Gastrointestinal quality of life after laparoscopic-assisted sigmoidectomy for diverticular disease.

PURPOSE: Laparoscopic-assisted sigmoidectomy is a widely applied technique in the operative treatment of diverticular disease. Treatment guidelines recommend operation of complicated diverticulitis and after recurrent attacks of uncomplicated diverticulitis. These guidelines have become subject to controversy. The objective of this study was to assess disease-related quality of life after laparoscopic sigmoidectomy. METHODS: Data were collected retrospectively. Patients filled in a form describing their quality of life. All patients undergoing elective operation for diverticular disease between 1999 and 2006 at the Department of Surgery of the Uster Hospital, a regional medical center in Switzerland were included. The measurement tool we used is the Gastrointestinal Quality of Life Index (GIQLI). Wilcoxon-Mann-Whitney test or unpaired t-tests were applied to determine statistical significance of differences observed. RESULTS: A total of 130 patients were included and 120 questionnaires were available for analysis. Mean follow-up was 40 months. Of the total, 48% reported a GIQLI >100 before the operation, which rose to 83% after the operation (p < 0.0001). Mean GIQLI was 95 before and 114 after the operation (p < 0.0001). Female patients reported lower GIQLI rates. Overall, 96% were satisfied with the operation. CONCLUSIONS: The results in this study population show that in a majority of patients who underwent elective laparoscopic-assisted sigmoidectomy for recurrent diverticulitis gastrointestinal quality of life improved with the operation.

Use of severity classification systems in the surgical decision-making process in emergency laparotomy for perforated diverticulitis.

PURPOSE: Hartman's procedure (HP) or primary anastomosis (PA) are the two surgical techniques used in patients undergoing emergency colectomy for perforated diverticulitis. There are no objective criteria to guide the surgeon's choice of procedure. This study assesses whether classification and scoring systems can be used in the decision-making process. METHODS: One hundred eleven patients undergoing emergency laparotomy for perforated diverticulitis were analyzed. Logistic regression and interaction models were used to determine the predictive value in the two settings. RESULTS: Sixty five patients underwent HP and 46 patients underwent PA. Patients with HP had significantly higher scores, median age, and were more often on immunosuppressive medication. Mortality and surgical morbidity did not differ between the groups. The clinical anastomotic leak rate was 28.3% in the PA group. In the univariate logistic regression for in-hospital death, all scores showed a significant influence. The multivariate logistic regression analysis showed that only Charlson comorbidity index (CCI) and American Society of Anesthesiologists score had a significant influence on mortality. Each score was analyzed for its predictive value regarding mortality and morbidity with respect to type of operative procedure. Only CCI revealed a trend towards statistical significance. The risk of death increases with increasing CCI when PA is performed compared to HP. CONCLUSION: None of the tested scores can be used to help the surgeon decide whether a PA or HP is appropriate in a specific patient. Comorbidity, represented as CCI in this study, might be more important than the locoregional situation.

Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.

Purpose: We report on patient and surgeon experience after single-port endoscopic carpal tunnel release (CTR) using wide-awake local anesthesia no tourniquet (WALANT) technique. Methods: From July to November 2018, patients undergoing endoscopic CTR with WALANT were prospectively included. Follow-up was 3 months. Patient ratings before, during, and after the operation were collected. We recorded the surgeon's experience during surgery compared with the endoscopic CTR under local anesthesia with exsanguination and tourniquet. Complications were defined as nerve injury, infection, or the need for revision surgery. Results: The cohort consisted of 20 patients (24 wrists). All patients except one reported a complete or substantial decrease of symptoms. The 2 surgeons involved judged the procedure to be technically more demanding owing to impaired visualization (33%) caused by increased bleeding and edema in the operative field. There was one conversion from endoscopic to open surgery. Conclusions: We recommend starting single-port endoscopic CTR using WALANT with a noninflated tourniquet in place for use when necessary. Type of study/level of evidence: Therapeutic IV.

[Defect coverage of the hand using a rare Siamese combined flap]. / Defektdeckung an der Hand mit einer seltenen siamesischen Lappenkombination.

We report 2 cases of extensive soft tissue defects simultaneously affecting the palm and dorsum of the hand. The defect was covered with a Siamese flap combination consisting of a free, distally extended lateral upper arm flap with microvascular anastomosis, and a posterior interosseous artery flap. We discuss possible indications, the operative technique and advantages versus disadvantages of this rarely applied flap combination.

Early vs. delayed elective laparoscopic-assisted colectomy in sigmoid diverticulitis: timing of surgery in relation to the acute attack.

PURPOSE: The timing of elective surgery in acute sigmoid diverticulitis in relation to the acute attack is not clear. Early elective surgery during the same hospitalization as the acute attack or delayed surgery after an interval of several weeks are the options. This study was designed to evaluate the influence of timing on morbidity, conversion rate, histologic findings, and costs. METHODS: A total of 178 patients with elective laparoscopic-assisted sigmoid resections for diverticulitis between 1997 and 2005 were retrospectively assessed; 77 patients underwent early and 101 delayed surgery. Outcomes were surgical morbidity, conversion rate, histologic findings, and financial impact of timing. RESULTS: The two groups showed no significant difference apart from a higher body mass index in the delayed group (25.5 vs. 26.6 kg/m2, P = 0.035). Surgical morbidity was not significantly different. Conversion rate was significantly higher in the early group (P < 0.001). Converted patients had an increased surgical morbidity of 23.8 vs. 19.1 percent (P = 0.323) and hospitalization was significantly longer (13.5 vs. 10.5 days; P < 0.001). Histology revealed inflammation in 75.3 percent in the early group compared with 23.8 percent in the delayed group. Total treatment costs were not different between groups, whereas total earnings were higher in the delayed group resulting in a lower hospital deficit. CONCLUSIONS: Early elective surgery in patients with acute sigmoid diverticulitis results in a higher conversion rate. If patients respond to initial antibiotic therapy, delayed colectomy after an interval of six weeks or more is recommended.