Ileal GIST presenting with bacteremia and liver abscess: A case report and review of literature.

INTRODUCTION: Small intestine gastrointestinal stromal tumors can infrequently present with intra-abdominal abscess, perforation, obstruction or fistula. Tumor-small intestine fistula is a rare phenomenon and occurs as a result of GISTs' propensity to cause mucosal ulceration. This allows bacteria from the gut to gain access to the systemic circulation and predisposes the patient to bacteremia and pyogenic liver abscess. PRESENTATION OF CASE: We present a case of a 63-year-old female whose initial symptoms included fever, nausea, vomiting and right upper quadrant pain. Radiologic studies revealed a liver lesion and an intra-abdominal mass containing oral contrast, suggesting involvement of the gastrointestinal tract. She was found to have a liver abscess, Streptococcus anginosus bacteremia and an ileal GIST that formed a fistula between the tumor and small intestine. We performed a surgical resection of the tumor and percutaneous drainage of the liver abscess. Imatinib was initiated post operatively and she experienced no recurrence, as demonstrated by a surveillance computed tomography scan at 12 months. CONCLUSION: Findings of a liver lesion in association with a small intestine GIST should raise concern for both metastatic disease and a possible infectious complication such as a pyogenic liver abscess. If a member of the Streptococcus milleri group is isolated in blood cultures, a consideration for gastrointestinal malignancy is imperative. This case report reviews a rare presentation of an ileal GIST with tumor-intestinal fistula, complicated by liver abscess and Streptococcus anginosus bacteremia.

Actual versus estimated length of stay after colorectal surgery: which factors influence a deviation?

BACKGROUND: The aim of this study was to determine factors associated with deviation in length of hospital stay (LOS) from that determined by diagnosis-related groups. METHODS: A cohort study from a prospectively collected database was conducted, including consecutive patients undergoing surgery in a high-volume colorectal surgery department in 2009. RESULTS: For 1,461 included patients, average expected and actual LOS were 8.17 days (interquartile range, 4.7 to 11.9 days) and 8.31 days (interquartile range, 4 to 10 days), respectively. The most prominent factors associated with an increase of LOS from expected were parenteral nutrition (5.11 days), emergency room admittance (3.67 days), and ileus (3.45 days) (P ≤ .001 for all). Other independently associated factors included blood transfusion, anastomotic leak, sepsis, pulmonary embolism, and surgeon. Patients with higher severity illness indexes and longer postoperative intensive care stay had lower than expected LOS. CONCLUSIONS: After colorectal surgery, several modifiable factors are associated with deviation of LOS from expected. An opportunity hence exists to reduce both LOS and financial burden for hospitals in an era of pay for performance.