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The treatment of diverticulitis is experiencing a shift in management due to a number of large scale clinical trials. For instance, clinicians are beginning to recognize that avoidance of antibiotics in uncomplicated diverticulitis is not associated with worse outcomes. Additionally, while the decision to proceed with elective surgical resection for recurrent uncomplicated disease is less conclusive and favors a patient-centric approach, complicated disease with a large abscess denotes more aggressive disease and would likely benefit from elective surgical resection. Lastly, in patient with acutely perforated diverticulitis who require urgent surgical intervention, laparoscopic lavage is generally not recommended due to high re-intervention rates and the preferred surgical procedure is primary anastomosis with or without diversion due to high morbidity and low rates of Hartmann reversal.
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BACKGROUND: Disease-modifying anti-inflammatory bowel disease drugs (DMAIDs) revolutionized the management of ulcerative colitis (UC). This study assessed the relationship between the number and timing of drugs used to treat UC and the risk of colectomy and postoperative complications. METHODS: This was a retrospective review of adult patients with UC treated with disease-modifying drugs between 2005 and 2020 in the MarketScan database. Landmark and time-varying regression analyses were used to analyze risk of surgical resection. Multivariable Cox regression analysis was used to determine risk of postoperative complications, emergency room visits, and readmissions. RESULTS: A total of 12,193 patients with UC and treated with disease-modifying drugs were identified. With a median follow-up time of 1.7 years, 23.8% used >1 drug, and 8.3% of patients required surgical resection. In landmark analyses, using 2 and ≥3 drugs before the landmark date was associated with higher incidence of surgery for each landmark than 1 drug. Multivariable Cox regression showed hazard ratio (95% CIs) of 4.22 (3.59-4.97), 11.7 (9.01-15.3), and 22.9 (15.0-34.9) for using 2, 3, and ≥4 drugs, respectively, compared with using 1 DMAID. That risk was constant overtime. The number of drugs used preoperatively was not associated with an increased postoperative risk of any complication, emergency room visits, or readmission. CONCLUSION: The use of multiple disease-modifying drugs in UC is associated with an increased risk of surgical resection with each additional drug. This provides important prognostic data and highlights the importance of patient counseling with minimal concern regarding risk of postoperative morbidity for additional drugs.
Subject(s)
Colectomy , Colitis, Ulcerative , Postoperative Complications , Humans , Female , Male , Retrospective Studies , Adult , Colectomy/methods , Middle Aged , Colitis, Ulcerative/surgery , Colitis, Ulcerative/drug therapy , Postoperative Complications/epidemiology , Patient Readmission/statistics & numerical data , Proportional Hazards Models , Emergency Service, Hospital/statistics & numerical data , Risk FactorsABSTRACT
Meckel's diverticulum is the most common gastrointestinal congenital anomaly and may present with lower gastrointestinal bleeding, abdominal pain, and nausea. Imaging and endoscopic findings can be similar to those of Crohn's disease, including transmural inflammation, stricturing, and superficial ulceration frequently in the distal ileum. Here, we present a case series of three patients who were initially diagnosed with Crohn's disease and ultimately found to have Meckel's diverticulum alone on final pathology. This single-institution case series, the largest in the literature, highlights the importance of maintaining a high index of suspicion for Meckel's diverticulum, especially in the absence of microscopic evidence of inflammatory bowel disease.
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BACKGROUND: The COVID-19 pandemic severely impacted post-hospitalization care facilities in the United States and hindered their ability to accept new patients for various reasons. This study aimed to assess the impact of the pandemic on discharge disposition after colon surgery and associated postoperative outcomes. METHODS: A retrospective cohort study was performed using the National Surgical Quality Improvement Participant Use File and targeted colectomy. Patients were divided into the following 2 cohorts: (1) pre-pandemic (2017-2019) and (2) pandemic (2020). The primary outcomes included discharge disposition-post-hospitalization facility versus home. The secondary outcomes were rates of 30-day readmissions and other postoperative outcomes. The multivariable analysis assessed for confounders and effect modification on discharge to home. RESULTS: Discharge to posthospitalization facilities decreased by 30% in 2020 compared to 2017 to 2019 (7% vs 10%, P < .001). This occurred despite an increase in emergency cases (15% vs 13%, P < .001) and open surgical approach (32% vs 31%, P < .001) in 2020. Multivariable analysis revealed that patients in 2020 had 38% lower odds of going to post-hospitalization facilities (odds ratio 0.62, P < .001) after adjusting for surgical indications and underlying comorbidities. This decrease in patients going to a post-hospitalization facility was not associated with an increased length of stay or an increase in 30-day readmissions or postoperative complications. CONCLUSION: During the pandemic, patients undergoing colonic resection were less likely to be discharged to a post-hospitalization facility. This shift was not associated with an increase in 30-day complications. This should prompt further research to assess the reproducibility of these associations, especially in a setting without a global pandemic.
Subject(s)
COVID-19 , Quality Improvement , Humans , United States/epidemiology , Retrospective Studies , Pandemics , Reproducibility of Results , COVID-19/epidemiology , COVID-19/complications , Colectomy/adverse effects , Colon/surgery , Patient Discharge , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Patient ReadmissionABSTRACT
BACKGROUND: The progression to acute diverticulitis from the relatively benign condition of colonic diverticulosis is not well characterized. A smaller subset may even develop complicated (perforated) diverticulitis resulting in sepsis and/or death. Characterizing the differences between recurrent, uncomplicated diverticulitis, and the more virulent, complicated diverticulitis is necessary to guide clinical decision-making. Alterations to the microbiome offer a possible explanation for local inflammation and the pathophysiology of diverticular disease. OBJECTIVE: This study aimed to characterize the mucosal-associated microbiome in patients with recurrent uncomplicated diverticulitis and complicated (perforated) diverticulitis. DESIGN: Microbial DNA was extracted from full-thickness surgical specimens for 16S rRNA gene sequencing, targeting the V4 hypervariable region. Sequences were analyzed and a quantitative characterization based on taxonomic classification was performed. SETTING: A tertiary care academic medical center. PATIENTS: This study compared 48 patients with recurrent, uncomplicated diverticulitis and 35 patients with radiographically confirmed perforated (complicated) diverticulitis. Tissues were harvested from surgical resection specimens to include both diseased regions and nondiseased (adjacent normal) regions. MAIN OUTCOME MEASURES: We assessed differences in relative abundance and taxonomic classification of mucosal-associated microbes in surgical resection specimens from diverticular disease. RESULTS: When analyzing the tissue of diverticular resection specimens, the complicated diseased segments demonstrated an increased abundance of sulfur-reducing and sulfur-oxidizing bacteria compared to nondiseased, adjacent normal regions. When comparing diseased segments, tissues of patients with complicated diverticulitis had a marked increase in sulfur-reducing microbes. LIMITATIONS: We characterized the mucosal-associated microbiome present at the time of surgical resection, limiting conclusions on its role in pathophysiology. Furthermore, antibiotic usage and bowel preparation before surgery may result in perturbations to microbial flora. CONCLUSIONS: The microbiome of complicated diverticulitis is marked by a localized imbalance of sulfur-metabolizing microbes. The abundance of sulfur-reducing microbes may lead to an excess of hydrogen sulfide and subsequent inflammation. See Video Abstract at http://links.lww.com/DCR/C175 . LA MICROBIOMA DE LA DIVERTICULITIS COMPLICADA UN DESEQUILIBRIO DE LAS BACTERIAS METABOLIZADORAS DE AZUFRE: ANTECEDENTES: La progresión a diverticulitis aguda de la condición relativamente benigna de diverticulosis colónica no está bien caracterizada. Un subgrupo más pequeño puede incluso desarrollar diverticulitis complicada (perforada) que resulta en sepsis y/o muerte. Es necesario caracterizar las diferencias entre la diverticulitis recurrente no complicada y la diverticulitis complicada más virulenta para guiar la toma de decisiones clínicas. Las alteraciones del microbioma ofrecen una posible explicación de la inflamación local y la fisiopatología de la enfermedad diverticular.OBJETIVO: Caracterizar el microbioma asociado a la mucosa en pacientes con diverticulitis no complicada recurrente y diverticulitis complicada (perforada).DISEÑO: El ADN microbiano se extrajo de especímenes quirúrgicos de espesor completo para la secuenciación del gen 16S rRNA, dirigido a la región hipervariable V4. Se analizaron las secuencias y se realizó una caracterización cuantitativa basada en la clasificación taxonómica.AJUSTE: Un centro médico académico de atención terciaria.PACIENTES: Este estudio comparó 48 pacientes con diverticulitis recurrente no complicada y 35 pacientes con diverticulitis perforada (complicada) confirmada radiográficamente. Se recogieron tejidos de especímenes de resección quirúrgica para incluir tanto regiones enfermas como regiones no enfermas (normales adyacentes).PRINCIPALES MEDIDAS DE RESULTADO: Evaluamos las diferencias en la abundancia relativa y la clasificación taxonómica de los microbios asociados a la mucosa en muestras de resección quirúrgica de enfermedad diverticular.RESULTADOS: Al analizar el tejido de las muestras de resección diverticular, los segmentos enfermos complicados demostraron una mayor abundancia de bacterias reductoras de azufre y oxidantes de azufre en comparación con las regiones normales adyacentes no enfermas. Al comparar segmentos enfermos, los tejidos de pacientes complicados tenían un marcado aumento de microbios reductores de azufre.LIMITACIONES: Caracterizamos el microbioma asociado a la mucosa presente en el momento de la resección quirúrgica, lo que limita las conclusiones sobre su papel en la fisiopatología. Además, el uso de antibióticos y la preparación intestinal antes de la cirugía pueden provocar alteraciones en la flora microbiana.CONCLUSIONES: El microbioma de la diverticulitis complicada está marcado por un desequilibrio localizado de microbios metabolizadores de azufre. La abundancia de microbios reductores de azufre puede provocar un exceso de sulfuro de hidrógeno y la consiguiente inflamación. Consulte Video Resumen en http://links.lww.com/DCR/C175 . (Traducción-Dr. Ingrid Melo ).
Subject(s)
Diverticulitis , Microbiota , Sepsis , Humans , Inflammation , RNA, Ribosomal, 16SABSTRACT
BACKGROUND AND OBJECTIVES: In patients with colon cancer with synchronous liver metastasis, treatment algorithms are complex and often require multidisciplinary evaluation. Neoadjuvant therapy is frequently utilized, but there is an unclear relationship with postoperative outcomes in patients with simultaneous resection. METHODS: This is a retrospective cohort study from the National Surgical Quality Improvement Program and Targeted Colectomy databases. All patients with stage IV colon cancer undergoing simultaneous colectomy with synchronous liver metastasis resection or ablation between 2015 and 2019 were identified and categorized into subgroups based on receipt of neoadjuvant chemotherapy. Multivariable logistic regression was utilized to assess for risk factors of anastomotic leaks and serious postoperative complications. RESULTS: We identified 1006 patients who underwent simultaneous colectomy and liver operations. Of those, 418 (41.6%) received neoadjuvant chemotherapy within 90 days of surgery, while 588 (58.4%) had simultaneous upfront surgery. On multivariable logistic regression, neoadjuvant therapy was not associated with postoperative anastomotic leaks (odds ratio [OR]: 1.30; p = 0.39) or serious complications (OR: 1.04; p = 0.82). CONCLUSION: Neoadjuvant therapy does not increase postoperative complications in simultaneous colon and liver resections. These results may alleviate concerns regarding postoperative morbidity in the decision-making process of administering neoadjuvant therapy.
Subject(s)
Colonic Neoplasms , Liver Neoplasms , Humans , Anastomotic Leak/etiology , Neoadjuvant Therapy/adverse effects , Retrospective Studies , Colectomy/adverse effects , Colectomy/methods , Colonic Neoplasms/drug therapy , Colonic Neoplasms/surgery , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgery , Liver Neoplasms/drug therapy , Liver Neoplasms/surgeryABSTRACT
BACKGROUND: Early-onset colorectal cancers are increasing in incidence. Studies reported more left-sided cancers in patients aged <50 years. Some advocate for screening via flexible sigmoidoscopy at age 40 years. OBJECTIVE: The purpose of this study was to investigate characteristics and outcomes in sporadic right- and left-sided early-onset colorectal cancers. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a single, tertiary care institution. PATIENTS: This study included patients aged <50 years diagnosed with colorectal cancer between 2000 and 2018. MAIN OUTCOME MEASURES: We analyzed patient demographics, tumor characteristics, and survival. RESULTS: A total of 489 patients aged 20 to 49 years were identified from 2000 to 2018. The majority of patients were white (90%) and male (57%). The median age at diagnosis was 44 years, and 75% were diagnosed at age 40-49 years. There was a predominance of left-sided tumors (80%). The majority of patients presented with stage 3 (35%) and stage 4 (35%) disease. Right-sided tumors were more likely to have mucinous (24% vs 7.4%; p < 0.001) and signet-ring cell (4.4% vs 1.7%; p < 0.001) histology. There was no difference in age, sex, race, ethnicity, and stage at presentation. Right-sided tumors were associated with lower 5-year overall survival (44% vs 61%; p < 0.005) with the decrease in survival most prominent in right-sided stage 3 tumors (41% vs 72%; p < 0.0001) and in ages 40 to 49 years (43% vs 61%; p = 0.03). Sex, tumor location, increasing stage, and signet-ring cell histology were independent prognostic factors of overall survival. There was no difference in disease-free survival. LIMITATIONS: This study was a retrospective review at a single institution. CONCLUSIONS: The majority of early-onset colorectal cancers arise from age 40 to 49 years with a left-sided predominance but higher mortality in right-sided tumors. These findings provide further evidence in favor of recommending earlier initial screening colonoscopy for colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B892 . CARACTERSTICAS Y RESULTADOS DEL CNCER COLORRECTAL DE INICIO TEMPRANO DEL LADO DERECHO FRENTE AL IZQUIERDO: ANTECEDENTES:Los cánceres colorrectales de aparición temprana están aumentando en incidencia. Los estudios han informado una preponderancia de cánceres en el lado izquierdo en pacientes <50 años, lo que ha llevado a algunos a abogar por la detección con sigmoidoscopia flexible a los 40 años.OBJETIVO:El propósito de nuestro estudio fue investigar las características del tumor y los resultados de los pacientes en cánceres colorrectales esporádicos del lado derecho e izquierdo de aparición temprana.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se realizó en una única institución de atención terciaria.PACIENTES:Pacientes <50 años diagnosticados de cáncer colorrectal entre 2000 y 2018.RESULTADO PRINCIPAL:Analizamos los datos demográficos de los pacientes, las características del tumor, la supervivencia general y la supervivencia libre de enfermedad.RESULTADOS:Se identificaron un total de 489 pacientes de entre 20 y 49 años entre 2000 y 2018. La mayoría de los pacientes eran blancos (90%) y varones (57%). La mediana de edad en el momento del diagnóstico fue de 44 años y el 75% se diagnosticó entre los 40 y los 49 años. Predominó los tumores del lado izquierdo (80%). La mayoría de los pacientes presentaban enfermedad en estadio 3 (35%) y estadio 4 (35%). Los tumores del lado derecho tenían más probabilidades de tener histología mucinosa (24% frente a 7,4%, p < 0,001) y de células en anillo de sello (4,4% frente a 1,7%, p < 0,001). No hubo diferencia en edad, sexo, raza, etnia, estadio AJCC en la presentación. Los tumores del lado derecho se asociaron con una menor supervivencia general a 5 años (44% frente al 61%, p < 0,005) con la disminución de la supervivencia más prominente en los tumores del lado derecho en estadio 3 (41% frente al 72%, p < 0,0001) y en edades 40-49 (43% vs 61%, p = 0.03). El sexo, la ubicación del tumor, el estadio AJCC en aumento y la histología de las células en anillo de sello fueron factores pronósticos independientes de la supervivencia general. No hubo diferencias significativas en la supervivencia libre de enfermedad.LIMITACIONES:Este estudio fue una revisión retrospectiva en una sola institución.CONCLUSIONES:La mayoría de los cánceres colorrectales de aparición temprana surgen entre los 40 y los 49 años con un predominio en el lado izquierdo pero una mayor mortalidad en los tumores del lado derecho. Estos hallazgos proporcionan evidencia adicional a favor de recomendar una colonoscopia de detección inicial más temprana para el cáncer colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B892 . (Traducción-Dr. Ingrid Melo ).
Subject(s)
Carcinoma, Signet Ring Cell , Colorectal Neoplasms , Humans , Male , Adult , Middle Aged , Retrospective Studies , Neoplasm Staging , Follow-Up Studies , Colorectal Neoplasms/diagnosis , Colorectal Neoplasms/epidemiology , Carcinoma, Signet Ring Cell/pathologyABSTRACT
Necrotizing soft tissue infections of the perineum are rapidly progressing infections associated with significant morbidity and mortality. Prompt diagnosis and management with early surgical debridement is necessary to improve survival from this deadly disease. Repeat debridements are not uncommon. Important adjuncts to surgery include broad-spectrum antibiotics and management in an intensive care unit, as patients frequently develop multisystem organ failure. Once the acute phase is managed, fecal diversion with either an ostomy or fecal management catheter can be considered to decrease soiling of the wound and facilitate healing. Long-term management requires meticulous wound care, often with the assistance of negative pressure wound therapy. Patients may ultimately require skin grafts or tissue flaps for soft tissue coverage following extensive surgical debridements.
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Neutrophilic dermatosis (ND) is a category of diseases characterized by trauma-induced, autoinflammatory cutaneous eruption. Comorbid systemic disease is common with a predilection for malignancy, inflammatory bowel disease, and rheumatologic disease. Rarely, it can manifest with aseptic shock, an entity referred to as necrotizing neutrophilic dermatosis (NND). NND may occur in the postoperative setting and is often misdiagnosed as a necrotizing soft tissue infection. Unfortunately, the treatment for a necrotizing soft tissue infection, namely, wide debridement, is often detrimental in the setting of NND. We present the case of a woman with underlying myelodysplastic syndrome who developed episodic postoperative hemodynamic collapse followed by delayed necrotic peristomal ulceration following colonic diversion for complicated diverticulitis. Infectious workup and operative re-exploration were unrevealing. Pathologic assessment of affected skin tissue showed changes consistent with ND, ultimately leading to the diagnosis of NND. Her clinical course dramatically improved with the initiation of immunosuppressive therapy. The mimicry of NND to a potentially lethal necrotizing soft-tissue infection creates a grave diagnostic dilemma in the postoperative period. A general lack of knowledge of NND among non-dermatologic specialists produces an opportunity for misdiagnosis and inappropriate surgical interventions, namely, serial debridement. Several clinical cues may aid in the earlier recognition of NND. The cornerstone of treatment involves systemic corticosteroid therapy with adjunctive therapy for refractory cases. NND must be considered in the differential diagnosis of necrotizing soft tissue infection as early recognition may result in the avoidance of deleterious surgical interventions.
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Ileal pouch-anal anastomosis allows for reestablishing gastrointestinal continuity in patients after proctocolectomy. The technical elements of pouch creation and gaining reach into the pelvis are demanding and require a variety of surgical maneuvers to achieve a tension-free anastomosis. We present a brief review of the literature discussing various approaches aimed at improving ileal pouch reach into the low pelvis. Although these techniques are used with different frequencies, they serve as important adjuncts to the gastrointestinal surgeons' armamentarium.