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1.
Medicine (Baltimore) ; 100(5): e24271, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33592870

RESUMO

ABSTRACT: Recent reports have documented an unchanged rate of occurrence of colorectal cancer (CRC) and have publicised doubts regarding the benefit of prompt colonoscopy procedures after an episode of acute diverticulitis (AD). These reports mandate further evaluation of colonoscopy yield and timing in this regard. The current study aims to determine whether the rate of advanced colonic neoplasia after AD differs from that of average-risk patients, and to identify risk factors that are associated with their development.In this retrospective study, we included all patients who had been hospitalized to the surgery ward in the years 2008 to 2016 with radiographically confirmed AD, and had completed colonoscopies within one year of index hospitalization. Patients who were referred for screening colonoscopies during the same years were included as a control group. We compared the rates of diagnosis of CRC and advanced polyps for both groups before and after adjustment for multiple confounders. Moreover, we investigated risk factors that were associated with increased rate of advanced neoplasia diagnosis.A total of 350 patients were included in the AD group and 1502 patients in the screening colonoscopy control group. The CRC diagnosis rates (1.7% vs 0.3%; P = .09) and overall diagnosis rates of advanced neoplasia (12.3% vs 9.6%; P = .19) were not significantly different when findings were compared between the AD and control groups, respectively. Cases of complicated diverticulitis, however, were associated with increased risk of advanced neoplasia diagnosis (odds ratio (OR) 3.729, 95% confidence interval (CI) 1.803-7.713; P = .01).The diagnosis rate for advanced neoplasia after AD was not significantly different from that of average-risk populations. A course of complicated AD, however, was a potential risk factor.


Assuntos
Colonoscopia , Neoplasias Colorretais/diagnóstico , Doença Diverticular do Colo , Detecção Precoce de Câncer , Neoplasias , Exacerbação dos Sintomas , Colonoscopia/métodos , Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/epidemiologia , Correlação de Dados , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/epidemiologia , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/estatística & dados numéricos , Feminino , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias/diagnóstico por imagem , Neoplasias/patologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/estatística & dados numéricos
3.
Am Surg ; 86(4): 308-312, 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32391754

RESUMO

Acute diverticulitis is an emergency surgical condition that is commonly managed via an acute surgical unit model. Operative surgery is indicated in selected situations including generalized peritonitis or fistulous disease; however, limited data exist on how borderline patients potentially needing surgery may be salvaged by close clinical management with modern interventional techniques. The aims of the study were to identify the operative surgery rates in acute diverticulitis and predictors for identifying patients with complicated diverticulitis. Retrospective data collection was performed on a prospectively held database at a high-volume acute surgical unit at Logan Hospital, Queensland. Patient demographic data, disease-related factors, and treatment-related factors were collected for reporting and analysis. Over three years (2016-2018), 201 patients (64%) were admitted with uncomplicated diverticulitis and 113 patients (36%) with complicated diverticulitis. An observable downward trend was noted in the number of yearly admissions for uncomplicated diverticulitis. Complicated diverticulitis was associated with male gender (P = 0.039), increased length of hospital stay (P < 0.001), temperature ≥37.5 (P = 0.025), increased white cell count (P < 0.001), and elevated C-reactive protein (P < 0.001). Twelve patients (11%) with complicated diverticulitis initially failed conservative management. Seven patients (6%) underwent a definitive Hartmann's procedure, and 5 patients (4%) underwent percutaneous drainage of abscesses. Acute diverticulitis can be safely managed nonoperatively by medical therapy and percutaneous drainage of abscesses, with surgery reserved for patients with complicated diverticulitis with sepsis or peritonitis.


Assuntos
Antibacterianos/uso terapêutico , Doença Diverticular do Colo/terapia , Drenagem , Abscesso Abdominal/tratamento farmacológico , Abscesso Abdominal/etiologia , Abscesso Abdominal/cirurgia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Colostomia , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/tratamento farmacológico , Doença Diverticular do Colo/cirurgia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Peritonite/etiologia , Peritonite/cirurgia , Estudos Retrospectivos
4.
Ann R Coll Surg Engl ; 102(8): 581-589, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32233866

RESUMO

INTRODUCTION: Free abdominal gas is an important finding with major clinical implications. However, data on the aetiologies and prognosis of patients with free gas are scarce. Our primary aim was to describe the sources of free abdominal gas on emergency department (ED) computed tomography (CT). The secondary aim was to evaluate the association between the amount of free gas and all-cause mortality. METHODS: All patients who underwent CT in the ED between February 2012 and February 2019 with free abdominal gas were included in the study. A scoring system was used to assess the amount of free gas: small - gas bubbles; medium - any gas pocket ≤2cm in diameter; large - any gas pocket >2cm. Data were collected from laboratory and clinical assessment regarding the source of free gas and all-cause mortality. RESULTS: A total of 372 patients had free abdominal gas. Colonic diverticulitis was the most common aetiology among those with a small or medium amount of free gas (81/250 [32.4%] and 12/71 [16.9%] respectively). For patients with a large amount of gas, peptic disease was the most common aetiology (11/51 [21.6%]). Three-quarters of the patients (280/372, 75.2%) had the source of free gas identified during ED admission. Ninety-day mortality rates were 7.2%, 9.9% and 21.6% for patients with small, medium and large amounts of gas respectively (p=0.007). CONCLUSIONS: Colonic diverticulitis was the most common source of free abdominal gas and peptic disease was the most common cause of a large amount of free gas. Mortality rates correlated with the amount of gas and were significantly higher in patients with a large amount.


Assuntos
Pneumoperitônio , Adulto , Idoso , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/epidemiologia , Serviço Hospitalar de Emergência , Feminino , Gastroenteropatias/complicações , Gastroenteropatias/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pneumoperitônio/diagnóstico por imagem , Pneumoperitônio/etiologia , Pneumoperitônio/mortalidade , Pneumoperitônio/patologia , Prognóstico , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
5.
Dis Colon Rectum ; 63(5): 701-709, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32271220

RESUMO

BACKGROUND: CT findings of acute diverticulitis can overlap with features of malignancy, and current guidelines recommend colonic evaluation after acute diverticulitis. However, the benefits of routine colonic evaluation have been questioned. OBJECTIVE: We review 30 studies, composed of 29,348 subjects, to evaluate the role of routine colonic evaluation after CT-proven acute diverticulitis. DATA SOURCES: Medline, EMBASE, and the Cochrane Library were searched for articles published up to July 2018 to identify all relevant articles. STUDY SELECTION: A combination of both Medical Subject Headings and non-Medical Subject Headings key terms using Boolean operators were used on Medline, including colonic neoplasms, colorectal cancer, colon cancer, colonic cancer, colonoscopy, and diverticulitis. Any randomized or nonrandomized, English-language article that specifically analyzed incidence of colorectal cancer after performing colonoscopy in patients with previous diverticulitis was included. MAIN OUTCOME MEASURES: The desired outcome was to evaluate for incidence of colonic malignancy in cases of acute colonic diverticulitis. Subgroup analyses for incidence of malignancy in uncomplicated and complicated diverticulitis, and Asian population studies were also performed. RESULTS: Findings of colonic malignancy occurred in 1.67% (95% CI, 1.24-2.14) of patients with CT-diagnosed diverticulitis. The risk of malignancy in cases with uncomplicated diverticulitis was 1.22% (95% CI, 0.63-1.97) as compared with 6.14% (95% CI, 3.20-9.82) in cases with complicated diverticulitis, with a relative risk of 5.033 (95% CI, 3.194-7.930; p < 0.001). LIMITATIONS: Significant variability in design and methodology of the individual studies contributed to the heterogeneity of this study, but these were addressed by using the random-effects model analysis. CONCLUSIONS: Colonic evaluation is worth considering for patients with diverticulitis because of the small but serious risk of underlying malignancy. The risk of malignancy is higher for patients of advanced age and with complicated diverticulitis.


Assuntos
Neoplasias Colorretais/diagnóstico , Doença Diverticular do Colo/diagnóstico por imagem , Colonoscopia , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/patologia , Humanos , Tomografia Computadorizada por Raios X
9.
Ann R Coll Surg Engl ; 102(3): e51-e53, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31697162

RESUMO

Diverticular disease is a common clinical condition among Western populations, which increases with age. It can present in a variety of manners and has myriad of potential disease complications. We present a rare case of an adult patient with an extraperitoneal complications of a diverticular perforation presenting with facial swelling due to a colo-urachal fistula associated with a patent urachal remnant. Perforation should be considered in patients presenting with surgical emphysema with background of diverticular disease.


Assuntos
Anafilaxia/etiologia , Doença Diverticular do Colo/complicações , Edema/etiologia , Face , Fístula/complicações , Fístula Intestinal/complicações , Perfuração Intestinal/etiologia , Úraco , Doença Diverticular do Colo/diagnóstico por imagem , Humanos , Perfuração Intestinal/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade
10.
JAAPA ; 33(1): 24-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31880646

RESUMO

Segmental colitis associated with diverticulosis (SCAD) is a rare variant of chronic colitis that is limited to segments of the left colon that harbor diverticula. Histologically, SCAD is known to mimic chronic idiopathic inflammatory bowel disease. Patients usually present with hematochezia and cramping abdominal pain; SCAD often resolves spontaneously without treatment, or completely after a limited course of therapy. Due to the histologic overlap with ulcerative colitis and occasional Crohn colitis, the implications of an inaccurate diagnosis are significant.


Assuntos
Colectomia , Colite/cirurgia , Doença Diverticular do Colo/cirurgia , Ileostomia , Dor Abdominal/etiologia , Colite/complicações , Colite/patologia , Colonoscopia , Diarreia/etiologia , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/patologia , Diverticulose Cólica/complicações , Diverticulose Cólica/patologia , Diverticulose Cólica/cirurgia , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Pessoa de Meia-Idade
11.
Dis Colon Rectum ; 63(1): 26-28, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31804267

RESUMO

CASE SUMMARY: A 62-year-old previously healthy man presented with left lower quadrant pain and fever. Physical examination showed left lower quadrant peritonitis. Computed tomography scan showed a pelvic abscess with extraluminal air (). Intravenous antibiotics were started, and CT-guided percutaneous drainage was performed. The drain was removed 1 week after discharge. One week later, he presented with dysuria and pneumaturia and was started on antibiotics. Colonoscopy confirmed diverticulosis with no other mucosal abnormalities. He underwent a successful laparoscopic sigmoidectomy with colovesical fistula takedown.


Assuntos
Abscesso Abdominal/etiologia , Antibacterianos/administração & dosagem , Doença Diverticular do Colo/complicações , Drenagem/métodos , Abscesso Abdominal/diagnóstico , Abscesso Abdominal/terapia , Administração Intravenosa , Colonoscopia , Doença Diverticular do Colo/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X
12.
J Surg Res ; 247: 220-226, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31708198

RESUMO

BACKGROUND: Despite the increased adoption of minimally invasive techniques in colorectal surgery, an open resection with ostomy creation remains an accepted operation for perforated diverticulitis. In the United States, there is an increase in the rates of both morbid obesity and diverticular disease. Therefore, we wanted to explore whether outcomes for morbidly obese patients with diverticulitis are worse than nonmorbidly obese patients after open colectomy for diverticulitis. MATERIALS AND METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2015, we identified adults with emergent admission for diverticulitis (International Classification of Diseases, Ninth Revision, code 562.11) with evidence of preoperative sepsis and intraoperative contaminated/dirty wound classification, in which a resection with ostomy (Current Procedural Terminology codes 44141, 44143, or 44144) was performed. We excluded cases with age >90 y, ventilator dependence, evidence of disseminated cancer and missing sex, race, body mass index, functional status, American Society of Anesthesiologists class, length of stay (LOS), or operative time data. Morbid obesity was defined as body mass index >35 kg/m2. Risk variables of interest included age, sex, race, medical comorbidities, requirement for preoperative transfusion, preoperative sepsis, and operative time. Outcomes of interest included LOS, 30-d postoperative complications, and mortality. Univariate and propensity scores with postmatching analyses were performed. RESULTS: A total of 2019 patients met inclusion and exclusion criteria, of which 413 (20.5%) were morbidly obese. Morbidly obese patients tended to be younger (mean 57.2 versus 62.6 y) and female (54.5% versus 45.5%). Morbidly obese patients also had higher rates of insulin-dependent diabetes (8.0% versus 4.2%), hypertension (60.1% versus 51.3%), renal failure (3.4% versus 1.5%), and higher American Society of Anesthesiologists class (class 4: 23.5% versus 19.6% and class 5: 1.45% versus 0.87%). Morbidly obese patient had no increase in 30-d mortality or LOS, but they had higher rates of superficial wound infection (9.0% versus 5.8%; P = 0.0259), deep wound infection (4.4% versus 1.9%; P = 0.0073), acute renal failure (4.8% versus 2.4%; P = 0.0189), postoperative septic shock (17.7% versus 12.1%; P = 0.0040), and return to the operating room (11.1% versus 6.4%; P = 0.0015). We identified 397 morbidly obese patients well matched by propensity score to 397 nonmorbidly obese patients. Conditional logistic regression showed no difference in LOS (median 12.9 versus 12.4 d; P = 0.4648) and no increased risk of 30-d mortality (P = 0.947), but morbid obesity was an independent predictor for return to the operating room (adjusted odds ratio: 27.09 [95% confidence interval: 2.68-274.20]; P = 0.005). CONCLUSIONS: This analysis of a large national clinical database demonstrates that morbidly obese patients presenting with perforated diverticulitis undergoing a Hartmann's procedure do not have increased mortality or LOS compared with nonobese patients. After adjusting for the effects of morbid obesity, morbidly obese patients had increased risk of return to operating room. Despite literature describing the many perioperative risks of obesity, our analysis showed only increased reoperation for obese patients with diverticulitis.


Assuntos
Colostomia/efeitos adversos , Doença Diverticular do Colo/cirurgia , Perfuração Intestinal/cirurgia , Obesidade Mórbida/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Sepse/cirurgia , Adulto , Idoso , Índice de Massa Corporal , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/mortalidade , Feminino , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/mortalidade , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Período Perioperatório/mortalidade , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Sepse/etiologia , Sepse/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
Rev. argent. coloproctología ; 30(4): 104-113, dic. 2019. ilus, tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1096799

RESUMO

Introducción: Los pacientes que se presentan con cuadros de peritonitis de origen diverticular (estadios Hinchey III o IV) en un contexto de sepsis severa con inestabilidad hemodinámica (shock séptico) la realización de anastomosis primaria presenta una alta tasa de dehiscencia anastomótica y mortalidad operatoria, aconsejándose la realización de una resección y abocamiento a la manera de Hartmann. Sin embargo, la alta tasa de complicaciones relacionadas a la confección del ostoma, la complejidad de la cirugía de restauración del tránsito intestinal, asociado a que entre el 40 % y el 60 % de los Hartmann no se reconstruyen, ha estimulado a que se intenten otras variables de resolución para esta compleja y grave patología. Diversas publicaciones en los últimos años han propuesto la táctica de "cirugía del control del daño" con el objeto de disminuir la morbimortalidad de estos gravísimos cuadros sépticos y a su vez reducir la tasa de ostomías. El objetivo de este trabajo es presentar nuestra experiencia inicial con esta modalidad de manejo de la peritonitis diverticular Hinchey III/IV sepsis severa e inestabilidad hemodinámica (shock séptico) y realizar una revisión bibliográfica del tema. Material y método: Estudio observacional, descriptivo, de series de casos. Entre noviembre de 2015 y diciembre de 2016. Servicio de coloproctología del complejo médico hospitalario Churruca-Visca de la ciudad de Buenos Aires y práctica privada de los autores. Se utilizó la técnica de laparotomía abreviada y cierre temporal del abdomen mediante un sistema de presión negativa. Resultados: En el periodo descripto se operaron 17 pacientes con peritonitis generalizada purulenta o fecal de origen diverticular. Catorce casos fueron Hinchey III (82,36%) y 3 casos Hinchey IV (17,64%). En 3 casos se observó inestabilidad hemodinámica en el preoperatorio o intraoperatorio. Todos ellos correspondientes al estadio IV de Hinchey. Se describen los 3 casos tratados mediante esta táctica quirúrgica. Discusión: La alta tasa de morbimortalidad de este subgrupo de pacientes incentivó a diversos grupos quirúrgicos a implementar la técnica de control del daño, permitiendo de esta manera estabilizar a los pacientes hemodinámicamente y en un segundo tiempo evaluar la reconstrucción del tránsito intestinal. En concordancia con estas publicaciones, dos de nuestros pacientes operados con esta estrategia, pudieron ser anastomosados luego del segundo lavado abdominal. Conclusión: En pacientes con peritonitis diverticular severa asociado a shock séptico el concepto de laparotomía abreviada con control inicial del foco séptico, cierre temporal del abdomen con sistema de presión negativa y posterior evaluación de la reconstrucción del tránsito intestinal, es muy alentador. Permitiendo una disminución de la morbimortalidad como así también del número de ostomías. (AU)


Introduction: Patients presenting with diverticular peritonitis (Hinchey III or IV stages) in a context of severe sepsis with hemodynamic instability (septic shock), performing primary anastomosis has a high rate of dehiscence anastomotic and operative mortality, advising the realization of a resection and ostoma in the manner of Hartmann. However, the high rate of complications related to performing of ostoma, the complexity of intestinal transit restoration surgery, associated with the 40% to 60% of Hartmann reversal not performed, has encouraged other variables to be attempted resolution for this complex and serious pathology. Several publications in recent years have proposed the tactic of "damage control surgery" in order to reduce the morbidity of these serious septic charts while reducing the rate of ostomies. The objective of this study is to present our initial experience with this modality of management of the diverticular peritonitis Hinchey III/IV severe sepsis and hemodynamic instability (septic shock) and to carry out a bibliographic review of the subject. Material and method: Observational, descriptive study of case series. Between November 2015 and December 2016. Coloproctology service of the Churruca-Visca hospital medical complex in the city of Buenos Aires and private practice of the authors. The technique of abbreviated laparotomy and temporary closure of the abdomen was used by a negative pressure system. Results: In the period described, 17 patients with generalized purulent or fecal peritonitis of diverticular origin were operated. Fourteen cases were Hinchey III (82.36%) and 3 cases Hinchey IV (17.64%).In 3 cases, hemodynamic instability was observed in the preoperative or intraoperative period. all of them corresponding to Hinchey's Stage IV. The 3 cases treated using this surgical tactic are described. Discussion: The high morbidity rate of this subgroup of patients encouraged various surgical groups to implement the damage control technique, thus allowing patients to stabilize hemodynamically and in a second time evaluate reconstruction intestinal transit. In line with these publications, two of our patients operated on with this strategy could be anastomosated after the second abdominal wash. Conclusion: In patients with severe diverticular peritonitis associated with septic shock, the concept of abbreviated laparotomy with initial control of the septic focus, temporary closure of the abdomen with negative pressure system and subsequent evaluation of transit reconstruction intestinal, it's encouraging. Allowing a decrease in morbidity as well as the number of ostomies. (AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Peritonite/cirurgia , Choque Séptico , Doença Diverticular do Colo/cirurgia , Tratamento de Ferimentos com Pressão Negativa , Laparotomia/métodos , Peritonite/etiologia , Reoperação , Lavagem Peritoneal , Colostomia/métodos , Colostomia/mortalidade , Doença Aguda , Epidemiologia Descritiva , Sepse , Doença Diverticular do Colo/complicações , Técnicas de Fechamento de Ferimentos Abdominais , Laparotomia/mortalidade
14.
Int J Colorectal Dis ; 34(12): 2111-2120, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31713714

RESUMO

PURPOSE: Laparoscopic peritoneal lavage (LPL) is feasible in selected patients with pelvic abscess and generalized purulent peritonitis caused by acute diverticulitis. We aimed to compare LPL and laparoscopic sigmoidectomy (LS) in complicated acute diverticulitis. METHODS: This prospective, observational, multicenter study included patients with a pelvic abscess not amenable to conservative management and patients with Hinchey III acute diverticulitis, from 2015 to 2018. Sixty-six patients were enrolled: 28 (42%) underwent LPL and 38 (58%) underwent LS. In LS, patients had a primary anastomosis, with or without ileostomy, or an end colostomy (HA). Major outcomes were mortality, morbidity, failure of source control, reoperation, length of stay, and diverticulitis recurrence. RESULTS: Patient demographics were similar in the two groups. In LPL, ASA score > 2 and Mannheim Peritonitis Index were significantly higher (p = 0.05 and 0.004). In LS, 24 patients (63%) had a PA and 14 (37%) an HA. No death was recorded. Overall, morbidity was 33% in LPL and 18% in LS (p = 0.169). However, failure to achieve source control of the peritoneal infection and the need to return to the operating room were more frequent in LPL (p = 0.002 and p = 0.006). Mean postoperative length of stay was comparable (p = 0.08). Diverticular recurrence was significantly higher in LPL (p = 0.003). CONCLUSION: LPL is related to a higher reoperation rate, more frequent postoperative ongoing sepsis, and higher recurrence rates. Therefore, laparoscopic lavage for perforated diverticulitis carries a high risk of failure in daily practice.


Assuntos
Abscesso Abdominal/cirurgia , Colectomia/métodos , Doença Diverticular do Colo/cirurgia , Laparoscopia , Lavagem Peritoneal/métodos , Doenças do Colo Sigmoide/cirurgia , Abscesso Abdominal/diagnóstico , Abscesso Abdominal/etiologia , Abscesso Abdominal/mortalidade , Idoso , Colectomia/efeitos adversos , Colectomia/mortalidade , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/diagnóstico , Doença Diverticular do Colo/mortalidade , Europa (Continente) , Feminino , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Lavagem Peritoneal/efeitos adversos , Lavagem Peritoneal/mortalidade , Peritonite/diagnóstico , Peritonite/etiologia , Peritonite/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Estudos Prospectivos , Recidiva , Reoperação , Medição de Risco , Fatores de Risco , Doenças do Colo Sigmoide/complicações , Doenças do Colo Sigmoide/diagnóstico , Doenças do Colo Sigmoide/mortalidade , Fatores de Tempo , Resultado do Tratamento
16.
Dis Colon Rectum ; 62(10): 1153-1156, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31490823

RESUMO

CASE SUMMARY: A healthy 65-year-old woman presents to the emergency department with a 12-hour history of sudden-onset severe lower abdominal pain. This is her first episode. She reports nausea, vomiting, and anorexia. Her last colonoscopy was at age 60, and was normal, except for diverticulosis of the sigmoid colon. Physical examination is significant for fever, tachycardia, and generalized abdominal pain with rebound tenderness. Pertinent laboratory findings include a leukocytosis and metabolic acidosis. A CT scan is obtained and is consistent with freely perforated diverticulitis, including a thickened sigmoid colon, free fluid in the pelvis, and free air noted near the diaphragm (). The surgeon completes the patient evaluation, recommends initiation of intravenous fluid resuscitation and antibiotics, and plans to go immediately to the operating room for surgical resection.


Assuntos
Colo Sigmoide/cirurgia , Colostomia/métodos , Gerenciamento Clínico , Doença Diverticular do Colo/cirurgia , Perfuração Intestinal/cirurgia , Laparoscopia/métodos , Idoso , Anastomose Cirúrgica/métodos , Colo Sigmoide/diagnóstico por imagem , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/diagnóstico , Feminino , Humanos , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/etiologia , Radiografia Abdominal , Tomografia Computadorizada por Raios X , Ultrassonografia
17.
JSLS ; 23(3)2019.
Artigo em Inglês | MEDLINE | ID: mdl-31431798

RESUMO

Background and Objectives: The applications of laparoscopic surgery are expanding, but there is still controversy about its application in patients with peritonitis resulting from diverticulitis perforation. This study aimed to investigate the factors affecting the postoperative mortality rate in patients undergoing surgery for perforated diverticulitis. Further, we compared the recovery courses of patients between open and laparoscopic surgeries. Methods: We analyzed the medical records of adult patients with peritonitis caused by perforated diverticulitis from six hospitals of Hallym University Medical Center from January 2006 to December 2016. Results: A total of 166 patients were identified. In the univariate analysis, the statistically significant factors associated with postoperative mortality were age ≥ 60 years, body mass index ≥ 23 kg/m2, American Society of Anesthesiologists score ≥ 3, hypertension, serum blood urea nitrogen ≥ 23 mg/dL, creatinine ≥ 1.2 mg/dL, albumin < 3.0 g/dL, modified Hinchey score ≥ grade III, formation of stoma, and laparoscopic surgery. In multivariate analysis, serum albumin < 3.0 g/dL was the only factor associated with mortality. After case-control matching, we compared postoperative hospital course and prognosis between open and laparoscopic surgery groups. There was no significant difference in the clinical course between the groups. No significant difference was observed in the complication rate, reoperation rate, readmission rate, and mortality. Conclusion: Low preoperative serum albumin level (<3.0 g/dL) affects the mortality rate of patients after surgery. The hospital course and prognosis after laparoscopic surgery and conventional open surgery are comparable in patients with peritonitis caused by diverticulitis perforation.


Assuntos
Doença Diverticular do Colo/cirurgia , Perfuração Intestinal/cirurgia , Laparoscopia , Laparotomia , Adulto , Idoso , Estudos de Casos e Controles , Doença Diverticular do Colo/sangue , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/mortalidade , Feminino , Humanos , Perfuração Intestinal/sangue , Perfuração Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Peritonite/sangue , Peritonite/etiologia , Peritonite/mortalidade , Peritonite/cirurgia , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , República da Coreia , Estudos Retrospectivos , Fatores de Risco , Albumina Sérica/metabolismo , Taxa de Sobrevida
18.
World J Emerg Surg ; 14: 32, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31338117

RESUMO

Introduction: Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. The aim of this meta-analysis is to determine which of the two procedures has a more favorable outcome. Methods: A systematic review of the existing literature was performed using the PRISMA guidelines. A meta-analysis was carried out using a Mantel-Haenszel, random effects model, and forest plots were generated. The Newcastle-Ottawa and Jadad scoring tools were used to assess the included studies. Results: A total of 25 studies involving 3546 patients were included in this study. The overall mortality in the HP group was 10.8% across the observational studies and 9.4% in the randomized controlled trials (RCTs). The mortality rate in the PRA group was lower than that in the HP group, at 8.2% in the observational studies and 4.3% in the RCTs. A comparison of PRA vs HP demonstrated a 40% lower mortality rate in the PRA group than in the HP (OR 0.60, 95% CI 0.38-0.95, p = 0.03) when analyzing the observational studies. However, meta-analysis of the three RCTs did not demonstrate any difference in mortality, (OR 0.44 (95% CI 0.14-1.34, p = 0.15). Wound infection rates between the two groups were comparable (OR 0.75, 95% CI 0.20-2.78, p = 0.67). Conclusion: Analysis of observational studies suggests that PRA may be associated with a lower overall mortality. There were no differences in wound infection rates. Based on the current evidence, both surgical strategies appear to be acceptable.


Assuntos
Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/normas , Doença Diverticular do Colo/cirurgia , Doença Diverticular do Colo/complicações , Humanos , Perfuração Intestinal/cirurgia , Peritonite/cirurgia
19.
World J Emerg Surg ; 14: 31, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31320921

RESUMO

Background: Diverticular abscess diameter of 3-6 cm is generally accepted as a cutoff determining whether percutaneous drainage is recommended in addition to antibiotics, but this is not based on high-quality evidence. The aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. Methods: This was a retrospective cohort study conducted in an academic teaching hospital functioning as a secondary and tertiary referral center. Altogether, 241 patients with computer tomography-verified acute left-sided colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during 2006-2013. The main measured outcomes were need of emergency surgery and 30-day mortality, and these were compared between antibiotics only and percutaneous drainage groups. Treatment choices, including surgery, were also analyzed for all patients. Results: Abscesses under 40 mm were mostly treated with antibiotics alone with a high success rate (93 out of 107, 87%). In abscesses over 40 mm, the use of emergency surgery increased and the use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at 13-18% regardless of the abscess size. There were no differences in failure rate, 30-day mortality, the need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage vs. antibiotics alone, even when groups were adjusted for potential confounders. Conclusions: Percutaneous drainage as a treatment for large abscess does not seem to be superior to the treatment with only antibiotics.


Assuntos
Abscesso Abdominal/terapia , Doença Diverticular do Colo/terapia , Resultado do Tratamento , Abscesso Abdominal/etiologia , Idoso , Antibacterianos/uso terapêutico , Estudos de Coortes , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Doença Diverticular do Colo/complicações , Drenagem/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos
20.
Lancet Gastroenterol Hepatol ; 4(8): 599-610, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31178342

RESUMO

BACKGROUND: Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. METHODS: A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485. FINDINGS: Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% [95% CI 88·7-100] vs 71·7% [95% CI 60·1-83·3], hazard ratio 2·79 [95% CI 1·86-4·18]; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 [44%] of 66 patients vs 25 [39%] of 64, p=0·60; mortality: two [3%] vs four [6%], p=0·44). INTERPRETATION: In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease). FUNDING: Netherlands Organisation for Health Research and Development.


Assuntos
Colo Sigmoide/cirurgia , Doença Diverticular do Colo/cirurgia , Perfuração Intestinal/cirurgia , Peritonite/etiologia , Protectomia , Reto/cirurgia , Idoso , Anastomose Cirúrgica/efeitos adversos , Colostomia , Doença Diverticular do Colo/complicações , Feminino , Humanos , Ileostomia , Perfuração Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Protectomia/efeitos adversos , Resultado do Tratamento
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