Long-term outcome after conservative and surgical treatment of acute sigmoid diverticulitis

Does surgery improve quality of life in patients with ongoing- or recurrent diverticulitis; a systematic review and meta-analysis

BACKGROUND

Recurrences or persistent symptoms after an initial episode of diverticulitis are common, yet surgical treatment is rarely performed. Current guidelines lack clear recommendations on whether or not to operate, even though recent studies suggest an improved quality of life following surgery. The aim of this study is therefore to compare quality of life in patients with recurrent or ongoing diverticulitis treated conservatively versus surgically, giving a more definitive answer to the question of whether or not to operate on these patients.

METHODS

A systematic literature search was conducted in EMBASE, MEDLINE and Cochrane. Only comparative studies reporting on quality of life were included. Statistical analysis included calculation of weighted mean differences and pooled odds ratios.

RESULTS

Five studies were included; two RCT's and three retrospective observational studies. Compared to conservative treatment, the SF-36 scores were higher in the surgically treated group at each follow-up moment but only the difference in SF-36 physical scores at six months follow-up was statistically significant (MD 6.02, 95%CI 2.62-9.42). GIQLI scores were also higher in the surgical group with a MD of 14.01 (95%CI 8.15-19.87) at six months follow-up and 7.42 (95%CI 1.23-12.85) at last available follow-up. Also, at last available follow-up, significantly fewer recurrences occurred in the surgery group (OR 0.10, 95%CI 0.05-0.23, p < 0.001).

CONCLUSION

Although surgery for recurrent diverticulitis is not without risk, it might improve long-term quality of life in patients suffering from recurrent- or ongoing diverticulitis when compared to conservative treatment. Therefore, it should be considered in this patient group.

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.

Recurrence of diverticulitis after prophylactic sigmoidectomy: an underestimated problem?

AIM

Several papers have been published about the risk of recurrence after an attack of diverticulitis treated conservatively. However, very few papers have been devoted to the risk of postoperative recurrence of diverticulitis (PRD) after prophylactic sigmoidectomy (PS). The aim of this work was to report the rate of PRD after PS and to assess possible risk factors for recurrence after surgery.

METHOD

All consecutive patients who underwent elective laparoscopic PS for diverticulitis between 2005 and 2019 were retrospectively included. PRD was assessed.

RESULTS

Three hundred and sixty four patients (199 men, mean age 54 ± 13 years) were included. Among these, 26 (7%) presented with 1.7 ± 1 (range 1-4) episodes of recurrence of diverticulitis after a mean delay of 44 ± 39 months (1 month-11 years) after surgery. Patients who presented with postoperative recurrence of diverticulitis were younger (46 ± 11 vs. 55 ± 13 years, p = 0.002) and more frequently had uncomplicated diverticulitis [15/26 (58%) vs. 97/338 (29%), p = 0.002] and more than two previous episodes before PS [17/26 (65%) vs. 132/338 (39%), p = 0.009] than patients without PRD. After multivariate analysis, two independent risk factors for PRD were identified: patients with more than two episodes before PS (OR = 3.3, 95% CI = 1.2-9, p = 0.005) and age < 50 years (OR = 4.5, 95% CI = 2-11, p = 0.001). If both factors were present, recurrence reached 18% (9/51).

CONCLUSION

Postoperative recurrence of diverticulitis is rare (7%) after PS for diverticulitis. Some patients (i.e. those with more than two episodes before PS and/or age <50 years) could be exposed to a higher risk of recurrence (up to 18%), making prophylactic surgery questionable in these patients.

The outcomes of right-sided and left-sided colonic diverticulitis following non-operative management: a systematic review and meta-analysis

Background

There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD.

Methods

A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure.

Results

Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8–13%, I² = 86%, p < 0.01) in right-sided and 20% (95% CI 16–24%, I² = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6–13%, I² = 77%, p < 0.01) in right-sided and 15% (95% CI 8–27%, I² = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2–10%, I² = 84%, p < 0.01) in right-sided and 4% (95% CI 2–7%, I² = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited.

Conclusion

Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.

Elective surgical versus conservative management of complicated diverticulitis: A systematic review and meta-analysis

OBJECTIVES

There is no consensus on the optimal treatment for patients with complicated diverticulitis. In this systematic review and meta-analysis we aimed to determine the indications for elective surgery in complicated diverticulitis by comparing conservative treatment with elective surgery.

METHODS

A meta-analysis of recurrence, morbidity and stoma rates was performed using a random effects model. Patient-reported quality of life (QoL) and cost-effectiveness outcomes were synthesized qualitatively.

RESULTS

Eleven randomized controlled trials and non-randomized studies with a total of 7415 patients were included. In statistical terms, the recurrence of diverticulitis was significantly higher in the conservatively treated group than in the elective surgery group (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.51). The stoma rate (OR 2.34, 95% CI 1.88-2.92) and the morbidity rate (OR 4.29, 95% CI 2.24-8.23) were significantly higher in the elective surgery group than in the conservatively treated group. There was some evidence for a significant increase in QoL and long-term cost-effectiveness in the elective surgery group than in the conservatively treated group.

CONCLUSIONS

Indications for elective surgery should not include the prevention of emergency colostomy or complications. Elective surgical resection may be considered in patients with complicated diverticulitis with the goal of improving their QoL and long-term cost-effectiveness.

Update on the management of sigmoid diverticulitis

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

Surgical resection does not avoid the risk of diverticulitis recurrence-a systematic review of risk factors

PURPOSE

Fifteen percent of patients undergoing elective sigmoidectomy will present a diverticulitis recurrence, which is associated with significant costs and morbidity. We aimed to systematically review the risk factors associated with recurrence after elective sigmoidectomy.

METHODS

PubMed/MEDLINE, Embase, Cochrane, and Web of Science were searched for studies published until May 1, 2020. Original studies were included if (i) they included patients undergoing sigmoidectomy for diverticular disease, (ii) they reported postoperative recurrent diverticulitis, and (iii) they analyzed ≥ 1 variable associated with recurrence. The primary outcome was the risk factors for recurrence of diverticulitis after sigmoidectomy.

RESULTS

From the 1463 studies initially screened, six studies were included. From the 1062 patients included, 62 patients recurred (5.8%), and six variables were associated with recurrence. Two were preoperative: age (HR = 0.96, p = 0.02) and irritable bowel syndrome (33.3% with recurrence versus 12.1% without recurrence, p = 0.02). Two were operative factors: uncomplicated recurrent diverticulitis as indication for surgery (73.3% with recurrence versus 49.9% without recurrence, p = 0.049) and anastomotic level (colorectal: HR = 11.4, p = 0.02, or colosigmoid: OR = 4, p = 0.033). Two were postoperative variables: the absence of active diverticulitis on pathology (39.6% with recurrence versus 26.6% without recurrence) and persistence of postoperative pain (HR = 4.8, p < 0.01).

CONCLUSION

Identification of preoperative variables that predict the occurrence of diverticulitis recurrence should help surgical decision-making for elective sigmoidectomy, while peri- and postoperative factors should be taken into account for optimal patient follow-up.

Recurrence of Acute Right Colon Diverticulitis Following Nonoperative Management: A Systematic Review and Meta-analysis

BACKGROUND

There are currently no guidelines on the management of right colon diverticulitis. Treatment options have been extrapolated from the management of left-sided diverticulitis. Gaining knowledge of the risk and morbidity of diverticulitis recurrence is integral to weighing the benefit of elective surgery for right-sided diverticulitis.

OBJECTIVE

The purpose of this study was to summarize the recurrence rate and the morbidity of recurrence of Hinchey classification I/II, right-sided diverticulitis following nonoperative management.

DATA SOURCES

PubMed, EMBASE, and Cochrane Database of Collected Reviews were searched up to June 2019.

STUDY SELECTION

Observational cohort studies evaluating outcomes following nonoperative management were reviewed. No randomized controlled trials were available.

INTERVENTIONS

Intravenous antibiotics with or without percutaneous drainage of associated abscess were administered.

MAIN OUTCOME MEASURES

The primary outcomes measured were the recurrence rate and morbidity associated with recurrence. Two independent investigators extracted data. The rates of recurrence were pooled by using a random-effects model.

RESULTS

There were 1584 adult participants from a total of 11 studies (9 retrospective cohort and 2 prospective cohort studies) included in the analysis. Over a median follow-up period of 34.2 months, the pooled recurrence rate was 12% (95% CI, 10%-15%). Twenty of 202 patients (9.9%) required urgent surgery at the time of first recurrence. There was no mortality. Subset analysis excluding 3 studies that included percutaneous drainage as a nonoperative treatment option did not change the recurrence rate (12% (95% CI, 9%-15%)) or heterogeneity. Funnel plot assessment revealed no publication bias.

LIMITATIONS

There were no randomized controlled trials available. The statistical heterogeneity was moderate (I = 46%).

CONCLUSIONS

Nonoperative management of Hinchey I/II right-sided diverticulitis is safe and feasible. The recurrence rate is relatively low, and complications that require urgent operation are uncommon.

PROSPERO

CRD42019131673.

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

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

Elective Laparoscopic Sigmoid Colectomy for Diverticulitis-an Updated Look at Recurrence After Surgery

BACKGROUND

Surgical management of diverticulitis is evolving and the decision to offer elective sigmoidectomy for diverticulitis has become more individualized. However, preoperative variables that may predict recurrent diverticulitis after resection and guide surgical decision-making were not well studied.

METHODS

This was a retrospective chart review with a prospective questionnaire follow-up of patients. Patients who underwent elective sigmoidectomy for diverticulitis from 2002 to 2016 at a tertiary academic colorectal surgery practice were included and their medical records reviewed. They were then contacted with a questionnaire to inquire about recurrence of diverticulitis since resection. The primary outcome was rate of recurrent diverticulitis after elective sigmoidectomy. The secondary outcome was risk factors for recurrence after sigmoidectomy.

RESULTS

Of 662 patients who underwent elective sigmoidectomy for diverticulitis, 361 had long-term follow-up data available. Mean follow-up was 86 months. Indication for surgery was uncomplicated recurrent diverticulitis in 50%. Recurrent diverticulitis developed in 15 (4.2%) patients. Mean time to recurrence was 55 (range, 6-109) months. All recurrences were confirmed by CT scan. Univariate analysis showed that preoperative diagnosis of irritable bowel syndrome and uncomplicated recurrent diverticulitis was significantly more prevalent in patients who experienced recurrent diverticulitis after sigmoidectomy (p = 0.049 and p = 0.02); however, these variables did not predict recurrence after resection.

CONCLUSIONS

Overall rate of recurrent diverticulitis after elective sigmoidectomy was 4.2%. Preoperative diagnosis of irritable bowel syndrome and uncomplicated recurrent diverticulitis was associated with but not significant predictor of recurrence after elective resection.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Surgical Management of Diverticular Disease in the Elective Setting

Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.

A novel endoscopic grading system for prediction of disease-related outcomes in patients with diverticulosis

BACKGROUND

We describe a simple endoscopic grading system of diverticular disease for the assessment of disease severity and prediction of outcomes.

METHODS

A retrospective analysis of prospectively maintained colonoscopy database was conducted. A single endoscopist prospectively graded disease severity according to the number and size of diverticula, the degree of muscular hypertrophy and rigidity of the sigmoid colon.

RESULTS

762 patients were included in the analysis. Mean patient age was 70 years (range 37-97). Endoscopic severity of diverticulosis was predictive of the need for surgery, with 2% in the mild-moderate, 12% in the severe and 33% in the acute group (p < 0001). Time to surgery showed correlation to severity grade, with mean periods of 107.5 months in the moderate group vs. 3 and 2.5 months in the severe and acute group (p < 0001). The mean follow up was 11 years.

CONCLUSION

Surgeons should consider using endoscopic grading as an adjunct to clinical management decisions.

Long-term outcomes of sigmoid diverticulitis: a single-center experience

BACKGROUND

During the last decade, guidelines for the treatment of sigmoid diverticulitis have dramatically changed. The aim of this study is to report the long-term outcomes of patients treated for diverticulitis at a nonspecialized single center.

MATERIALS AND METHODS

After obtaining institutional review board approval, medical records of all patients admitted to our institution with the diagnosis of sigmoid diverticulitis between 1998 and 2008 were reviewed. A follow-up of at least 5 years was required.

RESULTS

During the study period, 266 patients were admitted to our hospital due to sigmoid diverticulitis with a mean follow-up period of 120 ± 2 months. Of the entire cohort, 249 patients (93.5%) were treated conservatively and 17 (6.5%) patients required emergent surgery on initial presentation. Patients treated conservatively (n = 249) encountered a median of two recurrent episodes (range 0-4). During follow-up, none of these patients required emergent surgery, and 27 patients (11%) underwent elective surgery for recurrent episodes (n = 24), chronic smoldering disease (n = 2), and fistula (n = 1). Minor and major complication rates after elective surgery were 18.5% and 30%, respectively. Specifically, four patients (15%) suffered an anastomotic leak (AL). Late complications after elective surgery occurred in 33% of patients including incisional hernias (11%), bowel obstruction (3.7%), anastomotic stenosis (3.7%), and recurrent diverticulitis (15%).

CONCLUSIONS

Patients treated conservatively during their index admission for sigmoid diverticulitis do not require emergent surgery during long-term follow-up and the majority of patients (89%) do not require elective surgery. Elective sigmoidectomy at nonspecialized centers may result in high rates of recurrent diverticulitis (15%) and anastomotic leak (15%).

Sigmoid resection for diverticulitis is more difficult than for malignancies

PURPOSE

Sigmoid resection for diverticulitis is usually the first procedure performed when starting the learning process for laparoscopic colorectal surgery. The aim of this study is to evaluate the difficulty of laparoscopic sigmoid resection for diverticulitis in comparison to sigmoid malignancy in order to assess its role in the residents training program.

METHODS

A cohort of patients was selected who suffered either from malignancy or recurrent diverticulitis in the sigmoid colon. Laparoscopic sigmoid resection was performed. The degree of difficulty was assessed by intraoperative complications and intraoperative technical challenges. Furthermore, take-overs from assistant to surgeon, surgeon to surgeon, and conversion were reported.

RESULTS

A total of 224 patients were included, 119 (53.1%) men and 105 (46.9%) women. Patients suffering from diverticulitis had significantly less co-morbidities than those with malignancies. In the diverticulitis group, there were significantly more technical challenges. There was a higher rate in take-overs from residents (p = 0.02) as well as surgeon to surgeon (p = 0.04). The rate of conversions was also significantly higher in the diverticulitis group (p = 0.03) when compared to the malignancy group.

CONCLUSIONS

The outcomes of our study show that diverticulitis may not be the ideal condition to start the learning process for laparoscopic colorectal surgery.

Outcomes of colonic diverticulitis according to the reason of immunosuppression

BACKGROUND

The aims of this study were to analyze the relationship between the different causes of immunosuppression (IMS) and diverticulitis.

METHODS

IMS patients admitted for colonic diverticulitis were included in the study. Patients were divided in 5 groups according to the reasons of IMS: group I, chronic corticosteroid therapy; group II, transplant patients; group III, malignant neoplasm disease; group IV, chronic renal failure; group V, others immunosuppressant treatment. Rate of emergency surgery, outcomes in terms of postoperative mortality, and recurrence rate after nonoperative management were analyzed according to the reason of IMS.

RESULTS

Emergency surgery was performed in 76 patients (39.3%). It was needed more frequently in group I. Overall, postoperative mortality was of 31.6% and recurrence rate after successful nonoperative management occurred in 30 patients (27.8%). No differences were observed among the groups.

CONCLUSIONS

The rate of emergency surgery in IMS patients at the first episode of acute colonic diverticulitis is high. Elective surgery in IMS patients should be individually indicated according to persistence of symptoms or early recurrences.

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.

Recurrences and Ongoing Complaints of Diverticulitis; Results of a Survey among Gastroenterologists and Surgeons

OBJECTIVE

This study aims to investigate the current opinion of gastroenterologists and surgeons on treatment strategies for patients, with recurrences or ongoing complaints of diverticulitis.

BACKGROUND

Treatment of recurrences and ongoing complaints remains a point of debate. No randomized trials have been published yet and guidelines are not uniform in their advice.

DESIGN

A web-based survey was conducted among gastroenterologists and GE-surgeons. Questions were aimed at the treatment options for recurrent diverticulitis and ongoing complaints.

RESULTS

In total, 123 surveys were filled out. The number of patients with recurrent or ongoing diverticulitis who were seen at the outpatient clinic each year was 7 (0-30) and 5 (0-115) respectively. Surgeons see significantly more patients on an annual basis 20 vs. 15% (p = 0.00). Both surgeons and gastroenterologists preferred to treat patients in a conservative manner using pain medication and lifestyle advise (64.4 vs. 54.0, p = 0.27); however, gastroenterologists would treat patients with mesalazine medication, which is significantly more (28%, p = 0.04) than in the surgical group. Surgeons are inclined more towards surgery (31.5%, p = 0.02).

CONCLUSIONS

Both surgeons and gastroenterologists prefer to treat recurrent diverticulitis and ongoing complaints in a conservative manner. Quality of life, the risk of complications and the viewpoint of the patient are considered important factors in the decision to resect the affected colon.

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.

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

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

Primary anastomosis with a defunctioning stoma versus Hartmann's procedure for perforated diverticulitis--a comparison of stoma reversal rates

PURPOSE

The ideal treatment of patients with perforated diverticulitis is still controversial. Hartmann's procedure has been the treatment of choice for decades, but primary anastomosis with a defunctioning stoma has become an accepted alternative. The aim of this study was to evaluate the stoma reversal rates after these two surgical strategies.

METHODS

A retrospective review of the data from patients with perforated sigmoid diverticulitis between 2002 and 2011 undergoing a Hartmann's procedure (HP) versus a primary anastomosis with a defunctioning stoma (PA) was performed. Additionally, patients were contacted by mail or telephone in March 2012 using a standardized questionnaire.

RESULTS

A total of 98 patients were identified: 72 undergoing HP and 26 patients receiving PA. The median follow-up time was 63 months (range 4-118). Whilst 85 % of patients with PA have had their stoma reversed, only 58 % of patients with an HP had a stoma reversal (p = 0.046). The median period until stoma reversal was significantly longer for HP (19 weeks) than for PA (12 weeks; p = 0.03). The 30-day mortality for PA was 12 % as opposed to 25 % for HP (p = 0.167). According to the Clavien-Dindo classification, surgical complications occurred significantly less frequently in patients with PA (p = 0.014).

CONCLUSION

The stoma reversal rates for PA are significantly higher than for HP. Thus, depending on the overall clinical situation, primary resection and anastomosis with a proximal defunctioning stoma might be the optimal procedure for selected patients with perforated diverticular disease.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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