Does surgery improve quality of life in patients with ongoing- or recurrent diverticulitis; a systematic review and meta-analysis.

BACKGROUND: Recurrences or persistent symptoms after an initial episode of diverticulitis are common, yet surgical treatment is rarely performed. Current guidelines lack clear recommendations on whether or not to operate, even though recent studies suggest an improved quality of life following surgery. The aim of this study is therefore to compare quality of life in patients with recurrent or ongoing diverticulitis treated conservatively versus surgically, giving a more definitive answer to the question of whether or not to operate on these patients. METHODS: A systematic literature search was conducted in EMBASE, MEDLINE and Cochrane. Only comparative studies reporting on quality of life were included. Statistical analysis included calculation of weighted mean differences and pooled odds ratios. RESULTS: Five studies were included; two RCT's and three retrospective observational studies. Compared to conservative treatment, the SF-36 scores were higher in the surgically treated group at each follow-up moment but only the difference in SF-36 physical scores at six months follow-up was statistically significant (MD 6.02, 95%CI 2.62-9.42). GIQLI scores were also higher in the surgical group with a MD of 14.01 (95%CI 8.15-19.87) at six months follow-up and 7.42 (95%CI 1.23-12.85) at last available follow-up. Also, at last available follow-up, significantly fewer recurrences occurred in the surgery group (OR 0.10, 95%CI 0.05-0.23, p < 0.001). CONCLUSION: Although surgery for recurrent diverticulitis is not without risk, it might improve long-term quality of life in patients suffering from recurrent- or ongoing diverticulitis when compared to conservative treatment. Therefore, it should be considered in this patient group.

Intestinal motility distal of a deviating ileostomy after rectal resection with the construction of a primary anastomosis: results of the prospective COLO-MOVE study.

PURPOSE: No consensus exists regarding the use of preoperative bowel preparation for patients undergoing a low anterior resection (LAR). Several comparative studies show similar outcomes when a single time enema (STE) is compared with mechanical bowel preparation (MBP). It is hypothesized that STE is comparable with MBP due to a decrease in intestinal motility distal of a newly constructed diverting ileostomy (DI). METHODS: In this prospective single-centre cohort study, patients undergoing a LAR with primary anastomosis and DI construction were given a STE 2 h pre-operatively. Radio-opaque markers were inserted in the efferent loop of the DI during surgery, and plain abdominal X-rays were made during the first, third, fifth and seventh postoperative day to visualize intestinal motility. RESULTS: Thirty-nine patients were included. Radio-opaque markers were situated in the ileum or right colon in 100%, 100% and 97.1% of the patients during respectively the first, third and fifth postoperative day. One patient had its most distal marker situated in the left colon during day five. In none of the patients, the markers were seen distal of the anastomosis. CONCLUSION: Intestinal motility distally of the DI is decreased in patients who undergo a LAR resection with the construction of an anastomosis and DI, while preoperatively receiving a STE.

Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction.

BACKGROUND: Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is used infrequently owing to uncertainty about its oncological safety. This population study compared long-term oncological outcomes between emergency resection and SEMS placement as BTS. METHODS: Through a national collaborative research project, long-term outcome data were collected for all patients who underwent resection for left-sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1 : 2 propensity score matching. RESULTS: Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS-related perforation rate was 7·7 per cent (17 of 222). Three-year locoregional recurrence rates after SEMS insertion and emergency resection were 11·4 and 13·6 per cent (P = 0·457), disease-free survival rates were 58·8 and 52·6 per cent (P = 0·175), and overall survival rates were 74·0 and 68·3 per cent (P = 0·231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23·9 versus 45·3 per cent; P < 0·001), especially in elderly patients (29·0 versus 57·9 per cent; P < 0·001). For patients in the SEMS group with or without perforation, 3-year locoregional recurrence rates were 18 and 11·0 per cent (P = 0·432), disease-free survival rates were 49 and 59·6 per cent (P = 0·717), and overall survival rates 61 and 75·1 per cent (P = 0·529), respectively. CONCLUSION: Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS-related perforation, as well as permanent stoma, might influence shared decision-making for individual patients.

Incidence of and risk factors for stoma-site incisional herniation after reversal.

BACKGROUND: Stoma reversal is often considered a straightforward procedure with low short-term complication rates. The aim of this study was to determine the rate of incisional hernia following stoma reversal and identify risk factors for its development. METHODS: This was an observational study of consecutive patients who underwent stoma reversal between 2009 and 2015 at a teaching hospital. Patients followed for at least 12 months were eligible. The primary outcome was the development of incisional hernia at the previous stoma site. Independent risk factors were assessed using multivariable logistic regression analysis. RESULTS: After a median follow-up of 24 (range 12-89) months, 110 of 318 included patients (34·6 per cent) developed an incisional hernia at the previous stoma site. In 85 (77·3 per cent) the hernia was symptomatic, and 72 patients (65·5 per cent) underwent surgical correction. Higher BMI (odds ratio (OR) 1·12, 95 per cent c.i. 1·04 to 1·21), stoma prolapse (OR 3·27, 1·04 to 10·27), parastomal hernia (OR 5·08, 1·30 to 19·85) and hypertension (OR 2·52, 1·14 to 5·54) were identified as independent risk factors for the development of incisional hernia at the previous stoma site. In addition, the risk of incisional hernia was greater in patients with underlying malignant disease who had undergone a colostomy than in those who had had an ileostomy (OR 5·05, 2·28 to 11·23). CONCLUSION: Incisional hernia of the previous stoma site was common and frequently required surgical correction. Higher BMI, reversal of colostomy in patients with an underlying malignancy, stoma prolapse, parastomal hernia and hypertension were identified as independent risk factors.

[Ileostomy versus colostomy: which is preferable?] / Dubbelloops ileostoma versus colostoma: wat verdient de voorkeur?

OBJECTIVE: To investigate whether an ileostomy or colostomy should be preferred in patients requiring temporary double-barrel stoma construction and in whom it is technically possible to construct both types. DESIGN: Systematic literature search and retrospective comparative analysis. METHOD: PubMed, Embase and the Cochrane Library were searched for all literature comparing loop ileostomy and loop colostomy. In addition, we retrospectively analysed 361 patients who had received a loop ileostomy or loop colostomy designed to be temporary between 2009 and 2015 in our hospital, Meander Medisch Centrum, Amersfoort, the Netherlands. Outcome measures were: quality of life, short-term and long-term complications. RESULTS: The literature search yielded 2092 studies, of which eight were ultimately included. Ileostomy was the preferred stoma in the overall conclusion of six of these studies; no preference was given in the other two. In addition, we analyzed 361 patients from our own hospital in whom a temporary deviating stoma was constructed. 49.6% (n = 179) had a colostomy constructed, the other 50.4% (n = 182) an ileostomy. Significantly fewer stoma retractions (p < 0.01) and incisional hernias (p < 0.01) were reported in the loop ileostomy group. Patients with an ileostomy, however, more often presented with a high-output stoma (p < 0.01) resulting in dehydration (p = 0.03). CONCLUSION: A loop ileostomy has a number of advantages over a colostomy. However, in patients with an increased risk of dehydration or compromised renal function, colostomy construction should be seriously considered given the higher complication risk if a high-output stoma develops.

A Population-Based Analysis of Three Treatment Modalities for Malignant Obstruction of the Proximal Colon: Acute Resection Versus Stent or Stoma as a Bridge to Surgery.

BACKGROUND: Malignant obstruction of the proximal colon (MOPC) traditionally has been treated with acute resection. However, morbidity and mortality rates following these emergency surgeries are high. Initial bowel decompression by stent placement or stoma construction has been used for distal obstructions as an alternative approach. This study evaluated whether these alternative treatment strategies could be beneficial for patients with a MOPC as well. METHODS: All patients undergoing a colonic resection for a MOPC between January 2009 and December 2013 and who were registered in the Dutch Surgical Colorectal Audit were analyzed. RESULTS: From the 49,013 patients registered in the DSCA, 1860 (3.8 %) were selected for further analysis. Acute resection was performed in 1774 patients (95.4 %), 44 patients (2.4 %) were treated with initial decompression using stent placement and resection, and 42 patients (2.3 %) with stoma construction followed by resection. Thirty-day mortality was 8.8, 2.4, and 2.4 %, respectively. Mortality was significantly lower after a bridging strategy (stent or stoma) compared with acute resection (p = 0.04). Complications following the resection occurred in 39.6% in the acute resection group and in 27.3 and 31.7% in the stent and stoma group, respectively (p = 0.167). CONCLUSIONS: Acute resection was performed in the vast majority of patients with obstructive proximal colon cancer and resulted in a 40 % morbidity and 9 % mortality rate. A bridging strategy may be a valid alternative in some of these patients, because a significantly lower postoperative mortality rate was seen in a subgroup of patients initially treated with a stent or stoma.

Emergency resection versus bridge to surgery with stenting in patients with acute right-sided colonic obstruction: a systematic review focusing on mortality and morbidity rates.

PURPOSE: No consensus exists on the optimal treatment of acute malignant right-sided colonic obstruction (RSCO). This systematic review aims to compare procedure-related mortality and morbidity rates between primary resection and stent placement as a bridge to surgery followed by elective resection for patients with acute RSCO. METHODS: PubMed, Embase and Cochrane library were searched for all relevant literature. Primary endpoints were procedure-related mortality and morbidity. Methodological quality of the included studies was assessed using the MINORS criteria. RESULTS: Fourteen cohort studies were eligible for analysis. A total of 2873 patients were included in the acute resection group and 155 patients in the stent group. Mean mortality rate for patients who underwent acute resection with primary anastomosis was 10.8% (8.1-18.5%). Overall mortality for patients initially treated with a colonic stent followed with elective resection was 0%. Major morbidity was 23.9% (9.3-35.6%) and 0.8% (0-4.8%), respectively. Both mortality and major morbidity were significantly different. In addition, stent placement shows lower rates of anastomotic leakages (0 vs 9.1%) and fewer permanent ileostomies (0 vs 1.0%). CONCLUSION: Primary resection for patients with acute RSCO seems to be associated with higher mortality and major morbidity rates than stent placement and elective resection. In addition, stent placement resulted in fewer anastomotic leakages and permanent ileostomies. However, as no high-level studies are available on the optimal treatment of RSCO and proximal stenting is considered technically challenging, future comparative studies are warranted for the development of an evidence-based clinical decision guideline.