Perforated diverticulitis: To anastomose or not to anastomose? A systematic review and meta-analysis.

BACKGROUND: No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We hypothesise that resection with primary anastomosis is a safe alternative in selected patients. We aim to conduct a systematic review and meta-analysis on the available literature. METHODS: Studies that compared emergency Hartmann's with primary anastomosis in perforated left sided colonic diverticulitis were systematically reviewed. The search strategy included all study types that compared primary anastomosis to Hartmann's in perforated diverticulitis and reported on morbidity and mortality. 5 databases (PubMed, MEDLINE via PubMed, OVID, EMBASE via OVID and The Cochrane Collaboration). The Cochrane's Bias Methods Group tool was used to assess the risk of bias and a meta-analysis of the relevant studies was conducted. RESULTS: The review retrieved 1933 abstracts of which 14 studies (2 RCTs, 4 prospective non-randomised and 8 retrospective non-randomised) with 765 patients in total, 482 in the Hartmann's group and 283 in the primary anastomosis group, met the inclusion criteria. This showed a significantly lower mortality with primary anastomosis (10.6%) compared to Hartmann's (20.7%) (p = 0.0003). Morbidity was also significantly lower (41.8% vs. 51.2%) (p = 0.0483). The RR for mortality was 0.92 in favour of primary anastomosis (p = 0.0019). The average anastomotic leak rate was 5.9%. CONCLUSION: Resection and primary anastomosis should be considered as a feasible and safe operative strategy in selected patients with perforated diverticulitis. There is however a paucity of high level evidence and further research is needed.

Management and short-term outcome of malignant colorectal polyps in the north of England(1).

AIM: Management of malignant colorectal polyps (MCP) is contentious, with no randomized controlled trials comparing endoscopic with surgical management. This study reviews the management and outcomes of MCPs across a UK region. METHOD: Patients with a malignant polyp were identified using the NORCCAG (NORthern Colorectal Cancer Audit Group) database between April 2006 and July 2010. All histopathology reports and follow-up procedures were reviewed. RESULTS: Of 386 patients identified, 165 (42.7%) had the polyp biopsied and 221 (57.3%) had an endoscopic local excision (37 piecemeal excision, 184 polypectomy). All patients having an endoscopic biopsy underwent surgery. 103 (46.6%) having a local excision had follow-up surgery, of whom 79 (76.7%) had no residual cancer. Of the 118 patients managed endoscopically, none had residual cancer on follow-up endoscopy. The 21 (5.4%) Dukes C cancers were associated with Kikuchi SM3/Haggitt 4 lesions (χ(2) =10.85, P=0.005) and lesions with an involved/unsure excision margin (χ(2) =7.44, P=0.017). Predictors of finding residual tumour at surgery after local excision were Kikuchi SM3/Haggitt Level 4 (χ(2) =17.07, P<0.001) and an involved/unsure excision margin (χ(2) =20.45, P<0.001). An excision margin >0 mm was associated with the finding of no residual tumour (χ(2) =25.21, P<0.001). There was no difference in survival between surgical and endoscopic management (χ(2) =0.634, P=0.426) after a mean follow-up of 25.1 months. CONCLUSION: Endoscopic management of a subgroup of MCPs appears safe. A clear resection margin (>0 mm) appears sufficient to avoid surgery, except in locally advanced lesions (Kikuchi 3/Haggitt 4) which have a greater risk of residual cancer at surgery and lymph node metastasis.

The Vanguard endovascular stent-graft: mid-term results from a single centre.

PURPOSE: Despite initial enthusiasm for endovascular aortic repair, few descriptions of longer-term follow-up of any endovascular device have been published. This paper represents the experience of a single centre with the Vanguard device over a 5-year period. METHODS: Fifty-five patients with a median age of 71 years (range 45-87 years) and aneurysm diameter of 59 mm (45-84 mm) received a bifurcated Vanguard stent-graft between December 1995 and July 1999. Follow-up was according to the Eurostar criteria (clinical assessment, plain film radiography and computed tomography) at 1, 3, 6, 12, 18 and 24 months and then annually thereafter. RESULTS: All primary stent deployments were successful. Median duration of surgery was 120 min (70-360 min). Median post-operative stay was 3 days (1-19 days) with a peri-operative mortality of 5.5%. In the follow-up period (median 40 months, range 6-64 months) there was one aneurysm associated death, and 14 deaths due to other causes. There have been three device migrations, 12 occluded graft limbs, four type II endoleaks and nine type III endoleaks. At 48 months, this has resulted in a survival rate of 67%, an endoleak free survival of 81% and intervention free survival of 59% (Kaplan-Meier). CONCLUSION: Medium term results with the Vanguard device appear to be at least equivalent to open repair with regard to morbidity and mortality. Nevertheless, several delayed complications appear to be related to endograft limb distortion. Important lessons have been learnt in relation to the deployment of bifurcated endografts to reduce the incidence of secondary limb related problems.