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World Journal of Gastroenterology Mar 2021Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and... (Review)
Review
Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.
Topics: Aged; Colectomy; Colon, Sigmoid; Diverticulitis; Diverticulitis, Colonic; Elective Surgical Procedures; Humans; Laparoscopy
PubMed: 33727769
DOI: 10.3748/wjg.v27.i9.760 -
JAMA Surgery Feb 2021Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.
OBJECTIVE
To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis.
DESIGN, SETTING, AND PARTICIPANTS
This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography-verified free air, were eligible. Those available for trial intervention (Hinchey stages
INTERVENTIONS
Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization.
MAIN OUTCOMES AND MEASURES
The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life.
RESULTS
Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups.
CONCLUSIONS AND RELEVANCE
Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01047462.
Topics: Aged; Colectomy; Diverticulitis, Colonic; Female; Humans; Intestinal Perforation; Laparoscopy; Male; Norway; Peritoneal Lavage; Sweden
PubMed: 33355658
DOI: 10.1001/jamasurg.2020.5618 -
Clinics in Colon and Rectal Surgery Jan 2023Given the progression of laparoscopic surgery, questions continue to arise as to the ideal technique for a laparoscopic colectomy. The most debated of these questions is... (Review)
Review
Given the progression of laparoscopic surgery, questions continue to arise as to the ideal technique for a laparoscopic colectomy. The most debated of these questions is whether it is best to complete an intracorporeal (ICA) or extracorporeal (ECA) intestinal anastomosis. Here, we review the literature to date and report the equivalent safety and efficacy of ICA and ECA for laparoscopic right colectomy. However, these studies also indicate that when completed, ICA may prove beneficial with respect to earlier return of bowel function, less postoperative pain, shorter incision length, and reduced risk of wound infections. For this, we present the tips and tricks for completing all forms of laparoscopic ICAs during laparoscopic colectomy.
PubMed: 36619285
DOI: 10.1055/s-0042-1758560 -
The British Journal of Surgery Dec 2022Complete mesocolic excision (CME) for right colonic cancer is a more complex operation than standard right hemicolectomy but evidence to support its routine use is still...
BACKGROUND
Complete mesocolic excision (CME) for right colonic cancer is a more complex operation than standard right hemicolectomy but evidence to support its routine use is still limited. This prospective multicentre study evaluated the effect of CME on long-term survival in colorectal cancer centres in Germany (RESECTAT trial). The primary hypothesis was that 5-year disease-free survival would be higher after CME than non-CME surgery. A secondary hypothesis was that there would be improved survival of patients with a mesenteric area greater than 15 000 mm2.
METHODS
Centres were asked to continue their current surgical practices. The surgery was classified as CME if the superior mesenteric vein was dissected; otherwise it was assumed that no CME had been performed. All specimens were shipped to one institution for pathological analysis and documentation. Clinical data were recorded in an established registry for quality assurance. The primary endpoint was 5-year overall survival for stages I-III. Multivariable adjustment for group allocation was planned. Using a primary hypothesis of an increase in disease-free survival from 60 to 70 per cent, a sample size of 662 patients was calculated with a 50 per cent anticipated drop-out rate.
RESULTS
A total of 1004 patients from 53 centres were recruited for the final analysis (496 CME, 508 no CME). Most operations (88.4 per cent) were done by an open approach. Anastomotic leak occurred in 3.4 per cent in the CME and 1.8 per cent in the non-CME group. There were slightly more lymph nodes found in CME than non-CME specimens (mean 55.6 and 50.4 respectively). Positive central mesenteric nodes were detected more in non-CME than CME specimens (5.9 versus 4.0 per cent). One-fifth of patients had died at the time of study with recorded recurrences (63, 6.3 per cent), too few to calculate disease-free survival (the original primary outcome), so overall survival (not disease-specific) results are presented. Short-term and overall survival were similar in the CME and non-CME groups. Adjusted Cox regression indicated a possible benefit for overall survival with CME in stage III disease (HR 0.52, 95 per cent c.i. 0.31 to 0.85; P = 0.010) but less so for disease-free survival (HR 0.66; P = 0.068). The secondary outcome (15 000 mm2 mesenteric size) did not influence survival at any stage (removal of more mesentery did not alter survival).
CONCLUSION
No general benefit of CME could be established. The observation of better overall survival in stage III on unplanned exploratory analysis is of uncertain significance.
Topics: Humans; Prospective Studies; Mesocolon; Colonic Neoplasms; Colectomy; Lymph Node Excision; Laparoscopy; Treatment Outcome
PubMed: 36369986
DOI: 10.1093/bjs/znac379 -
Clinics in Colon and Rectal Surgery Sep 2021Subtotal colectomy (STC) or total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA) performed in two or three stages remain the procedure of choice for... (Review)
Review
Subtotal colectomy (STC) or total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA) performed in two or three stages remain the procedure of choice for patients with ulcerative colitis (UC). Minimally invasive laparoscopic approaches for STC and IPAA have been established for over a decade, having been shown to reduce postoperative pain, length of stay, and improve fertility. However "straight-stick" laparoscopy has ergonomic and visual disadvantages in the pelvis, which may contribute to IPAA failure. The robotic platform was developed to overcome these limitations. Robotic STC is associated with lower conversion rates and earlier return of bowel function with acceptably longer operative time (mean, 28 minutes) than laparoscopic STC. The robotic approach has also been shown in case series to be safe in urgent settings. Robotic IPAA is associated with lower blood loss and length of stay than laparoscopic IPAA. Robotic TPC/IPAA has been shown in small case series to be safe and feasible despite longer operating times.
PubMed: 35069021
DOI: 10.1055/s-0041-1726447 -
International Journal of Colorectal... Jul 2022This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy.
METHODS
A systematic review of studies published from 2004 to 2022 in the Web of Science, PubMed, and Scopus databases and comparing laparoscopic (LLC) and robotic left colectomy (RLC) was performed. All comparative studies evaluating robotic left colectomy (RLC) versus laparoscopic (LLC) left colectomy with at least 20 patients in the robotic arm were included. Abstract, editorials, and reviews were excluded. The Newcastle-Ottawa Scale for cohort studies was used to assess the methodological quality. The random-effect model was used to calculate pooled effect estimates.
RESULTS
Among the 139 articles identified, 11 were eligible, with a total of 52,589 patients (RLC, n = 13,506 versus LLC, n = 39,083). The rate of conversion to open surgery was lower for robotic procedures (RR 0.5, 0.5-0.6; p < 0.001). Operative time was longer for the robotic procedures in the pooled analysis (WMD 39.1, 17.3-60.9, p = 0.002). Overall complications (RR 0.9, 0.8-0.9, p < 0.001), anastomotic leaks (RR 0.7, 0.7-0.8; p < 0.001), and superficial wound infection (RR 3.1, 2.8-3.4; p < 0.001) were less common after RLC. There were no significant differences in mortality (RR 1.1; 0.8-1.6, p = 0.124). There were no differences between RLC and LLC with regards to postoperative variables in the subgroup analysis on malignancies.
CONCLUSIONS
Robotic left colectomy requires less conversion to open surgery than the standard laparoscopic approach. Postoperative morbidity rates seemed to be lower during RLC, but this was not confirmed in the procedures performed for malignancies.
Topics: Colectomy; Humans; Laparoscopy; Length of Stay; Operative Time; Postoperative Complications; Robotic Surgical Procedures
PubMed: 35650261
DOI: 10.1007/s00384-022-04194-8 -
JSLS : Journal of the Society of... 2020Published comparisons of minimally invasive approaches to colon surgery are limited. The objective of the current study is to compare the effectiveness of... (Comparative Study)
Comparative Study
BACKGROUND AND OBJECTIVES
Published comparisons of minimally invasive approaches to colon surgery are limited. The objective of the current study is to compare the effectiveness of robotic-assisted and laparoscopic sigmoid resection.
METHODS
A multicenter retrospective comparative analysis of perioperative outcomes from consecutive robotic-assisted and laparoscopic sigmoid resections performed between 2010 and 2015 by six general and colorectal surgeons, who are experienced in both robotic-assisted and laparoscopic surgical techniques and who had >50 annual case volumes for each approach. Baseline characteristics and surgical risk factors between the two groups were balanced using a propensity score methodology with inverse probability of treatment weighting. Mean standardized differences were reported, and in all instances, a -value < 0.05 was considered statistically significant.
RESULTS
Three hundred thirty-six cases (robotic-assisted, n = 211; laparoscopic, n = 125) met eligibility criteria and were included in the study. Following weighting, patient demographics and baseline characteristics were comparable between the robotic-assisted (n = 344) and laparoscopic (n = 349) groups. The laparoscopic group was associated with shorter operating room and surgical times. The robotic-assisted group had lower estimated blood loss and shorter time to first flatus compared to the laparoscopic group. Rates of complications post discharge to 30 d tended to be lower for the RA group: 5.1% vs 8.6% [ = 0.0657]. The RA group also had lower rates of readmissions and reoperations: 4% vs 8% [ = 0.029] and 0.5% vs 5.1% [ = 0.0003], respectively.
CONCLUSIONS
Robotic-assisted sigmoid colon resection is clinically effective and provides a minimally invasive alternative to the laparoscopic approach with improved intraoperative and postoperative outcomes for colorectal patients.
Topics: Adult; Aged; Colectomy; Colon, Sigmoid; Female; Humans; Laparoscopy; Male; Middle Aged; Outcome Assessment, Health Care; Retrospective Studies; Robotic Surgical Procedures
PubMed: 32831543
DOI: 10.4293/JSLS.2020.00028 -
Familial Cancer Oct 2022Desmoid tumours (DT) are one of the main causes of death in patients with familial adenomatous polyposis (FAP). Surgical trauma is a risk factor for DT, yet a colectomy... (Meta-Analysis)
Meta-Analysis Review
Desmoid tumours (DT) are one of the main causes of death in patients with familial adenomatous polyposis (FAP). Surgical trauma is a risk factor for DT, yet a colectomy is inevitable in FAP to prevent colorectal cancer. This systematic review and meta-analysis aimed to synthesize the available evidence on DT risk related to type, approach and timing of colectomy. A search was performed in MEDLINE, EMBASE and the Cochrane Library. Studies were considered eligible when DT incidence was reported after different types, approaches and timing of colectomy. Twenty studies including 6452 FAP patients were selected, all observational. No significant difference in DT incidence was observed after IRA versus IPAA (OR 0.99, 95% CI 0.69-1.42) and after open versus laparoscopic colectomy (OR 0.88, 95% CI 0.42-1.86). Conflicting DT incidences were seen after early versus late colectomy and when analysing open versus laparoscopic colectomy according to colectomy type. Three studies reported a (non-significantly) higher DT incidence after laparoscopic IPAA compared to laparoscopic IRA, with OR varying between 1.77 and 4.09. A significantly higher DT incidence was observed in patients with a history of abdominal surgery (OR 3.40, 95% CI 1.64-7.03, p = 0.001). Current literature does not allow to state firmly whether type, approach, or timing of colectomy affects DT risk in FAP patients. Fewer DT were observed after laparoscopic IRA compared to laparoscopic IPAA, suggesting laparoscopic IRA as the preferred choice if appropriate considering rectal polyp burden. PROSPERO REGISTRATION NUMBER: CRD42020161424.
Topics: Humans; Fibromatosis, Aggressive; Colectomy; Adenomatous Polyposis Coli; Laparoscopy; Incidence; Proctocolectomy, Restorative
PubMed: 35022961
DOI: 10.1007/s10689-022-00288-y -
World Journal of Clinical Cases Jan 2022Currently, the standard surgical procedure for right colon cancer is complete mesocolic excision. Whether preventive extended lymph node dissection for colon cancer... (Clinical Trial)
Clinical Trial
BACKGROUND
Currently, the standard surgical procedure for right colon cancer is complete mesocolic excision. Whether preventive extended lymph node dissection for colon cancer located in the hepatic flexure or right transverse colon should be performed remains controversial because the safety and effectiveness of the operation have not been proven, and infrapyloric lymph nodes (No. 206) and lymph nodes in the greater curvature of the stomach (No. 204) have not been strictly defined and distinguished as surgical indicators in previous studies.
AIM
To analyze the metastatic status of infrapyloric lymph nodes and lymph nodes of the greater curvature of the stomach and perioperative complications and systematically evaluate the feasibility and safety of laparoscopic extended right colectomy using prospective data collected retrospectively.
METHODS
The study was a clinical study. Twenty patients with colon cancer who underwent laparoscopic extended right colon resection in our hospital from June 2020 to May 2021 were included.
RESULTS
Among the patients who underwent extended right colon resection, there were no intraoperative complications or conversion to laparotomy; 2 patients had gastrocolic ligament lymph node metastasis, and 5 patients had postoperative complications. The patients with postoperative complications received conservative treatment.
CONCLUSION
Laparoscopic extended right colon resection is safe. However, malignant tumors located in the liver flexure or the right-side transverse colon are more likely to metastasize to the gastrocolic ligament lymph nodes, and notably, the incidence of gastroparesis was high. The number of patients was small, and the follow-up time was short. It is necessary to further increase the sample size to evaluate the No. 204 and No. 206 lymph node metastasis rates and the long-term survival impact.
PubMed: 35097078
DOI: 10.12998/wjcc.v10.i2.528 -
Local and Regional Anesthesia 2021The quadratus lumborum block is a novel truncal block where local anaesthetic is injected adjacent to the quadratus lumborum muscle. It is used for caesarean sections,... (Review)
Review
The quadratus lumborum block is a novel truncal block where local anaesthetic is injected adjacent to the quadratus lumborum muscle. It is used for caesarean sections, hip arthroplasty, gynecologic surgery, colectomy, and recently nephrectomy. To date, there are no reviews that outline the efficacy and performance of the quadratus lumborum blocks in patients receiving laparoscopic nephrectomy. The objective of this project was to outline the current available data from both clinical trials along with case series and reports regarding the methods and utility of quadratus lumborum blocks for analgesia in patients receiving nephrectomy. For this literature review, we searched Pubmed, Embase, and Web of Science from their inception until 5/31/2020. Our search terms were as follows: "(nephrectomy OR laparoscopic nephrectomy) AND (QL block OR Quadratus Lumborum block OR QL OR TQL OR Thoracolumbar fascia block)." We analyzed all relevant clinical trials for quality using the Jadad scale. Our search yielded a total of 30 articles, 23 of which we ultimately reviewed for this manuscript. The qualitative sum of these data show that patients receiving quadratus lumborum block for nephrectomies have reduced opioid requirements, reduced pain scores, and improved side-effects relative to other analgesic modalities like epidurals. Based on these findings, we conclude that the quadratus lumborum block is a useful analgesic for patients undergoing nephrectomy.
PubMed: 33907461
DOI: 10.2147/LRA.S290224