G. Tiberio

Obstructing colonic cancer : Failure and survival patterns over a ten-year follow-up after one-stage curative surgery

BACKGROUND: Large-bowel cancers that present as obstructing lesions have a poor prognosis. However, little is known of the reasons for the dismal survival and of failure patterns after potentially curative treatment. METHOD: An observational study and multivariate analysis were conducted to identify determinants of survival and to compare recurrence patterns between obstructing and nonobstructing tumors after primary resection and anastomosis as curative treatment. RESULTS: Over a period of ten years (1980–1989), 528 patients with colonic cancer were treated at one institution. The cancer was obstructing in 179 cases and nonobstructing in 349. One-stage primary resection and anastomosis as curative treatment were performed in 107 obstructed and 256 nonobstructed patients. Three hundred thirty-six potentially cured survivors (94 in the former group and 242 in the latter) were followed for a median of 55 months. During follow-up, local recurrence occurred in 37 patients (12 obstructed (12.8 percent) and 25 nonobstructed (10.4 percent),P=0.44) and metastatic disease in 68 (25 obstructed (27.6 percent) and 43 nonobstructed (17.8 percent),P=0.029). Multivariate analysis of survival showed that age over 70 years, Dukes stage, histologic grade, and recurrence were the only prognostic factors. No statistically significant determinant turned out for local recurrence, whereas at multivariate analysis for metastatic and overall relapse, Dukes stage, positive nodes, and obstruction remained independent prognostic factors. CONCLUSIONS: After one-stage emergency curative treatment, patients presenting with obstructing tumors of the colon have a smaller survival probability than that of patients with nonobstructing lesions. Local recurrence pattern is similar between groups. Conversely, obstruction, along with pathologic stage and positive nodes, carries a significantly higher risk of metastatic tumor recurrence and death.

Outcome of large-bowel perforation in patients with colorectal cancer.

PURPOSE: Perforation of the colon is seldom associated with malignant disease. Operative mortality varies widely in published studies and little is known about patterns of failure and long-term outcome. An observational study was undertaken to assess the outcome of colorectal cancer complicated by perforation. METHOD: we reviewed a series of 83 consecutive patients treated during a 14-year period at one institution. RESULTS: Fifty-four (65 percent) patients had perforation of the tumor itself, and 29 (35 percent) had diastatic perforation proximal to an obstructing tumor. Twenty-six (31.5 percent) patients had metastatic disease at laparotomy. Primary resection of the diseased segment was performed in 47 (87 percent) patients with perforation of the tumor itself and in 21 (72.4 percent) patients with diastatic perforation proximal to an obstructing tumor. However, only 57 patients (39 (72.2 percent) with perforation of the tumor itself; 18 (62 percent) with diastatic perforation proximal to an obstructing tumor;P=not significant) were potentially cured. Operative mortality was 16.7 and 48.3 percent, respectively (P<0.01) and correlated significantly with Hincheys stage (P<0.001) and advanced disease (P=0.023). At a mean follow-up of 43 (median 31) months, 21 (46 percent) of the 46 potentially cured survivors were alive. The local recurrence rate was 22.9 percent in patients with perforation of the tumor itself and 18.2 percent in patients with diastatic perforation proximal to an obstructing tumor (P=not significant). Peritoneal seeding occurred in 17 and 0 percent (P=not significant); the mean disease-free interval was 33.9 and 49.9 months (P=not significant); and five-year cumulative disease-related survival probability was 0.51 and 0.90 (P=0.049), respectively. CONCLUSIONS: Diastatic perforation proximal to an obstructing tumor is associated with higher operative mortality and better cancer-related survival than a tumor perforating through the bowel wall. Early diagnosis in diastatic perforation and aggressive management of sepsis associated with radical surgical resection is recommended.

Follow-up in colorectal cancer patients: A cost-benefit analysis

AbstractBackground: No conclusive evidence exists concerning the effectiveness of follow-up programs after curative surgery for colorectal cancer, and presently cost-benefit analyses have not indicated that follow-up strategies increase survival or quality of life. Methods: Five hundred five patients who survived curvative surgery for stage I–III colorectal adenocarcinoma were closely followed for at least 4 years. Results: One hundred forty-one (28%) patients had recurrence. Of these, 32 underwent one or more surgical procedures for cure, whereas 109 could only benefit from palliation. Eighteen were cured. The mean survival of all recurrent cases was 44.4 months. Of those operated on with curative intent, the mean survival was 69.3 months compared with 37.1 months in those operated on with palliative intent. Of those 18 patients who were cured by reoperative surgery, the average survival was 81.4 months. The overall follow-up cost was

Emergency management of caustic ingestion in adults

1,914,900 (U.S.) for the 505 patients;

Intraluminal Duodenal Diverticulum Causing Acute Pancreatitis: CT Scan Diagnosis and Review of the Literature

13,580 (U.S.) for each recurrence,

Neurofibromatosis-1 and ampullary gangliocytic paraganglioma causing biliary and pancreatic obstruction.

59,841 (U.S.) for each case treated for cure, and

Emergency Ultrasound Evaluation of Caustic Injuries to the Stomach

136,779 (U.S.) for those effectively cured. Conclusions: Careful postoperative monitoring is expensive yet effective when one considers that one-quarter of the detected recurrences were suitable for potentially curative second surgery; however, only 3.6% of the original group were effectively cured. Follow-up programs should be tailored according to the stage and site of the primary to reduce costs.

Parenteral Antibiotics and Selective Intestinal Decontamination Do Not Prevent Enteric Bacterial Overgrowth or Translocation Observed in a Swine Model of Small Bowel Transplantation

A study of 57 patients admitted to the Department of Emergency Surgery at the Ospedale Maggiore in Milan between 1980 and 1992 following the recent ingestion of a caustic substance is presented herein. Through this study, an aggressive diagnostic and therapeutic approach has been employed, including early surgery which plays a fundamental role in the prevention of acute hemorrhagic or perforative complications as well as in the development of scar tissue and neoplastic strictures over time. The criteria for early emergency surgery were the presence of endoscopic grade 3 and 4 lesions as well as those on the borderline between grades 2 and 3 with clinical symptoms. In 11 patients with lesions of moderate severity, the treatment of choice was medical therapy, which required subsequent surgical intervention for strictures in 5 patients. In 13 patients with severe lesions, an early surgical approach was performed with a mortality rate of 23%.

Luminal bacterial overgrowth and intestinal translocation in pigs given either cyclosporin A or 15-deoxyspergualin after small bowel transplantation.

Background: Intraluminal duodenal diverticulum is a rare congenital anomaly. First described by Boyd in 1845, no more than 100 cases have been reported up to now: only 17 are associated with acute pancreatitis. Methods: A new case of intraluminal duodenal diverticulum with acute pancreatitis is reported and the literature about this association reviewed. Results: The diagnosis was made by helical CT scan. The pathogenesis of pancreatitis was possibly due to a pure duodenal content reflux through the papilla of Vater. The patient was successfully treated by surgery. Conclusions: Intraluminal duodenal diverticulum is a rare but curable cause of pancreatitis, usually affecting young people. We describe, for the first time, its unusual helical CT imaging with two-dimensional reformations.

Artificial nutrition in the management of lesions caused by caustic ingestion

SummaryGangliocytic paragangliomas (GPs) are exceedingly rare tumors that arise in close proximity of the papilla of Vater. Nevertheless, jaundice is an uncommon presenting symptom, reported in only 3 of 125 cases described in the literature to date, with gastrointestinal bleeding being more common.Association between GPs and neurofibromatosis 1 (NF-1), described in two patients, may be more than casual, being the frequency in normal population 1:3000.We report an additional case of this association, presenting for the first time with simultaneous obstruction of the common biliary duct, and of the main pancreatic duct. Previous cases of GPs with jaundice and/or NF-1 are reviewed, and updating of the histogenesis presented.