Ronald J. Place

Practice parameters for the management of rectal cancer (revised).

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Giant condyloma acuminatum of the anorectum: trends in epidemiology and management: report of a case and review of the literature.

PURPOSE: Giant condyloma acuminatum (Buschke-Loewenstein tumor) of the anorectum is a rare disease with a potentially fatal course. Controversy exists as to the epidemiology, pathologic nature, and management of the tumor. METHODS: We present a 42-year-old male with a 12-cm × 10-cm exophytic mass of the anal verge. Treatment included wide local excision and partial closure with rotation flaps. Pathology revealed a giant condyloma acuminatum with foci of well-differentiated squamous-cell carcinoma. We identified 51 reported cases of giant condyloma acuminatum in the English literature, and to our knowledge this is the largest review to date. RESULTS: Giant condyloma acuminatum presents with a 2.7:1 male-to-female ratio. For patients younger than 50 years of age, this ratio is increased to 3.5:1. The mean age at presentation is 43.9 years, 42.9 in males and 46.6 in females (P=0.44). There seems to be a recent trend toward a younger presentation. The most common presenting symptoms are perianal mass (47 percent), pain (32 percent), abscess or fistula (32 percent), and bleeding (18 percent). Giant condyloma acuminatum has been linked to human papilloma virus and has distinct histologic features. Foci of invasive carcinoma are noted in 50 percent of the reports, “carcinomain situ” in 8 percent, and no invasion in 42 percent. Historically, treatment strategies have included topical chemotherapy, wide local excision, abdominopelvic resection, and the frequent addition of adjuvant and neoadjuvant systemic chemotherapy and radiation therapy. Recurrence is common. CONCLUSION: There seems to be a trend toward younger age at presentation and male predominance of giant condyloma acuminatum of the anorectum. Foci of invasive cancer within giant condyloma specimens are of uncertain significance and do not seem to correlate with recurrence or prognosis. Local invasion and local recurrence are the major source of morbidity in this disease. Complete excision is the preferred initial therapy when feasible. Wide local excision, fecal diversion, or abdominoperineal resection have been used. Chemotherapy with 5-fluorouracil and focused radiation therapy may be used in certain cases of recurrence or extensive pelvic disease, with unpredictable response. Controlled, prospective, multi-institutional studies are necessary to further define the nature and treatment of this rare disease.

outcome of Hiv-infected Patients With Invasive Squamous-cell Carcinoma of the Anal Canal in the Era of Highly Active Antiretroviral Therapy

PURPOSE:Before the development of highly active antiretroviral therapy for the treatment of HIV infection, HIV patients diagnosed with invasive squamous-cell carcinoma of the anal canal carried a very poor prognosis. This study was designed to determine the outcome in a similar group of patients in the era of highly active antiretroviral therapy.METHODS:HIV-positive patients treated for invasive squamous-cell carcinoma of the anal canal at the University of Texas Medical Center affiliated hospitals from 1980 to 2001 were identified from operative data and cancer registries. We reviewed these records and collected data regarding age, CD4 count, highly active antiretroviral therapy, cancer treatment, complications, and survival. The patients were divided into two groups based on the presence or absence of highly active antiretroviral therapy and compared using a Kaplan-Meier approach.RESULTS:Fourteen patients with HIV and invasive squamous-cell carcinoma of the anal canal were identified. Six were in the prehighly active antiretroviral therapy group and eight in the highly active antiretroviral therapy group. All were considered for treatment with chemotherapy and radiation. In the prehighly active antiretroviral therapy group, one patient refused therapy and three were unable to complete the squamous-cell carcinoma therapy as planned because of complications. Four of eight highly active antiretroviral therapy patients were unable to complete the squamous-cell carcinoma therapy as planned. The prehighly active antiretroviral therapy patients had a mean age of 40 years and a mean CD4 count of 190 at the time of diagnosis. The highly active antiretroviral therapy patients had a mean age of 44 years and a mean CD4 count of 255 at the time of diagnosis. The 24-month survival was 17 percent in the prehighly active antiretroviral therapy group and 67 percent in the highly active antiretroviral therapy group (P = 0.0524). All six patients in the prehighly active antiretroviral therapy group died with active squamous-cell carcinoma vs. two in the highly active antiretroviral therapy group. Four of the remaining six patients had no evidence of active squamous-cell carcinoma at the last follow-up visit.CONCLUSIONS:A review of patients with HIV and invasive squamous-cell carcinoma of the anal canal suggests a trend toward a higher CD4 count at the time of diagnosis and improved survival in patients receiving highly active antiretroviral therapy. In this new era, HIV-positive patients should be on highly active antiretroviral therapy. If not, highly active antiretroviral therapy should be initiated, and standard multimodality therapies for invasive squamous-cell carcinoma of the anal canal are recommended.

Stereotactic breast biopsy is accurate, minimally invasive, and cost effective

BACKGROUND We reviewed our experience with stereotactic core needle breast biopsy (SCNBB) for accuracy, complication rate, and staging profile of malignancies diagnosed. METHODS Since March 1993, 530 stereotactic biopsies were performed. Of these, 25 cases underwent stereotactic core needle biopsy with subsequent wire-guided biopsy. RESULTS In 25 patients with stereotactic and open biopsy, there was an accuracy for SCNBB of 96%. The number of biopsies rose from 100 to 250 biopsies annually, with an equivalent pre-test positive predictive value for mammography (17% to 19% historical versus 20% with SCNBB). The total number of de novo cancer diagnoses have increased from a mean of 57 to a mean of 71 annually. The percentage of tumors in situ, stage I or stage II, has increased from 60% to 69%. CONCLUSIONS Stereotactic core needle biopsy combines a high accuracy with a low complication rate. Its aggressive application for tissue diagnosis in suspicious nonpalpable mammographic lesions has increased the proportion of early (in situ and T1 or T2) tumors discovered, and increased the total number of breast cancers diagnosed.

Flexible endorectal ultrasound for predicting pathologic stage of rectal cancers

BACKGROUND Endorectal ultrasound (ERUS) is an accurate method for preoperative staging of rectal cancers. Most often, a rigid 360-degree rotating probe is used. We studied whether flexible probes could attain equivalent accuracy for bowel wall penetration. METHODS Forty-five patients were prospectively evaluated with flexible devices. Results were compared with 20 rigid and 10 flexible probe studies. To assess learning curves, we used logistic regression analysis and coefficients of correlation on accuracy data to compare ERUS accuracy with the number of examinations. RESULTS Level of invasion was correct in 49%. Nodal examinations were correct in 78%. Learning curves leveled out at 100 examinations with 87% accuracy for the rigid probe (R = 0.46) and 77% for the flexible devices (R = 0.31). CONCLUSIONS The coefficient of correlation for each method portends a more reliable learning curve for the rigid devices. Flexible devices were less accurate for level of invasion than the literature reported for rigid devices.

Trauma experience comparison of army forward surgical team surgeons at Ben Taub Hospital and Madigan Army Medical Center

Far forward life-saving surgical care is the mission of an army forward surgical team (FST). Trauma skill maintenance is necessary to complete that mission. A new program has been developed for FST training using the resources of a Level 1 trauma center. We sought to compare the experience of FST surgeons at a major urban trauma center with the yearly trauma experience at an army Level 2 trauma center.General surgeons of the 250th FST prospectively tabulated data for trauma patients during a September 1999 unit deployment to Ben Taub Hospital (Houston, Texas). Data collected included nature and location of injury, hospital admission, and surgical intervention. During 1999, similar data were collected at Madigan Army Medical Center (MAMC) (Ft. Lewis, Washington), home station of the 250th and Level 2 trauma center since November 1998.The FST general surgeons observed 319 injuries. Of those injured, 104 were admitted and 19 underwent urgent operation. Direct participation by FST general surgeons in the operative procedures varied. In 1999, MAMC general surgeons treated 455 trauma victims in direct supervision of Army general surgery residents. Madigan Army Medical Center general surgeons admitted 304 and urgently operated on 57 trauma patients, while 107 patients were transferred to another institution for definitive management of orthopedic and nonoperative neurosurgical injuries.CONCLUSIONS:The volume of trauma surgical cases at MAMC during 1999 was 3 times that seen in the 1-month rotation at Ben Taub. General surgeons performed more trauma and abdominal surgery at MAMC with significantly more direct involvement in patient care and operative procedures. The experience of the 250th FST does not justify trauma sustainment deployments for surgeons from military trauma centers.

A comparison of open versus closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery.

BACKGROUND Surgical excision using the Harmonic Scalpel is a modern technique for symptomatic third- and fourth-degree hemorrhoids. The resulting mucosal defect is then left open or sutured closed depending on surgeon preference. PURPOSE The purpose of this study was to compare the open vs. closed techniques of hemorrhoid excision using the Harmonic Scalpel in an outpatient setting. METHODS From July 2000 through October 2001, 42 patients underwent surgical excision of complex grade III or grade IV hemorrhoids via the Harmonic Scalpel with closure of the overlying mucosa (closed), and without closure of the overlying mucosa (open). Quality of life was assessed using the Short Form-36 survey. RESULTS Both groups were comparable in terms of patient demographics and type of anesthesia. There were no late complications. Mean follow-up was 16.9 (range, 12-27) months. CONCLUSION Leaving the mucosal defect open following Harmonic Scalpel hemorrhoidectomy significantly reduces operative time, and thus operative costs, without diminishing quality of life. Although morbidity was equivalent, this requires further evaluation with a prospective study to ensure patient safety.

In-flight transfusion of packed red blood cells on a combat search and rescue mission: a case report from operation enduring freedom.

Injuries on the battlefield can occur far from the nearest medical treatment facility. This is especially likely for downed pilots and special operations personnel. Some of these injuries lead to significant blood loss requiring transfusion. We present two cases of injured coalition force members during Operation Enduring Freedom that illustrate the potential need for a transfusion capability at the site of injury to prevent death. Consideration should be given to augmenting transfusion capabilities in military environments with predictably long evacuation times.

Returning to Duty from Temporary Disability in the U.S. Army: Observational Data and Commentary for Commanders, Providers, and Soldiers

Before 2011, Army commanders were unable to achieve complete visibility of soldiers possessing temporary medical limitations. The creation of time-limited definitions and technical categorization of this group, now known as the medically not ready (MNR) population, eventually allowed its quantification. With heightened visibility of the group, leaders in the Fort Stewart community facilitated its management through soldier medical readiness councils. In this commentary, we introduce a project that identified and tracked a cohort of 2,490 MNR soldiers for a 1-year period until they either recovered or entered the medical separation process. We identified that musculoskeletal injuries accounted for a heretofore unrecognized 87.4% majority of the MNR population. Prognosis of the MNR population was generally good. Fifty percent of the population returned to duty within 90 days of illness/injury. Seventy-seven percent returned to duty during the follow-up period. Although low back and knee/leg injuries were the largest contributors to the MNR population, low back issues were more likely to result in medical separation. Traumatic brain injury and post-traumatic stress disorder did not contribute significantly to the MNR population. This article seeks to describe the natural history of the MNR category of temporary disability for commanders, providers, and soldiers alike.

The Effectiveness of Soldier Medical Readiness Councils in Reducing and Shaping the Population of Soldiers Not Medically Deployable

The population of Soldiers not medically fit for deployment has created readiness problems for the U.S. Army in recent years. To address this issue, the 3rd Infantry Division created councils of experts to address the size of its medically nondeployable population. Our results demonstrate success in effectively reducing the subpopulation of Soldiers who have been medically nondeployable for long periods of time by enforcing their return to duty or medical retirement. This study also demonstrates that council-based management affects the composition of the medically-not-ready population. Traditional approaches allow a minority subpopulation of Soldiers with poor prognoses to dwell within the nondeployable population for long periods of time (6-18+ months), whereas the healthier majority recovers within the first 6 months. This creates a dynamic in which remaining in the population for longer time periods increases the probability of being medically retired. Our study demonstrates that councils consistently and actively shape the character of the group such that those remaining in the medically-not-ready population for longer periods of time do not have an increased risk of medical retirement. Soldier Medical Readiness Councils have already been adopted by the Army. This article provides evidence to support their efficacy.