The American Society of Colon and Rectal Surgeons Annual Meeting Abstracts • General Surgery ...

547 Pages·2017·43.69 MB·English

The American Society of Colon and Rectal Surgeons
Annual Meeting Abstracts
• General Surgery Residents’ Forum
• Research Forum
• Podium Abstracts
• Poster Abstracts
• Video Abstracts
June 10–14, 2017
Washington State Convention Center and
Sheraton Seattle Hotel
Seattle, WA
General SurGery reSidentS’ Forum
IS NEUTROPHIL LYMPHOCYTE RATIO december 2014 were identified from our prospectively
ASSOCIATED WITH INCREASED MORBIDITY maintained database. Patients who had preoperative as
AFTER COLORECTAL SURGERY? well as postoperative first and second day nlr (abstracted
GS1 from CBC) were included in the study. Patients received
General Surgery residents’ Forum
neoadjuvant chemoradiation, on steroids, had anorectal
C.Benlice, a. onder, H. aydinli, r. Babazade, S. Steele,
and emergency surgeries were excluded. Patients were
e.Gorgun
divided into two groups based on the presence of post-
Cleveland, OH
operative complications. demographics, preoperative
Purpose/Background: in the current study, we aimed comorbidities, operative details and postoperative 30-day
to evaluate the association between pre- and postoperative morbidity and mortality were reviewed and compared.
neutrophil lymphocyte ratio (nlr) and 30-day postopera- Results/Outcome(s): a total of 1328 patients met the
tive complications after colorectal surgery and determine, inclusion criteria during the study period with a mean age of
if any trends in nlr predicts complications. 61 ±16 years. 518 (39%) patients experienced at least one
Methods/Interventions: Patients who underwent postoperative morbidity. table summarizes the comparative
elective colorectal surgery between January 2010 and analysis for demographics and preoperative comorbidities.
GS1 Comparison of perioperative characteristics and postoperative outcomes between the groups
Morbidity (+) Morbidity (-)
Variable (N=518) (N=810) P value
Age¥, years 62.0 ± 17.2 60.9 ± 16.2 0.24
Gender <0.001
Female 226(34.1) 437 (65.9)
Male 292 (43.9) 373 (56.1)
BMI ¥ (kg/m2) 27.9 ± 7.0 27.2 ± 7.2 0.07
Surgical procedures
Right colectomy w ICA 215 (41.0) 310 (59.0)
Left colectomy w CCA 145 (33.6) 286 (66.4)
LAR w CRA 93 (41.0) 134 (59.0)
Total colectomy w IRA 65 (44.8) 80(55.2)
Diabetes Mellitus 78 (54.9) 64 (45.1) <0.001
Surgical approach <0.001
Minimal invasive approach 274 (34.6) 517 (65.4)
Open 244 (45.4) 293 (54.6)
Pre op NLR 9.9 ± 12.8 10.2 ± 13.5 0.66
NLR on POD1 16.6 ± 20.2 13.8 ± 13.8 0.028
NLR on POD2 9.9 ± 12.9 8.0 ± 8.9 0.016
Length of hospital stay¥, days 11.4 ± 7.9 6.4 ± 4.1 <0.001
ASA score 0.15
1/2 161 (36.4) 281 (63.6)
3/4 332 (40.6) 486 (59.4)
Diagnosis 0.001
Cancer 245 (41.5) 346 (58.5)
Diverticulosis 102 (32.2) 215 (67.8)
Crohn’s Disease 98 (46.4) 113 (53.6)
Polyposis syndromes 31 (27.4) 82 (72.6)
Ulcerative colitis 25 (49.0) 26 (51.0)
Constipation 17 (37.8) 28 (62.2)
Operative time¥, minutes 207 ± 100 190 ± 81 0.001
Values are expressed as absolute numbers (percentages) unless indicated otherwise; ¥ values are expressed as
mean (Standard Deviation). ICA: ileocolic anastomosis; CCA: colo-colonic anastomosis; LAR w CRA: low anterior
resection and colorectal anastomosis; IRA: ileorectal anastomosis; EBL: estimated blood loss; NLR: neutrophil
lymphocyte ratio; WBCs: white blood cells.
2
3
Gender (p<0.001), diabetes mellitus (p<0.001), type of same time period. lesions were deemed “unresectable”
specific diagnosis (p=0.001), type of operation (p=0.03) due to various characteristics, including polyp size, loca-
and open surgery (p<0.001), nlr on Pod-1 (p=0.02) tion, and sessile nature. the biopsies on these polyps were
and Pod-2 (p=0.01) were statistically different required to result in benign pathology. if malignancy was
between the groups. Patients who had postoperative identified, the patient proceeded for oncologic resection.
morbidity were found to have longer operative time (207 ± C0 videocolonoscopy was utilized to identify the lesion
2
100 vs 190 ± 81 minutes, p<0.001) and length of hospital and determine feasibility of endoscopic resection. Various
stay (11.4 ± 7.9 vs 6.4 ± 4.1 days, p<0.001). an analysis endoscopic and laparoscopic techniques were utilized
of possible cut-offs rounded to one decimal demonstrated including submucosal saline lift, dual channel scope with
that a cut-off of 9.2 maximized the univariate odds ratio endoscopic graspers, it knife, and endoscopic snares.
(or 2.05; 95% Ci 1.56 – 2.71) and also the covariate-ad- laparoscopic assistance was utilized for retraction, better
justed odds ratio (or 1.544; 95% Ci 1.133 - 2.105) among polyp visualization and access, suture repair or imbrication,
all cut-offs. on multivariate analysis, presence of diabetes omental interposition, or wedge resection. Patients were
mellitus [odds ratio: 1.97 (95% Confidence interval: 1.27 followed for postoperative complications, estimated blood
- 3.08), p=0.003] and nlr on Pod2 ≥ 9.2 [or: 1.43 loss (eBl) length of stay (loS), operative time and total
(95% Ci: 1.03 -1.98), p=0.02] were significantly related cost.
to postoperative complication. Results/Outcome(s): Sixteen patients were identi-
Conclusions/Discussion: neutrophil lymphocyte ratio fied in the CelS group and compared to 16 matched,
after colorectal surgery may provide clinicians with an randomized individuals in the lC group. total loS, eBl,
additional tool for identifying high risk patients for postop- postoperative complications and operative time and cost
erative complications. routine use of neutrophil lympho- were analyzed for each patient and compared between the
cyte ratio may lead to early intervention and potentially CelS and lC groups. Between-subjects analysis revealed
improve the management of complications after colorectal that those in the CelS group had statistically significant
surgery. lower operative times (average 161 mins in CelS vs
252 mins in lC), eBl (average 8.13cc in CelS vs 65.12cc
in lC), and loS (0.63 days in CelS vs 3.19 days in
COMBINED ENDOSCOPIC AND LAPAROSCOPIC lC) [all with p < 0.001] when compared to their lC
SURGERY OFFERS IMPROVED PATIENT counterparts.
OUTCOMES VERSUS LAPAROSCOPIC Conclusions/Discussion: CelS for the removal of
COLECTOMY FOR ENDOSCOPICALLY endoscopically unresectable benign colorectal neoplasms
UNRESECTABLE COLORECTAL NEOPLASMS. offers a safe, cost-effective, and minimally invasive alter-
GS2 native to formal laparoscopic colectomy in select patients
General Surgery residents’ Forum
with lower operative times, less eBl, and shorter length
S.Bhat, a. Cavalea, m. Beasley, m. Casillas, a. russ
of stay.
Knoxville, TN
Purpose/Background: large, sessile or inaccessible
colorectal polyps are often deemed unresectable by endo- A SURGICAL CLOSTRIDIUM ASSOCIATED RISK
scopic means and thus referred for a formal colectomy. OF DEATH SCORE PREDICTS MORTALITY
this increases the operative risk to the patient and AFTER COLECTOMY FOR CLOSTRIDIUM
recovery time. as endoscopic techniques progress, resec- DIFFICILE INFECTION.
tion of these neoplasms is becoming possible. resection GS3
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can often be facilitated with laparoscopic assistance, as
a.Kulaylat, Z. Kassam, C. Hollenbeak, d. Stewart
advancements have enabled more aggressive resection
Hershey, PA; Medford, MA
such as endoscopic mucosal resection (emr) or endo-
scopic submucosal dissection (eSd) without the inherent Purpose/Background: a Clostridium difficile-associated
morbidity of a formal colectomy. the purpose of our study risk of inpatient death score (CardS) was recently devel-
is to compare combined endoscopic and laparoscopic oped and validated using a national cohort of both non-
surgery (CelS) to formal laparoscopic colectomy (lC) in surgical and surgical patients admitted with Clostridium
the treatment of colorectal neoplasms. difficile infection (Cdi). However, risk scores specifically
Methods/Interventions: We present a single institu- designed to estimate mortality following surgery for Cdi
tion case-control observational study from January 2015 are currently unavailable. the aim of this study was to
through october 2016, representing a series of patients develop a risk score for patients with Cdi who underwent
with endoscopically unresectable colorectal neoplasms total abdominal colectomy (taC) due to failure of medical
referred for surgical intervention. Sixteen individuals were therapy.
selected for CelS during this period. they were then Methods/Interventions: a retrospective cohort study
compared with 16 randomized lC patients during the (2005–2014) was performed using the national Surgical
4 General SurGery reSidentS’ Forum
Quality improvement Project (nSQiP) Participant use may represent a point before which surgical intervention
File to identify all patients undergoing taC with a primary should be considered. sCardS suggests that the subgroup
diagnosis of Cdi. Clinical variables reflecting patients’ of Cdi patients with intermediate levels of comorbidities
acute and chronic comorbidities, similar to the original have mortality following taC that is significantly greater
CardS study, were used to construct a model estimating than estimated by the nSQiP calculator, which may affect
predicted probability of mortality after surgery, referred discussions regarding surgical candidacy and timing of
to as surgical CardS (sCardS). risk estimates were surgery.
compared to those obtained using the american College
of Surgeons nSQiP risk calculator, assuming a similar
distribution of aSa classification. RISK FACTORS FOR AND MANAGEMENT OF
Results/Outcome(s): a total of 532 patients who PELVIC SEPSIS AFTER ILEAL POUCH-ANAL
underwent taC for Cdi were identified, of whom 32.7% ANASTOMOSIS FOR CHRONIC ULCERATIVE
experienced 30-day postoperative mortality. Patient COLITIS.
covariates significantly associated with mortality included GS4
General Surgery residents’ Forum
age greater than 80 years (odds ratio [or] 5.5, P=0.003),
n. mcKenna, m. Khasawneh, a. lightner, S. Kelley,
need for preoperative mechanical ventilation (or 3.1,
K. mathis
P<0.001), chronic steroid use (or 2.9, P<0.001), under-
Rochester, MN
lying cardiopulmonary disease (or 2.0, P=0.001) and
acute renal failure (or=1.7, p=0.03). these and other Purpose/Background: a total proctocolectomy with
comorbidities, including hepatic disease, a cancer diagnosis creation of an ileal pouch-anal anastomosis (iPaa) is
and diabetes mellitus, were used to construct a model the surgical treatment of choice for patients with chronic
to estimate the predicted probability of mortality, which ulcerative colitis (CuC). Some patients will unfortunately
ranged from 8.0% to 96.1% based upon individual comor- develop pelvic sepsis, the leading cause of pouch failure
bidity profiles. at intermediate levels of comorbidities, and subsequent pouch excision. We sought to evaluate the
estimates of postoperative mortality differed substantially 30-day incidence of pelvic sepsis and evaluate risk factors
to those obtained using the nSQiP risk calculator, espe- associated with this complication.
cially in terms of estimating the impact of chronic steroid Methods/Interventions: We performed a retrospective
use, acute renal failure and cardiopulmonary disease on review of all patients undergoing either two or three stage
mortality (table 1). iPaa for CuC at our institution between January 2002
Conclusions/Discussion: among patients with and July 2015. Baseline demographics, perioperative clin-
Cdi who require total colectomy, sCardS allows for ical and surgical variables, incidence of pelvic sepsis, and
Cdi-specific preoperative risk stratification, and may be management outcomes were recorded from the medical
helpful in avoiding futile surgery in the face of a comor- records. Summary, univariate, and multivariate statistical
bidity burden associated with a low likelihood of survival analyses were performed.
following surgery. the need for mechanical ventilation is Results/Outcome(s): a total of 910 patients underwent
associated with significantly higher odds of mortality, and iPaa between January 2002 and July 2015. Seventy four
patients (8.1%) developed pelvic sepsis within 30 days
postoperatively. on univariate analysis, patient age ≤ 50
GS3 Comparison of risk of 30-day mortality between
years at the time of operation (p = 0.048), patients without
sCARDS and ACS NSQIP Risk Calculators, varying by
a prior abdominal operation (p = 0.04), an estimated
cumulative comorbidities for a hypothetical 65 year blood loss (eBl) greater than 300 cc (p = 0.03), and
old patient requiring TAC for CDI patients who received a postoperative blood transfusion
(p < 0.0001) had a significantly increased risk of pelvic
Comorbidity sCARDS* ACS NSQIP*
sepsis. on multivariate analysis, receiving a postoperative
blood transfusion remained a significant risk factor for
Baseline 30-day Mortality 13% 14%
development of pelvic sepsis (odds ratio, 3.72; 95% confi-
Mechanical Ventilation 32% 30%
dence interval, 1.90-7.02; p = 0.0002). Preoperative steroid
Chronic Steroid Use 57% 36% use (p = 0.16) and immunomodulator use (p = 0.28)
Acute Renal Failure 69% 43% were not significantly associated with pelvic sepsis. the
Cardiopulmonary 82% 62% diagnosis of pelvic sepsis was made as an inpatient in
Hepatic 88% 79% 62.2% (n=46) of cases on a median postoperative day
Cancer 89% 92% of 12 (range 6-20 days). of those 74 patients with pelvic
Diabetes 86% 93% sepsis, 62% (n=46) were managed with percutaneous
*Each line represents the cumulative risk of mortality drain placement, 16.2% (n=12) were managed oper-
for a given comorbidity along with the preceding comor- atively, 14.9% (n=11) were managed with antibiotic
therapy alone, and 6.8% (n=5) were managed with a
bidities.
5
combination of operative and radiological procedures. per group with follow-up longer than 3 and 5 years,
the majority (91.5%, n=65) of patients with pelvic sepsis respectively. l-iPaa was associated with significantly
underwent ileostomy closure with restoration of bowel decreased number of stools at night and less frequent pad
continuity. usage at 1 year, both during the day and at night (table),
Conclusions/Discussion: Pelvic sepsis, while occurring although differences disappeared with further follow-up.
in less than 10% of patients, remains a dreaded compli- l-iPaa was also associated with improved overall
cation following iPaa due to an association with pouch CGQol, and energy scores at 1 year postoperatively, and
dysfunction and failure. We found postoperative blood decreased social restrictions for 1-2 years postoperatively.
transfusion was significantly associated with pelvic sepsis CGQol scores also became comparable during subsequent
underscoring the need for meticulous intraoperative tech- follow-up (table). there were no significant differences
nique, liberal use of hemostatic agents intraoperatively, in quality of health, dietary, work or sexual restrictions.
and careful selection for postoperative blood transfusion. l-iPaa and o-iPaa had similar rates (p=0.07) and
causes of pouch failure. Cumulative pouch survivals were
94% (95% confidence interval (Ci) 89% - 97%) vs. 98%
(Ci 94% - 99%) for liPaa vs. oiPaa and 94% (Ci 89%
- 97% Ci) vs. 96% (Ci 88% - 99%) at 5-year and 10-year
follow-up, respectively (p=0.12). a subset multivariate
analysis indicated incomplete donuts (p=0.01), anasto-
motic separation (p<0.001), pelvic sepsis (p<0.001) and
fistula (p<0.001) as independent factors associated with
CASE-MATCHED COMPARISON OF LONG- pouch failure after l.
TERM FUNCTIONAL AND QUALITY OF LIFE Conclusions/Discussion: laparoscopic and open
OUTCOMES FOLLOWING LAPAROSCOPIC VS. iPaa are associated with equivalent long-term func-
OPEN ILEAL POUCH-ANAL ANASTOMOSIS. tional outcomes, quality of life and pouch survival rates.
GS5 the laparoscopic technique is associated with temporary
General Surgery residents’ Forum
benefits lasting up to two years.
o. lavryk, l. Stocchi, J. ashburn, m. Costedio,
e. Gorgun, H. Kessler, t. Hull, C. delaney
Cleveland, OH
IMPROVED STAGE-SPECIFIC SURVIVAL
Purpose/Background: laparoscopic ileal pouch- AND SUPERIOR MARGIN NEGATIVITY FOR
anal anastomosis (l-iPaa) is associated with recovery RECTAL ADENOCARCINOMA AT ACADEMIC
benefits when compared with open (o-iPaa). there is COMPREHENSIVE CANCER INSTITUTIONS.
limited data on comparative long-term quality of life and GS6
General Surgery residents’ Forum
functional outcomes, which this study aimed to assess.
S. Sujatha-Bhaskar, J. Gahagan, S. Gambhir, m. Jafari,
Methods/Interventions: an irB-approved, prospec-
S. mills, a. Pigazzi, m. Stamos, J. Carmichael
tively maintained database was queried to identify patients
Orange, CA
undergoing l-iPaa (multiport, single-port or robotic),
case-matched with o-iPaa based on age±5 years, gender, Purpose/Background: rectal adenocarcinoma is
body mass index (Bmi) ±5 kg/m2, diagnosis (ulcerative predominantly managed at three institution types, defined
or indeterminate colitis, familial adenomatous polyp- by the american College of Surgeons Commission on
osis), date of surgery±3 years, stapled/handsewn anasto- Cancer Program: academic comprehensive cancer insti-
mosis, omission of diverting loop ileostomy, and length of tutions (aC), comprehensive community programs (CC),
follow-up±3 years. We assessed functional results, dietary, and community centers (Co). aC and CC participate in
social, work, sexual restrictions and the Cleveland Clinic clinical research and are involved in over five hundred
global quality of life score (CGQol) at 1, 2, 3, 5 and newly diagnosed cancer cases per year. Co provide care
10 years postoperatively. Functional outcomes were for one hundred to five hundred new cases yearly. the
assessed based on number of stools (total, day/night) and classification of aC includes national Cancer institute-
seepage protection use (day/night). Variables were eval- designated cancer centers and mandates multidisciplinary
uated with Kaplan-meier survival curves, univariate and postgraduate resident education. in this study, we aim
multivariate analyses. to compare short and long-term outcomes among these
Results/Outcome(s): out of 4595 iPaas, 529 patients institution types.
underwent l-iPaa, of whom 404 patients were well Methods/Interventions: a retrospective review of the
matched 1:1 to an equivalent number of o-iPaa based national Cancer database from 2008-2014 was performed
on all criteria. median follow-ups were 2.0 (0.5 – 17.8) vs. identifying patients who underwent neoadjuvant chemora-
2.4 (0.5 - 22.2) years in l-iPaa vs. o-iPaa, respectively diation, surgical management, and adjuvant chemotherapy
(p=0.18). there were 266 (66%) and 196 (49%) patients for pathologic stage ii and stage iii rectal cancer. Cases
6 General SurGery reSidentS’ Forum
were stratified based on institution types. multivariate 1.33, 95% Ci 1.04-1.72, p < 0.05). Compared to aC, both
analysis was used to compare outcomes by institution type, CC (1.28, 1.10-1.49, p < 0.01) and Co (or 1.45, 1.16-
and a Cox proportion hazard model was used to estimate 1.80, p < 0.01) demonstrated higher 5-year death hazard
long-term overall survival by institution. rates. Patients with pathological stage ii and Stage iii
Results/Outcome(s): of 8,367 cases, 3,270 (39%) were disease treated at aC demonstrated superior 5-year overall
treated at aC, 4,181 (50%) were treated at CC, and 916 survival compared to CC and Co - Stage ii (aC 85%, CC
(11%) at Co. minimally invasive (laparoscopic or robotic) 77%, Co 72%, p < 0.01), Stage iii (aC 68%, CC 63%, Co
proctectomy was more prevalent at aC and CC compared 59%, p < 0.05).
to Co (aC 42%, CC 42%, Co 27%). over this six-year Conclusions/Discussion: rectal cancer care at
study period, each aC-designated institution managed an academic comprehensive cancer institutions is associated
average of approximately 15 cases of pathological Stage ii/ with superior margin negativity and improved overall
iii rectal adenocarcinoma, each CC-designated institution and stage-specific survival. as we move forward with
individually managed approximately 8 cases and each the national accreditation Program for rectal Cancer
Co-designated institution managed approximately 3 cases. (naPrC), these best practices must be considered and
mean time between diagnosis and operative intervention replicated when possible.
was longest for aC (141.5 ± 40.2 days) compared to CC
(129.9 ± 35.0 days) and Co (132.6 ± 36.2 days), (p < 0.01).
Compared to CC, aC demonstrated superior overall nega-
tive margin rates (or 1.31, 95% Ci 1.07-1.61, p < 0.01)
and superior negative circumferential margin rates (or
GS5 Quality of life and functional outcomes of laparoscopic vs. open IPAA
Open IPAA Laparoscopic IPAA
Variable (n=404) (n=404) P value
Overall CGQOL
1 y, n=312 0.7 ± 0.2 0.8 ± 0.2 0.001
3 y, n=263 0.8 ± 0.2 0.8 ± 0.2 0.94
5 y, n=255 0.8 ± 0.2 0.7 ± 0.2 0.99
Energy level
1 y, n=312 6.9 ±2.1 7.4 ± 2.0 0.02
3 y, n=263 7.2 ±2.1 7.3 ± 2.0 0.64
5 y, n=255 7.0 ± 2.1 7.2 ±2.1 0.46
Seepage protection use during the day
1 y, n=312 70 (22.4%) 36 (11.6%) 0.04
3 y, n=191 53 (27.7%) 43 (22.7%) 0.43
5 y, n=184 41 (19.3%) 23 (12.5%) 0.56
Seepage protection use during night
1 y, n=312 101 (32.4%) 65 (20.8%) 0.04
3 y, n=191 53 (27.7%) 43 (22.7%) 0.43
5 y, n=184 41 (22.5%) 64 (34.7%) 0.56
Number of stools per day
1 y, n=312 5.7 ± 2.3 5.3 ± 2.1 0.08
3 y, n=224 6.1 ± 3.4 5.4 ± 2.2 0.27
5 y, n=213 5.8 ± 2.7 5.4 ± 2.1 0.45
Number of stools per night
1 y, n=312 2.5 ±1.7 2.0 ± 1.4 0.006
3 y, n=224 2.6 ± 2.1 2.2 ± 1.7 0.06
5 y, n=213 2.5 ± 1.7 2.1 ± 1.4 0.09
Total number of stools
1 y, n=312 8.1 ± 3.1 7.0 ±2.8 <0.001
3 y, n=224 8.5 ± 5.0 7.5 ± 3.2 0.22
5 y, n=213 8.0 ± 3.6 7.3 ± 2.7 0.22
IPAA=ileal pouch anal anastomosis; CGQOL = Cleveland Clinic global quality of life score
7
for anastomotic disruption, pelvic packing has fallen out of
favor. Furthermore, difficulty in obtaining thumbtacks and
retained foreign objects in the pelvis has made this option
less attractive. Suture ligation, although useful for a single
bleeding vessel, is not appropriate in the setting of massive,
diffuse hemorrhage. We have adopted the technique of
muscle fragment welding for massive sacral plexus bleeding
as first described by Hangzhou in 1994. this review will
aim to discuss sacral plexus anatomy, describe the muscle
fragment welding technique with stepwise illustrations and
discuss our ongoing clinical series where this technique has
been applied. We believe that all surgeons operating in the
pelvis should be aware of this technique, as it is a matter of
when, and not if massive sacral bleeding will occur.
Methods/Interventions: this is an ongoing retrospec-
tive review of twelve patients who underwent muscle
fragment welding, with four additional patients since
our published review in 2003. our technique requires
adequate exposure, packing the pelvis and stabalization
of the patient. a small piece of rectus abdominus muscle,
1.5-2 cm, is harvested and held in place with long forceps
against the site of bleeding, functioning as a “biologic
welding rod”. electrocautery is adjusted to the highest
setting and applied to the tip of the forceps to “weld”
closed the bleeding point. the current is delivered until
the muscle fragment and underlying presacral tissue turn
into a charcoal gray coagulum.
Stage ii and Stage iii Survival by Facility type Results/Outcome(s): this technique was successful
for control of sacral plexus bleeding in all twelve patients.
no significant complications were encountered during our
MUSCLE FRAGMENT WELDING: ONGOING application.
CLINICAL SERIES WITH ILLUSTRATED Conclusions/Discussion: muscle fragment welding is
TECHNIQUE FOR CONTROL OF SACRAL a safe, readily available, and highly effective method of
PLEXUS HEMORRHAGE. controlling massive sacral bleeding. this step by step illus-
GS7 tration will demonstrate the technique used in our practice
General Surgery residents’ Forum
since 1996.
m. Brown, H. abcarian, J. Cheape, B. Jenkins,
m. lawrence, C. orsay, V. Hooks
North Augusta, SC; Chicago, IL
IMPACT OF FREQUENCY OF OPERATING
Purpose/Background: despite multiple publications ROOM STAFF CHANGES ON COMPLICATIONS
in the colon and rectal literature on muscle fragment IN COLORECTAL SURGERY: A POTENTIALLY
welding, it remains apparent there is a lack of awareness MODIFIABLE FACTOR TO IMPROVE PATIENT
of this technique. rectal mobilization requires careful OUTCOMES.
dissection as massive sacral bleeding, although rare, can GS8
General Surgery residents’ Forum
be a life-threatening complication. Whenever this type of
a. ofshteyn, V. Kejriwal, J. munger, d. Popowich,
hemorrhage is encountered, the first step is adequate expo-
S. Gorfine, J. Bauer, d. Chessin
sure. extending the incision or converting from minimally
New York, NY
invasive operations to an open exposure is mandatory in
our opinion. direct pressure should be applied with pelvic Purpose/Background: operating room circulator and
packing and additional suction equipment set up. alerting scrub technicians are often given breaks by other staff
the anesthesia team and resuscitation of the patient with during surgical procedures, especially when surgeries are
blood products is vital. next, different techniques used to long or start later in the day. there is minimal reported
alleviate bleeding should be considered. Pelvic packing, data on how this factor impacts surgical outcomes. our
suture ligation and application of metallic thumbtacks literature review uncovered no reports on the impact
have traditionally been described. However, given the of this variable on complications in patients undergoing
need for re-exploration, risk of pelvic sepsis and potential bowel resection. therefore, our aim was to evaluate the
8 General SurGery reSidentS’ Forum
effect of operating room staff handoffs on surgical patient 95% Ci 0.17-0.94, p=0.036). the strongest predictors of
complications within 30 days of a colorectal surgery. complications were patient factors including heart disease
Methods/Interventions: Patient data from 2012 to (or 2.38, 95% Ci 1.16-4.89, p=0.018), Caucasian
2016 was extracted from an electronic medical record of a race (or 2.10, 95% Ci 1.07-4.09, p=0.030) and other
tertiary care academic center. Patients aged 18 to 97 who race (or 2.54, 95% Ci 1.18-5.49, p=0.017); and oper-
underwent a colorectal intervention involving a bowel ative factors, including procedure type such as ileostomy
anastomosis with complete charting documentation were takedown (or 0.25, 95% Ci 0.09-0.70, p=0.008) and low
included. multivariate logistic regression models were used anterior resection (or 0.20, 95% Ci 0.05-0.83, p=0.027),
to evaluate the effect of intraoperative staffing changes on open vs. laparoscopic surgery (or 2.11, 95% Ci 1.27-3.51,
patient outcomes. the primary outcome was morbidity and p=0.004) and high estimated blood loss (or 2.97, 95% Ci
mortality within 30 days of index procedure. models were 1.12-7.85, p=0.028).
adjusted for patient demographics and comorbidities as Conclusions/Discussion: in our analysis of colorectal
well as operative factors including start time, complexity, surgery patients having the same scrub technician start
and procedure length. and finish the case was protective against postoperative
Results/Outcome(s): 980 patients were captured morbidity for longer cases. Patient race, presence of heart
through iCd-9 and CPt code extraction. of those, 644 disease, procedure type, use of open surgery, and high
patients fit our selection criteria. the morbidity rate estimated blood loss were significantly associated with
was 25% within 30 days of surgery, ranging from minor postoperative complications. to our knowledge, this is the
complications including wound infection to major compli- first investigation focusing on intraoperative handoffs and
cations such as anastomotic leak. Having the same scrub patient outcomes in colorectal surgery. Further studies
technician start and finish the case (two intraoperative on systemic factors including staff changes could guide
scrub changes) was a protective factor against complica- operating room scheduling and staffing to reduce their
tions in procedures longer than 130 minutes (or 0.40, potential impact on postoperative complications.
reSearCH Forum
INHIBITION OF RAB13 EXPRESSION IN in HK (p=0.0138) or si-nS HK cell groups (p=0.0097).
LYMPH NODE STROMAL CELL-DERIVED Furthermore, liver and lung metastases were significantly
EXTRACELLULAR VESICLES DECREASES THEIR lower when raB13 expression was decreased in HK cells
PROMOTION OF COLORECTAL CANCER (p=0.0444 and p=0.0240 respectively).
GROWTH AND METASTASIS. Conclusions/Discussion: rab-13 is a ras-related small
rF1 GtPase with roles in membrane trafficking. We have
research Forum
demonstrated the importance of this gene in the stromal
G. maresh, r. Sullivan, S. mcChesney, X. Zhang, Z. lin,
cell promotion of CrC tumor initiation and metastasis and
e.Flemington, l. li, d. margolin
hope to use this to help develop new therapeutics based on
New Orleans, LA
the clarification of this cancer-related biological pathways.
Purpose/Background: ninety percent of CrC deaths
are caused by metastasis. lymph node (ln) involvement,
depth of tumor invasion, and extra-nodal metastases
influence the outcomes of CrC. metastasis is closely
connected with the interaction between CrC and ln
stromal microenvironment. We hypothesized that ln
stromal cells (lnSC) interact with CrC cells via rna
delivered by lnSC extracellular vesicles (eV). We aim
to identify effector rnas in lnSC eV and determine
whether targeting them reduces primary tumor growth and
metastases.
Methods/Interventions: We used next-Generation
Sequencing (nGS) of rnas from lnSC, an lnSC cell
line (HK) and eV from both cells, rt-PCr, WSt-1 cell
proliferation assay, transfection of HK cells with sirna for
raB13 (si-raB HK) or a non-Silencing control (si-nS Figure. Ht29-luc cells (1×10^4) mixed with media (no HK), HK,
HK), orthotopic intra-rectal (ir) injection nod/SCid si-nS HK, or si-raB HK cells (3×10^5) then injected ir into
6 mice/group and evaluated by Bli weekly.
mouse model of CrC, and whole body bioluminescent
imaging (Bli) of luciferase expressing tumors.
Results/Outcome(s): We identified rnas by nGS
from 53,723 genes. over 150 were enriched greater than DNA REPAIR GENES AND RESPONSE TO
2-fold in eVs vs. cells, and 13 were common to eV in both NEOADJUVANT CHEMORADIATION IN
lnSC and HK. rt-PCr confirmed these 13 rnas were RECTAL CANCER: A PREDICTIVE SCORE TO
more highly expressed in HK-eV than HK cells. among IDENTIFY THE COMPLETE RESPONDER.
six CrC cell lines by rt-PCr, Ht29 cells had the lowest rF2
research Forum
expression of one gene, raB13. When raB13 rna
r.Perez, a. Habr-Gama, F. Koyama, J. restrepo,
was silenced by sirna transfection, rt-PCr showed a
G.Pagin São Julião, B. Borba Vailati, r. azevedo,
decrease in expression in HK cells from 50% at 24 hrs to
S. araujo, a. aranha Camargo
93% by 5 days. a proliferation assay was used to analyze
Sao Paulo, Brazil
the functional consequences of raB13 knockdown, using
Ht29 cells treated with supernatant (containing eVs) Purpose/Background: neoadjuvant chemoradiation
from si-raB HK cells or si-nS HK cells. there was a (nCrt) may lead to complete tumor regression in a
decrease in cancer cell proliferation in the presence of proportion of patients and may offer the opportunity for
si-raB HK vs. si-nS HK cell supernatant (p=0.0002). organ-preserving strategies. Pre-treatment prediction of
We used our orthotopic mouse model to test whether tumor response to nCrt would allow identification of
silencing raB13 in HK cells would change their tumor ideal candidates to this treatment alternative avoiding the
promoting effects in vivo. luciferase-tagged Ht29 cells unnecessary detrimental effects of radiation for patients
(Ht29-luc, 1×10^4 cells) were mixed without or with unlikely to develop complete response (Cr). deregulation
HK, si-raB HK or si-nS HK cells, injected into mice and of dna repair pathways may be involved in several
assessed weekly by Bli. HK cells promoted tumor growth. carcinogenetic processes of human cancers including
However, the presence of si-raB HK cells impaired colorectal malignancies. the purpose of this study was to
Ht29-luc cell tumor growth in comparison to that of HK develop and test the performance of dna repair deregula-
cells (p=0.0018) or si-nS HK cells (p=0.0207) at 9 weeks tion score in the prediction of tumor response to neoajdu-
post injection (Fig 1). at necropsy, the Ht29-luc tumor vant Crt by comparing patients with Cr and incomplete
weights were significantly lower in si-raB HK group than response (ir).
9
10 reSearch Forum
Methods/Interventions: twenty-five patients with
t2-3n0-1m0 distal rectal cancer underwent pre-treatment
biopsy collection prior to nCrt. all patients underwent
50.4-54Gy of radiation and 5Fu-based chemotherapy. We
performed global gene expression analysis using rnaseq
to search for differentially expressed dna repair genes
between patients with complete and incomplete response
to nCrt. differentially expressed genes according to
tumor response were selected to establish an 8-gene score
(XPA, XRCC3, ATRIP, UBE2A, APEX2, NEIL2, HTLF,
XRCC4). expression values in rPKm of up-regulated
genes among Crs were multiplied by +1. expression
values for down-regulated genes among Crs were multi-
plied by -1. the sum of all expression values for all 8 genes
was performed to determine individual score results for
each patient. average scores between Cr and ir were
compared. a roC curve was created to estimate the
predictive value of the score.
Results/Outcome(s): overall 9 patients developed Cr
and 16 incomplete responses to nCrt and were included
in the study. 120 million sequences were generated for
each sample and were mapped to the human genome
reference sequence (Hg19) using Bioscope software.
the average score was 28 for Crs and 16 for ir (p<0.001).
the roC curve resulted in an auC 0.94 with high sensi-
tivity (87%) and specificity (100%) using a cutoff of >20.5
for the prediction of response.
Conclusions/Discussion: a dna deregulation score
may provide accurate prediction of tumor response to
nCrt and may be used in clinical practice to select ideal Figure. dna deregulation score for complete and incomplete
candidates more likely to develop complete response to responders to nCrt. the roC curve for the prediction of response
treatment. Prospective and independent validation is with high sensitivity and specificity.
required before definitive implementation into clinical
practice.
WHY HAVE US RATES OF PRIMARY
ANASTOMOSIS WITH DIVERTING ILEOSTOMY
IN PATIENTS WITH ACUTE DIVERTICULITIS
REQUIRING URGENT OPERATIVE
INTERVENTION PLATEAUED?
rF3
research Forum
C.Cauley, H. Kunitake, r. Patel, P. Fagenholz,
d.Berger, d. rattner, G. Velmahos, l. Bordeianou
Boston, MA
Purpose/Background: Prior studies suggested that
emergent resections and anastomosis with diverting ileos-
tomy (di) may be safe even with perforated diverticulitis
requiring urgent surgical intervention. recent aSCrS
guidelines suggest anastomosis be performed based on
clinical factors and surgeon preference. this study aims to
1) describe di utilization versus colostomy with Hartman
pouch (C) for acute diverticulitis in a nationally represen-
tative cohort 2) compare outcomes of di versus C 3) and
identify factors that may justify C instead of di.
Methods/Interventions: multi-institutional cohort
study of patients in nationwide inpatient Sample