Predictive value of a pathophysiological score in the surgical treatment of perforated diverticular disease.

Resection is the preferred method of perforated diverticular disease treatment compared to conservative treatment. However, the immediate or deferred timing of bowel continuity restoration for advanced degrees of peritoneal contamination is debatable. This is a retrospective study designed to identify operative mortality predictors and guidelines for safe primary anastomosis. A pathophysiological score (acute physiology and chronic health evaluation, APACHE II) was applied to 135 consecutive patients who had undergone surgery for acute inflammatory complication of diverticular disease. A multivariate analysis was used to identify prognostic factors such as age, chronic diseases, neoplastic cancer, Acute Physiology Score (APS), Hinchey's classification and APACHE II scores. Seventy patients underwent primary resection and anastomosis, 35 underwent Hartmann's procedure and 15 conservative treatment. There was a significant correlation between operative mortality and increasing disease severity based on Hinchey's classification, APS and APACHE II scores. The multivariate analysis proved APACHE II scores to be the only prognostic factor of operative mortality. Both single and multivariate analysis of variance failed to identify a factor significantly associated with surgical and/or medical postoperative complications. APACHE II scores were the best predictor for operative mortality in patients with diverticular disease complications, but none of the classification criteria used was effective in predicting postoperative complication. Patients with phlegmonous sigmoiditis can be safely treated with primary resection and anastomosis. Conservative treatment should not be considered an effective method for diverticular disease. A prospective trial comparing resection with and without colostomy should be done for local and diffuse purulent peritonitis treatment. Hartmann's procedure is seen to be the only indicator for faecal peritonitis.

Patterns of distribution of endoscopic and histological changes in the ileal reservoir after restorative proctocolectomy for ulcerative colitis. A long-term follow-up study.

OBJECTIVE: This study was undertaken to assess the long-term macroscopic appearance of the ileal reservoir after restorative proctocolectomy for ulcerative colitis, to determine whether there is any correlation between macroscopic and histological changes and whether the distribution of these is homogeneous, focal or patchy. BACKGROUND: No study has examined the macroscopic appearance of the ileal reservoir over a long period and it is still unknown to what degree histological changes are diffuse or patchy. Moreover, the relationship between macroscopic and histological changes is poorly understood. METHOD: Fifty-nine patients were examined by one clinician (PSC) 5.3-14.5 years (median 8.2 years) postoperatively. A rigid sigmoidoscopy of the reservoir was performed. Four zones in the posterior midline at 5-cm intervals from the ileoanal anastomosis were inspected. At each level a macroscopic score of severity of inflammation was given and a biopsy taken. The degree of acute and chronic inflammation was assessed using a histopathological scoring system. RESULTS: All reservoirs showed macroscopic abnormalities, which were more marked distally in 14 (24%). There was no case in which severity of inflammation was greater in proximal than in distal zones. Endoscopy overall correlated with both acute and chronic histological changes. On histological examination the patients could be divided into three groups as follows: (1) all four biopsies were normal (group 1, n = 8, 14%), (2) the score of acute and chronic inflammation decreased from distal to proximal zones (group 2, n = 25, 42%) and (3) all four biopsies were abnormal with the same score (group 3, n = 26, 44%). The latter group significantly correlated with a present or past history of pouchitis. CONCLUSION: The study has shown that when there is a gradation of inflammation within the ileal reservoir this is more severe in distal than in proximal zones.