Sigmoid volvulus: outcomes of treatment and predictors of morbidity and mortality

Purpose To analyze the treatment outcomes for sigmoid volvulus (SV) and identify risk factors of complications and mortality. Methods Observational study of all consecutive adult patients diagnosed with SV who were admitted from January 2000 to December 2020 in a tertiary university institution for conservative management, urgent or elective surgery. Primary outcomes were 30-day postoperative morbidity, mortality and 2-year overall survival (OS), including analysis of risk factors for postoperative morbidity or mortality and prognostic factors for 2-year OS. Results A total of 92 patients were included. Conservative management was performed in 43 cases (46.7%), 27 patients (29.4%) underwent emergent surgery and 22 (23.9%) were scheduled for elective surgery. Successful decompression was achieved in 87.8% of cases, but the recurrence rate was 47.2%. Mortality rates following episodes were higher for conservative treatment than for urgent or elective surgery (37.2%, 22.2%, 9.1%, respectively; p = 0.044). ASA score > III was an independent risk factor for complications (OR = 5.570, 95% CI = 1.740–17.829, p < 0.001) and mortality (OR = 6.139, 95% CI = 2.629–14.335, p < 0.001) in the 30 days after admission. Patients who underwent elective surgery showed higher 2-year OS than those with conservative treatment (p = 0.011). Elective surgery (HR = 2.604, 95% CI = 1.185–5.714, p = 0.017) and ASA score > III (HR = 0.351, 95% CI = 0.192–0.641, p = 0.001) were independent prognostic factors for 2-year OS. Conclusion Successful endoscopic decompression can be achieved in most SV patients, but with the drawbacks of high recurrence, morbidity and mortality rates. Concurrent severe comorbidities and conservative treatment were independent prognostic factors for morbidity and survival in SV.

The Efficacy and Safety of a Conservative Management Approach to Radiation-Induced Male Urethral Strictures in Elderly Patients With Comorbidities

Objectives To assess the outcomes of a conservative management approach to radiation-induced urethral stricture disease (R-USD) in an elderly population with comorbidities. Methods Patients with R-USD managed with endoscopic procedures and/or clean intermittent catheterization (CIC) between 2007 and 2019 were included. Patients were excluded if they had an obliterative stricture, prior urethral reconstruction/urinary diversion surgery, or < 3 months follow-up. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, uroflowmetry/post-void residual, and urinary incontinence (UI). Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. Results Ninety-one men were analyzed with a median follow-up of 15.0 months (IQR 8.9 to 37.9). Median age was 75.4 years (IQR 70.0 to 80.0), body mass index was 26.5 kg/m2 (IQR 24.8 to 30.3), and Charlson comorbidity index was 6 (IQR 5 to 8). Median stricture length was 2.0 cm (IQR 2.0 to 3.0). Stricture location was bulbar (12%), bulbomembranous (75%), and prostatic (13%). A total of 90% underwent dilation, and 44% underwent direct visual internal urethrotomy (DVIU). For those that underwent these procedures, median number of dilations and DVIUs per patient was 2 (IQR 1 to 5) and 1 (IQR 1 to 3), respectively. Forty percent used CIC. Thirty-four percent developed a UTI, and 15% had an AUR episode requiring urgent treatment. Creatinine values, uroflowmetry measurements, and UI rates remained stable. Eighty percent avoided reconstructive surgery or indwelling catheterization. Conclusion Most elderly patients with comorbidities with R-USD appear to be effectively managed in the short-term with conservative strategies. Close observation is warranted because of the risk of UTIs and AUR. The potential long-term consequences of repetitive conservative interventions must be considered.

Successful treatment of phrenic nerve injury with diaphragmatic plication 5 years after onset: A case report

Diaphragmatic paralysis due to phrenic nerve injury is an occasional complication of cardiothoracic surgery. Although diaphragmatic plication is widely used to treat patients with severe irreversible symptoms, its surgical indication and timing remain controversial. Here, we present a rare case of diaphragmatic paralysis in a 65-year-old woman who underwent cardiac surgery and whose respiratory symptoms worsened despite >5 years of conservative management. Consequently, she underwent diaphragmatic plication using an endostapler to resect the redundant diaphragm, followed by over-suturing of all staple lines. She was discharged without any complications and her symptoms and chest radiography and spirometry results improved postoperatively.

Conservative Management of the Duodenal Injury during Percutaneous Nephrostomy Placement: A Few and Far between Complications of the Urological Literature

Herein, we reported a duodenal perforation case as an intestinal injury during a percutaneous nephrostomy procedure. A 73-year-old woman with bilateral nephrostomy catheters was applied to the emergency service with right flank pain. Early in the day, her bilateral nephrostomy catheters had been changed. On physical examination, she had a defense and rebound at her right quadrant, and costovertebral angle tenderness was also positive. In the contrast-enhanced abdominal computed tomography scan, the right nephrostomy catheter was located in the second part of the duodenum, and the contrast agent did not leak into the peritoneum from the injury area. We decided on conservative management of the case with active surveillance using daily blood tests and physical examinations. The nephrostomy catheter in the duodenum was left to prevent fistula between the duodenum and the skin, and a new one was placed in the right kidney. The broad spectrum antibiotherapy regime was applied, and the patient was followed up closely. The catheter in the duodenum was removed on the 20th day, uneventfully, and the patient was discharged successfully on the 24th day with her permanent bilateral nephrostomy tubes. On the first follow-up, one month later, the patient had no active medical complaint.

Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65–74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65–92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1–48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.