Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus.

BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â€‹%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â€‹% vs 0.0 â€‹%, p â€‹= â€‹0.045), reduced ostomy rate (38.3 â€‹% vs 29.4 â€‹%, p â€‹= â€‹0.013), an increased overall length of stay (12 days vs 8 days, p â€‹< â€‹0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â€‹< â€‹0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Development and validation of multivariable predictive models for recurrence and mortality following nonoperative management of sigmoid volvulus.

AIM: Sigmoid volvulus is a challenging condition, and deciding between elective surgery or expectant management can be complex. The aim of this study was to develop a tool for predicting the risk of recurrent sigmoid volvulus and all-cause mortality within 1 year following initial nonoperative management. METHOD: This is a retrospective cohort study using Medicare claims data from 2016 to 2018 of beneficiaries admitted urgently/emergently for volvulus, undergoing colonic decompression and discharged alive without surgery (excluding those discharged to hospice). The primary outcomes were recurrent sigmoid volvulus and all-cause mortality within 1 year. Proportional hazards models and logistic regression were employed to identify risk factors and develop prediction equations, which were subsequently validated. RESULTS: Among the 2078 patients managed nonoperatively, 36.1% experienced recurrent sigmoid volvulus and 28.6% died within 1 year. The prediction model for recurrence integrated age, sex, race, palliative care consultations and four comorbidities, achieving area under the curve values of 0.63 in both the training and testing samples. The model for mortality incorporated age, palliative care consultations and nine comorbidities, with area under the curve values of 0.76 in the training and 0.70 in the testing sample. CONCLUSION: This study provides a straightforward predictive tool that utilizes easily accessible data to estimate individualized risks of recurrent sigmoid volvulus and all-cause mortality for older adults initially managed nonoperatively. The tool can assist clinicians and patients in making informed decisions about such risks. While the accuracy of the calculator was validated, further confirmation through external validation and prospective studies would enhance its clinical utility.

Does Computed Tomography-Based Virtual Colonoscopy Improve the Accuracy of Preoperative Assessment Based on Magnetic Resonance Imaging in Women Managed for Colorectal Endometriosis?

STUDY OBJECTIVE: To evaluate whether combining computed tomography-based virtual colonoscopy (CTC) with magnetic resonance imaging (MRI) improves preoperative assessment of colorectal endometriosis. DESIGN: Retrospective study using prospectively recorded data (Canadian Task Force classification II-2). SETTING: University tertiary referral center. PATIENTS: Seventy-one women treated for colorectal endometriosis managed between June 2015 and May 2016. INTERVENTIONS: Patients included in our study underwent colorectal surgery for deep endometriosis infiltrating the rectum or the sigmoid colon and had preoperative assessment using MRI and CTC. To establish the correlation between preoperative and intraoperative findings, the concordance kappa index was used. MEASUREMENTS AND MAIN RESULTS: Preoperative data provided by MRI, CTC, and a combination of both were compared with intraoperative findings. All 71 patients had a total of 105 endometriotic intestinal lesions intraoperatively confirmed. Some 71.2% of rectal nodules and 60.0% of sigmoid nodules infiltrated the muscularis propria of the intestinal wall, with most infiltrating between 25% and 50% of the rectal circumference; 73% of rectal nodules and 96% of sigmoid nodules led to varying degrees of stenosis. The concordance between intraoperative and preoperative findings concerning the presence of rectal nodules was high, at .88 when associating CTC with MRI, whereas each imaging technique taken individually provided lower concordance coefficients. In our study 80.3% of patients underwent the procedure that had been preoperatively planned. CONCLUSION: Our study suggests that associating MRI with CTC leads to improved accuracy in preoperative assessment of colorectal endometriosis and in subsequent preoperative choice of surgical procedures on the digestive tract.

Implementing a Process to Measure Return on Investment for Nursing Professional Development.

Return on investment (ROI) is one way to quantify the value that nursing professional development brings to the organization. This article describes a process to begin tracking ROI for nursing professional development. Implementing a process of tracking nursing professional development practitioners' ROI increased awareness of the financial impact and effectiveness of the department.

Impact of hospital and surgeon case volume on morbidity in colorectal endometriosis management: a plea to define criteria for expert centers.

National and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS). METHODS: We conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach. RESULTS: The study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III-V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p < 0.001) was defined. The OCO per surgeon and per year varied between seven (p = 0.007) and 13 procedures (p = 0.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (p = 0.0013). CONCLUSION: Our results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.

[Sigmoid colon diverticulitis : Treatment modalities 2011-2013]. / Sigmadivertikulitis : Behandlungsmodalitäten 2011 bis 2013.

INTRODUCTION: Diverticulosis is a relevant disease in Germany with a prevalence of over 60 % in patients aged ≥70 years. The S2k guidelines for the treatment of diverticulosis were recently published. Systematic epidemiological data on treatment modalities do not exist. METHODS: Analysis of in-hospital treatment modalities for diverticulosis based on data from the Federal Office of Statistics. RESULTS: Approximately 130,000 inpatient cases of diverticulosis are treated in Germany per year. Approximately 25 % undergo surgery and of these slightly under 50 % (12,000 procedures) are carried out by laparoscopy. The complication rates are 18 % in a best case scenario and up to 85 % in a worst case scenario. A stage-adjusted classification of treatment modalities based on data from the Federal Office of Statistics is currently practically impossible. CONCLUSION: To enable stage-adjusted epidemiological analysis of diverticulosis, a standardized and transparent documentation system enabling systematic analysis is necessary, which does not currently exist (e. g. ICD 10 coding); moreover, information on conservative and interventional treatment options are not included in the operations and procedures key (OPS) coding system.

[Surgical Indications for Diverticulitis in Germany: Are All Operations Justified?]. / Operationsindikation der Sigmadivertikulitis in Deutschland: Sind alle Operationen gerechtfertigt?

INTRODUCTION: Pathological changes of preexisting sigma diverticulosis into a state of sigma diverticulitis are possible. Treatment of sigma diverticulitis accounts for a significant proportion of emergency treatments in clinics. The number of patients treated for sigma diverticulitis has risen steadily in recent years. Although it can be observed that operated cases making 7 % compared with 14 % to all stationary admissions, there is a less marked increase. Nevertheless, the question should be clarified as to how high the proportion of complicated surgical cases is in relation to non-complicated cases. It is important to clarify, in this context, if each operation is justified or whether in some cases there is over-treatment. MATERIAL AND METHODS: All data relating to Germany, were prospectively collected by the treating hospitals using the DRG and evaluated by the Federal Statistical Office. The treatment numbers from Erlangen were prospectively collected from the encrypted DRG and analysed retrospectively by the coding officer. The investigated period lasted from 2005 to 2010. To demonstrate some treatment options, the following possible forms of therapy were examined with reference to the Hansen/Stock classification. RESULTS: In Germany, about 40 % of stationary patients with sigma diverticulitis are treated surgically. It is striking that in about two thirds of all operated patients uncomplicated forms of diverticulitis were present. The remainder consisted of covered or free perforations. For these complicated forms, various treatment approaches have been established. Ultimately, in dependence of timing these are always surgically treated. In the milder forms the general indication for surgery has come into discussion as the recommendation for a surgical approach after the second relapse in the symptom-free interval is being questioned by several groups based on the age of the studies on which the recommendations are based. CONCLUSION: A significant increase in hospital admissions and surgically treated patients is demonstrated. Striking was that a closer analysis of data revealed that mainly non-complicated cases were surgically treated. This should be seen as a clear indication for an over-treatment. Therefore, possibly not all surgeries performed are justified. In the case of complicated forms, in consideration of various treatment paths, surgery is inevitable in most cases.

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).

Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial.

BACKGROUND: The short-term results of the Sigma trial show that laparoscopic sigmoid resection (LSR) used electively for diverticular disease offers advantages over open sigmoid resection (OSR). This study aimed to compare the overall mortality and morbidity rates after evaluation of the clinical outcomes at the 6-month follow-up evaluation. METHODS: In a prospective, multicenter, double-blind, parallel-arm, randomized control trial, eligible patients were randomized to either LSR or OSR. The short-term results and methodologic details have been published previously. Follow-up evaluation was performed at the outpatient clinic 6 weeks and 6 months after surgery. RESULTS: In this trial, 104 patients were randomized for either LSR or OSR, and the conversion rate was 19.2%. The LSR approach was associated with short-term benefits such as a 15.4% reduction in the major complications rate, less pain, and a shorter hospital stay at the cost of a longer operating time. At the 6-month follow-up evaluation, no significant differences in morbidity or mortality rates were found. Two patients died of cardiac causes (overall mortality, 3%). Late complications (7 LSR vs. 12 OSR; p = 0.205) consisted of three incisional hernias, five small bowel obstructions, four enterocutaneous fistulas, one intraabdominal abscess, one retained gauze, two anastomotic strictures, and three recurrent episodes of diverticulitis. Nine of these patients underwent additional surgical interventions. Consideration of the major morbidity over the total follow-up period (0-6 months) shows that the LSR patients experienced significantly fewer complications than the OSR patients (9 LSR vs. 23 OSR; p = 0.003). The Short Form-36 (SF-36) questionnaire showed significantly better quality of life for LSR at the 6-week follow-up assessment. However, at the 6-month follow-up assessment, these differences were decreased. CONCLUSIONS: The late clinical outcomes did not differ between LSR and OSR during the 30-day to 6-month follow-up period. Consideration of total postoperative morbidity shows a 27% reduction in major morbidity for patients undergoing laparoscopic surgery for diverticular disease.

The cost effectiveness of elective laparoscopic sigmoid resection for symptomatic diverticular disease: financial outcome of the randomized control Sigma trial.

BACKGROUND: Direct healthcare costs of patients with symptomatic diverticular disease randomized for either laparoscopic or open elective sigmoid resection are compared. Cost-effectiveness analysis of the laparoscopic approach compared with open sigmoid resections is presented. METHODS: An economic evaluation of the randomized control Sigma trial was conducted, comparing elective laparoscopic sigmoid resection (LSR) to open sigmoid resection (OSR) in patients with symptomatic diverticulitis. Prospective registration of detailed intervention units per patient resulted in actual resource use per individual patient. To avoid distributional assumptions, the nonparametric bootstrap was applied. For the cost-effectiveness analysis, differences in total cost between LSR and OSR were compared with the differences in VAS pain score, SF-36 values for general health, and complication rate. RESULTS: The difference in total healthcare costs between the group that received LSR (euro 9969) and the group that received OSR (euro 9366) was not statistically significant. The slight increase in total costs was determined mainly by the significantly higher operation costs of LSR (euro 6663 vs. euro 5306). Lower costs for hospitalization (euro 2983 vs. euro 3598), blood products (euro 87 vs. euro 240), paramedical services (euro 157 vs. euro 278), and emergency attendance (euro 72 vs. euro 115) in the LSR group partially compensated these increased operation costs. The incremental cost-effectiveness ratios (ICER) indicate that improvements in pain, quality of life, and complication rate could be achieved at limited costs. CONCLUSION: Total healthcare costs of laparoscopic and open elective sigmoid resections for symptomatic diverticular disease are similar. As the clinical outcomes are in favor of the LSR group, candidates for an elective sigmoid resection should preferably be approached laparoscopically.

[Analysis of the cost-income ratio for open and laparoscopic sigmoid resection]. / Wirtschaftlichkeitsanalyse für die konventionelle und laparoskopische Sigmaresektion im Hinblick auf die Einführung der DRG's.

Based on the example of the sigmoid resection, we did a cost-income analysis evaluating the particular expenses and effects of the new DRG-based medical financing system. We analysed the cost of diagnostic tests, medication and nutrition, surgery, personnel and non medical expenses for 20 open and 27 laparoscopic operated patients. The cost of open surgery was calculated to be 3,288.44 euro per patient while laparoscopic surgery was calculated to cost 4,271.98 euro. Based on an average hospitalisation period of 16 days, the estimated income for the hospital was 5,738.98 euro. Independent of the length of hospitalisation, an income of 6,621.34 euro for the hospital was estimated using the new DRG-based medical financing system. Thus, implementation of the new DRG-based medical financing system makes it possible to give patients the benefit of shorter hospital stays following laparoscopic surgery. The cost for the hospital, however, is only minimally reduced.

An experimental assessment of suture techniques using Lapra-ty clips through the laparoscope and a case report: laparoscopic closure using Lapra-ty for a perforation of the sigmoid colon.

BACKGROUND/AIMS: As endoscopic procedures become various and complicated, it becomes necessary to develop alternative techniques for tissue suture and ligation. We have developed a new suture technique intracorporeal knotting. METHODOLOGY: An 8-cm suture material having a knot on the other side of a needle, was used in laparoscopic surgery. Furthermore, a 5-mm2 Vicryl mesh was pierced as a buttress. The Lapra-ty was used to secure the tissue. Under laparotomy, the forestomach of a male Donryu rat at 6 weeks of age was incised and sutured with 3-0 Vicryl. 3-0 Vicryl was secured with the knot substitute (group A) or three-throw knot (group B) under Nembutal anesthesia. The animals were sacrificed 7 days after operation. Specimens were taken from the forestomach. Those were fixed with 10% formalin and stained with hematoxylin eosin and Elastica Wangieson methods. The histological findings were compared between group A and group B. A successful laparoscopic closure using Lapra-ty is reported in a patient with a perforation of the sigmoid colon. RESULTS: Microscopically, in this method, neither erosion, ulcer nor microabscess is evidenced. This method may make an intracorporeal knot easy. Also we treated a patient who had a perforation of the sigmoid colon using Lapra-ty. The patient recovered without any trouble. CONCLUSIONS: This method could make ligation technique much easier and the operating time shorter.

Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences.

PURPOSE: Although laparoscopic colectomy has demonstrated a variety of advantages, it remains unclear whether the reductions in length of stay and faster return of bowel function will offset potential increases in cost caused by operating time and instrumentation. The purpose of this study was to compare the direct cost structure of elective open and laparoscopic resection for sigmoid diverticulitis. METHODS: We compared consecutive elective open and laparoscopic sigmoid colectomies (n = 71 and n = 61, respectively) performed from March 1, 1999, through December 31, 2000. Data collected included age, gender, body mass index, American Society of Anesthesia score, indication for surgery, morbidity, mortality, conversion (laparoscopic only), operating time, and length of hospital stay. Direct cost data were provided by Stanford's integrated hospital cost management and decision software. Indirect costs and total costs were not addressed. Data were analyzed by Student's t-test and chi-squared test where appropriate. Significance was set at P < 0.05. All data are presented as mean +/- standard error of the mean. RESULTS: There were 132 elective sigmoid colectomies for diverticular disease (61 laparoscopic and 71 open procedures). There were no significant differences between the groups with respect to age, male/female ratio, or body mass index. Operating time was similar (109 +/- 7 minutes for laparoscopic procedures vs. 101 +/- 7 minutes for open procedures). The laparoscopic group had a significantly shorter length of stay (3.1 +/- 0.2 vs. 6.8 +/- 0.4 days), fewer pulmonary complications (1 (1.6 percent) vs. 4 (5.6 percent)) and fewer wound infections (0 vs. 5 (7 percent)). Conversion to open colectomy was required in 4 (6.6 percent) of 61 patients. Readmission occurred in three laparoscopic colectomy patients (4.9 percent) and four open colectomy patients (5.6 percent). There was one operative death in the laparoscopic group (1.6 percent) and no deaths in the open group. Total direct cost per case was significantly less for laparoscopic procedures ($3,458 +/- 437) than for open colectomies ($4321 +/- 501; P < 0.05, Student's t-test), and operating costs were not significantly different between the groups. CONCLUSION: The data demonstrate that laparoscopic colectomy is a cost-effective means of electively managing sigmoid diverticular disease. This operative approach may become very important in an era of increasing constraints on hospital occupancy rates and access to nursing services in many regions of the country.