Anastomotic leak in patients with acute complicated diverticulitis undergoing primary anastomosis: risk factors and the role of diverting loop ileostomy

Diverticular disease complicated by colovesical and colovaginal fistulas: not so complex robotically

INTRODUCTION

Fistulizing diverticulitis occurs in only 2% of diverticular disease cases, but its symptoms, such as urinary tract infections (UTI), pneumaturia, fecaluria, or vaginal discharge, are highly disruptive to patients. Therefore, surgery is commonly recommended. Laparoscopy has been proven feasible and safe for fistulizing diverticulitis, although revealing a conversion rate of 36%. Robotic surgery might reduce the conversion rate due to advanced instrumentation and improved optics.

METHODS

All consecutive patients diagnosed with diverticulitis complicated by a colovesical or/and colovaginal fistula who underwent robotic surgical resection at Mayo Clinic Rochester (January 2018-June 2024) were included. Exclusion criteria were concurrent Crohn's disease, colorectal cancer, isolated coloovarian fistula, and less than one month of follow-up.

RESULTS

Eighty-nine patients were included in the study: fifty-eight (65%) patients presented with a colovesical fistula, 26 (29%) patients with a colovaginal fistula, and 5 (6%) patients with both. Ureteral ICG was utilized in 44% of cases. There were no intraoperative complications and one conversion secondary to loss of planes. Fourteen (16%) and 8 (9%) received an end colostomy or a loop ileostomy, respectively. Overall, 30-days complications were 35%, with anastomotic leak and abscess occurring in 3% and 6% of cases, respectively. One patient experienced a postoperative bladder leak, managed with a Foley catheter for 14 days, leaving no sequelae. With a median follow-up of 16.5 months, one (1%) fistula recurred after 14 days.

CONCLUSIONS

Robotic surgery for fistulizing diverticulitis is feasible, with an acceptable complication rate and extremely low conversion and recurrence rates.

Stenosis of the colorectal anastomosis after surgery for diverticulitis: A national retrospective cohort study

AIM

The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis.

METHOD

This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage.

RESULTS

Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted.

CONCLUSION

AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.

Outcome of early versus late ileostomy closure in patients with rectal cancers undergoing low anterior resection: A prospective cohort study

BACKGROUND

Protective loop ileostomy is performed following low anterior resection (LAR) in patients with rectal cancer to reduce the complications of primary anastomosis. The optimal timing for ileostomy closure remains controversial. The aim of the current study was to compare the effects of early (<2 weeks) versus late (≥2 months) closure of the stoma in patients with rectal cancer undergoing LAR on surgical outcome and complications rates.

METHODS

This prospective cohort study was conducted in two referral centers in Shiraz, Iran, during a 2-year period. We have consecutively and prospectively included adult patients with rectal adenocarcinoma who underwent LAR followed by protective loop ileostomy in our center during the study period. The baseline, tumor characteristics and complication as well as outcome was recorded in a 1-year follow-up and was compared between early and late ileostomy closure.

RESULTS

Overall, 69 patients (32 in early and 37 in late group) were included. The mean age of the patients was 59.40 ± 9.30 years and there were 46 (66.7%) men and 23 (33.3%) women. Patients undergoing early closure of the ileostomy had significantly shorter operation duration (p<0.001) and lower intraoperative bleeding (p<0.001) compared to late ileostomy closure. There was no significant difference between two study groups regarding the complications. Early closure was also not found to be a predictive factor of post-ileostomy closure complications.

CONCLUSION

Early closure (<2 weeks) of ileostomy after LAR in patients with rectal adenocarcinoma is a safe and feasible technique which is associated with favorable outcome.

Smoking Cessation for Preoperative Optimization

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Operative management of anastomotic leak after sigmoid colectomy for left-sided diverticular disease: Ileostomy creation may be as safe as colostomy creation

AIM

The management of anastomotic leak after sigmoid colectomy for diverticular disease has not been well defined. Specifically, there is a lack of literature on optimal types of reoperations for leaks. The aim of this study was to describe and compare reoperative approaches and their postoperative outcomes.

METHODS

We performed a retrospective cohort study using the NSQIP Colectomy Module (2012-2019) and single-institution chart review. Patients with diverticular disease who underwent elective sigmoid colectomy were included. Primary outcomes were anastomotic leak requiring reoperation and management of anastomotic leak.

RESULTS

Of 37,471 patients who underwent sigmoid colectomy for diverticular disease, 1003 (2.7%) suffered an anastomotic leak, of whom 583 underwent reoperation. Of the 572 patients who were not initially diverted and underwent reoperation for leak, 302 (52.8%) were managed with stoma creation - 200 (35.0%) with colostomy and 102 (17.8%) with ileostomy. The remaining 47.2% underwent colectomy with reanastomosis, suturing of large bowel, and drainage. There were no differences in length of stay, readmission, or mortality between patients who underwent ileostomy or colostomy at reoperation (p > 0.05). Single-institution analysis demonstrated that 100% of patients with ileostomies underwent subsequent ileostomy closure, compared to 60% of patients with colostomies.

CONCLUSIONS

In patients who suffer anastomotic leaks after sigmoid colectomy for diverticular disease and undergo reoperations, ileostomy at the time of reoperation appears to be safe, with comparable results to colostomy. Ileostomies were more frequently closed than colostomies. When faced with a colorectal anastomotic leak, ileostomy creation may be considered.