April 1995 SSAT A1241

ILEO-ANAL POUCH ELECTROLYTE TRANSPORT ANALYSIS UTILIZING A DIALYSIS TECHNIQUE. p. Reissman, E.D. Ehrenpreis, J. Pfeifer, J.J. Nogueras, S.D. Woxner, Departments of Colorectal Surgery and Gastroenterology, Cleveland Clinic Florida, Fort Landerdale, Florida.

OBJECTIVES: To develop a simple reproducible method for studying the electrolyte transport within the ileo-anal pouch (IAP), using a dialysis technique. The first stage of the study was to determine the optimal dialysis time to reach an equilibrium/steady state of the measured electrolytes.

MATERIALS AND METHODS: 10 patients [7 males and 3 females, mean age 40.3 (27-52) years], who had undergone a restorative proctocolectomy with construction of an lAP were studied. All patients suffered from ulcerative colitis, had their ileostomy closed for 14 (10-21) months, had 4.6 (3-7) bowel movements per 24 hours and were not taking any medications. We used a dialysis technique of transanal insertion of a semipermeable regenerated cellulose dialysis bag (Spectra Pore® Houston, TX), 0.8 x 5cm in size. Each bag was filled with 5cc of 10% Dextran 40® (Kendall McGraw. IJwine. CA) as the inert colloid solution. Each patient, after spontaneous evacuation of his IAP, had 5 bags consecutively inserted for periods of 15.30,60,90 and 120 rain. Electrolyte and glucose levels in each bag were recorded.

RESULTS: Accumulated ahalysis of the dialysis bags showed a similar pattern in 9 of the patients with an equilibrium alter 60 minutes. In one patient the equilibrium state was reached after 30 minutes. The following 60 minute levels (mean ± SEM and range) in meq/l were recorded: Na - 147+~2.6(138-158), K - 4.0_+0.3(2.7-5 2), Ca - 6.9_+I.5(2.1-12.2), Mg - 3.3_+0.8(2.1-7.3), Phes - 7.0_+1.0(4.1- 11.0), CI - 109_+3.5(103-120), Glucose- 26 8_+2.2(20-36).

CONCLUSIONS: The proposed technique of"pouch dialysis" is a simple and feasible method for analysis of IAP electrolyte transport. The optimal dialysis time required in this method is 60 rain. Further studies of medications effect and physiologic adaptation of the IAP using this technique are in progress.

LAPAROSCOPIC SURGERY IN THE MANAGEMENT OF INFLAMMATORY BOWEL DISEASE: A VIABLE OPTION. P. Reissman, B.A. SaLky*, S.D. Wexner, Department of Colorectal Surge~, Cleveland Clinic Florida, Fort Landerdale, Florida and the *Division of Laparoscopic Surgery, Department of Surgery, Mount Sinai Medical Center, New York, New York.

The role of laparoscopic surgery in the treatment of various upper and lower gastrointestinal disorders is still under investigation. However, a variety of laparescopic procedures may be applied in the surgical treatment of inflammatory. bowel disease (JED). We present our initial results of laparoscopic and laparoscopic assisted management of IBD in 67 consecutive patients [35 females and 32 males, mean age of 36 (20-79) years0]. The indications for surgery included: terminal ileitis in 25 patients, mueosal ulcerative colitis in 23, Crohn's colitis in i 1, severe penanal Crohn's disease in 4, duodenal Cmhn's disease in 3 and Crolm's recto- vaginal fistula in i The procedures performed included: total abdominal coteotomy (TAC) in 30 patients (22 had TAC with ileoanal reservoir, 6 had TAC with ileerectal anastomosis and 2 had TAC with end ileostomy., ileocolic resection in 26. diverting loop ileostomy in 5. closure of an end ileostomy in 5, closure of an end ileosmmy with fleorectal anastomosis in 3 patients who already underwent a TAC with as end ileostemy and duodenal bypass gastro-jcjunostomy in 3,

There ~ere 16 complications in 13 patients (19%) and included: 3 enterotomies, 4 bleeding, 3 peMc abscess, 2 intestinal obstruction, 2 paralytic ileus, i anastomotic leak. and 1 efferent loop obstruction after gastro-jejunostomy. However, only 3 patients required repeat laparotomy for morbidit7 and there was no monatib. In 7 patients (10%) the procedure was converted to laparotomy due to a large inflammatory mass and fistulae in 4, bleeding in 2 and an enterotomy in 1. The mean operating time was 2.9 (0.7-6) hours and the mean length of hospital stay was 6 5 (3-19) days. When compared with ileocolic resection, TAC was associated with higher morbidity. (30% versus 12%, p<0.05) and longer hospitalization 8.7 (4-t9) days versus 5.3 (3-7) days. respectively, p<0.05

According to this initial experience, laparuscopic surgery is a versatile and effective modali~' in the surgical management of inflammatory bowel disease.

O DOES THE COMBINATION OF NEOADJUVANT CHEMOTHERAPY AND POSTOPERATIVE INTRAPERITONEAL THERAPY INCREASE PERIOPERATIVE COMPLICATIONS IN PATIENTS WITH GASTRIC AOENOCARCINOMA? Jnhn V. Reynnld~. M~rtin ,q KRrp~h .Ir., David Kel~Rn, G~rdes Hans. ,~.c.hw~rtT: C ~ r O~r~i~: ~ RodrigtJez, Elliot Newman: Murray F. Rrennan. Memorial SIoan-Kettering Cancer Center, New York, NY.

Introduction: Neoadjuvant chemotherapy for the treatment of gastric adenoearcinoma is a novel approach to a largely incurable disease which is currently under active investigation in the US and Europe. Data which examines the morbidity or mortality of th!s:approach are sparse, The aim of this study was to assess the consequences of preoperative chemotherapy [5-FU 1.5g/m2, Adriamycin 30mg/m2 and Methotrexate 1.5g/m2 (FAMTx)] followed by radical gastrectomy and intrspedtoneal and systemic 5-FU/Cisplatin (Pestop therapy POT) on patient morbidity an mortality. Methods: Thirty-two patients with locally advanced gastric carcinomas consented to enter a phase II Trial involving three cycles of preoperative FAMTX followed by a curative gastrectomy and three cycles of POT. Preoperative staging involved physical exam, abdominal/pelvic CT scanning and endoscopic ultrasonography. Patients were selected if they had endosonograhic T3-4, Nany, M0 tumors or aneuploid T2, Nany M0. All morbidity and mortality data was prospectively entered into a computerized database. A comparison group of 3t patients staged as EUS- T3,Nany,MO during the study period 7/91 to 1/94, who received a curative surgical resection without additional therapy during their hospitalization, served as a control. Contingency testing was done by the Fisher exact test. Results: There were no significant differences between the two groups with respect to gender, site of disease, type of operation or pathologic stage. The control group were older [mean 65vs.55yrs (p<,01)]. Overall morbidity following curative resection was significantly higher in the protocol group (p=0.04). Specifically, the rate of anastomotic leak (.05}, pneumonia (.04) and wound inf. (.006) were all increased in the protocol treated group. No significant differences were seen in postop or intraoperative bleeding, bowel obstruction, pu}m embolism or cardiac events. Thirty day mortality was 6% for both groups. Conclusion: Preoperative and post operative chemotherapy significantly increased the incidence of postop compl}eations, specifically wound infections and anastomotic leak rate, ]f this aggressive treatment approach proves beneficial in prolonging the survival of patients with advanced gastric cancer, then further study will be needed to lower the rate of these potentially letha] complications.

O SHUNT SURGERY DURING THE ERA OF LIVER TRANSPLANTATION. Layton F. Rikke~s, Gongliang Jin. Alan N. Lanqnas, Byers W. Shaw, Jr. Department of Surgery, University of Nebraska Medical Center. Omaha, Nebraska

Since initiation of our Liver Transplant (LT) program in July, 1985, we have had a standardized approach to definitive treatment of adult patients with chronic liver disease complicated by variceal hemorrhage. Abstinent cirrhotics and nonalcoholic cirrhotics with advanced liver disease (Child's class B- or C) underwent LT (n=171, group i). Although all LT patients included in this study had a history of variceal bleeding, only 25% had bled within a month of LT. Shunt surgery (s) was done in patients who failed sclerotherapy, lived in rural areas, or bled form gastric varices as a long-term bridge to LT (n=36, group 2) or as definitive treatment for nontransplant candidates (n=25, group 3). S patients received either a DSRS (n=49) or a nonselective shunt (n=12). Future transplant candidates (group 2) generally had nonalcoholic liver diseases (64%) and Child's class A or B hepatic function (92%). As would be expected because of their more advanced liver disease, group 1 had a higher hospital mortality rate (19%) than group 2 (6%) or group 3 (8%) (p < .05). Two year survival rates for groups i, 2 and 3 are 73%, 92%, and 74% respectively. Three group 2 patients have undergone LT and only one patient has died of hepatic failure without benefit of a LT. S prevented recurrent bleeding in 92% of patients. Quality of life after s has been generally good with 8% having at least one episode of encephalopathy and 10% developing moderate to severe ascites. We conclude that shunt operations may serve as an excellent long- term bridge to LT and that they still play an important role for selected patients with variceal bleeding who are not LT candidates.