Does the presence of abscesses in diverticular disease prelude surgery?

Long-term Implications of Persistent Diverticulitis: A Retrospective Cohort Study of 915 Patients

BACKGROUND

Persistent (or ongoing) diverticulitis is a well-recognized outcome after treatment for acute sigmoid diverticulitis; however, its definition, incidence, and risk factors, as well as its long-term implications, remain poorly described.

OBJECTIVE

The purpose of this study was to assess the incidence, risk factors, and long-term outcomes of persistent diverticulitis.

DESIGN

This was a retrospective cohort study.

SETTINGS

Two university-affiliated hospitals in Montreal, Quebec, Canada were included.

PATIENTS

The study was composed of consecutive patients managed nonoperatively for acute sigmoid diverticulitis.

INTERVENTION

Nonoperative management of acute sigmoid diverticulitis was involved.

MAIN OUTCOME MEASURES

Persistent diverticulitis, defined as inpatient or outpatient treatment for signs and symptoms of ongoing diverticulitis within the first 60 days after treatment of the index episode, was measured.

RESULTS

In total, 915 patients were discharged after an index episode of diverticulitis managed nonoperatively. Seventy-five patients (8.2%; 95% CI, 6.5%-10.2%) presented within 60 days with persistent diverticulitis. Factors associated with persistent diverticulitis were younger age (adjusted OR = 0.98 (95% CI, 0.96-0.99)), immunosuppression (adjusted OR = 2.02 (95% CI, 1.04-3.88)), and abscess (adjusted OR = 2.05 (95% CI, 1.03-3.92)). Among the 75 patients with persistent disease, 42 (56.0%) required hospital admission, 6 (8.0%) required percutaneous drainage, and 5 (6.7%) required resection. After a median follow-up of 39.0 months (range, 17.0-67.3 mo), the overall recurrence rate in the entire cohort was 31.3% (286/910). After excluding patients who were managed operatively for their persistent episode of diverticulitis, the cumulative incidence of recurrent diverticulitis (log-rank: p < 0.001) and sigmoid colectomy (log-rank: p < 0.001) were higher among patients who experienced persistent diverticulitis after the index episode. After adjustment for relevant patient and disease factors, persistent diverticulitis was associated with higher hazards of recurrence (adjusted HR = 1.94 (95% CI, 1.37-2.76) and colectomy (adjusted HR = 5.11 (95% CI, 2.96-8.83)).

LIMITATIONS

The study was limited by its observational study design and modest sample size.

CONCLUSIONS

Approximately 10% of patients experience persistent diverticulitis after treatment for an index episode of diverticulitis. Persistent diverticulitis is a poor prognostic factor for long-term outcomes, including recurrent diverticulitis and colectomy. See Video Abstract at http://links.lww.com/DCR/B593.

REPERCUSIONES A LARGO PLAZO DE LA DIVERTICULITIS PERSISTENTE ESTUDIO DE UNA COHORTE RETROSPECTIVA DE PACIENTES

ANTECEDENTES:La diverticulitis persistente (o continua) es un resultado bien conocido posterior al tratamiento de la diverticulitis aguda del sigmoides; sin embargo, la definición, incidencia y factores de riesgo, así como sus repercusiones a largo plazo siguen estando descritas de manera deficiente.OBJETIVO:Evaluar la incidencia, los factores de riesgo y los resultados a largo plazo de la diverticulitis persistente.DISEÑO:Estudio de una cohorte retrospectiva.AMBITO:Dos hospitales universitarios afiliados en Montreal, Quebec, Canadá.PACIENTES:pacientes consecutivos tratados sin cirugia por diverticulitis aguda del sigmoides.INTERVENCIÓN:Tratamiento no quirúrgico de la diverticulitis aguda del sigmoides.PRINCIPALES RESULTADOS EVALUADOS:Diverticulitis persistente, definida como tratamiento hospitalario o ambulatorio por signos y síntomas de diverticulitis continua dentro de los primeros 60 días posteriores al tratamiento del episodio índice.RESULTADOS:Un total de 915 pacientes fueron dados de alta posterior al episodio índice de diverticulitis tratados sin cirugia. Setenta y cinco pacientes (8,2%; IC del 95%: 6,5-10,2%) presentaron diverticulitis persistente dentro de los 60 días. Los factores asociados con la diverticulitis persistente fueron una edad menor (aOR: 0,98, IC del 95%: 0,96-0,99), inmunosupresión (aOR: 2,02, IC del 95%: 1,04-3,88) y abscesos (aOR: 2,05, IC del 95%: 1,03-3,92). Entre los 75 pacientes con enfermedad persistente, 42 (56,0%) requirieron ingreso hospitalario, 6 (8,0%) drenaje percutáneo y 5 (6,7%) resección. Posterior a seguimiento medio de 39,0 (17,0-67,3) meses, la tasa global de recurrencia de toda la cohorte fue del 31,3% (286/910). Después de excluir a los pacientes que fueron tratados quirúrgicamente por su episodio persistente de diverticulitis, la incidencia acumulada de diverticulitis recurrente (rango logarítmico: p <0,001) y colectomía sigmoidea (rango logarítmico: p <0,001) fue mayor entre los pacientes que experimentaron diverticulitis persistente después el episodio índice. Posterior al ajuste de factores importantes de la enfermedad y del paciente, la diverticulitis persistente se asoció con mayores riesgos de recurrencia (aHR: 1,94, IC 95% 1,37-2,76) y colectomía (aHR: 5,11, IC 95% 2,96-8,83).LIMITACIONES:Diseño de estudio observacional, un modesto tamaño de muestra.CONCLUSIONES:Aproximadamente el 10% de los pacientes presentan diverticulitis persistente después del tratamiento del episodio índice de diverticulitis. La diverticulitis persistente, en sus resultados a largo plazo, es un factor de mal pronóstico, donse se inlcuye la diverticulitis recurente y colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B593.

Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review

BACKGROUND

The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof.

METHOD

Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared.

RESULTS

Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%).

CONCLUSION

This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.

Systematic Review and Meta-analysis on Colorectal Cancer Findings on Colonic Evaluation After CT-Confirmed Acute Diverticulitis

BACKGROUND

CT findings of acute diverticulitis can overlap with features of malignancy, and current guidelines recommend colonic evaluation after acute diverticulitis. However, the benefits of routine colonic evaluation have been questioned.

OBJECTIVE

We review 30 studies, composed of 29,348 subjects, to evaluate the role of routine colonic evaluation after CT-proven acute diverticulitis.

DATA SOURCES

Medline, EMBASE, and the Cochrane Library were searched for articles published up to July 2018 to identify all relevant articles.

STUDY SELECTION

A combination of both Medical Subject Headings and non-Medical Subject Headings key terms using Boolean operators were used on Medline, including colonic neoplasms, colorectal cancer, colon cancer, colonic cancer, colonoscopy, and diverticulitis. Any randomized or nonrandomized, English-language article that specifically analyzed incidence of colorectal cancer after performing colonoscopy in patients with previous diverticulitis was included.

MAIN OUTCOME MEASURES

The desired outcome was to evaluate for incidence of colonic malignancy in cases of acute colonic diverticulitis. Subgroup analyses for incidence of malignancy in uncomplicated and complicated diverticulitis, and Asian population studies were also performed.

RESULTS

Findings of colonic malignancy occurred in 1.67% (95% CI, 1.24-2.14) of patients with CT-diagnosed diverticulitis. The risk of malignancy in cases with uncomplicated diverticulitis was 1.22% (95% CI, 0.63-1.97) as compared with 6.14% (95% CI, 3.20-9.82) in cases with complicated diverticulitis, with a relative risk of 5.033 (95% CI, 3.194-7.930; p < 0.001).

LIMITATIONS

Significant variability in design and methodology of the individual studies contributed to the heterogeneity of this study, but these were addressed by using the random-effects model analysis.

CONCLUSIONS

Colonic evaluation is worth considering for patients with diverticulitis because of the small but serious risk of underlying malignancy. The risk of malignancy is higher for patients of advanced age and with complicated diverticulitis.

Systematic review of failure of nonoperative management in complicated sigmoid diverticulitis with abscess

PURPOSE

The aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess.

METHODS

Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30 days. Recurrence was defined as development of symptoms after an asymptomatic period of 30-90 days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition.

RESULTS

Twenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001).

CONCLUSION

The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30 days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at the mean follow-up of 38 months.

Readmission for Treatment Failure After Nonoperative Management of Acute Diverticulitis: A Nationwide Readmissions Database Analysis

BACKGROUND

The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood.

OBJECTIVE

The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database.

DESIGN

This was a retrospective cohort study.

SETTINGS

A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included.

PATIENTS

Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included.

INTERVENTIONS

Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage.

MAIN OUTCOME MEASURES

Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured.

RESULTS

In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis.

LIMITATIONS

The study was limited by residual confounding from missing covariates and its observational study design.

CONCLUSIONS

The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).

Long-term mortality and recurrence in patients treated for colonic diverticulitis with abscess formation: a nationwide register-based cohort study

PURPOSE

The study aimed to investigate long-term mortality, recurrence, and death related to recurrence for patients admitted with acute diverticulitis with abscess formation (Hinchey stage Ib-II).

METHODS

The cohort was identified by linking administrative registers for all Danish citizens in years 2000-2012. Patients were identified from ICD-10 discharge codes and stratified according to treatment (antibiotics, percutaneous abscess drainage, or surgery).

RESULTS

From 6,641,672 persons, 3148 patients were identified with acute diverticulitis with abscess formation. Survival was comparable between treatment groups with a 1-year survival of 81-83% and a 5-year survival of 66-67% (p = 0.66). Glucocorticoid usage prior to admission increased risk of mortality with hazard ratio 1.64 (95%CI 1.39-1.93), 1.77 (1.20-2.63), and 1.92 (1.07-3.44) for the antibiotics, drainage, and operative treatment group, respectively. Drainage treatment increased risk of recurrence with sub-distribution hazard (SDH) of 1.52 (1.19-1.95) and operative treatment decreased risk with a SDH of 0.55 (0.32-0.93), both compared with antibiotic treatment (p = 0.0001). Recurrence occurred in 23.6% (18.5-30.1%) of patients in the drainage group, 15.5% (13.9-17.3%) in the antibiotics group, and 9.1% (5.1-16.1%) in the operative group. Recurrence-related mortality was 2.0% (0.9-4.4%) for the drainage group, 1.1% (0.7-1.8%) for the antibiotics group, and 0.6% (0.1-4.3%) for the operative group (p = 0.24). Most recurrences and recurrence-related mortality occurred within the first year after primary admission.

CONCLUSIONS

This study with complete national data revealed a high mortality and recurrence rate after diverticular abscesses. Survival was comparable between treatment groups, but patients treated with drainage had significantly higher risk of recurrence.

Risk factors for recurrence after acute colonic diverticulitis: a systematic review

PURPOSE

Several factors may influence the risk of recurrence after an episode of acute colonic diverticulitis. Until now, a comprehensive systematic overview and evaluation of relevant risk factors have not been presented. This review aimed at assembling and evaluating current evidence on risk factors for recurrence after conservatively treated acute colonic diverticulitis.

METHODS

PubMed, Embase, and Cochrane databases were searched for studies evaluating risk factors for recurrence after acute diverticulitis treated non-surgically defined as antibiotic treatment, percutaneous abscess drainage, or by observation. Randomized clinical trials and observational studies were included. Analyzed outcome variables were extracted and grouped. No meta-analysis was performed due to low inter-study comparability. Variables were rated according to their likelihood of causing recurrence (no/low, medium, high).

RESULTS

Of 1153 screened records, 35 studies were included, enrolling 396,676 patients with acute diverticulitis. A total of 50,555 patients experienced recurrences. Primary diverticulitis with abscess formation and young age increased the risk of recurrence. Readmission risk was higher within the first year after remission. In addition, the risk of subsequent diverticulitis more than doubled after two earlier episodes of diverticulitis and the risk increased further for every episode.

CONCLUSIONS

The best treatment strategy for recurrent diverticulitis is undetermined. However, the risk of a new recurrence seemed to increase after each recurrence making elective resection a viable option at some point after multiple recurrences depending on patient risk factors and preferences.

Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review

PURPOSE

This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options.

METHODS

PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence.

RESULTS

Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain.

CONCLUSIONS

Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.

Short-term mortality, readmission, and recurrence in treatment of acute diverticulitis with abscess formation: a nationwide register-based cohort study

PURPOSE

The aim of the study was to investigate short-term mortality, readmission, and recurrence in a national cohort of patients with Hinchey Ib-II diverticulitis.

METHODS

The retrospective cohort-investigation was conducted using a database consisting of the entire Danish population (n = 6,641,672) in year 2000-2012, formed by linking the Danish Registers. Patients admitted with acute Hinchey Ib-II diverticulitis were identified from ICD-10 discharge codes and stratified according to treatment into an operative, drainage, and antibiotics group. The primary outcome was 30-day mortality from admission, secondary outcomes were mortality, readmission, and recurrence within 30 days post-discharge. The study was reported using RECORD guidelines.

RESULTS

A total of 3148 eligible patients were identified. The cohort had a mean age of 65.1 year, 25.6 % had previously been admitted with diverticulitis, and 48.1 % had registered comorbidities. Within 30 days from admission, 8.7 % of the patients died. Of patients discharged, 2.5 % died, 23.8 % was readmitted, and 5.9 % was readmitted due to diverticulitis within 30 days from discharge. In multivariate analyses, increasing age was associated with mortality at odds-ratio (95 % CI) 1.10 (1.09-1.12). Previous complicated and uncomplicated diverticulitis reduced mortality with odds-ratio 0.50 (0.33-0.76) and 0.73 (0.58-0.92), while uncomplicated diverticulitis also increased risk of recurrence with odds-ratio 1.51 (1.24-1.84). Glucocorticoid usage was associated with mortality with odds-ratio 1.49 (1.23-1.81) and readmission with odds-ratio 2.91 (1.24-6.80).

CONCLUSION

Acute diverticulitis with abscess formation is a severe and life-threatening condition. Direct comparisons of treatment groups were not possible due to possible confounding by indication.

Percutaneous Drainage of a Diverticular Abscess Should be Limited to Two Attempts for a Resilient Diverticular Abscess

Management of a resilient diverticular abscess poses a big challenge. Currently there are no guidelines for the number of percutaneous drainages to be performed in resilient diverticular abscesses before attempting surgery. All patients (n = 117) who presented with a computed tomography scan-proven diverticular abscess from July 2008 to June 2011 were studied. They were divided into four groups based on the number of percutaneous drainages they underwent for their diverticular abscess: six patients underwent three or more drainages, nine patients underwent two drainages, 27 patients had one drainage, and 75 patients had no drainage. Readjustment, flushing, and upgrading size of the drain were not considered as separate drainage procedures. The size of abscess cavity was significantly higher for the patients who had three or more drainages (mean 8 cm, P < 0.001). A Hartmann's procedure was performed in the majority of patients in the three or more drainage group (83%) but in decreasing frequency as the number of drainages performed dropped: two drainage group (44%), one drainage group (15%), and no drainage group (19%). There was a significantly higher preoperative hospital stay for drainage and antibiotics in the patients from the three or more drainage group ( P < 0.001). Patients with a resilient diverticular abscess are very likely to undergo a Hartmann's procedure after two attempted drainages. By performing additional percutaneous drainages in an attempt to avoid ostomy, patients are at an increased risk of sepsis and peritonitis with prolonged antibiotics and increased healthcare costs. We recommend limiting percutaneous drainage procedures to two attempts to cool down a resilient diverticular abscess before definitive surgery.

Inter-observer reliability of computed tomographic classifications of diverticulitis

AIM

The wide use of computed tomography (CT) for diverticulitis has initiated new classifications, but their reliability has not been studied. The aim of the study was to assess the inter-observer agreement of radiologists on the classifications of diverticulitis.

METHOD

A set of 100 CT examinations of patients with an episode of diverticulitis was used to assess inter-observer agreement. Cases were derived from two prospective trials and a retrospective cohort to comprise an evenly distributed case mix of patients. The reference standard was the modified Hinchey classification based on all available information. Three blinded radiologists independently read all CT examinations. We calculated the proportion of agreement and kappa values for the Hinchey and Ambrosetti classifications. For the Dharmarajan classification only inter-observer agreement was calculated.

RESULTS

The agreement with the reference standard was substantial for both the modified Hinchey and the Ambrosetti classifications (P = 0.68 and P = 0.76). Overall inter-observer agreement for the modified Hinchey classification was substantial (median kappa 0.72), for the Ambrosetti classification almost perfect (median kappa 0.83) and for the Dharmarajan classification substantial (median kappa 0.76).

CONCLUSION

The Ambrosetti classification is more reproducible than the modified Hinchey and Dharmarajan classifications. The Ambrosetti and modified Hinchey classifications have a substantial agreement with the reference standard and therefore produce a reliable classification. The Dhamarajan is applicable only in complicated diverticulitis and is an important complementary classification to the other more general classifications of diverticulitis.

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.