Reversal of end-ileostomy in patients with Crohn's disease.

PURPOSE: End-ileostomy after two-staged ileocolic resection is frequently performed in Crohn's disease patients at high risk for postoperative complications. However, there is paucity on data regarding the morbidity after the stoma reversal. METHODS: One hundred thirty patients undergoing closure of end-ileostomy between 1994 and 2016 were included. Data collection was retrospective in 11 first, and it was prospective in 119 last patients. Anastomotic complications were defined as anastomotic leak, perianastomotic abscess, and perianastomotic peritonitis. RESULTS: The median interval between ileostomy construction and reversal was 4.0 months. Ninety-seven of 121 patients with available data (80%) gained weight between both surgeries. Hemoglobin level increased between surgeries in 107 patients (85%). Fifteen patients (11.5%) received parenteral fluid substitution or parenteral nutrition between both surgeries. There were 37 hospital readmissions during the time between stoma construction and reversal (29%). After ileostomy reversal, 14 patients developed anastomotic complications (11%). By multivariate regression analysis, preoperative steroid intake (hazard ratio 4.5, 95% CI: 1.11-18.0, p = 0.035) and hospital readmission for infectious complications (HR 4.5, 95% CI: 1.11-18.0, p = 0.035) were statistically significantly associated with an increased risk to develop postoperative anastomotic complications. There were no postoperative deaths. CONCLUSION: Closure of end-ileostomy could be complicated by some serious morbidity. These risks should be taken into consideration weighing carefully between the one- and two-stage ileocolic resection in Crohn's disease patients.

German National Guideline on the management of pilonidal disease: update 2020.

BACKGROUND: The present German National Guideline is an updated version of previous Guideline published in 2014. It aims to compare various treatment methods and to assist physicians with evidence-based recommendations. METHODS: Systemic literature review. RESULTS: Three types of disease manifestation could be differentiated: asymptomatic disease, an acute abscess, and the chronic pilonidal disease. At present, there is no treatment method fulfilling all desired criteria: simple, painless procedure associated with rapid wound healing, and low recurrence rate. Thus, treatment modality should be tailored to disease manifestation and extent. CONCLUSION: Asymptomatic pilonidal disease should not be treated. A pilonidal abscess should be unroofed. After resolution of the acute inflammation, the disease should be treated definitely. As for today, sinus excision is the standard treatment of the chronic pilonidal disease. Wide excision and open treatment of chronic disease is a safe procedure which, however, leads to prolonged secondary healing and time off-work, as well as to considerable recurrence rate. The extent of excision should be as limited as possible. Excision and midline wound closure is associated with impaired outcomes. Today, it has become obsolete. Minimally invasive procedures (e.g., pit picking surgery) represent a treatment option for chronic pilonidal disease. However, the recurrence rate is higher compared to excision procedures. Nevertheless, they may be used for small primary disease. Off-midline procedures should be used for disease not suitable for minimally invasive treatments. The Limberg flap and the Karydakis procedure are two best described methods which are associated with similar short- and long-term results.

Disease phenotype rather than treatment strategy impacts the long-term quality of life in patients with diverticular disease.

PURPOSE: To identify the impact of the severity of diverticular disease on long-term quality of life. METHODS: Consecutive patients, hospitalized between October 2009 and November 2015 due to uncomplicated (UD) and complicated diverticulitis (CD) of the left colon, were analyzed. Patients undergoing emergent surgery for perforated disease were excluded. Primary endpoint was health-related quality of life (HrQol), measured by the Short Form 36 questionnaire (SF-36). Physical (PCS) and mental (MCS) compository scores were calculated from SF-36 subscales. To overcome bias, one-to-one propensity score matching and multivariable logistic regression analysis were performed. RESULTS: Two hundred eighty of the overall 392 patients (Male 138, Female 142; mean age 60.5 years, range 27-91) answered the SF-36 questionnaire. The median follow-up period was 37.8 months (range 15-85). After propensity score matching, each group consisted of 51 patients. Results of the SF-36 questionnaires showed a statistically significant difference, favoring patients with CD in 5 of 8 domains. Also, PCS (56.3 vs. 52.9, p = 0.13) and MCS (53.3 vs. 46.7, p = 0.005) were higher in patients treated for CD. By a multivariate analysis, complicated disease was independently associated with a better scoring on 6 out of 8 SF-36 subscales and on MCS. Treatment strategy (surgery or conservative) did not have any impact on SF-36 subscales, MCS, or PCS on multivariate analysis. CONCLUSION: In contrast to complicated disease, the uncomplicated diverticular disease is associated with an impaired long-term quality of life especially in domains composing mental health scores independently of chosen treatment strategy. STUDY REGISTRATION: The study is registered with the Research Registry at June 19, 2019. Research registry UIN: researchregistry4959 .

[Preoperative imaging for colorectal cancer: surgeons' perspective]. / Bildgebung vor kolorektaler Chirurgie aus Sicht des Chirurgen.

Preoperative radiological diagnostics in patients with colorectal cancer has several objectives. The diagnostic localization of the colonic tumor is essential for planning the resection. The radiologically suspected infiltration of neighboring structures may lead to the decision for neoadjuvant treatment. In patients with rectal carcinomas, the T and N stages, the distance to the circumference resection margin (CRM), and the penetration of the tumor into the mesentery must be determined. This crucial to determine whether the patient should undergo neoadjuvant treatment. Prior to the planned relocation of an upstream stoma, radiological diagnostics may be added to clinical and endoscopic assessment but should not be routinely used.

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome.

PURPOSE: Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. METHODS: Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. RESULTS: Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014). CONCLUSION: Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a "Damage Control Strategy".

PURPOSE: Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a "Damage Control Strategy" (DCS). MATERIALS AND METHODS: Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann's procedure) after 24-48 h. RESULTS: Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30-92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5 days (3-66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%). CONCLUSION: The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

German national guideline on the management of pilonidal disease.

PURPOSE: The present national guideline aims to provide recommendations for physicians involved in the treatment of patients with pilonidal disease. It has been published previously as an extended version in German language. METHODS: This is a systemic literature review. The present guideline was reviewed and accepted by an expert panel in a consensus conference. RESULTS: Some of the present guideline conclusions were based on low- to moderate-quality trials. Therefore, an agreement was necessary in those cases to provide recommendations. However, recommendations regarding the most frequently used surgical procedures were based on numerous prospective randomized trials. CONCLUSIONS: An asymptomatic pilonidal disease does not require treatment. A pilonidal abscess should be incised. After regression of the acute inflammation, a definitive treatment method should be applied. An excision is the standard treatment method for the chronic pilonidal disease. Open wound healing is associated with a low postoperative morbidity rate; however, it is complicated by a long healing time. The minimally invasive procedures (e.g., pit picking surgery) represent a potential treatment option for a limited chronic pilonidal disease. However, the recurrence rate is higher compared to open healing. Excision followed by a midline wound closure is associated with a considerable recurrence rate and increased incidence of wound complications and should therefore be abandoned. Off-midline procedures can be adopted as a primary treatment option in chronic pilonidal disease. At present, there is no evidence of any outcome differences between various off-midline procedures. The Limberg flap and the Karydakis flap are most thoroughly analyzed off-midline procedures.

Damage control strategy for the treatment of perforated diverticulitis with generalized peritonitis.

BACKGROUND: The best surgical strategy for the management of perforated diverticulitis with generalized peritonitis of the sigmoid colon is not clearly defined. The aim of this retrospective cohort study was to evaluate the value of a damage control strategy. METHODS: All patients who underwent emergency laparotomy for perforated diverticular disease of the sigmoid colon with generalized peritonitis between 2010 and 2015 were included. The damage control strategy (study group), included a two- stage procedure: limited resection of the diseased colonic segment, closure of proximal colon and distal stump, and application of an abdominal vacuum at the initial surgery followed by second-look laparotomy 24-48 h later At this point a choice was made between anastomosis and Hartmann's procedure. The control group consisted of patients receiving definitive reconstruction (anastomosis or Hartmann's procedure) at the initial operation. RESULTS: Thirty-seven patients were included in the study. Damage control strategy was applied in 19 patients and the control group consisted of 18 patients. Both groups were comparable in terms of demographics, severity of peritonitis, and comorbidities. The overall postoperative mortality was 11 % (n = 4). There were no statistically significant differences between both groups regarding postoperative morbidity and mortality; however, a significantly higher proportion of patients in the control group had a stoma after the initial hospital stay (83 vs. 47 %, p = 0.038). This difference was still significant after adjustment for sex, age, Mannheim Peritonitis Index, American Society of Anesthesiologists class and presence of septic shock at presentation. At the end of the follow-up period, 15 of 17 survivors in the study group and 13 of 16 survivors in the control group had their intestinal continuity restored (p = 0.66). CONCLUSIONS: Damage control strategy in patients with generalized peritonitis due to perforated diverticulitis leads to a significantly reduced stoma rate after the initial hospital stay without an increased risk of postoperative morbidity.

[Treatment of a postoperative rectal stenosis with a self-expanding biodegradable polydioxanone stent]. / Behandlung einer postoperativen Rektumstenose mittels eines selbstexpandierenden resorbierbaren Polydioxanon-Stents.

Rectal stricture is a serious although infrequent complication of transanal endoscopic microsurgery (TEM). In some cases, these strictures may be refractory to treatment by endoscopic balloon dilatation. Biodegradable stents might improve the outcome by providing an extended period of dilatation. Moreover, these stents can remain in place without the need to remove them. In the presented case, a biodegradable polidioxanone stent originally developed to treat benign oesophageal stenoses was used to treat a patient suffering from rectal stricture following a TEM.

[Postoperative morbidity after bowel resections in patients with Crohn's disease: risk, management strategies, prevention]. / Postoperative Komplikationen nach Darmresektionen bei Patienten mit Morbus Crohn: Risiko, Behandlung, Prävention.

The postoperative morbidity rate following bowel resections for Crohn's disease is higher than for other benign disease. The incidence of postoperative intraabdominal septic complications (anastomotic leak, bowel fistula, intraabdominal abscess, peritonitis) is 5 - 30 %. Preoperative weight loss, prolonged refractory symptoms and penetrating disease behaviour are significant determinants of postoperative complication risk. Preoperative enteral nutrition, antibiotics, percutaneous abscess drainage and cessation of steroids might reduce the risk of surgery, however, more evidence is needed. The intake of immunosuppressive agents (mainly, azathioprine) can be continued perioperatively. The occurrence of postoperative intraabdominal septic complications is associated with an increased risk of surgical recurrence in patients with terminal ileitis, however, the long-term prognosis could be improved in the latter patients by secondary fecal diversion. There is no association between postoperative morbidity and long-term outcome in patients with Crohn's colitis.

Comparison between preoperative quantitative assessment of bowel wall vascularization by contrast-enhanced ultrasound and operative macroscopic findings and results of histopathological scoring in Crohn's disease.

PURPOSE: Patients with Crohn's disease (CD) often undergo several radiological imaging studies, which - with the exception of MRI and US - subject patients to ionizing radiation. Thus, efforts have been made to identify the inflammation activity using ultrasound techniques. The aim of our study was to describe the perfusion pattern of the inflamed bowel wall in CD using contrast-enhanced ultrasound (CEUS) and specific quantification software for perfusion assessment. Moreover, we compared these findings with the operative macroscopic findings as well as with the transparietal histopathological findings of surgical specimens applying an advanced histopathological scoring system. MATERIALS AND METHODS: We prospectively performed CEUS in 20 consecutive patients with proven CD and planned bowel surgery due to CD within the next 15 days. We then applied the quantification software Qontrast to obtain contrast-enhanced sonographic perfusion maps. The surgeon defined the clinical behavior of CD according to the Vienna classification. The resected segments were then assessed by a pathologist using an advanced scoring system. We compared the results of CEUS, macroscopic findings and histopathological scoring. RESULTS: We found a strong negative correlation (r = - 0.677, p < 0.01) between the histopathological score and the time-to-peak (TTP). Moreover, we detected a strong correlation between TTP and single parameters of the histopathological scoring system. CONCLUSION: Ultrasound as a widely available radiation-free imaging method would be preferable for assessing inflammatory activity of CD, particularly since the ultrasound findings correlate significantly with a histopathological scoring system.

Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease.

BACKGROUND: In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD. METHODS: A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes. RESULTS: The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042). CONCLUSION: Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

[Surgical therapy for adrenal tumours]. / Chirurgische Therapie der Nebennierenrinden-Adenome.

Four endoscopic and four open accesses are available for the surgery of adrenal tumours. The decision to use one of the available techniques depends on tumour size, body mass index, previous abdominal surgery and the experience of the surgeon. Currently, the lateral laparoscopic and the dorsal retroperitoneoscopic approaches are most frequently used. Conventional surgery should be used if malignancy is suspected, especially for tumours larger than 6 cm. In individual cases, even tumours up to 10 cm can be operated laparoscopically if there is no suspicion of invasive growth or lymphatic metastases. Each surgeon should choose the most familiar access. The retroperitoneoscopic and laparoscopic accesses for benign adrenal tumours up to 6 cm are considered to be equivalent. The surgeon should also be able to approach adrenal tumours conventionally.

[Acne inversa (hidradenitis suppurativa)]. / Acne inversa (Hidradenitis suppurativa).

Hidradenitis suppurativa (acne inversa) is a chronic inflammatory follicular skin disease which leads to fistulae, abscesses and scarring. The Hurley classification is used to quantify the extent of the disease whereby stage III is associated with extensive disfiguring lesions. The most frequently used conservative treatment options are topical clindamycin, systemic antibiotics, e.g. clindamycin and rifampicin, anti-TNF antibodies and laser epilation. Complete excision of fistulae with or without plastic coverage of defects are the mainstays of surgical treatment. Preoperative and postoperative strategies to diminish tissue loss and options for recurrence prevention are discussed.

COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer.

INTRODUCTION: Laparoscopic resection of rectal cancer has been proven efficacious but morbidity and oncological outcome need to be investigated in a randomized clinical trial. TRIAL DESIGN: Non-inferiority randomized clinical trial. METHODS: The COLOR II trial is an ongoing international randomized clinical trial. Currently 27 hospitals from Europe, South Korea and Canada are including patients. The primary endpoint is loco-regional recurrence rate three years post-operatively. Secondary endpoints cover quality of life, overall and disease free survival, post-operative morbidity and health economy analysis. RESULTS: By July 2008, 27 hospitals from the Netherlands, Belgium, Germany, Sweden, Spain, Denmark, South Korea and Canada had included 739 patients. The intra-operative conversion rate in the laparoscopic group was 17%. Distribution of age, location of the tumor and radiotherapy were equal in both treatment groups. Most tumors are located in the mid-rectum (41%). CONCLUSION: Laparoscopic surgery in the treatment of rectal cancer is feasible. The results and safety of laparoscopic surgery in the treatment of rectal cancer remain unknown, but are subject of interim analysis within the COLOR II trial. Completion of inclusion is expected by the end of 2009. TRIAL REGISTRATION: Clinicaltrials.gov, identifier: NCT00297791 (www.clinicaltrials.gov).

[Perianal fistulas in Crohn's disease: treatment results at an interdisciplinary unit]. / Perianale Crohn-Fisteln : Ergebnisse der Behandlung in einer interdisziplinären Sprechstunde.

BACKGROUND: Approximately one third of patients with Crohn's disease develop perianal fistulas. This study was conducted to determinate outcome predictors in patients treated at a specialized multidisciplinary unit. PATIENTS AND METHODS: Between May 2005 and May 2008, all patients with perianal Crohn's fistulas were treated by the same surgeon and a gastroenterologist specialized in managing patients with Crohn's disease. Deep fistulas were treated by fistulotomy. For high fistulas, a noncutting seton was placed followed by maintenance treatment with azathioprine and/or infliximab. "Optimal outcome" was recorded when (a) there was no need for diverting stoma, (b) complete healing was achieved by fistulotomy, or (c) fistula symptoms were under control, i.e. there was no need for treatment extension during follow-up. RESULTS: Thirty-four male and 32 female patients underwent 100 surgical interventions. The most frequent types of fistula were high trans-sphincteric (62%) and high intersphincteric (15%). Eleven of the 32 females presented with rectovaginal fistulae. At the study end, complete healing was observed in 12 patients and 32 had good control of fistula symptoms. Seven required proctectomy, fistula symptoms were not under control in 12, and three required diverting stoma. Altogether 44 patients (67%) achieved optimal outcome. The following factors were predictors of nonoptimal outcome by multivariate analysis: presence of Crohn's colitis (P=0.01), age at the onset of Crohn's disease <20 years (P=0.02), and types of fistula not suitable for fistulotomy (P=0.05). CONCLUSIONS: The multidisciplinary approach at specialized units will lead to successful outcome in >60% of patients with Crohn's perianal fistulas. The presence of Crohn's colitis, young age at disease onset, and presence of high fistulas are indicators of poor prognosis.