Hartmann's colectomy and reversal in diverticulitis: a population-level assessment

Acute diverticulitis in immunocompromised patients: evidence from an international multicenter observational registry (Web-based International Register of Emergency Surgery and Trauma, Wires-T)

BACKGROUND

Immunocompromised patients with acute diverticulitis are at increased risk of morbidity and mortality. The aim of this study was to compare clinical presentations, types of treatment, and outcomes between immunocompromised and immunocompetent patients with acute diverticulitis.

METHODS

We compared the data of patients with acute diverticulitis extracted from the Web-based International Registry of Emergency Surgery and Trauma (WIRES-T) from January 2018 to December 2021. First, two groups were identified: medical therapy (A) and surgical therapy (B). Each group was divided into three subgroups: nonimmunocompromised (grade 0), mildly to moderately (grade 1), and severely immunocompromised (grade 2).

RESULTS

Data from 482 patients were analyzed-229 patients (47.5%) [M:F = 1:1; median age: 60 (24-95) years] in group A and 253 patients (52.5%) [M:F = 1:1; median age: 71 (26-94) years] in group B. There was a significant difference between the two groups in grade distribution: 69.9% versus 38.3% for grade 0, 26.6% versus 51% for grade 1, and 3.5% versus 10.7% for grade 2 (p < 0.00001). In group A, severe sepsis (p = 0.027) was more common in higher grades of immunodeficiency. Patients with grade 2 needed longer hospitalization (p = 0.005). In group B, a similar condition was found in terms of severe sepsis (p = 0.002), quick Sequential Organ Failure Assessment score > 2 (p = 0.0002), and Mannheim Peritonitis Index (p = 0.010). A Hartmann's procedure is mainly performed in grades 1-2 (p < 0.0001). Major complications increased significantly after a Hartmann's procedure (p = 0.047). Mortality was higher in the immunocompromised patients (p = 0.002).

CONCLUSIONS

Immunocompromised patients with acute diverticulitis present with a more severe clinical picture. When surgery is required, immunocompromised patients mainly undergo a Hartmann's procedure. Postoperative morbidity and mortality are, however, higher in immunocompromised patients, who also require a longer hospital stay.

Stoma reversal after Hartmann's procedure for acute diverticulitis

BACKGROUND

Hartmann's procedure is a treatment option for perforated acute diverticulitis, especially when organ dysfunction(s) are present. Its use has been criticized mostly out of fear of high permanent stoma rate. The aim of this study was to investigate the rate of stoma reversal, reasons behind nonreversal, and safety of reversal surgery.

METHODS

This was a single-center retrospective study of patients undergoing urgent Hartmann's procedure due to acute diverticulitis between the years 2006 and 2017 with follow-up until March 2021.

RESULTS

A total of 3,319 episodes of diverticulitis in 2,932 patients were screened. The Hartmann's procedure was performed on 218 patients, of whom 157 (72%) had peritonitis (48 (22%) with organ dysfunction). At 2-years, 76 (34.9%) patients had died with stoma, 42 (19.3%) were alive with stoma, and 100 (45.9%) had undergone stoma reversal. The survival of patients with and without reversal were 100% and 42.7% at 1-year, 96.0% and 35.0% at 2-years and 88.9% and 20.7% at 5-years, respectively. The risk factors for nonreversal were old age, a need for outside assistance, low HElsinki Staging for Acute Diverticulitis stage, and higher C-reactive protein level upon hospital admission. The most common reasons for nonreversal in surviving patients were patient not willing to have the operation 18 (41%) and dementia 10 (23%). Twelve (12%) patients had a major complication after reversal (Clavien-Dindo IIIb-IV) and 90-day mortality after reversal was 0%.

CONCLUSION

After the Hartmann's procedure for acute diverticulitis, one-third died, half underwent stoma reversal, and one-fifth did not undergo stoma reversal within 2 years. Patients who survive with stoma are either not willing to have reversal or have severe comorbidities excluding elective surgery. The Hartmann's procedure remains a viable option for high-risk patients with perforated acute diverticulitis.

Comparison of surgical outcomes for colostomy closure performed by acute care surgeons versus a dedicated colorectal surgery service

BACKGROUND

Despite colostomy closure being a common procedure, it remains highly morbid. Previous literature suggests that complication rates, including surgical site infections, intra-abdominal abscess, and anastomotic failures, reach as high as 50%. With the creation of a dedicated colorectal service, colostomy reversals have been largely migrated from the acute care surgery services. This study analyzes the differences in outcomes in colostomy closures performed between colorectal surgeons and acute care surgeons.

METHODS

We retrospectively analyzed our experience with 127 colostomy closures performed in our hospital system by acute care surgeons and colorectal surgeons from 2016 through 2020. Demographic data, operative data, and outcomes such as abscess formation, anastomotic leak, and readmission were analyzed. Multivariate regression analysis was performed for intraabdominal abscesses and anastomotic leaks.

RESULTS

In total, 71 colostomy closures were performed by colorectal surgeons (56%) and 56 by acute care surgeons (43%). The majority of colostomy reversals were after Hartmann's procedure for perforated diverticulitis. No differences in demographics were identified, except for a shorter interval to closure in the acute care surgeons group (10.0 vs 7.2 months; P = .049). Two (3.6%) acute care surgeon patients required colorectal surgeon consultation during the definitive repair. Regression analysis identified body mass index (odds ratio 2.43; P = .001), male gender (odds ratio -2.39; P = .18), and colorectal surgeons (odds ratio -2.28; P = .025) as significant risk factors for anastomotic leak.

CONCLUSION

Analysis of the current series identified female gender and increased body mass index as higher risk, while procedures performed by colorectal surgeons were at decreased risk for anastomotic leak. Our study identified colostomy reversals performed by a dedicated colorectal service decreased the rate of anastomotic leak.

Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis

BACKGROUND

The aim of this study was to perform a systematic review of the literature on and updated meta-analysis of surgical postoperative complications after laparoscopic Hartmann's reversal (LHR) and open Hartmann's reversal (OHR).

METHODS

Studies comparing LHR versus OHR published from inception until June 2020 were selected and submitted to a systematic review and meta-analysis. Articles were searched in the MEDLINE and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Twenty-three retrospective comparative studies (including 5 case-controlled studies) with a total of 3139 patients with LHR and a total of 10,325 patients with OHR were included. Meta-analysis showed that LHR was significantly associated with a decreased rate of revision surgery (OR = 0.73, 95% CI = 0.60-0.89, p < 0.001), anastomotic leakage (OR = 0.61, 95% CI = 0.49-0.75, p < 0.00001), postoperative morbidity (OR = 0.53, 95% CI = 0.47-0.58, p < 0.00001), intra-abdominal abscess (OR = 0.67 [0.52-0.87], 95% CI = , p = 0.003), wound abscess (OR = 0.53 [0.46-0.61], 95% CI = , p < 0.00001), and postoperative ileus (OR = 0.46, 95% CI = 0.29-0.72, p = 0.0008), respectively. Conversely, mortality was comparable between LHR and OHR.

CONCLUSIONS

These results suggest that LHR significantly improved surgical postoperative outcomes. However, considering the low level of evidence, further randomized trials are required to validate these findings.

Surgical management in immunosuppressed patients with sigmoid diverticulitis, still a challenge: a single-center observational study

PURPOSE

The question of whether immunosuppressed (IS) patients should be offered elective sigmoidectomy following a single episode of diverticulitis is controversial. We intended to examine the perioperative outcome of IS and immunocompetent (IC) patients after sigmoid resection.

METHODS

A single institutional cohort study was conducted, including all surgically treated patients with sigmoid diverticulitis between 2004 and 2021. IS and IC patients were further subdivided into emergency and elective cases. Morbidity and mortality in both groups and factors influencing surgical outcome were examined using uni- and multivariate regression analyses.

RESULTS

A total of 281 patients were included in the final analysis. Emergency surgery was performed on 98 patients while 183 patients underwent elective sigmoid resection. Emergency sigmoidectomy demonstrates significantly higher morbidity and mortality rates in IS patients as compared to IC patients (81.81% vs. 42.1%; p = 0.001, respectively 27.27% vs. 3.94%; p = 0.004), while major morbidity and mortality was similar in both groups in the elective setting (IS: 23.52% vs. IC: 13.85%; p = 0.488, respectively IS: 5.88% vs. IC: 0%; p = 1). On multivariate regression analysis for major postoperative morbidity, ASA score [OR 1.837; (95% CI 1.166-2.894); p = 0.009] and emergency surgery under immunosuppression [OR 3.065; (95% CI 1.128-8.326); p = 0.028] were significant. In-hospital mortality was significantly related to age [OR 1.139; (95% CI 1.012-1.282); p = 0.031], preoperative CRP count [OR 1.137; (95% CI 1.028-1.259); p = 0.013], and immunosuppression [OR 35.246; (95% CI 1.923-646.176), p = 0.016] on multivariate analysis.

CONCLUSIONS

Elective surgery for sigmoid diverticulitis in immunocompromised patients demonstrates higher efficacy and safety when compared to sigmoid resection in the emergency setting.

Elective Surgery for Diverticulitis and the Risk of Recurrence and Ostomy

OBJECTIVE

To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence.

BACKGROUND

While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks.

METHODS

Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014).

RESULTS

Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%].

CONCLUSIONS

Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.

The role of damage control surgery in the treatment of perforated colonic diverticulitis: a systematic review and meta-analysis

INTRODUCTION

Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II-IV complicated acute diverticulitis (CAD).

METHODS

A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953).

RESULTS

Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%].

CONCLUSIONS

The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach.

Outcomes of colostomy takedown following Hartmann's procedure: successful restoration of continuity comes with a high risk of morbidity

AIM

Restoration of bowel continuity following a Hartmann's procedure is a major surgical undertaking associated with significant morbidity. The aim of this study was to review the authors' experience with Hartmann's reversal.

METHOD

This was a retrospective review of consecutive patients from institutional databases who were selected to undergo open or laparoscopic Hartmann's reversal at two tertiary academic referral centres and a public safety net hospital (2010-2019). The main outcome measure was the rate of successful stoma reversal. Secondary outcomes included 30-day postoperative outcomes and procedural details.

RESULTS

One hundred and fifty patients underwent attempted reversal during the study period, which was successful in all but three patients (98%). Patients were 59% Hispanic and 73% male, with a mean age of 48.7 ± 14.1 years, mean American Society of Anesthesiologists classification of 2.2 ± 0.6 and mean body mass index (BMI) of 28.6 ± 5.3 kg/m² , with 39% of patients having a BMI > 30 kg/m² . The mean time interval between the index procedure and reversal was 14.4 months, 53% of the index cases were performed at outside institutions and the most common index diagnoses were diverticulitis (54%), abdominal trauma (16%) and colorectal malignancy (15%). In 22% of cases a laparoscopic approach was used, with 42% of these requiring conversion to open. Proximal diverting stomas were created in 32 patients (21%), of which 94% were reversed. The overall morbidity rate was 54%, comprising ileus (32%), wound infection (15%) and anastomotic leak (6%), with a major morbidity rate (Clavien-Dindo ≥ 3) of 23%.

CONCLUSION

Hartmann's reversal remains a highly morbid procedure. Our results suggest that operative candidates can be successfully reversed, but there is significant morbidity associated with restoration of intestinal continuity, particularly in obese patients. A laparoscopic approach may decrease morbidity in selected patients but such cases have a high conversion rate.

Analysis of factors affecting reversal of Hartmann's procedure and post-reversal complications

Although Hartmann’s procedure (HP) is commonly used as emergency treatment for colorectal disease, the reversal of HP (HR) is infrequently performed. The aims were to evaluate the rate of HR and determine the factors predictive of achieving HR. We retrospectively reviewed the medical records of patients who underwent HP between January 2007 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify which factors were independently associated with HR. In the study period, 437 patients underwent HP, and 127 (29.0%) subsequently underwent HR. Of these, 46 (35.9%) patients experienced post-HR complications. In multivariable analysis, an interval between HP and HR of > 6 months was associated with the only lower rate of post-HR complications. Multivariate analysis showed that HR was less likely in patients aged > 70 years, those with American Society of Anesthesiologists (ASA) class III or IV, elective surgery, those experiencing more than two HP-related complications, and those with a malignancy (an indication for HP). One-third of the patients underwent HR. Age > 70 years, ASA class III or IV, elective surgery, more than two HP-related complications, and malignancy were associated with a non-HR rate.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis

BACKGROUND

Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach.

METHODS

The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat).

RESULTS

A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group.

CONCLUSIONS

Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings.

Timing of laparoscopic elective surgery for acute left colonic diverticulitis. Retrospective analysis of 332 patients

PURPOSE

The optimal time to perform elective surgery remains to be determined. We analyzed the impact of time interval to surgery on short-terme outcome parameters in patients undergoing elective laparoscopic left colonic resection for diverticulitis.

MATERIALS AND METHODS

Retrospective analysis of two series of case-matched patients according to the timing of operation after the last episode of diverticulitis: group A (within 90 days) and group B (beyond 90 days).

RESULTS

332 patients had left colonic resection for diverticulitis. 117 patients were included in group A vs 114 patients in group B. Overall abdominal morbidity in Group A was 21% vs 5% in group B (p = 0.02). Mean hospital stay was 7.7 days in group A vs 5 days in group B (p = 0.08). Residual inflammation was significantly increased in group A (31%) as compared to group B (11%) (p = 0.01).

CONCLUSIONS

Laparoscopic left colonic resection for acute diverticulitis is best performed beyond the third month after the last acute episode.

Management of Freely Perforated Diverticulitis

A healthy 65-year-old woman presents to the emergency department with a 12-hour history of sudden-onset severe lower abdominal pain. This is her first episode. She reports nausea, vomiting, and anorexia. Her last colonoscopy was at age 60, and was normal, except for diverticulosis of the sigmoid colon. Physical examination is significant for fever, tachycardia, and generalized abdominal pain with rebound tenderness. Pertinent laboratory findings include a leukocytosis and metabolic acidosis. A CT scan is obtained and is consistent with freely perforated diverticulitis, including a thickened sigmoid colon, free fluid in the pelvis, and free air noted near the diaphragm (). The surgeon completes the patient evaluation, recommends initiation of intravenous fluid resuscitation and antibiotics, and plans to go immediately to the operating room for surgical resection.

COLOSTOMY CLOSURE: RISK FACTORS FOR COMPLICATIONS

Background

: The restoration of intestinal continuity is an elective procedure that is not free of complications; on the contrary, many studies have proven a high level of morbidity and mortality. It is multifactorial, and has factors inherent to the patients and to the surgical technique.

Aim

: To identify epidemiological features of patients that underwent ostomy closure analyzing the information about the surgical procedure and its arising complications.

Method

: It was realized a retrospective analysis of medical records of patients who underwent ostomy closure over a period of seven years (2009-2015).

Results

: A total of 39 patients were included, 53.8% male and 46.2% female, with mean age of 52.4 years. Hartmann´s procedure and ileostomy were the mainly reasons for restoration of intestinal continuity, representing together 87%. Termino-terminal anastomosis was performed in 71.8% of cases, by using mainly the manual technique. 25.6% developed complications, highlighting anastomotic leakage; there were three deaths (7.6%). The surgical time, the necessity of ICU and blood transfusion significantly related to post-operative complications.

Conclusion

: It was found that the majority of the patients were male, with an average age of 52 years. It was observed that the surgical time, the necessity of blood transfusion and ICU were factors significantly associated with complications.

Reversal of Hartmann's procedure: a single-centre experience of 533 consecutive cases

AIM

Hartmann's procedure (HP) is common. However, restoration of intestinal continuity is not so frequent. The aim of this study was to determine predictive factors which might influence outcomes following the reversal of HP.

METHOD

All consecutive patients who underwent elective and emergency HP in a single institution between January 1999 and December 2014 were included. Data concerning patient, disease and treatment features were collected. Univariate and multivariate binary logistic regression models were used to determine prognostic factors.

RESULTS

A total of 533 consecutive patients underwent HP over the 16-year period. Factors that were associated with a higher probability of reversal were age (< 69 years), American Society of Anesthesiologists (ASA) grade (I or II), indication for HP (likelihood of anastomotic leakage) and length of rectal stump reaching or exceeding the sacral promontory. A reduced probability of intestinal reconstruction was associated with anal incontinence, Stage IV cancer, postoperative transfusion or elective surgery.

CONCLUSION

Age, ASA grade, the indication for HP, the length of rectal stump, anal incontinence, tumour stage, postoperative transfusion and elective surgery determine the probability of reversal.

Two-year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis

Background

Traditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium‐term follow‐up results of DILALA are reported here.

Methods

Patients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287.

Results

Forty‐three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months.

Conclusion

Laparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.

Laparoscopic lavage still an option

Hartmann's procedure, reversal and rate of stoma-free survival

Background Hartmann's procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann's is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann's procedure between 2008 and 2014. Reversal of Hartmann's rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien-Dindo) including 30-day mortality were recorded. Results Hartmann's procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann's rate was 47% (n = 108). Median age of patients was 58 years (range 21-84 years), American Society of Anesthesiologists grade 2 (range 1-4), length of stay was eight days (range 2-42 days). Median time to reversal of Hartmann's was 11 months (range 4-96 months). The overall complication rate from reversal of Hartmann's was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann's procedure was 7% (n = 15). Where Hartmann's procedure wass not reversed, for 30% (n = 31) this was the patient's choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann's procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann's procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann's procedure in this study.

Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?

BACKGROUND

Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patient's ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes.

METHODS

This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated.

RESULTS

Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis.

CONCLUSION

Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.

Laparoscopic lavage is superior to colon resection for perforated purulent diverticulitis-a meta-analysis

PURPOSE

Perforated diverticulitis often requires surgery with a colon resection such as Hartmann's procedure, with inherent morbidity. Recent studies suggest that laparoscopic lavage may be an alternative surgical treatment. The aim of this study was to compare re-operations, morbidity, and mortality as well as health economic outcomes between laparoscopic lavage and colon resection for perforated purulent diverticulitis.

METHODS

PubMed, Cochrane, Centre for Reviews and Dissemination, and Embase were searched. Published randomized controlled trials and prospective and retrospective cohorts with laparoscopic lavage and colon resection as interventions were identified. Trial limitations were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Re-operations, complications at 90 days classified according to Clavien-Dindo and mortality were extracted.

RESULTS

Three randomized trials published between 2005 and 2015 were included in the analysis. The studies included a total of 358 patients with 185 patients undergoing laparoscopic lavage. At 12 months, the relative risk of having a re-operation was lower for laparoscopic lavage compared to colon resection in the two trials that had a 12 month follow-up. We found no significant differences in Clavien-Dindo complications classified more than level IIIB or mortality at 90 days.

CONCLUSIONS

The risk for re-operations within the first 12 months after index surgery was lower for laparoscopic lavage compared to colon resection, with overall comparable morbidity and mortality. Furthermore, Hartmann's resection was more costly than laparoscopic lavage. We therefore consider laparoscopic lavage a valid alternative to surgery with resection for perforated purulent diverticulitis.

Health economic analysis of laparoscopic lavage versus Hartmann's procedure for diverticulitis in the randomized DILALA trial

BACKGROUND

Open surgery with resection and colostomy (Hartmann's procedure) has been the standard treatment for perforated diverticulitis with purulent peritonitis. In recent years laparoscopic lavage has emerged as an alternative, with potential benefits for patients with purulent peritonitis, Hinchey grade III. The aim of this study was to compare laparoscopic lavage and Hartmann's procedure with health economic evaluation within the framework of the DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial.

METHODS

Clinical effectiveness and resource use were derived from the DILALA trial and unit costs from Swedish sources. Costs were analysed from the perspective of the healthcare sector. The study period was divided into short-term analysis (base-case A), within 12 months, and long-term analysis (base-case B), from inclusion in the trial throughout the patient's expected life.

RESULTS

The study included 43 patients who underwent laparoscopic lavage and 40 who had Hartmann's procedure in Denmark and Sweden during 2010-2014. In base-case A, the difference in mean cost per patient between laparoscopic lavage and Hartmann's procedure was €-8983 (95 per cent c.i. -16 232 to -1735). The mean(s.d.) costs per patient in base-case B were €25 703(27 544) and €45 498(38 928) for laparoscopic lavage and Hartmann's procedure respectively, resulting in a difference of €-19 794 (95 per cent c.i. -34 657 to -4931). The results were robust as demonstrated in sensitivity analyses.

CONCLUSION

The significant cost reduction in this study, together with results of safety and efficacy from RCTs, support the routine use of laparoscopic lavage as treatment for complicated diverticulitis with purulent peritonitis.

Sigmoid resection with primary anastomosis and ileostomy versus laparoscopic lavage in purulent peritonitis from perforated diverticulitis: outcome analysis in a prospective cohort of 40 consecutive patients

PURPOSE

This prospective study aimed to compare outcomes after laparoscopic peritoneal lavage (LPL) and sigmoid resection with primary colorectal anastomosis (RPA).

METHODS

From June 2010 to June 2015, 40 patients presenting with Hinchey III peritonitis from perforated diverticulitis underwent LPL or RPA. Patients with Hinchey II or IV peritonitis and patients who underwent an upfront Hartmann procedure were excluded. Primary endpoint was overall 30-day or in-hospital postoperative morbidity after surgical treatment of peritonitis.

RESULTS

Twenty-five patients underwent RPA and 15 LPL. Overall postoperative morbidity and mortality rates were not significantly different after RPA and LPL (40 vs 67 %, p = 0.19; 4 vs 6.7 %, p = 1, respectively). Intra-abdominal morbidity and reoperation rates were significantly higher after LPL compared to RPA (53 vs 12 %, p < 0.01; 40 vs 4 %, p = 0.02, respectively). Multivariate analysis showed that LPL (p = 0.028, HR = 18.936, CI 95 % = 1.369-261.886) was associated with an increased risk of postoperative intra-abdominal septic morbidity. Among 6 patients who underwent reoperation after LPL, 4 had a Hartmann procedure. All surviving patients who had a procedure requiring stoma creation underwent stoma reversal after a median delay of 92 days after LPL and 72 days after RPA (p = 0.07).

CONCLUSION

LPL for perforated diverticulitis is associated with a high risk of inadequate intra-abdominal sepsis control requiring a Hartmann procedure in up to 25 % of patients. RPA appears to be safer and more effective. It may represent the best option in this context.

Outcomes of colonic diverticulitis according to the reason of immunosuppression

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Markov Decision Model to Guide Treatment of Recurrent Colonic Diverticulitis

BACKGROUND & AIMS

Although colonic diverticulitis is a common disorder, there is no clear treatment strategy for patients with recurrent episodes of diverticulitis. We investigated whether colonic resection or conservative or medical treatments have the greatest effects on quality-adjusted life-years (QALYs).

METHODS

A Markov model simulating patients with 2 episodes of non-surgically treated diverticulitis was used to simulate all relevant outcomes of each treatment strategy. A 1-year cycle length with 10-year follow-up period was used to allow for chance of recurrent diverticulitis. Primary outcome was QALYs gained from each strategy. Factors considered were morbidity, mortality, chance of colostomy formation, risk of recurrence, and persistence of abdominal pain. The probabilities of clinical events were determined by using the best available published data.

RESULTS

A strategy in which colonic resection was performed after 2 episodes of diverticulitis was associated with the lowest quality-adjusted survival (a gain of 8.66 QALYs) and highest chance of stoma formation (1.1%) but the lowest chance of a mild (3.5%) or severe (1.1%) recurrence. The strategies of colonic resection or conservative or medical treatment after the third episode of diverticulitis were comparable in terms of quality-adjusted survival, providing 8.78, 8.76, and 8.74 QALYs, respectively. Probabilistic sensitivity analysis did not change these results. Persistent abdominal complaints were lowest in the medical treatment strategy.

CONCLUSIONS

Elective surgery after 2 episodes of diverticulitis should be questioned in terms of QALYs. After the third episode of diverticulitis, surgical or conservative or medical treatments provide similar QALYs, but rates of abdominal symptoms are lower with the medical treatment strategy. This Markov decision model has limitations when the individual patient and physician face a complex decision weighing early and long-term risks and benefits of elective surgery or conservative management.

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

BACKGROUND

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

AIM

To create formal guidelines for diagnosis and management.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking

Background

Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding.

Methods

A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed.

Results

Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities.

Conclusion

Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Palliative treatment of malignant colorectal obstruction caused by advanced malignancy: a self-expanding metallic stent or surgery? A system review and meta-analysis

We conducted a meta-analysis to compare the outcomes of a self-expanding metallic stent (SEMS) vs. surgery for the palliative treatment of colorectal obstruction caused by advanced colorectal malignancy. The databases of MEDLINE, EMBASE, Cochrane controlled trials registry and the Chinese Wanfang were retrieved (updated to 31 August 2011) to identify eligible studies. We calculated the odds ratio or weighted mean difference and its corresponding 95 % confidence interval. In total, nine primary studies were included in this analysis. The success rate of SEMS placement was 93.9 %, with short-term and long-term complication rates of 26.2 and 16.1 %, respectively. Combined analyses revealed that the SEMS group had a similar risk of short-term complications as the surgical group (P = 0.22). Moreover, SEMS was not associated with a higher mortality risk than surgical intervention (P = 0.22) and it required a significantly shorter hospitalization time (P < 0.01); however, SEMS patients had a higher risk of long-term complications (P = 0.03). Because of great heterogeneities between patients and chemoradiotherapy, we did not analyze the survival times of the two groups. These results support the feasibility of SEMS as a palliative treatment for malignant colorectal obstruction caused by incurable malignancy, as it requires shorter hospitalization and is followed by quick recovery. However, the risk of long-term complications such as perforation and stent migration should be borne in mind.

Subspecialist emergency management of diverticulitis is associated with reduced mortality and fewer stomas

AIM

The aim of the study was to compare outcomes for emergency management of diverticulitis before and after the creation of a regional subspecialist colorectal unit.

METHOD

We retrieved data on all emergency admissions for diverticulitis from the regional surgical audit database and compared results before (January 1998 to August 2002) and after (August 2002 to December 2008) establishment of the subspecialist colorectal surgery unit in August 2002. Additional data were retrieved from electronic patient records. The primary outcome measures were mortality and rate of primary anastomosis following resection.

RESULTS

There were 879 patients before and 1280 patients after subspecialization. Nonoperative management was undertaken in approximately 80% of cases. Total mortality fell from 3.3 to 1.5% (P = 0.008), attributable to reduced operative mortality (9.6 to 4.2%; P = 0.019). The primary anastomosis rate for all left colon resections increased from 50.3 to 77.9%; P < 0.0001. Stoma formation of any type fell from 46.6 to 27.7%; P < 0001).

CONCLUSION

Emergency management of diverticulitis by subspecialist colorectal surgeons is associated with low overall and operative mortality whilst safely achieving high rates of primary anastomosis.

A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis

OBJECTIVES

To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis.

BACKGROUND

The surgical management of left-sided colonic perforation with purulent or fecal peritonitis remains controversial. PA with ileostomy seems to be superior to HP; however, results in the literature are affected by a significant selection bias. No randomized clinical trial has yet compared the 2 procedures.

METHODS

Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from 4 centers were randomized to HP (n = 30) and to PA (with diverting ileostomy, n = 32), with a planned stoma reversal operation after 3 months in both groups. Data were analyzed on an intention-to-treat basis. The primary end point was the overall complication rate. The study was discontinued following an interim analysis that found significant differences of relevant secondary end points as well as a decreasing accrual rate (NCT01233713).

RESULTS

Patient demographics were equally distributed in both groups (Hinchey III: 76% vs 75% and Hinchey IV: 24% vs 25%, for HP vs PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs 9% and morbidity 67% vs 75% in HP vs PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs 20%, P = 0.046), operating time (73 minutes vs 183 minutes, P < 0.001), hospital stay (6 days vs 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs US $24,014) were significantly reduced in the PA group.

CONCLUSIONS

This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.

Grenzen des laparoskopischen Operierens bei abdomineller Sepsis

<b><i>Hintergrund: </i></b>Zahlreiche präklinische Daten weisen auf Vorteile des laparoskopischen Operierens auch bei abdomineller Sepsisquelle und septischem Patienten hin. <b><i>Methode und Ergebnisse: </i></b>Anhand derzeit verfügbarer Literatur betrachten wir die Möglichkeiten und Limitierungen laparoskopischen Operierens beim septischen Patienten mit abdominellem Fokus. Neben generellen Überlegungen werden im Speziellen das Vorgehen bei Appendizitis, Cholezystitis, perforiertem Ulkus, Sigmadivertikulitis und akuter Pankreatitis erörtert. <b><i>Schlussfolgerungen: </i></b>Erfahrene laparoskopische Chirurgen können die Sanierung der abdominellen Sepsisquelle bei Appendizitis, Cholezystitis, perforiertem Ulkus oder auch Sigmadivertikulitis sicher durchführen. Kombinationen aus interventionellen Techniken und minimal invasiven Operationen bieten insbesondere bei der perforierten Sigmadivertikulitis und bei infizierten Pankreasnekrosen innovative Ansätze, die derzeit in multizentrischen prospektiven Studien untersucht werden.

Do older Americans undergo stoma reversal following low anterior resection for rectal cancer?

OBJECTIVE

For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR).

DESIGN

SEER-Medicare-linked analysis from 1991-2007.

SETTINGS AND PARTICIPANTS

A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma.

MAIN OUTCOME MEASURES

(1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal.

RESULTS

Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age <80 y (P < 0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P < 0.001), neoadjuvant radiation (P < 0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P < 0.0001).

CONCLUSIONS

Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.

Case-matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients versus immunocompetent patients

AIM

To compare the perioperative outcomes following surgery for sigmoid diverticulitis in transplant recipients and immunocompetent patients.

METHOD

Solid organ transplant recipients operated on for sigmoid diverticulitis from 1995 to 2010 were case-matched to immunocompetent patients based on surgical procedure, American Society of Anesthesiologists classification, Hinchey score, elective vs urgent surgery, age ± 10 years and year of surgery ± 5 years. Demographics, clinical presentation and perioperative outcomes were assessed.

RESULTS

Of 5329 consecutive patients undergoing heart, lung, kidney and liver transplantation since 1995, 51 (0.6%) underwent surgery for diverticulitis between 1995 and 2010 with 14% mortality and 45% morbidity. Urgent surgery in 37/51 patients [Hartmann's procedure 28, sigmoidectomy with diverting ileostomy 8, loop ileostomy 1 (9 cases within 2 months after transplantation)] was associated with significantly increased postoperative mortality (19%vs 0%, P = 0.01), increased morbidity (51%vs 24%, P = 0.03) and longer mean hospital stay (19 vs 13 days, P = 0.1) when compared with immunocompetent patients. Four patients undergoing urgent surgery had suffered previous episodes of diverticulitis treated nonoperatively. Elective surgery was associated with no mortality in 14 transplant recipients (nine sigmoidectomy with diverting ileostomy, five sigmoidectomy without diversion) or in immunocompetent controls. Following elective procedures, transplant recipients had similar morbidity and increased hospital stay (29% and 9.6 vs 6.5 days, P = 0.2, respectively). Permanent stoma rates and postoperative morbidity after stoma takedown were comparable in the two groups. All living patients except one (kidney) retained their graft function.

CONCLUSIONS

Urgent surgery for sigmoid diverticulitis in transplant recipients is associated with worse postoperative outcomes when compared with immunocompetent patients, unlike elective surgery. Future studies will need to clarify the role of early surgery after the first diverticulitis episode.

Damage control surgery with abdominal vacuum and delayed bowel reconstruction in patients with perforated diverticulitis Hinchey III/IV

OBJECTIVE

With the use of abdominal vacuum therapy, we have developed a damage control concept for patients with perforated diverticulitis and generalized peritonitis. The primary aim of this concept was to enhance recovery and allow bowel reconstruction in a second-look operation.

METHODS

A total of 51 patients (28 female, 55%) with a median (range) age of 69 (28-87) years, with perforated diverticulitis Hinchey III (n = 40, 78%) or Hinchey IV (n = 11, 22%) and a median (range) Mannheim peritonitis index of 26 (12-39), admitted between October 2006 and September 2011, were prospectively enrolled in the study. At initial operation, limited resection of the diseased segment, lavage, and application of abdominal vacuum-assisted closure dressing was performed. After patient resuscitation, a second look was performed in an elective setting.

RESULTS

Hospital mortality rate was 9.8%; 35 (76%) of patients were discharged with reconstructed colon, and 93% of patients live without a stoma at follow-up. Risk factors for mortality were American Society of Anesthesiologist score (p = 0.01), organ failure at initial presentation (p = 0.03), cardiac comorbidity (p = 0.05), and a Hartmann procedure at second look (p = 0.00).

CONCLUSION

With this abdominal vacuum-based damage control concept, an acceptable hospital mortality rate and a high rate of bowel reconstruction at second look were achieved in patients with perforated diverticulitis and generalized peritonitis.

Morbidity and mortality of the Hartmann procedure for diverticular disease over 18 years in a single institution

AIM

Hartmann's procedure for perforated diverticulitis is associated with substantial morbidity and mortality. This study analyses factors associated with morbidity/mortality and possible changes over time.

METHOD

Patients treated by urgent Hartmann's procedure for perforated diverticulitis between 1992 and 2010 were studied, and information was collected on age, sex, perioperative details, 30-day morbidity and mortality recorded in an institutional review board approved database supplemented by chart review. Patients were divided into four groups based on the year of surgery. Univariate and multivariate logistic regression analysis was performed to identify risk factors associated with morbidity and mortality.

RESULTS

In all, 199 patients (51% female, mean age 65 years, mean body mass index 28 kg/m(2)) were identified. The American Society of Anesthesiologists (ASA) score was 4 in 30% of patients and Hinchey Stage IV in 16%. The mean length of stay was 12.5 ± 10 days. Mortality was 15% and did not change significantly over time. Overall morbidity was 52% and significantly increased over time on univariate analysis (P = 0.007) but not on multivariate analysis (P = 0.11). Independent predictors of morbidity on multivariate analysis were Hinchey IV (P < 0.001) and hypoproteinaemia (P = 0.001). Independent predictors for mortality were ASA > 3 (P = 0.01), abnormal creatinine (P = 0.007), steroid use (P = 0.007), Hinchey IV (P = 0.032), low albumin (P < 0.001) and low body mass index (P = 0.001).

CONCLUSION

Mortality after Hartmann's procedure for perforated diverticulitis has not decreased during the last 18 years. Morbidity has actually increased over time although this is related to increased disease severity and comorbidity. Future efforts should focus on the identification of patient subgroups benefiting from earlier elective surgery and alternative surgical approaches when perforated diverticulitis does occur.

Low complication rate after stoma closure. Consultants attended 90% of the operations

AIM

To evaluate complications after stoma closure.

METHOD

Using a retrospective review of 997 medical records, data were collected from all patients undergoing stoma closure at the Department of Surgery P, Aarhus University Hospital, Denmark, from 1996 to 2010. Patient data after Hartmann reversal and loop-ileostomy closure were compared. Data regarding the grade of the operating surgeon and assistant were extracted.

RESULTS

Out of 997 patients, 700 (70.6%) had a loop-ileostomy closure and 172 (17.4%) had a Hartmann reversal. Postoperative mortality was 0.5%. Seven patients required re-operation (0.7%). Morbidity was registered in 31.9% of the patients, with 131 (13.1%) having early complications and 187 (18.8%) having late complications. Wound infection was the most frequent early complication, which occurred in 31 patients (3.1%). Only 10 patients (1%) had an anastomotic leak. Incisional hernia was the most frequent late complication, occurring in 92 patients (9.3%). A consultant attended 90% of the operations. Junior surgeons never performed stoma closure without supervision. Body mass index was significantly associated with the development of incisional hernia. Hartmann reversal was associated with higher rates of complications compared with loop-ileostomy closure. In patients with Hartmann reversal, stapled anastomosis was associated with stricture in 12 out of 95 cases (12.6%), whereas hand-sewn anastomosis was not associated with stricture (0 out of 64 patients; 0%; P < 0.05).

CONCLUSION

Stoma closure is associated with low rates of leakage. A favourable case mix and high degree of consultant attendance may explain the good results.

Mortality following Hartmann's procedure--correlation of Dr. Foster's report with CR-POSSUM

AIMS

Dr. Foster Intelligence highlighted a higher than expected mortality rate from emergency Hartmann's procedure at a district general hospital from April 2007 to March 2009 (6.5% expected, 30% actual mortality). A retrospective audit of all Hartmann's procedures over 4 years was performed.

METHODS

Notes were examined for all emergency Hartmann's procedures between April 2006 and March 2010. CR-POSSUM scores were calculated for each patient. Results were analysed in SPSS (IBM Corp.).

RESULTS

The mean CR-POSSUM score for the entire cohort was 27.78%, which compared to an observed mortality rate of 22.5% (18/80 cases, p=0.61). There was a significant correlation between mortality and CR-POSSUM score (p=0.001) and ASA grade (p=0.001). Those aged 81 and above had a significantly higher mortality (P≤0.05). There was no statistically significant correlation between grade of surgeon and mortality (p=0.42). Overall consultant presence in theatre was 72.5% (58/79 cases) and in those that died 82.4% (14/17 cases). Those patients who had an admission to diagnosis time of 10 days or more were at significantly greater risk of death (p<0.05).

CONCLUSIONS

Dr. Foster's data does not sufficiently take into account the pre-operative state of each patient. The CR-POSSUM predicted mortality scores for the studied patient population and the actual mortality were similar. This suggests that the studied patient population were of a higher risk group than presumed by Dr. Foster's data. This study has highlighted that an older population and a delay in diagnosis following admission may have contributed to the increase in mortality in some cases.

Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data

BACKGROUND

The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma. Our study compared the surgical outcomes of patients with perforated diverticulitis who underwent a HP to primary anastomosis with proximal diversion (PAPD).

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2009 to identify all cases of perforated diverticulitis classified as contaminated or dirty/infected. Patients were stratified into HP or PAPD, and logistic regression models were created to control for patient demographics, comorbidities, perioperative risk, and illness severity to determine the impact of surgical procedure on outcome.

RESULTS

There were 2,018 patients meeting the inclusion criteria of which 340 (17%) underwent PAPD and the remainder underwent HP. Significant independent predictors of infectious outcomes were alcohol use, preoperative sepsis, and operative time. There was no significant difference in risk of infectious complications, return to the operating room, prolonged ventilator use, death, or hospital length of stay between the two procedures. When considering only dirty/infected cases, the mortality risk was twofold greater when PAPD was performed.

CONCLUSION

The treatment of acute diverticulitis in the setting of contamination can be safely treated with resection, primary anastomosis, and proximal diversion as opposed to a HP in certain circumstances. Given the decreased morbidity of subsequent loop ileostomy takedown compared with a Hartmann's reversal, this procedure should be given consideration in the management of acute, perforated diverticulitis but may not be warranted in cases of feculent peritonitis.

Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann's procedure

BACKGROUND

This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann's procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis.

METHODS

A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P < 5 % was considered statistically significant in this study.

RESULTS

A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann's for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs. 6.7 ± 2.2 days, P < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %.

CONCLUSIONS

Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.

Laparoscopic reversal of Hartmann's procedure

Reversal of Hartmann's procedure is a major surgical procedure associated with significant morbidity and mortality. Because of the difficulty of the procedure, laparoscopic reversal of Hartmann's procedure is not well established. We describe our experience with this laparoscopic procedure to assess its difficulty and safety. Five patients (4 men and 1 woman) underwent laparoscopic reversal of Hartmann's procedure (LRHP). The initial surgeries were performed to manage obstructive colorectal cancer for 4 patients, and rectovesical fistula for one patient. The procedure was laparoscopically completed for 4 patients. Conversion to open laparotomy was required for one patient, secondary to massive adhesion in lower abdomen. Transient ileostomies were made in 2 cases. Operative time ranged from 240 to 545 minutes. There was no operative mortality. LRHP can be performed safely by an experienced surgeon. However, it is still technically challenging and time consuming.