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Hamel JF, Alves A, Beyer-Bergot L, Zerbib P, Bridoux V, Manceau G, Panis Y, Buscail E, Khaoudy I, Gaillard M, Viennet M, Thobie A, Menahem B, Eveno C, Bonnel C, Mabrut JY, Badic B, Godet C, Eid Y, Duchalais E, Lakkis Z, Cotte E, Laforest A, Defourneaux V, Maggiorri L, Rebibo L, Christou N, Talal A, Mege D, Aubert M, Bonnamy C, Germain A, Mauvais F, Tresallet C, Roudie J, Laurent A, Trilling B, Bertrand M, Massalou D, Romain B, Tranchart H, Ouaissi M, Pellegrin A, Sabbagh C, Venara A. Stenosis of the colorectal anastomosis after surgery for diverticulitis: A national retrospective cohort study. Colorectal Dis 2024; 26:1437-1446. [PMID: 38886887 DOI: 10.1111/codi.17076] [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] [Received: 06/09/2023] [Revised: 05/11/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024]
Abstract
AIM The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis. METHOD This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage. RESULTS Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted. CONCLUSION AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.
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Affiliation(s)
- Jean-Francois Hamel
- Faculty of Health, Department of Medicine, University of Angers, Angers, France
- Department of Biostatistics, University Hospital of Angers, Angers, France
| | - Arnaud Alves
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Laura Beyer-Bergot
- Department of Digestive Surgery Assistance, Publique Hôpitaux de Marseille, North University Hospital, Marseille, France
| | - Philippe Zerbib
- Department of Digestive Surgery and Transplantation, Huriez Hospital, Université Lille Nord de France, Lille, France
| | - Valérie Bridoux
- Department of Digestive Surgery, University Hospital of Rouen, Rouen, France
| | - Gilles Manceau
- Department of Surgery, European Georges Pompidou Hospital, Paris, France
| | - Yves Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
| | - Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, Toulouse, France
| | - Iman Khaoudy
- Department of Digestive Surgery, Le Havre Hospital, Le Havre, France
| | - Martin Gaillard
- Department of Digestive Surgery, Cochin Hospital, Paris, France
| | - Manon Viennet
- Department of General Surgery, University Hospital of Bocage, Dijon, France
| | - Alexandre Thobie
- Department of Digestive Surgery, Avranches-Granville Hospital, Avranches, France
| | - Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Clarisse Eveno
- Department of Digestive Surgery, University Hospital of Lille, Lille, France
| | - Catherine Bonnel
- Department of Digestive Surgery, Nord-Essonne Hospital, Longjumeau, France
| | - Jean-Yves Mabrut
- Department of Digestive Surgery and Transplantation, Croix Rousse University Hospital, Lyon, France
| | - Bodgan Badic
- Department of General and Digestive Surgery, University Hospital, Brest, France
| | - Camille Godet
- Department of Digestive Surgery, Memorial Hospital of Saint-Lô, Saint-Lô, France
| | - Yassine Eid
- Department of Digestive Surgery, Robert Bisson Hospital, Lisieux, France
| | - Emilie Duchalais
- Department of Oncological, Digestive and Endocrine Surgery, University Hospital of Nantes, Nantes, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Eddy Cotte
- Department of Digestive Surgery, Hôpital Lyon Sud, Lyon, France
| | - Anais Laforest
- Department of Digestive Surgery, Montsouris Institut, Paris, France
| | | | - Léon Maggiorri
- Department of Digestive Surgery, Hôpital Saint-Louis, Université Paris VII, APHP, Paris, France
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Hôpital Bichat-Claude-Bernard, Paris, France
| | - Niki Christou
- Department of Digestive Surgery, Limoges Hospital, Limoges, France
| | - Ali Talal
- Department of Digestive Surgery, Argentan Hospital, Argentan, France
| | - Diane Mege
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University Hospital, Marseille, France
| | - Mathilde Aubert
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University Hospital, Marseille, France
| | - Cécile Bonnamy
- Department of Digestive Surgery, Bayeux Hospital, Bayeux, France
| | | | - François Mauvais
- Department of Digestive Surgery, Beauvais Hospital, Beauvais, France
| | - Christophe Tresallet
- Department of Digestive Surgical Oncology, Avicenne University Hospital, Sorbonne Paris Nord University, Paris, France
| | - Jean Roudie
- Department of Digestive Surgery, Martinique Hospital, Fort-de-France, France
| | - Alexis Laurent
- Department of Digestive Surgery, Créteil Hospital, Créteil, France
| | - Bertrand Trilling
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Martin Bertrand
- Department of Digestive Surgery, University Hospital of Nîmes, Nîmes, France
| | - Damien Massalou
- Department of Digestive Surgery, Hôpital L'Archet, Nice University, Nice, France
| | - Benoit Romain
- Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, Clamart, France
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepatobiliary and Liver Transplantation, Trousseau Hospital, University Hospital of Tours, Tours, France
| | | | - Charles Sabbagh
- Department of Surgery, Amiens University Hospital, Amiens, France
| | - Aurélien Venara
- Faculty of Health, Department of Medicine, University of Angers, Angers, France
- UMR INSERM 1235, The Enteric Nervous System in Gut and Brain Diseases, IMAD, Nantes, France
- Department of Surgery, Angers University Hospital, Angers, France
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Branche C, Sakowitz S, Porter G, Cho NY, Chervu N, Mallick S, Bakhtiyar SS, Benharash P. Utilization of minimally invasive colectomy at safety-net hospitals in the United States. Surgery 2024; 176:172-179. [PMID: 38729887 DOI: 10.1016/j.surg.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Prior literature has reported inferior surgical outcomes and reduced access to minimally invasive procedures at safety-net hospitals. However, this relationship has not yet been elucidated for elective colectomy. We sought to characterize the association between safety-net hospitals and likelihood of minimally invasive resection, perioperative outcomes, and costs. METHODS All adult (≥18 years) hospitalization records entailing elective colectomy were identified in the 2016-2020 National Inpatient Sample. Centers in the top quartile of safety-net burden were considered safety-net hospitals (others: non-safety-net hospitals). Multivariable regression models were developed to assess the impact of safety-net hospitals status on key outcomes. RESULTS Of ∼532,640 patients, 95,570 (17.9%) were treated at safety-net hospitals. The safety-net hospitals cohort was younger and more often of Black race or Hispanic ethnicity. After adjustment, care at safety-net hospitals remained independently associated with reduced odds of minimally invasive surgery (adjusted odds ratio 0.92; 95% confidence interval 0.87-0.97). The interaction between safety-net hospital status and race was significant, such that Black race remained linked with lower odds of minimally invasive surgery at safety-net hospitals (reference: White race). Additionally, safety-net hospitals was associated with greater likelihood of in-hospital mortality (adjusted odds ratio 1.34, confidence interval 1.04-1.74) and any perioperative complication (adjusted odds ratio 1.15, confidence interval 1.08-1.22), as well as increased length of stay (β+0.26 days, confidence interval 0.17-0.35) and costs (β+$2,510, confidence interval 2,020-3,000). CONCLUSION Care at safety-net hospitals was linked with lower odds of minimally invasive colectomy, as well as greater complications and costs. Black patients treated at safety-net hospitals demonstrated reduced likelihood of minimally invasive surgery, relative to White patients. Further investigation is needed to elucidate the root causes of these disparities in care.
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Affiliation(s)
- Corynn Branche
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Stanford University, Palo Alto, CA. https://twitter.com/CoreLabUCLA
| | - Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Giselle Porter
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nam Yong Cho
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Yapa AKDS, Humes DJ, Crooks CJ, Lewis-Lloyd CA. Venous thromboembolism following colectomy for diverticular disease: an English population-based cohort study. Langenbecks Arch Surg 2023; 408:203. [PMID: 37212868 PMCID: PMC10203000 DOI: 10.1007/s00423-023-02920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/29/2023] [Indexed: 05/23/2023]
Abstract
AIM This study reports venous thromboembolism (VTE) rates following colectomy for diverticular disease to explore the magnitude of postoperative VTE risk in this population and identify high risk subgroups of interest. METHOD English national cohort study of colectomy patients between 2000 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type, absolute incidence rates (IR) per 1000 person-years and adjusted incidence rate ratios (aIRR) were calculated for 30- and 90-day post-colectomy VTE. RESULTS Of 24,394 patients who underwent colectomy for diverticular disease, over half (57.39%) were emergency procedures with the highest VTE rate seen in patients ≥70-years-old (IR 142.27 per 1000 person-years, 95%CI 118.32-171.08) at 30 days post colectomy. Emergency resections (IR 135.18 per 1000 person-years, 95%CI 115.72-157.91) had double the risk (aIRR 2.07, 95%CI 1.47-2.90) of developing a VTE at 30 days following colectomy compared to elective resections (IR 51.14 per 1000 person-years, 95%CI 38.30-68.27). Minimally invasive surgery (MIS) was shown to be associated with a 64% reduction in VTE risk (aIRR 0.36 95%CI 0.20-0.65) compared to open colectomies at 30 days post-op. At 90 days following emergency resections, VTE risks remained raised compared to elective colectomies. CONCLUSION Following emergency colectomy for diverticular disease, the VTE risk is approximately double compared to elective resections at 30 days while MIS was found to be associated with a reduced risk of VTE. This suggests advancements in postoperative VTE prevention in diverticular disease patients should focus on those undergoing emergency colectomies.
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Affiliation(s)
- Anjali K D S Yapa
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK.
| | - David J Humes
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Colin J Crooks
- Gastrointestinal & Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Christopher A Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
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Lee C, Mabeza RM, Verma A, Sakowitz S, Tran Z, Hadaya J, Lee H, Benharash P. Association of frailty with outcomes after elective colon resection for diverticular disease. Surgery 2022; 172:506-511. [PMID: 35513905 DOI: 10.1016/j.surg.2022.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Frailty has been associated with greater postoperative morbidity and mortality but its impact has not been investigated in patients with diverticulitis undergoing elective colon resection. Therefore, the present study examined the association of frailty with perioperative outcomes following elective colectomy for diverticular disease. METHODS The 2017-2019 American College of Surgeons-National Surgical Quality Improvement Program data registry was queried to identify patients (aged ≥18 years) undergoing elective colon resection for diverticular disease. The 5-factor modified frailty index (mFI-5) was used to stratify patients into non-frail (mFI 0), prefrail (mFI 1), and frail (mFI ≥2) cohorts. Major adverse events, surgical site infection, and postoperative ileus as well as prolonged length of stay, nonhome discharge, and unplanned readmission were evaluated using multivariable logistic models. RESULTS Of the 20,966 patients, 10.0% were frail. Compared to others, frail patients were generally older (non-frail: 55 years, [46-63], prefrail: 62, [54-70], frail: 64, [57-71]) and more commonly female (non-frail: 53.1%, prefrail: 58.6, frail: 64.4, P < .001). Frail patients more frequently underwent open colectomy and stoma creation compared with others. Frailty was associated with greater adjusted odds of major adverse event (adjusted odds ratio 1.25, 95% confidence interval 1.06-1.48), surgical site infection (adjusted odds ratio 1.28, 95% confidence interval 1.06-1.54), and postoperative ileus (adjusted odds ratio 1.59, 95% confidence interval 1.27-1.98). Similarly, frailty portended greater odds of prolonged length of stay, nonhome discharge, and unplanned readmission. CONCLUSION Frailty as defined by the mFI-5 was associated with greater morbidity and hospital resource use. Deployment of frailty instruments may augment traditional risk calculators and improve patient selection for elective colectomy.
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Affiliation(s)
- Cory Lee
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Lin S, Dewey EN, Tsikitis VL. Are Surgical Guideline Changes in Diverticulitis Care Associated With Decreased Inpatient Healthcare Expenditure? ANNALS OF SURGERY OPEN 2021; 2:e088. [PMID: 37635832 PMCID: PMC10455212 DOI: 10.1097/as9.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 05/12/2021] [Indexed: 11/26/2022] Open
Abstract
Objective To examine possible associations in inpatient healthcare expenditure and guideline changes in the surgical management of diverticulitis, in terms of both cost per discharge and total aggregate costs of care. Background Medical costs throughout the healthcare system continue to rise due to increased prices for services, increased quantities of high-priced technologies, and an increase in the amount of overall services. Methods We used a retrospective case-control design using the Healthcare Cost and Utilization Project National Inpatient Sample to evaluate cost per discharge and total aggregate costs of diverticulitis management between 2004 and 2015. The year 2010 was selected as the transition between the pre and postguideline implementation period. Results The sample consisted of 450,122 unweighted (2,227,765 weighted) inpatient discharges for diverticulitis. Before the implementation period, inpatient costs per discharge increased 1.13% in 2015 dollars (95% confidence intervals [CI] 0.76% to 1.49%) per quarter. In the postimplementation period, the costs per discharge decreased 0.27% (95% CI -0.39% to -0.15%) per quarter. In aggregate, costs of care for diverticulitis increased 0.61% (95% CI 0.28% to 0.95%) per quarter prior to the guideline change, and decreased 0.52% (95% CI -0.87% to -0.17) following the guideline change. Conclusions This is the first study to investigate any associations between evidence-based guidelines meant to decrease surgical utilization and inpatient healthcare costs. Decreased inpatient costs of diverticulitis management may be associated with guideline changes to reduce surgical intervention for diverticulitis, both in regards to cost per discharge and aggregate costs of care.
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Affiliation(s)
- Saunders Lin
- From the Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Elizabeth N. Dewey
- From the Department of Surgery, Oregon Health and Science University, Portland, OR
| | - V. Liana Tsikitis
- From the Department of Surgery, Oregon Health and Science University, Portland, OR
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Park YY, Nam S, Han JH, Lee J, Cheong C. Predictive factors for conservative treatment failure of right colonic diverticulitis. Ann Surg Treat Res 2021; 100:347-355. [PMID: 34136431 PMCID: PMC8176199 DOI: 10.4174/astr.2021.100.6.347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/26/2021] [Accepted: 03/12/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Conservative treatment is the first-line therapy for acute colonic diverticulitis without severe complications, but treatment failure may increase hospitalization duration, medical costs, and morbidities. Usage of the modified Hinchey classification is insufficient to predict the outcome of conservative management. We aimed to investigate the clinical efficacy of the modified Hinchey classification and to evaluate predictive factors such as inflammatory markers for the failure of conservative management. Methods Patients diagnosed with right colonic diverticulitis undergoing conservative treatment at 3 hospitals between 2017 and 2019 were included. Patients were categorized into conservative treatment success (n = 494) or failure (n = 46) groups. Clinical characteristics and blood inflammatory markers were assessed. Results The conservative treatment failure group presented with more elderly patients (>50 years, P = 0.002), more recurrent episodes (P < 0.001), a higher lymphocyte count (P = 0.021), higher C-reactive protein (CRP) levels (P = 0.044), and higher modified Glasgow prognostic scores (P = 0.021). Multivariate analysis revealed that age of >50 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.27–5.08; P = 0.008), recurrent episodes (OR, 4.78; 95% CI, 2.38–9.61; P < 0.001), and higher CRP levels (OR, 1.08; 95% CI, 1.03–1.12; P = 0.001) were predictive factors for conservative treatment failure, but not the modified Hinchey grade (P = 0.159). Conclusion Age of >50 years, recurrent episodes, and CRP levels are potential predictors for conservative management failure of patients with right-sided colonic diverticulitis. Further studies are warranted to identify candidates requiring early surgical intervention.
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Affiliation(s)
- Youn Young Park
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soomin Nam
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jeong Hee Han
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Jaeim Lee
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chinock Cheong
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Perez NP, Chang DC, Goldstone RN, Bordeianou L, Ricciardi R, Cavallaro PM. Relationship Between Diverticular Disease and Incisional Hernia After Elective Colectomy: a Population-Based Study. J Gastrointest Surg 2021; 25:1297-1306. [PMID: 32748338 PMCID: PMC7854815 DOI: 10.1007/s11605-020-04762-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent genetic studies identified common mutations between diverticular disease and connective tissue disorders, some of which are associated with abdominal wall hernias. Scarce data exists, however, shedding light on the potential clinical implications of this shared etiology, particularly in the era of laparoscopic surgery. METHODS The New York Statewide Planning and Research Cooperative System database was used to identify adult patients undergoing elective sigmoid and left hemicolectomy (open or laparoscopic) from January 1, 2010, to December 31, 2016, for diverticulitis or descending/sigmoid colon cancer. The incidences of incisional hernia diagnosis and repair were compared using competing risks regression models, clustered by surgeon and adjusted for a host of demographic/clinical variables. Subsequent abdominal surgery and death were considered competing risks. RESULTS Among 8279 patients included in the study cohort, 6811 (82.2%) underwent colectomy for diverticulitis and 1468 (17.8%) for colon cancer. The overall 5-year risk of incisional hernia was 3.5% among patients with colon cancer, regardless of colectomy route, which was significantly lower than that among diverticulitis patients after both open (10.7%; p < 0.001) and laparoscopic (7.2%; p = 0.007) colectomies. Multivariable analyses demonstrated that patients with diverticulitis experienced a two-fold increase in the risk for hernia diagnosis (aHR 1.8; p < 0.001) and repair (aHR 2.1; p < 0.001), and these findings persisted after stratification by colectomy route. CONCLUSIONS Patients undergoing elective colectomy for diverticulitis, including via laparoscopic approach, experience higher rates of incisional hernia compared with patients undergoing similar resections for colon cancer. When performing resections for diverticulitis, surgeons should strongly consider adherence to evidence-based guidelines for fascial closure to prevent this important complication.
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Affiliation(s)
- Numa P Perez
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA.
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA.
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Robert N Goldstone
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
| | - Liliana Bordeianou
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
| | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
| | - Paul M Cavallaro
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
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Abstract
Left sided colonic diverticulitis is a common and costly gastrointestinal disease in Western countries, characterized by acute onset of often severe abdominal pain. Imaging is necessary to make an initial diagnosis and determine disease severity. Colonoscopy should be done six to eight weeks after diagnosis to rule out a missed colon malignancy. Antibiotic treatment is used selectively in immunocompetent patients with mild acute uncomplicated diverticulitis. The clinical course of diverticulitis commonly includes unpredictable recurrences and chronic gastrointestinal symptoms, which are a detriment to quality of life. A better understanding of prognosis has prompted a shift toward non-operative approaches. The decision to undergo prophylactic colon resection should be individualized to consider the severity of diverticulitis, the patient's health and immune status, and the patient's preferences and values, as well as benefits and risks. Because only a section of colon is removed, recurrent diverticulitis remains a risk. Acute diverticulitis with an abscess is treated with antibiotics that cover Gram negative and anaerobic bacteria, with or without percutaneous drainage. Acute diverticulitis with purulent or feculent contamination of the peritoneal cavity is managed with surgery; primary resection and anastomosis is the procedure of choice in stable patients.
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Affiliation(s)
- Anne F Peery
- University of North Carolina School of Medicine, Chapel Hill, NC 27599-7555, USA
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Garfinkle R, Boutros M. Elective surgery for diverticulitis – What does the surgeon need to consider? SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2020.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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von Strauss Und Torney M, Moffa G, Kaech M, Haak F, Riss S, Deutschmann E, Bucher HC, Kettelhack C, Paterson HM. Risk of Emergency Surgery or Death After Initial Nonoperative Management of Complicated Diverticulitis in Scotland and Switzerland. JAMA Surg 2021; 155:600-606. [PMID: 32401298 DOI: 10.1001/jamasurg.2020.0757] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance National guidelines on interval resection for prevention of recurrence after complicated diverticulitis are inconsistent. Although US and German guidelines favor interval colonic resection to prevent a perceived high risk of recurrence, UK guidelines do not. Objectives To investigate patient management and outcomes after an index inpatient episode of nonoperatively managed complicated diverticulitis in Switzerland and Scotland and determine whether interval resection was associated with the rate of disease-specific emergency surgery or death in either country. Design, Setting, and Participants This secondary analysis of anonymized complete national inpatient data sets included all patients with an inpatient episode of successfully nonoperatively managed complicated diverticulitis in Switzerland and Scotland from January 1, 2005, to December 31, 2015. The 2 countries have contrasting health care systems: Switzerland is insurance funded, while Scotland is state funded. Statistical analysis was conducted from February 1, 2018, to October 17, 2019. Main Outcomes and Measures The primary end point defined a priori before the analysis was adverse outcome, defined as any disease-specific emergency surgical intervention or inpatient death after the initial successful nonsurgical inpatient management of an episode of complicated diverticulitis, including complications from interval elective surgery. Results The study cohort comprised 13 861 inpatients in Switzerland (6967 women) and 5129 inpatients in Scotland (2804 women) with an index episode of complicated acute diverticulitis managed nonoperatively. The primary end point was observed in 698 Swiss patients (5.0%) and 255 Scottish patients (5.0%) (odds ratio, 0.98; 95% CI, 0.81-1.19). Elective interval colonic resection was undertaken in 3280 Swiss patients (23.7%; median follow-up, 53 months [interquartile range, 24-90 months]) and 231 Scottish patients (4.5%; median follow-up, 57 months [interquartile range, 27-91 months]). Death after urgent readmission for recurrent diverticulitis occurred in 104 patients (0.8%) in Switzerland and 65 patients (1.3%) in Scotland. None of the investigated confounders had a significant association with the outcome apart from comorbidity. Conclusions and Relevance This study found no difference in the rate of adverse outcome (emergency surgery and/or inpatient death) despite a 5-fold difference in interval resection rates.
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Affiliation(s)
- Marco von Strauss Und Torney
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland.,Academic Coloproctology, University of Edinburgh/Western General Hospital, Edinburgh, United Kingdom
| | - Giusi Moffa
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Max Kaech
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Fabian Haak
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Stefan Riss
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Deutschmann
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christoph Kettelhack
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Hugh M Paterson
- Academic Coloproctology, University of Edinburgh/Western General Hospital, Edinburgh, United Kingdom
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11
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Abstract
Diverticulosis is an anatomic change in the colon that is characterized by outpouching of the mucosa and submucosa through the muscularis. Its prevalence increases with age so most of the elderly patients have this condition. Although diverticulosis is common, diverticular disease, in which there are clinical sequelae, is rare. This collective term includes diverticulitis, diverticular hemorrhage and less well-defined entities such as segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Diverticulitis presents as acute lower abdominal pain, and initial management traditionally includes antibiotics, with surgery reserved for complicated disease, although newer evidence questions the optimal role and timing of both interventions.
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Affiliation(s)
- David Wan
- Division of Gastroenterology and Hepatology, Joan & Sanford I. Weill Department of Medicine, Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Tibor Krisko
- Division of Gastroenterology and Hepatology, Joan & Sanford I. Weill Department of Medicine, Weill Cornell Medicine, 413 East 69th Street, BRB 650, New York, NY 10021, USA.
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12
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Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology 2021; 160:906-911.e1. [PMID: 33279517 PMCID: PMC7878331 DOI: 10.1053/j.gastro.2020.09.059] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 12/02/2022]
Abstract
Colonic diverticulitis is a painful gastrointestinal disease that recurs unpredictably and can lead to chronic gastrointestinal symptoms. Gastroenterologists commonly care for patients with this disease. The purpose of this Clinical Practice Update is to provide practical and evidence-based advice for management of diverticulitis. We reviewed systematic reviews, meta-analyses, randomized controlled trials, and observational studies to develop 14 best practices. In brief, computed tomography is often necessary to make a diagnosis. Rarely, a colon malignancy is misdiagnosed as diverticulitis. Whether patients should have a colonoscopy after an episode of diverticulitis depends on the patient's history, most recent colonoscopy, and disease severity and course. In patients with a history of diverticulitis and chronic symptoms, alternative diagnoses should be excluded with both imaging and lower endoscopy. Antibiotic treatment can be used selectively rather than routinely in immunocompetent patients with mild acute uncomplicated diverticulitis. Antibiotic treatment is strongly advised in immunocompromised patients. To reduce the risk of recurrence, patients should consume a high-quality diet, have a normal body mass index, be physically active, not smoke, and avoid nonsteroidal anti-inflammatory drug use except aspirin prescribed for secondary prevention of cardiovascular disease. At the same time, patients should understand that genetic factors also contribute to diverticulitis risk. Patients should be educated that the risk of complicated diverticulitis is highest with the first presentation. An elective segmental resection should not be advised based on the number of episodes. Instead, a discussion of elective segmental resection should be personalized to consider severity of disease, patient preferences and values, as well as risks and benefits.
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Affiliation(s)
- Anne F. Peery
- University of North Carolina, Chapel Hill, North Carolina
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13
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Olson MT, Elnahas S, Dameworth J, Row D, Gagliano RA, Roy SB, Kang P, Walia R, Bremner RM. Management and Outcomes of Diverticulitis After Lung Transplantation. Prog Transplant 2020; 30:235-242. [PMID: 32583709 DOI: 10.1177/1526924820933830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Most lung transplant patients are older than 50 years. Complications from colonic diverticula are not uncommon, especially with chronic immunosuppression. However, limited data exist regarding the optimal management of these patients. We sought to investigate the incidence, risk factors, and outcomes of diverticulitis after lung transplant. METHODS We conducted a retrospective study to review patients undergoing lung transplant between 2007 and 2016 with posttransplant acute colonic diverticulitis. Patients were grouped based on medical or surgical management. RESULTS Of 512 transplant recipients, 17 (3.32%) developed 26 episodes of diverticulitis over a median follow-up of 39 months. Nine patients had documented diverticulosis on pretransplant colonoscopy. These patients had a higher incidence of surgical intervention for diverticulitis, were more likely to have recurrent diverticulitis, and had longer lengths of stay than patients without pretransplant diverticulosis. Six (35.3%) of 17 patients required surgery (ie, Hartmann procedure; 4 during the initial episode and 2 during their third and fourth episodes); 11 patients (64.7%) were managed with antibiotics alone. Patients in the surgical group presented earlier posttransplant (P = .004) and were on higher doses of tacrolimus (P = .03). Six (46.1%) of 13 patients with medically managed first episodes of diverticulitis experienced recurrence. No recurrence occurred after surgical management. No deaths were attributable to diverticulitis in either group. CONCLUSIONS Patients with pretransplant diverticulosis experienced earlier, more complicated episodes of diverticulitis posttransplant than patients without. Surgical patients received higher doses of tacrolimus and presented earlier than medical patients. Uncomplicated diverticulitis in posttransplant patients can be managed medically, even in the case of recurrent, uncomplicated disease.
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Affiliation(s)
- Michael T Olson
- University of Arizona College of Medicine, Phoenix, AZ, USA.,Norton Thoracic Institute, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Shaimaa Elnahas
- Norton Thoracic Institute, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jonathan Dameworth
- Department of Surgery, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - David Row
- Department of Surgery, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ronald A Gagliano
- Department of Surgery, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sreeja Biswas Roy
- Department of Internal Medicine, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Paul Kang
- Norton Thoracic Institute, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Rajat Walia
- Norton Thoracic Institute, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, 6586St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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