Gastric adenocarcinoma metastasis to the rectum causing complete obstruction, a case report.

Gastric adenocarcinoma is a leading cause of mortality worldwide. The most common sites of metastases are the liver, peritoneum, lungs, and bones. Cases have been described in the colon and rectum, but are very rare. This case report describes a patient in remission from diffuse signet ring cell type gastric adenocarcinoma with resection and chemoradiation close to 10 years prior to presenting with a near-obstructing rectal mass that was consistent with metastatic gastric adenocarcinoma. Gastric cancer spreads via hematogenous, lymphatic, peritoneal seeding, or local recurrence pathways. Given the length of time between initial presentation and eventual metastasis, the theory of dormancy is discussed and proposed as a possible cause in the delay of metastasis to the rectum. This highlights the importance of maintaining a high index of suspicion for recurrence and metastasis in a patient with a history of gastric cancer, who presents with a new obstructing rectal mass.

Is colorectal neoplasia more aggressive in the young? A look at shifting guidelines.

BACKGROUND: This study aimed to compare factors associated with CRC in patients younger than 50 and in those 50 and older, that required surgical resection due to malignancy or premalignant conditions. METHODS: A retrospective chart review was conducted looking at patients who had bowel resection due to CRC or advanced polyps; individuals found to have hereditary tumors and inflammatory bowel disease were excluded. Data was analyzed with chi square test of association comparing proportions of patients in the two age groups. RESULTS: A significantly higher proportion of the younger population had advanced stages of CRC. Data from this and other studies suggests that the colorectal tumors seen in patients under 50 have a higher virulence, and perhaps this is due to different tumor biology. CONCLUSION: These findings illustrate how changes in screening guidelines reinforced by proper support from insurance providers/payors and a widespread aggressive educational campaign for patients and providers can benefit this increasingly vulnerable population.

Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Surgery: Better Pain Control and Patient Outcomes with Liposomal Bupivacaine than Bupivacaine.

Transversus abdominis plane (TAP) blocks are a safe and effective way to provide immediate postoperative pain relief in surgical patients, and have been shown to decrease narcotic requirements. Concerns about complications of narcotics, increase in hospital length of stay (LOS), and health-care costs make this of particular interest. We compared standard bupivacaine TAP blocks with those carried out using liposomal bupivacaine to evaluate postoperative outcomes. Fifty patients undergoing elective laparoscopic colectomy received laparoscopic liposomal bupivacaine TAP blocks using 80 cc of local anesthetic, and data were collected prospectively during hospitalization. Data collected included amount of narcotic medication used during hospitalization, number of days to ambulation, number of days to bowel function, and LOS. These patients were compared with the last 50 patients recruited to the control/bupivacaine TAP block arm of the study. The same data parameters were collected and all patients were on an enhanced recovery protocol, which included scheduled acetaminophen, ibuprofen, and gabapentin by mouth, as well as clear liquid diet starting on postoperative day zero. Statistical analysis was performed using Student's t test and Fisher's exact test; P < 0.05 was considered statistically significant. Patients treated with liposomal bupivacaine needed less narcotics (5.06 vs 18.75 mg, P = 0.0002), had earlier bowel function (1.7 vs 2.4 days, P = 0.0002), and shorter LOS (2.7 vs 3.4 days, P = 0.0146). Patients undergoing laparoscopic colon resections seem to require fewer narcotics and have better patient outcomes with liposomal bupivacaine TAP blocks. Based on our data, liposomal bupivacaine seems to be superior to bupivacaine for TAP blocks.

Comparison of Therapeutic Benefit of Bupivacaine HCl Transversus Abdominis Plane (TAP) Block as Part of an Enhanced Recovery Pathway versus Traditional Oral and Intravenous Pain Control after Minimally Invasive Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial.

Enhanced recovery pathways (ERPs), when combined with transversus abdominis plane (TAP) blocks, have been proven to reduce the length of stay (LOS) and improve quality outcomes. Nonopioid pain management is an essential component of this pathway, leading to a reduction in immobility, postoperative ileus, and an increase in patient satisfaction. TAP block variations have been studied in general and gynecologic surgery. This study evaluates the effectiveness of laparoscopic TAP blocks in conjunction with the benefit of an ERP. One hundred thirty-seven consecutive laparoscopic and robotic-assisted Colorectal Surgery patients received TAP blocks under laparoscopic guidance while under anesthesia, randomized to a placebo, bupivacaine TAP block, or bupivacaine TAP block with an ERP arm of the trial. Patient demographics, operative techniques, and postoperative outcomes were analyzed using statistical analysis software. Our main objective was to determine short-term benefits of TAP blocks on reducing total narcotic consumption. Secondary objectives included effects of TAP blocks on time to ambulation, time to bowel function, and LOS. To isolate the effect of the TAP blocks, no efforts were made to control nursing or patient education in patients managed without an ERP. Of 137 patients, 14 were withdrawn. All cases were elective, with the main diagnosis colon cancer or dysplastic polyps (47.1%). The median age in each group was comparable (P = 0.12), with female majority in both groups (58.5%). Most procedures were segmental colon resections (74.7%). Thirty-one patients received a placebo, 41 bupivacaine TAP, and 51 bupivacaine TAP plus ERP. In terms of primary endpoints, the bupivacaine plus ERP arm used statistically significant less IV narcotics on postoperative day 1 and in total (P = 0.001, P = 0.008). All patients ambulated on average within the first 24 hours postoperatively, with the TAP plus ERP group approximately 0.5 days sooner (P = 0.001). The TAP plus ERP group also had a return of bowel function and LOS approximately 24 hours early (P = 0.001 and P = 0.001). This study shows that a laparoscopically placed bupivacaine TAP block when used as part of an ERP can reduce LOS, postoperative narcotics, time to ambulation and bowel function, and LOS. Defined pain regimens with auxiliary staff teaching can add to the improvement in quality outcomes in laparoscopic colorectal surgery and, with the addition of the TAP block, can add to patient satisfaction and lower hospital costs.

Does obesity influence lymph node harvest among patients undergoing colectomy for colon cancer?

Adequate lymph node harvest among patients undergoing colectomy for cancer is critical for staging and therapy. Obesity is prevalent in the American population. We investigated whether lymph node harvest was compromised in obese patients undergoing colectomy for cancer. Medical records of patients who had undergone colectomy for colon cancer were reviewed. We correlated the number of lymph nodes with body mass index (BMI) and compared the number of lymph nodes among patients with BMI less than 30 kg/m2 to those with BMI of 30 kg/m2 or greater ("obese"). Among all 191 patients, the correlation coefficient was 0.04 (P > 0.2). The mean number of nodes harvested from 122 nonobese patients was 12.4 +/- 6 and that for 69 obese patients 12.8 +/- 6 (P > 0.2). Among 130 patients undergoing right colectomy and 35 patients undergoing sigmoid colectomy, the correlation coefficients were 0.02 (P > 0.2) and 0.16 (P > 0.2), respectively. There was not a statistically significant difference in lymph node harvest between obese and nonobese patients (14.1 +/- 7 vs. 13.8 +/- 6, P > 0.2; and 11.8 +/- 6 vs. 8.6 +/- 5, P > 0.2), respectively. Obesity did not compromise the number of lymph nodes harvested from patients undergoing colectomy for colon cancer.

Cervical spine fractures in patients 65 years or older: a 3-year experience at a level I trauma center.

BACKGROUND: Cervical spine fractures in the elderly carry a mortality as high as 26%. We reviewed our experience to define the level of injury, prevalence of neurologic deficits, treatments employed, and the correlation between patients' pre- and posthospital residences. Also, we correlated the prevalence of advanced directives with length of stay. METHODS: We queried the data collected prospectively at an American College of Surgeons verified Level I hospital (National TRACS, American College of Surgeons) regarding patients aged 65 years or older presenting with cervical spine fractures (International Classification of Diseases-9 code 805.X) in calendar years 2000 through 2003. RESULTS: We identified 58 patients (ages 65-94). Mortality was 24%. Twelve patients had quadriplegia or paraplegia and seven of these patients died. Respiratory failure was the primary cause of death. Application of rigid collars and a halo brace were the most commonly employed therapies. Mortality rates for halo stabilization and rigid collar and halo stabilization were similar (23% vs. 29%). Despite having a higher mean Injury Severity Score, the 16 patients with advanced directives had an intensive care unit length of stay similar to that of patients without advanced directives but a statistically significant shorter overall length of stay (13 vs. 6.9 days). Eighteen of 45 patients living at home at the time of injury returned home. CONCLUSIONS: Cervical spine injury in the elderly does not inevitably relegate patients to a setting of more acute nursing care. The health and social factors that allowed many to return to living at home warrant investigation, as support of these factors may assist others with this injury.

Colonoscopic perforation management by laparoendoscopy: an algorithm.

BACKGROUND AND OBJECTIVES: The role of laparoscopy in the management of iatrogenic colonoscopic injuries has increased with surgeons becoming facile with minimally invasive methods. However, with a limited number of reported cases of successful laparoscopic repair, the exact role of this modality is still being defined. Drawing from previous literature and our own experiences, we have formulated a simple algorithm that has helped us treat colonoscopic perforations. METHODS: A retrospective review was undertaken of patients treated for colonoscopic perforations since the algorithm's introduction. For each patient, initial clinical assessment, management, and postoperative recovery were carefully documented. A Medline search was performed, incorporating the following search words: colonoscopy, perforation, and laparoscopy. Twenty-three articles involving 106 patients were identified and reviewed. RESULTS: Between May 2009 and August 2012, 7 consecutive patients with colonoscopic perforations were managed by 2 surgeons using the algorithm. There were no complications and no deaths, with a mean length of stay of 4.43 days (range, 2-7 days). Of the 7 patients, 6 required surgery. A single patient was managed conservatively and later underwent an elective colon resection. CONCLUSIONS: Traditionally, laparotomy was the preferred method for treating colonoscopic perforations. Our initial experience reinforces previous views that laparoendoscopic surgery is a safe and effective alternative to traditional surgery for managing this complication. We have formulated a simple algorithm that we have found helpful for surgeons considering a laparoscopic approach to managing this condition.

Colorectal cancer: are the "young" being overlooked?

BACKGROUND: Colorectal cancer (CRC) is increasing in young patients. We aimed to assess the trends of CRC and its corresponding clinical presentation in the young. METHODS: Cancer registry patients were divided into 3 groups according to age:<50, 50-75, and >75 years. Charts were reviewed for average-risk patients <50 years of age to assess clinicopathological data. RESULTS: We identified 3,599 patients between 1982 and 2010. Patients aged <50 years increased from 6.8% in (1982-1990) to 8.5% in (2000-2010) with a decrease in the 50-75-year age group from 45.5% to 43.4% (P = .03). One hundred eighty-eight patients were <50 years of age at the time of diagnosis. None had screening tests. Eighty-four percent had symptoms including rectal bleeding (76.5%), abdominal pain (58%), and an altered bowel pattern (71%). Twenty-one percent had symptoms for >6 months before diagnosis. Forty percent had stage III and 20% stage IV disease. This is unlike the 50-75-year age group in which the majority of patients had stage I disease. CONCLUSIONS: Young CRC patients are mostly symptomatic. Advanced disease at presentation could be caused by a delay in investigating these patients. Colonoscopy should be offered early to young patients presenting with warning symptoms.

Use of pre-operative Tc99m-Sestamibi scintigraphy and intraoperative parathyroid hormone monitoring to eliminate neck exploration in mediastinal parathyroid adenocarcinoma.

A 66-year-old white woman was found to have an elevated serum calcium and parathyroid hormone (PTH) on routine health evaluation. Physical examination was unremarkable as was ultrasonography of the neck. A sestamibi parathyroid scan revealed abnormal uptake in the anterior mediastinum. Computed tomography of the chest demonstrated an anterior mediastinal mass compatible with a parathyroid adenoma but no neck masses. The patient underwent mediastinoscopy that was converted to a median sternotomy to fully access the mass. The mass was completely resected with surrounding thymus gland. Frozen section confirmed that excised tissue was parathyroid gland in origin. An intraoperative PTH obtained 20 minutes after specimen removal showed a decrease of more than 50% from preoperative levels. The strategy for initial surgery for hyperparathyroidism when a sestamibi scan is "positive" in the mediastinum (only) is a point of some controversy. Traditional recommendations have been to "clear the neck" of abnormal parathyroid tissue before undertaking a more morbid sternotomy. Mediastinoscopy was attempted to remove the mediastinal lesion and to avoid a sternotomy. Preoperative Tc99m sestamibi scintigraphy, frozen section histology, and intraoperative PTH monitoring permitted the authors to conclude that neck exploration was unnecessary.

ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency.

OBJECTIVE: We compared the operative experience of chief residents at the Michigan State University Integrated Residency Program in General Surgery before and after duty-hour restrictions mandated by the Accreditation Council for Graduate Medical Education. SUMMARY BACKGROUND DATA: Conflicting evidence exists regarding the influence of duty-hour restrictions upon resident operative experience. METHODS: Resident self-reported operative experience submitted to the Residency Review Committee (RRC) for Surgery was tabulated. To control for a possible overall decrease in surgical procedures, for example, a decrease in referrals to the institution, the departmental database of surgical billings that is maintained independently from resident operative experience data also was reviewed. RESULTS: An overall decrease of nearly 20% occurred in resident operative volume after promulgation of duty-hour restrictions. All residents met minimum RRC operative experience requirements. Over the same period, no decrease was found in the number surgical procedures performed by the department. CONCLUSIONS: Our data suggest that restriction of resident duty hours is associated with a significant decrease in operative experience.