Background
The present German National Guideline is an updated version of previous Guideline published in 2014. It aims to compare various treatment methods and to assist physicians with ...evidence-based recommendations.
Methods
Systemic literature review.
Results
Three types of disease manifestation could be differentiated: asymptomatic disease, an acute abscess, and the chronic pilonidal disease. At present, there is no treatment method fulfilling all desired criteria: simple, painless procedure associated with rapid wound healing, and low recurrence rate. Thus, treatment modality should be tailored to disease manifestation and extent.
Conclusion
Asymptomatic pilonidal disease should not be treated. A pilonidal abscess should be unroofed. After resolution of the acute inflammation, the disease should be treated definitely. As for today, sinus excision is the standard treatment of the chronic pilonidal disease. Wide excision and open treatment of chronic disease is a safe procedure which, however, leads to prolonged secondary healing and time off-work, as well as to considerable recurrence rate. The extent of excision should be as limited as possible. Excision and midline wound closure is associated with impaired outcomes. Today, it has become obsolete. Minimally invasive procedures (e.g., pit picking surgery) represent a treatment option for chronic pilonidal disease. However, the recurrence rate is higher compared to excision procedures. Nevertheless, they may be used for small primary disease. Off-midline procedures should be used for disease not suitable for minimally invasive treatments. The Limberg flap and the Karydakis procedure are two best described methods which are associated with similar short- and long-term results.
Purpose
The present national guideline aims to provide recommendations for physicians involved in the treatment of patients with pilonidal disease. It has been published previously as an extended ...version in German language.
Methods
This is a systemic literature review. The present guideline was reviewed and accepted by an expert panel in a consensus conference.
Results
Some of the present guideline conclusions were based on low- to moderate-quality trials. Therefore, an agreement was necessary in those cases to provide recommendations. However, recommendations regarding the most frequently used surgical procedures were based on numerous prospective randomized trials.
Conclusions
An asymptomatic pilonidal disease does not require treatment. A pilonidal abscess should be incised. After regression of the acute inflammation, a definitive treatment method should be applied. An excision is the standard treatment method for the chronic pilonidal disease. Open wound healing is associated with a low postoperative morbidity rate; however, it is complicated by a long healing time. The minimally invasive procedures (e.g., pit picking surgery) represent a potential treatment option for a limited chronic pilonidal disease. However, the recurrence rate is higher compared to open healing. Excision followed by a midline wound closure is associated with a considerable recurrence rate and increased incidence of wound complications and should therefore be abandoned. Off-midline procedures can be adopted as a primary treatment option in chronic pilonidal disease. At present, there is no evidence of any outcome differences between various off-midline procedures. The Limberg flap and the Karydakis flap are most thoroughly analyzed off-midline procedures.
Purpose
Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a “Damage Control Strategy” ...(DCS).
Materials and methods
Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept:
1
limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and
2
definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann’s procedure) after 24–48 h.
Results
Fifty-eight patients were included into the analysis W:M 28:30, median age 70.1 years (30–92). Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (
n
= 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (
n
= 5), and median postoperative hospital stay was 18.5 days (3–66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%).
Conclusion
The use of the
Damage Control
strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.
Purpose
End-ileostomy after two-staged ileocolic resection is frequently performed in Crohn’s disease patients at high risk for postoperative complications. However, there is paucity on data ...regarding the morbidity after the stoma reversal.
Methods
One hundred thirty patients undergoing closure of end-ileostomy between 1994 and 2016 were included. Data collection was retrospective in 11 first, and it was prospective in 119 last patients. Anastomotic complications were defined as anastomotic leak, perianastomotic abscess, and perianastomotic peritonitis.
Results
The median interval between ileostomy construction and reversal was 4.0 months. Ninety-seven of 121 patients with available data (80%) gained weight between both surgeries. Hemoglobin level increased between surgeries in 107 patients (85%). Fifteen patients (11.5%) received parenteral fluid substitution or parenteral nutrition between both surgeries. There were 37 hospital readmissions during the time between stoma construction and reversal (29%). After ileostomy reversal, 14 patients developed anastomotic complications (11%). By multivariate regression analysis, preoperative steroid intake (hazard ratio 4.5, 95% CI: 1.11–18.0,
p
= 0.035) and hospital readmission for infectious complications (HR 4.5, 95% CI: 1.11–18.0, p = 0.035) were statistically significantly associated with an increased risk to develop postoperative anastomotic complications. There were no postoperative deaths.
Conclusion
Closure of end-ileostomy could be complicated by some serious morbidity. These risks should be taken into consideration weighing carefully between the one- and two-stage ileocolic resection in Crohn’s disease patients.
Background
The best surgical strategy for the management of perforated diverticulitis with generalized peritonitis of the sigmoid colon is not clearly defined. The aim of this retrospective cohort ...study was to evaluate the value of a damage control strategy.
Methods
All patients who underwent emergency laparotomy for perforated diverticular disease of the sigmoid colon with generalized peritonitis between 2010 and 2015 were included. The damage control strategy (study group), included a two- stage procedure: limited resection of the diseased colonic segment, closure of proximal colon and distal stump, and application of an abdominal vacuum at the initial surgery followed by second-look laparotomy 24–48 h later At this point a choice was made between anastomosis and Hartmann’s procedure. The control group consisted of patients receiving definitive reconstruction (anastomosis or Hartmann’s procedure) at the initial operation.
Results
Thirty-seven patients were included in the study. Damage control strategy was applied in 19 patients and the control group consisted of 18 patients. Both groups were comparable in terms of demographics, severity of peritonitis, and comorbidities. The overall postoperative mortality was 11 % (
n
= 4). There were no statistically significant differences between both groups regarding postoperative morbidity and mortality; however, a significantly higher proportion of patients in the control group had a stoma after the initial hospital stay (83 vs. 47 %,
p
= 0.038). This difference was still significant after adjustment for sex, age, Mannheim Peritonitis Index, American Society of Anesthesiologists class and presence of septic shock at presentation. At the end of the follow-up period, 15 of 17 survivors in the study group and 13 of 16 survivors in the control group had their intestinal continuity restored (
p
= 0.66).
Conclusions
Damage control strategy in patients with generalized peritonitis due to perforated diverticulitis leads to a significantly reduced stoma rate after the initial hospital stay without an increased risk of postoperative morbidity.
Purpose
Damage control strategy
(DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter ...cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery.
Methods
Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included.
Damage control strategy
is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann’s procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed.
Results
Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%,
p
= 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9;
p
= 0.001), and increased operation time (105 vs. 84 min.,
p
= 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (
p
< 0.001). Complication rate (44 vs. 24%,
p
= 0.092), mortality (12 vs. 0%,
p
= 0.061), overall number of surgeries (3.4 vs. 2.4,
p
= 0.017), enterostomy rate (76 vs. 36%,
p
= 0.001), and length of hospital stay (25 vs. 18.8 days,
p
= 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%,
p
= 0.005) and with fungal infection (100 vs. 49%,
p
= 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%,
p
< 0.001), enterostomy rate (81 vs. 48%,
p
= 0.017), and anastomotic leakage (29 vs. 6%,
p
= 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%,
p
= 0.014).
Conclusion
Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.
Purpose
To identify the impact of the severity of diverticular disease on long-term quality of life.
Methods
Consecutive patients, hospitalized between October 2009 and November 2015 due to ...uncomplicated (UD) and complicated diverticulitis (CD) of the left colon, were analyzed. Patients undergoing emergent surgery for perforated disease were excluded. Primary endpoint was health-related quality of life (HrQol), measured by the Short Form 36 questionnaire (SF-36). Physical (PCS) and mental (MCS) compository scores were calculated from SF-36 subscales. To overcome bias, one-to-one propensity score matching and multivariable logistic regression analysis were performed.
Results
Two hundred eighty of the overall 392 patients (Male 138, Female 142; mean age 60.5 years, range 27–91) answered the SF-36 questionnaire. The median follow-up period was 37.8 months (range 15–85). After propensity score matching, each group consisted of 51 patients. Results of the SF-36 questionnaires showed a statistically significant difference, favoring patients with CD in 5 of 8 domains. Also, PCS (56.3 vs. 52.9,
p
= 0.13) and MCS (53.3 vs. 46.7,
p
= 0.005) were higher in patients treated for CD. By a multivariate analysis, complicated disease was independently associated with a better scoring on 6 out of 8 SF-36 subscales and on MCS. Treatment strategy (surgery or conservative) did not have any impact on SF-36 subscales, MCS, or PCS on multivariate analysis.
Conclusion
In contrast to complicated disease, the uncomplicated diverticular disease is associated with an impaired long-term quality of life especially in domains composing mental health scores independently of chosen treatment strategy.
Study registration
The study is registered with the Research Registry at June 19, 2019.
Research registry UIN:
researchregistry4959
.
Abstract
Background
To assess the risk of postoperative peristomal pyoderma gangrenosum in Crohn’s disease patients undergoing bowel resection with formation of an ostomy.
Methods
All patients with ...Crohn’s disease undergoing intestinal resection with formation of an ostomy were included in the present retrospective analysis. The data collection was performed prospectively. All cases of pyoderma gangrenosum were identified by clinical examination and documented on photographs. “Extended colectomies” were total colectomy and proctocolectomy.
Results
Between 2009 and 2021, 99 patients underwent intestinal resections with formation of an ostomy – 95 ileostomies and 4 colostomies. Ileocolic resections were performed in 62 patients, small bowel resections in 2 and colorectal resections in 35 patients. Additional abdominoperineal rectal resections were performed in 19 out of latter 35 patients. At the time of surgery, 31 patients were on biological treatment, 19 on steroids. Postoperatively, 10 patients (10%) developed peristomal pyoderma gangrenosum – all during first 3 postoperative months and all in presence of an ileostomy. By univariate analysis, abdominoperineal resection (26% vs. 9%, p=0.03), presence of colonic disease (20% vs. 2%, p=0.005), preoperative biological treatment (24% vs. 4%, p=0.008), extended colectomy (27% vs. 5%, p=0.008), non-stricturing/non-penetrating disease (35% vs. 5%, p=0.002) were associated with an increased risk of peristomal pyoderma gangrenosum. By multivariate analysis, preoperative intake of biologic treatment (Hazard Ratio 5.5, p=0.03), and non-stricturing/non-penetrating disease (HR 8.3, p=0.006) were associated with the risk of postoperative pyoderma gangrenosum.
Conclusion
Crohn’s disease patients with colonic disease undergoing bowel resections for non-stricturing/non-penetrating disease are at high risk to develop peristomal pyoderma gangrenosum during the early postoperative period. Preoperative biological treatment does not decrease the risk of pyoderma formation; moreover, it might even increase it.
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