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P Ambrosetti

Publications and source records attributed to P Ambrosetti.

At least 19 recordsLinked to original sources
PubMed2002

Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients.

PURPOSE: This study was designed to evaluate the long-term natural history of sigmoid diverticulitis in patients treated nonoperatively after a first acute episode and to assess the role of elective colectomy. METHODS: Between 1986 and 1991, 144 patients were admitted for acute diverticulitis diagnosed by abdominal computed tomography and had a successful nonoperative treatment. Remote complications (persisting or recurring diverticulitis) were also diagnosed by computed tomography. Patients had a poor outcome if they had one of these complications. Diverticulitis was graded mild or severe on computed tomography according to Ambrosetti's criteria. We determined statistically whether young age (< or =50 years old) and severe diverticulitis were risk factors for a poor outcome. RESULTS: One hundred eighteen patients with a contributive computed tomographic scan at admission were followed up. Median age was 63 (range, 23-93) years, with a median follow-up of 9.5 (range, 0.2-13.8) years. Eighty patients had no complications, and 38 had remote complications. The incidence of remote complications was the highest (54 percent at 5 years) for young patients with severe diverticulitis on computed tomography and the lowest (19 percent at 5 years) for older patients with mild disease. Young age and severe diverticulitis taken separately were both statistically significant factors of poor outcome (P = 0.007 and P = 0.003, respectively), although age was no longer significant after stratification for disease severity on computed tomography (P = 0.07). Twenty-four patients died. The cause of death was unrelated to diverticulitis in 21 cases and unknown in the remaining 3. CONCLUSIONS: We propose that after a first acute episode of diverticulitis treated nonoperatively, elective colectomy should be offered to young patients (< or =50 years old) with severe diverticulitis on computed tomography.

Adult↗
PubMed2001

Colonic diverticulitis: impact of imaging on surgical management -- a prospective study of 542 patients.

The aim of this study was to compare the performance of the CT and the water-soluble contrast enema (CE) in the diagnosis and the severity of acute left-colonic diverticulitis, and to recognize the impact of CT during the acute phase and after a first acute episode successfully treated medically. From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a CE and a CT within 72 h of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiological exams showed signs of acute diverticulitis and/or diverticulitis was surgically removed and histologically proven. Diverticulitis was considered moderate when CT showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and CE showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess and/or extraluminal air and/or contrast were observed on CT and when one or both of the latter signs were seen on CE. Five hundred forty-two patients entered the study; 465 patients (86%) had a CT exam, 439 (81%) had a CE, and 420 (77%) had both exams. The performance of CT is significantly superior to CE in terms of sensitivity (98 vs 92%, p<0.01), and in the evaluation of the severity of the inflammation (26 vs 9%, p<0.02). Moreover, of 69 patients who had an associated abscess seen on CT, only 20 (29%) had indirect signs of this complication on CE. During the acute phase the chances of medical treatment failure are statistically greater when diverticulitis is considered severe on CT than when it is considered moderate (26% for the severe diverticulitis vs 4% for the moderate ones, p<0.0001). After successful medical treatment of the acute episode, patients with severe diverticulitis on the CT had statistically greater incidence of secondary bad outcome than patients with moderate diverticulitis (36 vs 17%, p<0.0001). Computed tomography should be preferred to CE as the initial radiological exam of diverticulitis because of its statistically significant superiority in sensitivity and for its statistically much higher performance in the detection of severe infection, especially when an abscess is associated with the disease. The severity of diverticulitis on CT is statistically predictive of the risk of medical treatment failure during the acute phase and of the chances of bad secondary outcome after a successful medical treatment of the first episode.

Abscess↗
PubMed2000

Acute left colonic diverticulitis--compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients.

PURPOSE: The most valuable radiologic examination to be done initially when acute left colonic diverticulitis is suspected is still a matter of controversy. This study compares the performance between water-soluble contrast enema and computed tomography. METHODS: From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a contrast enema and a computed tomography within 72 hours of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiologic examinations showed signs of acute diverticulitis or diverticulitis was surgically removed and histologically proven or both. Diverticulitis was considered moderate when computed tomography showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and contrast enema showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess or extraluminal air or contrast or all three were observed on computed tomography and when one or both of the last two signs were seen on contrast enema. Of 542 patients, 420 who had both computed tomography and contrast enema entered the study. RESULTS: The performance of computed tomography was significantly superior to contrast enema in terms of sensitivity (98 vs. 92 percent; P = 0.01), which was calculated from patients who had their colon removed and whose diverticulitis was histologically proven, and in the evaluation of the severity of the inflammation (26 vs. 9 percent; P = 0.02). Moreover, of 69 patients who had an associated abscess seen on computed tomography, only 20 (29 percent) had indirect signs of this complication on contrast enema. CONCLUSIONS: In the diagnostic evaluation of acute left-colonic diverticulitis, computed tomography should be preferred to contrast enema as the initial radiologic examination because of its statistically significant superiority in sensitivity and for its significantly better performance in the detection of severe infection, especially when an abscess is associated with the disease.

Abscess↗
PubMed2000

Sphincter-sparing surgery after preoperative radiotherapy for low rectal cancers: feasibility, oncologic results and quality of life outcomes.

The present study assesses the choice of surgical procedure, oncologic results and quality of life (QOL) outcomes in a retrospective cohort of 53 patients with low-lying rectal cancers (within 6 cm of the anal verge) treated surgically following preoperative radiotherapy (RT, median dose 45Gy) with or without concomitant 5-fluorouracil. QOL was assessed in 23 patients by using two questionnaires developed by the QOL Study Group of the European Organization for Research and Treatment of Cancer: EORTC QLQ-C30 and EORTC QLQ-CR38. After a median interval of 29 days from completion of RT, abdominoperineal resection (APR) was performed in 29 patients (55%), low anterior resection in 23 patients (20 with coloanal anastomosis) and transrectal excision in one patient. The 3-year actuarial overall survival and locoregional control rates were 71.4% and 77.5% respectively, with no differences observed between patients operated by APR or restorative procedures. For all scales of EORTC QLQ-C30 and EORTC QLQ-CR38, no significant differences in median scores were observed between the two surgical groups. Although patients having had APR tended to report a lower body image score (P = 0.12) and more sexual dysfunction in male patients, all APR patients tended to report better physical function, future perspective and global QOL. In conclusion, sphincter-sparing surgery after preoperative RT seems to be feasible, in routine practice, in a significant proportion of low rectal cancers without compromising the oncologic results. However, prospective studies are mandatory to confirm this finding and to clarify the putative QOL advantages of sphincter-conserving approaches.

Aged↗
PubMed1999

[Left colectomy with immediate anastomosis in emergency surgery].

PURPOSE OF THE STUDY: A retrospective study of our experience with one-stage left colectomy for acute diverticulitis and obstruction with a review of the literature to more clearly define the indications of this procedure. PATIENTS AND METHODS: 30 patients were operated for acute diverticulitis (group 1) and 47 for obstruction (group 2). Only 7 patients (23%) of group 1 had an intraoperative colonic lavage while this was performed for all the patients of group 2. RESULTS: The postoperative morbidity and mortality for the patients of group 1 and 2 were 37 and 28%, and 7 and 11% respectively. None of the patients of group 1 had clinical anastomotic leak, while this occurred in 2 patients (4%) of group 2. The mean hospital stay was 26 days for patients of group 1 and 17 days for patients of group 2. CONCLUSIONS: Bowel obstruction should be treated by one-stage left colectomy and intraoperative colonic lavage for patients with low anaesthetic risks (ASA 1 and 2). Immediate anastomosis protected by colostomy or ileostomy could be proposed for patients with an intermediate risk (ASA 3). Patients with acute diverticulitis and a localized abscess or peritonitis should be treated with one-stage colectomy; an immediate protected anastomosis could be performed in patients with generalized purulent peritonitis while a Hartmann's type colectomy should be the reasonable option for fecal generalized peritonitis. Intraoperative colonic lavage does not seem mandatory.

Acute Disease↗
PubMed1998

Prospective randomized comparison of imipenem-cilastatin and piperacillin-tazobactam in nosocomial pneumonia or peritonitis.

Nosocomial pneumonia and acute peritonitis may be caused by a wide array of pathogens, and combination therapy is often recommended. We have previously shown that imipenem-cilastatin monotherapy was as efficacious as the combination of imipenem-cilastatin plus netilmicin in these two settings. The efficacy of imipenem-cilastatin is now compared to that of piperacillin-tazobactam as monotherapy in patients with nosocomial pneumonia or acute peritonitis. Three hundred seventy one patients with nosocomial pneumonia or peritonitis were randomly assigned to receive either imipenem-cilastatin (0.5 g four times a day) or piperacillin-tazobactam (4.5 g three times a day). Three hundred thirteen were assessable (154 with nosocomial pneumonia and 159 with peritonitis). For nosocomial pneumonia, clinical-failure rates in the piperacillin-tazobactam group (13 of 75 [17%]) and in the imipenem-cilastatin group (23 of 79 [29%]) were similar (P = 0.09), as were the numbers of deaths due to infection (6 in the imipenem-cilastatin group [8%], 7 in the piperacillin-tazobactam group [9%]) (P = 0.78). For acute peritonitis, clinical success rates were comparable (piperacillin-tazobactam, 72 of 76 [95%]; imipenem-cilastatin, 77 of 83 [93%]). For infections due to Pseudomonas aeruginosa, 45 patients had nosocomial pneumonia (21 in the piperacillin-tazobactam group and 24 in the imipenem-cilastatin group) and 10 had peritonitis (5 in each group). In the patients with nosocomial pneumonia, clinical failure was less frequent in the piperacillin-tazobactam group (2 of 21 [10%]) than in the imipenem-cilastatin [corrected] group (12 of 24 [50%]) (P = 0.004). Bacterial resistance to allocated regimen was the main cause of clinical failure (1 in the piperacillin-tazobactam group and 12 in the imipenem-cilastatin group). For the patients with peritonitis, no difference in clinical outcome was observed (five of five cured in each group). The overall frequencies of adverse events related to treatment in the two groups were similar (24 in the piperacillin-tazobactam group, 22 in the imipenem-cilastatin group). Diarrhea was significantly more frequent in the piperacillin-tazobactam group (10 of 24) than in the imipenem-cilastatin group (2 of 22). This study suggests that piperacillin-tazobactam monotherapy is at least as effective and safe as imipenem-cilastatin monotherapy in the treatment of nosocomial pneumonia or peritonitis. In P. aeruginosa pneumonia, piperacillin-tazobactam achieved a better clinical efficacy than imipenem-cilastatin, due to reduced development of microbiological resistance. Tolerance was comparable, with the exception of diarrhea, which was more frequent with piperacillin-tazobactam.

Acute Disease↗
PubMed1998

[Acute left-sided colonic diverticulitis: diagnosis and surgical indications after successful conservative therapy of first time acute diverticulitis].

PURPOSE: To compare the performances of computed tomography (CT) and water soluble contrast enema in the diagnosis and evaluation of the severity of acute left colonic diverticulitis, and to propose indications for elective colectomy after a first episode of diverticulitis successfully treated medically. PATIENTS AND METHODS: Prospective non-randomized study (1986-1997) of 542 patients (290 women and 252 men with a median age of 64 years) whose final diagnosis was confirmed either histologically or radiologically. 465 patients (86%) had a CT, 439 (81%) had a water soluble contrast enema, and 420 (77%) had both examinations. Diverticulitis was considered moderate when CT showed localized thickening of colonic wall (> or = 5 mm) and inflammation of pericolic fat and water soluble contrast enema showed segmental lumen narrowing and tattered mucosa; it was considered severe when abscess and/or extraluminal air/or extraluminal contrast were described by CT or the two latter by water soluble contrast enema. RESULTS: 410 patients (76%) were treated medically and 132 were operated during their hospitalization. Sensitivity of CT for diagnosis of diverticulitis was 96%, compared to 87% for water soluble contrast enema (p < 0.0001). Severe diverticulitis was found in 139 patients (30%) by CT and in 45 patients (11%) by water soluble contrast enema (p < 0.0001). Age < or = 50 years, severe diverticulitis in the initial CT and associated pelvic abscess were found to be statistically significant parameters to predict the risk of secondary complications after a first episode of diverticulitis successfully treated medically. CONCLUSIONS: Performances of CT for diagnosis and evaluation of severity of acute diverticulitis are statistically higher than that of water soluble contrast enema. We would recommend elective colectomy in patients 50 years of age or younger with a severe diverticulitis in initial CT, and in all patients with an associated pelvic abscess.

Abdominal Abscess↗
PubMed1997

Computed tomography in acute left colonic diverticulitis.

BACKGROUND: The use of computed tomography (CT) in acute left colonic diverticulitis remains controversial. The purpose of this study was to define the value of CT both during the acute phase of inflammation and, later, to indicate secondary complications after successful medical treatment. METHODS: Some 423 patients with radiologically or histologically proven diverticulitis were studied prospectively from 1986 to 1995. Diverticulitis was considered moderate when CT showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat; it was considered severe when abscess and/or extraluminal air and/or extraluminal contrast were observed. RESULTS: The sensitivity of CT was 97 per cent. Of 42 patients who failed conservative treatment, 32 had severe diverticulitis on CT, compared with 74 (24 per cent) of 303 who had successful conservative treatment (P < 0.0001). After a median follow-up of 46 months, 60 (20 per cent) of 300 patients had secondary complications despite initially successful conservative treatment: 28 (47 per cent) of these had initial severe diverticulitis on CT compared with 44 (19 per cent) of 236 patients who had no complications (P < 0.0001). CONCLUSION: Abscess formation and extracolonic contrast or gas are findings that may be used to predict failure of medical treatment during the first admission and a high risk of secondary complications after initially successful medical management of acute diverticulitis.

Acute Disease↗
PubMed1996

Stapled ileal pouch anal anastomoses are safer than handsewn anastomoses in patients with ulcerative colitis.

BACKGROUND: One of the theoretic advantages of using a stapled versus handsewn ileal pouch anal anastomosis (IPAA) in restorative proctocolectomy is a reduction in septic complications. We performed this study to compare the incidence of early septic complications in patients undergoing restorative proctocolectomy with stapled or handsewn IPAA. PATIENTS AND METHODS: A chart review of 692 patients undergoing restorative proctocolectomy for treatment of ulcerative colitis was performed. The incidence of early septic complications in patients having stapled IPAA was compared to that in patients having handsewn IPAA. Follow-up studies included an annual questionnaire and physical examination. RESULTS: Of the 692 patients, 238 had handsewn IPAA and 454 had stapled IPAA; these two groups were similar in sex, duration of disease, age at surgery, and type of surgical procedure performed. In the handsewn IPAA group, 25 patients (10.5%) had 32 septic complications, and 24 required 89 reparations. In 7 patients, the pouch was excised. In the stapled IPAA group, 21 patients (4.6%) had 23 septic complications, and 14 required 40 reparations. One patient needed pouch excision. There were more patients (P=0.0001) with early septic complications, and more (P<0.0001) pouch excisions because of these complications, in patients with handsewn IPAA than in patients with stapled IPAA. The sepsis-related reoperation rates did not differ significantly. CONCLUSIONS: The stapled technique for IPAA has fewer septic complications and results in fewer sepsis-related pouch excisions, in our hands, than the handsewn technique technique, for treating patients with ulcerative colitis.

Adolescent↗
PubMed1994

Left-sided colon and colorectal anastomoses: Doppler ultrasound as an aid to assess bowel vascularization. A prospective evaluation of 200 consecutive elective cases.

Two hundred non-randomized left-sided colon and colorectal anastomoses were performed on 199 consecutive patients admitted over a 4-year period (107 men and 92 woman with a median age of 66 years). There were 117 high anastomoses (above the peritoneal reflection), 86 (74%) of which were hand sewn, and 83 low anastomoses, 78 (94%) stapled with an EEA instrument. Adequate blood supply was assessed with a Doppler ultrasound in all but 5 cases. In ten patients bowel edges to be anastomosed were recut because of a negative Doppler ultrasound reading. One hundred and eighty-nine anastomoses were radiologically controlled. In-hospital post-operative mortality was 2.5% and morbidity 20%. There were two (1%) clinical anastomotic leaks and three (1.5%) radiological leaks. Use of Doppler ultrasound is simple and safe to assess vascularization of the intestinal edges. It may have contributed to the low anastomotic complication rate observed in this series.

Adult↗
PubMed1994

Surgical pitfalls in a patient with type IV Ehlers-Danlos syndrome and spontaneous colonic rupture. Report of a case.

PURPOSE: This paper intends to stress the importance of early diagnosis and discuss surgical treatment of Type IV Ehlers-Danlos syndrome (EDS-4), an autosomal dominant connective tissue disease characterized by typical features of the face and extremities, inappropriate and easy bruising, and extreme tissue fragility, which may lead to dramatic and often fatal complications, mostly spontaneous arterial or intestinal rupture. METHODS: We report the case of a 41-year-old female who presented with spontaneous perforation of the sigmoid colon. RESULTS: The patient was seen over a nine-year period, during which time she required six operations and presented with a great number of surgical complications including stenosis of an end-colostomy, repeated subocclusive episodes caused by intraperitoneal adhesions, and enterocutaneous fistulas, finally ending with an ileostomy and short bowel syndrome. It is only after a difficult laparotomy for ovarian cyst excision, marked by numerous adhesions and friable bowel, that the diagnosis of EDS-4 was considered and established. CONCLUSIONS: In case of "idiopathic" spontaneous perforation of the colon in a young adult, features of EDS-4 should be thoroughly looked into and, if found, skin fibroblast culture with collagen Type III analysis performed. The surgical treatment of choice consists of subtotal colectomy and permanent end-ileostomy. In case of patient refusal, a second-stage ileorectal anastomosis can be performed but carries the high risk of anastomotic leakage.

Adult↗
PubMed1994

Acute left colonic diverticulitis in young patients.

BACKGROUND: This prospective study was done to compare acute left-sided colonic diverticulitis in young patients (50 years of age or less) and older patients (more than 50 years of age) for severity of disease and immediate and late outcome. STUDY DESIGN: Of the 265 patients studied, 61 were 50 years of age or less; of these, 49 were men. In all instances, diagnosis was confirmed radiologically or histologically. RESULTS: Operations were performed less often upon younger patients than older patients (15 versus 33 percent, p = 0.001). Severe diverticulitis was found more often in younger men than older men (39 versus 23 percent). After successful conservative treatment during the first hospitalization period, younger men had a statistically greater risk of poor outcome than older men (29 versus 5 percent, p = 0.003). CONCLUSIONS: Although younger men have severe acute diverticulitis more often than older men, operative treatment during the first episode is less often needed. On the other hand, after conservative treatment, younger men have a statistically greater chance of poor secondary outcome than older men.

Abscess↗
PubMed1994

Acute left colonic diverticulitis: a prospective analysis of 226 consecutive cases.

BACKGROUND: The purpose of this prospective study was to evaluate the immediate and late outcome of acute left colonic diverticulitis and to correlate it with age (younger and older than 50 years of age), gender, and initial computed tomography (CT) findings. METHODS: Analysis was made of data collected prospectively from all patients admitted because of acute colonic diverticulitis between October 1986 and January 1992. Diagnosis relied on results of operation, CT, and Gastrografin enema. Two hundred twenty-six patients were urgently hospitalized for acute left colonic diverticulitis; 47 were younger than 50 years of age (21%). RESULTS: Sixty-six patients (29%) were operated on during their first hospitalization. The remaining 160 patients treated conservatively underwent CT and an enema within 72 hours of admission. Fifty-nine of 179 patients (33%) older than 50 years of age required operation during their first attack, compared with 7 in 47 patients (15%) younger than 50 years of age (p = 0.02), although on CT severe diverticulitis was found in 36 of 141 patients (26%) older than 50 years of age and in 16 of 43 patients (37%) younger than 50 years of age (p = 0.13). Of the 160 patients treated conservatively, 11 of 40 patients (28%) younger than 50 years of age experienced recurrences or complications after their first discharge, compared with 16 in 120 patients (13%) older than 50 years of age (p = 0.04). CONCLUSIONS: Patients younger than 50 years of age were significantly more prone to recurrences and complications after conservative treatment of their diverticulitis, whereas older patients required operation significantly more often during their first hospitalization.

Acute Disease↗
PubMed1993

[Value of computerized tomography in acute diverticulitis of the left colon].

This prospective study focuses on the prediction of late outcome after acute left colonic diverticulitis successfully treated conservatively and in which the diagnosis was confirmed radiologically (computed tomography [CT] and gastrografin enema [GE]). Acute diverticulitis was diagnosed in 226 patients. Sixty-six patients (29%) were operated on during their first hospitalization, and 2 of them died (3% mortality). The remaining 160 patients, successfully treated conservatively, had a CT and a GE within 72 hours of admission and entered this study. Signs of severity on CT included the presence of abscess(es) and/or extraluminal air and/or extraluminal hydrosoluble contrast (Gastrografin). Follow-up averaged 25 months (range 1 month to 5.3 years). Twenty-seven of these 160 patients (17%) had a poor outcome (persistent diverticulitis in 12, colonic stenosis in 6, recurrences in 7, residual parasigmoid abscess and colovesical fistula in one each). When comparing these 27 patients with the 133 others it appeared that: (1) men up to 50 years of age were significantly more prone to develop such complications (p = 0.003); (2) the probability of developing a complication was significantly greater when the initial CT had revealed an abscess and/or extraluminal air and/or extraluminal Gastrografin (p = 0.005). These results support the view that elective colectomy can reasonably be proposed after a first attack of acute left diverticulitis treated conservatively in men up to 50 years of age, and/or in patients whose initial CT revealed findings of severe diverticulitis.

Age Factors↗
PubMed1993

[Multiple tumors of colon and rectum].

The possible occurrence of multiple synchronous or metachronous malignant lesions in patients with carcinoma of the colon and rectum is a well known event. In this population-based study in the Geneva area from 1970 to 1986, the frequency of synchronous colorectal carcinomas was 1.1% and that of metachronous carcinomas 1%. The relative risk of metachronous colorectal carcinoma is higher than in the general population (colon after rectum 1.2, colon after colon 1.7 and rectum after rectum 1.4). A high association of adenomatous polyps with multiple colorectal carcinoma was observed. The 5-year actuarial survival in case of curative resection was 87% for metachronous carcinomas, 35% for single carcinomas and 33% for synchronous carcinomas. We conclude that complete preoperative colonoscopy, whenever possible, should be performed to screen patients with synchronous carcinomas. Finally, a lifelong follow-up of the residual colon or rectum should be planned to detect metachronous lesions.

Actuarial Analysis↗