Is a defunctioning ostomy needed in rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? A National Surgical Quality Improvement Program analysis

Is a defunctioning ostomy needed in rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? A National Surgical Quality Improvement Program analysis

Vol. 219, No. 4S, October 2014 decision-making, acceptability of the tool, and the feasibility of implementation. RESULTS: Of the thirteen patients r...

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Vol. 219, No. 4S, October 2014

decision-making, acceptability of the tool, and the feasibility of implementation. RESULTS: Of the thirteen patients recruited thus far, the mean age of patients was 62.85  11.10. The average location of tumor was 6.4  1.7 cm above the anal verge. Prior to PtDA use, only one patient (7.7%) preferred a permanent stoma, whereas viewing the PtDA resulted in four patients (30.8%) preferring APR. Post PtDA use, there was an knowledge improvement score of 37.5% and a decisional conflict reduction of 6.9%. The majority (92.3%) would recommend the tool to others. The study will be complete in August 2014. CONCLUSIONS: The rectal cancer PtDA may reduce variability in rectal cancer surgery consent process. Our results suggested it would improve patient knowledge, reduce decisional conflict, and help patients identify their values and choice preferences. Evaluation of the outcome of ligation of intersphincteric fistula tract (lift) and fistulectomy in transsphincteric anal fistula Arshad Ahmad, MS, Abhinav A Sonkar, MS, FACS, FRCS, FUCCI, Suresh Kumar, MS, Ravi Kumar, MS King George’s Medical University, Lucknow, Uttar Pradesh, India INTRODUCTION: Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing procedure for transsphincteric anal fistula. Coring out fistulectomy involves damage to sphincters and compromises continence to varying extent. METHODS: Patients of transsphincteric anal fistula were included in the study. Clinical assessment of continence and anal manometry was performed and resting and maximal anal pressures were recorded. LIFT and Fistulectectomy were performed randomly in these patients. Coring out fistulectomy was followed by suture repair of the defect created in the sphincter complex. Patients were followed up to one year for healing, persistent discharge or recurrence. Clinical assessment of continence and anal manometry was performed in all the patients after the procedure. RESULTS: One hundred and sixty patients were included in the study. LIFT and coring out fistulectomy was performed in eighty patients each. Primary healing occurred in 83.75% patients of LIFT group while 86.25 patients of fistulectomy group. Mean duration of healing in LIFT group was seven weeks while in fistulectomy group was 9.71 weeks. There was no significant change in resting and maximal anal pressures after LIFT. Grade 1 incontinence was reported in 18.75% patients and grade 2 incontinence in 3.75% patients following fistulectomy. There was significant change in the resting and maximal anal pressures after fistulectomy. CONCLUSIONS: LIFT is a sphincter preserving procedure with no change in continence and has less morbidity compared to coring out fistulectomy. However the two procedures have comparable results.

Scientific Poster Presentations: 2014 Clinical Congress


FTY720, a Sphingosine-1-phosphate receptor modulator, as a novel targeted therapy against colitis-associated cancer Masayuki Nagahashi, MD, Jie Liang, Akimitsu Yamada, Wei-Ching Huang, PhD, Yu Koyama, MD, PhD, Toshifumi Wakai, MD, PhD, Sheldon Milstien, Sarah Spiegel, PhD, Kazuaki Takabe, MD, PhD, FACS Virginia Commonwealth University, Richmond, VA and Niigata University, Niigata, Japan INTRODUCTION: Inflammatory bowel disease is an important risk factor for the development of colon cancer (colitis-associated cancer; CAC). It has been implicated that Sphingosine-1-phosphate (S1P), a bioactive lipid mediator, is a key mediator of inflammation, tumorigenesis and cancer progression. S1P is generated by sphingosine kinase 1 (SphK1) and exerts its functions by binding to specific G protein-coupled receptors (S1PR1-5). Recently FTY720, a functional antagonist of S1PR1, was approved by FDA for multiple sclerosis. The aim of this study is to elucidate the effect of FTY720 on CAC as a preclinical study. METHODS: Acute colitis was induced with 5% dextran sodium sulfate (DSS) for 5 days in C57bl/6 mice. CAC was established by injection of azoxymethane followed by administration of DSS. FTY720 was administered orally. RESULTS: In acute colitis model, FTY720 significantly improved severity of colitis. Key transcription factors of NF-kB and STAT3 and pro-inflammatory cytokine IL-6 were up-regulated during colitis and FTY720 suppressed these factors. SphK1, S1PR1 and S1P levels in colon were also higher with colitis and FTY720 reduced these levels. In CAC model, FTY720 drastically reduced the number and size of tumors. Further, FTY720 decreased levels of SphK1 and S1PR1 and eliminated the NF-kB-IL-6-Stat3 amplification cascade that involves in development of CAC. CONCLUSIONS: These results suggest that FTY720 can be a candidate in treating colon cancer in individuals with IBD. M.N. is a Japan Society for the Promotion of Science Postdoctoral Fellow. This work was supported by NIH grants R37GM043880, R01CA61774 (to S.S.) and R01CA160688 (to K.T.). Is a defunctioning ostomy needed in rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? A National Surgical Quality Improvement Program analysis Evangelos Messaris, MD, PhD, FACS, Tara M Connelly, MB, BCh, MS, Jennifer Miller, MD, Niraj J Gusani, MD, MS, FACS, Joyce Wong, MD, Neil Bhayani, MD Penn State Hershey Medical Center, Hershey, PA INTRODUCTION: A temporary proximal defunctioning ostomy is often performed during a low anterior resection (LAR) after radiation for rectal cancer. The aim of this study was to compare


Scientific Poster Presentations: 2014 Clinical Congress

postoperative outcomes in rectal cancer patients with and without a protective ostomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database records (2005 e 2012) were utilized to identify patients undergoing LAR following preoperative chemoradiation for rectal cancer (ICD-9: 154.1) and were stratified into 2 groups: diverting stoma (CPT code 44146, 44208) or no diverting stoma (CPT code 44145, 44207). The outcome measures were postoperative infectious complications, need for reoperation, and mortality. RESULTS: 1,406 patients were analysed: 607 (43.2%) received a protective ostomy and 799 (56.8%) were not diverted. There were no significant differences across the stoma/no stoma groups in demographic variables, co-morbidities and ASA score (p>0.05). The mean body mass index was greater in the stoma group (ostomy: 28.37.2 m/kg2 versus no ostomy: 27.46.6 m/kg2, p¼0.02). Although, operative time was increased in patients that received an ostomy (ostomy: 23094 minutes versus no ostomy: 21899 minutes, p¼0.02), there were no differences in overall anesthesia time or length of stay (p>0.05).No differences were seen in superficial or organ space infections, sepsis and septic shock and mortality between the two groups. CONCLUSIONS: Defunctioning ostomy does not decrease mortality or infectious complications in rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation. No factors were identified that could assist surgeons in deciding whether to perform a protective ostomy. Impact on surgical outcomes of complete neoadjuvant treatment of rectal cancer (CONTRE) Nishit Shah, MD, Matthew Vrees, MD, Steven Schechter, MD, FACS, FASCRS, Leslie A Roth, MD, Kimberly Perez, MD, Thomas DiPetrillo, MD, Nicklas B Oldenburg, MD, Timothy Kinsella, MD, Howard Safran, MD, William M Sikov, MD Rhode Island Hospital, Providence, RI INTRODUCTION: Preoperative chemoradiation followed by surgery is the standard approach for patients with stage II-III rectal cancer, resulting in decreased local recurrence. However, several studies have shown indifferent compliance of adjuvant chemotherapy after surgery, due to toxicity or patients declining further treatment. CONTRE is a multicenter phase II study, examining the feasibility of induction chemotherapy followed by chemoradiation prior to surgery. The aim of this study was to assess the impact of induction therapy on surgical outcomes.

J Am Coll Surg

3-5cm n¼5; >5cm n¼29. Thirteen pts (33%) had a complete pathologic response. 34 pts completed neoadjuvant treatment and underwent surgery. Four patients underwent abdominoperineal resection and 30 patients underwent a low anterior resection (LAR). In LAR pts, the median time to ileostomy reversal was 2.6 months. Four LAR patients were unable to have their temporary ileostomy reversed due to: persistent pouch leak (n¼1); persistent pelvic fluid (n¼1); patient/physician preference (n¼2). Postoperative Grade 3 toxicities included ileus (n¼2), anastomotic leak (n¼1), abscess (n¼2), diarrhea (n¼2) and dehydration (n¼2). CONCLUSIONS: Surgical morbidity is not increased following complete neoadjuvant treatment for rectal cancer. CONTRE is a well-tolerated alternative to current standard treatment, which has a minimal impact on postsurgical complications. It represents a new framework to sequence treatment in the management of rectal cancer. The current status and clinical and financial outcomes of urgent and emergent laparoscopic colectomy: results from a large population-based study Rodrigo Pedraza, MD, Reena N Tahilramani, MD, Jean Paul LeFave, MD, Ali Mahmood, MD, Eric M Haas, MD, FACS, FASCRS University of Texas Medical School at Houston and Colorectal Surgical Associates and University General Hospital, Houston, TX INTRODUCTION: Population-based studies evaluating laparoscopic colectomy and comparing outcomes to open surgery have been restricted to elective resections. Hence, data assessing nonelective laparoscopic colectomies are scant and limited. We aimed to assess and compare the role of laparoscopic versus open colectomy in the urgent and emergent setting utilizing the largest inpatient United States of America (USA) database. METHODS: Utilizing Premier Inc. database, from October 2008 to June 2011 we identified either open or laparoscopic right, left, and sigmoid colectomies in the nonelective setting. Demographic, clinical, and financial outcomes were analyzed. Using logistic regression, postoperative outcomes were adjusted based on age, gender, type of hospital, disease severity, and disease process.

METHODS: Patients with T3-4 and/or N1-2 rectal cancer, received mFOLFOX6 x 8 cycles, followed by 50.4 Gy radiation with concurrent fluoropyrimidine therapy, concluding with surgery.

RESULTS: A total of 22,719 urgent and emergent colectomies were identified during the study period, of which 95.8% were open and 4.2% were laparoscopic. Colorectal surgeons performed a significantly higher percentage of laparoscopic than open cases whereas general surgeons performed a higher percentage of open than laparoscopic cases. When compared to open surgery, laparoscopic colectomy resulted in significantly reduced complications (38.1% vs 29.0%), length of stay (14.8 vs 10.8 days) and mortality (6.6% vs 3.1%), and costs ($32,421 vs $24,848). After adjusting outcomes, laparoscopic colectomy resulted in significantly reduced complications and length of stay with similar costs.

RESULTS: 39 pts were enrolled, median age 61, stage II n¼7; stage III n¼32. Distance from the anal verge: <3cm n¼5;

CONCLUSIONS: Our analysis revealed that fewer than 5% of urgent and emergent colectomies in the USA are performed