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Mo1755

Does Time Interval Between Chemoradiation and Surgery Affect Outcomes inPancreatic Cancer?Kathryn T. Chen, Karthik Devarajan, John P. Hoffman

Introduction: Neoadjuvant chemoradiation given for locally advanced pancreatic cancer isrecognized to improve respectability rates, and response to therapy has also been shown tobe a prognostic factor. There is no data in the literature regarding time interval betweenchemoradiation and surgery, and response rates. We sought to evaluate the relationshipbetween time interval from radiation therapy and pathologic response. Methods: We retro-spectively analyzed the records of 55 patients who underwent neoadjuvant chemoradiationfor borderline resectable pancreatic cancers prior to definitive resection. Patients eitherproceeded directly to resection following chemoradiation or continued on chemotherapydepending on CA19-9 and pathologic response. We divided patients into three groups withrespect to time interval between completion of chemoradiation and resection: A (0-10 weeks),B (10-20 weeks), and C (.20 weeks). Pathologic response was defined as major (.95%fibrosis), partial (50-94% fibrosis), or minor (,50% fibrosis). Results: There were 32 patientsin group A, 9 patients in group B, and 14 patients in groups C. There was no significantdifference between the groups with respect to age or CA19-9 at diagnosis. The median post-chemoradiation CA19-9 was significantly higher for group C compared to group A, butthere was no subsequent difference in the median pre-operative CA19-9. There was nodifference with regards to R0 resection between all three groups. Patients in groups B andC were significantly more likely to have a major response than in group A (p ,0.026).Conclusion: There is no detriment in prolonged time interval between neoadjuvant chemora-diation and definitive resection provided there is ongoing chemotherapy. In our series,patients with a time interval greater than 20 weeks were more likely to have a major responseto neoadjuvant therapy prior to surgery.

Mo1756

Gastrointestinal Stromal Tumors of Extraintestinal Origin: Prognosis Based onLocationJoyce Wong, Ciara E. Calitri, Gang Han, Anthony P. Conley, Ricardo J. Gonzalez

Background: While gastrointestinal stromal tumors (GIST) commonly arise from a gastricor intestinal (INT) location, extraintestinal GIST (E-INT) have been described. This studyaddresses the clinical and prognostic differences in GIST arising from the stomach or intestinaltract as well as extraintestinal or unknown (UNK) locations. Methods: A prospectivelymaintained single-institution database of patients with the diagnosis of GIST was reviewed.Demographics, pathologic factors and survival were analyzed using Pearson's chi-squaretest, Fishers exact test, or Kaplan Meier curves where applicable. Results: From 1990-2011,282 patients with pathologic confirmation of GIST were referred to our center. The majoritywere male (56%) and Caucasian (83%). Tumors were commonly of gastric (N=148, 52%)or INT (100, 35%) origin. Less commonly, GIST arose from an E-INT (22, 8%) or unknown(UNK, 12, 4%) location. Multivariate analysis stratified by tumor origin showed that agevaried across groups, with E-INT GIST found in older patients (median age 69 vs. 65 yearsfor gastric, 60 for INT, and 64 for UNK, p=0.03). Tumor size was also greater in the E-INT group: median size 13cm vs. 6.4cm in gastric, 7.6cm in INT, and 8.6cm in UNK, p=0.05. Gender, ethnicity, and tumor mitotic rate were similar across groups. Additionally,use of neoadjuvant or adjuvant therapy was similar across groups. Ultimately, 84% of gastric

S-1108SSAT Abstracts

GIST underwent surgical exploration vs. 93% INT, 82% E-INT, and 50% of UNK-primaryGIST. Nearly 10% of gastric and INT GIST were unresectable at surgery, vs. 44% E-INT.GIST of E-INT location also had higher rates of margin-positive resections, versus those ofgastric or INT origin (56% vs. 12% and 24%, respectively, P,0.0001). The median follow-up was 77 months. Unknown primary and E-INT GIST exhibited a worse median OS (42and 38 months, respectively), while INT or gastric GIST had better median OS (86 and 79months, respectively, P,0.05). Smaller tumor size, negative surgical margins, lower mitoticrate, and use of tyrosine kinase inhibitors all positively impacted OS. 35% of gastric GISTdeveloped recurrent disease vs. 61% INT and E-INT, and 100% of UNK primary GIST.Only mitotic rate and mutational status affected DFS; univariate analysis demonstratedmitotic rate.10/50 high power fields and PDGFRA mutations were associated with worseDFS (P,0.05). However, disease free survival (DFS) did not differ according to tumor origin.Conclusion: Although GISTs are considered to have variable malignant potential, E-INT andUNK GIST are more likely to be unresectable at presentation and to develop disease recur-rence. Extraintestinal and unknown primary GIST have a worse OS. This may be due to asignificantly larger tumor size and advanced stage at presentation that may prohibit effectivesurgical resection.

Mo1757

Diagnostic Strategy for Acute Abdomen Caused by Perforation of theGastrointestinal Tract. Can Computed Tomography Detect Perforated SiteEven in the Small and Large Bowel?Tatsuya Ueno, Michinaga Takahashi, Shinji Goto, Shun Sato, Masanori Akada, KyoheiAriake, Shinpei Maeda, Takashi Hirosawa, Masato Katahira, Chikashi Shibata, HIrooNaito

Due to advanced technology, computed tomography(CT) scan can make more precisediagnosis than ever even in the field of gastrointestinal (GI) tract. We previously reportedaccuracy rate of CT in diagnosing perforated gastro and duodenal ulcer, was more than90%, which means that GI endoscopy and/or upper GI series are not required to confirmthe perforated sites of upper GI tract in most cases. It's still uncertain, however, whetheror not CT scan can accurately detect perforated site in patients (Pts) with small and largebowel perforation (SLBP). AIM: To clarify how precisely CT scan can detect perforated sitein SLBP, and if CT scan can differentiate gastroduodenal perforation(GDP) from SLBP.Method: Since 2002 to 2010, Medical records of Pts with GDP and SLBP who underwentlaparotomy or laparoscopic operation, were retrospectively reviewed. Results: one hundredand fifty-eight Pts (92 for GDP and 66 for SLBP) were operated for GDP and SLBP. Gastriccancer, gastric ulcer, and duodenal ulcer induced the perforation in all GDP Pts. Causes ofSLBP were idiopathic(20 Pts), cancer-related perforation(15), diverticulum(8), trauma(7),foreign body(6), and others(10). Accuracy rate of CT scan in diagnosing site for GDP was93.3%. On the other hand, the accuracy rate in SLBP was 84.6% (70.4% for small boweland 89.7% for large bowel), and the rate decreased to 57.1% when limited to trauma. TwoPts who underwent laparotomy after diagnosed as SLBP on CT scan, had no perforation.One of them had trauma, and the other was finally diagnosed as pneumatosis intestinalis.There were no Pts who were at first diagnosed as GDP, but had actually SLBP. Mortalityrate of GDP was 7.6%, while that of total SLBP, idiopathic, cancer-related, diverticulum,and trauma-related perforation, were 18.2%, 15.0%, 40.0%, 25.0%, and 0.0% respectively.Conclusion: When compared to GDP, accuracy rate to detect perforated site in SLBP, wasdecreased, especially in small bowel and trauma-related perforation. This decrease might beassociated with little inflammatory change such as edema at perforated site soon after traumaand little intraluminal gas in the small bowel. When SLBP is suspected on CT scan, earlyexploratory laparotomy or laparoscopic examination should be considered. Once GDP isdetected on CT scan, surgical or conservative therapy should be started as soon as possible.Gastrointestinal endoscopy and/or upper GI series were considered unnecessary in GDP.

Mo1758

Ileo-Cecal Resection in Crohn's Disease Patients: Clinical Impact on Quality ofLife and NutritionGiuseppe S. Sica, Silvia Di Pardo, Edoardo Iaculli, Cristina Fiorani, Andrea Divizia,Emanuele Picone, Achille Gaspari, Livia Biancone

Background. Relationship between surgery, quality of life (QoL) and nutrition in Crohn'sDisease (CD) patients is unclear. Aim of the study was to evaluate the consequences ofsurgical resection on the QoL with particular regard to nutritional aspects, of a consecutivegroup of CD patients under regular follow up. Methods. Eighty consecutive patients undergo-ing ileocecal resection were randomly selected from database. Patients were divided into 2groups: A laparoscopic and B open resection. Body Mass Index (BMI), biochemical levelsof albumin, creatinine, urea, cholesterol, triglycerides, serum iron, ferritin and completeblood count (Hb hemoglobin and Ht hematocrit) were recorded before surgery and 6 and12 months after the operation. The Student t test was performed in order to find differencesbefore and after surgery. Patients were also asked to fill out the specific IBDQ-QoL question-naire and a second multiple choice questionnaire designed to specifically evaluate nutritionalaspects. Results. Data from 68 patients (31group A and 37 group B) were completed inorder to make comparisons. The two groups were homogeneous in term of gender, age andduration of disease. BMI significantly increase after surgery in the short and long term ingroup A (p 0.002 and 0.0001) and at 12 moths in group B (p 0.003). Albumin levels alsoshowed a significant increase in both groups 6 months after surgery (A:p=0.0001 and B:p=0.015), whilst a further increase at 12 months is seen only in group A (p=0.04). Serumiron level is increased 12 months after I-C resection (group A p=0.003; group B p=0.02),and so is the Hb level (group A p=0.02; group B p=0.05). Significant differences in Ht werevisible at 12 month only in group A (p=0.02). Thirty-five patients (68.5%) filled the IBDQ-QoL questionnaire. Mean score was 163/224 with no differences between the two groups.All patients filled the nutritional based questionnaire: 52% before surgery but only 9.5%after after ileo-cecal resection were forced on a specific diet. 71.5% of patients believe its QoLimproved after ileo-cecal resection, whilst 20 % sees no differences and 8.5% a worsening. Nosignificant differences were noted between groups. Conclusion. QoL, with particular regardto nutritional aspects seems ameliorate after ileo-cecal resection in CD patients. Laparoscopic

surgery may play a role in the middle and long term outcome probably thanks to the shortestrecovery time and the favorable acceptation among patients .

Mo1759

Role of Gastrografin Challenge in Early Postoperative Small BowelObstructionMohammad A. Khasawneh, Maria L. Martinez Ugarte, Eric J. Dozois, Michael P. Bannon,Martin D. Zielinski

Introduction: Early small bowel obstruction (ESBO) following abdominal surgery presentsa diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin (GG), hasbeen shown to have diagnostic and therapeutic properties when used in the setting of smallbowel obstruction outside the early postoperative period (. 6weeks). We hypothesize thata GG challenge will reduce need for re-exploration in patients with ESBO. Methods: Patientswith ESBO (, 6 weeks following abdominal surgery) who underwent a GG challengebetween 2010 - 2012 were case controlled, based on age ± 5 and sex, to an equal numberof patients that did not receive a GG challenge. Groups were compared to assess differencesin rates of reoperation for obstruction. Results: 105 patients with ESBO who received a GGchallenge. There were 76 males in each group (72%) with an average age of 64 years (range,59-68). An open or laparoscopic approach in the index operation was done equally betweengroups (67% vs 70% and 33% vs 30%, respectively p=0.44). The mean time from surgeryto GG challenge was (11.3, range=9.8-12.9) days. There was no difference between groupsin the rate of re-operation (12% vs 9%, p=0.48), days from surgery to re-operation (9.1[range 4.2-14] vs 13.5 [range 7.9-19.2], p=0.23), morbidity (35% vs 42%, p=0.23), andmortality (8% vs 7%, p=0.78). Hospital length of stay was greater in patients who receivedGG (18.2 vs 11.5, p=0.0001) days. There were no GG aspiration events. . There were morepatients that received abdominal computed tomography in the GG group (74% vs 45%, p=0.0001), of these patients, the GG group were more likely to have a transition point (55%vs 33%, p=0.01).The GG challenge had a positive predictive value of 91%, negative predictivevalue of 50%, sensitivity of 96% and specificity of 30% to predict ESBO resolution withoutoperative intervention. Conclusion: Use of the GG challenge in the immediate postoperativeperiod appeared to be safe. There was no difference, however, in the rate of re-explorationbetween groups. Further study in a prospective, randomized fashion is needed to elucidatethe effects of GG in ESBO.

Mo1760

Assessment of Postoperative Complications in Patients With IBD. A SingleAcademic Medical Center ExperienceSamantha J. Quade, Joshua Mourot, Anita Afzali, Mika N. Sinanan, Scott D. Lee, Jie KateHu, Christopher J. Park

Background: In Chrons Disease approximately 70% of all patients will ultimately requiresurgical intervention. Previous literature indicates that 30% of patients have postoperativecomplications. Pre operative nutrition with TPN has also been controversial. Our retrospectivereview demographics and patient characteristics were documented and both preoperativeand surgical characteristics were identified to ascertain if the results from a single institutionwere congruent with the previous published literature. Purpose: Assessment of post operativecomplications, pre operative predictive factors and need for reoperation and reinstitutionofmedical therapy in IBD.Methods: Retrospective review of 57 patients charts who underwentsurgical intervention for IBD. Patients undergoing surgical resection were included in theinitial analysis. Pre operative surgical characteristics, nutrition and surgical indication forintervention were analyzed. The need for reoperation and reinstitution of medical therapywas based on patient symptoms and an endoscopic evaluation, which included a Rutgeertsscore. RESULTS: 57 patients [current analysis] 51% female, mean age 45 years, 30% ofpatients had undergone prior resection. 77% Chrons Disease. Patient characteristics included46% smoking, anatomical site of disease 44% TI disease, small bowel in 17% and colonicin 30%. Medical Therapy included Biologics in 53%, IM 38% and steroids in 43%. Albuminmean 3.5g/dL [ postoperative early complications :mean 3.3 g/dL, no complications 3.6 g/dL]. Preoperative TPN 84% with an associated overall complication rate 31%. SurgicalIndication: Stricture/Obstruction 39%, Fistula 19%, Refractory to medications 21%, Abscess5%, Perforation 2%. Surgical Operation: Ileocolectomy 35%, TI resection 5%, stricturoplasty4% and the remaining small bowel resection. Type of anastomosis Hand Sewn end-to-end58% patients [41% complication rate], side to end 18% [57% complication rate] and stapledend to end 24% [complication rate 67%]. Perioperative blood transfusion was required in5% patients , 100% patients had complications. Operative Blood Loss no complication 82ccand complication 232cc mean. Perioperative length of stay mean 8 days [5.6 vs. 12.2 withpost operative complication]. Overall Complication rate was 39%. Anastomotic leak rate4%, Bowel obstruction 5%, prolonged ileus defined as . 5days 18%, Abscess formation5%, Superficial wound infection 7% [no deep wound infections], UTI 5%, DVT 2%, PE0%, Hernia 2%. Reoperation required in 20% of patients. CONCLUSIONS: Surgical Interven-tion for IBD can be associated with high morbidity and high rates of further medical andsurgical intervention. Initial data analysis it appears that factors associated with a higherpost operative complication rate are Albumin , 3.3, Perioperative Blood transfusion andstapled anastomosis.

S-1109 SSAT Abstracts

Mo1761

Laparoscopic vs. Open Unilateral Inguinal Hernia Repairs: A NSQIP AnalysisMuhammad Asad Khan, Roman Grinberg, John Afthinos, Karen E. Gibbs

Objectives: Open inguinal hernia repair has been the mainstay in both elective and emergenthernias for most of surgical history. The advancement of laparoscopic hernia repair haschallenged this notion; however few trials have compared the laparoscopic approach toopen. We sought to query the NSQIP database to amass a large number of patients to bettercharacterize patent comorbidities and outcomes of both approaches. Methods: The NSQIPdatabase was queried for laparoscopic or open inguinal hernia repair for unilateral herniasfrom 2007 to 2009. Age, gender and comorbidities were quantified and outcomes datacollected. Specifically, morbidity, mortality, length of stay and operative times were examined.Statistical analysis was then performed. A p-value of , 0.05 was considered significant.Results: A total of 29,755 patients were identified, out of which 25,192 underwent openhernia repair, while 4,563 underwent laparoscopic repair. Conclusions: Our study revealedthat only 15% of unilateral hernias were repaired laparoscopically. The more diverse anes-thetic choices available for open repair allowed patients with significant comorbidities toundergo hernia repair. Despite this there was an increased overall rate of morbidity (0.5%vs. 0.2%, p = 0.012). Other outcomes measures were not different except for length of stay,which was longer for the open group. Conclusions: Our study revealed that only 15% ofunilateral hernias were repaired laparoscopically. The more diverse anesthetic choices avail-able for open repair allowed patients with significant comorbidities to undergo hernia repair.Despite this there was an increased overall rate of morbidity (0.5% vs. 0.2%, p = 0.012).Other outcomes measures were not different except for length of stay, which was longerfor the open group.Table 1. Patient Comorbdities

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