Assessment of recurrence and complications following uncomplicated diverticulitis.

BACKGROUND: The natural history of sigmoid diverticulitis has been inferred from population-based or retrospective studies. This study assessed the risk of a recurrent attack following the first episode of uncomplicated diverticulitis. METHODS: Patients admitted between January 2007 and December 2011 with a first episode of uncomplicated sigmoid diverticulitis confirmed on computed tomography were enrolled in this prospective study. After successful medical management of the first episode, follow-up was conducted through yearly telephone interviews. Cox proportional hazards regression was performed to model the impact of various parameters on eventual recurrences and complications. RESULTS: During a median follow-up of 24 (range 3-63) months, 46 (16·4 per cent) of 280 patients experienced a second episode of diverticulitis. Six patients (2·1 per cent) subsequently developed complicated diverticulitis and four (1·4 per cent) underwent emergency surgery for peritonitis. In multivariable analysis, a raised serum level of C-reactive protein (over 240 mg/l) during the first attack was associated with early recurrence (hazard ratio 1·75, 95 per cent confidence interval 1·04 to 2·94; P = 0·035). CONCLUSION: Uncomplicated sigmoid diverticulitis follows a benign course with few recurrences and little need for emergency surgery. REGISTRATION NUMBER: NCT01015378 (http://www.clinicaltrials.gov).

Sigmoid diverticulitis in 2011: many questions; few answers.

AIM: Patients were studied after a first episode of acute left-colonic diverticulitis for the initial and later evolution of the disease with the aim of defining evidence-based indications for elective surgery. METHOD: Relevant data from prospective studies were retrieved from a MEDLINE search of English language articles. RESULTS: Young male patients (≤ 50 years of age) had a higher risk of CT-graded severe diverticulitis. After medical treatment of the first episode, the incidence of complications was highest for young patients with CT-graded severe diverticulitis and lowest for older patients with CT-graded moderate diverticulitis. Recurrence in the form of diffuse peritonitis was rare. CT grading of initial diverticulitis seemed to be a predictor of recurrence, whereas the role of age was less clear. A family history of diverticulitis might be predictive of recurrence. CONCLUSION: CT grading of acute diverticulitis helps to predict poor outcome after medical treatment of a first episode. Elective surgical resection should be proposed to patients with residual symptoms who do not respond to conservative treatment. Additional research is needed to clarify the role of a genetic predisposition in the development of diverticulitis in young adults.

A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2.

AIM: After an initial uncomplicated attack, sigmoid diverticulitis may recur, but the morphological characteristics of recurrent diverticulitis have not been investigated. We compared the clinical and radiological severity, the respective location and clinical outcome of the first two episodes of sigmoid diverticulitis. METHOD: We reviewed the charts of 60 patients [median age 61 (range 31-90) years] who were admitted initially for a first episode of uncomplicated left colonic diverticulitis, and who were eventually readmitted for a second episode, both being documented by abdominal computed tomography (CT) scan. RESULTS: The median delay between the two episodes was 19 (3-97) months. Six (10%) patients developed a second complicated episode of diverticulitis [Hinchey II (n = 2), CT-guided percutaneous drainage; Hinchey III (n = 3), emergency Hartmann's operation; colovesical fistula (n = 1), elective sigmoid resection]. Fifty-four (90%) patients were admitted for a second episode of uncomplicated diverticulitis. In this group, the duration of hospital stay [11 (4-22) vs 10 (1-39) days, P = 0.28], serum levels of C-reactive protein [131 (31-350) vs 112 (22-333) mm, P = 0.62] and CT scan-based severity score [3 (1-6) vs 3 (0-7) points, P = 0.07] were similar between the two episodes. In 19 out of 54 (35%) patients with simple recurrent diverticulitis, although disease severity was similar, the disease topography differed and recurrence involved another segment of the left colon. CONCLUSION: The majority of patients who develop recurrence do so in a similar mode and location. However, 10% develop complicated diverticulitis and in 35% of patients recurrent diverticulitis occurs at a different location.

Colon carcinoma immunoscintigraphy by monoclonal anti-CEA antibody labeled with gallium-67-aminooxyacetyldeferroxamine.

Previous experimental results in nude mice showing that radiolabeling the monoclonal antibody anti-CEA 35 with 67Ga-aminooxyacetyldeferroxamine could give better tumor localization than radioiodination prompted us to initiate the present clinical study. The 67Ga-labeled antibody anti-CEA 35 (185 MBq, 0.7-1.7 mg) was injected preoperatively into 14 patients for colorectal carcinoma imaging. The same antibody labeled with 125I (3.7 MBq, 0.25 mg) was injected simultaneously to compare the 67Ga and 125I dose recoveries in surgical specimens. Twelve of 14 primary tumors gave a positive 67Ga scintigraph. The mean %ID/g recovered in all tumors 3-9 days after injection was significantly higher for 67Ga (0.019%) than for 125I (0.005%) (p < 0.001, paired t test). The tumor-to-normal tissue ratios were generally higher for 67Ga, with the exception of liver. We conclude that 67Ga-aminooxyacetyldeferroxamine improved immunoscintigraphy outside the liver, particularly in the pelvic region. We also show that deferroxamine infusion accelerates the excretion of 67Ga in eight patients and propose that this could lead to further improvement of immunoscintigraphy.

Acute left colonic diverticulitis: a prospective analysis of 226 consecutive cases.

BACKGROUND: The purpose of this prospective study was to evaluate the immediate and late outcome of acute left colonic diverticulitis and to correlate it with age (younger and older than 50 years of age), gender, and initial computed tomography (CT) findings. METHODS: Analysis was made of data collected prospectively from all patients admitted because of acute colonic diverticulitis between October 1986 and January 1992. Diagnosis relied on results of operation, CT, and Gastrografin enema. Two hundred twenty-six patients were urgently hospitalized for acute left colonic diverticulitis; 47 were younger than 50 years of age (21%). RESULTS: Sixty-six patients (29%) were operated on during their first hospitalization. The remaining 160 patients treated conservatively underwent CT and an enema within 72 hours of admission. Fifty-nine of 179 patients (33%) older than 50 years of age required operation during their first attack, compared with 7 in 47 patients (15%) younger than 50 years of age (p = 0.02), although on CT severe diverticulitis was found in 36 of 141 patients (26%) older than 50 years of age and in 16 of 43 patients (37%) younger than 50 years of age (p = 0.13). Of the 160 patients treated conservatively, 11 of 40 patients (28%) younger than 50 years of age experienced recurrences or complications after their first discharge, compared with 16 in 120 patients (13%) older than 50 years of age (p = 0.04). CONCLUSIONS: Patients younger than 50 years of age were significantly more prone to recurrences and complications after conservative treatment of their diverticulitis, whereas older patients required operation significantly more often during their first hospitalization.

Acute left colonic diverticulitis in young patients.

BACKGROUND: This prospective study was done to compare acute left-sided colonic diverticulitis in young patients (50 years of age or less) and older patients (more than 50 years of age) for severity of disease and immediate and late outcome. STUDY DESIGN: Of the 265 patients studied, 61 were 50 years of age or less; of these, 49 were men. In all instances, diagnosis was confirmed radiologically or histologically. RESULTS: Operations were performed less often upon younger patients than older patients (15 versus 33 percent, p = 0.001). Severe diverticulitis was found more often in younger men than older men (39 versus 23 percent). After successful conservative treatment during the first hospitalization period, younger men had a statistically greater risk of poor outcome than older men (29 versus 5 percent, p = 0.003). CONCLUSIONS: Although younger men have severe acute diverticulitis more often than older men, operative treatment during the first episode is less often needed. On the other hand, after conservative treatment, younger men have a statistically greater chance of poor secondary outcome than older men.

Stapled ileal pouch anal anastomoses are safer than handsewn anastomoses in patients with ulcerative colitis.

BACKGROUND: One of the theoretic advantages of using a stapled versus handsewn ileal pouch anal anastomosis (IPAA) in restorative proctocolectomy is a reduction in septic complications. We performed this study to compare the incidence of early septic complications in patients undergoing restorative proctocolectomy with stapled or handsewn IPAA. PATIENTS AND METHODS: A chart review of 692 patients undergoing restorative proctocolectomy for treatment of ulcerative colitis was performed. The incidence of early septic complications in patients having stapled IPAA was compared to that in patients having handsewn IPAA. Follow-up studies included an annual questionnaire and physical examination. RESULTS: Of the 692 patients, 238 had handsewn IPAA and 454 had stapled IPAA; these two groups were similar in sex, duration of disease, age at surgery, and type of surgical procedure performed. In the handsewn IPAA group, 25 patients (10.5%) had 32 septic complications, and 24 required 89 reparations. In 7 patients, the pouch was excised. In the stapled IPAA group, 21 patients (4.6%) had 23 septic complications, and 14 required 40 reparations. One patient needed pouch excision. There were more patients (P=0.0001) with early septic complications, and more (P<0.0001) pouch excisions because of these complications, in patients with handsewn IPAA than in patients with stapled IPAA. The sepsis-related reoperation rates did not differ significantly. CONCLUSIONS: The stapled technique for IPAA has fewer septic complications and results in fewer sepsis-related pouch excisions, in our hands, than the handsewn technique technique, for treating patients with ulcerative colitis.

Ruptured arterial aneurysms in the area of the celiac trunk.

Three cases of ruptured aneurysms of the digestive arteries are reported and the different available radiological methods leading to the diagnosis are discussed. Computed tomography and selective arteriography seem to be the methods of choice in this condition. Since the patients do not usually present typical signs until the aneurysm ruptures, the diagnosis is late. Early management of these patients is necessary in order to decrease the mortality rate.

Single photon emission computed tomography study of human cancer: utilization of 57Co-labelled bleomycin.

The sensitivity and specificity of single photon emission tomography with 57Co-labelled bleomycin (57Co-BLM) for the detection of cancer was determined from a prospective study involving a large group of patients selected to investigate roentgenographic abnormalities. Eighty-four of the 104 patients studied had malignant disease, of whom 76 had a positive scintigram. Eighteen of the 20 patients with benign disorders had a negative scintigram. The sensitivity and specificity was therefore 90.5 and 90% respectively. For the subset of patients who underwent investigation below the diaphragm, the sensitivity was 85.7%, while for investigation above the diaphragm, it reached 95.2% (this excluded reconstructions on the bladder level, because it produced large artifacts). This study leads to the conclusion that SPECT can be used specifically to investigate unidentified X-ray abnormality and diagnose malignancy using 57Co-BLM. In addition, we propose further investigation to evaluate the usefulness of this method in staging cancer.

[Perforated tubular duplication of the sigmoid colon in adults]. / Perforation d'une duplication tubulaire sigmoïdienne chez l'adulte.

Intestinal duplications are rare malformations and a diagnostic challenge. The case presented herein relates to a perforated tubular duplication of the sigmoid colon in a 23-year-old man with intermittent abdominal pain during 3 months and a bout of peritonitis which resolved spontaneously. This case is unusual since duplications generally spare adults, are seldom found in the colon, and do not perforate. The only cases of duplication which can be suspected preoperatively belong to the communicating type or those containing ectopic gastric mucosa. The intraoperative finding in this case of a malformative mesenteric cyst reminds us that duplications can be found in association with other intestinal, vertebral, or genitourinary tract malformations. In conclusion, intestinal duplications should be resected even when they are asymptomatic, as occasional cancerous transformation associated with a poor prognosis have been reported.

[Acute Budd-Chiari's syndrome after surgical treatment of polycystic liver disease]. / Syndrome aigu de Budd-Chiari après traitement chirurgical d'une polykystose hépatique.

A case of acute Budd-Chiari syndrome after surgical treatment of polycystic liver disease is described. This complication, presently unreported in the literature, was secondary to the operative interruption of two hepatic veins, while the third was already obstructed by pericystic fibrosis. Preoperative radiologic vascular mapping should be performed in case of voluminous polycystic liver disease when associated liver resection appears likely.

[Left colectomy with immediate anastomosis in emergency surgery]. / La colectomie gauche avec anastomose immédiate dans la chirurgie d'urgence.

PURPOSE OF THE STUDY: A retrospective study of our experience with one-stage left colectomy for acute diverticulitis and obstruction with a review of the literature to more clearly define the indications of this procedure. PATIENTS AND METHODS: 30 patients were operated for acute diverticulitis (group 1) and 47 for obstruction (group 2). Only 7 patients (23%) of group 1 had an intraoperative colonic lavage while this was performed for all the patients of group 2. RESULTS: The postoperative morbidity and mortality for the patients of group 1 and 2 were 37 and 28%, and 7 and 11% respectively. None of the patients of group 1 had clinical anastomotic leak, while this occurred in 2 patients (4%) of group 2. The mean hospital stay was 26 days for patients of group 1 and 17 days for patients of group 2. CONCLUSIONS: Bowel obstruction should be treated by one-stage left colectomy and intraoperative colonic lavage for patients with low anaesthetic risks (ASA 1 and 2). Immediate anastomosis protected by colostomy or ileostomy could be proposed for patients with an intermediate risk (ASA 3). Patients with acute diverticulitis and a localized abscess or peritonitis should be treated with one-stage colectomy; an immediate protected anastomosis could be performed in patients with generalized purulent peritonitis while a Hartmann's type colectomy should be the reasonable option for fecal generalized peritonitis. Intraoperative colonic lavage does not seem mandatory.

[The swiss experience of ileo-anal anastomosis with reservoir (AIA). Complications and functional results]. / Expérience suisse de l'anastomose iléo-anale avec réservoir (AIA). Complications et résultats fonctionnels.

Two hundred and thirteen ileal pouch-anal anastomoses were performed in Switzerland from August 1980 to December 1991, 174 (82%) of them in 7 centres. One hundred and sixty four patients (77%) were operated for ulcerative colitis, 47 (22%) for familial polyposis and 2 others (1%) for another reason. A J pouch was created in 176 cases (83%), an S pouch in 35 cases (16%) and a W pouch in 2 cases (1%). Detailed results were available for 157 (74%) of the 213 operated patients: 81 females (52%) and 76 males (48%) with a mean age of 33.5 years (10-65). One hundred and twenty seven patients (81%) were operated for ulcerative colitis, including 42 as an emergency, and 30 (19%) for familial polyposis. One hundred patients (64%) developed complications which required one or several reoperations (laparotomy and/or perineal operation) in 64 cases (41%). Pouchitis was the most frequent complication (19%). Small bowel obstruction and pelvic abscess secondary to an anastomotic leak were the complications most frequently requiring second laparotomy with an incidence of 13% and 11%, respectively. The mean number of stools per 24 hours was 5.5 (2 to 14). 27% of patients passed one or several nocturnal stools every night, 27% occasionally, and 46% never. Occasional faecal incontinence was reported by 8 patients (6%) and 4 patients (3%) reported uncontrollable urgency. Nine patients retained a permanent ileostomy (failure rate: 6%).

[Stomach adenocarcinoma: what form of gastrectomy?]. / Adénocarcinome gastrique: quelle gastrectomie?

Three hundred and sixty consecutive cases of gastric adenocarcinoma were studied retrospectively between 1976 and 1987. Surgery was curative in 195 patients: 91 had a subtotal gastrectomy 83 a total gastrectomy and 21 a proximal gastrectomy. Subtotal and total gastrectomy were compared within this group in terms of postoperative morbidity and mortality, abdominal comfort and 5-year actuarial survival: Postoperative mortality was greater after total gastrectomy (9.6 vs 2.2%, p = 0.04), as were anastomotic leaks (19 vs 2%, p = 0.0009). Mean weight loss was greater after total gastrectomy (p = 0.005). Comparison of patients with similar tumor staging and localization did not show any significant difference in 5-year actuarial survival. If subtotal gastrectomy is certainly justified for distal gastric cancer, it should be considered for some proximal localization.