PURPOSE: There is limited information evaluating outcomes of surgery for sigmoid diverticulitis in lung transplant recipients when compared to immuno-competent patients. This study aims to evaluate the differences in disease presentation and management between such patients and immuno-competent counterparts.
METHODS: Lung transplant recipients who underwent surgery for CT-proven sigmoid diverticulitis were identified from prospectively maintained diverticulitis and lung transplant databases and case-matched to an equal number of immuno-competent patients undergoing surgery for diverticulitis based on surgical procedure, ASA, Hinchey score, elective vs. urgent surgery, age±10 years and year of surgery±5. Demographics, clinical presentation and perioperative outcomes were assessed.
RESULTS: Of 920 consecutive lung transplant recipients since 1980, 14 patients (1.5%) underwent surgery during 1995-2010. Urgent procedures were performed in 12 patients (Hartmann’s procedure 8, sigmoidectomy with diverting ileostomy 3, loop ileostomy creation 1), 4 of whom within a month after transplantation (33%) with 50% mortality (N=2). Two patients required urgent surgery for recurrent diverticulitis following initially successful antibiotics treatment. When compared to immuno-competent patients, following urgent operations, transplant recipients suffered significantly increased postoperative mortality (3 patients, 25% vs. 0%, p=0.01), increased overall morbidity (67% vs. 25 %, p=0.1) and longer mean length of hospital stay (24 vs. 13 days, p=0.1). Two patients underwent elective sigmoid resection with diverting ileostomy with no mortality. Number of patients with permanent stoma without restoration of continuity were comparable between transplant recipients and immuno-competent patients (9% vs. 13%, p=0.7). Of the patients that survived to outpatient follow up, there was no evidence of early 1 year graft failure or BOS.
CONCLUSIONS: Urgent surgery for sigmoid diverticulitis in lung transplant recipients is associated with high mortality, especially during the early post-transplant period. Elective surgery, on the other hand, can be performed safely. This supports the consideration of a lower threshold for elective surgery in transplant recipients and close monitoring with a multidisciplinary decision-making process for those who develop an attack, since an urgent procedure carries significant risks.
CLINICAL IMPLICATIONS: Elective surgery should be considered in a lung transplant recipients with a history of diverticulitis
DISCLOSURE: The following authors have nothing to disclose: Avraham Reshef, Luca Stocchi, Marie Budev, Ravi Kiran
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