Ductal lavage for detection of cellular atypia in women at high risk for breast cancer.

BACKGROUND: Breast cancer originates in breast epithelium and is associated with progressive molecular and morphologic changes. Women with atypical breast ductal epithelial cells have an increased relative risk of breast cancer. In this study, ductal lavage, a new procedure for collecting ductal cells with a microcatheter, was compared with nipple aspiration with regard to safety, tolerability, and the ability to detect abnormal breast epithelial cells. METHODS: Women at high risk for breast cancer who had nonsuspicious mammograms and clinical breast examinations underwent nipple aspiration followed by lavage of fluid-yielding ducts. All statistical tests were two-sided. RESULTS: The 507 women enrolled included 291 (57%) with a history of breast cancer and 199 (39%) with a 5-year Gail risk for breast cancer of 1.7% or more. Nipple aspirate fluid (NAF) samples were evaluated cytologically for 417 women, and ductal lavage samples were evaluated for 383 women. Adequate samples for diagnosis were collected from 111 (27%) and 299 (78%) women, respectively. A median of 13,500 epithelial cells per duct (range, 43-492,000 cells) was collected by ductal lavage compared with a median of 120 epithelial cells per breast (range, 10-74,300) collected by nipple aspiration. For ductal lavage, 92 (24%) subjects had abnormal cells that were mildly (17%) or markedly (6%) atypical or malignant (<1%). For NAF, corresponding percentages were 6%, 3%, and fewer than 1%. Ductal lavage detected abnormal intraductal breast cells 3.2 times more often than nipple aspiration (79 versus 25 breasts; McNemar's test, P<.001). No serious procedure-related adverse events were reported. CONCLUSIONS: Large numbers of ductal cells can be collected by ductal lavage to detect atypical cellular changes within the breast. Ductal lavage is a safe and well-tolerated procedure and is a more sensitive method of detecting cellular atypia than nipple aspiration.

Ileocecectomy is definitive treatment for advanced appendicitis.

Although appendectomy is the most commonly performed emergency operation septic complications of appendectomy remain a major source of morbidity. Historically, advanced appendicitis has been treated by appendectomy with cecostomy and/or drainage tubes. Our objective was to evaluate the use of ileocecal resection for the immediate treatment of advanced appendicitis. We examined the cases of all patients undergoing ileocecal resection for appendicitis from August 1989 through April 2000. There were 92 patients (60 male and 32 female) with a median age of 34 (range 6-71). Abdominal pain was present in 98 per cent of patients with duration of 5.1+/-0.6 days. Right lower quadrant tenderness was present in 91 per cent with accompanying right lower quadrant mass in 30 per cent. Temperature on admission was 38.0+/-0.1 degrees C with a white blood cell count of 15,300+/-500. Preoperative radiological studies included abdominal X-rays (33), contrast enemas (two), CT scans (41), and abdominal ultrasound (17); these studies yielded a correct preoperative diagnosis in 89 per cent. Previous appendectomy had been performed in six patients with failed percutaneous drainage of intra-abdominal abscesses in five. There were 94 cecal resections performed in 92 patients. The extent of surgical resection varied between patients and ranged from partial cecectomy (34) to ileocecectomy (55) to ileocecectomy with diverting ileostomy (five). Intra-abdominal abscesses were present at operation in 46 cases (50%), and drains were placed in 38 (41%). Skin incisions were packed open in most cases (65); there was skin closure in 27. There was no mortality encountered in this period. There were 25 complications in 23 patients (25%). Complications included postoperative abscess (10; 11%), wound infection (10; 11%), partial small bowel obstruction (two) and pulmonary embolus (one). Reoperation was required in seven patients and CT-guided percutaneous drainage in five patients. Anastomic leaks occurred in two cases of partial cecectomy and required conversion to ileocecectomy. Mean hospital stay was 10.5+/-1.0 days with adjusted hospital costs of $31,689+/-3018. We conclude that definitive treatment of advanced appendicitis can be performed by resection of the involved areas of the ileocecum. This can be accomplished with a primary anastomosis obviating the need for ileostomy and secondary operation. This aggressive surgical approach may reduce infectious complications and reduce hospital costs.

Surgical diverticulitis: treatment options.

Acute diverticulitis requiring surgical intervention has conventionally been treated by resection with colostomy or delayed resection with primary anastomosis at a second admission. Our objective was to determine the outcome for treatment of diverticulitis with resection and primary anastomosis during the same hospitalization. We conducted a retrospective review of patients (n = 74) undergoing surgery for diverticulitis. Groups included: 1) resection with primary anastomosis (n = 33), 2) resection with colostomy followed by a takedown colostomy (n = 32), and 3) delayed resection with primary anastomosis at a second admission (n = 9). Despite local perforation primary anastomosis was often performed unless patients were clinically unstable or had fecal contamination. The operation was urgent in five (15%) patients in Group 1 as compared with 26 patients (88%) in Group 2. Serious intra-abdominal complications occurred in two patients (6%) in Group 1 as compared with nine patients (28%) in Group 2 and one patient (11%) in Group 3. Postoperative abscesses occurred in two patients in Group 1, five patients in Group 2, and one patient in Group 3. We have shown that resection with primary anastomosis for acute diverticulitis--even in selected patients requiring urgent operation--can be safely performed during the same hospital admission with a low complication rate.

Same admission colon resection with primary anastomosis for acute diverticulitis.

Current standard of care for complicated diverticulitis includes urgent resection with colostomy versus antibiotic treatment, followed by delayed resection with primary anastomosis at a second admission. In certain circumstances, it is possible to perform resection and anastomosis on the same admission for acute diverticulitis. A retrospective review was completed for patients undergoing surgery for diverticulitis from 1991 to 1998. Groups included: 1) sigmoid resection with primary anastomosis on same admission (n = 18); 2) resection with protective end colostomy (n = 16); and 3) in-patient antibiotic treatment alone, followed by a second admission for resection with primary anastomosis (n = 5). Four patients initially treated with antibiotics worsened symptomatically or developed radiographic evidence of perforation and required resection with colostomy. Five patients in Group 1 had abscesses or contained perforations based on radiographic studies. Findings on CT scans did not predict treatment. Group 1 patients had uneventful recoveries and few minor complications (wound infections and an incisional hernia). One anastomotic leak occurred in Group 2 after colostomy closure. Although there will continue to be a role for emergent operation for diverticulitis, same admission sigmoid resection with primary anastomosis after antibiotic treatment is safe, uses a shorter course of antibiotics, and has a low complication rate.

Surgical approach to cecal diverticulitis.

BACKGROUND: Cecal diverticulitis is a rare condition in the Western world, with a higher incidence in people of Asian descent. The treatment for cecal diverticulitis has ranged from expectant medical management, which is similar to uncomplicated left-sided diverticulitis, to right hemicolectomy. STUDY DESIGN: A retrospective chart review was conducted of the 49 patients treated for cecal diverticulitis at Olive View-UCLA Medical Center from 1976 to 1998. This was the largest-ever single-institution review of cecal diverticulitis reported in the mainland US. RESULTS: The clinical presentation was similar to that of acute appendicitis, with abdominal pain, low-grade fever, nausea/vomiting, abdominal tenderness, and leukocytosis. Operations performed included right hemicolectomy in 39 patients (80%), diverticulectomy in 7 patients (14%), and appendectomy with drainage of intraabdominal abscess in 3 patients (6%). Of the 7 patients who had diverticulectomy, 1 required right hemicolectomy at 6 months followup for continued symptoms. Of the three patients who underwent appendectomy with drainage, all required subsequent hemicolectomy for continued inflammation. Of the 39 patients who received immediate hemicolectomies, there were complications in 7 (18%), with no mortality. CONCLUSIONS: We endorse an aggressive operative approach to the management of cecal diverticulitis, with the resection of all clinically apparent disease at the time of the initial operation. In cases of a solitary diverticulum, we recommend the use of diverticulectomy when it is technically feasible. When confronted with multiple diverticuli and cecal phlegmon, or when neoplastic disease cannot be excluded, we advocate immediate right hemicolectomy. This procedure can be safely performed in the unprepared colon with few complications. Excisional treatment for cecal diverticulitis prevents the recurrence of symptoms, which may be more common in the Western population.

White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis.

The white blood cell (WBC) count is considered to be a useful test in the diagnosis of appendicitis. The purpose of this study was to examine the clinical features of patients with normal WBC appendicitis and also to determine whether a higher WBC count correlates with a more advanced stage of appendicitis. Patients with pathologically confirmed appendicitis from January 1989 to December 1994 were included in the study (n = 1919). The age, gender, temperature, length of hospital stay, and severity of disease (1 = acute appendicitis; 2 = gangrenous appendicitis; 3 = perforated appendicitis with abscess formation; 4 = appendicitis with diffuse peritonitis) were compared for patients with a normal WBC count (range, 3.8-10.9) versus those who had an elevated WBC count. A normal WBC count was seen in 11 per cent of patients (n = 209). There was no difference in age, temperature, gender, or severity of disease in the patients with a normal WBC count compared with those with an elevated WBC count (P > 0.05). The severity of disease of patients with a normal WBC count were: 1 = 58 per cent; 2 = 13 per cent; 3 = 7 per cent; and 4 = 22 per cent. For patients with an elevated WBC count the scores were: 1 = 57 per cent; 2 = 17 per cent; 3 = 13 per cent; and 4 = 14 per cent. The proportion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count.

Emergent ileocecectomy for infection and inflammation.

The role of right colectomy in controlling inflammatory conditions and intra-abdominal sepsis remains controversial. The objective of this study was to define the outcome following emergency ileocecal resection for infectious and inflammatory causes. Retrospective analysis of 83 consecutive patients who underwent such treatment in a university-affiliated public hospital over a 7-year period was performed. Preoperative diagnosis was correct in 54 per cent of patients; CT scan (29 patients) did not improve this rate (59%). Free perforation was noted in 16 per cent of patients, and a defined abscess was found in 39 per cent. Common pathologic diagnoses included appendicitis (39%), diverticulitis (23%), cancer (14%), and Crohn's disease (8%). Primary ileocolic anastomosis was performed in 74 patients (89%); 9 patients (11%) required an ileostomy. Mean postoperative stay was 10 days, and there was no mortality. Complications occurred in 15 patients (18%), and 2 required reoperation (2%). Preoperative presence of an abscess was not associated with an increased complication rate (16%), but free perforation was associated with a 31 per cent complication rate. Definitive emergency treatment of infectious and inflammatory disease of the ileocecum can be safely accomplished by resection with primary anastomosis in the majority of patients, obviating the need for ileostomy and a second operation.

Abdominal tuberculosis: the surgical perspective.

The increasing incidence of pulmonary tuberculosis (TB) has led many to predict a corresponding increase in abdominal TB. This study reports the incidence, presentation, and outcome of abdominal TB to elucidate factors that might assist the surgeon to treat this potentially curable disease. A retrospective review of patients diagnosed with tuberculosis between 1993 and 1995 was performed at two hospitals. Diagnosis of abdominal TB was based on acid fast bacilli on tissue stains and/or culture. Seven patients were diagnosed with abdominal TB. Two patients were HIV positive; six were recent immigrants. Abdominal pain, fever, and significant weight loss were the most common symptoms. All preoperative radiologic tests failed to demonstrate findings suggestive of TB. All patients were brought to operation. Indications included perforated viscus (2), acute abdomen (1), small bowel obstruction (1), colocutaneous fistula (1), pelvic neoplasm (1), and biliary colic (1). Abdominal TB was either diagnosed or suspected intraoperatively in six patients. Postoperative anti-TB chemotherapy was promptly instituted. Although abdominal TB can be cured medically if treated early enough, the nonspecific presentation delays diagnosis in the majority of cases. Diagnosis of abdominal TB can be made or at least highly suspected intraoperatively such that anti-TB medications can be initiated promptly. Appropriate surgical therapy and prompt initiation of anti-tuberculosis medications can successfully treat abdominal TB.

Analysis of risk factors of postappendectomy intra-abdominal abscess.

BACKGROUND: Postappendectomy intra-abdominal abscesses (PAIAA) complicate the recovery of a small but significant fraction of patients with advanced appendicitis. STUDY DESIGN: A retrospective review of 1,184 patients with appendicitis was undertaken to define the clinical characteristics and risk factors associated with PAIAA. RESULTS: Thirty-three patients with 36 PAIAAs were found, an incidence of 2.8 percent. The mean age of patients with PAIAA was less than the overall group (16.9 versus 23.1 years, p = 0.002), and the mean core temperature of the PAIAA group was significantly higher (38.5 versus 38.2 degrees C). The incidence of PAIAA increased as the degree of appendiceal pathology worsened. The incidence of PAIAA was six (3.2 percent) of 190 in patients with gangrenous appendicitis and was 27 (8.7 percent) of 309 among patients with perforated appendicitis. Logistic regression analysis showed that independent predictors for the occurrence of PAIAA were young age and perforation. Although children presented with a higher rate of perforated appendicitis, this did not account for the younger age of the patients with PAIAA. Children (less than ten years of age) with perforation had PAIAA in ten (14 percent) of 69 cases compared with the incidence in the older patients with perforation of 17 (7.1 percent) of 240. CONCLUSIONS: These findings improve the surgeon's ability to identify patients at risk for PAIAA. Alterations in the perioperative management of perforated appendicitis, particularly in the pediatric patient, may reduce the occurrence of PAIAA.

Biliary disease during pregnancy.

BACKGROUND: Biliary disease during pregnancy is rare and the need for surgery in these cases is controversial. We evaluated our experience with biliary disease during pregnancy with regard to outcome and cost containment. PATIENTS AND METHODS: We reviewed the clinical course of pregnant women with biliary disease at the University of California at Los Angeles and Olive View-UCLA Medical Centers from 1988 to 1993. RESULTS: Seventy-two of 46,075 pregnant women presented with biliary disease (incidence 0.16%). Sixteen underwent surgery while pregnant, 5 in the first and 11 in the second trimester. No maternal or fetal deaths occurred secondary to medical or surgical management of biliary disease. Patients who were treated medically at initial presentation had a 69% rate of relapse prior to delivery, compared to no relapses in those treated surgically (P < 0.01). Patients who experienced relapse spent an average of 3.0 additional days in hospital. CONCLUSION: Surgical therapy for biliary disease performed in the second trimester of pregnancy does not increase morbidity and may help reduce relapses and additional days in hospital.

Management of pancreatitis complicating pregnancy.

Pregnancy complicated by pancreatitis may lead to significant fetal and maternal morbidity and mortality. We reviewed the clinical course of 30 women who developed pancreatitis in our institution during pregnancy from 1988 to 1992. Pancreatitis complicated 0.07 per cent of pregnancies (n = 46,075) during this time period. The etiology was gallstones in 22 patients, alcohol in 2 patients, and idiopathic in 6 patients. Average age, multiparity, and symptoms at presentation were similar between patients with gallstone (GSP) or non-gallstone pancreatitis (NGSP). All patients were initially treated medically. GSP patients had significantly lower Ranson criteria than NGSP (0.7 vs. 1.9, P < 0.01), but response to initial therapy, need for emergency surgery, fetal outcome, and fetal and maternal mortality (0 per cent) were the same. Twenty-six of 30 patients were successfully treated with conservative management. A significantly higher relapse rate was seen in GSP than NGSP patients before delivery (72% vs. 0%, P < 0.05). These relapses required hospitalization 90 per cent of the time and resulted in 3.9 additional days per patient. Six patients underwent surgery during pregnancy (two in the first trimester and four in the second trimester) without fetal or maternal mortality and with normal birthweights and Apgar scores. No relapses or additional days in hospital were noted in GSP patients following surgery. We recommend that GSP patients presenting in the first or second trimester should, if possible, undergo cholecystectomy in the second trimester when the risk of anesthesia and premature labor are the lowest. Patients presenting in the third trimester should undergo surgery immediately post-partum.(ABSTRACT TRUNCATED AT 250 WORDS)

Cecectomy for complicated appendicitis.

BACKGROUND: Cecal leak or disruption after appendectomy for complicated appendicitis is a consequence of severity of disease and is related to residual abscess cavity, inflammation, phlegmon, and nonviable intestine. In an attempt to improve results, we have begun to resect the cecum and other localized infected tissue in instances of complicated appendicitis in which the viability of the appendiceal base and adjacent cecum is questionable. STUDY DESIGN: This is a prospective series of all patients who have undergone resectional therapy for complicated appendicitis in the last four years. Patients with other inflammatory conditions of the right colon have been specifically excluded. RESULTS: Seventeen patients have undergone resectional therapy for complicated appendicitis. Thirteen (76.5 percent) were men; the mean age was 42.4 years. The mean temperature and leukocyte count were 37.8 degrees C and 16.1 x 10(9) per L, respectively. These patients presented with a mean of 6.8 days of abdominal pain. Nine had a palpable abdominal mass, and all had tenderness in the right lower quadrant. In ten patients an abscess was encountered at operation. While the extent of the resection varied, it generally included the cecum, part of the right colon, and 5 to 7 cm of terminal ileum. Fourteen patients had a primary anastomosis, while the other three had the creation of an ileostomy. Complications were encountered in only two patients: one wound infection and one pulmonary embolus. There were no instances of postoperative intra-abdominal abscess, intestinal obstruction, or fecal fistula. All patients had a benign postoperative course and were discharged on the average of 9.9 days postoperatively. The ileostomies in three patients have been closed and no complications have occurred on follow-up examination. CONCLUSIONS: We conclude that aggressive resectional therapy of the cecum during appendectomy in selected patients with complicated appendicitis is effective therapy and can be performed safely.

Treatment of Zenker's diverticula by cricopharyngeus myotomy under local anesthesia.

Optimum surgical management of the hypopharyngeal diverticulum is controversial. The authors discuss 48 consecutive patients (average age 72.1 years) with documented hypopharyngeal diverticula who were treated by cricopharyngeus myotomy, leaving the diverticula in situ. All came to the hospital with dysphagia; other symptoms included postdeglutitive cough, regurgitation, aspiration, and weight loss. Seven patients had had previous surgery for a Zenker's diverticulum with recurrence. Aspiration pneumonia was treated in 9 patients; 28 patients had concurrent chronic obstructive pulmonary disease or cardiovascular disease. Thirty-nine patients had cricopharyngeus myotomy under local anesthesia, 5 had cricopharyngeus myotomy under general endotracheal anesthesia, and 4 patients underwent myotomy with a cervical esophagostomy. There was one mortality (2.1%) and no incidence of postoperative bleeding, sepsis, or cranial nerve injury. Follow-up was done with 30 patients via telephone an average of 64 months after operation. Twenty-one of 30 patients reported excellent relief of symptoms, 5 reported improvement with occasional symptoms, and 4 patients described persistent dysphagia. Cricopharyngeus myotomy under local anesthetic is a safe and effective approach to the patient with a hypopharyngeal diverticulum. The awake patient can swallow on command, which enables the surgeon to identify the upper esophageal sphincter (UES) and to perform an accurate, complete myotomy. The absence of a pharyngeal suture line eliminates the risk of leakage and mediastinal sepsis, and allows early, postoperative feeding and discharge.

The role of Yersinia enterocolitica in appendicitis in the southwestern United States.

Infection with Yersinia enterocolitica had been associated with acute appendicitis in approximately six per cent of patients in northern European countries. However, the incidence of Y. enterocolitica in patients with appendicitis in this country is uncertain. Therefore, this study was undertaken to ascertain whether Y. enterocolitica is a possible infectious agent in appendicitis in the southwestern United States. Fifty prospective patients (35 men and 15 women) with an average age of 22.3 years (range 3 to 62 years) underwent appendectomy for presumed appendicitis. Portions of each specimen were cultured for Y. enterocolitica with highly selective media (Cefsulodin-Irgasan-Novobiocin [CIN] agar). Pathologically, 44 of the patients had appendicitis and 6 patients had normal appendices. Four of the 44 patients (9.1%) with appendicitis were found to be culture positive for Y. enterocolitica, while it was recovered from none of the normal appendices. This indicates that Y. enterocolitica may represent the major pathogen in acute appendicitis in a small, but distinct, portion of indigent patients within Los Angeles County as it does elsewhere in the world.

Cecal diverticulitis: a continuing diagnostic dilemma.

Cecal diverticulitis is a rare entity and remains a difficult diagnostic problem. A retrospective review was undertaken of 16 patients (11 men, 5 women; average age, 33.2 years) with a pathologic diagnosis of cecal or right colon diverticulosis who received treatment from 1979 to the present. Preoperative symptoms were difficult to distinguish from appendicitis. The majority complained of right lower quadrant pain and tenderness. Diagnostic studies were not helpful. Preoperative diagnosis was appendicitis in 88% (14 of 16) and correct in 1 patient (6%). At exploratory celiotomy, the surgeon was able to make the diagnosis of cecal diverticulitis in 9 (60%) of the 15 patients in whom the correct diagnosis had not been made preoperatively. Neoplasm was suspected in 5 patients, and an appendiceal abscess was suspected in 1. Treatment was colectomy in 9 and local excision in 4 patients. In 3 patients, the inflamed diverticulum was left in situ at initial exploration; all underwent later excision, one of these urgently for sepsis. No patient died; however, one anastomotic leak requiring reoperation occurred. On the basis of this experience, we recommend excisional therapy in all cases in which the intraoperative diagnosis is certain. Suspicion of a neoplastic process continues to prompt colectomy in an emergency setting.