Perforations of the colon. Apropos of 74 cases

74 colic perforations were surgically handled between 1975 and 1988. Among the non-traumatic perforations, which represent 74% of this series, 39 cases (71%) complicated the course of acute diverticulitis, 9 cases (15%) were due to cancers and 7 cases (13%) were of miscellaneous origin. Traumatic perforations (26%) were iatrogenically induced in 84% (16 cases). In 78% the perforation was located in the sigmoid or recto-sigmoid. The treatment consisted in performing either a diverting colostomy (30 cases--40%) or a colic resection (44 cases--60%) with or without immediate anastomosis (respectively 10 cases--13.5% and 34 cases--46%). The overall mortality was 10.8%, which referred to etiology, turns to be 15% (3/19 cases) in traumatic perforations, 13% (5/39 cases) in diverticulitis and 0% in cancer. Related to treatment, mortality reached 23% for derivation and drainage procedure and 2% for resection. Post-operative complications were respectively 10% and 47%. Among post operative complications (22 cases--29%) 11 patients were reoperated on with an additional mortality of 18%. These results give strong evidence to the reliability and value of urgent colic resection in perforated colon and enhance the necessity of undelayed operation.     

Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management

OBJECTIVE: To review our experience with management of pancreaticobiliary and duodenal (PB/D) perforations after periampullary endoscopic interventions. Although pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures are rare, their management has not been well described. PATIENTS: Individuals who experienced pancreaticobiliary and duodenal perforations. MAIN OUTCOME MEASURES: Comorbidities, interventions performed, mechanism/site of perforation, management, and hospital morbidity/mortality. RESULTS: Seventy-five perforations (0.6%) occurred in 12,427 procedures; 20 perforations (27%) occurred during biliary stricture dilatation, 18 (24%) during diagnostic endoscopic retrograde cholangiopancreatography, and 15 (20%) during management of choledocholithiasis. Perforations were caused by guidewire insertion in 24 patients (32%), sphincterotomy in 11 (15%), passage of the endoscope in 8 (11%), or stent migration in 7 (9%) and were identified during the index procedure in 45 patients (60%). Delayed presentations included pain in 33 patients (44%), leukocytosis in 26 (35%), and/or fever in 13 (17%) and were diagnosed using computed tomography in 19 patients (25%) and abdominal radiography in 10 (13%); 9 cases (12%) were diagnosed more than 24 hours after the procedure. Indications for operative treatment were gaping duodenal perforations and perforations in patients with surgically altered anatomy. Indications for nonoperative management included contained bile duct perforations and focal duodenal perforations. Management was nonoperative in 53 patients (71%) and operative in 22 (29%). Patients with duodenal perforations, higher American Society of Anesthesia status (P<.01 each), and older age (mean +/- SEM, 65 +/- 4 vs 55 +/- 2 years; P = .02) were more likely to require operative management. Hospital stay (mean +/- SEM, 16 +/- 4 vs 4 +/- 1 days; P<.05) and mortality (13% vs 4%; P<.05) were greater in operative patients (P<.05 each). CONCLUSIONS: Most (70%) pancreaticobiliary and duodenal perforations secondary to periampullary endoscopic interventions can be managed nonoperatively. Most biliary perforations can be managed nonoperatively; a requirement for operative treatment increases the mortality rate.     

Surgery for Small Bowel Perforation in an Asian Population: Predictors of Morbidity and Mortality

Introduction

Peritonitis from small bowel perforation is associated with prohibitive morbidity and mortality rates. The aims of our study were to review our institution’s experience in the surgical management of small bowel perforation and to identify factors that could predict morbidity and mortality.

Methods

A retrospective review of all patients who underwent operative intervention for peritonitis from small bowel perforation from January 2003 to May 2008 was performed. Patients were identified from the hospital’s diagnostic index and operating records. The severity of abdominal sepsis for all patients was graded using the Mannheim peritonitis index (MPI). All the complications were graded according to the classification proposed by Clavien and group.

Results

Forty-seven patients, of median age 68 years (18–95 years), formed the study group. Pneumoperitoneum on chest radiographs was seen in only 11 (23.4%) patients. Foreign body ingestion (17.0%), adhesions (14.9%), and malignancy (12.8%) accounted for majority of the pathologies. There was one patient who had several small bowel perforations from Degos disease. Small bowel resection was performed in the majority of the patients (74.5%). The mortality rate in our series was 19.1%, while another 57.4% patients had perioperative complications. On univariate analysis, American Society of Anesthesiologists score?≥?3, MPI?>?26, hypotension, stoma creation, abnormal electrolyte level, and renal impairment were related to worse outcome, while the three independent variables that were related to worse outcome after multivariate analysis were MPI?>?26, hypotension, and abnormal serum potassium level.

Conclusion

Surgery for small bowel perforation is associated with significant morbidity and mortality rates. Patients with more severe peritonitis and physiological derangement were more likely to fare worse.     

Non-traumatic colic perforation in free peritoneum. Apropos of 61 cases

Sixty-one non-traumatic perforations in free peritoneum are reported. The principal aetiology is diverticulitis (35 cases) followed by cancer (22 cases). 18 derivations were carried out, 34 colectomies without anastomosis, 5 ideal colectomies and 4 diverticulectomies. Total mortality was 19.7-14% for diverticulitis, 22.2% for perforations at the cancer site, 50% from diastasic perforations. Stress is laid on the need to treat colic perforation by colectomy without anastomosis, confining derivation openeum. Sixty-one cases.     

Evaluation of prosthetic mesh closure in semiopen-abdomen patients

Abstract Background. To avoid the adverse consequences of abdominal compartment syndrome and to reduce the high mortality the celiotomy wound in patients with abdominal sepsis was closed without tension using prosthetic mesh. This produces a semiopen situation that permits staged reinterventions together with the functional reconstitution of the continuity of the abdominal wall. Material and Methods. Twenty-five patients with intra-abdominal sepsis of various causes were evaluated retrospectively to assess the results of semiopen management of the septic abdomen and reoperations on demand in severe peritonitis. All of the patients were in a state of neglected peritonitis, and had at least one failing organ system. The Mannheim Peritonitis Index (MPI) scoring system was used for stratification of abdominal sepsis. Results. The mean MPI score of 25 patients was 24, ranging 10 to 33. Eight (32%) patients were reexplored (MPI=21). There were overall 9 (36%) complications in patients with mean MPI score of 23. Six (24%) mesh-related complications (infection and enterocutaneous fistulas) developed (MPI=19). The mean MPI score of patients without complications was 24. Four (16%) patients died with index MPI score of 26 due to fulminant hepatitis, myocardial infarction, and multiple organ failure. The admission period averaged 63 days. Conclusions. In 25 critically ill patients with abdominal sepsis the mortality was lower than expected, relative to heterogeneous data from the literature; also, major complications occurred less frequently although the mean MPI score was high. The authors conclude that this approach is a reliable contribution to the complex treatment of these patients. Electronic Publication     

Severity Scoring Systems for Prognosis and Efficacy of Polymyxin B-Immobilized Fiber Treatment for Colonic Perforation

Purpose There is no established system for predicting prognosis and evaluating the efficacy of antiseptic treatments such as polymyxin B-immobilized fiber (PMX) according to the severity of peritonitis in patients with colonic perforation. We investigated the predictive value of various severity scoring systems for survival and for the efficacy of antiseptic treatments, to identify high-risk patients. Methods We reviewed 26 consecutive patients who underwent emergency operations between 1996 and 2003 for colorectal perforation not caused by trauma or iatrogenic disease. Several severity scores, i.e., Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Mannheim Peritonitis Index (MPI), and Multiple Organ Failure (MOF) were calculated and analyzed as predictive scoring systems for prognosis, survival and efficacy of PMX treatment. Results An APACHE II score of 19, a SOFA score of 8, an MPI score of 30, and an MOF score of 7 or more were significantly related to a poor prognosis. With or without PMX treatment, an APACHE II score of 15 or less, a SOFA score of 7 or less, an MPI score of 27 or less, and an MOF score of 7 or less were all related to a good prognosis. Conversely, all patients died when the severity scoring points were higher than 20 in APACHE II, higher than 12 in SOFA, and higher than 39 in MPI. When PMX treatment was given to patients with an intermediate score, no correlation between survival and its efficacy was found, except in the MOF scoring system. Conclusion These severity scoring systems can assist with the prediction of prognosis. They may also be useful for determining if PMX treatment would be unnecessary or ineffective in certain patients. However, the optimal application of PMX treatment in selected patients according to the severity scoring systems needs further investigation. This study was presented at the 104th Annual Congress of the Japan Surgical Society, Osaka, Japan, April 7–9, 2004.     

Severe secondary peritonitis following gastrointestinal tract perforation.

BACKGROUND AND AIMS: Early prognostic evaluation of abdominal sepsis is useful in the assessment of the severity of the disease and to select high-risk patients for early surgical reintervention. The aim of this study was to identify prognostic factors in a well-defined patient population most likely to benefit from early reoperation. MATERIAL AND METHODS: Retrospective analysis of 66 consecutive patients with secondary peritonitis caused by gastrointestinal tract perforation and requiring postoperative treatment in an intensive care unit was performed using univariate and multivariate analysis to identify risk factors for hospital mortality. RESULTS: The overall hospital mortality rate was 36 %. Significant risk factors in the univariate analysis included advanced age (p = 0.000), pre-existing illness (p = 0.000), chronic medication (p = 0.028), hospital transfer (p = 0.036), non-traumatic cause of perforation (p = 0.031), high Mannheim peritonitis index (MPI) score (p = 0.001), and high C-reactive protein (CRP) level in the early postoperative phase (p = 0.015). In a multivariate analysis, only advanced age (odds ratio 1.1008, p = 0.000) and high postoperative CRP level (odds ratio 1.0095, p = 0.008) were identified as independent prognostic factors for hospital mortality. CONCLUSION: In addition to factors associated with the physiological reserve of the patient, type of peritonitis and high MPI score, elevated CRP levels in the early postoperative phase in patients operated for severe secondary peritonitis have prognostic significance. However, before a properly designed randomized study on the value of planned relaparotomy in secondary peritonitis can be initiated, more reliable methods to identify high-risk patients need to be found.     

Value of dobutamine stress myocardial contrast perfusion echocardiography in patients with advanced liver disease.

Although dobutamine stress echocardiography has been used for the preoperative evaluation of patients with advanced liver disease (ALD), no data exist regarding the value of myocardial perfusion imaging (MPI) with real-time myocardial contrast echocardiography (RTMCE) in this patient population. We sought to determine the value of MPI during dobutamine stress RTMCE for predicting prognosis in patients with ALD. We examined both wall motion and MPI in 230 patients with ALD who underwent dobutamine stress RTMCE using intravenous commercially available contrast agents (Optison, GE-Amersham, Princeton, NJ; or Definity, Bristol-Myers Squibb Medical Imaging, North Billerica, MA). The prognostic value of clinical variables, including the Model for End-Stage Liver Disease (MELD) score, and echocardiographic data were examined using a Cox Hazard model. The primary endpoint was mortality of all causes. Among the 85 patients who underwent orthotopic liver transplantation, 4 had abnormal MPI and 81 had normal perfusion. The hospital mortality rate was 50% (2/4) in patients with abnormal MPI and 2% (2/81) in patients with normal MPI (P = 0.01). Among patients with abnormal MPI, 1 died from myocardial infarction in the first postoperative day and the second 1 from hemorrhagic shock. During a median follow-up of 15 months, 53 (23%) patients died. The independent predictors of death were an age of > or = 65 yr (RR = 2.2; 95% confidence interval (CI) = 1.1-4.4; P = 0.03), MELD score of > or = 25 (RR = 3.2; 95% CI = 1.8-5.5; P < 0.0001), and abnormal MPI (RR = 2.4; 95% CI = 1.1-5.2; P = 0.02). The 2-yr mortality was 24% for patients with normal MPI and 45% for those with inducible MPI abnormalities (P = 0.003). In conclusion, MPI obtained by RTMCE appears to be a useful tool in predicting mortality in patients with ALD. Further studies are required to verify its independent value.     

Perforation and rupture of the oesophagus: treatment and prognosis

AIM OF THE STUDY: To analyze treatment and prognosis of perforations and ruptures of the oesophagus. MATERIAL AND METHODS: This retrospective study included 40 patients (26 men and 14 women; mean age = 59 +/- 17 years) with a perforation or a rupture of the oesophagus. Seven perforations were cervical: iatrogenic (n = 6) or following ingestion of a foreign body (n = 1). Thirty-three perforations were thoracic: iatrogenic (n = 15), spontaneous rupture (n = 14), following ingestion of foreign body (n = 3) or traumatic (n = 1). All patients with cervical perforations were operated on (suture or drainage). One patient with thoracic perforation died before surgery, 2 underwent non-operative treatment and 30 were operated on. Twenty-eight underwent an oesophageal procedure: suture (n = 13), oesophagectomy (n = 11) or double exclusion (n = 4). Two uderwent surgery without oesophageal procedure (one pleural decortication, and one ablation of a pleural foreign body). RESULTS: The overall mortality rate was 17% (7/40), 21% (3/14) after spontaneous ruptures and 19% (4/21) after iatrogenic perforations (no death for other aetiologies). The mortality rate was 14% (1/7) for cervical lesions and 18% (6/33) for thoracic ones. It was 8% (1/13) after intrathoracic suture, 18% (2/11) after oesophagectomy and 50% (2/4) after double exclusion. CONCLUSION: Iatrogenic perforation and spontaneous rupture had the same poor prognosis. Non-surgical treatment is rarely indicated. oesophagectomy is a good option in case of non suturable oesophagus or delayed operation.     

Causes and treatment outcome of perforation peritonitis in north eastern Nigeria

Background: Intestinal perforations cause generalized peritonitis and overwhelming sepsis resulting in high morbidity and mortality. The purpose of the present study was to review the causes and treatment outcome of non-traumatic perforation peritonitis in a government referral hospital in north-eastern Nigeria. Patients and Methods: In a retrospective study, the clinical records of 153 patients with intraoperative diagnosis of non-traumatic perforation associated peritonitis managed in the Federal Medical Centre, Azare, Nigeria between June 2004 and May 2009 were reviewed. Results: One hundred and fifty-three patients, comprising 112 males (73.2%) and 41 females were operated for perforation peritonitis, including 31 (20.3%) children. The mean age was 21.88 years ± 14.51 (range 4–70). The mean time lapse between onset of symptoms and presentation to hospital was 5.4 ± 3.7 days (range 0.75–21). Forty-eight (31.4%) of the patients were operated within 24 h of presentation and 105 (68.3%) after 24 h. The main symptoms were abdominal pain in 150 (98.9%), fever in 108 (70.6%), and abdominal distention in 108 (70.6%). The main causes of perforation peritonitis were typhoid ileal perforation in 98 (64.0%), perforated peptic ulcer in 25 (16.3%) and perforated appendix in 22. Tuberculous ileal perforation was seen in one (0.6%) patient. Wound infection 39 (25.5%) and wound dehiscence 15 (9.8%), were the most common postoperative complications. Enterocutaneous fistula was seen in 21 (13.7%) of the patients and was associated with mortality in nine (42.8%) patients. The overall mortality rate was 26.1%, mainly from overwhelming sepsis and severe electrolyte derangement. Conclusion: The outcome of perforation peritonitis depended on the underlying cause, the duration of symptoms before treatment, and the general health of the patient. Typhoid ileal perforation is the most common cause of perforation peritonitis in our environment.     

三种术前营养评价方法对消化道恶性肿瘤患者术后并发症预测价值比较

目的比较欧洲营养风险筛查2002（NRS2002）、微型营养评价法（MNA）和主观全面评价法（SGA）3种术前营养评估方法对消化道恶性肿瘤患者术后并发症的预测价值。方法前瞻性入组2012年1月至2013年6月间南华大学附属第一医院普通外科和肿瘤外科收治的235例消化道恶性肿瘤患者,其中食管癌31例,胃癌82例,结直肠癌122例。分别采用NRS2002、MNA和SGA3种营养评价方法进行术前营养评估,分别比较这3种方法筛选出的存在营养不良（营养风险）患者与营养正常（无营养风险）患者术后并发症发生率。结果按照SGA评分,235例消化道恶性肿瘤患者术前重度营养不良、中度营养不良和无营养不良者术后并发症发生率分别为40．5％（17／42）、25．3％（22／87）和14．2％（15／106）,差异有统计学意义（P〈0．01）。按照iVINA评分,术前营养不良、潜在营养不良者和营养正常者术后并发症发生率分别为32．9％（23／70）、24．7％（18／73）和14．1％（13／92）,差异有统计学意义（P〈0．05）。按照NRS2002评分,术前存在营养风险和无营养风险者术后并发症发生率分别为27．6％（27／98）和19．7％（27／137）,差异无统计学意义（P〉0．05）。多因素逻辑回归分析证实,SGA评分和MNA评分均为术后并发症的独立预测因素（均P〈0．01）。SGA评分预测术后并发症的敏感性较MNA评分为高（90．7％比79．6％）,特异性相当（49．7％比50．8％）。结论SGA评分和MNA评分均能有效预测消化道恶性肿瘤患者术后并发症的发生情况;但相较之下,SGA的预测敏感性更高。术前制定营养支持方案时应重点参考SGA评估结果。     

Patients with pancreatic intraductal papillary mucinous neoplasms are at high risk of colorectal cancer development

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has been recognized recently and is being diagnosed with increasing frequency. Although IPMN has a more favorable prognosis than standard invasive ductal carcinoma (IDC) of the pancreas, recent reports suggest that IPMN patients are at higher risks of synchronous or metachronous primary cancers arising from various organs other than the pancreas (extrapancreatic cancers). METHODS: Records of 370 patients (69 of IPMN, 301 of IDC) who underwent surgery were used to assess risk factors for preoperative or postoperative extrapancreatic cancers. To calculate the rate of increase of extrapancreatic cancers in IPMN patients, compared with the normal population, the observed/expected ratio (O/E ratio) was calculated by using the Osaka Cancer Registry, one of the world largest cancer databases. RESULTS: The incidence of preoperative extrapancreatic cancers was significantly higher in IPMN patients (28%, 19 patients) than that in IDC (9%, 27 patients). In the IPMN-group, the preoperative incidence of colorectal cancer was 12% followed by gastric cancer at 4%. Logistic regression analysis showed IPMN and age to be independent risk factors for preoperative colorectal cancer development. The O/E ratio of preoperative colorectal cancer was significantly high in IPMN patients (5.37; 95% confidence interval, 2.31-10.58) but not in IDC patients (1.24; 95% confidence interval, 0.46-2.70). The incidence of postoperative extrapancreatic cancers also was significantly higher in IPMN patients (15%, 10 patients) than that in IDC (4%, 12 patients). During the postoperative follow-up, 4% of IPMN (3 patients) and 0.7% of IDC (2 patients) died from extrapancreatic cancers. CONCLUSIONS: Our results indicate that IPMN patients are at significantly higher risks of extrapancreatic cancers including colorectal cancer. A careful systemic checkup is therefore required for preoperative screening and postoperative follow-up for IPMN patients.     

Factors that predict morbidity and mortality in patients with perforated peptic ulcers.

BACKGROUND: The demographic changes of perforated peptic ulcer disease were assessed in a well-defined population in northern Finland. The high mortality from perforated peptic ulcer underlines the importance of risk stratification, and clinical variables and three scoring systems were therefore tested for their ability to predict the probability of morbidity and mortality. METHODS: Two hundred and eighty patients admitted to a university hospital with peptic ulcer perforation during the 22-year period 1979-2000 were identified using a computer database, and their clinical data were reviewed from the database and patient records. RESULTS: The annual operation rate for ulcer perforation has varied from 2.7/100,000 in 1979 to 6.2 in 1985 and 3.6 in 2000 without any significant changes during the examination period. More operations have been performed for duodenal (157) than for gastric (123) ulcer perforations, but their incidence rates were quite similar at the beginning and the end of the period. Of the clinical variables, two or more associated illnesses, duration of symptoms for more than 24 hours, the amount of abdominal liquid, and low albumin concentration predicted morbidity, while a long duration of symptoms and the amount of abdominal liquid were independent risk factors for mortality. The MPI score correctly predicted 96% of postoperative complications and all the three scores, i.e. the Boey score, the MPI score and the ASA score, were good predictors of mortality. CONCLUSION: The incidence of peptic ulcer perforation has not changed during the 22-year period in northern Finland. All the three scores, i.e. the Boey score, the MPI score and the ASA score, predict mortality in patients with peptic ulcer perforation and are suitable for risk stratification preoperatively in the surgical ward.     

POSSUM、P-POSSUM和Cr-POSSUM对结直肠癌患者住院期间病死率预测能力的比较

目的 比较并发症和病死率的生理和手术严重性评分(physiological and operative severity score for the enumeration of mortality and morbidity,POSSUM)、并发症和病死率的生理和手术严重性评分(Portsmouth POSSUM,P-POSSUM)、结直肠切除的并发症和病死率的生理和手术严重性评分(colorectal POSSUM,Cr-POSSUM)对结直肠癌患者住院期间病死率的预测能力.方法 调查北京大学第三医院1992-2005年903例结直肠癌外科手术切除的资料.903例中,结肠癌518例,直肠癌385例.用ROC曲线分析判断评分的判别能力,用Hosmer-Lemeshow检验判断评分的拟合优度,用不同危险因素群的O∶E值判断评分的预测能力.结果 903例患者住院期间的病死率为1.0%(9/903).POSSUM、P-POSSUM、Cr-POSSUM预测的病死率分别为5.6%、2.8%、4.8%,三种评分预测的病死率明显高于实际的病死率,O:E值分别为0.18、0.35、0.2.结论 POSSUM、P-POSSUM和Cr-POSSUM在结直肠癌手术中预测的病死率高于实际病死率.     

Peritonitis in diverticulitis: the Bern concept

INTRODUCTION: The colon is the most frequent origine for a diffuse peritonitis and diverticular perforation is again the most common source of a spontaneous secondary peritonitis. This paper first focuses on the treatment of peritonitis and secondly on the strategies of source control in peritonitis with special emphasis on the tactics (primary anastomosis vs. Hartmann procedure with colostomy) for surgical source control. PATIENT AND METHODS: Prospective analysis of 404 patients suffering from peritonitis (11/93-2/98), treated with an uniform treatment concept including early operation, source control and extensive intraoperative lavage (20 to 30 liters) as a standard procedure. Other treatment measures were added in special indications "on demand" only. Peritonitis was graded with the Mannheim Peritonitis Index (MPI). Tactics of source control in peritonitis due to diverticulitis were performed according to "general condition" respectively the MPI of the patient. RESULTS: The 404 patients averaged a MPI of 19 (0-35) in "local" peritonitis and a MPI of 26 (11-43) in "diffuse" peritonitis. The colon as a source of peritonitis resulted in MPI of 16 (0-33) in the case of "local" respectively 27 (11-43) in "diffuse" peritonitis. From 181 patients suffering from diverticulitis 144 needed an operation and in 78 (54%) peritonitis was present. Fourty-six percent (36) of the patients suffered from "local", 54% (42) from "diffuse" peritonitis. Resection with primary anastomosis was performed in 26% (20/78) whereas in 74% (58/78) of the patients a Hartmann procedure with colostomy was performed. The correlating MPI was 16 (0-28) vs. 23 (16-27) respectively. The analysis of complications and mortality based on the MPI showed a decent discrimination potential for primary anastomosis vs Hartmann procedure: morbidity 35% vs. 41%; reoperation 5% vs. 5%; mortality 0% vs. 14%. CONCLUSION: In case of peritonitis due to diverticulitis the treatment of peritonitis comes first. Thanks to advances in intensive care and improved anti-inflammatory care, a more conservative surgical concept nowadays is accepted. In the case of diverticulitis the MPI is helpful to choose between primary anastomosis vs. Hartmann procedure with colostomy as source control. The MPI includes the "general condition" of the patient into the tactical decision how to attain source control.     

Local Involvement of the Urinary Bladder in Primary Colorectal Cancer: Outcome with En Bloc Resection

Background Colorectal cancers that adhere to the urinary bladder require en bloc partial or total cystectomy to achieve negative tumor margins. Methods This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer. Results Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54%, with a mean follow-up of 7.6 (range 5–12) years. Five-year survival for margin negative patients was 72% (26/36) and 27% (4/15) for node negative and positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in five, with ten patients requiring urinary diversion. Conclusions En bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node negative tumors is good. Bladder reconstruction is achievable in most patients.     

结直肠癌评分系统对术后病死率预测能力的研究

目的 评估大不列颠和爱尔兰结直肠协会(Association of Coloproctology of Great Britain and Ireland,ACPGBI)评分系统在国内的临床应用价值.方法 回顾性分析1992-2005年904例结直肠癌患者的临床资料,其中结肠癌525例,直肠癌379例.按照手术时机、疾病种类将病例分为急诊手术组、非急诊手术组;结直肠专科医师手术组、其他外科医师手术组;结肠癌组、直肠癌组.分别计算各组预测病死率,根据ACPGBI评分计算预测结果,并与实际结果进行比较.数据采用t检验、x2检验、受试者工作特征曲线-ROC(receiver operator characteristic curve)、拟合优度(goodness-of-fit)检验、不同危险因素群的O:E比,并分组进行评判.结果 术后30天内实际病死率1.0%(9/904).ACPGBI预测病死率为8.3%(75/904).对于急诊手术组、非急诊手术组、专科医生手术组、非专科医生手术组、结肠癌组和直肠癌组,预测值均偏高.病死率预测高的组,实际病死率也高.结论 ACPGBI预测病死率高于结直肠癌手术后实际病死率.ACPGBI预测结直肠癌手术后病死率的趋势,有一定临床意义.     

Local Involvement of the Urinary Bladder in Primary Colorectal Cancer: Outcome with En-Bloc Resection

Background Colorectal cancers that adhere to the urinary bladder require en-bloc partial or total cystectomy to achieve negative tumor margins. Methods This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer. Results Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54% with a mean follow-up of 7.6 years (range 5–12). Five-year survival for margin-negative patients was 72% (26/36) and 27% (4/15) for node-negative and -positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in 5, with 10 patients requiring urinary diversion. Conclusions En-bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node-negative tumors is good. Bladder reconstruction is achievable in most patients.     

The Association Française de Chirurgie (AFC) colorectal index: a reliable preoperative prognostic index in colorectal surgery

INTRODUCTION: Evaluation of outcome after colorectal surgery is always necessary. A new index which permits to appreciate preoperatively postoperative mortality after colorectal resection in colorectal cancer (CRC) and in diverticular disease has been published (i.e., Association Fran?aise de Chirurgie, AFC colorectal index). PATIENTS AND METHODS: From November 2002 to July 2004, in-hospital mortality was analysed on 253 patients who underwent colic resection (N = 220, 87%) or rectal resection, with anastomosis (N = 175, 70%). Mortality was analysed according to emergency resection, neurological co morbidity, lost of weight more than 10% of weight, age older than 70 years. RESULTS: Mean age of patients was 63 +/- 18 years (17-92) (45% older than 70 years), 26% of patients were ASA >or= III, 35% underwent surgery in emergency, and 12% underwent laparoscopic surgery. One hundred and fifteen (45%) patients underwent surgery for CRC and 50 (20%), for diverticular disease and 11 patients underwent surgery for ischemic colitis. Overall mortality rate was 10% (N = 26), it was 19% in emergency surgery versus 5% after elective surgery. Global morbidity was 38%, percentage of anastomotic leak was 8% (N = 14/175), reoperation was necessary in 14%. The mean length of stay was 13 +/- 8 days. Ten percent of patients necessitated unplanned readmission. After surgery for CCR or diverticular disease. -i) overall mortality was 9% - ii) among patients who had 0, 1, 2, or 3 predictive risk factors of mortality; mortality was 0% , 5% 15% and 33%. After surgery for other aetiology than CCR or diverticular disease, among patients who had 0, 1, 2, or 3 predictive risk factors of mortality; mortality was 0%, 12% 36% and 25%. CONCLUSIONS: These results showed the reproducibility of the AFC colorectal index and its potential application in all aetiologies after colorectal surgery.     

Operative and nonoperative management of esophageal perforations.

During a 21-year period, 72 patients were treated for esophageal perforations; the diagnosis was made only at postmortem examination in 13 other patients. Fifty-eight of 85 patients (68%) sustained iatrogenic perforations, 11 patients (13%) had "spontaneous" perforation, nine patients (11%) had foreign body related perforation, and seven patients (8%) had perforation caused by external trauma. Eleven cervical perforations, contained between the cervical paravertebral structures, plus eight thoracic perforations, contained in the mediastinum, were treated with antibiotics, intravenous hydration, and nasogastric drainage. The mortality rate after this nonoperative approach was 16% (3/19 patients). Indications for operative treatment in 53 patients were hydropneumothorax with mediastinal emphysema, sepsis, shock and respiratory failure. The operative mortality rate in these instances was 17% (9/53 patients). Six of the nine patients who died had been operated on more than 24 hours after the onset of symptoms. For cervical perforations the best results were obtained by drainage plus repair of the perforation (mortality rate: 0%; 0/10 patients) and for thoracic perforations by suturing supported by a pedicled pleural flap (mortality rate: 11%; 1/9 patients). Simple drainage of thoracic perforation was followed by a mortality rate of 43% (3/7 patients).