Acute diverticulitis with extraluminal air: is conservative treatment sufficient? A single-center retrospective study

BACKGROUND

Acute diverticulitis with extraluminal air constitutes a heterogeneous condition whose management is controversial. The aims of this study are to report the failure rate of conservative treatment for diverticulitis with extraluminal air and to report risk factors of conservative treatment failure.

METHODS

A retrospective study was performed from an institutional review board-approved database of patients admitted with acute diverticulitis with extraluminal air from 2015 to 2021 at a tertiary referral center. All patients managed for acute diverticulitis with covered perforation (without intraabdominal abscess) were included. The primary endpoint was failure of medical treatment, defined as a need for unplanned surgery or percutaneous drainage within 30 days after admission.

RESULTS

Ninety-three patients (61% male, mean age 57 ± 17 years) were retrospectively included. Ten patients had failure of conservative treatment (11%). These patients were significantly older than 50 years (n = 9/10, 90% versus n = 47/83, 57%, p = 0.007), associated with cardiovascular disease (n = 6/10, 60% versus n = 10/83, 12%, p = 0.002), American Society of Anesthesiologists (ASA) score of 3-4 (n = 4/7, 57% versus 6/33, 18%, p = 0.05), under anticoagulant and antiplatelet (n = 6/10, 60% versus n = 11/83, 13%, p = 0.04) and steroid or immunosuppressive therapy (n = 3/10, 30% versus 5/83, 6%, p = 0.04), and with distant pneumoperitoneum location (n = 7/10, 70% versus n = 14/83, 17%, p = 0.001) compared with those with successful conservative treatment. On multivariate analysis, only distant pneumoperitoneum was an independent risk factor of failure (odds ratio (OR) 6.5, 95% confidence interval (CI) [2-21], p = 0.002).

CONCLUSIONS

Conservative treatment with antibiotics for acute diverticulitis with extraluminal air is safe with a success rate of 89%. Patients with distant pneumoperitoneum should be carefully monitored.

Surgical management of the rectocele - An update

Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.

[Giant renal angiomyolipoma with right heart failure]

We report the case of a 63-year-old woman presenting a 26cm right renal angiomyolipoma with intratumoral arteriovenous fistula responsible for a high-output right heart failure. A radical surgical treatment after preoperative embolization allowed rapid improvement of cardiac symptoms with an uneventful postoperative course.

Incidence and prevention of ventral incisional hernia

OBJECTIVE

Ventral incisional hernia is a common complication of abdominal surgery. The incidence ranges from 2% to 20% and varies greatly from one series to another. The goal of this study was to determine the incidence, risk factors, and preventive measures for ventral incisional hernia.

MATERIALS AND METHODS

An analysis of the surgical literature was performed using the search engines EMBASE, Cochrane Library, and PubMed with the keywords: abdominal hernia, wound dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention.

RESULTS

The overall incidence of incisional hernia after laparotomy was 9.9%. The incidence was significantly higher for midline incisions compared with transverse incisions (11% vs. 4.7%; P=0.006). In contrast, the incidence of ventral hernia was only 0.7% after laparoscopy. A compilation of all the studies comparing laparotomy to laparoscopy showed a significantly higher incidence of incisional hernia after laparotomy (P=0.001). Independent risk factors for incisional hernia included age and infectious complications. Only two meta-analyses were able to show a significant decrease in risk-related to the use of non absorbable or slowly absorbable suture material. No difference in incisional hernia risk was shown with different suture techniques (11.1% for running suture, 9.8% for interrupted sutures: NS).

CONCLUSION

A review of the literature shows that only the choice of incisional approach (transverse incision or laparotomy vs. midline laparotomy) allows a significant decrease in the incidence of ventral incisional hernia.