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.

What is the likelihood of colorectal cancer when surgery for ulcerative-colitis-associated dysplasia is deferred?

AIM: Surgery aims to prevent cancer-related morbidity for patients with ulcerative colitis (UC) associated dysplasia. The literature varies widely regarding the likelihood of dysplastic progression to higher grades of dysplasia or cancer. The aim of this study was to characterize the likelihood of the development of colorectal cancer (CRC) of patients with UC-associated dysplasia who chose to defer surgery. METHOD: A retrospective review was carried out of patients undergoing surgery for UC at the Mayo Clinic, who were diagnosed to have dysplasia between August 1993 and July 2012. The relationships between grade of dysplasia, time to surgery and the detection of unsuspected carcinoma were investigated. RESULTS: In all, 175 patients underwent surgery at a median of 4.9 (interquartile range 2.5-8.9) months after a diagnosis of dysplasia. Their median age was 52 (interquartile range 43-59) years. An initial diagnosis of indeterminate dysplasia was not associated with CRC [0/23; 17.7 (8.1-29.6) months]. Thirty-six patients who had an initial diagnosis of dysplasia progressed from indeterminate to low-grade dysplasia [24.2 (11.0-30.4) months]. Low-grade dysplasia was associated with a 2% (1/56; T2N0M0) risk of CRC when present in random surveillance biopsies and a 3% (2/61; T1N0M0, T4N0M0) risk if detected in endoscopically visible lesions [7.4 (5.2-33.3) months]. Eighteen patients progressed from indeterminate to high-grade dysplasia [19.1 (9.2-133.9) months]. Seventeen patients progressed from low to high-grade dysplasia [11.0 (5.8-30.1) months]. None of the patients with high-grade dysplasia (0/35) progressed to CRC [4.5 (1.7-9.9) months]. CONCLUSION: Dysplasia was associated with a low incidence of node negative CRC if surgery was deferred for up to 5 years. These findings may help inform the decision-making process for asymptomatic patients who are having to decide between intensive surveillance or surgery for UC-associated dysplasia.