Hartmann's Group Research Articles

Complicated destructive appendicitis: finding the optimal treatment method

Aim. To analyze the current practice for the surgical treatment of destructive acute appendicitis complicated by typhlitis and periappendicular abscess.
 Methods. This study analyzed the treatment outcomes in 84 patients with acute destructive appendicitis aged 18 to 79 years who were treated in the Department of Surgery No. 2 of the City Clinical Hospital No. 7 of Kazan between 2016 and 2021 years. According to the method for completion of surgical intervention, patients were divided into 2 groups, similar in age, duration of the disease and morphological changes in the appendix. In the comparison group, 54 patients had the surgical intervention completed by gauze-glove drainage of the appendix bed. In 30 patients of the main group, the appendix stump and the adjacent intestinal wall was covered with a Tachocomb plate. Then the VAC system with the Vivano device and supplies from Hartmann Group (Germany) was connected. The statistical significance of the differences between the indicators was assessed by using the Student's t-test.
 Results. The analysis of the surgical techniques used showed that in the main group, postoperative wound complications decreased by 3 times (23.3% of patients, p=0.04), intra-abdominal fluid collections decreased by 2 times (6.7% of patients, p=0.02), the hospital lengths of stay decreased by 1.8 times (p=0.02) compared with the comparison group.
 Conclusion. The use of ligature appendectomy in combination with plastic closure of the appendix stump with a TachoComb and the technology of local vacuum-assisted laparostomy in patients with destructive appendicitis complicated by periappendicular abscess contributes to a 3-fold reduction in wound postoperative complications and reduces the hospital lengths of stay in this group of patients by 1.8 times.

Out of the Loop: The Value of a Preoperative Loopogram for Colostomy Reversal in Trauma.

Stoma is occasionally fashioned during trauma surgery. A loopogram is routinely conducted in the surgical planning for stoma reversal. This is associated with medical and cost implications. A study was undertaken to evaluate the influence of loopograms on the management of trauma patients at a Johannesburg hospital. A retrospective analysis of records in the stoma database (January 2013 to December 2018) was conducted. The patient demographics, method of injury, stoma-type, loopogram findings and post-operative courses were analysed. 112 records were obtained. 9 (8%) patients were excluded for pending investigations or surgery. 13 (11.6%) patients were excluded for incomplete data. The remaining 90 (80.3%) patients, with a mean age of 32.9 had non-contributory loopograms and underwent a reversal procedure. 43 (47.8%) had a loop colostomy while 47 (52.2%) had undergone a Hartmann's procedure. Mechanism of injury was stab wounds (81.4%L; 61.7%H); gunshot wounds (13.9%L; 29.7%H) and blunt trauma (L5% and 9%H). The post-operative complication rate was 30% for the loop group (2.3% ≥ Clavien-Dindo 3) and 25.5% for the Hartmann's group (4% ≥ Clavien-Dindo 3). The average timing to reversal was 38weeks (range 12-60) in the Hartmann's group and 22weeks (range 12-32) the loop colostomy group. Significant findings are infrequent on loopogram for trauma patients. When these findings are detected, the effect on management is questionable. They are not without complications and have cost and time implications. Loopograms are helpful in selective cases rather than as a routine investigation, particularly in resource-limited settings.

Evaluating outcomes of primary anastomosis versus Hartmann's procedure in sigmoid volvulus: A retrospective-cohort study

BackgroundThe aim of this study is to compare the short outcomes of two methods of sigmoid resection and primary anastomosis with sigmoid resection and end colostomy (Hartmann's procedure) for sigmoid volvulus. MethodsThis retrospective study included 102, of which 56 patients underwent end colostomy (Hartmann's procedure) and 46 patients underwent resection and primary anastomosis for sigmoid volvulus. The medical records of the patients were reviewed to evaluate the patients' characteristics, operative data, short-term postoperative outcomes and mortality. ResultsThe mean age of patients in the groups of Hartmann's procedure and primary anastomosis were 68.23 ± 13.42 and 70.10 ± 12.71, respectively. From the 46 patients who had primary colorectal anastomosis, 2 patients (4.3%) suffered from anastomosis leakage, which was not significantly different. This study showed that anastomosis leakage, prolonged ileus, bleeding, surgical site infection and fascial dehiscence were not different between Hartmann's procedure and primary anastomosis, significantly, p < 0.05. Hospital stay in the Hartmann group was less than primary anastomosis group in the same admission, p = 0.04. The mortality rate was not statistically different among the two groups, p = 0.549. ConclusionsPostoperative complications and mortality rate do not different among the two groups however, the duration of hospitalization was lesser in Hartmann's procedure group.

A Double-Blind, Randomized Control Trial of Rapidly Infused High Strong Ion Difference (SID) Fluid Versus Hartmann's Solution on Acid-Base Status in Sepsis Patients in the Emergency Department.

Balanced fluids are preferred in initial resuscitation of septic patients based on several recent studies. The Stewart's concept on acid-base balance predicts that high strong ion difference (SID) fluid thus will increase the pH level. To date, the impact of high SID fluid in septic patient with metabolic acidosis remains uncertain. We conducted single center, randomized, double-blind trial to compare the effect of high SID fluid vs. Hartmann's solution on acid-base status in selected sepsis patients in the Emergency Department. Septic patient with hyperlactatemia and metabolic acidosis were randomized to receive either high SID fl uid or Hartmann's solution during initial fl uid resuscitation. The primary outcome measures the pH and bicarbonate levels difference pre- and post- resuscitation. One hundred and sixty-two patients underwent randomization, 81 were assigned each to receive high SID fluid or Hartmann's solution. Both groups had similar baseline characteristics. High SID group received 23.5 mL/kg and the Hartmann's group received 22.7 mL/kg (p = 0.360). High SID fluid increased the mean (± SD) pH by 0.107 (± 0.09) vs. Hartmann's solution by 0.014 (± 0.12), p ≤ 0.001. Mean bicarbonate level increased signifi cantly in high SID group compared to Hartmann's (4.30 ± 3.76 vs. 1.25 ± 3.33, p ≤ 0.001). High SID group had higher post resuscitation lactate clearance than Hartmann's group (25.4 ± 28.3% vs. 12.0 ± 34.1%, p = 0.009). Shorter hospital stay was observed in highSID group 8.04 ± 5.96 days vs. Hartmann's group 12.18 ± 12.41 days (p = 0.048). Both groups showed no difference in incidence of pulmonary oedema, acute kidney injury and mortality. Initial resuscitation using high SID fluid in selected septic patient improves pH and bicarbonate levels. The high SID group had better post resuscitation lactate clearance and shorter hospital stay.

Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial

Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485. Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% [95% CI 88·7-100] vs 71·7% [95% CI 60·1-83·3], hazard ratio 2·79 [95% CI 1·86-4·18]; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 [44%] of 66 patients vs 25 [39%] of 64, p=0·60; mortality: two [3%] vs four [6%], p=0·44). In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease). Netherlands Organisation for Health Research and Development.

A New Perspective on Vacuum-Assisted Closure for the Treatment of Anastomotic Leak Following Low Anterior Resection for Rectal Cancer, Is It Worthy?

Anastomotic dehiscence is a common complication of anterior resection. In this work, we evaluate the management of the pelvic cavity after low rectal resection using vacuum closure (VAC) with a gastroscope, and we establish factors that determine the success of closure and analyzed the rate of ileostomy closure after leakage was resolved. This is a descriptive case series analysis conducted at a tertiary hospital. Twenty-two patients with low colorectal anastomosis leakage or opening of the rectal stump after anterior resection for rectal cancer were included. They were treated with VAC therapy. The total number of endoscopic sessions was 3.1 ± 1.9 in the anterior resection with anastomosis group and 3.2 ± 1.8 in the Hartmann group. In 11 patients the therapy was administered in an ambulatory setting. The mean time to healing was 22.3 ± 14.7 days. Full resolution was achieved in 19 patients (followed-up 1 year). Ileostomy closure was carried out in 5 patients (38.46%) during follow-up. None of these patients showed leakage signs. Statistically significant differences were obtained depending on the onset of therapy, with better results in patients who underwent earlier vacuum-assisted therapy (before the sixth week after initial surgery), P = .041. VAC therapy is an alternative to surgery that can be safely administered in an ambulatory setting. Early administration in the 6 weeks following surgery is an independent predictive factor for successful closure; however, colonic transit was only recovered in a small percentage of patients.

Bowel perforation in type IV vascular Ehlers-Danlos syndrome. A systematic review.

Spontaneous gastrointestinal (GI) perforation is a well-known complication occurring in patients suffering from Type IV vascular Ehlers-Danlos syndrome (EDS IV). The aim of the present study was to review the current literature on spontaneous GI perforation in EDS IV and illustrate the surgical management and outcome when possible. A systematic review of all the published data on EDS IV patients with spontaneous GI perforation between January 2000 and December 2015 was conducted using three major databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trails. References of the selected articles were screened to avoid missing main articles. Twenty-seven published case reports and four retrospective studies, including 31 and 527 cases, respectively, matched the search criteria. A case from our institution was added. Mean age was 26years (range 6-64years). The most frequent site of perforation was the colon, particularly the sigmoid, followed by small bowel, upper rectum, and finally stomach. The majority of cases were initially managed with Hartmann's procedure. In recurrent perforations, total colectomy was performed. The reperforation rate was considerably higher in the "partial colectomy with anastomosis" group than in the Hartmann group. Colonic perforation is the most common spontaneous GI perforation in EDS IV patients. Anunexpected fragility of the tissues should raise the possibility of a connective tissue disorder and prompt further investigation with eventual management of these high-risk patients with a multidisciplinary team approach in dedicated centres. In the emergency setting, a Hartmann procedure should be performed.

Two-year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis.

BackgroundTraditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium‐term follow‐up results of DILALA are reported here.MethodsPatients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287.ResultsForty‐three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months.ConclusionLaparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.

Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: Open Hartmann's procedure vs. laparoscopic lavage and drainage in the elderly

Hartmann's procedure (HP) is the most performed technique for acute diverticulitis. Laparoscopic lavage and drainage (LLD) is an option evaluated as definitive treatment for diverticulitis Hinchey grade II–III. Aim of the study is to analyze and compare LLD vs HP outcomes.From January 1st 2009 and December 31st 2012 we prospectively enrolled 30 patients with diagnosis of acute diverticulitis Hinchey grade II–III. Fourteen patients underwent to LLD (LLD group, LLDG) and 16 patients to HP (Hartmann group, HG). We evaluated: demographic variables, comorbidities, admission clinical status, radiological imaging, intraoperative outcomes (operative time), postoperative outcomes (admission to ICU, timing of drainage removal, restore of bowel functions, timing of oral solid intake), mortality rate (perioperative and after 12 months) and morbidity rate (surgical, infectious, cardiovascular, renal and systemic complications). Exclusion criteria were: other diseases, colon cancer's suspect or diagnosis, conversion to HP.Patients' mean age was 64.8 years in HG and 62.6 in LLDG. M:F ratio was 6:10 in HG, 8:6 in LLDG. Data showed improved outcomes in LLDG for: total operative time (p < 0.0001), admission to ICU (p 0.0447), restoration of bowel functions (p 0.0035 for gases, p 0.0152 for feces), mobilization (p 0.0087) and length of hospital stay (p 0.0132).According to literature, LLD is related to operative risk, morbidity and mortality rate and length of stay lower than HP. LLD also gives the possibility to avoid stoma. Despite limits of our study, we consider LLD as a “safe and effective” treatment for Hinchey grade II–III acute diverticulitis.

A randomised controlled trial of Hartmann's solution versus half normal saline in postoperative paediatric spinal instrumentation and craniotomy patients

ObjectiveTo compare the difference in plasma sodium at 16–18 h following major surgery in children who were prescribed either Hartmann's and 5% dextrose or 0.45% saline and 5% dextrose.DesignA prospective,...

Low Rectal Cancer: Abdominoperineal Resection or Low Hartmann Resection? A Postoperative Outcome Analysis

In distal rectum cancers, when the sphincters are not affected and it is not possible to perform a coloanal anastomosis because of the presence of comorbidities or the advanced age of the patient, a low Hartmann resection with total mesorectal excision can be performed. Low Hartmann resection is usually considered to be a shorter procedure and to have an inferior morbidity compared with abdominoperineal resection of the rectum. This study aimed to compare the postoperative outcome of a series of patients with low rectal cancer who have undergone either low Hartmann resection or abdominoperineal resection. This study is a retrospective analysis of data collected in a prospective database. This study was conducted in a specialized Colorectal Unit, Department of Surgery, of a tertiary teaching hospital. Patients who underwent low Hartmann or abdominoperineal resection for rectal cancer between 1996 and 2009 at our specialized Colorectal Unit were considered. The main interventions were low Hartmann resection vs abdominoperineal resection. The main outcome measures were 60-day morbidity and mortality. The pelvic abscess rate was 12.2% in patients who underwent low Hartmann resection and 3.0% in those who underwent abdominoperineal resection (P = .02). The reoperation rate was 14.6% in the Hartmann group and 3.8% in the abdominoperineal group (P = .013). The rehospitalization rates in the Hartmann and abdominoperineal groups were 7.3% and 0.7% (P = .015). No differences were found in the other variables analyzed. At multivariate analysis, the surgical technique performed was the only independent risk factor for pelvic abscess development, readmission, and reoperation. : This study was limited by its retrospective nature. In our series, low Hartmann resection was associated with higher pelvic abscess, reoperation, and readmission rates. These findings suggest that in patients with rectal cancer without sphincter infiltration and who are unsuitable for coloanal anastomosis, abdominoperineal resection should be a valid alternative to low Hartmann resection.

Complicated Sigmoid Diverticulitis—Hartmann’s Procedure or Primary Anastomosis ?

Introduction : Diverticular disease of the colon is a common condition in developed countries. For perforated diverticulitis Hartmann’s procedure is a safe and quick treatment option. But intestinal restoration needs further interventions. This leads to high complication rates and cost. Therefore a critical evaluation of surgical treatment options is necessary.Methods : During a period of 18 months 88 patients underwent surgical resection for diverticulitis. Forty patients had emergency surgery. Among those a primary anastomosis was performed in 21 patients. The other 19 patients had interval colostomy. Among 21 patients with primary anastomosis major complications occurred in two patients, vs. twelve in patients with Hartmann’s operation (p = 0.03). In the Hartmann group eight patients had major general complications, vs. one patient in the group with primary anastomosis (p = 0.06). The mean hospital stay was 38 days after Hartmann’s procedure, vs. 13 days for patients with primary anastomosis (p < 0.01).Conclusion : In emergency surgery for complicated diverticulitis primary anastomosis is not associated with an increased postoperative morbidity. A primary anastomosis reduces the need for further surgical interventions and complex re-operations. Thus, an overall reduction of morbidity, cost, complication rate and hospital stay is possible. Therefore this technique is advantageous for patients and hospitals.

A Ten-Year Audit of Perforated Sigmoid Diverticulitis: Highlighting the Outcomes of Laparoscopic Lavage

This study was designed to review the results of laparoscopic lavage for the management of perforated sigmoid diverticulitis. A 10-year retrospective review was conducted of 78 consecutive cases of sigmoid diverticulitis warranting emergency surgical intervention (1999-2008). Hinchey grades were I (12 patients), II (31 patients), III (29 patients), and IV (6 patients). The patients' mean age was 72 years. Procedures performed were laparoscopic washout (35), Hartmann procedure (31), percutaneous drainage of abscess (4), and resection and primary anastomosis (8). Overall mortality was 5 of 78 (7%); all of these patients were in the Hartmann group. Washout was successful in 27 of 35 cases, meaning recovery from the initial episode of peritonitis without resection. The short-term failures of washout in 8 patients were because of perforated cancer (1), fecal fistula formation (2), and inadequate washout and ongoing sepsis (5). In long-term follow-up, 8 patients in the washout group developed symptoms of recurrent complicated diverticulitis, including painful phlegmon (3), stricture (1), fistulas (3), and repeat perforation (1); all 8 patients underwent delayed resection. Eight patients underwent early planned resection without experiencing further symptoms. Eleven patients were observed without further symptoms with a mean follow-up of 20 months (range, 6-60 mo). Laparoscopic washout is an emerging technique that is particularly applicable to the management of Hinchey III perforated peritonitis. Short- and long-term problems exist with the technique that may be overcome with further improvement in technique and case selection. Resection and radiological drainage remain widely used in managing perforated sigmoid diverticulitis.

CR09 *LAPAROSCOPIC WASHOUT FOR DIVERTICULITIS

Background: Hartmann's procedure has been the treatment for complicated perforated diverticular disease. Laparoscopic washout with colonic preservation can replace radical resection. Laparoscopic washout is associated with less morbidity, mortality and improved quality of life.Methods: An 8‐year retrospective review of 80 consecutive cases of sigmoid diverticulitis warranting emergency surgical intervention (2000–2008). During this time approximately 2000 admissions for diverticulitis were recorded.Results: Hinchey grades were I(10), II(26), III(38) and IV(6).Patients age mean 77, median 74. Procedures performed were Laparoscopic washout (34), Hartmann's procedure (34), percutaneous drainage of abscess (5), resection and primary anastomosis (3).Overall mortality was 7% (all in the Hartmann's group). Washout achieved success in 28 of 34 cases without immediate colonic resection. Short‐term failures of washout in 6 were due to perforated cancer (2), faecal fistula formation (2), inadequate washout and ongoing sepsis (2). All failures underwent Hartmann's resection without complication. In long‐term follow up 8 patients developed symptoms of recurrent complicated diverticulitis including (delayed stricture, fistulae and repeat perforation) and underwent sigmoid resection. 8 patients underwent planned resection without experiencing further symptoms. 10 patients were observed without symptoms with mean follow up of 20 months.Conclusions: Laparoscopic washout is superior in cases of perforated Diverticulitis with purulent peritonitis(Hinchey III). It is recommended in Hinchey I and II cases, when percutaneous drainage is unhelpful. Hartmann's colonic resection should be reserved for genuine cases of faecal peritonitis (Hinchey IV).

Comparison of pentastarch and Hartmann’s solution for volume preloading in spinal anaesthesia for elective caesarean section

We studied 160 patients undergoing elective Caesarean section under spinal anaesthesia who received a preloading volume of 15 ml kg-1 of 10% pentastarch in 0.9% saline, or Hartmann's solution, in a prospective, randomized, double-blind study. We compared the incidence of spinal-induced hypotension in each group. Hypotension was defined as a decrease in systolic arterial pressure to less than 70% of baseline values or < or = 90 mm Hg, whichever was the greater. The groups were comparable in physical characteristics and there was no serious morbidity. Fetal outcome was similar in both groups. Significantly more patients in the Hartmann's group (n = 38, 47.5%) developed hypotension than in the pentastarch group (n = 10, 12.5%) (P < 0.0001). Linear regression analysis showed that the only significant variable was type of fluid used. Blood glucose concentrations were not related to the presence of hypotension. We conclude that starches may be suitable for preloading in Caesarean section under spinal anaesthesia and provide an alternative to the aggressive use of vasoconstrictors.

The Effect of Substrate Load and Blood Glucose Management on Cerebral Dysfunction Following Cardiopulmonary Bypass

Seventy patients undergoing elective coronary artery bypass grafting were prospectively randomized into either of two primes: 5% dextrose or Hartmann's solution. The groups were comparable. Neuropsychological assessment was performed before and eight weeks after surgery. During bypass blood glucose concentrations rose to a mean of 26 mmol/L in the 5% dextrose group and 6 mmol/L in the Hartmann's group. No deaths occurred in either group; 2 clinically evident neurological events were noted, both taking place in the hyperglycemic group. Detailed analysis of the results showed differences between the groups. When score changes between tests were assessed it was found that in 17 of the 18 versions of the tests more patients in the hyperglycemic group deteriorated than the normoglycemic controls. With a two-tailed binomial statistic this difference was significant at the 5% level. Learning ability was likewise found to worsen in the hyperglycemic group after surgery.Hyperglycemia may be a detrimental factor in...

The Effect of Substrate Load and Blood Glucose Management on Cerebral Dysfunction Following Cardiopulmonary Bypass

Seventy patients undergoing elective coronary artery bypass grafting were prospectively randomized into either of two primes: 5% dextrose or Hartmann's solution. The groups were comparable. Neuropsychological assessment was performed before and eight weeks after surgery. During bypass blood glucose concentrations rose to a mean of 26 mmol/L in the 5% dextrose group and 6 mmol/L in the Hartmann's group. No deaths occurred in either group; 2 clinically evident neurological events were noted, both taking place in the hyperglycemic group. Detailed analysis of the results showed differences between the groups. When score changes between tests were assessed it was found that in 17 of the 18 versions of the tests more patients in the hyperglycemic group deteriorated than the normoglycemic controls. With a two-tailed binomial statistic this difference was significant at the 5% level. Learning ability was likewise found to worsen in the hyperglycemic group after surgery. Hyperglycemia may be a detrimental factor in the development of postcardiac surgical intellectual dysfunction. The authors would advocate the avoidance of glucose-containing bypass primes and the close monitoring of blood glucose during cardiopulmonary bypass.

Primary resection and anastomosis for treatment of acute diverticulitis.

The patterns of presentation and associated treatments of 65 patients with acute perforated diverticulitis of the left colon have been reviewed. Four types of operations were identified: primary resection with anastomosis (group I, N = 29), primary resection with anastomosis and protective colostomy (group II, N = 5), primary resection with Hartmann procedure (group III, N = 26), and delayed resection three-staged procedure (group IV, N = 5). The severity of disease was also classified (stages I to IV). Postoperative mortality rates in the first two groups were lower than that of the Hartmann group (3.4 vs. 15.3 percent). The mean length of initial hospitalization was 16 +/- 1.2 days for group I, 18.2 +/- 4.4 days for group II, 19.4 +/- 2 days for group III, 26.4 +/- 4.4 days for group IV (P less than .05, t-test group IV vs. groups I, II, and III). Complications in the Hartmann group were high with a 23 percent wound infection rate and mortality after closure of colostomy and bowel reconstruction was 3.8 percent. These data demonstrate that primary resection with anastomosis is a satisfactory operation for the majority of patients with perforated diverticulitis (stages I to III), and there appears to be no clinical indication to use the three-staged operation.

Emergency surgery for complicated diverticular disease. A five-year experience.

Ninety-three patients who underwent surgery were studied retrospectively over a five-year period for complications of diverticular disease, including free perforation in 32 patients (with fecal peritonitis in 8), inflammation or peritonitis in 22 patients, an abscess in 11 patients, and intestinal obstruction in 14 patients. Sixty-eight patients (73 percent) had systemic symptoms and signs consistent with serious sepsis. There has been a growing popularity of the Hartmann procedure throughout the study period. The overall 30-day mortality rate was 10.8 percent. Because of a high proportion of poor-risk patients, the Hartmann group fared particularly badly compared with those who had other operations, with a 28 percent mortality rate, 69 percent incidence of major complications, and one third of the survivors having a permanent colostomy. Other operative procedures are discussed, but until prospective data become available, it is unlikely that the widespread popularity of the Hartmann procedure will decline. Therefore, the importance of meticulous attention to technical detail is stressed if results are to improve.

Acute perforations of the sigmoid colon secondary to diverticulitis

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.