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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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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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AlSulaim HA, Garfinkle R, Marinescu D, Morin N, Ghitulescu GA, Vasilevsky CA, Faria J, Pang A, Boutros M. Is the Hartmann's procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 2018. Surg Endosc 2023; 37:7717-7728. [PMID: 37563342 DOI: 10.1007/s00464-023-10317-1] [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: 02/07/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Historically, Hartmann's procedure (HP) has been the operation of choice for diverticulitis in the emergency setting. However, recent evidence has demonstrated the safety of primary anastomosis (PA) with or without diverting ileostomy. The purpose of this study was to evaluate the trends of, and factors associated with, HP compared to PA in emergency surgery for diverticulitis over 25 years. METHODS Using the National Inpatient Sample database, we identified adult patients ≥ 18 years old who underwent emergency surgery for diverticulitis (HP or PA) between 1993 and 2018 using ICD-9 and ICD-10 codes. Patients with inflammatory bowel disease, gastrointestinal cancer or who underwent elective diverticulitis surgery were excluded. Trends in HP were analyzed using multivariable linear regression, and factors associated with HP were assessed with multiple logistic regression. RESULTS Of 499,433 patients who underwent colectomy in the emergency setting for acute diverticulitis, 271,288 (54.3%) had a HP and 228,145 (45.7%) had a PA. Median age was 61 years (IQR: 50-73), 53% were women, and 70.5% were white. The proportion of HP slightly increased over the study period-HP comprised 52.6% of included cases in 1993-98 and 55.2% of cases in 2014-2018 (p = 0.017). Advanced age (reference = 18-44 years; 45-54 years: OR 1.16, 95% CI 1.10-1.22; 55-64 years: OR 1.26, 95% CI 1.20-1.33; 65-74 years: OR 1.33, 95% CI 1.25-1.42; ≥ 75 years: OR 1.51, 95% CI 1.41-1.62), complicated diverticulitis (OR 1.41, 95% CI 1.36-1.46), and severity of illness (reference = minor; moderate: OR 1.46, 95% CI 1.38-1.54; major/extreme: OR 3.43, 95% CI 3.25-3.63) were associated with increased odds of HP. CONCLUSIONS Over a 26-year period, HP has remained the most performed procedure in the emergency setting for diverticulitis. Future work should focus on knowledge translation with a possible change in practice as more randomized controlled trials provide support for PA.
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Affiliation(s)
- Hatim A AlSulaim
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
- Department of Surgery, Unaizah College of Medicine, Qassim University, Unaizah, Saudi Arabia
| | - Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Daniel Marinescu
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | | | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Julio Faria
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Allison Pang
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.
- Department of Surgery, McGill University, Montreal, QC, Canada.
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Lee Y, McKechnie T, Samarasinghe Y, Eskicioglu C, Kuhnen AH, Hong D. Primary anastomosis with diverting loop ileostomy versus Hartmann's procedure for acute complicated diverticulitis: analysis of the National Inpatient Sample 2015-2019. Int J Colorectal Dis 2023; 38:156. [PMID: 37261576 DOI: 10.1007/s00384-023-04452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Up to 50% of patients with acute complicated diverticulitis require operative management on their index admission. There is ongoing debate as to whether primary anastomosis with diverting ileostomy versus a Hartmann's procedure is the optimal surgical approach for these patients. This study aims to compare postoperative complications in patients undergoing either Hartmann's procedure or primary anastomosis and diverting ileostomy for perforated diverticulitis using recent National Inpatient Sample data. METHODS Patients who underwent either primary anastomosis with diverting ileostomy or Hartmann's procedure for acute complicated diverticulitis from the 2015 to 2019 NIS database sample were included. Primary outcomes were postoperative in-hospital mortality and morbidity. Secondary outcomes were postoperative cause-specific complications, total admission cost, and length of stay (LOS). Univariate and multivariate regression were utilized to compare the two operative approaches. RESULTS Overall, 642 patients underwent primary anastomosis with diverting ileostomy and 4,482 patients underwent Hartmann's procedure. There was no difference in in-hospital mortality (OR 0.93, 95%CI 0.45-1.92, p = 0.84) or in-hospital morbidity (OR 1.10, 95%CI 0.90-1.35, p = 0.33). Adjusted analysis suggested shorter postoperative LOS for patients undergoing Hartmann's procedure (MD 0.79 days, 95%CI 0.15-1.43 days, p = 0.013) and decreased total admission cost (MD $4,893.99, 95%CI $1,425.04-$8,362.94, p = 0.006). CONCLUSIONS The present study supports that primary anastomosis with diverting ileostomy is safe for properly selected patients presenting with complicated diverticulitis. Primary anastomosis with diverting ileostomy is associated with greater total hospitalization costs and LOS.
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Affiliation(s)
- Yung Lee
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Tyler McKechnie
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Cagla Eskicioglu
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Angela H Kuhnen
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Colon and Rectal Surgery, Lahey Hospital, Burlington, MA, USA
| | - Dennis Hong
- Division of General Surgery, McMaster University, Hamilton, ON, Canada.
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Yoon P, Rajasekar G, Nuño M, Raskin E, Lyo V. Severe Obesity Contributes to Worse Outcomes After Elective Colectomy for Chronic Diverticular Disease. J Gastrointest Surg 2022; 26:1472-1481. [PMID: 35334024 DOI: 10.1007/s11605-022-05303-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/13/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both obesity and chronic diverticular disease (DD) are on the rise. Understanding surgical outcomes for patients with obesity undergoing colectomy for DD is imperative to improve care and minimize complications. Our objective was to investigate the impact of obesity on outcomes after elective colectomy specifically for chronic DD. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, patients who underwent elective colectomy for chronic DD were grouped into four body mass index categories. Baseline characteristics, surgical approach and procedure, and 30-day morbidity and mortality were assessed. RESULTS Of 24,559 patients, 21.7% were of normal weight, 35.8% were overweight, 35.9% were obese, and 6.6% were severely obese. Patients with severe obesity were younger, more functionally dependent, and had more comorbidities (all P [Formula: see text] 0.0001). Patients with severe obesity were more likely to have unplanned conversion to open surgery from laparoscopic and robotic approaches (AOR 2.15, 95% CI 1.24-3.70). Obesity class did not significantly affect the type of surgical procedure patients underwent (Hartmann's, colectomy with anastomosis and diversion, or colectomy with primary anastomosis). There were increased odds of any perioperative complications (AOR 1.43, 95% CI 1.19-1.71) and non-home discharge (AOR 2.39, 95% CI 1.59-3.57) in patients with severe obesity compared to normal weight patients. CONCLUSIONS Obesity is associated with poorer outcomes in patients undergoing elective colectomy for chronic DD. Futures studies to examine the impact of preemptive weight loss to improve outcomes after elective colectomy for chronic sequelae of DD are needed.
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Affiliation(s)
- Paul Yoon
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd., NAOB 6113, Sacramento, CA, 95817, USA
| | - Ganesh Rajasekar
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd., NAOB 6113, Sacramento, CA, 95817, USA
| | - Miriam Nuño
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd., NAOB 6113, Sacramento, CA, 95817, USA
| | - Elizabeth Raskin
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd., NAOB 6113, Sacramento, CA, 95817, USA
| | - Victoria Lyo
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd., NAOB 6113, Sacramento, CA, 95817, USA.
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Quinn S, Akram W, Hao S, Honaker MD. Emergency Surgery for Diverticulitis: Relationship of Outcomes to Patient Age and Surgical Procedure. J Am Med Dir Assoc 2022; 23:616-622.e1. [PMID: 35245484 DOI: 10.1016/j.jamda.2022.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To compare outcomes in emergent surgical treatment of acute diverticulitis in the older population. DESIGN Retrospective multi-institute database cohort analysis. SETTINGS AND PARTICIPANTS American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) and NSQIP Colectomy Targeted Database. METHODS The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Database was merged with the main participate use file to identify adult patients undergoing emergent Hartmann procedure or primary anastomosis with diverting loop ileostomy for acute diverticulitis. Patients were subdivided into age cohorts (<65 years, 65-79 years, ≥80 years) and primary postoperative outcomes including mortality, morbidity, and readmission were compared using multivariate regression. RESULTS A total of 6091 patients were identified. On multivariate analysis, 30-day mortality was higher in patients undergoing a Hartmann procedure aged 65-79 years [odds ratio (OR) 2.39, P < .001] and ≥80 years (OR 6.28, P < .001) compared to patients aged <65 years. In patients undergoing a primary anastomosis with diverting loop ileostomy, 30-day morbidity was lower only in the cohort aged ≥80 years (OR 2.63, P = .04). Readmission rates were similar across age groups within each procedure cohort. Comparing the 2 procedures, readmission rates in patients aged 65-79 years who underwent a Hartmann procedure were lower than those that underwent a primary anastomosis with diverting loop ileostomy (OR 2.43, P = .001). In patients aged ≥80 years, readmission rates were lower in patients who underwent a primary anastomosis with diverting loop ileostomy (OR 0.12, P = .04). Thirty-day mortality was also lower in patients aged ≥80 years if they underwent a primary anastomosis with diverting loop ileostomy (OR 0.15, P = .03) but similar for patients aged 65-79 years (OR 0.81, P = .70). CONCLUSION AND IMPLICATIONS In patients undergoing a Hartmann procedure emergently for diverticulitis, mortality is higher in older patients. Patients aged ≥ 80 years had increased mortality if they underwent a Hartmann procedure compared to a primary anastomosis with diverting ileostomy; however, readmission rates vary with procedure performed. Careful consideration of age should be taken into account when operating emergently for diverticulitis.
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Affiliation(s)
- Seth Quinn
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Warqaa Akram
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Scarlett Hao
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Michael D Honaker
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
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Faes S, Hübner M, Girardin T, Demartines N, Hahnloser D. Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series. BJS Open 2021; 5:6423702. [PMID: 34750614 PMCID: PMC8576255 DOI: 10.1093/bjsopen/zrab106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 12/29/2022] Open
Abstract
Background Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization. Methods A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically. Results Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)). Conclusion Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.
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Affiliation(s)
- Seraina Faes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Timothée Girardin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
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Trends in emergent diverticular disease management: a nationwide cohort study from 2009 to 2018. Tech Coloproctol 2021; 25:549-558. [PMID: 33660190 DOI: 10.1007/s10151-021-02423-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Diverticular disease is a common disorder. Several guidelines report on its optimal management. The aim of this study was to describe the evolution of the prevalence of this disease, the treatment strategies, and the mortality rate on a national level. METHODS We conducted a retrospective study on prospective data using a nationwide database. All consecutive adult patients diagnosed with diverticular disease and admitted via the emergency department from 2009 to 2018 were included in the study. We performed a descriptive analysis for epidemiologic data, diagnosis, and treatment. RESULTS During the data collection period, 233,386 patients were included in the study. The number of admissions for emergent diverticular disease increased by 65.8%, from 16,754 in 2009 to 27,781 in 2018, for both uncomplicated and complicated diverticular disease. Among these patients, 19,350 (8.3%) were operated on. The rate of surgical treatment progressively decreased from 9.7% in 2009 to 7.6% in 2018. The three main interventions were Hartmann's procedure (HP, n = 9111, 47.1%), resection with primary anastomosis (RPA, n = 4335, 22.4%), and peritoneal lavage (PL, n = 4836, 25%). We observed a progressive annual increase in HPs (n = 716 in 2009 and n = 1055 in 2018) as well as a decline in PLs since 2015, while the number of RPAs remained stable. CONCLUSIONS Although admissions for emergent diverticular disease have increased during the study period, the rate of surgical treatment has decreased, suggesting an evolution toward more conservative management of this pathology.
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Madiedo A, Hall J. Minimally Invasive Management of Diverticular Disease. Clin Colon Rectal Surg 2021; 34:113-120. [PMID: 33642951 PMCID: PMC7904339 DOI: 10.1055/s-0040-1716703] [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: 10/22/2022]
Abstract
Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective. Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion. In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.
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Affiliation(s)
- Andrea Madiedo
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Jason Hall
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
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10
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Russell T, Chen F. Quality issues in emergency colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020; 63:728-747. [PMID: 32384404 DOI: 10.1097/dcr.0000000000001679] [Citation(s) in RCA: 197] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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12
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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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Kazi A, Finco TB, Zakhary B, Firek M, Gerber A, Brenner M, Coimbra R. Acute Colonic Diverticulitis and Cirrhosis: Outcomes of Laparoscopic Colectomy Compared with an Open Approach. J Am Coll Surg 2020; 230:1045-1053. [PMID: 32229299 DOI: 10.1016/j.jamcollsurg.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The impact of cirrhosis on outcomes of acute colonic diverticulitis (ACD) has been studied infrequently. We investigated the effect of cirrhosis on outcomes of surgical patients with ACD treated by either an open or laparoscopic approach. METHODS A cross-sectional study was performed using the Nationwide Inpatient Sample 2012 to 2014. Patients with ACD were stratified into compensated and decompensated cirrhosis for comparisons of demographic characteristics, hospital length of stay, complications, mortality, and cost. Groups were stratified according to surgical treatment: open colectomy and laparoscopic colectomy. A comparative effectiveness analysis of outcomes was performed between the 2 surgical treatments. Univariate comparisons between groups and multivariate regression analysis were performed to identify risk factors for mortality and specific complications. RESULTS Of 1,172,875 patients hospitalized with the diagnosis of ACD during the study period, 1,145 were cirrhotic. The majority were male (59%). There were 660 compensated cirrhotic patients and 485 decompensated cirrhotic patients and all underwent either open (n = 875) or laparoscopic colectomy (n = 270). Consistently, marked increases in mortality, hospital length of stay, and cost were observed in decompensated cirrhotic patients regardless of the type of treatment. Laparoscopic colectomy was accompanied by shorter hospital length of stay, lower costs, and significantly decreased mortality rate compared with open colectomy in compensated and decompensated cirrhotic patients. CONCLUSIONS The presence of cirrhosis markedly impacts outcomes in patients with ACD, leading to prolonged hospitalization, higher cost, and increased complications and deaths. Laparoscopic colectomy is associated with better outcomes in patients requiring surgical management, including those with decompensated cirrhosis.
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Affiliation(s)
- Albert Kazi
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Tiago B Finco
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Matthew Firek
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Ari Gerber
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA
| | - Megan Brenner
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA; Department of Surgery, University of California Riverside, Riverside, CA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System-Medical Center, Moreno Valley, CA; Department of Surgery, Loma Linda University, Loma Linda, CA.
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Abstract
BACKGROUND Acute diverticulitis is a common disease with public health significance. Many studies with a high level of evidence have been published recently on the surgical management of acute diverticulitis. OBJECTIVE The aim of this systematic review was to define the accurate surgical management of acute diverticulitis. DATA SOURCES Medline, Embase, and the Cochrane Library were sources used. STUDY SELECTION One reviewer conducted a systematic study with combinations of key words for the disease and the surgical procedure. Additional studies were searched in the reference lists of all included articles. The results of the systematic review were submitted to a working group composed of 13 practitioners. All of the conclusions were obtained by full consensus and validated by an external committee. INTERVENTIONS The interventions assessed were laparoscopic peritoneal lavage, primary resection with anastomosis with or without ileostomy, and the Hartmann procedure, with either a laparoscopic or an open approach. MAIN OUTCOME MEASURES Morbidity, mortality, long-term stoma rates, and quality of life were measured. RESULTS Seventy-one articles were included. Five guidelines were retrieved, along with 4 meta-analyses, 14 systematic reviews, and 5 randomized controlled trials that generated 8 publications, all with a low risk of bias, except for blinding. Laparoscopic peritoneal lavage showed concerning results of deep abscesses and unplanned reoperations. Studies on Hinchey III/IV diverticulitis showed similar morbidity and mortality. A reduced length of stay with Hartmann procedure compared with primary resection with anastomosis was reported in the short term, and in the long term, more definite stoma along with poorer quality of life was reported with Hartmann procedure. No high-quality data were found to support the laparoscopic approach. LIMITATIONS Trials specifically assessing Hinchey IV diverticulitis have not yet been completed. CONCLUSIONS High-quality studies showed that laparoscopic peritoneal lavage was associated with an increased morbidity and that Hartmann procedure was associated with poorer long-term outcomes than primary resection with anastomosis with ileostomy, but Hartmann procedure is still acceptable, especially in high-risk patients.
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15
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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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16
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Thompson EV, Snyder JR. Recognition and Management of Colonic Perforation following Endoscopy. Clin Colon Rectal Surg 2019; 32:183-189. [PMID: 31061648 DOI: 10.1055/s-0038-1677024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although rare, perforation can be a devastating complication of colonoscopy. Incidence ranges from 0.012 to 0.65% during diagnostic procedures and is higher in therapeutic procedures. Early diagnosis and management are of paramount importance to decrease morbidity. Diagnostic imaging after colonoscopy can reveal extraintestinal air, but overall clinical status including leukocytosis, fever, pain, and peritonitis is equally important to determine management. With the expanding availability of complex endoscopic interventions, an increasing number of perforations are recognized during colonoscopy or immediately afterward based on high degree of suspicion. Colonoscopic management of these early perforations may be feasible and avoid the morbidity of surgery. Patients who require surgery may be managed with laparoscopic or open surgical techniques. Surgical management may consist of primary repair of the injury, resection with anastomosis, or resection with ostomy. Mechanical bowel preparation before endoscopy decreases fecal contamination after perforation, often obviating the need for ostomy creation.
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Affiliation(s)
- Earl V Thompson
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan R Snyder
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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17
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Lee JM, Bai P Chang J, El Hechi M, Kongkaewpaisan N, Bonde A, Mendoza AE, Saillant NN, Fagenholz PJ, Velmahos G, Kaafarani HM. Hartmann's Procedure vs Primary Anastomosis with Diverting Loop Ileostomy for Acute Diverticulitis: Nationwide Analysis of 2,729 Emergency Surgery Patients. J Am Coll Surg 2019; 229:48-55. [PMID: 30902639 DOI: 10.1016/j.jamcollsurg.2019.03.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/11/2019] [Accepted: 03/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recent small randomized trials suggest that primary anastomosis with a diverting loop ileostomy (PADLI) is a safe alternative to Hartmann's procedure (HP) for patients with acute diverticulitis necessitating emergent operation. We sought to examine the 30-day outcomes of patients undergoing emergent HP vs PADLI. METHOD Using the American College of Surgeons NSQIP Colectomy Procedure Targeted Database from 2012 to 2016, all patients with acute diverticulitis who underwent emergent HP or PADLI were identified. Multivariable logistic models were constructed to compare the 30-day mortality, overall morbidity, and individual postoperative complications (eg surgical site infection, bleeding, sepsis) of the 2 procedures, controlling for all preoperative variables (eg demographics, comorbidities, laboratory values, illness severity), as well as intraoperative and procedure-specific variables (eg wound classification). RESULTS Of 130,963 patients, 2,729 patients were included. Median age was 64 years, 48.5% were male; the majority of patients underwent HP and only 208 (7.6%) underwent PADLI. Hartmann's procedure patients had more comorbidities (eg COPD: 9.8% vs 4.8%; p = 0.017), were more functionally dependent (6.3% vs 2.4%; p = 0.025), and were sicker (eg septic shock: 11.1% vs 5.3%; p = 0.015) compared with PADLI patients. The mortality rates for HP vs PADLI were 7.6% and 2.9%, respectively (p = 0.011). The morbidity rates were 55.4% and 48.6%, respectively (p = 0.056). In multivariable analyses, compared with HP, PADLI did not result in increased rates of mortality (odds ratio 0.21; 95% CI 0.03 to 1.58; p = 0.129) or morbidity (odds ratio 0.96; 95% CI 0.63 to 1.45; p = 0.834). The odds of most major postoperative complications were also similar for HP and PADLI overall. CONCLUSIONS Currently, surgeons perform HP more frequently than PADLI. When controlling for patient population differences, PADLI appears to be at least a safe alternative to HP for select patient populations needing emergent surgical management of acute diverticulitis.
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Affiliation(s)
- Jae Moo Lee
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jun Bai P Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Majed El Hechi
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Alexander Bonde
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - April E Mendoza
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | - George Velmahos
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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18
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Resio BJ, Pei KY, Liang J, Zhang Y. Evaluating the adoption of primary anastomosis with proximal diversion for emergent cases of surgically managed diverticulitis. Surgery 2018; 164:1230-1233. [DOI: 10.1016/j.surg.2018.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/29/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
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19
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Gachabayov M, Oberkofler CE, Tuech JJ, Hahnloser D, Bergamaschi R. Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis. Colorectal Dis 2018; 20:753-770. [PMID: 29694694 DOI: 10.1111/codi.14237] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
AIM It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates. METHOD The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)]. CONCLUSION This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.
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Affiliation(s)
- M Gachabayov
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - C E Oberkofler
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J J Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - R Bergamaschi
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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20
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Horwood C, Wisler J, Byrd S, Woodling K, Schneider EB, Rushing A. Management outcomes of diverticulitis and colitis in patients with active cancer. Surgery 2018; 164:350-353. [PMID: 29801733 DOI: 10.1016/j.surg.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/12/2018] [Accepted: 03/05/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Little is reported in the literature on management strategies and outcomes in patients with an active cancer diagnosis who undergo emergent general surgery. The purpose of this study is to evaluate preoperative risk factors in both operative and non-operative management, as well as to describe the outcomes of colonic emergencies within a cancer patient population. METHODS A single institution cancer database was reviewed retrospectively to identify patients with an active cancer diagnosis who had an emergency general surgery consult placed for an acute colonic pathology. RESULTS A total of 87 patients were included. Among these, 38 patients underwent operative and 49 underwent nonoperative management. There was a 71% rate of postoperative complications in the operative group; these patients were also more likely to require intensive care unit admission (P < .001), die during their hospitalization (P = .003), have a greater 30-day mortality (P = .001) and were less likely to be discharged to home (P < .001). No patients in the nonoperative group required admission to the intensive care unit, 3 of the 49 (6%) died during their hospitalization, and 75% of nonoperative patients were discharged to home. CONCLUSION When clinically appropriate, patients with active cancer who present with an acute colonic emergency can undergo nonoperative management safely. In contrast, patients undergoing operative management have a substantial risk of morbidity and mortality.
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Affiliation(s)
| | | | - Sara Byrd
- The Ohio State University, Department of Surgery, Columbus
| | | | | | - Amy Rushing
- The Ohio State University, Department of Surgery, Columbus.
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21
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Laparoscopic lavage versus surgical resection for acute diverticulitis with generalised peritonitis: a systematic review and meta-analysis. Tech Coloproctol 2017; 21:93-110. [PMID: 28197792 DOI: 10.1007/s10151-017-1585-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
Abstract
This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34-4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02-0.51), and a shorter length of postoperative hospital stay during index admission (WMD = -2.03, 95% CI -2.59 to -1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30-90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien-Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38-0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness.
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22
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Mozer AB, Spaniolas K, Sippey ME, Celio A, Manwaring ML, Kasten KR. Post-operative morbidity, but not mortality, is worsened by operative delay in septic diverticulitis. Int J Colorectal Dis 2017; 32:193-199. [PMID: 27815699 DOI: 10.1007/s00384-016-2689-0] [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] [Accepted: 10/12/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Optimal timing of surgery for acute diverticulitis remains unclear. A non-operative approach followed by elective surgery 6-week post-resolution is favored. However, a subset of patients fail on the non-operative management during index admission. Here, we examine patients requiring emergent operation to evaluate the effect of surgical delay on patient outcomes. METHODS Patients undergoing emergent operative intervention for acute diverticulitis were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012. Primary endpoints of 30-day overall morbidity and mortality were evaluated via univariate and multivariate analysis. RESULTS Of the 2,119 patients identified for study inclusion, 57.2 % (n = 1212) underwent emergent operative intervention within 24 h, 26.3 % (n = 558) between days 1-3, 12.9 % (n = 273) between days 3-7, and 3.6 % (n = 76) greater than 7 days from admission. End colostomy was performed in 77.4 % (n = 1,640) of cases. Unadjusted age and presence of major comorbidities increased with operative delay. Further, unadjusted 30-day overall morbidity, mortality, septic complications, and post-operative length of stay increased significantly with operative delay. On multivariate analysis, operative delay was not associated with increased 30-day mortality but was associated with increased 30-day overall morbidity. CONCLUSIONS Hartmann's procedure has remained the standard operation in emergent surgical management of acute diverticulitis. Delay in definitive surgical therapy greater than 24 h from admission is associated with higher rates of morbidity and protracted post-operative length of stay, but there is no increase in 30-day mortality. Prospective study is necessary to further answer the question of surgical timing in acute diverticulitis.
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Affiliation(s)
- Anthony B Mozer
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Konstantinos Spaniolas
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Megan E Sippey
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Adam Celio
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Mark L Manwaring
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Kevin R Kasten
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA.
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Matsushima K, Inaba K, Jhaveri V, Cheng V, Herr K, Siboni S, Strumwasser A, Demetriades D. Loss of muscle mass: a significant predictor of postoperative complications in acute diverticulitis. J Surg Res 2016; 211:39-44. [PMID: 28501129 DOI: 10.1016/j.jss.2016.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 11/03/2016] [Accepted: 12/01/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe muscle mass depletion, sarcopenia, has been shown to be associated with poor operative outcomes. However, its impact on emergency abdominal operations remains unclear. The purpose of this study was to examine the association between low muscle mass (LMM) and outcomes after emergency operations for acute diverticulitis. PATIENTS AND METHODS Patients ≥18 y requiring an emergency operation for acute diverticulitis between January 2007 and September 2014 were included. On preoperative computed tomography, the cross-sectional area (CSA) and transverse diameter (TVD) of the right and left psoas muscle were measured at the level of the third lumbar vertebral body. Sensitivity analysis was performed to determine appropriate CSA and TVD cutoff values defining low skeletal muscle mass. Clinical outcomes of patients with low muscle mass (LMM group) were compared with the non-LMM group. RESULTS A total of 89 patients met our inclusion criteria. Median CSA and TVD were 794 mm2 and 24 mm, respectively. There was a strong correlation between the CSA and TVD (R2 = 0.84). In univariable analysis, significantly higher rates of postoperative major complications (63% versus 37%, P = 0.027) and surgical site infection (47% versus 19%, P = 0.008) were identified in the LMM group. After adjusting for clinically important covariates in a logistic regression model, patients with LMM were significantly associated with higher odds of major complications and surgical site infection. CONCLUSIONS Preoperative assessment of the psoas muscle CSA and TVD on computed tomography can be a practical method for identifying patients at risk for postoperative complications.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California.
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Vidhi Jhaveri
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Vincent Cheng
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Keith Herr
- Department of Radiology, University of Southern California, Los Angeles, California
| | - Stefano Siboni
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Aaron Strumwasser
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
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Deep organ space infection after emergency bowel resection and anastomosis: The anatomic site does not matter. J Trauma Acute Care Surg 2016; 79:805-11. [PMID: 26496105 DOI: 10.1097/ta.0000000000000840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Deep organ space infection (DOSI) is a serious complication after emergency bowel resection and anastomosis. The aim of this study was to identify the incidence and risk factors for the development of DOSI. METHODS National Surgical Quality Improvement Program database study including patients who underwent large bowel or small bowel resection and primary anastomosis. The incidence, outcomes, and risk factors for DOSI were evaluated using univariate and multivariate analyses. RESULTS A total of 87,562 patients underwent small bowel, large bowel, or rectal resection and anastomosis. Of these, 14,942 (17.1%) underwent emergency operations and formed the study population. The overall mortality rate in emergency operations was 12.5%, and the rate of DOSI was 5.6%. A total of 18.0% required ventilatory support in more than 48 hours, and 16.0% required reoperation. Predictors of DOSI included age, steroid use, sepsis or septic shock on admission, severe wound contamination, and advanced American Society of Anesthesiologists classification. The anatomic location of resection and anastomosis was not significantly associated with DOSI. CONCLUSION Patients undergoing emergency bowel resection and anastomosis have a high mortality, risk of DOSI, and systemic complications. Independent predictors of DOSI include wound and American Society of Anesthesiologists classification, sepsis or septic shock on admission, and steroid use. The anatomic location of resection and anastomosis was not significantly associated with DOSI. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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25
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Daher R, Barouki E, Chouillard E. Laparoscopic treatment of complicated colonic diverticular disease: A review. World J Gastrointest Surg 2016; 8:134-142. [PMID: 26981187 PMCID: PMC4770167 DOI: 10.4240/wjgs.v8.i2.134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 10/11/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.
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Focchi S, Carrara A, Avesani EC. Advances in management of patients with acute diverticulitis. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Sartelli M, Moore FA, Ansaloni L, Di Saverio S, Coccolini F, Griffiths EA, Coimbra R, Agresta F, Sakakushev B, Ordoñez CA, Abu-Zidan FM, Karamarkovic A, Augustin G, Costa Navarro D, Ulrych J, Demetrashvili Z, Melo RB, Marwah S, Zachariah SK, Wani I, Shelat VG, Kim JI, McFarlane M, Pintar T, Rems M, Bala M, Ben-Ishay O, Gomes CA, Faro MP, Pereira GA, Catani M, Baiocchi G, Bini R, Anania G, Negoi I, Kecbaja Z, Omari AH, Cui Y, Kenig J, Sato N, Vereczkei A, Skrovina M, Das K, Bellanova G, Di Carlo I, Segovia Lohse HA, Kong V, Kok KY, Massalou D, Smirnov D, Gachabayov M, Gkiokas G, Marinis A, Spyropoulos C, Nikolopoulos I, Bouliaris K, Tepp J, Lohsiriwat V, Çolak E, Isik A, Rios-Cruz D, Soto R, Abbas A, Tranà C, Caproli E, Soldatenkova D, Corcione F, Piazza D, Catena F. A proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg Surg 2015; 10:3. [PMID: 25972914 PMCID: PMC4429354 DOI: 10.1186/1749-7922-10-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/30/2014] [Indexed: 02/08/2023] Open
Abstract
Computed tomography (CT) imaging is the most appropriate diagnostic tool to confirm suspected left colonic diverticulitis. However, the utility of CT imaging goes beyond accurate diagnosis of diverticulitis; the grade of severity on CT imaging may drive treatment planning of patients presenting with acute diverticulitis. The appropriate management of left colon acute diverticulitis remains still debated because of the vast spectrum of clinical presentations and different approaches to treatment proposed. The authors present a new simple classification system based on both CT scan results driving decisions making management of acute diverticulitis that may be universally accepted for day to day practice.
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Affiliation(s)
| | | | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | | | | | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ferdinando Agresta
- Department of Surgery, Ospedale Civile, ULSS19 del Veneto, Adria, (RO) Italy
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Carlos A Ordoñez
- Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Fikri M Abu-Zidan
- Department of Surgery, Faculty of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Goran Augustin
- Department of Surgery, University Hospital Center, Zagreb, Croatia
| | - David Costa Navarro
- General and Digestive Tract Surgery, Alicante University General Hospital, Alicante, Spain
| | - Jan Ulrych
- 1st Surgical Department of First Faculty of Medicine, General University Hospital, Prague Charles University, Prague, Czech Republic
| | - Zaza Demetrashvili
- Department of General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Renato B Melo
- Department of General Surgery, Centro Hospitalar São João, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | | | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Jae Il Kim
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Michael McFarlane
- Department of Surgery, Radiology, Anaesthetics and Intensive Care University Hospital of the West Indies, Kingston, Jamaica
| | - Tadaja Pintar
- Department of Abdominal Surgery, Umc Ljubljana, Ljubljana, Slovenia
| | - Miran Rems
- Surgical Department, General Hospital Jesenice, Jesenice, Slovenia
| | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Carlos Augusto Gomes
- Federal University of Juiz de Fora (UFJF) AND Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Juiz de Fora, MG Brazil
| | - Mario Paulo Faro
- Department of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gerson Alves Pereira
- Emergency Surgery and trauma Unit, Department of Surgery, Ribeirão, Preto, Brazil
| | | | - Gianluca Baiocchi
- Clinical and Experimental Sciences, Brescia Ospedali Civili, Brescia, Italy
| | - Roberto Bini
- General and Emergency Surgery SG Bosco Hospital, Turin, Italy
| | - Gabriele Anania
- Department of Surgery, Arcispedale S. Anna, Medical University of Ferrara, Ferrara, Italy
| | - Ionut Negoi
- Emergency Hospital of Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Zurabs Kecbaja
- General and Emergency Surgery Department, Riga East University Hospital “Gailezers”, Riga, Latvia
| | - Abdelkarim H Omari
- Department of General Surgery, King Abdalla University Hospital, Irbid, Jordan
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Jakub Kenig
- 3rd Department of Generał Surgery, Narutowicz Hospital, Krakow, Połand
| | - Norio Sato
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | - Matej Skrovina
- Department of Surgery Hospital and Oncological Centre Novy Jicin, Novy Jicin, Czech Republic
| | - Koray Das
- Department of General Surgery, Numune Training and Research Hospital, Adana, Turkey
| | | | | | | | - Victor Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Kenneth Y Kok
- Department of Surgery, Ripas Hospital, Bandar Seri Begawan, Brunei
| | - Damien Massalou
- Department of Surgery, University Hospital of Nice, University of Nice Sophia-Antipolis, Sophia-Antipolis, France
| | - Dmitry Smirnov
- Department of Surgical Diseases, South Ural State Medical University, Chelyabinsk City, Russian Federation
| | - Mahir Gachabayov
- Department of Surgery, Clinical Hospital of Emergency Medicine, Vladimir City, Russian Federation
| | - Georgios Gkiokas
- 2nd Department of Surgery, Aretaieio University Hospital, Athens, Greece
| | | | | | | | | | - Jaan Tepp
- Department of General Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Varut Lohsiriwat
- Department of Surgery, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
| | - Elif Çolak
- Department of Surgery, Samsun Education and Research Hospital, Samsun, Turkey
| | - Arda Isik
- Department of Surgery, Mengucek Gazi Training Research Hospital, Erzincan, Turkey
| | - Daniel Rios-Cruz
- Department of Surgery, Hospital de Alta Especialidad de Veracruz, Veracruz, Mexico
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Ashraf Abbas
- Emergency Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Cristian Tranà
- Department of Emergency Medicine and Surgery, Macerata Hospital, Macerata, Italy
| | | | - Darija Soldatenkova
- General and Emergency Surgery Department, Riga East University Hospital “Gailezers”, Riga, Latvia
| | - Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, Colli-Monaldi Hospital, Naples, Italy
| | - Diego Piazza
- Division of Surgery, Vittorio Emanuele Hospital, Catania, Italy
| | - Fausto Catena
- Emergency Department, Maggiore University Hospital, Parma, Italy
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Complications after laparotomy for trauma: a retrospective analysis in a level I trauma centre. Langenbecks Arch Surg 2014; 400:83-90. [PMID: 25534708 DOI: 10.1007/s00423-014-1260-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Laparotomy is a potential life-saving procedure after traumatic abdominal injury. There is limited literature about morbidity and mortality rates after trauma laparotomy. The primary aim of this study is to describe the complications which may occur due to laparotomy for trauma. METHODS Retrospective evaluated single-centre study with data registry up to 1 year after initial laparotomy for trauma was performed in a level 1 trauma centre in The Netherlands. Between January 2000 and January 2011, a total of 2390 severely injured trauma patients (ISS ≥ 16) were transported to the VUMC. Patient demographics; mechanism of injury; injury patterns defined by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and Revised Trauma Score (RTS); surgical interventions and findings; and morbidity and mortality were documented. RESULTS A total of 92 trauma patients who underwent a trauma laparotomy met the inclusion criteria. Of these patients, 71 % were male. Median age was 37 years. Median ISS was 27. Mechanisms of injury comprised of car accidents (20 %), fall from height (17 %), motorcycle accidents (12 %), pedestrian/cyclist hit by a vehicle (9 %) and other in three patients (5 %). Penetrating injuries accounted for 37 % of the injuries, consisting of stab wounds (21 %) and gunshot wounds (16 %). Complications classified by the Clavien-Dindo Classification of Surgical Complications showed grade I complications in 21 patients (23 %), grade II in 36 patients (39 %), grade III in 21 patients (23 %), grade IV in 2 patients (2 %) and grade V in 16 patients (17 %). CONCLUSION Laparotomy for trauma has a high complication rate resulting in significant morbidity and mortality. Most events occur in the early postoperative period. Further prospective research needs to be conducted in order to identify possibilities to improve care in the future.
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Management of acute diverticulitis and its complications. Indian J Surg 2014; 76:429-35. [PMID: 25614717 DOI: 10.1007/s12262-014-1086-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann's procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications-such as fistulating disease, strictures or recurrent diverticular bleeding-and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases.
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Teloken PE, Spilsbury K, Levitt M, Makin G, Salama P, Tan P, Penter C, Platell C. Outcomes in patients undergoing urgent colorectal surgery. ANZ J Surg 2014; 84:960-4. [DOI: 10.1111/ans.12580] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2014] [Indexed: 12/19/2022]
Affiliation(s)
| | - Katrina Spilsbury
- Centre for Population Health Research; Curtin University; Perth Western Australia Australia
| | - Michael Levitt
- Colorectal Surgical Unit; St John of God Hospital; Perth Western Australia Australia
| | - Gregory Makin
- Colorectal Surgical Unit; St John of God Hospital; Perth Western Australia Australia
| | - Paul Salama
- Colorectal Surgical Unit; St John of God Hospital; Perth Western Australia Australia
- School of Surgery and Pathology; University of Western Australia; Perth Western Australia Australia
| | - Patrick Tan
- Colorectal Surgical Unit; St John of God Hospital; Perth Western Australia Australia
| | - Cheryl Penter
- Colorectal Surgical Unit; St John of God Hospital; Perth Western Australia Australia
- Department of Surgery; University of Western Australia; Perth Western Australia Australia
| | - Cameron Platell
- Colorectal Surgical Unit; St John of God Hospital; Perth Western Australia Australia
- Department of Surgery; University of Western Australia; Perth Western Australia Australia
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Kwon E, Browder T, Fildes J. Surgical Management of Fulminant Diverticulitis. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0040-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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