RESUMEN
Recent studies have suggested that virtual colonoscopy (VC) and actual colonoscopy (AC) have similar efficacy for detection of polyps >6 mm. However, procedural risks with emerging technology such as VC need to be assessed before widespread implementation. We propose to demonstrate complication rates after AC that can be used for a comparative benchmark in VC. From 1994 to 1999 all patients undergoing AC who sustained perforation that required operation were analyzed for the mortality and complications. There were 26,162 consecutive colonoscopies that required 21 operations for perforation. Of these 16,948 (65%) colonoscopies were diagnostic and 9,214 (35%) were therapeutic with 11 (0.06%) and 10 (0.11%) operations respectively. Overall risk for colonoscopic perforation that requires operation was one in 1,246 (one in 1,541 for diagnostic and one in 921 for therapeutic). Five perforations were oversewn, 15 were resected (five with stoma), and one was drained. One patient died. There were two reoperations. Mortality was 0.006 per cent (one in 16,948) for diagnostic and zero for therapeutic colonoscopy. Overall risk for perforation that requires operation or mortality after AC is low. Virtual colonoscopists who propose screening and subsequent therapeutic interventions need to report high volume without complications as the perforation rate requiring operation was one in 1,246.
Asunto(s)
Colon/lesiones , Colonoscopía/efectos adversos , Perforación Intestinal/etiología , Pólipos del Colon/diagnóstico , Colonoscopía/métodos , Humanos , Perforación Intestinal/terapia , Factores de Riesgo , Interfaz Usuario-ComputadorRESUMEN
INTRODUCTION: Readmission after discharge from the hospital is an undesirable outcome. In an attempt to prevent unplanned readmissions after abdominal or perineal colon resection, we proposed to identify risk factors associated with return to the hospital. METHODS: Study participants consisted of 249 patients who were operated on from July 1, 1996, to March 30, 1998. All patients who were readmitted within 90 days of discharge from the hospital after surgery were evaluated for the study. A retrospective review of charts was performed to assess whether readmission within 90 days was a direct consequence of the recent operation (unplanned related readmission). These patients were compared with a control group consisting of patients who were never readmitted or who were readmitted with an unrelated problem. RESULTS: Of the 249 patients, 59 (24 percent) were readmitted within 90 days of discharge from the hospital. Twenty-two (9 percent) were unplanned related readmissions. Ten patients were readmitted with unrelated emergencies, and 27 patients were readmitted electively. In the unplanned related group, there was no correlation between age, gender, admission diagnosis, activity status, or postoperative length of stay and the likelihood of readmission. Patients with multiple chronic medical problems or those who developed postoperative complications did not have a higher readmission rate. Patients with ulcerative colitis or those who underwent abdominoperineal resection or total/subtotal colectomy had a higher incidence of readmissions, although the difference was not significant. The mean interval between discharge from the hospital and readmission with a related complication was 19 days. Small-bowel obstruction was the most common reason for readmission, and all cases resolved with conservative management. Mean length of stay during all readmissions was 8 days. CONCLUSION: The incidence of unplanned related readmissions 90 days after abdominal or perineal colon resection is 9 percent, and these readmissions could not be predicted from the postoperative course. Because 82 percent of unplanned readmissions occurred within 30 days, this time frame is suitable for computerized comparative analysis.
Asunto(s)
Enfermedades del Colon/cirugía , Readmisión del Paciente/estadística & datos numéricos , Enfermedades del Recto/cirugía , Adulto , Anciano , Colectomía/efectos adversos , Femenino , Predicción , Humanos , Ileostomía/efectos adversos , Incidencia , Masculino , Persona de Mediana Edad , Alta del Paciente , Complicaciones Posoperatorias , Pronóstico , Estudios Retrospectivos , Factores de RiesgoRESUMEN
There is a lack of consensus regarding the optimal operative treatment for full-thickness rectal prolapse. We describe our experience in the management of procidentia and evaluate our current practice for improvement of results. The medical records of patients undergoing surgery for rectal prolapse between 1989 to 1999 were retrospectively reviewed. A total of 36 perineal proctosigmoidectomies (PPSs) and 29 abdominal procedures [17 anterior resections (ARs) and 12 Ripstein procedures (RPs)] were performed during the 10-year period. Patients undergoing PPS were significantly older and had more comorbidities. Mean operating time and length of hospital stay were shorter for the PPS group. Early and late postoperative complication rates were also significantly lower in the PPS group. Six patients (16%) in the PPS group developed recurrence at a mean follow-up of 50 months. Operation under general anesthesia or removal of a longer segment of prolapsed bowel did not reduce recurrence after PPS. No full-thickness recurrence was noted after AR or RP. We conclude that abdominal procedures (AR and RP) have the lowest recurrence but at a significantly higher cost in terms of complications. PPS is a valuable option in selected patients and can be performed with minimal morbidity and a relatively low recurrence rate.
Asunto(s)
Complicaciones Posoperatorias , Prolapso Rectal/cirugía , Músculos Abdominales/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Colon Sigmoide/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Perineo/cirugía , Recto/cirugía , Recurrencia , Estudios RetrospectivosRESUMEN
The vast majority of hyperplastic polyps are small, left-sided, and inconsequential in nature. However, hyperplastic polyps that are large, right-sided, mixed, and found in association with a family history of carcinoma may represent an "atypical" group, and their clinical significance is uncertain. We believe that these atypical lesions should not be lumped together with the common variety of diminutive hyperplastic polyps. Rather, when such hyperplastic polyps are encountered, they should be excised and the patient should be placed on regular colonoscopic surveillance.
Asunto(s)
Enfermedades del Colon/patología , Transformación Celular Neoplásica , Pólipos del Colon/patología , Femenino , Humanos , Hiperplasia , MasculinoRESUMEN
Dieulafoy's lesion is an unusual source of massive lower gastrointestinal hemorrhage. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. Although Dieulafoy's lesions were initially described only in the stomach and upper small intestine, they are being identified with increasing frequency in the colon and rectum. To our knowledge, however, Dieulafoy's lesion of the anal canal has not been described previously. We present two patients with Dieulafoy's lesion of the anal canal who presented with sudden onset of massive hemorrhage. The clinicopathologic features of this unusual clinical entity are discussed and suggestions are made for diagnosis and management.
Asunto(s)
Angiodisplasia/diagnóstico , Hemorragia Gastrointestinal/etiología , Mucosa Intestinal/irrigación sanguínea , Enfermedades del Recto/diagnóstico , Recto/irrigación sanguínea , Anciano , Anciano de 80 o más Años , Angiodisplasia/cirugía , Arteriolas/cirugía , Femenino , Hemorragia Gastrointestinal/cirugía , Hemorroides/diagnóstico , Hemorroides/cirugía , Humanos , Enfermedades del Recto/cirugía , Recurrencia , Técnicas de SuturaRESUMEN
The aim of this study was to review experience with transanal endoscopic microsurgery (TEM) and to assess its applicability to an existing practice of colorectal surgeons. Patients undergoing TEM excision of rectal lesions from March 1997 through May 1999 were selected for this study. Medical records were reviewed retrospectively to obtain pertinent data, including indications for TEM, tumor size, distance from anal verge, duration of operation, completeness of tumor resection, postoperative complications, duration of stay and follow-up, and recurrence. Thirty-one patients underwent TEM during the 2-year period. Indications for TEM included benign disease in eight patients and cancer in 23 patients. Mean distance of the tumor from the anal verge was 8.3 cm. Mean size of the lesion was 2.8 cm, and mean specimen size was 4.5 cm. Larger specimen sizes allowed for tumors to be removed with negative margins (97%) in all cases but one. Mean duration of operation was 140 minutes (including set-up time), and mean duration of hospital stay was 1.2 days. Major postoperative complications occurred in one patient. Mean duration of follow-up was 15 months, and recurrence developed in two patients during this period. Transanal endoscopic microsurgery excision of rectal lesions with negative margins was possible in 97% of cases with minimal morbidity and a short-duration hospital stay. Follow-up was too brief to evaluate recurrence, but the thoroughness of resection of tumor in a high proportion of cases is promising.
Asunto(s)
Microcirugia/métodos , Proctoscopía/métodos , Enfermedades del Recto/cirugía , Neoplasias del Recto/cirugía , Anciano , Colonoscopía , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Microcirugia/efectos adversos , Microcirugia/instrumentación , Recurrencia Local de Neoplasia/etiología , Estadificación de Neoplasias , Proctoscopía/efectos adversos , Enfermedades del Recto/diagnóstico , Neoplasias del Recto/clasificación , Neoplasias del Recto/diagnóstico , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Retención Urinaria/etiologíaRESUMEN
PURPOSE: The occurrence of neoplasia after ureterosigmoidostomy is well-documented in the literature. Because of its rarity, few general surgeons will gain significant exposure to this entity, and colorectal surgeons are likely to be involved with the care of these patients. The purpose of this article is to apprise colorectal surgeons about the management of neoplasia after ureterosigmoidostomy and to familiarize them with the unique anatomy of the reconstructed pelvis. METHODS: We performed a MEDLINE search to identify articles on ureterosigmoid tumors. The theories regarding the cause and pathology of these tumors were critically analyzed. A consensus was developed for screening patients with ureterosigmoidostomy and for treatment of neoplasia. RESULTS: The incidence of carcinoma after ureterosigmoidostomy ranges from 2 to 15 percent. Polyps are more common, and it seems that these tumors also follow the sequence of adenocarcinoma that is seen in the common variety of colorectal neoplasia. Neoplastic changes begin with the interaction of urine and feces and the healing colonic mucosa. Both production of nitrosamines by the action of bacteria on urine and DNA damage caused by reactive oxygen radicals produced by neutrophils at the healing anastomosis have been implicated in the pathogenesis of neoplasia. The latent period between formation of ureterosigmoidostomy and the appearance of carcinoma is between 20 and 26 years. Obstructive urinary symptoms that develop more than two years after ureterosigmoidostomy should be viewed with suspicion. The patient should be investigated with a CT scan and colonoscopy, and a barium enema may be required to delineate the anatomy further. If a benign tumor is encountered during colonoscopy, it may be removed by snare polypectomy. For a malignant tumor the segment of colon with ureteric implants should be excised, along with its lymphatic drainage. Bowel continuity is restored primarily, and the ureters are implanted in an ileal conduit. CONCLUSIONS: Patients with ureterosigmoidostomy should be followed closely for the rest of their lives. The aim of screening is to identify and treat neoplasia before malignancy develops. Furthermore, early detection of neoplasia by close screening will improve survival. Although urine cytology and occult blood are inexpensive tests, colonoscopy remains the criterion standard for follow-up of these patients. Annual colonoscopic surveillance should be started soon after the ureterosigmoidostomy but not later than five to six years after the procedure. Patients who are noncompliant with the vigorous follow-up schedule should be offered the option of resection of the colonic segment at risk with urinary diversion.
Asunto(s)
Anastomosis Quirúrgica/efectos adversos , Colon Sigmoide/cirugía , Neoplasias del Colon/etiología , Uréter/cirugía , Derivación Urinaria/efectos adversos , Adenocarcinoma/diagnóstico , Adenocarcinoma/etiología , Adenocarcinoma/cirugía , Carcinoma/diagnóstico , Carcinoma/etiología , Carcinoma/cirugía , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/cirugía , Pólipos del Colon/diagnóstico , Pólipos del Colon/etiología , Pólipos del Colon/cirugía , Colonoscopía , Daño del ADN , Heces , Estudios de Seguimiento , Radicales Libres/metabolismo , Humanos , Incidencia , Mucosa Intestinal/fisiopatología , Mucosa Intestinal/cirugía , Tamizaje Masivo , Neutrófilos/metabolismo , Nitrosaminas/metabolismo , Especies Reactivas de Oxígeno/metabolismo , Factores de Tiempo , Orina , Cicatrización de HeridasRESUMEN
PURPOSE: This study is designed to review a carcinoembryonic antigen (CEA)-driven postoperative protocol designed to identify patients suitable for curative reresection when recurrent colorectal cancer is identified. METHODS: A total of 285 patients who were operated on for colon or rectal carcinoma between 1981 and 1985 were evaluated (with CEA levels) every two months for the first two years, every three months for the third year, every six months for years 4 and 5, and annually thereafter. CEA levels above 5 microg were considered abnormal and were evaluated with diagnostic imaging and/or endoscopy. RESULTS: Follow-up was available for 280 patients (98.2 percent). Distribution of patients by Astler-Coller was: A, 14 percent; B1, 20 percent; B2, 39 percent; C1, 5 percent; C2, 21 percent. There were 62 of 280 patients (22 percent) who developed elevated CEA levels, with 44 patients who demonstrated clinical or radiographic evidence of recurrence. Eleven patients were selected for surgery with curative intent (4 hepatic resections, 1 pulmonary wedge resection, 2 abdominoperineal resections, 2 segmental bowel resections, and 2 cranial metastasectomies). Three of 11 patients (27 percent) benefited and have disease-free survivals greater than 60 months. Of the 223 patients without elevated CEA, 22 (9.9 percent) had recurrent cancer without any survivors. Overall, 3 of 285 patients (1.1 percent) were cured as a result of CEA follow-up. CONCLUSION: CEA-driven surgery is useful in selected patients and can produce long-term survivors.
Asunto(s)
Biomarcadores de Tumor/sangre , Antígeno Carcinoembrionario/sangre , Neoplasias Colorrectales/cirugía , Recurrencia Local de Neoplasia/diagnóstico , Anciano , Neoplasias Colorrectales/sangre , Neoplasias Colorrectales/mortalidad , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Recurrencia Local de Neoplasia/sangre , Cuidados Posoperatorios , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Factores de TiempoRESUMEN
BACKGROUND: Transanal repair of rectocele involving the suprasphincteric portion of the rectovaginal septum has been shown to provide excellent results in up to 90 per cent of cases. Selection of patients suitable for repair is important. Rectocele with concomitant cystocele is best repaired transvaginally. An alternative approach is recommended for enterocele. METHODS: With the patient in the prone position and using local anaesthesia, a mucomuscular endorectal flap is raised and the underlying tissues are plicated. The excessive flap is excised, and the cut edges are approximated. A retrospective review of 123 consecutive cases of transanal repair of rectocele was conducted. Patient satisfaction and complications were compared with those in a previously reported study. RESULTS: Overall patient satisfaction improved from 63 per cent of 59 patients in an earlier study to 82 per cent in this report. The overall complication rate decreased from 7 to 3 per cent. CONCLUSION: This study demonstrates the validity of a simple technique of transanal repair of rectocele in an ambulatory setting. Minimal morbidity and successful outcome can be achieved with this procedure.
Asunto(s)
Enfermedades del Recto/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Cirugía Colorrectal/métodos , Estreñimiento/etiología , Estreñimiento/cirugía , Femenino , Estudios de Seguimiento , Herniorrafia , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Recurrencia , Resultado del TratamientoRESUMEN
PURPOSE: A study of 523 fistulas of cryptoglandular origin operated on between January 1985 and December 1991 at the Lehigh Valley Hospital was undertaken for the purpose of establishing whether the "so-called" simple fistula-in-ano has a favorable outcome. High transsphincteric fistulas with or without high blind tract, suprasphincteric, extrasphincteric, and horseshoe fistulas as well as fistulas associated with inflammatory bowel disease were excluded. METHODS: Four-hundred sixty-one patients with anal fistulas classified as simple fistulas-in-ano (uncomplicated transsphincteric, low and high blind track intersphincteric) were studied retrospectively. There were 310 males and 151 females with an average age of 42 years and mean follow-up of 34 months. RESULTS: Thirty (6.5 percent) patients developed recurrent fistulas: 16 (53.3 percent) because of missed internal openings at initial surgery, six (20 percent) attributed to missed secondary tracks, five (16.7 percent) because of premature fistulotomy wound closure, and three (10 percent) because of miscellaneous factors. CONCLUSION: All so-called simple fistulas-in-ano may not have readily detectable primary openings and may possess secondary tracks which preclude their behavior as simple fistulas.
Asunto(s)
Fístula Rectal/clasificación , Fístula Rectal/cirugía , Índice de Severidad de la Enfermedad , Adulto , Anciano , Electrocoagulación/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Fístula Rectal/diagnóstico , Fístula Rectal/epidemiología , Fístula Rectal/etiología , Recurrencia , Estudios Retrospectivos , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
Delayed hemorrhage following surgical hemorrhoidectomy is a well-recognized complication. Emergency treatment may include suture ligation, anal packing, or other means of tamponade. At the Lehigh Valley Hospital, 27 patients were seen with the complication of delayed hemorrhage over an eight-year period from 1983 to 1990, for an incidence of 0.8 percent. Twenty-five patients (93 percent) underwent surgery primarily for hemorrhoidal disease; one patient had hemorrhoids removed in addition to a sphincterotomy for anal tissue, and the remaining patient had hemorrhoidectomy with fistulotomy. The mean interval from the operation to hemorrhage was six days. Treatment modalities included bedside anal packing in 20 patients (74 percent), observation alone in five patients (18 percent), and suture ligation in the operating room in two patients. Anal packing was successful in controlling postoperative hemorrhage in 20/20 patients, but late complications requiring reoperation developed in 15 percent.
Asunto(s)
Hemorragia/etiología , Hemorroides/cirugía , Complicaciones Posoperatorias , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hemorragia/terapia , Técnicas Hemostáticas , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/terapia , Factores de TiempoRESUMEN
Acute hemorrhoidal crisis can occur in the pregnant female. When medical therapy fails to relieve pain, operative intervention may be necessary. The surgeon, however, may be reluctant to operate due to potential complications to the mother and fetus. From July 1983 to July 1989, hemorrhoidectomy was performed in 25 of 12,455 pregnant women (0.2 percent) who delivered in our institution. Twenty-two women were in their third trimester, 80 percent were multiparous, and each had a remote history of hemorrhoidal symptoms, including intermittent pain, bleeding, and protrusion. Closed hemorrhoidectomy was performed under local anesthesia. The surgery was directed at removing only symptomatic disease, which included three quadrants in 14 patients, two quadrants in seven patients, and one quadrant in four patients. All patients experienced relief of intractable pain the day after surgery, except one patient who required a hemostatic packing during the immediate post-operative period. There were no other maternal or fetal complications. Subsequent follow-up for anorectal disease ranged from 6 months to 6 years. Six (24 percent) patients required additional hemorrhoid treatment. Hemorrhoidectomy in selected pregnant patients is safe in our experience.
Asunto(s)
Hemorroides/cirugía , Complicaciones Cardiovasculares del Embarazo/cirugía , Adulto , Femenino , Hemorragia/terapia , Hemorroides/fisiopatología , Humanos , Dolor Intratable/etiología , Dolor Intratable/terapia , Complicaciones Posoperatorias/terapia , Embarazo , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Factores de RiesgoRESUMEN
A voluntary community colorectal cancer screening project to detect occult blood in the stool of asymptomatic individuals was undertaken; 49,353 Hemoccult II kits were distributed. A total of 23,674 completed kits were returned to a central repository and processed (compliance rate, 48 percent); 851 participants had positive results (3.6 percent). Of the 640 who underwent further medical evaluation, 299 participants (46.7 percent) who had adequate follow-up had no evidence of disease. Diverse disease entities were detected in 341 participants, which was 1.4 percent of those enrolled. Forty-one patients (0.17 percent) showed significant findings that included 29 cancers (0.12 percent) and 12 (0.05 percent) noninvasive malignant polyps. Of the cancers, there were 27 colorectal, one non-Hodgkin's lymphoma, and one carcinoma of the vocal cord. In addition, 107 patients (0.45 percent) had benign polyps and 193 patients (0.82 percent) had various diseases of the gastrointestinal tract and other medical conditions. The cost of the program was modest and the results conformed to those found in previous screening surveys. The heightened public awareness of testing for colorectal disease and the detection of early lesions justifies the guaiac test screening program for mass survey.
Asunto(s)
Neoplasias Colorrectales/epidemiología , Tamizaje Masivo , Adulto , Anciano , Neoplasias Colorrectales/diagnóstico , Análisis Costo-Beneficio , Humanos , Tamizaje Masivo/economía , Tamizaje Masivo/métodos , Persona de Mediana Edad , Sangre Oculta , Cooperación del Paciente , Pennsylvania , Juego de Reactivos para Diagnóstico/economíaRESUMEN
Between September 1959 and December 1986, a total of 210 patients in a consecutive series were operated on for inflammatory bowel disease. One hundred ten (66 percent) had ileorectal anastomosis performed. There were no postoperative deaths. There were six failures in 53 ileorectal anastomoses for ulcerative colitis (11 percent), and five failures (8 percent) in 61 for Crohn's disease. The overall failure rate was 11 in 110 (10 percent). Ileorectal anastomosis, in suitable patients, is still a viable operation in the late 1980s.
Asunto(s)
Colitis Ulcerosa/cirugía , Enfermedad de Crohn/cirugía , Íleon/cirugía , Recto/cirugía , Anastomosis Quirúrgica , Humanos , Complicaciones Posoperatorias , Pronóstico , Calidad de Vida , Neoplasias del Recto , Factores de RiesgoRESUMEN
A prospective, double-blind, randomized study was undertaken to compare perioperative parenteral metronidazole and erythromycin, One neomycin, and cefazolinhundred fifty-five patients were randomized into two groups by the pharmacy department. The resulting difference between the overall septic complication rate in patients receiving erythromycin, neomycin, and cefazolin (10.9 percent) and the rate in patients receiving metronidazole alone (31.9 percent) was significant. This indicates that an antibiotic to cover aerobic bacteria should be added to the regimen when metronidazole is used.
Asunto(s)
Cefazolina/uso terapéutico , Colon/cirugía , Eritromicina/uso terapéutico , Metronidazol/uso terapéutico , Neomicina/uso terapéutico , Premedicación , Infección de la Herida Quirúrgica/prevención & control , Método Doble Ciego , Quimioterapia Combinada/uso terapéutico , Humanos , Inyecciones Intravenosas , Metronidazol/administración & dosificación , Complicaciones Posoperatorias , Estudios Prospectivos , Distribución AleatoriaRESUMEN
A technique is described and illustrated by case reports wherein removal of foreign bodies of the rectum is simplified by using the flexible sigmoidscope. Evidence from the literature indicates that delayed perforation is rare in this situation, and that outpatient management would suffice for most patients.
Asunto(s)
Cuerpos Extraños/terapia , Recto , Sigmoidoscopía , Adulto , Femenino , Humanos , Masculino , SigmoidoscopiosRESUMEN
Twenty-eight patients who underwent the Bacon pull-through procedure for carcinoma of the midrectum were reviewed retrospectively. The results were comparable to low anterior resection and abdominoperineal resection. Although the indications are limited, it is a viable option in a highly selected group of patients.
Asunto(s)
Canal Anal/cirugía , Colon/cirugía , Neoplasias del Recto/cirugía , Recto/cirugía , Anciano , Femenino , Estudios de Seguimiento , Humanos , Mucosa Intestinal/cirugía , Masculino , Persona de Mediana Edad , Músculos/cirugía , Técnicas de SuturaRESUMEN
Continuous chemotherapy for hepatic metastases secondary to carcinoma of the colon and/or rectum was delivered via implantable pump in 20 patients. This is a follow-up to a preliminary report published in January 1985. Pumps were placed by a single surgeon in a community hospital; there was no mortality and minimal morbidity. Follow-up of these patients revealed a significant long-term complication rate secondary to effects of chemotherapy. Nine patients were alive at the cutoff date of this report; mean follow-up was 16 months. Eleven patients have died following implantation, with a mean survival of 14 months. Statistical analyses demonstrated increased survival rates for those patients whose tumors were poorly differentiated when compared with those with moderately differentiated or well-differentiated tumors. The objective response of liver metastases was overwhelmingly positive, as judged by CT scan and serial CEA levels. The significant rehospitalization rate for complications and the marginal increase in survival, however, have discouraged implantation of the pump at our institution.