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BACKGROUND Whether prolonged survival with current chemotherapy using molecular target agents has changed the rate of primary tumor-related complications in patients with unresectable stage IV colorectal cancer is unclear. OBJECTIVE This study aimed to investigate the rate of primary tumor-related complications among patients receiving targeted therapy as compared with patients receiving chemotherapy without molecular target agents. DESIGN This was a retrospective review of data from a prospectively maintained database. SETTINGS The study was conducted at a high-volume multidisciplinary tertiary cancer center in Japan. PATIENTS Subjects were 352 consecutive patients with unresectable stage IV colorectal cancer who received systemic chemotherapy without primary tumor resection from 2001 to 2015. Patients were categorized into nontargeted and targeted groups according to the use of molecular target agents. MAIN OUTCOME MEASURES Complication rates attributed to primary tumors were measured. RESULTS Of the 352 patients, 159 were categorized into the nontargeted group and 193 patients into the targeted group. Competing risk-adjusted univariate analysis revealed that the primary tumor-related complication rates in the nontargeted group were 6.9% (95% CI, 3.8%-11.9%) at 1 year and 8.2% (95% CI, 4.8%-13.8%) at 2 years, whereas the targeted group had complication rates of 11.5% (95% CI, 7.5%-16.6%) at 1 year and 16.7% (95% CI, 12.4%-23.3%) at 2 years. Multivariate analysis revealed that the targeted group was ≈2 times more likely to have primary tumor-related complications (subdistribution HR = 2.04 (95% CI, 1.12-4.01); p = 0.020). Median survival time was 12.0 months in the nontargeted group and 24.1 months in the targeted group (p < 0.001). LIMITATIONS This study was limited by the retrospective design. CONCLUSIONS Targeted therapy was associated with a significantly increased risk of primary tumor-related complications during chemotherapy. However, targeted therapy also improved overall survival, making it a tolerable therapy. See Video Abstract at http://links.lww.com/DCR/B536. COMPLICACIONES PRIMARIAS RELACIONADAS CON EL TUMOR ENTRE PACIENTES CON CNCER COLORRECTAL EN ESTADIO IV IRRESECABLE EN LA ERA DE LA TERAPIA DIRIGIDA UN ANLISIS DE REGRESIN DEL RIESGO COMPETITIVO ANTECEDENTES:No esta claro si la supervivencia prolongada con la quimioterapia actual utilizando agentes moleculares dirigidos ha cambiado la tasa de complicaciones relacionadas con el tumor primario en pacientes con cancer colorrectal en estadio IV irresecable.OBJETIVO:Este estudio tuvo como objetivo investigar la tasa de complicaciones relacionadas con el tumor primario entre los pacientes que reciben terapia dirigida, en comparacion con pacientes que reciben quimioterapia sin agentes moleculares dirigidos.DISENO:Revision retrospectiva de datos de una base de datos mantenida prospectivamente.ESCENARIO CLINICO:Centro oncologico de tercer nivel multidisciplinario de alto volumen en Japon.PACIENTES:352 pacientes consecutivos con cancer colorrectal en estadio IV irresecable que recibieron quimioterapia sistemica sin reseccion del tumor primario entre 2001 y 2015. Los pacientes se clasificaron en grupos dirigidos y no dirigidos segun el uso de agentes moleculares dirigidos.PRINCIPALES MEDIDAS DE VALORACION:Tasas de complicaciones debidas a tumores primarios.RESULTADOS:De los 352 pacientes, 159 se clasificaron en el grupo no dirigido y 193 pacientes en el grupo dirigido. El analisis univariado ajustado al riesgo competitivo revelo que las tasas de complicaciones primarias relacionadas con el tumor en el grupo no dirigido fueron del 6,9% (intervalo de confianza (IC) del 95%, 3,8 - 11,9%) al ano y del 8,2% (IC del 95%, 4,8%). - 13,8%) a los dos anos, mientras que el grupo dirigido tuvo tasas de complicaciones del 11,5% (IC del 95%, 7,5 - 16,6%) al ano y del 16,7% (IC del 95%, 12,4 - 23,3%) a los dos anos. El analisis multivariado revelo que el grupo dirigido tenia aproximadamente dos veces mas probabilidades de tener complicaciones relacionadas con el tumor primario (razon de riesgo de subdistribucion, 2,04; IC del 95%, 1,12 a 4,01; p = 0,020). La mediana del tiempo de supervivencia fue de 12,0 meses en el grupo no dirigido y de 24,1 meses en el grupo dirigido (p

BACKGROUND Previous data reveal that females account for a disproportionate majority of all patients diagnosed with diverticulitis. OBJECTIVE This study analyzed the variation in mortality from diverticular disease by sex. DESIGN This was a nationwide retrospective cohort study. SETTINGS Data were obtained from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research national registry. PATIENTS All citizens of the United States who died from an underlying cause of death of diverticulitis between January 1999 and December 2016 were included. MAIN OUTCOME MEASURES The primary outcome addressed was overall mortality rate of diverticulitis by sex. Secondary outcomes included pattern variances in demographics and secondary causes of death. RESULTS During the study period, 55,096 patients (0.12%) died with an underlying cause of death of diverticulitis from a total of 44,915,066 deaths. Compared with other causes, females were disproportionally more likely to die from diverticulitis than males (0.17% females vs 0.08% males; p < 0.001). Age-adjusted incidence of death was higher for females compared with males. Female patients were less likely to die within the hospital compared with males (OR = 0.72 (95% CI, 0.69-0.75); p < 0.001). Conversely, female patients were more likely to die either at nursing homes or hospice facilities (OR = 1.64 (95% CI, 1.55-1.73); p < 0.001). In addition, females with an underlying cause of death of diverticulitis were less likely to have a surgical complication as their secondary cause of death (OR = 0.72 (95% CI, 0.66-0.78); p < 0.001) but more likely to have nonsurgical complications related to diverticulitis such as sepsis (OR = 1.04 (95% CI, 1.01-1.05); p < 0.03), nonsurgical GI disorders such as obstruction (OR = 1.16 (95% CI, 1.09-1.24); p < 0.001), or chronic pelvic fistulizing disease (OR = 1.43 (95% CI, 1.23-1.66); p < 0.001). LIMITATIONS The study was limited by a lack of more specific clinical data. CONCLUSIONS Females have a higher incidence of diverticular disease mortality. Their deaths are more commonly secondary to nonsurgical infections, obstruction, or pelvic fistulae. Female patients represent a particularly vulnerable population that may benefit from more intensive diverticulitis evaluation. See Video Abstract at http://links.lww.com/DCR/B257. ?EXISTEN VARIACIONES EN LA MORTALIDAD POR ENFERMEDAD DIVERTICULAR POR GENERO?: Los datos anteriores revelan que las mujeres representan una mayoria desproporcionada de todos los pacientes diagnosticados con diverticulitis.Este estudio analizo la variacion en la mortalidad por enfermedad diverticular por genero.Estudio de cohorte retrospectivo a nivel nacional.Los datos se obtuvieron del registro nacional WONDER del Centro de Control de Enfermedades.Se incluyeron todos los ciudadanos de los Estados Unidos que murieron por una causa subyacente de muerte (UCOD por sus siglas en ingles) de diverticulitis del 1 / 1999-12 / 2016.El resultado primario abordado fue la tasa de mortalidad general de la diverticulitis por genero. Los resultados secundarios incluyeron variaciones de patrones en la demografia y causas secundarias de muerte.Falta de datos clinicos mas especificos.Durante el periodo de estudio, 55.096 pacientes (0,12%) murieron con un UCOD de diverticulitis de un total de 44.915.066 muertes. En comparacion con otras causas, las mujeres tenian una probabilidad desproporcionadamente mayor de morir de diverticulitis que los hombres (0.17% F vs. 0.08% M, p

A healthy 65-year-old woman presents to the emergency room with a 12-hour history of sudden onset severe lower abdominal pain. This is her first episode. She reports nausea, vomiting, and anorexia. Her last colonoscopy was at age 60, and was normal, except for diverticulosis of the sigmoid colon. Physical examination is significant for fever, tachycardia, and generalized abdominal pain with rebound tenderness. Pertinent laboratory findings include a leukocytosis and metabolic acidosis. A computed tomography (CT) scan is obtained and is consistent with freely perforated diverticulitis, including a thickened sigmoid colon, free fluid in the pelvis and free air noted near the diaphragm (Figure 1). The surgeon completes the patient evaluation, recommends initiation of IV fluid resuscitation and antibiotics, and plans to go immediately to the operating room for surgical resection.

BACKGROUND With increasing public reporting of outcomes and bundled payments, hospitals and providers are scrutinized for morbidity and mortality. The impact of patient transfer before colorectal surgery has not been well characterized in a risk-adjusted fashion. OBJECTIVE We hypothesized that hospital-to-hospital transfer would independently predict morbidity and mortality beyond traditional predictor variables. DESIGN We constructed a retrospective cohort of 158,446 patients who underwent colorectal surgery using the 2009-2013 American College of Surgeons National Surgical Quality Improvement Program database. SETTINGS The study was conducted at a tertiary care hospital. PATIENTS All of the patients who underwent colorectal surgery during the study period were included. Patients were excluded for unknown transfer status or transfer from a chronic care facility. MAIN OUTCOME MEASURES Baseline characteristics were compared by transfer status. Multivariate logistic regression was used to evaluate the impact of transfer on major complications and mortality. RESULTS A total of 7259 operations (4.6%) were performed after transfer. Transferred patients had higher rates of complications (p < 0.0001) with significant differences in unplanned endotracheal reintubation, bleeding, organ-space surgical site infection, wound dehiscence, postoperative sepsis, cardiac arrest requiring cardiopulmonary resuscitation, deep venous thrombosis, and myocardial infarction. Transferred patients also had longer hospital stays (9 vs 6 days; p < 0.0001) and a higher risk of death (13.2% vs 2.6%; p < 0.0001). On multivariate analysis, transferred patients had higher mortality rates despite risk adjustment (OR = 1.13 (95% CI, 1.02-1.25); p = 0.019) and were also more likely to have serious complications (OR = 1.12 (95% CI, 1.06-1.19); p < 0.001). LIMITATIONS We were unable to analyze outcomes beyond 30 days, and we did not have information on preoperative evaluation or the reason for patient transfer. CONCLUSIONS Hospital-to-hospital transfer independently contributed to patient morbidity and mortality in patients undergoing colorectal surgery. The impact of hospital transfer must be considered when evaluating surgeon and hospital performance, because the increased risk of serious complications or death is not fully accounted for by traditional methods.

Serious GI adverse events in the outpatient setting were examined for patients with a full spectrum of comorbid conditions and combinations of multiple comorbidities.This is a retrospective follow-up study.Ambulatory surgery and hospital discharge data sets from California, Florida, and New York, 2006 to 2009, were used.The outpatient colonoscopies of 4,234,084 adults aged 19 to 85 and over and payers were examined.Thirty-day hospitalizations due to colonic perforations and GI bleeding, measured as cumulative outcomes, were investigated.About 24% of patients undergoing outpatient colonoscopy had a comorbid condition. In comparison with patients without comorbidities, the adjusted risks of adverse events were greater for patients with several single comorbidities and combinations of multiple comorbid conditions. Elderly patients and those treated in freestanding Ambulatory Surgery Centers had higher odds of colonic perforations and GI bleeding than younger patients and patients treated in hospital outpatient departments.The study was constrained by limitations inherent in administrative data.Given the large number of outpatient colonoscopies performed in the United States, these procedures should be provided with caution to patients with chronic and multiple comorbidities and the elderly, because these populations are associated with higher rates of colonic perforations and GI bleeding.

BACKGROUND Colorectal endoscopic submucosal dissection has gained popularity as a minimally invasive technique for the treatment of colorectal neoplasms in many countries, including Japan. However, most previous studies of endoscopic submucosal dissection had relatively small sample sizes and only included patients treated at specialized centers. Associations between hospital volume and complication rates after colorectal endoscopic submucosal dissection are still poorly understood. OBJECTIVE Our aim was to clarify the relationships between hospital volume and the occurrence rates of bleeding and perforation after colorectal endoscopic submucosal dissection. DESIGN This was a retrospective cohort study. Hospital volume was defined as the number of colorectal endoscopic submucosal dissections performed at each hospital between April 2012 and March 2013 and was categorized into the following quartiles: 1) very low-volume (18 or less patients during the year), 2) low-volume (19-35 patients), 3) high-volume (36-58 patients), and 4) very high-volume (59 or more). SETTINGS This study was based on a national inpatient data from the Japanese Diagnosis Procedure Combination database. PATIENTS A total of 7567 patients with colorectal endoscopic submucosal dissection were included. MAIN OUTCOME MEASURES Severe postoperative bleeding requiring endoscopic hemostasis or blood transfusion within 1 week after endoscopic submucosal dissection and perforation requiring open surgery were the main outcomes measured. RESULTS Severe postoperative bleeding and perforation occurred in 331 (4.4%) and 13 patients (0.2%). Multivariable logistic regression analysis showed that the very high hospital volume group had a significantly lower proportion of severe postoperative bleeding than the very low hospital volume group (OR = 0.48 [95 % CI, 0.27-0.83]; p = 0.009). LIMITATIONS This study lacked some information on clinicopathologic features including en bloc resection, curative resection, and relapse. Individual endoscopist experience could not be analyzed. CONCLUSIONS The present study clearly showed a significant association between higher hospital volume and lower occurrence of severe postoperative bleeding.

BACKGROUND There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis. OBJECTIVE The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes. DESIGN This is a population-based retrospective cohort study using administrative discharge data. SETTING This study was conducted in Ontario, Canada. PATIENTS All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012). MAIN OUTCOME MEASURES Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics. RESULTS There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p

Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable.The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis.This study was conducted as a retrospective analysis of prospectively collected data.This study was conducted at a single tertiary care institution.Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria.Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed.Seventy-five patients required emergency surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized (Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2-82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3-90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0-10). The feasibility of the method was 96.0% (95% CI 90.4-100), and its applicability was 59.0% (95% CI 44.8-73.2). Median operative time was 89 minutes (range, 40-200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7-36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76-93).This was a single-institution retrospective study.The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis.

Laparoscopic lavage has shown promising results in nonfeculent perforated diverticulitis. It is an appealing strategy; it avoids the complications associated with resection. However, there has been some reluctance to widespread uptake because of the scarcity of large-scale studies.This study investigated national trends in management of perforated diverticulitis.This retrospective population study used an Irish national database to identify patients acutely admitted with diverticulitis, as defined by the International Classification of Diseases. Demographics, procedures, comorbidities, and outcomes were obtained for the years 1995 to 2008.The study was conducted in Ireland.Patients with International Classification of Diseases codes corresponding to diverticulitis who underwent operative intervention were included.The primary outcome was mortality, and secondary outcomes were length of stay and postoperative complications.Two thousand four hundred fifty-five patients underwent surgery for diverticulitis, of whom 427 underwent laparoscopic lavage. Patients selected for laparoscopic lavage had lower mortality (4.0% vs 10.4%, p0.001), complications (14.1% vs 25.0%, p0.001), and length of stay (10 days vs 20 days, p0.001) than those requiring laparotomy/resection. Patients older than 65 years were more likely to die (OR 4.1, p0.001), as were those with connective tissue disease (OR 7.3, p0.05) or chronic kidney disease (OR 8.0, p0.001).This retrospective study is limited by the quality of data obtained and is subject to selection bias. Furthermore, the lack of disease stratification means it is not possible to identify the extent of peritonitis; feculent peritonitis has worse outcomes and is not likely to be included in the lavage group.The number of patients selected for laparoscopic lavage in perforated diverticulitis is increasing, and the outcomes in this study are comparable to other reports. Those patients in whom laparoscopic lavage alone was suitable had lower mortality and morbidity than those in whom resection was considered necessary.

BACKGROUND: Many surgeons prefer immediate diversion in patients with endoscopically obstructed rectal cancer before starting neoadjuvant chemotherapy. OBJECTIVE: The aim of this study was to compare immediate neoadjuvant chemoradiotherapy with diversion for endoscopically obstructed rectal cancer. DESIGN: This study is a retrospective review of patients with rectal adenocarcinoma treated from January 2000 to December 2009. Demographic, tumor, treatment, and outcome data were obtained. Data were analyzed by the use of the Fisher exact probability test and the Student t test. SETTINGS: This study was conducted at a tertiary care hospital/referral center. PATIENTS: Included were patients with a rectal adenocarcinoma unable to be traversed endoscopically but without clinical evidence of obstruction before the initiation of neoadjuvant chemoradiotherapy. Patients with recurrent tumors or those who did not complete neoadjuvant chemoradiotherapy because of compliance were excluded. MAIN OUTCOME MEASURES: The primary outcomes measured were the interval from diagnosis to neoadjuvant chemoradiotherapy initiation and resection and the incidence of complete obstruction. RESULTS: Eighty-five patients with endoscopically obstructed rectal cancer were identified; 16 underwent immediate diversion before neoadjuvant chemoradiotherapy (diverted group) and 69 were treated with immediate neoadjuvant chemoradiotherapy. Five patients undergoing immediate neoadjuvant chemoradiotherapy presented with bloating and distension; 2 were treated with dietary modification, and 3 (4.3%) progressed to complete obstruction following completion of neoadjuvant chemoradiotherapy and required diversion. Both groups were similar in age, tumor height, and surgical margin status. Patients undergoing diversion required a significantly greater number of permanent stomas and were associated with a higher rate of radical pelvic surgery. There was a significant delay in the initiation of neoadjuvant chemoradiotherapy (p < 0.05) and proctectomy (p < 0.001) from the time of diagnosis in the diverted group compared with the immediate neoadjuvant chemoradiotherapy group. The tumors of patients undergoing diversions were more likely to be unresectable following neoadjuvant chemoradiotherapy. LIMITATIONS: This study was limited by its retrospective design and possible selection bias. CONCLUSIONS: Immediate diversion is unnecessary in endoscopically obstructed rectal cancer without clinical signs of obstruction. There appears to be a relationship between immediate diversion and delay in initiation of neoadjuvant chemoradiotherapy and proctectomy. We conclude that immediate neoadjuvant chemoradiotherapy in patients with endoscopically obstructed rectal cancer is safe and feasible.

It is routine practice to perform colonoscopy as a follow-up after an attack of diverticulitis, with the main aim to exclude any underlying malignancy.This study aimed to determine whether colonoscopy is necessary and what additional information is gained from this procedure.This is a study of a retrospective cohort.From January 2003 to June 2009, patients in whom left-sided diverticulitis was diagnosed on CT scan were matched with colonoscopy reports within 1 year from the date of CT by the use of radiology and endoscopy databases. Patients who had colonoscopy within 1 year before the CT scan were excluded. The Western Australian Cancer Registry was cross-referenced to identify patients who subsequently received diagnoses of cancers for whom colonoscopy reports were unavailable.The main outcome measures were the number of patients in whom colorectal cancers were diagnosed and other incidental findings, eg, polyps, colitis, and stricture.Left-sided diverticulitis was diagnosed in 1088 patients on CT scan, whereas follow-up colonoscopy reports were available for 319 patients. Eighty-two (26%) patients had incidental findings of polyps (9 polyps1 cm), and 9 patients (2.8%) received diagnoses of colorectal cancers on colonoscopy. After cross-referencing with the cancer registry, the overall prevalence of colorectal cancer among the cohort within 1 year of CT scan was 2.1% (23 cases). The odds of a diagnosis of colorectal cancer were 6.7 times (95% CI 2.4-18.7) in patients with an abscess reported on CT, 4 times (95% CI 1.1-14.9) in patients with local perforation, and 18 times (95% CI 5.1-63.7) in patients with fistula compared with patients with uncomplicated diverticulitis.This study was limited by the unavailability of data for private/interstate hospitals, and the relatively small number of cancer cases reduced the statistical power of the study.We recommend routine colonoscopy after an attack of presumed left-sided diverticulitis in patients who have not had recent colonic luminal evaluation. The rate of occult carcinoma is substantial in this patient population, in particular, when abscess, local perforation, and fistula are observed.

PURPOSE: Indications for operative intervention in the treatment of diverticulitis have become unclear. We hypothesized that surgical treatment for diverticulitis has decreased resulting in proportionately more complicated diverticulitis cases (free perforation and/or abscess). METHODS: We conducted a retrospective analysis of patients with diverticular disease in the Nationwide Inpatient Sample from 1991 through 2005. We used diagnostic codes to identify all patient discharges with diverticular disease and then determined the proportion of discharges with diverticulitis, perforated disease, diverticular abscess, and surgical treatment. RESULTS: During the study period, 685,390 diverticulitis discharges were recorded. The ratio of diverticulitis discharges increased from 5.1 cases per 1,000 inpatients in 1991 to 7.6 cases per 1,000 inpatients in 2005 (P < 0.0001). The proportion of patients who underwent colectomy for uncomplicated diverticulitis declined from 17.9% in 1991 to 13.7% in 2005 (P < 0.0.0001). During the same period, the proportion of free diverticular perforations as a fraction of all diverticulitis cases remained unchanged (1.5%). The proportion of diverticular abscess discharges as a fraction of all diverticulitis cases increased from 5.9% in 1991 to 9.6% in 2005 (P < 0.0001). Last, we noted a decrease in diverticular perforations and/or abscess treated with colectomy, 71.0% in 1991 to 55.5% in 2005 (P < 0.0001). CONCLUSIONS: Despite a significant decline in surgical treatment for diverticulitis, there has been no change in the proportion of patients discharged for free diverticular perforation. There was an increase in diverticular abscess discharges, but this finding was not associated with an increase in same stay surgical treatment.

This study was designed to compare postoperative outcomes of laparoscopic peritoneal lavage and open primary anastomosis with defunctioning stoma in the management of Hinchey 3 diverticulitis.From 1994 to 2006, 35 patients underwent laparoscopic peritoneal lavage for Hinchey 3 diverticulitis in three institutions. Data prospectively collected were compared with those of a retrospective series of 24 patients matched for Hinchey's classification and who underwent primary anastomosis with defunctioning stoma.There was no postoperative death. Postoperative morbidity was not different between the two groups. One patient in the laparoscopic peritoneal lavage group required a Hartmann's procedure because of a colonic fistula. One patient in the primary anastomosis with defunctioning stoma group underwent a reoperation for incisional dehiscence. The median hospital stay was lower in patients treated by laparoscopic peritoneal lavage (8 vs. 17 days, P0.0001). Twenty-five patients in the laparoscopic peritoneal lavage group underwent elective laparoscopic resection. One of them required conversion to laparotomy. All patients in the primary anastomosis with defunctioning stoma group have had their ileostomy closed. Cumulative surgical morbidity (16 vs. 37.5 percent, P = 0.0507) and hospital stay (14 vs. 23 days, P0.0001) were lower in the laparoscopic peritoneal lavage group.In the management of Hinchey 3 diverticulitis, laparoscopic peritoneal lavage does not result in excess morbidity or mortality, it reduces the length of hospital stay and avoids a stoma in most patients, and it is, therefore, a reasonable alternative to primary anastomosis with defunctioning stoma.

INTRODUCTION: Few population-based studies investigate perforated colorectal cancers. This study was designed to compare the epidemiologic characteristics of perforated CRC with those of uncomplicated CRC and to determine patterns of failure and prognosis in a well-defined French population. METHODS: Between 1976 and 2000, 89 patients who received an emergency operation caused by perforation and 5,462 who underwent elective surgery were registered in the digestive cancer registry of Burgundy (France). RESULTS: Perforated colorectal cancers represented 1.6 percent of registered colorectal cancers. The five-year cumulative local recurrence rate was higher for perforated (15.7 percent) than for uncomplicated cancers (7.8 percent; P = 0.021), as well as for the peritoneal carcinomatosis rate (respectively 13.8 and 6.3 percent; P = 0.036). In multivariate analysis, perforation was an independent risk factor for local recurrence or peritoneal carcinomatosis (odds ratio, 2.17; P = 0.004). Operative mortality was higher among perforated cancers (20.2 percent) than after elective surgery (6.6 percent, P < 0.001). The five-year relative survival rates were 37 percent after emergency surgery and 49.2 percent after elective surgery (P = 0.036). After adjustment for sex, stage, and age, perforation remained significantly associated with a poor prognosis. After exclusion of operative mortality, perforation was no more significant. CONCLUSIONS: Perforation is a rare complication of colorectal cancer. The prognosis is poor because of high operative mortality and high risk of local recurrence and peritoneal carcinomatosis.

PURPOSE: Body packers, i.e. individuals carrying illegal drug packages in their bodies, are usually managed medically. For the minority, surgical intervention is needed. METHODS: We review our experience to compare surgical and nonsurgical approaches for treating symptomatic body-packing patients. RESULTS: From April 2004 to March 2007, 45 patients were referred to our hospital. Nine of them underwent surgical intervention. The number of packets and total swallowed drugs were more among surgically-treated patients (P = 0.003, 0.004 respectively). The mean duration between drug swallowing and admission to the hospital was longer among surgically-treated patients (P = 0.001). Surgically-treated patients were more symptomatic. Resistant toxicity and symptomatic cocaine and heroin mixture packing were the most common indications for surgery. Surgery was usually performed without any complication. CONCLUSION: Surgical intervention is indicated for body packers with persistent nonresponsive toxicity, gastrointestinal obstruction or perforation, and symptomatic cocaine packers.

Endoscopic deployment of self-expanding metal stents offers an alternative to surgical intervention in rectocolonic obstructions. Reported clinical failures in the literature are all related to the site of stent placement. We report a case of serious intra-abdominal disease after technically and clinically successful stent deployment: a potentially dangerous situation of which the surgeon should be aware. A previously healthy 72-year-old female was referred to our department with symptoms of an obstructing colorectal tumor. Successful stent placement resulted in resolution of the obstructive condition. Three days after stent deployment, x-ray examinations revealed a small-bowel obstruction and emergency surgery was performed. Intraoperative findings demonstrated a segment of ileum fixated to the tumor in the small pelvis, resulting in the obstructive condition. Furthermore, a cecal perforation, probably caused by ischemic conditions developed before stent-decompression of the colon was revealed during the operation. The patient died in the postoperative course. We discuss the observation of patients treated with self-expanding metal stents based on the selection-strategy used to allocate patients to this specific treatment. We conclude that although a patient is eligible for treatment with self-expanding metal stents, large-bowel obstruction can be too "old" for stent-decompression, causing ischemic perforation of the colon. Furthermore, we underline the need to focus on the possibility of obstructions other than those being treated.

Sclerosing mesenteritis is a rare condition that is characterized by fibrosis affecting mainly small-bowel mesentery, which in extensive cases may mimic advanced intra-abdominal malignancy. Establishing the diagnosis in such cases is a clinical and histopathologic challenge. We report the successful management of a case of extensive sclerosing mesenteritis with occult ileal perforation, which was possibly the triggering cause. Severe complications occurred as a result of both the disease itself and its surgical treatment. Despite the complex course and life-threatening complications, a good prognosis can be expected. Although occasional recovery has been attributed to spontaneous regression and response to immunosuppressive therapy, a search for, and full eradication of, possible triggering focus is of paramount importance.

Clostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C. difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis. A population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fisher’s exact tests. Statistical significance was designated as P < 0.05. Sixty-seven patients (mean age, 69 (range, 40–86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure

Diverticulitis has been described as a more virulent disease in young patients, necessitating an aggressive surgical approach. We hypothesized that the subgroup of young patients who do not require surgery on their initial presentation are unlikely to present at a later date with perforation and do not always require prophylactic resection as commonly recommended. A retrospective chart review was conducted of all patients presenting to Fletcher Allen Health Care, the teaching hospital of the University of Vermont, from January 1, 1990 to June 30, 2001. Outcomes in patients aged 50 years or younger (Group 1) were compared with patients older than aged 50 years (Group 2) using a log-rank test. A total of 762 patients were admitted with sigmoid diverticulitis during the study period, 238 (31 percent) of whom underwent surgery. Two hundred fifty-nine patients (34 percent) were younger than aged 50 years (Group 1). The risk of requiring surgery on initial hospital presentation was similar between the two groups (24 vs. 22 percent, respectively; P = 0.8). However, Group 1 patients were more likely to be treated operatively at some point during the study period (40 vs. 26 percent; P = 0.001) because of an increase in elective resections. Of 196 patients in Group 1 who had an initial medically managed admission, only 1 presented at a later date with perforation (0.5 percent). The risk of subsequent diverticular perforation in medically managed young patients with sigmoid diverticulitis is very low. As such, the frequently espoused policy of routine surgery after a single attack of diverticulitis in young patients may not be warranted. A more selective approach seems to be safe.

Acute abdominal pain, especially in the presence of free intra-abdominal air, in a pregnant patient who has previously undergone ileal pouch-anal anastomosis may be a result of acute perforation of the pouch. The case of a 30-year-old multigravida with an uncomplicated pregnancy at 27 weeks gestation who was admitted to the perinatal ward for preterm labor is described. The patient's past medical history was significant for an ileal pouch-anal anastomosis for ulcerative colitis. Forty-eight hours after admission, she acutely developed generalized abdominal pain with associated dyspnea. A spiral CT of the chest to rule out pulmonary embolus revealed free intra-abdominal air. An emergency cesarean section was performed, which resulted in a viable female infant. The etiology for the free air was a perforation of the ileal pouch secondary to adhesions to the posterior part of the uterus. Perforation of the pouch has been reported secondary to a variety of factors. However, no cases of ileal pouch perforation in pregnancy have been reported. Adhesions that involve the pouch and an enlarged contracting uterus may result in perforation of the pouch. Awareness and knowledge of this potential complication may lead to earlier recognition and optimal management.

Stapled hemorrhoidectomy is considered to be safe and carries advantages. We describe a patient with rectal perforation and fecal peritonitis after stapled hemorrhoidectomy. We suggest that it should be performed by experienced colorectal surgeons who are familiar with the technique and aware of possible complications.

PURPOSE: This article reports an unusual presentation of bowel perforation. METHODS: We report the case of a 30-year-old HIV-infected male who suffered from an advanced state of CD4 cell depletion (29 CD4 cells per 106/l). Abdominal pain and diarrhea led to further examinations. RESULTS: Colonoscopy revealed a severe tuberculous ileocecal inflammation. Tuberculosis and HIV infection were treated. The patient’s response to antiretroviral therapy was excellent. After 11 months of potent antiretroviral treatment and 12 months of antituberculous therapy he suffered from acute abdominal pain with fever and ileus. Laparotomy revealed two intestinal perforations of the jejunum and inflammation of the whole ileocecal region. CONCLUSION: Immunopathologic reactions caused by immune restoration are novel presentations of highly active antiretroviral treatment as shown here. The presented patient is an unusual case with a very late onset of inflammatory response, which led to intestinal perforation.

BACKGROUND: Although many trials show some advantages of laparoscopic appendectomy over open appendectomy, the value of laparoscopic appendectomy is still controversial. Specifically the question of whether there are benefits of laparoscopic appendectomy over open appendectomy in complicated appendicitis remains to be answered. METHODS: Of 1,106 consecutive appendectomies (717 laparoscopic appendectomies, 330 open appendectomies, and 59 conversions) between 1989 and 1999, the results of 299 patients with complicated appendicitis (defined by perforation, abscess, or peritonitis) were analyzed retrospectively to compare the complications of laparoscopic appendectomy and conversion (intention-to-treat group) with those of open appendectomy. RESULTS: Complicated appendicitis (n=299) was treated by laparoscopic appendectomy in 171 patients, by open appendectomy in 82 patients, and by conversion in 46 patients. Laparoscopic appendectomy and conversion showed fewer abdominal wall complications than open appendectomy (13/217; 6 percentvs. 15/82; 18.3 percent;P

This study was designed to assess the medical and surgical treatment of colonoscopic perforations.A retrospective review of colonoscopic perforations from 1970 to 1999 was performed.In 30 years, 34,620 colonoscopies resulted in 31 (0.09 percent) perforations. Eighteen (58 percent) resulted from therapeutic colonoscopies, whereas 13 (42 percent) occurred after diagnostic colonoscopies. Sixteen perforations (52 percent) were identified during the procedure, 13 (42 percent) within 24 hours, and two (6 percent) within 48 hours. Twenty patients (65 percent) underwent surgical therapy, and 11 (35 percent) were treated medically with intestinal rest and intravenous antibiotics. In the medically treated group, one patient required rehospitalization for percutaneous drainage of an intra-abdominal abscess, and one patient died after requesting no further treatment because of an underlying terminal medical condition. Three patients failed medical treatment and required surgical intervention. One underwent repair with proximal diversion, whereas the remaining two received a colorrhaphy without resection or diversion. In the surgical treatment group, nine patients received colorrhaphy without diversion, seven underwent resection with primary anastomosis, and four had resection with diversion.Selected patients with colonoscopic perforation may be safely treated nonoperatively. Surgical treatment is reserved for patients with a large perforation or diffuse peritonitis.

PURPOSE: Our hypothesis was that in patients with perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV) a one-stage sigmoid colon resection is safe and cost effective when performed by an experienced colorectal surgeon. We evaluated outcome and cost of one-stagevs. two-stage sigmoid colon resection after diverticulitis perforation and peritonitis. METHODS: Patients undergoing emergency resection for perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV). Outcome, costs, and insurers reimbursement were compared between 13 patients undergoing sigmoid colon resection and primary anastomosis (Group A) and 42 patients undergoing sigmoid colon resection with Hartmann's procedure and secondary descendorectostomy (Group B). RESULTS: Group A patients were comparable to Group B patients in age, gender, preoperative risk and severity of peritonitis (Mannheim Peritonitis Index and C-reactive protein). Operating room time for sigmoid colon resection with primary anastomosis (3.3±1.2 hours) was identical to the time for sigmoid colon resection with colostomy (3.3±1 hour), and morbidity and mortality, intensive care unit, and in-hospital stay were not significantly different between the two groups. In Group B patients' intestinal continuity was restored 169±74 days after the primary resection in 32 of 42 patients only (78 percent). The second procedure took on average 1.4 hours longer than the first procedure. Patients in Group B received more antibiotics (2.2vs. 2) albeit for a shorter period of time (4.5vs. 5.7 days,P = not significant). Overall expenses for restoration of intestinal continuity were between 74 and 229 percent higher for Group B patients than for Group A patients. Reimbursement was 18,191±16,761 SFr (Group A) and 41,321±26,983 SFr (Group B) respectively. CONCLUSION: With meticulous surgical technique and extensive intraoperative lavage, perforated sigmoid colon diverticulitis with peritonitis can be treated by a one-stage sigmoid colon resection and anastomosis with a low mortality and morbidity. A one-stage procedure is considerably cheaper and patients are rehabilitated faster and to a higher percentage.

PURPOSE: Patients with colorectal polyps often display a large kink or distinct mucosal fold in the area where the polypectomy is to take place. As a result, there is a higher risk of perforation or partial ablation during an endoscopic polypectomy. Is it safer to perform an endoscopic polypectomy using the control and assistance of a laparoscope? Can a segment resection of the colon that would otherwise be necessary be avoided? METHODS: An endoscopic polypectomy using a laparoscope was conducted on six patients whose colorectal polyps were in an anatomically unfavorable location. The need for an open or laparoscopic segment resection or colotomy was indicated in all cases. The growth was located in the rectosigmoidal transition in five patients and in the region of the left flexure in one patient. We decided that an endoscopic polypectomy using the assistance of a laparoscope would be the most comfortable and technically elegant method, as well as easy. Except the well-known risks of laparoscopy and endoscopic polypectomy, no other risks have been seen in our patients. The affected area of the colon, the sigma, and the left flexure were mobilized and stretched as much as possible to enable a simultaneous and low-risk endoscopic polypectomy. In one case, we had to conduct a fractionated ablation because of a very wide-based finding. RESULTS: The operation averaged 57 minutes, and no operation-specific complications were observed. Postoperative recovery in the hospital was very short and averaged 2.5 days. The histopathologic findings were benign in all cases, but a serious dysplasia was diagnosed in one patient. CONCLUSIONS: The laparoscopic-assisted polypectomy is a safe method to remove even complicated polyps in anatomically unfavorable locations.

PURPOSE: Abnormalities of enteric collagen and smooth-muscle cell content have been documented in Crohn's disease. We studied the relationships among connective tissue changes, disease "type," and other disease features using immunohistochemistry and image analysis. METHODS: Twenty consecutive ileal resections for Crohn's disease and ten normal terminal ileal specimens were evaluated using conventional histopathologic examination. Monoclonal antibodies to smooth-muscle actin and Type III collagen fibers were used to determine the percentage area of the submucosa occupied by these constituents using image analysis. RESULTS: There were no significant differences in smooth-muscle content among stenosed, perforated, and ulcerated specimens. There was a significantly increased submucosal Type III collagen content in stenosed vs. other types. The only factor that correlated with smooth-muscle cell content was the amount of ulcer-associated cell lineage present. CONCLUSIONS: Increased deposition of Type III collagen fibers rather than smooth-muscle proliferation is associated with a stenotic phenotype. Loss of Type III collagen fibers may play a role in the development of perforating complications. We have found no evidence that smooth-muscle cells are the source of Type III collagen fiber production although there is evidence that ulcer-associated cell lineage may be related to the stimulus leading to submucosal neomuscularization.

PURPOSE: Stercoral perforation of the colon is reported to be a rare disease with poor prognosis. The aim of this study was to determine the frequency of stercoral perforation of the colon, to define diagnostic criteria for stercoral perforation of the colon, and to analyze the patient outcome in a university hospital gastrointestinal surgery unit. METHODS: From November 1993 until November 1998 all surgically treated patients with a colorectal disease were prospectively recorded in a computerized database. Diagnosis of stercoral perforation of the colon was made if 1) the colonic perforation was round or ovoid, exceeded 1 cm in diameter, and lay antimesenteric; 2) fecalomas were present within the colon, protruding through the perforation site or lying within the abdominal cavity; and 3) pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site were present microscopically. Any additional colon pathology led to exclusion from the diagnosis of stercoral perforation of the colon. Using the same criteria, 81 cases in the literature were found to qualify and were further analyzed. RESULTS: In a five-year period 1,295 patients underwent colorectal interventions through laparotomy. A total of 566 (44 percent) cases were emergencies, 220 (17 percent) of these caused by colonic perforation. Seven patients had stercoral perforation of the colon. The incidence of stercoral perforation of the colon was 0.5 percent of all surgical colorectal procedures through laparotomy, 1.2 percent of all emergency colorectal procedures, and 3.2 percent of all colonic perforations. The mean age of the patients was 59 (median, 64; range, 22–85) years. All perforations were situated in the left hemicolon or upper rectum. The round or ovoid perforation had a mean diameter of 3.6 cm. Fecalomas were present in all patients and protruded from the perforation site or were found within the free abdominal cavity in three of them. Generalized stercoral peritonitis was a constant finding. Using a colonic resection without immediate restoration of continuity, an extensive intraoperative lavage, and antibiotics, there was no in-hospital mortality. Analysis of the reports in the literature revealed additionally that 28 percent of patients with stercoral perforation of the colon have multiple stercoral ulcers in the colon and that substantial mortality is encountered if only minor surgical procedures of treatment are used. CONCLUSIONS: The incidence of stercoral perforation of the colon seemed to have been underestimated. The reason for this might be the lack of defined diagnostic criteria for this disease. Low mortality is obtained by early surgical eradication of the affected part of the colon, including all stercoral ulcers, and by aggressive therapy for peritonitis.

A technique for endoscopic removal of a chicken bone impacted in the sigmoid colon is described. Using biopsy forceps, a silk tie was looped around the impacted bone and then gently pulled caudally as it exited the anus. This disimpacted the bone. There were no complications.

PURPOSE: The aim of this study was to evaluate the use of laparostomy in the management of patients with severe intra-abdominal infection resulting from colorectal disease. METHODS: Seven patients, four with inflammatory bowel disease, two with colorectal carcinoma, and one with diverticular perforation, underwent laparostomy during a six-year period for postoperative, severe, intra-abdominal infection. RESULTS: The median age was 42 years, the mean Acute Physiology and Chronic Health Evaluation II score was 22.7, and the observed mortality was 28.6 percent (2/7 patients). In one patient the laparostomy was closed at 11 days; in all the others the wound was left to heal by granulation and contraction, and two of these later required reconstructive surgery. The median follow-up was three years and seven months. CONCLUSION: Laparostomy is an effective and practical method of managing patients with severe intra-abdominal infection as a result of colorectal disease.

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.

INTRODUCTION: The use of retrograde irrigation enemas is common in the treatment of chronic constipation, especially in the elderly. Perforation of the rectum and sigmoid colon caused by cleansing enemas, used by chronically constipated patients, has not been previously described. METHODS: We reviewed all patients with colorectal perforations caused by irrigation enemas admitted to our service in the three-year period between January 1995 and December 1997. RESULTS: Thirteen patients were treated by our surgical service because of perforations of the rectum and sigmoid colon related to a previous retrograde irrigation enema. Ten of these patients came from nursing homes, and the other three lived at home. The relevant information relating the enema administration to the patient's condition was given in only two of the ten patients referred to the emergency room by the institution's nursing or medical staff. In the other eight the information was vague and sometimes misleading. The diagnosis of colorectal performation was made by history, plain abdominal x-rays, and CT scan with or without meglumine diatrizoate enemas. Ten patients survived, regardless of age, previous diseases, or operative findings. In all of them, diagnosis was made within 36 hours from the perforation. The three deaths occurred in patients in whom the diagnosis was made late. CONCLUSIONS: Awareness of the possible injury from enemas administered to chronically constipated patients should be stressed. A high degree of suspicion by the attending physician is extremely important, because prompt diagnosis and early surgical treatment carries a relatively good prognosis.

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

The pathogenesis of free perforations occurring on the antimesenteric border of the pelvic colon during the course of diverticular disease has received little attention, with most being generically referred to as diverticular perforations. PURPOSE: This study was designed to identify the pathogenetic factors responsible for free perforations that may occur in the antimesenteric intertenial area during the course of diverticular disease. METHODS: Vascular alterations of the colonic wall associated with diverticula and open antimesenteric perforations were analyzed. RESULTS: Previous data on the site of diverticula formation and related intramural vascular alterations were confirmed. A subserosal vascular network developed in the antimesenteric intertenial area in instances of multiple bilateral diverticula. Free perforations occurred in the antimesenteric haustral area only with multiple bilateral diverticula. CONCLUSIONS: Alterations of the intramural vascular pattern secondary to the presence of multiple and bilateral diverticula may predispose the colonic wall to acute vascular injury. These changes may be enhanced by an episodic increase of intraluminal pressure and consequent distention of the colonic wall occurring in the course of diverticular disease.

PURPOSE: We report the case of a renal transplant recipient with rectal lymphoma manifested by sudden onset of abdominal pain from a perforated rectum who was treated successfully with prompt surgical resection and reduction of immunosuppressants. METHODS: An emergent anterior resection with Hartmann's procedure was done. Immunosuppressants were drastically reduced by discontinuation of cyclosporine. RESULTS: Pathologic examination showed diffusely infiltrated large-cell malignant lymphoma with an immunoblastic feature. The patient has been followed-up for four years, with no tumor recurrence or graft rejection. CONCLUSION: Rectal lymphoma, although rare, should be kept in the list of differential diagnoses for transplant recipients who exhibit lower gastrointestinal bleeding, intestinal obstruction, or abdominal pain.

PURPOSE: Perforations are rare but serious complications of colorectal cancer, with mortality rates of 30 to 40 percent. The aim of this retrospective study was to investigate possible indicators of prognosis and causes of death and to evaluate the risk of this complication by comparing results in perforated tumors with uncomplicated cancers or largebowel perforations attributable to benign causes. METHODS: Data of postoperative and long-term results of 35 patients with perforated colorectal cancers were compared in 868 patients with uncomplicated cancers and 130 patients with large-bowel perforations attributable to benign diseases. Postoperative survival in perforated cancers (mortality, 40 percent) was determined by degree of peritonitis, septic state, and tumor stages. RESULTS: Comparison of the three groups demonstrated advanced tumor stages, a higher rate of septic organ failures, and higher mortality rates for perforated cancers. Long-term survival depended on tumor stages but did not differ in perforated and uncomplicated cancers. CONCLUSIONS: A cumulative effect of malignancy and sepsis may be responsible for the high postoperative mortality in malignant perforation. Patients with perforated cancers represent the highest risk group in colonic perforation.

Since its introduction into clinical medicine, flexible fiberoptic colonoscopy has had a great impact on diagnosis and management of diseases of the colon and rectum. There are three mechanisms responsible for colonoscopic perforation: specifically, mechanical perforation directly from the colonoscope or a biopsy forceps, barotrauma from overzealous air insufflation, and, finally, perforations that occur during therapeutic procedures. Perforation of the colon, which requires surgical intervention more frequently than bleeding, occurs in less than 1 percent of patients undergoing diagnostic colonoscopy and may be seen in up to 3 percent of patients undergoing therapeutic procedures such as polyp removal, dilation of strictures, or laser ablative procedures. Management of colonic perforation secondary to colonoscopy remains a controversial issue in that it can be effectively managed by operative and nonoperative measures. If a perforation does occur, signs and symptoms that the patient will experience will be related to both the size and site of the perforation, adequacy of the bowel preparation, amount of peritoneal soilage, underlying colonic pathology (where a thin walled colon from colitis or ischemia, for example, may result in a larger perforation than a healthy colon), and, finally, overall clinical condition of the patient. Radiology often establishes diagnosis. Plain films of the abdomen and an upright chest x-ray may reveal extravasated air confined to the bowel wall, free intraperitoneal air, retroperitoneal air, subcutaneous emphysema, or even a pneumothorax. A localized perforation may demonstrate lack of pneumoperitoneum. Some surgeons recommend surgery for all colonoscopic perforations; however, there does appear to be a role for conservative management in a select group of patients such as those with silent asymptomatic perforations and those with localized peritonitis without signs of sepsis that continue to improve clinically with conservative management. Finally, conservative management works well in those patients with postpolypectomy coagulation syndrome. Surgery is most definitely indicated in the presence of a large perforation demonstrated either colonoscopically or radiographically and in the setting of generalized peritonitis or ongoing sepsis. The presence of concomitant pathology at time of colonoscopic perforation such as a large sessile polyp likely to be a carcinoma, unremitting colitis, or perforation proximal to a nearly obstructing distal colonic lesion may force immediate surgery. Finally, in the patient who deteriorates with conservative management, one should proceed to surgery.

BACKGROUND AND PURPOSE: In an ongoing randomized screening study of 68,306 patients for early detection of colorectal neoplasm, those with positive Hemoccult II® tests (Smith Kline Diagnostic, Sunnyvale, CA) were examined with a flexible sigmoidoscope (FS; 60 cm) and doublecontrast barium enema (DCE). The aim of this study was to determine the rate of complications to the work-up. METHODS: A total of 2,108 FS, 1,987 DCE, 190 colonoscopies, and 104 laparotomies were performed because of a positive Hemoccult®. RESULTS: One patient's large bowel was perforated during diagnostic endoscopy. Four perforations of the large bowel occurred during endoscopic polypectomy (0.8 percent of 513 adenomas removed), and one case of bleeding occurred 12 days after polypectomy. No complications occurred in connection with the 1,987 DCE. Five of 104 laparotomized patients underwent relaparotomy, 3 after removal of a colorectal carcinoma, and 2 of 4 patients with diverticular disease. All five patients healed but required a longer stay at the hospital. CONCLUSIONS: Complications occurred in 0.3 percent of the endoscopies, and 5 percent of patients had to undergo laparotomy again. No mortality occurred. If mortality attributable to colorectal cancer will decrease because of screening, we find the complication rate is acceptable.

PURPOSE: This is a study of the long-term course of surgically treated Crohn's disease designed to identify prognostic factors predictive of the time course and probability of surgical recurrence. PATIENTS AND METHODS: The study is based on the records of 101 patients admitted to our institution for surgical treatment of Crohn's disease from January 1, 1970, to December 31, 1985. Follow-up was complete in 97 (96 percent) and incomplete in 4 patients. Median follow-up from the date of first operation was 13.25 years. The cumulative probability of requiring surgical treatment for recurrent disease was calculated using the life table method and further analyzed with the log-rank test and Cox regression. RESULTS: The time to reoperation in this series was not significantly influenced by sex, age at onset of symptoms, age at diagnosis, age at first operation, anatomic location, and number of sites involved at the time of first operation. The only variable that had a statistically significant effect on the time to reoperation was characterization of disease at the time of operation as being perforating (P) opposed to nonperforating (NP). Median interval between the first and second intestinal operation was 1.7 years for the P group and 13 years for the NP group (Pvalue, 0.005),and the median time between any two operations undergone during the study period was 2 years for the P group and 9.9 years for the NP group (tP=0.0002).The risk of having to undergo reoperation for recurrence was greatest during the first two years after an operation, and this was mainly because of a short time to surgical recurrence in the P group of indications. Thereafter, the yearly hazard of requiring further surgery was maintained at approximately 5 percent. CONCLUSION: The cumulative probability of requiring a reoperation for patients undergoing surgery for the P type of Crohn's disease is significantly different from that of patients with NP indications. The risk of having to undergo further surgery is particularly high during the first two years following an operation for perforating disease. The concept of a relatively aggressive perforating type of Crohn's disease and a more indolent nonperforating type is confirmed by the results of this study.

PURPOSE: Adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDS) on the upper gastrointestinal (GI) tract and small intestine are well described. Evidence is also accumulating that implicate NSAIDS in inducing and exacerbating damage in the distal GI tract. The purpose of this review is to identify possible adverse effects of NSAIDS on the large intestine and increase the clinical awareness of these toxicologic effects. METHODS: A literature review identified the diversity of toxicologic effects induced by NSAIDS in the large intestine. The epidemiology, pathogenesis, and clinical implications of these adverse effects are described. RESULTS: NSAID use has been associated with colonic bleeding, iron deficiency anemia, strictures, ulcerations, perforations, diarrhea, and death. In addition, NSAIDS can exacerbate inflammatory bowel disease and ulcerative colitis. The prevalence of NSAID-induced large intestinal damage is unknown. Diagnosis can be made by colonoscopy and barium scans. Although the clinical presentation of NSAID-induced gastropathy and enteropathy, bleeding or perforation, may be more dramatic than colonopathy, the overall clinical significance of these adverse effects of NSAIDS on the large intestine has not been fully characterized. CONCLUSIONS: This review illustrates that NSAID-induced large bowel toxicity can cause significant morbidity in some patients, ranging from profuse diarrhea, chronic blood loss, and iron deficiency anemia to fatality. The pathogenesis is likely multifactorial and is thought to be related to inhibition of prostaglandin synthesis. Because NSAIDS are widely prescribed and some are available without a prescription, heightened awareness of these toxicologic manifestations throughout the GI tract may reduce morbidity.

PURPOSE: The operation of choice for acutely obstructed carcinoma of the left colon is controversial. The aim of the study was to evaluate the results of its management by emergency subtotal/total colectomy with immediate anastomosis without diversion. METHODS: An emergency subtotal/total colectomy was performed in 44 patients (mean age, 72.4 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers. RESULTS: Postoperative mortality was 6.8 percent. Two patients over 90 years of age died postoperatively as a result of cardiopulmunary complications. An 83-year-old female died as a result of an anastomotic dehiscence. Morbidity was 6.8 percent including one fistula which recovered without surgery. There were three synchronous colon cancers. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy. CONCLUSION: Emergency subtotal colectomy achieves in one stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serosal tears on the cecum, ensures restoration of gut contiguityviaa “safe” ileocolonic anastomosis, and removes occasional lesions proximal to the index cancer. It is a safe procedure given that operative mortality rates are as low as with elective surgery.

Intramural hematomas of the intestine most often occur in the setting of blunt abdominal trauma. However, spontaneous hematomas can occur secondary to either hematologic disorders, or use of anticoagulant therapy. There has been no clearly documented report of a spontaneous rectal hematoma. We describe the novel treatment of a patient with a spontaneous intramural hematoma of the rectum which presented as an abdominal catastrophe.

In a 10-year experience with 4,784 consecutive colonoscopic polypectomies, the need for operative intervention in just two of seven perforations indicates that patients with specially defined, limited perforations can usually be treated nonoperatively. This specific complication, which has been termed “mini-perforation,” is generally detected within 6–24 hours of polypectomy, and is characterized by local pain and tenderness, without signs of diffuse or spreading peritoneal irritation. Free intra-abdominal or retroperitoneal air on x-ray documents the actual perforation. Complete resolution of symptoms within 24–48 hours confirms the diagnosis of “mini-perforation. ” Success depends on good bowel preparation for colonoscopy, and early recognition of perforation, with institution of bowel rest and intravenous antibiotics. The “mini-perforation” spontaneously closes, probably by omental adherence. Frequent serial clinical examinations are mandatory so that frank perforation with advancing peritonitis will be promptly recognized and treated surgically. An understanding of the three levels of cautery injury to the colon wall—“serosal burn,” “mini-perforation, ” and “frank perforation” are essential in managing the complications of colonoscopic polypectomy.

Intestinal perforation due to cytomegalovirus (CMV) infection in patients with AIDS is the most common life-threatening condition requiring emergency celiotomy in these patients. The authors describe a patient with AIDS with intestinal perforation due to CMV infection, and review 14 additional cases reported in the English-language surgical literature. The diagnostic triad of pneumoperitoneum on x-ray, evidence or history of CMV infection, and AIDS occurred in 70 percent of patients. The most common site of intestinal perforation was the colon (53 percent), followed in frequency by the distal ileum (40 percent) and appendix (7 percent); perforation usually occurred between the distal ileum and splenic flexure of the colon. Colonoscopy, rather than sigmoidoscopy, is recommended as a screening examination in patients with AIDS suspected of having colonic ulceration due to CMV infection. Multiple biopsies of ulcerated tissue should be obtained. Gross and microscopic analyses of involved intestinal tissue reveal the characteristic findings of ulceration and CMV infection. Despite aggressive therapy, the operative mortality rate in patients with AIDS with intestinal perforation due to CMV infection was 54 percent and the overall mortality rate was 87 percent. Postoperative complications occurred in most patients and consisted mainly of systemic sepsis and pneumonia caused by Pneumocystis carinii infection. An increased awareness of this syndrome by physicians frequently called on to manage patients with AIDS is recommended.