Correspondence
Measurement of cross-sectional area of the psoas for sarcopenia doi:10.1111/codi.12840
Dear Editor, Jones et al. [1] highlighted the effectiveness of preoperative determination of lean muscle mass, referred as sarcopenia, as a means to identify those at higher risk of major complications after colorectal resection. Given the limitations of current methodology we find the results of Jones et al. [1] particularly important for testing the hypothesis of their article. Sarcopenia is a generalized process which requires assessment of whole-body muscle mass rather than regional measurements of muscle area [2,3]. In the study by Jones et al. [1], diagnosis of sarcopenia was based on measurement of psoas muscle area (PMA) at the third lumbar region. To the best of our knowledge there is no validation study for the use of PMA alone to predict sarcopenia. Jones et al. [1] reported that the method in their work had previously been used in validation studies by Shen et al. [4] and Mourtzakis et al. [5], but Shen et al. [4] reported the validation analysis of total muscle area at the level of the fourth/fifth lumbar region, not PMA at the third lumbar vertebra. Besides this, the study by Mourtzakis et al. [5] assessed the validity of measuring total muscle area at the third lumbar region, consisting of the psoas, paraspinal muscles (erector spinae, quadratus lumborum) and the abdominal wall muscles (transversus abdominus, external and internal oblique and rectus abdominus). Also, the cut-off points (< 385 mm²/m² for women and < 545 mm²/m² for men) currently used to define sarcopenia were generated for measurement of total muscle area in the third lumbar region, not only the PMA [6]. It is therefore hard to conclude that the evaluation of muscle mass in their study is optimal.
Conflicts of interest No conflicts of interest.
C. Haymana* and U. Safer† *Department of Endocrinology, Gulhane School of Medicine, 06018, Ankara, Turkey and †Department of Geriatrics, Gulhane School of Medicine, 06018, Ankara, Turkey E-mail: [email protected] Received 23 October 2014; accepted 25 October 2014; Accepted Article online 17 November 2014
172
References 1 Jones KI, Doleman B, Scott S, Lund JN, Williams JP. Simple psoas cross sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications. Colorectal Dis 2015; 17: O20–6. 2 Binay Safer V, Safer U. Usefulness and limitations of single-slice computed tomography analysis at the third lumbar region in the assessment of sarcopenia. Crit Care 2013; 17: 466. 3 Safer U, Safer VB. Could single-slice quantitative computerized tomography image analysis at the midpoint of the third lumbar region accurately predict total body skeletal muscle? JPEN J Parenter Enteral Nutr 2014; 38: 415. 4 Shen W, Punyanitya M, Wang Z et al. Total body skeletal muscle and adipose tissue volumes: estimation from a single abdominal cross-sectional image. J Appl Physiol 2004; 97: 2333–8. 5 Mourtzakis M, Prado CM, Lieffers JR, Reiman T, McCargar LJ, Baracos VE. A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Appl Physiol Nutr Metab 2008; 33: 997–1006. 6 Prado CM, Lieffers JR, McCargar LJ et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol 2008; 9: 629–35.
Preventing or repairing ileal conduit herniation? doi:10.1111/codi.12856
Dear Sir, We enjoyed the video vignette clearly demonstrating the benefits of a laparoscopic modified Sugarbaker repair for ileal conduit herniation [1], yet could not help but be reminded of Benjamin Franklin’s (1706– 90) quote: ‘an ounce of prevention is worth a pound of cure’. Parastomal herniation is an oft encountered problem when the trephine is raised through the belly of the rectus muscle, as is traditionally done and illustrated in the video. With this in mind, the lateral rectus abdominis positioned stoma (or LRAPS) technique to stoma formation was described, with the aim of minimizing abdominal wall disruption and subsequent hernia formation [2]. Briefly, dissection employs horizontal (rather than cruciate) incisions in the sheaths above the arcuate line of Douglas, with the rectus muscle swept medially to accommodate the trephine. This approach
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
Correspondence
was adopted by one surgeon (ACC) for ileal conduit formation in 47 consecutive patients undergoing radical cystectomy since February 2008. At 1-year follow-up eight patients had died. None of the remaining 39 patients had clinical evidence of herniation, of whom 33 had undergone surveillance CT scanning with no radiological evidence of herniation. Careful radiological scrutiny of the trephine site revealed that the ileal conduit was completely lateral to the rectus muscle in 25 cases (76%; a ‘true’ LRAPS). In the remainder of cases there were fibres of the rectus abdominis muscle, of varying width, lateral to the emerging ileum (an ‘incomplete’ LRAPS). Although surveillance CT scrutiny did not detect conduit herniation in this cohort we remain aware that Franklin also wrote ‘when you are finished changing, you’re finished’. A LRAPS at ileal conduit formation is clearly worth considering as the trephine has to be less capacious.
D. C. Bosanquet*, A. Mainwaring †, O. Rutka*, B. M. Stephenson* and A. C. Carter † * Departments of General Surgery, Royal Gwent Hospital, Cardiff Road, Newport, South Wales, NP20 2UB, UK and † Urology, Royal Gwent Hospital, Cardiff Road, Newport, South Wales, NP20 2UB, UK E-mail: [email protected] Received 28 October 2014; accepted 29 October 2014; Accepted Article online 3 December 2014
References 1 Gosselink MP, Mishra A, Mortensen NJ et al. Laparoscopic modified Sugarbaker technique for the repair of an urostomal hernia: a video vignette. Colorectal Dis 2014; 17: 90–1. 2 Stephenson BM, Evans MD, Hilton J, McKain ES, Williams GL. Minimal anatomical disruption in stoma formation: the lateral rectus abdominis positioned stoma (LRAPS). Colorectal Dis 2010; 12: 1049–52.
Sigmoid diverticulitis with brain abscess doi:10.1111/codi.12842
Dear Sir, Acute diverticular disease with abscess formation is the most common form of complicated diverticulitis. While typically manifesting as a localized pericolic abscess or distant extension into the pelvis, unusual presentations are occasionally seen. Pyogenic liver abscesses have resulted from infectious spread into the portal circula-
tion and retroperitoneal spread allows for extra-abdominal spread [1]. Atypical involvement of the brain and nervous system, however, are among the rarest complications observed. A 67-year-old female with a history of recurrent diverticulitis presented to the emergency department with a 1-week history of weakness, anorexia, fevers, vomiting and diarrhoea. On examination the patient was tender to palpation in the left lower quadrant of the abdomen with hypoactive bowel sounds. Her laboratory findings were significant for leukocytosis of 16.5 kcounts/ll with 85% neutrophils. A computed tomography (CT) of the abdomen and pelvis demonstrated sigmoid diverticulitis complicated by a 6 9 4 cm abscess located medial to the sigmoid colon abutting the dome of the urinary bladder. The patient was initially admitted to the medicine service, started on intravenous antibiotics and underwent CT-guided drainage of the abscess by interventional radiology. Despite these interventions, the patient continued to have fever and leukocytosis, and repeat imaging showed failed resolution of the abscess. Colorectal surgery was consulted. The patient underwent an exploratory laparotomy with sigmoid resection and end colostomy. On postoperative day 6 the patient demonstrated an acute change in mental status, with confusion, garbled speech and a notable right hemiparesis on physical examination. CT and subsequent magnetic resonance imaging of the brain demonstrated a 5.3 9 2.7 9 3.4 cm ring-enhancing parasagittal parietal lesion suggestive of an abscess. Image-guided stereotactic needle drainage of the abscess was productive of purulent material and an external ventricular drain was placed by the neurosurgery service. The patient demonstrated a slow but improving hospital course, with an eventual return to baseline functionality at follow-up visit. The overall occurrence of brain abscess formation from any cause is exceedingly small with an incidence rate of approximately 0.3–1.3 per 100 000 persons per year [2]. Brain abscesses are most frequently seen in immunocompromised patients, patients who have had recent neurosurgery or head trauma or from direct spread of a parameningeal infection [3]. While the overall rate of abscess formation is 7.4% in patients with acute diverticular disease [4] the unusual manifestation of a brain abscess is remarkably rare, with only four cases previously reported in the literature [5–8]. While such unusual complications of acute diverticulitis are rare, it is important to maintain cognizance of this phenomenon. Encountering any mental status changes in these patients with fever, headache or nausea [9]
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
173
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Measurement of cross-sectional area of the psoas for sarcopenia doi:10.1111/codi.12840
Dear Editor, Jones et al. [1] highlighted the effectiveness of preoperative determination of lean muscle mass, referred as sarcopenia, as a means to identify those at higher risk of major complications after colorectal resection. Given the limitations of current methodology we find the results of Jones et al. [1] particularly important for testing the hypothesis of their article. Sarcopenia is a generalized process which requires assessment of whole-body muscle mass rather than regional measurements of muscle area [2,3]. In the study by Jones et al. [1], diagnosis of sarcopenia was based on measurement of psoas muscle area (PMA) at the third lumbar region. To the best of our knowledge there is no validation study for the use of PMA alone to predict sarcopenia. Jones et al. [1] reported that the method in their work had previously been used in validation studies by Shen et al. [4] and Mourtzakis et al. [5], but Shen et al. [4] reported the validation analysis of total muscle area at the level of the fourth/fifth lumbar region, not PMA at the third lumbar vertebra. Besides this, the study by Mourtzakis et al. [5] assessed the validity of measuring total muscle area at the third lumbar region, consisting of the psoas, paraspinal muscles (erector spinae, quadratus lumborum) and the abdominal wall muscles (transversus abdominus, external and internal oblique and rectus abdominus). Also, the cut-off points (< 385 mm²/m² for women and < 545 mm²/m² for men) currently used to define sarcopenia were generated for measurement of total muscle area in the third lumbar region, not only the PMA [6]. It is therefore hard to conclude that the evaluation of muscle mass in their study is optimal.
Conflicts of interest No conflicts of interest.
C. Haymana* and U. Safer† *Department of Endocrinology, Gulhane School of Medicine, 06018, Ankara, Turkey and †Department of Geriatrics, Gulhane School of Medicine, 06018, Ankara, Turkey E-mail: [email protected] Received 23 October 2014; accepted 25 October 2014; Accepted Article online 17 November 2014
172
References 1 Jones KI, Doleman B, Scott S, Lund JN, Williams JP. Simple psoas cross sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications. Colorectal Dis 2015; 17: O20–6. 2 Binay Safer V, Safer U. Usefulness and limitations of single-slice computed tomography analysis at the third lumbar region in the assessment of sarcopenia. Crit Care 2013; 17: 466. 3 Safer U, Safer VB. Could single-slice quantitative computerized tomography image analysis at the midpoint of the third lumbar region accurately predict total body skeletal muscle? JPEN J Parenter Enteral Nutr 2014; 38: 415. 4 Shen W, Punyanitya M, Wang Z et al. Total body skeletal muscle and adipose tissue volumes: estimation from a single abdominal cross-sectional image. J Appl Physiol 2004; 97: 2333–8. 5 Mourtzakis M, Prado CM, Lieffers JR, Reiman T, McCargar LJ, Baracos VE. A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Appl Physiol Nutr Metab 2008; 33: 997–1006. 6 Prado CM, Lieffers JR, McCargar LJ et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol 2008; 9: 629–35.
Preventing or repairing ileal conduit herniation? doi:10.1111/codi.12856
Dear Sir, We enjoyed the video vignette clearly demonstrating the benefits of a laparoscopic modified Sugarbaker repair for ileal conduit herniation [1], yet could not help but be reminded of Benjamin Franklin’s (1706– 90) quote: ‘an ounce of prevention is worth a pound of cure’. Parastomal herniation is an oft encountered problem when the trephine is raised through the belly of the rectus muscle, as is traditionally done and illustrated in the video. With this in mind, the lateral rectus abdominis positioned stoma (or LRAPS) technique to stoma formation was described, with the aim of minimizing abdominal wall disruption and subsequent hernia formation [2]. Briefly, dissection employs horizontal (rather than cruciate) incisions in the sheaths above the arcuate line of Douglas, with the rectus muscle swept medially to accommodate the trephine. This approach
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
Correspondence
was adopted by one surgeon (ACC) for ileal conduit formation in 47 consecutive patients undergoing radical cystectomy since February 2008. At 1-year follow-up eight patients had died. None of the remaining 39 patients had clinical evidence of herniation, of whom 33 had undergone surveillance CT scanning with no radiological evidence of herniation. Careful radiological scrutiny of the trephine site revealed that the ileal conduit was completely lateral to the rectus muscle in 25 cases (76%; a ‘true’ LRAPS). In the remainder of cases there were fibres of the rectus abdominis muscle, of varying width, lateral to the emerging ileum (an ‘incomplete’ LRAPS). Although surveillance CT scrutiny did not detect conduit herniation in this cohort we remain aware that Franklin also wrote ‘when you are finished changing, you’re finished’. A LRAPS at ileal conduit formation is clearly worth considering as the trephine has to be less capacious.
D. C. Bosanquet*, A. Mainwaring †, O. Rutka*, B. M. Stephenson* and A. C. Carter † * Departments of General Surgery, Royal Gwent Hospital, Cardiff Road, Newport, South Wales, NP20 2UB, UK and † Urology, Royal Gwent Hospital, Cardiff Road, Newport, South Wales, NP20 2UB, UK E-mail: [email protected] Received 28 October 2014; accepted 29 October 2014; Accepted Article online 3 December 2014
References 1 Gosselink MP, Mishra A, Mortensen NJ et al. Laparoscopic modified Sugarbaker technique for the repair of an urostomal hernia: a video vignette. Colorectal Dis 2014; 17: 90–1. 2 Stephenson BM, Evans MD, Hilton J, McKain ES, Williams GL. Minimal anatomical disruption in stoma formation: the lateral rectus abdominis positioned stoma (LRAPS). Colorectal Dis 2010; 12: 1049–52.
Sigmoid diverticulitis with brain abscess doi:10.1111/codi.12842
Dear Sir, Acute diverticular disease with abscess formation is the most common form of complicated diverticulitis. While typically manifesting as a localized pericolic abscess or distant extension into the pelvis, unusual presentations are occasionally seen. Pyogenic liver abscesses have resulted from infectious spread into the portal circula-
tion and retroperitoneal spread allows for extra-abdominal spread [1]. Atypical involvement of the brain and nervous system, however, are among the rarest complications observed. A 67-year-old female with a history of recurrent diverticulitis presented to the emergency department with a 1-week history of weakness, anorexia, fevers, vomiting and diarrhoea. On examination the patient was tender to palpation in the left lower quadrant of the abdomen with hypoactive bowel sounds. Her laboratory findings were significant for leukocytosis of 16.5 kcounts/ll with 85% neutrophils. A computed tomography (CT) of the abdomen and pelvis demonstrated sigmoid diverticulitis complicated by a 6 9 4 cm abscess located medial to the sigmoid colon abutting the dome of the urinary bladder. The patient was initially admitted to the medicine service, started on intravenous antibiotics and underwent CT-guided drainage of the abscess by interventional radiology. Despite these interventions, the patient continued to have fever and leukocytosis, and repeat imaging showed failed resolution of the abscess. Colorectal surgery was consulted. The patient underwent an exploratory laparotomy with sigmoid resection and end colostomy. On postoperative day 6 the patient demonstrated an acute change in mental status, with confusion, garbled speech and a notable right hemiparesis on physical examination. CT and subsequent magnetic resonance imaging of the brain demonstrated a 5.3 9 2.7 9 3.4 cm ring-enhancing parasagittal parietal lesion suggestive of an abscess. Image-guided stereotactic needle drainage of the abscess was productive of purulent material and an external ventricular drain was placed by the neurosurgery service. The patient demonstrated a slow but improving hospital course, with an eventual return to baseline functionality at follow-up visit. The overall occurrence of brain abscess formation from any cause is exceedingly small with an incidence rate of approximately 0.3–1.3 per 100 000 persons per year [2]. Brain abscesses are most frequently seen in immunocompromised patients, patients who have had recent neurosurgery or head trauma or from direct spread of a parameningeal infection [3]. While the overall rate of abscess formation is 7.4% in patients with acute diverticular disease [4] the unusual manifestation of a brain abscess is remarkably rare, with only four cases previously reported in the literature [5–8]. While such unusual complications of acute diverticulitis are rare, it is important to maintain cognizance of this phenomenon. Encountering any mental status changes in these patients with fever, headache or nausea [9]
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 172–176
173
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
