-
Langenbeck's Archives of Surgery Jun 2024Robotic assisted surgery is an alternative, fast evolving technique for performing colorectal surgery. The primary aim of this single center analysis is to compare... (Comparative Study)
Comparative Study
Robotic surgery versus conventional laparoscopy in sigmoid colectomy for diverticular disease-a comparison of operative trauma and cost-effectiveness: retrospective, single-center analysis.
PURPOSE
Robotic assisted surgery is an alternative, fast evolving technique for performing colorectal surgery. The primary aim of this single center analysis is to compare elective laparoscopic and robotic sigmoid colectomies for diverticular disease on the extent of operative trauma and the costs.
METHODS
Retrospective analysis from our prospective clinical database to identify all consecutive patients aged ≥ 18 years who underwent elective minimally invasive left sided colectomy for diverticular disease from January 2016 until December 2020 at our tertiary referral institution.
RESULTS
In total, 83 patients (31 female and 52 male) with sigmoid diverticulitis underwent elective minimally invasive sigmoid colectomy, of which 42 underwent conventional laparoscopic surgery (LS) and 41 robotic assisted surgery (RS). The mean C-reactive protein difference between the preoperative and postoperative value was significantly lower in the robotic assisted group (4,03 mg/dL) than in the laparoscopic group (7.32 mg/dL) (p = 0.030). Similarly, the robotic´s hemoglobin difference was significantly lower (p = 0.039). The first postoperative bowel movement in the LS group occurred after a mean of 2.19 days, later than after a mean of 1.63 days in the RS group (p = 0.011). An overview of overall charge revealed significantly lower total costs per operation and postoperative hospital stay for the robotic approach, 6058 € vs. 6142 € (p = 0,014) not including the acquisition and maintenance costs for both systems.
CONCLUSION
Robotic colon resection for diverticular disease is cost-effective and delivers reduced intraoperative trauma with significantly lower postoperative C-reactive protein and hemoglobin drift compared to conventional laparoscopy.
Topics: Humans; Male; Female; Robotic Surgical Procedures; Laparoscopy; Colectomy; Retrospective Studies; Middle Aged; Cost-Benefit Analysis; Aged; Adult; Sigmoid Diseases; Colon, Sigmoid; Diverticulitis, Colonic
PubMed: 38935194
DOI: 10.1007/s00423-024-03382-0 -
Trauma Surgery & Acute Care Open 2024The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer,...
BACKGROUND
The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.
METHODS
We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.
RESULTS
Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).
CONCLUSIONS
Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.
LEVEL OF EVIDENCE
III.
PubMed: 38933602
DOI: 10.1136/tsaco-2023-001288 -
Annals of Surgery Open : Perspectives... Jun 2024To compare long-term outcomes after laparoscopic lavage with resection surgery for perforated diverticulitis, Hinchey grade III as practiced in Sweden for 3 years.
OBJECTIVE
To compare long-term outcomes after laparoscopic lavage with resection surgery for perforated diverticulitis, Hinchey grade III as practiced in Sweden for 3 years.
BACKGROUND
Laparoscopic lavage has been studied in 3 randomized controlled trials. Long-term results indicate that additional surgery and a remaining stoma are less common after lavage compared with resection, but data from routine care and larger cohorts are needed to get a more complete picture.
METHODS
LapLav is a national cohort study with nearly complete coverage of all patients operated in Sweden between 2016 and 2018. The cohort was retrieved from the national patient register by a definition based on the Classification of Diseases and Related Health Problems-10 code plus the surgical procedural code. All medical records have been reviewed and data retrieved in addition to registry data. Propensity score with inverse probability weighting was used to balance the 2 groups, that is, laparoscopic lavage resection surgery.
RESULTS
Before the propensity score was applied, the cohort consisted of 499 patients. Additional surgery was more common in the resection group [odds ratio, 0.714; 95% confidence interval (CI) = 0.529-0.962; = 0.0271]. Mortality did not differ between the groups (hazard ratio, 1.20; 95% CI = 0.69-2.07; = 0.516). In the lavage group, 27% of patients went on to have resection surgery.
CONCLUSIONS
In Swedish routine care, laparoscopic lavage was feasible and safe for the surgical treatment of perforated diverticulitis, Hinchey grade III. Our results indicate that laparoscopic lavage can be used as a first-choice treatment.
PubMed: 38911640
DOI: 10.1097/AS9.0000000000000433 -
The Journal of Surgical Research Jun 2024Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to...
INTRODUCTION
Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination.
METHODS
This retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality.
RESULTS
We identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027).
CONCLUSIONS
In the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.
PubMed: 38909476
DOI: 10.1016/j.jss.2024.05.037 -
Cureus May 2024Perforated peptic ulcers, though relatively rare, represent critical surgical emergencies with potentially life-threatening consequences. Their significance lies not...
Perforated peptic ulcers, though relatively rare, represent critical surgical emergencies with potentially life-threatening consequences. Their significance lies not only in their acute presentation but also in the diagnostic challenges they pose, particularly in patients with complex medical histories. Here we present a case of a 71-year-old female with a complex medical history, including insulin-dependent type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, dementia, diverticulitis, and chronic back pain, who initially were unresponsive and cyanotic. Despite challenges in diagnosis due to her medical complexity and opioid use, she was ultimately diagnosed with a perforated duodenal ulcer. Tragically, despite immediate surgical intervention, she succumbed to her illness, highlighting the complexities involved in managing perforated peptic ulcers, especially in patients with multiple chronic medical conditions. Peptic ulcer disease (PUD) can often remain asymptomatic, leading to delayed diagnosis and potentially life-threatening complications like perforation. Mortality rates associated with perforated peptic ulcers vary widely, ranging from 1.3% to 20%, with risk factors including nonsteroidal anti-inflammatory drug (NSAID) use, infection, smoking, and corticosteroid use. Diagnosis necessitates a high index of suspicion, thorough clinical examination, and imaging modalities such as computed tomography (CT) scans with oral contrast. Treatment strategies range from nonoperative management with intravenous (IV) histamine H2-receptor blockers or proton pump inhibitors (PPIs) to surgical intervention, depending on the patient's hemodynamic stability. However, the case presented underscores the challenges in timely diagnosis and intervention, particularly in patients with complex medical histories, where symptoms may be masked or attributed to other comorbidities. Recent studies indicate a demographic shift toward older age and a higher prevalence among females, emphasizing the importance of increased awareness and vigilance among healthcare providers. Early recognition of symptoms, prompt investigation, and interdisciplinary collaboration are crucial in optimizing outcomes for patients presenting with perforated peptic ulcers, especially in the context of their underlying medical conditions.
PubMed: 38894771
DOI: 10.7759/cureus.60620 -
Colorectal Disease : the Official... Jun 2024The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis...
AIM
The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis.
METHOD
This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage.
RESULTS
Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted.
CONCLUSION
AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.
PubMed: 38886887
DOI: 10.1111/codi.17076 -
The American Surgeon Jun 2024
PubMed: 38877880
DOI: 10.1177/00031348241257813 -
Surgical Endoscopy Jun 2024Frailty has been associated with increased postoperative mortality and morbidity; however, the use of the modified frailty index (mFI-11) to assess patients undergoing...
BACKGROUND
Frailty has been associated with increased postoperative mortality and morbidity; however, the use of the modified frailty index (mFI-11) to assess patients undergoing surgery for diverticular disease has not been widely assessed. This paper aims to examine frailty, evaluated by mFI-11, to assess postoperative morbidity and mortality among patients undergoing operative intervention for colonic diverticular disease.
METHODS
We used data from the Healthcare Cost and Utilization Project National Inpatient Sample (October 1, 2015-December 31, 2019). ICD-10-CM codes were utilized to identify a cohort of adult patients with a primary admission diagnosis of diverticulitis. mFI-11 items were adapted to correspond with ICD-10-CM codes. Patients were stratified into robust (mFI < 0.27) and frail (mFI ≥ 0.27) groups. Primary outcomes were in-hospital postoperative morbidity and mortality. Secondary outcomes included system-specific postoperative complications, length of stay (LOS), total admission cost, and discharge disposition. Multivariable regression models were fit.
RESULTS
Of the 26,826 patients, there were 24,194 patients with mFI-11 < 0.27 (i.e., robust) and 2,632 patients with mFI-11 ≥ 0.27 (i.e., frail). Adjusted analysis showed significant increases in postoperative mortality (aOR 2.16, 95% CI 1.38-3.38, p = 0.001) and overall postoperative morbidity (aOR 1.84, 95% CI 1.65-2.06, p < 0.001). LOS was higher in the frail group (MD 1.78 days, 95% CI 1.46-2.11, p < 0.001) as well as total cost (MD $25,495.19, 95% CI $19,851.63-$31,138.75, p < 0.001).
CONCLUSION
In the elective setting, a high mFI-11 (i.e., presence of the variables comprising the index) could alert clinicians to the possibility of implementing preoperative optimization strategies. In the emergent setting, a high mFI-11 may help guide prognostication for these vulnerable patients.
PubMed: 38874611
DOI: 10.1007/s00464-024-10965-x -
Cureus May 2024Background The term "diverticula" refers to the existence of diverticula in the gastrointestinal tract but is mainly located in the sigmoid colon and is used to describe...
Background The term "diverticula" refers to the existence of diverticula in the gastrointestinal tract but is mainly located in the sigmoid colon and is used to describe colonic diverticulosis. Diverticula, which are sac-like protrusions in the wall of the large bowel, are becoming more prevalent globally, in both developed and developing nations. This increase in occurrence is primarily attributed to changes in dietary and lifestyle patterns. Raising public awareness can potentially contribute to a decrease in the incidence of the disease and its associated complications. Aim This study aims to assess knowledge and awareness levels among the Saudi Arabian population regarding diverticulitis and its risk factors. Methods A descriptive cross-sectional study was conducted in Saudi Arabia between 1st January 2024 to 1st April 2024 using an online questionnaire for data collection. The target population consists of individuals who are between 18 years and 45, in Saudi Arabia without a history of diverticulitis. The study questionnaire covered participants' demographic (Western, Central, Southern, Eastern, Northern) regions, knowledge, awareness and practice of diverticulitis. Results A total of 548 eligible participants completed the study questionnaire, most of them (80.3%; 395) were from the Western region including Mecca, Medina and Jeddah. Participants' ages ranged from 18 to more than 40 years with a mean age of 30.5 ± 11.9 years old. A greater percentage (72.3%) of the participants were males compared to the percentage of females, which was 27.7%. The vast majority of the study participants had an inadequate knowledge level about diverticulitis (85.9%; 471) while only 31 (5.7%) had adequate knowledge and awareness about the disease. The most reported sources of information included study courses (6.4%), media (5.3%), and physicians (4.7%) while most respondents (83.6%) had no source. Conclusion In conclusion, aside from preventive strategies, the current study found that the public knew very little about diverticulitis, including its risk factors, clinical presentation, and diagnostic process. The two significant predictors of public awareness level were age and doctors as information sources.
PubMed: 38864053
DOI: 10.7759/cureus.60124 -
Preventive Medicine Jun 2024The pathogenic mechanisms of syphilis and the host defense mechanisms against syphilis remain poorly understood. Exploration of the susceptibility factors of syphilis...
OBJECTIVE
The pathogenic mechanisms of syphilis and the host defense mechanisms against syphilis remain poorly understood. Exploration of the susceptibility factors of syphilis may provide crucial clues for unraveling its underlying mechanisms.
METHODS
A two-sample Mendelian Randomization framework was utilized, and the inverse-variance weighted method was used as the main analysis. All data was sourced from Genome-wide association studies datasets from 2015 to 2022 in Europe, and all participants were of European descent. Only summary-level statistics were used. Sensitivity analyses were conducted to evaluate the heterogeneity and pleiotropy of the datasets.
RESULTS
Our study established 18 exposure factors (12 risk factors and 6 protective factors) for syphilis susceptibility. Twelve factors encompassing body mass index, waist circumference, darker natural skin, cooked vegetable intake, processed meat intake, diabetes mellitus, glucose regulation disorders, gout, autoimmune diseases, rheumatoid arthritis, diverticulitis, and longer menstrual cycles were found to increase susceptibility to syphilis. In contrast, 6 factors including easier skin tanning, blonde natural hair color, irritability, higher neuroticism scores, extended sleep duration, and delayed age at first sexual intercourse were connected to a reduced risk of syphilis infection (all P < 0.05).
CONCLUSIONS
This study identified 18 influencing factors of syphilis susceptibility. These findings offered novel insights for further probing into the underlying pathogenic mechanisms of syphilis and underscored the importance of multifaceted prevention strategies against syphilis.
PubMed: 38851401
DOI: 10.1016/j.ypmed.2024.108033