Treatment for acute uncomplicated diverticulitis without antibiotherapy: systematic review and meta-analysis of randomized clinical trials

Background: Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned. Objective: The aim of this study is to examine the safety and efficacy of treatment regimens without antibiotics compared with that of traditional treatments with antibiotics in selected patients with AUD. Data sources: PubMed, Medline, Embase, Web of Science, and the Cochrane Library Methods: A systematic review was performed according to PRISMA and AMSTAR guidelines by searching through Medline, Embase, Web of Science, and the Cochrane Library for randomized clinical trials (RCTs) published before December 2022. The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. Study selection: RCTs on treating AUD without antibiotics published in English before December 2022 were included. Intervention: Treatments without antibiotics were compared with treatments with antibiotics. Main outcome measures: The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. Results: The search yielded 1163 studies. Four RCTs with 1809 patients were included in the review. Among these patients, 50.1% were treated conservatively without antibiotics. The meta-analysis showed no significant differences between nonantibiotic and antibiotic treatment groups with respect to rates of readmission [odds ratio (OR) = 1.39; 95% CI: 0.93-2.06; P = 0.11; I-2 = 0%], change in strategy (OR = 1.03; 95% CI: 0.52-2,02; P = 0.94; I-2 = 44%), emergency surgery (OR = 0.43; 95% CI: 0.12-1.53; P = 0.19; I-2 = 0%), worsening (OR = 0.91; 95% CI: 0.48-1.73; P = 0.78; I-2 = 0%), and persistent diverticulitis (OR = 1.54; 95% CI: 0.63-3.26; P = 0.26; I-2 = 0%). Limitations: Heterogeneity and a limited number of RCTs. Conclusions: Treatment for AUD without antibiotic therapy is safe and effective in selected patients. Further RTCs should confirm the present findings

Diagnostic Accuracy of Abdominal CT for Locally Advanced Colon Tumors: Can We Really Entrust Certain Decisions to the Reliability of CT?

Many different options of neoadjuvant treatments for advanced colon cancer are emerging. An accurate preoperative staging is crucial to select the most appropriate treatment option. A retrospective study was carried out on a national series of operated patients with T4 tumors. Considering the anatomo-pathological analysis of the surgical specimen as the gold standard, a diagnostic accuracy study was carried out on the variables T and N staging and the presence of peritoneal metastases (M1c). The parameters calculated were sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, as well as the overall accuracy. A total of 50 centers participated in the study in which 1950 patients were analyzed. The sensitivity of CT for correct staging of T4 colon tumors was 57%. Regarding N staging, the overall accuracy was 63%, with a sensitivity of 64% and a specificity of 62%; however, the positive and negative likelihood ratios were 1.7 and 0.58, respectively. For the diagnosis of peritoneal metastases, the accuracy was 94.8%, with a sensitivity of 40% and specificity of 98%; in the case of peritoneal metastases, the positive and negative likelihood ratios were 24.4 and 0.61, respectively. The diagnostic accuracy of CT in the setting of advanced colon cancer still has some shortcomings for accurate diagnosis of stage T4, correct classification of lymph nodes, and preoperative detection of peritoneal metastases

SARS-CoV-2 Infection in Multiple Sclerosis

To understand COVID-19 characteristics in people with multiple sclerosis (MS) and identify high-risk individuals due to their immunocompromised state resulting from the use of disease-modifying treatments. Retrospective and multicenter registry in patients with MS with suspected or confirmed COVID-19 diagnosis and available disease course (mild = ambulatory; severe = hospitalization; and critical = intensive care unit/death). Cases were analyzed for associations between MS characteristics and COVID-19 course and for identifying risk factors for a fatal outcome. Of the 326 patients analyzed, 120 were cases confirmed by real-time PCR, 34 by a serologic test, and 205 were suspected. Sixty-nine patients (21.3%) developed severe infection, 10 (3%) critical, and 7 (2.1%) died. Ambulatory patients were higher in relapsing MS forms, treated with injectables and oral first-line agents, whereas more severe cases were observed in patients on pulsed immunosuppressors and critical cases among patients with no therapy. Severe and critical infections were more likely to affect older males with comorbidities, with progressive MS forms, a longer disease course, and higher disability. Fifteen of 33 patients treated with rituximab were hospitalized. Four deceased patients have progressive MS, 5 were not receiving MS therapy, and 2 were treated (natalizumab and rituximab). Multivariate analysis showed age (OR 1.09, 95% CI, 1.04-1.17) as the only independent risk factor for a fatal outcome. This study has not demonstrated the presumed critical role of MS therapy in the course of COVID-19 but evidenced that people with MS with advanced age and disease, in progressive course, and those who are more disabled have a higher probability of severe and even fatal diseas

Multimodal Management of Fecal Incontinence Focused on Sphincteroplasty: Long-Term Outcomes from a Single Center Case Series

The management of patients with fecal incontinence and an external anal sphincter (EAS) defect remains controversial. A retrospective series of overlapping anal sphincteroplasties performed between 1985–2013 from a single center, supplemented by selective puborectalis plication and internal anal sphincter repair is presented. Patients were clinically followed along with anorectal manometry, continence scoring (Cleveland Clinic Incontinence Score—CCS) and patient satisfaction scales. Patients with a suboptimal outcome were managed with combinations of biofeedback therapy (BFT), peripheral tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS) or repeat sphincteroplasty. There were 120 anterior sphincter repairs with 90 (75%) levatorplasties and 84 (70%) IAS repairs. Over a median follow-up of 120 months (IQR 60–173.7 months) there were significant improvements in the recorded CCIS values (90.8% with a preoperative CCIS > 15 vs. 2.5% postoperatively; p < 0.001). There were 42 patients who required ancillary treatment with four repeat sphincteroplasties, 35 patients undergoing biofeedback therapy, 10 patients treated with PTNS and three managed with SNS implants with an ultimate good functional outcome in 92.9% of cases. No difference was noted in ultimate functional outcome between those treated with sphincteroplasty alone compared with those who needed ancillary treatments (97.1% vs. 85.7%, respectively). Overall, 93.3% considered the outcome as either good or excellent. Long-term functional outcomes of an overlapping sphincteroplasty are good. If the initial outcome is suboptimal, response to ancillary treatments remains good and patients are not compromised by a first-up uncomplicated sphincter repair

Colorectal cancer and its delayed diagnosis: have we improved in the past 25 years? Cáncer colorrectal: retraso diagnóstico. ¿Hemos mejorado algo en los últimos 25 años?

Objective: to determine the current delay in diagnosing colorectal cancer (CRC) and establish whether there has been any improvement in the past 25 years in the same healthcare setting using the same methods. Patients and method: 152 patients undergoing surgery at our unit were personally interviewed during their hospital stay to determine the delay incurred for the diagnosis and treatment of their CRC. SPSS software was used for univariate and multivariate analysis of the data obtained. Results: the study population was comprised of 152 patients of mean age 71 years (SD 10; range 36 to 90 years), 82 men and 70 women (53.9 and 46.1% respectively; p > 0.05). The diagnostic delay for CRC at our unit currently runs at 7.28 months despite the fact that in 58% of patients the disease produced obvious symptoms such as rectal bleeding. Although this delay in diagnosis is reduced over that observed 25 years ago, the difference is statistically not significant in terms of both doctor-attributed or patient-attributed delay (doctor-attributed delay was 3.28 months in 1985 versus 1.89 at present and patient-attributed delay was 3.18 months versus today's 2.75; p > 0.05). Unlike the situation 25 years ago, no link was detected between diagnostic delay and tumor stage. Paradoxically, stage D disease was diagnosed earlier (at 5.71 months) than stage A disease (at 11.16 months) (p Objetivo: determinar la situación actual en cuanto al retraso diagnóstico del cáncer colorrectal (CCR) y analizar si se ha producido alguna mejora con respecto a lo acontecido hace 25 años en un mismo medio sanitario y con una misma metodología. Pacientes y método: se entrevistó personalmente a 152 pacientes durante su ingreso para tratamiento quirúrgico en nuestro Servicio con el fin de determinar el retraso acumulado para el diagnóstico y tratamiento de su CCR. Se realizó un análisis estadístico univariable y mutivariable mediante el software SPSS. Resultados: se incluyeron 152 pacientes con una edad media de 71 años con una desviación típica de 10 (edad mínima 36 y máxima 90 años), con un total de 82 varones y 70 mujeres (53,9 y 46,1% respectivamente; p > 0,05). El retraso diagnóstico del cáncer colorrectal en el momento actual en nuestro medio es de 7,28 meses, a pesar de que la mayoría de los pacientes cursa con sintomatología florida, como es la rectorragia en un 58% de pacientes. Aunque el retraso es menor que hace 25 años, la diferencia no llega a ser significativa en cuanto a retraso médico ni por parte del paciente (retraso médico 3,28 meses en 1985 frente a 1,89 en el momento actual y retraso del paciente de 3,18 en 1985 frente a 2,75 en la actualidad) (p > 0,05). A diferencia de lo que acontecía hace 25 años, no se ha encontrado relación entre retraso diagnóstico y estadio anatomopatológico, con el hecho paradójico de un menor retraso en estadio D (5,71 meses) que en A (11,16 meses) (p < 0,05). Conclusión: el retraso diagnóstico en el CCR es de 7,28 meses; cifra muy elevada para una patología que presenta sintomatología en el 90% de pacientes. En los últimos 25 años apenas ha variado el retraso global, aunque ha mejorado de forma importante el atribuible al médico. En nuestro estudio no se ha encontrado relación entre retraso diagnóstico y estadio anatomopatológico. Dada la alta prevalencia del cáncer colorrectal y la insuficiencia de las campañas para diagnóstico temprano del mismo en fase sintomática, con la ausencia de mejoría en cuanto al pronóstico, creemos necesaria la potenciación de programas de screening mediante colonoscopia

Colorectal cancer and its delayed diagnosis: have we improved in the past 25 years?

Objective: to determine the current delay in diagnosing colorectal cancer (CRC) and establish whether there has been any improvement in the past 25 years in the same healthcare setting using the same methods. Patients and method: 152 patients undergoing surgery at our unit were personally interviewed during their hospital stay to determine the delay incurred for the diagnosis and treatment of their CRC. SPSS software was used for univariate and multivariate analysis of the data obtained. Results: the study population was comprised of 152 patients of mean age 71 years (SD 10; range 36 to 90 years), 82 men and 70 women (53.9 and 46.1% respectively; p > 0.05). The diagnostic delay for CRC at our unit currently runs at 7.28 months despite the fact that in 58% of patients the disease produced obvious symptoms such as rectal bleeding. Although this delay in diagnosis is reduced over that observed 25 years ago, the difference is statistically not significant in terms of both doctor-attributed or patient-attributed delay (doctor-attributed delay was 3.28 months in 1985 versus 1.89 at present and patient-attributed delay was 3.18 months versus today's 2.75; p > 0.05). Unlike the situation 25 years ago, no link was detected between diagnostic delay and tumor stage. Paradoxically, stage D disease was diagnosed earlier (at 5.71 months) than stage A disease (at 11.16 months) (p < 0.05). Conclusion: the diagnostic delay for CRC at our centre is 7.28 months. This delay is excessive for a disease that produces evident symptoms in 90% of patients. Over the last 25 years little improvement has been noted in the overall delay in diagnosing CRC, although the delay attributed to the care provider has significantly improved. No relationship was detected between diagnostic delay and disease stage upon diagnosis. We feel the high prevalence of CRC, the failure of campaigns to increase awareness of early symptoms and no real improvement in its prognosis justify the introduction of large-scale colonoscopy screening for this disease

Peri-ileostomy pyoderma gangrenosum: case report

Pyoderma gangrenosum is one of the most severe complications that can occur following stoma placement. Despite few cases reported in the literature, it is considered an underdiagnosed entity. We present a case of peri-ileostomy pyoderma gangrenosum (PPG) in a patient who underwent a pancoloproctectomy and permanent ileostomy due to ulcerative colitis (UC). Treatment was based on local cures, proper fitting of ostomy devices, topical tacrolimus and systemic corticosteroids, adalimumab and antibiotics. Satisfactory resolution was achieved in eight weeks

Hemoptysis due to pulmonary pseudosequestration secondary to gastro-pulmonary fistula after a revisional bariatric operation

We report the case of a patient with a history of a complicated revisional bariatric operation who developed a lung pseudosequestration secondary to a gastro-pulmonary fistula. As the patient presented with recurrent hemoptysis, she was initially submitted to embolization of the aberrant vessels and later to a definite operation, which consisted on a diversion of the gastric fistula into a Roux-en-Y intestinal loop. It is an exceptional case about late complications of bariatric surgery, and it underlines the importance of discarding these complications even when the clinical manifestations affect another anatomic region different from the operated abdomen