Outcomes of initially nonoperative management of diverticulitis with abscess formation in immunosuppressed patients. DIPLICAB study COLLABORATIVE group.

AIM: Management of diverticulitis with abscess formation in immunosuppressed patients (IMS) remains unclear. The main objective of the study was to assess short- and long-term outcomes between IMS and immunocompetent patients (IC). The secondary aim was to identify risk factors for emergency surgery. METHODS: A nationwide retrospective cohort study was performed at 29 Spanish referral centres between 2015-2019 including consecutive patients with first episode of diverticulitis classified as modified Hinchey Ib or II. IMS included immunosuppressive therapy, biologic therapy, malignant neoplasm with active chemotherapy and chronic steroid therapy. A multivariate analysis was performed to identify independent risk factors to emergency surgery in IMS. RESULTS: A total of 1395 patients were included; 118 IMS and 1277 IC. There were no significant differences in emergency surgery between IMS and IC (19.5% and 13.5%, p = 0.075) but IMS was associated with higher mortality (15.1% vs. 0.6%, p < 0.001). Similar recurrent episodes were found between IMS and IC (28% vs. 28.2%, p = 0.963). Following multivariate analysis, immunosuppressive treatment, p = 0.002; OR: 3.35 (1.57-7.15), free gas bubbles, p < 0.001; OR: 2.91 (2.01-4.21), Hinchey II, p = 0.002; OR: 1.88 (1.26-2.83), use of morphine, p < 0.001; OR: 3.08 (1.98-4.80), abscess size ≥5 cm, p = 0.001; OR: 1.97 (1.33-2.93) and leucocytosis at third day, p < 0.001; OR: 1.001 (1.001-1.002) were independently associated with emergency surgery in IMS. CONCLUSION: Nonoperative management in IMS has been shown to be safe with similar treatment failure than IC. IMS presented higher mortality in emergency surgery and similar rate of recurrent diverticulitis than IC. Identifying risk factors to emergency surgery may anticipate emergency surgery.

Impact of CT-measured sarcopenic obesity on postoperative outcomes following colon cancer surgery.

OBJECTIVE: This study aimed to investigate the influence of sarcopenic obesity on anastomotic leak following elective colon resection for non-metastatic colon cancer. Secondary outcomes included overall morbidity, mortality and length of hospital stay. METHODS: This retrospective observational study, conducted at a colorectal surgery referral centre, spanned from January 1, 2015, to January 1, 2020. A total of 544 consecutive patients who underwent elective colon resection were included in the analysis, excluding patients with rectal cancer, urgent surgery, absence of anastomosis, lack of imaging, multivisceral resections and synchronic tumours. RESULTS: Postoperative complications were observed in 177 (32.3%) patients, with 51 (9.31%) classified as severe (Clavien-Dindo > II). Sarcopenic obesity was identified in 9.39% of the sample and emerged as an independent predictor of increased overall morbidity [OR 2.15 (1.14-3.69); p = 0.016] and 30-day mortality [OR 5.07 (1.22-20.93); p = 0.03] and was significantly associated with the development of anastomotic leak [OR 2.95 (1.41-6.18); p = 0.007]. Furthermore, it increased the risk of reoperation and was linked to a prolonged length of hospital stay. CONCLUSIONS: CT-measured sarcopenic obesity demonstrates a discernible correlation with an elevated risk of postoperative morbidity and mortality in the context of colon cancer surgery.

High incidence of surgery and initiation of medical therapies after colectomy for ulcerative colitis or inflammatory bowel disease unclassified.

BACKGROUND AND AIMS: Despite novel medical therapies, colectomy has a role in the management of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU). This study aimed to determine the incidence of unplanned surgery and initiation of immunomodulatory or biologic therapy (IMBT) after colectomy in patients with UC or IBDU, and identify associated factors. METHODS: Data of patients with preoperative diagnosis of UC or IBDU who underwent colectomy and were followed up at a single tertiary centre was retrospectively collected. The primary outcome was the risk of unplanned surgery and initiation of IMBT during follow-up after colectomy. Secondary outcomes were development of Crohn's disease-like (CDL) complications and failure of reconstructive techniques. RESULTS: 68 patients were included. After a median follow-up of 9.9 years, 32.4% of patients underwent unplanned surgery and IMBT was started in 38.2%. Unplanned surgery-free survival was 85% (95% confidence interval [CI] 73.8-91.6%) at 1 year, 76% (95% CI 63.2-84.9%) at 5 years and 69.1% (95% CI 55-79.6%) at 10 years. IMBT-free survival was 96.9% (95% CI 88.2-99.2%) at 1 year, 77.6% (95% CI 64.5-86.3%) at 5 years and 63.3% (95% CI 48.8-74.7%) at 10 years. 29.4% of patients met criteria for CDL complications. CDL complications were significantly associated to IMBT (hazard ratio 4.5, 95% CI 2-10.1). CONCLUSION: In a retrospective study, we found a high incidence of unplanned surgery and IMBT therapy initiation after colectomy among patients with UC or IBDU. These results further question the historical concept of surgery as a "definitive" treatment.

Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group.

BACKGROUND: To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery. METHODS: This nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed. RESULTS: Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37-0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85). CONCLUSION: Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Prophylactic Use of Negative Pressure Wound Therapy Reduces Surgical Site Infections in Elective Colorectal Surgery: A Prospective Cohort Study.

Background: The main purpose was to assess the efficacy of negative pressure wound therapy (NPWT) for surgical site infection (SSI) in elective open and laparoscopic open-assisted colorectal surgery. The primary end point was to establish SSI within 30 days post-operatively. The secondary aim was hospital stay and to assess SSI predictors in a multivariable analysis. Patients and Methods: A prospective cohort study was undertaken between January 2017 and December 2018 in patients undergoing elective colorectal surgery, both through open and minimally invasive approaches, to whom NPWT or fully occlusive dressing were applied. Baseline data were compared between the two groups and multivariable analysis was performed to identify SSI risk factors. Results: Two hundred patients were included: 100 NPWT patients and 100 closed dressing patients. No differences between the two groups were found. The incidence of SSI in the control dressing group was 19% versus 9% in the NPWT group, which was substantially different (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.11-0.83; p = 0.02). No differences were found in hospital length of stay (12.33 d in NPWT group vs. 12.39 d in the control group; p = 0.82). A body mass index (BMI) of 30-35 (p = 0.04), BMI >35 (p = 0.03), and midline wound (p = 2.68) were found to be predictors of SSI in multivariable analysis. Conclusion: The prophylactic use of NPWT in laparotomy incisions for patients undergoing elective colorectal surgery (both through open and laparoscopic approach) is associated with a reduction in SSI rates.

Experience, complications and prognostic factors of the ileoanal pouch in ulcerative colitis: An observational study. / Experiencia, complicaciones y factores pronósticos con el reservorio anal en la colitis ulcerosa. Estudio observacional.

INTRODUCTION: Ileoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure. METHODS: A retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors. RESULTS: The study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years (p<0.01; HR: 5.55), handsewn anastomosis (p<0.01; HR: 3.78), pouch-vaginal (p=0.02; HR: 2.86), pelvic (p<0.01; HR: 5.17) and cutaneous p=0.01; HR: 3.01) fistulae were the main pouch failure risk factors. CONCLUSION: Restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.

Colorectal cancer: comparative analysis between two series of patients separated by more than three decades

Abstract Aim This study characterizes Colorectal Cancer (CRC) incidence in the University Hospital Ramon and Cajal, Madrid, and analyzes variations over time. It establishes risk groups, aiming to discover whether diagnosis can be determined in less advanced stages of disease. Method Evolutionary epidemiological study of genetic and environmental factors contributing to the development of CRC in this district that enables the comparison of two cohorts of patients separated by 37 years: G1 (patients of current group) and G2 (patients of historical group). The main risk variables gleaned retrospectively were analyzed and the statistical association between cohorts was determined. Results The mean age of patients increased significantly from 64 to 71 along with the incidence of ascending colon cancer. G1 scored higher than G2 for: the incidence of colon cancer in men, detection of adenomatous polyps (48.1%), percentage of resectability with curative intent (80.4%), and Dukes A stage (34.1%) (p < 0.001). Conclusion Biological aspects of CRC have been compared against its profile three decades earlier. We can confirm the existence of concrete changes in the manifestation and staging at the time of diagnosis or following earlier treatment. (AU)

Resecciones colorrectales segmentarias en pacientes con colitis ulcerosa y displasia o adenocarcinoma / Segmental colectomy in patients with colitis-associated neoplasia or dysplasia

Resumen Introducción: El tratamiento estándar para los pacientes con colitis ulcerosa y displasia o adenocarcinoma de colon ha sido la proctocolectomía total, lo que conlleva una morbilidad y una reducción en la calidad de vida significativa. Materiales y Método: Se hace un análisis retrospectivo de 5 pacientes con colitis ulcerosa a los que se realiza una resección segmentaria por displasia o adenocarcinoma. Resultados: La mediana de edad al diagnóstico de colitis ulcerosa y de la neoplasia fue de 56 y 62 años respectivamente. El tiempo de evolución de la enfermedad fue de 1 a 13 años. La mediana de seguimiento postoperatorio fue de 57 meses apareciendo en uno de los pacientes un nuevo foco de displasia. Conclusiones: En determinados pacientes seleccionados, las resecciones segmentarias podrían ser una opción segura si tienen buen control de la enfermedad, escasa actividad inflamatoria, pocos años de evolución y que puedan realizar un adecuado seguimiento posterior.

Introduction: The historical management for patients with ulcerative colitis and displasia or adenocarcinoma associated was to perform a total proctocolectomy, what cause important morbidity and affect patient's quality of life. Materials and Method: A retrospective review about 5 patients with a segmental colectomy due to dysplasia or adenocarcinoma is done. Results: The median age at diagnosis of ulcerative colitis and cancer was 56 and 62 years respectively. Disease time evolution was between 1 and 13 years. The patients were followed up for a median of 57 months. During the follow-up evaluation, 1 patient was found to have dysplasia. Conclusion: Segmental colectomy could be a safe option in clinically stable patients, few years of diagnosis and with and a suitable follow up.

Ultrashort bowel syndrome: surgical management and long-term results of an exceptional case.

Management of the short bowel syndrome is a multidisciplinary and very complex problem. The authors report the successful long-term results of an original combination of autologous gastrointestinal reconstruction in a boy who at the age of 16 years lost all but 5 cm of the small bowel. This case demonstrates that lengthening and antipropulsive interposition of a long segment of the colon can be another alternative to early transplantation in exceptional cases.