Laparoscopic surgery for fistulas that complicate diverticular disease

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.

Retrospective study on the feasibility and safety of laparoscopic surgery for complicated fistulizing diverticular disease in a high-volume colorectal center

BACKGROUND

We assessed feasibility and safety of laparoscopic sigmoidectomy for complicated fistulizing diverticular disease in a tertiary care colorectal center.

METHODS

A single-center retrospective study of patients undergoing sigmoidectomy for fistulizing diverticular disease between 2011 and 2021 was realized. Primary outcomes were rates of conversion to open surgery and severe postoperative morbidity at 30 days. Secondary outcomes included rates of postoperative bladder leaks on cystogram.

RESULTS

Among the 104 patients, 32.7% had previous laparotomy. Laparoscopy was the initial approach in 103 (99.0%), with 6 (5.8%) conversions to laparotomy. Clavien-Dindo grade ≥ III complication rate at 30 days was 10.6%, including two (1.9%) anastomotic leaks. The median postoperative length of stay was 4.0 days. Seven (6.7%) patients underwent reoperation, six (5.8%) were readmitted, and one (0.9%) died within 30 days. Twelve (11.5%) ileostomies were created initially, and two (1.9%) were created following anastomotic leaks. At last follow-up, 101 (97.1%) patients were stoma-free. Urgent surgeries had a higher rate of severe postoperative complications. Among colovesical fistula patients (n = 73), postoperative cystograms were performed in 56.2%, identifying two out of the three bladder leaks detected on closed suction drains. No differences in postoperative outcomes occurred between groups with and without postoperative cystograms, including Foley catheter removal within seven days (73.2% vs. 90.6%, p = 0.08).

CONCLUSIONS

Laparoscopic surgery for complicated fistulizing diverticulitis showed low rates of severe complications, conversions to open surgery and permanent stomas in high-volume colorectal center.

Colouterine fistula relating to diverticulitis: a rare clinical entity

Colouterine fistula is a rare but recognizable complication of diverticulitis. This case illustrates the presence of a colouterine fistula in an elderly patient who had an atypical presentation for diverticulitis. She was initially treated with intravenous antibiotics for diverticulitis with a contained abscess. This gave her an opportunity to avoid surgery. However, her sepsis failed to respond to the initial treatment. Progress computerized tomography imaging demonstrated the presence of a colouterine fistula for which she required source control. Thus she underwent laparotomy, Hartmann's procedure, and total abdominal hysterectomy with bilateral salpingo-oophorectomy. The diagnosis of colouterine fistula was confirmed intraoperatively and on histopathology. Subsequently, the patient had an uneventful recovery following the operation. This case highlights the rarity but also the veracity of this clinical entity.

Short Term Outcomes of Open and Minimally Invasive Approaches to Segmental Colectomy for Benign Colovesical Fistula

Background. We speculated that a minimally invasive (MIS) colectomy for colovesical fistula is associated with less morbidity compared to an open colectomy. Methods. Multivariate analysis using logistic regression was used to investigate the outcomes of patients who underwent colectomy for benign colovesical fistula during 2012–2017 by surgical approach using the NSQIP database. Results. We identified 748 patients underwent partial colectomy for benign colovesical fistula during 2012–2017. Surgeons used the MIS approach in 72.7% of operations, with a conversion rate of 13.1%. The MIS approach was associated with lower morbidity (27.4% vs. 43.1%, AOR: 0.46, $P=0.02$ ) compared to the open approach. The mean operation duration was longer in MIS operations compared to open (225 min vs. 201 min, $P<0.01$ ). The robotic approach to colectomy showed no significant difference in morbidity (28.4% vs. 27.2%, $P=0.77$ ) but a decrease in conversion rate (8.1% vs. 13.8%, $P<0.01$ ) and an increase in operation length (249 min vs. 222 min, mean difference: 27 min, $P<0.01$ ) compared to a laparoscopic approach. There was no significant difference in the anastomotic leak rate between MIS and open approaches (3.7% vs. 5.4%, $P=0.14$ ) and between laparoscopic and robotic approaches (2.8% vs. 3.8%, $P=0.99$ ). Conclusions. We found a 72.7% utilization rate of MIS approach to colectomy for benign colovesical fistula in the NSQIP hospitals with a 13.6% conversion rate. Patients with MIS approach had significantly lower morbidity compared to open. A robotic approach to partial colectomy has the same morbidity risk with a decreased conversion rate compared to laparoscopic approach.

Burden of Colovesical Fistula and Changing Treatment Pathways: A Systematic Literature Review

PURPOSE

Colovesical fistula (CVF) is a rare complication of sigmoid diverticulitis causing significant morbidity and quality of life impairment. Aim of this study was to analyze contemporary literature data to appraise the current standard of care and changes of treatment algorithms over time.

MATERIALS AND METHODS

A systematic review of the literature on surgical management of CVF was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines.

RESULTS

Fourteen papers published between 2014 and 2020 and including 1061 patients were analyzed. One-stage colonic resection with primary anastomosis, with or without loop ileostomy, was the most common surgical procedure. A laparoscopic or robotic approach was attempted in 39.5% of patients, and conversion rate to open surgery was 7.8%. Clavien-Dindo grade ≥3 complication rate, 30-day mortality, and recurrence rate were 7.4%, 1.5%, and 0.5%, respectively.

CONCLUSIONS

Minimally invasive sigmoidectomy with primary anastomosis is safe and should be the first-choice approach for CVF. Bladder repair is not necessary after a negative intraoperative leak test. A standardized perioperative care can improve clinical outcomes and reduce the length of hospital stay and the duration of Foley catheterization.

Colovesical Fistulae: The Varying Aetiologies

The most common presenting symptoms of colovesical fistulae (CVF) are pneumaturia and fecaluria. The most important aspect remains not only to investigate the aetiology, and the degree of both severity and complexity, but also the subsequent influence of this on overall management. In a younger population, management usually consists of curative surgery. However, this may not be possible in older patients where surgical candidacy is a genuine concern and a clinical challenge arises relating to pursuing a conservative strategy. We attempted to briefly outline how two patients were managed with a similar non-surgical approach due to frailty. These cases attempt to highlight the importance of multi-disciplinary specialty input, with a view to optimising patient care.

Indications and outcomes of enterovesical and colovesical fistulas: systematic review of the literature and meta-analysis of prevalence

BACKGROUND

Entero-colovesical fistula is a rare complication of various benign and malignant diseases. The diagnosis is prominently based on clinical symptoms; imaging studies are necessary not only to confirm the presence of the fistula, but more importantly to demonstrate the extent and the nature of the fistula. There is still a lack of consensus regarding the if, when and how to repair the fistula. The aim of the study is to review the different surgical treatment options, focus on surgical indications, and explore cumulative recurrence, morbidity, and mortality rates of entero-vesical and colo-vesical fistula patients.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. Random effects meta-analyses of proportions were developed to assess primary and secondary endpoints. I2 statistic and Cochran's Q test were computed to assess inter-studies' heterogeneity.

RESULTS

Twenty-two studies were included in the analysis with a total of 861 patients. Meta-analyses of proportions pointed out 5, 22.2, and 4.9% rates for recurrence, complications, and mortality respectively. A single-stage procedure was performed in 75.5% of the cases, whereas a multi-stage operation in 15.5% of patients. Palliative surgery was performed in 6.2% of the cases. In 2.3% of the cases, the surgical procedure was not specified. Simple and advanced repair of the bladder was performed in 84.3% and 15.6% of the cases respectively.

CONCLUSIONS

Although burdened by a non-negligible rate of complications, surgical repair of entero-colovesical fistula leads to excellent results in terms of primary healing. Our review offers opportunities for significant further research in this field. Level of Evidence Level III according to ELIS (SR/MA with up to two negative criteria).

The colovescical fistula in diverticular disease: Laparoscopic approach in two different cases

INTRODUCTION

The colovescical fistula is one of the complications of diverticular disease. It can cause significant symptoms like pneumaturia and fecaluria affecting the quality of life and sometimes leading to death, usually secondary to sepsis. We describe two cases of colovescical fistula treated by laparoscopic approach in patients with diagnosis of complicated acute diverticulitis.

CASE REPORT

We studied two patients with clinical, radiological and endoscopic diagnosis of colovescical fistula as a consequence of diverticular disease. We performed a totally laparoscopic treatment with colonic resection and colo-proctoanastomosis after the closure of the fistula with intracorporeal sutures.

DISCUSSION

Colovescical fistula should be suspected in patients who present fever with persistent dysuria, pneumaturia or fecaluria. The diagnosis is confirmed by a CT abdominal scan, a colonoscopy in order to rule out a colon cancer and a cystoscopy to assess the grade of bladder involvement.

CONCLUSION

Although colovescical fistulas caused by diverticular disease were once considered a contraindication to laparoscopic resection, nowadays they are increasingly treated by experienced surgeons using laparoscopic techniques. Compared with laparoscopic surgery for uncomplicated diverticulitis the mini-invasive treatment of colovescical fistulas requires a longer operative time and advanced surgical skills.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure

The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.

Over 1-Year Followup of Laparoscopic Treatment of Enterovesical Fistula

Background and Objective:

Entero vesical fistulas (EVFs) are an uncommon complication mainly of diverticular disease (70%) and less commonly of Crohn's disease (10%). Only about 10% are caused by malignancies. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with EVF. The aim of this study was to assess the feasibility and safety of laparoscopic surgery in the treatment of EVFs in patients with complicated diverticular and Crohn's disease.

Methods:

All patients with the diagnosis of EVF who underwent laparoscopic surgery were identified from prospective collected data based in two institutions between 2007 and 2017. Patients with malignancy were excluded. Recorded parameters included operative time, conversion to open surgery, the presence of a protective loop ileostomy, perioperative complications, number of units of blood transfused, postoperative course, and histologic findings.

Results:

Seventeen patients were included in the study: 10 patients with a colo-vesical fistula due to diverticular disease, and 7 patients with an ileo-vesical fistula due to Crohn's disease. There were no conversions to open surgery and none of the patients needed a protective ileostomy. The bladder was sutured in 12 patients (70%). No intra-operative complications were met, and no blood transfusions were needed; there were no anastomotic leaks, nor mortality in both groups.

Conclusions:

The laparoscopic approach for benign EVF in selected patients is both feasible and safe in the hands of experienced surgeons with extensive expertise in laparoscopic surgery.

Short-term Outcomes of Laparoscopic Versus Open Treatment of Internal Enteric Fistulae: A Logistic Regression Analysis

Although laparoscopy improves outcomes for common general surgical procedures, its role in complex colorectal procedures is not clearly defined. We sought to evaluate whether laparoscopy retains its short-term benefits when used for treatment of complex intra-abdominal fistulae. A retrospective analysis was conducted including patients undergoing surgeries for enteric fistulas over a 7-year period. The χ tests, the Fisher exact tests, and Student t tests were used. Logistic regression models were used to assess the relationship between outcome and predictors. A total of 74 patients (31 open, 43 laparoscopic) were included. There was no difference in age, sex, body mass index, and comorbidities between the 2 groups. The laparoscopic group had significantly shorter length of stay, estimated blood loss, and significantly lower incidence of major complications compared with open group. Our findings suggest that laparoscopy is safe and retains its short-term benefits for treatment of complex colorectal and small bowel procedures.

The present status and developments of laparoscopic surgery for colorectal cancer

Laparoscopic surgery for colorectal cancer has been shown to be less invasive than open surgery, while maintaining a similar safety level in many clinical trials. Furthermore, there are no significant differences between laparoscopic surgery and open surgery with respect to the long-term outcomes in colon cancer. Thus, laparoscopic surgery has been accepted as one of the standard treatments for colon cancer. In addition, laparoscopic surgery has also achieved favorable outcomes in the treatments of rectal cancer, with many reports showing long-term outcomes comparable to those of open surgery. Furthermore, the magnification in laparoscopy improves visualization in the pelvic cavity and facilitates precise manipulation, as well as providing an excellent educational opportunity. Laparoscopic surgery may be an ideal approach for the treatment of rectal cancer and colon cancer. Recently, two trials showed that, among patients with advanced rectal cancer, the use of laparoscopic surgery as compared with open surgery confirmed to meet the criterion for non-inferiority for long-term outcomes. In addition, new techniques such as single-port and robotic surgery have been introduced for laparoscopic surgery in recent years.

Diverticular colovesical fistula: What should we really be doing?

BACKGROUND

Colovesical fistula secondary to diverticular disease is increasing in incidence. Presentation and severity may differ, but a common management strategy may be applied. The aim of this study is to evaluate the characteristics and perioperative management of patients with colovesical fistulae and determine optimal management.

METHODS

From 2003 to 2012, all charts of surgical patients with diverticular colovesical fistulae at two different institutions were reviewed. Patient and presentation characteristics and perioperative management and outcomes were recorded. Patient groups with early and late catheter removal (< 8 and ≥ 8 days) were compared with significance level set at p < 0.05.

RESULTS

Seventy-eight patient charts were reviewed. The mean duration of symptoms was 7.5 months. Laparoscopic assisted surgery was carried out in 35% of patients. Complex bladder repair was performed in 27%. Mean length of stay was 8 days. Mean urinary catheter duration was 13 days. Seventy percent of patients underwent postoperative cystogram, with 4% positive for extravasation. Patients with early catheter removal were significantly older, more likely to have received intraoperative methylene blue instillation, and less likely to have had a complex bladder repair (p < 0.05). Complication rate, length of stay, postoperative cystography, and stent use were similar for both catheter removal groups.

CONCLUSIONS

Intraoperative methylene blue bladder instillation should be utilized to limit unnecessary bladder repairs. In the setting of negative methylene blue extravasation, surgeons may confidently remove urinary catheters in 7 days or less, in some cases as early as 48 h. In complex bladder repairs, cystogram is still an important adjunct, with those patients with negative studies benefiting from catheter removal at 7 days or less.

Laparoscopic Management of Colonic Diverticular Disease and its Complications: an Analysis

Dense inflammatory reactions, loss of tissue planes and sepsis make surgical treatment of diverticulitis complex and difficult. Experience with laparoscopic management of this disease is scanty in our country. This study aims to assess the pattern of presentation, the site of involvement and complications of diverticulitis coli. This study also aims to audit the results of laparoscopic approach for complicated colonic diverticulitis. A retrospective analysis of all patients who had laparoscopic management of complicated diverticulitis patients from August 2007 to October 2014 was done from the database. The site of involvement, extent and presence or absence of complications of diverticular disease was noted. The surgical approach, intraoperative parameters and short-term outcome measures were analysed. There were 38 (8.8 %) patients with diverticular disease out of 427 patients who had laparoscopic colorectal surgery in the study period with a median age of 59 years. Out of 38 patients, 50 % had comorbid conditions. Internal fistulae were seen in 9 (23.6 %) patients, 6 with colovesical and 3 with colovaginal fistulae. Elective laparoscopic colectomy with primary anastomosis was done in 34 (89 %) cases of which, and 10 (26 %) patients had abscess on presentation requiring drainage. Four patients required emergency laparoscopic surgery of which primary resection and anastomosis was done in 3 (7.8 %), and Hartmann's operation was done in 1 (2.6 %) patient. Two patients required stoma. The morbidity was seen in 15 % cases, and the mean hospital stay was 9.54 days. Laparoscopic approach for diverticular disease and its complication is feasible and safe. Careful selection of patients, judicious use of diverting stoma and appropriate selection of the procedure help to achieve good results even in those with septic complications and fistulising disease.

Colovesical Fistula Complicating Diverticular Disease: A 14-Year Experience

OBJECTIVE

Colovesical fistulas (CVF) constitute the most common type of spontaneously occurring fistulas associated with diverticular disease. One-stage laparoscopic resection has been shown to be feasible, but studies comparing this approach to open surgery are scarce. The aim of this study was to compare the clinical outcomes of open and laparoscopic surgery for CVF of diverticular origin.

MATERIALS AND METHODS

From January 2000 to July 2014, 37 colectomies were performed for diverticular disease-related CVF. Twenty-eight patients who underwent resection and primary anastomosis were divided in 2 groups: the laparoscopic surgery group (group A) and the open surgery group (group B). We have analyzed the following parameters: operative time, complication rate, hospital stay, recurrence, and early mortality rate.

RESULTS

Groups A and B were comparable in terms of age, sex, diverticulitis episodes, previous abdominal surgery, and body mass index.The mean duration of surgery was significantly shorter in group B: 175 versus 237 minutes (P=0.011). There was a faster recovery of gastrointestinal transit in group A (2 vs. 13; P=0, 0002). However, there were no significant differences between the groups with respect to serious postoperative morbidity [(Clavien-Dindo scores of 3, 4, and 5) 4 vs. 0; P=0.098)] and with respect to hospital stay (10.5 vs. 9.5 d; P=0.537). There was no recurrence during a median follow-up of 12 months.

CONCLUSIONS

Laparoscopic resection and primary anastomosis should be considered a safe and feasible option for the management of diverticular CVF. Despite progresses in minimally invasive colorectal surgery, the conversion rate and morbidity are still high.

Evaluating surgical management and outcomes of colovaginal fistulas

BACKGROUND

Colovaginal fistula is a rare condition associated with significant morbidity. The literature characterizing colovaginal fistula repair is sparse. We present our institution's experience treating colovaginal fistulas.

METHODS

A retrospective review of all patients surgically treated for colovaginal fistula between 2005 and 2015 was performed. Patient demographics, intra-operative details, and post-operative outcomes were reviewed.

RESULTS

We identified 27 patients with a mean age of 71 (±13) and BMI of 30 (±9). The most common etiology for fistula was diverticulitis (n = 24, 89%). A laparoscopic approach was initiated in 19 patients (70%) and an open approach for 8 (30%) with 8 patients converted from laparoscopy to open (42%). At a mean follow-up of 18 months (±21), there were no recurrences.

CONCLUSION

We present one of the largest series of the surgical management of colovaginal fistulas. Although our conversion rate was high, we recommend a laparoscopic approach be utilized when feasible.

Present laparoscopic surgery for colorectal cancer in Japan

In many clinical studies, laparoscopic surgery (LS) for colon cancer has been shown to be less invasive than open surgery (OS) while maintaining similar safety. Furthermore, there are no significant differences between LS and OS in long-term outcomes. Thus, LS has been accepted as one of the standard treatments for colon cancer. In the treatments of rectal cancer as well, LS has achieved favorable outcomes, with many reports showing long-term outcomes comparable to those of OS. Furthermore, the magnification in laparoscopy improves visualization in the pelvic cavity and facilitates precise manipulation, as well as providing excellent educational effects. For these reasons, rectal cancer has seemed to be well indicated for LS, as has been colon cancer. The indication for LS in the treatment of locally advanced rectal cancer, which is relatively unresectable (e.g., cancer invading other organs), remains an open issue. In recent years, new techniques such as single-port and robotic surgery have begun to be introduced for LS. Presently, various clinical studies in our country as well as in most Western countries have demonstrated that LS, with these new techniques, are gradually showing long-term outcomes.

Laparoscopic surgery of benign entero-vesical or entero-vaginal fistulae

PURPOSE

Entero-vesical or entero-vaginal fistulae (EVF) are an uncommon septic complication mainly of diverticular disease. The fistulae are usually situated within extensive and dense inflammatory masses occluding the entrance of the pelvis. There are still some controversies regarding laparoscopic feasibility and treatment modalities of this disorder.

METHODS

A retrospective chart review of all patients with EVF operated at our department since 2008. Patients were identified by use of the computerized hospital information system.

RESULTS

In nineteen patients (ten males), median age 68 years, 13 patients had entero-vesical fistulae, and 6 patients had entero-vaginal fistulae. The fistulae were caused by complicated diverticular disease in 16 patients (84 %), Crohn's disease (two patients), and ulcerative colitis (one patient). All cases were attempted laparoscopically. Operative treatment involved separation of the inflammatory mass and resection of the affected colorectal segment. There were three conversions (16 %), all three requiring bladder repair considered too extensive for laparoscopic means. In two further patients small bladder defects were sutured laparoscopically, the remaining patients required no bladder repair. The inferior mesentric artery (IMA) was preserved in all cases. Median operative time was 180 min. Two patients received a protective ileostomy: one converted patient and one cachectic patient with Crohn's disease under immune-modulating therapy. Both ileostomies were closed. Altogether, there were five complications in five patients (26 %), four of them were minor (Clavien grade I and II). The cachectic patient with Crohn's disease suffered a major (grade IIIb) complication (stoma prolapse, treated by early closure of the ileostomy). There was no anastomotic leakage and no mortality. Median hospital stay was 12 days.

CONCLUSIONS

The laparoscopic approach is a safe option for the treatment of EVF of benign inflammatory origin. In most cases it offers all the advantages pertaining to minimally invasive surgery. For a definite and causal approach, the disorder belongs primarily within the therapeutic domain of the visceral surgeon. Following the separation of the inflammatory colon, most of the bladder lesions caused by EVF will heal without further surgical measures.

Is laparoscopic surgery the best treatment in fistulas complicating diverticular disease of the sigmoid colon? A systematic review

INTRODUCTION

Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open surgery. Aim of this review is to assess the possible advantages deriving from a laparoscopic approach in the treatment of diverticular fistulas of the colon.

METHODS

Studies presenting at least 10 adult patients who underwent laparoscopic surgery for sigmoid diverticular fistula were reviewed. Fistula recurrence, reintervention, Hartmann's procedure or proximal diversion, conversion to laparotomy were the outcomes considered.

RESULTS

11 non randomized studies were included. Rates of fistula recurrence (0.8%), early reintervention (30 days) (2%) and need for Hartmann's procedure or proximal diversion (1.4%) did not show significant difference between laparoscopy and open technique.

DISCUSSION

there is still concern about which surgery in complicated diverticulitis should be preferred. Laparoscopic approach has led to less postoperative pain, shorter hospital stay, faster recovery and better cosmetic results. Laparoscopic resection and primary anastomosis is a possible approach to sigmoid fistulas but its advantages in terms of lower mortality rate and postoperative stay after colon resection with primary anastomosis should be interpreted with caution. When there is firm evidence supporting it, it is likely that minimally invasive surgery should become the standard approach for diverticular fistulas, thus achieving adequate exposure and better visualization of the surgical field.

CONCLUSION

The lack of RCTs, the small sample size, the heterogeneity of literature do not allow to draw statistically significant conclusions on the laparoscopic surgery for fistulas despite this approach is considered safe.

Management of diverticular disease

Diverticular disease is a common condition in Western countries and the incidence and prevalence of the disease is increasing. The pathogenetic factors involved include structural changes in the gut that increase with age, a diet low in fibre and rich in meat, changes in intestinal motility, the concept of enteric neuropathy and an underlying genetic background. Current treatment strategies are hampered by insufficient options to stratify patients according to individual risk. One of the main reasons is the lack of an all-encompassing classification system of diverticular disease. In response, the German Society for Gastroenterology and Digestive Diseases (DGVS) has proposed a classification system as part of its new guideline for the diagnosis and management of diverticular disease. The classification system includes five main types of disease: asymptomatic diverticulosis, acute uncomplicated and complicated diverticulitis, as well as chronic diverticular disease and diverticular bleeding. Here, we review prevention and treatment strategies stratified by these five main types of disease, from prevention of the first attack of diverticulitis to the management of chronic complications and diverticular bleeding.

Laparoscopic management of diverticular colovesical fistula: experience in 15 cases and review of the literature

Colovesical fistulas secondary to diverticular disease may be considered a contraindication to the laparoscopic approach. The feasibility of laparoscopic management of complicated diverticulitis and mixed diverticular fistulas has been demonstrated. However, few studies on the laparoscopic management of diverticular colovesical fistulas exist. A retrospective analysis was performed of 15 patients with diverticular colovesical fistula, who underwent laparoscopic-assisted anterior resection and bladder repair. Median operating time was 135 minutes and median blood loss, 75 mL. Five patients were converted to an open procedure (33.3%) with an associated increase in hospital stay (P = 0.035). Median time to return of bowel function was 2 days and median length of stay, 6 days. Overall morbidity was 20% with no major complications. There was no mortality. There was no recurrence during median follow-up of 12.4 months. These results suggest that laparoscopic management of diverticular colovesical fistulas is both feasible and safe in the setting of appropriate surgical expertise.

Hand-assisted laparoscopic colectomy for colovesical fistula associated with diverticular disease

To evaluate the feasibility and short-term outcome of hand-assisted laparoscopic colectomy (HALC) for the treatment of colovesical fistula complicating diverticulitis, we reviewed the files of all 34 patients who underwent surgery for diverticular colovesical fistula in 1999 to 2010 at a major tertiary medical center. Twenty-one were treated with HALC and 13 with open colectomy. There were no differences in demographic parameters among the groups. HALC and open colectomy had similar operating time. HALC was associated with a significantly shorter hospital stay compared with open colectomy (5 vs. 8 d, P=0.001). HALC proved to be technically feasible and safe in this setting. It provided benefits of tactile feedback and manual manipulation as in open colectomy while maintaining the advantages of a minimal invasive approach.

Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review

Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the Cochrane Consumers and Communication Review Group's template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches.

Outcome of colonic fistula surgery in the modern surgical era

BACKGROUND

Various conditions lead to the development of colonic fistulas. Contemporary surgical data is scarce and it is unclear whether advances in surgical care have impacted outcome. The aim of the present study was to review the short- and long-term outcome of patients treated surgically for colonic fistula over an 8-year period at a tertiary institution.

METHODS

A retrospective review was performed, focusing on the type of operative interventions, short- and long-term complications, length of hospital stay, readmission rate, mortality rate, and fistula recurrence.

RESULTS

Forty-five patients were treated for colonic fistula. The most common etiology was diverticulitis (74%). Fistula type was colovesical (58%), colocutaneous (18%) and colovaginal (15%). Laparoscopic resection was performed in 42% of cases. An intraoperative complication occurred in 4%. A primary anastomosis was performed in 96% of patients and 10 (23%) had a temporary stoma. Median length of hospital stay was 6 days. Postoperative complications were common (47%) and wound infection was noted in 20% of patients. The readmission rate was 29% and the 90-day mortality was 4%. All patients healed their fistula with no recurrences noted during a median follow-up of 37 months.

CONCLUSIONS

Surgical intervention healed the majority of patients with colonic fistula. However postoperative complications were common and readmission occurred in one-third of the cases. Laparoscopic excision was feasible in nearly half of the patients.

[Laparoscopic repair of enterovesical fistula in patient affected by left megaureter]

INTRODUCTION

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. We present the case of EVF secondary to diverticular disease in a male with congenital megaureter. A laparoscopic repair of the colon vesical fistula was performed with colon resection.

MATERIALS AND METHODS

With the patient in the Trendelenburg position -30° degrees on the right side, 5 trocars are positioned trans-peritoneally. The exploration of the abdominal cavity shows the sigmoid diverticular disease adhering tenaciously to the posterior wall of the bladder. The intestinal loops are medialized. The inferior mesenteric vein is isolated, clipped and divided. The mesosigma is isolated and the inferior mesenteric artery is closed 2 cm from its emergence from the aorta with EndoGIA™ 45 stapler. The left colon is isolated from its splenic flexure to the mesorectum. The peritoneum between the bladder and sigmoid colon at the site of the tenacious adhesions is incised. The left megaureter is isolated from the diverticular disease and the bladder is opened on the site of the fistula, to permit a wide resection of the fistula. The posterior wall of the bladder is then closed with double running sutures. Section of the rectum with EndoGIA™ 45 stapler. Extraction of 20 cm of sigma comprising diverticular disease by a 5 cm suprapubic laparotomy. The sigma is cut and the proximal head of the circular stapler is inserted and closed with a running suture. The left colon is put back in place into the peritoneal cavity. The laparotomy is closed and the surgery is reconverted into laparoscopy. A colorectal end-to-end anastomosis according to Knight Griffen is performed with ILS 29 circular stapler. The anastomosis is tested for leakage with hydropneumatic test: no evidence of spillage. A laminar drainage is placed close to the anastomosis and the incisions are closed.

RESULTS

The operative time was 240 minutes. There were no intra- or post-operative complications. The bladder catheter was removed on day 7 after cystography. The patient was discharged asymptomatic on the 8th post-operative day.

CONCLUSIONS

Laparoscopic treatment of enterovesical fistulas for benign disease is a safe and standardized procedure. It remains a difficult procedure with a conversion rate higher than laparoscopy for uncomplicated diverticulitis or malignancy. The procedure in a single session with intracorporeal bowel anastomosis is the standard.

Laparoscopic conservative surgery of colovesical fistula: is it the right way?

Enterovesical fistula is a rare disease. The standard treatment of colovesical fistula is removal of the fistula, suture of the bladder wall, and colic resection with or without temporary colostomy. The usual approach is open because the laparoscopic one has high conversion rates and morbidity. We report the first laparoscopic conservative treatment of colovesical fistula in our knowledge and its long-term results. A 69-year-old man was affected by colovesical fistula due to endoscopic exeresis of a 2 cm adenomatous polyp in the sigmoid diverticulum. We performed a laparoscopic conservative treatment of the fistula without colic resection. Operative time was 210 min and estimated blood loss was 300 ml. The catheter was removed after 10 days. Time to first flatus was 2 days and the hospital stay was 8 days. No peri- or post-operative complications occurred. At 48-month follow-up fistula did not recur. Laparoscopic conservative surgery for colovesical fistula is safe and feasible. It could be a therapeutic option in selected cases, especially if diverticular disease and inflammation are slight.

Outcome of surgery for colovesical and colovaginal fistulas of diverticular origin in 40 patients

INTRODUCTION

According to literature, colonic resection with a primary anastomosis and no defunctioning ileostomy is a safe treatment for colovesical or colovaginal fistula of diverticular origin. This study investigates the outcome of surgery for this patient group in a regional hospital.

METHODS

Patients were obtained from a prospective database in the period 2004-2011. Several variables were investigated for their relation with surgical outcome.

RESULTS

A colovesical (n = 35) or colovaginal (n = 5) fistula was diagnosed in 18 men and 22 women. The mean age was 69 years (range, 45-90). A rectosigmoid resection with primary anastomosis was performed in 32 patients. Fourteen patients received a defunctioning ileostomy. Eight patients were treated with a Hartmann procedure. Overall 30-day treatment-related morbidity and mortality was 48 and 8 %, respectively. Major morbidity, because of anastomotic leakage, was mainly observed in the primary anastomosis group without a defunctioning ileostomy. Morbidity and mortality were associated with high body mass index, diabetes, use of corticosteroids, and American Society of Anesthesiologists classification, though not significantly.

CONCLUSIONS

One should be liberal in the use of a defunctioning ileostomy in case of a primary anastomosis after colonic resection for a diverticular fistula, in order to prevent high morbidity rates due to anastomotic leakage.

Management and Outcomes of Colovesical Fistula Repair

This large retrospective study presents the largest colovesical fistula (CVF) series to date. We report on recurrence risk factors and patient satisfaction based on quality of life after CVF repair. Approval was obtained from The Mount Sinai School of Medicine Institutional Review Board, and a retrospective review was performed from 2003 to 2010 involving 72 consecutive patients who underwent a colovesical fistula repair. The CVF recurrence rate was 11 per cent. Ten percent of our patients who had a history of radiation therapy were at a significantly higher risk of developing a recurrence. Noted recurrence rates were significantly higher in advanced bladder repairs compared with simple repair ( P = 0.022). The modified (Gastrointestinal Quality of Life Index) surveys showed overall patient satisfaction score was 3.6, out of a maximum score of 4, regardless of the type of repair or any postoperative complications. Our study found the CVF recurrence rate to be 11 per cent. Patients at higher risk of recurrence include those needing advanced bladder repair, those with “complex” CVF, and those whose fistulas involve the urethra. Patient satisfaction was found to be more closely linked to the resolution of CVF symptoms, irrespective of the type of repair performed or development of postoperative complications.

Current management of diverticular disease complications

Diverticular disease is a common problem in the western population and sometimes leads to serious complications such as hemorrhage, bowel stenosis, obstruction, abscesses, fistulae, bowel perforation, and peritonitis. The severity of these complications can differ, and it is not always clear which procedure is indicated in each case and what measures should be followed before bringing the patient into the operating room. Certain operations have high rates of morbidity and mortality, especially in compromised patients. Along with advancements in imaging and minimally invasive techniques, the indications for surgery have currently being adapted to "damage limitation" or "down-staging" protocols, which seem to offer improved results. There are still some questions to be solved in the following years by prospective studies, such as the usefulness of laparoscopic lavage in purulent peritonitis or of Hartmann's procedure in fecal peritonitis. These indications, based on current literature, are systematically discussed in the present review.

Enterovesical fistulas: diagnosis and management

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.

Laparoscopic sigmoid resections for diverticulitis complicated by abscesses or fistulas

BACKGROUND AND AIMS

Treatment of choice in recurrent and complicated diverticulitis is surgical resection of the inflamed bowel. Whereas it is accepted that recurrent diverticulitis (RD) can be handled laparoscopically, this is still not generally recommended for complicated diverticulitis (CD). Therefore, we analysed our results of laparoscopic sigmoidectomies concerning intraoperative course, conversion rate, morbidity and hospital stay in RD and CD.

MATERIALS AND METHODS

Between 09/2002 and 01/2006, laparoscopic sigmoidectomies were offered to all patients suffering from recurrent or complicated diverticulitis (Hinchey I+II). All resections were performed in a four-port technique with the use of Ultracision and intraabdominal stapler anastomosis. Data were prospectively collected and retrospectively analysed in an intention-to-treat view.

RESULTS

Out of 127 laparoscopic colectomies, 58 were performed for diverticulitis (RD 32; CD 26). Eight patients with colovesical and one patient with colovaginal fistula are included. Three patients with abscesses underwent pretreatment by percutaneous drainage. Operative time was longer in CD than in RD (205+/-41 vs 147+/-34 min; p<0.001) and associated with higher blood loss, but conversion rate was low (RD, 2/32 vs CD, 3/26; p=0.64). There was one intraoperative complication in each group; postoperative major complications occurred in 3.13% (RD) vs 11.5% (CD; p=0.316). One anastomotic leakage occurred in the RD group. Length of hospital stay was shorter for RD than for CD (7.1+/-3.4 vs 10.7+/-6.4 days; p=0.02).

CONCLUSIONS

Laparoscopic resections should not be limited to recurrent diverticular disease but can be safely applied for complicated diverticulitis.

The impact of uncomplicated and complicated diverticulitis on laparoscopic surgery conversion rates and patient outcomes

BACKGROUND

The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease.

METHODS

Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture.

RESULTS

The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70).

CONCLUSIONS

A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure.

What is a meant when a laparoscopic surgical procedure is described as “safe”?

BACKGROUND

The literature on laparoscopic surgery contains many studies concluding that a procedure is "safe." This study aimed to review systematically articles from the past 10 years that judged a laparoscopic technique for colon resection and anastomosis to be "safe."

METHODS

The authors searched the Medline database from January 1995 to August 2005 using the search terms "laparoscopic," "colon," and "safe," selecting studies of laparoscopic colon resection or laparoscopic techniques of colonic anastomosis. They calculated exact 95% confidence intervals around estimates of the risk for death reported in the studies to determine the upper limit of the possible risk for death in a study reporting no deaths.

RESULTS

Of 135 studies matching the search criteria, 41 (30%) described operations involving laparoscopic colonic resection or anastomosis. These studies enrolled a mean number of 233 subjects. There were 26 retrospective studies, 12 prospective studies, 2 randomized control trials, and 1 case report. The estimated upper 95% confidence limits for studies reporting mortality ranged from 1.66% to 97.5%. Of the studies that reported mortality and concluded that laparoscopic colon surgery is "safe," 77.8% could not exclude a mortality rate higher than 5%.

CONCLUSION

Many studies concluding that laparoscopic colon surgery is "safe" could not exclude a high risk of operative mortality. The term "safe" is not a useful descriptor of the relative safety of laparoscopic surgical procedures, and statements about the safety of a surgical procedure should be justified with precise estimates and confidence intervals of the risk for adverse events.

Laparoscopic sigmoid colectomy for diverticular disease

Laparoscopic management of sigmoid diverticular disease has emerged as an important adjunct to the armamentarium of surgical options for this disease process. Although there are no prospective randomized studies directly comparing laparoscopic and open colectomy for diverticulitis, the comparative studies provide compelling data. The magnitude of benefits achieved with laparoscopic colectomy in the hands of experienced laparoscopic colon surgeons may soon be sufficient to make laparoscopic colectomy the standard of care.

Laparoscopic colectomy for diverticulitis is not associated with increased morbidity when compared with non-diverticular disease

BACKGROUND AND AIMS

It was the aim of this prospective study to compare the outcome of laparoscopic sigmoid and anterior resection for diverticulitis and non-diverticular disease.

PATIENTS AND METHODS

All patients who underwent laparoscopic colectomy for benign and malignant disease within a 10-year period were entered into the prospective PC database registry. For outcome analysis, patients who underwent laparoscopic sigmoid and anterior resection for diverticular disease were compared with patients who underwent the same operation for non-inflammatory (non-diverticular) disease. The parameters analyzed included age, gender, co-morbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion, morbidity including major (requiring reoperation), minor (conservative treatment) and late-onset (postdischarge) complications, stay in the ICU, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t-test and chi-square analysis (p<0.05 was considered statistically significant).

RESULTS

A total of 676 patients were evaluated including 363 with diverticular disease and 313 with non-inflammatory disease. There were no significant differences in conversion rates (6.6 vs. 7.3%, p>0.05), so that the laparoscopic completion rate was 93.4% (n=339) in the diverticulitis group and 92.7% (n=290) in the non-diverticulitis group. The two groups did not differ significantly in age or presence of co-morbid conditions (p>0.05). In the diverticulitis group, recurrent diverticulitis (58.4%), and complicated diverticulitis (27.7%) were the most common indications, whereas in the non-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%) were the main indications. The most common procedure was laparoscopic sigmoid resection, followed by sigmoid resection with rectopexy and anterior resection. No significant differences were documented for major complications (7.4 vs. 7.9%), minor complications (11.5 vs. 14.5%), late-onset complications (3.0 vs. 3.5), reoperation (8.6 vs. 9.3%) or mortality (0.6 vs. 0.7%) between the two groups (p>0.05). In the postoperative course, no differences were noted in terms of stay in the ICU, postoperative ileus, parenteral analgesics, oral feeding, and length of hospitalization (p>0.05).

CONCLUSION

These data indicate that laparoscopic sigmoid and anterior resection can be performed with acceptable morbidity and mortality for both diverticular disease and non-diverticular disease. The results show in particular that laparoscopic resection for inflammation is not associated with increased morbidity.

Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases

BACKGROUND

Laparoscopic surgery has been applied to the management of various colorectal conditions, with shorter recovery periods than reported for open surgery. This study reviewed the feasibility and outcome of laparoscopic surgery for benign internal enteric fistulas.

METHODS

All the patients undergoing laparoscopic surgery for colovesical, colovaginal, enterovesical, and enterocolic fistulas caused by diverticulitis or Crohn's disease from 1995 to 2003 were identified from the prospective laparoscopic surgery database and retrospectively analyzed. Crohn's ileo-ileal fistulas were excluded from the study because these are generally resected more simply en bloc with the terminal ileum.

RESULTS

This study enrolled 43 patients (23 men and 20 women) with median age of 43 years, a mean body mass index of 24.5, and in American Society of Anesthesiology (ASA) distribution of 3/33/8/0 (class 1/2/3/4). The diagnosis was diverticular for 24 patients and Crohn's disease for 19 patients. The mean operative time was 163 +/- 80 min (155 in completed and 180 in converted cases), and the mean length of hospital stay was 5.2 +/- 4.7 days (3.9 in completed and 7.9 days in converted cases). A total of 14 patients (32.6%) required conversion for dense adhesions (n = 8), duodenal involvement (n = 3), multiple fistulae (n = 1), fecal leak (n = 1), and additional pathology (n = 1). Conversion rates, analyzed by fistula type, were duodenal (100%), vaginal (66.7%), sigmoid (27.7%), bladder (15.4%), enterocolic (0%), and colocolic (0%). There were six major complications (14%) including anastomotic leak (n = 3), abscesses (n = 2), and postoperative bleeding (n = 1). There were seven minor complications (16.3%) including postoperative ileus (n = 2), transient pleural effusion (n = 1), wound infection (n = 1), transient small bowel obstruction (n = 2), and brachial plexus neuralgia (n = 1). There was no significant difference in the complication (p = 0.57), reoperation (p = 0.3), or readmission (p = 0.4) rates between the completed and converted cases.

CONCLUSIONS

Laparoscopic surgery for benign internal enteric fistula offers the earlier recovery seen with other laparoscopic colorectal operations. Duodenal and vaginal involvement by the fistula is associated with a higher conversion rate. A low threshold toward early conversion is useful in these difficult cases to reduce delays in the operating room and the unnecessary use of hospital resources.

Laparoscopic management of diverticular disease

Laparoscopy surgery has achieved wide acceptance for the treatment of benign disease of the colon. A review of the literature regarding the indications, surgical technique, and outcomes of laparoscopic surgery for diverticular disease is presented.

Diverticulitis: when and how to operate?

Diverticular disease, and particularly diverticulitis, has increasing incidence in industrialised countries. Diverticular disease can be classified as symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease. Conservative or medical management is usually indicated for acute uncomplicated diverticulitis. Indications for surgery include recurrent attacks and complications of the disease. Surgical treatment options have changed considerably over the years along with the inventions of new diagnostic tools and new surgical therapeutic approaches. Indications and timing for surgery of diverticular disease are determined mainly by the stage of the disease. In addition to this major factor, the individual risk factors of the patient along with the course of the disease after conservative or operative therapy do play a big role in decision-making and treatment of this disease. In this context, the purpose of this article is to review the surgical treatment of diverticulitis with regard to indications, timeliness of operative intervention, operative options and techniques, and special circumstances.