Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?

Hinchey I and II diverticular abscesses: long-term outcome of conservative treatment

BACKGROUND

The management of diverticular disease and its complications are an increasing burden to the health system. The natural history of conservatively managed diverticular abscesses (Hinchey I and II) is poorly described and it remains open to debate whether subsequent sigmoid resection is indicated after conservative management. This observational study compares outcomes of patients treated with conservative management (antibiotics +/- percutaneous drainage) and surgery.

METHODS

All patients admitted at Christchurch Hospital with diverticulitis between 1 January 1998 and 31 December 2009 were recorded in a database. A retrospective analysis of patients with an abscess due to complicated diverticulitis was undertaken. Initial management, recurrence and subsequent surgery were recorded. The patients were followed until 1 January 2014.

RESULTS

Of 1044 patients with diverticulitis, 107 with diverticular abscess were included in this analysis. The median age was 66 ± 16 and 60 were male. All patients had sigmoid diverticulitis and were diagnosed with a computed tomography. The median abscess size was 4.2 ± 2.1 cm. During median follow-up of 110 months, the overall recurrence rate was 20% (21/107). Recurrence varied according to initial treatment; namely antibiotics (30%), percutaneous drainage plus antibiotics (27%) and surgery (5%) (P = 0.004). The median time to recurrence was 4 ± 11.7 months, and most recurrences were treated conservatively; four patients underwent delayed surgery.

CONCLUSION

Recurrence after diverticular abscess is higher after initial conservative treatment (antibiotics +/- percutaneous drainage) compared with surgery, however, patients with recurrent disease can be treated conservatively with similar good outcomes and few patients required further surgery.

Minimally Invasive Management of Complicated Diverticular Disease: Current Status and Review of Literature

BACKGROUND

Diverticulitis is a common condition which carries significant morbidity and socioeconomic burden (McGillicuddy et al in Arch Surg 144:1157-1162, 2009). The surgical management of diverticulitis has undergone significant changes in recent years. This article reviews the role of minimally invasive approach in management of complicated diverticulitis, with a focus on recent concepts and advances.

MATERIALS AND METHODS

A literature review of past 10 years (January 2004 to September 2014) was performed using the electronic database MEDLINE from PubMed which included articles only in English.

RESULTS

We identified total of 139 articles, out of which 50 were excluded resulting in 89 full-text articles for review 16 retrospective studies, 7 prospective cohorts, 1 case-control series and 1 systematic review were included. These suggest that urgent surgery is performed for those with sepsis and diffuse peritonitis or those who fail to improve despite medical therapy and/or percutaneous drainage. In addition, 3 randomized control trials: DILALA, LapLAND and the Scandinavian Diverticulitis trial are working towards evaluating whether laparoscopic lavage is safe in management of complicated diverticular diseases. Growing trend toward conservative or minimally invasive treatment modality even in severe acute diverticulitis was noticed.

CONCLUSIONS

Laparoscopic peritoneal lavage has evolved as a good alternative to invasive surgery, yet clear indications for its role in the management of complicated diverticulitis need to be established. Recent evidence suggests that existing guidelines for optimal management of complicated diverticulitis should be updated. Non-resectional radiographic techniques are likely to play a prominent role in the initial treatment of complicated diverticulitis in the near future.

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.

Recent advances in the treatment of colonic diverticular disease and prevention of acute diverticulitis

The incidence of diverticulosis and diverticular disease of the colon is increasing worldwide. Although the majority of patients remains asymptomatic long-life, the prevalence of diverticular disease of the colon, including acute diverticulitis, is substantial and is becoming a significant burden on National Health Systems in terms of direct and indirect costs. Focus is now being drawn on identifying the correct therapeutic approach by testing various treatments. Fiber, non-absorbable antibiotics and probiotics seem to be effective in treating symptomatic and uncomplicated patients, and 5-aminosalicylic acid might help prevent acute diverticulitis. Unfortunately, robust evidence on the effectiveness of a medical strategy to prevent acute diverticulitis recurrence is still lacking. We herein provide a concise review on the effectiveness and future perspectives of these treatments.

A Markov Decision Model to Guide Treatment of Recurrent Colonic Diverticulitis

BACKGROUND & AIMS

Although colonic diverticulitis is a common disorder, there is no clear treatment strategy for patients with recurrent episodes of diverticulitis. We investigated whether colonic resection or conservative or medical treatments have the greatest effects on quality-adjusted life-years (QALYs).

METHODS

A Markov model simulating patients with 2 episodes of non-surgically treated diverticulitis was used to simulate all relevant outcomes of each treatment strategy. A 1-year cycle length with 10-year follow-up period was used to allow for chance of recurrent diverticulitis. Primary outcome was QALYs gained from each strategy. Factors considered were morbidity, mortality, chance of colostomy formation, risk of recurrence, and persistence of abdominal pain. The probabilities of clinical events were determined by using the best available published data.

RESULTS

A strategy in which colonic resection was performed after 2 episodes of diverticulitis was associated with the lowest quality-adjusted survival (a gain of 8.66 QALYs) and highest chance of stoma formation (1.1%) but the lowest chance of a mild (3.5%) or severe (1.1%) recurrence. The strategies of colonic resection or conservative or medical treatment after the third episode of diverticulitis were comparable in terms of quality-adjusted survival, providing 8.78, 8.76, and 8.74 QALYs, respectively. Probabilistic sensitivity analysis did not change these results. Persistent abdominal complaints were lowest in the medical treatment strategy.

CONCLUSIONS

Elective surgery after 2 episodes of diverticulitis should be questioned in terms of QALYs. After the third episode of diverticulitis, surgical or conservative or medical treatments provide similar QALYs, but rates of abdominal symptoms are lower with the medical treatment strategy. This Markov decision model has limitations when the individual patient and physician face a complex decision weighing early and long-term risks and benefits of elective surgery or conservative management.

Natural history of uncomplicated sigmoid diverticulitis

While diverticular disease is extremely common, the natural history (NH) of its most frequent presentation (i.e., sigmoid diverticulitis) is poorly investigated. Relevant information is mostly restricted to population-based or retrospective studies. This comprehensive review aimed to evaluate the NH of simple sigmoid diverticulitis. While there is a clear lack of uniformity in terminology, which results in difficulties interpreting and comparing findings between studies, this review demonstrates the benign nature of simple sigmoid diverticulitis. The overall recurrence rate is relatively low, ranging from 13% to 47%, depending on the definition used by the authors. Among different risk factors for recurrence, patients with C-reactive protein > 240 mg/L are three times more likely to recur. Other risk factors include: Young age, a history of several episodes of acute diverticulitis, medical vs surgical management, male patients, radiological signs of complicated first episode, higher comorbidity index, family history of diverticulitis, and length of involved colon > 5 cm. The risk of developing a complicated second episode (and its corollary to require an emergency operation) is less than 2%-5%. In fact, the old rationale for elective surgery as a preventive treatment, based mainly on concerns that recurrence would result in a progressively increased risk of sepsis or the need for a colostomy, is not upheld by the current evidence.

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.

Diverticula and Diverticulitis: Time for a Reappraisal

Colonic diverticula are very common and may be associated with symptoms or complicated by diverticulitis and its associated problems. Many of the traditional concepts relating to the pathophysiology, prevention, and management of these entities have been questioned recently based on findings from high-quality prospective studies. Although dietary fiber may protect against symptoms and complications, its impact on the formation of diverticula may be limited. It is now evident that the risk for an episode of diverticulitis in an individual with diverticula is lower than previously thought. Furthermore, the necessity for antibiotic use in uncomplicated diverticulitis has been questioned and serious doubt cast upon the belief that surgery should be performed when a second attack occurs. Although data are far from conclusive, there is some evidence to suggest that diverticulosis may be associated with chronic abdominal symptoms, with or without underlying chronic inflammatory changes in the involved segment of the colon. In addition, colonoscopy is not routinely required after an attack of acute uncomplicated diverticulitis, as the risk of cancer in this population is not much higher than in the general population.

Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon

BACKGROUND

The incidence of diverticulosis and diverticular disease of the colon, including diverticulitis, is increasing worldwide, and becoming a significant burden on national health systems. Treatment of patients with diverticulosis and DD is generally based on high-fibre diet and antibiotics, respectively. However, new pathophysiological knowledge suggests that further treatment may be useful.

AIM

To review the current treatment of diverticulosis and diverticular disease.

METHODS

A search of PubMed and Medline databases was performed to identify articles relevant to the management of diverticulosis and diverticular disease. Major international conferences were also reviewed.

RESULTS

Two randomised controlled trials (RCT) found the role of antibiotics in managing acute diverticulitis to be questionable, particularly in patients with no complicating comorbidities. One RCT found mesalazine to be effective in preventing acute diverticulitis in patients with symptomatic uncomplicated diverticular disease. The role of rifaximin or mesalazine in preventing diverticulitis recurrence, based on the results of 1 and 4 RCTs, respectively, remains unclear. RCTs found rifaximin and mesalazine to be effective in treating symptomatic uncomplicated diverticular disease. The use of probiotics in diverticular disease and in preventing acute diverticulitis occurrence/recurrence appears promising but unconclusive. Finally, the role of fibre in treating diverticulosis remains unclear.

CONCLUSIONS

Available evidence suggests that antibiotics have a role only in the treatment of complicated diverticulitis. It appears to be some evidence for a role for rifaximin and mesalazine in treating symptomatic uncomplicated diverticular disease. Finally, there is not currently adequate evidence to recommend any medical treatment for the prevention of diverticulitis recurrence.

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.

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.

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.

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.

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.

Toward an evidence-based step-up approach in diagnosing diverticulitis

BACKGROUND

The lack of pathognomonic findings and the chance of complicated disease have resulted in the widespread use of additional imaging to diagnose acute colonic diverticulitis (ACD). The added value of additional imaging in the diagnostic workup of patients suspected of ACD is not well defined.

AIMS

The aim of this study was to systematically review the literature of the accuracy of the clinical evaluation and diagnostic modalities for patients with suspected ACD, to come to an evidence-based approach to diagnose ACD.

METHODS

A systematic review and meta-analysis of studies that reported diagnostic accuracy of the clinical diagnosis and diagnostic modalities in patients with suspected diverticulitis were performed. Study quality was assessed with the STARD checklist. True-positive, true-negative, false-positive, and false-negative findings were extracted and pooled estimates of sensitivity and specificity per diagnostic test were calculated, if applicable.

RESULTS

The overall quality of the studies reporting the diagnostic accuracy of the clinical diagnosis, contrast enema and magnetic resonance imaging (MRI) were moderate to poor and not suitable for meta-analysis. Sensitivity of the clinical diagnosis varied between 64% and 68%. Ultrasound (US) and computed tomography (CT) studies were eligible for meta-analysis. Summary sensitivity estimates for US were 90% (95% CI: 76-98%) versus 95% (95% CI: 91-97%) for CT (p = 0.86). Summary specificity estimates for US were 90% (95% CI: 86-94%) versus 96% (95% CI: 90-100%) for CT (p = 0.04). Sensitivity for MRI was 98% and specificity varied between 70% and 78%. Sensitivity of contrast enema studies varied between 80% and 83%.

CONCLUSION

In two-thirds of the patients, the diagnosis of ACD can be made based on clinical evaluation alone. In one-third of the patients, additional imaging is a necessity to establish the diagnosis. US and CT are comparable in diagnosing diverticulitis and superior to other modalities. CT has the advantage of higher specificity and the ability to identify alternative diagnoses. The role of MRI is not yet clear in diagnosing ACD. Contrast enema is considered an obsolete imaging technique to diagnose ACD based on lower sensitivity and specificity than US and CT. A step-up approach with CT performed after an inconclusive or negative US, seems a logical and safe approach for patients suspected of ACD.

Clinical decision support for colon and rectal surgery: an overview

Clinical decision support (CDS) has been shown to improve clinical processes, promote patient safety, and reduce costs in healthcare settings, and it is now a requirement for clinicians as part of the Meaningful Use Regulation. However, most evidence for CDS has been evaluated primarily in internal medicine care settings, and colon and rectal surgery (CRS) has unique needs with CDS that are not frequently described in the literature. The authors reviewed published literature in informatics and medical journals, combined with expert opinion to define CDS, describe the evidence for CDS, outline the implementation process for CDS, and present applications of CDS in CRS.CDS functionalities such as order sets, documentation templates, and order facilitation aids are most often described in the literature and most likely to be beneficial in CRS. Further research is necessary to identify and better evaluate additional CDS systems in the setting of CRS.

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.

Review article: The pathogenesis and management of acute colonic diverticulitis

BACKGROUND

Acute diverticulitis, defined as acute inflammation associated with a colonic diverticulum, is a common emergency presentation managed by both surgeons and physicians. There have been advances in both the medical and the surgical treatments offered to patients in recent years.

AIM

To review the current understanding of the aetiology and treatment of acute diverticulitis.

METHODS

A search of PubMed and Medline databases was performed to identify articles relevant to the aetiology, pathogenesis and management of acute diverticulitis.

RESULTS

There are 75 hospital admissions per year for acute diverticulitis per 100,000 of the population in the United States. Recent reports suggest a 26% increase in admissions over a 7-year period. Factors predisposing to the development of acute diverticulitis include obesity, smoking, diet, lack of physical activity and medication use such as aspirin and nonsteroidal anti-inflammatory drugs. The condition is associated with a low mortality of about 1% following medical therapy, rising to 4% in-hospital mortality in those requiring surgery. There is limited evidence on the efficacy of individual antibiotic regimens, and antibiotic treatment may not be required in all patients. The rates of recurrence reported for patients with acute diverticulitis following medical management vary from 13% to 36%. The surgical management of those patients who fail medical treatment has moved towards a laparoscopic nonresectional approach; however, the evidence supporting this is limited.

CONCLUSIONS

Further high-quality randomised controlled trials are required of both medical and surgical treatments in patients with acute diverticulitis, if management is to be evidence-based.

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.

Preventing recurrent acute diverticulitis with pharmacological therapies

Acute diverticulitis of the colon represents a significant burden for national health systems, in terms of direct and indirect costs. Past guidelines claimed that recurrent episodes (two or more) of diverticulitis need surgery, but revised guidelines recommend an individualized approach to patients after an attack of acute diverticulitis. For these reasons, conservative treatment has become the preferred choice after an episode of diverticulitis. Thus, significant efforts are now being focused to identify the correct therapeutic approach to prevent diverticulitis relapses. Nonabsorbable antibiotics, 5-aminosalicylic acid and probiotics are currently being investigated in this way. The effectiveness and the future perspectives of these treatments are discussed herein.

Colonic diverticulitis with comorbid diseases may require elective colectomy

AIM: To investigate the comorbid disease could be the predictors for the elective colectomy in colonic diverticulitis.

METHODS: A retrospective chart review of 246 patients with colonic diverticulitis admitted between 2000 and 2008 was conducted, and 19 patients received emergent operation were identified and analyzed. Data were collected with regard to age, sex, albumin level on admission, left or right inflammation site, the history of recurrent diverticulitis, preoperative comorbidity, smoking habits, medication, treatment policy, morbidity, and mortality. Preoperative comorbid diseases included cardiovascular disease, diabetes, pulmonary disease, peptic ulcer disease, gouty arthritis, and uremia. Medications in use included non-steroidal anti-inflammatory drugs, acetylsalicylic acid (Aspirin), and corticosteroids. Univariate and multivariate logistic regression analyses were performed to identify the relevant risk factors correlating to colectomy.

RESULTS: The mean age of the 246 patients was 69.5 years (range, 24-94 years). Most diverticulitis could be managed with conservative treatment (n = 227, 92.3%), and urgent colectomy was performed in 19 patients (7.7%). There were three deaths in the surgical group and four deaths in the nonsurgical group. The overall mortality rate in the study was 1.7% among patients with conservative treatment and 15.7% among patients undergoing urgent colectomy. Multiple logistic regression analysis indicated that comorbidities were risk factors for urgent colectomy for diverticulitis.

CONCLUSION: To avoid high mortality and morbidity related to urgent colectomy, we suggest that patients with colonic diverticulitis and comorbid diseases may require elective colectomy.

Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis

BACKGROUND

The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed.

METHODS

A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities.

RESULTS

The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy.

CONCLUSION

Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.

Risk factors for severe diverticulitis in computed tomography-confirmed acute diverticulitis in Korea

Background/Aims

Acute complicated diverticulitis can be subdivided into moderate diverticulitis and severe diverticulitis. Although there have been numerous studies on the risk factors for complicated diverticulitis, little research has focused on severe diverticulitis. This study was designed to identify the risk factors for severe diverticulitis in an acute diverticulitis attack using the modified Hinchey classification.

Methods

Patients were included if they had any evidence of acute diverticulitis detected by computed tomography. The patients were subdivided into severe diverticulitis (Hinchey class ≥Ib; abscesses or peritonitis) and moderate diverticulitis (Hinchey class Ia; pericolic inflammation) groups.

Results

Of the 128 patients, 25 exhibited severe diverticulitis, and 103 exhibited moderate diverticulitis. In a multivariate analysis, age >50 years (odds ratio [OR], 5.27; p=0.017), smoking (OR, 3.61; p=0.044), comorbidity (OR, 4.98; p=0.045), leukocytosis (OR, 7.70; p=0.003), recurrence (OR, 4.95; p=0.032), and left-sided diverticulitis (OR, 6.92; p=0.006) were significantly associated with severe diverticulitis.

Conclusions

This study suggests that the risk factors for severe diverticulitis are age >50 years, smoking, comorbidity, leukocytosis, recurrent episodes, and left-sided diverticulitis.

Assessment of recurrence and complications following uncomplicated diverticulitis

BACKGROUND

The natural history of sigmoid diverticulitis has been inferred from population-based or retrospective studies. This study assessed the risk of a recurrent attack following the first episode of uncomplicated diverticulitis.

METHODS

Patients admitted between January 2007 and December 2011 with a first episode of uncomplicated sigmoid diverticulitis confirmed on computed tomography were enrolled in this prospective study. After successful medical management of the first episode, follow-up was conducted through yearly telephone interviews. Cox proportional hazards regression was performed to model the impact of various parameters on eventual recurrences and complications.

RESULTS

During a median follow-up of 24 (range 3-63) months, 46 (16·4 per cent) of 280 patients experienced a second episode of diverticulitis. Six patients (2·1 per cent) subsequently developed complicated diverticulitis and four (1·4 per cent) underwent emergency surgery for peritonitis. In multivariable analysis, a raised serum level of C-reactive protein (over 240 mg/l) during the first attack was associated with early recurrence (hazard ratio 1·75, 95 per cent confidence interval 1·04 to 2·94; P = 0·035).

CONCLUSION

Uncomplicated sigmoid diverticulitis follows a benign course with few recurrences and little need for emergency surgery.

REGISTRATION NUMBER

NCT01015378 (http://www.clinicaltrials.gov).

Glucocorticoid-induced tumour necrosis factor receptor expression: a potential molecular link between steroid intake and complicated diverticulitis?

AIM

Immunosuppression and steroid medication have been identified as risk factors for complicated sigmoid diverticulitis. The underlying molecular mechanisms have not yet been elucidated. We hypothesized that glucocorticoid-induced tumour necrosis factor receptor (GITR) and matrix metalloproteinase-9 (MMP-9) might play a role.

METHOD

GITR and MMP-9 were analysed at protein [immunohistochemistry/immunofluorescence (IF)] and messenger RNA level (real-time polymerase chain reaction) in surgical specimens with complicated and non-complicated diverticulitis (n=101). IF double staining and regression analysis were performed for both markers. GITR expression was correlated with clinical data and its usefulness as a diagnostic test was investigated.

RESULTS

High GITR expression (≥41%) was observed in the inflammatory infiltrate in complicated diverticulitis, in contrast to non-complicated diverticulitis where GITR expression was low (P<0.001). High GITR expression was significantly associated with steroid use and pulmonary diseases (both P<0.001). MMP-9 expression correlated with GITR expression (R(2) =0.7268, P<0.0001, r=0.85) as demonstrated with IF double-staining experiments. Co-labelling of GITR with CD68, but not CD15, suggested that GITR-expressing cells in diverticulitis are macrophages. GITR expression was superior to C-reactive protein (CRP), white cell count and temperature in distinguishing complicated and non-complicated diverticulitis.

CONCLUSIONS

Our results suggest that GITR expression in inflammatory cells might potentially indicate a molecular link between steroid use and complicated forms of acute sigmoid diverticulitis. Increased MMP-9 expression by GITR signalling might explain the morphological changes in the colonic wall of perforated and phlegmonous diverticulitis. Analysis of soluble GITR might be a promising strategy for future research.

Laparoscopic surgery for complicated diverticular disease: a single-centre experience

AIM

The role of laparoscopic surgery in the management of patients with diverticular disease is still not universally accepted. The aim of our study was to evaluate the results of laparoscopic surgery for diverticular disease in a centre with a specialist interest in minimally invasive surgery.

METHOD

All diverticular resections carried out between 2006 and 2010 were reviewed. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Complicated diverticular disease was defined as diverticulitis with associated abscess, phlegmon, fistula, stricture, obstruction, bleeding or perforation.

RESULTS

One hundred and two patients (58 men) who had surgery for diverticular disease were identified (median age 59 years, range 49-70 years). Sixty-four patients (64%) had surgery for complicated diverticular disease. The indications were recurrent acute diverticulitis (37%), colovesical fistula (21%), stricture formation (17%) and colonic perforation (16%). Sixty-nine cases (88%) were completed by elective laparoscopy. Postoperative mortality was 0%. For elective cases there was no difference in morbidity rates between patients with complicated and uncomplicated diverticular disease. The overall anastomotic leakage rate was 1% and the wound infection rate 7%. There was a nonsignificant trend to higher conversion to open surgery in the elective group in complicated (11.4%) compared with uncomplicated patients (5.2%) (P=0.67). Electively, the rate of stoma formation was higher in the complicated (31.6%) than the uncomplicated group (5.2%) (P<0.02).

CONCLUSION

Laparoscopic surgery for both complicated and uncomplicated diverticular disease is associated with low rates of postoperative morbidity and relatively low conversion rates. Laparoscopic surgery is now the standard of care for complicated and uncomplicated diverticular disease in our institution.

Uncomplicated diverticulitis, more complicated than we thought

INTRODUCTION

The classification of complicated and uncomplicated diverticulitis has been used for many years. We note variations in the course of uncomplicated diverticulitis. We propose and describe three categories of uncomplicated diverticulitis.

METHODS

A review was performed on 907 patients who underwent sigmoid resection for diverticulitis between January 1, 2005 and December 30, 2009 at Mayo Clinic, Rochester. Overall, 223 individuals were excluded as they were not uncomplicated diverticulitis. The remaining 684 patients were divided into three classifications as follows: 54 (7.9 %) atypical, 66 (9.6 %) chronic/smoldering, and 564 (82 %) acute resolving. Data elements abstracted included demographics, preoperative symptoms, imaging and endoscopy, operative and pathologic findings, postoperative complications, and resolution of symptoms.

RESULTS

The 30-day complication rate of the atypical, chronic/smoldering, and acute groups was 26 %, 22 %, and 35 %, respectively. Resolution of symptoms for the atypical and chronic/smoldering groups was 93 % and 89 %, respectively. Only two patients in the acute resolving group required an operation for recurrence.

CONCLUSION

A spectrum of clinical presentation for uncomplicated diverticulitis may require different approaches. A select group of patients with chronic/smoldering and atypical disease will continue to be burdened by symptoms. The success of surgical intervention was greater than 89 % in both groups with acceptable morbidity, and should remain an option.

Systematic review of medical therapy to prevent recurrent diverticulitis

AIM AND BACKGROUND

One of today's controversies remains the prevention of recurrent diverticulitis. Current guidelines advise a conservative approach, based on studies showing low recurrence rates and a high operative morbidity and mortality. Conservative measures in prevention recurrence are dietary advises and medical therapies, including probiotics and 5-aminosalicylic acid.

OBJECTIVES

The aim of this systematic review is to assess whether medical or dietary therapies can prevent recurrent diverticulitis after a primary episode of acute diverticulitis. METHOD AND SEARCH STRATEGY: We searched different databases for papers published between January 1966 and January 2011.

STUDY SELECTION

Clinical studies were eligible for inclusion if they assessed the prevention of recurrent diverticulitis with a medical or dietary therapy. Exclusion criteria were studies without a control group.

RESULTS

Three randomized controlled trials (RCT), all with a Jadad quality score of 2 out of 5, were included in this systematic review. Mesalazine results in significantly less disease recurrence and fewer symptoms after an acute episode. The use of probiotics decreases symptoms but does not reduce recurrence. No difference in effect is seen when Balsalazide is added to probiotics compared to probiotics only. No relevant studies on dietary therapy/advices or antibiotics for prevention of recurrent diverticulitis were found.

CONCLUSION

The evidence that supports medical therapy to prevent recurrent diverticulitis is of poor quality. Treatment with 5-aminosalicylic acid seems promising. Based on current data, no recommendation of any non-operative relapse prevention therapy for diverticular disease can be made.

Sigmoid diverticulitis in 2011: many questions; few answers

AIM

Patients were studied after a first episode of acute left-colonic diverticulitis for the initial and later evolution of the disease with the aim of defining evidence-based indications for elective surgery.

METHOD

Relevant data from prospective studies were retrieved from a MEDLINE search of English language articles.

RESULTS

Young male patients (≤ 50 years of age) had a higher risk of CT-graded severe diverticulitis. After medical treatment of the first episode, the incidence of complications was highest for young patients with CT-graded severe diverticulitis and lowest for older patients with CT-graded moderate diverticulitis. Recurrence in the form of diffuse peritonitis was rare. CT grading of initial diverticulitis seemed to be a predictor of recurrence, whereas the role of age was less clear. A family history of diverticulitis might be predictive of recurrence.

CONCLUSION

CT grading of acute diverticulitis helps to predict poor outcome after medical treatment of a first episode. Elective surgical resection should be proposed to patients with residual symptoms who do not respond to conservative treatment. Additional research is needed to clarify the role of a genetic predisposition in the development of diverticulitis in young adults.

Elective sigmoid colectomy for diverticular disease. Laparoscopic vs open surgery: a systematic review

AIM

A meta-analysis of nonrandomized studies and one randomized trial was conducted to compare laparoscopic surgery with open surgery in the elective treatment of patients with diverticular disease.

METHOD

Published randomized and controlled clinical trials that directly compared elective open (OSR) with laparoscopic surgical resection (LSR) in patients with diverticular disease were identified using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. End-points included 30-day mortality and morbidity and were compared by determining the relative risk ratio, odds ratio, and the absolute effects.

RESULTS

Eleven nonrandomized studies of 1430 patients were identified and included in the meta-analysis. There was only one randomized study, which included 104 patients. The meta-analysis suggested that elective LSR was a safe and appropriate option for patients with diverticular disease and was associated with lower overall morbidity (P = 0.01) and minor complication rate (P = 0.008).

CONCLUSION

The results of the nonrandomized study generally agreed with those of the randomized study, except for the incidence of minor complications, which was higher in both the LSR and OSR groups of the randomized study. In this study, the high overall morbidity of 42.3% reported in the LSR group is a cause for concern.

Clinical presentation and risks

BACKGROUND

A recurrent episode of diverticulitis is a new distinct episode of acute inflammation after a period of complete remission of symptoms. Outdated literature suggested a high recurrence rate (>40%) and a worse clinical presentation with less chance of conservative treatment. More recent studies showed a more benign course with no need toward an aggressive policy of treatment.

METHODS

We report data from revised literature and from our study: a 4-year multicenter retrospective and prospective database analysis of 743 patients hospitalized for acute diverticulitis (AD) treated medically or surgically and then followed for a minimum of 9 years.

RESULTS

The literature showed a recurrence rate of 25-35% at 5 years of follow-up, with a reduced risk of severe complications (i.e. perforations), a risk of subsequent emergency surgery of 2-14% and a risk of stoma and related death of 0-2.7%. Several risk factors of recurrence have been advocated: family history, abscess, severe CT stage, comorbidities (renal failure, collagen vascular disease) and nonsteroidal anti-inflammatory drugs. Young age is still a matter of debate. These studies have different limitations: retrospective, lack of definition of AD, small number of patients, long recruiting time, short follow-up, study population or hospital-system based. In our study of 320 followed-up, medically treated patients, 61% were asymptomatic and 22% complained of chronic symptoms: the 12-year actuarial risk of recurrence, emergency surgery, stoma and death was 21.2, 8.3, 1 and 0%, respectively. Recurrence was related to very young age (<40 years) and more than 3 previous episodes of AD.

CONCLUSION

This study confirms the benign course of diverticulitis treated conservatively, with a low long-term risk of serious complications and death, and does not support an aggressive surgical policy to prevent them.

The surgeon's view

Diverticular disease affects up to 50% of people by the time they reach the age of 80. The major complications of diverticular disease (abscess, perforation, fistula, obstruction and bleeding) have their own management pathways, but the treatment of uncomplicated diverticulitis is controversial. On initial presentation, diverticulitis is always treated conservatively. Whether this should be followed by resectional surgery has been the subject of speculation for many decades. The American Society of Colon and Rectal Surgeons recommended in 2000 that an elective resection should follow two attacks of acute diverticulitis. Much of the work underpinning their policy was based on seminal studies by Parks in the 1960s and 1970s who followed cohorts of patients with diverticular disease and examined their outcomes. However, many of these studies were based on inaccurate diagnostic data where the diagnosis was made primarily on clinical grounds. Investigations such as barium enema or colonoscopy are not reliable in confirming the presence of inflammation. Since CT scanning has become routine, the diagnosis of acute diverticulitis can now be made accurately. In recent years much work has been done, such as by Ambrosetti, who has produced evidence predicting the outcome of diverticulitis based on CT findings. More recent papers, in which the diagnosis of acute diverticulitis is likely to have been made more accurately, confirm that although recurrent attacks of diverticulitis are fairly common, there is a very low incidence of serious complications after long-term follow-up. It has also become apparent that the majority of patients who present with the major complications of diverticulitis, specifically abscess, perforation and fistula, do so as their first presentation of the disease, without previous episodes of diverticulitis. The corollary of this is that patients having had acute diverticulitis do not run the risk of developing life-threatening complications without elective surgery. The complications of left-sided colonic resection are not inconsiderable with anastomotic leaks, the formation of a stoma, either temporary or permanent, as well as mortality. When these data are put alongside the very low risk of serious harm to the patient after diverticulitis, the balance of opinion has now swung heavily in favour of a more conservative approach. In addition to this there are modern and innovative medical therapeutic approaches to the treatment of diverticulitis such as 5ASAs, poorly absorbed antibiotics and probiotics.

Hartmann's procedure or primary anastomosis?

Perforation following acute diverticulitis is a typical scenario during the first attack. Different classification systems exist to classify acute perforated diverticulitis. While the Hinchey classification, which is based on intraoperative findings, is internationally best known, the German Hansen-Stock classification which is based on CT scan is widely accepted within Germany. When surgery is necessary, sigmoid colectomy is the standard of care. An important question is whether patients should receive primary anastomosis or a Hartmann procedure subsequently. A priori there are several arguments for both procedures. Hartmann's operation is extremely safe and, therefore, represents the best option in severely ill patients and/or extensive peritonitis. However, this operation carries a high risk of stoma nonreversal, or, when reversal is attempted, a high risk in terms of morbidity and mortality. In contrast, primary anastomosis with or without loop ileostoma is a slightly more lengthy procedure as normally the splenic flexure needs to be mobilized and construction of the anastomosis may consume more time than the Hartmann operation. The big advantage of primary anastomosis, however, is that there is no need for the potentially risky stoma reversal operation. The most interesting question is when to do the Hartmann operation or primary anastomosis. Several comparative case series were published showing that primary anastomosis is feasible in many patients. However, no randomized trial is available to date. It is of note, that all non-randomized case series are biased, i.e. that patients in better condition received anastomosis and those with severe peritonitis underwent Hartmann's operation. This bias is undoubtedly likely to be present, even if not obvious, in the published papers! Our own data suggest that this decision should not be based on the extent of peritonitis but rather on patient condition and comorbidity. In conclusion, sigmoid colectomy and primary anastomosis is feasible and safe in many patients who need surgery for perforated diverticulitis, particularly when combined with loop ileostomy. Based on our own published analysis, however, we recommend performing Hartmann's operation in severely ill patients who carry substantial comorbidity, while the extent of peritonitis appears not to be of predominant importance.

Changing epidemiology: does it increase our understanding?

During the last decade there have been a number of reports using routinely collected health care administration data and from large cohort studies that have attempted to describe changes in the occurrence and identify risk factors for the development of the condition along with reporting its associated mortality. This article identified all studies reporting the occurrence and mortality associated with diverticulosis, diverticular disease and the complications of diverticular disease, notably, bleeding, perforation, fistula, stricture and abscess formation which show that there is strong evidence of an increasing health care burden associated with diverticular disease in terms of hospitalization. There is evidence of an increase in the incidence of some of the associated complications of diverticular disease, notably perforation. A number of risk factors such as body mass index, comorbidity, smoking and concurrent medications such as opiate analgesics and steroids may predispose to the development of complications. The mortality associated with hospital admission for diverticular disease is significant as is the excess mortality associated with a diagnosis of one of the complications of diverticular disease.

A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2

AIM

After an initial uncomplicated attack, sigmoid diverticulitis may recur, but the morphological characteristics of recurrent diverticulitis have not been investigated. We compared the clinical and radiological severity, the respective location and clinical outcome of the first two episodes of sigmoid diverticulitis.

METHOD

We reviewed the charts of 60 patients [median age 61 (range 31-90) years] who were admitted initially for a first episode of uncomplicated left colonic diverticulitis, and who were eventually readmitted for a second episode, both being documented by abdominal computed tomography (CT) scan.

RESULTS

The median delay between the two episodes was 19 (3-97) months. Six (10%) patients developed a second complicated episode of diverticulitis [Hinchey II (n = 2), CT-guided percutaneous drainage; Hinchey III (n = 3), emergency Hartmann's operation; colovesical fistula (n = 1), elective sigmoid resection]. Fifty-four (90%) patients were admitted for a second episode of uncomplicated diverticulitis. In this group, the duration of hospital stay [11 (4-22) vs 10 (1-39) days, P = 0.28], serum levels of C-reactive protein [131 (31-350) vs 112 (22-333) mm, P = 0.62] and CT scan-based severity score [3 (1-6) vs 3 (0-7) points, P = 0.07] were similar between the two episodes. In 19 out of 54 (35%) patients with simple recurrent diverticulitis, although disease severity was similar, the disease topography differed and recurrence involved another segment of the left colon.

CONCLUSION

The majority of patients who develop recurrence do so in a similar mode and location. However, 10% develop complicated diverticulitis and in 35% of patients recurrent diverticulitis occurs at a different location.

Timing of rectosigmoid resection for diverticular disease: the patient's view

AIM

The study aimed to determine the patient's view on the timing of elective resection for sigmoid diverticulitis.

METHOD

A questionnaire was answered by 162 (69%) of 236 consecutive patients who had a resection of the rectosigmoid for diverticulitis from July 2002 to August 2005. Patients (n=45) having resection at or after the first inflammatory attack were excluded, leaving 117 eligible for analysis. Questions asked included those concerning symptoms before surgery, improvement of symptoms after surgery and the timing of surgery.

RESULTS

Patient assessment of symptoms after surgery was as follows: no improvement (2%; n=2), some improvement (10%; n=12), marked improvement (34%; n=39) and complete resolution (54%; n=63). Forty-five (38%) patients would have preferred an earlier operation. Preference for earlier surgery related to the number of previous inflammatory attacks was expressed as follows: 13 (34%) of 38 patients after two inflammatory attacks, 5 (18%) of 28 patients after three, seven (37%) of 19 patients after four, four (44%) of nine patients after five, and 16 (70%) of 23 patients after six or more inflammatory attacks would have preferred earlier surgery. Statistically significant factors influencing this potential choice were number of episodes of pain (P=0.006, OR=1.23, 95% CI: 1.060-1.430) and number of attacks of inflammation (P=0.048, OR=1.27, 95% CI: 1.002-1.598).

CONCLUSION

Surgery for recurrent diverticulitis resulted in a marked improvement or complete relief of symptoms in 88% of patients. A large proportion of patients with recurrent episodes of sigmoid diverticulitis would have preferred earlier resection.

[Colonic diverticular disease: diagnosis and therapy]

Colonic diverticular disease is one of the most common gastrointestinal disorders in the Western world, affecting approximately 50% of the population above the age of 70 years. Symptoms develop only in about one quarter of the affected individuals with complications in one-third of the symptomatic patients. Diagnosis is mostly confirmed by colonoscopy. Abdominal CT is the most sensitive for the diagnosis of complicated severe diverticulitis, while colonoscopy or in severe cases angiography may be performed in bleeding patients. Initial therapy of non-complicated symptomatic diverticulitis includes antibiotics and more recently non-absorbable antibiotics. In complicated cases should be treated with broad spectrum i.v. antibiotics, however surgery may became necessary in a minority of the cases. The proportion of patients needing acute surgical intervention has decreased in the last decades with the advancement of conservative management including medical therapy, endoscopy and imaging techniques and the indication of elective was also changed.

How complicated is complicated diverticulitis?--phlegmonous diverticulitis revisited

PURPOSE

The purpose of this study is to elucidate the accuracy of a clinical classification system for acute diverticulitis with special regard to "phlegmonous diverticulitis".

METHODS

A consecutive patient series (n = 318; General Hospital Nuremberg, 1/2004-12/2006) was classified preoperatively (imaging with 4/16-slice spiral CT scanner) according to the Hansen and Stock (H&S) classification which is commonly used in Germany and evaluated based on histopathology.

RESULTS

Pre-treatment classification grouped 30 patients (9.4%) as uncomplicated diverticulitis (type I according to H&S), for whom treatment was merely conservative. One hundred twelve patients (35.2%) were classified as phlegmonous diverticulitis (type IIA), 84 (26.4%) as "covered perforations" (type IIB) and 27 (8.5%) as "free perforations" (type IIC), and 54 (17.0%) as chronically recurrent diverticulitis (type III, 17.0%). The remaining 11 patients (3.5%) were not staged preoperatively. Accuracy of staging of complicated diverticulitis differed significantly between type IIC (100.0%), type IIB (91.0%), and type IIA (36.1%). The latter group was frequently understaged as it concealed a substantial number of patients (n = 44; 53.0%) with IIB disease. Neither laboratory tests (CRP/WBC) nor clinical parameters allowed distinction of correctly and falsely staged patients with type IIA disease.

CONCLUSIONS

Patients with phlegmonous diverticulitis (type IIA) represent the most challenging group among patients with acute diverticulitis as they are frequently understaged and conceal cases with covered perforations (type IIB). This may support the view to subsume phlegmonous diverticulitis (type IIA) under complicated diverticulitis.

Multicentre observational study of the natural history of left-sided acute diverticulitis

BACKGROUND

The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD.

METHODS

The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up.

RESULTS

Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment.

CONCLUSION

Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery

BACKGROUND

Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain.

OBJECTIVE

This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups.

DESIGN

This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis.

SETTING

Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007.

PATIENTS

Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy.

MAIN OUTCOME MEASURE

The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications.

RESULTS

Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59-4.63), colostomy (OR 1.9, 95% CI 1.69-2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01-2.11), wound (OR 1.9, 95% CI 1.50-2.39), pulmonary (OR 4.2, 95% CI 3.59-4.85), cardiac (OR 4.6, 95% CI 3.68-5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53-4.35), renal (OR 4.1, 95% CI 3.22-5.12), and thromboembolic (OR 1.6, 95% CI 1.00-2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19-1.67) and pulmonary (OR 2.2, 95% CI 1.94-2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality.

LIMITATIONS

Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors.

CONCLUSIONS

Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.