Primary anastomosis with a defunctioning stoma versus Hartmann's procedure for perforated diverticulitis—a comparison of stoma reversal rates

Purpose

The ideal treatment of patients with perforated diverticulitis is still controversial. Hartmann's procedure has been the treatment of choice for decades, but primary anastomosis with a defunctioning stoma has become an accepted alternative. The aim of this study was to evaluate the stoma reversal rates after these two surgical strategies.

Methods

A retrospective review of the data from patients with perforated sigmoid diverticulitis between 2002 and 2011 undergoing a Hartmann's procedure (HP) versus a primary anastomosis with a defunctioning stoma (PA) was performed. Additionally, patients were contacted by mail or telephone in March 2012 using a standardized questionnaire.

Results

A total of 98 patients were identified: 72 undergoing HP and 26 patients receiving PA. The median follow-up time was 63 months (range 4–118). Whilst 85 % of patients with PA have had their stoma reversed, only 58 % of patients with an HP had a stoma reversal (p?=?0.046). The median period until stoma reversal was significantly longer for HP (19 weeks) than for PA (12 weeks; p?=?0.03). The 30-day mortality for PA was 12 % as opposed to 25 % for HP (p?=?0.167). According to the Clavien–Dindo classification, surgical complications occurred significantly less frequently in patients with PA (p?=?0.014).

Conclusion

The stoma reversal rates for PA are significantly higher than for HP. Thus, depending on the overall clinical situation, primary resection and anastomosis with a proximal defunctioning stoma might be the optimal procedure for selected patients with perforated diverticular disease.     

Macrophage and T-lymphocyte Infiltrates in Human Peritoneal Adhesions Indicate a Chronic Inflammatory Disease

Background Peritoneal adhesions are common and lead to significant clinical morbidity and mortality. Besides various individual factors, notably the inflammatory response to peritoneal defects affects adhesion formation. The aim of this study was to investigate whether there is inflammatory activity even in persistent adhesions. Methods Tissue specimens of 40 patients suffering peritoneal adhesions were prospectively collected. Expression profiles of seven parameters as potential mediators in cellular immune response, cell differentiation, and wound healing were analyzed (macrophages [CD68], B-lymphocytes [CD20] and T-lymphocytes [CD45], cyclo-oxygenase-2 [COX-2], Notch-3, β-catenin, and c-myc). Furthermore, clinical details and co-morbidities were recorded. Results Infiltrates of mononuclear round cells were found in all adhesion specimens irrespective of the maturity. Immunohistochemical analysis identified mononuclear round cells as macrophages (CD68) and as T-lymphocytes (CD45). Expression of CD68 was significantly elevated in adhesion tissue with an age <12 months. Positive expression of CD45, COX-2, Notch-3, β-catenin, and c-myc, was observed even in long-lasting adhesions. Conclusions A persistent inflammatory process has to be considered, even in mature adhesions. Macrophages may play an important role in triggering adhesions, whereas T-cells and the Notch-3/β-catenin complex signaling pathway may play a crucial role in maintaining adhesions. These findings indicate that adhesions should not be regarded simply as an adynamic result of an operative trauma but rather may be grasped as a permanent process in remodeled tissue.     

Different matrix micro-environments in colon cancer and diverticular disease

Background and aims The extracellular matrix and the interactive signalling between its components are thought to play a pivotal role for tumour development and metastasis formation. An altered matrix composition as potential underlying pathology for the development of colorectal cancer was hypothesized. Methods In a retrospective study of patients with colon cancer, the extracellular matrix in tumour-free bowel specimen was investigated in comparison with non-infected bowel specimen from patients operated on for colonic diverticulosis. The following matrix parameters with known associations to tumour formation, cell proliferation, invasion and metastasis were analysed by immunohistochemistry and quantified by a scoring system: VEGF, TGF-β, ESDN, CD117, c-erb-2, cyclin D1, p53, p27, COX-2, YB-1, collagen I/III, MMP-13, PAI and uPAR. Expression profiles and correlations were calculated. Results The comparison of the two groups revealed a significantly decreased immunostaining for CD117 and TGF-β in the cancer group (8.5±2.6 vs 10.3±2,1 and 4.9±1.5 vs 8.1±3, respectively), whereas PAI scores were significantly higher than in patients with diverticular disease (8.1±1.6 vs 6.2±0.9). Overall correlation patterns of matrix parameters indicated pronounced differences between tumour-free tissue in cancer patients compared with patients with diverticular disease. Conclusions Our results indicate distinct differences in the colonic tissue architecture between cancer patients and patients with diverticulitis that support the notion of an altered matrix composition predisposing to the development of colon cancer. The first two authors contributed equally to this work.     

Diagnosis of cornual obstruction by transcervical fallopian tube cannulation

Interstitial fallopian tube obstruction (IFTO) occurs in 15% of hysterosalpingograms (HSG) performed for infertility. Conventional HSG or laparoscopy may not differentiate cornual spasm or other temporary cause from true obstruction. We used transcervical cannulation of the proximal oviduct with a 3-F Teflon catheter and flexible guidewire 0.018 inch (0.043 cm) in diameter under hysteroscopic or fluoroscopic guidance to evaluate IFTO in 28 patients. Fluoroscopic catheterization techniques with selective salpingography demonstrated patency in 84% of obstructed tubes. Hysteroscopic cannulation with direct visualization by laparoscopy or laparotomy was successful in 92%. In one patient, perforation of the isthmus occurred without sequelae. Transcervical coaxial cannulation of the proximal oviduct is an effective method for evaluating cornual obstruction.     

Abdominal compartment syndrome]

Abdominal compartment syndrome (ACS) is characterized by a persistent pathologic increase in intra-abdominal pressure (IAP) exceeding 20 mmHg with consecutive dysfunction of multiple organ systems. The main causes of ACS are abdominal trauma, obstruction, infection, and sepsis, but it may also be initiated by extra-abdominal diseases. The gold standard for diagnosis is repeated assessment of the IAP measurements of bladder pressure. The incidence of ACS is up to 15% in operative ICUs and the therapy of choice for it is decompressive laparotomy. Nevertheless, mortality is high, up to 60%.