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Huang SS, Sung CW, Wang HP, Lien WC. The outcomes of right-sided and left-sided colonic diverticulitis following non-operative management: a systematic review and meta-analysis. World J Emerg Surg 2022; 17:56. [PMID: 36320045 PMCID: PMC9628071 DOI: 10.1186/s13017-022-00463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/31/2022] [Indexed: 11/07/2022] Open
Abstract
Background There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD. Methods A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure. Results Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8–13%, I2 = 86%, p < 0.01) in right-sided and 20% (95% CI 16–24%, I2 = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6–13%, I2 = 77%, p < 0.01) in right-sided and 15% (95% CI 8–27%, I2 = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2–10%, I2 = 84%, p < 0.01) in right-sided and 4% (95% CI 2–7%, I2 = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited. Conclusion Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.
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Affiliation(s)
- Sih-Shiang Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hsin-Chu Hospital, Hsinchu City, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wan-Ching Lien
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Emergency Medicine, National Taiwan University College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, Taipei, 100, Taiwan.
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Recurrent diverticulitis after elective surgery. Int J Colorectal Dis 2022; 37:2149-2155. [PMID: 36048197 DOI: 10.1007/s00384-022-04248-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Elective sigmoid resection is proposed as a treatment for symptomatic diverticular disease for the possible improvement in quality of life achievable. Albeit encouraging results have been reported, recurrent diverticulitis is still a concern deeply affecting quality of life. The aim of this study is to determine the rate of recurrent diverticulitis after elective sigmoid resection and to look for possible perioperative risk factors. METHODS Patients who underwent elective resection for DD with at least a 3-year follow-up were included. Postoperative recurrence was defined as left-sided or lower abdominal pain, with CT scan-confirmed findings of diverticulitis. RESULTS Twenty of 232 (8.6%) patients developed CT-proven recurrent diverticulitis after elective surgery. All the 20 recurrent diverticulitis were uncomplicated and did not need surgery. Eighty-five percent of the recurrences occurred in patients with a preoperative diagnosis of uncomplicated DD, 70% in patients who had at least 4 episodes of diverticulitis, and 70% in patients with a history of diverticulitis extended to the descending colon. Univariate analysis showed that recurrence was associated with diverticulitis of the sigmoid and of the descending colon (p = 0.04), with a preoperative diagnosis of IBS (p = 0.04) and with a longer than 5 years diverticular disease (p = 0.03). Multivariate analysis was not able to determine risks factors for recurrence. CONCLUSION Our study showed that patients with a preoperative diagnosis of IBS, diverticulitis involving the descending colon, and a long-lasting disease are more likely to have recurrent diverticulitis. However, these variables could not be assumed as risk factors.
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Longchamp G, Abbassi Z, Meyer J, Toso C, Buchs NC, Ris F. Surgical resection does not avoid the risk of diverticulitis recurrence-a systematic review of risk factors. Int J Colorectal Dis 2021; 36:227-237. [PMID: 32989503 PMCID: PMC7801345 DOI: 10.1007/s00384-020-03762-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Fifteen percent of patients undergoing elective sigmoidectomy will present a diverticulitis recurrence, which is associated with significant costs and morbidity. We aimed to systematically review the risk factors associated with recurrence after elective sigmoidectomy. METHODS PubMed/MEDLINE, Embase, Cochrane, and Web of Science were searched for studies published until May 1, 2020. Original studies were included if (i) they included patients undergoing sigmoidectomy for diverticular disease, (ii) they reported postoperative recurrent diverticulitis, and (iii) they analyzed ≥ 1 variable associated with recurrence. The primary outcome was the risk factors for recurrence of diverticulitis after sigmoidectomy. RESULTS From the 1463 studies initially screened, six studies were included. From the 1062 patients included, 62 patients recurred (5.8%), and six variables were associated with recurrence. Two were preoperative: age (HR = 0.96, p = 0.02) and irritable bowel syndrome (33.3% with recurrence versus 12.1% without recurrence, p = 0.02). Two were operative factors: uncomplicated recurrent diverticulitis as indication for surgery (73.3% with recurrence versus 49.9% without recurrence, p = 0.049) and anastomotic level (colorectal: HR = 11.4, p = 0.02, or colosigmoid: OR = 4, p = 0.033). Two were postoperative variables: the absence of active diverticulitis on pathology (39.6% with recurrence versus 26.6% without recurrence) and persistence of postoperative pain (HR = 4.8, p < 0.01). CONCLUSION Identification of preoperative variables that predict the occurrence of diverticulitis recurrence should help surgical decision-making for elective sigmoidectomy, while peri- and postoperative factors should be taken into account for optimal patient follow-up.
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Affiliation(s)
- Gregoire Longchamp
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-PerreT-Gentil 4, 1211, Geneva, Switzerland
| | - Ziad Abbassi
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-PerreT-Gentil 4, 1211, Geneva, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-PerreT-Gentil 4, 1211, Geneva, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-PerreT-Gentil 4, 1211, Geneva, Switzerland
| | - Nicolas C Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-PerreT-Gentil 4, 1211, Geneva, Switzerland
| | - Frederic Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-PerreT-Gentil 4, 1211, Geneva, Switzerland.
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Lock JF, Galata C, Reißfelder C, Ritz JP, Schiedeck T, Germer CT. The Indications for and Timing of Surgery for Diverticular Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:591-596. [PMID: 33161943 DOI: 10.3238/arztebl.2020.0591] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 11/14/2019] [Accepted: 05/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease. METHODS This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease. RESULTS Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails. CONCLUSION The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.
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Affiliation(s)
- Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Christian Galata
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reißfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jörg-Peter Ritz
- Department of General and Visceral Surgery, Helios Klinikum Schwerin, Schwerin, Germany
| | - Thomas Schiedeck
- Department of General, Visceral, Thoracic and Pediatric Surgery, Klinikum Ludwigsburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
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Severi C, Carabotti M, Cicenia A, Pallotta L, Annibale B. Recent advances in understanding and managing diverticulitis. F1000Res 2018; 7:F1000 Faculty Rev-971. [PMID: 30026920 PMCID: PMC6039950 DOI: 10.12688/f1000research.14299.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 02/05/2023] Open
Abstract
In the past few decades, the increasing socioeconomic burden of acute diverticulitis (AD) has become evident, and with the growth of the population age, this significant economic impact will likely continue to rise. Furthermore, recent evidence showed an increased rate of hospital admissions especially evident among women and younger individuals. The natural history and pathophysiology of this clinical condition is still to be fully defined, and efforts continue to be made in the identification of risk factors and the establishment of relative preventive strategies. The actual therapeutic strategies aimed to modulate gut microbiota, such as rifaximin or probiotics, or to reduce mucosal inflammation, such as mesalazine, present a relatively poor efficacy for both the prevention of the first AD episode (primary prevention) and its recurrence (secondary prevention). In the last few years, the main goal achieved has been in the management of AD in that uncomplicated AD can, to a larger extent, be managed in an outpatient setting with no or little supportive therapy, a strategy that will certainly impact on the health costs of this disease. The problem of AD recurrence remains a topic of debate. The aim of this review is to present updated evidence on AD epidemiology and relative open clinical questions and to analyze in detail predisposing and protective factors with an attempt to integrate their possible modes of action into the several pathogenic mechanisms that have been suggested to contribute to this multifactorial disease. A unifying hypothesis dealing with the colonic luminal and extra-luminal microenvironments separately is provided. Finally, evidence-based changes in therapeutic management will be summarized. Because of an ascertained multifactorial pathogenesis of uncomplicated and complicated AD, it is probable that a single 'causa prima' will not be identifiable, and a better stratification of patients could allow one to pursue tailored therapeutic algorithm strategies.
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Affiliation(s)
- Carola Severi
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Alessia Cicenia
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Lucia Pallotta
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
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