Management of Right Colonic Uncomplicated Diverticulitis: Outpatient Versus Inpatient Management

Background  

Initial conservative management may be the mainstay of therapy for uncomplicated right colonic diverticulitis. However, definitive treatment guidelines have not yet been established. In this study, we assessed the efficacy of outpatient management versus inpatient management for preventing recurrence of this condition.     

Acute Colonic Diverticulitis and Cirrhosis: Outcomes of Laparoscopic Colectomy Compared with an Open Approach

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The Limited Role of Ultrasound in the Diagnostic Process of Colonic Diverticulitis

Background

Diverticulitis is commonly diagnosed using ultrasound (US), followed by computed tomography (CT). Our aim was to determine the diagnostic accuracy of US compared with CT for patients with uncomplicated and complicated diverticulitis.

Methods

We reviewed medical records of 232 patients admitted with diverticulitis via the emergency department between January 2009 and January 2011. Patients who had undergone US and a CT scan were identified and further analyzed.

Results

A total of 123 patients underwent an US and a CT scan. In 78/94 patients with uncomplicated diverticulitis, results of US and CT scan were compatible (83 %); in 6 of the remaining 29 patients both modalities showed a complicated diverticulitis (21 %). US misdiagnosed 17 % of patients with uncomplicated diverticulitis and 79 % with complicated diverticulitis.

Conclusions

US is insufficient for diagnosing a complicated diverticulitis. Missing a complicated diverticulitis can have important clinical implications, and if diverticulitis is suspected, we suggest obtaining a CT scan to confirm diagnosis and to exclude complications.     

Effectiveness of Elective Laparoscopic Treatment for Colonic Diverticulitis

Background and Objectives:

To analyze the short- and long-term outcomes of laparoscopic sigmoid colectomy for the elective treatment of diverticular disease.

Methods:

A consecutive unselected series of 94 patients undergoing elective laparoscopic sigmoid colectomy for diverticular disease from 2008 to 2012 was analyzed. We collected patients-, surgery- and hospital stay–related data, as well as the short- and long-term outcomes. Operative steps, instrumentation, and postoperative cares were standardized. Comorbidity was assessed by Charlson comorbidity index. Complications were classified using the Clavien-Dindo classification system. The qualitative long-term assessment was carried out by subjecting patients to the validated gastrointestinal quality of life index questionnaire before and after surgery.

Results:

The mean age of our cohort was 61.3 ± 11.0 years with a Charlson comorbidity index of 1.2 ± 1.5.Mean operative time was 213.5 ± 60.8 minutes and estimated blood loss was 67.2 ± 94.3 mL. We had 3 cases (3.2%) of conversion to open laparotomy. The rates of postoperative complications were 35.1%, 6.3%, 2.1%, and 1.06%, respectively, for grades 1, 2, 3b, and 5 according to the Clavien-Dindo system. Length of hospital stay was 8.1 ± 1.9 days, and we have not recorded readmissions in patients discharged within 60 days after surgery. Median follow-up was of 9.6 ± 2.7 months. We observed no recurrence of diverticular disease, but there was evidence of 3 cases of incisional hernia (3.19%). The difference between preoperative and late gastrointestinal quality of life index score was statistically significant (97.1 ± 5.8 vs 129.6 ± 8.0).

Conclusions:

Elective laparoscopic treatment of colonic diverticular disease represents an effective option that produces adequate postoperative results and ensures a satisfactory functional outcome.     

Outcomes of Laparoscopic Versus Open Colectomy in Elective Surgery for Diverticulitis

Background  

The role of laparoscopy in the management of diverticular disease is evolving. Concerns were raised in the past because laparoscopic resection for diverticulitis is often difficult and occasionally hazardous. This study was undertaken to evaluate the difference in overall outcomes between elective open and laparoscopic surgery with or without anastomosis for diverticulitis.     

Prospective Randomized Trial of Hybrid NOTES Colectomy Versus Conventional Laparoscopic Colectomy for Left-sided Colonic Tumors

Background

We conducted a randomized study of a laparoscopic technique for removing left-sided colon tumors that can reduce postoperative pain and other wound-related complications compared to the conventional technique. It is a novel technique of hybrid natural orifice translumenal endoscopic surgery (NOTES) colectomy (HNC) whereby laparoscopic colonic mobilization, transection, and anastomosis are performed intracorporeally. The specimen is then delivered through the anus using the transanal endoscopic operation (TEO) device, precluding the need for mini-laparotomy. We compared the short-term outcomes of patients who underwent HNC with those who underwent conventional laparoscopic colectomy (CL).

Methods

Patients suffering left-sided colonic tumor were recruited and were randomized into two groups: HNC and CL. Operative data and complications were prospectively recorded and analyzed.

Results

During a 3-year period, we recruited 70 patients (35 per group). No significant difference was observed between the two groups with respect to operating time (105 vs. 100 min, p = 0.851), blood loss (30 vs. 30 ml, p = 0.954), or length of hospital stay (5 vs. 5 days, p = 0.990). The maximum pain score during the first week was significantly lower in the HNC group (1 vs. 2, p = 0.017). No patients in the HNC group developed wound infection, whereas four patients in the CL group did so (p = 0.005).

Conclusions

With this hybrid NOTES technique, selected patients with left-sided colonic tumors can enjoy the full benefits of minimally invasive surgery with significantly less wound pain and a lower wound infection rate than are observed with CL.     

Outcome of Right Colectomy for Cancer in Octogenarians

Background  Colorectal cancer is one of the commonest malignancies in the elderly and, as such, is a major cause of morbidity and mortality. There is no consensus yet if age itself is a risk factor for adverse outcome after colectomy. The aims of the study were to evaluate the impact of age on operative results of right colectomy for cancer and to define factors that influence the postoperative mortality in octogenarians. Methods  Data of all patients who underwent right colectomy for colon cancer between January 2001 and December 2006 were collected retrospectively. Patients were divided into two groups: those who were 80 years and older and those who were less than 80 years old. Analysis included patients’ demographics, comorbidities, American Society of Anesthesiologists class, functional status, mode of presentation, stage of disease, length of hospital stay, postoperative morbidity, and mortality. Results  A total of 124 consecutive patients with right colon cancer were operated. Control group included 84 patients less than 80 year old. Study group included 40 patients 80 years or older. In Cox multivariate regression analysis, poor functional status and emergent surgery were independent factors for postoperative mortality. Conclusions  There was no significant difference in the outcome of elective right colectomy between elderly patients and their younger counterparts. Operative mortality of emergency surgery was significantly higher in octogenarians. Emergent setting and poor functional status are major risk factors for postoperative mortality. This study was presented in part at the Biennial Meeting of the Israel Surgical Association, Jerusalem, Israel, June 6–7, 2007.     

Emergency Laparoscopic-assisted versus Open Right Hemicolectomy for Obstructing Right-sided Colonic Carcinoma: A Comparative Study of Short-term Clinical Outcomes

Background The aim of the present study was to compare the clinical outcomes of emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma. Methods Between July 2003 and July 2006, 43 consecutive patients with obstructing right-sided colonic carcinoma underwent emergency right hemicolectomy at our institution, 14 with the laparoscopic-assisted approach and 29 with the open approach. Clinical data were retrospectively recorded and compared between the two groups. Results There were no significant differences between the two groups with respect to age, gender, co-morbidities, duration of obstructing symptoms, tumor length, and tumor staging. The laparoscopic-assisted group had longer operative time than the open group (187.5 min versus 145 min; p = 0.034) but less blood loss (20 ml versus 100 ml; p = 0.020). The median time to full ambulation was significantly shorter in the laparoscopic-assisted group (4 days versus 6 days; p = 0.016), but the time to return of gastrointestinal function and the duration of hospital stay were similar between the two groups. More patients in the open group developed postoperative complications (55.2% versus 28.6%), but the difference was not statistically significant. Conclusions Emergency laparoscopic-assisted right hemicolectomy for obstructing right-sided colonic carcinoma is feasible and safe. In comparison with the open approach, the laparoscopic-assisted procedure is associated with less blood loss, earlier ambulation, and possibly lower morbidity rate. This work was presented in part as a poster at Digestive Disease Week 2006, May 20–25, 2006, Los Angeles, CA, and as free paper at the Congress of Endoscopic and Laparoscopic Surgeons of Asia 2006, October 18–21, 2006, Seoul, Korea.     

The Impact of Uncomplicated and Complicated Diverticulitis on Laparoscopic Surgery Conversion Rates and Patient Outcomes

Background The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease. Methods Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture. Results The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70). Conclusions A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure. Presented in parts at the Society of American Gastrointestinal and Endoscopic Surgeons, Dallas, TX, April 2006; the 10th World Congress of Endoscopic Surgery, Berlin, Germany, September 2006; and the Annual meeting of the Association of Coloproctology of Great Britain and Ireland, Newcastle, England, July 2006     

Influence of Age on Clinical Outcome of Acute Diverticulitis

Background

The controversy about the treatment of acute colonic diverticulitis in young patients continues. The discussion is focused on whether younger age is a risk factor for recurrence or a complicated course, thereby subject to different treatment choices.

Aim

In this study, we investigated whether an episode of acute diverticulitis at a younger age (≤50 years) has a higher recurrence rate or a more severe outcome.

Material and Methods

A retrospective cohort study was conducted in four teaching hospitals using hospital registry codes for diverticulitis. All patients diagnosed with acute diverticulitis between January 2004 and January 2012, confirmed by imaging, were included.

Results

A total of 1,441 consecutive patients were identified as having primary acute diverticulitis of the sigmoid colon. Four hundred and sixty-three patients (32.1 %) were ≤50 years (group 1) and 978 patients (67.9 %) were older than 50 years (group 2). Twenty patients (4.3 %) needed emergency surgery, due to perforated diverticulitis, within 72 h at first presentation in group 1 compared to 77 patients (7.8 %) in group 2 (p?=?0.029). Surgery within 30 days was needed for 29 of 463 patient (6.2 %) in group 1 and 104 of 978 patients (10.6 %) in group 2 (p?=?0.02). Recurrence rate after a median follow-up of 22 months was comparable among groups (25.6 % (111 patients) in group 1 versus 23.8 % (208 patients) in group 2; p?=?0.278). Also, cumulative recurrence was comparable among groups.

Conclusion

Younger age is neither associated with a more severe presentation of diverticulitis nor with a higher incidence in recurrence.     

Colonic Endolumenal Stenting Devices and Elective Surgery Versus Emergency Subtotal/Total Colectomy in the Management of Malignant Obstructed Left Colon Carcinoma

Background

Traditionally, left-sided acute bowel obstruction is treated by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a high complication rate. Total abdominal colectomy is a one-stage procedure that will remove synchronous proximal neoplasms, reduce the risk of subsequent metachronous tumor, and avoid stoma. Colorectal stents are being used for palliation and as a bridge to surgery in obstructing colorectal carcinoma, making elective surgery straightforward, enabling easily mobilization and resection of the colon with a possible trend toward reduction in postoperative complication rates compared to emergency surgery. The purpose of this work was to compare the procedures of endoscopic stenting followed by elective colectomy versus total abdominal colectomy and ileorectal anastomosis in the management of acute obstructed carcinoma of the left colon as regards feasibility, safety, and clinical outcomes

Methods

From January 2009 through May 2012, 60 patients were randomized to either emergency stenting followed by elective resection (ESER group) or total abdominal colectomy and ileorectal anastomosis (TACIR group).

Results

Twenty nine patients (96.7 %) had successful stenting and underwent elective surgery 7–10 days later (ESER group). Postoperative complications were encountered in four patients in the ESER group compared to 15 patients in the TACIR group (p?=?0.012). Anastomotic leakage was encountered in one patient (3.3 %) in the TACIR group. There were no operative mortalities in the present study. Within the first three postoperative months, the TACIR group patients had significantly more frequent bowel motions per day compared to the ESER group patients although (p?=?0.013). In both study groups, the follow-up duration ranged from 6 to 40 months with a median of 18 months. Recurrent disease was encountered in five patients (17.2 %) in the ESER group compared to four patients (13.3 %) in the TACIR group (p?=?0.228).

Conclusion

Both techniques are feasible, safe, and produce comparable oncological outcomes. However, endoscopic stenting followed by elective resection was associated with significantly less postoperative complications and bowel motions per day.     

Acute Diverticulitis of the Left Colon: Value of the Initial CT and Timing of Elective Colectomy

Computed Tomography is undeniably the most useful tool to confirm the suspected diagnosis of acute left-colonic diverticulitis and to objectively grade its severity into moderate diverticulitis (no signs of colonic perforation) and severe diverticulitis (signs of colonic perforation). Indeed, the severity of acute diverticulitis is statistically predictive of the risk both to need surgical treatment of the first episode of acute diverticulitis, and to follow a complicated evolution after successful conservative treatment of the acute phase. Consequently, CT brings a major contribution to define the place of surgery during the acute phase of diverticulitis, and, later on, inside the long-term evolution of the disease after initial successful conservative treatment. This paper was originally presented as part of the SSAT/AGA/ASGE State-of-the-Art Conference on Management Of Diverticular Disease at the SSAT 47th Annual Meeting, May 2006, in Los Angeles, California.     

Outcome Assessment in Total Knee Arthroplasty: A Systematic Review and Critical Appraisal

Background

The Outcome Measures in Rheumatology (OMERACT) initiative developed a core outcome set (COS) of domains to assess effectiveness of interventions for knee osteoarthritis. These domains (pain, physical function, patient global assessment, imaging at 1 year) should be assessed in every trial to make research evidence meaningful and comparable. We systematically evaluated and critically appraised the use of measurement instruments and outcome domains in prospective studies evaluating patients with knee osteoarthritis undergoing total knee arthroplasty (TKA) and assessed their accordance with the OMERACT COS.

加速康复外科理念在腹腔镜结肠次全切除术治疗慢传输型便秘围手术期的应用价值

目的探讨加速康复外科理念在腹腔镜结肠次全切除术治疗慢传输型便秘围手术期的应用价值。方法 2008年12月至2011年1月130例腹腔镜结肠次全切除术慢传输型便秘(slow transit constipation,STC)随机分为术后施行加速康复外科(fast track surgery,FTS)的62例(FTS组),及未行FTS 68例(传统对照组),观察两组患者手术前后体质量变化、术后排气时间、排便时间、耐受半流质饮食时间、住院时间、患者舒适度等指标。结果 FTS组与传统对照组相比,FTS组术后排气时间、排便时间早于对照组,体质量损失小于对照组,住院时间缩短,舒适度亦显著优于对照组,以上各项差异均有统计学意义(P<0.05)。术后并发症发生率FTS组12.9%,传统方法组14.7%,差异无统计学意义(P>0.05)。112例获6～18个月随访,两组的胃肠生活质量指标评分和便秘症状改善度差异无统计学意义(P>0.05)。结论对于慢传输型便秘患者,在腹腔镜结肠次全切除术的围手术期应用FTS理念,治疗过程安全、有效,可以缩短住院时间,加速病人的康复。     

A Critical Appraisal of the Role of Neoadjuvant Chemotherapy for Colorectal Liver Metastases: A Case-Controlled Study

Background The aim of this study was to analyze the outcome of patients that received neoadjuvant chemotherapy prior to resection for colorectal liver metastases (CRLM) and compare them with a matched cohort of patients that underwent resection followed by adjuvant chemotherapy. Methods 687 patients have undergone curative resection between January 1993 and January 2006. In this period, 84 patients received neo-adjuvant chemotherapy and 71 of this group went on to resection. A control group was chosen, matched with these patients, made up of patients who underwent resection followed by adjuvant chemotherapy. Results There was no difference in clinico-pathological features between the neoadjuvant and the control group. However patients in the control group had more-extended resections and longer hospital stays than those in the neoadjuvant group (p = 0.015). Patients in the control group had an increased incidence of early recurrences (p < 0.001). Despite this, there was no significant difference in either the cancer-specific or the disease-free survival between the two groups of patients. Conclusion Neoadjuvant chemotherapy has a role in the management of patients with disease that is considered initially unresectable as a down-sizing technique. In patients with resectable disease, the test-of-time approach that neoadjuvant therapy offers is yet to be proven.     

Acute and Elective Laparoscopic Resection for Complicated Sigmoid Diverticulitis: Clinical and Histological Outcome

Background

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

Methods

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

Results

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

Conclusions

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.     

Sigmoid Resection with Primary Anastomosis for Uncomplicated Giant Colonic Diverticulum: a Report of two Cases

Giant colonic diverticulum (GCD) is a rare complication of colonic diverticulosis. A small number of cases has been reported in the literature. Patients with GCD have often few non-specific symptoms. Unfortunately, severe complications exist and may lead to surgical acute abdomen. Therefore, this complication of the diverticular disease must be known and properly treated. There is no gold standard diagnostic test, but an air-fluid or air-filled, rounded, pseudo-cystic image in relation with the colonic wall in a patient with colonic diverticula should suggest this diagnosis to the clinician. We report two cases of a 70-year-old male patient and a 44-year-old female patient having a giant sigmoid diverticulum. The treatment of choice of an uncomplicated GCD is an elective colonic resection, including the giant diverticulum, with primary anastomosis; while in case of complicated GCD (peritonitis, abscess or complex fistula), a two-stage resection should be considered.