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

Performance of Ultrasonography in the Diagnosis of Acute Colonic Diverticulitis

OBJECTIVES

Computed tomography is regarded as the reference-standard imaging modality for the assessment of acute left-sided colonic diverticulitis (ALCD). However, its utility may be impaired by cost issues, limited availability, radiation exposure, and contrast-related adverse effects. Ultrasonography is increasingly advocated as an alternative technique for evaluating ALCD, although there is variation regarding its accuracy in disease diagnosis and staging and in determining alternative diagnoses. The aim of this study was to assess the performance of ultrasonography in diagnosing ALCD, differentiating complicated from non-complicated disease and defining alternative diseases related to left lower quadrant pain.

METHODS

Within a 2-year period, all consecutive adult patients with clinically suspected ALCD and available abdominal computed tomography were prospectively evaluated and planned to undergo an abdominal ultrasonographic examination, tailored to the assessment of left lower quadrant. Computed tomography (CT) was regarded as the reference standard.

RESULTS

A total of 132 patients (60 males, 72 females; mean age: 61.3 ± 11 years) were included. The sensitivity, specificity, and area under curve of ultrasonography for diagnosing ALCD were 88.6, 84.9, and 86.8%, with positive and negative predictive values of 89.7 and 83.3%, respectively. The method had sensitivity, specificity, and area under curve of 77.8, 100, and 88.9%, respectively, for defining complicated disease. The area under the curve for the identification of alternative diseases in patients with left lower quadrant pain was 90.9%.

CONCLUSIONS

Ultrasonography has high diagnostic accuracy for diagnosing ALCD, differentiating complicated from non-complicated disease and establishing alternative diagnoses related to left lower quadrant pain. A low threshold to get a CT should be maintained as not to miss cases that may mimic ALCD.

Management of acute diverticulitis with pericolic free gas (ADIFAS): an international multicenter observational study

BACKGROUND

There are no specific recommendations regarding the optimal management of this group of patients. The World Society of Emergency Surgery suggested a nonoperative strategy with antibiotic therapy, but this was a weak recommendation. This study aims to identify the optimal management of patients with acute diverticulitis (AD) presenting with pericolic free air with or without pericolic fluid.

METHODS

A multicenter, prospective, international study of patients diagnosed with AD and pericolic-free air with or without pericolic free fluid at a computed tomography (CT) scan between May 2020 and June 2021 was included. Patients were excluded if they had intra-abdominal distant free air, an abscess, generalized peritonitis, or less than a 1-year follow-up. The primary outcome was the rate of failure of nonoperative management within the index admission. Secondary outcomes included the rate of failure of nonoperative management within the first year and risk factors for failure.

RESULTS

A total of 810 patients were recruited across 69 European and South American centers; 744 patients (92%) were treated nonoperatively, and 66 (8%) underwent immediate surgery. Baseline characteristics were similar between groups. Hinchey II-IV on diagnostic imaging was the only independent risk factor for surgical intervention during index admission (odds ratios: 12.5, 95% CI: 2.4-64, P =0.003). Among patients treated nonoperatively, at index admission, 697 (94%) patients were discharged without any complications, 35 (4.7%) required emergency surgery, and 12 (1.6%) percutaneous drainage. Free pericolic fluid on CT scan was associated with a higher risk of failure of nonoperative management (odds ratios: 4.9, 95% CI: 1.2-19.9, P =0.023), with 88% of success compared to 96% without free fluid ( P <0.001). The rate of treatment failure with nonoperative management during the first year of follow-up was 16.5%.

CONCLUSION

Patients with AD presenting with pericolic free gas can be successfully managed nonoperatively in the vast majority of cases. Patients with both free pericolic gas and free pericolic fluid on a CT scan are at a higher risk of failing nonoperative management and require closer observation.

Surgeon-Performed Point-of-Care Ultrasound in the Diagnosis of Acute Sigmoid Diverticulitis: A Pragmatic Prospective Multicenter Cohort Study

Background and purpose Early diagnosis and risk stratification of sigmoid diverticulitis rely heavily on timely imaging. Computerized tomography (CT), the gold standard diagnostic test, may be delayed due to resource constraints or patient comorbidity. Point-of-care ultrasound (POCUS) has an established role in trauma evaluation, and could potentially diagnose and stage acute diverticulitis, thus shortening the time to definitive treatment.  Aims This study aimed to benchmark the accuracy of surgeon-performed POCUS against CT in diagnosing and staging acute diverticulitis. A secondary aim was to evaluate the duration between the POCUS and the confirmatory CT scan report. Patients and methods A pragmatic prospective multicenter cohort study (ClinicalTrials.gov Identifier: NCT02682368) was conducted. Surgeons performed point-of-care ultrasound as first-line imaging for suspected acute diverticulitis. POCUS diagnosis and radiologic Hinchey classification were compared to CT as the reference standard. Results Of 45 patients with suspected acute diverticulitis, POCUS classified 37 (82.2%) as uncomplicated diverticulitis, four (8.8%) as complicated diverticulitis, and four (8.8%) as other diagnoses. The POCUS-estimated modified radiologic Hinchey classification was largely concordant with CT staging with an accuracy of 88.8% (95% CI, 75.95-96.2%), a sensitivity of 100% (95% CI, 90.2- 100%) and a specificity of 44.4% (95% CI, 13.7-78.8%). The positive predictive value (PPV) was 87.8% and the negative predictive value (NPV) was 100%. There was moderate agreement between CT and POCUS, with a Cohen's kappa coefficient of 0.56. The mean delay between CT and POCUS was 9.14 hours (range 0.33 to 43.5). Conclusion We examined the role of POCUS in the management of acute diverticulitis and our findings suggest that it is a promising imaging modality with the potential to reduce radiation exposure and treatment delays. Adding a POCUS training module to the surgical curriculum could enhance diagnosis and expedite the management of acute diverticulitis.

Diagnostic Accuracy of Point-of-Care Ultrasound Integrated into Clinical Examination for Acute Diverticulitis: A Prospective Multicenter Study

PURPOSE

 Diverticulitis is a common cause of abdominal pain and CT scan is commonly used for its diagnosis in the emergency department (ED). The diagnostic performance of point-of-care ultrasound (POCUS) integrated into a clinical exam for diverticulitis is still not established. We evaluate the accuracy of clinical-sonographic assessment for the diagnosis of diverticulitis and whether POCUS could improve the selection of patients needing CT scan for complicated diverticulitis.

MATERIALS AND METHODS

 This is a multicentric observational study involving adult patients suspected of having diverticulitis presenting at 4 EDs. 21 sonographer physicians were asked to diagnose diverticulitis and complicated diverticulitis based on clinical-sonographic assessment. The final diagnosis was established by two reviewers, blinded to POCUS, based on data collected during the one-month follow-up comprehensive CT scan.

RESULTS

 Among 393 enrolled patients, 218 (55.5 %) were diagnosed with diverticulitis and 33 (8 %) had complicated diverticulitis. The time to diagnosis by the sonographer physicians was shorter compared to standard care (97 ± 102 vs. 330 ± 319 minutes, p < 0.001). Clinical-sonographic assessment showed optimal sensitivity (92.7 %) and specificity (90.9 %) for diverticulitis. However, the sensitivity (50 %) for complicated diverticulitis was low. The sonographer physician would have proceeded to CT scan in 194 (49.4 %) patients and the CT scan request compared to the final diagnosis of complicated diverticulitis demonstrated 94 % sensitivity.

CONCLUSION

 Clinical-sonographic assessment is rapid and accurate for the diagnosis of diverticulitis. Even if POCUS has low sensitivity for complicated diverticulitis, it can be used to safely select patients needing CT.

Ultrasound can differentiate complicated and noncomplicated acute colonic diverticulitis: a prospective comparative study with computed tomography

OBJECTIVE

To prospectively assess the diagnostic value of intestinal ultrasound (US) compared to computerized tomography (CT) in differentiating uncomplicated and complicated acute colonic diverticulitis (ACD).

MATERIALS AND METHODS

During a period of 14 months patients referred to the department of Radiology with clinical suspicion of ACD underwent an US examination. All confirmed US ACD diagnosis were included and subsequently underwent an emergency abdominal CT, used as gold standard. The WSES (World Society for Emergent Surgery) classification of diverticulitis was used. Diverticulitis was prospectively classified as either uncomplicated or complicated. Sensitivity, specificity, positive predictive value, and negative predictive values of US were evaluated. Before CT scan, the radiologist indicated whether they would have required or not a complementary CT scan, based on US findings.

RESULTS

Of the 240 patients included in our study, 71 (29.6%) were Stage 0, 127 (53%) Stage 1A, and 42 (17.5%) were moderate-severe ACD (stages 1B, 2A, 2B, 3 and 4). The sensitivity of US for diagnosing complicated ACD was 84% and specificity of 95.8%. Most patients (24 of 27) misclassified by US as uncomplicated diverticulitis were classified on CT as stage 1A. From the 148 cases in which the radiologist considered CT unnecessary, only 3 of these revealed signs of complicated ACD on CT; none of them required emergency surgery.

CONCLUSION

US is an effective technique to differentiate complicated from uncomplicated ACD. Our results suggest that US, may be a valuable alternative to CT for the initial radiologic evaluation in patients with clinical suspicion of ACD.

Accuracy of preoperative CT staging of acute colonic diverticulitis using the classification of diverticular disease (CDD) - Is there a beneficial impact of water enema and visceral obesity?

PURPOSE

We evaluated the accuracy of preoperative CT in staging colonic diverticulitis (ACD) by using the classification of diverticular disease (CDD) and investigated the diagnostic impact of water enema (WE) and visceral obesity.

METHODS

In this retrospective study, the radiological and hospital information system was searched for patients who underwent CT for clinically suspected ACD prior to surgery between 2009 and 2019. From the initial population (n = 164), we included 155 patients (94.5 %) (85 women; mean age: 58 ± 13 years) matching the following inclusion criteria: i.) clinically suspected ACD, ii.) i.v. contrast-enhanced CT, iii.) surgery for ACD within 1 week after CT, iv.) histopathological report that proved ACD. The remaining 9 patients (5.5 %) were excluded because histopathological reports were lacking (n = 3) or CT was performed without intravenous contrast agent (n = 6). WE (+ butylscopolamine i.v.) was performed in 93 patients (group A, 60 %). 62 patients (group B, 40 %) had no WE. Visceral-to-subcutaneous fat ratio (V/S) was determined for each patient. Two radiologists blinded for final diagnosis independently staged ACD according to CDD and assessed prevalence and confidence ratings of ACD-related CT-findings: pericolonic fat stranding, covered- and free-perforation, local and generalized peritonitis, abscess. Interobserver-agreement of CT-findings were assessed and effects of WE and V/S ratio on the diagnostic accuracy of CT with surgical and histopathological findings as reference were determined by calculating a logistic regression model.

RESULTS

CT-staging showed high accuracy (94 %) and excellent interrater-correlation (ICC 0.96) for staging ACD. WE had no positive impact neither on diagnostic accuracy of staging, nor on confidence ratings of ACD-related CT-findings (all p > 0.5). Confidence ratings were significantly higher in examinations without WE for perforation, peritonitis as well as abscesses (all p < 0.5). Confidence ratings for the assessment of local peritonitis improved significantly with higher V/S (p = 0.049). The increase of V/S significantly correlated with the probability for correct CDD staging of ACD in CT (p = 0.023).

CONCLUSION

Increase of visceral obesity significantly improves accuracy of CT in preoperative staging acute colonic diverticulitis. However, independently of the degree of visceral obesity, water enema has no diagnostic benefit and may therefore be omitted. Overall, CT proves high accuracy in preoperative staging ACD using the classification of diverticular disease.

LEVEL OF EVIDENCE

Retrospective study, observational study.

To Fill or Not to Fill? - Value of the Administration of Positive Rectal Contrast for CT Evaluation of Diverticular Disease of the Colon

PURPOSE

 To assess the value of the administration of positive rectal contrast at CT in patients referred for suspected diverticular disease (DD) of the colon.

MATERIALS AND METHODS

 460 patients (253 male, 207 female; median age 62 years; interquartile range 24) with clinical suspicion of DD of the colon were included in this retrospective IRB-approved study. CT was performed with i. v. contrast only (n = 328, group M1), i. v. + positive rectal contrast (n = 82, group M2), neither i. v. nor rectal contrast (n = 32, group S1), or positive rectal contrast only (n = 19, group S2). Two readers in consensus evaluated all CT datasets concerning diagnosis of DD (yes/no) and categorized findings (classification of diverticular disease (CDD)). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values for the diagnosis of DD were calculated for all groups, using either clinical follow-up (n = 335) or intraoperative findings (n = 125) as the reference standard. In patients undergoing surgery, radiological staging of DD was correlated with the histopathology (weighted Cohen-k).

RESULTS

 224 patients (48.7 %) were diagnosed with DD. The sensitivity, specificity, PPV, and NPV were as follows. Group M1 / M2: 92 %/92 %, 97 %/94 %, 96 %/96 %, 94 %/89 %, respectively; group S1 / S2: 94 %/86 %, 93 %/80 %, 94 %/92 %, 93 %/67 %, respectively. Radiological staging and histopathology correlated substantially in all groups (k = 0.748-0.861).

CONCLUSION

 Abdominal CT had a high sensitivity and specificity for the diagnosis of DD. Disease staging correlated well with the findings at surgery. Additional positive rectal contrast administration did not have a significant advantage and may therefore be omitted in patients with suspected DD.

KEY POINTS

· CT has a high sensitivity and specificity for diagnosis of DD.. · CT staging using the CDD algorithm correlates very well with surgery.. · Positive rectal contrast administration does not improve diagnosis and radiological staging..

CITATION FORMAT

· Meyer S, Schmidbauer M, Wacker FK et al. To Fill or Not to Fill? - Value of the Administration of Positive Rectal Contrast for CT Evaluation of Diverticular Disease of the Colon. Fortschr Röntgenstr 2021; 193: 804 - 812.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

ACR Appropriateness Criteria® Left Lower Quadrant Pain-Suspected Diverticulitis

This review summarizes the relevant literature regarding imaging of suspected diverticulitis as an etiology for left lower quadrant pain, and imaging of complications of acute diverticulitis. The most common cause of left lower quadrant pain in adults is acute sigmoid or descending colonic diverticulitis. Appropriate imaging triage for patients with suspected diverticulitis should address the differential diagnostic possibilities and what information is necessary to make a definitive management decision. Patients with diverticulitis may require surgery or interventional radiology procedures because of associated complications, including abscesses, fistulas, obstruction, or perforation. As a result, there has been a trend toward greater use of imaging to confirm the diagnosis of diverticulitis, evaluate the extent of disease, and detect complications before deciding on appropriate treatment. Additionally, in the era of bundled payments and minimizing health care costs, patients with acute diverticulitis are being managed on an outpatient basis and rapid diagnostic imaging at the time of initial symptoms helps to streamline and triage patients to the appropriate treatment pathway. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute diverticulitis: old challenge, current trends, open questions

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.

Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis

BACKGROUND/OBJECTIVE

A preoperative reliable classification system between clinical and computed tomography (CT) findings to better plan surgery in acute complicated diverticulitis (ACD) is lacking. We studied the inter-observer agreement of CT scan data and their concordance with the preoperative clinical findings and the adherence with the intraoperative status using a new classification of diverticular disease (CDD).

METHODS

152 patients operated on for acute complicated diverticulitis (ACD) were retrospectively enrolled. All patients were studied with CT scan within 24 h before surgery and CT images were blinded reanalyzed by 2 couples of radiologists (A/B). Kappa value evaluated the inter-observer agreement between radiologists and the concordance between CDD, preoperative clinical findings and findings at operation. Univariate and multivariate analysis were used to evaluate the predicting values of CT classification and CDD stage at surgery on postoperative outcomes.

RESULTS

Overall inter-observer agreement for the CDD was high, with a kappa value of 0.905 (95% CI = 0.850-0.960) for observers A and B, while the concordance between radiological and surgical findings was weak (kappa values = 0.213 and 0,248, respectively and 95% CI = 0.106 to 0.319 and 95% CI = 0.142 to 0.355, respectively). When overall morbidity, mortality and the need of a terminal colostomy were considered as main endpoints no concordance was observed between surgical and radiological findings and the CDD (P=NS).

CONCLUSIONS

The need for a more accurate classification of ACD, able to better stage this emergency, and to provide surgeons with reliable information for the best treatment is advocated.

Conservative Treatment in Diverticulitis Patients with Pericolic Extraluminal Air and the Role of Antibiotic Treatment

BACKGROUND

Recently published studies advocate a conservative approach with observation and antibiotic treatment in diverticulitis patients with pericolic air on computed tomography (CT). The primary aim of this study was to assess the clinical course of initially conservatively treated diverticulitis patients with isolated pericolic air and to identify risk factors for conservative treatment failure. The secondary aim was to assess the outcome of non-antibiotic treatment.

METHODS

Patient data from a retrospective cohort study on risk factors for complicated diverticulitis were combined with data from the DIABOLO trial, a randomised controlled trial comparing non-antibiotic with antibiotic treatment in patients with uncomplicated diverticulitis. The present study identified all patients with Hinchey 1A diverticulitis with isolated pericolic air on CT. Pericolic air was defined as air located < 5 cm from the affected segment of colon. The primary outcome was failure of conservative management which was defined as need for percutaneous abscess drainage or emergency surgery within 30 days after presentation. A multivariable logistic regression of clinical, radiological and laboratorial parameters with respect to treatment failure was performed.

RESULTS

A total of 109 patients were included in the study. Fifty-two (48%) patients were treated with antibiotics. Nine (8%) patients failed conservative management, seven (13%) in the antibiotic treatment group and two (4%) in the non-antibiotic group (p = 0.083). Only (increased) CRP level at presentation was an independent predictor for treatment failure.

CONCLUSIONS

Conservative treatment in diverticulitis patients with isolated pericolic air is a suitable treatment strategy. Moreover, non-antibiotic treatment might be reasonable in selected patients.

Long-term quality of life after conservative treatment versus surgery for different stages of acute sigmoid diverticulitis

PURPOSE

It is controversial whether patients fare better with conservative or surgical treatment in certain stages of acute diverticulitis (AD), in particular when phlegmonous inflammation or covered micro- or macro-perforation are present. The aim of this study was to determine long-term quality of life (QoL) for AD patients who received either surgery or conservative treatment in different stages.

METHODS

We included patients treated for AD at the University Hospital Grosshadern, Munich, Germany, between January 1, 2000, and December 31, 2010. Patients were classified by the Hansen and Stock (HS) classification, the modified Hinchey classification, and the German classification of diverticular disease (CDD). Pre-therapeutic staging was based on multidetector computed tomography. Long-term QoL was assessed by the Cleveland Global Quality of Life (CGQL) questionnaire, the Short Form 36 (SF-36), and the Gastrointestinal Quality of Life Index (GIQLI). Data are mean ± SEM.

RESULTS

Patients with phlegmonous AD (HS type 2a, Hinchey Ia and CDD 1b, respectively) had a better long-term QoL on the GIQLI when they were operated (78.5 ± 2.5 vs. 70.7 ± 2.1; p < 0.05). Patients with micro-abscess (CDD 2a) had a better long-term QoL on the GIQLI, CGQL, and the "Role Physical" scale of the SF-36 when they were not operated (GIQLI 86.9 ± 2.1 vs. 76.8 ± 1.0; p = 0.10; CGQL 82.8 ± 5.1 vs. 65.3 ± 11.0; p = 0.08; SF-36/Role Physical 100 ± 0.0 vs. 41.7 ± 13.9; p < 0.001). Patients with macro-abscess (CDD 2b) had a better long-term QoL when they were operated (GIQLI 89.3 ± 1.4 vs. 69.5 ± 4.5; p < 0.01; CGQL 80.3 ± 7.6 vs. 60.5 ± 5.8; p < 0.05; SF-36/Role Physical 95.8 ± 4.2 vs. 47.9 ± 13.6; p < 0.001).

CONCLUSION

Considering long-term QoL, phlegmonous AD (HS type 2a, Hinchey Ia and CDD 1b, respectively) should be treated conservatively. In patients with covered perforation, abscess size should guide the decision on whether to perform surgery later on or not. In the light of long-term quality of life, patients fare better after elective sigmoid colectomy when abscess size exceeds 1 cm.

Randomised clinical trial: mesalazine versus placebo in the prevention of diverticulitis recurrence

BACKGROUND

Previous studies have reached conflicting conclusions regarding the efficacy of mesalazine in the prevention of recurrent diverticulitis.

AIM

To investigate the efficacy and safety of mesalazine granules in the prevention of recurrence of diverticulitis after acute uncomplicated diverticulitis.

METHODS

Two phase 3, randomised, placebo-controlled, double-blind multicentre trials (SAG-37 and SAG-51) investigated mesalazine granules in patients with prior episodes (<6 months) of uncomplicated left-sided diverticulitis. Patients were randomised to receive either 3 g mesalazine once daily or placebo (SAG-37, n=345) or to receive either 1.5 g mesalazine once daily, 3 g once daily or placebo for 96 weeks (SAG-51, n=330). The primary endpoint was the proportion of recurrence-free patients during 48 weeks (SAG-37 and SAG-51) or 96 weeks (SAG-51) of treatment.

RESULTS

Mesalazine did not increase the proportion of recurrence-free patients over 48 or 96 weeks compared to placebo. In SAG-37, the proportion of recurrence-free patients during 48 weeks was 67.9% with mesalazine and 74.4% with placebo (P=.226). In SAG-51, the proportion of recurrence-free patients over 48 weeks was 46.0% with 1.5 g mesalazine, 52.0% with 3 g mesalazine and 58.0% with placebo (P=.860 for 3 g mesalazine vs placebo) and over 96 weeks 6.9%, 9.8% and 23.1% respectively (P=.980 for 3 g mesalazine vs placebo). Patients with only one diverticulitis episode in the year prior to study entry had a lower recurrence risk compared to >1 episode. Safety data revealed no new adverse events.

CONCLUSION

Mesalazine was not superior to placebo in preventing recurrence of diverticulitis.

[Prognostic value of the presence of pericolic air bubbles detected by computed tomography in acute diverticulitis]

BACKGROUND

Diverticular disease is common in industrialized countries. Computed tomography has been used as the preferred diagnostic method; although different scales haves been described to classify the disease, none of them encompass total disease aspects and behaviour.

OBJETIVE

To analyze the patients with acute diverticulitis confirmed by computed tomography at the ABC Medical Center Campus Observatorio from January 1, 2010 to December 31, 2012, in whom pericolic free air in the form of bubbles was identified by computed tomography and if this finding can be considered as a prognostic factor for the disease.

METHODS

A series of 124 patients was analyzed who had acute diverticulitis confirmed by computed tomography, in order to identify the presence of pericolic bubbles.

RESULTS

Of the 124 patients, 29 presented with pericolic bubbles detected by computed tomography; of these, 62.1% had localized peritoneal signs at the time of the initial assessment, (P<.001); leukocytosis (13.33 vs 11.16, P<.001) and band count (0.97 vs 0.48, P<.001) was higher in this group. Patients with pericolonic bubbles had a longer hospital stay (5.5days vs 4.3days, P<.001) and started and tolerated liquids later (4.24days vs. 3.02days, P<.001) than the group of patients without this finding.

CONCLUSIONS

The presence of pericolic bubbles in patients with acute diverticulitis can be related to a more aggressive course of the disease.

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.

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

BACKGROUND

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

AIM

To create formal guidelines for diagnosis and management.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relation between quality of life and histopathology in diverticulitis; can we predict specimen-related outcome?

PURPOSE

An important factor in the decision to perform laparoscopic sigmoid resection for patient suffering from recurrent and ongoing diverticulitis is quality of life (QoL). It is unknown whether quality of life relates to the severity of diverticulitis as seen in the resected colonic segment. The aim of this study is to analyze histopathological findings of patients suffering from recurrent or ongoing diverticulitis and their QoL before and after surgery in order to improve patient outcome prediction.

METHODS

A cohort of consecutive patients with diverticulitis between January 2010 and April 2014 was analyzed. All patients were scheduled for surgery and had at least three episodes of diverticulitis or more within the last 2 years or experienced ongoing complaints for at least 3 months or more and confirmation by a radiologist. We compared QoL questionnaires, to known histopathological entities.

RESULTS

For this study, 54 consecutive patients were included, 15 (27.8%) men and 39 (72.2%) women. A marked difference in quality of life before and after surgery for patients having a more severe histopathological entity was not found (p = 0.83). However, a clinically relevant higher VAS score 6 months after surgery was shown in patients with peritonitis. Furthermore, these patients had more fibrosis in the histopathological samples.

CONCLUSION

In conclusion, even though a relation between the different pathological entities and QoL could not be determined, patients with diverticulitis and concomitant microscopic peritonitis had significantly more fibrosis and suffered from a higher VAS scores 6 months after surgery.

Diagnosis, Differential Diagnoses, and Classification of Diverticular Disease

Background

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

Methods

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

Results

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

Conclusion

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

[Diverticular disease - diagnosis and classification]

A reliable diagnosis is fundamental for operative, interventional and conservative treatment of the different facets of diverticular disease. Not only differential diagnoses but also overlap or coincidence with other entities sharing similar symptoms must be considered. Furthermore, an adequate surgical strategy and correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and Visceral Surgery (DGAV) has released a new classification of diverticulitis displaying the different facets of diverticular disease. This classification also comprises symptomatic uncomplicated diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding. While detailed history, physical examination and laboratory testing are of great importance for exploring a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging using ultrasonography (US) or computed tomography (CT). The diagnostic value of qualified US is equipotent to qualified CT, complies with relevant legislation for radiation exposure protection and is frequently effective for diagnosis. Therefore, US is considered to be the first choice for imaging in diverticular disease. In contrast, CT has definite indications in unclear, discrepant situations or insufficient US performance. Strengths and weaknesses of both methods are discussed. Endoscopy is not required for the diagnosis of diverticulitis and should not be performed in an acute attack. Colonoscopy, however, is warranted after healing of diverticulitis, prior to elective surgery and in cases of an atypical course. Prior exclusion of perforation is considered mandatory. An unequivocal indication for colonoscopy is diverticular bleeding and the rapid performance (within 12-24 h) allows better identification of sites of bleeding and endoscopic interventions.

Preoperative staging of perforated diverticulitis by computed tomography scanning

Background

Treatment of perforated diverticulitis depends on disease severity classified according to Hinchey’s preoperative classification. This study assessed the accuracy of preoperative staging of perforated diverticulitis by computerized tomography (CT) scanning.

Methods

All patients who presented with perforated diverticulitis between 1999 and 2009 in two teaching hospitals of Rotterdam, the Netherlands, and in addition had a preoperative CT scan within 24 h before emergency surgery were included. Two radiologists reviewed all CT scans and were asked to classify the severity of the disease according to the Hinchey classification. The CT classification was compared to Hinchey’s classification at surgery.

Results

Seventy-five patients were included, 48 of whom (64 %) were classified Hinchey 3 or 4 perforated diverticulitis during surgery. The positive predictive value of preoperative CT scanning for different stages of perforated diverticulitis ranged from 45 to 89 %, and accuracy was between 71 and 92 %. The combination of a large amount of free intra-abdominal air and fluid was strongly associated with Hinchey 3 or 4 and therefore represented a reliable indicator for required surgical treatment.

Conclusions

The accuracy of predicting Hinchey’s classification by preoperative CT scanning is not very high. Nonetheless, free intra-abdominal air in combination with diffuse fluid is a reliable indication for surgery as it is strongly associated with perforated diverticulitis with generalized peritonitis. In 42 % of cases, Hinchey 3 perforated diverticulitis is falsely classified as Hinchey 1 or 2 by CT scanning.

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment

BACKGROUND

In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA.

METHODS

The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed.

RESULTS

There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23).

CONCLUSIONS

Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.

How complicated is complicated diverticulitis?--phlegmonous diverticulitis revisited

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Emergency surgery in colonic diverticulitis in an Asian population

INTRODUCTION

Diverticulitis in Asians differs significantly from their Western counterparts in various aspects. This study was performed to highlight our institution's surgical experiences in patients with diverticulitis. The secondary aim was to compare the patients who underwent surgery for right- and left-sided diverticulitis.

METHODS

A retrospective review of all patients who underwent emergency surgery in patients with acute diverticulitis from July 2003 to April 2008 was performed. Right-sided pathology was regarded if it was located from the caecum till the transverse colon. Left-sided disease was regarded if it commenced from the splenic flexure.

RESULTS

The study group comprised of 104 patients, 68 (65.4%) of whom had right-sided diverticulitis. Caecum was the commonest site of disease, and the majority had only mild disease. In the 36 (34.6%) patients with left-sided diverticulitis, majority (63.8%) had an ASA score of three or four, with the sigmoid colon being the most common site of involvement. Most (91.7%) had worse peritoneal contamination with Hartmann's procedure being performed in 22 (61.1%) patients. Worse peri-operative outcome was also seen in this group. After multivariate analysis, the independent factors for right-sided disease were younger age, lower ASA score and no necessity for stoma.

CONCLUSIONS

In an Asian population, surgery in right-sided diverticulitis is more commonly performed and is associated with lower morbidity and mortality. Patients who underwent surgery for right-sided diverticulitis were younger, with lower ASA score and less likely to have stoma created.

Sigmoid diverticulitis in young patients--a more aggressive disease than in older patients?

INTRODUCTION

There is controversy over whether sigmoid diverticulitis (SD) is more aggressive with a higher risk of perforation in younger than in older patients. The aim of this study was to assess the clinical presentation and outcome of patients ≤40 and >40 years old with acute diverticulitis.

PATIENTS AND METHODS

Consecutive admissions of all patients with acute SD were prospectively recruited from January 1998 to June 2010.

RESULTS

A total of 1,019 patients were included: 513 (69 ≤40 years and 444 >40 years) presented with their first episode, while 506 (20 ≤40 years, 486 >40 years) had a prior history of SD. The percentage of patients with severe SD did not differ between the two age groups either for the first (covered perforation, 30.4% vs. 29.5%, p = 0.875; free perforation, 26.1% vs. 23.9%, p = 0.69) or for the recurrent episode (covered perforation, 15% vs. 8.2%, p = 0.287; free perforation, 5% vs. 4.1%, p = 0.846). Furthermore, the rate of emergency surgery did not differ between both age groups either for the first (26.1% vs. 23.9%, p = 0.690) or the recurrent episode (5% vs. 4.1%, p = 0.846). No differences in the rate of Hartmann's procedure (52.6% vs. 68.3%, p = 0.180) and failure of conservative treatment (3.4% vs. 4.9%, p = 0.607) were observed between younger and older patients.

CONCLUSION

Acute SD in younger patients is not more aggressive and has no higher risk of perforation or need for emergency surgery compared to older patients.