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Carabotti M, Sgamato C, Amato A, Beltrame B, Binda GA, Germanà B, Leandro G, Pasquale L, Peralta S, Viggiani MT, Severi C, Annibale B, Cuomo R. Italian guidelines for the diagnosis and management of colonic diverticulosis and diverticular disease. Dig Liver Dis 2024:S1590-8658(24)00841-7. [PMID: 39004551 DOI: 10.1016/j.dld.2024.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Abstract
Colonic diverticulosis and diverticular disease are among the most common gastrointestinal disorders encountered in clinical practice. These Italian guidelines focus on the diagnosis and management of diverticulosis and diverticular disease in the adult population, providing practical and evidence-based recommendations for clinicians. Experts from five Italian scientific societies, constituting a multidisciplinary panel, conducted a comprehensive review of meta-analyses, systematic reviews, randomised controlled trials, and observational studies to formulate 14 PICO questions. The assessment of the quality of the evidence and the formulation of the recommendations were carried out using an adaptation of the GRADE methodology. The guidelines covered the following topics: i) Management of diverticulosis; ii) Symptomatic uncomplicated diverticular disease: diagnosis and treatment; iii) Acute diverticulitis: diagnosis and treatment; iv) Management of diverticular disease complications; v) Prevention of recurrent acute diverticulitis; vi) Interventional management of diverticular disease.
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Affiliation(s)
- Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Costantino Sgamato
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
| | | | - Benedetta Beltrame
- Department of Technical-Health Care Professions Dietetics Unit- AUSL Toscana Centro Santa Maria Nuova Hospital, Italy
| | | | - Bastianello Germanà
- Gastroenterology and Digestive Endoscopy San Martino Hospital, Belluno, Italy
| | | | - Luigi Pasquale
- Gastroenterology and Digestive Endoscopy, Avellino, Italy
| | - Sergio Peralta
- UOS Diagnostic and Interventional Digestive Endoscopy AOU Policlinico P.Giaccone, Palermo, Italy
| | | | - Carola Severi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Rosario Cuomo
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
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Sokhal BS, Mostafa OES, Ramasamy S, Spyridon R, Zaman S, Hajibandeh S, Hajibandeh S. Level 1a Evidence Comparing Use of Antibiotics Versus No Antibiotics in Management of Acute Left-Sided Uncomplicated Diverticulitis. Am Surg 2024; 90:1167-1175. [PMID: 38205505 DOI: 10.1177/00031348241227183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Acute uncomplicated diverticulitis (AUD) is a common cause of acute abdominal pain. Recent guidelines advise selective use of antibiotics in AUD patients. This meta-analysis aimed to compare the effectiveness of no antibiotics vs antibiotics in AUD patients. METHODS This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify randomized controlled trials (RCTs) involving AUD patients which compared the use of antibiotics with no antibiotics. Pooled outcome data was calculated using random effects modeling with 95% confidence intervals (CIs). RESULTS 5 RCTs with 1934 AUD patients were included. 979 patients were managed without antibiotics (50.6%). Patients in the no antibiotic and antibiotic groups had comparable demographics (age, sex, and body mass index) and presenting features (temperature, pain score, and C-reactive protein levels). There was no significant difference in rates of complicated diverticulitis (OR: .61, 95% CI: 0.27-1.36, P = .23), abscess (OR: .51, 95% CI: .08-3.25, P = .47) or fistula (OR: .33, 95% CI: .03-3.15, P = .33) formation, perforation (OR: .98, 95% CI: .32-3.07, P = .98), recurrence (OR: .96, 95% CI: .66-1.41, P = .85), need for surgery (OR: 1.36, 95% CI: .47-3.95, P = .37), mortality (OR: 1.27, 95% CI: .14-11.76, P = .82), or length of stay (MD: .215, 95% CI: -.43-.73, P = .61) between the 2 groups. However, the likelihood of readmission was higher in the antibiotics group (OR: 2.13, 95% CI: 1.43-3.18, P = .0002). CONCLUSION There is no significant difference in baseline characteristics, clinical presentation, and adverse health outcomes between AUD patients treated without antibiotics compared to with antibiotics.
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Affiliation(s)
| | | | - Sadhasivam Ramasamy
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Roditis Spyridon
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Shafquat Zaman
- Department of General Surgery, Russells Hall Hospital, Dudley Group NHS Trust, Dudley, UK
| | - Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
- Department of General Surgery, University Hospitals Coventry & Warwickshire, Coventry, UK
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Mohamedahmed AY, Zaman S, Das N, Kakaniaris G, Vakis S, Eccersley J, Thomas P, Husain N. Systematic review and meta-analysis of the management of acute uncomplicated diverticulitis: time to change traditional practice. Int J Colorectal Dis 2024; 39:47. [PMID: 38578433 PMCID: PMC10997545 DOI: 10.1007/s00384-024-04618-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND To evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey grade 1a) acute diverticulitis. METHODS A systematic online search was conducted using electronic databases. Comparative studies of OP versus IP treatment and ABX versus NABX approach in the treatment of Hinchey grade 1a acute diverticulitis were included. Primary outcome was recurrence of diverticulitis. Emergency and elective surgical resections, development of complicated diverticulitis, mortality rate, and length of hospital stay were the other evaluated secondary outcome parameters. RESULTS The literature search identified twelve studies (n = 3,875) comparing NABX (n = 2,008) versus ABX (n = 1,867). The NABX group showed a lower disease recurrence rate and shorter length of hospital stay compared with the ABX group (P = 0.01) and (P = 0.004). No significant difference was observed in emergency resections (P = 0.33), elective resections (P = 0.73), development of complicated diverticulitis (P = 0.65), hospital re-admissions (P = 0.65) and 30-day mortality rate (P = 0.91). Twelve studies (n = 2,286) compared OP (n = 1,021) versus IP (n = 1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P = 0.10), emergency surgical resection (P = 0.40), elective resection (P = 0.30), disease recurrence (P = 0.22), and mortality rate (P = 0.61). CONCLUSION Observation-only treatment is feasible and safe in selected clinically stable patients with uncomplicated acute diverticulitis (Hinchey 1a classification). It may provide better outcomes including decreased length of hospital stay. Moreover, the OP approach in treating patients with Hinchey 1a acute diverticulitis is comparable to IP management. Future high-quality randomised controlled studies are needed to understand the outcomes of the NABX approach used in an OP setting in managing patients with uncomplicated acute diverticulitis.
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Affiliation(s)
- Ali Yasen Mohamedahmed
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Shafquat Zaman
- Department of General Surgery, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK.
- Institute of Cancer and Genomic Science, College of Medical and Dental Science, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Niloy Das
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Georgios Kakaniaris
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Stelios Vakis
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - James Eccersley
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Pradeep Thomas
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Najam Husain
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
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Serrano González J, Román García de León L, Galindo Jara P, Lucena de la Poza JL, Sánchez Movilla A, Colao García L, García Schiever JG, Varillas Delgado D. Non-antibiotic treatment of uncomplicated acute diverticulitis is applicable and safe in our environment. A prospective multicenter study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:140-147. [PMID: 37929981 DOI: 10.17235/reed.2023.9737/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
INTRODUCTION acute diverticulitis is one of the most frequent underlying causes behind individuals attending the Emergency Room with abdominal pain. The most widespread therapy for acute uncomplicated diverticulitis includes outpatient treatment with antibiotics; however, several publications indicate that patients can also be successfully treated without antibiotics. The results of the implementation of this more recent protocol in two hospitals in Madrid are presented. METHODS an observational prospective study was performed. Participants were patients diagnosed with uncomplicated acute diverticulitis at two hospitals in Madrid, Hospital Universitario de Torrejón and Hospital Universitario Puerta de Hierro Majadahonda, between December 2018 and August 2021, treated on an outpatient basis without antibiotic therapy. The study group was compared with a control group, composed of patients diagnosed with uncomplicated acute diverticulitis and treated with outpatient antibiotic therapy at Hospital Universitario Puerta de Hierro between March 2015 and March 2018. RESULTS three hundred and sixty-one patients were included, 182 in the study group and 179 in the control group. Diverticulitis was persistent in 19 patients (10.4 %) in the study group, who were not treated with antibiotics, and in five patients (2.8 %) in the control group, treated with outpatient antibiotic therapy (p = 0.004). Recurrences occurred in 23 patients (12.6 %) in the study group, and in 53 patients (29.6 %) in the control group (p < 0.0001). The analysis of the complications found no significant differences between both groups (p = 0.109). No urgent surgical intervention or mortality was recorded in the study group. CONCLUSIONS in our environment, symptomatic non-antibiotic treatment of uncomplicated acute diverticulitis cases is safe, without showing a higher rate of complications. Although, there seems to be a worse initial symptom control.
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Williams S, Bjarnason I, Hayee B, Haji A. Diverticular disease: update on pathophysiology, classification and management. Frontline Gastroenterol 2024; 15:50-58. [PMID: 38487561 PMCID: PMC10935533 DOI: 10.1136/flgastro-2022-102361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/19/2023] [Indexed: 03/17/2024] Open
Abstract
Colonic diverticulosis is prevalent, affecting approximately 70% of the western population by 80 years of age. Incidence is rapidly increasing in younger age groups. Between 10% and 25% of those with diverticular disease (DD) will experience acute diverticulitis. A further 15% will develop complications including abscess, bleeding and perforation. Such complications are associated with significant morbidity and mortality and constitute a worldwide health burden. Furthermore, chronic symptoms associated with DD are difficult to manage and present a further significant healthcare burden. The pathophysiology of DD is complex due to multifactorial contributing factors. These include diet, colonic wall structure, intestinal motility and genetic predispositions. Thus, targeted preventative measures have proved difficult to establish. Recently, commonly held conceptions on DD have been challenged. This review explores the latest understanding on pathophysiology, risk factors, classification and treatment options.
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Affiliation(s)
- Sophie Williams
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - Ingvar Bjarnason
- Department of Gastroenterology, King’s College Hospital, London, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King’s College Hospital, London, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital, London, UK
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Brière R, Benhamed A, Émond M, Blanchard PG, Drolet S. Evaluation of physicians' current practices and awareness regarding the treatment of acute uncomplicated diverticulitis: results of a provincial survey. CAN J EMERG MED 2023; 25:968-975. [PMID: 37861926 DOI: 10.1007/s43678-023-00606-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE International guidelines now recommend nonantibiotic treatment of uncomplicated diverticulitis. We assessed physicians' current management strategies for uncomplicated diverticulitis, their awareness of the updated recommendations, and barriers to practice change. METHODS A 21-question web-based survey conducted between 09/2022 and 11/2022 was sent to participants through their respective Quebec provincial associations or working groups. Participants included general surgeons, emergency physicians, gastroenterologists and general practitioners. Physicians who did not treat diverticulitis were excluded. The main outcomes were awareness of guideline recommendations on uncomplicated diverticulitis treatment, the use of nonantibiotic management for uncomplicated diverticulitis and identification of perceived barriers to practice change. RESULTS The participation rate was 15.9%. The 465 participants consisted primarily of general practitioners (41.7%), general surgeons (29.2%) and emergency physicians (17.8%). Eighty-two percent had heard of the nonantibiotic treatment strategy for uncomplicated diverticulitis; 7.5% were "uncomfortable" and 44.6% "somewhat uncomfortable" with this practice. A third (31.8%) of all physicians had no knowledge of the updated guidelines on uncomplicated diverticulitis treatment. Most reported "never" (41.6%) or "rarely" (25.1%) omitting antibiotics for uncomplicated diverticulitis. When informed about nonantibiotic treatment, 28.7% and 51.4% of all physicians, respectively, indicated that this "will" change or "may" change their practice. Common perceived barriers to nonantibiotic treatment were concerns about treatment failure (69.6%), unawareness of updated recommendations (67.0%), difficulty in ensuring proper follow-up (59.0%) and workplace culture (54.9%). CONCLUSION Physicians' awareness of practice guidelines recommending nonantibiotic treatment for uncomplicated diverticulitis and their application are suboptimal. Knowledge transfer activities, educational interventions and optimization of local protocols are needed to ensure the rational use of antibiotics.
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Affiliation(s)
- Raphaëlle Brière
- Département de Chirurgie, CHU de Québec, Université Laval, Quebec, QC, Canada.
| | - Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marcel Émond
- Département de Médecine Familiale et de Médecine d'urgence, Centre de Recherche du CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Pierre-Gilles Blanchard
- Département de Médecine Familiale et de Médecine d'urgence, Centre de Recherche du CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Sébastien Drolet
- Département de Chirurgie, CHU de Québec, Université Laval, Quebec, QC, Canada
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Zager Y, Khalilieh S, Mansour A, Cohen K, Nadler R, Anteby R, Ram E, Horesh N, Nachmany I, Gutman M, Berger Y. The value of CA125 in predicting acute complicated colonic diverticulitis. Int J Colorectal Dis 2023; 38:182. [PMID: 37389666 DOI: 10.1007/s00384-023-04478-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND CA125 is a widely used serum marker for epithelial ovarian cancer which levels may also rise in benign conditions involving peritoneal irritation. We aimed to determine if serum CA125 levels can predict disease severity in patients presenting with acute diverticulitis. METHODS We conducted a single-center prospective observational study, analyzing CA125 serum levels in patients who presented to the emergency department with computerized tomography-proven acute left-sided colonic diverticulitis. Univariate, multivariate, and receiver operating characteristic (ROC) analyses were used to correlate CA125 serum levels at time of initial presentation with the primary outcome (complicated diverticulitis) and secondary clinical outcomes (need for urgent intervention, length of hospital stay (LOS) and readmission rates). RESULTS One hundred and fifty-one patients were enrolled between January 2018 and July 2020 (66.9% females, median age 61 years). Twenty-five patients (16.5%) presented with complicated diverticulitis. CA125 levels were significantly higher among patients with complicated (median: 16 (7-159) u/ml) vs. uncomplicated (8 (3-39) u/ml) diverticulitis (p < 0.001) and also correlated with the Hinchey severity class (p < 0.001). Higher CA125 levels upon admission were associated with a longer LOS and a greater chance to undergo invasive procedure during the hospitalization. In patients with a measurable intra-abdominal abscess (n = 24), CA125 levels were correlated with the size of the abscess (Spearman's r = 0.46, p = 0.02). On ROC analysis to predict complicated diverticulitis, the area under the curve (AUC) for CA125 (AUC = 0.82) was bigger than for the leukocyte count (AUC = 0.53), body temperature (AUC = 0.59), and neutrophil-lymphocyte ratio (AUC = 0.70) - all p values < 0.05. On multivariate analysis of factors available at presentation, CA125 was found to be the only independent predictor of complicated diverticulitis (OR 1.12 (95% CI 1.06-1.19), p < 0.001). CONCLUSIONS The results from this feasibility study suggest that CA125 may accurately discriminate between simple and complicated diverticulitis, meriting further prospective investigation.
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Affiliation(s)
- Yaniv Zager
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Saed Khalilieh
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Aiham Mansour
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Karin Cohen
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Roy Nadler
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Roi Anteby
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Edward Ram
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Nir Horesh
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Ido Nachmany
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Mordechai Gutman
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Yaniv Berger
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Drapkina OM, Lazebnik LB, Bakulin IG, Skazyvaeva EV, Bakulina NV, Sitkin SI, Skalinskaya MI, Zhuravleva MS, Avalueva EB, Livzan MA, Bordin DS, Khavkin AI. Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:33-69. [DOI: 10.31146/1682-8658-ecg-210-2-33-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.
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Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine Russian Federation
| | - L. B. Lazebnik
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation
| | - I. G. Bakulin
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. V. Skazyvaeva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - N. V. Bakulina
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - S. I. Sitkin
- North-Western state medical University named after I. I. Mechnikov; Almazov National Medical Research Centre
| | - M. I. Skalinskaya
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - M. S. Zhuravleva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. B. Avalueva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | | | - D. S. Bordin
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation; Moscow Clinical Scientific Center named after Loginov
| | - A. I. Khavkin
- Veltischev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Pirogov Russian National Research Medical University
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Drapkina OM, Lazebnik LB, Bakulin IG, Skazyvaeva EV, Bakulina NV, Sitkin SI, Skalinskaya MI, Zhuravleva MS, Avalueva EB, Livzan MA, Bordin DS, Khavkin AI. Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:33-69. [DOI: https:/doi.org/10.31146/1682-8658-ecg-210-2-33-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.
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Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine Russian Federation
| | - L. B. Lazebnik
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation
| | - I. G. Bakulin
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. V. Skazyvaeva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - N. V. Bakulina
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - S. I. Sitkin
- North-Western state medical University named after I. I. Mechnikov; Almazov National Medical Research Centre
| | - M. I. Skalinskaya
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - M. S. Zhuravleva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. B. Avalueva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | | | - D. S. Bordin
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation; Moscow Clinical Scientific Center named after Loginov
| | - A. I. Khavkin
- Veltischev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Pirogov Russian National Research Medical University
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Piccin A, Gulotta M, di Bella S, Martingano P, Crocè LS, Giuffrè M. Diverticular Disease and Rifaximin: An Evidence-Based Review. Antibiotics (Basel) 2023; 12:antibiotics12030443. [PMID: 36978310 PMCID: PMC10044695 DOI: 10.3390/antibiotics12030443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis.
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Affiliation(s)
- Anna Piccin
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Marco Gulotta
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Stefano di Bella
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Infectious Disease Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Paola Martingano
- Department of Radiology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Lory Saveria Crocè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Liver Clinic, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Mauro Giuffrè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06510, USA
- Correspondence:
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Hanna C, Hanna NM. Just the facts: revisiting the role of antibiotics in acute uncomplicated diverticulitis. CAN J EMERG MED 2023; 25:118-120. [PMID: 36472809 DOI: 10.1007/s43678-022-00415-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Affiliation(s)
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada.
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12
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Langenfeld SJ. Turf wars, textbooks, and Darwin's Bulldog: The growing divide between dogma and reality for diverticulitis. Claude H. Organ, Jr. Memorial Lecture. Am J Surg 2022; 224:1362-1365. [PMID: 36150904 DOI: 10.1016/j.amjsurg.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
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13
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Chi-square automatic interaction detector decision tree analysis model: Predicting cefmetazole response in intra-abdominal infection. J Infect Chemother 2022; 29:7-14. [PMID: 36089256 DOI: 10.1016/j.jiac.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/27/2022] [Accepted: 09/03/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cefmetazole is used as the first-line treatment for intra-abdominal infections. However, only a few studies have investigated the risk factors for cefmetazole treatment failure. AIMS This study aimed to develop a decision tree-based predictive model to assess the effectiveness of cefmetazole in initial intra-abdominal infection treatment to improve the clinical treatment strategies. METHODS This retrospective cohort study included adult patients who were unexpectedly hospitalized due to intra-abdominal infections between 2003 and 2020 and initially treated with cefmetazole. The primary outcome was clinical intra-abdominal infection improvement. The chi-square automatic interaction detector decision tree analysis was used to create a predictive model for clinical improvement after cefmetazole treatment. RESULTS Among 2,194 patients, 1,807 (82.4%) showed clinical improvement post-treatment; their mean age was 48.7 (standard deviation: 18.8) years, and 1,213 (55.3%) patients were men. The intra-abdomせinal infections were appendicitis (n = 1,186, 54.1%), diverticulitis (n = 334, 15.2%), and pancreatitis (n = 285, 13.0%). The chi-square automatic interaction detector decision tree analysis identified the intra-abdominal infection type, C-reactive protein level, heart rate, and body temperature as predictive factors by categorizing patients into seven groups. The area under the receiver operating characteristic curve was 0.71 (95% confidence interval: 0.68-0.73). CONCLUSION This predictive model is easily understandable visually and may be applied in clinical practice.
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Cadet MJ. An Update on Managing Diverticulitis. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kang G, Son S, Shin YM, Pyo JS. Recurrence of Uncomplicated Diverticulitis: A Meta-Analysis. Medicina (B Aires) 2022; 58:medicina58060758. [PMID: 35744021 PMCID: PMC9228700 DOI: 10.3390/medicina58060758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/27/2022] [Accepted: 05/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background and objective: This study aimed to investigate the estimated rate and risk of recurrence of uncomplicated diverticulitis (UCD) after the first episode through a meta-analysis. Methods: Eligible studies were searched and reviewed; 27 studies were included in this study. Subgroup analyses were performed, based on lesion location, medical treatment, follow-up period, and study location. Results: The estimated recurrence rate of UCD was 0.129 (95% confidence interval [CI] 0.102–0.162). The recurrence rates of the right-and left-sided colon were 0.092 (95% CI 27.063–0.133) and 0.153 (95% CI 0.104–0.218), respectively. The recurrence rate according to follow-up period was highest in the subgroup 1–2 years, compared with that of other subgroups. The recurrence rate of the Asian subgroup was significantly lower than that of the non-Asian subgroup (0.092, 95% CI 0.064–0.132 vs. 0.147, 95% CI 0.110–0.192; p = 0.043 in the meta-regression test). There were significant correlations between UCD recurrence and older age and higher body temperature. However, UCD recurrence was not significantly correlated with medications, such as antibiotics or anti-inflammatory drugs. Conclusions: In this study, detailed information on estimated recurrence rates of UCD was obtained. In addition, older age and higher body temperature may be risk factors for UCD recurrence after the first episode.
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Affiliation(s)
- Guhyun Kang
- Department of Pathology, Daehang Hospital, Seoul 06699, Korea;
| | - Soomin Son
- Division of Molecular Life and Chemical Sciences, College of Natural Sciences, Ewha Woman’s University, Seoul 03760, Korea;
| | - Young-Min Shin
- Eulji University School of Medicine, Daejeon 34824, Korea;
| | - Jung-Soo Pyo
- Department of Pathology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu 11759, Korea
- Correspondence:
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Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
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Sahli H, Azhar N, Lydrup ML, Jörgren F, Schultz J, Buchwald P. Risk factors for recurrence and complications in acute uncomplicated diverticulitis: a retrospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Azhar N, Aref H, Brorsson A, Lydrup ML, Jörgren F, Schultz JK, Buchwald P. Management of acute uncomplicated diverticulitis without antibiotics: compliance and outcomes -a retrospective cohort study. BMC Emerg Med 2022; 22:28. [PMID: 35189812 PMCID: PMC8862329 DOI: 10.1186/s12873-022-00584-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/11/2022] [Indexed: 12/23/2022] Open
Abstract
Methods Recent randomized control trials (RCTs) have confirmed that antibiotics in acute uncomplicated diverticulitis (AUD) neither accelerate recovery nor prevent complications or recurrences. A retrospective cohort study was conducted, including all consecutive AUD patients hospitalized 2015- 2018 at Helsingborg Hospital (HH) and Skåne University Hospital (SUS), Sweden. HH had implemented a non-antibiotic treatment protocol in 2014 while SUS had not. Main outcomes were proportion of patients treated with antibiotics, complications, recurrences, and adherence to routinely colon evaluation. Results A total of 583 AUD patients were enrolled, 388 at SUS and 195 at HH. The diagnosis was CT-verified in 320 (83%) vs. 186 (95%) patients respectively (p < 0.001). Forty-three (11%) and 94 (48%) of patients respectively did not receive antibiotics during hospitalization (p < 0.001). CRP was higher in the antibiotic group compared to the non-antibiotic group, both at admission and peak (90 mg/L vs 65 mg/L; p = 0.016) and (138 mg/L and 97 mg/L; p < 0.001). There were no significant differences in recurrences (22.0% vs. 22.6%; p = 0.87) and complications (2.5% vs. 2.9%; p = 0.77) between the antibiotic/non-antibiotic groups. Conclusion The structured treatment protocol led to reduced antibiotic use and a higher standard of care in terms of CT-verification. Clinicians’ compliance to the treatment protocol and best clinical practice was poor and warrants further studies.
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Affiliation(s)
- Najia Azhar
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden. .,Department of Surgery, Skåne University Hospital, Malmö, Sweden.
| | - Hager Aref
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Adam Brorsson
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Marie-Louise Lydrup
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Jörgren
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | | | - Pamela Buchwald
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Skåne University Hospital, Malmö, Sweden
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Garfinkle R, Salama E, Amar-Zifkin A, Morin N, Ghitulescu G, Faria J, Vasilevsky CA, Boutros M. Observational versus antibiotic therapy for acute uncomplicated diverticulitis: A non-inferiority meta-analysis based on a Delphi consensus. Surgery 2022; 171:328-335. [PMID: 34344525 DOI: 10.1016/j.surg.2021.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/03/2021] [Accepted: 07/12/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The purpose of this study was to determine if observational therapy is noninferior to antibiotics for acute uncomplicated diverticulitis according to clinically relevant margins. METHODS MEDLINE, EMBASE, and Cochrane were systematically searched by 2 independent reviewers to identify comparative studies of observational therapy versus antibiotics for acute uncomplicated diverticulitis. Non-inferiority margins (ΔNI) for each outcome were based on Delphi consensus including 50 patients and 55 physicians: persistent diverticulitis (ΔNI = 4.0%), progression to complicated diverticulitis (ΔNI = 3.0%), and time to recovery (ΔNI = 5 days). Risk differences and mean differences were pooled using random-effects meta-analysis. One-sided 90% confidence intervals and Z-tests were used to determine non-inferiority. A sensitivity analysis was performed, excluding patients post hoc determined to have complicated diverticulitis. RESULTS Nine studies (3 randomized controlled trials, 6 observational studies) met inclusion criteria: observational therapy (n = 2,011) versus antibiotics (n = 1,144). Observational therapy was noninferior to antibiotics regarding the risk of persistent diverticulitis (pooled risk differences: -0.39%, 90% CI -3.22 to 2.44%, ΔNI: 4.0%, PNI < 0.001; I2 = 66%) and progression to complicated diverticulitis (pooled risk differences: -0.030%, 90% CI -0.99 to 0.92%, ΔNI: 3.0%, PNI < 0.001; I2 = 0%). On sensitivity analysis, observational therapy remained noninferior for both outcomes. When stratified by study design, observational therapy also remained noninferior for both outcomes among randomized controlled trials only. Only 1 study reported on time to recovery as a continuous outcome, with no statistical difference between antibiotics and observational therapy. CONCLUSION According to clinically relevant ΔNIs, observational therapy was noninferior to antibiotics for the treatment of acute uncomplicated diverticulitis with regard to persistent diverticulitis and progression to complicated diverticulitis.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Ebram Salama
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | | | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Gabriela Ghitulescu
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Julio Faria
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.
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20
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Yoshimoto H, Yamakawa K, Umemura Y, Fujii K, Nakamura E, Taniguchi K, Tanaka K, Takasu A, Uchiyama K. Seasonal Variation and Severity of Acute Abdomen in Japan: A Nine-Year Retrospective Analysis. J Pers Med 2021; 11:1346. [PMID: 34945818 PMCID: PMC8709094 DOI: 10.3390/jpm11121346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022] Open
Abstract
The seasonal incidence of acute abdomens, such as appendicitis, is reportedly more common in summer but is reported less frequently in Asia. Additionally, seasonal variations in the severity of acute abdomens have been evaluated insufficiently. This study evaluated the seasonal variations in the incidence and severity of acute abdomens in Japan. This retrospective observational study used a multicenter database containing data from 42 acute hospitals in Japan. We included all patients diagnosed with acute appendicitis, diverticulitis, cholecystitis, and cholangitis between January 2011 and December 2019. Baseline patient data included admission date, sequential organ failure assessment score, presence of sepsis, and disseminated intravascular coagulation. We enrolled 24,708 patients with acute abdomen. Seasonal admissions for all four acute abdominal diseases were the highest in summer [acute appendicitis, (OR = 1.35; 95% CI = 1.28-1.43); diverticulitis, (OR = 1.23; 95% CI = 1.16-1.31; cholecystitis (OR = 1.23; 95% CI = 1.11-1.36); and cholangitis (OR = 1.23; 95% CI = 1.12-1.36)]. The proportion of patients with sepsis and disseminated intravascular coagulation as well as the total SOFA score for each disease, did not differ significantly across seasons. Seasonal variations in disease severity were not observed.
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Affiliation(s)
- Hidero Yoshimoto
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (H.Y.); (K.F.); (K.T.); (K.T.); (K.U.)
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (E.N.); (A.T.)
| | - Yutaka Umemura
- Osaka General Medical Center, Division of Trauma and Surgical Critical Care, Osaka 558-8558, Japan;
| | - Kensuke Fujii
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (H.Y.); (K.F.); (K.T.); (K.T.); (K.U.)
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (E.N.); (A.T.)
- Department of Surgery, Kasaoka Daiichi Hospital, Kasaoka 714-0043, Japan
| | - Eriko Nakamura
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (E.N.); (A.T.)
| | - Kohei Taniguchi
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (H.Y.); (K.F.); (K.T.); (K.T.); (K.U.)
- Translational Research Program, Osaka Medical and Pharmaceutical University, Osaka 569-8686, Japan
| | - Keitaro Tanaka
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (H.Y.); (K.F.); (K.T.); (K.T.); (K.U.)
| | - Akira Takasu
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (E.N.); (A.T.)
| | - Kazuhisa Uchiyama
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (H.Y.); (K.F.); (K.T.); (K.T.); (K.U.)
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Abstract
Diverticulosis of the sigmoid colon is common in the developed world, affecting approximately 33% of persons older than 60 years. Up to 15% of these patients will develop diverticulitis at some point in their lifetime. The incidence of diverticulitis has increased in the last decade, accounting for nearly 300,000 US hospital admissions and $1.8 billion in annual direct medical costs. With such a wide prevalence and diverse spectrum of clinical presentation, there are bound to be multiple controversies regarding disease management. This article will serve to educate the reader on several important areas to consider when treating this ubiquitous disease.
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Affiliation(s)
- Aimal Khan
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, Room D5203 MCN, Nashville, TN 37232, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, Room D5203 MCN, Nashville, TN 37232, USA.
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The SARS-CoV-2 first wave impact in the acute inflammatory surgical pathologies. Sci Rep 2021; 11:19645. [PMID: 34608197 PMCID: PMC8490421 DOI: 10.1038/s41598-021-98878-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 09/13/2021] [Indexed: 12/29/2022] Open
Abstract
Anecdotal evidence suggests that community infection control measures during the COVID-19 outbreak have modified the number and natural history of acute surgical inflammatory processes (ASIP—appendicitis, cholecystitis, diverticulitis and perianal abscesses) admissions. This study aims to evaluate the impact of the COVID-19 pandemic on the presentation and treatment ASIP and quantify the effect of COVID-19 infection on the outcomes of ASIP patients. This was a multicentre, comparative study, whereby ASIP cases from 2019, 2020 and 2021 (March 14th to May 2nd) were analyzed. Data regarding patient and disease characteristics as well as outcomes, were collected from sixteen centres in Madrid, and one in Seville (Spain). The number of patients treated for ASIP in 2019 was 822 compared to 521 in 2020 and 835 in 2021. This 1/3rd reduction occurs mainly in patients with mild cases, while the number of severe cases was similar. Surgical standards suffered a step back during the first wave: Lower laparoscopic approach and longer length of stay. We also found a more conservative approach to the patients this year, non-justified by clinical circumstances. Luckily these standards improved again in 2021. The positive COVID-19 status itself did not have a direct impact on mortality. Strikingly, none of the 33 surgically treated COVID positive patients during both years died postoperatively. This is an interesting finding which, if confirmed through future research with a larger sample size of COVID-19 positive patients, can expedite the recovery phase of acute surgical services.
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Long-term Implications of Persistent Diverticulitis: A Retrospective Cohort Study of 915 Patients. Dis Colon Rectum 2021; 64:1112-1119. [PMID: 34397559 DOI: 10.1097/dcr.0000000000001969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Persistent (or ongoing) diverticulitis is a well-recognized outcome after treatment for acute sigmoid diverticulitis; however, its definition, incidence, and risk factors, as well as its long-term implications, remain poorly described. OBJECTIVE The purpose of this study was to assess the incidence, risk factors, and long-term outcomes of persistent diverticulitis. DESIGN This was a retrospective cohort study. SETTINGS Two university-affiliated hospitals in Montreal, Quebec, Canada were included. PATIENTS The study was composed of consecutive patients managed nonoperatively for acute sigmoid diverticulitis. INTERVENTION Nonoperative management of acute sigmoid diverticulitis was involved. MAIN OUTCOME MEASURES Persistent diverticulitis, defined as inpatient or outpatient treatment for signs and symptoms of ongoing diverticulitis within the first 60 days after treatment of the index episode, was measured. RESULTS In total, 915 patients were discharged after an index episode of diverticulitis managed nonoperatively. Seventy-five patients (8.2%; 95% CI, 6.5%-10.2%) presented within 60 days with persistent diverticulitis. Factors associated with persistent diverticulitis were younger age (adjusted OR = 0.98 (95% CI, 0.96-0.99)), immunosuppression (adjusted OR = 2.02 (95% CI, 1.04-3.88)), and abscess (adjusted OR = 2.05 (95% CI, 1.03-3.92)). Among the 75 patients with persistent disease, 42 (56.0%) required hospital admission, 6 (8.0%) required percutaneous drainage, and 5 (6.7%) required resection. After a median follow-up of 39.0 months (range, 17.0-67.3 mo), the overall recurrence rate in the entire cohort was 31.3% (286/910). After excluding patients who were managed operatively for their persistent episode of diverticulitis, the cumulative incidence of recurrent diverticulitis (log-rank: p < 0.001) and sigmoid colectomy (log-rank: p < 0.001) were higher among patients who experienced persistent diverticulitis after the index episode. After adjustment for relevant patient and disease factors, persistent diverticulitis was associated with higher hazards of recurrence (adjusted HR = 1.94 (95% CI, 1.37-2.76) and colectomy (adjusted HR = 5.11 (95% CI, 2.96-8.83)). LIMITATIONS The study was limited by its observational study design and modest sample size. CONCLUSIONS Approximately 10% of patients experience persistent diverticulitis after treatment for an index episode of diverticulitis. Persistent diverticulitis is a poor prognostic factor for long-term outcomes, including recurrent diverticulitis and colectomy. See Video Abstract at http://links.lww.com/DCR/B593. REPERCUSIONES A LARGO PLAZO DE LA DIVERTICULITIS PERSISTENTE ESTUDIO DE UNA COHORTE RETROSPECTIVA DE PACIENTES ANTECEDENTES:La diverticulitis persistente (o continua) es un resultado bien conocido posterior al tratamiento de la diverticulitis aguda del sigmoides; sin embargo, la definición, incidencia y factores de riesgo, así como sus repercusiones a largo plazo siguen estando descritas de manera deficiente.OBJETIVO:Evaluar la incidencia, los factores de riesgo y los resultados a largo plazo de la diverticulitis persistente.DISEÑO:Estudio de una cohorte retrospectiva.AMBITO:Dos hospitales universitarios afiliados en Montreal, Quebec, Canadá.PACIENTES:pacientes consecutivos tratados sin cirugia por diverticulitis aguda del sigmoides.INTERVENCIÓN:Tratamiento no quirúrgico de la diverticulitis aguda del sigmoides.PRINCIPALES RESULTADOS EVALUADOS:Diverticulitis persistente, definida como tratamiento hospitalario o ambulatorio por signos y síntomas de diverticulitis continua dentro de los primeros 60 días posteriores al tratamiento del episodio índice.RESULTADOS:Un total de 915 pacientes fueron dados de alta posterior al episodio índice de diverticulitis tratados sin cirugia. Setenta y cinco pacientes (8,2%; IC del 95%: 6,5-10,2%) presentaron diverticulitis persistente dentro de los 60 días. Los factores asociados con la diverticulitis persistente fueron una edad menor (aOR: 0,98, IC del 95%: 0,96-0,99), inmunosupresión (aOR: 2,02, IC del 95%: 1,04-3,88) y abscesos (aOR: 2,05, IC del 95%: 1,03-3,92). Entre los 75 pacientes con enfermedad persistente, 42 (56,0%) requirieron ingreso hospitalario, 6 (8,0%) drenaje percutáneo y 5 (6,7%) resección. Posterior a seguimiento medio de 39,0 (17,0-67,3) meses, la tasa global de recurrencia de toda la cohorte fue del 31,3% (286/910). Después de excluir a los pacientes que fueron tratados quirúrgicamente por su episodio persistente de diverticulitis, la incidencia acumulada de diverticulitis recurrente (rango logarítmico: p <0,001) y colectomía sigmoidea (rango logarítmico: p <0,001) fue mayor entre los pacientes que experimentaron diverticulitis persistente después el episodio índice. Posterior al ajuste de factores importantes de la enfermedad y del paciente, la diverticulitis persistente se asoció con mayores riesgos de recurrencia (aHR: 1,94, IC 95% 1,37-2,76) y colectomía (aHR: 5,11, IC 95% 2,96-8,83).LIMITACIONES:Diseño de estudio observacional, un modesto tamaño de muestra.CONCLUSIONES:Aproximadamente el 10% de los pacientes presentan diverticulitis persistente después del tratamiento del episodio índice de diverticulitis. La diverticulitis persistente, en sus resultados a largo plazo, es un factor de mal pronóstico, donse se inlcuye la diverticulitis recurente y colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B593.
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Makar M, Makar G, Xia W, Greenberg P, Patel AV. Association of Clostridioides difficile with adverse clinical outcomes in patients with acute diverticulitis: A nationwide study. J Gastroenterol Hepatol 2021; 36:983-989. [PMID: 32870544 DOI: 10.1111/jgh.15240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/03/2020] [Accepted: 08/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Acute diverticulitis (AD) is a common gastrointestinal disease with a significant health care-associated burden. Patients hospitalized with AD have many risk factors for developing Clostridioides difficile infection (CDI). CDI is associated with poor outcomes in many diseases but has yet to be studied in AD. METHODS We utilized data from the National Inpatient Sample from January 2012 to October 2015 for patients hospitalized with AD and CDI compared with AD alone. Primary outcomes, which were mortality, length of stay, and hospitalization cost, were compared. Secondary outcomes were complications of diverticulitis and need for surgical interventions. Risk factors for mortality in AD and risk factors associated with CDI in AD patients were analyzed. RESULTS Among 767 850 hospitalizations for AD, 8755 also had CDI. A propensity score-matched cohort analysis demonstrated that CDI was associated with increased risk of inpatient mortality (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.30, 5.95), prolonged duration of hospitalization by 4.27 days (P < 0.0001), total hospital cost by $33 271 (P < 0.0001), need for surgery (OR 1.45, 95% CI 1.22, 1.71), and complications of diverticulitis (OR 1.45, 95% CI 1.21, 1.74). Predictors of CDI among patients with AD included female gender (1.12 OR, 95% CI 1.01, 1.24), three or more comorbidities (1.81 OR, 95% CI 1.57, 2.09), and admissions to teaching hospitals (1.44 OR, 95% CI 1.22, 1.70). CONCLUSIONS Clostridioides difficile infection in AD is associated with increased mortality, length of stay, and hospital cost. Preventative measures should be made for at-risk patients with AD to decrease infection rate and poor outcomes.
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Affiliation(s)
- Michael Makar
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Gabriel Makar
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Weiyi Xia
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, New Jersey, USA
| | - Patricia Greenberg
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, New Jersey, USA
| | - Anish Vinit Patel
- Department of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Clements TW, Tolonen M, Ball CG, Kirkpatrick AW. Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies. Scand J Surg 2021; 110:139-149. [PMID: 33406974 DOI: 10.1177/1457496920984078] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed.
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Affiliation(s)
- T W Clements
- Foothills Medical Centre, Department of Critical Care Medicine and Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - M Tolonen
- HUS Helsinki University Hospital, Helsinki, Finland
| | - C G Ball
- Foothills Medical Centre, Department of Critical Care Medicine and Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - A W Kirkpatrick
- Foothills Medical Centre, Department of Critical Care Medicine and Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Canadian Forces Medical Services, University of Calgary, Calgary, AB, Canada
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Lauro A, Pozzi E, Vaccari S, Cervellera M, Tonini V. Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis. Dig Dis Sci 2020; 65:3463-3476. [PMID: 32980955 DOI: 10.1007/s10620-020-06621-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 02/05/2023]
Abstract
The medical and surgical management of uncomplicated diverticulitis has changed over the last several years. Although immunocompetent patients or those without comorbidities can be treated with antibiotics as an outpatient, the efficacy of high-fiber intake or drugs such as mesalamine or rifaximin is not yet clearly established in the treatment of acute episodes and in the prevention of recurrences. On the other hand, the choice between antibiotic treatment and percutaneous drainage is not always obvious in diverticulitis complicated by abscess formation, especially for larger abscesses; although the results of studies comparing the two approaches remain controversial, surgery must be pursued for abscesses > 8 cm. For emergency surgery, the debate is still ongoing regarding laparoscopic lavage and surgical resection followed by primary anastomosis, since for both approaches the published reports are not in agreement regarding possible benefits. Therefore, these approaches are recommended only for selected patients under the care of experienced surgeons. Also, the contribution of elective surgery toward the overall approach has been revised; currently, it is reserved primarily for patients with a high risk of recurrence and whenever more conservative treatments were not effective.
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Affiliation(s)
- Augusto Lauro
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - Eleonora Pozzi
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - Samuele Vaccari
- Department of Surgical Sciences, Umberto I University Hospital - La Sapienza, Rome, Italy.
| | - Maurizio Cervellera
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - Valeria Tonini
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
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Napolitano MA, Sparks AD, Randall JA, Brody FJ, Duncan JE. Elective surgery for diverticular disease in U.S. veterans: A VASQIP study of national trends and outcomes from 2004 to 2018. Am J Surg 2020; 221:1042-1049. [PMID: 32938529 DOI: 10.1016/j.amjsurg.2020.08.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Treatment for diverticular disease has evolved over time. In the United States, there has been a trend towards minimally invasive surgical approaches and fewer postoperative complications, but no study has investigated this subject in the Veterans Health Administration. METHODS This retrospective review identified patients undergoing elective surgery for diverticular disease from 2004 to 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and 30-day outcomes were compared. The 15-year time period was divided into 3-year increments to assess changes over time. RESULTS 4198 patients were identified. Complication rate decreased significantly over time (28.1%-15.7%, p < 0.001), as did infectious complications (21.5-6.3%, p < 0.001). Median hospital length-of-stay decreased from 7 to 5 days (p < 0.001). Rates of laparoscopic surgery increased over time (17.7%-48.1%, p < 0.001). CONCLUSIONS Increased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with fewer complications and a shorter length-of-stay. These trends mirror outcomes reported in non-veterans.
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Affiliation(s)
- Michael A Napolitano
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA; Department of Surgery, George Washington University, 2150 Pennsylvania Ave Suite 6B. Washington, DC, 20037, USA.
| | - Andrew D Sparks
- Department of Surgery, George Washington University, 2150 Pennsylvania Ave Suite 6B. Washington, DC, 20037, USA.
| | - J Alex Randall
- Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Ave, Maywood, IL, 60153, USA.
| | - Fred J Brody
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA.
| | - James E Duncan
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA.
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A Hospital Protocol for Decision Making in Emergency Admission for Acute Diverticulitis: Initial Results from Small Cohort Series. ACTA ACUST UNITED AC 2020; 56:medicina56080371. [PMID: 32722066 PMCID: PMC7466311 DOI: 10.3390/medicina56080371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/17/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
Background and objectives: We present initial results from a small cohort series for a hospital protocol related to the emergency hospitalization decision-making process for acute diverticulitis. We performed a retrospective analysis of 53 patients with acute diverticulitis admitted to the Department of Emergency and Trauma Surgery of the "Azienda Ospedaliero Universiaria-Ospedali Riuniti" in Ancona and to the Department of General and Emergency Surgery of the "Azienda Ospedaliera-Universitaria" in Perugia. Materials and Methods: All patients were evaluated according to hemodynamic status: stable or unstable. Secondly, it was distinguished whether patients were suffering from complicated or uncomplicated forms of diverticulitis. Finally, each patient was assigned to a risk class. In this way, we established a therapeutic/diagnostic process for each group of patients. Results: Non-operative treatment (NonOP) was performed in 16 patients, and it was successful in 69% of cases. This protocol primarily considers the patient's clinical condition and the severity of the disease. It is based on a multidisciplinary approach, in order to implement the most suitable treatment for each patient. In stable patients with uncomplicated diverticulitis or complicated Hinchey grade 1 or 2 diverticulitis, the management is conservative. In all grade 3 and grade 4 forms, patients should undergo urgent surgery. Conclusions: This protocol, which is based on both anatomical damage and the severity of clinical conditions, aims to standardize the choice of the best diagnostic and therapeutic strategy for the patient in order to reduce mortality and morbidity related to this pathology.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020; 63:728-747. [PMID: 32384404 DOI: 10.1097/dcr.0000000000001679] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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30
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Costi R, Annicchiarico A, Morini A, Romboli A, Zarzavadjian Le Bian A, Violi V. Acute diverticulitis: old challenge, current trends, open questions. MINERVA CHIR 2020; 75:173-192. [PMID: 32550727 DOI: 10.23736/s0026-4733.20.08314-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.
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Affiliation(s)
- Renato Costi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Unit of General Surgery, Department of Surgery, Hospital of Vaio, Fidenza, Parma, Italy.,AUSL di Parma, Parma, Italy
| | | | - Andrea Morini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Romboli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alban Zarzavadjian Le Bian
- Service of General, Digestive, Oncologic, Bariatric, and Metabolic Surgery, Avicenne Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris XIII University, Bobigny, France
| | - Vincenzo Violi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Unit of General Surgery, Department of Surgery, Hospital of Vaio, Fidenza, Parma, Italy.,AUSL di Parma, Parma, Italy
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31
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Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nat Rev Dis Primers 2020; 6:20. [PMID: 32218442 PMCID: PMC7486966 DOI: 10.1038/s41572-020-0153-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, Andria, Italy.
| | - Carmelo Scarpignato
- Faculty of Health Sciences, LUdeS Lugano Campus, Lugano, Switzerland
- United Campus of Malta, Birkirkara, Msida, Malta
| | - Lisa L Strate
- Division of Gastroenterology, Department of Medicine, Harborview Medical Center, University of Washington Medical School, Seattle, WA, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, University of Zaragoza, IIS Aragón (CIBERehd), Zaragoza, Spain
| | | | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Readmission for Treatment Failure After Nonoperative Management of Acute Diverticulitis: A Nationwide Readmissions Database Analysis. Dis Colon Rectum 2020; 63:217-225. [PMID: 31914114 DOI: 10.1097/dcr.0000000000001542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood. OBJECTIVE The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database. DESIGN This was a retrospective cohort study. SETTINGS A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included. PATIENTS Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included. INTERVENTIONS Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage. MAIN OUTCOME MEASURES Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured. RESULTS In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis. LIMITATIONS The study was limited by residual confounding from missing covariates and its observational study design. CONCLUSIONS The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).
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Unique Presentation of Acute Gastric Diverticulitis Resolved With Antibiotics. ACG Case Rep J 2019; 6:e00014. [PMID: 31616717 PMCID: PMC6657996 DOI: 10.14309/crj.0000000000000014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 11/12/2018] [Indexed: 11/17/2022] Open
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Tachezy M, Izbicki JR. [Evidence for standard surgical procedures: appendicitis, diverticulitis and cholecystitis]. Chirurg 2019; 90:351-356. [PMID: 30635701 DOI: 10.1007/s00104-018-0779-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute appendicitis, cholecystitis and sigmoid diverticulitis are the most common inflammatory visceral surgical emergencies. According to the principles of evidence-based medicine, treatment methods and surgical indications should be constantly questioned and validated by high-quality clinical studies. OBJECTIVE To identify and classify the current evidence on surgical treatment of acute appendicitis, cholecystitis and sigmoid diverticulitis. MATERIAL AND METHODS Targeted literature search in Medline, the Cochrane Library and study registers (clinicaltrials.gov). RESULTS AND CONCLUSION The indications for surgery are changing due to increasing numbers of high-quality clinical studies. Conservative treatment seems to be feasible in the early stages. In contrast, many surgical steps have not yet been sufficiently validated. Furthermore, there is a great need for high-quality, prospective randomized clinical trials, so that promotion of studies and the study culture in surgery should continue to be of greatest interest.
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Affiliation(s)
- M Tachezy
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - J R Izbicki
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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35
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Isacson D, Smedh K, Nikberg M, Chabok A. Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis. Br J Surg 2019; 106:1542-1548. [PMID: 31386199 DOI: 10.1002/bjs.11239] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/10/2019] [Accepted: 04/23/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND The aim of this study was to assess the long-term results in patients with uncomplicated diverticulitis who had participated in the Antibiotics in Acute Uncomplicated Diverticulitis (AVOD) RCT, which randomized patients with CT-verified left-sided acute uncomplicated diverticulitis to management without or with antibiotics. METHODS The medical records of patients who had participated in the AVOD trial were reviewed for long-term results such as recurrences, complications and surgery. Quality-of-life questionnaires (EQ-5D™) were sent to patients, who were also contacted by telephone. Descriptive statistics were used for the analysis of clinical outcomes. RESULTS A total of 556 of the 623 patients (89·2 per cent) were followed up for a median of 11 years. There were no differences between the no-antibiotic and antibiotic group in recurrences (both 31·3 per cent; P = 0·986), complications (4·4 versus 5·0 per cent; P = 0·737), surgery for diverticulitis (6·2 versus 7·1 per cent; P = 0·719) or colorectal cancer (0·4 versus 2·1 per cent; P = 0·061). The response rate for the EQ-5D™ was 52·8 versus 45·2 per cent respectively (P = 0·030), and no differences were found between the two groups in any of the measured dimensions. CONCLUSION Antibiotic avoidance for uncomplicated diverticulitis is safe in the long term.
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Affiliation(s)
- D Isacson
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, 72189, Västerås, Sweden
| | - K Smedh
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, 72189, Västerås, Sweden
| | - M Nikberg
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, 72189, Västerås, Sweden
| | - A Chabok
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, 72189, Västerås, Sweden
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36
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Azhar N, Kulstad H, Pålsson B, Kurt Schultz J, Lydrup ML, Buchwald P. Acute uncomplicated diverticulitis managed without antibiotics - difficult to introduce a new treatment protocol but few complications. Scand J Gastroenterol 2019; 54:64-68. [PMID: 30650309 DOI: 10.1080/00365521.2018.1552987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Routine antibiotic treatment of acute uncomplicated diverticulitis (AUD) has been shown ineffective. In this study, the adherence to a new treatment protocol for uncomplicated diverticulitis was evaluated and the incidence of complications in patients treated with and without antibiotics was investigated. MATERIALS AND METHODS A retrospective study of in-patients diagnosed with AUD at Helsingborg Hospital, Sweden between 01 January 2013 and 06 January 2015 was performed. Antibiotics were routinely administrated until 01 May 2014. Thereafter, a new antibiotic-free treatment protocol for uncomplicated diverticulitis was introduced. All the patients were followed regarding complications for minimum one year. RESULTS A total of 50 patients were studied after the new protocol implementation and, 60% (n = 31) of the patients were treated without antibiotics. Specialists initiated antibiotic therapy significantly more often than registrars (p=.03). More patients in the antibiotic group had comorbidities (p=.03), apart from that, no significant differences in baseline characteristics were noted between treatment groups. Patients treated with antibiotics after introduction of the new protocol had significantly higher C-reactive protein than patients managed without antibiotics (median 117 mg/L vs. 70, p=.005). The hospital stay was shorter in the non-antibiotic group (three days vs. two days; p=.008). No significant differences in complications were observed. CONCLUSIONS Protocol compliance was lower than expected, indicating that implementation of new treatment regimens is challenging. This study confirms that complications are rare in AUD treated without antibiotics. However, the selection of the sickest patients to the treatment with antibiotics limits the interpretation of the results.
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Affiliation(s)
- Najia Azhar
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
| | - Hanna Kulstad
- b Department of Surgery , Helsingborg Hospital , Helsingborg , Sweden
| | - Birger Pålsson
- b Department of Surgery , Helsingborg Hospital , Helsingborg , Sweden
| | - Johannes Kurt Schultz
- c Department of Digestive Surgery , Akershus University Hospital , Lørenskog , Norway
| | - Marie-Louise Lydrup
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
| | - Pamela Buchwald
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
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