Strictureplasty for Crohn's disease: meta-analysis.

PURPOSE: The objective of this study was to analyze patient outcome after strictureplasty for management of intestinal stricture caused by Crohn's disease based on differences in surgical procedures. METHODS: A MEDLINE search was performed using a medical subject heading analysis for strictureplasty in Crohn's disease. Meta-analysis of multiple variables for outcome was performed using random-effects models. RESULTS: Five hundred six patients underwent 1,825 strictureplasties for Crohn's disease with minimal morbidity and zero mortality. Ninety percent of strictures were less than 10 cm in length. Approximately 85 percent of these procedures used the Heineke-Mikulicz technique and 13 percent used Finney strictureplasty. Forty-four percent of procedures included concurrent bowel resection. Recurrence rate of Crohn's disease after strictureplasty was increased in patients with longer study duration after surgery (P = 0.04), who showed symptoms of active disease (P = 0.02), who experienced preoperative weight loss (P = 0.02), or who received the Heineke-Mikulicz procedure (P = 0.008). The proportion of patients requiring additional surgery was increased with longer study duration (P = 0.006), with preoperative weight loss (P = 0.001), or with the Heineke-Mikulicz procedure (P = 0.005). The proportion of patients requiring additional surgery was decreased when a Finney strictureplasty was used (P = 0.008) as compared with those treated by the Heineke-Mikulicz procedure. CONCLUSION: Although the Heineke-Mikulicz technique is most often used for Crohn's strictureplasty, outcome analysis revealed the Finney strictureplasty may reduce the reoperation rate.

Colorectal cancer staging and adjuvant chemotherapy.

Colorectal cancer is a significant cause of morbidity and mortality in Western populations. The standard of care for staging patients with colorectal cancer to determine prognosis and identify patients who will receive adjuvant therapy continues to be histopathology of regional lymph nodes. However, the significant variability in survival within each staging category likely reflects the heterogeneity of detecting micrometastatic disease employing this technique. Novel molecular markers of micrometastases currently in development will permit more accurate staging of patients with colorectal cancer. These advances in staging will distinguish patients who will maximally benefit from adjuvant therapy from those who have an especially good prognosis in whom chemotherapy can be avoided. In addition, new adjuvant chemotherapeutic agents, novel combinations of those agents and creative dosing schedules currently being investigated will offer considerable advantages with respect to ease of administration, safety and tolerability, quality of life and efficacy. Ultimately, it is anticipated that advances in molecular diagnostics will define unique biochemical characteristics of patients' tumours, permitting individualization of chemotherapeutic regimens employing novel agents that specifically exploit those characteristics.

Guanylyl cyclase C messenger RNA is a biomarker for recurrent stage II colorectal cancer.

BACKGROUND: Patients with stage II colorectal cancer and no histologic evidence of lymph node invasion develop recurrent disease, presumably because of undetected micrometastases. Guanylyl cyclase C is expressed by intestinal and colorectal cancer cells but not by extraintestinal tissues or tumors. OBJECTIVE: To examine the expression of guanylyl cyclase C messenger RNA (mRNA) in lymph nodes of patients with node-negative colorectal cancer who did and did not have recurrent disease. DESIGN: Case-control study. SETTING: Tertiary care academic medical center. PATIENTS: Paraffin-embedded lymph nodes were obtained from 21 patients with histologically confirmed node-negative colorectal cancer who had undergone resection. Controls included 11 patients without disease recurrence 6 or more years after resection, and case-patients included 10 patients whose disease recurred up to 3 years after resection. MEASUREMENTS: Sections of paraffin-embedded lymph nodes were obtained from each patient and were pooled, and their RNA was analyzed by reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: Guanylyl cyclase C mRNA was expressed in lymph nodes from all patients with recurrent disease but not in those from patients without recurrent disease (P = 0.004). Nested RT-PCR that used primers for carcinoembryonic antigen, a marker for colorectal cancer, identified carcinoembryonic antigen mRNA in lymph nodes from only 1 of 10 patients with recurrent disease and those from 0 of 11 patients without recurrent disease. The odds ratio for death associated with expression of guanylyl cyclase C mRNA in regional lymph nodes was 15.0 (95% CI, 1.1 to 756.7). CONCLUSIONS: Expression of guanylyl cyclase C mRNA in lymph nodes is associated with recurrence of colorectal cancer in patients with stage II disease. Analysis of guanylyl cyclase mRNA expression by RT-PCR may be useful for colorectal cancer staging.

Changing epidemiology of anorectal melanoma.

PURPOSE: We reviewed 117 cases of anorectal melanoma to better define epidemiologic and survival characteristics of this rare neoplasm. METHODS: The National Cancer Institute Surveillance, Epidemiology, and End Results database covering the period 1973 through 1992 was used. This represents 9.5 percent of the United States population. Melanoma arising in the anorectum was identified using International Classification of Diseases for Oncology codes. Two-tailed Student's t-test, chi-squared, and Wilcoxon's tests were used for comparisons of means, proportions, and actuarial survival rates, respectively. RESULTS: One hundred seventeen cases of anorectal melanoma were identified, representing 0.048 percent of all colorectal malignancies in the database. The male-to-female ratio was 1:1.72. The mean age was 66 +/- 16 years. Mean age by gender, however, was lower for males (57 years) then for females (71 years; P < 0.001). The age difference represents an increased incidence of anorectal melanoma in males younger than the age of 45 years. Furthermore, the incidence of anorectal melanoma in young males ages between 25 to 44 years tripled in the San Francisco area when compared with all other locations (14.4 vs. 4.8 per 10 million population; P = 0.06). Males have a survival advantage over females (62.8 percent vs. 51.4 percent 1-year and 40.6 percent vs. 27.7 percent 2-year; P < 0.01). CONCLUSIONS: The overall incidence of anorectal melanoma continues to rise and survival rates remain poor. A new trend toward bimodal age distribution was observed. There is indirect evidence that implicates human immunodeficiency virus infection as a risk factor. Survival rate is better in young patients aged 25 to 44 years.

Adenosquamous carcinoma of the colon, rectum, and anus: epidemiology, distribution, and survival characteristics.

PURPOSE: There have been 49 cases of adenosquamous carcinoma of the colon, rectum, and anus reported in the English literature. We have reviewed 145 cases of adenosquamous carcinoma to better define epidemiologic and survival characteristics of this extremely rare colon carcinoma. METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results program public use CD-ROM file for the years 1973 through 1992 were reviewed. This represents approximately 9.5 percent of the United States population. Adenosquamous carcinomas arising in the colon, rectum, and anus were identified using the International Classification of Diseases-O codes. The Astler-Coller tumor classification was used for staging. Two-tailed Student's t-test, Mantel-Haenszel chi-squared tests, and generalized Wilcoxon's tests were used for comparisons of means, proportions, and actuarial survival rates, respectively. Survival curves were calculated by the Kaplan-Meier method. RESULTS: One hundred forty-five cases of adenosquamous carcinoma were identified, representing 0.06 percent of all colorectal malignancies. The mean age of patients was 67 years. Eighty-four percent of patients were Caucasians, 15 percent were Afro-Americans, and 1 percent were other races. Afro-Americans were diagnosed at a significantly younger age (median age, 62 years; P = 0.03). Fifty-three percent of the carcinomas were located in the sigmoid colon, rectum, and anus, 28 percent in the right colon, and the rest in the middle segment. Seventy-four percent of distal cases were staged A through C, compared with 44 percent of proximal cases. Patients with adenosquamous carcinoma of the sigmoid colon, rectum, and anus survived longer than all other patients (P = 0.001). Patients with adenosquamous carcinoma Stages A and B1 had survival rates similar to patients with comparably staged adenocarcinomas. Fifty percent of the patients, including most of the patients with D stage, died in the first year. Patients with Stages B2, C, and D adenosquamous carcinomas had a significantly shorter survival than the comparably staged adenocarcinomas (P < or = 0.02). The overall adjusted five-year survival rate was 30.7 percent. In those patients who survived more than 24 months, the five-year survival was 84 percent. CONCLUSIONS: The survival rates for patients with adenosquamous carcinoma Stages A and B1 are similar to patients with comparably staged colorectal adenocarcinomas. However, we found that patients with colorectal and anal adenosquamous carcinomas staged B2 through D have significantly poorer survival than patients with comparably staged adenocarcinomas, supporting the previous reports of a poor prognosis associated with adenosquamous carcinomas.

Use of guanylyl cyclase C for detecting micrometastases in lymph nodes of patients with colon cancer.

INTRODUCTION: Guanylyl cyclase C appears to be expressed only in colorectal cancer cells in extraintestinal tissues. Thus, guanylyl cyclase C may be useful as a marker to detect colorectal cancer micrometastases not detectable by histopathology in lymph nodes of patients. METHODS: Twelve patients with colon adenocarcinoma, Dukes Stages A through C2, and one patient with a tubulovillous adenoma were included in this study. Forty-two lymph nodes were collected from fresh surgical specimens, and each was examined by histopathology and reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers. Histopathology identified colon cancer cells in 6 of 16 lymph nodes from five Dukes Stage C patients but not in lymph nodes from the patient with a tubulovillous adenoma, the Dukes Stage A patient, or six Dukes Stage B patients. Reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers was performed on all 42 lymph nodes. RESULTS: Guanylyl cyclase C messenger RNA was not detected by reverse transcription followed by polymerase chain reaction in lymph nodes from the patient with the tubulovillous adenoma or the patient with Dukes Stage A colon carcinoma. Seven lymph nodes from Dukes Stage C patients revealed guanylyl cyclase C messenger RNA including six lymph nodes containing histopathologically confirmed metastases. Of significance, guanylyl cyclase C messenger RNA was detected in 6 of 21 lymph nodes from Dukes Stage B patients. Indeed, clinical staging of two patients could be upgraded from B to C using reverse transcription followed by polymerase chain reaction and guanylyl cyclase C-specific primers. CONCLUSION: Reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers might be useful to more accurately assess micrometastases in lymph nodes of colorectal cancer patients undergoing disease staging.

Pulmonary scar carcinoma: report of three cases and review of the literature.

Pulmonary scar carcinoma was described as a distinct clinicopathological entity over 50 years ago. There are many theories on the formation of this entity. We present three cases of pulmonary scar carcinoma with a high ratio of adenocarcinoma. One patient had a favorable postoperative course despite a 14-month delay in treatment. Necropsy specimen of another patient showed two primary scar carcinomas unrelated to each other. Literature review and discussion of etiology, diagnosis, and treatment modalities of pulmonary scar carcinoma were done. Pathogenesis and prognosis of the neoplasms associated with apical scars are not clearly understood.

Pulmonary blastoma presenting as a solitary lip metastasis: case report and review of the literature.

Pulmonary blastoma (PB) is an uncommon primary lung malignancy. This neoplasm was first described by Barrett and Barnard in 1945. The tumor is composed of immature epithelial and mesenchymal tissues which may recapitulate early embryological lung development. Under the microscope, the globular component resembles immature bronchus and connective tissue as seen in embryonic lung. More than one hundred cases have been reported in the literature. PB is more frequent in older people and in males and tends to affect blacks at younger ages. Symptomatology varies from asymptomatic to symptoms of a non-specific pulmonary disease. Cough, hemoptysis, dyspnea, chest pain, respiratory distress, fever, anorexia and weight loss are the most common presenting features. The most common roentgenologic pattern is a well-demarcated peripheral lesion, encapsulated by compression or atelectatic lung tissue, although in some cases there is a tendency to lobulation and cavitation. The size of the mass varies from a small peripheral nodule to a mass occupying the entire lobe or hemithorax. The treatment of choice has been surgical excision, radiation and, in selected cases, a combination of chemotherapy with radiation. The prognosis of this malignancy is poor; overall five-year survival is approximately 16 percent. No correlation has been established between histopathologic criteria and survival. The factors that indicate poor prognosis are tumor recurrence, metastasis at initial presentation, tumor size over 5 cm and lymph node metastasis. Liver, central nervous system and bones are the most frequent location of distant metastases. A rare case is presented of a pulmonary blastoma with an upper lip metastasis occurring in a paraplegic male. Diagnosis was confirmed by autopsy findings.(ABSTRACT TRUNCATED AT 250 WORDS)

The learning curve for laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy (LC) in 1987 has resulted in its wide acceptance by surgeons in the United States. Questions about proper training and learning curve for surgeons wishing to perform laparoscopic procedures have been raised during this period. We retrospectively evaluated 416 consecutive cholecystectomy cases that were performed by eight surgeons in a community teaching hospital. In this report, 374 patients had LC and 42 patients (10%) had an attempted LC, which had to be converted to an open cholecystectomy (CONV). Surgeons A and B performed 40% and 18% of all LC cases, respectively, and were classified as the surgeons with the highest volume of cases. Parameters, including conversion rate, operative time, and complications, were evaluated to define the learning curve. Surgeons A and B experienced 17% and 14% initial conversion rates for the first 35 cases, respectively. These rates dramatically dropped to an acceptable level (4% and 3%) with increased experience. The operative time for surgeon A for the first and last 35 cases improved from 97 +/- 25 min to 74 +/- 32 min (p = 0.01). Although the procedure time for surgeon B improved by 4 min, this difference was not statistically significant. The operative time for all cases was 81 +/- 31 min and 87 +/- 27 min, respectively, for surgeons A and B, which was significantly less than that for other surgeons (p = 0.01). A total of 12 patients experienced complications related to LC. Most of the complications (75%) occurred in the first 30 cases for all surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective analysis of laparoscopic and open cholecystectomies.

A total of 686 consecutive cases were reviewed for comparison between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC). The procedures were performed by the teaching surgical service of a community hospital. Between March 1989 and December 1992, 381 patients had LC, 262 had OC, and 43 patients had attempted LC that was converted to open cholecystectomy (CONV). Postoperative hospital stay for LC was 2.9 +/- 3.7 days (range 12 h to 28 days) and was significantly less than those for OC (12.4 +/- 23.6 days) or CONV (8 +/- 8.3 days) (p < 0.0001). Patients who had LC revealed meaningfully decreased perioperative or postoperative antibiotic use, postoperative temperature elevations, and hospitalization when compared to OC or CONV (p < 0.0001). Bile duct injury was 0.26% with LC and 0.38% with OC. The percentage of postoperative bile leakage was 0.79% and 0.38% for LC and OC, respectively. LC cases were associated with lower complication rates when compared to OC or CONV (p < 0.005). No deaths were observed with LC (0%). However, the mortality rate for OC was 1.5%. The results of LC were more favorable than those of OC and CONV with respect to complications, morbidity, mortality, and length of hospital stay. Based on our experience, the patient outcome for LC was superior to OC.

Aortic blebs: an indication for urgent surgery.

A blister on an aortic aneurysm represents the final stage before rupture, regardless of patient symptoms or aneurysm size. The mechanisms of rupture are unclear but probably involve defects in the elastin and collagen matrices.