Clinics in Colon and Rectal Surgery最新文献

There have been extensive efforts to improve the quality of colon cancer surgery to reduce variation in practice and improve outcomes. Providing the most appropriate care begins with following guidelines for preoperative diagnostics and staging, which should lead to risk stratification, high-quality counselling, and even prehabilitation before an operation. Intraoperatively, adherence to standardized surgical protocols can enhance delivery of high-quality care, and documenting using synoptic formats can reduce ambiguity. Participating in programs that track data and provide feedback can further allow hospitals and surgeons to identify patterns and opportunities to improve the care they deliver.

The nonoperative management of rectal cancer, known as watch and wait (W&W), has gained increasing acceptance in recent years. This approach is based on using complete clinical response (cCR) as a marker for complete pathological response (pCR) following neoadjuvant chemoradiation (nCRT). Advances in nCRT regimens have resulted in higher tumor regression rates, making W&W a viable option for selected patients. This study presents the historical evolution and efficacy of the W&W strategy and offers modern recommendations based on recent clinical findings. Key findings include an 85 to 92% 5-year disease-free survival rate in patients achieving cCR, highlighting the potential for improved quality of life and reduced morbidity without compromising survival outcomes.

Diverticulitis is a prevalent medical issue, particularly among elderly individuals in the Western world. Management is nuanced and is influenced by both disease presentation and patient factors, especially those that affect risk of septic and surgical complications. This paper reviews existing literature to explore the incidence, presentation, and management of diverticulitis in complex medical contexts-immunocompromised populations, specifically highlighting those undergoing chemotherapy, HIV/AIDS patients, transplant recipients, and individuals with autoimmune and connective tissue diseases. Not surprisingly, management of diverticulitis in these complex patient populations is associated with increased morbidity. However, even taking into consideration the risk of septic and surgical complications, more recent data and treatment recommendations suggest that both nonoperative and operative management strategies may be appropriate based on individual patient presentations, mirroring the treatment paradigm of immunocompetent patients. In addition, in discussing operative management of complex medical patients, immunosuppression alone should not be considered a contraindication to primary anastomosis. Overall, there are limited existing data on diverticulitis in immunocompromised populations and, especially, patients with autoimmune and connective tissue disorders. Further research is warranted to better understand the impact of these chronic diseases on diverticulitis severity and to best inform evidence-based practices in this complex clinical scenario.

Clinicians appreciate the structural alterations of diverticular disease when navigating narrow, angulated colons with a colonoscope or removing stiff, fixed sigmoid colons at surgery. Investigation of these tissues reveals increased thickness of smooth muscle, alterations in the amount and structure of the extracellular matrix, and changes to the motility of the colon. More sophisticated technologies now allow scientists to unravel the connections between these alterations and the individual genetic background. This article explores the structural alterations of diverticular disease including collagen, smooth muscle, the enteric nervous system, and the interstitial cells of Cajal.

In this article, we describe four unusual variations of diverticulitis: nonsigmoid colonic diverticulitis, giant colonic diverticulum, segmental colitis associated with diverticulosis, and small bowel diverticulitis. We discuss the epidemiology, presentation, and treatment of these types and how they differ from the presentation of typical sigmoid diverticulitis. We also review unusual presentations of typical sigmoid diverticulitis, including hematogenous liver abscess, necrotizing soft-tissue infection, and genitourinary fistula. Diverticulitis is a heterogeneous disease, and understanding the range of its presentations will facilitate early diagnosis and treatment.

Diverticular disease consists of diverticulosis and diverticulitis. Diverticulosis is commonly encountered, and approximately 4% of patients with diverticulosis will progress to develop diverticulitis, which represents a significant health care burden in the United States. Diverticular disease has an increasing incidence both in the United States and globally as important risk factors, including obesity, are becoming more prevalent. The pathophysiology of diverticular disease remains incompletely understood, although geographic and population-based differences in its prevalence and anatomic distribution have generated several hypotheses as to the impact of genetic and environmental factors on development and disease progression. Uncomplicated diverticulitis has had a low mortality rate for the last several decades, but in-hospital mortality approaches 7% for patients with complicated diverticulitis who require emergent surgery. For patients that develop diverticulitis, recent population-based data have led to an improved understanding of which patients will suffer recurrent episodes. This knowledge has facilitated informed discussions with patients and has changed practice in terms of elective surgery.

The incidence of diverticulosis continues to rise throughout western nations with collateral increases in the frequency of diverticulitis. However, the mechanism behind the transition from asymptomatic diverticulosis to complicated diverticulitis is incompletely understood. Dietary intake has long been investigated as one of, if not the main, links in the continuum of disease. As the world's diet continues to evolve with increasingly prevalent processed and high-fat food, longitudinal studies have emerged with a goal of finally explaining how diet influences the development of diverticulitis. While low-fiber, high-fat diets are believed to play a role in the development of an index episode of diverticulitis, the role in recurrent disease remains uncertain. More recent avenues of interest include the role of the microbiome, probiotics, and adjunct treatments such as 5-ASA and rifaximin. While robust longitudinal studies have identified an association between low-fiber, high-fat diets and the development of index diverticulitis, the impact of dietary composition and modification on disease recurrence remains unclear and fails to meet the threshold for societal recommendations.

Achieving optimal outcomes is a universal goal among health care providers. However, disagreement often arises when selecting and measuring endpoints as markers of care performance. In diverticulitis, this task is complicated by variability in clinical presentation and existence of multiple evidence-based therapeutic options. The aim of this review is to summarize trends and challenges in outcomes measurement for diverticulitis. We discuss historical origins and compare existing frameworks for classifying outcomes. Next, focus is directed to an exploration of important outcomes through clinical controversies: antibiotics for acute uncomplicated diverticulitis, colectomy with primary anastomosis for acute complicated diverticulitis, and elective colectomy for recurrent diverticulitis. Finally, we review recommendations supporting case-by-case decision-making and implications for clinicians, in addition to ongoing international efforts to standardize outcomes that matter for common diseases.