May 24, 2022
Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.
This week’s selections again look back at some of the most engaging, relevant scientific literature from 2021, featured previously in this Brief.
Laparoscopic versus Open Colectomy in Acute Diverticulitis and Cirrhosis
Kazi A, Finco TB, Zakhary B, et al. Acute Colonic Diverticulitis and Cirrhosis: Outcomes of Laparoscopic Colectomy Compared with an Open Approach. J Am Coll Surg. 2020;230(6):1045-1053.
Using data from the National Inpatient Sample over the interval 2012–2014, the authors identified patients with acute diverticulitis (N = 1,172,875) and select patients who also had compensated (N = 660) and decompensated cirrhosis (N = 270). The cirrhotic patients underwent either open or laparoscopic colectomy. The data analysis showed that patients with decompensated cirrhosis had significantly higher mortality, length of hospital stay, and costs. In patients with compensated cirrhosis, laparoscopic colectomy was associated with improved rates of mortality and morbidity compared with open surgery.
The authors noted that the higher mortality observed in patients with decompensated cirrhosis could not be explained solely by an increased rate of perioperative complications. They hypothesized that patients with decompensated cirrhosis are at higher risk because of conditions associated with the underlying liver disease, such as malnutrition, coagulopathy, and immune suppression. These findings are not surprising and agree with other available data that show an increased risk for colonic diverticulitis in patients with cirrhosis. Patients with cirrhosis (especially decompensated cirrhosis) are candidates for careful monitoring of their liver disease, aggressive interventions to improve liver function, and nonoperative therapy for diverticulitis, when possible.
Perianal Crohn’s Disease: Contemporary Management Techniques and Treatment
Williams JL, Shaffer VO. Modern Management of Perianal Crohn's Disease: A Review. Am Surg. 2021;87(9):1361-1367.
In their review of management of perianal Crohn’s disease, Williams and Shaffer emphasized that perianal disease is the initial presenting symptom of Crohn’s disease in 10% of patients with this condition. Up to 25% of patients with Crohn’s disease will develop perianal symptoms at some point during long-term follow-up.
Perianal Crohn’s disease has three subtypes: abscesses and fistulas, tissue destruction (fissures, tags, and ulcerations), and stricture formation. The authors noted that perianal abscesses have increased in frequency since the introduction of anti-TNF agents for treatment of Crohn’s disease. Incision and drainage are the preferred first-line treatments. The authors cited data showing improved healing rates of fistula-in-ano in patients with Crohn’s disease treated with anti-TNF agents. Fistulotomy and placement of non-cutting setons are the main surgical interventions for these conditions, although fibrin glue/plug and the LIFT (ligation of intersphincteric fistula tract) procedure have value for select patients.
Unfortunately, a consistently successful surgical treatment for anal strictures in patients with Crohn’s disease has yet to be developed; periodic dilation is the intervention used most frequently. Fissures and anal ulcerations may occasionally require debridement, but treatments to control discomfort such as nitrate-based ointments and sitz baths are the primary therapeutic approaches recommended in the article.
Frailty Assessment to Determine Postoperative Risk of Complications Feasible and Potentially Beneficial
Wilson S, Sutherland E, Razak A, et al. Implementation of a Frailty Assessment and Targeted Care Interventions and Its Association with Reduced Postoperative Complications in Elderly Surgical Patients. J Am Coll Surg. 2021;233(6):764-775.e1.
Wilson and coauthors described outcomes after implementing a frailty assessment tool to identify patients with increased operative risk and to provide guidance for choosing evidence-based preoperative interventions in these patients to improve outcomes. The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework was applied to create a five-question frailty assessment tool. The tool was used for patients aged 65 years and older admitted to the general surgery and vascular surgery services of a single institution. A cohort of 1,158 patients was identified over a 1-year interval, and a frailty assessment was used in 60.1% of these patients. Nearly 90% of assessed patients were scored as frail or intermediately frail.
Preoperative interventions for delirium and aspiration were used in increasing proportions of frail patients over the study interval. A significant reduction in 30-day complication rates was observed. Nonetheless, the authors observed a high rate of variability among hospital staff in use of the frailty assessment and application of the frailty precautions. They concluded that frailty assessments and guided interventions were feasible and potentially beneficial. Staff will need to improve frailty assessment and preoperative intervention rates if maximize benefit are to be realized.