Complicated diverticulitis: is it time to rethink the rules?

Nontraumatic large bowel perforation: spectrum of etiologies and CT findings

Large bowel perforation is an abdominal emergency that results from a wide range of etiologies. Computed tomography is the most reliable modality in detecting the site of large bowel perforation. The diagnosis is made by identifying direct CT findings such as extraluminal gas or contrast and discontinuity along the bowel wall. Indirect CT findings can help support the diagnosis, and include bowel wall thickening, pericolic fat stranding, abnormal bowel wall enhancement, abscess, and a feculent collection adjacent to the bowel. Common etiologies that cause large bowel perforation are colon cancer, foreign body aspiration, stercoral colitis, diverticulitis, ischemia, inflammatory and infectious colitides, and various iatrogenic causes. Recognizing a large bowel perforation on CT can be difficult at times, and there are various entities that may be misinterpreted as a colonic perforation. The purpose of this article is to outline the MDCT technique used for evaluation of suspected colorectal perforation, discuss relevant imaging findings, review common etiologies, and point out potential pitfalls in making the diagnosis of large bowel perforation.

Management of Diverticulitis in 2017

Diverticulitis has become increasingly more common in the 20^th century and is now one of the most frequent indications for gastrointestinal tract-related hospitalizations. The spectrum of clinical presentation can vary widely from mild, uncomplicated disease that can be managed as an outpatient, to complicated diverticulitis with peritonitis and sepsis. Historically, all patients with diverticulitis were managed with, at a minimum, a course of antibiotics, with many patients undergoing urgent or emergent surgery with a sigmoid colectomy, end colostomy, and oversewn rectosigmoid "Hartmann's" stump. However, the treatment paradigm has shifted away from more aggressive surgical management over the years, with recent literature supporting the notion that nonoperative management may lead to equivalent or even superior outcomes in many circumstances. Therefore, the purpose of this review is to summarize and interpret the existing literature on the management of uncomplicated and complicated left-sided diverticulitis in 2017.

Diverticulitis recurrence after percutaneous abscess drainage

PURPOSE

Recurrent diverticulitis has been reported in 30-50% of patients who recover from an episode of diverticular-associated abscess. Our aim was to review the outcomes of patients who underwent non-operative management after percutaneous drainage (PD) of colonic diverticular abscess.

METHODS

All patients with a diverticular-associated abscess were identified between 2001 and 2012. Individual charts were queried for peri-procedural data and follow-up. The most recent follow-up data were acquired via the electronic medical record or telephone call.

RESULTS

A total of 165 patients underwent PD of diverticular-associated abscesses. Abscess locations were pelvic (n = 122), abdominal (n = 36), and both (n = 7), while median abscess size was 6.1 ± 2.2 cm. One hundred eighteen patients clinically improved following non-operative management, and 81 of these patients did not undergo subsequent colonic resection within 4 months of PD. Of these, 8 died within 12 months. Among the remaining 73 patients, there were no significant differences in demographics or abscess variables compared to those who underwent elective surgery within 4 months. Only 7 of 73 patients had documented episodes of recurrences, while 22 patients later had elective surgery (1.1 ± 1.2 years from the index case). Five-year colectomy-free survival was 55% (95%CI 42-66%), while the recurrence-free survival at 5 years was 77% (95%CI 65-86%). All recurrences were managed non-operatively initially and one patient went on to have elective resection.

CONCLUSION

A sizable number of patients successfully recover from complicated diverticulitis following PD. Subsequent non-operative management carries an acceptable risk for recurrent episodes and may be considered as a reasonable management option.

Laparoscopic approaches to complicated diverticulitis

BACKGROUND

The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis.

PURPOSE

The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis.

CONCLUSIONS

New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.

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.

Randomised clinical trial: mesalazine versus placebo in the prevention of diverticulitis recurrence

BACKGROUND

Previous studies have reached conflicting conclusions regarding the efficacy of mesalazine in the prevention of recurrent diverticulitis.

AIM

To investigate the efficacy and safety of mesalazine granules in the prevention of recurrence of diverticulitis after acute uncomplicated diverticulitis.

METHODS

Two phase 3, randomised, placebo-controlled, double-blind multicentre trials (SAG-37 and SAG-51) investigated mesalazine granules in patients with prior episodes (<6 months) of uncomplicated left-sided diverticulitis. Patients were randomised to receive either 3 g mesalazine once daily or placebo (SAG-37, n=345) or to receive either 1.5 g mesalazine once daily, 3 g once daily or placebo for 96 weeks (SAG-51, n=330). The primary endpoint was the proportion of recurrence-free patients during 48 weeks (SAG-37 and SAG-51) or 96 weeks (SAG-51) of treatment.

RESULTS

Mesalazine did not increase the proportion of recurrence-free patients over 48 or 96 weeks compared to placebo. In SAG-37, the proportion of recurrence-free patients during 48 weeks was 67.9% with mesalazine and 74.4% with placebo (P=.226). In SAG-51, the proportion of recurrence-free patients over 48 weeks was 46.0% with 1.5 g mesalazine, 52.0% with 3 g mesalazine and 58.0% with placebo (P=.860 for 3 g mesalazine vs placebo) and over 96 weeks 6.9%, 9.8% and 23.1% respectively (P=.980 for 3 g mesalazine vs placebo). Patients with only one diverticulitis episode in the year prior to study entry had a lower recurrence risk compared to >1 episode. Safety data revealed no new adverse events.

CONCLUSION

Mesalazine was not superior to placebo in preventing recurrence of diverticulitis.

Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?

BACKGROUND

Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patient's ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes.

METHODS

This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated.

RESULTS

Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis.

CONCLUSION

Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use

Background

The purpose of this study was to compare the outcome of Clostridium difficile infection (CDI) in patients on systemic steroids for various indications to patients not on steroids in term of disease severity, and associated morbidity and mortality.

Methods

We retrospectively reviewed records of all patients with CDI at our hospital from January 2011 to December 2016. Patients were evaluated for baseline characteristics, comorbidities, medications, disease severity, disease-related length of stay (LOS) from the diagnosis of CDI to discharge, need for surgical intervention, and disease-related mortality. Based on systemic steroids use, patients who were using steroids for different indications constituted the study population, and those with no steroids use were clustered as a control group.

Results

Of the 258 patients included, males were 127 (49%). Severe and severe-complicated CDI developed in 21/63 (33.3%) and 1/63 (1.6%) of patients on steroids (average daily dose of 20 mg), and in 73/195 (37.4%) and 5/195 (2.6%) of patients with no steroids use (P = 0.56 and P = 0.66, respectively). Surgical intervention was not required in the steroids group and 5/195 (2.7%) of patients not on steroids underwent bowel surgeries (P = 0.38). Mean LOS (days) was 11.6 ± 1.5 in the steroids group and 10.4 ± 0.7 in the no-steroids group (P = 0.4). CDI-related mortality occurred in 9/63(14.3%) of patients on steroids, and in 15/195 (7.7%) of patients not on steroids (P = 0.12; odds ratio (OR): 2; 95% confidence interval (CI): 0.8 - 4.8).

Conclusion

There was no significant difference in the severity of CDI, need for surgical interventions, disease-related LOS and mortality in systemic steroids users compared to patients not on steroids.

Factors Associated with Repeated Health Resource Utilization in Patients with Diverticulitis

Conservative management trends in diverticulitis may lead to increased hospitalizations secondary to repeated attacks. The study aimed to characterize trends in management and risk-assess patients with diverticulitis that required multiple admissions to identify high utilizers. A total of 265,724 patients with diverticulitis were identified from 1995 to 2014 from the New York SPARCS database. Patients with ≥2 hospital admissions were stratified across demographics, comorbidities, insurance status, and surgical intervention. In total, 42,850 patients had ≥2 hospital admissions. Risk factors for ≥2 admissions included younger age, White race, obesity, hypertension, pulmonary disease, hypothyroidism, rheumatoid arthritis, and depression. Fifty-two percent of these patients went on to have surgery. The percentage of elective cases increased from 59 to 70 %, while emergent cases conversely decreased from 41 to 30 %. One in five patients admitted with diverticulitis required two or more admissions. Numerous patient factors were correlated with increased risk of readmission. These factors may be used to guide treatment decisions and help reduce economic burden in frequent utilizers. Trends in surgery rates for these patients could reflect improved treatment options and/or changing clinical practice patterns.

Risk factors of admission for acute colonic diverticulitis in a population-based cohort study: The North Trondelag Health Study, Norway

AIM

To assess risk factors of hospital admission for acute colonic diverticulitis.

METHODS

The study was conducted as part of the second wave of the population-based North Trondelag Health Study (HUNT2), performed in North Trondelag County, Norway, 1995 to 1997. The study consisted of 42570 participants (65.1% from HUNT2) who were followed up from 1998 to 2012. Of these, 22436 (52.7%) were females. The cases were defined as those 358 participants admitted with acute colonic diverticulitis during follow-up. The remaining participants were used as controls. Univariable and multivariable Cox regression analyses was used for each sex separately after multiple imputation to calculate HR.

RESULTS

Multivariable Cox regression analyses showed that increasing age increased the risk of admission for acute colonic diverticulitis: Comparing with ages < 50 years, females with age 50-70 years had HR = 3.42, P < 0.001 and age > 70 years, HR = 6.19, P < 0.001. In males the corresponding values were HR = 1.85, P = 0.004 and 2.56, P < 0.001. In patients with obesity (body mass index ≥ 30) the HR = 2.06, P < 0.001 in females and HR = 2.58, P < 0.001 in males. In females, present (HR = 2.11, P < 0.001) or previous (HR = 1.65, P = 0.007) cigarette smoking increased the risk of admission. In males, breathlessness (HR = 2.57, P < 0.001) and living in rural areas (HR = 1.74, P = 0.007) increased the risk. Level of education, physical activity, constipation and type of bread eaten showed no association with admission for acute colonic diverticulitis.

CONCLUSION

The risk of hospital admission for acute colonic diverticulitis increased with increasing age, in obese individuals, in ever cigarette smoking females and in males living in rural areas.

[Prognostic value of the presence of pericolic air bubbles detected by computed tomography in acute diverticulitis]

BACKGROUND

Diverticular disease is common in industrialized countries. Computed tomography has been used as the preferred diagnostic method; although different scales haves been described to classify the disease, none of them encompass total disease aspects and behaviour.

OBJETIVE

To analyze the patients with acute diverticulitis confirmed by computed tomography at the ABC Medical Center Campus Observatorio from January 1, 2010 to December 31, 2012, in whom pericolic free air in the form of bubbles was identified by computed tomography and if this finding can be considered as a prognostic factor for the disease.

METHODS

A series of 124 patients was analyzed who had acute diverticulitis confirmed by computed tomography, in order to identify the presence of pericolic bubbles.

RESULTS

Of the 124 patients, 29 presented with pericolic bubbles detected by computed tomography; of these, 62.1% had localized peritoneal signs at the time of the initial assessment, (P<.001); leukocytosis (13.33 vs 11.16, P<.001) and band count (0.97 vs 0.48, P<.001) was higher in this group. Patients with pericolonic bubbles had a longer hospital stay (5.5days vs 4.3days, P<.001) and started and tolerated liquids later (4.24days vs. 3.02days, P<.001) than the group of patients without this finding.

CONCLUSIONS

The presence of pericolic bubbles in patients with acute diverticulitis can be related to a more aggressive course of the disease.

Patients with end-stage renal disease were at an increased risk of hospitalization for acute diverticulitis

Patients with end-stage renal disease (ESRD) show a high incidence of bacterial translocation and impaired gastrointestinal motility. The intestinal tract is believed to be the most crucial source of translocated bacteria. To evaluate the risk of colonic diverticulitis in patients with ESRD, we conducted a nationwide population-based cohort study. Patients who met the following 3 criteria were defined as patients with ESRD: patients diagnosed with ESRD who received regular hemodialysis between 2000 and 2005, patients who received hemodialysis for more than 90% of the time during the observation period (2000-2011), and patients with no prior history of hemodialysis between 1997 and 1999. We matched every patient with ESRD with 1 matched control on the basis of propensity scores. The first diagnosis of diverticulitis (ICD-9-CM codes 562.11 and 562.13) within the follow-up period was defined as the primary endpoint. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were calculated using the patients in the control group as the reference. We included 32,547 and 32,547 patients in the ESRD and matched control cohorts, respectively. The 12-year cumulative incidence of acute colonic diverticulitis for patients with ESRD was significantly higher than that for the controls (P < 0.001). After adjustment for age, sex, comorbidities, and medication use, the HR of acute colonic diverticulitis in the ESRD cohort was 11.20 times greater than that in the control cohort (95% CI: 8.14-15.42). The results indicated that patients with ESRD are at an increased risk for acute colonic diverticulitis.

Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe

BACKGROUND

Initial nonoperative management of diverticular abscess has become the standard of care; however, the need for elective resection after this index episode is unclear.

OBJECTIVE

The purpose of this study was to assess the long-term outcomes of expectant management after initial nonoperative treatment of diverticular abscess.

DESIGN

This was a retrospective chart review with prospective telephone follow-up of patients.

SETTINGS

The study was conducted at a large tertiary academic colorectal surgery practice in Canada.

PATIENTS

Adult patients with CT-documented acute sigmoid diverticulitis complicated by abscess managed nonoperatively from 2000 to 2013 were included.

INTERVENTIONS

Long-term definitive nonoperative management of diverticular abscess.

MAIN OUTCOME MEASURES

The primary outcome was emergency sigmoidectomy or death from recurrent diverticulitis. Secondary outcomes were recurrent diverticulitis and elective sigmoidectomy for diverticulitis.

RESULTS

Of 135 patients with acute diverticulitis complicated by abscess, a total of 73 patients were managed with nonoperative intent and long-term expectant management. The median follow-up was 62 (Q1 to Q3: 28-98) months. After resolution of the index episode, 22 patients [30.1% (95% CI, 19.6%-40.6%)] experienced a recurrent episode of diverticulitis at a median of 23 (range, 9-40) months. Two patients [2.7% (95% CI, -1.0% to 6.4%)] had a recurrent episode with peritonitis that required sigmoidectomy with stoma at 6 and 64 months. Both patients underwent reversal after 4 and 8 months. Seven [9.6% (95% CI, 2.8%-16.4%)] patients experienced a complicated recurrence and underwent an elective sigmoidectomy [median time to colectomy, 33 (range, 16-56) months]. Thirteen patients [17.8% (95% CI, 9.0%-26.6%)] experienced an uncomplicated recurrence, all of whom were managed with continued nonoperative intent [median follow-up, 81 (range, 34-115) months]. No mortality occurred. On multivariate logistic regression, female gender (p = 0.048) and a previous episode of uncomplicated diverticulitis before the index diverticular abscess (p = 0.020) were associated with a recurrent episode.

LIMITATIONS

This study was limited by its retrospective design and modest sample size.

CONCLUSIONS

After initial successful nonoperative management of diverticulitis with abscess, expectant management with nonoperative intent is a safe long-term option with low rates of surgery, especially in the emergency setting. See Video, Supplemental Digital Content 1, on the nonoperative management of diverticular abscess at http://links.lww.com/DCR/A234.

Predictors of acute diverticulitis severity: A systematic review

BACKGROUND

Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring systems exist for predicting prognosis associated with severe complications of diverticulitis such as peritonitis. However, predicting disease severity has not received as much attention. Therefore, the aim of this review was to identify the factors that are predictive of severe acute diverticulitis.

METHODS

A systematic literature search was performed using Medline, PubMed, EMBASE, and the Cochrane Library to identify papers that evaluated factors predictive of severe diverticulitis. Severe diverticulitis was defined as complicated diverticulitis (associated with haemorrhage, abscess, phlegmon, perforation, purulent/faecal peritonitis, stricture, fistula, or small-bowel obstruction) or diverticulitis that resulted in prolonged hospital admission, surgical intervention or death.

RESULTS

Twenty one articles were included. Studies were categorised into those that identified patient characteristics (n = 12), medications (n = 5), biochemical markers (n = 8) or imaging (n = 3) as predictors. Predictors for severe diverticulitis included first episode of diverticulitis, co-morbidities (Charlson score ≥ 3), non-steroidal anti-inflammatory drug use, steroid use, a high CRP on admission and severe disease on radiological imaging. Age and gender were not associated with disease severity.

CONCLUSION

A number of predictors exist for identifying severe diverticulitis, and CT remains the gold standard for diagnosing complicated disease. Patients who present with identified risk factors for severe disease warrant early imaging, closer in-patient observation and a lower threshold for early surgical intervention. Patients without these factors may be suitable for outpatient-based treatment.

Increased Risk of Pyogenic Liver Abscess Among Patients With Colonic Diverticular Diseases: A Nationwide Cohort Study

Whether patients with diverticular diseases exhibit a higher risk of developing pyogenic liver abscess (PLA) remains inconclusive.From the inpatient claims in Taiwan's National Health Insurance Research Database, we identified 54,147 patients diagnosed with diverticulosis in the 1998 to 2010 period and 216,588 controls without the disorder. The 2 cohorts were matched by age, sex, and admission year, and were followed up until the end of 2010 to estimate the risk of PLA.Overall, the incidence of PLA was 2.44-fold higher in the diverticular-disease group than in the controls (11.5 vs 4.65 per 10,000 person-year). The adjusted hazard ratio (aHR) of PLA was 2.11 (95% confidence interval [CI], 1.81-2.44) for the diverticular-disease group, according to a multivariate Cox proportional hazards regression model. The age-specific data showed that the aHR for the diverticular-disease group, compared with the controls, was the highest inpatients younger than 50 years old (aHR, 4.03; 95% CI, 2.77-5.85). Further analysis showed that the diverticular-disease group exhibited an elevated risk of PLA regardless of whether patients had diverticulitis.The patients with diverticular diseases exhibited a higher risk of PLA.

Management of diverticular disease

Diverticular disease is a common condition in Western countries and the incidence and prevalence of the disease is increasing. The pathogenetic factors involved include structural changes in the gut that increase with age, a diet low in fibre and rich in meat, changes in intestinal motility, the concept of enteric neuropathy and an underlying genetic background. Current treatment strategies are hampered by insufficient options to stratify patients according to individual risk. One of the main reasons is the lack of an all-encompassing classification system of diverticular disease. In response, the German Society for Gastroenterology and Digestive Diseases (DGVS) has proposed a classification system as part of its new guideline for the diagnosis and management of diverticular disease. The classification system includes five main types of disease: asymptomatic diverticulosis, acute uncomplicated and complicated diverticulitis, as well as chronic diverticular disease and diverticular bleeding. Here, we review prevention and treatment strategies stratified by these five main types of disease, from prevention of the first attack of diverticulitis to the management of chronic complications and diverticular bleeding.

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.

[Treatment of the acute diverticulitis: A systematic review]

Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.

Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies

INTRODUCTION

Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either simple diverticulitis (SD) or complicated diverticulitis (CD).

PURPOSE

To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis.

METHODS

Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively.

RESULTS

Of the 576 patients in the CRSD, 139 (24.1%) had CD. The overall conversion rate was 12.8% (n = 74). The average BMI was 29.8 kg/m(2). The conversion rate for CD was 12.2%. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days, p = 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days, p = 0.08). The overall anastomotic leak rate was 2.1% (n = 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0% (n = 38), whereas those with CD had a postoperative morbidity rate of 19.6% (n = 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4%, n = 5, p = 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95% CI 1.11-3.46, p = 0.02) was found to be an independent risk factor for the development of postoperative complications.

CONCLUSIONS

Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.

Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery

BACKGROUND

Diverticular disease is one of the most common disorders of the gastrointestinal tract. 28-45% of the population develop colonic diverticula, while about 25% suffer symptoms and about 5% complications.

AIM

To create formal guidelines for diagnosis and management.

METHODS

Six working groups with 44 participants analyzed key questions in subject areas assigned to them. Following a systematic literature search, 451 publications were included. Consensus was obtained by agreement within the working groups, two Delphi processes and a guideline conference.

RESULTS

Targeted management of diverticular disease requires a classificatory diagnosis. A new classification was created. In addition to the clinical examination, intestinal ultrasound or computed tomography is the determining factor. Interval colonoscopy is recommended to exclude comorbidities. A low-fiber diet, obesity, lack of exercise, smoking and immunosuppression have an adverse impact on diverticulosis. This can lead to diverticulitis. Antibiotics are no longer recommended in uncomplicated diverticulitis if no risk factors such as immunosuppression are present. If close monitoring is ensured, uncomplicated diverticulitis can be treated on an outpatient basis. Complicated diverticulitis should be treated in hospital, involving broad-spectrum antibiotic therapy, where necessary abscess drainage, and surgery, if possible laparoscopically. In the case of chronic relapsing diverticulitis, the risk of perforation decreases with each episode, so that surgery is no longer recommended after the second episode but only following individual assessment.

CONCLUSIONS

New findings on diverticular disease call into question the overuse of antibiotics and excessive indications for surgery. Targeted treatment requires a precise diagnosis and intensive interdisciplinary cooperation.

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.

Diagnosis, Differential Diagnoses, and Classification of Diverticular Disease

Background

While detailed history, physical examination, and laboratory tests are of great importance when examining a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging (ultrasonography (US), computed tomography (CT)).

Methods

Qualified US has diagnostic value equipotent to qualified CT, follows relevant legislation for radiation exposure protection, and is frequently effectual for diagnosis. Furthermore, its unsurpassed resolution allows detailed investigation down to the histological level. Subsequently, US is considered the first choice of imaging in diverticular disease. Vice versa, CT has definite indications in unclear/discrepant situations or insufficient US performance.

Results

Endoscopy is not required for the diagnosis of diverticulitis and shall not be performed in the acute attack. Colonoscopy, however, is warranted after healing of acute diverticulitis, prior to elective surgery, and in atypical cases suggesting other diagnoses. Perforation/abscess must be excluded before colonoscopy.

Conclusion

Reliable diagnosis is fundamental for surgical, interventional, and conservative treatment of the different presentations of diverticular disease. Not only complications of acute diverticulitis but also a number of differential diagnoses must be considered. For an adequate surgical strategy, correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV) has passed a new classification of diverticulitis displaying the different facets of diverticular disease. This classification addresses different types (not stages) of the condition, and includes symptomatic diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding.

Long-term use of steroids protects from the development of symptomatic diverticulitis requiring hospitalization in the Asian population

OBJECTIVE

The pathophysiology of diverticulitis is poorly understood. Factors such as physical inactivity, constipation, obesity, smoking, and the use of nonsteroidal antiinflammatory drugs (NSAIDs) have been associated with an increased risk of diverticular disease. To evaluate whether patients exhibiting long-term steroid use are at increased risk of colonic diverticulitis.

METHOD

We conducted a population-based, nested case-control study. Data were retrospectively collected from the National Health Insurance Research Database. The study cohort comprised patients diagnosed with diverticulitis, identified using inpatient discharge records using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes (562.11 and 562.13), and those who were administered one or more prescriptions for corticosteroids for systemic use. Control patients were matched to cases by age, sex, NSAID use, laxative drug use, and index date. We enrolled 690 patients with colonic diverticulitis and 2760 in the control group. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression.

RESULTS

Compared with steroid nonusers, the adjusted ORs were 0.60 (95% CI = 0.35-1.06) and 0.80 (95% CI = 0.64-1.008) in current steroid users and previous steroid users, respectively. In addition, the adjusted ORs were 0.55 (95% CI = 0.31-0.98), 0.57 (95% CI = 0.31-0.98), and 0.44 (95% CI = 0.22-0.86) for steroid use duration more than half time by an exposure period of 90 days, 180 days, and 365 days before the claim date of colonic diverticulitis, respectively.

CONCLUSIONS

The results indicated that long-term steroid use within one year is associated with lower risk of colonic diverticulitis.

Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking

Background

Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding.

Methods

A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed.

Results

Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities.

Conclusion

Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.

Elective Surgery for Sigmoid Diverticulitis - Indications, Techniques, and Results

Diverticulitis is one of the leading indications for elective colonic resections although there is an ongoing controversial discussion about classification, stage-dependent therapeutic options, and therapy settings. As there is a rising trend towards conservative therapy for diverticular disease even in patients with a complicated form of diverticulitis, we provide a compact overview of current surgical therapy principles and the remaining questions to be answered.

Validation of a grading system for complicated diverticulitis in the prediction of need for operative or percutaneous intervention

INTRODUCTION

The current surgical management of acute complicated diverticulitis has seen a major paradigm shift from routine operative intervention to a more conservative approach. This has been made possible by the widespread availability of computed tomography (CT) to enable stratification of the disease severity of acute complicated diverticulitis. The aim of this study was to retrospectively validate a CT grading system for acute complicated diverticulitis in the prediction of the need for operative or percutaneous intervention.

METHODS

Hospital and radiology records were reviewed to identify patients with acute complicated diverticulitis confirmed by CT. A consultant gastrointestinal radiologist, blinded to the clinical outcomes of patients, assigned a score according to the CT grading system.

RESULTS

Three hundred and sixty-seven patients (34.6%) had CT performed for acute diverticulitis during the study period. Forty-four patients (12.0%) had acute complicated diverticulitis (abscess and/or free intraperitoneal air) confirmed on CT. There were 22 women (50%) and the overall median age was 59 years (range: 19-92 years). According to the CT findings, there was one case with grade 1, eighteen patients with grade 2, four with grade 3 and twenty-one with grade 4 diverticulitis. Three patients with grade 2, three patients with grade 3 and ten patients with grade 4 disease underwent acute radiological or surgical intervention.

CONCLUSIONS

The use of a CT grading system for acute complicated diverticulitis did not predict the need for acute radiological or operative intervention in this small study. Decision making guided by the patient's clinical condition still retains a primary role in the management of acute complicated diverticulitis.

Assessment of risk for recurrent diverticulitis: a proposal of risk score for complicated recurrence

Recurrence of acute diverticulitis is common, and--especially complicated recurrence--causes significant morbidity. To prevent recurrence, selected patients have been offered prophylactic sigmoid resection. However, as there is no tool to predict whose diverticulitis will recur and, in particular, who will have complicated recurrence, the indications for sigmoid resections have been variable. The objective of this study was to identify risk factors predicting recurrence of acute diverticulitis. This is a retrospective cohort study of patients presenting with computed tomography-confirmed acute diverticulitis and treated nonresectionally during 2006 to 2010. Risk factors for recurrence were identified using uni- and multivariate Cox regression. A total of 512 patients were included. History of diverticulitis was an independent risk factor predicting uncomplicated recurrence of diverticulitis (1-2 earlier diverticulitis HR 1.6, 3 or more--HR 3.2). History of diverticulitis (HR 3.3), abscess (HR 6.2), and corticosteroid medication (HR 16.1) were independent risk factors for complicated recurrence. Based on regression coefficients, risk scoring was created: 1 point for history of diverticulitis, 2 points for abscess, and 3 points for corticosteroid medication. The risk score was unable to predict uncomplicated recurrence (AUC 0.48), but was able to predict complicated recurrence (AUC 0.80). Patients were further divided into low-risk (0-2 points) and high-risk (>2 points) groups. Low-risk and high-risk groups had 3% and 43% 5-year complicated recurrence rates, respectively. Risk for complicated recurrence of acute diverticulitis can be assessed using risk scoring. The risk for uncomplicated recurrence increases along with increasing number of previous diverticulitis.

Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a definitive treatment? Retrospective analysis of 63 cases

BACKGROUND

The ideal treatment of perforated diverticulitis and the indications for elective colon resection remain controversial. Considering the significant morbidity and mortality rates related to traditional resection, efforts have been made to reduce the invasiveness of surgery in recent decades. Laparoscopic peritoneal lavage has emerged as an effective alternative option. We retrospectively investigated the effectiveness of laparoscopic peritoneal lavage for perforated diverticulitis and the possibility that it could be a definitive treatment.

METHODS

We included patients treated with laparoscopic peritoneal lavage for perforated diverticulitis. The inclusion criteria were all emergency patients with generalized peritonitis due to Hinchey III perforated diverticulitis and some cases of Hinchey II and IV.

RESULTS

Sixty-three patients were treated with laparoscopic peritoneal lavage. Six patients (9.5 %) had Hinchey II diverticulitis; 54 patients (85.7 %) had Hinchey III; and three patients (4.8 %) had Hinchey IV. The mean operative time was 87.3 min (±25.4 min), and the overall morbidity rate was 14.3 %. One patient died because of pulmonary embolism, and there were six early reinterventions because of treatment failure. Delayed colon resection was performed in four of the remaining 57 patients (7 %) because of recurrent diverticulitis. In the other 53 patients (93 %), we saw no recurrence of diverticulitis and no intervention was performed after a median follow-up period of 54 months (interquartile range 27-98 months).

CONCLUSIONS

Laparoscopic peritoneal lavage for perforated diverticulitis can be considered a safe and effective alternative to traditional surgical resection, and using this approach, most elective colon resection might be avoided.

No antibiotics in acute uncomplicated diverticulitis: does it work?

BACKGROUND

The first randomized multicenter study evaluating the need for antibiotic treatment in patients with acute uncomplicated diverticulitis (AUD) could not demonstrate any benefit gained from antibiotic use. The aim of this study was to review the application of the no antibiotic policy and its consequences in regard to complications and recurrence.

METHODS

This retrospective population-based cohort study included all patients diagnosed with all types of colonic diverticulitis during the year 2011 at Västmanland Hospital Västerås, Sweden. All medical records were carefully reviewed. Primary outcomes were the types of treatment adopted for diverticulitis, complications and recurrence.

RESULTS

In total, 246 patients with computer tomography-verified diverticulitis were identified, 195 with primary AUD and 51 with acute complicated diverticulitis. Age, sex, and temperature at admission were similar between the groups but there was a significant difference in white blood cell count, C-reactive protein, and length of hospital stay. In the AUD group, 178 (91.3%) patients were not treated with antibiotics. In this group, there were six (3.4%) readmissions but only two developed an abscess. Of the remaining 17 patients (8.7%) who were treated with antibiotics in the AUD group, one developed an abscess. Twenty-five (12.8%) patients in the AUD group presented with a recurrence within 1 year.

CONCLUSION

The no-antibiotic policy for AUD is safe and applicable in clinical practice. The previous results of a low complication and recurrence rate in AUD are confirmed. There is no need for antibiotic treatment for AUD. What does this paper add to the literature? Despite published papers with excellent results, there are still doubts about patient safety against the policy to not use antibiotics in acute uncomplicated diverticulitis. This is the first paper, in actual clinical practice, to confirm that the no antibiotic policy for acute uncomplicated diverticulitis is applicable and safe.

A retrospective case note review of laparoscopic versus open reversal of Hartmann's procedure

INTRODUCTION

First described in 1921, Hartmann's procedure is the gold standard treatment for complicated sigmoid diverticular disease. It is also used commonly for other causes of perforation of the large bowel. However, the reversal rate in the UK is much lower than in comparable countries, at only 18-22%. Furthermore, laparoscopic reversal (LRH) is used far less frequently than open reversal (ORH) despite evidence that a laparoscopic technique reduces patient morbidity and decreases patient recovery time.

METHODS

This retrospective case note review undertook an analysis of all the patients who had undergone Hartmann's procedure at two centres in Leeds Teaching Hospitals NHS Trust between February 2007 and February 2012. Out of 305 patients, 235 were identified and included in the analysis. Comparisons were then drawn between LRH and ORH groups.

RESULTS

The reversal rate was 21%. Three-quarters (76%) were performed using an open technique, 20% were laparoscopic and 5% were converted to an open procedure. The mean hospital stay was longer for the ORH group (9.82 days, standard deviation [SD]: 5.85 days, 95% confidence interval [CI]: 2.99 days) than for the LRH group (7.29 days, SD: 4.65 days, 95% CI: 11.58 days) p=0.006). Seven ORH patients (21%) were reoperated but only one LRH patient (13%) had a reoperation at six months. Five factors were found to have a significant effect on the likelihood of reversal of Hartmann's procedure.

CONCLUSIONS

The overall reversal rate for Hartmann's procedure remains low. Shorter hospital stays, lower 6-month reoperation rates and reduced 30-day complication rates are associated with LRH when compared with ORH.

Colonic diverticulitis in chemotherapy patients: should operative indications change? A retrospective cohort study

INTRODUCTION

Management of the immunosuppressed patient with diverticular disease remains controversial. We report the largest series of colon cancer patients undergoing chemotherapy and hospitalized for acute diverticulitis, to determine whether recent treatment with systemic chemotherapy is associated with increased risk for/increased severity of recurrent diverticulitis.

METHODS

Retrospective cohort study of adult patients hospitalized for an initial episode of acute colonic diverticulitis at Memorial Sloan Kettering Cancer Center, 1988-2004. Outcomes in patients receiving systemic chemotherapy within one month of admission for diverticulitis ("Chemo") were compared to outcomes of patients not receiving chemotherapy within the past month ("No-chemo").

RESULTS

A total 131 patients met inclusion criteria. Chemo patients did not differ significantly from No-chemo group in terms of severity of acute diverticulitis at index admission (13.2% vs. 4.4%, respectively, p = 0.12), resumption of chemotherapy (median 2 months), failure of non-operative management (13.2% vs 4.4%, respectively, p = 0.12), frequency of recurrence (20.5% vs 18.5%), hospital length of stay (p = 0.08), and likelihood of interval resection (24.0% vs. 16.2%, respectively, p = 0.39). Chemo patients recurred with more severe disease, were more likely to undergo emergent surgery (75.0% vs. 23.5%, respectively, p = 0.03), and were more likely to be diverted (100.0% vs. 25.0%, respectively, p = 0.03). Chemo patients were significantly more likely to incur a postoperative complication (100% vs 9.1% p < 0.01) following interval resection. Overall mortality was significantly higher in the Chemo vs. No-chemo group. Median survival in Chemo patients was 3.4 years; in No-chemo patients, median survival was not reached at 10 years.

CONCLUSION

Our data do not support routine elective surgery for acute diverticulitis in patients receiving chemotherapy. Non-operative management in the acute or interval setting appears preferable whenever possible.

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.

Laparoscopic resection of chronic sigmoid diverticulitis with fistula

BACKGROUND AND OBJECTIVES

A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula.

METHODS

A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period.

RESULTS

Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence.

CONCLUSIONS

Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.

Elective operation after acute complicated diverticulitis: Is it still mandatory?

AIM: To investigate recurrence rates, patterns and complications after nonoperatively managed complicated diverticulitis (CD).

METHODS: A retrospective study of patients treated for CD was performed. CD was defined on computed tomography by the presence of a localized abscess, pelvic abscess or extraluminal air. For follow-up, patients were contacted by telephone. Numbers of elective surgeries, recurrences and abdominal pain were analyzed.

RESULTS: A total of 114 patients (median age 57 years (range 29-97)), were admitted for CD. Nine patients required surgical intervention for failure of conservative therapy (Hartmann’s procedure: n = 6; resection and colorectal anastomosis: n = 3). Of the 105 remaining patients, 24 (22.9%) underwent elective sigmoid resection. The 81 (71%) non-operated patients were all contacted after a median follow-up of 32 mo (4-63). Among them, six had developed a recurrent episode of diverticulitis at a median follow-up of 12 mo (6-36); however, no patient required hospitalization. Sixty-eight patients (84%) were asymptomatic and 13 (16%) had recurrent abdominal pain.

CONCLUSION: Conservative policy is feasible and safe in 71% of cases, with a low medium-term recurrence risk.

Influence of CD68+ macrophages and neutrophils on anastomotic healing following laparoscopic sigmoid resection due to diverticulitis

BACKGROUND

The aim of this prospective study was to evaluate the predictive value of a potential preexisting low-grade inflammation regarding the incidence of anastomotic leakage in elective laparoscopic sigmoid resection due to diverticulitis.

METHODS

Patients with either chronically recurrent diverticulitis or sigmoid stenosis caused by chronic diverticulitis were included in this study. All patients with acute local or systemic inflammation were excluded. Detailed patient information (e.g. American Society of Anesthesiologists (ASA) grade, comorbidities, duration of hospital stay, and anastomotic leakage) was prospectively recorded. CD68(+) macrophages, neutrophils, CD3(+) T-lymphocytes, CD11c(+) dendritic cells, MHCII, TNFR1, and NF-κB were evaluated by immunohistochemistry within the acquired sample of colonic bowel wall tissue. Clinical and immunohistochemical data was compared between groups (leakage vs. no leakage). Additionally, a matched-pair analysis was performed due to the widely heterogeneous groups concerning the number of patients and to minimize the effect of extraneous variables.

RESULTS

A total of 83 patients were included in the study, of which 7 patients suffered an anastomotic leakage. Neither the clinical nor the immunohistochemical parameters were significantly different between the groups. The matched-pair analysis revealed a nonsignificant increase in mean duration of hospital stay for the group with anastomotic leakage and a significantly higher percentage of CD68(+) macrophages and neutrophils in the colonic wall obtained at the index operation in both the mucosal and submucosal layers for the leakage group.

CONCLUSIONS

A preexisting low-grade inflammation represented by infiltrates of macrophages and neutrophils is a predictor for increased risk of developing colon anastomotic leakage.

Management of acute diverticulitis and its complications

Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann's procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications-such as fistulating disease, strictures or recurrent diverticular bleeding-and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases.

Surgical outcomes and their relation to the number of prior episodes of diverticulitis

PURPOSE

We aimed to investigate the relationship between the number of prior episodes of diverticulitis and outcomes of sigmoid colectomy.

METHODS

After institutional review board approval, a retrospective review was undertaken based on records of patients who underwent sigmoid resection with anastomosis for diverticulitis between 4 May 2007 and 29 February 2012. Patients were divided into two groups: 0-3 attacks (group 1) and ≥4 attacks (group 2). Statistical analyses were performed to determine whether the groups differed on demographic, intra-operative and postoperative variables.

RESULTS

We identified 247 patients who underwent sigmoid colectomy for diverticulitis (45 open, 202 laparoscopic). The two groups did not differ significantly in age, gender, American Society of Anesthesiologists score, past surgical history, body mass index, length of stay, use of a stoma or number of prior hospitalizations for diverticulitis. Group 1 had a higher rate of abscesses (30.6 vs 6.8%, P < 0.001) and fistulas (19.4 vs 0.9%, P < 0.001); a longer operative time (190.1 vs 166.3 min, P = 0.0024); and higher rates of postoperative complications (45.8 vs 23.3%, P < 0.001) and conversion (17.1 vs 4.4%, P = 0.0091). The most common surgical complications in groups 1 and 2 were wound infection (35 vs 10) and ileus (20 vs 8). Based on multivariate regression analysis, ≥4 attacks were independently correlated with a lower complication rate (odds ratio = 0.512, 95% confidence interval = 0.266-0.987, P = 0.046).

CONCLUSIONS

Patients who had ≥4 previous attacks of diverticulitis had fewer postoperative complications.

Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children

BACKGROUND

For decades, urgent operation has been considered the only appropriate management of acute appendicitis in children. The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children.

STUDY DESIGN

A prospective nonrandomized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy was performed. The primary result was 30-day success rate of nonoperative management. Secondary outcomes included comparisons of disability days, missed school days, hospital length of stay, and measures of quality of life and health care satisfaction.

RESULTS

Seventy-seven patients were enrolled during October 2012 to October 2013; 30 chose nonoperative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of nonoperative management were 93% (28 of 30) and 90% (27 of 30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed. Compared with the surgery group, the nonoperative group had fewer disability days (3 vs 17 days; p < 0.0001), returned to school more quickly (3 vs 5 days; p = 0.008), and exhibited higher quality of life scores in both the child (93 vs 88; p = 0.01) and the parent (96 vs 90; p = 0.03), but incurred a longer length of stay (38 vs 20 hours; p < 0.0001).

CONCLUSIONS

Nonoperative management of uncomplicated acute appendicitis in children is feasible, with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of longer-term success rate, safety, and cost effectiveness.

Survival after acute colon diverticulitis treated in hospital

PURPOSE

The aim of this study was to determine the short- and long-term relative survival as well as the causes of death in patients treated in hospital for acute colonic diverticulitis.

MATERIALS AND METHODS

The study included all patients treated at Levanger Hospital for acute colonic diverticulitis between 1988 and 2012. Vital statistics were complete. The median observation time was 6.95 years (range 0.28-24.66) or until death.

RESULTS

In total, 650 different patients were hospitalized with acute colonic diverticulitis. Among these patients, there were 851 admissions for the same disease during the 25 years. The admissions had the following diagnoses: simple diverticulitis, 738; abscess formation , 44; perforation and purulent peritonitis, 47; perforation and fecal peritonitis, 9; and intestinal obstruction, 13. During the observation time, 219 were dead and 431 were still alive. After the first admission, the 100 day relative survival in patients with uncomplicated diverticulitis was 97 % (CI 95 to 99), with abscess formation 79 % (62 to 89), with purulent peritonitis 84 % (69 to 92), with fecal peritonitis 44 % (10 to 74), and with intestinal obstruction 80 % (38 to 96). After surviving the first 100 days, the estimated 5-year relative survival in the remaining 609 patients was 96 % (CI 92 to 100) and 10-year survival was 91 % (CI 84 to 97). In patients who survived the first 100 days, the different subtypes of diverticulitis yielded no significant differences in long-term relative survival. All patients who had been admitted with ASA score 4 were dead after 2 years.

Major increase in admission- and incidence rates of acute colonic diverticulitis

PURPOSE

Hospitalization for acute colonic diverticulitis has become more and more frequent. We studied the changes in the rate of admission and incidence of the disease during the last 25 years.

METHODS

We performed a retrospective analysis of all cases treated for acute diverticulitis during 1988-2012 at one hospital serving a defined population in Mid-Norway. The study made a distinction between admission rates and incidence rates. The admission rates defined the total number of cases admitted, while the incidence rates defined the number of new patients hospitalized for acute diverticulitis (first admission). Poisson regression was used to analyse factors associated with diverticulitis incidence rates.

RESULTS

A total of 851 admissions in 650 different patients were identified, with an overall admission rate of 38.5 (CI 35.9 to 41.1) per 100,000 person-years. The admission rate increased from 17.9 (CI 14.1 to 22.3)/100,000 during 1988-1992 to 51.1 (CI 44.8 to 58.0)/100,000 during 2008-2012. Poisson regression analysis showed a significant increase in admission rates with a factor of 2.8 (C.I. 2.2 to 3.5) during 25 years. The overall incidence rate (IRR) of new patients was 29.4 (CI 27.1 to 31.7)/100,000 person-years. IRR increased significantly with a factor of 2.6 (CI 1.96 to 3.34) during 25 years, while IRR for perforations increased even more, by a factor of 3.3 (CI 1.24 to 8.58).

CONCLUSION

The hospital admission rates as well as incidence rates for acute colonic diverticulitis increased significantly during the 25-year time span.