Outcomes after medical and surgical treatment of diverticulitis: a systematic review of the available evidence

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.

Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database

Background

Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies.

Study design

We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012–2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL.

Results

In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70–0.96], ABP [0.69, 95%CI: 0.52–0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51–0.86], ABP [0.56, 95%CI: 0.34–0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50–0.67; AL:OR = 0.46, 95%CI:0.36–0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13–0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37–0.69], AL [OR = 0.47, 95%CI: 0.25–0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47–0.72, AL [OR = 0.49, 95%CI: 0.35–0.68]).

Conclusions

MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.

Trends and Outcomes of Acute Diverticulitis in Inflammatory Bowel Disease: A Propensity-matched National Study

BACKGROUND

Patients with inflammatory bowel disease (IBD) may be at increased risk for acute diverticulitis (AD) complications due to luminal inflammation and immune modifying medications. We aimed to assess outcomes of acute diverticulitis in patients with IBD.

METHODS

A propensity-matched analysis of the National Inpatient Sample database was performed to assess outcomes of AD in adult patients (older than 18 years) from 2004 to 2013 with and without IBD. Outcomes included in-hospital mortality, need for percutaneous drainage, surgery, venous thromboembolism (VTE), total cost, and length of stay (LOS). A subgroup analysis comparing patients with Crohn's disease (CD) and ulcerative colitis (UC) was performed.

RESULTS

After propensity matching, compared with non-IBD patients (n = 15,015); Patients with IBD (n = 15,106) did not have significantly higher rate of mortality and surgical intervention but had significantly higher rates of percutaneous drainage (4% vs 3.4%; P = 0.002), VTE (1.1% vs 0.7%; P < 0.001), longer LOS (P < 0.001), and total cost (P < 0.001). Compared with CD, UC was associated with significantly higher rates of surgical intervention (20.3% vs 19%; P = 0.04), in-hospital mortality (1.4% vs 0.4%; P < 0.001), VTE (1.6% vs 0.7%; P < 0.001), total cost ($41,672 ± $61,358 vs $33,951 ± $54,376; P < 0.001), and LOS (6.4 ± 6.4 vs 5.7 ± 5.3; P < 0.001). From 2004 to 2013, there was a significant increase of IBD (range 0.5% to 0.8%; P = < 0.001) in AD patients with overall stable mortality (0.5% to 1.0%; P = 0.47) of AD in patients with IBD.

CONCLUSIONS

Patients with IBD are at increased risk of complicated diverticulitis and worse outcomes compared with matched controls. Optimal AD management strategies in IBD are needed.

Post-Diverticulitis Colonoscopy Was Not Associated with Higher Colonic Adenoma and Carcinoma: A Multicenter Case-Control Study

Background and Objectives: Colonoscopy following an episode of acute diverticulitis is currently recommended to rule out underlying colon cancer. However, a number of studies have debated this recommendation. We aimed to explore whether patients with colonic diverticulosis who experienced an episode of acute diverticulitis had higher prevalence colonic pathologies, essentially colonic adenomas and colorectal carcinoma (CRC) on a follow-up colonoscopy. Materials and Methods: We performed a multicenter retrospective study that included patients with a diagnosis diverticulosis as the control group and allocated patients after diverticulitis according to computed tomography (CT) scan and clinical presentation that had performed colonoscopy within 6 months from the acute diverticulitis episode. We compared the detection rate of colonic pathologic findings in both groups. Results: Overall, 367 patients were included. Of them, 134 patients experienced an episode of diverticulitis vs. 233 patients who did not have diverticulitis. On univariate analysis, there was no difference between all pathological findings (CRC, colonic adenomas; OR (odds ratio) 1.51, p = 0.085), and even for each pathological findings alone, there was no difference (for colonic adenomas, p = 0.07; for CRC, p = 0.87). Further sub-analysis revealed that only male gender (OR 4.03, p = 0.004) and smoking (OR 8.67, p < 0.0001) correlated with colonic adenomas and CRC, while moderate to severe disease was not correlated with colonic pathological findings (OR 0.86, 95% CI (confidence interval) 0.4–1.82, p = 0.68). Conclusions: Post-diverticulitis screening colonoscopy has not found a higher rate of colonic pathological findings, especially colonic neoplasia. Decision to perform colonoscopy after acute diverticulitis should be individualized based on risk stratification of colonic neoplasia.

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.

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.

Underlying Colorectal Cancer Was Rarely Detected After an Episode of Acute Diverticulitis: a Retrospective Analysis of 225 Patients

PURPOSE

The aim of the present study was to determine the prevalence of underlying colorectal carcinoma (CRC) in a cohort of patients who experienced an episode of acute diverticulitis and to assess clinical and laboratory parameters that suggest CRC diagnosis.

METHODS

We performed a single center retrospective study in EMMS Nazareth Hospital from April 2014 to April 2018. All Patients who experienced an episode of acute diverticulitis and underwent a colonoscopy up to 6-month period were included in the study.

RESULTS

Two hundred twenty-five patients (225) patients were included. The mean age was 55.73 ± 13.81 (24-93). One hundred thirty-nine (139) patients were males. Underlying CRC was diagnosed in 2 out of 225 (0.89%) patients and colonic polyps were found in 17 out of 225 patients (7.56%). The average time interval between the episode of diverticulitis and the performance of colonoscopy was 6 weeks. Male gender was significantly associated with CRC and polyp findings (P = 0.039). Moreover, platelet count (353,000 vs. 234,000, P = 0.002) and platelet to lymphocyte ratio (223.65 vs. 127.4, P = 0.015) showed statistically significant correlation with CRC as compared to colonic polyps.

CONCLUSION

The rate of underlying CRC diagnosis was extremely low after an episode of acute diverticulitis. Male gender and platelet to lymphocyte ratio were predictors for the presence of underlying CRC.

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.

Colonic diverticular disease

Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.

Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial)

OBJECTIVE

The aim of this study was to establish whether surgical or conservative treatment leads to a higher quality of life (QoL) in patients with recurring diverticulitis and/or ongoing complaints.

SUMMARY OF BACKGROUND DATA

The 6 months' results of the DIRECT trial, a randomized trial comparing elective sigmoidectomy with conservative management in patients with recurring diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode of diverticulitis, demonstrated a significantly higher QoL after elective sigmoidectomy. The aim of the present study was to evaluate QoL at 5-year follow-up.

METHODS

From January 2010 to June 2014, 109 patients were randomized to either elective sigmoidectomy (N = 53) or conservative management (N = 56). In the present study, the primary outcome was QoL measured by the Gastrointestinal Quality of Life Index (GIQLI) at 5-year follow-up. Secondary outcome measures were SF-36 score, Visual Analogue Score (VAS) pain score, EuroQol-5D-3L (EQ-5D-3L) score, morbidity, mortality, perioperative complications, and long-term operative outcome.

RESULTS

At 5-year follow-up, mean GIQLI score was significantly higher in the operative group [118.2 (SD 21.0)] than the conservative group [108.5 (SD 20.0)] with a mean difference of 9.7 (95% confidence interval 1.7-17.7). All secondary QoL outcome measures showed significantly better results in the operative group, with a higher SF-36 physical (P = 0.030) and mental score (P = 0.010), higher EQ5D score (P = 0.016), and a lower VAS pain score (P = 0.011). Twenty-six (46%) patients in the conservative group ultimately required surgery due to severe ongoing complaints. Of the operatively treated patients, 8 (11%) patients had anastomotic leakage and reinterventions were required in 11 (15%) patients.

CONCLUSION

Consistent with the short-term results of the DIRECT trial, elective sigmoidectomy resulted in a significantly increased QoL at 5-year follow-up compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints. Surgeons should counsel these patients for elective sigmoidectomy weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Are Correlated with Complicated Diverticulitis and Hinchey Classification: A Simple Tool to Assess Disease Severity in the Emergency Department

Background and Aim

Rapid identification of patients with complications related to acute diverticulitis who require urgent intervention in the emergency department (ED) is essential. The aim of our study was to determine the role of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting severity of diverticulitis as assessed by Hinchey classification.

Patients and Methods

We performed a single retrospective study in EMMS Nazareth Hospital from 4/2014 to 4/2018. Patients were categorized into two groups: group A with mild to moderate complicated diverticulitis (Hinchey 1-2) and group B with severe complicated diverticulitis (Hinchey 3-4).

Results

Two hundred twenty-five patients were included. Two hundred seven patients were in group A, and 18 patients were in group B. On univariate analysis, age, NLR, and PLR correlated with advanced Hinchey classification and disease severity (stages 3-4) (OR 1.038, 95% CI 1.001–1.076, P=0.0416; OR 1.192, 95% CI 1.093–1.300, P < 0.0001; and OR 1.011, 95% CI 1.005–1.017, P=0.0005, respectively). On multivariate logistic regression analysis, the NLR and PLR remain significantly correlated with Hinchey 3-4 (OR 1.174, 95% CI 1.071–1.286, P=0.0006, and OR 1.008, 95% CI 1.001–1.015, P=0.0209, respectively). The area under the curve (AUC) for the NLR and PLR on univariate analysis was 0.7526 and 0.6748, respectively, and 0.7760 and 0.7391 on multivariate logistic regression analysis, respectively, and receiver-operating characteristic (ROC) curves were drawn.

Conclusion

The NLR and PLR independently associated with diverticulitis severity and positively correlated with advanced Hinchey classification. This simple available laboratory tool can be implemented into clinical practice to optimize patient management.

Diverticular disease management in primary care: How do estimates from community-dispensed antibiotics inform provision of care?

BACKGROUND

The literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed.

AIM

To estimate how often DDI is managed in primary care, using antibiotics dispensing data.

DESIGN AND SETTING

Hospitalisation records of New Zealand residents aged 30+ years during 2007-2016 were individually linked to databases of community-dispensed oral antibiotics.

METHOD

Patients with an index hospital admission 2007-2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007-2016 for these people with ten individually-matched non-DDI residents, taking the case's index date. Multivariable negative binomial models were used to estimate rates of antibiotic use.

RESULTS

From almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation.

CONCLUSION

DDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.

Cost-effectiveness analysis of a multicentre randomized clinical trial comparing surgery with conservative management for recurrent and ongoing diverticulitis (DIRECT trial)

Background

The results of the DIRECT trial, an RCT comparing conservative management with elective sigmoid resection in patients with recurrent diverticulitis or persistent complaints, showed that elective sigmoid resection leads to higher quality of life. The aim of this study is to determine the cost-effectiveness of surgical treatment at 1- and 5-year follow-up from a societal perspective.

Methods

Clinical effectiveness and resource use were derived from the DIRECT trial. The actual resource use and quality of life (EQ-5D-3L™ score) were documented prospectively per individual patient and analysed according to the intention-to-treat principle for up to 5 years after randomization. The main outcome was the incremental cost-effectiveness ratio (ICER), expressed as costs per quality-adjusted life-year (QALY).

Results

The study included 106 patients, of whom 50 were randomized to surgery and 56 to conservative treatment. At 1- and 5-year follow-up an incremental effect (QALY difference between groups) of 0·06 and 0·43 respectively was found, and an incremental cost (cost difference between groups) of €6957 and €2674 respectively, where surgery was more expensive than conservative treatment. This resulted in an ICER of €123 365 per additional QALY at 1-year follow-up, and €6275 at 5 years. At a threshold of €20 000 per QALY, operative treatment has 0 per cent probability of being cost-effective at 1-year follow-up, but a 95 per cent probability at 5 years.

Conclusion

At 5-year follow-up, elective sigmoid resection in patients with recurring diverticulitis or persistent complaints was found to be cost-effective. Registration number: NTR1478 (www.trialregistrer.nl).

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.

Does inferior mesenteric artery ligation affect outcome in elective colonic resection for diverticular disease?

BACKGROUND

The aim of our study was to analyse the role of inferior mesenteric artery (IMA) ligation during elective colonic resection for diverticular disease (DD) with respect to surgical outcome.

METHODS

All patients who underwent elective laparoscopic or open colonic resection for DD from January 2006 to December 2012 were studied. The patients were divided into two groups based on IMA ligation or preservation. The primary end point was to compare anastomotic leakage in the two groups. The secondary end points were operative time, stoma formation, overall post-operative complications, restoration of bowel function and length of post-operative hospital stay.

RESULTS

During the study period, 219 elective colonic resections with primary anastomosis for DD were performed. A laparoscopic technique was employed in 132 (60.3%) cases. IMA ligation was performed in 66 patients (30.1%). Overall anastomotic leakage rate was 4.1%, 4.5% in IMA ligation and 3.9% in IMA preservation group, respectively (P = ns). Mean operative time was 225 ± 43.4 and 191 ± 41.7 min in IMA ligation and preservation group, respectively (P = 0.002). No differences were observed in the rate of overall complications, stoma formation, restoration of bowel function and post-operative length of hospital stay.

CONCLUSIONS

No differences were observed in surgical outcome in IMA ligation and preservation groups, particularly preservation or ligation of the IMA did not affect leakage rate.

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.

Animal Models of Diverticulosis: Review and Recommendations

Diverticulosis is a structural alteration of the colon tissue characterized by the development of pouch-like structures called diverticula. It afflicts a significant portion of the population in Western countries, with a higher prevalence among the elderly. Diverticulosis is believed to be the result of a synergetic interaction between inherent tissue weakness, diet, colonic microstructure, motility, and genetic factors. A validated etiology has, however, not yet been established. Non-surgical treatment is currently lacking due to this poor understanding, and surgical colon resection is the only long-term solution following recurrent complications. With rising prevalence, the burden of diverticulosis on patients and hospital resources has increased over the past several years. More efficient and less invasive treatment approaches are, thus, urgently needed. Animal models of diverticulosis are crucial to enable a preclinical assessment and evaluation of such novel approaches. This review discusses the animal models of diverticulosis that have been proposed to date. The current models require either a significant amount of time to develop diverticulosis, present a relatively low success rate, or seriously deteriorate the animals' systemic health. Recommendations are thus provided to address these pitfalls through the selection of a suitable animal and the combination of multiple risk factors for diverticulosis.

Management outcomes of diverticulitis and colitis in patients with active cancer

BACKGROUND

Little is reported in the literature on management strategies and outcomes in patients with an active cancer diagnosis who undergo emergent general surgery. The purpose of this study is to evaluate preoperative risk factors in both operative and non-operative management, as well as to describe the outcomes of colonic emergencies within a cancer patient population.

METHODS

A single institution cancer database was reviewed retrospectively to identify patients with an active cancer diagnosis who had an emergency general surgery consult placed for an acute colonic pathology.

RESULTS

A total of 87 patients were included. Among these, 38 patients underwent operative and 49 underwent nonoperative management. There was a 71% rate of postoperative complications in the operative group; these patients were also more likely to require intensive care unit admission (P < .001), die during their hospitalization (P = .003), have a greater 30-day mortality (P = .001) and were less likely to be discharged to home (P < .001). No patients in the nonoperative group required admission to the intensive care unit, 3 of the 49 (6%) died during their hospitalization, and 75% of nonoperative patients were discharged to home.

CONCLUSION

When clinically appropriate, patients with active cancer who present with an acute colonic emergency can undergo nonoperative management safely. In contrast, patients undergoing operative management have a substantial risk of morbidity and mortality.

High Probability of an Underlying Colorectal Cancer Among Patients Treated for Acute Diverticulitis. A Population-Based Cohort Follow-Up Study

INTRODUCTION

Patients treated conservatively for acute diverticulitis (AD) are recommended colonic assessment to rule out an underlying Colorectal cancer (CRC). This has been questioned in patients with a CT diagnosis of uncomplicated AD. We analyzed the frequency of CRC and compared the characteristics of the CRC patients with controls.

METHOD

A cohort of patients treated conservatively for AD during 2005-2011 was identified through an administrative database. Patients diagnosed with CRC within 1 year after the index admission and four randomly selected controls were identified. The patients' files were reviewed to verify the diagnosis and obtain information about the clinical characteristics and the management. A blinded review was performed of CT examinations. The expected number of CRC was calculated from age, sex, and period-specific incidence data. The characteristics of the CRC patients were compared with the controls in a nested case-control study.

RESULTS

890 patients (298 men and 592 women) were treated conservatively for AD. 12 patients were diagnosed with CRC within 1 year, and ten of them in the sigmoid, giving a Standardized Incidence Ratio of 20.0 (95 % CI 10.2-35.7, p<0.001) for sigmoidal cancer. All CRC patients were aged over 70 years. The cancer was missed in six CT scans at the primary reading and in five at the blinded review.

CONCLUSION

Patients conservatively treated for AD are at high risk for an underlying CRC, especially if older than 70 years, which motivates routine follow-up. A CT diagnosis of uncomplicated AD does not rule out CRC.

Is early colonoscopy after CT-diagnosed diverticulitis still necessary?

PURPOSE

WHO GLOBOCAN 2012 data showed that Australia and New Zealand have the highest incidence rates of colorectal cancer in the world (Ferlay et al. 1). Current guidelines recommend that patients admitted for an episode of acute diverticulitis require an early follow-up colonoscopy to rule out colorectal malignancy as reported by Fozard et al. (Colorectal Dis 13:1-11, 2011). Recent studies however have indicated that this may not be warranted (Brar et al. Dis Colon rectum 56:1259-1264, 2013). This study aimed to review the current practice by looking at our institution's rate of colorectal malignancy diagnosed after an episode of acute diverticulitis.

METHODS

We conducted a retrospective analysis of patients who presented with acute diverticulitis at our institution between 2011 and 2013. Included in the study were patients who received follow-up colonic evaluation in the next 12 months after admission. Patients who had a colonoscopy in the last year prior to emergency presentation were excluded. The primary outcome measure was the incidence of histologically confirmed colorectal carcinoma diagnosed on follow-up colonoscopy. Secondary outcome measures were incidence of low-grade or advanced adenoma on follow-up colonic evaluation.

RESULTS

A total of 523 cases of acute diverticulitis were diagnosed on CT scan. Out of 351 patients with uncomplicated diverticulitis, 196 had follow-up colonoscopy, with one case of colorectal malignancy recorded. Low-grade and advanced adenomas were found on 10.7 and 2.0% of colonoscopies performed respectively in this subgroup. Seventy-four out of 172 patients with complicated diverticulitis had follow-up evaluation, with four cases of colorectal malignancy discovered. Low-grade and advanced adenomas were found on 6.75 and 5.41% of colonoscopies performed respectively in this subgroup.

CONCLUSION

Routine interval colonoscopy following an episode of conservatively managed uncomplicated diverticulitis may not be necessary. Interval colonoscopy is still indicated in patients with complicated diverticulitis. Further collaborative study across different institutions may be warranted to gain better statistical significance.

Risk factors of admission for acute colonic diverticulitis in a population-based cohort study: The North Trondelag Health Study, Norway

AIM

To assess risk factors of hospital admission for acute colonic diverticulitis.

METHODS

The study was conducted as part of the second wave of the population-based North Trondelag Health Study (HUNT2), performed in North Trondelag County, Norway, 1995 to 1997. The study consisted of 42570 participants (65.1% from HUNT2) who were followed up from 1998 to 2012. Of these, 22436 (52.7%) were females. The cases were defined as those 358 participants admitted with acute colonic diverticulitis during follow-up. The remaining participants were used as controls. Univariable and multivariable Cox regression analyses was used for each sex separately after multiple imputation to calculate HR.

RESULTS

Multivariable Cox regression analyses showed that increasing age increased the risk of admission for acute colonic diverticulitis: Comparing with ages < 50 years, females with age 50-70 years had HR = 3.42, P < 0.001 and age > 70 years, HR = 6.19, P < 0.001. In males the corresponding values were HR = 1.85, P = 0.004 and 2.56, P < 0.001. In patients with obesity (body mass index ≥ 30) the HR = 2.06, P < 0.001 in females and HR = 2.58, P < 0.001 in males. In females, present (HR = 2.11, P < 0.001) or previous (HR = 1.65, P = 0.007) cigarette smoking increased the risk of admission. In males, breathlessness (HR = 2.57, P < 0.001) and living in rural areas (HR = 1.74, P = 0.007) increased the risk. Level of education, physical activity, constipation and type of bread eaten showed no association with admission for acute colonic diverticulitis.

CONCLUSION

The risk of hospital admission for acute colonic diverticulitis increased with increasing age, in obese individuals, in ever cigarette smoking females and in males living in rural areas.

German Guidelines

Because of its frequency, diverticular disease is a burden on health care systems. Only few formal guidelines covering all aspects of the disease exist. Here, some selected statements from the German guidelines are given. The guidelines include significant recommendations for the diagnosis and management of diverticular disease. Both diagnosis and management depend definitely on clear definitions of the situation of an individual patient. Therefore, a new classification is proposed that is based on earlier suggestions. An internationally established classification would not only enable better patient care but could also lead to studies with comparable results.

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.

Smoking Is Associated with an Increased Risk for Surgery in Diverticulitis: A Case Control Study

Importance

Cigarette smoking increases the risk of surgery in Crohn’s disease. However, the effect of smoking on the need for surgery for diverticulitis is unknown.

Objective

We evaluated whether smoking was a risk factor for surgery among patients admitted to hospital with acute diverticulitis.

Design

We conducted a population-based comparative cohort study of patients admitted to hospital for diverticulitis who were treated with medical versus surgical management.

Setting & Participants

We used the population-based Discharge Abstract Database to identify 176 adults admitted emergently with a diagnosis of diverticulitis between 2009 and 2010 in Calgary.

Intervention & Main Outcome

We performed a medical chart review to confirm the diagnosis of diverticulitis and to extract clinical data. The primary outcome was a partial colectomy during hospitalization. Logistic regression evaluated the association between smoking and surgery after adjusting for potential confounders, including age, sex, comorbidity, and disease severity.

Results

A partial colectomy was performed on 35.6% of patients with diverticulitis and 1.3% died. Among diverticulitis patients, 26.8% were current smokers, 31.5% were ex-smokers, and 41.6% never smoked. Compared to non-smokers, current smokers (adjusted odds ratio [OR] 9.02; 95% confidence interval [CI]: 2.47–32.97) and former smokers (adjusted OR 5.41; 95% CI: 1.54–18.96) had increased odds of surgery.

Conclusion and Relevance

Smoking is associated with the need for surgical management of diverticulitis.

Effectiveness of elective laparoscopic treatment for colonic diverticulitis

Background and Objectives:

To analyze the short- and long-term outcomes of laparoscopic sigmoid colectomy for the elective treatment of diverticular disease.

Methods:

A consecutive unselected series of 94 patients undergoing elective laparoscopic sigmoid colectomy for diverticular disease from 2008 to 2012 was analyzed. We collected patients-, surgery- and hospital stay–related data, as well as the short- and long-term outcomes. Operative steps, instrumentation, and postoperative cares were standardized. Comorbidity was assessed by Charlson comorbidity index. Complications were classified using the Clavien-Dindo classification system. The qualitative long-term assessment was carried out by subjecting patients to the validated gastrointestinal quality of life index questionnaire before and after surgery.

Results:

The mean age of our cohort was 61.3 ± 11.0 years with a Charlson comorbidity index of 1.2 ± 1.5.

Mean operative time was 213.5 ± 60.8 minutes and estimated blood loss was 67.2 ± 94.3 mL. We had 3 cases (3.2%) of conversion to open laparotomy. The rates of postoperative complications were 35.1%, 6.3%, 2.1%, and 1.06%, respectively, for grades 1, 2, 3b, and 5 according to the Clavien-Dindo system. Length of hospital stay was 8.1 ± 1.9 days, and we have not recorded readmissions in patients discharged within 60 days after surgery. Median follow-up was of 9.6 ± 2.7 months. We observed no recurrence of diverticular disease, but there was evidence of 3 cases of incisional hernia (3.19%). The difference between preoperative and late gastrointestinal quality of life index score was statistically significant (97.1 ± 5.8 vs 129.6 ± 8.0).

Conclusions:

Elective laparoscopic treatment of colonic diverticular disease represents an effective option that produces adequate postoperative results and ensures a satisfactory functional outcome.

Management of diverticular disease

Diverticular disease is a common condition in Western countries and the incidence and prevalence of the disease is increasing. The pathogenetic factors involved include structural changes in the gut that increase with age, a diet low in fibre and rich in meat, changes in intestinal motility, the concept of enteric neuropathy and an underlying genetic background. Current treatment strategies are hampered by insufficient options to stratify patients according to individual risk. One of the main reasons is the lack of an all-encompassing classification system of diverticular disease. In response, the German Society for Gastroenterology and Digestive Diseases (DGVS) has proposed a classification system as part of its new guideline for the diagnosis and management of diverticular disease. The classification system includes five main types of disease: asymptomatic diverticulosis, acute uncomplicated and complicated diverticulitis, as well as chronic diverticular disease and diverticular bleeding. Here, we review prevention and treatment strategies stratified by these five main types of disease, from prevention of the first attack of diverticulitis to the management of chronic complications and diverticular bleeding.

Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study

PURPOSE

The aim of this study was to evaluate outpatient, non-antibiotic management in acute uncomplicated diverticulitis with regard to admissions, complications, and recurrences, within a 3-month follow-up period.

METHODS

A prospective, observational study in which patients with computer tomography-verified acute uncomplicated diverticulitis were managed as outpatients without antibiotics. The patients kept a personal journal, were contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3 months.

RESULTS

In total, 155 patients were included, of which 54 were men; the mean age of the patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein and white blood cell count were 73 mg/l and 10.5 × 10(9), respectively, and normalized in the vast majority of patients within the first week. The majority of the patients (97.4%) were managed successfully as outpatients without antibiotics, admissions, or complications. In only four (2.6%) patients, the management failed because of complications in three and deterioration in one. These patients were all treated successfully as inpatients without surgery. Five patients had recurrences and were treated as outpatients without antibiotics. Follow-up colonic investigations revealed cancer in two patients and polyps in 13 patients.

CONCLUSION

Previous results of low complication rates with the non-antibiotic policy were confirmed. The new policy of outpatient management without antibiotics in acute uncomplicated diverticulitis is now shown to be feasible, well functioning, and safe.

Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery

BACKGROUND

Diverticular disease is one of the most common disorders of the gastrointestinal tract. 28-45% of the population develop colonic diverticula, while about 25% suffer symptoms and about 5% complications.

AIM

To create formal guidelines for diagnosis and management.

METHODS

Six working groups with 44 participants analyzed key questions in subject areas assigned to them. Following a systematic literature search, 451 publications were included. Consensus was obtained by agreement within the working groups, two Delphi processes and a guideline conference.

RESULTS

Targeted management of diverticular disease requires a classificatory diagnosis. A new classification was created. In addition to the clinical examination, intestinal ultrasound or computed tomography is the determining factor. Interval colonoscopy is recommended to exclude comorbidities. A low-fiber diet, obesity, lack of exercise, smoking and immunosuppression have an adverse impact on diverticulosis. This can lead to diverticulitis. Antibiotics are no longer recommended in uncomplicated diverticulitis if no risk factors such as immunosuppression are present. If close monitoring is ensured, uncomplicated diverticulitis can be treated on an outpatient basis. Complicated diverticulitis should be treated in hospital, involving broad-spectrum antibiotic therapy, where necessary abscess drainage, and surgery, if possible laparoscopically. In the case of chronic relapsing diverticulitis, the risk of perforation decreases with each episode, so that surgery is no longer recommended after the second episode but only following individual assessment.

CONCLUSIONS

New findings on diverticular disease call into question the overuse of antibiotics and excessive indications for surgery. Targeted treatment requires a precise diagnosis and intensive interdisciplinary cooperation.

Elective Surgery for Sigmoid Diverticulitis - Indications, Techniques, and Results

Diverticulitis is one of the leading indications for elective colonic resections although there is an ongoing controversial discussion about classification, stage-dependent therapeutic options, and therapy settings. As there is a rising trend towards conservative therapy for diverticular disease even in patients with a complicated form of diverticulitis, we provide a compact overview of current surgical therapy principles and the remaining questions to be answered.

Routine colonic endoscopic evaluation following resolution of acute diverticulitis: Is it necessary?

Diverticular disease incidence is increasing up to 65% by age 85 in industrialized nations, low fiber diets, and in younger and obese patients. Twenty-five percent of patients with diverticulosis will develop acute diverticulitis. This imposes a significant burden on healthcare systems, resulting in greater than 300000 admissions per year with an estimated annual cost of $3 billion USD. Abdominal computed tomography (CT) is the diagnostic study of choice, with a sensitivity and specificity greater than 95%. Unfortunately, similar CT findings can be present in colonic neoplasia, especially when perforated or inflamed. This prompted professional societies such as the American Society of Colon Rectal Surgeons to recommend patients undergo routine colonoscopy after an episode of acute diverticulitis to rule out malignancy. Yet, the data supporting routine colonoscopy after acute diverticulitis is sparse and based small cohort studies utilizing outdated technology. While any patient with an indication for a colonoscopy should undergo appropriate endoscopic evaluation, in the era of widespread use of high-resolution computed tomography, routine colonic endoscopic evaluation following resolution of acute uncomplicated diverticulitis poses additional costs, comes with inherent risks, and may require further study. In this manuscript, we review the current data related to this recommendation.

[Diverticular disease - diagnosis and classification]

A reliable diagnosis is fundamental for operative, interventional and conservative treatment of the different facets of diverticular disease. Not only differential diagnoses but also overlap or coincidence with other entities sharing similar symptoms must be considered. Furthermore, an adequate surgical strategy and correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and Visceral Surgery (DGAV) has released a new classification of diverticulitis displaying the different facets of diverticular disease. This classification also comprises symptomatic uncomplicated diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding. While detailed history, physical examination and laboratory testing are of great importance for exploring a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging using ultrasonography (US) or computed tomography (CT). The diagnostic value of qualified US is equipotent to qualified CT, complies with relevant legislation for radiation exposure protection and is frequently effective for diagnosis. Therefore, US is considered to be the first choice for imaging in diverticular disease. In contrast, CT has definite indications in unclear, discrepant situations or insufficient US performance. Strengths and weaknesses of both methods are discussed. Endoscopy is not required for the diagnosis of diverticulitis and should not be performed in an acute attack. Colonoscopy, however, is warranted after healing of diverticulitis, prior to elective surgery and in cases of an atypical course. Prior exclusion of perforation is considered mandatory. An unequivocal indication for colonoscopy is diverticular bleeding and the rapid performance (within 12-24 h) allows better identification of sites of bleeding and endoscopic interventions.

Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis

OBJECTIVE

To determine the yield of colorectal cancer at routine colonic evaluation after radiologically proven acute diverticulitis.

BACKGROUND

Acute diverticulitis accounts for 152,000 hospitalizations in the United States alone. Current guidelines recommend routine colonic evaluation after acute diverticulitis to confirm the diagnosis and exclude malignancy. However, research suggests that the yield of colorectal cancer after computed tomography-proven uncomplicated diverticulitis may be low. In the era of widespread computed tomographic scanning for diverticulitis, routine colonic evaluation after diverticulitis may represent a nonessential burden on health care resources.

METHODS

The PubMed (MEDLINE), EMBASE, BIREME, CINAHL, and the Cochrane Library databases were searched. Original studies of colonic evaluation after proven acute diverticulitis were included. Meta-analysis of data from included studies was performed using a DerSimonian Laird random effect proportion analysis.

RESULTS

Eleven studies from 7 countries were included in the analysis. Out of a pooled population of 1970 patients, cancer was found in 22. The pooled proportional estimate of malignancy was 1.6% (95% confidence interval [CI], 0.9%-2.8%). Of the 1497 patients with uncomplicated diverticulitis, cancer was found in 5 (proportional estimate of risk 0.7%; CI, 0.3%-1.4%). Of the 79 patients with complicated disease, cancer was found in 6 (proportion estimate of risk 10.8%; CI, 5.2%-21.0%).

CONCLUSIONS

The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, routine colonoscopy may not be necessary. Patients with complicated diverticulitis still have a significant risk of colorectal cancer at subsequent colonic evaluation.

Major increase in admission- and incidence rates of acute colonic diverticulitis

PURPOSE

Hospitalization for acute colonic diverticulitis has become more and more frequent. We studied the changes in the rate of admission and incidence of the disease during the last 25 years.

METHODS

We performed a retrospective analysis of all cases treated for acute diverticulitis during 1988-2012 at one hospital serving a defined population in Mid-Norway. The study made a distinction between admission rates and incidence rates. The admission rates defined the total number of cases admitted, while the incidence rates defined the number of new patients hospitalized for acute diverticulitis (first admission). Poisson regression was used to analyse factors associated with diverticulitis incidence rates.

RESULTS

A total of 851 admissions in 650 different patients were identified, with an overall admission rate of 38.5 (CI 35.9 to 41.1) per 100,000 person-years. The admission rate increased from 17.9 (CI 14.1 to 22.3)/100,000 during 1988-1992 to 51.1 (CI 44.8 to 58.0)/100,000 during 2008-2012. Poisson regression analysis showed a significant increase in admission rates with a factor of 2.8 (C.I. 2.2 to 3.5) during 25 years. The overall incidence rate (IRR) of new patients was 29.4 (CI 27.1 to 31.7)/100,000 person-years. IRR increased significantly with a factor of 2.6 (CI 1.96 to 3.34) during 25 years, while IRR for perforations increased even more, by a factor of 3.3 (CI 1.24 to 8.58).

CONCLUSION

The hospital admission rates as well as incidence rates for acute colonic diverticulitis increased significantly during the 25-year time span.

Microencapsulated sodium butyrate administered to patients with diverticulosis decreases incidence of diverticulitis--a prospective randomized study

BACKGROUND

Microencapsulated sodium butyrate (MSB) has been previously associated with anti-inflammatory and regenerative properties regarding large bowel mucosa. We aimed to examine a role of MSB in patients with diverticulosis, hypothesizing its potential for reduction of diverticulitis episodes and diverticulitis prevention.

METHODS

Seventy-three patients with diverticulosis (diagnosed in colonoscopy or/and barium enema or/and CT colography) were recruited for the study and randomized. The investigated group was administered MSB 300 mg daily; the control group was administered placebo. After 12 months, a total of 52 patients completed the study and were subject to analysis (30 subjects and 22 controls). During the study, the number of episodes of diverticulitis (symptomatic diagnosis with acute pain, fever, and leukocytosis), hospitalizations, and surgery performed for diverticulitis were recorded. Additionally, a question regarding subjective improvement of symptoms reflected changes in quality of life during the analysis.

RESULTS

After 12 months, the study group noted a significantly decreased number of diverticulitis episodes in comparison to the control group. The subjective quality of life in the study group was higher than in the control group. There were no side effects of the MSB during the therapy.

CONCLUSIONS

MSB reduces the frequency of diverticulitis episodes, is safe, and improves the quality of life. It can play a role in the prevention of diverticulitis.

Diverticulitis in young versus elderly patients: a meta-analysis

OBJECTIVE

To compare patients younger and older than 50 years with diverticulitis with regard to complications, disease recurrence and to the need for surgery.

MATERIAL AND METHODS

A literature review and meta-analysis was conducted according to the PRISMA guidelines. MEDLINE, Embase and the Cochrane databases were searched for longitudinal cohort studies comparing patients younger and older than 50 years with diverticulitis.

RESULTS

Eight studies were included with a total of 4.751 (male:female 1:0.66) patients younger and 18.328 (male:female 1:1.67) older than 50 years of age. The risk of developing at least one recurrent episode was significantly higher among patients younger than 50 years (pooled RR 1.73; 95% CI 1.40-2.13) with an estimated cumulative risk of 30% compared with 17.3% in older patients. The risk of requiring surgery during hospitalization for a primary episode of diverticulitis was equal in both age groups (pooled RR 0.99; 95% CI 0.74-1.32) and estimated at approximately 20%. Patients younger than 50 years more frequently required urgent surgery during hospitalization for a subsequent recurrent episode (pooled RR 1.46; 95% CI 1.29-1.66); the cumulative risk was 7.3% in younger and 4.9% in patients older than 50 years.

CONCLUSION

Patients younger than 50 years only differ substantially in risk for recurrent disease from patients older than 50 years of age. Although the relative risk for requiring urgent surgery for recurrent disease was higher in younger patient, one should consider that the absolute risk difference is relatively small (7.3% vs. 4.9%).

Laparoscopic sigmoidectomy in moderate and severe diverticulitis: analysis of short-term outcomes in a continuous series of 121 patients

BACKGROUND

The role of laparoscopic surgery has been shown to be safe, feasible, and equivalent to open surgery for moderate diverticulitis, but its role in severe disease is still being elucidated. The aim of this study was to compare short-term outcomes in patients who underwent laparoscopic sigmoidectomy for moderate and severe diverticulitis.

METHODS

All patients who had elective laparoscopic sigmoidectomy for diverticulitis between April 2003 and September 2011 at the University Hospital of Luxembourg were selected from a retrospective database. The patients were divided in two groups: moderate acute diverticulitis (MAD) included patients with an episode of left-lower-quadrant pain, elevated inflammatory markers, and radiologic evidence of diverticulitis, and severe acute diverticulitis (SAD) included patients with diverticula associated with abscess, phlegmon, perforation, fistula, obstruction, bleeding, or stricture.

RESULTS

A total of 121 patients (81 MAD and 40 SAD) underwent elective laparoscopic sigmoidectomy with primary anastomosis. There were no significant differences between the two groups with respect to demographic characteristics, except for sex ratio. In this series the overall morbidity rate at 30 postoperative days (POD) was 12.4 %, with no significant differences between MAD and SAD (16.0 vs. 5 %, respectively; P = 0.083). No significant differences were found with respect to mean length of hospital stay (6.7 vs. 7.7 days; P = 0.399) as well. The overall conversion rate to open surgery was 2.5 % (3 patients), with no difference between the two groups. Conversion to laparotomy was associated with an increased morbidity rate (11.0 % for full laparoscopy vs. 66.6 % for conversion; P = 0.040) and a longer length of stay (6.8 vs. 16.7 days; P = 0.008). There were no deaths within 30 POD.

CONCLUSIONS

Elective laparoscopic sigmoidectomy is safe and feasible for patients with moderate and severe acute diverticulitis and the outcomes are equivalent.

Antibiotics for uncomplicated diverticulitis

BACKGROUND

Diverticulitis is an inflammatory complication to the very common condition diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics with reference to the microbiology, extrapolation from trials on complicated intra-abdominal infections and clinical experience.

OBJECTIVES

To assess the effects of antibiotic interventions for uncomplicated diverticulitis on relevant outcome.

SEARCH METHODS

Studies were identified by computerised searches of the The Cochrane Library (CENTRAL), MEDLINE and EMBASE. Ongoing trials were identified and reference lists of identified trials and relevant review articles were screened for additional studies.

SELECTION CRITERIA

RCTs including all types of patients with a radiological confirmed diagnosis of left-sided uncomplicated diverticulitis. Interventions of antibiotics compared to any other antibiotic treatment (different regime, route of administration, dosage or duration of treatment), placebo or no antibiotics. Outcome measures were complications, emergency surgery, recurrence, late complications and duration of hospital stay and recovery of signs of infection.

DATA COLLECTION AND ANALYSIS

Two authors performed the searches, identification of RCTs, trial assessment and data extraction. Disagreements were resolved by discussion or involvement of a third part. Authors of trials were contacted to obtain additional data if needed or were contacted for preliminary results of ongoing trials. Effect estimates were extracted as relative risks (RR).

MAIN RESULTS

Three RCTs were identified. A qualitative approach with no meta analysis was performed because of variety in interventions between included studies. Interventions compared were antibiotics to no antibiotics, single to double compound antibiotic therapy and short to long IV administration. None of the studies found significant difference between the tested interventions. Risk of bias varied from low to high. The newest RCT overall had the best quality and statistical power.

AUTHORS' CONCLUSIONS

The newest evidence from one RCT says there is no significant difference between antibiotics versus no antibiotics in the treatment of uncomplicated diverticulitis. Previous RCTs have only suggested a non-inferiority between different antibiotic regimes and treatment lengths. This new evidence needs confirmation from more RCTs before it can be implicated safely in clinical guidelines. Ongoing RCTs will be published in the years to come and more are needed. The role of antibiotics in the treatment of complicated diverticulitis has not been investigated yet.

Endoscopic evaluation of the colon after an episode of diverticulitis: a call for a more selective approach

PURPOSE

Routine colonic evaluation is advised after an episode of diverticulitis to exclude colorectal cancer. In the recent years, the possible relation between diverticulitis and colorectal cancer has been subject of debate. The aim of this study is to evaluate the benefit of routine colonic endoscopy after an episode of diverticulitis.

METHODS

Records of all consecutive patients presenting with a radiologically confirmed episode of diverticulitis between 2007 and 2010 were retrieved from an in-hospital database. Patients who subsequently underwent colonic evaluation were included. The endoscopic detection rate of hyperplastic polyps, adenomas and advanced colonic neoplasia was assessed. Findings were categorized on the basis of the most advanced lesion identified.

RESULTS

Three hundred and seven patients presented with a radiologically confirmed primary episode of diverticulitis. Two hundred and five patients underwent colonic evaluation. Hyperplastic polyps were found in15 (6.8 %), adenomas in 18 (8.8 %) and advanced neoplastic lesions in 7 (3.4 %) patients. Only two patients had a colorectal malignancy.

CONCLUSION

There appears to be no benefit in performing routine colonic evaluation after an episode of diverticulitis as the incidence of colorectal cancer is almost equal to that of the general population. A more selective approach might therefore be justified. Potentially, only patients with persisting abdominal complaints after an episode of diverticulitis should be offered colonic evaluation to definitively exclude causal pathology.