Outcome of a conservative policy for managing acute sigmoid diverticulitis

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

German guideline diverticular disease/diverticulitis: Part I: Methods, pathogenesis, epidemiology, clinical characteristics (definitions), natural course, diagnosis and classification

Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.

Challenging Surgical Dogma: Controversies in Diverticulitis

Diverticulosis of the sigmoid colon is common in the developed world, affecting approximately 33% of persons older than 60 years. Up to 15% of these patients will develop diverticulitis at some point in their lifetime. The incidence of diverticulitis has increased in the last decade, accounting for nearly 300,000 US hospital admissions and $1.8 billion in annual direct medical costs. With such a wide prevalence and diverse spectrum of clinical presentation, there are bound to be multiple controversies regarding disease management. This article will serve to educate the reader on several important areas to consider when treating this ubiquitous disease.

Update on the management of sigmoid diverticulitis

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.

CT colonography followed by elective surgery in patients with acute diverticulitis: a radiological-pathological correlation study

Purpose

To perform a radiologic-pathologic correlation analysis of sigmoid colon in patients undergoing pre-operative CT Colonography (CTC) after an episode of acute diverticulitis (AD).

Methods

Fifty-nine consecutive patients (31/28 M/F; 58 ± 13 years) underwent CTC 55 ± 18 days after AD, 8 ± 4 weeks before surgery. Thirty-seven patients (63%) underwent conventional abdominal CT at time of AD. An experienced blinded radiologist retrospectively analyzed all images: disease severity was graded according to the Ambrosetti classification on conventional CT and according to the diverticular disease severity score (DDSS) on CTC. A GI pathologist performed a dedicated analysis, evaluating the presence of acute and chronic inflammation, and fibrosis, using 0–3 point scale for each variable.

Results

Of 59 patients, 41 (69%) had at least one previous AD episode; twenty-six patients (44%) had a complicated AD. DDSS was mild-moderate in 34/59 (58%), and severe in 25/59 (42%). All patients had chronic inflammation, while 90% had low-to-severe fibrosis. Patients with moderate/severe fibrosis were older than those with no/mild fibrosis (61 ± 13 versus 54 ± 13). We found a significant correlation between DDSS and chronic inflammation (p = 0.004), as well as DDSS and fibrosis (p = 0.005). Furthermore, fibrosis was correlated with complicated acute diverticulitis (p = 0.0.27), and with age (p = 0.067). At multivariate analysis, complicated diverticulitis was the best predictor of fibrosis (odds ratio 4.4). Patient age and DDSS were other independent predictors.

Conclusion

DDSS-based assessment on preoperative CTC was a good predictor of chronic colonic inflammation and fibrosis. In addition, the presence of complicated diverticulitis on CT during the acute episode was most predictive of fibrosis.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

The Indications for and Timing of Surgery for Diverticular Disease

BACKGROUND

Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease.

METHODS

This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease.

RESULTS

Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails.

CONCLUSION

The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.

Early or delayed sigmoid resection in complicated diverticular disease? A single-center experience

Background

Diverticular disease appears to be one of the most common conditions in the Western world. The standard approach in treatment of diverticular disease is a laparoscopic resection, usually after an inflammation-free time of 4 to 6 weeks. The aim of this study was to evaluate the timing of operation.

Materials and methods

A total of 61 patients underwent left-sided colonic resection because of diverticular disease between January 2017 and February 2020. Because of complicated diverticulitis (CDD stage 2a or 2b) 37 patients were treated either early within 7 days after first symptoms (group A: n = 17) or delayed about 6 weeks after the first contact and conservative therapy (group B: n = 20).

Results

Overall mortality was 0%. The average operation time was shorter in the early elective group (group A: 140.4 min vs. group B: 151.2 min; p = 0.29). The hospital stay (group A: 9.9 days vs. group B: 16.9 days) and the postoperative stay (group A: 4.8 days vs. group B: 8.1 days) were significantly longer in group B (p = 0.01). We observed—although not reliable due to the low number of patients—more postoperative complications in the delayed group (group A: 5.9% vs. group B: 15.0%; p = 0.61).

Conclusion

The data in this study confirm the early operation as safe and efficient due to lower costs. We can recommend an early approach in selected cases with the first episode of a complicated diverticulitis.

A systematic review and meta-analysis of disease severity and risk of recurrence in young versus elderly patients with left-sided acute diverticulitis

Young patients are thought to have a more severe disease course and a higher rate of recurrent diverticulitis. However, these understandings are mainly based on studies with important limitations. This review aimed to clarify the true natural history of acute diverticulitis in young patients compared to elderly patients. PubMed and MEDLINE were searched for studies reporting outcomes on disease severity or recurrences in young and elderly patients with a computed tomography-proven diagnosis of acute diverticulitis. Twenty-seven studies were included. The proportion of complicated diverticulitis at presentation (21 studies) was not different for young patients (age cut-off 40-50 years) compared to elderly patients [risk ratio (RR) 1.19; 95% confidence interval 0.94-1.50]. The need for emergency surgery (11 studies) or percutaneous abscess drainage (two studies) yielded comparable results for both groups with a RR of 0.93 (95% confidence interval 0.70-1.24) and 1.65 (95% confidence interval 0.60-4.57), respectively. Crude data on recurrent diverticulitis rates (12 studies) demonstrated a significantly higher RR of 1.47 (95% confidence interval 1.20-1.80) for young patients. Notably, no association between age and recurrent diverticulitis was found in the studies that used survival analyses, taking length of follow-up per age group into account. In conclusion, young patients do not have a more severe course of acute diverticulitis. Published data on the risk of recurrent diverticulitis in young patients are conflicting, but those with the most robust design do not demonstrate an increased risk. Therefore, young patients should not be treated more aggressively nor have a lower threshold for elective surgery just because of their age.

Follow up colonoscopy may be omissible in uncomplicated left-sided acute diverticulitis diagnosed with CT- a retrospective cohort study

International guidelines recommend colonoscopy following hospitalisation for acute diverticulitis. There is a paucity of evidence supporting the efficacy of colonoscopy in this context, particularly for patients with CT-diagnosed uncomplicated left-sided diverticulitis. This study aims to investigate the frequency that colorectal cancer (CRC) and advanced adenomas (AA) are identified during follow-up colonoscopy after hospitalisation with CT-proven left-sided diverticulitis for the first time in a UK population. In this single-centre retrospective-cohort study all patients presenting with CT-diagnosed uncomplicated left-sided diverticulitis between 2014 and 2017 were identified. The incidence of histologically confirmed CRC and AA identified at follow-up colonoscopy 4–6 weeks following discharge was assessed. 204 patients with CT proven uncomplicated left-sided diverticulitis underwent follow-up colonoscopy. 72% were female and the median age was 63 years. There were no major complications. 22% of patients were found to have incidental hyperplastic polyps or adenomas with low-grade dysplasia. No CRC or AA were found. Routine colonoscopy following acute diverticulitis in this cohort did not identify a single CRC or AA and could arguably have been omitted. This would significantly reduce cost and pressure on endoscopy departments, in addition to the pain and discomfort that is commonly associated with colonoscopy.

Timing of laparoscopic elective surgery for acute left colonic diverticulitis. Retrospective analysis of 332 patients

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.

Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis

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.

Surgical management in acute diverticulitis and its association with multi-detector CT, modified Hinchey classification, and clinical parameters

PURPOSE

To assess whether CT findings, clinical parameters, and modified Hinchey classification are predictive of management outcomes of patients with acute diverticulitis.

MATERIALS AND METHODS

Data were accrued between January 2014 and December 2015. A total of 301 adult subjects were identified from radiology reports, of which six who did not met the inclusion criteria were excluded, thus yielding 295 subjects. Subjects were 43.1% (n = 127) male and 56.9% female (n = 168), with mean age 51.9 years (range 18-90). Two independent abdominal radiologists reviewed all scans; imaging features and a modified Hinchey classification were scored. Descriptive statistics compared the relationships between imaging findings, clinical parameters obtained from medical record review, and modified Hinchey classification with management outcomes.

RESULTS

CT findings associated with surgical management include the presence of a pericolonic fluid collection (36.8% vs. 8.2%, P = 0.0001), colonic fistula (13.2% vs. 0.4%, P = 0.0002), extraluminal air (26.4% vs. 9.3%, P = 0.0052), bowel obstruction (5.2% vs. 0.0%, P = 0.0162), and a modified Hinchey score of Ib or higher (55.3% vs. 11.7%, P = 0.0001). Slightly lower systolic blood pressure was also associated with operative management (137.2 mmHg vs. 128.2 mmHg, P = 0.0220).

CONCLUSION

Specific CT imaging features and modified Hinchey classification are associated with subsequent surgical management in patients with acute diverticulitis.

Management of acute uncomplicated diverticulitis without antibiotics: a systematic review, meta-analysis, and meta-regression of predictors of treatment failure

BACKGROUND

Diverticulitis is a common complication of diverticular disease of the colon. While complicated diverticulitis often warrants intervention, acute uncomplicated diverticulitis (AUD) is usually managed conservatively. The aim of the present review was to evaluate the efficacy and safety of conservative treatment of AUD without antibiotics compared to standard antibiotic treatment.

METHODS

A systematic literature review in compliance with PRISMA guidelines was conducted. Electronic databases including PubMed/Medline, Scopus, Embase and Cochrane central register of controlled trials were searched. Studies that assessed efficacy and safety of treatment of AUD without antibiotics were included. Outcome parameters were rates of treatment failure, recurrence of diverticulitis, complications and mortality, readmission to hospital, and need for surgery.

RESULTS

Nine studies including 2565 patients were included to the review. Of these patients, 65.1% were treated conservatively without antibiotics. Treatment failure was observed in 5.1% of patients not-given-antibiotic treatment versus 3.4% of those given antibiotic treatment. Recurrent diverticulitis occurred in 9.3% of patients in the non-antibiotic group versus 12.1% of patients in the antibiotic group. On meta-analysis of the studies, there were no significant differences between non-antibiotic and antibiotic treatment groups regarding rates of treatment failure (OR = 1.5, p = 0.06), recurrence of diverticulitis (OR = 0.81, p = 0.2), complications (OR = 0.56, p = 0.25), readmission rates (OR = 0.97, p = 0.91), need for surgery (OR = 0.59, p = 0.28), and mortality (OR = 0.64, p = 0.47). The only variable that was significantly associated with treatment failure in the non-antibiotic treatment group was associated comorbidities (standard error (SE) = - 0.07, 95% CI - 0.117 - 0.032; p < 0.001).

CONCLUSIONS

Treatment of AUD without antibiotics is feasible, safe, and effective. Adding broad-spectrum antibiotics to the treatment regimen did not serve to decrease treatment failure, recurrence, complications, hospital readmissions, and need for surgery significantly compared to non-antibiotic treatment.

Impact of CT imaging on predicting the surgical management of acute diverticulitis

Purpose

The incidence of colonic diverticular disease is increasing, and several grading systems based on CT findings have been developed. The objective of this study was to define the impact of various CT findings of colonic diverticulitis and to demonstrate which factors affect the need for operative treatment.

Methods

Three hundred fifty-seven patients diagnosed with colonic diverticulitis from January 2010 to July 2016 were retrospectively evaluated. Patients were excluded if pure diverticulosis, diverticular bleeding, colon cancer, or relevant data deficiencies, and the remaining patients (n = 178) were reviewed. Patients were categorized into a successful nonoperation group and an operation group. The operation group was then matched 1:2 with the nonoperative group based on age, gender, American Society of Anesthesiologists physical status classification, and body mass index.

Results

After propensity score matching, there were no significant differences regarding patients' demographic characteristics between the 2 groups. Left location was more associated with need for operation than the right side (79.2% vs. 31.3%, P < 0.001). CT findings such as distant intraperitoneal air, pericolic air, and free fluid were significantly more apparent in the operation group. When these factors were evaluated in a multivariate analysis, distant intraperitoneal air showed statistical significance (P = 0.046) and pericolic air and left location a significant trend (P = 0.071 and P = 0.067, respectively).

Conclusion

This study suggests that distant intraperitoneal air is the most important factor in the need for surgery in patients with colonic diverticulitis. Further study will be able to identify more detailed CT findings and verify their significance, and will be helpful in designing practical scoring and classification systems.

Randomized clinical trial of elective resection versus observation in diverticulitis with extraluminal air or abscess initially managed conservatively

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).

The Multidisciplinary Management of Acute Complicated Diverticulitis

BACKGROUND

Acute complicated diverticulitis (ACD) is an important and increasing issue in Western countries that leads to a significant impact and burden for patients, but also for the society due to its effects on hospital costs. In recent years, essential progression has been made regarding the research and implementation of novel or improved treatment strategies for the various disease entities of ACD. Much debated topics in the multidisciplinary approach of patients with ACD, such as the choice for nonoperative treatment options, the role of percutaneous drainage for diverticular abscesses, the role of laparoscopic lavage for perforated diverticulitis with purulent peritonitis, and the role of sigmoidectomy with primary anastomosis for patients with perforated diverticulitis, require clinicians to attentively follow and participate in these discussions.

SUMMARY

The aim of this review article is to provide clinicians with a structured overview of the recent literature on the multidisciplinary management of complicated diverticulitis by a panel of experts on the topic. By performing an extensive literature search in the online medical databases MEDLINE (Ovid) and Embase, insights into nonoperative treatment, percutaneous drainage, minimally invasive and open surgical treatment of ACD are provided. Furthermore, a comprehensive algorithm for the treatment of ACD has been developed.

KEY MESSAGES

Accurate patient evaluation and selection based on patient and disease characteristics is of paramount importance to determine the appropriate treatment strategy for patients with complicated diverticulitis. The presence of an experienced surgeon with advanced skills in laparoscopic emergency colorectal surgery is crucial for the treatment of patients with perforated diverticulitis in order to properly evaluate, select and treat patients suitable for nonoperative or operative treatment with an open or laparoscopic approach.

Laparoscopic versus open resection for sigmoid diverticulitis

BACKGROUND

Diverticular disease is a common condition in Western industrialised countries. Most individuals remain asymptomatic throughout life; however, 25% experience acute diverticulitis. The standard treatment for acute diverticulitis is open surgery. Laparoscopic surgery - a minimal-access procedure - offers an alternative approach to open surgery, as it is characterised by reduced operative stress that may translate into shorter hospitalisation and more rapid recovery, as well as improved quality of life.

OBJECTIVES

To evaluate the effectiveness of laparoscopic surgical resection compared with open surgical resection for individuals with acute sigmoid diverticulitis.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library; Ovid MEDLINE (1946 to 23 February 2017); Ovid Embase (1974 to 23 February 2017); clinicaltrials.gov (February 2017); and the World Health Organization (WHO) International Clinical Trials Registry (February 2017). We reviewed the bibliographies of identified trials to search for additional studies.

SELECTION CRITERIA

We included randomised controlled trials comparing elective or emergency laparoscopic sigmoid resection versus open surgical resection for acute sigmoid diverticulitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the domains of risk of bias from each included trial, and extracted data. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we planned to calculate mean differences (MDs) with 95% CIs for outcomes such as hospital stay, and standardised mean differences (SMDs) with 95% CIs for quality of life and global rating scales, if researchers used different scales.

MAIN RESULTS

Three trials with 392 participants met the inclusion criteria. Studies were conducted in three European countries (Switzerland, Netherlands, and Germany). The median age of participants ranged from 62 to 66 years; 53% to 64% were female. Inclusion criteria differed among studies. One trial included participants with Hinchey I characteristics as well as those who underwent Hartmann's procedure; the second trial included only participants with "a proven stage II/III disease according to the classification of Stock and Hansen"; the third trial considered for inclusion patients with "diverticular disease of sigmoid colon documented by colonoscopy and 2 episodes of uncomplicated diverticulitis, one at least being documented with CT scan, 1 episode of complicated diverticulitis, with a pericolic abscess (Hinchey stage I) or pelvic abscess (Hinchey stage II) requiring percutaneous drainage."We determined that two studies were at low risk of selection bias; two that reported considerable dropouts were at high risk of attrition bias; none reported blinding of outcome assessors (unclear detection bias); and all were exposed to performance bias owing to the nature of the intervention.Available low-quality evidence suggests that laparoscopic surgical resection may lead to little or no difference in mean hospital stay compared with open surgical resection (3 studies, 360 participants; MD -0.62 (days), 95% CI -2.49 to 1.25; I² = 0%).Low-quality evidence suggests that operating time was longer in the laparoscopic surgery group than in the open surgery group (3 studies, 360 participants; MD 49.28 (minutes), 95% CI 40.64 to 57.93; I² = 0%).We are uncertain whether laparoscopic surgery improves postoperative pain between day 1 and day 3 more effectively than open surgery. Low-quality evidence suggests that laparoscopic surgery may improve postoperative pain at the fourth postoperative day more effectively than open surgery (2 studies, 250 participants; MD = -0.65, 95% CI -1.04 to -0.25).Researchers reported quality of life differently across trials, hindering the possibility of meta-analysis. Low-quality evidence from one trial using the Short Form (SF)-36 questionnaire six weeks after surgery suggests that laparoscopic intervention may improve quality of life, whereas evidence from two other trials using the European Organization for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) v3 and the Gastrointestinal Quality of Life Index score, respectively, suggests that laparoscopic surgery may make little or no difference in improving quality of life compared with open surgery.We are uncertain whether laparoscopic surgery improves the following outcomes: 30-day postoperative mortality, early overall morbidity, major and minor complications, surgical complications, postoperative times to liquid and solid diets, and reoperations due to anastomotic leak.

AUTHORS' CONCLUSIONS

Results from the present comprehensive review indicate that evidence to support or refute the safety and effectiveness of laparoscopic surgery versus open surgical resection for treatment of patients with acute diverticular disease is insufficient. Well-designed trials with adequate sample size are needed to investigate the efficacy of laparoscopic surgery towards important patient-oriented (e.g. postoperative pain) and health system-oriented outcomes (e.g. mean hospital stay).

National complicated acute diverticulitis (CADS) study: a protocol for a prospective observational scoping study for acute diverticulitis

Background

Diverticular disease is a widely prevalent disease in western society, and acute diverticulitis is a common acute surgical presentation. However, there is a lack of level 1 evidence addressing the multifaceted presentations associated with acute diverticulitis. There is also a lack of robust epidemiological data that could be used to meaningfully inform randomised controlled trials. The National CADS project aims to generate baseline data for a cohort of patients managed for clinically suspected acute diverticulitis and evaluate the impact of variability in the management approach on patient outcomes in the short (3 months) and long (2 years) term.

Method

A Unit policy questionnaire will be completed by the principal investigator from all participating centres prior to study initiation. All patients aged above 18 years admitted with clinical suspicion of acute diverticulitis will be included from UK hospitals providing acute surgical care. Demographic, clinical, inpatient stay and outpatient follow-up data will be collected for index admissions between July and September 2014, 3 months follow-up and finally a 2-year follow-up.

Results

The study attracted participation from 108 centres nationally and has so far generated data on 2500 patients admitted between 1 July 2014 and 30 September 2014. Short-term follow-up data have been obtained for this cohort.

Conclusions

The National CADS study is currently ongoing with the long-term outcomes data anticipated to be submitted in autumn of 2016.

Health economic analysis of laparoscopic lavage versus Hartmann's procedure for diverticulitis in the randomized DILALA trial

BACKGROUND

Open surgery with resection and colostomy (Hartmann's procedure) has been the standard treatment for perforated diverticulitis with purulent peritonitis. In recent years laparoscopic lavage has emerged as an alternative, with potential benefits for patients with purulent peritonitis, Hinchey grade III. The aim of this study was to compare laparoscopic lavage and Hartmann's procedure with health economic evaluation within the framework of the DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial.

METHODS

Clinical effectiveness and resource use were derived from the DILALA trial and unit costs from Swedish sources. Costs were analysed from the perspective of the healthcare sector. The study period was divided into short-term analysis (base-case A), within 12 months, and long-term analysis (base-case B), from inclusion in the trial throughout the patient's expected life.

RESULTS

The study included 43 patients who underwent laparoscopic lavage and 40 who had Hartmann's procedure in Denmark and Sweden during 2010-2014. In base-case A, the difference in mean cost per patient between laparoscopic lavage and Hartmann's procedure was €-8983 (95 per cent c.i. -16 232 to -1735). The mean(s.d.) costs per patient in base-case B were €25 703(27 544) and €45 498(38 928) for laparoscopic lavage and Hartmann's procedure respectively, resulting in a difference of €-19 794 (95 per cent c.i. -34 657 to -4931). The results were robust as demonstrated in sensitivity analyses.

CONCLUSION

The significant cost reduction in this study, together with results of safety and efficacy from RCTs, support the routine use of laparoscopic lavage as treatment for complicated diverticulitis with purulent peritonitis.

Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis

BACKGROUND

Antibiotics are advised in most guidelines on acute diverticulitis, despite a lack of evidence to support their routine use. This trial compared the effectiveness of a strategy with or without antibiotics for a first episode of uncomplicated acute diverticulitis.

METHODS

Patients with CT-proven, primary, left-sided, uncomplicated, acute diverticulitis were included at 22 clinical sites in the Netherlands, and assigned randomly to an observational or antibiotic treatment strategy. The primary endpoint was time to recovery during 6 months of follow-up. Main secondary endpoints were readmission rate, complicated, ongoing and recurrent diverticulitis, sigmoid resection and mortality. Intention-to-treat and per-protocol analyses were done.

RESULTS

A total of 528 patients were included. Median time to recovery was 14 (i.q.r. 6-35) days for the observational and 12 (7-30) days for the antibiotic treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of 1-sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between the observation and antibiotic treatment groups were found for secondary endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P = 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8 versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P = 0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality (1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). Per-protocol analyses were concordant with the intention-to-treat analyses.

CONCLUSION

Observational treatment without antibiotics did not prolong recovery and can be considered appropriate in patients with uncomplicated diverticulitis. Registration number: NCT01111253 (http://www.clinicaltrials.gov).

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography

The diagnostic approach of patients with suspected acute diverticulitis remains debated. On the one hand, a scoring system with the best predictive value in diagnosing acute diverticulitis has been developed in order to reduce the use of computed tomography (CT) scan, while, on the other hand, patients with a high probability of acute diverticulitis should benefit from CT scan from a clinical viewpoint, ensuring that they will receive the most appropriate treatment. The place and classification of CT scan for acute diverticulitis need to be reassessed. If the management of uncomplicated acute diverticulitis, abscess, and fecal peritonitis is now well codified, urgent surgical or medical treatment of hemodynamically stable patients presenting with intraperitoneal air or fluid without uncontrolled sepsis is still under discussion. Furthermore, the indications for laparoscopic lavage are not yet well established. It is known for years that episode(s) of acute uncomplicated diverticulitis may induce painful recurrent bowel symptoms, known as symptomatic uncomplicated diverticular disease and irritable bowel syndrome-like diverticular disease. These two clinical expressions of diverticular disease, that may darken quality of life, are treated medically aimed at symptom relief. The possible place of surgery should be discussed. Clinical and CT scan classifications should be separated entities.

Natural history of uncomplicated sigmoid diverticulitis

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

Surgery for diverticulitis: a re-evaluation of the changing trends

The surgical management of diverticulitis continues to evolve but recent literature has not qualified just how different current practice is compared with the previous era. This study aims to update the seminal paper by Rodkey and Welch regarding indications and operation types performed for diverticulitis by comparing their findings with present practice at a community based institution. The charts of 407 patients admitted with "diverticular disease" between 2005 and 2010 were identified. For each admission, patients' demographics, presentations and management were recorded. Direct comparisons were made with results from the study by Rodkey and Welch. Of the 407 admissions studied, the distribution was 335 emergency and 72 elective. Medical management alone treated 90% of emergency admissions, while 4% required additional radiologic intervention. Emergency surgery was necessary in only 6% of cases with Hartmann's procedure being the most common procedure. Recurrent diverticulitis was a prime indication for elective surgery with 96% of cases undergoing a 1-staged procedure. Compared with the previous era, the nonoperative approach to managing acute diverticulitis is now applied for the vast majority of admissions. Improved success in medically temporizing patients in the present era has allowed for a higher percentage of successful single-staged elective surgeries.

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

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

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

BACKGROUND

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

AIM

To create formal guidelines for diagnosis and management.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnosis, Differential Diagnoses, and Classification of Diverticular Disease

Background

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

Methods

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

Results

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

Conclusion

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

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diverticular disease in Scotland: 2000-2010

AIM

Symptomatic diverticular disease (DD) may be increasing in incidence in western society particularly in younger age groups. This study aimed to describe hospital admission rates and management for DD in Scotland between 2000 and 2010.

METHOD

Data were obtained from the Scottish Morbidity Records (SMR01). The study cohort included all patients with a hospital admission and a primary diagnosis of DD of the large intestine (ICD-10 primary code K57).

RESULTS

Scottish NHS hospitals reported 90 990 admissions for DD (in 87 314 patients) from 2000 to 2010. The annual number of admissions increased by 55.2% from 6591 in 2000 to 10,228 in 2010, an average annual increase per year of 4.5%. Most of the increase attributable to DD was due to elective day cases (3618 in 2000; 6925 in 2010) a likely consequence of a greater proportion of the population accessing colonoscopy over that time period. There was an 11% increase in inpatient admissions (2973-3303), 60% of these patients being women. Admissions in younger age groups increased proportionally in the later years of the study, and there was an association between DD admissions and greater deprivation. Despite an increase in complicated DD from 22.9% in 2000 to 27.1% in 2010 and a 16.8% increase in emergency inpatient admissions, the rate of surgery fell during the period of study.

CONCLUSION

This report supports findings of other population-based studies of western countries indicating that DD is an increasing burden on health service resources, particularly in younger age groups.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis

BACKGROUND

There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis.

OBJECTIVE

The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes.

DESIGN

This is a population-based retrospective cohort study using administrative discharge data.

SETTING

This study was conducted in Ontario, Canada.

PATIENTS

All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012).

MAIN OUTCOME MEASURES

Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics.

RESULTS

There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001).

LIMITATIONS

There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data.

CONCLUSIONS

There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

A systematic review of complicated diverticulitis in post-transplant patients

BACKGROUND

Immunosuppression could increase the complication rate in patients with acute diverticulitis. This would justify a low threshold for elective sigmoid resection in these patients after an episode of diverticulitis. Well-documented groups of immunocompromised patients are transplant patients, in which many prospective studies have been conducted.

OBJECTIVES

The aim of this systematic review is to assess the incidence of complicated diverticulitis in post-transplant patients.

DATA SOURCE

We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases for papers published between January 1966 and January 2014.

STUDY SELECTION AND INTERVENTION

Publications dealing with post-transplant patients and left-sided diverticulitis were eligible for inclusion. The following exclusion criteria were used for study selection: abstracts, case-series and non-English articles.

MAIN OUTCOME MEASURES

Primary outcome measure was the incidence of complicated diverticulitis. Secondary outcome was the incidence of acute diverticulitis and the proportion of complicated diverticulitis. Pooling of data was only performed when more than five reported on the outcome of interest with comparable cohorts. Only studies describing proportion of complicated diverticulitis and renal transplant studies were eligible for pooling data.

RESULTS

Seventeen articles met the inclusion criteria. Nine renal transplant cohorts, four mixed lung-heart-heart lung transplant cohorts, two heart transplant cohorts, and two lung cohorts. A total of 11,966 post-transplant patients were included in the present review. Overall incidence of complicated diverticulitis in all transplantation studies ranged from 0.1 to 3.5%. Nine studies only included renal transplant patients. Pooled incidence of complicated diverticulitis in these patients was 1.0% (95% CI 0.6 to 1.5%). Ten studies provided proportion of complicated diverticulitis. Pooled incidence of acute diverticulitis in these studies was 1.7% (95% CI 1.0 to 2.7%). Pooled proportion of complicated diverticulitis among these patients was 40.1% (95% CI 32.2 to 49.7%). All studies were of moderate quality using the MINORS scoring scale.

CONCLUSION

The incidence of complicated diverticulitis is about one in 100 transplant patients. Additionally when a transplant patient develops an episode of acute diverticulitis, a high proportion of patients have a complicated disease course.

Italian consensus conference for colonic diverticulosis and diverticular disease

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

Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients

BACKGROUND

The optimal treatment for diverticulitis with extraluminal air is controversial.

OBJECTIVE

The purpose of this research was to evaluate the safety and effectiveness of nonoperative treatment of acute diverticulitis with extraluminal air.

DESIGN

This was a retrospective cohort.

SETTINGS

The study was conducted at an academic teaching hospital functioning as both a tertiary and secondary care referral center.

PATIENTS

All of the patients with CT-diagnosed acute perforated diverticulitis with extraluminal air from 2006 through 2010 were included in this study.

INTERVENTIONS

Nonoperative treatment composed of intravenous antibiotics, bowel rest, and percutaneous drainage were the included interventions.

MAIN OUTCOME MEASURES

The need for operative management and mortality were measured.

RESULTS

A total of 132 patients underwent nonoperative treatment, whereas 48 patients were primarily operated on. Patients treated nonoperatively were divided into 3 groups on the basis of identified factors that independently predicted risk for failure: 1) patients with pericolic air (n = 82) without abscess had a 99% success rate with 0% mortality. 2) Patients with distant intraperitoneal air (n = 29) had a 62% success ratewith 0% mortality. Abundant distant intraperitoneal air and fluid in the fossa Douglas were identified as risk factors for failure. Patients without these risk factors had an 86% success rate with nonoperative management. 3) Patients with distant retroperitoneal air (n = 14) had a 43% success rate with 7% mortality.

LIMITATIONS

Comparison of nonoperative versus operative treatment cannot be made because of the study's retrospective nature.

CONCLUSIONS

Nonoperative treatment of acute diverticulitis with extraluminal air is safe and effective in patients with a small amount of distant intraperitoneal air or pericolic air without clinical signs of peritonitis.

Inter-observer reliability of computed tomographic classifications of diverticulitis

AIM

The wide use of computed tomography (CT) for diverticulitis has initiated new classifications, but their reliability has not been studied. The aim of the study was to assess the inter-observer agreement of radiologists on the classifications of diverticulitis.

METHOD

A set of 100 CT examinations of patients with an episode of diverticulitis was used to assess inter-observer agreement. Cases were derived from two prospective trials and a retrospective cohort to comprise an evenly distributed case mix of patients. The reference standard was the modified Hinchey classification based on all available information. Three blinded radiologists independently read all CT examinations. We calculated the proportion of agreement and kappa values for the Hinchey and Ambrosetti classifications. For the Dharmarajan classification only inter-observer agreement was calculated.

RESULTS

The agreement with the reference standard was substantial for both the modified Hinchey and the Ambrosetti classifications (P = 0.68 and P = 0.76). Overall inter-observer agreement for the modified Hinchey classification was substantial (median kappa 0.72), for the Ambrosetti classification almost perfect (median kappa 0.83) and for the Dharmarajan classification substantial (median kappa 0.76).

CONCLUSION

The Ambrosetti classification is more reproducible than the modified Hinchey and Dharmarajan classifications. The Ambrosetti and modified Hinchey classifications have a substantial agreement with the reference standard and therefore produce a reliable classification. The Dhamarajan is applicable only in complicated diverticulitis and is an important complementary classification to the other more general classifications of diverticulitis.

Management of acute diverticulitis and its complications

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

Acute and elective laparoscopic resection for complicated sigmoid diverticulitis: clinical and histological outcome

BACKGROUND

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

METHODS

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

RESULTS

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

CONCLUSIONS

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.

Influence of age on clinical outcome of acute diverticulitis

BACKGROUND

The controversy about the treatment of acute colonic diverticulitis in young patients continues. The discussion is focused on whether younger age is a risk factor for recurrence or a complicated course, thereby subject to different treatment choices.

AIM

In this study, we investigated whether an episode of acute diverticulitis at a younger age (≤50 years) has a higher recurrence rate or a more severe outcome.

MATERIAL AND METHODS

A retrospective cohort study was conducted in four teaching hospitals using hospital registry codes for diverticulitis. All patients diagnosed with acute diverticulitis between January 2004 and January 2012, confirmed by imaging, were included.

RESULTS

A total of 1,441 consecutive patients were identified as having primary acute diverticulitis of the sigmoid colon. Four hundred and sixty-three patients (32.1%) were ≤50 years (group 1) and 978 patients (67.9%) were older than 50 years (group 2). Twenty patients (4.3%) needed emergency surgery, due to perforated diverticulitis, within 72 h at first presentation in group 1 compared to 77 patients (7.8%) in group 2 (p = 0.029). Surgery within 30 days was needed for 29 of 463 patient (6.2%) in group 1 and 104 of 978 patients (10.6%) in group 2 (p = 0.02). Recurrence rate after a median follow-up of 22 months was comparable among groups (25.6% (111 patients) in group 1 versus 23.8% (208 patients) in group 2; p = 0.278). Also, cumulative recurrence was comparable among groups.

CONCLUSION

Younger age is neither associated with a more severe presentation of diverticulitis nor with a higher incidence in recurrence.