Systematic review and comparison of national and international guidelines on diverticular disease.

PURPOSE: Diverticular disease is common and of increasing medical and economical importance. Various practice guidelines on diagnostic and treatment on this disease exist. We compared current guidelines on the disease in order to identify concordant and discordant recommendations. METHOD: Eleven national and international guidelines on diverticular disease published over the last 10 years have been identified by a systematic literature review on PubMed and compared in detail for 20 main and 51 subtopics. RESULTS: The available evidence for the most aspects was rated as moderate or low. There was concordance for the following items: Diagnosis of diverticulitis should be confirmed by imaging methods (10 of 10 guidelines). Mild forms may be treated out-patient (10/10). Abscesses are treated non-surgically (9/9). Elective surgery should be indicated by individual patient-related factors, only, and be performed laparoscopically (10/10, 9/9 respectively). Main differences were found in the questions of appropriate classification, imaging diagnostic (computed-tomography versus ultra-sound), need for antibiotics in out-patient treatment and mode of surgery for diverticular perforation. Despite growing evidence that antibiotics are not needed for treating mild diverticulitis, only 3/10 guidelines have corresponding recommendations. Hartmann's procedure has been abandoned several years ago and is now recommended for feculent peritonitis by the three most recent guidelines. In contrast, laparoscopic lavage without resection is not recommended anymore. CONCLUSION: There are dissents in the recommendations for central aspects regarding the diagnostic and treatment of diverticular disease in recently published guidelines.

[Hybrid TAMIS total mesorectal excision. A new perspective in treatment of distal rectal cancer - Technique and results]. / Hybrid-TAMIS totale mesorektale Exzision. Neue Perspektive in der Behandlung des distalen Rektumkarzinoms - Technik und Ergebnisse.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer. METHODS: Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome. RESULTS: The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range <1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder. CONCLUSION: Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.

Midterm functional results of taTME with neuromapping for low rectal cancer.

BACKGROUND: Information on functional outcomes after laparoscopic-assisted transanal total mesorectal excision (taTME) is limited. This study analyzed the functional results in patients with low rectal cancer. METHODS: Ten consecutive patients (nine males) undergoing electrophysiologically controlled nerve-sparing taTME were investigated prospectively and asked to complete functional questionnaires [the International Prostate Symptom Score (IPSS), International Index of Erectile Function, Female Sexual Function Index, Wexner score, and low anterior resection syndrome (LARS) score]. Bladder function was also assessed according to residual urine volume. Preoperative function was compared to the functional outcome 3 and 6 months, and 9 months if eligible, after stoma closure or surgery in the absence of a diverting stoma. RESULTS: Prior to therapy, urinary and sexual function was impaired in 40 and 60% of patients, respectively. None of the patients developed pathological residual urine volumes after at least unilateral functional pelvic nerve-sparing. Median IPSS was lower than preoperative scores (p > 0.05). Two males with incomplete nerve preservation were considered impotent during a median follow-up of 15 months (range 6-20 months). The female was judged to be sexually inactive. The median Wexner score was 1 (range 0-7) prior to any therapy and increased to 7 (range 0-15) at 6 months (p = 0.029), with 40% of patients categorized as having no LARS and 50% minor LARS. The median LARS score was 28 (range 9-38) at 3 months and 26 (range 9-32) at 6 months (p = 0.165). CONCLUSIONS: Despite a small sample size and confounding factors, data indicate that taTME has the potential to preserve continence, sufficient bowel function, and urogenital function.

Lymph node harvest in single incision laparoscopic surgery for colorectal malignancy.

AIM: Single incision laparoscopic surgery (SILS) has not been sufficiently evaluated with respect to its oncological equivalence to conventional laparoscopic or open surgery. METHOD: Of 507 patients who had SILS for colorectal diseases in our institution, 87 had segmental resection for colorectal adenocarcinoma. For each of the surgical specimens the number of lymph nodes which can be expected to be identified by the pathologist was calculated using the ACPGBI lymph node harvest model, which was developed from a nationwide database of 5845 surgical specimens. The predicted number of lymph nodes was compared with the number identified in our SILS specimens. RESULTS: The median predicted number of lymph nodes was 11 (4.5-14.8) compared with 18 (5-44) in the SILS specimens (P < 0.001). In all subgroups analysed for various operations, the lymph node harvest in the SILS specimens was significantly higher than predicted. CONCLUSION: In terms of lymph node harvest SILS seems to be comparable to conventional open or laparoscopic surgery.

Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy.

OBJECTIVE: Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch-anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA. METHOD: Three-dimensional vector-manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary. RESULTS: Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA. CONCLUSION: A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.

Prospective randomised trial comparing ileocaecal interposition and colon-J-pouch as rectal replacement after total mesorectal excision.

BACKGROUND: Ileocaecal interposition (ICI) is a technique of rectal replacement after total mesorectal excision (TME), but the method has never been evaluated in a randomised fashion. We performed a randomised, controlled trial to compare ICI and colon-J-pouch (CJP) for rectal replacements after TME for rectal cancer. MATERIALS AND METHODS: Fifteen patients were enrolled into each treatment group of the trial according to the protocol. Follow-up evaluations were performed 3 months and 1 year after ileostomy closure and at a mean of 5 years after initial surgery. RESULTS: Similar results between the groups were found for incontinence, urgency, constipation and quality of life at all follow-ups. The frequency of defecation was slightly lower in the CJP group at 3 months [3 (2-6) vs 5 (2-11) (p=0.043)] and at 1 year [3 (2-5) vs 5 (2-8) (p=0.034)]. However, this difference lost significance if patients who had postoperative radiotherapy were excluded from the analysis. Four out of the 15 patients treated with ICI experienced bowel obstruction, which required open surgery in two, endoscopic dilatation in one or maintenance of the ileostomy in one patient. None of the patients treated with CJP had similar complications. CONCLUSIONS: ICI and CJP reconstruction result in a similar functional outcome and quality of life. As ICI did not show any benefit over CJP and tended to result in a higher frequency of defecation, it should not be used as a first choice treatment. In addition, ICI was associated with significant complications after radiotherapy. Therefore, it must not be used if postoperative radiochemotheray is intended.

Pharmacokinetics and peritoneal penetration of moxifloxacin in peritonitis.

OBJECTIVES: To investigate the penetration of moxifloxacin into peritoneal exudate in patients with complicated intra-abdominal infections (cIAIs). PATIENTS AND METHODS: Patients (n = 10) with evidence of peritonitis who required surgery with drainage of the abdominal cavity received a single intravenous infusion of moxifloxacin, 400 mg, over 1 h. Plasma and peritoneal exudate samples were obtained over 24 h, and moxifloxacin concentrations were measured by HPLC with fluorescence detection. RESULTS: Plasma moxifloxacin concentrations decreased from a geometric mean of 3.61 mg/L at 1 h to 0.36 mg/L at 24 h. Concentrations in peritoneal exudate were highest 2 h after the start of the infusion, reaching a geometric mean of 3.32 mg/L, and declined to a geometric mean of 0.69 mg/L at 24 h. The exudate/plasma concentration ratio rose from 1.45 at 2 h to 1.91 at 24 h; the 95% confidence intervals for the ratio excluded unity at all time points, suggesting that moxifloxacin penetrates and accumulates in peritoneal exudate. The area under the concentration-time curve (AUC) tended to be greater in exudate; the time to peak concentrations (T(max)) was longer in exudate than in plasma, as were half-life and mean residence time (MRT). CONCLUSIONS: Following intravenous administration, moxifloxacin penetrated peritoneal exudate in patients with peritonitis, achieving and maintaining concentrations that exceed the MICs for pathogens commonly isolated in cIAIs. These findings support the clinical use of moxifloxacin as treatment for cIAIs.

[Contraction of the hip and fecal drainage via a fistula tract 30 years after "appendectomy"]. / Stuhlfistel und Hüftgelenkskontraktur 30 Jahre nach "Blinddarmoperation".

A 46-year-old female was admitted with increasing fecal drainage via a fistula tract in the right inguinal region. She had a history of surgery for appendicitis 30 years previously, from which there was disturbed wound healing resulting in a blunt fistula, and the patient suffered from contraction of the right hip. Computed tomographic scan and ultrasound demonstrated an inflammatory mass in the right inguinal region. Colonoscopy demonstrated a stenosis of the rectosigmoid junction but did not provide any further specific information. Surgery revealed the presumed diagnosis of complicated Crohn's disease, but an advanced squamous cell carcinoma was also identified. The patient died 23 months later due to generalized tumor. Although malignant transformation of a fistula tract is rare, this case demonstrates that long-standing fistulas should be cured as far as possible without significant morbidity. In the case of incurable fistulas, malignancy must definitely be excluded if the clinical appearance of the fistula changes.

[Vulnerability of ileocoecal interposition pouch and colonic J-pouch to postoperative adjuvant radiotherapy]. / Vulnerabilität von ileocoecalem Interpositionspouch und Colon-J-Pouch gegenüber der postoperativen, adjuvanten Strahlentherapie.

AIM: The interposition of an ileocoecal segment has been introduced as an alternative procedure to impair the functional outcome following total mesorectal excision (TME). Up to now, there is no information concerning the effect of postoperative radiotherapy on the functional outcome of this method. PATIENTS AND METHODS: We compared functional outcome, anorectal physiology, and radiation therapy-related morbidity of 18 patients treated with TME und ileocoecal interposition (ICI) of which ten had postoperative radiotherapy, with 15 patients who had TME and colonic J-pouch (CJP) reconstruction of which 7 were subjected to radiotherapy. RESULTS: Patients with no radiotherapy revealed a satisfying functional result with a similar median frequency of defecation of 4.25 (2-5) and 3 (2-6) and an incontinence-score of 2.8 (0-6) and 1.0 (0-2) after ICI and CJP, respectively. Median stool frequency (7 (2-11) (ICI) and 5 (2.5-11) (CJP)) and incontinence score (6 (0-12) (ICI) and 7 (6-12) (CJP)) were markedly increased in both groups after radiotherapy. Besides a reduced anal resting pressure, a lower compliance and a smaller volume of the neorectum were observed in the irradiated patients. A radiogenic injury which required surgery was seen in 4/10 patients after ICI. In three of these four patients the interposed ileocoecal segment was mainly affected. None of the patients treated with a CJP suffered a similar complication. DISCUSSION: These data indicate that postoperative radiotherapy severely impairs the functional outcome after TME independent of the type of surgery used for reconstruction, and causes a significant morbidity after ICI. CONCLUSION: Postoperative radiotherapy following TME should be indicated cautiously, and ICI should not be used if postoperative radiotherapy is intended.

Plasma concentration of biologically active fibronectin and fibronectin bound to gelatin-like material in a porcine model of hyperdynamic endotoxic shock.

Due to its opsonizing role, plasma fibronectin (pFN) binds to circulating degradation products deriving from collagenous structures and mediates their elimination by the reticuloendothelial system (RES). In septic shock, an overflow of this material may lead to a lack of pFN and an impaired RES activity. In fact, low pFN levels have been reported to correlate with unfavorable clinical outcome. However, dysfunction of the RES is also caused by other shock related factors, and death from septic shock also has been observed in the presence of normal FN levels. To investigate the involvement of opsonic FN in the progression of sepsis, we discriminated between biologically active FN and FN bound to gelatin-like material in pigs developing a hyperdynamic endotoxic shock. All FN determinations were performed with the immunochemical assay. Discrimination between free FN and complexed FN was achieved by separation on gelatin sepharose. A continuous decrease of total FN and free FN was observed in the septic group reaching 57% and 50% of the initial level at the end of the 5-h observation period, respectively. However, a significant difference was not detected before both the microcirculatory and macrocirculatory alterations indicative of hyperdynamic endotoxic shock were completely established. Complexed FN was increased slightly in both groups without any group specific differences. We conclude that the FN-mediated opsonization of circulating gelatine-like material does not play a critical role in early circulatory shock.

Negative side-effects of retention sutures for abdominal wound closure. A prospective randomised study.

OBJECTIVE: To assess the effect of retention sutures on the postoperative course of patients after major abdominal operations. DESIGN: Prospective, randomised study. SETTING: Teaching hospital, Germany. SUBJECTS: 95 patients who were at increased risk of wound failure after major abdominal operations. INTERVENTION: Conventional mass closure either with (n = 44) or without (n = 51) reinforcement by wire retention sutures. MAIN OUTCOME MEASURES: Pain intensity on postoperative days 3, 6, 9, and 12, patients' acceptance, retention-suture-related morbidity, general morbidity. RESULTS: Postoperative pain was overall more severe with retention sutures. On day 6, 31/49 control patients but only 13/41 patients with retention sutures were pain-free (p = 0.003, 95% CI 0.12 to 0.51). Twelve of 44 patients with retention sutures developed local complications of the sutures, and 21 of the 44 had to have them removed prematurely, in most cases because of intolerable pain. CONCLUSIONS: Retention sutures used to close abdominal wounds cause inconvenience, pain, and specific morbidity.