Current Management of Diverticulitis.

Diverticulosis and diverticulitis remain common diagnoses in western countries, and the incidence continues to rise. Diverticulitis accounts for roughly one-third of admissions to acute care hospitals annually, with even more patients being treated as outpatients due to improved understanding of risk stratification and the natural history of disease progression. Thus, having a thorough understanding of the etiology of the disease in conjunction with computed tomography findings and patient presentation can help dictate the appropriate treatment.

Screening for Colorectal Cancer.

Colorectal cancer remains the third leading cause of cancer death in the United States. Colorectal cancer screening allows for prevention and early detection of precancerous and cancerous lesions, and screening has been shown to be effective in preventing colorectal cancer deaths. Screening recommendations vary by patient risk profile. A variety of screening modalities exist.

The Impact of Prolonged Operative Time Associated With Minimally Invasive Colorectal Surgery: A Report From the Surgical Care Outcomes Assessment Program.

BACKGROUND: Increased operative time in colorectal surgery is associated with worse surgical outcomes. Laparoscopic and robotic operations have improved outcomes, despite longer operative times. Furthermore, the definition of "prolonged" operative time has not been consistently defined. OBJECTIVE: The first objective was to define prolonged operative time across multiple colorectal operations and surgical approaches. The second was to describe the impact of prolonged operative time on length of stay and short-term outcomes. DESIGN: A retrospective cohort study. SETTING: Forty-two hospitals in the Surgical Care Outcomes Assessment Program from 2011 to 2019. PATIENTS: There were a total of 23,098 adult patients (age 18 years or older) undergoing 6 common, elective colorectal operations: right colectomy, left/sigmoid colectomy, total colectomy, low anterior resection, IPAA, or abdominoperineal resection. MAIN OUTCOME MEASURES: Prolonged operative time defined as the 75th quartile of operative times for each operation and approach. Outcomes were length of stay, discharge home, and complications. Adjusted models were used to account for factors that could impact operative time and outcomes across the strata of open and minimally invasive approaches. RESULTS: Prolonged operative time was associated with longer median length of stay (7 vs 5 days open, 5 vs 4 days laparoscopic, 4 vs 3 days robotic) and more frequent complications (42% vs 28% open, 24% vs 17% laparoscopic, 27% vs 13% robotic) but similar discharge home (86% vs 87% open, 94% vs 94% laparoscopic, 93% vs 96% robotic). After adjustment, each additional hour of operative time above the median for a given operation was associated with 1.08 (1.06-1.09) relative risk of longer length of stay for open operations and 1.07 (1.06-1.09) relative risk for minimally invasive operations. LIMITATIONS: Our study was limited by being retrospective, resulting in selection bias, possible confounders for prolonged operative time, and lack of statistical power for subgroup analyses. CONCLUSIONS: Operative time has consistent overlap across surgical approaches. Prolonged operative time is associated with longer length of stay and higher probability of complications, but this negative effect is diminished with minimally invasive approaches. See Video Abstract . EL IMPACTO DEL TIEMPO OPERATORIO PROLONGADO ASOCIADO CON LA CIRUGA COLORRECTAL MNIMAMENTE INVASIVA UN INFORME DEL PROGRAMA DE EVALUACIN DE RESULTADOS DE ATENCIN QUIRRGICA: ANTECEDENTES:El aumento del tiempo operatorio en la cirugía colorrectal se asocia con peores resultados quirúrgicos. Las operaciones laparoscópicas y robóticas han mejorado los resultados, a pesar de los tiempos operatorios más prolongados. Además, la definición de tiempo operatorio "prolongado" no se ha definido de manera consistente.OBJETIVO:Primero, definir el tiempo operatorio prolongado a través de múltiples operaciones colorrectales y enfoques quirúrgicos. En segundo lugar, describir el impacto del tiempo operatorio prolongado sobre la duración de la estancia y los resultados a corto plazo.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:42 hospitales en el Programa de Evaluación de Resultados de Atención Quirúrgica de 2011-2019.PACIENTES:23 098 pacientes adultos (de 18 años de edad y mayores), que se sometieron a seis operaciones colorrectales electivas comunes: colectomía derecha, colectomía izquierda/sigmoidea, colectomía total, resección anterior baja, anastomosis ileoanal con bolsa o resección abdominoperineal.PRINCIPALES MEDIDAS DE RESULTADO:Tiempo operatorio prolongado definido como el cuartil 75 de tiempos operatorios para cada operación y abordaje. Los resultados fueron la duración de la estancia hospitalaria, el alta domiciliaria y las complicaciones. Se usaron modelos ajustados para tener en cuenta los factores que podrían afectar tanto el tiempo operatorio como los resultados en los estratos de abordajes abiertos y mínimamente invasivos.RESULTADOS:El tiempo operatorio prolongado se asoció con una estancia media más prolongada (7 vs. 5 días abiertos, 5 vs. 4 días laparoscópicos, 4 vs. 3 días robóticos), complicaciones más frecuentes (42 % vs. 28 % abiertos, 24 % vs. 17 % laparoscópica, 27% vs. 13% robótica), pero similar alta domiciliaria (86% vs. 87% abierta, 94% vs. 94% laparoscópica, 93% vs. 96% robótica). Después del ajuste, cada hora adicional de tiempo operatorio por encima de la mediana para una operación determinada se asoció con un riesgo relativo de 1,08 (1,06, 1,09) de estancia hospitalaria más larga para operaciones abiertas y un riesgo relativo de 1,07 (1,06, 1,09) para operaciones mínimamente invasivas.LIMITACIONES:Nuestro estudio estuvo limitado por ser retrospectivo, lo que resultó en un sesgo de selección, posibles factores de confusión por un tiempo operatorio prolongado y falta de poder estadístico para los análisis de subgrupos.CONCLUSIONES:El tiempo operatorio tiene una superposición constante entre los enfoques quirúrgicos. El tiempo operatorio prolongado se asocia con una estadía más prolongada y una mayor probabilidad de complicaciones, pero este efecto negativo disminuye con los enfoques mínimamente invasivos. ( Traducción-Dr. Mauricio Santamaria ).

Minimally-invasive approach to emergent colorectal surgery in aging adults: A report from the Surgical Care Outcomes Assessment Program.

BACKGROUND: Despite known benefits of minimally invasive surgery(MIS) in elective settings, MIS use in emergency colorectal surgery(CRS) is limited. Older adults are more likely to require emergent CRS, and MIS is used less frequently with increasing age. METHODS: A retrospective cohort was constructed of emergent CRS cases performed between 2011 and 2019. Discharge(DC) disposition, adverse events, and length of stay(LOS) between MIS and open surgery were compared and stratified by age. Adjustment was made for selected confounders using inverse probability weighting. RESULTS: Of 6913 emergent CRS cases across 50 hospitals, 1616(23%) were approached MIS. MIS cases were more likely [OR(95%CI)] to DC home [<65yo:1.7(1.3,2.2); 65-74:1.5(1.1,1.9); 75+:1.2(0.9,1.5)] and have fewer adverse events [<65yo:0.6(0.5,0.8); 65-74:0.7(0.5,0.9); 75+:0.7(0.5,0.9)]. LOS was shorter [Mean difference in days(95%CI)] [<65yo: 2.2(-2.9,-1.4); 65-74: 0.9(-2.7,1.0); 75+: 0.7(-1.7,0.2)]. CONCLUSIONS: MIS in emergent CRS is associated with increased DC to home, fewer adverse events, and shorter LOS. Benefits persisted with age after adjustment, suggesting an opportunity for improved MIS delivery in older adults.

The relationship of plasma glucose and glycosylated hemoglobin A1C levels among nondiabetic trauma patients.

OBJECTIVE: : Hyperglycemia (blood glucose >/=110 mg/dL) in trauma patients without a known history of diabetes mellitus (DM) is often attributed to the metabolic stress response of injury. We studied whether this hyperglycemia may actually indicate the presence of occult DM (ODM) as demonstrated by elevated glycosylated hemoglobin A1C (gHbA1C). METHODS: : After obtaining approval from the Institutional Review Board, a prospective, sequential case series study of nondiabetic adult patients presenting to an urban Level I trauma center from September 2006 to February 2007 was performed. In addition to basic demographics, all hyperglycemic patients had a measured gHbA1C. ODM was diagnosed when gHbA1C was >/=6%. RESULTS: : A total of 1,039 trauma patients were screened with 192 (18%) noted to be hyperglycemic. Of these 192 patients, 22% (n = 42) were found to have an elevated gHbA1C. Using logistic regression, being older (Odds ratio [OR] = 1.04; p < 0.004), having a higher body mass index (BMI) (OR = 1.12; p < 0.003), and being Native American (OR = 5.08; p < 0.017) were each identified as significant risk factors for elevated gHbA1C levels and the diagnosis of ODM. In contrast, the magnitude of observed hyperglycemia, gender, or other races were not shown to be significant risk factors for the presence of ODM. CONCLUSION: : Almost a quarter of nondiabetic trauma patients presenting with hyperglycemia were found to have elevated gHbA1C levels and ODM. Risk factors for ODM included advancing age and body mass index as well as being Native American. The hyperglycemia seen in trauma patients should not solely be attributed to the hormonal and metabolic response to injury; wider ODM screening for both acute management strategies and long-term health benefits is warranted.

Laparoscopic Heller myotomy with Toupet fundoplication: outcomes predictors in 121 consecutive patients.

HYPOTHESIS: This study was performed to assess the intermediate-term outcomes after laparoscopic Heller myotomy and posterior Toupet fundoplication in a single-surgeon series with the expectation of identifying patient and disease factors associated with poor outcomes. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary care teaching hospital with a comprehensive esophageal physiology laboratory. PATIENTS: A total of 121 patients undergoing laparoscopic Heller myotomy with Toupet fundoplication (between December 1, 1996, and December 31, 2004) for achalasia were included. INTERVENTIONS: All patients had preoperative objective documentation of achalasia. A 5- to 6-cm-long myotomy was performed on the distal esophagus. The myotomy incision was extended 2 cm onto the stomach. A partial (270 degrees ) posterior Toupet fundoplication was performed as an antireflux mechanism in all patients. MAIN OUTCOME MEASURES: Data on preoperative and postoperative symptoms, manometry, and 24-hour ambulatory pH were prospectively collected. Symptoms were recorded with a standardized assessment tool. Patients with postoperative dysphagia scores of 2 or greater were considered treatment failure. Logistic regression modeling was performed to identify variables significant for poor outcomes. RESULTS: Preoperatively, 89 patients (73.6%) had severe dysphagia (dysphagia score, 3 or 4) and 32 patients (26.4%) had mild or moderate dysphagia (dysphagia score, 1 or 2). After a median follow-up period of 9 months, 102 patients (84.3%) (P<.001) had excellent relief of dysphagia (dysphagia score, 0 or 1). Eight additional patients (6.6%) demonstrated a significant (25%-75% [P=.01]) improvement in dysphagia scores. Only 11 patients (9.0%) had either no change or worse dysphagia. Postoperatively, all patients with manometry had a normal lower esophageal sphincter pressure (mean +/- SD, 14.7 +/- 6.6 mm Hg; P<.001) and good lower esophageal sphincter relaxation. Odds of failure were greatest for patients with severe preoperative dysphagia, male patients, and patients with classic amotile achalasia. Of the 60 patients having heartburnlike symptoms preoperatively (mean +/- SD score, 2.52 +/- 1.00), 19 (31.7%) continued to have similar symptoms after surgery. Sixteen (33.3%) of the 48 patients having postoperative pH studies demonstrated objective reflux (DeMeester score, >14.7). Five (31.2%) of these patients had symptoms of their reflux. CONCLUSIONS: Dysphagia improves in most patients after laparoscopic Heller myotomy with partial fundoplication. Patients with severe preoperative dysphagia, esophageal dilation, or amotile achalasia may have greater chances of a poor outcome.

The evolving role of staging laparoscopy in the treatment of colorectal hepatic metastasis.

HYPOTHESIS: Laparoscopy is an increasingly important tool in the staging and treatment of hepatic malignancies. This study evaluates the effect of staging laparoscopy (SL) using intraoperative ultrasonography (IOUS) on the regional treatment of isolated hepatic colorectal metastasis. DESIGN: Analytic cohort study. SETTING: Tertiary care center. PATIENTS: Consecutive patients who have a colorectal metastasis confined to the liver and selected for surgical regional treatment. INTERVENTIONS: All patients underwent preoperative evaluation followed by SL/IOUS. Operative plans were based on preoperative imaging and were either carried out or altered intraoperatively according to SL/IOUS findings. MAIN OUTCOME MEASURE: Effect of SL/IOUS on surgical management. RESULTS: Between September 1996 and May 2004 one hundred fifty-two SL/IOUSs were performed in 136 patients (77 males and 59 females), who had a mean (SD) age of 63 (11) years. Data sets were complete in 138 events. All patients had isolated hepatic disease as defined by preoperative computed tomography in 152 (100%) and positron emission tomography in 107 (70%). Staging laparoscopy/IOUS identified surgically untreatable disease in 34 events (25%) because of peritoneal metastases (n = 15), nodal involvement (n = 11), diffuse hepatic disease (n = 5), no identifiable disease (n = 2), and untreatable disease (n = 1). Laparoscopic treatment events included radiofrequency ablations (n = 78), hepatic artery pump implantations (n = 40), resections (n = 26), and combined procedures (n = 37). Overall, SL/IOUS changed the treatment plan in 66 (48%) of 138 of events. This includes 32 (23%) of 138 events in which SL/IOUS findings significantly altered the actual procedure performed relative to the preoperative plan. Three minor complications occurred in the SL/IOUS-only group with a mean (SD) hospital stay of 1.3 (1) days. CONCLUSION: In the regional management of isolated colorectal hepatic metastasis, SL/IOUS avoids unnecessary laparotomies and influences definitive surgical intervention in a substantial proportion of patients.