Colonoscopy-assisted 'trephine' sigmoid colostomy.

Fecal diversion is often required to treat complex traumatic, malignant or inflammatory anorectal conditions. In such circumstances, the formation of a proximal, 'trephine' sigmoid colostomy would avoid the need for, and the associated morbidity of, a formal laparotomy. We describe a technique which combines intraoperative colonoscopy with a diverting, 'trephine' sigmoid colostomy, thereby helping the surgeon to identify the correct loop of bowel, to avoid inadvertent maturing of the wrong end of the divided colon, and to exclude intracolonic lesions.

Malignancy in HIV/AIDs: a single hospital experience.

BACKGROUND AND OBJECTIVES: Our hospital serves an area with a significant number of patients seropositive for the human immunodeficiency virus (HIV). Intravenous drug abuse and heterosexual exposure are by far the predominant risk factors for HIV and acquired immunodeficiency syndrome (AIDS). Seven percent of these patients develop malignancies. Our aim was to study the types of tumor, their distribution, and to evaluate the patients' outcome. METHODS: Of 3,578 patients with HIV infection or AIDS treated between 1993 and 1998, 245 had 1 or more malignancies. Information was collected on age, sex, race, predisposing risk factors for AIDS, malignancies, symptoms at presentation, the time of the onset of AIDS, CD4 cell counts, pathology findings, and mortality. RESULTS: Although aspects of our patients resembled those of previously studied groups of patients with AIDS, there also were ways in which our patients differed from those other groups. Of our patients, 21. 6% had non-AIDS-defining (NAD) invasive malignancies. This was considerably higher than the rate in most studies. Twenty-seven patients with such malignancies died during the study. Forty-two other patients had pre-invasive cancers. Among patients having AIDS-defining (AD) malignancies, 55.9% died, a fact that was related to patients' low CD4 cell counts and late presentation. Our 97 patients with Kaposi sarcoma included 22 women, a relatively high number that may be related to the fact that most of our patients were intravenous drug abusers or had become infected by heterosexual transmission of HIV. CONCLUSIONS: AIDS is associated with a high risk of malignancy and an unusual spectrum of tumors. Patients with invasive tumors have advanced disease at the time of initial presentation. Those with AD tumors have a worse prognosis than patients with NAD tumors. The impact of highly active antiretroviral therapy on both AD and NAD tumors needs to be further evaluated.

Gastric stromal tumor.

Gastric stromal tumors display a bewildering array of immunohistological and ultrastructural features as well as variable biological behavior. These tumors are rare as compared with ones that arise from the gastric epithelium. Moreover, they have been the subjects of controversy because of their uncertain histogenesis. We report the pathological features of gastric stromal tumors we recently encountered in three patients.

Paraganglioma of the pancreas: literature review and case report.

Extraadrenal paragangliomas are very rare tumors arising from cells derived from the neural crest. These tumors are encountered only as case reports, and as a result, little is known of their natural history. We present a case of pancreatic paraganglioma and review all previously reported cases.

Predictors of the severity of acute pancreatitis in patients with HIV infection or AIDS.

We retrospectively reviewed the charts of 54 human immunodeficiency virus (HIV) infected patients or acquired immunodeficiency syndrome (AIDS), who were hospitalized at the Bronx-Lebanon Hospital Center with acute pancreatitis between January 1993 and December 1995. Nineteen were female and 35 were male patients. Thirty-five (65%) of 54 patients were younger than 40 years (average age, 42 years). Forty-eight (89%) of the patients had a CD4 count of <200 units/ml of blood. Seventeen (32%) patients died either of complications of acute pancreatitis or of underlying disease. The conventional prognostic criteria used to assess the severity of pancreatitis, including Ranson's and Imrie's criteria and the APACHE II system, were applied. We determined that these criteria were not appropriate to our HIV/AIDS patients. Only serum calcium levels at 48 h after admission and serum creatinine and blood urea nitrogen (BUN) at admission and at 48 h after admission had significant p values (<0.05). We believe that the predictors commonly used to identify the severity of pancreatitis were not useful in these patients because of their low CD4 counts and preexisting liver and renal disease.

Acute acalculous cholecystitis in young patients without predisposing factors.

We report the atypical presentation of acute acalculous cholecystitis in four young, otherwise healthy patients. These cases emphasize the fact that the traditional concept of this disease as being associated with trauma, major surgery, or other pathology may no longer be true, and an important number of cases may appear de novo in patients without any predisposing factors.

Modern management of postoperative pain.

In the last 10 years there has been an increased awareness of the need for improved pain management, especially in the postoperative period, to a large extent stimulated by the US Agency for Health Care Policy and Research (AHCPR), which published its clinical practice guidelineS for pain management in 1992. Teams of surgeons, nurses and anesthesiologists now are combining modalities for managing pain so as to provide the most comfortable postoperative course possible for their patients.

Which one first? Barium enema or colonoscopy.

Barium enema and colonoscopy share common problems, including patient preparation and cooperation, technical difficulties in reaching the cecum, and variables relating to the expertise of the person performing the procedure. On the other hand, it has been well documented that colonoscopy has the advantage of detecting a larger number of lesions and smaller lesions, and the ability to be therapeutic as well as diagnostic. Colonoscopy also guides the surgeon in doing proper resections, based on tissue diagnoses, in cases when there are several lesions in different locations in colon. When colon lesions are suspected, barium enema as the first diagnostic procedure means that the patient must undergo a second bowel preparation prior to colonoscopy. Thus, instead of using colonoscopy to confirm or rule out the findings, the most logical approach is to do colonoscopy first, which avoids the repetition of bowel preparation and the cost of barium enema. If colonoscopy cannot be performed, or cannot be completed to the cecum, then the next best choice is to proceed to double contrast barium enema.