Notes: Abstract  Hereditary colorectal cancer results from specific genetic alterations. The causative genes for familial adenomatous polyposis, juvenile polyposis, Peutz-Jeghers syndrome, and hereditary nonpolyposis colorectal cancer have been cloned and characterized within the past decade. Genetic testing has therefore become more widely used to confirm the clinical diagnosis of each of those syndromes, to provide adequate surveillance, to allow screening of at-risk family members, and to help the surgeon in surgical decision making. The aim of this review is to analyze the importance of genetic testing in view of the clinical and surgical management of those gene-carriers individuals, and to discuss how should the surgeon integrate genetic testing in the evaluation of such patients.

Notes: Abstract. Background: Gastro-duodenal polyps develop in up to 90% of familial adenomatous polyposis (FAP) patients and periampullary carcinoma is one of the most common extra-colonic malignancies in this syndrome. Periampullary adenomas have been shown to be precursor lesions to periampullary carcinoma. Sulindac, a non-steroidal anti-inflammatory drug, has been reported to cause regression of rectal polyps in FAP patients, however its role in periampullary polyp regression is unclear. Methods: In May 1993, a prospective study was begun to evaluate the role of sulindac in prevention of polyp recurrence after resection of large (〉1 cm) duodenal polyps in FAP patients. Eight patients, mean age 50 years (range 35 to 65), with documented large periampullary polyps were placed on sulindac 150 mg twice daily. Prior to enrolment, all patients had their large polyps removed from the periampullary region by interventional endoscopy or by surgery. All patients had multiple small residual duodenal polyps. Follow-up was performed by one experienced endoscopist with a side-viewing video endoscope. Endoscopy was performed 6 monthly. Median follow-up time was 17.5 months (range 10 to 24 months). Results: In 3 patients, sulindac was discontinued due to side effects: abdominal cramps (n = 2) and upper G-I bleeding (n = 1). None of the patients had regression of small periampullary polyps. In addition, one patient developed an invasive periampullary carcinoma while on sulindac and 3 patients developed large recurrent periampullary polyps requiring further treatment. Summary: In our experience, sulindac is of no significant benefit for the control of periampullary polyps in FAP. Effective medical treatment of these polyps is still lacking.

Notes: Abstract Background: Diagnostic laparoscopy for the evaluation of injuries in patients with penetrating abdominal trauma has been shown to decrease the morbidity and mortality associated with mandatory laparotomy. The overall impact on patient care and hospital costs has not been thoroughly investigated. The goal of this study was to determine the economic impact of laparoscopy as a diagnostic tool in the management of patients following penetrating trauma to the abdomen or flank. Methods: Retrospective chart review of all hemodynamically stable patients with penetrating trauma to the abdomen or flank, but without other injuries requiring emergent intervention, admitted to a level I trauma center between January 1, 1992, and September 30, 1994. Those patients who underwent either laparoscopy (DL) or laparotomy (NL) or both (CONV) and who had no intraabdominal organ injuries requiring surgical therapeutic intervention were included in the study. Age, operative time, operative findings, length of hospitalization, Injury Severity Score (ISS), variable costs, and total costs were recorded for each patient. Results: Fourteen patients underwent negative/nontherapeutic laparoscopy (DL), 19 patients underwent negative/nontherapeutic laparotomy (NL), and four patients underwent both laparoscopy and laparotomy, a conversion procedure (CONV). There was no significant difference in age, operative times, or ISS between the DL and NL groups. Mean ISS of CONV patients was significantly greater than that of DL patients, 5.75 ± 1.97 vs 2.43 ± 0.63 (p 〈 0.05). Mean operative time for CONV patients was also significantly greater than both DL and NL patients, 106.5 ± 17.00 min vs 66.1 ± 6.55 and 47.3 ± 7.50 min, respectively (p 〈 0.05). The mean length of stay was significantly shorter in the DL group as compared to the NL or CONV groups, 1.43 ± 0.20 vs 4.26 ± 0.31 and 5.0 ± 0.82 (p 〈 0.0001). The variable costs for the DL group were significantly lower than those incurred by patients in the NL and CONV groups, $2,917 ± 175 vs $3,384 ± 102 and $3,774 ± 286, (p 〈 0.05). Variable costs were not significantly different between the NL and CONV groups. Total costs were also significantly lower in the DL group when compared to NL and CONV, $5,427 ± 394 vs $7,026 ± 251 and $7,855 ± 750 (p 〈 0.005), but again, they were not statistically different between the NL and CONV groups. The overall total costs for laparoscopy, including the costs incurred by conversion patients, was significantly less than the total costs for laparotomy patients, $5,664 ± 394 vs $7,028.47 ± 250 (p 〈 0.005). This resulted in an overall savings of $1,059.44 per laparoscopy performed. The overall negative/nontherapeutic laparotomy rate during this study was 19.1%, which was significantly lower than the negative or nontherapeutic exploration rate during the time period prior to the use of laparoscopy (p 〈 0.01, z = 2.550). Conclusion: Variable and total costs and length of stay were significantly lower in our population of patients who underwent DL as compared to NL. The rate of negative or nontherapeutic laparotomy was also significantly reduced when compared to the rate identified during the era prior to the use of laparoscopy. Laparoscopy resulted in an overall savings of $1,059 per laparoscopy performed when compared to laparotomy.