Laparoscopic Lavage Research Articles

Less Is (Sometimes) More: Laparoscopic Peritoneal Lavage and Drainage for Diverticulitis.

Introduction: Laparoscopic lavage and drainage (LLD) emerged as an alternative to Hartmann's procedure (HP) for patients with diverticulitis and uncontained perforation. Although initially popular as a less invasive approach, its use in modern practice is in question. This summary will review the available literature to show techniques, outcomes, and indications. Methods: The literature was reviewed for relevant case studies, randomized trials, prospective series, retrospective analyses, and meta-analyses to define peritoneal lavage and determine the clinical outcomes of peritoneal lavage. Results: LLD can be considered on an individual basis for Hinchey III diverticulitis (purulent peritonitis), but there are several contraindications. The extent of adhesionolysis (limited versus extensive) as well as the management of sites of perforation found during surgery are debated. Most surgeons continue lavage with warm saline until water runs clear and place drains in the operation. Three randomized controlled trials (RCTs), the LADIES, SCANDIV, and DILALA trials compared LLD with either resection and anastomosis or Hartmann's procedure. One other RCT (the LapLAND trial) is still with results pending. The LADIES trial studied LLD versus primary anastomosis and resection in Hinchey III diverticulitis and was terminated early secondary to higher 30-day morbidity in the LLD arm; however, 3-year data showed no significant difference in morbidity and mortality. The SCANDIV trial compared LLD with resection in acute diverticulitis (Hinchey I-III) and saw no difference in 90-day morbidity or mortality; however, it noted higher rates of reoperation in the LLD group. The DILALA trial compared Hinchey III diverticulitis patients undergoing LLD with open HP and found that the LLD group had a lower rate of reoperation at 2 years, but no difference in rates of readmission or mortality. Conclusions: Debate still remains over the technique of LLD and specific indications, as well as outcomes compared with resection and primary anastomosis or HP.

Diverticulosis coli

The incidence of colon diverticulosis and diverticulitis is increasing. This review summarises the current classification and treatment options. Antibiotic treatment is not indicated for uncomplicated diverticulitis in non-immunosuppressed patients. We discuss whether laparoscopic lavage is the best treatment for every patient with Hinchey III diverticulitis. For selected patients with Hinchey III diverticulitis, segmental resection with primary anastomosis may be the optimal surgical treatment. The indication for elective resection in diverticulitis should respect individual patient-related factors such as comorbidities and the impact on quality of life.

Case Report: A 31-Year-Old Man with Relapsing Complicated Diverticulitis after Initial Conservative Treatment

BACKGROUND: There is controversy regarding the surgical approach for severe complications of diverticular disease. The classical approach has been a Hartmann’s procedure, but laparoscopic lavage and drainage has been suggested as an alternative. We present a patient who initially responded to conservative management of complicated diverticulitis, but had a recurrence that was managed surgically. CASE PRESENTATION: A 31-year-old man presented with Hinchey Stage I diverticulitis and was discharged from the hospital after medical management. Six days later, he returned to the hospital with radiographic evidence of a pericolonic abscess. The patient was taken to the operating room for laparoscopic drainage with placement of a drain in the abscess cavity. He required reoperation with sigmoid colon resection, primary anastomosis, and diverting ileostomy. DISCUSSION: Despite requiring reoperation, the authors believe that initial conservative management possibly prevented progression to generalized feculent peritonitis. If this had occurred, the patient may have required Hartmann’s procedure, which is associated with more complications than primary anastomosis with protective ileostomy. CONCLUSION: The patient had recurrence of complicated diverticular disease that was initially managed conservatively and then with laparoscopic drainage, followed by primary anastomosis with protective ileostomy. Given individual patient factors, the authors believe that he was managed optimally. There is currently controversy between the use of laparoscopic lavage and drainage versus Hartmann’s procedure for the management of complicated colonic diverticular disease and more investigation is required on the subject.

Surgical and non-operative treatment of acute complicated diverticulitis in a COVID hospital

Surgical treatment of acute abdomen during the SARS-CoV-2 pandemic was accompanied by an extremely high mortality rate, however, only a few studies have presented the results of acute inflammatory complications of diverticular disease (AICDD).AIM: analysis of treatment of AICDD in a COVID-19 hospital.PATIENTS AND METHODS: the retrospective study included 78 patients with acute diverticulitis (AD) from a COVID hospital, confirmed by CT or intraoperative revision. Assessment of COVID pneumonia, comorbidities, organ dysfunction, CT findings, peritonitis, treatment methods, and in-hospital mortality among patients was performed.RESULTS: organ dysfunction of ≥ 1 point on the qSOFA scale was detected in 59.0% of the patients. According to CT data, abdominal distant gas was detected in 48 (61.5%) patients, and pericolic gas in 14 (17.9%) patients. Segmental colon resection was performed in 60 (76.9%) patients, laparoscopic lavage (LL) of the abdominal cavity — in 3, non-operative treatment (NOT) with drainage of fluid collections — in 6, and only NOT in 10 patients. Most patients with distant or pericolic gas were operated on within an average time of 1 [0; 3.5] hours after admission. Diffuse peritonitis was detected during surgery in 45 (75%) of them. After resection, organ dysfunction of ≥ 2 points on the SOFA scale developed or progressed in 52 (86.7%) patients. The overall mortality rate was 48.7%, and the postoperative mortality was 63.3%. All patients (n = 38) died after segmental colon resection. Successful NOT was achieved in 4 patients with pericolic gas and 3 patients with distant gas.CONCLUSION: surgery for AICDD in patients with COVID-19 is associated with extremely high mortality, therefore, in the absence of obvious signs of diffuse peritonitis, initial non-operative treatment may be life-saving.

Long-Term Results After Laparoscopic Lavage for Perforated Diverticulitis Purulent Peritonitis in Sweden: A Population-Based Observational Study.

To compare long-term outcomes after laparoscopic lavage with resection surgery for perforated diverticulitis, Hinchey grade III as practiced in Sweden for 3 years. Laparoscopic lavage has been studied in 3 randomized controlled trials. Long-term results indicate that additional surgery and a remaining stoma are less common after lavage compared with resection, but data from routine care and larger cohorts are needed to get a more complete picture. LapLav is a national cohort study with nearly complete coverage of all patients operated in Sweden between 2016 and 2018. The cohort was retrieved from the national patient register by a definition based on the Classification of Diseases and Related Health Problems-10 code plus the surgical procedural code. All medical records have been reviewed and data retrieved in addition to registry data. Propensity score with inverse probability weighting was used to balance the 2 groups, that is, laparoscopic lavage vs resection surgery. Before the propensity score was applied, the cohort consisted of 499 patients. Additional surgery was more common in the resection group [odds ratio, 0.714; 95% confidence interval (CI) = 0.529-0.962; P = 0.0271]. Mortality did not differ between the groups (hazard ratio, 1.20; 95% CI = 0.69-2.07; P = 0.516). In the lavage group, 27% of patients went on to have resection surgery. In Swedish routine care, laparoscopic lavage was feasible and safe for the surgical treatment of perforated diverticulitis, Hinchey grade III. Our results indicate that laparoscopic lavage can be used as a first-choice treatment.

Evaluation of laparoscopic peritoneal lavage for perforated diverticulitis: a national registry-based study.

Laparoscopic lavage (LPL) has been suggested for treatment of non-feculent perforated diverticulitis. In this observational study, the surgical treatment of diverticular disease in Sweden outside prospective trials was investigated. This population-based study used the National Patient Register to identify all patients in Sweden with emergency admissions for diverticular disease, as defined by ICD codes from July 2014 to December 2020. Demographics, surgical procedures and outcomes were assessed. In addition, register data since 1997 were retrieved to assess co-morbidities, previous abdominal surgeries, and previous admissions for diverticular disease. Among 47 294 patients with emergency hospital admission, 2035 underwent LPL (427 patients) or sigmoid resection (SR, 1608 patients) for diverticular disease. The mean follow-up was 30.8 months. Patients selected for LPL were younger, healthier and with less previous abdominal surgery for diverticular disease than those in the SR group (P < 0.01). LPL was associated with shorter postoperative hospital stay (mean 9.4 versus 14.9 days, P < 0.001) and lower 30-day mortality (3.5% versus 8.7%, P < 0.001). Diverticular disease-associated subsequent surgery was more common in the SR group than the LPL group except during the first year (P < 0.001). LPL had a lower mortality rate during the study period (stratified HR 0.70, 95% c.i. 0.53-0.92, P = 0.023). Laparoscopic lavage constitutes a safe alternative to sigmoid resection for selected patients judged clinically to require surgery.

Contemporary management of diverticulitis

The treatment of diverticulitis is experiencing a shift in management due to a number of large scale clinical trials. For instance, clinicians are beginning to recognize that avoidance of antibiotics in uncomplicated diverticulitis is not associated with worse outcomes. Additionally, while the decision to proceed with elective surgical resection for recurrent uncomplicated disease is less conclusive and favors a patient-centric approach, complicated disease with a large abscess denotes more aggressive disease and would likely benefit from elective surgical resection. Lastly, in patient with acutely perforated diverticulitis who require urgent surgical intervention, laparoscopic lavage is generally not recommended due to high re-intervention rates and the preferred surgical procedure is primary anastomosis with or without diversion due to high morbidity and low rates of Hartmann reversal.

Usefulness of Intraductal Placement of a Dumbbell-Shaped Fully Covered Self-Expandable Metal Stent for Post-Cholecystectomy Bile Leaks.

Background and aims: In the treatment of post-cholecystectomy bile leaks, endoscopic naso-biliary drainage (ENBD) or biliary stenting using plastic stents is the standard of care. Fully covered self-expandable metal stent (FCSEMS) placement across the sphincter of Oddi is considered a salvage therapy for refractory cases, but pancreatitis and migration are the major concerns. Intraductal placement of a dumbbell-shaped FCSEMS (D-SEMS) could avoid these drawbacks of FCMSESs. In this retrospective study, we investigated the usefulness of intraductal placement of the D-SEMS for post-cholecystectomy bile leaks. Methods: Six patients who underwent intraductal placement of the D-SEMS for post-cholecystectomy bile leaks were enrolled. This method was performed as initial treatment in three patients and as salvage treatment in three ENBD refractory cases. Results: Technical and clinical successes were obtained in 6 (100%) patients and 5 (83%) patients, respectively. One clinically unsuccessful patient required laparoscopic peritoneal lavage. The early adverse event was one case of mild pancreatitis (17%). The median duration of the D-SEMS indwelling was 61 days (42-606 days) with no migration cases, all of which were successfully removed. The median follow-up after index ERCP was 761 (range: 161-1392) days with no cases of recurrent bile leaks. Conclusions: Intraductal placement of the D-SEMS for post-cholecystectomy bile leaks might be safe and effective even in refractory cases.

Long-term results of laparoscopic lavage vs. sigmoid resection for perforated diverticulitis : Results of a meta-analysis

Long-term results of laparoscopic lavage vs. sigmoid resection for perforated diverticulitis : Results of a meta-analysis

The Short- and Long-Term Safety and Efficacy Profile of Subtotal Cholecystectomy: A Single-Centre, Long-Term, Follow-Up Study.

Background Subtotal cholecystectomy (STC) has been reported as an effective method to remove the gallbladder if the hepatocystic triangle anatomy is unfavourable. However, the evidence regarding its long-term outcomes from the United Kingdom (UK) is lacking. This study aimed to assess its short and long-term outcomes with a minimum of one-year follow-up. Methodology We retrospectively analysed all elective and emergency STCs performed in a single UK NHS Trust between 2014 and 2020. Relevant data were collected using electronic patient records and questionnaire-based, long-term, telephonic follow-up (median follow-up of 3.7 years). Outcomes examined were immediate/short-term complications (biliary injury, bile leak, return-to-theatre) and long-term problems (recurrent symptoms, choledocholithiasis, cholangitis/pancreatitis). Results There were a total of 50 STC cases (58% females) out of 4,341 cholecystectomies performed (1.15%), with the median age, body mass index, and length of stay being 69.5 years, 29 kg/m2 and eight days, respectively. Twenty-eight (56%) were emergency. No patient endured bile duct injury. Seven (14%) patients had postoperative bile leak which was significantly more common when Hartmann's pouch was left open (33% vs. 8%; p = 0.03). No bile duct injury was reported. Most were managed conservatively (endoscopic retrograde cholangiopancreatography + stent: four; radiological drainage: one; no intervention: one). Only one patient required laparoscopic lavage and drainage. The true incidence of developing choledocholithiasis over the long term was 4/50 (8%) in our study. The median interval between STC and the diagnosis of postoperative choledocholithiasis was 15.9 months. All four patients had undergone type 1 STC (where the remnant of Hartmann's pouch was closed with sutures); however, subsequent cross-sectional imaging (magnetic resonance cholangiopancreatography or computed tomography) showed that the gallbladder remnant was visible in only two of these four patients. Conclusions STC is a safe option in difficult situations and prevents bile duct injury. Although the risk of bile leak can be reduced by closing Hartmann's pouch remnant, this may slightly increase the risk of subsequent stone formation. Infrequent occurrence of recurrent gallstone-related symptoms or complications favours its use.

Outcome after stent and endoscopic vacuum therapy-based treatment for postemetic esophageal rupture

Objectives Extent of surgical repair of spontaneous esophageal effort rupture (Boerhaave syndrome) has gradually decreased by the emergence of minimal invasive treatment based on endoscopic stent sealing of the perforation. However, for this diagnosis, use of endoscopic vacuum therapy (EVT) is still in its beginning. We present our results after 7-years with both stent and/or EVT-based treatment. Materials and methods 17 consecutive patients with Boerhaave syndrome from June 2015 to May 2022 were retrospectively registered in a database. The perforation was sealed by stent and/or EVT, and gastric effluent was drained transthoracically by a chest tube or pigtail catheter. Eight out of 14 patients responded to questions on fatigue and dysphagia (Ogilvie’s score). Results Seventeen patients aged median 67 years (range 34–88), had a primary hospital stay of 38 days (7–68). Ninety-day mortality was 6% (n = 1). Perforations were sealed with stent (n = 10), EVT (n = 3) or stent and EVT (n = 4). One patient (6%) needed laparoscopic lavage and transhiatal drainage. Eight patients (47%) were re-stented due to persistent leakage (n = 4) and stent migration (n = 4). Fifteen patients (88%) had complications, including multi-organ failure (n = 9), pleural empyema (n = 8) and esophageal stricture (n = 3). The perforations healed. After 35.5 months (range 2–62) fourteen patients were alive. Eight that responded had no dysphagia and total fatigue score comparable to an age-matched reference population. Conclusion Mortality rate was low after initial stent and EVT-based treatment of Boerhaave syndrome, combined with adequate transthoracic drainage of gastric effluent. Patients required repeated minimal invasive procedures, but with no apparent negative effect on functional outcome.

Meta-analysis of Randomized Clinical Trials on Long-term Outcomes of Surgical Treatment of Perforated Diverticulitis.

To assess long-term outcomes of patients with perforated diverticulitis treated with resection or laparoscopic lavage (LL). Surgical treatment of perforated diverticulitis has changed in the last few decades. LL and increasing evidence that primary anastomosis (PRA) is feasible in certain patients have broadened surgical options. However, debate about the optimal surgical strategy lingers. PubMed, Scopus, and Web of Science were searched for randomized clinical trials (RCT) on surgical treatment of perforated diverticulitis from inception to October 2022. Long-term reports of RCT comparing surgical interventions for the treatment of perforated diverticulitis were selected. The main outcome measures were long-term ostomy, long-term complications, recurrence, and reintervention rates. After screening 2431 studies, 5 long-term follow-up studies of RCT comprising 499 patients were included. Three studies, excluding patients with fecal peritonitis, compared LL and colonic resection, and 2 compared PRA and Hartmann procedures. LL had lower odds of long-term ostomy [odds ratio (OR) = 0.133, 95% CI: 0.278-0.579; P < 0.001] and reoperation (OR = 0.585, 95% CI: 0.365-0.937; P = 0.02) compared with colonic resection but higher odds of diverticular disease recurrence (OR = 5.8, 95% CI: 2.33-14.42; P < 0.001). Colonic resection with PRA had lower odds of long-term ostomy (OR = 0.02, 95% CI: 0.003-0.195; P < 0.001), long-term complications (OR = 0.195, 95% CI: 0.113-0.335; P < 0.001), reoperation (OR = 0.2, 95% CI: 0.108-0.384; P < 0.001), and incisional hernia (OR = 0.184, 95% CI: 0.102-0.333; P < 0.001). There was no significant difference in odds of mortality among the procedures. Long-term follow-up of patients who underwent emergency surgery for perforated diverticulitis showed that LL had lower odds of long-term ostomy and reoperation, but more risk for disease recurrence when compared with resection in purulent peritonitis. Colonic resection with PRA had better long-term outcomes than the Hartmann procedure for fecal peritonitis.

Laparoscopic lavage for Hinchey III perforated diverticulitis: factors for treatment failure in two randomized clinical trials.

The Scandinavian Diverticulitis (SCANDIV) trial and the LOLA arm of the LADIES trial randomized patients with Hinchey III perforated diverticulitis to laparoscopic peritoneal lavage or sigmoid resection. The aim of this analysis was to identify risk factors for treatment failure in patients with Hinchey III perforated diverticulitis. This was a post hoc analysis of the SCANDIV trial and LOLA arm. Treatment failure was defined as morbidity requiring general anaesthesia (Clavien-Dindo grade IIIb or higher) within 90 days. Age, sex, BMI, ASA fitness grade, smoking status, previous episodes of diverticulitis, previous abdominal surgery, time to surgery, and surgical competence were all tested in univariable and multivariable logistic regression analyses using an interaction variable. The pooled analysis included 222 patients randomized to laparoscopic lavage and primary resection (116 and 106 patients respectively). Univariable analysis found ASA grade to be associated with advanced morbidity in both groups, and the following factors in the laparoscopic lavage group: smoking, corticosteroid use, and BMI. Significant factors for laparoscopic lavage morbidity in multivariable analysis were smoking (OR 7.05, 95 per cent c.i. 2.07 to 23.98; P = 0.002) and corticosteroid use (OR 6.02, 1.54 to 23.51; P = 0.010). Active smoking status and corticosteroid use were risk factors for laparoscopic lavage treatment failure (advanced morbidity) in patients with perforated diverticulitis.

Laparoscopic Surgery for Acute Appendicitis Complicated by Peritonitis

Introduction . Acute appendicitis (AA) is one of the most common acute abdominal surgical diseases. The current incidence, according to various authors, is 22.8 per 10,000 inhabitants. Annually, 50 to 70 thousand people die from AA and its complications around the world. Laparoscopy is generally accepted as the most effective method of differential diagnosis of AA. It is fundamentally significant to move from the diagnostic stage to the therapeutic one, i.e. to perform the elimination of the disease, including cases with other surgery-requiring pathology detected. Aim . To evaluate the role of video-endoscopic surgical methods in the surgical management of acute appendicitis complicated by peritonitis. Materials and methods . The analysis of recent publications and personal clinical experience revealed that diagnostic laparoscopy, unless contraindicated, should be performed as the initial step in suspected acute abdominal pathology. When the surgery is technically performable, laparoscopy also causes curative effect. Results and discussion. The use of laparoscopy in surgical treatment of acute appendicitis complicated by peritonitis has proven advantages for the patient over open surgery. An adequate appendectomy as a reliable method for elimination of the source of peritonitis is the key to successful treatment of patients. Laparoscopic lavage in the early postoperative period against the postoperative peritonitis with developing complications, is considered to be an alternative method to non-surgical treatment or delayed intervention and to have better ultimate results than percutaneous drainage or relaparotomy. Conclusion . The success of video-endoscopic technologies application depends not only on the technical aspects, but also on the correct choice of indications for such an intervention and their appropriate combination with open surgeries.

Functional Outcomes of Emergency Surgery for Perforated Diverticulitis, Hinchey Grade III

BackgroundLaparoscopic lavage as a treatment for perforated diverticulitis, Hinchey III, has been found safe and feasible in randomized trials. A few studies have reported functional outcomes and quality of life as secondary outcomes. This study investigated distress associated with dysfunction of the bowel or stoma, functional outcomes, and quality of life 2–3 years after surgery in a national unselected cohort.MethodsAll patients in Sweden who underwent emergency surgery for perforated diverticulitis with purulent peritonitis (2016–2018) were invited to answer a comprehensive, study-specific questionnaire 2–3 years after the index surgery.ResultsOut of 499 potential patients, 226 returned the questionnaire, and 209 were included in the analysis. There was no statistically significant difference between laparoscopic lavage and resection in distress associated with dysfunction of the bowel or stoma (odds ratio [OR], 1.32 [95% CI, 0.91–1.92]; p = 0.015). Bowel dysfunction measured by the LARS score was significantly higher for the lavage group (OR, 1.65 [95% CI, 1.11–2.45]), while stoma was more frequent after resection surgery (40 vs 6%).ConclusionsPatients experienced long-term distress from bodily dysfunction after emergency surgery for perforated diverticulitis regardless of the technique used. Regular follow-up could benefit these patients.Trial RegistrationThe project was registered at ClinicalTrials.gov on 2017–11-06. Identifier: NCT03332550. Acronym: LapLav.

A Meta-Analysis of Short-Term Outcomes After Laparoscopic Lavage Versus Colonic Resection in the Treatment of Perforated Diverticulitis.

The management of perforated non-faeculent diverticulitis has traditionally involved performing a colonic resection (CR). Laparoscopic lavage (LL) has emerged as a less invasive alternative in recent years. The aim of this meta-analysis was to assess the roleof LL in the surgical treatment of perforated non-faeculent diverticulitis. To that end, we conducted a search on Embase, Medline, and Cochrane databases forcomparative studies in the English language published till June 2021 [PROSPERO (CRD42021269410)]. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2)and the methodological index for non-randomised studies (MINORS). Data were analysed using Cochrane RevMan. Pooled odds ratio (POR) and cumulative weighted ratios (CWR) were calculated. A total of 13 studies involving 1061 patients were found eligible, including seven studies based on three randomised control trials (RCTs). LL was associated with a reduced risk of wound infection, stoma formation, and need for further surgery by 77% [POR: 0.23, 95% confidence interval (CI): 0.07-0.74], 83% (POR: 0.17, 95% CI: 0.05-0.56), and 53% (POR: 0.47, 95% CI: 0.23-0.97) respectively. Duration of surgery and hospitalisation was reduced by 54% and 43% respectively. However, LL was associated with higher rates of unplanned reoperations (POR: 2.05, 95% CI: 1.22-3.42), recurrence (POR: 9.47, 95% CI: 3.24-27.67), and peritonitis (POR: 8.92, 95% CI: 2.71-29.33). No differences in mortality or readmission rates were observed. LL in Hinchey III diverticulitis lowers the incidence of stoma formation and overall reoperations without an increase in mortality but at the cost of higher recurrence rates and peritonitis. A limitation of this study was the inclusion of non-RCTs. An elective resection should be considered after LL. Guidelines for surgical techniques in LL need to be standardised.

Long-term outcomes and risk factors for diverticulitis recurrence after a successful laparoscopic peritoneal lavage in Hinchey III peritonitis.

Recently, treatment of Hinchey III diverticulitis by laparoscopic peritoneal lavage has been questioned. Moreover, long-term outcomes have been scarcely reported. Primary outcome was to determine the recurrence rate of diverticulitis after a successful laparoscopic peritoneal lavage in Hinchey III diverticulitis. Secondary outcomes were identification of associated risk factors for recurrence and elective sigmoidectomy rate. A retrospective cohort study in a tertiary referral center was performed. Patients with Hinchey III diverticulitis who underwent a successful laparoscopic peritoneal lavage between June 2006 and December 2019 were eligible. Diverticulitis recurrence was analyzed according to the Kaplan-Meier and log-rank test, censoring for death, loss of follow-up, or elective sigmoid resection in the absence of recurrence. Risk factors for recurrence were identified using Cox regression analysis. Sixty-nine patients had a successful laparoscopic peritoneal lavage (mean age: 63years; 53.6% women). Four patients had an elective sigmoid resection without recurrences. Recurrence rate was 42% (n = 29) after a median follow-up of 63months. The cumulative global recurrence at 1, 3, and 5years was 30% (95% CI, 20-43%), 37.5% (95% CI, 27-51%), and 48.9% (95% CI, 36-64%), respectively. Smoking (HR, 2.87; 95% CI, 1.22-6.5; p = 0.016) and episodes of diverticulitis prior to laparoscopic peritoneal lavage (HR, 5.2; 95% CI, 2.11-12.81; p < 0.001) were independently associated with an increased risk of recurrence. Diverticulitis recurrence after a successful laparoscopic peritoneal lavage is high, decreasing after the first year of follow-up. Smoking and previous episodes of acute diverticulitis independently increase the risk of new episodes of diverticulitis.

Pseudomembranous colitis in patients with COVID-19 (review)

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications.PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females — 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%.The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy).RESULTS: the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics — 44.6%, glucocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy — 33.08%, laparoscopy — in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confirmation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients — 78.9%, mortality — 15.0%), colon resection (n = 6 (7.9%), mortality — 66.6%), ileo- or colostomy (n = 8 (10.5%), mortality — 37.5%), colectomy (n = 2 (2.6%), mortality — 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment — 8.8%.CONCLUSION: pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelming majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient’s condition and the development of severe intra-abdominal complications and sepsis.

Bandwagons in colorectal surgery.

Surgery, like other fields of medicine, has not been spared by a number of unfortunate phenomena. Although our perception may point at recent times, some trends can actually be traced back to 1979. Cohen and Rothschild stated that even when medical progress is extraordinary, the path has too often been driven by overwhelming acceptance of popular albeit unproven ideas. These are referred to as bandwagons. Some of such ideas were eventually proven as valid, but more often were abandoned and/or replaced by new bandwagons. In the specific case of colorectal surgery, there are at least five currently ongoing bandwagons: 1) laparoscopic lavage of perforated colon; 2) laparoscopic ventral rectopexy; 3) stapled hemorrhoidopexy, also known as procedure for prolapse and hemorrhoids (PPH); 4) watch and wait; 5) transanal total mesorectal excision (taTME). Preventing bandwagons from taking off requires efforts at different levels: 1) innovators must constrain their self-interest of fame and rather recognize the need for establishing evidence to support their ideas; 2) new treatment modalities must be carefully weighed by sufficiently powered clinical trials prior to been implemented on patients; 3) the media should not mislead patients into the "best" treatment without reliable evidence; 4) physicians should keep in mind that the process of innovation in medicine is slow and disregard the temptation to accept at face value perhaps plausible, yet unproven ideas.

Current Aspects on the Management of Perforated Acute Diverticulitis: A Narrative Review.

Unhealthy nutritional habits and the current western lifestyle have led to an increased incidence of acute diverticulitis, which mainly affects older patients. However, the disease course in younger patients might be more severe. It has a continued increase in surgical practice, as it is the most common clinical condition encountered in the emergencies. Diagnosis and management have changed over the past decade. C-reactive protein > 170 mg/L represents the cut-off point between moderate and severe diverticulitis, and a CT scan is mandatory. It demands urgent surgical management and has high morbidity and mortality rate, especially in immunosuppressed patients, reaching up to 25%. According to the contemporary guidelines, there have been certain indications for conservative management and re-evaluation (administration of antibiotics, CT-guided drainage of the abscess, when it is > 4 cm). They include pericolic air bubbles or a small amount of fluid, absence of abscess within a distance of 5 cm from the affected bowel or abscess ≤4 cm. In other cases, Hartmann’s sigmoidectomy is the procedure of choice. An alternative choice, nowadays, is resection and primary anastomosis with or without diverting stoma, especially in younger patients. Laparoscopic lavage only versus primary resection has been performed in severe cases of Hinchey III or IV. Damage control surgery, possible open abdomen, and reoperation are recommended in severe sepsis. Hinchey’s classification may not be absolutely adequate, and several modifications have been proposed. Current classification criteria (CRP, qSOFA score) are more appropriate. The decision-making must be individualized depending on the hemodynamic status (septic shock), age, comorbidity, immune status, intraoperative findings, and MPI (Mannheim peritonitis index).