430 Background: The role of interval appendectomy after conservative management of perforated appendicitis remains controversial. Determining the etiology of perforated appendicitis is one reason to perform interval appendectomies. This study hypothesizes that there is an increased rate of neoplasm in patients undergoing interval appendectomy. Methods: This is a retrospective review of all patients over 18 years of age who underwent appendectomy for presumed appendicitis from January, 2006 to December, 2010 at a single, tertiary care institution. Demographic data, pathologic diagnosis, clinico-pathologic characteristics, interval resection rate, and complication data were collected and analyzed. Results: During the study period, 376 patients underwent appendectomy. The mean age was 41 years (range 18 to 94). Interval appendectomy was performed in 18 patients (5.0%) (age 28 to 74). Neoplasms were identified in 14 patients (3.7 %); 6 were found in patients who had undergone interval appendectomy (33%). Nine were mucinous tumors (69.2%), 5 of which were associated with interval appendectomies. Neoplasms were identified in 8.3% of patients between 35 and 55 years old. Conclusions: Mucinous neoplasms of the appendix were found in 33% of patients undergoing interval appendectomy. Interval appendectomies should be considered in all patients 35 years and older due to increased risk of appendiceal neoplasm. [Table: see text]
Cancer recurrence after complete resection of the primary tumor is dreaded by patients and physicians alike. Intensive follow-up after curative resection is considered a marker of good practice and frequently perceived as an antidote against recurrence by patients and families. In the United States, there is abiding faith in frequent imaging and blood tests as the best tools for the job. Thoughtful practice, clinical guidelines, retrospective reviews of prospectively gathered data, and clinical trials of follow-up have focused on the number, frequency, and sequence of modalities. A different perspective on which to predicate follow-up of patients with curatively treated cancer is to consider whether meaningful treatment options exist for recurrence. In cancers for which there are meaningful treatment options, it is reasonable to expect that moreintensive follow-up may improve survival. This commentary discusses this perspective in the context of the established literature in patients with colorectal and breast cancers, two cancers considered to have effective treatments for metastatic and recurrent disease as compared with non–small-cell lung cancer (NSCLC) and pancreatic cancer, which do not.
# Diagnostic delays: A problem for young women with breast cancer? {#article-title-2} Breast cancer in young women is aggressive. Delays in diagnosis and treatment may contribute to the worse outcomes observed in the treatment of breast cancer in young women. The purpose of this study is to
Objective The authors reviewed the results of endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography in a series of patients who underwent laparoscopic cholecystectomy. Summary Background Data The indications for preoperative and postoperative ERCP and intraoperative cholangiography as adjuncts to laparoscopic cholecystectomy are evolving. The debate regarding the use of selective or routine intraoperative cholangiography has intensified with the advent of laparoscopic cholecystectomy. Methods The authors reviewed the records of 343 consecutive patients who underwent laparoscopic cholecystectomy during a 1-year period. Historical, biochemical, and radiologic findings for the patients who underwent ERCP and intraoperative cholangiography were analyzed. Results Three hundred forty-three patients underwent laparoscopic cholecystectomy during the period reviewed. Preoperative ERCP was performed in 42 patients. Twenty-seven of these patients (64%) had common bile duct (CBD) stones, which were cleared with a sphincterotomy. Intraoperative cholangiography was performed for 101 patients (29%). Three cholangiograms had false-positive results (3%), leading to two CBD explorations, in which no CBD stones were found, and one normal ERCP. Six patients underwent postoperative ERCP, three for the removal of retained CBD stones (0.9%), all of which were cleared with a sphincterotomy. Fifteen patients had gallstone pancreatitis, six of whom had CBD stones (40%) that were cleared by ERCP. There were 33 complications (10%) and no CBD injuries. Conclusion The use of routine intraoperative cholangiography is discouraged in view of its low yield and the significant rate of false positive cholangiogram results.
ContextIn Ontario, we identified that few hospitals have developed multi-disciplinary case conferences or forums for discussion of patients with palliative care issues.ObjectiveWe describe the process of creating a province-wide standards document for palliative care multidisciplinary case conferences (pMCCs).MethodsA provincial survey and a multidisciplinary cancer conference symposium identified pMCCs as a priority. A literature search focusing on pMCCs and their implementation was completed as well as a current state assessment (survey and interviews) to understand challenges with existing pMCCs in Ontario. A working group was then assembled to draft a recommendation report that was finalized by an expert panel.ResultsA total of 22 articles were identified and 10 were used by the working group to create a framework for the pMCC guideline. The current state assessment identified substantial variability in pMCC structure and function. The expert panel made recommendations about meeting format (multidisciplinary discussion encouraged), frequency (at least every two weeks), type of cases to present, attendees (palliative care, nursing, primary care, social work, and community nursing), provider roles and responsibilities, and institutional requirements (pMCC coordinator, meeting room and videoconference capability). All patients (not just those with cancer) with palliative care needs were to be discussed at the pMCC, and pMCCs should serve as a crucial link between the hospital and community.ConclusionWe have described the process of creating the first pMCC guideline. A key component of this guideline is that pMCCs should serve as a link between the hospital and community.
592 Background: Patients who present with peritoneal carcinomatosis (PC) from colorectal cancer are considered terminal, with an expected median survival of 6-8 months. Therapy is often considered palliative and aggressive treatments are nihilistically ignored. This study investigates the clinicopathologic characteristics and clinical outcomes of CRC patients who present with PC. Methods: This is a retrospective review of all patients who presented with stage IV CRC from 1/2000-12/2008 to a single, tertiary care institution. Patients with PC at the time of presentation were identified. Demographic data, clinicopathologic characteristics, treatment and survival data were collected and analyzed. Results: 591 patients who presented with stage IV colorectal cancer were identified. Complete data was available on 216 patients. PC was confirmed in 106 patients (17.9%). PC was the only site of metastatic disease in 40 patients (6.7%). Compared with patients who did not have PC, patients with PC had significantly more right-sided primary tumors (28% vs 47%) and more mucinous tumors (7% vs 22%). The median overall survival for patients with isolated PC was 11.1 months as compared with 9.1 months for PC patients with extraperitoneal metastases (p = 0.5). Conclusions: Patients with right-sided and mucinous primary colon cancers are at increased risk of developing PC. Despite a lack of aggressive therapy, patients with isolated PC achieved a 11 month median survival. Treating PC patients and patients at-risk for PC with optimal oncologic therapy, including cytoreduction and intraperitoneal chemotherapy, will improve survival and should be considered early in the management of PC patients. No significant financial relationships to disclose.
