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Mohamedahmed AY, Zaman S, Das N, Kakaniaris G, Vakis S, Eccersley J, Thomas P, Husain N. Systematic review and meta-analysis of the management of acute uncomplicated diverticulitis: time to change traditional practice. Int J Colorectal Dis 2024; 39:47. [PMID: 38578433 PMCID: PMC10997545 DOI: 10.1007/s00384-024-04618-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND To evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey grade 1a) acute diverticulitis. METHODS A systematic online search was conducted using electronic databases. Comparative studies of OP versus IP treatment and ABX versus NABX approach in the treatment of Hinchey grade 1a acute diverticulitis were included. Primary outcome was recurrence of diverticulitis. Emergency and elective surgical resections, development of complicated diverticulitis, mortality rate, and length of hospital stay were the other evaluated secondary outcome parameters. RESULTS The literature search identified twelve studies (n = 3,875) comparing NABX (n = 2,008) versus ABX (n = 1,867). The NABX group showed a lower disease recurrence rate and shorter length of hospital stay compared with the ABX group (P = 0.01) and (P = 0.004). No significant difference was observed in emergency resections (P = 0.33), elective resections (P = 0.73), development of complicated diverticulitis (P = 0.65), hospital re-admissions (P = 0.65) and 30-day mortality rate (P = 0.91). Twelve studies (n = 2,286) compared OP (n = 1,021) versus IP (n = 1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P = 0.10), emergency surgical resection (P = 0.40), elective resection (P = 0.30), disease recurrence (P = 0.22), and mortality rate (P = 0.61). CONCLUSION Observation-only treatment is feasible and safe in selected clinically stable patients with uncomplicated acute diverticulitis (Hinchey 1a classification). It may provide better outcomes including decreased length of hospital stay. Moreover, the OP approach in treating patients with Hinchey 1a acute diverticulitis is comparable to IP management. Future high-quality randomised controlled studies are needed to understand the outcomes of the NABX approach used in an OP setting in managing patients with uncomplicated acute diverticulitis.
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Affiliation(s)
- Ali Yasen Mohamedahmed
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Shafquat Zaman
- Department of General Surgery, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK.
- Institute of Cancer and Genomic Science, College of Medical and Dental Science, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Niloy Das
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Georgios Kakaniaris
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Stelios Vakis
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - James Eccersley
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Pradeep Thomas
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
| | - Najam Husain
- Department of General and Colorectal Surgery, Queen's Hospital Burton, University Hospital of Derby and Burton NHS Trust, Derby, UK
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Protective effects of amoxicillin and probiotics on colon disorders in an experimental model of acute diverticulitis disease. Inflammopharmacology 2022; 30:2153-2165. [DOI: 10.1007/s10787-022-01093-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
AbstractAcute diverticulitis disease is associated with inflammation and infection in the colon diverticula and may lead to severe morbidity. This study aimed to evaluate and compare the protective effects of amoxicillin antibiotic, either alone or in combination with probiotics (Lactobacillus acidophilus and Bifidobacterium lactis), in a rat model of acute diverticulitis disease. Acute diverticulitis was induced, in albino rats, by adding 3% weight/volume of dextran sulfate sodium (DSS) to the rats’ drinking water; daily for 7 days, in addition to injecting lipopolysaccharide (LPS) enema (4 mg/kg). The impact of treatments was assessed by measuring the physiological and immunological parameters and evaluating colon macroscopic and microscopic lesions. The results showed that both treatments (especially probiotics with amoxicillin) alleviated the adverse effects of DSS and LPS. This was obvious through the modulation of the rats’ body weight and the colon weight-to-length ratio. Also, there was a significant (p < 0.001) decrease in the colon macroscopic lesion score. The pro-inflammatory cytokines [(TNF)-α, (IL)-1β, (IFN)-γ, and (IL)-18]; in the colon tissue; were significantly (p < 0.001) decreased. Also, both treatments significantly ameliorated the elevation of myeloperoxidase activity and C-reactive protein levels, in addition to improving the histopathological alterations in the colon tissue. In conclusion, amoxicillin and probiotics–amoxicillin were effective in preventing the development of experimentally induced acute diverticulitis, through their anti-inflammatory and immunomodulatory effects. Furthermore, this study has explored the role of probiotics in preventing DSS/LPS-induced acute diverticulitis, so it can be applied as a promising treatment option for acute diverticulitis disease.
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Balk EM, Adam GP, Bhuma MR, Konnyu KJ, Saldanha IJ, Beland MD, Shah N. Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis : A Systematic Review. Ann Intern Med 2022; 175:379-387. [PMID: 35038271 DOI: 10.7326/m21-1645] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis. PURPOSE To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020. STUDY SELECTION Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes. DATA EXTRACTION 6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies. DATA SYNTHESIS Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies). LIMITATIONS The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect. CONCLUSION Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).
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Affiliation(s)
- Ethan M Balk
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., M.R.B., K.K., I.J.S.)
| | - Gaelen P Adam
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., M.R.B., K.K., I.J.S.)
| | - Monika Reddy Bhuma
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., M.R.B., K.K., I.J.S.)
| | - Kristin J Konnyu
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., M.R.B., K.K., I.J.S.)
| | - Ian J Saldanha
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., M.R.B., K.K., I.J.S.)
| | - Michael D Beland
- Warren Alpert Medical School at Brown University, Providence, Rhode Island (M.D.B., N.S.)
| | - Nishit Shah
- Warren Alpert Medical School at Brown University, Providence, Rhode Island (M.D.B., N.S.)
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Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, Fitterman N, Shamliyan T, Wilt TJ, Crandall CJ, Cooney TG, Cross JT, Hicks LA, Maroto M, Mustafa RA, Obley AJ, Owens DK, Tice J, Williams JW. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med 2022; 175:399-415. [PMID: 35038273 DOI: 10.7326/m21-2710] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic diverticulitis in adults. This guideline is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. METHODS The ACP Clinical Guidelines Committee (CGC) developed this guideline based on a systematic review on the use of computed tomography (CT) for the diagnosis of acute left-sided colonic diverticulitis and on management via hospitalization, antibiotic use, and interventional percutaneous abscess drainage. The systematic review evaluated outcomes that the CGC rated as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. TARGET AUDIENCE AND PATIENT POPULATION The target audience is all clinicians, and the target patient population is adults with suspected or known acute left-sided colonic diverticulitis. RECOMMENDATION 1 ACP suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis (conditional recommendation; low-certainty evidence). RECOMMENDATION 2 ACP suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting (conditional recommendation; low-certainty evidence). RECOMMENDATION 3 ACP suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics (conditional recommendation; low-certainty evidence).
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Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., I.E., T.S.)
| | | | | | | | - Tatyana Shamliyan
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., I.E., T.S.)
| | - Timothy J Wilt
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, Minnesota (T.J.W.)
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Biondo S, Bordin D, Golda T. Treatment for Uncomplicated Acute Diverticulitis. COLONIC DIVERTICULAR DISEASE 2022:273-289. [DOI: https:/doi.org/10.1007/978-3-030-93761-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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González Plo D, Plá Sánchez P, León Gámez CL, Remirez Arriaga X, Rial Justo X, Artés Caselles M, Lucena de la Poza JL, Sánchez Turrión V. Update on the management of uncomplicated acute diverticulitis at our centre. Equally effective, more efficient. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:426-430. [PMID: 32434733 DOI: 10.1016/j.gastrohep.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 10/17/2019] [Accepted: 01/20/2020] [Indexed: 06/11/2023]
Abstract
GOALS The current trend in the treatment of non-complicated diverticulitis is the outpatient management with antibiotic or even anti-inflammatory regimens in selected cases. We present a comparison of the results in our hospital with different protocols applied in 2016 and 2017. MATERIAL AND METHODS All patients selected for this study were diagnosed with diverticulitis grade Ia of Hinchey's classification according to radiological findings on abdominal CT. We have analyzed two retrospective cohorts: 100 patients treated in 2016 according to the old protocol and 104 patients treated in 2017 with a new protocol. In 2016, the candidates for ambulatory treatment remained under observation for 24 hours before being discharged. The treatment consisted of 14 days of ciprofloxacin and metronidazole. In 2017, only patients with more acute symptoms were observed 24 hours and amoxicillin-clavulanic acid was prescribed for only 5 days. RESULTS The persistence of the disease in 2016 was 6% and in 2017 was only 5.77% (p = 0.944). Recurrence during the first year was 13% in the first group, while in the second it was 5.7%, although this difference was not statistically significant. Likewise, a significant reduction in health costs was achieved. CONCLUSIONS Outpatient treatment of acute uncomplicated diverticulitis with oral treatment seems to be a safe and effective therapeutic strategy in selected patients with low comorbidity.
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Affiliation(s)
- Daniel González Plo
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España.
| | - Pau Plá Sánchez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Carmen Lucero León Gámez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Xabier Remirez Arriaga
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Xiana Rial Justo
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Mariano Artés Caselles
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - José Luis Lucena de la Poza
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Víctor Sánchez Turrión
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
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Abstract
Acute diverticulitis is a major health-care concern. The optimal management of this common condition has been critically examined in recent years leading to a number of paradigm changes. In many areas, the debate continues. Acute uncomplicated diverticulitis may be safely managed without antibiotics. A number of randomized controlled trials have examined the role of laparoscopic lavage vs resection for purulent peritonitis. In cases where resection is indicated the traditional Hartmann's procedure is being trialled against resection with primary anastomosis. In the follow up of an acute uncomplicated episode, the value of colonoscopy is being questioned but remains in current guidelines. In the elective setting, more recent studies have led to a trend away from resection to prevent complications but towards resection to improve quality of life. This article presents an overview of the current guidance, areas of controversy and the associated evidence base.
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Affiliation(s)
- Alex J Sagar
- Core Surgical Trainee 2, Surgical Emergency Unit, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 0LQ
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Cirocchi R, Randolph JJ, Binda GA, Gioia S, Henry BM, Tomaszewski KA, Allegritti M, Arezzo A, Marzaioli R, Ruscelli P. Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis. Tech Coloproctol 2019; 23:87-100. [PMID: 30684110 DOI: 10.1007/s10151-018-1919-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting. METHODS A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment. RESULTS This systematic review included 21 studies including 1781 patients who had outpatient management of AD including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data. CONCLUSIONS The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.
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Affiliation(s)
- R Cirocchi
- Department of Surgical Science, University of Perugia, Perugia, Italy
| | - J J Randolph
- Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, USA
| | - G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy
| | - S Gioia
- Section of Legal Medicine, AOSP Terni, via T. di Joannuccio snc, 05100, Terni, TR, Italy.
| | - B M Henry
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K A Tomaszewski
- International Evidence-Based Anatomy Working Group, Kraków, Poland
| | - M Allegritti
- Interventional Radiology Unit, AOSP Terni, via T. di Joannuccio snc, 05100, Terni, Italy
| | - A Arezzo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - R Marzaioli
- Department of Emergency and Organ Transplantation (DETO), University Medical School "A. Moro" Bari, Bari, Italy
| | - P Ruscelli
- Emergency Surgery Unit, Faculty of Medicine and Surgery, Torrette Hospital, Polytechnic University of Marche, Ancona, Italy
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Abstract
BACKGROUND The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world. PURPOSE Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis. METHODS PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs. RESULTS A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I2 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%. CONCLUSION Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.
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10
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Antibiotic treatment for uncomplicated and mild complicated diverticulitis: outpatient treatment for everyone. Int J Colorectal Dis 2017; 32:1313-1319. [PMID: 28664347 DOI: 10.1007/s00384-017-2847-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Antibiotic treatment is the treatment of choice for uncomplicated diverticulitis (uD) and can be performed for mild complicated diverticulitis (mcD). In several cases, outpatient treatment (OT) can be undertaken. This study assessed the 1-month failure rate of OT for uD/mcD compared to inpatient treatment (IT), and identified predictive factors for treatment failure. METHODS All consecutive patients (2006-2012) diagnosed with uD/mcD by CT scan were retrospectively analyzed. Acute uD was defined as absence of the following: abscess, fistula, extraluminal contrast, pneumoperitoneum, and need for immediate percutaneous drainage/surgery. Acute mcD was defined as complicated diverticulitis with abscess <4 cm or pneumoperitoneum <2 cm. All patients received antibiotherapy. Treatment failure was defined as (re)hospitalization the first month after treatment onset or need of drainage/surgery during hospitalization. All patients were contacted using a standardized questionnaire. RESULTS Out of 540 uD/mcD, IT was offered to 369 patients (68%) and OT to 171 patients (32%). The IT group had higher median age, more women, higher median Charlson Index, more severe median Ambrosetti score, longer median time in the emergency room, and higher median CRP. Response rates to the questionnaire were 56% (IT) vs. 62% (OT), p = 0.18. Failure rates were 32% in IT vs. 10% in OT group, p < 0.01. Among the uD/mcD patients, admission/CT time between midnight and 6 AM, Ambrosetti score of 4, and free air around the colon were risk factors for failure. CONCLUSIONS Outpatient treatment for uncomplicated/mild complicated diverticulitis is feasible and safe. Prognostic factors of failure necessitating closer follow-up were admission/CT time, Ambrosetti score of 4, and free air around the colon.
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Roig JV, Salvador A, Frasson M, Cantos M, Villodre C, Balciscueta Z, García-Calvo R, Aguiló J, Hernandis J, Rodríguez R, Landete F, García-Granero E. Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico. Cir Esp 2016; 94:569-577. [DOI: 10.1016/j.ciresp.2016.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/08/2016] [Accepted: 10/12/2016] [Indexed: 12/26/2022]
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Abstract
Acute diverticulitis occurs in up to 25% of patients with diverticulosis. The majority of cases are mild or uncomplicated and it has become a frequent reason for consultation in the emergency department. On the basis of the National Inpatient Sample database from the USA, 86% of patients admitted with diverticulitis were treated with medical therapy. However, several recent studies have shown that outpatient treatment with antibiotics is safe and effective. The aim of this systematic review is to update the evidence published in the outpatient treatment of uncomplicated acute diverticulitis. We performed a systematic review according to the PRISMA guidelines and searched in MEDLINE and Cochrane databases all English-language articles on the management of acute diverticulitis using the following search terms: 'diverticulitis', 'outpatient', and 'uncomplicated'. Data were extracted independently by two investigators. A total of 11 articles for full review were yielded: one randomized controlled trial, eight prospective cohort studies, and two retrospective cohort studies. Treatment successful rate on an outpatient basis, which means that no further complications were reported, ranged from 91.5 to 100%. Fewer than 8% of patients were readmitted in the hospital. Intolerance to oral intake and lack of family or social support are common exclusion criteria used for this approach, whereas severe comorbidities are not definitive exclusion criteria in all the studies. Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective, and economically efficient when applying an appropriate selection in most reviewed studies.
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Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, Gervaz P, Annibale B. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 2015; 19:615-26. [PMID: 26377584 DOI: 10.1007/s10151-015-1370-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 02/05/2023]
Abstract
The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.
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Affiliation(s)
- G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy.
| | - R Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - A Laghi
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - A Serventi
- Department of Surgery, Galliera Hospital, Genoa, Italy
| | - D Bellini
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - P Gervaz
- Coloproctology Unit, La Colline Clinic, Geneva, Switzerland
| | - B Annibale
- Division of Gastroenterology, Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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Tursi A. Efficacy, safety, and applicability of outpatient treatment for diverticulitis. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:29-36. [PMID: 24729730 PMCID: PMC3976207 DOI: 10.2147/dhps.s61277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute diverticulitis of the colon represents a significant burden for national health systems, in terms of direct and indirect costs. Although current guidelines recommend use of antibiotics for the outpatient treatment of acute uncomplicated diverticulitis, evidence for this is still lacking. Hence, significant effort is now being made to identify the appropriate therapeutic approach to treat and prevent relapses of diverticulitis. Outpatient treatment has been identified as a safe and effective therapeutic approach in up to 90% of patients with uncomplicated diverticulitis. It allows important costs saving to health systems without a negative influence on quality of life for patients with uncomplicated diverticulitis, and reduces health care costs by more than 60%.
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