Selective non-antibiotic treatment in sigmoid diverticulitis: is it time to change the traditional approach?

BACKGROUND: A growing body of knowledge is calling into question the use of antibiotics in acute diverticulitis (AD). Moreover, recent studies provide evidence regarding the security of treating patients with AD as outpatients. The aim of this study was to evaluate a restrictive antibiotic outpatient protocol for the treatment of mild-to-moderate episodes of AD. METHODS: All patients with symptoms of AD presenting to our emergency department were assigned a modified Neff stage. Patients with mild AD received outpatient treatment without antibiotics. Patients with mild AD and comorbidities were admitted to receive the same treatment. Patients with moderate AD were admitted for 48 h and were then managed as outpatients until they had completed 10 days of antibiotic treatment. RESULTS: Between April 2013 and November 2014, we attended 110 patients with a diagnosis of AD, 77 of whom we included in the study: 45 patients with mild AD and 32 with moderate AD. Of the patients with mild AD, 88.8 % successfully completed the non-antibiotic, non-admission treatment regime and 95.5 % benefited from a non-antibiotic regime, whether as outpatients or inpatients. A total of 88 % of patients with mild AD and 87.5 % of patients with moderate AD who met the inclusion criteria completed treatment as outpatients without incident. No major complications (abscess, emergency surgery) or deaths were recorded. CONCLUSIONS: Outpatient treatment without antibiotics for patients with mild AD is safe and effective. Patients with moderate AD can be safely treated with antibiotics in a mixed regime as inpatients and outpatients.

Does stapled anopexy for bleeding haemorrhoids cure associated anaemia?

AIM: The aim of this study was to evaluate the effectiveness of stapled anopexy (SA) in patients with chronic bleeding haemorrhoids and secondary anaemia. METHOD: Our department performed 340 SA procedure per patient for haemorrhoids between January 1999 and December 2011. Fifty (14.7%) of these patients (25 male patients and 25 female patients) had anaemia (haemoglobin concentration < 13 g/dl in male patients and < 12 g/dl in female patients) secondary to chronic haemorrhoidal bleeding. Patients with colorectal bleeding and anaemia not caused by haemorrhoids were excluded. The mean (SD) age was 56.4 (13.9) years and the mean (SD) haemoglobin concentration was 9.2 (1.6) g/dl for male patients and 10.4 (1.2) g/dl for female patients. Five (10%) patients with anaemia had Grade II, 22 (44%) had Grade III and 23 (46%) had Grade IV haemorrhoids. The median (range) duration of postoperative follow-up was six (1-12) years. RESULTS: None of the patients required early postoperative admission or experienced early or late complications related to SA. The procedure was successful (normal haemoglobin concentration and no bleeding at 6 months postsurgery) in 45 (90%) patients. Of the five (10%) patients in whom SA was ineffective, one had Grade II, three had Grade III and one had Grade IV haemorrhoids. All these patients underwent Milligan-Morgan haemorrhoidectomy 3 months after SA. CONCLUSION: SA is an effective treatment for patients with bleeding haemorrhoids and subsequent anaemia. In our experience, the success rate was satisfactory and there were no serious complications.

Day case stapled anopexy for the treatment of haemorrhoids and rectal mucosal prolapse.

AIM: Stapled anopexy (SA) gives better early postoperative results than classical haemorrhoidectomy. The aim of this study is to demonstrate that SA is a safe and effective procedure for the treatment of haemorrhoids and rectal mucose prolapse in a day-case surgery programme. METHOD: From January 2000 to December 2008, 297 SA procedures were performed; 230 (77.4%) were performed in the Day Surgery Unit (DSU). Third- and fourth-degree haemorrhoids, second-degree haemorrhoids with no response to conservative treatment and several cases of rectal prolapse were included. The mean age of the patients in the series was 48.1 years (range 21-85). Preoperative preparation included phosphate enemas and antibiotic prophylaxis. Patients were operated on mainly under spinal anaesthesia. Day-case rate, postoperative pain (measured by a visual analogic scale, 1-10), admissions, re-admissions, early postoperative situation and recurrence were evaluated in the study. RESULTS: The overall DSU rate was 78%, with a progressive increase from 46% to 99% in 2008. One hundred and eighty-five patients (80%) had pain scores under 2; no patient had a pain score over 7. Eighteen (8%) patients required admission on the day of surgery. Late admission was needed for 3 (3%) patients. Thirty-three patients reported their situation as excellent, 174 as good, 20 as acceptable and three as bad when they answered a phone questionnaire 24 h after surgery. Overall, 20 (9%) patients had recurrence of symptoms. CONCLUSION: SA is a safe and effective procedure for prolapsing haemorrhoids in the day case setting. The recurrence rate is higher than that observed in classical haemorrhoidectomy. Most patients can be managed as day-cases.