Timing of elective surgery for diverticular disease

Investigation of the clinical features and recurrence patterns of acute right-sided colonic diverticulitis: A retrospective cohort study

Background

Right-sided colonic diverticulitis (RCD) and left-sided colonic diverticulitis (LCD) are considered distinct diseases. However, separate guidelines for RCD do not exist. Since the establishment of RCD management would first require evaluation of disease characteristics and recurrence patterns, this study has aimed to investigate the differences in the clinical characteristics between RCD and LCD and the recurrence patterns of RCD.

Methods

Patients admitted for colonic diverticulitis between January 2012 and August 2020 were retrospectively reviewed. Clinical characteristics and recurrence rates in RCD and LCD patients, and predictors for recurrence and the recurrence patterns of RCD were analyzed.

Results

In total, 446 colonic diverticulitis patients (343 RCD, 103 LCD) were included in this study. RCD patients were more likely to be male, younger, taller, heavier, smoke, drink alcohol, have better physical performance scores, lower modified Hinchey stages and better initial laboratory findings. LCD patients were more likely to receive invasive treatments, have longer fasting and hospital days, higher mortality and cumulative recurrence rates (20.5% vs. 30.4%, P = 0.007). Recurrences in most RCD patients were of similar disease severity and received the same treatments for initial attacks, with rates of recurrence increasing after each recurrence. Predictors of the recurrence of RCD were complicated diverticulitis (hazard ratio[HR] 2.512, 95% confidence interval[CI] 0.127–5.599, p = 0.024) and percutaneous drainage (HR 6.549, 95% CI 1.535–27.930, p = 0.011).

Conclusion

RCD is less severe and has a lower recurrence rate than LCD, suggesting that RCD should be treated conservatively. Patients with complicated diseases and those requiring percutaneous drainage are more likely to experience a disease recurrence, suggesting nonsurgical management may be insufficient.

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Right-sided colonic diverticulitis patients were more likely to be male, younger, taller, heavier, smoke and drink alcohol.

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Right-sided colonic diverticulitis is less severe and has a lower recurrence rate than left-sided colonic diverticulitis.

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Patients with complicated disease and those requiring percutaneous drainage are more likely to experience disease recurrence.

What Are the Long-Term Changes to Bowel Function Patient-reported Outcomes After Elective Sigmoidectomy for Diverticular Disease?: Observational Study of Patients Undergoing Elective Sigmoidectomy for Diverticular Disease

Objective

To evaluate long-term changes to bowel function after elective sigmoidectomy for diverticular disease.

Background

For patients with diverticular disease, choosing surgery is often based on the presumption of improvement in preoperative symptoms. Our group previously reported bowel function does not change in the early perioperative period; however, studies of long-term outcomes are limited.

Methods

This is an observational study of patients that underwent elective sigmoidectomy for diverticular disease and completed the Colorectal Functional Outcome (COREFO) questionnaire before surgery. Patients were stratified into two groups based on presence or absence of a preoperative symptomatic score (i.e., total COREFO ≥ 15). Long-term bowel function (>1 year from surgery) was assessed using the COREFO questionnaire via telephone or subsequent clinic visit. Paired t-tests compared mean preoperative scores to mean long-term scores.

Results

Fifty-one patients met inclusion criteria (21 symptomatic, 30 asymptomatic). All symptomatic patients had uncomplicated disease, whereas 90% of asymptomatic patients had complicated disease. Median time from operation to questionnaire completion was 23 months (IQR = 13-34). Asymptomatic patients demonstrated impaired bowel function, predominantly driven by changes in the social impact domain. Symptomatic patients demonstrated improved bowel function, driven by changes in the incontinence, social impact, stool-related aspects, and need for medication domains.

Conclusions

In the long-term after elective sigmoidectomy for diverticular disease, patients with symptomatic bowel function preoperatively improve substantially, while those with asymptomatic preoperative scores demonstrate statistically significant impairment. Patients determined to be symptomatic with patient-reported outcomes likely benefit long-term from sigmoid resection.Mini-Abstract: In this manuscript, long-term changes to patient-reported bowel function were assessed using a validated questionnaire after sigmoidectomy for diverticular disease. We found that in patients with symptomatic preoperative bowel function, long-term bowel function improved after elective resection. Alternatively, patients with asymptomatic preoperative bowel function demonstrated long-term impairment in bowel function.

State-of-the-art surgery for sigmoid diverticulitis

Background

In the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease.

Purpose

This article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis.

Conclusion

Acute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann’s procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann’s procedure, and it is associated with a high rate of primary anastomosis.

Prognostic Value of the Diverticular Disease Severity Score Based on CT Colonography: Follow-up in Patients Recovering from Acute Diverticulitis

RATIONALE AND OBJECTIVES

To assess the prognostic value of a diverticular disease severity score (DDSS) based on computed tomography colonography (CTC) after acute diverticulitis (AD).

MATERIALS AND METHODS

Of 252 patients who had an AD episode, we finally selected 46 patients who underwent both conventional CT at the acute event and CTC after 9 ± 7 weeks. Of these 46 patients, 17 underwent elective surgery after CTC. Disease severity was assessed with a 0-4 modified Hinchey CT-based score and a 1-4 CTC-based DDSS. A phone survey was performed 27 months later (range 4-52) for the 29 patients not surgically treated.

RESULTS

Significant correlation was found between CTC-based DDSS and clinical follow-up (P = 0.022) or elective surgery (P = 0.007), but not between clinical follow-up and CT-based score, extraluminal gas, C-reactive protein serum level, age, gender, or first versus recurrent AD episode. CTC demonstrated relevant additional findings in five of 46 (11%) patients: two AD complications (enterocolic and enterotubal fistulae), two colon cancers, and one extracolonic (lung) cancer.

CONCLUSIONS

The CTC-based DDSS showed a prognostic value and correlated with the risk of undergoing surgery, and clinically relevant additional findings were found in more than 10% of patients. CTC could be the preferred test in patients recovering after AD.

Position paper: management of perforated sigmoid diverticulitis

Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy.

Surgical treatment of acute recurrent diverticulitis: early elective or late elective surgery. An analysis of 237 patients

BACKGROUND

The optimal timing of elective surgery in diverticulitis remains unclear. We attempted to investigate early elective versus late elective laparoscopic surgery in acute recurrent diverticulitis in a retrospective study.

METHOD

Data of patients undergoing elective laparoscopic surgery for diverticulitis were retrospectively gathered, including Hinchey stages I-II a/b. the primary endpoint was in-hospital complications according to the Clavien-Dindo classification. Secondary endpoints were surgical complications, operative time, conversion rate, and length of hospital stay.

RESULTS

Of 237 patients, 81 (34%) underwent early elective operation (group A) and 156 (66%) underwent late elective operation (group B). In-hospital complications developed in 32% in group A and in 34% in group B (risk difference 2%, 95% Confidence Interval (95% CI): -11%, 14%). Higher age (p = 0.048) and borderline higher American Society of Anesthesiologists score (p = 0.056) were risk factors for in-hospital complications. Severe surgical complications occurred in 9% of patients in group A and 10% in group B (risk difference 2%, 95% CI: -6%, 9%). Conversion rate was 9% in group A and 3% in group B (p = 0.070). Severity of disease did not seem to have an impact on complications or length of hospital stay. The median postoperative hospital stay was 8 days in both groups (interquartile range 6-10). Mean operative time was 220 min (SD 64) in group A and 202 min (SD 48) in group B.

CONCLUSIONS

This is the first study comparing early versus late elective surgery for diverticulitis in terms of the postoperative outcome using a validated classification. Although the retrospective setting and large confidence intervals don't allow definitive recommendations, these results are of utmost importance for the design of future prospective, randomized controlled trials.

Elective laparoscopic versus open colectomy for diverticulosis: an analysis of ACS-NSQIP database

BACKGROUND

The benefits of laparoscopic (LC) versus open (OC) colectomy for symptomatic colonic diverticulosis as an elective operation remain unclear.

METHODS

Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-user file, patients were identified who underwent elective colon resection for symptomatic colonic diverticulosis, between 2005 and 2008. Demographic, clinical, intraoperative variables, and 30-day morbidity and mortality were collected. Logistic regression analysis was performed to determine the association between the surgical approach (LC vs. OC) and risk-adjusted overall mortality, overall morbidity, serious morbidity, and wound complications.

RESULTS

A total of 7,629 patients were identified who underwent colon resection for symptomatic diverticulosis. They were subdivided into two groups: OC (3,870 (50.7%)) and LC (3,759 (49.3%)). Patients who underwent OC were significantly older (59.0 vs. 55.7 years, P < 0.0001) with more comorbidities compared with those who underwent LC. After risk-adjusted analysis, it was noted that the patients treated with LC were significantly less likely to experience overall morbidity (11.9% vs. 23.2%), serious morbidity (4.6% vs. 10.9%), and wound complications (9.1% vs. 17.5%), but not mortality (0.3% vs. 0.8%). Operative duration was significantly longer with LC (176.64 vs. 166.70 min, P < 0.0001), but the length of stay was significantly shorter (4.77 vs. 7.68 days, P < 0.0001). Using logistic regression analysis, patients with history of peripheral vascular disease, percutaneous coronary interventions, current steroid use, and hypertension requiring medication were at an increased risk of morbidity and mortality at 30 days. Patients with history of chronic obstructive pulmonary disease and smoking experienced more wound complications at 30 days.

CONCLUSIONS

In the elective setting for symptomatic diverticulosis, LC seems to be associated with lower 30-day morbidity and complication rates compared with OC.

Outcomes of laparoscopic versus open colectomy in elective surgery for diverticulitis

BACKGROUND

The role of laparoscopy in the management of diverticular disease is evolving. Concerns were raised in the past because laparoscopic resection for diverticulitis is often difficult and occasionally hazardous. This study was undertaken to evaluate the difference in overall outcomes between elective open and laparoscopic surgery with or without anastomosis for diverticulitis.

METHODS

Using the National Inpatient Sample (NIS) database, clinical data of patients who underwent elective open and laparoscopic surgery (lap) for diverticulitis from 2002 to 2007 were collected and analyzed. Patients who underwent emergent surgery were excluded.

RESULTS

A total of 124,734 patients underwent elective surgery for diverticulitis: open, 110,172 (88.3%); lap, 14,562 (11.7%). The overall intraoperative complication rate was significantly lower in the laparoscopy group (0.63% vs. 1.15%, P < 0.01). However, there was no significant difference observed in ureteral injury between groups (open, 0.17%; lap, 0.12%, P = 0.15). All evaluated postoperative complications (ileus, abdominal abscess, leak, wound infection, bowel obstruction, urinary tract infection, pneumonia, respiratory failure, venous thromboembolism) were significantly higher for the open procedures. The laparoscopy group had a shorter mean hospital stay (lap, 5.06 days; open, 6.68 days, P < 0.01) and lower total hospital charges (lap, $36,389; open, $39,406, P < 0.01) than the open group. Also, mortality was four times higher in the open group (open, 0.54%; lap, 0.13%, P < 0.01).

CONCLUSIONS

The laparoscopic operation was associated with lower morbidity, lower mortality, shorter hospital stay, and lower hospital charges compared to the open operation for diverticulitis. Elective laparoscopic surgery for diverticulitis is safe and can be considered the preferred operative option.