Arthur H. Aufses

Intussusception in adults : Institutional review

BACKGROUND Intestinal intussusception in the adult is a rare entity that differs greatly in etiology from its pediatric counterpart. Controversy remains regarding the optimal management of this problem in the adult patient. The purpose of this study was to determine the cause(s) of intussusception and to determine the role of intestinal reduction in the management of intussusception in adults. STUDY DESIGN A retrospective review performed at The Mount Sinai Medical Center identified 27 patients, 16 years and older, with a diagnosis of intestinal intussusception. Data related to presentation, diagnosis, treatment, and pathology were analyzed. RESULTS There were 13 males and 14 females. The median age of the group was 52 years with a range of 16 to 90 years. Abdominal pain was the most common presenting complaint. A preoperative diagnosis was suspected in 11 of 27 patients (40%). There were 22 small bowel lesions and 5 colonic lesions. A pathologic cause was identified in 85% of patients with 8 of 22 (36%) small bowel and 4 of 5 (80%) of large bowel lesions being malignant. All small bowel cancers represented metastatic disease and all large bowel malignancies were primary adenocarcinomas. The median age of patients with malignant disease was 60 years; it was 44 years for those with benign disease. Operative treatment consisted of resection alone in 58% of patients and resection after reduction in 42%. Three patients were treated nonoperatively. CONCLUSIONS Our data support a selective approach to the operative treatment of intussusception in adults. Colonic lesions should not be reduced before resection because they most likely represent a primary adenocarcinoma. Small bowel intussusception should be reduced only in patients in whom a benign diagnosis has been made preoperatively or in patients in whom resection may result in short gut syndrome.

A comparison of cancer risk in Crohn's disease and ulcerative colitis.

The authors estimated cancer risk among 579 patients hospitalized with Crohns disease between 1960–1976 by calculating the ratios of observed number of cancers (O) in our hospital sample to the expected number of cancers (E) based on the age‐ and sex‐specific cancer rates of a standard population. The authors then compared these O/E ratios with the O/E ratios similarly calculated among 267 patients hospitalized with ulcerative colitis. The risk of colorectal cancer was significantly increased in Crohns disease (O/E = 6.9, P< 0.001). This increase was similar in magnitude to that found in left‐sided ulcerative colitis (O/E = 8.6, P< 0.001) but was much less than that found in universal ulcerative colitis (O/E = 26.5, P< 0.001). The incidence of small bowel cancer was greatly increased in the combined group of regional enteritis and ileocolitis (O/E = 85.8, P< 0.001), and even more so in the regional enteritis group alone (O/E = 114.5, P< 0.001). The incidence of extraintestinal cancer did not increase in any of the patient groups.

Extraintestinal cancers in inflammatory bowel disease

The case histories of 1961 patients with inflammatory bowel disease (IBD), 1227 with Crohns disease (CD) and 734 with ulcerative colitis (UC), have been studied for the incidence of extraintestinal malignant neoplasms. There were 54 extraintestinal cancers in 51 patients: 28 patients with CD and 23 with UC; 25 men and 26 women. There were 9 breast, 7 skin, 15 reticuloendothelial, 11 genitourinary, 3 lung, 3 perianal, 2 pancreatic islet cell, and several miscellaneous cancers. The number of patient‐years from the onset of disease to the last date of follow‐up was calculated for men and women with each form of IBD. The observed number (O) of neoplasms was recorded. The expected number (E) of neoplasms was derived from the Department of Health, Education, and Welfare (DHEW) incidence figures for the same neoplasms that occurred in a standard age‐ and sex‐matched population. The O/E ratio was then calculated for each type of cancer as well as for the entire series. There were no statistically significant increases in overall O/E ratios of extraintestinal cancers for either CD (0.76) or UC (1.32). On the other hand, several specific types of cancer did appear to occur with a frequency that was significantly greater than expected. These cancers were classified into two groups. The first group included reticuloendothelial neoplasms. There was an excess of leukemias in UC (P < 0.005) and an excess of lymphomas in both UC and CD (P < 0.005). The second group included three squamous cell cancers of the perianal region, an incidence 30 times greater than expected, and two squamous cell cancers of the vagina, also in excess of the expected number. Lymphoma, leukemia, and squamous cell cancers have been reported to occur in excess in immunosuppressed or irradiated patients. It may therefore be speculated that the apparently increased incidence of these neoplasms in the patients with ileitis and colitis might be related to immunologic deficiencies associated with IBD, to the long‐term administration of steroids or other immunosuppressive medications that were given to most of the patients or, possibly, to increased exposure to ionizing radiation. The apparently increased incidence of perianal and vaginal cancers of the squamous variety might be a consequence of the combined effects of chronic inflammatory disease involving these areas and primary immune suppression.

Cancer in Crohn's disease after diversionary surgery: A report of seven carcinomas occurring in excluded bowel☆

Abstract The incidence of bowel cancer was studied in 132 patients who had undergone bypass surgery for Crohns disease and who had been admitted to The Mount Sinai Hospital between 1960 and 1976. Seven patients (5.3 per cent) developed cancer (4 of 63 with ileocolitis and 3 of 69 with ileitis). All seven cancers appeared in excluded loops, four in small bowel and three in colon. Six of the cancers occurred at sites of previous active inflammatory disease and one in a relatively normal “skipped” area of cecum. Four were associated with fistulas: two with enterovesical; one with enterocutaneous; and one with both. In only one case was a tumor mass palpable. All seven patients in this series underwent operation and all showed metastatic spread to liver, lymph nodes, or adjacent organs. All patients died within two years of the diagnostic laparotomy. The mean latent period between onset of disease and appearance of cancer was twenty-seven years, and between bypass surgery and appearance of cancer thirteen years. Four of the seven cancers occurred relatively early, within four years of the bypass procedure, but all seven cases had one feature in common—a long duration of Crohns disease prior to the development of cancer, ranging from seventeen to forty-four years. The diagnosis of cancer in excluded bowel was difficult to make and impossible to confirm prior to laparotomy. Among the large bowel cancers, a preoperative diagnosis was established, by sigmoidoscopy, in only one case. Cancer in a bypassed loop should be suspected in any case of Crohns disease of long duration when a late recrudescence of symptoms occurs, especially when the symptoms are associated with the new appearance of fistula or mass.

Effects of thymectomy in myasthenia gravis.

Factors influencing onset of remission in myasthenia gravis were evaluated in 2062 patients, of whom 962 had had thymectomy. Multivariate analysis showed that appearance of early remissions among all patients was significantly and independently influenced by thymectomy, by milder disease, and by absence of coexisting thymomas. Patients with mild generalized symptoms treated with thymectomy reached remission more frequently, even when compared with those with ocular myasthenia treated without surgery. Short duration of disease before thymectomy in mild cases was another factor associated with earlier remissions. Mortality for all patients was significantly and independently influenced by severity of symptoms, age, associated thymomas, and failure to remove the thymus. Patients without thymectomy and with thymomas had, in addition, earlier onset of extrathymic neoplasms. Morbidity after the transcervical approach was minimal. This study demonstrates that early thymectomy by the transcervical approach, when technically feasible, has significant clinical advantages over the transthoracic approach and should be advocated for all patients with myasthenia gravis, including those with ocular disease.

Patterns of neoplasia in Crohn's disease and ulcerative colitis

Cancer occurred in 28 of 579 patients (4.8%) with Crohns disease (CD) and in 30 of 267 (11.2%) with ulcerative colitis (UC) admitted to the Mount Sinai Hospital between 1960–1976. The proportion of cancers that were extraintestinal was greater in CD than in UC (43 vs. 12%), as was the proportion of gastrointestinal cancers that arose in apparently normal bowels (33 vs. 4%). The incidence of gastrointestinal cancer increased with duration of disease in both CD and UC, but the absolute rates were three times higher in UC. For extraintestinal cancer, on the other hand, there was less correlation with increasing duration of disease, and no higher frequency in UC than in CD. Mortality from gastrointestinal cancer was 82% in CD and 50% in UC, but occurred only within two years of tumor diagnosis; survival beyond two years seemed to indicate a favorable prognosis.

Cholesterol and obesity as prognostic factors in breast cancer.

Analysis of disease‐free survival rates in 374 women with operable breast cancer revealed that preoperative weight, particularly in combination with serum cholesterol, is a significant prognostic determinant. Overall, women weighing under 150 pounds had a significantly higher cumulative five‐year disease‐free survival rate (67%) compared with women weighing more (49%) (z = 2.2298, P = 0.026). Women with low serum cholesterol levels had better cumulative five‐year disease‐free survival (67%) than women with high serum cholesterol levels (58%) (z = 1.1008, P = 0.27). The combination of high weight and high serum cholesterol levels was associated with an extremely poor cumulative five‐year disease‐free survival (32%) compared with that observed for women in whom values of either, or both, variables were low (68%) (z = 3.7843, P = 0.0004). These patterns in disease‐free survival persisted even after controlling for tumor stage. The findings indicate that weight and cholesterol, in addition to their previously reported effect on the risk of breast cancer development, influence significantly the subsequent course of the disease.

Anal carcinoma in patients with Crohn's disease.

Three patients with Crohns disease and carcinoma of the anus are reported and compared to a group of patients with anal cancer and no inflammatory bowel disease. The three patients with Crohns disease were relatively young women with significant perianal disease. There were two squamous cell lesions and one cloacogenic tumor in this group. The relative incidence of anal cancer as a proportion of all colorectal cancer, in patients with Crohns disease (14%) was found to be significantly higher than the incidence of anal cancer in patients without inflammatory bowel disease (1.4%). Possible reasons for the increased incidence of anal cancer in Crohns disease mentioned were: an overall increase in malignancies in inflammatory bowel disease, the high incidence of perianal disease, and the chronic long-standing perianal inflammation present. All patients with Crohns disease, especially if they have active perianal disease, should be observed for the occurrence of anal cancer.

Malignant small bowel neoplasms: histopathologic determinants of recurrence and survival.

INTRODUCTION Small bowel neoplasms account for only a small percentage of gastrointestinal tumors, but their prognosis is one of the worst. PURPOSE This study examines the histopathology, treatment, recurrence, and overall survival of a group of patients with primary small bowel tumors. METHODS From 1970 to 1991, a retrospective review identified 73 patients with primary small bowel tumors. Four histologic groups were identified: 1) group 1, adenocarcinoma, 29 patients; group 2, lymphoma, 18 patients; group 3, sarcoma, 8 patients; and group 4, carcinoid, 18 patients. There were 44 men and 29 women. The median age was 57 years (range, 26 to 90). Median follow-up was 15 months. Survival analysis was by the Mantel-Cox and Breslow methods. RESULTS The most common, by type, was group 1, duodenum; group 2, jejunum; group 3, jejunum; and group 4, ileum. The preoperative diagnosis was made in only 14 patients. The median survival for adenocarcinomas and lymphomas was 13 months, 18 months for sarcomas, and 36 months for carcinoids. Curative resection could be achieved in 48 (65%) of 73 patients, and the median survival was significantly longer for this group (26 months vs. 11 months, p < 0.05). Of the 48 curative resections, 20 patients (42%) recurred: group 1, 8/19 (42%); group 2, 4/12 (33%); group 3, 4/13 (31%); group 4, 4/4 (100%). The median time to recurrence was 17 months, and the median survival after recurrence was 20 months. Adjuvant chemotherapy-radiation therapy did not alter survival in any group. CONCLUSIONS The preoperative diagnosis of small bowel tumors rarely is made because symptoms are vague and nonspecific. Surgical resection for cure results in improved survival. Recurrence is common and survival after recurrence is poor. Other treatment methods have no role in the management of these patients.

Hip Fracture in the Older Patient: Reasons for Delay in Hospitalization and Timing of Surgical Repair

OBJECTIVES: To quantify the interval between injury and hospitalization in older hip fracture patients, to quantify the time from hospital arrival to surgical repair of hip fracture, and to describe factors contributing to extended intervals between injury, hospitalization, and surgical repair of hip fracture.