Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis

Short- and long-term outcomes of acute diverticulitis in patients with transplanted kidneys

AIM

The safety of nonoperative treatment for patients with transplanted kidneys who develop acute diverticulitis is unclear. Our primary aim was to examine the long-term sequelae of nonoperative management in this group.

METHOD

We performed a population-based retrospective cohort study using linked administrative databases housed at ICES in Ontario, Canada. We included adult (≥18 years) patients admitted with acute diverticulitis between April 2002 and December 2019. Patients with a functioning kidney transplant were compared with those without a transplant. The primary outcome was failure of conservative management (operation, drainage procedure or death due to acute diverticulitis) beyond 30 days. The cumulative incidence function and a Fine-Grey subdistribution hazard model were used to evaluate this outcome accounting for competing risks.

RESULTS

We examined 165 patients with transplanted kidneys and 74 095 without. Patients with transplanted kidneys were managed conservatively 81% of the time at the index event versus 86% in nontransplant patients. Short-term outcomes were comparable, but cumulative failure of conservative management at 5 years occurred in 5.6% (95% CI 2.3%-11.1%) of patients with transplanted kidneys versus 2.1% (95% CI 2.0%-2.3%) in those without. Readmission for acute diverticulitis was also higher in transplanted patients at 5 years at 16.7% (95% CI 10.1%-24.7%) versus 11.6% (95% CI 11.3%-11.9%). Adjusted analyses showed increased failure of conservative management [subdistribution hazard ratio (sHR) 3.24, 95% CI 1.69-6.22] and readmissions (sHR 1.55, 95% CI 1.02-2.36) for patients with transplanted kidneys.

CONCLUSION

Most patients with transplanted kidneys are managed conservatively for acute diverticulitis. Although long-term readmission and failure of conservative management is higher for this group than the nontransplant population, serious outcomes are infrequent, substantiating the safety of this approach.

Comparison Between Primary Anastomosis Without Diverting Stoma and Hartmann's Procedure for Colorectal Perforation: A Retrospective Observational Study

Background Hartmann's procedure (HP) is performed for colorectal perforation to avoid the risk of anastomotic leakage. Few reports have compared the safety between primary anastomosis without diverting stoma (PAWODS) and HP for colorectal perforation, and whether PAWODS or HP should be performed has remained controversial. We aimed to investigate the feasibility and safety of performing PAWODS in comparison to HP for colorectal perforation. Methods The data of 97 consecutive patients with colorectal perforation who underwent surgery from April 2010 to December 2020 were collected retrospectively. PAWODS and HP were performed in 51 and 46 patients, respectively. Univariate and multivariate analyses were performed to compare the clinical characteristics and postoperative outcomes of patients treated with PAWODS with those treated with HP. Results In the multivariate analysis, low serum albumin (hazard ratio (HR)=3.49; 95%CI=1.247-9.757; P=0.017) and left-sided colon and rectum perforation (HR=16.8; 95%CI=1.792-157.599; P=0.014) were significantly associated with the decision to perform HP. There was a significant difference in the mortality of the two groups (PAWODS vs. HP: 0% vs. 8.7%; P=0.047). The severe morbidity rate (Clavien-Dindo III-V) was significantly higher in the HP group (PAWODS vs. HP: 10% vs. 30%; P=0.020). In the PAWODS group, anastomotic leakage occurred in five of 51 patients (9.8%), four (8.7%) of whom required re-operation. Conclusions In appropriately selected patients, PAWODS could be safely performed with an acceptable rate of anastomotic leakage. The serum albumin level and site of perforation may be simple and useful factors for guiding decision-making on the surgical procedure.

Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis

INTRODUCTION

While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes.

METHODS

Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay.

RESULTS

The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference.

CONCLUSIONS

There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.

Diverticular disease: update on pathophysiology, classification and management

Colonic diverticulosis is prevalent, affecting approximately 70% of the western population by 80 years of age. Incidence is rapidly increasing in younger age groups. Between 10% and 25% of those with diverticular disease (DD) will experience acute diverticulitis. A further 15% will develop complications including abscess, bleeding and perforation. Such complications are associated with significant morbidity and mortality and constitute a worldwide health burden. Furthermore, chronic symptoms associated with DD are difficult to manage and present a further significant healthcare burden. The pathophysiology of DD is complex due to multifactorial contributing factors. These include diet, colonic wall structure, intestinal motility and genetic predispositions. Thus, targeted preventative measures have proved difficult to establish. Recently, commonly held conceptions on DD have been challenged. This review explores the latest understanding on pathophysiology, risk factors, classification and treatment options.

Is the Hartmann's procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 2018

BACKGROUND

Historically, Hartmann's procedure (HP) has been the operation of choice for diverticulitis in the emergency setting. However, recent evidence has demonstrated the safety of primary anastomosis (PA) with or without diverting ileostomy. The purpose of this study was to evaluate the trends of, and factors associated with, HP compared to PA in emergency surgery for diverticulitis over 25 years.

METHODS

Using the National Inpatient Sample database, we identified adult patients ≥ 18 years old who underwent emergency surgery for diverticulitis (HP or PA) between 1993 and 2018 using ICD-9 and ICD-10 codes. Patients with inflammatory bowel disease, gastrointestinal cancer or who underwent elective diverticulitis surgery were excluded. Trends in HP were analyzed using multivariable linear regression, and factors associated with HP were assessed with multiple logistic regression.

RESULTS

Of 499,433 patients who underwent colectomy in the emergency setting for acute diverticulitis, 271,288 (54.3%) had a HP and 228,145 (45.7%) had a PA. Median age was 61 years (IQR: 50-73), 53% were women, and 70.5% were white. The proportion of HP slightly increased over the study period-HP comprised 52.6% of included cases in 1993-98 and 55.2% of cases in 2014-2018 (p = 0.017). Advanced age (reference = 18-44 years; 45-54 years: OR 1.16, 95% CI 1.10-1.22; 55-64 years: OR 1.26, 95% CI 1.20-1.33; 65-74 years: OR 1.33, 95% CI 1.25-1.42; ≥ 75 years: OR 1.51, 95% CI 1.41-1.62), complicated diverticulitis (OR 1.41, 95% CI 1.36-1.46), and severity of illness (reference = minor; moderate: OR 1.46, 95% CI 1.38-1.54; major/extreme: OR 3.43, 95% CI 3.25-3.63) were associated with increased odds of HP.

CONCLUSIONS

Over a 26-year period, HP has remained the most performed procedure in the emergency setting for diverticulitis. Future work should focus on knowledge translation with a possible change in practice as more randomized controlled trials provide support for PA.

Platelet to lymphocyte ratio is a risk factor for failure of non-operative treatment of colonic diverticulitis

Non-operative treatment is the mainstay of colonic diverticulitis, but some patients require surgery due to non-operative treatment failure. This study aims to identify risk factors for the failure of non-operative treatment of colonic diverticulitis. From January 2011 to December 2020, we retrospectively reviewed 2362 patients with non-operative treatment for first-attack acute diverticulitis. Patients were categorized into non-operative treatment success or failure groups. Clinical characteristics and serum inflammatory markers were analyzed by multivariable logistic regression to determine risk factors for non-operative treatment failure of colonic diverticulitis. Overall, 2.2% (n = 50) of patients underwent delayed surgery within 30 days (median 4.0 [3.0; 8.0]) due to non-operative treatment failure. Multivariable logistic regression identified that platelet to lymphocyte ratio (odds ratio [OR], 4.2; 95% confidence interval [CI], 0.05-0.13; p < 0.001), diabetes mellitus (OR, 2.2; 95% CI, 0.01-0.09; p = 0.025), left-sided colonic diverticulitis (OR, 4.1; 95% CI, 0.04-0.13; p < 0.001), and modified Hinchey classification (OR, 6.2; 95% CI, 0.09-0.17; p < 0.001) were risk factors for non-operative treatment failure. Platelet to lymphocyte ratio (PLR) is a potential risk factor for the non-operative treatment failure of acute first-attack colonic diverticulitis. Therefore, patients with higher PLR during non-operative treatment should be monitored with special caution.

Defining diverticular fistula through inpatient admissions: a population study

BACKGROUND

Diverticular fistula, a pathologic connection from the colon to the skin or another organ, is an uncommon sequela of diverticular disease. It is generally considered an indication for surgery. The current literature is limited in terms of defining the epidemiology of this disease process. This analysis defines the demographics of fistulous diverticular disease on a national level.

METHODS

A retrospective review of the 2018 National Inpatient Sample (NIS) was conducted, using ICD-10 codes for diverticular disease, diverticular-associated fistulas, and associated surgeries. Demographic factors were compared between groups, and several sub-group analyses were performed.

RESULTS

A total of 7,105,498 discharges were recorded: 119,115 (1.68%) with non-fistulizing diverticular disease and 3,843 (0.05%) with diverticular fistula. Patients with diverticular fistula were more likely to be younger (64.7 v 68.2 years, p < .0001) and female (57.3% v 55.4%, p = 0.028) than patients with non-fistulizing disease. They were also more likely to undergo surgery (64.9% v 25.7%, p < .0001), to be admitted electively (44.7% v 12.0%, p < .0001), and to have a longer length of stay (LOS) (mean 8.07 v 5.20 days, p < .0001). Diverticular fistula patients that underwent surgery were more likely to be male (44.8% v 39.0%, p = 0.003), to be admitted electively (65.3% v 6.7%, p < .0001), and to have longer LOS (mean 8.74 v 6.81 days, p < .0001) than those who received medical treatment alone.

CONCLUSION

Diverticular fistula is a rare diagnosis, accounting for 0.05% of total admissions and 3.12% of admissions for diverticular disease. However, this is more common than the previously reported rate of < 0.1% of diverticular disease admissions. While surgery is generally indicated for diverticular fistula, only 64.9% of patients underwent surgical treatment. Although this study is limited by its retrospective nature and use of administrative data, our findings elucidate the prevalence and patterns of inpatient admissions for diverticular fistula in the United States.

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.

Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

Background

This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.

Methods

Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.

Results

Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.

Conclusion

Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Graphical abstract

Role of protective stoma after primary anastomosis for generalized peritonitis due to perforated diverticulitis-DIVERTI 2 (a prospective multicenter randomized trial): rationale and design (nct04604730)

Background

Traditionally, patients with peritonitis Hinchey III and IV due to perforated diverticulitis were treated with Hartmann’s procedure. In the past decade, resection and primary anastomosis have gained popularity over Hartmann’s procedure and recent guidelines recommend Hartmann’s procedure in two situations only: critically ill patients and in selected patients with multiple comorbidity (at high risk of complications).

The protective stoma (PS) is recommended after resection with primary anastomosis, however its interest has never been studied. The aim of this trial is to define the role of systematic PS after resection and primary anastomosis for peritonitis Hinchey III and IV due to perforated diverticulitis.

Methods/design

This DIVERTI 2 trial is a multicenter, randomized, controlled, superiority trial comparing resection and primary anastomosis with (control group) or without (experimental group) PS in patients with peritonitis Hinchey III and IV due to perforated diverticulitis.

Primary endpoint is the overall 1 year morbidity according to the Clavien–Dindo classification of surgical complications. All complications occurring during hospitalization will be collected. Late complications occurring after hospitalization will be collected during follow-up.

In order to obtain 80% power for a difference given by respective main probabilities of 67% and 47% in the protective stoma and no protective stoma groups respectively, with a two-sided type I error of 5%, 96 patients will have to be included in each group, hence 192 patients overall. Expecting a 5% rate of patients not assessable for the primary end point (lost to follow-up), 204 patients will be enrolled.

Secondary endpoints are postoperative mortality, unplanned reinterventions, incisional surgical site infection (SSI), organ/space SSI, wound disruption, anastomotic leak, operating time, length of hospital stay, stoma at 1 year after initial surgery, quality of life, costs and quality-adjusted life years (QALYs).

Discussion

The DIVERTI 2 trial is a prospective, multicenter, randomized, study to define the best strategy between PS and no PS in resection and primary anastomosis for patients presenting with peritonitis due to perforated diverticulitis.

Trial registration

ClinicalTrial.gov: NCT04604730 date of registration October 27, 2020. https://clinicaltrials.gov/ct2/show/NCT04604730?recrs=a&cond=Diverticulitis&draw=2&rank=12.

Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or fecal peritonitis: Three-year follow-up of a randomised controlled trial

BACKGROUND

The aim of the present study is to present the three years follow-up a randomised controlled trial that compared Hartmann's Procedure (HP) with sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy) (PA) in a randomised design to determine the optimal treatment strategy for perforated diverticulitis with purulent or fecal peritonitis.

METHODS

Data were prospectively gathered for the first 12 months after randomization and retrospectively collected up to 36 months. The primary long-term endpoint was stoma free rate 36 months after the index procedure. Secondary outcomes were patients with a stoma at 36 months, percentage of stoma reversals, related reinterventions, parastomal/incisional hernia rates, total in hospital days including all readmissions regardless their relation to the intervention, overall morbidity and mortality.

RESULTS

Three years follow-up was completed in 119 of the originally 130 included patients, with 57 (48%) in the PA-group and 62 (52%) patients in the HP-group. 36 months stoma free rate was significantly better for patients undergoing PA compared with HP (PA 92% vs HP 81%, hazard ratio 2.326 [95% CI 1.538-3.517]; log-rank p < 0·0001). Stoma reversal rates did not significantly differ (PA 31/40(78%) versus HP 45/61(74%), p = 0.814). Overall cumulative morbidity (PA 21/57(36%) versus HP 30/62(48%), p = 0.266) and mortality (PA 6/57(11%) versus HP 7/62 (11%), p = 1.000) did not differ between groups. However, more parastomal hernias occurred in the HP-group (HP 10/62(16%) vs PA 1/57(2%), p = 0.009) and the mean total in hospital days after three years follow-up was significantly lower in the PA-group compared to the HP-group (PA 14 days (IQR 9.5-22.5) versus HP 17 days (IQR 12.5-27.5)), p = 0.025).

CONCLUSION

Long-term results showed that in haemodynamically stable, immunocompetent patients primary anastomosis is superior to Hartmann's procedure as treatment for perforated diverticulitis with respect to long-term stoma free rate, overall hospitalization and parastomal hernias.

Laparoscopic Colectomy for Acute Diverticulitis in the Urgent Setting is Associated with Similar Outcomes to Open

PURPOSE/BACKGROUND

The role of minimally invasive surgery (MIS) for the surgical treatment of diverticular disease is evolving. The aim of this study is to compare the outcomes of MIS colectomy to those of open surgery for patients with acute diverticulitis requiring urgent surgery.

METHODS

The American college of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing an urgent colectomy for acute diverticulitis between 2013 and 2018. The patients were then divided into 2 groups: MIS and open. Baseline characteristics and short-term outcomes were compared using univariable and multivariable regression analyses.

RESULTS/OUTCOMES

3487 patients were included in the analysis. Of these, 1272 (36.5%) underwent MIS colectomy and 2215 (63.5%) underwent open colectomy. Patients undergoing MIS colectomy were younger (58.7 vs 61.9 years) and less likely to be American Society of Anesthesiologists Classification (ASA) III (52.5 vs 57.9%) or IV (6.3 vs 10.5%). After adjusting for baseline differences, the odds of mortality for MIS and open groups were similar. While there was no difference in short-term complications between groups, the odds of developing an ileus were lower following MIS colectomy (OR .61, 95% CI: .49, .76). Both total length of stay (LOS) (12.3 vs 13.9 days) and post-operative LOS (7.6 days vs 9.5 days) were shorter for MIS colectomy. Minimally invasive surgery colectomy added an additional 40 minutes of operative time (202.2 vs 160.1 min).

CONCLUSION/DISCUSSION

Minimally invasive surgery colectomy appears to be safe for patients requiring urgent surgical management for acute diverticulitis. Decreased incidence of ileus and shorter LOS may justify any additional operative time for MIS colectomy in suitable candidates.

Long-term outcomes of Hartmann's procedure versus primary anastomosis for generalized peritonitis due to perforated diverticulitis: follow-up of a prospective multicenter randomized trial (DIVERTI)

BACKGROUND

Surgical management of Hinchey III and IV diverticulitis involves Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. These procedures were evaluated in four randomized controlled trials. Early results from these trials demonstrated similar rates of complications but higher rates of colonic restoration after PRA than HP. Long-term follow-up has not been reported to date. The aim of this study was to analyze long-term outcomes and quality of life (QoL) in patients previously enrolled in a prospective randomized trial comparing HP and PRA for generalized peritonitis due to perforated diverticulitis (DIVERTI trial).

STUDY DESIGN

Follow-up data were available for 78 of 102 patients. Demographic data, incisional hernia rate, need for additional surgery related to the primary procedure, and QoL were recorded.

RESULTS

The overall survival rate was 76% and did not differ between the two groups. Incisional hernia was reported in 21 (52%) patients in the HP arm and in 11 (29%) patients in the PRA arm (p = 0.035). The HP arm demonstrated significantly lower SF-36 physical and mental component scores. The mean general QoL (EQ-VAS) and mean EQ-5D index scores were better after PRA than after HP, but this difference was not statistically significant. The results of GIQLI, which measures intestine-specific QOL, did not differ between the two groups.

CONCLUSIONS

This follow-up study with a median follow-up time of > 9 years among living patients indicates that PRA for perforated diverticulitis is associated with fewer long-term complications and better QoL than HP. PRA significantly reduced the incisional hernia rate and the need for reoperation. Long-term survival was not jeopardized by the PRA approach. Future studies are needed to address the utility of protective stoma.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Diverticulitis Management, a Snapshot Collaborative Audit Study (DAMASCUS): Protocol for an international, multicentre, prospective observational study

AIM

Diverticular disease is an increasingly common problem in Western society with a variety of treatment options for those presenting with acute diverticulitis, dependent on clinical presentation. Additionally, there is significant international variability in the index management, and few published data on real-world clinical practice. The aim of DAMASCUS is to identify areas of practice variability and their potential association with differences in short- and medium-term clinical outcomes.

METHODS AND ANALYSIS

DAMASCUS is an international, collaborative, prospective observational study, recruiting patients from over 200 sites across six continents. The study opened in October 2020, with a rolling start. Identification of new sites ceased in February 2021 and data collection will cease in August 2021. All adult patients diagnosed with acute diverticulitis (radiologically or intra-operatively) at each participating centre will be included. The primary objective of DAMASCUS is to assess for national and international variability in the presentation and index management of acute diverticulitis (medical, interventional radiology and surgical). Secondary objectives include assessing 30-day and 6-month clinical outcome data (readmission, re-intervention, morbidity and mortality) and variations in surgical procedures for those undergoing surgery. All data will be recorded and managed using a secure REDCap electronic data capture tool and analysed using Stata (SE) version 16.1. The results will be reported in accordance with the STROBE statement.

CONCLUSION

By analysing variations in the management of acute diverticulitis and the subsequent outcomes, DAMASCUS will be an important step towards identifying optimal care for patients with diverticulitis.

Trends in emergent diverticular disease management: a nationwide cohort study from 2009 to 2018

BACKGROUND

Diverticular disease is a common disorder. Several guidelines report on its optimal management. The aim of this study was to describe the evolution of the prevalence of this disease, the treatment strategies, and the mortality rate on a national level.

METHODS

We conducted a retrospective study on prospective data using a nationwide database. All consecutive adult patients diagnosed with diverticular disease and admitted via the emergency department from 2009 to 2018 were included in the study. We performed a descriptive analysis for epidemiologic data, diagnosis, and treatment.

RESULTS

During the data collection period, 233,386 patients were included in the study. The number of admissions for emergent diverticular disease increased by 65.8%, from 16,754 in 2009 to 27,781 in 2018, for both uncomplicated and complicated diverticular disease. Among these patients, 19,350 (8.3%) were operated on. The rate of surgical treatment progressively decreased from 9.7% in 2009 to 7.6% in 2018. The three main interventions were Hartmann's procedure (HP, n = 9111, 47.1%), resection with primary anastomosis (RPA, n = 4335, 22.4%), and peritoneal lavage (PL, n = 4836, 25%). We observed a progressive annual increase in HPs (n = 716 in 2009 and n = 1055 in 2018) as well as a decline in PLs since 2015, while the number of RPAs remained stable.

CONCLUSIONS

Although admissions for emergent diverticular disease have increased during the study period, the rate of surgical treatment has decreased, suggesting an evolution toward more conservative management of this pathology.

Evaluation and Medical Management of Uncomplicated Diverticulitis

Uncomplicated diverticulitis is common, and its evaluation and treatment have evolved over time. Most patients present in a nontoxic manner with localized pain, leukocytosis, and reliable findings on computed tomography (CT). Healthy and stable patients are typically treated in the outpatient setting with very high rates of success. Recently, the necessity of antibiotic therapy has come into question, and several alternative agents have emerged, with the jury still out on their relative roles in diverticular disease. Currently, colonoscopy is still recommended after the resolution of an index episode of uncomplicated diverticulitis, and recurrence rates remain low. Several diet and lifestyle modifications have been shown to impact the rates of diverticulitis recurrence.

Elective surgery for diverticular disease in U.S. veterans: A VASQIP study of national trends and outcomes from 2004 to 2018

BACKGROUND

Treatment for diverticular disease has evolved over time. In the United States, there has been a trend towards minimally invasive surgical approaches and fewer postoperative complications, but no study has investigated this subject in the Veterans Health Administration.

METHODS

This retrospective review identified patients undergoing elective surgery for diverticular disease from 2004 to 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and 30-day outcomes were compared. The 15-year time period was divided into 3-year increments to assess changes over time.

RESULTS

4198 patients were identified. Complication rate decreased significantly over time (28.1%-15.7%, p < 0.001), as did infectious complications (21.5-6.3%, p < 0.001). Median hospital length-of-stay decreased from 7 to 5 days (p < 0.001). Rates of laparoscopic surgery increased over time (17.7%-48.1%, p < 0.001).

CONCLUSIONS

Increased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with fewer complications and a shorter length-of-stay. These trends mirror outcomes reported in non-veterans.

Prospectively Randomized Controlled Trial on Damage Control Surgery for Perforated Diverticulitis with Generalized Peritonitis

Introduction

Damage control surgery (DCS) with abdominal negative pressure therapy and delayed anastomosis creation in patients with perforated diverticulitis and generalized peritonitis was established at our Institution in 2006 and has been published. The concept was adopted in other hospitals and published as a case series. This is the first prospectively controlled randomized study comparing DCS and conventional treatment (Group C) in this setting.

Methods

All consecutive patients from 2013 to 2018 with indication for surgery were screened and randomized to Group DCS or Group C. The primary outcome was the rate of reconstructed bowel at discharge and at 6 month. Informed consent was obtained. The trial was approved by the local ethics committee and registered at CinicalTrials.gov: NCT04034407.

Results

A total of 56 patients were screened; 41 patients gave informed consent to participate and ultimately 21 patients (9 female) with intraoperatively confirmed Hinchey III (n = 14, 67%) or IV (n = 7, 33%), and a median (range) age of 66 (42–92), Mannheim Peritonitis Index of 25 (12–37) and Charlson Comorbidity Index of 3 (0–10) were intraoperatively randomized and treated as Group DCS (n = 13) or Group C (n = 8). Per protocol analysis: A primary anastomosis without ileostomy (PA) was performed in 92% (11/12) patients in Group DCS at the second-look operation, one patient died before second look, and one underwent a Hartmann procedure (HP). In Group C 63% (5/8) patients received a PA and 38% (3/8) patients a HP. Two patients in Group C, but none in Group DCS experienced anastomotic leakage (AI). ICU and hospital stay was median (range) 2 (1–10) and 17.5 (12–43) in DCS and 2 (1–62) and 22 (13–65) days in group C. In Group DCS 8% (1/12) patients was discharged with a stoma versus 57% (4/7) in Group C (p = 0.038, n.s., α = 0.025); one patient died before discharge. The odds ratio (95% confidence interval) for discharge with a stoma is 0.068 (0.005–0.861). Intent to treat analysis: A PA was performed in 90% (9/10) of patients randomized to DCS, one patient died before the second look, and one patient received a HP. In group C, 70% (7/10) were treated with PA and 30% (3/10) with HP. 29% (2/7) experienced AI treated with protective ileostomy. In group DCS, 9% (1/11) were discharged with a stoma versus 40% (4/10) in group C (p = 0.14, n.s.). The odds ratio for discharge with a stoma is 0.139 (0.012–1.608).

Conclusion

This is the first prospectively randomized controlled study showing that damage control surgery in perforated diverticulitis Hinchey III and IV enhances reconstruction of bowel continuity and can reduce the stoma rate at discharge.

Cost-effectiveness of sigmoid resection with primary anastomosis or end colostomy for perforated diverticulitis: an analysis of the randomized Ladies trial

BACKGROUND

Several studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost-related outcomes were rarely reported. The present study aimed to evaluate costs and cost-effectiveness within the DIVA arm of the Ladies trial.

METHODS

This was a cost-effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12-month follow-up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention-to-treat principle. Main outcomes were incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma-free or incremental quality-adjusted life-years respectively.

RESULTS

Overall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €-8126 (-14 660 to -1592). The ICER was €-39 094 (95 per cent bias-corrected and accelerated (BCa) c.i. -1213 to -116), indicating primary anastomosis to be more cost-effective. The ICUR was €-101 435 (BCa c.i. -1 113 264 to 251 840).

CONCLUSION

Primary anastomosis is more cost-effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Hospital admission for complicated diverticulitis is increasing in Italy, especially in younger patients: a national database study

BACKGROUND

Epidemiological studies show an increasing trend of hospitalization for acute diverticulitis (AD), but data regarding the trend in hospitalization for complicated AD in Italy are scarce. The aim of this study was to analyze the Italian trend in hospitalization for complicated AD, from 2008 to 2015.

METHODS

Using the Italian Hospital Information System, we identified all patients with complicated colonic AD as a discharge diagnosis. Age- and sex-specific rates for AD as well as type of hospital admission (emergency/elective), type of complication (peritonitis, obstruction, bleeding, abscess, fistula, perforation, sepsis) and type of treatment (medical/surgical), were analyzed.

RESULTS

A total of 41,622 patients with a discharge diagnosis of complicated AD were identified. Over the study period the admission rate grew from 8.8 to 11.8 per 100,000 inhabitants. The hospitalization rate was highest for patients ≥ 70 years, but the increase in the admission rate was higher among patients aged ≤ 60 years. There were more males in the group < 60 years and more females in the group ≥ 60 years old. The rate of emergency admissions associated with surgery showed a significant mean annual increase (+ 3.9% per year) in the rate of emergency admissions associated with surgery, whereas elective admissions for surgery remained stable. Peritonitis was the most frequent complication (35.5%). The rate of surgery increased in AD complicated by peritonitis (+ 5.1% per year), abscess (+ 5.8% per year) and decreased for obstruction (- 1.8% per year).

CONCLUSIONS

From 2008 to 2015, we documented an increasing rate of hospitalization for complicated AD, especially for younger patients, with an increase in surgery for peritonitis and abscess. Further studies are needed to clearly assess the risk factors for complications and risk of surgery.

Sigmoid resection with primary anastomosis versus the Hartmann's procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis

PURPOSE

The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann's procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence.

METHODS

A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs).

RESULTS

From a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients.

CONCLUSION

Although between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann's procedure in selected patients with Hinchey III or IV diverticulitis.

Multifocal Versus Conventional Unifocal Diverticulitis: A Comparison of Clinical and Transcriptomic Characteristics

BACKGROUND

The management of diverticulitis is compromised by difficulty in identifying patients who require surgery for recurrent or persistent disease. Here, we introduce the concept of multifocal diverticulitis (MFD), characterized by multiple episodes of diverticulitis occurring at different locations within the colon.

AIMS

To compare clinical characteristics, success of surgical management, and colonic transcriptomes of MFD patients to patients with conventional unifocal diverticulitis (UFD).

METHODS

This retrospective study included 404 patients with CT-confirmed diverticulitis episodes. Patients with diverticulitis seen in at least two different colonic locations were classified as the MFD group and compared to the UFD group based on number of episodes, sites of disease, family history, surgeries performed, and postoperative recurrence. RNA-seq was conducted on full-thickness colonic tissues of ten MFD and 11 UFD patients.

RESULTS

Twenty-eight patients (6.9%) with MFD were identified. MFD patients had more diverticulitis episodes and were more likely to have positive family history, have right-sided disease, require surgery, and have recurrence after surgery. All MFD patients treated with segmental resection had recurrence, while recurrence was less common in patients undergoing more extensive surgery (P < 0.001). Using RNA-seq, we identified 69 genes that were differentially expressed between MFD and UFD patients. Significantly down-regulated genes were associated with immune response pathways.

CONCLUSIONS

MFD appears to be a more severe subset of diverticulitis with a possible genetic component. Transcriptomic data suggest that MFD may be associated with alteration of the immune response.

Increasing primary anastomosis rate over time for the operative management of acute diverticulitis

BACKGROUND

Over the past two decades, there has been mounting evidence that primary anastomosis (PA) is a safe alternative to Hartmann's procedure (HP) in acute diverticulitis. In addition, specialized colorectal surgeons are more likely to perform PA. This study aimed to analyse if this evidence has led to an increase in the rate of PA in a major tertiary institution over time.

METHODS

A retrospective observational study of patients requiring operative management of acute diverticulitis from 1 January 2001 to 31 December 2015 at a tertiary teaching hospital.

RESULTS

One hundred and eighteen patients underwent surgery for acute diverticulitis. Patients who failed initial conservative management were more likely to have PA (43% versus 21%, P = 0.044). There was no difference in medical or surgical complications, readmission rate or mortality between patients who had a PA compared with HP. Patients were more likely to have a PA if a colorectal surgeon was operating compared with a colorectal surgery fellow or general surgeon (36% versus 19% versus 10%, P = 0.039). In patients with modified Hinchey 0-2, there was an increased PA rate within the study period, 21%, 43%, 63% to 57% from the first to the fourth quartile of patients (P = 0.038).

CONCLUSIONS

The mounting evidence for the safety of performing PA has led to an increase in the PA rates for acute diverticulitis. Patients who were operated by a colorectal surgeon were more likely to have a PA. The morbidity and mortality were similar in patients who had PA compared with HP.

Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial

BACKGROUND

Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial.

METHODS

A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485.

FINDINGS

Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% [95% CI 88·7-100] vs 71·7% [95% CI 60·1-83·3], hazard ratio 2·79 [95% CI 1·86-4·18]; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 [44%] of 66 patients vs 25 [39%] of 64, p=0·60; mortality: two [3%] vs four [6%], p=0·44).

INTERPRETATION

In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease).

FUNDING

Netherlands Organisation for Health Research and Development.

Long-term follow-up of a multicentre cohort study on laparoscopic peritoneal lavage for perforated diverticulitis

AIM

Laparoscopic peritoneal lavage has increasingly been investigated as a promising alternative to sigmoidectomy for perforated diverticulitis with purulent peritonitis. Most studies only reported outcomes up to 12 months. Therefore, the objective of this study was to evaluate long-term outcomes of patients treated with laparoscopic lavage.

METHODS

Between 2008 and 2010, 38 patients treated with laparoscopic lavage for perforated diverticulitis in 10 Dutch teaching hospitals were included. Long-term follow-up data on patient outcomes, e.g. diverticulitis recurrence, reoperations and readmissions, were collected retrospectively. The characteristics of patients with recurrent diverticulitis or complications requiring surgery or leading to death, categorized as 'overall complicated outcome', were compared with patients who developed no complications or complications not requiring surgery.

RESULTS

The median follow-up was 46 months (interquartile range 7-77), during which 17 episodes of recurrent diverticulitis (seven complicated) in 12 patients (32%) occurred. Twelve patients (32%) required additional surgery with a total of 29 procedures. Fifteen patients (39%) had a total of 50 readmissions. Of initially successfully treated patients (n = 31), 12 (31%) had recurrent diverticulitis or other complications. At 90 days, 32 (84%) patients were alive without undergoing a sigmoidectomy. However, seven (22%) of these patients eventually had a sigmoidectomy after 90 days. Diverticulitis-related events occurred up to 6 years after the index procedure.

CONCLUSION

Long-term diverticulitis recurrence, re-intervention and readmission rates after laparoscopic lavage were high. A complicated outcome was also seen in patients who had initially been treated successfully with laparoscopic lavage with relevant events occurring up to 6 years after initial surgery.

Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy

Introduction

Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS.

Methods

All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011–2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study.

Results

There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m² (SD ± 3.33). Thirteen cases (38%) were Wasvary’s modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann’s procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender (p = 0.010) and MPI (p = 0.034) correlated with a high percentage of Hartmann’s procedures.

Conclusion

DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.

Laparoscopic Lavage Versus Primary Resection for Acute Perforated Diverticulitis: Review and Meta-analysis

OBJECTIVE

To compare clinical outcomes after laparoscopic lavage (LL) or colonic resection (CR) for purulent diverticulitis.

BACKGROUND

Laparoscopic lavage has been suggested as an alternative treatment for traditional CR. Comparative studies to date have shown conflicting results.

METHODS

Electronic searches of Embase, Medline, Web of Science, and Cochrane databases were performed. Weighted mean differences (WMD) were calculated for effect size of continuous variables and pooled odds ratios (POR) calculated for discrete variables.

RESULTS

A total of 589 patients recruited from 3 randomized controlled trials (RCTs) and 4 comparative studies were included; 85% as Hinchey III. LL group had younger patients with higher body mass index and lower ASA grades, but comparable Hinchey classification and previous diverticulitis rates. No significant differences were noted for mortality, 30-day reoperations and unplanned readmissions. LL had higher rates of intraabdominal abscesses (POR = 2.85; 95% confidence interval, CI, 1.52-5.34; P = 0.001), peritonitis (POR = 7.80; 95% CI 2.12-28.69; P = 0.002), and increased long-term emergency reoperations (POR = 3.32; 95% CI 1.73-6.38; P < 0.001). Benefits of LL included shorter operative time, fewer cardiac complications, fewer wound infections, and shorter hospital stay. Overall, 90% had stomas after CR, of whom 74% underwent stoma reversal within 12-months. Approximately, 14% of LL patients required a stoma; 48% obtaining gut continuity within 12-months, whereas 36% underwent elective sigmoidectomy.

CONCLUSIONS

The preservation of diseased bowel by LL is associated with approximately 3 times greater risk of persistent peritonitis, intraabdominal abscesses and the need for emergency surgery compared with CR. Future studies should focus on developing composite predictive scores encompassing the wide variation in presentations of diverticulitis and treatment tailored on case-by-case basis.

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.

Uncomplicated Acute Diverticulitis: Identifying Risk Factors for Severe Outcomes

BACKGROUND

The management of uncomplicated (Modified Hinchey Classification Ia) acute diverticulitis (AD) has become increasingly conservative, with a focus on symptomatic relief and supportive management. Clear criteria for patient selection are required to implement this safely. This retrospective study aimed to identify risk factors for severe clinical course in patients with uncomplicated AD.

MATERIALS AND METHODS

Patients admitted to General Surgery at two New Zealand tertiary centres over a period of 18 months were included. Univariate and multivariate analyses were carried out in order to identify factors associated with a more severe clinical course. This was defined by three endpoints: need for procedural intervention, admission >7 days and 30-day readmission; these were analysed separately and as a combined outcome.

RESULTS

Uncomplicated AD was identified in 319 patients. Fifteen patients (5%) required procedural intervention; this was associated with SIRS (OR 3.92). Twenty-two (6.9%) patients were admitted for >7 days; this was associated with patient-reported pain score >8/10 (OR 5.67). Thirty-one patients (9.8%) required readmission within 30 days; this was associated with pain score >8/10 (OR 6.08) and first episode of AD (OR 2.47). Overall, 49 patients had a severe clinical course, and associated factors were regular steroid/immunomodulator use (OR 4.34), pain score >8/10 (OR 5.9) and higher temperature (OR 1.51) and CRP ≥200 (OR 4.1).

CONCLUSION

SIRS, high pain score and CRP, first episode and regular steroid/immunomodulator use were identified as predictors of worse outcome in uncomplicated AD. These findings have the potential to inform prospective treatment decisions in this patient group.

International Variation in Emergency Operation Rates for Acute Diverticulitis: Insights into Healthcare Value

BACKGROUND

International comparison of outcomes of surgical diseases has become a global focus because of widespread concern over surgical quality, rising costs and the value of healthcare. Acute diverticulitis is a common disease potentially amenable to optimization of strategies for operative intervention. The aim was to compare the emergency operative intervention rates for acute diverticulitis in USA, England and Australia.

METHODS

Unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2014 for hospitals in USA, England and Australia. The primary outcome measured was emergency operative intervention rate. Secondary outcomes included inpatient mortality and percutaneous drainage rate. Multivariable analysis was performed after development of a weighted comorbidity scoring system.

RESULTS

There were 15,150 unplanned admissions for acute diverticulitis. The emergency operative intervention rates were 16, 13 and 10% for USA, England and Australia. The percutaneous drainage rate was highest in USA at 10%, while the mortality rate was highest in England at 2.8%. The propensity for emergency operative intervention was higher in USA (OR 1.45, p < 0.001) and England (OR 1.49, p < 0.001) than in Australia. The risk of 7-day mortality was higher in England than in Australia (OR 2.79, p < 0.001). Percutaneous drainage was associated with reduced 7-day mortality risk.

CONCLUSION

Australia has a lower propensity for emergency operative intervention, while England has a greater risk of mortality for acute diverticulitis. International variations raise the issue of healthcare value in terms of differing resource use and outcomes.

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis

BACKGROUND

The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world.

PURPOSE

Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.

METHODS

PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.

RESULTS

A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I² 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%.

CONCLUSION

Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.

Laparoscopic versus open resection for sigmoid diverticulitis

BACKGROUND

Diverticular disease is a common condition in Western industrialised countries. Most individuals remain asymptomatic throughout life; however, 25% experience acute diverticulitis. The standard treatment for acute diverticulitis is open surgery. Laparoscopic surgery - a minimal-access procedure - offers an alternative approach to open surgery, as it is characterised by reduced operative stress that may translate into shorter hospitalisation and more rapid recovery, as well as improved quality of life.

OBJECTIVES

To evaluate the effectiveness of laparoscopic surgical resection compared with open surgical resection for individuals with acute sigmoid diverticulitis.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library; Ovid MEDLINE (1946 to 23 February 2017); Ovid Embase (1974 to 23 February 2017); clinicaltrials.gov (February 2017); and the World Health Organization (WHO) International Clinical Trials Registry (February 2017). We reviewed the bibliographies of identified trials to search for additional studies.

SELECTION CRITERIA

We included randomised controlled trials comparing elective or emergency laparoscopic sigmoid resection versus open surgical resection for acute sigmoid diverticulitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the domains of risk of bias from each included trial, and extracted data. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we planned to calculate mean differences (MDs) with 95% CIs for outcomes such as hospital stay, and standardised mean differences (SMDs) with 95% CIs for quality of life and global rating scales, if researchers used different scales.

MAIN RESULTS

Three trials with 392 participants met the inclusion criteria. Studies were conducted in three European countries (Switzerland, Netherlands, and Germany). The median age of participants ranged from 62 to 66 years; 53% to 64% were female. Inclusion criteria differed among studies. One trial included participants with Hinchey I characteristics as well as those who underwent Hartmann's procedure; the second trial included only participants with "a proven stage II/III disease according to the classification of Stock and Hansen"; the third trial considered for inclusion patients with "diverticular disease of sigmoid colon documented by colonoscopy and 2 episodes of uncomplicated diverticulitis, one at least being documented with CT scan, 1 episode of complicated diverticulitis, with a pericolic abscess (Hinchey stage I) or pelvic abscess (Hinchey stage II) requiring percutaneous drainage."We determined that two studies were at low risk of selection bias; two that reported considerable dropouts were at high risk of attrition bias; none reported blinding of outcome assessors (unclear detection bias); and all were exposed to performance bias owing to the nature of the intervention.Available low-quality evidence suggests that laparoscopic surgical resection may lead to little or no difference in mean hospital stay compared with open surgical resection (3 studies, 360 participants; MD -0.62 (days), 95% CI -2.49 to 1.25; I² = 0%).Low-quality evidence suggests that operating time was longer in the laparoscopic surgery group than in the open surgery group (3 studies, 360 participants; MD 49.28 (minutes), 95% CI 40.64 to 57.93; I² = 0%).We are uncertain whether laparoscopic surgery improves postoperative pain between day 1 and day 3 more effectively than open surgery. Low-quality evidence suggests that laparoscopic surgery may improve postoperative pain at the fourth postoperative day more effectively than open surgery (2 studies, 250 participants; MD = -0.65, 95% CI -1.04 to -0.25).Researchers reported quality of life differently across trials, hindering the possibility of meta-analysis. Low-quality evidence from one trial using the Short Form (SF)-36 questionnaire six weeks after surgery suggests that laparoscopic intervention may improve quality of life, whereas evidence from two other trials using the European Organization for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) v3 and the Gastrointestinal Quality of Life Index score, respectively, suggests that laparoscopic surgery may make little or no difference in improving quality of life compared with open surgery.We are uncertain whether laparoscopic surgery improves the following outcomes: 30-day postoperative mortality, early overall morbidity, major and minor complications, surgical complications, postoperative times to liquid and solid diets, and reoperations due to anastomotic leak.

AUTHORS' CONCLUSIONS

Results from the present comprehensive review indicate that evidence to support or refute the safety and effectiveness of laparoscopic surgery versus open surgical resection for treatment of patients with acute diverticular disease is insufficient. Well-designed trials with adequate sample size are needed to investigate the efficacy of laparoscopic surgery towards important patient-oriented (e.g. postoperative pain) and health system-oriented outcomes (e.g. mean hospital stay).

Predictive factors on CT imaging for progression of uncomplicated into complicated acute diverticulitis

PURPOSE

Since outpatient treatment and omitting antibiotics for uncomplicated acute colonic diverticulitis have been proven to be safe in the majority of patients, selection of patients that may not be suited for this treatment strategy becomes an important topic. The aim of this study is to identify computed tomography (CT) imaging predictors for a complicated disease course of initially uncomplicated acute diverticulitis.

METHODS

CT imaging from a randomized controlled trial (DIABOLO study) of an observational vs. antibiotic treatment strategy of first-episode uncomplicated acute diverticulitis patients was re-evaluated. For each patient that developed complicated diverticulitis within 90 days after randomization, two patients with an uncomplicated disease course were randomly selected. Two abdominal radiologists, blinded for outcomes, independently re-evaluated all CTs.

RESULTS

Of the 528 patients in the DIABOLO trial, 16 patients developed complications (abscess > 5 cm, perforation, bowel obstruction) within 90 days after randomization. In the group with a complicated course of initially uncomplicated diverticulitis, more patients with fluid collections (25 vs. 0%; p = 0.009) and a longer inflamed colon segment (86 ± 26 mm vs. 65 ± 21 mm; p = 0.007) were observed compared to an uncomplicated course of disease. Pericolic extraluminal air was no predictive factor.

CONCLUSION

Fluid collections and to a lesser extent the length of the inflamed colon segment may serve as predictive factors on initial CT for a complicated disease course in patients with uncomplicated acute colonic diverticulitis. These findings may aid in the selection of patients not suitable for outpatient treatment and treatment without antibiotics.