Explore the vast range of titles available.

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.

The status of lymph nodes is the most important prognosticator in colorectal cancer patients. Patients with lymph node involvement have a lower survival rate and are candidates for adjuvant therapy. The purpose of our study was to determine the number of lymph nodes that needs to be examined to accurately detect nodal metastasis. We conducted a retrospective study of 151 patients who underwent colorectal cancer operation at Harbor-UCLA Medical Center. Data from the operative report and pathology report were collected and analyzed. Fourteen (33.3%) patients with five to nine nodes examined had positive nodes. Twenty-six (57.8%) patients with 10 to 14 nodes examined had positive nodes. Patients who had 10 to 14 nodes examined were significantly more likely to have positive lymph nodes (P = 0.03). Patients with advanced T stage had a significantly higher number of positive lymph nodes (78.1% in T4 vs 11.1% in T1, P < 0.0001). Patients with poorly differentiated cancer showed a trend toward a higher positive node rate. Tumor differentiation and T stage seem to correlate with higher nodal metastasis rate. A higher number of lymph nodes examined was associated with a higher nodal metastasis rate. Examination of at least 10 lymph nodes would increase the yield of positive lymph nodes and avoid under-staging of patients with colorectal cancer.

Colorectal cancer (CRC) is a disease primarily affecting an older population. The incidence of CRC in young patients has been rising. The purpose of this study was to evaluate the characteristics of CRC in an ethnically diverse, young population. Two groups of patients with CRC (40 years old or younger and 60 years old or older) treated from 1998 to 2005 were retrospectively evaluated. Forty-one young patients with CRC were identified. Hispanics constituted 51 per cent of the young population. Forty-four per cent of the lesions were right-sided in the young group compared with 21 per cent in the older group (P = 0.004). Advanced tumor stage (T3 and T4) was noted in 87.8 per cent of the young and 63 per cent of the older patients (P = 0.002; OR, 4.08). Poorly differentiated tumor grade was more common in young patients (P = 0.003) as well as mucinous/signet ring characteristics (P = 0.005). Young patients had an increased likelihood of a family history (P = 0.0001). Operative intervention and survival were similar for the two groups. Our study confirms, in an ethnically diverse young population, that CRC tends to be advanced stage, aggressive, and frequently nonoperable at the time of diagnosis. It is important for physicians to recognize the poor outcome of CRC in a younger population and consider an aggressive approach to diagnosis and early treatment.

The integrity of a low pelvic anastomosis is often studied radiographically before takedown of a diverting ileostomy. The aim of this study is to determine the impact of routine water-soluble enema studies (WSE) in our patient population with low pelvic anastomosis. We retrospectively reviewed the operative database for a county teaching hospital from 1998 to 2008. All patients with low pelvic anastomosis (ultralow colorectal, coloanal, and ileoanal pouch anastomosis) with diverting ileostomy who underwent subsequent takedown were identified. Fifty patients met inclusion criteria. Thirty-eight patients were evaluated by WSE and 12 were not. Twenty-five patients (66%) were noted to have normal WSE studies before ostomy takedown. Thirteen patients (26%) were noted to have abnormalities on WSE. Two stenoses were clinically significant. Water-soluble enema study was 100 per cent sensitive and 69 per cent specific for detecting significant pathology. Digital rectal examination (DRE), colonoscopy, and flexible sigmoidoscopy were also 100 per cent sensitive in detecting substantial pathology. Routine use of WSE failed to demonstrate a significant impact on patients with low pelvic anastomosis undergoing ileostomy takedown. Routine DRE and rigid proctoscopy can be used to evaluate low pelvic anastomosis. WSE can be used selectively on patients with abnormal findings.

This study examines the clinical characteristics of patients who developed recurrent appendicitis after previous nonoperative management of perforated appendicitis. Retrospective chart review was performed, and data from the recurrent and initial episode of appendicitis were collected. In all, 237 patients from 1989 to 2001 were managed nonoperatively for perforated appendicitis and 32 (14%) were readmitted for recurrent appendicitis. Median white blood cell count at recurrence was 9.5 (interquartile range [IQR]: 6.6 to 13.2] versus 13.1 [IQR: 10.8 to 16.1] at initial presentation ( P = 0.002). Maximum temperature was 98.6°F [IQR: 98.2 to 100.5] at recurrence versus 100.3°F [IQR: 99.5 to 101.5] ( P = 0.008). Median time for intravenous antibiotics use was 3 [IQR: 3 to 7] days at recurrence versus 6 [IQR: 4 to 8] days initially ( P = 0.01). Inpatient stay was also shorter; median length was 6 [IQR: 3 to 8] days compared with 7 [IQR: 5 to 9] days at initial presentation ( P = 0.02). Patients managed nonoperatively for perforated appendicitis who later developed recurrent appendicitis exhibited a milder clinical course at recurrence. Elective interval appendectomy may be reserved until a recurrent episode.

Enhanced recovery programs after colorectal surgery have gained acceptance recently as they have shown a decrease length of hospital stay. However, these pathways require strict adherence to standardized programs with patient education and high compliance. This study was designed to assess the feasibility of such a program in a large county hospital. A retrospective review was performed of 54 consecutive patients who underwent laparoscopic or open segmental colorectal resection without an ostomy. The first 27 patients were treated in a conventional manner, whereas the latter 27 were treated using a protocol promoting early feeding and ambulation with decreased intravenous fluids and narcotic use. There were no baseline differences between the groups, however, there was a significant difference in the patients treated with the enhanced recovery program in terms of less intravenous fluids administered in surgery ( P = 0.001), and over the subsequent 3 days ( P = 0.0017), with a decrease in length of hospital stay of 4 compared with 6 days ( P = 0.003). There were no differences in terms of complication and readmission rates. Based on this study, we conclude that strict adherence to a standard enhanced recovery program was effective in reducing hospital stay in patients undergoing colorectal resection without any increase in complications.

The best way to evaluate the colon for both diagnosis of symptoms and surveillance is colonos-copy. However, access to colonoscopy is often restricted. Our objective was to assess the anatomic distribution and stage at presentation of colorectal cancer (CRC) in a county hospital population, the prevalence and distribution of CRC in younger patients, and the utility of flexible sigmoid-oscopy for early diagnosis of left-sided cancers in this population. We performed a retrospective chart review of 151 patients who underwent colorectal resection from 2001 to 2003. Overall, 66.9 per cent of patients underwent resection for left-sided CRC. Forty-two (27.8%) of 151 were under age 50. In patients over 50, 66.1 per cent were found to have left-sided CRC compared with 69 per cent of patients under 50. Fifty per cent (50.3%) of patients had stage III or IV (advanced) disease. Forty-nine and a half per cent of patients over 50 and 52.3 per cent under 50 had advanced disease. Forty-eight and a half per cent of patients with left-sided CRC had advanced stage disease compared with 54% of patients with right-sided CRC. In patients under 50, the rates were 55.2 per cent and 46.1 per cent respectively. Two-thirds of the CRC occurred in the left side of the colon in both older and younger population. Flexible sigmoidoscopy should be considered as an early tool in the diagnosis of CRC.

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.

A retrospective study of 117 patients with the diagnosis of colon cancer was performed to evaluate the clinical utility of the preoperative computed tomography (CT) scan and to assess the role of carcinoembryonic antigen (CEA) as a predictor of the need for CT scan in colon cancer patients. Forty-nine patients had a CT scan that altered their treatment. One hundred per cent of stage IV patients versus only 26.5 per cent of stage I, II, and III patients had their operative and/or treatment planning altered by the preoperative CT. The sensitivity of CT scan in predicting metastatic disease was 90.3 per cent. All patients with stage IV disease had an abnormal CEA (>3 ng/mL). There was 89.7 per cent of stage IV patients who had a CEA twice that of normal or above. By using a CEA level of 3.1 ng/mL or above as a prerequisite for preoperative tomography, 34 nonmetastatic patients would not have had preoperative CT scans. Using a prerequisite of 6.1 ng/mL or above, 49 nonmetastatic patients would not have had a preoperative CT scan, and 90 per cent of the stage IV patients would have been imaged. We recommend obtaining a preoperative CT scan on those patients with a CEA value twice that of normal or greater.

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.