Treating acute diverticulitis in pre- and post-solid-organ transplant patients: a single-institution cohort study

Aim

Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30-day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre- and post-transplant patients.

Method

This is a retrospective cohort study at a single-institution tertiary referral centre. Patients with a history of acute diverticulitis were extracted from a database of 6152 recipients of solid-organ abdominal transplant between 2000 and 2015 and stratified by the index episode of diverticulitis: before or after solid-organ transplant surgery. Outcomes included 30-day postoperative complications and failure of nonoperative management.

Results

Acute diverticulitis occurred in 93 patients, 69 (74%) posttransplant. Postcolectomy complications were higher posttransplant than pretransplant (43% vs. 13%, p = 0.04). Posttransplant status was not an independent risk factor for complications (odds ratio 3.59, 95% CI 0.79–16.31) when adjusting for sex and surgical acuity. Immediate urgent colectomy (29% vs. 31%, p = 0.84) and failure of nonoperative management (7% vs. 9%, p = 0.82) were similar. Complications occurred equally in those requiring urgent colectomy after nonoperative management and those undergoing immediate urgent colectomy.

Conclusion

Urgent colectomy rates are similar in solid-organ abdominal transplant recipients pre- and posttransplant. Posttransplant complication rates appear to be increased but transplant status as an independent factor is not significantly associated with an increased risk in this study cohort. These findings should be considered when counselling patients on the relative risks and benefits of surgical intervention for diverticulitis before versus after solid-organ transplantation.     

Emergency surgery comparison of right versus left acute colonic diverticulitis: A 10-year outcome analysis

IntroductionThe difference in outcome between right (RCD) and left colonic diverticulitis (LCD) is not well established. The aim of this study was to analyse the presentation and surgical outcome of RCD versus left-sided disease following emergency surgery.MethodWe conducted a retrospective review of patients presenting with acute diverticulitis over a 10-year period from 2004 to 2014 to a tertiary unit. Patient demographics, Hinchey classification, need for emergency surgery, perioperative outcome and recurrence were evaluated.ResultsIn total 360 patients presented with acute diverticulitis, 218 (61%) were right-sided and 142 (39%) were left-sided. The mean age (57 yrs vs 68 yrs) and median length of stay (4 days vs 5 days) were significantly less in RCD (p < 0.001). The need for emergency surgery was similar between RCD and LCD (30.7% vs 23.2%, p = 0.12). Sixty-seven (31%) patients with RCD required emergency surgery, 42 (62.7%) of these were based on a presumptive diagnosis of appendicitis and underwent laparoscopic appendicectomy only. Operative morbidity (10.4% vs 51.5%, p < 0.001) and mortality were significantly higher in LCD (1.5% v 15.2%, p = 0.007). Subgroup analysis of non-appendicectomy, RCD patients, showed LCD were more likely to require surgery (11.5% vs 23.2%, p = 0.003). There was no difference in recurrence (p = 0.6).ConclusionRight colonic diverticulitis patients are younger and disease course is more benign compared to LCD. Presentation can be confused with appendicitis without proper imaging. In the rare cases where emergency surgery is required, RCD is associated with a lower operative morbidity and mortality compared to left-sided disease.     

Risk of colorectal advanced neoplasia in patients with acute diverticulitis with and without previous colonoscopy

Background and Aim

Guidelines recommend a colonoscopy after an episode of complicated diverticulitis and after a first episode of uncomplicated diverticulitis. The influence of a previous colonoscopy on postdiverticulitis colonoscopic findings has not been studied. The aim of this work was to examine the incidence of adenoma detection rate (ADR), advanced adenoma (AA) and colorectal cancer (CRC) in patients with diverticulitis with and without previous colonoscopy.

Method

This was a retrospective case–control study of subjects with acute diverticulitis. Subsequent and previous colonoscopies were abstracted for ADR, AA and CRC diagnoses. The incidence of neoplasia was compared between patients with and without previous colonoscopy and also with that of a screening population.

Results

Compared with a healthy control group (n = 975), diverticulitis patients without prior colonoscopy (n = 325) had a significantly higher ADR (26.8% vs. 20.5%, p = 0.019) and invasive CRC rate (0.9% vs. 0%, p = 0.016). Risk factors for advanced neoplasia included age ≥ 70 years and complicated diverticulitis. Among subjects with diverticulitis and previous colonoscopy (n = 124), only one patient developed AA and there were no cancer cases.

Conclusions

A previous normal colonoscopy within 5 years before diverticulitis probably overshadows other risk factors for findings of advanced neoplasia and should be considered in the decision to repeat a colonoscopy.     

Colonoscopy after Hinchey I and II left-sided diverticulitis: utility or futility?

Background

Modern 64- to 128-slice computed tomography (CT) scanners have questioned the need for routine colonoscopy after hospital admission for presumed uncomplicated diverticulitis.

Methods

This is a retrospective review of all patients (>18 years) who underwent planned colonoscopy after admission for Hinchey I or II acute diverticulitis (January 2009 to January 2014). The findings on the final radiologist report were then correlated with the colonoscopy results.

Results

In total, 110 patients (mean age, 55.2 ± 16; 46.4% female) underwent a subsequent colonoscopy (median, 60 days) after admission for diverticulitis. Overall, 102 patients (92.7%) had CT findings consistent with definitive diverticulitis, 6 patients had a diagnosis suggestive of diverticulitis on CT scan, and 2 patients had masses on their admission CT scans. Within the group with definitive diverticulitis, follow-up colonoscopy identified diverticulosis in 99 (97.0%), whereas the other 3 had normal findings. Of the patients with CT scans suggestive of diverticulitis, follow-up colonoscopy showed 3 with diverticulosis, 2 with malignancies, and 1 with nonspecific inflammation. The reliability of CT scans for diverticulitis compared with colonoscopy was found to have a kappa = .829 (P < .001; 95% confidence interval, .629, 1.21).

Conclusions

Follow-up colonoscopy should be performed when a CT scan suggests malignancy, nonspecific inflammatory findings, or the patient is otherwise due for routine screening or surveillance. In this study, there was no benefit of follow-up colonoscopy in patients with CT-confirmed diverticulitis in the absence of other concerning or indeterminate findings.     

Laparoscopic one-stage resection of right and left colon complicated diverticulitis equivalent to hinchey stage I–II

Purpose  

The safety and effectiveness of laparoscopic surgery is well established for recurrent, uncomplicated diverticular disease, but not for complicated diverticular disease. Using the Hinchey classification, we compared laparoscopic colon resection (LAPH) with conventional open colon resection (OPH) for the treatment of complicated diverticulitis equivalent to Hinchey stage I–II.     

A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2

Aim After an initial uncomplicated attack, sigmoid diverticulitis may recur, but the morphological characteristics of recurrent diverticulitis have not been investigated. We compared the clinical and radiological severity, the respective location and clinical outcome of the first two episodes of sigmoid diverticulitis. Method We reviewed the charts of 60 patients [median age 61 (range 31–90) years] who were admitted initially for a first episode of uncomplicated left colonic diverticulitis, and who were eventually readmitted for a second episode, both being documented by abdominal computed tomography (CT) scan. Results The median delay between the two episodes was 19 (3–97) months. Six (10%) patients developed a second complicated episode of diverticulitis [Hinchey II (n = 2), CT‐guided percutaneous drainage; Hinchey III (n = 3), emergency Hartmann’s operation; colovesical fistula (n = 1), elective sigmoid resection]. Fifty‐four (90%) patients were admitted for a second episode of uncomplicated diverticulitis. In this group, the duration of hospital stay [11 (4–22) vs 10 (1–39) days, P = 0.28], serum levels of C‐reactive protein [131 (31–350) vs 112 (22–333) mm , P = 0.62] and CT scan‐based severity score [3 (1–6) vs 3 (0–7) points, P = 0.07] were similar between the two episodes. In 19 out of 54 (35%) patients with simple recurrent diverticulitis, although disease severity was similar, the disease topography differed and recurrence involved another segment of the left colon. Conclusion The majority of patients who develop recurrence do so in a similar mode and location. However, 10% develop complicated diverticulitis and in 35% of patients recurrent diverticulitis occurs at a different location.     

Increasing the number of attacks increases the conversion rate in laparoscopic diverticulitis surgery

Background  This study aimed to determine whether the number of diverticulitis or complicated diverticulitis episodes affects the conversion rate or postoperative complication rate in elective laparoscopic sigmoid colectomy. Methods  In this study, 216 charts were reviewed for baseline characteristics, diverticulitis history, and intra- and postoperative complications. Analysis was performed with the Student’s t-test, the chi-square test, and Fisher’s exact tests. Results  Of 216 sigmoid colectomies, 151 were laparoscopic, 19 were converted, and 46 were open. Baseline characteristics were similar for patients with zero to two and those with three or more inpatient diverticulitis attacks. Patients with uncomplicated diverticulitis had a higher rate of conversion after three or more inpatient episodes (2.6% vs 25%; p = 0.04). There was no difference in operative times or postoperative complication rates. Patients with a history of abscess had a 23% chance of conversion. Those with no abscess history had an 8% chance of conversion (p = 0.02). In general, converted procedures required more time than open procedures but were associated with decreased hospital length of stay (LOS) and a decreased rate of postoperative ileus. Conclusion  Multiple inpatient diverticulitis attacks and a history of abscess were associated with laparoscopic conversion. Converted procedures required more time than open procedures, but had reduced LOS and postoperative ileus. Laparoscopic sigmoid colectomy can be attempted safely for patients with three or more inpatient attacks or a history of complicated diverticulitis.     

Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann’s procedure

Background

This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann’s procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis.

Methods

A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P?Results A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1?%) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182?±?54.7?min, and EBL was 210?±?170.5?ml. Six LHP (14.6?%) were converted to open Hartmann’s for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1?%, respectively. For LLD, the operating time was 99.7?±?39.8?min, and blood loss was 34.4?±?21.2?ml. Three patients (6.4?%) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3?±?10.1 vs. 6.7?±?2.2?days, P?Conclusions Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.     

Laparoscopic Sigmoidectomy for Diverticulitis: a Prospective Study

Background:

Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of this prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy in patients with diverticulitis. Patients offered laparoscopic surgery presented with acute complicated diverticulitis (Hinchey type I, II, III), chronically recurrent diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis.

Method:

All patients who underwent laparoscopic colectomy within a 12-year period were prospectively entered into a database registry. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. A 4-trocar approach with suprapubic minilaparotomy was performed. Main data recorded were age, sex, postoperative pain, return of bowel function, operation time, duration of hospital stay, and early and late complications.

Results:

During the study period, 260 sigmoid colectomies were performed for diverticulitis. The cohort included 104 male and 156 female patients; M to F ratio was 4:6. Postoperative pain was controlled by NSAIDs or weak opioid analgesia. Fifteen patients (5.7%) required conversion from laparoscopic to open colectomy. The most common reasons for conversion were directly related to the inflammatory process, abscess, and peritonitis. Mean operative time was 130±54. Average postoperative hospital stay was 10±3 days. A longer hospital stay was recorded for Hinchey type IIb patients. Complications were recorded in 30 patients (11.5%). The most common complications that required reoperation were hemorrhage in 2 patients (0.76) and anastomotic leak in 5 patients (only 3 of them required reoperation). The mortality among them was 2 patients (0.76%).

Conclusions:

Laparoscopic surgery for diverticular disease is safe, feasible, and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.     

超声在不同分型急性结肠憩室炎诊断中的价值

目的 观察超声诊断单纯型及复杂型急性结肠憩室炎的价值。方法 回顾性分析17例急性结肠憩室炎患者的临床、超声及CT资料,分析超声诊断急性结肠憩室炎的价值。结果 17例中,11例接受超声检查,其中单纯型8例、复杂型3例。7例单纯型超声表现为局部结肠肠壁增厚,结肠边缘见囊袋状凸起,边界清,憩室周围可见高回声包绕;1例病灶位于升结肠,结肠边缘见囊袋状凸起,憩室内见高密度粪石,肠壁增厚伴周围脂肪密度升高,超声漏诊后经CT检出。3例复杂型超声均表现为憩室周围低回声包块,与周围肠管、膀胱分界不清。超声结合临床准确诊断10例(90.91%,10/11)急性结肠憩室炎,包括7例(7/8,87.50%)单纯型和3例(3/3,100%)复杂型。结论 超声有助于诊断急性结肠憩室炎,尤其复杂型急性结肠憩室炎。     

Endoscopic findings after CT proven acute diverticulitis: a systematic review and meta-analysis

Background

Traditionally, international guidelines recommend patients with acute diverticulitis should be followed up with a colonoscopy 6–8 weeks after discharge. However, the need for an interval colonoscopy has been increasingly challenged in the setting of computed tomography (CT). Previous meta-analyses have included studies which combined suspected rather than imaging confirmed diverticulitis and often without correlation with endoscopic findings. This meta-analysis aims to investigate endoscopic findings of patients with CT confirmed diverticulitis.

Methods

An electronic search of Medline, PubMed, Cochrane Library, Embase, CINAHL, Web of Science, Scopus, Clinicaltrials.gov and WHO ICTRP was performed up to October 18, 2021. Studies which reported CT confirmed acute diverticulitis in adults and who underwent endoscopic follow-up with either a colonoscopy or flexible sigmoidoscopy were included. Studies were excluded if diverticulitis was diagnosed by clinical grounds alone, ultrasound, barium enema, or other non-CT forms of imaging.

Results

A total of 68 studies with 13 905 patients were included. Median age was 58 years and male to female ratio was 0.84. Cancer was detected in 2.0% and advanced adenoma in 3.8%. Complicated diverticulitis had 9.2 higher odds of cancer compared to uncomplicated diverticulitis (95% CI 4.42–19.08, P < 0.001). Adenomas were detected in 17%. Of those diagnosed with colorectal cancer, 85% were concordant with the site of the diverticulitis on CT while 15% were incidental findings.

Conclusion

Routine colonoscopic follow up should be recommended in medically fit patients who have CT proven acute diverticulitis due to the higher than population prevalence of colorectal cancer and advanced adenomas.     

Evolution of pediatric gastrointestinal ulcer disease: Is acute surgical intervention relevant?

BackgroundThere is a lack of contemporary data about pediatric gastrointestinal ulcer disease. We hypothesized that ulcers found in immunosuppressed children were more likely to require surgical intervention.MethodsAll children <21 years (n = 129) diagnosed with ulcers at a quaternary hospital from 1990 to 2019 were retrospectively reviewed. Clinical findings and pertinent information were collected.ResultsOf 129 cases, 19 (14.7%) were immunosuppressed. Eight were post-transplant; four were diagnosed with post-transplant lymphoproliferative disease (PTLD).  Eight were associated with cancer. Three were both.  Three of 19 immunosuppressed and 28/110 immunocompetent patients were taking acid suppression therapy. Nine immunosuppressed patients required surgical intervention, including all PTLD cases, compared to 14 immunocompetent (47.3% vs 16.4%, p < 0.01). Five patients had duodenal perforation, two had multiple small bowel perforations, and two had uncontrolled bleeding. Of 9/19 immunosuppressed patients, surgical complications included bleeding (n = 7), sepsis (n = 2), ostomy reoperation/readmissions (n = 2), and death within 30 days (n = 2). Two/eighteen immunocompetent patients had bleeding complications.ConclusionSurgical treatment for ulcers remains relevant for pediatric patients. Immunosuppressed patients have more complications, longer hospital stays, and are more likely to need surgical intervention. Efforts should be made for ulcer prophylaxis with a low threshold to investigate epigastric pain in these complex patients.Level of evidencePrognosis Study Level III Evidence     

Outcomes of immediate dental implants in vascularised bone flaps for mandibular reconstruction

Background

The aim of this study is to assess the outcomes of immediate implant placement for dental rehabilitation following mandibular reconstruction with vascularised bone flaps in a single Australian tertiary cancer centre.

Methods

A retrospective analysis of patients who underwent immediate dental implant or delayed placement in vascularised bone flaps was performed. Primary outcome measures assessed included the number of implants placed, operative time, complication rates, time to radiotherapy initiation, dental rehabilitation rates and time to dental rehabilitation.

Results

In total, 187 dental implants were placed in 52 patients, of which 34 patients underwent immediate implant placement and 18 had delayed implant placement. There were no significant differences in the postoperative complication rate (32% immediate vs. 33% delayed, P = 0.89) or time to postoperative radiotherapy (median 42 days immediate vs. 47 days delayed, P = 0.24). Dental rehabilitation was achieved in 62% of the immediate cohort versus 78% of the delayed cohort. The time to be fitted with a dental prosthesis was significantly shorter in the immediate cohort (median 150 days immediate vs. 843 days delayed, P = 0.002).

Conclusions

The placement of immediate dental implants at the time of primary reconstruction of the mandible is a safe procedure and facilitates timely dental rehabilitation.     

Israeli Arabs develop diverticulitis at a younger age and are more likely to require surgery than Jews

Background

Only few studies have examined the impact of racial differences on the age of onset, course and outcomes of diverticulitis.

Aim

To provide data about the epidemiology of diverticulitis in northern Israel, and to determine whether ethnicity is a predictor of age of onset, complications, and need for surgery.

Methods

Was conducted a retrospective review of the charts of all patients diagnosed with a first episode of diverticulitis in our hospital between 2005 and 2012.

Results

Were found 638 patients with a first episode of acute diverticulitis in the eight year interval. Israeli Arabs developed a first episode of diverticulitis at a younger age compared to Jews (51.2 vs 63.8 years, p<0.01). Arabs living in rural areas developed diverticulitis at a younger age than Arabs living in urban centers (49.4 vs 54.5 years, P=0.03). Jewish and Arabic men developed diverticulitis at younger age compared to their female counterparts (59.9 vs 66.09, p<0.01, and 47.31 vs 56.93, p<0.01, respectively). Arabs were more likely [odds ratio (OR)=1.81 ,95% confidence interval (CI)1.12-2.90, p=0.017] than Jews to require surgical treatment (urgent or elective) for diverticulitis.

Conclusions

Israeli Arabs tend to develop diverticulitis at a younger age and are more likely to require surgical treatment for diverticulitis compared to Jews. Arabs living in rural areas develop diverticulitis at a younger age than Arabs living in urban centers. These findings highlight a need to address the root cause for ethnic differences in onset, course and outcome of acute diverticulitis.     

Persistent Perforation in Non-Faeculant Diverticular Peritonitis—Incidence and Clinical Significance

Background

Non-resectional strategies (NRS) have improved outcomes for a sub-group of patients with perforated diverticulitis. NRS are applicable to patients with non-faeculant peritonitis (Hinchey II and III). Success is dependent on the initial perforation sealing, which Hinchey estimated occurred ‘most of the time’. An exact percentage remains ill-defined.

Objective

We aimed to define the percentage and clinical significance of a persistent perforation in non-faeculant diverticular peritonitis.

Design

A retrospective review was conducted of all patients admitted with a diagnosis of perforated diverticulitis between January 1999 and July 2010. Patients undergoing an emergency operation were analysed according to Hinchey and physiological and operative severity scores and compared with histological findings.

Results

One hundred fifteen patients were identified. Fifty-three patients underwent a ‘resectional’ procedure. At surgery, 15 patients had faeculent peritonitis, 27 patients had purulent peritonitis and 11 patients had a contained abscess. Of the patients with non-faeculant peritonitis, 2/9 (22.2 %) Hinchey II and 10/27 (37.1 %) Hinchey III patients had persistent perforation on review of histology. Persistent perforation was associated with a significant increase in morbidity, length of stay, physiological and operative severity score (p?=?0.015, 0.011, 0.049 and 0.002, respectively).

Conclusion

A proportion of patients with non-faeculant peritonitis have a persistent perforation which is associated with a poorer outcome and is likely to result in failure of a non-resectional management strategy. Updated classification systems and tailored peri-operative investigations are required to identify this sub-group of patients and improve patient outcomes.     

Uncomplicated Diverticulitis, More Complicated than We Thought

Introduction

The classification of complicated and uncomplicated diverticulitis has been used for many years. We note variations in the course of uncomplicated diverticulitis. We propose and describe three categories of uncomplicated diverticulitis.

Methods

A review was performed on 907 patients who underwent sigmoid resection for diverticulitis between January 1, 2005 and December 30, 2009 at Mayo Clinic, Rochester. Overall, 223 individuals were excluded as they were not uncomplicated diverticulitis. The remaining 684 patients were divided into three classifications as follows: 54 (7.9?%) atypical, 66 (9.6?%) chronic/smoldering, and 564 (82?%) acute resolving. Data elements abstracted included demographics, preoperative symptoms, imaging and endoscopy, operative and pathologic findings, postoperative complications, and resolution of symptoms.

Results

The 30-day complication rate of the atypical, chronic/smoldering, and acute groups was 26?%, 22?%, and 35?%, respectively. Resolution of symptoms for the atypical and chronic/smoldering groups was 93?% and 89?%, respectively. Only two patients in the acute resolving group required an operation for recurrence.

Conclusion

A spectrum of clinical presentation for uncomplicated diverticulitis may require different approaches. A select group of patients with chronic/smoldering and atypical disease will continue to be burdened by symptoms. The success of surgical intervention was greater than 89?% in both groups with acceptable morbidity, and should remain an option.     

Treating acute colonic diverticulitis with extraluminal pericolic air: An Acute Care Surgery in the Netherlands (ACCSENT) multicenter retrospective cohort study

BackgroundOwing to improved quality of computed tomography, a new category of complicated acute diverticulitis, including patients with pericolic air but without abscess formation, can be defined (Hinchey 1a). Recent studies question whether this new category of acute diverticulitis could be treated as uncomplicated cases. The aim of our study is to report on the clinical course of acute diverticulitis Hinchey 1a in current clinical practice.MethodsFor this multicenter retrospective cohort study, patients presenting at the emergency department with Hinchey 1a acute diverticulitis as demonstrated by computed tomography scan, were identified. The primary outcome measure was successful conservative treatment with observation alone, antibiotics, and/or hospital admission. Readmissions, percutaneous drainage of abscesses, and emergency operations were considered as failure.ResultsBetween October 2016 and October 2018, 1,199 patients were clinically suspected for acute diverticulitis, of whom 101 (8.4%) were radiologically diagnosed to have type 1a acute diverticulitis (average age 57 (±13) years, 45% female) and started with conservative treatment. This was successful in 86 (85%) patients. One of the 15 unsuccessfully treated patients (1%) received percutaneous drainage of an abdominal abscess. Surgery was required in 9 cases (9%) after a median time of 6 days (range, 3 to 69 days). Although a difference in the volume of extraluminal air on computed tomography scan was found, this was not shown to be a risk factor for the clinical course.ConclusionPatients with type 1a acute diverticulitis can be treated successfully by conservative therapy in the majority of cases (85%). More research is required to define predictive factors for successful conservative management.     

Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection

ObjectiveThe study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections.MethodsPatients from WL Gore's Global Registry for Endovascular Aortic Treatment who underwent thoracic endovascular aortic repair for acute type B aortic dissections were included, and data were retrospectively analyzed.ResultsOf 5014 patients enrolled in the Global Registry for Endovascular Aortic Treatment, 172 underwent thoracic endovascular aortic repair for acute type B aortic dissections. Of these repairs, 102 were for complicated acute type B aortic dissections and 70 were for uncomplicated acute type B aortic dissections. There were 46 (45.1%) procedures related to aortic branch vessels versus 15 (21.4%) in complicated type B aortic dissections and uncomplicated type B aortic dissections (P = .002). The mean length of stay was 14.3 ± 10.6 days (median, 11; range, 2-75) versus 9.8 ± 7.9 days (median, 8; range, 0-42) in those with complicated type B aortic dissections versus those with uncomplicated acute type B aortic dissections (P < .001). Thirty-day mortality was not different between groups (complicated type B aortic dissections 2.9% vs uncomplicated acute type B aortic dissections 1.4%, P = .647), as well as aortic complications (8.8% vs 5.7%, P = .449). Aortic event-free survival was 62.9% ± 37.1% versus 70.6% ± 29.3% at 3 years (P = .696).ConclusionsIn the Global Registry for Endovascular Aortic Treatment, thoracic endovascular aortic repair results for complicated type B aortic dissections versus uncomplicated acute type B aortic dissections showed that 30-day mortality and perioperative complications were equally low for both. The midterm outcome was positive. These data confirm that thoracic endovascular aortic repair as the first-line strategy for treating complicated type B dissections is associated with a low risk of complications. Further studies with longer follow-up are necessary to define the role of thoracic endovascular aortic repair in uncomplicated acute type B dissections compared with medical therapy. However, in the absence of level A evidence from randomized trials, results of the uncomplicated acute type B aortic dissection patient cohort treated with thoracic endovascular aortic repair from registries are important to understand the related risk and benefit.     

Meckel's diverticulectomy: a multi-centre 19-year retrospective study

Background

Meckels diverticulum (MD) causes a number of acute surgical pathologies and can contain ectopic tissue with the surgical aim to resect all ectopic mucosa. This has traditionally implied a small bowel resection (BR); though contemporary literature has demonstrated Meckel's diverticulectomy to be safe. The aim of this study was to determine optimal resection strategy, and assess MD histopathological features and their relationship to outcomes.

Methods

A 19-year retrospective review of patient medical records across seven hospitals was conducted with demographic, clinical and pathological data collected. Analysis was conducted using a student's t-test for continuous variables and chi-squared test for categorical variables. Univariate regression was performed to identify risk factors. P < 0.05 was considered statistically significant.

Results

One hundred and sixty patients underwent resection of MD, 70 (44%) had Meckel's diverticulectomy and 90 (56%) had BR. No significant difference in length (P = 0.486), width (P = 0.238), or ratio (P = 0.188) of diverticulectomy compared to BR, with fewer complications in diverticulectomy. In all, 24 (15.3%) MD were perforated, of whom 5 had gastric mucosa, 2 had mixed ectopic mucosa and 1 carcinoid tissue. There were no cases of ectopic mucosa in the resection margin requiring re-operation, or causing base perforation. MD specimen with greater length: width ratio was a risk factor for perforation OR 1.437 P = 0.042 but not for malignancy P = 0.813 or ectopic tissue P = 0.185.

Conclusion

Meckel's diverticulectomy is safe via laparoscopic or open approach compared with BR. Despite higher perforation rates in MD with greater length: width ratio, no malignancy or ectopic risk was identified, supporting diverticulectomy as a safe operative approach.     

Long-term outcome after conservative and surgical treatment of acute sigmoid diverticulitis

Purpose  

This study was designed to compare the long-term outcome of patients treated with conservative versus surgical treatment for acute sigmoid diverticulitis (SD).