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La Torre M, Mingoli A, Brachini G, Lanciotti S, Casciani E, Speranza A, Mastroiacovo I, Frezza B, Cirillo B, Costa G, Sapienza P. Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis. Asian J Surg 2019; 43:476-481. [PMID: 31439460 DOI: 10.1016/j.asjsur.2019.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/23/2019] [Accepted: 07/18/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND/OBJECTIVE A preoperative reliable classification system between clinical and computed tomography (CT) findings to better plan surgery in acute complicated diverticulitis (ACD) is lacking. We studied the inter-observer agreement of CT scan data and their concordance with the preoperative clinical findings and the adherence with the intraoperative status using a new classification of diverticular disease (CDD). METHODS 152 patients operated on for acute complicated diverticulitis (ACD) were retrospectively enrolled. All patients were studied with CT scan within 24 h before surgery and CT images were blinded reanalyzed by 2 couples of radiologists (A/B). Kappa value evaluated the inter-observer agreement between radiologists and the concordance between CDD, preoperative clinical findings and findings at operation. Univariate and multivariate analysis were used to evaluate the predicting values of CT classification and CDD stage at surgery on postoperative outcomes. RESULTS Overall inter-observer agreement for the CDD was high, with a kappa value of 0.905 (95% CI = 0.850-0.960) for observers A and B, while the concordance between radiological and surgical findings was weak (kappa values = 0.213 and 0,248, respectively and 95% CI = 0.106 to 0.319 and 95% CI = 0.142 to 0.355, respectively). When overall morbidity, mortality and the need of a terminal colostomy were considered as main endpoints no concordance was observed between surgical and radiological findings and the CDD (P=NS). CONCLUSIONS The need for a more accurate classification of ACD, able to better stage this emergency, and to provide surgeons with reliable information for the best treatment is advocated.
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Affiliation(s)
- Marco La Torre
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Andrea Mingoli
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Gioia Brachini
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Silvia Lanciotti
- Emergency Department, Department of Radiology, "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Emanuele Casciani
- Emergency Department, Department of Radiology, "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Annarita Speranza
- Department of Radiology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Ilaria Mastroiacovo
- Department of Radiology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Barbara Frezza
- Emergency Department, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Bruno Cirillo
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Gianluca Costa
- Emergency Department, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Paolo Sapienza
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
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Valizadeh N, Suradkar K, Kiran RP. Specific Factors Predict the Risk for Urgent and Emergent Colectomy in Patients Undergoing Surgery for Diverticulitis. Am Surg 2018. [DOI: 10.1177/000313481808401135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aim of this study was to identify preoperative characteristics that may determine the need for emergency surgery for diverticulitis and assess postoperative outcomes for these patients when compared with elective surgery. All patients included in the ACS-NSQIP–targeted colectomy database from 2012 to 2013 who underwent colectomy with an underlying diagnosis of diverticulitis were included. Preoperative characteristics and 30-day postoperative outcomes were evaluated for patients who underwent elective versus emergent/urgent surgery using univariable and multivariable analyses. Of 8708 patients with diverticular disease, 28.1 per cent underwent emergent/urgent colectomy. Patients who underwent emergent/urgent colectomy had greater preoperative steroid use, diabetes mellitus, disseminated cancer, chronic renal failure, hypertension, chronic heart failure, chronic liver disease, COPD, and dependent functional health status ( P < 0001). There were more patients with age >65 years ( P < 0001), smoking history ( P < 0.05), and BMI < 18.5 kg/m2( P < 0001) in the emergent/urgent colectomy group. After performing multivariable analysis, preoperative steroid use, weight loss >10 per cent, BMI < 18 kg/m2, smoking, age > 65, and comorbid conditions were associated with a higher rate of emergent/urgent surgery. Mortality (5.2% vs 0.2%) and infectious and noninfectious complications were higher after nonelective colectomy. Emergent/urgent colectomy was also associated with longer hospital stay and reoperation. Emergency and urgent colectomy for diverticulitis is associated with significantly worse outcomes than after elective surgery, and patients with comorbid conditions who develop attacks of diverticulitis may in fact be the population that might best benefit from a lower threshold for an elective colectomy.
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Affiliation(s)
- Neda Valizadeh
- Division of Colorectal Surgery, Columbia University New York Presbyterian Hospital, New York, New York
| | - Kunal Suradkar
- Division of Colorectal Surgery, Columbia University New York Presbyterian Hospital, New York, New York
| | - Ravi P. Kiran
- Division of Colorectal Surgery, Columbia University New York Presbyterian Hospital, New York, New York
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Laparoscopic approaches to complicated diverticulitis. Langenbecks Arch Surg 2017; 403:11-22. [PMID: 28875302 DOI: 10.1007/s00423-017-1621-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. PURPOSE The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis. CONCLUSIONS New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.
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Miyagaki H, Rhee R, Shantha Kumara HMC, Yan X, Njoh L, Cekic V, Whelan RL. Surgical Treatment of Diverticulitis: Hand-Assisted Laparoscopic Resection Is Predominantly Used for Complex Cases and Is Associated With Increased Postoperative Complications and Prolonged Hospitalization. Surg Innov 2015; 23:277-83. [PMID: 26611789 DOI: 10.1177/1553350615618285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction Laparoscopic (LAP) colectomy is now the "gold" standard for diverticulitis; the role of hand-assisted LAP (HAL) and Open methods today is unclear. This study assessed the elective use of these methods for diverticulitis. Methods A retrospective review of demographic, comorbidity (Carlson Comorbidity Index [CCI]), resection type, and short-term outcomes was carried out. Results There were 125 (44.5%) LAP, 125 (44.5%) HAL, and 31 (11%) Open cases (overall N = 281). The mean age, body mass index, and percentage of high-risk patients (CCI score >2) of the HAL group were greater (P < .05) than the LAP group (vs Open, P = ns). The Open group's mean age and percent with CCI >2 was greater when compared with the LAP group (P < .05). More Open (P < .05) and HAL patients had complex disease (Open, 63%; HAL, 40%, LAP, 22%) and were diverted (Open, 35%; HAL, 10%; LAP, 3%). Time to bowel movement was not different; however, there was a stepwise increase in median length of stay (LOS; days) from the LAP (5 days) to HAL (6 days) to Open group (7 days) (P < .05 for all). The LAP complication rate (22.4%) was lower (P < .05) than the HAL (42.4%) or Open groups' (45.2%) rates. The LAP surgical site infection rate (5.6%) was lower (P < .05) than the HAL (12.8%) or Open groups (19.6%). Conclusion The HAL and Open groups had more high risk, complex disease, diverted, and older patients than the LAP group; likewise, the overall complication rate and LOS was higher in the HAL and Open groups. Use of HAL methods likely contributed to the high minimally invasive surgery utilization rate (89%).
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Affiliation(s)
- Hiromichi Miyagaki
- Mount Sinai Roosevelt Hospital Center, New York, NY, USA Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Rebecca Rhee
- Mount Sinai Roosevelt Hospital Center, New York, NY, USA
| | | | - Xiaohong Yan
- Mount Sinai Roosevelt Hospital Center, New York, NY, USA
| | - Linda Njoh
- Mount Sinai Roosevelt Hospital Center, New York, NY, USA
| | - Vesna Cekic
- Mount Sinai Roosevelt Hospital Center, New York, NY, USA
| | - Richard L Whelan
- Mount Sinai Roosevelt Hospital Center, New York, NY, USA Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Jurowich CF, Germer CT. Elective Surgery for Sigmoid Diverticulitis - Indications, Techniques, and Results. VISZERALMEDIZIN 2015; 31:112-6. [PMID: 26989381 PMCID: PMC4789971 DOI: 10.1159/000381500] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Christian F Jurowich
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph T Germer
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
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Abstract
Placement of percutaneous drainage catheters has become first-line therapy in the treatment of patients with intra-abdominal abscesses. Catheters can be used to avoid surgical intervention or to improve surgical outcomes. This article discusses the current evidence describing the optimal interval between percutaneous drainage procedures and surgery, focusing on patients with Crohn's disease, appendicitis, and diverticulitis.
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Affiliation(s)
- Jong Park
- Section of Vascular & Interventional Radiology, NYU Langone Medical Center, New York, New York
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Welchen Erfolg bringt die Sigmaresektion bei der akuten Sigmadivertikulitis tatsächlich? Chirurg 2013; 84:673-80. [DOI: 10.1007/s00104-013-2485-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Sartelli M, Catena F, Ansaloni L, Leppaniemi A, Taviloglu K, van Goor H, Viale P, Lazzareschi DV, de Werra C, Marrelli D, Colizza S, Scibé R, Alis H, Torer N, Navarro S, Catani M, Kauhanen S, Augustin G, Sakakushev B, Massalou D, Pletinckx P, Kenig J, Di Saverio S, Guercioni G, Rausei S, Laine S, Major P, Skrovina M, Angst E, Pittet O, Gerych I, Tepp J, Weiss G, Vasquez G, Vladov N, Tranà C, Vettoretto N, Delibegovic S, Dziki A, Giraudo G, Pereira J, Poiasina E, Tzerbinis H, Hutan M, Vereczkei A, Krasniqi A, Seretis C, Diaz-Nieto R, Mesina C, Rems M, Campanile FC, Agresta F, Coletta P, Uotila-Nieminen M, Dente M, Bouliaris K, Lasithiotakis K, Khokha V, Zivanović D, Smirnov D, Marinis A, Negoi I, Ney L, Bini R, Leon M, Aloia S, Huchon C, Moldovanu R, de Melo RB, Giakoustidis D, Ioannidis O, Cucchi M, Pintar T, Jovine E. Complicated intra-abdominal infections in Europe: preliminary data from the first three months of the CIAO Study. World J Emerg Surg 2012; 7:15. [PMID: 22613202 PMCID: PMC3444376 DOI: 10.1186/1749-7922-7-15] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 05/21/2012] [Indexed: 11/10/2022] Open
Abstract
The CIAO Study is a multicenter observational study currently underway in 66 European medical institutions over the course of a six-month study period (January-June 2012). This preliminary report overviews the findings of the first half of the study, which includes all data from the first three months of the six-month study period. Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study. 912 patients with a mean age of 54.4 years (range 4–98) were enrolled in the study during the first three-month period. 47.7% of the patients were women and 52.3% were men. Among these patients, 83.3% were affected by community-acquired IAIs while the remaining 16.7% presented with healthcare-associated infections. Intraperitoneal specimens were collected from 64.2% of the enrolled patients, and from these samples, 825 microorganisms were collectively identified. The overall mortality rate was 6.4% (58/912). According to univariate statistical analysis of the data, critical clinical condition of the patient upon hospital admission (defined by severe sepsis and septic shock) as well as healthcare-associated infections, non-appendicular origin, generalized peritonitis, and serious comorbidities such as malignancy and severe cardiovascular disease were all significant risk factors for patient mortality. White Blood Cell counts (WBCs) greater than 12,000 or less than 4,000 and core body temperatures exceeding 38°C or less than 36°C by the third post-operative day were statistically significant indicators of patient mortality.
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Lee Y, Francone T. Special Situations in the Management of Colonic Diverticular Disease. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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10
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Long-term outcome after conservative and surgical treatment of acute sigmoid diverticulitis. Langenbecks Arch Surg 2011; 396:825-32. [DOI: 10.1007/s00423-011-0815-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Accepted: 05/30/2011] [Indexed: 02/07/2023]
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11
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Katsuno G, Fukunaga M, Nagakari K, Yoshikawa S. Laparoscopic one-stage resection of right and left colon complicated diverticulitis equivalent to hinchey stage I–II. Surg Today 2011; 41:647-54. [DOI: 10.1007/s00595-010-4349-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 01/21/2010] [Indexed: 01/17/2023]
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12
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Sartelli M, Viale P, Koike K, Pea F, Tumietto F, van Goor H, Guercioni G, Nespoli A, Tranà C, Catena F, Ansaloni L, Leppaniemi A, Biffl W, Moore FA, Poggetti R, Pinna AD, Moore EE. WSES consensus conference: Guidelines for first-line management of intra-abdominal infections. World J Emerg Surg 2011; 6:2. [PMID: 21232143 PMCID: PMC3031281 DOI: 10.1186/1749-7922-6-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 01/13/2011] [Indexed: 12/11/2022] Open
Abstract
Intra-abdominal infections are still associated with high rate of morbidity and mortality.A multidisciplinary approach to the management of patients with intra-abdominal infections may be an important factor in the quality of care. The presence of a team of health professionals from various disciplines, working in concert, may improve efficiency, outcome, and the cost of care.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bologna on July 2010, during the 1st congress of the WSES, involving surgeons, infectious disease specialists, pharmacologists, radiologists and intensivists with the goal of defining recommendations for the early management of intra-abdominal infections.This document represents the executive summary of the final guidelines approved by the consensus conference.
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Dasari BV, Lawson J, Lee J. Transrectal drainage of a diverticular abscess using a pigtail catheter without radiological guidance: a case report. J Med Case Rep 2011; 5:1. [PMID: 21205286 PMCID: PMC3022561 DOI: 10.1186/1752-1947-5-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 01/04/2011] [Indexed: 01/16/2023] Open
Abstract
Introduction Percutaneous or endocavitory drainage of a diverticular abscess under radiological guidance often enables one to perform a one-staged resection and anastomosis (without stoma formation) instead of a two-staged procedure. It reduces the significant postoperative morbidity and mortality associated with the conventional emergency surgical management. However, radiological guidance is not always available due to limited resources during out-of-hours. Case presentation A 78-year-old Caucasian woman underwent transrectal drainage of a diverticular abscess performed with a pigtail catheter without radiological guidance. Technical details of the procedure are described and alternative options discussed. Conclusion In carefully selected patients, per-rectal drainage using a pigtail catheter can be performed without radiological guidance and the procedure offers a simple and effective way of controlling sepsis.
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Affiliation(s)
- Bobby Vm Dasari
- Level 2, Department of General Surgery, Belfast City Hospital, Belfast, BT9 7AB, UK.
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Affiliation(s)
- C Mortensen
- Department of Surgery, North Bristol NHS Trust, Bristol, UK.
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15
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Abstract
Elective surgical resection in cases of diverticulitis should be offered to patients who have experienced two episodes. High-risk patients such as immunocompromised individuals or transplant patients may warrant resection after one episode. It is controversial whether young patients or patients with right-sided diverticulitis need to be treated differently. Chronic diverticulitis can be successfully treated surgically in selected cases. Adequate surgical resection margins should include the top of the true rectum and the proximal extent of thickened inflamed colon to minimize the risk of recurrence. Careful operative planning and the use of proximal diversion if unsuspected significant inflammatory changes are encountered will improve surgical outcomes.
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Affiliation(s)
- Brett T Gemlo
- Division of Colon and Rectal Surgery, University of Minnesota, St. Paul, MN 55102, USA.
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Ritz JP, Lehmann KS, Loddenkemper C, Frericks B, Buhr HJ, Holmer C. Preoperative CT staging in sigmoid diverticulitis--does it correlate with intraoperative and histological findings? Langenbecks Arch Surg 2010; 395:1009-15. [PMID: 20574812 DOI: 10.1007/s00423-010-0609-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 02/04/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE This study was designed to evaluate whether the computed tomography (CT) reflects the extent of the inflammation in sigmoid diverticulitis (SD) in order to draw conclusions for selecting the appropriate treatment. METHODS Two hundred four patients who underwent resection for SD from January 2003 to December 2008 were included. The preoperative CT stage was compared with intraoperative and histological findings. Patients were classified into phlegmonous (Hansen-Stock IIa), abscess-forming (HS IIb), and free perforated (HS IIc) forms of SD. Patients with a recurrent type of diverticulitis were excluded. RESULTS In the phlegmonous type (HS IIa; n = 75), we found a correlation with the preoperative stage in 52% (intraoperative) and 56% (histological), an understaging in 12% (intraoperative) and 11% (histological), and an overstaging in 36% (intraoperative) and 33% (histological). In the abscess-forming type (HS IIb, Hinchey I/II; n = 87), we found conformity in 92% (intraoperative) and 90% (histological), understaging in 3% (intraoperative) and 0% (histological), and overstaging in 5% (intraoperative) and 10% (histological). In the presence of a free perforation (HS IIc, Hinchey III/IV; n = 42), we saw conformity in 100% (intraoperative and histological). The positive predictive value for correctly diagnosing of phlegmonous type (HS IIa), abscess-forming type (HS IIb), and free perforation (HS IIc) by CT was intraoperatively (histologically) 52% (56), 92% (90), and 100% (100), respectively. CONCLUSIONS The CT is one of the most accurate methods for staging in SD. However, in the phlegmonous type (HS IIa), it leads to an overestimation of the findings in every third patient. It must be clarified whether this pronounced low inflammation should really be regarded as a complicated form of SD. In contrast, the abscess-forming (HS IIb) and free perforated (HS IIc) type of complicated SD is very well reflected by CT.
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Affiliation(s)
- Jörg-Peter Ritz
- Department of General, Vascular and Thoracic Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
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Holmer C, Lehmann KS, Engelmann S, Frericks B, Loddenkemper C, Buhr HJ, Ritz JP. Microscopic findings in sigmoid diverticulitis--changes after conservative therapy. J Gastrointest Surg 2010; 14:812-7. [PMID: 20186500 DOI: 10.1007/s11605-009-1054-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 09/16/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The indications for prophylactic surgery for phlegmonous and covered perforated type of acute sigmoid diverticulitis (SD) are currently matters of debate, and a more conservative approach has been advocated. However, it has not yet been clarified to what extent CT findings indicative of acute SD correlate with histological findings, and it is still uncertain how these findings change in the time interval between initial antibiotic treatment and late elective surgery. The aim of this study was to record time-course changes of inflammation in phlegmonous and abscess-forming diverticulitis after conservative treatment in order to check the indication for surgery. MATERIAL AND METHODS This study included all patients who underwent surgery for CT morphologically phlegmonous and covered perforated SD from January 2002 to June 2007. Two groups were formed to record time-course changes: early elective surgery (7-10 days after antibiotic treatment) and late elective surgery (4-6 weeks after conservative treatment). Exclusion criteria were emergency interventions, free perforations (Hinchey III and IV), recurrent inflammations, and contrast allergy. The extent of the inflammation recorded preoperatively by CT scan was compared with histological findings. RESULTS A total of 257 patients (142 male and 115 female; mean age, 56.6 years) underwent surgery (116 early elective and 141 late elective) for phlegmonous and covered perforated SD. Phlegmonous SD was seen in 127 cases and covered perforated SD in 130 cases. In the phlegmonous type of SD, early surgery led to conformity with the preoperative stage in 56%, to more extensive findings in 11%, and to subsided inflammation in 33%. Late surgery led to conformity in 0% and to signs of subsided inflammation in 100%. In the covered perforated type of SD, early surgery led to conformity in 90%, to subsided inflammation in 10%, and to milder manifestation in 0%. In contrast, late surgery here led to conformity in 26% of the cases and to subsided inflammation in 74%. Considerable histological changes can be detected under conservative therapy. The acute inflammation subsides under antibiotic therapy as awaited. It must be clarified whether the phlegmonous form of SD should, in principal, be regarded as an indication for surgery, since it shows early and nearly complete regression of the inflammation. Otherwise, the covered perforated type of SD still shows marked inflammatory changes after conservative therapy in a high percentage of patients and should thus preferably be treated by surgery. However, the clinical appearance of the patient with sigmoid diverticulitis still remains the most important part of decision making.
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Affiliation(s)
- Christoph Holmer
- Department of General, Vascular and Thoracic Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
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Spirt MJ. Complicated intra-abdominal infections: a focus on appendicitis and diverticulitis. Postgrad Med 2010; 122:39-51. [PMID: 20107288 DOI: 10.3810/pgm.2010.01.2098] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Severe abdominal pain is a common complaint encountered by primary care and emergency room physicians. Caused by many conditions, including appendicitis and diverticulitis, severe abdominal pain may be a diagnostic challenge. Although different in many ways, appendicitis and diverticulitis are caused by obstruction of a blind pouch that leads to inflammation of the structure and surrounding tissue. Appendicitis and diverticulitis are 2 of the most frequently diagnosed causes of complicated intra-abdominal infections. Combined, appendicitis and diverticulitis comprise > 80% of all community-acquired complicated intra-abdominal infections. These conditions are serious and require prompt diagnosis and treatment. Because complicated intra-abdominal infections are typically polymicrobial, a wide variety of causative pathogens are identified, including Gram-positive and Gram-negative aerobic and anaerobic microorganisms. Treatment for these disorders often requires surgical and medical management. Although surgical intervention can be the definitive treatment for complicated intra-abdominal infections, successful management of appendicitis and diverticulitis will depend on appropriate selection of antimicrobials and optimal duration of therapy to maximize the coverage of potential causative pathogens and to minimize the development of resistance. Guidelines for empiric treatment of complicated intra-abdominal infections recommend broad-spectrum antimicrobials as monotherapy or in combinations, including standard antimicrobial regimens, such as piperacillin/tazobactam, imipenem/cilastatin, and piperacillin-tazobactam/amoxicillin-clavulanate regimens, and fluoroquinolone-based regimens. This review article compares the presentations and treatments of these common complicated intra-abdominal infections.
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Affiliation(s)
- Mitchell J Spirt
- Division of Gastroenterology, University of California Los Angeles, Los Angeles, CA 90067, USA.
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Reversal of Hartmann's procedure following acute diverticulitis: is timing everything? Int J Colorectal Dis 2009; 24:1219-25. [PMID: 19499234 DOI: 10.1007/s00384-009-0747-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients who undergo a Hartmann's procedure may not be offered a reversal due to concerns over the morbidity of the second procedure. The aims of this study were to examine the morbidity post reversal of Hartmann's procedure. METHODS Patients who underwent a Hartmann's procedure for acute diverticulitis (Hinchey 3 or 4) between 1995 and 2006 were studied. Clinical factors including patient comorbidities were analysed to elucidate what preoperative factors were associated with complications following reversal of Hartmann's procedure. RESULTS One hundred and ten patients were included. Median age was 70 years and 56% of the cohort were male (n = 61). The mortality and morbidity rate for the acute presentation was 7.3% (n = 8) and 34% (n = 37) respectively. Seventy six patients (69%) underwent a reversal at a median of 7 months (range 3-22 months) post-Hartmann's procedure. The complication rate in the reversal group was 25% (n = 18). A history of current smoking (p = 0.004), increasing time to reversal (p = 0.04) and low preoperative albumin (p = 0.003) were all associated with complications following reversal. CONCLUSIONS Reversal of Hartmann's procedure can be offered to appropriately selected patients though with a significant (25%) morbidity rate. The identification of potential modifiable factors such as current smoking, prolonged time to reversal and low preoperative albumin may allow optimisation of such patients preoperatively.
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Franklin ME, Portillo G, Treviño JM, Gonzalez JJ, Glass JL. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg 2008; 32:1507-11. [PMID: 18259803 DOI: 10.1007/s00268-007-9463-y] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. In patients with complicated acute diverticulitis and peritonitis without gross fecal contamination, laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity appears to alleviate morbidity and improve the outcome. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary. METHOD AND MATERIALS Records of patients who underwent intraoperative peritoneal lavage for purulent diverticulitis at the Texas Endosurgery Institute from April 1991 to September 2006 were retrospectively reviewed. RESULTS Forty patients were included in the study, with a male/female ratio of 26:14. The average age was 60 years. Many had associated co-morbidities. The average operating time was 62 minutes. There were no conversions to an open procedure. Apart from mild postoperative paralytic ileus in six patients and chest infections in two, there were no significant peroperative or postoperative complications. Just over 50% underwent elective interval laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, none of the other patients required further surgical intervention. CONCLUSION Laparoscopic lavage of the peritoneal cavity and drainage is a safe alternative to the current standard of treatment for the management of perforated diverticulitis with or without gross fecal contamination. It is associated with a decrease in the overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate; and there is a reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation. Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.
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Affiliation(s)
- Morris E Franklin
- Texas Endosurgery Institute, 4242 East Southcross, Suite 1, San Antonio, TX 78222, USA
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21
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Operative treatment of recurrent or complicated diverticulitis. J Gastrointest Surg 2008; 12:1321-3. [PMID: 18278536 DOI: 10.1007/s11605-008-0488-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 01/18/2008] [Indexed: 01/31/2023]
Abstract
Sigmoid diverticulosis remains a common disease in developed Western countries, and surgeons are frequently asked to manage diverticulitis and its complications. When to offer elective surgery to patients with uncomplicated, but recurrent, diverticulitis should be individualized, and practice recommendations by national societies continues to be debated. Complicated diverticulitis remains a surgically treated disease, and new technology such as colonic stents (for obstruction) and computed-tomography-guided percutaneous drainage (for abscess) have become bridging techniques to avoid two-stage operations in selected patients. Minimally invasive surgery for elective sigmoid resection has been shown to be safe and feasible and confers many patient-related short-term over traditional open surgery.
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Diverticular disease of the colon: A conservative approach works best. JAAPA 2008; 21:48-53. [DOI: 10.1097/01720610-200806000-00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Colon, Rectum, and Anus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Iacopini F, Bizzotto A, Boskoski I, Bulajic M, Costamagna G. Epidemiology and management of diverticular disease of the colon. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/1745509x.3.4.551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The aim of this review is mainly to show the high prevalence of diverticulosis and the clinical relevance of uncomplicated and complicated diverticular disease worldwide. The prevalence of diverticular disease is directly related to the aging of the population and in western countries is diagnosed in approximately 50–65% of adult subjects. The often more frequent adoption of an incorrect dietary style, such as a low-fiber diet, and the progressive increase in the average age of western populations will increase the prevalence of this pathology and the economic burden for health systems even more so. Furthermore, the management of uncomplicated diverticular disease, segmental colitis associated to diverticula and diverticulitis, which represent the different manifestations of the symptomatic spectrum of colonic diverticulosis, are reported.
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Affiliation(s)
- Federico Iacopini
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Alessandra Bizzotto
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Ivo Boskoski
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Milutin Bulajic
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Guido Costamagna
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
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Hjern F, Goldberg SM, Johansson C, Parker SC, Mellgren A. Management of diverticular fistulae to the female genital tract. Colorectal Dis 2007; 9:438-42. [PMID: 17504341 DOI: 10.1111/j.1463-1318.2006.01171.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Fistulae to the female genital tract are an infrequent but severe complication of diverticular disease. The purpose of this study was to evaluate treatment and outcome in patients with diverticular colo-genital fistulae. METHOD Sixty women treated for diverticular fistulae (DF) to the female genital tract during 1992-2004 were identified. Clinic and operative charts were reviewed. Mean age was 70 years and mean follow-up time after surgery was 1 year. RESULTS Most common presenting symptoms were vaginal discharge of faeces or gas (95% of patients) and abdominal pain (43%). About 75% of patients had undergone a hysterectomy. Forty-six patients underwent at least one radiological contrast study and the fistula was demonstrated in 35 (76%) patients. Fifty-seven patients had surgery, and findings included colo-vaginal fistulae (n = 47), colo-uterine fistulae (n = 2) and multiple fistulae involving vagina and other organs (n = 8). A sigmoid resection and primary anastomosis was performed in 51 and a Hartmann procedure with colostomy in six patients. Sixteen (28%) patients experienced morbidity after surgery, including anastomotic dehiscence (n = 4) and ureteric injury (n = 3). There was no mortality. CONCLUSION Diverticular fistulae to the female genital tract usually occur in elderly patients with a prior hysterectomy. Radiological contrast studies demonstrate the fistulous tract in most cases. Sigmoid resection and primary anastomosis results in a satisfactory outcome in the majority of patients.
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Affiliation(s)
- F Hjern
- Division of Surgery, Karolinska Institutet and Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007; 22:351-7. [PMID: 16437211 DOI: 10.1007/s00384-005-0059-4] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2005] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine the safety and feasibility of primary resection and anastomosis with or without a diverting stoma, as compared to Hartmann's procedure, for patients with acute complicated sigmoid diverticulitis. SEARCH STRATEGY MEDLINE was searched for studies and trials conducted between 1966 and December 2003. This search revealed trials comparing primary resection and anastomosis to Hartmann's procedure. The term "diverticulitis, colonic" with the sub-heading "surgery" was used and the search was limited to human studies and clinical trials. Additional studies were found using the MeSH terms: "surgical procedures, operative", "surgical anastomosis", and "Hartmann procedure", combined with the term "diverticulitis, colonic". The author also searched EMBASE and the Cochrane database for clinical trials using similar terminology. No language restrictions were applied. RESULTS Eighteen studies met the inclusion criteria and reported 884 patients with acute complicated diverticulitis. None of these studies were randomised; it is likely that there was a significant degree of selection bias. No significant differences were found between primary resection with anastomosis and Hartmann's procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure and anti-biotic treatment. Some studies found that primary anastomosis and a protecting stoma, with or without intra-operative colonic lavage, have more favourable results than Hartmann's procedure. CONCLUSIONS This review suggests that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann's procedure in terms of peri-operative complications. The need for revision of Hartmann's procedure could be subsequently avoided. Some articles showed that patients with severe peritonitis, who had a diverting stoma, in the setting of resection and primary anastomosis, had the lowest complication rate. However, the quality of these studies was poor with the presence of selection bias.
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Affiliation(s)
- Saleh Abbas
- Department of Surgery, Auckland Hospital, Grafton, Auckland, New Zealand.
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Oomen JLT, Engel AF, Cuesta MA. Outcome of elective primary surgery for diverticular disease of the sigmoid colon: a risk analysis based on the POSSUM scoring system. Colorectal Dis 2006; 8:91-7. [PMID: 16412067 DOI: 10.1111/j.1463-1318.2005.00867.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The outcome of surgery for diverticular disease of the sigmoid colon remains largely unclear. A comparison of studies is hardly possible because risk factors for diverticular disease severity and patient-related risk factors are lacking. The purpose of this study was to define morbidity and mortality of primary surgery for nonacute complications of diverticular disease of the sigmoid colon and to identify the risk factors that predict a higher morbidity and mortality. METHODS Patients who underwent elective surgery for complications of diverticular disease of the sigmoid colon (n = 149) were identified in a prospective computerized morbidity and mortality registration. In all patients, the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) was calculated, as were the morbidity and mortality rates. Factors predicting postoperative morbidity and mortality were identified. To audit mortality figures, a POSSUM based scoring system is introduced. RESULTS The mortality rate was 4.7% and morbidity rate was 53.7%. Significantly higher morbidity rates were correlated with a higher physiological POSSUM score (P = 0.010). Non-survivors were older (P = 0.029) and also had a higher physiological POSSUM score (P < 0.001) and operation severity POSSUM score (P < 0.001). CONCLUSION The morbidity and mortality rates of surgery for nonacute complications of diverticular disease of the sigmoid colon are considerable. To a large extent, mortality and morbidity are driven by patient- and disease-related factors, as expressed by elevated physiological severity and operative severity scores and failures of peri-operative management in most deceased patients.
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Affiliation(s)
- J L T Oomen
- Department of Surgery, Zaans Medical Centre, Zaandam, The Netherlands.
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Affiliation(s)
- Jennifer R Chapman
- Francisco Skemp Hospital, 800 West Avenue South, La Crosse, WI 54601, USA.
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Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, Larson D. Complicated diverticulitis: is it time to rethink the rules? Ann Surg 2005; 242:576-81; discussion 581-3. [PMID: 16192818 PMCID: PMC1402355 DOI: 10.1097/01.sla.0000184843.89836.35] [Citation(s) in RCA: 183] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Much of our knowledge and treatment of complicated diverticulitis (CD) are based on outdated literature reporting mortality rates of 10%. Practice parameters recommend elective resection after 2 episodes of diverticulitis to reduce morbidity and mortality. The aim of this study is to update our understanding of the morbidity, mortality, characteristics, and outcomes of CD. METHODS Three hundred thirty-seven patients hospitalized for CD were retrospectively analyzed. Characteristics and outcomes were determined using chi-squared and Fisher exact tests. RESULTS Mean age of patients was 65 years. Seventy percent had one or more comorbidities. A total of 46.6% had a history of at least one prior diverticulitis episode, whereas 53.4% presented with CD as their first episode. Overall mortality rate was 6.5% (86.4% associated with perforation, 9.5% anastomotic leak, 4.5% patient managed nonoperatively). A total of 89.5% of the perforation patients who died had no history of diverticulitis. Steroid use was significantly associated with perforation rates as well as mortality (P< 0.001 and P = 0.002). Comorbidities such as diabetes, collagen-vascular disease, and immune system compromise were also highly associated with death (P = 0.006, P = 0.009, and P = 0.003, respectively). Overall morbidity was 41.4%. Older age, gender, steroids, comorbidities, and perforation were significantly associated with morbidity. CONCLUSION Today, mortality from CD excluding perforation is reduced compared with past data. This, coupled with the fact that the majority of these patients presented with CD as their first episode, calls into question the current practice of elective resection as a stratagem for reducing mortality. Immunocompromised patients may benefit from early resection. New prospective data is needed to redefine target groups for prophylactic resection.
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Affiliation(s)
- Jennifer Chapman
- Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, Essani R, Beart RW. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005; 100:910-7. [PMID: 15784040 DOI: 10.1111/j.1572-0241.2005.41154.x] [Citation(s) in RCA: 321] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis. METHODS We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis. RESULTS In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%. CONCLUSIONS CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.
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Affiliation(s)
- Andreas M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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Killingback M, Barron PE, Dent OF. Elective surgery for diverticular disease: an audit of surgical pathology and treatment. ANZ J Surg 2005; 74:530-6. [PMID: 15230784 DOI: 10.1111/j.1445-2197.2004.03071.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is a need for a better classification of the surgical pathology of diverticular disease treated by elective resection. METHODS A prospective audit was conducted over a 25-year period, during which the surgeon studied the surgical pathology. The results of surgical treatment have been related to the pathology. RESULTS Two hundred and six patients were managed by elective resection with a postoperative mortality of 1.0% and a total morbidity of 51.5%. The surgical pathology was classified as: non-inflammatory 25 (12.6%), localized diverticulitis 90 (43.7%) and extracolic diverticulitis 90 (44.2%). CONCLUSIONS This classification is useful to relate the technical requirements of surgery and the outcome to the surgical pathology. Postoperative morbidity is associated with the presence and severity of inflammatory pathology and therefore the casemix of any series will have a significant impact on this aspect.
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Pugliese R, Di Lernia S, Sansonna F, Scandroglio I, Maggioni D, Ferrari C, Costanzi A, Chiara O. Laparoscopic treatment of sigmoid diverticulitis: a retrospective review of 103 cases. Surg Endosc 2004; 18:1344-8. [PMID: 15803234 DOI: 10.1007/s00464-003-9178-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2003] [Accepted: 02/17/2004] [Indexed: 12/27/2022]
Abstract
BACKGROUND Laparoscopic treatment of sigmoid diverticulitis is commonly accepted in Hinchey cases I and II, whereas it is debated in the case of purulent peritonitis, and not indicated for fecal peritonitis. METHODS A single-center experience of 103 patients treated for Hinchey I-III sigmoid diverticulitis was reviewed. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. Abscesses in patients with Hinchey IIa were drained percutaneously before surgery. Patients with Hinchey III underwent surgery in emergency. A four-trocar approach with left iliac fossa minilaparotomy was used. Fistulas were treated laparoscopically with Harmonic Scalpel dissection. RESULTS Laparoscopic treatment was successfully completed for 100 patients. Intraoperative complications occurred in 2.9% of the cases. Postoperative procedure-related morbidity was 8%, occurring mainly in Hinchey I patients. A longer hospital stay was recorded among Hinchey IIb patients treated for colovescical fistula. No mortality was observed. CONCLUSIONS Laparoscopic surgery for sigmoid diverticulitis in experienced hands can be a safe and effective gold standard procedure also for patients with fistula or purulent peritonitis.
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Affiliation(s)
- R Pugliese
- Department of General and Emergency Surgery, Hospital Niguarda Ca'Granda Milano Piazza Ospedale Maggiore, 3, 20162, Milano, Italy.
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Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of disease and outcome of complicated diverticular disease. Am J Surg 2004; 186:696-701. [PMID: 14672782 DOI: 10.1016/j.amjsurg.2003.08.019] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Diverticular disease is a common entity. The presentation, investigations performed, and management are variable. Our objectives were to assess the presentation, extent of disease, and treatment of a cohort of patients with colonic diverticulitis. METHODS All patients with a diagnosis of diverticulitis over a 9-year period were reviewed. Patients were assessed as to age, sex, presenting symptoms, diagnostic studies, extent of disease, treatment, and outcome. RESULTS Over a 9-year period (1992 to 2001), 192 patients were admitted with a diagnosis of colonic diverticulitis. The mean age was 61 years (range 28 to 90); 113 of 192 (59%) were female. The mean duration of symptoms prior to presentation was 14 days (range 1 to 270 days). One hundred eighteen of 192 (61%) had a previous documented attack of diverticulitis. Of the investigations performed 128 of 192 (66.7%) had a computed tomography (CT) scan of the abdomen and pelvis, 37 of 192 (20%) underwent a contrast enema, 61 of 192 (32%) underwent colonoscopy and 2 of 192 (1%) underwent a small bowel series. The abnormal findings on the CT scan were as follows: diverticular abscess (16%), diverticulitis (37%), diverticulosis without inflammation (15%), free air (10%) and fistula (1%). The locations of the diverticular abscesses were: pelvic (36%), pericolic sigmoid (36%), and "other," which included interloop (28%). Preoperative abscess drainage occurred in 10 of 192 (5%), which were either percutaneous, 6 of 192 (3%), or transrectal, 4 of 192 (2%). Nine of 192 (6%) presented with a fistula, colovesical fistulae (3%), colocutaneous (1%), enterocolic (1%), or colovaginal (1%). Overall, 73 of 192 (38%) underwent surgery. All patients undergoing surgery had a resection of their colon. The operative findings were localized abscess in 16 of 73 (22%), purulent/feculent peritonitis in 12 of 73 (17%), and phlegmon in 10 of 73 (14%). Sixty-seven of 73 (92%) had a primary resection with anastomosis; 38 of 67 (56%) had a protecting stoma. Five of 73 (7%) patients were found to have an unsuspected carcinoma. Overall, 29 of 192 (15%) developed a complication related to diverticulitis. Morbidity was 15.1%, of which 34% was infection related. Four of 192 patients (2%) died. CONCLUSIONS In our experience, most patients presented with abdominal pain predominantly in the left lower quadrant. The symptoms were present on average of 14 days, most were female (59%), and most patients had a previous attack of diverticulitis. The commonest investigation performed was a CT scan (66.7%); however, other investigations were performed, for example, barium enemas. The practice of resection and primary anastomosis for acute diverticulitis has an acceptable morbidity and mortality. For high-risk anastomoses, a covering loop ileostomy and not a Hartmann's procedure is preferred. Surgery remains safe for the majority of patients and is associated with resolution of symptoms. We believe that because of the high number of patients in our series who had a previous attack of diverticulitis, therapy should be focused on preventing recurrent and virulent attacks by earlier operative intervention.
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Affiliation(s)
- Anil M Bahadursingh
- Department of Surgery, Division of Colon and Rectal Surgery, Saint Louis University Health Sciences Center, St. Louis, MO 63110-0250, USA.
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Lee EC, Murray JJ, Coller JA, Roberts PL, Schoetz DJ. Intraoperative colonic lavage in nonelective surgery for diverticular disease. Dis Colon Rectum 1997; 40:669-74. [PMID: 9194460 DOI: 10.1007/bf02140895] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Staged resection of the sigmoid colon has been the traditional strategy for treating patients who require nonelective surgery to manage complications of diverticular disease. Resection and primary anastomosis has not generally been recommended when the clinical setting is compromised by contiguous inflammation or inadequate mechanical cleansing of the colon because of concerns regarding the potential risk of anastomotic dehiscence. Although many reports have confirmed that intraoperative colonic lavage (ICL) is a safe method for relieving fecal loading of the colon to facilitate primary intestinal anastomosis in patients with mechanical obstruction of the distal colon, there is very limited experience with the use of this technique in treating acute inflammatory disorders of the colon. In this report, we present our results with ICL in the nonelective treatment of patients with complications of diverticulitis. METHODS Records of all patients undergoing urgent operations at the Lahey Clinic to treat complications of diverticular disease from July 1987 to January 1996 were reviewed. RESULTS Of 62 patients who required nonelective operations, 33 underwent ICL in an attempt to perform primary anastomosis. In five patients, the operation included creation of a colostomy. The indication for surgery was obstruction in 13 patients (39 percent), persistent abscess or phlegmon in 13 (39 percent), perforation in 6 patients (18 percent), and hemorrhage in 1 patient (3 percent). According to Hinchey's classification system, 18 patients had Stage I disease, 10 had Stage II, and 5 patients had Stage III disease. There were no patients with Stage IV disease. The single anastomotic complication in the series was responsible for the sole operative mortality. The morbidity rate of 42 percent, included three intraoperative complications (2 splenic injuries and 1 ureteral laceration), two intra-abdominal abscesses (6 percent), and six wound infections (18 percent). CONCLUSION In our experience, ICL has proven to be a safe method for accomplishing single-stage resection of the colon in selected patients with diverticulitis who require an urgent operation. When there is no evidence of diffuse purulent or feculent peritonitis, we believe this is the preferred method for treating patients who are hemodynamically stable.
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Affiliation(s)
- E C Lee
- Department of Colon and Rectal Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts 01805, USA
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Eingeladener Kommentar. Eur Surg 1997. [DOI: 10.1007/bf02620289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Invited commentary to: “Die einzeitige Therapie bei komplizierter Sigmadivertikulitis”. ACTA ACUST UNITED AC 1996. [DOI: 10.1007/bf02629288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sitzler PJ, Inman RD, Heddle RM. Peri-colic diverticular mass of the sigmoid colon presenting in A strangulated inguinal hernia. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1996; 66:500-1. [PMID: 8678886 DOI: 10.1111/j.1445-2197.1996.tb00794.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- P J Sitzler
- Kent and Canterbury Hospital, England, United Kingdom
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Abstract
PURPOSE This study was undertaken to examine the longterm results of medical and surgical management for diverticulitis. METHODS A retrospective review of all patients admitted to Naval Medical Center Portsmouth, Virginia, between January 1991 and February 1994, was conducted. Of 78 patients included in the study, 65 were able to be contacted for follow-up. RESULTS The surgically treated group consisted of 33 patients, and medically treated group had 32 patients. Of the medically treated group, 62.5 percent were found to have continuing symptoms. Medically treated patients with a long history and infrequent flares tended to be less symptomatic after hospitalization. Conversely, those medical patients with a short intense history were more likely to have symptoms. The frequency of symptoms in the surgical group was surprising, because 27.2 percent of this group reported continuing symptoms. CONCLUSIONS Close follow-up of medically treated patients for objective evidence of diverticulitis is indicated. When surgical therapy is undertaken, patients should be counseled that symptoms may be largely unchanged following operation.
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Affiliation(s)
- K D Munson
- Department of Surgery, Naval Medical Center Portsmouth, United States Navy, Portsmouth, Virginia, 23708, USA
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