Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer.

OBJECTIVE: To compare transanal endoscopic microsurgery (TEMS) with conventional transanal excision (TAE) in terms of the quality of resection, local recurrence, and survival rates in patients with stage I rectal cancer. BACKGROUND: Although TEMS is often considered a superior surgical technique to TAE, it is poorly suited for excising tumors in the lower third of the rectum. Such tumors may confer a worse prognosis. METHODS: We retrospectively reviewed information on all patients with stage pT1 and pT2 rectal adenocarcinoma who underwent local excision from 1997 through mid-2006. We excluded patients with node-positive, metastatic, recurrent, previously irradiated, or snare-excised tumors. RESULTS: Our study included 42 TEMS and 129 TAE patients. We found no significant differences in patient characteristics, adjuvant therapy, tumor stage, or adverse histopathologic features. In the TAE group, 52 (40%) of tumors were <5 cm from the anal verge (AV); in the TEMS group, only 1 (2%) (P = 0.0001). Surgical margins were less often positive in the TEMS group (2%) than in the TAE group (16%) (P = 0.017). For patients with tumors > or =5 cm from the AV, the estimated 5-year disease-free survival (DFS) rate was similar between the TEMS group (84.1%) and the TAE group (76.1%) (P = 0.651). But within the TAE group, the estimated 5-year DFS rate was better for patients with tumors > or =5 cm from the AV (76.1%) vs. <5 cm from the AV (60.5%) (P = 0.029). In our multivariate analysis, the tumor distance from the anal verge, the resection margin status, the T stage, and the use of adjuvant therapy--but not the surgical technique (i.e., TEMS or TAE) itself--were independent predictors of local recurrence and DFS. CONCLUSIONS: The quality of resection is better with TEMS than with TAE. However, the apparently better oncologic outcomes with TEMS can be partly explained by case selection of lower-risk tumors of the upper rectum.

Contemporary indications for and early outcomes of abdominoperineal resection.

The purpose of this study was to review and characterize the indications and early outcomes of abdominoperineal resection (APR) when used in a colorectal practice in an academic setting. Data was collected from the charts of all patients undergoing APR in a retrospective manner. Data collected included demographic information and details regarding the clinical presentation. Operative factors, information regarding the postoperative course, and morbidity and mortality were evaluated. Forty-four patients were treated with an APR in this practice between the years 1992 and 2004. The indications for operation were primary rectal cancer (n = 31), recurrent rectal cancer (n = 6), intractable Crohn disease (n = 3), anal melanoma (n = 1), cloacogenic cancer (n = 1), squamous cell cancer (n = 1), and gastrointestinal stromal tumor (n = 1). Complications in the first 60 days affected 14 patients (32%). The most common complication was intra-abdominal/pelvic abscess formation occurring in 6 of these 14 patients (43%). Additional complications in the first 60 days included rectus flap necrosis, perineal wound evisceration, prolonged ileus, and urinary retention. There was no surgical mortality. Long-term complications occurred in 7 patients (16%), with parastomal hernia being the most common (43%). Although relatively infrequently used, APR will continue to play a role for selected patients in the future. Despite the significant morbidity associated with this surgery, APR may provide beneficial treatment for select cases of low rectal cancer, end-stage inflammatory bowel disease, and anal malignancies.

Carcinoembryonic antigen and albumin predict survival in patients with advanced colon and rectal cancer.

HYPOTHESIS: Patients with stage IV colon or rectal cancer at initial diagnosis have characteristics that will predict subsequent survival time. DESIGN: Retrospective cohort study. SETTING: Urban county teaching hospital providing tertiary care. PATIENTS: Patients who came to the study institution with stage IV colon or rectal cancer between 1991-1999. MAIN OUTCOME MEASURE: Survival duration (days) after diagnosis. RESULTS: One hundred five patients were identified, with a median survival of 225 days (interquartile range, 72-688 days). Univariate analysis identified carcinoembryonic antigen (CEA) and albumin (ALB) as possible predictors for survival. Classification and regression tree analysis, a form of binary recursive partitioning, was used to identify optimal cut points for CEA (275 ng/mL) and ALB (2.7 g/dL) levels. Based on the cut points, patients were stratified into the following groups: (1) low CEA, high ALB; (2) low CEA, low ALB; (3) high CEA, high ALB; and (4) high CEA, low ALB. The median survival times for the first group and the fourth group were 287 days (interquartile range, 150-851 days) and 39 days (interquartile range, 14-168 days), respectively. A Kaplan-Meier analysis was performed, and a statistically significant difference was identified across all strata (P =.004). Additionally, groups 1 and 4 demonstrated the largest overall survival difference (P<.001). CONCLUSIONS: Patients with stage IV colon and rectal cancer with a CEA level greater than or equal to 275 ng/mL and an ALB level less than 2.7 g/dL had a significantly shorter survival time. Conversely, patients with an ALB level greater than or equal to 2.7 g/dL and a CEA level less than 275 ng/mL had a longer survival time.

An assessment of the severity of recurrent appendicitis.

BACKGROUND: This study examines the clinical characteristics of patients who developed recurrent appendicitis after previous nonoperative management of perforated appendicitis. METHODS: Retrospective chart review was performed, and data from the recurrent and initial episode of appendicitis were collected. RESULTS: In all, 237 patients from 1989 to 2001 were managed nonoperatively for perforated appendicitis and 32 (14%) were readmitted for recurrent appendicitis. Median white blood cell count at recurrence was 9.5 (interquartile range [IQR]: 6.6 to 13.2] versus 13.1 [IQR: 10.8 to 16.1] at initial presentation (P = 0.002). Maximum temperature was 98.6 degrees F [IQR: 98.2 to 100.5] at recurrence versus 100.3 degrees F [IQR: 99.5 to 101.5] (P = 0.008). Median time for intravenous antibiotics use was 3 [IQR: 3 to 7] days at recurrence versus 6 [IQR: 4 to 8] days initially (P = 0.01). Inpatient stay was also shorter; median length was 6 [IQR: 3 to 8] days compared with 7 [IQR: 5 to 9] days at initial presentation (P = 0.02). CONCLUSIONS: Patients managed nonoperatively for perforated appendicitis who later developed recurrent appendicitis exhibited a milder clinical course at recurrence. Elective interval appendectomy may be reserved until a recurrent episode.

Stapled hemorrhoidectomy: a review of our early experience.

Treatment of hemorrhoids may safely be accomplished by using a circular stapler instead of the conventional open procedure for large symptomatic hemorrhoids. Our purpose was to assess the safety and early post-op results of this new surgical technique as it was introduced into clinical practice. Medical records from 62 patients treated by circumferential mucosectomy/stapled hemorrhoidectomy were obtained from 6 surgeons. Preoperative factors assessed included demographics, comorbidities, prior anorectal surgery, hemorrhoid grade, and the indications for surgery. Operative factors examined included operating time, use of perioperative antibiotics, and oversewing of the suture line. Postoperative factors included complications and date of last follow-up. Sixty-two patients underwent this operation, and complications were reported in six patients (10%). There was one death unrelated to the hemorrhoid surgery. Postoperative pain, defined as requiring pain control with intravenous medication, hospital admission, or an emergency department visit, occurred in two patients. Two patients reported postoperative bleeding. One patient experienced bleeding the first evening, and the second patient had bleeding 1 week postoperatively. The first patient was admitted overnight and required no blood transfusion or further intervention. The second patient was subsequently found to have a bleeding diverticulum. One patient experienced urinary retention that resolved with conservative management. Postoperative follow-up was available for over 90 per cent of the patients at a median of 4 weeks postoperatively. No additional complications were discovered at follow-up. This data suggests that stapled hemorrhoidectomy is a safe and effective approach to hemorrhoidal disease. Our findings indicate an acceptable complication rate among a group of surgeons beginning to integrate this modality into clinical practice.

Diverticulitis: truly minimally invasive management.

The purpose of this study is to evaluate the treatment of patients with acute diverticulitis in the inpatient setting using minimal intervention. This was a retrospective study of 75 patients admitted over a 3-year period with acute diverticulitis as evidenced by computed tomography (CT) and clinical scenario. Of the patients enrolled, 24 (32%) had abscesses identified on their initial CT scan. An additional four patients had abscesses noted on a subsequent CT scan obtained because of lack of complete improvement with medical management, thus raising the total number of abscesses to 28 (37%). Of the patients with abscesses, 10 (36%) underwent drainage using a CT-guided percutaneous or ultrasound-guided transrectal approach an average of 6 days after admission. Of the 75 patients, five (7%) required operative intervention during the initial hospitalization for failure of medical management, two (40%) of whom had abscesses on presentation. The overall median length of hospitalization was 5 (interquartile range [IQR] 4-9) days, and 18 patients (24%) had recurrences during the study period. Our conservative approach to percutaneous and surgical intervention resulted in relatively low percutaneous drainage, a low operative rate, and a reasonable length of hospitalization and recurrence rate.

Colonic histoplasmosis presenting as colon cancer in the nonimmunocompromised patient: report of a case and review of the literature.

Histoplasma capsulatum is an important pathogen that is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts. Failure to recognize and treat disseminated histoplasmosis in AIDS patients invariably leads to death. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, and depending on the layer of bowel wall involved present as bleeding, obstruction, perforation, or peritonitis. Because they can be variable in appearance, they may be mistaken for Crohn's disease or malignant tumors. Four distinct pathologic patterns of GI histoplasmosis have been described that all have differing clinical presentations. We report a case of a non-AIDS patient who presented with a near-obstructing colonic mass suspicious for advanced malignancy but was found to have histoplasmosis on final pathology. The patient underwent successful operative resection, systemic anti-fungal therapy, and extensive workup for immunosuppressive disorders, which were negative. The patient was from an area in Mexico known to be endemic for histoplasmosis. This is the first report of a colonic mass lesion occurring in a non-AIDS patient, and review of the worldwide literature regarding GI histoplasmosis reveals excellent long-term survival with aggressive therapy. We discuss the surgical and medical management of colonic histoplasmosis in this report.

Viral and fungal infectious colitides.

Viral and fungal colitides are rare in the immunocompetent host but are most clinically significant in populations with compromised immune function. They may be associated with high mortality, particularly when treatment is delayed. It is important to be aware of these diseases when treating patients with colitis to allow early diagnosis and treatment, which will improve outcome.

Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage.

PURPOSE: There is no definite consensus on the management of intra-abdominal abscesses in adults. This retrospective study evaluated the use of antibiotic therapy and percutaneous image-guided drainage in adult patients with intra-abdominal abscesses. METHODS: A retrospective chart review of 114 patients with intra-abdominal abscesses was conducted. Data collected included patient demographics, presenting symptoms, radiographic interpretation, vital signs, antibiotic coverage, laboratory values, and details of the hospital course. Bivariate statistical tests were performed using the Wilcoxon rank-sum test, chi-squared test, or Fisher's exact test, where appropriate. RESULTS: Sixty-seven of 114 patients (59 percent) had intra-abdominal abscesses resulting from appendicitis, diverticulitis in 30 patients (26 percent), postoperative in 13 patients (11 percent), and undetermined in 4 patients (4 percent). Three patients (3 percent; 95 percent confidence interval, 1-8 percent) failed conservative management and underwent urgent operation. Sixty-one (54 percent; 95 percent confidence interval, 44-63 percent) patients improved with intravenous antibiotic therapy alone. Fifty patients (44 percent; 95 percent confidence interval, 35-54 percent) underwent image-guided percutaneous drainage after 48 to 72 hours of antibiotic therapy. Patients who improved on antibiotics alone had average abscess diameter of 4 cm, whereas patients who underwent percutaneous drainage had average diameter of 6.5 cm (P<0.0001). Maximal temperature at time of admission was 100.8 degrees F for antibiotic group and 101.2 degrees F for percutaneous drainage group (P=0.0067). CONCLUSIONS: The majority of the patients with intra-abdominal abscesses improved with antibiotic therapy alone. Those patients with an abscess diameter>6.5 cm and temperature at admission>101.2 degrees F have higher likelihood of failing conservative therapy with antibiotics alone and requiring percutaneous drainage.

Strategies for palliative care in advanced colorectal cancer.

Palliative care has appropriately been receiving increased attention in recent years. From the surgeon's standpoint, therapy is considered palliative when resection of all known tumor sites is no longer possible or advisable. Since a cure, as commonly defined, is not possible, the goal of treatment and eventually the success of therapy becomes judged by the control of symptoms and alleviation of suffering. Providing optimal palliative care for the patient with advanced colorectal cancer is a complex and challenging process. The process of providing palliative care may be a departure from the traditional surgical satisfaction derived from the complete excision of a malignancy, but surgeons achieving excellence in palliative care will likely find this a rewarding endeavor.