Optimal Operative Strategy for Hinchey III Sigmoid Diverticulitis: A Decision Analysis.

BACKGROUND: Operative approaches for Hinchey III diverticulitis include the Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage. Several randomized controlled trials and meta-analyses have compared these approaches; however, results are conflicting and previous studies have not captured the complexity of balancing surgical risks and quality of life. OBJECTIVE: This study aimed to determine the optimal operative strategy for patients with Hinchey III sigmoid diverticulitis. DESIGN: We developed a Markov cohort model, incorporating perioperative morbidity/mortality, emergency and elective reoperations, and quality-of-life weights. We derived model parameters from systematic reviews and meta-analyses, where possible. We performed a second-order Monte Carlo probabilistic sensitivity analysis to account for joint uncertainty in model parameters. SETTING: This study measured outcomes over patients' lifetime horizon. PATIENTS: The base case was a simulated cohort of 65-year-old patients with Hinchey III diverticulitis. A scenario simulating a cohort of highly comorbid 80-year-old patients was also planned. INTERVENTIONS: Hartmann procedure, primary resection and anastomosis (with or without diverting ileostomy), and laparoscopic lavage were performed. MAIN OUTCOME MEASURES: Quality-adjusted life years were the primary outcome measured. RESULTS: Following surgery for Hinchey III diverticulitis, 39.5% of patients who underwent the Hartmann procedure, 14.3% of patients who underwent laparoscopic lavage, and 16.7% of patients who underwent primary resection and anastomosis had a stoma at 12 months. After applying quality-of-life weights, primary resection and anastomosis was the optimal operative strategy, yielding 18.0 quality-adjusted life years; laparoscopic lavage and the Hartmann procedure yielded 9.6 and 13.7 fewer quality-adjusted life months. A scenario analysis for elderly, highly comorbid patients could not be performed because of a lack of high-quality evidence to inform model parameters. LIMITATIONS: This model required assumptions about the long-term postoperative course of patients who underwent laparoscopic lavage because few long-term data for this group have been published. CONCLUSIONS: Although the Hartmann procedure is widely used for Hinchey III diverticulitis, when considering both surgical risks and quality of life, both laparoscopic lavage and primary resection and anastomosis provide greater quality-adjusted life years for patients with Hinchey III diverticulitis, and primary resection and anastomosis appears to be the optimal approach. See Video Abstract at http://links.lww.com/DCR/B223. ESTRATEGIA OPERATIVA ÓPTIMA EN DIVERTICULITIS HINCHEY III DE SIGMOIDES: UN ANÁLISIS DE DECISION: Los enfoques quirúrgicos para la diverticulitis Hinchey III incluyen el procedimiento de Hartmann, la resección primaria y anastomosis, y el lavado laparoscópico. Varios ensayos controlados aleatorios y metanálisis han comparado estos enfoques; sin embargo, los resultados son contradictorios y los estudios previos no han captado la complejidad de equilibrar los riesgos quirúrgicos y la calidad de vida.Determinar la estrategia operativa óptima para pacientes con diverticulitis Hinchey III de sigmoides.Desarrollamos un modelo de cohorte de Markov, incorporando morbilidad / mortalidad perioperatoria, reoperaciones electivas y de emergencia, y pesos de calidad de vida. Derivamos los parámetros del modelo de revisiones sistemáticas y metaanálisis, cuando fue posible. Realizamos un análisis de sensibilidad probabilístico Monte Carlo de segundo orden para tener en cuenta la incertidumbre conjunta en los parámetros del modelo.Seguimiento de por vida.El caso base fue una cohorte simulada de pacientes de 65 años con diverticulitis de Hinchey III. También se planeó un escenario que simulaba una cohorte de pacientes de 80 años altamente comórbidos.Procedimiento de Hartmann, resección primaria y anastomosis (con o sin desviación de ileostomía) y lavado laparoscópico.Años de vida ajustados por calidad.Después de la cirugía para la diverticulitis de Hinchey III, el 39.5% de los pacientes que se sometieron al procedimiento de Hartmann, el 14.3% de los pacientes que se sometieron a un lavado laparoscópico, y el 16.7% de los pacientes que se sometieron a resección primaria y anastomosis tuvieron un estoma a los 12 meses. Después de aplicar el peso de la calidad de vida, la resección primaria y la anastomosis fueron la estrategia operativa óptima, que dio como resultado 18.0 años de vida ajustados en función de la calidad; el lavado laparoscópico y el procedimiento de Hartmann arrojaron 9.6 y 13.7 meses de vida ajustados en función de la calidad, respectivamente. No se pudo realizar un análisis de escenarios para pacientes de edad avanzada altamente comórbidos debido a la falta de evidencia de alta calidad para informar los parámetros del modelo.Este modelo requirió suposiciones sobre el curso postoperatorio a largo plazo de pacientes que se sometieron a lavado laparoscópico, ya que se han publicado pocos datos a largo plazo para este grupo.Aunque el procedimiento de Hartmann se usa ampliamente para la diverticulitis de Hinchey III, cuando se consideran tanto los riesgos quirúrgicos como la calidad de vida, tanto el lavado laparoscópico como la resección primaria y la anastomosis proporcionan una mayor calidad de años de vida ajustada para los pacientes con diverticulitis de Hinchey III y la resección primaria y anastomosis parece ser el enfoque óptimo. Consulte Video Resumen en http://links.lww.com/DCR/B223.

Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting.

OBJECTIVES: To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting. METHODS: A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported. RESULTS: During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25 ± 4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases. CONCLUSION: Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.

Multicenter Assessment of Grafts in Coronaries: Midterm Evaluation of the C-Port Device (the MAGIC Study).

OBJECTIVE: The commercially available C-Port distal anastomotic device (Food and Drug Administration cleared in 2007) is an automated miniature vascular stapler that performs the coronary anastomosis. This prospective multicenter registry sought to evaluate midterm patency using this device compared with hand-sewn grafts. METHODS: Patients receiving at least one C-Port anastomosis during coronary artery bypass grafting surgery were enrolled at eight sites. Of the 117 patients enrolled, 78 patients (67%) with 104 C-Port vein grafts completed the study to patency assessment via computed tomography angiography. Clinical follow-up and index graft patency (Gated 64-slice computed tomography scan) were performed at least 12 months postoperatively. The primary efficacy endpoint was patency compared with the peer-reviewed results from the PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT IV) trial. RESULTS: The patient population was consistent with the PREVENT IV placebo cohort. The mortality at 12 months was 0.85% (1/117). The major cardiac morbidity rate was 3.4% (4/117). The C-Port vein graft occlusion rate was 16.3% (17/104) compared with 26.6% (597/2242) in the PREVENT IV trial (P = 0.011). Within this study, C-Port graft occlusion rates were not significantly different from the hand-sewn grafts (P = 0.821). CONCLUSIONS: The C-Port device is safe and effective in creating the distal anastomosis with equivalent patency rates to hand-sewn grafts at 12 months. When compared with hand-sewn anastomoses from a recent large prospective trial, the C-Port device demonstrated a statistically significant reduction in midterm graft occlusion. Further studies are required to evaluate its effect in less invasive coronary surgery.

A prospective observational study of abdominal injury management in contemporary military operations: damage control laparotomy is associated with high survivability and low rates of fecal diversion.

OBJECTIVE: This study describes the cause, management, and outcomes of abdominal injury in a mature deployed military trauma system, with particular focus on damage control, hollow visceral injury (HVI), and stoma utilization. BACKGROUND: Damage control laparotomy (DCL) is established in military and civilian practice. However, optimal management of HVI during military DCL remains controversial. METHODS: We studied abdominal trauma managed over 5 months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan (Role 3). Data included demographics, wounding mechanism, injuries sustained, prehospital times, location of first laparotomy (Role 3 or forward), use of DCL or definitive laparotomy, subsequent surgical details, resource utilization, complications, and mortality. RESULTS: Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and 6 blunt trauma (6%)]. Seventy-two of 94 patients (77%) underwent DCL. Four patients were palliated. Seventy of 94 (74%) sustained HVI; 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 therapeutically managed HVI patients (88%). Six patients were managed with fecal diversion, and 6 patients were evacuated with discontinuous bowel. Anastomotic leaks occurred in 4 of 56 HVI patients (7%) with known outcomes. Median New Injury Severity Score for DCL patients was 29 (interquartile range: 18-41) versus 19.5 (interquartile range: 12-34) for patients undergoing definitive laparotomy (P = 0.016). Overall mortality was 15 of 94 (16%). CONCLUSIONS: Damage control is now used routinely for battlefield abdominal trauma. In a well-practiced Combat Support Hospital, this strategy is associated with low mortality and infrequent fecal diversion.

Hartmann's operation: how often is it reversed and at what cost? A multicentre study.

AIM: The study evaluated the rate of reversal of Hartmann's operation after the initial surgery and its morbidity. METHOD: A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann's operation from 2004 to 2008. The incidence of reversal was determined. RESULTS: Four hundred and fifty-two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann's procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD. CONCLUSION: Hartmann's reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity.

Robotic tubal anastomosis: surgical technique and cost effectiveness.

OBJECTIVE: To evaluate the feasibility of robotic microsurgical tubal anastomosis and compare the results and cost effectiveness with the same procedure performed by laparotomy. DESIGN: Prospective cohort study. SETTING: University hospital. PATIENT(S): Patients with a history of bilateral tubal ligation who desired reversal for future fertility. INTERVENTION(S): Tubal anastomoses through either a robotic approach or through a laparotomy. MAIN OUTCOME MEASURE(S): Operative times, hospitalization, complications, postoperative patency, clinical outcomes, and the cost per live birth. RESULT(S): The mean operative time for robotic anastomoses was statistically significantly greater than open anastomoses (ROBOT 201 minutes; OPEN 155.3 minutes), although hospitalization times were statistically significantly shorter (ROBOT 4 hours; OPEN 34.7 hours). The return to instrumental activities of daily living was accelerated in the patients who had undergone a robotic anastomosis (ROBOT 11.1 days; OPEN 28.1 days). Although this was a small series, the pregnancy rates were comparable between groups (ROBOT 62.5%; OPEN 50%), yet the rate of abnormal pregnancy was higher in the robotic group (ectopic: ROBOT 4, OPEN 1; spontaneous pregnancy loss: ROBOT 2, OPEN 1). The cost per delivery was similar between the groups (ROBOT $92,488.00, OPEN $92,205.90). CONCLUSION(S): Robotically assisted laparoscopic microsurgical tubal anastomosis is feasible and cost effective with results that are comparable with the traditional open approach.

[The bidirectional cavo-pulmonary anastomosis: a clinico-functional assessment in a medium-term follow-up]. / Anastomosi cavo-polmonare bidirezionale: valutazione clinico-funzionale in un follow-up a medio termine.

BACKGROUND: The bidirectional cavo-pulmonary anastomosis is a useful surgical procedure for patients with complex congenital heart disease characterized by univentricular physiology. This operation significantly increases effective pulmonary blood flow and rarely causes distortion of the main pulmonary arterial branches. The aim of this study was to evaluate the clinical and pathophysiologic consequences of bidirectional cavo-pulmonary anastomosis as well as the effectiveness of this surgical approach as a definitive palliation. METHODS: Clinical, hemodynamic and functional data of 12 patients who had undergone a bidirectional cavo-pulmonary anastomosis were reviewed. Each patient underwent clinical examination, chest x-ray, ambulatory EKG, bidimensional color-Doppler echocardiography, spirometric analysis, lung perfusion scintigraphy, cardiac catheterization and angiography, and stress test. Stress test data were compared to those obtained by a normal population of age-matched children. RESULTS: After a mean follow-up interval of 28 +/- 20 months all patients showed a good clinical condition. Improved oxygenation, exercise tolerance and growth velocity were noted in all patients. Only 34% of patients showed abnormalities of chest x-ray, 29% manifested significant arrhythmias during ambulatory EKG and 20% showed abnormal ventricular function echocardiographically. Spirometry was normal in all patients, while lung perfusion scintigraphy was constantly abnormal with right/left and upper/lower perfusion mismatch. At cardiac catheterization a reduction of end diastolic volume (from 106.9 +/- 50.6 to 67.3 +/- 41.6 ml, p < 0.05) and end systolic volume (from 58.0 +/- 27.9 to 32.5 +/- 33.5 ml, p < 0.05) was noted. The functional evaluation of these patients was highly abnormal due to an impaired response to effort as evidenced by work time (p < 0.0001 vs normal) and stress-induced cardiovascular modifications. CONCLUSIONS: On the basis of these findings, we suggest that: 1) bidirectional cavo-pulmonary anastomosis is useful as an intermediate step towards a Fontan procedure, as it improves the hemodynamic performance of the systemic ventricle; 2) conversely, bidirectional cavo-pulmonary anastomosis should not be considered a form of definitive palliation for complex congenital heart disease because in these patients the response to exercise remains unsatisfactory.

[The assessment of the efficacy of surgical treatment in critical ischemia of the lower extremities by the forming of arteriovenous anastomoses]. / Otsenka éffektivnosti khirurgicheskogo lecheniia kriticheskoi ishemii nizhnikh konechnostei putem formirovaniia arteriovenoznykh soustii.

The authors show the significance of radionuclide angiography in evaluating the efficacy of surgical treatment of lower limb critical ischemia by formation of an arteriovenous anastomosis on the side of the affection. An operation for formation of an arteriovenous anastomosis on the lower third of the leg or the foot was found to be most effective. Increased perfusion of the ischemic limb on the level of balanced mixing of the blood flow was revealed in most patients, which the authors believe to be caused by venous stasis in the lower limb due to reduced difference in pressure in the arterial and venous bed. The highest percentage of favorable late--term results of the operation was revealed among this contingent of patients.