Propensity-Matched Analysis of Sigmoidectomies for Diverticular Disease

Background and Objectives:

The role for the robotic-assisted approach as a minimally invasive alternative to open colorectal surgery is in the evaluation phase. While the benefits of minimally invasive colorectal surgery when compared to the open approach have been clearly demonstrated, the adoption of laparoscopy has been limited. The purpose of this study was to evaluate clinical outcomes, hospital and payer characteristics of patients undergoing robotic-assisted, laparoscopic, and open elective sigmoidectomy for diverticular disease in the United States.

Methods:

This is a retrospective propensity score–matched analysis. The Premier Healthcare Database was queried for patients with diverticular disease. Patients with diverticular disease who underwent robotic-assisted, laparoscopic, and open sigmoidectomy for diverticular disease from January 2013 through September 2015 were included. Propensity-score matching (1:1) facilitated comparison of robotic-assisted versus open approach and robotic-assisted versus laparoscopic approach. Peri-operative outcomes were assessed for both comparisons.

Results:

There were several outcomes advantages for the robotic-assisted approach when compared to laparoscopic and open sigmoidectomy for diverticular disease that included significantly fewer conversions to open (P = .0002), shorter hospital length of stay, fewer postoperative complications—ileus, wound complications, and acute renal failure—and more patients discharged directly to home.

Conclusions:

The robotic-assisted minimally invasive approach to elective sigmoidectomy for diverticular disease results in favorable intra-operative and postoperative outcomes when compared to laparoscopic and open approaches.

Disparities in elective surgery for diverticulitis: Identifying the gap in care

BACKGROUND

Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications.

METHODS

The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models.

RESULTS

Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons.

CONCLUSIONS

Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.

Mediastinal, retroperitoneal, and subcutaneous emphysema due to sigmoid colon penetration: A case report and literature review

INTRODUCTION

Mediastinal and subcutaneous emphysema usually result from spontaneous rupture of the alveolar wall. We present an extremely rare case of massive mediastinal, retroperitoneal, and subcutaneous emphysema due to the penetration of the colon into the mesentery.

PRESENTATION OF CASE

A 57-year-old man presented to our institution with a history of chest pain. The patient's medical history included malignant rheumatoid arthritis during the use of steroids and an immunosuppressive agent. The patient had no signs of peritoneal irritation or abdominal pain. A chest radiography revealed subcutaneous emphysema of the neck, mediastinal emphysema, as well as subdiaphragmatic free air. Computed tomography showed extensive retroperitoneal, mediastinal, and mesenteric emphysema of the sigmoid colon without pneumothorax. Diagnostic laparoscopy was performed and revealed perforation into the sigmoid mesentery. Segmental resection of the sigmoid colon and end-colostomy were performed. The diverticulum was communicating with the outside of the mesentery via the mesentery. The mediastinal emphysema disappeared a few days after the surgery.

DISCUSSION

Colonic perforation generally results in free perforation. Colonic gas may spread via various anatomical pathways when perforation of the colon occurs in the retroperitoneum; thus, diverse atypical clinical symptoms may be present. Signs of peritoneal irritation can be hidden in cases of retroperitoneal colonic perforation. The atypical manifestation of a retroperitoneal colonic perforation can cause difficulties in making a diagnosis.

CONCLUSIONS

Massive mediastinal and retroperitoneum emphysema are rare signs of colonic perforation. Emergency laparotomy should be considered in colonic penetration of the diverticulitis where the emphysema expands to the mediastinum extensively.

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

BACKGROUND

Diverticulitis can lead to localized or generalized peritonitis and consequently induce abdominal adhesion formation. If adhesions would lead to abdominal complaints, it might be expected that these would be more prominent after operation for perforated diverticulitis with peritonitis than after elective sigmoid resection.

AIMS

The primary outcome of the study was the incidence of abdominal complaints in the long-term after acute and elective surgery for diverticulitis.

METHODS

During the period 2003 through 2009, 269 patients were operated for diverticular disease. Two hundred eight of them were invited to fill out a questionnaire composed of the gastrointestinal quality of life index and additional questions and finally 109 were suitable for analysis with a mean follow-up of 7.5 years.

RESULTS

Analysis did not reveal any significant differences in the incidence of abdominal complaints or other parameters.

CONCLUSION

This retrospective study on patients after operation for diverticulitis shows that in the long term, the severity of the abdominal complaints is influenced neither by the stage of the disease nor by the fact of whether it was performed in an acute or elective setting.

An analysis of unplanned return to the operating room following deceased donor kidney transplantation

INTRODUCTION

This study was undertaken to characterize unplanned return to the OR following kidney transplantation(KT).

METHODS

All patients undergoing KT at a single center from 1/2015 through 11/2017 were evaluated. The primary endpoint was unplanned return to the OR within 90 days. Perioperative and one year patient and graft outcomes were also determined.

RESULTS

Of 190 patients, 14(7.4%) of patients had unplanned reoperation. The most common individual indications were bleeding from biopsy sites(n = 2), poor vascular flow on postop ultrasound(n = 4), and perforated diverticulitis(n = 2). Forty Three percent of all reoperations were unrelated to the technical conduct of the transplant operation. Reoperated patients had significantly worse survival at one year(78.6% vs. 96.6%), although graft function in survivors was similar to those who did not return to the OR.

CONCLUSION

Reoperation following KT is frequently unrelated to the technical conduct of the transplant procedure, thus it may not be useful as a quality metric.

Successful Conservative Management of Hepatic Portal Venous Gas due to Anastomosis Leakage After a Sigmoidectomy

In past decades, hepatic portal venous gas (HPVG) has rarely been reported, and the mortality rate has been very high. In most cases, surgical intervention was needed. Presently, abdominal computed tomography can be conveniently used to diagnose HPVG, which has various underlying causes and benign courses. We present the case of a patient with HPVG due to anastomosis leakage after a sigmoidectomy for diverticulitis; the patient was cured with conservative management.

Laparoscopic sigmoid colectomy and splenectomy for diverticulitis and splenic sarcoidosis

Splenectomy together with colectomy is most commonly performed as a result of iatrogenic injury and not as an additional elective procedure. A 50-year-old African American female presented with recurrent episodes of diverticulitis. She had mediastinal, and porta hepatis lymphadenopathy and subcutaneous nodules, but multiple biopsies were unable to establish the diagnosis. On computed tomography scan, innumerable hypodense splenic lesions were noted. The patient underwent combined laparoscopic sigmoid colectomy and splenectomy. First, the severely inflamed sigmoid colon was mobilised followed by descending colon and splenic flexure. The spleen, which showed multiple granulomas, was dissected out and the hilum secured with a stapler. The rectum was now stapled, the Pfannenstiel incision was reopened, the spleen was removed in a retrieval bag and the colon was pulled out. The colorectal anastomosis was created with an end-to-end anastomotic (circular) stapler. Pathology demonstrated multiple non-caseating granulomas indicative for sarcoidosis and acute/chronic diverticulitis. The patient developed a superficial surgical site infection but no other complications. Prednisone and methotrexate were started and her sarcoidosis improved. She was well at her 2 years of follow-up. Only few patients have an indication for elective splenectomy together with segmental colectomy. The procedure can be safely performed using a laparoscopic approach.

Conservative Treatment in Diverticulitis Patients with Pericolic Extraluminal Air and the Role of Antibiotic Treatment

BACKGROUND

Recently published studies advocate a conservative approach with observation and antibiotic treatment in diverticulitis patients with pericolic air on computed tomography (CT). The primary aim of this study was to assess the clinical course of initially conservatively treated diverticulitis patients with isolated pericolic air and to identify risk factors for conservative treatment failure. The secondary aim was to assess the outcome of non-antibiotic treatment.

METHODS

Patient data from a retrospective cohort study on risk factors for complicated diverticulitis were combined with data from the DIABOLO trial, a randomised controlled trial comparing non-antibiotic with antibiotic treatment in patients with uncomplicated diverticulitis. The present study identified all patients with Hinchey 1A diverticulitis with isolated pericolic air on CT. Pericolic air was defined as air located < 5 cm from the affected segment of colon. The primary outcome was failure of conservative management which was defined as need for percutaneous abscess drainage or emergency surgery within 30 days after presentation. A multivariable logistic regression of clinical, radiological and laboratorial parameters with respect to treatment failure was performed.

RESULTS

A total of 109 patients were included in the study. Fifty-two (48%) patients were treated with antibiotics. Nine (8%) patients failed conservative management, seven (13%) in the antibiotic treatment group and two (4%) in the non-antibiotic group (p = 0.083). Only (increased) CRP level at presentation was an independent predictor for treatment failure.

CONCLUSIONS

Conservative treatment in diverticulitis patients with isolated pericolic air is a suitable treatment strategy. Moreover, non-antibiotic treatment might be reasonable in selected patients.

Perforated cecal diverticulitis with CT diagnosis and medical management

Acute diverticulitis is a painful condition of the gastrointestinal tract that results from sudden inflammation of one or more diverticula in the bowel wall. Right-sided acute diverticulitis, such as cecal diverticulitis, is uncommon diagnosis that can be easily misdiagnosed as acute appendicitis as it shares similar clinical presentation. An unusual complication of right-sided acute diverticulitis such as perforated cecal diverticulitis has different management from acute appendicitis. Thus, definitive diagnosis of this clinical condition with imaging is crucial to optimal management. We report a case of 43-year-old man who presented to the Emergency Department with acute onset severe right lower quadrant abdominal pain associated with anorexia, fever, and nausea. Computed tomography scans obtained showed findings consistent with perforated diverticulitis limited to the cecum, and normal caliber appendix. Conservative medical treatment was decided based on localized imaging findings with excellent outcome.

The Natural History of Colonic Diverticulosis: Much Ado about Nothing?

BACKGROUND

Colonic diverticulosis is the most common incidental lesion found on routine colonoscopy. However, its true natural history is unclear. The aim of this review is to examine the epidemiology of colonic diverticulosis and the incidence of complications, namely acute diverticulitis and diverticular hemorrhage.

SUMMARY

Many studies have evaluated the epidemiology and risk factors of diverticulosis. Despite the common nature of this entity, little is known about the risk of complications in asymptomatic individuals. It has been suggested that the lifetime risk of acute diverticulitis is 10-25% and that of diverticular hemorrhage is 3-5%. These risk estimates were based on older literature without accurate studies on true prevalence. Three recent retrospective observational cohort studies including subjects identified at colonoscopy have addressed this issue, providing information on the long-term risk of complications of colonic diverticulosis. Cumulative data from these studies support an incidence of acute diverticulitis of 1.5-6.0 per 1,000 patient-years and 0.46 per 1,000 patient-years for diverticular hemorrhage.

KEY MESSAGES

Diverticulosis is a very common condition in individuals > 50 years of age. Based on population-based colonoscopy studies, the natural history of colonic diverticulosis appears favorable with a far lower incidence of complications than previously thought.

Risk Factors for Recurrence of Right Colonic Diverticulitis

BACKGROUND

Right colonic diverticulitis (RCD) is more common in Asian countries than in Western countries, and the risk factors for recurrence of RCD are not fully understood. The objective of this study was to assess the risk factors for recurrence of RCD.

METHODS

We analyzed 296 patients admitted for treatment of RCD in the Gachon University Gil Medical Center from December 2001 to October 2014. Gender, age, BMI, obesity, hypertension, diabetes mellitus, alcohol consumption, smoking, Hinchey classification, and hospital stay were investigated as risk factors for recurrence.

RESULTS

Of the 296 patients with RCD, 31 patients recurred after conservative treatment. The median time interval between the initial episode and recurrence of diverticulitis was 10.4 months. In the univariate analysis, a high recurrence rate was observed in patients with a history of alcohol consumption, smoking, and long hospital stay. In the multivariate analysis, the recurrence rate was much higher (p < 0.001) in patients who stayed in the hospital for more than 10 days after the first attack. Smoking also elevated the recurrence rate (p = 0.011).

CONCLUSION

Factors associated with recurrence of RCD may include smoking and the long hospital stay due to complexity when first diverticulitis occurs. Further prospective large-scale studies are needed to draw a definite conclusion.

Risk of colorectal cancer in patients with diverticular disease

Colorectal cancer constitutes an important burden on the healthcare system. Screening at-risk populations to reduce colorectal cancer-related morbidity and mortality has become part of good clinical practice. However, recommendations regarding subgroups of patients with diverticular disease are subject to controversy.

Herein, we review the most recent literature regarding the prevalence of colorectal cancer in patients with diverticular disease, diverticulitis and uncomplicated diverticulitis.

The recent literature does not identify diverticular disease as a long-term risk factor for colorectal cancer. However, the risk of colorectal cancer is increased in the short-term period after hospitalization related to diverticular disease. According to a recent systematic review and meta-analysis, the prevalence of colorectal cancer is 1.6% in patients with acute diverticulitis who underwent colonoscopy. The risk of having colorectal cancer after an episode of acute diverticulitis is 44-fold higher than that of an age- and gender-adjusted reference population. Despite lower among patients with uncomplicated episode, the risk of colorectal cancer remains 40-fold higher in that subpopulation than that in the reference population.

To conclude, the recent literature describes an increased risk of colorectal cancer among patients with acute diverticulitis compared to the reference population. Colonoscopy is therefore recommended in patients with diverticulitis to exclude colorectal cancer.

Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced

The use of point-of-care ultrasound (POCUS) by non-radiologists has dramatically increased. POCUS is completely different from the routine radiological studies. POCUS is a Physiological, On spot, extension of the Clinical examination, that is Unique, and Safe. This review aims to lay the basic principles of using POCUS in diagnosing intestinal pathologies so as to encourage acute care physicians to learn and master this important tool. It will be a useful primer for clinicians who want to introduce POCUS into their clinical practice. It will cover the basic physics, technical aspects, and simple applications including detection of free fluid, free intraperitoneal air, and bowel obstruction followed by specific POCUS findings of the most common intestinal pathologies encountered by acute care physicians including acute appendicitis, epiploic appendagitis, acute diverticulitis, pseudomembranous colitis, intestinal tuberculosis, Crohn’s disease, and colonic tumours. Deep understanding of the basic physics of ultrasound and its artefacts is the first step in mastering POCUS. This helps reaching an accurate POCUS diagnosis and avoiding its pitfalls. With increased skills, detailed and accurate POCUS findings of specific intestinal pathologies can be achieved and properly correlated with the clinical picture. We have personally experienced and enjoyed this approach to a stage that an ultrasound machine is always accompanying us in our clinical on calls and rounds.

Surgery After an Initial Episode of Uncomplicated Diverticulitis: Does Time to Resection Matter?

BACKGROUND

The aim of this study was to determine whether time to surgery after an initial episode of uncomplicated diverticulitis is associated with undergoing an emergent versus an elective resection.

METHODS

In this retrospective, administrative claims database study, we identified patients at least 18 y old in the 2005-2011 California State Inpatient Database who had an initial episode of uncomplicated diverticulitis and then underwent a bowel resection within 2 y. After characterizing the distribution in time to surgery among all patients, we used a multivariable logistic regression to determine whether time to surgery was associated with undergoing an emergent resection. Next, we assessed differences in three outcomes between elective and emergent resections: at least one of eight postoperative complications, extended length of stay (defined as the top decile of hospitalizations), and 30-d inpatient readmissions. Analyses adjusted for time between initial hospitalization and resection, number of inpatient hospitalizations for diverticulitis before the resection, clinical factors, and hospital clustering.

RESULTS

We identified 4478 patients with an initial episode of uncomplicated diverticulitis followed by a bowel resection within the subsequent 2 y. One-fifth (21.1%) underwent an emergent resection. The median time from the initial episode to resection was 3.8 mo (IQR: 2.3-8.1 mo) for elective resections and 5.1 mo (IQR: 2.3-12.4 mo) for emergent resections. The adjusted odds of undergoing an emergent relative to an elective resection increased by 7% (aOR 1.07 [1.02-1.11]) for every 3 passing mo. Emergent resections were associated with greater adjusted odds of complications (adjusted odds ratio [aOR] 1.75 [95%-CI 1.43-2.15]), extended LOS (aOR 4.52 [3.31-6.17]), and 30-d readmissions (aOR 1.49 [1.09-2.04]).

CONCLUSIONS

Among patients who experienced an initial episode of uncomplicated diverticulitis and eventually underwent a resection, the odds of having an emergent relative to elective surgery increased with every 3 passing mo. These findings may inform the management of uncomplicated diverticulitis for high-risk patients eventually needing surgery.

Risk factors including the presence of inflammation at the resection margins for colorectal anastomotic stenosis following surgery for diverticular disease

AIM

The aim of this study was to investigate risk factors for anastomotic stenosis in patients operated on for diverticular disease. Histological inflammation and diverticula at the resection margins were also considered.

METHOD

Patients' characteristics, the surgical technique and postoperative complications were collected from the medical records. Anastomotic stenoses were evaluated prospectively by rigid sigmoidoscopy during follow-up examination. Histological specimens were examined by a single pathologist who investigated inflammation and diverticula at the resection margins. Twenty patients with anastomotic colorectal stenosis from a single tertiary centre were compared with 24 consecutive patients without stenosis. They were all operated on for diverticular disease over a specified time period.

RESULTS

Histological inflammation and diverticula were found in 25% and 30% of the resection margins respectively. Univariate analysis showed that age > 71 years (P = 0.0002), female gender (P = 0.0069) and anastomoses located below 12 cm from the anal verge (P = 0.020) were risk factors for stenosis. No correlation was found between anastomotic stenosis and the presence of histological inflammation or diverticula at the resection margins. By multivariate analysis, only age > 71 years was found to be a statistically significant risk factor for stenosis (P = 0.0003, OR = 60.8, 95% CI: 6.4-575.5).

CONCLUSION

Anastomotic stenosis is a frequent, long-term complication following surgery for diverticular disease. An analysis demonstrated that age is a risk factor for colorectal stenosis and that histological inflammation and the presence of diverticula near/at the resection margins have no effect on the incidence of stenosis.

Medical hypothesis: speculating on the pathogenesis of acute diverticulitis

The pathogenetic process of acute diverticulitis remains speculative. According to the most widely accepted theory, the mechanism involved is “traumatic” damage to the mucosa due to fecolith impaction, as occurs in large diverticula. However, not uncommonly, diverticulitis develops in young patients with only few and small diverticula, where fecolith trapping is very unlikely. Therefore, another theory is necessary to clarify this process. A possible explanation could be “ischemic” damage. According to this theory, an ischemic lesion is caused by the compression of vascular structures in the neck of the diverticular task, as a result of prolonged and/or recurrent contractile spikes related to neuromuscular alterations in the diverticular tract. Clearly, the “traumatic” and “ischemic” mechanisms of acute diverticulitis are not mutually exclusive, and may act in different patients. The existing data corroborating these theories are presented and different potential therapeutic approaches are briefly discussed.

Diverticular Disease: An Update on Pathogenesis and Management

Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review.

Suprapubic single-port approach for complicated diverticulitis

BACKGROUND

Laparoscopic sigmoidectomy is the gold standard for elective surgical treatment of diverticulitis. A periumbilical single-port technique reduces the size of the access wound, usually to 3-4 cm. However, in the presence of large phlegmon or fistulae, the risk of conversion is higher and the extraction site might be enlarged. A suprapubic Pfannenstiel incision reduces the risk of incisional hernia compared to umbilical access and might provide the possibility to perform sigmoidectomy with a hybrid technique. The aim of the present study was to investigate the feasibility of laparoscopic sigmoidectomy through a single suprapubic transverse access for large diverticular phlegmon.

METHODS

Consecutive patients with a diverticular inflammatory mass ≥ 5 cm, with or without sigmoid-vesical fistula, were considered candidates for laparoscopic sigmoidectomy through a 5-cm single-port suprapubic (SPSP) access, extended (if required) to match the size of the inflammatory mass.

RESULTS

Twenty patients underwent SPSP sigmoidectomy at our institution in April 2014-April 2017. All procedures were completed by SPSP access, with no intraoperative complications or need for additional trocar placement. Eight patients had a sigmoid-vesical fistula (bladder sutured in three patients). The splenic flexure was mobilized in nine patients. Median operative time was 178 min and median hospital stay was 5.5 days (iqr 4-6). Postoperative complications occurred in four patients and included one subcutaneous hematoma, one urinary tract infection, and two superficial wound infections. After a median follow-up time of 25 months (interquartile range 15-38), all patients experienced complete resolution of symptoms, with no incisional hernias reported.

CONCLUSIONS

SPSP sigmoidectomy for diverticulitis is feasible and effective, minimizing the size of the access wound and avoiding increased risk of hernia. This approach might be especially valuable for the management of large diverticular phlegmon and sigmoid-vesical fistula.

Intraoperative air leak test reduces the rate of postoperative anastomotic leak: analysis of 777 laparoscopic left-sided colon resections

BACKGROUND

The evidence supporting the use of the air leak test (ALT) after laparoscopic left-sided colon resection (LLCR) to test the colorectal anastomosis (CA) integrity aiming at reducing the rate of postoperative CA leakage (CAL) is not conclusive. The aim of this study was to challenge the use of ALT after elective LLCR.

METHODS

It is a retrospective analysis of a prospectively collected database including all patients undergoing elective LLCR with primary CA and no proximal bowel diversion between January 1996 and June 2017. The decision to perform the ALT was based on the individual surgeon routine practice. A multivariate analysis was performed to identify independent risk factors for CAL.

RESULTS

A total of 777 LLCR without proximal diversion were included in the analysis: the CA was tested in 398 patients (ALT group), while intraoperative ALT was not performed in 379 patients (No-ALT group). The two groups were similar in demographic characteristics, indication, and type of procedure. Intraoperative ALT was positive in 20 (5%) patients: a stoma was created in 14 (70%) patients, while 6 (30%) patients had a suture repair alone. Overall, postoperative CAL occurred in 32 patients (4.1%): the postoperative CAL rate was lower in ALT patients (2.5% vs. 5.8%, p = 0.025). A reoperation was needed in 87.5% of cases. No CAL occurred in the 20 patients with intraoperative positive ALT. Multivariate analysis showed that ASA score 3-4 (OR 5.39, 95% CI 2.53-11.51, p < 0.001) and male sex (OR 3.96, 95% CI 1.66-9.43, p = 0.002) were independent risk factors for postoperative CAL, while intraoperative ALT independently reduced the postoperative CAL rate (OR 0.40, 95% CI 0.18-0.88, p = 0.022).

CONCLUSION

Intraoperative ALT allows to detect AL defects after LLCR that can be effectively managed intraoperatively, leading to a significant lower risk of postoperative CAL.

Primary classic Hodgkin lymphoma of the ileum and Epstein-Barr virus mucocutaneous ulcer of the colon: two entities compared

Primary classic Hodgkin lymphoma of the gastrointestinal tract represents a rare occurrence. A full patient's work-up is essential in order to exclude a secondary intestinal involvement. Histologically Epstein-Barr virus mucocutaneous ulcer closely resembles Hodgkin lymphoma. The differential diagnosis between these two entities is relevant, since both the therapeutic approach and the clinical behavior are different. Herein, we describe a case of primary classic Hodgkin lymphoma arising in the ileum and a case of Epstein-Barr virus mucocutaneous ulcer of the colon, focusing on the main clinicopathological differences.

An outcome analysis of laparoscopic management of diverticulitis

BACKGROUND

All operative procedures for simple or complicated diverticulitis, including primary resection and anastomosis (PRA) with or without a diverting stoma, Hartmann procedure (HP), or stoma reversal, whether done in an elective setting or as an emergency, can be performed laparoscopically. However, owing to low incidence of the disease and complexity of the procedure, there are very few studies on outcomes of laparoscopic surgery for sigmoid diverticulitis from India.

AIM

The present study was undertaken to evaluate outcomes of laparoscopically treated patients of sigmoid diverticulitis.

METHODS

Prospective observational study enrolled 37 patients with sigmoid diverticulitis managed laparoscopically from March 2015 to March 2017. Demographic, clinical, operative, postoperative, and complication data were entered into a patient proforma and analyzed.

RESULTS

Eleven simple and 26 complicated diverticulitis patients were operated laparoscopically, 22 in emergency setting and 15 in elective setting. Only three patients required conversion to open surgery-two due to dense adhesions and one due to chronic obstructive pulmonary disease (COPD). No patients had ureteric or bowel injury. Eighteen patients underwent laparoscopic PRA without stoma, 11 patients had PRA with stoma, 6 had HP, and 2 had laparoscopic lavage. Results showed lesser blood loss, shorter hospital stay, and fewer complications in the elective group and simple diverticulitis patients. None of the patients had anastomosis-related complications. Two patients had stoma-related complications.

CONCLUSION

Laparoscopic management of diverticulitis is feasible, safe, provides the benefits of less wound-related complications, and shorter hospital stay and should be the surgical procedure of choice in elective or emergency setting for simple/complicated diverticulitis.

Diverticulitis of the transverse colon manifesting as colocutaneous fistula

The transverse colon is a particularly rare site for a diverticulum to develop, with only few reports of solitary diverticula described in the literature. Among the reported complications, colocutaneous fistulas appear relatively infrequently. We describe the case of an 80-year-old woman with a solitary diverticulum of the transverse colon presenting as acute diverticulitis with abscess formation in the epigastric region. A fistulous tract was found between the inflamed colon and the skin. A wedge resection of the inflamed colon together with the fistula and the solitary diverticulum was performed followed by primary suturing of the healthy colonic tissue. Despite the sufficient treatment and thorough clearance of the area, the patient died ten days later from ventilator associated pneumonia. Although rare, in patients presenting with a subcutaneous abscess in the abdominal region, there should be a high level of suspicion for active intraperitoneal inflammation derived from complicated diverticular disease given the continuously elevated prevalence of the condition in Western societies. The decision regarding proper management of this clinical state should be based on thorough clinical examination and imaging.