Comparison of surgical outcomes in elective sigmoid resection for diverticulitis in different indication-specific strategies: A propensity-score matched cohort study with 636 patients

Objective

Comparing different surgical guidelines for recurrent uncomplicated diverticulitis, a careful benefit-risk assessment is recommended although different approaches giving the indication for surgery exists. The purpose of this study was to evaluate the impact of indications-specific strategies on surgical outcomes allowing adequate benefit-risk consulting.

Methods

All patients undergoing elective colonic resection for diverticulitis between January 2011 and March 2020 in our institution were included. They were divided into two groups based on the strategy for surgical indication: relative surgery indication group (RSI; CDD (classification of diverticula disease) Type 2a, 3a and 3b, n = 585) and absolute surgery indication group (ASI; CDD Type 2b and 3c, n = 318). Propensity score-matching (PSM) was applied at a ratio of 1:1 to compare the RSI and the ASI group.

Results

In the univariate analysis, RSI patients were younger (62±10.4 vs. 67.7±11.4, p<0.05), had a higher physical status (ASA score 1 or 2 in 80.7% vs. 60.8%, p<0.05), were less immunosuppressed (3.4% vs. 6.9%, p<0.05) and suffered less from coronary heart disease (3.8% vs. 7.2%, p<0.05). After PSM, 318 vs. 318 patients were selected and baseline characteristics resulted comparable. The proportion of laparoscopic resection was 94.7% in RSI versus 84.6% in ASI (p<0.05) and the conversion rate to open surgery for laparoscopic resection was 5.0% in RSI and 13.8% in ASI (p<0.05). Intraoperative complications were rare in both groups (3.1% vs. 5.3%, p=0.24). Mean operation time was shorter in RSI (211±62 vs. 229±72, p<0.05). Major morbidity (Clavien/Dindo ≥3b) occurred less frequently in RSI (3.8% vs. 10.1%, p<0.05) and the overall comprehensive complications index (CCI) was lower in RSI (9.4±12.2 vs. 12.9±14.9, p<0.05). Anastomotic insufficiency occurred in 0.9% in RSI and in 2.5% in ASI (p=0.22). A defunctioning stoma was received by 0.9% in RSI and 11.0% in ASI (p<0.05).

Conclusion

Our study demonstrates that even after PSM analysis patients with RSI in contrast to patients with more advanced diverticular disease have a lower risk of suffering from postoperative overall morbidity and major morbidities as well as the risk of receiving a temporary stoma. These observations should be considered when counselling patients with an equivocal indication for surgery for diverticular disease.

Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): A prospective comparative single center study

Objective

Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study).

Methods

All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8-53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease–Health-Related Quality of Life (GERD-HRQL) questionnaire.

Results

A total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p < 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores.

Conclusion

While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery.

[Traumatic pneumatocele--a case report]

The posttraumatic pneumatocele is a rare intrapulmonary lesion following blunt thoracic injury. By means of a well documented case report this rare form of lung contusion is demonstrated and the clinically important differential diagnosis is discussed.