Safety of nonoperative management after acute diverticulitis.

PURPOSE: The role of surgery in the management of diverticular disease after an episode of acute diverticulitis (AD) managed in a conservative form is evolving. Age, number of episodes of AD, type of episode, and symptoms after the episodes are factors related to the need for elective surgery. The aim of this study is to evaluate the safety of conservative management and the risk factors for emergency surgery after a first episode of AD managed without surgery. METHODS: We retrospectively evaluated 405 patients diagnosed as having had a first episode of AD. Sixty-nine patients underwent emergency surgery on the first admission, and 69 patients had an elective operation in the follow-up (group A). The remaining 267 patients were managed initially without surgery (group B). Thirteen of these 267 patients needed a further urgent surgical procedure. Factors involved in the decision of elective surgery and the probability of emergency surgery after the first episode of AD managed without surgery were evaluated in relation to demographic factors, risk factors, presence of recurrences, and type of the first episode. RESULTS: Patients, mean age was 62.7 years, 71 were aged less than 51, and 151 were males. The mean follow-up for patients with nonoperative management was 91.2 months. An elective operation was performed in 69 patients. Compared to patients in group B, those in group A more frequently had a first episode of complicated acute diverticulitis (CAD) (37.1% vs. 16.4%; P = 0.000) and were more likely to be smokers (46.3% vs. 19.3%; P = 0.000) and to suffer more than one episode of AD (42% vs. 26.9%; P = 0.027). Nonoperative management was chosen for 267 patients, but 13 patients needed an emergency operation later. In the multivariate analysis, we found a significant relation between the presence of CAD in the first episode and the need for emergency surgery. There were no differences in surgical mortality between the patients in the two groups, but patients treated with elective surgery had a higher rate of stoma than patients treated non-operatively (7.2% vs. 1.4%; P = 0.028); this difference was not observed in the subgroup of patients with CAD (15.3% vs. 6.8%; P = 0.458). CONCLUSION: After an episode of AD, nonoperative management is safe because fewer than 5% of patients will need an emergent procedure in a subsequent attack of AD. A first episode of CAD is the only risk factor for emergency surgery in patients managed conservatively.

Complicaciones de la anastomosis esofagogástrica en la operación de Ivor Lewis / Oesophagogastric anastomosis complications in the Ivor Lewis operation

Introducción La esofaguectomía es el principal tratamiento del cáncer de esófago. La dehiscencia de la anastomosis esofagogástrica es una complicación grave de la operación de Ivor Lewis que se asocia a una elevada mortalidad. El objetivo de este estudio es analizar su incidencia, su diagnóstico y los resultados del tratamiento. Material y métodos Análisis descriptivo de una serie consecutiva de esofaguectomías según la técnica de Ivor Lewis realizadas durante 5 años. Todas las anastomosis se realizaron de forma manual. Se registró la morbilidad general, dehiscencia de anastomosis, mortalidad intrahospitalaria, supervivencia y estenosis de la anastomosis. Resultados Se realizaron 41 anastomosis intratorácicas. Se presentaron complicaciones, de cualquier índole, en el 49% de los casos y se diagnosticaron 3 dehiscencias de la anastomosis (7,3%), una de ellas asintomática. Se reintervino de urgencia a un paciente, y los otros dos fueron tratados con drenajes y tratamiento conservador. La mortalidad de la serie fue del 7,3%, ninguna relacionada con la dehiscencia. La supervivencia a los 5 años fue del 27%. Un 34% de los pacientes desarrollaron estenosis de la anastomosis. Conclusiones La anastomosis intratorácica tras esofaguectomía puede realizarse, en nuestra experiencia, con una baja incidencia de dehiscencias y sin mortalidad por esta causa. El tratamiento de las mismas debe individualizarse y una parte considerable no precisa reintervención quirúrgica (AU)

Introduction: Oesophagectomy is the principal treatment for cancer of the oesophagus. The oesophagogastric anastomotic leak is a serious complication of the Ivor Lewis operation, and is associated with increased mortality. The objective of this study is to analyse its incidence, its diagnosis and treatment results. Material and methods: A descriptive analysis of a consecutive series of oesophagectomies, carried out during a 5 year period, using the Ivor Lewis technique. All patients had hand sewn anastomosis. Data were collected on general morbidity, anastomosis leak, hospitalmortality, survival, and stenosis of the anastomosis. Results: A total of 41 intrathoracic anastomoses were performed. Complications, of any type, were observed in 49% of cases, of which 3 (7.3%) were anastomotic leaks, one of the masymptomatic. One patient was urgently reoperated, and two others were treated with drains and conservative treatment. The mortality of the series was 7.3%, none associated with the anastomotic leak. The survival at 5 years was 27%, and 34% of the patients developed stenos is of the anastomosis. Conclusions: Intrathoracic anastomosis after oesophagectomy, in our experience, can be performed with a low incidence of anastomotic leaks and without mortality due to this cause. Their treatment must be individualised and a considerable proportion do not require surgical intervention (AU)

[Oesophagogastric anastomosis complications in the Ivor Lewis operation]. / Complicaciones de la anastomosis esofagogástrica en la operación de Ivor Lewis.

INTRODUCTION: Oesophagectomy is the principal treatment for cancer of the oesophagus. The oesophagogastric anastomotic leak is a serious complication of the Ivor Lewis operation, and is associated with increased mortality. The objective of this study is to analyse its incidence, its diagnosis and treatment results. MATERIAL AND METHODS: A descriptive analysis of a consecutive series of oesophagectomies, carried out during a 5 year period, using the Ivor Lewis technique. All patients had hand sewn anastomosis. Data were collected on general morbidity, anastomosis leak, hospital mortality, survival, and stenosis of the anastomosis. RESULTS: A total of 41 intrathoracic anastomoses were performed. Complications, of any type, were observed in 49% of cases, of which 3 (7.3%) were anastomotic leaks, one of them asymptomatic. One patient was urgently reoperated, and two others were treated with drains and conservative treatment. The mortality of the series was 7.3%, none associated with the anastomotic leak. The survival at 5 years was 27%, and 34% of the patients developed stenosis of the anastomosis. CONCLUSIONS: Intrathoracic anastomosis after oesophagectomy, in our experience, can be performed with a low incidence of anastomotic leaks and without mortality due to this cause. Their treatment must be individualised and a considerable proportion do not require surgical intervention.