Emergency management of diverticulitis

Diverticulosis and Diverticulitis: Epidemiology, Pathophysiology, and Current Treatment Trends

Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.

How do cognitive processes influence script concordance test responses?

INTRODUCTION

The script concordance test (SCT) is a test of clinical decision-making (CDM) that compares the thought process of learners to that of experts to determine to what extent their cognitive 'scripts' align. Without understanding test-takers' cognitive process, however, it is unclear what influences their responses. The objective of this study was to gather response process validity evidence by studying the cognitive process of test-takers to determine whether the SCT tests CDM and what cognitive processes may influence SCT responses.

METHODS

Cases from an SCT used in a national validation study were administered and semi-structured cognitive interviews were conducted with ten residents and five staff surgeons. A retrospective verbal probing technique was used. Data was independently analysed and coded by two analysts. Themes were identified as factors that influence SCT responses during the cognitive interview.

RESULTS

Cognitive interviews demonstrated variability in CDM among test-takers. Consistent with dual process theory, test-takers relied on scripts formed through past experiences, when available, to make decisions and used conscious deliberation in the absence of experience. However, test-takers' response process was also influenced by their comprehension of specific terms, desire for additional information, disagreement with the planned management, underlying knowledge gaps and desire to demonstrate confidence or humility.

CONCLUSION

The rationale behind SCT answers may be influenced by comprehension, underlying knowledge and social desirability in addition to formed scripts and/or conscious deliberation. Having test-takers verbalise their rationale for responses provides a depth of assessment that is otherwise lost in the SCT's current format. With the improved ability to standardise CDM assessment using the SCT, consideration of test-makers improving the SCT construction process and combining the SCT question format with verbal responses may improve the use of the SCT for CDM assessment.

Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis

BACKGROUND

Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach.

METHODS

The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat).

RESULTS

A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group.

CONCLUSIONS

Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings.

Current Options for the Emergency Management of Diverticular Disease and Options to Reduce the Need for Colostomy

This article reviews the current options and recommendations for the emergency management of acute diverticulitis, including the spectrum of antibiotics, percutaneous drainage, laparoscopic lavage, and surgical options for resection with the restoration of bowel continuity.

Use of Primary Anastomosis With Diverting Ileostomy in Patients With Acute Diverticulitis Requiring Urgent Operative Intervention

BACKGROUND

Previous studies suggest that urgent colectomy and primary anastomosis with diversion is safe for perforated diverticulitis. Current guidelines support this approach.

OBJECTIVE

The purpose of this study was to describe the use of urgent or emergent primary anastomosis with diversion in diverticulitis before the 2014 American Society of Colon and Rectal Surgeons guidelines and compare national outcomes of primary anastomosis with diversion to the Hartmann procedure.

DESIGN

This was a national retrospective cohort study.

SETTINGS

The study was conducted with a national all-payer US sample from 1998 to 2011.

PATIENTS

Patients included those admitted and treated with urgent or emergent colectomy for diverticulitis. Exclusion criteria were age <18 years, concurrent diagnosis of colorectal cancer or IBD, no fecal diversion performed, and operations >24 hours after admission.

MAIN OUTCOME MEASURES

In-hospital mortality was measured.

RESULTS

A total of 124,198 patients underwent emergent or urgent colectomy for acute diverticulitis; 67,721 underwent concurrent fecal diversion, including 65,084 (96.1%) who underwent end colostomy and 2637 (3.9%) who underwent anastomosis with ileostomy. The rate of primary anastomosis with diverting ileostomy increased from 30 to 60 diverting ileostomy cases per 1000 operative diverticulitis cases in 1998 versus 2011 (incidence rate ratio = 2.04 (95% CI, 1.70-2.50). However, overall use remained low, with >90% of patients undergoing end colostomy. Complication rates were higher (32.1% vs 23.3%; p < 0.001) and in-hospital mortality rates were higher (16.0% vs 6.4%; p < 0.001) for primary anastomosis with diversion patients compared with end colostomy. These findings were consistent on multivariable logistic regression. Other factors that contributed to in-hospital mortality included increasing age, increasing comorbid disease burden, and socioeconomic status.

LIMITATIONS

Billing data can be inaccurate or biased because of nonmedically trained professional data entry. Selection bias could have affected the results of this retrospective study.

CONCLUSIONS

The use of primary anastomosis with proximal diversion for urgent colectomy in diverticulitis increased over our study period; however, overall use remained low. Poor national outcomes after primary anastomosis with proximal diversion might affect compliance with new guidelines. See Video Abstract at http://links.lww.com/DCR/A600.

The influence of rifaximin on diverticulitis rate and quality of life in patients with diverticulosis

Diverticulosis, its associated symptoms and complications are one of the most common pathologies of the gastrointestinal tract in more economically developed countries. Presence of diverticuli and their clinical consequences can be divided into four categories: 1) diverticulosis, i.e. an asymptomatic presence of diverticuli that are usually found by accident 2) symptomatic uncomplicated diverticulosis 3) diverticulitis (acute uncomplicated diverticulitis) 4) complications of diverticulitis (conditions requiring hospital stay). The aim of this study was to retrospectively analyze the efficacy of rifaximin in preventing diverticulitis in patients visiting proctology clinics. The diagnostic criterium for diverticulosis was confirmation by colonoscopy, barium enema or CT colography (virtual colonoscopy) as well as history of at least one documented episode of diverticulosis. History of diverticulosis was evaluated based on medical records, clinical symptoms, elevated level of CRP (&gt;5.0) and/or diagnostic imaging (ultrasound, CT). After setting strict exclusion criteria, 248 patients were qualified for the study out of 686, and they were later divided into two groups: control group (group I - 145 patients) and studied group (group II - 103 patients receiving rifaximin prophylaxis). Diverticulitis rate was comparable in both groups over a period of 6 months before study (p = 0.1306) and 6 months of treatment (p=0.3044). Between the 6th and 12th month of treatment, a significantly lower rate of diverticulitis was noted in the group receiving rifaximin compared to control group (p&lt;0.0001). Patients receiving rifaximin reported higher quality of life (which was assessed using the VAS scale) compared to control group after 12 months. The results confirmed the efficacy of riaximin in prevention of diverticulitis, even in the scheme of repeated courses every 3 months. Not only did application of rifaximin lower the rate of diverticulitis and its complications in patients after an episode of diverticulitis, but also it improved the patients' quality of life. It seems that diverticulitis prophylaxis based on rifaximin can be economically efficient, however, it requires further research.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Factors Associated with Repeated Health Resource Utilization in Patients with Diverticulitis

Conservative management trends in diverticulitis may lead to increased hospitalizations secondary to repeated attacks. The study aimed to characterize trends in management and risk-assess patients with diverticulitis that required multiple admissions to identify high utilizers. A total of 265,724 patients with diverticulitis were identified from 1995 to 2014 from the New York SPARCS database. Patients with ≥2 hospital admissions were stratified across demographics, comorbidities, insurance status, and surgical intervention. In total, 42,850 patients had ≥2 hospital admissions. Risk factors for ≥2 admissions included younger age, White race, obesity, hypertension, pulmonary disease, hypothyroidism, rheumatoid arthritis, and depression. Fifty-two percent of these patients went on to have surgery. The percentage of elective cases increased from 59 to 70 %, while emergent cases conversely decreased from 41 to 30 %. One in five patients admitted with diverticulitis required two or more admissions. Numerous patient factors were correlated with increased risk of readmission. These factors may be used to guide treatment decisions and help reduce economic burden in frequent utilizers. Trends in surgery rates for these patients could reflect improved treatment options and/or changing clinical practice patterns.

Conservative treatment of acute cholecystitis: a systematic review and pooled analysis

BACKGROUND

In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. Cholecystectomy, however, is associated with relatively high complication rates, and therefore the decision whether or not to perform surgery should be well considered. For some patients, the surgical risk-benefit profile may favour conservative treatment. The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Prospective studies reporting on the success rate of conservative treatment (i.e. non-invasive treatment) of acute cholecystitis during index admission were included, as well as prospective and retrospective studies reporting on the recurrence rate of gallstone-related disease during long-term follow-up (i.e. ≥12 months) after initial non-surgical management. Study selection was undertaken independently by two reviewers using predefined criteria. The risk of bias was assessed. The pooled success and mortality rate during index admission and the pooled recurrence rate of gallstone-related disease during long-term follow-up were calculated using a random-effects model.

RESULTS

A total of 1841 patients were included in 10 randomized controlled trials and 14 non-randomized studies. Conservative treatment during index admission was successful in 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8-0.9), a mortality rate of 0.5 % (95 % CI 0.001-0.009) and a recurrence rate of 20 % (95 % CI 0.1-0.3).

DISCUSSION

Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe, especially in patients with mild disease. During long-term follow-up, less than a quarter of the patients appear to develop recurrent gallstone-related disease, although this outcome is based on limited data.

Treatment Modalities and Antimicrobial Stewardship Initiatives in the Management of Intra-Abdominal Infections

Antimicrobial stewardship programs (ASPs) focus on improving the utilization of broad spectrum antibiotics to decrease the incidence of multidrug-resistant Gram positive and Gram negative pathogens. Hospital admission for both medical and surgical intra-abdominal infections (IAIs) commonly results in the empiric use of broad spectrum antibiotics such as fluoroquinolones, beta-lactam beta-lactamase inhibitors, and carbapenems that can select for resistant organisms. This review will discuss the management of uncomplicated and complicated IAIs as well as highlight stewardship initiatives focusing on the proper use of broad spectrum antibiotics.

Emergency laparoscopy: Role and implementation

Laparoscopic surgery has emerged over the past two decades as the surgical approach of choice in the treatment of many digestive disorders. Laparoscopy has its place in the management of abdominal surgical emergencies since it provides the same benefits: less postoperative pain and shorter length of hospital stay when compared to laparotomy. However, its role in the management of abdominal emergencies has not yet been fully clarified. In this review, we focus on what has been validated concerning the role of emergency laparoscopy in the management of abdominal diseases.

Is colonoscopy necessary after computed tomography diagnosis of acute diverticulitis?

Background/Aims

A diagnosis of acute diverticulitis is based on computed tomography (CT). Colonoscopy is commonly performed after the acute event to exclude other diagnoses. This study aimed to determine whether colonoscopy is necessary and what additional information is gained from a colonoscopy after acute diverticulitis.

Methods

Acute diverticulitis was diagnosed by clinical criteria and characteristic CT findings. We analyzed the number of patients in whom colorectal cancers were diagnosed and other incidental findings of polyps and other diseases.

Results

A total of 177 patients were analyzed retrospectively. The mean age was 43.3±15.3 years (range, 13-82 years) and 97 patients (54.8%) were male. Sixty-one patients had undergone a colonoscopy within 1 year of the acute attack. Advanced adenomatous lesions and colonic malignancy were not detected. Nineteen patients (31.1%) had ≥1 polyp and 11 patients (18.0%) had an adenomatous polyp. No new or different diagnosis was made after colonoscopy. None of the 116 patients who did not undergo colonoscopy within a year after acute diverticulitis had a diagnosis of colorectal cancer registered with the Korea Central Cancer Registry.

Conclusions

Routine colonoscopy yields little benefit in patients with acute diverticulitis diagnosed by typical clinical symptoms and CT. The current practice of a colonoscopy after acute diverticulitis needs to be reevaluated.

Acute right-sided colonic diverticulitis mimicking appendicitis: a report of two cases

We describe two right-sided diverticulitis cases that presented with marked right iliac fossa tenderness with guarding and rebound and laboratory parameters resembling acute appendicitis. The imaging findings suggested diverticulitis in both cases. One of the patients underwent surgery and the other one was followed up with medical treatment. Awareness of these imaging findings may aid in the diagnosis of right-sided diverticulitis, which is frequently misdiagnosed and mistreated.

Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis

BACKGROUND

This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis.

OBJECTIVE

This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis.

METHODS

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes.

RESULTS

Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann's procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001).

CONCLUSIONS

Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Non-operative management of acute cholecystitis in the elderly

BACKGROUND

Although cholecystectomy is the standard therapy for acute cholecystitis (AC), operative morbidity in the elderly may be high owing to medical co-morbidities and decreased physiological reserve. Outcomes of AC in the elderly have not been fully defined with regard to operative and long-term non-operative management.

METHODS

Patients aged 65 years or over admitted to a tertiary care centre with a diagnosis of AC between January 2000 and December 2009 were reviewed retrospectively. Patient data, operative and postoperative details were obtained. To determine cholecystectomy rates in the non-operative group, medical records were reviewed, and patients and families were interviewed.

RESULTS

A total of 290 patients underwent cholecystectomy during the index admission, of whom 59 (20·3 per cent) required conversion to open operation. Fifty-eight of these patients experienced 98 complications, including acute respiratory failure (27), pneumonia (18), myocardial infarction (16) and sepsis (15). Some 185 patients had non-operative treatment, of whom 67 underwent percutaneous cholecystostomy. Forty-four patients subsequently had elective cholecystectomy, with a complication rate of 23 per cent. One hundred and twenty-six patients were discharged without a plan for cholecystectomy; the rate of recurrent AC was 4 per cent among the two-thirds of patients followed to within 15 months of death. No deaths or major complications occurred among those with recurrent AC.

CONCLUSION

Despite selection of the best elderly candidates for cholecystectomy, postoperative morbidity was significant. Medical management, with interval cholecystectomy only for recurrent AC, may be appropriate in selected patients.