Changing trends in surgery for abdominal Crohn's disease.

AIM: The introduction of biological agents and laparoscopy are, arguably, the most important developments for the treatment of Crohn's disease (CD) in the last two decades. Due to the efficacy of biological agents in treating mild disease, it is likely that the percentage of surgery for complex cases may have increased. The objective of this study was to analyse the changing characteristics and results of the surgical treatment of patients with CD over the past 13 years. METHODS: All patients who underwent abdominal surgery for CD between 2004 and 2016 were retrospectively identified. Data were compared between two periods (2004-2010 and 2011-2016). RESULTS: A total of 908 procedures were performed (48% men, mean age 43 ± 16 years). Demographic and CD characteristics changed significantly over time: comorbidities were more frequent (35% vs 46%, P < 0.0001), and preoperative steroids (28% vs 36%, P < 0.01) and anti-tumour necrosis factor (20% vs 40%, P < 0.0001) treatments were more frequently used in the second period. Smoking (14% vs 8%, P < 0.0001) and use of immunosuppressors (32% vs 22%, P < 0.001) decreased significantly. More cases of penetrating disease (22% vs 32%, P < 0.001) were operated upon in the second period. The laparoscopic approach (49% vs 57%, P < 0.04) was more frequently performed and mean blood loss (167 ± 222 vs 123 ± 243 ml, P < 0.01) decreased significantly. Postoperative morbidity did not change between the two periods. CONCLUSION: Despite a higher incidence of comorbidities and the use of biologics postoperative morbidity remained unchanged. An increased use of laparoscopy and a decreased intra-operative blood loss may have contributed to offsetting the impact of increased comorbidity.

Cyclooxygenase blockade elevates leukotriene E4 production during acute anaphylaxis in sheep.

We examined changes in the levels of eicosanoids in blood and pulmonary lymph of anesthetized sheep undergoing acute anaphylaxis. Within 1-3 min of intravenous antigenic challenge of previously sensitized sheep, there were approximately 7-30-fold elevations in mean arterial plasma levels of thromboxane B2 and 6-ketoprostaglandin F1 alpha, respectively, as measured by RIA. Negligible changes in levels of these cyclooxygenase products were found in both nonsensitized sheep and in sensitized sheep treated with indomethacin before antigenic challenge. In contrast, no changes in levels of sulfidopeptide leukotrienes (SPLT) in pulmonary lymph were detectable by RIA during anaphylaxis in sensitized or nonsensitized sheep, but levels of SPLT in indomethacin-treated sensitized sheep increased more than fivefold above levels in lymph from both other groups of animals. The immunoreactive SPLT in lymph from indomethacin-treated sheep was accounted for as LTE4, as demonstrated by mobility on HPLC and absorbance at 280 nm. These results support the possibility that certain undesirable effects of nonsteroidal antiinflammatory drugs, such as cardiopulmonary reactions in aspirin-sensitive individuals, and impaired renal and cardiac function during therapy with these drugs, may be related in part to augmented synthesis of the 5-lipoxygenase pathway products, especially those of the sulfidopeptide class. Increased LT production could also limit the antiinflammatory effectiveness of these drugs in many disease states.

Segmental Colectomy for Ulcerative Colitis: Is There a Place in Selected Patients Without Active Colitis? An International Multicentric Retrospective Study in 72 Patients.

BACKGROUND AND AIMS: The aim of this study was to report a multicentric experience of segmental colectomy [SC] in ulcerative colitis [UC] patients without active colitis, in order to assess if SC can or cannot represent an alternative to ileal pouch-anal anastomosis [IPAA]. METHODS: All UC patients undergoing SC were included. Postoperative complications according to ClavienDindo's classification, long term results, and risk factors for postoperative colitis and reoperation for colitis on the remnant colon, were assessed. RESULTS: A TOTAL OF: 72 UC patients underwent: sigmoidectomy [n = 28], right colectomy [n = 24], proctectomy [n = 11], or left colectomy [n = 9] for colonic cancer [n = 27], 'diverticulitis' [n = 17], colonic stenosis [n = 5], dysplasia or polyps [n = 8], and miscellaneous [n = 15]. Three patients died postoperatively and 5/69 patients [7%] developed early flare of UC within 3 months after SC. After a median followup of 40 months, 24/69 patients [35%] were reoperated after a median delay after SC of 19 months [range, 2-158 months]: 22/24 [92%] underwent total colectomy and ileorectal anastomosis [n = 9] or total coloproctectomy [TCP] [n = 13] and 2/24 [8%] an additional SC. Reasons for reoperation were: colitis [n = 14; 20%], cancer [n = 3] or dysplasia [n = 3], colonic stenosis [n = 1], and unknown reasons [n = 3]. Endoscopic score of colitis before SC was Mayo 23 in 5/5 [100%] patients with early flare vs 15/42 without early flare [36%; p = 0.0101] and in 9/12 [75%] patients with reoperation for colitis vs 11/35 without reoperation [31%; p = 0.016]. CONCLUSIONS: After segmental colectomy in UC patients, postoperative early colitis is rare [7%]. Segmental colectomy could possibly represent an alternative to IPAA in selected UC patients without active colitis.

Leukotriene D4: a potent coronary artery vasoconstrictor associated with impaired ventricular contraction.

Leukotriene D4 (2 c 10(-9) mole), injected into the left circumflex coronary artery of anesthetized sheep, produced profound coronary vasoconstriction and impaired regional ventricular wall motion. This cardiac effect was neither inhibited by prior treatment of the sheep with a cyclooxygenase inhibitor nor associated with thromboxane B2 release into the coronary sinus. Intravenous FPL 55712 completely abolished the coronary vasoconstriction of leukotriene D4, but a significant reduction of regional wall shortening persisted.

Karyometric marker features in normal-appearing glands adjacent to human colonic adenocarcinoma.

The expression of nuclear marker features in normal-appearing tissue adjacent to colonic adenocarcinoma was investigated. Formalin-fixed, paraffin-embedded tissue sections of colon from 9 patients with adenocarcinoma and from 9 normal controls were cut 4 microns thick, Feulgen stained, and measured by a cell image analysis system using a Matrox MVP-AT/NP imaging board. Thirty nuclei in the tumor region, 30 nuclei 2 mm into the histologically normal-appearing distal margin, and the same number at 5, 10, 20, and 50 mm into the margin were measured for each patient. An additional 30 nuclei were recorded from 9 patients each free from colonic disease. Nuclear features were selected to discriminate between tumor nuclei and nuclei from normal control subjects and between nuclei measured in the histologically normal-appearing margin next to the tumor and control nuclei. Eight micromorphometric measures were found to be statistically significantly different in nuclei measured in the margin site, including features describing staining density (total absorbance, average absorbance 20% below mean, average absorbance 20% above mean) chromatin texture (cooccurrence matrix, run length, and peripheral tendency) and nuclear area. The category differences are statistically highly significant.

Prognostic value of bcl-2 oncoprotein expression in stage II colon carcinoma.

The bcl-2 proto-oncogene encodes a Mr 25,000 protein that has been shown to prevent apoptosis or programmed cell death. The bcl-2 protein is detectable in basal cells of normal colonic epithelium, and an altered topographic distribution of this protein is found in colonic neoplasms. However, the clinical significance of abnormal bcl-2 expression in colon carcinomas remains unknown. We examined the prognostic value of the bcl-2 protein in TNM stage II colon carcinomas and its relationship to DNA ploidy, cell proliferation indices, p53 expression, and clinicopathological features. We analyzed 119 resected and otherwise untreated, paraffin-embedded stage II colon carcinomas for bcl-2 and p53 protein expression using immunohistochemistry. DNA ploidy and proliferative index (% S-phase + % G2-M) were determined by flow cytometry, and tumor grade and vascular microinvasion were assessed on histological sections. Cytoplasmic expression of the bcl-2 protein was detected in 72 (66%) of 110 carcinomas, and a high level of expression was significantly correlated with diploid DNA content (P = 0.02) and low proliferative activity (P = 0.005). bcl-2 was not associated with nuclear p53 expression. In a univariate analysis, a higher fraction of bcl-2-positive tumor cells was associated with better relapse-free survival (P = 0.02) and overall survival (P = 0.05) rates. Moreover, a high level of bcl-2 expression was an independent predictor of better relapse-free survival (P = 0.04), but not overall survival (P = 0.14), after adjustment for other variables, including proliferative index, DNA ploidy, and race. In conclusion, bcl-2 overexpression is associated with favorable prognostic features and may predict clinical outcome in stage II colon carcinomas.

Apoptotic and mitotic indices predict survival rates in lymph node-negative colon carcinomas.

An imbalance between apoptosis and mitosis is believed to underlie colon cancer development and progression. These processes regulate the growth of normal and neoplastic epithelia, and in tumors, may confer prognostic information. To test this hypothesis, we determined apoptotic and mitotic indices (AI, MI) by morphology in H&E sections of 154 lymph node-negative, sporadic colon carcinomas. The relationship of these indices to genetic (p53 and Bcl-2) and biological features (DNA ploidy and cell kinetics) and patient survival rates was determined. Tumor features were compared in proximal and distal tumors, given postulated differences in their pathogenesis. Bcl-2 and p53 proteins were examined using immunohistochemistry and DNA ploidy and proliferative indices (PIs) by flow cytometry. Tumor features were dichotomized for analysis of relapse-free survival and overall survival (OS) rates using a Cox proportional hazards model. Median patient follow-up was 8.8 years. The median AI and MI were 1.2% (0-7.6) and 0.40% (0-1.8), respectively, and did not differ by tumor site. AI correlated with histological grade (P = 0.03); MI correlated with PI (P = 0.02) and inversely with Bcl-2 in distal tumors (P = 0.02). p53 and Bcl-2 expression were detected in 52 and 53% of tumors, respectively. Distal tumor site was associated with aneuploidy (P = 0.001), p53 (P = 0.001), and PI > 15% (P = 0.002). In a univariate analysis, colon cancers with high MIs (>0.5%) had a poor prognosis (P = 0.04). Bcl-2 overexpression (>20% + tumor cells) was associated with more favorable OS (P = 0.04). The association of ploidy and PI with outcome was of borderline significance for all tumors; however, diploidy predicted better survival in proximal cancers. In distal cancers, low AIs (< or = 0.25%) and high MIs (>0.5%) were adverse prognostic markers. After adjustment for other variables, an increased MI predicted shorter OS with a hazard ratio (HR) for death of 2.70; 95% confidence interval (CI) was 1.23-5.91 (P = 0.01). Expression of Bcl-2 was associated with more favorable OS (HR, 0.46; 95% CI, 0.21-1.0; P = 0.06). In proximal cancers, Bcl-2 expression was the most important predictor of OS (HR, 0.17; 95% CI, 0.03-0.85; P = 0.03). In distal tumors, low AIs (HR, 3.33; 95% CI, 1.27-9.09; P = 0.01) and high MIs predicted poor survival. In conclusion, increased mitosis and low or absent Bcl-2 expression are significant risk factors for death in node-negative colon cancers, as are low rates of apoptosis in distal tumors. If validated prospectively, our results may identify patient subsets than can benefit from adjuvant chemotherapy.

Pancreatic microcystic adenoma coexistent with pancreatic ductal carcinoma. A report of two cases.

We report two cases of microcystic (glycogen-rich) adenoma of the pancreas with coexistent pancreatic adenocarcinoma. Both patients presented with an epigastric mass. On laparotomy, each had two separate pancreatic tumors. The benign tumors were composed of small cysts with a flattened to cuboidal glycogen-rich epithelium. Both malignant tumors were composed of mucinous epithelium and showed positive staining for CEA and Leu-M1. Although pancreatic microcystic adenoma and ductal adenocarcinoma are believed to arise from different precursor cells, the association reported here suggests a common predisposition to both tumors. Careful examination of the pancreas is warranted in cases of microcystic adenoma to rule out a possible coexistent pancreatic carcinoma.

The implications of acute pouchitis on the long-term functional results after restorative proctocolectomy.

A prospective study was conducted to determine the implications of acute pouchitis on the long-term functional results of restorative proctocolectomy with J-pouch ileoanal anastomosis (IPAA). Between July 1988 and June 1996, 137 consecutive patients underwent IPAA for treatment of ulcerative colitis. 127 patients (93%) have been available for follow-up. All patients completed diaries detailing bowel habits over a 7-day period at 3, 6, 9, 12, 18, 24 months, and yearly after reestablishment of intestinal continuity. Diaries were completed only during time periods in which patients were not suffering from acute symptomatic pouchitis. Patients with chronic pouchitis (n = 7) were excluded from this study leaving 120 patients for analysis. Fifty patients suffered at least one episode of pouchitis (Pouchitis Group). Seventy patients never had pouchitis (No Pouchitis Group). Patients with a history of pouchitis having significantly more bowel movements per day were more likely to ever have minor incontinence (75% vs. 45%, p < 0.005) or major incontinence (37% vs. 17%, p < 0.02). The stools of Pouchitis Group were less likely to be formed (24% vs. 31%, p < 0.001). Pouchitis Group patients also were more likely to wear a protective pad during the day (21% vs. 7% p < 0.04) or during the night (40% vs. 13%, p < 0.001). Even in the absence of clinically active pouchitis, patients who have suffered at least one episode of pouchitis have a poorer long-term functional result after IPAA. The results of this study suggest that ileal pouchitis may represent a chronic condition that displays episodic symptomatic exacerbations.

Osteoclast-like giant cell tumor of the pancreas: immunophenotypic similarity to giant cell tumor of bone.

An immunophenotype was performed on an osteoclast-like giant cell tumor of the pancreas using a panel of antibodies to epithelial and leukocyte antigens. Several antibodies to cytokeratin and carcinoembryonic antigen were negative in the tumor. Osteoclast-like cells were positive for CD4, CD13, CD45, CD68, CD71, and vimentin, but negative for lysozyme and HLA-DR. Mononuclear tumor cells were positive for CD4, CD11c, CD13, CD14, CD45, CD68, CD71, HLA-DR, and vimentin, but negative for lysozyme. The phenotype is similar to that previously described for giant cell tumor of bone. The osteoclast-like cell phenotype is also similar to that reported for normal osteoclasts. The findings support a nonepithelial origin for osteoclast-like giant cell tumor of the pancreas, and suggest a derivation similar to giant cell tumor of bone.

Complications of tracheal reconstruction. Incidence, treatment, and prevention.

Between 1962 and 1982, 416 primary tracheal reconstructions and 21 staged reconstructions were performed. Since then 80 additional tracheal reconstructions have been accomplished (to April of 1985). The first 20 years of our experience (1962 to 1982) have been scrutinized to identify complications and describe their management in patients operated on for tumors or postintubation lesions only. Because the series includes all cases, commencing in 1962 when tracheal surgery was not well developed, many complications reflect a learning experience. The first and second halves of the series have therefore been compared. Measures to prevent complications are discussed.

Prospective analysis of perioperative morbidity in one hundred consecutive colectomies for ulcerative colitis.

BACKGROUND: This study was undertaken to evaluate prospectively the indications for surgical treatment and perioperative morbidity for patients with idiopathic ulcerative colitis (UC). METHODS: Between January 1985 and August 1994, 145 patients were referred to the senior author (F.M.) for treatment of UC. Data were prospectively collected. One hundred patients have completed all stages of their surgical treatment and have been followed up for at least 1 year. These 100 patients form the basis of this study. RESULTS: Thirty patients underwent a proctocolectomy with end-ileostomy in one (25) or two (5) stages. Seventy patients underwent a restorative proctocolectomy with ileal J-pouch anal anastomosis in either one (2), two (37), or three stages (31). In total 100 patients underwent 204 procedures. Failure of medical treatment was by far the most common indication. The initial colectomy was performed electively in 61 patients and urgently in the remaining 39. The rate of perioperative complications for elective and urgent colectomy was 26% and 44%, respectively (p < 0.05). CONCLUSIONS: The overall perioperative morbidity rate remains high and almost doubles for urgent cases. Reducing the need for urgent procedures by earlier elective colectomy may allow for a reduction in perioperative morbidity.

Incidence and therapeutic implications of synchronous colonic pathology in colorectal adenocarcinoma.

BACKGROUND: The presence of synchronous benign and malignant colonic pathology may influence the magnitude of surgery for colorectal adenocarcinoma. The aim of this prospective study was to quantitate the need for a more extensive surgical procedure because of synchronous pathology in colorectal cancer patients. METHODS: Between 1984 and 1996, 235 consecutive patients were treated for colorectal adenocarcinoma. Preoperative survey of the colon in 228 patients included colonoscopy (91%) and double contrast barium enema (35.7%). Seven patients were excluded for incomplete preoperative survey because of perforating or obstructing colon carcinoma or acute ulcerative colitis. RESULTS: One hundred four patients (45.6%) had the following synchronous colonic lesions: benign polyps (68 patients, 29.8%), diverticular disease (30, 13.1%), ulcerative colitis (10, 4.4%), synchronous adenocarcinoma (8, 3.5%), and Crohn's colitis (3, 1.3%). Pathologic examination demonstrated three additional synchronous adenocarcinomas for a total of 11 patients (4.9%). Twenty-five (11%) required more extensive surgery than dictated by the primary cancer. Of these 25 patients, 17 had a benign or premalignant condition associated with their carcinoma and 8 had a synchronous carcinoma. Seventeen patients underwent a sphincter-saving procedure. Of the remaining eight patients requiring sphincter ablation, seven were needed because of a synchronous nonmalignant lesion, rather than because of the primary tumor. CONCLUSIONS: In our patient population, the incidence of synchronous colorectal lesions was 45.6%. Synchronous colorectal cancer occurred in 4.9%. In 11%, the presence of synchronous colorectal lesions made the surgical procedure more extensive than that dictated by the primary cancer, and in 3%, the need for a sphincter ablating procedure was dictated by a synchronous nonmalignant lesion.

Surgical treatment of anorectal complications in Crohn's disease.

BACKGROUND: The purpose of our study was to elucidate features, surgical procedures, and long-term results in patients with anorectal complications of Crohn's disease. METHODS: Physical findings, surgical treatment, and long-term outcome were recorded prospectively for 224 patients who had anorectal complications of Crohn's disease between October 1984 and May 1999. RESULTS: Presenting complications included abscess (n = 36), fistula-in-ano (n = 51), rectovaginal fistula (n = 20), anal stenosis (n = 40), anal incontinence (n = 11), or a combination of features (n = 66). Twenty-four patients did not undergo surgical treatment; the remaining 200 patients underwent 284 procedures. Ultimately, 139 patients (62%) retained anorectal function; reasons for proctectomy in the remaining 85 patients included disease (n = 66), extensive fistular disease (n = 15), fecal incontinence (n = 2), and tight anal stenosis (n = 1). Patients with rectal disease had a significantly higher rate of proctectomy than patients with rectal sparing (77.6% vs. 13.6%, respectively, P<.0001). In the absence of rectal involvement, patients with multiple complications had a significantly higher rate of proctectomy than patients with single complications (23% vs. 10%, P<.05). CONCLUSIONS: A wide spectrum of surgical techniques is required for the management of the diverse anorectal complications of Crohn's disease. Complete healing and control of sepsis can be achieved in the majority of patients. Active rectal disease and multiple complications significantly increase the need for proctectomy.

Analysis of clinicopathologic prognostic features in patients with gastric adenocarcinoma.

BACKGROUND: We evaluated the influence of several clinicopathologic variables on 5-year actuarial survival rate after curative resection of gastric adenocarcinoma. METHODS: Clinical characteristics were retrieved from the records of all patients who underwent gastric resection for curative intent between 1965 and 1986 at The University of Chicago Medical Center, and follow-up was obtained from our tumor registry. Pathologic characteristics were determined from a detailed review of all available histopathologic slides. RESULTS: One hundred seventy-eight patients underwent a curative resection during the study period at our institution. Overall 5-year actuarial survival rate was 29%. The relationship between clinicopathologic variables and 5-year survival rate was evaluated by Kaplan-Meier survival curve construction and chi-squared analysis. Lymphatic and/or capillary microinvasion (absent vs present, p < 0.001), tumor location (antrum and body vs gastroesophageal junction, p = 0.05), local extent of disease (limited to the gastric wall versus involving adjacent organs, p = 0.003), stage (absence versus presence of lymph node metastases, p < 0.001), Lauren type (intestinal versus diffuse, p < 0.01), and Ming type (expanding versus infiltrative, p < 0.02) significantly influenced survival. When a multivariate analysis with logistic regression of 5-year survival was performed, lymphatic and/or capillary microinvasion emerged as the only statistically significant, independent prognostic factor associated with long-term survival (p = 0.039). If microinvasion was omitted from the analysis, lymph node metastases (p < 0.05) and the extension to adjacent organs (p < 0.04) became the only statistically significant variables. Multiple correlation analyses suggested that microinvasion is an early histopathologic finding that correlates with a more aggressive natural history. CONCLUSIONS: Lymphatic and/or capillary microinvasion is a more powerful predictor of 5-year survival than lymph node metastases or tumor extension to adjacent organs. Correlation among clinicopathologic variables suggests that microinvasion may represent an early finding, serving as a potential marker for a biologically more aggressive tumor.

Prospective study of the features, indications, and surgical treatment in 513 consecutive patients affected by Crohn's disease.

BACKGROUND: The aim of this prospective study was to elucidate the features, indications, and surgical treatment in patients affected by complications of Crohn's disease. METHODS: Between January 1985 and July 1996, 513 consecutive patients (248 male, 265 female; mean age, 38 years) were operated on for 542 occurrences of Crohn's disease. Data were collected prospectively. RESULTS: Indications for abdominal surgery were often multiple but included failure of medical management (n = 220), obstruction (n = 94), intestinal fistula (n = 68), mass (n = 56), abdominal abscess (n = 33), hemorrhage (n = 7), and peritonitis (n = 9). Four hundred sixty-four abdominal procedures were performed, necessitating 425 intestinal resections and 97 stricture plasties. The use of stricture plasty was more common in the second half of the study (16.0% versus 7.3%, second half versus first half; p < 0.01). Perioperative complications occurred in 75 of the 464 abdominal operations (16%). There were no deaths. One hundred thirty patients (25%) required operation for perineal complications of Crohn's disease. The presence of Crohn's disease in the rectal mucosa was associated with a higher risk for permanent stomas in patients requiring operation for treatment of perianal Crohn's disease (67% versus 11%; p < 0.001). CONCLUSIONS: Patterns of surgical treatment in Crohn's disease are changing, with more emphasis on nonresectional options. The presence of rectal involvement significantly increases the need for a permanent stoma in patients with perianal Crohn's disease.

Introduction of human adenomatous polyposis coli gene into Min mice via cationic liposomes.

BACKGROUND: The adenomatous polyposis coli (APC) gene is a tumor-suppressor gene involved in familial polyposis coli (FAP), a hereditary disease heralded by the development of hundreds of colorectal adenomas. A mouse model for FAP, the multiple intestinal neoplasia (Min) mouse, develops multiple adenomatous polyps of the large and small intestine similar to their human counterparts. To test the feasibility of introducing normal human APC as a means of either preventing or reversing polyp formation, we describe a method of in vivo transfection of APC into colonic epithelium of the Min mouse. METHODS: Anesthetized young (4 weeks) Min mice were treated with enemas containing lipofectant and a normal human APC cDNA plasmid every 72 hours for 2 months and then euthanized at 24, 48, and 72 hours after the last treatment. Polymerase chain reaction (PCR) was used to detect the presence of the plasmid DNA. RESULTS: PCR on the extracted colonic epithelial DNA showed the presence of plasmid DNA up to 72 hours after the last treatment. Expression of the plasmid construct was confirmed by reverse transcriptase-PCR. CONCLUSIONS: We have demonstrated the repeated introduction and detection of normal human APC in the colonic epithelium of the Min Mouse in vivo during an extended period of time with no toxic side effects by means of our prolonged therapy.

Regional lymph node dissection for malignant melanoma of the extremities.

Seven hundred thirty-nine patients with malignant melanoma of the extremities were treated with a uniform surgical approach that included wide and deep excision of the primary site and regional node dissection therapeutically and electively for invasive lesions (Clark's levels III, IV, and V). Of the 490 patients who underwent lymph node dissections, follow-up was available for 457 (93%). Life-table comparison of 362 patients with histologically negative nodes to 95 with histologically proved lymph node metastases yielded statistically significant differences in survival (P less than 0.001). Five-year cumulative survival rates were 91% in the group without and 48% in the group with nodal metastases. Among histologically positive patients, differences in life-table survival curves for the 60 clinically negative patients compared to the 35 clinically positive patients were also statistically significant (P = 0.004); 5-year cumulative survival rates were 57% for the former group and 33% for the latter. Although there appears to be an advantage to regional lymph node dissection for micrometastases as opposed to gross nodal involvement, for the majority of patients metastatic melanoma in these nodes is the major indicator of systemic disease.

Local recurrence after curative resection of colorectal adenocarcinoma.

A total of 853 patients with 861 colorectal adenocarcinomas were operated on at our institution between 1965 and 1981. Complete follow-up information was obtained in all but six patients (99.4%), and all available histologic slides were reviewed to determine pathologic stage and characteristics. Six hundred fifty-one patients (76.3%) underwent a potentially curative procedure, and their operative mortality rate was 2.8%. Of the 627 patients available for analysis, 50 (8%) had a local recurrence. The median time to local recurrence was 18 months, and only 16% of local recurrences were diagnosed 5 years after the original resection. Median survival of patients with a local recurrence was 3 1/2 years from the original resection, and 16 patients (32%) survived 5 years or longer. A multivariate logistic regression analysis was conducted to examine the influence of several clinical and pathologic characteristics on local recurrence among Dukes' stages B and C adenocarcinomas (n = 539) after exclusion of patients with synchronous tumors (n = 8), postoperative deaths (n = 18), loss to follow-up (n = 6), or incomplete data (n = 11). This analysis revealed that the local recurrence rate was significantly related to depth of invasion (B1 + C1 = 0%; B2 + C1 = 10%; p less than 0.01), site of origin (right plus transverse colon = 6%; left plus rectosigmoid colon = 10%; rectum = 12%; p less than 0.05), and lymphatic or capillary microinvasion (absent, 6%; present, 14%; p less than 0.05). This analysis attempts to identify patients at high risk for development of local recurrent disease to select candidates for postoperative adjuvant therapy.

Bullet emboli to the systemic and venous circulation.

The rarity of bullet emboli leads to frequent delays in diagnosis and inadequate early management. Our recent experience with this entity is described, and 153 cases reported in the English-language literature are reviewed and summarized. The majority of cases occurs as a consequence of civilian violence among men in their 20s and 30s. Most bullet emboli follow the direction of blood flow, although 15% of venous bullets cause embolization in a retrograde manner. One in 10 arterial emboli follow a right-heart or venous injury. Arterial bullets are symptomatic in 80% of cases, venous bullets in only one third. The choice of surgical management must be individualized according to the symptoms caused by the bullet and its location in the vascular system. In general, arterial bullet emboli are removed because of symptoms or findings of acute peripheral ischemia. Arterial and venous emboli not causing symptoms should be removed according to the risk of possible displacement and further embolization. Selective intraoperative angiograms and phlebograms can precisely localize the migrating bullet and permit appropriate placement of incisions before removal.