larger tumors. 5-year OS was worst in transverse cancers for all stages combined.
 

49.12 Predictive Factors for Complicated Diverticulitis: An Analysis of the NSQIP Database.

Posted on January 31, 2019

G. U. Anyanwu1, N. P. Omesiete1, M. Diri1, V. Nfonsam1  1University of Arizona,Surgery,Tucson, AZ, USA

Introduction:
The incidence of diverticulitis is on the rise in the last few decades. Uncomplicated diverticulitis could be treated with expectant management and at time surgical intervention. Complicated diverticulitis, however, could lead to significant morbidity and mortality in addition to major healthcare cost. The aim of this study is to assess the factors that contributes to an increased risk in developing complicated diverticulitis.

Methods:
A 10-year (2006-2016) retrospective analysis of all patients who underwent surgical intervention for diverticulitis using the NSQIP database was performed. The patients were subdivided to complicated and uncomplicated disease. Demographic factors included age, gender, and race/ethnicity. Additional factors analyzed included diabetes, obesity, COPD, smoking status, chronic steroid use, renal failure, Heart Failure, previous MI, previous cardiac surgery (PCS), and previous Percutaneous Coronary Intervention (PCI). A multi regression analysis was performed to determine the predictors for complicated diverticulitis.

Results:

.A total of 65,032 patients were analyzed; 56,919 with uncomplicated diverticulitis and 8,113 with complicated diverticulitis. Patients aged 70-80 (OR 1.42, p<0.0005), African Americans (OR 1.13, p<0.05) and patients with BMI≥30 (OR 1.10 p=0.0038) had a higher chance of developing complicated diverticulitis. Additionally, diabetes (OR 1.14, p<0.0005); especially if patients were not on insulin therapy (OR 1.24, p<0.005); COPD (OR 1.16, p<0.01), history of smoking (OR 1.29, p <0.0005), HF (OR 1.64, p=0.0001), ARF (OR 1.92, p<0.0005), CRF (OR 1.67, p<0.0005), and chronic steroid use (OR 1.68, p<0.0005) were predisposing factors for complicated diverticulitis. However, we found patients with PCS (OR 0.39, p<0.0005) and past PCI (OR 0.37, p<0.0005) had decreased odds of developing complicated diverticulitis.

Conclusion:

This study demonstrated that blacks, older patients, history of smoking, heart failure, diabetes, elevated BMI and acute/chronic renal failure are risk factors for complicated diverticulitis. These patients might benefit from closer monitoring prior to surgery and modifiable risked could be addressed
 

49.11 Perioperative Outcomes and Predictors of Mortality Following Surgery for Sigmoid Volvulus.

Posted on January 31, 2019

A. Easterday1, A. Person1, S. Aurit1, R. Driessen1, D. Mukkai Krishnamurty1  1Creighton University Medical Center,Department Of Surgery,Omaha, NE, USA

Introduction: Data on perioperative outcomes following surgery for sigmoid volvulus is limited. The aim of this study is to develop a model to predict need for emergent surgery and post-operative mortality following resection for sigmoid volvulus.

Methods: The NSQIP database was queried from 2012-2016 to identify patients undergoing segmental resection for sigmoid volvulus. Pre-, intra-, and post-operative variables were compared. Primary and secondary outcomes were emergent surgery and risk of mortality, respectively. Chi-square and Fischer’s test for categorical variables and the Mann-Whitney test for continuous variables were used. Significant variables for each outcome were entered into a logistic regression model to predict the outcomes. Statistical significance was set at p<0.05. 

Results: A total of 2,086 patients met inclusion criteria and 51.6 percent underwent an elective resection. Median age was 68 years. Laparoscopic resection (30.5% vs. 9.1%; p<0.001) and mechanical bowel preparation (50% vs. 8.7%; p<0.001) were more commonly used in the elective setting. Patients having emergent resection were more likely to suffer from post-operative superficial surgical site infection (p<0.001), pneumonia (p<0.001), cardiac arrest (p=0.038), septic shock (p=0.001), myocardial infarction (p=0.034), and had a higher need for perioperative transfusion (p<0.001). No difference was seen in ileus, anastomotic leaks, readmission or re-operation rates in patients undergoing emergency vs. elective resection. Overall mortality rate was 6.2% (8.5% in the emergent group vs. 4.1% in the elective group; p<0.001). On multivariate analysis, factors associated with increased risk of emergency surgery included female gender (OR 2.01; p<0.001), relative hematocrit elevation (OR=1.058; p<0.001), relative leukocytosis (OR=1.172; p<0.001), acute kidney injury (OR=6.274; p=0.035), pre-operative sepsis (OR=2.037; p<0.001), functional independence prior to surgery (OR=1.525; p=0.011), and bleeding disorders (OR=1.592; p=0.020). Factors predictive of post-operative mortality included increased age (OR=1.064; p<0.001), systemic sepsis (OR=3.848; p<0.001), and emergent surgery (OR=2.086; p=0.007). Independence prior to illness (OR=0.371; p<0.001), higher albumin levels (OR=0.579; p=0.007), and lower BMI (OR=0.952; p=0.037) were shown to be protective. 

Conclusion: Emergent resection for sigmoid volvulus is independently associated with poor post-operative outcomes and mortality. Pre-operative factors that predict need for emergent resection and post-operative mortality identified in this study can be used to aid in shared decision making and counselling for patients admitted with sigmoid volvulus.

49.10 Evaluation of Baseline Bowel Function in Patients Considering Surgery for Diverticular Disease

Posted on January 31, 2019

R. V. Lyn1, J. L. Goldwag2,3, S. J. Ivatury2,3  1Dartmouth College,Hanover, NH, USA 2Dartmouth Hitchcock Medical Center,Lebanon, NH, USA 3Geisel School of Medicine,Lebanon, NH, USA

Introduction:
Diverticular disease is common and many patients are sent for operative consideration. The aim of this study is to evaluate baseline bowel function for patients considering sigmoid colectomy for diverticular disease. 

Methods:
This is an observational study. We have collected bowel function patient reported outcomes using the Colorectal Functional Outcome Questionnaire (COREFO) questionnaire during each outpatient visit in our clinic. The COREFO is a validated bowel function questionnaire that assesses bowel function in five domains and a Total COREFO score. The scores range from 0 to 100, with a higher score indicating a poorer function. A score greater than 15 is considered symptomatic. We included all patients who were seen for diverticular disease, were considering surgery, and completed a COREFO questionnaire at their initial visit from May 2015 to July 2018. We excluded those that already had a sigmoid resection or those that did not complete their questionnaire. We evaluated the average scores of each domain and the Total COREFO score at baseline.

Results:
88 patients met criteria for inclusion in this study. The mean age was 57±11 years with 67% women. The median number of reported episodes of diverticulitis prior to the baseline visit was 4 (IQR: 2-5). The mean baseline scores for the domains and Total COREFO score are shown in Figure 1. The social impact, stool-related aspects, and need for medication domains were within the symptomatic range at baseline while the frequency and incontinence domains were in the asymptomatic range. The mean Total COREFO score at baseline was also in the symptomatic range. 

Conclusion:
Patients considering elective surgery for diverticular disease present with significant bowel dysfunction at baseline. Surgeons should be aware that this dysfunction lies primarily in the effect of bowel movements on a patient’s lifestyle (social impact), pain and bleeding with bowel movements (stool-related aspects), and the use of medication and foods to improve bowel movements (need for medication). 
 

49.09 Minimally Invasive Abdominoperineal Resection for Rectal Cancer: Does the Approach Matter?

Posted on January 31, 2019

D. T. Thompson1, P. Goffredo1, A. F. Utria1, I. Gribovskaja-Rupp1, J. Hrabe1, M. R. Kapadia1, I. Hassan1  1University Of Iowa,Iowa City, IA, USA

Introduction:
Laparoscopic and robotic platforms are commonly utilized minimally invasive approaches to perform abdominoperineal resections (APR) for rectal cancer (RC). There is however limited empiric evidence regarding the comparative effectiveness of these techniques with or without open assistance (OA). We hypothesized that in selected patients, differing minimally invasive approaches would not impact short-term outcomes. We therefore analyzed characteristics and perioperative outcomes of patients undergoing laparoscopic and robotic APR with or without OA for RC using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database Proctectomy Targeted Participant Use File (PUF).

Methods:
CPT code 45395 was used to identify patients from the 2016 ACS-NSQIP Proctectomy PUF database. Patients were analyzed if based on NSQIP definitions they underwent elective laparoscopic, robotic, laparoscopic with OA, or robotic with OA APR for RC. Patient disease and treatment characteristics, operation time (OT), length of stay (LOS), and perioperative clinical outcomes along with lymph node harvest (LNH) and circumferential margin (CRM) status were compared. Analyses were performed using chi-square tests, Fisher’s Exact tests, Student’s t-tests, Mann-Whitney U tests, and one-way ANOVA.

Results:
We identified 412 patients of which 128 (31%) were laparoscopic, 116 (28%) robotic, 107 (26%) laparoscopic with OA, and 61 (15%) robotic with OA. The characteristics of the cohort were as follows: mean age 65±13 years, 65% males, median BMI 28 kg/m2 (range 16-53), ASA ≥ 3 60%, neoadjuvant therapy 66%, locally advanced cancer 64%, and distal third of rectum tumor location 70%. There were no significant differences across the four groups for these variables (all p>0.05). Two-thirds of patients did not have complications and there were no reported mortalities. Short-term perioperative and measured oncologic outcomes were similar between groups (Table 1). A comparison of laparoscopic and robotic vs. OA approaches did not show a significant difference in LOS (median 6 vs. 6 days), OT (300 vs. 290 minutes), CRM (9% vs. 7% positive), LNH (16 vs. 16 nodes), or Clavien-Dindo grade ≥ 3 complications (7% vs. 7% positive) (all p>0.05).

Conclusion:
Patients undergoing laparoscopic or robotic APR are well selected and experience similar short-term clinical and oncologic outcomes regardless of minimally invasive technique. Further investigation into long term results is essential. Ultimately, surgeon preference and experience as well as system resources likely dictate which approach to utilize for APR in patients with rectal cancer.
 

49.08 Prevalence of Surgically Complex Diverticulitis in Young Hispanic Males in 2016

Posted on January 31, 2019

T. Gaglani1, C. H. Davis2, E. P. Askenasy1, M. V. Cusick1,2  1The University of Texas Health Science Center at Houston,Department Of Surgery,Houston, TEXAS, USA 2Houston Methodist Hospital,Department Of Surgery,Houston, TEXAS, USA

Introduction: The prevalence of diverticular disease has been increasing over the last 25 years in western society. While diverticulitis was traditionally viewed as a disease of older individuals, the incidence in patients ages 18 to 44 has increased by 82 percent over the last 20 years. Additionally, it has been observed that young Hispanic men are more likely to have severe diverticular disease. This study aims to ascertain a demographic correlation between age and ethnicity with severity of diverticular disease and required surgical intervention.

Methods:  Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients with primary diagnosis of diverticulitis undergoing surgical intervention in 2016 were identified. Severity of disease (as determined by ICD 10 code) and extent of intervention (as determined by CPT code) were then compared between Hispanic and non-Hispanic patients focusing on comparing young (age<50) Hispanic males to young non-Hispanic males using Fisher’s exact test.

Results: A total of 11,045 operations were performed on patients diagnosed with diverticulitis. Of these cases, 731(6.6%) were performed in Hispanic patients. The mean ages of the Hispanic and non-Hispanic patients were 52.7 and 59.4 years, respectively. Of all 5,010 male patients requiring surgery for diverticulitis, Hispanics were almost twice as likely than non-Hispanics to present at age <50 (53.1% vs. 30.4%, p<0.001). More young Hispanic males had perforated diverticulitis (143/310) compared to non-Hispanic males (844/2205), 46.1% vs. 38.3%, respectively (p=0.009). In terms of more invasive procedures, 42.6% of young Hispanic males underwent open operations vs. 33.8% of young non-Hispanic males (p=0.007; male and female combined, 39.7% vs 33.0%, respectively, p=0.021). More young Hispanics required a stay of 7 or more hospital days than young non-Hispanics (31.2% vs. 25.1%, respectively, p=0.015).

Conclusion: These data indicate that diverticular disease often presents at an earlier age in the Hispanic population. Further, young Hispanic males had nearly double the rate of surgical intervention for diverticulitis. Additionally young Hispanic males had significantly longer length of stay suggesting a higher level of complexity. Further studies are needed to assess differences in operative technique and outcome. This study is limited as it only considered operative diverticulitis patients and not those managed non-operatively.
 

49.07 Quantitative Computed Tomography Image Analysis of Lateral Pelvic Lymph Node Status in Rectal Cancer

Posted on January 31, 2019

A. Usui1, K. Okita1, T. Nishidate1, K. Okuya1, E. Akizuki1, M. Ishii1, T. Satoyoshi1, I. Takemasa1  1Sapporo Medical University Hospital,Sapporo, Hokkaido, Japan

Introduction:
Lateral pelvic lymph node (LPLN) dissection in advanced lower advanced rectal cancer remains a subject of debate, and in order to justify this procedure, a reliable method of nodal characterization to assess preoperative nodal status is essential. Computed tomography (CT) of the pelvis is utilized to determine preoperative lymph node metastasis in rectal cancer, and morphological and internal structure of lymph nodes report to be promising factors. In this study, quantitative analysis of morphological and internal structure of LPLN in lower rectal cancer patients was performed to clarify the diagnostic value of these parameters in terms of metastasis.

Methods:
Data were retrospectively collected for 41 patients who had undergone total mesenteric excision with LPLN dissection for lower advanced rectal cancer from 2007 to 2014 at our institution. None of the patients had any treatment prior to surgery. All patients underwent preoperative enhanced CT. A single LPLN largest in short axis diameter was selected on the enhanced phase CT image for each patient, and the region of interest was manually drawn along the margin of the node. The number of voxels was calculated to determine the size of the lymph node and the mean signal intensity was recorded for the enhancement quality. Internal heterogeneity was quantified using kurtosis, skewness, and standard deviation of the pixel distribution histogram. All factors were compared between LPLN with and without metastasis pathologically proven with surgery.

Results:
An average of 16.9 LPLN was identified histopathologically for each patient (range: 2 to 39). Of the 41 patients, the LPLN detected on CT in 9 patients were too small for quantitative evaluation. Nine patients were histologically positive for LPLN metastasis. Compared to those without metastasis, the LPLN in these patients had a significantly increased number of voxels and significantly low mean signal intensity. Regarding heterogeneity, skewness was significantly higher and standard deviation was significantly lower in positive LPLN status. No significant difference was observed in kurtosis.

Conclusion:
LPLN with pathologically proven metastasis are presented on enhanced CT as larger in size, less enhanced, and CT enhancement was less heterogenous, compared to non-metastatic lymph nodes. Quantitative analysis with enhance CT using number of voxels, mean signal intensity, skewness, and standard deviation of the pixel distribution histogram are promising for discriminating metastatic lateral pelvic lymph nodes in lower rectal cancer.
 

49.06 Impact of Hospital Volume on Outcomes of Robotic versus Laparoscopic Resection for Rectal Cancer

Posted on January 31, 2019

N. Kim1, S. W. De Geus2, A. D. Geary2, S. Ng2, J. F. Hall1, J. F. Tseng2, U. Phatak1  1Boston Medical Center,Department Of Colorectal Surgery,Boston, MA, USA 2Boston Medical Center,Department Of General Surgery,Boston, MA, USA

Introduction: Robotic surgery for colorectal disease is rapidly gaining popularity. However, the impact of hospital volume on the outcomes of robotic surgery (RS) versus laparoscopic surgery (LS) remains unclear. This study investigates from the National Cancer Database whether hospital volume is a factor in determining the short- and long-term outcomes of RS versus LS for rectal cancer.

 

Methods:  Patients with stage I-III rectal cancer who underwent RS or LS between 2011 and 2014 were identified from the National Cancer Database. Institutions were defined as being either low-volume hospitals (LVH: 15 operations/year) or high-volume hospitals (HVH> 15 operations/year). Propensity-scores for the probability of undergoing RS were created within each volume group. Patients were matched based on propensity-score. Within each group, conversion rates, positive margin rates, readmission rates, 30-day and 90-day mortality, length of stay, number of lymph nodes dissected and overall survival were compared between patients who had RS vs LS. Survival analysis was performed using the Kaplan-Meier method.

Results: 8,235 patients underwent minimal invasive surgery for rectal cancer. Overall, 28.8% (n=2,374) of resections were performed robotically. Rectal cancer surgery at a HVH was associated with lower positive resection margins (5.0% vs. 6.3%; p=0.0080), lower rates of conversion to open (11.2% vs. 15.7%; p<0.0001), and 90-day (1.7% vs. 2.7%; p=0.0009) mortality. After matching, conversion rates were significantly lower after RS compared to LS (LVH: 10.1% vs. 18.8%; p<0.0001; HVH: 6.3 vs. 13.4; p<0.0001). There following factors were not significant for patients that received either RS or LS; positive margins rates (LVH: 5.5% vs. 6.9%; p=0.2014; HVH: 5.1% vs. 4.8%; p=0.7211), number of lymph nodes resected (LVH: 14 vs. 15 nodes; p=0.4129; HVH: 16 vs. 16 nodes; p=0.5739), median length of stay (LVH: 5 vs. 5 months; p=0.1324; HVH: 5 vs. 5 months; p=0.1324), readmission (LVH: 9.3% vs. 7.3%; p=0.0936; HVH: 8.9% vs. 8.9%; p=0.9460), 90-day mortality (LVH: 2.3% vs. 2.7%; p=0.5742; HVH: 1.2% vs. 1.9%; p=0.1567) and overall 3 year survival (LVH: 86.9% vs. 86.7%; log-rank p=9148; HVH: 88.6% vs. 88.6%; log-rank p=0.5114).

Conclusion: Although outcomes after major operations are influenced by various factors beyond hospital volume alone, the results of this study suggest that patients with rectal cancer are at higher risk of having positive resection margins, higher rates of conversion to open and 90-day mortality if they are treated at LVH as opposed to at HVH.  However, for both high- and low-volume hospitals, robotic resections of rectal cancer were associated with surgical and oncologic outcomes that were similar to those for laparoscopic operations. Although residual selection bias regarding RS vs LS must be acknowledged, our data suggest that robotic colorectal resections when feasible is a reasonable approach across hospital volume strata.

49.05 Risk Factors Associated with Recurrence Following Treatment for Stage ? Colon Cancer.

Posted on January 31, 2019

A. Obana1, K. Okada1, K. Kitamura1, T. Matsumura1, T. Suwa1, K. Karikomi1, M. Koyama1,2  1Kashiwa Kosei General Hospital,General Surgery,Kashiwa, CHIBA, Japan 2Hirosaki University for Cancer of The Colon and Rectum,Hirosaki, AOMORI, Japan

Introduction:

It is reported that the prognosis and response to chemotherapy for unresectable recurrent colon cancer are different according to the primary tumor location. This appears to be related to pathological and genetic aspects, which may have ramifications for both cancer surveillance and the adjuvant chemotherapy plan. We analyzed and compared the risk factors for recurrence of colon cancer classified as stage ?  between the right and left colon. 

Methods:

We reviewed 214 patients with stage ? colon cancer (including rectosigmoid) in multiple facilities from 1994 to 1997, 1999 to 2003, and performed histopathological evaluation retrospectively. All patients were classified by the primary tumor location, and the risk factors for recurrence were analyzed from clinical pathological aspects, including tumor depth, histology, lymph node metastasis, vascular invasion(ly,v), budding, extramural cancer deposition(EX), perineural invasion(PN), the number of dissected lymph nodes, and use of postoperative chemotherapy, as well as postoperative outcomes (recurrence rate, recurrence free survival rate). Chi-square test was used for univariate analysis, and multiple logistic regression analysis for multivariate analysis.

Results:
The 5 year disease-free survival rate (5Y DFS) was 66.1% for the right side of colon, and 66.7% for the left side. Multivariate analysis of right colon cancer cases showed that three independent factors associated with an increase in recurrence rate were tumor depth (T3:20.7%,T4:46.4%, P=0.010), lymph node metastasis (N1:25.7%,N2-3:51.4%,P=0.043), and perineural invasion (PN0:25.8%,PN1:46.5%,P=0.037). On the other hand, for the left colon, four independent factors associated with an increase in recurrence rate were tumor depth (T3:21.2%,T4:53.8%, P=0.021), lymph node metastasis (N1:22.5%,N2-3:55.9%,P=0.032), extramural cancer invasion (EX-:17.5%,EX+:52.1%, P=0.003), and histology (well-differentiated type:29.5%?other types:70.0%, P=0.008).

Conclusion:
Among patients with stage ? colon cancer, those with T4 and/or N2-3 have high recurrence rates after surgery. In addition, when the primary tumor is located on right side, patients with PN1 should be followed up carefully to detect early recurrence. On the other hand, when the primary tumor is located on left side, patients with EX+, mucinous carcinoma, or low differentiated adenocarcinoma should also undergo close follow-up.

49.04 Two-stage Complete Fistulotomy Approach for Horseshoe Fistula does not Affect Continence

Posted on January 31, 2019

A. Usui1, Y. Ishiyama1, A. Nishio1, M. Kawamura1, Y. Kono1, G. Ishiyama1  1Sapporo Ishiyama Hospital,Sapporo, HOKKAIDO, Japan

Introduction: Horseshoe fistulas are deep posterior anal fistulas which extend into the ischiorectal space in the shape of a horseshoe, involving muscle structure associated with continence. Surgical management is challenging due to its complex configuration and sphincter involvement. Failures in surgery for horseshoe fistulas often are attributed to insufficient drainage of the fistula or unsuccessful eradication of the fistula. These issues can be resolved with complete fistulotomy, which has been discredited for its high rate of incontinence, but recent studies have shown severance of the superficial external sphincter does not affect continence. We have chosen complete fistulotomy as the initial procedure of choice for horseshoe fistulas and divided the procedure in two stages to avoid impairment of sphincter function.

Methods: A retrospective review of 139 patients who underwent surgery for horseshoe fistula using this method between 2014 and 2017 was conducted. Incisions for the initial surgery were placed along the extended fistula arms so that the lateral tracts of the horseshoe were deroofed. The large open wound allowed a wider view enabling the eradication of fistula walls with a direct vision of the sepsis origin, as well as easier drainage. A loose seton was placed in the primary tract through the fistula origin which was laid open in the second surgery after the lateral wound was partially healed.

Results:

Fistula tracts extended into the supralevator space in 14 of the patients. An upward intersphincteric extension to the submucosa of the rectum was observed in 15. Twenty-one patients (15.1%) had undergone previous surgery intended to cure a lower anal fistula, implying the difficulty in accurate diagnosis for deep posterior anal fistulas.

All patients were followed up for a median of 22 months (range 3-53) and recurrence was observed in 12. In all but 1 patient, recurrence occurred as a superficial residual infection with the sepsis origin cured. Recurrence rate was 5.41% in those with tracts extending only to the ischiorectal fossa. Those with fistula extending higher intersphincterically had a significantly higher recurrence rate. Furthermore, patients who resided further than 50km from the hospital and could not visit the outpatient clinic frequently also had a significantly higher recurrence rate, indicating wound observation for premature closure is crucial in preventing recurrence. In regard to anal sphincter function, no patient had any continence issues including minor problems at the end of the follow up period.

Conclusion:Managing horseshoe fistula with the two-stage complete fistulotomy approach allows for complete eradication of the fistula tract without compromising anal sphincter function.
 

49.03 Impact of Primary Tumor Resection in Colorectal Cancer with Unresectable Metastasis

Posted on January 31, 2019

N. Ichikawa1, S. Homma1, T. Yoshida1, F. Kawamata1, T. Mitsuhashi2, H. Iijima3, S. Shibasaki1, H. Kawamura1, K. Ogasawara4, K. Kazui5, Y. Kamiizumi6, A. Taketomi1  1Hokkaido University,Department Of Gastroenterological Surgery 1,Sapporo, HOKKAIDO, Japan 2Hokkaido University Hospital,Department Of Surgical Pathology,Sapporo, HOKKAIDO, Japan 3Hokkaido University Hospital,Clinical Research And Medical Innovation Center,Sapporo, HOKKAIDO, Japan 4Kushiro Rosai Hospital, Japan Labour Health and Welfare Organization,Department Of Surgery,Kushiro, HOKKAIDO, Japan 5Hokkaido Hospital, Japan Community Healthcare Organization,Department Of Surgery,Sapporo, HOKKAIDO, Japan 6Iwamizawa Municipal Hospital,Department Of Surgery,Iwamizawa, HOKKAIDO, Japan

Introduction: The prognostic benefit of primary tumor resection in colorectal cancer patients with unresectable distant metastasis remains unclear. We aimed to assess whether palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is associated with improved survival.

Methods: The survival period of 123 colorectal cancer patients diagnosed from January 2010 to December 2015 in 4 Japanese hospitals was analyzed. Sixty-four patients with and 59 without primary tumor resection were compared, retrospectively. In the patients with primary tumor resection, the survival period of 39 patients with lymphocyte:monocyte ratio (LMR) increase after primary tumor resection (LMR-increase) and 25 patients with LMR decrease (LMR-decrease) was also compared.

Results: Eighty nine colon cancer and 34 rectal cancer patients were eligible for the analysis. The mean age was 63 years old and male to female ratio was 63: 60. In the resection group, more patients were accompanied by non-differentiated adenocarcinoma (36% vs 15%, p <0.01), obstructive symptom (80% vs 51%, p <0.01), high serum albumen (3.8 vs 3.6 mg/dL, p =0.02) and no lymph node metastasis (20% vs 2%, p <0.01) than the non-resection group. The patients who underwent primary tumor palliative resection had prolonged median survival compared with patients never resected (24.5 vs 14.5 months, p =0.01). Multivariate analysis identified possible independent prognostic variables as the pathology containing non-differentiated adenocarcinoma (Hazard Ratio, 3.7), non-resection of primary lesion (2.7), and no use of irinotecan (2.6). Moreover, in the patients with primary tumor resection, the median survival times of the LMR-increase and LMR-decrease groups were 27.3 and 20.8 months, respectively (p =0.02, Figure). The preoperative lymphocyte population and LMR in peripheral blood of the LMR-increase group were significantly less than those of LMR-decrease group. There were no differences in any other patient characteristics and the extent of metastases between the 2 groups. When assessed the resected specimen in available cases, there were more CD163+ and CD8+ cells invaded into tumor stroma, significantly. (n=5)

Conclusion: Palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is possibly associated with improved survival, especially in the case with lymphocyte:monocyte ratio  increase after primary tumor resection.

 

49.02 Chasing Zero Cuff: Robotic Distal Dissection Superior to Laparoscopy in Ileal Pouch Anal Anastomosis

Posted on January 31, 2019

A. W. Elias1, R. G. Landmann2  1Mayo Clinic – Florida,General Surgery,Jacksonville, FL, USA 2MD Anderson Cancer Center, Baptist Health,Colon & Rectal Surgery,Jacksonville, FL, USA

Introduction: Improved rectal dissection allows more distal transection and minimization of the rectal cuff during pouch procedures. Data is limited comparing robotic versus laparoscopic ileal J pouch-anal anastomosis (IPAA) procedures. Herein, we sought to compare robotic versus laparoscopic ileal pouch-anal anastomosis outcomes.

Methods: A prospectively maintained database was utilized to perform a retrospective matched cohort study. 44 consecutive patients who underwent ileal pouch-anal anastomosis between 2008-2017 at a US tertiary care hospital via robotic approach were matched to 72 laparoscopic controls by surgeon, age, gender, BMI, comorbidities, and operative history. Distal extent of dissection, intraoperative, and postoperative outcomes were analyzed.

Results: 116 patients (58% male) with median age 37.8 years [range 1716-68], BMI 24.5 [range 16.1-40.7], ASA score II [range I-III] underwent restorative ileal pouch-anal anastomosis (44 robotic, 72 laparoscopic), predominantly (90%) for ulcerative colitis. Distal extent of dissection (distance from dentate line) was significantly improved robotically (0 versus 1.3cm) (p<0.001). There were no significant differences in blood loss, complications, number of bowel movements at 30-days, 1 and 2 years, or use of pre-operative immunomodulators, steroids, ASA-derivatives, or TPN; however, more robotic patients utilized biologics (p = 0.007). Robotic procedure length was 20 minutes longer. Robotic median time to diet resumption was shorter (1 versus 2 days) (p<0.001). Despite equal medians, robotic admission length (4 days) and time until ostomy function (1 day) was significantly shorter (p = 0.02 and p=0.005, respectively). There were no reoperations or mortalities.

Conclusion: Robotic surgery enables superior total mesorectal excision and distal transection with elimination of the at-risk rectal cuff with improved postoperative outcomes in patients undergoing IPAA for ulcerative colitis and familial adenomatous polyposis. This technique can be applied to inflammatory and oncologic operations to improve negative margin rates and improve rates of sphincter preservation/intestinal continuity.

 

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