Timing of Preoperative Antibiotic Prophylaxis and Surgical Site Infection: TAPAS, An Observational Cohort Study.

OBJECTIVE: To test the hypothesis that surgical site infection (SSI) risk differs, after administration of surgical antibiotic prophylaxis (SAP) within 60-30 or 30-0 minutes before incision. BACKGROUND: The importance of appropriate timing of SAP before surgery has long been recognized. However, available evidence is contradictive on the best timing within a 60-0 minutes time interval before incision. Here, we aim to evaluate previous contradictions with a carefully designed observational cohort. METHODS: An observational cohort study was conducted in a Dutch tertiary referral center. For 2 years, consecutive patients with SAP indication undergoing general, orthopedic, or gynecologic surgery were followed for the occurrence of superficial and deep SSI as defined by the Center of Disease Control and Prevention. The association between timing of SAP and SSI was assessed using multivariable logistic regression. RESULTS: After 3001 surgical procedures, 161 SSIs were detected. In 87% of the procedures, SAP was administered within 60 minutes before incision. Only antibiotics with short infusion time were used. Multivariable logistic regression indicated there was no conclusive evidence of a difference in SSI risk after SAP administration 60-30 minutes or 30-0 minutes before incision [odds ratio: 0.82; 95% confidence interval (0.57-1.19)]. CONCLUSIONS: For SAP with short infusion time no clear superior timing interval within the 60-minute interval before incision could be identified in this cohort. We were unable to reproduce differences in SSI risk found in earlier studies.

Quality of Life and Persistent Symptoms After Uncomplicated Acute Diverticulitis.

BACKGROUND: Although acute diverticulitis and its recurrence are well studied, little is known about the period after these attacks have passed. Many patients appear to be affected by persistent symptoms that impair quality of life. The few published studies on this topic are mostly limited by the lack of CT confirmation of the acute diverticulitis diagnosis, low numbers of patients, or cross-sectional design. OBJECTIVE: This study longitudinally evaluated quality of life and symptoms after antibiotic or observational treatment of uncomplicated acute diverticulitis. DESIGN: This was an observational study of randomized clinical trial data. SETTINGS: This study was conducted at a single tertiary care center. PATIENTS: Patients with CT-proven, primary, left-sided, uncomplicated acute diverticulitis were randomly assigned to observational or antibiotic treatment. MAIN OUTCOME MEASURES: Quality of life was assessed using questionnaires (EuroQol 5D, Short Form-36, and Gastrointestinal Quality of Life Index) at baseline and 3, 6, 12, and 24 months after random assignment. Patients were considered to have persistent symptoms when specific quality-of-life scores at the 12- and 24-month follow-ups were among the lowest 16% of scores measured in a healthy reference group. RESULTS: A total of 528 patients were included. No difference was detected between the observational and antibiotic groups in any quality-of-life score during follow-up. Overall, 32.2% to 38.2% of patients had persistent symptoms after 1 or 2 years, depending on which questionnaire (sub)score was assessed. Risk factors for persistent symptoms based on to the Gastrointestinal Quality of Life index GI symptoms score included a mean pain score ≥3.75 (OR = 2.77 (95% CI, 1.60-4.80)) during the first 10 days of disease and prolonged (≥28 d) time to recovery (OR = 2.25 (95% CI, 1.31-3.88)). Flatulence, rumblings, bloating, fullness, and many stools were the top 5 complaints at the 12- and 24-month follow-ups. LIMITATIONS: The study was limited by possible selection bias of patients included in a randomized controlled trial. CONCLUSIONS: More than one third of patients experience persistent symptoms after an episode of acute uncomplicated diverticulitis. Long-term quality of life is comparable after initial antibiotic or observational treatment. See Video Abstract at http://links.lww.com/DCR/A916.

Yield of colonoscopy after recent CT-proven uncomplicated acute diverticulitis: a comparative cohort study.

BACKGROUND: Current guidelines recommend routine follow-up colonoscopy after acute diverticulitis to confirm the diagnosis and exclude malignancy. Its value, however, has recently been questioned because of contradictory study results. Our objective was to compare the colonoscopic detection rate of advanced colonic neoplasia (ACN), comprising colorectal cancer (CRC) and advanced adenoma (AA), in patients after a CT-proven primary episode of uncomplicated acute diverticulitis with average risk participants in a primary colonoscopy CRC screening program. METHODS: A retrospective comparison was performed of prospectively collected data from cohorts derived from two multicenter randomized clinical trials executed in the Netherlands between 2009 and 2013. 401 uncomplicated diverticulitis patients and 1,426 CRC screening participants underwent colonic evaluation by colonoscopy. Main outcome was the diagnostic yield for ACN, calculated as number of diverticulitis patients and screening participants with ACN relative to their totals, with differences expressed as odds ratios (OR). The histopathology outcome of removed lesions during colonoscopy was used as definitive diagnosis. RESULTS: AA detection was similar [5.5 vs. 8.7%; OR 0.62 (95% CI 0.38-1.01); P = 0.053]. CRC was detected in 1.2% (5/401) of diverticulitis patients versus 0.6% (9/1,426) of screening participants [OR 1.30 (95% CI 0.39-4.36); P = 0.673]. ACN was diagnosed in 6.7% (27/401) of diverticulitis patients versus 9.1% (130/1,426) of screening participants [OR 0.71 (95% CI 0.45-1.11); P = 0.134]. ORs were adjusted for age, family history of CRC, smoking, BMI, and cecal intubation rate. CONCLUSIONS: ACN detection does not differ significantly between patients with recent uncomplicated diverticulitis and average risk screening participants. Routine follow-up colonoscopy after primary CT-proven uncomplicated left-sided acute diverticulitis can be omitted; these patients can participate in CRC screening programs. Follow-up colonoscopy may be beneficial when targeted at high-risk patients, but such an approach first needs prospective evaluation.

Systematic review of medical therapy to prevent recurrent diverticulitis.

AIM AND BACKGROUND: One of today's controversies remains the prevention of recurrent diverticulitis. Current guidelines advise a conservative approach, based on studies showing low recurrence rates and a high operative morbidity and mortality. Conservative measures in prevention recurrence are dietary advises and medical therapies, including probiotics and 5-aminosalicylic acid. OBJECTIVES: The aim of this systematic review is to assess whether medical or dietary therapies can prevent recurrent diverticulitis after a primary episode of acute diverticulitis. METHOD AND SEARCH STRATEGY: We searched different databases for papers published between January 1966 and January 2011. STUDY SELECTION: Clinical studies were eligible for inclusion if they assessed the prevention of recurrent diverticulitis with a medical or dietary therapy. Exclusion criteria were studies without a control group. RESULTS: Three randomized controlled trials (RCT), all with a Jadad quality score of 2 out of 5, were included in this systematic review. Mesalazine results in significantly less disease recurrence and fewer symptoms after an acute episode. The use of probiotics decreases symptoms but does not reduce recurrence. No difference in effect is seen when Balsalazide is added to probiotics compared to probiotics only. No relevant studies on dietary therapy/advices or antibiotics for prevention of recurrent diverticulitis were found. CONCLUSION: The evidence that supports medical therapy to prevent recurrent diverticulitis is of poor quality. Treatment with 5-aminosalicylic acid seems promising. Based on current data, no recommendation of any non-operative relapse prevention therapy for diverticular disease can be made.

A systematic review of high-fibre dietary therapy in diverticular disease.

PURPOSE: The exact pathogenesis of diverticular disease of the sigmoid colon is not well established. However, the hypothesis that a low-fibre diet may result in diverticulosis and a high-fibre diet will prevent symptoms or complications of diverticular disease is widely accepted. The aim of this review is to assess whether a high-fibre diet can improve symptoms and/or prevent complications of diverticular disease of the sigmoid colon and/or prevent recurrent diverticulitis after a primary episode. METHODS: Clinical studies were eligible for inclusion if they assessed the treatment of diverticular disease or the prevention of recurrent diverticulitis with a high-fibre diet. The following exclusion criteria were used for study selection: studies without comparison of the patient group with a control group. RESULTS: No studies concerning prevention of recurrent diverticulitis with a high-fibre diet met our inclusion criteria. Three randomised controlled trials (RCT) and one case-control study were included in this systematic review. One RCT of moderate quality showed no difference in the primary endpoints. A second RCT of moderate quality and the case-control study found a significant difference in favour of a high-fibre diet in the treatment of symptomatic diverticular disease. The third RCT of moderate quality found a significant difference in favour of methylcellulose (fibre supplement). This study also showed a placebo effect. CONCLUSION: High-quality evidence for a high-fibre diet in the treatment of diverticular disease is lacking, and most recommendations are based on inconsistent level 2 and mostly level 3 evidence. Nevertheless, high-fibre diet is still recommended in several guidelines.

A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial).

BACKGROUND: Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects. METHODS: A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included. CONCLUSION: A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach. TRIAL REGISTRATION NUMBER: NCT01111253.

Unusual presentation of a late-onset recurrence of malignant peritoneal mesothelioma.

A man aged 79 years with a history of malignant peritoneal mesothelioma presented 8 years after primary presentation with a suspected right-sided painful inguinal hernia and hydrocele, both present for 5 months. During surgery, however, the inguinal swelling appeared to be a tumour. Laboratory examination was non-alarming and ultrasonography not specific for mesothelioma. Pathological examination showed it to be a recurrence of the malignant mesothelioma, which was treated palliative with radiotherapy. This clinical picture is rare and a recurrence-free survival of 8 years is remarkable.

[Optimal timing of antibiotic prophylaxis: effect on surgical site infection is overrated]. / Optimale timing van antibiotische profylaxe: overschatting van het effect op wondinfecties.

Surgical site infection (SSI) is a common complication of surgery and a major cause of morbidity, mortality and health care costs. Several patient and perioperative care related factors play a role in SSI, which above all is the result of a complex process. Timing of antibiotic prophylaxis (AP) is a process indicator that has been described extensively. However, the optimal timing remains controversial. A large SSI reduction was initially shown for administration of AP within two hours before incision. Later the optimal timing seemed to be 30-60 minutes or the final 30 minutes before incision. Recently, it has been shown that there is no significant association between timing and SSI. This controversy is reflected in several guidelines with dissimilar advice. If there is no optimal AP timing, it should not be a process indicator. Other SSI risk factors that are presently not the focus of attention may be more important process indicators.

External validation of two tools for the clinical diagnosis of acute diverticulitis without imaging.

AIM: External validation and comparison of the diagnostic accuracy of two predictive tools, the emergency department triad and the clinical scoring tool in diagnosing acute diverticulitis. METHODS: Two derivation datasets were used crosswise for external validation. In addition, both tools were validated in a third independent cohort. Predictive values were reassessed and the Area Under the Curve expressed discriminatory capacity. Performance was compared by calculating positive predictive values of the emergency department triad in the validation cohorts and with a cut-off analysis for the clinical scoring tool at a positive predictive value of 90%. RESULTS: Predictive value of the emergency department triad was comparable to the clinical scoring tool. The positive predictive value of the emergency department triad (97%) decreased in the clinical scoring tool cohort (81%) and was excellent in the independent cohort (100%), identifying 24%, 20% and 14% of the patients. A smaller proportion of patients with diverticulitis could be identified with the clinical scoring tool (6%, 19% and 9%). CONCLUSION: The emergency department triad as well as the clinical scoring tool have significant predictive value in external cohorts of patients suspected of diverticulitis. These tools can be used to select patients in whom additional imaging to diagnose acute diverticulitis may be omitted.

Endoscopic type 2 endoleak repair following endovascular aortic aneurysm repair: acute results and follow-up experience.

The purpose of this study was to evaluate immediate and long-term results of endoscopic type 2 endoleak repair (EER) following endovascular abdominal aortic aneurysm repair. The basic methods include a retrospective review of electronic and paper medical records of patients admitted or referred to our institution for EER. Between July 1999 and October 2007, eight consecutive patients underwent EER. Mean operative time was 190 (104-355) min. One patient died preoperatively, due to profuse venous bleeding . One procedure was redone due to a missed pair of lumbar arteries. Mean hospital stay was five days (2-10). During mean follow-up, 50 months (29-91), one patient required additional coil embolization for a persistent type 2 endoleak. Four patients were diagnosed with a type 1 and one with a type 3 endoleak; three of these patients required an additional procedure. In conclusion, in this small series EER proved not to be beneficial.