Jubilee Congress 10 years ECC

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1 2016 GEUROPEAN COLORECTAL CON RESS 28 Nov - 2 Dec 2016 St.Gallen Switzerland 28 November 2 December 2016 St.Gallen, Switzerland Jubilee Congress 10 years ECC POSTER EXHIBITION Poster Award 2,000 Friday, 2 December 2016

2 1/989 Malignant colorectal polyp: Management and outcomes in a single tertiary care center Muneer Junejo, Jyotirmoy Roy, Patrick Scott, UK Objectives With increasingly use of colonoscopy, the incidence of malignant colorectal adenomas is reported at around 4.7% of all polyps removed. Histology-based risk stratification has been proposed by the Association of Coloproctology of Great Britain and Ireland. We evaluated the validity of these criteria at a tertiary care referral centre. Method Retrospective evaluation of all malignant polyps was done over a 3-year period with a minimal follow-up of 1 year. Data was collected on size, level of invasion, grade, resection margin, lympho-vascular involvement and TNM staging for resections. Surveillance protocols and modalities were recorded for all patients. Rate of recurrence and residual disease was assessed respectively in patients under observation and following resection surgery. Results All Fifty patients identified with malignant colorectal polyp #underwent a multidisciplinary team assessment. Median age was 67.5 years (range 31 to 92). Rectum was the predominant site of malignant polyps (54%). 16 (32%) patients were identified as very low-risk or low risk and underwent surveillance with no recurrence during follow-up. One (2%) medium risk patient underwent resection showing no residual disease. 2 (4%) high-risk patients were observed, with local recurrence observed in one requiring surgery. Amongst 15 (30%) very high-risk patients, 3 were unfit for surgery, 5 were observed with local recurrence in 3 on surveillance, 5 patients underwent primary resection with residual disease noted in 3. Data was incomplete or inadequate in 16 (32%) patients to stratify risk. Conclusion High recurrence and residual disease in the high-risk or very high-risk group supports primary surgical resection. Very low-risk and low-risk patients can be monitored safely. Role of surgery and surveillance protocols for medium-risk patient remains unclear. Improved reporting of histology and evaluation of a large cohort is required to establish optimal care for these patients. 2

3 2/993 A New Infrared Oximeter to Identify Colon Ischemia in a Pig Model Robert Lohman, Risal Djohan, Amir Ghaznavi, Charles LeVea, Kate Bechtel, USA Objective: Occult tissue ischemia increases the risk of complications after colorectal surgery. Composite tissue oxygenation (StO2) is a sensitive measure of tissue oxygenation. We used a new infrared oximeter (ViOptix, Inc., Fremont CA) to compare StO2 in areas of normally perfused and ischemic colon. Method: Four female pigs (109 kg ± 6 kg) were studied. A segment of left colon was marked at 3 points, each 12 cm apart. StO2 was measured with four different oximeters. Baseline StO2 measurements were taken at the proximal point (location #1), the central point (location #2) and the distal point (location #3). Next a 20 cm segment of colon, centered on location #2, was separated from its mesentery and StO2 was measured at the same points. Then the colon was divided at location #2. StO2 was measured at locations #1 and #3, and the cut ends of the colon (location #2) over a seven-hour period. Samples of the colon were recovered for histologic study. Results: Initial StO2 values were similar for all locations (53.1% ± 6.8%). After the colon was separated from its mesentery, StO2 values began to fall at location #2 (40.2% ± 11.1%). After the colon was divided at location #2, StO2 eventually reached a nadir of 15.0% ± 9.8%. Furthermore, StO2 at location #2 was always significantly less (p < ) than at locations #1 and #3 after the colon had been separated from the mesentery. After the colon was divided, StO2 values at all locations remained stable over time (9% CV for locations #1 and #3 as compared with 20% CV for location #2). Histologic analysis confirmed architectural changes associated with ischemic injury at location #2 while samples from locations #1 and #3 showed no signs of injury. Conclusion: This new tissue oximeter can be used to measure StO2 and identify ischemic areas of the colon. Recognition of critically ischemic tissue may be an important step to reduce the risk of complications such as anastomotic leak and stricture after colorectal surgery. 3

4 3/1004 Retropneumoperitoneum and pneumomediastinum after stapled hemorroidectomy Se Seol, Wj Lee, Sh Woo, Dh Kim, KR Stapled hemorrhoidectomy has become increasingly popular over the past 15years for the treatment of third-degree hemorrhoids. Most have shown stapled hemorrhoidectomy to be associated with reduced postoperative pain, less bleeding, a shorter hospital stay and earlier return to normal activities. But some articles have been published about severe adverse effects of this operation, and in the present article we describe a case of a complication that occurred with the use of the stapling hemorrhoidectomy. A 54 year old asian female patient with third degree hemorrhoids underwent a stapling procedure for the treatment of hemorrhoids. Retropneumoperitoneum and pneumomediastinum developed on postoperative day 7. The 1cm sized defect was observed in the posterior wall of surgical site. Leakage from anastomosis site made presacral abscess oragnization. Pus like discharge flowed from a defect. The wound was washed with a normal saline solution using a rectal tube. 14 days after admission with conservative treatment, the patient was discharged without complications. Our experience, taken together with some other cases previously published of complications after such an operation, suggests caution in the use of this technique for the treatment of a hemorrhoids. Key words: stapled hemorrhoidectomy, Retropneumoperitoneum, Pneumomediastinum 4

5 4/1054 Laparoscopic ultra-low anterior resection of the rectum vs laparoscopic pull-through resection of rectum in patients with T1-T3 low rectal cancer. Ilya Chernikovskiy, Andrey Ivanov, Ekaterina Baron, Artem Gavriliukov, Nina Savanovich, RU Background. Laparoscopic ultra-low anterior resection of the rectum (LS-ULAR) is followed by three issues: the need to form preventive stoma; difficulties with adequate assessment of distal resection margins; high cost of operation. The alternative operation without these issues is laparoscopic pull-through resection of rectum (LS-PTR) with hand-sewn coloanal anastomosis. Methods. Patients with low rectal adenocarcinoma Т1-3N0 2М0 located in the 2-5 cm from anal verge without sphincter and levator muscles invasion were included in study. 24 patients underwent LS-ULAR, 18 underwent LS-PTR. Both groups were comparable in sex, age, body mass index and CR-POSSUM score. Primary end-points were results in Wexner score and in sphincterometry. Secondary end-points were duration of operations, blood loss, complications, and resection margins. Results. In both groups there were no significant differences in average duration of operations (206 ± 46 min vs. 216 ± 24 min (p = 0.72)), blood loss (85 ml vs 113 ml (p = 0.93)), distal resection margins (all negative), quality of total mesorectal excision (TME) (18 vs 14, as grade 3 (p = 0,83). The number of postoperative complications was equal in both groups. In a year after operation there were no significant differences between groups in a Wexner score (5.2 vs. 5.9) and in sphincterometry (the average amplitude of contraction was 15.8 and 16.4 mm hg). Conclusions. Both surgical techniques are comparable in the duration of surgery, intraoperative blood loss, quality of TME, number of complications. Performing LS-PTR requires much more mobilization of colon and a more careful evaluation of colotransplant blood supply. Functional results for more than 12 months are identical and do not directly depend on the formation of reservoirs. LS-PTR showed a much lower cost. 5

6 5 / 1061 Limberg flap in management of pilonidal sinus disease; Systematic review and a local experience Mohamed Boshnaq, Yih Chyn Phan, Iana Martini, Mohan Harilingam, Mansoor Akhtar, George Tsavellas, UK Objectives: Limberg flap is a technique used in treating sacrococcygeal pilonidal sinus disease (PSD). In this study, we have reviewed all published evidence of Limberg flap use in PSD for the past 20 years. We have also included our own local experience of Limberg flap. Methods: The Medline and Embase database were searched for the words pilonidal, sinus, Limberg, flap using a wildcard character (*). Non-English language, non-original articles and those are not related to our scope of search were omitted. We included a retrospective cohort study of patients who underwent elective Limberg flap reconstruction for either primary or recurrent PSD in our district general hospital. Data including the length of hospital stay, post-operative complications and recurrence were collected using a prospectively maintained hospital discharge database and patient records. Results: Literature review revealed 68 studies (22 case series, 35 comparative studies, 9 RCTs and 2 meta-analyses). Number of patients in case series 7-411, recurrence rate 0-7.4%. Follow up in comparative studies ranged between 6-65 months. Recurrence rate was 0-8.3%, compared to % for primary closure and 0-11% for Karydakis flap. RCTs showed that Limberg flap or its modification is superior to primary closure. Comparable results have been achieved when compared to Karydakis flap. 26 patients included in the cohort study (16 male and 10 females, average age 27 years). 6 patients out of the 26 presented with recurrent disease. Postoperative length of hospital stay ranged from 4 to 7 days (average 5). Post-operative complication rate was (11.5%) [2 partial wound dehiscence, 1 wound infection]. Recurrence rate was 7.7%. The average post-operative period was 18 months. Conclusion: Incorporating our personal experiences with a thorough review of the available literature on the technique, Limberg flap presents a safe and effective method that should be offered for patients with primary or recurrent PSD. 6

7 6 / 1062 Evaluation of percutaneous posterior tibial nerve stimulation efficacy for patients with faecal incontinence Saulius Švagždys, Greta Žemaitytė, Mantas Vilčinskas, LT Aim: percutaneous posterior tibial nerve stimulation (PTNS) is one of neuromodulating methods used for faecal incontinence treatment. This method has been used for four years in Lithuania. The aim of our study is to evaluate the efficiency of this method on continence and quality of live. Methods: patients with faecal incontinence and anatomically intact sphincter muscles and extant anorectal reflexes after anal manometry and endorectal ultrasound examination, prospectively were included in this study. Incontinence severity was evaluated by Wexner scale and specific quality of live (QOL) questionnaire SF 36 before and after treatment. Treatment lasts 20 PTNS sessions (1 month) by applying 200 µs, 10 ma, 10 Hz current to both n. tibialis posterior. Wilcoxon test for dependent samples was used to determine the statistically significant differences. Results: 21 patient were recruited to the study in 24 month period. Data of 16 (76 %) patients with good effect of treatment was analysed. The Wexner score improved after treatment from 13,9 ± 3,9 to 11,1 ± 5 (p = 0,091). The Lifestyle alteration question from the Wexner questioner value improved from 2,96 ± 1,9 to 2,14 ± 1,4 (p = 0,016), The improvement of general QOL after treatment was discovered either from 53,33 ± 20,4 to 58,1 ± 25,3 (p = 0,27), a lifestyle domain questions value from 14,04 ± 5,4 to 22,1 ± 7,3 (p = 0,048), a depression/ self-perception domain from 11,2 ± 3,9 to 13,5 ± 4,8 (p = 0,2). Conclusion: PTNS is effective and acceptable method of faecal incontinence treatment with significant effects on patients lifestyle. The bigger numbers of participant are needed to get statistically reliable results of other parts of tests values. 7

8 7 / 1065 An overview of Quality of life in patients requiring stoma formation in University College Hospital Galway. Sadia Gul Jaskani, Emmeline Nugent, Myles Joyce, IE AIM: The aim of this study was to identify factors affecting quality of life (QOL) in patients requiring stoma formation. We wished to identify any variances in QOL in patients with Colostomies versus Ileostomies versus Ileal conduit with the intention of identifying modifiable factors. METHODS: A prospective analysis stoma patients database for their post op quality of life was performed. The database included patients who underwent stoma creation surgery from January 2012 to Oct 2015 in university college hospital Galway. Patients were posted a stoma specific validated quality of life (QOL) questionnaire. Other data points collected included stoma specific complications, pre-operative stoma siting, weight, and available social support. RESULTS:284 patients were eligible for inclusion. 184 (64%) patients responded. Mean QOL score was 56/80. There was a significant difference in total QOL score in patients with a stoma specific complication versus those without (P = 0.017). Factors such as patient weight, social support, age, gender, elective vs. emergency surgery, malignant vs. benign disease, temporary vs. permanent stoma and pre-operative stoma siting were not found to impact QOL score. Commonest stoma specific complication reported was parastomal hernia in colostomy in ileal conduit group, while skin problem were commonest in ileostomy group CONCLUSION: The need for stoma formation is a life changing event. While QOL is reduced for the majority of patients requiring stoma formation there is no significant difference for those requiring Colostomies versus Ileostomies versus Ileal conduit. Patients suffering stoma related complications had a statistically significantly reduced QOL. Thus adherence to optimal surgical technique to reduce stoma related complications is important. 8

9 8 / 1067 Colorectal cancer steam cell quantity corelation with tumor invasion degree and its predictive value Giorgi Merabishvili, Tea Zurabashvili, Omar Khardzeishvili, GE Background colorectal cancer stem (CSC) cells are malignanat cell population, they are related and have major role in cancer recidives, its chemo-resistance and predicts desease relapse. Many biological feature of (CSC) are yet poorly undersood and is under research. The aim of our research is to rate (CSC) quantity corelation with tumor invasion degree and its predictive value during colorectal average differntiate carcinoma. From the prognosing factors today we have choosed invasion degree. ( By TNM classification. Tis, T1, T2, T3, T4). (A frequent complication in colorectal cancer is regeneration of the tumor after therapy and its chemo-resistence. CSC has major role in cancer recidives, its chemo-resistance and predicts desease relapse. It is well recognized that tumor initiation, growth, invasion and metastasis are promoted by CSCs. An important reason for the widespread interest in the CSC model is that it can comprehensibly explain essential and poorly understood clinical events, such as therapy resistance, minimal residual disease, and tumor recurrence. Material and methods The study is done on 20 patient, aged from visualization of primary antibodies done by streptasidin-biotin-peroqsidaze complex (Biogenex, San Ramon, CA). Semi-quantitative analysis is done by 10X10 enlargement and quality evaluated by 4 denominator 0 (negative), 1+(weak), 2+(medium), 3+(high). Positive cells are counted on 10X20 enlargement (microscopy). Data is processed on SPSS v.19.0programme.) Result According to a survey result, new diagnostic, treatment and prevention methods of colorectal cancer (CC) will be implemented in treatment of colon cancer. conclusion A better understanding of how tumor-initiating cells, such as CSCs, escape chemo-therapy, the establishment of appropriate biomarkers, and the definition of novel clinical endpoints for monitoring the efficacy of combined and multimodal therapeutic strategies will be a challenge to improving future (CC) treatment. 9

10 9 / 1068 A Prospective Randomised Trial Evaluating the Short-term Outcomes of Transanal Haemorrhoidal Dearterialisation versus Tissue-selecting Technique Alex Leung, HK Objectives Tissue-selecting Technique(TST) is a novel stapled hemorrhoidectomy specifically targeting offending piles, thereby sparing the need for circumferential circular stapling. The aim of this study was to compare the short term outcomes of two minimal invasive treatments of haemorrhoids: transanal haemorrhoidal dearterialisation (THD) and TST. Methods Patients presenting with symptomatic haemorrhoids were recruited. Patients were randomized into two groups: (1)TST and (2)THD.Patient demographics, perioperative data, post-operative pain scores, recurrence, and patient satisfaction scores were evaluated. Patients with acute thrombosed haemorrhoids, external haemorrhoids only, or other concomitant anal diseases were excluded. Results From 2013 to 2015, we have recruited 80 patients with 40 in each group. There were no significant differences in the demographic data, perioperative data, postoperative pain score. The median symptom scores for bleeding and prolapse were significantly lower in the TST group at 1 year time( bleeding: 1.0 vs 2, p=0.001 ; prolapse: 1 vs 2, p=0.025, on a scale of 1-5 (5=worst symptom) The recurrence rate required additional procedure is also significantly lower in the TST group (4/40 vs 17/40, p=0.001 ) The median satisfaction scores after TST and THD were 4 and 3, on a scale of 1-4 (4=excellent satisfaction) (p< ), respectively. Conclusion Both THD and PPH are safe, and they appear to have similar short-term outcomes, however, TST has better improvement in symptoms, lower recurrence rate and higher patient satisfaction. 10

11 10 / 1069 The Expression Of MST1/2,YAP1 In Colorectal Cancer Fengming Yi, Long Feng, Jie Li, CN Objectives: MST1/2 and Yap1 promote the occurrence of tumor. We aimed to investigate the expression of Hippo pathway components MST1/2 and Yap1 in colorectal cancer(crc). Methods: Eighty-eight (including 30 colorectal cancer, 30 human rectal adenocarcinoma, 28 of benign colocrectal polyps) specimens were recruited from the second affiliated hospital of Nanchang university during June 2013 and December Immunohistochemistry was used to detect the expression of MST1/2, Yap1 protein. The expression of MST1/2, Yap1 protein and clinicopathologic features in colorectal adenocarcinoma was evaluated. Results: The expression of MST1/2 protein in the colonic carcinoma group (median=70) were significantly higher than that in colon polyps group (median = 10)( P< 0.001); MST1/2 in group rectal adenocarcinoma (median=60) statistically higher than that of colon polyps group (median=10) (P =0.004). The expression of Yap1 protein in the colonic carcinoma group (median = 50) obviously higher than that of colon polyps group (median=0) (P=0.003). Yap1 protein expression level in group rectal adenocarcinoma (median=55) obviously higher than that of colon polyps group (median=0) (P<0.001). Furthermore, It showed there is no correlation (P>0.05) between the expression levels of MST1/2, Yap1 and the colorectal adenocarcinoma patients' age, sex, smoking history, drinking history, location, tumor size, differentiation degree, T stage, N stage, tumor markers carcinoembryonic antigen, carbohydrate antigen-199 expression level, blood test index level (WBC, RBC, HGB, PLT, ALB).The average DFS was ±2.167M in the Yap1 positive group, and average DFS was ±2.488M in the negative group. Conclusions: Yap1 may play an important role in development and cell malignant transformation of colorectal adenocarcinoma. As a tumor suppressor gene, MST1/2 in colorectal cancer is lack of specificity, and further study needs to present these imbalances in colorectal cancer. 11

12 11 / 1070 Evaluation of fecal S100A12 in patients with inflammatory bowel disease Fengming Yi, Long Feng, CN Background and Aim: The diagnosis and evaluation is quite complex for inflammatory bowel disease(ibd). An ideal, noninvasive marker is quite urgent for IBD. Fecal S100A12 is a member of the S100 protein family and secreted by activated neutrophils. We aim to evaluate it as a biomarker for IBD patients in China. Methods: Fecal S100A12 was measured in 18 Crohn s disease(cd), 21 ulcerative colitis(uc), and 17 healthy controls(hc). Diagnositic value was evaluated by receiver operating characteristic(roc) analysis in comparison with C-reactive protein(crp) and erythrocyte sedimentation rate(esr). The correlation between fecal S100A12 and clinical characters were also evaluated thereby. Results: There are significantly increase in both UC and CD when compare to HC(p<0.01, p<0.01; respectively ). The fecal S100A12 is correlated with fecal occult blood(p=0.02, r=0.55) in UC. However, the fecal S100A12 is correlated with disease duration, ALB, and PLT in CD(p=0.01, r=-0.53; p<0.01, r=-0.65; p=0.04, r=0.45. respectively). There are no correlation between fecal S100A12 and other clinical characters. Conclusion: Fecal S100A12 is valuable in distinguish IBD patients with HC. However, the sensitivity and specificity is limited when compared with western countries. The correlation between S100A12 and clinical characters is limited as well. More research need to do to explore it in Chinese patients. 12

13 12 / 1071 Diverticulitis Quality of Life (DV-QoL) in patiens with uncomplicated disease surgery or conservative treatment? A multicentre study Alice Bressan, Massimo Vecchiato, Edoardo Vincenzo Savarino, Angelo Turoldo, Anna Chiara Frigo, Nicolò De Manzini, Roberto Petri, Stefano Merigliano, Lino Polese, IT BACKGROUND Controversies exist in indication of elective colonic resection for uncomplicated diverticulitis. AIMS To evaluate quality of life in patients operated for uncomplicated diverticulitis and in patients treated conservatively. PATIENTS All consecutive patients who underwent colectomy for uncomplicated diverticulitis or were hospitalized for acute uncomplicated diverticulitis in 3 centers (Padua, Trieste, Udine), from 2008 to 2015, were enrolled. SF-36 and DV-Qol were administered with reference to quality of life before and after surgical or conservative treatment. RESULTS Ninety-seven surgical and 44 medical patients were enrolled and satisfied the inclusion criteria of the study. Surgical patients had worse scores before treatment (basal) with respect to patients treated conservatively (mean :21.12 vs 15.41, p= ) but better scores (final) after treatment (mean: 6.90 vs 10.61, p= ). Differences between basal and final DV-QoL scores were significantly higher in surgical vs medical patients (p=0.0002). DV-QoL improvement after surgery was not statistically different between patients with risk factors (colonic stenosis and /or 2 or more of previous attacks of diverticulitis) and those without. CONCLUSIONS DV-QoL is an useful questionnaire for evaluation of quality of life in patients with uncomplicated diverticulitis and it can be also applied to surgical patients. Surgery for uncomplicated diverticulitis could improve Qol, even in absence of risk factors. 13

14 13 / 1072 Malignant large bowel obstruction: Results of a single operator technique from endoscopic stenting to surgery. Saleem Ahmed, Yiu Hin Kwan, Wong Kar Yong, How Kwang Yeong, Ng Chee Yung, Fong Sau Shung, SG Title: Malignant large bowel obstruction: Results of a single operator technique from endoscopic stenting to surgery. Objectives: Malignant large bowel obstruction (MLBO) is a challenging surgical emergency with high rates of morbidity and mortality and significant risks of requiring a stoma. Colonic stenting as a bridge to surgery has allowed conversion of emergency surgery to one done in an elective setting. This has been shown to result in a lower stoma rate and equivalent short term surgical results. We hypothesize that a technique whereby the same operator performs the stenting and surgery will have excellent short and long-term outcomes. The aim of the study was to review our experience and assess the effectiveness of single operator colonic stenting in malignant colon obstruction as a bridge to surgery. Methods: We undertook a retrospective analysis of all patients who underwent colonic stenting followed by surgery for MLBO by the same operator in our institution from 2010 to Results: During the study period, there were a total of 45 patients (mean age 68.1) operated by 2 surgeons. 34 were male. Technical success was achieved in 45 patients (97.9%) and clinical success was achieved in 40 patients (88.9%). All patients with technical and clinical failures required emergency surgery. 22 patients (56.4%) underwent laparoscopic surgery while the rest underwent open surgery. Overall stoma rate was 2.6%. The 30-day and 1-year mortality rate of the entire cohort is 0% and 7.7% respectively. Conclusion: Single operator colonic stenting and surgery in MLBO yields good results and should be a consideration for patients who present with malignant colon obstruction. 14

15 14 / 1074 Megacolon leading to cardiorespiratory arrest in 19 year/old male Maria Joao Jervis, Regina Candeias, Pedro Febra, Andre Pacheco, PT Objectives: The author presents a case report of a 19 year old male that was carried to the emergency room in cardiorespiratory arrest presenting with severe abdominal distension. He recurred to a primary care center three hours before complaining about vomiting, diarrhea and dyspnea, and transfer to the hospital was decided. He entered the hospital in invasive mechanical ventilation, with acute abdominal compartment syndrome and diminished peripheric perfusion. Methods: The patient was brought to the operating room for emergent surgery. Intraoperatively, a megacolon filled with molded faeces (severe fecal impaction) was found. Total colectomy was performed, and a terminal ileostomy was constructed in the right flank. Results: The patient recovered from surgery without major neurologic sequelae. He suffered from amnesia for the event, and denied opioid consumption. Ileorectal anastomosis was performed 3 months after the initial presentation. Conclusion: The anatomopathological analysis was inconclusive. Severe fecal impaction causing important abdominal distension can produce significative ventilatory depression and circulatory compromise, ultimately leading to cardiorespiratory arrest. The patient described in this case suffered from constipation since childhood, without other known previous illness or medication. 15

16 15 / 1076 Pharmacological Prophylaxis for Venous Thromboembolism in Colorectal Cancer Patients: Introduction of Quality Improvement Interventions to Improve Compliance Yih Chyn Phan, Melanie D Costa, Mohamed Boshnaq, Mansoor Akhtar, UK Introduction NICE Guidelines 92 recommend patients undergoing major cancer surgery in the abdomen or pelvis should receive extended postoperative venous thromboembolism (VTE) prophylaxis of 28 days. The aim of this audit as to evaluate compliance with the recommended guidelines and improvements achieved after two rounds of interventions. Methodology The study was conducted in 3 phases. A quality intervention to improve compliance was introduced for the first phase. Subsequently, a more robust quality intervention was implemented after the second phase. The second intervention included sending weekly reminders to all nursing and medical staff, educating pharmacists and putting posters on the general surgical wards in the hospital. All patients who underwent major abdominal or pelvic surgery for colorectal cancer were included. Results The compliance in the first phase was found to be only 18%. After two interventions, the compliance has improved significantly to 94% in the third phase. Conclusions There was a significant improvement in the compliance with VTE prophylaxis recommendations after two quality improvement interventions, improving patients safety and ensuring a better service delivery to our patients. 16

17 16 / 1077 Validity of MRI Tumour Volumetry as a biomarker in rectal cancer Eyas Qasem, Richard John Egan, Richard Hugtenburg, Toby Wells, Peter Chowdhury, John Beynon, Mark Davies, Martyn Evans, Dean Harris, UK Objectives. MRI is the gold standard in the staging of rectal cancer. Tumour volumetry is a recently described imaging concept that may have advantages over radiological TNM staging and in assessing tumour response to chemoradiotherapy. This study aims to investigate the performance of tumour volumetry against traditional radiological and pathological staging modalities, and introduces the novel concept of tumour volumetry to mesorectal volume ratio (TMVR). Methods. Patients with histologically proven rectal cancer treated at a single cancer institute by surgery alone were selected from a prospective database. Axial MRI images for T2 to T4 disease were selected and transferred to an offline workstation ( Prosoma ). A single investigator manually contoured each axial slice for the rectal tumour and mesorectum defining the tumour (Tv) and mesorectal volumes. The ratio of tumour volume to mesorectal volume (TMVR) was calculated. Correlations between the tumour volume, TMRV and tumour length were compared with MRI and pathological T staging. Results. 35 patients with primary rectal cancer treated without neoadjuvant therapy were analysed. A distinct correlation was observed between increasing tumour volume (continuous scale) and advancing ordinal T stage. Tumour volume correlated better with pathological T stage than radiological T stage. In particular there was improved prediction of pathological T3 subset (a-d) with volumetric over MR-T stage. Correction of TV with mesorectal volume did not improve accuracy. There was no correlation between radiological tumour length and final T stage. Conclusion: This early analysis reveals tumour volumetry to be a promising predictor of final pathological T stage. This likely reflects that volumetry is a continuous scale which smooths out differences between discrete T staging categories. The observation will need validating in a larger patient cohort, and performance after neoadjuvant therapy is to be determined. 17

18 17 / 1078 Macro/microscopic anatomy of Denonvilliers fascia in men: a sheet plastination and confocal microscopy study Zhaoya Xu, Pierre Chapuis, Les Bokey, Ming Zhang, NZ Objective: The presence or absence of Denonvilliers fascia has been debated for over 100 years. Its recognition at operation and its presumed oncological significance are considered important. The original description of the fascia was based exclusively on findings observed in 12 male cadavers and defined the fascia as Behind the prostate, between the seminal vesicles and the rectum, there is a clear and distinct membranous layer (Denonvilliers, 1837). The aim of this study was to investigate the in situ architecture of Denonvilliers fascia in men using a combination of epoxy sheet plastination and confocal microscopy technologies. Methods: Six male cadavers (age range, years; mean age, 75 years) were used in this study. The cadavers were bequeathed for medical education and research purposes under the Human Tissues Act and were prepared as sets of transverse (2 sets), coronal (1 set) and sagittal (3 sets) plastinated sections. The thickness of the section was 2.5mm and the interval between adjacent sections was 0.9mm. The sections were examined under a stereoscope and a confocal microscope. Results: The posterior prostate capsule and posterior vesical fasciae formed a segmented membrane-like structure in the pre-rectal space. The posterior prostate capsule was predominantly derived from the posterosuperiorly diffused aponeurotic fibers of the external urethral sphincter. Other segmented membrane-like structures in the pre-rectal space included the connective tissue sheaths of the inferior vesical neurovascular bundle, isolated longitudinal rectal aponeurotic bundles, and inferior extension of the peritoneum. Conclusions: This study identified the nature, fine architecture and distribution of the membrane-like structures in the prerectal space and concluded that there is no clearly identified membranous layer consistent with Denonvilliers fascia. Previous studies may have misidentified the fragmented membrane-like structures as Denonvilliers fascia. 18

19 18 / 1079 Immunological Testing of Digitally Extracted Faeces in the Detection of Colorectal Cancer Jennie Grainger, Sunanda Mahapatra, Fraser Cameron, Paul Skaife, UK Introduction: Suspected colorectal cancer (CRC) referral pathways identify symptomatic patients with view to early diagnosis to improve outcome. These referral pathways put a significant demand on out-patients, endoscopy and radiology in order to meet National targets. In 2013/14 209,265 colorectal fast-track referrals were made.these are set to increase with the introduction of the new NICE guidance in Faecal occult blood testing (FOBT) in symptomatic patients could reduce the number of fast-track referrals. Current FOBT used in screening has been reported as having a sensitivity of only 55% in diagnosing CRC. Aim: To investigate the sensitivity and specificity of immunological faecal occult blood testing (FOBTi) in the detection of CRC by obtaining a faecal sample by digital rectal examination (DRE) in symptomatic patients. Methods: A prospective study was performed on patients referred with symptoms suggestive of CRC, excluding those with overt rectal bleeding. Following written consent, a DRE was performed and faecal sample obtained for FOBTi testing. Patients were classified as either FOBTi positive or negative. Colonic investigations were later correlated to the FOBTi result. Results: Five hundred and thirty-nine FOBTi samples were obtained, followed by complete colonic investigations. Three hundred and seventy-seven patients tested FOBTi negative,162 FOBTi negative. In the negative group, 3 cancers were detected, 1 of whom was an adenocarcinoma and 2 were NETs. Of the patients who tested positive, 44% had cancer. Other diagnosis include diverticular disease (14%), polyps (12%), IBD (4%). 24% had normal investigations. FOBTi has a 96.5% sensitivity and specificity of 80.8%. The positive predictive value is 45.1% and negative predictive value is 99.2%. Discussion: Immunological FOBT is a discriminatory test for CRC in secondary care. A negative test could allow a patient to be referred in a less urgent manner, taking pressures off endoscopy and radiology services. 19

20 19 / 1082 There is a place for Intraoperative radiotherapy in primary locally advanced rectal cancer (LARC) and locally recurrent rectal (LRRC)?.Five-Year Institutional Experience Fernando Fernández-López, Jesús Paredes Cotoré, Manuel Bustamante Montalvo, Antonio Gómez Caamaño, Roberto García Figuieras, Ana Maria Alvarez Castro, ES 1.- Introduction Local relapse occurs in up to 40% of cases of local advanced rectal cancer (LARC) and local recurrence rectal cancer (LRRC). In these circumstances aggressive local control offers the best chance for improved survival. It is in this setting that intraoperative radiotherapy (IORT) has been considered as a potentially valuable treatment option in RC. 2.-Objetive We evaluated the role of intraoperative radiation therapy (IORT) during radical resection of LARC / LRRC. 3.- Methods We retrospectively evaluated 29 patients with LACR / LRRC treated with IORT at our institution from 2012 to IORT was delivered in a conventional multi-energy accelerator bunker with (PRIMUS, Siemens) using electrons directed toward the tumor bed (energies of 6 and 9 MeV). We analyzed factors associated with postoperative morbidity, local control (LC), and overall survival (OS). 4.- Results R0 resection rate was 52%, R1 26%, and two cases was R2. There was no difference in R0 resection rate among patients with primary versus recurrent tumors. IORT was delivered at a median dose of 12.5 Gy (range 10 15). A positive microscopic margin (R1) was not associated with worse LC. The median post-iort OS for all patients was 67.7 months for all patients. One- and 3 year post-iort overall survival were 85%, and 80% for patients with primary cancers. R1 resection also was not associated with worse post-iort OS. 5.- Conclusion The advantage of IORT is its ability to increase the effective radiation dose to the tumor bed or margin at risk for local failure while excluding or limiting the dose to adjacent sensitive abdominal/pelvic structures For patients with primary or recurrent locally advanced RC, treatment with radical surgery and IORT achieved excellent LC outcomes in R0 and R1 microscopic margin status. Despite methodological weaknesses in the studies evaluated, our results suggest that IORT may improve oncological outcomes in advanced and recurrent RC. 20

21 20 / 1083 Emergency Colorectal Cancer Presentations: Can we Prevent in Primary Care? Sunanda Roy Mahapatra, Jennie Grainger, Edward Nevins, Zaid Ahamoodi, Raj Rajaganeshan, UK Introduction: Survival from colorectal cancer (CRC) is largely dependant on the stage of their cancer at the time of diagnosis, with a higher mortality seen in patients presenting as an emergency. Quite often patients who do present as an emergency have had symptoms which have persisted for a significant period of time without investigation. We wanted to analyse our emergency admissions to try and identify any factors that may reduce emergency presentations. Methods: A retrospective analysis was performed of all CRC patients who presented as an emergency at Whiston hospital during Patients who were not operated on were excluded. Results: In total we identified 29 patients who had emergency surgery. The mean age was 72.6 years (range years). 76% of patients were admitted through A&E, of which the majority (79%) presented with abdominal pain. 86% of patients had had symptoms prior to admission, with the duration of symptoms ranging from 6 days to 1 year. 59% of patients had consulted their GP with these symptoms at some point leading up to admission. Of these 71% had consulted their GP more than once, with 35% consulting 5 times or more. Of those who had consulted their GP, 29% were referred to out-patients for an opinion, of which all but one were referred on a rapid access basis. Of the patients who had consulted their GP, 35% had an investigation organised on an out-patient basis with CT being the most common investigation (83%). 60% (3/5) of the CT scans were reported as normal. Conclusion: Most patients who present as an emergency for CRC have had persistent symptoms for up to a year and have consulted their GP previously. 21

22 21 / 1086 Various techniques of large bowel anastomosis and their impact on microcirculation in anastomosis region: experimental study on pig Slavomir Blažej, Milan Kaška, Jiří Páral, CZ Background Looking for new surgical solutions how perform safe reconnection of bowel ends after resection regarding applied materials is focused on using synthetic tissue adhesive in comparison with standard methods (sewing and stapling). This project is interested in quality of anastomotic region tissue microcirculation (tightly after bowel re-connection) and healing (7 days) using manual suture, stapling or glue. Materials and Methods An experimental study involved 18 young female domestic pigs divided in three subgroups with 6 animals in each according to a surgical method of an anastomosis construction in sigmoid colon region using: a suture or a stapler or gluing (cyanoacrylate adhesive). Blood microcirculation in anastomosis region was monitored using Laser Doppler Flowmetry (LDF) until 120 min. postoperatively. Changes of microcirculation intensity were expressed in percentages of value drop ( = - %) from the base line value (in moment of LDF probes fixation to bowel serosa) which was established as 100% individually. Quality of anastomosis healing (7 days postoperatively) were controlled by macroscopic and by histological examinations. Results Anastomoses in all three animal subgroups recovered with no pathological signs. Evaluation of microcirculation in anastomosis region showed the smallest drop in animals constructed with suture ( = %), stapling and gluing ( = % and = %, respectively) demonstrated their significant deeper drop in relation to sutured (p = and p = 0.003) 120 min postoperatively. Difference of microcirculation drop between stapled and glued anastomoses is not significant (p=0.159). Histologically outcomes were excellent in each of the three tested surgical technique. Conclusions Suture, stapling or gluing of large bowel ends can have different negative impacts on microcirculation intensity right after anastomosis construction, but final results of anastomosis healing is excellent in all three tested techniques. 22

23 22 / 1093 New perspectives for surgical treatment options for colorectal cancer after 10 years of screening program Andra Iulia Suceveanu, Adrian paul Suceveanu, Felix Voinea, Vitalie Morosanu, Laura Mazilu, RO Background. The rationale for colorectal cancer screening is based on the assumptions that screening reduces the diagnosis of cancer in non-curative stages, in this way modifying the treatment approach and lowering the mortality rates. Aim. The aims of our study were to follow-up the transformation of surgical treatment management for colorectal cancer after 10 years from the onset of screening program and to study the consequence of surgical treatments applied over the survival rates in the same period of time. Material and method. We retrospectively studied the files of 2156 patients admitted and surgically treated for colorectal cancer at Emergency Hospital of Constanta County during Jan and Dec. 2015). Results. From the total of 2165 cases of colorectal cancer surgically treated, we discovered an increasing number of curative treatments compared to palliative ones, especially in the last 4 years. If in 2005, 42% of surgical interventions were palliative and 58% were curative, the number of curative interventions increased significantly over the time, in the last 4 years of the study period reaching a percentage of 78% (p=0.0229, ss). The overall survival rates at five years also improved from 42% to 64% for all stages of colorectal cancer surgically treated (p=0,040, ss). Conclusions. The screening for colorectal cancer changes the perspectives of surgical treatment, modifying together the profile of surgical approach and also the survival rates. 23

24 23 / 1094 The incidence of prolonged postoperative ileus after laparoscopic colorectal surgery does ERAS bring anything new? Michał Pędziwiatr, Magdalena Pisarska, Jan Kulawik, Dorota Radkowiak, Anna Zychowicz, Michał Nowakowski, Andrzej Budzyński, PL A substantial percentage of patients undergoing colorectal surgery develop prolonged postoperative ileus (PPOI). Since the data on its incidence and risk factors in patients undergoing laparoscopic colorectal surgery with ERAS protocol are sparse we aimed to analyze them in a group consecutive patients operated on laparoscopically for colorectal cancer. The study was a prospective observation of 295 patients. In all of them the 16-item ERAS protocol was applied. PPOI was defined as primary or when other complications led to paralytic ileus as secondary. For the purposes of further analysis, the entire group of patients was divided into subgroups, depending on the presence of PPOI. The primary outcome was the occurrence of PPOI. Secondary outcomes were risk factors of PPOI. PPOI incidence rate was 9.8%. In 8 (27.6% of PPOI group) patients it was secondary to other underlying complication. In the remaining 21 (72.4% of PPOI group) cases it was primary. Further analysis showed that of 21 patients with primary PPOI in 7 (33.3%) cases it resolved completely on 4 POD, in 10 (47.6%) on 5 POD and in 4 (19.1%) on 6 POD. Using univariate regression analysis, we observed that only the female sex (OR 2.71, 95 % CI , p = 0.035) was an independent predictor of PPOI development. Age > 65 years was associated with a lower risk of PPOI (OR 0.33, 95 % CI , p = 0.026). We have also observed that patients after procedures involving handling the small bowel were more likely to develop PPOI (OR 2.65, 95 % CI , p=0.0499). The remaining parameters were not stastically significant. We conclude, that the incidence of PPOI in patients after laparoscopy with ERAS protocol is low and usually resolves within 5 days. However, longer PPOI may indicate underlying complications. Traditional risk factors for PPOI seem to play a limited role in its development. 24

25 24 /1095 Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery Magdalena Pisarska, Michał Pędziwiatr, Michał Nowakowski, Jan Kulawik, Anna Zychowicz, Dorota Radkowiak, Andrzej Budzyński, PL Although the relation between the adherence to ERAS protocol and clinical outcomes was extensively studied there is still ongoing discussion on the need and feasibility of full compliance in laparoscopic colorectal surgery. In this study we aimed to answer the question whether the strict adherence to the protocol (>90%) leads to further improvement in clinical outcomes comparing to high (70-90%) and low (<70%) compliance groups. The analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between January 2012 and July Patients were divided into three groups depending on the compliance with ERAS protocol: <70% (group 1), 70-90% (group 2), >90% (group 3). Compliance was calculated as the number of pre and intraoperative interventions fulfilled/13 (number of protocol elements included) similarly to Gustafsson et al. The measured outcomes were: length of stay (LOS), complication rate, readmission rate, recovery parameters (tolerance of early oral diet in 1st postoperative day and mobilization of a patient on the day of surgery). Group 1 consisted of 70, Group 2 of 65 and Group 3 of 116 patients. There were no statistical differences between the groups based on demographic parameters, stage of cancer and operative parameters (operative time, blood loss, conversion). The overall compliance with the protocol in the study group was 85.6±11.9%. We observed that with its increase, the median LOS decreased (6 vs. 4 vs. 3 days). There was also significant decrease in complication rate and their severity (35.7% vs. 36.4% vs. 16.4%). Moreover, we observed differences in recovery parameters between the groups: tolerance of an oral diet on the 1st postoperative day (52.8% vs. 79.5% vs. 87.9%), mobilization of a patient on the day of surgery (68.6% vs. 92.3% vs. 99.1%), respectively. Full implementation of the ERAS protocol significantly improves short-term outcomes both in comparison to the high and low compliant groups. 25

26 25 / 1096 Markers of inflammation in the eraly detection of infectious complications after laparoscopic colorectal cancer surgery with ERAS protocol Michał Pędziwiatr, Mateusz Wierdak, Magdalena Pisarska, Beata Kuśnierz-Cabala, Jan Kulawik, Michał Nowakowski, Andrzej Budzyński, PL The aim ot this study was to assess the usefulness of serum level of C-reactive protein (CRP), Interleukin-6 (IL-6) and Procalcitonin (PCT) as early indicators of infectious complications in patients undergoing laparoscopic colorectal cancer surgery with ERAS protocol. Prospective analysis included 51 consecutive patients who underwent laparoscopic colorectal cancer resection between August 2014 and June In all cases standardized 16-item perioperative care ERAS protocol was used (mean compliance >85%). Blood samples were collected preoperatively and on POD 1, 2, 3. Following parameters were measured: CRP, IL-6 and PCT. Subsequently, patients were divided into two groups depending on the presence of infectious complications. We analyzed the differences and dynamics of change in levels of markers. Eventually, the sensivity and specificity of all measurements in subsequent days was established using ROC curves analysis. Group 1 comprised 34 not complicated patients and group 2 17 patients with at least one infectious complication. There were no differences in preoperative levels of analyzed markers. However, comparing to group 1 we observed significant increase of both absolute values and delta increments in all postoperative days. ROC curve analysis showed that a cut-off of 129 mg/l in the CRP (92% sensitivity /specificity 80% ) in POD3, 78 pg/ml in the IL-6 (91% sensitivity / specificity 97 %) in POD2 and 0,24 ng/ ml in the PCT (93% sensitivity/specificity 68%) in POD 3 were the best predictors for early detection of infectious complications. Analyzed markers may be relevant in the early detection of complications. It is an important observation since laparoscopic surgery with ERAS significantly shortens length of stay. Therefore, determining the role of early postoperative inflammatory markers may be of great value in selecting patients who are still asymptomatic and may require prolonged hospitalization due to high risk of complications and readmission. 26

27 26 / 1097 Does Near-infrared fluorescence angiography (NIR) change operative strategy during emergency procedures? Emilie Liot, Michela Assalino, Philippe Morel, Frederic Ris, CH Introduction One of the issues of emergency surgical interventions is to evaluate the viability of organs. Near-infrared fluorescence angiography (NIR) allows an intraoperative assessment of organ perfusion and may help to decide about organ resection. The aim of this study was to assess if NIR changed operative strategy during emergency surgery. Patients and methods Retrospective evaluation of 56 consecutive patients who had an emergency abdominal surgical procedure in our institution between July 2014 and December 2016 using intraoperative NIR. Primary endpoint was the change of operative strategy due to the result of the NIR test. Secondary endpoints were indications for the use of NIR test as well as reoperation rate. Results In total 27 men and 29 women were included. Initial laparoscopy was performed in 39 % of all cases and immediate open surgery in 61%. Conversion rate to open surgery was 41 %. In 32 % of the cases, the result of the NIR test leaded to a change in the operation strategy. 33% of those patients had a resection or an enlarged resection which initially wasn t planned. 67% had no resection contrary to the initial intention. Importantly, none of those patients had a reoperation for ischemia. Main indication for NIR use was guidance of bowel resection, control of the stumps after resection and anastomosis. Reoperation rate was 20%. Small bowel resection was necessary in only one case. 2 patients had an anastomotic leak whereas one of those anastomosis was tested using NIR during initial surgery. 14.3% patients died during the post operative care but none of those presented bowel ischemia or anastomotic leak. Conclusion NIR is a simple no time consuming procedure which can be easily done during emergency surgery to assess the perfusion of organs. It may help the surgeon to preserve well-vascularized organs, especially knowing that we had no reoperation rate for ischemia when operative strategy was changed for a less aggressive attitude. 27

28 27 / 1100 A Meta-analysis on the Clinical Outcomes of Bridge to Surgery Stenting versus Emergency Surgery in Malignant left sided Colonic Obstruction Samuel HT Poon, Rosemarie Hon Yiu Chiu, Lam Chi Cheung, Wai Yiu Lam, Chi Chung Foo, Wai Lun Law, HK Introduction Left-sided malignant colonic obstruction was conventionally managed by emergency operation until the introduction of bridge to surgery stenting (BTS stenting). Despite evidence showing superior short-term outcome, the long-term oncological safety for BTS stenting is still questionable. Large-scale comparative studies on the long-term outcomes were scarce. The aim of this meta-analysis was to compare the short-term and long-term outcomes of BTS stenting and emergency surgery for malignant left-sided colonic obstruction. Method Two authors systematically reviewed literatures available in PubMed in the recent ten years on both short and long-term outcomes for the two approaches. Meta-analysis for short & long-term outcome was performed with random effect model. Results BTS stenting has significantly less postoperative morbidities when compared with emergency surgery (RR= 0.64; p <0.001). Permanent stoma rate and postoperative mortality were comparable between the two groups. However, BTS stenting was associated with a higher chance of loco-regional and systemic recurrence (RR = 1.91; p = 0.008), especially for the perforated cases (RR = 2.08; p = 0.026), when only the randomized controlled trials were included. Nevertheless, there was no significant difference in terms of survival between the two groups. Conclusion BTS stenting has superior short-term outcome but there is a concern for higher incidence of recurrence. Although no difference in survival outcome was demonstrated in this study, the scarcity of data in this regard should prompt more research and the follow-up results of some of the earlier randomized control trials should help to answer such query. 28

29 28 / 1101 An atypical colorectal recurrence how was it and how we did it Filipa Taré, Hugo Capote, Eduardo Soeiro, PT Presentation of an atypical form of colorectal cancer (CRC) recurrence. Case report and brief literature review. We report the case of a 75 years old male patient, with relevant history of Diabetes Mellitus type 2, hypertension, obesity and chronic etanolism, who was diagnosed a sigmoid polyp with low-grade dysplasia (LGD) for which he was submitted to a laparoscopic sigmoidectomy in February/2015 which showed adenocarcinoma (ADC), G1, in pt3n0m0. It was decided surveillance during which there was no clinical or analytical evidence of recurrence up to 8 months postoperatively. In October/2015 the patient presented signs and symptoms of an infected sacral dermoid cyst, refractory to antibiotic therapy, so we proceeded to surgical exploration of the lesion where we found fistulization from it to the anal canal; biopsies of this recto-cutaneous fistula showed infiltration by ADC and the staging with MRI and PET-CT showed only the presence of tumor in the fistulous tract. The patient was thus subjected to abdominal-perineal resection with en-bloc excision of the fistula in February/2016, with final staging of pt4n0m0. The postoperative course was complicated by perineal wound dehiscence, requiring negative pressure therapy and antibiotics. The healing/cicatrization was complete only 3 months after surgery, so it wasn t started adjuvant chemotherapy. Currently, the patient remains without evidence of local or distant recurrence at 6 months postoperative. CRC recurrence occurs in over 50% of patients undergoing curative surgery, of which 85% occur in the first 2.5 years after surgery. Local recurrence is seen in 20-30% of cases (usually in the form of high-risk polyps) and current guidelines recommend the first colonoscopic re-evaluation only 1 year after surgery. The form of the recurrence of this clinical case isn t usually found in the literature and represented a surgical challenge to our team, with a dedicated and long recovery. 29

30 29 / 1102 When Colon meets Pancreas. A rare case report. Sara Nogueira, Bruno Pinto, Miguel Carracha, Eduardo Silva, Francisco Carneiro, PT Objectives: The authors present a rare case of bowel perforation with peritonitis, due to metastatic pancreatic carcinoma. Methods: Review of the case and available literature. Results: A 60 year-old male presents to the emergency department with agitation, mental confusion, fever and abdominal pain. The physical exam showed a mild fever (37,8), hypotension (110/67mmHg) without tachycardia, and a tense abdomen. He was first observed by a general physician that promptly initiated support measures, asked for blood tests and a surgeon s evaluation. The laboratory tests showed a marked increase in inflammatory parameters (23200 leucocytes; RCP 23 mg/dl) and renal insufficiency (serum creatinine 2,86 mg/dl). Given the hemodynamic stability, the patient was sent to perform a CT-Scan that showed a pneumoperitoneum and a mass in the tail of the pancreas. He was submitted to an emergency laparotomy, revealing a perforated sigmoid mass with faecal peritonitis. We decided for an Hartmann procedure with oncological purposes and the patient had a regular post-operative evolution, with discharge at the 5th post-operative day. The pathological analysis of the specimen showed a carcinoma with pancreatic origin infiltrating the bowel wall and 3 positive nodes in 24. An appropriate staging was performed, revealing a locally advanced disease with metastatic spread. The case was presented and discussed in a multidisciplinary meeting and it was decided to follow-up the surgery with quimotherapy Discussion: Colon perforation due to malignant disease is rare, being obstruction the most common presentation of the disease. Metastatic disease of the colon is even more uncommon, with breast cancer, pulmonary cancer and malignant melanoma leading the charts. We encountered only 4 cases of colonic metastasis of pancreatic cancer, none of them presenting as perforation. 30

31 30 / 1104 Colonoscopy follow-up, are we abusing endoscopy resources? Iana Martini, Mehreen Yousuff, Mohamed Boshnaq, UK Aim: The aim of this study was to determine whether correct colonoscopy follow-up was requested in patients noted to have polyp disease on baseline colonoscopy in line with current protocols. Recommended follow-up was determined primarily based on biopsy histology; however patient risk factors and co-morbidities were also considered. Methods: All patients who underwent a colonoscopy in January 2015 at a District General Hospital were considered. Patients who did not have polyps on colonoscopy or those with missing data on patient database systems were excluded. Data including patient demographics, polyp number, size and histology were collected using Patient Centre, DART database, colonoscopy and clinic letters. Follow-up was determined by looking for request details on Patient Centre and by checking clinic letters for intended follow-up. Results: 464 patients had a colonoscopy in one month. 360 patients were excluded as they were found to have no polyps. Another 44 patients were excluded due to missing data. 60 patients were ultimately included in the study (age 36-84, male to female 61:43). Baseline colonoscopy identified 35 patients with adenomatous polyps, five with sessile polyps, two with serrated polyps and 18 with hyperplastic polyps. 38 patients (63.3%) had a correct follow-up plan according to guidelines while 22 patients (36.7%) had an incorrect plan for follow-up. 20 of these 22 patients had an expedited plan for follow-up without an explanation for the rationale behind this. Two patients had no plans for follow-up colonoscopy despite fulfilling criteria for this. Conclusion: There is a tendency to expedite follow-up colonoscopy without a clear rationale behind this. While the obvious aim of such an approach may include the potential for earlier detection of colorectal malignancy, the unnecessary use of a costly and invasive procedure like colonoscopy and resultant exhaustion of endoscopic resources by not following recommendations is a significant drawback. 31

32 31 / 1105 Laparoscopic extralevator abdominoperineal excision without changing position for distal rectal cancer Jun-Yang Lu, Yi Xiao, Hui-Zhong Qiu, Bin Wu, Guo-Le Lin, Xi-Yu Sun, Bei-Zhan Niu, CN Objective: To evaluate the short-term outcomes of laparoscopic extralevator abdominoperineal excision(elape) without changing position during operation. Methods: Totally 145 patients with distal advanced rectal cancer underwent surgical procedures in Peking Union Midical College Hospital from Jaunary 2013 to December There were 89 male and 56 female patients with a mean age of (59±10) years. 33 percent of the patients received preoperative concomitant chemotherapy and radiation. 109 patients underwent laparoscopic abdominoperineal excision(ape) procedure, while 36 patients underwent laparoscopic ELAPE procedure. In both groups, patients were kept Lithotomy- Trendelenburg position during operation. Retrospectively collect and compare the pathoclinical features, operation time, blood loss, node retrieval, lateral margin and complictions between ELAPE and APE procedures both by laparoscopic approach. Results: No significant differences were found in terms of age, gender, BMI, distance from anal verge, size of tumor, percentage of neoadjuvant chemoradiation, operation time, bleeding volume and TNM staging between these two groups (all P>0.05). The rate of positive lateral margin(3% vs. 10%, P=0.302), lymph node retrieval and postoperative complications (33% vs. 23%, P=0.215) were comparable for ELAPE and APE procedures. Conclusions: Laparoscopic extralevator abdominoperineal excision without changing position is feasible for distal rectal cancer. Some essential steps can be simultaneously accomplished during operation without changing position. Keywords: Rectal neoplasms; Laparoscopy; Levator ani 32

33 32 / 1106 Transdermal slow release fentanyl patches for the management of post-operative analgesia following major abdominal surgery: a systematic review Sunanda Roy Mahapatra, Fok Mathew, Jennie Grainger, James Melling, Dominic Cliff, Dale Vimalachandran, UK Introduction Pain control represents a significant barrier to the enhanced recovery of patients following major open abdominal surgery and has traditionally been achieved with potent opioids delivered through the intravenous route in combination with invasive techniques such as epidural analgesia. Recent evidence has suggested preoperative application of transdermal slow-release fentanyl patches (TDF) may not only provide effective and better analgesic control but also offer logistical advantages for patient and nursing staff, along with an improved side effect profile. This systematic review aims to review the effectiveness of TDF in acute post-operative pain relief in major abdominal surgery. Methods Electronic searches were performed on five major databases from inception to October 2015 to identify relevant studies. Eligibility decisions, methodological quality, data extraction and analysis were performed according to predefined clinical criteria and endpoints. Results Ten studies were identified of which included nine randomised controlled trials (RCT) and one non-randomised controlled trial. In total, 429 and 329 patients received TDF patches and placebo patches respectively. There were significantly improved patient reported pain score, supplementary morphine usage for patients receiving TDF compared to placebo. No difference was found in reported nausea and vomiting between groups. Respiratory side effects were comparable between the two groups. Discussion This systematic review demonstrates that TDF may offer a safe and effective method for analgesia provision following major abdominal surgery. However, further research with high powered studies are required to more accurately define its effectiveness in major abdominal surgery and closely evaluate the side effect profile. Our future studies will look at usage of alternate analgesic techniques including fentanyl patches in open colorectal operations. 33

34 33 / 1107 What to expect after Hartmann Procedure? A retrospective analysis in a single institution Ana Alagoa João, Ricardo Rocha, Carla Carneiro, António Sampaio Soares, Marta Fragoso, David Aparício, Rui Marinho, Marta Sousa, Cisaltina Sobrinho, Énio Afonso, Carlos Leichsenring, Vasco Geraldes, Vítor Nunes, PT INTRODUCTION Hartmann procedure (HP) is a surgical option in a variety of left colon pathologies and clinical settings. Our aim was to analyse clinical factors associated with morbidity and mortality. METHODS Retrospective analysis of patients submitted to HP between 2012 and 2015, in a single institution. Information was collected on age, gender, comorbidities, surgical indication, in-hospital morbidity, 30-day mortality and intestinal reconstruction. Univariate and multivariate analysis were performed to determine predictors of morbi-mortality; p<0.05 was considered statistically significant. RESULTS A total of 95 patients (mean age 69.4 ± 13.8 years, 55.7% male) underwent HP, an emergent intervention in 90.5% of cases. Comorbidities were present in 88.4%, the most frequent being arterial hypertension (62.9%), diabetes mellitus (20.6%) and heart failure (18.9%). Main conditions leading to surgery were colo-rectal cancer (27.8%), perforated diverticulitis (23.7%), anastomotic complications (15.5%), sigmoid volvulus (12.4%) and ischemic colitis (8.2%). ASA score was 3 in 56.9% of patients. Mortality rate was 23.2% at 30 days; a significant association with surgical indication was not found. HP reversal was obtained in 62% (mean time 10.5 ± 7.4 months). On univariate analysis, age was a risk factor for mortality (67.5 vs 75.8 years), medical complications (66.3 vs 72.5), septic shock (67.3 vs 75.3) and need for organ support (67.7 vs 74.7); no comorbidity alone predicted death or perioperative complications, except for heart failure. After controlling for age and comorbidities, ASA score was considered a risk factor for mortality (OR 3.2), medical complications (OR 2.3) and need for organ support (OR 4.9). CONCLUSION High morbi-mortality rates in HP stand related to the patient s age. Nevertheless, ASA score was the most important risk factor for mortality at 30 days, reflecting not only the patient s comorbidities but also the clinical context in which HP is performed. 34

35 34 / 1108 The Combined Introduction of Laparoscopic Colectomy (LC) and Enhanced Recovery After Surgery (ERAS) to a Rural Hospital in Australia: Benefits and Difficulties. Sang Woo (Sean) Park, Basavaraj Mundasad, AU Objectives Laparoscopic colectomy (LC) is considered the gold standard for colorectal resection while ERAS programs have shown improvement in patient outcomes following colorectal surgery. LC has traditionally been the domain of colorectal specialists in large metropolitan centres and not part of general surgical training in Australia, compromising accessibility and equity for rural Australians. To our knowledge, there are no rural centres in Australia that have ERAS and LC introduced in a combined fashion. Armidale is a regional town in Australia approximately 400kms from Newcastle, the nearest metropolitan centre. Methods The combined introduction of ERAS/LC was designed by multidisciplinary team. The training process for the Armidale surgeons entailed courses, preceptorship at a tertiary centre alongside a colorectal surgeon and proctorship with onsite training and supervision during surgery. Patients were selected based on BMI, ASA and extent of previous abdominal surgery. Key elements of multimodal ERAS protocols included preoperative counselling, standardised analgesia, reduced fasting time, and early mobilisation and stimulation of gut motility. Results Eleven patients (median age 71 years) underwent ERAS/LC program over the course of 1 year. These included five right hemicolectomies with a mean operative time (OT) of 192 mins and mean length of stay (LOS) of 3.4 days, five anterior resections with one conversion to open (OT: 303 mins; LOS: 3.8 days) and one transverse colectomy (OT: 224 mins; LOS: 3 days). There were no major post-operative complications or mortality. Conclusion This study demonstrates that it is safe and effective to implement a combined introduction of ERAS/LC in a rural hospital through preceptorship/proctorship and multidisciplinary team. This has important implications for public health within Australia, such as improved accessibility, quality of surgical care and cost effectiveness for a larger cohort of patients in rural Australia. 35

36 35 / 1109 Clinical results of trans-anal TME for very low rectal cancer near the anus Masaaki Ito, Yuji Nishizawa, Takeshi Sasaki, Yuichiro Tsukada, JP Objective: The aim of this study was to clarify the short-term results of trans-anal TME (tatme) for very low rectal cancer near the anus. Methods: We experienced this procedure in sixty patients; 48 primary rectal cancer, 8 GIST, 2 NET and 2 recurrent disease. In former time, below first tatme was performed by one-team and we began two-team tatme since Transanal intersphincteric dissection was performed from 2cm distal side of the tumor till the level that the puborectal muscle was exposed and then placed Gelpoint path in the anal canal in most of the patients with very low rectal cancer. Reconstruction was made by hand-sewn colo-anal anastomosis. Results: Of 60 patients, ISR was performed in 53 patients, APR in 3, LAR in 1, Hartmann in 2 and TPE in 2 patients. Average BMI was 23 and average distance from the tumor to the anal verge was 4.3cm (2-7cm). In 55 anus-preserving procedures, lateral lymph node dissection (LLND) was performed in 16 patients in which median operative time and bleeding were 353 min and 111 ml and those of patients without LLND were 227 min and 75 ml, respectively. No complications were found in TAMIS related procedures. Conversion was found in one. We had grade III postoperative leakages in 4 patients and grade IV in 1 patient. R0 operation was achieved in all patients. Urinary dysfunction with residual urine of > 100ml at 7 POD was found in 4 patients, who would all recover in one month. Simultaneous performance by two-team was done in 18 patients. Average operative time in ISR by two-team is 138 min and one in two-team is 282 min, which differences were statistically significant. Conclusion: Trans-anal TME could offer feasible procedures in any lower rectal cancer patients with the various morphology of the pelvis and two-team operation could make great reduction of operative time. 36

37 36 / 1111 Biomechanical, Physiotherapeutic and Medical combined approach to the treatment of Pudendal Neuralgia after Colonoscopy a Case Report Francisco Helio Cavalcante Felix, BR Objectives: The aim of the study was to evaluate the positive effects of combination of pelvic floor physiotherapeutic methods and biomechanical whole body allingment on the pelvic pain management. Methods: 41 years old man with moderate to severe pelvic pain that started one day after colonoscopy. Blood analisys has shown normal hemoglobin and leukocyte levels and normal reactive C protein levels. Abdominal roentgenogram, ultrasound and abdominal and pelvic magnetic ressonance imaging showed no notable findings. Digital rectum examination showed a tight pelvic floor with muscular hypertonus and tenderness at the projection area of obturator internus and piriformis on the left with increased pelvic pain following digital pressure at this point. Rectal sigmoidoscopy was normal. After two months of clinical uncertainty, pudendal neuralgia caused by muscle entrapment or by muscular trigger points in the pelvic floor was the main diagnostic hypothesis. The patient refused any invasive treatment, such as pudendal nerve block or surgery. He underwent treatment with pregabalin150mg; internal and external manual physiotherapy with myofascial and trigger point release techniques; and biomechanical approach aiming a whole body alligment with static and dynamic sacroiliac joint components repositioning to stretch and lengthen the pelvic floor muscles. Results: Examination showed that physiotherapeutic myofascial release techniques and biomechanical approach for body allingment improved the pelvic pain levels due to pudendal neuralgia in the short term. Pregabalin was discontinued after 30 days. After six months of biomechanical approach and physiotherapy, the patient became pain free for most of the time with very episodic low level pain easily managed with simple self-myofascial release techniques. Conclusion: In short and medium term treatment, physiotherapy combined with biomechanical approach have highly improved pelvic pain due to pudendal neuralgia after a colorectal procedure. 37

38 37 / 1112 Emergency Hartmann s procedure: the risk of permanent colostomy Cosimo Riccardo Scarpa, Nicolas Buchs, Guillaume Giudicelli, Boris Schiltz, Philippe Morel, Frederic Ris, CH Objective: The risk of postoperative complications after Hartmann s procedure (HP) is significant. Most of the time, the end colostomy created in emergency is aimed to be temporary, even if the rate of further reversal is poorly reported. The aim of this study was to analyze our reversal rate after emergency HP and to identify the risk factors, which may contraindicate the restoration of bowel continuity. Method: The records of all patients who underwent an emergency HP in our unit between October 2008 and Juin 2015 were prospectively collected. Recorded data included age, sex, mortality, morbidity, ASA and Charlson s score and biological parameters. Patients have been divided into two groups: those in which the continuity was restored and those who still present a colostomy. Univariate and logistic regression analysis were performed in order to identify the risk factors associated with a permanent colostomy after an emergency HP. Results : During the study period, 156 patients underwent an emergency HP. Indication included perforated diverticulitis (57.7%), occlusive cancer (12.2%), iatrogenic perforation (9.6%), ischemic colitis (5.8%), perforated tumor (5.1%) and others causes (9.6%). Average follow-up was 150 weeks (1-404), 79 patients (50.7%) had a reversal of their Hartmann. 77 patients (49.3%) did not undergo reversal of their colostomy. Among them, 48 have passed away: 28 due to a postoperative infective complication or acute cardiac and respiratory failure (30-day mortality rate: 18%), and 20 because of their tumoral disease. Therefore, among the 29 patients still alive, the risk factors associated with a permanent colostomy were: preoperative Charslon s score, ASA score, cardiac disease, senile dementia and incontinence. Conclusions: The risk of a permanent stoma is significant in this series. Several risk factors have been found to be associated with a definitive colostomy and should be considered in preoperative decision-making and patient s counselling. 38

39 38 / years of Endorectal mucosal advancement flap for complex peri-anal fistula Michele Podetta, Cosimo Riccardo Scarpa, Guillaume Zufferey, Frederic Ris, Karel Skala, Nicolas Buchs, Bruno Roche, CH Objective: Surgical management of complex anal fistula is always a challenge and can have a high recurrence rate. Endorectal mucosal advancement flap (EMAF) is a procedure with satisfactory results but often considered technically demanding. The aim of this study was to assess the long term results of this technique in our institution. Method: Retrospective single center study from 2005 to All consecutive patients with complex peri-anal fistula of cryptoglandular origin, who had an EMAF procedure were included. Results: We identified 127 patients, 80 (64%) men and 47 (36%) women, with a median age of 47 years (range 24-93), median follow-up was up to 7 years (range months). There was no mortality and no fecal diversion necessary. Primary healing occurred in 93 patients (73%) within 3 months from the intervention, in 7 patients (5.5%), a minor surgical procedure was required for complete recovery, leading to a primary healing rate of 78.8%. 21 patients did not heal or recurred during the 1st year post op (16.5%) and 6 patients (4.7%) had a fistula disease min 1 year post 1st EMAF. They underwent further treatment (3 fistulectomy and 24 re-emaf) with a healing rate of 77.7%. 4 patients needed more than 2 EMAF. Conclusions: EMAF is a safe repetable treatment for complex anal fistulas, it allows an healing rate of 78% with results stable over time. 39

40 39 / 1114 Robotic total mesorectal excision: Short-term outcomes from 42 cases at a single institution Daniel Langer, Inna Tučkova, Jaroslav Kalvach, Miroslav Ryska, CZ Introduction: Since the beginning of the Millennium we have been witnessing the robotisation of minimally invasive procedures in many surgical fields. Robotic assistance in the treatment of rectal cancer has also been published in the past years. Methods: Retrospective analysis of 42 patients with rectal cancer, where we performed robotic-assisted low anterior resection or abdominoperineal resection of the rectum from January 2014 until June We have monitored epidemiological data, staging of the disease, completed neoadjuvant treatments, surgical conversion rate, blood loss, intraoperative and early post-operative complications. We have also observed the completeness of the resection, quality of TME (the protocol of Quirke) and any recurrences in the follow-up care. Results: 42 patients underwent robotic-assisted surgery for rectal cancer in our institution: 29 men and 13 women with the average age of 62.5 years (33 to 80 years). Neoadjuvant oncological treatment was indicated in 47 % patients with carcinoma in the 2nd to 4th cancer stage (AJCC). The average blood loss was 155 ml (0 to 600 ml). We have witnessed complications in 9 patients (5x anastomotic leak, 2x bleeding, 2x adhesion ileus). None of the patients has passed away. The average duration of the operation was 250 min. We have identified complete or partially complete TME in 24 (78.6 %) patients, CRM positive in none of the patients. Conclusion: Da Vinci system is a safe manipulator in surgical treatment of patients with rectal carcinoma. What is missing at present is an assessment of the long-term benefits of robotic operations for patients in the field of abdominal surgery with a high degree of evidence-based medicine. The implementation of a sufficient number of randomised control trials going forward is necessary. Our preliminary results are similar to the results of the papers published thus far. Supported by M

41 40 / 1115 Perineal hernia repair with biological mesh Torben Pedersen, Jeppe Kildsig, Peter Gocht-Jensen, DK Perineal hernia repair with biological mesh. Torben Pedersen, MD, Jeppe Kildsig, MD and Peter Gocht-Jensen, MD. Copenhagen University Hospital Herlev. Objectives: Perineal hernia is a rare and probably underdiagnosed complication after extirpation of the rectum, with an estimated incidence of <1%. We present three cases of perineal herniotomy and repair with a biological mesh. Methods: Perineal herniotomies performed from at Copenhagen University Hospital Herlev were identified and medical charts were retrospectively reviewed. Results: Three cases were identified. (1)A 65-year-old female presented with symptoms of perineal hernia 17 months after receiving a laparoscopic abdominoperineal resection (APE) with closure of the pelvic floor with vicryl 2-0 sutures. A CT-scan confirmed the diagnosis. 20 month PO there has been no recidive. (2) A 76-year-old female presented with a perineal bulge 6 years after a rectum extirpation. Clinical exam showed a perianal hernia. 20 months PO there has been no recidive. (3)A 73-year-old man presented with symptoms of a perineal hernia 3 months after receiving a laparoscopic APE, with closure of the pelvic with vicryl 2-0 sutures. Ultrasound of the perineum showed a perineal hernia. 26 month PO there is no sign of recidive. All herniotomies were performed with perineal approach with the patient in knee-elbow rent. The hernia-sac was exposed, opened, resected and sutured. The perineal defect was closed with a 10x10 cm Permacol mesh and sutured to the remains of the levatores with a prolene suture. Two drains were placed, one cranial to the levatores and one superficial to the mesh. Subcutis was closed with a nylon suture and skin was closed with a nylon suture. Metronidazole and Piperacillin/Tazobactam was administered perioperatively for prophylaxis. Conclusion: Perineal herniation after rectum extirpation is a rare condition. We found that perineal hernia repair with a biological mesh is a simple, safe and effective treatment. 41

42 41 / 1116 Analysis of the association between patient and tumour related factors and Stage III colon cancer: Results from a prospective national cohort study Jakob Lykke, DK OBJECTIVE: The study aimed to examine the association between patient- and tumour related factors and stage III disease in radical resected non-metastatic colon cancer. METHODES: All patients in Denmark who were diagnosed with UICC (Union for International Cancer Control) stage I to III adenocarcinoma of the colon and so treated in the period from 2003 to 2011 were included in the analysis. The primary outcome measure was UICC stage III disease. RESULTS: In a multivariate analysis age, LNY, pt-stage, tumour sub-site and priority of surgery were independently associated with the risk of stage III disease. Each level of age, LNY and pt stage was compared to the preceding level. Odds ratios (OR) were as follow: Age: <65/ years: (Confidence Interval (CI): ), 65-75/ >75 years: (CI: ). LNY 0-5/ 6-11: ( ), LNY 6-11/ 12-17: ( ), LNY 12-17/ >=18: ( ). pt1/ pt2: (CI: ), pt2/p T3: (CI: ), pt3/ pt4: (CI: ). Only tumours of the transverse colon were independently associated with a lower risk of stage III disease compared to tumours at the sigmoid colon: Sigmoid colon: 1, Transvers colon: (CI: ). Elective surgery: 1, Acute surgery: (CI: ). CONCLUSIONS: Our study has demonstrated that the risk for stage III disease in colon cancer is independently associated with lower age, high pt-stage, tumour sub-site and priority of surgery. Further research should consider whether age, pt-stage, tumour sub-site and priority of surgery should be taken into account when diagnosis and treatment are planned for colon cancer. 42

43 42 / 1117 Perineal reconstruction using biological mesh after extralevator abdominoperineal excision and pelvic exenteration Boris Schlitz, Nicolas Christian Buchs, Cosimo Riccardo Scarpa, Emilie Liot, Philippe Morel, Frederic Ris, CH Objectives: We aimed to evaluate the outcomes after perineal reconstruction with biological mesh during extralevator abdominoperineal excision (ELAPE) and pelvic exenteration (PE). Methods: From January 2012 to December 2015, a retrospective study of consecutive patients who underwent ELAPE or PE with perineal mesh (StratticeTM) was conducted. Patients requiring a flap were excluded from the analysis. Results: Eleven patients (5 male: 45%) underwent ELAPE (n=5) or PE (n=6) with biological mesh reconstruction of the perineum. Mean age was 63 years (SD 10.1). Mean ASA (American Society of Aneshesiologists) score was 2.4 (range: 2-4) and mean BMI (Body Mass Index) was 24.7 kg/ m2 (SD 5.5). Overall, six patients were active or ex-smokers, and two had diabetes. All the patients had preoperative pelvic chemoradiotherapy. Mean operative time was 401 min (SD 139.8). All but one had perineal drainage. Overall, six patients had a postoperative complication (morbidity rate: 54%). Severe complications (grade >2 according to Dindo- Clavien classification) were observed in 2 patients. Both required surgical debridement for a perineal wound infection. In addition, another patient had a superficial perineal wound dehiscence, which was treated conservatively. In total, three patients had a perineal wound complication. No mesh was removed. Median hospital stay was 17 (Range 12-48) days. After a mean follow-up of 18 (SD 10.3) months, no perineal hernia was radiologically or clinically found. Conclusion: Perineal reconstruction using a biological mesh is feasible and safe. Our results showed an acceptable risk of wound complications, with the potential to avoid perineal hernia. 43

44 43 / 1118 Definition of colorectal anastomotic leakage: level of consensus among Dutch and Chinese colorectal surgeons. Stefanus van Rooijen, Audrey Jongen, Zhouqiao Wu, Jiafu Ji, Gerrit Slooter, Rudi Roumen, Nicole Bouvy, NL Introduction Colorectal anastomotic leakage (CAL) is the most feared complication after colorectal surgery. Despite increased awareness of the complication, no consensus exists for a general definition for CAL. The large variety in applied definitions may partly explain differences in reported CAL incidence between Asian and Western studies (1.5-23%) and complicates the interpretation reported outcomes. The purpose of this study was to determine the level of consensus on the definition of CAL among Dutch and Chinese colorectal surgeons. Methods Dutch and Chinese colorectal surgeons were asked to partake in an online questionnaire. Consensus was defined as >80% agreement between respondents on various statements. Results Fifty-nine Dutch and 202 Chinese dedicated colorectal surgeons participated in the online survey. Consensus was found on only one of the general definitions of CAL in both countries: extravasation of contrast after rectal enema at the CT-scan. Another two were found relevant according to Dutch surgeons: necrosis of the anastomosis found during reoperation, and a radiological collection with percutaneous drainage. No consensus was found for all other items on the available general definitions, clinical and radiological diagnosis of CAL. Conclusions There is no universally accepted definition of colorectal anastomotic leakage in the Netherlands and China. Large differences exist between the two countries regarding views on the general definition, which may lead to a higher number of reported subclinical CAL in the Netherlands. However, many similarities were found between surgeons from both countries, as they both consider clinical signs as poor predictors of CAL and rely heavily on radiological examinations. 44

45 44 / 1120 Ultrasound Guided Sacral Neuromodulation- A comparison with Landmarks and Measurement Methods Fayyaz Akbar, Sacha Koch, UK Objectives To compare the accuracy of ultrasound guidance for localisation of third sacral foramen (S3) with the other published landmarks and measurements methods in conjunction with fluoroscopy during sacral neuromodulation (SNS). Methods A prospective study was conducted from October 2015 to June Symptomatic patients with faecal incontinence who underwent appropriate investigations were initially treated with conservatively.these patients were then offered the sacral neuromodulation if symptoms still persisted. The procedure was performed under local anaesthesia with selective use of mild sedation in anxious patients. A preliminary ultrasound examination was performed using a linear 10 MHz probe. The location of S3 was found with ultrasound. The skin was marked. The Landmarks and Measurement methods were used and skin markings were drawn. Following infiltration of local anaesthesia and skin preparation with antiseptic solution, a needle was placed in S3 foramen under ultrasound guidance and position was confirmed with fluoroscopy. Then stimulation was started eliciting the appropriate sensory response from the patient. The measurements were taken and difference among skin markings for the location of S3 foramen was observed among the mentioned techniques. Data were collected and analysed with Excel & SPSS. Results There were 21 women (age range mean 60.4 years) who underwent needle insertion in S3. A successful needle insertion was achieved in all cases. The accuracy of ultrasound, measurements and landmarks methods was 52%, 42.8% and 57% respectively. However these differences were not significant statistically ( p= 0.44, p=0.715, Paired sample T test). There was no correlation of BMI (p=0.260, Pearson Rho test) or height (p= 0.113, Pearson's Rho test) on the accuracy of ultrasound guided technique Conclusion Ultrasound guided localisation of S3 is a safe technique for SNS with a comparable accuracy to landmarks and measurements methods. 45

46 45 / 1121 Changing Bowel habits and Self-care Practice in Patients Undergoing Sphincter-Saving surgery for Rectal Cancer Jeong Hyeonju, KR Purpose This study was conducted as survey research for identifying changes in the bowel habits and self-care practice of rectal cancer patients undergoing sphincter-saving surgery(sss). Methods The subjects of this study were rectal cancer patients who had passed over 2 years since SSS, the patients general and clinical characteristics and changes in their bowel habits were determined by using the tool developed by Temple et al(2005). Results The subjects mean number of bowel movements was 6.97±5.03 times, and observed changes in bowel habits in the subjects were frequent bowel movement in 74 patients (69.2%), fecal incontinence in 48 (44.9. Among the subjects, 32 (31.8%) were taking drug for changed bowel habits, and 11 of them (10.3%) were taking drug every day. One subject (0.8%) reported having further treatment at the hospital. The subjects answered that they were doing self-care practice for changed bowel habits in various ways. That is, most of them (78.5%) were controlling diet, and 37 (34.6%) were doing pelvic floor muscle exercise regularly. But bowel habits doesn`t diffent between 2 groups. Conclusion Bowel habits is very important to QOL. So, it is necessary to give sufficient information about possible postoperative changes in bowel habits to patients who have the risk factors of bowel incontinence before surgery. In addition, we need to develop education programs for rectal cancer patients to do self-care practice effectively after SSS so that they adapt themselves to postoperative changes and manage properly. 46

47 46 / 1122 Chemoradiotherapy followed by laparoscopic surgery in locally advanced rectal cancer Vsevolod Galkin, Dmitrii Erygin, Nevolskikh Alexey, Berdov Boris, Titova Ludmila, Ruhadze Georgy, Pochuev Taras, RU BACKGROUND. Laparoscopic surgery for rectal cancer is increasingly being performed worldwide. However the role of this surgical approach after chemoradiotherapy in locally advanced rectal cancer (LARC) is not well defined yet. OBJECTIVES. To present our experience with laparoscopic surgery of LARC after preoperative chemoradiotherapy (PCRT). METHODS. Forty-seven consecutive patients with locally advanced rectal adenocarcinoma (T3-4 or N+, median distance of 5 cm from the anal verge) were treated with CRT (50 Gy in 25 fractions; capecitabin 1650 mg/m2 on days 1-14 and 22-35, and oxaliplatin 50 mg/m2 on days 1, 8, 22, and 29) followed by laparoscopic total mesorectal excision (LTME) between 2013 and Adjuvant 5-FU based chemotherapy was planned for pathological stage UICC II. RESULTS. The median operative time was 250 ( ) minutes. Conversion to an open surgical procedure was required in 27% of the cases. The median length of hospital stay after the operation was 11 (4-44) days. Sphincter sparing surgical procedures were done in 34 patients (72%). There was no postoperative mortality. Postoperative complications (II-III Clavien-Dindo) were observed in 13% of the patients. Anastomotic leakage occurred in 12% patients. Postoperative histology revealed UICC stage 0 in 15%, stage I in 21%, stage II in 23%, stage III in 32%, and stage IV in 9% of the patients. After median follow-up of 15 (1-44) months, no local recurrences were observed. Overall and disease-free cumulative 2-year survivals (excluding stage IV) were 93% and 73%, respectively. CONCLUSIONS. The combination of PCRT with LTME appears to be feasible, safe and effective method of LARC treatment. Laparoscopic surgery may become a preferred approach since it is a minimally invasive procedure and has an acceptable postoperative outcome. 47

48 47 / 1123 Socioeconomic status: Is it a prognostic factor of overall survival in colorectal cancers: A Retrospective analysis from a tertiary care cancer center in India Jay Anam, Vijayraj Patil, Avanish Saklani, Ashish Pokharkar, IN Introduction Socioeconomic status is a marker of standard of living which indirectly reflects on dietary behavioural habits, physical activity & education of population. These factors influence the patient perception of disease,selection of treatment option, adherence to treatment protocol and also on oncological outcomes. In a diverse country like India, divide between rich and poor is quite wide compared to other developed countries. In this study we assess the influence of socioeconomic status on epidemiology and oncological outcomes of colorectal cancer in Indian scenario. Materials and Method Retrospective study of all newly diagnosed patients of colorectal adenocarcinoma registered over 1 year were included. All cases were discussed in multidisciplinary tumor board meetings and treated as per standard prevailing guidelines. Patients registered into Private category and General category As per their affording capabilities. Patients in general category get subsidy for all their investigations, interventions and medications. On admission, they are eligible only for the general ward. Results 776 colorectal patients were treated over 12 months. Median follow up period was months. There was a significant difference in stage at presentation, with 33.2% general category patients presenting in stage IV vs 25.2% private patients. Also in the operated patients the T and N stage was significantly higher in general patients. Among those treated with curative intent, recurrence rate was 19.5 % in private vs 14% in general category, however total number of deaths was 32% in general vs 25.3% in private category patients. Thus mean overall survival for general category patients was 30 months vs 32 months for private category, which is significant. Conclusion Socioeconomic condition does play a role, not only in etiology but also the stage at presentation as well as overall survival in colorectal patients. 48

49 48 / 1125 Rescue surgery for anal canal epidermoid carcinomas Isabel Armas, Rita Marques Ferreira, Silvia Borges, Luis Pedro Afonso, Carlos Gonçalves Dias, Joaquim Abreu de Sousa, PT Background: Anal canal tumours are rare and the vast majority (85%) are epidermoid carcinomas. The standard treatmentconsists in primary chemo and radiotherapy(cht/rt), placing syrgery in the category of rescue treatment whenever Cht/Rt is not indicated or in cases of disease persistence or recurrence. The purpose os this study was to analize our department numbers and find prognostic factors in this group of patients. Methods: Retrospective analysis of all patients with histologic diagnosis os anal cabal epidermoid carcinoma between January 2005 and June 2015 at our department. Results: Included 18 patients with median age of 65 years old and female sex dominance (94%). 14 of these patients underwent Cht/Rt followed by surgery (8 by persistence, 5 by recurrence, 1 by anal incontinence due to Rt). One patient didn t complete the scheme due to intolerance. Three patients had no conditions to Cht/Rt. The surgical procedures were 16 abdominoperineal resections and 2 associated with inguinal lymphadenectomy. Regarding TNM staging: 11% stage I, 61% stage II, 17% stage IIIa and 11% stage IIIb. Average follow-up time was 39 months with mortality rate of 56% (6 patients in stage II, 4 patients in stage III, 4 R1 resections and 60% T3). Conclusions: This numbers reveal the rarity of surgical indication in these patients demonstrating that besides the aggressive rescue surgery the prognosis is still reserved. 49

50 49 / 1127 Robotic anterior resection: Can it be superior to the laparoscopic approach? Short term quality of life outcomes. A single centre study. Dariush Kamali, Kareem Omar, Zehra Imam, Anil Reddy, Madan Jha, UK Introduction Urinary and sexual dysfunction is not uncommon after rectal cancer surgery. Laparoscopic surgery is accepted amongst many to be the operative approach of choice for the surgical treatment of rectal cancer. The da VinciTM robot has potential to overcome limitations of laparoscopic surgery, providing, a three-dimensional view with instruments that permit movements of 360º. This may translate into greater vision and precision with a lower incidence of iatrogenic injury to autonomic pelvic nerves. Our aim was to study the quality of life (QoL) of patients undergoing anterior resection by robotic (r-ar) or laparoscopic (l-ar) approach. Methods All operations were performed by two surgeons; both experienced in laparoscopic surgery and recently introduced robotic surgery. Consecutive series of patients treated using the da VinciTM robotic system (Intuitive Surgical ) and conventional laparoscopy during July 2014 to September 2016 were analysed. Oncological outcomes were determined by post operative histology. QoL was prospectively obtained using EORTC QLC-CR30 and QLC-CR29 questionnaires. Results 36 patients (18 r-elape vs.18 l-elape) were studied. Groups were similarly matched for age, gender and ASA status. Median follow-up was 23 months (3-26) laparoscopic vs. 9 months (2-18) robotic. There was no significant difference regarding the length of specimen, lymph node harvest or R0 resection between groups. There was no significant difference in global health scores in either group [r-ar (81.9) vs. (74.4) l-ar]. Impotence scores were significantly lower in r-ar (7.4) vs. l-ar (33.3) p=<0.05. Conclusion To our knowledge, this is the first study that compares QoL of patients after anterior resection between robotic and laparoscopic approach. Low impotence scores in our study may be attributed by better visualisation and improved dissection. This observed benefit warrants a larger study. 50

51 50 / 1129 Systematic levels of the inflammatory cytokines predict the infectious complications but not prolonged postoperative ileus after colorectal surgery Zhouqiao Wu, G.S.A Boersema, A.G. Menon, G.J. Kleinrensink, J. Jeekel, J.F. Lange, NL Aim: Postoperative ileus (POI), a transit cessation of bowel motility, is common after surgery. Previous knowledge from animal studies does indicate that the POI mechanism involves an inflammatory response, which is also activated during postoperative infectious complications. This study aimed to determine whether the selected inflammatory biomarkers might facilitate an early detection of prolonged POI (PPOI) or infectious complications. Method: Forty-seven adult patients who underwent oncological colorectal surgery were included. They filled out a perioperative diary to report their gastrointestinal symptoms. Blood samples were collected preoperatively, and on day 1 and 3 after surgery. Levels of leucocytes, CRP, interleukin (IL)-6, TNF-α, and IL-1β were analyzed. Results: Patients with PPOI had significantly longer stay in hospital than patients without (13.6±10.5 days versus 7.4±3.2 days, p<0.001); they also had higher levels of IL-6 ratios, leucocyte count, and CRP-levels after surgery, but not significant. Similar data were also found in the patients with infectious complications (incidence 48% in total, i.e. surgical site infection 26%, pneumonia 11%, anastomotic leakage 9%, urinary infection 9%), with higher levels of IL-6 ratios and CRP-levels after surgery (p<0.05 respectively). The ROC analysis found better diagnostic values of IL-6 ratio on both day 1 and 3 after surgery than that of CRP (POD 1; ROC 0.825, p<0.001). Conclusion: Perioperative changes of the inflammatory cytokines cannot predict PPOI after colorectal surgery. Instead, systematic changes of IL-6 level on postoperative day 1 and 3 may predict the infectious complications with a better diagnostic value compared with leukocyte count and CRP changes. 51

52 51 / 1130 Chemoradiation after upfront rectal resection : a cinical dilemma! Rahul Bhamre, Manish Bhandare, Rajesh Shinde, Avanish Saklani, IN Objectives: Trials like the GITSG, NCCTG, and NSABP R01 established the role of adjuvant chemoradiotherapy for upfront resected stage II, III rectal cancer, although they were conducted mostly in the pre TME era and with inferior chemotherapy. Combined modality therapy in the adjuvant setting is associated with increased morbidity. Our aim is to analyze the oncological outcomes of stage II/III rectal cancers following upfront surgical resection. Methods: Retrospective analysis of a prospectively maintained database of adenocarcinoma rectum patients, from July 2010 to March 2015 was performed at a tertiary referral cancer center in India. Non metastatic rectal cancer patients who underwent upfront surgery were included. Based on final histology a joint clinic decision of adjuvant treatment was planned. Results: 130 patients underwent upfront surgery. 84 patients were eligible for adjuvant treatment ( pt3/t4, N0/N+) and were included for analysis. Adjuvant chemoradiotherapy was administered to 29 patients and the rest (n= 53) received adjuvant chemotherapy (FOLFOX/CAPOX). At a median followup of 20 months there were 10 recurrences (3 locoregional) in the adjuvant CT/RT group and 15 (2 locoregional) in adjuvant chemotherapy group. The estimated DFS at 3 yrs in the adjuvant CT/RT group was 68.7% and in adjuvant chemotherapy group was 49.7% (p = 0.417). Conclusion: There seems to be a trans Atlantic difference in practice guidelines regarding type of adjuvant therapy for upfront resected rectal cancer. Our study does not show any benefit of adjuvant chemoradiotherapy over chemotherapy alone on local control as well as overall and disease free survival after upfront rectal cancer resection. Adjuvant chemoradiation should be avoided in low risk, stage II/III rectal cancer after upfront resection. Further carefully planned studies needs to be performed to establish the ideal therapy in the adjuvant setting for high risk, stage II/III rectal cancer after upfront resection. 52

53 52 / 1131 Association of TOB1 gene expression with colorectal cancer stage and anatomical tumor location Bujar Osmani, Ljubomir Ognjenovic, Darko Djambaz, Kiril Pakovski, Nikola Vukovic, Zoran Karadzov, Sasho Panov, MK Objective: Transducer of ERBB2.1 (TOB1) is a tumor-suppressor gene encoding a protein which functions as a negative regulator of the receptor tyrosine-kinase ERBB2 with antiproliferative, proapoptotic and anti-invasive effects on the cancer cells. Inactivation of TOB1 or reduced gene expression was identified in many human neoplasms including breast, lung, pancreas, gastric and other cancer types. We aimed to investigate the associations between stage and distinct tumor location with TOB1 gene expression levels in colorectal cancer patients. Methods: A group of 42 patients with colorectal cancer was recruited in the study. Tumor samples were taken immediately after surgical resection and were frozen until analysis. A normal mucosa sample at a distance>10 cm of the tumor was collected from each patient. Total RNA was isolated using Tri-reagent and cdna was synthetized by reverse transcription. Amplification and relative quantitative Real-Time Polymerase Chain Reaction (qrt-pcr) was performed using TaqMan probes. TOB1 expression was calculated relative to the reference G3PDH geneand normalized to the normal mucosa sample using ΔΔCt method. Two-tailed Mann-Whitney U-test was used for statistical analysis. Results: The mean TOB1 gene expression levels were 3.2 times higher in patients with stage IIa than in the IIIb and higher stages (p=0,038) and was 4.9 times lower in proximal than in the distal colon and rectum (p=0,026). Conclusion: Our results suggest that TOB1 gene expression is associated with lower stages and with proximal colon cancer location. Opposing to some previous studies, our results further support the anti-proliferative role of this gene in colorectal cancer pathogenesis. Additional research is needed to establish a possible use of this molecular marker in a diagnostic and/or prognostic purposes. 53

54 53 / 1132 mixed type adenoendocrine tumor of colorectum (MANEC): clinical presentation and surgical awareness Johnson Chou Chen Chen, Joe Bin Chen, TW The mixed adenocarcinomawih neuroendocrine carcinoma is rare disease entity. Most of coloerctal surgeons could miss the submucosal lesion with relative early stage of adenocarcinoma and existing larger neuroenocrine carcinoma. We would like to present two cases of mixed adeconeuroendocrine carcinoma with different symptom and organ presentation. Surgical approach is necessary to get complete pathology and pathology confirmation, also provide subsequent chemotherapy regiment. Aslo, colorectal surgeons relief bowel obstruction signs, to make nutritional life support. The first case is female patient recievd laparosopic cholecystectomy due to GB stone, the following intestinal obstruction happened on her. CT scan showed hepatic flexure colon tumor with bowel obstruction. right hemicolectomy with anastomosis was performed. The patient discharge with stable condition at POD 8th. The second male patient works in China,with chest pain, CXR showed multiple lung nodules, and further CT scan showed S colon ca,wih lung and liver metastasis. Open anterior resection was done and tissue prove as MANEC. The MANEC is not real rare disease, and surgical resection provide pathologist for disease confrimation, also provide hematologist to choice right chemotherapy regiment. 54

55 54 / 1133 Risk impact of left colon cancer after first episode of left colon diverticulitis: population study on clinical database David Aparício, Carlos Leichsenring, Ricardo Rocha, Ana Alagoa João, António Soares, Joana Seabra, António Gomes, MArta Fragoso, Rui Marinho, Carla Carneiro, Vasco Geraldes, Vitor Nunes, PT Objectives We aimed to determine the cumulative risk of left colon cancer (LCC) in patients with left colon diverticulitis (LCD) who weren t submitted to a left colon resection for any reason. Methods We performed a retrospective analysis, on clinical database, between 2000 and Inclusion criteria: first episode of hospital admission for a LCD; subsequent colonoscopy in the 6 months of follow up, without evidence of colorectal cancer; not submitted to previous left colon resection; not submitted to colon resection during follow up for other reasons than colorectal cancer. Patients with pathological diagnosis of LCC after hospital admission for LCD were included. Results 839 patients were admitted to the hospital for diverticular disease. 445 were selected based on inclusion criteria: 52% female; average age 61 (range ). Of this patients, 6 (2%) were diagnosed with LCC after a first colonoscopy (in the first 6 months) without evidence of colorectal cancer. Average age: 61 (range 28-86). LCC diagnosis was made on average 82 months of follow up (range ). The cumulative risk of LCC after a first episode of LCD, comparing with a Portuguese reference population (49.74/ ) is 28.1 times higher. Conclusion Although the occurrence of LCC after a first episode of LCD is low, the risk is increased compared with the general population. Colonoscopy screening for LCC should be maintained after a LCD episode. The adequate periodicity of colonoscopy evaluation and the length of follow up is yet to be defined. 55

56 55 / 1134 Enhanced recovery : Does time wane adherence to protocols? Nikhil Vijay Kulkarni, Arjun Gowda, Sudeep Thomas, Aarti Varma, Dilip Mathur, UK Enhanced recovery protocols (ERPs) significantly improve outcomes after major colorectal surgery. NICE recommends the implementation of ERPs for patients after major coloretal surgery. ERPs are rigorously adhered to after colorectal surgery in our district general hospital. There is an active ERP co-ordination multi-disciplinary team comprising of surgeons, colorectal nurse specialists and anaesthetists ensuring that there is adherence to protocol. Data is prospectively collected and results are presented regularly in audit meetings. OBJECTIVES Analyse prospectively collected data from 2 periods : January 2013 to August 2014 & January 2015 to August Compare adherence to ERPs and outcomes over these 2 time periods METHOD Prospectively collected data from January 2013 to August 2014 was compared with data from January 2015 to August RESULTS Number of cases Laparoscopic intent in resections Day of surgery admissions Oral bowel preparation Pre-operative carbohydrate loading drinks Fasting before surgery (median) Goal directed fluid replacement (use of waveform analysis machine) Patients started eating on post op day (median) Patients independently mobile on post op day (median) Length of stay (median) January 2013 to August % 100% 91% 93% 3 hours 59% days January 2015 to August % 100% 92% 97% 3 hours 55% days Our results show that adherence to ERPs was maintained during both the periods. The laparoscopic intent in major colorectal resections improved from 66 to 76%. The median length of stay reduced from 8 to 7 days. However, use of waveform analysis machines for peri-operative fluid management fell from 59% to 55%. These results will be disseminated through the enhanced recovery meetings which will help improve and maintain our performance. CONCLUSION Enhanced recovery protocols can be adhered to by district hospitals through involvement of a dedicated and enthusiastic multi-disciplinary team. 56

57 56 / 1136 Early laparoscopic surgical treatment of acute complicated diverticulitis: a single surgical equipe experience. Federica Maffeis, Paolo Ubiali, IT Objects Published studies are still controversial concerning the ideal type and timing of the surgical intervention in acute complicated diverticulitis. The aim of this review is analyzed the experience of a single surgical equipe performing early laparoscopic colonic resection for acute complicated diverticulitis. Methods From March 2008 to April 2015 a total of 280 patients were hospitalizated for acute complicated diverticulitis in the Department of General Surgery of Humanitas Gavazzeni (Bergamo, Italy): 227 underwent laparoscopic left colonic resection after initial antibiotic treatment and within 8-10 days after admission. Main outcomes were operative time, conversion rate, complications and length of hospital stay. Results Mean age for 106 females and 124 males enrolled was 60 years (range years); mean body mass index (BMI) value was 31,2 kg/m2 (range kg/m2). Mean operative time was 170 min ( range min), only one patient had conversion to laparotomy and no ostomy was performed. In three patients (1,3%) an anastomotic leakage was observed, requiring a loop ostomy. Nobody ended up with a permanent stoma. Six patients (2,6%) sustained an uncomplicated wound seroma requiring conservative treatment. The median total/global hospital stay was 13 days (range days) and postoperative 7 days (range 5-18 days). Conclusion Our experience demostrates the feasibility of an early laparoscopic colonic resection without ostomy for acute complicated diverticulitis with low morbidity rate and clear benefits for the patients. 57

58 57 / 1138 Laparoscopic management of Ileo-colic Crohn s disease a single centre experience Fillippos Sagias, Syed Naqvi, Samuel Stefan, Nasir Ahmad, Jim S Khan, UK Background Performing laparoscopic surgery in patients with IBD is technically demanding due to the inflammatory nature of the disease and dealing with masses, fistulae and abscesses. We aimed to review the feasibility and safety of laparoscopic surgery in a large cohort of patients with Crohns disease. Methods Between October 2006 and July 2014, all patients who had laparoscopic surgery for Crohns disease were entered into a prospective database. The data included age, sex, number of ports, type of operation, conversion rate, blood loss, operating time and complications, length of stay, and post-operative complications. The surgery was performed by a consultant laparoscopic surgeon or by senior colorectal trainees under direct supervision. All these patients had long term follow up for assessment of the disease activity and recurrence. Results One hundred and seventeen laparoscopic resections for patients with Crohns disease were performed over a period of 8 years. There were 117 patients (51 males and 66 females) with a median age of 39 years (range years). Fifty one right hemicolectomies, 25 subtotal colectomies, 19 proctectomies, 13 redo ileocolic resections, 5 ileocolic resections, 2 extended right hemicolectomies and 2 small bowel resections were performed. The average operating time was minutes (range ). There were 2 conversions to laparotomies. Median incision length was 5cm and median length of stay was 5 days (range 2-76). Major morbidity was seen in 6.9% of patients. 64 patients (54.7%) were on steroids at the time of surgery and 62 (52.9%) patients had previous abdominal surgery. 17 patients (14.5%) had two or more operations previously. Conclusion Laparoscopic resections are safe and feasible in more than 90% of patients with primary or recurrent Crohn s disease when performed by an experienced laparoscopic colorectal surgeon. 58

59 58 / 1140 Robotic versus laparoscopic rectal cancer surgery: A single centre experience from a tertiary cancer referral centre in india Rajesh S Shinde, Avanish Saklani, Rahul Bhamre, Devayani Niyogi, IN Aim: To analyze and compare outcomes of Laparoscopic vs. Robotic Rectal surgeries. Objective: Minimal access surgery has shown equivalent oncological outcomes & better outcomes for rectal cancer surgery. We have evidence in support of Laparoscopic surgeries. But literature comparing laparoscopic & robotic rectal cancer surgery is scarce. So we intended to analyze the same at a tertiary cancer referral centre from India. Materials & Methods: This is a prospective analysis of is a retrospectively maintained database. 149 consecutive patients (93 Laparoscopic and 56 Robotic) undergoing curative intent surgery for rectal cancer in colorectal services at TMH from October 2013 to September 2015 were assessed. We used Standard Laparoscopic methods, and da Vinci Xi system with single docking and single-phase technique for total robotic rectal surgery. Results: Analysis of comparison of demographic factors, tumour stage and surgical outcomes was done. Median age was 51 years & male to female ratio was 2:1. 35 of the patients had T1/T2 tumours & 104 had T3/T4 tumours. 109 received NACTRT, 31 had upfront surgeries and 9 received either SCRT/ SCRT+ chemo/nact. Sphincter preservation rate was 66.07% versus 62.3% in robotic / laparoscopic arms respectively. Conversion rate was 1.7 versus 6.45% in robotic / laparoscopic arms. Median operative time was 270 versus 312 min in robotic/laparoscopic arms. Anastomotic leak rate was 0 versus 5.3% in robotic / laparoscopic arms. There was no difference in blood loss/ hospital stay in both arms. There was no significant difference in lymph node harvest, CRM positive rates in both arms. Conclusion: Robotic and laparoscopic approaches have equivalent peri-operative and short term oncological outcomes. Single docking single-phase robotic technique can be performed safely for locally advanced, low rectal tumours. 59

60 59 / 1141 Diverting Ileostomy versus Diverting Colostomy for the Sphincter Preserving Surgery of the Rectal Tumor Toshinori Kobayashi, Fusao Sumiyama, Ryo Inada, Masaharu Oishi, Kaori Shigemitsu, Madoka Hamada, JP IAbstract Purpose: As diverting colostomy (DC) can be associated with the high risks of stoma construction, diverting ileostomy (DI) is considered better for the sphincter preserving surgery. However, mobilization technique of the transverse colon by opening bursa omentalis, and adding the separation of transverse mesocolon from mesogastrium enable us safe construction of DC. We compared the outcomes of DC to DI for the sphincter preserving surgery for the rectal tumor. Methods: From October 2013 to March 2016, 147 cases of rectal tumor underwent sphincter-preserving surgery. One hundred thirty nine cases (94.6%) of them underwent laparoscopic surgery. Diverting stoma was constructed in 53 cases among them. We compared the outcomes of DC (n=15) to DI (n=38) in terms of comorbidities of the stoma. There were no difference with respect to age, gender, tumor stage, tumor location, duration of operation, blood loss and postoperative hospital stay between the groups. In 10 cases of DC and 33 cases of DI, stoma closure was completed. Results: There was no stoma related death. Stoma related complication, after stoma construction, was significantly higher in the DI group in terms of skin irritation and dehydration. Discolouration Erosion Tissue overgrowth (DET) score was significantly higher in the DI group (DI: median 5.0 range 0-11, DC median 2.0 range 0-5) p=0.0008). Two cases of DC group and 6 cases of DI group experienced wound disruption. No case experienced septic complication. After stoma closure, one case of DI and two cases of DC experienced wound infection but difference was not significant. Obstructive complication was observed 11 cases of DI and one case of DC, but difference was not significant. Conclusion: Appropriate construction of DC with laparoscopic surgery will decrease stoma related complications for the sphincter preserving surgery. 60

61 60 / 1142 Relation between peri-stoma mucocutaneous separation and the type of sutures applied Charef Raslan, Catherine Bowes, Kim Gorissen, UK Introduction: Mucocutaneous (MC) separation is one of the most common and challenging complications after stoma formation. It is unclear whether using certain types of sutures to mature stomas play a role in reducing the risk of MC separation. Aim The aim of our study was to determine if type of suture (monofilament vs multifilament) was related to short term complications of stoma formation. Methods We performed a prospective observational study (May 16- July 16), all patients who underwent stoma formation at our surgical emergency unit were included. Patients were divided into 2 groups: group A was identified as patients who had their stoma matured with monofilament sutures, group B with multifilament braided sutures. MC separation was defined as a more than 5mm detachment of the peristomal skin from the stomal mucosa. Results In this 12 week period; 44 consecutive patients were included in the study. 23 patients were males. Median age was 67.5 (range 23-92). Median BMI was 23.2 (range ). (13pt, 29.5%) had their stoma formed for bowel perforation, (14pt, 31.8%) for malignancy, (13pt, 29.5%) for IBD and (4, 9.2%) for ischemic bowel. 5 patients died within 4 weeks (3 due to disease progression of metastatic cancer, 2 due to multi-organ failure). Monofilament sutures were used to mature the stoma in (19pt, 43.2%), where as multifilament sutures were used in (25pt, 56.8%). Early MC separation was identified in (12, 27.2%). (7pt, 15.9%) of those had ileostomy formation, where as (5pt, 11.3%) had a colostomy. MC separation was slightly higher in group A in comparison with group B (28% vs 26.3%: p=0.8197), but was not significant. Conclusion The result of this small cohort showed that the risk of MC separation appeared slightly higher in the group who had their stoma matured with rapid-absorbing multifilament sutures, but the difference was not statistically significant. Further research is needed to determine if type of suture is related to early complications. 61

62 61 / 1143 Optimal Distal Resection Margin and Oncological Outcomes for Sphincter Preserving Rectal Cancer Surgery : A Surgical Dilemma Devayani Niyogi, Rahul Bhamre, Rajesh Shinde, Avanish Saklani, IN Objectives : Recent advances in surgical techniques have increased the number of sphincter saving surgeries for rectal cancer. The definition of DRM (distal resection margin) is still a topic of debate. Primary aim is to assess the impact of DRM on local oncological failure. Secondary aim is to assess the correlation distance with Overall Survival (OS) and Disease free Survival (DFS) Methods : Retrospective analysis of a prospectively maintained data was done. All consecutive rectal cancer patients who underwent sphincter saving surgery for low and mid rectal cancers from 1st January 2012 to 1st January 2015 at a single tertiary cancer center were included. DRM was grouped into <5 mm, 6-10 mm and >10 mm. Results : 336 patients underwent sphincter saving surgery, out of which 249 were mid and low rectal tumours. 7 patients were CRM (circumferential resection margin) positive and were excluded from the study. 194 patients underwent AR (Anterior resection) and 55 patients underwent ISR (Intersphincteric resection). 2 patients had positive DRM and underwent completion APR. There were 59 recurrences, out of which 9 were locoregional. The 3 year DFS was 69.7 % with no significant difference in DRM subgroups. The 3 year OS was 85.7 % with no difference in DRM subgroups. Conclusion : Distance of DRM does not have a significant impact on recurrence rates and pattern as well as survival as long as a negative margin is achieved. A tumour free margin with a DRM of less than 1 cm does not compromise the outcomes in mid and low rectal cancers. There may be role of intra operative frozen section to confirm tumour free margin if DRM is less than 2 cms. 62

63 62 / 1144 Laser therapy for Chronic Radiation Proctopathy (CRP) Lucia Marini, Stefano Merigliano, Lino Polese, IT INTRODUCTION: Chronic Radiation Proctopathy (CRP) is a frequent complication in patients who underwent high-dosage radiotherapy for pelvic cancer. The symptoms, such as rectal bleeding, often occur months or even years after therapy. Hemostasis can be optained with several therapeutic options. AIM OF STUDY: To determine the effectiveness of endoscopic diode laser therapy in patients with CRP and rectal bleeding. MATERIAL AND METHOD: A retrospective search of patients with CRP treated with diode laser therapy at the Hospital of Padova from 2013 to RESULTS: We enrolled in the study 10 patients with CRP. Median age of patients was 75 years. All patients underwent high-dosage radiotherapy for prostatic cancer. All patients presented with rectal bleeding and 4 patients needed blood transfusions. 4 patients were taking antiaggregants and 2 anticoagulants. These were not suspended to perform endoscopic laser therapy. The median amount of sessions of laser therapy was 2 and the average overall quantity of Joule was Bleeding resolved in 8/10 (80%) patients and improved in all (100%). None of the patients required blood transfusions after laser therapy. There were no complications during the various procedures. CONCLUSIONS: In our small experience endoscopic diode laser therapy is a safe and effective treatment for patients with Chronic Radiation Proctopathy. It can be performed without suspension of antiaggregant and anticoagulant therapy. 63

64 63 / 1145 Pelvic Exenteration for Rectal Cancer Analysis of 127 cases of a single teaching institution from 2012 to 2016 Mariane Camargo, Anna Carolina Batista Dantas, Lucas Soares Gerbasi, Sergio Carlos Nahas, Ivan Cecconello, Ulysses Ribeiro Junior, BR ObjectivesTo describe the results of a single teaching institution experience with pelvic exenteration over a 4-year period,with a detailed examination of operative data and follow up.methods Retrospective analysis of prospectively collected data of 127 patients that underwent pelvic exenteration for rectal cancer between Jan/12 and Apr/16 at Cancer Institute of Clinics Hospital,Faculty of Medicine of University of Sao Paulo performed by colorectal surgeons.results127 patients 93 females and 34 males-underwent pelvic exenter ation for rectal cancer between Jan/12 and Apr/16.The median age was 61,18(±13,4)yr.Tumor localization was:54(42,52%) lower rectum,22(17,32%)medium retum,17(13,39%)upper rectum,21(16,54%)rectosigmoid transition and 13(10,24%) sigmoid.77 patients(60,63%)underwent neoadjuvant CRT and 33(25,78%)needed adjuvant chemotherapy.17(13,39%) were palliative surgeries and 93,7% were elective surgeries.type of rectal resection:abdominoperineal resections 50(39,37%),rectosigmoidectomy 73(57,48%)and total colectomy 4 (3,15%).37(29,13%)were posterior exenterations,77(60,63%)were supralevator exenterations and 13(10,24%)were total exenterations.the main number of resected organs was 2,18(range 1 to 5).The resected organs were:uterus 41,73%,ovaries37,8%,vaginal vault 25,98%, bladder 29,92%,ureter 10,24%, prostate13,39%, sacrum 4,72%.106(83,46%)patients had a R0 resection,16(12,60%)r1 resections,5(3,94%)were R2 resections.64(50,39%)patients had a T4b tumor and 43(33,86%)positive lymph nodes.the median follow-up was 19,43(±13.7)months.41(32,28%)patients had recurrence.90-day mortality was 6,29% and overall mortality during follow-up was 34(26,77%).Conclusion Pelvic exenteration is a potentially curative strategy for locally advanced rectal cancer conferring potential survival gains and locoregional disease control.although the procedure is still associated with significant morbidity,mortality rates are acceptable. Careful patient selection can optimize outcomes. 64

65 64 / 1146 Hybrid versus pure laparoscopic techniques in low anterior resection: A multicenter study of quality of mesorectal excision and clinical outcomes Patricia Tejedor, Carlos Pastor, Arsenio Sánchez, David Alias, Ana Moreno, Ignacio Valverde, Hector Guadalajara, Mario Ortega, Damián García Olmo, ES Objectives To identify variations of the quality of total mesorectal excision(tme) specimens and oncological outcomes comparing hybrid versus pure laparoscopic techniques in low anterior resections (LAR)for rectal cancer. Methods Non-randomized cohort study was conducted in consecutive patients with rectal cancer who underwent LAR at 3 university hospitals in Madrid-Spain from January 2012 to September 2016.Postoperative and pathological outcomes were reviewed. We selected only fully-completed laparoscopic cases divided into two groups;1)hybrid-technique(ht): any part of the TME dissection was performed by open approach throught the Pfannenstiel and the rectum was transected with Contour 2)Pure laparoscopic-technique(lt):whole TME dissection was performed by laparoscopic approach and the rectum was transected with Endogia. Results 107 patients were analyzed: 73 LT(68.2%) vs. 34 HT(31.w8%). There were no statistical differences between groups in preoperative tumor characteristics, neoadjuvant chemoradiotherapy (LT68% vs HT78%) and mean distance to the anal verge (LT10.6cm vs HT11.5cm).The specimen s pathological report in 62 patients with total TME dissection showed a higher percentage of incomplete excision in the LT group (34.1%) compared to the HT group (5.6%)(p>0.05). Distal margins were similar for both groups. However, the HT group had a higher percentage of positive circumferential margins (8.8% vs 2.7%). There were no differences in postoperative complications including anastomotic leakage regarding the surgical technique. With a mean follow-up of months there were significant higher percentages of local recurrence in the HT group (HT9.7% vs. LT0%). Conclusion In our experience, laparoscopic LAR may be performed either by hybrid or pure laparoscopic approach with similar clinical outcomes. Despite of this, comparisons between both techniques showed lower percentages of circumferential radial margins and local recurrences in the pure laparoscopic techniques. 65

66 65 / 1147 Evaluation of intraperitoneal lavage cytology before and after colorectal cancer resection Isabel María Gallarín Salamanca, María Teresa Espín Jaime, Mirian Catalina Fernandez, Jesus Salas Martínez, ES OBJETIVES The significance of intraperitoneal cancer cells in patients with colorectal cancer, particularly in patients with no other adverse prognostic features, is poorly defined. Consequently peritoneal lavage is not part of routine practice during colorectal cancer resection, in contrast with other abdominal malignancies. The aim of this study was to assess the usefulness of intraperitoneal lavage cytology (lavage Cy) status before and after the resection of colorectal cancer METHODS Between 12 March 2013 and 31 August 2016, intraoperative peritoneal lavage cytology was performed before and after of cancer resection, in 198 patients who underwent curative colorectal procedures. The lavage Cy-positive [lavage Cy (+)] rate were examined in this cases of colorectal cancer in relation to various clinicopathological factors. RESULTS The overall lavage Cy (+) rate was 1.5% (malignant cells were detected in the intraoperative peritoneal lavage cytology samples from 3 patients, before of cancer resection) The lavage Cy (+) rate within the group with lymph node metastases was significantly higher than that in the group without lymph node metastases (100% vs. 0%, p=0,02). The lavage Cy (+) rate was not significantly associated with any of the clinicopathological factors examined. CONCLUSION: The timing of peritoneal lavage and type of lavage fluid used is controversial. Most studies carried out lavage only prior to resection. In this studies the detection rate post resection it was lower than the pre resection rate. Thus, meticulous follow-up and possibly adjuvant chemotherapy may be beneficial for patients with free cancer cells in lavage fluid, even after curative surgery. 66

67 66 / 1149 Laparoscopic surgery for inflammatory bowel disease Eva Koblihova, Mojmir Kasalicky, CZ Introduction: 20 % of patients with Crohn s disease (CD) and 80 % patients with ulcerative colitis (UC) will require an operation in their life. Minimally invasive surgery has becoming a gold standard worldwide. Advantages of laparoscopic approach include reduction of perioperative complications, faster recovery time and reduction of analgesics. Long term outcomes include fewer adhesions with positive influence in fertility in young women with UC, fewer incisional hernias and better cosmetics. Methods: Patients without any previous gut resection with inflammatory bowel disease (IBD) were indicated for the laparoscopy. Patients with CD with the tight stenosis in distal ileum and/or ileo-colon or various colon stenosis, patients with UC with ineffective medical therapy, steroid dependence or dysplasia undergone the surgery. Results: From January 2009 to June 2016 we performed 165 ileocolic resections, 46 hemicolectomies, 40 subtotal colectomies and 13 proctocolectomies with ileoanal pouch anastomosis either totally laparoscopically or laparoscopically assisted. Restoration of gas movement were 4.6 days in average and restoration of stool were 5.1 days in average. Length of hospital stay were 5.2 days. Complications occurred in 14 patients (5%). Conclusion: Laparoscopic surgery in IBD is safe and feasible in well-selected patients thanks to short- and long-term outcomes. Laparoscopic approach should be performed by experienced surgeons in high volume centres. Supported by MO

68 67 / 1150 Diagnostic accuracy of faecal biomarkers in detecting colorectal cancer and adenoma in symptomatic patients Monika Maria Widlak, Claire Louise Thomas, Matthew G Thomas, Claudia Tomkins, Steven Smith, Nicola O Connell, Subiatu Wurie, Leighanne Burns, Christopher Harmston, Charles Evans, Chuka Nwokolo, Baljit Singh, Ramesh P Arasaradnam, UK Background: The diagnosis of colorectal cancer (CRC) can be difficult as symptoms are variable with poor specificity. Thus there is a quest for simple, non-invasive testing that can help streamline those with significant colonic pathology. Aims: Prospective diagnostic accuracy study using faecal haemoglobin (F-Hb) and faecal calprotectin (FCP) to detect CRC and adenomas in symptomatic patients referred from primary care. Methods: 799 patients referred for urgent lower gastrointestinal investigations were prospectively recruited. Of this, 430 completed colonic investigations and returned stool samples, and were included in final statistical analysis. Faecal immunochemical test for faecal haemoglobin was performed on HM- JACKarc analyser, and faecal calprotectin by ThermoFisher EliA. Results: The negative predictive value (NPV) of faecal haemoglobin alone and faecal haemoglobin in combination with faecal calprotectin was 99% for colorectal cancer, with a sensitivity and specificity of 84% and 93% respectively. Faecal haemoglobin measurements were higher in left sided colonic lesions compared with the right side; 713 vs 94.0; p = 2.03%). For adenomas, the NPV using both markers was 94% with a sensitivity and specificity of 69% and 56% respectively. Conclusions: Undetectable faecal haemoglobin is a good rule out test for CRC, with a NPV of 99%. Faecal calprotectin does not appear to provide additional diagnostic information. Further studies to determine the health economic benefits of implementing faecal immunochemical testing for haemoglobin in primary care are required. 68

69 68 / 1151 Anastomotic leak after laparoscopic surgery in patients operated for rectal or recto-sigmoid tumors in own material. Mariusz Uryszek, PL Summary The aim of the study was to evaluate the incidence of anastomotic leak after laparoscopic surgery in patients operated for rectal tumors located no farther than 20 cm from the anal sphincter. Data are retrospective on the basis of their own material. Material: Of the more than 578 patients operated in due to colorectal tumors selected 115 laparoscopic operations, in which a tumour was observed at a distance of not more than 20 cm from the anal sphincter. In 97 patients they had cancer, 12 polyps, endometriosis in 1 patient and diverticular disease in 4 patients. Method: All patients were operated laparoscopically. In some cases we performed a protective ileostomy. We assesed the influence of the distance of the position of the tumor in relation to the sphincter, the tumour stage, the effect of radio therapy or chemotherapy and others. Results: Anastomotic leak was observed in 10 patients (8.6%). This 5 (4.3%) patients required surgery with the need to disconnect the anastomosis. Because of the complications of the healing of the anastomosis 2 patients died (1.7%). Statistically, only the conversion is performed, length of hospital stay and operative time were relevant for the occurrence of anastomotic leak (p <0.001). Conclusions: The proportion of anastomotic leakage in our study is similar to that given in the literature. Formation of ileostomy in patients after operations of the low-lying tumor completely prevent the creation of anastomosis. Performed of conversion in patients with low-lying tumor does not guarantee anastomotic leak. 69

70 69 / 1152 Intracorporal versus extracorporeal anastomosis during laparoscopic right hemicolectomy: An institutional experience Nuno Rama, Paulo Alves, Paulo Clara, Sandra Amado, Miguel Coelho, Vitor Faria, PT Introduction: Nowadays laparoscopic colectomy is a feasible, safe and effective approach in terms of short-term, long-term and oncologic outcomes in colorectal surgical practice. Right colectomy with intracorporal anastomosis (IA) is a procedure of increasing popularity, which may alleviate some of the technical limitations that surgeons face with a laparoscopicassisted extracorporeal anastomosis (EA). This study aims to compare short- -term outcomes of both options. Method: We design a retrospective comparative study of two anastomosis techniques for laparoscopic right hemicolectomy. A total of 122 consecutive patients, operated for neoplasm of the right colon, from the 1st September, 2014 to 31st August, 2016, were identified. The intracorporal group included one quarter of patient, operated by two experienced colorectal surgeons. Results: A total of 122 patients underwent laparoscopic right hemicolectomy over the study period, with the most common indication for surgery in both groups was cancer (85%). EA had a significantly higher rate of minor complications but no difference in serious complications compared to IA. Multivariate analysis comparing IA versus EA, showed no significant difference in risk of anastomotic leak, intraabdominal abscess or wound complications, and a small, but not significant, length of stay and return of bowel function. Conclusion: Minimally invasive right colectomy with IA is associated with similar postoperative outcomes compared to EA, presenting some advantages in terms of flexibility of specimen extraction. We think that IA represents a safe, valid and feasible technique in the arsenal of experienced colorectal surgeons. Keywords: Intracorporal anastomosis; Laparoscopic right colectomy; Outcomes 70

71 70 / 1153 Neutropenic Enterocolitis: a medical or surgical concern? A case-by-case decision making. A case report and critical analysis of the literature. Elia Poiasina, Luca Ansaloni, IT OBJECTIVE. Neutropenic enterocolitisis (NE) a life threatening complication that may occur after intensive chemotherapy in acute leukemia and solid tumors. The reported incidence varied considerably from 0.8% to 26%, demonstrating that there is not a standard clinical definition for NE. Risk factors include neutropenia, associated with sepsis and right sided abdominal pain. Timely conservative treatment frequently allows resolution of NE. Surgical intervention is however recommended in presence of bleeding, perforation or deterioration with multisystem organ failure. MATERIALS AND METHOD. 35 years-old woman was treated for breast cancer with Docetaxel 170 mg, after a previous treatment with epirubicin and cyclophosphamide. Eight days after the initiation of the first course, she was admitted to the Department of General Surgery, for acute right sided abdominal pain, mimicking acute appendicitis, and fever. Neutrophil count was 80/mm3. A CT-scan revealed concentrated thickening of the cecum wall (26 mm). The progressive deterioration of the general clinical condition, made mandatory a surgical approach, even in absence of perforation or bleeding. We found a necrosis of the cecum, with its inpending perforation. The patient is still alive after three years from the operation. CONCLUSIONS. In absence of clear signs of perforation or acute bleeding, only the presence of severe sepsis and the bowel wall thickining > 10 mm represent prognostic factors, which adversely affects the outcome.ne may be a severe complication of taxane-based chemotherapy: clinicians should be acutely aware of the association of NE with chemotherapy, because the outcome would depend significantly on an early and appropriate treatment, either conservative or surgical. In conclusions, analysis of the literature reveals that the predominant view among surgeons and nonsurgeons is that treatment must be individualized on a case-by-case basis. 71

72 71 / 1155 A comparison for lymph nodes harvesting between Laparotomy and Laparoscopic technique in Right Hemicolectomy Chui Ling Teng, Anwar Hussain, Umar Shariff, Philip Varghese, UK Introduction Literature strongly supports the theory that lymph node evaluation indirectly measures that quality of colon cancer resection. Lymph node burden is direct prognostic marker of colon cancer. Our study aims to compare the lymph node harvest between open and standard laparoscopic right hemi-colectomy Method A retrospective study of prospectively maintained database of patients whom underwent right hemicolectomy from January 2010 to December 2014, in the high volume colorectal unit of University Hospital of North Midlands. Data was collected via hospital trust computer system and histology report, including basic demographic data, methods of surgery and number of lymph nodes harvested. Result 412 patients were identified. Among them, 88 patients were excluded due to non-malignant pathology. Among 324 patients, 163 (50.30%) are male and 161 (49.70%) are female. The age ranges from 30 years old to 94 years old. 174 (53.70%) cases are laparotomy cases while 150 (46.30%) cases are laparoscopy cases. Median numbers of lymph nodes harvested were 20 (6-53) in open group and 17 (4-46). Conclusion We concluded that there is no statistically significant difference in the lymph node harvest between open and laparoscopic right hemi-colectomy. 72

73 72 / 1156 Transanal Inspection and management of low ColoRectal Anastomosis performed with a New Technique: the TICRANT study - pilot report Francesco Crafa, Sebastian Smolarek, Jacques Megevand, Paolo DelRio, Giannandrea Baldazzi, Giampiero Ucchino, Silvia Quaresima, Giovanni Romano, Adele Noviello, Giulia Missori, Mostafa Shalaby, Diletta Cassini, Pasquale Ascenzi, Luana Franceschilli, Pierpaolo Sileri, IT Background: Anastomotic leakage is one of the most serious complications after rectal cancer surgery. Method: We conducted a prospective multicenter interventional study to assess a newly described technique of creating colo-rectal anastomosis. The primary outcome was to access the safety and efficacy of this technique in the reduction of anastomotic leak. Result: Fifty-three patients with rectal cancer who underwent low or ultra-low anterior resection were included into the study. There were 35 males and 18 females with a median age of 68 years (range; 49-89). The median tumor distance from the anal verge was 8 cm (range; 4-12), and the median BMI was 24 kg (range; 20-35). Thirty patients underwent open, 16 laparoscopic and 7 robotic surgeries. Multiple firing ( 2) was required in 30 patients to obtain a complete rectal division. Forty-five patients had colo-rectal anastomosis and 8 patients had coloanal anastomosis. Protective ileostomy was created in 40 patients at the time of initial surgery. There was no mortality in the first 30 days postoperatively, and only 10 (19%) patients developed complications. There were 3 anastomotic leakages (6%); 2 of them were subclinical with ileostomy created at initial operation and both were treated conservatively with trans-anal drainage, and intravenous antibiotics. One patient required reoperation, and ileostomy. The median length of hospital stay was 10 days (range 4-20 days). Pathological examination of postoperative specimen showed tumor free distal, radial and circumferential margins in all patients. Conclusion: Our technique is safe and efficient method of creation of colorectal anastomosis. It is also universal method which can be used in open, laparoscopic and robotic surgery.conclude that chemotherapy for stage IIIA colon cancer may not be necessary. 73

74 73 / 1157 Usefulness of the <inferior approach> in laparoscopic right colectomy Kaori Shigemitsu, Fusao Sumiyama, Toshinori Kobayashi, Ryo Inada, Masaharu Oishi, Madoka Hamada, JP <Purpose> Laparoscopic right hemicolectomy is fraught with risk of injury, such as duodenum, ureter, gastrocolic trunk and right accesary colonal vein. We have introduced inferior approach as the surgical procedure for laparoscopic right hemicolectomy in order to perform the safe and minimally invasive surgery while ensuring the curability of cancer. <Surgical technique> First, peritoneal incision is started from root of mesentery of terminal ileum to the caudal side of cecum to enter the layer of subperitoneal fascia. We proceed the peeling to headside and transfer the layer at the lower edge of duodenum and entered the Treitz prepancreatic fascia and peel between the fascia and mesocolon as much as possible. From the head side, we open the bursa omentalis and enter into the Toldt fusion fasia to be continuous with the peeling layer from caudal side.then the dissection is proceeded toward the head side along the the left edge of the superior mesenteric vein on the inside approach. After that, from the caudal side of the ileocolic vessels we enter the above-mentioned layer and cut the root of the vessels. We cut the right branch of the middle colic artery and finish the dissection and takedown of hepatic flexure. <Result> This surgical procedure is performed from April 2015 to March Operation time 257 ( ) minutes, in the amount of bleeding 50 (31-181) ml, except for the two cases of postoperative ileus, we have not experienced more than GradeII of Clavian -Dindo classification. <Conclusion> Inferior approach is useful for safe and radical laparoscopic right hemicolectomy. 74

75 74 / 1158 Undifferentiated colon carcinoma : an extremely rare entity Azza Gabsi, Yosra Yahiaoui, Amina Mokrani, Khadija Meddeb, Mouna Ayadi, Nesrine Chraiet, Henda Rais, Amel Mezlini, TN Introduction: Undifferentiated colon carcinoma is quite rare. It accounts for 0,04 à 0,1% of all colon carcinoma. Its prognosis is very poor. Case report : We present a case of 64 year old man with history of benign prostatic hypertophy presented to the hospital with acute intestinal obstruction. Abdominal CT scan showed colic distension upstream of an irregular circumferential wall thickening of the right colon extended 9 cm, increased prostate size and 3 osteolytic lesions of the average arc of the 8th rib. He was operated on urgently. He had a hemicolectomy with ileocolic anastomosis. Histological study had concluded an undifferentiated colon carcinoma infiltrating the serosa without lymphadenopathy. Immunohistochemestry study was negative PS100, CD45, Vimentin, CK7, CK20, Synaptophysin, Chromogranin, CD117 and DOG-1. Conclusion: Treating undifferentiated carcinoma of the colon is based on surgery and chemotherapy. The extreme rarity of this entity makes it difficult to manage. 75

76 75 / 1160 Does laparoscopy improve healthcare in colo-rectal surgery? Viewpoints from business intelligence Patrick de Hoogt, Jan Stoot, NL Objectives: The objective of this study was to evaluate whether laparoscopic colorectal surgery improves healthcare in comparison with open colorectal surgery from bussiness intelligence (BI) viewpoint. We hypothesized that laparoscopic colorectal surgery to be more cost-effective than open colorectal surgery because of a shorter hospital stay, even though material costs of laparoscopic technique are more expensive. Methods In this retrospective cohort study all consequetive patients selected for colorectal surgery were included from January 2010 and January 2015 (n=2040). All patientdata were retrieved from the prospective fully digitalised patient data system. Patients were divided into three groups: patients undergoing colonic surgery, rectal surgery and appendicular surgery. For each group, all relevant baseline characteristics (gender, age, ASA classification) were determined. Primary outcome of this study was total cost in euro s regarding surgery and total hospital stay. Results Rectum: Total cost for open surgery (n=189) versus laparoscopic(n=118) (p= 0.220). Ward cost for open surgery were 2225,68 versus laparoscopic (p=0.005) Colon: Total cost for open surgery(n=580) versus laparoscopic(n=335) (p=0.040), Ward cost for open surgery were versus laparoscopic (p=0.000). Appendicular: Total cost for open surgery(n=345) versus laparoscopic(n=473) (p=0.858), Ward cost for open surgery were versus laparoscopic (p=0.067). Conclusion From BI viewpoint the laparoscopic procedural costs of occupation of the operation theatre and equipment costs were higher, but no differences were seen in total hospital costs due to shorter hospital stay in laparoscopic surgery. 76

77 2017 GEUROPEAN COLORECTAL CON RESS December 2017 St.Gallen Switzerland EUROPEAN COLORECTAL CONGRESS 4 7 December 2017 Congress Management Medkongress AG Rorschacher Strasse 311 CH-9016 St.Gallen Switzerland Phone Fax info@colorectalsurgery.eu Congress Venue Olma Messen St.Gallen Halle 2 + 3, St.Jakobstrasse St.Gallen, Switzerland Masterclass Venue Olma Messen St.Gallen Halle St.Jakobstrasse St.Gallen, Switzerland 77