Jason F. Hall

Long-Term Follow-up After an Initial Episode of Diverticulitis: What Are the Predictors of Recurrence?

PURPOSE: The purpose of our study was to determine the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively. METHODS: We retrospectively analyzed 954 consecutive patients who presented to our institution with diverticulitis from 2002 to 2008. Patients were identified with International Classification of Diseases, 9th Revision/Current Procedural Terminology codes. Patients were excluded if they had subsequent colectomy based on the first attack (n = 81), or if the attack they had between 2002 and 2008 was not their first attack (n = 201). We evaluated CT variables chosen by a panel of expert gastrointestinal radiologists. These radiologists reviewed the available published literature for CT imaging characteristics thought to predict diverticulitis severity. CT variables (n = 20) were determined by prospective reevaluation of scans by blinded study radiologists. Clinical variables (n = 43) were coded based on a retrospective chart review. Univariate analysis of variables in relation to recurrent disease was performed by a log-rank test of Kaplan-Meier estimates. Multivariate analysis was performed using Cox proportional hazards modeling. Variables with P < .2 on univariate analysis were included in a stepwise selection algorithm. RESULTS: The study population included 672 patients; mean age, 61 ± 15 years; mean follow-up, 42.8 ± 24 months. The index presentation of diverticulitis was most commonly located in the sigmoid colon (72%), followed by descending colon (33%), right colon (5%), and transverse colon (3%). Overall recurrence at 5 years was 36% by (95% CI 31.4%–40.6%) Kaplan-Meier estimate. Complicated recurrence (fistula, abscess, free perforation) occurred in 3.9% (95% CI 2.2%–5.6%) of patients at 5 years by Kaplan-Meier estimate. Family history of diverticulitis (HR 2.2, 95% CI 1.4–3.2), length of involved colon >5 cm (HR 1.7, 95% CI 1.3–2.3), and retroperitoneal abscess (HR 4.5, 95% CI 1.1–18.4) were associated with diverticulitis recurrence. Right colon disease (HR 0.27, 95% CI 0.09–0.86) was associated with freedom from recurrence. CONCLUSION: Although diverticulitis recurrence is common following an initial attack that has been managed medically, complicated recurrence is uncommon. Patients who present with a family history of diverticulitis, long segment of involved colon, and/or retroperitoneal abscess are at higher risk for recurrent disease. Patients who present with right-sided diverticulitis are at low risk for recurrent disease. These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy.

Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management

BACKGROUND Fulminant Clostridium difficile colitis is a common nosocomial infection that occurs with increasing frequency. METHODS A total of 3,237 consecutive cases of C difficile cytotoxin-positive stool samples from 1998 to 2006 were reviewed. Commonly referenced indicators for surgical intervention were gathered on the day of surgery. The preoperative characteristics of patients surviving subtotal colectomy were compared with those who did not survive. RESULTS Thirty-six patients underwent colectomy. Twenty-three patients (64%) were discharged from the hospital alive. Preoperative intubation and vasopressor requirement were risk factors for in-hospital mortality (odds ratio [OR], 7.15; 95% confidence interval [95% CI], 1.28-39.8 and OR, 6.0; CI, 1.08-33, respectively). Patients who had a recent surgical procedure had a lower in-hospital mortality rate (OR, .11; 95% CI, .02-.52). CONCLUSIONS Fulminant C difficile colitis is associated with a high mortality rate. Development of a vasopressor requirement or need for intubation are ominous signs and should lead to rapid surgical intervention.

Anastomotic Leak Testing After Colorectal Resection: What Are the Data?

OBJECTIVE To determine the value of anastomotic leak testing of left-sided colorectal anastomoses. DESIGN Cohort analysis. SETTING Subspecialty practice at a tertiary care facility. PATIENTS Consecutive subjects were selected from a prospective colorectal database of 2627 patients treated between January l, 2001, and December 31, 2007. INTERVENTION Creation of left-sided colorectal anastomoses and air leak testing per surgeon preference. MAIN OUTCOMES MEASURES Anastomosis type, method (handsewn vs stapled), performance of air leak testing, repair method of anastomoses after air leak tests yielding positive results, and development of postoperative clinical leak. RESULTS A total of 998 left-sided colorectal anastomoses were performed without proximal diversion; 90.1% were stapled and 9.9% were handsewn. Intraoperative air leaks were noted in 65 of 825 tested anastomoses (7.9%), that is, 7.8% of stapled anastomoses and 9.5% of handsewn anastomoses. A clinical leak developed in 48 patients (4.8%). Clinical leaks were noted in 7.7% of anastomoses with positive air leak test results compared with 3.8% of anastomoses with negative air leak test results and 8.1% of all untested anastomoses (P < .03). If air leak testing yielded positive results, suture repair alone was associated with the highest rate of postoperative clinical leak compared with diversion or reanastomosis, 12.2% vs 0% vs 0%, respectively (P = .19). CONCLUSIONS Our data indicate a high rate of air leaks at air leak testing of left-sided colorectal anastomoses. In addition, the high rate of clinical leaks in untested anastomoses leads us to recommend air leak testing of all left-sided anastomoses, whether stapled or handsewn.

Is the Decline in the Surgical Treatment for Diverticulitis Associated with an Increase in Complicated Diverticulitis

PURPOSE: Indications for operative intervention in the treatment of diverticulitis have become unclear. We hypothesized that surgical treatment for diverticulitis has decreased resulting in proportionately more complicated diverticulitis cases (free perforation and/or abscess). METHODS: We conducted a retrospective analysis of patients with diverticular disease in the Nationwide Inpatient Sample from 1991 through 2005. We used diagnostic codes to identify all patient discharges with diverticular disease and then determined the proportion of discharges with diverticulitis, perforated disease, diverticular abscess, and surgical treatment. RESULTS: During the study period, 685,390 diverticulitis discharges were recorded. The ratio of diverticulitis discharges increased from 5.1 cases per 1,000 inpatients in 1991 to 7.6 cases per 1,000 inpatients in 2005 (P < 0.0001). The proportion of patients who underwent colectomy for uncomplicated diverticulitis declined from 17.9% in 1991 to 13.7% in 2005 (P < 0.0.0001). During the same period, the proportion of free diverticular perforations as a fraction of all diverticulitis cases remained unchanged (1.5%). The proportion of diverticular abscess discharges as a fraction of all diverticulitis cases increased from 5.9% in 1991 to 9.6% in 2005 (P < 0.0001). Last, we noted a decrease in diverticular perforations and/or abscess treated with colectomy, 71.0% in 1991 to 55.5% in 2005 (P < 0.0001). CONCLUSIONS: Despite a significant decline in surgical treatment for diverticulitis, there has been no change in the proportion of patients discharged for free diverticular perforation. There was an increase in diverticular abscess discharges, but this finding was not associated with an increase in same stay surgical treatment.

Nonoperative Management of Perianal Abscess in Infants Is Associated With Decreased Risk for Fistula Formation

OBJECTIVE. We sought to determine the frequency of progression in infants of perianal abscess with and without surgical drainage to fistula in ano to optimize a treatment plan for these children. METHODS. A retrospective cohort study was conducted of all patients who were ≤1 year of age and presented with perianal abscess to 2 pediatric tertiary care institutions during a 10-year period (January 1995 to February 2005, inclusive). Patients were divided into those who underwent surgical drainage and those who did not, and the rate of subsequent fistula formation was determined. RESULTS. Of 165 children initially identified, follow-up was available for 140. Ninety-four percent of children were male. Mean age was 4.2 ± 3.1 months. Of the 140 patients, 83 abscesses were drained and 57 were not drained. Of patients who underwent surgical drainage, 50 developed a fistula, whereas of those who did not undergo drainage only 9 developed a fistula. Synchronous administration of antibiotics (intravenous or oral) used in 57 of 58 patients from 1 institution was associated with an even greater decrease in fistula formation (12.5%) in the undrained population. CONCLUSIONS. Perianal abscess formation in infants who are younger than 12 months is a separate entity from abscess formation in older age groups. In this largest study to date, a combined center series of patients who presented to 2 academic pediatric hospitals with infantile perianal abscess, local hygiene and systemic antibiotics without surgical drainage minimized formation of fistula in ano.

New Paradigms in the Management of Diverticular Disease

colonic diverticulum is a saccular outpouching of the colonic wall. iverticula may be “false,” containing mucosa and muscularis mucosa, or true,” containing all layers of the bowel wall. Although the terms iverticulosis, diverticulitis, and diverticular disease are often used nterchangeably, in this monograph, diverticulosis refers to the presence f diverticula within the colon in the absence of inflammation. Diverticlitis refers to the presence of peridiverticular inflammation and infection nd diverticular disease refers to the range of problems that may be aused by diverticula. Diverticular disease represents a wide spectrum of conditions ranging rom mild left lower quadrant pain and bloating to free perforation with eritonitis and sepsis. These presentations have typically been classified nto complicated or uncomplicated disease. Complicated presentations of iverticular disease refer specifically to episodes of perforation, obstrucion, stricture, fistula, or hemorrhage. Diverticular hemorrhage is associted with diverticulosis and not diverticulitis. Other presentations includng those patients with fever, leukocytosis, and left-sided abdominal pain ith an inflammatory phlegmon are considered uncomplicated disease. This monograph examines the current evaluation and treatment of acute iverticulitis. The management of this common condition has changed onsiderably since the previous monograph on colonic diverticular isease.

Colonic Diverticulitis: Does Age Predict Severity of Disease on CT Imaging?

PURPOSE: The aim of our study was to determine whether young patients with diverticulitis were more likely to present with abdominal CT evidence of severe disease. METHODS: We analyzed the abdominal CT scans of 932 patients who presented to our institution with CT scan findings consistent with diverticulitis from January 2002 through June 2007. Radiologists retrospectively reviewed all abdominal scans for the presence of imaging findings consistent with diverticulitis (bowel wall thickness, extraluminal air, free perforation, abscess, or fistula). The cohort was divided into 2 groups; patients ≤50 years of age and patients >51 years of age. RESULTS: Two hundred forty-three patients were ≤50 years and 689 patients were >51 years. Young patients were more likely to be male (63% vs 42%, P < .0001). Young patients had a higher proportion of scans with extraluminal air than older patients (19.7% vs 12.6%, P < .008). Young patients were more likely to present with severe disease found by CT than older patients (19.3% vs 11.5%). When we adjusted for gender, young males had a higher proportion of scans with extraluminal air than older males (22.4% vs 13.1%, P = .014). Young males were also more likely to present with severe disease (22% vs 12%). CONCLUSION: Young patients were more likely to have extraluminal air and severe disease found by CT. Young male patients presented more commonly with evidence of severe disease. They did not differ from older patients in rates of free perforation, abscess, or fistula formation.

How often do patients return to the operating room after colorectal resections

Aim  We sought to identify the rate of re‐operation after an index colorectal surgical procedure and potential contributing risk factors.

Endometriosis of the appendix: Report of three cases

Endometriosis of the appendix is an entity of extragonadal endometriosis. It commonly affects women in the childbearing age with a wide spectrum of clinical manifestations. Women can present with symptoms mimicking acute appendicitis or chronic pelvic pain. The surgical management varies from simple appendectomy to right hemicolectomy depending on the clinical findings. We report 3 cases of endometriosis of the appendix presenting with appendiceal intussusception. The surgical literature is reviewed and current surgical management is discussed.

Outcomes after operations for anal fistula: results of a prospective, multicenter, regional study.

BACKGROUND:There are various surgical techniques used treat anal fistulas. The adoption and success rates of newer techniques have not been clearly established. OBJECTIVE:The purpose of this study was to determine the healing rate after operations for anal fistulas in New England colorectal surgery practices. DESIGN:We conducted a retrospective review of a prospectively collected database. SETTINGS:The study was conducted at colorectal surgery practices in New England. PATIENTS:A prospective, multicenter registry was created by the New England Society of Colon and Rectal Surgeons. Surgeons were invited to collect data prospectively regarding patients operated on for anal fistulas between January 1, 2011, and August 1, 2013. Fistula classification, surgical intervention, continence scores, and healing were determined by the treating surgeon. INTERVENTION:Operation for anal fistula was performed. MAIN OUTCOME MEASURES:We measured the proportion of patients with healed fistulas at 3 months. RESULTS:Sixteen surgeons submitted data regarding 240 operations for fistula with curative intent. Mean patient age was 45 ± 14 years. A total of 158 patients (66%) were men, and 110 (46%) had undergone an anorectal operation. Twenty-nine (12%) had Crohn’s disease. The healing rates of fistulotomy, advancement flap, and fistula plugs at 3 months were 94% (95% CI, 89–97), 60% (95% CI, 33–77), and 20% (95% CI, 5–50). The healing rate of the ligation of intersphincteric fistula tract procedure at 3 months was 79% (95% CI, 65–88). Hospital site was the only variable associated with healing (p < 0.05). Hospitals that performed more ligation of intersphincteric fistula tract procedures had higher healing rates at 3 months (p < 0.0001). LIMITATIONS:This study was limited by selection bias and reporting bias. CONCLUSIONS:A wide variety of techniques are used to treat anal fistulas in our region. Fistulotomy continues to have excellent results. There has been enthusiastic early adoption of the ligation of intersphincteric fistula tract technique. Early healing rates after the ligation of intersphincteric fistula tract procedure appear to be excellent.