Surgical Management of Diverticular Disease in the Elective Setting.

Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.

Accuracy of national surgery quality improvement program models in predicting postoperative morbidity in patients undergoing colectomy.

BACKGROUND: The National Surgery Quality Improvement Program (NSQIP) is the standard for assessment of acuity-adjusted outcomes in surgery. The validity of NSQIP has not been well established in colorectal surgery. Technical and process variables, which NSQIP may not consider, affect morbidity rate. OBJECTIVE: A retrospective observational study was undertaken to determine the accuracy of NSQIP models in predicting morbidity for patients undergoing laparoscopic or open colectomy. METHODS: NSQIP participant use files for 2005 to 2008 were obtained. Data were selected using Current Procedural Terminology coding for open or laparoscopic colectomy. NSQIP-generated predicted morbidities were used to create area under the receiver operator curves (AUROCs). RESULTS: AUROCs demonstrated an accurate predictive model if the value was above 0.8 and indicated a marginal predictor mode if below 0.7. The AUROC for the general NSQIP model was 0.817 (confidence interval [CI] = 0.815-0.819, p < 0.001). AUROC for the combined laparoscopic and open colectomy group was 0.703 (CI = 0.698-0.709, p value < 0.001). AUROCs for the individual laparoscopic and open colectomy groups were 0.627 (CI = 0.615-0.640, p < 0.001) and 0.701 (CI = 0.695-0.707, p < 0.001). CONCLUSION: This study demonstrates that although NSQIP-generated morbidities used to create AUROCs are accurate for patients in an overall surgical model, predictive models for morbidity are marginal for laparoscopic and open abdominal colectomies. NSQIP risk models tend to emphasize comorbidities rather than intraoperative details or technical aspects of colonic resections.

Clostridium difficile of the ileum following total abdominal colectomy, with or without proctectomy: who is at risk?

BACKGROUND: Clostridium difficile enteritis is considered a rare entity, although recent data suggest a significant increase in prevalence and incidence. There is paucity of data evaluating risk factors of C difficile enteritis following total colectomy. OBJECTIVE: The aim of this study was to determine the incidence and risk factors of C difficile enteritis for patients who had undergone total abdominal colectomy with or without proctectomy. DESIGN: This study involves a retrospective chart review of 310 patients. Univariate analysis was performed on potential risk factors (p ≤ 0.05) with the use of a logistic regression model, and a Fisher exact test was used for variables that had no occurrences of C difficile. These groups of variables were then examined in a multiple variate setting with stepwise logistic regression analysis. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: A data analysis was performed on patients who had undergone total abdominal colectomy with or without proctectomy who were tested for C difficile of the ileum. RESULTS: Twenty-two of 137 patients that were tested (16%) were positive for C difficile of the ileum. Univariate analysis of known risk factors for C difficile demonstrated that black race was a protective factor against C difficile (p = 0.016). The multivariate analysis demonstrated that emergency surgery (p = 0.035), race (p = 0.003), and increasing age by decade (p = 0.033) were risk factors for C difficile. LIMITATIONS: This study was limited by the small patient sample, and it was not a randomized trial. CONCLUSIONS: Black race is protective, and whites are 4 times more likely to acquire C difficile of the ileum after undergoing a total abdominal colectomy with or without proctectomy. The data also demonstrated that an increased age by a decade and emergency surgery are risk factors for C difficile enteritis, whereas the described risk factors of C difficile of the colon and type of colon surgery do not appear to influence the risk of C difficile of the ileum.

Retrorectal tumors.

Tumors that arise in the retrorectal (presacral) space are uncommon lesions that present with nonspecific signs and symptoms, which lead to difficult diagnoses. For complete evaluation of the lesion, cross-sectional imaging is required to determine the extent of resection and the appropriate surgical approach. Surgical removal leads to favorable outcomes for patients with benign purely cystic retrorectal tumors. Preoperative tissue diagnosis with transperineal and transsacral biopsies of solid or heterogeneous cystic lesions, are essential to determine the necessity of neoadjuvant therapy, which may decrease local recurrence after surgery and avoid an unnecessary delay in systemic therapy.