Results of conservative treatment for perforated gastroduodenal ulcers in patients not eligible for surgical repair.

BACKGROUND: Conservative treatment of perforated gastroduodenal ulcer has been shown to be associated with good results in patients whose general condition is good. However, its use in patients not eligible for surgical repair has not been supported. The aim of this study is to evaluate the results of conservative treatment in these patients in the era of proton pump inhibitor. MATERIAL AND METHODS: In the period 1978-2004, 533 patients were admitted for perforated gastroduodenal ulcer. 503 patients underwent surgery, while 30 (median age 79 [42-98] years) were allocated to conservative treatment due to poor general condition. Conservative treatment consisted of nasogastric aspiration, antibiotics and antisecretory therapy (H2-blockers from 1978-1995, 11 patients, and proton pump inhibitors (PPI) from 1996, 19 patients). Endpoints were: hospital morbidity and mortality and hospital stay. RESULTS: Overall morbidity and mortality were 33% and 30%. Median hospital stay was 11 days (range 0-32). General complications developed in 73% versus 16% of patients (p = 0.023) and mortality was 64% versus 11% (p = 0.008) for the H2-blocker and PPI groups respectively. On multivariate analysis mortality correlated with presence of shock at admission and type of antisecretory therapy. CONCLUSION: In the era of PPI conservative treatment for perforated ulcer is possible with acceptable morbidity and mortality in patients not eligible for surgical repair. However, presence of shock at admission was associated with high mortality and, even in these patients, militates in favour of a surgical approach.

Surgical treatment of appendiceal adenocarcinoid (goblet cell carcinoid).

Adenocarcinoid of the appendix is an infrequent tumor with histologic features of both adenocarcinoma and carcinoid tumor. Although its malignant potential remains unclear, adenocarcinoids seem to be biologically more aggressive than conventional carcinoids. The aim of this study was to analyze long-term results of surgical treatment for appendiceal adenocarcinoid. A retrospective review (1991-2003) identified seven patients (median age 72, range 27-81 years) treated for appendiceal adenocarcinoid. The clinical data of these patients were reviewed. Follow-up was complete for all patients (median 60 months, range 24-108 months). Most cases presented with associated acute appendicitis (71%). First intention surgery consisted of appendectomy (m = 6) and right hemicolectomy (m = 1). In three patients, additional surgical procedures were performed (right colectomy). Indications for colectomy were tumor size (three cases) associated with appendectomy margin invasion in one case. One patient with lymph node and peritoneal involvement experienced recurrence 9 months after hemicolectomy and died of the disease at 2 years. One patient subsequently died of colon carcinoma 6 years after adenocarcinoid treatment. Five patients were alive without disease at the time of the last follow-up. Synchronous or metachronous colon carcinomas developed in three patients (43%). Our results suggest that appendectomy alone could be used for appendiceal adenocarcinoid provided that the tumor (1) is less than 1 cm; (2) does not extend beyond the appendix adventitia; (3) has less than 2 mitoses/10 high power fields; and (4) has surgical margins that are tumor free. Otherwise, carcinologic right colectomy seems to be indicated. The risk for developing colorectal adenocarcinoma seems to be extremely high in patients treated for appendiceal adenocarcinoid and warrants close follow-up with colonoscopic screening.