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Fabian E, Roskaric T, Pfeifer J, Wenzl H, Hammer HF, Lackner C, Rosanelli G, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz : Case No 166: An 82-year-old woman with voluminous diarrhea and weight loss. Wien Klin Wochenschr 2023; 135:429-435. [PMID: 36534207 PMCID: PMC10444654 DOI: 10.1007/s00508-022-02112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Elisabeth Fabian
- Department of Internal Medicine II , University Hospital Krems, Karl Landsteiner University of Health Sciences, Krems on the Danube, Austria
| | - Thomas Roskaric
- Department of Surgery, State Hospital Wolfsberg, Wolfsberg, Austria
| | - Johann Pfeifer
- Department of Surgery, Medical University of Graz, Graz, Austria
| | - Heimo Wenzl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Heinz F Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Carolin Lackner
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Georg Rosanelli
- Department of Surgery, Elisabethinen Hospital, Graz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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Stovall SL, Kaplan JA, Law JK, Flum DR, Simianu VV. Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care. World J Gastrointest Surg 2023; 15:1007-1019. [PMID: 37405108 PMCID: PMC10315108 DOI: 10.4240/wjgs.v15.i6.1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 06/15/2023] Open
Abstract
The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.
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Affiliation(s)
- Stephanie Lee Stovall
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Joanna K Law
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - David R Flum
- Department of Surgery, University of Washington Medical, Seattle, WA 98195, United States
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
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GOUVAS N, AGALIANOS C, MANATAKIS DK, PECHLIVANIDES G, XYNOS E. Elective surgery for conservatively treated acute uncomplicated diverticulitis: a systematic review of postoperative outcomes. Minerva Surg 2022; 77:591-601. [DOI: 10.23736/s2724-5691.22.09726-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hawkins AT, Samuels LR, Rothman RL, Geiger TM, Penson DF, Resnick MJ. National Variation in Elective Colon Resection for Diverticular Disease. Ann Surg 2022; 275:363-370. [PMID: 32740245 PMCID: PMC9365505 DOI: 10.1097/sla.0000000000004236] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to characterize the extent of geographic variation in elective sigmoid resection for diverticulitis and to identify factors associated with observed variation. INTRODUCTION National guidelines for treatment of recurrent diverticulitis fail to offer strong recommendations for or against surgical intervention. We hypothesize that healthcare market factors will be significantly associated with geographic variation in colon resection for diverticulitis, a discretionary surgical intervention. METHODS We used Center for Medicare Services 100% inpatient Limited Data Set (LDS) files from January 2013 through September 2015 to calculate an observed to expected standardized colon resection ratio for each hospital referral region (HRR). We then analyzed patient, hospital-, and market-level factors associated with variation of colectomy. For each HRR, a Herfindahl-Hirschman index, a measure of market competition, was calculated. RESULTS A total of 19,557 Medicare patients underwent an elective colon resection for diverticulitis at 2462 hospitals over the study period. Standardized colon resection ratios ranged from 0 in the Tuscaloosa HRR to 3.7 in the Royal Oak, MI HRR. Few patient factors were associated with variation, but a number of hospital factors (size, area, profit status, and critical access designation) all were associated with variation. In an analysis of market factors, increased surgeon density, and decreased market competition were associated with higher predicted rates of colon resection. CONCLUSION We observed pronounced variation (excess of 3-fold) in standardized colon resection ratios for recurrent diverticulitis. Surgeon density and hospital level factors were strongly associated with this variation and may be the main drivers of colonic resection for diverticular disease. Further investigation and stronger national guidelines are needed to optimize patient selection for colectomy.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren R Samuels
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Russell L Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
- GRECC, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Matthew J Resnick
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
- Embold Health, Nashville, Tennessee
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Thornblade LW, Simianu VV, Davidson GH, Flum DR. Elective Surgery for Diverticulitis and the Risk of Recurrence and Ostomy. Ann Surg 2021; 273:1157-1164. [PMID: 31651534 PMCID: PMC7174092 DOI: 10.1097/sla.0000000000003639] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence. BACKGROUND While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks. METHODS Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014). RESULTS Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%]. CONCLUSIONS Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.
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Chabok A, Thorisson A, Nikberg M, Schultz JK, Sallinen V. Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis. Scand J Surg 2021; 110:180-186. [PMID: 33934672 PMCID: PMC8258726 DOI: 10.1177/14574969211011032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/30/2021] [Indexed: 12/13/2022]
Abstract
Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.
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Affiliation(s)
- A. Chabok
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - A Thorisson
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
- Department of Radiology, Region Västmanland Hospital, Västerås, Sweden
| | - M. Nikberg
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - J. K. Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - V Sallinen
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Kim NE, Hall JF. Acute diverticulitis: Surgical management. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2020.100799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Garfinkle R, Boutros M. Elective surgery for diverticulitis – What does the surgeon need to consider? SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2020.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sohn M, Agha A, Iesalnieks I, Tiefes A, Hochrein A, Friess H, Wilhelm D, Schorn S. Risk of colectomy after conservative treatment of diverticulitis of the left hemicolon complicated by abdominal or pelvic abscess: protocol of a systematic review and meta-analysis. BMJ Open 2020; 10:e042350. [PMID: 33384397 PMCID: PMC7780530 DOI: 10.1136/bmjopen-2020-042350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/23/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute diverticulitis of the sigmoid colon is increasingly treated by a non-operative approach. The need for colectomy after recovery from a flare of acute diverticulitis of the left colon, complicated diverticular abscess is still controversial. The primary aim of this study is to assess the risk of interval emergency surgery by systematic review and meta-analysis. METHODS AND ANALYSIS The systematic review and meta-analysis will be conducted in accordance to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE will be screened for the predefined searching term: (Diverticulitis OR Diverticulum) AND (Abscess OR pelvic abscess OR pericolic abscess OR intraabdominal abscess) AND (surgery OR operation OR sigmoidectomy OR drainage OR percutaneous drainage OR conservative therapy OR watchful waiting). All studies published in an English or German-speaking peer-reviewed journal will be suitable for this analysis. Case reports, case series of less than five patients, studies without follow-up information, systematic and non-systematic reviews and meta-analyses will be excluded. Primary endpoint is the rate of interval emergency surgery. Using the Review Manager Software (Review Manager/RevMan, V.5.3, Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration, 2012) meta-analysis will be pooled using the Mantel-Haenszel method for random effects. The Risk of Bias in Non-randomized Studies of Interventions tool will be used to assess methodological quality of non-randomised studies. Risk of bias in randomised studies will be assessed using the Cochrane developed RoB 2-tool. ETHICS AND DISSEMINATION As no new data are being collected, ethical approval is exempt for this study. This systematic review is to provide a new insight on the need for surgical treatment after a first attack of acute diverticulitis, complicated by intra-abdominal or pelvic abscesses. The results of this study will be presented at national and international meetings and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020164813.
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Affiliation(s)
- Maximilian Sohn
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | - Ayman Agha
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | - Igors Iesalnieks
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | - Anna Tiefes
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | | | - Helmut Friess
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
| | - Dirk Wilhelm
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
| | - Stephan Schorn
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 PMCID: PMC7575828 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent. To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether. The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables. Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing. Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known. The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy. After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy. For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”. Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary. For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents. Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance. Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key. Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease. While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined. Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Recurrence of Acute Right Colon Diverticulitis Following Nonoperative Management: A Systematic Review and Meta-analysis. Dis Colon Rectum 2020; 63:1466-1473. [PMID: 32969890 DOI: 10.1097/dcr.0000000000001787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are currently no guidelines on the management of right colon diverticulitis. Treatment options have been extrapolated from the management of left-sided diverticulitis. Gaining knowledge of the risk and morbidity of diverticulitis recurrence is integral to weighing the benefit of elective surgery for right-sided diverticulitis. OBJECTIVE The purpose of this study was to summarize the recurrence rate and the morbidity of recurrence of Hinchey classification I/II, right-sided diverticulitis following nonoperative management. DATA SOURCES PubMed, EMBASE, and Cochrane Database of Collected Reviews were searched up to June 2019. STUDY SELECTION Observational cohort studies evaluating outcomes following nonoperative management were reviewed. No randomized controlled trials were available. INTERVENTIONS Intravenous antibiotics with or without percutaneous drainage of associated abscess were administered. MAIN OUTCOME MEASURES The primary outcomes measured were the recurrence rate and morbidity associated with recurrence. Two independent investigators extracted data. The rates of recurrence were pooled by using a random-effects model. RESULTS There were 1584 adult participants from a total of 11 studies (9 retrospective cohort and 2 prospective cohort studies) included in the analysis. Over a median follow-up period of 34.2 months, the pooled recurrence rate was 12% (95% CI, 10%-15%). Twenty of 202 patients (9.9%) required urgent surgery at the time of first recurrence. There was no mortality. Subset analysis excluding 3 studies that included percutaneous drainage as a nonoperative treatment option did not change the recurrence rate (12% (95% CI, 9%-15%)) or heterogeneity. Funnel plot assessment revealed no publication bias. LIMITATIONS There were no randomized controlled trials available. The statistical heterogeneity was moderate (I = 46%). CONCLUSIONS Nonoperative management of Hinchey I/II right-sided diverticulitis is safe and feasible. The recurrence rate is relatively low, and complications that require urgent operation are uncommon. PROSPERO CRD42019131673.
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O'Grady M, Turner G, Currie W, Yi M, Frizelle F, Purcell R. Acute diverticulitis: an ongoing economic burden on the health system. ANZ J Surg 2020; 90:2046-2049. [PMID: 32808421 DOI: 10.1111/ans.16234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute diverticulitis (AD) is an increasingly common cause of acute hospital admissions. An understanding of its economic burden is necessary to plan resource allocation, and for targeting health research funding. The aim of this study is to obtain an accurate estimate of the cost of AD, accounting not only for the initial episode, but all related costs incurred during long-term follow-up. METHODS The study captures a cohort of patients who had an initial admission for AD from 1 January 2012-31 December 2012, and their treatment over a 6-year period. Cases were identified from a prospectively maintained database, with AD confirmed by computed tomography scan. The primary outcome was total healthcare cost related to AD. RESULTS The study included 170 patients. The total cost was NZD1 956 859 with a median cost per patient of NZD4814. A total of 57% of the cost was incurred for the initial inpatient admission, with the remaining 43% incurred through re-admission, follow-up appointments, investigations and management. Half of the total cost was incurred by 11.8% of the cohort. In multivariate analysis, high cost of care was significantly associated with complicated and recurrent disease, operative intervention and length of stay. CONCLUSION This study provides an accurate estimate of the overall cost of AD and its sequelae. There are considerable long-term costs associated with the index episode and a large proportion of the expenditure is incurred by a small group that included those with complicated disease. These findings are important for healthcare resource allocation and for targeting health research funding.
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Affiliation(s)
- Michael O'Grady
- Department of Surgery, University of Otago, Christchurch, New Zealand.,General Surgery, Canterbury District Health Board, Christchurch, New Zealand
| | - Gregory Turner
- Department of Surgery, University of Otago, Christchurch, New Zealand.,General Surgery, Canterbury District Health Board, Christchurch, New Zealand
| | - William Currie
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Ma Yi
- General Surgery, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch, New Zealand.,General Surgery, Canterbury District Health Board, Christchurch, New Zealand
| | - Rachel Purcell
- Department of Surgery, University of Otago, Christchurch, New Zealand
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13
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020; 63:728-747. [PMID: 32384404 DOI: 10.1097/dcr.0000000000001679] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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14
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O’Grady M, Clarke L, Turner G, Doogue M, Purcell R, Pearson J, Frizelle F. Statin use and risk of acute diverticulitis: A population-based case-control study. Medicine (Baltimore) 2020; 99:e20264. [PMID: 32443369 PMCID: PMC7253659 DOI: 10.1097/md.0000000000020264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The goal of the study was to examine the association between statin use and the development of acute diverticulitis requiring hospital admission.Acute diverticulitis is a common and costly gastrointestinal disorder. Although the incidence is increasing its pathophysiology and modifiable risk factors are incompletely understood. Statins affect the inflammatory response and represent a potential risk reducing agent.A retrospective, population-based, case-control study was carried out on a cohort of adults, resident in Canterbury, New Zealand. All identified cases were admitted to hospital and had computed tomography confirmed diverticulitis. The positive control group comprised patients on non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs), and the negative control group were patients on selective serotonin reuptake inhibitors (SSRIs). Medicine exposure was obtained from the Pharmaceutical Management Agency of New Zealand. Subgroup analysis was done by age and for complicated and recurrent diverticulitis.During the study period, there were 381,792 adults resident in Canterbury. The annual incidence of diverticulitis requiring hospital presentation was 18.6 per 100,000 per year. Complicated disease was seen in 37.4% (158) of patients, and 14.7% (62) had recurrent disease. Statins were not found to affect the risk of developing acute diverticulitis, nor the risk of complicated or recurrent diverticulitis. Subgroup analysis suggested statin use was associated with a decreased risk of acute diverticulitis in the elderly (age >64 years). NSAIDs were associated with a decreased risk of acute diverticulitis (risk ratio = 0.65, confidence interval: 0.26-0.46, P < .01), as were SSRIs (risk ratio = 0.37, confidence interval: 0.26-0.54, P < .01).This population-based study does not support the hypothesis that statins have a preventative effect on the development of diverticulitis, including complicated disease. We also found a decreased risk of diverticulitis associated with NSAID and SSRI use.
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Affiliation(s)
| | | | | | - Matt Doogue
- University of Otago, Christchurch, New Zealand
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15
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Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nat Rev Dis Primers 2020; 6:20. [PMID: 32218442 PMCID: PMC7486966 DOI: 10.1038/s41572-020-0153-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, Andria, Italy.
| | - Carmelo Scarpignato
- Faculty of Health Sciences, LUdeS Lugano Campus, Lugano, Switzerland
- United Campus of Malta, Birkirkara, Msida, Malta
| | - Lisa L Strate
- Division of Gastroenterology, Department of Medicine, Harborview Medical Center, University of Washington Medical School, Seattle, WA, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, University of Zaragoza, IIS Aragón (CIBERehd), Zaragoza, Spain
| | | | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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16
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Kassir R, Tsiminikakis N, Celebic A, Felsenheld C, Helmy N, Kassir R, Chouillard E. Timing of laparoscopic elective surgery for acute left colonic diverticulitis. Retrospective analysis of 332 patients. Am J Surg 2019; 220:182-186. [PMID: 31668707 DOI: 10.1016/j.amjsurg.2019.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The optimal time to perform elective surgery remains to be determined. We analyzed the impact of time interval to surgery on short-terme outcome parameters in patients undergoing elective laparoscopic left colonic resection for diverticulitis. MATERIALS AND METHODS Retrospective analysis of two series of case-matched patients according to the timing of operation after the last episode of diverticulitis: group A (within 90 days) and group B (beyond 90 days). RESULTS 332 patients had left colonic resection for diverticulitis. 117 patients were included in group A vs 114 patients in group B. Overall abdominal morbidity in Group A was 21% vs 5% in group B (p = 0.02). Mean hospital stay was 7.7 days in group A vs 5 days in group B (p = 0.08). Residual inflammation was significantly increased in group A (31%) as compared to group B (11%) (p = 0.01). CONCLUSIONS Laparoscopic left colonic resection for acute diverticulitis is best performed beyond the third month after the last acute episode.
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Affiliation(s)
- Radwan Kassir
- Department of Digestive Surgery, Department of Digestive Surgery, CHU Felix-Guyon, Saint Denis, France.
| | - Nikos Tsiminikakis
- Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France
| | - Aleksandar Celebic
- Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France
| | - Carole Felsenheld
- Department of Pathology, Centre Hospitalier Intercommunal, Poissy, France
| | - Nada Helmy
- Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France
| | - Rani Kassir
- Department of Digestive Surgery, Department of Digestive Surgery, CHU Felix-Guyon, Saint Denis, France
| | - Elie Chouillard
- Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France
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17
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Beresneva O, Hall J. Influence of body mass index on outcomes in patients undergoing surgery for diverticular disease. Surg Open Sci 2019; 1:80-85. [PMID: 32754697 PMCID: PMC7391909 DOI: 10.1016/j.sopen.2019.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We hypothesized that increasing body mass index is a risk factor for surgical complications in surgery for diverticulitis. We assessed the relationship of body mass index and surgical complications following surgery for diverticular disease. METHODS We used National Surgical Quality Improvement Program database from 2005 to 2015. Patients undergoing surgery for diverticular disease during that period were included and stratified into 9 groups based on their body mass index (< 18.5, 18.6-24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9, 40.0-44.9, 45.0-49.9, 50.0-54.9, > 55). Outcomes of interest were complications of superficial surgical site infection, deep incisional surgical site infection, organ space surgical site infection, wound disruption complications, pneumonia, ventilator dependence > 48 hours, acute renal failure, myocardial infarction, return to operating room, and 30-day mortality. RESULTS Morbidly obese patients had higher rates of diabetes, hypertension, and steroid use. They had higher American Society of Anesthesiologists classification and were more likely to have emergency and open cases. Interestingly, increased body mass index was inversely associated with age. Increasing body mass index was associated with worse outcomes including superficial surgical site infection, deep incisional surgical site infection, organ space surgical site infection, wound disruption complications, ventilator dependence > 48 hours, acute renal failure, and return to operating room. Risk of developing pneumonia didn't have similar correlation with body mass index. Overweight status had protective effect on mortality. No statistically significant differences in increased rates of myocardial infarction were noted. Underweight patients also developed worse outcomes. CONCLUSION Obesity is associated with a number of complications following surgery for diverticulitis. Elevated body mass index adds significant risk to procedures for diverticulitis and should be accounted for in risk stratification models. Patients should be counseled on weight reduction before undergoing elective surgery for diverticular disease.
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Affiliation(s)
- Olga Beresneva
- Boston University/Boston Medical Center, Department of Surgery, 88 East Newton St, C515, Boston, MA 02118
| | - Jason Hall
- Boston University/Boston Medical Center, Department of Surgery, 88 East Newton St, C515, Boston, MA 02118
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18
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La Torre M, Mingoli A, Brachini G, Lanciotti S, Casciani E, Speranza A, Mastroiacovo I, Frezza B, Cirillo B, Costa G, Sapienza P. Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis. Asian J Surg 2019; 43:476-481. [PMID: 31439460 DOI: 10.1016/j.asjsur.2019.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/23/2019] [Accepted: 07/18/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND/OBJECTIVE A preoperative reliable classification system between clinical and computed tomography (CT) findings to better plan surgery in acute complicated diverticulitis (ACD) is lacking. We studied the inter-observer agreement of CT scan data and their concordance with the preoperative clinical findings and the adherence with the intraoperative status using a new classification of diverticular disease (CDD). METHODS 152 patients operated on for acute complicated diverticulitis (ACD) were retrospectively enrolled. All patients were studied with CT scan within 24 h before surgery and CT images were blinded reanalyzed by 2 couples of radiologists (A/B). Kappa value evaluated the inter-observer agreement between radiologists and the concordance between CDD, preoperative clinical findings and findings at operation. Univariate and multivariate analysis were used to evaluate the predicting values of CT classification and CDD stage at surgery on postoperative outcomes. RESULTS Overall inter-observer agreement for the CDD was high, with a kappa value of 0.905 (95% CI = 0.850-0.960) for observers A and B, while the concordance between radiological and surgical findings was weak (kappa values = 0.213 and 0,248, respectively and 95% CI = 0.106 to 0.319 and 95% CI = 0.142 to 0.355, respectively). When overall morbidity, mortality and the need of a terminal colostomy were considered as main endpoints no concordance was observed between surgical and radiological findings and the CDD (P=NS). CONCLUSIONS The need for a more accurate classification of ACD, able to better stage this emergency, and to provide surgeons with reliable information for the best treatment is advocated.
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Affiliation(s)
- Marco La Torre
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Andrea Mingoli
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Gioia Brachini
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Silvia Lanciotti
- Emergency Department, Department of Radiology, "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Emanuele Casciani
- Emergency Department, Department of Radiology, "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Annarita Speranza
- Department of Radiology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Ilaria Mastroiacovo
- Department of Radiology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Barbara Frezza
- Emergency Department, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Bruno Cirillo
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Gianluca Costa
- Emergency Department, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Paolo Sapienza
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
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Ditzel M, Vennix S, Menon AG, Verbeek PC, Bemelman WA, Lange JF. Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up. Dig Surg 2019; 36:129-136. [PMID: 29428950 PMCID: PMC6482984 DOI: 10.1159/000486868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/16/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Diverticulitis can lead to localized or generalized peritonitis and consequently induce abdominal adhesion formation. If adhesions would lead to abdominal complaints, it might be expected that these would be more prominent after operation for perforated diverticulitis with peritonitis than after elective sigmoid resection. AIMS The primary outcome of the study was the incidence of abdominal complaints in the long-term after acute and elective surgery for diverticulitis. METHODS During the period 2003 through 2009, 269 patients were operated for diverticular disease. Two hundred eight of them were invited to fill out a questionnaire composed of the gastrointestinal quality of life index and additional questions and finally 109 were suitable for analysis with a mean follow-up of 7.5 years. RESULTS Analysis did not reveal any significant differences in the incidence of abdominal complaints or other parameters. CONCLUSION This retrospective study on patients after operation for diverticulitis shows that in the long term, the severity of the abdominal complaints is influenced neither by the stage of the disease nor by the fact of whether it was performed in an acute or elective setting.
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Affiliation(s)
- Max Ditzel
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands,Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands,*Max Ditzel, MD, Department of Surgery, Academic Medical Center, Diezestraat 8-II, NL–1078 JP Amsterdam (The Netherlands), E-Mail
| | - Sandra Vennix
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Anand G. Menon
- Department of Surgery, Erasmus Medical Center, Havenziekenhuis, Rotterdam, The Netherlands
| | - Paul C.M. Verbeek
- Department of Surgery, Flevohospital Almere, Almere, The Netherlands
| | - Willem A. Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Johan F. Lange
- Department of Surgery, Erasmus Medical Center, Havenziekenhuis, Rotterdam, The Netherlands,Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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20
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Al Harakeh H, Paily AJ, Doughan S, Shaikh I. Recurrent Acute Diverticulitis: When to Operate? Inflamm Intest Dis 2018; 3:91-99. [PMID: 30733953 DOI: 10.1159/000494973] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/29/2018] [Indexed: 12/11/2022] Open
Abstract
Objective Recurrent acute diverticulitis carries a major burden to any form of health care. Patients present repeatedly to medical centers with a multitude of symptoms and may require different modalities of treatment with significant morbidities and impact on quality of life. Methods We therefore wanted to identify factors that would imply the need and time of surgery versus conservative management. The literature was thoroughly searched for major studies tackling this topic. Furthermore, studies reporting on decision making based on quality of life were included. Risks of developing recurrent diverticulitis and the potential need of surgery were identified. Relevant surgical details that would decrease recurrence were also denoted. Results Surgery has been the mainstay of treatment for quite some time. However, the paradigms of treatment have changed over the last few years, especially when long-term population studies confirmed that not all patients require surgical treatment with its associated risk of morbidity. Conclusion Treatment now has to be patient-tailored with special attention to the subgroup of high-risk patients. These patients must be adequately selected, identifying the impact of the disease on the quality of life and weighing in the risks of the surgical intervention.
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Affiliation(s)
| | - Abhilash J Paily
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Samer Doughan
- American University of Beirut - Medical Center, Beirut, Lebanon
| | - Irshad Shaikh
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
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21
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Valizadeh N, Suradkar K, Kiran RP. Specific Factors Predict the Risk for Urgent and Emergent Colectomy in Patients Undergoing Surgery for Diverticulitis. Am Surg 2018. [DOI: 10.1177/000313481808401135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aim of this study was to identify preoperative characteristics that may determine the need for emergency surgery for diverticulitis and assess postoperative outcomes for these patients when compared with elective surgery. All patients included in the ACS-NSQIP–targeted colectomy database from 2012 to 2013 who underwent colectomy with an underlying diagnosis of diverticulitis were included. Preoperative characteristics and 30-day postoperative outcomes were evaluated for patients who underwent elective versus emergent/urgent surgery using univariable and multivariable analyses. Of 8708 patients with diverticular disease, 28.1 per cent underwent emergent/urgent colectomy. Patients who underwent emergent/urgent colectomy had greater preoperative steroid use, diabetes mellitus, disseminated cancer, chronic renal failure, hypertension, chronic heart failure, chronic liver disease, COPD, and dependent functional health status ( P < 0001). There were more patients with age >65 years ( P < 0001), smoking history ( P < 0.05), and BMI < 18.5 kg/m2( P < 0001) in the emergent/urgent colectomy group. After performing multivariable analysis, preoperative steroid use, weight loss >10 per cent, BMI < 18 kg/m2, smoking, age > 65, and comorbid conditions were associated with a higher rate of emergent/urgent surgery. Mortality (5.2% vs 0.2%) and infectious and noninfectious complications were higher after nonelective colectomy. Emergent/urgent colectomy was also associated with longer hospital stay and reoperation. Emergency and urgent colectomy for diverticulitis is associated with significantly worse outcomes than after elective surgery, and patients with comorbid conditions who develop attacks of diverticulitis may in fact be the population that might best benefit from a lower threshold for an elective colectomy.
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Affiliation(s)
- Neda Valizadeh
- Division of Colorectal Surgery, Columbia University New York Presbyterian Hospital, New York, New York
| | - Kunal Suradkar
- Division of Colorectal Surgery, Columbia University New York Presbyterian Hospital, New York, New York
| | - Ravi P. Kiran
- Division of Colorectal Surgery, Columbia University New York Presbyterian Hospital, New York, New York
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Varma S, Mehta A, Canner JK, Azar F, Efron DT, Efron J, Safar B, Sakran JV. Surgery After an Initial Episode of Uncomplicated Diverticulitis: Does Time to Resection Matter? J Surg Res 2018; 234:224-230. [PMID: 30527478 DOI: 10.1016/j.jss.2018.09.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/21/2018] [Accepted: 09/12/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to determine whether time to surgery after an initial episode of uncomplicated diverticulitis is associated with undergoing an emergent versus an elective resection. METHODS In this retrospective, administrative claims database study, we identified patients at least 18 y old in the 2005-2011 California State Inpatient Database who had an initial episode of uncomplicated diverticulitis and then underwent a bowel resection within 2 y. After characterizing the distribution in time to surgery among all patients, we used a multivariable logistic regression to determine whether time to surgery was associated with undergoing an emergent resection. Next, we assessed differences in three outcomes between elective and emergent resections: at least one of eight postoperative complications, extended length of stay (defined as the top decile of hospitalizations), and 30-d inpatient readmissions. Analyses adjusted for time between initial hospitalization and resection, number of inpatient hospitalizations for diverticulitis before the resection, clinical factors, and hospital clustering. RESULTS We identified 4478 patients with an initial episode of uncomplicated diverticulitis followed by a bowel resection within the subsequent 2 y. One-fifth (21.1%) underwent an emergent resection. The median time from the initial episode to resection was 3.8 mo (IQR: 2.3-8.1 mo) for elective resections and 5.1 mo (IQR: 2.3-12.4 mo) for emergent resections. The adjusted odds of undergoing an emergent relative to an elective resection increased by 7% (aOR 1.07 [1.02-1.11]) for every 3 passing mo. Emergent resections were associated with greater adjusted odds of complications (adjusted odds ratio [aOR] 1.75 [95%-CI 1.43-2.15]), extended LOS (aOR 4.52 [3.31-6.17]), and 30-d readmissions (aOR 1.49 [1.09-2.04]). CONCLUSIONS Among patients who experienced an initial episode of uncomplicated diverticulitis and eventually underwent a resection, the odds of having an emergent relative to elective surgery increased with every 3 passing mo. These findings may inform the management of uncomplicated diverticulitis for high-risk patients eventually needing surgery.
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Affiliation(s)
- Sanskriti Varma
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ambar Mehta
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, New York, New York
| | | | - Faris Azar
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
| | - David T Efron
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
| | - Jonathan Efron
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
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23
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Binda GA, Mataloni F, Bruzzone M, Carabotti M, Cirocchi R, Nascimbeni R, Gambassi G, Amato A, Vettoretto N, Pinnarelli L, Cuomo R, Annibale B. Trends in hospital admission for acute diverticulitis in Italy from 2008 to 2015. Tech Coloproctol 2018; 22:597-604. [PMID: 30196450 DOI: 10.1007/s10151-018-1840-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Epidemiological studies in Western countries have documented an increase of hospitalizations for acute diverticulitis (AD) but Italian evidence is scarce. The aim of the present study was to analyse the trend in hospitalization for AD, including in-hospital mortality, in Italy from 2008 to 2015. METHODS Through the Italian Hospital Information System of the National Health System, we identified diverticulitis of the colon as a discharge diagnosis. Age- and gender-specific rates of hospitalization for AD were assessed. RESULTS 174,436 hospitalizations were identified with an increasing rate in 2008-2015 from 39 to 48 per 100,000 inhabitants (p < 0.001). The rate of hospitalization was higher for women, but the increasing trend over time was even more pronounced among men (mean increase per year 3.9% and 2.1% among men and women, respectively) (p < 0.001). The increased rate of hospitalization was accounted for by patients less than 70 years old, especially those under 60. In contrast, the hospitalization rate for older patients (age ≥ 70 years) was higher but remained unchanged during the study period. The number of patients with one hospital admissions was significantly higher than the number of patients with at least two hospitalizations (p < 0.001) and both groups showed a significant and comparable increase year by year. The overall in-hospital mortality rate increased from 1.2 to 1.5% (p = 0.017). More specifically, the increase was observed in patients at their first hospitalization [from 1 to 1.4% (mean increase per year of 3%, p = 0.003)]. An increase in mortality was most evident among women (from 1.4 to 1.8% p = 0.025) and in older patients [age 70-79 years from 1.2 to 1.7% (p = 0.034), ≥ 80 years from 2.9 to 4% (p = 0.001)]. CONCLUSIONS In Italy, between 2008 and 2015, the rate of hospitalization for AD has been constantly increasing due to the hospitalization of younger individuals, especially men. There was a significant increase of in-hospital mortality especially among women, elderly and during the first hospitalization. These findings suggest the need for increased awareness and clinical skills in the management of this common condition.
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Affiliation(s)
- Gian Andrea Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy.
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy.
| | - F Mataloni
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - M Bruzzone
- Clinical Epidemiology Unit, Ospedale Policlinico San Martino, Genoa, Italy
| | - M Carabotti
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sapienza University, Rome, Italy
| | - R Cirocchi
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy
- Department of General Surgery and Surgical Oncology, Hospital of Terni, University of Perugia, Terni, Italy
| | - R Nascimbeni
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - G Gambassi
- Department of Internal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Amato
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy
- Department of Surgery, Borea Hospital, Sanremo, Imperia, Italy
| | - N Vettoretto
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy
- Department of Surgery, Montichiari, Ospedali Civili Brescia, Brescia, Italy
| | - L Pinnarelli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - R Cuomo
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - B Annibale
- Italian Group of Diverticular Disease (GRIMAD), Rome, Italy
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sapienza University, Rome, Italy
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Lanas A, Abad-Baroja D, Lanas-Gimeno A. Progress and challenges in the management of diverticular disease: which treatment? Therap Adv Gastroenterol 2018; 11:1756284818789055. [PMID: 30046356 PMCID: PMC6056793 DOI: 10.1177/1756284818789055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 06/11/2018] [Indexed: 02/04/2023] Open
Abstract
Diverticular disease of the colon (DDC) includes a spectrum of conditions from asymptomatic diverticulosis to symptomatic uncomplicated diverticulosis, segmental colitis associated with diverticulosis, and acute diverticulitis without or with complications that may have serious consequences. Clinical and scientific interest in DDC is increasing because of the rising incidence of all conditions within the DDC spectrum, a better, although still limited understanding of the pathogenic mechanisms involved; the increasing socioeconomic burden; and the new therapeutic options being tested. The goals of treatment in DDC are symptom and inflammation relief and preventing disease progression or recurrence. The basis for preventing disease progression remains a high-fiber diet and physical exercise, although evidence is poor. Other current strategies do not meet expectations or lack a solid mechanistic foundation; these strategies include modulation of gut microbiota or dysbiosis with rifaximin or probiotics, or using mesalazine for low-grade inflammation in uncomplicated symptomatic diverticulosis. Most acute diverticulitis is uncomplicated, and the trend is to avoid hospitalization and unnecessary antibiotic therapy, but patients with comorbidities, sepsis, or immunodeficiency should receive broad spectrum and appropriate antibiotics. Complicated acute diverticulitis may require interventional radiology or surgery, although the best surgical approach (open versus laparoscopic) remains a matter of discussion. Prevention of acute diverticulitis recurrence remains undefined, as do therapeutic strategies. Mesalazine with or without probiotics has failed to prevent diverticulitis recurrence, whereas new studies are needed to validate preliminary positive results with rifaximin. Surgery is another option, but the number of acute events cannot guide this indication. We need to identify risk factors and disease progression or recurrence mechanisms to implement appropriate preventive strategies.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico
Universitario Lozano Blesa, C/ San Juan Bosco 15, Zaragoza, 50009, Spain.
University of Zaragoza. IIS Aragón. CIBERehs
| | - Daniel Abad-Baroja
- Servicio de Aparato Digestivo University Clinic
Hospital Lozano Blesa, Spain
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26
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Setlur A, Blaustein S. An adult disease in an adolescent: Rare presentation of diverticulitis with abscess. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.
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28
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Lin M, Raman SR. Evaluation of Quality of Life and Surgical Outcomes for Treatment of Diverticular Disease. Clin Colon Rectal Surg 2018; 31:251-257. [PMID: 29942216 DOI: 10.1055/s-0037-1607969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The prevalence of diverticular disease in the Western and industrialized nations has increased over the last century, and our understanding of this disease and its management continues to evolve. In this article, we review the literature regarding the postoperative quality of life (QOL) and functional outcomes following surgical management of diverticulitis, including information regarding bowel function, recurrence of symptoms, and other postoperative sequelae. While objective parameters, such as attacks of diverticulitis, complications, and clinical episodes have been studied, there is a paucity of data on less objective factors, such as overall patient satisfaction after operative management of diverticular disease. The literature shows improvement in QOL following surgical intervention for diverticulitis if preoperative QOL was significantly low, secondary to severe/complicated diverticulitis. However, a subset of patients does continue to have symptoms following surgical intervention for diverticulitis. Often neglected in the literature, there remains a need for prospective data evaluating preoperative function to ascertain the impact of surgery on patients' QOL and postoperative function.
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Affiliation(s)
- Mayin Lin
- Mercy Surgical Affiliates, Des Moines, Iowa
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29
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Dean M, Valentino J, Ritter K, Church J. A novel endoscopic grading system for prediction of disease-related outcomes in patients with diverticulosis. Am J Surg 2018; 216:926-931. [PMID: 29792278 DOI: 10.1016/j.amjsurg.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 04/29/2018] [Accepted: 05/06/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND We describe a simple endoscopic grading system of diverticular disease for the assessment of disease severity and prediction of outcomes. METHODS A retrospective analysis of prospectively maintained colonoscopy database was conducted. A single endoscopist prospectively graded disease severity according to the number and size of diverticula, the degree of muscular hypertrophy and rigidity of the sigmoid colon. RESULTS 762 patients were included in the analysis. Mean patient age was 70 years (range 37-97). Endoscopic severity of diverticulosis was predictive of the need for surgery, with 2% in the mild-moderate, 12% in the severe and 33% in the acute group (p < 0001). Time to surgery showed correlation to severity grade, with mean periods of 107.5 months in the moderate group vs. 3 and 2.5 months in the severe and acute group (p < 0001). The mean follow up was 11 years. CONCLUSION Surgeons should consider using endoscopic grading as an adjunct to clinical management decisions.
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Affiliation(s)
- Meara Dean
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 2049 East 100th Street, 44195, Cleveland, OH, USA
| | - Joseph Valentino
- University of Kansas Health System, 1450 Jayhawk Blvd, Lawrence, 66045, Kansas City, USA
| | - Kaitlin Ritter
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 2049 East 100th Street, 44195, Cleveland, OH, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 2049 East 100th Street, 44195, Cleveland, OH, USA.
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You K, Bendl R, Taut C, Sullivan R, Gachabayov M, Bergamaschi R, Connolly TM, Yang K, Giuratrabocchetta S, Denoya PI, Zawin M, Ferretti J, Baer A, Wertheim W. Randomized clinical trial of elective resection versus observation in diverticulitis with extraluminal air or abscess initially managed conservatively. Br J Surg 2018; 105:971-979. [DOI: 10.1002/bjs.10868] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The aim of this RCT was to determine whether elective resection following successful non-operative management of a first episode of acute sigmoid diverticulitis complicated by extraluminal air with or without abscess is superior to observation in terms of recurrence rates.
Methods
This was a single-centre, sequential design RCT. Patients were randomized to elective surgery or observation following non-operative management and colonoscopy. Non-operative management included nil by mouth, intravenous fluids, intravenous antibiotics, CT with intravenous contrast on arrival at hospital, and repeat CT with intravenous and rectal contrast on day 3 in hospital. The primary endpoint was recurrent diverticulitis at 24 months. Patients with a history of sigmoid diverticulitis, immunosuppression or peritonitis were not included.
Results
Of 137 screened patients, 107 were assigned randomly to elective surgery (26) or observation (81), and underwent the allocated intervention after successful non-operative management. Conservative management failed in 15 patients. Groups were similar in age, sex, BMI, co-morbidities and colorectal POSSUM. Rates of recurrent diverticulitis differed significantly in the elective surgery and observation groups (8 versus 32 per cent; P = 0·019) at a mean(s.d.) follow-up of 37·8(8·6) and 35·2(9·2) months respectively. There was also a significant difference in time to recurrence (median 11 versus 7 months; P = 0·015). A total of 28 patients presented with recurrent diverticulitis complicated by extraluminal air and/or abscess (2 elective surgery, 26 observation), all of whom recovered with repeat non-operative management.
Conclusion
The majority of patients observed following conservative management of diverticulitis with local extraluminal air do not require elective surgery. Registration number: NCT01986686 (http://www.clinicaltrials.gov).
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Affiliation(s)
- K You
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, USA
| | - R Bendl
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, USA
| | - C Taut
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, USA
| | - R Sullivan
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, USA
| | - M Gachabayov
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, USA
| | - R Bergamaschi
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, USA
| | - T M Connolly
- Division of Colon and Rectal Surgery, State University of New York
| | - K Yang
- Division of Colon and Rectal Surgery, State University of New York
| | | | - P I Denoya
- Division of Colon and Rectal Surgery, State University of New York
| | - M Zawin
- Department of Radiology, State University of New York
| | - J Ferretti
- Division of Interventional Radiology, State University of New York
| | - A Baer
- Department of Emergency Medicine, State University of New York
| | - W Wertheim
- Department of Medicine, State University of New York
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Gorgun E, Isik O, Sapci I, Aytac E, Abbas MA, Ozuner G, Church J, Steele SR. Colonoscopy-induced acute diverticulitis: myth or reality? Surg Endosc 2018; 32:3290-3294. [PMID: 29344786 DOI: 10.1007/s00464-018-6049-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/11/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Colonoscopy in patients with diverticulosis can be technically challenging and limited data exist relating to the risk of post-colonoscopy diverticulitis. Our aim was to evaluate the incidence, management, and outcomes of acute diverticulitis following colonoscopy. METHODS Study design is retrospective cohort study. Data were gathered by conducting an automated search of the electronic patient database using current procedural terminology and ICD-9 codes. Patients who underwent a colonoscopy from 2003 to 2012 were reviewed to find patients who developed acute diverticulitis within 30 days after colonoscopy. Patient demographics and colonoscopy-related outcomes were documented, which include interval between colonoscopy and diverticulitis, colonoscopy indication, simultaneous colonoscopic interventions, and follow-up after colonoscopy. RESULTS From 236,377 colonoscopies performed during the study period, 68 patients (mean age 56 years) developed post-colonoscopy diverticulitis (0.029%; 2.9 per 10,000 colonoscopies). Incomplete colonoscopies were more frequent among patients with a history of previous diverticulitis [n = 10 (29%) vs. n = 3 (9%), p = 0.03]. Mean time to develop diverticulitis after colonoscopy was 12 ± 8 days, and 30 (44%) patients required hospitalization. 34 (50%) patients had a history of diverticulitis prior to colonoscopy. Among those patients, 14 underwent colonoscopy with an indication of surveillance for previous disease. When colonoscopy was performed within 6 weeks of a diverticulitis attack, surgical intervention was required more often when compared with colonoscopies performed after 6 weeks of an acute attack [n = 6 (100%) vs. n = 10 (36%), p = 0.006]. 6 (9%) out of 68 patients received emergency surgical treatment. 15 (24%) out of 62 patients who had non-surgical treatment initially underwent an elective sigmoidectomy at a later date. Recurrent diverticulitis developed in 16 (23%) patients after post-colonoscopy diverticulitis. CONCLUSIONS Post-colonoscopy diverticulitis is a rare, but potentially serious complication. Although a rare entity, possibility of this complication should be kept in mind in patients presenting with symptoms after colonoscopy.
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Affiliation(s)
- Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
| | - Ozgen Isik
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Erman Aytac
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Maher A Abbas
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Gokhan Ozuner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - James Church
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
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Seoane Urgorri A, Zaffalon D, Pera Román M, Batlle García M, Riu Pons F, Dedeu Cusco JM, Pantaleón Sánchez M, Bessa Caserras X, Barranco Priego L, Álvarez-González MA. Routine lower gastrointestinal endoscopy for radiographically confirmed acute diverticulitis. In whom and when is it indicated? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:571-576. [DOI: 10.17235/reed.2018.5524/2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Long-term outcomes of sigmoid diverticulitis: a single-center experience. J Surg Res 2017; 221:8-14. [PMID: 29229157 DOI: 10.1016/j.jss.2017.07.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/25/2017] [Accepted: 07/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND During the last decade, guidelines for the treatment of sigmoid diverticulitis have dramatically changed. The aim of this study is to report the long-term outcomes of patients treated for diverticulitis at a nonspecialized single center. MATERIALS AND METHODS After obtaining institutional review board approval, medical records of all patients admitted to our institution with the diagnosis of sigmoid diverticulitis between 1998 and 2008 were reviewed. A follow-up of at least 5 years was required. RESULTS During the study period, 266 patients were admitted to our hospital due to sigmoid diverticulitis with a mean follow-up period of 120 ± 2 months. Of the entire cohort, 249 patients (93.5%) were treated conservatively and 17 (6.5%) patients required emergent surgery on initial presentation. Patients treated conservatively (n = 249) encountered a median of two recurrent episodes (range 0-4). During follow-up, none of these patients required emergent surgery, and 27 patients (11%) underwent elective surgery for recurrent episodes (n = 24), chronic smoldering disease (n = 2), and fistula (n = 1). Minor and major complication rates after elective surgery were 18.5% and 30%, respectively. Specifically, four patients (15%) suffered an anastomotic leak (AL). Late complications after elective surgery occurred in 33% of patients including incisional hernias (11%), bowel obstruction (3.7%), anastomotic stenosis (3.7%), and recurrent diverticulitis (15%). CONCLUSIONS Patients treated conservatively during their index admission for sigmoid diverticulitis do not require emergent surgery during long-term follow-up and the majority of patients (89%) do not require elective surgery. Elective sigmoidectomy at nonspecialized centers may result in high rates of recurrent diverticulitis (15%) and anastomotic leak (15%).
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Tochigi T, Kosugi C, Shuto K, Mori M, Hirano A, Koda K. Management of complicated diverticulitis of the colon. Ann Gastroenterol Surg 2017; 2:22-27. [PMID: 29863123 PMCID: PMC5868871 DOI: 10.1002/ags3.12035] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/13/2017] [Indexed: 12/21/2022] Open
Abstract
Diverticular disease of the colon occurs quite frequently in developed countries, and its prevalence has recently increased in Japan. The appearance of diverticulosis increases with age, although mostly remaining asymptomatic. Approximately 20% of cases require treatment. As the Western lifestyle and number of elderly people increase, the need for medical treatment also increases. Computed tomography (CT) is the gold standard for diagnosing diverticulitis. Complicated diverticulitis is classified by the size and range of abscess formation and the severity of the peritonitis. Each case should be classified based on clinical and computed tomography (CT) findings and then treated appropriately. Most patients with uncomplicated diverticulitis (stages 0–Ia) can be treated conservatively. Diverticulitis with a localized abscess (stages Ib–II) is generally resolved with conservative treatment. If the abscess is larger or conservative treatment fails, however, percutaneous drainage or surgery should be considered. Operative treatment is considered standard therapy for severe diverticulitis with perforation and generalized peritonitis (stages III–IV). Colonic diverticulitis treated conservatively frequently recurs. Elective surgery after recovery should be considered carefully and decisions made on a case‐by‐case basis. Because cases of colonic diverticulitis will undoubtedly increase in Japan, it is likely that we will be confronted with increasing numbers of treatment decisions. We therefore need to have a systematic strategy for treating the various stages of colonic diverticulitis appropriately. We herein review the management of complicated diverticulitis.
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Affiliation(s)
- Toru Tochigi
- Department of Surgery Teikyo University Chiba Medical Center Ichihara Chiba Japan
| | - Chihiro Kosugi
- Department of Surgery Teikyo University Chiba Medical Center Ichihara Chiba Japan
| | - Kiyohiko Shuto
- Department of Surgery Teikyo University Chiba Medical Center Ichihara Chiba Japan
| | - Mikito Mori
- Department of Surgery Teikyo University Chiba Medical Center Ichihara Chiba Japan
| | - Atsushi Hirano
- Department of Surgery Teikyo University Chiba Medical Center Ichihara Chiba Japan
| | - Keiji Koda
- Department of Surgery Teikyo University Chiba Medical Center Ichihara Chiba Japan
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Khan RMA, Hajibandeh S, Hajibandeh S. Early elective versus delayed elective surgery in acute recurrent diverticulitis: A systematic review and meta-analysis. Int J Surg 2017; 46:92-101. [PMID: 28882772 DOI: 10.1016/j.ijsu.2017.08.583] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/10/2017] [Accepted: 08/21/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To investigate outcomes of early versus delayed surgery in patients with acute recurrent diverticulitis. METHODS We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of early versus delayed surgery in patients with acute recurrent diverticulitis. We used the Newcastle-Ottawa scale to assess the risk of bias of included studies. Random-effects models were applied to calculate pooled outcome data. RESULTS We identified three retrospective and one prospective cohort studies enrolling a total of 1046 patients. The included patients were comparable in terms of age, ASA score and Hinchey classifications (Hinchey I and II). The results of our analyses suggested that there was no difference between two groups in surgical site infection [Odds ratio (OR) 1.61, 95% CI 0.79-3.27, P = 0.19], intra-abdominal abscess (OR 0.92, 95% CI 0.21-4.00, P = 0.91), anastomotic leak (OR1.27, 95% CI 0.50-3.25, P = 0.61), 30-day mortality [Risk difference (RD) 0.00 95% CI -0.01-0.01, P = 0.80], postoperative ileus (OR 1.35, 95% CI 0.50-3.66, P = 0.55), postoperative bleeding (OR 0.93, 95% CI 0.32-2.69, P = 0.89), ureteric injury (OR 0.62, 95% CI 0.08-5.07, P = 0.65), and overall morbidity (OR 1.42 95% CI 0.76-2.66, P = 0.27). The early surgery was associated with longer operative time [Mean Difference (MD) 12.8, 95% CI 5.08-20.53, P = 0.001] and length of stay (MD 4.41, 95% CI -0.34-8.53, P = 0.03). Among those undergoing laparoscopic surgery, conversion to open surgery was higher in the early surgery group (OR 2.71, 95% CI 1.36-5.40, P = 0.005). CONCLUSIONS The best available evidence suggests that there is no difference between early elective and delayed elective surgery for acute recurrent diverticulitis in terms of clinical outcomes. However, longer operative time and length of stay and higher conversion rate to open surgery associated with early elective surgery may make the delayed elective surgery more cost-effective. The best available evidence is derived from non-randomised studies; therefore, high quality randomised controlled trials are required to provide more robust basis for definite conclusions.
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Affiliation(s)
| | - Shahin Hajibandeh
- Department of General Surgery, North Manchester General Hospital, Manchester, UK
| | - Shahab Hajibandeh
- Department of General Surgery, Salford Royal Foundation Trust, Salford, UK.
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von Strauss Und Torney M, Thommen S, Dell-Kuster S, Hoffmann H, Rosenthal R, Young J, Kettelhack C. Surgical treatment of uncomplicated diverticulitis in Switzerland: comparison of population-based data over two time periods. Colorectal Dis 2017; 19:840-850. [PMID: 28371339 DOI: 10.1111/codi.13670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 12/06/2016] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- M von Strauss Und Torney
- Department of Surgery, Cantonal Hospital Aarau, Aarau, Switzerland.,Department of Surgery, University Hospital Basel, Basel, Switzerland.,Colorectal Unit, Western General Hospital Edinburgh, Edinburgh, UK
| | - S Thommen
- Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland
| | - S Dell-Kuster
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland
| | - H Hoffmann
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - R Rosenthal
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - J Young
- Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland
| | - C Kettelhack
- Department of Surgery, University Hospital Basel, Basel, Switzerland
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Bendl RF, Bergamaschi R. Do Patients Mandate Resection After a First Episode of Acute Diverticulitis of the Colon with a Complication? Adv Surg 2017; 51:179-191. [PMID: 28797339 DOI: 10.1016/j.yasu.2017.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ryan Francis Bendl
- Department of Surgery, Norwalk Hospital, 30 Stevens Street, Suite D, Norwalk, CT 06856, USA.
| | - Roberto Bergamaschi
- Division of Colorectal Surgery, Department of Surgery, Stony Brook School of Medicine, Stony Brook, NY 11794, USA
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Hess GF, Schäfer J, Rosenthal R, Kettelhack C, Oertli D. Reversal after Hartmann's procedure in patients with complicated sigmoid diverticulitis. Colorectal Dis 2017; 19:582-588. [PMID: 27805772 DOI: 10.1111/codi.13553] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 08/19/2016] [Indexed: 02/08/2023]
Abstract
AIM Hartmann's procedure (HP) is commonly used for the emergency treatment of complicated sigmoid diverticulitis (CSD). It is intended to restore intestinal continuity; however, in practice, reversal is not carried out in all patients. It is important to know the frequency of reversal and the impact of patient-related factors on the decision for reversal. METHOD A retrospective study was conducted on all patients who underwent HP for CSD at a tertiary referral hospital between 1 May 2005 and 31 December 2010. We assessed the frequency of reversal over time and the prognostic factors affecting the decision for reversal. RESULTS Of 67 patients [median age 76 (interquartile range: 68-81) years] who had HP for CSD, 28 (42%) underwent reversal. The cumulative incidence of reversal after 48 weeks was 48% (95% CI: 36-62%). Reversal was less likely in elderly patients [hazard ratio (HR) per decade increase = 0.43; 95% CI: 0.26-0.71], with cardiac insufficiency or coronary heart disease (HR = 0.60; 95% CI: 0.26-1.40) and with preoperative immunosuppression or chemotherapy (HR = 0.31; 95% CI: 0.07-1.33). There was no apparent effect of these factors on mortality. CONCLUSION Approximately half of the patients having HP for CSD undergo reversal within 48 weeks of the initial operation. The finding that age, cardiac or coronary heart disease and preoperative immunosuppression or chemotherapy have an impact on the decision for reversal is relevant to healthcare professionals and patients.
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Affiliation(s)
- G F Hess
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - J Schäfer
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - R Rosenthal
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - C Kettelhack
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - D Oertli
- Department of Surgery, University Hospital Basel, Basel, Switzerland
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Abstract
PURPOSE WHO GLOBOCAN 2012 data showed that Australia and New Zealand have the highest incidence rates of colorectal cancer in the world (Ferlay et al. 1). Current guidelines recommend that patients admitted for an episode of acute diverticulitis require an early follow-up colonoscopy to rule out colorectal malignancy as reported by Fozard et al. (Colorectal Dis 13:1-11, 2011). Recent studies however have indicated that this may not be warranted (Brar et al. Dis Colon rectum 56:1259-1264, 2013). This study aimed to review the current practice by looking at our institution's rate of colorectal malignancy diagnosed after an episode of acute diverticulitis. METHODS We conducted a retrospective analysis of patients who presented with acute diverticulitis at our institution between 2011 and 2013. Included in the study were patients who received follow-up colonic evaluation in the next 12 months after admission. Patients who had a colonoscopy in the last year prior to emergency presentation were excluded. The primary outcome measure was the incidence of histologically confirmed colorectal carcinoma diagnosed on follow-up colonoscopy. Secondary outcome measures were incidence of low-grade or advanced adenoma on follow-up colonic evaluation. RESULTS A total of 523 cases of acute diverticulitis were diagnosed on CT scan. Out of 351 patients with uncomplicated diverticulitis, 196 had follow-up colonoscopy, with one case of colorectal malignancy recorded. Low-grade and advanced adenomas were found on 10.7 and 2.0% of colonoscopies performed respectively in this subgroup. Seventy-four out of 172 patients with complicated diverticulitis had follow-up evaluation, with four cases of colorectal malignancy discovered. Low-grade and advanced adenomas were found on 6.75 and 5.41% of colonoscopies performed respectively in this subgroup. CONCLUSION Routine interval colonoscopy following an episode of conservatively managed uncomplicated diverticulitis may not be necessary. Interval colonoscopy is still indicated in patients with complicated diverticulitis. Further collaborative study across different institutions may be warranted to gain better statistical significance.
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Marshall JR, Buchwald PL, Gandhi J, Schultz JK, Hider PN, Frizelle FA, Eglinton TW. Laparoscopic Lavage in the Management of Hinchey Grade III Diverticulitis: A Systematic Review. Ann Surg 2017; 265:670-676. [PMID: 27631772 DOI: 10.1097/sla.0000000000002005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the outcomes of laparoscopic lavage and sigmoid resection in perforated diverticulitis with purulent peritonitis. BACKGROUND Peritonitis secondary to perforated diverticulitis has conventionally been managed by resection and stoma formation. Case series have suggested that patients can be safely managed with laparoscopic lavage, resulting in reduced mortality and stoma formation. Recently, 3 randomized controlled trials have published contradictory conclusions. METHODS MEDLINE from 1946 to present, Cochrane Database of Systematic Reviews, and Cochrane database of Registered clinical trials and EMBASE (all via OVID) were searched using the terms "laparoscopy" AND ("primary resection" OR "Hartmann procedure", OR "sigmoidectomy"), AND "Diverticulitis", AND "Peritonitis" AND "therapeutic irrigation" or "lavage" AND randomized controlled trial and any derivatives of those terms. We included all randomized controlled trials. Data were extracted from each study using a purpose-designed template. Statistical analysis was undertaken using Revman 5. RESULTS Three randomized controlled trials were identified from 48 potential studies. The analysis included 307 patients of whom 159 underwent laparoscopic lavage. Overall, the rate of reintervention within 30 days postoperatively was 45/159 (28.3%) in the lavage group and 13/148 (8.8%) in the resection group (relative risk 3.01, 95% confidence interval 1.15-7.90). There was no significant difference in Intensive Care Unit admissions, 30 and 90-day mortality, or stoma rates at 12 months. CONCLUSION Laparoscopic lavage used in the management of Hinchey grade III diverticulitis leads to more reinterventions within 30 days postoperatively, but does not increase the 30 or 90-day mortality rates compared with sigmoid resection.
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Affiliation(s)
- James R Marshall
- *Department of Surgery, Christchurch Hospital, Christchurch, New Zealand †University of Otago, Christchurch, New Zealand ‡Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway §Faculty of Medicine, University of Oslo, Oslo, Norway
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Mathews SN, Lamm R, Yang J, Kang L, Telem D, Pryor AD, Talamini M, Genua J. Factors Associated with Repeated Health Resource Utilization in Patients with Diverticulitis. J Gastrointest Surg 2017; 21:112-120. [PMID: 27613732 DOI: 10.1007/s11605-016-3245-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/08/2016] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Steven N Mathews
- Stony Brook University School of Medicine, Stony Brook University Medical Center, 26 Barker Drive, Stony Brook, NY, 11790, USA.
| | - Ryan Lamm
- Stony Brook University School of Medicine, Stony Brook University Medical Center, 26 Barker Drive, Stony Brook, NY, 11790, USA
| | - Jie Yang
- Department of Family, Population and Preventative Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Lijuan Kang
- Department of Family, Population and Preventative Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Dana Telem
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Mark Talamini
- Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Jill Genua
- Division of Colon and Rectal Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
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When Should We Operate for Recurrent Diverticulitis? J Clin Gastroenterol 2016; 50 Suppl 1:S80-2. [PMID: 27622374 DOI: 10.1097/mcg.0000000000000667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Recent guidelines on elective surgery for recurrent diverticulitis have removed generalized recommendations for elective preventive surgery and advice individualized decision per patient. We discuss the clinical evidence and potential use of risk factors to help with decision-making for patient selection for elective surgery in the presence of a history of diverticulitis.
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Long-term Outcomes of Elective Surgery for Diverticular Disease: A Call for Standardization. J Clin Gastroenterol 2016; 50 Suppl 1:S77-9. [PMID: 27622373 DOI: 10.1097/mcg.0000000000000599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
To date, the appropriate management of diverticular disease is still controversial. The American Society of Colon and Rectal Surgeons declared that the decision between conservative or surgical approach should be taken by a case-by-case evaluation. There is still lack of evidence in literature about long-term outcomes after elective sigmoid resection for diverticular disease. Considering the potentially key role of the surgical technique in long-term outcomes, there is the need for surgeons to define strict rules to standardize the surgical technique. Currently there are 5 areas of debate in elective surgery for diverticular disease: laparoscopic versus open approach, the site of the proximal and distal colonic division, the vascular approach and the mobilization of the splenic flexure. The purpose of this paper is to review existing knowledge about technical aspects, which represent how the surgeon is able to affect the long-term results.
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Horesh N, Wasserberg N, Zbar AP, Gravetz A, Berger Y, Gutman M, Rosin D, Zmora O. Changing paradigms in the management of diverticulitis. Int J Surg 2016; 33 Pt A:146-50. [DOI: 10.1016/j.ijsu.2016.07.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/21/2016] [Accepted: 07/26/2016] [Indexed: 12/15/2022]
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Horesh N, Shwaartz C, Amiel I, Nevler A, Shabtai E, Lebedeyev A, Nadler R, Rosin D, Gutman M, Zmora O. Diverticulitis: does age matter? J Dig Dis 2016; 17:313-8. [PMID: 27106275 DOI: 10.1111/1751-2980.12350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/01/2016] [Accepted: 04/18/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Acute diverticulitis has been traditionally associated with worse outcome in young patients, indicating a more aggressive surgical approach is required for them. The aim of this study was to assess whether acute diverticulitis was more virulent in young patients. METHODS A retrospective, cross-sectional study included all patients who were admitted for a first episode of acute diverticulitis between January 2004 and December 2013. The patients were divided into two groups (≤50 years and >50 years) based on their age. Patients' characteristics, clinical and surgical data were recorded and analyzed. RESULTS Overall, 636 patients were included in the database, including 177 (27.8%) in the younger group and 459 in the elder group. There were no significant differences between the groups in disease complexity, peritonitis, laboratory work-up, vital signs on presentation, bowel obstruction or the presence of fistula and abscess in need of drainage. Younger patients had more free extra-luminal air on computed tomography (CT) scan (P = 0.03). Surgical data, including the intra-operative modified Hinchey score and the need for emergency and additional surgery did not significantly differ between the two groups. Young patients had more readmissions (P = 0.01) due to acute diverticulitis, diverticular complications and elective surgery. Length of hospital stay (P = 0.0001) was longer and postoperative complications were more common in the elder patients. CONCLUSIONS The clinical presentation of acute diverticulitis does not seem to be worse in the young population. Younger patients tend to have a more severe presentation on CT scan and more readmissions, but this did not translate to a more severe disease course.
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Affiliation(s)
- Nir Horesh
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Chaya Shwaartz
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Imri Amiel
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Avinoam Nevler
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Esther Shabtai
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Alexander Lebedeyev
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Roi Nadler
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Danny Rosin
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Mordechai Gutman
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Oded Zmora
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
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Ambrosetti P, Gervaz P. Management of sigmoid diverticulitis: an update. Updates Surg 2016; 68:25-35. [PMID: 27086288 DOI: 10.1007/s13304-016-0365-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/29/2016] [Indexed: 12/17/2022]
Abstract
The role, indications and modalities of elective resection for sigmoid diverticulitis remain the cause of fierce debate. During the past two decades clinicians have increasingly recognized that: (1) young patients (<50) are no more at risk to develop more aggressive course of the disease; and (2) patients who present initially with a first uncomplicated attack are no more at risk for developing subsequent complicated diverticulitis requiring emergency surgery. Hence, the previously well-recognized indications (based upon age of the patients or the number of attacks) are no longer valid. Yet, the number of sigmoid resections performed for diverticulitis in industrialized countries is increasing, which seems to indicate that in many cases, uncomplicated sigmoid diverticulitis progressively evolves towards a chronic symptomatic condition, which significantly impacts upon the patients' quality of life. The aims of this review are twofold: (1) to identify which disease presentation still represents good indications for elective laparoscopic sigmoid resection; and (2) to summarize the technical aspects of surgery for a benign condition, such as diverticular disease.
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Affiliation(s)
- Patrick Ambrosetti
- Department of Surgery, Clinique Générale Beaulieu, Ch. Beau-Soleil, 1205, Geneva, Switzerland
| | - Pascal Gervaz
- Coloproctology Unit, Clinique Hirslanden La Colline, Geneva, Switzerland.
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Abstract
BACKGROUND The indications for interval elective colectomy following diverticulitis are unclear; evidence lends increasing support for nonoperative management. OBJECTIVE This study aims to evaluate the temporal trends in the use of elective colectomy following diverticulitis. DESIGN This is a population-based retrospective cohort study using administrative discharge data. SETTING This study was conducted in Ontario, Canada. PATIENTS Patients who had had an episode of diverticulitis managed nonoperatively and were eligible for elective colectomy, from 2002 to 2012, were selected. MAIN OUTCOME MEASURES Changes in the proportion of patients who undergo elective colectomy following an episode of diverticulitis treated nonoperatively were evaluated. Cochran-Armitage was used to test for trends; adjusted analysis was performed by using multivariable logistic regression with generalized estimating equations. RESULTS A total of 14,124 patients were admitted with an episode of diverticulitis and treated nonoperatively, making them eligible for interval elective colectomy. Median follow-up was 3.9 years (maximum, 10; interquartile range, 1.7-6.4). Overall, 1342 (9.5%) patients underwent elective colectomy; 33% of these colectomies were performed laparoscopically, and 7.5% patients received an ostomy. In-hospital mortality was 0.2%. The majority (76%) of elective operations were performed within 1 year of discharge (median, 160 days; interquartile range, 88-346). The proportion of patients undergoing elective colectomy within 1 year of discharge declined from 9.6% of patients in 2002 to 3.9% by 2011 (p < 0.001). The decline was most pronounced in patients <50 years of age (from 17% to 5%), and those with complicated disease (from 28% to 8%) (all p < 0.001). In multivariable regression, younger age, lower medical comorbidity, complicated disease, and early readmission were associated with elective colectomy. After adjusting for changes in patient characteristics, the odds of elective surgery decreased by 0.93 per annum (adjusted OR; 95% CI, 0.90-0.95). LIMITATIONS Administrative health databases contain limited clinical detail; the rationale for elective surgery was not available. CONCLUSIONS Consistent with evolving practice guidelines, there has been a decrease in the use of elective colectomy following an episode of diverticulitis.
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Elective colonic resection after acute diverticulitis improves quality of life, intestinal symptoms and functional outcome: experts’ perspectives and review of literature. Updates Surg 2016; 68:53-8. [DOI: 10.1007/s13304-016-0349-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/16/2016] [Indexed: 01/01/2023]
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Minimally Invasive Management of Complicated Diverticular Disease: Current Status and Review of Literature. Dig Dis Sci 2016; 61:663-72. [PMID: 26547753 DOI: 10.1007/s10620-015-3924-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 10/05/2015] [Indexed: 12/16/2022]
Abstract
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.
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