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Sacks OA, Hall J. Management of Diverticulitis: A Review. JAMA Surg 2024; 159:696-703. [PMID: 38630452 DOI: 10.1001/jamasurg.2023.8104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Importance Care of patients with diverticulitis is undergoing a paradigm shift. This narrative review summarizes the current evidence for left-sided uncomplicated and complicated diverticulitis. The latest pathophysiology, advances in diagnosis, and prevention strategies are also reviewed. Observations Treatment is moving to the outpatient setting, physicians are forgoing antibiotics for uncomplicated disease, and the decision for elective surgery for diverticulitis has become preference sensitive. Furthermore, the most current data guiding surgical management of diverticulitis include the adoption of new minimally invasive and robot-assisted techniques. Conclusions and Relevance This review provides an updated summary of the best practices in the management of diverticulitis to guide colorectal and general surgeons in their treatment of patients with this common disease.
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Affiliation(s)
- Olivia A Sacks
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Jason Hall
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
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Le NK, Cho NY, Mallick S, Chervu N, Kim S, Sakowitz S, Benharash P, Lee H. Open Versus Minimally Invasive Emergent Colectomy for Diverticulitis. Am Surg 2024:31348241248701. [PMID: 38682325 DOI: 10.1177/00031348241248701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND The role of minimally invasive surgery (MIS) in the acute management of diverticulitis remains controversial. Using a national cohort, we examined the relationship between operative approaches with acute clinical and financial outcomes. METHODS Adults undergoing emergent colectomy for diverticulitis were tabulated from the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program. Regression models were developed to analyze the association between open and MIS approaches with major adverse events (MAE), as well as secondary endpoints. A subgroup analysis was conducted to compare outcomes between open and MIS requiring conversion to open (CTO). RESULTS Of 9194 patients, 1580 (17.3%) underwent MIS colectomy. The proportion of MIS resection increased from 15.1% in 2015 to 19.1% in 2020 (nptrend<.001). Compared to Open, MIS patients were younger, equally likely to be female, had a lower proportion of patients with ASA class ≥3, and a higher BMI. Preoperatively, MIS patients were less frequently diagnosed with sepsis. Following adjustment with open as reference, MIS approach had reduced odds of MAE (AOR .56), ostomy creation (AOR .12), shorter postoperative length of stay (LOS; β -1.63), and a lower likelihood of nonhome discharge (AOR .45, all P < .001). Additionally, CTO was linked to decreased likelihood of MAE (AOR .78, P = .01), ostomy creation (AOR .02, P < .001), comparable LOS (β -.46, P = .41), and reduced odds of nonhome discharge (AOR .58, P < .001), relative to open. DISCUSSION Compared to planned open colectomy, MIS resection was associated with improved clinical and financial outcomes, even in cases of CTO. Our findings suggest that whenever possible, MIS should be attempted first in emergent colectomy for diverticulitis. Nevertheless, future prospective studies are likely needed to further elucidate specific patient and clinical factors.
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Affiliation(s)
- Nguyen K Le
- David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Nam Yong Cho
- David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Saad Mallick
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Nikhil Chervu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Shineui Kim
- David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Sara Sakowitz
- David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Hanjoo Lee
- Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
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Sarmiento-Altamirano D, Neira-Quezada D, Willches-Encalada E, Cabrera-Ordoñez C, Valdivieso-Espinoza R, Himmler A, Di Saverio S. The influence of preoperative e intraoperative factors in predicting postoperative morbidity and mortality in perforated diverticulitis: a systematic review and meta-analysis. Updates Surg 2024; 76:397-409. [PMID: 38282071 DOI: 10.1007/s13304-023-01738-7] [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: 04/08/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024]
Abstract
To determine if preoperative-intraoperative factors such as age, comorbidities, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and severity of peritonitis affect the rate of morbidity and mortality in patients undergoing a primary anastomosis (PA) or Hartmann Procedure (HP) for perforated diverticulitis. This is a systematic review and meta-analysis, conducted according to PRISMA, with an electronic search of the PubMed, Medline, Cochrane Library, and Google Scholar databases. The search retrieved 614 studies, of which 11 were included. Preoperative-Intraoperative factors including age, ASA classification, BMI, severity of peritonitis, and comorbidities were collected. Primary endpoints were mortality and postoperative complications including sepsis, surgical site infection, wound dehiscence, hemorrhage, postoperative ileus, stoma complications, anastomotic leak, and stump leakage. 133,304 patients were included, of whom 126,504 (94.9%) underwent a HP and 6800 (5.1%) underwent a PA. There was no difference between the groups with regards to comorbidities (p = 0.32), BMI (p = 0.28), or severity of peritonitis (p = 0.09). There was no difference in mortality [RR 0.76 (0.44-1.33); p = 0.33]; [RR 0.66 (0.33-1.35); p = 0.25]. More non-surgical postoperative complications occurred in the HP group (p = 0.02). There was a significant association in the HP group between the severity of peritonitis and mortality (p = 0.01), and surgical site infection (p = 0.01). In patients with perforated diverticulitis, PA can be chosen. Age, comorbidities, and BMI do not influence postoperative outcomes. The severity of peritonitis should be taken into account as a predictor of postoperative morbidity and mortality.
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Affiliation(s)
| | | | | | | | | | - Amber Himmler
- University of California San Francisco, San Francisco, USA
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
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Omoto R. Comparison Between Primary Anastomosis Without Diverting Stoma and Hartmann's Procedure for Colorectal Perforation: A Retrospective Observational Study. Cureus 2024; 16:e58402. [PMID: 38756300 PMCID: PMC11098055 DOI: 10.7759/cureus.58402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Background Hartmann's procedure (HP) is performed for colorectal perforation to avoid the risk of anastomotic leakage. Few reports have compared the safety between primary anastomosis without diverting stoma (PAWODS) and HP for colorectal perforation, and whether PAWODS or HP should be performed has remained controversial. We aimed to investigate the feasibility and safety of performing PAWODS in comparison to HP for colorectal perforation. Methods The data of 97 consecutive patients with colorectal perforation who underwent surgery from April 2010 to December 2020 were collected retrospectively. PAWODS and HP were performed in 51 and 46 patients, respectively. Univariate and multivariate analyses were performed to compare the clinical characteristics and postoperative outcomes of patients treated with PAWODS with those treated with HP. Results In the multivariate analysis, low serum albumin (hazard ratio (HR)=3.49; 95%CI=1.247-9.757; P=0.017) and left-sided colon and rectum perforation (HR=16.8; 95%CI=1.792-157.599; P=0.014) were significantly associated with the decision to perform HP. There was a significant difference in the mortality of the two groups (PAWODS vs. HP: 0% vs. 8.7%; P=0.047). The severe morbidity rate (Clavien-Dindo III-V) was significantly higher in the HP group (PAWODS vs. HP: 10% vs. 30%; P=0.020). In the PAWODS group, anastomotic leakage occurred in five of 51 patients (9.8%), four (8.7%) of whom required re-operation. Conclusions In appropriately selected patients, PAWODS could be safely performed with an acceptable rate of anastomotic leakage. The serum albumin level and site of perforation may be simple and useful factors for guiding decision-making on the surgical procedure.
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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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Williams B, Gupta A, Koller SD, Starr TJ, Star MJH, Shaw DD, Hakim AH, Leinicke J, Visenio M, Perrone KH, Torgerson ZH, Person AD, Ternent CA, Chen KA, Kapadia MR, Keller DS, Elnagar J, Okonkwo A, Gagliano RA, Clark CE, Arcomano N, Abcarian AM, Beaty JS. Emergency Colon and Rectal Surgery, What Every Surgeon Needs to Know. Curr Probl Surg 2024; 61:101427. [PMID: 38161059 DOI: 10.1016/j.cpsurg.2023.101427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Brian Williams
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Abhinav Gupta
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Sarah D Koller
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Tanya Jt Starr
- Health Corporation of America, Midwest Division, Kansas City, KS
| | | | - Darcy D Shaw
- Health Corporation of America, Midwest Division, Kansas City, KS
| | - Ali H Hakim
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Leinicke
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Michael Visenio
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Kenneth H Perrone
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | | | - Austin D Person
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Charles A Ternent
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Kevin A Chen
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Muneera R Kapadia
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Deborah S Keller
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA; Marks Colorectal Surgical Associates, Wynnewood, PA
| | - Jaafar Elnagar
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA
| | | | | | | | - Nicolas Arcomano
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Ariane M Abcarian
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL; Cook County Health, Chicago, IL
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Paasch C, De Santo G, Berndt N, Strik MW, Lefering R, Siegel R. Feasibility of laparoscopic resection for perforated diverticulitis: a retrospective observational study of 77 consecutive patients. Acta Chir Belg 2023; 123:632-639. [PMID: 36062887 DOI: 10.1080/00015458.2022.2122006] [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: 09/29/2021] [Accepted: 09/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Perforated colonic diverticulitis with purulent or fecal contamination (PCD) is a surgical emergency with high morbidity and mortality. Traditionally, open surgery as a Hartmann procedure (HP) has been performed. Feasibility of the laparoscopic approach (LA) either with primary anastomosis (PA) or as an HP has been shown, but evidence and implementation into daily routine remain low. We analysed all patients with PCD and emergency surgery at our institution to compare post-operative outcomes between LA and open surgery. Our results should add more evidence about the potential benefit of LA in treating PCD. METHODS This retrospective analysis conducted at a tertiary care centre in Germany included all patients with PCD undergoing emergency surgery between June 2007 and February 2019. Mortality and postoperative morbidity according to Clavien-Dindo-Classification are the primary endpoints. Secondary endpoints were stoma-free survival and length of hospital stay. RESULTS Seventy-seven patients were identified (41 female/36 male; median age 67.9 years). Sixty patients underwent a LA (conversion in 9 of 60, 15%). PA has been performed in 25 of 77 patients (22 LA, 3 with open surgery). Severe complications and death (Clavien-Dindo-Classification grade IIIb-V) were lower in patients with LA (17/60, 28%) compared to open surgery (9/17, 53%; p = 0.082) as well as the length of hospital stay (LOS; LA 9 days vs. open surgery 17 days; p = 0.016). CONCLUSION The LA is feasible in the majority of patients with PCD and may be warranted as a routine in emergency surgery. Although limited by a selection bias of this retrospective study, the LA seems to reduce morbidity and LOS.
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Affiliation(s)
- Christoph Paasch
- Clinic for General and Visceral Surgery, University Hospital Brandenburg an der Havel, Brandenburg Medical University, Brandenburg an der Havel, Germany
- Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Gianluca De Santo
- Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Nadja Berndt
- Medical School, Charité - University Medicine Berlin, Berlin, Germany
| | - Martin W Strik
- Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Robert Siegel
- Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany
- Faculty of Health, Witten/Herdecke University, Witten, Germany
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Salim N, Daidone C, Smith L, Raza A. Robotic Sigmoidectomy With Natural Orifice Specimen Extraction: A Single-Center Experience. Cureus 2023; 15:e49902. [PMID: 38174165 PMCID: PMC10763519 DOI: 10.7759/cureus.49902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
Background Natural orifice specimen extraction (NOSE) involves the removal of specimens through a naturally occurring orifice, such as the anus, rather than trans-abdominal extraction. NOSE procedures have been shown to significantly reduce postoperative complications and improve healing. Objective The purpose of this case series is to report the outcomes of 27 patients undergoing sigmoidectomies through natural orifice specimen extraction. Materials and methods We carefully recorded demographic data on age and BMI, as well as operative data on surgical indication, and length of stay. We also collected data on postoperative complications, including infection, hernia, wound dehiscence, urinary tract infections (UTIs), or anastomotic leaks. Results Our patients were majority female (n = 21, 77.8%) with a median age of 53.5 (range: 25-79) and median BMI of 33.2 kg/m2 (range: 16.7 - 48.3 kg/m2). Thirteen patients (48.1%) were obese (BMI > 30.0 kg/m2). The majority of these patients underwent sigmoidectomies for benign conditions such as recurrent diverticulitis (n = 9, 33.3%), rectal prolapse (n = 8, 29.6%), perforated diverticulitis (n = 3, 11.1%), colovesical fistula (n = 3, 11.1%), and abdominal abscess (n = 3, 11.1%) (Table 1). One patient was receiving treatment for sigmoid cancer. The average estimated blood loss was 63.26 mL. The average hospital stay was 3.61 days. Three patients (11.1%) developed a fever postoperatively (temperature >= 100.4 F), which resolved the day after. One patient completed a post-operative hospital stay of 19 days for dialysis and rehab placement. No patients (0.0%) experienced any postoperative complications, including wound infection, hernia, dehiscence, UTIs, or anastomotic leakages. There was no postoperative mortality. Conclusions Our study demonstrates the practicality and safety of NOSE procedures for sigmoidectomies as an alternative to transabdominal approaches to treat benign colon diseases.
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Affiliation(s)
- Naved Salim
- Department of Research, Edward Via College of Osteopathic Medicine, Monroe, USA
| | - Camryn Daidone
- Department of Research, Edward Via College of Osteopathic Medicine, Monroe, USA
| | - Leslie Smith
- Department of General Surgery, Rapides Regional Medical Center, Alexandria, USA
| | - Ahsan Raza
- Department of General Surgery, Rapides Regional Medical Center, Alexandria, USA
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Lluís N, Carbonell S, Villodre C, Zapater P, Cantó M, Mena L, Ramia JM, Lluís F. Propensity score matching analysis of laparoscopic surgery vs. open approach in 4 297 adult patients with acute appendicitis, acute cholecystitis or gastrointestinal tract perforation: a prospective multicentre study of nationwide outcomes. Int J Surg 2023; 109:1603-1611. [PMID: 37060247 PMCID: PMC10389196 DOI: 10.1097/js9.0000000000000384] [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: 08/30/2022] [Accepted: 03/27/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND AND AIMS Previous studies indicated that laparoscopic surgery could improve postoperative outcomes in acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, or acute diverticulitis, but some reported opposite results or differences in the magnitude of improvement. A contemporary analysis using propensity score matching that compares outcomes is lacking. METHODS Over a 6-month period, 38 centres (5% of all public hospitals) attending emergency general surgery patients on a 24 h, 7 days a week basis, enroled all consecutive adult patients who underwent laparoscopic surgery or open approach. RESULTS The study included 2 645 patients with acute appendicitis [32 years (22-51), 44.3% women], 1 182 with acute cholecystitis [65 years (48-76); 46.7% women], and 470 with gastrointestinal tract perforation [65 years (50-76); 34% women]. After propensity score matching, hospital stays decreased in acute appendicitis [open, 2 days (2-4); lap, 2 days (1-4); P <0.001], acute cholecystitis [open, 7 days (4-12); lap, 4 days (3-6); P <0.001], and gastrointestinal tract perforation [open, 11 days (7-17); lap, 6 days (5-8.5); P <0.001]. A decrease in 30-day morbidity was observed in acute appendicitis (open, 15.7%; lap, 9.7%; P <0.001), acute cholecystitis (open, 41%; lap, 21.7%; P <0.001), and gastrointestinal tract perforation (open, 45.2%; lap, 23.5%; P <0.001). A decrease in 30-day mortality was found in acute cholecystitis (open, 8.8%; lap, 2.8%; P =0.013) and gastrointestinal tract perforation (open, 10.4%; lap, 1.7%; P =0.013). CONCLUSIONS This clinically based, multicentre study suggests that an initial laparoscopic approach could be considered not only in patients with acute appendicitis or acute cholecystitis but also in patients with a perforation of the gastrointestinal tract.
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Affiliation(s)
- Núria Lluís
- Hepatobiliary and Pancreas Surgery, Department of Surgical Oncology, Miami Cancer Institute, Miami, FL
| | - Silvia Carbonell
- Departments of Surgery
- Institute for Health and Biomedical Research of Alicante, ISABIAL
| | - Celia Villodre
- Departments of Surgery
- Institute for Health and Biomedical Research of Alicante, ISABIAL
| | - Pedro Zapater
- Clinical Pharmacology
- Institute for Health and Biomedical Research of Alicante, ISABIAL
| | - Miguel Cantó
- Institute for Health and Biomedical Research of Alicante, ISABIAL
- Computing, BomhardIP, Alicante, Spain
| | - Luís Mena
- Clinical Documentation, Dr. Balmis General University Hospital
- Institute for Health and Biomedical Research of Alicante, ISABIAL
| | - José M. Ramia
- Departments of Surgery
- Institute for Health and Biomedical Research of Alicante, ISABIAL
| | - Félix Lluís
- Departments of Surgery
- Institute for Health and Biomedical Research of Alicante, ISABIAL
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10
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Dreifuss NH, Casas MA, Angeramo CA, Schlottmann F, Laxague F, Bun ME, Rotholtz NA. Sigmoid resection and primary anastomosis for perforated diverticulitis with peritonitis: To divert or not to divert-A systematic review and meta-analysis. Surgery 2023:S0039-6060(23)00241-6. [PMID: 37258308 DOI: 10.1016/j.surg.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/19/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND The role of proximal diversion in patients undergoing sigmoid resection and primary anastomosis for diverticulitis with generalized peritonitis is unclear. The aim of this study was to compare the clinical outcomes of sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with a proximal diversion in perforated diverticulitis with diffuse peritonitis. METHOD A systematic literature search on sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with proximal diversion for diverticulitis with diffuse peritonitis was conducted in the Medline and EMBASE databases. Randomized clinical trials and observational studies reporting the primary outcome of interest (30-day mortality) were included. Secondary outcomes were major morbidity, anastomotic leak, reoperation, stoma nonreversal rates, and length of hospital stay. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes. RESULTS A total of 17 studies involving 544 patients (sigmoid resection and primary anastomosis: 287 versus sigmoid resection and primary anastomosis with proximal diversion: 257) were included. Thirty-day mortality (odds ratio 1.12, 95% confidence interval 0.53-2.40, P = .76), major morbidity (odds ratio 1.40, 95% confidence interval 0.80-2.44, P = .24), anastomotic leak (odds ratio 0.34, 95% confidence interval 0.099-1.20, P = .10), reoperation (odds ratio 0.49, 95% confidence interval 0.17-1.46, P = .20), and length of stay (sigmoid resection and primary anastomosis: 12.1 vs resection and primary anastomosis with diverting ileostomy: 15 days, P = .44) were similar between groups. The risk of definitive stoma was significantly lower after sigmoid resection and primary anastomosis (odds ratio 0.05, 95% confidence interval 0.006-0.35, P = .003). CONCLUSION Sigmoid resection and primary anastomosis with or without proximal diversion have similar postoperative outcomes in selected patients with diverticulitis and diffuse peritonitis. However, further randomized controlled trials are needed to confirm these results.
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Affiliation(s)
- Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Maria A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Cristian A Angeramo
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Francisco Laxague
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Maximiliano E Bun
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Nicolás A Rotholtz
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina.
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11
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SAGES masters program: the top 10 seminal articles for the laparoscopic left and sigmoid colectomy pathway for complex disease. Surg Endosc 2023; 37:2538-2547. [PMID: 36922428 DOI: 10.1007/s00464-023-09965-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND The SAGES University Colorectal Masters Program is a structured educational curriculum that is designed to aid practicing surgeons develop and maintain knowledge and technical skills for laparoscopic colorectal surgery. The Colorectal Pathway is based on three anchoring procedures (laparoscopic right colectomy, laparoscopic left and sigmoid colectomy for uncomplicated and complex disease, and intracorporeal anastomosis for minimally invasive right colectomy) corresponding to three levels of performance (competency, proficiency and mastery). This manuscript presents focused summaries of the top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease. METHODS A systematic literature search of Web of Science for the most cited articles on the topic of laparoscopic complex left/sigmoid colectomy yielded 30 citations. These articles were reviewed and ranked by the SAGES Colorectal Task Force and invited subject experts according to their citation index. The top 10 ranked articles were then reviewed and summarized, with emphasis on relevance and impact in the field, study findings, strength and limitations and conclusions. RESULTS The top 10 seminal articles selected for the laparoscopic left/sigmoid colectomy for complex disease anchoring procedure include advanced procedures such as minimally invasive splenic flexure mobilization techniques, laparoscopic surgery for complicated and/or diverticulitis, splenic flexure tumors, complete mesocolic excision, and other techniques (e.g., Deloyers or colonic transposition in cases with limited colonic reach after extended left-sided resection). CONCLUSIONS The SAGES Colorectal Masters Program top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease anchoring procedure are presented. These procedures were the most essential in the armamentarium of practicing surgeons that perform minimally invasive surgery for complex left and sigmoid colon pathology.
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12
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Zamaray B, Veld JV, Burghgraef TA, Brohet R, van Westreenen HL, van Hooft JE, Siersema PD, Tanis PJ, Consten ECJ, Amelung F, Bastiaenen V, van der Bilt J, Burghgraef T, Draaisma W, de Groot J, Kok N, Kusters M, Nagtegaal I, Zwanenburg E. Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer - A prediction model. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:738-746. [PMID: 36641294 DOI: 10.1016/j.ejso.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS. MATERIALS AND METHODS Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T0) and after resection, in patients having a stoma in situ (T1). These risk factors were used to construct a web-based prediction tool. RESULTS Of 2099 patients included in the study (T0), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T1), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T0 and T1 population. Other predictors at T0 were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T1, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T0 and an AUC of 0.81 for T1. CONCLUSIONS PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.
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Affiliation(s)
- Bobby Zamaray
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - J V Veld
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - T A Burghgraef
- Department of Surgery, Meander Hospital, Amersfoort, the Netherlands
| | - R Brohet
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands
| | | | - J E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Location AMC, the Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands; Department of Oncological and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands; Department of Surgery, Meander Hospital, Amersfoort, the Netherlands.
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13
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Zhang Y, Liu C, Nistala KRY, Chong CS. Open versus laparoscopic Hartmann's procedure: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2421-2430. [PMID: 36416926 DOI: 10.1007/s00384-022-04285-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Hartmann's procedure is traditionally performed in emergency situations where single-step procedures with immediate anastomosis may be unsafe. However, it can be associated with significant morbidity and low colostomy reversal rate. Whilst randomised controlled trials and a Cochrane review have reported strong evidence of laparoscopic over open colectomies, no such reviews have been performed for Hartmann's procedure. Hence, this paper aims to summarise the existing evidence to determine the efficacy of laparoscopic Hartmann's procedure over its open counterpart. METHODS Embase, Medline and Cochrane databases were searched from inception to 15 November 2020 for keywords relating to 'laparoscopy' and 'Hartmann' using strict inclusion and exclusion criteria. Odds ratio was estimated for dichotomous outcomes and weighted mean difference was estimated for continuous outcomes. RESULTS From the 836 articles yielded from the search strategy, 12 articles were selected for meta-analysis. Pooled analysis revealed that laparoscopic Hartmann's procedure (LHP) allows for a shorter length of stay, and a lower risk of overall surgical site infections and superficial surgical site infections. There was no significant difference in other outcomes. Single-arm analysis of LHP also showed an unprecedented high colostomy reversal rate of over 80%. CONCLUSION In clinically suitable patients, laparoscopic Hartmann's procedure has benefits over open Hartmann's procedure. Despite the selection bias of single-arm studies, LHP has reported a high stoma reversal rate of over 80%. Future well-controlled studies should be done to affirm the findings.
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Affiliation(s)
- Yingjia Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chunxi Liu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Choon Seng Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Division of Colorectal Surgery, Department of Surgery, University Surgical Cluster, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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14
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Short Term Outcomes of Open and Minimally Invasive Approaches to Segmental Colectomy for Benign Colovesical Fistula. Surg Res Pract 2022; 2022:9242813. [DOI: 10.1155/2022/9242813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
Background. We speculated that a minimally invasive (MIS) colectomy for colovesical fistula is associated with less morbidity compared to an open colectomy. Methods. Multivariate analysis using logistic regression was used to investigate the outcomes of patients who underwent colectomy for benign colovesical fistula during 2012–2017 by surgical approach using the NSQIP database. Results. We identified 748 patients underwent partial colectomy for benign colovesical fistula during 2012–2017. Surgeons used the MIS approach in 72.7% of operations, with a conversion rate of 13.1%. The MIS approach was associated with lower morbidity (27.4% vs. 43.1%, AOR: 0.46,
) compared to the open approach. The mean operation duration was longer in MIS operations compared to open (225 min vs. 201 min,
). The robotic approach to colectomy showed no significant difference in morbidity (28.4% vs. 27.2%,
) but a decrease in conversion rate (8.1% vs. 13.8%,
) and an increase in operation length (249 min vs. 222 min, mean difference: 27 min,
) compared to a laparoscopic approach. There was no significant difference in the anastomotic leak rate between MIS and open approaches (3.7% vs. 5.4%,
) and between laparoscopic and robotic approaches (2.8% vs. 3.8%,
). Conclusions. We found a 72.7% utilization rate of MIS approach to colectomy for benign colovesical fistula in the NSQIP hospitals with a 13.6% conversion rate. Patients with MIS approach had significantly lower morbidity compared to open. A robotic approach to partial colectomy has the same morbidity risk with a decreased conversion rate compared to laparoscopic approach.
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15
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Chen YC, Tsai YY, Chang SC, Chen HC, Ke TW, Fingerhut A, Chen WTL. Laparoscopic versus open emergent colectomy for ischemic colitis: a propensity score-matched comparison. World J Emerg Surg 2022; 17:53. [PMID: 36229844 PMCID: PMC9563494 DOI: 10.1186/s13017-022-00458-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/06/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Laparoscopic colectomy is rarely performed for ischemic colitis. The aim of this propensity score-matched study was to compare preoperative characteristics, intraoperative details and short-term outcomes for emergent laparoscopic colectomy versus the traditional open approach for patients with ischemic colitis.
Methods Retrospective review of 96 patients who underwent emergent colectomy for ischemic colitis between January 2011 and December 2020 (39 via laparoscopy, 57 via laparotomy) was performed. We compared short-term outcomes after using a one-to-one ratio and nearest-neighbor propensity score matching to obtain similar preoperative and intraoperative parameters in each group. Results Patients in the open group experienced more surgical site complications (52.6% vs. 23.0%, p = 0.004), more intra-abdominal abscesses (47.3% vs. 17.9%, p = 0.003), longer need for ventilator support (20 days vs. 0 days, p < 0.001), more major complications (77.2% vs. 43.5%, p = 0.001), higher mortality (49.1% vs. 20.5%, p = 0.004), and longer hospital stay (32 days vs. 19 days, p = 0.001). After propensity score matching (31 patients in each group), patients undergoing open (vs. laparoscopy) had more surgical site complications (45.1% vs. 19.4%, p = 0.030) and required longer ventilator support (14 vs. 3 days, p = 0.039). After multivariate analysis, Charlson Comorbidity Index (p = 0.024), APACHE II score (p = 0.001), and Favier’s classification (p = 0.023) were independent predictors of mortality. Conclusions Laparoscopic emergent colectomy for ischemic colitis is feasible and is associated with fewer surgical site complications and better respiratory function, compared to the open approach.
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Affiliation(s)
- Yi-Chang Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC.,Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Yuan-Yao Tsai
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Sheng-Chi Chang
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Hung-Chang Chen
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Tao-Wei Ke
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Abe Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| | - William Tzu-Liang Chen
- Department of Colorectal Surgery, China Medical University Hsinchu Hospital, No. 199, Sec.1, Xinglong RD, Zhubei City, 30272, Hsinchu County, Taiwan, ROC.
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16
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Aoki H, Yamanaka K, Kurimoto M, Hanabata Y, Shinkura A, Harada K, Kayano M, Tashima M, Tamura J. Evaluating the outcomes of primary anastomosis with hand-sewn full-circular reinforcement in managing perforated left-sided colonic diverticulitis. Ann Med Surg (Lond) 2022; 82:104728. [PMID: 36268302 PMCID: PMC9577872 DOI: 10.1016/j.amsu.2022.104728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/18/2022] [Indexed: 11/29/2022] Open
Abstract
Background It is a challenge to avoid stoma formation in emergency surgery of perforated left-sided diverticulum. The hand-sewn full-circular reinforcement of the colorectal anastomosis is used during complete pelvic peritonectomy to avoid a diverting ileostomy. This study examined the effect of applying the reinforcement method to perforated left-sided colonic diverticulitis with respect to the permanent stoma rate and cost-effectiveness. Materials and methods This historical cohort study examined all patients who underwent emergency surgery for perforation of a left-sided diverticulum at the Hyogo Prefectural Amagasaki General Medical Center between July 2015 and September 2019. The cohort was divided into two groups: those who underwent conventional method (Group F) and those for whom the hand-sewn full-circular reinforcement method was actively performed (Group L). Results The number of patients who underwent emergency surgery which did not lead to an ostomy increased significantly from 12% (3/25) in Group F to 42% (11/26) in Group L (P = 0.0015). The rate of permanent stoma decreased from 80% in Group F to 27% in Group L (P < 0.001). Total treatment costs for patients under the age of 80 in Group L were significantly lower than those in Group F (2170000 ± 1020000 vs 3270000 ± 1960000 JPY; P = 0.018). Conclusions In emergency surgery for left-sided perforated colonic diverticulitis, applying the hand-sewn full-circle reinforcement of the anastomotic site may reduce stoma formation at the initial surgery and consequently decrease permanent stoma rate and contribute to cost-effectiveness without increasing complications such as anastomotic leakage. Primary anastomosis was used as an emergency approach to perforated diverticulitis. Primary anastomosis was reinforced by a hand-sewn serosal suture. Full-circle reinforcement of the anastomosis may decrease the permanent stoma rate. Full-circle reinforcement of the anastomosis may be cost effective in approach to perforated diverticulitis.
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17
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Pavlidis ET, Pavlidis TE. Current Aspects on the Management of Perforated Acute Diverticulitis: A Narrative Review. Cureus 2022; 14:e28446. [PMID: 36176861 PMCID: PMC9509703 DOI: 10.7759/cureus.28446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 02/05/2023] Open
Abstract
Unhealthy nutritional habits and the current western lifestyle have led to an increased incidence of acute diverticulitis, which mainly affects older patients. However, the disease course in younger patients might be more severe. It has a continued increase in surgical practice, as it is the most common clinical condition encountered in the emergencies. Diagnosis and management have changed over the past decade. C-reactive protein > 170 mg/L represents the cut-off point between moderate and severe diverticulitis, and a CT scan is mandatory. It demands urgent surgical management and has high morbidity and mortality rate, especially in immunosuppressed patients, reaching up to 25%. According to the contemporary guidelines, there have been certain indications for conservative management and re-evaluation (administration of antibiotics, CT-guided drainage of the abscess, when it is > 4 cm). They include pericolic air bubbles or a small amount of fluid, absence of abscess within a distance of 5 cm from the affected bowel or abscess ≤4 cm. In other cases, Hartmann's sigmoidectomy is the procedure of choice. An alternative choice, nowadays, is resection and primary anastomosis with or without diverting stoma, especially in younger patients. Laparoscopic lavage only versus primary resection has been performed in severe cases of Hinchey III or IV. Damage control surgery, possible open abdomen, and reoperation are recommended in severe sepsis. Hinchey's classification may not be absolutely adequate, and several modifications have been proposed. Current classification criteria (CRP, qSOFA score) are more appropriate. The decision-making must be individualized depending on the hemodynamic status (septic shock), age, comorbidity, immune status, intraoperative findings, and MPI (Mannheim peritonitis index).
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Affiliation(s)
- Efstathios T Pavlidis
- 2nd Surgical Propedeutic Department, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, GRC
| | - Theodoros E Pavlidis
- 2nd Surgical Propedeutic Department, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, GRC
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18
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Fugazzola P, Ceresoli M, Coccolini F, Gabrielli F, Puzziello A, Monzani F, Amato B, Sganga G, Sartelli M, Menichetti F, Puglisi GA, Tartaglia D, Carcoforo P, Avenia N, Kluger Y, Paolillo C, Zago M, Leppäniemi A, Tomasoni M, Cobianchi L, Dal Mas F, Improta M, Moore EE, Peitzman AB, Sugrue M, Agnoletti V, Fraga GP, Weber DG, Damaskos D, Abu-Zidan FM, Wani I, Kirkpatrick AW, Pikoulis M, Pararas N, Tan E, Broek RT, Maier RV, Davies RJ, Kashuk J, Shelat VG, Mefire AC, Augustin G, Magnone S, Poiasina E, De Simone B, Chiarugi M, Biffl W, Baiocchi GL, Catena F, Ansaloni L. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg 2022; 17:5. [PMID: 35063008 PMCID: PMC8781436 DOI: 10.1186/s13017-022-00408-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/27/2021] [Indexed: 02/08/2023] Open
Abstract
Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.
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Affiliation(s)
- Paola Fugazzola
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy.
| | - Marco Ceresoli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Federico Coccolini
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Francesco Gabrielli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alessandro Puzziello
- Department of Surgery and Transplants, AOU San Giovanni di Dio and Ruggi d'Aragona, University of Salerno, Fisciano, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Francesco Menichetti
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Dario Tartaglia
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Paolo Carcoforo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Nicola Avenia
- Medical School, General Surgery and Surgical Specialties Unit, S. Maria University Hospital University of Perugia, Terni, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ciro Paolillo
- Emergency Room Brescia Spedali Civili General Hospital, Brescia, Italy
| | - Mauro Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matteo Tomasoni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Lorenzo Cobianchi
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Lincoln International Business School, University of Lincoln, Lincoln, UK
| | | | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO, USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Michael Sugrue
- Donegal Clinical Research Academy, Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | | | - Gustavo P Fraga
- Surgery Department, Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | | | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Imtiaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Sringar, Kashmir, India
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attiko Hospital, MSc "Global Health-Disaster Medicine", National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Nikolaos Pararas
- General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Edward Tan
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Goran Augustin
- Department of Surgery, University Hospital Centre, Zagreb, Croatia
| | - Stefano Magnone
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Elia Poiasina
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Massimo Chiarugi
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Gian Luca Baiocchi
- Department of General Surgery, ASST Cremona, University of Brescia, Cremona, Italy
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Luca Ansaloni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
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19
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Koprowski MA, Affleck A, Tsikitis VL. Emerging evidence and recent controversies in diverticulitis: a 5-year review. Ann Gastroenterol 2022; 35:8-16. [PMID: 34987283 PMCID: PMC8713340 DOI: 10.20524/aog.2021.0677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022] Open
Abstract
Diverticulitis is a common gastrointestinal disease that still garners significant attention and study because of its heterogeneity in presentation and outcome. We provide a review of the newest and most controversial topics in diverticulitis. Recent discoveries on the influence of diet and other environmental risk factors are discussed, showing how the epidemiology of the disease process is shifting away from what was previously felt to be a disorder primarily limited to older western populations. Interestingly, as has long been suspected, genetic mutations and variations associated with the development of diverticulitis are being discovered and are summarized here. The data for non-operative and outpatient management of diverticulitis are reviewed, as are pharmacologic agents studied for use in the secondary prevention of diverticulitis. Lastly, we present controversies in the surgical treatment of diverticulitis. This review will provide a synopsis of the last 5 years of literature relating to diverticulitis.
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Affiliation(s)
| | - Arthur Affleck
- Department of Surgery (Marina Affi Koprowski, Arthur Affleck)
| | - Vassiliki Liana Tsikitis
- Division of Gastrointestinal Surgery, Department of Surgery (Vassiliki Liana Tsikitis), Oregon Health and Science University, Portland, OR, USA
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Warps ALK, Zwanenburg ES, Dekker JWT, Tollenaar RAEM, Bemelman WA, Hompes R, Tanis PJ, de Groof EJ. Laparoscopic Versus Open Colorectal Surgery in the Emergency Setting: A Systematic Review and Meta-analysis. ANNALS OF SURGERY OPEN 2021; 2:e097. [PMID: 37635817 PMCID: PMC10455067 DOI: 10.1097/as9.0000000000000097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/19/2021] [Indexed: 11/26/2022] Open
Abstract
Objective This systematic review and meta-analysis aimed to compare published outcomes of patients undergoing laparoscopic versus open emergency colorectal surgery, with mortality as primary outcome. Background In contrast to the elective setting, the value of laparoscopic emergency colorectal surgery remains unclear. Methods PubMed, Embase, the Cochrane Library, and CINAHL were searched until January 6, 2021. Only comparative studies were included. Meta-analyses were performed using a random-effect model. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale were used for quality assessment. Results Overall, 28 observational studies and 1 randomized controlled trial were included, comprising 7865 laparoscopy patients and 55,862 open surgery patients. Quality assessment revealed 'good quality' in 16 of 28 observational studies, and low to intermediate risk of bias for the randomized trial. Laparoscopy was associated with significantly lower postoperative mortality compared to open surgery (odds ratio [OR] 0.44; 95% confidence interval [CI], 0.35-0.54). Laparoscopy resulted in significantly less postoperative overall morbidity (OR, 0.53; 95% CI, 0.43-0.65), wound infection (OR, 0.63; 95% CI, 0.45-0.88), wound dehiscence (OR, 0.37; 95% CI, 0.18-0.77), ileus (OR, 0.68; 95% CI 0.51-0.91), pulmonary (OR, 0.43; 95% CI, 0.24-0.78) and cardiac complications (OR, 0.56; 95% CI, 0.35-0.90), and shorter length of stay. No meta-analyses were performed for long-term outcomes due to scarcity of data. Conclusions The systematic review and meta-analysis suggest a benefit of laparoscopy for emergency colorectal surgery, with a lower risk of postoperative mortality and morbidity. However, the almost exclusive use of retrospective observational study designs with inherent biases should be taken into account.
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Affiliation(s)
- Anne-Loes K Warps
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
- Department of Surgery, Leiden University Medical Center, Albinusdreef, Leiden, The Netherlands
- Dutch ColoRectal Audit (DCRA), Dutch Institute for Clinical Auditing, Rijnsburgerweg, Leiden, The Netherlands
| | - Emma S Zwanenburg
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Jan Willem T Dekker
- Department of Surgery, Reinier de Graaf Groep, Reinier de Graafweg, Delft, The Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Albinusdreef, Leiden, The Netherlands
- Dutch ColoRectal Audit (DCRA), Dutch Institute for Clinical Auditing, Rijnsburgerweg, Leiden, The Netherlands
| | - Willem A Bemelman
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Roel Hompes
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, de Boelelaan, Amsterdam, The Netherlands
| | - Elisabeth J de Groof
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
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Abstract
BACKGROUND Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting. OBJECTIVE The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis. DESIGN This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching. SETTINGS Interventions were performed in hospitals participating in the national database. PATIENTS Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat. MAIN OUTCOME MEASURES Outcomes measures included length of stay and overall morbidity and mortality. RESULTS Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates. LIMITATIONS Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors. CONCLUSIONS Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421. ABORDAJE ABIERTO VERSUS MNIMAMENTE INVASIVO PARA COLECTOMA DE EMERGENCIA EN DIVERTICULITIS PERFORADA ANTECEDENTES:Tradicionalmente, la diverticulitis perforada se ha tratado con un abordaje abierto, con un procedimiento de Hartmann o una colectomía con anastomosis primaria. La cirugía mínimamente invasiva se asocia con ventajas posoperatorias en el escenario electivo y puede mostrar beneficio en el escenario emergente.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios del abordaje abierto versus el mínimamente invasivo para la diverticulitis perforada emergente.DISEÑO:Ésta fue una revisión retrospectiva de la base de datos de colectomía dirigida del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos utilizando el pareamiento por puntaje de propensión.ESCENARIO:Las intervenciones se realizaron en los hospitales participantes en la base de datos nacional.PACIENTES:Se incluyeron pacientes que fueron sometidos a colectomía emergente de 2012 a 2017. Los procedimientos se dividieron en procedimiento de Hartmann y anastomosis primaria. Los grupos abierto versus mínimamente invasivo se definieron por intención de tratar.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron la duración de la estancia, la morbilidad general y la mortalidad.RESULTADOS:De 130,616 pacientes, 7,105 cumplieron los criterios de inclusión (4,486 procedimiento de Hartmann y 2,619 anastomosis primaria). 1,989 casos abiertos de procedimientos de Hartmann se emparejaron con 663 casos mínimamente invasivos. El grupo mínimamente invasivo se sometió a operaciones más prolongadas y tuvo tasas más bajas de insuficiencia respiratoria. No hubo diferencias en las complicaciones generales, la mortalidad, la duración de la estancia o el alta domiciliaria. En el grupo de anastomosis primaria, 1,027 casos se emparejaron 1: 1. El abordaje mínimamente invasivo se asoció con tiempos quirúrgicos más prolongados, pero también con tasas reducidas de dehiscencia de herida, sepsis, sangrado, complicaciones generales y la duración de la estancia. No se detectaron diferencias en las tasas de fuga anastomótica, mortalidad, reintervención o reingreso.LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva, pérdida de datos, falta de uniformidad, sesgo de selección y errores de codificación.CONCLUSIONES:La anastomosis primaria mínimamente invasiva emergente resulta en una estancia más corta y una disminución de la morbilidad a los 30 días en comparación con la anastomosis primaria abierta para la diverticulitis perforada. El procedimiento de Hartmann abierto y mínimamente invasivo de emergencia para la diverticulitis perforada tiene resultados comparables, quizás debido a una tasa de conversión del 40%. Consulte el Video Resumen en http://links.lww.com/DCR/B421.
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Moghadamyeghaneh Z, Talus H, Fitzgerald S, Muthusamy M, Stamos MJ, Roudnitsky V. Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis. Am Surg 2020; 87:561-567. [PMID: 33118383 DOI: 10.1177/0003134820950295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality. METHODS The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach. RESULTS We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, P < .01) and mean hospitalization length of patients (13 days vs 10 days, P < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, P < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, P = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, P < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, P = .04) and CHF (9% vs 3.1%, P < .0). CONCLUSION The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis.
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Affiliation(s)
| | - Henry Talus
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Simon Fitzgerald
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Muthukumar Muthusamy
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Michael J Stamos
- Department of Surgery, University of California, Irvine, CA, USA
| | - Valery Roudnitsky
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
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Short- and long-term outcomes for primary anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors. Langenbecks Arch Surg 2020; 406:121-129. [PMID: 33083847 PMCID: PMC7870590 DOI: 10.1007/s00423-020-02015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/16/2020] [Indexed: 11/13/2022]
Abstract
Purpose The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. Methods Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. Results Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06–0.96, p = .044). Conclusions In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.
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Technical Evidence Review for Emergency Major Abdominal Operation Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2020; 231:743-764.e5. [PMID: 32979468 DOI: 10.1016/j.jamcollsurg.2020.08.772] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
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Chadi SA, Guidolin K, Caycedo-Marulanda A, Sharkawy A, Spinelli A, Quereshy FA, Okrainec A. Current Evidence for Minimally Invasive Surgery During the COVID-19 Pandemic and Risk Mitigation Strategies: A Narrative Review. Ann Surg 2020; 272:e118-e124. [PMID: 32675513 PMCID: PMC7268822 DOI: 10.1097/sla.0000000000004010] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks. SUMMARY BACKGROUND DATA The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action. METHODS We conducted a narrative review of the existing literature surrounding the risks of viral transmission during laparoscopic surgery and balance these risks against the benefits of minimally invasive approaches. We also propose mitigation measures to address these risks that we have adopted in our institution. RESULTS AND CONCLUSION While it is currently assumed that open surgery minimizes operating room staff exposure to the virus, our findings reveal that this may not be the case. A well-informed, evidence-based opinion is critical when making decisions regarding which operative approach to pursue, for the safety and well-being of the patient, the operating room staff, and the healthcare system at large. Minimally invasive surgical approaches offer significant advantages with respect to both patient care, and the mitigation of the risk of viral transmission during surgery, provided the appropriate equipment and expertise are present.
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Affiliation(s)
- Sami A Chadi
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Keegan Guidolin
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | | | - Abdu Sharkawy
- Department of Medicine, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milano, Italy
| | - Fayez A Quereshy
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Allan Okrainec
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
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Curran T, Kwaan MR. Controversies in the Management of Diverticulitis. Adv Surg 2020; 54:1-16. [PMID: 32713424 DOI: 10.1016/j.yasu.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Thomas Curran
- Medical University of South Carolina, 30 Courtenay Drive, Suite 249, MSC 295, Charleston, SC 29425, USA.
| | - Mary R Kwaan
- David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Avenue, 72-215 CHS, Los Angeles, CA 90095-3075, USA
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Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis. J Gastrointest Surg 2020; 24:1173-1182. [PMID: 31845141 DOI: 10.1007/s11605-019-04490-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 11/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach. METHODS The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat). RESULTS A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group. CONCLUSIONS Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings.
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Binda GA. Management of acute perforated diverticulitis with generalized peritonitis: is this the end of the Hartmann’s era? Tech Coloproctol 2020; 24:509-511. [DOI: 10.1007/s10151-020-02201-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 01/20/2023]
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Laparoscopy and resection with primary anastomosis for perforated diverticulitis: challenging old dogmas. Updates Surg 2020; 72:21-28. [DOI: 10.1007/s13304-020-00708-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/16/2020] [Indexed: 01/25/2023]
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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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Cirocchi R, Fearnhead N, Vettoretto N, Cassini D, Popivanov G, Henry BM, Tomaszewski K, D'Andrea V, Davies J, Di Saverio S. The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: A systematic review and meta-analysis. Surgeon 2019; 17:360-369. [PMID: 30314956 DOI: 10.1016/j.surge.2018.08.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 08/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nowadays sigmoidectomy is recommended as "gold standard" treatment for generalized purulent or faecal peritonitis from sigmoid perforated diverticulitis. This systematic review and meta-analysis aimed to assess effectiveness and safety of laparoscopic access versus open sigmoidectomy in acute setting. METHODS A systematic literature search was performed for randomized controlled trials (RCTs) and non-RCTs published in PubMed, SCOPUS and Web of Science. RESULTS The search yielded four non-RCTs encompassing 436 patients undergoing either laparoscopic (181 patients, 41.51%) versus open sigmoid resection (255 patients, 58.49%). All studies reported ASA scores, but only four studies reported other severity scoring systems (Mannheim Peritonitis Index, P-POSSUM). Level of surgical expertise was reported in only one study. Laparoscopy improves slightly the rates of overall post-operative complications and post-operative hospital stay, respectively (RR 0.62, 95% CI 0.49 to 0.80 and MD -6.53, 95% CI -16.05 to 2.99). Laparoscopy did not seem to improve the other clinical outcomes: rate of Hartmann's vs anastomosis, operating time, reoperation rate and postoperative 30-day mortality. CONCLUSION In this review four prospective studies were included, over 20 + year period, including overall 400 + patients. This meta-analysis revealed significant advantages associated with a laparoscopic over open approach to emergency sigmoidectomy in acute diverticulitis in terms of postoperative complication rates, although no differences were found in other outcomes. The lack of hemodynamic data and reasons for operative approach hamper interpretation of the data suggesting that patients undergoing open surgery were sicker and these results must be considered with extreme caution and this hypothesis requires confirmation by future prospective randomised controlled trials.
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Affiliation(s)
- Roberto Cirocchi
- Department of Surgical and Biomedical Sciences, University of Perugia, Italy.
| | - Nicola Fearnhead
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | | | | | - Georgi Popivanov
- Military Medical Academy, Clinic of Endoscopic, Endocrine Surgery and Coloproctology, Sofia, Bulgaria.
| | | | | | - Vito D'Andrea
- Department of Surgical Sciences, The University of Rome "La Sapienza", Rome, Italy.
| | - Justin Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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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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Neifert S, Ilonzo N, Gribben JL, Leitman IM. Economic Disparities in Patients Undergoing Sigmoidectomy. JSLS 2019; 22:JSLS.2018.00066. [PMID: 30607106 PMCID: PMC6305960 DOI: 10.4293/jsls.2018.00066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background and Objectives: Disparities in health care outcomes and resources utilized are present in the treatment of many conditions and represent an area for targeted improvement. This study analyzes the differences in outcomes and total hospital charges between the highest and lowest income quartiles of patients undergoing sigmoid colectomy. Methods: This retrospective cohort study included patients undergoing sigmoid colectomy from 2013 to 2014 queried from the Agency for Healthcare Research and Quality National Inpatient Sample Database who were categorized as the lowest and highest income quartile based on average income of the patient's ZIP code. Patients were grouped into income quartiles, as defined by average income in the ZIP code of residence. In-hospital complications were the primary outcome of this study. We hypothesized that patients in the lowest income quartile would have poorer outcomes than those in the highest income quartile prior to data collection. Results: The lowest (n = 40,995) and highest (n = 40,940) income quartiles are not significantly different based on age or gender. The lowest income quartile was sicker, with higher mean scores for the All Patient Refined Diagnosis Related Group Severity Index and All Patient Refined Diagnosis Related Group Risk of Mortality Index. The lowest income quartile cohort had higher rates of postoperative complications and higher total charges than those in the highest income quartile. Adjusted regression analysis showed significantly lower total charges for the lowest income quartile but no significant differences in overall complications, mortality rates, or nonhome discharge. Conclusions: Patients in the highest income quartile utilize more hospital resources than the lowest income quartile. Additional study is required to understand why these differences exist. Key Points: 1. Significant differences in outcomes and hospital charges exist between socioeconomic groups undergoing sigmoidectomy. 2. There does not seem to be a difference in outcomes after sigmoidectomy among different socioeconomic groups. 3. Elective and laparoscopic sigmoid colectomy is more frequently applied to higher socioeconomic groups. 4. Hospital charges are also greater among patients of higher socioeconomic groups undergoing sigmoid colectomy. Question: Does socioeconomic status affect outcomes and total charges in patients undergoing sigmoid colectomy? Findings: Unadjusted analysis showed significant disparities between the highest and lowest income quartile in outcomes after sigmoid colon resection. Adjusted analysis showed no difference in outcomes, with patients in the highest income quartile having higher total charges. Meaning: There is a value difference between high-income and low-income patients undergoing sigmoid colectomy.
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Affiliation(s)
- Sean Neifert
- Icahn School of Medicine at Mount Sinai, New York, New York
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Bemelman WA. Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis. Tech Coloproctol 2018; 22:739-740. [PMID: 30460620 DOI: 10.1007/s10151-018-1881-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Affiliation(s)
- W A Bemelman
- Amsterdam University Medical Centers, Amsterdam, The Netherlands.
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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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Otani K, Kawai K, Hata K, Tanaka T, Nishikawa T, Sasaki K, Kaneko M, Murono K, Emoto S, Nozawa H. Colon cancer with perforation. Surg Today 2018; 49:15-20. [PMID: 29691659 DOI: 10.1007/s00595-018-1661-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/30/2018] [Indexed: 02/04/2023]
Abstract
Perforation of the colon is a rare complication for patients with colon cancer and usually requires emergent surgery. The characteristics of perforation differ based on the site of perforation, presenting as either perforation at the cancer site or perforation proximal to the cancer site. Peritonitis due to perforation tends to be more severe in cases of perforation proximal to the cancer site; however, the difference in the outcome between the two types remains unclear. Surgical treatment of colon cancer with perforation has changed over time. Recently, many reports have shown the safety and effectiveness of single-stage operation consisting of resection and primary anastomosis with intraoperative colonic lavage. Under certain conditions, laparoscopic surgery can be feasible and help minimize the invasion. However, emergent surgery for colon cancer with perforation is associated with a high rate of mortality and morbidity. The long-term prognosis seems to have no association with the existence of perforation. Oncologically curative resection may be warranted for perforated colon cancer. In this report, we perform a literature review and investigate the characteristics and surgical strategy for colon cancer with perforation.
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Affiliation(s)
- Kensuke Otani
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
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Lambrichts DPV, Birindelli A, Tonini V, Cirocchi R, Cervellera M, Lange JF, Bemelman WA, Di Saverio S. The Multidisciplinary Management of Acute Complicated Diverticulitis. Inflamm Intest Dis 2018; 3:80-90. [PMID: 30733952 DOI: 10.1159/000486677] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/08/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute complicated diverticulitis (ACD) is an important and increasing issue in Western countries that leads to a significant impact and burden for patients, but also for the society due to its effects on hospital costs. In recent years, essential progression has been made regarding the research and implementation of novel or improved treatment strategies for the various disease entities of ACD. Much debated topics in the multidisciplinary approach of patients with ACD, such as the choice for nonoperative treatment options, the role of percutaneous drainage for diverticular abscesses, the role of laparoscopic lavage for perforated diverticulitis with purulent peritonitis, and the role of sigmoidectomy with primary anastomosis for patients with perforated diverticulitis, require clinicians to attentively follow and participate in these discussions. SUMMARY The aim of this review article is to provide clinicians with a structured overview of the recent literature on the multidisciplinary management of complicated diverticulitis by a panel of experts on the topic. By performing an extensive literature search in the online medical databases MEDLINE (Ovid) and Embase, insights into nonoperative treatment, percutaneous drainage, minimally invasive and open surgical treatment of ACD are provided. Furthermore, a comprehensive algorithm for the treatment of ACD has been developed. KEY MESSAGES Accurate patient evaluation and selection based on patient and disease characteristics is of paramount importance to determine the appropriate treatment strategy for patients with complicated diverticulitis. The presence of an experienced surgeon with advanced skills in laparoscopic emergency colorectal surgery is crucial for the treatment of patients with perforated diverticulitis in order to properly evaluate, select and treat patients suitable for nonoperative or operative treatment with an open or laparoscopic approach.
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Affiliation(s)
- Daniël P V Lambrichts
- Erasmus University Medical Center Rotterdam, Department of Surgery, Rotterdam, The Netherlands.,Academic Medical Center Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Arianna Birindelli
- Emergency and Trauma Surgery Unit, Maggiore Hospital, AUSL Bologna, Bologna, Italy.,Emergency Surgery Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Queen Elizabeth University Hospital NHS, Birmingham, United Kingdom
| | - Valeria Tonini
- Emergency Surgery Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Maurizio Cervellera
- Emergency Surgery Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Johan F Lange
- Erasmus University Medical Center Rotterdam, Department of Surgery, Rotterdam, The Netherlands.,IJsselland Ziekenhuis, Department of Surgery, Capelle aan den IJssel, The Netherlands.,Havenziekenhuis, Department of Surgery, Rotterdam, The Netherlands
| | - Willem A Bemelman
- Academic Medical Center Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Salomone Di Saverio
- Emergency and Trauma Surgery Unit, Maggiore Hospital, AUSL Bologna, Bologna, Italy.,Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
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39
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Laparoscopic approaches to complicated diverticulitis. Langenbecks Arch Surg 2017; 403:11-22. [PMID: 28875302 DOI: 10.1007/s00423-017-1621-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. PURPOSE The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis. CONCLUSIONS New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.
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Laparoscopic Approach in Colonic Diverticulitis: Dispelling Myths and Misperceptions. Surg Laparosc Endosc Percutan Tech 2017; 27:73-82. [DOI: 10.1097/sle.0000000000000386] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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41
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Di Saverio S, Birindelli A, Mandrioli M, Podda M, Binda GA. Intracorporeal anastomoses in emergency laparoscopic colorectal surgery from a series of 59 cases: where and how to do it - a technical note and video. Colorectal Dis 2017; 19:O103-O107. [PMID: 28258628 DOI: 10.1111/codi.13642] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 12/12/2016] [Indexed: 12/13/2022]
Abstract
AIM Laparoscopy offers the benefits of minimally invasive surgery and faster recovery. Acute surgical patients may potentially benefit from the great advantages of emergency laparoscopy, which is more clinically relevant in acute than elective patients. Fashioning a laparoscopic intracorporeal anastomosis (ICA) after emergent colorectal resection, whenever technically feasible and not contraindicated by the patient's general and haemodynamic condition, is a most challenging technical skill. METHOD During the period 2010-2016, 59 patients underwent a laparoscopic procedure for colorectal emergency in an acute care setting by a single operating surgeon with advanced laparoscopic skills and specific expertise in both colorectal surgery and acute care surgery. This series includes 32 laparoscopic right colectomies (12 for obstruction and 20 for perforation/peritonitis) and 27 left colectomies (6 for obstruction and 21 for perforation/peritonitis). Twenty-eight ileocolic side-to-side ICA, and 27 left colonic ICA (3 colocolic, 24 colorectal) were performed. RESULTS Reasonably good postoperative outcomes were observed in the entire series of 59 laparoscopic colectomies performed in an urgent setting. Overall, the major morbidity rate in the entire group was 16.9% (10/59) with an incidence of intra-abdominal abscess of 11.8% (7/59); the overall leak rate was 3.4% (2/59). The re-operation rate was 3.4% (2/59). A video included in the Supporting Information shows five different sites and techniques for ICA and describes technical details with tips and tricks. All patients shown in the video had an uneventful postoperative recovery and were managed postoperatively according to enhanced recovery after surgery protocols. CONCLUSION This case series illustrates all possible sites and techniques for colonic ICA in an emergency setting. All colorectal and acute care surgeons should have laparoscopic suturing skills.
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Affiliation(s)
- S Di Saverio
- Maggiore Hospital Regional Emergency Surgery and Trauma Center - Bologna Local Health District, Bologna, Italy
| | - A Birindelli
- Maggiore Hospital Regional Emergency Surgery and Trauma Center - Bologna Local Health District, Bologna, Italy
| | - M Mandrioli
- Maggiore Hospital Regional Emergency Surgery and Trauma Center - Bologna Local Health District, Bologna, Italy
| | - M Podda
- General and Emergency Surgery, San Marcellino Hospital, Muravera, Italy
| | - G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy
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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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Agresta F, Campanile FC, Podda M, Cillara N, Pernazza G, Giaccaglia V, Ciccoritti L, Ioia G, Mandalà S, La Barbera C, Birindelli A, Sartelli M, Di Saverio S. Current status of laparoscopy for acute abdomen in Italy: a critical appraisal of 2012 clinical guidelines from two consecutive nationwide surveys with analysis of 271,323 cases over 5 years. Surg Endosc 2016; 31:1785-1795. [PMID: 27572068 DOI: 10.1007/s00464-016-5175-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several authors have demonstrated the safety and feasibility of laparoscopy in selected cases of abdominal emergencies. The aim of the study was to analyse the current Italian practice on the use of laparoscopy in abdominal emergencies and to evaluate the impact of the 2012 national guidelines on the daily surgical activity. METHODS Two surveys (42 closed-ended questions) on the use of laparoscopy in acute abdomen were conducted nationwide with an online questionnaire, respectively, before (2010) and after (2014) the national guidelines publication. Data from two surveys were compared using Chi-square or Fisher's exact test, and data were considered significant when p < 0.05. RESULTS Two-hundred and one and 234 surgical units answered to the surveys in 2010 and 2014, respectively. Out of 144,310 and 127,013 overall surgical procedures, 23,407 and 20,102, respectively, were abdominal emergency operations. Respectively 24.74 % (in 2010) versus 30.27 % (in 2014) of these emergency procedures were approached laparoscopically, p = 0.42. The adoption of laparoscopy increased in all the considered clinical scenarios, with statistical significance in acute appendicitis (44 vs. 64.7 %; p = 0.004). The percentage of units approaching Hinchey III acute diverticulitis with laparoscopy in 26-75 % of cases (14.0 vs. 29.7 %; p = 0.009), those with >25 % of surgeons confident with laparoscopic approach to acute diverticulitis (29.9 vs. 54 %; p = 0.0009), the units with >50 % of surgeons confident with laparoscopic approach to acute appendicitis, cholecystitis and perforated duodenal ulcer, all significantly increased in the time frame. The majority of respondents declared that the 2012 national guidelines influenced their clinical practice. CONCLUSIONS The surveys showed an increasing use of laparoscopy for patients with abdominal emergencies. The 2012 national guidelines profoundly influenced the Italian surgical practice in the laparoscopic approach to the acute abdomen.
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Affiliation(s)
| | - Fabio Cesare Campanile
- Division of Surgery, Ospedale San Giovanni Decollato - Andosilla, Civita Castellana, VT, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari - General, Emergency and Laparoscopic Surgery - SS 554, Km 4.500, Monserrato, CA, Italy
| | - Nicola Cillara
- UOC Chirurgia Generale PO SS. Trinità ASL8CA, Via Is Mirrionis 92, 09121, Cagliari, Italy
| | - Graziano Pernazza
- General Surgery 1 Unit, Surgical Sciences Department, AO San Giovanni Addolorata, Rome, Italy
| | - Valentina Giaccaglia
- General Surgery Unit, Department of Surgical and Medical Sciences and Translational Medicine, Sant'Andrea Hospital, 'Sapienza' University of Rome, Rome, Italy
| | - Luigi Ciccoritti
- UOC Chirurgia Generale PO Santa Maria della Stella Loc. Ciconia, 05018, Orvieto, TR, Italy
| | - Giovanna Ioia
- ASST Bergamo EST - Bolognini Seriate, Seriate, Italy
| | - Stefano Mandalà
- Unit of General Surgery, Noto-Pasqualino Hospital, Via Dante Alighieri n 330, 90141, Palermo, Italy
| | - Camillo La Barbera
- Unit of General Surgery, Noto-Pasqualino Hospital, Via Dante Alighieri n 330, 90141, Palermo, Italy
| | - Arianna Birindelli
- S. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | | | - Salomone Di Saverio
- General, Emergency and Trauma Surgery Service, Maggiore Hospital Regional Trauma Center, AUSL Bologna, l.go Nigrisoli 2, 40100, Bologna, Italy.
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Wu Z, Lange J, Ji J. Time for hand-sewn anastomosis again? Comments on risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients. Int J Colorectal Dis 2016; 31:1485-6. [PMID: 26876069 DOI: 10.1007/s00384-016-2533-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 02/04/2023]
Affiliation(s)
- Zhouqiao Wu
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Fu-Cheng Road #52, Haidian District, 100142, Beijing, China
| | - Johan Lange
- Department of Surgery, Academic Colorectal Center, Havenziekenhuis, Rotterdam, The Netherlands
| | - Jiafu Ji
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Fu-Cheng Road #52, Haidian District, 100142, Beijing, China.
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Di Saverio S, Vennix S, Birindelli A, Weber D, Lombardi R, Mandrioli M, Tarasconi A, Bemelman WA. Pushing the envelope: laparoscopy and primary anastomosis are technically feasible in stable patients with Hinchey IV perforated acute diverticulitis and gross faeculent peritonitis. Surg Endosc 2016; 30:5656-5664. [PMID: 27005295 DOI: 10.1007/s00464-016-4869-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 03/09/2016] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Modern management of severe acute complicated diverticulitis continues to evolve towards more conservative and minimally invasive strategies. Although open sigmoid colectomy with end colostomy remains the most commonly used procedure for the treatment of perforated diverticulitis with purulent/faeculent peritonitis, recent major advances challenged this traditional approach, including the increasing attitude towards primary anastomosis as an alternative to end colostomy and use of laparoscopic approach for urgent colectomy. TECHNIQUE Provided an accurate patients selection, having the necessary haemodynamic stability, pneumoperitoneum is established with open Hasson technique and diagnostic laparoscopy is performed. If faeculent peritonitis (Hinchey IV perforated diverticulitis) is found, laparoscopy can be continued and a further three working ports are placed using bladeless trocars, as in traditional laparoscopic sigmoidectomy, with the addition of fourth trocar in left flank. The feacal matter is aspirated either with large-size suction devices or, in case of free solid stools, these can be removed with novel application of tight sealing endobags, which can be used for scooping the feacal content out and for its protected retrieval. After decontamination, a sigmoid colectomy is performed in the traditional laparoscopic fashion. The sigmoid is fully mobilised from the retroperitoneum, and mesocolon is divided up to the origin of left colic vessels. Whenever mesentery has extremely inflamed and thickened oedematous tissues, an endostapler with vascular load can be used to avoid vascular selective ligatures. Splenic flexure should be appropriately mobilised. The specimen is extracted through mini-Pfannenstiel incision with muscle splitting technique. Transanal colo-rectal anastomosis is fashioned. Air-leak test must be performed and drains placed where appropriate. RESULTS The video shows operative technique for a single-stage, entirely laparoscopic, washout and sigmoid colectomy with primary colorectal anastomosis in a 35-year-old male patient with severe and diffuse free faeculent diverticular peritonitis (Hinchey IV). The patient was managed post-operatively according to enhanced recovery protocol and discharged home after 9 days, following an uneventful recovery. CONCLUSIONS This case documents the technical feasibility of a minimally invasive single-stage procedure in a patient with Hinchey IV perforated diverticulitis with diffuse feacal peritonitis. The laparoscopic approach facilitated an effective decontamination of the peritoneal cavity, with a combination of large suction devices and aid of protected retrieval by closed endobags for effectively and completely laparoscopic removal of the solid feacal matter, offering clear advantages and excellent results even in such challenging cases. With necessary expertise, the sigmoid resection can be thereafter safely and entirely performed laparoscopically, the specimen extracted through mini-Pfannenstiel incision, and a laparoscopic intracorporeal transanal circular primary anastomosis performed.
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Affiliation(s)
- Salomone Di Saverio
- General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy.
| | - Sandra Vennix
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Arianna Birindelli
- General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy
| | | | - Raffaele Lombardi
- General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy
| | - Matteo Mandrioli
- General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy
| | - Antonio Tarasconi
- General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
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