Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study

BACKGROUND

In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level.

METHODS

All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD.

RESULTS

In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma.

CONCLUSIONS

This series provides a real-life picture of elective sigmoidectomy for SDD at a national level.

TRIAL REGISTRATION

Comité National Information et Liberté (CNIL) (n°920361).

[Late intestinal fistula following implantation of parietal abdominal prostheses]

STUDY AIM

The aim of this retrospective study was to describe an unusual complication of the nonabsorbable meshes used for repair of incisional hernia or inguinal hernia.

PATIENTS AND METHODS

This study included eight observations of intestinal fistulas that occurred between 1 and 13 years after using Mersilène (Dacron) mesh for repair of an incisional hernia (7 cases) and an inguinal hernia (1 case). There were 6 men and 2 women (mean age: 58 years, range: 35-85 years) with an external intestinal fistula (n = 6) or an internal intestinal fistula (n = 2). All the patients required a reoperation for extraction of the mesh and treatment of the bowel injuries.

RESULTS

There was one secondary death in a 85 years old woman in relation with a vascular complication after incomplete excision of the prosthesis. In five patients out of six, there was a recurrence of the incisional hernia.

CONCLUSION

The intestinal fistulas associated with prosthetic repair of the abdominal wall are mostly observed with intraperitoneal mesh but this factor is not exclusive. Their frequency after repair of incisional or inguinal hernia with non absorbable mesh is estimated between 0.3 and 3.5%. The use of nonabsorbable mesh should be limited to the indications of strict necessity, without any septic context or emergency surgery. The contact of the mesh with the bowel should be formally avoided.

[Use of the vacuum-assisted closure system for the treatment of perineal gangrene involving the abdominal wall]

The vacuum-assisted closure (VAC) system is used for the treatment of complicated wounds and large tissular dehiscences. The study aim was to report a case of perineal gangrene extended to the abdominal wall in a 53-year old woman. After several extensive surgical debridments, using of the VAC was followed by a good and rapid healing of the wound.

[Long-term results of the treatment of eventrations by intraperitoneal non-absorbable prosthesis (149 patients)]

The authors report a series of 149 cases of incisional hernia, operated between 1983 and 1993, by insertion of a non-absorbable prosthetic mesh within the intraperitoneal cavity. This series consisted of 93 women and 56 men, with a mean age 57 years. One third of repairs were performed because of primary treatment failure. One or more operative risk factors were present in 127 patients. A non-absorbable intraperitoneal prosthetic mesh was inserted with tension to allow good musculo-aponeurotic repair. Postoperative mortality was 0.6%. All but 13 of the patients, were reviewed with a mean follow-up of 83 months. Twenty eight patients (20%) developed recurrence. In 8 cases, the cause of recurrence was failure of prosthetic mesh insertion because of excessive tension. Three patients (1.7%) developed a fistula in contact with the prosthetic mesh, that had to be removed. A small bowel fistula was observed in 2 cases after an intraoperative wound in 1 case, and a colonic fistula in 1 case. The results of incisional hernia repair with nonabsorbable intraperitoneal prosthetic mesh can be compared with these of other techniques using prosthetic materials. This technique does not require dissection of the intermediate planes and avoids undermining which causes substantial bleeding. The risk of sepsis is also decreased by deep placement of the prosthesis. The exceptional cases of fistula or the possibility of migration of the prosthesis are not exclusively observed with this technique, but must clearly encourage a very strict aseptic technique, with placement of omentum between the prosthetic mesh and the viscera.