Colonoscopic evaluation of rectal bleeding in young adults.

The role of colonoscopy in the evaluation of blood loss per rectum has been studied extensively in older patients but not in the younger adult population. The objective of this study was to review the diagnostic yield of colonoscopy in patients 40 years of age or younger with passage of minimal amounts of bright red blood per rectum or occult blood positive stools. Retrospectively, 5924 colonoscopic examinations were reviewed. All patients, 40 years of age or younger, with rectal bleeding as the only indication for colonoscopy were selected. A total of 280 patients met these criteria and 59 (21%) had significant findings. Polyps were present in 25 (8.9%) of patients. Other findings included colitis, diverticular disease, and angiodysplastic lesions present in 8.6 per cent, 2.1 per cent, and 1.1 per cent, respectively. Adenocarcinoma was present in one patient (0.03%). These results suggest that colonoscopy in patients 40 years of age or younger with rectal bleeding may be justified because significant findings may be present in up to 21 per cent of patients.

Isolated regional lymph node dissection: morbidity, mortality and economic considerations.

Between 1971-1979, 330 consecutive isolated regional lymph node dissections (RLNDs) were performed as therapeutic procedures for metastatic disease, at the University of Louisville Affiliated Hospitals and the Ellis-Fischel State Cancer Hospital in Columbia, Missouri. This retrospective analysis includes 133 radical neck RLNDs, 87 axillary RLNDs, and 110 superficial groin RLNDs. All accessioned cases were elective and were performed as isolated procedures, discrete from resection of contiguous or remote organs. No patients received preoperative irradiation, chemotherapy or immunotherapy. Forty-eight per cent of the 330 RLND procedures resulted in some form of postoperative complication. However, 91% of the incurred morbidity was localized to the operative site and was related to serum collection and/or flap necrosis. The occurrence of postoperative complications for each RLND site resulted in a prolongation of the patients' hospital stays by a mean of 9 days, and was most extended for the superficial groin RLND by a mean of 11 days. Nine patients (3%) died. These data for morbidity and mortality rates, as well as the implicit economic impact, represent substantial factors in the utilization of elective RLND.

Colonoscopic diagnosis of angiodysplasias of the gastrointestinal tract.

We have reviewed our experience with colonoscopy in the diagnosis of angiodysplastic lesions of the colon. In 14 of the patients in our series, the lesions in the colon were diagnosed colonoscopically, confirming arteriographic findings in many but being the only diagnostic modality facilitating the diagnosis in three of the patients. Results of our experience indicate that colonoscopy is an effective means of diagnosing or confirming the diagnosis of angiodysplastic lesions of the right colon. It should be part of the evaluation along with superior and inferior mesenteric angiography of every patient with occult gastrointestinal tract bleeding or iron deficiency anemia, or both, for whom no diagnosis can be made with standard barium contrast techniques.

Hepatic arterial infusion chemotherapy for cancer of the liver.

Hepatic artery infusion chemotherapy (HAIC) provides objective palliation for unresectable primary and secondary liver neoplasms. By utilizing HAIC rather than systemic chemotherapy, a greater concentration of the chemotherapeutic agent(s) within the liver is achieved with a comparative decrease in toxic side effects. A review of pertinent literature disclosed response rates of 50-71% associated with the administration of 5-fluorouracil (5-FU) and 5-fluoro-2-deoxyuridine (5-FUDR) via the hepatic artery, whereas response rates of 0-25% have been tabulated for systemic chemotherapy.

Value of colonoscopy in patients with rectal blood loss unexplained by rigid proctosigmoidoscopy and barium contrast enema examinations.

Total colonoscopy is the procedure of choice for patients with any amount of rectal blood loss unexplained by proctosigmoidoscopy and barium contrast enema examinations. In 168 endoscopic examinations, 46 unsuspected lesions in 39 patients (23 percent) were detected, 50 percent of which were 1 cm or greater in diameter. Considering that 30 percent of all unsuspected lesions, 100 percent of angiodysplastic abnormalities and 40 percent of unsuspected carcinomas were located proximal to the splenic flexure, emphasis is placed on the importance of examining the entire colon to the cecum.

Detection of intracolonic lesion by barium contrast enema. The importance of adequate colon preparation to diagnostic accuracy.

Frequently, the clinical significance of the barium contrast enema is minimal because of inadequate colon preparation prior to examination. The frequency of false-positive routine barium enemas was 17% in 230 consecutive patients who underwent colonoscopy for removal of specific radiographically identified polypoid colon lesions. Initial barium enema inaccuracies were documented with postendoscopic air-contrast radiography in colons that were endoscopically proved to be mechanically clean following a two-day colon preparation. These results suggest that more emphasis on a two-day colon preparation, before the initial barium contrast enema, would substantially reduce the frequency of false-positive interpretations.

Colorectal carcinoma: overview of management techniques.

The fact that the national death rate from carcinoma of the colon and rectum has remained static over the past two decades is strong incentive for future investigation of measures to allow detection in its early and more favorable stage. Although no significant improvements in surgical techniques have afforded improvement in longevity, certain technical factors are known to inhibit tumor implantation during surgery. Data suggest that the extent of en bloc resection is the most crucial factor in avoiding recurrence. Extensive use of radiotherapy as the sole method of treatment or as preoperative or postoperative adjunctive therapy remains investigational, but it seems likely that this form of treatment will play an increasing role in the future. Preoperative radiotherapy seems to be useful in reducing the stage of the neoplasm and the incidence of extraserosal involvement; postoperative radiotherapy is beneficial for palliation. Chemotherapy, particularly with the fluorinated pyrimidines (5-FU and 5-FUDR), is being evaluated for its usefulness in lengthening survival time; response to 5-FU is occasionally dramatic. It remains for major investigational centers to clarify the role of combination chemotherapy in metastatic disease. Immunotherapy at present must be considered an unproven mode of treatment and of inconclusive benefit in any stage of colorectal carcinoma. Carcinoembryonic antigen assay is a useful prognostic and diagnostic tool in localizing primary tumor and in subsequent evaluation of response to treatment.

Diagnostic and therapeutic colonoscopy. A critical review of 662 examinations.

The results of 662 therapeutic and diagnostic colonoscopic examinations were reviewed to assess the morbidity, clinical benefit, diagnostic accuracy, and indications for the procedure, with special emphasis on detection and endoscopic excision of small, occult, invasive cancers. Overall, the frequency of detecting occult lesions (19%), the (89%) ability to clarify questionable radiographic findings, and a substantial reduction in laparotomy-colotomy procedures required for removal of colonic polyps (88%), coupled with a low morbidity (3%) and low false-negative examination rate (1%) established colonoscopy as one of the most important advances in the management of colon disease in recent years. Although early experience suggests that small, occult, invasive carcinomas, when properly selected, could be adequately treated by endoscopic excision, larger series and longer follow-up periods are necessary to validate any conclusions regarding the decision to manage these lesions conservatively.

Reassessment of intraoperative decisions: why operations for cancer of the large bowel fail.

A program developed for the intraoperative judgement decisions commonly faced in cancer of the colon and rectum has been published and has been found to correlate frequently with the management carried out in a cancer hospital and on the ward services of university programs in city/county and Veterans Administration hospitals. Those patients whose management varies with the recommendations of the program are subject to statistically significant excess risk of dying in the hospital and excess risk of failure of ultimate control of their malignant process. It is our opinion that this program is not only useful in demonstrating the explicit nature of surgical judgement but is also useful to the operating surgeon as an indication for the need for consultation or reassessment of his obwervations.

Delineation of critical factors in the treatment of pancreatic trauma.

An analysis of 100 patients sustaining multiple injury and pancreatic trauma was completed. Sixteen patients with penetrating injury died within the first 24 hours, 14 of whom died intraoperatively from major hepatic and/or retroperitoneal venous injury. Eighty-four patients survived long enough to permit evaluation of treatment. There was no statistically significant relationship between mode (p = 0.3) or anatomic area (p = 0.5) of injury and death. However, death was more common in the presence of duct injury (p less than 0.0001). Thirty-nine patients were determined to have duct injury and 45 did not. These two groups were equivalent, with the exception of a higher incidence of concomitant bowel injury (p less than 0.05) in those with duct violation. Combined sump and Penrose drainage was found to be adequate treatment of both proximal and distal nonductal injury with no significant difference in mortality or morbidity rates (p = 0.5). Resection of distal ductal injuries as opposed to drainage alone resulted in significantly lower morbidity and mortality rates (p less than 0.05), comparable to those of drained nonductal injuries. No conclusions could be made relevant to proximal duct injuries, except that drainage alone is inadequate. Seventeen (20 percent) of the 84 patients evaluated died. Pancreatic related mortality rate was 17 percent (14 patients). Two of 23 patients with blunt injury (9 percent) and 12 of 61 patients with penetrating injury (20 percent died). Gram-negative sepsis (82 percent) was the most common cause of death (p less than 0.01), and sepsis was correlated with the presence of pancreatic duct (p less than 0.0001) and bowel (p less than 0.001) injury.

The surgical treatment of carcinoma of the colon and rectum: an index of quality care and sociologic and geographic distribution.

A comparative experience of 474 patients with primary carcinoma of the colon and rectum has been evaluated in several hospital settings, with particular respect to patient populations, geographic distribution, and surgical characteristics. The differences and similarities are interpreted with caution but may provide a format by which significant objective determinants become the basis for subsequent assessment of quality care in an illness which is prevalent and amenable to relatively standardized operative management. No difference in quality of medical care provided was detectable across the sociologic and geographic boundaries studied. Notable increases in extent of neoplasm and severity of co-existent illness in the urban, "indigent" population adversely influenced both short and long-term mortality rates.

Fiberoptic endoscopy. Precise definition of upper gastrointestinal disease.

When properly employed, endoscopic examination of the upper gastrointestinal tract with the flexible maneuverable-tip fiberoptic instruments is the most accurate method of diagnosing any upper gastrointestinal tract disease. Two hundred consecutive endoscopic procedures in the upper gastrointestinal tract were performed without significant morbidity or mortality; the results were reviewed to ascertain the overall diagnostic value of this modality. Although the overall numbers in each subgroup are still small, the experience indicates that: (1) thorough endoscopic examination of the upper gastrointestinal tract can be carried out expeditiously in most patients without morbidity; (2) upper gastrointestinal tract disease can be precisely defined in the majority of patients; and (3) endoscopic examination frequently alters the initial clinical diagnosis. The precise cause of upper gastrointestinal tract hemorrhage can be diagnosed in at least three of four cases. Some unnecessary operations can be avoided and proper therapy for specific sources of bleeding can be initiated promptly.

Clinical aspects of invasive carcinoid tumors.

In a retrospective study at the University of Louisville Affiliated Hospitals, 42 patients with carcinoid tumors not arising in the anorectal area were identified in ten years (1962-1972). The ileum was the organ most frequently involved with primary tumor (28%). The nonappendiceal gastrointestinal tumors were multiple in 28%, metastatic in 66%, and associated with a second malignancy in 25%. Of the symptomatic small-bowel tumors, 83% were metastatic at the time of diagnosis. Carcinoid syndrome was observed in only two patients, both of whom had liver metastases and elevated urinary 5-HIAA levels. Resections for cure were done on 25 patients, palliative resections on six, and biopsy on six. Six tumors were from autopsy meterial. Among the 24 patients treated and followed up for five years, the survival rate was only 16%. In those patients having resection for cure, the five-year survival rate was 39%, exculding appendiceal tumors. The advanced stage of disease at time of discovery and the dismal prognosis for invasive carcinoids are contrary to many clinicians' impressions of the nature of carcinoid tumors but entirely consistent with several other recent reports (James Ewing Society meeting, April 1973).