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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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Pantel H, Reddy VB. Management of Colonic Emergencies. Surg Clin North Am 2023; 103:1133-1152. [PMID: 37838460 DOI: 10.1016/j.suc.2023.06.006] [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] [Indexed: 10/16/2023]
Abstract
The etiology of colonic emergencies includes a wide-ranging and diverse set of pathologic conditions. Fortunately, for the surgeon treating a patient with one of these emergencies, the surgical management of these various causes is limited to choosing among proximal diversion, segmental colectomy with or without proximal diversion, or a total abdominal colectomy with end ileostomy (or rarely, an ileorectal anastomosis). The nuanced complexity in these situations usually revolves around the nonsurgical and/or endoscopic options and deciding when to proceed to the operating room.
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Affiliation(s)
- Haddon Pantel
- Colon and Rectal Surgery, Yale University School of Medicine, 450 George Street, New Haven, CT 06510, USA
| | - Vikram B Reddy
- Colon and Rectal Surgery, Yale University School of Medicine, 450 George Street, New Haven, CT 06510, USA.
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Stovall SL, Kaplan JA, Law JK, Flum DR, Simianu VV. Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care. World J Gastrointest Surg 2023; 15:1007-1019. [PMID: 37405108 PMCID: PMC10315108 DOI: 10.4240/wjgs.v15.i6.1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 06/15/2023] Open
Abstract
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.
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Affiliation(s)
- Stephanie Lee Stovall
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Joanna K Law
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - David R Flum
- Department of Surgery, University of Washington Medical, Seattle, WA 98195, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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Lee KY, Lee J, Oh ST, Lee CS, Kim NS, Song JM, Yoo RN, Choi BJ. Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study. PLoS One 2023; 18:e0286562. [PMID: 37267375 DOI: 10.1371/journal.pone.0286562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Although the advantages of laparoscopic Hartmann reversal (LHR) compared to open Hartmann reversal (OHR) have been reported in the literature, the number of multicenter studies with good matching investigating this topic is rare. In the present study, we aimed to confirm the advantages of LHR in terms of short-term outcomes through propensity score matching of LHR and OHR groups, using data collected from multiple institutions. METHODS Patients who underwent Hartmann reversal at six institutions under the Catholic Medical Center of the Catholic University of Korea between January 1, 2005, and December 31, 2021, were included. The patients were divided into the LHR and OHR groups based on the technique used. The two groups were matched using propensity score matching (1:1 ratio, logistic regression with the nearest-neighbor method). The primary outcome was postoperative ileus (POI) frequency, and secondary outcomes were time to solid diet (days) and length of stay (days). RESULTS Among 337 patients, propensity score matching was performed on 322, after excluding 15 who had undergone open conversion. Of these, 63 patients were assigned to each group through propensity score matching. There was no difference in the frequency of adhesiolysis (77.8% vs. 82.5%, p = 0.503) or the operation time. (210 (IQR 159-290) vs. 233 (IQR 160-280), p = 0.718) between the two groups. As the primary outcome, the LHR group showed significantly lower POI frequency than the OHR group. (4.8% vs. 22.2%, p = 0.0041) Regarding the secondary outcomes, the LHR group showed a shorter period to solid diet than the OHR group. The length of hospital stay was also significantly shorter in the LHR group (4 vs. 6, p < 0.0001; 9 vs. 12, p<0.0001). CONCLUSION LHR is an effective method to ensure faster recovery of patients after surgery compared to OHR.
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Affiliation(s)
- Kil-Yong Lee
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Jaeim Lee
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Seong Taek Oh
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Chul Seung Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Nam Suk Kim
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Myung Song
- Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Ri-Na Yoo
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Byung Jo Choi
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
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Salusjärvi JM, Koskenvuo LE, Mali JP, Mentula PJ, Leppäniemi AK, Sallinen VJ. Stoma reversal after Hartmann's procedure for acute diverticulitis. Surgery 2023; 173:920-926. [PMID: 36517294 DOI: 10.1016/j.surg.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hartmann's procedure is a treatment option for perforated acute diverticulitis, especially when organ dysfunction(s) are present. Its use has been criticized mostly out of fear of high permanent stoma rate. The aim of this study was to investigate the rate of stoma reversal, reasons behind nonreversal, and safety of reversal surgery. METHODS This was a single-center retrospective study of patients undergoing urgent Hartmann's procedure due to acute diverticulitis between the years 2006 and 2017 with follow-up until March 2021. RESULTS A total of 3,319 episodes of diverticulitis in 2,932 patients were screened. The Hartmann's procedure was performed on 218 patients, of whom 157 (72%) had peritonitis (48 (22%) with organ dysfunction). At 2-years, 76 (34.9%) patients had died with stoma, 42 (19.3%) were alive with stoma, and 100 (45.9%) had undergone stoma reversal. The survival of patients with and without reversal were 100% and 42.7% at 1-year, 96.0% and 35.0% at 2-years and 88.9% and 20.7% at 5-years, respectively. The risk factors for nonreversal were old age, a need for outside assistance, low HElsinki Staging for Acute Diverticulitis stage, and higher C-reactive protein level upon hospital admission. The most common reasons for nonreversal in surviving patients were patient not willing to have the operation 18 (41%) and dementia 10 (23%). Twelve (12%) patients had a major complication after reversal (Clavien-Dindo IIIb-IV) and 90-day mortality after reversal was 0%. CONCLUSION After the Hartmann's procedure for acute diverticulitis, one-third died, half underwent stoma reversal, and one-fifth did not undergo stoma reversal within 2 years. Patients who survive with stoma are either not willing to have reversal or have severe comorbidities excluding elective surgery. The Hartmann's procedure remains a viable option for high-risk patients with perforated acute diverticulitis.
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Affiliation(s)
- Johannes M Salusjärvi
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Laura E Koskenvuo
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. https://twitter.com/LauraKoskenvuo
| | - Juha P Mali
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu J Mentula
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ari K Leppäniemi
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville J Sallinen
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. https://twitter.com/villesallinen
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Ferrara F, Guerci C, Bondurri A, Spinelli A, De Nardi P. Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee. Updates Surg 2023:10.1007/s13304-023-01487-7. [PMID: 36934347 PMCID: PMC10024796 DOI: 10.1007/s13304-023-01487-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/23/2023] [Indexed: 03/20/2023]
Abstract
Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients can undergo Hartmann's procedure (H) or resection with primary anastomosis (RA), with or without diverting stoma. This multicenter observational retrospective study aims to evaluate the adherence to current guidelines by assessing the rate of RA and H in Lombardy, Italy, and to analyze differences in patients' features. This study included data collected from nine surgical units performing emergency surgery in Lombardy, in 2019 and 2021. Data for each year were retrospectively collected through a survey among Italian Society of Colorectal Surgery (SICCR) Lombardy members. Additional data were about: Hinchey's classification, laparoscopic (VLS) or converted procedures, procedures with more than two operators, procedures in which the first operator was older than 40 years, night or weekend procedures, older-than-80 patients, COVID-19 positivity (just 2021). The total number of operations performed was 254, 115 RA and 130 H (45.3% and 51.2%, diff. 12%, p = 0.73), and 9 (3.5%) other procedures. RAs were more frequent for Hinchey 1 and 2 patients, whereas Hs were more frequent for Hinchey 3 and 4. RAs without ileostomy were significantly less than Hs (66 vs. 130, p = 0.04). Laparoscopy was more used for RA compared to H (57 vs. 21, p = 0.03), whereas no difference was found between RA and H with respect to conversion rate, the presence of more than two operators in the team, the presence of a first operator older than 40 years, night or weekend operations, and for older-than-80 patients. This study confirms the adherence to current guidelines for the treatment of acute colonic diverticulitis in Lombardy, Italy. It can be considered as a preliminary survey with interesting results that may open the way to a further prospective observational study to clarify some aspects in the management of this disease.
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Affiliation(s)
- Francesco Ferrara
- Unit of General and Emergency Surgery, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Claudio Guerci
- Unit of General Surgery, ASST Fatebenefratelli Sacco, Luigi Sacco University Hospital, Via San Martino 4, Trescore Cremasco, 26017 Milan, Italy
| | - Andrea Bondurri
- Unit of General Surgery, ASST Fatebenefratelli Sacco, Luigi Sacco University Hospital, Via San Martino 4, Trescore Cremasco, 26017 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paola De Nardi
- Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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7
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A Brave New World: Colorectal Anastomosis in Trauma, Diverticulitis, Peritonitis, and Colonic Obstruction. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Diverticulosis of the sigmoid colon is common in the developed world, affecting approximately 33% of persons older than 60 years. Up to 15% of these patients will develop diverticulitis at some point in their lifetime. The incidence of diverticulitis has increased in the last decade, accounting for nearly 300,000 US hospital admissions and $1.8 billion in annual direct medical costs. With such a wide prevalence and diverse spectrum of clinical presentation, there are bound to be multiple controversies regarding disease management. This article will serve to educate the reader on several important areas to consider when treating this ubiquitous disease.
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Affiliation(s)
- Aimal Khan
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, Room D5203 MCN, Nashville, TN 37232, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, Room D5203 MCN, Nashville, TN 37232, 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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Sanaiha Y, Hadaya J, Aguayo E, Chen F, Benharash P. Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort. JAMA Netw Open 2021; 4:e2130674. [PMID: 34739065 PMCID: PMC8571654 DOI: 10.1001/jamanetworkopen.2021.30674] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. OBJECTIVE To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. EXPOSURES Undergoing HP vs PAPD. MAIN OUTCOMES AND MEASURES Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. RESULTS During the study period, an estimated 1 072 395 adults (615 954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34 126 patients required diversion, with 32 326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P < .001) and decreased rates of end organ dysfunction (520 patients [28.9%] vs 11 514 patients [35.6%]; P < .001). In inverse probability treatment weight analysis, the odds of mortality (adjusted odds ratio [aOR], 0.63; 95% CI, 0.32-1.40), complications (aOR, 0.86; 95% CI, 0.66-1.13), and nonhome discharge (aOR 1.15; 95% CI, 0.83-1.60) were similar for PAPD compared with HP. Among 1772 patients who underwent PAPD and survived index hospitalization, there was an increased incidence of 90-day readmission compared with 30 851 patients who underwent HP and survived index hospitalization (393 patients [22.2%] vs 4384 patients [14.2%]; P < .001) with increased hazard of ostomy reversal (hazard ratio, 1.46; 95% CI, 1.08-1.99). CONCLUSIONS AND RELEVANCE This study found that the use of PAPD was associated with comparable index hospitalization outcomes vs use of HP, while readmission rate and ostomy risk were statistically significantly increased among patients who underwent PAPD compared with patients who underwent HP. These findings suggest that further delineation of criteria for appropriate application of PAPD in the urgent setting are warranted.
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Affiliation(s)
- Yas Sanaiha
- Cardiac Outcomes Research Laboratory, University of California, Los Angeles
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Sylmara
| | - Joseph Hadaya
- Cardiac Outcomes Research Laboratory, University of California, Los Angeles
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Sylmara
| | - Esteban Aguayo
- Cardiac Outcomes Research Laboratory, University of California, Los Angeles
| | - Formosa Chen
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Sylmara
| | - Peyman Benharash
- Cardiac Outcomes Research Laboratory, University of California, Los Angeles
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Rodriguez JER, Coelho DPD, Villalaz EDS, Figueiredo AR, Martins PDK, Guimarães JJP, de Souza AMC, Guimarães AGDP. Rectosigmoid transition perforation by ingá ( Inga laurina) seeds in the Brazilian amazon: Case report and surgical treatment. Ann Med Surg (Lond) 2021; 70:102897. [PMID: 34691434 PMCID: PMC8519804 DOI: 10.1016/j.amsu.2021.102897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/25/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Foreign body ingestion is a common clinical scenario found in clinical practice. Perforations related to foreign bodies are rare, but they can present as a serious condition in emergency surgery services. The most common sites of perforation are angled areas, such as: ileocecal valve, sigmoid colon, duodenojejunal flexure and small intestine. We are going to describe a rare case of extensive perforation of rectosigmoid transition, without associated obstructive clinical picture, related to voluntary ingestion of foreign body caused by multiple seeds of a typical amazon fruit. Presentation of case This case report describes the presentation and management of a 46-year-old man who presented signs of acute perforating abdomen, without obstructive condition, after ingestion of foreign body. Imaging examination revealed the presence of foreign bodies with signs of intestinal perforation. Exploratory laparotomy was performed to treat the lesion and remove foreign bodies. Discussion Bowel perforation by a non-sharp foreign body is a rare complication of object ingestion. Object shape, quantity, narrowing of gastrointestinal tract are factors that can favor perforation. The clinic is not very specific, usually preceded by when obstructive or sub occlusive, and the clinical history is relevant for diagnostic formulation. Regions and cultures with a high intake of food with seeds may constitute an extra risk factor. Conclusion The importance of alerting surgical teams to the possibility of bowel perforation without associated occlusive conditions caused by multiple non-sharp seeds is highlighted, as well as the need for early treatment aiming at favorable clinical outcome. Intestinal perforation by multiple non sharp fruits seeds is rare It is possible that there is no intestinal obstruction before perforation The use of protective terminal colostomy as described is an option
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Berg A, Rosenzweig M, Kuo YH, Onayemi A, Mohidul S, Moen M, Sciarretta J, Davis JM, Ahmed N. The results of rapid source control laparotomy or open abdomen for acute diverticulitis. Langenbecks Arch Surg 2021; 407:259-265. [PMID: 34455491 PMCID: PMC8402969 DOI: 10.1007/s00423-021-02304-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 08/16/2021] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Rapid source control laparotomy (RSCL) for the management of non-traumatic intra-abdominal emergencies has increased over the past 25 years when it was advocated for trauma patients. Little data, however, support its widespread use. We hypothesize that the patients with RSCL will have poorer outcomes than those treated with primary fascial closure (PFC). METHODS Patients operated for acute diverticulitis from 2014 to 2016 using The American College of Surgeons sponsored National Surgical Quality Improvement Program (NSQIP) data were reviewed. Two groups were identified: PFC, patients with their closed fascia but skin left open (PFC) and RSCL, patients with their left open fascia after the initial operation. The primary outcome of the study was 30-day mortality, with secondary analyses evaluating complications, discharge location and length of stay. Univariate analysis was initially performed followed by propensity score matching. RESULTS A total of 460 patients were surgically treated for Hinchey IV diverticulitis of whom 101 (21.9%) had RSCL. The length of stay of the RSCL patients was significantly longer (15 versus 12 days, p, 0.02) than patients in the PFC group. Similarly, the discharge destination for the PFC group was twice as likely to be discharged home as the RSCL group. CONCLUSION RSCL for acute diverticulitis is a widely used but is associated with prolonged hospitalizations resulting in high rates of discharge to skilled nursing or rehabilitation facilities. Its routine use for diverticulitis should be limited.
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Affiliation(s)
- Arthur Berg
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Matthew Rosenzweig
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Yen-Hong Kuo
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Ayolola Onayemi
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | | | - Micaela Moen
- Grand Strand Medical Center, Myrtle Beach, SC, USA
| | - Jason Sciarretta
- Emory School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - John Mihran Davis
- South Shore University Hospital - Northwell Health, Bay Shore, NY, USA. .,South Shore University Hospital - Northwell Health, 301 East Main Street, NY, 17061, Bay Shore, USA.
| | - Nasim Ahmed
- Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
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Hoffman RL, Consuegra H, Long K, Buzas C. Anastomotic leak in patients with acute complicated diverticulitis undergoing primary anastomosis: risk factors and the role of diverting loop ileostomy. Int J Colorectal Dis 2021; 36:1543-1550. [PMID: 34041593 DOI: 10.1007/s00384-021-03957-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent data has suggested that primary anastomosis (PA), with or without a diverting loop ileostomy (DLI), is a safe option for the treatment of acute complicated diverticulitis. This study aimed to evaluate risk factors associated with anastomotic leak in patients who underwent a sigmoid colectomy with PA and to determine whether a DLI was protective against a clinically significant anastomotic leak. METHODS Patients with acute complicated diverticulitis who underwent a laparoscopic or open sigmoid colectomy with PA, with or without a DLI, were identified in the NSQIP PUF(2016-2017). The rates of anastomotic leak, receipt of DLI, and type of leak management were compared. Multivariate logistic regression was performed. RESULTS There were 497 patients identified. Seventy-nine(15.9%) patients had a DLI, while 418 (84.1%) did not. Twenty-six anastomotic leaks were identified (5.2%). On multivariate analysis, current smoking (OR 4.02; 95% CI 1.44-11.26) and chronic steroid use (OR 3.84; 95% CI 1.16-12.69) were significantly associated with an increased risk of leak. Of the 26 patients with anastomotic leaks, 5 (19.2%) had a DLI. There was no significant difference in the rate of leak between those with a DLI(5; 6.3%) and those without(21; 5.3%; p = 0.59). Patients who had a DLI were significantly less likely to experience an anastomotic leak requiring re-operation (p < 0.01). CONCLUSIONS Regardless of the presence of a DLI, chronic steroid use and smoking are associated with an increased risk of anastomotic leak in patients with acute complicated diverticulitis undergoing colectomy with PA. The presence of a diverting loop ileostomy is protective against re-operation.
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Affiliation(s)
- Rebecca L Hoffman
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA.
| | - Hadassah Consuegra
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Kevin Long
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Christopher Buzas
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
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14
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Alverdy JC. Bowel preparation in colorectal surgery: the day of reckoning is here. Br J Surg 2021; 108:340-341. [PMID: 33793758 PMCID: PMC8815791 DOI: 10.1093/bjs/znab021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 11/13/2022]
Abstract
Before the use of mechanical bowel preparation is either eliminated or subjected to a clinical trial, its scientific premise should be reconsidered, and consensus of its redesign discussed by a panel of experts including surgeons, infectious disease specialists, microbiome scientists, and clinical trialists.
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Affiliation(s)
- J C Alverdy
- Correspondence to: Department of Surgery, University of Chicago, 5841 S Maryland MC 6090, Chicago, Illinois 60647, USA (e-mail: )
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15
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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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16
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Zaborowski AM, Winter DC. Evidence-based treatment strategies for acute diverticulitis. Int J Colorectal Dis 2021; 36:467-475. [PMID: 33156365 DOI: 10.1007/s00384-020-03788-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Diverticular disease is a common acquired condition of the lower gastrointestinal tract that may be associated with significant morbidity. The term encompasses a spectrum of pathological processes with varying clinical manifestations. The purpose of this review was to update the reader on modern evidence-based treatment strategies for acute diverticulitis. METHODS A literature search of the PUBMED database was performed using the keywords 'diverticulosis', 'diverticular disease' and 'diverticulitis'. Only articles published in the English language were included. RESULTS Evidence-based treatment strategies for acute diverticulitis have evolved over time. Data have questioned the need for antibiotic therapy for Hinchey I disease and the role of percutaneous abscess drainage for Hinchey II. Clinical trials have demonstrated laparoscopic lavage is an appropriate option for select patients with Hinchey III disease and primary resection with anastomosis and defunctioning stoma may be considered in some cases of Hinchey IV disease. CONCLUSION Risk-adapted treatment strategies and operative decision-making for acute diverticulitis are increasingly based on a combination of patient and disease factors.
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Affiliation(s)
- Alexandra M Zaborowski
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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17
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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18
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Zizzo M, Castro Ruiz C, Zanelli M, Bassi MC, Sanguedolce F, Ascani S, Annessi V. Damage control surgery for the treatment of perforated acute colonic diverticulitis: A systematic review. Medicine (Baltimore) 2020; 99:e23323. [PMID: 33235095 PMCID: PMC7710165 DOI: 10.1097/md.0000000000023323] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Acute colonic diverticulitis (ACD) complications arise in approximately 8% to 35% patients and the most common ones are represented by phlegmon or abscess, followed by perforation, peritonitis, obstruction, and fistula. In accordance with current guidelines, patients affected by generalized peritonitis should undergo emergency surgery. However, decisions on whether and when to operate ACD patients remain a substantially debated topic while algorithm for the best treatment has not yet been determined. Damage control surgery (DCS) represents a well-established method in treating critically ill patients with traumatic abdomen injuries. At present, such surgical approach is also finding application in non-traumatic emergencies such as perforated ACD. Thanks to a thorough systematic review of the literature, we aimed at achieving deeper knowledge of both indications and short- and long-term outcomes related to DCS in perforated ACD. METHODS We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science databases were used to search all related literature. RESULTS The 8 included articles covered an approximately 13 years study period (2006-2018), with a total 359 patient population. At presentation, most patients showed III and IV American Society of Anesthesiologists (ASA) score (81.6%) while having Hinchey III perforated ACD (69.9%). Most patients received a limited resection plus vacuum-assisted closure at first-look while about half entire population underwent primary resection anastomosis (PRA) at a second-look. Overall morbidity rate, 30-day mortality rate and overall mortality rate at follow-up were between 23% and 74%, 0% and 20%, 7% and 33%, respectively. Patients had a 100% definitive abdominal wall closure rate and a definitive stoma rate at follow-up ranging between 0% and 33%. CONCLUSION DCS application to ACD patients seems to offer good outcomes with a lower percentage of patients with definitive ostomy, if compared to Hartmann's procedure. However, correct definition of DCS eligible patients is paramount in avoiding overtreatment. In accordance to 2016 WSES (World Society of Emergency Surgery) Guidelines, DCS remains an effective surgical strategy in critically ill patients affected by sepsis/septic shock and hemodynamical unstability.
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Affiliation(s)
- Maurizio Zizzo
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena
| | - Carolina Castro Ruiz
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena
| | - Magda Zanelli
- Pathology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia
| | - Maria Chiara Bassi
- Medical Library, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia
| | | | - Stefano Ascani
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, Terni, Italy
| | - Valerio Annessi
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia
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19
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Nascimbeni R, Amato A, Cirocchi R, Serventi A, Laghi A, Bellini M, Tellan G, Zago M, Scarpignato C, Binda GA. Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper. Tech Coloproctol 2020; 25:153-165. [PMID: 33155148 PMCID: PMC7884367 DOI: 10.1007/s10151-020-02346-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.
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Affiliation(s)
- R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25124, Brescia, Italy.
| | - A Amato
- Unit of Coloproctology, Department of Surgery, Borea Hospital, Sanremo, Italy
| | - R Cirocchi
- Department of Surgical and Medical Sciences, University of Perugia, Terni, Italy
| | - A Serventi
- Department of Surgery, Galliano Hospital, Acqui Terme, Italy
| | - A Laghi
- Department of Surgical-Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - G Tellan
- Department of Internal, Anesthesiological and Cardiovascular Clinical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - C Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta
- Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
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20
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Lambrichts DPV, van Dieren S, Bemelman WA, Lange JF. Cost-effectiveness of sigmoid resection with primary anastomosis or end colostomy for perforated diverticulitis: an analysis of the randomized Ladies trial. Br J Surg 2020; 107:1686-1694. [PMID: 32521053 PMCID: PMC7687276 DOI: 10.1002/bjs.11715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/11/2020] [Accepted: 04/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Several studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost-related outcomes were rarely reported. The present study aimed to evaluate costs and cost-effectiveness within the DIVA arm of the Ladies trial. METHODS This was a cost-effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12-month follow-up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention-to-treat principle. Main outcomes were incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma-free or incremental quality-adjusted life-years respectively. RESULTS Overall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €-8126 (-14 660 to -1592). The ICER was €-39 094 (95 per cent bias-corrected and accelerated (BCa) c.i. -1213 to -116), indicating primary anastomosis to be more cost-effective. The ICUR was €-101 435 (BCa c.i. -1 113 264 to 251 840). CONCLUSION Primary anastomosis is more cost-effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.
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Affiliation(s)
- D. P. V. Lambrichts
- Departments of SurgeryErasmus University Medical CentreRotterdamthe Netherlands
- Amsterdam University Medical Centre, AMCAmsterdamthe Netherlands
| | - S. van Dieren
- Amsterdam University Medical Centre, AMCAmsterdamthe Netherlands
| | - W. A. Bemelman
- Amsterdam University Medical Centre, AMCAmsterdamthe Netherlands
| | - J. F. Lange
- Departments of SurgeryErasmus University Medical CentreRotterdamthe Netherlands
- IJsselland Hospital, Capelle aan den IJsselthe Netherlands
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21
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Gachabayov M, Tuech JJ, Tulina I, Coget J, Bridoux V, Bergamaschi R. Primary anastomosis and nonrestorative resection for perforated diverticulitis with peritonitis: meta-analysis of randomized trials. Colorectal Dis 2020; 22:1245-1257. [PMID: 32060982 DOI: 10.1111/codi.15016] [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: 09/24/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of this meta-analysis was to comparatively evaluate the outcomes of primary anastomosis (PRA) and nonrestorative resection (NRR) as emergency surgery and ostomy reversal in patients with perforated diverticulitis and peritonitis. METHODS PubMed, MEDLINE via Ovid, Embase, CINAHL, Cochrane Library and Web of Science databases were systematically searched. Postoperative morbidity following emergency resection was the primary end-point. Quality assessment of the included studies was performed using the Cochrane Quality Assessment Tool including recruitment bias and crossover with intention-to-treat analysis. The Haenszel-Mantel method with odds ratios (OR, 95% CI) and the inverse variance method with mean difference (MD, 95% CI) as effect measures were utilized for dichotomous and continuous outcomes, respectively. RESULTS Four randomized controlled trials totaling 382 patients (180 PRA vs 204 NRR) were included. Morbidity rates following emergency resection did not differ (OR = 0.99, 95% CI 0.65, 1.51; P = 0.95; number needed to treat/harm (NNT) 96). Organ/space surgical site infection rates were 3.3% in PRA vs 11.3% in NRR (OR = 0.29, 95% CI 0.12, 0.74; P = 0.009; NNT = 13). Postoperative morbidity rates following ostomy reversal were significantly lower in PRA (OR = 0.31, 95% CI 0.15, 0.64; P = 0.001; NNT = 7). Pooled ostomy non-reversal rates were 16% in PRA vs 35.5% in NRR (OR = 0.37, 95% CI 0.22, 0.62; P = 0.0001; NNT = 6) with high heterogeneity (I2 = 63%; τ2 = 8.17). Meta-regression analysis revealed significant negative correlation between the PRA-to-NRR crossover rate and the ostomy non-reversal rate (P = 0.029). CONCLUSION This meta-analysis found that PRA was associated with better short- and long-term outcomes at the cost of significantly longer operating time at emergency surgery.
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Affiliation(s)
- M Gachabayov
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - J J Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen Cedex, France
| | - I Tulina
- Department of Surgery, Sechenov Moscow Medical University, Moscow, Russia
| | - J Coget
- Department of Digestive Surgery, Rouen University Hospital, Rouen Cedex, France
| | - V Bridoux
- Department of Digestive Surgery, Rouen University Hospital, Rouen Cedex, France
| | - R Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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22
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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: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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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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24
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Ryan OK, Ryan ÉJ, Creavin B, Boland MR, Kelly ME, Winter DC. Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann’s procedure for the management of acute perforated diverticulitis with generalised peritonitis. Tech Coloproctol 2020; 24:527-543. [DOI: 10.1007/s10151-020-02172-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/07/2020] [Indexed: 12/29/2022]
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25
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Lambrichts DPV, Edomskis PP, van der Bogt RD, Kleinrensink GJ, Bemelman WA, Lange JF. Sigmoid resection with primary anastomosis versus the Hartmann's procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1371-1386. [PMID: 32504331 PMCID: PMC7340681 DOI: 10.1007/s00384-020-03617-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann's procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence. METHODS A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs). RESULTS From a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients. CONCLUSION Although between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann's procedure in selected patients with Hinchey III or IV diverticulitis.
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Affiliation(s)
- Daniël PV Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands ,Department of Surgery, Amsterdam University Medical Center, AMC, Amsterdam, The Netherlands
| | - Pim P Edomskis
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gert-Jan Kleinrensink
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Center, AMC, Amsterdam, The Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands ,Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
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Halim H, Askari A, Nunn R, Hollingshead J. Primary resection anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis. World J Emerg Surg 2019; 14:32. [PMID: 31338117 PMCID: PMC6625026 DOI: 10.1186/s13017-019-0251-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/25/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann’s procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. The aim of this meta-analysis is to determine which of the two procedures has a more favorable outcome. Methods A systematic review of the existing literature was performed using the PRISMA guidelines. A meta-analysis was carried out using a Mantel-Haenszel, random effects model, and forest plots were generated. The Newcastle-Ottawa and Jadad scoring tools were used to assess the included studies. Results A total of 25 studies involving 3546 patients were included in this study. The overall mortality in the HP group was 10.8% across the observational studies and 9.4% in the randomized controlled trials (RCTs). The mortality rate in the PRA group was lower than that in the HP group, at 8.2% in the observational studies and 4.3% in the RCTs. A comparison of PRA vs HP demonstrated a 40% lower mortality rate in the PRA group than in the HP (OR 0.60, 95% CI 0.38–0.95, p = 0.03) when analyzing the observational studies. However, meta-analysis of the three RCTs did not demonstrate any difference in mortality, (OR 0.44 (95% CI 0.14–1.34, p = 0.15). Wound infection rates between the two groups were comparable (OR 0.75, 95% CI 0.20–2.78, p = 0.67). Conclusion Analysis of observational studies suggests that PRA may be associated with a lower overall mortality. There were no differences in wound infection rates. Based on the current evidence, both surgical strategies appear to be acceptable.
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Affiliation(s)
- Hosam Halim
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - Alan Askari
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - Rebecca Nunn
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - James Hollingshead
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
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Thambi P, Borowski DW, Sathasivam R, Obuobi RB, Viswanath YKS, Gill TS. Single-incision laparoscopic reversal of Hartmann's operation through the stoma site: comparative outcomes with conventional laparoscopic and open surgery. Colorectal Dis 2019; 21:833-840. [PMID: 30897258 DOI: 10.1111/codi.14617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/01/2019] [Indexed: 12/11/2022]
Abstract
AIM Restoration of bowel continuity after Hartmann's procedure (RoH) can be challenging and associated with considerable morbidity. A technique using single-incision laparoscopic surgery through the stoma site (SIL RoH) has been shown to be feasible and safe. In this study, we compared clinical outcomes of SIL RoH with conventional laparoscopic surgery (CL) and open surgery (OS). METHODS This was a retrospective analysis of a prospectively maintained database between 2007 and 2017 in a UK colorectal unit. The access technique was decided by the surgeon on a case by case basis. RESULTS A total of 106 patients underwent RoH. It was carried out for diverticular disease (n = 71, 67.6%), cancer (n = 19, 17.9%) and anastomotic leak (n = 4, 3.8%). The remainder (n = 12, 11.3%) were for miscellaneous reasons including trauma. Most RoHs were performed via OS (n = 87, 81.1%). The most common intended approaches for RoH were SIL (n = 56, 52.8%) and OS (n = 34, 32.1%) with fewer starting with CL (n = 16, 15.1%). Conversion to OS took place in five (8.9%) patients with SIL and six (37.5%) with CL (P = 0.005). Postoperative complications occurred in 17 (30.4%) for SIL, seven (43.8%) for CL and 17 (50.0%) for OS (P = 0.162). Median operating time for SIL was 146 min (range 44-389), 211 min (109-320) for CL and 211 min (85-420) for OS (P < 0.001). Median length of stay was 4 days (2-44) for SIL compared to 6 (3-34) for CL and 7 (4-34) for OS (P < 0.001). Discharge on or before day 5 was achieved in 41 (74.5%) patients for SIL compared to six (37.5%) for CL and seven (20.6%) for OS (P < 0.001). CONCLUSION Compared to OS and CL, SIL RoH appears to have shorter operating times and hospitalization, with no discernible difference in morbidity; this finding requires further evaluation in a randomized setting.
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Affiliation(s)
- P Thambi
- Department of Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK
| | - D W Borowski
- Department of Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK.,Welwitschia Hospital, Walvis Bay, Namibia
| | - R Sathasivam
- Department of Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK
| | - R-B Obuobi
- Department of Surgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Y K S Viswanath
- Department of Surgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - T S Gill
- Department of Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK
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Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial. Lancet Gastroenterol Hepatol 2019; 4:599-610. [PMID: 31178342 DOI: 10.1016/s2468-1253(19)30174-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. METHODS A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485. FINDINGS Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% [95% CI 88·7-100] vs 71·7% [95% CI 60·1-83·3], hazard ratio 2·79 [95% CI 1·86-4·18]; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 [44%] of 66 patients vs 25 [39%] of 64, p=0·60; mortality: two [3%] vs four [6%], p=0·44). INTERPRETATION In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease). FUNDING Netherlands Organisation for Health Research and Development.
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Authors’ Reply: Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”. World J Surg 2019; 43:1395-1396. [DOI: 10.1007/s00268-019-04974-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Moro-Valdezate D, Royo-Aznar A, Martín-Arévalo J, Pla-Martí V, García-Botello S, León-Espinoza C, Fernández-Moreno MC, Espín-Basany E, Espí-Macías A. Outcomes of Hartmann's procedure and subsequent intestinal restoration. Which patients are most likely to undergo reversal? Am J Surg 2019; 218:918-927. [PMID: 30853093 DOI: 10.1016/j.amjsurg.2019.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/06/2019] [Accepted: 02/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aim of the study was to describe characteristics and outcomes of Hartmann's procedure (HP) and subsequent intestinal restoration. METHODS Retrospective study including all patients who underwent HP over a period of 16 consecutive years. We propose a classification and regression tree for a more accurate view of the relationship between the variables related to intestinal restoration and their weighting in the decision to reverse HP. RESULTS 533 patients were included. Overall morbidity rate of HP was 53.5% and mortality 21.0%. Overall morbidity of the intestinal continuity reconstruction was 47.3% and mortality 0.9%. Patients with a benign disease, aged under 69 years and with low comorbidity, had an 84.4% probability of undergoing intestinal reconstruction. CONCLUSIONS HP is associated with high morbidity and mortality. Restoration of intestinal continuity involves minor, but frequent, morbidity and a low mortality rate. Age and comorbidities can decrease, and even override, the decision to reverse HP.
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Affiliation(s)
- D Moro-Valdezate
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - A Royo-Aznar
- Department of Surgery, Universtitat Autònoma de Barcelona, Barcelona, Spain
| | - J Martín-Arévalo
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - V Pla-Martí
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - S García-Botello
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - C León-Espinoza
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - M C Fernández-Moreno
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - E Espín-Basany
- Department of Surgery, Universtitat Autònoma de Barcelona, Barcelona, Spain
| | - A Espí-Macías
- Department of Surgery, University of Valencia, Valencia, Spain
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Safety of primary anastomosis following emergency left sided colorectal resection: an international, multi-centre prospective audit. Colorectal Dis 2018; 20 Suppl 6:47-57. [PMID: 30255647 DOI: 10.1111/codi.14373] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection. METHODS A pre-planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (> 16 years) who underwent emergency (unplanned, within 24 h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30-day major complication rate (Clavien-Dindo grade 3 to 5). RESULTS From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83-2.79, P = 0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43-11.02, P = 0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur. CONCLUSIONS Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications.
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Affiliation(s)
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- European Society of Coloproctology (ESCP) Cohort Studies Committee, Hospital Universitari i Politècnic la Fe, València, Spain
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Sohn M, Iesalnieks I. Authors reply: Damage control surgery in patients with generalized peritonitis secondary to perforated diverticulitis-the risk of overtreatment. Tech Coloproctol 2018; 22:565-566. [PMID: 29980887 DOI: 10.1007/s10151-018-1815-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Affiliation(s)
- M Sohn
- Clinic for General, Visceral, Endocrine, and Minimally Invasive Surgery, Bogenhausen Hospital, Munich, Germany.
| | - I Iesalnieks
- Clinic for General, Visceral, Endocrine, and Minimally Invasive Surgery, Bogenhausen Hospital, Munich, Germany
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