Value of CT for acute left-colonic diverticulitis: the surgeon's view

Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy

Management of diverticular abscess (DA) is still controversial. Antibiotic therapy is indicated in abscesses ≤ 4 cm, while percutaneous drainage/surgery in abscesses > 4 cm. The study aims to assess the role of antibiotics and surgical treatments in patients affected by DA. We retrospectively analyzed 100 consecutive patients with DA between 2013 and 2020, with a minimum follow-up of 12 months. They were divided into two groups depending on abscess size ≤ or > 4 cm (group 1 and group 2, respectively). All patients were initially treated with intravenous antibiotics. Surgery was considered in patients with generalized peritonitis at admission or after the failure of antibiotic therapy. The primary endpoint was to compare recurrence rates for antibiotics and surgery. The secondary endpoint was to assess the failure rate of each antibiotic regimen resulting in surgery. In group 1, 31 (72.1%) patients were conservatively treated and 12 (27.9%) underwent surgery. In group 2, percentages were respectively 50.9% (29 patients) and 49.1% (28 patients). We observed 4 recurrences in group 1 and 6 in group 2. Recurrence required surgery in 3 patients/group. We administered amoxicillin-clavulanic acid to 74 patients, piperacillin-tazobactam to 14 patients and ciprofloxacin + metronidazole to 12 patients. All patients referred to surgery had been previously treated with amoxicillin-Powered by Editorial Manager^® and ProduXion Manager^® from Aries Systems Corporation clavulanic acid. No percutaneous drainage was performed in a hundred consecutive patients. Surgical treatment was associated with a lower risk of recurrence in patients with abscess > 4 cm, compared to antibiotics. Amoxicillin-clavulanic acid was associated with a higher therapeutic failure rate than piperacillin-tazobactam/ciprofloxacin + metronidazole.

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

PURPOSE/BACKGROUND

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

METHODS

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

RESULTS/OUTCOMES

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

CONCLUSION/DISCUSSION

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

Is There an Impact of the Duration of Antibiotic Therapy on the Outcome of Nonsurgical Treatment of Complicated Diverticulitis?

BACKGROUND

Patients treated nonsurgically for complicated diverticulitis are managed by antibiotics. However, there are no recommendations concerning their duration. We aimed to determine the impact of the duration of antibiotic therapy on the risk of failure of nonsurgical treatment of complicated acute diverticulitis.

PATIENTS AND METHODS

This was a single-center retrospective study of patients with computer tomography (CT)-diagnosed complicated diverticulitis between January 2015 and April 2020. Treatment failure was defined as early recurrence and/or a persistent abscess by control CT.

RESULTS

In total, 148 patients fulfilled the inclusion criteria [87 men (58.8%), mean age 55±15 y]. The diverticulitis was classified as Hinchey I in 41.9%, Hinchey II in 9.5%, and pericolic free air in 48.6% of cases. The median abscess size was 2.9±1.7 cm. The median duration of antibiotic treatment was 10±4.2 days. The median follow-up was 64±60 months. The rate of failure was 12.8%. In univariate analysis, treatment >10 days (P=0.015) and an abscess >3 cm (P=0.032) were associated with a risk of treatment failure. In multivariate analysis, only the diameter of the abscess remained associated with a risk of failure (odds ratio: 1.6, 95% confidence interval: 1.09-2.4, P=0.01).

CONCLUSION

This study suggests that there is no need to extend the duration of antibiotic treatment beyond 10 days in nonsurgically treated complicated acute diverticulitis.

Update on the management of sigmoid diverticulitis

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.

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.

Paradigm shift: the Copernican revolution in diverticular disease

Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a "curative" endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of "Copernican revolution" in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.

Multicentre study of non-surgical management of diverticulitis with abscess formation

This multicentre retrospective cohort study included 447 patients with Hinchey Ib and II diverticular abscesses, who were treated with antibiotics, with or without percutaneous drainage. Abscesses of 3 and 5 cm in size were at higher risk of short‐term treatment failure and emergency surgery respectively. Initial non‐surgical treatment of Hinchey Ib and II diverticular abscesses was comparable between patients treated with antibiotics only and those who underwent percutaneous drainage in combination with antibiotics, with regard to short‐ and long‐term outcomes.

Most do not need drainage

Surgical management in acute diverticulitis and its association with multi-detector CT, modified Hinchey classification, and clinical parameters

PURPOSE

To assess whether CT findings, clinical parameters, and modified Hinchey classification are predictive of management outcomes of patients with acute diverticulitis.

MATERIALS AND METHODS

Data were accrued between January 2014 and December 2015. A total of 301 adult subjects were identified from radiology reports, of which six who did not met the inclusion criteria were excluded, thus yielding 295 subjects. Subjects were 43.1% (n = 127) male and 56.9% female (n = 168), with mean age 51.9 years (range 18-90). Two independent abdominal radiologists reviewed all scans; imaging features and a modified Hinchey classification were scored. Descriptive statistics compared the relationships between imaging findings, clinical parameters obtained from medical record review, and modified Hinchey classification with management outcomes.

RESULTS

CT findings associated with surgical management include the presence of a pericolonic fluid collection (36.8% vs. 8.2%, P = 0.0001), colonic fistula (13.2% vs. 0.4%, P = 0.0002), extraluminal air (26.4% vs. 9.3%, P = 0.0052), bowel obstruction (5.2% vs. 0.0%, P = 0.0162), and a modified Hinchey score of Ib or higher (55.3% vs. 11.7%, P = 0.0001). Slightly lower systolic blood pressure was also associated with operative management (137.2 mmHg vs. 128.2 mmHg, P = 0.0220).

CONCLUSION

Specific CT imaging features and modified Hinchey classification are associated with subsequent surgical management in patients with acute diverticulitis.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?

BACKGROUND

Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patient's ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes.

METHODS

This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated.

RESULTS

Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis.

CONCLUSION

Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.

Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review

PURPOSE

This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options.

METHODS

PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence.

RESULTS

Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain.

CONCLUSIONS

Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.

The Current Role of Radiologic and Endoscopic Imaging in the Diagnosis and Follow-Up of Colonic Diverticular Disease

OBJECTIVE

Colonic diverticular disease is among the most prevalent conditions in Western society and is a common cause for outpatient visits and hospitalizations. The role of imaging is in evolution, but it has proven useful in confirming clinically suspected disease, assessing severity and complications, and directing patient management.

CONCLUSION

This review focuses on the current role of radiologic and endoscopic imaging in distinct clinical scenarios of diverticular disease, with emphasis on diverticulitis and its follow-up.

Minimally Invasive Management of Complicated Diverticular Disease: Current Status and Review of Literature

BACKGROUND

Diverticulitis is a common condition which carries significant morbidity and socioeconomic burden (McGillicuddy et al in Arch Surg 144:1157-1162, 2009). The surgical management of diverticulitis has undergone significant changes in recent years. This article reviews the role of minimally invasive approach in management of complicated diverticulitis, with a focus on recent concepts and advances.

MATERIALS AND METHODS

A literature review of past 10 years (January 2004 to September 2014) was performed using the electronic database MEDLINE from PubMed which included articles only in English.

RESULTS

We identified total of 139 articles, out of which 50 were excluded resulting in 89 full-text articles for review 16 retrospective studies, 7 prospective cohorts, 1 case-control series and 1 systematic review were included. These suggest that urgent surgery is performed for those with sepsis and diffuse peritonitis or those who fail to improve despite medical therapy and/or percutaneous drainage. In addition, 3 randomized control trials: DILALA, LapLAND and the Scandinavian Diverticulitis trial are working towards evaluating whether laparoscopic lavage is safe in management of complicated diverticular diseases. Growing trend toward conservative or minimally invasive treatment modality even in severe acute diverticulitis was noticed.

CONCLUSIONS

Laparoscopic peritoneal lavage has evolved as a good alternative to invasive surgery, yet clear indications for its role in the management of complicated diverticulitis need to be established. Recent evidence suggests that existing guidelines for optimal management of complicated diverticulitis should be updated. Non-resectional radiographic techniques are likely to play a prominent role in the initial treatment of complicated diverticulitis in the near future.

Effects of diabetes mellitus in patients presenting with diverticulitis: clinical correlations and disease characteristics in more than 1,000 patients

BACKGROUND

The epidemic increase in the incidence of diabetes mellitus (DM) worldwide represents a potential source of surgical morbidity. The impact of DM on the need for surgical management and its effect on surgical outcomes for colonic diverticulitis have not been well defined.

METHODS

We investigated all DM versus non-DM patients admitted with a diagnosis of acute diverticulitis between January 1, 2003, and December 31, 2011, to a large urban safety net hospital. An administrative database search for patients with diverticulitis was divided into two groups: those with and without DM. They were retrospectively analyzed for severity of diverticulitis (Hinchey and Ambrosetti scores), mortality, length of hospital stay, need for operation, postoperative complications, and readmission rates.

RESULTS

There were 1,019 admissions with acute diverticulitis, 164 (16.1%) of which had DM. DM versus non-DM patients presented with a higher Hinchey score of 3 or 4 (12.2% vs. 9.2%, p < 0.001), a more severe computed tomographic Ambrosetti score (43.9% vs. 31.7%, p < 0.001), older age, and significantly more comorbid conditions. There was no significant difference in the failure of nonoperative management (2.2% DM vs. 2.5% non-DM, p = 1.000), readmission, or death rates. Operated DM patients had a higher incidence of in-hospital infectious complications (28.7% vs. 8.2%, p < 0.001) and a higher incidence of acute renal failure (5.5% vs. 0.7%, p < 0.001).

CONCLUSION

Although diabetic patients with colonic diverticulitis present at a more advanced level (as measured by Hinchey and Ambrosetti scores), the nonoperative success rate is similar to non-DM patients. Surgical management in DM patients is associated with a higher incidence of infectious complications and acute kidney injury. However, DM did not appear to increase operative mortality in surgically managed patients. These data suggest that greater attention should be placed on steps to reduce the negative impact of DM on both immune response and renal function in patients requiring surgery of colonic diverticulitis.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

The Role of C-reactive Protein in the Prediction of the Clinical Severity of Acute Diverticulitis

The aim of this study is to investigate the value of C-reactive protein (CRP) and of other laboratory parameters obtained during the initial evaluation of the patient in the prediction of the clinical severity of acute diverticulitis. The records of patients treated for acute diverticulitis at the Oulu University Hospital from December 2006 to December 2008 were retrospectively reviewed. Mild disease was defined when conservative treatment was successful. Severe acute diverticulitis was considered when percutaneous drainage of an abscess and/or surgery was necessary. From the 182 patients considered for analysis, 158 (87%) had mild disease, whereas 24 (13%) had severe. CRP ( P = 0.034) and the Hinchey classification ( P = 0.006) were shown to be independent risk factors for severe acute diverticulitis in the logistic regression analysis. The receiver operating characteristic curve showed that a CRP cutoff value of 170 mg/L significantly discriminated severe from mild diverticulitis (87.5% sensitivity, 91.1% specificity, area under the curve 0.942, P < 0.00001). CRP is a useful tool in the prediction of the clinical severity of acute diverticulitis. A mild episode is very likely in patients with CRP less than 170 mg/L. Those with higher CRP values have a greater probability to undergo surgical treatment or at least a percutaneous intervention.

Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis

BACKGROUND

The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management.

METHODS

A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013).

RESULTS

Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making.

CONCLUSION

The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients.

Acute and elective laparoscopic resection for complicated sigmoid diverticulitis: clinical and histological outcome

BACKGROUND

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

METHODS

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

RESULTS

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

CONCLUSIONS

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.