Pokala R. Kiran

Asymmetric endoscopic inflammation of the ileal pouch: a sign of ischemic pouchitis?

Background:Pouchitis is associated with dysbiosis and dysregulated mucosal immunity, although secondary pouchitis with special etiologic factors, such as ischemia, can occur. The aim was to describe a disease phenotype of the ileal pouch with an endoscopic appearance suggestive of ischemia. Methods:We identified consecutive patients with endoscopic asymmetric inflammation of the pouch (inflammation of side of the pouch with a completely normal other limb of the pouch one limb and a sharp demarcation along the staple suture line). Patients with Crohns disease (CD) of the pouch or antibiotic‐responsive pouchitis, matched for duration of the pouch, served as controls. Histology slides of mucosal biopsies were re‐reviewed independently by 2 blinded gastrointestinal pathologists. Demographic, clinical, endoscopic, histologic, and imaging characteristics were compared between the groups. Results:Ten patients with “ischemic” pouchitis, 15 with CD of the pouch, and 15 with antibiotic‐responsive pouchitis were studied. Pyloric gland metaplasia was observed only in the groups with CD of the pouch (23.1%) or antibiotic‐responsive pouchitis (13.3%). Of patients with “ischemic” pouchitis, 80% had extracellular hemosiderin or hematoidin deposits (versus 30.8% those with CD of the pouch and 13.3% of those with pouchitis, P = 0.003). The majority of patients (80%) with “ischemic” pouchitis did not respond to conventional antibiotic therapy. It appeared that subsequent abdominal surgeries after pouch construction and a history of postoperative portal vein thrombi were associated with “ischemic” pouchitis. Conclusions:Endoscopic asymmetric inflammation of the pouch may represent an ischemia‐associated pouchitis with characteristic clinical, radiographic, and histologic features. Its hemodynamic, cellular, and molecular basis of mechanism warrants further study. Inflamm Bowel Dis 2010

715 Venous Thromboembolism (VTE) After Colorectal Surgery: Making the Case for Continuing Prophylaxis After Discharge in High-Risk Patients

Introduction: Individuals with pancreatic ductal adenocarcinoma (PDAC) demonstrate a generally poor outcome following resection. Molecular profiling has previously enhanced the identification of phenotypic subtypes of ampullary adenocarcinoma. Furthermore an intestinal subtype of PDAC has been described however the prognostic impact of this variant has not been described in detail. We sought to better characterize the intestinal subgroup of PDAC and assess the impact on outcome. Methods: We assessed the potential clinical utility of molecular pathological phenotypes defined using a combination of histopathology and protein expression (CDX2 [caudal-type homeodomain transcription factor 2] an intestinal marker and MUC1 a pancreaticobiliary marker) assessed by immunohistochemistry (Figure 1) in 95 patients who underwent operative resection for PDAC by pancreaticoduodenectomy at a single institution over a 12 year time period. A tissue microarray was used with at least 4 cores evaluated for each tumor for protein expression analysis in addition towhole section analysis of tumormorphology. Care was taken to exclude all other periampullary malignancies from the analysis. Results: In addition to prognostic impact of T stage, lymph node status, resection margin status, perineural invasion and vascular invasion, a small proportion of tumors had features of an intestinal histological subtype (13%) and a more favorable prognosis. CDX2 and MUC1 expression were significant prognostic variables. Patients with CDX2 negative tumors had a significantly shorter survival (Hazard ratio [HR] = 2.77, 95%CI: 1.5-5.2, P = 0.002 as did those with MUC1 positive tumors (HR = 2.89, 95%CI: 1.7-4.9, P , 0.0001 no survivors at 24 months). Patients with CDX2 negative/ MUC1 negative tumors had an intermediate outcome (Figure 1). In a multivariate analysis lymph node involvement, vascular invasion, positive MUC1 expression and loss of CDX2 expression were independent predictors of poor outcome. Conclusion: Morphological determination of intestinal subtype of PDAC has clinical relevance. Furthermore maintenance of CDX2 expression identifies a group of PDAC patients with a relatively good outcome while MUC1 expression identified patients with a very poor outcome. When combined histopathological and molecular criteria define clinically relevant phenotypes of PDAC with significant implications for prognostication, current therapeutic strategies and may facilitate future trial design.

Su1612 Long Term Outcomes of Continent Ileostomy Created in the Pediatric Age Group

Background/aim: Continent ileostomy (CI) is a surgically created intra-abdominal pouch in patients with a permanent end ileostomy. CI is one of the few surgical options that may be offered to patients who were fated to live with a permanent ileostomy, but want to avoid a stoma appliance at any cost. Data about durability, clinical and functional outcomes of CI created in pediatric patients are limited. In this study, we aimed to evaluate our 36-year operative experience on CI in pediatric patients with a 21 year median follow-up. Methods: Pediatric (≤21 years)* patients undergoing a CI procedure at a single institution from 19732009 were identified. CI revisions that required pouchotomy or re-construction following total or partial excision of CI were defined as major and those that did not require bowel resection were defined as minor revisions. CI failure was defined as excision of the pouch and formation of an end ileostomy. Results: 49 patients (26 male), median age 18 (12-21) years and median body mass index 22 (16-38.6) underwent CI. 10 (20%) patients had a CI at the time of total proctocolectomy. 12 (25%) patients underwent conversion of an ileoanal pouch (IPAA) to a CI. The majority of the patients (n=39, 80%) had ulcerative colitis or indeterminate colitis at the time of CI creation; however Crohns disease were diagnosed in 4 patients postoperatively. There were no intra-operative or early post-operative deaths. One patients who underwent CI excision seven years after CI creation due to complicated Crohns disease, died ten years after CI excision. Median follow-up time was 21(range 1-38) years. Valve slippage (33%), small bowel obstruction (25%), pouchitis (25%) and fistula (23%) were the common complications (table). 37 patients (76%) underwent at least 1 revision procedure after CI creation. 36 (74%) patients underwent major revision and 6 (12%) patients underwent minor revisions. Median pouch intubation was 6 (range 4-10) times per day. Pouch failure occurred in 9 (18%) patients with 7 out of 9 cases being due to complications from Crohns disease. Conclusions: CI is safe and durable in pediatric patients. Development of Crohns disease after CI creation seems to be a risk factor for failure. Since likelihood of further revisions is high, patients with CI should be followedup regularly. * Council on Child and Adolescent Health. Age Limits of Pediatrics. Pediatrics 1988;81:736. Primary diagnosis, complications and follow-up details

T1295 Development of a Nomogram for Prediction of Pouch Failure in Ulcerative Colitis (UC) Patients With Restorative Proctocolectomy

Background: A proportion of UC pts with ileal pouch-anal anastomoosis (IPAA) develop pouch failure. Information on factors that may reliably predict pouch failure for pts who have pouch related symptoms or disorders requiring referral to a specialized care is minimal. Aim: To develop and internally validate a nomogram to predict the probability of pouch failure. Methods: The study cohort included all eligible UC patients with IPAA at Pouchitis Clinic from 2002 to 2009. Inclusion criteria were patients 1) having underlying IBD; 2) regularly monitored at the Pouchitis Clinic. 36 demographic and clinical variables were prospectively collected. Multivariable accelerated failure time regressionmodel was developed to predict pouch failure, defined as pouch excision or permanent diversion. Discrimination and calibration of the model were assessed following bootstrapping methods for correcting optimism, and the model was presented as a nomogram. Results: 921 patients were included for the model. The mean age for this cohort was 45.5 years old. The mean follow-up at the Pouchitis Clinic was 5.8 years. Kaplan-Meier plot showed that the probabilities for pouch retention are 0.939, 0.916 and 0.907 at 3, 5 and 7 years, respectively. The predictor variables which were included in the nomogram were smoking, duration of the pouch, preoperative diagnosis, pouch diagnosis at the first Pouchitis Clinic visit and post-op use of biologics (Figure 1). The concordance index was 0.824. Conclusions: The nomogram model appeared to predict pouch failure reasonably well with satisfactory concordance index and calibration curve. The nomogram is readily applicable for clinical practice in pouch patients.

M1532 Benefits of Laparoscopy: Does the Disease Condition That Indicated Colectomy Matter?

The benefits of laparoscopic (LC) over open colectomy (OC) have been well characterized for a variety of conditions. Whether the relative benefits of LC differ for different conditions has not been previously investigated. The aim of this study was to identify whether there are differences in benefits of LC for colon cancer (CC), Crohns disease (CD), and diverticular disease (DD). Data of patients with CC, CD, and DD undergoing elective colectomy from January 2000 to December 2007 were identified from departmental databases. Patients with CC, CD, and DD undergoing LC were matched 1:1 for diagnosis, gender, body mass index, surgical procedure, American Society of Anesthesiologists scale, and date of surgery to patients undergoing OC. TNM stage was also matched for patients with CC. Two hundred eighty-nine patients undergoing LC (CC, 93; CD, 140; DD, 56) were matched 1:1 to 289 patients undergoing OC. Median age was 49 years (range, 14 to 91 years) in LC and 52 years (range, 14 to 98 years) in OC (P = 0.35). All other matched criteria were also similar in both groups. The conversion rate to OC was 13 per cent (n = 36). Patients undergoing LC had significantly shorter lengths of stay (LOS) (3 days [range, 1 to 70 days] vs 6 days [range, 1 to 37 days], P < 0.001) and lower estimated blood loss (EBL) (100 mL [range, 10 to 1750 mL] vs 200 mL [range, 10 to 1700 mL], P < 0.001). Median operative time was similar in both groups (LC: 145 minutes [range, 35 to 431 minutes] vs OC: 135 minutes [range, 23 to 485 minutes], P = 0.54). The conversion rate was lower for DD (2%) when compared with CC (18.9%) and CD (13.4%). Improvement in EBL with LC was least pronounced in patients with CD and most pronounced in patients with DD (P interaction < 0.001). In the LC group, patients with DD presented less postoperative complications (P = 0.009). LC results in reduced LOS and EBL with similar complications rates when compared with OC. The benefits of LC are more pronounced in DD when compared with CD and CC.

1026 Predicting Organ Space Surgical Site Infection with a Nomogram

Purpose We hypothesized that organ space surgical site infections (organ space SSI) are a unique type of surgical site infection and therefore are associated with a unique set of risk factors. The aim of this study was to create a predictive model for organ space SSI after small bowel, colon, or rectal operations.