Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis.

AIM: Currently in the UK the standard surgical practice for the management of perforated sigmoid diverticulitis is a Hartmann's procedure. There have been a number of recent publications on the use of laparoscopic peritoneal lavage for perforated sigmoid diverticulitis, as an alternative to the emergency Hartmann's procedure, with its associated morbidity and mortality. We aim to review the current literature on this topic. METHOD: A search was made on the electronic database MEDLINE from PubMed, EMBASE and the Cochrane library. The keywords 'diverticulitis', 'perforated' and 'laparoscopy' were searched for in the titles and abstracts without language restrictions. Further studies were identified from searches on Google Scholar, as well as manual searches through reference lists of the relevant studies found. All included studies were quality assessed. RESULTS: Twelve relevant studies were included. A total of 301 patients were reported, with a mean age of 57 years. All were non-randomized studies. The majority of patients were of Hinchey classification III. All were treated with intravenous antibiotics followed by laparoscopic lavage and insertion of intra-abdominal/pelvic drains. The mean conversion rate was 4.9% and mean length of hospital stay was 9.3 days. The mean complication rate was 18.9% and the overall mortality rate was 0.25%. Subsequent elective resections with primary anastamosis were performed in 51% of patients and the majority were completed laparoscopically. CONCLUSION: Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis appears to be a potentially effective and more conservative alternative to a Hartmann's procedure. Randomized control trials are needed to better evaluate its role.

Colorectal foreign bodies: a systematic review.

AIM: To perform a systematic review of the published reports on retained colorectal foreign bodies (CFBs) to collate the features and formulate a simple management plan based on the available evidence. METHOD: An extensive search was carried out to identify articles on CFBs. The search was carried out on electronic databases Cinahl, Embase, Medline, PubMed and PsychInfo from 1950 to January 2009. Internet journals were also scoured and a general search was carried out using the search engine 'Google'. Papers published in languages other than English were not included. RESULTS: This review covers a total of 193 patients with 196 presentations. There were 188 men and 5 women, a ratio of approximately 37:1. The mean age at presentation was 44.1 years (SD 16.6) in the single case reports and 39.3, 40 and 60.8 years in the three case series. Household objects, such as bottles and glasses, accounted for the largest percentage (42.2%) of inserted objects. Presentation for treatment occurred most often within 24 h of insertion and the majority of objects were removed transanally using manual manipulation with or without the use of a variety of tools, or via a scope. CONCLUSIONS: The incidence of CFBs is disproportionately higher in men. Various techniques for removal are available, including some that are minimally invasive. The appropriate technique will depend on the size and surface of the retained object and the presence of complications such as perforation or obstruction.

Intestinal obstruction from inspissated barium (Barolith): a systematic review of all cases from 1950 to 2006.

OBJECTIVE: Having encountered a case of large bowel obstruction secondary to a barolith and successfully treated it using colonoscopic dissolution, we systematically reviewed all cases of barolith obstruction to appreciate its incidence and explore its methods of treatment. METHOD: A literature search was carried out in the databases British Nursing Index, Cinahal, Embase, Medline, and Pub Med. There was no restriction placed on language of publication in the search. RESULTS: There were 22 reports describing a total of 31 cases. About one third of the reported cases were successfully treated with conservative measures including the use of laxatives. Significantly, surgery was performed in nearly half of the patients. Interestingly, endoscopic dissolution was attempted in only 3 cases and it was successful in all of them. CONCLUSION: This systematic review reveals several reported cases of barolith obstruction from 1950-2006. Only three case reports described colonoscopic dissolution. In our institute, we have recently encountered a case of large bowel obstruction secondary to a barolith and we successfully treated it using colonoscopic dissolution. Given the absence of guidelines to treat barolith induced obstruction, we are of the opinion that should a barolith obstruction occur, in the absence of perforation or ischaemic bowel, endoscopic dissolution by an experienced endoscopist under general anaesthetic offers a safe, effective, and minimally invasive method of relieving the obstruction. Should this fail surgery is indicated.

Early symptomatic recurrence after intestinal resection in Crohn's disease is unpredictable.

OBJECTIVE: To identify predictors of early symptomatic recurrence of Crohn's disease (CD) after surgical resection. METHOD: We studied a cohort of 128 patients who had undergone at least one intestinal resection for CD. Factors that might predict early recurrence were documented for analysis using a standardized pro forma. These comprised age, gender, family history, extra-intestinal manifestations, smoking, complicated disease at first presentation, site of disease, preoperative inflammatory markers, involvement of resection margins, orientation and method of anastomosis and postoperative medical therapy. All symptomatic recurrences were confirmed by endoscopic, radiological, or operative means. We defined early recurrence as that which occurred within 36 months of first surgery. Univariate analysis was conducted to compare the distribution of each factor in those who developed early recurrence (n = 48) and those who remained disease free for the first 36 months (n = 50). RESULTS: Of the 128 patients studied, 98 fulfilled the inclusion criteria of at least 36 months of follow up. Of these patients, 48 (49%) patients developed recurrence. Trends towards fewer early recurrences were seen in patients with colonic disease (33%vs 56%, P = 0.068). Of the current smokers, 60% developed early recurrence compared with 43% of nonsmokers (P = 0.269). All other factors examined were similarly distributed between the two groups. Metronidazole as adjuvant treatment does not appear to protect against early symptomatic recurrence. CONCLUSION: This study shows that early symptomatic postoperative recurrence of CD remains unpredictable. Against expectation, abstinence from smoking and postoperative adjuvant metronidazole did not appear to protect against early symptomatic recurrence.

Protein and mRNA expression of tissue factor pathway inhibitor-1 (TFPI-1) in breast, pancreatic and colorectal cancer cells.

BACKGROUND: Patients with solo tumour malignancy are at higher risk of developing venous thromboembolism. When prophylactic anticoagulation (and in particular heparin) is used during cancer therapy however, patients appear to have a prolonged survival. Tumours express large quantities of procoagulant molecules, which predispose patients to these conditions. Tissue Factor (TF) is an important example, which may have a role in the biology of malignant disease. Intra-tumour vessel coagulation however is not a common phenomenon. Our hypothesis is that cancer cells produce anticoagulant molecules, which may prevent intra-tumour vessel auto-coagulation. Our results show that one such factor--Tissue Factor Pathway Inhibitor (TFPI-1) is expressed by a number of different cancer cells. METHODS: Seven human cancer cell lines were studied: three breast, two colorectal and two pancreatic. Cells were maintained in cell culture, and at 90% confluence protein and RNA were extracted. RNA integrity was confirmed using an RNA integrity gel and RNA purity determined by spectrophotometry. Reverse transcription polymerase chain reaction (RT-PCR) was used for TFPI-1 mRNA detection and immunoblotting used for TFPI-1 protein detection. RESULTS: Six cell lines (two breast, two colorectal, and two pancreatic) expressed the TFPI-1 gene. Gene function was confirmed by detection of TFPI-1 protein expression in these cell lines. CONCLUSION: TFPI-1 is expressed by breast cancer and other cancer cell lines maintained in cell culture. This has not been previously reported. Functional expression of TFPI-1 by cancer cells suggests that it has an important role in cancer biology. Further experiments are required to establish its function.