Appendiceal cancer masked as inflammatory appendicitis in the elderly, not an uncommon presentation (Surveillance Epidemiology and End Results (SEER)-Medicare Analysis).

BACKGROUND: The misdiagnosis of appendiceal cancer as inflammatory appendicitis is becoming of greater clinical concern because of the rise of nonoperative management especially in the elder population. To quantify this rate of misdiagnosis, we retrospectively reviewed SEER-Medicare data. METHODS: The SEER-Medicare database was reviewed from 2000 to 2014. We identified patients older than 65 years old who were diagnosed with appendiceal cancer and then cross-referenced them for a diagnosis of inflammatory appendicitis. Demographic data and oncologic stage were collected. RESULTS: Our results showed that 28.6% of appendiceal cancer patients received an incorrect initial diagnosis of inflammatory appendicitis. Patients older than 75 years of age were more likely to be misdiagnosed than those between ages 65 and 75 (risk ratio [RR]: 0.81; 95% confidence interval: 0.70-0.93; P = .003). We found that 42% of patients within the misdiagnosis group presented with an earlier stage of disease (stage 1 or 2) compared to 26% of those primarily diagnosed with appendiceal cancer (P < .001). CONCLUSION: A significant proportion of patients older than 65 years old with appendiceal cancer were initially misdiagnosed with acute appendicitis. We suggest caution when considering a nonoperative approach for appendicitis in the elderly and follow-up imaging or an interval appendectomy should be part of the treatment plan.

Benign anorectal disease: hemorrhoids, fissures, and fistulas.

Hemorrhoids, anal fissures, and fistulas are common benign anorectal diseases that have a significant impact on patients' lives. They are primarily encountered by primary care providers, including internists, gastroenterologists, pediatricians, gynecologists, and emergency care providers. Most complex anorectal disease cases are referred to colorectal surgeons. Knowledge of these disease processes is essential for proper treatment and follow up. Hemorrhoids and fissures frequently benefit from non-operative treatment; they may, however, require surgical procedures. The treatment of anorectal abscess and fistulas is mainly surgical. The aim of this review is to examine the etiology, diagnosis, medical, and surgical treatment for these benign anorectal diseases.

Anal intraepithelial neoplasia: diagnosis, screening, and treatment.

Anal intraepithelial neoplasia (AIN) is a premalignant lesion for anal cancer. It is more commonly found in high-risk patients (e.g., human papilloma virus (HPV)/human immunodeficiency virus infections, post-organ transplantation patients, and men who have sex with men) and development is driven by HPV infection. The incidence of AIN is difficult to estimate, but is heavily skewed by preexisting conditions, particularly in high-risk populations. The diagnosis is made from cytology or biopsy during routine examinations, and can be performed at a primary care provider's office. A pathologist can then review and classify cells, based on nucleus-to-cytoplasm ratios. The classification of low or high grade can better predict progression from AIN to anal cancer. There is little debate that AIN can develop into anal cancer, and the main rationale for treatment is to delay the progression. Significant controversy remains regarding screening, surveillance, and treatment for AIN. Management options are separated into surveillance (watchful waiting) and interventional strategies. Emerging data suggest that close patient follow up with a combination of ablative and topical treatments may offer the greatest benefit. HPV vaccination offers a unique treatment prior to HPV infection and the subsequent development of AIN, but its use after the development of AIN is limited. Ablative treatment includes excision, fulguration, and laser therapy.

Hepatic and splenic blush on computed tomography in children following blunt abdominal trauma: Is intervention necessary?

BACKGROUND: There are no widely accepted guidelines for management of pediatric patients who have evidence of solid organ contrast extravasation ("blush") on computed tomography (CT) scans following blunt abdominal trauma. We report our experience as a Level 1 pediatric trauma center in managing cases with hepatic and splenic blush. METHODS: All pediatric blunt abdominal trauma cases resulting in liver or splenic injury were queried from 2008 to 2014. Patients were excluded if a CT was unavailable in the medical record. The presence of contrast blush was based on final reports from attending pediatric radiologists. Correlations between incidence of contrast blush and major outcomes of interest were determined using χ and Wilcoxon rank-sum tests for categorical and continuous variables, respectively, evaluating statistical significance at p < 0.05. RESULTS: Of 318 patients with splenic or liver injury after blunt abdominal trauma, we report on 30 patients (9%) with solid organ blush, resulting in 18 cases of hepatic blush and 16 cases of splenic blush (four patients had extravasation from both organs). Blush was not found to correlate significantly with age, gender, or type of injury (liver vs. splenic) but was found to associate with higher grades of solid organ injury (p = 0.002) and higher ISS overall (p < 0.001). Patients with contrast blush on imaging were more likely to be admitted to the intensive care unit (90% vs. 41%, p < 0.001), receive blood products, (50% vs. 12%, p < 0.001), and be considered for an intervention (p < 0.001). Eighty percent of patients with an isolated contrast blush of the spleen or liver did not require an operation. Only 17% of patients with blush required definitive treatment, such as embolization (n = 1), packing (n = 1), or splenectomy (n = 3). Blush had no significant correlation with overall survival (p = 0.13). CONCLUSIONS: The finding of a blush on CT from a splenic or liver injury is associated with higher grade of injury. These patients receive intensive medical management but do not uniformly require invasive intervention. From our data, we suggest that a blush can safely be managed nonoperatively and that treatment should be dictated by change in physiology. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Single-Incision Total Proctocolectomy and Ileal Pouch Anal Anastomosis in Pediatric Patients: Lessons Learned.

BACKGROUND: Total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) have become the standard of care for patients with ulcerative colitis refractory to medical management. The purpose of our study is to show our single-site approach and to identify maneuvers that improve efficiency. MATERIALS AND METHODS: We retrospectively reviewed patients who underwent single-site three-stage TPC-IPAA for ulcerative colitis at our institution. Primary outcomes included operative time, conversion from single site to standard laparoscopy, time to oral intake and stoma function, postoperative complications, and length of stay. The GelPOINT(™) Advanced Access Platform (Applied Medical, Santa Margarita, CA) was used. RESULTS: Eight patients were identified who had undergone single-site surgery with the GelPOINT platform. Six of the 8 patients underwent the first stage, total abdominal colectomy (TAC), and all 8 underwent the second stage (proctectomy/IPAA). The mean operating time for TAC was 242 ± 32 minutes. The mean time until tolerance of clear diet was 1.2 ± 0.4 days, and time until tolerance of regular diet was 3.3 ± 1.2 days. The mean time to stoma function was 1.5 ± 0.55 days, and that for postoperative opioid use was 4.0 ± 1.3 days. The median length of stay was 5 days (range, 3-10 days). There was one postoperative complication. The mean operating time for the proctectomy/IPAA was 283 ± 50 minutes. The mean time until tolerance of clear diet was 1.0 ± 0.5 days, and time until tolerance of regular diet was 3.3 ± 1.1 days. The mean time to stoma function was 1.6 days ± 0.52 days, and that for postoperative opioid use was 3.3 ± 1.4 days. Median length of stay was 4 days (range, 3-9 days). There was one postoperative complication. Technical adaptations that included extracorporeal mesenteric division, rectal eversion, and rotation of the GelPOINT device served to improve the ease and efficiency of the procedure. CONCLUSIONS: Single-site TPC-IPAA is both feasible and safe. Incorporation of adapted technical maneuvers can increase efficiency.