Outcomes of Elderly Patients Undergoing Emergency Surgery for Complicated Colorectal Cancer: A Retrospective Cohort Study.

OBJECTIVE: Colorectal cancer is one of the most frequent types of malignant neoplasms. Age is a risk factor for this disease, with 75% of cases diagnosed in patients older than 65 years. Complications such as obstruction, hemorrhage, and perforation are present in more than one-third of cases and require emergency treatment. We aim to analyze the profile of elderly patients undergoing surgery for complicated colorectal cancer, and to evaluate factors related to worse short-term prognosis. METHODS: A retrospective analysis of patients who underwent emergency surgical treatment for complicated colorectal cancer was performed. Demographics, clinical, radiological and histological data were collected. RESULTS: Sixty-seven patients were analyzed. The median age was 72 years, and almost half (46%) of the patients were female. Obstruction was the most prevalent complication at initial presentation (72%). The most common sites of neoplasia were the left and sigmoid colon in 22 patients (32.8%), and the right colon in 17 patients (25.4%). Resection was performed in 88% of cases, followed by primary anastomosis in almost half. The most frequent clinical stages were II (48%) and III (22%). Forty-three patients (65.7%) had some form of postoperative complication. Clavien-Dindo grades 1, 2, and 4, were the most frequent. Complete oncologic resection was observed in 80% of the cases. The thirty-day mortality rate was 10.4%. Advanced age was associated with worse morbidity and mortality. CONCLUSION: Elderly patients with complicated colorectal cancer undergoing emergency surgery have high morbidity and mortality rates. Advanced age is significantly associated with worse outcomes.

Outcomes of elderly patients undergoing emergency surgery for complicated colorectal cancer: a retrospective cohort study

OBJECTIVE: Colorectal cancer is one of the most frequent types of malignant neoplasms. Age is a risk factor for this disease, with 75% of cases diagnosed in patients older than 65 years. Complications such as obstruction, hemorrhage, and perforation are present in more than one-third of cases and require emergency treatment. We aim to analyze the profile of elderly patients undergoing surgery for complicated colorectal cancer, and to evaluate factors related to worse short-term prognosis. METHODS: A retrospective analysis of patients who underwent emergency surgical treatment for complicated colorectal cancer was performed. Demographics, clinical, radiological and histological data were collected. RESULTS: Sixty-seven patients were analyzed. The median age was 72 years, and almost half (46%) of the patients were female. Obstruction was the most prevalent complication at initial presentation (72%). The most common sites of neoplasia were the left and sigmoid colon in 22 patients (32.8%), and the right colon in 17 patients (25.4%). Resection was performed in 88% of cases, followed by primary anastomosis in almost half. The most frequent clinical stages were II (48%) and III (22%). Forty-three patients (65.7%) had some form of postoperative complication. Clavien-Dindo grades 1, 2, and 4, were the most frequent. Complete oncologic resection was observed in 80% of the cases. The thirty-day mortality rate was 10.4%. Advanced age was associated with worse morbidity and mortality. CONCLUSION: Elderly patients with complicated colorectal cancer undergoing emergency surgery have high morbidity and mortality rates. Advanced age is significantly associated with worse outcomes.

Acute appendicitis, inflammatory appendiceal mass and the risk of a hidden malignant tumor: a systematic review of the literature.

INTRODUCTION: Acute appendicitis is significantly common. Despite the increased use of computed tomography, the number of perforated cases has been stable in the past three decades. Between 2% and 6% of patients with acute appendicitis present appendiceal mass, often described as inflammatory phlegmon or abscess. Malignant tumors are confirmed by pathological analysis in 0.9-1.4% of all appendectomies performed to treat acute appendicitis. However, recent series demonstrate an elevated incidence of malignancies, ranging from 5.9 to 12%, in patients with inflammatory appendiceal mass. METHODS: The analysis was based on a systematic review of the literature. The articles were searched in PubMed for the period from 1987 to 2016. Articles presenting the incidence of the hidden malignancy among patients with appendiceal inflammatory mass were selected. Variables as age, interval appendectomy rate, the incidence of neoplasm, time to surgery, minimally invasive assessment, histology, right colectomy rate and morbidity were analyzed. RESULTS: A total of 13.244 patients were described as presenting acute appendicitis. Appendiceal tumor is present in approximately 1% of the appendectomies, while the rate of neoplasm varies from 10 to 29% in patients presenting appendiceal inflammatory mass. Interval appendectomies, despite been the minority of the procedures, disregard the higher morbidity associated with right sided colectomies. The review of literature also describes oncologic, histologic and clinical aspects of patients presenting appendiceal neoplasm, describing the most frequent histologic subtypes of this illness. CONCLUSION: Hidden appendiceal neoplasm in acute appendicitis are rare, fortunately. However, its incidence is much higher in patients presenting appendiceal inflammatory mass. Hence, interval appendectomy should be considered in this subgroup of patients.

Pancreaticoduodenectomy in patients with type 1 Neurofibromatosis: Report of two cases and literature review.

INTRODUCTION: Type 1 Neurofibromatosis (NF1) is one of the most common autosomal dominantly inherited multisystem disorders. It is associated with an increased risk of developing neurologic and gastrointestinal (GI) malignant neoplasms. The incidence of GI involvement is reported in 10-25% of patients. Less than 5% of NF1 patients with GI neoplasms manifest symptoms. The presence of synchronic gastrointestinal stromal and neuroendocrine tumors is rare in these patients. PRESENTATION OF CASES: The first case is a 37 year-old male patient with a history of abdominal pain for a few months. Imaging study showed a periampullary mass and a solid lesion at the third duodenal portion. He was submitted to a pancreatoduodenectomy and histological anaylisis showed two low-grade neuroendocrine tumors and a gastrointestinal stromal tumor. The second case is a 47 year-old female patient with a routine computed tomography scan showing a duodenal and a jejunal lesion. Duodenopancreatectomy was performed and histological analysis showed a neuroendocrine adenocarcinoma of the duodenum and two jejunal lesions compatible with GI tumors. DISCUSSION: GI symptoms such as jaundice, pain and bleeding in NF1 patients should prompt urgent admission Occasionally, associated gastrointestinal tumors may be incidentally found in asymptomatic NF1 patients. The presence of a periampullary or duodenal neoplasia such as neuroendocrine tumors should be evaluated. CONCLUSION: Although rare, the synchronic presentation of gastrointestinal tumors in patients with NF1 should be ruled out since it can lead to higher morbidity and mortality rates. Single-stage surgical management is feasable and yields satisfactory results.

Valor de predição para malignidade dos aspectos macroscópicos do nódulo tireoidiano / Predictive value for malignancy of the thyroid nodule macroscopically

Introdução: A punção aspirativa por agulha fina (PAAF) é um método de alta acurácia no diagnóstico pré-operatório dos nódulos tireoidianos, mas o "padrão folicular" segue sendo um fator de falha. Por outro lado, a utilidade do exame intra-operatório de congelação é controversa. Aspectos macroscópicos dos nódulos tireoidianos podem aumentar a acurácia diagnóstica pré e intra-operatória da PAAF e a biópsia de congelação. Objetivo: Avaliar os aspectos macroscópicos do espécime cirúrgico na tomada de decisão frente à doença nodular da glândula tireoide. Método: Durante 2007, 85 pacientes submetidos a tratamento cirúrgico por doença nodular tireoidiana foram avaliados por estudo prospectivo e os aspectos macroscópicos de 125 nódulos foram comparados aos achado histopatológicos. Resultados: Foi observado que o padrão de crescimento recente, a presença de aderências da tireoide, a ausência de hemorragia, a presença de necrose e a má delimitação do nódulo tiveram significado estatístico no resultado de doença maligna. Conclusão: Padrão de crescimento, aderências da tireoide, necrose e a má delimitação do nódulo são fatores indicativos de malignidade, enquanto a presença de hemorragia é fator protetor.

Introduction: The fine needle aspiration (FNA) is a method of high accuracy in the preoperative diagnosis of thyroid nodules, but the "follicular" remains a factor of failure. Furthermore, the usefulness of intraoperative examination of freezing is controversial. Macroscopic aspects of thyroid nodules may increase the diagnostic accuracy of preoperative and intraoperative FNA biopsy and freezing. Objective: To evaluate the macroscopic aspects of the surgical specimen in the decision facing the nodular disease of thyroid gland. Methods: During 2007, 85 patients underwent surgical treatment for thyroid nodular diseases were evaluated by prospective and macroscopic aspects of 125 nodules were compared with histopathological findings. Results: We found that the pattern of recent growth, the presence of adhesions of the thyroid, absence of hemorrhage, necrosis and poor demarcation of the nodule had statistical significance in the outcome of malignant disease. Conclusion:Pattern of growth, thyroid adhesions, necrosis and poor demarcation of the nodule are predictors of malignancy, while the presence of hemorrhage is a protective factor.

The role of intraoperative frozen sections for thyroid nodules.

UNLABELLED: The role of intraoperative frozen sections (FS) during thyroidectomy is controversial. AIM: to evaluate the role of FS for thyroid nodules management. PATIENTS AND METHODS: All patients who had thyroid surgery for nodular disease and previous USG-guided FNAB in 2006 were prospectively analyzed. They underwent intraoperative FS evaluation, and the biopsy material was classified as benign, malignant or follicular neoplasm. FNAB, FS and paraffin sections were compared. RESULTS: Under the FS, 54% of the nodules were benign, 30% were follicular neoplasms, and 16% were malignant. All cases considered benign and malignant under the FS evaluation were confirmed through the histological 'paraffin' analysis. Since it is not considered a definitive indication for total thyroidectomy, if the follicular neoplasms were classified as 'benign' under the FS, their sensitivity, specificity, positive and negative predictive values and global diagnostic accuracy were 69%, 100%, 100%, 91,5% e 77%, respectively. Among the 42 cases classified as 'follicular neoplasm' under the FNAB, in 1 case the FS conclusion was for papillary carcinoma, in 3 cases as benign (all confirmed through the 'paraffin'); and 38 cases continued as 'follicular pattern', being 29 follicular adenomas and 9 carcinomas through the 'paraffin'. CONCLUSION: The FS is only indicated when the FNAB reports 'follicular neoplasm'.

O papel da biópsia intraoperatória de congelação para os nódulos tireoidianos / The role of intraoperative frozen sections for thyroid nodules

O valor da biópsia de congelação (BC) durante a tireoidectomia é controverso. OBJETIVO: Avaliar o papel da BC na conduta frente os nódulos tireoidianos. CASUÍSTICA E MÉTODO: Trabalho prospectivo de pacientes submetidos à cirurgia tireoidiana por doença nodular e com PAAF guiada por USG prévia em 2006. A BC intra-operatória foi classificada em benigna, maligna ou neoplasia folicular. PAAF, BC e exame de "parafina" foram comparados. RESULTADOS: À BC, 54 por cento dos nódulos eram benignos, 30 por cento neoplasia foliculares e 16 por cento malignos. Todos os casos considerados benignos e malignos pela BC foram confirmados pelo exame de "parafina". Classificando as neoplásicas foliculares como "benignas" à BC, pois não possuem critério para indicação de tireoidectomia total, sensibilidade, especificidade, valores preditivos para os testes positivo e negativo e acurácia global foram, respectivamente, 69 por cento, 100 por cento, 100 por cento, 91,5 por cento e 77 por cento. Casos classificados como "benignos" e "malignos" à PAAF foram confirmados pela BC e "parafina." Dentre os 42 casos de "neoplasia folicular" à PAAF, em um caso, a BC concluiu como carcinoma papilífero, em três, como benigno (confirmados pela "parafina"); e, em 38, manteve "padrão folicular", sendo 29 adenomas foliculares e nove carcinomas à "parafina". CONCLUSÕES: A BC somente está indicada nos casos cuja PAAF seja "neoplasia folicular."

The role of intraoperative frozen sections (FS) during thyroidectomy is controversial. AIM: to evaluate the role of FS for thyroid nodules management. PATIENTS AND METHODS: All patients who had thyroid surgery for nodular disease and previous USG-guided FNAB in 2006 were prospectively analyzed. They underwent intraoperative FS evaluation, and the biopsy material was classified as benign, malignant or follicular neoplasm. FNAB, FS and paraffin sections were compared. RESULTS: Under the FS, 54 percent of the nodules were benign, 30 percent were follicular neoplasms, and 16 percent were malignant. All cases considered benign and malignant under the FS evaluation were confirmed through the histological "paraffin" analysis. Since it is not considered a definitive indication for total thyroidectomy, if the follicular neoplasms were classified as "benign" under the FS, their sensitivity, specificity, positive and negative predictive values and global diagnostic accuracy were 69 percent, 100 percent, 100 percent, 91,5 percent e 77 percent, respectively. Among the 42 cases classified as "follicular neoplasm" under the FNAB, in 1 case the FS conclusion was for papillary carcinoma, in 3 cases as benign (all confirmed through the "paraffin"); and 38 cases continued as "follicular pattern", being 29 follicular adenomas and 9 carcinomas through the "paraffin". CONCLUSION: The FS is only indicated when the FNAB reports "follicular neoplasm".