The Evolving Role of Laparoscopy in Colonic Diverticular Disease: A Systematic Review

Background

A PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials.

Results

Elective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis.

Conclusions

Elective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.     

Pesticide assessment: Protecting public health on the home turf

Pesticide regulation is examined in the context of Health Canada’s Pest Management Regulatory Agency’s assessment of the chlorophenoxy herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) for turf. 2,4-D is the most common herbicide used to kill weeds in grass.The medical literature does not uniformly indicate harms from herbicides. However, the balance of epidemiological research suggests that 2,4-D can be persuasively linked to cancers, neurological impairment and reproductive problems. These may arise from 2,4-D itself, from breakdown products or dioxin contamination, or from a combination of chemicals.Regulators rely largely on toxicology, but experiments may not replicate exposures from 2,4-D application to lawns because environmental breakdown products (eg, 2,4-dichlorophenol) may not accumulate and selected herbicides are possibly less contaminated. Dioxins are bioaccumulative chemicals that may cause cancer, harm neurological development, impair reproduction, disrupt the endocrine system and alter immune function. No dioxin analyses were submitted to the Pest Management Regulatory Agency, and the principal contaminants of 2,4-D are not among the 17 congeners covered in pesticide regulation. Independent assessment of all dioxins is needed, in tissues and in the environment.The 2,4-D assessment does not approach standards for ethics, rigour or transparency in medical research. Canada needs a stronger regulator for pesticides. Potentially toxic chemicals should not be registered when more benign solutions exist, risks are not clearly quantifiable or potential risks outweigh benefits. Until landscaping pesticides are curtailed nationally, local bylaws and Quebec’s Pesticide Code are prudent measures to protect public health. Physicians have a role in public education regarding pesticides.     

Bursting pressure of experimental aneurysms

The laser-sealed arteriotomy (LSA) technique was used to create experimental aneurysms in the rat carotid artery. Animals were reexplored 2, 4, and 8 weeks following LSA, at which time the aneurysms were measured and subjected to a bursting strength pressure. In addition, a group of hypertensive rats with LSA was also tested 2 weeks after surgery. The LSA procedure produced aneurysms of a stable size and bursting pressure over the time studied. The bursting pressure technique may be applicable for assessing aneurysm therapy in an experimental setting.     

Causes of jaundice during hepatic artery infusion chemotherapy

Jaundice develops in many patients with liver metastases from colorectal adenocarcinoma during hepatic arterial infusion chemotherapy (HAIC). The usual cause is thought to be hepatotoxicity from the chemotherapeutic agent or biliary obstruction from progressive neoplastic disease. The authors evaluated the abdominal computed tomography and ultrasound examinations performed on 49 patients who were jaundiced during long-term HAIC. In only one patient was diffuse intrahepatic biliary dilatation caused by an obstructing mass in the porta. Two patients had metastatic hepatic lesions causing focal biliary obstruction. Intrahepatic dilatation without an obstructing mass occurred in 20 patients. Percutaneous or endoscopic cholangiograms were commonly interpreted prospectively as showing extrinsic compression by metastases, but no mass was confirmed on imaging studies. Seven patients had focal intrahepatic ductal dilatation from stricture without an associated mass. The remaining 19 patients had normal-caliber ducts; their jaundice was caused by chemical hepatitis. This series suggests that the most common causes of jaundice in these patients are chemical hepatitis and common bile duct stricture, complications of intraarterial chemotherapy, rather than neoplastic obstruction. Stricture formation may be confused with extrinsic compression on direct cholangiograms.     

Arteriovenous malformations of the extremities: MR imaging

Eight patients with angiographically proved arteriovenous malformations (AVMs) of the extremities (seven congenital, one posttraumatic) were evaluated with magnetic resonance (MR) imaging using a 0.35-T superconducting system and spin-echo pulse sequences. Congenital AVMs appeared as accumulations of dilated tortuous blood vessels infiltrating the involved muscles. A posttraumatic acquired AVM of the shoulder consisted of a large feeding artery associated with a pseudoaneurysm and a soft-tissue mass. MR imaging allowed precise anatomic localization and provided details concerning the size and extent of the AVMs. The relationship of AVMs to specific muscle groups, bones, and vascular structures could be accurately determined. Although major feeding and draining vessels were identified, the exact arteries and veins supplying and draining the AVM could not be ascertained. Images obtained in the transverse plane consistently yielded the most useful information. MR imaging and angiography may be complementary techniques in the initial evaluation, follow-up, and treatment planning of AVMs of the extremities.