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Rizzuto A, Andreuccetti J, Bracale U, Silvestri V, Pontecorvi E, Reggio S, Sagnelli C, Peltrini R, Amaddeo A, Bozzarello C, Pignata G, Cuccurullo D, Corcione F. Shifting paradigms: a pivotal study on laparoscopic resection for colovesical fistulas in diverticular disease. Front Surg 2024; 11:1370370. [PMID: 38496209 PMCID: PMC10940422 DOI: 10.3389/fsurg.2024.1370370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
Background Colovesical fistulas (CVFs) pose a challenge in diverticulitis, affecting 4% to 20% of sigmoid colon cases. Complicated diverticular disease contributes significantly, accounting for 60%-70% of all CVFs. Existing studies on laparoscopic CVF management lack clarity on its effectiveness in diverticular cases compared to open surgery. This study redefines paradigms by assessing the potentiality, adequacy, and utility of laparoscopy in treating CVFs due to complicated diverticular disease, marking a paradigm shift in surgical approaches. Methods Conducting a retrospective analysis at Ospedale Monaldi A.O.R.N dei Colli and University Federico II, Naples, Italy, patients undergoing surgery for CVF secondary to diverticular disease between 2010 and 2020 were examined. Comprehensive data, including demographics, clinical parameters, preoperative diagnoses, operative and postoperative details, and histopathological examination, were meticulously recorded. Patients were classified into open surgery (Group A) and laparoscopy (Group B). Statistical analysis used IBM SPSS Statistic 19.0. Results From January 2010 to December 2020, 76 patients underwent surgery for colovesical fistula secondary to diverticular disease. Laparoscopic surgery (Group B, n = 40) and open surgery (Group A, n = 36) showed no statistically significant differences in operative time, bladder suture, or associated procedures. Laparoscopy demonstrated advantages, including lower intraoperative blood loss, reduced postoperative primary ileus, and a significantly shorter length of stay. Postoperative morbidity differed significantly between groups. Mortality occurred in Group A but was unrelated to surgical complications. No reoperations were observed. Two-year follow-up revealed no fistula recurrence. Conclusion This pivotal study marks a paradigm shift by emphasizing laparoscopic resection and primary anastomosis as a safe and feasible option for managing CVF secondary to diverticular disease. Comparable conversion, morbidity, and mortality rates to the open approach underscore the transformative potential of these findings. The study's emphasis on patient selection and surgeon experience challenges existing paradigms, offering a progressive shift toward minimally invasive solutions.
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Affiliation(s)
- Antonia Rizzuto
- Department of Medical and Surgical Science, University of Magna Graecia, Catanzaro, Italy
| | | | - Umberto Bracale
- Department of Medicine, University of Salerno, Fisciano, Italy
| | - Vania Silvestri
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Emanuele Pontecorvi
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Stefano Reggio
- Department of General, Laparoscopic and Robotic Surgery, Monaldi Hospital, Naples, Italy
| | - Carlo Sagnelli
- Department of General, Laparoscopic and Robotic Surgery, Monaldi Hospital, Naples, Italy
| | - Roberto Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Angela Amaddeo
- Department of Medical and Surgical Science, University of Magna Graecia, Catanzaro, Italy
| | - Cristina Bozzarello
- Department of Medical and Surgical Science, University of Magna Graecia, Catanzaro, Italy
| | - Giusto Pignata
- Department of General Surgery, Civil Hospital of Brescia, Brescia, Italy
| | - Diego Cuccurullo
- Department of General, Laparoscopic and Robotic Surgery, Monaldi Hospital, Naples, Italy
| | - Francesco Corcione
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Trejo-Avila M, Vergara-Fernández O. Open versus laparoscopic surgery for the treatment of diverticular colovesical fistulas: A systematic review and meta-analysis. ANZ J Surg 2021; 91:E570-E577. [PMID: 34056819 DOI: 10.1111/ans.16985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to analyze the evidence regarding open versus laparoscopic surgery for the treatment of diverticular colovesical fistula (CVF) in terms of perioperative outcomes. METHODS A systematic review was performed using PubMed, Cochrane, Google Scholar, and Web of Science databases for studies comparing laparoscopic versus open surgery for CVF. We pooled odds ratios (OR) and mean differences (MD) using random or fixed effects models. RESULTS Five non-randomized studies with 227 patients met the inclusion criteria. All were retrospective studies, published between 2014 and 2020. For laparoscopic surgery, the pooled rate for conversion to laparotomy was 36%. Laparoscopic and open procedures required similar operative time (MD: -11.62; 95% confidence interval [CI]: -51.41 to 28.16). No difference was found in terms of stoma rates between laparoscopic and open surgery (OR: 1.12; 95% CI 0.44-2.86). Overall, the rate of total postoperative complications was lower in the laparoscopic group (OR: 0.55; 95% CI: 0.30-0.99). The pooled analysis showed equivalent rates of anastomotic leaks (OR: 0.61; 95% CI 0.15-2.45), surgical site infections (OR: 0.44; 95% CI 0.19-1.01), and mortality (OR: 0.18; 95% CI 0.03-1.15). The length of stay was significantly reduced with laparoscopic surgery (MD: -2.89; 95% CI -4.20 to -1.58). CONCLUSION Among patients with CVF, the laparoscopic approach appears to have shorter hospital length of stay, with no differences in anastomotic leaks, surgical site infections, stoma rates, and mortality, when compared with open surgery.
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Affiliation(s)
- Mario Trejo-Avila
- Department of Colon and Rectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Omar Vergara-Fernández
- Department of Colon and Rectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Raman S, Gorvet M, Lange K, Rettenmaier N. Outcomes after CT guided drainage of diverticular abscesses and predictive factors for fistulous communication to the colon. Am J Surg 2020; 222:193-197. [PMID: 33059942 DOI: 10.1016/j.amjsurg.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/22/2020] [Accepted: 10/05/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of the study is to analyze patient outcomes following CT guided drainage of colonic diverticular abscesses and identify the factors associated with development of fistulous communication to the drain. METHODS All patients undergoing CT guided abscess drainage, from 2009 to 2017, were included in this single institutional study. Clinical and demographic variables associated with development of colonic fistula were investigated. RESULTS One-hundred-and-five patients (55% female), mean abscess size and BMI of 6.3 cm and 30.28 kg/m2, respectively, underwent CT guided abscess drainage. Patients with fistula had longer operative times (p = 0.03). On multivariable analysis, females (p = 0.02) and higher BMI (p = 0.01) were protective against, while increasing size (p = 0.01) was predictive of developing fistulous communication to the drain. CONCLUSION More than half of patients developed colonic fistula after CT guided drainage. Male sex, lower BMI and increasing abscess size were predictive of developing colonic fistula.
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Affiliation(s)
- Shankar Raman
- MercyOne Des Moines Medical Center, 1111 6th Ave., Des Moines, IA, 50314, USA.
| | - Marc Gorvet
- MercyOne Des Moines Medical Center, 1111 6th Ave., Des Moines, IA, 50314, USA.
| | - Krystle Lange
- MercyOne Des Moines Medical Center, 1111 6th Ave., Des Moines, IA, 50313, USA.
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Ho MF, Ng DCK, Lee JFY, Ng SSM. Laparoscopic-assisted omental patch repair of colovaginal fistula - a video vignette. Colorectal Dis 2020; 22:1202-1203. [PMID: 32202688 DOI: 10.1111/codi.15048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/04/2020] [Indexed: 02/08/2023]
Affiliation(s)
- M-F Ho
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR.,Department of Surgery, North District Hospital, New Territories East Cluster Hospitals, Hong Kong SAR
| | - D C-K Ng
- Department of Surgery, North District Hospital, New Territories East Cluster Hospitals, Hong Kong SAR
| | - J F-Y Lee
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR
| | - S S-M Ng
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR
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Keady C, Hechtl D, Joyce M. When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement. World J Gastrointest Surg 2020; 12:208-225. [PMID: 32551027 PMCID: PMC7289647 DOI: 10.4240/wjgs.v12.i5.208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/10/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Conor Keady
- Department of Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Daniel Hechtl
- Department of Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Myles Joyce
- Department of Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
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Kitaguchi D, Enomoto T, Ohara Y, Owada Y, Hisakura K, Akashi Y, Takahashi K, Ogawa K, Shimomura O, Oda T. Laparoscopic surgery for diverticular colovesical fistula: single-center experience of 11 cases. BMC Res Notes 2020; 13:177. [PMID: 32209133 PMCID: PMC7092560 DOI: 10.1186/s13104-020-05022-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/16/2020] [Indexed: 12/26/2022] Open
Abstract
Objective Laparoscopic surgery for diverticular colovesical fistula (CVF) is technically challenging, and the incidence of conversion to open surgery (COS) is high. This study aimed to review our experience with laparoscopic surgery for diverticular CVF and identify preoperative risk factors for COS. Results This was a single institution, retrospective, observational study of 11 patients (10 males and 1 female) who underwent laparoscopic sigmoid colon resection with fistula resection for diverticular CVF from 2014 to 2019. Preoperative magnetic resonance imaging (MRI) was performed to evaluate the fistula location in the bladder, patency of the rectovesical pouch (i.e., the destination of dissection procedure between sigmoid colon and bladder) and estimate the contact area between the sigmoid colon and bladder. The relationship between preoperative variables and COS incidence was analyzed between completed laparoscopy and COS groups. The overall incidence of postoperative morbidity (Clavien–Dindo classification Grade II or higher) was 36% (4/11). Severe morbidity, reoperation, and mortality were not observed. The incidence of COS was 27% (3/11). Posterior bladder fistulas were significantly associated with COS. CVFs located on the posterior bladder appears to be a risk factor for COS. Identifying risk factors for COS preoperatively could help guide the intraoperative course.
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Affiliation(s)
- Daichi Kitaguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Katsuji Hisakura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Dolejs SC, Penning AJ, Guzman MJ, Fajardo AD, Holcomb BK, Robb BW, Waters JA. Perioperative Management of Patients with Colovesical Fistula. J Gastrointest Surg 2019; 23:1867-1873. [PMID: 30411309 DOI: 10.1007/s11605-018-4034-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 10/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Colovesical fistula (CVF) is an uncommon complication of diverticulitis. Substantial heterogeneity exists in the perioperative management of this condition. We seek to evaluate the role of bladder leak testing, closed suction drainage, prolonged bladder catheter usage, and routine postoperative cystogram in the management of CVF. STUDY DESIGN This is a retrospective study from a single academic health center investigation patients undergoing operation for diverticular CVF from 2005 to 2015 (n = 89). RESULTS Patients undergoing operative repair for diverticular CVF resection had a mortality of 4% and overall morbidity of 46%. Intraoperative bladder leak test was performed in 36 patients (40%) and demonstrated a leak in 4 patients (11%). No patients with a negative intraoperative bladder leak test developed a urinary leak. Overall, five (6%) patients developed postoperative bladder leak. Three were identified by elevated drain creatinine and two by cystogram. The diagnostic yield of routine cystogram was 3%. All bladder leaks were diagnosed between postoperative day 3 and 7. Of patients with a postoperative bladder leak, none required reoperation and all resolved within 2 months. CONCLUSIONS There is significant variability in the management of patients undergoing operation for CVF. Routine intraoperative bladder leak test should be performed. Cystogram may add cost and is low yield for routine evaluation for bladder leak after operation for CVF. Urinary catheter removal before postoperative day 7 should be considered.
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Affiliation(s)
- Scott C Dolejs
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Alyssa J Penning
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Michael J Guzman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Alyssa D Fajardo
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Bryan K Holcomb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Bruce W Robb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Joshua A Waters
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA. .,, 1801 N. Senate Blvd., Suite 635, Indianapolis, IN, 46202, USA.
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Is suturing of the bladder defect in benign Enterovesical fistula necessary? BMC Surg 2019; 19:85. [PMID: 31286905 PMCID: PMC6615302 DOI: 10.1186/s12893-019-0542-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Enterovesical fistula (EVF) is a abnormal connection between the intestine and the bladder. The aim of the study was to analyze whether closure of the defect in the bladder wall during surgery is always necessary. METHODS Fifty-nine patients with benign EVF undergoing surgical treatment were enrolled. A one-stage surgical procedure was performed in all patients. After the separation of the diseased bowel segment, methylene blue was introduced. Through a catheter into the bladder. Only patients with urinary bladder leakage were sutured. RESULTS The most common intestinal fistula involving the urinary bladder was colovesical fistula, observed in 53% of cases. Two-thirds of patients had diverticular disease as the underlying pathology. There was no relationship between suturing of the bladder and perioperative complications. Recurrent EVF was observed in one patient with bladder suturing and in two patients without suture. CONCLUSIONS These findings suggest that closure of the bladder defect is not necessary in cases where a leak is not demonstrated from the bladder intraoperatively. This study is limited by its retrospective design and small numbers and a randomized controlled trial is recommended to answer this question definitively.
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Laparoscopic Surgery for Diverticular Fistulas: Outcomes of 111 Consecutive Cases at a Single Institution. J Gastrointest Surg 2019; 23:1015-1021. [PMID: 30251070 DOI: 10.1007/s11605-018-3950-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The purpose of this study was to review our experience with laparoscopic colectomy and fistula resection, evaluate the frequency of conversion to open, and to compare the perioperative courses of the complete laparoscopic and conversion groups. METHODS This study is a retrospective analysis of 111 consecutive adult patients with diverticular fistulae diagnosed clinically or radiographically over 11 years at a single institution. Five patients were excluded for preoperative comorbidities. The remaining 106 consecutive patients underwent minimally invasive sigmoid colectomy with primary anastomosis. Preoperative, intraoperative, and postoperative variables were collected from the colorectal surgery service database. A retrospective cohort analysis was performed between laparoscopic and converted groups. RESULTS Within the group, 47% had colovesical fistulas, followed by colovaginal, coloenteric, colocutaneous, and colocolonic fistulas. The overall conversion rate to laparotomy was 34.7% (n = 37). The most common reason for conversion was dense fibrosis. Mean operative time was similar between groups. Combined postoperative complications occurred in 26.4% of patients (21.4% laparoscopic and 37.8% converted, p = 0.075). Length of stay was significantly shorter in the laparoscopic group (5.8 vs 8.1 days, p = 0.014). There were two anastomotic leaks, both in the open group. There were no 30-day mortalities. CONCLUSIONS Laparoscopic sigmoid colectomy for diverticular fistula is safe, with complication rates comparable to open sigmoid resection. We identify a conversion rate which allows the majority of patients to benefit from minimally invasive procedures.
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Nevo Y, Shapiro R, Froylich D, Meron-Eldar S, Zippel D, Nissan A, Hazzan D. Over 1-Year Followup of Laparoscopic Treatment of Enterovesical Fistula. JSLS 2019; 23:JSLS.2018.00095. [PMID: 30740013 PMCID: PMC6364704 DOI: 10.4293/jsls.2018.00095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Yehonatan Nevo
- Department of General Surgery and Oncological Surgery-Surgery C, Sheba Medical Center, Tel Hashomer, Israel
| | - Ron Shapiro
- Department of General Surgery and Oncological Surgery-Surgery C, Sheba Medical Center, Tel Hashomer, Israel
| | - Dvir Froylich
- Department of Surgery B, Carmel Medical Center, Haifa, Israel
| | - Shai Meron-Eldar
- Division of General Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Douglas Zippel
- Department of General Surgery and Oncological Surgery-Surgery C, Sheba Medical Center, Tel Hashomer, Israel
| | - Aviram Nissan
- Department of General Surgery and Oncological Surgery-Surgery C, Sheba Medical Center, Tel Hashomer, Israel
| | - David Hazzan
- Department of General Surgery and Oncological Surgery-Surgery C, Sheba Medical Center, Tel Hashomer, Israel
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Short-term Outcomes of Laparoscopic Versus Open Treatment of Internal Enteric Fistulae: A Logistic Regression Analysis. Surg Laparosc Endosc Percutan Tech 2018; 28:250-255. [PMID: 29975354 DOI: 10.1097/sle.0000000000000557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Colovesical Fistula Complicating Diverticular Disease: A 14-Year Experience. Surg Laparosc Endosc Percutan Tech 2017; 27:94-97. [PMID: 28368961 DOI: 10.1097/sle.0000000000000375] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Laparoscopic approaches to complicated diverticulitis. Langenbecks Arch Surg 2017; 403:11-22. [PMID: 28875302 DOI: 10.1007/s00423-017-1621-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. PURPOSE The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis. CONCLUSIONS New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.
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Risk factors associated with postoperative morbidity in over 500 colovesical fistula patients undergoing colorectal surgery: a retrospective cohort study from ACS-NSQIP database. Int J Colorectal Dis 2017; 32:469-474. [PMID: 27915373 DOI: 10.1007/s00384-016-2721-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate the impact of various factors on 30-day postoperative morbidity in patients who underwent colorectal surgery (CRS) for colovesical fistula (CVF) in the elective and emergency settings. METHODS Patients who underwent CRS for CVF between 2005 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database by using current procedural terminology codes. Demographics, perioperative, and operative factors were assessed and compared between two groups classified according to the presence or absence of postoperative complications. RESULTS Five hundred twelve patients met the inclusion criteria [mean age of 61.4 (±14.7) years, female 214 (42%)]. Etiology of fistula was diverticulitis [N = 438 (85.5%)], colon cancer [N = 39 (7.6%)], and Crohn's disease [N = 35 (6.8%)]. One hundred fifty-two procedures (29.7%) were performed laparoscopically. In 186 patients (36%), no bladder intervention was performed. One hundred forty-nine patients (29.1%) had at least one postoperative complication. Patients who developed complication were older (P = <0.001), more often female (P = <0.001), hypertensive (P = 0.005), anemic (P = <0.001), preoperatively transfused (P = 0.02), and with class 2-3 wound classification (P = 0.01). Independent risk factors affecting morbidity were increased age [odds ratio (OR) 1.23 (1.03-1.47), P = 0.01], decreased hematocrit level [OR 3.04(1.83-5.06), P < 0.0001], and open approach [OR 2.56 (1.35-4.84), P = 0.003]. CONCLUSIONS Morbidity for CVF remains high. Lower preoperative hematocrit level and increased age were associated with higher risk of complication. Laparoscopic surgery may be preferable when possible as morbidity is less with this approach.
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Wen Y, Althans AR, Brady JT, Dosokey EMG, Choi D, Nishtala M, Delaney CP, Steele SR. Evaluating surgical management and outcomes of colovaginal fistulas. Am J Surg 2016; 213:553-557. [PMID: 27889268 DOI: 10.1016/j.amjsurg.2016.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/02/2016] [Accepted: 11/05/2016] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Yuxiang Wen
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Alison R Althans
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Justin T Brady
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Eslam M G Dosokey
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Dongjin Choi
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Madhuri Nishtala
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Conor P Delaney
- Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Scott R Steele
- Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Rotholtz NA, Canelas AG, Bun ME, Laporte M, Sadava EE, Ferrentino N, Guckenheimer SA. Laparoscopic approach in complicated diverticular disease. World J Gastrointest Surg 2016; 8:308-314. [PMID: 27152137 PMCID: PMC4840170 DOI: 10.4240/wjgs.v8.i4.308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/27/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the results of laparoscopic colectomy in complicated diverticular disease.
METHODS: This was a retrospective cohort study conducted at an academic teaching hospital. Data were collected from a database established earlier, which comprise of all patients who underwent laparoscopic colectomy for diverticular disease between 2000 and 2013. The series was divided into two groups that were compared: Patients with complicated disease (abscess, perforation, fistula, or stenosis) (G1) and patients undergoing surgery for recurrent diverticulitis (G2). Recurrent diverticulitis was defined as two or more episodes of diverticulitis regardless of patient age. Data regarding patient demographics, comorbidities, prior abdominal operations, history of acute diverticulitis, classification of acute diverticulitis at index admission and intra and postoperative variables were extracted. Univariate analysis was performed in both groups.
RESULTS: Two hundred and sixty patients were included: 28% (72 patients) belonged to G1 and 72% (188 patients) to G2. The mean age was 57 (27-89) years. The average number of episodes of diverticulitis before surgery was 2.1 (r 0-10); 43 patients had no previous inflammatory pathology. There were significant differences between the two groups with respect to conversion rate and hospital stay (G1 18% vs G2 3.2%, P = 0.001; G1: 4.7 d vs G2 3.3 d, P < 0.001). The anastomotic dehiscence rate was 2.3%, with no statistical difference between the groups (G1 2.7% vs G2 2.1%, P = 0.5). There were no differences in demographic data (body mass index, American Society of Anesthesiology and previous abdominal surgery), operative time and intraoperative and postoperative complications between the groups. The mortality rate was 0.38% (1 patient), represented by a death secondary to septic shock in G2.
CONCLUSION: The results support that the laparoscopic approach in any kind of complicated diverticular disease can be performed with low morbidity and acceptable conversion rates when compared with patients undergoing laparoscopic surgery for recurrent diverticulitis.
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Abstract
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.
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Affiliation(s)
- Matthias Kraemer
- Abteilung Allgemeine und Viszeralchirurgie, Koloproktologie, St. Barbara-Klinik, Am Heessener Wald 1, 59073, Hamm, Germany.
| | - David Kara
- Abteilung Allgemeine und Viszeralchirurgie, Koloproktologie, St. Barbara-Klinik, Am Heessener Wald 1, 59073, Hamm, Germany
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Is laparoscopic surgery the best treatment in fistulas complicating diverticular disease of the sigmoid colon? A systematic review. Int J Surg 2015; 24:95-100. [PMID: 26584958 DOI: 10.1016/j.ijsu.2015.11.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 11/01/2015] [Accepted: 11/05/2015] [Indexed: 12/30/2022]
Abstract
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.
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19
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Role of minimally invasive surgery in the treatment of diverticular disease: an evidence-based analysis. Updates Surg 2015; 67:353-65. [DOI: 10.1007/s13304-015-0329-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 09/14/2015] [Indexed: 02/08/2023]
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Laparoscopic management of diverticular colovesical fistula: experience in 15 cases and review of the literature. Int Surg 2014; 98:101-9. [PMID: 23701143 DOI: 10.9738/intsurg-d-13-00024.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Abstract
BACKGROUND AND OBJECTIVES A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula. METHODS A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period. RESULTS Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence. CONCLUSIONS Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.
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Affiliation(s)
| | - Anna T Tsay
- Department of Surgery, Kaiser Permanente, Los Angeles, CA, USA
| | - Maher A Abbas
- Chair, Minimally Invasive and Robotic Surgery, 4760 Sunset Boulevard, Third Floor, Los Angeles, CA 90027, USA.
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Cirocchi R, Cochetti G, Randolph J, Listorti C, Castellani E, Renzi C, Mearini E, Fingerhut A. Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review. Tech Coloproctol 2014; 18:873-85. [PMID: 24848529 DOI: 10.1007/s10151-014-1157-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 04/13/2014] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- R Cirocchi
- Department of General and Oncologic Surgery, St. Maria Hospital, University of Perugia, Località Sant'Andrea delle Fratte, Via Gambuli n.1, 06156, Perugia, Italy
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23
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Burke JP, Talha S, Yii H, Coffey JC, Waldron D, Condon E. Laparoscopic-assisted Sigmoid Colectomy for Diverticular Colovesical Fistula. Am Surg 2013; 79:289-291. [DOI: 10.1177/000313481307900902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- John P. Burke
- Department of Colorectal Surgery Limerick University Hospital Dooradyle, Limerick, Ireland
| | - Samir Talha
- Department of Colorectal Surgery Limerick University Hospital Dooradyle, Limerick, Ireland
| | - Hung Yii
- Department of Colorectal Surgery Limerick University Hospital Dooradyle, Limerick, Ireland
| | - J. Calvin Coffey
- Department of Colorectal Surgery Limerick University Hospital Dooradyle, Limerick, Ireland
| | - David Waldron
- Department of Colorectal Surgery Limerick University Hospital Dooradyle, Limerick, Ireland
| | - Eoghan Condon
- Department of Colorectal Surgery Limerick University Hospital Dooradyle, Limerick, Ireland
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24
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Minimally invasive surgery for diverticulitis. Tech Coloproctol 2012; 17 Suppl 1:S11-22. [DOI: 10.1007/s10151-012-0940-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/06/2011] [Indexed: 01/19/2023]
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Royds J, O'Riordan JM, Eguare E, O'Riordan D, Neary PC. Laparoscopic surgery for complicated diverticular disease: a single-centre experience. Colorectal Dis 2012; 14:1248-54. [PMID: 22182066 DOI: 10.1111/j.1463-1318.2011.02924.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM The role of laparoscopic surgery in the management of patients with diverticular disease is still not universally accepted. The aim of our study was to evaluate the results of laparoscopic surgery for diverticular disease in a centre with a specialist interest in minimally invasive surgery. METHOD All diverticular resections carried out between 2006 and 2010 were reviewed. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Complicated diverticular disease was defined as diverticulitis with associated abscess, phlegmon, fistula, stricture, obstruction, bleeding or perforation. RESULTS One hundred and two patients (58 men) who had surgery for diverticular disease were identified (median age 59 years, range 49-70 years). Sixty-four patients (64%) had surgery for complicated diverticular disease. The indications were recurrent acute diverticulitis (37%), colovesical fistula (21%), stricture formation (17%) and colonic perforation (16%). Sixty-nine cases (88%) were completed by elective laparoscopy. Postoperative mortality was 0%. For elective cases there was no difference in morbidity rates between patients with complicated and uncomplicated diverticular disease. The overall anastomotic leakage rate was 1% and the wound infection rate 7%. There was a nonsignificant trend to higher conversion to open surgery in the elective group in complicated (11.4%) compared with uncomplicated patients (5.2%) (P=0.67). Electively, the rate of stoma formation was higher in the complicated (31.6%) than the uncomplicated group (5.2%) (P<0.02). CONCLUSION Laparoscopic surgery for both complicated and uncomplicated diverticular disease is associated with low rates of postoperative morbidity and relatively low conversion rates. Laparoscopic surgery is now the standard of care for complicated and uncomplicated diverticular disease in our institution.
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Affiliation(s)
- J Royds
- Minimally Invasive Surgery Unit, Division of Colorectal Surgery, AMNCH, Tallaght Hospital, Dublin 24, Ireland.
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Fingerhut A, Veyrie N. Complicated diverticular disease: the changing paradigm for treatment. Rev Col Bras Cir 2012; 39:322-7. [PMID: 22936232 DOI: 10.1590/s0100-69912012000400013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/18/2012] [Indexed: 11/22/2022] Open
Abstract
The term "complicated" diverticulitis is reserved for inflamed diverticular disease complicated by bleeding, abscess, peritonitis, fistula or bowel obstruction. Hemorrhage is best treated by angioembolization (interventional radiology). Treatment of infected diverticulitis has evolved enormously thanks to: 1) laparoscopic colonic resection followed or not (Hartmann's procedure) by restoration of intestinal continuity, 2) simple laparoscopic lavage (for peritonitis +/- resection). Diverticulitis (inflammation) may be treated with antibiotics alone, anti-inflammatory drugs, combined with bed rest and hygienic measures. Diverticular abscesses (Hinchey Grades I, II) may be initially treated by antibiotics alone and/or percutaneous drainage, depending on the size of the abscess. Generalized purulent peritonitis (Hinchey III) may be treated by the classic Hartmann procedure, or exteriorization of the perforation as a stoma, primary resection with or without anastomosis, with or without diversion, and last, simple laparoscopic lavage, usually even without drainage. Feculent peritonitis (Hinchey IV), a traditional indication for Hartmann's procedure, may also benefit from primary resection followed by anastomosis, with or without diversion, and even laparoscopic lavage. Acute obstruction (nearby inflammation, or adhesions, pseudotumoral formation, chronic strictures) and fistula are most often treated by resection, ideally laparoscopic. Minimal invasive therapeutic algorithms that, combined with less strict indications for radical surgery before a definite recurrence pattern is established, has definitely lead to fewer resections and/or stomas, reducing their attendant morbidity and mortality, improved post-interventional quality of life, and less costly therapeutic policies.
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Smeenk RM, Plaisier PW, van der Hoeven JAB, Hesp WLEM. Outcome of surgery for colovesical and colovaginal fistulas of diverticular origin in 40 patients. J Gastrointest Surg 2012; 16:1559-65. [PMID: 22653331 DOI: 10.1007/s11605-012-1919-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 05/15/2012] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- R M Smeenk
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
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Colovaginal and colovesical fistulae: the diagnostic paradigm. Tech Coloproctol 2012; 16:119-26. [PMID: 22350172 DOI: 10.1007/s10151-012-0807-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 01/22/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND Colovaginal and colovesical fistulae (CVF) are relatively uncommon conditions, most frequently resulting from diverticular disease or colorectal cancer. A high suspicion of a CVF can usually be obtained from an accurate clinical history. Demonstrating CVF radiologically is often challenging, and patients frequently undergo a multitude of investigations prior to definitive management. The aim of this study was to develop an algorithm for the investigation of suspected CVF in order to improve diagnosis and subsequent management. METHODS Thirty-seven patients from a single NHS Trust with a diagnosis of colovaginal or colovesical fistula were included in the study. Clinical records and imaging were reviewed retrospectively, and data on demographics, symptoms, investigations, management and outcome were collated. RESULTS A total of 87.5% patients with a colovesical fistula presented with pathognomic symptoms of faecaluria or pneumaturia. The commonest aetiologies were diverticular disease (72.9%), colonic and gynaecological neoplasia (10.8% each). Computerised tomography (CT) was the most frequently performed investigation (91.9%) and was most sensitive in detecting the fistula (76.5%) and underlying aetiology (94.1%). Colonoscopy was most sensitive in detecting an underlying colonic malignancy (100%). Resectional surgery was performed in 62.1% of cases, although morbidity and 1-year mortality was significant, with rates of 21.7 and 17.4%, respectively. CONCLUSIONS The diagnosis of CVF is predominately a clinical one, and patients with a suspected CVF are over-investigated. Investigations should be focused on determining aetiology rather than demonstrating the fistulous tract itself. We propose that, in the majority of cases, CT and lower gastrointestinal endoscopy should suffice.
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Martin ST, Stocchi L. New and emerging treatments for the prevention of recurrent diverticulitis. Clin Exp Gastroenterol 2011; 4:203-12. [PMID: 22016581 PMCID: PMC3190288 DOI: 10.2147/ceg.s15373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Indexed: 12/23/2022] Open
Abstract
Sigmoid diverticulitis is a common benign condition which carries significant morbidity and socioeconomic burden. This article describes the management of sigmoid diverticulitis with a focus on indications for surgical intervention. The mainstay of management of uncomplicated diverticulitis is broad-spectrum antibiotic therapy. The old surgical dictum that two episodes of sigmoid diverticulitis warranted surgical intervention has been challenged by recently published data. Surgery for diverticulitis thus needs to be tailored to suit individual presentation; patients presenting with recurrent diverticulitis, severe symptoms or debilitating disease impacting patient’s quality of life mandate surgical intervention. Complicated diverticular disease typically prompts intervention to resect a diseased, strictured sigmoid colon, fistulizing disease, or a life-threatening colonic perforation. Laterally, minimally invasive surgery has been utilized in the management of this disease and recent data suggests that localized colonic perforation may be managed by laparoscopic peritoneal lavage, without resection. This review focuses discussion on available evidence for contemporary surgical and nonoperative management of diverticulitis.
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Affiliation(s)
- Sean T Martin
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
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Hirata T, Yokomizo H, Kimura Y, Nakasima M, Yamada K, Tanaka E, Hayashi K, Yamane T. Clinical Study of 5 Cases of Colon Diverticulitis with Colovesical Fistula Treated Laparoscopically. ACTA ACUST UNITED AC 2011. [DOI: 10.5833/jjgs.44.468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Martel G, Bouchard A, Soto CM, Poulin EC, Mamazza J, Boushey RP. Laparoscopic colectomy for complex diverticular disease: a justifiable choice? Surg Endosc 2010; 24:2273-80. [PMID: 20186433 DOI: 10.1007/s00464-010-0951-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Accepted: 01/14/2010] [Indexed: 01/06/2023]
Abstract
BACKGROUND Surgery is increasingly reserved for complicated diverticulitis. The role of laparoscopy in this context is ill defined. This study aimed to evaluate the safety, feasibility, and outcomes associated with the application of laparoscopy to an unrestricted spectrum of diverticular pathologies, with an emphasis on complicated disease. METHODS Consecutive patients who underwent elective, urgent, or emergent laparoscopic colectomy for diverticular disease from 1991 to 2007 were analyzed from a prospectively collected database. Laparoscopy was offered to all patients presenting for surgical attention, thus minimizing selection bias. Complicated cases had abscesses, perforations, fistulas, or strictures. Uncomplicated cases had chronic or recurrent diverticulitis. Summary statistics and univariate comparisons were generated. RESULTS A total of 183 patients were analyzed, including 39 complicated cases. The complicated cohort included 12 abscesses or perforations (31%), 18 fistulas (46%), and 11 strictures (28%). Intraoperative complications were comparable between the two groups (7.7 vs. 9.7%), although the complicated cases resulted in more conversions (23 vs. 4.2%; p = 0.0007). More than 79% of the complicated patients and 96% of the uncomplicated patients underwent unprotected primary anastomosis. Medical (23 vs. 1.4%; p < 0.0001) and surgical (28 vs. 14%; p = 0.035) complications were more frequent in the complicated group. Leak rates were acceptably low (6.5 vs. 2.2%; p = 0.23). There were no recorded deaths. Finally, the time until discharge from hospital was significantly longer in the complicated group by a median of 1 day. CONCLUSIONS The laparoscopic management of complicated diverticular disease is feasible and appears to be safe in the hands of experts. Despite a high rate of conversion to open surgery, laparoscopy was the sole operative intervention for the majority of patients with complicated diverticular disease. Further studies are needed to allow rigorous comparison with an open control group.
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Affiliation(s)
- Guillaume Martel
- Minimally Invasive Surgery Research Group, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
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