Permanent diversion rates after neoadjuvant therapy and coloanal anastomosis for rectal cancer.

BACKGROUND: The aim of this study was to assess the rate of permanent diversion in patients undergoing coloanal anastomosis after neoadjuvant therapy for rectal cancer. METHODS: We performed a retrospective review of patients with rectal cancer who underwent a total mesorectal excision of a tumor within 9 cm of the anal verge. RESULTS: There were 201 patients who underwent resection with coloanal anastomosis, with a mean follow-up period of 51 months. The average tumor distance from the anal verge was 7 cm (range, 4-9 cm). Neoadjuvant therapy was administrated in 145 patients, 47 had no radiation, and 9 received radiation postoperatively. Thirty-two patients (16%) had long-term complications including incontinence, fistulas, and strictures. Twenty-five patients (12%) had recurrent disease, 16 of these were local recurrence. The total rate of permanent diversion was 29 (14%). Reasons for diversion included local recurrence in 12 patients (6%), complications in 10 patients (5%), and poor function in 7 patients (3%). CONCLUSIONS: Poor bowel function, late complications, and local recurrence all contribute to permanent diversion after a coloanal anastomosis. Neoadjuvant therapy in conjunction with a total mesorectal excision and coloanal anastomosis leads to acceptably low permanent diversion rates in the vast majority of patients.

Colorectal cancer screening.

Colorectal cancer (CRC) constitutes the second leading cause of death from cancer in the United States. Increased screening for CRC have been associated with a decreased incidence in the past two decades. Continued efforts are necessary to maintain this trend. Appropriate risk stratification of individuals and compliance with recommended screening strategies are important. Colonoscopy continues to play an important role in screening; however, several different screening options are available for average-risk individuals. This article reviews the current options open to physicians to adequately screen patients for CRC based on inherit risks.

Clinical outcomes of complicated diverticulitis managed nonoperatively.

BACKGROUND: Surgical resection is typically recommended for patients with computed tomography (CT)-confirmed complicated diverticulitis. This study was designed to assess outcomes of patients with complicated diverticulitis managed nonoperatively. METHODS: A retrospective study covering 14 years evaluated patients with complicated diverticulitis diagnosed by CT scan. Patient outcomes, including recurrence and need for operations, were reviewed. RESULTS: Of 256 patients identified, 99 were managed nonoperatively. Forty-six of the 99 patients had a recurrent episode of diverticulitis. Of these 46 patients, 20 underwent a sigmoid colon resection, with only 1 patient requiring a colostomy for obstruction. None of these recurrences resulted in the need for emergency resection. CONCLUSIONS: Surgical treatment should play an important role in the management of patients with complicated diverticulitis because of the high risk of recurrence. However, nonoperative management may be appropriate in a select population if age or medical comorbidities preclude a safe operation since the need for emergency operation is unlikely.

Risk of late bleeding following hemorrhoidal banding in patients on antithrombotic prophylaxis.

BACKGROUND: The risk of bleeding following rubber band ligation of internal hemorrhoids is 1%-2%. This risk may be increased in patients taking antithrombotic therapy. The goal of the current study was to find a safer approach to banding without increasing the risk of bleeding. METHODS: This retrospective review identified patients undergoing banding while on antithrombotic therapy. These medications were held for 7-10 days following the procedure. The number of bands placed while on antithrombotic therapy and their post band complications were recorded. RESULTS: There were 605 bands placed on 364 patients taking antithrombotic medications. There were 23 complications involving bleeding, a value that was not statistically different from those not taking antithrombotic therapy. Patients on clopidogrel experienced 50% of the significant bleeding episodes and 18% of the insignificant bleeding episodes. CONCLUSIONS: Holding antithrombotic medication following banding appears to equalize the risk of bleeding to that of patients not taking antithrombotic medications. Patients taking clopidogrel may be at higher risk for bleeding complications.

Incidence and propagation of infrageniculate deep venous thrombosis in trauma patients.

BACKGROUND: The incidence and propagation of thrombosis involving vessels distal to the popliteal vein has not been clearly defined in trauma patients. Our aim was to determine the incidence and rate of propagation of infrageniculate deep venous thrombosis (DVT) in a trauma population and identify potential risk factors specific to propagation. METHODS: Retrospective review of all trauma admissions between the years 2001 and 2003 was conducted. Only those 18 years or older with an isolated infrageniculate DVT who underwent a lower extremity venous duplex scan during admission were included in the study. Nature of injury, injury severity score (ISS), method of DVT prophylaxis, thrombus location, and risk factors for hypercoagulable states were recorded. RESULTS: During the study period, 698 trauma admissions were included, and 109 (15.7%) with infrageniculate DVT were identified. Thirty-nine (35.7%) had thrombus propagation (14 suprageniculate and 25 infrageniculate) with a mean ISS of 27.6. Seventy (64.3%) had infrageniculate DVT without propagation and a mean ISS of 19.6. Thirty-eight (97%) patients with propagating infrageniculate DVT had received mechanical prophylaxis, and 33 (84%) also received chemical prophylaxis. The 14 patients with suprageniculate thrombus propagation were the most severely injured (mean ISS = 35.1). Elevated ISS, operation, age < or =62 years, and intensive care unit admission were positively correlated with propagation of infrageniculate DVT. CONCLUSION: The incidence and propagation of infrageniculate DVT in an aggressively prophylaxed trauma population are greater than previously reported. The clinical significance of isolated infrageniculate DVT remains to be determined, but when associated with a multiple injury trauma, the patient may be at risk for future suprageniculate DVT formation and may benefit from therapeutic anticoagulation.

Management of diverticulitis in younger patients.

PURPOSE: This study was designed to evaluate the clinical course of sigmoid diverticulitis patients younger than aged 50 years examined by abdominal CT during the first episode of disease to elucidate whether the criteria used for older patients can safely be followed in their younger counterparts. METHODS: Retrospective review of patients with sigmoid diverticulitis treated from 1990 to 2003 was performed. INCLUSION CRITERIA: patients younger than aged 50 years with sigmoid diverticulitis documented by CT scan. Severity of disease was classified according to radiographic findings. Age, gender, treatment, recurrent disease, and need for colostomy were documented. RESULTS: A total of 5,499 patients were identified with sigmoid diverticulitis: 962 patients were younger than aged 50 years, and 411 had a CT scan on their first episode of disease. Of the 411 patients, 335 were classified as uncomplicated and 76 were complicated. Of the uncomplicated patients, 101 underwent an elective operation and 234 were followed nonoperatively. Of those followed, 67 had a recurrent uncomplicated episode, 10 had a recurrent complicated episode, of whom 5 required emergent operation and colostomy. Of the 76 patients with complicated disease, 23 had an emergent operation with colostomy, and 38 had an elective operation. Fifteen patients were followed without an operation and seven had a recurrent uncomplicated episode. None required emergent operation or colostomy. CONCLUSIONS: Younger patients with uncomplicated diverticulitis by CT criteria respond well to medical management and seldom required an emergent operation and colostomy. Young patients with diverticulitis should be treated according to the same criteria used for older patients.

Motorcycle collisions involving white-tailed deer in central and northern Wisconsin: a rural trauma center experience.

BACKGROUND: Risk of deer motorcycle collisions (DMC) continues to increase in Midwestern and East Coast States and is a growing regional public health issue. METHODS: We conducted a retrospective chart review of all motorcycle collisions involving animals over a 9-year period from October 1993 to October 2002. Data collected included Injury Severity Score (ISS), injury type, outcome, use of helmets/alcohol, time of year/day. RESULTS: Fifty-five DMC were identified, 49 drivers, and 6 passengers. ISS for helmeted patients was 6.02+/-4.6 and 17.6+/-14.9 for non-helmeted patients. There were 7 human fatalities (all without helmets). Of the 55 patients, 16% of those injured were intoxicated, without helmets, and had average ISS higher than those non-intoxicated. Head, chest and orthopedic extremity trauma accounted for >70% of injuries seen within the entire population. Incidence peaked in June/July, and 55% of the collisions occurred between the hours of 1800 and 2200. CONCLUSION: DMC are a significant public health issue in mid-western states. Education about helmet and alcohol use and safety on rural roads may be the best prevention. Continued research focusing on prevention is necessary.

Diffuse idiopathic skeletal hyperostosis: a rare cause of Dysphagia, airway obstruction, and dysphonia.

BACKGROUND: We retrospectively query the clinical records of patients with cervical osteophytes to distinguish the clinical features of those presenting with symptomatic dysphagia and airway obstruction. STUDY DESIGN: Retrospective review of all patients presenting over a 20-year period (1985 to 2005) with the diagnosis of cervical osteophytes and dysphagia with or without airway compromise. Two hundred thirty-four patients were identified at Marshfield Clinic between 1985 and 2005; 9 (3.8%) met criteria for inclusion. RESULTS: Eight of nine patients presented with dysphagia. Three of nine patients presented with acute airway obstruction requiring intubation and tracheotomy. Osteophytes occurred at multiple levels, with C4, C5, and C6 being most commonly involved. Surgical decompression resulted in complete resolution of symptoms in four of five patients. CONCLUSIONS: Although commonly found and usually asymptomatic in the older population, anterior cervical osteophytes can be a source of considerable morbidity and potential life-threatening airway obstruction. Recognizing this clinical entity is imperative in establishing a diagnosis and initiating appropriate treatment. Surgical decompression appears to be beneficial in relieving symptoms.

Twenty-year outcome following central duct resection for bloody nipple discharge.

BACKGROUND: Patients found with pathologic nipple discharge present a diagnostic dilemma to surgeons. No one diagnostic test, including cytology or radiologic imaging, has proved superior to any other in the differentiation of benign versus malignant sources of pathologic nipple discharge. Ductoscopy has been introduced as a way to assist with identification of potential sources of pathologic nipple discharge. Ductoscopy is also useful in the resection of deep or peripheral masses that may be missed with standard blind resection. This report evaluates the risk of missed malignancy following central duct resection (CDR). METHODS: Records of 56 patients who underwent CDR for pathologic nipple discharge greater than 15 years previous were reviewed. Data including type of nipple discharge, future biopsy, and pathology reports were all examined. RESULTS: Of the 56 patients, 36 had bloody, 18 serous, and 2 green initial discharges. Fifty-seven percent were found to have intraductal papilloma as the source of discharge, with fibrocystic disease and ductal ectasia providing the next most common causes. One woman was found to have ductal cancer and one lobular carcinoma in situ at time of CDR. Patients were followed for a mean period of 22 years. Fourteen women required future biopsy. Of these, 10 had benign disease and 4 had cancer, 3 on the ipsilateral side. The 3 women with breast cancer were 9, 13, and 17 years from initial resection. CONCLUSIONS: CDR for pathologic nipple discharge is an effective way to diagnose and treat pathologic nipple discharge without missing underlying cancers.