Primary colonic lymphoma.

Surgical resection of primary colonic lymphoma can be an important therapeutic tool. We performed a nonrandomized retrospective descriptive study at the University hospital tertiary care center. From January 1990 to June 2002, a total of 15 patients with primary colonic lymphoma were identified from the tumor registry at University of Alabama at Birmingham and retrospectively reviewed under Institutional Review Board approved protocol. Demographic data, clinical features, treatment method (surgery and/or chemotherapy), recurrence rate, and survival were analyzed. The results are presented as mean +/- standard deviation or median and range. Differences in survival were evaluated by the log-rank test and the interval of disease-free survival was calculated using the Kaplan-Meier method. A P value of <0.05 was considered statistically significant. Main outcome measures included surgical results, morbidity, mortality, and recurrence rate. Mean age was 51.5 years (standard deviation 16.4), 33 per cent were male and 67 per cent were female. Presenting symptoms were diarrhea (53.5%), lower gastrointestinal bleeding (13.3%), and nausea and vomiting (46.7%) secondary to low-grade obstruction. Concomitant colorectal disease was present in one patient with ulcerative colitis. Preoperative diagnosis of lymphoma was made in 13 patients (87%) with colonoscopy and biopsy. CT scan was performed in all patients; and none had radiographic evidence of systemic extension. Only one patient had a history of lymphoproliferative disease and exposure to radiation. The most common disease location was the cecum (60%), followed by the right colon (27%), and the sigmoid colon (13%). The mean lactic dehydrogenase (LDH) value was 214.9 u/L (range 129-309). Thirty-three per cent of the patients had an LDH value that was above the upper normal limit. LDH returned to normal after treatment in all patients. Operations performed consisted of right hemicolectomy (13), total proctocolectomy with ileal J J-pouch (1), and sigmoid colectomy (1). Eighty-seven per cent had negative margins at the time of operation. Twelve patients received postoperative chemotherapy (80%). According to the clinical classification of primary non-Hodgkin lymphoma (NHL) of the gastrointestinal tract (Lugano, 1993) all patients corresponded to stage IE. Mean hospital stay was 6.4 days (range 3-26). There was no surgical mortality and the morbidity rate was 20 per cent (3 patients). One patient had a systemic recurrence (7%) approximately 4 months after surgical resection. Mean follow-up was 31 months (median 2-73). Surgical resection of localized, primary colonic lymphoma provides excellent local disease control and should be considered a primary treatment option. The role of chemotherapy remains controversial depending on the grade, stage, and extension of residual disease.

Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract.

Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) > 2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21-75.92] and serum creatinine > 1.5 mg/dL (OR = 3.05; 95% C.I., 1.25-7.42) with mortality. Age was suggestive but not a significant risk factor for mortality (P = 0.09). Multivariate analysis found serum LA > 2.0 (OR = 30.37; 95% C.I., 7.31-126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level > 2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.

Results of long-term follow-up for transanal excision for rectal cancer.

Low anterior resection and abdominoperineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. It is our hypothesis that selected patients with early T stage, well or moderate grade of differentiation, and small tumor size are good candidates for transanal excision in terms of minimal morbidity, low recurrence rate, and sphincter preservation. From January 1993 until August 2001 30 patients underwent transanal excision; three patients were excluded because they had histology other than adenocarcinoma. Factors analyzed included those related to the patient [age (years), gender, race, body mass index, and anal tone], tumor [size (cm), distance from the anal verge (cm), differentiation, and American Joint Committee on Cancer stage], and additional treatment. Median follow-up of the group was 40.7 months (range 0.6-99) and the primary end points were local and distant recurrence. Data are presented as mean (range). The median age of the group was 58.9 years (range 27-94); 52 per cent were female and 48 per cent were male. The mean body mass index was 25.9 (range 22.7-36.7). Preoperatively 81, 11, and 4 per cent of the patients had stage I, II, and III/IV cancer, respectively. Preoperative size of the tumor was 2.0 cm (1-3 cm), and distance from the anal verge was 5.0 cm (3-15 cm). Blood loss was 50 cm3 (5-200 cm3), and there were no operative complications. Tumor differentiation levels were well (37%) and moderate (63%). All patients had negative margins. Additional treatment consisted of radiation therapy in seven patients (six postoperative and one preoperative). Chemotherapy was given to seven patients (six postoperative and one preoperative). The local recurrence rate was 7.4 per cent (two patients), and 3.7 per cent recurred distantly (one patient). Transanal excision of low rectal cancer in selected patients is an acceptable alternative to formal resection. Important selection criteria include early T stage, well or moderate differentiation, relatively small tumor size, and negative microscopic margins. The roles of radiation and chemotherapy remain controversial.

Laparoscopic vs conventional ileocolectomy for primary Crohn disease.

HYPOTHESIS: Laparoscopic ileocolectomy can reduce the length of hospital stay and hospital charges compared with conventional surgery in the treatment of primary Crohn disease. DESIGN: Nonrandomized, comparative, retrospective analysis of a prospective database. SETTING: University hospital tertiary care center for inflammatory bowel disease. PATIENTS: Forty patients, 20 in the laparoscopic group (group A) and 20 in the conventional group (group B). INTERVENTION: From July 1, 1996, to June 30, 2001, we collected data on the following demographic clinical end points: age, sex, duration of disease, preoperative medical treatment, previous abdominal surgery, procedure performed, conversions to open surgery, operating time, number of trocars used, size of incision, blood loss, time to resolution of ileus, time to starting solid food diet, duration of hospital stay, hospital charges, morbidity, and mortality. MAIN OUTCOME MEASURES: Surgical results, length of hospital stay, hospital charges, and recurrences. RESULTS: The mean age of the patients was 34.7 years (range, 20-68 years) in group A vs 40.0 years (range, 18-75 years) in group B. The male-female ratio was 1:2 in group A vs 1:1 in group B. The morbidity was 5% in group B. There was no mortality. Operating time was longer in group A (mean, 145.0 minutes; range, 45-270 minutes) compared with group B (mean, 133.5 minutes; range, 98-177 minutes) (P =.36). Blood loss was significantly higher in group B (mean, 265.5 mL; range, 100-400 mL) compared with group A (77.2 mL; range, 25-350 mL) (P<.001). Also, the size of the incision was significantly longer in group B (mean, 13.5 cm; range, 8-18 cm) compared with group A (mean, 5.5 cm; range, 3-12 cm) (P<.001). Bowel function returned more quickly in the laparoscopic group vs the conventional group in terms of return of bowel movements (1.70 vs 2.63 days) (P<.001) and resumption of a regular diet (1.35 vs 2.73 days) (P<.001). The mean length of stay was significantly shorter in the laparoscopic group (4.25 days) vs the conventional group (8.25 days) (P<.001). The mean hospital charges were US $9614 in group A vs US $17 079 in group B (P<.05). The mean follow-up was 17.2 months in group A (range, 2.3-59.9 months) vs 18.7 months in group B (range, 1.0-37.5 months). CONCLUSIONS: Laparoscopic-assisted ileocolectomy for primary Crohn disease of the terminal ileum and/or cecum is safe and successful in most cases. Laparoscopic surgery for Crohn disease should be considered as the preferred operative approach for primary resections.