Single-stage procedure in management of uncomplicated acute sigmoid volvulus without colonic lavage

Aim: The management of sigmoid volvulus remains controversial. We aimed to evaluate the postoperative outcome of patients with acute non-complicated sigmoid volvulus managed with resection and anastomosis without preoperative colonic lavage. Methods: From January 2007 to December 2009, 40 patients with uncomplicated sigmoid volvulus underwent bowel decompression, resection and anastomosis without preoperative mechanical colonic preparation. Results: A total of 40 patients underwent the procedure, one patient developed anastomotic leak. Wound infection was reported in three patients, one death was a result of respiratory failure. Conclusion: Surgical management of sigmoid volvulus in one step without preoperative colonic lavage is a safe procedure and is recommended for acute cases.     

Comparative study to determine the need for intraoperative colonic irrigation for primary anastomosis in left-sided colonic emergencies

Objective  To compare the outcome of resection and primary anastomoses in patients undergoing emergency surgery of the left colon with and without intraoperative colonic irrigation.
Method  From January 2004 to December 2006, 102 consecutive patients with acute occlusion or perforation of the left colon were operated on an emergency basis in two Coloproctology units. According to the sample size calculation, 61 patients from one unit underwent surgery with intraoperative colonic irrigation, whereas 41 patients from the second unit underwent surgery without intraoperative colonic irrigation. The endpoints were mortality and morbidity.
Results  Thirty (49.2%) patients with intraoperative colonic irrigation and 8 (19.5%) without colonic irrigation developed one or more complications postoperatively (odds ratio 4.0, 95% CI 1.6–10.0, P  = 0.002). An increased number of wound infections was seen in the group managed with colonic irrigation 15 vs 3 ( P  = 0.034). The postoperative mortality rate and the occurrence of dehiscence of the anastomoses were similar in both study groups.
Conclusion  The present findings indicate that resection and primary anastomosis in patients undergoing emergency surgery of the left colon can be safely performed without intraoperative colonic irrigation.     

左半结肠切除术中高渗灌洗液的应用观察

目的 总结在左半结肠切除一期肠吻合术中高渗液甘露醇结肠灌洗的临床效果.方法 我院对31例左半结肠切除患者,术中依次行生理盐水、甲硝唑和20%甘露醇结肠灌洗,病变切除再行一期肠吻合.结果 除3例切口感染外,其余病例均在4～5天后开始进食,未发生吻合口瘘,痊愈出院.结论 左半结肠梗阻性病变需行结肠切除时,采用生理盐水、甲硝唑和甘露醇结肠灌洗,再行一期吻合术,术后肠功能恢复快,可防止吻合口瘘的发生.     

结肠癌急性梗阻一期切除吻合术中不灌洗肠腔的探讨

研究一种结肠癌急性梗阻一期切除吻合的更简单、合理、安全的术中处理方法。方法肠切开减压后，用左右手交替挤压法清洁肠道，不灌洗肠腔、使肠吻合后吻合口处持续有少许较稀薄的肠内容物通过。结果采用本方法清洁肠道一期切除吻合的结肠癌急梗阻更３８例，术后无一例发生吻合口漏。     

术中结肠灌洗在左半大肠癌并急性肠梗阻Ⅰ期切除吻合中的研究

目的探讨术中结肠灌洗在左半大肠癌并急性肠梗阻Ⅰ期切除吻合中的应用价值。方法对我科2006年收治86例左半结肠癌并急性肠梗阻Ⅰ期切除吻合进行回顾性分析。根据术中采用不同的肠道准备方法,86例患者被随机分为全结肠灌洗组(39组)及单纯肠道减压组(47例)。结果全结肠灌洗组并发症发生6例,发生率15.4%,死亡1例,死亡率2.6%。单纯肠道减压组发症发生8例,发生率17.0%,死亡2例,死亡率4.3%。非灌洗组和灌洗组并发症发生率两者间差异无统计学意义(P=0.838)。结论左半大肠癌并急性肠梗阻Ⅰ期切除吻合是安全可靠的,疗效满意。不同术中肠道准备不是影响治疗效果的关键,不灌洗肠腔是可行的。     

无术中结肠灌洗结肠减压在左半结肠癌急性梗阻一期切除吻合中应用

左半结肠癌急性梗阻传统主张分期手术，自Dudley报道术中结肠灌洗以来，一期切除吻合的报道增多。我们应用不行术中结肠灌洗的简单、快速、能够彻底减压的肠减压法，使左半结肠癌急性梗阻得以安全一期切除吻合，现报道如下。[第一段]     

低位结肠癌伴急性梗阻一期切除吻合32例临床分析

目的探讨低位结肠癌伴急性梗阻一期切除吻合临床疗效。方法对32例低位结肠癌伴急性梗阻采取传统的根治术式，严格术中无菌操作；彻底肠道减压；一层套入式吻合。结果临床观察显示，32例一期切除吻合术均未发生漏，一期愈合。结论本术式一期进行根治，一层吻合，符合早期根治原则，5年生存率明显提高，是治疗低位结肠癌伴急性梗阻有效措施。     

Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta‐analysis

Aim

It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta‐analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates.

Method

The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end‐point. A subgroup meta‐analysis of randomized controlled trials was performed in addition to a meta‐analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively.

Results

Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)].

Conclusion

This meta‐analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.     

Colonic stenting as bridge to surgery versus emergency surgery for management of acute left-sided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study)

Background

Acute left-sided colonic obstruction is most often caused by malignancy and the surgical treatment is associated with a high mortality and morbidity rate. Moreover, these operated patients end up with a temporary or permanent stoma. Initial insertion of an enteral stent to decompress the obstructed colon, allowing for surgery to be performed electively, is gaining popularity. In uncontrolled studies stent placement before elective surgery has been suggested to decrease mortality, morbidity and number of colostomies. However stent perforation can lead to peritoneal tumor spill, changing a potentially curable disease in an incurable one. Therefore it is of paramount importance to compare the outcomes of colonic stenting followed by elective surgery with emergency surgery for the management of acute left-sided malignant colonic obstruction in a randomized multicenter fashion.

Methods/design

Patients with acute left-sided malignant colonic obstruction eligible for this study will be randomized to either emergency surgery (current standard treatment) or colonic stenting as bridge to elective surgery. Outcome measurements are effectiveness and costs of both strategies. Effectiveness will be evaluated in terms of quality of life, morbidity and mortality. Quality of life will be measured with standardized questionnaires (EORTC QLQ-C30, EORTC QLQ-CR38, EQ-5D and EQ-VAS). Morbidity is defined as every event leading to hospital admission or prolonging hospital stay. Mortality will be analyzed as total mortality as well as procedure-related mortality. The total costs of treatment will be evaluated by counting volumes and calculating unit prices. Including 120 patients on a 1:1 basis will have 80% power to detect an effect size of 0.5 on the EORTC QLQ-C30 global health scale, using a two group t-test with a 0.05 two-sided significance level. Differences in quality of life and morbidity will be analyzed using mixed-models repeated measures analysis of variance. Mortality will be compared using Kaplan-Meier curves and log-rank statistics.

Discussion

The Stent-in 2 study is a randomized controlled multicenter trial that will provide evidence whether or not colonic stenting as bridge to surgery is to be performed in patients with acute left-sided colonic obstruction.

Trial registration

Current Controlled Trials ISRCTN46462267.     

Superior vena cava obstruction: a review of the literature and report of 2 cases due to benign intrathoracic tumors.

A review of the literature shows an increaseing number of cases of superior vena cava obstruction associated with malignancy and a marked decrease in the number of patients with caval obstruction of benign origin. In contrast to granulomatous diseases and aneurysms of the ascending thoracic aorta, which have decreased, the incidence of benign tumors is essentially unchanged. Clinical features of superior vena cava obstruction in relation to the anatomical site of obstruction and collateral pathways are correlated. Diagnostic approaches, including angiography and technetium scanning are usually definitive in outlining the site of obstruction. Experimental data and the numerous available techniques for surgical correction indicate that an entirely satisfactory procedure is not available for all patients. Methods include the use of venous bypass or Teflon prostheses and the addition of a small arteriovenous fistula proximally. Two new cases of superior caval obstruction due to benign tumor are reported. In 1 patient, who had intrapericardial bronchogenic cyst with fibrotic caval obstruction and thrombosis, a method for caval reconstruction while maintaining venous return to the right atrium is described. The second patient had an intrathoracic thyroid adenoma and caval obstruction without thrombosis.     

直肠癌低前切除结肠J型贮袋吻合与直接吻合的Meta分析

目的：评价直肠癌低前切除后采用结肠J型贮袋直肠肛管吻合与直接吻合相比对术后排便功能的影响。方法：从中下段直肠癌病例为研究对象,用rectal cancer,J pouch,randomized等作为关键词,检索出符合入选标准的随机对照临床试验,采用固定效应模型与随机效应模型对患者术后1年的排便功能及直肠生理指标进行Meta分析。结果：共筛选出符合入选标准的随机对照临床试验8项（378例）。术后1年结肠贮袋组在24h排便频次、有无急迫感和是否需要药物治疗方面均优于直接吻合组;2组在5项生理性评估指标中仅1项差异有显著性意义。结论：中下段直肠癌切除术后采用结肠J型贮袋直肠肛管吻合,术后1年内有明显改善排便功能的作用,但对直肠生理功能的影响尚等进一步研究。     

Conversion from laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) to one anastomosis gastric bypass (OAGB): preliminary data from a multicenter retrospective study

BackgroundLaparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes.ObjectivesTo retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB.SettingHigh-volume centers for bariatric surgery.MethodsProspectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded.ResultsThree hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m² at the time of first intervention, 41.8 ± 6.3 kg/m² at redo time, and 30.5 ± 5.5 kg/m² at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6–156) months and overall complications rate was 8.6%.ConclusionOur data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.     

A retrospective 5-year study in Moldova of acute renal failure due to leptospirosis: 58 cases and a review of the literature.

BACKGROUND: Renal involvement [as acute renal failure (ARF)] is a prominent feature of both mild and severe leptospirosis-a re-emerging infectious disease. Few large series describe in detail clinical and laboratory features of cases with ARF and their outcome. METHODS: We performed a retrospective analysis (1997-2001) of all consecutive, serological confirmed leptospirosis cases with ARF (n=58, 53 male, age 44+/-13 years, rural residents=31%, animal contact=88%. RESULTS: Clinical manifestations (>50% prevalence): oliguria 95%, fever and jaundice 93%, nausea and vomiting 83%, haemorrhagic diathesis 80%, headache, hepatomegaly 76%, myalgias, abdominal pain 70%, hypotension 62%, disturbed consciousness 50%. A pattern of multiple organ failure (MOF) was frequent: ARF together with hepatic failure in 72%, respiratory failure in 38%, circulatory failure in 33%, pancreatitis in 25% and rhabdomyolysis in 5% of cases. Renal dysfunction: 35% of cases had a renal K(+)-wasting defect and 43% a FE(Na)(+)>1% and low-osmolarity urine despite volume depletion. Haematuria was encountered in 12 and mild proteinuria in 10 subjects. Outcome: 26% deaths, 64% normal hepatic and renal function at 90 days from presentation (however 29% maintained the initial tubular defect), 10% persistent mild renal failure. All deceased patients had, beside ARF, at least two other organ failures, affected consciousness, and haemorrhagic diathesis vs a prevalence for the above features of only 34, 33, and 72%, respectively, in the survivors group (P<0.05). CONCLUSIONS: Leptospirosis presenting with ARF is a severe disease, frequently leading to MOF and to death in one-third of the patients. In particular, the haemorrhagic diathesis and cerebral involvement are markers for unfavourable patient and renal outcomes.     

Use of a patient consultation questionnaire and weighted numerical scoring system for the prediction of colorectal cancer and other colorectal pathology in symptomatic patients: A prospective cohort validation study of a Welsh population

Objective There is currently no system in widespread use that accurately prioritizes colorectal referrals in symptomatic patients with an acceptable degree of sensitivity and specificity. We have validated a weighted numerical scoring system for the prioritization of such colorectal referrals in an attempt to rectify this, with detection of colorectal cancer (CRC) the primary outcome. Method We conducted a prospective study of symptomatic patients referred by primary care to the colorectal service in a district general hospital. A computer‐generated weighted numerical score (WNS) was derived from the primary symptoms and symptom combinations. Patients underwent colorectal investigations and a final diagnosis was established. Sensitivity, specificity and accuracy of CRC detection as determined by the WNS, Department of Health (DOH) and National Institute for Health and Clinical Excellence guidelines was determined. Primary Care compliance with guidelines was analysed. Results A definitive diagnosis was established in 3457 patients. One hundred and eighty‐six (5.4%) had CRC. The mean score for the cancer patients (76.9, 95%CI 72–81) was significantly higher than that of non‐cancer patients (52, 95%CI 52–53) P < 0.001. Receiver Operator Curve analysis demonstrates a high discriminatory power for the Patient Consultation Questionnaire (PCQ) with an area under curve of 0.76. Compliance by primary care with the nationally recommended referral guidelines was poor with only 55% and 58% compliance with DOH and National Institute for Clinical Excellence referral guidelines for suspected cancer respectively. Conclusion The PCQ and the WNS is an efficient, objective system that allows the accurate prioritization of colorectal referrals with a high sensitivity for cancer and other serious colorectal pathologies.     

Assessment of three year experience of a strategy for patient selection and timing of operation in the management of acute thoracic and lumbar spine fractures: a prospective study

Summary Background. The purpose of this article is to report experience gained over three years of the use of a protocol for patient selection and timing of operation for acute thoracic and lumbar fractures. Method. At admission, all patients underwent neurological and imaging exams. All patients with a spinal cord lesion scored as ASIA A at any level inferior to T10 and as ASIA B, C or D at any level, were categorized as emergency and operated on within eight hours from trauma. ASIA A cases in the T1–T10 tract and ASIA E cases at any level were treated in the ordinary operative work schedule. Findings. Ninety-four patients with surgically treated lumbar or thoracic fractures took part in this study. On the imaging studies, 12 patients were classified as A, 50 as B and 32 as C following the AO classification. At the neurological exam, 39 patients were scored as ASIA A, nine as B, six as C, two as D and 38 as E. At follow-up, of the 39 patients scored as ASIA A, 13 (33%) improved at least one grade and of the 17 scored as ASIA B, C or D, 11 (64.7%) improved. None of the 38 patients scored as ASIA E deteriorated. Conclusions. The findings show that the strategy in the protocol was safe and followed by satisfactory rates of neurological outcome. Larger prospective studies, preferably randomized, are needed to establish definitively its place in the management of patients with spinal injury.     

Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: a prospective randomized study of effectiveness and safety in comparison to standard single-pulse technique

OBJECTIVE

To asses the efficacy and safety of bidirectional synchronous twin‐pulse extracorporeal shock wave lithotripsy (ESWL) compared with standard ESWL.

PATIENTS AND METHODS

Between March 2003 and December 2006, 240 patients with a radio‐opaque single renal stone of ≤25 mm were randomized to treatment either by the Twinheads (TH) lithotripter (FMD, Lorton, Virginia, USA) or the Dornier Lithotripter S (DLS, Dornier MedTech Europe GmbH, Germering, Germany). Before and after ESWL, urinary N‐acetyl‐B‐glucosaminidase (NAG) levels were assessed and patients were evaluated with dynamic MRI. The efficacy and complications were compared, with success defined as no residual fragments.

RESULTS

For stones of >10 mm the rate for the failure of disintegration was 13.3% for the DLS vs 1.4% for the TH (P = 0.009). For stones of ≤10 mm the stone‐free rate was 74.4% for the TH vs 67.7% for the DLS (P = 0.6), while for stones of >10 mm it was 78.1% and 66.7%, respectively (P = 0.14). The median (range) number of sessions in both groups was 2 (1–5). After ESWL urinary NAG levels were increased significantly in both groups; in the TH group it declined below the level before ESWL after 2 days, while in the DLS group it remained high after 7 days. In the DLS group four patients developed subcapsular or parenchymal haematoma after ESWL, vs none in the TH group. There was loss of corticomedullary differentiation after ESWL in three patients in the DLS group and only one in the TH group. In the DLS group there was a statistically significantly decrease in bilateral renal perfusion after ESWL, but no changes in the TH group.

CONCLUSIONS

Synchronous twin‐pulse ESWL has clinical advantages over standard ESWL in terms of safety and efficacy.