Is it possible to limit the use of CT scanning in acute diverticular disease without compromising outcomes? A preliminary experience.

The aim of our study was to determine whether the use of CT scanning in the assessment of acute diverticulitis can be reduced without a negative effect on outcome. Our series consisted of 93 out of 100 patients with acute diverticulitis admitted to the Emergency Room of our institution in the period from February 2012 to March 2013.The Hinchey classification system was used to stage disease based on findings on ultrasound (US) examination and/or computed tomography (CT) scanning. We compared the patients' Hinchey stage (HS) on admission and 72 hours later. Types of treatment were defined as emergency or delayed intervention (operative approaches (OA); ultrasound-guided percutaneous drainage (UPD), and surgery. The borderline between conservative and surgical management was identified. In patients with a HS

"High or low Inferior Mesenteric Artery ligation in Laparoscopic low Anterior Resection: study protocol for a randomized controlled trial" (HIGHLOW trial).

BACKGROUND: The position of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision can affect genito-urinary function, bowel function, oncological outcomes, and the incidence of anastomotic leakage. Ligation to the inferior mesenteric artery at the origin or preservation of the left colic artery are both widely performed in rectal surgery. The aim of this study is to compare the incidence of genito-urinary dysfunction, anastomotic leak and oncological outcomes in laparoscopic anterior rectal resection with total mesorectal excision with high or low ligation of the inferior mesenteric artery in a controlled randomized trial. METHODS/DESIGN: The HIGHLOW study is a multicenter randomized controlled trial in which patients are randomly assigned to high or low inferior mesenteric artery ligation during laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. Inclusion criteria are middle or low rectal cancer (0 to 12 cm from the anal verge), an American Society of Anesthesiologists score of I, II, or III, and a body mass index lower than 30. The primary end-point measure is the incidence of post-operative genito-urinary dysfunction. The secondary end-point measure is the incidence of anastomotic leakage in the two groups. A total of 200 patients (100 per arm) will reliably have 84.45 power in estimating a 20% difference in the incidence of genito-urinary dysfunctions. With a group size of 100 patients per arm it is possible to find a significant difference (α = 0.05, ß = 0.1555). Allowing for an estimated dropout rate of 5%, the required sample size is 212 patients. DISCUSSION: The HIGHLOW trial is a randomized multicenter controlled trial that will provide evidence on the merits of the level of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision in terms of better preserved post-operative genito-urinary function. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02153801 Protocol Registration Receipt 29/5/2014.

Limiting stochastic harm when monitoring diverticular flogosis for lower Hinchey classes. Personal proposal for a selection method Reliability Ultrasound Score (RUS).

BACKGROUND: An article in the BMJ issueof May 2012 (11) tackled the issue of safeguarding health by preventing diagnostic overtreatment. An observation of the diagnostic options in clinical routine enabled us to critically assess the appropriateness or notof the use of ionising radiation in monitoring acute diverticulitis by means of CT imaging. This disease, which has alwaysbeen frequent in elderly patients, has recently assumed a new role as an endemicdiseasein the Caucasian populationaged 40 to 50 in the Western world (6). MATERIAL AND METHOD: We considered 79 cases coming under observation in the Emergency Roomover a period of 115 months, selected from a pool of 136 according to Hinchey Score (Hs) 0-1a-1b- assigned on admission after an Ultrasound(US) examination . The choice of the first diagnostic approach depended on the severity of the patient 's clinical condition, the degree of collaboration of the same and the discretion of the radiologist, although the concerted opinion was to prefer the US test given its clearly- established advantages of being convenient and harmless. During the period of recovery we noted the tendency to subordinate the choice of instrument to the habit and discretion of the attending practitioner. Our proposal was to introduce a standardised personal criterion which took into account the problem of stochastic harm from ionising radiation. The need of exposure or not to verify the clinical condition by means of a CT as opposed to a US was thus deduced by means of an Reliability Ultrasound Score (RUS) RESULTS: Using such score we were able to schedule in 14 out of the 37 cases in one branch of the study, an effective diagnostic check-up programmein safety and with an overall saving of 32 % of the ionising radiation. During this study wequantified a total amount of miniSivertnot dispensed, in 79 cases with Hs<2deserving of hospital admission. CONCLUSION: This choice moves in the direction of safeguarding the patient fromdiagnostic overtreatment,with a potential increase in stochastic harm. The application of a reliability assessment filterof the US examination is currently in the study phase as regards acute diverticular disease in classesHS=/>2°.