Kaiser Sadiq

Background: Diverticulitis prevalence is on the rise, with recurrences occurring in up to one-third following an uncomplicated initial episode. While sigmoid resection was historically routine after a second episode, current guidelines recommend individualization. This review evaluates long-term outcomes for recurrent diverticulitis, comparing different treatment approaches. Methods: A systematic review (PROSPERO ID CRD42024600674) adhering to PRISMA guidelines searched several electronic databases. Clinical trials and observational studies published in English over the past decade that reported outcomes for persistent or recurrent diverticulitis were sought. Results: From 189 references, three retrospective cohort studies and one randomized control trial (RCT) were included, totaling 446 patients (42.1% male). Recurrence rates were 5.6–21.1% over follow-up durations ranging between 17 and 190 months. Definitions for recurrent diverticulitis varied across studies, with employed treatments including elective resection and nonoperative management. Outcomes evaluated included quality of life (QoL) assessments, reintervention rates, and recurrence risk. QoL showed greater improvement with surgery, but reintervention was more common after surgery (21%) than with nonoperative management. Recurrent or persistent diverticulitis demonstrated a higher recurrence risk, with increased incidence of surgery and comparable incidence of ostomy. Conclusions: Persistent or recurrent diverticulitis appears to be associated with higher rates of recurrence and surgery. However, contemporary literature detailing long-term outcomes is limited. Although surgical intervention may enhance QoL, it may also necessitate more reinterventions. Standardizing recurrent diverticulitis definitions would enable comparative analyses and inform guideline updates, facilitating evidence-based clinical decision-making.

Introduction: Tailgut cysts, or retrorectal cystic hamartomas, are uncommon developmental lesions found in the theoretical space between the rectum and the sacrum. Frequently asymptomatic and incidentally detected, they occur predominantly in women. Compression of nearby structures may cause perineal and back pain and even obstructed labor. Case Report: We report a case of a 50-year-old man with prior coccygeal fracture who presented with dull perineal pain, worsened by prolonged sitting. MRI revealed a cystic mass, and surgical excision was performed via a posterior perineal approach. Postoperative recovery was uneventful apart from surgery-related increased perineal pain. Pathology demonstrated a retrorectal cystic hamartoma. Discussion: Tailgut cysts are thought to originate from the embryonic tail, which normally regresses by the eighth week of gestation. MRI is the preferred imaging modality, with cysts appearing hypointense on T1 and hyperintense on T2 images. Solid components or irregular cyst walls on imaging may suggest malignancy. Preoperative biopsy carries risks of hemorrhage, infection, and tract seeding. In purely cystic lesions, complete surgical resection without biopsy is preferred. A perineal approach is recommended for small lesions below S3, while abdominal and abdominoperineal approaches are needed for larger lesions and those superior to S3. Routine coccygectomy was previously thought necessary to prevent recurrence but is now understood to be avoidable unless needed for exposure or the cyst is adherent. Malignant transformation occurs in up to 27% of cases, with recurrence up to 16%. Complete excision is essential to prevent recurrence and obtain a definitive diagnosis. Conclusion: Tailgut cysts, the most common retrorectal tumors, are often asymptomatic. MRI is the preferred imaging modality. Complete surgical resection is crucial to prevent malignancy and recurrence. The role of preoperative biopsy is controversial, and routine coccygectomy is no longer recommended.

Introduction: Hemorrhagic transformation is a major complication of large vessel occlusion (LVO) recanalization after mechanical thrombectomy in acute ischemic stroke. The hypoperfusion index ratio (HIR) quantifies the severity of cerebral hypoperfusion in the setting of an acute ischemic stroke using CT perfusion (CTP) to compare the volume of severely hypoperfused tissue (time-to-maximum [Tmax] > 10 s) to total hypoperfused tissue (Tmax >6 s), and has emerged as a potential predictor of ischemic core growth and poor outcomes. We investigated whether computed tomography perfusion (CTP) derived hypoperfusion index ratio correlates with the rate of hemorrhagic transformation. Methods: We conducted a retrospective cohort analysis of a prospectively maintained patient database. Included patients underwent mechanical thrombectomy for large vessel ischemic stroke from January 2019 to December 2022 at a single comprehensive stroke center. Patients were separated into 2 groups depending on whether hemorrhagic transformation developed. Hemorrhagic transformation included any hemorrhage that could be classified according to the ECASS criteria as hemorrhagic infarction (HI)1, HI2, parenchymal hematoma (PH)1 and PH2. Hypoperfusion index ratio on admission CTP was determined using VizAI software. Data were analyzed using Chi-square and Mann-Whitney U tests. Results: Among the 289 patients included (median age, 72.5; 41.5% female), 55 (19%) had hemorrhagic transformation. Patients with hemorrhagic transformation had a significantly higher hypoperfusion index ratio (median, 0 vs 0.2; P = 0.004) compared with those with no hemorrhagic transformation. Multivariable analysis showed that for every 0.1 increase in the hypoperfusion index ratio, there was a significant 4.64-fold increase in hemorrhagic transformation (OR 4.64; 95% CI 1.40 to 15.18; p = 0.011). Conclusion: In patients with LVO who underwent mechanical thrombectomy, a higher hypoperfusion index ratio on admission CTP was associated with an increased rate of hemorrhagic transformation. This suggests that the hypoperfusion index ratio could be used as a predictor for hemorrhagic transformation after mechanical thrombectomy.

Background: Diverting loop ileostomies (DLI) are commonly used to protect high-risk anastomoses. While a higher body mass index (BMI) is known to increase postoperative morbidity, its specific effect on DLI-related complications is less well understood. Methods: This systematic review and meta-analysis followed PRISMA guidelines, and Cochrane Library, Embase, PubMed, and Google Scholar were searched for English publications without time restrictions. Statistical analysis was performed using Meta-Mar v3.5.1. Results: Out of 586 studies yielded and 6 manually retrieved, 26 were included, totaling 5,141 patients (53.5% male). The mean ages were 35.0–65.3 years, and the mean BMI was 19.8–27.1 kg/m². Higher BMI increased stoma-site incisional hernia in 100% (n = 7) with a standardized mean difference of 0.88 (95% CI, 0.34–1.42). Two studies (40%) reported increased peristomal skin complications. One study each (100%) found increased risk for delayed reversal, stoma outlet obstruction, stoma-specific morbidity score, and longer operative time. Elevated BMI increased anastomotic leakage in 2 studies (50%), surgical site infection in 1 (33%), permanent stoma in 1 (20%), and overall complications in 2 (67%). However, no significant BMI differences were seen for high-output ileostomies, stoma retraction, parastomal hernia, complications after reversal, length of hospital stay, or mortality. BMI > 30 was associated with higher complication risks overall (OR [95% CI], 2.01 [1.11–3.64]), but BMI > 25 showed no significant difference except for stoma-site incisional hernia (OR [95% CI], 4.66 [3.54–6.14]) and parastomal hernia (OR [95% CI], 2.41 [1.70–3.40]). Conclusion: Increased BMI is a risk factor for certain DLI-related complications, particularly stoma-site incisional hernia. If feasible, mesh placement at the ileostomy site should be strongly considered for patients with a BMI > 25 to reduce the risk of stoma-site incisional hernia. Weight loss prior to DLI and reversal should be encouraged.