Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?

Towards a tailored approach for patients with acute diverticulitis and abscess formation. The DivAbsc2023 multicentre case-control study

BACKGROUND

This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses.

METHODS

This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed.

RESULTS

Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23).

CONCLUSIONS

Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.

Free perforation during the first episode of acute diverticulitis: can it be avoided?

The aims of the present study are to compare the severity of acute diverticulitis in the first episode and in later bouts, and to determine whether there are risk factors for the presence of free perforation at the onset of diverticulitis. A single-center retrospective study was conducted of patients who developed a first episode of acute diverticulitis between January 2011 and August 2021 diagnosed by computed tomography and followed up for at least 1 year. Free perforation was considered to be present in patients with diverticulitis stage III and IV according to the Hinchey classification (modified by Wasvary). The analysis included 394 patients (224 men and 170 women) with a mean age of 58 years. Forty-eight patients (12.2%) presented free perforation at some point in the course of the disease, 43 during the first episode and 5 during subsequent bouts. The perforation subgroup showed higher rates of stoma creation and mortality (relative risks of 12.3 and 23.5, respectively). In the multivariate analysis, age (OR: 1.041 95% CI 1.016-1.067), lung disease (OR 2.154 95% CI 1.038-4.472) and immunosuppression (OR: 2.812 95% CI 1.315-6.015) were independent factors for free perforation at diverticulitis onset. Free perforation occurs more frequently during the first episode of acute diverticulitis. Older patients, immunosuppressed patients and those with respiratory disease have a greater risk of presenting freely perforated diverticulitis. Therefore, it is essential to maintain a high level of clinical suspicion in these patients to activate early focus control and thus avoid fatal outcomes.

Sarcopenia is a Poor Predictor of Outcomes in Elective Colectomy for Diverticulitis

BACKGROUND

Sarcopenia is associated with adverse perioperative outcomes in patients undergoing operations for malignancy, but its influence on patients undergoing elective colectomy for diverticulitis is unknown. We hypothesized that sarcopenia is associated with adverse perioperative events in patients undergoing elective colectomy for diverticulitis.

METHODS

Comorbidities, operative characteristics, and postoperative complications were extrapolated from our institutional EMR in patients undergoing elective colectomy for diverticulitis from 2016 to 2020. Sarcopenia was calculated using perioperative imaging and defined by standard skeletal muscle index (SMI) and psoas muscle index (PMI) thresholds. Univariate analysis was used to compare sarcopenic and non-sarcopenic patients.

RESULTS

148 patients met inclusion criteria. Using SMI thresholds, 95 patients (64%) were sarcopenic. With SMI criteria, sarcopenic patients were older (67 vs 52 years old; P < .01) and had lower BMIs (26.2 vs 34.0, respectively; P < .001) than non-sarcopenic patients. There were no differences in baseline characteristics, postoperative complications, and non-home discharge between groups (P > .05 for all). Postoperative length of stay was greater in sarcopenic patients (3 IQR 2-5 vs 2 IQR 2-3 days; P < .01). Using PMI thresholds, 68 (46%) met criteria for sarcopenia. Using PMI thresholds, sarcopenic patients were older (68 vs 57.5 years old; P < .01) and had lower BMIs (25.8 vs 32.8; P < .01). There were no differences in comorbidities or measured operative outcomes between groups (P > .05 for all), other than postoperative length of stay which was longer in the sarcopenic group (3.5 IQR 3-5 vs 2 IQR 2-3; P < .01).

CONCLUSIONS

Incidence of sarcopenia was high in patients undergoing elective colectomy for diverticulitis in our practice, but sarcopenia was not associated with adverse perioperative outcomes. In select patients, elective colectomy for diverticulitis can be safely performed in the presence of sarcopenia.

Conservative management of complicated colonic diverticulitis: long-term results

BACKGROUND

The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease.

AIM

To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis.

METHODS

This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis.

RESULTS

We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05).

CONCLUSIONS

Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.

Long-term outcomes and risk factors for diverticulitis recurrence after a successful laparoscopic peritoneal lavage in Hinchey III peritonitis

PURPOSE

Recently, treatment of Hinchey III diverticulitis by laparoscopic peritoneal lavage has been questioned. Moreover, long-term outcomes have been scarcely reported. Primary outcome was to determine the recurrence rate of diverticulitis after a successful laparoscopic peritoneal lavage in Hinchey III diverticulitis. Secondary outcomes were identification of associated risk factors for recurrence and elective sigmoidectomy rate.

METHODS

A retrospective cohort study in a tertiary referral center was performed. Patients with Hinchey III diverticulitis who underwent a successful laparoscopic peritoneal lavage between June 2006 and December 2019 were eligible. Diverticulitis recurrence was analyzed according to the Kaplan-Meier and log-rank test, censoring for death, loss of follow-up, or elective sigmoid resection in the absence of recurrence. Risk factors for recurrence were identified using Cox regression analysis.

RESULTS

Sixty-nine patients had a successful laparoscopic peritoneal lavage (mean age: 63 years; 53.6% women). Four patients had an elective sigmoid resection without recurrences. Recurrence rate was 42% (n = 29) after a median follow-up of 63 months. The cumulative global recurrence at 1, 3, and 5 years was 30% (95% CI, 20-43%), 37.5% (95% CI, 27-51%), and 48.9% (95% CI, 36-64%), respectively. Smoking (HR, 2.87; 95% CI, 1.22-6.5; p = 0.016) and episodes of diverticulitis prior to laparoscopic peritoneal lavage (HR, 5.2; 95% CI, 2.11-12.81; p < 0.001) were independently associated with an increased risk of recurrence.

CONCLUSIONS

Diverticulitis recurrence after a successful laparoscopic peritoneal lavage is high, decreasing after the first year of follow-up. Smoking and previous episodes of acute diverticulitis independently increase the risk of new episodes of diverticulitis.

Managing a patient with acute colonic diverticulitis

ABSTRACT

Acute diverticulitis is a common condition in Western society with the potential for substantial patient morbidity. Depending on the severity, the patient's clinical presentation and treatment options vary considerably, leaving uncertainty about optimal management. Traditionally, surgery was recommended to prevent complications, persistent symptoms, and recurrent episodes. Improvements in the understanding of the disease's natural history, diagnostic imaging, and long-term outcomes have prompted changes to diagnosis and treatment guidelines.

National Variation in Elective Colon Resection for Diverticular Disease

OBJECTIVE

This study aims to characterize the extent of geographic variation in elective sigmoid resection for diverticulitis and to identify factors associated with observed variation.

INTRODUCTION

National guidelines for treatment of recurrent diverticulitis fail to offer strong recommendations for or against surgical intervention. We hypothesize that healthcare market factors will be significantly associated with geographic variation in colon resection for diverticulitis, a discretionary surgical intervention.

METHODS

We used Center for Medicare Services 100% inpatient Limited Data Set (LDS) files from January 2013 through September 2015 to calculate an observed to expected standardized colon resection ratio for each hospital referral region (HRR). We then analyzed patient, hospital-, and market-level factors associated with variation of colectomy. For each HRR, a Herfindahl-Hirschman index, a measure of market competition, was calculated.

RESULTS

A total of 19,557 Medicare patients underwent an elective colon resection for diverticulitis at 2462 hospitals over the study period. Standardized colon resection ratios ranged from 0 in the Tuscaloosa HRR to 3.7 in the Royal Oak, MI HRR. Few patient factors were associated with variation, but a number of hospital factors (size, area, profit status, and critical access designation) all were associated with variation. In an analysis of market factors, increased surgeon density, and decreased market competition were associated with higher predicted rates of colon resection.

CONCLUSION

We observed pronounced variation (excess of 3-fold) in standardized colon resection ratios for recurrent diverticulitis. Surgeon density and hospital level factors were strongly associated with this variation and may be the main drivers of colonic resection for diverticular disease. Further investigation and stronger national guidelines are needed to optimize patient selection for colectomy.

Are Surgical Guideline Changes in Diverticulitis Care Associated With Decreased Inpatient Healthcare Expenditure?

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.

Conservative treatment of uncomplicated right-sided diverticulitis: a systematic review and meta-analysis

PURPOSE

Right-sided diverticulitis has different epidemiologic features compared to left-sided diverticulitis. However, data on the appropriate treatment of right-sided diverticulitis are lacking. This systematic review aimed to examine the outcomes of conservative treatment for uncomplicated right-sided diverticulitis.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched for articles published from January 1, 1990, to May 31, 2020. A total of 21 studies were included in the systematic review. We calculated proportions and 95% confidence intervals (CIs) to assess the outcomes of individual studies and pooled the results using a random effects model.

RESULTS

A total of 2811 patients (59.1% men; mean and median age, 37-54 years) with right-sided diverticulitis were included. The pooled rate of treatment failure was 2.5% (95% CI 1.2-4.3%; p <0.01; I² = 64.0%). The recurrence rate ranged from 0 to 26.9%, and the pooled recurrence rate was 10.9% (95% CI 8.1-14.1%; p <0.01; I² = 78.2%). The pooled rate of complicated diverticulitis at recurrence was 4.4% (95% CI 1.4-9.0%; p = 0.84; I² = 0%). The pooled rate of emergency surgery at recurrence was 9.0% (95% CI 4.6-14.7%; p = 0.12; I² = 30.3%).

CONCLUSIONS

Conservative treatment of uncomplicated right-sided diverticulitis results in a low rate of recurrence and complicated diverticulitis at recurrence. Based on these results, unnecessary surgery may be avoided and a new treatment paradigm for uncomplicated right-sided diverticulitis may be introduced.

Predictive factors for conservative treatment failure of right colonic diverticulitis

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.

[Actual issues of diagnosis and treatment of diverticulitis]

The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center retrospective and randomized prospective studies. Modern diagnostic and therapeutic approaches, certain unsolved problems in indications for surgeries and their technique, as well as the role of surgical interventions in prevention of recurrences and severe complications of diverticulitis are demonstrated.

Evidence-based treatment strategies for acute diverticulitis

PURPOSE

Diverticular disease is a common acquired condition of the lower gastrointestinal tract that may be associated with significant morbidity. The term encompasses a spectrum of pathological processes with varying clinical manifestations. The purpose of this review was to update the reader on modern evidence-based treatment strategies for acute diverticulitis.

METHODS

A literature search of the PUBMED database was performed using the keywords 'diverticulosis', 'diverticular disease' and 'diverticulitis'. Only articles published in the English language were included.

RESULTS

Evidence-based treatment strategies for acute diverticulitis have evolved over time. Data have questioned the need for antibiotic therapy for Hinchey I disease and the role of percutaneous abscess drainage for Hinchey II. Clinical trials have demonstrated laparoscopic lavage is an appropriate option for select patients with Hinchey III disease and primary resection with anastomosis and defunctioning stoma may be considered in some cases of Hinchey IV disease.

CONCLUSION

Risk-adapted treatment strategies and operative decision-making for acute diverticulitis are increasingly based on a combination of patient and disease factors.

Comparing Laparoscopic Elective Sigmoid Resection With Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis: The Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) Randomized Clinical Trial

Question

Does elective sigmoid resection improve the quality of life in patients with recurrent diverticulitis, complicated diverticulitis, and/or chronic pain after an episode of diverticulitis?

Findings

In this randomized clinical trial that included 85 adults, the Gastrointestinal Quality of Life Index (GIQLI) score improved 11.8 points in patients randomized to sigmoid resection and 0.2 points in patients randomized to conservative treatment between baseline and 6 months, a statistically and clinically significant difference. Among 41 patients randomized to sigmoid resection, 4 (10%) experienced major complications.

Meaning

Sigmoid resection improved quality of life in patients with recurrent, complicated, or persistent painful diverticulitis but was associated with a small but significant risk of major complications.

Importance

Diverticulitis has a tendency to recur and affect quality of life.

Objective

To assess whether sigmoid resection is superior to conservative treatment in improving quality of life of patients with recurrent, complicated, or persistent painful diverticulitis.

Design, Setting, and Participants

This open-label randomized clinical trial assessed for eligibility 128 patients with recurrent, complicated, or persistent painful diverticulitis in 6 Finnish hospitals from September 29, 2014, to October 10, 2018. Exclusion criteria included age younger than 18 years or older than 75 years; lack of (virtual) colonoscopy or sigmoidoscopy data within 2 years, or presence of cancer, contraindication to laparoscopy, or fistula. Outcomes were assessed using intention-to-treat analysis. A prespecified interim analysis was undertaken when 66 patients had been randomized and their 6-month follow-up was assessable. Data were analyzed from June 2018 to May 2020.

Interventions

Laparoscopic sigmoid resection or conservative treatment.

Main Outcomes and Measures

The primary outcome was difference in Gastrointestinal Quality of Life Index (GIQLI) score between randomization and 6 months.

Results

Of 128 patients assessed for eligibility, 90 were randomized (28 male [31%]; mean [SD] age, 54.11 [11.9] years; 62 female [69%]; mean [SD] age, 57.13 [7.6] years). A total of 72 patients were included in analyses for the primary outcome (37 in the surgery group and 35 in the conservative treatment group), and 85 were included in analyses for clinical outcomes (41 in the surgery group and 44 in the conservative treatment group). The difference between GIQLI score at randomization and 6 months was a mean of 11.96 points higher in the surgery group than in the conservative treatment group (mean [SD] of 11.76 [15.89] points vs −0.2 [19.07] points; difference, 11.96; 95% CI, 3.72-20.19; P = .005). Four patients (10%) in the surgery group and no patients in the conservative treatment group experienced major complications (Clavien-Dindo grade III or higher). There were 2 patients (5%) in the surgery group and 12 patients (31%) in the conservative treatment group who had new episodes of diverticulitis within 6 months.

Conclusions and Relevance

In this randomized clinical trial, elective laparoscopic sigmoid resection improved quality of life in patients with recurrent, complicated, or persistent painful diverticulitis but carried a 10% risk of major complications.

Trial Registration

ClinicalTrials.gov Identifier: NCT02174926.

Risk factors and incidence of 90-day readmission for diverticulitis after an acute diverticulitis index admission

OBJECTIVES

Acute diverticulitis is the third most frequent cause of gastrointestinal admission in the USA. We sought to determine the incidence of recurrence within a 90-day period and determine its impact on mortality and hospital utilization.

METHODS

Nationwide Readmission Database (NRD) 2016 was used to identify patients ≥ 18 years old with a principal diagnosis of acute diverticulitis who were readmitted for recurrence within 90 days. The primary outcome was 90-day readmission rate for acute diverticulitis, and predictors were analyzed using a multivariate regression analysis. Secondary outcomes were mortality and hospital resource utilization.

RESULTS

A total of 171,238 admissions were included which met inclusion criteria. Ninety-day readmission for acute diverticulitis after index diverticulitis hospitalization was 8.9%. Readmissions were associated with in-hospital additional total cost of $444,726,560 and 65,685 total hospital days and mortality rate of 4.69% compared with mortality rate of 5.20% on index hospitalization (p < 0.01). In multivariable analysis, increased odds of readmission were associated with disposition against medical advice (OR 1.75, 95% CI 1.31-2.33), younger age (OR 0.98, 95% CI 0.98-0.99), and shorter length of stay (OR 0.99, CI 0.98-0.99).

CONCLUSIONS

Acute diverticulitis is frequently associated with recurrence within 90 days and bears a substantial financial and mortality burden. Targeted interventions are needed to minimize readmissions in identified subpopulations.

The Use of Biochemical Markers in Complicated and Uncomplicated Acute Diverticulitis

Objective

Diverticulosis is extremely common in western society. A recent study has shown that outpatient, nonantibiotic management of acute uncomplicated diverticulitis may be a feasible and safe option. However, the ability to identify these patients is still difficult. This study explores the ability of white cell count, C-reactive protein, and bilirubin in differentiating patients with complicated and uncomplicated diverticulitis, as well as progression to surgical intervention.

Methods

This is a retrospective study of patients admitted with acute diverticulitis over a 5-year period (2009–2014) at a single institution in Australia. Patients were classified into 3 groups; uncomplicated diverticulitis, complicated diverticulitis without surgery, and complicated diverticulitis with surgery. Analysis of variance (ANOVA) and Bonferroni's post hoc analyses were used to compare markers across the groups.

Results

A total of 541 patients met the inclusion criteria for this study. One-way ANOVA showed a significant difference in white cell count (P &lt; 0.0001), C-reactive protein (P &lt; 0.0001), and bilirubin (P = 0.0006) between all 3 groups. Post hoc analyses showed a significant difference in white cell count, C-reactive protein, and bilirubin when comparing uncomplicated diverticulitis against complicated diverticulitis without surgery (P &lt; 0.05) and complicated diverticulitis with surgery (P &lt; 0.05). White cell count also showed a significant difference when comparing complicated diverticulitis without surgery and complicated diverticulitis with surgery (P &lt; 0.05).

Conclusions

White cell count, C-reactive protein, and bilirubin can distinguish between uncomplicated and complicated diverticulitis.

Risk of colectomy after conservative treatment of diverticulitis of the left hemicolon complicated by abdominal or pelvic abscess: protocol of a systematic review and meta-analysis

INTRODUCTION

Acute diverticulitis of the sigmoid colon is increasingly treated by a non-operative approach. The need for colectomy after recovery from a flare of acute diverticulitis of the left colon, complicated diverticular abscess is still controversial. The primary aim of this study is to assess the risk of interval emergency surgery by systematic review and meta-analysis.

METHODS AND ANALYSIS

The systematic review and meta-analysis will be conducted in accordance to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE will be screened for the predefined searching term: (Diverticulitis OR Diverticulum) AND (Abscess OR pelvic abscess OR pericolic abscess OR intraabdominal abscess) AND (surgery OR operation OR sigmoidectomy OR drainage OR percutaneous drainage OR conservative therapy OR watchful waiting). All studies published in an English or German-speaking peer-reviewed journal will be suitable for this analysis. Case reports, case series of less than five patients, studies without follow-up information, systematic and non-systematic reviews and meta-analyses will be excluded. Primary endpoint is the rate of interval emergency surgery. Using the Review Manager Software (Review Manager/RevMan, V.5.3, Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration, 2012) meta-analysis will be pooled using the Mantel-Haenszel method for random effects. The Risk of Bias in Non-randomized Studies of Interventions tool will be used to assess methodological quality of non-randomised studies. Risk of bias in randomised studies will be assessed using the Cochrane developed RoB 2-tool.

ETHICS AND DISSEMINATION

As no new data are being collected, ethical approval is exempt for this study. This systematic review is to provide a new insight on the need for surgical treatment after a first attack of acute diverticulitis, complicated by intra-abdominal or pelvic abscesses. The results of this study will be presented at national and international meetings and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020164813.

Complicated Diverticular Disease

The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

Recurrence of Acute Right Colon Diverticulitis Following Nonoperative Management: A Systematic Review and Meta-analysis

BACKGROUND

There are currently no guidelines on the management of right colon diverticulitis. Treatment options have been extrapolated from the management of left-sided diverticulitis. Gaining knowledge of the risk and morbidity of diverticulitis recurrence is integral to weighing the benefit of elective surgery for right-sided diverticulitis.

OBJECTIVE

The purpose of this study was to summarize the recurrence rate and the morbidity of recurrence of Hinchey classification I/II, right-sided diverticulitis following nonoperative management.

DATA SOURCES

PubMed, EMBASE, and Cochrane Database of Collected Reviews were searched up to June 2019.

STUDY SELECTION

Observational cohort studies evaluating outcomes following nonoperative management were reviewed. No randomized controlled trials were available.

INTERVENTIONS

Intravenous antibiotics with or without percutaneous drainage of associated abscess were administered.

MAIN OUTCOME MEASURES

The primary outcomes measured were the recurrence rate and morbidity associated with recurrence. Two independent investigators extracted data. The rates of recurrence were pooled by using a random-effects model.

RESULTS

There were 1584 adult participants from a total of 11 studies (9 retrospective cohort and 2 prospective cohort studies) included in the analysis. Over a median follow-up period of 34.2 months, the pooled recurrence rate was 12% (95% CI, 10%-15%). Twenty of 202 patients (9.9%) required urgent surgery at the time of first recurrence. There was no mortality. Subset analysis excluding 3 studies that included percutaneous drainage as a nonoperative treatment option did not change the recurrence rate (12% (95% CI, 9%-15%)) or heterogeneity. Funnel plot assessment revealed no publication bias.

LIMITATIONS

There were no randomized controlled trials available. The statistical heterogeneity was moderate (I = 46%).

CONCLUSIONS

Nonoperative management of Hinchey I/II right-sided diverticulitis is safe and feasible. The recurrence rate is relatively low, and complications that require urgent operation are uncommon.

PROSPERO

CRD42019131673.

Family History Is Associated With Recurrent Diverticulitis After an Episode of Diverticulitis Managed Nonoperatively

BACKGROUND

To date, the impact of family history on diverticulitis outcomes has been poorly described.

OBJECTIVE

This study aims to evaluate the association between family history and diverticulitis recurrence after an episode of diverticulitis managed nonoperatively.

DESIGN

This is a retrospective cohort study with prospective telephone follow-up.

SETTINGS

This study was conducted at 2 McGill University-affiliated tertiary care hospitals in Montreal, Canada.

PATIENTS

All immunocompetent patients with CT-proven left-sided diverticulitis who were managed nonoperatively from 2007 to 2017 were included.

INTERVENTION

A positive family history for diverticulitis, as assessed by a detailed telephone questionnaire, was obtained.

MAIN OUTCOME MEASURES

The primary outcome was diverticulitis recurrence occurring >60 days after the index episode. Secondary outcomes included a complicated recurrence and >1 recurrence (ie, re-recurrence).

RESULTS

Of the 879 patients identified in the database, 433 completed the telephone questionnaire (response rate: 48.9%). Among them, 173 (40.0%) had a positive family history of diverticulitis and 260 (60.0%) did not. Compared to patients with no family history, patients with family history had a younger median age (59.0 vs 62.0 years, p = 0.020) and a higher incidence of abscess (24.3% vs 3.5%, p < 0.001). After a median follow-up of 40.1 (17.4-65.3) months, patients with a positive family history had a higher cumulative incidence of recurrence (log-rank test: p < 0.001). On Cox regression, a positive family history remained associated with diverticulitis recurrence (HR, 3.74; 95% CI, 2.67-5.24). Among patients with a positive family history, >1 relative with a history of diverticulitis had a higher hazard of recurrence (HR, 2.93; 95% CI, 1.96-4.39) than patients with only 1 relative with a history of diverticulitis. Positive family history was also associated with the development of a complicated recurrence (HR, 8.30; 95% CI, 3.64-18.9) and >1 recurrence (HR, 2.03; 95% CI, 1.13-3.65).

LIMITATIONS

This study has the potential for recall and nonresponse bias.

CONCLUSION

Patients with a positive family history of diverticulitis are at higher risk for recurrent diverticulitis and complicated recurrences. See Video Abstract at http://links.lww.com/DCR/B215. LOS ANTECEDENTES FAMILIARES ESTÁN ASOCIADOS CON DIVERTICULITIS RECURRENTE, DESPUÉS DE UN EPISODIO DE DIVERTICULITIS MANEJADA SIN OPERACIÓN: Hasta la fecha, el impacto de los antecedentes familiares en los resultados de la diverticulitis, ha sido mal descrito.Evaluar la asociación entre los antecedentes familiares y la recurrencia de diverticulitis después de un episodio de diverticulitis manejado de forma no operatoria.Estudio de cohorte retrospectivo con seguimiento telefónico prospectivo.Dos hospitales de atención terciaria afiliados a la Universidad McGill en Montreal, Canadá.Todos los pacientes inmunocompetentes con diverticulitis izquierda comprobada por TAC, que fueron manejados sin cirugía desde 2007-2017.Una historia familiar positiva para diverticulitis, según lo evaluado por un detallado cuestionario telefónico.El resultado primario fue la recurrencia de diverticulitis ocurriendo > 60 días después del episodio índice. Resultados secundarios incluyeron una recurrencia complicada y >1 recurrencia (es decir, re-recurrencia).De los 879 pacientes identificados en la base de datos, 433 completaron el cuestionario telefónico (tasa de respuesta: 48,9%). Entre ellos, 173 (40.0%) tenían antecedentes familiares positivos de diverticulitis y 260 (60.0%) no tenían. Comparados con los pacientes sin antecedentes familiares, los pacientes con antecedentes familiares tenían una mediana de edad más joven (59.0 vs 62.0 años, p = 0.020) y una mayor incidencia de abscesos (24.3% vs 3.5%, p < 0.001). Después de una mediana de seguimiento de 40.1 (17.4-65.3) meses, los pacientes con antecedentes familiares positivos tuvieron una mayor incidencia acumulada de recurrencia (prueba de log-rank: p < 0.001). En la regresión de Cox, un historial familiar positivo, permaneció asociado con recurrencia de diverticulitis (HR, 3.74; IC 95%, 2.67-5.24). Entre los pacientes con antecedentes familiares positivos, >1 familiar con antecedentes de diverticulitis, tuvieron mayores riesgos de recurrencia (HR, 2.93; IC 95%, 1.96-4.39) en comparación de los pacientes con solo 1 familiar. La historia familiar positiva también se asoció con el desarrollo de una recurrencia complicada (HR, 8.30; IC 95%, 3.64-18.9) y >1 recurrencia (HR, 2.03; IC 95%, 1.13-3.65).Potencial de recuerdo y sesgo de no respuesta.Los pacientes con antecedentes familiares positivos de diverticulitis tienen un mayor riesgo para diverticulitis recurrente y recurrencias complicadas. Consulte Video Resumen http://links.lww.com/DCR/B215. (Traducción-Dr. Fidel Ruiz Healy).

Management and Outcomes of Diverticulitis After Lung Transplantation

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.

Quality of life in uncomplicated recurrent diverticulitis: surgical vs. conservative treatment

Elective sigmoid colectomy for recurrent uncomplicated diverticulitis remains controversial and is decided on an individual basis. Eighty patients treated conservatively (44 patients) or by elective surgery (36 patients) for recurrent uncomplicated diverticulitis were contacted and assessed for quality of life. The mean difference in quality of life scores was greater after surgery (overall + 2.14%, laparoscopic resection +4.95%, p = 0.36 and p = 0.11, respectively) as compared to conservative management. Female patients undergoing laparoscopic resection had statistically significantly higher quality of life scores than women treated conservatively (+8.98%; p = 0.049). Twenty-eight of 29 responding patients stated that they were highly satisfied and would have the operation done again. Elective sigmoidectomy is a valid treatment option for recurrent uncomplicated diverticulitis in terms of quality of life. Quality of life improved most if surgery was performed laparoscopically, especially in women.

Acute diverticulitis: Key features for guiding clinical management

Diverticular disease of the colon and small bowel is an important cause of pathology leading to emergency department visits and urgent gastrointestinal surgery. CT is a highly sensitive and specific modality for the diagnosis of acute diverticulitis and its complications as well as for the exclusion of alternate causes of pathology. Ultrasound, MRI and virtual CT colonoscopy have important adjunct roles for screening and workup of complications in specific patient populations. While diverticular disease most commonly involves the descending and sigmoid colon, it can also affect the proximal colon and small bowel. Acute diverticulitis may be categorized as uncomplicated or complicated according to the degree of inflammatory changes and related complications it induces, although some degree of overlap exists in clinical practice. Uncomplicated diverticulitis is classically characterized by localized inflammation surrounding a diverticulum ranging from wall thickening and phlegmonous change to the development of small, localized pericolic abscesses. Complicated forms of disease manifest with larger pericolic and distant abscesses, fistulae to adjacent organs, perforation, and peritonitis. Recurrent episodes of diverticulitis may lead to muscular hypertrophy of the bowel wall and luminal narrowing, potentially leading to bowel obstruction. Several imaging features may help to differentiate diverticulitis from colonic malignancy, however this remains a diagnostic imaging challenge that often requires further evaluation with colonoscopy. In this review, we discuss the pathophysiology and key imaging features of acute diverticulitis and its complications. We explore both common and uncommon presentations of the disease involving the colon and small bowel, acute and chronic manifestations of disease, and pitfalls to recognize when imaging alone may be insufficient to distinguish benign from malignant.

Influence of obesity on the risk of recurrent acute diverticulitis

BACKGROUND

Acute diverticulitis (AD) is a common surgical problem with increasing incidence. Obesity has become epidemic in western countries. Obesity has been shown to increase the risk of developing AD; however, little is known about its influence on the risk of recurrence. The decision to perform elective surgical resection to reduce the risk of recurrent AD is made on an individual basis considering perceived risk of recurrence weighed against patient comorbidity. The aim of this study is to assess whether obesity affects the likelihood of developing recurrent AD.

METHODS

A retrospective audit was conducted of all admissions with AD to a tertiary centre between 1998 and 2010. Medical records were reviewed and patients with an index presentation with AD included in the analysis. Imaging was used to calculate body mass index (BMI) for assessment of obesity. Follow-up was for a minimum of 3 years from admission.

RESULTS

A total of 1299 patients were admitted with an index presentation of AD in the study period. 18.3% overall had recurrent AD, all of whom had confirmation on imaging. Computed tomography was used to calculate BMI in 849 patients, of whom 470 (55.4%) were considered obese (BMI >30). The likelihood of recurrent AD was not significantly different in obese patients compared to their non-obese counterparts (P = 0.2473).

CONCLUSION

While obesity increases the risk of developing AD overall, it does not appear to increase the likelihood of developing recurrent AD. This has implications for risk stratification when considering surgical resection to prevent recurrent AD.

Prospective evaluation of functional outcomes after laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery for diverticular disease in consecutive male patients

BACKGROUND

To date, there has been no consensus concerning the vascular approach during sigmoid colectomy for diverticular disease. The aim of this study was to determine the functional impact of elective laparoscopic sigmoidectomy performed with high ligation of the inferior mesenteric artery for diverticulitis in consecutive male patients.

METHODS

Twenty-five consecutive patients of median age 53 years were enrolled in a prospective single-centre pilot study at a tertiary teaching hospital. Main outcome measures were functional results. Patients were asked to complete standardized, validated questionnaires to evaluate preoperative and 6 months postoperative bowel symptomatology (Jorge-Wexner Incontinence Score and KESS score), urinary function (IPSS), and sexual function (IIEF). Secondary outcomes were surgical data, morbidity, and quality of life (SF-36).

RESULTS

There were no significant differences between preoperative and 6 months postoperative total scores for bowel symptomatology, urinary function, and sexual function. There were no perioperative deaths. The morbidity rate was 12% including three minor and no major events. Quality of life demonstrated statistically better general health (p < 0.01) and better medical status over the prior 4 weeks at 6 months after surgery, compared to baseline. This single-centre prospective study has a limited number of patients, relatively short follow-up time, and includes only male patients.

CONCLUSION

Laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery for diverticular disease does not induce functional disorders at 6 months after surgery. The benefit of the operation for quality of life is even greater for general health and medical status.

Complicated diverticulitis mimicking colonic carcinoma: combined approach with endoscopy and budesonide

Complicated diverticulitis is an uncommon endoscopic finding. We report an unusual case of complicated diverticulitis in a 53-year-old man suffering from chronic constipation, abdominal pain and a recent episode of subocclusion. He underwent to colonoscopy that showed left-sided diverticulosis and a 3 cm irregular mass in the sigmoid. During biopsy sampling due to the suspect of colonic carcinoma, pus and bleeding came out from the lesion. After lavage, a large diverticulum with visible vessel at the bottom was found, which was clipped with stopping bleeding. After a short course of in-hospital treatment, at discharging the patient was treated with budesonide MMX9 mg/day for 8 weeks. At that time, colonoscopy did not show sign of diverticular inflammation, and inflammatory indexes were normal. This case demonstrates that the use of a topical steroid, combined with an endoscopic approach, may easily resolve an unusual endoscopic complication in patients suffering from complicated diverticular disease.

Role of Inflammation in the Pathogenesis of Diverticular Disease

Diverticulosis of the colon is the most common condition in Western societies and it is the most common anatomic alteration of the human colon. Recurrent abdominal pain is experienced by about 20% of patients with diverticulosis, but the pathophysiologic mechanisms of its occurrence are not completely understood. In the last years, several fine papers have showed clearly the role of low-grade inflammation both in the occurrence of symptoms in people having diverticulosis, both in symptom persistence following acute diverticulitis, even if the evidence available is not so strong. We do not know yet what the trigger of this low-grade inflammation occurrence is. However, some preliminary evidence found colonic dysbiosis linked to low-grade inflammation and therefore to symptom occurrence in those patients. The aim of this paper is to summarize current evidences about the role of inflammation in symptom occurrence in symptomatic uncomplicated diverticular disease and in symptom persistence after an episode of acute diverticulitis.

Recurrent Acute Diverticulitis: When to Operate?

Objective

Recurrent acute diverticulitis carries a major burden to any form of health care. Patients present repeatedly to medical centers with a multitude of symptoms and may require different modalities of treatment with significant morbidities and impact on quality of life.

Methods

We therefore wanted to identify factors that would imply the need and time of surgery versus conservative management. The literature was thoroughly searched for major studies tackling this topic. Furthermore, studies reporting on decision making based on quality of life were included. Risks of developing recurrent diverticulitis and the potential need of surgery were identified. Relevant surgical details that would decrease recurrence were also denoted.

Results

Surgery has been the mainstay of treatment for quite some time. However, the paradigms of treatment have changed over the last few years, especially when long-term population studies confirmed that not all patients require surgical treatment with its associated risk of morbidity.

Conclusion

Treatment now has to be patient-tailored with special attention to the subgroup of high-risk patients. These patients must be adequately selected, identifying the impact of the disease on the quality of life and weighing in the risks of the surgical intervention.

Specific Factors Predict the Risk for Urgent and Emergent Colectomy in Patients Undergoing Surgery for Diverticulitis

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.

Diverticulosis today

The incidence of diverticulosis and diverticular disease of the colon is increasing worldwide. Although the majority of patients remains asymptomatic long-life, the prevalence of diverticular disease of the colon, including acute diverticulitis, is substantial and is becoming a significant burden on National Health Systems in terms of direct and indirect costs. Fiber, non-absorbable antibiotics and probiotics seem to be effective in treating symptomatic and uncomplicated patients, and 5-aminosalicylic acid might help prevent acute diverticulitis. Unfortunately, robust evidence on the effectiveness of a medical strategy to prevent acute diverticulitis recurrence is still lacking. Focus is now being drawn on identifying a new endoscopic classification of the disease to evaluate the correct therapeutic approach by testing various treatments.

Trends in hospital admission for acute diverticulitis in Italy from 2008 to 2015

BACKGROUND

Epidemiological studies in Western countries have documented an increase of hospitalizations for acute diverticulitis (AD) but Italian evidence is scarce. The aim of the present study was to analyse the trend in hospitalization for AD, including in-hospital mortality, in Italy from 2008 to 2015.

METHODS

Through the Italian Hospital Information System of the National Health System, we identified diverticulitis of the colon as a discharge diagnosis. Age- and gender-specific rates of hospitalization for AD were assessed.

RESULTS

174,436 hospitalizations were identified with an increasing rate in 2008-2015 from 39 to 48 per 100,000 inhabitants (p < 0.001). The rate of hospitalization was higher for women, but the increasing trend over time was even more pronounced among men (mean increase per year 3.9% and 2.1% among men and women, respectively) (p < 0.001). The increased rate of hospitalization was accounted for by patients less than 70 years old, especially those under 60. In contrast, the hospitalization rate for older patients (age ≥ 70 years) was higher but remained unchanged during the study period. The number of patients with one hospital admissions was significantly higher than the number of patients with at least two hospitalizations (p < 0.001) and both groups showed a significant and comparable increase year by year. The overall in-hospital mortality rate increased from 1.2 to 1.5% (p = 0.017). More specifically, the increase was observed in patients at their first hospitalization [from 1 to 1.4% (mean increase per year of 3%, p = 0.003)]. An increase in mortality was most evident among women (from 1.4 to 1.8% p = 0.025) and in older patients [age 70-79 years from 1.2 to 1.7% (p = 0.034), ≥ 80 years from 2.9 to 4% (p = 0.001)].

CONCLUSIONS

In Italy, between 2008 and 2015, the rate of hospitalization for AD has been constantly increasing due to the hospitalization of younger individuals, especially men. There was a significant increase of in-hospital mortality especially among women, elderly and during the first hospitalization. These findings suggest the need for increased awareness and clinical skills in the management of this common condition.

Surgical Management of Diverticular Disease in the Elective Setting

Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.

Evaluation of Quality of Life and Surgical Outcomes for Treatment of Diverticular Disease

The prevalence of diverticular disease in the Western and industrialized nations has increased over the last century, and our understanding of this disease and its management continues to evolve. In this article, we review the literature regarding the postoperative quality of life (QOL) and functional outcomes following surgical management of diverticulitis, including information regarding bowel function, recurrence of symptoms, and other postoperative sequelae. While objective parameters, such as attacks of diverticulitis, complications, and clinical episodes have been studied, there is a paucity of data on less objective factors, such as overall patient satisfaction after operative management of diverticular disease. The literature shows improvement in QOL following surgical intervention for diverticulitis if preoperative QOL was significantly low, secondary to severe/complicated diverticulitis. However, a subset of patients does continue to have symptoms following surgical intervention for diverticulitis. Often neglected in the literature, there remains a need for prospective data evaluating preoperative function to ascertain the impact of surgery on patients' QOL and postoperative function.

Risk of Recurrent Disease and Surgery Following an Admission for Acute Diverticulitis

BACKGROUND

Diverticular disease accounts for significant morbidity and mortality and may take the form of recurrent episodes of acute diverticulitis. The role of elective surgery is not clearly defined.

OBJECTIVE

This study aimed to define the rate of hospital admission for recurrent acute diverticulitis and risk factors associated with recurrence and surgery.

DESIGN

This is a retrospective population-based cohort study.

SETTINGS

National Health Service hospital admissions for acute diverticulitis in England between April 2006 and March 2011 were reviewed.

PATIENTS

Hospital Episode Statistics data identified adult patients with the first episode of acute diverticulitis (index admission), and then identified recurrent admissions and elective or emergency surgery for acute diverticulitis during a minimum follow-up period of 4 years. Exclusion criteria included previous diagnoses of acute diverticulitis, colorectal cancer, or GI bleeding, and prior colectomy or surgery or death during the index admission.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

The primary outcomes measured were recurrent admissions for acute diverticulitis and patients requiring either elective or emergency surgery during the study period.

RESULTS

Some 65,162 patients were identified with the first episode of acute diverticulitis. The rate of hospital admission for recurrent acute diverticulitis was 11.2%. A logistic regression model examined factors associated with recurrent acute diverticulitis and surgery: patient age, female sex, smoking, obesity, comorbidity score >20, dyslipidemia, and complicated acute diverticulitis increased the risk of recurrent acute diverticulitis. There was an inverse relationship between patient age and recurrence. Similar factors were associated with elective and emergency surgery.

LIMITATIONS

The cases of acute diverticulitis required inpatient management and the use of Hospital Episode Statistics, relying on the accuracy of diagnostic coding.

CONCLUSIONS

This is the largest study assessing the rates of hospital admission for recurrent acute diverticulitis. Knowledge of the rate and risk factors for recurrent acute diverticulitis is required to aid discussion and decision making with patients regarding the need and timing of elective surgery. Some factors associated with recurrence are modifiable; therefore, weight reduction and smoking cessation can be championed. See Video Abstract at http://links.lww.com/DCR/A449.

Mesalamine (5-ASA) for the prevention of recurrent diverticulitis

BACKGROUND

Diverticular disease is a common condition that increases in prevalence with age. Recent theories on the pathogenesis of diverticular inflammation have implicated chronic inflammation similar to that seen in ulcerative colitis. Mesalamine, or 5-aminosalicylic acid (5-ASA), is a mainstay of therapy for individuals with ulcerative colitis. Accordingly, 5-ASA has been studied for prevention of recurrent diverticulitis.

OBJECTIVES

To evaluate the efficacy of mesalamine (5-ASA) for prevention of recurrent diverticulitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), in the Cochrane Library; Ovid MEDLINE (from 1950 to 9 September 2017); Ovid Embase (from 1974 to 9 September 2017); and two clinical trials registries for ongoing trials - Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform database (9 September 2017).We also searched proceedings from major gastrointestinal conferences - Digestive Disease Week (DDW), United European Gastroenterology Week (UEGW), and the American College of Gastroenterology (ACG) Annual Scientific Meeting - from 2010 to September 2017. In addition, we scanned reference lists from eligible publications, and we contacted corresponding authors to ask about additional trials.

SELECTION CRITERIA

We included randomised controlled clinical trials comparing the efficacy of 5-ASA versus placebo or another active drug for prevention of recurrent diverticulitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as defined by Cochrane. Three review authors assessed eligibility for inclusion. Two review authors selected studies, extracted data, and assessed methodological quality independently. We calculated risk ratios (RRs) for prevention of diverticulitis recurrence using an intention-to-treat principle and random-effects models. We assessed heterogeneity using criteria for Chi2 (P < 0.10) and I2 tests (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR vs odds ratio (OR)) and meta-analytical models (fixed-effect vs random-effects).

MAIN RESULTS

We included in this review seven studies with a total of 1805 participants. We judged all seven studies to have unclear or high risk of bias. Investigators found no evidence of an effect when comparing 5-ASA versus control for prevention of recurrent diverticulitis (31.3% vs 29.8%; RR 0.69, 95% confidence interval (CI) 0.43 to 1.09); very low quality of evidence).Five of the seven studies provided data on adverse events of 5-ASA therapy. The most commonly reported side effects were gastrointestinal symptoms (epigastric pain, nausea, and diarrhoea). No significant difference was seen between 5-ASA and control (67.8% vs 64.6%; RR 0.98, 95% CI 0.91 to 1.06; P = 0.63; moderate quality of evidence), nor was significant heterogeneity observed (I2 = 0%; P = 0.50).

AUTHORS' CONCLUSIONS

The effects of 5-ASA on recurrence of diverticulitis are uncertain owing to the small number of heterogenous trials included in this review. Rates of recurrent diverticulitis were similar among participants using 5-ASA and control participants. Effective medical strategies for prevention of recurrent diverticulitis are needed, and further randomised, double-blinded, placebo-controlled trials of rigorous design are warranted to specify the effects of 5-ASA (mesalamine) in the management of diverticulitis.

Surgical treatment of uncomplicated diverticulitis in Switzerland: comparison of population-based data over two time periods

AIM

The standard of care for acute uncomplicated diverticulitis used to be an elective colon resection after the second or third episode. This practice was replaced by a more conservative and individualized approach. This study investigates current surgical practice in the treatment of acute uncomplicated diverticulitis in Switzerland.

METHOD

Retrospective cross-sectional analysis of all hospital admissions due to uncomplicated diverticulitis in Switzerland using prospectively collected data from the Swiss Federal Statistical Office in two periods: 2004/2005 and 2010/2011. Treatment options were compared between the two periods with adjustment for baseline characteristics of patients and treating institutions.

RESULTS

A total of 24 497 patients (11 835 in 2004/2005; 12 662 in 2010/2011) were admitted to Swiss hospitals for uncomplicated diverticulitis. Between periods, the incidence increased from 81 to 85 admissions per 10⁵ inhabitants per year. Elective admissions decreased from 46% (n = 5490) to 34% (n = 4294). The unadjusted resection rate decreased from 40% (n = 4730) to 34% (n = 4308). In the adjusted analysis, inpatients were more likely to have a resection in 2010/2011 than in 2004/2005 [odds ratio of 1.38 (95% confidence interval 1.25-1.54)]. In addition, private insurance, elective mode of admission and younger age increased the odds for resection while there was no evidence of an association between resection and either gender or comorbidities.

CONCLUSION

The probability of colon resection for patients hospitalized with acute uncomplicated diverticulitis increased between periods while the overall number of colon resections declined. A change of practice expected given the paradigm shift towards conservative treatment could not be confirmed in this analysis.

Laparoscopic peritoneal lavage or surgical resection for acute perforated sigmoid diverticulitis: A systematic review and meta-analysis

BACKGROUND

Laparoscopic peritoneal lavage (LPL) has been proposed as an alternative, less invasive technique in the treatment of acute perforated sigmoid diverticulitis (APSD). The aim of this meta-analysis is to compare the effectiveness of LPL versus surgical resection (SR) in terms of morbidity and mortality in the management of APSD.

METHODS

A comprehensive search was conducted for randomised controlled trials (RCTs) comparing LPL versus SR in the treatment of APSD. The end points included peri-operative mortality, severe adverse events, overall mortality, post-operative abscess, percutaneous reinterventions, reoperation, operative time, postoperative stay, and readmissions.

RESULTS

Three RCTs with a total of 372 patients, randomised to either LPL or SR were included. There was no significant difference in peri-operative mortality between LPL and SR (OR 1.356, 95% CI 0.365 to 5.032, p = 0.649), or serious adverse events (OR = 1.866, 95% CI = 0.680 to 5.120, p = 0.226). The LPL required significantly less time to complete than SR (WMD = -72.105, 95% CI = -88.335 to -55.876, p < 0.0001). The LPL group was associated with a significantly higher rate of postoperative abscess formation (OR = 4.121, 95% CI = 1.890 to 8.986, p = 0.0004) and subsequent percutaneous interventions (OR = 5.414, 95% CI 1.618 to 18.118, p = 0.006).

CONCLUSION

Laparoscopic peritoneal lavage is a safe and quick alternative in the management of APSD. In comparison to SR, LPL results in higher rates of postoperative abscess formation requiring more percutaneous drainage interventions without any difference in perioperative mortality and serious morbidity.

Diagnosis and management of right colonic diverticular disease: A review

The aim of this narrative review is to define the clinical-pathological characteristics and to clarify the management of right colonic diverticular disease. It is rare in Europe, USA and Australia and more common in Asia. In the recent years its incidence has increased in the West, with various distributions among populations. Many studies have reported that it is difficult to differentiate the presenting symptoms of this disease from those of appendicitis before surgery, because the signs and symptoms are similar, so misdiagnosis is not infrequent. With accurate imaging studies it is possible to reach a precise preoperative diagnosis, in order to assess an accurate treatment strategy. Currently the management of this disease is not well defined, no clear guidelines have been proposed and it is not known whether the guidelines for left colonic diverticular disease can also be applied for it. Several authors have stated that conservative management is the best approach, even in case of recurrence, and surgery should be indicated in selected cases.

When Should We Operate for Recurrent Diverticulitis?

Recent guidelines on elective surgery for recurrent diverticulitis have removed generalized recommendations for elective preventive surgery and advice individualized decision per patient. We discuss the clinical evidence and potential use of risk factors to help with decision-making for patient selection for elective surgery in the presence of a history of diverticulitis.

Myths and Evidences in Diverticular Disease

Diverticular disease is a very common entity affecting the elders, but also a few people in the young age group. Most patients are asymptomatic, but about 30% of them will have abdominal complaints. As the pathophysiology of diverticular disease has changed since its description, we address some important points about the disease. Recent knowledge has changed the way we treat the patients with diverticular disease: conservatively or surgically.

Long-term Outcomes of Elective Surgery for Diverticular Disease: A Call for Standardization

To date, the appropriate management of diverticular disease is still controversial. The American Society of Colon and Rectal Surgeons declared that the decision between conservative or surgical approach should be taken by a case-by-case evaluation. There is still lack of evidence in literature about long-term outcomes after elective sigmoid resection for diverticular disease. Considering the potentially key role of the surgical technique in long-term outcomes, there is the need for surgeons to define strict rules to standardize the surgical technique. Currently there are 5 areas of debate in elective surgery for diverticular disease: laparoscopic versus open approach, the site of the proximal and distal colonic division, the vascular approach and the mobilization of the splenic flexure. The purpose of this paper is to review existing knowledge about technical aspects, which represent how the surgeon is able to affect the long-term results.

Acute colonic diverticulitis: an update on clinical classification and management with MDCT correlation

Currently, the most commonly used classification of acute colonic diverticulitis (ACD) is the modified Hinchey classification, which corresponds to a slightly more complex classification by comparison with the original description. This modified classification allows to categorize patients with ACD into four major categories (I, II, III, IV) and two additional subcategories (Ia and Ib), depending on the severity of the disease. Several studies have clearly demonstrated the impact of this classification for determining the best therapeutic approach and predicting perioperative complications for patients who need surgery. This review provides an update on the classification of ACD along with a special emphasis on the corresponding MDCT features of the different categories and subcategories. This modified Hinchey classification should be known by emergency physicians, radiologists, and surgeons in order to improve patient care and management because each category has a specific therapeutic approach.

Management of sigmoid diverticulitis: an update

The role, indications and modalities of elective resection for sigmoid diverticulitis remain the cause of fierce debate. During the past two decades clinicians have increasingly recognized that: (1) young patients (<50) are no more at risk to develop more aggressive course of the disease; and (2) patients who present initially with a first uncomplicated attack are no more at risk for developing subsequent complicated diverticulitis requiring emergency surgery. Hence, the previously well-recognized indications (based upon age of the patients or the number of attacks) are no longer valid. Yet, the number of sigmoid resections performed for diverticulitis in industrialized countries is increasing, which seems to indicate that in many cases, uncomplicated sigmoid diverticulitis progressively evolves towards a chronic symptomatic condition, which significantly impacts upon the patients' quality of life. The aims of this review are twofold: (1) to identify which disease presentation still represents good indications for elective laparoscopic sigmoid resection; and (2) to summarize the technical aspects of surgery for a benign condition, such as diverticular disease.