BACKGROUND: Following the nonoperative management of acute diverticulitis, guidelines recommend routine follow-up colonoscopy; however, evidence to support this recommendation are lacking.OBJECTIVE: This study aims to determine the diagnostic yield of endoscopy for clinically significant neoplasia following the successful nonoperative management of acute diverticulitis.DESIGN: This study is a retrospective review.SETTING: This study was conducted in a large urban health region.PATIENTS: Adult patients who were admitted with a diagnosis of acute diverticulitis confirmed by CT and who were successfully managed nonoperatively to hospital discharge were included. Patients who underwent colonoscopy within 2 years of presentation were excluded.MAIN OUTCOME MEASURE: The primary outcome measured was the incidence of clinically significant neoplasia (invasive malignancy or advanced adenoma) on follow-up endoscopy within 1 year of admission.RESULTS: Four hundred fifty-eight patients were selected for analysis, of which 249 patients (54%) underwent endoscopy within 1 year of admission. Seventy-seven (30.9%) patients were found to have polyps, 19 (7.6%) patients had advanced adenomas, and 4 (1.6%) patients had an invasive malignancy; 23 patients (9.2%) were found to have clinically significant neoplasia. On subgroup analysis, patients presenting with complicated diverticulitis (n = 74) had a significantly higher incidence of advanced adenoma (18.9% vs 5%, p = 0.001) and invasive malignancy (5.4% vs 0%, p = 0.007) in comparison with patients who presented with uncomplicated diverticulitis (n = 175). On multivariate analysis, patient age (OR 1.04 (1.01-1.08), p = 0.02) and the presence of abscess (OR 4.15 (1.68-10.3), p = 0.002) were identified as significant risk factors for clinically significant neoplasia.LIMITATIONS: The use of retrospective data was a limitation of this study; 54% of selected patients underwent endoscopic follow-up.CONCLUSIONS: The incidence of clinically significant neoplasia on endoscopic follow-up after the nonoperative management of acute diverticulitis is 9.2%. Those with complicated diverticulitis are at higher risk, whereas the incidence of clinically significant neoplasia in those with uncomplicated diverticulitis is equal to the incidence in average-risk individuals. Routine diagnostic colonoscopy following the nonoperative management of acute uncomplicated diverticulitis may not be warranted.

ASA: American Society of Anesthesiologists.BMI: body mass index.IPAA: ileal pouch anal anastomosis.Lap: laparoscopic.* Due to the conservative nature of interaction analysis, the significance level used for identifying interactions was 0.10, which is warranted to achieve a prudent balance of probabilities between type I and type II errors.

INTRODUCTION: Obesity rates have soared drastically in recent years and complications of obesity lead to increased health-care costs.Whether costs after colorectal surgery are specifically higher for obese patients has however not previously been assessed.The aim of this study was to compare direct costs for obese and non-obese patients undergoing colon resection.METHODS: All patients undergoing elective open partial colectomy at a single high-volume colorectal unit over the last 3 years were identified.Patients with metastatic malignancy were excluded.Patients were stratified based on increasing body mass index (BMI) and matched for age, gender and ASA class.Data relating to operation, length of stay (LOS) and complications and costs were compared.Subgroup analysis was performed on underweight and morbidly (BMI>40) obese patients.RESULTS: A total of 285 complete charts for patient undergoing partial colon resection were reviewed.Groups were similar with regards to age, gender, ASA class and procedure.Cancer and diverticulitis were the main diagnoses across all groups, except for the underweight group, where Crohn's disease predominated and this group was excluded from further analysis.Mean LOS was similar between groups.Obese patients had greater mean hospital costs ($14803) than non-obese ($12992) but this difference was not significant (p=0.82).Wound infection rate approached 45% in the morbidly obese group and was only 8% in patients who were not obese.The overall morbidity, wound infection and costs progressively increased with increasing BMI (table).Morbidly obese patients had significantly increased overall morbidity and costs when compared to non obese patients (p=0.04).CONCLUSION: For patients undergoing elective colon resection, obesity leads to increased direct costs, with the morbidly obese having the greatest costs.The increased costs are likely due both to operating room costs and to the increasing higher overall morbidity, especially wound infection associated with increasing BMI.This risk should be accounted for in future health care policy including reimbursement and resource allocation strategies.

656 Background: There are emerging data showing prognostic significance of pre-treatment leukocytosis (elevated white blood cell count) in cervical cancer patients. However the prognostic impact of leukocytosis in anal cancer patients has not been previously reported. The purpose of this study was to determine the association of pre-treatment leukocytosis on outcome in patients with anal cancer treated with radical chemoradiotherapy (CRT) or radiotherapy (RT). Methods: 126 patients with anal cancer, treated with radical CRT (91.3%) or RT (8.7%) from 2 major Canadian cancer centers (University of Calgary, n=65 and University of Alberta, n=61), between 2000 and 2008 were evaluated. Demographic, clinical, hematologic and treatment factors were retrieved from retrospective review of the patients’ records. The association of clinical factors and hematologic status with overall survival (OS) and disease-free survival (DFS) was analyzed using Cox proportional hazards regression models. Results: Median follow-up was 24 months. Median tumor size was 4 cm. Mean age was 59 years and M:F was 29:97. Pre-treatment leukocytosis (WBC count greater than 10^9/L) was identified in 16% (20/126) of patients. After adjusting for gender, tumor size and stage in a multivariate analysis, leukocytosis remained significantly associated with worse 2-year OS [HR 2.9 (95% CI 1.1-7.9), p=0.036] and worse DFS [HR 2.2 (95% CI1.1-4.8), p=.045]. The patient group with both pre-treatment hemoglobin (Hgb) less than 125 g/L (lowest quartile) and leukocytosis had very poor outcomes, 2-year OS 61% versus 89% for patients without these factors; more than doubling the hazard for DFS [HR2.7 (95% CI 1.1-6.8), p=0.033] and for OS [4.5 (95% CI 1.5-13.2), p=.006]. Conclusions: Pre-treatment leukocytosis is associated with worse OS and DFS in patients with anal cancer treated with radical CRT or RT. Patients with both low Hgb and leukocytosis had very poor outcomes. These hematologic parameters represent potential biomarkers for prognosis and treatment response, and warrant further investigation to uncover the underlying biologic mechanisms and therapeutic strategies in this patient group.

PURPOSE: Sphincter-sparing chemoradiotherapy (CRT) is the standard of care for patients with anal canal cancer.Despite good response rates, some patients require radical surgery (abdominoperineal resection or exenteration)for persistent or recurrent disease.The purpose of this study was to evaluate the outcomes of patients following radical resection for persistent or recurrent disease.METHODS: All patients treated with CRT or RT for anal cancer between 1990 and 2008 were identified using the regional cancer registry.Inclusion criteria: pathologically confirmed squamous cell carcinoma of the anal canal, localized disease, receiving ≥ 45Gy of RT.Statistical analysis was conducted to calculate survival rates and identify risk factors for poor outcomes.RESULTS: 105 patients (25 male) were identified.Median age was 57 years (range 33-87 yr).Median follow up was 40 months (range 3-185).Median T stage and size at presentation were 2 and 35 mm (range 6-260mm) respectively.Median dose to the primary tumor was 54 Gy (45-76 Gy) at a median 28 fractions (range 20-37).92 patients(88.5%)received concurrent chemotherapy.At 3 month followup 85 (83.3%) patients had complete clinical response, one patient had insufficient followup.19 (18.1%) patients had persistent disease, of whom 12 underwent radical resection for cure; 5 (41.7%) are alive at a median of 106 months from diagnosis, while the remaining 7 died at a median 15 months from diagnosis.Recurrence occurred in 17 (20.0%) patients at a median time of 9 months (4-53m).8 patients underwent radical resection for recurrence; 2 (25.0%) patients are alive at 127 and 21 months, the remaining 6 died at a median time from recurrence of 24.5 months.Overall, disease specific and disease free survival, were 66%, 71% and 67% respectively for all anal canal carcinoma patients at 5 years.Multivariate analysis showed tumor size to be a significant risk factor for disease free (aOR 1.02, 95% CI: 1.01-1.04)and overall survival (aOR 1.03, 95% CI: 1.01-1.04)for all patients.CONCLU-SION: Despite good response rates to sphincter-sparing therapy, 20% still required radical resection for persistent or recurrent disease.Survival rates following radical resection are poor.