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Gachabayov M, Kajmolli A, Quintero L, Felsenreich DM, Popa DE, Ignjatovic D, Bergamaschi R. Inadvertent laparoscopic lavage of perforated colon cancer: a systematic review. Langenbecks Arch Surg 2024; 409:35. [PMID: 38197963 DOI: 10.1007/s00423-023-03224-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/31/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Although laparoscopic lavage for perforated diverticulitis with peritonitis has been grabbing the headlines, it is known that the clinical presentation of peritonitis can also be caused by an underlying perforated carcinoma. The aim of this study was to determine the incidence of patients undergoing inadvertent laparoscopic lavage of perforated colon cancer as well as the delay in cancer diagnosis. METHODS The PubMed database was systematically searched to include all studies meeting inclusion criteria. Studies were screened through titles and abstracts with potentially eligible studies undergoing full-text screening. The primary endpoints of this meta-analysis were the rates of perforated colon cancer patients having undergone inadvertent laparoscopic lavage as well as the delay in cancer diagnosis. This was expressed in pooled rate % and 95% confidence intervals. RESULTS Eleven studies (three randomized, two prospective, six retrospective) totaling 642 patients met inclusion criteria. Eight studies reported how patients were screened for cancer and the number of patients who completed follow-up. The pooled cancer rate was 3.4% (0.9%, 5.8%) with low heterogeneity (Isquare2 = 34.02%) in eight studies. Cancer rates were 8.2% (0%, 3%) (Isquare2 = 58.2%) and 1.7% (0%, 4.5%) (Isquare2 = 0%) in prospective and retrospective studies, respectively. Randomized trials reported a cancer rate of 7.2% (3.1%, 11.2%) with low among-study heterogeneity (Isquare2 = 0%) and a median delay to diagnosis of 2 (1.5-5) months. CONCLUSIONS This systematic review found that 7% of patients undergoing laparoscopic lavage for peritonitis had perforated colon cancer with a delay to diagnosis of up to 5 months.
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Affiliation(s)
- Mahir Gachabayov
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA
- Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Agon Kajmolli
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA
- Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Luis Quintero
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA
- Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Daniel M Felsenreich
- Division of Visceral Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Dorin E Popa
- Department of General Surgery, Linköping University Hospital, Linköping, Sweden
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway
| | - Roberto Bergamaschi
- Department of Surgery, Jacobi Medical Center, New York City Health Hospitals, Building 1, Suite 610, 1400 Pelham Parkway S, New York, NY, USA.
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Kechagias KS, Katsikas-Triantafyllidis K, Geropoulos G, Giannos P, Zafeiri M, Tariq-Mian I, Paraskevaidi M, Mitra A, Kyrgiou M. Diverticulitis during pregnancy: A review of the reported cases. Front Med (Lausanne) 2022; 9:942666. [PMID: 36438049 PMCID: PMC9691677 DOI: 10.3389/fmed.2022.942666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/21/2022] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Diverticular disease of the colon represents a common clinical condition in the western world. Its prevalence increases with age and only 5% of cases occur in adults younger than 40 years of age, making it a rare condition during pregnancy. The aim of this review was to provide an overview of the reported cases of diverticulitis during pregnancy. METHODS We conducted a systematic review of the literature based on preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. We searched three different electronic databases namely PubMed, Scopus and Web of Science from inception to December 2021. Literature search and data extraction were completed in duplicates. RESULTS The initial search yielded 564 articles from which 12 were finally included in our review. Ten articles were case reports and two were observational studies. The mean age of the cases was 34 years. The presenting complain was provided for 11 cases. The majority of the patients (10/11, 91%) presented with abdominal pain located mainly on the left (6/11, 55%) or right (4/11, 36%) iliac fossa. The most common diagnostic modality used for the diagnosis of the condition was ultrasonography in nine cases (9/12, 75%) followed by magnetic resonance imaging (MRI) in two cases (2/12, 17%). In spite of clinical and radiological evaluation, the initial diagnosis was inaccurate in seven cases (7/12, 58%). The therapeutic approach was available for 11 cases and it was based on the administration of intravenous antibiotics in six cases (6/11, 55%) and surgical management in five cases (5/11, 45%). Data for the type of delivery was provided in nine studies with five patients (5/9, 56%) delivering vaginally and four patients (4/9, 44%) delivering with cesarean section. CONCLUSION As advanced maternal age becomes more common, the frequency of diverticulitis in pregnancy may increase. Although available guidelines do not exist, the clinical awareness, early recognition of the disorder, using diagnostic modalities such as ultrasound and MRI, and rapid therapeutic approach with antibiotics, may improve maternal and neonatal outcomes.
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Affiliation(s)
- Konstantinos S. Kechagias
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
- Society of Meta-Research and Biomedical Innovation, London, United Kingdom
| | | | - Georgios Geropoulos
- Department of General Surgery, NHS Foundation Trust, Royal Marsden Hospital, London, United Kingdom
| | - Panagiotis Giannos
- Society of Meta-Research and Biomedical Innovation, London, United Kingdom
- Department of Life Sciences, Faculty of Natural Sciences, Imperial College London, London, United Kingdom
| | - Marina Zafeiri
- Society of Meta-Research and Biomedical Innovation, London, United Kingdom
| | - Imran Tariq-Mian
- Society of Meta-Research and Biomedical Innovation, London, United Kingdom
| | - Maria Paraskevaidi
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Anita Mitra
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Maria Kyrgiou
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Life Sciences, Faculty of Natural Sciences, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
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Characteristics, treatment, and outcome of diverticulitis after immune checkpoint inhibitor treatment in patients with malignancies. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04405-3. [PMID: 36242603 DOI: 10.1007/s00432-022-04405-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/05/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) are efficacious for treating various malignancies. In addition to immune-related adverse events (irAEs), growing evidence suggests that ICIs might also be associated with diverticulitis. We aim to assess the clinical presentations and management of colonic diverticulitis among cancer patients after ICI treatment. METHODS A retrospective study was conducted on ICI-treated adult cancer patients between 01/2010 and 06/2020. Patients were grouped based on when diverticulitis developed relative to ICI treatment, either before (controls) or after (cases). Patient clinical characters, treatment, and outcomes were compared between both groups. RESULTS 77 eligible patients were included: 63 patients developed diverticulitis after ICI exposure (46 had initial episode after ICI exposure, 17 had a history of diverticulitis prior then recurred after ICI exposure), and 14 had diverticulitis before ICI exposure. Diverticulitis occurred after a median of 129 days after ICI initiation. Clinical characteristics overlapped with traditional diverticulitis. 93% of patients had symptom resolution after treatment, while 23.8% experienced complications. These patients exhibited higher rates of hospitalization (87% vs 48%, P = 0.015) and surgery/interventional radiology procedures (27% vs 0, P = 0.002), and worse overall survival (P = 0.022). History of diverticulitis was not associated with a more severe disease course. Immunosuppressants (e.g., corticosteroids) were rarely required unless for concurrent ICI-mediated colitis. CONCLUSION Colonic diverticulitis can occur after ICI therapy at very low incidence (0.5%). Its clinical presentation, evaluation, and management are similar to traditional diverticulitis, but associated with higher complication rates requiring surgical intervention and has lower overall survival.
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Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly. MEDICINA (KAUNAS, LITHUANIA) 2021; 58:medicina58010029. [PMID: 35056340 PMCID: PMC8778743 DOI: 10.3390/medicina58010029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/04/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65-74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65-92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1-48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.
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Azhar N, Buchwald P, Ansari HZ, Schyman T, Yaqub S, Øresland T, Schultz JK. Risk of colorectal cancer following CT-verified acute diverticulitis: a nationwide population-based cohort study. Colorectal Dis 2020; 22:1406-1414. [PMID: 32301257 DOI: 10.1111/codi.15073] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/11/2020] [Indexed: 12/12/2022]
Abstract
AIM Routine colonoscopy to exclude colorectal cancer (CRC) after CT-verified acute diverticulitis is controversial. This study aimed to compare the incidence of CRC in patients with acute diverticulitis with that in the general population. METHOD Patients with an emergency admission for diverticular disease to any Norwegian hospital between 1 January 2008 and 31 December 2010 were included through identification in the Norwegian Patient Registry using International Classification of Diseases (ICD-10) codes K57.1-9. To estimate the age-specific distribution of CT-verified acute uncomplicated diverticulitis (AUD) and acute complicated diverticulitis (ACD) in this nationwide study population, numbers from the largest Norwegian emergency hospital were used. Patients diagnosed with CRC within 1 year following their admission for acute diverticulitis were detected through cross-matching with the Cancer Registry of Norway. Based on both Norwegian age-specific incidence of CRC and estimated age-specific distribution of CT-verified diverticulitis, standard morbidity ratios (SMRs) were calculated. RESULTS A total of 7473 patients with emergency admissions for diverticular disease were identified (estimated CT-verified AUD n = 3523, ACD n = 1206); of these 155 patients were diagnosed with CRC within 1 year. Eighty had a CT-verified diverticulitis at index admission [41 AUD (51.3%); 39 ACD (49.7%)]. Compared with the general population, the SMR was 6.6 following CT-verified AUD and 16.3 following ACD, respectively. CONCLUSION In the first year after CT-verified acute diverticulitis, especially after ACD, the risk of CRC is higher than in the general population. This probably represents misdiagnosis of CRC as acute diverticulitis. Follow-up colonoscopy should be recommended to all patients admitted with acute diverticulitis.
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Affiliation(s)
- N Azhar
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - P Buchwald
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - H Z Ansari
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| | - T Schyman
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - S Yaqub
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - T Øresland
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - J K Schultz
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
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Niyozbekov BM, Rzaev TZ, Khalilov ZB, Chinikov MA. [Minimally invasive interventions in emergency large bowel surgery]. Khirurgiia (Mosk) 2020:109-113. [PMID: 32573541 DOI: 10.17116/hirurgia2020061109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The current trends in the treatment of various surgical diseases of large bowel using minimally invasive operations are reviewed in the manuscript. It is shown that laparoscopy is currently possible in most cases for urgent large bowel diseases.
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Affiliation(s)
- B M Niyozbekov
- Peoples' Friendship University of Russia, Moscow, Russia
| | - T Z Rzaev
- Peoples' Friendship University of Russia, Moscow, Russia
| | - Z B Khalilov
- Central Hospital of Baku, Baku, Republic of Azerbaijan
| | - M A Chinikov
- Peoples' Friendship University of Russia, Moscow, Russia
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Gasser E, Alexander P, Reich-Weinberger S, Buchner S, Kogler P, Zitt M, Kafka-Ritsch R, Öfner D. Damage control surgery for perforated diverticulitis: a two center experience with two different abdominal negative pressure therapy devices. Acta Chir Belg 2019; 119:370-375. [PMID: 30388397 DOI: 10.1080/00015458.2018.1534397] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: The adoption of abdominal negative pressure therapy (NPT) during urgent laparotomy has shown to be helpful to control abdominal sepsis, improve morbidity and increase anastomosis rate. The aim of this study was to compare feasibility and outcome of two different abdominal negative pressure devices. Methods: The retrospective two-center study includes 78 consecutive patients with perforated sigmoid diverticulitis, who underwent urgent laparotomy using the ABThera™ (KCI, Wien, Austria) abdominal NPT device (Group A, n = 51) or the Suprasorb® CNP (Lohmann & Rauscher, Wien, Austria) abdominal NPT device (Group B, n = 27). Results: The mean length of abdominal NPT was 3.6 days in Group A and 2.8 days in Group B. Revisional surgery after closure of the abdomen was necessary due to surgical site infections, fascial dehiscence or anastomotic insufficiency in 25% and 29%, respectively. NPT-associated complications like fistula formation or acute bleeding were not observed. Mortality was 15% (Group A) and 7% (Group B). Conclusion: Despite the good feasibility and the well-known positive effect of abdominal NPT, perforated diverticulitis is still associated with high morbidity. However, the analysis did not show significant differences between the two abdominal NPT devices.
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Affiliation(s)
- Elisabeth Gasser
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Perathoner Alexander
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Selina Buchner
- Department of Surgery, Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - Pamela Kogler
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Matthias Zitt
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Department of Surgery, Paracelsus Private Medical University Salzburg, Salzburg, Austria
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Azhar N, Kulstad H, Pålsson B, Kurt Schultz J, Lydrup ML, Buchwald P. Acute uncomplicated diverticulitis managed without antibiotics - difficult to introduce a new treatment protocol but few complications. Scand J Gastroenterol 2019; 54:64-68. [PMID: 30650309 DOI: 10.1080/00365521.2018.1552987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Routine antibiotic treatment of acute uncomplicated diverticulitis (AUD) has been shown ineffective. In this study, the adherence to a new treatment protocol for uncomplicated diverticulitis was evaluated and the incidence of complications in patients treated with and without antibiotics was investigated. MATERIALS AND METHODS A retrospective study of in-patients diagnosed with AUD at Helsingborg Hospital, Sweden between 01 January 2013 and 06 January 2015 was performed. Antibiotics were routinely administrated until 01 May 2014. Thereafter, a new antibiotic-free treatment protocol for uncomplicated diverticulitis was introduced. All the patients were followed regarding complications for minimum one year. RESULTS A total of 50 patients were studied after the new protocol implementation and, 60% (n = 31) of the patients were treated without antibiotics. Specialists initiated antibiotic therapy significantly more often than registrars (p=.03). More patients in the antibiotic group had comorbidities (p=.03), apart from that, no significant differences in baseline characteristics were noted between treatment groups. Patients treated with antibiotics after introduction of the new protocol had significantly higher C-reactive protein than patients managed without antibiotics (median 117 mg/L vs. 70, p=.005). The hospital stay was shorter in the non-antibiotic group (three days vs. two days; p=.008). No significant differences in complications were observed. CONCLUSIONS Protocol compliance was lower than expected, indicating that implementation of new treatment regimens is challenging. This study confirms that complications are rare in AUD treated without antibiotics. However, the selection of the sickest patients to the treatment with antibiotics limits the interpretation of the results.
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Affiliation(s)
- Najia Azhar
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
| | - Hanna Kulstad
- b Department of Surgery , Helsingborg Hospital , Helsingborg , Sweden
| | - Birger Pålsson
- b Department of Surgery , Helsingborg Hospital , Helsingborg , Sweden
| | - Johannes Kurt Schultz
- c Department of Digestive Surgery , Akershus University Hospital , Lørenskog , Norway
| | - Marie-Louise Lydrup
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
| | - Pamela Buchwald
- a Colorectal Unit, Department of Surgery , Skåne University Hospital Malmö , Malmö, Sweden
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Gachabayov M, Oberkofler CE, Tuech JJ, Hahnloser D, Bergamaschi R. Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis. Colorectal Dis 2018; 20:753-770. [PMID: 29694694 DOI: 10.1111/codi.14237] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
AIM It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates. METHOD The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively. RESULTS Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)]. CONCLUSION This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.
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Affiliation(s)
- M Gachabayov
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - C E Oberkofler
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J J Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - R Bergamaschi
- Division of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Abstract
Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.
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12
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Bollom A, Austrie J, Hirsch W, Nee J, Friedlander D, Ellingson K, Cheng V, Lembo A. Emergency Department Burden of Diverticulitis in the USA, 2006-2013. Dig Dis Sci 2017; 62:2694-2703. [PMID: 28332105 PMCID: PMC5610055 DOI: 10.1007/s10620-017-4525-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/28/2017] [Indexed: 01/10/2023]
Abstract
GOALS The aim of this study was to analyze recent trends in emergency department (ED) visits for diverticulitis between 2006 and 2013. BACKGROUND Acute diverticulitis is a serious medical condition that frequently leads to ED visits, hospitalizations, and surgeries resulting in a significant health care burden. METHODS Data were obtained from the National Emergency Department Sample (NEDS) records in which diverticulitis (ICD-9-CM codes 562.11 and 562.13) was the primary diagnosis in the ED between 2006 and 2013. The NEDS collects data from more than 25 million visits in over 950 hospital emergency departments and is weighted to provide national estimates. Our findings reflected patient and hospital characteristics such as demographics, geographical region, and total charges for ED and inpatient stays. RESULTS Between 2006 and 2013, the rate of diverticulitis-related ED visits increased by 26.8% from 89.8 to 113.9 visits per 100,000 population. The aggregate national cost of diverticulitis-related ED visits increased by 105%, from approximately $822 million in 2006 to over $1.6 billion in 2013. Cost data were adjusted for inflation and reported in 2015 dollars. The percentage of individuals admitted to the same hospital from the ED decreased from 58.0 to 47.1% from 2006 to 2013, respectively, while the rate of bowel surgeries per 100,000 ED visits for diverticulitis decreased by 33.7% from 2006 to 2013. CONCLUSIONS The number of ED visits due to diverticulitis and associated costs continued to rise between 2006 and 2013, while the rate of bowel surgeries and inpatient admissions through the ED for diverticulitis decreased.
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Affiliation(s)
- Andrea Bollom
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jasmine Austrie
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - William Hirsch
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Judy Nee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Daniel Friedlander
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Kelli Ellingson
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Vivian Cheng
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Anthony Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
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Laparoscopic approaches to complicated diverticulitis. Langenbecks Arch Surg 2017; 403:11-22. [PMID: 28875302 DOI: 10.1007/s00423-017-1621-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. PURPOSE The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis. CONCLUSIONS New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.
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Maconi G. Diagnosis of symptomatic uncomplicated diverticular disease and the role of Rifaximin in management. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:25-32. [PMID: 28467330 PMCID: PMC6166204 DOI: 10.23750/abm.v88i1.6360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 12/12/2022]
Abstract
Patients with diverticulosis who develop persistent abdominal pain, bloating and changes in bowel habits not associated with overt inflammation may have symptomatic uncomplicated diverticular disease (SUDD). The severity and frequency of SUDD symptoms may have an impact on daily activities and severely affect quality of life. Effective management of SUDD should follow a three part strategy: divert, tackle and maintain. Divert to make the correct diagnosis: several symptoms of SUDD are common to other conditions that require different therapeutic approaches. However, several key differences should be used to diagnose SUDD. Pain in SUDD is normally in the iliac fossa, persistent, often lasting more than 24 hrs, and is not relieved by bowel movement, as is often the case with irritable bowel syndrome. Another difference is in the timing: the prevalence of SUDD increases with age, and patients under the age of 40 years are less likely to have diverticula. It is useful to establish whether a patient has diverticulosis, especially if the patient is relatively young; lack of diverticula excludes SUDD. Cross-sectional imaging is indicated; however, recent archival image data or ultrasonography may be useful alternatives. Laboratory tests should be ordered to exclude overt inflammation. Once the diagnosis of SUDD is made, the patient should receive effective therapy to tackle the condition. This should include dietary fibre supplementation and cyclic treatment with rifaximin 400 mg twice daily for 7 days per month. Once symptom control is achieved, it should be maintained by continuing therapy for at least 12 months.
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Affiliation(s)
- Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy.
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Preoperative vitamin C supplementation improves colorectal anastomotic healing and biochemical parameters in malnourished rats. Int J Colorectal Dis 2016; 31:1759-1766. [PMID: 27614446 DOI: 10.1007/s00384-016-2647-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 02/06/2023]
Abstract
PURPOSES The objective of this study was to evaluate the effect of supplementation with vitamin C on intestinal anastomosis healing in malnourished rats. METHODS Male Wistar rats were divided into three groups: (1) sham, well-nourished rats that received vehicle; (2) FR+Veh, rats that were subjected to food restriction and received vehicle; and (3) FR+VC, rats that were subjected to food restriction and received vitamin C. Four days before surgery, the animals received vitamin C (100 mg/kg/day) via gavage and underwent colon resection with anastomosis in a single plane. The survival rate of rats was monitored until day 7 after surgery. Regarding anastomosis tissues, we examined intra-abdominal adhesion index, hydroxyproline content, collagen density, inflammatory parameters, and oxidative damage to proteins and lipids. RESULTS Malnutrition decreases body weight and increases mortality; the survival rate was 90 % in group 1, 60 % in group 2, and 80 % in group 3. Vitamin C was able to increase hydroxyproline concentration and density of collagen and decrease the intra-abdominal adhesion index, as well as the infiltration of neutrophils and oxidative damage to proteins in malnourished rats compared to group treated with vehicle. CONCLUSIONS Preoperative vitamin C supplementation can improve the intestinal anastomosis healing, biochemical alterations, and prolong survival in rats subjected to food restriction.
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Jongen AC, Bosmans JW, Kartal S, Lubbers T, Sosef M, Slooter GD, Stoot JH, van Schooten FJ, Bouvy ND, Derikx JP. Predictive Factors for Anastomotic Leakage After Colorectal Surgery: Study Protocol for a Prospective Observational Study (REVEAL Study). JMIR Res Protoc 2016; 5:e90. [PMID: 27282451 PMCID: PMC4919551 DOI: 10.2196/resprot.5477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/07/2016] [Accepted: 02/07/2016] [Indexed: 12/28/2022] Open
Abstract
Background Anastomotic leakage (AL) remains the most important complication following colorectal surgery, and is associated with high morbidity and mortality rates. Previous research has focused on identifying risk factors and potential biomarkers for AL, but the sensitivity of these tests remains poor. Objective This prospective multicenter observational study aims at combining multiple parameters to establish a diagnostic algorithm for colorectal AL. Methods This study aims to include 588 patients undergoing surgery for colorectal carcinoma. Patients will be eligible for inclusion when surgery includes the construction of a colorectal anastomosis. Patient characteristics will be collected upon consented inclusion, and buccal swabs, breath, stool, and blood samples will be obtained prior to surgery. These samples will allow for the collection of information regarding patients’ inflammatory status, genetic predisposition, and intestinal microbiota. Additionally, breath and blood samples will be taken postoperatively and patients will be strictly observed during their in-hospital stay, and the period shortly thereafter. Results This study has been open for inclusion since August 2015. Conclusions An estimated 8-10% of patients will develop AL following surgery, and they will be compared to non-leakage patients. The objectives of this study are twofold. The primary aim is to establish and validate a diagnostic algorithm for the pre-operative prediction of the risk of AL development using a combination of inflammatory, immune-related, and genetic parameters. Previously established risk factors and novel parameters will be incorporated into this algorithm, which will aid in the recognition of patients who are at risk for AL. Based on these results, recommendations can be made regarding the construction of an anastomosis or deviating stoma, and possible preventive strategies. Furthermore, we aim to develop a new algorithm for the post-operative diagnosis of AL at an earlier stage, which will positively reflect on short-term survival rates. Trial Registration Clinicaltrials.gov: NCT02347735; https://clinicaltrials.gov/ct2/show/NCT02347735 (archived by WebCite at http://www.webcitation.org/6hm6rxCsA)
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Affiliation(s)
- Audrey Chm Jongen
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.
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Abstract
BACKGROUND Diverticulitis is commonly diagnosed using ultrasound (US), followed by computed tomography (CT). Our aim was to determine the diagnostic accuracy of US compared with CT for patients with uncomplicated and complicated diverticulitis. METHODS We reviewed medical records of 232 patients admitted with diverticulitis via the emergency department between January 2009 and January 2011. Patients who had undergone US and a CT scan were identified and further analyzed. RESULTS A total of 123 patients underwent an US and a CT scan. In 78/94 patients with uncomplicated diverticulitis, results of US and CT scan were compatible (83 %); in 6 of the remaining 29 patients both modalities showed a complicated diverticulitis (21 %). US misdiagnosed 17 % of patients with uncomplicated diverticulitis and 79 % with complicated diverticulitis. CONCLUSIONS US is insufficient for diagnosing a complicated diverticulitis. Missing a complicated diverticulitis can have important clinical implications, and if diverticulitis is suspected, we suggest obtaining a CT scan to confirm diagnosis and to exclude complications.
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18
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Yauw STK, Wever KE, Hoesseini A, Ritskes-Hoitinga M, van Goor H. Systematic review of experimental studies on intestinal anastomosis. Br J Surg 2015; 102:726-34. [PMID: 25846745 DOI: 10.1002/bjs.9776] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/04/2014] [Accepted: 12/18/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND The contribution of animal research to a reduction in clinical intestinal anastomotic leakage is unknown, despite numerous experimental studies. In view of the current societal call to replace, reduce and refine animal experiments, this study examined the quality of animal research related to anastomotic healing and leakage. METHODS Animal studies on intestinal anastomotic healing were retrieved systematically from PubMed and Embase. Study objective, conclusion and animal model were recorded. Reporting quality and internal validity (reporting of randomization and blinding) were assessed. RESULTS A total of 1342 studies were identified, with a rising publication rate. The objectives of most studies were therapeutic interventions (64·8 per cent) and identification of risk factors (27·5 per cent). Of 350 articles studying experimental therapies, 298 (85·1 per cent) reported a positive effect on anastomotic healing. On average, 44·7 per cent of relevant study characteristics were not reported, in particular details on anastomotic complications (31·6 per cent), use of antibiotics (75·7 per cent), sterile surgery (83·4 per cent) and postoperative analgesia (91·4 per cent). The proportion of studies with randomization, blinding of surgery and blinding of primary outcome assessment has increased in the past two decades but remains insufficient, being included in only 62·4, 4·9 and 8·5 per cent of publications respectively. Animal models varied widely in terms of species, method to compromise healing, intestinal segment and outcome measures used. CONCLUSION Animal research on anastomotic leakage is of poor quality and still increasing, contrary to societal aims. Reporting and study quality must improve if results are to impact on patients.
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Affiliation(s)
- S T K Yauw
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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George J, Ben-Sassi A, Dixon R. Spontaneous haemoperitoneum due to a sigmoid diverticulum. BMJ Case Rep 2014; 2014:bcr-2014-207849. [PMID: 25480140 DOI: 10.1136/bcr-2014-207849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Spontaneous haemoperitoneum is rare. When it occurs it is a life-threatening condition. Common causes of this are gynaecological in nature and rarely due to colonic diverticular perforation. Diverticulitis is a common condition affecting people in western countries. This presentation of spontaneous haemoperitoneum highlights the disproportionate abdominal pain and opioid-induced constipation. Significant bloods on admission included haemoglobin of 148 g/L, C reactive protein (CRP) of 1.1 mg/L, white cell count (WCC) of 12.7×10(9)/L (neutrophils 10.9×10(9)/L). Bloods repeated 10 h later revealed the haemoglobin had dropped to 100 g/L, CRP had increased significantly to 120 mg/L, WCC: 7.4×10(9)/L (neutrophils 5.3×10(9)/L) and a reduced packed cell volume: 0.307 L/L. CT scan revealed free fluid and a possible mass. At laparoscopy, frank haemoperitoneum was seen and a decision was made to open and perform a Hartmann's procedure. The patient did very well postoperatively and was discharged on the ninth postoperative day. He is currently awaiting reversal of the ileostomy.
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Affiliation(s)
- Jayan George
- Respiratory Department, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Abozed Ben-Sassi
- Department of General Surgical Directorate, Wrexham Maelor Hospital, Wrexham, UK
| | - Rebecca Dixon
- Department of Radiology, Wrexham Maelor Hospital, Wrexham, UK
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Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence: a randomised multicentre pilot double-blind placebo-controlled study of 24-month duration. Int J Colorectal Dis 2013; 28:1423-31. [PMID: 23754545 DOI: 10.1007/s00384-013-1722-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Recurrence of diverticulitis is frequent within 5 years from the uncomplicated first attack, and its prophylaxis is still unclear. We have undertaken a multicentre, randomised, double-blind, placebo-controlled pilot study in order to evaluate the role of mesalazine in preventing diverticulitis recurrence as well as its effects on symptoms associated to diverticular disease. METHODS Ninety-six patients with the recent first episode of uncomplicated diverticulitis were randomised to receive mesalazine 800 mg twice daily for 10 days every month or placebo for 24 months. The primary efficacy end point was the diverticulitis recurrence at intention to treat analysis. Clinical evaluations were performed using the Therapy Impact Questionnaire (TIQ) for physical condition and quality of life at admission and at 3-month intervals. Treatment tolerability and routine biochemistry parameters as well as the use of additional drugs were also evaluated. RESULTS Ninety-two patients (mean age, 61.5) completed the study, 45 of whom received mesalazine, and 47, placebo. Diverticulitis relapse incidence in mesalazine-treated group was 5/45 (11%) at the 12th month and 6/45 (13%) at the 24th month; in the placebo-treated group, the correspondent rates were 13% (6/47) and 28% (13/47), respectively. Mean values of TIQ at 24 months were significantly better in mesalazine-treated group than in placebo-treated group (p = 0.02); in addition, average additional drug consumption was significantly lower (-20.4%, p < 0.03) in mesalazine than in placebo. CONCLUSIONS Diverticulitis recurrence occurred in as many as 28% of patients under placebo within 24 months from the initial episode. Intermittent prophylaxis with mesalazine did not significantly reduce the risk of relapse but induced a significant improvement of patients' physical conditions and significantly lowered the additional consumption of other gastrointestinal drugs.
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Reddy VB, Longo WE. The burden of diverticular disease on patients and healthcare systems. Gastroenterol Hepatol (N Y) 2013; 9:21-7. [PMID: 24707230 PMCID: PMC3975974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Diverticulitis is a debilitating complication of diverticular disease that affects approximately 2.5 million individuals in the United States. Compared to many other gastrointestinal conditions, diverticular disease is poorly understood in terms of its burden on patients and healthcare systems. This review examines the existing literature and discusses the current knowledge of the burden of diverticular disease. Literature confirmed that bothersome symptoms (such as abdominal pain and bloating) and potentially serious, disease-related complications (such as diverticulitis and diverticular bleeding) place a significant burden on patients. Broad-spectrum antibiotic therapy and surgery are the generally accepted mainstays of treatment for acute complications of diverticular disease. Despite these options, patients frequently experience substantially reduced quality of life (particularly in terms of social and emotional functioning) and increased mortality (predominantly due to disease-related complications) compared to healthy controls. Furthermore, diverticular disease accounted for 254,179 inpatient discharges and 1,493,865 outpatient clinic visits in the United States in 2002, at an estimated cost per hospitalization of $9,742-$11,729. Enhancing the quality of life of patients with diverticular disease and reducing disease exacerbations and complications will substantially benefit patients and healthcare systems. However, long-established treatment algorithms fall short of these therapeutic goals. Research into new treatment options for patients with diverticular disease should therefore be pursued.
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Affiliation(s)
- Vikram B Reddy
- Dr. Reddy is an Assistant Professor of Colon and Rectal Surgery in the Department of Surgery at Yale University School of Medicine in New Haven, Connecticut, where Dr. Longo is a Professor of Surgery (Gastrointestinal); a Professor of Obstetrics, Gynecology, and Reproductive Sciences; and Section Chief and Director of Colon and Rectal Surgery
| | - Walter E Longo
- Dr. Reddy is an Assistant Professor of Colon and Rectal Surgery in the Department of Surgery at Yale University School of Medicine in New Haven, Connecticut, where Dr. Longo is a Professor of Surgery (Gastrointestinal); a Professor of Obstetrics, Gynecology, and Reproductive Sciences; and Section Chief and Director of Colon and Rectal Surgery
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Biondo S, Lopez Borao J, Millan M, Kreisler E, Jaurrieta E. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis 2012; 14:e1-e11. [PMID: 21848896 DOI: 10.1111/j.1463-1318.2011.02766.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM This paper addresses the current status of the treatment of acute colonic diverticulitis by an evidence-based review. METHOD A systematic search in PUBMED, MEDLINE, EMBASE and Google scholar on colonic diverticulitis was performed. Diagnostic tools, randomized controlled trials, non-randomized comparative studies, observational epidemiological studies, national and international guidelines, reviews of observational studies on elective and emergency surgical treatment of diverticulitis, and studies of prognostic significance were reviewed. Criteria for eligibility of the studies were diagnosis and classification, medical treatment, inpatients and outpatients, diverticulitis in young patients, immunosuppression, recurrence, elective resection, emergency surgery, and predictive factors. RESULTS Some 92 publications were selected for comprehensive review. The review highlighted that computed tomography is the most effective test in the diagnosis and staging of acute diverticulitis; outpatient treatment can be performed for uncomplicated diverticulitis in patients without associated comorbidities; conservative treatment is aimed at those patients with uncomplicated acute diverticulitis; elective surgery must be done on an individual basis; laparoscopic approach for elective treatment of diverticulitis is appropriate but may be technically complex; in perforated diverticulitis, resection with primary anastomosis is a safe procedure that requires experience and should take into account strict exclusion criteria. CONCLUSION The heterogeneity of patients with colonic diverticular disease means that both elective and urgent treatment should be tailored on an individual basis.
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Affiliation(s)
- S Biondo
- Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, IDIBELL (Bellvitge Biomedical Research Institute), Barcelona, Spain.
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Tursi A, Joseph RE, Streck P. Expanding applications: the potential usage of 5-aminosalicylic acid in diverticular disease. Dig Dis Sci 2011; 56:3112-21. [PMID: 21567193 DOI: 10.1007/s10620-011-1731-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 04/18/2011] [Indexed: 12/21/2022]
Abstract
Diverticular disease is a common bowel condition, the pathogenesis of which is incompletely understood. Acute exacerbations of diverticular disease usually require dietary changes, antibiotic therapy, and may necessitate urgent surgery. Approximately 25-33% of patients experience symptomatic and acute inflammatory disease recurrence, suggesting that current long-term management is inadequate. Because inflammatory complications of diverticular disease, including diverticulitis, are similarities to inflammatory bowel diseases, evidence suggests that patients may respond to anti-inflammatory therapies used in these conditions. Here, we explore the rationale and evidence for use of inflammatory bowel disease treatment, namely 5-aminosalicylic acid (5-ASA; mesalamine), in diverticular disease, and review clinical data on the efficacy of mesalamine either alone or in combination with other agents for the treatment of diverticular disease. PubMed and conference abstracts were searched for clinical studies examining the use of mesalamine in treating diverticular disease. Studies were evaluated for treatment efficacy in symptom reduction, recurrence prevention, or improving quality of life. The results of our search suggest that single-agent mesalamine can reduce diverticular disease symptoms and improve quality of life more effectively than antibiotic treatment alone. Mesalamine in combination with antibiotics can also reduce symptoms and improve quality of life with greater efficacy than either treatment alone. Combining mesalamine and probiotics treatments may reduce recurrent attacks of diverticular disease. Further randomized, well-controlled studies are required for validation; however, it seems that mesalamine is an important agent in future diverticular disease management.
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Affiliation(s)
- Antonio Tursi
- Gastroenterology Service, ASL BAT, Via Torino, 49, 76123 Andria, BT, Italy.
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Lee Y, Francone T. Special Situations in the Management of Colonic Diverticular Disease. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ribas Y, Bombardó J, Aguilar F, Jovell E, Alcantara-Moral M, Campillo F, Lleonart X, Serra-Aracil X. Prospective randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicillin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis. Int J Colorectal Dis 2010; 25:1363-70. [PMID: 20526718 DOI: 10.1007/s00384-010-0967-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2010] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Medical treatment of uncomplicated acute diverticulitis is not standardized, and there is an enormous diversity in clinical practice. Our aim was to demonstrate that uncomplicated diverticulitis can be managed with orally administered amoxicillin plus clavulanic acid and a short hospital admission. METHODS A prospective randomized trial was established to compare patients with uncomplicated diverticulitis who received oral antibiotic after a short course of intravenous antibiotic with those who received intravenous antibiotic for a longer period. The antibiotic treatment consisted of amoxicillin plus clavulanic acid 1 g every 8 h. We included 50 patients, 25 in each group. Patients in group 1 began oral antibiotic as soon as they improved and were discharged the day after. Patients in group 2 received intravenous antibiotic for 7 days. Both groups received oral antibiotic at discharge. The endpoint of the study was "failure of treatment," which was defined as the impossibility of discharging on the expected day, emergency admission, or hospital readmission. RESULTS Both groups were comparable in patient demographics and clinical characteristics. Most patients clearly improved between 24 and 48 h after admission. There were no significant differences between the groups when comparing failure of treatment. Treatment of patients in group 1 represented a savings in hospitalization costs of 1,244<euro> per patient. CONCLUSIONS Most patients with uncomplicated diverticulitis can be managed safely with oral antibiotic; thus, a very short hospital stay is a safe option.
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Affiliation(s)
- Yolanda Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, Carretera de Torrebonica s/n, Terrassa, Spain.
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Lam TJ, Meurs-Szojda MM, Gundlach L, Belien JAM, Meijer GA, Mulder CJ, Felt-Bersma RJF. There is no increased risk for colorectal cancer and adenomas in patients with diverticulitis: a retrospective longitudinal study. Colorectal Dis 2010; 12:1122-6. [PMID: 19575738 DOI: 10.1111/j.1463-1318.2009.01992.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AIM This study was designed to assess the relationship between diverticulitis and the development of colorectal cancer (CRC) and colonic adenomas. METHOD A retrospective study was longitudinally conducted. Patients who had been admitted to the hospital between 1990 and 2000 with diverticulitis were retrieved and the incidence of CRC and prevalence of colonic adenomas in these patients was determined. Data were collected from the electronic clinical and pathology records. The incidence of CRC and prevalence of adenomas in this patient cohort was compared with the general population. The patients were followed until 2008. RESULTS A total of 288 patients with diverticulitis were included (167 of whom were female patients [58%]). The mean age of patients at admittance for diverticulitis was 66 years (range: 27-92). CRC was detected in five patients (1.7%) (95% CI 0.8-3.5) with a mean age of 77 years; colonic adenomas were found in 18 patients (6.3%) (95% CI 4.3-9.0) with a mean age of 62 years. The lifetime risks of developing CRC and adenomas were presumed to be 4% and 20% respectively. Expected rates for CRC and adenomas in our patients were calculated as 17 (95% CI 4.0-8.6) and 69 patients (95% CI 20.1-28.3) respectively. CONCLUSION This study showed a lower prevalence of CRC and colonic adenomas in patients with diverticulitis compared with the lifetime risk which means that diverticulitis is not a risk factor for development of CRC and adenomas. Long-term colonic screening after a negative colonoscopy for diverticulitis (generally performed several weeks after recovery) does not seem to be justified.
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Affiliation(s)
- T J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands.
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27
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Perathoner A, Klaus A, Mühlmann G, Oberwalder M, Margreiter R, Kafka-Ritsch R. Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis--a proof of concept. Int J Colorectal Dis 2010; 25:767-74. [PMID: 20148255 DOI: 10.1007/s00384-010-0887-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE Perforated diverticulitis with advanced generalized peritonitis is a life-threatening condition requiring emergency operation. To reduce the rate of colostomy formation, a new treatment algorithm with damage control operation, lavage, limited closure of perforation, abdominal vacuum-assisted closure (VAC; V.A.C.), and second look to restore intestinal continuity was developed. METHODS This algorithm allowed for three surgical procedures: primary anastomosis +/- VAC in stable patients (group I), but damage control with lavage, limited resection of the diseased colonic segment, VAC and second-look operation with delayed anastomosis in patients with advanced peritonitis or septic shock (group II), and Hartmann procedure was done for social reasons in stable patients (group III) RESULTS: All 27 consecutive patients (16 women; median age 68 years) requiring emergency laparotomy for perforated diverticulitis (Hinchey III/IV) between October 2006 and September 2008 were prospectively enrolled in the study. No major complications were observed in group I (n = 6). Nine patients in group II (n = 15) had intestinal continuity restored during a second-look operation, of whom one patient developed anastomotic leakage. The median length of stay at intensive care unit was 5 days. Considering an overall mortality rate of 26% (n = 7), the rate of anastomosis in surviving patients was 70%. CONCLUSIONS Damage control with lavage, limited bowel resection, VAC, and scheduled second-look operation represents a feasible strategy in patients with perforated diverticulitis (Hinchey III and IV) to enhance sepsis control and improve rate of anastomosis.
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Affiliation(s)
- Alexander Perathoner
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA. Patterns of recurrence in patients with acute diverticulitis. Br J Surg 2010; 97:952-7. [DOI: 10.1002/bjs.7035] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Background
The natural history of acute diverticulitis remains unclear, with the role of prophylactic surgery following conservatively managed diverticulitis increasingly controversial. This study investigated recurrence rates, patterns and complications after conservatively managed diverticulitis.
Methods
This was a retrospective chart review of all patients admitted with diverticulitis between June 1997 and June 2002. Demographic data, management, recurrence rates, complications and subsequent surgery were recorded.
Results
Some 502 patients were identified, 337 with uncomplicated and 165 with complicated diverticulitis. Median follow-up was 101 (range 60–124) months. Of 320 patients with uncomplicated diverticulitis managed conservatively, 60 (18·8 per cent) had one episode of recurrence, whereas 15 (4·7 per cent) had two or more episodes. After an initial attack of uncomplicated diverticulitis, only 5·0 per cent developed complicated disease. Complicated disease recurred in 24 per cent, compared with a recurrence rate of 23·4 per cent in those with uncomplicated diverticulitis (P = 0·622). When recurrence occurred, it usually did so within 12 months of the initial episode.
Conclusion
Acute diverticulitis has a low recurrence rate and rarely progresses to complications. Any recurrence is usually early, in a pattern more consistent with failure of the index episode to settle. Subsequent elective surgery to prevent recurrence and the development of complications should be used sparingly.
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Affiliation(s)
- T Eglinton
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - T Nguyen
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - S Raniga
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - L Dixon
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - B Dobbs
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - F A Frizelle
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
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30
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Ooi K, Wong SW. Management of symptomatic colonic diverticular disease. Med J Aust 2009; 190:37-40. [DOI: 10.5694/j.1326-5377.2009.tb02262.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 06/19/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Kevin Ooi
- Department of Surgery, Prince of Wales Hospital and University of New South Wales, Sydney, NSW
| | - Shing W Wong
- Department of Surgery, Prince of Wales Hospital and University of New South Wales, Sydney, NSW
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Diverticular disease of the colon: A conservative approach works best. JAAPA 2008; 21:48-53. [DOI: 10.1097/01720610-200806000-00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The acute abdomen accounts for up to 40% of all emergency-surgical hospital admissions and is considered in the differential in the more than 7 million visits to the emergency department annually for abdominal pain in the United States. A large percentage of these cases are secondary to perforation or impending gastrointestinal perforation. Gastrointestinal perforation causes considerable mortality and usually requires emergency surgery.Rapid diagnosis and treatment of these conditions is essential to reduce the high morbidity and mortality of late-stage presentation. Successful treatment requires a thorough understanding of the anatomy, microbiology, and pathophysiology of this disease process and in-depth knowledge of the therapy, including resuscitation,antibiotics, source control, and physiologic support.
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Affiliation(s)
- John T Langell
- Department of Surgery, University of Utah, 30 North 1900 East, SOM 3B115, Salt Lake City, UT 84132, USA.
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Scott DA, Glancy S. Spontaneous resolution of a giant colonic diverticulum. Clin Radiol 2008; 63:833-5. [PMID: 18555044 DOI: 10.1016/j.crad.2007.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2007] [Revised: 08/12/2007] [Accepted: 08/20/2007] [Indexed: 12/16/2022]
Affiliation(s)
- D A Scott
- Western General Hospital, Crewe Rd South, Edinburgh, EH4 2XU, UK.
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Szojda MM, Cuesta MA, Mulder CM, Felt-Bersma RJF. Review article: Management of diverticulitis. Aliment Pharmacol Ther 2007; 26 Suppl 2:67-76. [PMID: 18081651 DOI: 10.1111/j.1365-2036.2007.03491.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM The incidence and therefore complications of (sigmoid) diverticular disease are increasing. METHODS Review of current literature. RESULTS From all patients, 15% will develop diverticulitis, 5% complications and 5% diverticular bleeding. Diagnosis is established with computerised tomography. Colonoscopy is needed to rule out malignancy. NSAIDs increase the risk of perforation; steroids, diabetes, collagen vascular disease and immune compromised are associated with complicated disease and death. In mild diverticulitis, antibiotics are recommended. In complicated disease with abscesses, <5 cm antibiotics are sufficient. Larger abscesses are drained under computerised tomography-guidance. Peritonitis forms an indication for surgery. Diverticulitis recurrence rate is around 30%, most are uncomplicated. Recurrence after surgery is around 10%. Elective surgery is reserved for fistula closure and obstruction. The need for elective surgery to prevent recurrence has diminished because of new insights. Important is to identify risk groups. New issues are the possible relationship between diverticulitis and cancer, segmental colitis associated with diverticulitis, and treatment of diverticulitis with mesalazine and probiotics. CONCLUSIONS Uncomplicated diverticulitis is treated medically. Complicated diverticulitis with small abscesses is treated with antibiotics while larger abscesses are drained with computerised tomography-guided puncture. Emergency surgery is reserved for peritonitis, elective surgery for fistula/stenosis. Surgery to prevent recurrence is indicated only in selected cases (e.g. immune compromised).
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Affiliation(s)
- M M Szojda
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
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Iacopini F, Bizzotto A, Boskoski I, Bulajic M, Costamagna G. Epidemiology and management of diverticular disease of the colon. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/1745509x.3.4.551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The aim of this review is mainly to show the high prevalence of diverticulosis and the clinical relevance of uncomplicated and complicated diverticular disease worldwide. The prevalence of diverticular disease is directly related to the aging of the population and in western countries is diagnosed in approximately 50–65% of adult subjects. The often more frequent adoption of an incorrect dietary style, such as a low-fiber diet, and the progressive increase in the average age of western populations will increase the prevalence of this pathology and the economic burden for health systems even more so. Furthermore, the management of uncomplicated diverticular disease, segmental colitis associated to diverticula and diverticulitis, which represent the different manifestations of the symptomatic spectrum of colonic diverticulosis, are reported.
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Affiliation(s)
- Federico Iacopini
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Alessandra Bizzotto
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Ivo Boskoski
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Milutin Bulajic
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Guido Costamagna
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
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Santaniello M, Bergamaschi R. Perforated diverticulitis: should the method of surgical access to the abdomen determine treatment? Colorectal Dis 2007; 9:494-5. [PMID: 17573741 DOI: 10.1111/j.1463-1318.2006.01177.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- M Santaniello
- Department of Surgery, Lehigh Valley Hospital, Penn State University Campus, Allentown, PA 18105-1556, USA
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Junghans T, Schwenk W. Indikation zur chirurgischen Therapie der Sigmadivertikulitis aus der Sicht des Chirurgen*. Visc Med 2006. [DOI: 10.1159/000096185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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