Fístula sigmoido-apendiceal como forma de presentación de la diverticulitis complicada
Abstract
ABSTRACT
Fistulas in complicated diverticular disease account for up to 20% of cases. Within the colloenteric category, only five cases of sigmoid-appendale fistulas have been found. The feasibility of tomography colonography is reported in the diagnosis of this entity and successful surgical management is presented despite laparoscopic conver- sion, without affecting evolution.
Key words. Complicated diverticulitis, fistula, diverticu- lar disease.
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Patient: Female, 76
Final Diagnosis: Complicated recurrent diverticulitis
Symptoms: Abdominal pain • bloating • inability to pass stool and gas
Medication: —
Clinical Procedure: Hartmann’s procedure
Specialty: Surgery
Objective
Unusual clinical course
Background
Although diverticular disease is well described and treated in daily clinical practice, there are cases that attract great interest because of their complexity and difficulty in management. Herein, we describe a rare case of colo-colonic fistula-complicated diverticulitis that necessitated urgent surgical intervention.
Case Report
A 76-year-old female patient with a known history of diverticular disease of the sigmoid colon presented in the Emergency Department for evaluation of left lower quadrant abdominal pain. The clinical and radiological examinations revealed a recurrent episode of acute diverticulitis of the sigmoid colon. However, it was of great interest that we detected a sigmoido-cecal fistula in the abdominal computed tomography (CT). The patient was admitted to the hospital for conservative treatment. After 48 hours, the patient’s clinical status deteriorated, with pain aggravation, abdominal distension, bloating, and metallic bowel sounds. The simple abdominal x-ray revealed large-bowel obstruction and the CT demonstrated worsening inflammation of the sigmoid colon. An exploratory laparotomy revealed an inflamed dolichol-sigmoid colon forming a fistulous tract with the cecum and thus, mimicking a closed loop obstruction. The sigmoid colon was transected en bloc with the sigmoido-cecal fistula and a Hartmann’s procedure was performed.
Conclusions
This case is extremely unusual as the patient presented at the same time two complications of diverticular disease, both obstruction and this rare formation of sigmoido-cecal fistula. It is presented in order to acquaint surgeons with the possibility of an unexpected course of this disease which indeed necessitates an individualized management.
Acute diverticulitis is a common condition that has been increasing in incidence in the United States. It is associated with increasing age, but the pathophysiology of acute diverticulitis is still being elucidated. It is now believed to have a significant contribution from inflammatory processes rather than being a strictly infectious process. There are still many questions to be answered regarding the optimal management of acute diverticulitis because recent studies have challenged traditional practices, such as the routine use of antibiotics, surgical technique, and dietary restrictions for prevention of recurrence.
Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.
Background:
Diverticular disease accounts for significant morbidity and mortality and may take the form of recurrent episodes of acute diverticulitis. The role of elective surgery is not clearly defined.
Objective:
This study aimed to define the rate of hospital admission for recurrent acute diverticulitis and risk factors associated with recurrence and surgery.
Design:
This is a retrospective population-based cohort study.
Settings:
National Health Service hospital admissions for acute diverticulitis in England between April 2006 and March 2011 were reviewed.
Patients:
Hospital Episode Statistics data identified adult patients with the first episode of acute diverticulitis (index admission), and then identified recurrent admissions and elective or emergency surgery for acute diverticulitis during a minimum follow-up period of 4 years. Exclusion criteria included previous diagnoses of acute diverticulitis, colorectal cancer, or GI bleeding, and prior colectomy or surgery or death during the index admission.
Interventions:
There were no interventions.
Main outcome measures:
The primary outcomes measured were recurrent admissions for acute diverticulitis and patients requiring either elective or emergency surgery during the study period.
Results:
Some 65,162 patients were identified with the first episode of acute diverticulitis. The rate of hospital admission for recurrent acute diverticulitis was 11.2%. A logistic regression model examined factors associated with recurrent acute diverticulitis and surgery: patient age, female sex, smoking, obesity, comorbidity score >20, dyslipidemia, and complicated acute diverticulitis increased the risk of recurrent acute diverticulitis. There was an inverse relationship between patient age and recurrence. Similar factors were associated with elective and emergency surgery.
Limitations:
The cases of acute diverticulitis required inpatient management and the use of Hospital Episode Statistics, relying on the accuracy of diagnostic coding.
Conclusions:
This is the largest study assessing the rates of hospital admission for recurrent acute diverticulitis. Knowledge of the rate and risk factors for recurrent acute diverticulitis is required to aid discussion and decision making with patients regarding the need and timing of elective surgery. Some factors associated with recurrence are modifiable; therefore, weight reduction and smoking cessation can be championed. See Video Abstract at http://links.lww.com/DCR/A449.
Introduction:
Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open surgery. Aim of this review is to assess the possible advantages deriving from a laparoscopic approach in the treatment of diverticular fistulas of the colon.
Methods:
Studies presenting at least 10 adult patients who underwent laparoscopic surgery for sigmoid diverticular fistula were reviewed. Fistula recurrence, reintervention, Hartmann's procedure or proximal diversion, conversion to laparotomy were the outcomes considered.
Results:
11 non randomized studies were included. Rates of fistula recurrence (0.8%), early reintervention (30 days) (2%) and need for Hartmann's procedure or proximal diversion (1.4%) did not show significant difference between laparoscopy and open technique.
Discussion:
there is still concern about which surgery in complicated diverticulitis should be preferred. Laparoscopic approach has led to less postoperative pain, shorter hospital stay, faster recovery and better cosmetic results. Laparoscopic resection and primary anastomosis is a possible approach to sigmoid fistulas but its advantages in terms of lower mortality rate and postoperative stay after colon resection with primary anastomosis should be interpreted with caution. When there is firm evidence supporting it, it is likely that minimally invasive surgery should become the standard approach for diverticular fistulas, thus achieving adequate exposure and better visualization of the surgical field.
Conclusion:
The lack of RCTs, the small sample size, the heterogeneity of literature do not allow to draw statistically significant conclusions on the laparoscopic surgery for fistulas despite this approach is considered safe.
Objectives:
Data on the incidence and natural history of diverticulitis are largely hospital-based and exclude the majority of diverticulitis patients, who are treated in an outpatient setting for uncomplicated diverticulitis. We assessed temporal trends in the epidemiology of diverticulitis in the general population.
Methods:
Through the Rochester Epidemiology Project we reviewed the records of all individuals with a diagnosis of diverticulitis from 1980 to 2007 in Olmsted County, Minnesota, USA.
Results:
In 1980-1989, the incidence of diverticulitis was 115/100,000 person-years, which increased to 188/100,000 in 2000-2007 (P<0.001). Incidence increased with age (P<0.001); however, the temporal increase was greater in younger people (P<0.001). Ten years after the index and second diverticulitis episodes, 22% and 55% had a recurrence, respectively. This recurrence rate was greater in younger people (hazard ratio (HR) per decade 0.63; 95% confidence interval (CI), 0.59-0.66) and women (HR 0.68; 95% CI, 0.58-0.80). Complications were seen in 12%; this rate did not change over time. Recurrent diverticulitis was associated with a decreased risk of complications (P<0.001). Age was associated with increased risk of local (odds ratio (OR) 1.27 per decade; 95% CI, 1.04-1.57) and systemic (OR 1.83; 95% CI, 1.20-2.80) complications. Survival after diverticulitis was lower in older people (P<0.001) and men (P<0.001) and worsened over time (P<0.001). The incidence of surgery for diverticulitis did not change from 1980 to 2007.
Conclusions:
The incidence of diverticulitis has increased by 50% in 2000-2007 compared with 1990-1999, and more so in younger people. Complications are relatively uncommon. Recurrent diverticulitis is frequent but typically uncomplicated. Younger people with diverticulitis have less severe disease, more recurrence, and better survival.Am J Gastroenterol advance online publication, 29 September 2015; doi:10.1038/ajg.2015.302.
Robotic abdominal surgery is growing despite a paucity of clinical reports to evaluate its impact on patient outcomes. In this retrospective case series, we aim to analyze our early experience with robotic resection in 11 consecutive patients with chronic colonic diverticulitis complicated by fistula to bladder, vagina, or skin and to compare the results of the robotic approach to 20 patients undergoing laparoscopic resection for the same indication. Our main outcome measures include operative time, blood loss, conversion rate, transfusion rate, hospital length of stay, complications, readmission, and fistula healing rate. In our study, we found robotic resection for colonic diverticulitis with fistula was technically feasible and yielded 100 % fistula healing rate. The operative time, complication and readmission rates were similar to laparoscopy. A higher conversion rate, diverting stoma need, and longer hospital length of stay were noted in the robotic group; however, these findings could have been attributed to a higher number of cases involving rectal excision in the robotic group. Larger studies are needed to further examine the impact of robotic surgery on the outcome of patients with complicated chronic sigmoid diverticulitis.
Most studies of trends in diverticular disease have focused on diverticulitis or on a composite outcome of diverticulitis and bleeding. We aimed to quantify and compare the prevalence of hospitalization for diverticular bleeding and diverticulitis overall and by sex and race.
We analyzed data from the Nationwide Inpatient Sample from 2000 through 2010. We identified adult patients with a discharge diagnosis of diverticular bleeding or diverticulitis. Using yearly US Intercensal data, we calculated age-, sex-, and race- specific rates, as well as age-adjusted prevalence rates.
The prevalence of hospitalization per 100,000 persons for diverticular bleeding decreased over the 10 year (y) period from 32.5 to 27.1 (-5.4; 95% confidence interval (CI), -5.1 to -5.7). The prevalence of hospitalization for diverticulitis peaked in 2008 (74.1/100,000 in 2000, 96.0/100,000 in 2008 and 91.9/100,000 in 2010). The prevalence of diverticulitis was higher in women than men, whereas women and men had similar rates of diverticular bleeding. The prevalence of diverticular bleeding was highest in Blacks (34.4/100,000 in 2010); whereas the prevalence of diverticulitis was highest in Whites (75.5/100,000 in 2010).
Over the past 10 y, the prevalence of hospitalization for diverticulitis increased and then plateaued while that of diverticular bleeding decreased. The prevalence according to sex and race differed for diverticulitis and diverticular bleeding. These findings indicate different mechanisms of pathogenesis for these disorders.
Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.