Kyle G. Cologne

Rectal Foreign Bodies: What Is the Current Standard?

Rectal foreign bodies represent a challenging and unique field of colorectal trauma. The approach includes a careful history and physical examination, a high index of suspicion for any evidence of perforation, a creative approach to nonoperative removal, and appropriate short-term follow-up to detect any delayed perforation.

Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications.

BACKGROUND: The best management for diverticulitis with abscess formation remains unknown. OBJECTIVE: The purpose of this study was to determine the natural course and outcomes of patients with medically treated diverticular abscess. DESIGN: We conducted a retrospective review of all patients at our institution with diverticular abscess confirmed by CT from 2004 to 2014. SETTINGS: This study was conducted in a tertiary referral hospital. PATIENTS: A total of 1194 patients were treated for acute diverticulitis in 10 years; 210 patients with CT-documented diverticular abscess were analyzed (140 men (66.7%) and 70 women (33.3%); median age 45 years; range, 23–84 years). MAIN OUTCOME MEASURES: Overall recurrence and disease complication rates, as well as the need for subsequent operation after initial successful nonsurgical management, were measured, along with analysis of the whole cohort and the subgroup of patients with percutaneous drainage for diverticular abscess. RESULTS: During the initial presentation, 25 patients failed nonoperative management and required an urgent operation. A total of 185 patients were initially successfully managed without surgery and were discharged from the hospital. Of these, recurrent diverticulitis developed in 112 (60.5%) after an average time interval of 5.3 months (range, 0.8–20.0 months); 47 patients (42%) experienced more than 1 episode. The modified Hinchey stage at time of recurrence (compared with index stay) increased in 51 patients (45.6%). Seventy one (63%) of 112 recurrences showed local disease complications (recurrent abscess, fistula, stricture, or peritonitis). Fistula formation (colovesicular/colovaginal/colocutaneous) and recurrent abscess were the 2 most frequent complications. Twenty nine (26%) of 112 recurrences required an urgent operation; overall, 66 (59%) of 112 patients eventually underwent surgery at our institution. The original abscess size in patients who later developed recurrences was significantly larger than in patients who did not develop recurrence (5.3 vs 3.2 cm; p < 0.001). Paradoxically, larger abscesses also had a higher chance of successful CT-guided drainage (average size, 6.5 cm; range, 1.1–14 cm), yet CT-guided drainage did not change the overall outcome. Of 65 (31.0%) of 210 patients with CT-guided drainage, 45 (73.8%) of 61 after initial success experienced a recurrence. Furthermore, local disease complications at the time of recurrence were noted in 32 of 61 patients (52.5% of all CT-guided drainage, 71.1% of post-CT–guided drainage recurrences), and 13 (29.2%) of 45 patients with recurrence after successful CT-guided drainage subsequently required an urgent operation. LIMITATIONS: The study was limited by its retrospective noncomparative design. CONCLUSIONS: Diverticular abscesses represent complicated diverticulitis and are associated with a high risk of recurrences and disease complications. Recurrences (contrary to other series) were often more severe than the index presentation. The successful CT-guided drainage of a diverticular abscess does not appear to lower the risks of future recurrence or complication rates and frequently is only a bridge to surgery. After initial successful nonoperative management, patients with diverticular abscess should be offered interval elective colectomy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A216).

Treatment of frostbite with subatmospheric pressure therapy.

Frostbite may result in loss of skin and tissue requiring amputation; it occurs most often on the exposed areas such as extremity digits, ears, etc. The usual treatment is observation for demarcation of the injury before amputation or autoamputation of the dry gangrene that may set in between 1 and 3 weeks. In some instances, tissue viability is assessed by a pyrophosphate nuclear scan. This was a 43-year-old African-American man who developed frostbite of his right foot. He presented 72 hours after injury with hyperemia and cellulitis over the dorsum of the foot and a blistered dorsal surface of the great toe with loss of sensation on all toes and early signs of necrosis. The patient received a 7-day course of ampicillin-sulbactam and a 6-day course of vacuum-assisted closure therapy during a 7-day hospitalization. At the time of discharge, he had re-epithialialization of the dorsal surface of the right toe and healthy granulation tissue with islands of epidermis emerging on the ventral surface of the right toe. Re-epithelialization was complete by 26 days after injury. In the future, this treatment therapy may find a larger application in frostbite injuries because it may accelerate healing. A study of frostbite treatment confirming the usefulness of this modality may be indicated.

Management of Complex Anal Fistulas.

Complex anal fistulas require careful evaluation. Prior to any attempts at definitive repair, the anatomy must be well defined and the sepsis resolved. Several muscle-sparing approaches to anal fistula are appropriate, and are often catered to the patient based on their presentation and previous repairs. Emerging technologies show promise for fistula repair, but lack long-term data.

A Novel Classification, Evaluation, and Treatment Strategy for Supralevator Abscesses.

1109 Diseases of the Colon & ReCtum Volume 58: 11 (2015) Bodenhamer 1 described the unique clinical features of deep-seated abscesses pointing into the rectum in 1855. Pain enhanced with defecation, as well as tenesmus, is a unique feature. in 1938, Buie recommended internal drainage for infections “pointing” into the rectum and external drainage for those pointing externally combined with enlarging the opening through the levators. Goldberg et al codified their classification and treatment approach in 1980. they established a straightforward and now classic paradigm in which intersphincteric supralevator abscesses require internal (intrarectal) drainage. extrasphincteric supralevators are drained externally toward the perineum. this strategy avoids the formation of suprasphincteric and extrasphincteric fistula. this elegant and simple construct is still valid. however, it is a singledimension construct of complex 3-dimensional pathology. failure to account for supralevator infections in 3 dimensions leads to diagnostic and therapeutic uncertainties.

Does one score fit all? Measuring risk in ulcerative colitis.

BACKGROUND The American College of Surgeons Surgical Risk Calculator was developed to improve risk stratification and surgical quality but has not been studied at the institutional level for specific disease states, like ulcerative colitis (UC). METHODS UC patients undergoing colorectal resection had predicted risk calculator data compared with actual outcomes for length of stay (LOS), complications, reoperation, and death. Main outcome measures were the difference in actual vs predicted outcomes. RESULTS Seventy patients were evaluated. The actual and predicted mean LOS was identical, but not representative of the actual LOS picture, which had 10 LOS outliers (14.3%). The actual incidence of any complication (P < .001) and major complications (P < .001) was higher than predicted. The most common complications actually encountered-intrabdominal abscess (14.3%), postoperative ileus (7.2%), and anastomotic leak (5.7%), were not even calculated by the tool. CONCLUSIONS For UC, the calculator poorly evaluates relevant risks, complications, and is greatly impacted by outliers. These limitations caution use for surgical quality reporting and determining specific patient outcomes, at least in UC.

Three-dimensional Laparoscopy: Does Improved Visualization Decrease the Learning Curve among Trainees in Advanced Procedures?

Purpose: Complex laparoscopy is difficult to master because it involves 3-dimensional (3D) interpretation on a 2-dimensional (2D) viewing screen. The use of 3D technology has an uncertain effect on training surgeons. We aim to evaluate the effectiveness of 3D on learning and performing laparoscopic tasks. Methods: Medical students without laparoscopic experience (novices) were evaluated doing inanimate object transfer and laparoscopic suturing. Tasks were repeated using 2D and 3D cameras with standard instruments. Time and error rates (missed attempts, dropped objects, and failure to complete the task) were recorded. Results: Twenty-nine novice medical students experienced a 45.5% decrease in the time to complete PEG transfer using 3D (mean 207 s with 2D vs. 113 s with 3D). Error rate was reduced to 50% (2D, 4 errors vs. 3D, 2 errors) and mean drop rate was reduced to 0. Similar decreases in suture time (46.5%) were seen (mean 403 s with 2D vs. 220 s with 3D). Conclusions: Our results indicate that 3D significantly improved visualization and ability to perform complex tasks in the skills laboratory setting. This technology may be very effective in teaching advanced laparoscopic skills in the era of work-hour restrictions.

Effects of diabetes mellitus in patients presenting with diverticulitis: clinical correlations and disease characteristics in more than 1,000 patients.

BACKGROUND The epidemic increase in the incidence of diabetes mellitus (DM) worldwide represents a potential source of surgical morbidity. The impact of DM on the need for surgical management and its effect on surgical outcomes for colonic diverticulitis have not been well defined. METHODS We investigated all DM versus non-DM patients admitted with a diagnosis of acute diverticulitis between January 1, 2003, and December 31, 2011, to a large urban safety net hospital. An administrative database search for patients with diverticulitis was divided into two groups: those with and without DM. They were retrospectively analyzed for severity of diverticulitis (Hinchey and Ambrosetti scores), mortality, length of hospital stay, need for operation, postoperative complications, and readmission rates. RESULTS There were 1,019 admissions with acute diverticulitis, 164 (16.1%) of which had DM. DM versus non-DM patients presented with a higher Hinchey score of 3 or 4 (12.2% vs. 9.2%, p < 0.001), a more severe computed tomographic Ambrosetti score (43.9% vs. 31.7%, p < 0.001), older age, and significantly more comorbid conditions. There was no significant difference in the failure of nonoperative management (2.2% DM vs. 2.5% non-DM, p = 1.000), readmission, or death rates. Operated DM patients had a higher incidence of in-hospital infectious complications (28.7% vs. 8.2%, p < 0.001) and a higher incidence of acute renal failure (5.5% vs. 0.7%, p < 0.001). CONCLUSION Although diabetic patients with colonic diverticulitis present at a more advanced level (as measured by Hinchey and Ambrosetti scores), the nonoperative success rate is similar to non-DM patients. Surgical management in DM patients is associated with a higher incidence of infectious complications and acute kidney injury. However, DM did not appear to increase operative mortality in surgically managed patients. These data suggest that greater attention should be placed on steps to reduce the negative impact of DM on both immune response and renal function in patients requiring surgery of colonic diverticulitis. LEVEL OF EVIDENCE Epidemiologic study, level III.

Development of Minimally Invasive Colorectal Surgery: History, Evidence, Learning Curve, and Current Adaptation

Minimally invasive surgery has revolutionized the way surgeons practice colorectal surgery. It has resulted in decreased lengths of stay, a marked decrease in wound infections, and has shown some evidence of an overall lower complication rate versus open surgery. This chapter will outline the history of minimally invasive colorectal surgery, examine evidence detailing its safety compared with open surgery, discuss the learning curve required to achieve proficiency, and outline the extent of its current use.

Treatment-Based Three-Dimensional Classification and Management of Anorectal Infections

This article provides a current overview on clinical anatomy, pathophysiology, workup and surgical management of anorectal abscesses. Based on the three-dimensional nature of anorectal abscesses, a novel treatment-based classification is proposed. It examines the basis of a philosophic shift from simple drainage to concomitant definitive treatment of abscesses and their underlying primary fistulous trajectories. Complications are discussed specifically in this context.