Surgeon, not disease severity, often determines the operation for acute complicated diverticulitis

Colorectal Anastomosis Versus Colostomy Creation in High MELD Patients: An ACS-NSQIP Analysis

BACKGROUND

Liver failure patients are at increased risk of surgical complications. The decision to perform a colonic anastomosis vs a colostomy in urgent colorectal surgery remains unclear.

METHODS

The ACS-NSQIP database was queried for patients undergoing nonelective colorectal surgery between 2016 and 2018. MELD score was calculated and stratified into 3 groups. Subgroup analysis of the high-MELD group was performed.

RESULTS

Higher MELD scores were associated with significantly higher mortality. Colostomy formation was consistent between intermediate and high-MELD groups. In high-MELD patients, colonic anastomosis was associated with higher mortality than those receiving colostomy (41.1% vs 28.4%, P < .001). Patients receiving colostomy had higher rates of wound complications, but lower rates of return to OR and non-wound complications. Regression analysis revealed that colostomy formation remained an independent predictor of survival (mortality OR = .594, P < .001).

DISCUSSION

High-MELD patients undergoing nonelective colorectal surgery have increased risk of complications such as mortality. Patients in this group receiving an anastomosis have increased complications and mortality, and may benefit from colostomy formation.

Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State

BACKGROUND

The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions.

METHODS

A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients.

RESULTS

During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization).

DISCUSSION

Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.

Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Regional variation in hospitalizations and outpatient appointments for diverticular disease in Norway: a nationwide cross-sectional study

OBJECTIVE

To investigate the use of specialized health care services for diverticular disease in different hospital referral regions in Norway.

MATERIALS AND METHODS

Nationwide cross-sectional study with data from the Norwegian Patient Registry and Statistics Norway. All Norwegian inhabitants aged 40 years and older in the years 2012-16 (2,517,938) were included. We obtained the rates (n/100,000 population) for hospitalizations, outpatient appointments, and surgery for diverticular disease for the population in each hospital referral region. We also quantified the use of lower gastrointestinal (LGI) endoscopy in hospitalizations and outpatient appointments for diverticular disease and the use of LGI endoscopy performed on any indication.

RESULTS

There were 131 hospitalizations and 381 outpatient appointments for diverticular disease per 100,000 population annually. Hospitalization rates varied 1.9-fold across regions from 94 to 175. Outpatient appointment rates varied 2.5-fold across regions from 258 to 655. Outpatient appointments were strongly correlated to hospitalizations (r_s=0.75, p < .001) and outpatient LGI endoscopy for any indication (r_s=0.67, p < .001). Hospitalization and surgery rates remained stable over the study period, while outpatient appointment rates increased by 37%. Concurrently, rates of outpatient LGI endoscopy performed on any indication increased by 35%.

CONCLUSION

There was considerable regional variation in both hospitalizations and outpatient appointments for diverticular disease. The extent of variation and the correlation with diagnostic intensity of LGI endoscopy indicate that the regional variation in health care utilization for diverticular disease to a large extent can be explained by regional differences in clinical practice rather than disease burden.

Disparities in elective surgery for diverticulitis: Identifying the gap in care

BACKGROUND

Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications.

METHODS

The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models.

RESULTS

Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons.

CONCLUSIONS

Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.

Emergency Hartmann's Procedure and Its Reversal: A Totally Laparoscopic 2-Step Surgery for the Treatment of Hinchey III and IV Diverticulitis

BACKGROUND

Hartmann's procedure (HP) followed by reversal restoration is the first choice for treatment of diffuse diverticular peritonitis. There is no unanimous consensus regarding the use of laparoscopy to treat the same condition.

METHODS

Data from 60 patients with diverticular diffuse peritonitis who underwent urgent HP followed by laparoscopic reversal were retrospectively analyzed. Patients were divided into 2 groups according to the open or laparoscopic HP (OHP, 24 patients; LHP, 36 patients). Outcomes were measured in terms of functional recovery, morbidity, mortality, and length of hospital stay.

RESULTS

HPs showed no differences among the groups in terms of operative time, blood loss, and length of intensive care unit stay. Overall morbidity was significantly lower in LHP than in OHP, corresponding to 33.3% and 66.7% respectively ( P = .018). The incidence of both surgical and medical complications was higher in OHP than in LHP (41.7% vs 22.2% [ P = .044] and 45.8% vs 24.3% [ P = .023], respectively). Mortality was 16.6% for each group. LHP showed a faster return to bowel movements and a shorter hospital stay than OHP. The secondary intestinal reversal was possible in 92% of cases, successfully completed laparoscopically in 91.3%. No patients of LHP group required a conversion to open intestinal reversal.

CONCLUSION

LHP for treatment of diverticular diffuse peritonitis showed significantly lower morbidity, faster recovery, shorter hospital stay, and higher rates of successful laparoscopic reversal when compared with OHP.

Contemporary Review of Risk-Stratified Management in Acute Uncomplicated and Complicated Diverticulitis

BACKGROUND

Acute colonic diverticulitis is a common clinical condition. Severity of the disease is based on clinical, laboratory, and radiological investigations and dictates the need for medical or surgical intervention. Recent clinical trials have improved the understanding of the natural history of the disease resulting in new approaches to and better evidence for the management of acute diverticulitis.

METHODS

We searched the Cochrane Library (years 2004-2015), MEDLINE (years 2004-2015), and EMBASE (years 2004-2015) databases. We used the search terms "diverticulitis, colonic" or "acute diverticulitis" or "divertic*" in combination with the terms "management," "antibiotics," "non-operative," or "surgery." Registers for clinical trials (such as the WHO registry and the https://clinicaltrials.gov/ ) were searched for ongoing, recruiting, or closed trials not yet published.

RESULTS

Antibiotic treatment can be avoided in simple, non-complicated diverticulitis and outpatient management is safe. The management of complicated disease, ranging from a localized abscess to perforation with diffuse peritonitis, has changed towards either percutaneous or minimally invasive approaches in selected cases. The role of laparoscopic lavage without resection in perforated non-fecal diverticulitis is still debated; however, recent evidence from two randomised controlled trials has found a higher re-intervention in this group of patients.

CONCLUSIONS

A shift in management has occurred towards conservative management in acute uncomplicated disease. Those with uncomplicated acute diverticulitis may be treated without antibiotics. For complicated diverticulitis with purulent peritonitis, the use of peritoneal lavage appears to be non-superior to resection.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Variation and Acquisition of Complex Techniques

Background. Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between techniques. We used pancreaticoduodenectomy as a model to catalogue variability between surgeons and investigate factors that affect fellows’ acquisition of techniques. Materials and methods. Semistructured interviews and operative note analysis were conducted to determine techniques of 5 attending surgeons, and these data were mapped to identify variations. Identical interviews and questioning were completed with 4 fellowship graduates whose practice includes pancreaticoduodenectomy. Results. All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were 21 surgical step data points that differed. Of 5 surgeons, 4 were unable to identify colleagues’ techniques. Fellows reported adopting techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Residency training did not strongly influence their choice of technique; however, senior partners after fellowship did influence technique. Conclusions. The number of variants of pancreaticoduodenectomy based on granular, step-by-step differences is larger than previously described. Results hint that variation may be furthered by the fact that surgeons are not aware of the techniques used by colleagues. Fellows choose techniques based on factors not directly related to their own outcomes but rather mentor factors. Whether fellows adopt techniques that will be optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.

Laparoscopic versus robotic-assisted colectomy and rectal resection: a systematic review and meta-analysis

PURPOSE

Lately, the main technical innovations in the field of colorectal surgery have been the introduction of laparoscopic and robotic techniques; the aim of this study is to investigate the results and the advantages of these two surgical approaches.

METHODS

Twenty-two studies including 1652 laparoscopic and 1120 robotic-assisted resections were analyzed and categorized into right, left, and pelvic resections of the middle/low rectum, aiming to the following outcomes: operating time, blood loss, bowel function recovery, return to oral intake, morbidity, hospital stay, and costs.

RESULTS

The vast majority of the studies were non-randomized investigations (19/22 studies) enrolling small cohorts of patients (median 55.0 laparoscopic and 34.5 robotic-assisted group) with a mean age of 62.2-61.0 years. Funnel plot analysis documented heterogeneity in studies which combined cancers and benign diseases. Our meta-analysis demonstrated a significant difference in favor of laparoscopic procedures regarding costs and operating time (standardized mean difference (SMD) 0.686 and 0.493) and in favor of robotic surgery concerning morbidity rate (odds ratio (OR) 0.763), although no benefits were documented when analyzing exclusively randomized trials. When we differentiated approaches by side of resections, a significant difference was found in favor of the laparoscopic group when analyzing operating time in left-sided and pelvic procedures (SMD 0.609 and 0.529) and blood loss in pelvic resections (SMD 0.339).

CONCLUSION

Laparoscopic techniques were documented as the shorter procedures, which provided lower blood loss in pelvic resections, while morbidity rate was more favorable in robotic surgery. However, these results could not be confirmed when we focused the analysis on randomized trials only.

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis

BACKGROUND

The management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention.

METHODS

A retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS).

RESULTS

One hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmann's procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis.

CONCLUSIONS

Although surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.

Left Colon Diverticulitis Presenting as Perforated Lumbar Abscess: A Case Report and Review of the Current Literature

Diverticular perforation is a common complication of diverticulitis and can lead to the creation of abscesses. The presence of such abscesses on the abdominal wall is rare and can lead to misdiagnosis. We present the case of a patient with abdominal pain and the formation of a large left lumbar abscess due to perforation of a diverticulum of the left colon and our surgical treatment of choice with favorable results.

Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: open Hartmann's procedure vs. laparoscopic lavage and drainage in the elderly

Hartmann's procedure (HP) is the most performed technique for acute diverticulitis. Laparoscopic lavage and drainage (LLD) is an option evaluated as definitive treatment for diverticulitis Hinchey grade II-III. Aim of the study is to analyze and compare LLD vs HP outcomes. From January 1st 2009 and December 31st 2012 we prospectively enrolled 30 patients with diagnosis of acute diverticulitis Hinchey grade II-III. Fourteen patients underwent to LLD (LLD group, LLDG) and 16 patients to HP (Hartmann group, HG). We evaluated: demographic variables, comorbidities, admission clinical status, radiological imaging, intraoperative outcomes (operative time), postoperative outcomes (admission to ICU, timing of drainage removal, restore of bowel functions, timing of oral solid intake), mortality rate (perioperative and after 12 months) and morbidity rate (surgical, infectious, cardiovascular, renal and systemic complications). Exclusion criteria were: other diseases, colon cancer's suspect or diagnosis, conversion to HP. Patients' mean age was 64.8 years in HG and 62.6 in LLDG. M:F ratio was 6:10 in HG, 8:6 in LLDG. Data showed improved outcomes in LLDG for: total operative time (p < 0.0001), admission to ICU (p 0.0447), restoration of bowel functions (p 0.0035 for gases, p 0.0152 for feces), mobilization (p 0.0087) and length of hospital stay (p 0.0132). According to literature, LLD is related to operative risk, morbidity and mortality rate and length of stay lower than HP. LLD also gives the possibility to avoid stoma. Despite limits of our study, we consider LLD as a "safe and effective" treatment for Hinchey grade II-III acute diverticulitis.