Management, treatment and outcomes of acute appendicitis in an elderly population: a single-center experience.

INTRODUCTION: Only 5-10% of cases of acute appendicitis (AA) are diagnosed above the age of 60 years. Complicated AA is more common in the elderly, who also have more comorbidities. The goals of this study were to describe our experience with elderly patients and identify predictors of increased morbidity. MATERIAL AND METHODS: Patients ≥65 years who were treated for AA between 2006 and 2013 were selected. The control consisted of patients aged 20-45 years, who were randomly selected from a pool of 900 patients. RESULTS: Seventy-four patients ≥65 years, mean age of 74.6 ± 7.4, were included. Time from onset of symptoms to surgery was similar between the groups. CT scan was performed for all patients in the elderly group compared to 55.6% in the younger group (p < 0.001). 77% of the younger patients underwent laparoscopic appendectomy compared to 43.2% of the elderly patients (p < 0.001). Pathological findings of severe appendicitis were significantly more common in the elderly group (39.2 vs. 10.5%, p < 0.001). Sixteen elderly patients (21.6%) developed complications, compared with 4 patients (3.2%) in the younger group (p < 0.001). The length of stay was longer in the elderly group and even longer for patients with complications (p < 0.001). There was no mortality. Cardiac disease was the only independent predictor of peri-operative complications (OR = 4.2). CONCLUSIONS: Severe forms of acute appendicitis and post-operative morbidity are higher in the elderly population. Cardiac disease is the only predictor for increased morbidity. Although CT scan was performed universally in the elderly group, it did not appear to increase time from presentation to surgery.

Percutaneous cholecystostomy is safe and effective option for acute calculous cholecystitis in select group of high-risk patients.

PURPOSE: In high-risk patients with acute calculous cholecystitis (ACC), percutaneous cholecystostomy (PC) can serve as a bridging option to cholecystectomy [laparoscopic cholecystectomy (LC)] or as definitive treatment. The purpose of this study was to identify predictors of the need for permanent PC. METHODS: Data from 257 PCs performed for ACC (mean age 67.3 ± 14) was collected for a 10-year period. Demographic and clinical characteristics at initial admission, co-morbidities were analyzed. Patients who underwent interval LC were defined as the surgery group (SG; n = 163, 63.4 %) and the remaining patients as the non-SG (NSG; n = 94, 36.6 %). RESULTS: Patients in the SG were significantly younger and had a shorter length of hospital stay (p < 0.01). The rate of coronary artery disease (CAD; 63.2 vs. 20.2 %), chronic renal failure (14.9 vs. 6.1 %), and the mean number of co-morbidities (2.2 vs. 1.4) were significantly higher in the NSG. Sepsis at admission was more common in the NSG (19.1 vs. 4.9 %, p < 0.001). 56 patients (34.4 %) in the SG and 24 patients (25.5 %) in the NSG developed tube-related complications. In hospital mortality was similar between the groups. Multivariate analysis showed that age ≥75, increased alkaline phosphatase (ALK-P), history of CAD, were predictors of PC as a definite treatment in this high-risk group of patients with ACC. CONCLUSIONS: High operative risk due to older age and CAD preclude LC in more than one-third of patients following PC especially presenting with sepsis and elevated ALK-P. This study suggests that PC could be a safe treatment option in this select group of high-risk patients.

Esophageal adenocarcinoma in patients < or = 50 years old: delayed diagnosis and advanced disease at presentation.

During the past decade, we encountered an increasing number of young patients with esophageal adenocarcinoma. It is not clear whether young patients have more aggressive course and worse prognosis. Our aim was to compare clinicopathological characteristics/treatment results of patients with esophageal adenocarcinoma who were < or = 50 and > 50 years of age. We studied 263 consecutive patients with resectable esophageal adenocarcinoma: 32 (12.1%) were < or = 50 years old. Dysphagia was present in 69 per cent of patients < or = 50 years old and in 48 per cent of older patients (P = 0.019). The median duration of dysphagia was 3.5 months in younger patients compared to 2 months in patients > 50 years (P < 0.0001). Seven of 22 (31.8%) young and three of 108 (2.8%) older patients with dysphagia reported dysphagia for > or = 6 months (P < 0.0001). Fifty per cent of younger patients were stage III/IV and > 70 per cent were node positive (P = 0.04 and P = 0.02 vs patients > 50 years, respectively). Five-year survival was 32.6 per cent for < or = 50 years and 45.5 per cent for > 50 years. More than 10 per cent of esophageal adenocarcinoma patients undergoing surgery are now < or = 50 years of age. They usually present with dysphagia, are symptomatic for a longer time before diagnosis, and have more advanced disease compared to older patients. With appropriate aggressive treatment, survival is similar. Liberal use of endoscopy and aggressive diagnostic approach are paramount in young patients with dysphagia/symptoms of gastroesophageal reflux disease (GERD).

Surgery for late-onset ulcerative colitis: predictors of short-term outcome.

BACKGROUND: Onset of ulcerative colitis and Crohn disease after the age of 65 (late-onset disease) is not common, and is usually associated with a worse prognosis. We review our experience with late-onset ulcerative colitis and define the predictors of short-term outcome. METHODS: A retrospective analysis of our surgical experience with 33 patients suffering from late-onset ulcerative colitis. The medical records of 17 women and 16 men who had surgery between 1984 and 1999 were reviewed for age at surgery, sex, duration of disease, extent of disease, indications for surgery, surgical procedures and outcome. Additionally, we identified predictors of outcome. RESULTS: The median age at surgery was 74 years (range 65-83). The most common indication for surgery was refractoriness to medical treatment. There were 4 deaths for a mortality rate of 12%, and 7 major complications. There was no mortality for elective procedures. On univariate analysis, albumin levels of 2.8 g/dl or less and urgent surgery were predictors of poor outcome. Disease of short duration (3 years or less from onset of disease to surgery) was also associated with a poor outcome, but this did not reach statistical significance. CONCLUSIONS: We conclude that in the elderly population suffering from late-onset ulcerative colitis and requiring an operation, urgent surgery and hypoalbuminemia are predictors of adverse outcome. Age at surgery, sex and the extent of colonic involvement did not influence outcome. Low complication and death rates should be expected for elective procedures in the elderly.

Surgery for ulcerative colitis in elderly persons: changes in indications for surgery and outcome over time.

HYPOTHESIS: Medical therapy has changed the indications for surgery over the last 4 decades. Advances in perioperative care have significantly improved the outcome. DESIGN: The medical records of all patients 65 years and older who underwent surgery for ulcerative colitis during a 40-year period were analyzed retrospectively. SETTING: Tertiary referral center. PATIENTS: One hundred thirteen consecutive patients 65 years and older who underwent surgery for ulcerative colitis between January 1, 1960, and June 30, 1999. MAIN OUTCOME MEASURES: Changes in elective and urgent indications for surgery. Changes over time in outcome and the factors that brought about these changes. Predictors of poor outcome in an elderly population with ulcerative colitis. RESULTS: One hundred thirteen patients were divided into 3 cohorts of 38, 38, and 37 consecutive patients admitted to the hospital during the periods 1960 through 1984, 1985 through 1993, and 1994 through 1999, respectively. Indications for surgery and morbidity and mortality rates have changed with time. Dysplasia has replaced carcinoma as a major indication for elective surgery (P =.001). Toxic megacolon has become significantly less common as an indication for urgent surgery (P =.001). Surgery-associated adverse outcomes have decreased significantly from 50% (13% deaths, 37% major complications) to 27% (3% deaths, 24% major complications) (P =.04). Male sex, an albumin level of 2.8 g/dL or less, and urgent surgery were found to be independent predictors of poor outcome. CONCLUSIONS: In our referral center, the indications for urgent and elective surgery have changed during the past 4 decades from toxic megacolon and carcinoma, to disease refractory, to medical therapy and dysplasia, respectively. Morbidity and mortality have decreased dramatically over time. Urgent procedures, low levels of albumin, and male sex are all predictors of poor outcome.

Multi-stage regulation, a key to reliable adaptive biochemical pathways.

A general "multi-stage" regulation model, based on linearly connected regulatory units, is formulated to demonstrate how biochemical pathways may achieve high levels of accuracy. The general mechanism, which is robust to changes in biochemical parameters, such as protein concentration and kinetic rate constants, is incorporated into a mathematical model of the bacterial chemotaxis network and provides a new framework for explaining regulation and adaptiveness in this extensively studied system. Although conventional theories suggest that methylation feedback pathways are responsible for chemotactic regulation, the model, which is deduced from known experimental data, indicates that protein interactions downstream of the bacterial receptor complex, such as CheAs and CheZ, may play a crucial and complementary role.

Ulcerative colitis and thrombotic thrombocytopenic purpura.

Inflammatory bowel disease is often associated with hematologic abnormalities such as anemia, leukocytosis, and thrombocytosis. We report for the first time an unusual case of ulcerative colitis complicated by thrombotic thrombocytopenic purpura. Severe lower gastrointestinal bleeding resolved with subtotal colectomy, but the thrombotic thrombocytopenic purpura proved unresponsive to medical treatment. Splenectomy and completion proctectomy were performed, ultimately resulting in a successful outcome.

Gallstone ileus and Crohn's disease without biliary-enteric fistula: report of a unique case.

Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for fewer than 3% of laparotomies for intestinal obstruction. Patients with long-standing Crohn's disease have an increased risk of developing gallstone disease. However, gallstone ileus is not common in these patients. We report the case of a 70-year-old female with Crohn's disease who presented with gallstone ileus, and present a review of the literature. We discuss the association between gallstone ileus and Crohn's disease, and the treatment options for these patients. We emphasize the importance of including gallstone ileus in the differential diagnosis in patients presenting with intestinal obstruction, especially patients with long-standing Crohn's disease. We advocate the early utilization of computerized tomography to confirm the diagnosis, and prompt early surgical intervention.

Conservative treatment of a traumatic tear of the left hepatic duct: case report.

Injury to the extra-hepatic biliary system in blunt abdominal trauma is rare and difficult to diagnose. In adults, all reported cases were treated surgically. We report a case of a traumatic tear of the left hepatic duct that was treated successfully by endoscopic retrograde cholangiopancreatography and stenting.

Intersubband-transition-induced phase matching.

We suggest the use of the refractive-index changes associated with the intersubband transitions in quantum wells for phase matching in nonlinear materials. An improvement in the conversion efficiency of mid-IR second-harmonic generation by almost 2 orders of magnitude over non-phase-matched bulk GaAs is predicted. We also show that the linear phase contributions of intersubband transitions used for resonant enhancement of second-harmonic generation must be considered, as they could limit the conversion efficiency by increasing the phase mismatch on one hand or offset the bulk's dispersion and lead to phase matching on the other.