Bilateral adrenal hemorrhage after colectomy for perforated diverticulitis: A case report.

INTRODUCTION: Bilateral adrenal hemorrhage can lead to acute adrenal insufficiency. This is a rare complication in the post-operative setting, and we present a case in which it developed after a colectomy for perforated diverticulitis. PRESENTATION OF CASE: The patient is a 65-year-old female who presented with abdominal pain, nausea, emesis, and hematochezia, and CT scan showing sigmoid diverticulitis with peri-sigmoid abscess. After a failure of non-operative treatment, she underwent Hartmann's resection, and her post-operative course was complicated by refractory tachycardia, hypotension, hyponatremia, and nausea/vomiting. Bleeding, hypovolemia, and sepsis were ruled out. A CT scan showed enlarged poorly defined adrenals bilaterally, suggestive of bilateral adrenal hemorrhage. Serum cortisol level was low and diagnostic of acute adrenal insufficiency. With intravenous steroid therapy (hydrocortisone), her vital signs, laboratory abnormalities, and diet intolerance all resolved. She was discharged on oral prednisone and continued long term. DISCUSSION: Bilateral adrenal hemorrhage is rare post-operatively and can lead to adrenal insufficiency. 15% of patients who die in shock have bilateral adrenal hemorrhage on autopsy, indicating the necessity of timely diagnosis and treatment of this condition. Corticosteroid therapy is the mainstay of treatment. CONCLUSION: This case study illustrates that post-operative delay of progression or worsening of condition, with no alternative explanation, can be due to acute adrenal insufficiency resulting from bilateral adrenal hemorrhage, and timely diagnosis and treatment of this condition is paramount for a favorable outcome.

Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study.

AIM: Frailty is defined as a decrease in physiological reserve with increased risk of morbidity following significant physiological stressors. This study examines the predictive power of the five-item modified frailty index (5-mFI) in predicting outcomes in colorectal surgery patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Database was queried from 2011 to 2016 to determine the predictive power of 5-mFI in patients who had colorectal surgery. RESULTS: Of 295 490 patients, 45.8% had a score of 0, 36.2% had a score of 1 and 18% had a score of ≥ 2. On univariate analysis, frailer patients had significantly greater incidences for overall morbidity, serious morbidity, mortality, prolonged length of hospital stay, discharge to a facility other than home, reoperation and unplanned readmission. These findings were consistent on multivariate analysis where the frailest patients had greater odds of postoperative overall morbidity (OR 1.39; 95% CI 1.35-1.43), serious morbidity (OR 1.39; 95% CI 1.33-1.45), mortality (OR 2.00; 95% CI 1.87-2.14), prolonged length of hospital stay (OR 1.24; 95% CI 1.20-1.27), discharge destination to a facility other than home (OR 2.80; 95% CI 2.70-2.90), reoperation (OR 1.17; 95% CI 1.11-1.23) and unplanned readmission (OR 1.31; 95% CI 1.26-1.36). Weighted kappa statistics showed strong agreement between the 5-mFI and 11-mFI (kappa = 0.987, P < 0.001). CONCLUSIONS: The 5-mFI is a valid and easy to use predictor of 30-day postoperative outcomes after colorectal surgery. This tool may guide the surgeon to proactively recognize frail patients to instigate interventions to optimize them preoperatively.

Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome.

AIM: Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms. METHOD: A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed. RESULTS: Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001). CONCLUSION: Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.

Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial.

OBJECTIVE: To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up. DESIGN: Randomised controlled trial. SETTING: University hospital in Sweden. POPULATION: A total of 165 women diagnosed with a third- to fourth-degree perineal tear. METHODS: The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up. MAIN OUTCOME MEASURES: Anal incontinence measured by the validated Pescatori incontinence score. RESULTS: A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces. CONCLUSION: Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.

Pelvic organ prolapse and urinary incontinence in women with surgically managed rectal prolapse: a population-based case-control study.

PURPOSE: This study aimed to investigate the prevalence of genital prolapse surgery and urinary incontinence in female patients operated on for rectal prolapse compared with a matched control group without rectal prolapse. METHODS: Fifty-two patients with a history of abdominal rectal prolapse surgery and 200 randomly selected age-matched and gender-matched control subjects without rectal prolapse received an extensive health care history survey. RESULTS: Response rate in the patient group was 48 of 52 (92 percent) and 165 of 200 (82 percent) in the control group. Rectal prolapse was associated with an increased risk of surgery for uterine prolapse (odds ratio = 3.1; 95 percent confidence interval = 1.4-6.9) and vaginal wall prolapse (odds ratio = 3.2; 95 percent confidence interval = 1.3-7.8). Mean age at hysterectomy because of uterine prolapse was 54.7 years in the patient group compared with 62.6 years in the control group (P < 0.01). Mean age at vaginal wall prolapse surgery was 60.2 years in the patient group compared with 66.6 years in the control group (P < 0.05). There were no significant differences between the cohorts regarding prevalence or age at debut of urinary incontinence. CONCLUSION: Our results indicate a strong association between rectal and genital prolapse surgery suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment.