Thomas Golda

Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis A Prospective, Multicenter Randomized Clinical Trial (DIVER Trial)

Objective:We compare the results of 2 different strategies for the management of patients with uncomplicated left colonic diverticulitis and to analyze differences in quality of life and economic costs. Background:The most frequent standard management of acute uncomplicated diverticulitis still is hospital admission both in Europe and United States. Methods:This multicenter, randomized controlled trial included patients older than 18 years with acute uncomplicated diverticulitis. All the patients underwent abdominal computed tomography. There were 2 strategies of management: hospitalization (group 1) and outpatient (group 2). The first dose of antibiotic was given intravenously to all patients in the emergency department and then group 1 patients were hospitalized whereas patients in group 2 were discharged. The primary end point was the treatment failure rate of the outpatient protocol and need for hospital admission. The secondary end points included quality-of-life assessment and evaluation of costs. Results:A total of 132 patients were randomized: 4 patients in group 1 and 3 patients in group 2 presented treatment failure without differences between the groups (P = 0.619). The overall health care cost per episode was 3 times lower in group 2, with savings of &OV0556;1124.70 per patient. No differences were observed between the groups in terms of quality of life. Conclusions:Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis. Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis. Trial registration ID: EudraCT number 2008-008452-17.

Generalized peritonitis due to perforated diverticulitis: Hartmann's procedure or primary anastomosis?

PurposeHartmann’s procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis due to perforated diverticulitis. The aims of this study were to assess the feasibility and safety of resection with primary anastomosis (RPA) in patients with purulent or fecal diverticular peritonitis and review morbidity and mortality after single stage procedure and Hartmann in our experience.MethodsFrom January 1995 through December 2008, patients operated for generalized diverticular peritonitis were studied. Patients were classified into two main groups: RPA and HP.ResultsA total of 87 patients underwent emergency surgery for diverticulitis complicated with purulent or diffuse fecal peritonitis. Sixty (69%) had undergone HP while RPA was performed in 27 patients (31%). At the multivariate analysis, RPA was associated with less post-operative complications (P < 0.05). Three out of the 27 patients with RPA (11.1%) developed a clinical anastomotic leakage and needed re-operation.ConclusionsRPA can be safely performed without adding morbidity and mortality in cases of diffuse diverticular peritonitis. HP should be reserved only for hemodynamically unstable or high-risk patients. Specialization in colorectal surgery improves mortality and raises the percentage of one-stage procedures.

Impact of Surgical Specialization on Emergency Colorectal Surgery Outcomes

OBJECTIVE To evaluate the impact of surgeon specialization on emergency colorectal resection in terms of mortality, morbidity, and type of operation performed. DESIGN Observational study from January 1, 1993, through December 31, 2006. SETTING Bellvitge University Hospital, Barcelona, Spain. PATIENTS A total of 1046 patients underwent emergency colorectal resection. Patients were classified into 2 groups: those operated on by a colorectal surgeon (CS) and those operated on by a general surgeon (GS). MAIN OUTCOME MEASURES Preoperative variables studied were sex, age, American Society of Anesthesiologists grade, associated medical disease, presentation, reason for surgery, and type of operation. Univariate relations between predictors and outcomes were estimated, and multivariate logistic regression analysis was used to assess the prognostic effect of the combination of the variables. RESULTS Patients in the CS group underwent a significantly higher percentage of resection and primary anastomosis. The postoperative morbidity rate was 52.2% in the CS group and 60.5% in the GS group (P = .01). The anastomotic dehiscence rate was lower in the CS group (6.2%) than in the GS group (12.1%) (P = .01). Postoperative mortality decreased among patients in the CS group (17.9%) with respect to the patients in the GS group (28.3%) (P < .001). Being operated on by a CS was predictive in both the univariate and multivariate analyses for postoperative complications and mortality, and it was the only variable with predictive value for anastomotic dehiscence. CONCLUSIONS Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.

Recurrence and virulence of colonic diverticulitis in immunocompromised patients

BACKGROUND To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status. METHODS Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates. RESULTS Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004). CONCLUSIONS After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.

Differences in patient postoperative and long-term outcomes between obstructive and perforated colonic cancer

BACKGROUND The aim of this observational study was to analyze the differences between patients with obstructive and perforated colonic cancer who managed with emergency curative surgery. METHODS Between January 1994 and December 2000, patients deemed to have undergone curative resection for complicated colonic cancer were considered for inclusion in the study. They were classified into 2 groups: patients with obstructive cancer (OC) and patients with perforated cancer (PC). The main end points were postsurgical outcomes and long-term overall survival, cancer-related survival, and tumor recurrence. RESULTS Of the 236 patients, surgery was deemed to be radical and performed with intent to cure in 155 patients (65.7%): 117 patients in the OC group and 38 patients in the PC group. No statistical differences were observed between the percentage of radical surgery between the 2 groups (P = .63). The overall postsurgical mortality rate was 12.2%: 14 patients in the OC group and 5 patients in the PC group (P = .839). Overall survival, probability of being free of recurrence, and cancer-related survival of the entire series were 64.57%, 67.72% and 73.03%, respectively. There were no differences between the 2 groups with respect to tumor recurrence, type of recurrence, overall survival, probability of being free of recurrence, and cancer-related survival at 5 years. CONCLUSIONS In our experience, patients with perforated colonic cancer do not seem to show worse long-term outcomes than those with OC. Studies with larger series are needed for further investigations.

Long-term results of surgery plus fibrin sealant for anal fistula

Aim  The long‐term recurrence rate of fibrin glue treatment was analysed in patients with trans‐sphincteric cryptoglandular fistula operated by a two‐phase procedure: (i) fistulectomy with seton placement; (ii) fibrin sealant (Tissucol Duo®, Baxter) insertion in the track.

Body packer: revisión y experiencia en un hospital de referencia

Resumen El transporte de drogas ilegales en el interior del organismo ( body packer ) representa un problema medico-legal en claro aumento en las ultimas decadas. Los facultativos, especialmente aquellos con actividad en los servicios de urgencias, han de familiarizarse con el manejo diagnostico y terapeutico –habitualmente conservador– de este tipo de pacientes y de sus posibles complicaciones. El presente articulo revisa los conceptos y fisiopatologia generales asociados al transporte de paquetes en el tracto digestivo y describe la experiencia de un centro sanitario de referencia con un protocolo especificamente disenado para estos enfermos.

Complicaciones del tratamiento de la oclusion del colon distal con protesis endoluminales

INTRODUCTION The high morbidity and mortality of emergency surgery, has led to the use of endoluminal self-expanding metal implants (stents) in the management of intestinal occlusion. The purpose of this study was to review the results of the management of intestinal occlusion treatment in a Colorectal Surgery Unit in those patients who had a stent implant, and the relationship between chemotherapy and complications. MATERIAL AND METHODS A retrospective study was carried out on patients treated with a stent in a university hospital between 2004 and 2010. RESULTS A total of 93 patients were treated, of which 77 were considered palliative for a stage IV neoplasm of the colon with non-resectable metastases or due to a performance status > 2. Other indications were 7 ASA IV patients with acute renal failure, 6 with benign disease, and 3 due to other causes. The technical and clinical success of the procedure was 93.5% and 78.5%, respectively. Delayed occlusion was 19.3% and perforation 6.4%. There was migration (2.1%) and intestinal bleeding (2.1%) and 1.1% with tenesmus. No significant differences were seen between complications and chemotherapy. The overall mortality was 17.2%. CONCLUSIONS Stents, as a definitive treatment option in palliative patients with and without chemotherapy, is an alternative treatment that is not exempt from complications. We believe that in patients with mortality risk factors and patients with tumours with non-resectable metastases it could be the initial treatment of choice.