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Agresta F, Montori G, Podda M, Ortenzi M, Giordano A, Bergamini C, Mazzarolo G, Licitra E, Gobbi T, Procida G, Borgo AD, Botteri E, Ansaloni L, Fugazzola P, Savino G, Guerrieri M, Campanile FC, Sartori A, Petz W, Silecchia G, di Saverio S, Catena F, Agrusa A, Salemi M, Morales-Conde S, Arezzo A. Diverticulitis, surgery, evidence-based medicine, and the Steve Jobs' dots: a narrative review. Eur J Trauma Emerg Surg 2024; 50:81-91. [PMID: 37747500 DOI: 10.1007/s00068-023-02362-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/27/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Emergency treatment of acute diverticulitis remains a hazy field. Despite a number of clinical studies, randomized controlled trials (RCTs), guidelines and surgical societies recommendations, the most critical hot topics have yet to be addressed. METHODS Literature research from 1963 until today was performed. Data regarding the principal RCTs and observational studies were summarized in descriptive tables. In particular we aimed to focus on the following topics: the role of laparoscopy, the acute care setting, the RCTs, guidelines, observational studies and classifications proposed by literature, the problem in case of a pandemic, and the importance of adapting treatment /place/surgeon conditions. RESULTS In the evaluation of these points we did not try to find any prospective evolution of the concepts achievements. On the contrary we simply report the individuals strands of research from a retrospective point of view, similarly to what Steve Jobes said: "you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future". We have finally obtained what can be defined "a narrative review of the literature on diverticulitis". CONCLUSIONS Not only evidence-based medicine but also the contextualization, as also the role of 'competent' surgeons, should guide to novel approach in acute diverticulitis management.
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Affiliation(s)
- Ferdinando Agresta
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy.
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Monica Ortenzi
- Clinica di Chirurgia Generale e d'Urgenza, Università Politecnica delle Marche, Ancona, Italy
| | - Alessio Giordano
- Surgery Department, Emergency Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Carlo Bergamini
- Surgery Department, Emergency Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Giorgio Mazzarolo
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Edelweiss Licitra
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Tobia Gobbi
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Giuseppa Procida
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Andrea Dal Borgo
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | | | - Luca Ansaloni
- Unit of General Surgery I, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Paola Fugazzola
- Unit of General Surgery I, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Grazia Savino
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Mario Guerrieri
- Clinica di Chirurgia Generale e d'Urgenza, Università Politecnica delle Marche, Ancona, Italy
| | | | - Alberto Sartori
- Department of General Surgery, Ospedale di Montebelluna, Montebelluna, Italy
| | - Wanda Petz
- Division of Digestive Surgery, IEO European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Gianfranco Silecchia
- Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Latina, Italy
| | - Salomone di Saverio
- Department of General Surgery, ASUR Marche, AV5, Hospital of San Benedetto del Tronto, San Benedetto del Tronto, Italy
| | - Fausto Catena
- Department of Surgery, "Bufalini" Hospital, Cesena, Italy
| | - Antonino Agrusa
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Michelangelo Salemi
- Medical Director of ULSS 2Trevigiana, Vittorio Veneto Hospital, Vittorio Veneto, TV, Italy
| | | | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
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Vaghiri S, Krieg S, Prassas D, Loosen SH, Roderburg C, Luedde T, Knoefel WT, Krieg A. A New Nomogram-Based Prediction Model for Postoperative Outcome after Sigmoid Resection for Diverticular Disease. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1083. [PMID: 37374287 DOI: 10.3390/medicina59061083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/28/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Sigmoid resection still bears a considerable risk of complications. The primary aim was to evaluate and incorporate influencing factors of adverse perioperative outcomes following sigmoid resection into a nomogram-based prediction model. Materials and Methods: Patients from a prospectively maintained database (2004-2022) who underwent either elective or emergency sigmoidectomy for diverticular disease were enrolled. A multivariate logistic regression model was constructed to identify patient-specific, disease-related, or surgical factors and preoperative laboratory results that may predict postoperative outcome. Results: Overall morbidity and mortality rates were 41.3% and 3.55%, respectively, in 282 included patients. Logistic regression analysis revealed preoperative hemoglobin levels (p = 0.042), ASA classification (p = 0.040), type of surgical access (p = 0.014), and operative time (p = 0.049) as significant predictors of an eventful postoperative course and enabled the establishment of a dynamic nomogram. Postoperative length of hospital stay was influenced by low preoperative hemoglobin (p = 0.018), ASA class 4 (p = 0.002), immunosuppression (p = 0.010), emergency intervention (p = 0.024), and operative time (p = 0.010). Conclusions: A nomogram-based scoring tool will help stratify risk and reduce preventable complications.
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Affiliation(s)
- Sascha Vaghiri
- Department of Surgery (A), Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | - Sarah Krieg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery (A), Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | - Sven Heiko Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | - Christoph Roderburg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery (A), Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany
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Bezerra RP, Costa ACD, Santa-Cruz F, Ferraz ÁAB. HARTMANN PROCEDURE OR RESECTION WITH PRIMARY ANASTOMOSIS FOR TREATMENT OF PERFORATED DIVERTICULITIS? SYSTEMATIC REVIEW AND META-ANALYSIS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2021; 33:e1546. [PMID: 33470376 PMCID: PMC7812685 DOI: 10.1590/0102-672020200003e1546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Mortality after emergency surgery in randomized controlled trials. The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. AIM To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. METHOD Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. RESULTS There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. CONCLUSION Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.
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Affiliation(s)
| | | | | | - Álvaro A B Ferraz
- Department of Surgery, Federal University of Pernambuco, Recife, PE, Brazil
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4
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Lambrichts DPV, Edomskis PP, van der Bogt RD, Kleinrensink GJ, Bemelman WA, Lange JF. Sigmoid resection with primary anastomosis versus the Hartmann's procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1371-1386. [PMID: 32504331 PMCID: PMC7340681 DOI: 10.1007/s00384-020-03617-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann's procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence. METHODS A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs). RESULTS From a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients. CONCLUSION Although between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann's procedure in selected patients with Hinchey III or IV diverticulitis.
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Affiliation(s)
- Daniël PV Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands ,Department of Surgery, Amsterdam University Medical Center, AMC, Amsterdam, The Netherlands
| | - Pim P Edomskis
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gert-Jan Kleinrensink
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Center, AMC, Amsterdam, The Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands ,Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
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Halim H, Askari A, Nunn R, Hollingshead J. Primary resection anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis. World J Emerg Surg 2019; 14:32. [PMID: 31338117 PMCID: PMC6625026 DOI: 10.1186/s13017-019-0251-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/25/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann’s procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. The aim of this meta-analysis is to determine which of the two procedures has a more favorable outcome. Methods A systematic review of the existing literature was performed using the PRISMA guidelines. A meta-analysis was carried out using a Mantel-Haenszel, random effects model, and forest plots were generated. The Newcastle-Ottawa and Jadad scoring tools were used to assess the included studies. Results A total of 25 studies involving 3546 patients were included in this study. The overall mortality in the HP group was 10.8% across the observational studies and 9.4% in the randomized controlled trials (RCTs). The mortality rate in the PRA group was lower than that in the HP group, at 8.2% in the observational studies and 4.3% in the RCTs. A comparison of PRA vs HP demonstrated a 40% lower mortality rate in the PRA group than in the HP (OR 0.60, 95% CI 0.38–0.95, p = 0.03) when analyzing the observational studies. However, meta-analysis of the three RCTs did not demonstrate any difference in mortality, (OR 0.44 (95% CI 0.14–1.34, p = 0.15). Wound infection rates between the two groups were comparable (OR 0.75, 95% CI 0.20–2.78, p = 0.67). Conclusion Analysis of observational studies suggests that PRA may be associated with a lower overall mortality. There were no differences in wound infection rates. Based on the current evidence, both surgical strategies appear to be acceptable.
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Affiliation(s)
- Hosam Halim
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - Alan Askari
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - Rebecca Nunn
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - James Hollingshead
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
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6
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Gachabayov M, Oberkofler CE, Tuech JJ, Hahnloser D, Bergamaschi R. Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis. Colorectal Dis 2018; 20:753-770. [PMID: 29694694 DOI: 10.1111/codi.14237] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
AIM It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates. METHOD The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)]. CONCLUSION This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.
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Affiliation(s)
- M Gachabayov
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - C E Oberkofler
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J J Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - R Bergamaschi
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Theodoropoulos D. Current Options for the Emergency Management of Diverticular Disease and Options to Reduce the Need for Colostomy. Clin Colon Rectal Surg 2018; 31:229-235. [PMID: 29942213 DOI: 10.1055/s-0037-1607961] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This article reviews the current options and recommendations for the emergency management of acute diverticulitis, including the spectrum of antibiotics, percutaneous drainage, laparoscopic lavage, and surgical options for resection with the restoration of bowel continuity.
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8
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Bostock IC, Hill MV, Counihan TC, Ivatury SJ. Mortality after emergency Hartmann's procedure in octogenarians: a propensity score-matched analysis. J Surg Res 2017; 221:167-172. [PMID: 29229124 DOI: 10.1016/j.jss.2017.08.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/02/2017] [Accepted: 08/14/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Complicated diverticulitis is associated with a postoperative mortality rate of 20%. We hypothesized that age ≥80 was an independent risk factor for mortality after Hartmann's procedure for diverticular disease when controlling for baseline comorbidities. METHODS Patients who underwent an urgent or emergent Hartmann's procedure (Current Procedural Terminology codes 44143 and 44206) for diverticular disease (International Classification of Diseases-9:562.xx) were identified using the American College of Surgeons National Surgical Quality Improvement Project 2005-2013 user file. Using propensity score matching to control for baseline comorbidities, a group of patients ≥80 years old was matched to a group of those <80 years old. Univariate and multivariable logistic regression were performed. A P value <0.05 was considered statistically significant with a confidence interval (CI) of 95%. RESULTS From a total of 2986 patients, 464 patients (15.5%) were ≥80 years old. Two groups of 284 patients in each study arm were matched using propensity-matching. The mean age of the ≥80 group and <80 group was 84.4 ± 3.3 versus 63.77 ± 911.8; P < 0.0001, respectively. There was no statistical difference in baseline comorbidities or operative time between the groups. There was a significant difference in mortality with 19% and 9.2% in the >80 group versus <80 groups, respectively (P = 0.001). Factors associated with mortality included ascites (odds ratio [OR] 4.95, confidence interval [CI] 1.64-14.93, P = 0.005), previous cardiac surgery (OR 3.68, CI 1.46-9.26, P = 0.006), partially dependent or fully dependent functional status (OR 2.51, CI 1.12-5.56, P = 0.02), albumin <3 (OR 2.49, CI 1.18-5.29, P = 0.01), and American Society of Anesthesiologist class >3 (OR 2.10, CI 1.10-4.46, P = 0.05). CONCLUSIONS Octogenarians presenting with complicated diverticulitis requiring an emergent Hartmann's procedure have a higher mortality rate compared to those <80, even after controlling for baseline comorbidities. STUDY TYPE This is a retrospective, descriptive study.
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Affiliation(s)
- Ian C Bostock
- Department of Colorectal Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Maureen V Hill
- Department of Colorectal Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Timothy C Counihan
- Department of Colorectal Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Srinivas Joga Ivatury
- Department of Colorectal Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Department of Colorectal Surgery, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
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10
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Rosado-Cobián R, Blasco-Segura T, Ferrer-Márquez M, Marín-Ortega H, Pérez-Domínguez L, Biondo S, Roig-Vila JV. Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons. Cir Esp 2017; 95:369-377. [PMID: 28416357 DOI: 10.1016/j.ciresp.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/15/2017] [Accepted: 03/20/2017] [Indexed: 11/17/2022]
Abstract
The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed.
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Affiliation(s)
- Rafael Rosado-Cobián
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Teresa Blasco-Segura
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, España
| | - Manuel Ferrer-Márquez
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España.
| | - Héctor Marín-Ortega
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Cruces , Barakaldo (Vizcaya), España
| | - Lucinda Pérez-Domínguez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Álvaro Cunqueiro Complejo Hospitalario Universitario de Vigo, Vigo, España
| | - Sebastiano Biondo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital de Bellvitge, Barcelona, España
| | - José Vicente Roig-Vila
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Nisa 9 de Octubre, Valencia, España
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Cirocchi R, Afshar S, Di Saverio S, Popivanov G, De Sol A, Gubbiotti F, Tugnoli G, Sartelli M, Catena F, Cavaliere D, Taboła R, Fingerhut A, Binda GA. A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine. World J Emerg Surg 2017; 12:14. [PMID: 28293278 PMCID: PMC5345194 DOI: 10.1186/s13017-017-0120-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/01/2017] [Indexed: 02/08/2023] Open
Abstract
The management of patients with colonic diverticular perforation is still evolving. Initial lavage with or without simple suture and drainage was suggested in the late 19th century, replaced progressively by the three-stage Mayo Clinic or the two-stage Mickulicz procedures. Fears of inadequate source control prompted the implementation of the resection of the affected segment of colon with formation of a colostomy (Hartman procedure) in the 1970’s. Ensuing development of the treatment strategies was driven by the recognition of the high morbidity and mortality and low reversal rates associated with the Hartman procedure. This led to the wider use of resection and primary anastomosis during the 1990’s. The technique of lavage and drainage regained popularity during the 1990’s. This procedure can also be performed laparoscopically with the advantage of faster recovery and shorter hospital stay. This strategy allows resectional surgery to be postponed or avoided altogether in many patients; and higher rates of primary resection and anastomosis can be achieved avoiding the need for a stoma. The three recent randomized controlled trials comparing laparoscopic peritoneal lavage alone to resectional surgery reported inconsistent outcomes. The aim of this review is to review the historical evolution and future reflections of surgical treatment modalities for diffuse purulent and feculent peritonitis. In this review we classified the various surgical strategies according to Krukowski et al. and Vermeulen et al. and reviewed the literature related to surgical treatment separately for each period.
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Affiliation(s)
- Roberto Cirocchi
- Department of General Surgery, University of Perugia, Terni Hospital, Terni, Italy
| | - Sorena Afshar
- Department of General Surgery, Cumberland Infirmary, Carlisle, UK
| | - Salomone Di Saverio
- General (Colorectal) Emergency and Trauma Surgery Service, Maggiore Hospital Regional Emergency Surgery and Trauma Center - Bologna Local Health District, Bologna, Italy
| | | | | | | | - Gregorio Tugnoli
- General (Colorectal) Emergency and Trauma Surgery Service, Maggiore Hospital Regional Emergency Surgery and Trauma Center - Bologna Local Health District, Bologna, Italy
| | | | - Fausto Catena
- Department of Emergency Surgery, Parma Hospital, Parma, Italy
| | | | - Renata Taboła
- Department of Gastrointestinal and General Surgery, Medical University of Wrocław, Wrocław, Poland
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.,First Department of Surgery, Hippokration University Hospital, University of Athens, Athens, Greece
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Angenete E, Bock D, Rosenberg J, Haglind E. Laparoscopic lavage is superior to colon resection for perforated purulent diverticulitis-a meta-analysis. Int J Colorectal Dis 2017; 32:163-169. [PMID: 27567926 PMCID: PMC5285409 DOI: 10.1007/s00384-016-2636-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Perforated diverticulitis often requires surgery with a colon resection such as Hartmann's procedure, with inherent morbidity. Recent studies suggest that laparoscopic lavage may be an alternative surgical treatment. The aim of this study was to compare re-operations, morbidity, and mortality as well as health economic outcomes between laparoscopic lavage and colon resection for perforated purulent diverticulitis. METHODS PubMed, Cochrane, Centre for Reviews and Dissemination, and Embase were searched. Published randomized controlled trials and prospective and retrospective cohorts with laparoscopic lavage and colon resection as interventions were identified. Trial limitations were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Re-operations, complications at 90 days classified according to Clavien-Dindo and mortality were extracted. RESULTS Three randomized trials published between 2005 and 2015 were included in the analysis. The studies included a total of 358 patients with 185 patients undergoing laparoscopic lavage. At 12 months, the relative risk of having a re-operation was lower for laparoscopic lavage compared to colon resection in the two trials that had a 12 month follow-up. We found no significant differences in Clavien-Dindo complications classified more than level IIIB or mortality at 90 days. CONCLUSIONS The risk for re-operations within the first 12 months after index surgery was lower for laparoscopic lavage compared to colon resection, with overall comparable morbidity and mortality. Furthermore, Hartmann's resection was more costly than laparoscopic lavage. We therefore consider laparoscopic lavage a valid alternative to surgery with resection for perforated purulent diverticulitis.
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Affiliation(s)
- Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden.
| | - David Bock
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - Jacob Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730, Herlev, Denmark
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
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Kruis W, Germer CT, Leifeld L. Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery. Digestion 2015; 90:190-207. [PMID: 25413249 DOI: 10.1159/000367625] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Diverticular disease is one of the most common disorders of the gastrointestinal tract. 28-45% of the population develop colonic diverticula, while about 25% suffer symptoms and about 5% complications. AIM To create formal guidelines for diagnosis and management. METHODS Six working groups with 44 participants analyzed key questions in subject areas assigned to them. Following a systematic literature search, 451 publications were included. Consensus was obtained by agreement within the working groups, two Delphi processes and a guideline conference. RESULTS Targeted management of diverticular disease requires a classificatory diagnosis. A new classification was created. In addition to the clinical examination, intestinal ultrasound or computed tomography is the determining factor. Interval colonoscopy is recommended to exclude comorbidities. A low-fiber diet, obesity, lack of exercise, smoking and immunosuppression have an adverse impact on diverticulosis. This can lead to diverticulitis. Antibiotics are no longer recommended in uncomplicated diverticulitis if no risk factors such as immunosuppression are present. If close monitoring is ensured, uncomplicated diverticulitis can be treated on an outpatient basis. Complicated diverticulitis should be treated in hospital, involving broad-spectrum antibiotic therapy, where necessary abscess drainage, and surgery, if possible laparoscopically. In the case of chronic relapsing diverticulitis, the risk of perforation decreases with each episode, so that surgery is no longer recommended after the second episode but only following individual assessment. CONCLUSIONS New findings on diverticular disease call into question the overuse of antibiotics and excessive indications for surgery. Targeted treatment requires a precise diagnosis and intensive interdisciplinary cooperation.
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Böhm SK. Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking. VISZERALMEDIZIN 2015; 31:84-94. [PMID: 26989377 PMCID: PMC4789955 DOI: 10.1159/000381867] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding. Methods A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed. Results Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities. Conclusion Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.
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Affiliation(s)
- Stephan K Böhm
- Medizinische Universitätsklinik, Kantonsspital Baselland, Bruderholz, Switzerland
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Identification of diverticulitis patients at high risk for recurrence and poor outcomes. J Trauma Acute Care Surg 2015; 78:112-9. [DOI: 10.1097/ta.0000000000000466] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Sudarshan M, Feldman LS, St Louis E, Al-Habboubi M, Hassan MME, Fata P, Deckelbaum DL, Razek TS, Khwaja KA. Predictors of mortality and morbidity for acute care surgery patients. J Surg Res 2014; 193:868-73. [PMID: 25439507 DOI: 10.1016/j.jss.2014.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 08/19/2014] [Accepted: 09/04/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND As the implementation of exclusive acute care surgery (ACS) services thrives, prognostication for mortality and morbidity will be important to complement clinical management of these diverse and complex patients. Our objective is to investigate prognostic risk factors from patient level characteristics and clinical presentation to predict outcomes including mortality, postoperative complications, intensive care unit (ICU) admission and prolonged duration of hospital stay. METHODS Retrospective review of all emergency general surgery admissions over a 1-year period at a large teaching hospital was conducted. Factors collected included history of present illness, physical exam and laboratory parameters at presentation. Univariate analysis was performed to examine the relationship between each variable and our outcomes with chi-square for categorical variables and the Wilcoxon rank-sum statistic for continuous variables. Multivariate analysis was performed using backward stepwise logistic regression to evaluate for independent predictors. RESULTS A total of 527 ACS admissions were identified with 8.1% requiring ICU stay and an overall crude mortality rate of 3.04%. Operative management was required in 258 patients with 22% having postoperative complications. Use of anti-coagulants, systolic blood pressure <90, hypothermia and leukopenia were independent predictors of in-hospital mortality. Leukopenia, smoking and tachycardia at presentation were also prognostic for the development of postoperative complications. For ICU admission, use of anti-coagulants, leukopenia, leukocytosis and tachypnea at presentation were all independent predictive factors. A prolonged length of stay was associated with increasing age, higher American Society of Anesthesiologists class, tachycardia and presence of complications on multivariate analysis. CONCLUSIONS Factors present at initial presentation can be used to predict morbidity and mortality in ACS patients.
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Affiliation(s)
- Monisha Sudarshan
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Liane S Feldman
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Etienne St Louis
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Mostafa Al-Habboubi
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | | | - Paola Fata
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Dan Leon Deckelbaum
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Tarek S Razek
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Kosar A Khwaja
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada.
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Management of acute diverticulitis and its complications. Indian J Surg 2014; 76:429-35. [PMID: 25614717 DOI: 10.1007/s12262-014-1086-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann's procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications-such as fistulating disease, strictures or recurrent diverticular bleeding-and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases.
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Alizai PH, Schulze-Hagen M, Klink CD, Ulmer F, Roeth AA, Neumann UP, Jansen M, Rosch R. Primary anastomosis with a defunctioning stoma versus Hartmann's procedure for perforated diverticulitis--a comparison of stoma reversal rates. Int J Colorectal Dis 2013; 28:1681-8. [PMID: 23913315 DOI: 10.1007/s00384-013-1753-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The ideal treatment of patients with perforated diverticulitis is still controversial. Hartmann's procedure has been the treatment of choice for decades, but primary anastomosis with a defunctioning stoma has become an accepted alternative. The aim of this study was to evaluate the stoma reversal rates after these two surgical strategies. METHODS A retrospective review of the data from patients with perforated sigmoid diverticulitis between 2002 and 2011 undergoing a Hartmann's procedure (HP) versus a primary anastomosis with a defunctioning stoma (PA) was performed. Additionally, patients were contacted by mail or telephone in March 2012 using a standardized questionnaire. RESULTS A total of 98 patients were identified: 72 undergoing HP and 26 patients receiving PA. The median follow-up time was 63 months (range 4-118). Whilst 85 % of patients with PA have had their stoma reversed, only 58 % of patients with an HP had a stoma reversal (p = 0.046). The median period until stoma reversal was significantly longer for HP (19 weeks) than for PA (12 weeks; p = 0.03). The 30-day mortality for PA was 12 % as opposed to 25 % for HP (p = 0.167). According to the Clavien-Dindo classification, surgical complications occurred significantly less frequently in patients with PA (p = 0.014). CONCLUSION The stoma reversal rates for PA are significantly higher than for HP. Thus, depending on the overall clinical situation, primary resection and anastomosis with a proximal defunctioning stoma might be the optimal procedure for selected patients with perforated diverticular disease.
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Affiliation(s)
- P H Alizai
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany,
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Cirocchi R, Trastulli S, Desiderio J, Listorti C, Boselli C, Parisi A, Noya G, Liu L. Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 2013; 28:447-57. [PMID: 23242271 DOI: 10.1007/s00384-012-1622-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis. OBJECTIVE This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis. METHODS A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes. RESULTS Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann's procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001). CONCLUSIONS Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.
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Affiliation(s)
- Roberto Cirocchi
- Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy
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Predictors of mortality after emergent surgery for acute colonic diverticulitis. J Trauma Acute Care Surg 2013; 74:611-6. [DOI: 10.1097/ta.0b013e31827d5d93] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lidsky ME, Thacker JKM, Lagoo-Deenadayalan SA, Scarborough JE. Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis. Surgery 2012; 152:465-72. [PMID: 22938905 DOI: 10.1016/j.surg.2012.06.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 06/29/2012] [Indexed: 01/28/2023]
Abstract
BACKGROUND The objectives of our study were to determine the association between age and postoperative outcomes after emergency surgery for diverticulitis and to identify risk factors for postoperative mortality among elderly patients. METHODS All patients from the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 Participant User Files undergoing emergent surgery for diverticulitis were included. Multivariate logistic regression was used to determine the association between age and postoperative morbidity and mortality after adjustment for perioperative variables. A separate regression model was used to determine risk factors for postoperative mortality among elderly patients, with specific postoperative complications being included as potential predictors. RESULTS We included 2,264 patients for analysis, of whom 1,267 (56%) were <65 years old (nonelderly), 648 (28.6%) were 65-79 years old (elderly), and 349 (15.4%) were ≥80 years old (super-elderly). Advanced age was a significant predictor of 30-day postoperative mortality, and to a lesser extent postoperative morbidity. Among those patients ≥65 years old, super-elderly age classification remained a significant predictor of mortality after adjustment for the presence or absence of postoperative complications. Mortality among elderly and super-elderly patients was greatest in the setting of specific complications, such as septic shock, prolonged postoperative mechanical ventilation, and acute renal failure. CONCLUSION Advanced age is an independent risk factor for death after emergency surgery for diverticulitis, with mortality being greatest among elderly patients who experience certain postoperative complications. Prevention of these complications should form the cornerstone of initiatives designed to lower the mortality associated with emergency surgery in elderly patients.
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Affiliation(s)
- Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
Perforation following acute diverticulitis is a typical scenario during the first attack. Different classification systems exist to classify acute perforated diverticulitis. While the Hinchey classification, which is based on intraoperative findings, is internationally best known, the German Hansen-Stock classification which is based on CT scan is widely accepted within Germany. When surgery is necessary, sigmoid colectomy is the standard of care. An important question is whether patients should receive primary anastomosis or a Hartmann procedure subsequently. A priori there are several arguments for both procedures. Hartmann's operation is extremely safe and, therefore, represents the best option in severely ill patients and/or extensive peritonitis. However, this operation carries a high risk of stoma nonreversal, or, when reversal is attempted, a high risk in terms of morbidity and mortality. In contrast, primary anastomosis with or without loop ileostoma is a slightly more lengthy procedure as normally the splenic flexure needs to be mobilized and construction of the anastomosis may consume more time than the Hartmann operation. The big advantage of primary anastomosis, however, is that there is no need for the potentially risky stoma reversal operation. The most interesting question is when to do the Hartmann operation or primary anastomosis. Several comparative case series were published showing that primary anastomosis is feasible in many patients. However, no randomized trial is available to date. It is of note, that all non-randomized case series are biased, i.e. that patients in better condition received anastomosis and those with severe peritonitis underwent Hartmann's operation. This bias is undoubtedly likely to be present, even if not obvious, in the published papers! Our own data suggest that this decision should not be based on the extent of peritonitis but rather on patient condition and comorbidity. In conclusion, sigmoid colectomy and primary anastomosis is feasible and safe in many patients who need surgery for perforated diverticulitis, particularly when combined with loop ileostomy. Based on our own published analysis, however, we recommend performing Hartmann's operation in severely ill patients who carry substantial comorbidity, while the extent of peritonitis appears not to be of predominant importance.
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Affiliation(s)
- Martin E Kreis
- Ludwig Maximilians University, Klinikum Grosshadern, Department of Surgery, Munich, Germany.
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Trends in the incidence of intestinal perforation in US dialysis patients (1992-2005). J Nephrol 2012; 26:281-8. [PMID: 22419235 DOI: 10.5301/jn.5000104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2011] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about the incidence of intestinal perforation in patients undergoing dialysis. Concerns exist that sevelamer hydrochloride may increase the risk of intestinal perforation. We examined long-term trends for the incidence of intestinal perforation among US dialysis patients. METHODS We studied all dialysis patients (1992-2005) who had Medicare as primary payer. We used ICD-9 diagnosis code 569.83 to ascertain events of intestinal perforation. We studied (a) all perforations and (b) perforations that did not appear to be associated with specific causative conditions (specific diseases or iatrogenic procedures within 7 days of perforation). We used Poisson regression to model the annual number of intestinal perforations and tested for any changes in levels and temporal trends of incidence rates before versus after January 1, 1999. RESULTS Overall, 1,060,132 patients contributed 2.7 million patient-years. We observed 12,355 events of intestinal perforation and 7,814 spontaneous perforations. The corresponding incidence rates were 4.6 (total) and 2.9 (spontaneous perforation) episodes per 1,000 person-years, respectively. For both outcome definitions, 30-day mortality was 42%. Unadjusted and adjusted incidence rates were not materially different over time. Formal tests for any changes in the level or slope of incidence comparing time periods before and after January 1, 1999, indicated no evidence for any changes in the incidence of intestinal perforation over time. CONCLUSIONS In US dialysis patients, incidence of intestinal perforation was low, but associated with high short-term mortality. We did not detect any significant changes in the incidence of intestinal perforation before versus after approval of sevelamer hydrochloride in late 1998.
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Naraynsingh V, Maharaj R, Hassranah D, Hariharan S, Dan D, Zbar AP. Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making? Tech Coloproctol 2011; 15:199-203. [PMID: 21271350 DOI: 10.1007/s10151-011-0675-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/09/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although the Hinchey scoring system has guided surgical decision making for perforated diverticulitis, what constitutes optimal surgical management is controversial. We report our experience of selective primary closure of the perforation without use of a transverse colostomy and the specific circumstances in which this may be safe. METHODS All cases of perforated diverticular disease of the sigmoid colon with Hinchey grade IV (faecal) peritonitis seen over a 4-year period from one surgical unit were reviewed. RESULTS Primary closure without a diverting stoma was performed in six of the eight patients studied since the bowel was deemed healthy, and resection and primary end-to-end anastomosis were performed in the other two patients because there was associated scarring and stricture formation distally. In the primary closure patients, the site of the perforation was dissected and closed with attendant omentoplasty and a meticulous peritoneal toilet. In one of these cases, a diverting stoma was later fashioned after the patient developed a short-lived faecal fistula. CONCLUSION The status of the underlying bowel, not the degree of peritoneal soiling, is the most significant consideration in defining the role of minimally invasive surgical treatment options for perforated diverticulitis. A new classification system that remains to be validated, taking into account the degree of colonic scarring and stricture formation, is proposed as a guide for surgical decision making in patients with perforated left-sided diverticulitis with faecal peritonitis.
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Affiliation(s)
- V Naraynsingh
- Department of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies, Trinidad, West Indies
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