Incidental paraduodenal hernia found during laparoscopic colectomy.

This paper describes a rare right paraduodenal hernia discovered during an elective laparoscopic colon resection. Our patient was a 60-year-old Asian man with a history of multiple bouts of diverticulitis and a lifelong history of mild constipation and postprandial abdominal pain. Prior CT scans and preoperative barium enema confirmed the diagnosis of diverticular disease, and no other abnormalities were appreciated. At laparoscopic exploration, a right paraduodenal hernia was found with complete herniation of the small intestine under the ascending colon and hepatic flexure. The unclear anatomy prompted conversion to an open laparotomy. This allowed safe reduction of the hernia and sac excision. Adhesions were lysed to relieve a partial duodenal obstruction, and a Ladd's procedure was performed to correct the incomplete rotation. Additionally, a sigmoid colectomy was performed. After prolonged ileus, the patient was discharged on postoperative day 14. At 6-month follow-up, the patient was asymptomatic and doing well.

Outcome analysis of HIV-positive patients with anal squamous cell carcinoma.

PURPOSE: With improved antiretroviral therapy, HIV-positive patients are achieving a longer life expectancy. An increased incidence of anal squamous cell carcinomas has been noted in these patients. The purpose of this study was to determine the outcome of HIV-positive patients with anal squamous cell carcinomas. METHODS: We conducted a review based on our tumor registry from 1980 through 1999. We identified 73 patients with anal squamous cell carcinoma treated at the University of Texas Southwestern Medical Center affiliated hospitals; 23 were HIV positive (18 had AIDS). In the HIV-positive group, 9 had in situ squamous carcinomas and 14 had invasive squamous cell carcinomas. Data collected included age, CD4 count, treatment, complications, and survival; these data were analyzed by Student's t-test. RESULTS: All patients were male. Those with squamous cell cancer of the anus were offered radiation therapy and chemotherapy. Beginning in 1998, all patients received highly active antiretroviral therapy before treatment. Seven of 14 anal squamous cell carcinoma patients had their therapy adjusted owing to toxicity. Morbidity included proctocolitis and diarrhea (n = 2) requiring diversion (n = 1), hemorrhagic cystitis (n = 1), neutropenic fever (n = 3), bone marrow suppression (n = 1), and urethral stricture (n = 1). Mean age was 42 years for anal squamous cell carcinoma patients and 36 years for squamous cell carcinoma in situ patients (P = 0.05). Mean CD4 count was 222 cells/ml in patients with infiltrating carcinoma and 200 in the in situ patients (P = NS). One-year and five-year mortality rates, respectively, were 40 percent and 80 percent for infiltrating carcinoma patients and 17 percent and 50 percent for the in situ patients. Both of the in situ patients who died had CD4 counts <20 cells/ml at diagnosis, whereas the rest had CD4 counts >100 cells/ml and are currently without anal disease. Mean CD4 count at diagnosis for all patients who died was 133 cells/ml, whereas for those surviving, it was 261 cells/ml (P = 0.03). Eight (all with infiltrating carcinoma) of the 10 patients who died had persistent anal disease, but none had metastasis. CONCLUSION: HIV-positive patients with in situ carcinomas present at an earlier age than those with infiltrating lesions. In situ patients with CD4 counts as low as 105 cells/ml do well with local excision. A low CD4 count at diagnosis without highly active antiretroviral therapy predicts a poor prognosis. Because these patients appear to succumb to their HIV status and not the anal disease, anal squamous cell carcinoma should be included with cervical squamous cell carcinoma as an AIDS-defining illness. HIV-positive patients, particularly AIDS patients, with invasive anal cancers and without effective antiretroviral therapy obtain little benefit and significant toxicity from current radiation therapy and chemotherapy. Initiation of highly active antiretroviral therapy in HIV-positive patients before radiation therapy and chemotherapy are begun may decrease toxicity and improve survival. Additional clinical trials are warranted to test this theory.

Primary colonic lymphoma.

BACKGROUND AND OBJECTIVES: The colon is a rare location for gastrointestinal non-Hodgkin's lymphoma (NHL). This study was undertaken to identify risk factors, presentation, treatment, and prognosis for primary colonic lymphoma (PCL) through review of a large tertiary care hospital system experience. METHODS: A retrospective review of all patients with colonic malignancy and NHL was performed using pathology and cancer registry databases from January 1989 to December 1998. Criteria for inclusion were no evidence of extraperitoneal disease, no leukemic or lymphomatous abnormalities in the blood, and disease confined to the colon. RESULTS: Seven patients met the inclusion criteria (4 male, 3 female; 33-72 years). They represented 1.4% of all NHL, 14% of gastrointestinal NHL and 0.9% of all colonic malignancies diagnosed during this period. Three of the patients had positive serology for human immunodeficiency virus; one was taking steroids chronically for Addison disease. The most common presentation was nonspecific abdominal pain. The lack of specific symptoms delayed diagnosis from 1-12 months. All patients underwent laparotomy with resection. The most common tumor location was the cecum (5/7, 71%). Regional lymph nodes were affected in all but 1 patient. All tumors were B-cell lymphomas (5 small noncleaved cell, 2 large cell). Six of 7 patients received adjuvant chemotherapy. Of the 6 patients available for follow-up four remain alive (12, 19, 23, and 25 months after diagnosis). In both patients who died the disease recurred diffusely. CONCLUSIONS: The colon is a rare location for NHL. Immunosuppression is the most common risk factor. Patients' frequently present with non-specific abdominal pain, this leads to lengthy delays in diagnosis. Most of these tumors are located in the cecal area. Surgery is the most widely utilized form of therapy. Although adjuvant therapy is frequently utilized, its' impact on survival is unclear.

Ketorolac improves recovery after outpatient anorectal surgery.

PURPOSE: The purpose of this study was to evaluate the effectiveness of ketorolac combined with local anesthetics for anorectal surgery. METHODS: From June 1998 through March 1999, 123 outpatients undergoing anorectal surgery were entered into a prospective, randomized, double-blinded study involving three treatment groups. All patients received intravenous sedation consisting of fentanyl and a propofol infusion, with a local anesthesia mixture of lidocaine, bupivacaine, and bicarbonate. Group A (41 patients) received placebo (saline) injections. Group B (41 patients) received 60 mg of intravenous ketorolac at the onset of the procedure, and Group C (41 patients) received 60 mg of ketorolac mixed with the local anesthetic. Data were analyzed using analysis of variance and chi-squared tests. RESULTS: All groups had similar demographic characteristics and operative procedures. Twenty-nine of the 123 patients were human immunodeficiency virus-positive. There was no difference in operative or anesthesia time. Anesthesia and fluids given were similar in across groups. A significantly higher percentage of Group A patients had pain (34 percent) and required additional oral analgesia (20 percent) in the Day Surgery Unit. Only 5 percent of Group B and Group C patients complained of pain, with oral analgesics given to 2 percent of Group B and none in Group C. Voiding difficulties were more common in Group A patients, one patient requiring catheterization. CONCLUSION: The addition of ketorolac (60 mg), either intravenous or injected with local anesthetics, reduces voiding problems and significantly decreases postoperative analgesic requirements in outpatients undergoing anorectal surgery.

Rare presentation of actinomycosis as an abdominal mass: report of a case.

PURPOSE: The purpose of this article was to report an unusual presentation of abdominal actinomycosis masquerading as a tumor. METHODS: The patient was a 54-year-old male who presented with vague abdominal discomfort and a palpable left lower quadrant mass defined on CT scan. Multiple intraoperative core biopsies were nondiagnostic, and he underwent en bloc resection of the mass and adjacent organs for a presumed tumor. RESULTS: Examination of tissue from deep within the excised specimen revealed sulfur granules diagnostic for actinomycosis. CONCLUSION: Abdominal actinomycosis is an extremely rare infection that can mimic multiple disease processes and requires accurate diagnosis for successful therapy. This novel presentation and a review of the literature are reported.

Practice parameters for the treatment of sigmoid diverticulitis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Appendiceal diverticulitis.

We report the case of a 56-year-old man with episodic right lower quadrant abdominal pain. Preoperative evaluation included computed tomography (CT) showing a right lower quadrant phlegmon consistent with cecal diverticulitis or appendicitis. The patient was treated with a short course of bowel rest and antibiotics. Four weeks later, he had an appendectomy. The patient was found to have chronic appendiceal diverticulitis and recovered uneventfully. Histopathologic studies revealed herniated mucosa through the muscular layer associated with chronic inflammation and marked fibrosis. These findings represent appendiceal diverticulitis. Diverticulosis of the appendix is believed to be uncommon and roentgenologic diagnosis of appendiceal diverticular disease is rarely made. We discuss the diagnosis and CT findings of appendiceal diverticulitis and present a thorough review of the literature.

Anorectal lymphoma and AIDS: an outcome analysis.

BACKGROUND AND OBJECTIVE: Primary lymphoma of the anus is an extremely rare problem. In patients with the Acquired Immune Deficiency Syndrome (AIDS), there is a marked increase in gastrointestinal non-Hodgkin's lymphomas (NHL). The aim of this study was to evaluate the outcome of patients with anorectal NHL and AIDS. METHODS: Over an 18-year period, we identified 6 patients with AIDS and primary anorectal NHL. Five were male. All were high-grade B-cell lymphomas and half showed systemic "B" symptoms. Patient's mean CD4 count was 93 (range 8 to 201). RESULTS: The average life span for those with "B" symptoms was 6.7 months and 16 months for those without symptoms. No benefit was shown from radiation or chemotherapy in those with "B" symptoms. Younger patients and those without systemic constitutional symptoms of lymphoma do better. One patient without "B" symptoms was able to tolerate his radiation and chemotherapy and is disease free at 10 months. CONCLUSION: Despite traditional non-Hodgkin's lymphoma treatment regimens, our AIDS patients (and those examined in a review of the pertinent literature) with anorectal NHL and "B" symptoms have a poor prognosis. For those without "B" symptoms and who can tolerate the therapy, NHL remission may be obtained.

Posterior sagittal anorectoplasty in adults: secondary repair for persistent incontinence in patients with anorectal malformations.

PURPOSE: Posterior sagittal anorectoplasty, regarded as a standard surgical primary repair for anorectal malformations in infancy, was evaluated for effectiveness when performed as a secondary operation for establishing continence in the adult. The purpose of this review was to evaluate our results of performing posterior sagittal anorectoplasty in adult patients and to emphasize the extensive evaluation required to perform proper patient selection. METHOD: From January 1, 1992, to December 31, 1996, eight patients with Grade 3 incontinence underwent posterior sagittal anorectoplasty. The ages ranged from 13 to 40 (mean, 26) years. RESULTS: All patients had diverting stomas at the time of repair and all but one had restoration of intestinal continuity. Of eight patients who underwent posterior sagittal anorectoplasty, one failed secondary to rectal ischemia and retained a diverting stoma. Six patients had restoration of continuity. Five patients were continent and one had incontinence only to gas. DISCUSSION: We have established that posterior sagittal anorectoplasty can effectively be used to establish continence as a secondary procedure for a select group of adult patients.

Hyperplastic-adenomatous polyposis syndrome.

BACKGROUND: Although the syndrome of familial adenomatous polyposis is well known, sporadic patients with multiple polyposis are rare. There are no known syndromes associated with hyperplastic polyposis. In our search of the English surgical literature, we find no reference to a hyperplastic-adenomatous polyposis syndrome. STUDY DESIGN: Over a 3-year period, we identified six patients ages 41 to 75 (mean age 61) with 50 to 100 hyperplastic polyps associated with adenomas. RESULTS: Most of the hyperplastic polyps were found in the left colon and the largest ranged in size from 6 mm to 18 mm. The larger polyps were clinically indistinguishable from adenomas. Three of our six patients had invasive cancer of the proximal colon. All tumors were confined to the bowel wall. There was a family history of colon cancer in only one patient and no family history of polyposis. CONCLUSION: These patients differ from previously described patients with polyposis syndromes; hyperplastic-adenomatous polyposis syndrome (HAPS) occurs in an older population with no family history of polyposis, has fewer polyps, most of which are hyperplastic, and is strongly associated with adenocarcinoma of the colon. In this series, we describe a previously unreported hyperplastic-adenomatous polyposis syndrome.

Rectal sleeve advancement: repair of rectovaginal fistula associated with anorectal stricture in Crohn's disease.

Successful repair of rectovaginal fistula in patients with Crohn's disease has been reported when these patients have a normal appearing rectum. We report the performance of stricturectomy in conjunction with circumferential rectal sleeve advancement for patients who have a rectovaginal fistula arising from an anorectal stricture secondary to Crohn's disease. This technique provides for repair of rectovaginal fistula and correction of the anal stricture and maintains continence.

Streptococcus sanguis bacteremia and colorectal cancer.

Streptococcal bacteremia is an uncommon presentation for colorectal malignancy, yet most physicians are aware of the association between Streptococcus bovis infection and these malignancies. Many are unaware, however, that other streptococcal species are associated with colon and rectal cancers. In this case report and brief review, we highlight this association and discuss a case of Streptococcus sanguis bacteremia associated with an early invasive rectal cancer.