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Despite advances in perioperative care and operative techniques, urgent colorectal operations are associated with higher morbidity and mortality. To evaluate our rate of complications in elective and urgent colorectal operations, we performed retrospective chart review of 209 consecutive patients who underwent colorectal resection between 1998 and 2002 at Harbor-UCLA Medical Center. One hundred, forty-three (71%) patients underwent elective colorectal resection. A total of 19 (13.3%) complications occurred in the elective group, compared with 24 (38.1%) in the urgent group ( P = 0.003). Both right-sided and left-sided operations were associated with higher incidence of complications when performed urgently. Wound infection occurred in 7.7 per cent of patients undergoing an elective operation and 14.3 per cent in an urgent setting ( P = 0.21). Intra-abdominal abscess occurred in 1.4 per cent of patients undergoing elective operation, compared with 11.1 per cent in the urgent operation group. Four (1.9%) patients developed wound dehiscence, 1 in elective and 3 in the urgent group ( P = 0.09). Anastomotic leak occurred in 1.9 per cent of patients, 2 in each group ( P = 0.6). There were six deaths, 3 in elective and 3 in urgent cases ( P = 0.4). Urgent operation of the colon and rectum is associated with higher incidence of complications. Both right- and left-sided resections have a higher complication rate when performed in a nonelective setting.

Few studies have examined outcomes of laparoscopic and open sigmoid colectomy performed at US academic centers. Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium (UHC) Clinical Database of 10,603 patients who underwent laparoscopic or open sigmoid colectomy for benign and malignant disease between 2003-2006. A total of 1,092 patients (10.3%) underwent laparoscopic sigmoid colectomy. Laparoscopic sigmoid colectomy was associated with a significantly shorter length of stay (5.4 vs 7.4 days), lower overall complication rate (19.7 vs 26.0%), lower 30-day readmission rate (3.4 vs 4.6), and a lower hospital cost ($13,814 vs $15,626). When a subset analysis of malignant and benign groups was performed, a significantly shorter length of stay in both the malignant laparoscopic group (6.4 +/- 6.4 vs 7.8 +/- 6.6 days) and in the benign laparoscopic groups (5.1 +/- 3.5 vs 7.2 +/- 7.6) exists. A lower wound complication rate (2.1 vs 5.5%, malignant and 4.0 vs 6.1, benign) is also evident. Laparoscopic sigmoid colectomy was associated with a shorter length of stay, less complications, and a lower 30-day readmission rate. The shorter length of stay and wound infection rate maintain significance when comparing laparoscopic vs open sigmoid resections for malignant and benign disease.

Few studies have compared outcomes of right colectomy (RC) and left colectomy (LC) with respect to both benign and malignant disease. The objective of this study was to compare outcomes of RC versus LC for benign and malignant disease using a national administrative database of academic medical centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, data was obtained from the University HealthSystem Consortium Clinical Data Base for patients that underwent RC and LC for benign and malignant disease between 2002 and 2006. The main outcomes compared were demographics, length of hospital stay, observed to expected in-hospital mortality, complications, 30-day readmission, and mean cost. There were a total of 27,483 patients; 12,971 patients (47.2%) underwent RC. Compared with LC for benign disease, RC was associated with a shorter length of stay, lower overall complications, lower wound infections, lower 30-day readmissions, and lower cost. Compared with LC for malignant disease, RC was associated with lower overall complications, lower wound infections, and lower cost. In this analysis of academic centers, RC was associated with a lower length of stay, lower morbidity, and lower cost when compared with LC for benign and malignant disease.

Blood transfusion is associated with higher postoperative complication. With the availability of autologous blood and erythropoietin, it would be advantageous to identify patients who are at higher risk for requiring blood transfusion. Our aim is to identify possible predictive factors for perioperative blood transfusion in patients undergoing colorectal resection. We examined 206 patients who underwent colorectal resections. We analyzed factors including preoperative hematocrit, age, history of radiation, type of resection, operative blood loss, additional surgical procedure, surgery duration, and comorbidity. Forty-one patients (19.9%) received perioperative blood transfusion. Twenty patients (55.6%) with preoperative hematocrit less than 30 received transfusion (p<0.0001). Twenty-one patients (12.4%) with preoperative hematocrit greater than 30 received perioperative blood transfusion. Thirty-three patients (17.9%) under 65 years received transfusion. Eight patients (36.4%) more than the age of 65 received transfusion (p=0.05). Ten patients (16.1%) without any comorbidity received transfusion, whereas ten patients (15.1%) with one comorbidity, ten patients (22.2%) with two comorbidities, and 11 patients (33.3%) with greater than three comorbidities received blood transfusion (p=0.07). In the multivariate analysis, relative risk of perioperative blood transfusion was 3.63 for patients with preoperative hematocrit less than 30 (p<0.0001), 1.26 for patients more than the age of 65 (p=0.49), and 1.07 for each comorbidity (p=0.62). Patients with higher number of comorbidities and age greater than 65 tend to have lower preoperative hematocrit than other patients. Hematocrit less than 30 is an independent risk factor for requiring perioperative blood transfusion, and patients with hematocrit less than 30 should be considered for autologous blood transfusion and erythropoietin.

The surgical treatment of low rectal cancer commonly includes low pelvic anastomoses with coloanal or ultralow colorectal anastomoses. Anastomotic leak rates in low pelvic anastomoses range from 4 to 26%. Many surgeons opt to routinely create a diverting ostomy to reduce the extent of morbidity should an anastomotic leak occur. The intent of our study was to determine if our policy of selected diversion is safe. A retrospective chart review of 66 rectal cancer patients who underwent proctectomy and low pelvic anastomoses -- less than 6 cm from anal verge, with or without a diverting ostomy -- was undertaken. Temporary diverting stomas were utilized at the discretion of the attending surgeon primarily based on subjective criteria. The main outcome was postoperative complications. Forty-nine patients (78% preoperatively irradiated) were treated with a one-stage operation, whereas 17 (53% preoperatively irradiated) underwent reconstruction with proximal diversion. The mean anastomotic height for patients with a single stage procedure was 3.8 cm above the anal verge versus 2.6 for patients with a two-stage procedure (p = 0.076). Complication rates were lower in patients who did not undergo diversion (29% vs 47%, p = 16). With regard to anastomotic-associated complications for single stage versus two stage, complication rates were 8% versus 18%, respectively (p = 0.27). Low pelvic anastomoses in rectal cancer patients can be safely performed as a single-stage procedure, reserving the use of diversion for select cases.

Histoplasma capsulatum is an important pathogen that is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts. Failure to recognize and treat disseminated histoplasmosis in AIDS patients invariably leads to death. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, and depending on the layer of bowel wall involved present as bleeding, obstruction, perforation, or peritonitis. Because they can be variable in appearance, they may be mistaken for Crohn's disease or malignant tumors. Four distinct pathologic patterns of GI histoplasmosis have been described that all have differing clinical presentations. We report a case of a non-AIDS patient who presented with a near-obstructing colonic mass suspicious for advanced malignancy but was found to have histoplasmosis on final pathology. The patient underwent successful operative resection, systemic anti-fungal therapy, and extensive workup for immunosuppressive disorders, which were negative. The patient was from an area in Mexico known to be endemic for histoplasmosis. This is the first report of a colonic mass lesion occurring in a non-AIDS patient, and review of the worldwide literature regarding GI histoplasmosis reveals excellent long-term survival with aggressive therapy. We discuss the surgical and medical management of colonic histoplasmosis in this report.

Histoplasma capsulatum is an important pathogen that is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts. Failure to recognize and treat disseminated histoplasmosis in AIDS patients invariably leads to death. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, and depending on the layer of bowel wall involved present as bleeding, obstruction, perforation, or peritonitis. Because they can be variable in appearance, they may be mistaken for Crohn's disease or malignant tumors. Four distinct pathologic patterns of GI histoplasmosis have been described that all have differing clinical presentations. We report a case of a non-AIDS patient who presented with a near-obstructing colonic mass suspicious for advanced malignancy but was found to have histoplasmosis on final pathology. The patient underwent successful operative resection, systemic antifungal therapy, and extensive workup for immunosuppressive disorders, which were negative. The patient was from an area in Mexico known to be endemic for histoplasmosis. This is the first report of a colonic mass lesion occurring in a non-AIDS patient, and review of the worldwide literature regarding GI histoplasmosis reveals excellent long-term survival with aggressive therapy. We discuss the surgical and medical management of colonic histoplasmosis in this report.

The lectin recognition hypothesis proposes that the specific binding of a legume lectin to a carbohydrate of a compatible Rhizobium (sensu lato) allows the two organisms to recognize each other as symbionts. Although there is extensive evidence supporting the hypothesis, other experiments contradict it. Thus, the controversy remains unresolved. As a first step to testing the lectin recognition hypothesis in the Medicago sativa-Rhizobium meliloti symbiosis, we cloned and sequenced lectin genes from alfalfa. We are now reporting the nucleotide sequence of the Mslec1 gene, so named because of its high sequence similarity to the Mtlec1 gene.