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Abstract
BACKGROUND Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis has been regarded as an infectious disease. Risk factors for diverticulitis, however, may suggest that the condition is inflammatory rather than infectious which makes the use of antibiotics questionable. OBJECTIVES The objectives of this systematic review were to determine if antibiotic treatment of uncomplicated acute diverticulitis affects the risk of complications (immediate or late) or the need for emergency surgery. SEARCH METHODS For this update, a comprehensive systematic literature search was conducted in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform on February 2021. SELECTION CRITERIA Randomised controlled trials (RCTs), including all types of patients with a radiologically confirmed diagnosis of left-sided uncomplicated acute diverticulitis. Comparator and interventions included antibiotics compared to no antibiotics, placebo, or to any other antibiotic treatment (different regimens, routes of administration, dosage or duration of treatment). Primary outcome measures were complications and emergency surgery. Secondary outcomes were recurrence, late complications, elective colonic resections, length of hospital stay, length to recovery of symptoms, adverse events and mortality. DATA COLLECTION AND ANALYSIS Two authors performed the searches, identification and assessment of RCTs and data extraction. Disagreements were resolved by discussion or involvement of the third author. Authors of trials were contacted to obtain additional data if needed or for preliminary results of ongoing trials. The Cochrane Collaboration's tool for assessing risk of bias was used to assess the methodological quality of the identified trials. The overall quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effect estimates were extracted as risk ratios (RRs) with 95% confidence intervals. Random-effects meta-analyses were performed with the Mantel-Haenzel method. MAIN RESULTS The authors included five studies. Three studies compared no antibiotics to antibiotics; all three were original RCTs of which two also published long-term follow-up information. For the outcome of short-term complications there may be little or no difference between antibiotics and no antibiotics (RR 0.89; 95% CI 0.30 to 2.62; 3 studies, 1329 participants; low-certainty evidence). The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics (RR 0.47; 95% CI 0.13, 1.71; 1329 participants; 3 studies; low-certainty evidence). However, there is considerable imprecision due to wide confidence intervals for this effect estimate causing uncertainty which means that there may also be a benefit with antibiotics. One of the two remaining trials compared single to double compound antibiotic therapy and, due to wide confidence intervals, the estimate was imprecise and indicated an uncertain clinical effect between these two antibiotic regimens (RR 0.70; 95% CI 0.11 to 4.58; 51 participants; 1 study; low-certainty evidence). The last trial compared short to long intravenous administration of antibiotics and did not report any events for our primary outcomes. Both trials included few participants and one had overall high risk of bias. Since the first publication of this systematic review, an increasing amount of evidence supporting the treatment of uncomplicated acute diverticulitis without antibiotics has been published, but the total body of evidence is still limited. AUTHORS' CONCLUSIONS The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications. The quality of the evidence is low. Only three RCTs on the need for antibiotics are currently available. More trials are needed to obtain more precise effect estimates.
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Affiliation(s)
- Marie-Louise Dichman
- Department of Surgical Gastroenterology , Hvidovre University Hospital, Copenhagen, Denmark
| | - Steffen Jais Rosenstock
- Department of Surgical Gastroenterology , Hvidovre University Hospital , Copenhagen, Denmark
| | - Daniel M Shabanzadeh
- Department of Surgical Gastroenterology , Hvidovre University Hosipital , Copenhagen, Denmark
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2
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Current Guidelines and Controversies in the Management of Diverticulitis. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-021-00240-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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3
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Alverdy JC, Schardey HM. Anastomotic Leak: Toward an Understanding of Its Root Causes. J Gastrointest Surg 2021; 25:2966-2975. [PMID: 34100248 PMCID: PMC8815793 DOI: 10.1007/s11605-021-05048-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/18/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND When an anastomotic leak is discussed at a typical surgical morbidity and mortality conference, it is often presented as a due to an error in surgical technique involving ischemia, tension, or device failure. Here we assert that without direct visual analysis of the leak site and its tissue histology, an ex post facto claim that an anastomotic leak is due to an error in surgical technique remains speculative. METHODS The arguments and rationale used to conclude that an anastomotic leak is due to an error in surgical technique are critically reviewed and assessed for their validity. RESULTS No case series or literature exists in which a root cause analysis has been carried out with visual and tissue level evidence to determine the root cause(s) of an anastomotic leak. CONCLUSIONS At the individual case level, declaring that an anastomotic leak is due to an error in surgical technique without clear and compelling evidence either visually and/or at the tissue level to substantiate such a claim remains speculative.
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Affiliation(s)
- John C Alverdy
- Department of Surgery, University of Chicago, Pritzker School of Medicine, 5841 S. Maryland, Chicago, IL, 60637, USA,Corresponding author
| | - Hans Martin Schardey
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany and Department of General, Visceral and Vascular Surgery, Agatharied Hospital, Norbert-Kerkel-Platz, 83734, Hausham, Germany
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4
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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5
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Costi R, Annicchiarico A, Morini A, Romboli A, Zarzavadjian Le Bian A, Violi V. Acute diverticulitis: old challenge, current trends, open questions. MINERVA CHIR 2020; 75:173-192. [PMID: 32550727 DOI: 10.23736/s0026-4733.20.08314-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.
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Affiliation(s)
- Renato Costi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Unit of General Surgery, Department of Surgery, Hospital of Vaio, Fidenza, Parma, Italy.,AUSL di Parma, Parma, Italy
| | | | - Andrea Morini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Romboli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alban Zarzavadjian Le Bian
- Service of General, Digestive, Oncologic, Bariatric, and Metabolic Surgery, Avicenne Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris XIII University, Bobigny, France
| | - Vincenzo Violi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Unit of General Surgery, Department of Surgery, Hospital of Vaio, Fidenza, Parma, Italy.,AUSL di Parma, Parma, Italy
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6
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Treatment of Uncomplicated Acute Diverticulitis Without Antibiotics: A Systematic Review and Meta-analysis. Dis Colon Rectum 2019; 62:1533-1547. [PMID: 30663999 DOI: 10.1097/dcr.0000000000001330] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite low-quality and conflicting evidence, the Association of Coloproctology of Great Britain and Ireland recommends the routine use of antibiotics in the treatment of uncomplicated acute diverticulitis. Recent studies have shown that treatment without antibiotics did not prolong recovery. Some new guidelines currently recommend selective use of antibiotics. OBJECTIVE The purpose of this study was to compare the safety, effectiveness, and outcomes in treating uncomplicated acute diverticulitis without antibiotics with treatment with antibiotics. DATA SOURCES PubMed, Embase, Clinicaltrials.gov, and the Cochrane Library were searched with the key words antibiotics and diverticulitis. STUDY SELECTION All studies published in English on treating uncomplicated acute diverticulitis without antibiotics and containing >20 individuals were included. INTERVENTION Treatment without antibiotics versus treatment with antibiotics were compared. MAIN OUTCOME MEASURES The primary outcome was the percentage of patients requiring additional treatment or intervention to settle during the initial episode. The secondary outcomes were duration of hospital stay, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, and complication. RESULTS Search yielded 1164 studies. Nine studies were eligible and included in the meta-analysis, composed of 2505 patients, including 1663 treated without antibiotics and 842 treated with an antibiotic. The no-antibiotics group had a significantly shorter hospital stay (mean difference = -0.68; p = 0.04). There was no significant difference in the percentage of patients requiring additional treatment or intervention to settle during the initial episode (5.3% vs 3.6%; risk ratio = 1.48; p = 0.28), rate of readmission or deferred admission (risk ratio = 1.17; p = 0.26), need for surgical or radiological intervention (risk ratio = 0.61; p = 0.34), recurrence (risk ratio = 0.83; p = 0.21), and complications (risk ratio = 0.70-1.18; p = 0.67-0.91). LIMITATIONS Only a limited number of studies were available, and they were of variable qualities. CONCLUSIONS Treatment of uncomplicated acute diverticulitis without antibiotics is associated with a significantly shorter hospital stay. There is no significant difference in the percentage of patients requiring additional treatment or intervention to settle in the initial episode, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, or complications.
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Prospective randomized clinical trial of uncomplicated right-sided colonic diverticulitis: antibiotics versus no antibiotics. Int J Colorectal Dis 2019; 34:1413-1420. [PMID: 31267222 DOI: 10.1007/s00384-019-03343-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Antibiotics are widely used in the treatment of uncomplicated left-sided colonic diverticulitis. In Asian countries, however, right-sided colonic diverticulitis is more common than left-sided colonic diverticulitis. The aim of the present study was to evaluate the need for antibiotics in the treatment of uncomplicated right-sided colonic diverticulitis in an Asian population. METHODS Patients were randomized to two management strategies: antibiotics and no antibiotics. At 4-6 weeks after discharge, the patients in both groups underwent computed tomography or were contacted by phone to confirm the effectiveness of the treatment. The primary end point was the treatment failure rate of the initial treatment, and secondary end points were the length of hospital stay and total admission costs. RESULTS Patients were randomized to treatment with (61 patients) or without (64 patients) antibiotics. The rates of treatment failure in the antibiotics and no antibiotics groups were 1.7% and 4.6%, respectively, with no significant difference (P = 0.619). There was also no significant difference in the length of hospital stay between the groups (P = 0.983). Total admission costs were lower in the no antibiotics group than in the antibiotics group (US$1004.70 vs US$1112.40, respectively, P = 0.037). CONCLUSION Conservative management of uncomplicated right-sided colonic diverticulitis without antibiotics shows similar treatment failure rates and length of hospital stay, and is associated with lower hospital costs, compared with standard antibiotic treatment. Therefore, conservative management can be considered as a safe treatment option. TRIAL REGISTRATION ClinicalTrial.gov No. NCT02314013.
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8
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Abstract
BACKGROUND Uncomplicated colonic diverticulitis is common. There is no consensus regarding the most appropriate management. Some authors have reported the efficacy and safety of observational management, and others have argued for a more aggressive approach with oral or intravenous antibiotic treatment. OBJECTIVE The purpose of this study was to perform an updated meta-analysis of the different management strategies for uncomplicated diverticulitis with 2 separate meta-analyses. DATA SOURCES MEDLINE, Embase, and Cochrane databases were used. STUDY SELECTION All randomized clinical trials, prospective, and retrospective comparative studies were included. INTERVENTIONS Observational and antibiotics treatment or oral and intravenous antibiotics treatment were included. MAIN OUTCOME MEASURES Successful management (emergency management, recurrence, elective management) was measured. RESULTS After review of 293 identified records, 11 studies fit inclusion criteria: 7 studies compared observational management and antibiotics treatment (2321 patients), and 4 studies compared oral and intravenous antibiotics treatment (355 patients). There was no significant difference between observational management and antibiotics treatment in terms of emergency surgery (0.7% vs 1.4%; p = 0.1) and recurrence (11% vs 12%; p = 0.3). In this part, considering only randomized trials, elective surgery during the follow-up occurred more frequently in the observational group than the antibiotic group (2.5% vs 0.9%; p = 0.04). The second meta-analysis showed that failure and recurrence rates were similar between oral and intravenous antibiotics treatment (6% vs 7% (p = 0.6) and 8% vs 9% (p = 0.8)). LIMITATIONS Inclusion of nonrandomized studies, identification of high risks of bias (selection, performance, and detection bias), and presence of heterogeneity between the studies limited this work. CONCLUSIONS Observational management was not statistically different from antibiotic treatment for the primary outcome of needing to undergo surgery. However, in patients being treated by antibiotics, our studies demonstrated that oral administration was similar to intravenous administration and provided lower costs. Although it may be difficult for physicians to do, there is mounting evidence that not treating uncomplicated colonic diverticulitis with antibiotics is a viable treatment alternative.
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9
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Azhar N, Kulstad H, Pålsson B, Kurt Schultz J, Lydrup ML, Buchwald P. Acute uncomplicated diverticulitis managed without antibiotics - difficult to introduce a new treatment protocol but few complications. Scand J Gastroenterol 2019; 54:64-68. [PMID: 30650309 DOI: 10.1080/00365521.2018.1552987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Routine antibiotic treatment of acute uncomplicated diverticulitis (AUD) has been shown ineffective. In this study, the adherence to a new treatment protocol for uncomplicated diverticulitis was evaluated and the incidence of complications in patients treated with and without antibiotics was investigated. MATERIALS AND METHODS A retrospective study of in-patients diagnosed with AUD at Helsingborg Hospital, Sweden between 01 January 2013 and 06 January 2015 was performed. Antibiotics were routinely administrated until 01 May 2014. Thereafter, a new antibiotic-free treatment protocol for uncomplicated diverticulitis was introduced. All the patients were followed regarding complications for minimum one year. RESULTS A total of 50 patients were studied after the new protocol implementation and, 60% (n = 31) of the patients were treated without antibiotics. Specialists initiated antibiotic therapy significantly more often than registrars (p=.03). More patients in the antibiotic group had comorbidities (p=.03), apart from that, no significant differences in baseline characteristics were noted between treatment groups. Patients treated with antibiotics after introduction of the new protocol had significantly higher C-reactive protein than patients managed without antibiotics (median 117 mg/L vs. 70, p=.005). The hospital stay was shorter in the non-antibiotic group (three days vs. two days; p=.008). No significant differences in complications were observed. CONCLUSIONS Protocol compliance was lower than expected, indicating that implementation of new treatment regimens is challenging. This study confirms that complications are rare in AUD treated without antibiotics. However, the selection of the sickest patients to the treatment with antibiotics limits the interpretation of the results.
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Affiliation(s)
- Najia Azhar
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
| | - Hanna Kulstad
- b Department of Surgery , Helsingborg Hospital , Helsingborg , Sweden
| | - Birger Pålsson
- b Department of Surgery , Helsingborg Hospital , Helsingborg , Sweden
| | - Johannes Kurt Schultz
- c Department of Digestive Surgery , Akershus University Hospital , Lørenskog , Norway
| | - Marie-Louise Lydrup
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
| | - Pamela Buchwald
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
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10
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Abstract
Acute diverticulitis is a common condition that has been increasing in incidence in the United States. It is associated with increasing age, but the pathophysiology of acute diverticulitis is still being elucidated. It is now believed to have a significant contribution from inflammatory processes rather than being a strictly infectious process. There are still many questions to be answered regarding the optimal management of acute diverticulitis because recent studies have challenged traditional practices, such as the routine use of antibiotics, surgical technique, and dietary restrictions for prevention of recurrence.
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11
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Ceresoli M, Lo Bianco G, Gianotti L, Nespoli L. Inflammation management in acute diverticulitis: current perspectives. J Inflamm Res 2018; 11:239-246. [PMID: 29881303 PMCID: PMC5985778 DOI: 10.2147/jir.s142990] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The pathogenesis of diverticular disease and acute diverticulitis is still unclear and many different hypotheses have been formulated. Seemingly, there are several related factors such as chronic inflammation, gut microbiome, obesity and the immunogenic properties of fat tissue and diet. Inflammation plays a pivotal role in diverticular disease and acute diverticulitis. The aim of the present review is to investigate the role of inflammation in diverticular disease as well as in mild and complicated acute diverticulitis with a focus on current research and treatment perspectives.
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Affiliation(s)
- Marco Ceresoli
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giulia Lo Bianco
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luca Gianotti
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luca Nespoli
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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12
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Abstract
Diverticular disease includes diverticulosis, which are sac protrusions of the intestinal mucosa, and diverticulitis, inflammation of the diverticula. Diverticular disease is listed as one of the top 10 leading physician diagnoses for gastrointestinal disorders in outpatient clinic visits in the United States. There are several classifications of diverticular disease ranging from asymptomatic diverticulosis to diverticulitis with complications. Several theories are linked to the development of diverticula which includes the physiology of the colon itself, collagen cross-linking, and recently challenged, low-fiber intake. The differential diagnoses of lower abdominal pain in addition to diverticular disease have overlapping signs and symptoms, which can make a diagnosis challenging. Identification of the distinct signs and symptoms of each classification will assist the practitioner in making the correct diagnosis and lead to appropriate management. The findings from recent studies have changed the paradigm of diverticular disease. The purpose of this article is to discuss traditional dogma and evolving concepts in the pathophysiology, prevention, and management of diverticular disease. Practitioners must be knowledgeable about diverticular disease for improved outcomes.
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13
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Abstract
The management of perforated diverticulitis is a challenging aspect of general surgery. The prevalence of colonic diverticular disease has increased over the last decade and will continue to increase as the baby boomers add to the elderly population. Improvements in diagnostic imaging modalities, efforts to maintain intestinal continuity, and percutaneous drainage procedures now result in several alternatives when selecting a management strategy for complicated presentations. Specifically, laparoscopic lavage and resection with primary anastomosis have emerged as options for treatment of Hinchey III and IV diverticulitis in place of diversion in the appropriately selected patient. Percutaneous drainage of Hinchey II diverticulitis in centers equipped with interventional radiology provides another minimally invasive adjunct. The objective of this paper is to provide an update on the current management of perforated diverticulitis, with a focus on the advantages and disadvantages of the surgical options for the treatment of Hinchey III and IV diverticulitis.
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Affiliation(s)
- Evon Zoog
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - W. Heath Giles
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Robert A. Maxwell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
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14
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Boermeester MA, Humes DJ, Velmahos GC, Søreide K. Contemporary Review of Risk-Stratified Management in Acute Uncomplicated and Complicated Diverticulitis. World J Surg 2017; 40:2537-45. [PMID: 27206400 DOI: 10.1007/s00268-016-3560-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute colonic diverticulitis is a common clinical condition. Severity of the disease is based on clinical, laboratory, and radiological investigations and dictates the need for medical or surgical intervention. Recent clinical trials have improved the understanding of the natural history of the disease resulting in new approaches to and better evidence for the management of acute diverticulitis. METHODS We searched the Cochrane Library (years 2004-2015), MEDLINE (years 2004-2015), and EMBASE (years 2004-2015) databases. We used the search terms "diverticulitis, colonic" or "acute diverticulitis" or "divertic*" in combination with the terms "management," "antibiotics," "non-operative," or "surgery." Registers for clinical trials (such as the WHO registry and the https://clinicaltrials.gov/ ) were searched for ongoing, recruiting, or closed trials not yet published. RESULTS Antibiotic treatment can be avoided in simple, non-complicated diverticulitis and outpatient management is safe. The management of complicated disease, ranging from a localized abscess to perforation with diffuse peritonitis, has changed towards either percutaneous or minimally invasive approaches in selected cases. The role of laparoscopic lavage without resection in perforated non-fecal diverticulitis is still debated; however, recent evidence from two randomised controlled trials has found a higher re-intervention in this group of patients. CONCLUSIONS A shift in management has occurred towards conservative management in acute uncomplicated disease. Those with uncomplicated acute diverticulitis may be treated without antibiotics. For complicated diverticulitis with purulent peritonitis, the use of peritoneal lavage appears to be non-superior to resection.
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Affiliation(s)
| | - David J Humes
- Division of Epidemiology and Public Health, School of Community Health Sciences, City Hospital, University of Nottingham, Clinical Sciences Building 2, Nottingham, UK. .,Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - George C Velmahos
- Division of Trauma Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P. O. Box 8100, 4068, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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15
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Methodological overview of systematic reviews to establish the evidence base for emergency general surgery. Br J Surg 2017; 104:513-524. [PMID: 28295254 PMCID: PMC5363346 DOI: 10.1002/bjs.10476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/23/2016] [Accepted: 11/30/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions. METHODS Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist. RESULTS The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias. CONCLUSION This overview of reviews highlights the need for more and better research in this field.
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16
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Wintenberger C, Guery B, Bonnet E, Castan B, Cohen R, Diamantis S, Lesprit P, Maulin L, Péan Y, Peju E, Piroth L, Stahl JP, Strady C, Varon E, Vuotto F, Gauzit R. Proposal for shorter antibiotic therapies. Med Mal Infect 2017; 47:92-141. [PMID: 28279491 DOI: 10.1016/j.medmal.2017.01.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 01/30/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Reducing antibiotic consumption has now become a major public health priority. Reducing treatment duration is one of the means to achieve this objective. Guidelines on the therapeutic management of the most frequent infections recommend ranges of treatment duration in the ratio of one to two. The Recommendation Group of the French Infectious Diseases Society (SPILF) was asked to collect literature data to then recommend the shortest treatment durations possible for various infections. METHODS Analysis of the literature focused on guidelines published in French and English, supported by a systematic search on PubMed. Articles dating from one year before the guidelines publication to August 31, 2015 were searched on the website. RESULTS The shortest treatment durations based on the relevant clinical data were suggested for upper and lower respiratory tract infections, central venous catheter-related and uncomplicated primary bacteremia, infective endocarditis, bacterial meningitis, intra-abdominal, urinary tract, upper reproductive tract, bone and joint, skin and soft tissue infections, and febrile neutropenia. Details of analyzed articles were shown in tables. CONCLUSION This work stresses the need for new well-conducted studies evaluating treatment durations for some common infections. Following the above-mentioned work focusing on existing literature data, the Recommendation Group of the SPILF suggests specific study proposals.
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Affiliation(s)
- C Wintenberger
- Département de médecine interne, CHU de Grenoble Alpes, 38043 Grenoble, France
| | - B Guery
- Service de maladies infectieuses, CHU vaudois et université de Lausanne, Lausanne, Switzerland
| | - E Bonnet
- Équipe mobile d'infectiologie, hôpital Joseph-Ducuing, 15, rue Varsovie, 31300 Toulouse, France
| | - B Castan
- Unité fonctionnelle d'infectiologie régionale, hôpital Eugenie, boulevard Rossini, 20000 Ajaccio, France
| | - R Cohen
- IMRB-GRC GEMINI, unité Court Séjour, université Paris Est, Petits Nourrissons, centre hospitalier intercommunal de Créteil, ACTIV France, 40, avenue de Verdun, 94000 Créteil, France
| | - S Diamantis
- Service de maladies infectieuses et tropicales, centre hospitalier de Melun, 2, rue Fréteau-de-Peny, 77011 Melun cedex, France
| | - P Lesprit
- Infectiologie transversale, hôpital Foch, 40, rue Worth, 92151 Suresnes, France
| | - L Maulin
- Centre hospitalier du Pays-d'Aix, avenue de Tamaris, 13616 Aix-en-Provence, France
| | - Y Péan
- Observatoire national de l'épidémiologie de la résistance bactérienne aux antibiotiques (ONERBA), 10, rue de la Bonne-Aventure, 78000 Versailles, France
| | - E Peju
- Département d'infectiologie, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon cedex, France
| | - L Piroth
- Département d'infectiologie, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon cedex, France
| | - J P Stahl
- Infectiologie, université, CHU de Grenoble Alpes, 38043 Grenoble, France
| | - C Strady
- Cabinet d'infectiologie, clinique Saint-André, groupe Courlancy, 5, boulevard de la Paix, 51100 Reims, France
| | - E Varon
- Laboratoire de microbiologie, hôpital européen Georges-Pompidou, 75908 Paris cedex 15, France
| | - F Vuotto
- Service de maladies infectieuses, CHU vaudois et université de Lausanne, Lausanne, Switzerland
| | - R Gauzit
- Réanimation et infectiologie transversale, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
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Søreide K, Boermeester MA, Humes DJ, Velmahos GC. Acute colonic diverticulitis: modern understanding of pathomechanisms, risk factors, disease burden and severity. Scand J Gastroenterol 2016; 51:1416-1422. [PMID: 27539786 DOI: 10.1080/00365521.2016.1218536] [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] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Conservative, non-antibiotic and non-surgical management of acute diverticulitis is currently being investigated. To better inform clinical decisions, better understanding of disease mechanisms, disease burden and severity is needed. METHODS Literature search of risk factors, pathophysiology, epidemiology and disease burden/severity reported over the last decade. RESULTS Acute diverticulitis is a common disease and has a high disease burden. Incidence of hospital admissions is reported around 71 per 100,000 population, with reported increase in several subpopulations over the last decades. The incidence is likely to increase further with the aging populations. Risk factors for left-sided acute diverticulitis include dietary, anthropometric and lifestyle factors. Disease mechanisms are still poorly understood, but a distinction between inflammation and infection is emerging. The integrative and complex role of the gut microbiota has become an interesting factor for both understanding the disease as well as a potential target for intervention using probiotics. Mild, self-limiting events are increasingly reported from studies of successful non-antibiotic management in a considerable number of cases. Risk markers of progression to or presence of severe, complicated disease are needed for better disease stratification. Current risk stratification by clinical, imaging or endoscopic means is imperfect and needs validation. Long-term results from minimal-invasive and comparative surgical trials may better help inform clinicians and patients. CONCLUSIONS Over- and under-treatment as well as over- and under-diagnosis of severity is likely to continue in clinical practice due to lack of reliable, robust and universal severity and classification systems. Better understanding of pathophysiology is needed.
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Affiliation(s)
- Kjetil Søreide
- a Department of Gastrointestinal Surgery , Stavanger University Hospital , Stavanger , Norway.,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Marja A Boermeester
- c Department of Surgery , Academic Medical Center , Amsterdam , the Netherlands
| | - David J Humes
- d Division of Epidemiology and Public Health , School of Community Health Sciences, University of Nottingham , Nottingham , UK
| | - George C Velmahos
- e Division of Trauma Emergency Surgery and Surgical Critical Care , Massachusetts General Hospital , Boston , MA , USA.,f Harvard Medical School , Boston , MA , USA
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Brochmann ND, Schultz JK, Jakobsen GS, Øresland T. Management of acute uncomplicated diverticulitis without antibiotics: a single-centre cohort study. Colorectal Dis 2016; 18:1101-1107. [PMID: 27089051 DOI: 10.1111/codi.13355] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/18/2016] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to evaluate the implementation of nonantibiotic management of acute uncomplicated diverticulitis at a large university hospital in Norway with regard to management failure, disease recurrence and complications. METHOD On 1 January 2013 we implemented a new policy for the management of acute uncomplicated diverticulitis without antibiotics. Antibiotic treatment was only provided in the case of defined criteria. All patients admitted from 1 January 2013 to 30 June 2014 with a CT-verified, left-sided, acute uncomplicated diverticulitis were included in the study and evaluated retrospectively, with 12 months' follow-up. RESULTS Of 244 admissions with acute uncomplicated diverticulitis, 177 (73%) were managed without antibiotics. Among these there were seven (4%) management failures, including five patients in whom a deteriorating clinical picture prompted antibiotic treatment and two readmissions within 1 month due to persisting symptoms. The only complication in this group was one fistula (< 1%). Eight (5%) patients had a recurrence of acute diverticulitis requiring hospital care and two (1%) underwent elective surgery within the first year. Twenty (8%) patients met predefined exemption criteria and received antibiotics from admission, six (30%) of whom developed complications. The recurrence rate in this group was 10% and none had surgery performed. The 47 (20%) policy violators treated with antibiotics from admission had no complications. Their recurrence rate was 11% and one (2%) patient underwent elective surgery. CONCLUSION This study confirms that nonantibiotic management of acute uncomplicated diverticulitis is safe and feasible. Most complications occurred in a small group of high-risk patients treated with antibiotics.
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Affiliation(s)
- N D Brochmann
- Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - J K Schultz
- Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway. .,Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway.
| | - G S Jakobsen
- Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - T Øresland
- Clinic of Surgical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
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Abstract
Throughout the last century, the incidence of diverticular disease of the colon has increased tremendously in industrialized countries; nevertheless, the management of this condition is still controversial. Although several international guidelines for the management of diverticular disease are based on the same evidence, the recommendations differ greatly, emphasizing the lack of high-quality prospective studies. In Scandinavia, official guidelines for the management of diverticular disease exist only in Denmark. However, the treatment policies are quite similar in all Scandinavian countries. Computed tomography is the first choice for imaging of acute diverticulitis and its complications. Furthermore, the use of antibiotics in uncomplicated diverticulitis is nearly abandoned in Scandinavia, whereas several international guidelines still recommend their use. There is a broad consensus that abscesses secondary to acute diverticulitis can safely be managed with percutaneous drainage, which is in line with international recommendations. The surgical management of perforated diverticulitis with peritonitis is still as controversial in Scandinavia as elsewhere. Common surgical options are laparoscopic peritoneal lavage, primary resection with anastomosis, and primary resection with terminal colostomy (Hartmann's procedure). Elective sigmoid resection in patients with diverticular disease seems to be performed less frequently in Scandinavia than in other European countries; the right indications are a current matter of debate. Symptomatic uncomplicated diverticular disease in the absence of diverticulitis has not gained great attention in Scandinavia.
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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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Kruse E, Leifeld L. Prevention and Conservative Therapy of Diverticular Disease. VISZERALMEDIZIN 2016; 31:103-6. [PMID: 26989379 PMCID: PMC4789966 DOI: 10.1159/000377651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Diverticular disease is a common problem. Prevention and treatment of complications depend on the stage of the disease. Lifestyle modifications are suitable preventive measures, aiming to reduce obesity and to balance the diet with a high amount of fiber and a low amount of meat. However, evidence to guide the pharmacological treatment of diverticular disease and diverticulitis is limited. METHODS Literature review. RESULTS Antibiotics are not proven to be effective in patients with uncomplicated diverticulitis and without further risk factors; neither do they improve treatment nor prevent complications. Mesalazine might have an effect on pain relief in diverticular disease even though it has no significant effect on the outcome of diverticulitis. In complicated diverticulitis, inpatient treatment including antibiotics is mandatory. CONCLUSION Evidence for the treatment of diverticular disease is limited. Further research is needed.
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Affiliation(s)
- Elena Kruse
- Department of Internal Medicine III, St. Bernward Hospital, Hildesheim, Germany
| | - Ludger Leifeld
- Department of Internal Medicine III, St. Bernward Hospital, Hildesheim, Germany
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Nespoli L, Lo Bianco G, Uggeri F, Romano F, Nespoli A, Bernasconi DP, Gianotti L. Effect of oral mesalamine on inflammatory response in acute uncomplicated diverticulitis. World J Gastroenterol 2015; 21:8366-8372. [PMID: 26217088 PMCID: PMC4507106 DOI: 10.3748/wjg.v21.i27.8366] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/24/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis.
METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay.
RESULTS: Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03).
CONCLUSION: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.
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Bugiantella W, Rondelli F, Longaroni M, Mariani E, Sanguinetti A, Avenia N. Left colon acute diverticulitis: an update on diagnosis, treatment and prevention. Int J Surg 2014; 13:157-164. [PMID: 25497007 DOI: 10.1016/j.ijsu.2014.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Diverticulosis of the colon is a common disease with an increasing incidence in Western Countries. It represents a significant burden for National Health Systems in terms of costs. Most people with diverticulosis remain asymptomatic, about one quarter of them will develop an episode of symptomatic diverticular disease and up to 5% an episode of acute diverticulitis (AD). AD shows an increasing prevalence. Recently, progresses have been reached about the etiology, pathogenesis, natural course of diverticular disease and its complications; improvements about the diagnosis and treatment of AD have been achieved. However, the treatment options are not well defined because of a lack of solid evidence: there are few systematic reviews and well conducted trials to guide decision-making in the treatment of AD and in the prevention of its recurrences. This review describes the recent evidence about diagnosis, treatment and prevention of AD.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100 Perugia, Italy.
| | - Maurizio Longaroni
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Enrico Mariani
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
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Vennix S, Morton DG, Hahnloser D, Lange JF, Bemelman WA. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis 2014; 16:866-78. [PMID: 24801825 DOI: 10.1111/codi.12659] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/07/2014] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- S Vennix
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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26
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Daniels L, Budding AE, de Korte N, Eck A, Bogaards JA, Stockmann HB, Consten EC, Savelkoul PH, Boermeester MA. Fecal microbiome analysis as a diagnostic test for diverticulitis. Eur J Clin Microbiol Infect Dis 2014; 33:1927-36. [PMID: 24894339 DOI: 10.1007/s10096-014-2162-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 05/12/2014] [Indexed: 12/18/2022]
Abstract
Disease-specific variations in intestinal microbiome composition have been found for a number of intestinal disorders, but little is known about diverticulitis. The purpose of this study was to compare the fecal microbiota of diverticulitis patients with control subjects from a general gastroenterological practice and to investigate the feasibility of predictive diagnostics based on complex microbiota data. Thirty-one patients with computed tomography (CT)-proven left-sided uncomplicated acute diverticulitis were included and compared with 25 control subjects evaluated for a range of gastrointestinal indications. A high-throughput polymerase chain reaction (PCR)-based profiling technique (IS-pro) was performed on DNA isolates from baseline fecal samples. Differences in bacterial phylum abundance and diversity (Shannon index) of the resulting profiles were assessed by conventional statistics. Dissimilarity in microbiome composition was analyzed with principal coordinate analysis (PCoA) based on cosine distance measures. To develop a prediction model for the diagnosis of diverticulitis, we used cross-validated partial least squares discriminant analysis (PLS-DA). Firmicutes/Bacteroidetes ratios and Proteobacteria load were comparable among patients and controls (p = 0.20). The Shannon index indicated a higher diversity in diverticulitis for Proteobacteria (p < 0.00002) and all phyla combined (p = 0.002). PCoA based on Proteobacteria profiles resulted in visually separate clusters of patients and controls. The diagnostic accuracy of the cross-validated PLS-DA regression model was 84 %. The most discriminative species derived largely from the family Enterobacteriaceae. Diverticulitis patients have a higher diversity of fecal microbiota than controls from a mixed population, with the phylum Proteobacteria defining the difference. The analysis of intestinal microbiota offers a novel way to diagnose diverticulitis.
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Affiliation(s)
- L Daniels
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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27
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Kruse E, Leifeld L. [Prevention and conservative therapy of diverticular disease]. Chirurg 2014; 85:299-303. [PMID: 24610006 DOI: 10.1007/s00104-013-2619-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Diverticulosis and diverticular disease are a common problem in daily practice and one third of the patients with diverticulosis develop symptoms. Patients with uncomplicated diverticulitis are very often treated with antibiotics. There is growing evidence that antibiotics are not necessary in uncomplicated cases. One problem is the different classification of diverticulitis and diverticular disease. Therefore, it is not easy to compare different studies. The evidence for therapy with antibiotics, mesalamine, probiotics and fibers are initially discussed and secondly therapeutic recommendations are given for the various stages of diverticular disease.
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Affiliation(s)
- E Kruse
- Medizinische Klinik III, St. Bernward Krankenhaus Hildesheim, Treibestr. 9, 31134, Hildesheim, Deutschland,
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Smolarz CM, Hohertz B, Seupaul RA. Are Antibiotics Required for the Treatment of Uncomplicated Diverticulitis? Ann Emerg Med 2014; 63:52-3. [DOI: 10.1016/j.annemergmed.2013.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 07/31/2013] [Accepted: 08/01/2013] [Indexed: 11/17/2022]
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30
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Lanas A, Ponce J, Bignamini A, Mearin F. One year intermittent rifaximin plus fibre supplementation vs. fibre supplementation alone to prevent diverticulitis recurrence: a proof-of-concept study. Dig Liver Dis 2013; 45:104-9. [PMID: 23092785 DOI: 10.1016/j.dld.2012.09.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/07/2012] [Accepted: 09/19/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evidence supporting appropriate medical therapy to prevent recurrence of colonic diverticulitis is limited. Our goal was to evaluate the potential of rifaximin given periodically in addition to fibre for the prophylaxis of recurrences. METHODS We conducted a multicentre, randomized, open controlled study in patients with a recent episode of colonic diverticulitis, currently in remission. Patients received 3.5 g of high-fibre supplementation b.d. with or without one week per month of the non-absorbable antibiotic rifaximin (400 mg b.d.) for 12months. Primary endpoint was recurrence of diverticulitis, encompassing acute symptomatic flare with or without complications, analyzed by multivariable logistic regression analysis and by Cox proportional hazard method. RESULTS After randomizing 165 patients, the study was interrupted since the recruitment rate was largely below the minimum anticipated, and the trial was switched from evidence-gathering to proof-of-concept. Recurrences occurred in 10.4% of patients given rifaximin plus fibres vs. 19.3% of patients receiving fibres alone. The logistic analysis adjusted for sex, age, illness duration, time from last episode, disease localization and centre recruitment rate, yielded a significant treatment effect (odds ratio 3.20; 95% confidence interval: 1.16-8.82; P=0.025). Patients with diverticulitis diagnosed since ≥1 year receiving rifaximin also had a lower incidence of recurrences (10%; 95% confidence interval: 2-47% vs. 67%; 95% confidence interval: 37-100%). Both treatments were safe. CONCLUSIONS This study represents a proof-of concept of the efficacy of cyclic rifaximin treatment, added to fibre supplements, to reduce the risk of recurrences of diverticulitis in patients in remission.
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Affiliation(s)
- Angel Lanas
- Service of Digestive Diseases, University Hospital Lozano Blesa, IIS Aragón, CIBERehd, University of Zaragoza, Spain.
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31
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Sartelli M, Viale P, Catena F, Ansaloni L, Moore E, Malangoni M, Moore FA, Velmahos G, Coimbra R, Ivatury R, Peitzman A, Koike K, Leppaniemi A, Biffl W, Burlew CC, Balogh ZJ, Boffard K, Bendinelli C, Gupta S, Kluger Y, Agresta F, Di Saverio S, Wani I, Escalona A, Ordonez C, Fraga GP, Junior GAP, Bala M, Cui Y, Marwah S, Sakakushev B, Kong V, Naidoo N, Ahmed A, Abbas A, Guercioni G, Vettoretto N, Díaz-Nieto R, Gerych I, Tranà C, Faro MP, Yuan KC, Kok KYY, Mefire AC, Lee JG, Hong SK, Ghnnam W, Siribumrungwong B, Sato N, Murata K, Irahara T, Coccolini F, Lohse HAS, Verni A, Shoko T. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 2013; 8:3. [PMID: 23294512 PMCID: PMC3545734 DOI: 10.1186/1749-7922-8-3] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/02/2013] [Indexed: 12/11/2022] Open
Abstract
Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.
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Affiliation(s)
| | - Pierluigi Viale
- Clinic of Infectious Diseases, Department of Internal Medicine Geriatrics and Nephrologic Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- Emergency Surgery, Maggiore Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- Department of General Surgery, Ospedali Riuniti, Bergamo, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | | | - George Velmahos
- Harvard Medical School, Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital, Boston, MA, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Andrew Peitzman
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kaoru Koike
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University Hospital Meilahti, Helsinki, Finland
| | - Walter Biffl
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | - Zsolt J Balogh
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Ken Boffard
- Department of Surgery, Charlotte Maxeke Johannesburg Hospital University of the Witwatersrand, Johannesburg, South Africa
| | - Cino Bendinelli
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Sanjay Gupta
- Department of Surgery, Govt Medical College and Hospital, Chandigarh, India
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Imtiaz Wani
- Department of Digestive Surgery Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Escalona
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Carlos Ordonez
- Department of Surgery, Universidad del Valle, Fundacion Valle del Lili, Cali, Colombia
| | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinicas - University of Campinas, Campinas, Brazil
| | | | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital /UMBAL/ St George Plovdiv, Plovdiv, Bulgaria
| | - Victor Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Noel Naidoo
- Department of Surgery, Port Shepstone Hospital, Kwazulu Natal, South Africa
| | - Adamu Ahmed
- Department of Surgery, Ahmadu Bello University Teaching Hospital Zaria, Kaduna, Nigeria
| | - Ashraf Abbas
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | | | | | - Rafael Díaz-Nieto
- Department of General and Digestive Surgery, University Hospital, Malaga, Spain
| | - Ihor Gerych
- Department of General Surgery, Lviv Emergency Hospital, Lviv, Ukraine
| | | | - Mario Paulo Faro
- Division of General and Emergency Surgery, Faculdade de Medicina da Fundação do ABC, São Paulo, Santo André, Brazil
| | - Kuo-Ching Yuan
- Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | | | - Jae Gil Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Ulsan, Seoul, Republic of Korea
| | - Wagih Ghnnam
- Wagih Ghnnam, Department of Surgery, Khamis Mushayt General Hospital, Khamis Mushayt, Saudi Arabia
| | - Boonying Siribumrungwong
- Boonying Siribumrungwong, Department of Surgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Norio Sato
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kiyoshi Murata
- Department of Acute and Critical Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Emergency and Critical Care Center of Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Alfredo Verni
- Department of Surgery, Cutral Co Clinic, Neuquen, Argentina
| | - Tomohisa Shoko
- The Shock Trauma and Emergency Medical Center, Matsudo City Hospital, Chiba, Japan
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Abstract
PURPOSE OF REVIEW The field of colorectal surgery continues to move forward as technical innovations emerge and as surgeons ask critical questions. The results of subsequent investigations often lead to changes in practice. This review examines recent publications that describe these practice changes. RECENT FINDINGS We identified and reviewed recent publications in the areas of rectal cancer controversies, genetic risk profiling, practice improvements, diverticulitis, enhanced recovery protocols, fecal incontinence, and single incision laparoscopic surgery. SUMMARY New technologies and practice innovations will continue to enhance patient outcomes. Multiinstitutional studies, randomized when able, are necessary to further define the safety and efficacy of new surgical techniques and to further define best practices in colorectal surgery.
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Fingerhut A, Veyrie N. Complicated diverticular disease: the changing paradigm for treatment. Rev Col Bras Cir 2012; 39:322-7. [PMID: 22936232 DOI: 10.1590/s0100-69912012000400013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/18/2012] [Indexed: 11/22/2022] Open
Abstract
The term "complicated" diverticulitis is reserved for inflamed diverticular disease complicated by bleeding, abscess, peritonitis, fistula or bowel obstruction. Hemorrhage is best treated by angioembolization (interventional radiology). Treatment of infected diverticulitis has evolved enormously thanks to: 1) laparoscopic colonic resection followed or not (Hartmann's procedure) by restoration of intestinal continuity, 2) simple laparoscopic lavage (for peritonitis +/- resection). Diverticulitis (inflammation) may be treated with antibiotics alone, anti-inflammatory drugs, combined with bed rest and hygienic measures. Diverticular abscesses (Hinchey Grades I, II) may be initially treated by antibiotics alone and/or percutaneous drainage, depending on the size of the abscess. Generalized purulent peritonitis (Hinchey III) may be treated by the classic Hartmann procedure, or exteriorization of the perforation as a stoma, primary resection with or without anastomosis, with or without diversion, and last, simple laparoscopic lavage, usually even without drainage. Feculent peritonitis (Hinchey IV), a traditional indication for Hartmann's procedure, may also benefit from primary resection followed by anastomosis, with or without diversion, and even laparoscopic lavage. Acute obstruction (nearby inflammation, or adhesions, pseudotumoral formation, chronic strictures) and fistula are most often treated by resection, ideally laparoscopic. Minimal invasive therapeutic algorithms that, combined with less strict indications for radical surgery before a definite recurrence pattern is established, has definitely lead to fewer resections and/or stomas, reducing their attendant morbidity and mortality, improved post-interventional quality of life, and less costly therapeutic policies.
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Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99:532-9. [PMID: 22290281 DOI: 10.1002/bjs.8688] [Citation(s) in RCA: 304] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up. METHODS This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics. RESULTS Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881). CONCLUSION Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.
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Affiliation(s)
- A Chabok
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research Uppsala University, Västmanlands Hospital, Västerås, Sweden
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Helwig U. Möglichkeiten und Grenzen der ambulanten Therapie der Divertikelkrankheit. VISZERALMEDIZIN 2012. [DOI: 10.1159/000339393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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The evolving diagnosis and treatment of uncomplicated diverticulitis (from the perspective of emergency physicians). Dis Colon Rectum 2012; 55:e4; author reply e4. [PMID: 22156881 DOI: 10.1097/dcr.0b013e3182386edf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Gonzales ER, Alavi K. Evaluation and Treatment of Uncomplicated Diverticular Disease. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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