Complete Colectomy Research Articles

Current Management of T1 Colon Cancer in Denmark: A Nationwide Cohort Study.

To describe the management of T1 colon cancer in a retrospective study of a national cancer registry. There is increasing interest in the potential of local excision (LE) as an organ-preserving treatment for early colon cancer. However, accurate identification of patients who may have lymph node metastases (LNM) and require further surgery is a major challenge. Patients diagnosed with T1 colon cancer in Denmark from 2016 to 2020 were included and divided according to treatment: polypectomy (referred to as LE), upfront colectomy and completion colectomy. Primary outcome was the proportion of patients diagnosed by LE. Secondary outcomes included the rate of LNM, the association of histopathological risk factors with LNM, and overall survival. 1,749 patients were included, and 1,022 patients (58.4%) underwent initial LE. The rate of R1 margins after initial LE was 31.0%. Colectomy was performed in 1,160 patients (upfront in 727, completion in 433), of whom 58.3% had pT1 cancer. The rate of LNM was 11.5%. Rates of LNM were similar in patients undergoing upfront or completion colectomy (10.2% vs 12.4%, P=0.392), and in patients with any single histopathological risk factor compared to those with none (8.9% vs 10.6%, P=0.565). Although overall survival was significantly shorter in patients undergoing LE alone, no association between survival and treatment strategy was found on multivariable analysis. LE is the most common mode of diagnosis in patients with T1 colon cancer and does not negatively impact survival and postoperative outcomes. Current strategies to stratify patients to completion surgery appear insufficient, and more robust predictors are needed.

Laparoscopic assisted colectomy versus laparoscopic complete colectomy: a cost analysis.

To compare the short-term outcomes and explore the potential economic benefits of laparoscopic-assisted colectomy with extracorporeal anastomosis (LAC/EA) vs. laparoscopic complete colectomy with intracorporeal anastomosis (LCC/IA) for patients with non-metastatic resectable colon cancer. Data of patients who underwent laparoscopic hemicolectomy from January 2017 to March 2023 were collected and analyzed. Propensity score matching (PSM) analyses was carried out to minimize the selection bias. Before PSM, a total of 113 patients met the inclusion criteria (39 in the LCC/IA vs. 74 in the LAC/EA). Clinicopathologic characteristics were comparable except for the median number of removed lymph nodes (P = 0.023). LCC/IA was associated with longer operative time, less intraoperative blood loss, and shorter incision length. The rate of 30-day postoperative complications was similar, but the time to first flatus and soft diet was shorter in the LCC/IA. No deaths were reported in either group within 30days after surgery. Costs of surgical instruments (25,945.8 ± 1,918.0 vs. 23,551.9 ± 2,665.5 RMB; P < 0.01) were higher for the LCC/IA but overall costs were similar (LCC/IA, 43,220.0 ± 4,954.0 vs. LAC/EA, 41,269.2 ± 6,685.9 RMB; P = 0.112). After PSM, 38 patients in the LCC/IA and 63 patients in the LAC/EA were compared. LCC/IA was superior in terms of intraoperative blood loss, incision length, and postoperative functional recovery. There was an extra charge of 2385.0 RMB regarding surgical instruments in the LCC/IA but the overall cost did not reach statistical significance. LCC/IA is a feasible, safe, and cost-effective surgical treatment for patients with non-metastatic resectable colon cancer.

Abstract PO5-20-08: A Case of Multifocal Ductal Breast Carcinoma with Extension into Lobules and Concurrent Primary Colon Adenocarcinoma

Abstract Background Multifocal (MF) multicentric breast cancer is a form of breast cancer that consists of disease independently developing at various locations due to a tumor clone spreading within the ductal complex. Multifocal breast cancer is associated with increased local recurrence. Our case highlights an example of multifocal breast cancer and addresses treatment challenges. Case presentation The patient is a 52-year-old African American female with a history of HCV cirrhosis, diabetes mellitus, and hypertension who presented with a palpable 4 cm right breast mass, without adenopathy, clinically Stage II, T2N0. Mammogram revealed a 2.5 cm right breast mass and three right level 1 axillary nodes with biopsy confirming invasive ductal carcinoma with extension into the lobules, ER positive (3%)/PR-/HER2-, Ki-67 95%. Neoadjuvant paclitaxel, carboplatin, and pembrolizumab was initiated but she incurred complications of decompensated liver cirrhosis after the second cycle and treatment was held. After 2 cycles her tumor was not palpable, and surgery was recommended, but due to COVID infection and concurrent decompensated liver failure surgery management was delayed. She underwent staged surgery with partial mastectomy without lymph node exploration. Histopathology showed DCIS grade 3 with extension into lobules and invasive ductal carcinoma with no lymphovascular invasion and all margins were negative, pathological stage ypT3NxM0. Immunohistochemistry demonstrated partial ER+ (50%)/PR-/HER2-, Ki-67 80%. She was given 4 cycles of adjuvant cyclophosphamide, adriamycin, pembrolizumab and continued on maintenance pembrolizumab. The patient was found with anemia out of proportion to chemotherapy and underwent colonoscopy that showed a colonic mass. Biopsy showed a primary moderately differentiated colonic adenocarcinoma. Her re-excision with new margins for partial mastectomy had negative margins, and 2 negative sentinel lymph nodes for ypN0. Genetic testing was negative. She continued on adjuvant immunotherapy with pembrolizumab for breast cancer. She is planned to start on adjuvant anastrozole. Patient has completed adjuvant radiation treatment and has no new complaints. She is pending curative intent completion colectomy for colon cancer. Discussion This case of MF breast cancer is significant, as one foci was ER negative, which responded to neoadjuvant chemoimmunotherapy and other ER positive that did not respond to treatment and was surgically excised. The pathology report from the surgical specimen revealed DCIS with extension into the lobules. Due to her tenuous clinical condition, she had staged surgeries for breast cancer, and now colon cancer. Genetic testing is negative. Currently, there is insufficient data to suggest which surgical approach is preferred in MF breast cancer. Based on the literature, breast conservation therapy (BCT) is a feasible option and is oncologically safe. Due to the patients’ medical condition and infections, it was felt a less invasive surgery could offer cure and minimize complications. Our patient underwent neoadjuvant chemoimmunotherapy, followed by partial mastectomy, adjuvant chemoimmunotherapy, second staged completion breast surgery, radiation therapy, and anti-estrogen therapy. MF breast cancer is associated with increased lymph node involvement. A 2022 meta-analysis found that multifocal and multicentric breast cancer has a slightly increased risk of death as compared to unifocal tumors. Lastly, our patient is African American, and multifocal tumors occur with a higher incidence in African Americans (43.4%) and Asian patients (37%) as compared to whites (28.9%). This case of breast cancer highlights treatment challenges in a case of multifocal multicentric breast cancer occurring concurrently with a secondary primary colonic cancer. Citation Format: Rabab Jafry, Hina Khan, Jessica Jones. A Case of Multifocal Ductal Breast Carcinoma with Extension into Lobules and Concurrent Primary Colon Adenocarcinoma [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-08.

Laparoscopic Colectomy Via Distance Mentoring: A Model to Develop Laparoscopic Surgery in Developing Caribbean Nations

Although laparoscopic colectomy is the standard of care for colorectal carcinoma, the skill sets to complete colectomy laparoscopically is not universally available in developing nations such as those in the Caribbean. We encountered this situation in Jamaica, where with limited experience in laparoscopic colorectal resections completed a laparoscopic sigmoid colectomy via remote mentoring. This may be, in select cases, a method to increase the availability of laparoscopic colorectal operations in developing countries.

Lymphoglandular Complex-Like Colorectal Carcinoma-A Series of 20 Colorectal Cases, Including Newly Reported Features of Malignant Behavior.

Distinguishing colon carcinoma that is surrounded by well-circumscribed lymphoid tissue from adenomas involving lymphoglandular complexes can be difficult. We assessed a multi-institutional international cohort of 20 colorectal carcinomas with associated prominent lymphoid infiltrates, which we referred to as lymphoglandular complex-like carcinoma (LGCC). We collected clinical and endoscopic features, including lesion size, endoscopic appearance, location, procedure, follow-up, AJCC stage, and mismatch repair status. We recorded the presence of the following histologic features: haphazard gland distribution, gland angulation, gland fusion, solid nest formation, single-cell formation, stromal desmoplasia, presence of lymphovascular invasion and perineural invasion, presence of lamina propria, cytologic atypia as low- or high-grade, presence of goblet cells in the invasive component, and the presence of a surface lesion. Most cases (9 of 13) were described endoscopically as sessile polyps with an average size of 1.56 cm. Most cases (90%) were associated with a surface lesion, of which the majority were tubular adenomas, though a subset was associated with sessile serrated lesions with dysplasia (3 of 18). All cases of LGCC demonstrated haphazard gland distribution and either gland angulation, fusion, or solid nest formation. A portion of cases demonstrated single-cell infiltration (35%) and desmoplasia (50%), and rarely lymphovascular invasion was present (5%). A subset (10%) of cases invaded beyond the submucosa. Deficient mismatch repair was present in 22% (2 of 9) of cases for which it was performed. In cases of colectomy or completion colectomy, nodal metastasis was present in 38% (3 of 8). No cases demonstrated disease recurrence or disease-specific mortality. Overall, LGCC represents an enigmatic subset of carcinomas that is important to distinguish from adenomas involving lymphoglandular complexes due to its varying prognostic outcomes.

Combined endoscopic and laparoscopic surgery (CELS) for early colon cancer in high-risk patients

BackgroundLocal excision of early colon cancers could be an option in selected patients with high risk of complications and no sign of lymph node metastasis (LNM). The primary aim was to assess feasibility in high-risk patients with early colon cancer treated with Combined Endoscopic and Laparoscopic Surgery (CELS).MethodsA non-randomized prospective feasibility study including 25 patients with Performance Status score ≥ 1 and/or American Society of Anesthesiologists score ≥ 3, and clinical Union of International Cancer Control stage-1 colon cancer suitable for CELS resection. The primary outcome was failure of CELS resection, defined as either: Incomplete resection (R1/R2), local recurrence within 3 months, complication related to CELS within 30 days (Clavien–Dindo grade ≥ 3), death within 30 days or death within 90 days due to complications to surgery.ResultsFifteen patients with clinical T1 (cT1) and ten with clinical T2 (cT2) colon cancer and without suspicion of metastases were included. Failure occurred in two patients due to incomplete resections. Histopathological examination classified seven patients as having pT1, nine as pT2, six as pT3 adenocarcinomas, and three as non-invasive tumors. In three patients, the surgical strategy was changed intraoperatively to conventional colectomy due to tumor location or size. Median length of stay was 1 day. Seven patients had completion colectomy performed due to histological high-risk factors. None had LNM.ConclusionsIn selected patients, CELS resection was feasible, and could spare some patients large bowel resection.

Metastasis to lymph nodes around the vascular tie worsens long-term oncological outcomes following complete mesocolic excision and conventional colectomy for right-sided colon cancer.

Oncologic outcomes after complete mesocolic excision (CME) in colon cancer are under investigation. The aim of our study was to compare CME and conventional colectomy (CC) in terms of pathological and oncological outcomes for right colon cancer and to evaluate the impact of lymph node metastasis around the vascular tie on survival. Consecutive patients with right colon cancer who had CME or CC between January 2011 and August 2018 at two specialized centers in Turkey were included. Statistical analyses were performed with respect to demographic characteristics, operative and pathologic outcomes, harvested and metastatic lymph nodes around the vascular tie (LNVT), recurrences, and survival. There were 91 patients in the CME group (58 males, mean age 64 ± 16years) and 192 patients in the CC group (96 males, mean age 66 ± 14years). The mean number of harvested lymph nodes (CME: 42 ± 15 vs CC: 34 ± 13, p = 0.01) and LNVT were higher in the CME group (CME: 3.2 ± 2.2 vs CC: 2.4 ± 1.6, p = 0.001). LNVT metastases were 7.7% and 8.3% in the CME and CC groups, respectively (p = 0.85). Three-year overall and disease-free survival rates were 96.4% and 90.9% in the CME group and 90.4% and 87.6% in the CC group in stage I-III patients (p > 0.05). In stage III patients, the 3-year overall survival (92.5% vs 63.5%, p = 0.03) and disease-free survival (85.6% vs 52.1%, p = 0.008) were significantly better in LNVT-negative patients than in LNVT-positive patients. LNVT metastasis seems to be the key factor associated with poor disease-free and overall survival in right colon cancer regardless of the radicality of surgery.

P3.47: Multimodality Surgical Management of Patients with Global Gut Dysmotility: Techniques and Long-Term Outcome

Introduction: Global gut dysmotility (GGD) is a severely disabling disorder with the potential to develop gut failure with impaired quality of life. With the lack of effective medical therapy and pacing technology, surgical management with different modalities including gut transplantation (GTx) has recently evolved as part of the multidisciplinary treatment approach for this orphan population. Methods: Between August 2012 and January 2019, a total of 172 patients with the diagnosis of GGD were referred to Cleveland Clinic, Center of Gut Rehabilitation and Transplantation (CGRT). TPN dependence was documented in 116 (76%). Of those, 82 (71%) underwent rehabilitative surgery (RS) and/or GTx. The diagnosis was confirmed by exclusion of gastrointestinal mechanical obstruction with radiologic evidence of global dysmotility including capsule endoscopy and sitz marker methodology. Most patients were adult female (88%) with extensive psychiatric history in more than 50% of the cases. Previous management included pharmacologic therapy, gastric pacing, partial colon resection, and external venting. Results: With the intent to treat or as a bridge to GTx, 62 (76%) underwent RS with completion colectomy and ileorectal anastomosis (n=47), pyloroplasty (n=27) and chimney ileostomy (n=40). GTx with liver-free (n=19) and liver-contained (n=1) allograft was performed in a total of 20 (24%). Of these transplant recipients, 7 (35%) failed RS at our institution. With a mean follow up of 32 + 15 months, 160 patients are currently alive with an overall survival rate of (93%). In those with TPN dependency, the survival rate was better after RS (94%) compared to GTx (80%). Restoration of oral tolerance with achievement of full nutritional autonomy was accomplished in 20 (32%) and 10 (63%) of the current survivors, respectively. Conclusion: Gut Rehabilitative surgery and transplantation are effective treatment modalities for GGD patients. RS can be utilized as a long-term therapy or bridge for gut transplantation.

Surgical Procedures and Short-Term Outcomes of a Complete Laparoscopic Colectomy with Intracorporeal Anastomosis for Right-Sided Colon Cancer

Surgical Procedures and Short-Term Outcomes of a Complete Laparoscopic Colectomy with Intracorporeal Anastomosis for Right-Sided Colon Cancer

0521 Perioperative Positive Airway Pressure Compliance in Obstructive Sleep Apnea Patients

Obstructive sleep apnea (OSA) increases risk for perioperative complications, so screening for OSA is recommended preoperatively. Preoperative patients with OSA and prescribed positive airway pressure (PAP) therapy are advised to use PAP after surgery. Postoperative circumstances may alter the PAP experience. Patterns of postoperative PAP use are not fully defined. Our aim was to use PAP download data to characterize perioperative PAP adherence and apnea-hypopnea indices (AHI) in a cohort of OSA patients. Single-center, retrospective review of surgical patients with OSA on PAP therapy in whom we had pre- and postoperative PAP download information. Surgeries included were: knee, hip, and shoulder arthroplasty; cholecystectomy; partial or complete colectomy; hysterectomy; and prostatectomy after 10/1/2015. Seventy-six patients (45% female) with mean age 67 ± 12 years and mean baseline AHI 36 ± 29 events/hour were identified. Only 2 patients (3%) did not use their PAP immediately after surgery. For the remaining 74 patients, the mean use of PAP in the 30 days preoperatively was 408 ± 99 minutes per night versus 413 ± 125 minutes per night during the 7 days postoperatively (p = 0.6). PAP usage duration was greatest on the first postoperative night. The mean AHI in the 30 days preoperatively was 3.4 ± 5.2 events/hour versus 4.8 ± 7.4 events/hour over the 7 days postoperatively (p = 0.004). There were no significant differences in the preoperative versus postoperative PAP adherence or AHI values in those undergoing inpatient (62 patients; 84%) versus outpatient surgery. Compared to the preoperative period, nightly PAP use did not decline in the 7 days postoperatively in our cohort, although the AHI increased slightly but in a statistically significant manner. No significant changes in PAP usage or AHI were found when comparing inpatient versus outpatient surgeries. Support (If Any):

Adenocarcinoma and polyposis of the colon in a 20-year-old patient with Trisomy 13: a case report

BackgroundTrisomy 13 is one of the most common autosomal trisomies, and although increasing in number, patients surviving past the neonatal period remain rare. The natural history and expected complications in these patients as they age remains unknown. Despite the rarity of this condition, unusual malignancies have been reported in the medical literature for decades. It is clear that providers should suspect unusual malignancies in these patients, particularly as they age.Case presentationWe report a 20-year-old Caucasian woman with Trisomy 13 who presented with colonic volvulus, found to have colonic polyposis and adenocarcinoma of the colon. Genetics of pathology specimens revealed 47(XX) + 13 without other mutations. She underwent prophylactic completion colectomy due to presumed risk of colorectal cancers given underlying adenomatous polyposis. She has recovered well without evidence of recurrence.ConclusionsThe presence of colonic polyposis and colorectal cancer without family history or known mutations for polyposis syndrome suggests an intrinsic predisposition toward colorectal cancer in this patient with Trisomy 13. Recent research into colorectal cancer oncogenes supports that aneuploidy or increased copy number of certain genes on chromosome 13 may increase the risk of malignant transformation. This is an important correlation for researchers studying these topics and clinicians caring for patients with Trisomy 13 as they age.

Idiopathic Colonic Varices and the Need for Polypectomy: A Rare and Unique Clinical Challenge

Colonic varices are a rare finding on colonoscopy and are most commonly associated with portal hypertension. Idiopathic colonic varices (ICV) comprise a small subset of colonic varices and have been reported in only 45 cases in the literature. Most cases present with lower GI bleeding and require prompt diagnostic colonoscopy. We present a unique case of ICV found on diagnostic colonoscopy complicated by the need for polypectomy. A 62 year-old male with a history of HTN and CKD presented with a 25 lb weight loss, anorexia and normocytic anemia. Colonoscopy revealed large pan-colonic varices and multiple polyps, two of which were >1cm in size. Polypectomy was not performed due to proximity to the varices and risk of gastrointestinal hemorrhage; however a 1.5 cm sessile sigmoid polyp was sampled and confirmed to be a tubular adenoma. Work-up for underlying liver disease, vascular shunts, and portal hypertension was undertaken to identify an etiology for the colonic varices. Laboratory data revealed normal liver enzymes, an INR of 1.0, and negative serologic work-up. An MRI of the abdomen revealed a normal sized heart, no hepatosplenomegaly and patent intraabdominal vasculature. Direct mesenteric angiography and liver biopsy were normal with a HVPG of 5mmHg. Without evidence of portal hypertension, arteriovenous shunt, or chronic liver disease, these large pan-colonic varices were determined to be idiopathic. Given the rarity of the disease, there are no guidelines for the management of ICV and many cases of bleeding result in complete colectomy. Unlike varices due to portal hypertension, there are no conservative pharmacologic therapies for bleeding prophylaxis or diminution of ICV in part due to an unclear mechanism of formation. Previous cases have suggested congenital vascular anomalies but this remains uncertain. Furthermore, of the 45 cases of ICV reported none have been complicated by the need for polypectomy. Our patient has multiple large polyps, including an advanced adenoma adjacent to large colonic varices and a resultant unknown bleeding risk with polypectomy. We are thus led to consider if prophylactic total colectomy should be undertaken to reduce the risk of colon cancer and bleeding, versus attempted polypectomy with the possibility of significant GI bleeding. Given the ambiguity of proper management, the risks and benefits of the above therapies were discussed with the patient and he elected for polypectomy, which has been scheduled.Figure: Large diffuse varices seen on colonoscopy.Figure. 1: 5cm polyp adjacent to varix.

Segmental colectomy for bleeding diverticular disease guided by the PEEP test.

Many patients with massive lower gastrointestinal (GI) haemorrhage from diverticulosis are subjected to total colectomy when preoperative localisation is unavailable. We dissected colectomy specimens and noted that there was limited retrograde reflux in most of these cases. Therefore, we sought to assess the value of a positive endoluminal erythrocyte presence (PEEP) test (presence of fresh blood in the caecum) to direct segmental colectomies in 14 patients who required emergency operations for massive lower GI haemorrhage. Overall, 13 (93%) patients who had segmental colectomy guided by the PEEP test had successful control of bleeding. There was no mortality and a 14% postoperative morbidity after segmental resections guided by the PEEP test. One patient had persistent bleeding and required a completion colectomy on the third postoperative day. We propose that the PEEP test be added to the surgical armamentarium to guide segmental resection in the absence of localisation by conventional means. However, we advocate blind total colectomy if the PEEP test is equivocal and early completion colectomy if there is significant re-bleeding.

PTH-292 Malignant colorectal polyp outcomes – a four year cohort study

<h3>Introduction</h3> The introduction of the bowel cancer screening programme (BCSP) has increased the detection of early colorectal cancers (CRC), including malignant polyps (MP). There remains, however, a lack of data on the ideal management of MPs. Formal operative bowel resection offers the sureity of extensive local resection (and assessment of loco-regional lymph nodes), but at the price of the attendant morbidity/mortality and, in cases of post-polypectomy resections, the specimen is often free of tumour. Endoscopic excision avoids that morbidity/mortality but at the potential price of local recurrence and undetected lymph node spread. The risk of residual disease after local or endoscopic resection based on histological factors is summarised in the ACPGBI position statement.¹We aimed to assess outcomes of all patients treated for MPs in a single NHS trust. <h3>Method</h3> All T1 M0 cancers with a date of diagnosis between 01/04/10–31/03/14 were identified from a prospective, consecutive database of CRCs treated in the Trust, and the demographic, treatment and pathology data items exported. Electronic records of all subsequent endoscopic, radiological and histological tests were then searched to identify subsequent outcomes. Primary outcomes were disease-specific mortality, disease recurrence and metastases. <h3>Results</h3> Of 1238 CRCs ascertained, 130 (10.3%) fitted the inclusion criteria (T1 M0). Follow-up ranged from 3 to 58 months (median 34). Decision making in respect of local vs. formal surgical resection was based on multi-disciplinary discussion, informed by histopathological criteria where available, co-morbidities and patient preference. 34 (26.2%) underwent immediate formal resection, 68 (52.3%) were managed solely endoscopically, and 28 (21.5%) underwent endoscopic resection followed by completion colectomy (of which 24 had no residual disease). 10 patients died during follow-up, though none due to colorectal cancer or treatment. There was one case of liver metastases (who underwent local excision only, Kikuchi 2) and no local recurrences. <h3>Conclusion</h3> The low incidence of recurrence and metastases in this cohort reinforces that appropriate local resection of MPs does not negatively affect outcome at intermediate follow-up. The current ACPGBI position statement scoring system appears to appropriately select patients at low risk of residual disease. It is of note that there was no residual disease in 86% of formal resection specimens. There were missing histopathological criteria in many patients due to fragmentation of specimens and lack of synoptic reporting. Improving the proportion of en bloc local resections plus synoptic reporting may reduce the need for ‘unnecessary’ resections. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Williams JG, <i>et al</i>. Management of the malignant colorectal polyp: ACPGBI position statement. <i>Colorectal Dis.</i>2013;<b>15</b>(Suppl 2):1–38

PTU-066 Characteristics and outcomes of patients undergoing second intestinal resection for crohn’s disease in a tertiary referral centre

Introduction Up to 70% of patients with Crohn’s disease (CD) may require surgery at some point in their lives and 39% may require several surgeries. Repeated resections put patients at risk of greater morbidity including short gut syndrome and intestinal failure. Method We aimed to examine the demographic and clinical characteristics and outcomes of patients requiring repeated resections for CD. We performed a retrospective analysis by interrogating the pathology database over a five year period from 2009 to 2013 to identify cases and data was extracted by chart review. Results Of 152 cases in the time frame, 54 were having repeat intestinal resections undertaken. Median age was 43 years (range 20 to 75). 59.3% were female. The median duration between resections in this group was 9 years (range 1 to 49). 29.6% were emergency procedures. 41 patients had 1 previous resection, 9 had 2 previous surgeries with 4 having had 3 or more prior resections. The most common procedures were re-do right hemicolectomy accounting for 38.9% of procedures. 13.0% of patients had repeat small bowel resections. 14.8% had right hemicolectomy after previous small bowel resection. 14.8% had small bowel resection after previous partial or total colectomy. 11.1% patients had completion colectomy. 25.9% of patients had no prophylactic therapy against CD since the previous resection. Median duration to repeat resection in this group was 15 years. 35 patients had received azathioprine with a median duration to resection of 8 years, 20 patients had been on anti-tnf with median duration to resection of 8.5 years and 11 had methotrexate with median duration to resection of 7 years. Median duration of follow-up was 30 months (range 3 to 69). At end of follow up 66.6% of patients remained steroid and repeat resection free. 11.1% had required corticosteroids, 7.4% had gone on to have a further resection within the period of follow up and 5.6% of patients had died. In the same follow up period only 1 death was noted in the group who had their first resection (1%). 4 were lost to follow up (mean duration 17.5 months). Conclusion Repeat resections are common undertakings in patients with postoperative CD. The proportion of these cases being done as emergencies is similar to those in the surgery naïve cohort. The most common procedure is redo right hemicolectomy and resection of anastomosis. Duration to repeat resection is considerably longer in those who don’t receive medical prophylaxis against CD, indicating a prolonged silent, indolent disease course in a particular subgroup. Among patients who receive prophylaxis, patients with anti-TNF have a longer median duration to repeat resection compared to those on immunomodulators. Disclosure of interest None Declared.

PTU-223 Conversion to open surgery from laparoscopy: to ‘try and fail’ or ‘not try at all’?: Abstract PTU-223 Table 1

Introduction Clarification as to whether conversion to open surgery during laparoscopic colectomy leads to adverse clinical outcomes when compared to laparoscopic surgery that is completed will help establish if the minimally invasive approach should routinely be attempted in most instances with open surgery reserved for only when this were to fail. Method The National Surgery Quality Improvement Program 2012 database was used for analysis of patients who underwent laparoscopic colectomy. Patients were categorised into those who completed laparoscopic procedures, who had laparoscopic procedures with conversion to open, and who had open procedures. Analysis was carried out using chi-squared test, fisher exact test, and logistic regression. Results Of the 16,648 patients included, 7409 (44.50%) underwent open surgery. Of the 9239 who underwent laparoscopic colectomy, 1147 (12.41%) had conversion to open procedure. Strongest association with conversion was found with emergency procedures, preoperative sepsis and septic shock. The other associated factors were male sex, history of CHF, COPD, hypertension, steroid use and disseminated cancer. Post-operatively, compared to the patients who had laparoscopic procedure those who had conversion to open procedure had a higher risk of surgical and medical complications (see Table 1). However, when compared to patients who completed open surgery straightaway, patients who had conversion to open surgery had a higher risk for superficial SSI. While other complications were comparable to open surgery, converted patients had a lower risk of post-operative pneumonia, re-intubation, need for ventilation > 48 h, bleeding that required transfusion, sepsis, septic shock and return to the operating room. Conclusion While patients who have open conversion have worse outcomes than those who complete laparoscopic colectomy, outcomes for converted patients are not significantly worse than for comparable patients who undergo open surgery straightaway. Considering the benefits of the minimally invasive approach, laparoscopic colectomy may reasonably be attempted in any patient, even when completion may not be assured, with conversion reserved for when this is not feasible. Disclosure of interest None Declared.

Fatal Clostridium difficile Infection of the Small Bowel after Total Colectomy: A Case Report and Review

Introduction:Clostridium difficile infection occurring in the small bowel is exceedingly rare, especially following total colectomy. We describe a case of C. difficile small-bowel enteritis occurring in a patient 27 years after total colectomy and review cases of C. difficile enteritis in patients following complete colectomy. Case: A 74-year-old male nursing home resident with a past medical history of ulcerative colitis with subsequent colectomy and Kock pouch ileostomy, DM and dementia was evaluated for stomal obstruction and infection following increased difficulty with stoma self-care and mild epigastric pain. He received a seven-day course of antibiotics and pouch care while the surgical team contemplated a revision of the ileostomy. On the 12th day of admission, he developed nausea, vomiting, cramping abdominal pain and increased ileostomy output. On abdominal examination, he had marked diffuse tenderness, hyperactive bowel sounds and voluminous output from the stoma. Laboratory investigation revealed a WBC count of 31,000 cells/mm3 and a sudden worsening of renal function with a serum creatinine of 3.8mg/dl. On the 14th day of admission, ileostomy stool cultures tested positive for C. difficile toxin A and B; he previously tested negative for this on the 3rd day of admission. He subsequently developed septic shock and despite aggressive resuscitation and treatment with oral vancomycin, flagyl and vancomycin solution via ileostomy, he died on the 20th day of admission. Discussion: Isolated small bowel C. difficile infection in the absence of colonic involvement, especially post-colectomy, is exceedingly rare. A review of cases of C. difficile enteritis post-colectomy revealed a high mortality rate that is likely due to missed diagnosis and delayed institution of treatment because of low clinical suspicion. Advanced age and prior or ongoing antibiotic therapy are associated with increased mortality. The high mortality rate of almost 60% seen in C. difficile enteritis is worse than is seen in colitis and has been attributed to the increased permeability of the small bowel predisposing to septicemia and multi-organ involvement. The pathogenesis of C. difficile in the small bowel following colectomy is thought to be due to phenotypic changes that occur in the small bowel mucosa leading to colonic-type metaplasia and partial villous atrophy. These changes facilitate fecal floral establishment in the small bowel and explain the development of C. diff enteritis in this group of patients. Small bowel C. difficile infection should be strongly considered in the differential diagnosis of high risk patients even in the absence of a colon as early diagnosis and treatment could be life saving.

Ipilimumab-induced Colitis with Concomitant Clostridium difficile Infection

Introduction: Ipilimumab (Anti-Cytotoxic T lymphocyte-associated antigen (CTLA)-4 antibody)-induced colitis is a rare immune-mediated adverse event. Prompt diagnosis and treatment can prevent life-threatening complications. We report a case of colitis caused by Ipilimumab with concomitant Clostridium difficile (C. diff) infection and successful treatment with systemic corticosteroids. Case Report: A 32-year-old female who was undergoing Ipilimumab therapy post cycle number four for relapse of malignant melanoma presented with bloody diarrhea for two days. The patient denied fever, nausea, and vomiting. Examination revealed a soft but tender abdomen in the left lower quadrant. Stool studies were positive for C. diff toxin. She was treated with PO Vancomycin. Diarrhea slowly improved with recurrent episodes of bright red blood. Repeat C. diff toxin on day 10 was negative. IV Solumedrol 40 mg q8hrs was started with immediate response and complete resolution of hematochezia and diarrhea. Colonoscopy on day 13 showed severe colitis with erythema, edema, and friability with a plethora of large crated ulcers in the left colon, predominantly the splenic flexure. Biopsy showed mucosal ulceration and granulation tissue with rare cryptitis. She remained asymptomatic for the next few days on IV steroids, and was transitioned to 60-mg prednisone with a slow taper of Vancomycin over three weeks. As an outpatient, she was switched to Budesonide with plan for repeat colonoscopy. Discussion: Colonic toxicity is an immune-mediated adverse event caused by a biological agent. With increased use of Ipilimumab to treat malignant melanoma, the incidence of colitis is rising (recorded in about 20% of the patients receiving this treatment). Typical symptoms include abdominal pain and diarrhea, sometimes bloody. Endoscopy can show segmental or diffuse colitis. Biopsies show nonspecific inflammatory infiltrate with predominant T-cells, cryptitis, and abscess formation. Fatal complications (5%) like perforation (<1%) can occur without prompt appropriate treatment. Systemic steroids are the treatment of choice. Limited or no response to steroids in a week should lead to the use of infliximab. Failure of medical treatment can necessitate partial or complete colectomy with diverting ileostomy. Few cases have been reported of concomitant C. diff colitis, which complicates the course. Our patient was initially treated only for C. diff. Lack of sustained response to antibiotics prompted initiation of corticosteroids. Colonoscopy showed significantly deep ulcerations, suggesting that perforation could have occurred without timely steroids. C. diff infection should not preclude use of systemic steroids if immune mediated colitis is suspected.

Intersphincteric proctectomy with end-colostomy for anorectal Crohn's disease results in early and severe proximal colonic recurrence

BackgroundPerianal Crohn's disease (CD) represents a more aggressive phenotype of inflammatory bowel disease and often coincides with proctocolitis. This study aims to assess the outcome of patients undergoing proctectomy with end-colostomy. MethodsA retrospective outcome analysis of 10 consecutive patients who underwent intersphincteric proctectomy with end-colostomy between February 2007 and May 2011 was performed. All patients suffered from refractory distal and perianal CD. The proximal colon was normal at endoscopy. All data were extracted from a prospectively maintained database. The main outcome parameter was disease recurrence and need for completion colectomy. ResultsSevere and early endoscopic recurrence in the proximal colon occurred in 9/10 patients at a median time interval of 9.5months (range: 1.9–23.6months). Despite protracted medical treatment, completion colectomy was necessary in 5 patients. One patient, who underwent a second segmental colectomy with a new end-colostomy, showed again endoscopic recurrence and is currently treated with anti-TNF agents. ConclusionsIntersphincteric proctectomy with colostomy seems to be an ineffective surgery for perianal CD with coexisting proctitis and results in a high risk of recurrence of the disease in the remaining colon. Therefore, despite a normal appearance of the proximal colon, a proctocolectomy with end-ileostomy seems to be the surgical approach of choice in these patients.

Serrated polyposis syndrome and colonoscopic surveillance: who is it safe to follow?

Results Of 67 patients 18 presented with CRC (mean age 57yrs, 12 Female). Only one of 18 reported a first degree relative (FDR) with CRC. Over a median follow-up of 8 years from time of surgery with an average interval of 16 months between colonoscopies, two patients developed metachronous CRC: one identified at prophylactic completion colectomy and one in association with first diagnosis of SPS 19 yrs following initial CRC and 30 months after a previous colonoscopy. Of 45 patients with polyps alone (mean age 48 yrs, 27 female) followed for a median of 9 years with an average interval of 15 months between colonoscopies, none developed CRC despite 33 having multiple pan colonic polyps. Of these 33, 70% had an adenoma, 18 % a sessile serrated polyp and 53 % polyps >10 mm. A FDR with CRC was reported in 14/45 (31%). Four patients with multiple pan colonic polyps and no FDR with CRC underwent prophylactic subtotal colectomy (mean age 58 yrs, 3 females) after being followed for a median of 5 years with an average interval between colonoscopies of 8 months. All had adenomas and one a sessile serrated polyp. No significant smoking effect was seen in any group.