Background
Colonoscopy in patients with diverticulosis can be technically challenging and limited data exist relating to the risk of post-colonoscopy diverticulitis. Our aim was to evaluate the ...incidence, management, and outcomes of acute diverticulitis following colonoscopy.
Methods
Study design is retrospective cohort study. Data were gathered by conducting an automated search of the electronic patient database using current procedural terminology and ICD-9 codes. Patients who underwent a colonoscopy from 2003 to 2012 were reviewed to find patients who developed acute diverticulitis within 30 days after colonoscopy. Patient demographics and colonoscopy-related outcomes were documented, which include interval between colonoscopy and diverticulitis, colonoscopy indication, simultaneous colonoscopic interventions, and follow-up after colonoscopy.
Results
From 236,377 colonoscopies performed during the study period, 68 patients (mean age 56 years) developed post-colonoscopy diverticulitis (0.029%; 2.9 per 10,000 colonoscopies). Incomplete colonoscopies were more frequent among patients with a history of previous diverticulitis
n
= 10 (29%) vs.
n
= 3 (9%),
p
= 0.03. Mean time to develop diverticulitis after colonoscopy was 12 ± 8 days, and 30 (44%) patients required hospitalization. 34 (50%) patients had a history of diverticulitis prior to colonoscopy. Among those patients, 14 underwent colonoscopy with an indication of surveillance for previous disease. When colonoscopy was performed within 6 weeks of a diverticulitis attack, surgical intervention was required more often when compared with colonoscopies performed after 6 weeks of an acute attack
n
= 6 (100%) vs.
n
= 10 (36%),
p
= 0.006. 6 (9%) out of 68 patients received emergency surgical treatment. 15 (24%) out of 62 patients who had non-surgical treatment initially underwent an elective sigmoidectomy at a later date. Recurrent diverticulitis developed in 16 (23%) patients after post-colonoscopy diverticulitis.
Conclusions
Post-colonoscopy diverticulitis is a rare, but potentially serious complication. Although a rare entity, possibility of this complication should be kept in mind in patients presenting with symptoms after colonoscopy.
Purpose
The aim of this study was to evaluate the impact of various factors on 30-day postoperative morbidity in patients who underwent colorectal surgery (CRS) for colovesical fistula (CVF) in the ...elective and emergency settings.
Methods
Patients who underwent CRS for CVF between 2005 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database by using current procedural terminology codes. Demographics, perioperative, and operative factors were assessed and compared between two groups classified according to the presence or absence of postoperative complications.
Results
Five hundred twelve patients met the inclusion criteria mean age of 61.4 (±14.7) years, female 214 (42%). Etiology of fistula was diverticulitis
N
= 438 (85.5%), colon cancer
N
= 39 (7.6%), and Crohn’s disease
N
= 35 (6.8%). One hundred fifty-two procedures (29.7%) were performed laparoscopically. In 186 patients (36%), no bladder intervention was performed. One hundred forty-nine patients (29.1%) had at least one postoperative complication. Patients who developed complication were older (
P
= <0.001), more often female (
P
= <0.001), hypertensive (
P
= 0.005), anemic (
P
= <0.001), preoperatively transfused (
P
= 0.02), and with class 2–3 wound classification (
P
= 0.01). Independent risk factors affecting morbidity were increased age odds ratio (OR) 1.23 (1.03–1.47),
P
= 0.01, decreased hematocrit level OR 3.04(1.83–5.06),
P
< 0.0001, and open approach OR 2.56 (1.35–4.84),
P
= 0.003.
Conclusions
Morbidity for CVF remains high. Lower preoperative hematocrit level and increased age were associated with higher risk of complication. Laparoscopic surgery may be preferable when possible as morbidity is less with this approach.
Splenic artery pseudoaneurysm is uncommon. We report our institution's recent 18-year experience with these aneurysms and review the literature.
We reviewed the records for 37 patients with visceral ...artery pseudoaneurysm evaluated at our institution from 1980 to 1998. From this group we found only 10 patients (27%) with splenic artery pseudoaneurysm. We also reviewed 147 cases of splenic artery pseudoaneurysm reported in the English literature.
In this series of 10 patients, 5 were men. Mean age was 51.2 years (range, 35-78 years). Causes of aneurysm included chronic pancreatitis in 4 patients, trauma in 2 patients, iatrogenic cause in 1 patient, and unknown cause in 3. The most common symptom was bleeding in 7 patients and abdominal or flank pain in 5 patients; 2 patients had no symptoms. Aneurysm diameter was known for four pseudoaneurysms, and ranged from 0.3 to 3 cm (mean, 1.7 cm). Splenectomy and distal pancreatectomy were performed in 4 patients, splenectomy alone in 2 patients, endovascular transcatheter embolization in 2 patients, and simple ligation in 1 patient. One patient with a ruptured pseudoaneurysm died before any intervention could be performed; there were no postoperative deaths. Follow-up data were available for 7 patients, with a mean of 46.3 months (range, 4.5-120 months).
Splenic artery pseudoaneurysm is rare and usually is a complication of pancreatitis or trauma. Average aneurysm diameter in our series of 10 patients was smaller than previously reported (1.7 cm vs 5.0 cm). Although conservative management has produced excellent results in some reports, from our experience and the literature, we recommend repair of all splenic artery pseudoaneurysms.
Purpose
Endoscopic stenting is used with increasing frequency to treat colorectal conditions. Little is known about what influences outcome. This study aimed to determine the impact of various ...factors on the short- and long-term results of colorectal stenting.
Methods
A retrospective review was conducted of all endoscopic stenting procedures performed by a colorectal surgeon at a tertiary referral institution between 2003 and 2013. Main outcome measures included technical success, clinical success, complications, and predictors of outcome.
Results
Of the stent procedures, 183 were performed in 165 patients. The majority of patients (90 %) presented with a malignant obstruction (intrinsic colonic vs. extrinsic non-colonic). Carcinomatosis was present in 22 % of patients with malignancy, and it was associated with lower technical success compared to non-carcinomatosis (adjusted odds ratio AOR 0.2 95 % confidence interval (CI) 0.1–0.8;
p
= 0.021). Colonic malignancy was associated with higher clinical success compared to non-colonic malignancy (AOR 3.8 95 % CI 1.4–10.3;
p
= 0.009). Carcinomatosis increased the risk of complications compared to non-carcinomatosis (AOR 3.2 95 % CI 1.0–10.0;
p
= 0.049). The risk of complication was higher when a stent was deployed in the rectum compared to the colon (AOR 4.1 95 % CI 1.5–11.7;
p
= 0.008). The use of a covered stent was associated with higher complication rate compared to a non-covered stent (AOR 13.6 95 % CI 2.6–71.2;
p
= 0.002). Balloon dilation was associated with an increased risk of complications (AOR 4.6 95 % CI 1.3–16.2;
p
= 0.017).
Conclusions
Carcinomatosis was associated with lower technical success rate. Clinical success was higher in patients with a primary colonic malignancy. The use of a covered stent, balloon dilation of stricture, lesions in the rectum, and carcinomatosis were associated with higher risk for complications.
Although the technical success rate of endoscopic stenting has been defined, there is a paucity of outcome data. The purpose of this study was to evaluate the long-term results of colorectal stenting ...for both malignant and benign disease. A retrospective review was conducted of patients who underwent stenting at a tertiary center over 4 years. One surgeon performed all stents under endoscopic and fluoroscopic guidance. A total of 49 stent procedures were performed in 36 patients (19 females, mean age 65 years). Mean follow-up was 15 months. Twenty-eight patients (78%) underwent stenting for malignant disease and eight patients (22%) for benign conditions. The most common reason for intervention was obstruction (81%). Technical success rate was 72 per cent. Carcinomatosis was associated with a higher technical failure rate. Procedural related complications occurred in two patients (6%). Long-term stent migration rate was 24 per cent and was more common in patients with benign disease and patients who received nonmetal stents or stents with diameter < 25 mm. Endoscopic reintervention was required in 33 per cent of patients with initial technical success. Long-term need for subsequent operative intervention was 14 per cent. Endoscopic stenting is a viable option for a select group of patients with colorectal disease. Patient's selection and stent choice influence outcome.
Background
This study aimed to compare perioperative outcomes of patients undergoing robotic, laparoscopic, and open colectomy using a procedure‐targeted database.
Methods
Retrospective review of ...patients undergoing elective colectomy in 2013 was conducted using the procedure‐targeted database of the American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP). Robotic, laparoscopic, and open groups were matched (1:1:1) based on age, gender, body mass index, surgical procedure, diagnosis and ASA classification. Demographics, comorbidities, and short‐term (30 day) outcomes were compared.
Results
Out of 12 790 patients, 387 fulfilled criteria per group after matching. Univariate comparison showed operating time was longer (P < 0.001) and hospital stay was shorter (P < 0.001) in the robotic group. Morbidity (P < 0.001), superficial SSI (P < 0.001), bleeding requiring transfusion (P < 0.001), ventilator dependency (P = 0.003), and ileus (P < 0.001) rates were lower in the robotic group. After adjusting for confounders, outcomes were comparable between the groups except hospital stay which was shorter in the robotic group (P < 0.001).
Conclusions
ACS‐NSQIP data demonstrated several short‐term advantages of robotic surgery compared with laparoscopic and open surgery.
The present study reports an early institutional experience with robotic proctectomy (RP) and outcome comparison with laparoscopic proctectomy (LP) in patients with inflammatory bowel disease (IBD). ...Patients who underwent either RP or LP during proctocolectomy for IBD between January 2010 and June 2014 were matched (1:1) and reviewed. Twenty-one patients undergoing RP fulfilled the study criteria and were matched with an equal number of patients who had LP. Operative time was longer (304 vs. 213 min, P=0.008) and estimated blood loss was higher in the RP group (360 vs. 188 mL, P=0.002). Conversion rates (9.5% vs. 14.3%, P>0.99), time to first bowel movement(2.29±1.53 vs. 2.79±2.26, P=0.620), and hospital length stay(7.85±6.41 vs. 9.19±7.47 d, P=0.390) were similar in both groups. No difference was noted in postoperative complications, ileal pouch to anal canal anastomosis-related outcomes, Cleveland Global Quality of Life, and Short Form-12 health survey outcomes between RP and LP. Our good results with standard laparoscopy are unlikely to be improved with robotics in proctectomy cases. Potential benefits of robotic approach for completion proctectomy warrant further investigation as experience grows with robotics.
One component of the Surgical Care Improvement Project (SCIP) is the prevention of surgical site infections (SSIs) by: 1) timing the administration of prophylactic antibiotics (PAs) within 1 hour of ...incision; 2) using approved PA regimens; and 3) discontinuing PA within 24 hours. We sought to evaluate institutional compliance with SCIP recommendations in patients undergoing elective colorectal surgery and determine whether they affected the incidence of SSI. One hundred four elective colorectal cases were reviewed. In 58 patients (56%), PAs were administered within 1 hour of incision. In 71 cases (68%), the PA choice was considered compliant. There were a total of 12 SSIs (11.5%) overall. The incidence of SSI was significantly higher in cases in which PAs were not administered within 1 hour of incision (10 of 46 or 22% vs two of 58 or 3.5%, P = 0.005). There was no significant difference in the incidence of SSI in patients who received compliant versus noncompliant PA (12.7% vs 9.1%, P = 0.75). Timely PA administration significantly reduces the incidence of SSI in patients undergoing elective colorectal surgery. Efforts should focus on ensuring that PAs are given in a timely manner to reduce SSI in colorectal surgery.
The purpose of this study was to determine the long-term outcome of endorectal advancement flap (ERF) for complex anorectal fistulae. A total of 38 ERF were performed in 36 patients (2003-2007). Mean ...age was 45 years. The most common fistula type was transsphincteric. Eighty-one per cent of patients had prior surgical interventions. Primary closure rate was 83 per cent. Of the six initial failures, four were noted in patients operated for recurrent rectovaginal fistula. Postoperative complications occurred in seven patients (19%). During a mean follow-up of 27 months, recurrent disease was noted in five patients (14%). All recurrences were noted in patients with left sided fistulae. At last follow-up, all patients had healed their fistula except for two. We conclude that ERF closed most complex anorectal fistulae with an acceptable complication rate and low recurrence rate. Recurrent rectovaginal fistula was associated with a lower closure rate.
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