Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement

INTRODUCTION

The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures.

METHODS

One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control.

RESULTS

Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control.

CONCLUSIONS

We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.

Anal Cancer: Emerging Standards in a Rare Rare Disease

The social stigma surrounding an anal cancer diagnosis has traditionally prevented open discussions about this disease. However, as recent treatment options and an increasing rate of diagnoses are made worldwide, awareness is growing. In the United States alone, 9,090 individuals were expected to be diagnosed with anal cancer in 2021. The US annual incidence of squamous cell carcinoma of the anus continues to increase by 2.7% yearly, whereas the mortality rate increases by 3.1%. The main risk factor for anal cancer is a human papillomavirus infection; those with chronic immunosuppression are also at risk. Patients with HIV are 19 times more likely to develop anal cancer compared with the general population. In this review, we have provided an overview of the carcinoma of the anal canal, the role of screening, advancements in radiation therapy, and current trials investigating acute and chronic treatment-related toxicities. This article is a comprehensive approach to presenting the existing data in an effort to encourage continuous international interest in anal cancer.

Malignant Large Bowel Obstruction

Large bowel obstruction is a serious and potentially life-threatening surgical emergency which is associated with high morbidity and mortality rate. The most common etiology is colorectal cancer which accounts for over 60% of all large bowel obstructions. Proper assessment, thoughtful decision-making and prompt treatment is necessary to decrease the high morbidity and mortality which is associated with this entity. Knowledge of the key elements regarding the presentation of a patient with a large bowel obstruction will help the surgeon in formulating an appropriate treatment plan for the patient. Comprehensive knowledge and understanding of the various treatment options available is necessary when caring for these patients. This chapter will review the presentation of patients with malignant large bowel obstruction, discuss the various diagnostic modalities available, as well as discuss treatment options and the various clinical scenarios in which they are most appropriately utilized.

The correlation Between anal pap cytology and histologic outcomes in HIV-Positive males

BACKGROUND

Anal intraepithelial neoplasia is a precursor to anal carcinoma. The use of anal pap cytology has been accepted as a screening method for anal carcinoma, however sensitivity and specificity vary.

MATERIALS AND METHODS

Retrospective cohort study involving 155 HIV-positive males with abnormal anal cytology and surgical resection.

RESULTS

155 patients met inclusion criteria. 31.6% were diagnosed with atypical cytology, 61.9% with low-grade cytology, and 6.4% with high-grade cytology. At surgery, 19.4% were diagnosed with condylomata, 34.8% with anal intraepithelial neoplasia 1, 17.4% with anal intraepithelial neoplasia 2, 27.1% with anal intraepithelial neoplasia 3 and 1.3% with anal carcinoma. There was a positive correlation between high-grade anal cytology and high-grade histology (r = 0.27; p = 0.0008). Comparison of risk factors showed no significant association.

CONCLUSION

Anal cytology has a significant correlation with surgical histology. There were still instances of high-grade lesions being found after low-grade cytology. This highlights the necessity of patients with low-grade cytology undergoing anoscopic evaluation.

Idiopathic Myointimal Hyperplasia of the Mesenteric Veins: A Rare Imitator of Inflammatory Bowel Disease

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare cause of chronic colonic ischemia characterized by intimal smooth muscle proliferation and luminal narrowing of the small to medium sized mesenteric veins. It predominantly affects the rectosigmoid colon in otherwise healthy, middle-aged males. Definitive diagnosis and treatment are surgical; however, patients are frequently misdiagnosed, which often results in a protracted clinical course. We describe a case of IMHMV presenting as left hemicolitis in a 53-year-old male, as well as the endoscopic, histopathologic, and radiographic findings that established the diagnosis.

Benchmarking patient satisfaction scores in a colorectal patient population

BACKGROUND

Healthcare reimbursement is rapidly moving away from a fee-for-service model toward value-based purchasing. An integral component of this new focus on quality is patient-centered outcomes. One metric used to define patient satisfaction is the Press Ganey Patient Satisfaction Survey. Data are lacking to accurately benchmark these scores based on diagnosis. We sought to identify if different colorectal disease processes affected a patient's perception of their healthcare experience.

METHODS

Adult colorectal patients seen between July 2015 and September 2016 in a tertiary hospital colorectal clinic were mailed a Press Ganey survey. Patients were stratified based on diagnosis: neoplasia, IBD, anorectal and benign colorectal disease. Survey scores were compared across the groups with adjustment for confounding variables.

RESULTS

312 patients responded and formed the cohort. The mean age was 61 (range 18-93) and 56% were women. The cohort breakdown was 38% neoplasia, 32% anorectal, 21% benign, and 9% IBD. In a multivariable model, there was a difference in PG scores by diagnosis; patients with neoplasia had higher Overall scores (β 10.2; Std Error 4.0; p = 0.01), Care Provider scores (β 8.5; Std Error 4.2; p = 0.04), Nurse Assistant scores (β 15.0; Std Error 5.7; p = 0.01), and Personal Issues scores (β 11.8; Std Error 5/0; p = 0.01).

CONCLUSION

Press Ganey scores were found to vary significantly. Patients with a neoplasia diagnosis reported higher overall satisfaction, Care Provider, Nurse Assistant, and Personal Issues scores. Adjustment for disease condition is important when assessing patient satisfaction as an indicator of quality and as a metric for reimbursement. This study adds to increasing evidence about bias in these scores.

Comparing pathologic outcomes for robotic versus laparoscopic Surgery in rectal cancer resection: a propensity adjusted analysis of 7616 patients

BACKGROUND

Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach.

METHODS

The National Cancer Database (2010-2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival.

RESULTS

7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group [LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57)]. Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06); [Formula: see text] = 1). For secondary outcomes, there was no difference in 30-day readmission [LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24)] and 90-day mortality [LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24)]. While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group.

CONCLUSION

This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.

Surgical management of primary colonic lymphoma: Big data for a rare problem

BACKGROUND AND OBJECTIVES

Primary colonic lymphoma (PCL) is rare, heterogeneous, and presents a therapeutic challenge for surgeons. Optimal treatment strategies are difficult to standardize, leading to variation in therapy. Our objective was to describe the patient characteristics, short-term outcomes, and five-year survival of patients undergoing nonpalliative surgery for PCL.

METHODS

We performed a retrospective cohort analysis in the National Cancer Database. Included patients underwent surgery for PCL between 2004 to 2014. Patients with metastases and palliative operations were excluded. Univariate predictors of overall survival were analyzed using multivariable Cox proportional hazard analysis.

RESULTS

We identified 2153 patients. Median patient age was 68. Diffuse large B-cell lymphoma accounted for 57% of tumors. 30- and 90-Day mortality were high (5.6% and 11.1%, respectively). Thirty-nine percent of patients received adjuvant chemotherapy. For patients surviving 90 days, 5-year survival was 71.8%. Chemotherapy improved survival (surgery+chemo, 75.4% vs surgery, 68.6%; P = .01). Adjuvant chemotherapy was associated with overall survival after controlling for age, comorbidity, and lymphoma subtype (HR 1.27; 95% CI, 1.07-1.51; P = .01).

CONCLUSIONS

Patients undergoing surgery for PCL have high rates of margin positivity and high short-term mortality. Chemotherapy improves survival, but <50% receive it. These data suggest the opportunity for improvement of care in patients with PCL.

Correction to: Progression of anal intraepithelial neoplasia in HIV-positive individuals: predisposing factors

Unfortunately, the "Informed consent" statement was incorrectly published in the original version. The complete correct reference should read as follows.

Resection for anal melanoma: Is there an optimal approach?

BACKGROUND

Anal melanoma is a lethal disease, but its rarity makes understanding the behavior and effects of intervention challenging. Local resection and abdominal perineal resection are the proposed treatments for nonmetastatic disease. We hypothesize that there is no difference in overall survival between surgical therapies.

METHODS

The National Cancer Database (2004-2014) was queried for adults with a diagnosis of anal melanoma who underwent curative resection. Patients with metastatic disease were excluded. Patients were divided into 2 groups based on surgical approach (local resection versus abdominal perineal resection). Unadjusted and adjusted analyses were used to examine the association between surgical approach and R0 resection rate, short-term survival, and overall survival.

RESULTS

A total of 570 patients with anal melanoma who underwent resection were identified. The median age was 68 and 59% of patients were female. A total of 383 (67%) underwent local resection. Abdominal perineal resection was associated with higher rates of R0 resection rates (abdominal perineal resection 91% versus local resection 73%; P < .001). Overall 5-year survival for the entire cohort was 20%. There was no significant difference in 5-year overall survival (abdominal perineal resection 21% vs local resection 17%; P = .31). This persisted in a Cox proportional hazard multivariable model (odds ratio 0.84; 95% confidence interval 0.66-1.06; P = .15). Additionally, there was no improvement in overall survival for patients who underwent R0 resection (odds ratio 1.18; 95% confidence interval 0.90-1.56; P = .22).

CONCLUSION

Anal melanoma has a very poor prognosis, with only 1 of 5 patients alive at 5 years. Although local resection was associated with lower rates of R0 resection, there was no discernable difference in overall survival in both unadjusted and adjusted analysis.

Correction: Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease

[This corrects the article DOI: 10.1371/journal.pone.0179710.].

Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease

Inability to distinguish Crohn's colitis from ulcerative colitis leads to the diagnosis of indeterminate colitis. This greatly effects medical and surgical care of the patient because treatments for the two diseases vary. Approximately 30 percent of inflammatory bowel disease patients cannot be accurately diagnosed, increasing their risk of inappropriate treatment. We sought to determine whether transcriptomic patterns could be used to develop diagnostic biomarker(s) to delineate inflammatory bowel disease more accurately. Four patients groups were assessed via whole-transcriptome microarray, qPCR, Western blot, and immunohistochemistry for differential expression of Human α-Defensin-5. In addition, immunohistochemistry for Paneth cells and Lysozyme, a Paneth cell marker, was also performed. Aberrant expression of Human α-Defensin-5 levels using transcript, Western blot, and immunohistochemistry staining levels was significantly upregulated in Crohn's colitis, p< 0.0001. Among patients with indeterminate colitis, Human α-Defensin-5 is a reliable differentiator with a positive predictive value of 96 percent. We also observed abundant ectopic crypt Paneth cells in all colectomy tissue samples of Crohn's colitis patients. In a retrospective study, we show that Human α-Defensin-5 could be used in indeterminate colitis patients to determine if they have either ulcerative colitis (low levels of Human α-Defensin-5) or Crohn's colitis (high levels of Human α-Defensin-5). Twenty of 67 patients (30 percent) who underwent restorative proctocolectomy for definitive ulcerative colitis were clinically changed to de novo Crohn's disease. These patients were profiled by Human α-Defensin-5 immunohistochemistry. All patients tested strongly positive. In addition, we observed by both hematoxylin and eosin and Lysozyme staining, a large number of ectopic Paneth cells in the colonic crypt of Crohn's colitis patient samples. Our experiments are the first to show that Human α-Defensin-5 is a potential candidate biomarker to molecularly differentiate Crohn's colitis from ulcerative colitis, to our knowledge. These data give us both a potential diagnostic marker in Human α-Defensin-5 and insight to develop future mechanistic studies to better understand crypt biology in Crohn's colitis.

Smoking as dominant risk factor for anastomotic leak after left colon resection

BACKGROUND

Some risk factors for anastomotic leak have been identified, but the effect of smoking is unknown.

METHODS

This study aimed to evaluate the effect of smoking on clinical leak after left-sided anastomoses. Adult patients who underwent elective left colectomy between January 1, 2008 and December 31, 2012 were included. Those with stomas and inflammatory bowel diseases were excluded. Primary outcome was anastomotic leak requiring percutaneous drainage or operative intervention within 30 days.

RESULTS

There were 246 patients included; 56% were female. Most had a diagnosis of diverticular disease (53%) or cancer (37%). Anastomotic leak rate was 6.5% (n = 16). The rate in smokers was 17% versus 5% in nonsmokers (P = .01). Smokers had over 4 times greater chance of leak (odds ratio 4.2, 95% confidence interval 1.3 to 13.5, P = .02).

CONCLUSION

Smoking is a risk factor for leak after left colectomy. Consideration should be given to delaying elective left colectomy until smoking cessation is achieved.

Abstract LB-463: Proteomic patterns of colonic submucosa delineates the inflammatory colitides. This could aid understand IBD-related colorectal malignancy

Purpose: Differentiating Crohn's colitis (CC) and ulcerative colitis (UC) can be challenging even in combination of clinical, endoscopic, radiologic and histopathology examination. Biomarker studies have thus far been unsuccessful for disease delineation. We aim to use unique tissue proteomic methods to evaluate colonic tissue layers for potential biomarkers to identify CC vs. UC. Methods: Fresh-frozen colon specimens from resections for IBD and/or colorectal cancer were retrospectively retrieved. Colitis diagnoses were histologically re-confirmed by a blinded gastrointestinal pathologist. Three sample groups (n=5 each group) were examined: normal colon from CRC specimens (control), UC & CC. MALDI-MS was used to profile mucosal and submucosal compartments individually. Frozen tissues were sectioned at ∼10–15 μm for mounting onto either metal or conductive glass target plates (the glass plates allowing for histologic and MALDI-MS analysis on the same section). Sinapinic acid (20 mg/mL in 50:50 acetonitrile: 0.1% TFA in water) was used to give the best combination of uniform crystal coverage and signal quality for direct tissue protein analysis. Results: MALDI-MS achieved high mass accuracy (±0.01 Daltons) in the lower mass range (&lt;15 kDa). There was distinguishable isotopic resolution of mass-to-charge ratio (m/z) values between normal vs the IBD and more strikingly between CC vs. UC (p&lt; 0.0009) of SAM and FDR tests. There were 5 statistically significant discriminative m/z peaks observed in CC vs UC submucosa. The mucosa did not yield such distinctive peaks. Both the mucosa and submucosa provided signatures that differentiated IBD (CC or UC)) from control tissues (p&lt; 0.001). Conclusions: MALDI-MS tissue profiling as described distinguished the colitides. The methodology revealed 5 m/z peaks of interest. Analyses are underway to identify these IBD discriminative proteins. We hypothesize that these biomarker candidates that distinguish UC from CC will allow delineation of indeterminate colitis into UC or CC. Whether these protein fingerprints play a role in colonic carcinogenesis remains to be elucidated.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-463. doi:10.1158/1538-7445.AM2011-LB-463

Proteomic profiling of mucosal and submucosal colonic tissues yields protein signatures that differentiate the inflammatory colitides

BACKGROUND

Differentiating ulcerative colitis (UC) from Crohn's colitis (CC) can be difficult and may lead to inaccurate diagnoses in up to 30% of inflammatory bowel disease (IBD) patients. Much of the diagnostic uncertainty arises from the overlap of clinical and histologic features. Matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) permits a histology-directed cellular protein analysis of tissues. As a pilot study, we evaluated the ability of histology-directed MALDI-MS to determine the proteomic patterns for potential differences between CC and UC specimens.

METHODS

Mucosal and submucosal layers of CC and UC colon resection samples were analyzed after histologic assessment. To determine whether MALDI-MS would distinguish inflammation, the uninflamed (n = 21) versus inflamed submucosa (n = 22) were compared in UC and the uninflamed (n = 17) versus inflamed submucosa (n = 20) in CC. To determine whether there were proteomic differences between the colitides, the uninflamed UC submucosa (n = 21) was compared versus the uninflamed CC submucosa (n = 17), the inflamed UC submucosa (n = 22) was compared versus the inflamed CC submucosa (n = 20), and inflamed UC mucosa versus inflamed CC mucosa. Pairwise statistics comparisons of the subsets were performed.

RESULTS

Pairwise comparative analyses of the clinical groups allowed identifying subsets of features important for classification. Comparison of inflamed versus uninflamed CC submucosa showed two significant peaks: m/z 6445 (P = 0.0003) and 12692 (P = 0.003). In the case of inflamed versus uninflamed UC submucosa, several significant differentiating peaks were found, but classification was worse. Comparisons of the proteomic spectra of inflamed submucosa between UC and CC identified two discrete significant peaks: m/z 8773 (P = 0.006) and 9245 (P = 0.0009). Comparisons of the proteomic spectra of uninflamed submucosa between UC and CC identified three discrete significant peaks: m/z 2778 (P = 0.005), 9232 (P = 0.005), and 9519 (P = 0.005). No significantly different features were found between UC and CC inflamed mucosa.

CONCLUSIONS

MALDI-MS was able to distinguish CC and UC specimens while profiling the colonic submucosa. Further analyses and protein identification of the differential protein peaks may aid in accurately diagnosing IBD and developing appropriate personalized therapies.

Endoscopic ultrasound to guide the combined medical and surgical management of pediatric perianal Crohn's disease

BACKGROUND

Perianal fistulas are a debilitating manifestation of Crohn's disease (CD) in the pediatric population and present a management challenge. The aims of this study were to describe our experience using endoscopic ultrasound (EUS) to guide management of perianal CD (PCD) in a pediatric population, and determine whether using EUS to monitor healing after seton placement improves outcomes.

METHODS

We conducted a retrospective study of 2 cohorts: pediatric subjects with PCD who underwent EUS and pediatric subjects who underwent seton placement between 2002 and 2007.

RESULTS

In all, 25 children underwent a total of 42 EUS procedures. Of 28 EUSs performed to evaluate suspected perianal disease, complex fistulizing disease was identified in 15 (54%). Setons were placed after most EUSs demonstrating complex fistulizing disease and after none demonstrating superficial or no fistulizing disease. Of 14 EUSs performed to monitor healing around a seton, 7 (50%) demonstrated persistent peri-seton inflammation. Setons were more often left in place after an EUS revealing persistent inflammation (86% versus 0%), and the patients were more likely to have a biologic initiated or changed (57% versus 0%). Among all subjects who underwent seton placement, time from seton removal to recurrence was longer for those followed by EUS compared to those followed by physical exam only; however, we were not powered to test for statistical significance.

CONCLUSIONS

EUS to guide the combined medical and surgical management of PCD is feasible in the pediatric population. Larger prospective studies are needed to determine if EUS-directed management improves outcomes in pediatric patients with PCD.

Prevalence and outcome of anemia after restorative proctocolectomy: a clinical literature review

PURPOSE

Iron and/or vitamin B12 deficiency anemias, which have adverse effects on patients' quality of life, are commonly observed and often overlooked complications after restorative proctocolectomy. We performed a systematic review of publications on the prevalence of anemia as well as on the impact of anemia on a range of clinical, functional, quality of life, and economic outcomes in restorative proctocolectomy patients. This information is important to help healthcare providers through a comprehensive overview to increase awareness about a condition that could require therapy to improve patient healthcare and quality of life.

METHODS

We reviewed the English language publications on the incidence of anemia and its adverse effect after restorative proctocolectomy The United States National Library of Medicine database (MEDLINE), the Excerpta Medica database (EMBASE), the Cochran Library, and the Google search engine were searched for published articles on the prevalence and impact of anemia in post-restorative proctocolectomy surgical patients.

RESULTS

The long-term complication most frequently described after RPC is pouchitis. Pouchitis is significantly associated with iron deficiency anemia caused by pouch mucosal bleeding. Other causes are insufficient and/or impaired iron absorption. It has also been observed, however, that restorative proctocolectomy patients with underlying familial adenomatous polyposis rarely develop pouchitis yet show higher rates of iron deficiency anemia compared to those patients with underlying ulcerative colitis. Other causes shown as independent risk factors for iron deficiency anemia in restorative proctocolectomy patients are malignancy, desmoid tumors, and J-pouch configuration. Vitamin B12 deficiency anemia is also common after restorative proctocolectomy. About one-third of restorative proctocolectomy patients show abnormal Schilling test and 5 percent have low referenced serum cobalamin. It has been observed that the degree resection of the terminal-ileum, malabsorption, bacterial overgrowth, and dietary factors are among the known causes of cobalamin deficiency. Folate deficiency has not been reported in restorative proctocolectomy patients. Describing restorative proctocolectomy surgery and its outcomes, in patients without anemia, the quality of life is reported excellent regardless of operative technique.

CONCLUSIONS

Anemia is not uncommon following restorative proctocolectomy and has been shown to have negative effects on the patient's quality of life and the economy and may substantially increase healthcare costs. The treatment of anemia and its underlying causes is important to improving clinical and economic outcomes.

A randomized prospective trial of endoscopic ultrasound to guide combination medical and surgical treatment for Crohn's perianal fistulas

AIMS

To prospectively determine if rectal endoscopic ultrasound (EUS) can guide combination medical and surgical therapy and improve outcomes for patients with perianal fistulizing Crohn's disease.

METHODS

Ten patients with perianal Crohn's disease were prospectively enrolled in a randomized prospective pilot study. The patients were randomized to either the EUS cohort or the control group. All patients underwent a rectal EUS to delineate fistula anatomy followed by an examination under anesthesia by a colorectal surgeon with seton placement and/or incision and drainage, as indicated. The surgeon was blinded to the initial EUS results of patients in the control group. Medical treatment was maximized with 6-mercaptopurine (1.0-1.5 mg/kg) or azathioprine (2.0-2.5 mg/kg), ciprofloxacin (1,000 mg a day) or metronidazole (1,500 mg a day), and infliximab (5 mg/kg at 0, 2, and 6 wk and then every 8 wk). For patients in the control group, additional interventions (seton removal and repeat surgery) were at the discretion of the surgeon (without EUS guidance). Patients in the EUS cohort had EUS performed at weeks 22 and 38, with additional surgical interventions based on EUS findings. The primary end point was complete cessation of drainage at week 54. All patients had a repeat EUS performed at week 54 to determine the fistula status on EUS (secondary end point). The need for additional surgery was defined as a treatment failure.

RESULTS

Ten patients were enrolled in the study. One of 5 (20%) in the control group and 4 of 5 (80%) in the EUS group had complete cessation of drainage. From the control group, 3 patients failed due to repeat surgery (2 for persistent/recurrent fistula and 1 for abscess), and 1 had a persistent drainage at week 54. In the EUS cohort, 1 patient had a recurrent abscess after his seton fell out prematurely. In the EUS cohort, the median time to cessation of drainage was 99 days, and the time to EUS evidence of fistula inactivity was 229 days.

CONCLUSION

This pilot study suggests that using EUS to guide combination medical and surgical therapy for perianal fistulizing Crohn's disease improves the outcomes.

Small Bowel Adenocarcinoma Complicating Crohn's Disease: Case Series and Review of the Literature

Colonic adenocarcinoma frequently complicates inflammatory bowel disease of the colon, but small bowel adenocarcinoma (SBA) is a rare complication of Crohn's disease (CD). We present two patients with SBA in CD and review the literature with regards to CD-related SBA. A 45-year-old male with a 17-year history of ileal CD presented with obstructive symptoms but no radiographic evidence of a mass. After laparoscopic ileocolectomy and repair of incidental ileosigmoid fistula, pathology showed a T3N0 adenocarcinoma within the ileal CD. Two years after his resection he was without evidence of disease. A 59-year-old male with a 15-year history of CD presented with an acute exacerbation. Small bowel follow through demonstrated a long ileal stricture for which he underwent an ileocolic resection. Postoperative pathology confirmed a T3N1 CD-related SBA. He died from metastatic cancer 3 months later. Review of the literature identified 154 cases of SBA complicating CD with several distinguishing features from de novo SBA. Patients with SBA and CD are, as a group, younger and more likely to be male. SBA is rarely diagnosed preoperatively in these patients, and has a poor prognosis due to its advanced stage at diagnosis.

Small bowel adenocarcinoma complicating Crohn's disease: case series and review of the literature

Colonic adenocarcinoma frequently complicates inflammatory bowel disease of the colon, but small bowel adenocarcinoma (SBA) is a rare complication of Crohn's disease (CD). We present two patients with SBA in CD and review the literature with regards to CD-related SBA. A 45-year-old male with a 17-year history of ileal CD presented with obstructive symptoms but no radiographic evidence of a mass. After laparoscopic ileocolectomy and repair of incidental ileosigmoid fistula, pathology showed a T3N0 adenocarcinoma within the ileal CD. Two years after his resection he was without evidence of disease. A 59-year-old male with a 15-year history of CD presented with an acute exacerbation. Small bowel follow through demonstrated a long ileal stricture for which he underwent an ileocolic resection. Postoperative pathology confirmed a T3N1 CD-related SBA. He died from metastatic cancer 3 months later. Review of the literature identified 154 cases of SBA complicating CD with several distinguishing features from de novo SBA. Patients with SBA and CD are, as a group, younger and more likely to be male. SBA is rarely diagnosed preoperatively in these patients, and has a poor prognosis due to its advanced stage at diagnosis.

Evolution of the restorative proctocolectomy and its effects on gastrointestinal hormones

Gastrointestinal (GI) peptide hormones are chemical messengers that regulate secretory, mechanical, metabolic, and trophic functions of the gut. Restorative proctocolectomy (RPC) or resection of the colon and rectum with maintenance of intestinal continuity through the construction of an ileal pouch reservoir and preservation of the anal sphincters has become the standard of care for the surgical treatment of ulcerative colitis and familial adenomatous polyposis. The manipulation of the digestive system to create the ileal pouch involves altering gut-associated lymphoid tissue among other anatomic changes that lead to changes in GI peptides. In addition, the ileal pouch epithelium responds to a wide variety of stimuli by adjusting its cellularity and function. These adaptive mechanisms involve systemic factors, such as humoral and neural stimuli, as well as local factors, such as changes in intestinal peristalsis and intraluminal nutrients. There have been conflicting reports as to whether the alterations in GI hormones after RPC have actual clinical implications. What the studies on alterations of GI peptides' response and behavior after RPC have contributed, however, is a window into the possible etiology of complications after pouch surgery, such as pouchitis and malabsorption. Given the possibility of pharmacologically modifying GI peptides or select components of adaptation as a therapeutic strategy for patients with ileal pouch dysfunction or pouchitis, a clear understanding of human pouch mucosal adaptation is of paramount importance. In this review, we summarize the evolution of the RPC and its effects on the GI hormones as well as their possible clinical implications.

Carcinoid tumors are 15 times more common in patients with Crohn's disease

BACKGROUND

The coexistence of intestinal neoplasms with Crohn's disease (CD) has been reported, but the evidence of an increased risk of carcinoid tumor with Crohn's disease has been mixed. We present 4 patients with CD with associated carcinoid tumor.

METHODS

The charts of 111 patients with CD who had undergone resection between June 2001 and March 2005 were reviewed. The number of incidental carcinoid tumors in patients who underwent an appendectomy was used as a control.

RESULTS

Four cases of carcinoid tumor discovered in patients at resection for CD were identified. None had metastatic disease or carcinoid syndrome. These included 1 cecal (1 mm), 2 appendiceal (3 and 7 mm), and 1 transverse colon (7 mm) carcinoid tumors. None of the carcinoid tumors were identified in regions of active Crohn's disease. The incidence of carcinoid tumor in patients with Crohn's disease was 4 of 111 (3.6%). In comparison, 3 of 1199 patients (0.25%) who had appendectomies were identified as having appendiceal carcinoid tumor. Crohn's disease was associated with an increased incidence of carcinoid tumor; OR 14.9 (95% CI 2.5-102.5), P<0.0001.

CONCLUSIONS

There was a significantly increased incidence of carcinoid tumor in our Crohn's patients compared to the control patients. None of the carcinoid tumors developed in areas of Crohn's disease. This suggests that the development of carcinoid tumors may be secondary to distant proinflammatory mediators, rather than a local inflammatory effect from adjacent Crohn's disease. Patients with CD may be at increased risk of developing a carcinoid tumor.

Lichtenstein vs anterior preperitoneal prosthetic mesh placement in open inguinal hernia repair: a prospective, randomized trial

Male veterans with unilateral primary inguinal hernia, classified intraoperatively as Gilbert Type III or IV, were randomized to subaponeurotic (Lichtenstein, n=126) or preperitoneal (Read-Rives, n=121) repair under general or spinal anesthesia. The two groups of patients were comparable in age, body weight index, comorbidities, and size and type of hernia. Of the 247 patients enrolled, 224 were followed for at least 2 years (median 82 months, range 24-110 months), 16 were lost to follow-up, and seven died from causes unrelated to the surgery. The average operative time of the Read-Rives repair was 9 min longer than that of the Lichtenstein repair. There were no wound infections, and the frequencies of other short- and long-term complications were low and similar in the two groups. Six patients developed hernia recurrence, five in the Lichtenstein group (4.3%), and one in the Read-Rives group (<1%), ( P=0.21). Both anterior repairs are associated with low postoperative morbidity and recurrence rates. The Lichtenstein repair is technically easier and less time consuming. There is no statistically significant difference in the recurrence rate between the two repairs.

Central venous catheter placement in patients with disorders of hemostasis

BACKGROUND

Patients requiring central venous access frequently have disorders of hemostasis. The aim of this study was to identify factors predictive of bleeding complications after central venous catheterization in this group of patients.

METHODS

A retrospective analysis of all central venous catheters placed over a 2-year period (1997 to 1999) at our institution were performed. The age, sex, clinical diagnosis, most recent platelet count, prothrombin international normalized ratio (INR), activated partial thromboplastin time (aPTT), catheter type, the number of passes to complete the procedure, and bleeding complications were retrieved from the medical records.

RESULTS

In a 2-year period, 2,010 central venous catheters were placed in 1,825 patients. Three hundred and thirty placements were in patients with disorders of hemostasis. In 88 of the 330 patients, the underlying coagulopathy was not corrected before catheter placement. In these patients, there were 3 bleeding complications requiring placement of a purse string suture at the catheter entry site. In the remaining 242 patients, there was 1 bleeding complication. Of the variables analyzed, only a low platelet count (<50 x 10(9)/L) was significantly associated with bleeding complications.

CONCLUSION

Central venous access procedures can be safely performed in patients with underlying disorders of hemostasis. Even patients with low platelet counts have infrequent (3 of 88) bleeding complications, and these problems are easily managed.

An outbreak of mycoplasma pneumoniae respiratory illness in a semi-closed religious commune

Of approximately 200 members of a religious commune, 37 came to the emergency department of Cook County Hospital for primary medical care of respiratory illness. Of the 37, 31 were seen during a two-week period, indicating a rapid spread of disease. The major symptoms were cough, fever, coryza, and sore throat. Infiltrates were detected in 38%. Paired sera from four of nine patients showed a significant rise to Mycoplasma pneumoniae. Of 24 sera collected at the time of the first visit, 33% had a titer to the agent, of 64 or greater--presumptive evidence of Mycoplasma infection. Therefore, M pneumoniae was implicated as the causative agent in this outbreak of respiratory illness in a semi-closed community.

Legionnaires' disease in children

In a retrospective survey of sera collected from 126 patients under the age of 10 years, seroreactivity was first detected at 1 year of age when the geometric mean titer rose from 12 to 24. This activity increased to a titer of 102 in the 4- to 6-year-old group and was maintained in the 7- to 9-year-old group. At the time of serum collection, at least 25% of those sampled had a titer of 256 or greater, a level currently thought to be presumptive evidence of infection at some undetermined time. No difference in the geometric mean titer could be ascertained when the population was divided by clinical diagnosis or by sex. No seasonal variation was observed. Of 35 paired sera from children under the age of 5 years, three fourfold rises were observed. One rise to a titer of 128 was detected in an 11-month-old girl with a clinical diagnosis of bronchiolitis. The second rise in a 5-year-old boy with pneumonia was an increase from 256 to 2,048. The third rise in a 6-month-old with pneumonia did not meet the currently accepted level necessary for confirmed diagnosis. These data suggest that infection with Legionella pneumophila, or a closely related agent, is common in this population, occurring before 9 years of age, and may be a cause of mild respiratory disease in infants and children.

Use and withdrawal of amantadine chemoprophylaxis during epidemic influenza A

A controlled investigation of chemoprophylaxis with amantadine hydrochloride during an epidemic of influenza A was performed in nonimmune students. Illness was significantly decreased and serologic evidence of infection reduced by treatment. During the post-treatment period, while influenza was still prevalent, an accelerated rate of infection occurred among persons previously protected by chemotherapy. When used, chemoprophylaxis should be continued until influenza is no longer prevalent or, preferably, should be combined with vaccine administration to ensure protection after treatment.

Effect of isoprinosine against influenza and some other viruses causing respiratory diseases

The antiviral activity of isoprinosine was tested in tissue cultures and mice. In tissue cultures, concentrations of 25 to 100 mug/ml inhibited the infectivity of influenza and herpes hominis viruses but not parainfluenza virus, rhinovirus, or adenovirus. Among different strains of influenza A, there was considerable variability in the inhibitory concentration of isoprinosine. For influenza B, a zone effect was observed in the inhibitory drug concentration. Oral prophylactic administration of isoprinosine beginning 24 hr before infection with an intermediate challenge dose of influenza A and continued as treatment for 5 days produced a significant reduction in mortality. No protection was provided against a high dose challenge. Oral or intraperitoneal treatment of mice beginning 24 hr after infection with influenza A or B viruses significantly delayed or prevented death when the drug was administered for 10 days, but not when treatment was limited to 4 days. An increased fatality rate which occurred in treated mice given a virus dose of low lethality could not be attributed to drug toxicity.