Microscopic findings in sigmoid diverticulitis--changes after conservative therapy

Validation of the German Classification of Diverticular Disease (VADIS)-a prospective bicentric observational study

PURPOSE

The German Classification of Diverticular Disease was introduced a few years ago. The aim of this study was to determine whether Classification of Diverticular Disease enables an exact stratification of different types of diverticular disease in terms of course and treatment.

METHODS

This was a prospective, bicentric observational trial. Patients aged ≥ 18 years with diverticular disease were prospectively included. The primary endpoint was the rate of recurrence within 2 year follow-up. Secondary outcome measures were Gastrointestinal Quality of Life Index, Quality of life measured by SF-36, frequency of gastrointestinal complaints, and postoperative complications.

RESULTS

A total of 172 patients were included. After conservative management, 40% of patients required surgery for recurrence in type 1b vs. 80% in type 2a/b (p = 0.04). Sixty percent of patients with type 2a (micro-abscess) were in need of surgery for recurrence vs. 100% of patients with type 2b (macro-abscess) (p = 0.11). Patients with type 2a reached 123 ± 15 points in the Gastrointestinal Quality of Life Index compared with 111 ± 14 in type 2b (p = 0.05) and higher scores in the "Mental Component Summary" scale of SF-36 (52 ± 10 vs. 43 ± 13; p = 0.04). Patients with recurrent diverticulitis without complications (type 3b) had less often painful constipation (30% vs. 73%; p = 0.006) when they were operated compared with conservative treatment.

CONCLUSION

Differentiation into type 2a and 2b based on abscess size seems reasonable as patients with type 2b required surgery while patients with type 2a may be treated conservatively. Sigmoid colectomy in patients with type 3b seems to have gastrointestinal complaints during long-term follow-up.

TRIAL REGISTRATION

https://www.drks.de ID: DRKS00005576.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

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

[Diverticular disease - diagnosis and classification]

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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