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Kollatos C, Sköldberg F, Graf W. Evaluation of laparoscopic peritoneal lavage for perforated diverticulitis: a national registry-based study. Br J Surg 2024; 111:znae109. [PMID: 38713610 PMCID: PMC11075766 DOI: 10.1093/bjs/znae109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND Laparoscopic lavage (LPL) has been suggested for treatment of non-feculent perforated diverticulitis. In this observational study, the surgical treatment of diverticular disease in Sweden outside prospective trials was investigated. METHODS This population-based study used the National Patient Register to identify all patients in Sweden with emergency admissions for diverticular disease, as defined by ICD codes from July 2014 to December 2020. Demographics, surgical procedures and outcomes were assessed. In addition, register data since 1997 were retrieved to assess co-morbidities, previous abdominal surgeries, and previous admissions for diverticular disease. RESULTS Among 47 294 patients with emergency hospital admission, 2035 underwent LPL (427 patients) or sigmoid resection (SR, 1608 patients) for diverticular disease. The mean follow-up was 30.8 months. Patients selected for LPL were younger, healthier and with less previous abdominal surgery for diverticular disease than those in the SR group (P < 0.01). LPL was associated with shorter postoperative hospital stay (mean 9.4 versus 14.9 days, P < 0.001) and lower 30-day mortality (3.5% versus 8.7%, P < 0.001). Diverticular disease-associated subsequent surgery was more common in the SR group than the LPL group except during the first year (P < 0.001). LPL had a lower mortality rate during the study period (stratified HR 0.70, 95% c.i. 0.53-0.92, P = 0.023). CONCLUSION Laparoscopic lavage constitutes a safe alternative to sigmoid resection for selected patients judged clinically to require surgery.
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Affiliation(s)
- Christos Kollatos
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Filip Sköldberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
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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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Cirocchi R, Nascimbeni R, Binda GA, Vettoretto N, Cuomo R, Gambassi G, Amato A, Annibale B. Surgical treatment of acute complicated diverticulitis in the elderly. MINERVA CHIR 2019; 74:465-471. [PMID: 30306769 DOI: 10.23736/s0026-4733.18.07744-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although the true prevalence is unknown, colonic diverticulosis is one of the most common disease of the digestive tract in Western countries. Based on administrative data of hospitalized patients, the incidence of diverticulitis has been increasing in last decades. In general, elderly patients undergo less frequently an elective colonic resection; but a substantial part of emergency surgeries is performed in elderly patients. In these older patients the choice of any clinical and surgical option is to be correlated not only to the severity of diverticulitis, but also to general status and the co-existing comorbidities. In this regard, it is mandatory that all patients undergo a multidimensional, comprehensive geriatric assessment to correctly identify those who are fit, vulnerable or frail. The analysis of data currently available highlights three relevant elements: type and severity of peritoneal contamination, hemodynamic conditions (stable or unstable), and concomitant comorbidities (fit or frail status). There is no single ideal surgical treatment that can be considered as gold standard for all clinical presentations; the final clinical decision-making should always be based on patient's general health status, severity of peritonitis and of sepsis. In a septic elderly patient who is hemodynamically unstable, treatment should be as prompt as possible independent of the Hinchey's stage, and could include either a Mickulicz stoma or a DCS strategy. In an elderly patient who is fit and hemodynamically stable, the surgical options are similar to those in a younger patient. If a patient is frail but hemodynamically stable, he should be treated with a Hartmann's procedures.
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Affiliation(s)
- Roberto Cirocchi
- Department of Surgery and Biochemical Sciences, University of Perugia, Terni, Italy -
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Gian A Binda
- Department of General Surgery, Galliera Hospital, Genoa, Italy
| | - Nereo Vettoretto
- Unit of Laparoscopic Surgery, Department of Surgery, M. Mellini Hospital, Chiari, Brescia, Italy
| | - Rosario Cuomo
- Department of Surgery and Biochemical Sciences, University of Perugia, Terni, Italy
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Gambassi
- Department of Internal Medicine, Sacred Heart Catholic University, Rome, Italy
| | - Antonio Amato
- Department of Surgery, Hospital of Sanremo, Sanremo, Imperia, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Science and Translational Medicine, Sapienza University, Rome, Italy
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Gregori M, Cassini D, Depalma N, Miccini M, Manoochehri F, Baldazzi GA. Laparoscopic lavage and drainage for Hinchey III diverticulitis: review of technical aspects. Updates Surg 2019; 71:237-246. [PMID: 30097970 DOI: 10.1007/s13304-018-0576-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/07/2018] [Indexed: 02/07/2023]
Abstract
The surgical treatment for patients with generalized peritonitis complicating sigmoid diverticulitis is currently debated; particularly in case of diffuse purulent contamination (Hinchey 3). Laparoscopic lavage and drainage (LLD) has been proposed by some authors as a safe and effective alternative to single- or multi-stage resective surgery. However, among all the different studies on LLD, there is no uniformity in terms of surgical technique adopted and data show significant differences in postoperative outcomes. Aim of this review was to analyze the differences and similarities among the authors in terms of application, surgical technique and outcomes of LLD in Hinchey 3 patients. A bibliographical research was performed by referring to PubMed and Cochrane. "Purulent peritonitis", "Hinchey 3 diverticulitis", "acute diverticulitis", "colonic perforation" and "complicated diverticulitis" were used as key words. Twenty-eight papers were selected, excluding meta-analysis, reviews and case reports with a very small number of patients. The aim of this review was to establish how LLD should be done, suggesting important technical tricks. We found agreement in terms of indications, preoperative management, ports' positioning, antibiotics, enteral feeding and drain management. On the contrast, different statements regarding indications, adhesiolysis and management of colonic hole and failure of laparoscopic lavage are reported. A widespread diffusion of LLD and standardization of its technique are impossible because of data heterogeneity and selection bias in the limited RCTs. It is necessary to wait for long terms results from randomized clinical trials (RCTs) in progress to establish the efficacy and safety of this technique. More importantly, an increased number of highly skilled and dedicated colorectal laparoscopic surgeons are required to standardized the procedure.
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Affiliation(s)
- Matteo Gregori
- University Hospitals Birmingham, "Queen Elizabeth Hospital" Birmingham, Birmingham, UK.
- , 3 New Street Chambers, 67A New Street, Birmingham, B2 4DU, UK.
| | - Diletta Cassini
- Department of Mini-invasive and Robotic Surgery, Abano Terme, Padua, Italy
| | - Norma Depalma
- First Department of Surgery "Pietro Valdoni", "Sapienza" Medical School, Rome, Italy
| | - Michelangelo Miccini
- First Department of Surgery "Pietro Valdoni", "Sapienza" Medical School, Rome, Italy
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Biffoni M, Urciuoli P, Grimaldi G, Eberspacher C, Santoro A, Pironi D, Sorrenti S. Colovesical fistula complicating diverticular disease: diagnosis and surgical management in elderly. MINERVA CHIR 2018; 74:187-188. [PMID: 29600834 DOI: 10.23736/s0026-4733.18.07723-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Marco Biffoni
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Paolo Urciuoli
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | | | | | - Alberto Santoro
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Daniele Pironi
- Department of Surgical Sciences, Sapienza University, Rome, Italy -
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Grimaldi G, Eberspacher C, Romani AM, Merletti D, Maturo A, Pontone S, Pironi D. Modified transverse coloplasty pouch: new reconstruction techniques after total mesorectal excision. Our experience. G Chir 2018; 38:285-290. [PMID: 29442059 DOI: 10.11138/gchir/2017.38.6.285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM The incidence of rectal cancer continues to rise. The functional results after complete Total Mesorectal Excision (TME) depend on the segment of colon used for reconstruction of colonic continuity and the form, the volume and the functional proprieties of the "neorectum". The aim of our study is evaluate the efficacy of our Modified Transverse Coloplasty Pouch (MTCP) after the treatment of low rectal cancer in terms of functional outcomes and quality of life. PATIENTS AND METHODS The study included 136 patients, underwent TME from January 2007 to December 2016 with diagnosis of extraperitoneal carcinoma of the rectum. The average distance of the tumor from the dentate line was 5.6 cm. Our follow-up protocol included functional outcome evaluation at 7th post-operative day (POD), 2nd month, and 6th month after the surgery. RESULTS All patients (M/F 84/52) underwent anterior rectal resection (TME) with MTCP. Frequency of bowel movements per 24 hours in the studied patients compared at 7th POD, 2 months, and 6 months. Since the first post-operative weeks there is an encouraging reduction of the frequency of bowel movements. CONCLUSION Modified Transverse Coloplasty Pouch (MTCP) had better functional results and quality of life compared to patients with a Colonic J Pouch (CJP) and traditional Transverse Coloplasty Pouch (TCP).
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