Hartmann's procedure versus primary anastomosis for Hinchey stage III diverticulitis: a prospective case-control study.

INTRODUCTION: Hartmann's procedure (HP) is the conventional treatment in patients with complicated diverticulitis. Segmental resection with primary anastomosis (PA) is a treatment alternative for those patients. Our aim was to compare the postoperative results of HP and PA in patients with complicated diverticulitis (Hinchey stage III). METHODS: A case-control study was conducted on patients operated on for purulent Hinchey stage III diverticulitis, within the time frame of 2000 and 2019. RESULTS: Twenty-seven patients that underwent PA were compared with 27 that underwent HP. The patients that underwent HP had a greater probability of morbidity at 30 days (OR 3.5; 95% CI 1.13-11.25), as well as a greater probability of major complications (OR 10.9; 95% CI 1.26-95.05). CONCLUSION: The patients that underwent segmental resection and PA presented with lower morbidity rates and higher stoma reversal rates than the patients that underwent HP.

Laparoscopic resection and primary anastomosis for perforated diverticulitis: with or without loop ileostomy?

BACKGROUND: Evidence is growing about the benefits of laparoscopic resection with primary anastomosis (RPA) in perforated diverticulitis. However, the role of a diverting ileostomy in this setting is unclear. The aim of this study was to analyze the outcomes of laparoscopic RPA with or without a proximal diversion in Hinchey III diverticulitis. METHODS: This is a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for perforated Hinchey III diverticulitis during the period 2000-2019. The sample was divided into two groups: RPA without diversion (G1) and RPA with protective ileostomy (G2). Primary outcomes of interest were 30-day overall morbidity, mortality, length of hospital stay (LOS), and urgent reoperation rates. Secondary outcomes of interest included operative time, readmission, and anastomotic leak rates. RESULTS: Laparoscopic RPA was performed in 94 patients: 76 without diversion (G1) and 18 with proximal loop ileostomy (G2). Mortality (G1: 1.3% vs. G2: 0%, p = 0.6), urgent reoperation (G1: 7.9% vs. G2: 5.6%, p = 0.73), and anastomotic leak rates (G1: 5.3% vs. G2: 0%, p = 0.32) were comparable between groups. Higher overall morbidity (G1: 27.6% vs. G2: 55.6%, p = 0.02) and readmission rates (G1: 1.3% vs. G2: 11.1%, p = 0.03), and longer LOS (G1: 6.3 vs. G2: 9.2 days, p = 0.02) and operative time (G1: 182.4 vs. G2: 230.2 min, p = 0.003) were found in patients with proximal diversion. CONCLUSION: Laparoscopic RPA had favorable outcomes in selected patients with Hinchey III diverticulitis. The addition of a proximal ileostomy resulted in increased morbidity, readmissions, and length of stay. Further investigation is needed to establish which patients might benefit from proximal diversion.

Impacto de la subespecialización en los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III / Outcomes of emergent laparoscopic sigmoid resection for Hinchey III diverticulitis: Does specialization matter?

Introducción: La sigmoidectomía por diverticulitis perforada es una cirugía de urgencia comúnmente realizada por cirujanos generales. Está descripta la correlación positiva entre el volumen del cirujano y los mejores resultados postoperatorios. Sin embargo, existe escasa evidencia de la influencia de la especialización en cirugía colorrectal sobre los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada. Objetivo: Evaluar el impacto de la especialización en cirugía colorrectal en los resultados postoperatorios de la sigmoidectomía laparoscópica por diverticulitis Hinchey III. Diseño: Estudio retrospectivo sobre una base de datos cargada de forma prospectiva. Material y métodos: Se incluyeron pacientes sometidos a sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III. La muestra fue dividida en dos grupos: pacientes operados por un cirujano colorrectal (CC) y aquellos operados por un cirujano general (CG). Las variables demográficas, operatorias y postoperatorias fueron comparadas entre los grupos. El objetivo primario fue determinar si existían diferencias en la proporción de anastomosis primaria, morbilidad y mortalidad a 30 días entre los grupos. Resultados: Se incluyeron 101 pacientes en el análisis; 58 operados por CC y 43 por CG. Los pacientes operados por CC presentaron una mayor proporción de anastomosis primaria (CC: 98,3% vs. CG: 67,4%, p<0,001). Los CG realizaron más estomas (CC: 13,8% vs. CG: 46,5%, p<0,001), presentaron un mayor índice de conversión (CC: 20,6% vs. CG: 39,5%, p=0,03) y una mayor estadía hospitalaria (CC: 6,2 vs. CG: 10,8 días, p<0,001). La morbilidad global (CC: 34,4% vs. CG: 46,5%, p=0.22), dehiscencia anastomótica (CC: 3,5% vs. CG: 6,8%, p=0.48) y la mortalidad (CC: 1,7% vs. CG: 9,3 %, p=0,08) fueron similares entre ambos grupos. Conclusión: La sigmoidectomía laparoscópica de urgencia realizada por CG presenta similar morbilidad y mortalidad postoperatoria que la realizada por CC. Sin embargo, la participación del especialista se asoció a una mayor frecuencia de anastomosis primarias, menos estomas y una estadía hospitalaria más corta.

Background: Sigmoid resection for perforated diverticulitis is one of the most common emergency surgeries and often performed by general surgeons. Relationship between high-volume surgeons and improved postoperative outcomes is well established. However, the influence of colorectal specialization on outcomes after emergency laparoscopic sigmoidectomy for perforated diverticulitis is not well described. Aim: Evaluate the impact of colorectal surgery training on the outcomes after emergency laparoscopic sigmoid resection for Hinchey III diverticulitis. Design: Retrospective analysis of prospectively collected database.Method: Patients undergoing emergent laparoscopic sigmoid resection for perforated (Hinchey III) diverticulitis were identified and stratified by involvement of colorectal or general surgeon. This study was conducted from 2000 to 2018 at a teaching hospital. Primary outcome measures were primary anastomosis, postoperative morbidity and mortality.Results: A total of 101 patients were identified; 58 by colorectal and 43 by general surgeons. Patients in the colorectal surgeon group had higher rates of primary anastomosis (CS: 98, 2% vs. GS: 67, 4%, p<0.001). General surgeons performed more ostomies (CS: 13, 8% vs. GS: 46, 5%, p<0.001), had a higher conversion rate (CS: 20, 6% vs. GS: 39, 5%, p=0.03) and longer mean length of hospital stay (CS: 6, 2 vs. GS: 10, 8 days, p<0.001). Overall morbidity (CS: 34, 4% vs. GS: 46, 5%, p=0.22), anastomotic leak rate (CC: 3,5% vs. CG: 6,8%, p=0.48) and mortality (CS: 1, 7% vs. GS: 9,3 %, p=0.08) were similar between groups. Conclusion: Emergency laparoscopic sigmoid resection by general surgeons wasn ́t associated with higher rates of postoperative morbidity, anastomotic leakage or mortality. However, patients operated by colorectal surgeons had higher rates of primary anastomosis, lower rates of ostomy, conversion and shorter length of hospital stay.

Peritonitis diverticular: ¿Qué nos enseñó Ladies Trial? Análisis metodológico de su diseño, aplicación y resultados / Diverticular peritonitis: What did LADIES Trial teach us? Analysis of design, application and results

Contexto y Antecedentes: LADIES TRIAL es uno de los ensayos más importantes referidos a peritonitis diverticular. A pesar de este y otros ensayos publicados, aún se debate cuáles son los procedimientos adecuados para cada escenario de peritonitis diverticular, haciendo necesaria una revisión profunda de la metodología empleada en los ensayos para validar u objetar sus conclusiones. Objetivos: Analizar la metodología empleada en el diseño, aplicación, análisis de resultados y conclusiones de sus publicaciones. Secundariamente, colaborar en el mejoramiento de la investigación de la peritonitis diverticular y facilitar el análisis del tema por parte de los lectores. Métodos: Se analizaron las partes centrales de toda investigación, desde la pregunta de investigación, elaboración de hipótesis, operacionalización de variables y diseño del ensayo, análisis estadístico de resultados y conclusiones. Se buscaron errores, sesgos y debilidades que pudiesen objetar los hallazgos del estudio. Resultados: LADIES se trató de un estudio randomizado, abierto con análisis de superioridad según intención de tratar modificada en aquellos casos de incumplimiento de los criterios de inclusión y exclusión. Su diseño fue en general correcto, aunque en su aplicación se detectaron errores, debilidades y sesgos. En cuanto a resultados LOLA mostró que en Hinchey III el lavado laparoscópico tiene mayor morbimortalidad temprana que la sigmoidectomía, con un tiempo operatorio menor. Por su parte, DIVA mostró que en Hinchey III y IV la anastomosis primaria tiene mayor sobrevida libre de ostomía con menor morbilidad, combinando la cirugía inicial y cierre ostomía, respecto de la operación de Hartmann. Conclusiones: El no haber llegado al tamaño de muestra calculado hizo que solo grandes diferencias consiguieran significancia estadística. Las bajas frecuencias de eventos adversos acentuaron este problema metodológico. La especialización de los centros y cirujanos intervinientes, como la exclusión de pacientes hemodinámicamente inestables o bajo corticoterapia comprometieron su validación externa.

Background: LADIES TRIAL is considered one of the most important trials related to diverticular peritonitis. Its protocol and results were published in 2010, 2015, 2017, and 2019. Despite this one and other published trials, the proper procedures for each diverticular peritonitis scenario are still being debated, a thorough review of the methodology used in this trial is necessary to validate or reject their conclusions. Aim: To analyze the methodology used in the design, application, analysis of results, and conclusions of all LADIES TRIAL publications. Secondly, to collaborate in the improvement of the research about diverticular peritonitis and to facilitate its analysis by the readers. Methods: The central parts of a research trial were analyzed, from the research question, hypothesis development, operationalization of variables and trial design, statistical analysis of results, to conclusions. Errors, biases and weaknesses were searched for to try and challenge the trial's findings. Results: LADIES was a randomized, open-label, superiority trial analyzed according to intention to treat modified in cases of non-compliance with the inclusion-exclusion criteria. Its design was generally correct, although errors, weaknesses, and biases were detected in its application. Regarding results, LOLA showed that, in Hinchey 3, laparoscopic lavage has a higher rate in early morbidity and mortality than sigmoidectomy, but with a shorter operative time. For its part, DIVA showed that, in Hinchey 3 and 4, the primary anastomosis has higher ostomy-free survival with less morbidity, combining the initial surgery and ostomy closure, compared to the Hartmann procedure. Conclusions: Not having reached the sample size calculated in its design implies that only large effect differences achieved statistical significance. The low frequencies of adverse events accentuated this methodological problem. The specialization of the intervening centers and surgeons, the exclusion of hemodynamically unstable patients or patients undergoing steroid therapy, compromised the external validation of their findings.

Manejo conservador en diverticulitis aguda perforada con aire extraluminal / Conservative management of perforated diverticulitis with extraluminal air

Resumen Introducción: El tratamiento óptimo de la diverticulitis perforada con aire extraluminal (DPA) es materia de debate. El manejo conservador es controversial; en casos seleccionados puede ofrecer menor morbimortalidad y evitar una ostomía. Objetivo: Describir las características clínicas, imagenológicas, necesidad de intervención quirúrgica y morbimortalidad de pacientes con DPA tratados con manejo conservador. Materiales y Método: Estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de DPA hemodinámicamente estables sin evidencia de peritonitis entre los años 2009 y 2015. Resultados: Se hospitalizaron 162 pacientes con diagnóstico de diverticulitis aguda (DA), el 53,1% fueron diverticulitis agudas complicadas (DC), de las cuales el 43% (37 casos) eran DPA, la edad promedio fue 59,6 años, la mayoría eran mujeres (54,1%). Las manifestaciones clínicas más comunes fueron dolor abdominal (97,3%), signos peritoneales (59,5%) y fiebre (40,5%). La tomografía axial computada de abdomen y pelvis (TC AP) mostró burbujas extracolónicas en el 78,4% y neumoperitoneo en el 21,6%. El manejo conservador fue exitoso en el 87,8%. Durante el seguimiento de 71,2 meses la recurrencia fue 28,1% y el 31,3% se realizó sigmoidectomía electiva. La falla del tratamiento médico se presentó en 5 casos (12,2%), uno de los cuales fallece. Conclusión: el manejo conservador de la DPA es una alternativa válida de tratamiento con alto porcentaje de éxito en pacientes hospitalizados seleccionados. La decisión de cirugía de urgencia y de sigmoidectomía electiva posterior a una DPA tratada médicamente debe ser individualizada.

Background: The conservative management of perforated diverticulitis with extraluminal air (PDA) is controversial. In selected hospitalized patients may offer less morbidity and mortality and avoid an ostomy. Aim: To describe its clinical and imagenologic characteristics, the need for surgical procedure and morbimortality of patients with perforated diverticulitis with extraluminal air in conservative management. Materials and Methods: Retrospective descriptive study of hemodynamically stable hospitalized patients with a PDA diagnosis without evidence of peritonitis during the years 2009 and 2015. Results: 162 patients were admitted with the diagnosis of acute diverticulitis. 53.1% of cases were acute complicated diverticulitis, 43% (37 cases) were PDA. The average age was 59.6 years and most of them women (54.1%). The most common clinical manifestations were abdominal pain (97.3%), peritoneal signs (59.5%) and fever (40.5%). The abdomen and pelvic computerized axial tomography scan showed extra-colonic bubbles in 78.4% and pneumoperitoneum in 21.6%. The conservative management was successful in 87.8% of cases. After a 71.2-month follow-up, the recurrence was 28.1% and 31.3% had an elective sigmoidectomy. 5 cases did not respond to medical treatment, one of them resulting in death. Conclusion: The conservative management of PDA is a valid treatment option with a high degree of success in the selected sample of hospitalized patients. The decision of having emergency surgery and elective sigmoidectomy post DPA should be evaluated individually.

Emergent laparoscopic sigmoid resection for perforated diverticulitis: can it be safely performed by residents?

AIM: Outcomes after resident involvement in emergent colectomies have rarely been studied. The aim of this study was to analyse the outcomes of laparoscopic sigmoidectomy for Hinchey III diverticulitis performed by residents. METHOD: This study was a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for diverticulitis. The sample was divided into two groups: patients operated on by a supervised resident (SR) or a senior surgeon (SS). Supervising surgeons and SSs could be general surgeons (GSs) or colorectal surgeons (CSs). A SR was considered the first surgeon if he/she completed at least three of five defined steps of the procedure. The primary end-points included length of hospital stay (LOS), morbidity and 30-day mortality. A sub-analysis of patients operated on by a SR assisted by either a CS or GS was performed. RESULTS: Supervised residents and SSs operated on 59 and 42 patients, respectively. The presence of a CS was more frequent in the SS group (SR 41% vs SS 81%, P < 0.001). LOS (SR 9.4 days vs SS 6.4 days, P = 0.04) was higher in the SR group. Overall morbidity (SR 39% vs SS 43%, P = 0.69) and 30-day mortality (SR 5% vs SS 5%, P = 0.94) were also comparable among the groups. Procedures performed by SRs and supervised by a CS were associated with lower morbidity (GS 48% vs CS 25%, P = 0.06) and mortality (GS 8% vs CS 0%, P = 0.26). CONCLUSION: Laparoscopic sigmoidectomy for Hinchey III diverticulitis has comparable outcomes when performed by a supervised SR or a SS. Procedures performed by residents assisted by a CS seem to have better outcomes than those assisted by a GS.

Safety and feasibility of laparoscopic sigmoid resection without diversion in perforated diverticulitis.

BACKGROUND: Laparoscopic primary anastomosis (PA) without diversion for diverticulitis has historically been confined to the elective setting. Hartmann's procedure is associated with high morbidity rates that might be reduced with less invasive and one-step approaches. The aim of this study was to analyze the results of laparoscopic PA without diversion in Hinchey III perforated diverticulitis. METHODS: We performed a retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic sigmoidectomy for diverticular disease during the period 2000-2018. The sample was divided in two groups: elective laparoscopic sigmoid resection for recurrent diverticulitis (G1) and emergent laparoscopic sigmoidectomy for Hinchey III diverticulitis (G2). Demographics, operative variables, and postoperative outcomes were compared between groups. RESULTS: A total of 415 patients underwent laparoscopic sigmoid resection for diverticular disease. PA without diversion was performed in 351 patients; 278 (79.2%) belonged to G1 (recurrent diverticulitis) and 73 (20.8%) to G2 (perforated diverticulitis). Median age, gender, and BMI score were similar in both groups. Patients with ASA III score were more frequent in G2 (p: 0.02). Conversion rate (G1: 4% vs. G2: 18%, p < 0.001), operative time (G1: 157 min vs. G2: 183 min, p < 0.001), and median length of hospital stay (G1: 3 days vs. G2: 5 days, p < 0.001) were significantly higher in G2. Overall postoperative morbidity (G1: 22.3% vs. G2: 28.7%, p = 0.27) and anastomotic leak rate (G1: 5.7% vs. G2: 5.4%, p = 0.92) were similar between groups. There was no mortality in G1 and one patient (1.3%) died in G2 (p = 0.21). CONCLUSION: Laparoscopic sigmoid resection without diversion is feasible and safe in patients with perforated diverticulitis. In centers with vast experience in laparoscopic colorectal surgery, patients undergoing this procedure have similar morbidity and mortality to those undergoing elective sigmoidectomy.