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

Results of surgical treatment of patients with acute destructive diverticulitis of the colon using minimally invasive technologies

Among the diseases of the colon, diverticular disease occupies one of the leading positions, the frequency of which is currently 1.2 cases per 1000 people. Complications in this condition develop in 5% of cases and account for 3-5% of all patients with acute abdominal diseases. Surgical intervention is required in 15% to 30% of such patients. The mortality rate after surgical treatment of acute complications of the diverticular disease remains high, ranging from 7% to 25%. The purpose of our study was to compare the outcomes in the treatment of patients with acute destructive diverticulitis of the colon using traditional surgical treatment versus minimally invasive technologies. In the study, 114 patients diagnosed with acute destructive diverticulitis were examined. Group I consisted of 56 patients who underwent initial surgical interventions employing minimally invasive methods like laparoscopy, laparoscopic-assisted techniques, or percutaneous drainage guided by ultrasound. Group II comprised 58 patients who underwent the first surgical intervention through laparotomy access. The data of our study show that the overall proportion of patients with complications was higher in Group II – 20 (34.5%) compared to 6 (10.1%) in Group I (p=0.005). The application of diverse surgical methods did not notably impact the mortality rate, with 6 (10.3%) fatalities in Group II compared to 2 (3.6%) in Group I (p=0.2). Stoma creation was more frequent in Group II, in 40 (67%) patients, whereas in Group I, the occurrence of stomas was lower, in 15 (25.9%) cases. The average period to stoma closure was 5 months in Group II and 2 months in Group I. There was observed a decrease in the time of urgent surgery from 143±13.5 minutes in Group II to 65.7±15.2 minutes in Group I (p<0.01) and the duration of the first hospitalization from 14.2±1.8 days to 5.6±0.7 days, accordingly (p<0.01). When dealing with primary anastomosis or severe peritonitis, utilizing a laparoscope for dynamic laparoscopy allows for real-time monitoring of the abdominal cavity and early identification of complications, eliminating the need for scheduled laparostomy. The research data demonstrate that, while not affecting mortality, minimally invasive methods have several significant advantages, including a reduction in the number of complications, a decrease in the proportion of patients with stomas, a reduction in the time to reconstructive surgery, and a decrease in the duration of urgent surgery and the length of hospitalization.

The optimal timing of elective surgery in sigmoid diverticular disease: a meta-analysis

PURPOSE

The aim of this meta-analysis was to investigate the optimal time point of elective sigmoidectomy regarding the intraoperative and postoperative course in diverticular disease.

METHODS

A comprehensive literature research was conducted for studies comparing the operative outcome of early elective (EE) versus delayed elective (DE) minimally invasive sigmoidectomy in patients with acute or recurrent diverticular disease. Subsequently, data from eligible studies were extracted, qualitatively assessed, and entered into a meta-analysis. By using random effect models, the pooled hazard ratio of outcomes of interest was calculated.

RESULTS

Eleven observational studies with a total of 2096 patients were included (EE group n = 828, DE group n = 1268). Early elective sigmoidectomy was associated with a significantly higher conversion rate as the primary outcome in comparison to the delayed elective group (OR 2.48, 95% CI 1.5427-4.0019, p = 0.0002). Of the secondary outcomes analyzed only operative time (SMD 0.14, 95% CI 0.0020-0.2701, p = 0.0466) and time of first postoperative bowel movement (SMD 0.57, 95% CI 0.1202-1.0233, p = 0.0131) were significant in favor of the delayed elective approach.

CONCLUSIONS

Delayed elective sigmoid resection demonstrates benefit in terms of reduced conversion rates and shortened operative time as opposed to an early approach. Conversely, operative morbidities seem to be unaffected by the timing of surgery. However, a final and robust conclusion based on the included observational cohort studies must be cautiously made. We therefore highly advocate larger randomized controlled trials with homogenous study protocols.

Early elective versus elective sigmoid resection in diverticular disease: not only timing matters-a single institutional retrospective review of 133 patients

Purpose

The optimal timing of elective surgery in patients with the colonic diverticular disease remains controversial. We aimed to analyze the timing of sigmoidectomy in patients with diverticular disease and its influence on postoperative course with respect to the classification of diverticular disease (CDD).

Methods

Patients who underwent elective laparoscopic sigmoidectomy were retrospectively enrolled and subdivided into two groups based on the time interval between the last attack and surgery: group A, early elective (≤ 6 weeks), and group B, elective (> 6 weeks). Multivariate regression models were used to identify factors which predict conversion to laparotomy, postoperative course, and length of hospital stay.

Results

A total of 133 patients (group A (n = 88), group B (n = 45)) were included. Basic demographic data did not differ between groups except for a higher rate of diabetes in group B (p = 0.009). The conversion rate was significantly higher in group A in comparison to group B (group A vs. group B: n = 23 (26.1%) vs. n = 3 (6.7%), p = 0.007). Logistic regression analysis revealed the timing of surgery and CDD stage as significant predictors for intraoperative conversion. Moreover, the postoperative course was influenced by high age as well as intraoperative conversion and length of hospital stay by conversion, preoperative CRP levels, and elective surgery.

Conclusions

Both, timing of surgery and the disease stage, influence the conversion rates in laparoscopic sigmoidectomy for diverticular disease. Accordingly, patients with complicated acute or chronic sigmoid diverticulitis should be operated in the inflammation-free interval.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02464-1.