Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons

An evaluation of patient experience before and after elective colectomy for diverticulitis between patients older and younger than 65 years: A pilot feasibility study in mobile health use

BACKGROUND

Mobile health (mHealth) platforms are being used to understand patient-reported experiences before and after surgery. Currently, there is limited literature describing the feasibility of using mHealth to evaluate patient experience among older adults. The objective of this study was to determine the feasibility of using mHealth to evaluate patient-reported outcomes among patients older and younger than 65 years undergoing elective colectomy for diverticulitis.

METHODS

A prospective pilot study was performed between June 1, 2020 and August 31, 2021, enrolling patients aged > 18 years undergoing elective colectomy for diverticulitis at a single academic center (n = 62). A Health Insurance Portability and Accountability Act-compliant mHealth platform was used to deliver patient-reported quality-of-life surveys at 3 time points: preoperatively, 3 months postoperatively, and 6 months postoperatively. The primary outcome was the feasibility of using mHealth in patients older and younger than 65 years to collect outcomes using recruitment, engagement, and survey completion rates. Preliminary findings of patient experiences were evaluated for patients older and younger than 65 years as secondary outcomes.

RESULTS

Overall, 33.9% of participants were older than 65 years with a median age of 59.8 years (IQR, 53.3-67.9). mHealth enrollment was high (100%) with survey response rates of 79% preoperatively, 64.5% at 3 months postoperatively, and 17.7% at 6 months postoperatively. Response rates were similar among patients older and younger than 65 years (P = .79 preoperatively and P = .39 at 3 months postoperatively).

CONCLUSION

Utilization of mHealth to evaluate patient-reported outcomes is feasible in the preoperative and early postoperative settings, including older adults undergoing elective surgery for diverticulitis. Future work will focus on improving long-term outcomes to better examine potential differences when considering patient-centered outcomes among older adult patients.

Decision Aid for Colectomy in Recurrent Diverticulitis: Development and Usability Study

BACKGROUND

Diverticular disease is a common gastrointestinal diagnosis with over 2.7 million clinic visits yearly. National guidelines from the American Society of Colon and Rectal Surgeons state that "the decision to recommend elective sigmoid colectomy after recovery from uncomplicated acute diverticulitis should be individualized." However, tools to individualize this decision are lacking.

OBJECTIVE

This study aimed to develop an online educational decision aid (DA) to facilitate effective surgeon and patient communication about treatment options for recurrent left-sided diverticulitis.

METHODS

We used a modified design sprint methodology to create a prototype DA. We engaged a multidisciplinary team and adapted elements from the Ottawa Personal Decision Guide. We then iteratively refined the prototype by conducting a mixed methods assessment of content and usability testing, involving cognitive interviews with patients and surgeons. The findings informed the refinement of the DA. Further testing included an in-clinic feasibility review.

RESULTS

Over a 4-day in-person rapid design sprint, including patients, surgeons, and health communication experts, we developed a prototype of a diverticulitis DA, comprising an interactive website and handout with 3 discrete sections. The first section contains education about diverticulitis and treatment options. The second section clarifies the potential risks and benefits of both clinical treatment options (medical management vs colectomy). The third section invites patients to participate in a value clarification exercise. After navigating the DA, the patient prints a synopsis that they bring to their clinic appointment, which serves as a guide for shared decision-making.

CONCLUSIONS

Design sprint methodology, emphasizing stakeholder co-design and complemented by extensive user testing, is an effective and efficient strategy to create a DA for patients living with recurrent diverticulitis facing critical treatment decisions.

Neutrophil- and Platelet-Lymphocyte Ratio as Biomarkers of Severity in Complicated Diverticular Disease

INTRODUCTION

Diverticulitis is a prevalent gastrointestinal disease that may require surgical intervention. The aim of the study was to investigate the involvement of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) as biomarkers of severity in complicated diverticular disease (CDD) in Mexican patients and their correlation with the need for surgical intervention, the length of hospital stay, and mortality.

MATERIAL AND METHODS

An observational, longitudinal, and retrospective study performed from 2017 to 2021 was considered in patients over 18 years of age, with a diagnosis of CDD by using computed tomography and with a hemogram taken in the first 24 hours upon admission to the emergency department to describe the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) of NLR and PLR in the CDD.  Results: A total of 102 Mexican patients suffering from CDD, 54% women and 46% men with a mean of 59 years, were analyzed. According to Hinchey's classification, 79 (77.5%) patients showed type I, 12 (12.8%) type II, 5 (4.9%) type III, and 6 (5.9%) type IV. The mean hospital stay was 8.8 days, with a mortality rate of 3.9%. The cut-off value was established at 5.1 for NLR according to the results of the receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.633, a sensitivity of 90%, a specificity of 43%, PPV of 21.8%, and NPV of 96% for the prediction of CDD. A cut-off value for PLR at 72 was established according to the results of the ROC curve with an AUC of 0.482, a sensitivity of 78%, a specificity of 40%, PPV of 96%, and NPV of 9% for the prediction of CDD.

CONCLUSION

The NLR and PLR are easily calculable and accessible biomarkers that can be part of the decision-making for the diagnosis and treatment of CDD in Mexican people as has been observed in other populations. However, more prospective, multicenter comparative studies are needed to assess the efficacy and safety of these biomarkers in relation to those already described.

Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review

BACKGROUND

This systematic umbrella review aims to investigate and provide an analysis of guidelines regarding the treatment of diverticular abscesses.

MATERIAL AND METHODS

A systematic literature search was performed using the Cochrane Overviews of Reviews model and the 'Clinical Practice Guidelines'; at the end of initial search, only 12 guidelines were included in this analysis. The quality of the guidelines was assessed by adopting the "Appraisal of Guidelines for Research and Evaluation II" (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses.

CONCLUSIONS

Currently, different scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only a few guidelines suggest the use of percutaneous drainage for abscesses with a diameter greater than 4 cm. The differences among guidelines are the consequence of the different selection of scientific evidence. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.

Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

Antibiotics for uncomplicated diverticulitis

BACKGROUND

Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis has been regarded as an infectious disease. Risk factors for diverticulitis, however, may suggest that the condition is inflammatory rather than infectious which makes the use of antibiotics questionable.

OBJECTIVES

The objectives of this systematic review were to determine if antibiotic treatment of uncomplicated acute diverticulitis affects the risk of complications (immediate or late) or the need for emergency surgery.

SEARCH METHODS

For this update, a comprehensive systematic literature search was conducted in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform on February 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including all types of patients with a radiologically confirmed diagnosis of left-sided uncomplicated acute diverticulitis. Comparator and interventions included antibiotics compared to no antibiotics, placebo, or to any other antibiotic treatment (different regimens, routes of administration, dosage or duration of treatment). Primary outcome measures were complications and emergency surgery. Secondary outcomes were recurrence, late complications, elective colonic resections, length of hospital stay, length to recovery of symptoms, adverse events and mortality.

DATA COLLECTION AND ANALYSIS

Two authors performed the searches, identification and assessment of RCTs and data extraction. Disagreements were resolved by discussion or involvement of the third author. Authors of trials were contacted to obtain additional data if needed or for preliminary results of ongoing trials. The Cochrane Collaboration's tool for assessing risk of bias was used to assess the methodological quality of the identified trials. The overall quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effect estimates were extracted as risk ratios (RRs) with 95% confidence intervals. Random-effects meta-analyses were performed with the Mantel-Haenzel method.

MAIN RESULTS

The authors included five studies. Three studies compared no antibiotics to antibiotics; all three were original RCTs of which two also published long-term follow-up information.  For the outcome of short-term complications there may be little or no difference between antibiotics and no antibiotics (RR 0.89; 95% CI 0.30 to 2.62; 3 studies, 1329 participants; low-certainty evidence). The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics (RR 0.47; 95% CI 0.13, 1.71; 1329 participants; 3 studies; low-certainty evidence). However, there is considerable imprecision due to wide confidence intervals for this effect estimate causing uncertainty which means that there may also be a benefit with antibiotics. One of the two remaining trials compared single to double compound antibiotic therapy and, due to wide confidence intervals, the estimate was imprecise and indicated an uncertain clinical effect between these two antibiotic regimens (RR 0.70; 95% CI 0.11 to 4.58; 51 participants; 1 study; low-certainty evidence). The last trial compared short to long intravenous administration of antibiotics and did not report any events for our primary outcomes. Both trials included few participants and one had overall high risk of bias. Since the first publication of this systematic review, an increasing amount of evidence supporting the treatment of uncomplicated acute diverticulitis without antibiotics has been published, but the total body of evidence is still limited.

AUTHORS' CONCLUSIONS

The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications. The quality of the evidence is low. Only three RCTs on the need for antibiotics are currently available. More trials are needed to obtain more precise effect estimates.

Surgeons' Perspective of Decision Making in Recurrent Diverticulitis: A Qualitative Analysis

Objective

This study employs qualitative methodology to assess surgeons' perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making.

Summary Background Data

The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons' current attitudes and opinions.

Methods

We performed semi-structured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework.

Results

25 surgeons were enrolled over a nine-month period. There was diversity in surgeons' gender, age, experience, training, specialty (colorectal vs general surgery) and geography. Surgeons described the difficult process to determine who receives an operation. We identified seven major themes as well as twenty subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction. [What about what surprised you/].

Conclusions

Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision making warrant development.

Elective Surgery for Diverticulitis in Swiss Hospitals

Objective: To assess current management of diverticulitis in Switzerland.

Methods: Prospective observational study of diverticulitis management and outcomes in surgical departments over a 3-month time period. Hospital category was graded according to the Swiss Medical Association (FMH) as: U: University; A: Cantonal; B: Regional; P: Private.

Results: 75 participating hospitals treated 1,015 patients, among whom 214 patients (21%) had elective sigmoid resections in 49 hospitals. Indication for elective resection were recurrent diverticulitis, previous complicated diverticulitis, fistulas, and stenosis. Surgeries were performed completely laparoscopically in 185 cases (86%) and required conversion to open in 19 cases (9%). Overall postoperative complication rate was 18% (n = 39) and no mortality was observed. Operation time, surgeons experience and hospital stay differed considerably between hospital categories.

Conclusions: Elective sigmoid resection for diverticulitis in Switzerland was mainly performed laparoscopically with low postoperative morbidity. Different practices and outcomes between institutions were observed.

State-of-the-art surgery for sigmoid diverticulitis

Background

In the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease.

Purpose

This article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis.

Conclusion

Acute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann’s procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann’s procedure, and it is associated with a high rate of primary anastomosis.

Elective Surgery for Diverticulitis and the Risk of Recurrence and Ostomy

OBJECTIVE

To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence.

BACKGROUND

While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks.

METHODS

Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014).

RESULTS

Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%].

CONCLUSIONS

Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.

Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis

Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Spatial distribution and source analysis of heavy metals in soils influenced by industrial enterprise distribution: Case study in Jiangsu Province

Heavy metal pollution is frequent in China and has received increasing attention globally. This study investigated the influence of Chinese industrialization and urbanization on soil environmental quality. Soil samples from Jiangsu Province were collected, the Cd, Pb, Cr, Cu, Zn, Hg, and As contents were measured, and their spatial variability structure, spatial distribution pattern, and pollution degree were analyzed. The mean values of Hg, Cd, Pb, Cr, Cu, and As were all higher than the background values in Jiangsu Province. Cr and As levels represented moderate pollution, Cu, Zn, Cd, and Pb represented mild pollution, Cr and As represented slight pollution, and Hg was not a pollutant. Spatial distribution patterns were both zonal and concentrated in nature. High concentrations of heavy metals were distributed in developed cities and industrial parks along the Yangtze River. Soil heavy metal pollution showed a decreasing trend from south to north, consistent with the economic gradient. Industrialization had the greatest influence on the spatial heterogeneity of heavy metal pollution. Cr, Cu, Zn, and As were affected by both natural and anthropogenic sources, while Cd and Pb were mainly affected by the latter. Hg was mainly derived from industrial activities such as petrochemical production. There was spatial consistency between industrial enterprise distribution and soil heavy metal pollution with a tendency toward composite pollution accumulated by multiple elements in the soil surrounding industries.

[X-ray-surgery of diverticular disease complicated by abscess formation]

PURPOSE

Show the possibility of an alternative use of interventional radiology techniques in complex treatment of patients with inflammatory complications of the diverticular disease of the colon.

MATERIAL AND METHODS

In 2012-2016, there were 87 patients under our supervision with complicated diverticular disease. In 57 (65.5%) cases were diagnosed infiltrate, in 24 (27.6%) cases - abscess of paracolon area (Ib-II type by Hinchey), in 6 (6.9%) cases (III-IV type according Hinchey) generalized peritonitis have been identified.

RESULTS

Emergency laparotomy was performed in 13 patients. Abscesses of paracolon (Ib-II type by Hinchey) area were diagnosed sonographically during the initial examination in 17 patients. 26 percutaneous drainage of diverticulogenous abscesses of different localizations self-locking drainage #8Fr 'pig tail' was carried out under the combined ultrasonic and X-ray control in this group of patients. The technical success of percutaneous drainaging of the abscesses was achieved in all manipulations. 13 patients had a single drainaging, and for diverticular disease - disease-free during the observation period of 1 year to 5 years. Resection of the colon in a planned manner after percutaneous drainage of recurrent abscess of paracolon area was performed in 4 patients. Complications related with the technique of installing drainage were not reported, mortality in the group of drained patients was absent.

CONCLUSION

Ultrasound examination of patients with suspected inflammatory complications of diverticular disease - a necessary and sufficient method for initial diagnosis of the disease. Percutaneous drainage of diverticulogenous abscesses (Hinchey Ib-II) is represented by the pragmatic 'first line' choice in patients with complicated diverticular disease, that allows to treat the pathology steadfastly in most of the cases.

Predicting Future Elective Colon Resection for Diverticulitis Using Patterns of Health Care Utilization

Background

Recurrent diverticulitis is the most common reason for elective colon surgery and, although professional societies now recommend against early resection, its use continues to rise. Shared decision making decreases use of low-value surgery but identifying which patients are most likely to elect surgery has proven difficult. We hypothesized that Machine Learning algorithms using health care utilization (HCU) data can predict future clinical events including early resection for diverticulitis.

Study Design

We developed models for predicting future surgery among patients with new diagnoses of diverticulitis (2009-2012) from the MarketScan® database. Claims data (diagnosis, procedural, and drug codes) were used to train three Machine Learning algorithms to predict surgery occurring between 52 and 104 weeks following diagnosis.

Results

Of 82,231 patients with incident diverticulitis (age 51 ± 8 years, 52% female), 1.2% went on to elective colon resection. Using maximal training data (152 consecutive weeks of claims), the Gradient Boosting Machine model predicted elective surgery with an area under the curve (AUC) of 75% (95% uncertainty interval [UI] 71-79%). Models trained on less data resulted in less accurate prediction (AUC: 68% [64-74%] using 128 weeks, 57% [53-63%] using 104 weeks). The majority of resections (85%) were identified as low-value.

Conclusion

By applying Machine Learning to HCU data from the time around a diagnosis of diverticulitis, we predicted elective surgery weeks to months in advance, with moderate accuracy. Identifying patients who are most likely to elect surgery for diverticulitis provides an opportunity for effective shared decision making initiatives aimed at reducing the use of costly low-value care.

Mortality after emergency Hartmann's procedure in octogenarians: a propensity score-matched analysis

BACKGROUND

Complicated diverticulitis is associated with a postoperative mortality rate of 20%. We hypothesized that age ≥80 was an independent risk factor for mortality after Hartmann's procedure for diverticular disease when controlling for baseline comorbidities.

METHODS

Patients who underwent an urgent or emergent Hartmann's procedure (Current Procedural Terminology codes 44143 and 44206) for diverticular disease (International Classification of Diseases-9:562.xx) were identified using the American College of Surgeons National Surgical Quality Improvement Project 2005-2013 user file. Using propensity score matching to control for baseline comorbidities, a group of patients ≥80 years old was matched to a group of those <80 years old. Univariate and multivariable logistic regression were performed. A P value <0.05 was considered statistically significant with a confidence interval (CI) of 95%.

RESULTS

From a total of 2986 patients, 464 patients (15.5%) were ≥80 years old. Two groups of 284 patients in each study arm were matched using propensity-matching. The mean age of the ≥80 group and <80 group was 84.4 ± 3.3 versus 63.77 ± 911.8; P < 0.0001, respectively. There was no statistical difference in baseline comorbidities or operative time between the groups. There was a significant difference in mortality with 19% and 9.2% in the >80 group versus <80 groups, respectively (P = 0.001). Factors associated with mortality included ascites (odds ratio [OR] 4.95, confidence interval [CI] 1.64-14.93, P = 0.005), previous cardiac surgery (OR 3.68, CI 1.46-9.26, P = 0.006), partially dependent or fully dependent functional status (OR 2.51, CI 1.12-5.56, P = 0.02), albumin <3 (OR 2.49, CI 1.18-5.29, P = 0.01), and American Society of Anesthesiologist class >3 (OR 2.10, CI 1.10-4.46, P = 0.05).

CONCLUSIONS

Octogenarians presenting with complicated diverticulitis requiring an emergent Hartmann's procedure have a higher mortality rate compared to those <80, even after controlling for baseline comorbidities.

STUDY TYPE

This is a retrospective, descriptive study.

Laparoscopic Management of Colonic Diverticular Disease and its Complications: an Analysis

Dense inflammatory reactions, loss of tissue planes and sepsis make surgical treatment of diverticulitis complex and difficult. Experience with laparoscopic management of this disease is scanty in our country. This study aims to assess the pattern of presentation, the site of involvement and complications of diverticulitis coli. This study also aims to audit the results of laparoscopic approach for complicated colonic diverticulitis. A retrospective analysis of all patients who had laparoscopic management of complicated diverticulitis patients from August 2007 to October 2014 was done from the database. The site of involvement, extent and presence or absence of complications of diverticular disease was noted. The surgical approach, intraoperative parameters and short-term outcome measures were analysed. There were 38 (8.8 %) patients with diverticular disease out of 427 patients who had laparoscopic colorectal surgery in the study period with a median age of 59 years. Out of 38 patients, 50 % had comorbid conditions. Internal fistulae were seen in 9 (23.6 %) patients, 6 with colovesical and 3 with colovaginal fistulae. Elective laparoscopic colectomy with primary anastomosis was done in 34 (89 %) cases of which, and 10 (26 %) patients had abscess on presentation requiring drainage. Four patients required emergency laparoscopic surgery of which primary resection and anastomosis was done in 3 (7.8 %), and Hartmann's operation was done in 1 (2.6 %) patient. Two patients required stoma. The morbidity was seen in 15 % cases, and the mean hospital stay was 9.54 days. Laparoscopic approach for diverticular disease and its complication is feasible and safe. Careful selection of patients, judicious use of diverting stoma and appropriate selection of the procedure help to achieve good results even in those with septic complications and fistulising disease.

Delta neutrophil index as a promising prognostic marker of emergent surgical intervention for acute diverticulitis in the emergency department

BACKGROUND

Early identification of patients with acute diverticulitis who require emergent surgical intervention in the emergency department (ED) is important to the physician. Although computed tomography (CT) has an important role in evaluating the severity of diverticulitis, its findings alone may not predict the need for emergent surgical intervention in all patients with acute diverticulitis in the ED. Serum inflammation markers may help to differentiate severity of acute diverticulitis and predict the need for surgical intervention in clinical practice. No information is currently available on the clinical usefulness of the delta neutrophil index (DNI), with respect to the prediction of emergent surgical intervention in patients with acute diverticulitis at the ED.

METHODS

This was a retrospective observational study of consecutive adult patients with acute diverticulitis confirmed by CT in the ED, between January 2014 and December 2016. Recruited patients were divided into two groups: emergent surgical intervention and no surgical intervention. The following laboratory serum parameters were examined in the ED: DNI value, C-reactive protein (CRP) levels, white blood cell count, neutrophil count, and neutrophil-to-lymphocyte ratio (NLR). The patients were also examined for the presence or absence of complications by CT.

RESULTS

A total of 132 patients were finally included in the study, with the emergent surgical intervention group constituting 52 patients. The median DNI value, CRP levels, neutrophil count, and NLR were significantly higher in the emergent surgical intervention group than in the no surgical intervention group. The area under the curve for predicting emergent surgical intervention, using the DNI was significantly higher than that of CRP levels, neutrophil count, or NLR. Moreover, the combination of initial DNI and CT was most powerful diagnostic modality.

CONCLUSIONS

DNI values measured at the ED combined with CT were good predictors for emergent surgical intervention in acute diverticulitis. If the DNI value is greater than 0.7% and complications in CT are suspected in patients suspected to have acute diverticulitis, the need for emergent surgical intervention should be considered carefully in the ED.

Neutrophil to Lymphocyte Count Ratio Has a Close Association With Severe Acute Colonic Diverticulitis in Patients Undergoing Surgical Treatment

Objective:

To investigate the diagnostic potential of neutrophil-to-lymphocyte count ratio (NLCR) for acute diverticulitis.

Summary of Background Data:

We evaluated NLCR in patients with acute colonic diverticulitis who were treated with conservative and surgical treatments.

Methods:

A total of 205 patients who underwent surgical treatment or conservative management of acute diverticulitis between 2012 and 2016 were reviewed. Patients' age; sex; hospital days; co-morbidity; complication; period of use of antibiotics; treatment method; body temperature; and initial laboratory results such as neutrophil count, lymphocyte count, NLCR, and serum levels of C-reactive protein (CRP) were assessed.

Results:

The median ages of the conservative and surgical treatment groups were 46 and 68 years, respectively. Median CRP and glucose levels were high in acute colonic diverticulitis patients who underwent surgical treatment (P &lt; 0.001, P &lt; 0.001). Albumin level was low in the surgical treatment group (P &lt; 0.001). NLCR was significantly different in both groups (conservative management vs surgical treatment, 4.1 mg/L versus 8.5 mg/L; P &lt; 0.001). Median white blood cells was 11.36 × 109/L in the conservative management group and 14.0 × 109/L in the surgical treatment group, with no significance (P = 0.071). Multivariate analysis revealed that NLCR &gt;10.21 [odds ratio (OR) = 5.613, P = 0.022]; CRP &gt;17.23 mg/L (OR = 4.241, P = 0.006); and albumin ≤3.5 (OR = 4.192, P = 0.036) were significant for acute colonic diverticulitis patients.

Conclusion:

NLCR, CRP, and albumin levels were significantly associated with acute colonic diverticulitis in the surgical treatment group, and NLCR was the most powerful predictive marker of severe acute colonic diverticulitis.

Surgical treatment of uncomplicated diverticulitis in Switzerland: comparison of population-based data over two time periods

AIM

The standard of care for acute uncomplicated diverticulitis used to be an elective colon resection after the second or third episode. This practice was replaced by a more conservative and individualized approach. This study investigates current surgical practice in the treatment of acute uncomplicated diverticulitis in Switzerland.

METHOD

Retrospective cross-sectional analysis of all hospital admissions due to uncomplicated diverticulitis in Switzerland using prospectively collected data from the Swiss Federal Statistical Office in two periods: 2004/2005 and 2010/2011. Treatment options were compared between the two periods with adjustment for baseline characteristics of patients and treating institutions.

RESULTS

A total of 24 497 patients (11 835 in 2004/2005; 12 662 in 2010/2011) were admitted to Swiss hospitals for uncomplicated diverticulitis. Between periods, the incidence increased from 81 to 85 admissions per 10⁵ inhabitants per year. Elective admissions decreased from 46% (n = 5490) to 34% (n = 4294). The unadjusted resection rate decreased from 40% (n = 4730) to 34% (n = 4308). In the adjusted analysis, inpatients were more likely to have a resection in 2010/2011 than in 2004/2005 [odds ratio of 1.38 (95% confidence interval 1.25-1.54)]. In addition, private insurance, elective mode of admission and younger age increased the odds for resection while there was no evidence of an association between resection and either gender or comorbidities.

CONCLUSION

The probability of colon resection for patients hospitalized with acute uncomplicated diverticulitis increased between periods while the overall number of colon resections declined. A change of practice expected given the paradigm shift towards conservative treatment could not be confirmed in this analysis.

Analysis of risk factors for colonic diverticular bleeding and recurrence

The increase in incidence of colonic diverticular bleeding is relative to an age-related rise in the incidence of colonic diverticulosis and use of antithrombotic medication. However, risk factors related to the onset, recurrence, and prophylaxis have not been established. Therefore, we aimed to determine risk factors for the onset and recurrence of colonic diverticular bleeding.An age- and sex-matched case-control study was performed to assess the risk factors for the onset of colonic diverticular bleeding. The distribution of diverticulosis, comorbidity, and medication were evaluated from medical records. We also assigned patients with a first-time bleeding into groups with and without rebleeding during follow-up to determine risk factors for recurrence.Bilateral colonic diverticulosis, nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin (LDA), and anticoagulants were significant risk factors for the onset of colonic diverticular bleeding on multivariate analysis. In contrast, the use of selective cyclooxygenase-2 (COX-2) inhibitor was not a risk factor for the onset. The incidence of bleeding in direct oral anticoagulant and warfarin users was not different between the 2 groups. The cumulative recurrence rate at 1 year was 15%. Recurrence rate was significantly higher in patients with a prior history of colonic diverticular bleeding than those without. Steroid use was associated with recurrence.Extensive distribution of diverticulosis and use of nonselective NSAIDs, LDA, and anticoagulants are regarded as risk factors for the onset of colonic diverticular bleeding. In addition, a prior history of colonic diverticular bleeding is related to the recurrence.

Number of Diverticulitis Episodes Before Resection and Factors Associated With Earlier Interventions

IMPORTANCE

Despite professional recommendations to delay elective colon resection for patients with uncomplicated diverticulitis, early surgery (after <3 preceding episodes) appears to be common. Several factors have been suggested to contribute to early surgery, including increasing numbers of younger patients, a lower threshold to operate laparoscopically, and growing recognition of "smoldering" (or nonrecovering) diverticulitis episodes. However, the relevance of these factors in early surgery has not been well tested, and most prior studies have focused on hospitalizations, missing outpatient events and making it difficult to assess guideline adherence in earlier interventions.

OBJECTIVE

To describe patterns of episodes of diverticulitis before surgery and factors associated with earlier interventions using inpatient, outpatient, and antibiotic prescription claims.

DESIGN, SETTING, AND PARTICIPANTS

This investigation was a nationwide retrospective cohort study from January 1, 2009, to December 31, 2012. The dates of the analysis were July 2014 to May 2015. Participants were immunocompetent adult patients (age range, 18-64 years) with incident, uncomplicated diverticulitis.

EXPOSURE

Elective colectomy for diverticulitis.

MAIN OUTCOMES AND MEASURES

Inpatient, outpatient, and antibiotic prescription claims for diverticulitis captured in the MarketScan (Truven Health Analytics) databases.

RESULTS

Of 87 461 immunocompetent patients having at least 1 claim for diverticulitis, 6.4% (n = 5604) underwent a resection. The final study cohort comprised 3054 nonimmunocompromised patients who underwent elective resection for uncomplicated diverticulitis, of whom 55.6% (n = 1699) were male. Before elective surgery, they had a mean (SD) of 1.0 (0.9) inpatient claims, 1.5 (1.5) outpatient claims, and 0.5 (1.2) antibiotic prescription claims related to diverticulitis. Resection occurred after fewer than 3 episodes in 94.9% (2897 of 3054) of patients if counting inpatient claims only, in 80.5% (2459 of 3054) if counting inpatient and outpatient claims only, and in 56.3% (1720 of 3054) if counting all types of claims. Based on all types of claims, patients having surgery after fewer than 3 episodes were of similar mean age compared with patients having delayed surgery (both 47.7 years, P = .91), were less likely to undergo laparoscopy (65.1% [1120 of 1720] vs 70.8% [944 of 1334], P = .001), and had more time between the last 2 episodes preceding surgery (157 vs 96 days, P < .001). Patients with health maintenance organization or capitated insurance plans had lower rates of early surgery (50.1% [247 of 493] vs 57.4% [1429 of 2490], P = .01) than those with other insurance plan types.

CONCLUSIONS AND RELEVANCE

After considering all types of diverticulitis claims, 56.3% (1720 of 3054) of elective resections for uncomplicated diverticulitis occurred after fewer than 3 episodes. Earlier surgery was not explained by younger age, laparoscopy, time between the last 2 episodes preceding surgery, or financial risk-bearing for patients. In delivering value-added surgical care, factors driving early, elective resection for diverticulitis need to be determined.

The Impact of Elective Colon Resection on Rates of Emergency Surgery for Diverticulitis

OBJECTIVE

To determine the impact of elective colectomy on emergency diverticulitis surgery at the population level.

BACKGROUND

Current recommendations suggest avoiding elective colon resection for uncomplicated diverticulitis because of uncertain effectiveness at reducing recurrence and emergency surgery. The influence of these recommendations on use of elective colectomy or rates of emergency surgery remains undetermined.

METHODS

A retrospective cohort study using a statewide hospital discharge database identified all patients admitted for diverticulitis in Washington State (1987-2012). Sex- and age-adjusted rates (standardized to the 2000 state census) of admissions, elective and emergency/urgent surgical and percutaneous interventions for diverticulitis were calculated and temporal changes assessed.

RESULTS

A total of 84,313 patients (mean age 63.3 years and 58.9% female) were hospitalized for diverticulitis (72.2% emergent/urgent). Elective colectomy increased from 7.9 to 17.2 per 100,000 people (P < 0.001), rising fastest since 2000. Emergency/urgent colectomy increased from 7.1 to 10.2 per 100,000 (P < 0.001), nonelective percutaneous interventions increased from 0.1 to 3.7 per 100,000 (P = 0.04) and the frequency of emergency/urgent admissions (with or without a resection) increased from 34.0 to 85.0 per 100,000 (P < 0.001). In 2012, 47.5% of elective resections were performed laparoscopically compared to 17.5% in 2008 (when the code was introduced).

CONCLUSIONS

The elective colectomy rate for diverticulitis more than doubled, without a decrease in emergency surgery, percutaneous interventions, or admissions for diverticulitis. This may reflect changes in thresholds for elective surgery and/or an increase in the frequency or severity of the disease. These trends do not support the practice of elective colectomy to prevent emergency surgery.

Prevalence and distribution of colonic diverticula assessed with CT colonography (CTC)

OBJECTIVES

This study aimed to evaluate the prevalence of colonic diverticula according to age, gender, distribution, disease extension and symptoms with CT colonography (CTC).

METHODS

The study population included 1091 consecutive patients who underwent CTC. Patients with diverticula were retrospectively stratified according to age, gender, clinical symptoms and colonic segment involvement. Extension of colonic diverticula was evaluated using a three-point quantitative scale. Using this data, a multivariate regression analysis was applied to investigate the existence of any correlation among variables.

RESULTS

Colonic diverticula were observed in 561 patients (240 men, mean age 68 ± 12 years). Symptomatic uncomplicated diverticular disease (SUDD) was present in 47.4% of cases. In 25.6% of patients ≤40 years, at least one diverticulum in the colon was observed. Prevalence of right-sided diverticula in patients >60 years was 14.2% in caecum and 18.5% in ascending colon. No significant difference was found between symptomatic and asymptomatic patients regarding diverticula prevalence and extension. No correlation was present between diverticula extension and symptoms.

CONCLUSION

The incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding, with their prevalence increasing with patient age. SUDD does not seem to be related to diverticula distribution and extension.

KEY POINTS

Incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding. SUDD does not seem to be related to diverticula distribution and extension.

A national evaluation of the management practices of acute diverticulitis

INTRODUCTION

Diverticulitis is a common surgical admission that presents with a wide range of symptoms and severity. Overall there has been a shift to conservative management practices, including the consideration of non-antibiotic treatment approaches in select cases.

METHODS

A national survey of all consultant surgeons evaluating their practices was performed. Reasons for changes in management, use of radiological imaging, role of non-antibiotic treatment approaches and indications for elective surgical management were evaluated.

RESULTS

Response rate for this survey was 67.7% (n = 67/99). An overwhelming 92.5% stated that computed tomography imaging was routinely used to investigate acute presentations. Interestingly, 22.4% stated they would consider a non-antibiotic treatment approach in uncomplicated diverticulitis. Main reasons for adopting this approach was low inflammatory markers with short duration of symptoms. Co-amoxiclav was the most common antibiotic used for acute diverticulitis, with considerable variability in duration of treatment. Additionally, there was considerable heterogeneity regarding how many recurrences were necessary before surgical management was required.

CONCLUSION

This review highlights substantial variation in the management of diverticulitis across Ireland. Shifts to non-antibiotic treatment approaches for uncomplicated cases are observed, but less so than in Northern Europe. National guidelines are required to establish uniform treatment protocols including indications for surgical resection.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

A comparison of outcomes of emergent, urgent, and elective surgical treatment of diverticulitis

BACKGROUND

There is a controversy regarding the best urgent surgical treatment of colonic diverticulitis. We sought to compare outcomes of patients who underwent surgery for diverticulitis by the type of admission.

METHODS

The National Surgical Quality Improvement Program databases were used to examine the clinical data of patients who underwent colorectal resection for diverticulitis during 2012 to 2013. Multivariate regression analysis was performed to identify outcomes of patients.

RESULTS

We sampled a total of 13,510 patients admitted for diverticulitis who underwent colorectal resection, of which 7.8% had emergent and 19.7% had urgent operation. Patients with perforation (adjusted odds ratio [AOR] 188.56, P < .01) and preoperative sepsis (AOR 28.17, P < .01) had significantly higher rates of emergent surgery. Patients who underwent emergent operation had higher mortality (AOR 4.08, P = .04) and morbidity (AOR 2.14, P < .01). Emergent operations had a significantly higher risk of anastomosis leakage compared with elective operation (AOR 3.92, P = .02).

CONCLUSIONS

Emergent treatment of diverticulitis is associated with a high morbidity and mortality. In the setting of emergent treatment of diverticulitis, colonic anastomosis without a stoma has a high risk of anastomosis leakage.

Natural history of bleeding risk in colonic diverticulosis patients: a long-term colonoscopy-based cohort study

BACKGROUND

The natural history of bleeding risk from colonic diverticulosis remains unclear.

AIM

To identify the incidence of bleeding in colonic diverticulosis patients and associated risk factors.

METHODS

A cohort of 1514 patients with colonoscopy-confirmed asymptomatic diverticulosis was selected between 2001 and 2013. Age, sex and location of colonic diverticulosis (right or left side, or bilateral) were assessed. The endpoint was a bleeding event, and data were censored at the time of last colonoscopy. The cumulative and overall incidences of bleeding were estimated using the Kaplan-Meier and person-years methods. The Cox proportional hazards model was used to estimate age- and sex-adjusted hazard ratios (aHRs).

RESULTS

The median follow-up period was 46 months. Bleeding events occurred in 35 patients, and the median time-to-event interval was 50 months. Kaplan-Meier analysis showed that the cumulative incidence of diverticular bleeding was 0.21% at 12 months, 2.2% at 60 months and 9.5% at 120 months. By the person-years method, the overall incidence rate of bleeding was 0.46 per 1000 patient-years. On multivariate analysis, age ≥70 (aHR. 3.7) and bilateral diverticulosis (aHR, 2.4) were significant risk factors for bleeding.

CONCLUSIONS

This long-term follow-up study demonstrated that the cumulative incidence of bleeding from diverticulosis was approximately 2% at 5 years and 10% at 10 years, and the overall incidence was 0.46 per 1000 patient-years. Bilateral diverticulosis increased the risk of bleeding.

Right-Sided Diverticulosis and Disparities from Left-Sided Diverticulosis in the Vietnamese Population Living in Boston, Mass., USA: A Retrospective Cohort Study

OBJECTIVE

To report the prevalence, clinical differences and complications of right-sided diverticulosis (RD) and to investigate the potential disparities from left-sided diverticulosis (LD) in the Vietnamese population.

SUBJECTS AND METHODS

A retrospective cohort study was conducted using medical records of Vietnamese-born patients from 2000 to 2013 in a community teaching hospital in Boston, Mass., USA. By simple randomization, a randomized control group of 299 Caucasian patients was also selected from the same time frame [167 males (M) and 132 females (F)]. Colonoscopy reports were reviewed for demographics (age and gender), indication and anatomical location of the colonic diverticulosis (CD), concomitant colonic findings, symptoms, and endoscopic complications.

RESULTS

A total of 207 patients were included in the Vietnamese cohort (mean age 61.6 ± 8.9 years). The mean age at first screening colonoscopy was 58.2 ± 7.2 years (114 F/92 M, 55.7/44.4%). Our study identified 104 (50.5%) patients with LD (57 M/47 F), 65 (31.1%) with RD (35 M/30 F) and 38 (18.4%) with both LD and RD (23 M/15 F); 133 (64%) were asymptomatic. A total of 21 (33%) patients with RD were symptomatic. The mean age of the control group was 61.6 ± 8.1 years. The average age at first screening colonoscopy was 52.8 ± 6.4 years. Of the 299 in the Caucasian group, 254 (84.9%) had LD (114 M/140 F), 9 (3.0%) had RD (2 M/7 F) and 36 (12%) had both LD and RD (16 M/20 F); 225 (75%) were asymptomatic and came in for screening colonoscopies. A total of 2 patients (22%) with RD were symptomatic.

CONCLUSION

RD was common in this Vietnamese population, and the prevalence was higher than in the Caucasian control group.

Prediction and management of recurrent right colon diverticulitis

PURPOSE

While the incidence of right colonic diverticulitis (RCD) is rare in Western countries, the right colon is the most common site of diverticulitis in Asian countries. However, its recurrent pattern and management were rarely studied. This study was designed to elucidate the pattern of recurrence in RCD.

METHODS

Of the 154 patients admitted as right colonic diverticulitis between February 2004 and March 2012, 104 patients were enrolled, prospectively. The recurrence rate, size, multiplicity, location, diagnostic criteria score, and predisposing factors were evaluated based on Hinchey's classification of diverticulitis.

RESULTS

There were 104 patients with right colonic diverticulitis in this study, and 20 patients (19.2 %) recurred after medical treatment. When the diverticula were not located in the right colon, the recurrence rate was significantly higher than the diverticula located only in the right colon (p = 0.004). The recurrence rate of diverticulitis for a single diverticulum was significantly lower than that for multiple diverticula (p = 0.02). Of the 20 patients with recurrence, 1 (5 %) patient underwent laparoscopic diverticulectomy due to a misdiagnosis of diverticulitis as appendicitis. The remaining 19 patients (95 %) received nonoperative management and recovered without any sequelae.

CONCLUSIONS

The recurrence rate was 19.2 %, and the predisposing factors were the location of diverticula and the multiplicity of primary diverticula. The re-recurrence rate of recurred patients was 26.3 %. The recurred lesions were controlled simply by nonoperative management. Elective surgery was also a treatment option.

Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines

AIM

The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient.

RESULTS

Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence.

CONCLUSION

Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials

BACKGROUND & AIMS

No therapy has been proven to prevent the recurrence of diverticulitis. Mesalamine has shown efficacy in preventing relapse in inflammatory bowel disease, and there is preliminary evidence that it might be effective for diverticular disease. We investigated the efficacy of mesalamine in preventing recurrence of diverticulitis in 2 identical but separate phase 3, randomized, double-blind, placebo-controlled, multicenter trials (identical confirmatory trials were conducted for regulatory reasons).

METHODS

We evaluated the efficacy and safety of multimatrix mesalamine vs placebo in the prevention of recurrent diverticulitis in 590 (PREVENT1) and 592 (PREVENT2) adult patients with ≥1 episodes of acute diverticulitis in the previous 24 months that resolved without surgery. Patients received mesalamine (1.2 g, 2.4 g, or 4.8 g) or placebo once daily for 104 weeks. The primary end point was the proportion of recurrence-free patients at week 104. Diverticulitis recurrence was defined as surgical intervention at any time for diverticular disease or presence of computed tomography scan results demonstrating bowel wall thickening (>5 mm) and/or fat stranding consistent with diverticulitis. For a portion of the study, recurrence also required the presence of abdominal pain and an increase in white blood cells.

RESULTS

Mesalamine did not reduce the rate of diverticulitis recurrence at week 104. Among patients in PREVENT1, 53%-63% did not have disease recurrence, compared with 65% of those given placebo. Among patients in PREVENT2, 59%-69% of patients did not have disease recurrence, compared with 68% of those given placebo. Mesalamine did not reduce time to recurrence, and the proportions of patients requiring surgery were comparable among treatment groups. No new adverse events were identified with mesalamine administration.

CONCLUSIONS

Mesalamine was not superior to placebo in preventing recurrent diverticulitis. Mesalamine is not recommended for this indication. ClinicalTrials.gov ID: NCT00545740 and NCT00545103.

[Clinical characteristics and treatment outcome of colonic diverticulitis in young patients]

BACKGROUND/AIMS

The clinical course and the most appropriate management of colonic diverticulitis in young patients are currently unresolved. This retrospective study was designed to compare young patients (≤40 years) with older patients (>40 years) regarding clinical characteristics of acute colonic diverticulitis and to determine whether differences exist in treatment outcome.

METHODS

Three-hundred sixty eight patients presenting with acute colonic diverticulitis from March 2001 through April 2011 at Ewha Womans University Mokdong Hospital were reviewed retrospectively. The differences in clinical characteristics, treatment modality and recurrence between each group were analyzed.

RESULTS

Two-hundred and six patients were aged 40 years or younger and 162 patients were older than 40 years. The older group was diagnosed more frequently with severe diverticulitis. Surgical treatment was significantly more frequent in the older group than in the younger group (15.4% vs. 4.4%, p<0.001). No significant difference was found in preatment modality between the two groups in patients with recurrence. The difference in recurrence between groups was not statistically significant. In multivariate analysis, left colonic diverticulitis was significantly associated with severe diverticulitis (OR, 14.651; 95% CI, 4.829-44.457) and emergency surgery (OR, 13.745; 95% CI, 4.390-43.031).

CONCLUSIONS

When patients with colonic diverticulitis are treated conservatively, young age is no longer an independent risk factor for subsequent poor outcome. Diverticulitis in young patients does not have a particularly aggressive or fulminant course. Therefore, we recommend that diverticulitis management should be based on the severity and location of the disease, and not on the age of the patient.

Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence: a randomised multicentre pilot double-blind placebo-controlled study of 24-month duration

BACKGROUND AND AIM

Recurrence of diverticulitis is frequent within 5 years from the uncomplicated first attack, and its prophylaxis is still unclear. We have undertaken a multicentre, randomised, double-blind, placebo-controlled pilot study in order to evaluate the role of mesalazine in preventing diverticulitis recurrence as well as its effects on symptoms associated to diverticular disease.

METHODS

Ninety-six patients with the recent first episode of uncomplicated diverticulitis were randomised to receive mesalazine 800 mg twice daily for 10 days every month or placebo for 24 months. The primary efficacy end point was the diverticulitis recurrence at intention to treat analysis. Clinical evaluations were performed using the Therapy Impact Questionnaire (TIQ) for physical condition and quality of life at admission and at 3-month intervals. Treatment tolerability and routine biochemistry parameters as well as the use of additional drugs were also evaluated.

RESULTS

Ninety-two patients (mean age, 61.5) completed the study, 45 of whom received mesalazine, and 47, placebo. Diverticulitis relapse incidence in mesalazine-treated group was 5/45 (11%) at the 12th month and 6/45 (13%) at the 24th month; in the placebo-treated group, the correspondent rates were 13% (6/47) and 28% (13/47), respectively. Mean values of TIQ at 24 months were significantly better in mesalazine-treated group than in placebo-treated group (p = 0.02); in addition, average additional drug consumption was significantly lower (-20.4%, p < 0.03) in mesalazine than in placebo.

CONCLUSIONS

Diverticulitis recurrence occurred in as many as 28% of patients under placebo within 24 months from the initial episode. Intermittent prophylaxis with mesalazine did not significantly reduce the risk of relapse but induced a significant improvement of patients' physical conditions and significantly lowered the additional consumption of other gastrointestinal drugs.

A randomized controlled study of mesalamine after acute diverticulitis: results of the DIVA trial

BACKGROUND/AIMS

We evaluated the efficacy of mesalamine (Asacol) in reducing gastrointestinal symptoms after an acute attack of diverticulitis.

METHODS

This was a 1-year double-blind, randomized, placebo-controlled study in which patients with computed tomography scan confirmed acute diverticulitis received placebo, mesalamine, or mesalamine+Bifidobacterium infantis 35624 (Align) for 12 weeks and followed for 9 additional months. Efficacy was assessed using a global symptom score (GSS) of 10 symptoms (abdominal pain, abdominal tenderness, nausea/vomiting, bloating, constipation, diarrhea, mucus, urgency, painful straining, and dysuria). Patients were required to have a GSS≥12 at baseline, including an abdominal pain score >2.

RESULTS

One hundred seventeen patients (placebo, 41; mesalamine, 40; mesalamine+probiotic, 36) were randomized and treated. GSS decreased in all groups during treatment without a statistically significant difference between mesalamine and placebo, however; scores were consistently lower for mesalamine at all time points. The rate of complete response (GSS=0) was significantly higher with mesalamine than placebo at weeks 6 and 52 (P<0.05), and was particularly high for rectosigmoid symptoms at weeks 6, 12, 26, and 52. Recurrence of diverticulitis was low and comparable across groups. Probiotic in combination with mesalamine did not provide additional efficacy.

CONCLUSIONS

In the first US randomized placebo-controlled trial of anti-inflammatory treatment after a documented case of diverticulitis, mesalamine demonstrated a consistent trend in reducing symptoms. Addition of probiotic did not increase mesalamine efficacy. This study supports further investigation into the use of anti-inflammatory agents, such as mesalamine, in the long-term management of diverticulitis. ClinicalTrials.gov NCT00554099.

Early experience with laparoscopic lavage for perforated diverticulitis

BACKGROUND

Laparoscopic lavage has recently emerged as a promising alternative to sigmoid resection in the treatment of perforated diverticulitis. This study examined an early experience with this technique.

METHODS

The files of all patients with complicated diverticulitis were searched in 34 teaching hospitals of the Netherlands. Patients with perforated diverticulitis treated with laparoscopic lavage between 1 January 2008 and 31 December 2010 were included.

RESULTS

Treatment with laparoscopic lavage was performed in only 38 patients in ten hospitals. Lavage was successful in controlling sepsis in 31 of the 38 included patients, with 32 per cent morbidity (10 of 31 patients) and fast recovery. Overall, 17 of 38 patients developed complications, of whom two had a missed overt sigmoid perforation. Two patients died from multiple organ failure and one from aspiration pneumonia; one other patient died after palliative management of inoperable lung carcinoma. Three patients in whom lavage was successful underwent subsequent sigmoid resection for recurrent diverticulitis. Patients in whom lavage was unsuccessful tended to have more co-morbidities, a higher preoperative C-reactive protein concentration and a higher Mannheim Peritonitis Index.

CONCLUSION

Laparoscopic lavage for perforated diverticulitis was feasible in the majority of patients, but identification of an overt sigmoid perforation and patient selection are of critical importance.

Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis

BACKGROUND

The objectives of our study were to determine the association between age and postoperative outcomes after emergency surgery for diverticulitis and to identify risk factors for postoperative mortality among elderly patients.

METHODS

All patients from the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 Participant User Files undergoing emergent surgery for diverticulitis were included. Multivariate logistic regression was used to determine the association between age and postoperative morbidity and mortality after adjustment for perioperative variables. A separate regression model was used to determine risk factors for postoperative mortality among elderly patients, with specific postoperative complications being included as potential predictors.

RESULTS

We included 2,264 patients for analysis, of whom 1,267 (56%) were <65 years old (nonelderly), 648 (28.6%) were 65-79 years old (elderly), and 349 (15.4%) were ≥80 years old (super-elderly). Advanced age was a significant predictor of 30-day postoperative mortality, and to a lesser extent postoperative morbidity. Among those patients ≥65 years old, super-elderly age classification remained a significant predictor of mortality after adjustment for the presence or absence of postoperative complications. Mortality among elderly and super-elderly patients was greatest in the setting of specific complications, such as septic shock, prolonged postoperative mechanical ventilation, and acute renal failure.

CONCLUSION

Advanced age is an independent risk factor for death after emergency surgery for diverticulitis, with mortality being greatest among elderly patients who experience certain postoperative complications. Prevention of these complications should form the cornerstone of initiatives designed to lower the mortality associated with emergency surgery in elderly patients.

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis

BACKGROUND

The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up.

METHODS

This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.

RESULTS

Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881).

CONCLUSION

Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment

BACKGROUND

In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA.

METHODS

The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed.

RESULTS

There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23).

CONCLUSIONS

Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.