Engaging clinicians in a quality improvement strategy for early-stage breast cancer treatment

Physicians are skeptical of quality improvement and obtaining their enthusiastic participation continues to be a challenge. We designed and initiated a clinician-driven quality improvement project to improve the provision of efficacious breast cancer treatments among women presenting to an academic medical center for their initial treatment of early-stage breast cancer. All 156 identified physicians agreed to participate in the project and provided access to their office records or specific medical information.

The history of Crohn's disease

Although it is likely that cases of what we know as granulomatous inflammatory bowel disease (Crohn's disease) may have been recorded as early as 1769, this illness is basically a disease of the 20th century. This historical review traces the development of our understanding of the disease and the evolution of its operative management.

The quality of early-stage breast cancer care

OBJECTIVE

To assess whether recent practice has improved, the authors created detailed, evidence-based guidelines and assessed the quality of early-stage breast cancer care at four hospitals in the metropolitan New York area.

SUMMARY BACKGROUND DATA

Adjuvant treatments for early-stage breast cancer have been shown to improve health and longevity. However, reports from the 1980s showed marked underuse of these therapies.

METHODS

All 723 women with early-stage breast cancer who had a definitive surgical procedure at four participating hospitals in the Mount Sinai-NYU Health System between April 1994 and August 1996 were included. Inpatient and outpatient records were abstracted.

RESULTS

Fifty-nine percent of women underwent breast-conserving surgery, of whom 81% received radiation therapy. Hospital-specific radiation therapy rates varied from 69% to 87%. Seventy-eight percent of women with stage 1B or greater cancer received systemic treatment, with hospital-specific rates varying from 71% to 86%. Between 18% and 33% of women who could have benefited from local or systemic adjuvant treatments did not receive them. The risk of not getting a beneficial adjuvant treatment varied more than twofold by the hospital where the breast cancer surgery was performed.

CONCLUSIONS

The hospital where breast cancer surgery is performed is associated with the likelihood that women receive effective local and systemic adjuvant treatments. Surgeons and members of hospital quality improvement programs should encourage multidisciplinary approaches to breast cancer care.

The history of surgery for Crohn's disease at The Mount Sinai Hospital

Almost certainly, the physicians and surgeons of The Mount Sinai Hospital cared for patients with inflammatory bowel disease prior to 1932. However, the accepted beginning of the surgery of granulomatous inflammatory bowel disease (IBD) and Crohn's disease (CD) at our institution occurred when the landmark paper by Crohn, Ginzburg, and Oppenheimer was published in 1932. As a major referral center for patients with both medical and surgical complications of IBD, the surgical service has had a long and abiding interest in the disease. This review highlights the major contributions of our staff to the management of this illness over the past 67 years. Despite major innovations in both medical and surgical management of patients with Crohn's disease, individuals suffering from this condition are ideally managed by a multidisciplinary team.

Intussusception in adults: institutional review

BACKGROUND

Intestinal intussusception in the adult is a rare entity that differs greatly in etiology from its pediatric counterpart. Controversy remains regarding the optimal management of this problem in the adult patient. The purpose of this study was to determine the cause(s) of intussusception and to determine the role of intestinal reduction in the management of intussusception in adults.

STUDY DESIGN

A retrospective review performed at The Mount Sinai Medical Center identified 27 patients, 16 years and older, with a diagnosis of intestinal intussusception. Data related to presentation, diagnosis, treatment, and pathology were analyzed.

RESULTS

There were 13 males and 14 females. The median age of the group was 52 years with a range of 16 to 90 years. Abdominal pain was the most common presenting complaint. A preoperative diagnosis was suspected in 11 of 27 patients (40%). There were 22 small bowel lesions and 5 colonic lesions. A pathologic cause was identified in 85% of patients with 8 of 22 (36%) small bowel and 4 of 5 (80%) of large bowel lesions being malignant. All small bowel cancers represented metastatic disease and all large bowel malignancies were primary adenocarcinomas. The median age of patients with malignant disease was 60 years; it was 44 years for those with benign disease. Operative treatment consisted of resection alone in 58% of patients and resection after reduction in 42%. Three patients were treated nonoperatively.

CONCLUSIONS

Our data support a selective approach to the operative treatment of intussusception in adults. Colonic lesions should not be reduced before resection because they most likely represent a primary adenocarcinoma. Small bowel intussusception should be reduced only in patients in whom a benign diagnosis has been made preoperatively or in patients in whom resection may result in short gut syndrome.

Complications requiring reoperation following pancreatectomy

CONCLUSIONS

In this series, the overall reoperative rate following pancreatic surgery is 9%. Complications following pancreatectomy that require reoperation fall into four categories: hemorrhage, infectious, delayed gastric emptying, and anastomotic leak. A delay in the management of these types of complications can be fatal.

BACKGROUND

Despite the improvement in the morbidity and mortality rates associated with pancreatic resection, complication still arise that require surgical intervention. This study reviews the pancreatic surgical experience at a major medical center to determine the overall reoperative complication rate.

STUDY DESIGN

From 1985 to 1995, 107 patients underwent pancreatic resection. There were 50 pancreaticoduodenectomies, 20 total pancreatectomies, and 37 distal pancreatectomies for 102 periampullary or pancreatic cancers and five for chronic pancreatitis. The operative mortality rate was 6.5% and the morbidity rate was 43%. Ten patients (9%) developed complications that required reoperation.

RESULTS

Re-exploration was performed in five patients for hemorrhage. Four patients had bleeding intra-abdominally and one had a suture line bleed. One patient developed a wound infection and fascial necrosis which necessitated reoperation. Three patients were explored for sepsis and one was found to have a pancreatic leak. One patient had persistent gastric outlet obstruction and he required conversion of the gastrojejunostomy to a Roux-en-y anastomosis. The mortality rate for re-exploration was 3/10 (30%).

Comparison of primary and reoperative surgery in patients with Crohns disease

OBJECTIVE

This study was performed to determine the clinical results of patients with Crohns disease who require surgical resection. The outcome of patients undergoing initial surgery was compared with those having reoperation.

METHODS

One hundred sixty-four patients undergoing intestinal resection for Crohns disease at The Mount Sinai Hospital from 1976 to 1989 were studied prospectively. The mean duration of follow-up was 72 months.

RESULTS

Ninety patients (55%) underwent initial intestinal resection whereas 74 patients (45%) underwent reoperation for recurrent disease. Patients undergoing reoperation were older (33.4 vs. 38.7 years), had longer durations of disease (8.7 vs. 15.2 years), had shorter resections (60 vs. 46 cm), and were more likely to require ileostomy. Forty-seven percent of the patients with multiple previous resections required an ileostomy. This group also received a mean of 2.3 U blood in the perioperative period and showed a trend to increased symptomatic recurrence (49% vs. 71% at 5 years).

CONCLUSIONS

Patients with Crohns disease undergoing first and second reoperation have outcomes similar to those in patients undergoing primary resection. Patients requiring multiple reoperations are more likely to require blood transfusions and permanent ileostomy and to show a greater trend to early symptomatic recurrence.

The nature and fate of categorical surgical residents who "drop out"

BACKGROUND

Little is known about the fate of categorical surgical residents who leave a program or if they differ from those who successfully complete a program.

METHODS

Matching into separate categorical and preliminary categories with elimination of the pyramid began in 1982. The files of all categorical residents matched between 1982 and 1995 were reviewed for demographic and scholastic data. Drop-outs were compared with the residents who completed the program and with the current house staff. All residents have been followed up to the present.

RESULTS

Between 1982 and 1996, 19 of 88 (22%) categorical residents who matched into the program left voluntarily. Eleven of 63 (17%) were male and 8 of 25 (32%) female (P = 0.12; test of proportions-Z = -1.55). They entered both surgical and nonsurgical fields. The major reasons for leaving were related to life-style issues. Their academic credentials are very similar to those who remained.

CONCLUSIONS

The drop-out rate of categorical surgical residents is significant, and replacing them is not easy. We have not identified any characteristics that might predict attrition.

Malignant small bowel neoplasms: histopathologic determinants of recurrence and survival

INTRODUCTION

Small bowel neoplasms account for only a small percentage of gastrointestinal tumors, but their prognosis is one of the worst.

PURPOSE

This study examines the histopathology, treatment, recurrence, and overall survival of a group of patients with primary small bowel tumors.

METHODS

From 1970 to 1991, a retrospective review identified 73 patients with primary small bowel tumors. Four histologic groups were identified: 1) group 1, adenocarcinoma, 29 patients; group 2, lymphoma, 18 patients; group 3, sarcoma, 8 patients; and group 4, carcinoid, 18 patients. There were 44 men and 29 women. The median age was 57 years (range, 26 to 90). Median follow-up was 15 months. Survival analysis was by the Mantel-Cox and Breslow methods.

RESULTS

The most common, by type, was group 1, duodenum; group 2, jejunum; group 3, jejunum; and group 4, ileum. The preoperative diagnosis was made in only 14 patients. The median survival for adenocarcinomas and lymphomas was 13 months, 18 months for sarcomas, and 36 months for carcinoids. Curative resection could be achieved in 48 (65%) of 73 patients, and the median survival was significantly longer for this group (26 months vs. 11 months, p < 0.05). Of the 48 curative resections, 20 patients (42%) recurred: group 1, 8/19 (42%); group 2, 4/12 (33%); group 3, 4/13 (31%); group 4, 4/4 (100%). The median time to recurrence was 17 months, and the median survival after recurrence was 20 months. Adjuvant chemotherapy-radiation therapy did not alter survival in any group.

CONCLUSIONS

The preoperative diagnosis of small bowel tumors rarely is made because symptoms are vague and nonspecific. Surgical resection for cure results in improved survival. Recurrence is common and survival after recurrence is poor. Other treatment methods have no role in the management of these patients.

Colorectal adenocarcinoma in Crohn's disease

OBJECTIVE

The authors' aim was to review the clinical features and estimate the long-term survival of patients with colorectal carcinoma complicating Crohn's disease.

SUMMARY BACKGROUND DATA

Recent studies have demonstrated a significantly increased risk of colorectal carcinoma in patients with Crohns disease.

METHODS

The authors reviewed retrospectively the medical records of 30 patients with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1989 in whom colorectal adenocarcinoma developed. All patients were operated on and follow-up was complete for all patients to 10 years after operation, to the time of death, or to the closing date of the study in December 1989.

RESULTS

The 30 patients in the series had 33 colorectal adenocarcinomas; three patients (10%) presented with two synchronous cancers. The patients were relatively young (mean age, 53 years) and had long-standing Crohn's disease (duration >20 years in 87%). The 5-year actuarial survival was 44% for the overall series: 100% for stage A, 86% for stage B, 60% for stage C. All five patients with excluded bowel tumor died of large bowel cancer within 2.4 years; by contrast, the actuarial 5-year survival for patients with in-continuity tumors was 56%.

CONCLUSIONS

The incidence, characteristics, and prognosis of colorectal carcinoma complicating Crohn's disease are similar to the features of cancer in ulcerative colitis, including young age, multiple neoplasms, long duration of disease, and greater than a 50% 5-year survival rate (without excluded loops). These observations suggest the advisability of surveillance programs for Crohn's disease of the colon similar to those for ulcerative colitis of comparable duration and extent.

A prospective, randomized trial of short versus long tubes in adhesive small-bowel obstruction

BACKGROUND

Many cases of acute adhesive small-bowel obstruction (SBO) can be successfully treated with intestinal tube decompression. There is considerable controversy, however, regarding whether a short nasogastric tube (NGT) or a long nasointestinal tube (LT) is the best method of intestinal tube decompression.

PATIENTS AND METHODS

A prospective, randomized trial was conducted to compare NGT and LT decompression with respect to the success of nonoperative treatment and morbidity of surgical intervention in 55 patients with acute adhesive SBO.

RESULTS

Twenty-eight patients were managed with NGT and 27 with LT. There were 44 cases of partial SBO (23 NGT, 21 LT) and 11 cases of complete SBO (5 NGT, 6 LT). Twenty-one patients ultimately required operation, including 13 managed with NGT (46%) and 8 with LT (30%) (P = 0.16). The mean period between admission and operation was 60 hours in the NGT group versus 65 hours in the LT group. At operation, 3 patients in the NGT group had ischemic bowel that required resection. Postoperative complications occurred in 23% of patients treated with NGT versus 38% of patients treated with LT (P = 0.89). Postoperative ileus averaged 6.1 days for NGT patients versus 4.6 days for LT patients (P = 0.44). There were no deaths.

CONCLUSIONS

Patients with adhesive SBO can safely be given a trial of tube decompression upon hospital admission. There was no advantage of one type of tube over the other in patients with adhesive SBO.

Jejunal obstruction as a late result of neonatal jejunal atresia

The authors report on two adults who had jejunal dilatation after having had resection for jejunal atresia in the neonatal period. Both patients presented 20 years after the initial procedure, with severe iron deficiency anemia, marked jejunal dilatation proximal to the old anastomotic site (which was not narrowed), and a bezoar within the dilated segment. Upper gastrointestinal series were used to evaluate both patients before surgical resection of the enlarged intestine, with subsequent correction of the anemia.

Prediction of early symptomatic recurrence after intestinal resection in Crohn's disease

OBJECTIVE

This study was performed to identify clinical criteria that may help recognize patients with Crohn's disease who are at high risk for early symptomatic postoperative recurrence.

SUMMARY BACKGROUND DATA

Currently, no reliable criteria are available to help recognize patients who are prone to experience early symptomatic recurrence.

METHODS

One hundred sixty-four patients undergoing intestinal resection for Crohn's disease at the Mount Sinai Hospital between 1976 and 1989 were studied prospectively. Patients with symptomatic recurrent disease within 36 months were defined as having an early recurrence.

RESULTS

Multivariate analysis revealed that the number of anastomoses was the most important prognostic indicator (p = 0.001), followed by inflammation at the resection margins (p < 0.05). Patients requiring an ileostomy had a significantly lower early recurrence rate than those having single or multiple anastomoses. There was no significant correlation between inflammation at the margins and early recurrence in patients requiring an ileostomy (n = 38), or a single anastomosis (n = 98). When the margins were examined in the 28 patients with 2 or more anastomoses, 10 of 11 patients (91%) with inflammation at either margin experienced early recurrence. Patients having multiple anastomoses with normal margins had the same recurrence rate as patients with single anastomosis (42%).

CONCLUSIONS

Patients with extensive Crohn's disease requiring multiple resections with anastomosis, especially when microscopic inflammation is present at the margins, are at very high risk for symptomatic early recurrence. Ileostomy seems to be associated with a significantly lower early recurrence potential than anastomosis. Further study is needed to determine whether avoidance of multiple anastomosis and adjuvant medical treatment can alter the course of the disease after intestinal resection in patients at high risk for early symptomatic recurrence.

Clinicopathologic correlations of ABO and Rhesus blood type in colorectal cancer

There is no specific association established between colorectal cancer and blood group type. In this study, the distribution of ABO and Rh blood groups was studied in 838 patients with colorectal cancer. There was no difference in distribution of ABO blood groups between patients who were Rh+ and Rh-. There was no difference in ABO blood group or Rh factor and tumor location. The highest A/O ratio was found in rectal cancer. Although there was no difference in stage distribution for each ABO blood group, there was a significant difference between the Rh+ and Rh- groups (P < 0.037). It is not clear, however, whether the prognosis is different between the two groups since there were more early tumors as well as incurable tumors in the Rh- group. All patients with synchronous cancer were Rh+. Further studies on blood group antigens are needed to elucidate the relationship between these antigens and colorectal cancer.

Histopathological determinants of survival in resected cases of pancreas cancer

We have examined the histopathological factors affecting the degree of local spread, regional lymph node (RLN) metastases, and overall survival (O.S.) in a group of 39 cases of resected carcinoma of the exocrine pancreas. Although the mean O.S. for the group was 14.3 months, resected patients without RLN involvement had a mean survival of 24 months. In contrast the mean O.S. rate was 8 months for patients with RLNs involved. Size, tumor location, and histological grade were compared to RLN involvement and O.S. The mean size of primary tumor did not differ significantly between patients with or without RLN's (r.1 versus 4.6 cms). However, 7 or 8 T1 tumors were < 4 cm and 35% of tumors < 4 cm were T1 lesions. In contrast, only 1 of 17 tumors (6%) > 4 cm was T1. Histological grade was correlated with nodal status and O.S. There was a significant difference between histological grade and the presence of metastatic lymph nodes (G1, 37% positive, G2-4.50% positive). Patients with well differentiated tumors had a mean survival of 21 months compared to a mean survival of 10 months for less differentiated tumors (p < 0.05). This difference was even more significant when stratified for nodal status. The patients with well differentiated tumors and no RLN involvement had a mean survival of 32.5 months compared to 8.6 months for well differentiated tumors with RLN involvement. In summary, we have shown that size, histological grade, and local spread predict for nodal status. However, specific patient subsets (G1, node negative) may exhibit an excellent survival when curative pancreas resection is successful.

Surgical treatment of tumors of the distal rectum with sphincter preservation

One hundred one patients with villous adenoma or invasive carcinoma of the distal rectum treated with local excision or coloanal anastomosis were studied. Twenty-three (45%) of the 51 patients with villous adenomas had transanal excision, another 23 (45%) had a posterior proctotomy, and five (10%) had a coloanal anastomosis. Only two patients with a villous adenoma developed a recurrence requiring repeat local excision. Fifteen (30%) of the 50 patients with invasive cancer were treated by transanal excision. All had tumors confined to the submucosa or superficial muscularis. Eighteen (85%) of 21 patients having posterior proctotomy also had tumors with similar depth of invasion. Six (43%) of the 14 patients having coloanal anastomosis had Dukes' B tumors, six (43%) were Dukes' C, and another two (14%) underwent palliative resection. The overall actuarial 5-year survival was 77%. Only four patients treated by transanal excision or posterior proctotomy died of metastatic disease. In the coloanal group, two of 12 patients undergoing curative resection died of recurrent cancer, and another has a pelvic recurrence. Villous adenomas of the distal rectum and selected carcinomas may be treated with local excision and coloanal anastomosis with preservation of sphincter function with good results.

Lymphoma in inflammatory bowel disease

Nine patients with lymphoma occurring in association with inflammatory bowel disease were admitted to The Mount Sinai Hospital between 1960 and 1983. Five (two men and three women) occurred among 1156 patients (0.43%) with ulcerative colitis (UC) and four (men), among 1480 patients (0.27%) with Crohn's disease (CD), a strong male preponderance in the latter group. In all four of the patients with CD and in four of the five patients with UC, the lymphomas were extraintestinal. The mean age of onset of UC in these patients was late (46 years, 19 years older than in our overall series), with lymphomas occurring a mean of only 12 years later. By contrast, patients with CD had bowel disease much younger (mean age, 26 years), and their lymphomas appeared after a longer disease duration (mean, 24 years). The risk factors for the one patient with colonic lymphoma were similar to those with colitis-associated colorectal carcinoma: extensive and long-standing colitis and relatively young age when malignant disease developed. Four of the patients with lymphoma had associated colonic carcinoma; in three of them, the carcinoma appeared within the first decade of colitis, an unusual occurrence. A second malignant lesion also occurred in three patients with UC.

Malignant melanoma in inflammatory bowel disease

Malignant melanoma occurred in 11 patients with inflammatory bowel disease (IBD). Six cases occurred in patients with ileocolitis, two in regional enteritis, one in granulomatous colitis, and two in patients with ulcerative colitis. The mean age at development of IBD was 24 yr, and at development of melanoma was 40 yr: the mean duration from onset of IBD to development of melanoma was thus 16 yr. All patients for whom complete information was available, except two, had received steroids and azulfidine for approximately a decade, as well as blood transfusions, usually multiple, and on repeated occasions. Six of the 11 patients had undergone one to seven prior operations (mean 3.5). All patients had wide radical excision of the melanoma, with or without concomitant or subsequent nodal dissection. Two patients (ages 25 and 36 yr) died rapidly from widely disseminated malignant melanoma. These cases may be coincidental, or else there may be an association between IBD and melanoma, related to immunosuppression either from the disease itself, from the medical and surgical therapy, and/or from x-ray exposure.

Adenocarcinoma of the small intestine in Crohn's disease

Nineteen patients admitted to The Mount Sinai Hospital with Crohn's disease between 1960 and 1989 had 20 adenocarcinomas of the small intestine. Sixteen patients had regional enteritis and three, ileocolitis. There were 15 males and four females. Carcinomas occurred in association with fistulas (four patients), fistulous tracts (three patients), excluded bowel (five patients/six cancers) and multiple strictures (three patients). None of the patients in our study had cancer develop in the first decade of Crohn's disease, and 11 had carcinoma in the third decade. As cancers occurred in three patients with multiple strictures admitted for strictureplasty, we recommend that all strictures be widely opened and carefully examined prior to strictureplasty, with frozen section biopsies of all suspicious areas. The possibility of small intestinal Crohn's carcinoma should be suspected in patients with long-standing disease, with or without excluded bowel, who present with sudden change in symptoms, especially after a lengthy quiescent period. Cancer should also be considered in patients in whom complete obstruction fails to resolve with adequate decompression and in those with multiple strictures.

Small bowel length in Crohn's disease

The length of the small intestine in patients with Crohn's disease who are referred for surgery has not been well studied. In this report, 25 patients with Crohn's disease who were being operated on for the first time had their small intestine measured at the time of surgery. The mean length of small intestine in this group was 501 cm, which was not different from a group of patients without Crohn's disease who were being operated on for other problems. In the group of patients with Crohn's disease, as well as the entire group, there was a correlation between increasing height and longer small bowel length. No other parameters investigated, including weight, surface area, age, sex, and duration of disease, correlated with bowel length. The results of this study are somewhat encouraging to patients with Crohn's disease, since these patients do not start off with a shortened bowel prior to surgery.

Malignant colorectal strictures in Crohn's disease

One hundred thirty-two of 980 patients (13.5%) with Crohn's disease (CD) involving the colon, admitted to The Mount Sinai Hospital between 1959 and 1985, developed 175 colonic strictures. Thirty-three patients developed more than one stricture. The frequency was twice as great in colitis (19%) as in ileocolitis (11%). Ten malignant strictures were identified in nine patients (three ileocolitis, six colitis). One of these patients had three strictures (two malignant, and one benign), and two had two strictures (one malignant and one benign). The frequency of cancer in patients with stricture (6.8%) was higher than in those without stricture (0.7%, six of 848, p less than 0.001). There were no differences in clinical symptoms between patients with benign and malignant stricture. Seventeen of 165 benign strictures (10.3%) were long, extending over more than one anatomical segment of colon, but all 10 malignant strictures were short (p less than 0.0001). The age at the diagnosis of stricture was higher in the nine patients with malignant stricture than in the 123 patients with benign stricture (mean age 57.2 vs. 41.4 yr, respectively, p less than 0.01). The proportion of strictures that were malignant increased with duration of disease from 3.3% with less than 20 yr of CD, to 11% with CD of 20 yr or more. All nine patients with malignant stricture were treated surgically, and four of the nine died of colon cancer during a mean follow-up of 4.3 yr. Prognosis was worse in six other nonstricture cancers in this series, with five colon cancer deaths during mean follow-up of 1.6 yr. In view of the high rate of malignancy, 6.8% in this series, colonoscopy with biopsy is essential in Crohn's disease patients with colonic strictures, and surgery must be considered when a stricture cannot be fully assessed during colonoscopy.

Colorectal cancer in ulcerative colitis. Influence of anatomical extent and age at onset on colitis-cancer interval

We have examined the age at onset of both ulcerative colitis and colitis-associated colorectal cancer in 100 patients seen at Mount Sinai Hospital between 1959 and 1988. There were 85 patients with extensive colitis and 15 with left sided colitis. There was a strong direct correlation between the age at onset of ulcerative colitis and age at diagnosis of cancer (p less than 0.0001); this correlation was found both in patients with extensive colitis (p less than 0.0001) and in those with left sided colitis (p less than 0.005). Patients with left sided colitis developed both their colitis and their cancers about a decade later than did those with extensive disease, but the mean duration of colitis before diagnosis of cancer was virtually the same (about 21 years) in both groups, irrespective of the age at onset of disease.

Synchronous carcinoma of the colon and rectum

Reports on the incidence of synchronous carcinoma of the colon and rectum have varied from 2 to 11 per cent. The variability is a result of a lack of uniformity in criteria of diagnosis, differences in the population studied and differences in time period used. In this study, we evaluated the incidence and distribution of synchronous lesions during a recent time period before the use of colonoscopy became widespread. We reviewed the records of all patients with newly diagnosed adenocarcinoma of the colon and rectum who were operated upon at our institution between 1976 and 1981. In a total group of 1,000 patients of which 52 per cent were men, there were 54 patients or 5.4 per cent who had synchronous carcinomas. The group of patients with synchronous carcinomas were older than the group with nonsynchronous carcinomas (72.4 versus 68.8 years). There was also a higher incidence of associated benign polyps in the group with synchronous carcinomas (70 versus 30 per cent for a nonsynchronous carcinomas). The anatomic distribution of carcinomas of the colon and rectum in the group with synchronous lesions (111 in total) revealed a higher percentage of carcinomas located on the right side (29.7 versus 22.5 per cent), although the difference did not reach statistical significance. Synchronous carcinomas were located in nonadjacent segments of the colon in 37 per cent. There was no difference in stage between the groups with and without synchronous carcinomas. The preoperative identification of synchronous lesions by either colonoscopy or barium enema is important for the proper treatment of patients with carcinoma of the colon and rectum. Failure to locate these tumors may lead to the demise of the patient.

Management of severe hemorrhage in ulcerative colitis

Twenty-five patients with ulcerative colitis were treated between 1959 and 1986 at the Mount Sinai Hospital, with severe gastrointestinal hemorrhage as their major complaint. Twenty-two patients required operation, while three patients were treated medically. Total proctocolectomy with ileostomy was carried out in 5 patients, and subtotal colectomy accompanied by mucous fistula (14), Hartmann closure (2), or ileosigmoidostomy (1) was performed in 17 patients. Eleven of the patients who underwent operation had emergency colectomies, while the remaining 11 had semielective procedures. Subtotal colectomy was performed in 10 of the 11 emergency cases. Indications for emergency surgery were massive hemorrhage alone in seven patients and severe hemorrhage complicated by toxic megacolon in four patients. One patient died postoperatively of a perforated duodenal ulcer following emergency subtotal colectomy. There were two late deaths from leukemia in one surgically treated patient and one medically treated patient at 9 and 18 months, respectively. All 4 of the 25 patients with remaining intact rectums were alive and well at 3- to 12-year follow-up. Subtotal colectomy can be undertaken in patients with massive hemorrhage from ulcerative colitis for whom subsequent ileoanal anastomosis is planned, provided that one recognizes and is prepared for the approximately 12% risk of continued rectal hemorrhage.

Gastric fistulas in Crohn's disease. Report of cases

Nine cases of gastric fistula occurring in patients with Crohn's disease were treated at The Mount Sinai Hospital over the past three decades. Six cases were found in a review of 1480 patients with Crohn's disease admitted between 1960 and 1983. Three others seen at this institution outside the time frame of the author's study have also been included. Among six new cases, five with cologastric fistula occurred among 907 patients with Crohn's disease involving the colon (0.6 percent), while only one with ileogastric fistula was encountered among 1211 patients with ileal disease (0.08 percent). Fistulas between the stomach and colon always originated in an area of colitis, usually passing from distal transverse colon to greater curvature, but occasionally from midtransverse colon to antrum. The only pathognomonic clinical features were feculent vomiting, eructations, or odor. Diagnosis usually was made by barium enema or, less frequently, by upper gastrointestinal series; rarely, the gastric fistula was found unexpectedly at surgery. The conventional and recommended therapy is colectomy with wedge excision of the stomach. Medical treatment with 6-mercaptopurine has been completely successful in one patient and intermittently successful in a second patient.

Operative ultrasound establishes resectability of metastases by major hepatic resection

In this study, the utility of intraoperative ultrasound in the surgical management of hepatic colorectal metastases requiring hepatic resection has been demonstrated. The intraoperative ultrasound technique has been described as a method to accurately monitor curative resection of large colorectal metastases requiring anatomical procedures such as right hepatic trisegmentectomy, bisegmentectomy, and hepatic lobectomy. Preoperative analysis of the patients reported utilizing either computed tomography, ultrasound, or magnetic resonance imaging demonstrated very well the extent of tumor but could not define a major anatomical resection along normal tissue planes. In the 3 patients demonstrated, intraoperative ultrasound was able to confirm a normal hepatic parenchymal dissection overlying the extensive tumors and enabled completion of the curative resections. Furthermore, we have described the intraoperative ultrasound criteria for assessment of resectability. These included a definition of the proximity of the major portal and hepatic venous structures, exclusion of simultaneous minimal metastatic disease in the remaining parenchyma, and the distinction between marginal resectability and resectability for cure along the proposed parenchymal dissection plane. We conclude that intraoperative ultrasound is important in the surgical management of metastatic colorectal cancer and can provide for a more complete clinical staging and appropriate selection of patients for curative major hepatic resection.

Clinical significance of rectal cancer in young patients

Thirty-nine patients (age 40 years and younger) with rectal cancer treated at the Mount Sinai Hospital between 1967 and 1985 were studied. Their mean age was 34 years (range, 21 to 40). A positive family history for colorectal cancer was found in six patients (15 percent). Fifty percent of patients under age 30 had metastatic disease at diagnosis. Twenty-seven patients (69 percent) had potentially curative resections. Of these, 17 (63 percent) had lymph-node metastasis. This rate is twice as high as in a group of 315 patients with rectal cancer over age 40 (31 percent). The overall five-year survival for young patients having curative resection was 53 percent. Noncolorectal cancer occurred in three patients in this series and six patients also had first-degree relatives with noncolorectal cancer. Young patients with rectal cancer appear to belong to a high-risk cancer group which often seems to have a genetic pattern of predisposition.

Gaucher disease: fate of the splenic remnant after partial splenectomy--a case of rapid enlargement

In Gaucher disease, partial splenectomy has been suggested for alleviating the complications of splenomegaly as well as for avoiding the immunologic compromise and potential acceleration of bony and hepatic involvement that may follow total splenic resection. However, the fate of the splenic remnant has been reported rarely. A subtotal splenectomy (85%) was performed in a 19-month-old girl with rapidly progressing Gaucher disease and massive splenomegaly (12% of body weight). Within 3 months, the splenic remnant had increased four-fold in size. Previous reports indicated only three Gaucher patients had significant enlargement of the splenic remnant after partial splenectomy. These findings indicate that splenomegaly may recur rapidly in Gaucher disease following partial splenectomy.

Short-term administration of SMS 201-995 in the management of an external pancreatic fistula

A patient presented to the hospital with a persistent high-output (greater than 250 ml/day) external pancreatic fistula after an enucleation of an insulinoma 5 months earlier. Daily treatment with SMS 201-995, a long-acting somatostatin analogue, for 8 days decreased fistulous output to less than 5 ml/day. The patient was discharged in stable condition 9 days after admission. All drainage ceased 2 days later, and the fistula has remained closed. SMS 201-995 has been shown to be effective in decreasing fistulous output of external pancreatic fistulas of various origins. With its few side effects and remarkable effectiveness, SMS 201-995 should be considered in the conservative management of any external pancreatic fistula.

Age and sex distribution of patients with colorectal cancer

A retrospective review of 922 colorectal cancer patients was undertaken to determine whether the nonuniform anatomic distribution of colorectal cancer was influenced by age and/or sex. The mean age of patients with right colon lesions (71.2 years) was significantly higher than for either patients with left colon lesions (68.2 years) or rectal lesions (65.6 years). Further analysis disclosed that patients with proximal tumors were older than patients with distal tumors primarily because of the later presentation of females with cecal or ascending colon cancers. Comparison of the anatomic distribution of tumors in patient groups above and below the age of 70 revealed that right colon cancers accounted for a greater percentage of colorectal tumors in the older patient group than in the younger patient group. These findings support the roles played by both age and sex in influencing colorectal cancer location. Furthermore, these data provide a plausible explanation for the increasing incidence of proximal colonic lesions.

Colorectal cancer location and synchronous adenomas

In this study, the relationship between the location of colorectal cancer and synchronous benign adenomas was assessed in 591 patients. Adenomas were found in 29.7% of all patients. Patients with cancer of the cecum, ascending colon, and hepatic flexure had the highest percentage of benign adenomas. Patients with right-sided cancer had adenomas in 47% of resected specimens, which percentage was significantly higher than that in the group of patients with left-sided cancer, who had adenomas in 22% of their specimens (p less than 0.001). Patients with cancer and synchronous adenomas were also older (70.2 vs 67.8, p less than 0.02) and more likely to be male (p less than 0.002) than patients with cancer and no adenomas. It is suggested that efforts be made to identify adenomas preoperatively in patients with colorectal cancer. In addition, since patients with cancer and associated adenomas are at increased risk of developing metachronous cancer, the group with right-sided cancer should be part of a particularly active surveillance program.

Production of ethane by rats treated with the colon carcinogen, 1,2-dimethylhydrazine

Ethane was exhaled by rats treated with the colon carcinogen, 1,2-dimethylhydrazine (DMH). At 1 hr, ethane production (mean +/- SD) was 0.2 +/- 0.2 nmol/kg (controls) and 5.2 +/- 1.3, 13.7 +/- 3.4, and 27.7 +/- 9.6, respectively, for DMH injections of 0.15 mmol/kg (20 mg/kg of the dihydrochloride salt), 0.45 mmol/kg, and 1.35 mmol/kg. Rates of ethane evolution tapered off after 2 hr, but persisted for up to 3 hr at the lower dose, and up to 5-6 hr at the higher dose. Although ethane is produced in vivo during lipid peroxidation, experiments with vitamin E, a potent lipid antioxidant, indicated that lipid peroxidation was unlikely to be the source of ethane in DMH-treated rats: pretreatment with vitamin E had no effect on ethane formation from DMH but did suppress ethane production from rats treated with carbon tetrachloride, an inducer of hepatic lipid peroxidation. When rats were injected with 1,2-diethylhydrazine in place of DMH, large amounts of ethane and ethylene were produced (9800 and 5600 nmol/kg/hr). The hydrocarbon gases exhaled by rats may arise from dimerization of methyl radicals (.CH3) generated during the metabolism of DMH, and from ethyl radicals (.CH2CH3) generated during the metabolism of 1,2-diethylhydrazine. Previously, it was shown that methane and ethane are formed from methyl radicals in vitro. Other investigators have observed formation of hydrocarbon gases during the in vitro metabolism of monoalkylhydrazines by microsomes, and ethyl radicals, derived from monoethylhydrazine, have been detected by electron spin-resonance spectroscopy. The results presented here suggest that in vivo metabolism of DMH may produce methyl radicals. Methyl radicals are capable of interacting with biomolecules. Their indiscriminate reaction with tissue constituents may be a contributory factor in DMH-induced carcinogenesis.

Perforating and non-perforating indications for repeated operations in Crohn's disease: evidence for two clinical forms

The surgical indications in 770 patients with Crohn's disease undergoing intestinal resection at The Mount Sinai Hospital from 1960-83 have been reviewed. Surgical indications were divided into two principal categories: 375 cases with perforating indications and 395 cases non-perforating. Among 292 patients who underwent second operations for recurrent Crohn's disease, the indications for second operation were closely dependent on the indication for primary resection. Second operations were undertaken for perforating indications much more often among cases where the initial indication had been perforating, than among those whose initial indications had been non-perforating (73% v 29%, p less than 0.00001). This trend to similarities in the indications which bring patients to surgery was maintained within each anatomical category of Crohn's disease and even between second and third operations (p less than 0.001). Operations for perforating indications were followed by reoperation approximately twice as fast as operations for non-perforating indications, whether going from first to second operation (perforating 4.7 v non-perforating 8.8 years, p less than 0.001), or from second to third (perforating 2.3 v non-perforating 5.2 years, p less than 0.005). Crohn's disease thus seems to occur in two different clinical patterns, independent of anatomic distribution. These are a relatively aggressive perforating type and a more indolent non-perforating type, which tend to retain their identities between repeated operations and to influence the speed with which reoperation occurs.

Correlation of presence of granulomas with clinical and immunologic variables in Crohn's disease

Approximately 50% of patients with Crohn's disease have epithelioid granulomas present in the diseased intestine. Some studies have associated the presence of granulomas with a good prognosis. In this prospective study, 44 patients with Crohn's disease requiring surgery were followed up for five years. Twenty-two patients (50%) had granulomas. Patients with granulomas were younger and had a shorter duration of disease. They also had more extensive disease and a greater degree of peripheral lymphopenia. Follow-up showed a trend toward greater recurrence rate in the patients with granulomas. It seems that patients with aggressive and extensive Crohn's disease are not protected from the development of symptomatic early recurrence by the presence of epithelioid granulomas.

Relationship of postoperative septic complications and blood transfusions in patients with Crohn's disease

We prospectively studied 169 patients with Crohn's disease to determine if postoperative infectious complications could be related to perioperative blood transfusions. Postoperative septic complications developed in 18 of the 69 patients who received more than 1 unit of blood (26 percent) compared with 8 of the 100 patients (8 percent) who received 1 unit of blood or no blood (p = 0.0014). Previous operation, low body weight, and having an ostomy were also related to septic complications. Patients receiving more than 1 unit of blood were significantly more likely to have low preoperative serum albumin levels, to have undergone abdominoperineal or small bowel resection, and to have an ostomy. Postoperative septic complications were significantly related to perioperative blood transfusions after controlling for these potential confounding factors independently by subgrouping and simultaneously by using multiple logistic regression. Blood transfusion may be a more significant factor in postoperative immune suppression and susceptibility to infection than previously recognized.

Free perforation due to cancer in Crohn's disease

Free perforation of cancer in Crohn's disease is exceedingly rare. Three cases were found among 1010 patients admitted to Mount Sinai Hospital between 1960 and 1980. Free perforation of cancer occurs late in the course of Crohn's disease between the second and third decades of disease, whereas spontaneous free perforation usually occurs within the first 5 years. Cancer-related perforation is associated with weight loss, mass and fistula, and carries a poor prognosis.

Emergency and elective surgery in patients over age 70

Emergency surgery in 100 patients over age 70 was associated with a 31 per cent morbidity and a 20 per cent mortality, significantly greater than the 6.8 per cent morbidity and 1.9 per cent mortality following elective procedures in the same age group (P less than .0005). Sixteen per cent (100 of 613) of all geriatric patients were operated on under emergent conditions and the postoperative hospitalization was often significantly prolonged when compared with similar elective operations (P less than .05). Emergency surgery was most commonly performed on the large bowel (25%), abdominal wall (17%), stomach (17%), biliary tract (11%), and small bowel (10%). Inguinal herniorraphy was the most frequently performed elective procedure (33%), followed by colon resection (25%), and cholecystectomy (12%). Fifty-nine per cent (23 of 39) of complications associated with urgent operation and 39 per cent (16 of 41) following elective surgery involved the cardiorespiratory systems and were frequently related to underlying diseases. Of the 20 patients who died in the intensive care unit of multisystem failure, 16 had undergone emergency procedures. Elective surgery in the elderly may be performed safely; however, emergency surgery entails a high risk to the patient and a high cost in hospital resources.

In vivo ethane production in vitamin E-deficient rats with DMH-induced colon cancer

The effect of both a vitamin E-deficient and a high polyunsaturated fat (PUFA) diet was tested on rats injected with the colon carcinogen 1,2-dimethylhydrazine (DMH). In vivo lipid peroxidation was monitored by measuring exhaled ethane from the animals. Higher mean weights were found in animals fed high PUFA and vitamin E-sufficient diets. There was no difference in ethane exhalation between DMH-treated and control animals regardless of diet. Mean ethane exhalation was highest in animals fed either vitamin E-deficient or high PUFA diets. There was no difference in tumor formation between the vitamin E-deficient and the vitamin E-sufficient groups. The high PUFA groups had more tumors than the low PUFA groups. Diet was shown to be the major factor affecting ethane exhalation. There was no evidence that vitamin E-deficiency promoted DMH-induced tumors or that DMH caused increased lipid peroxidation.

Effects of thymectomy in myasthenia gravis

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

Spontaneous free perforation and perforated abscess in 30 patients with Crohn's disease

Spontaneous free perforation is an uncommon event in the natural history of Crohn's disease. It occurred in 21 of 1415 patients (1.5%) admitted with Crohn's disease to The Mount Sinai Hospital between 1960 and 1983. The mean duration from onset of Crohn's disease to occurrence of perforation was 3.3 years. Ten patients had small bowel perforation, ten patients had large bowel perforation, and one patient had simultaneous perforation of both ileum and cecum. The incidence of perforation in disease segments of small bowel was 1.0% (jejunum 6.0%, ileum 0.7%), and in the colon, 1.3%. Besides the 21 patients with spontaneous free perforation, an additional nine patients had spontaneous free rupture of an abscess into the peritoneal cavity. The mean duration from onset of Crohn's disease to rupture of abscess was 8.5 years. All 30 patients had surgery within 24 hours of perforation or rupture. All 21 patients with spontaneous free perforations survived, as did all but one of the nine patients with perforated abscess. The cornerstone of the treatment of ileocolonic lesions perforating into the general peritoneal cavity is proximal diversion with delayed reconstruction of intestinal continuity whenever possible. With perforation of the small bowel, primary reanastomosis is possible in selected patients.

Preoperative localization and intraoperative glucose monitoring in the management of patients with pancreatic insulinoma

Whipples triad of hypoglycemic episodes associated with fasting blood sugar levels of less than 50 milligrams per 100 milliliters with relief of the symptoms by the administration of glucose intravenously leads to the clinical diagnosis of insulinoma. This diagnosis can be confirmed in a laboratory by the biochemical measurement of an inappropriate insulin elevation in response to fasting or the infusion of calcium or tolbutamide. Since more than 90 per cent of the tumors are benign, the potential for operative cure is high. Unfortunately, because of multicentricity (12 to 13 per cent) and the frequent small size of the tumor, some series report 15 to 30 per cent of inadequate or failed operations. Preoperative localization, in most centers, has depended upon sonography (positive in one of six patients in our series), computerized tomographic scanning (positive in one of five patients), celiac axis angiography (positive in six of 15 patients) and transportal venous sampling for insulin levels (positive in 11 of 13 patients in our series). We found that the combination of arteriography and transportal sampling has been the most accurate means of precise preoperative localization. In conjunction with preoperative localization, we have used intraoperative monitoring of glucose levels as a guide to the completeness of resection of insulin producing tumors. Sustained elevation of blood glucose levels has confirmed the adequacy of surgical intervention. Failure of the blood sugar level to increase had led to the successful search for additional tumors not identified preoperatively or to further resection. The combination of arteriography, transportal sampling and monitoring of glucose levels has led to the cure of 15 patients operated upon at the Mount Sinai Hospital from 1977 to 1984.

Immunoglobulins (Ig) in circulating immune complexes (CIC) in cancer and inflammatory bowel disease (IBD)

Chronically inflamed tissues and most malignancies have antigenic properties. Patients with long-standing inflammatory bowel disease (IBD) are prone to development of colorectal cancer, which is known to shed antigens in the bloodstream. In an effort to study immunological aspects of these diseases, sera from patients with IBD and colorectal cancer were evaluated for presence of circulating antigen-antibody immune complexes (CIC), and compared to normal controls. CIC were precipitated by polyethylene glycol (PEG) and found to be elevated in all diseased groups. Dissociation of CIC and quantification of their antibody component revealed significant elevation of each immunoglobulin in IBD and in patients with colorectal cancer versus control: IgG = 1.776 +/- 1.573 vs 0.734 +/- 0.618 (P less than 0.001); IgA = 0.368 +/- 0.452 vs 0.090 +/- 0.198 (P less than 0.001); IgM = 0.434 +/- 0.235 vs 0.080 +/- 0.285 (P less than 0.001) serum total Ig levels were consistently much higher than CIC Ig. No correlation was found between the individual serum Ig components and the precipitable complexes-bound Ig, suggesting a selective recognition of antigenic components in the CIC, rather than non-specific association and subsequent precipitation of serum Ig. CIC may represent an easily accessible source of immunological determinants for the study of malignant and chronic inflammatory diseases.

Local recurrence following surgical treatment of rectal cancer. Comparison of anterior and abdominoperineal resection

Three hundred twenty patients with rectal cancer were studied to determine factors that correlate with development of pelvic recurrence. The mean age was 65 years; anterior resection was performed in 202 (63 percent) and abdominoperineal resection in 118 (37 percent). Fifty-two patients (16 percent) developed pelvic recurrence. The mean duration of follow-up to development of pelvic recurrence was 22 months. Depth of tumor invasion, presence of lymph node metastasis, and colloid features were found to correlate with pelvic recurrence. The recurrence rate in patients having anterior resections was the same as that of patients undergoing abdominoperineal resections. Patients having anterior resection with distal margins of 1 cm or less had an extremely high recurrence rate (36 percent). Pelvic recurrent did not continue to improve when the distal margins were extended over 2 cm. Microscopic lateral tumor extension, which is not removed during operation, appears to be the major determinant of local recurrence in rectal cancer.