Andreas M. Kaiser

Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment.

Objectives:Diverticular disease imposes an impressive clinical burden to the United States population, with over 300,000 admissions and 1.5 million days of inpatient care annually. Consensus regarding the treatment of diverticulitis has evolved over time, with increasing advocacy of primary anastomosis for acute diverticulitis, and nonoperative treatment of recurrent mild/moderate diverticulitis. We analyzed whether these changes are reflected in patterns of practice in a nationally-representative patient cohort. Methods:We used the 1998 to 2005 nationwide inpatient sample to analyze the care received by 267,000 patients admitted with acute diverticulitis, and 33,500 patients operated electively for diverticulitis. Census data were used to calculate population-based incidence rates of disease and surgical treatment. Weighted logistic regression with cluster adjustment at the hospital level was used for hypothesis testing. Results:Overall annual age-adjusted admissions for acute diverticulitis increased from 120,500 in 1998 to 151,900 in 2005 (26% increase). Rates of admission increased more rapidly within patients aged 18 to 44 years (82%) and 45 to 74 years (36%). Elective operations for diverticulitis rose from 16,100 to 22,500 per year during the same time period (29%), also with a more rapid increase (73%) in rates of surgery for individuals aged 18 to 44 years. Multivariate analysis found no evidence that primary anastomosis is becoming more commonly used. Conclusions:We are the first to report dramatic changes in rates of treatment for diverticulitis in the United States. The causes of this emerging disease pattern are unknown, but certainly deserve further investigation. For patients undergoing surgery for acute diverticulitis, there was little change over time in the likelihood of a primary anastomosis.

The Management of Complicated Diverticulitis and the Role of Computed Tomography

PURPOSE:Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis.METHODS:We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, “diverticulitis” mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis.RESULTS:In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%.CONCLUSIONS:CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patients age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

Practice parameters for the treatment of sigmoid diverticulitis.

Diseases of the Colon & ReCtum Volume 57: 3 (2014) the american society of Colon and Rectal surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. the Clinical Practice Guideline Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. this Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. this is accompanied by developing Clinical Practice Guidelines based on the best available evidence. these guidelines are inclusive, and not prescriptive. their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. these guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. it should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Endorectal Advancement Flap for Cryptoglandular or Crohn's Fistula-in-Ano

PURPOSE: Objectives of surgical treatment for transsphincteric and complex anorectal fistulas are the successful elimination of current/recurrent disease and the preservation of sphincter function. The concept of endorectal advancement flaps is to preserve the sphincter by closing off the primary opening by means of a mobilized flap. We performed a systematic review of the literature to assess the role of this technique. METHODS: A literature search on transanal rectal advancement flaps to treat cryptoglandular or Crohn fistula-in-ano was performed for the 30-year period between 1978 and 2008. Rectovaginal/rectourinary or cancer-related fistulas were excluded. Each study was examined for length of follow-up and the 2 major end points: success rate and incontinence rate. RESULTS: From 35 studies with 2065 patients, we identified 1654 patients undergoing endorectal advancement flaps for cryptoglandular or Crohn disease. Four hundred eleven subjects were excluded (319 rectovaginal/rectourinary fistulas; 92 other causes). The quality of the reports was limited (low-level evidence) with numerous structural and design flaws. Weighted success and incontinence rates were 80.8%/13.2% for cryptoglandular and 64%/9.4% for Crohn fistulas. CONCLUSION: Endorectal advancement flap is one tool, although not a perfect one, to treat complex anorectal fistulas of cryptoglandular or Crohn origin. Higher level evidence would be needed for comparison with other surgical techniques.

management of Retained Colorectal Foreign Bodies: Predictors of Operative Intervention

PURPOSEThis study was designed to review experience at our hospital with retained colorectal foreign bodies.METHODSWe reviewed the consultation records at Los Angeles County + University of Southern California General Hospital from October 1993 through October 2002. Ninety-three cases of transanally introduced, retained foreign bodies were identified in 87 patients. Data collected included patient demographics, extraction method, location, size and type of foreign body, and postextraction course.RESULTSOf 93 cases reviewed, there were 87 individuals who presented with first-time episodes of having a retained colorectal foreign body. For these patients, bedside extraction was successful in 74 percent. Ultimately, 23 patients were taken to the operating room for removal of their foreign body. In total, 17 examinations under anesthesia and 8 laparotomies were performed (2 patients initially underwent an anesthetized examination before laparotomy). In the eight patients who underwent exploratory laparotomy, only one had successful delivery of the foreign object into the rectum for transanal extraction. The remainder required repair of perforated bowel or retrieval of the foreign body via a colotomy. In our review, a majority of cases had objects retained within the rectum; the rest were located in the sigmoid colon. Fifty-five percent of patients (6/11) presenting with a foreign body in the sigmoid colon required operative intervention vs. 24 percent of patients (17/70) with objects in their rectum (P = 0.04).CONCLUSIONSThis is the largest single institution series of retained colorectal foreign bodies. Although foreign objects located in the sigmoid colon can be retrieved at the bedside, these cases are more likely to require operative intervention.

Practice parameters for the management of colon cancer.

DISEASES OF THE COLON & RECTUM VOLUME 55: 8 (2012) The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which to base decisions, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

The surgisis® AFP™ anal fistula plug: Report of a consensus conference

A Consensus Conference was held in Chicago on 27th May 2007 at the Illinois Airport Hilton Hotel to develop uniformity of opinion from surgeons with considerable experience in the use of the Anal Fistula Plug. Of the 15 surgeons in attendance, five had performed 50 or more Anal Fistula Plug procedures. Success rates with this approach have been reported to be as high as 85% [1]. Anecdotal communications have however suggested lower rates of success. Concerns have been expressed over plug extrusion and inadequacy of long-term followup. It was thought prudent to hold this conference because, despite a number of publications attesting to the safety and efficacy of the procedure, to date there has not been uniformity of opinion regarding indications and technique, nor has there been level I evidence of any actual benefit.

Potentials of robust intensity modulated scanning proton plans for locally advanced lung cancer in comparison to intensity modulated photon plans

BACKGROUND AND PURPOSE The potentials of lung sparing, dose escalation, and the robustness of intensity modulated proton plans (IMPT(robust)), obtained by minimax optimization on multiple scenarios, were studied. MATERIALS AND METHODS IMPT(robust) optimization as described by Fredriksson et al. [23] was evaluated by means of comparative treatment planning using breath hold CT data from 6 non-small cell lung cancer (NSCLC) patients. IMPT(robust) and single field uniform dose (SFUD) proton plans were compared to Tomotherapy and 7-field intensity modulated photon therapy (IMXT). Plan robustness against set-up errors, range uncertainties, and between field motions were analyzed as well as lung exposure quantified by the mean lung dose (MLD) and the partial lung volumes receiving at least 20, 10, and 5 Gy(RBE) (V20, V10, V5). Robustness was analyzed with regard to stability of the effective uniform dose (EUD) and the dose level reached or exceeded in 95% of the CTV (D95). RESULTS MLD by IMPT(robust) was less than by SFUD, and Tomotherapy in each patient, on average by 14.8% and 28.5% (p<0.05, Friedman test). V20-V5 were higher with Tomotherapy compared to both proton therapy techniques, on average by a factor of >1.8. Robustness of IMPT(robust) was high. EUD and D95 values were maintained above 96% and 94% of the reference plan values for all tested scenarios. With dose escalation to 86 Gy(RBE) lung tissue tolerances were maintained. CONCLUSIONS IMPT(robust) proved advantageous in terms of lung exposure and possible dose escalation while being also markedly robust. However, motion during delivery of a field remains a major problem of IMPT(robust) to be mitigated by high scanning speed and variable spot size.

The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence.

623 Diseases of the Colon & ReCtum Volume 58: 7 (2015) the american society of Colon and Rectal surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. the Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. this Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. this is accompanied by developing Clinical Practice Guidelines based on the best available evidence. these guidelines are inclusive and not prescriptive. their purpose is to provide information based on which decisions can be made, rather than to dictate a specific form of treatment. these guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. it should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Effect of high-dose steroids on anastomotic complications after proctocolectomy with ileal pouch–anal anastomosis

This review was designed to determine whether “high-dose” steroid therapy (≥20 mg prednisone/day) increases the likelihood of anastomotic complications after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The hospital records of 100 patients undergoing proctocolectomy with IPAA were reviewed. Patient characteristics were analyzed to determine what factors were associated with higher rates of anastomosis-related complications. Seventy-one of our patients were given diverting ileostomies, whereas the remaining 29 underwent a single-stage procedure. Fifty-four percent of the patients in our review were taking steroids preoperatively, 39 of whom were on high-dose therapy. The overall anastomosis-related complication rate was 14%. There was no significant difference in complication rates with respect to age, steroid use, steroid dose, use of a diverting ileostomy, type of anastomosis, duration of disease, or presence of backwash ileitis. A trend toward higher leakage rates was found in patients undergoing single-stage procedures (10.3% vs. 2.8%, P = 0.14) as well as in patients undergoing single-stage procedures on high-dose steroids (22% vs. 5.0, P = 0.22). Nevertheless, neither of these trends was found to be statistically significant, which was likely infiuenced by the small sample size. Our data suggest that there may be an increase in anastomotic leakage rates in patients on high-dose steroids undergoing a single-stage proctocolectomy with IPAA. Nevertheless, our rate was not as high as the rates seen by other investigators and did not reach statistical significance. During preoperative counseling, patients on high-dose steroids should be informed of this uncertain but real risk of anastomotic leakage.