Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients

Incidence of diverticulitis recurrence after sigmoid colectomy: a retrospective cohort study from a tertiary center and systematic review

INTRODUCTION

Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease.

METHODS

Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021).

RESULTS

One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years.

CONCLUSION

The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.

Endoscopic management of colovesical and colovaginal fistulas with over-the-scope clips: A single-institution case series

AIM

Conventional surgical management of colovesical and colovaginal fistulas can be morbid and is contraindicated in many patients. Our aim in this work is to evaluate our experience in the management of colovesical and colovaginal fistulas with endoscopic over-the-scope (OTS) clips.

METHOD

A retrospective review of all patients who underwent attempted endoscopic OTS clip management of colovesical and colovaginal fistulas between 2013 and 2020 was performed. Preoperative risk factors, operative details and postoperative outcomes are reported.

RESULTS

Ten patients were identified. Fistula types were: colovesical (five), rectovesical (two), colovaginal (two) and rectovaginal (one). The aetiology of the fistula was diverticular disease in seven (70%) cases and surgical complication of pelvic surgery in three (30%). The mean defect age was 157 ± 98 days, the mean defect diameter was 4.5 mm (range 2-10 mm) and the mean fistula length was 15 mm (range 2-25 mm). In nine (90%) cases, fistula identification and cannulation were performed through the nonenteric lumen of the fistula. Initial management with an OTS clip was technically successful in eight (80%) patients. Of the eight patients who underwent OTS clip placement, long-term success (mean follow-up 218 days, range 25-673 days) was achieved after initial intervention in four (50%) patients. One patient underwent serial OTS clip procedures and achieved long-term success after four interventions; three patients have not undergone a repeat procedure after initial failure.

CONCLUSION

Endoscopic management of colovesical and colovaginal fistulas with OTS clips offers a promising therapeutic option for patients with contraindications to conventional surgical management. Immediate technical success and long-term success rates are similar to other gastrointestinal tract applications of OTS clips.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Can We Predict Surgically Complex Diverticulitis in Elective Cases?

BACKGROUND

Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis.

OBJECTIVE

The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population.

DESIGN

This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database.

SETTINGS

Individuals diagnosed with diverticulitis who underwent elective surgery were included.

PATIENTS

A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis.

INTERVENTIONS

We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model.

MAIN OUTCOME MEASURES

The predictive factors of persistent complex diverticulitis for elective colon resection were measured.

RESULTS

The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490).

LIMITATIONS

The study was limited by its retrospective review and observational bias.

CONCLUSIONS

Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ¿PODEMOS PREDECIR DIVERTICULITIS QUIRÚRGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, según la presentación del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fístula o estenosis, en el momento de la cirugía electiva, y caracterizar los resultados en esta población de pacientes.Esta fue una revisión retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugía electiva.1502 pacientes fueron sometidos a cirugía electiva por diverticulitis, de los cuales 559 (37%) pacientes tenían una indicación quirúrgica de diverticulitis compleja persistente.Realizamos un análisis de regresión logística para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de predicción.Se midieron los factores predictivos de diverticulitis compleja persistente para la resección de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p <0,001), tenían un peor estado funcional (p <0,001), más comorbilidades (diabetes e hipertensión) y un índice de comorbilidad de Charlson más alto (2,7 frente a 1,6, p <0,001). Tenían más probabilidades de tener antecedentes de consumo de tabaco o alcohol (p <0.001) y estar desnutridos. Curiosamente, los pacientes con diverticulitis compleja persistente no tuvieron más episodios que los pacientes sin complicaciones (p = 0,67). El tiempo quirúrgico fue más largo en la diverticulitis compleja y era más probable que requirieran estomas para desvio y resecciones concurrentes de estructuras adyacentes. El área bajo la curva de prueba fue (0.75, intervalo de confianza del 95% 0.72-0.78), la sensibilidad y la especificidad fueron 0.890 (intervalo de confianza del 95%; 0.870-0.891) y 0.450 (intervalo de confianza del 95%; 0.410-0.490), respectivamente.El estudio estuvo limitado por su revisión retrospectiva y sesgo observacional.Los pacientes sometidos a cirugía electiva por diverticulitis compleja no tuvieron más episodios. En cambio, la diverticulitis compleja puede ser un reflejo de un paciente complicado, lo que sugiere que los pacientes complicados deben tener un algoritmo de atención diferente al momento de su presentación inicial con diverticulitis para prevenir el desarrollo de una enfermedad compleja. Consulte Video Resumen en http://links.lww.com/DCR/B183. (Traducción-Dr. Yesenia Rojas-Kahlil).

The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: A systematic review and meta-analysis

BACKGROUND

Nowadays sigmoidectomy is recommended as "gold standard" treatment for generalized purulent or faecal peritonitis from sigmoid perforated diverticulitis. This systematic review and meta-analysis aimed to assess effectiveness and safety of laparoscopic access versus open sigmoidectomy in acute setting.

METHODS

A systematic literature search was performed for randomized controlled trials (RCTs) and non-RCTs published in PubMed, SCOPUS and Web of Science.

RESULTS

The search yielded four non-RCTs encompassing 436 patients undergoing either laparoscopic (181 patients, 41.51%) versus open sigmoid resection (255 patients, 58.49%). All studies reported ASA scores, but only four studies reported other severity scoring systems (Mannheim Peritonitis Index, P-POSSUM). Level of surgical expertise was reported in only one study. Laparoscopy improves slightly the rates of overall post-operative complications and post-operative hospital stay, respectively (RR 0.62, 95% CI 0.49 to 0.80 and MD -6.53, 95% CI -16.05 to 2.99). Laparoscopy did not seem to improve the other clinical outcomes: rate of Hartmann's vs anastomosis, operating time, reoperation rate and postoperative 30-day mortality.

CONCLUSION

In this review four prospective studies were included, over 20 + year period, including overall 400 + patients. This meta-analysis revealed significant advantages associated with a laparoscopic over open approach to emergency sigmoidectomy in acute diverticulitis in terms of postoperative complication rates, although no differences were found in other outcomes. The lack of hemodynamic data and reasons for operative approach hamper interpretation of the data suggesting that patients undergoing open surgery were sicker and these results must be considered with extreme caution and this hypothesis requires confirmation by future prospective randomised controlled trials.

Robotic versus laparoscopic elective colectomy for left side diverticulitis: a propensity score-matched analysis of the NSQIP database

PURPOSE

Robotic surgery might have an advantage over conventional laparoscopy for colonic diverticulitis. We intend to compare both approaches in the elective management of left side diverticulitis.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database (2012-2014) was surveyed for patients undergoing elective left/sigmoid colectomy for diverticulitis. Patient demographics, co-morbidities, disease complexity, and intraoperative details were matched on propensity scores derived from logistic regression model.

RESULTS

We identified 441 robotic and 6584 laparoscopic cases. Mean age was 56.8 years. Mean BMI was 29.5, and 46.5% of patients were males. Low preoperative albumin (< 3.5 mg/dl, 11.1% vs. 6.8%, p = 0.003), splenectomy (0.45% vs. 0.05%, p = 0.002), and enterotomy repair (1.1% vs. 0.4%, p = 0.029) were higher in the robotic group than the laparoscopic group. Hand assistance (35.8% vs. 42.9%, p = 0.003), splenic flexure takedown (41.5% vs. 49.2%, p = 0.002), and ureteric stent placement (18.6% vs. 23.5%, p = 0.017) were less common in the robotic group than the laparoscopic group. Case-matched analysis showed that robotic surgery was associated with shorter hospital stay (3.89 ± 2.18 days vs. 4.75 ± 3.25 days, p < 0.001), lower conversion rate (7.5% vs. 14.3%, p = 0.001), and longer operative time (219.2 ± 95.6 min vs. 188.8 ± 82.3 min, p < 0.001) than laparoscopic surgery. Robotic approach was associated with lower overall morbidity in multivariate analysis (OR = 0.72, 95% CI = 0.55-0.96), but not in case-matched analysis (14.4% vs. 19.2%, p = 0.058).

CONCLUSIONS

Robotic surgery is associated with shorter hospital stay and lower conversion rate and may offer lower overall morbidity than laparoscopy after elective left side colectomy for diverticulitis. Controlled prospective studies are needed to confirm these findings.

Incidence, associated risk factors, and impact of conversion to laparotomy in elective minimally invasive sigmoidectomy for diverticular disease

BACKGROUND

Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes.

METHODS

The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases.

RESULTS

The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases.

CONCLUSIONS

Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.

Peripheral vs pedicle division in laparoscopic resection of sigmoid diverticulitis: a 10-year experience

PURPOSE

Laparoscopic rectosigmoid resection is the standard surgical treatment for recurrent sigmoid diverticulitis. However, speaking of mesenterium division, no unique standard procedure is actually provided. Surgeons can perform it at the level of either the sigmoid vessels or the inferior mesenteric vessels. The objective of this study was to compare intra- and postoperative complications of both techniques.

METHODS

From a prospective collected database of patients that underwent elective laparoscopic sigmoid resection between January 2004 and December 2014, a retrospective analysis according to the selected operative technique was performed.

RESULTS

A total of 1016 patients were operated, and a pedicle division of the mesenteric vessels was performed in 280 patients (central group 27.6%) while a peripheral division was performed in 736 patients (peripheral group 72.4%). Comparison of these two groups demonstrated no statistically significant difference regarding age or stage of disease. Thirteen patients (1.3%) developed anastomotic leak; among them, nine belonged to the peripheral group (1.2 vs 1.4% p = 0.794). Twenty-four patients (2.4%) developed postoperative rectal bleeding but only in nine cases was a bleeding of the anastomosis confirmed using endoscopy (seven peripheral group vs two central group, 0.95 vs 0.7% p = 0.712). Moreover, postoperative morbidity did not significantly differ between the two groups. A very low mortality rate was observed, with 2 deaths (both in the peripheral group).

CONCLUSIONS

Ligation of inferior mesenteric vessels does not seem to affect anastomotic healing; both surgical techniques presented similar incidence of anastomotic bleeding. In this analysis, we could not identify any significant difference in overall morbidity and mortality.

Surgical protocol and outcome for sigmoidovesical fistula secondary to diverticular disease of the left colon: A retrospective cohort study

BACKGROUND

Diverticular disease of sigmoid colon can rarely be complicated by a connective track to urinary bladder. Pneumaturia and fecaluria are the pathognomonic symptoms. Resection surgery is the preferred treatment to overcome the renal sequellae of the disease. The purpose of this study is to propose a guiding classification to help general surgeons during surgical management of diverticular disease complicated by sigmoidovesical fistula (SVF).

PATIENTS AND METHODS

The data of 40 cases with colovesical fistula due to diverticular disease of sigmoid colon were retrospectively analyzed. Clinicopathological variables, imaging reports, types of treatment and patient outcome were evaluated.

RESULTS

There were 36 men (90%) and four women (10%) in which the ages ranged from 32 to 79 with a mean of 58.1 years. Pneumaturia was the most common presenting symptom in 38 cases (95%) followed by urinary symptoms in 35 cases (87.5%) then fecaluria in 33 cases (82.5%). 37 patients underwent surgical resection while three patients were in poor general condition to withstand major resection. 16 patients underwent one stage resection and anastomosis, 16 patients were managed by two stage procedure and the remaining 5 patients were treated by three stages operation.

CONCLUSIONS

Adequately performed CT followed by colonoscopy is the mainstay for diagnosis. Type 1 SVF should be treated in a single stage by complete resection and immediate anastomosis without a stoma. Type 2 cases are best managed in two stages while those with type 3 SVF are emergently managed by three stage procedure. Treatment of type 4 should be individualized.

Elective vs. early elective surgery in diverticular disease: a retrospective study on the optimal timing of non-emergency treatment

PURPOSE

This study set out to compare the in-hospital outcomes of early elective and elective laparoscopic sigmoidectomy due to diverticulitis.

METHODS

We examined the data for 378 diverticulitis patients who received an elective laparoscopic sigmoid resection between 2008 and 2012. We divided the patients into two groups: elective (group A, n = 278) and early elective (group B, n = 100). Patients in group A received surgery during the inflammation-free interval, and those in group B immediately after treating the attack with IV antibiotics for a mean period of 8 days (IQR = 3).

RESULTS

Overall mortality was 0%. The mean operation duration was the same in both groups being 77.5 and 80 min respectively. There was no significant difference in the outcomes between the two groups, measured using the Clavien-Dindo classification of surgical complication (CCSC; p = 0.992). A revision due to complications was necessary in 16 cases (group A) and six cases (group B) (p = 0.820). The conversion rate to open surgery was low (six individuals in group A, vs. four in group B; p = 0.331). Patients in group B suffered significantly fewer diverticulitis attacks (three in group A, vs. two in group B; p = 0.026).

CONCLUSION

Our study showed no difference in outcome between elective and early elective cases. Operation durations were optimal in both cases and were 50% shorter than those recorded in the literature. An early elective operation represents a good treatment option, especially for patients suffering from complicated diverticulitis.

Early elective versus delayed elective surgery in acute recurrent diverticulitis: A systematic review and meta-analysis

OBJECTIVES

To investigate outcomes of early versus delayed surgery in patients with acute recurrent diverticulitis.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of early versus delayed surgery in patients with acute recurrent diverticulitis. We used the Newcastle-Ottawa scale to assess the risk of bias of included studies. Random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified three retrospective and one prospective cohort studies enrolling a total of 1046 patients. The included patients were comparable in terms of age, ASA score and Hinchey classifications (Hinchey I and II). The results of our analyses suggested that there was no difference between two groups in surgical site infection [Odds ratio (OR) 1.61, 95% CI 0.79-3.27, P = 0.19], intra-abdominal abscess (OR 0.92, 95% CI 0.21-4.00, P = 0.91), anastomotic leak (OR1.27, 95% CI 0.50-3.25, P = 0.61), 30-day mortality [Risk difference (RD) 0.00 95% CI -0.01-0.01, P = 0.80], postoperative ileus (OR 1.35, 95% CI 0.50-3.66, P = 0.55), postoperative bleeding (OR 0.93, 95% CI 0.32-2.69, P = 0.89), ureteric injury (OR 0.62, 95% CI 0.08-5.07, P = 0.65), and overall morbidity (OR 1.42 95% CI 0.76-2.66, P = 0.27). The early surgery was associated with longer operative time [Mean Difference (MD) 12.8, 95% CI 5.08-20.53, P = 0.001] and length of stay (MD 4.41, 95% CI -0.34-8.53, P = 0.03). Among those undergoing laparoscopic surgery, conversion to open surgery was higher in the early surgery group (OR 2.71, 95% CI 1.36-5.40, P = 0.005).

CONCLUSIONS

The best available evidence suggests that there is no difference between early elective and delayed elective surgery for acute recurrent diverticulitis in terms of clinical outcomes. However, longer operative time and length of stay and higher conversion rate to open surgery associated with early elective surgery may make the delayed elective surgery more cost-effective. The best available evidence is derived from non-randomised studies; therefore, high quality randomised controlled trials are required to provide more robust basis for definite conclusions.

Mortality and complications following surgery for diverticulitis: Systematic review and meta-analysis

BACKGROUND

The surgical treatment of diverticulitis is in a state of evolution. Clinicians across many disciplines need to counsel patients regarding surgical choices.

OBJECTIVES

A systematic review and meta-analysis was conducted to determine the mortality and complication rates following surgery for diverticulitis in both the emergent and elective setting.

METHODS

We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant articles published from 1980 to 2012. The primary outcome of interest was the point estimate of mortality, following surgery for diverticulitis.

RESULTS

Of the 289 citations reviewed, we included 59 studies. Overall, the point estimate for mortality was 3.05%, with a 95% confidence intereval (CI) of 1.73-5.32 and p < 0.001. Mortality following emergent surgery was 10.64% (95% CI 7.95-14.11; p < 0.001), versus 0.50% (95% CI 0.46-0.54; p < 0.001) following elective operations. A laparoscopic approach had an estimated mortality of 0.75% (95% CI 0.35-1.58; p < 0.001), compared to an open surgical approach, which had a mortality of 4.69% (95% CI 2.29-9.36, p < 0.001). The mortality following a resection with primary anastomosis was 1.96% (95% CI 1.22-3.13; p < 0.001) and for the Hartmann's procedure was 14.18% (95% CI 9.83-20.03; p < 0.001). A comparative analysis found that the risk of post-operative mortality was significantly higher following emergent surgery, compared to elective surgery (odds ratio (OR): 6.12 with 95% CI 1.62-23.10; p = 0.008; Q = 2.56, p = 0.46 and I2 = 0); the open approach, compared to a laparoscopic approach (OR: 36.43 with 95% CI 9.94-133.6; p = 0.13; and Q = 2.79, p = 0.25 and I2 = 28.26); and for Hartmann's procedure, compared to primary anastomosis without diversion (OR: 25.45 with 95% CI 15.13-42.81, p < 0.001; and Q = 23.34, p = 0.14 and I2 = 27.16). The overall reported post-operative complication rate was 32.64% (95% CI 27.43-38.32; p < 0.00). The overall surgical and medical complication rates were 18.96% and 13.93%, respectively.

CONCLUSIONS

Urgent surgical treatment of diverticulitis has a significant complication rate. Even elective surgery has a significant complication rate that needs to be considered when doing the clinical decision-making for recurrent diverticulitis.

Laparoscopic approach in complicated diverticular disease

AIM: To analyze the results of laparoscopic colectomy in complicated diverticular disease.

METHODS: This was a retrospective cohort study conducted at an academic teaching hospital. Data were collected from a database established earlier, which comprise of all patients who underwent laparoscopic colectomy for diverticular disease between 2000 and 2013. The series was divided into two groups that were compared: Patients with complicated disease (abscess, perforation, fistula, or stenosis) (G1) and patients undergoing surgery for recurrent diverticulitis (G2). Recurrent diverticulitis was defined as two or more episodes of diverticulitis regardless of patient age. Data regarding patient demographics, comorbidities, prior abdominal operations, history of acute diverticulitis, classification of acute diverticulitis at index admission and intra and postoperative variables were extracted. Univariate analysis was performed in both groups.

RESULTS: Two hundred and sixty patients were included: 28% (72 patients) belonged to G1 and 72% (188 patients) to G2. The mean age was 57 (27-89) years. The average number of episodes of diverticulitis before surgery was 2.1 (r 0-10); 43 patients had no previous inflammatory pathology. There were significant differences between the two groups with respect to conversion rate and hospital stay (G1 18% vs G2 3.2%, P = 0.001; G1: 4.7 d vs G2 3.3 d, P < 0.001). The anastomotic dehiscence rate was 2.3%, with no statistical difference between the groups (G1 2.7% vs G2 2.1%, P = 0.5). There were no differences in demographic data (body mass index, American Society of Anesthesiology and previous abdominal surgery), operative time and intraoperative and postoperative complications between the groups. The mortality rate was 0.38% (1 patient), represented by a death secondary to septic shock in G2.

CONCLUSION: The results support that the laparoscopic approach in any kind of complicated diverticular disease can be performed with low morbidity and acceptable conversion rates when compared with patients undergoing laparoscopic surgery for recurrent diverticulitis.

Management of sigmoid diverticulitis: an update

The role, indications and modalities of elective resection for sigmoid diverticulitis remain the cause of fierce debate. During the past two decades clinicians have increasingly recognized that: (1) young patients (<50) are no more at risk to develop more aggressive course of the disease; and (2) patients who present initially with a first uncomplicated attack are no more at risk for developing subsequent complicated diverticulitis requiring emergency surgery. Hence, the previously well-recognized indications (based upon age of the patients or the number of attacks) are no longer valid. Yet, the number of sigmoid resections performed for diverticulitis in industrialized countries is increasing, which seems to indicate that in many cases, uncomplicated sigmoid diverticulitis progressively evolves towards a chronic symptomatic condition, which significantly impacts upon the patients' quality of life. The aims of this review are twofold: (1) to identify which disease presentation still represents good indications for elective laparoscopic sigmoid resection; and (2) to summarize the technical aspects of surgery for a benign condition, such as diverticular disease.

Effectiveness of elective laparoscopic treatment for colonic diverticulitis

Background and Objectives:

To analyze the short- and long-term outcomes of laparoscopic sigmoid colectomy for the elective treatment of diverticular disease.

Methods:

A consecutive unselected series of 94 patients undergoing elective laparoscopic sigmoid colectomy for diverticular disease from 2008 to 2012 was analyzed. We collected patients-, surgery- and hospital stay–related data, as well as the short- and long-term outcomes. Operative steps, instrumentation, and postoperative cares were standardized. Comorbidity was assessed by Charlson comorbidity index. Complications were classified using the Clavien-Dindo classification system. The qualitative long-term assessment was carried out by subjecting patients to the validated gastrointestinal quality of life index questionnaire before and after surgery.

Results:

The mean age of our cohort was 61.3 ± 11.0 years with a Charlson comorbidity index of 1.2 ± 1.5.

Mean operative time was 213.5 ± 60.8 minutes and estimated blood loss was 67.2 ± 94.3 mL. We had 3 cases (3.2%) of conversion to open laparotomy. The rates of postoperative complications were 35.1%, 6.3%, 2.1%, and 1.06%, respectively, for grades 1, 2, 3b, and 5 according to the Clavien-Dindo system. Length of hospital stay was 8.1 ± 1.9 days, and we have not recorded readmissions in patients discharged within 60 days after surgery. Median follow-up was of 9.6 ± 2.7 months. We observed no recurrence of diverticular disease, but there was evidence of 3 cases of incisional hernia (3.19%). The difference between preoperative and late gastrointestinal quality of life index score was statistically significant (97.1 ± 5.8 vs 129.6 ± 8.0).

Conclusions:

Elective laparoscopic treatment of colonic diverticular disease represents an effective option that produces adequate postoperative results and ensures a satisfactory functional outcome.

Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis: Systematic Review and Meta-analysis

BACKGROUND & AIMS

Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative treatment approach. However, some studies suggest that surgical intervention reduces recurrence and chronic abdominal problems. We conducted a systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis.

METHODS

We searched the CENTRAL, MEDLINE, EMBASE, and PsycInfo databases for randomized trials and cohort studies reporting on QOL or other PROs after conservative or operative treatment for uncomplicated diverticulitis from January 1990 through May 2014. Eight PROs were defined and graded according to their clinical relevance. Risk of bias was assessed by using the Cochrane Collaboration tool. Subgroup and sensitivity analyses were performed to test the robustness of the results. The review protocol was registered through PROSPERO (CRD42013005854).

RESULTS

We analyzed data from 21 studies that comprised 1858 patients; all studies had a high risk of bias. There were no head-to-head comparisons of gastrointestinal symptoms or general QOL between elective surgical vs conservative treatment of recurrent diverticulitis. On the basis of Short-Form 36 scores, patients had higher QOL scores after elective laparoscopic resection (73.4; 95% confidence interval [CI], 65.7-81.1) than conservative treatment (58.1; 95% CI, 47.2-69.1). A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%-14%) than conservative treatment (36%; 95% CI, 27%-45%) in all cohorts and in 1 trial comparing these treatments (odds ratio, 0.35; 95% CI, 0.16-0.7). The proportion of patients with chronic abdominal pain after elective laparoscopy was 11% (95% CI, 1%-21%) compared with 38% (95% CI, 19%-56%) after conservative treatment.

CONCLUSIONS

On the basis of a systematic review and meta-analysis, patients have better QOL and fewer symptoms after laparoscopic surgery vs conservative treatment. However, studies of PROs for treatment of diverticulitis were of low quality.

Observational study on preservation of the superior rectal artery in sigmoid resection for diverticular disease

AIM

Recent investigations have shown improved patient reported outcome after preservation of the inferior mesenteric artery in sigmoid resection for diverticular disease. We report on our experience with preservation of the superior rectal artery (SRA).

METHODS

This is an observational single center study in a high-volume, level II inner city hospital from 2006 to 2008. Inclusion criteria were all patients with diverticular disease. Exclusion criteria were stoma formation, cancer, and iatrogenic perforation. Patients were investigated in group A with preservation of the SRA, and group B ligation of the SRA. Outcomes assessed, included incidence of anastomotic breakdown, intraoperative complications, hospital stay, and risk factors.

RESULTS

The patient population included 259 patients, 46 patients were excluded, leaving 100 patients in group A and 113 patients in group B. Patients in both groups were comparable regarding age, gender, co-morbidities and stage of disease. Anastomotic breakdown occurred in one patient in group A and in eight patients in group B (p = 0.038). Incidence of intraoperative bleeding, wound dehiscence, and length of stay was increased in group B (p < 0.03; p < 0.04; p = 0.05). Obesity was an independent risk factor for anastomotic dehiscence in group B (p < 0.04).

CONCLUSION

Our data comprise the largest patient population reported so far on vascular preservation in surgery for diverticular disease. The results of this study support the establishment of evidence based recommendations on the level of dissection in diverticular disease. Specifically obese patients are at risk of anastomotic breakdown with ligation of the SRA.

Sigmoid stricture associated with diverticular disease should be an indication for elective surgery with lymph node clearance

BACKGROUND

The literature concerning stricture secondary to diverticulitis is poor. Stricture in this setting should be an indication for surgery because (a) of the potential risk of cancer and (b) morbidity is not increased compared to other indications for colectomy. The goal of this report is to study the post-surgical morbidity and the quality of life in patients after sigmoidectomy for sigmoid stricture associated with diverticular disease.

METHOD

This is a monocenter retrospective observational study including patients with a preoperative diagnosis of sigmoid stricture associated with diverticular disease undergoing operation between Jan 1, 2007 and Dec 31, 2013. The GastroIntestinal Quality of Life Index was used to assess patient satisfaction.

RESULTS

Sixteen patients were included of which nine were female. Median age was 69.5 (46-84) and the median body mass index was 23.55kg/m(2) (17.2-28.4). Elective sigmoidectomy was performed in all 16 patients. Overall, complications occurred in five patients (31.2%) (4 minor complications and 1 major complication according to the Dindo and Clavien Classification); none resulted in death. Pathology identified two adenocarcinomas (12.5%). The mean GastroIntestinal Quality of Life Index was 122 (67-144) and 10/11 patients were satisfied with their surgical intervention.

CONCLUSION

Sigmoid stricture prevents endoscopic exploration of the entire colon and thus it may prove difficult to rule out a malignancy. Surgery does not impair the quality of life since morbidity is similar to other indications for sigmoidectomy. For these reasons, we recommend that stricture associated with diverticular disease should be an indication for sigmoidectomy including lymph node clearance.

Significant reduction in the incidence of small bowel obstruction and ventral hernia after laparoscopic compared to open segmental colorectal resection

PURPOSE

The aim of this study is to assess the incidence of incisional ventral hernia and small bowel obstruction following laparoscopic and open colorectal resection.

METHODS

A retrospective review was performed of a large database comprising 13 hospitals, serving 3.6 million patients in Southern California. Patients 18 years and older undergoing elective colorectal resection over a 3-year period were included. The crude incidence rates were calculated, and relative risks of ventral hernia and small bowel obstruction were determined using multivariable proportional hazard modeling.

RESULTS

Four thousand six hundred and thirteen patients underwent 4765 colorectal resections between August 2008 and August 2011. Fifty-nine percent of the cases were performed laparoscopically; the median age was 63 years, and 49% were males. Colorectal carcinoma (45%) and diverticulitis (18%) were the most common indications for surgery. The median follow-up was 2.4 years. Kaplan-Meier estimates of ventral hernia at 1, 2, and 3 years among the open cohort were significantly higher at 10.1, 17.0, and 20.5%, compared to 5.7, 8.7, and 10.8% in the laparoscopic cohort (p < 0.001). Similarly, small bowel obstruction was higher in the open compared to the laparoscopic group (open 10.4, 15.0, and 18.3% vs. laparoscopic 2.7, 4.4, and 5.5%, p < 0.001). Patients undergoing laparoscopic colorectal resection were less likely to develop ventral hernia [adjusted hazard ratio (AHR) 0.64 (95% CI 0.52, 0.80); p < 0.0001] and small bowel obstruction [AHR 0.41 (95% CI 0.31, 0.54); p < 0.0001].

CONCLUSIONS

The incidence of incisional ventral hernia and small bowel obstruction is significantly reduced in patients who undergo laparoscopic compared to open colorectal resection.

Laparoscopic management of diverticular colovesical fistula: experience in 15 cases and review of the literature

Colovesical fistulas secondary to diverticular disease may be considered a contraindication to the laparoscopic approach. The feasibility of laparoscopic management of complicated diverticulitis and mixed diverticular fistulas has been demonstrated. However, few studies on the laparoscopic management of diverticular colovesical fistulas exist. A retrospective analysis was performed of 15 patients with diverticular colovesical fistula, who underwent laparoscopic-assisted anterior resection and bladder repair. Median operating time was 135 minutes and median blood loss, 75 mL. Five patients were converted to an open procedure (33.3%) with an associated increase in hospital stay (P = 0.035). Median time to return of bowel function was 2 days and median length of stay, 6 days. Overall morbidity was 20% with no major complications. There was no mortality. There was no recurrence during median follow-up of 12.4 months. These results suggest that laparoscopic management of diverticular colovesical fistulas is both feasible and safe in the setting of appropriate surgical expertise.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic emergency surgery for diverticular disease that failed medical treatment: a valuable option? Results of a retrospective comparative cohort study

BACKGROUND

Laparoscopic surgery has become the standard of treatment for elective management of diverticular disease. However, its use in the acute setting remains controversial.

OBJECTIVE

The aim of this study is to compare the outcomes of laparoscopic surgery with open surgery in the acute management of complicated diverticular disease that failed initial medical treatment.

SETTINGS

This is a single-center comparative retrospective cohort study.

PATIENTS

Patients undergoing surgery for complicated diverticular disease after an attempt at medical treatment from 2000 to 2011 were selected.

INTERVENTION

Laparoscopic versus open surgery was compared.

OUTCOME MEASURES

The primary outcomes were overall 30-day morbidity and mortality. Secondary outcomes were length of stay, time to resume diet, and need for a permanent stoma.

RESULTS

Forty-two patients were identified by using medical records: 24 laparoscopic surgery and 18 open surgery. Baseline demographics, ASA classification, Acute Physiology and Chronic Health Evaluation scores, Hinchey classification, and Charlson Comorbidity Index did not differ between groups. The mean operative time was 36 minutes longer (p = 0.05) and blood loss was 460 mL less (p < 0.001) for laparoscopic surgery. Two patients (8.3%) in the laparoscopic surgery group required conversion to open surgery. There was no mortality. Overall morbidity was lower favoring laparoscopic surgery (16.7% vs 55.6%; p = 0.01). Two patients in the laparoscopic surgery group experienced an anastomotic leak compared with none in the open surgery group. Mean time to resume diet (3 vs 6.5 days; p < 0.01) and length of stay (5 vs 8 days; p = 0.04) were shorter for the laparoscopic surgery group. Rate of permanent stoma at last follow-up (median, 332 days) did not differ significantly between groups.

LIMITATIONS

This study is limited by selection bias.

CONCLUSIONS

Compared with open surgery, laparoscopic surgery for patients in whom medical treatment for complicated diverticular disease failed is associated with favorable outcomes, including a reduced rate of morbidity and a shorter length of stay. When applied to selected patients, this approach appears to be a safe procedure with a low rate of conversion.

2013 WSES guidelines for management of intra-abdominal infections

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.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Sigmoid diverticulitis in 2011: many questions; few answers

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Hospital discharge criteria following colorectal surgery: a systematic review

AIM

The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature.

METHODS

A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study.

RESULTS

The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined.

CONCLUSION

A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.

Current status of the treatment of acute colonic diverticulitis: a systematic review

AIM

This paper addresses the current status of the treatment of acute colonic diverticulitis by an evidence-based review.

METHOD

A systematic search in PUBMED, MEDLINE, EMBASE and Google scholar on colonic diverticulitis was performed. Diagnostic tools, randomized controlled trials, non-randomized comparative studies, observational epidemiological studies, national and international guidelines, reviews of observational studies on elective and emergency surgical treatment of diverticulitis, and studies of prognostic significance were reviewed. Criteria for eligibility of the studies were diagnosis and classification, medical treatment, inpatients and outpatients, diverticulitis in young patients, immunosuppression, recurrence, elective resection, emergency surgery, and predictive factors.

RESULTS

Some 92 publications were selected for comprehensive review. The review highlighted that computed tomography is the most effective test in the diagnosis and staging of acute diverticulitis; outpatient treatment can be performed for uncomplicated diverticulitis in patients without associated comorbidities; conservative treatment is aimed at those patients with uncomplicated acute diverticulitis; elective surgery must be done on an individual basis; laparoscopic approach for elective treatment of diverticulitis is appropriate but may be technically complex; in perforated diverticulitis, resection with primary anastomosis is a safe procedure that requires experience and should take into account strict exclusion criteria.

CONCLUSION

The heterogeneity of patients with colonic diverticular disease means that both elective and urgent treatment should be tailored on an individual basis.

[Perforation risk and patient age. Risk analysis in acute sigmoid diverticulitis]

INTRODUCTION

It is often postulated that younger patients with acute sigmoid diverticulitis (SD) have an increased risk of perforation which constitutes an indication for early surgery. The aim of this study was to correlate the severity of sigmoid diverticulitis with patient age in order to check the surgical indication in younger patients.

PATIENTS AND METHODS

Patients with acute SD from January 1998 to June 2009 were included. Two age groups were distinguished: group I (GI) ≤40 years in age and group II (GII) >40 years. The perforation risk associated with first episode SD was determined by multivariate analysis. SD was classified according to Hansen and Stock (H/S).

RESULTS

In the total cohort of 959 patients, including 86 in GI (8.9%) and 873 in GII (91.1%) 468 had a first episode, with 64 in GI (13.7%) and 404 in GII (86.3%). The proportion of first episodes was 74.4% in GI and 46.3% in GII (p<0.001). The perforation risk did not differ (H/S IIb: 29.7% in GI vs. 29.2% in GII, p=0.938; H/S IIc: 25% in GI vs. 25% in GII, p=1). Treatment regimes were (GI vs. GII) emergency operations 25% vs. 25% (p=1), elective operations 17.2% vs. 10% (p=0.096) and conservative treatment 57.8% vs. 64.9% (p=0.276).

CONCLUSION

First episodes of SD were more frequent in younger patients (≤40) and did not involve a higher risk of perforation. The indication for treatment of acute SD should not be based on age but on the severity of inflammation and the individual situation of patients.

[Current state of laparoscopic hepatic surgery: results of a survey of DGAV-members]

BACKGROUND

To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008.

MATERIALS AND METHODS

A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously.

RESULTS

A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551).

CONCLUSION

Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.

Problems of randomization to open or laparoscopic sigmoidectomy for diverticular disease

PURPOSE

Although complicated sigmoid diverticulitis is the most common reason for laparoscopic sigmoidectomy, the level of evidence for preference of the laparoscopic approach is low.

METHODS

A multicenter, randomized clinical trial comparing laparoscopic and open sigmoidectomy for diverticulitis was conducted to evaluate the short- and mid-term outcome after both techniques. Data were assessed from randomized patients and from patients who refused randomization. Results of the here presented interim analysis describe the difficulties in randomization leading to abortion of recruitment.

RESULTS

149 patients were enrolled in the randomized trial within 36 months until the interim analysis. A further 294 nonrandomized patients who preferred one of both surgical approaches were assessed. Several differences between these groups were apparent including simple epidemiological characteristics such as age (65 vs. 60 years, p < 0.001), gender (65% vs. 55% female, p = 0.05), BMI (27 vs. 26 kg/m(2), p = 0.01), and ASA class < III (72% vs. 87%, p < 0.001).

CONCLUSION

The majority of eligible patients refused a random allocation. A widespread presumption of the advantages of laparoscopic surgery was probably the main reason for refusal. Patients participating in randomization did not reflect the general population in recruiting hospitals. Future trials comparing minimal invasive procedures should be conducted before presumptions concerning the outcome are widespread in the general population.

WSES consensus conference: Guidelines for first-line management of intra-abdominal infections

Intra-abdominal infections are still associated with high rate of morbidity and mortality.A multidisciplinary approach to the management of patients with intra-abdominal infections may be an important factor in the quality of care. The presence of a team of health professionals from various disciplines, working in concert, may improve efficiency, outcome, and the cost of care.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bologna on July 2010, during the 1st congress of the WSES, involving surgeons, infectious disease specialists, pharmacologists, radiologists and intensivists with the goal of defining recommendations for the early management of intra-abdominal infections.This document represents the executive summary of the final guidelines approved by the consensus conference.

Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy

BACKGROUND

This study was designed to asses the predictive factors of postoperative complications in patients who underwent a laparoscopic elective approach for recurrent diverticulitis and to determine the relationship between the number of acute episodes and surgical morbidity.

METHODS

A retrospective analysis was performed on patients with colonic diverticular disease treated by an elective laparoscopic approach between July 2000 and November 2007. The variables studied were age, sex, BMI, ASA, number of previous acute episodes, local severity, abdominal surgery history, comorbidity, and laparoscopic training of the surgeon. Logistic regression analysis was used to establish significant results.

RESULTS

A total of 137 patients were analyzed; 87 (63.5%) were men with a mean age of 56.7 (range, 27-89) years. Intraoperative and postoperative complications occurred in 2.9% (n = 4) and 12.4% (n = 17) of the patients respectively. Conversion rate was 9.4% (n = 13). Local severity (odds ratio (OR), 16.34; 95% confidence interval (CI), 4.1-64.5, p = 0.00007), history of abdominal surgery (OR, 3.02; 95% CI, 0.8-11.5; p = 0.02), and the training of the operating surgeon (OR, 4.8; 95% CI, 1.02-22.7; p = 0.001) were significant risk factors related to surgery conversion. A history of three or more acute episodes was significantly associated with a high severity of local process and was a risk factor related to conversion (OR, 2.6; 95% CI, 0.5-12.3; p = 0.22). The severity of the local process seems to be a risk factor for perioperative complications. A significant association (chi2, 4.45; p = 0.03) between conversion and postoperative complications also was observed (OR: 3.79, 95% CI, 1.02-14.07; p = 0.04).

CONCLUSIONS

A history of three or more acute episodes of diverticulitis with conservative treatment is associated with a high severity of the local process during laparoscopic sigmoidectomy and increases the rate of conversion and perioperative complications.

Short-term outcomes after elective minimally invasive colectomy for diverticulitis

BACKGROUND

The role of minimally invasive surgery in complicated diverticulitis is still being elucidated. The aim of this study was to compare short-term outcomes in patients undergoing minimally invasive surgery for complicated or uncomplicated diverticular disease.

METHODS

All patients who had elective minimally invasive surgery for diverticulitis between 2003 and 2008 were identified from a prospectively maintained database. Complicated disease was defined as diverticulitis associated with abscess, fistula, stricture or bleeding. Univariable analysis was performed to compare safety and short-term outcomes in patients with complicated and uncomplicated diverticulitis.

RESULTS

A total of 361 patients (136 with complicated and 225 with uncomplicated diverticulitis) were operated on with either a laparoscopic (36·0 per cent) or a hand-assisted laparoscopic (64·0 per cent) surgical technique. There were no significant differences between the groups with respect to age, sex, body mass index, laparoscopic approach, postoperative recovery protocol or previous open surgery. Conversion rates were similar for complicated and uncomplicated disease (14·0 versus 11·6 per cent respectively; P = 0·514). There was no difference between the groups with respect to return of bowel function (mean 3·1 versus 3·2 days respectively; P = 0·156), morbidity (27·9 versus 19·6 per cent; P = 0·070) or mean length of stay (5·4 versus 4·8 days; P = 0·186). There were no deaths within 30 days.

CONCLUSION

Elective minimally invasive colectomy is feasible for patients with uncomplicated and complicated diverticulitis, with equivalent outcomes.

Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial

BACKGROUND

The short-term results of the Sigma trial show that laparoscopic sigmoid resection (LSR) used electively for diverticular disease offers advantages over open sigmoid resection (OSR). This study aimed to compare the overall mortality and morbidity rates after evaluation of the clinical outcomes at the 6-month follow-up evaluation.

METHODS

In a prospective, multicenter, double-blind, parallel-arm, randomized control trial, eligible patients were randomized to either LSR or OSR. The short-term results and methodologic details have been published previously. Follow-up evaluation was performed at the outpatient clinic 6 weeks and 6 months after surgery.

RESULTS

In this trial, 104 patients were randomized for either LSR or OSR, and the conversion rate was 19.2%. The LSR approach was associated with short-term benefits such as a 15.4% reduction in the major complications rate, less pain, and a shorter hospital stay at the cost of a longer operating time. At the 6-month follow-up evaluation, no significant differences in morbidity or mortality rates were found. Two patients died of cardiac causes (overall mortality, 3%). Late complications (7 LSR vs. 12 OSR; p = 0.205) consisted of three incisional hernias, five small bowel obstructions, four enterocutaneous fistulas, one intraabdominal abscess, one retained gauze, two anastomotic strictures, and three recurrent episodes of diverticulitis. Nine of these patients underwent additional surgical interventions. Consideration of the major morbidity over the total follow-up period (0-6 months) shows that the LSR patients experienced significantly fewer complications than the OSR patients (9 LSR vs. 23 OSR; p = 0.003). The Short Form-36 (SF-36) questionnaire showed significantly better quality of life for LSR at the 6-week follow-up assessment. However, at the 6-month follow-up assessment, these differences were decreased.

CONCLUSIONS

The late clinical outcomes did not differ between LSR and OSR during the 30-day to 6-month follow-up period. Consideration of total postoperative morbidity shows a 27% reduction in major morbidity for patients undergoing laparoscopic surgery for diverticular disease.

Emergency management of diverticulitis

Diverticulitis is a common problem, and although most cases will respond to conservative measures, surgeons will frequently need to treat patients requiring emergency surgery. Surgical management has progressed over the past 30 years, with a change in practice from routine drainage and proximal diversion (necessitating two further major procedures) to primary resection and anastomosis in selected cases. In 2004, surgeons must use clinical judgment to determine which approach will optimize outcomes both in terms of morbidity and mortality and in terms of quality of life for their patients.

Preoperative CT staging in sigmoid diverticulitis--does it correlate with intraoperative and histological findings?

PURPOSE

This study was designed to evaluate whether the computed tomography (CT) reflects the extent of the inflammation in sigmoid diverticulitis (SD) in order to draw conclusions for selecting the appropriate treatment.

METHODS

Two hundred four patients who underwent resection for SD from January 2003 to December 2008 were included. The preoperative CT stage was compared with intraoperative and histological findings. Patients were classified into phlegmonous (Hansen-Stock IIa), abscess-forming (HS IIb), and free perforated (HS IIc) forms of SD. Patients with a recurrent type of diverticulitis were excluded.

RESULTS

In the phlegmonous type (HS IIa; n = 75), we found a correlation with the preoperative stage in 52% (intraoperative) and 56% (histological), an understaging in 12% (intraoperative) and 11% (histological), and an overstaging in 36% (intraoperative) and 33% (histological). In the abscess-forming type (HS IIb, Hinchey I/II; n = 87), we found conformity in 92% (intraoperative) and 90% (histological), understaging in 3% (intraoperative) and 0% (histological), and overstaging in 5% (intraoperative) and 10% (histological). In the presence of a free perforation (HS IIc, Hinchey III/IV; n = 42), we saw conformity in 100% (intraoperative and histological). The positive predictive value for correctly diagnosing of phlegmonous type (HS IIa), abscess-forming type (HS IIb), and free perforation (HS IIc) by CT was intraoperatively (histologically) 52% (56), 92% (90), and 100% (100), respectively.

CONCLUSIONS

The CT is one of the most accurate methods for staging in SD. However, in the phlegmonous type (HS IIa), it leads to an overestimation of the findings in every third patient. It must be clarified whether this pronounced low inflammation should really be regarded as a complicated form of SD. In contrast, the abscess-forming (HS IIb) and free perforated (HS IIc) type of complicated SD is very well reflected by CT.