Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess

Background There are limited data assessing the effectiveness of antibiotics as sole initial therapy in patients with large diverticular abscess. The aim of our study was to compare outcomes of selected patients treated with initial antibiotics alone versus percutaneous drainage. Methods All patients with diverticular abscess ≥3 cm in diameter treated in our institution in 1994–2012 with percutaneous drainage or antibiotics alone followed by surgery were identified from an institutional diverticular disease database. Groups were compared based on patient and disease characteristics, treatment failures and postoperative outcomes. Results Thirty-two patients were treated with antibiotics alone because of either technically impossible percutaneous drainage (n = 15) or surgeon preference (n = 17) while 114 underwent percutaneous drainage. Failure of initial treatment required urgent surgery in 8 patients with persistent symptoms during treatment with antibiotics alone (25 %) and in 21 patients (18 %) after initial percutaneous drainage (p = 0.21). Reasons for urgent surgery after percutaneous drainage were persistent symptoms (n = 16), technical failure of percutaneous drainage (n = 4) and small bowel injury (n = 1). Patients treated with antibiotics had a significantly smaller abscess diameter (5.9 vs. 7.1 cm, p = 0.001) and shorter interval from initial treatment to sigmoidectomy (mean 50 vs. 80 days, p = 0.02). The Charlson comorbidity index, initial treatment failure rates, postoperative mortality, overall morbidity, length of hospital stay during treatments, and overall and permanent stoma rates were comparable in the two groups. Postoperative complications following antibiotics alone were significantly less severe than after percutaneous drainage based on the Clavien–Dindo classification (p = 0.04). Conclusions Selected patients with diverticular abscess can be initially treated with antibiotics without adverse consequences on their outcomes

Comparing simultaneous versus staged resection in patients with synchronous colorectal liver metastases: case match study

INTRODUCTION: There is no consensus on the optimal timing of liver resection in patients with synchronous colorectal liver metastasis. METHODS: Patients undergoing hepatic resections between 2004- 2013 for synchronous colorectal liver metastases were analyzed from a prospectively maintained and institutional review board approved database. Patients who underwent simultaneous resection of a colorectal primary and hepatic metastasis in a single operation (Group I) were case-matched 1:1with patients who underwent staged operation (Group II) according to age, sex, ASA classification, size of liver lesion and number of liver lesion. RESULTS: 66 patients (33 Group I, 33 Group II) were matched from a total cohort of 106 patients with synchronous colorectal liver metastasis. The patients’ characteristics of both groups were similar. 62% were male and the mean age was 55.511 years. Blood loss and duration of surgery did not differ between simultaneous resections and staged resection (p¼0.63; p¼0.14, respectively). Perioperative complication rate were similar in both groups (P¼0.70). There was no mortality. The median number of in-hospital days during the course of treatment was 9 (4-23) days in Group I and 6 (3-17) days in Group II (p <0.001). There was no difference in 2 years disease free survival and overall survival were found between Group I and Group II ( 30% and 34%, p¼ 0.58; 67% and 62%, p¼0.86 respectively). CONCLUSIONS: Simultaneous liver resections result in similar short and long eterm outcomes as in patients undergoing sequential resections for synchronous colorectal cancer with comparable metastatic disease burden

Outcomes of percutaneous drainage without surgery for patients with diverticular abscess

BACKGROUND: Data on percutaneous drainage followed by observation for diverticular abscess is scant. OBJECTIVE: The aim of this study is to assess outcomes of percutaneous drainage alone in the management of peridiverticular abscess. DESIGN: This is a retrospective study from a prospectively collected database. SETTING: This study was conducted in a high-volume, specialized colorectal surgery unit. PATIENTS: All patients with a diverticular abscess of at least 3 cm in diameter, treated between 2001 and 2012, who had prohibitive comorbidities or refused surgery after percutaneous drainage were included. MAIN OUTCOME MEASURES: The primary outcome measured was the treatment of diverticular abscess with percutaneous drainage alone. RESULTS: A total of 18 patients (11 surgery refusal, 7 comorbidity) were followed up until death, surgery for recurrent diverticulitis, or for a median of 90 (17–139) months. The median abscess size was 5 (3.8–10) cm, and the location was pelvic in 8 cases and intra-abdominal in 10. The mean duration of drainage was 20 ± 1.3 days, with the exception of 2 patients who only had aspiration of the abscess because of technical difficulty in drain placement. Three patients died of preexisting comorbidities between 2 and 8 months after percutaneous drainage. Seven of the surviving patients (7/15) experienced recurrent diverticulitis; 3 of these patients underwent surgery between 7 months and 7 years after the index percutaneous drainage. Of the remaining 4 cases of recurrence, one abscess was treated with repeat percutaneous drainage alone and 3 patients had uncomplicated diverticulitis treated with antibiotics. There were no significant associations between long-term failure of percutaneous drainage and the location of the abscess ( p = 0.54) or previous episodes of diverticulitis ( p = 0.9). LIMITATIONS: This study was limited because of its retrospective nature, its nonrandomized design, and its small sample size. CONCLUSIONS: Percutaneous drainage alone was successful in avoiding surgery in the majority of this selected patient population with sigmoid diverticular abscess. Future studies should assess the appropriate indications for a more liberal use of percutaneous drainage not followed by elective surgery

Comparing perineal repairs for rectal prolapse: Delorme versus Altemeier

Purpose Data comparing surgical outcomes and quality of life (QOL) following perineal repair of rectal prolapse are limited. The aim of our study was to compare the shortterm outcome and QOL of two perineal procedures in patients with rectal prolapse. Methods All patients with full-thickness rectal prolapse admitted to our institution and undergoing Delorme and Altemeier procedures from 2005 to 2013 were identified using an institutional, IRB-approved rectal prolapse database. Short-term outcomes and QOL were compared. Results Seventy-five patients (93 % female) underwent rectal prolapse surgery: 22 Altemeier and 53 Delorme, mean age 72 ± 15 years. Sixty-six percentage of patients were ASA grade III or IV (Table 1). The median hospital stay was longer in Altemeier’s group [4 (1–44) days vs. 3 (0–14) days; p = 0.01]. After a median follow-up of 13 (1–88) months, the rate of recurrent prolapse was 14 % (n = 11) [Altemeier 2 (9 %) vs. Delorme 9 (16 %) p = 0.071]. Postoperative complication rate was 12 % (n = 9) [Altemeier 5 (22 %) vs. Delorme 4 (7 %), p = 0.04]. There was no mortality. The Cleveland Global Quality of Life scores in each group were 0.6 ± 0.2 and 0.5 ± 0.3, respectively (p = 0.59), and were not changed by the surgery. Conclusions In patients where abdominal repair of rectal prolapse is judged to be unwise, a Delorme procedure offers short-term control of the prolapse with low risk of complications and with reasonable function. In addition patients that recur after a Delorme procedure can undergo another similar transanal procedure without compromising the vascular supply of the rectum