Presence Of Diverticular Disease Research Articles

Strategies, Technologies, and Tips for Successful Cecal Intubation.

Successful cecal intubation is crucial in ensuring a complete evaluation of the colonic mucosa. Although completion of colonoscopies should be successful in close to 100% of all examinations in the hands of experienced gastroenterologists, there are some patients with colons which can be difficult to navigate. Factors such as older age, presence of diverticular disease, as well as high or low body mass index can present challenges for endoscopists. Challenges can be divided into those that are left sided and are associated with severe angulations of the colon versus those that are right sided and present as redundant colons. Both require different strategies to achieve completion. This review will cover methods, technologies as well the evolution of colonoscope insertion tubes which can help in navigating colons, especially those that are challenging. There will also be a discussion about basic principles and techniques that should be employed in all colonoscopies.

Colonoscopic findings in patients with pelvic floor dysfunction.

Colonoscopy is often performed in the initial workup of pelvic floor dysfunction, even in the absence of red flag symptoms. Current guidelines suggest colonoscopy is only required in the presence of rectal bleeding, diarrhoea or change in bowel habit. The aim of this study was to evaluate the prevalence of significant pathology found at colonoscopy in patients with pelvic floor dysfunction. Retrospective chart review was performed on all patients presenting to a functional colorectal outpatient clinic between May 2018 and August 2019. Information was collected on presenting symptoms, whether colonoscopy had been performed within 5 years, quality of bowel preparation, withdrawal time, number of polyps detected, histology, presence of diverticular disease, colorectal malignancy, inflammatory bowel disease, solitary rectal ulcer or rectal prolapse. There were 260 patients seen within the study period, of which 67% had undergone recent colonoscopy within the last 5 years. The mean age was 53 and 219 (84%) patients were female. Average withdrawal time was 13 min. Polyps were found in 48.7% and adenomas in 32.4% of all colonoscopies. The adenoma detection rate was 32.7%. None of the colonoscopies found evidence of malignancy. A new diagnosis of inflammatory bowel disease was discovered in two patients. There was low rates of serious pathology such as malignancy or inflammatory bowel disease in patients referred to a functional clinic. However, colonoscopy is still useful in workup of pelvic floor dysfunction, as many patients have erratic bowel habits or vague symptoms, and will have adenomas found.

Association between diverticular disease and prevalence of colorectal adenomatous polyps or adenocarcinomas

Background/Aim: Although the link between diverticular disease (DD) of the colon and colon polyp is known, the relationship between colon adenocarcinoma is not clear. This study evaluated the association between DD and adenomatous polyp or colon adenocarcinoma. Methods: Patients who underwent colonoscopy for the first time in 2020-2021 were evaluated and included in this retrospective cohort study. Patients with a previous history of cancer diagnosis, colon surgery, DD, and inflammatory bowel disease were excluded from the study. Age, gender, colonoscopy indications, colonoscopy diagnoses, presence of DD, characteristics of polyps (pathology, diameter, number, localization), and presence of adenocarcinoma were recorded. Obtained data were analyzed between DD and non-DD groups. Results: A total of 2633 patients were included in the study. The prevalence of DD was 16.4%. Colon adenocarcinoma was detected in 4.7%. The adenomatous polyp rate was 14.1%. A significantly higher rate of adenomatous polyps was detected in the DD group compared to the non-DD group (19.7% vs. 12.9%; P = 0.001). Higher rates of high-grade dysplasia (3.0 vs. 1.1%; P = 0.002) and colon adenocarcinoma (7.2% vs. 4.2%; P = 0.008) were observed in the DD group also. In logistic regression analyses, it was observed that the presence of concomitant DD increases the risk of adenomatous polyps (OR: 1.469, 95% CI: 1.158–1.865), the risk of adenomatous polyps with positive villous component (OR: 2.378, 95% CI: 1.437–3.934), the risk of adenomatous polyps with high-grade dysplasia (OR: 2.822, 95% CI: 1.426–5.582), and the risk of colon adenocarcinoma (OR: 2.953, 95% CI: 1.445–6.533). Conclusion: DD is associated with precancerous lesions of the colon (adenomatous polyp, villous adenoma, high-grade dysplasia) and colon adenocarcinoma. Further studies are needed to investigate its association with colon carcinogenesis and its role and value in cancer screening.

SP1.1.6Incidence of post colonoscopy colorectal cancer, are we compliant with national guidelines?

Abstract Aims To investigate the incidence of post colonoscopy colorectal cancer (PCCRC) at a district NHS trust and assess compliance with UK key performance indicators and quality assurance standards for colonoscopy guidelines endorsed by JAG and the ACPGBI Methods We conducted a retrospective review of our trust colorectal MDT database to identify patients diagnosed with colorectal cancer in the period between January 2016 till June 2019 who underwent a colonoscopy within 6-36 month prior to their diagnosis with colorectal cancer. Patient demographics, indication of colonoscopy, date of cancer diagnosis, procedure related factors such as quality of bowel preparation, presence of diverticular disease, prior history of inflammatory bowel disease, previously diagnosed polyps and also grade of endoscopist were extrapolated. Results 1323 patients were diagnosed with colorectal cancer during the study period, out of these there were 111 patients who underwent a colonoscopy within 6-36 month prior to their diagnostic colonoscopy. After exclusion of cases with anastomotic recurrence (n = 2) and cases with no PCCRC (n = 82), there were 27 patients with confirmed PCCRC in accordance with WEO classification (PCCRC 2.8%, acceptable target 5%) Upon review of the 27 cases with PCCRC, there was equal gender distribution while the majority were 71-80 years old. There was evidence of diverticular disease in 44% and previous colonic polyps in 48%. The quality of bowel preparation was recorded as good in 25 cases while grade of endoscopist was consultant (n = 24), associate specialist (n = 1), nurse endoscopist (n = 2) Conclusions The incidence of PCCRC in our trust falls within national guidelines.

A Quantitatively Large and Highly Statistically Significant Correlation Between Hypertension and Colonic Diverticulosis: Proposed Pathophysiology and Clinical Significance

Introduction: Colonic diverticuli are clinically important because they can cause diverticulitis or diverticular bleeding. Their etiology is incompletely understood. Diverticuli occur at points of weakness in the bowel wall where vasa recta penetrate the colonic circular muscle layer. It is hypothesized that diverticuli form from increased intraluminal pressure generated by exaggerated segmental contractions possibly from abnormal neural patterns or abnormal motility. Structural colonic wall abnormalities of collagen or elastin may also contribute to the pathogenesis. Methods: Retrospective review of 285 medical records from consecutive patients undergoing surveillance colonoscopy from January-May, 2013 and August-December, 2014 at an academic university teaching hospital. Demographic/clinical data included age, gender, BMI, hypertension, diabetes, coronary artery disease, smoking history, alcohol use, polyps, dyslipidemia, hemorrhoids, and colonoscopy indication. Correlations between these factors and presence of diverticular disease were assessed. Results: Mean age of population=65.7 ± 10.0 years. Average BMI=28.81 ± 5.09 kg/m2. Hypertension and age were statistically significant risk factors for diverticuli (Table 1) (p < .0001, p=.02, respectively). Number of polyps was also correlated with diverticuli, p=0.003. Other analyzed parameters were not risk factors for colonic diverticuli.Table 1: Correlation of Clinico-Epidemiologic Parameters with the Presence of Diverticulosis Detected During ColonoscopyConclusion: This study shows a quantitatively strong and highly statistically significant correlation between hypertension and colonic diverticulosis that suggests that hypertension may play an important etiologic role in diverticulosis. We propose that, in patients with hypertension, bounding pulsations leads to weakening of the adventitia surrounding the vasa recta. Thus, due to the chronic wear and tear, permitting herniation of the mucosa immediately adjacent to the vasa recta. Age may be an etiologic factor due to prolongued exposure to hypertension damage creating a greater wear and tear. If this hypothesis is correct, patients with hypertension could benefit from blood pressure control, not only to prevent cardiovascular disease, but also, to prevent colonic diverticulosis. A previous study reported this correlation of hypertension with diverticulosis (Azzam et al., 2013) but did not propose a pathophysiology for this phenomena.

PTH-040 Laparoscopic-assisted colonoscopic polypectomy is a safe and effective option for difficult polyps: a single tertiary referral centre experience

<h3>Introduction</h3> Colonic polyps deemed difficult to access or resect at endoscopy are often referred for surgical resection. We report our experience using laparoscopic assisted colonoscopic polyp resection at a single tertiary referral centre. <h3>Method</h3> Combined procedures from 2012 to 2014 for patients referred for resection of colonic polypsons deemed not amenable for safe endoscopic resection or where access was difficult, and therefore planned for laparoscopic assistance, were analysed. Clinical data regarding primary lesion, reason for referral for laparoscopic assistance, and outcomes were recorded. <h3>Results</h3> 15 patients have so far been planned for laparo-endoscopic procedures following multidisciplinary meetings, of whom 1 patient proceeded with surgery alone. 14 patients, with median age 73.0 years (range 35.7–85.1 years) were studied. The main reasons for laparoscopic assistance were: large high risk polyps, unfavourable location and the presence of diverticular disease. The median size of the polyps was 5 cm (range 2.3–15 cm). All procedures were performed under general anaesthetic. Completion of colonoscopic resection was performed with surgical presence without laparoscopic assistance in one. Laparoscopic adhesiolysis was performed in 5 patients to facilitate access. Seven patients required surgical resection (laparoscopic right hemicolectomy in 6 and sigmoid resection in 1). A cancer was confirmed histologically in 3 of these patients, with the other four being adenomas with high-grade dysplasia (HGD, 1) or low grade dysplasia (LGD, 3). In the remaining 7 patients, complete polypectomy was achieved, with histopathology showing adenomas with HGD (2), LGD (1), and lipomas in 3 patients with submucosal lesions, and non-diagnostic material in one patient. Median post-operative length of stay was 2 days (range 1 to 5 days) following colonoscopic resection, and uncomplicated except for post-polypectomy syndrome in one patient. Three of these patients have been followed-up to 6 months, with no recurrence of the lesion seen. Amongst patients requiring surgical resection, length of stay was longer (median 6 days [range 3–21 days], p = 0.002, Mann Whitney), with one patient suffering from anastomotic leak and another from an intra-abdominal fluid collection managed conservatively. <h3>Conclusion</h3> Attempted laparoscopic-assisted colonoscopic polypectomy is an effective strategy in a selected patients, enabling safe and complete polypectomy for lesions that are difficult to resect at primary colonoscopy. This approach may help to reduce surgical morbidity and reduce length of hospital stay. <h3>Disclosure of interest</h3> None Declared.

PTH-305 A review of recurrent referrals to the lower gastro-intestinal (lgi) fast track service – is one referral enough?

Introduction Average monthly referrals to our institution fast track LGI clinics have almost doubled between 2010 and 2014. Patients are being repeatedly referred, increasing the workload and cost of this service. We examined the outcomes of those re-referrals. Method A retrospective review of a prospectively maintained database and notes review was performed. Results Over the three-year study period, 3696 were referred to the fast track clinic. Eighty (2.2%) were referred twice or more. 19/80 (24%) were re-referred having missed their first appointment. 29/80 (36%) had repeated investigations that were normal with 24/80 (30%) confirming the presence of diverticular disease. Seven patients had colorectal cancer (CRC) diagnosed following the second referral and one after the third. Five of these newly diagnosed individuals had failed to attend or declined investigation initially. Conclusion Discussion Re-referral of patients to fast track LGI clinics has significant cost implications. The implication of patients attending such a clinic needs to be emphasised in the primary care setting to minimise non-attendance. 66% of those re-referred had diverticular disease or normal bowel diagnosed on repeat investigation, suggesting that second referral or repeat investigation was unnecessary. Further education/guidelines for both patient and health care professional would help minimise this repetition. CRC detection miss rates are a known phenomenon and need to be audited and highlighted to the LGI MDT to improve service provision and excellence. Disclosure of interest None Declared.

Variation in caecal intubation rates between screening and symptomatic patients.

The caecal intubation rate (CIR) is an important quality standard for endoscopists, as well as for national bowel cancer screening programmes; however, individuals undergoing colonoscopy for bowel screening and symptomatic patients represent different groups, and their characteristics may affect colonoscopy performance. To compare colonoscopists' performance, as assessed by the CIR, in symptomatic patients compared to individuals undergoing colonoscopy for bowel cancer screening. Retrospective audit of CIRs for all patients undergoing colonoscopy at our institution during the year 2008. We retrieved the data from an endoscopy reporting software database and from the local bowel cancer screening programme database. Demographic data was extracted, as well as details of known factors that may affect completion of colonoscopy, such as poor bowel preparation, presence of diverticular disease, polyps, tumour and strictures. The unadjusted CIRs for colonoscopists participating in the screening programme were compared between the bowel screening and the symptomatic patient groups. Five screening colonoscopists performed 1056 colonoscopies, of which 488 were bowel screening procedures. The overall CIR was significantly lower in the symptomatic, compared to the screening, individuals (88.5% versus 93%, P < 0.02). No significant differences were observed between the two groups for risk factors that could impair the CIR. The CIR was <90% for two of the five colonoscopists in symptomatic patients, and just under 90% for one colonoscopist in screening individuals. Multivariate analysis revealed that non-screening colonoscopy was an independent predictor for an incomplete procedure (OR 1.8; 95% CI 1.2-2.8). The CIR, a key quality performance indicator for colonoscopy, is lower in symptomatic patients compared to individuals undergoing colorectal cancer screening. These results suggested that CIR should be monitored independently in screening and non-screening colonoscopies.

Role of cyclooxygenase isoforms in the altered excitatory motor pathways of human colon with diverticular disease

The COX isoforms (COX-1, COX-2) regulate human gut motility, although their role under pathological conditions remains unclear. This study examines the effects of COX inhibitors on excitatory motility in colonic tissue from patients with diverticular disease (DD). Longitudinal muscle preparations, from patients with DD or uncomplicated cancer (controls), were set up in organ baths and connected to isotonic transducers. Indomethacin (COX-1/COX-2 inhibitor), SC-560 (COX-1 inhibitor) or DFU (COX-2 inhibitor) were assayed on electrically evoked, neurogenic, cholinergic and tachykininergic contractions, or carbachol- and substance P (SP)-induced myogenic contractions. Distribution and expression of COX isoforms in the neuromuscular compartment were assessed by RT-PCR, Western blot and immunohistochemical analysis. In control preparations, neurogenic cholinergic contractions were enhanced by COX inhibitors, whereas tachykininergic responses were blunted. Carbachol-evoked contractions were increased by indomethacin or SC-560, but not DFU, whereas all inhibitors reduced SP-induced motor responses. In preparations from DD patients, COX inhibitors did not affect electrically evoked cholinergic contractions. Both indomethacin and DFU, but not SC-560, decreased tachykininergic responses. COX inhibitors did not modify carbachol-evoked motor responses, whereas they counteracted SP-induced contractions. COX-1 expression was decreased in myenteric neurons, whereas COX-2 was enhanced in glial cells and smooth muscle. In control colon, COX-1 and COX-2 down-regulate cholinergic motility, whereas both isoforms enhance tachykininergic motor activity. In the presence of DD, there is a loss of modulation by both COX isoforms on the cholinergic system, whereas COX-2 displays an enhanced facilitatory control on tachykininergic contractile activity.

De novo rectovaginal fistulation and multisite ulceration as a consequence of nicorandil therapy

Dear Editor: Nicorandil has been implicated with multisite ulceration, gastrointestinal perforation and fistulation in the presence of diverticular disease. We describe a case rectovaginal fistulation and vulval ulceration in a patient who was taking nicorandil who did not have diverticular disease. A 77-year-old Caucasian lady was referred to the colorectal outpatient clinic with perineal pain, rectal bleeding and vaginal discharge. She had six per vaginal deliveries without obstetric complications and described no additional gastrointestinal or gynaecological symptoms. Her past medical history included ischaemic heart disease for which she was on nicorandil (30 mg twice daily) for the last 8 years. Examination revealed bilateral punched out vulval ulcers and possible rectovaginal fistulation; further examination was not possible due to patient discomfort. Examination under anaesthesia confirmed a rectovaginal fistula. There was a small 0.5-cm-diameter rectal opening above the sphincter complex not associated with the dentate line and a 1-cm-diameter opening in the vagina above the introitus. Bilateral punched out vulval ulcers were also evident. There was no evidence of neoplasia. Flexible sigmoidoscopy revealed multiple 1-cm discrete sigmoid ulcers with intervening healthy mucosa and no evidence of diverticulosis. Histology from these ulcers showed non-specific acute inflammation with occasional regenerative epithelial cells with no features suggestive of inflammatory bowel disease, diverticular disease, neoplasia or cryptogranulomatous disease. In view of the reported association between nicorandil and GI ulceration, this was considered a possible causative agent; hence, cardiology colleagues were involved, and nicorandil was stopped. Six months following cessation of nicorandil, the patient’s symptoms were fully resolved, and on repeat EUA, the vulval ulcerations and the rectovaginal fistula had healed. The association between use of nicorandil and ulceration is well documented [1], and it has been implicated in ulceration at various locations with oral, anal and intestinal ulceration recognised as potential side effects in the British National Formulary [2]. McDaid et al.’s case–control study of 153 patients with diverticular disease showed that 16 % of patients who developed fistulae were on nicorandil compared with 2 % in those who did not develop fistulae [3]. Trechot et al. looked at eight reported cases of nicorandil-induced fistulae into adjacent organs; all showed spontaneous healing between 1 and 10 months following the cessation of nicorandil except in one case which where that information up was not available [4]. The diagnosis of nicorandil-induced ulceration or fistulation is dependent upon a combination of the B. Chaudhery :A. Lyons North Bristol NHS Trust, Bristol, UK

Do trainee surgeons really take that much longer when operating in day-case surgery?

s / International Journal of Surgery 10 (2012) S53–S109 S76 ABSTRACTS 0610: DO TRAINEE SURGEONS REALLY TAKE THAT MUCH LONGER WHEN OPERATING IN DAY-CASE SURGERY? Ahmed M. El-Sharkawy, Elena Theophilidou, John W. Quarmby. Royal Derby Hospital, Derby, UK Aim: Theatre time pressures may prevent trainees from taking the lead when operating and this can impact on their training. We aim to assess the operating time taken by trainee surgeons in the Day-Case Surgical Unit (DSU). Method: Operative Room Management Information System records for DSU were reviewed between December 2007-2008 and 2010-2011 at the Royal Derby Hospital. Data was collected on operating times for general surgical cases and compared between consultants, associate specialists (AS) and trainees. Results: The total number of open hernia procedures performed was 772 by consultants, 398 by AS and 97 by trainees. The mean time for all open hernia surgery in minutes was 38.8 for consultants, 34.2 for AS and 41.2 for trainees. Sub-group analysis demonstrated similar trends. Furthermore, operative time in minutes for excision of benign lesions was 18.5 for consultants, 13.5 for AS and 21.5 for trainees. Similar results were demonstrated when comparing other day-case procedures including laparoscopic cholecystectomy. Conclusions: The results show that there are little differences in operating times, particularly when trainees perform appropriately selected cases. DSU provides the perfect setting for trainees to perform appropriately selected procedures on relatively uncomplicated patients in order to develop and practice their operative skills. 0616: THE IMPORTANCE OF CONSULTANT-LED SUPERVISION AND TRAINING IN EMERGENCY COLOSTOMY FORMATION Pritesh Morar, Riaz Agha, John Meyrick-Thomas. West Hertfordshire NHS Trust, Vicarage Road, Watford, Hertfordshire, UK Aim: We performed an audit systematically analysing the early incidence of problematic stomas at our district general hospital. The aim of the audit was to quantify our incidence of problematic stomas, attribute causative factors, highlight awareness and implement change. Method: The standard* showed 66% of stomas were healthy and 34% were problematic nationwide. A problematic stoma was defined by complications within 3 weeks of surgery, requiring one or more accessories. Retrospective evaluation of 41 patients’ notes over a six month period yielded the following data: the type of operation; elective or emergency; consultant or trainee performed; and stoma-related outcome. Results: Of the 16 end colostomies produced: 25% were healthy and 75% were problematic. Retraction compromised 75% of problematic end colostomies; problematic stomas were noted in trainee (79%) verses consultant (30%) constructions, emergency (65%) verses elective (29%) constructions, with Hartmann's procedures (50%) in the presence of diverticular disease (80%). Conclusion: In conclusion, a higher incidence of end colostomy retraction following Hartmann's procedures performed by unsupervised trainees in the emergency setting exists. Consultant supervision in such settings is vital, providing additional experience in tension-free stoma formations. *Standard from National Audit of Stoma Complications within 3 weeks of Surgery, (Cottam and Richards 2006) 0619: ARE MEDICAL TRAINEES FOLLOWING BEST PRACTICE GUIDELINES WHEN PERFORMING ARTERIAL BLOOD GAS SAMPLING ON ACUTE SURGICAL PATIENTS? MATHURI SAKTHITHASAN, MICHAEL MAGRO , AKLAK CHOUDHURY, ROBERT FOWLERQUEEN'S HOSPITAL. BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST, ROMFORD, UNITED KINGDOM Mathuri Sakthithasan, Michael Magro, Aklak Choudhury. Queens Hospital,

Does colonoscopists' performance vary between bowel screening and patients with symptoms – a comparison of colonoscopy completion rates

IntroductionColonoscopy completion rates (CCR) are an important quality assurance parameter for individual endoscopists and for the national Bowel Screening Programme (BSP). The standard is set at an unadjusted completion rate...

Technical quality of CT colonography in relation with diverticular disease

The aim of the study is to explore how the technical quality of the examination was affected by diverticular disease. We retrospectively evaluated a consecutive series of 78 subjects who underwent CTC for screening (n=58) or staging (n=20) colorectal cancer, 38 of them (49%) after an incomplete optical colonoscopy. Patients were administered a mild laxative and a iodinated contrast material for fecal tagging. We scored both the bowel preparation and the overall colon distension as poor, good, or optimal and measured the mean sigmoid colon diameter. We counted the number of diverticula and classified patients as having or not a severe diverticular disease (SDD). The number of the prompts of computer aided diagnosis (CAD) per patient was also considered. Mann-Whitney U and χ(2) tests were performed. No CTC complications occurred. The bowel cleansing was poor in 8 (10%) patients, good in 29 (37%) and optimal in 41 (53%); colon distension was poor in 7 (9%) patients, good in 38 (49%), and optimal in 33 (42%). Fifty-four (69%) showed diverticula and 30 (38%) had an SDD. Bowel cleansing and distension were not significantly impaired by neither diverticula (p>0.590) nor the SDD (p>0.110). Mean sigmoid colon diameter was reduced in presence of diverticula (28 mm versus 23 mm, p=0.009) or SDD (26 mm versus 22 mm, p=0.016). The mean number of CAD prompts per patient was not significantly increased by the presence of SDD (p=0.829). Bowel cleansing and distension at CTC were not influenced by the presence of diverticular disease.

M1199 Atorvastatin Induces Apoptosis In Vitro and Slows Growth of Tumor Xenografts but Does Not Reduce Polyp Initiation

endoscopy. CRLs were categorized into adenomatous and serrated lesions. Results A total of 2,310 patients (mean age 58.4 yrs, range 18-93 yrs and 46.1% males) were included. Seventy-nine % of patients were referred due to symptoms, while 20.7% for screening or surveillance indications. In the total population, 37% (n=855) had diverticular disease, of which 77% (n=658) left-sided, 2% (n=16) right-sided and 21% (n=181) generalized. Endoscopic signs of diverticulitis were found in 9.0% (n=77) of the patients with diverticular disease. Of all patients, 27% (n=619) had at least one adenoma and 13% (n=307) at least one serrated lesion. In patients with diverticular disease vs. those without, adenomas were found in 26.8% vs. 17.5% (p<0.001), serrated lesions in 9.5% vs. 6.2% (p=0.004) and both lesions combined in 7.0% vs. 5.2% (p=0.08) of patients, respectively. Multiple logistic regression analysis with interactions, showed that the relationship between diverticular disease and CRLs was affected by age (p<0.001). Presence of diverticular disease was associated with increased risk for CRLs in patients aged <70 yrs (OR 2.2, 95% CI 1.7-3.0, p<0.001), while this was not found in patients aged ≥70 yrs. Noteworthy, the association between diverticular disease and risk for CRLs gradually increased with younger age, as follows: OR 3.0 (95% CI 2.1-4.3, p<0.001) for age <60 yrs, OR 4.5 (95% CI 2.8-7.0, p<0.001) for age <50 yrs and OR 6.6 (95% CI 3.8-11.6, p<0.001) for age <40 yrs. Conclusion We found an age-dependent association between diverticular disease and colorectal lesions. In younger patients diverticular disease is an independent risk factor for simultaneous presence of colorectal lesions, while this is not the case in patients aged 70 yrs or more.

Results of colectomy for diverticular disease of the colon.

A retrospective study of 71 patients who had a colonic resection for diverticular disease at one hospital during a 7-year period was undertaken. Patients were divided into those undergoing surgery for complications of diverticular disease (49) and those in whom abdominal pain and an altered bowel habit were attributed to the presence of diverticular disease in the absence of any detectable complication (22). In both groups major complications occurred after operation. The incidence of complications was greater when surgery was undertaken in stages to effect colonic resection and restoration of intestinal continuity. Symptoms were more often cured or relieved in those patients undergoing surgery for complicated diverticular disease than in those with 'uncomplicated' disease. These poor results may be due to incorrectly attributing symptoms to diverticula which happened to be present.

Analysis of Possible Facilitating Factors of Perforation Due To Colonoscopy

Aims: Colorectal perforation is an infrecuent complication of colonoscopy. Studies concerning possible factors which may facilitate endoscopic colon perforation are scant. The aim of this study is to review our iatrogenic perforations in order to determine risk factors, paying special attention to sedation. Material and Methods: We have analized perforations non directly caused by therapeutical manoeuvres in a series of 18781 consecutive colonoscopies, 6781 under concious sedation (Diazepam) and 12000 under deep sedation (Propofol IV). We compared colonoscopies with iatrogenic perforation with a control group, alleatorily selected, of 281 colonoscopies without complications. We considered as possible risk factors the following parameters: age and sex, inpatient/outpapient, colonoscopy indication, patient tolerance, bowel preparation, presence of diverticular disease, previous abdominal surgery, endoscopist expertise (staff or resident) and type of sedation. Univariate analysis was performed by means of Student, Fisher and Chi square tests. A logistic regression multivariate analysis was performed. We determined Odds ratio (95% C.I.) to calculate the increased perforation risk for the different variables. Results: 23 cases of perforation were registered (0.122%). Univariate analysis showed a higher perforation risk for age (perforated: 76.4 ± 8.5 years; controls: 57.4 ± 16.9, p < 0.01), inpatients: perforated 18/109; outpatients 5/191, p < 0.001, OR = 7.36 CI(2.5-20.45); diverticular disease: perforated 13/77; without diverticles: 10/224, p < 0.001, OR 0 4.35 CI(1.82-10.38); and previous abdominal surgery: perforated 15/36; without surgery: perforated 8/41, p < 0.05, OR = 2.95 CI(1.06-8.15). Multivariate analysis showed an independent prognostic value for age > 70 years (OR = 6.55, CI(1.76-24.32), p = 0.005; inpatients: OR = 4.69, CI(1.56-14.08) p = 0.006 and diverticular disease: OR = 2.64, CI(1.01-6.86), p = 0.047. Conclusions: 1. Perforation rate after colonoscopy performance was 0.122% in our series. 2. Age older than 70 years, inpatients and the presence of diverticular disease are risk factors with independent predictive value for perforation. 3. Deep sedation does not significantly increase perforation risk. Aims: Colorectal perforation is an infrecuent complication of colonoscopy. Studies concerning possible factors which may facilitate endoscopic colon perforation are scant. The aim of this study is to review our iatrogenic perforations in order to determine risk factors, paying special attention to sedation. Material and Methods: We have analized perforations non directly caused by therapeutical manoeuvres in a series of 18781 consecutive colonoscopies, 6781 under concious sedation (Diazepam) and 12000 under deep sedation (Propofol IV). We compared colonoscopies with iatrogenic perforation with a control group, alleatorily selected, of 281 colonoscopies without complications. We considered as possible risk factors the following parameters: age and sex, inpatient/outpapient, colonoscopy indication, patient tolerance, bowel preparation, presence of diverticular disease, previous abdominal surgery, endoscopist expertise (staff or resident) and type of sedation. Univariate analysis was performed by means of Student, Fisher and Chi square tests. A logistic regression multivariate analysis was performed. We determined Odds ratio (95% C.I.) to calculate the increased perforation risk for the different variables. Results: 23 cases of perforation were registered (0.122%). Univariate analysis showed a higher perforation risk for age (perforated: 76.4 ± 8.5 years; controls: 57.4 ± 16.9, p < 0.01), inpatients: perforated 18/109; outpatients 5/191, p < 0.001, OR = 7.36 CI(2.5-20.45); diverticular disease: perforated 13/77; without diverticles: 10/224, p < 0.001, OR 0 4.35 CI(1.82-10.38); and previous abdominal surgery: perforated 15/36; without surgery: perforated 8/41, p < 0.05, OR = 2.95 CI(1.06-8.15). Multivariate analysis showed an independent prognostic value for age > 70 years (OR = 6.55, CI(1.76-24.32), p = 0.005; inpatients: OR = 4.69, CI(1.56-14.08) p = 0.006 and diverticular disease: OR = 2.64, CI(1.01-6.86), p = 0.047. Conclusions: 1. Perforation rate after colonoscopy performance was 0.122% in our series. 2. Age older than 70 years, inpatients and the presence of diverticular disease are risk factors with independent predictive value for perforation. 3. Deep sedation does not significantly increase perforation risk.

The effect of diverticular disease on the colonic J pouch

The aim of this study was to assess the impact of the diverticular disease (DD) on function and on postoperative complications of the colonic J-pouch (CJP) with pouch-anal anastomosis. Patients who underwent a CJP between December 1990 and August 2001, were retrospectively reviewed. The presence of DD in the CJP was assessed on pouchogram prior to ileostomy closure. A questionnaire designed to evaluate the degree of continence (total incontinence score (IS): 0 = worst, 20 = best) and pouch evacuation (total evacuation score (ES): 0 = worst, 28 = best) was used for comparison between patients with DD and those without DD (NDD). Sixty-six patients (47 males; 19 females) with a median age of 68 years (range 28-87 years) were included. The median follow-up period was 22 months (range 2-106 months). Twenty-four patients comprised the DD group and 42 were in the NDD group. The two groups were comparable for age, gender and time from ileostomy closure; all patients with postoperative chemoradiation therapy were in the NDD group. The total ES and IS total did not significantly differ between the two groups with a P-value of 0.11 and 0.09 respectively. Furthermore, there was no significant difference in the total incidence of pouch complications between the two groups (3 strictures, 1 leak, 1 fistula in the NDD group vs. 1 pelvic sepsis in the DD group; P = 0.4). The presence of DD in a CJP does not seem to impact pouch function or the postoperative complication rate.

Factors that predict incomplete colonoscopy: thinner is not always better

OBJECTIVE: The aim of this study was to determine whether anatomic factors such as body mass index (BMI) impacts the success rate of cecal intubation during colonoscopy. METHODS: We retrospectively reviewed the cecal intubation rate of 2000 colonoscopies performed at our institution from March 1997 to March 1999. The analysis sample was composed of charts for all incomplete procedures and a sample (23%) of complete examinations that were randomly selected. Data collected included age, gender, height, weight, bowel habits, abdominal surgery, psychiatric medication use, the presence of diverticular disease, amount of sedation administered, and location and reason for halting the examination. Patients were divided by BMI: thin (BMI ≤22.1), average weight (BMI >22.1–25.0), overweight (BMI = 25.1–29.9), and obese (BMI >30). RESULTS: Colonoscopies in women had a lower adjusted completion rate (94.8%) than in men (98.2%) ( p < 0.005). A low BMI in women was predictive of an incomplete examination ( p < 0.001). Factors that did not predict incomplete examinations in women included age and previous hysterectomy. The small number of male patients with an incomplete examination (n = 16) precluded accurate identification of any factors. CONCLUSIONS: Women with a low BMI (especially <22) were more likely to have an incomplete procedure. This finding may have implications for colorectal cancer screening in female patients.

Factors That Predict Incomplete Colonoscopy: Thinner Is Not Always Better

The aim of this study was to determine whether anatomic factors such as body mass index (BMI) impacts the success rate of cecal intubation during colonoscopy. We retrospectively reviewed the cecal intubation rate of 2000 colonoscopies performed at our institution from March 1997 to March 1999. The analysis sample was composed of charts for all incomplete procedures and a sample (23%) of complete examinations that were randomly selected. Data collected included age, gender, height, weight, bowel habits, abdominal surgery, psychiatric medication use, the presence of diverticular disease, amount of sedation administered, and location and reason for halting the examination. Patients were divided by BMI: thin (BMI < or = 22.1), average weight (BMI > 22.1-25.0), overweight (BMI = 25.1-29.9), and obese (BMI > 30). Colonoscopies in women had a lower adjusted completion rate (94.8%) than in men (98.2%) (p < 0.005). A low BMI in women was predictive of an incomplete examination (p < 0.001). Factors that did not predict incomplete examinations in women included age and previous hysterectomy. The small number of male patients with an incomplete examination (n = 16) precluded accurate identification of any factors. Women with a low BMI (especially < 22) were more likely to have an incomplete procedure. This finding may have implications for colorectal cancer screening in female patients.

Evaluation of Delorme's procedure as a treatment for full-thickness rectal prolapse.

Delorme's procedure is a well tolerated perineal operation for full-thickness rectal prolapse. However, prolapse recurrence is common and reported recurrence rates vary widely. This study attempted to standardize outcome assessment for recurrence following primary and subsequent Delorme's operations. Patient and operative factors were analysed to identify any that might improve patient selection. Some 101 primary and 17 secondary Delorme's procedures were carried out on 113 consecutive patients presenting with rectal prolapse, who were followed for a minimum of 12 months, unless death or recurrent prolapse intervened. The rate of prolapse recurrence was calculated using the Kaplan-Meier method of analysis. Patient age, sex, grade of incontinence, presence of diverticular disease, length of mucosal resection and position in the operative series were analysed to identify factors affecting recurrence. The predicted recurrence-free period for 50 per cent of patients undergoing primary and secondary Delorme's procedures was 91 (95 per cent confidence interval 77-105) and 27 (15-39) months respectively. None of the patient or operative factors analysed was related to recurrent prolapse. Delorme's procedure is a simple operation with satisfactory functional results which can be considered in all patients of all ages. However, high recurrence rates for primary and repeat operations should be explained to patients when planning their surgical management.