Small-bowel tumors: epidemiologic and clinical characteristics of 1260 cases from the connecticut tumor registry.

OBJECTIVE: To examine the epidemiology and clinical characteristics of small-bowel cancer. DESIGN: Patients with small-bowel tumors reported between 1980 and 2000, studied retrospectively. SETTING: Data from the Connecticut Tumor Registry. PATIENTS: One thousand sixty small-bowel cancer cases: 628 men (49.84%) and 632 women (50.16%). Mean age at presentation was 65.2 years. RESULTS: The most common location of small-bowel tumors was the ileum (374 cases; 29.7%), followed by the duodenum (320 cases; 25.4%) and the jejunum (193 cases; 15.3%). In 367 patient cases (29.1%: 192 men [30.6%] and 175 women [27.7%]), a prior or subsequent tumor of the gastrointestinal tract was reported. The most prevalent histologic type was carcinoid (417 cases; 33%), followed by adenocarcinoma (341 cases; 27%) and lymphoma (205 cases; 16.3%). The patient population was predominantly white (1159 patients; 92%), followed by African American patients (91 patients; 7.2%). Stratification by consecutive 7-year intervals showed the following: from 1980 to 1986, there were 10.5 cases per 100 000 individuals; from 1987 to 1993, there were 13.05 cases per 100 000 individuals; and from 1994 to 2000, there were 14.86 cases per 100 000 individuals. Men comprised 44.8% of cases from 1980 to 1986, 50.2% of cases from 1987 to 1993, and 53.3% of cases from 1994 to 2000. African American patients accounted for 7.5% of all cases from 1980 to 1986, 5.8% from 1986 to 1993, and 8.2% of cases from 1994 to 2000. In 1106 patients (87.7%), the primary therapy was surgical, including intestinal bypass, radical excision, excisional biopsy, and subtotal or total excision. CONCLUSIONS: The incidence of small-bowel tumors in Connecticut has increased during the past 2 decades, with the highest rate of increase in men. Carcinoid tumors are the most common small intestinal cancers identified histologically, followed by adenocarcinomas. The former seems to be more frequently seen in the ileum, the latter in the duodenum. Surgery is the treatment of choice for the cure or palliation of small-bowel cancers.

Laparoscopic gastric wedge resection for Dieulafoy's disease following preoperative endoscopic localization with India ink and endoscopic clips.

BACKGROUND: Dieulafoy's lesion is a vascular malformation, usually of the stomach but occasionally of the small or large bowel. It is an uncommon, but clinically significant, source of upper gastrointestinal hemorrhage. Three cases have been reported in the literature of laparoscopic gastric wedge resection of these lesions by using intraoperative endoscopic localization. We present the only reported case of preoperative endoscopic localization of a Dieulafoy's lesion with India ink and an endoscopic clip before laparoscopic resection. CASE REPORT: We present an 82-year-old female patient who presented to the emergency department with 3 episodes of hematemesis. Esophagogastroduodenoscopy revealed an actively bleeding Dieulafoy's lesion in the fundus of the stomach along the greater curvature, which was controlled endoscopically. However, the patient had a recurrent episode of bleeding. Repeat endoscopy was performed and the lesion was tagged with 2 endoscopic clips and marked with India ink. A laparoscopic wedge resection was performed after the India ink was identified in the fundus. The patient did well postoperatively. CONCLUSION: Preoperative localization of a Dieulafoy's lesion with India ink and endoscopic clips before laparoscopic wedge resection is a feasible procedure. Therefore, no need exists for intraoperative endoscopy to aid in the localization, as previously reported.

The postoperative surveillance of patients with colon cancer and rectal cancer.

BACKGROUND: Colon cancer is relatively common; however, the results of treatment have marginally improved over the last half century. Though about 85% of patients have colorectal tumors resected with curative intent, a significant number of these patients will eventually die from cancer. As a result, many clinicians have advocated intensive follow-up in such patients as an attempt to increase survival. DATA SOURCES: A review of the literature focusing on studies that have specifically addressed postoperative surveillance programs in patients with colorectal cancer was conducted. Only studies with level A evidence were included. Further references were obtained through cross-referencing the bibliography cited in each work. CONCLUSION: One of the six prospective randomized studies demonstrated a statistically significant survival benefit. Undoubtedly, survival benefits can be shown with a well-designed evidence-based follow-up strategy. However, well-designed large prospective multi-institutional randomized studies are needed to establish a consensus for follow-up.

Anastomotic disruption after large bowel resection.

Anastomotic disruption is a feared and serious complication of colon surgery. Decades of research have identified factors favoring successful healing of anastomoses as well as risk factors for anastomotic disruption. However, some factors, such as the role of mechanical bowel preparation, remain controversial. Despite proper caution and excellent surgical technique, some anastomotic leaks are inevitable. The rapid identification of anastomotic leaks and the timely treatment in these cases are paramount.

Management of parastomal ulcers.

Management of surgically placed ostomies is an important aspect of any general surgical or colon and rectal surgery practice. Complications with surgically placed ostomies are common and their causes are multifactorial. Parastomal ulceration, although rare, is a particularly difficult management problem. We conducted a literature search using MD Consult, Science Direct, OVID, Medline, and Cochrane Databases to review the causes and management options of parastomal ulceration. Both the etiology and treatments are varied. Different physicians and ostomy specialists have used a large array of methods to manage parastomal ulcers; these including local wound care; steroid creams; systemic steroids; and, when conservative measures fail, surgery. Most patients with parastomal ulcers who do not have associated IBD or peristomal pyoderma gangrenosum (PPG) often respond quickly to local wound care and conservative management. Patients with PPG, IBD, or other systemic causes of their ulceration need both systemic and local care and are more likely to need long term treatment and possibly surgical revision of the ostomy. The treatment is complicated, but improved with the help of ostomy specialists.

Management of less common tumors of the colon, rectum, and anus.

The majority of colorectal and anal malignancies are adenocarcinomas and squamous cell cancers, respectively. Despite the predominance of these neoplasms in these locations, rare histiotypes of the colon, rectum, and anus do occur. These histotypes include but are not limited to lymphoma, melanoma, diffuse cavernous hemangioma, and sarcomas, such as leiomyosarcoma or Kaposi's sarcoma. These tumors often present challenges to clinicians with respect to diagnosis, staging, management, and pathology because of their unfamiliarity. A Medline search using "colon," "rectum,""anus," "lymphoma," "melanoma," "diffuse cavernous hemangioma," "squamous cell carcinoma," "carcinoid," "sarcoma," "leiomyosarcoma," "Kaposi's sarcoma," "Paget's disease," "Bowen's disease," and "basal cell carcinoma" as key words was performed as well as a cross-referencing of the bibliography cited in each work. Rare tumors of the colon, rectum, and anus present diagnostic and management dilemmas for clinicians. Because of their infrequency and poor prognosis, the optimal management of these tumors is controversial. For some histotypes, such as squamous cell carcinoma and carcinoids of the rectum, treatment depends on location and size of the tumor. For uncommon anal lesions, such as Bowen's disease, Paget's disease, and basal cell carcinoma, wide local excision (WLE) with negative margins is the standard of care. For other lesions such as anorectal melanoma or leiomyosarcoma, abdominal perineal resection versus WLE is still being debated. Because the optimal treatment of these tumors is still unclear, we recommend a multidisciplinary approach including a surgeon, primary care physician, medical oncologist, radiation oncologist, and pathologist to offer the patient the best outcome.

The demographics, histopathology and patterns of treatment of anal cancer in Connecticut: 1980-2000.

OBJECTIVES: Examine the epidemiology and clinical characteristics of anal cancer in the State of Connecticut. MATERIALS AND METHODS: The Department of Health Connecticut Tumor Registry resources were utilized for the years 1980-2000. RESULTS: A total of 646 anal cancers (410 females, 236 males) were diagnosed (mean age: 63.4 years). The most prominent histological type was squamous cell carcinoma, followed by adenocarcinoma and cloacogenic carcinoma. Females predominated in both the first and second decade of the study period. Black males accounted for 2.3% of all cases during the first decade, compared to 5% during the second decade. Surgery alone was the most common treatment modality, followed by radiation alone and a combination of surgery and radiation therapy. Chemotherapy data were not available although it is currently considered an important part of therapy. CONCLUSIONS: Anal cancer incidence in Connecticut increased in the 21-year period 1980 to 2000, affecting the rate for African-American men more than other race-specific and gender-specific population subgroups. Anal cancer affects women more often than men. Squamous cell carcinoma is the most common histological type.

The role of arachidonic acid regulatory enzymes in colorectal disease.

PURPOSE: Nonsteroidal anti-inflammatory drugs have a wide ranging effect on diseases of the colon and rectum. Interestingly, nonsteroidal anti-inflammatory drugs seem to play a beneficial role in colorectal cancer chemoprevention and adenoma regression, but may have a deleterious effect in inflammatory bowel disease. Prostaglandin inhibition is central to both the beneficial and toxic effects of this class of drugs. Arachidonic acid metabolism is essential to prostaglandin synthesis. METHODS: A Medline search using "nonsteroidal anti-inflammatory drugs," "colon cancer," "inflammatory bowel disease," "colitis," "COX inhibitors," "arachidonic acid," and "chemoprevention" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. RESULTS: Based on numerous studies, nonsteroidal anti-inflammatory drugs have a beneficial role in colon cancer and colonic adenomas. However, they have been reported to have a deleterious effect on the colon in inflammatory bowel disease and have been shown to cause colitis. Nonsteroidal anti-inflammatory drugs work via multiple pathways, some well defined, and others unknown. CONCLUSIONS: In the new millennium, nonsteroidal anti-inflammatory drugs may be used for chemoprevention of colorectal and other cancers. In addition, they may be used in combination with surgery and chemotherapy to primarily treat colorectal carcinoma. Undoubtedly, the use of novel cyclooxygenase inhibitors with less of a toxicity profile will allow more widespread use of nonsteroidal anti-inflammatory drugs for a variety of diseases. The future of this class of drugs is promising.

Colorectal manifestations of collagen vascular disease.

BACKGROUND: The collagen vascular diseases are a collection of conditions, which are thought to be secondary to pathologic alterations in the immune system. Deposition of immune complexes in blood vessel walls resulting in either ischemia or thrombosis is the most widely accepted pathologic mechanism. The lack of familiarity with this subgroup of disease can lead to unnecessary surgical intervention. DATA SOURCES: A Medline search was performed of all the English-language literature. Further references were obtained through cross-referencing the bibliography cited in each work. CONCLUSION: Clinical manifestations are varied and complications include constipation, fecal incontinence, pseudoobstruction, perforation, hemorrhage, and mesenteric ischemia. Colorectal manifestations typically follow dermal presentations. Management should be conservative especially for pseudo-obstructions. Surgical intervention increases morbidity and should be chosen when absolutely necessary. Because of the high incidence of colorectal malignancies in patients with dermatomyositis, aggressive screening should be performed.

Laparoscopic ventral hernia repair using a two (5-mm) port technique.

OBJECTIVE: High recurrence rates have been documented after primary repair of incisional hernias. Laparoscopic ventral and incisional hernia repairs have been performed with very low rates of recurrence. We have modified the standard technique of laparoscopic repair in patients with small incisional and ventral hernias. The purpose of this study was to document the technique utilizing only two 5-mm ports and demonstrate that it is safe, effective, and feasible. METHODS: Three patients with small incisional or ventral hernias were examined. The standard laparoscopic ventral hernia repair technique was modified as follows: two 5-mm ports were inserted on opposite sides of the defect. The defects ranged from 2.5 cm to 4 cm in size. Expanded polytetrafluoroethylene mesh (DualMesh, WL Gore, Flagstaff, AZ) was used to cover the hernia defect, overlapping the defect margins circumferentially by 3 cm. The mesh diameter ranged from 8.5 cm to 10 cm. The mesh was inserted through a 5-mm skin incision site and affixed into position with transfascial sutures and spiral tacks. RESULTS: The operative time ranged from 53 minutes to 57 minutes. All patients were discharged home the day of surgery and reported minimal postoperative pain. Follow-up ranged from 6 months to 1 year; all patients were doing well without recurrence. CONCLUSION: Laparoscopic repair of ventral or incisional hernias can be performed using only two 5-mm ports. This technique can be done on an outpatient basis in a safe, timely fashion.

Management of disorders of the posterior pelvic floor.

INTRODUCTION: Constipation is a relatively common problem affecting 15 percent of adults in the Western world, and over half of these cases are related to pelvic floor disorders. This article reviews the clinical presentation and diagnostic approach to posterior pelvic floor disorders, including how to image and treat them. METHODS: A Pubmed search using keywords "rectal prolapse," "rectocele," "perineal hernia," and "anismus" was performed, and bibliographies of the revealed articles were cross-referenced to obtain a representative cross-section of the literature, both investigational studies and reviews, that are currently available on posterior pelvic floor disorders. DISCUSSION: Pelvic floor disorders can occur with or without concomitant physical anatomical defects, and there are a number of imaging modalities available to detect such abnormalities in order to decide on the appropriate course of treatment. Depending on the nature of the disorder, operative or non-operative therapy may be indicated. CONCLUSION: Correctly diagnosing pelvic floor disorders can be complex and challenging, and the various imaging modalities as well as clinical history and exam must be considered together in order to arrive at a diagnosis.

The management of rectal cancer in the elderly.

INTRODUCTION: The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies. METHODS: A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. DISCUSSION: Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference. CONCLUSION: Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.

Efficacy of dextran solutions in vascular surgery.

The purpose of this paper is to discuss the role and efficacy of dextran in vascular procedures using evidence-based data from the review of surgical literature. A medline search using "dextran,'' "vascular surgery,'' and "antiplatelet therapy'' as keywords was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. Dextran is commonly used in carotid endarterectomy (CEA) patients where the embolic rate is reduced by 46%, resulting in fewer procedure-related strokes. As a prophylactic agent against thrombosis, multiple randomized studies have reported its benefit over other antithrombotic medications. Dextran is also particularly useful in "difficult'' infragenicular lower extremity bypasses where artificial grafts (such as polytetrafluoroethylene [PTFE] or umbilical vein) are used in the setting of poor outflow vessels, or those with composite grafts and small-caliber venous conduits. Distal bypasses with adjunctive procedures (eg, arteriovenous fistula or anastomotic cuffs) also have a better outcome with the addition of dextran. Dextran has numerous important implications in vascular surgery, in particular with CEA patients or "difficult'' infragenicular bypasses. Its effectiveness with endovascular stents remains unknown.

Colorectal cancer presenting as surgical emergencies.

Colorectal Cancer (CRC) is a major cause of cancer morbidity and mortality. Surgery is considered the first line therapy for CRC, and is generally encountered by many surgeons under elective conditions. Unfortunately, colorectal cancer may present acutely as a surgical emergency. These conditions include, but are not limited to perforation, hemorrhage, and obstruction. The presentation of a patient with these conditions can lead to higher morbidity and mortality. The choice of operation depends mainly on the site of the disease (left-sided versus right-sided), the patient's physical condition, nutritional status, and age. The treatment for right-sided lesions is a right hemicolectomy. However, treatment of left-sided lesions is still undecided. There are many therapeutic options such as primary or staged resections, Hartman's procedure, subtotal colectomy, or colostomy. Other therapies involve non-operative techniques such as laser therapy, colonic stenting, emergency endoscopy, and comfort measures.

Surgical treatment of achalasia: current status and controversies.

OBJECTIVE: To review the current management of achalasia, and the controversies regarding the different treatment options. METHODS: A review of the literature was performed. The key words used were esophageal achalasia, Heller myotomy, endoscopic balloon dilatation, laparoscopic Heller myotomy, and fundoplication. RESULTS: Patients who fail medical therapy (e.g. pharmacologic therapy, botulinum toxin, balloon dilatation) should be considered for surgical therapy for the management of achalasia. Currently, numerous surgical procedures exist for the treatment of achalasia (transabdominal cardiomyotomy, thoracoscopic or open transthoracic cardiomyotomy, and laparoscopic Heller myotomy with an antireflux procedure). CONCLUSIONS: Laparoscopic Heller myotomy is generally accepted as the operative procedure of choice for achalasia. However, controversy exists as to whether a concomitant antireflux procedure is necessary, and if so, what type should be performed. Given the deleterious effects of postoperative reflux, and the facility of including an antireflux procedure at the time of the myotomy, there is merit in undertaking an antireflux procedure at the time of the laparoscopic Heller myotomy.

Assessment and management of the obese patient.

BACKGROUND: The perioperative care of the clinically severe obese patient presents numerous unique challenges. As an increasing number of people in North America fall into the category of the clinically severe obese, the care of these patients will become increasingly more challenging and prevalent. These patients have unique issues with regards to cardiovascular, pulmonary, and thromboembolic complications. In addition, hospital equipment must be able to accommodate the body habitus of this population. MATERIALS AND METHODS: A Medline search using "perioperative care," "morbid obesity," "thromboembolic complications," "preoperative screening," and "postoperative care" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. DISCUSSION: The management of the clinically severe obese patient requires meticulous preoperative, perioperative, and postoperative care. Careful preoperative planning is essential before taking the patient to the operating room. To have excellent outcomes, a multidisciplinary approach, including the primary care physician, anesthesiologist, surgeon, nursing staff, and social work, is necessary.

Do vascular surgery patients need a cardiology work-up? A review of pre-operative cardiac clearance guidelines in vascular surgery.

OBJECTIVES: to outline the appropriate pre-operative cardiac work-up for patients who are scheduled for major peripheral vascular surgery. DESIGN: review of the literature. MATERIALS AND METHODS: a review of the literature focusing on studies that have correlated the pre-operative cardiac work-up patients receive to the cardiac morbidity and mortality following vascular surgery. Only studies with level A evidence were included. RESULTS: peri-operative beta blockade has been shown to decrease cardiac complications after vascular surgery in all risk groups. Non-invasive cardiac testing is only necessary for patients in the intermediate/high risk group. Coronary revascularization should only be considered after a positive non-invasive cardiac test. CONCLUSIONS: patients must be risk stratified pre-operatively based on history and physical examination. Low risk patients should receive peri-operative beta blockade only with no further non-invasive testing. On the other hand, intermediate and high risk patients should undergo non-invasive cardiac testing before going to the operating room.

Incidental gallbladder carcinoma associated with a cholecystoduodenal fistula.

The development of a cholecystoduodenal fistula may complicate 5% of all patients with cholelithiasis. It has been theorized that a cholecystoduodenal fistula may represent a significant risk factor in the development of gallbladder carcinoma because of the chronic reflux of duodenal contents. We report the case of a patient with a cholecystoduodenal fistula and an early gallbladder cancer to support this theory. Once developed, gallbladder cancer has a very poor prognosis. Early detection with timely resection is necessary to improve the survival rate in gallbladder carcinoma patients.