Of 226 patients who entered a prospective study on acute left colonic diverticulitis, 66 (29%) were operated: 51 underwent a Hartmann’s procedure for diffuse peritonitis in 27 (52%), localized peritonitis in 14 (27%) and isolated abscess in 10 cases (21%). Overall, 31 patients (14%) had an isolated associated abscess (15 mesocolic, 13 pelvic and 3 abdominal) which was percuta-neously drained in 4 cases and operated in 10 cases. Of the 15 patients with mesocolic abscess, 12 (80%) were never operated. Two patients died postoper-atively (4%). Thirty-nine patients (81 %) had bowel continuity restored, with 1 postoperative death (2.5%). Continuity was reestablished in all patients under 79 years but in only 2 of 10 older patients (20%). Hartmann’s procedure remains an excellent option for diverticulitis with diffuse or localized peritonitis, in spite of the fact that most elderly patients ( > 80 years) keep their colosto-my. Isolated mesocolic associated abscess has most often a spontaneously favorable course.
In a prospective evaluation of 140 consecutive patients with acute left-sided colonic diverticulitis demonstrated by computerized tomography (CT) in all cases, 22 (16 percent) were found to have an associated abscess without peritonitis. Thirteen of these 22 required surgery (seven during the first stay and six from 2 to 11 months after the acute episode; median, three months). Nine patients were treated conservatively, eight of whom are now totally asymptomatic 24 months after the initial attack (range, 10-47 months). There were 10 mesocolic abscesses (seven treated with antibiotics alone), nine pelvic abscesses (seven requiring surgery), and three intra-abdominal abscesses, all operated upon. These results suggest that mesocolic abscesses can usually be managed conservatively without drainage; should surgery be necessary, en bloc resection with immediate anastomosis can usually be safely performed. Pelvic and intraabdominal abscesses behave more aggressively and usually require a two-stage surgical procedure when initial percutaneous drainage cannot be performed or is felt to be hazardous.
This prospective study examined factors which may predict a poor outcome (complications and recurrence) after a first attack of diverticulitis which has been successfully managed conservatively. Twenty-four of 107 patients who entered the study had a poor outcome: persistent diverticulitis (nine cases), recurrence (seven cases), colonic stenosis (six cases), residual parasigmoid abscess (one case) and colovesical fistula (one case). Eight of the 18 men aged 50 years or less had a poor outcome compared with 16 of the remaining 89 patients (P = 0.032). Twelve of 76 patients (16 per cent) with mild findings on computed tomography (CT) (localized thickening of colonic wall and inflammation of pericolic fat) had a poor outcome compared with 11 of 23 patients (48 per cent) whose CT was estimated as severe (abscess and/or extraluminal air and/or extraluminal Gastrografin) (P = 0.004). These results suggest that elective colectomy can be proposed after a first attack of acute left diverticulitis in men up to 50 years of age and/or in patients whose initial CT reveals findings of severe diverticulitis.
The continuing development of robotic surgery supports its use in laparoscopic gastrointestinal surgery. Our study retrospectively reviewed the surgical outcome and patient’s satisfaction of gastrointestinal laparoscopic robotic procedures. From January 2003 to September 2007, 94 patients (27 women, 67 men) with a mean age of 53 years (range 19–84 years) underwent laparoscopic surgery with a da Vinci robotic system. There were 40 colorectal cases (43%), 31 anti-reflux surgery cases (33%) and 14 obesity surgery cases (15%); the remaining cases consisted of gastric and gallbladder surgery, intra-abdominal tumour excisions, and hepatic cyst resections. The majority of the cases (88, 94%) were performed for benign disease. The mean operative time was 153 min (range 60–330 min). One patient needed a blood transfusion. The mean body mass index was 25 (range 16–47). No death occurred. Five cases (5.3%) were converted to conventional laparoscopic surgery (n = 3) or to laparotomy (n = 2). Morbidity consisted of one Nissen redo surgery to loosen a tight anti-reflux valve 6 days after robotic surgery, a robotic left ureter repair and pelvic haemorrhage following proctectomy requiring re-operation to control haemostasis and to remove pelvic haematoma. Mean follow-up time was 11 months (range 15 days to 34 months). One case of incisional trocar hernia needed re-operation. Overall patient’s satisfaction was high: few scars were cheloïd, while functional surgical outcome was rated high by most of the patients. Our preliminary experience was encouraging, with minimal morbidity and very high acceptance by patients.
The medical records of 15 patients found to have pneumoretroperitoneum in a 10-year period were reviewed. The cause of retroperitoneal emphysema was infection in six patients, trauma in five and iatrogenic in four. Emphysema was confined to the retroperitoneum in 11 patients, and extended to the mediastinum in four and to the soft tissue of the neck in three. Failure to diagnose pneumoretroperitoneum resulted in delayed intervention in two patients. One patient with pneumoretroperitoneum and pneumoperitoneum secondary to a lung lesion underwent unnecessary laparotomy. Outcome was favourable in these three patients. The presence of air in the retroperitoneum is not dangerous but its early recognition and detection of the source are important as septic conditions may be involved.
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