Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals

BACKGROUND

The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis.

METHOD

The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results.

RESULTS

Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks.

CONCLUSION

The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study

BACKGROUND

In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level.

METHODS

All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD.

RESULTS

In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma.

CONCLUSIONS

This series provides a real-life picture of elective sigmoidectomy for SDD at a national level.

TRIAL REGISTRATION

Comité National Information et Liberté (CNIL) (n°920361).

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study

OBJECTIVE

To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19.

METHODS

From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21).

RESULTS

A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity.

CONCLUSION

This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality.

[How to manage abdominal hernia on peritoneal dialysis?]

Abdominal hernias are a frequent complication in peritoneal dialysis, representing up to 60.4% of anatomical complications. Their prevalence varies between 7 and 27.5%. Established risk factors are male gender, an older age, multiparity, a low body mass index and a paramedian approach for the catheter insertion. Polykystic renal disease and the intra-peritoneal volume are controversial risk factors. The diagnosis is mainly clinical, though peritoneography imaging can be useful in difficult cases. Hernia's complications, of strangulation, incarceration, bowel occlusion and peritonitis; can be very serious, leading to technique failure and may result in death. The complication risk varies from 4 to 20% in the literature review. There are no guidelines regarding hernia's prevention or treatment. A surgical repair is recommended, by implementing a synthetic prothesis with an inguinal approach for inguinal and femoral hernias, with a simple stitch or a bioprothesis for ombilical hernias. The management of peritoneal dialysis after hernia repair is not codified. After an initial 48h interruption, an intermittent peritoneal dialysis program using low volume seems efficient at low risk, preventing a temporary transfer to haemodialysis.

Simultaneous Removal And Reinsertion of the PD Catheter in Relapsing Peritonitis

Background:Relapsing peritonitis in peritoneal dialysis (PD) is associated with lower cure rates and more hemodialysis (HD) transfers, as catheter removal is recommended in these situations. The aim of our study was to evaluate the continuation of PD without perioperative transfer to HD in patients who underwent a simultaneous catheter removal and replacement for relapsing peritonitis.Methods:This was a retrospective monocentric study. Patients with simultaneous catheter removal and replacement for relapsing peritonitis or peritonitis at high risk of relapse (fungal or Pseudomonas infection) between 1 January 2007 and 31 December 2016 were included. The events of interest were the continuation of PD without perioperative transfer to HD, postoperative complications, new infection with the same organism, and technique survival.Results:Of the 271 incident patients in PD during this period, 11 had a simultaneous catheter removal and replacement for relapsing peritonitis (8) or high risk of relapse peritonitis (3). Eight (72.7%) patients pursued PD without transfer to HD. Six infections were due to microorganisms other than gram-positive cocci. At 1 year, 7 (63.6%) of the 11 patients were still on PD. After the surgery, there were no peritonitis or catheter-related infections caused by the same organism.Conclusion:Simultaneous catheter removal and replacement for peritonitis appears to be an effective procedure for maintaining patients on PD.

Fungal Peritonitis Caused by Rhodotorula mucilaginosa in a CAPD Patient Treated with Liposomal Amphotericin B: A Case Report and Literature Review

Rhodotorula mucilaginosa is a ubiquitous yeast that may cause serious peritoneal dialysis (PD) infections. A 70-year-old man receiving continuous ambulatory peritoneal dialysis (CAPD) for 6 months presented with a PD infection caused by Rhodotorula mucilaginosa The patient was treated with intravenous liposomal amphotericin B. His peritoneal catheter was simultaneously removed and reinserted. To date, only 10 cases of Rhodotorula CAPD infections have been reported. Catheters, corticoids, cancer, and previous antibiotic therapy were the main risk factors for these infections. For most patients, the peritoneal catheter was removed, leading to a definitive transfer to hemodialysis. Along with flucytosine, amphotericin B is the main antifungal that is used. Both have a lower minimal inhibitory concentration (MIC), whereas fluconazole and caspofungin have the highest MICs. We highlighted the efficacy of liposomal amphotericin B associated with simultaneous withdrawal and reinsertion of a peritoneal catheter in a case of Rhodotorula peritonitis in a CAPD patient. Further studies are needed to evaluate the treatment of this condition.

[News in peritoneal dialysis]

Peritoneal dialysis, like hemodialysis, is a first-line therapy for patients with end-stage renal disease. Progress in medical devices and materials has reduced infectious complications such as peritonitis and catheter exit-site infections and thus decreased morbidity. Peritoneal dialysis fluids are increasingly biocompatible, result in fewer glucose degradation products, protect the peritoneal membrane better and thus improve tolerance. The maintenance of residual renal function, together with better comfort and no pain, help control the fluid and sodium balance. Automated peritoneal dialysis can be performed each night, either autonomously or assisted by a visiting nurse twice a day (to prepare, connect, and disconnect the machine). This treatment can thus be provided to most patients, regardless of their age. Peritoneal dialysis is indicated principally for young people waiting for a kidney transplantation (to preserve their vascular network), elderly patients who wish to remain either at home or in an institution, and patients with cardiac insufficiency, because of the better hemodynamic tolerance. Numerous obstacles, mainly nonmedical, still impede the development of peritoneal dialysis. Patients seen in emergencies start hemodialysis without necessarily receiving any information about peritoneal dialysis. Indeed, neither physicians nor patients receive adequate information.

[Late intestinal fistula following implantation of parietal abdominal prostheses]

STUDY AIM

The aim of this retrospective study was to describe an unusual complication of the nonabsorbable meshes used for repair of incisional hernia or inguinal hernia.

PATIENTS AND METHODS

This study included eight observations of intestinal fistulas that occurred between 1 and 13 years after using Mersilène (Dacron) mesh for repair of an incisional hernia (7 cases) and an inguinal hernia (1 case). There were 6 men and 2 women (mean age: 58 years, range: 35-85 years) with an external intestinal fistula (n = 6) or an internal intestinal fistula (n = 2). All the patients required a reoperation for extraction of the mesh and treatment of the bowel injuries.

RESULTS

There was one secondary death in a 85 years old woman in relation with a vascular complication after incomplete excision of the prosthesis. In five patients out of six, there was a recurrence of the incisional hernia.

CONCLUSION

The intestinal fistulas associated with prosthetic repair of the abdominal wall are mostly observed with intraperitoneal mesh but this factor is not exclusive. Their frequency after repair of incisional or inguinal hernia with non absorbable mesh is estimated between 0.3 and 3.5%. The use of nonabsorbable mesh should be limited to the indications of strict necessity, without any septic context or emergency surgery. The contact of the mesh with the bowel should be formally avoided.

[Use of the vacuum-assisted closure system for the treatment of perineal gangrene involving the abdominal wall]

The vacuum-assisted closure (VAC) system is used for the treatment of complicated wounds and large tissular dehiscences. The study aim was to report a case of perineal gangrene extended to the abdominal wall in a 53-year old woman. After several extensive surgical debridments, using of the VAC was followed by a good and rapid healing of the wound.

[Long-term results of the treatment of eventrations by intraperitoneal non-absorbable prosthesis (149 patients)]

The authors report a series of 149 cases of incisional hernia, operated between 1983 and 1993, by insertion of a non-absorbable prosthetic mesh within the intraperitoneal cavity. This series consisted of 93 women and 56 men, with a mean age 57 years. One third of repairs were performed because of primary treatment failure. One or more operative risk factors were present in 127 patients. A non-absorbable intraperitoneal prosthetic mesh was inserted with tension to allow good musculo-aponeurotic repair. Postoperative mortality was 0.6%. All but 13 of the patients, were reviewed with a mean follow-up of 83 months. Twenty eight patients (20%) developed recurrence. In 8 cases, the cause of recurrence was failure of prosthetic mesh insertion because of excessive tension. Three patients (1.7%) developed a fistula in contact with the prosthetic mesh, that had to be removed. A small bowel fistula was observed in 2 cases after an intraoperative wound in 1 case, and a colonic fistula in 1 case. The results of incisional hernia repair with nonabsorbable intraperitoneal prosthetic mesh can be compared with these of other techniques using prosthetic materials. This technique does not require dissection of the intermediate planes and avoids undermining which causes substantial bleeding. The risk of sepsis is also decreased by deep placement of the prosthesis. The exceptional cases of fistula or the possibility of migration of the prosthesis are not exclusively observed with this technique, but must clearly encourage a very strict aseptic technique, with placement of omentum between the prosthetic mesh and the viscera.