Brian Buchberg

Trends in Diverticulitis Management in the United States From 2002 to 2007

OBJECTIVE To demonstrate the recent trends of admission and surgical management for diverticulitis in the United States. DESIGN Retrospective database analysis. SETTING The National Inpatient Sample database. PATIENTS Patients admitted to the hospital for diverticulitis from 2002 to 2007. MAIN OUTCOME MEASURES Patient characteristics, surgical approach, and mortality were evaluated for elective or emergent admission. RESULTS A total of 1,073,397 patients were admitted with diverticulitis (emergent: 78.3%, elective: 21.7%). The emergent admission rate increased by 9.5% over the study period. For emergent patients, 12.2% underwent urgent surgical resection and 87.8% were treated with nonoperative methods (percutaneous abscess drainage: 1.88% and medical treatment: 85.92%). There was only a 4.3% increase in urgent surgical resections, while elective surgical resections increased by 38.7.%. The overall rate of elective laparoscopic colon resection was 10.5%. Elective laparoscopic surgery nearly doubled from 6.9% in 2002 to 13.5% in 2007 (P < .001). Primary anastomosis rates increased for elective resections over time (92.1% in 2002 to 94.5% in 2007; P < .001). For urgent open operation, use of colostomy decreased significantly from 61.2% in 2002 to 54.0% in 2007 (P < .001). In-hospital mortality significantly decreased in both elective and urgent surgery (elective: 0.53% in 2002 to 0.44% in 2007; P = .001; urgent: 4.5% in 2002 to 2.5% in 2007; P < .001). CONCLUSION Diverticulitis continues to be a source of significant morbidity in the United States. However, our data show a trend toward increased use of laparoscopic techniques for elective operations and primary anastomosis for urgent operations.

Incidence and Risk Factors of Venous Thromboembolism in Colorectal Surgery Does Laparoscopy Impart an Advantage

OBJECTIVES Laparoscopy is increasingly used in colon and rectal procedures. However, little is known regarding the incidence of venous thromboembolism (VTE) in laparoscopic colorectal (LC) compared with that in open colorectal (OC) procedures. We aimed to compare the incidences and to highlight the risk factors of developing VTE after LC and OC surgery. DESIGN Analysis of the Nationwide Inpatient Sample data from 2002 through 2006. SETTING National database. PATIENTS Patients who underwent elective LC and OC surgery from 2002 through 2006. MAIN OUTCOMES MEASURE Incidence of VTE during initial hospitalization after LC and OC surgery; VTE classified by surgical site, pathology type, and at-risk patient population. RESULTS Over a 60-month period, 149,304 patients underwent LC or OC resection. Overall, the incidence of VTE was significantly higher in OC cases (2036 of 141,456 [1.44%]) compared with the incidence in LC cases (65 of 7848 [0.83%]) (P < .001). When stratified according to pathologic condition and surgical site, the overall rate of VTE was highest in patients with inflammatory bowel disease and in those undergoing rectal resections. Patients who underwent OC surgery were almost twice as likely to develop VTE compared with patients who underwent LC surgery. We also identified malignancy, obesity, and congestive heart failure as statistically significant (P < .05) risk factors for VTE in OC and LC surgery. CONCLUSIONS On the basis of data from a large clinical data set, the incidence of perioperative VTE is lower after LC than after OC surgery. These findings may help colorectal surgeons use appropriate VTE prophylaxis for patients undergoing colorectal procedures.

The Use of a Compression Device as an Alternative to Hand-Sewn and Stapled Colorectal Anastomoses: Is Three a Crowd?

BackgroundThe NiTi CAR™ 27 is a newer device that uses compression to create an anastomosis. An analysis of this device in the creation of colorectal anastomoses in humans has yet to be reported in the USA.MethodsA non-randomized, prospective pilot study of the NiTi CAR™ 27 device in patients undergoing a left-sided colectomy between March 2008 and August 2009 was performed.ResultsTwenty-three patients (9 men and 14 women) underwent a left-sided colectomy and compression anastomosis with the CAR™ 27 device. Minor morbidities, 3 of 23 (13%) patients, included one small postoperative abscess requiring antibiotics alone and two postoperative anastomotic strictures requiring balloon dilation. Major morbidities, 1 of 23 (4%) patients, included a partial anastomotic dehiscence/leak requiring surgical dismantling of the anastomosis and diversion.ConclusionThe CAR™ 27 device shows promise as a safe and effective alternative for the creation of colorectal anastomoses. However, studies in a larger patient population are warranted to demonstrate equivalence of this device.

Does Primary Anastomosis with Diversion Have Any Advantages over Hartmann’s Procedure in Acute Diverticulitis?

Background: The optimal treatment for acute complicated diverticulitis is still a matter of debate. We evaluated outcomes of primary anastomosis with proximal diversion (PAD) versus Hartman’s procedure (HP) in acute diverticulitis. Methods: Using the National Inpatient Sample database, we examined the clinical data of patients who underwent an urgent open colorectal resection (sigmoidectomy or anterior resection) for acute diverticulitis from 2002 to 2007 in the United States. We evaluated patient characteristics, patient comorbidities, perioperative complications, in-hospital mortality, length of hospital stay and total hospital charges between two groups. Results: A total of 99,259 patients underwent urgent surgery for acute diverticulitis during these years (Primary anastomosis without diversion: 39.3%; HP: 57.3% and PAD: 3.4%). The overall complication rate was lower in the PAD group compared with the HP group (PAD: 39.06% vs. HP: 40.84%; p = 0.04). Patients in the HP group had a shorter mean length of stay (12.5 vs.14.4 days, p < 0.001) and lower mean hospital costs (USD 65,037 vs. USD 73,440, p < 0.01) compared with the PAD group. Mortality was higher in the HP group (4.82 vs. 3.99%, p = 0.03). Conclusion: PAD has improved outcomes compared with HP, and should be considered in patients who are deemed candidates for two-stage operations for acute diverticulitis.

Case of intestinal tuberculosis mimicking Crohn's disease.

Summary Background: Intestinal tuberculosis can closely mimic Crohn’s disease and colon cancer. Presented here is a case of intestinal tuberculosis that closely mimicked both. Case Report: A 23 year old Hispanic female presented with several months of weight loss, recurrent fever, and emesis. The patient did not have pulmonary symptoms or radiographic evidence of tuberculosis. Colonoscopy evaluation with biopsy of the affected bowel segments were thought to be consistent with either colon cancer or Crohn’s Disease. Acid fast bacilli staining and histological analysis did not display evidence of tuberculosis on two separate occasions. The patient developed colonic obstruction acutely during the course of treatment requiring resection of the affected bowel segment. Acid fast staining of the resected lymph nodes was positive and submucosal caseating granulomas were identified histologically, consistent with intestinal tuberculosis. Conclusions: Intestinal tuberculosis remains a diagnostic challenge. Consideration of the disease should be maintained in equivocal cases.

Timing of Radiation Therapy, Lymph Node Retrieval, and Survival in Rectal Cancer

BACKGROUND: Lymph node retrieval is an independent prognostic factor for survival in rectal cancer. Preoperative radiotherapy has been shown to impact the number of lymph nodes retrieved. OBJECTIVE: This study aimed to analyze colorectal cancer-specific mortality and overall mortality associated with the number of lymph nodes retrieved in relation to use and timing of radiotherapy. DESIGN: This study was designed as a retrospective analysis. SETTINGS: Analysis of the California Cancer Registry was conducted. PATIENTS: Patients with rectal cancer from 1994 to 2006 with a follow-up until January 2008 were included. MAIN OUTCOME MEASURES: The number of lymph nodes (1–3, 4–6, 7–11, ≥12) stratified by stage (I, II, and III) was analyzed based on radiotherapy status (no radiotherapy, preoperative radiotherapy, and postoperative radiotherapy). Multivariate colorectal cancer-specific survival and overall mortality analyses were performed using Cox proportional-hazard ratios. RESULTS: A total of 17,670 incident cases of stage I, II, and III rectal cancer were identified. The number of lymph nodes retrieved in cases receiving preoperative radiotherapy was lower than others. In stage II cases receiving preoperative radiotherapy, retrieval of 7 to 11 lymph nodes (compared with 0 lymph nodes retrieved as a reference) reached the nadir of colorectal cancer-specific mortality benefit (HR = 0.39, 95% CI, 0.28–0.56) and overall mortality (HR = 0.62, 95% CI, 0.48–0.80). In stage II cases with no radiotherapy or postoperative radiotherapy, retrieval of ≥12 lymph nodes remained the strongest prognosticator of colorectal cancer-specific mortality (HR = 0.34, 95% CI, 0.25–0.46; HR = 0.36, 95% CI, 0.24–0.53 respectively). LIMITATIONS: The California Cancer Registry does not include radiation dose and duration, chemotherapy type and dosage, margin status and surgeon characteristics, and stated reasons for lower number of lymph nodes retrieved or patient-related factors. In addition, no central pathology laboratory was used. CONCLUSIONS: In stage II rectal cancer cases receiving preoperative radiotherapy vs either postoperative or no radiotherapy, a lower threshold of lymph node retrieval may be sufficient to evaluate prognosis and to guide further therapy.

No Visible Scar (NVIS) Colectomy: A New Approach to Minimal Access Surgery to the Colon

Introduction: Minimally invasive surgery continues to revolutionize surgical standards with trends toward further minimalization and improved cosmesis. Approaches such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) have thus emerged. The authors devised an alternative method for a more efficient approach to minimally invasive surgery called no visible scar (NVIS). This study describes NVIS and its ability to provide operative capacity and outcomes similar to other minimal access techniques, but with improved cosmesis and possibly decreased associated complications. Methods: This is a retrospective analysis of patients undergoing colectomy between June 2009 and March 2010 to evaluate our outcomes with the NVIS technique (surgical approach via a 4-5 cm suprapubic site for inserting trocars/multiport and specimen extraction, with a 5-mm umbilical incision for a single trocar). Outcome measures included intraoperative complications, postoperative morbidity, and cosmetic outcome. Results: Ten patients with a mean age of 60.3 years underwent NVIS colectomy. The average operating time was 161.3 minutes with a mean blood loss of 56.5 mL. There were no conversions to open surgery. One patient required additional trocar placement. No perioperative complications were encountered. On follow-up, no wound complications were noted and all patients appeared satisfied with their cosmetic outcome. One patient was readmitted for a low-grade fever, but the NVIS technique was not identified as a contributor. Conclusion: NVIS is a safe and feasible minimal access alternative, which improves cosmesis and may decrease complications associated with other minimally invasive techniques. Further analysis in a larger patient population is warranted to support our findings.

Removal of a phytobezoar through exploratory laparoscopy: a case of small bowel obstruction

Correspondence: Steven Mills Division of Colon and rectal Surgery, University of California, Irvine, 333 City Blvd West, Suite 850, Orange, CA 92868 Tel +1 714 456 8511 Fax +1 714 456 6027 email sdmills@uci.edu Abstract: Small bowel obstruction due to bezoars occurs rarely. Traditionally, laparotomy has been the preferred approach to obstruction secondary to bezoars. We report on an 81-year-old female who presented to the emergency room with abdominal pain and vomiting. Computed tomography (CT) scan showed evidence of a small bowel obstruction and laparoscopic exploration of the transition point found on CT revealed a phytobezoar. The small bowel obstruction was managed with laparoscopy and a small access site for specimen removal. In select patients with small bowel obstruction, laparoscopy may be used as a diagnostic and possibly therapeutic technique.